Building Individual and Organizational Wellness Through Effective Followership.

Burnout is widespread across the healthcare industry. Physician burnout has been linked to significant decrements in personal wellness, patient satisfaction, patient outcomes, and organizational financial losses. Appropriately, burnout has been identified as an important issue for leaders in the field as it can lead to physician turnover and loss of talent. In this article, we address how burnout is related to followership. We assert that physicians can utilize effective followership to increase wellness not only for themselves, but also for their leaders and organizations.

Introduction

What is Followership?

When people traditionally think of followers the initial reaction is usually negative.1 Some of the descriptions ascribed to followers in the past have been impulsive, masochistic, alienated and passive. These epithets conjure ideas of individuals that are either aloof or willing to do anything they are told without thinking about it. As our understanding of leadership has evolved, so too has our understanding of followers. The two are inextricably linked; without followers there can be no leaders.2 Almost everyone is a follower in some leader-follower dynamic, eg a chief executive officer must answer to a board of directors. There is an increasing understanding that the inspirational achievements of leaders are facilitated by the dedicated work of their followers.2 As such, the partnership between followers and leaders is an essential element to personal and organizational success. Partnership has the potential to provide the follower with more control of their destiny, an increased sense of effectiveness at work, and an understanding of their personal value.3

While the Merriam-Webster dictionary defines followership as “the capacity or willingness to follow a leader”, we feel that definition underserves the potential power of followers.4 We define followership as the leadership practiced by individuals who are in positions of responsibility, but not authority, whereby they exert their influence to execute the vision of their leaders or accomplish organizational goals. Our definition highlights two important aspects of followership. The first is that leadership is not tied to positional authority. Leadership skills are similar regardless of one’s role within a hierarchy. The position in which one finds themselves at any given time defines the scope of responsibility and sphere of influence. This supports our second part of the definition, which is that effective followers lead with the aim of supporting their leaders and their organizations. Ultimately, leaders shoulder the burden of responsibility for their decisions. They must own the success or failure of the mission. Followers, however, through how they exert their influence and take ownership themselves, may determine the success or failure of a leader or an organization.5 Ideally, leaders and followers have a shared sense of responsibility and commitment to the mission.

Burnout is a pervasive problem in medicine affecting approximately 42% of physicians.6 It is costly, resulting in anywhere from a $500,000 to $1,000,000 payout for organizations who have lost a physician to burnout.7 Physicians suffering from burnout can experience insomnia, anger, impaired memory, decreased attention and moral distress. The experience is cumulative: physician burnout can lead to worse patient outcomes, less cost effective and efficient health care systems, and poor physician health.8 While the focus of this paper is on physicians, the frequency of burnout and impact are similarly felt among other health care professionals.9,10

Burnout has numerous causes, but many of them relate to feeling helpless in our workspaces. Individuals cite lack of ownership, autonomy, and purpose as common contributors to burnout. Depersonalization, decreased empathy, and lack of quality feedback add additional fuel to a situation that often culminates in feelings of moral distress for physicians.8,11 Many of these causes are rooted in dysfunction within the leader-follower relationship.

Effective leadership has been demonstrated to correlate with decreased burnout for physicians, non-physician employees, and leaders within health care systems.12,13 There is also evidence that increased well-being and decreased burnout amongst leaders increases their effectiveness.12 While we currently lack evidence that effective followership similarly effects burnout and well-being, followership style does impact job satisfaction and performance.14 Furthermore, active engagement by followers is positively correlated with job satisfaction and organizational commitment.15,16 In this perspective, we argue that effective followers in medical hierarchies may decrease burnout in all members of an organization by supporting leaders, committing to organizational success, and improving individual well-being.

Understanding Followership

The construct of followership we find most applicable to the field of medicine is that described by Ira Chaleff in his book, The Courageous Follower.2 He explains that there are four types of followers: individualists, resources, implementers and partners. We have outlined the different followership styles, their characteristics and potential pitfalls and benefits in Table 1.

Table 1

Follower Types Outlined with Common Traits, Potential Advantages, and Potential Disadvantages

Follower Type	Traits	Advantages	Disadvantages
Partner	Supports changeChallenges the leader in a respectful mannerThinks of and helps execute change initiatives	Reliable hard workersProvides well researched solutionsWilling to take on additional tasks in the name of progressProvides an internal check to leaders	At risk for burnout if working with a leader who does not allow for partnershipAt risk for taking on too many tasks
Implementer	Supports changeUnlikely to challenge the leader	Reliable hard workersDedicated to forward progression	Unwillingness to challenge may let leader go unchecked or uncorrected if they veer off courseLack of ability to challenge may feel like having little responsibility
Resource	Low level of support for changeUnlikely to challenge the leaderDoes their work, often well, but no more	Reliable workersKnowledgeable in their fieldConsistent follow-through	Unwillingness to change may limit organizational progressionUnwillingness to challenge may let the leader go unchecked or uncorrected if they veer off course
Individualist	Resists changeChallenges the leader, often without respectRarely offers solutions	Allows for dissenting opinions to be heard and consideredProvides a balance check to the leaderForces leaders to validate assumptions	Can lead to organizational stress, stifle progress, and lead to decreased levels support amongst other team members.Potential to cause a toxic work environment

Individualists are followers who often offer little support to their leader, yet they consistently challenge leaders or courses of action.2 In medicine, we experience these individuals as those who dispute policies and defy leaders. They are vocal about their disapproval and resist the ideas of others, but they do not recommend solutions of their own for how to improve. While there may be times when an individualist is necessary, followers who consistently practice this type of followership may be seen as cynical and destined to dissatisfaction in their work environment.

