Module 8 Outline: Organizational approaches to reducing burnout risk

Through the first seven modules you hopefully have gained an understanding of the many factors that impact public health workers’ risks of developing burnout. As we’ve discussed, burnout is caused by a chronic imbalance between work demands and the resources needed to effectively respond.

At this point, you are probably eager to learn more about how to address demand-resource imbalances. This is the focus of the final few modules of this training series (Unit 3). In this module, we explore organizational approaches to reducing burnout risk for public health workers.

Organizational approaches are actions that change something about the organization itself, like the work environment or policies and procedures. This contrasts with the employee-focused approaches that we will discuss in Module 9. Such approaches are typically actions directed at individual workers, such as stress management trainings or cultural change to support individual’s taking time for rest.

As we noted in earlier modules, being chronically “out of balance” leads to bad outcomes for individual public health workers, and the organizations and people they serve through their work. Demand-resource imbalances do not fix themselves and tend to get worse without some sort of intervention. It is important to note that interventions to address demand-resource imbalance are not just for major and longstanding problems. It is possible to develop interventions that are preventative or protective in nature.

Public health workers face complex burnout risks. Protecting these workers requires developing and implementing interventions that are multi-faceted and address multiple levels. Let’s return to a concept we first introduced in Module 1 of this training series, the IGLOO framework. This is a helpful framework to guide the planning of such interventions.

As a quick reminder, IGLOO encourages intervention users to consider five levels of function within and around work organizations: Individual, Group, Leader, Organization, and Overarching context. At each level, the focus can be on changing the worker and their abilities to respond to demands, or aspects of the organization or work environment. For any effort to prevent burnout to be successful, changes focused on the individual or the organization need to account for the influences at all levels of the IGLOO framework.

Our focus in this module is on approaches for changing aspects of the organization to prevent public health worker burnout, with efforts targeting individual workers featured in the next module. Organizational strategies generally involve modifying or redesigning work tasks and physical and environmental features at work. It can also involve changing policies and procedures that may affect workers’ abilities to manage demand-resource balance. As a reminder, you are not using these strategies at only at the “organization” level. You can also use them for each of the levels of this IGLOO framework.

As we introduce these strategies, we acknowledge that some public health supervisors may face limitations or barriers due to civil service constraints and collective bargaining agreements that exist in many public health work contexts. As we walk through different approaches in this module, we encourage you to think about the things you can change within your own role, as well as what changes you could suggest to those individuals who develop and refine policies and practices that affect public health workers.

Organizational strategies focused on the individual level help workers respond more effectively to demand-resource imbalances. Evidence-based examples of these types of interventions include:

Offering programs and resources to support health and well-being
Organizational efforts can help to shape an intentional culture that values worker health and well-being. It helps workers to do a better job of recognizing and responding to their own (and their peers’) health and well-being.  A primary example is an organization-wide health and wellness initiative. These types of wellness programs may include formal rewards for healthy behaviors or simply health-promoting messages throughout the organization.

Another specific example is organizations that provide and encourage utilization of an Employee Assistance Program (EAP) offer access to a wealth of information and, often, therapeutic resources. An EAP can help workers with mild to moderate day-to-day challenges and sometimes traumatic incidents that may occur in the work environment or community (e.g., Attridge & VandePol, 2010). Encouraging workers to use EAPs has several benefits for organizations, including reduced absences and time lost due to illness, and generally more productive time while working (e.g., Nunes et al., 2017; Richmond et al., 2017).

Engaging workers in job crafting
Enabling workers to have some say in how they manage their responsibilities is called job crafting (e.g., Wrzesniewski & Dutton, 2001). This practice increases workers’ control and allows them to respond to demands in a way that works for them.  Job crafting empowers workers with some degree of autonomy. It also opens up access to other resources that they might not be able to access or use if they have to do their tasks in an overly prescribed way.

Research shows that job crafting can help workers better manage work demands and protect their well-being (e.g., Tims et al., 2013). Granting workers some degree of control can also increase their ownership over and personal meaning derived from their work, which is helpful in sustaining a sense of meaning and purpose at work.

Job crafting can be delivered as a broad-based intervention or can be targeted to specific groups (e.g., top performers; those struggling to perform). Job crafting does not have to be complicated. Generally, it involves helping workers to identify their typical demands, as well as the resources, strengths, values, and motivations they have related to those demands (see Niessen et al., 2016).

