Clinician burnout is one of the most tenacious problems facing the contemporary health system. Recent years have seen a plethora of guidance on reducing burnout and improving health care workers’ well-being following the pandemic, but little evidence of improvement. Seeing the problem through an occupational health lens can reveal different solutions.
Occupational health is a subfield of public health concerned with promoting workers’ health, safety, and well-being. From the perspective of occupational health, work-related stress constitutes a hazardous exposure and significant safety risk for the health care workforce. Due to an onslaught of work-related stressors, from staffing shortages to resource constraints to entrenched social injustices, most of the U.S. health care workforce currently practices in unsafe conditions.
It is time to see clinician burnout for what it is: a problem of hazardous work environments.
From mental health to occupational health
Longstanding models for clinician burnout rely on a mental health lens that locates distress within individual workers. Systems-oriented approaches have gained increasing attention since the National Academies of Medicine’s 2019 report advocated this strategy. Yet “system,” a phrase that signals health care’s adaptive complexity and distributed responsibility, is a slippery concept that is difficult to operationalize and measure. Systems approaches to clinician well-being have the potential to default to tips from health systems on individualized coping strategies.
Researchers continue to rely on individual measures of work-related distress, and interventions still focus on individual clinicians. Such methods reify burnout as an individual’s problem. Explaining individual distress through a mental health lens risks blaming the victims for problems that have structural causes, then encouraging the victims to fix themselves and get back to work.
The field of occupational health and safety provides an alternative lens for studying and responding to clinician burnout that recognizes that work itself can be hazardous to workers’ health. Responding to clinician burnout from an occupational health perspective requires fixing the root causes of such distress, which frequently originate in the organizational and external environments. This strategy acknowledges that work is a social determinant of health akin to other social determinants (e.g., food security and housing).
The insight that organizational factors shape worker well-being, in itself, is not novel. Yet research conducted within this paradigm also recognizes that forces further upstream have downstream effects on worker well-being. External environmental factors affecting clinician well-being may include employment and labor market patterns such as nursing staffing shortages; cultural factors such as mistrust and misinformation; and social, policy, and economic stressors such as the corporatization of medicine, deep-seated health inequities, and mixed public health messaging.
Four ways an occupational health lens can improve clinician burnout
Adopting an occupational health lens on clinician burnout means shifting our focus from distressed workers to hazardous work environments. How should we do this?
First, flip the conceptual framing of burnout to begin from hazardous work environments. Reframing the problem means that the change we seek is environmental. Solutions for burnout require changed environments that can support the workforce within them.
For example, Optum, a health care services provider with burnout rates 10 percent lower than average, has eliminated prior authorization to streamline referrals to specialty care. Atrius Health likewise reduced electronic communication in-basket volume by 25 percent through a multiyear initiative. Such initiatives can reduce the administrative burden that is a leading cause of clinician burnout.
Second, embrace a workplace health and safety framework for clinician well-being. The National Institute for Occupational Safety and Health (NIOSH) calls for regulating health care spaces for psychosocial safety in a similar way to how they are regulated for physical safety. Its revised Hierarchy of Controls for limiting hazardous exposures in the workplace follows an inverted pyramid structure, in which interventions effect greater change the further they move from targeting individuals. This approach suggests that redesigning the workspace to foster social interaction among teams and implementing feedback sessions among administrative leaders and clinicians would both be more effective at reducing burnout than encouraging personal change through stress-reduction techniques.
Third, prioritize analysis of and response to the structural conditions that lead to distressed work environments. Doing so requires going beyond standard epidemiological methods and tools. This enterprise can be enhanced by collaboration with social scientists and historians, who can offer different forms of evidence and insights into the structural drivers of workplace distress (e.g., staff turnover and labor shortages). Data from our study of frontline physicians during COVID-19 highlight a possible role for institutional advocacy—such as investing in community-based vaccination campaigns.
Fourth, adopt measurement strategies that incorporate organizational-level metrics for understanding clinician burnout and well-being. Measuring organizational resilience, a unit’s ability to adapt and perform in the face of organizational stressors that lead to burnout, is one such strategy. Urging health systems and organizations to perform self-studies that assess organizational culture and its relationship to worker well-being is another.
NIOSH offers a wealth of planning, assessment, and evaluation tools for assessing the work environment and integrating safety, health, and well-being into the workplace in ways that go beyond wellness programs for individuals. Such approaches can help quality improvement researchers and implementation scientists to target the environment as opposed to individual mental health.
When clinicians did not have adequate gloves, gowns, and masks during the COVID-19 pandemic, we were outraged. Why should psychosocial safety be treated any differently?
Occupational health and safety provides evidence-based solutions that can break through the impasse of clinician burnout and health care worker retention. It is time that we embrace it to improve clinician well-being.
Mara Buchbinder is a medical anthropologist. Tania M. Jenkins is a sociologist. John Staley is a public health policy and management expert. Nancy Berlinger is a senior research scholar. Liza Buchbinder is an internal medicine physician and medical anthropologist.
