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Morale is the collective measure of job ­satisfaction, personal well-being, quality of interactions, and activity level of individuals that work together. This chapter addresses how to build an environment that supports and enhances the job satisfaction of the people with whom you work and for whom you are responsible. The principles presented are equally applicable to a clinical teaching service, laboratory group, residency program, department, or medical school. They are less about how to succeed in formal administrative roles and more about specific behaviors that enhance the morale of everyone you supervise, direct, or with whom you collaborate.

Despite its recognition as an essential component of a successful organization and a core responsibility of leaders, relatively little attention has been paid to the factors that drive resident and faculty morale in the medical literature [1, 2]. Extensive work within the field of organizational behavior has focused primarily on the business community [3], whose goals and methods may overlap with but are not identical to those of healthcare in general or medical education in particular. Consequently, the following are suggested best practices based on observations of groups that succeeded or failed to work well together in academic medicine. They begin with four basic principles that are applicable across a range of situations (Table 43.1). These will be followed by a series of specific issues that require special attention.

Table 43.1 Essential qualities to strengthen morale
Full size table

General Principles

Be Engaged

Leadership is fundamental to academic medicine. From the clinical instructor supervising a medical student to the dean managing a medical school, academic life inevitably includes responsibility for the welfare of the people around you. Engagement means recognition and acceptance of your responsibility as a leader. The capacity to encourage and empower your trainees and colleagues does not arise from administrative authority, but from a personal interest in them and a genuine desire to facilitate their work and professional development. Your goal should be for trainees and faculty to accept your directions not because of your position, but because they know you care about them, understand their concerns, are fair, and have good reasons for your decisions. It should never come down to them doing something because you have the power to force them. Ironically, this principle of leadership is easier to learn at the bottom of the academic ladder than at the top.

Every faculty member works within an academic and health-care hierarchy that has expectations of performance and grants autonomy within the unavoidable limits of institutional mission, financial priorities, regulatory requirements, and administrative directives. Although it is easy to see the organizational chart extending above you (seemingly to infinity, as every chair has discovered), it is equally important even as an entry-level faculty member to recognize who is depending on you and how you can serve them.

Take a moment to notice the people who are looking to you for direction. Most conspicuous are likely to be the medical students and house officers assigned to your clinical service. Consider your role in terms of their needs. You are responsible to provide them with direction, to serve as a role model, and to create an environment that facilitates their professional growth. They will soon be your colleagues; treat them as such and help them get there.

Next you may notice allied health or technical professionals, such as nurses, social workers, laboratory technicians, activity therapists, dieticians, and innumerable others. You are responsible for their integration into clinical and research operations. Their work is essential to yours; help them do it. You will inevitably encounter clerical and administrative staff. The paperwork they handle may seem an annoyance or even a hindrance to your work, but no system can operate without them; comply with their requests and they will keep you on track and in compliance with critical regulations. Less conspicuous may be the housekeeping, maintenance, and security staff. Much of their work is invisible; that does not mean it should be overlooked. All of these workers are skilled at what they do and take their responsibilities as seriously as you do yours; respect their roles, their training, their professionalism, and their judgment. None of these people really work for you, but sometimes they may have to follow your directions (e.g., medical orders), and they are always affected by how you lead (see Case Study #1).

In the normal flow of academic life as your career progresses, formal leadership roles are expected. The skills you develop early in your career will serve you well as you take on these responsibilities. Your challenge will be to fully assume the role you are assigned and learn to adapt your relationships to the new position.

As your administrative role grows, so do your obligations to faculty, trainees, and auxiliary staff. They need to know that someone is at the helm directing everyone’s efforts and protecting them from threats to their own goals, priorities, and job security. Be active and visible in the role. Few things undermine staff morale more than their feeling unnoticed and unappreciated. Give people the assurance that you are there and are aware of their work, their needs, the rules that govern them, and the forces that affect them. Regular acknowledgement of their challenges and achievements is an important element of group leadership. Invisible or absentee leadership rarely engenders confidence, enhances energy, or facilitates individual or group success. If 80% of success is showing up, make sure you are there (see Case Study #2).