Even in remote or hybrid working situations, it may be possible to implement some core principles of job crafting with a relatively straightforward and high-level virtual training (e.g., Uglanova & Dettmers, 2022). In reality, just about any job may be a candidate for job crafting (for examples, see Dutton & Wrzesniewski, 2020).

Let’s talk through some examples of what job crafting might look like in public health:

• Task crafting – You work in a collaborative team. You really hate spreadsheets, but your coworker likes working with them. However, you enjoy creating data summaries. Could these tasks be reallocated so you each spend more time on the tasks you enjoy most?
• Relational crafting – For tasks that are tedious or time-consuming, try working with someone you enjoy. Even working in the same room with someone, even if not actively collaborating, could help provide a sense of connection.
• Cognitive crafting – You despise having to complete paperwork to request funding for a community project. Try reframing the work – instead of it being a nuisance, think about it as an opportunity to get to that task you enjoy more.

Offering flexible work scheduling and working arrangements
Numerous studies show that where and when possible, allowing workers to have some say and flexibility over when (and in some cases, where) they do their work can help with demand-resource balance (e.g., Kelly & Moen, 2007). The logic here is similar to job crafting. A key difference is that interventions along these lines help workers better manage demands outside of work. Some workers also find flexible scheduling and working arrangements to be helpful in managing work demands too. For example, workers can avoid commuting time or avoid interruptions by working outside of the office. Generally, these types of interventions are integrated with efforts to improve leader, supervisor, or manager support. One example is the STAR method, highlighted in the readings and resources section of this module.

Organizational strategies delivered at a group level tend to target improvements to social norms and peer networks. Examples include:

Changing policies and practices that reinforce negative workgroup norms
Our attitudes and behaviors at work are not only determined by our own choices. Often, we are influenced by social cues and norms. These can be (and hopefully are) positive most of the time. Sometimes, however, these social forces can be negative, such as when incivility, harassment, or other forms of interpersonal mistreatment are present. Other types of negative social norms can also creep in, such as a tendency to glorify being “stressed out” or to wear one’s stress like a badge of honor (Black & Britt, 2022).

Organizations often need to redirect these types of social forces in a more positive direction. This might include implementing (and enforcing) zero tolerance policies for harassment or other forms of incivility. Many public health organizations may already have such policies in place. These types of policies should encourage workers to speak up and assure that they will not have negative consequences for reporting issues.

Keep in mind that there are some more complicated nuances to these types of policies. For instance, some policies can create fear or even retaliation concerns for those reporting (Cortina & Magley, 2003; Patterson et al., 2008) and repercussions may need to be appropriate based on severity of offense, history of the offender, etc. Regardless, it is important to monitor how effective your current policy is. You can do this by incorporating some questions into an anonymous survey to gather information on the nature of the work environment, employees’ understanding of current policies/procedures, and actual comfort with speaking up.

Another intervention to address stress or overwork norms would be to review and modify work-related performance management and rewards systems. For example, organizations could stop promoting overwork through social norm changes and/or formal policies surrounding overtime work. Another strategy might be to change the processes for promotion opportunities.

Taking steps to reorient workgroup norms toward healthier work can reduce a persistent source of chronic social demands. Without intervention, these social demands negatively affect workers, over and above the demands of daily tasks.

Improving open and productive within- and between-group communication
Good communication in a workplace helps reduce demands like ambiguity, role conflict, interpersonal mistreatment, etc.  Going one step further, leaders/managers/supervisors can encourage and make it safe for workers to speak up about concerns.

As an example, consider working with a facilitator to hold small group discussions about problems in the work environment. Talk through workplace issues that contribute to stress and potential improvements (e.g., Tsutsumi et al., 2009). Making sure you have a good structure for these discussions (e.g., less time spent on problems versus solutions) or the help of a facilitator is important so that these can be productive and oriented toward solving problems instead of a complaining session that can actually make morale worse.

