I have spent the last 20 years of my life as a hospital CEO. I have been CEO at small, rural facilities and larger urban settings. I have focused much of my career on completing short term CEO assignments at hospitals requiring immediate turnaround tactics to keep them open. I also pursued a journey of completing doctoral education in psychology. My research interests in psychology have been centered on stress reactivity and effective stress mitigation techniques. As a result, I have the background and passion to help hospital administrators learn to manage stress more effectively, leading to more fulfilling careers and personal lives.
Leading hospitals is challenging and stressful, and it takes a significant toll on the personal side as well. But it is a tremendously important job. The decisions we make can literally determine whether a hospital survives or fails. The closure of a hospital, particularly in rural settings, can be devastating to the community and workers who lose their jobs. Unfortunately, the focus for stress management in health care typically resides on front-line workers, which is certainly necessary. However, administrators also need assistance managing stress, but this in-and-of-itself causes stress because when are we supposed to find time to take care of ourselves?
Stress in Hospital Administrators
One of the reasons a hospital administrator’s job is so difficult is because there are so many stakeholders we must consider in our decisions (figure 1). And frequently these varied stakeholders have different and even competing agendas. This can leave the administrator in the middle trying to figure out how to get stakeholders moving in the same direction.
Figure 1 – Herding the Clan
From a psychological standpoint, this scenario is a classic evolutionary stressor. From one context, humans as a species have survived as a result of the strength of our clan, which operated under a herd mentality. Historically, the clan provided protection and strength in numbers, leading to a Maslow concept of safety. Although the world is completely different today than what our ancestors faced, our psychological drives, reactions, and schemas have not changed with the pace of our civilization. As the clan leader, the administrator must herd the clan forward, toward a safer, more stable future. But when he/she is faced with diverging stakeholder interests and resistance, it can cause strong cognitive dissonance and misplaced evolutionary safety-related schemas, resulting in stress reactive pathway excitation. And if stakeholders go off in their own directions, the administrator can be left with a feeling of betrayal and abandonment. From an evolutionary perspective being abandoned from the clan is essentially a death sentence.
This scenario is further compounded with the multiple additional stressors administrators face. First, administrators must achieve their goals, which is particularly challenging with today’s continually decreasing margins and ever-increasing satisfaction and quality targets. As a CEO, I still become frustrated when the targets frequently change for no apparent reason, leaving me scrambling to update and communicate strategy. Second, administrators often hold the perception that they must always show strength and certainty. As the leader you are supposed to take definitive action, have all the answers, and display unwavering confidence. And yet, I can easily remember how many times as a CEO I walked into a room nervous and uncertain, hoping no one would notice. Third, administrators work tremendously long hours. The average hospital administrator works a 12.5-hour day and then adds more hours on the weekend. This creates tremendous pressure and stress that carries well into the personal side of life. It also makes self-care quite difficult. I frequently get up at 3:45 in the morning to get a quick workout in for my mental well-being as much as anything. Fourth, job security for administrators has hit a relative low with the average hospital administrator remaining on the job for an average of 18 months. Not only is losing a job stressful, but the resulting consequences of dealing with the job loss, beginning a job search, uprooting the family, and moving to a new location are stressful for you and the family. I once went to an ACHE seminar and an Interim CEO was speaking. She started her speech by saying, “We are ALL interim CEO’s!” Quite true, but quite sad.
A final area of stress for administrators is that leading a hospital is a lonely job. Most of us do not expect this when we pursue this career. This hit me quite hard on a personal side when I realized that there is little glamour, and few thank you’s in our roles. Hospital administrators often report a feeling of isolation with little meaningful and honest support. I know, I spend many late nights in the office feeling this. And I’ve spent many times trying to figure out who is my friend and who is my foe. And to top it all off, few people feel sorry for a hospital CEO, as the majority of the population (and even stakeholders) have no idea what we do and just assume we are paid exorbitant salaries, which is certainly not always the case. There are many other stressors affecting administrators – this list is far from exclusive, but the focal point is that administrators face tremendous stressors, many of which can feel uncontrollable and isolating.
From an evolutionary and biopsychosocial standpoint, it’s no wonder why hospital administrators are so stressed – psychologically, it makes perfect sense. We shoulder great responsibility and with that we endure perpetual, longitudinal chronic stress, leading to stress reactive responses and the associated ill effects that stress causes. Many of the stressors we face are frankly out of our control. So, the key for administrators is to learn to focus on what is within our personal ability to control. This is often easier said than done. I remember when I was going through a particularly difficult time in my life, I went to a therapist to seek assistance. After explaining my situation over several sessions and looking forward to meaningful guidance, the well-meaning therapist told me that I have control over my schedule and can simply structure my calendar to work from 9 to 5, enabling me to balance my life better. She said the hours I kept were my choice. Really? Can any of you limit your schedule to 9 to 5 every day? I could not get the therapist to understand that I have a busy medical staff than can only meet with me at 7 am and then I have board meetings, medical executive committees, community meetings, individual physician meetings, chamber of commerce meetings, political meetings, and many others that can only take place in evenings. So much for having significant control over the schedule.
It is important to note that stress with a short duration can make a person more effective by leading to better preparation for upcoming stressful activities and providing better outcomes, which subsequently reduce stress (e.g., preparing for an important presentation). The detrimental aspects occur when stress becomes a heightened, perpetual, unmitigated chronic state of arousal, leading to allostatic stasis, a detrimental biological effect reducing homeostatic balance. Longitudinal stress produces physiological strains, which can become chronic conditions, including diabetes, high blood pressure, respiratory diseases, cancer, chronic inflammation, immunological deficiencies, dementia, depression, and anxiety.
