The Signal Problem in Workforce Well-Being: Toward an Integrative Reference Model
Why health systems are drowning in data and still cannot get to action
Let me start with a simple question.
Why are so many health systems saying “we’re working on well-being” while the people doing the work say “nothing has changed”?
It is not because health systems are indifferent. Most are spending real money and real time. There are task forces, pilots, dashboards, steering committees, and pulse surveys. There are mindfulness apps, recharge rooms, EHR optimization sprints, staffing councils, lean events, peer support offerings, recharge lounges, “joy in work” campaigns.
On paper, that should work.
In practice, results are inconsistent. Burnout scores stay high. Intent to leave stays high. Leaders feel stuck. Clinicians feel unheard. Executives feel unconvinced.
So here is the deeper question under all of that.
If the intention is there and the activity is there, why is the outcome still unstable?
After sitting with that question, interviewing leaders and clinicians, building maps of workforce strain, and reviewing the literature on system design and human performance, I no longer think the core blocker is willpower, or even resources.
I think the blocker is clarity.
More specifically, I think we have a signal problem.
The Signal Problem
Most health systems are already collecting the right signals. Not just HCAHPS and turnover rates. I mean:
Throughput time.
After-hours inbox volume.
Interruptions per hour.
Near-miss reports during shift change.
Perceived moral distress during specific service lines.
Emotional exhaustion.
Psychological safety.
Overtime utilization.
Vacancy and time-to-fill.
“How often do you feel you cannot safely recover between emotionally intense situations.”
None of that is hypothetical. These are real signals that show up in real organizations.
Here is the problem. These signals rarely live together in a way that decision-makers can interpret together.
Operations holds one part.
Quality and safety hold another.
Patient experience holds another.
Well-being offices hold another.
Finance tracks the downstream cost of churn.
Each person at the table is technically correct inside their lane. None of them are looking at the whole pattern.
So leaders walk out of the same meeting with five different definitions of the problem they are all supposedly solving.
That fracture is not just frustrating. It is dangerous. It creates activity with no convergence. It overextends already thin teams. And it burns trust.
The National Academy of Medicine has already said clearly that clinician well-being is a systems issue, shaped by the design of work, leadership expectations, and organizational structure, not just by individual coping.¹ Systems engineering models like SEIPS explicitly tie human performance, reliability, and well-being to the shape of the work system itself.² And the Institute for Healthcare Improvement’s Framework for Improving Joy in Work calls for improving how work is experienced at the same time that we improve how work is structured.³
In theory, senior leaders agree with this. In practice, health systems still tend to treat “efficiency,” “safety,” “engagement,” and “well-being” as parallel projects with separate owners.
That split view is the signal problem.
We are not struggling because we lack data. We are struggling because we lack a shared way to read it.
Why this matters more than most people think
Let me give you a real pattern you can see repeatedly.
A hospital invests in documentation efficiency. The informatics team streamlines clicks, removes duplicate fields, and reduces charting time per encounter. The result is celebrated as an operational win.
At the exact same time, nurses quietly report feeling more emotionally flooded between cases. Why? Because the “extra” three minutes that used to exist between a traumatic interaction and the next room have disappeared. That time was not wasted time. It was unstructured decompression. It was how they reset their nervous system enough to be fully present with the next human being.
So what happened?
In the operations view, we just eliminated waste.
In the safety view, we reduced documentation defects.
In the well-being view, we removed the only natural recovery buffer.
In the retention view, we increased emotional exhaustion, which is a predictor of intent to leave.¹ ⁴
In the finance view, we increased future vacancy risk in a hard-to-recruit area.
No one is lying. No one is wrong. But no one is seeing the whole interaction in one frame.
That is the signal problem in practice. You can have an intervention that is provably “good” in one domain and simultaneously planting a burnout driver in another. And because those domains are measured, reported, and budgeted separately, the organization will not feel the full cost of that trade-off until it shows up months later as churn and moral injury.
