Leading Systems Toward Improving Professional Well-being

Near the end of 2019, the National Academies of Science, Engineering, and Medicine released a groundbreaking and comprehensive report that used a systems approach to address the challenges of professional well-being and clinician burnout.¹  While we hope that this report stimulates more research and innovation aimed at improving professional well-being, we also think that it serves as a clarion call for a new kind of leadership within the intensive care unit (ICU).

Most clinicians are called into their vocations by a deep desire to care for and heal fellow humans during illness. Professional well-being can be defined as the positive perceptions and the constructive conditions at work that enable us to thrive and achieve our full vocational call.¹  The very construct of professional well-being, then, is an acknowledgment that we are served as much by the high-quality care we provide to our patients as our patients are served by the care they receive from us. Although difficult to measure, professional well-being is often conceptualized to include such domains as feeling engaged while at work, feeling fulfilled from work, and feeling satisfied with our work.² 

Many of our professional oaths, pledges, or codes of ethics increasingly acknowledge the potential interplay between our professional well-being and the care that we aspire to provide our patients. Provision 5 of the American Nursing Association’s code of ethics asks nurses to preserve their own integrity and well-being in order to continue to uphold their commitment to caring for their patients.³  The document cites compassion fatigue as a threat to nurses’ professional well-being and asks nurses to aspire to mitigate its effect with “a healthy diet, exercise, … sufficient rest, … family and personal relationships, engag[ing] in adequate leisure and recreational activities and attend[ing] to spiritual or religious needs.”³  The most recent version of the physician pledge from the World Medical Association’s Declaration of Geneva also added a statement about professional well-being, “I will attend to my own health, well-being, and abilities in order to provide care of the highest standards.”⁴ 

Clinician burnout is likely the most corrosive threat to professional well-being. The World Health Organization defines burnout as a work-related syndrome of stress characterized by 3 overlapping dimensions: (1) physical or emotional exhaustion, which often comes with the sense of being overwhelmed or overextended at work; (2) excessively negative or detached responses to many aspects of the work, including negative reactions to patients, teammates, or leaders; and (3) feelings of incompetence or lack of achievement or a lack of productivity at work.¹ 

The scientific literature suggests that critical care clinicians suffer higher rates of burnout than do clinicians in other specialties.⁵  It has been estimated that around 30% of critical care nurses suffer symptoms consistent with severe burnout and that up to 45% of critical care physicians report severe burnout symptoms.⁵  Although more information is needed on the prevalence of burnout in other critical care health professionals such as social workers and physical or occupational therapists, the effect of burnout on our critical care system is captured not only by the multiple epidemio logic studies showing high rates of posttraumatic stress disorder, substance abuse, and suicide in our clinicians^5,6  but also by the emotional and psychological distress often captured in critical care clinicians’ stories.⁷ 

If at work, we aspire to have strong enough bodies full of healing energy, burnout is a dead or dying work body.⁷  As in the Sutphen poem “Living in the Body,”⁸  we “only get one” and our work bodies— our work energy—will never be enough, it will “not be beautiful enough… . it will pull [us] down into a sleepy swamp and demand apples and coffee and chocolate cake.” When we acknowledge both our commitment to professional well-being and the difficult truth of how vulnerable our work bodies are to burnout, what emerges is a moral call for work systems that can provide care for our patients while also ensuring that we clinicians can keep on living, working, and healing. Work systems that break our healing bodies are morally corrupt and can no longer be tolerated.

The systems approach (referred to in the 2019 report) is an amalgamation of various scientific disciplines,¹  all of which acknowledge health care as a complex adaptive system (ie, with multiple, interdependent and layered levels) that uses technologies to improve the performance, safety, and well-being of multiple stakeholders. Because such an approach acknowledges that change creates unintended consequences, it necessarily must also prioritize the early integration of learning and improvement activities.¹  The report draws from a conceptual model of burnout and well-being that acknowledges 3 interacting system levels that affect the balance between job demands and resources: (1) frontline care delivery is the system within which clinicians interact with patients and patients’ families, using technologies and procedures to provide care; (2) health care organization refers to an interconnected set of work systems that create and sustain a particular culture, a particular system of payment and reward, a set of management styles and policies; and (3) external environment includes the political, economic, and cultural factors that influence and constrain health care organizations.¹ 

Too many of the interventions that have been tested for improving professional well-being or clinician burnout have been focused on the individual clinician, often targeting clinicians’ behaviors, coping strategies, or resilience in the face of stress.⁶  For example, in a recent systematic review of interventions to prevent physician burnout, 12 of the 15 clinical trials were individual-focused interventions such as small group curricula, stress management, self-care training, or communication skills training whereas only 3 focused on work system factors such as professional relationship and social support, team organization, or technology-related factors.⁹  Although both individual- and systems-level approaches are modestly effective at improving burnout symptoms, few interventions have been tested that mixed individual with systems approaches.⁹ 

We believe that the systems approach that under-girds this 2019 report will require health care systems to seek out a different type of ICU leaders—systems leaders—who can leverage this kind of systems thinking in order to address the ICU’s most intractable problems.¹⁰  Such leaders not only will be expected to intuitively understand the systems approach to problems but will be called to leverage such understanding toward multipronged, interdisciplinary interventions. Such ICU leaders may dare to mix individual, interprofessional team approaches along with work system interventions into their complex plan for improving professional well-being.

Because the systems approach assumes that all clinicians’ perspectives are valuable, the new ICU leader is called to make changes that reflect the collective wisdom of multiple stakeholders and will need skills in fostering deep shared reflection among all types of stakeholders (patients, patients’ families, clinicians, and organizational leaders). Such leaders may accomplish this through facilitating group conversations and building consensus.

The new ICU leader can no longer be reactive to each new problem or crisis as if such problems are all independent of one another. The systems approach asks that our leaders be capable of leveraging the collective wisdom of the group toward creating a positive vision for the ICU that can fundamentally address many problems at the same time. This approach may mean that as ICU leaders focus on addressing one problem (eg, professional well-being and clinician burnout) they must also be willing to collaborate with other health system leaders focused on improving other intractable problems within the health care system (eg, the electronic health record, or diversity/equity).

Transforming our ICU systems to improve professional well-being and eliminate clinician burnout will benefit from the generation of upcoming research and innovation that will leverage the systems-based approach to the problem. We hope that, along with these advancements in knowledge, health care systems are bold enough to insist on ICU leaders who are skilled at harnessing our collective imaginations to achieve truly transformative change.