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COVID-19 Articles: The Open Mind

Nurturing Morale

Vinson, Amy E. MD

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doi: 10.1213/ANE.0000000000004965
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I have been privileged to participate, lead, or observe countless reports of how the coronavirus disease 2019 (COVID-19) pandemic impacts the well-being of anesthesiologists and a consistent theme is the role of leadership in establishing esprit de corps. I have spent the past few years studying well-being, implementing initiatives, and generally talking, writing, and thinking about wellness. I would like to offer my observations of how the pandemic affects anesthesiologists now, will affect us during the catch-up phase, and how leaders can mitigate that stress. Listening to my colleagues around the country, it is clear that many are far more worried about the personal impact of the recovery than the initial first wave of the COVID-19 pandemic. If we are currently in the “Great Pause,” we will next be entering the “Great Catch-Up.”

Morale must be nurtured, and it will likely be greatly strained heading into the slog of “catching up.” Some leaders seem to take morale for granted out of a sense of expected professionalism, forgetting that the best of us can become strained over time. Dedicated professionals stretched too thin for too long can burn out, disengage, get depressed, or tragically even become suicidal.1 The times we find ourselves in are most certainly a strain, but the unknown we will venture into following this will be done without any of the usual comforts of normalcy we have come to rely on for rejuvenation, reassurance, and endurance. The need for compassionate, honest, and servant leadership will be profound, whether you are leading a team in the operating room (OR) or a department.

SOURCES OF CHALLENGE

Articulating the personal impacts of the COVID-19 pandemic may help us address them. The short list below of stress sources is designed to start the conversation, but integral to meaningful self-compassion is this acknowledgment: whatever you are experiencing is a normal human response to an extraordinary human event. What we do as leaders can open a safe space for people to better express their needs and for us to meet them.

The Practice of Medicine

Clinicians are no stranger to long hours, death, and tragedy, but for those on the very front lines of this pandemic, those experiences are being amplified and repeated. I won’t even begin to describe the deluge of traumatic daily events many in our ranks are experiencing—I’ll leave that for them to express as only someone who has walked through a thing can.

Physical Health

Personal risk stokes anxiety about the availability, use, and reuse of personal protective equipment (PPE), risk of illness to self or family, and the emotional impact of caring for a sick colleague. This rightfully has been the primary “wellness” focus during the pandemic.

Psychological Safety

“Gaslighting,” or attempting to convince someone of something that is contrary to what they know to be true, can be psychologically disorienting. With fluctuating, and occasionally contradictory, local and national recommendations on PPE and practice, one can easily see how this perception can needlessly develop. This highlights the need for honest, transparent, and consistent communication from leadership that acknowledges the unprecedented nature of the challenge, and that we are working outside of what we previously felt was optimized practice (eg, reuse of single-use PPE). There is a vast difference between saying: “You don’t need PPE because this situation is far safer than we thought” and “Look, we don’t have enough masks and we need to think outside the box to conserve them for the very highest risk situations.”

Training Stressors

Trainees may have either copious free time with limited educational experiences or responsibilities beyond their capabilities, unclear supervisory chains, and taxing duty hours, despite the Accreditation Council for Graduate Medical Education (ACGME) affirming its nonnegotiable commitment to appropriate PPE, supervision, and duty hours.2

Financial Stressors

Financial strain affects clinicians from trainees to near-retirees. Trainees may see expected jobs disappear or may find themselves unable to obtain board certifications linked to bonuses. Some practicing clinicians are facing pay cuts or even unemployment. Concerns about the financial effects lingering for months exacerbate clinician’s worries about debt repayment, childcare costs, and anticipated retirement dates.

Family Stressors

Clinicians at all stages feel familial pressures and limited bandwidth to comfort and serve loved ones. Anyone with small children understands the chasm between a “vacation” and a “family trip.” Families previously relying on daycares, schools, and activities scramble to find solutions while still having work obligations from home. At home, they may need to relieve a partner who has been trying to work from home, learn how to homeschool and reassure bored and anxious children. Some clinicians are directly caring or indirectly monitoring older relatives and may be further stressed by a lack of information. Bringing home illness to the family harangues minute-by-minute behavior when working. Existing familial stressors are aggravated, including sensitive issues of domestic violence, illness, and financial insecurity.

Social Stressors

Forced home by quarantine, illness or furlough or living away from family, isolation limits life-sustaining connectivity. Also, social distancing and travel restrictions have eliminated countless trips and vacations. For those already experiencing burnout, these are not mere frivolities, but often lifelines and sources of restoration and hope.

Professionalism Stressors

Lurking feelings of inadequacy or guilt may plague clinicians faced with the accomplishments of colleagues, particularly those who are willingly working outside of their expertise, unable to practice or with minimal patient care-loads. Other activities related to career and promotion are also stalled, including interviews, presentations, and networking at national meetings, visiting professorships, and lectures.