Encouraging positive peer-to-peer support
One of the most important but often overlooked resources is a healthy peer-to-peer or coworker support network. Organizations can foster meaningful and positive social connections among coworkers with group-level interventions. These interventions improve support-seeking and support-providing actions among group members. Examples of evidence-based approaches for doing this are plentiful and some of our researcher-developed favorites that are also well suited to public health are:

• Coworker Health Awareness Training (CHAT; Oakie et al., 2017) to increase awareness of needs for support among one’s coworkers and peers. It also covers how to respond to signs that a coworker may be struggling with a mental health or stress problem.
• Critical Incident Debriefing and Training, Battle Buddies, and other group-based methods for addressing difficult events. These trainings focus on discussing difficult events, responses to the event within the team, and then focusing on how to maintain focus moving forward (Adler et al., 2009; 2011, Albott et al., 2020).
• The First Responder ECHO (Extension for Community Outcomes) tele-mentoring program. ECHO teaches psychological first aid and self-care strategies in a way that also helps workers support their coworkers in a high demand work situation (Katzman et al., 2021).
• The Community of Practice and Safety Support (COMPASS) is a peer-led social support group and team-based program. It was designed for preventing injuries and promoting health and well-being among home care workers but could also apply to public health (Olson et al., 2018).

Organizational strategies targeted toward leaders, supervisors, or managers help these individuals better manage the demand-resource realities for their employees. Examples include:

Engaging in realistic work demand and resource management
Although most burnout prevention efforts tend to focus on increasing workers’ access to resources, it can also be helpful to at least try to address the demand side of this equation. Leaders, managers, and supervisors are uniquely suited to evaluate workers’ task assignments and access to resources.

Several of the intervention recommendations we have already highlighted in this module can help with demand reduction efforts.

In addition, there is evidence that leaders, managers, and supervisors can play a major role in establishing and sustaining healthy work-life cultures (Foucreault et al., 2018). They can also help workers to establish their own strategies for work-home balance (e.g., Koch & Binnewies, 2015).

Another strategy that can help is job rotation. Many public health workers are accustomed to this type of practice in emergency response, but some level of rotation can be used in everyday operations too.

When implementing this, organizations should factor in worker preferences and personal resource limitations around scheduling or physical demands (e.g., Asensio-Cuesta et al., 2019).

A final strategy is advocating for adequate staffing to prevent workers from having to take on more demands than they can safely handle.

Improving leader/supervisor/manager social support
In addition to peer or coworker support, workers also need the support of their leaders, supervisors, and/or managers. Although this may seem obvious, such support is not always present or perceived to be accessible by workers. Leaders, supervisors, and managers have to create intentional opportunities to connect with workers. This is more straightforward in traditional office settings. It may take some more planning and creativity in hybrid or fully remote environments.

Leaders may also need to provide targeted support for workers’ well-being. Evidence-based methods and techniques can address this type of support need. Within public health, the following examples are particularly relevant:

There are several structured supervisor-focused interventions that can also be implemented in full or adapted. One of our favorites is the mental health awareness training (MHAT) program. It is designed to increase supervisors’ understanding of common mental health problems, awareness of employees needs for support, and what they can do as supervisors to help (Dimoff & Kelloway, 2019; Dimoff et al., 2016).

Improving performance feedback systems
One of the most important interaction opportunities between employees and supervisors comes during what are hopefully frequent performance feedback or review meetings. Here are several particularly relevant best practices:

Ensure workers have psychologically safe ways to seek feedback from their leaders, managers, and/or supervisors. This requires ensuring no retaliation if/when individual workers raise concerns or need help dealing with difficult issues. Ideally employees should have opportunities to give input on a one-to-one basis. However, it can also help to create opportunities for group discussions.  There are several established models for this, including Schwartz Rounds (Flanagan et al., 2020) and safety/quality huddle discussions (e.g., Schatz & Bergren, 2022). What they share is a focus on building a collective sense of responsibility and trust within a group to identify and jointly respond to concerns in a positive way.

Engage workers in the management of their own task-related performance. Create opportunities for workers to actively participate in the definition and assignment of work tasks, projects, or assignments. This should also involve collaboration with workers to determine the resources needed to effectively meet those demands.

Provide feedback not only about performance-related problems or deficits, but also about positive achievements and successes. Again, there are many models to facilitate this type of positive feedback process. The simplest method is to provide positive feedback in real time when a worker completes quality work or handles a situation well. This real-time positive feedback can be very impactful (Rivera et al. 2021).

