Ulrich Wiesmann
Until recently, positive psychology identified members of the health workforce as a target group for promoting well‐being at work. Formally, the job of a health professional is to systematically provide preventive, curative, promotional, or rehabilitative health care services (Wikipedia, 2015). In this respect, they represent human resources that people can make use of to improve their health or overcome diseases. The World Health Organization speaks of a health workforce, which is defined as “all people engaged in actions whose primary intent is to enhance health” (World Health Organization, 2006, p. 1). Of course, the complex task of health care is an interdisciplinary endeavor, which brings together health workers from different backgrounds such as physicians, dentists, nurses, psychotherapists, community health workers, social health workers, and other providers (including health management, health support personnel, and others). This chapter is specifically focused on those health professionals who are directly involved with patients, that is, who are in face‐to‐face contact with patients.
Members of the health workforce are committed to a high standard of excellence in different areas. Due to their professional training, they hold particular competencies – knowledge, skills, abilities, and behaviors – which enable them to successfully enhance the health of others. In doing so, they acknowledge duties and responsibilities for the people whom they care for. In other words, delivering health care is focused on the benefit of patients, or clients, and thus implies ethical and moral considerations. Health professionals should attend to the best interest of their patients and not to self‐interest, showing respect to people entrusted to their care. Remarkably, many health professionals consider the focus on self‐care as rather a private matter, not a professional one. The culture of medicine implies a self‐image of a physician as an invincible caregiver (Wallace & Lemaire, 2009).
In principle, the idea of caring for one’s own health and well‐being should apply to all health professionals who are directly involved with patients, or clients (Figley & Beder, 2012; Figley, Huggard, & Rees, 2013). Health professionals are directly and indirectly confronted with potentially traumatizing events, such as severely injured and dying patients or histories of violence and sexual abuse. These cumulative experiences may result in a secondary trauma (Canfield, 2005; Collins & Long, 2003; Figley, 1995), end up in burnout (Maslach, Schaufeli, & Leiter, 2001), and impair subjective well‐being (Diener, Lucas, & Oishi, 2002).
With respect to the process of giving health care services, professionals’ negative mental conditions would be detrimental to the intentional enhancement of patients’/clients’ health. An emotionally unbalanced and mentally unstable physician or nurse would set a bad example. Therefore, workers enrolled in the health sector owe it to their clients to take care of themselves as professionals (Hantke & Görges, 2012; Larsen & Stamm, 2008).
In practice, the quality of life health professionals experience at work has been largely neglected. At first glance, the question of how these workers can enhance their own health, well‐being and professional fulfillment (Brown & Gunderman, 2006) appears to be a weird focus against a background of patients’ suffering. Personal well‐being seems to naturally emerge if a health professional does a good job. What can be more professionally rewarding than a patient who has been healed, or a client who has overcome a life‐threatening disease? For sure, this is important, too. But at a second glance it becomes evident that health professionals are no longer genuine human resources for health if they are burned out or sick. If their resources are depleted, the quality of health care they deliver will become poor (e.g., Scheepers, Boerebach, Arah, Heineman, & Lombarts, 2015).
In this chapter, research on well‐being among health professionals is reviewed and evaluated. First, a positive psychology framework is suggested, based on both a hedonic and eudaimonic well‐being perspective (Ryff, 1989, 1995), which may serve as a positive psychology guideline for research in the health care setting. Before turning to positive psychology approaches, research on occupational stress and its threat to the well‐being of health professionals is summarized. Studies in this domain have explored detrimental work‐related and individual factors that predict a broad scope of negative mental conditions. Subsequently, research is presented substantiating that the absence of these negative factors, as well as the presence of their “positive” opposites, respectively (e.g., lack of autonomy and autonomy/self‐determination), predict an alleviation of negative outcomes (e.g., burnout).
Subsequently, some core concepts in positive psychology will be discussed, that reflect a new model of human being and a new understanding of well‐being. Researchers are taking increasing interest in resources, potentials, competencies and positive states of health personnel. In this section, research on issues such as job satisfaction, work engagement, self‐determination, or autonomy, job crafting, mindfulness, resilience, and empowerment is presented. Next, “positive” intervention studies are scrutinized which were designed to improve subjective well‐being in health personnel. The chapter ends with an outlook on future research and conclusions.
The question how to maintain or to enhance the well‐being of health professionals is an imperative topic. Hence, it is important to get an idea what well‐being as a positive psychology concept is about. Prominent researchers such as Diener, Oishi, and Lucas (2003, p. 404) suggest the following definition, which captures certain specific aspects of this phenomenon:
The field of subjective well‐being (SWB) comprises the scientific analysis of how people evaluate their lives – both at the moment and for longer periods such as for the past year. These evaluations include people’s emotional reactions to events, their moods, and judgments they form about their life satisfaction, fulfillment, and satisfaction with domains such as marriage and work. Thus, SWB concerns the study of what lay people might call happiness or satisfaction.
Researchers have further distinguished between hedonic well‐being and eudaimonic well‐being (Ryan & Deci, 2001; Ryff, 1989, 1995). The former refers to the above‐reported definition of SWB, and it includes the affective component of hedonic balance (the prominence of positive emotions in daily experience) and the cognitive component of life satisfaction (as a global evaluation). The latter instead refers to the fulfillment of psychological needs and the idea of a fully functioning person. In other words, hedonic well‐being encompasses the phenomenon of “feeling good”, reflecting pleasant experiences and positive evaluations, and eudaimonic well‐being puts emphasis on “functioning well” and on developing one’s resources and potentials. The latter therefore includes elements of a good life that go beyond pleasant affect and life satisfaction. “The main themes of eudaimonia revolve around the ideas of flourishing, true self, actualizing potential, and personal expressiveness. In essence, who are you and are you living that out?” (Kimiecik, 2011, p. 776).
Relying on classical psychological works (e.g., Allport, 1961; Erikson, 1982; Maslow, 1968; Rogers, 1961), Ryff (1989, 1995) distinguished six dimensions of psychological well‐being (PWB) that can be understood as facets of positive psychological functioning: self‐acceptance, positive relations with others, autonomy, environmental mastery, purpose in life, and personal growth. These dimensions represent six qualities of human wellness.
