Responding to the Great Resignation: Detoxify and Rebuild the Culture.

INTRODUCTION

We have all looked death in the face for two years. In the ICU and at grocery store checkout lines, we have contemplated succumbing to COVID-19 or transmitting it to loved ones. In this context, Americans are leaving their jobs in an exodus called “The Great Resignation”; physicians and other healthcare workers (HCWs) are no exception.[1] Indeed, all types of HCWs are departing their jobs, thus putting additional pressure on physicians and healthcare organizations.[2] Healthcare leaders, trying to reestablish viable frameworks for care after the pandemic, may be unaware of these changes. In this Viewpoint, we offer constructs to understand factors that lead physicians and other HCWs to resign, and provide suggestions as to how leaders can restore organizational loyalty and reduce turnover. Our hope is that healthcare leaders will seize this opportunity to prioritize concrete support and culture change for their workforce, leading to a stronger sense of community and a renewed commitment to the work.

WHY DO PEOPLE STAY IN A JOB?

Healthcare workers stay in jobs and maintain work hours due to values alignment, perception of an equitable culture, job satisfaction,[2] and support for professional development. Leiter and Maslach found that retention relates to manageable workloads, work-life balance, feeling valued, work flexibility, salary, and benefits.[3] Many of these factors were adversely affected during different phases of the pandemic; for example, values were likely closely aligned earlier in the pandemic but then drifted apart as healthcare organizations’ focus on service shifted to fiscal sustainability.

In Bogaert’s study of 7300 diverse public health workers,[4] satisfaction with supervisor was one of the strongest predictors of intent to stay (85% greater odds vs those not satisfied). Intent to stay also correlated strongly with overall job satisfaction (60% greater odds of staying) and organizational support (56% higher odds of remaining). Organizational support was evidenced by addressing training needs, good communication, rewarding innovation, and reasonable workloads.

WHAT IS THE GREAT RESIGNATION ABOUT?

Chaotic clinical environments exacerbated by COVID-related work conditions added to underlying time pressures, lack of work-home balance, work overload, and perceived lack of organizational support; these have all contributed to the Great Resignation in healthcare.[1] Recent work suggests that people are driven from jobs by toxic cultures,[5] including lack of equity, disrespect, and unethical work climates. Many health systems have quickly returned to full in-person schedules, boosting workloads while paying little attention to workers’ feelings and values after two years of the pandemic. For clinicians and staff, this lack of attention to key drivers of burnout may well be the major cause for departure. Costs of leaving due to burnout are high, estimated at 4 billion dollars annually in the USA.[1]

In addition, as reported by NPR, the job exodus is in part existential with many HCWs having “pandemic epiphanies” about how they want to live their lives. It is known that traumatic events lead to “rewiring” and strengthening of neural networks; we thus postulate that recent traumatic events, including remote work with simultaneous home schooling, separating dying patients from their families, and other social and economic challenges, have led to job dissatisfaction and many HCWs making dramatic choices in how and where they wish to work. Prioritizing business goals in ways that don’t align with worker values is another source of concern, especially for clinicians who want employers to acknowledge their childcare stress, health issues, the need for equity and inclusion, and financial challenges,[1] as well as the moral injury of attempting to provide high-quality care under such straining circumstances.

WHAT CAN LEADERS DO?

Constructs from job decision science may allow us to attenuate a Great Resignation in medicine. Ignoring key aspects of the humanity of healthcare workers is fueling a national tendency to depart. Because satisfied and engaged workers stay, we must build satisfaction-enhancing organizational cultures, which include aspects such as quality emphasis, cohesion, communication, and values. Organizations can demonstrate support by addressing training and keeping workloads reasonable. Supervisors must show respect, support work-life balance, prioritize inclusion and equity, turn attention to career development,[4] and modulate their attention to finances based upon worker capacity.

Pre-existing disparities were exacerbated as the pandemic disproportionately increased caregiving burdens of women and workers of color, while career development opportunities, salaries, and benefits often stalled due to health systems’ fiscal challenges. The odds of burnout among female clinicians remain over 50% higher than in men, and workers of color are 30% more likely to intend to leave jobs.[4] Explicit understanding of the unique challenges faced by women and people of color is crucial in demonstrating all workers are valued and creating a culture of equity and inclusivity. Specific strategies should be developed to address unique systemic challenges faced by women and people of color, particularly by giving workers most affected the power to implement proposed solutions they develop.

Shanafelt and colleagues found that providing 20% time for clinicians to do “what they most care about” is associated with 50% less burnout,[6] a factor closely tied to retention. Giving more time to do what clinicians value may be less costly than scrambling to replace job vacancies and is a tangible way to demonstrate respect and values alignment.

Schein has described organizational culture as “a deep phenomenon including a set of assumptions that is transmitted to new team members as the organization’s way of thinking and feeling”.[7] One culture type, termed group culture, is associated with worker satisfaction. Group culture includes cohesion, participation and communication; thus, evidence suggests that leaders emphasizing the building of cohesive teams with strong communication and participation could be a powerful remedy for the rewiring from trauma, and lead to greater satisfaction and retention. Because values are critically important to a supportive workplace, meeting with clinicians to encourage value definition and alignment can be a powerful means of promoting retention.

WHAT REMAINS UNKNOWN?

While we know feeling valued relates to less burnout, we don’t know what underlies “feeling valued”. And if we wait for colleagues to come with plans to leave, it is often too late to remedy past errors to retain them. Until more is known, we believe it is prudent to assume anyone in healthcare may be re-evaluating their job, and focus on the universal approaches outlined above.

CONCLUSION

The experiences of the healthcare workforce have led to an exceptionally challenging time for sustainability in work.[1] Having a laser focus upon workload, values and caring for the healthcare workforce can pay huge dividends in maintaining a healthy and sufficient team; a resilient organization will identify ways to be flexible and shift quickly with surges in stress. Healthcare workers would be thrilled to stay at workplaces that demonstrate respect for their tremendous sacrifices, value workers above financial incentives,[5] and acknowledge and address moral injury. Healthcare leaders are being called upon to demonstrate that their organizations are places worth staying, places that care about their employees, are grateful for their dedication and service, and will refashion work in a just and sustainable manner.