One effective approach is to be present on the front lines of the work. Administrators who sit in distant offices making decisions about work hours, clinical quotas, and staffing ratios are unlikely to fully grasp the impact of their policies on job satisfaction or the work environment. Leaders who maintain a clinic schedule, cover an inpatient service, and schedule themselves for regular call shifts gain insight and credibility available no other way.

Additional efforts may be required to identify career milestones such as awards and publications; personal events such as birthdays, births, and deaths; and individual issues such as medical or family problems. The extra effort to ask about these things periodically not only communicates interest but allows you to appreciate that you are surrounded by real, three-dimensional people. They will respond accordingly.

Be Supportive

Relationships with colleagues are an important source of job satisfaction [4, 5]. To make the most of this resource, it is essential that relationships be positive, constructive, and supportive. Support for individuals covers a broad range of intellectual, emotional, social, and academic needs experienced by trainees, faculty, and other staff. Support for these needs may be offered up or down the chain of command, laterally among peers, and elsewhere. It may take the form of ­personal warmth, career advice, clinical consultation, research collaborations, or any number of other means by which the interests of another person become paramount. As a general attitude, several elements are essential.

Be respectful in every interaction [6]. Recognize the worth of the person you are seeing as a professional (or potential professional), a colleague, and a fellow human being. Seek to understand his or her perspective, feelings, and needs. Ask yourself how you might be most helpful and follow through on your thoughts, if only with a word. Be aware of the unspoken ­implications of your feedback and recommendations regarding the value of a person’s skills, interests, and potential. Few things are as demoralizing as disregard or condescension [7]; take care to emphasize the positive and to convey your respect and desire to be helpful.

Support does not always mean agreement. Confrontation of incorrect information or maladaptive responses may be the most constructive response [8]. In some cases, it may even be helpful to directly question someone’s priorities or goals. Faulty understanding of the facts is relatively easy to detect and is essential to correct. Take the time to probe how your trainee or colleague understands things; be straightforward in addressing errors of fact. Errors of interpretation are equally important but may be harder to counteract. Be willing to share your perspective on what is happening behind the scenes and on the implicit meaning of policies and decisions. Care enough to confront maladaptive behaviors; do not stand by and allow a trainee to unknowingly build a reputation as oppositional, high maintenance, or entitled. Prompt, focused feedback on these behaviors is hard to give and painful to receive, but is essential to professional development. Good reality testing is a precious service, even when that reality hurts.

Be attentive to individuals’ career development. Programs and departments differ in the degree to which work assignments are allocated based on the needs of the department versus the interests of the individual. The morale of trainees is closely correlated with their perception of the educational value of their clinical rotations as compared to the service needs of the department. The attachment faculty members feel to the institution will be affected by whether they perceive that their positions represent a positive career move or just fill gaps in clinical or research operations. From an administrative perspective, policies differ as to whether they primarily serve the department or its individual members. For example, when taking corrective action, a training program may have a low threshold for termination in order to maintain the integrity and reputation of the program or may favor extensive remediation in the hope that every trainee will successfully reach graduation. To some degree, the difference is how these issues are framed. More substantive is how they are actually approached. As a steward over the education of trainees and career growth of faculty, remember that their success is your success and their morale is dependent on your support (see Case Study #3).

Be Transparent

Regular, high-quality communication facilitates every aspect of clinical care, education, and administration. In contrast, job satisfaction and performance suffer when policies are announced without context, decisions are made without discussion, and evaluations are issued without prior expectations. Even controversial or difficult decisions will be accepted more readily if the process by which they are reached is explained. Similarly, summative feedback should be the culmination of a series of earlier communications about performance. The endpoints of these processes should not be their only visible feature.

Transparency promotes both the reality and the appearance of fairness and integrity. These are essential qualities of leadership that build confidence and satisfaction among trainees and faculty [9]. Openness in decision-making encourages a balanced approach and carries with it a built-in corrective for bias and favoritism. It builds trust in the leader and demonstrates the leader’s trust in the group. This working relationship encourages an alignment of individuals’ values and goals with those of the institution. Beware of decisions that you do not want to be widely known; this is a warning sign that your integrity is compromised. As a general rule, it is a poor policy that is based on not being exposed.

Whether as a supervisor or administrator, be clear about your expectations for trainees, faculty, and others for whom you are responsible. Establish standards of performance, explain how they will be monitored, and provide frequent feedback on how each person is doing relative to those standards and to their peers. Meet with them regularly to review expectations and performance. Be clear when standards are not being met and about the consequences of nonperformance (see Case Study #4).

