Caring for the Health Care Workforce During Crisis: Creating a Resilient Organization

Unexpected crises happen: a pandemic occurs with a new pathogen for which there is no cure, a natural disaster strikes bringing in mass casualties, a nuclear reactor explosion contaminates and sickens an entire region, or some other calamity not yet imagined. Learn what you and your organization can do before, during, and after a crisis to increase the likelihood your workforce will cope and even thrive.

Introduction

How Will This Module Help Me?

Unexpected crises happen: a pandemic occurs with a new pathogen for which there is no cure, a natural disaster strikes bringing in mass casualties, a nuclear reactor explosion contaminates and sickens an entire region, or some other calamity not yet imagined. Actions taken by your organization before, during, and after a crisis will increase the likelihood your workforce will cope or even thrive.

How do physicians and other health care workers respond to a crisis? Stress may come from 1 of 4 major sources (Figure 1):

Figure 1. Four Causes of Stress Injury¹

Figure 1 republished with permission from Watson P. Caring for yourself & others during the COVID-19 pandemic: managing healthcare workers' stress. Schwartz Center for Compassionate Healthcare webinar. March 24, 2020. Accessed April 23, 2020. https://youtu.be/F4LU-EoAFew

How physicians and other health care workers are supported during a time of acute stress impacts whether they are able to cope and then recover from the crisis, or alternatively, whether they will adopt unhealthy coping mechanisms and show signs of stress injury (eg, burnout, insomnia, dysphoria) or even worse, chronic stress illness (eg, depression, anxiety, post-traumatic stress disorder [PTSD], substance abuse).

Fortunately, progression from a stress reaction to stress injury to a chronic stress illness is not inevitable. Proactive institutional supports initiated before a crisis, “stress first aid” delivered during the crisis, and “recovery aid” provided after the crisis will each increase the odds that individuals will recover and thrive (Figure 2).¹

Successful organizations take a systems approach and focus on becoming a resilient organization prior to times of crisis, rather than limiting their efforts to a focus on individual resilience or only attending to the well-being of health care workers after crisis develops. Furthermore, resilient organizations need to rapidly reconfigure their well-being priorities to meet the biggest new drivers of stress in a crisis setting.

Figure 2. Conceptual Model: Stress First Aid During and After Crisis Impacts Outcomes¹

Fifteen STEPS to Care for the Health Care Workforce

Before Crisis: Create a Resilient Organization

Appoint a Chief Wellness Oficer (CWO) and Establish a Professional Well- Being Program

Create a Plan in Coordination with Hospital Incident Command System (HICS) Leadership

Support Workforce Needs for Professional Competency During Crisis Reassignments

Identify Non-Essential Tasks that Could Be Suspended or Reduced During a Crisis

Develop Mechanisms to Assess Stress and Needs Within the Workforce

During Crisis: Support Physicians and Other Health Care Workers

Assess the Current Situation; If Necessary, Develop New Crisis-Specific Support and Resources

Emphasize and Embody the Importance of Visible Leadership

Connect with Other Institutions to Share and Learn

Regularly Evaluate Stressors and Stress Levels Within the Workforce

Adapt Support Plan to Meet Evolving Needs

After Crisis: Become an Even More Resilient Organization

Debrief Unit by Unit as well as by Profession

Catalogue What Was Learned and Update the Crisis Plan

Deploy an Organization-Wide Approach to Support Workforce Recovery and Restoration

Honor the Dedication and Memorialize the Sacrifice of Health Care Professionals

Resume Ongoing Efforts to Promote a Thriving Workforce

Before Crisis: Create a Resilient Organization

STEP 1: Appoint a Chief Wellness Officer (CWO) and Establish a Professional Well-Being Program

With a chief wellness oficer and well-being program in place, a unit already exists that can rapidly shift the focus of their work to address the needs created by the crisis event.^2- 8 In crises with significant societal disruption and anticipated psychological stress, it will be necessary for the CWO to partner with behavioral health, communications, and other support services.

In many organizations the CWO is appointed to lead the workforce support response in a crisis since the CWO and their team will have built partnerships or relationships with all these health care system units prior to the crisis. Depending on the nature of the crisis, the CWO may form a task force to help coordinate across many areas, such as providing food, transportation, lodging, security, communications, and behavioral health.

