At HCA Healthcare, we are constantly working to transform and improve the very environments in which physicians work and learn. Guided by two complementary theories — Job Demands-Resources Theory and Self-Determination Theory — our approach examines the built environment, policies, procedures, and operations, and interpersonal relationships to shift conditions from need-thwarting to need-supporting.

Self-Determination Theory

The main aim of Self-Determination Theory (SDT) is to understand what humans need for flourishing, and what forces will interfere and promote that outcome. SDT seeks to understand the motivation behind human behavior and the factors that influence the pursuit of goals and aspirations. SDT defines three basic psychological needs that everyone needs for flourishing: autonomy, belonging, and competence.

  • Autonomy is the need to feel that one's actions day to day are endorsed and in alignment with one's values. It is a sense that "I believe in..." "I understand..." "I agree with..." the activities one does throughout the day. It is not independence, lack of supervision, or freedom from constraints. Colleagues can have psychological autonomy even without decision latitude if they endorse the activities they are asked to do. The opposite of autonomy is feeling controlled - forced, coerced, or compelled to do something - either from external forces (rewards and punishments) or internal forces (guilt, shame, pride). Autonomy is often the basic psychological need most closely linked to flourishing, yet least likely to be understood and targeted in workplace well-being initiatives.
  • Belonging includes warm and close relationships with people you care about, feeling understood and accepted, feeling part of a community, team, or group, and giving and receiving support (mutual care). Belonging may be supported through team events (social events), but these also could occasionally harm belonging to some individuals. Wellness interventions often default to this basic psychological need; however, supporting the other basic needs – autonomy and competence – themselves will create a sense of belonging. So, it is vital to avoid focusing on belonging at the expense of other needs.
  • Competence includes both the need to feel some sense of mastery (self-efficacy) and a sense of growth. These are often at odds with one another given that to grow one needs to move away from the comfort of mastery. In one large study making progress toward one’s goals on a day-to-day basis was the best predictor of whether a team member had a “great day.”
  • Although not a basic psychological need, meaningful work is one of the strongest predictors of well-being at work. In SDT, meaning emerges out of a workplace that supports the three basic needs of autonomy, belonging, and competence. However, because of its strong impact we have chosen to call it out specifically to keep it salient. Meaning is a felt experience that one’s efforts are valuable, align with one’s personal values, and contribute to pro-social outcomes.

Job Demands-Resource Theory

The Job Demands Resource (JDR) Theory is used to analyze how the work environment affects well-being and job performance. Job characteristics can be divided into two buckets, job demands and job resources.

Job demands refer to “those physical, psychological, social, or organizational aspects of the job that require sustained physical and/or psychological effort and are therefore associated with certain physiological and/or psychological costs” (Demerouti et al., 2001, p. 501). These can include factors such as lack of social support, work-home demands, and workload expectations, among others. However, not all job demands are bad. Challenge demands or those that still require effort but result in growth or accomplishment that is valued by the team member. Conversely, hindrance job demands are those demands that do not contribute to growth or accomplishment and typically appear to be simply “in the way.” Reducing hindrance demands is a key initiative in decreasing workplace burnout in the JD-R theory.

Job resources, in contrast, are defined as “those physical, psychological, social, or organizational aspects of the job that are functional in achieving work goals, reduce job demands and the associated physiological and psychological costs, or stimulate personal growth, learning, and development” (Demerouti et al., 2001, p. 501). Examples of job resources include structural empowerment, rewards, and support from supervisors.

Job resources foster engagement and motivation in the workplace, while job demands can lead to exhaustion, strain, and ultimately, burnout. According to the Job Demands-Resources (JDR) theory, the physical and psychological burden of job demands are lessened when sufficient job resources are present. HCA Healthcare and Claremont Graduate University's Physician Wellness Research Lab apply the JDR Model to develop theories and interventions based on its principles.

Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol. 2001;86(3):501-512.

Job Demands-Resource theory is probably the first place to start on your quest to develop a top rate program. If your program and/or institution does not yet have a deliberate formal approach to identifying, triaging, tracking, fixing, and communicating the reduction of hindrance job demands, this would be the first place to start. The reduction of hindrance job demands supports the “I matter, my work matters, and I’m growing and capable” (Ann Brafford, JD, PhD, MAPP), narrative in very direct ways. It results in tangible changes for residents, fellows, and faculty, and it is likely the cornerstone on which all other well-being initiatives must rest.

SDT & JDR Resources