As a supervisor and as an administrator, transparency works both ways. Listen to others’ opinions and be open to different perspectives. Make it clear that you have heard what they have to say and that you are taking their views into account. Decisions made by consensus have a power not shared by administrative decrees, providing greater understanding and acceptance. For those issues that must be decided by a smaller group, take not one but two moments to explain your decisions: first to share the background information that informed your choice and then to review the rationale you followed. Even those who disagree will at least have the correct information in front of them and will know the basis on which the decision was made.

Balance Direction and Autonomy

Productivity and a positive work environment require a constructive interaction between the leader and members of a group [7, 10]. Professional satisfaction and effectiveness improve when the goals and methods of the group are clear to everyone and their efforts are united [11]. Leaders give direction and structure to group endeavors; workers provide the energy and productivity necessary to accomplish them. Good leaders motivate not only through support and clarity of expectation but also through clarity of vision; good workers accept that vision as their own and align their activities with it.

The directive nature of leadership stands in contrast to the need to promote independence among the members of the group. Medicine is hardly the place to find individuals who will be satisfied with subservient roles and rote activities. Little wonder, then, that personal control over job descriptions and work hours are among the most common factors cited in studies of physician morale, among both faculty and residents [12–14]. Part of the role of a faculty member is to find ways to grow professionally; part of the role of a leader is to facilitate that independent activity and growth in others.

A key challenge of life in academic medicine is to balance these seemingly incompatible goals [15]. The least elegant approach is for the administrative leader to give everyone control over a few things and to retain control over everything else. More effective strategies include the exploration of convergent interests, education and persuasion, job matching, and creative negotiation. Faculty at all levels have a role to play in this process.

Convergent interests are those areas in which what someone wants to do and what the administration needs him or her to do are the same. This is an essential element of contract negotiation for a new faculty member. To be effective, both parties need to be clear about their goals and motivations. As an entry-level faculty member, think carefully about your priorities, interests, and dislikes. Keep in mind that an activity that you found tolerable for a few months of residency may be less so when telescoped over decades. If your true motivation for taking a job is only partially related to the job description (e.g., you want to teach medical students, but the only faculty job available is on an inpatient unit you barely survived as a resident), say so before you sign the contract. As a senior administrator in the department, be clear about the prospects of career development and flexibility of assignment for a new faculty member. The two of you must work creatively to match personal interests with departmental needs, and each must be willing to adjust expectations.

This process will go on as interests and job descriptions evolve over the course of a career. Much of your contribution to your own career development as a faculty member is your ability to find professional interests that will benefit your department. Much of your contribution to faculty as an administrator will be your ability to find the right person to meet a need in the department. The right person is not only the person with the right skills but also the right interests and career goals. If that faculty member is not obvious, opportunities for faculty training may develop both the interest and the skills the department needs.

For trainees, the process has the added dimension of certification requirements. Students and residents must achieve certain competencies to graduate, and the department has an obligation to make those available and to facilitate the process. Education directors must maintain the quality and integrity of their programs. Consequently, certain activities and standards cannot be neglected or compromised. Even with these constraints, however, it is possible to introduce a measure of independence to the process. Directors of medical student education can offer a variety of clerkship options and can direct students to the sites most compatible with their interests. Residency program directors can be flexible with scheduling, creative with electives, and active in arranging faculty mentors. A simple rule to follow when a trainee asks to deviate from the standard schedule is, “Say, ‘Yes,’ whenever possible; say, ‘No,’ whenever necessary.”

Specific Issues

The general principles just described come into play in a variety of situations, a few of which are delineated below. These are specific areas that will be especially important to the morale of trainees and faculty. They are described from the perspective of the person best positioned to have an impact on the group dynamic.

Supervision and Mentorship

The learning environment is among the most important factors cited by residents in the quality of their training experiences [16], and no one has a more profound effect on that environment than the clinical supervisor. It is essential that faculty master the skills needed to oversee the work of their trainees, recognize their strengths and weaknesses, guide them toward a mastery of the field, and support them in their struggle to achieve it.