STEP 2: Create a Plan in Coordination with Hospital Incident Command System (HICS) Leadership

Assemble a time-limited group charged with identifying the needs of the workforce for the tangible physical, logistical, and psychosocial support needed at work and at home during a crisis. Create a “Caring for the Health Care Workforce Plan,” and work with Hospital Incident Command (HICS) leadership to ensure that the plan includes these dimensions of basic logistical, communications, psychosocial, and mental health support. In creating a plan to support health care workers, be aware that the barriers to seeking and receiving help may be greater among those in the healing professions.

Video: Watch How Rush University System for Health in Chicago Approaches Their “Caring for the Health Care Workforce” Plan

Video: Interdisciplinary Support to Promote Wellness During Crisis

There are 2 frameworks that may prove useful as the plan is developed. The first is the Stanford Medicine “Hear me, Protect me, Prepare me, Support me, Care for me” model, and the second is the Mt. Sinai hierarchy of basic needs.^9,10 Figure 3 illustrates Stanford's model, and Table 1 covers domains of needs and examples of programs to meet those needs following the Mt. Sinai model. An organization that has cataloged existing resources, identified potential workforce needs, and outlined a plan for how to address them will be a step ahead when a crisis occurs.

Figure 3. Requests Driven by Principle Desires During the COVID-19 Crisis⁹

Figure 3 adapted with permission from Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA. Published April 7, 2020. doi:10.1001/jama.2020.5893

Table 1. Domains of Need for Workforce Psychosocial Support During a Crisis¹⁰

Personal safety

Family safety

Dependent care

Transportation and parking

Healthy food and water

Lodging

Communication and leadership

Communication

Psychosocial and mental health needs

Psychological safety

Peer support

Self-care

Table 1 adapted with permission from Well-being staff resources during COVID-19. Mt. Sinai. Accessed May 1, 2020. https://www.mountsinai.org/about/covid19/staff-resources/well-being

STEP 3: Support Workforce Needs for Professional Competency During Crisis Reassignments

Physicians and other health care workers may need to be reassigned to responsibilities that are outside of their recent practice and comfort zone. This is a substantial source of stress, which can be reduced by communicating that the reassigned health care worker will have the support of the organization to prepare them. This stress can also be reduced by providing the reassigned health care worker with resources before they relocate. The message “you are not alone; we are here to support you” could be reassuring to clinicians stepping into new or unfamiliar roles. A mentoring and training system will help preserve feelings of professional competence. A structure that includes oversight and ready access to expertise is essential.

Patience with onboarding and creating psychological safety are also key. This professional transition support could take one of several forms as outlined in Table 2. These physicians will also need support and understanding of potential medicolegal issues that could arise from their assumption of new areas of responsibility.

Table 2. Professional Transition Support During Crisis Reassignments

Electronic Health Record

Develop crisis-specific templates and order sets for the EHR.

Liability Extend support and understanding in case medicolegal issues arise because clinicians are assuming new responsibilities.

STEP 4: Identify Non-Essential Tasks that Could Be Suspended or Reduced During a Crisis

During ordinary times physicians may spend as much as 2 hours on EHR and desk work for every hour of direct patient care. This is wasteful at any time; it is unsustainable during a crisis. Physicians often also devote time to numerous other tasks such as annual compliance training, patient satisfaction reports, and, for academic physicians, applications related to promotion and reappointment. Leaders can free up physician time, cognitive bandwidth, and emotional reserve by monitoring changing requirements from The Centers for Medicare & Medicaid Services (CMS) among others, and are taking some of the following steps to lighten administrative burden (Figure 4).

Figure 4. Modifying Policies and Reducing Non-Essential Tasks During a Crisis

Any activities involving medical students or other health professions students should be part of a voluntary, student-led program overseen by their school in compliance with guidance from the Liaison Committee on Medical Education (LCME) or other accreditor. No direct solicitation of individual students should occur.

STEP 5: Develop Mechanisms to Assess Stress and Needs Within the Workforce

Understanding the evolving stresses and needs of the workforce will allow leaders to be flexible in meeting those needs. An organization can utilize existing well-being infrastructure to understand the needs of the workforce. For example, the CWO, department well-being champions, and team members can scan for units at risk for moral distress (ie, in a respiratory crisis with a shortage of ventilators the workforce will experience moral distress when triaging limited supplies) to identify the necessary communication and resources to prepare and support health care workers dealing with these issues (Interactive 1).

