National Plan for Health Workforce Well-Being (2022)

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1 Priority Area: Create and Sustain Positive Work and Learning Environments and Culture Transform health systems, health education, and training by prioritizing and investing in efforts to optimize environments that prevent and reduce burnout, foster professional well-being, and support quality care (NASEM, 2019). “Invest in and prioritize a true well-being program and prioritize it to make it a culture. Often organizational policies and expecta- tions are conflicting with true commitment to well-being. There needs to be more than just telling people to take care of themselves.” - Frontline Health Worker1 Positive work and learning environments for health workers are intertwined with safe environments for patient care and population health. Not only is it part of an organization’s ethical responsibility to invest in health worker well-being, but evidence also suggests that it is central to optimizing patient outcomes and addressing costs associated with staff turnover, lost revenue, financial risk, and threats to a health system’s long-term viability (Shanafelt et al., 2017). However, there is no one-size-fits-all solution to improv- ing health worker well-being, and there are challenges for organi- zations and small practices alike in navigating appropriate invest- ments that are reflective of their local context. For health systems, 1 For background on this quote and those in other chapters, visit the NAM’s Clinician Burnout Crisis in the Era of COVID-19: Insights from the Frontlines of Care webpage at: https://nam.edu/initiatives/ clinician-resilience-and-well-being/clinician-burnout-crisis-in-the-era-of-covid-19/. 9 

10 | National Plan for Health Workforce Well-Being changing the environment and culture will require a systems ap- proach of active and engaged executive leadership that meaning- fully involves staff throughout the organization, including service line directors, department chairs, clinical learning environment directors, and frontline workers in decision-making, establish- ing frameworks for holding each other accountable, and fostering a culture of continuous learning and improvement (NASEM, 2019). Strategies to encourage respect among health workers and to com- bat workplace bullying, abuse, and threats toward health workers are important to prevent harm from disrespect in work and learn- ing environments, protect health workers, and ensure workers can focus on delivering care (Sokol-Hessner et al., 2018). Addressing health worker well-being requires financial, time, and human resource investments, and leaders and health workers must make the case to address well-being when faced with numer- ous and seemingly competing challenges. Estimates on the cost of turnover, depending on role types, range from $88,000 to more than $1 million to replace a registered nurse or physician (Dyr- bye et al., 2017). Studies point to the potential of burned out and overworked physicians making unnecessary referrals and ordering more tests, and burnout among health workers may raise health expenditures via medical errors, malpractice claims, absenteeism, and lower productivity (Dyrbye et al., 2017). Therefore, emphasiz- ing and addressing well-being is aligned with organizational goals to improve quality care and reduce costs. It is not an additional pri- ority, but rather a central priority, with additive benefits across the health system. Though optimizing work conditions and managing the workforce were challenges for many health systems, including small and rural practices, before the pandemic, these pressures have only grown more acute. For example, the end of temporary federal assistance for rural hospitals that face closures due to financial challenges will threaten access to much needed health care services for Medi- care and Medicaid recipients (Bhatnagar et al., 2022). It is clear that many health systems, from rural to urban and small to large health care delivery organizations, have coped with profound pressure on staff and resources (KaufmanHall, 2022). Work stressors dur- ing the COVID-19 pandemic have driven health workers to leave PREPUBLICATION COPY - Uncorrected Proofs 

Create and Sustain Positive Work and Learning Environments and Culture | 11 the profession, exacerbating the burdens on remaining staff and perpetuating a cycle of introducing new workers into unhealthy work and learning environments, particularly in rural commu- nities (Wright, 2021). As health systems mitigate critical staffing shortages (e.g., contracting labor to ensure that patient care and organizational operations remain safe), they must also address other factors impacting the workforce and broader society, such as structural racism, sexism, ableism, and anti-LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, and ally/ asexual) discrimination and bias. Not surprisingly, discrimination and bias affect education, training, and work environments for health workers, with devastating results for patient experiences, perceptions, and outcomes (ANA, 2022; Hu et al., 2019; Leape et al., 2012). Health workers want to see an enhanced commitment from their organizations to promote diversity, equity, inclusion, and acces- sibility in the health system in partnership with their communi- ties (NAM, 2022a, 2022b). Diversifying the workforce has the dual benefits of improving patient care experiences and increasing the available staff to provide care. Leaders and health workers can build upon this practice of embracing all health worker identities by practicing cultural humility, “being aware of how an individual’s culture can impact their health behaviors and using this aware- ness to cultivate sensitive approaches in treating patients” (Prasad et al., 2016). It is important to recognize that individuals—from practicing health workers to learners—hail from a range of differ- ent backgrounds, experiences, and professional cultures, yet they ultimately come together as a care team. Purposeful interactions celebrating and respecting professional strengths and appreciat- ing personal differences are key to the well-being of both patients and providers. The consistent and sustainable delivery of safe and high-quality patient care is only possible when clinical learning environments ensure the well-being of all health workers (ACGME, 2019). Ex- ecutive and educational leaders must partner to foster an enabling culture—the importance of designing solutions to keep pace with the rapidly changing health delivery environment cannot be over- stated (Nasca et al., 2014). Significant opportunities remain to op- PREPUBLICATION COPY - Uncorrected Proofs 