When we treat each outcome stream in isolation, we accidentally create harm we did not intend to create.⁵ ⁶
This is why “we’re already doing X for well-being” so often lands as unconvincing to the people doing the work. The local lived experience of harm can be growing while the spreadsheet says “improvement.”
That gap erodes credibility.
The old model: more projects
The traditional response to distress signals in the workforce is to launch programs. Wellness rounds. Peer groups. Listening sessions. Offloading initiatives. Gratitude boards. Resiliency training.
You can feel the care behind those efforts. Many of them are important. Some of them are lifesaving.
But here is the structural flaw. When these programs live outside of the way work is designed, they are often experienced as “support on top of strain,” not “reduction of strain.”³
Leaders then hear:
“We offered help and no one used it.”
“Engagement is low.”
“They say they’re drowning, but they do not come to the resources.”
Front line teams hear:
“You added another expectation to a day that is already past full.”
“You are asking me to self-regulate a system problem and calling that support.”
“You are saying I am burning out because I am not doing enough yoga.”
Again, both groups are telling the truth from their vantage point.
The system still has no shared view.
The real ask from the workforce
When you listen to physicians, nurses, techs, APPs, environmental services leads, educators, charge nurses, unit directors, one theme surfaces again and again. They are not just asking for “less stress.”
What they are actually asking for is coherence.
Coherence means:
Do not fix one pressure point in a way that makes a different pressure point worse.
Do not ask for moral endurance while quietly tightening throughput.
Do not call me “the heart of the organization” and then staff me at survival levels.
Do not publish “joy” language while the reality I live in feels extractive.
People are not asking health systems to be perfect. They are asking them to be internally consistent.
That is a very reasonable ask.
And it is one that cannot be delivered without a way to see the whole system of strain, support, meaning, structure, and risk at once.
Which brings us to Meridian.
Meridian Reference Engine: why we built it
PaperMap developed the Meridian Reference Engine for one reason. We were watching smart, ethical leaders sit in meetings with all the right data and still leave without alignment. It was not a talent problem. It was not a compassion problem. It was an interpretive problem.
Meridian is not “another survey” and it is not “another score.” It is a reference model that allows different kinds of signals to live in the same field of view.
Here is how it works.
Meridian takes in what a system already knows. Burnout scores. Psychological safety feedback. Near-miss patterns. Overtime and vacancy data. Escalation bottlenecks. Perceived fairness. Turnaround time. Interruptions per hour. Perceived ability to recover between emotionally intense events. All of it.
Then, instead of sorting that information by department or by initiative, Meridian orients it across four directional fields that describe the actual lived reality of work.
Ease. How work flows. Where friction lives. Where cognitive load spikes. Where interruption is constant. Where the process itself is punishing.
Support. How the system protects and resources its people. Backup, coverage, psychological safety, access to recovery, ability to speak up without retaliation.
Navigation. How leadership provides clarity and fairness. Do I know where decisions are made. Can I get help without chasing six people. Do I understand priorities. Do I feel informed or blindsided.
Worth. How the work connects to meaning and identity. Am I doing work that aligns with my purpose. Am I treated as a replaceable unit or as a trained professional. Do I feel my contribution matters.
Everything the organization is already measuring can be located somewhere on this map.
Throughput delay sits in Ease.
Escalation confusion sits in Navigation.
Moral residue after high-acuity trauma sits in Worth and Support.
Near-misses clustering at the end of a 12-hour shift sit in Ease and Support.²
Complaints about “we only hear from leadership when something goes wrong” sit in Navigation.³
“I love this work but it is becoming incompatible with my physical and emotional limits” sits in Worth.¹ ⁴
Once these signals are placed, a pattern emerges. You can literally see where the pressure concentrates.
This is the moment when leaders stop arguing about whose metric matters and start solving the same problem.
What changes when you can see the pattern
When Meridian is used, three shifts happen that are very hard to create without it.