The stress reactive response occurs in milliseconds; however, one of the most significant problems with this rapid response is that the prefrontal cortex, where most executive functioning occurs, lags behind the amygdala, which controls the initial emotional reaction to a stressor. This delay yields a person who is in a heightened emotional state but who has not yet been able to process the danger and its relevance. Literally, the person is primed to act before thinking, which in an emergency situation is invaluable; however, most situations humans now encounter are not true emergencies and this delay can cause emotional reactions and behavioral responses that are not warranted. I’ve seen too many well-meaning hospital leaders lose control and react emotionally. This never comes across well and leads to organizational dysfunction and loss of credibility. Once trust and credibility are lost, there is little than can be done to regain them.
What Can We Hospital Administrators Do?
So, what can we do to bring control to our busy, hectic lives and mitigate stress? As a doctoral level stress expert and CEO for 20 years, I feel that I should have the answer. I should be able to provide a bulleted list of actions steps that you can take and implement with a checklist and measures of success. But even with my background I can’t provide these answers. I don’t want to be that therapist that I once saw and give you suggestions that are simply not realistic. The only person who can provide the answers to managing your stress is you.
But what I can do is twofold. First, I can let you know that you are not alone. I’ve been there. I am still there. I am not a practicing psychologist even though I pursued that doctorate. I am a sitting hospital CEO, who is still struggling with the answer of how to reduce and manage the stress from this extremely important but demanding career. So, fellow hospital administrators, know that you are not alone when you are sitting at your desk at 7 pm trying to prepare for a confrontational medical executive committee the next morning at 7 am. I am also sitting there in my office with you. Second, I can share some actions that have helped me and that also have been shown effective in psychological research. I’m not saying these will work for you. Perhaps they will – or perhaps they will stir you to come up with actions that resonate with you. The key is to try something, to take baby steps – pick a few things no matter how minor they sound and give them a go. More often than not, you will find that the simple things make a more profound difference in managing stress than overzealous, grandiose programs. There are three main ways that I have found success in reducing stress reactivity.
First, understanding the importance of cognitive reappraisal, which is a well-researched psychological concept. It means that you can reframe your thoughts from maladaptive, reactive responses to more proactive, adaptive ones. Basically, you have the power to choose how you interpret events and label them. For example, I once had an Assistant VP from the corporate office of a hospital where I was CEO who I believed challenged me continually. He had never been a CEO, yet he clearly came across that he knew how to run a hospital better than I did. Initially, this upset me greatly, and I fought him. I would get so worked up about his comments that it would distract me the rest of the day, and I would wake up at 2 am thinking about it. I’m sure you have all experienced similar situations. But finally, I looked at the situation and changed how I thought about it. Instead of fighting him, I engaged him. I assigned him a project to complete in my hospital and made a point to make him feel welcomed when he visited. This reduced my stress and improved our relationship. I won’t lie to you – I still didn’t care much for him, but by changing what I could control (my reaction to him) and reappraising the situation, I was able to not be distracted and wake up thinking about his behaviors. Eventually, we actually did come to respect each other. When I left that hospital and moved on, he even told me how much he respected me and appreciated my mentoring. As another example of cognitive reappraisal, I practice what I call the 12-month rule. If a stressor will not be present in 12 months, or I believe that I will have forgotten about it – I acknowledge that it’s not worth spending my mental energy on. By releasing it, or delegating it to someone else, I can free my mind for what is impactful and discard that which is not.
Second, making time for things that I enjoy. Most of us will say that we have no time for things we enjoy. And trust me, I understand. However, life is short, and I can’t stress enough the psychological importance of making quality time every day for what drives you outside of the office. For me, I could not function without a bit of exercise and coffee my wife each morning. These two actions do not take up that much time, but the value they bring is truly powerful. They ground me and start me on a positive path for the day. I swear that they make me more effective. Additionally, when the alarm goes off, I spend 5 to 10 minutes in quiet deep breath and mental silence (better known as meditation). I do this before anything else, especially checking email and text messages. Again, this starts the day off in a calm, collected, positive manner.
Third, finding intrinsic motivation. I always strive to return to why I went into this profession. The ideology most of us had during graduate school is often lost after a few years in the field. So, I seek satisfaction as a hospital administrator each and every day. For me this involves getting out of my office several times a day to say hello to patients. This has provided amazing results by placing all my daily stressors into context. It is also the best place to interact with your medical staff and employees. By being present with them, I see what they are doing, and they see that I genuinely care about them. It really is powerful, and I enjoy it so much. Frequently, I even take my wife with me to meet everyone.
These three areas work well for me. They are also each overwhelmingly supported in peer reviewed psychological research for effectively reducing stress. Again, these may or may not resonate with you, but any efforts that you make to reduce stress will decrease health issues, lead to better relationships, and make you happier overall. And they will make you more effective at your job. As mentioned, stress reactive pathways cause emotional reactions, which lead one to acting before thinking. This is certainly maladaptive to reaching our professional and personal goals. Any time you can make to find calmness, no matter how small, will pay great dividends in balancing your life, making you happier and more fulfilled in all arenas. And I’ll be right there with you working on this myself.
About Dr. Jeff Comer, Hospital CEO and Stress Management for High Performers
Jeff Comer is the son of a hospital CEO and has spent 20 years as a CEO himself. He leads small, rural hospitals and large urban medical centers. He focuses much of his career on short-term turnarounds where he works to save hospitals from closure. Seeing the stress in hospital administrator roles, Jeff pursued his doctoral education in psychology with research interests in stress reactivity. He now enjoys blending his background as a hospital CEO with his expertise in stress management. Please see Dr. Comer’s website at www.wjeffcomer.com.