Organizational strategies directed at the overall organization generally involve changes to the broader work environment. Examples include:

Increasing organizational support
At an organizational level, increasing support can and should be accomplished with a variety of strategies. Not all workers will perceive support in the same way. Generally helpful strategies to consider, however, include policies and benefits that support the worker in and outside of work. This could include paid time off, dependent care benefits, or even financial wellness programs and resources.

Organizations can also show support through mentorship programs. Formal mentoring programs are particularly helpful for minority public health workers who may otherwise have challenges identifying a mentor within the organization (see U.S. Surgeon General, 2022).

Improving situational controls
Although it is more common to think of physical and environmental controls in terms of safety, chronic exposure to physical and environmental demands can also contribute to burnout. For this reason, public health organizations need to strive to control physical and environmental demands outside of workers’ control.

For public health workers, this might include ensuring that work environments offer temperature and humidity controls, as well as proper lighting, reasonably comfortable and ergonomically appropriate furniture, and adequate sound containment options.

Going a bit further, physically unsafe work environments may benefit from safeguards such as better lighting, security cameras, fencing, door locks, etc. that can provide workers with safer spaces (physically and psychologically).

Conducting regular workforce health and well-being assessments
One widely applicable organization-level strategy is some sort of workforce health and well-being surveillance or monitoring program. In other types of organizations, this is commonly known as a pulse check or recurring survey of work-related health risks. In practice, this type of data collection can be designed to target any type of concern, including burnout risk.

Numerous software vendors offer smartphone-based apps and internet surveys. The information provided in this training series equips you to develop your own approach that fits your own organization. Having a recurring assessment could help you and others in your organization know…

• The extent to which members of your workforce are feeling overburdened and under-resourced,
• Whether any active initiatives to address burnout or other health-risks are working (or not), and
• Clearly signal to your workers that the organization supports and wants to help them maintain well-being.

As a helpful resource if you decide to pursue this option, check out the NIOSH Worker Well-Being Questionnaire (WellBQ) linked in the supplemental resources to this module.

Finally, organizational strategies targeting the overarching context may target the broader industry, community, or society. Examples include:

Focus on doing more, with more
A persistent reality among public health workers, and one we heard frequently in our interviews with public health professionals, is to always have to “do more, with less.” As emphasized throughout this training, that experience reflects a most definite chronic demand-resource imbalance. This is not sustainable and will lead to burnout and other forms of negative outcomes (for public health workers and the people they serve).

A primary overarching context strategy is for public health organizations and professional groups to communicate the value of public health and its resource needs to policymakers at local, territorial, tribal, state, and federal levels.

As a leader, manager, or supervisor, you may look for opportunities to find grants or other non-profit funding to meet a specific resource need. We know this is hard to fit in to an already busy schedule, but it can have important long-term benefits. The goal is to shift the public health worker experience from “doing more, with less” to “doing more, with more.”

Improving trust and support in communities being served
Public health work is intended to serve the greater good of a broader community. This work is easier when public health organizations are trusted by the communities in which they operate. Initiatives to inform communities about public health priorities, opportunities, and needs can improve transparency. These initiatives can also create a better understanding between government policy makers and the individuals who are tasked with putting policy and guidance into public health practice.

What this looks like will differ based on the particular situation, but the main point to note here is that improving trust in the communities being served helps to protect public health workers from burnout. It reduces powerful constraint-type demands coming from outside of the public health organization.

Continuing broad discussions about public health worker burnout and strategies to prevent it
As we noted earlier in this training series, until recently, burnout has received surprisingly little attention within public health. It is important to sustain momentum in this initiative to prevent public health worker burnout. Hopefully there will be more efforts like this training, the National Association of County and City Health Officials’ (NACCHO) resilience library, and others that prioritize public health worker well-being.

Partnering with non-public health organizations to advance public health missions
Another example of an organizational strategy is to extend beyond the immediate organization through partnerships. For instance, finding existing opportunities like sporting events or church gatherings where public health initiatives, such as vaccination clinics, can be jointly held.  These sorts of connections or tie-ins with community organizations and partners can essentially provide “peer support” to yield helpful resources for carrying out public health work.

In our teaching and consulting, we are often asked questions like, “If our company could do just one thing to protect our workers, what should it be?”

