Strategies for Health Organizations

Recognizing and rewarding workers starts with ensuring that their basic needs are met and that the totality of remuneration is consistent with their experience and effort. These approaches include:

• Conducting pay equity audits and paying a fair, living wage commensurate with experience and effort (including for “invisible work”)
• Providing workers with employer-sponsored benefits, including paid family and medical leave, health insurance, paid time off, and other benefits to address workers’ social needs

‍Evidence

Low wages disproportionately affect health care support and public safety workers (e.g., aides, technicians, EMTs) for whom median hourly wages often fall below $15/hour.¹ As a result, many experience financial instability, food insecurity, and poor health outcomes; and low wages have been associated with worker turnover and shortages. Fair and adequate wages, through policies such as minimum wage increases, have been shown to improve physical and mental health.² In one study, adequate pay for EMS workers (as indicated by worker non-reliance on overtime pay to make ends meet) was associated with 63% reduced odds of burnout.³ Another study of hazard pay in Washington state during COVID-19 improved overall economic well-being for direct care workers and was reported to improve recruitment and retention.⁴ 

In healthcare, pay disparities related to gender and race/ethnicity have also been shown across disciplines from direct care workers to physicians,^5-7 and have been associated with turnover.⁸ Pay equity audits have been show to promote transparency and internal pay equity in the workplace.⁹ 

Studies also show that the provision of employer-sponsored benefits, including health insurance and paid time off, improves worker retention and decreases turnover.^10.11 Employers can also provide additional benefits that address workers’ social needs. For example, childcare stress has been associated with increased anxiety, depression and burnout¹² and healthcare workers with young children have a higher rate of turnover.¹³ A 2022 report by the Urban Institute, suggests some employers are providing support for child care.¹⁴ 

‍Resources

The Good Jobs Institute provides an 8-step template for conducting a pay analysis  to help organization understand whether full-time hourly employees earn enough money to support their household.

MIT developed the Living Wage Calculator to help organizations and individuals estimate the local wage rate required by workers to cover the costs of their families’ basic needs. 

The Urban Institute report Employers, Work-Family Supports, and Low-Wage Workers presents the findings from interviews with 16 organizations including employer perceptions and strategies around paid leave, workplace flexibility and control, and support for child care. 

The United States Department of Labor has published guidance for calculating overtime pay in the health care industry and provides general resources on minimum wage and overtime pay.

‍Spotlights

‍Erlanger Health System: In early 2023, close to 2000 nurses employed by Erlanger Health System received a 10% pay increase. The pay increase was the latest incentive offered by the health system to retain its nursing workforce and prevent extreme burnout (bonuses and overtime pay were offered during the COVID-19 pandemic, and reliance on travel nurses was avoided). Since the pay increase went into effect, Erlanger has seen a significant decrease in the number of nurses calling in sick. 

‍Daily Pay: In an effort to alleviate employee stress, Trinity Health System is implementing a daily pay system, which allows workers to access their daily pay the following day (or same day, with a nominal fee). The program, which Trinity Health expects to expand across its organization of 120,000 employees, is available to all workers except for executives and allows them to request daily pay using an app. The program was developed in response to worker feedback and has been viewed as beneficial by Trinity Health leadership and staff. 

‍Hospital-based childcare: Recognizing that childcare is a major stressor for employees, and in light of retention challenges related to work-life demands (especially for women, who make up the majority of the health care workforce but also bear the brunt of caregiving duties), a small contingent of hospitals across the country are offering on-site childcare. These include Roper St. Francis Healthcare in Charleston, SC Wellstar Health System in Atlanta, and Ballad Health in the Appalachian region. 

‍References

¹ Characteristics of minimum wage workers, 2020. U.S Bureau of Labor Statistics. Feb 2021.  

² Ziemann M, Pittman P. Under what working conditions? An examination of health worker occupational health and compensation. Fitzhugh Mullan Institute for Health Workforce Equity, George Washington University. May 2022. 