Self‐acceptance is a main criterion of mental health as well as self‐actualization (Abraham Maslow, 1968), the fully functioning person (Carl Rogers, 1961) and maturity (Gordon Allport, 1961). Holding positive attitudes toward oneself and toward one’s past life, and accepting both one’s good and bad characteristics are a central characteristic of positive psychological functioning. Positive relations with others are also vital for mental health. Many theories and models in positive psychology emphasize the importance of warm, trusting interpersonal relations reflecting genuine social interests (having strong feelings of empathy and affection for others), close connection with others (intimacy), and guidance and direction of others (generativity). Autonomy is also emphasized as an integral part of positive psychological functioning. Self‐determination, independence from others, and inner regulation of behavior characterize this facet of well‐being. Environmental mastery reflects the individual’s ability to choose or create environments based on his or her needs and ideas. It is a characteristic of mental health in that individuals are able to advance in the world and shape complex environments creatively. Purpose in life or meaning in life is also an integral part of mental health. The fully functioning individual has goals, intentions, and a sense of direction that nurture the feeling that life is meaningful. Personal growth goes beyond the achievement of the other characteristics of optimal psychological functioning. It refers to the individual’s striving to develop his or her potential, grow, and expand as a person. Personal growth implies an intrinsic motivational force in the direction of self‐realization.
Well‐being researchers argue that it is important to study both aspects. From the positive psychology point of view, the eudaimonic approach is a good reference model for exploring well‐being in the health workforce, because it is linked with professional personality development. The hedonistic “feeling good” aspect might often be misplaced, for example, when an oncologist has to break serious news to her patient, while having developed a patient‐oriented style in delivering serious news might nurture the six facets of PWB. So far, the eudaimonic approach has not been fully applied. A main reason is that this is a general view of well‐being which is not focused on specific life domains, such as the occupational context. Nevertheless, with respect to work‐related well‐being, the theoretically derived components of PWB cover the realization of one’s true potential as a human being working as a health professional. In trying to find out if health professionals are working in accordance to their true selves, it would be interesting to invite them to address the following eudaimonic questions.
Reflecting on experiences as a health practitioner, can I hold a positive attitude to myself, or do I despise what I am doing in my job (self‐acceptance)? Are my relations with patients and their families, and with my colleagues, rewarding, supportive, sincere and genuine/authentic (positive relations with others)? Can I do my work in a self‐determined way, or am I heteronomous in that I cannot make decisions (autonomy)? Can I participate in the creation of my working site, or am I not allowed to design the place where I am working with patients (environmental mastery)? Can I find a meaning in life in what I am professionally doing, or does my caring for others make no sense (purpose in life)? Can I develop my professional potential and can I expand as a person in my work‐site, or do I waste away (personal growth)?
The review of the literature on well‐being in health personnel shows that the majority of studies investigate hedonic aspects of well‐being, using different measures of happiness, life satisfaction and job satisfaction, or health and quality of life indicators. As already mentioned, most of these studies also evaluate occupational stress, in an attempt to elucidate the consequences of stressful conditions, such as depression, suicidal ideations, psychological distress, burnout. Publications on these topics are abundant.
In the following sections, determinants of work‐related stress that threaten the well‐being of health personnel and instigate habitual stress reactions are reviewed. Then, well‐being enhancing factors are examined, taking the perspective of positive psychology (Seligman & Csikszentmihalyi, 2000).
When talking about occupational stress of health professionals, it is important to have a look at the macro‐social conditions and economic‐political context that determine their work life. Nowadays, multinational health care companies that are listed on the stock exchange earn their money by employing members of the health workforce. Due to shortage of financial resources and a rising competitive pressure in the health care system, the workload of health professionals is increasing tremendously. At the same time, the commercialization of public health care systems is taking place all over the world, which means that health care services are provided for those able to pay. Working conditions reflect the maxim “health care for profit,” which conflicts with the professionals’ ethical responsibilities. As a consequence of this economic‐political development, and in addition to the emotional strain and pressure resulting from working with patients, the quality of life conditions of health professionals are alarmingly worsening.
Huge empirical evidence highlights that health professionals are an occupational group at risk of a wide range of psychological impairments (Humphries et al., 2014; Moreau & Mageau, 2012). About one third of physicians report to be dissatisfied with their work, a similar percentage of residents are not contented with their career choice, and the situation for nurses is comparable (Brown & Gunderman, 2006; Djukic, 2011; Lu, Barriball, Zhang, & While, 2012; Lu, While, & Barriball, 2005; Utriainen & Kyngäs, 2009; Van Ham, Verhoeven, Groenier, Groothoff, & De Haan, 2006). Physicians, especially female medical practitioners and nurses, are vulnerable to committing suicide (Hem et al., 2005a, 2005b; Schernhammer & Colditz, 2004). Health professionals experience high levels of stress and psychological distress, which often manifest as fatigue, depression, insomnia, and substance abuse (Firth‐Cozens, 2001; Hegney et al., 2014; Mohammed, Ali, Youssef, Fahmy, & Haggag, 2014; Oyane, Pallesen, Moen, Akerstedt, & Bjorvatn, 2013; Pereira‐Lima & Loureiro, 2015; Smith‐Miller, Shaw‐Kokot, Curro, & Jones, 2014). Secondary trauma and compassion fatigue are also widespread problems, as health professionals are continuously confronted with adverse events such as death and dying, and severely injured and ill persons (e.g., Fernando & Consedine, 2014; Mathieu, 2014; Rossi et al., 2012; Sprang, Clark, & Whitt‐Woosley, 2007; Wentzel & Brysiewicz, 2014). A vast number of empirical studies show that they suffer from job burnout, “a psychological syndrome in response to chronic interpersonal stressors on the job. The three key dimensions of this response are an overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment” (Maslach et al., 2001, p. 399). Burnout is a state of depletion of resources that has been shown to be contagious. The burnout syndrome was detected in different health professional groups, as reported in Table 23.1.
Table 23.1 Burnout studies across health professional groups.
Source: Author.
| Professional group | Evidence |
| 1 Emergency nurses | Adriaenssens, De Gucht, & Maes (2015) |
| 2 Intensive/critical care nurses | Bakker, Le Blanc, & Schaufeli (2005), Epp (2012) |
| 3 Oncology/hematology nurses | Sherman, Edwards, Simonton, & Mehta (2006), Toh, Ang, & Devi (2012) |
| 4 Hospital nurses | Sahraian, Fazelzadeh, Mehdizadeh, & Toobaee (2008), Wang, Kunaviktikul, & Wichaikhum (2013) |
| 5 Mental health nurses | Edwards, Burnard, Coyle, Fothergill, & Hannigan (2000) |
| 6 Palliative care personnel | Pereira, Fonseca, & Carvalho (2011) |
| 7 Residents | Ishak et al. (2009), N. K. Thomas (2004), West, Shanafelt, & Kolars (2011) |
| 8 U.S. medical students, residents, and early career physicians | Dyrbye et al. (2014) |
| 9 Physicians/surgeons | Arora, Asha, Chinnappa, & Diwan (2013), Klein, Frie, Blum, & von dem Knesebeck (2010), Roberts, Cannon, Wellik, Wu, & Budavari (2013) |
| 10 Dentists | Hakanen & Schaufeli (2012), Hakanen, Schaufeli, & Ahola (2008) |
| 11 Human service workers | Thomas, Kohli, & Choi (2014) |
| 12 Dietitians | Gingras, de Jonge, & Purdy (2010) |
| 13 Paediatric oncology staff | Mukherjee, Beresford, Glaser, & Sloper (2009) |
| 14 Cancer professionals | Trufelli et al. (2008) |
| 15 Oncologists | Sherman et al. (2006) |
| 16 Health professionals from other clinical settings | Bohmert, Kuhnert, & Nienhaus (2011), Hyman et al. (2011), Kareaga, Exeberria, & Smith (2009) |
The condition of burnout has both somatic consequences (Kakiashvili, Leszek, & Rutkowski, 2013) and negative economic outcomes, such as absenteeism, job terminations, and turnovers (e.g., Adriaenssens et al., 2015; Davey, Cummings, Newburn‐Cook, & Lo, 2009; Flinkman, Leino‐Kilpi, & Salantera, 2010; Hayes et al., 2006).
