As two doctors who worked on the pandemic frontlines, we have watched many of our colleagues leave. They joined the approximately 20% of healthcare workers who have quit since 2020, highlighting a healthcare worker shortage accelerated by the pandemic. Those left are struggling to fill the gaps with fewer resources, threatening the healthcare infrastructure.
To slow the exodus, workers and institutions have taken action. British nurses staged the largest strike in their history. The U.S. Surgeon General named health worker burnout and workplace well-being priority areas. Five state legislatures are introducing safe staffing ratio legislation in response to demands for adequate pay, staffing, and safety.
We want a future for healthcare workers that is more than a bare minimum, one in which we can sustainably, effectively, and meaningfully provide the best care possible to each patient. This long term retention is critical to the future of healthcare because training workers is a long and expensive process.
We propose the overlooked framework of "flow" to guide workplace transformations necessary to retain more healthcare workers.
Coined in the 1970s by psychologist Mihály Csíkszentmihályi, PhD, flow is defined as "the state in which people are so involved in an activity that nothing else seems to matter." Flow has been linked to benefits like better performance, positive emotions, and wellbeing. Similar concepts like "deep work" have been championed by popular authors like Cal Newport for white collar office workers.
Newport recently said his advice is not applicable in highly structured work environments, such as the emergency department. While flow in healthcare may look different than what Newport describes in the office, it is possible. As described by one surgeon, "It feels almost as if we're watching ourselves operate...unaware of time passing...whatever we are doing in flow becomes its own reward." Flow is not only possible but necessary in healthcare to sustain long-term worker satisfaction.
Csíkszentmihályi described eight characteristics of flow: clarity of goals, transformation of time, intrinsic reward, action and awareness, challenge-skill balance, loss of self-consciousness, sense of control, and concentration on the task. We will discuss three examples that illustrate how this framework can guide the formation of a more sustainable healthcare work environment.
Clarity of Goals
Flow begins with a precise goal that shapes activity structure and direction. An emergency department doctor's goal, when evaluating a patient with abdominal pain, is to identify whether to mobilize immediate treatment or develop a plan for safe follow-up.
This clinical goal, which the physician has been trained for, is quickly clouded by other considerations. If the physician does not order a test -- even if it's unnecessary -- will there be a potential lawsuit? Will waiting until more results return before making a decision result in worse metrics? Does cutting healthcare costs in this situation conflict with optimal patient care?
One goal has become many. Trying to serve multiple masters raises the question: Within the confines of a healthcare system that often prioritizes the profit of many stakeholders, what are concrete steps to promote a "patient first" work culture?
Sense of Personal Control
A sense of personal control is essential to believing the goal is achievable. Lack of clinician control over their time, decisions, and actions is one of the most often cited contributors to burnout. Switching from one task to another is cognitively demanding and disruptive. The cognitive whack-a-mole of competing tasks in clinical settings is not only prohibitive to flow, but also adversely affects patient experiences.
Healthcare workers often cannot control the inflow of work because illness can be unpredictable. It is therefore especially important to protect autonomy outside of complex triage decisions in order to preserve cognitive capacity when it counts. Switching from writing notes to assessing a patient with acute stroke is good. A high volume of competing administrative tasks or understaffing to the point of overwhelming clinician decision-making is dangerous.
Giving nurses control over how to delegate their own time, among other measures of autonomy, correlates with better patient outcomes. Many industries are asking how to permanently integrate more flexibility at work after the acute COVID era. Healthcare must also soul-search: In healthcare's highly-structured work environment, where can we increase cognitive flexibility?
Concentration on the Task at Hand
When artists and athletes experience a state of flow, they describe an intense focus on their task to the point where the subjective experience of time itself is distorted.
That level of focus is rare in the current healthcare setting. Hospital doctors are paged around three to four times an hour. Nurses are interrupted an average of 13 times an hour while giving patients medicine. Each interruption is associated with a 12.7% increase in risk of clinical error.
Healthcare workers are trained to quickly and precisely execute complex tasks. Yet, they are in environments often hostile to the focus required. Tasks formerly completed by administrative workers are now being shunted to physicians and nurses without a system for discerning the routine from the urgent.
Some hospital settings have experimented with no-interruption zones during medication dispensation with good outcomes. Flow can guide expansion of this principle into other areas like patient rounding. It challenges the assumption that workers need to be constantly accessible to provide good patient care.
Looking at these three attributes of flow, it is evident that healthcare work environments often lack clear goals, fail to give workers sufficient control in executing complex tasks, and do not adequately protect worker focus. These conditions make it difficult to experience flow, which limits the capacity to perform high quality work and decreases satisfaction.
One might argue that implementing changes necessary to protect healthcare worker flow is wishful thinking when it is hard enough to meet basic labor conditions. But by considering these questions stemming from the conditions of flow, we can examine ways to transform the healthcare workplace in ways that acknowledge the systemic roots of burnout instead of perpetuating a system that devalues worker contribution, autonomy, and satisfaction, to squeeze more for less.
It costs $1.1 million to train one physician. It costs $52,000 to replace a bedside nurse who leaves an institution. Even more important than the money are the people. In our colleagues who left, we saw people committed to excellent patient care who left when it became impossible to continue on meaningfully and sustainably. We want to make this profession a place that can support that commitment. Flow can be a framework to guide structural changes for a more meaningful and sustainable healthcare workplace.
Joy C. Liu, MD, is an internal medicine resident interested in end-of-life care, global health, and public policy. Dharushana Muthulingam, MD, is an infectious disease physician and writer.