As a supervisor, be clear about your expectations and your standards. Accrediting bodies for both medical schools and residencies require that every training experience has explicit learning objectives and that these be made clear from the outset to the trainee. Most of these address global goals related to competencies expected at graduation and during subsequent practice. As such, they are essential for both teacher and learner. In most settings, they are well developed and regularly distributed to trainees. It is somewhat surprising therefore that one of students’ and residents’ most frequent complaints is that they do not know what is expected of them or the standard by which their performance will be judged.

To a large degree, the missing element is clarity about specifics. Students should already be aware that a goal of the rotation is for them to master diagnostic skills in that rotation’s clinical area. What they most want to know is what time you expect them to come in, what information to present at rounds, and to whom their routine questions should be addressed. House officers understand that they will be evaluated on their patient care. They need to know what that means to you. Do you want them to check every order with you ahead of time? Do you want them to use lab tests liberally or conservatively? Do you prefer careful observation or aggressive treatment? To the degree that you are aware of your style compared to that of your colleagues, make it clear to your trainees.

The second complaint of residents is that they do not know how they are doing [17]. Give formative feedback regularly, including both positive and negative elements [18]. Give specific direction for improvement and follow-up feedback on the trainee’s progress. Be sure your supervision includes the standards you will use in your summative assessment. There should never be a surprise when a student or resident reads a final evaluation.

Finally, trainees seek mentors more than supervisors [19]. Supervision is about direction, oversight, and evaluation. In the clinical setting, it is about ensuring that patient care meets appropriate standards and that trainees demonstrate appropriate skills. In several important ways, supervision is less about education than it is about the protection of patients in spite of education. Mentorship, in contrast, is a relationship between a trainee and a more experienced colleague who come together to share experience, knowledge, skills, and attitudes. A supervisor gives the trainee assignments; a mentor brings the trainee along as they work side by side on a common project. Supervisors give directions; mentors explain their thinking and invite the trainee to reason with them. Supervisors seek objectivity in evaluations; mentors seek a relationship that fosters growth. Supervision produces graduates; mentorship produces colleagues. Serve as a mentor by taking an interest in your students and residents, by inviting them into your professional world, by coming to know them as individuals, and by focusing your teaching less on the goals and objectives of the rotation and more on their goals as physicians.

The principle of mentorship applies equally well to relations between early-career and experienced faculty. As a new addition to the department, seek out senior people worthy of your trust and confidence. Ask them questions, seek their guidance, and learn from their experience. As you grow in experience, reach out to younger faculty, include them in your projects, share the insights you have gained, and try to help them move up the academic ladder. Treat their requests for your time and attention as the honor that they are. The relationships that result and the growth that follows will create a satisfying and productive work environment for early-career and experienced faculty alike.

Work Expectations and Schedules

One of the most frequently cited correlates with burnout among house officers and faculty is lack of control over schedules, work settings, and job expectations [12–14]. To the degree possible, seek residents’ input in their rotation and call schedules and give faculty control over their daily schedules. Of course it will be necessary to set limits on their autonomy, but make clear the ­reasons those limits are set and how decisions are made. Once the schedule is in place, avoid unnecessary and last-minute changes. Constant and unpredictable changes in schedules are frustrating and demoralizing, enhancing the sense that their lives are out of their own control.

Monitor work expectations to ensure that they are reasonable. It is easy to achieve burnout among faculty simply by holding them accountable for 25% more work than they can possibly do. The outcomes will be demoralization, cynicism, and exhaustion. Establish meaningful metrics of their work, such as hours, patients, or projects. Listen to their feedback on the viability of their workload. Spend time walking in their shoes, rotating through the clinics or completing a specific assignment. Make adjustments to keep things reasonable.

For trainees, the workload must be managed to avoid a compromise of the learning experience. Assignment of too few patients wastes their time and effort; assignment of too many deprives them of the opportunity to be thorough and reflective about what they are doing. Keep track of the numbers of hours they work, patients they see, and other work that they do. Seek their input regarding the value and burden of specific assignments. Make necessary adjustments promptly.

Social Activities

There is a reason that universities provide homes for their presidents and departments have catering budgets for their chairs [10]. Social gatherings are important to people who work together. In part, this is because eating, drinking, and socializing tend to be more fun than working. As such, receptions and parties can be ideal ways to thank people for their hard work or congratulate them on a recent achievement. Even a simple gift of food or flowers goes a long way to demonstrate recognition and appreciation.