A review of the scientific literature from PsycINFO and Medline reveals a myriad of studies exploring the factors that cause occupational stress and impair the well‐being of health professionals. These studies refer to very heterogeneous theories (if any) and are empirically focused. They primarily investigate the working conditions and psycho‐social characteristics of nurses and physicians, who are also heterogeneous with respect to work setting and specialty. The majority of the studies are focused on deficits in health‐related quality of life, investigated through negative indicators of well‐being. Their main objective is to evaluate different aspects of negative mental health, while no space is left for the evaluation of the idea of hedonic and eudaimonic well‐being components.
When asked about stressful working conditions, health professionals report heavy workload, huge administrative tasks, financial issues, limited amount of personal time, exposure to patients’ suffering and death, the possibility of making professional mistakes, and the threat of lawsuits (e.g., Moreau & Mageau, 2012). Most of these working conditions can be summarized under the global concept of job demands. Recent reviews of studies on health professionals’ work stress have identified several causes of psychological strain (e.g., Adriaenssens et al., 2015; Arora et al., 2013; Gurman, Klein, & Weksler, 2012; Hyman et al., 2011; Pereira et al., 2011; Sherman et al., 2006; Trufelli et al., 2008). Following Adriaenssens et al.’s (2015) taxonomy, a distinction is made between work‐related factors and individual factors. Among work‐related factors, researchers discuss eight categories of detrimental forces in the work setting of health professionals: traumatic events, job characteristics, heavy workload/high work demands, lack of autonomy, low social support, organizational factors, staffing issues, and organizational culture.
In oncology and emergency settings, health professionals are particularly exposed to traumatic events, which can cause tremendous emotional stress. Health professionals in these specialties are often confronted with severe injuries, life‐threatening diseases, suffering and dying patients, desperate families, suicidal ideation or suicide, and are the target of aggressive behaviors. Witnessing such an event is a trauma if this event involves (1) witnessing actual or threatened death or serious injury, or a threat to the physical integrity of others, and (2) if the health professional reaction involves intense fear, helplessness, or horror. Such a vicarious traumatization may lead to post‐traumatic stress disorder among health personnel (Canfield, 2005).
Furthermore, three classes of job characteristics represent influential occupational risk factors: job demands, low decision latitude, and low social support. In this context, the demand control model developed by Karasek and Theorell (1990) has been one of the most used theoretical models explaining work stress. As the authors state, “elevation of risk with a demanding job appears only when these demands are in interaction with low control on the job” (p. 9). As a consequence, heavy workload should be irrelevant unless the decision latitudes of health professionals are large. It is questionable that this assumption applies to health care services, because of emotional costs and ethical/moral pressure when caring for suffering patients. Later, social support was added to this model, and it was re‐named as the demand control support model. Social support received by supervisors and colleagues has been shown to reduce the job strain caused by high job demands and low job control.
Heavy workload or high work demands represent important clinical stressors that lead to job burnout. This also involves the problem of time pressure: having only a limited amount of time available for a patient and/or the problem of lack of variety can mean that work is heteronomous and incongruent with self‐endorsed values and interests. Health professionals often have to work overtime to sufficiently care for their patients due to a high patient‐to‐health professional ratio. These pressures are further exaggerated through sickness and absenteeism, resulting in compulsory overtime and further pressure and fatigue. A closely related problem is lack of breaks and its effect on reduced recreational space during the work period. A consequence of all of these factors is that work demands interfere with family life and may lead to conflicts in private life, and, vice versa, conflicts at home may enter the work site: stressors in personal life impair the working atmosphere. Finally, a particular job demand of health professionals is the complexity of treatments and concerns about treatment toxicity (e.g., in oncology). “The combination of increasingly complex cancer treatments with higher demands from patients and the ‘downsizing’ of hospital services for patients with cancer put oncology staff at particular risk of work stress and burnout” (Jones, Wells, Gao, Cassidy, & Davie, 2013, p. 46). In witnessing patients’ extreme suffering and dying, health professionals are more likely to feel a failure (in terms of committing a fundamental attribution error, overemphasizing internal and overlooking external conditions).
Lack of autonomy in health care decisions is a severe problem in health care. Medical systems are hierarchic organizations. The lower the position in the hierarchy, the lower the individual health professional’s self‐determination. Administrative and financial issues can also restrict decision latitudes and (sometimes) dictate health care interventions or confine them to the absolutely necessary, but not sufficient. This autonomy issue will re‐appear in the next section of this chapter.
Health care service is delivered in an interpersonal context. Low social support means that there is no teamwork in that staff members do not help each other. There is no mutual trust, no work group cohesion, little social or emotional exchange. It also means that one’s work is not recognized and appreciated by one’s colleagues or superiors. In its most malicious form, low social support manifests itself as bullying (Johnson, 2009).
Organizational factors have been identified as work‐stress factors. Health professionals often feel that their work environment is unfavorable, for example, ward architecture, room size, no space for confidential conversations with patients, lack of privacy settings, small locker rooms, and so on. Moreover, interdisciplinary communication and collaboration may be strenuous, due to the factors previously discussed. As a consequence, intra‐ and interprofessional information provision may be poor, and both the individual health professional and patient can be left at a disadvantage.
Furthermore, staffing issues – which are closely connected to heavy workload – increase the occupational stress level, such as low quality of staffing, understaffing (high patient‐to‐health workers ratio), inequitable working schedules, and inadequacy of shift work. With respect to the latter, permanent night shift is detrimental to long‐term quality of life. In addition to little personal manpower, lack of material resources also seems to be a crucial factor.
