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Health Promoting Work Systems Series

Editor’s Note: At times, as we move along our pathways towards creating and maintaining Wellness among our colleagues, it may feel as if there is no one else out there who understands the significance of our endeavors. We may feel alone and lacking in leadership skills, or at times, we may feel troubled by the “brick walls” which we encounter. We may even run the risk of developing a “learned helplessness” during our attempts to maintain wellness and “heal” those systemic environments in which we work every day. But let me assure you, we are not alone, for others also benefit from the discussions and the work which we undertake everyday while championing for both wellness and health-promoting work environments. To help our members develop the leadership skills to drawn upon, we are offering a 3-part series, by Katherine Sanders, PhD, to develop those skills to be able to drawn upon, while championing for and partnering with system leadership in creating systemic health-promoting work environments. The following is the first in the series.

- Dr. R. Levin 


Work’s Impact on Physician Health

Katherine Sanders, PhD
Human Factors & Work Systems Engineer

The research linking work system design with mental and physical health outcomes is well established. We just need to find some common understandings in order to address it effectively.

Four decades of research on burnout
It might seem like the burnout crisis in medicine is a recent development. The truth is, researchers have been analyzing the occupational health of healthcare professionals for 40 years. Add to that the 100 years of research on the impact of work on employee health, and we already have important insight into how work systems impact the health and wellbeing of physicians.

Many of you are aware of Christina Maslach’s work from the early 1980s on physician burnout. You probably have completed surveys investigating burnout (eg, emotional exhaustion, depersonalization and diminished sense of personal accomplishment).* What’s interesting to me is that her original recommendations about how to prevent it and how to heal it have been overtaken by the measurement of burnout characteristics. It seems the surveys have taken on a life of their own, perhaps distracting leaders from actually addressing burnout’s root causes.

As many times happens in academia, while Maslach was starting her work on burnout, psychologist Robert Karasek was also researching the impact of job design on employee health. His was the first longitudinal study to link the design of jobs with mental health outcomes.

What Karasek found was that high “strain” results when we endure high demands without having adequate control over how to meet those demands (Figure 1).

Figure 1 

His Job Strain Model demonstrated the strong association between poorly designed work systems and employees’ poor mental health. When the subsequent Whitehall studies linked Karasek’s Job Strain Model to coronary heart disease, we had solid evidence that employees in high strain jobs are at higher risk for poor physical health outcomes as well.†

And so the research linking work system design with mental and physical health outcomes is well established. But the question remains: What do we do about it? 

A systems approach
It’s wonderful to see occupational health taking center stage at the National Academy of Medicine through their Action Collaborative on Clinician Well-Being and Resilience.

One of their recent papers promotes a systems approach to reduce occupational stress. As a work systems engineer, I wholeheartedly agree with the authors’ assertion that: “While stress-reduction techniques may be helpful for individuals, a systems approach is required to effectively address a problem generated by the system.” 

When we design a work system to be health-promoting as well as productive, it’s essential to view each part of the system through the lens of employee health.

Analyzing the health of a work system
I use this work systems model (adapted from Smith and Sainfort, 1989) to investigate the health of a work system (Figure 2).

The model depicts the interdependent elements of a work system:

  • The people with their unique needs, abilities, expectations and limitations 
  • The jobs we design for them to perform 
  • The technologies we ask them to work with 
  • The environments we shape for them to work within, both physical and social 
  • And the organizational policies we create that shape their daily activities 

Figure 2

The importance of the systems approach is to emphasize that changes in one part of the system will affect the others. For example, if you change the technologies people are working with, you are likely also impacting the design of their jobs, the skills they need to do their jobs, their physical and social work environment, as well as the organizational policies and reward structures. 

So how do we clarify what kinds of system changes have the highest probability of improving the occupational health of physicians? 

The stress-strain process
When the people within a work system (or occupation) show high levels of mental and physical strain, we know there is a systemic root cause.

Unfortunately, some organizations see the trend and respond by asking that their employees become more resilient. That’s one option. It doesn’t change what’s causing the strain. At best, it reduces the symptoms people are suffering. 

I developed the occupational Stress-Strain Process diagram (Figure 3) to help explain a complex, interactive and non-linear process. Although over-simplified, the model helps us identify not only how a chronic stressor leads to mental and physical strain, but also where we can intervene to help people.

