Although top-down strategic lens and bottom-up proactive lens approaches are important, current strategies tend to focus heavily on top-down approaches,(1,2) leaving opportunity for complementary bottom-up approaches to improve engagement. The job demands-resource model is a way to 1) re-frame burnout and engagement, 2) introduce the proactive (bottom-up) and strategic (top-down) model, and 3) provide exercises that leaders can use to apply a bottom-up approach. Engaging employees at the individual level will improve the ability of teams to meet organizational goals, improve performance, improve engagement, and reduce burnout.
Because engagement and burnout affect many organizational performance metrics,(3-5) they have become priorities for health systems to address. One study determined that average burnout-related costs are $7,600 per physician per year.(3) Despite national attention, a recent study indicates burnout among physicians is increasing.(6) Given this trend, we believe it is reasonable to explore the relationship between engagement and burnout, and help physician leaders apply relevant organization development theories.
THE JOB DEMAND-RESOURCE MODEL (JD-R)
The Job Demand-Resource model (JD-R) not only defines burnout and engagement, but also it identifies their drivers,(7,8) separating job demands from resources. Job demands impair performance and contribute to negative outcomes but, when reduced, have the potential to decrease burnout. Conversely, every job has “resources” that can be mobilized to increase engagement and generate positive outcomes.
Burnout is the chronic state of physical or emotional exhaustion, mental distancing, and reduced personal efficacy. Burnout commonly manifests as cynicism and doubt in one’s workforce contributions.(7,8) According to JD-R, the job demands include 12 drivers, which are divided into qualitative, quantitative, and organizational domains, as illustrated in Table 1.
Engagement represents the positive psychological states of vigor (energy and resilience), dedication (pride and sense of significance), and absorption (engrossed in one’s work).
According to JD-R, 22 “resources” generate the positive and motivational aspects of work that lead to engagement.(7) These 22 resources are categorized into four domains (see Table 1). Studies using this model have demonstrated that increasing the resources reduces burnout and increases engagement, whereas reducing job demands only reduces burnout, with no effect on engagement.(1,7) Given recent burnout trends,(6) perhaps increasing efforts to understand and support the activities that physicians find engaging could complement and improve activities to reduce burnout.
STRATEGIC AND PROACTIVE APPROACHES TO ENGAGEMENT
Organizational dynamic studies have shown that high employee engagement fosters creativity and innovation, which leads to increased employee and client satisfaction, increased profitability, and reduced turnover.(1,2) The “strategic and proactive model” was borne out of the JD-R model and mainly focuses on ways to enhance employee engagement. The top-down (strategic) and/or bottom-up (proactive) approach were designed to help executives, managers, and employees create sustainable engagement.(2)
In this article we use the terms “top-down” and “bottom- up” when discussing the resources shown to improve engagement. Table 1 allows the reader to compare how both models overlap regarding drivers of burnout and engagement.
Top-down Approach
In an organization using the top-down approach, employee engagement efforts are initiated at a high level, typically through human resource management policies, practices, and procedures.(9) Employees in an organization with an effective human resource system report that having access to the social, organizational, work, and development resources listed in the JD-R model enhances their ability to endure job demands. Top-down approaches attempt to create alignment throughout organizations by relying on structure, policies, hiring practices, socialization of values, and matching performance expectations with employee development expectations.
Research has shown that when organizations have these practices and systems in place, they hire, onboard, and develop employees more effectively, which is a signal to employees that management is supportive.(2) Similar research has demonstrated that aligning the social, work, development, and organizational resources positively influences the work climate, which influences engagement.(9) Organizational leadership development programs represent another top-down approach also shown to improve employee engagement.(2)
A review of all leadership styles and theories would be beyond the scope of this article; however, regardless of the style used, effective leadership behaviors generate empowerment, autonomous motivation, and self-efficacy.(2) Effective leadership behaviors lead to a healthy problem-solving culture,(10) job autonomy, opportunities to safely provide and receive feedback, and growth opportunities.(11) These behaviors reduce the cognitive, emotional, and physical demands of the job, and improve the quality of work relationships, which improve employee attitudes and performance.(2,11)
Bottom-up Approach
The bottom-up approach facilitates engagement by encouraging employees to act with a sense of autonomy and empowerment by mobilizing intrinsic resources. As shown in Table 1, the JD-R model divides 22 resources over four domains (social, work, organization, and development). These resources enhance employee engagement.