Finally, aspects of the organizational culture might also yield stress. A low degree of innovation and change, a lack of interest in quality assurance initiatives, and low financial reward (in combination with high workload and individual efforts) increase job dissatisfaction and burnout. The latter point is central to the effort–reward theory of work stress (Siegrist & Peter, 1994), which has also inspired a lot of occupational stress researchers. An imbalance between efforts and rewards, also known as inequity (van Dierendonck, Schaufeli, & Buunk, 2001), causes emotional distress.
Among individual factors, researchers distinguish between demographic characteristics, personality characteristics, deficits in patient‐centered communication skills, and role stress/role ambiguity. The reviews show a mixed picture with respect to demographic characteristics such as age, gender, or health profession. Systematic effects of these variables on health‐related quality of life or burnout are not convincingly documented.
Investigations into the role of personality characteristics elaborated low resilience (Epstein & Krasner, 2013; Taku, 2014), low hardiness and its constituents (low commitment, low engagement, low control), high neuroticism, high perfectionism, low self‐criticism, an external locus of control, and passive‐avoidant and emotional coping styles. The problem is that these personality variables overlap as regards content with outcome measures of burnout and psychological distress. Therefore, it is unclear what a high correlation between a personality trait and a burnout measure really means.
Deficits in patient‐centered communication skills and lack of empathy are associated with job burnout. These deficits lead to dissatisfying doctor–patient relationships, especially when patients behave in a “difficult” way. From the perspective of the health professional, difficult patients display traits or behavioral dispositions such as being depressive, dependent, manipulative, self‐destructive, noncompliant, or aggressive/hostile. Difficult patients are time‐ and attention‐consuming, and health professionals often experience feeling of frustration and exhaustion. At the same time, burned out health professionals become “difficult” for their patients, because burnout impedes critical self‐reflection and creates biases toward patients, perceiving them as “difficult.”
Role stress reflects a disparity between a health professional’s perception of the characteristics of his or her job and what is actually being accomplished when caring for patients. Role ambiguity may emerge, that is, the lack of clear consistent information about the behavior expected in a role as a member of a particular health profession. If expectations, objectives, and responsibilities have not been clearly explicated, health professionals become ambivalent in appraising their supervisor’s or colleagues’ responses to their work as success or as failure. There is empirical evidence of the negative impact of role stress and role ambiguity on subjective well‐being and burnout in nurses (e.g., Brunetto, Farr‐Wharton, & Shacklock, 2011; Chen, Chen, Tsai, & Lo, 2007; Iliopoulou & While, 2010; Ruel, 2010; Tunc & Kutanis, 2009).
Which of the two broad categories – work‐related factors or individual factors – has a deeper impact on well‐being? Jones et al. (2013) argue that the organizational culture, the health care setting, and the nature of the health care work have been largely underestimated. This means that individual factors have been overestimated. This is reflected in the fact that most intervention concepts have a focus on modifying individuals’ stress reactions and coping strategies, not on the characteristics of the work setting (see below). For example, acute settings such as oncology or emergency are supposed to be more demanding than palliative care settings or rehabilitative settings (see Prins et al., 2010). As Jones et al. note, “… the theoretical basis of studies in this area needs to be strengthened and … future work should focus more on organizational factors” (2013, p. 46).
In the aftermath of identifying stress‐enhancing conditions, focusing on deficits in working conditions and individual characteristics of health professionals, the interest in stress‐lowering factors (resources) such as work engagement, commitment, psychological growth, resilience, and empowerment have been explored. These issues will be presented in the next section.
Recapitalizing the “negative” psychology findings, Sherman et al. (2006, Table 5, p. 76) specify in their review “positive” organizational and individual factors that minimize caregiver stress and burnout in oncology. From a positive psychology point of view, these strategies do represent organizational and individual assets for enhancing well‐being, and not merely for reducing psychological distress. Sherman et al.’s compilation is a useful summary about which resources could represent well‐being enhancing factors for health professionals (see Table 23.2).
Table 23.2 Positive organizational and individual resources.
Source: Adapted from Sherman et al. (2006, Table 5, p. 76).
| Organization |
| Adequate staffing, reduced work hours or patient contact |
| Increased staff autonomy and decision latitude |
| Flexibility in scheduling or assignment to work setting |
| Enhanced teamwork, reduced interdisciplinary conflict |
| Adequate space, facilities |
| Reallocation of selected tasks or conflicting responsibilities |
| Individual staff member |
| Increased personal days/vacation time |
| Communication and management skills training |
| Training courses in interpersonal skills |
| Recognition and appreciation of staff, feedback to staff |
| Support groups |
| Grief/bereavement workshops |
| Stress management programs, healthful lifestyle |
| Enhanced sense of meaningfulness of work, Logo‐therapy |
| Humor |
These assets fit perfectly in positive psychology as a science of positive subjective experience, positive individual traits, and positive institutions. Whereas “negative psychology” gives attention exclusively to repairing damage (e.g., burnout) caused by pathological conditions (located in the individual and/or institution), positive psychology focuses on “the fulfilled individual and the thriving community” (Seligman & Csikszentmihalyi, 2000, p. 5):
The field of positive psychology at the subjective level is about valued subjective experiences: well‐being, contentment, and satisfaction (in the past); hope and optimism (for the future); and flow and happiness (in the present). At the individual level, it is about positive individual traits: the capacity for love and vocation, courage, interpersonal skill, aesthetic sensibility, perseverance, forgiveness, originality, future mindedness, spirituality, high talent, and wisdom. At the group level, it is about the civic virtues and the institutions that move individuals toward better citizenship: responsibility, nurturance, altruism, civility, moderation, tolerance, and work ethic. (Seligman & Csikszentmihalyi, 2000, p. 5)
It is exactly the merit of positive psychology that it puts an emphasis on resources, potentials and strengths of individuals and their working environment. Positive occupational psychology research primarily scrutinizes the experience of nurses and physicians, and it includes heterogeneous measures of well‐being referring to different theories and constructs, such as job satisfaction, work engagement, self‐determination/autonomy, job crafting, mindfulness, resilience, and empowerment. The concept of eudaimonic well‐being (Ryff, 1989, 1995), which has been suggested as a possible theoretical guideline for positive psychology research, has not been fully applied yet in the health care setting.
Recent research discovered job satisfaction as a central outcome variable in positive psychology. Van Ham et al. (2006) assert that job satisfaction is an ambiguous term that can be operationalized in different ways considering a number of dimensions. Job satisfaction implies “all the feelings that an individual has about his/her job” (Lu et al., 2005, p. 211). This definition illustrates that subjective interpretation and expectations play a major role in evaluating job satisfaction. Following Spector (1997), several areas of job satisfaction can be distinguished: “appreciation, communication, co‐workers, fringe benefits, job conditions, nature of the work itself, the nature of the organization itself, an organization’s policies and procedures, pay, personal growth, promotion opportunities, recognition, security and supervision” (p. 212). The list is very long and presumably not exhaustive. Identifying the contents of job satisfaction is thus a complicated topic as they might be easily confounded with determinants of job satisfaction.
