Nobody denies that burnout and stress is high amongst many health professionals around the world.

But that doesn’t mean joy in work is impossible, says the Massachusetts-based Institute for Healthcare Improvement (IHI). In fact, it argues, improving joy in work is “possible, important and effective” as joy impacts not only on staff satisfaction but also on patient experience, quality of care and an organisation’s performance.

The institute sought to put its theory into action with a series of innovation projects in 2015-16 involving hospitals and health organisations in both the United States and the United Kingdom – including the American Association of Critical Care Nurses – and earlier this year published the resulting IHI Framework for Improving Joy in Work.

Dr Donald Berwick, IHI’s president emeritus, admits that joy in work sounds “flaky”. And, as he writes in a foreword to the 42-page framework document, the first feedback he received to suggesting joy in work should be a strategic goal for health organisations was “Get real!”

He acknowledges getting through the day is probably a more common goal in “inevitably stressed” work environments where “truly good people try hard to cope with systems that don’t serve them well, facing demands they can, at best, barely meet”.  But the research literature is there that joy is both possible and important for the healing professions.

Why focus on joy in work?

Recent US studies found that 33 per cent of registered nurses seek another job within a year and 50 per cent of doctors report symptoms of burnout.

The institute decided that part of the solution was to focus on steps to restore joy to the healthcare workforce through a practical framework. It did a scan of the current published literature on engagement, satisfaction, and burnout; carried out interviews and site visits based on the literature scan; and worked with 11 health and healthcare systems in a two-month prototype programme testing steps, refining the framework, and identifying ideas for improvement.

The report – two of its six authors are nurses – says focusing on joy in the “physically, intellectually and emotionally demanding” health professions was important for three reasons.

Firstly, it says joy is one of healthcare’s greatest assets and looking at assets – and not just the health system’s deficits and gaps – may help find a solution to burnout. “Healthcare is one of the few professions that regularly provides the opportunity for its workforce to profoundly improve lives,” says the report. “Caring and healing should be naturally joyful activities.”

The second reason was that joy was more than the absence of burnout – it was also about having meaning and purpose. “By focusing on joy through this lens, healthcare leaders can reduce burnout while simultaneously building the resilience healthcare workers rely on each day.”

Finally, having joy in work can be seen as a fundamental right. The report authors point to the work of W Edwards Deming, the ‘father of quality management’, who said, “Management’s overall aim should be to create a system in which everybody may take joy in [their] work.”

The report says there is also a strong business case for improving joy, though it acknowledges there is not a single validated measure for joy in the workplace. But the business case for joy in work draws on outcomes including staff engagement, satisfaction, patient experience, burnout and turnover rates which in turn have been linked to greater professional productivity, lower turnover rates, improved patient experience, outcomes and safety resulting in lower costs.

“Perhaps the best case for improving joy is that it incorporates the most essential aspects of positive daily work life,” says the report. “A focus on joy is a step toward creating safe, humane places for people to find meaning and purpose in their work.”

Taking action on joy

Creating joy and engagement in the workplace is a key role of effective leaders, believes the Institute.

But it says in developing the framework it became evident that leaders often find it challenging to see a way to move from the current state to joy in work. This led to the ‘Four Steps for Leaders’ (see box) to help guide them in: finding out what matters to their staff, identifying impediments to joy, taking a systems approach to addressing those barriers, and testing whether the approaches are working.

An example from one of the framework prototype initiatives was a hospital inpatient unit deciding to focus on improving teamwork by testing introducing change-of-shift huddles to the unit’s various teams until the nurses involved established the best time, what to focus on and who would lead the huddle. By the end of four months, 90 per cent of teams on the unit were conducting daily huddles and engagement scores had risen by 30 per cent.

Another example was staff at the University of Virginia School of Nursing who identified a strong desire not to feel the pressure to respond to work emails when on time off. A small group of staff tested a small change – stopping sending email to staff during their time off – and the positive benefits led to it being expanded to all employees.

The paper says the ‘Four Steps for Leaders’ do not ignore the larger organisational issues, or “boulders” that exist, such as the impact of electronic health record functionality on clinicians’ daily work, or workload and staffing issues.

“Rather, the steps empower local teams to identify and address impediments they can change, while larger system-wide issues that affect joy in work are also being prioritized and addressed by senior leaders. This process converts the conversation from ‘If only they would …’ to ‘What can we do today?’”

The institute also created a framework that sets out the nine core components they believe contribute to a happy, healthy, productive workforce.

With Maslow’s hierarchy of needs in mind, it identified that there were five fundamental human needs that must be met to improve joy in work. These are: physical and psychological safety; meaning and purpose; choice and autonomy; camaraderie and teamwork; and fairness and equity.

“While all five of these human needs will not be resolved before addressing local impediments to joy in work, actions and a commitment to addressing all five will ensure lasting results,” says the report.

The framework and steps aim to help health leaders start on the path to more joy in the workplace and less burnout – a path that the institute believes is worth following for both the benefit of staff and patients.

“The gifts of hope, confidence, and safety that healthcare should offer patients and families can only come from a workforce that feels hopeful, confident, and safe,” says Berwick. “Joy in Work is an essential resource for the enterprise of healing.”

He adds that leaders who use the framework “might well find that the joy it helps uncover is, in large part, your own”.

Four Steps for Leaders (towards fostering joy in the healthcare workforce)

  1. Ask staff, ‘What matters to you?’
  2. Identify unique impediments to joy in work in the local context.
  3. Commit to a systems approach to making joy in work a shared responsibility at all levels of the organisation.
  4. Use improvement science to test approaches to improving joy in work in your organisation.

IHI Framework for Improving Joy in Work

  • Physical and psychological safety: Do people feel free from physical harm? Including work-related injuries, infections and violence? Do they feel secure and free to express relevant thoughts and feelings, ask questions, admit mistakes or speak up about unsafe conditions?
  • Meaning and purpose: Do people feel that the work they do makes a difference?
  • Choice and autonomy: Do people feel they have a choice and voice in the way things are done?
  • Camaraderie and teamwork: Do people feel like they are part of a team and have mutual support and companionship?
  • Recognition and rewards: Is there meaningful recognition of people’s contribution? Are team accomplishments celebrated?
  • Wellness and resilience: Is the health and wellness of all employees valued including cultivating personal resilience, stress management, an appreciation of work/life balance and provision of mental health support?
  • Participative management: Do leaders involve and engage others before implementing change? Keep individuals informed of future changes that may impact on them? Do they consistently listen to everyone – not only when things are going well?
  • Daily improvement: Does the organisation use improvement science to identify, test, and implement improvements to the system or processes?
  • Real-time measurement: Do the measurement systems used enable regular feedback to facilitate ongoing improvement?
  • Source:Perlo J et al (2017) IHI Framework for Improving Joy in Work. (IHI White Paper) Cambridge, Massachusetts: Institute for Healthcare Improvement. (Available online at


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