The Human Factors Science of Joy At Work in Healthcare

by Dr. Yin Shanqing, Assistant Director, Human Factors & Systems Design, KKH

In May 2019, the World Health Organization officially endorsed the 11th revision of the International Classification of Diseases, a.k.a ICD-11. Within it, burnout is defined as a "syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed". In its previous edition, it was simply listed as a "state of vital exhaustion". This move is huge, as it now acknowledges burnout as a condition that needs to be addressed. More importantly, this elaboration avoids labelling burnout as being an individual's medical condition, but more specifically an issue caused by unhealthy workplaces.

Concerns regarding fatigue and burnout are not new. In 2011, the Joint Commissions released a sentinel event alert about healthcare worker fatigue and patient safety. In 2015, Singapore's Workplace Safety & Health Council released a study citing fatigue as the "leading root cause for work-related ill-health". Studies across different segments of our healthcare community, from nurses to residents to even mental health professionals, all paint a common, unhealthy picture. COVID-19 merely exacerbated the situation but it also fueled the conversation.

The response by healthcare institutions have been swift and zealous. We have seen a spike in mindfulness workshops, helplines and peer support programs, as well as other more direct offerings by in-house psychological services. Indeed, COVID-19 raised the awareness on mental health at the workplace everywhere.

While burnout and workplace stresses are occupational phenomena of bad systems, our responses have largely been more people-focused than system-focused. Mindfulness, counselling and other mental health training do provide a sense of control. However, these interventions shouldn't be used to "paper over the fact that a job is objectively bad".

The Science of Work

While human factors don't traditionally address burnout, the nature of our business, to optimize human well-being and overall system performance, implies an instrumental role in improving the workplace. Topics like fatigue, shiftwork, workload, interruptions and more are well-researched in human factors science.

It is no secret that junior doctors work long hours, to the tune of "30 to 36 hours continuously" when on call, over and above the already long hours on regular days. After 21 hours of prolonged wakefulness, your performance is similar to having 0.08% blood alcohol concentration, which happens to be Singapore's legal limit for driving under influence. By understanding our circadian rhythm and diurnal characteristics, we know that we inherently function poorer at dead of night, we do not sleep as well during the day, and irregular shift work can cause circadian rhythm disorders. All these negative effects can be managed using adequate rest breaks and mindful shiftwork design. Yet we systematically ignore these research findings and tolerate setting our colleagues up to fail.

These long working hours do no favors to the high mental effort and focused attention required in clinical care and on-the-job training. Rising complex cases and constant protocol changes add to the performance demands without the benefits of intuitive routines. With limited time and attention to go around, clinicians are regularly interrupted to receive new requests on the fly. Although not all interruptions are created equally, they always trigger an unexpected surge for cognitive resources and can lead to clinical inefficiency and errors. Cognitive task analyses can help (re)design jobs to be cognitively efficient. Interruption management comes in many forms, from social considerations to spatial modifications.

Thus, human factors presents an encyclopedic array of theories and evidences to make sense of clinicians' overwhelming workload. Workload can be described from within a systems hierarchy, starting with situation- and patient-level tasks, which are embedded within job-level work, up to unit-level work measures such as nurse-patient ratio and number of complex cases. The Theory of Multiple Resources is popularly referenced to make sense of how we multi-task and why we fare better at singing while driving but not reading and chatting. Jens Rasmussen's SRK Model of human behavior describes how unconscious, routine, well-practiced tasks are effortless, whereas improvising during foreign or novel situations is strenuous. Ultimately there may be a "red-line" of workload and breaching this red-line (i.e. overload) invites performance degradation. Armed with these insights, human factors can help reduce the stresses from heavy cognitive lifting.

The Role of Human Factors in Joy At Work

The need for healthcare to improve is undeniable but we can most certainly improve intelligently. Just as we rely on our clinical specialists to help us manage the complexities of specific diseases, human factors professionals provide the expertise to navigate and apply the wealth of human factors knowledge towards a better workplace. In our quest to tackle stress, fatigue and burnout, human factors complements our symptomatic treatments by addressing the fundamentals of human-centric work (re)design. Our preference for system-focused interventions affords greater odds of success.

Whereas everyone focuses on higher-order factors like motivation and value, human factors breaks these concepts down into actual, tangible components of work, allowing us to elicit joy at a more "molecular" level.