12 | National Plan for Health Workforce Well-Being timize care delivery models to leverage technology and advanced analytics (see Chapter 5), team-based principles, and other emerg- ing approaches. Priority Area: Create and sustain positive work and learning environments and culture. Culture of well-being is integrated into program Goal 1 operations, human resource management, services, and curricula. Academic Institutions, Clinical Training Programs, and Accreditation Bodies Health Systems Actors Health Workers Insurers and Payers 1A. Instill approaches to decrease workplace stress and burn- out, and improve health worker and learner well-being in strategic plans, organizational values, and human resources policies and procedures. 1B. Implement well-being onboarding programs for students as they enter health professions schools to build coping and Actions resiliency skills. 1C. Provide training opportunities for faculty to help inte- grate well-being into programming. 1D. Set reasonable productivity expectations and provide adequate resources to support expectations. PREPUBLICATION COPY - Uncorrected Proofs 

Create and Sustain Positive Work and Learning Environments and Culture | 13 Settings are diverse, equitable, accessible, and Goal 2 inclusive. Academic Institutions, Clinical Training Programs, and Accreditation Bodies Health Information Technology (IT) Companies Actors Health Systems Health Workers 2A. Examine institutional policies, organizational goals, and objectives with an equity lens. 2B. Revise clinical algorithms that erroneously rely on race. 2C. Establish policies and processes to support the timely reporting of and response to discriminatory behaviors. This includes a clear reporting process, support for reporters, and outcomes commensurate with the demonstrated behavior and situation. 2D. Establish mentorship programs to help all health Actions workers thrive in educational, training, and practice environments. 2E. Review leadership opportunities and pathways to ensure they are diverse, accessible, equitable, and inclusive, and are available at multiple levels of a health system and training program. 2F. Provide appropriate education and trainings for work- ers, staff, and leaders to address issues (e.g., discrimination, lateral violence, bullying, harassment) and progress toward cultural humility. PREPUBLICATION COPY - Uncorrected Proofs 

14 | National Plan for Health Workforce Well-Being There is increased retention and decreased turnover of Goal 3 health workers. Academic Institutions, Clinical Training Programs, and Accreditation Bodies Federal, State, and Local Governments Actors Health Systems Health Workers 3A. Provide mechanisms and systems to allow health workers to operate as teams. 3B. Invest in appropriate and flexible staffing plans that allow for safe patient care, including needed backup. 3C. Create and implement processes for meaningful recognition for all members of the health workforce. 3D. Examine sick leave and personal time off policies and staffing to accommodate health workers who need time off, regardless of their tenure. 3E. Develop and incentivize coverage systems that allow health workers to take time off, especially so that frontline workers can hand off responsibility for patient care during their time away. Actions 3F. Offer employee benefits that include child care and elder care services. 3G. Ensure that health worker meal and rest breaks are expected and routine, not exceptional. 3H. Learn about health worker experiences directly by asking them and conducting surveys and listening sessions while they are employed, and conducting exit interviews to understand why they are leaving their positions. 3I. Promote work-life integration for health workers through structures such as sufficient staff, flexible schedules, access to and use of health care, and low-cost and healthy food options. 3J. Address accountability and reward systems to re-orient promotion/tenure and salary processes so that they reward behaviors contributing to positive learning environments. PREPUBLICATION COPY - Uncorrected Proofs 