SOURCES OF REMEDY

I would like to highlight some preferable organizational behaviors. I also want to emphasize that this situation exposes the human toll of what we do and does create an opening for people to be more proactive about their own well-being. We ought to both meet this need and seize this opportunity

Occupational Health

We all watch the news and understand that there is not enough PPE to use in the manner we have always been taught is “best” for this situation. We must continue to advocate for the safest modes of conservation and limited reuse of PPE, industrious test usage, and meticulous workflows to limit PPE waste. Leaders must openly discuss concerns regarding limited PPE and explain the rationale for their organization’s decisions.

Wellness Resources

Copious resources are being developed or offered gratis in areas like physical fitness, mindfulness, entertainment, and childhood education. Collation of these resources is being done by nearly every national organization (eg, American Board of Anesthesiologists, American Society of Anesthesiologists, American Medical Association) and these lists, complemented with existing and emerging local resources, should be provided to clinicians. Low utilization of effective resources should not occur due to a lack of awareness.

Childcare

Emergency childcare is offered through established portals (eg, Care.com) or newly created exchanges (eg, preclinical medical students hoping to help in a tangible way). Departments and organizations should assess the needs of clinicians to establish who is being disproportionately affected by the lack of childcare, especially as we head into periods of “catch-up” work with extended hours when these needs may escalate.

Peer Support

Peer support is established as a particularly effective method of recovery following traumatic events.3,4 Many departments already have peer support programs, but for those who do not or who have nascent programs, it is critical to encourage proactive informal peer support.

Connectivity

Varied methods of virtual connectivity reduce isolation and foster community. These can be in the form of virtual daily briefings, social gatherings, education and instruction (I’ve seen everything from meditation to sourdough bread making), or psychological support sessions. Secure messaging applications (eg, Slack) to rapidly disseminate information and encouragement in a way that is too cumbersome through traditional e-mail can also be helpful in organizing the mountains of new information we must master.

Career Issues

Some are experiencing career-defining periods of rapid academic productivity due to the increase in nonclinical time, while others with primary care giving responsibilities are unable to seize 30 minutes of uninterrupted time and thus find themselves academically stalled. These opportunity disparities must be taken into account moving forward for those in academic medicine, especially when we enter the “catch-up” phase. Offering a grace period of 6–24 months for productivity requirements could address these concerns.

Morale

Beyond all of these areas, discrete and intentional methods of specifically nurturing morale are vital, especially as we head into the arduous task of “catching up.” Express gratitude a lot. Feed people often. Reach out, be extra kind and extra patient. Listen to and laugh with your colleagues. Ultimately, a happy team is an effective team.5

Leadership

Leaders in these times can offer stability in times of great uncertainty. Shanafelt et al6 described the characteristics of leaders associated with lower rates of burnout and found that literally every good leadership practice helped. In a time when people are looking to their leaders more than ever, I would emphasize again a continued commitment to encouraging proactive self-care and utilization of well-being resources according to each’s need. Offer honesty and transparency, knowing how educated those led already are, hopefully avoiding those “gaslighting” moments of false reassurance. Additionally, even the best leaders will have blind spots, so establishing lines of anonymous feedback will yield concerns not previously acknowledged (eg, intermittently monitored, single-question online survey left open as a “comment box”). Finally, just as with our patients, in times of stress, people will often not fully digest everything said to them, so repetition, while sometimes frustrating, is important.

Morale is likely high right now due to astounding camaraderie, but that may be challenged on reentry as we wade into our new normal, requiring redoubled well-being efforts going forward. Proactive morale building and connectivity fostering, coupled with transparent and honest leadership, will be critical.

DISCLOSURES

Name: Amy E. Vinson, MD.

Contribution: This author wrote the entire manuscript.

Conflicts of Interest: A. E. Vinson is the Chair of the American Society of Anesthesiologists’ Committee on Physician Well-being.

This manuscript was handled by: James A. DiNardo, MD, FAAP.

FOOTNOTES

    REFERENCES

    1. Shanafelt TD, West CP, Sinsky C, et al.Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proc. 2019;94:1681–1694.
    2. ACGME. ACGME Response to the Coronavirus (COVID-19). March 18, 2020. Available at: https://acgme.org/Newsroom/Newsroom-Details/ArticleID/10111/ACGME-Response-to-the-Coronavirus-COVID-19. Accessed April 23, 2020.
    3. Shapiro J, Galowitz PPeer support for clinicians. Acad Med. 2016;91:1200–1204.
    4. Vinson AE, Mitchell JDAssessing levels of support for residents following adverse outcomes: a national survey of anesthesia residency programs in the United States. Med Teach. 2014;36:858–866.
    5. Kaplan S, LaPort K, Waller MJThe role of positive affectivity in team effectiveness during crises. J Organ Behav. 2012;34:473–491.
    6. Shanafelt TD, Gorringe G, Menaker R, et al.Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90:432–440.
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