“I go when I have a gap in my schedule. I've been walking through ED and our med-surg and ICU units that have COVID-19 patients and then check one or two other units, time permitting. In the ED, I routinely check in with the attending(s) and charge nurse unless they are busy with other activities. I typically go into a few team rooms and/or talk briefly to teams on rounds to pose the questions below and also do the same with nursing leaders and nurses that I see and who look like they have time to talk. If people look busy, I typically wave and smile. I have also been routinely thanking many of the medical, nursing, and especially the environmental services and public safety staff that I see for being present and for their contributions. It typically takes me 30-40 minutes to round. When I have less time, I go to the ED and a couple of units and can do this in about 20 minutes. I've gone every day that I have been in the hospital (about 6 days/wk) for the last month and have found it to be both enjoyable and a valuable activity. I think people have appreciated seeing our leaders present, especially during the first few weeks when activities and concerns were ramping up.”

— Thomas Staiger, MD, Medical Director, University of Washington Medical Center

Interactive 1. Mechanisms to Assess Stress and Needs Within the Workforce

Listening Sessions⁹

Leadership Walk-Rounds^11,12

Roll-Up Communication

Department Updates

Surveys

The AMA created 2 surveys for organizations to assess how health care workers are coping with the COVID-19 crisis:

Daily Huddles

During Crisis: Support Physicians and Other Health Care Workers

STEP 6: Assess the Current Situation; If Necessary, Develop New Crisis-Specific Support and Resources

The most well-intended, meticulous playbook created before crisis may not be enough to meet the needs of the current crisis, which may have been unanticipated and not previously experienced. The CWO and wellness leadership team, potentially with the aid of psychiatry and behavioral health leads, must assess the situation, evaluate the adequacy of the plan, and consider the need to evolve it before deployment. In some cases, it may even be necessary to discard the prior playbook and rapidly develop a new plan to address current needs.

For example, during the first week of the 2020 COVID-19 crisis Stanford held 8 listening sessions with clinicians to surface primary sources of anxiety and fear.⁹ Three questions were discussed in each session:

Some organizations established respite stations throughout areas where frontline workers were most affected. These stations might include healthy food, water, and reminders of available peer support and mental health services.

If the task force addressing care team needs has a strong mechanism to capture the “voice from the field” and relay them to leadership, incident command, and behavioral health leads who can effectuate rapid change, then this is the way to develop new supports. Organizations may find that most, if not all, of the new resources rolled out during a crisis were based on real and perceived needs ascertained by leaders and the frontline caregivers.

STEP 7: Emphasize and Embody the Importance of Visible Leadership

Leaders at multiple levels within an organization need to be visible to the physicians and other health care workers they lead. Additionally, leaders must be adept at receiving and responding to the needs and concerns of the workforce that come through varied communication channels (eg, in-person, electronic, or virtual).

Unmet needs for information can create a great deal of anxiety. The uncertainty inherent in a rapidly changing environment is a significant stressor that can be ameliorated with good multichannel communication that is honest and transparent. The leaders will not always have the answers and in the face of uncertainty should strive to be transparent about what is known, what they can do, and what they are trying to do (Figure 5).

Figure 5. Mechanisms of Leadership and Communication

STEP 8: Connect with Other Institutions to Share and Learn

Organizations can learn from each other, rather than building all programs from scratch. Existing networks of CWOs or other hospital leaders, professional associations, social networking sites, and other social media can serve as a rapid means of disseminating shared learnings.

STEP 9: Regularly Evaluate Stressors and Stress Levels Within the Workforce

It is important to keep a finger on the pulse of stress and anxiety in the health care workforce during the crisis. This assessment should also include assessing the adequacy of support resources and the need for new resources. Accurate assessment can help identify:

Listening sessions, leadership walk-rounds, and pulse stress surveys as outlined in Interactive 1 can help leaders track the stress levels of the workforce during and after the crisis. Both proactive and reactive means to assess and react to stress are helpful. For example, mental health liaisons can proactively reach out to units under stress and a mental health crisis team is available to react as needed to hot spots of stress.

STEP 10: Adapt Support Plan to Meet Evolving Needs

Depending on the duration of the crisis, sources of concern and needs may evolve over time. These sources could include the need for new information (eg, adequacy of PPE, new PPE use guidelines, change in the number of hospitalized patients, fluctuations in number of employees who have developed infection) or new support (eg, childcare when schools close, lodging close to hospital because of increased reliance on rapid cycle shifts). This evolving plan might also include a recognition of the need for a stronger ethics infrastructure to address ethically challenging situations that arise during the crisis. Leaders must continually develop plans to address new and emerging needs.

