What began as a tug of anxiety was soon replaced by fear. This was serious. The hospital entrances were all closed, the halls quiet. When I first donned an N95 mask, then added a surgical mask and a visor, it hit me: This was not a drill. I didn’t realize it at the time, but my hospital would become an early epicenter of the COVID-19 pandemic, where my fear would be met by heightened pride and deepened respect for my coworkers.
These are the reflections of Mary Ann, a Connecticut hospital nurse technician and one of the millions of healthcare workers in the United States who have shown up for every shift through the pandemic, staying focused on their patients and taking care of each other while also maintaining life at home.
The COVID-19 virus has killed hundreds of thousands of people—including many healthcare workers—and has shaken the confidence of some of the highest- performing teams. It has injured the morale of many clinicians, half of whom already were experiencing burnout (Wan 2019). Healthcare workers are accustomed to working in high-pressure situations that can lead to stress and burnout under normal conditions, but even the best teams are not immune from the impact of this pandemic.
A Dizzying Pace of Change
In a matter of a few short months, the world changed. The United States confirmed its first COVID-19 case in January 2020. The shock to the economy, schools, industries, and even toilet paper supplies was immediate and massive. It profoundly altered day-to-day lives and routines and became a global traumatic experience with no end in sight.
Some healthcare organizations had time to prepare before they experienced the full effects of the pandemic. A few faced a steady burn, while many others experienced a tectonic shift that rocked the ground beneath their feet. The pandemic called into question our nation’s readiness to protect our medical staffs with the most basic personal protective equipment (PPE), even as we required new levels of stamina and endurance from them, day in and day out. It also brought to a palpable new level the anxieties of life-and-death decisions and the daily ethical considerations surrounding limited ventilator resourcing, PPE distribution, and do-not-resuscitate orders. The new reality was marked by strict protocols for entry to facilities, advanced deployment of telehealth, reduced or eliminated patient visitation, and more. In May, health systems began to resume elective procedures and ambulatory visits, with an extraordinarily strained and stressed workforce, then pulled back in July in the face of another surge.
Introducing Compassion Tribe
At the Healthcare Experience Foundation (HXF), our core value is to create environments in which every person can both deliver and receive the best healthcare experience. Recognizing the profound and uncertain impact of the coronavirus and receiving many requests for assistance, we mobilized a partnership with the Maryland Healthcare Education Institute (MHEI) in late March to provide resources to the healthcare workforce. In just four days, HXF and MHEI developed and deployed a program called Compassion Tribe as a virtual support community during the pandemic. The program includes tips, resources, and tools for organizations as well as individual leaders, staff, and physicians.
During Compassion Tribe’s real-time, interactive video-conference sessions, participants share their emotions, concerns, fears, and hopes. Some sessions have been celebratory (sharing how one hospital plays “Here Comes the Sun” over its speaker system when a patient is successfully extubated). In other sessions, the tone has been somber (describing the difficulty in managing families when the no-visitation policy is in effect). These Compassion Tribe forums provide a special opportunity for a peer-group experience encompassing a variety of organizations and roles where participants can share experiences and leading practices, look for solutions, and find validation for their emotions and assurance that they are doing their best in a very bad moment. For example, during one forum session in which a nurse shared the pain of managing six ventilator patients in an overcrowded emergency department with no family to support them, a leader described the anguish of furloughing hundreds of staff.
The most prominent requests for support from forum participants have revolved around the following themes:
- Restoring resilience
- Overcoming emotional exhaustion
- Leading through change
- Reducing blame and incivility
- Building trust
- Engaging in difficult patient and family communication
- Managing stress
- Reducing anxiety
- Motivating caregivers
- “Communicating up” to keep leadership informed
- Managing conflict
- Maintaining momentum and engagement
Feedback from forum session participants has enabled HXF and MHEI to develop targeted resources that respond to requests for assistance—requests that are likely repeated at many other organizations. (Free “rapid learning bites” based on the most frequently requested topics are available at www.compassiontribe.org.)
Leaders must address these workforce wellness issues now and devote purposeful energy to increasing staff resilience to both survive and move forward. As COVID-19 continues to wreak havoc with operations, fear left unchecked will only continue to exacerbate stress. The future of healthcare systems depends on engaged workforces that are able to provide their patients with excellent care.
Tackling Workforce Concerns
In our experiences over the past several months, we at HXF have seen several common themes emerge across the healthcare workforce. These themes are present in rural hospitals, for-profit health systems, large academic medical centers, long-term care facilities, hospices, mental health hospitals, and clinics alike. They transcend the continuum of care. Most of the themes reflect anxieties that are intensified by information (and misinformation) overload, and they stem from several concerns:
- Timeline. How long will this pandemic last?
- Personal safety. How will the pandemic affect my personal health and the health of my loved ones?
- Job security. How will a loss in income upend my life and the lives of my family and colleagues?
- Added pressures. How can I balance new daily demands at work with my home life?
Despite the disruption to the daily sense of normal, stories of positivity have emerged. The stories shared in Compassion Tribe forums and our interviews with healthcare leaders reflect rededication to purpose, appreciation of leadership, teamwork, rapid innovations, pride, and community respect and support. We have seen the strongest teams and health systems overcome great obstacles by embracing a culture of gratitude and appreciation for innovation in decision making. We have learned and shared new ways of teaming that restore professionalism and nurture personal and professional relationships created during the shared experiences of this crisis.
