Ask leaders of health care organizations about their top three challenges for the year ahead, and many answer, “Workforce, workforce, and workforce.” These leaders go on to say that they are struggling to recruit and retain caregivers of all types, that the costs are breaking their budgets, and that morale is at historic lows. As a direct result, every type of performance is suffering: financial, safety, and overall quality, including the patient experience.
With an air of desperation, organizations are trying many tactics, including awarding bonuses for signing, staying, and referring new recruits. They are implementing programs to reduce burnout like mindfulness training and investing in AI and other technologies that reduce administrative burden. All of these tactics to improve compensation and mitigate the deadening aspects of work have merit, but organizations should not rely upon them to create the loyalty and resilience needed for excellence in health care.
Our data on hundreds of thousands of physicians, nurses, and other caregivers in the United States shows that pride in their work and loyalty to their colleagues are the strongest correlates of their readiness to stay with their organization and continue showing up for work. Competitive pay and other support options are essential to recruiting caregivers, of course, but organizational culture, including a commitment to excellence, is what makes them stay.
Improving organizational culture is a leadership challenge that is more complex than finding the money to increase compensation or correcting the problems that cause unhappiness. After all, in life in general, happiness is something beyond the absence of unhappiness. The same is true in health care. For example, “service recovery” programs that quickly address patients’ complaints can mitigate their ire, but lack of ire does not equate to loyalty. Similarly, organizational responses to caregivers’ pain may prove that the leaders care, but it doesn’t mean that the caregivers will keep showing up and doing whatever it takes to meet their patients’ needs.
What does drive loyalty and resilience among caregivers? As is true in other industries during these difficult times, getting back to basics is crucial — and in health care that means focusing organizational culture on the noble cause of reducing patients’ suffering and then supporting caregivers in that work. Our data demonstrates that this is not wishful thinking; it is an operational imperative.
For example, we have analyzed the drivers of loyalty for 410,000 health care employees during the pandemic. In these analyses, we examine factors that correlate with employees’ expressing strong agreement with these two statements: “I would stay with this organization if offered a similar position elsewhere” and “I would like to be working at this organization three years from now.” For both metrics, there has been a marked decline across the country from 2020 to 2022 (on a 1-5 scale, from 4.15 to 4.00 for the first statement and from 3.93 to 3.78 for the latter).
But the patterns of change have not been the same in every organization and for every job type. There has been a “spreading of the pack,” with greater variation than in the past in measures of workforce engagement between organizations doing well and those doing poorly. The data suggests that leadership matters as never before — not just at the C-suite level but also at the front lines where managers really determine how organizational culture feels for employees. For example, there can be vast differences in how caregiver morale in two patient care units that are physically adjacent to each other but have different nurse managers.
Whatever variation exists among managers, there seems to be remarkable consistency in what matters to the people working for them. In our analyses, for all types of health care personnel, their organizations’ commitment to quality and patient-centered care was among the top drivers of their likelihood to stay. When employees gave their organization low ratings on these issues, they were more than six times as likely to say they were preparing to leave. These issues were important to security guards, maintenance, and clerical personnel as well as clinicians.
That finding may seem surprising at first glance, but as one hospital executive said to us, “It makes perfect sense. When patients feel mistreated, they don’t yell at the doctor very often; they take it out on the clerks and security guards. But when patients have a great experience, the clerks and security guards get to bask in the glow – and that makes them want to stay.”
For physicians, the top factors that correlated with their expressed likelihood of staying were whether they like their work, feel the organization is making good use of their skills, and the organizational culture. For example, if physicians felt that the organization did not have an inclusive culture, that increased their risk for considering leaving 5.5-fold. Competitive compensation packages are presumably critical to recruiting physicians, but culture is essential to retaining them.
Press Ganey’s data is completely consistent with the findings of a study of 20,627 physicians and advanced practice clinicians in 120 large U.S. health care organizations by Mark Linzer and his colleagues that was published last November in the JAMA Health Forum. It found that intent to leave had increased from 24% in 2019 to more than 40% in 2021 but identified several factors that mitigated the risk of burnout. In multivariate regression analyses, positive factors included feeling valued, good teamwork, and having values that are aligned with those of leaders.
Our data for physicians, nurses, and all types of personnel demonstrate a halo of positive effects that accompany these sources of caregiver pride. For example, these measures of overall “engagement” with the organization also correlate strongly with measures of safety culture, such as their confidence in the organization’s commitment to preventing and reporting adverse events — and those safety culture measures are associated with lower rates of safety events. In short, data confirms that excellence in all performance areas that drive business success are intertwined: patient experience, quality and safety, and the engagement of the workforce.
The implications of these findings for health care leaders are that they, of course, must listen carefully to grasp what issues are causing employees’ pain and fear and try to address them. But leaders must also listen to understand their employees’ hopes for what their work means to them and reinforce the aspirations that brought their employees to health care to begin with.
To do that, leaders must be clear about their values, their commitment to safety, the reduction of suffering, and a culture of respect and inclusion. They must prove their authenticity by committing to measuring how things are going on these issues, being transparent with the findings, and using them to improve. The result will be greater workforce loyalty and resilience, which will translate to better performance of all types.
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