In their pioneering work, Herzberg and Mausner (1959) postulated a two‐factor theory of job satisfaction, assuming a positive and a negative dimension – job satisfaction and job dissatisfaction. These are supposed to be distinct phenomena which feed upon different sources. Job satisfaction is energized by intrinsic factors labeled as “motivators” such as achievement, recognition, work itself and responsibility; whereas job dissatisfaction is largely determined by extrinsic factors they called “hygiene factors,” for example, company policy, administration, supervision, salary, interpersonal relations and working conditions (see Lu et al., 2005, p. 212).
In a review including 1,157 studies conducted among U.S. physicians, Scheurer, McKean, Miller, and Wetterneck (2009) identified three basic types of satisfaction: overall satisfaction, career/professional satisfaction, and practice/job/work satisfaction. Overall, they revealed relative stability in repeated cross‐sectional surveys, documenting a rate of 80% satisfied physicians. However, the proportion of “very satisfied” general practitioners declined – as compared to other specialists. Contrasting findings were detected in another review (Williams and Skinner, 2003), showing a decline in physician job satisfaction from the 1960s to 2002. Van Ham et al. (2006) recognized three factors that increase physicians’ job satisfaction: variety in the job, relationships and contact with colleagues, and lecturing to medical students. Factors impeding job satisfaction were low income, too many working hours, administrative burdens, heavy workload, lack of time, and lack of recognition. Haggerty, Fields, Selby‐Nelson, Foley, and Shrader (2013) concede that especially rural doctors are disadvantaged.
With respect to nurses, a review of 1,189 research papers (Lu et al., 2005) described a mixed picture of job satisfaction, highlighting the impact of organizational, professional, and personal variables. These variables include working conditions, interaction (with patients, co‐workers, managers), work itself (including workload, scheduling, challenging work, routinization, task requirements), remuneration (pay, salary), self‐growth and promotion, praise and recognition, control and responsibility, job security, leadership styles, and organizational policies. Again, this empirically based list is extensive. As a consequence, a comprehensive theory or model that can explain and predict job satisfaction satisfactorily is still lacking.
Most importantly, job satisfaction is not only an outcome variable in positive psychology. Williams and Skinner (2003) found in their narrative review that job satisfaction is strongly associated with vital outcomes of both physician and patient. Physician outcomes are turnover, mental and physical health, nonwork satisfactions and work‐related issues, and patient outcomes imply quality of care and patient relationships (2003, see Figure 1, p. 129).
In the realm of occupational health psychology, the idea of positive psychology has been incorporated into the job demands‐resources model (e.g., Hakanen et al., 2008), which extends the aforementioned demand control model. As reflected in the name of the model, psychosocial work characteristics can be categorized as either job demands or job resources. The former are aspects of a job that require effort and are associated with costs. The latter represent the physical, psychological, social, or organizational aspects of a job that may reduce job demands and associated costs, are functional in achieving work goals, and stimulate personal benefits such as personal growth, learning, and development. Job resources are both extrinsically and intrinsically motivating. Intrinsic motivation is nurtured by satisfying basic needs of autonomy, belongingness and competence (Hakanen et al., 2008, p. 225). In this approach, three of the six facets of Ryff’s PWB are affected – autonomy, positive relations with others, and personal growth. The three basic needs are also the core components of self‐determination (Deci & Ryan, 2000; Ryan & Deci, 2000; Ryan, Huta, & Deci, 2008, see below).
Job resources are supposed to foster work engagement – a permanent state which is conceptualized as the opposite of job burnout. Schaufeli, Salanova, González‐Romá, and Bakker (2002, pp. 74) define work engagement as follows:
A positive, fulfilling, work‐related state of mind that is characterized by vigor, dedication, and absorption. Rather than a momentary and specific state, engagement refers to a more persistent and pervasive affective‐cognitive state that is not focused on any particular object, event, individual, or behavior. Vigor is characterized by high levels of energy and mental resilience while working, the willingness to invest effort in one’s work, and persistence even in the face of difficulties. Dedication refers to being strongly involved in one’s work and experiencing a sense of significance, enthusiasm, inspiration, pride, and challenge … The final dimension of engagement, absorption, is characterized by being fully concentrated and happily engrossed in one’s work, whereby time passes quickly and one has difficulties with detaching oneself from work.
According to the demands‐resources model, work engagement is a kind of job‐related well‐being (van Beek, Hu, Schaufeli, Taris, & Schreurs, 2012). If so, it seems to be a special facet of hedonic well‐being – feeling good at work and feeling happy to do this kind of work. Work engagement is linked with positive outcomes such as organizational commitment, which is the counterpart of turnover intentions. Put in positive terms, it is a health professional’s identification with and involvement in his or her health institution or with his or her health profession, respectively.
Simpson’s (2009) review of antecedents and/or consequences of work engagement in the nurse workforce provided consistent evidence of the primary role of organizational predictors, and to a lesser extent individual predictors. Work engagement, in its turn, has a positive impact on productivity and performance. In a Dutch study involving residents, highly engaged young physicians reported fewer errors (Prins et al., 2009). In an Italian study involving different health professions, both organizational and personal factors were profoundly linked with work engagement (Fiabane, Giorgi, Sguazzin, & Argentero, 2013).
Recently, research on well‐being in health personnel has been inspired by self‐determination theory (SDT; Deci & Ryan, 2000; Ryan & Deci, 2000; Ryan et al., 2008), which assumes that human beings are inherently active and growth‐oriented organisms. The working environment either promotes, stimulates, and encourages this disposition or blocks, suppresses, and eliminates it. This means that the interplay between health professional and his or her working environment is important to understand the achievement of subjective well‐being or personal growth.
SDT distinguishes between intrinsic and extrinsic motivation. Health professionals who are intrinsically motivated to work on a task see that experience as fascinating, pleasing, and satisfying. In other words, they are engaged in their work for its own sake, and act in a deliberate way. This means that intrinsically motivated work activity is autonomous or self‐determined. In contrast, health professionals who are extrinsically motivated to work on a task do so because of its instrumental value. In general, intrinsic motivation of health professionals is very high, because choosing this career is associated with pro‐social attitudes and values. For example, in a study involving surgeons, anesthesiologists, and gynecologists, about one third reported that work affords flow experience (see Chapter 7, this volume). Performing surgery, doing research and communicating with patients were the work activities prominently associated with flow. Intrinsic motivation to work as a physician was important for the vast majority of the respondents (Delle Fave, 2006).
