What Women Need: a Study of Institutional Factors and Women Faculty's Intent to Remain in Academic Medicine.

BACKGROUND: A longstanding gender gap exists in the retention of women in academic medicine. Several strategies have been suggested to promote the retention of women, but there are limited data on impacts of interventions. OBJECTIVE: To identify what institutional factors, if any, impact women faculty's intent to remain in academic medicine, either at their institutions or elsewhere. DESIGN: A survey was designed to evaluate institutional retention-linked factors, programs and interventions, their impact, and women's intent to remain at their institutions and within academic medicine. Survey data were analyzed using non-parametric statistics and regression analyses. PARTICIPANTS: Women with faculty appointments within departments of medicine recruited from national organizations and specific social media groups. MAIN MEASURES: Institutional factors that may be associated with women's decision to remain at their current institutions or within academic medicine. KEY RESULTS: Of 410 surveys of women at institutions across the USA, fair and transparent family leave policies and opportunities for work-life integration showed strong associations with intent to remain at one's institution (leave policies: OR 2.22, 95% CI 1.20-4.18, p = 0.01; work-life: OR 4.82, 95% CI 2.50-9.64, p < 0.001) and within academic medicine (leave policies: OR 2.31, 95% CI 1.09-5.03, p = 0.03; work-life: OR 4.66, 95% CI 2.04-11.36, p < 0.001). Other institutional factors associated with intent to remain in academics include peer mentorship (OR 3.16, 95% CI 1.56-6.57, p < 0.01) and women role models (OR 2.21, 95% CI 1.04-4.68, p = 0.04). Institutions helping employees recognize bias, fair compensation and provision of resources, satisfaction with mentorship, peer mentorship, and women role models within the institutions were associated with intent to remain at an institution. CONCLUSIONS: Our findings suggest that institutional factors such as support for work-life integration, fair and transparent policies, and meaningful mentorship opportunities appear impactful in the retention of women in academic medicine.

Frustration With Technology and its Relation to Emotional Exhaustion Among Health Care Workers: Cross-sectional Observational Study.

BACKGROUND: New technology adoption is common in health care, but it may elicit frustration if end users are not sufficiently considered in their design or trained in their use. These frustrations may contribute to burnout. OBJECTIVE: This study aimed to evaluate and quantify health care workers' frustration with technology and its relationship with emotional exhaustion, after controlling for measures of work-life integration that may indicate excessive job demands. METHODS: This was a cross-sectional, observational study of health care workers across 31 Michigan hospitals. We used the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey to measure work-life integration and emotional exhaustion among the survey respondents. We used mixed-effects hierarchical linear regression to evaluate the relationship among frustration with technology, other components of work-life integration, and emotional exhaustion, with adjustment for unit and health care worker characteristics. RESULTS: Of 15,505 respondents, 5065 (32.7%) reported that they experienced frustration with technology on at least 3-5 days per week. Frustration with technology was associated with higher scores for the composite Emotional Exhaustion scale (r=0.35, P<.001) and each individual item on the Emotional Exhaustion scale (r=0.29-0.36, P<.001 for all). Each 10-point increase in the frustration with technology score was associated with a 1.2-point increase (95% CI 1.1-1.4) in emotional exhaustion (both measured on 100-point scales), after adjustment for other work-life integration items and unit and health care worker characteristics. CONCLUSIONS: This study found that frustration with technology and several other markers of work-life integration are independently associated with emotional exhaustion among health care workers. Frustration with technology is common but not ubiquitous among health care workers, and it is one of several work-life integration factors associated with emotional exhaustion. Minimizing frustration with health care technology may be an effective approach in reducing burnout among health care workers.

Strategies and Tactics for Achieving Work-Life Integration as a Junior Faculty Member.

Staying balanced: In this Science Voices article, Prof. Steven Townsend addresses strategies for obtaining a healthy start in academic careers and the provides a personal insight on assessing priorities and obtaining work-life integration as an independent researcher.

Gender and the Balance of Parenting and Professional Life among Gynecology Subspecialists.

