The Workweek Revolution: a Solution to the Health Care Exodus

The health care workforce has been pushed to the brink by the COVID-19 pandemic, resulting in a decline in workforce numbers. To relieve the physical and emotional burdens of this population it may be worth looking at the evolving concept of full-time work. Reducing the hours expected for full-time work without a decrease in compensation may increase the well-being of health care providers while maintaining productivity. Some may view a change in work-hour expectations as an evolutionary idea, others will see it as revolutionary.

Great Resignation or Great Revolution?

The COVID-19 pandemic appears to have been a catalyst in what has been called “the great resignation.”¹ Though health care workers have demonstrated remarkable resilience, polling data from a February 2022 USA Today-Ipsos survey of health care providers reveals some cause for concern. More than half of respondents (52%) said they are feeling burned out, and 23% said “they are likely to leave the field in the near future.”² More worrisome, 39% of respondents agreed “the American health care system is on the verge of collapse.”²

Findings of another survey conducted by Morning Consult in January 2022 ​​indicate that 18% of health care workers quit their jobs during the COVID-19 pandemic, while another 12% were laid off.³ One in 4 health care workers leaving the field constitutes a significant exodus. The number of hours worked may play an essential role in this issue. The effect of full-time work, typically 40 hours per week, multiplied by the intensity of the work, cannot be ignored; but can it be changed?

Have you ever wondered why we work 40 hours a week and call it full-time? It was not always so. At the start of the first industrial revolution, it was common for people to work over 80 hours a week, sometimes even 100 hours, over 6 days.⁴ Advances in technology allowed businesses and their labor to increase efficiency, productivity, and profitability. As one industrial revolution gave way to the next, workers realized that there was an opportunity for them to improve their lot in life with improvement in processes.

In 1866 the National Labor Union lobbied Congress to establish a national 8-hour workday. Though they were unsuccessful, just 3 years later, President Ulysses S. Grant issued executive order number 18​​2, which established the 8-hour workday for government employees without a reduction in pay.⁵ Not long thereafter, private industry started to follow suit. Twenty years later, on the heels of worker lobbying, the Illinois legislature passed a similar law but applied it to all businesses in the state. “Eight hours for work, 8 hours for rest, and 8 hours for what we will,” was the goal of laborers in the state. People in Chicago began demonstrations on behalf of the 8-hour workday that lead to deadly confrontations between police and protestors.⁶

In the 1920s, it was not labor but management with the revolutionary idea. Henry Ford may not have been the father of the 40-hour workweek, but he certainly gave the movement some gas when his company decided to establish a 5-day week, 8-hour shifts, eliminating work on Saturday.⁷ Just over 10 years later, the United States Congress passed the Fair Labor Standards Act, which effectively established the 40-hour workweek once it was amended in 1940.⁸

Effect of Long Work Hours on Health

It is not surprising that long work hours would prove untenable. The association between long work hours and health has been the subject of many studies. In 2014, Bannai and Tamakoshi published a systematic review of epidemiologic evidence from 1995 to 2012. They excluded shift work since prior studies had shown detrimental health effects. Their review of 17 articles and 19 studies concluded that “working long hours is associated with depressive state, anxiety, sleep condition, and coronary heart disease.”⁹

In 2012, Stimpfel et al studied the extended work shifts for nurses (beyond 12 hours/shift). Eighty percent of nurses from 4 states said they were satisfied with 12-hour shifts. However, as nurses worked longer hours, patient satisfaction with nursing care decreased. They also noted that as nurses worked shifts of 10 hours or longer, they were 2.5 times more likely to experience burnout and job dissatisfaction than nurses working shorter shifts. Those same nurses were more likely to leave their jobs.¹⁰

Just as the industrial revolutions ushered in an era of improvements in efficiency by technology and/or process, the information age has brought similar.

The Efficiency Revolution: a Shorter Workweek

When Henry Ford disrupted the automobile industry workweek, he said “It is high time to rid ourselves of the notion that leisure for workmen is either ‘lost time’ or a class privilege.” However, his motivations were not purely altruistic. He and his executive team expected that employee effectiveness and productivity would increase, though work hours would decrease.⁷

In 1932, economist John Maynard Keynes opined about the economic possibilities of future generations. He remarked that industrialized societies should be afforded opportunities for increased leisure time but that they had not taken the advantage up to that point. He believed future generations would take full advantage of the efficiency made possible by technological advances stating that they will perhaps work “3-hour shifts or a 15-hour week,” which he thought would come to pass by 2030.¹¹ Perhaps he was right, even if he was off on his timing. The concept of a shorter workweek is gaining traction in both the public and private sectors globally.^12-17

Recently, Iceland’s government piloted the idea of a 35-hour workweek (down from 40) for approximately 1% of its workforce across a variety of 9 to 5 and shift workers in industries like childcare, social services, and hospitals in addition to office workers; worker pay was not reduced. They reported their workforce had no loss of productivity, decreased worker stress and burnout, increased health, and improved work-life balance. Presently, 86% of Iceland’s workforce now implements a 35-hour workday.¹⁸ Other countries and companies, great and small, have taken notice and are piloting the idea.¹² In 2019, Microsoft Japan tested the idea with its 2300 employees. They gave employees 5 Fridays off in a row without changing their pay and subsidized family vacations up to $920 (US). The following results were reported¹³:

1. Happier employees
2. Productivity increased by 40%
3. Employees took 25% less time off
4. Electricity use decreased by 23%
5. Employees printed 59% fewer pages
6. More efficient meetings
7. 92% of employees reported they liked the shorter workweek

Not everyone agrees that cutting hours is a good idea. Historically, physicians in training have been known to work long hours. However, in 2003 the Accreditation Council for Graduate Medical Education required residencies to cap resident hours to a maximum of 80 per week in the name of “patient safety, resident well-being, and education.” Indeed, residents’ well-being increased but not necessarily test scores, which raised some questions about the action’s effectiveness on education and patient safety.¹⁹

Will Health Care Join the Revolution?

Logic suggests that health care systems will ignore the swirling winds of change. After all, revenue is driven by the number of patients seen, which is limited to its workforce’s per hour capacity. Then again, perhaps health care systems will be wise to pay attention to lessons learned in other industries. Technology can be used to facilitate not just an increasing number of patients but instead to off-load the physical, mental, and emotional burdens borne by the workforce. For example, the same IT and staffing procedures that allow for quick and efficient visits (and allow for more visits per hour) can be used to shorten the work day for individual workers. Alternatively, they could be used to facilitate fewer but more in-depth quality visits during the same time period.  Staggered staffing in either case would allow clinics to remain open for the same, if not longer, total hours. The efficiency created thereby preserves patient access and may allow the same work to continue, but with reduced time and/or patient case burden on individual workers.

Conclusion

If the health care profession follows other industries, then hospital, health systems, and private practice workplaces may adopt a decreased expectation in the number of hours worked. Some evidence suggests that current productivity can be maintained while the well-being of the health care workforce can improve with a shorter workweek. When the health care workforce is healthy, patients are the ultimate beneficiaries. Perhaps the great resignation from health care can be transformed into a great revolution and draw that workforce back into the fold.

Jonathan T. Baird, DMSc, PA-C, ATC, is a faculty member in the Physician Assistant Program at Rocky Mountain University of Health Professions in Provo, Utah. He is a former president of the Utah Academy of Physician Assistants, and current delegate to the American Academy of Physician Assistants. 

This article originally appeared on Clinical Advisor