Empowering Workers & Strengthening Leadership and Governance
Federal, state, and local governments can invest in programs to implement and develop the evidence to support organizational change. Stronger worker and learner protections are also needed to ensure individuals are able to speak up in the face of negative conditions driving burnout and moral injury. The approaches here are one part of the broader set of Government Actionable Strategies needed to change incentives and accountability for organizations to prioritize worker and learner well-being.
Note: Research examining the most effective policies is often limited. Where there is evidence, we try to provide it. In many cases, we provide spotlights of federal, state, or local policies and programs that can be adopted or adapted in other places.
Invest in Programs and Evidence
Federal, state, and local governments can both elevate the issue of health and public safety worker burnout and moral injury and make investments to advance health and public safety worker well-being. Approaches include:
- Increasing awareness of health and public safety worker and learner well-being
- Funding implementation, research, resources, and support
Resources
The 2022 U.S. Surgeon General’s Advisory on Addressing Health Worker Burnout raised awareness and understanding for this issue and drew attention to needed actions by health care organizations, government, health insurers, technology companies, academic institutions, and others. The Advisory recommends federal, state, local and Tribal governments can invest in evidence-based practices, plans, and partnerships.
The National Academy of Medicine (NAM) Action Collaborative on Clinician Well-Being and Resilience call for collective action at organizational, state, and national levels, as well as investment in research and information sharing to advance evidence-based solutions. The National Plan for Health Workforce Well-Being prioritizes investing in measurement, assessment, strategies, and research and recommends:
- Coordinating and funding a research agenda
- Creating and managing a national registry of evidence-based interventions
- Enhancing wide-scale uptake of implementation best practices and approaches
- Convening conference and symposia to share strategies for improving well-being and preventing and reducing burnout and distress
The VA Clinician Burnout Research Agenda reviewed existing evidence and developed a research agenda to guide future investments in research on the drivers of burnout and effective interventions. Some of the key recommendations include:
- Prioritize research on interventions at the organization or system levels
- Focus on effectiveness of interventions on clinicians of color and other dimensions
- Include studies on the role of effective VA leadership.
Spotlights
Congress passed the Dr. Lorna Breen Health Care Provider Protection Act in 2022 authorizing grants to improve mental health and resiliency for health care providers. The American Rescue Plan Act of 2021 provided funding for this purpose and HRSA awarded 44 grants and the technical assistance center in early 2022. In addition, HHS must: 1) Conduct a campaign to encourage health care providers to seek support and treatment and disseminate best practices; and 2) Study and develop policy recommendations.
The National Institute for Occupational Safety and Health (NIOSH) is federally funded to support research and develop resources to improve workplace safety. Key programs include the Total Worker Health® Program, which includes guides, making the business case resources, and the NIOSH Worker Well-Being Questionnaire, and Healthcare Workers resources on infectious and chemical agents, work stress, and pandemic planning. NIOSH is also launching a Mental Health Initiative for Health Workers
Strengthening Protections to Speak Up
Government policies to protect worker and learner voice - particularly the ability to speak up in the face of unsafe or unfair conditions affecting patients and communities - is central to addressing burnout and moral injury. While actions to empower workers and strengthen leadership and governance are needed, stronger protections - whistleblower protections, restrictions against noncompete agreements, and right to unionize laws - ensure workers have voice even in the most challenging environments.
Evidence
OSHA enforces federal laws to protect workers from retaliation for reporting violations of workplace safety and health. However, outside of workplace safety and health, whistleblower laws vary across states in scope of coverage (e.g., public vs. private employees), incentives for disclosure (e.g., rewards and protection from retaliation), and ways to report (e.g, hotlines, confidentiality, and anonymity).1 This variation can discourage speaking up in the face of unsafe or unfair conditions for patients and communities.
Unions are playing an increasing role in health care. An estimated 13.5% of healthcare practitioners, 9.4% of healthcare support occupations, and 35.5% of protective service occupations are represented by unions.2 In health care, evidence examining COVID-19 in nursing homes suggests unions may play a role in better patient outcomes and were associated with decreased staff turnover.3,4 However, an evaluation of surgical residency programs found resident unions were not associated with improved reports of burnout, suicidality, job satisfaction, or mistreatment.5 In general, state “right-to-work" laws, which decrease union bargaining power, have been associated with lower wages and increased occupational fatalities.6-8
Resources
OSHA’s Whistleblower Protection Program, which aims to protect workers from retaliation for reporting violations of workplace safety and health, has been criticized for being insufficient.
Michaels and Barab argue for modernizing OSHA, including: 1) developing a nimble standard-setting process; 2) increasing deterrence; 3) providing full OSHA coverage for all workers; and 4) strengthening whistleblower protections.
Spotlights
In January 2023, the Federal Trade Commission solicited public comment on a new rule to ban non-compete clauses. A number of states have banned noncompete agreements specifically for healthcare workers (e.g., New Hampshire, Delaware, Massachusetts, and Rhode Island) while some states have more generally banned non-compete clauses (including California, North Dakota, and Oklahoma).
The U.S. Department of Labor maintains a Worker Organizing Resource and Knowledge Center with information and resources on unions and collective bargaining, including information on and examples successful labor-management partnerships.
California passed legislation to help individuals obtain and maintain health benefits through California Health Benefit Exchange if they lose employer-provided healthcare coverage as a result of a labor dispute.
References
1 West JP & Bowman JS. Whistleblowing Policies in American States: A Nationwide Analysis. The American Review of Public Administration. 2020;50(2), 119–132.
2 U.S. Bureau of Labor Statistics (Jan 19, 2023). Economic News Release: Union Members Summary.
3 Dean A, et al. Resident Mortality And Worker Infection Rates From COVID-19 Lower In Union Than Nonunion US Nursing Homes, 2020–21. Health Affairs. 2022;41(5): 751-9.
4 Dean A, McCallum J, Venkataramani A, Michaels D. Labor Unions and Staff Turnover in US Nursing Homes. JAMA Netw Open. 2023;6(10):e2337898.
5 Brajcich BC, et al. National Evaluation of the Association Between Resident Labor Union Participation and Surgical Resident Well-being. JAMA Netw Open. 2021 Sep 1;4(9):e2123412.
6 Sudheer C, et al. The economic impact of right-to-work laws: Evidence from collective bargaining agreements and corporate policies. J Financial Economics. 2020;137(2):451-69.
7 Zoorob M. Does ‘right to work’ imperil the right to health? The effect of labour unions on workplace fatalities. Occupational and Environmental Medicine. 2018;75:736-738
8 Hagedorn J, Paras CA, Greenwich H, Hagopian A. The Role of Labor Unions in Creating Working Conditions That Promote Public Health. Am J Public Health. 2016;106(6):989-995.
