By Jennifer Thew, RN
Editor’s note: This article appears in the November/December 2019 edition of HealthLeaders magazine.
If you look around your healthcare organization, do you see engaged and efficient clinicians? Do you see happy patients? Do your most recent clinician satisfaction scores make you proud? If that's not the case, it's time to think about incorporating a culture of joy and love into your hospital or health system to turn things around.
Many studies on the topic of incorporating joy in the workplace are proving that "soft" skills used in work environments are the new "hard" skills and that, if implemented well, softer skills can help healthcare organizations reap hard results in employee engagement, patient safety, and nurse retention and recruitment.
The value in soft skills
When Perry M. Gee, PhD, RN, nurse scientist at Intermountain Healthcare in Salt Lake City, first heard about the concept of cultivating joy among the healthcare workforce, he was skeptical.
"When I started hearing the term joy a few years ago, it was really frustrating to me," he says. "The frustration was, because I'm an academic and a researcher, joy was not in the literature. It's not something that we had a firm definition of, and I really had a hard time getting my arms around it."
While he eventually came around to the concept, Gee is not alone in his need for the tangible. Even Donald Berwick, MD, president emeritus and senior fellow at the Institute for Healthcare Improvement, a leading proponent of joy in work, acknowledges in the whitepaper IHI Framework for Improving Joy in Work that the idea can sound "flaky" to some.
Given the drive for healthcare organizations to achieve measurable outcomes and return on investment, it's understandable that those in the healthcare industry are focused on concrete concepts.
Yet, skills often labeled as "soft," such as resilience, can impact the "hard" issues like financial goals, patient outcomes, and patient experience that healthcare organizations are eager to achieve.
"The [qualities] that we look for in leaders are what are referred to as 'soft skills.' Yet, when we talk about those skills, we somehow think they are less valuable because they are called soft," says Julie Kennedy Oehlert, DNP, RN, chief experience officer at Vidant Health in Greenville, North Carolina. "[S]oft skills, which are communication, listening, empathy, teamwork, problem solving, flexibility; those are things that we need in the healthcare environment today times 10."
Healthcare leaders like Oehlert are starting to get behind the idea that those "soft skills" can yield big results when it comes to achieving organizational goals.
Coming around to joy
Intermountain's Gee began to embrace the idea of joy in work precisely because of research and data.
"I have done research for the last four or five years with nurses in clinical settings looking primarily at burnout and resilience," Gee says. "And what I personally encountered was, even though these people were working in very stressful environments, some of them had some symptoms of burnout, and some of them were using their own personal resilience. You could see the joy on their faces when we would meet during focus groups."
While the nurses did have struggles, Gee says, these clinicians also spoke about times when they learned from another colleague or times when they helped a patient or family member, which gave them joy.
"The nurses really are the ones that convinced me that joy was a very important work concern," he says.
However, he says, "Joy is hard to quantify in one particular term. I think it's a combination of a lot of factors."
Joy in work, Gee says, can be pinpointed by asking the question, "Why do I want to come to work?"
Gee's own model of resilience includes components such as connection with others and a sense of purpose.
"I think joy combines with that sense of purpose," he says. "I came into nursing or healthcare to serve others and to make people's lives better. That gives me some joy. I get joy from my connections with patients and with families. And, personally for me, when I worked at the bedside, I'd have tremendous joy when I would do patient teaching and you see a patient or family 'get it.' "
But, as Gee points out, nurses need work environments that foster joy in work.
"Burnout is really a workplace condition. It's not a psychological condition," he says. "If your work environment is not conducive to joy, lots of things can happen. You may quit the job to leave that work environment. And people who are burned out or working in an environment that is not efficient and conducive to patient care make more errors."
Burnout's high cost
Clinician burnout, compassion fatigue, and moral distress are frequently mentioned issues in today's healthcare industry.
And for good reason. They are common and costly.
Of 15,000 physicians surveyed for Medscape's National Physician Burnout, Depression & Suicide Report 2019, 44% said they experienced burnout.
The American Medical Association estimates physician burnout costs range from $500,000 to more than $1 million per physician. In its 2019 National Health Care Retention & RN Staffing Report, Nursing Solutions Inc. estimates the average cost of bedside RN turnover to be between $40,300 and $64,000, resulting in the average hospital losing $4.4 million to $6.9 million annually.
Additionally, when researchers at Penn Nursing's Center for Health Outcomes and Policy Research performed a meta-analysis of 16 years of studies, they found an association between the nurse work environment and nurse job outcomes, nurse assessments of quality and safety, patient health outcomes, and patient satisfaction. In short, the study found that better work environments were associated with lower odds of negative outcomes.
Make joy a strategic priority
Jessica Perlo, MPH, director at the IHI in Boston, says that the work environment is essential to preventing burnout among the healthcare workforce.