The work environment can facilitate or undermine intrinsic motivation and its consequences by fulfilling or frustrating three innate psychological needs: relatedness, competence, and autonomy (Ryan & Deci, 2000). Relatedness refers to the search for positive relationships with patients and colleagues, as well as mutual respect, caring, and trust; competence represents the need for accomplishing challenging tasks at work successfully and to care for patients and their families professionally; autonomy is the need to experience freedom of choice and the opportunity to initiate health care activities (see van Beek et al., 2012, p. 34)
Referring to Gagné and Deci’s (2005) article, van Beek et al. (2012) summarized results from studies outside of the health care setting: “Satisfaction of the three psychological needs, autonomous motivation, and the possibility of satisfying one’s innate growth tendency are associated with optimal functioning and well‐being. With respect to the work context, research has shown that satisfaction of psychological needs and autonomous motivation are associated with positive outcomes, such as task persistence, superior performance, job satisfaction, positive work attitudes, organizational commitment” (p. 34). In their study involving Chinese health professionals, van Beek et al. (2012) showed that intrinsic motivation was positively linked with work engagement, which was also in line with the job demands‐resources model. At the same time, a positive relationship was detected between extrinsic motivation and work engagement, suggesting that health professionals engage in their health care activities for their instrumental value as well. In a study of Canadian nurses, Trépanier, Fernet, and Austin (2015) found that basic need satisfaction promotes work engagement and reduces turnover intentions.
The concept of job crafting focuses on how employees redraft or restyle their job. “Job crafting captures what employees do to redesign their own jobs in ways that can foster job satisfaction, as well as engagement, resilience and thriving at work” (Berg, Dutton, & Wrzesniewski, 2008, p. 1). By independently modifying aspects of their job, employees can improve the fit between job characteristics and their own needs, abilities, and preferences (Tims, Bakker, & Derks, 2013). In principle, they can apply three types of customizing strategies. First, they can change the scope of their sphere of action. For example, a resident may ask for different tasks that require new skills because performing colonoscopies day in and day out is too monotonous, which means that this person is definitely underchallenged in his or her job. Second, employees can change their relationships at work by modifying the nature or extent of interactions. For example, a nurse may intensify contact with a colleague her or she finds to be inspiring. Third, they can use cognitive strategies by changing the ways they perceive and think about their job tasks. For example, a resident performing colonoscopies may consider this task as boring but could reframe it as important (Berg et al., 2008; Tims et al., 2013).
According to Slemp and Vella‐Brodrick (2014), job crafting has to be distinguished from job enlargement or job enrichment. Whereas the latter terms allude to making changes with respect to structural job characteristics, job crafting represents a series of individual strategies in shaping and molding job experiences according to individual needs and desires. In accordance with SDT, job crafting satisfies the basic psychological needs – relatedness, competence, and autonomy – that that lead to optimal functioning and subjective well‐being. Indeed, job crafting reflects exerting control over work, creating a positive self‐image, and connecting with others in the workplace. Job crafting could also be a means for cultivating positive meaning and identity in work over time (Wrzesniewski, LoBuglio, Dutton, & Berg, 2013).
The literature review suggests that job crafting has not yet been explored in the health workforce. Only one U.S. study investigates how nurses deal with adversity at the worksite (Caza, 2008). Using narrative interviews, the researcher explored the role of work identity and found out that job crafting was one out five identity‐based response moves (the others being disengagement, stoic coping, switching jobs, and identity customization).
According to K. W. Brown, Ryan, and Creswell (2007), mindfulness is rooted in the fundamental activities of consciousness: awareness of stimuli which can be perceived with one or more of the five physical senses, and attention in terms of turning toward a stimulus in a focused way. Mindfulness “is most commonly defined as the state of being attentive to and aware of what is taking place in the present” (Brown & Ryan, 2003, p. 822) and can be conceived of as “a receptive attention to and awareness of present events and experience” (Brown et al., 2007, p. 212). Empirical evidence shows that mindfulness has beneficial effects on psychological well‐being and physical health.
Shapiro and Carlson (2009) argue that mindfulness is particularly appropriate for members of the health workforce. Given the emotional burden and ethical‐moral responsibilities when caring for suffering and dying patients, mindful health care professionals can explore their own suffering, affliction, fatigue, anxiety, or depressive reactions, and put these experiences in a personal context. First and foremost, it helps to understand the causes and consequences of these experiences. As a medium‐term effect, mindfulness generates well‐being. “It teaches us to become interested in the inner workings of our own minds, bodies, and hearts, with kindness, and in this way discover what it means to be human” (Shapiro & Carlson, 2009, p. 107). In line with SDT, mindful persons are happier because they choose options for themselves that are consistent with their needs, values, and interests.
Richards, Campenni, and Muse‐Burke (2010) showed that mindfulness mediates the relationship between self‐care importance and well‐being in mental health care workers. Mindfulness‐based intervention programs designed for different health professional groups seem to promote employees’ well‐being (e.g., Boellinghaus, Jones, & Hutton, 2014; Byron et al., 2014; Cohen‐Katz, Wiley, Capuano, Baker, & Shapiro, 2004) and decrease negative mental states such as burnout, depression, anxiety, and stress (Cohen‐Katz et al., 2005; Fortney, Luchterhand, Zakletskaia, Zgierska, & Rakel, 2013; Goodman & Schorling, 2012; Krasner et al., 2009; Moody et al., 2013). The only randomized controlled study in positive psychology will be described in the section on interventions below.
Zwack and Schweitzer (2013) explicitly investigated the work experience of health professionals from a positive psychology perspective revolving around the concept of resilience: If around 20% of physicians are affected by burnout, what about the other 80%? How can physicians stay healthy and maintain or enhance their well‐being despite facing adversities in delivering health care services? The authors identified three dimensions of (1) general sources of gratification (e.g., from the doctor–patient relationship, medical efficacy), (2) behavioral routines and practices (e.g., leisure time activity to reduce stress, quest for and cultivation of contact with colleagues, proactive engagement with limits, self‐demarcation), and (3) attitudes and mental strategies (e.g., acceptance and realism, self‐awareness and reflexivity, appreciating good things).