The immediate effect of a social hour on morale is augmented by additional benefits. Some business is easier to conduct without a formal meeting, but other more global consequences are equally important. Opportunities to meet in a relaxed environment allow people to develop personal relationships that will assist them in the workplace. Informal meetings facilitate introductions across disciplines and along administrative hierarchies. Senior leaders usually seen at a podium or experienced only via mass-mailed communications become real and accessible ­people. New faculty members have faces and voices to accompany their names. Trainees stand equal ground with faculty as they chat together.

A good place to begin as a new faculty member is with bagels before rounds or cookies for a workroom. A word of explanation and a few minutes to share the snacks together will be appreciated as much as the food. Once or twice a year, consider hosting a picnic or theme party for trainees and their families. As you move up the administrative ladder, more formal gatherings may be appropriate. Take care to reach out to everyone within your sphere, including colleagues, trainees, and staff who might otherwise be overlooked. Develop the habit of social activity early. The benefits far exceed the costs.

Response to Complaints

No program or department is free of problems. Whether they are transient obstacles or long-term structural inadequacies, issues will periodically arise that cause dissatisfaction. The existence of these difficulties is less important than how they are handled [20]. Trainees and faculty want to be heard and respected when they call attention to a problem. They want to see some indication that their opinions make a difference. Morale may actually improve in the face of a challenge if people feel that they have a role in addressing it.

An effective leader welcomes feedback on the status of the workplace and quality of the work. Workers who care enough to confront a smoldering issue and offer an opinion about what is not working should be seen as an asset, not a liability. They may well hold the key to the problem and its solution.

Take seriously complaints from whatever source. Look into the problem to see if there is substance to it. If it cannot be objectively verified, try to understand why it is seen as a concern. Take action promptly to explore possible solutions. Engage those most affected in the process. Keep everyone apprised of what is going on. Make changes where you can; give explanations where you cannot (see Case Study #5).

Disaffected Personnel

A spirit of collegiality within a department can make the difference between a satisfying work experience and a tense, abrasive environment. One angry individual can stir up an entire program or department, often without it being immediately apparent where the trouble originated. In some cases, even the person who is agitating the situation is unaware of his or her role. Left uncorrected, the destructive influence of that individual on group cohesion and satisfaction can be devastating.

Your first obligation when an individual stirs up a group with complaints and angry dissatisfaction is to determine if this is a legitimate whistle-blower or if the person has become a scapegoat for a larger problem. A whistle-blower calls attention to an unacknowledged violation of legal requirements or local policies. A scapegoat is blamed for a systemic problem not of his or her making. A capable leader promptly recognizes and addresses the whistle-blower’s concerns and helps to disentangle the scapegoated worker’s role in the problem.

Once it has become clear that an individual is creating chaos and inappropriate concern within a group, several actions are appropriate. Make a sincere effort to understand the person’s perspective. Promptly engage the rest of the group in the discussion to determine how widespread the concerns are. Educate everyone about the factors that led to the policy or situation about which some of them are angry. Seek their recommendations and act on the reasonable ones. Work to find common ground; avoid allowing the group to split into warring factions. If the problem persists, give the person at the center of the storm feedback on your view of his or her role. Throughout this process, your goal should be to bring the outlier back into the functioning group. Once that happens, things will calm down quickly.

Key Concepts

  • Morale: the collective measure of job satisfaction, personal well-being, quality of interactions, and activity level of individuals that work together

  • Engagement: recognition and acceptance of your responsibility as a leader, involvement with the people and processes with which you work, and active participation in decision-making

  • Support: development of relationships that are respectful, warm, positive, and constructive, exemplified by empathic listening, emotional engagement, career assistance, and prompt feedback

  • Transparency: clarity regarding goals and objectives, performance standards, decisions, and the processes by which they are established and monitored

  • Direction and autonomy: the degree to which a person’s work is directed by institutional versus individual priorities

Adverse Events and Disciplinary Action

Negative events are an unfortunate reality of academic medicine, whether they are related to unfavorable clinical outcomes, unsuccessful educational experiences, or transgression of regulatory expectations. These events require investigation, sometimes involve assignment of fault, may require corrective action such as remedial training or disciplinary sanctions, and may involve legal action. Because of the sensitive nature of the events that lead to these inquiries and the potential consequences of the findings, they are exceptionally difficult for the subject of the investigation, the investigator, and the administrative leader charged with deciding and implementing corrective action. Less well appreciated is the secondary impact of such action on the individual’s peer group, who are likely to perceive the procedures not only as a problem for the subject of the action but as equally threatening to themselves.