After Crisis: Become an Even More Resilient Organization

STEP 11: Debrief Unit by Unit as well as by Profession

After the crisis it is helpful to continue to support individual health professionals and learn from this experience to be better prepared for future crises. In small group debriefs (hospital work units, specialty divisions, etc.) leaders or facilitators can adopt an appreciative inquiry approach, asking “What went well?” and “Is there a positive story you can share?” Although stress first aid is an ongoing process, adapting previous approaches can be helpful as the workforce debriefs and reflects on their experience.¹ Examples of other questions to consider reviewing during the debriefing sessions are shown in Interactive 2. Offering these sessions as an integrated part of the workday that is strongly encouraged but not mandated may be most effective.

The leader or facilitator may also ask for creative, constructive ideas for ways to improve the unit or profession's response to a crisis in the future. Finally, the leader or facilitator can ask, “How are you doing personally?”

Interactive 2. Stress First Aid Group Discussion Questions¹

Has there been an impact on how you connect with others?

Do you have any concerns about being able to handle anything?

Have you noticed any change in your confidence in:

Interactive 2 adapted with permission from Watson P. Caring for yourself & others during the COVID-19 pandemic: managing healthcare workers' stress. Schwartz Center for Compassionate Healthcare webinar. March 24, 2020. Accessed April 23, 2020. https://youtu.be/F4LU-EoAFew

STEP 12: Catalogue What Was Learned and Update the Crisis Plan

Diffcult as it is to consider facing another crisis when the current crisis is just subsiding, the odds are that another will develop. It is important to learn from the current crisis while it is relatively fresh. At the same time, the nature of the next crisis is unknown and will undoubtedly bring with it unique needs; this means that no matter how much preparation is done ahead of time, provisions for doing real-time assessment and response will remain critical. The CWO and team can integrate the learnings from the debriefing sessions covered in STEP 11 into the “Caring for the Health Care Workforce Plan” outlined in STEP 2.

STEP 13: Deploy an Organization-Wide Approach to Support Workforce Recovery and Restoration

Physicians and other health care workers will continue to need help after the crisis subsides to deal with this communal, work-related trauma. Bearing close witness to significant tragedy can have long-lasting effects. In fact, many individuals are able to hold it together during the stressful time but may feel things are falling apart afterward. This time is when recovery aid is helpful (Figure 2). Furthermore, barriers to seeking care may be greater for those in the healing professions than others, so finding ways to normalize recovery aid is also useful. Universal screening for depression and post-traumatic stress can be considered.

It is important to continue to provide confidential and readily accessible emotional, psychological, and mental health support for 6-12 months after the crisis has passed. This may include telephone support lines, virtual visits, and in-person visits. It may also include collegial support groups, which provide an opportunity to find meaning in the tragedy and allow participants to make sense of an intense, uncontrolled period.

In addition, team members may need to be reminded to take breaks during work and to take their vacation time. Physicians and other health care workers may benefit from guidance as to how to re-enter “ordinary time” with their friends and family who have not had such an intense experience.

STEP 14: Honor the Dedication and Memorialize the Sacrifice of Health Care Professionals

Recognize health care workers and their families for their incredible efforts. This recognition is part of how culture is built and maintained. Look for physical tokens to recognize these efforts.

Consider a time of remembrance ceremony and a physical memorial for any physicians or other members of your health care teams who have been injured, died, or suffered loss during the crisis.

STEP 15: Resume Ongoing Efforts to Promote a Thriving Workforce

The work you and your team had done prior to the current crisis helped sustain the workforce during the crisis. Now it is time to keep strengthening these programmatic offerings. It matters!

Conclusion

Crises are inherently stressful and often involve uncertainty, unpredictability, and increased work intensity. Such events also require flexibility, endurance, equanimity, and professionalism from health care workers precisely when these attributes are most threatened. For health care professionals to successfully navigate these challenges and serve their patients and society during a public health emergency, they need organizational support. How well organizations plan for and support their workforce during a crisis will influence the organization's capacity for patient care, and the personal impact of the crisis on the health care workforce.

Short-term stress has the potential to lead to long-term growth and thriving, known as post-traumatic stress growth, or to long-term stress injury and illness depending on the infrastructure, culture, and actions of an organization. Creating a plan to provide support for the workforce during and after a crisis will help maintain a healthy and suficient workforce to meet societal needs over time.

It is critical that crisis preparations include plans to support physical, emotional, and psychosocial needs of the workforce. It is also critical for organizations to attend to the well-being of the health care workforce prior to an emergency so that they do not enter times of crisis with a team that is already exhausted, depleted, and burned out. In most cases, the well-being infrastructure that is in place prior to a crisis can serve as the framework to apply new or modified support systems in the midst of an emergency. Taking action before, during, and after will help the organization weather the crisis.

Further Reading

Journal Articles and Other Publications

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.