In their review, Jackson, Firtko, and Edenborough (2007) identified similar personal resilience or self‐development strategies nurses used to bolster resilience: (1) Building positive nurturing professional relationships and networks. This strategy underscores the importance of social support for resilience. The institutional network becomes a support system nurses can fall back on in case of need. (2) Maintaining positivity. This orientation emphasizes the positive effects of drawing on some form of positive emotion in the midst of stress and adversity. With respect to future prospects, maintaining positivity implies optimism and a positive outlook on things to come, and appreciating potentially positive aspects and benefits. (3) Developing emotional insight. This strategy encompasses emotional intelligence and understanding one’s own emotional needs, with respect to both negative and positive emotions, and getting to know the emotional conditions and needs of co‐workers. (4) Achieving life balance and spirituality. Resilient individuals possess a philosophical, religious, or other spiritually based belief system that provides a purpose in life, a coherent life narrative, and a positive understanding of oneself as a unique human being. Moreover, regular practice of healthy habits outside of work acts as a counterbalance against work‐related stress. It is important to find a balance between demanding work/tension and necessary recreation/relaxation. The final strategy is (5) becoming more reflective. Self‐reflection is an important prerequisite for learning and positive change. It implies developing insights into concrete experiences. This increase in level of knowledge can be applied in future situations.
Cicolini, Comparcini, and Simonetti (2014) reviewed empirical studies investigating the role of empowerment for job satisfaction in nurses. Two aspects of empowerment emerged. Structural empowerment denotes nurses’ access to four different organizational empowerment structures, or applications (Kanter, 1977): information (data, technical knowledge, expertise), resources (money, material, time, equipment), support (leadership, guidance, feedback), and opportunity (for autonomy, self‐determination, challenge, personal growth). Psychological empowerment “deals with ways in which these applications are experienced and understood by workers … and occurs when there is a sense of motivation in relation to the workplace environment” (Cicolini et al., 2014, p. 856). These authors found substantial relationships between empowerment, job satisfaction, and other organizational outcomes. Structural empowerment proves to be a prerequisite for psychological empowerment. In other words, the combination of the two is a strong predictor of job satisfaction. As a conclusion, “removing disempowering structures from the work setting leads to a strong sense of autonomy among employees, who have a strong belief that they have an impact at work” (Cicolini et al., 2014, p. 867). Concordantly, Pearson et al. (2006) backed up in their review the importance of structural requirements such as adequate workload and staffing for creating and maintaining healthy work environments.
It is not surprising to find that intervention research on both the promotion of well‐being and the prevention of work‐related stress and its consequences is very heterogeneous. Before presenting the few positive psychology interventions aimed at enhancing well‐being in health personnel, reviews will be summarized that examined the alleviation of negative outcomes such as burnout, anxiety, or psychological distress. These works are interesting from a positive psychology point of view because the interventions addressed positive factors related to both the organization and the individual.
Some studies explored the effectiveness of a positive psychology intervention on alleviating negative states, such as stress symptoms. Awa, Plaumann, and Walter (2010) reviewed intervention programs published between 1995 and 2007 aimed at preventing burnout. They identified 25 studies that included, among other workers, health care professionals, dentists, interdisciplinary care workers, and social workers. About two thirds (68%) of the interventions were person‐directed, as they aimed at changing factors located within the individual staff member. Participants were offered individual or group sessions of “cognitive‐behavioral training, psychotherapy, counseling, adaptive skills training, communication skills training, social support, relaxation exercises or recreational music making amongst others” (p. 187). Only few studies (8%) were organization‐directed, measuring “work process structuring, work performance appraisals, work shift readjustments, and job evaluations” (p. 187). About one quarter (24%) implemented a combination of both person‐ and organization‐directed interventions. The duration of interventions and assessment points in time varied to a high degree. In about two thirds of the studies, interventions lasted less than 6 months. The time span between pre‐test and post‐tests also differed from study to study.
Bearing this diversity in mind, this review highlighted that the majority of person‐directed studies (82%) backed up a significant reduction in burnout and associated negative indicators such as “state anxiety, psychological distress, depression, moods, fear, perceived stress, self‐esteem, feelings of guilt, feeling of deprivation, effort‐reward imbalance, and emotional job demands amongst others” (Awa et al., 2010, p. 187). Results concerning organization‐directed interventions were inconclusive, due to the limited number of studies with such a focus. Finally, the authors found evidence that combined interventions delivered better results than separate person‐ or organization‐directed interventions.
In their recent Cochrane review (an update of Marine, Ruotsalainen, Serra, & Verbeek, 2006), Ruotsalainen, Verbeek, Mariné, and Serra (2015) scrutinized 58 studies that aimed at preventing occupational stress in healthcare workers. They categorized interventions as cognitive‐behavioral training (24%), mental and physical relaxation (36%), a combination of cognitive behavioral training and relaxation (10%), and organizational interventions (34%). Outcomes were classified as stress, anxiety, or general health. The authors conclude that there is only low‐quality evidence concerning psychological interventions, and that there is no evidence that organizational interventions would have an effect. However, the latter finding is based on a very small number of studies.
In their short programmatic paper, Muha and Manion (2010) proposed 6 positive psychology principles, summarized in the acronym PROPEL. These are passion (creating a compelling and detailed vision of how health professionals can live a valuable life); relationships (positive interactions must outweigh negative ones with a 5:1 ratio at least); optimism (getting an idea that mutually satisfying solutions can be found); proactivity (consistently focusing on strengths rather than deficits); energy (making and taking opportunities to routinely recharge and recover), and legacy (enabling health professionals to make a difference in the lives of their patients and families). All principles aim at instigating positive emotions in health professional leaders and staff, which is a prerequisite for optimal organizational functioning. Unfortunately, the PROPEL approach has not been subjected to empirical interventional research. Essentially, it is striking to see that there are only a few intervention studies inspired by positive psychological theory.
Ouweneel, Le Blanc, and Schaufeli (2013) developed an online positive psychology intervention program to instigate and reinforce positive emotions, self‐efficacy, and work engagement. However, it is unclear from the study if their sample included health professionals. Nevertheless, their person‐directed approach is very appealing. They compared a self‐enhancement group with a control group that only monitored their well‐being. The self‐enhancement interventions included happiness activities, goal setting at work, and resource building assignments. They demonstrated that the intervention had a significant impact on positive emotions and self‐efficacy, but not on work engagement. Only initially unengaged individuals had a benefit in increase of work engagement.
An employer‐provided intervention program with protected time to promote physician well‐being was also recently developed (West et al., 2014). This program took place every 2 weeks for 1 hour of paid time over a period of 9 months. This group‐based program included elements of mindfulness, reflection, exchange of experiences, and group learning intended to promote group cohesiveness. In their randomized controlled trial, the authors showed that the intervention group significantly improved in meaning, empowerment, and engagement in work. Most importantly, these changes were sustained over a period of 12 months. However, no differences could be found in overall quality of life and job satisfaction. The same was true for stress levels and depressive symptoms.
