We have chosen a profession that invites those who are ill to share their suffering, stories and worries, and that gives us the privilege to serve and help in removing or preventing some of the burden(s)” (p. 4).1 This touches on the highest aspirations any profession can wish for in a society. Yet, although such professional purpose should lead to a high level of satisfaction, we hear and read much more about burnout, distrust, and lack of engagement than we do about joy.
People used to believe that you don’t have to be happy at work to succeed, that work is not personal. That thinking has been debunked, and the research is clear that happy people work better.2 Science is on our side: there are clear neurological links between feelings, thoughts, and actions.3,4 Why then are 50% of people not engaged emotionally or intellectually in their organization, and why are another 20% actively disengaged, leaving less than one-in-three engaged systemically?2 For physicians, increasing demands on time and resources, poorly designed systems to do the daily work, and attacks by politicians in some provinces have resulted in alarming levels of systemic disengagement and burnout.5
When leaders, physicians, and others are disengaged, they infect others with their attitude, negatively affecting outcomes and quality of care. Joy in work is not only a core part of Deming’s6 theory of improvement, but he also argues that it is a fundamental right and, as leaders, we have a responsibility to ensure that workers and co-workers enjoy that right.
A recent white paper from the Institute for Healthcare Improvement1 (IHI) provides an evidence-based framework to improve morale and work satisfaction among individuals and teams and in the system. It describes how we, who provide services in the health system, can go from the current state to enjoyment in our work.
There are four steps, each leading to the next according to IHI.1 However, it is clear that the four steps are more closely integrated (Table 1).
1. Ask staff and team members, “What matters to you?”
This step is about asking the right questions and really listening; it is about doing something with, not for others. It helps to identify what contributes to or distracts from enjoyment in work. This type of “appreciative inquiry” taps into strengths and highlights what is already working. For example, ask What makes a good day for you? What makes you proud to work here? When we are at our best, what does that look like? Top
2. Identify unique impediments to joy in work in the local context
What processes, issues, or circumstances are keeping people from meeting professional, social, and psychological needs. This second step allows leaders to address the psychological needs of humans, not unlike Maslow’s hierarchy of needs.7
Steps 1 and 2 take place in the same conversation and continue over time. These conversations about what really matters build the trust needed to identify frustrations during the workday. They allow people to address the impediments together and set priorities for when and how to deal with them. Everyone must feel that they have been listened to before they can be open and honest. Respecting all voices also builds camaraderie and equity.
3. Commit to a systems approach to make joy in work a shared responsibility at all levels in the organization
Although making a workplace joyful is a leader’s job, everyone from executive to clinical administrative staff also has a role to play. As partners, multidisciplinary teams share responsibilities to remove impediments and improve and sustain joy. From creating effective systems, to building teams, to bolstering one’s own resilience, each person contributes to supporting a positive culture.
Like Maslow’s pyramid,7 the IHI paper1 identifies five levels of fundamental human needs that play a central role in improving joy in work: physical and psychological safety; meaning and purpose; choice and autonomy; camaraderie and teamwork; and fairness and equity. Although all five of these human needs will not be resolved before addressing local impediments to joy in work, actions and a commitment to address all five will ensure lasting results.
4. Use improvement science to test approaches for increasing joy in work in your organization
This step allows leaders to determine whether changes are leading to improvement, and whether they are effective and sustainable in different groups, teams, departments, and clinics. Key elements of improvement science include: making the aim clear and numerical (how much, by whom, by when); starting small and using measurements to refine successive steps; launching a pilot before expanding the change idea into different settings and conditions; tracking and sharing the results; involving each person and all people.8
These four steps, some with short-term outcomes, others with a longer time line, are also an essential part of the fourth component of the quadruple aim,9 i.e., care for providers. Indeed, “joy in work” is an important element of improved clinician experience for both the individual and the team (Figure1). Although the four steps do not ignore larger organizational issues, such as staffing pressure or the impact of electronic health records on clinicians’ daily work, they empower local teams to identify and address impediments that they can change. They help everyone see the organization as “us” not “them.” Top
In the context of today’s stresses in the health care system, let us as physicians take the lead and show how this framework can change the conversations from “If only they would” to “What can we do today?”
1.Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI framework for improving joy in work. Cambridge, Mass: Institute for Healthcare Improvement; 2017. Available: https://tinyurl.com/jdkc999 (accessed 19 Dec. 2017).
2.McKee A. Being happy at work matters. In: Happiness. Boston: Harvard Business Review Press; 2017.
3.Boyatzis RE, Passarelli AM, Koenig K, Lowe M, Mathew B, Stoller JK, et al. Examination of the neural substrates activated in memories of experiences with resonant and dissonant leaders. Leadersh Q 2012;23(2):259-72.
4.Goleman D, Boyatzis R, McKee A. Primal leadership: unleashing the power of emotional intelligence. Boston: Harvard Business Review Press; 2013.
5.Gandhi S. Burnt-out doctors are facing a health-care crisis of their own. HuffPost 2017;23 Aug. Available: https://tinyurl.com/y8ye6xsm (accessed 19 Dec. 2017).
6.Deming WE. Out of the crisis. Cambridge, Mass.: Massachusetts Institute of Technology; 1986.
7.Maslow A. A theory of human motivation. Psychol Rev 1943;50(4):370-96.
8.Langley G, Nolan K, Nolan T, Norman C, Provost L. The improvement guide: a practical approach to enhancing organizational performance. San Francisco: Jossey-Bass; 2009.
9.Bodemheimer T, Sinsky C. Form triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014; 2(6):573-6. Available: https://tinyurl.com/yb5wptc5 (accessed 19 Dec. 2017).
Johny Van Aerde, MD, MA, PhD, FRCPC, is editor-in-chief of the Canadian Journal of Physician Leadership and a former president of the Canadian Society of Physician Leaders.