This model shows there are ample targets for enhancing the resources that improve engagement, as opposed to only focusing on burnout by reducing job demands. The implication is that engagement and burnout can improve if leaders help individuals and teams learn about themselves and examine ways to identify and leverage their strengths.
The bottom-up approach recategorized the resources of the JD-R model into four individual-level categories: self-management, job-crafting, strengths use, and ego mobilization.(12,13)
Self-management. Self-management strategies consist of five self-influential categories, many of which overlap with emotional intelligence.(14-19) They are self-observation, self-goal setting, self-cueing, self-reward, and self-punishment.
Self-observation means that employees are aware of when and why they demonstrate particular behaviors. This self-awareness helps employees alter thoughts and behaviors in ways that increase performance and their contributions to the organization.(2)
Self-goal setting suggests that employees are capable of setting challenging and attainable goals that improve performance.(2) Self-cueing allows employees to use reminders to help them focus on what needs to be accomplished.(2) Finally, employees can use rewards or punishments to drive personal desirable or discourage personal undesirable behaviors, respectively.(2)
Job-crafting. This concept is based on the observation that every job offers employees some latitude to shape and customize job-related tasks to align with their skills and training competencies.(2) Job-crafting represents an individual-level, self-initiated intervention whereby employees can change the task or work relationships to optimize attainment of personal and organizational goals.(2)
Strengths Use. Using one’s personal strengths as a natural capacity for behaving, thinking, or feeling allows optimal functioning and performance in pursuit of valued outcomes.(2) When employees harmonize their personal values and strengths, they are more likely to reach personal goals. Research has shown that when employees use their strengths, well-being and self-esteem improves, and stress is reduced.(2)
Mobilizing Ego Resources. This concept implies that individuals can mobilize their own energetic, emotional, and cognitive resources to improve their own well-being and performance. (2,20) Employees have the ability and self-insight to creatively use personal energy and ideas to engage in activities during work or non-work time and to refuel. Chosen activities are aimed at improving one’s own physical and psychological state.(2)
PRACTICAL APPLICATIONS OF JD-R THEORY AND BOTTOM-UP APPROACH
Two critical questions for organizational leaders to consider are: 1) Are the leadership skills needed to employ a bottom- up approach teachable? and 2) How can leaders learn how to apply a bottom-up approach?
First, research supports that these are teachable skills.(2) Therefore, leadership development programs should train leaders how to help employees assess their present work situation and provide them latitude to make the adjustments that might improve it. The skills needed for leaders to serve as better coaches to others are appreciative inquiry(21-23) and process consultation,(24) which we discuss briefly below.
Appreciative inquiry teaches leaders how to shift problem-solving from using “an adaptive learning mindset” (i.e., fixing problems) to using a “generative learning mindset” (i.e., building capacity to learn).(24) Appreciative inquiry is “possibility-centric” and helps leaders and teams reframe dialogues about meeting challenges by appreciating what is, valuing what is, envisioning what could be, and designing what should be.(22,24)
Process consulting (PC) builds helpful relationships with individuals, groups, or organizations that are dealing with problems. PC works under the assumption that a coach does not know enough about a particular situation to be able to make specific recommendations on what individuals or groups should do to solve the problem. PC uses pure inquiry, exploratory inquiry, diagnostic inquiry, and confrontative inquiry as ways of helping others uncover the source of their problem and then engaging them in generating solutions.(24)
Building these competencies in leaders promotes more productive conversations with others to uncover their strengths and values and create a sense of achievement. Leaders who are comfortable engaging in PC(24) and appreciative inquiry(22) can potentially eliminate the causes of underperformance at the individual level by fully engaging their staff in problem-solving and solution-generation. Additionally, learning behaviors inherent in appreciative inquiry and PC enhance trust and safety(25) and improve performance.
These approaches affect how leaders and employees relate to each other and help them set more realistic goals that align organizational and personal goals with personal abilities. Ideally, the goals will leverage existing competencies and create a partnership between leader and employee to pursue more satisfying growth and development opportunities.
