The Dutch Ministry of Social Affairs and Employment funded the program development. Following the approved grant proposal, the program included (1) a feedback tool addressing working conditions and well-being, and (2) a team-based intervention aimed at improving working conditions. The project team consisted of researchers (MD, KL, RS), trainers (NH), and software developers, all familiar with the medical profession.
The project team developed the program in three consecutive steps: a preparatory phase, needs assessment, and program design (October 2016 until March 2017). Next, we piloted the program (April 2017 until September 2017).
The institutional ethical review board of the Academic Medical Center of the University of Amsterdam (AMC) confirmed that the Medical Research Involving Human Subjects Act (WMO) did not apply to this study and thus waived ethical approval (reference number: W18_234 # 18.279).
Step 1—Preparatory phase
Two researchers searched and mapped reliable and valid measures of physicians’ working conditions and well-being for potential inclusion in the feedback tool. To inform the intervention, they also mapped evidence-based interventions to improve physicians’ well-being. We used the resulting overview to construct the needs assessment’s survey.
Step 2—Needs assessment
Our needs assessment included one focus group in an academic hospital (n = 12) and one in a non-academic teaching hospital (n = 12), followed by an online survey (n = 218).
The focus groups lasted 75 min and aimed to obtain in-depth insight into physicians’ needs concerning their working conditions and well-being. Beside residents and medical specialists, we invited human resources staff and senior hospital management to illustrate how hospital policies and practices could address physicians’ needs. Four key questions structured the discussion: ‘What characterises well-being in practice?’, ‘What needs do physicians have to improve their well-being?’, ‘What influences physicians’ well-being in practice?’, and ‘What possibilities do you see for promoting physicians’ well-being?’. A moderator facilitated the focus groups; two observers made notes about verbal and non-verbal communication. Participants indicated that a feedback tool to assess working conditions and well-being should be easily accessible, time-friendly, and encourage discussion. Furthermore, an intervention should provide a positive and psychologically safe environment. Also, it should address team members’ shared workplace issues (e.g. lack of social support) while respecting individuals’ needs (e.g. no collegial contact outside working hours).
The survey aimed to quantify physicians’ needs regarding the feedback tool and intervention. Using the previously mentioned overview (step 1), we listed working conditions and well-being aspects for which validated measures were available, as well as evidence-based interventions. The survey asked physicians to rate working conditions (e.g. workload) and well-being aspects (e.g. work engagement) of interest. Additionally, physicians indicated preferred methods of discussing the feedback tool’s results and evidence-based interventions.
Project team members invited physicians from Dutch hospitals for the survey using their professional networks, company newsletters and websites. In total, 218 physicians participated, of which 50.3% were male. The mean age was 43.3 (SD = 9.97) years. The most represented specialties were surgery (17.8%), neurology (14.1%), and internal medicine (12.0%). Of the working conditions of interest, administrative burden, appreciation by patients, learning and professional development opportunities, inspirational leadership, and workload were most frequently rated. The top rated well-being aspect was work-life balance. Furthermore, physicians preferred to discuss the feedback tool’s results in a facilitated team dialogue. The most preferred interventions were team communication training and collaborative job crafting training.
Step 3—Program design
Based on the previous steps, we designed the content of the (1) feedback tool and (2) intervention, shown in Fig. 1. The job demands-resources (JD-R) model  and positive psychology  guided the program design. According to the JD‑R model, individuals classify perceived working conditions as job demands (i.e. workplace stressors, requiring energy) or job resources (i.e. workplace resources, providing energy). Optimising the balance between both can improve well-being. Also, focusing on enhancing team strengths and workplace resources—i.e. positive psychology—is worthwhile to improve well-being . Workplace resources are functional in achieving work goals, stimulating personal growth, and alleviating the negative impact of stressors [12, 14].
The feedback tool (1) consisted of a self-report questionnaire and feedback report on perceived working conditions and well-being. The questionnaire counted 75 items (completion time of 10–15 min) based on validated measures of working conditions (i.e. administrative burden, collegial support, inspirational leadership, intrinsic motivation for patient care, learning and professional development opportunities, participation in decision making, workload) and well-being (i.e. emotional exhaustion, work engagement, work fatigue, work-home interference). Software developers implemented the feedback tool in an existing online environment, wherein physicians could conduct the questionnaire and download the feedback report. The feedback report included results benchmarked against ratings from peers and explained the JD‑R model assisting physicians to analyse working conditions in relation to their well-being. When peer scores were unavailable, the report showed benchmarks of the general working population.
The intervention consisted of two consecutive parts: (2a) a facilitated team dialogue and (2b) a team training on team communication and collaborative job crafting (Fig. 1). The (2a) team dialogue was a two-hour session led by an external trainer, in which teams discussed their working conditions and well-being to formulate improvement actions. The feedback tool’s results served as input for the dialogue, although physicians decided what they wanted to share. We organised a focus group with trainers and senior physicians (n = 8) to design a team dialogue guide.
This guide included an exemplar schedule and defined preferred conditions for a productive meeting (i.e. no beepers, external facilitator). Also, the guide suggested an appreciative inquiry approach, which invites participants to discuss stories about what is working well. The resulting identified strengths are the starting point for positive change actions .
The (2b) team training was a four-hour training in which physicians practised with providing team members feedforward. Furthermore, physicians exercised collaborative job crafting to address the formulated improvement actions regarding working conditions and well-being from the facilitated team dialogue. Typically, feedforward focuses on future expectations and tasks to create lasting improvement . Collaborative job crafting refers to physicians determining together how to alter workplace stressors and resources to meet their well-being goals . To design the team training, trainers used prior communication and job crafting workshops, and collaborative job crafting literature . The training combined both topics because of the relevance of communication for team learning of job crafting .
Project team members invited physician teams to participate in the program’s pilot using their professional networks, company websites and newsletters. We piloted the feedback tool in 14 Dutch hospitals, and 377 physicians from 48 teams completed the questionnaire (71% response rate) and received a feedback report: 47.7% were male, 78.8% medical specialists, and 21.2% residents. After completing the feedback tool, teams were more inclined to participate in the facilitated team dialogues. We selected physician teams based on variation in size and specialty (medical or surgical) and conducted four team dialogues in different hospitals. From those teams, two were willing and available to address their formulated improvement actions in the team training, completing all program components.
To evaluate the program, we inspected respondents’ answers on open text evaluations of the feedback tool and consulted its helpdesk to obtain insight into participants’ experiences. Furthermore, we examined observers’ notes from the intervention, inspected printed evaluation forms from the team training, and conducted 14 telephone interviews with participants.