STUDY OBJECTIVE: To compare the parenting and career patterns of female and male gynecology subspecialists. DESIGN: Cross-sectional survey study (Canadian Task Force classification II-3). SETTING: Survey administered electronically in February 2015 to physician members of the Society of Gynecologic Oncology, the American Society for Reproductive Medicine, and the American Urogynecologic Society. PARTICIPANTS: All physician members of the 3 national gynecology subspecialty organizations listed above. MEASUREMENTS AND MAIN RESULTS: There were 75 questions in 4 domains: demographics, mentoring issues, work-life balance, and caregiving responsibilities. Data were analyzed for survey sampling weights. Six hundred seventy-seven physicians completed the survey, 62% of whom were women (n = 420; 20.2% response rate). Sixty-four percent were aged 36 to 55 years. Eighty-two percent of respondents had at least 1 child, and men had more children than women (42% of men had 3 or more children compared with 20% of women, p <.0001). Thirty-seven percent of women reported that career plans affected the decision to become a parent somewhat or very much compared with 23% of men (p = .0006). Eighty-three percent of women believed career affected the timing of becoming a parent somewhat or very much compared with 48% of men (p <.0001). In addition, 76% of female physicians perceived that having children decreased their academic productivity compared with 54% of male physicians (p <.0001). Most men and women believed having children had no effect or increased their clinical performance (76% and 65%, respectively), but this was significantly lower in women (p = .01). CONCLUSION: Female gynecology subspecialists perceive that their career impacted decisions on parenting more frequently than their male counterparts. They were also more likely than men to report that having children had a negative impact on academic and, to a lesser extent, clinical performance. Increased support for combining childbirth and parenting with training and academic careers is needed.

Work-Life Integration and Time Management Strategies.

When choosing a career as a surgeon, we knowingly dedicate ourselves to a lifetime of service and education. Our commitment as physicians is but one of many commitments in the larger scheme of life where we function as family members, friends, athletes, and numerous other roles. Work and life are often described as two separate entities diametrically opposed to each other. In reality, personal and professional goals are part of a continuum where work is a major part of our lives and who we are as people and is not necessarily separate from the others. The goal-directed nature with which we approach our responsibilities as surgeons should be applied to all domains of life. As we progress along the training paradigm from intern to attending, control over time allocation increases. Understanding oneself, determining priorities, applying realistic expectations, cultivating a supportive environment, setting personal and professional goals, and being held accountable for progress and completion of these goals will allow us to utilize limited time efficiently to achieve what we individually desire from life.

"It breaks your soul": An in-depth exploration of workplace injustice in nursing.

AIM(S): To understand nurses' experiences of injustice in the workplace and to identify the impact of injustice on well-being. BACKGROUND: Little is known about how nurses view injustice or its effects on their well-being, although research indicates that such perceptions are central to workplace practices such as performance management and outcomes such as employee well-being. METHOD(S): A qualitative study was conducted with semi-structured interviews for nurses employed in Australian public hospitals. Data were analysed using content analysis. RESULTS: Experiences of injustice and unfairness negatively impacted on performance and the personal health of nurses. Unfair treatment was met with reduced effort and commitment. CONCLUSION(S): This study provides valuable insights into how nurses perceive and experience injustice at work and supports the link between injustice and nurses' decreased well-being and effectiveness. IMPLICATIONS FOR NURSING MANAGEMENT: Implications for nurse managers include the need for managers to engage in regular conversations regarding systemic barriers to performance and implementing performance management as an ongoing dialogue designed for employee voice and relationship management. This process also suggests a need for leadership development in nursing management. Using such steps and strategies would significantly enhance best practice in nursing management.

Parental satisfaction of U.S. physicians: associated factors and comparison with the general U.S. working population.

BACKGROUND: Physicians work considerably longer hours and are less satisfied with work-life balance than U.S. workers in other fields. There is, however, minimal data on physicians' parental satisfaction. METHODS: To evaluate differences in parental satisfaction among physicians and workers in other fields, we surveyed U.S. physicians as well as a probability-based sample of the general U.S. working population between August 2014-October 2014. Parental satisfaction and the perceived impact of career on relationships with children were evaluated. RESULTS: Among 6880 responding physicians (cooperation rate 19.2 %), 5582 (81.1 %) had children. Overall, physicians were satisfied in their relationships with their children, with 4782 (85.9 %) indicating that they were either very satisfied [n = 2738; (49.2 %)] or satisfied [n = 2044 (36.7 %)]. In contrast, less than half believed their career had made either a major [n = 1212; (21.8 %)] or minor positive [n = 1260; (22.7 %)] impact on their relationship with their children, with a slightly larger proportion indicating a major (n = 2071 [37.2 %]) or minor (n = 501 [9 %]) negative impact. Women physicians were less likely to believe their career had made a positive impact as were younger physicians. Hours worked/week inversely correlated with the belief that career had made a positive impact on relationships with children. Both men (OR: 2.75; p < 0.0001) and women (OR: 4.33; p < 0.0001) physicians were significantly more likely to report that their career had a negative impact on relationships with their children than the sex-matched U.S. working population. CONCLUSIONS: U.S. physicians report generally high satisfaction in their relationships with their children. Despite their high satisfaction, physicians have a more negative perception of the impact of their career on relationships with their children than U.S. workers in general.