Bolier and her colleagues (2014) conducted an online intervention study aimed at promoting the well‐being of nurses and other health professionals. In the experimental condition, the authors offered screening, personalized feedback and a tailored offer of online self‐help interventions. Five programs consisting of different modules were available: Psyfit (aimed at enhancing well‐being and mental fitness); Colour Your Life (a cognitive‐behavioral program for alleviating [subclinical] depressive conditions); Strong at work (aimed at reducing work stress and improving coping strategies); Don’t Panic Online (a cognitive‐behavioral program for alleviating [subclinical] panic conditions and mild cases of panic disorder); and Drinking Less (aimed at changing risky drinking). The control condition was a waitlist group, getting the same intervention after the 6‐month follow‐up assessment. The authors were able to demonstrate that the intervention effectively enhanced especially psychological well‐being, disclosing a medium‐effect size after 3 months and 6 months follow‐up. However, this pattern should be interpreted cautiously because of high attrition rates, especially in the intervention group.
An important future research task for positive work psychology in the health domain would be the formulation of a meta‐theoretical conception that might integrate positive phenomena such as job satisfaction, work engagement, self‐determination/autonomy, job crafting, mindfulness, resilience, and empowerment. Moreover, it would be important to expand the person‐centered perspective in positive psychology by embedding it into a positive organizational psychology framework (e.g., Bakker, 2013) and by applying it to different health care settings. It would be interesting to investigate to what extent hedonic and eudaimonic facets of well‐being could represent central organizational goals (among others).
One rather unexplored research avenue should address the relative influence of individual and work‐related factors on the hedonic and eudaimonic well‐being of health professionals. In this respect, it would be also important to compare different professional groups of the health workforce in different health care areas, or sectors (e.g., oncology, emergency, psychiatry).
The majority of positive psychology studies providing evidence of health professionals’ well‐being so far is limited by its cross‐sectional design. Therefore, an interpretation of cause–effect relations is not possible. Consequently, positive psychology needs prospective studies with longitudinal designs to explore changes, developments, and continuity. Such research designs would allow for more analysis of determinants, mediators/moderators, and consequences of well‐being.
Positive psychology lacks intervention studies, preferably randomized controlled trials, in health care institutions/settings. Goldenhar, LaMontagne, Katz, Heaney, and Landsbergis (2001) described the intervention research process as consisting of three phases, which can be understood as a research circle: development, implementation, and effectiveness. Whereas mainstream intervention research focuses on short‐term program effectiveness (in terms of effect sizes), little attention has been devoted to the theory‐driven development of a program and how to successfully implement it permanently and sustainably. Thus, the connection between interventional research and organizational change seems to be the key.
Positive psychology for health professionals is a new field of research that is gradually developing. Started at the end of the last century as a science of positive subjective experience, positive individual traits, and positive institutions (Seligman & Csikszentmihalyi, 2000), positive psychology has raised important research questions and provided interesting answers. But still a vast research field lies ahead. On the one hand, we already seem to know detrimental work‐related and individual factors that lead to burnout, depression, suicidal ideation, anxiety, and other forms of psychological distress. We also have an idea of what could be positive outcomes of caring for people and their families, learning something about job satisfaction, work engagement, self‐determination/autonomy, job crafting, mindfulness, resilience, and empowerment. On the other hand, these positive concepts stem from different theoretical perspectives, and sometimes, one and the same term is explored from different theoretical backgrounds.
One integrative starting point could be the concept of eudaimonic well‐being (or PWB). As already foreshadowed at the beginning of this chapter, the significance of eudaimonia in occupational positive psychology, the fulfillment of individual needs and the idea of a fully functioning person in a fully functioning organization, should be explored systematically and in more detail. Recent empirical work on work engagement (including vigor, dedication, and absorption), self‐determination, and organizational commitment (identification with and involvement in a health institution, identification with a health profession) are all steps in the right direction. With respect to the investigation of well‐being, a theoretically derived research agenda would be imperative. The classical six facets of positive psychological functioning in the health workforce should be of special interest: self‐acceptance, positive relations with others, autonomy, environmental mastery, purpose in life, and personal growth. As Ruotsalainen et al. (2015) ascertained, there is a lack of studies exploring the well‐being (both SWB and PWB) of physicians.
Positive psychology has not yet developed a footprint of a positive health care setting or institution. Instead of having worked out a theoretically driven concept, there is a loose list of positive work‐related factors. It starts with the claim for “adequate” space and facilities such as “favorable” ward architecture, “adequate” size of locker room and work rooms (including space for confidential conversations with patients). Researchers also suggested that “adequate” staffing (including quality of staffing) and reduced work hours or patient contact would be important (in view of the documented huge workload for the individual health professional). The question would be how to operationalize adequacy, and who should have the power to define and to realize it. The question of adequacy or sufficiency is also connected with issues of increased staff autonomy and decision latitude. The question arises who determines autonomy or decision latitudes (with respect to functions, techniques, professional work, economy), for example, in a commercial enterprise such as a hospital: the provider, the management board, the operative and strategic controlling division, the head physician, the head nurse, or the individual health professional directly involved with the patient? The same holds true for flexibility in scheduling or assignment to work setting. Other researchers emphasize enhanced teamwork and social support to be important, having an impact on increasing mutual trust, good cooperation, and a culture of resolving conflicts. To sum up, positive psychology has given no theoretical input on “positive leadership” or “human resource management” in health institutions, that is, how to let human resources for health thrive.
There is a lack of evidence concerning the main characteristics of a positive organizational culture and their significance for bringing about hedonic and eudaimonic well‐being (SWB and PWB) among health professionals as an organizational goal. In this respect, positive organizational psychology has not yet initiated a value‐driven discourse on ethics for institutions in which preventive, curative, promotional, or rehabilitative health care services are provided. In this context, the nature of the health care work would be a significant determinant that influences different aspects of well‐being for different health professional groups.
Consequently, there is little research on creating healthy institutions for health professionals. In this context, an empowerment and participation perspective would be of special interest (Cicolini et al., 2014). This is a political issue, too. The intervention research conducted so far has focused on modifying individuals’ stress reactions and coping strategies, not on the characteristics of the work setting itself. As already delineated, the organizational culture, the health care setting, and the nature of the health care work have been largely underestimated in relation to health professionals’ well‐being. Clinics are run by analogy with industrial units of health care products. Economic issues add more weight to organizational decisions than moral–ethical arguments. Staff health matters are directed by economic principles and profit interests. Persons in need of health care treatments are treated like customers, not like patients. This means that the nature of the classical doctor–patient relationship has become ambivalent and hesitant. Especially in oncology and emergency units, caring for severely injured, severely ill, and dying patients is extremely straining, also because of the complexities of treatments and concerns about treatment toxicity. This means that the nature of health care work can push health professionals to their individual limits. As a consequence, evidence‐based structural solutions are necessary.