³ Crowe RP, Fernandez AR, Pepe PE, et al. The association of job demands and resources with burnout among emergency medical services professionals. J Am Coll Emerg Physicians Open. 2020 Jan 27;1(1):6-16.

⁴ SEIU 775, Center for American Progress (undated). Higher home care wages reduce economic hardship and improve recruitment and retention in one of the country’s fastest-growing jobs. Seattle, WA, SEIU775; Washington, DC, Center for American Progress.

⁵ Horstman, C. Male Physicians Earn More than Women in Primary and Specialty Care. The Commonwealth Fund. Blog, July 27, 2022.

⁶ Campbell S, Drake ADR, Espinoza R, Scales K. Caring for the future: The power and potential of America’s direct care workforce. PHI. 2021.

⁷ Frogner BK, Schwartz M. Examining Wage Disparities by Race and Ethnicity of Health Care Workers. Med Care. 2021;59(Suppl 5):S471-S478. 

⁸ Cobb AJ, Keller J, Nurmohamed S. How Do I Compare? The Effect of Work-Unit Demographics on Reactions to Pay Inequality. ILR Review. 2022;75(3), 665–692.

⁹ Pay Equity Audits and Transparency Foster Trust, SHRM Research Shows. Society for Human Resources Management. Oct. 25, 2021.

¹⁰ Stone R, Wilhelm J, Bishop CE, et al. Predictors of intent to leave the job among home health workers: analysis of the National Home Health Aide Survey. The Gerontologist. 2017;57(5):890-899. 

¹¹ Temple A, Dobbs D, Andel R. Exploring correlates of turnover among nursing assistants in the National Nursing Home Survey. J Nurs Adm. 2011;41(7-8 Suppl):S34-42.

¹² Harry EM et al. (2022). Childcare stress, burnout, and intent to reduce hours or leave the job during the COVID-19 pandemic among US health care workers. JAMA Network Open, 5(7):e2221776

¹³ Frogner BK, Dill JS. Tracking Turnover Among Health Care Workers During the COVID-19 Pandemic: A Cross-sectional Study. JAMA Health Forum. 2022;3(4):e220371.

¹⁴ Stanczyk A, Adelstein S, Lauderback E, Adams G. Employers, Work-Family Supports, and Low-Wage Workers. Urban Institute. Oct. 11, 2019.

Worker well-being is inextricably linked with access to opportunities for personal and professional growth. Employers can promote access to these opportunities by: 

• Creating career ladders and apprenticeships
• Developing advanced roles for workers
• Coaching and mentoring workers and learners

‍Evidence

Studies have found workers who lack opportunities for growth are more likely to feel stressed out, while career development is associated with lower emotional exhaustion and retention.^1-3 Career ladder programs have been shown to improve engagement and satisfaction among pharmacists⁴ and increase salaries and promotion opportunities among medical assistants.⁵ A national scan of the literature finds that programs that create advanced role opportunities for home care have a positive impact on workers, patients, employers, and health systems – including high rates of job satisfaction and retention.⁶  

‍Mentoring has been shown to directly and indirectly increase worker perceptions of social support, reduce burnout, and improve career satisfaction in health care and academic medicine.^7-9 The benefits may also be bidirectional with benefits for mentors,^10,11 although mentors can become burned out without additional supports and training.⁷ A similar but distinct practice, coaching interventions with physicians have been shown in randomized control trials to decrease emotional exhaustion and burnout and increase quality of life, work engagement, and job satisfaction.^{12, 13} 

‍Resources 

The National Fund for Workforce Solutions’ CareerSTAT Guide to Investing in Frontline Health Care Workers provide health care employers with strategies and a framework for investing in the skills and careers of frontline workers. The guide includes case studies, such as:

• The Genesis HealthCare Geriatric Nursing Assistant Specialist role developed as a career step-up for Certified Nursing Assistants. Since 1999, Genesis has trained more than 4,000 CNAs, had a 98% reduction in use of staffing agencies, and maintained 81% retention for its 2013 program participants. 
• Jersey City medical Center trains employees ranging from housekeepers to patient transporters as patient care technicians, emergency medical technicians, and medical billers/coders. 