Eight Domains of Pediatrician Wellness: A Stakeholder Informed Model.

BACKGROUND: Physician wellness is important to health care systems and quality patient care. There has been limited research clarifying the physician wellness construct. We aimed to develop a stakeholder-informed model of pediatrician wellness. METHODS: We performed a group concept mapping (GCM) study to create a model of pediatrician wellness. We followed the four main steps of GCM and recruited pediatricians at multiple sites and on social media. During brainstorming, pediatricians individually responded to a prompt to generate ideas describing the concept of pediatrician wellness. Second, pediatricians sorted the list of brainstormed ideas into conceptually similar groups and rated them on importance. Sorted data were analyzed to create maps showing each idea as a point, with lines around groups of points to create clusters of wellness. Mean importance scores for each cluster were calculated and compared using pattern match. RESULTS: Pediatricians in this study identified eight clusters of wellness: 1) Experiencing belonging and support at work, 2) Alignment in my purpose, my work, and my legacy, 3) Feelings of confidence and fulfillment at work, 4) Skills and mindset for emotional well-being, 5) Harmony in personal, professional, and community life, 6) Time and resources to support holistic sense of self, 7) Work boundaries and flexibility, and 8) Organizational culture of inclusion and trust. There were no significant differences in mean cluster rating score; the highest rated cluster was Harmony in personal, professional and community life (3.62). CONCLUSION: Pediatricians identified eight domains of wellness, spanning professional and personal life, work, and individual factors.

The Well-Being of Women in Healthcare Professions: A Comprehensive Review.

Background: A multidisciplinary team of health scientists and educators at an academic medical center came together to consider the various factors that impact well-being among self-identified women working in healthcare and conducted a comprehensive literature review to identify the existing body of knowledge. Objectives: To examine how well-being is defined, what instruments are used to measure it, and correlation between professional and personal gender-specific factors that impact the well-being of women in healthcare occupations. Methods: A total of 71 studies published in 26 countries between 1979-2022 were extracted from PubMed. Studies enrolled adult women (18-74 y.o.) healthcare professionals including nurses, physicians, clinical social workers, and mental health providers. Well-being related phenomena such as quality of life (QOL), stress, burnout, resiliency, and wellness were investigated. In this review, women are broadly defined to include any individual who primarily identifies as a woman regardless of their sex assigned at birth. Results: The results of our analysis were consistent across the scope of the literature and indicated that women in healthcare occupations endure a significantly higher level of stress and burnout compared to their male counterparts. The following gender-specific factors were identified as having direct correlation to well-being: job satisfaction, psychological health, and work-life integration. Conclusions: The findings from this review indicate a need for evidence-based integrative interventions across healthcare enterprises to combat stress and burnout and strengthen the resiliency and well-being of women in healthcare. Using information from this review, our team will launch a comprehensive well-being assessment and a series of interventions to support resiliency and well-being at our academic medical center.

Career Vitality: Perceptions from Women Faculty in Health Professions.

OBJECTIVE: Career vitality is experienced when personal and professional life commitments align. To examine perceptions of and strategies used by women faculty in health professions to achieve career vitality. METHODS: A 2-round Delphi method was used to identify career vitality descriptors, personal-professional-life equilibrium, and strategies for achieving career vitality among 16 women faculty recruited from the National Academies of Practice. Qualitative analysis identified themes. RESULTS: The consensus-generated descriptors of career vitality were 'growth mindset', 'motivated/passionate', and 'collaborative'. Descriptors of personal-professional-life equilibrium were 'prioritize', 'balance', and 'nimbleness'. Personal resilience was the major strategy to gain equilibrium. Challenging perceptions to overcome included role expectations for women working outside the home, which correlated with a system strategy such as organizational tools. CONCLUSION: Achieving career vitality and personal-professional-life equilibrium is challenging. The strategies generated can be utilized by women faculty to better align work-related demands when challenges are high, and resources are low.