Resources display little support for their leader and are unlikely to challenge them.2 In medicine, these individuals are our colleagues who come in and get the job done but are unlikely to participate in any endeavor that pushes clinical care forward. They are unlikely to speak up if they feel their leader is making a mistake, instead relying on the leadership skills of the other followers around them. Followers may embody this style when responsibilities and stressors outside of the work environment dominate their time but spending extensive time in the resource role can decrease both one’s sense of purpose and sense of ownership.

Implementers are followers who will support leaders and embrace change.2 They are unlikely to challenge their boss, however if they feel the change is unnecessary, untimely, or even unsafe. Implementers are conscientious and hard working. They may be less confident in their own knowledge, leadership, or creativity. Often implementers are people pleasers; they may find it hard to give critical feedback to their bosses. While successful organizations need implementers to carry out the decisions of leaders when good decisions are made, they can be destructive when poor decisions are made. Individuals who function in the implementer role may personally experience a decreased sense of effectiveness since they do not advocate for their own ideas or practice agency. Additionally, their lack of agency may lead to moral distress if they feel trapped in decisions made by their leaders.

Partners champion change but also give critical feedback to their boss when it is necessary.2 In medicine, these colleagues are often the individuals who are viewed as potential leaders and are selected for future positions of authority. They volunteer to spearhead initiatives, create a sense of teamwork in their spaces through their influence, and are highly reliable in following through on commitments. Partners have dedicated themselves to the success of their bosses and their organizations. They have strong sense of ownership for the outcomes of their teams and organizations.5 They support their leaders in public, yet they will not hesitate to challenge their leaders in private when they feel as though their leader is going down the wrong path.

Partnering provides the greatest opportunities to practice agency and embrace a sense of purpose. The medical field demands a high level of leadership from all physicians even though many physicians will not serve in positions of legitimate authority at any point during their careers. As such, physicians should strive to be partners, not only to benefit the leaders, but to benefit themselves as well.

Followership Style and Well-Being

While the impact of effective leadership and its impact on the well-being and satisfaction of individual physicians has been studied, the role of effective followership has not. Leader behaviors such as inspiring others to do their best, empowering others to do their jobs, recognizing a job well done, and developing talents and skills have been shown to decrease burnout, but this places the responsibility on the supervisors.13 Individual interventions proposed to reduce burnout focus on individual stress reduction and personal well-being, but do not address how a follower may develop their own sense of agency to decrease burnout in themselves and those around them. Practicing followership skills that allow individuals to overcome perceptions of powerlessness, self-doubt, and unsafe work environments may serve as a preventative strategy for burnout. Effective followers may contribute to individual (for themselves and others) and organizational well-being by partnering with their leaders. We believe that effective followers are as important as effective leaders for organizational wellness (See Figure 1).

Figure 1

The connection between leadership, followership, and burnout. When effective followers partner with supportive and effective leaders, we see organizational wellness. When effective leaders work with ineffective followers, we see leader burnout. When effective followers want to partner with leaders but have leaders who do not give them the autonomy to do so, we see follower burnout. When neither the leaders or the followers are working in service to the other, we see the whole organization suffer.

When considering burnout and the relationship between leaders and followers, the work of Daniel Pink in his book Drive is a potentially useful framework. Pink describes that autonomy, mastery, and purpose motivate employees (followers).17 Leaders and followers both have the ability to impact these variables, but it is leaders who must allow the freedom to build all three. Followers are motivated when they have autonomy to set their goals and schedule their time. In many organizations where leaders have partnered with followers and given them more autonomy, the result has been increased productivity and work satisfaction.17 Followers who partner with their leaders may feel more valued and supported as they work toward mastering their trade. Often as followers in health care, individuals can choose an area for continued growth (clinical care, teaching, research, leadership), and leaders can assist them in determining activities to help them achieve their goals and increase their expertise. Finally, leaders and followers are more motivated when they feel that their work has true meaning and purpose.17 While this may seem obvious in health care, there are many times that the workload exceeds the resources and time and sense of purpose can be lost. While still in the follower role, being a partner can optimize an individual’s sense autonomy, mastery, and purpose.

Partners in medicine can utilize responsibility, service, and challenge not only to help their organization, but to combat many of the root causes of burnout. In Table 2, we summarize how effective followership behaviors can impact the wellness of the follower and the organization. Taking on responsibility when time is scarce can seem daunting, but this responsibility may provide an increased sense of mastery and purpose as a follower. Other responsibility actions that can be more easily deployed are providing well-researched solutions and asking for feedback. Taking responsibility provides time for followers to interface one on one with the leaders. These increased connections can help create more of a sense of shared purpose and community at work. Providing well-researched solutions can lead to an increased sense of personal effectiveness and increased sense of ownership (purpose).