‍The Healthcare Career Advancement Program (H-CAP) is a national labor/management organization that works with employers, unions, and workers to deploy high-quality health workforce training and promote career progression. Their resources include the Toolkit for High Road Apprenticeship in the Healthcare Industry as well as additional resources for planning, recruiting, mentorship, assessment, and program evaluation for apprenticeship programs.

The Department of Labor’s report, Using Registered Apprenticeships to Build and Fill Healthcare Career Paths. provides examples of registered apprenticeship healthcare models.  Additional healthcare apprenticeship information is available at apprenticeship.gov. The Center for Health Workforce Studies at the University of Washington’s Use of Apprenticeship to Meet Demand for Medical Assistants in the U.S. describes key components of Registered Apprenticeship Programs, as well as strategies for financial support.

Manuals for mentors and mentees are available for many disciplines and populations, including for public safety officers, public health trainees, women, and individuals underrepresented in medicine. Much of the information contained in these resources is relevant across disciplines and settings. 

‍Coaching in Medical Education: A Faculty Handbook is a helpful tool from the American Medical Association for any educator’s coaching toolkit, containing best practices and recommendations. 

Johnson & Johnson describe robust nurse residency programs at three health systems (UConn Health, Los Angeles Medical Center, and NYC Health + Hospitals) that provide coaching, mentorship, and peer support.

‍Spotlights

‍The Missoula College Nursing Program at the University of Montana is creating an accelerated LPN to RN bridge program to promote career pathways and bolster the nursing workforce in rural healthcare facilities in the state. The Missoula College Nursing Program will allow students to receive online instruction and complete their clinical training in their own community. It will also grant academic credits for experience gained in students’ current clinical roles. 

Geisinger health system launched Geisinger Nursing Scholars Program, a career development program providing existing employees $40,000 in financial support for pursuing a health career, with a goal of funding 175 scholars per year. 

‍References

¹ American Psychological Association. Work in America Survey: Workplaces as engines of psychological health and well-being. 2023.

² Lee RT, Seo B, Hladkyj S, Lovell BL, Schwartzmann L. Correlates of physician burnout across regions and specialties: a meta-analysis. Hum Resour Health. 2013 Sep 28;11:48.

³ Yarbrough S, Martin P, Alfred D, McNeill C. Professional values, job satisfaction, career development, and intent to stay. Nursing Ethics. 2017;24(6):675-685.

⁴ Bondi, DS, Acquisto, NM, Buckley, MS, et al. Rewards, recognition, and advancement for clinical pharmacists. J Am Coll Clin Pharm. 2023; 6(4): 427-439.

⁵ Dill, J., Morgan, J.C. & Chuang, E. Career Ladders for Medical Assistants in Primary Care Clinics. Gen Intern Med. 2021;36(11):3423-3430. 

⁶ Advancing the Home Care Workforce: A Review of Program Approaches, Evidence, and the Challenges of Widespread Adoption. Fitzhugh Mullan Institute for Health Workforce Equity. 2021.

⁷ Thomas CH, Lankau MJ. Preventing burnout: The effects of LMX and mentoring on socialization, role stress, and burnout. Human Resource Management. 2009 48(3), 417–432.

⁸ Cavanaugh K, Belfer B, Cline D, et al. The positive impact of mentoring on burnout: Organizational research and best practice interventions for cancer hospital employees. Journal of Clinical Oncology 2021 39:15_suppl, 11012-11012 

⁹ Henry-Noel N, Bishop M, Gwede CK, et al. Mentorship in Medicine and Other Health Professions. J Canc Educ 34, 629–637 (2019). 

¹⁰ Newsome AS, Ku PM, Murray B, et al. Kindling the fire: The power of mentorship. Am J Health Syst Pharm. 2021 Dec 9;78(24):2271-2276. 

¹¹ Warren OJ, Carnall R. Medical leadership: why it's important, what is required, and how we develop it. Postgrad Med J. 2011;87(1023):27-32.

