My guest post appeared on January 23, 2019 in Patient Safety Beat, a blog of the Betsy Lehman Center for Patient Safety.
Health care organizations are moving to address clinician burnout with a real sense of urgency. It is now commonly accepted that burnout is widespread among health care professionals and has serious repercussions for patient safety and the quality of care. A report released last week by several major Massachusetts health care organizations labeled the situation “a public health crisis” and warned about the adverse impact “on the health and well-being of the American public.”
And though there is currently little evidence about how to effectively tackle the problem, the experience of hospitals and physician practices with various initiatives – and the lessons learned – provide a roadmap for beginning to address a crisis that is having a profound effect on the health care system.
While the term “burnout” is often used informally to indicate fatigue or boredom, it has been defined by psychologists as including three components: emotional exhaustion, depersonalization, and inefficacy, or a low sense of personal accomplishment in one’s work.
The definition may be relatively clear, but there is little agreement about how to identify individual clinicians with burnout. The most commonly used survey tool was developed for research into causal factors, not for the diagnosis of burnout in individuals and the term burnout is often loosely used to include other associated but distinct conditions, such as depression, professional dissatisfaction, moral distress, and substance misuse. As Steven Adelman, M.D., Director of Physician Health Services in Massachusetts, notes, “Several different diagnoses have been conflated into the term ‘burnout.’ The word is often used as a catchall.”
I was intrigued when I read in Beyond the Wall of Resistance by Rick Maurer about Douglas McGregor’s theories on leadership. (Apparently, McGregor wasn’t the first to put forth these theories, but was the first to name them, back in the 1950s.) McGregor was a social psychologist interested in how human factors affected organizational behavior and organizational outcomes.
In short, McGregor’s work described two approaches to leadership. Theory X maintained that workers need to be led. That without tight oversight, workers will become unmotivated, unambitious, and resistant to change. In contrast, Theory Y put forth that workers were not passive and under the right conditions, the average adult will accept responsibility and engage in work with creative energy.
McGregor described the difference between the two approaches this way, “Theory X places exclusive reliance upon external control of human behavior, whereas Theory Y relies heavily on self-control and self-direction. It is worth noting that this difference is the difference between treating people as children and treating them as mature adults.”
Theory X dictates the need for a dictatorial style of management. It’s the old “top-down, mandating” type of leadership that is about control. It fuels a lack of engagement and fails to extract the full potential of employees and of the collective whole. Theory Y treats workers with respect and engages them fully in their work.
From my observations, Theory X seems to be a lot more prevalent in health care. And there is evidence it contributes to clinician burnout. A 2015 Mayo Clinic study showed that certain behaviors of leaders predicted a lower risk of burnout among physicians. These behaviors, such as “Encourages employees to suggest ideas for improvement,” are consistent with Theory Y.
Where can we find theory Y? There are a number of leadership philosophies that embrace it. For example…
I love the idea of turning a negative approach to improvement in health care—looking for problems—on its head. Appreciative inquiry, a process of focusing on a group’s inherent strengths and fostering positive interactions among group members, is one way of fostering change with a positive approach. Positive deviance (PD) is another.
Basically, PD involves identifying what’s working and usual local solutions owned by the people involved to make improvements. According to Leading Change in Healthcare: Transforming Organizations Using Complexity, Positive Psychology, and Relationship-centered Care, a fascinating book I’m currently reading, PD was first developed as a way to address malnutrition in poor communities—by looking for children who were healthy despite the limited resources, learning what the mothers of these children were doing differently (the “deviance”), and creating opportunities for other mothers to practice these different behaviors.
What if we were to apply positive deviance to the problem of clinician burnout? What might that look like?