"Whether we focus on satisfaction, resilience, or joy doesn't matter as much as not putting the burden solely on the individual, but also the system to improve it," she says. "If 50%–60% of our healthcare team is burned out, we don't have an individual problem, we have a systems problem."
To address these issues at a systemic level, IHI began to make joy in the work environment a strategic priority in 2015.
"Our partner [organizations] came to us because, at the time, they were saying engagement was standing in the way of their achieving Triple Aim results. There was a steady drum beat of news and research on burnout, and that connection between satisfaction and outcomes was becoming clearer to our partners. So, we knew we had to help and that improvement methodologies had a role to play in being part of the solution," Perlo says.
IHI took inspiration from the work of W. Edwards Deming, a pioneer in quality improvement, and began its focus on joy in work.
"[Deming] said management's overall aim should be to create a system in which everybody may take joy in their work," Perlo says. "We define joy in work as an intellectual, behavioral, and emotional commitment to meaningful, satisfying work. Without joy and meaning in work, the workforce cannot reach its potential. We believe that it encapsulates this aspirational goal of true workforce engagement and well-being."
Perlo points out that instilling joy in the workplace does differ a bit from resilience and job satisfaction.
"Oftentimes, interventions that are focused on resilience are for satisfaction of the individual rather than identifying or ameliorating the cause [of burnout]," she says.
Perlo stresses that to achieve joy at work, a systemic approach is needed, which is why IHI created its framework for improving joy at work.
The framework outlines roles for all leaders, from the C-suite to the point of service, in promoting joy in work.
In the framework, IHI encourages a distribution of leadership so there is space for everyone to accept responsibility and act in service of a shared purpose, not just those in nominal positions of authority. Given this broader definition, here are four steps leaders can take to move the workplace culture toward one that supports joy.
Step 1: Ask staff, "What matters to you?"
"The 'What Matters to You' conversations have proven to be crucial to this work," Perlo says.
These conversations can clear up any assumptions or misconceptions leaders may have about what is important to their work colleagues.
"Oftentimes, we assume we know what makes for a good day for our colleagues, but we've never actually asked what they care about and why they got into [healthcare] to begin with," she points out. "When we start to do that and are also given an opportunity to reflect ourselves and can share our interests in a way that helps us connect to each other's shared values, we are more willing to contribute our time, our energy, and our care to a shared goal."
Step 2: Identify unique impediments to joy in work in the local context.
"After we know what makes for a good day, we are better positioned to understand where the pebbles in the shoes are," Perlo says. "Oftentimes, leaders were afraid to ask "What Matters" because the expectation is that we will fix the impediments coming up for our teams. This isn't always feasible. What we're trying to do is shift this mindset from doing 'for' to doing 'with,' which is much more manageable. We ask one another what's getting in the way of more good days and then use improvement science to start with small tests of change. Doing so helps us to address the innate human needs that might not be met in the current environment: things like meaning, choice, camaraderie, and equity."
Step 3: Commit to a systems approach to making joy in work a shared responsibility at all levels of the organization.
Leaders at all levels should look at processes, issues, or circumstances that are impeding what matters.
"Then we're committing to, at all levels, creating partnerships, multidisciplinary when possible, and opportunities for people to come together and share responsibility for removing the impediments to joy," Perlo says. "While it's ultimately senior leaders' responsibility to ensure staff experience joy at work, the second part of the IHI Framework for Joy in Work is about shared and overlapping responsibilities at all levels of the organization. There is a role for everyone to play in finding and creating joy in work and more importantly, tools and resources to help them to do that."
Step 4: Use improvement science to test approaches to improving joy in work at your organization.
"We're encouraging folks to use improvement science to accelerate progress and to help determine whether their changes are actually leading to improvement," Perlo says. "This is also a way for us to address the underlying systems creating burnout. Together with teams, we set an aim for their work, decided on measures that would tell us if we are making progress, and selected components of the Framework for Improving Joy based on conversations and data from our staff. This is where it's also helpful to be a part of a collaborative or community of practice around the work. This is why IHI is launching a results-oriented network focused on supporting teams to work together to test, learn from, and contextualize evidence-backed, high-leverage changes to increase joy at scale."
Perlo also recommends measuring whether improvements are successful. Leaders don't have to reinvent the wheel and can use existing metrics like employee satisfaction, staff engagement, or burnout data, she says. They can also use turnover, retention, and absenteeism data. If leaders choose to use that information, she recommends increasing the frequency of data collection and analysis.
For example, this can include tools like an app that pings employees to ask them if they've had a good day, or something as simple as asking employees to drop dark-colored or light-colored pebbles in a clear container to indicate whether they've seen improvements or setbacks in their work environment, she says.
Love is all you need
At Vidant Health, leaders are using an innovative foundation for their organizational culture—relationships structured around love and empathy.