Characterizing burnout and resilience among nurses: A latent profile analysis of emotional exhaustion, emotional thriving and emotional recovery.

AIMS: To identify subgroups of nurses with distinct profiles of burnout (emotional exhaustion) and resilience (emotional thriving and emotional recovery) and describe nurse characteristics associated with each profile. DESIGN: Cross-sectional, correlational design. METHODS: Data were collected via electronic survey from 2018 to 2019. Latent profile analysis was used to identify subgroups of nurses with distinct profiles of emotional exhaustion, emotional thriving and emotional recovery, with each measured on a 0-100 scale. Bivariate statistics were used to determine profile differences in nurse sociodemographic, professional and psychological characteristics. RESULTS: Four distinct profile subgroups were identified: (1) "exhausted" (14% with very high emotional exhaustion, low emotional thriving and moderate emotional recovery), (2) "exhausted with thriving" (6% with high emotional exhaustion, moderate-high emotional thriving and low emotional recovery), (3) "exhausted with thriving and recovery" (52% with moderate-high emotional exhaustion, emotional thriving and emotional recovery), and (4) "thriving and recovery" (27% with low emotional exhaustion and very high emotional thriving and emotional recovery). Nurses in the "exhausted" and "exhausted with thriving" profiles reported greater depression and poorer work-life integration. Nurses in "exhausted" profile were more likely to work in an inpatient setting. Nurses in the "exhausted with thriving and recovery" and "thriving and recovery" profiles reported more positive emotions, more well-being behaviours, and better work-life integration, with the "thriving and recovery" subgroup having the highest levels of these characteristics, lower depression scores and greater racial minority representation. CONCLUSION: Approaches designed to improve nurse well-being should be tailored to the nurses' profile of emotional exhaustion, thriving and recovery to maximize effectiveness. IMPACT: Given the growing shortage of nurses in healthcare systems, it is critical that multilevel strategies be investigated to retain nursing staff that consider the intersectionality and complexity of the different aspects of burnout and resilience experienced by the nurse. NO PATIENT OR PUBLIC CONTRIBUTION: The aim was to assess burnout and resilience among nurses.

Challenges for dermatologists during the COVID-19 pandemic: A qualitative study.

Burnout is increasing in all fields of medicine, including dermatology. The coronavirus disease 2019 (COVID-19) pandemic presented new and additional challenges for dermatologists. Objective: Dermatologists of different ages, areas of expertise, and practice settings were convened in 5 focus group to describe the impact of the COVID-19 pandemic on their clinical practice, working environment, and personal lives. Methods: Qualitative analysis of the discussions w\s performed on the result of the 5 focus groups of dermatologists (n = 22). Groups were prompted with questions relating to their jobs, personal lives, teledermatology, and pandemic. Responses were recorded, transcribed, deidentified, and coded for recurring themes. The focus groups occurred via a secure videoconferencing platform between December 2020 and January 2021. All participants were currently practicing dermatology in a variety of setting including academic institutions, private practices, and multiple practice types. General dermatologists, residents in training, dermatologic surgeons, dermatopathologists, and dermatologists with significant administrative or educational duties were included. Results: We identified 4 main themes from the focus group discussions regarding dermatologist and physician wellbeing during the COVID-19 pandemic: (1) adjusting to new administrative, staffing, and educational demands; (2) integration of work as a dermatologist with family life; (3) new technologies such as teledermatology; and (4) adjusting to change with redefining personal and professional priorities. Limitations: The small number of participants in our convenience cohort disproportionately represented academic dermatologists. Impacts of regional COVID-19 vaccination rates and ideological differences in different geographical locations were not assessed. All of our participants were located in the United States. Physicians severely impacted by health or financial concerns may not have been able to participate in our study. We did not have a comparison group and did not measure or assess burnout in individual participants. Conclusion: During the COVID-19 pandemic, there were common changes and stressors that dermatologists experienced, which affected physician wellbeing. Identifying and addressing these changes could offer the opportunity to improve the wellbeing of dermatologists.