More broadly, this approach can evolve an organization’s hiring and onboarding processes and modify its leadership training programs. Interventions of this nature should be followed up with quantitative and qualitative assessments to test their effectiveness and analyzed to assess their effect on burnout and engagement(2) in addition to productivity.
Organizations that want to help leaders create the work climate that gives employees autonomy and safety to enact changes that improve work performance need a plan to operationalize.(2) The four exercises discussed later are practical approaches that, when used simultaneously, can help teams self-manage, use their strengths, job-craft, and mobilize personal energy to achieve valued goals.
JUSTIFYING THE BOTTOM-UP APPROACH IN HEALTHCARE
Organizations that expect their leaders to promote employee engagement should help them develop new “learnership” skills.(4,13) Shanafelt, et al., present a model that advocates using both top-down and bottom-up approaches.(4)
Facilitating this approach with coaching has been shown to improve engagement and reduce burnout.(1,2,11,26) One study piloted the use of certified coaches to conduct telephonic sessions with physician faculty for 3.5 hours of coaching over five months. It included time spent creating a relationship, needs assessments, value assessments, goal-setting, and action planning. These data show that coaching can improve physician engagement and should be considered as a complementary strategy when using both a bottom-up and top-down approach.
TEAM EXERCISES
The four exercises discussed here offer practical ways for teams to apply the abstract concepts presented above. The exercises use structured questions that can help leaders ask the team questions that facilitate the co-creation of a work climate that fosters self-management, job-crafting, strengths utilization, and optimization of discretionary efforts.
This bottom-up approach will help participants understand themselves in the context of their potential contributions to the team and organization. The exercise will help employees identify and articulate their values, the activities they find engaging, and their perceived strengths.
These are the resources in the JD-R model and are the resources each person can mobilize to improve their situation and enhance organizational performance. Sharing the results of these exercises among the team creates team awareness and builds on existing trust and safety, which are characteristics of high-performing teams.
Completion of these exercises requires a psychologically safe and trusting work environment. If doubts about trust and psychological safety exist among the team, then it is unlikely that its members will be completely honest in their responses. In this instance, it might be wise to address why safety and trust are low. This might require enlisting a practitioner of organization development to serve as a facilitator.
Exercise 1. Appreciative Coaching: Crafting a Personal Mission Statement
This exercise uses appreciative inquiry techniques. To reiterate, appreciative inquiry is a highly collaborative, strengths-focused, problem-solving approach proven to facilitate the implementation of sustained change and development programs in organizations.(21-23) It is possibility-centric and helps teams discover the best of what is, dream of what could be, design what should be, and deliver what needs to occur.(21,22) This approach helps leaders engage teams in self-determined change efforts by building on what is working well within the team as opposed to focusing on improving what is wrong with the team.
Appreciative inquiry uses storytelling to help individuals and teams construct a positive future built on past successes.(21)
Step 1: Faculty are asked to describe, in one page, a past situation where they lost track of time at work or achieved something of which they were proud, the people who benefitted, the outcomes achieved, why they chose the story, and how they felt because of this success.
Step 2: Faculty are asked to circle specific places, things, or people mentioned in their story.
Step 3: They are then asked to draw a square around any mention of “making a difference and taking action.”
Step 4: They are asked to underline anything that improved because of their effort.
Step 5: Participants place the circled items (their cause), squared items (their actions), and underlined items (their impact) into a word parking lot (see Exercise 1 in the appendix).(27)
Step 6: They are then asked to construct a one- or two-sentence personal mission statement using the words and themes from the parking lot of words.
By viewing themselves through the lens of a past success, participants can articulate what mattered to them and to others and reflect on the intrapersonal resources they mobilized to achieve the success highlighted in their story.
Exercise 2. Values Assessment
Values determine one’s priorities and serve as internal and external motivators.(13) Having clarity of values allows people to self-manage by pursuing activities aligned with their values. Understanding team members’ values improves performance.(5,28)
In this exercise, participants are asked to complete a values self-assessment created by MJB (see Exercise 2 in the Appendix). Participants are asked to review their success story and reflect on how their values contributed to the success highlighted in their mission statement.
Exercise 3. Engagement Grid
In this adapted exercise, participants are asked to select three of the 12 listed characteristics shown to foster engagement (see Exercise 3 in the Appendix).(28) Each participant is asked to explain why they selected the three characteristics they did, then re-evaluate their personal mission statement (Exercise 1) for the presence of characteristics that contributed to past success. They are also asked to reflect on how their values contributed to past success.