This is a great question. We should note it is best practice to conduct a thorough assessment to identify the critical demand-resource imbalances. That said, we have yet to find an organization and set of workers that will not benefit from positive social support.

This resource is so important that we felt compelled to carve out a portion of this module to focus on it. Multi-level social support interventions are among the safest and most impactful options to prevent burnout in service-oriented occupations like public health. It is impossible to achieve demand-resource balance without consistent access to social support.

As we’ve discussed, social support interventions can take many forms and can be delivered at every level of the IGLOO framework. It is important to consider the wide variety of ways that individuals and organizations can provide social support. There are three forms of social support:

Emotional support is what typically comes to mind for most people when thinking of social support. This form involves caring for emotional needs, being compassionate, etc. For supervisors, it may be important to target social support toward individual needs with care. We’re told to “treat everyone equally”, but we can have compassion and common sense to know that some workers’ life circumstances may require unique support to help them balance their work and non-work demands.

Social support can also be practical help (instrumental) or information to solve a problem (informational). Sometimes these forms of support are especially important to workers experiencing high demands. Showing care is one thing, but stepping in and helping problem solve is all the more helpful.

Social support can also be shown by providing feedback to an individual on how they’re doing (appraisal). This is a really important role of supervisors, as employees often look to their leader for some sort of feedback. Letting them know what they’re doing right can help them to address demands, as can drawing attention to any work concerns. That does not sound like the most supportive thing to point out someone’s flaws. However, if they are conducting work in a less efficient way or creating more demands for themselves, they need to know that too.

The evidence-base surrounding social support interventions is vast and clearly shows their effectiveness at improving worker health and well-being. It’s also a key component to reducing burnout risk.

There are many reasons for this including that social support interventions are:

• Well-informed by psychosocial theory and evidence
• Simply structured and easily delivered
• Powered by social norms and comparison to encourage further positive social support, awareness, responsibility
• Able to raise awareness of collective vulnerability (i.e., we’re not all ok, and that’s ok)
• Able to reduce social demands (such as active and passive mistreatment). These interventions also increase social resources that help when responding to other demands
  • For instance, a peer can take on a task for us. A leader can help to create a more realistic and less stressful expectation.
  • Researchers have also often explored social support as a “buffer” that can reduce the negative impact of demands on our health. For example, if you have a demanding day, a supervisor providing encouragement can help you to keep working through demands without feeling burned out.
• Helpful in sense-making and coping with difficulties. Sharing with those who understand work demands best (coworkers vs. those outside of work) can be an important tool for processing more difficult work situations.

One critical thing to keep in mind is making sure your support (and the support offered by others in the workplace) is actually helpful.  An emerging area of literature has talked about scenarios when “helping hurts” (e.g., Beehr et al., 2010).

You can probably think of a few examples of when someone’s help was really unhelpful. Here are a few to consider as a leader…

• Undermining someone’s self-worth by giving help too quickly or bringing attention to a weakness through giving support (for example, “It looks like you’re struggling; let me help you,” or, “I can do this better/quicker, so let me do it.”)
• Providing an unhelpful type of support (for example, offering emotional support or encouragement, when what is really needed is instrumental support – “That stinks; You know I’m here if you want to talk” instead of, “How can I help you get today’s tasks done?”).

Related to this point, you also want to make sure that any one employee (or even you as the leader) does not become overly taxed by offering support to those in need. Offering social support can come with some positive benefits because it feels good to help others; however, that does not mean that it cannot be depleting over time (Lanaj et al., 2016).

It is important again to remember that social support cannot substitute for professional mental health services. That said, active social support networks are a first line of defense. They help us care for each other and facilitate access to professional mental health services when needed.

We covered a lot of ground in this module, so we want to conclude by quickly summarizing the main points to remember:

• Burnout results from chronic experiences with demand-resource imbalances.
• To address these imbalances in a real and lasting way, organizations must help workers better manage work-related demands and access the resources needed to meet those demands.
• Organizational approaches can and should complement employee-focused efforts (which we discuss more in the next module).
• Among the many multi-level intervention options, one of the most important, broad-reaching, and cost effective is ensuring access to positive social support.

Here is a quick reminder of the other content covered in this training series. We hope you find this information helpful and that you will take the time to review the final modules.