"We embrace the definition of love used by Dr. Martin Luther King Jr… love is 'an understanding, redeeming goodwill for all men, an overflowing love that seeks nothing in return,' " Oehlert says.
This type of love involves creating a safe, welcoming place where team members care about each other, she says.
"We talk a lot about the importance of empathy. Empathy put into action is compassion, which is one of [Vidant's] values," says Oehlert. "We have decided that if we design educational offerings and leadership development [around] love, and stress that empathy is of key importance in relationships, that even those times that are difficult in the health system or on the unit will be easier with love and empathy."
She continues, "it is very simple: How we treat each other is how we treat our patients, and how we experience each other is how our patients will experience us. We do not look at patient experience and design a good experience for them without thinking about how the providers feel or how the team members feel. When you look at experience in this way, you can positively contribute to both patients and care providers, which helps prevent burnout and shows that the relationship between the two is valued."
Embrace love, improve outcomes
According to Oehlert, systemwide team engagement has been improving steadily since implementing love and empathy into the workplace and has risen 5.4% over the last four reporting cycles, according to the Press Ganey Engagement and Pulse Surveys that Vidant uses to measure employee engagement. From 2017 to 2019, the organization has seen the following increases in engagement:
- Clinical team member: 1.5% increase
- Non-clinical team member: 0.2% increase
- Clinical leader: 11.2% increase
- Non-clinical leader: 4.7% increase
- Supervisor, non-clinical: 12.4% increase
- Supervisor, clinical: 14.2% increase
- Manager, non-clinical: no change
- Manager, clinical: 4.7% increase
- Director, non-clinical: 1.1% increase
- Director, clinical: 10.8% increase
- Executive/VP: 4.7% increase
From 2015 to 2019, the questions pertaining to manager effectiveness saw "problematic" ratings decrease by 4.1%, and managers rated as "excellent" increased by 6.2%.
From 2015 to 2017, physicians rated as "engaged" increased by 6.5%.
Additionally, reporting of near misses has almost doubled over the last few years, Oehlert says. In FY 2019, 19,120 patient events were reported, a 7% increase from FY18. Of these, 4,849 were safety catches, up from 2,760 safety catches in FY18.
Improvements have also been seen in the two Agency for Healthcare Research and Quality questions regarding non-punitive response to error. These questions ask whether team members feel like their mistakes will be held against them, and whether when an event is reported it feels like the person is being written up. The AHRQ question, which highlights a non-punitive approach to safety reporting, is the single most improved question in the last reporting period of the AHRQ survey.
"If you can take the fear and blame out of your culture, what's left is all the good things about healthcare—love, compassion, empathy, shared decision-making, interprofessionality," she says. "When you take fear and shame and blame out, what's left is really good human stuff, which is what healthcare should be about."
Patient experiences continue to trend upward as team engagement improves, Oehlert says.
Also, the nurse turnover rate at Vidant Medical Center for FY19 is 16.33%, compared to the national average of 17.4%.
"We realize that our culture and our engagement impacts turnover. Right now, our RN turnover is 16%, which is below the national average. We had traditionally recruited and hired locally (North Carolina and Virginia), and now we are confident in our strategy and are attracting nurses from a wider demographic," Oehlert says. "Last year, we hired nurses from 10 different states. Our newest RN recruitment campaign (#carelikecrazy) ties together our intention of love and caring right in our recruitment."
Create a strategy 'around culture'
To help measure success, says Oehlert, organizations should create standard definitions of the components of their mission, values, and goals.
"If you don't know how the organization defines something, it's hard to measure it. We measure our definition of engagement on our engagement survey, and we also define culture in a specific way," she says.
For example, at Vidant:
- Culture is defined as, "How relationships are structured."
- Empathy is defined as, "Recognizing and appreciating the feelings, thoughts, and stories of others by connecting and being sensitive to what, how, and why people feel and think the way they do."
- Engagement is defined as, "Our shared commitment and partnership in shaping a positive, motivating, and relationship-focused culture where we can all thrive."
"What that does for the organization is it [allows us to] agree on it so we know what we're going for. I think that is important if you're [creating] strategy around culture," she says.
Additionally, when creating developmental offerings, Vidant leaders rely heavily on design thinking, which Oehlert says includes engaging people, getting their feedback, and trialing ideas and innovations.
And again, what are often considered to be soft ideas can translate into hard results.
"A lot of the wicked problems in healthcare today can be healed when you have a strategy that includes love and empathy. You will not have good quality outcomes if you don't have love and empathy within the culture in good measure, because people will be afraid to report quality and safety issues. You will not have excellent patient experiences unless the teams that care for patients are supported and loved. You will not be successful with recruitment and retention if your team members will not recruit for you and may not choose to stay at an organization that does not care about them," she says.
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.