Table 2

Increasing Wellness Through Effective Followership

Effective Followership	Impact on the Follower Wellness	Impact for Organizational Wellness
Takes initiative	Increases sense of purpose	Allows supervisor to focus on other tasks and supports team getting job done
Researches problems to provide context	Increases sense of ownership	Saves time for supervisor by providing data to help guide decision making
Proposes solutions	Increases sense of effectiveness	Solves problems helping to move things forward and reduces tasks for supervisor
Take ownership of team failures	Decreases depersonalization	Fosters sense of team and generates more motivation to solve problems from the bottom up
Provides constructive criticism to colleagues and superiors	Increases sense of ownership	Improves accountability and lost time for personal and organizational improvement by pointing out potential weaknesses
Handles disagreements in private	Increases empathy	Allows for disagreements to be settled with a private conversation allowing for the opportunity for improved communication and avoiding negative spillage into the workplace
Acknowledges work of others	Decreases depersonalization	Encouraging other brings up moral for the entire team
Volunteers to assist with change	Increases sense of autonomy	Directly supports superiors while fostering teamwork, can lead to work diversification

Commitment to serve a boss/organization is generally not something physicians lack. Because there are many contributors to burnout that cannot be fixed by our behavior alone it is important to realize why we serve. The why is an important aspect of burnout prevention. Pink specifically described the importance of purpose in motivating employees. We have encountered groups of physicians who have lost beloved leaders to burnout. Each time they remark that they wish they had known because they might have been able to help. This is where a follower’s commitment to serve plays a role.

Many physician leaders are still practicing clinicians and as such share in the workload burdens of their followers. When followers take on additional leadership commitments or initiatives it is almost always in addition to their current clinical load. A group of physician partners can serve their leader and each other by dividing tasks and executing them efficiently and effectively. Doing so protects the energy of the team and the energy of the leader.2 That said, followers have to be cautious of not falling into the same trap of taking on too much in an overburdened system. The point we want to emphasize here is that effective followers and leaders need to be aware of workload and how each may be able to support the other.

Challenging is an uncomfortable but vitally necessary aspect of any leader-follower relationship.2 Physicians generally want to know when something is not going well, and this is true for physician leaders as well. Followers can provide key insights into systems problems impacting organizational success and individual well-being. Followers should give leaders the benefit of the doubt and openly discuss issues they have of concern. This allows for a deeper conversation between the follower and the leader and can lead to an increased awareness of system factors and increased empathy for the leader. Moreover, by taking ownership and solving problems followers can enhance their own sense of purpose and mastery. These activities also prepare followers for future leadership positions if they are so interested.

Participating in transformation or change is easily one of the most challenging followership characteristics because it requires additional time. Despite this, projects that fuel passion can increase sense of autonomy and purpose, protecting against burnout.18 At the same time, projects often provide opportunities for significant professional growth. Followers should strive to take on projects that speak to them. To set themselves up for success, followers are encouraged to meet with their leaders to define scope and objectives for projects they take on. We also want to encourage followers to ask for autonomy and if appropriate positional authority when taking on a project. Leaders recognizing the potential of these projects to improve the system and employee well-being should look for opportunities to empower and invest in followers.

A Note to Leaders

The culture in medicine has clearly been evolving to maintain a focus on leadership amongst physicians. Because physicians will spend most their careers in a position where they have responsibility without legitimate authority, the ask is to wield leadership and influence from the position of the follower. To support followers’ efforts to partner with leaders, the organizational culture and frontline leaders should keep the needs of their followers in mind. A climate of psychological safety is one of these needs. For followers to freely voice their concerns and challenge their leaders, they must believe that they will not be ridiculed, punished, or belittled for doing so.19 Leaders who support the voices of followers and create a climate of psychological safety benefit from followers’ proactive ideas and solutions, while simultaneously fostering well-being for both the leader and the follower.

In addition to psychological safety, there are other specific steps that leaders can take to help support followers and maximize the leader-follower relationship. This includes providing opportunities for followers to be successful as mentioned above. Leaders can provide stretch assignments or other opportunities to allow followers to use their talents and further their professional development (mastery). Leaders can be proactive in removing barriers for followers as they work through projects or are trying to solve problems. Leaders can praise and recognize effective followership which helps to foster a sense of value and purpose among followers. Leaders can invest in the professional development of followers by coaching them and providing feedback. These steps demonstrate to followers that the leader cares about them and builds a positive relationship.

Ultimately, we believe that mastering followership at the partner level by employing a tangible set of skills and shifting one’s mindset, fosters autonomy, mastery, and purpose giving followers more control over their professional and personal lives. There are many systemic organizational factors external to the follower/leader relationship that can contribute to burnout, but they are likely better fought or endured with a united front.