You stop confusing symptoms with structures.
Most organizations react to loud pain. “The ICU is angry” becomes the problem. Meridian lets you see whether the ICU signal is actually a Navigation problem (unclear authority, distrust in local decision rights), an Ease problem (constant workarounds and rework), a Support problem (no safe recovery after high acuity), or a Worth problem (moral injury, loss of professional identity). Those are different problems that require different levers. Without that clarity, you will spend money soothing the wrong layer.
You can finally tell a story that finance respects.
Everyone says “well-being has a cost if we ignore it,” but that is often hand-waved. With Meridian, you can map a hotspot in Support and Worth to vacancy exposure, agency spend, and near-miss risk in a high-revenue service line. Suddenly this is not “feelings.” It is operational fragility with financial consequences. Burnout and emotional exhaustion have been linked to higher intent to leave and higher turnover, which carries measurable cost.¹ ⁴ Now you can show that in your own environment.
You can track movement over time.
You can take a baseline read, intervene, and then re-map. Did Navigation shift after we changed escalation pathways and clarified who owns last-call authority overnight. Did Support improve after we built protected decompression buffers back into the workday. Did Ease improve after we removed two redundant documentation loops. Did Worth improve after we gave voice and recognition to the emotional labor of certain roles.² ³
That is not “people said they liked it.” That is traceable movement in the lived architecture of work.
Executives understand that. Boards understand that. Regulators will eventually expect that.
Why this is urgent now
It is easy to describe burnout like a personal state. It feels personal. It is experienced personally. But the National Academy of Medicine has been direct. Burnout is a system property.¹
The Systems Engineering Initiative for Patient Safety has shown for years that reliability, human performance, and safety are inseparable from work system design.² That is not aspirational language. It is a structural reality.
The Institute for Healthcare Improvement is calling for organizations to redesign how work feels and how work functions at the same time.³ That is not a “perk.” That is a requirement for stability.
We are past the point where we can treat well-being as a side project. Turnover is expensive. Vacancies are breaking care teams. Constant emotional overload creates cognitive slip, which creates safety exposure.² ⁵
This is all the same problem. We just have not been looking at it as one problem.
Which brings us back to clarity.
Healthcare does not just need more programs. It needs a way to read itself.
Where this is going
The question I am sitting with now is not “how do we convince leaders to care.” Most of the leaders I work with already care.
The better question is “how do we give them a structure they can defend.”
A structure that lets the CMO, the CNO, the Chief Experience Officer, the wellness lead, Quality, and Finance sit around the same table and see the same thing. A structure that lets a nurse say “this is what the work actually feels like” and have that statement land as operational evidence, not as an anecdote.
That is why we built Meridian. Not to invent a new buzzword. To create a reference that makes the existing evidence visible, sharable, and actionable.
Because we do not need to convince people that workforce well-being matters. That argument is over.¹
We need to make workforce well-being legible.
With you on the map,
Richie Akers, CWP
Founder and Principal Well-Being Architect
PaperMap Creative
richie@papermapcreative.com
References
National Academy of Medicine. (2019). Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. National Academies Press.
Carayon, P., Schoofs Hundt, A., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2014). SEIPS 2.0: A human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics, 57(11), 1669–1686.
Perlo, J., Balik, B., Swensen, S., Kabcenell, A., Landsman, J., Feeley, D., & Nolan, K. (2017). IHI Framework for Improving Joy in Work. Institute for Healthcare Improvement.
West, C. P., Dyrbye, L. N., Shanafelt, T. D., & Sinsky, C. A. (2021). Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Health Affairs, 40(6), 897–908.
Holden, R. J., et al. (2023). Workflow interventions and clinician well-being: A systematic review. Journal of Patient Safety, 19(3), 156–167.
SEIPS-based analyses of documentation burden and cognitive load in clinical environments have shown that attempts to improve efficiency can introduce new strain when recovery buffers are removed, particularly in high-acuity care.² 5