Never underestimate the depth of vulnerability felt by students, house officers, and early-career faculty even under the best of circumstances. Insecure in their clinical skills and uncertain of their reputation among senior faculty, the prospect of their being found at fault and subjected to corrective action as a result of an adverse event or an administrative peccadillo can be overwhelming [5]. When the inevitable adverse event occurs, they fear the worst [21].

Transparency and support are the key elements of leadership when any investigation of clinical care becomes necessary. For routine adverse event reviews, make sure that the process and intent of the review are clear. Most trainees and even many faculty are unfamiliar with quality assurance procedures and assume that any review is about their performance. Take the time to explain the process, keep them informed about the findings, and above all, share the conclusions with them. Offer personal and professional support when appropriate. If the case is to be presented in a mortality and morbidity conference, ensure that it is done constructively. If there is a risk of legal action, involve risk management staff as early as possible.

Most cases of corrective action do not involve specific adverse events, but a failure to meet the expectations of a training program or faculty appointment. When this occurs, meet with the trainee or faculty member early and often through the process to explain exactly what is happening at each step. Offer support wherever possible, even if the outcome may be unfavorable. Consider the appointment of a faculty member to serve as advisor and advocate for the person during the case. Work to find the most constructive outcome for everyone involved. Give preferential consideration to remediation over termination. Even for the extreme case in which termination becomes unavoidable, do everything possible to establish a follow-up plan, such as a transfer to another program (with full disclosure to the receiving program), medical evaluation, additional training, or treatment, to address contributing factors. If someone has to walk the plank, make sure there is a lifeboat at the other end.

These extra actions are appropriate even in cases of egregious ethical violations, not least because of the collateral damage to morale that disciplinary actions can have on a program or department. Meet with residents and faculty periodically to go over the policies that govern corrective actions. When such action is contemplated, confidentiality prevents disclosure of details of the case, but a review of procedures will help allay fears of arbitrary, unfair, or disproportionate actions. Your attitude during these meetings conveys as much as the policies you present (see Case Study #6). Make clear that your goal is for every resident to successfully complete the program and for every faculty member to develop a flourishing career. Make sure your actions reflect that.

Conclusion

Morale requires the involvement of every person who works together, but there is much that a single individual can do, even from the bottom of the hierarchy. Awareness of self and others, constructive engagement, balance of direction with autonomy, and openness in decision-making and communication will set the stage for specific actions that contribute to a positive work environment and individual job satisfaction.

Words to the Wise

  • As a supervisor and mentor, be supportive and transparent. Be clear in your expectations. Give prompt, specific, and constructive feedback. Share your experience and insights. Invite others to share in your work.

  • Monitor trainee schedules and workloads to ensure that they are both manageable and constructive. Minimize noneducational service responsibilities (i.e., “scut work”). Be flexible about the amount of control you exercise over faculty job descriptions, giving as much autonomy as possible.

  • Use social activities to build relationships, recognize accomplishments, and engender positive feelings.

  • Be involved and supportive when handling complaints. Get those most affected by a problem engaged in finding a solution. Identify issues that can be corrected and move quickly to address them.

  • Address difficult situations promptly, openly, and supportively. Be sensitive to those who have experienced untoward events. Use corrective action to help people succeed rather than to punish. Do your best to reintegrate those who are angry or discontent.

Ask Your Mentor or Colleagues

  • What have been the hardest things for your students and residents to deal with? What have been the hardest things for the faculty?

  • What things do the students and residents most value? What is most valued by faculty?

  • What parts of your career have brought you the greatest satisfaction? Which parts the greatest frustration?

  • What behind-the-scenes administrative issues (e.g., how work quality is judged, what it takes to get promoted, how adverse events are reviewed) most surprised you?

  • How can I be most helpful to my colleagues and the department?

  • How can I ensure that I have time to work on my most valued activities?