¹² McGonagle AK, Schwab L, Yahanda N, et al. Coaching for primary care physician well-being: A randomized trial and follow-up analysis. J Occup Health Psychol. 2020 Oct;25(5):297-314.

¹³ Dyrbye LN, Shanafelt TD, Gill PR, Satele DV, West CP. Effect of a Professional Coaching Intervention on the Well-being and Distress of Physicians: A Pilot Randomized Clinical Trial. JAMA Intern Med. 2019 Oct 1;179(10):1406-1414.

Meaningful recognition is tied to purpose and can promote a culture of kindness, gratitude, and trust. Specific strategies include: 

• Establishing formal recognition programs
• Offering incentive bonuses

‍Evidence

Meaningful recognition (i.e., acknowledging a person’s valuable contributions) has been associated with decreased burnout in critical care nurses^1,2 and peer-to-peer recognition has been associated with feeling recognized at work and a more supportive work environment in a small study of emergency medicine residents.³ Incentive or merit bonuses have been linked to increased worker performance and motivation, as well as patient safety, quality, and experience,⁴ and in a 2022 survey of nurse leaders, retention bonuses were the most commonly reported reward likely to prevent them from leaving.⁵ While many organizations implemented retention bonuses during COVID-19, there is a dearth of evidence on their effectiveness and critics warn that they do not replace the need for broader structural and organizational strategies to promote worker well-being.⁶ 

‍Resources

The American Organization for Nursing Leadership’s Nursing Leadership Workforce Compendium identifies workforce solutions that support nurse leader practices. In addition to widely addressing the issue of recruitment and retention, leadership, practice environment, and other areas, the report highlights reward and recognition strategies and identifies exemplars, such as:

• The Institute for Nursing Excellence – Penn Medicine Princeton which includes a center for professional development and recognition 
• The DAISY Award for Extraordinary Nurses established to say recognize nurses across the globe with a formal recognition program, in partnership with healthcare organizations. The DAISY Award comes with benefits for recipients including scholarships, grants, and conference offerings. 

‍Building a better carrot: Developing a staff financial incentive bonus program provides an overview of financial incentive bonus programs and employer considerations for their development, from the Medical Group Management Association. 

‍Bondi, et al.’s white paper on Rewards, recognition, and advancement for clinical pharmacists reviews the literature on rewards and recognition, and presents the findings on a survey of clinical pharmacists reward, recognition, and advancement programs.

‍Spotlights

‍Hall Ambulance Service Employee Recognition Awards: Each year, Hall Ambulance Services spends two days honoring their employees with over one hundred awards and monetary gifts.

‍UI Health Employee and Physician Recognition Program: The University of Illinois Hospital & Health Sciences System (UI Health) takes a multi-pronged approach to employee recognition. The health system’s recognition program includes on the spot recognition with shout-out and safety cards, an ICARE Award for high performing employees who demonstrate organizational values, a Safety Star Award, and a Class Act Award, as well as employee of the year awards in several categories. Awards come with formal organizational recognition, team celebration, and prizes. 

‍References

¹ Kelly LA, Lefton C. Effect of Meaningful Recognition on Critical Care Nurses' Compassion Fatigue. Am J Crit Care. 2017 Nov;26(6):438-444.

² Kelly LA, Johnson KL, Bay RC, Todd M. Key Elements of the Critical Care Work Environment Associated With Burnout and Compassion Satisfaction. Am J Crit Care. 2021 Mar 1;30(2):113-120. 

³ Chang J, Saggar V, Cortijo-Brown A, et al. Improving physician well-being and reducing burnout using a peer-to-peer recognition program. AEM Educ Train. 2023 Mar 26;7(2):e1086.

⁴ Williams W. Development and Implementation of a Staff Incentive Bonus Program. Medical Group Management Association. September 4, 2019. 

⁵ Nursing Leadership Workforce Compendium. American Organization for Nursing Leadership. 

⁶ Muoio D. Will Bonuses and Benefits be Enough to Tackle Healthcare’s Workforce Shortages? Fierce Healthcare. October 5, 2021.