Reflections on work-life integration post-pandemic: A perspective from pharmacy practice faculty.

INTRODUCTION: The effects of COVID-19 will have a lasting impact on how work is conducted moving forward. Prior to the pandemic, work-life integration and well-being were priorities for many organizations, including pharmacy. The disruption associated with the COVID-19 pandemic pushed businesses and organizations worldwide into an era of agility and flexibility previously unknown to the majority of workplaces. PERSPECTIVE: Increased remote work has presented both increased challenges (e.g., engagement) and opportunities (e.g., productivity). After a year of experience, this shift in the nature of how work is done has provided an opportunity to reimagine how and where work will be conducted in the future. IMPLICATIONS: Schools and colleges of pharmacy have an opportunity to re-evaluate how academic and practice responsibilities are accomplished in regards to work life-integration and management of concurrent work and family responsibilities. Administration and faculty should foster a culture of transparency on this topic to collaboratively incorporate methods that better facilitate work-life integration moving forward.

Balance Versus Integration: Work-Life Considerations.

The term work-life balance may cause physicians to feel inadequate in pursuing a reality in which work and life each have equal importance. Furthermore, the term implies competition between these 2 realms. Instead, work-life integration is a more constructive and realistic term. Achieving harmonious integration requires self-reflection on the current state, goals, and resources and strategies needed to achieve and maintain such a state. Prioritizing aspects of both, and aligning them with individual requirements, while incorporating consistent and intentional investment of time and efforts in both professional and personal arenas is crucial to cultivate and sustain longitudinal well-being.

Managing Physician Fatigue.

Physician fatigue, also known as burnout, is a highly prevalent but often underrecognized result of workplace stressors. The consequences of burnout can include poor work-life integration, isolation, depression, and suicide. As a result, an organization may experience high physician turnover, patient safety issues, malpractice suits, and financial losses. Physicians should be encouraged to play a role in their wellness by taking mental time away from work, pursuing hobbies, attending wellness programs, and ensuring quality time with family. Ultimately, it is an organization that must acknowledge physician burnout, identify risk factors, and invest in targeted interventions to prevent this immense threat to their stability.

Work-Life Balance for Oral and Maxillofacial Surgeons.

Oral and maxillofacial surgeons experience high levels of stress and work-home conflict, which predispose them to burnout. There is emerging evidence in support of work-life integration to prevent burnout; interventional strategies exist on an individual and organizational level. This article explores the current evidence on promoting work-life integration for improved surgeon satisfaction, performance, and efficiency. Work-life integration initiatives can help promote the recruitment and retention of a diverse surgical workforce in oral and maxillofacial surgery.

Are We Making an Impact? A Qualitative Program Assessment of the Resident Leadership, Well-being, and Resiliency Program for General Surgery Residents.

OBJECTIVE: After implementing a formal resident well-being and resiliency program in our surgery residency, we performed in-depth qualitative interviews to understand residents' perceptions of: (1) the impact and benefits, (2) the essential elements for success, and (3) the desired changes to the well-being program. DESIGN: The well-being program is structured to address mental, physical, and social aspects of resident well-being through monthly experiential sessions. All General Surgery residents participated in the program; content is delivered during residents' protected educational time. For this study, we conducted individual semistructured interviews: residents were asked for their feedback to understand the value, benefits, and drawbacks of program. SETTING: Accreditation Council for Graduate Medical Education-accredited General Surgery residency program PARTICIPANTS: We used purposeful selection to maximize diversity in recruiting residents who had participated in program for at least 1 year. Recruitment continued until themes were saturated. Eleven residents were interviewed including 2 from each residency year. RESULTS: Residents reported benefits in 3 thematic spheres: (1) Culture/Community, (2) Communication/Emotional Intelligence, and (3) Work-Life Integration Skills. Key structural elements of success for a well-being program included a committed leader, a receptive department culture, occurrence during protected time, and interactive sessions that taught applicable life skills. In discussing opportunities for improvement, residents desired more faculty-level involvement. Some residents were skeptical of the benefit of time spent learning nontechnical skills; some wanted more emphasis placed on accountability to patients and work. CONCLUSIONS: Our qualitative assessment of a novel resident well-being program demonstrates reported benefits that reflect the intent of the program. Residents most benefited from sessions that were interactive, introduced readily applicable skills for their day-to-day lives, and included reinforcement of principles through experiential learning. Engagement of the department leadership is essential to the success of the program, as is ongoing feedback and modification to ensure that program is tailored to the needs of residents.

