Strategies for Health Organizations

Leadership is critical to workers' and learners’ experience of burnout, including leaders at all levels from C-suite to unit-level managers. Strategies to develop and hold leaders accountable must occur in concert with strategies to establish organizational Commitment & Governance and support Worker Voice. Organizational approaches to transform leadership to improve worker and learner well-being include:

• Creating leader development programs that establish healthy leadership behaviors that support and model worker well-being
• Conducting regular assessment of leadership skills that inform individualized development programs
• Establishing accountability for change, including bonus structures tied to measure of worker well-being (e.g., workforce turnover, burnout, moral injury)

Evidence

Evidence demonstrates the behaviors and leadership styles of supervisors are associated with health worker burnout.¹ Relational, participative, distributive, transformational, facilitative leadership styles in healthcare settings are associated with teamwork, communication, psychological safety, mindfulness of others, lower emotional exhaustion and depersonalization, and increased personal accomplishment; in contrast, transactional leadership styles have been associated with greater emotional exhaustion among workers.^2-4 

Specific actions, behaviors, and approaches associated with supportive leadership styles, such as leader check-ins and Positive Leaderships WalkRounds have been associated with improvements in emotional exhaustion, values alignment, teamwork climate, safety and quality improvement climate, and work-life balance.^5,6 A study at one academic medical center found two “transformational” leadership behaviors (idealized influence and individualized consideration) and one “transactional” behavior (contingent award) were associated with lower burnout.⁷ Another study showed that two 2-hour sessions on leadership training for physician resident supervisors (i.e., chief residents) significantly improved burnout rates among their direct reports.⁸

‍Resources

AMA Steps Forward provides two leadership resources:

• The Wellness-Centered Leadership Playbook describes four strategies to 1) build trust; 2) give and receive feedback; 3) prioritize clinician well-being; and 4) make unit-level changes effectively.
• The Cultivating Leadership: Measure and Assess Leader Behavior to Improve Professional Well-Being Module describes five steps to measure and improve leader behaviors to improve team satisfaction and reduce burnout.

‍Institute for Healthcare Improvement's High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs describes 5 recommended leadership behaviors to accelerate cultural change and support efforts to achieve Triple Aim results, and presents IHI’s High-Impact Leadership Framework that serves as a guide for where leaders need to focus efforts and resources in order to drive improvement and innovation.

‍Relate Lab, a collaboration between the Oregon Health and Science University and Intend Health Strategies, aims to build skills in relationship-based leadership models and engages participants across medicine, nursing, social work, public health. They offer relational leadership and relational community organizing programming (courses may require fees; a sliding fee scale is available).

Resources from the literature:

• A consensus literature review by Olson, et al. summarizes and links to studies that address: selecting, assessing, and developing leaders who demonstrate 12 leadership traits associated with well-being; egalitarian leadership process; employing leadership structures that include physicians; and participative decision-making.  
• A meta-analysis Montano et al. summarizes and assesses research on leadership styles and mental health among multiple leader-employee relationships. 
• A systematic literature review by Specchia et al. describes the association between different leadership styles and nurses' job satisfaction. 
• Lyle-Edrosolo’s The Business Case for Addressing Burnout in Frontline Leaders: A Toolkit of Interventions From Nurse Executives Around the United States describes making the business case for leadership and examples of best practices from nurse executives.

‍Spotlights
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‍Mayo Clinic has developed programs that develop and measure leadership approaches. Highlights of their work include:
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Shanafelt and Noseworthy describe Nine Organizational Strategies to Promote Engagement and Reduce Burnout implemented at Mayo Clinic, including selecting the right leaders, developing, preparing, and equipping them for the role, assessing their performance. 

In a 2013 survey, over 2800 physicians rated the leadership qualities of their immediate supervisor in 12 dimensions. Each 1-point increase in composite leadership score was associated with a 3.3% decrease in the likelihood of burnout and a 9.0% increase in the likelihood of satisfaction of the physicians supervised.

Mayo Clinic uses the Listen-Act-Develop model in their leadership development process and conducts ongoing assessments of leadership behavior on 12 dimensions.

‍References

¹ Dyrbye LN, Major-Elechi B, Hays JT, et al. Physicians' Ratings of their Supervisor's Leadership Behaviors and Their Subsequent Burnout and Satisfaction: A Longitudinal Study. Mayo Clin Proc. 2021 Oct;96(10):2598-2605. 

² Kelly RJ, Hearld LR. Burnout and Leadership Style in Behavioral Health Care: a Literature Review. J Behav Health Serv Res. 2020 Oct;47(4):581-600. 

³ Edwards ST, Marino M, Solberg LI, et al. Cultural And Structural Features Of Zero-Burnout Primary Care Practices. Health Aff (Millwood). 2021 Jun;40(6):928-936. 

⁴ Park B, Tuepker A, Vasquez Guzman CE, et al. An antidote to what's ailing healthcare workers: a new (old) way of relational leadership. Leadersh Health Serv (Bradf Engl). 2023 Mar 28 (ahead-of-print). 

⁵ Hurtado DA, Greenspan SA, Valenzuela S, et al. Promise and Perils of Leader-Employee Check-ins in Reducing Emotional Exhaustion in Primary Care Clinics: Quasi-Experimental and Qualitative Evidence. Mayo Clin Proc. 2023 Jun;98(6):856-867.

⁶ Sexton JB, Adair KC, Profit J, et al. Safety Culture and Workforce Well-Being Associations with Positive Leadership WalkRounds. Jt Comm J Qual Patient Saf. 2021 Jul;47(7):403-411.

⁷ Hu JS, Phillips J, Wee CP, Pangaro LN. Physician Burnout-Evidence That Leadership Behaviors Make a Difference: A Cross-Sectional Survey of an Academic Medical Center [published online ahead of print, 2022 Oct 19]. Mil Med. 2022;usac312.

⁸ Briggs SE, Heman-Ackah SM, Hamilton F. The Impact of Leadership Training on Burnout and Fulfillment Among Direct Reports. Journal of Healthcare Management. 2024;69(6):402.

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