Exercise 4. Emotional Intelligence Assessment
Leaders who possess a high emotional intelligence (EI) create a culture of high performance and a safe and empowered work environment.(17,18) EI is composed of personal and social competencies. Personal competency is self-awareness and self-management; social competency is social awareness and relationship management.
Exercise 4 asks participants to first conduct a self-assessment of their emotional intelligence (see Exercise 4 in the Appendix).(29) They are then instructed to ask three other people whom they trust to conduct an external EI assessment. The assessments are combined using the table in Exercise 4. This combined approach gives a more accurate picture of one’s emotional intelligence strengths.
While the first three exercises focus on the individual’s strengths and motivations, EI assessments help individuals improve how they navigate and use their social and developmental resources to meet their goals.
Using all four exercises will lead to generative conversations between the individual and the leader that will align the strengths, interests, and goals of the individual with those of the organization. Members of the team will better understand how and why they and their colleagues can position themselves to improve team performance. The exercises help existing leaders learn how to assess for the elements that create high performance while simultaneously create a safe and empowered work environment.(17,18)
Ultimately, on a large scale, this approach could positively influence organizations in an upward fashion.
DISCUSSION
Inertia in reducing burnout could come from an over reliance on top-down transformations and too little effort made to use bottom-up approaches. Much has been written about the importance of engagement, burnout, and values on organizational performance, but there seems to be a paucity of tangible practices to help leaders conduct these efforts.
Teams that complete the exercises provided in this article can be more intentional in self-management, job-crafting, and mobilizing strengths and cognitive resources, which are the elements of the bottom-up approach that has proven to improve engagement and reduce burnout.(1,2,26)
The exercises are designed to help leaders guide employees to explore past successes when they were engaged, lived their values, and mobilized personal strengths. Using appreciative coaching techniques, participants practice self-reflection and use the information that surfaces to rationally choose career opportunities.
Additionally, these exercises help participants create short-term and intermediate goals that leverage existing strengths and pursue activities they value and find engaging. Leaders who conduct these exercises can use the results to map each team member’s strengths, interests, and values that align with new opportunities. Consequently, when new opportunities arise, teams have a better chance of selecting the right individual(s) to contribute to the team’s success. The exercises help leaders understand where competency gaps exist and must be closed if performance improvement is desired.
The four exercises help participants understand how they can contribute their unique talents to meeting organizational goals without compromising deeply held personal values. The process helps participants have more meaningful intrapersonal and interpersonal conversations about their careers.
The exercises were well-received. Although we do not have quantitative outcome data, we offer representative comments from faculty who completed the exercises in Table 2.
We represent that these four exercises use a bottom-up approach, which we believe will help leaders assist physicians and other employees identify individual-level resources and envision ways they can contribute to a healthier and more productive workplace.
Studies using mixed methods designed to objectively assess the impact this approach has on engagement and burnout should be conducted in healthcare. Data can be captured using the Humanistic Bundle(30) or a variety of employee-level assessment tools and tracked longitudinally with traditional key performance metrics.
Qualitative assessments identify the reasons certain exercises are valuable to participants and how a bottom-up approach might complement top-down approaches. Studies should attempt to determine if this approach is associated with balanced improvements in people-oriented and results-oriented key performance indicators.
Finally, more robust prospective studies using these exercises as interventions should be conducted that include both physicians and non-physicians to determine their effect on organizational specific key performance indicators.
CONCLUSION
Despite decades of awareness, national trends in healthcare burnout and disengagement are increasing. Burnout and engagement represent problematic symptoms inherent in complex systems. Literature rooted in organizational psychology supports the use of bottom-up and top-down approaches; however, we believe too little emphasis has been placed on the former approach.
Using the practical exercises described here facilitates self-exploration and reflection, which makes the use of abstract social science concepts like appreciative inquiry and process consulting more accessible to healthcare leaders. Ultimately, we hope this article helps leaders who are interested in engaging their team differently become comfortable applying proven social science techniques that enhance teamwork and create the positive work environment that enhances engagement and reduces burnout.
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APPENDIX