Issues Faced by Senior Women Physicians: A National Survey.

Background: As the first large numbers of female physicians complete their careers, information is needed to enable institutions and individuals to optimize the final career phase and transition to retirement of these women, as well as to help younger women physicians prepare for later phases of their careers. Materials and Methods: To identify the leading issues for older female physicians, a 34-item electronic questionnaire covering heath, finances, preparation for and attitudes about retirement, caretaking responsibilities, life-work integration, various aspects of discrimination and harassment, professional isolation, and work-related stress and burnout-incorporating standardized measures of career satisfaction was distributed through the Kansas Medical Society and nationally through the American Medical Association Senior Physicians Section newsletter to female physicians older than 60 years in 2018. A total of 155 physicians self-identified as eligible and completed at least half of the survey. Results: Respondents were 60-87 years of age, mean 70.4 (±6.4) years. The majority reported good health and being financially well prepared for retirement. Twenty percent were caretakers for grandchildren, parents, or spouses. Measures of career and job satisfaction were reasonably high, despite negative work environment and burnout scores. Problems with family/career balance, age- and gender-based discrimination and harassment, salary inequity, and professional isolation persisted throughout their careers, but diminished in frequency for senior women. Conclusions: Issues faced by younger women physicians do not disappear with age or seniority. To recruit and support female physicians, issues such as balancing family/work responsibilities, combating harassment and bias, and promoting healthy work environments must be addressed throughout their entire careers.

Embracing social media in the era of work-life integration.

Radiology practices are leveraging social media for networking, education, branding, and marketing. This change inherently requires radiologists to increase their engagement in social media and may negatively affect work-life integration and contribute to radiologist burnout. In this article, we describe specific strategies that radiology practices may deploy to help balance work-life integration.

Formal and Informal Work-Life Balance Practices of Athletic Trainers in Collegiate and University Settings.

CONTEXT: Organizational policies for work-life balance exist, but little is known about athletic trainers' (ATs') awareness of and willingness to use them. OBJECTIVE: To explore ATs' formal and informal work-life balance policies in the collegiate and university athletic training setting. DESIGN: Sequential mixed-methods study. SETTING: Web-based survey. PATIENTS OR OTHER PARTICIPANTS: We sent 4673 e-mails to National Athletic Trainers' Association ATs (full-time employment for at least 1 year, nonacademic appointment); 1221 participants began our survey (access rate = 26.1%), and 783 completed the survey (64.1% completion rate). Demographics were as follows: men = 375 (48.0%) and women = 404 (51.7%); age = 36 ± 10 years; experience = 13 ± 9 years; years at current place of employment = 8 ± 8 years; and participants with children or minor dependents = 262 (33.5%). MAIN OUTCOME MEASURE(S): We created a 17-item instrument from an earlier qualitative study. A panel of experts (n = 3; employer, employee, and researcher) completed a content analysis. Variables of interest were confidence (scale = 1-4) and satisfaction (scale = 1-5) with policies. We used Pearson χ2 analyses to compare the effect of undergoing an orientation and the presence or absence of children on the main outcome measures. RESULTS: A majority of participants had experienced formal orientation through the human resources department (n = 522, 66.8%), the direct supervisor (n = 240, 30.7%), or a colleague (n = 114, 14.6%). However, many had received no orientation (n = 184, 23.6%). Those who had undergone orientation indicated greater confidence in knowing about (P < .001) and greater satisfaction with (P < .001) formal workplace policies and benefits. Those with children stated that they had greater confidence in knowing about (P < .001) and greater satisfaction with (P = .013) formal workplace policies and benefits. Those who had been oriented felt greater confidence in knowing about (P = .009) but no difference in satisfaction with (P = .060) informal workplace policies and benefits. We did not identify differences between those with and those without children regarding their confidence in knowing about (P = .653) or satisfaction with (P = .150) informal workplace policies and benefits. CONCLUSIONS: Athletic trainers in the collegiate and university setting were not confident in their knowledge of formal or informal work-life balance policies.