Figure 3 Stress Strain
Figure 3

Here’s an example: 

Let’s say my stressor (1) is “overload,” meaning the work system requires from me more than I can realistically accomplish. (Given that many jobs are designed without a reasonable upper limit on productivity demands, “overload” is a frequent stressor.) 

We filter the demands placed on us through our individual perceptions and hardiness (2) – essentially our unique psychological and physical resources. (Genetics deal us each a hand, and then our environments, experiences and choices over a lifetime contribute to the resources we have available to us.)

Those of us with fewer inner resources will view the additional work as more stressful than those with greater resilience. I might be working alongside someone in the same job with the same demands but, if I am not able to access the same inner resources, my response to those demands may be much more negative.

It’s my interpretation of what’s happening that will provoke an immediate psychological and physiological response (3). Embodying this response might lead to acute strain (4), such as a tension headache or a GI tract irritation. If I then have a chance to rest and recover (5), I may be able to return to my original state. 

A chronic strain outcome (6) develops when our exposure to a stressor continues over a period of time without the ability to rest or recover. We develop chronic headaches, anxiety, depression, high blood pressure or an autoimmune disorder, for example.‡

Once we find ourselves in the chronic strain portion of the process, we must find a way to heal and/or cope with our new reality. We all know what we should do to improve our resiliency and hardiness. And when we find a way to successfully recover from some sort of deformation, we have improved our resiliency (7).

But we all also have a history of “successful” ways to put our heads down and push through. Coping mechanisms (8) are a grab bag of personal habits based on what we reach for to comfort ourselves. Some of us might love to go for a run after work or release tension through martial arts or dance. Others self-medicate by smoking, drinking or eating comfort foods. By the time we are in the coping mechanism loop, we’re doing the best we can with the resources we have left. 

Supporting occupational health
It is true that if you are hardy and resilient you can withstand more stressors for longer periods. But we all know that time takes a toll on each of us. The chronic effects of poorly designed work systems will eventually degrade the health and performance of even the most hardy and resilient. We can’t tell when, and each of us has our own trajectory, but eventually, our working lives are written on our bodies and minds. 

That’s why it’s essential to know which part of the process you are planning to intervene in. The color-coding shows where different professions intervene to assist people.

In reverse order this time, the pink coping mechanisms are a grab-bag of personal choice. They are what we select to comfort ourselves in the short term, but have long-term consequences on our hardiness and resilience. 

The orange interventions (3, 4, & 5) are where medical professionals assist us. They help us lesson the toll that our stress responses take. Interventions early in the process might include biofeedback, or even just remembering to slow down and deepen the breath. Eventually our physician might suggest antianxiety medications, painkillers, physical therapy or surgery. 

The green interventions (2 & 7) are our wellness initiatives. We can eat better, move, take mindfulness classes and try to live our spiritual ideals. It all does us good. It increases our hardiness and resiliency. It allows us to change our level of response to stressors, resulting in less damage to our health.

The blue (1 & 5) shows where work systems engineers help support occupational health. We support you in identifying stressors, and then by designing new ways of working that either remove or reduce your exposure to the stressors. (In this example, overload might be a signal of chronic understaffing. Or it might be a call for workflow, job, technology and/or team redesign.) 

Engineers can also help identify places where rest breaks are necessary in a system. We must intentionally design slack into a system to promote rest and recovery, as well as providing time for social support. After all, it’s great to have a meditation room on site, but if you have no time to use it, it won’t help you.

But even this is not enough. Human factors engineers either reduce the stressors or reduce people’s exposure to the stressors. Yet, the goal for health is not only to reduce harm, but also to promote health! 

So next time we’ll look at what makes work healthy for people--things like meaning, challenge, social support and progress toward meaningful goals. These are factors to design into work systems and to preserve at all costs.

I’d love to hear your thoughts. How do you see the health of your own work system?  

*If you’ve not read Maslach’s original book, Burnout: The Cost of Caring, I highly recommend it.

Kelloway & Day (2005) do a fantastic job of summarizing the research evidence on work’s impact on mental and physical health. When you add in ergonomics, it is a wonderfully complete picture.

‡If you’re interested in the physiology of chronic stress, you might enjoy Robert Salpolsky’s classic book

Why Zebras Don’t Get Ulcers, or the Discovery documentary, Stress: Portrait of a Killer

Please visit my websites for additional resources and descriptions of a systems approach and healthy work.

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