Create and Sustain Positive Work and Learning Environments and Culture | 15 Leadership recognizes negative impacts of health Goal 4 worker burnout and fosters a culture of well-being. Health Systems Actors Health Workers Professional and Specialty Societies 4A. Use data to develop strategies that will continually im- prove well-being and decrease health worker burnout and distress. 4B. Ensure that leaders consider well-being when making decisions, to account for the potential impact on patients, the workforce, and their health systems. 4C. Provide protected time for and empower managers, health workers, and other staff to address well-being in the Actions workplace. 4D. Invest in well-being leadership roles, such as Chief Well- ness Officers (and Chief Nursing and Chief Pharmacy Offi- cers, as appropriate) that: • report to executive leadership and governance and are integrated in the leadership team, • facilitate uptake and accountability of well-being within the heath workforce, and • are allocated the resources necessary to implement strategies that will improve health worker well-being. PREPUBLICATION COPY - Uncorrected Proofs 

16 | National Plan for Health Workforce Well-Being Accountability standards and best practices for well- Goal 5 being are adopted. Academic Institutions, Clinical Training Programs, and Accreditation Bodies Health Systems Actors Professional and Specialty Societies Private and Non-Profit Organizations 5A. Establish and implement accountability measures and incentives for leaders (see Action 3J). 5B. Fund and evaluate demonstration programs and grants in Actions the workplace and learning environments. 5C. Decrease the amount of time between research and translating evidence into real-world settings. NOTE: The list of actors in this table is not exhaustive. Many of the actors named in this table will need to plan and coordinate their actions with each other as part of a systems approach to health workforce well-being. RELATED RESOURCES2 1 Advance Organizational Commitment • White Paper: Framework for Improving Joy in Work (Institute for Healthcare Improvement) • Report: CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, Version 2.0 (Accreditation Council for Graduate Medical Education) • Guide: Well-Being Playbook: A Guide for Hospital and Health System Leaders (American Hospital Association) 2 For additional resources, visit the NAM’s Resource Compendium for Health Care Worker Well-Being webpage at: https://nam.edu/compendium-of-key-resources-for-improving-clinician-well-being/. PREPUBLICATION COPY - Uncorrected Proofs 

Create and Sustain Positive Work and Learning Environments and Culture | 17 • Guide: Establishing a Chief Wellness Officer Position (Ameri- can Medical Association) • Guide: The Pharmacist’s Fundamental Rights and Responsi- bilities (American Pharmacists Association and the National Alliance of State Pharmacy Associations) • Guide: NIOSH Safe Patient Handling and Mobility (National Institute for Occupational Safety and Health) • Case Example: Workplace Wellness Champions: Lessons Learned and Implications for Future Programming (Amaya et al., 2017) • Infographic: Survey Shows Substantial Racism in Nursing (National Commission to Address Racism in Nursing) • Recognition Programs: • Joy in Medicine Health System Recognition Program (American Medical Association) • Beacon Award (American Association of Critical-Care Nurses) • Pathway to Excellence Program and the Magnet Recog- nition Program (American Nurses Credentialing Center) • ASHP Certified Center of Excellence in Medication- Use Safety and Pharmacy Practice (American Society of Health System Pharmacists) Strengthen Leadership Behaviors • Guide: Chief Wellness Officer Roadmap (American Medical Association) • Discussion Paper: A Call to Action: Align Well-Being and An- tiracism Strategies (Barrett et al., 2021) Conduct Workplace Assessment • Overview of Established Tools: Valid and Reliable Survey In- struments to Measure Burnout, Well-Being, and Other Work- Related Dimensions (National Academy of Medicine) • Infographic/Assessment Tool: Standards for Establishing and Sustaining a Healthy Work Environment (American As- sociation of Critical-Care Nurses) • Guide: NIOSH Total Worker Health Program (National Insti- tute for Occupational Safety and Health) PREPUBLICATION COPY - Uncorrected Proofs 

18 | National Plan for Health Workforce Well-Being Cultivate a Culture of Connection and Support • Guide: A Nurse’s Guide to Preventing Compassion Fatigue, Moral Distress, and Burnout (American Nurses Foundation) • Guide: “What Matters to You?” Conversation Guide for Im- proving Joy in Work (Institute for Healthcare Improvement) • Case Study: Culture of Well-Being (American Hospital Asso- ciation) PREPUBLICATION COPY - Uncorrected Proofs