Organizational Factors

Organizational leadership, culture, and policies can play a significant role in burnout and well-being.

Burnout is driven largely by external factors outside the control of an individual clinician. These include the culture and policies of the organizations that employ clinicians, much of which is determined by leadership.

Leadership and Culture

As the U.S. health care industry evolves, clinicians are increasingly employed by large organizations like hospitals and health maintenance organizations – introducing a bureaucratic load that can impact clinicians’ sense of autonomy, control, and satisfaction. Amid this transition, it is more important than ever that organizational leaders partner with clinicians to shape culture, multi-component strategies, and policies that support their well-being.

Although burnout is widely recognized as a significant problem that impacts the quality of health care, including number of medical errors, and clinicians’ well-being, organizations must recognize it as a system issue, rather than placing the onus on clinicians to build personal resilience. Individual strategies to reduce burnout, such as stress management workshops and mindfulness trainings can result in well-meaning but inadequate solutions focused solely on the individual clinician. These activities do not address the upstream drivers that contribute to burnout, and may allow harmful system trends to continue. Furthermore, simply raising concern about burnout and its prevention without dedicated investment and follow-up by organizational leadership may alienate clinicians and contribute further to cynicism and reduction of work effort.

Evidence shows that the vision, mission, and values of an organization shape its culture and affect clinicians’ satisfaction, sense of belonging, and clarity of purpose. Specifically, an emphasis on productivity as a core value is associated with decreased professional satisfaction, whereas an emphasis on quality of care and work-life integration increases satisfaction and reduces stress. Leaders should be aware of the many factors that influence organizational culture and take steps to realign policies with values as needed.

The effectiveness of direct supervisors may also negatively or positively influence burnout. In one study, positive leadership skills in supervisors were associated with increased physician satisfaction and decreased burnout risk. Organizations that lack skilled supervisors, therefore, may be missing a crucial protective factor. The problem can be perpetuated when organizations fail to establish leadership standards, hold leaders accountable, and remove those who are ineffective.

Diversity and Inclusion

Despite widespread efforts to increase diversity, racial and ethnic minorities are still significantly underrepresented in health care professions. For example, African Americans make up about 13 percent of the U.S. population but only 7.5 percent of students entering medical school, a disparity that may have its roots in early education. According to the Association of American Medical Colleges, pervasive unconscious bias results in physicians from underrepresented groups being paid less, receiving fewer opportunities for advancement, and feeling marginalized within their teams. Organizations may send unintentional signals that reinforce this marginalization through “lack of diversity among top leadership positions; institutional grant and funding awardees; success stories featured in school magazines; names of centers, departments, and buildings; and even the portraits adorning the walls.” Health care professionals from underrepresented groups are often asked to serve on diversity taskforces, a request that, while well-intentioned, further pigeonholes these individuals and adds to their workload.

Women physicians may also experience exclusion and marginalization at work due to the perception that women are not well-suited for certain specialties or the assumption that women prioritize family life over career advancement. As a result, female physicians may feel unable to acknowledge their stress for fear of confirming biases. Women also endure sexual harassment, hold fewer leadership positions, are paid less, are less likely to be promoted from entry-level to senior-level administrative positions, and receive less recognition than male colleagues.

Finally, although more research is needed to understand the experiences of LGBTQ clinicians, one study shows that a significant percentage of LGBTQ physicians report being harassed and ostracized by colleagues or have witnessed disrespectful or discriminatory treatment of LGBTQ patients. In addition, some organizations do not offer partner benefits for LGBTQ employees, making them feel unwelcome or unable to accept a position that might otherwise advance their career.

Overall, discrimination and exclusion in the workplace may contribute to the erosion of important factors that protect against burnout – including effective teamwork, supportive professional relationships, fairness and opportunity, and a culture that values work-life integration.

We can help prevent #burnout by looking at the culture and policies of the organizations that employ clinicians.

Workload and Compensation

Burnout risk rises with increased workload and hours worked. Physicians work about 10 more hours per week than other professionals, with nearly 40 percent working more than 60 hours—a schedule that many report doesn’t leave enough time for family or personal interests. Among surgeons, long work weeks and many nights on call are strongly correlated with burnout, depression, medical errors, and intent to leave the profession. Nurses, too, experience unrealistic workloads with unmanageably high patient-to-nurse ratios, a trend associated with burnout and turnover. Outside of actual hours worked, feeling pressured for time to deliver high-quality care also contributes to stress and dissatisfaction. More flexible organizational policies – such as allowing clinicians to work less than full time or to flex hours within the work week – may improve satisfaction with work-life integration, although stigma may prevent clinicians from utilizing them.

Consistent with the finding that productivity as an organizational value increases stress, physicians may be at greater risk for burnout when their income is based on individual productivity. This compensation structure may encourage physicians to spend less time per patient, order more tests, and work longer hours—effects that are harmful to quality of care as well as clinician well-being. Significant levels of educational debt among physicians and pharmacists, as well as cultural normalization of excessive work hours, may compound the tendency toward overwork within the individual productivity model of compensation. Risk may be mitigated by a salaried compensation structure or by innovative models that reward quality and patient satisfaction over volume, incorporate self-care requirements, or offer sabbatical-like opportunities.

Other Factors

Many other elements relating to organizational culture and policies affect clinician well-being. Visit our Conceptual Model to see all the factors that shape burnout risk, or click here for information about documentation requirements, teamwork, and workplace safety.

Bottom Line

Organizations that employ clinicians have a responsibility to design policies and foster workplace culture that promotes well-being. The leaders responsible for shaping these elements—from CEOs to frontline supervisors—are among most critical campions in the movement to prevent and reduce burnout.

Over 150 organizations are taking the lead and have committed to promoting well-being within their institutions. Read their commitment statements.