In fact, the positive stories are countless—reports of sacrifice and staff fully showing up every single day to care for others. As Mary Ann, the Connecticut nurse technician, explained, “It is a scary time, and yet we are watching out for each other on the floor in ways we never did before COVID-19.” Positive emotions (e.g., joy, inspiration, gratitude, hope, love) need to be present in multiples to mitigate the negative effects of a crisis. When leaders, staff, and clinicians can intentionally seek out the silver-lining moments and find positive emotions—even if they must dig really deep—the process can support resilience against any fears.
Fortifying for the Future
Our forums revealed a call for resilience, but what is resilience? It is the process of adjusting well in the face of adversity, trauma, tragedy, or challenging life situations (American Psychological Association 2020). Further, it is essentially the “stretchy piece between burnout and engagement that keeps pulling us back to the center and hopefully keeps us grounded” (Mayzell 2020, p. 5).
Working toward resilience does not mean that we ignore troubles or stress. Rather, it means we prepare ourselves to overcome troubles or stress. When achieved meaningfully and executed successfully, preparedness can serve as an automatic reflex. Training for preparedness is as simple as practicing a positive frame of mind. When we sustain a positive frame of mind in healthcare, we think more clearly, display agility, and retain focus on solutions—all essential for the safest, highest-quality care.
Healthcare organizations are uniquely complex, human systems and require various strategies to fortify resilience. Institutional and individual safety nets are necessary for both the COVID-19 crisis and beyond. Attention to the following domains will help healthcare leaders manage the human effects of this pandemic and prepare for future crises:
- Caring and supportive relationships. Prioritize relationships that lift you up. Trust and respect form the foundation of the best teams.
- Meaningful plans. Remind yourself of the why—the purpose of your work. Simple practices such as opening meetings with a patient or employee story can help maintain professional focus and connection to mission through the pandemic.
- A positive view of yourself. Projecting confidence in your unique abilities without arrogance is a powerful way to show up as your best self each day.
- Communication and problem-solving skills. Succeeding in crisis can compel you to find solutions quickly and effectively. Know your dominant style and grow in your comfort to adapt to the style of others. Find shared meaning instead of pointing blame.
- Control of feelings and impulses. Give yourself time and space to think. Acting on feelings is a choice. Assume positive intent in other people.
- Self-care. In an emergency, you must put your oxygen mask on first. If you do not take care of yourself as a leader, you cannot bring your best to your employees and patients, make sound decisions, and respond to their concerns with compassion.
Even in the midst of a crisis, you as a healthcare leader can start to shore up your staff’s—and your own—resilience. Whether followed weekly, daily, or on every shift, the following leadership strategies can support an engaged, productive, and safe workforce.
Prep Your Workforce
“We don’t rise to the level of our expectations; we fall to the level of our training,” observed the Greek poet Archilochus.
In healthcare, we train for emergencies. We practice drills, tasks, and incident command system protocols; we secure supplies and coordinate responses with community agencies. However, we have not adequately prepared our workforce for COVID-19. We have undervalued the practices, training, and repetition required to handle workforce anxiety, coping, and burnout, as well as the pace that is necessary to innovate. To move forward, we must seed great teams that build on their strengths and recognize their vulnerabilities.
Senior leadership must face the task of restoring any trust lost during the pandemic. To that end, amplify your visibility across shifts to reestablish team unity. Create aligned messaging and demonstrate an interest in learning about and connecting personally with employees. Prepare to hear the good messages as well as the tough ones. Tough messages are powerful because they let you know that employees feel safe speaking up. Blind spots exist at all levels in the organization. Seek them out.
Cultivate Effective Managers
Management (notably clinical management) must be developed to maintain staff engagement, identify early warning signs and symptoms of problems, and convey communication that reflects the senior leadership team’s intent—all especially vital skills during a crisis. These skills must be practiced continuously, because trust is hard to build in the throes of a crisis.
Any honest assessment will reveal hidden conflicts or fears. Seeking to understand, acknowledging other perspectives as legitimate, and building shared expectations are essential at all levels of the organization. Social distancing and PPE complicate interactions, so it is necessary to work more diligently to demonstrate tone and intent.
Incivility jeopardizes culture as well as employee and patient safety. Healthy teams share five common attributes: psychological safety, trust, respect, confidence, and communication. If these attributes have been compromised during the pandemic, identify the behaviors that demonstrate excellence and those that jeopardize teamwork.
Crises open the window for powerful moments of change. Acknowledge your starting point, be intentional about the goals and aspirations for the organization, and be transparent with expectations moving forward.
Review What Works, and Why
At every healthcare organization, there are success stories of innovation and speed in decision making during the pandemic. Be intentional in documenting and deconstructing the rapid pace of progress. I have heard so many people say, “We did X, which normally would have taken us years.” Or, “We were able to get a decision on Y, which normally would have gotten stuck in our bureaucracy.” The ability to refer back to and replicate such successes can be helpful when similar challenges are faced in the future.
Recommit to Hiring the Right People
When making future staffing decisions, consider the profiles of those who fully showed up during the pandemic with a generous spirit, went above and beyond, and demonstrated compassion with patients and team members. Make certain that those you hire next continue to lift up and restore your entire team.
After any storm passes, we can choose the lens through which we see our surroundings. Do we focus on the physical destruction where cracks gave out under the pressure and force of the storm? Or do we choose instead to see the strength of what remains—the structures that did not bend or sway but instead held steadfast in unsettling times?
The millions of healthcare workers in the United States have a tough road ahead. Leaders face the daunting task of steering the journey while caring for the care providers. The way to start is by showing gratitude. Personally, I am thankful to all of the frontline workers who risk their lives every day to save others, and I am most grateful to Mary Ann—my mother—who has remained a steadfast symbol of their courage that we can all emulate and support in the face of uncertainty.