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The Management Moment

The Public Health Worker Mental Health Crisis—A Major Leadership Challenge

Wiesman, John DrPH, MPH; Baker, Edward L. MD, MPH

Editor(s): Baker, Edward L. MD, MPH, Column Editor

Author Information
Journal of Public Health Management and Practice: January/February 2022 - Volume 28 - Issue 1 - p 95-98
doi: 10.1097/PHH.0000000000001476
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Context

As we move into the fall of 2021, public health leaders are faced with a dual crisis. First, responding to the evolving challenges of the COVID-19 pandemic continues to be “job one” for most public health leaders. Now, a parallel crisis is emerging as the public health workforce experiences unprecedented levels of poor mental health as they experience “COVID fatigue,” burnout, and a range of mental health challenges. This workforce mental health crisis has received increasing attention1 as its protean manifestations present leadership challenges that must be addressed if the public health workforce, our most valuable resource, is to be supported, nurtured, and thrive into the future. In this column, we build on a prior Management Moment column on the subject of “COVID fatigue” written 1 year ago,2 which provided initial insights into and suggestions for leader actions, and offer further suggestions based on recent research and shared experience.

Dr Cynthia Morrow3 and others4,5 have applied the concept of “moral injury,” a term that refers to “the psychological, behavioral, social, and/or spiritual distress experienced by individuals who are performing or exposed to actions that contradict their moral values,” to characterize this mental health crisis. It is distinct from “burnout.” While the concept of “occupational moral injury” may have originated with combat medicine and treatment of war veterans, the COVID-19 pandemic has brought attention to its applicability to the field of public health in which many workers are under constant stress working in an atmosphere characterized by distrust and threats.1 In this regard, “moral injury” results from systemic forces that compromise the ability of public health professionals to serve their communities.

The Scope of the Crisis

A recent CDC MMWR article6 provided urgent findings of the scope and scale of this crisis. The article documented rates of depression, anxiety, posttraumatic stress disorder, and suicidal ideation among 26 174 state and local public health workers; 53% of those surveyed reported at least one adverse mental health condition in the preceding 2 weeks. Among other findings, 8.4% reported suicidal ideation. Long work hours and inability to take time off were cited as factors contributing to mental health conditions. Among other suggestions, the authors pointed to the desirability of leaders acting to address the crisis by expanding staff size, addressing need to reduce long work hours, and encouraging use of employee assistance programs.

Another study7 of current public health workers revealed that 66% reported burnout when surveyed in August and September 2020. As a result, fewer workers planned to remain in the public health workforce for 3 or more years. The authors concluded that “pandemic-related burnout threatens the US public health workforce's future when many challenges related to the ongoing COVID-19 response remain unaddressed.”

The Role of Public Health Leaders

Acknowledge that a mental health crisis exists

In the case of the public health workforce mental health crisis, leaders must begin by acknowledging that a crisis exists with far-reaching consequences. To begin the process of responding to any crisis, leaders must establish a “sense of urgency”8 by emphatically stating that a crisis exists and demands immediate attention. Along with establishing a sense of urgency, public health leaders must enlist the involvement of those who share this sense of urgency and their governing bodies to form a “guiding coalition” in order to implement a shared vision and immediate action plan. As part of this response, federal agencies should immediately work with ASTHO and NACCHO to aggressively mobilize the public health system to address and support the public health workforce's mental health needs, working synergistically with promising steps now underway.9,10

Forge a collective mindset

In addition to acknowledging that a crisis exists, leaders have an opportunity to help others frame the issues that may lead to constructive action. In our view, leaders may be able to forge a mindset within which concerted thought and action can occur. This mindset can focus around (1) restoring routine, (2) fostering recovery, and (3) promoting renewal of spirit and commitment.

Restore routine and set limits

Among the many challenges faced by the workforce during the pandemic, disruption and elimination of daily routines, both at work and at home, have negatively impacted public health workers' resilience and stamina. Leaders should prioritize the establishment of healthy workplace routines. For example, the length of the “normal workday” can be reexamined. Workers can be asked, “What does your optimal work week look like?” and “What practices should we revisit or reinforce that might work for you (eg, avoiding late night e-mails or extensive weekend ‘catching up’)?” In that regard, leaders must model behaviors that restore healthy work routines that offer a respite from the “always-on” dynamic of the COVID-19 response. Leaders can encourage the creation of institutional norms in which limits are set, monitored, and supported as workers transition into the future of public health work.

Foster recovery

To foster the recovery process, leaders can encourage individuals to acknowledge their own personal needs and to seek support and assistance. That can start with leaders intentionally sharing their needs and how they are getting support. This is an opportunity to display authentic leadership. As the term “posttraumatic stress disorder” indicates, the prolonged effect of continued stress may persist in various forms long after the initial sources of stress have mitigated or subsided. Now that medical research is focusing on “long COVID” as a persistent syndrome characterized by decreased stamina, “brain fog,” and other symptoms, one may wonder whether the current mental health conditions experienced by public health workers may result in latent negative impacts on functioning within the workplace for months to come. To foster short-term recovery and prevent longer-term functional difficulties, access to professional assistance (eg, mental health professionals, employee assistance programs, beefed up work wellness programs, and other employer-sponsored resources) hold potential benefits.

Promote renewal of spirit and commitment

As the COVID-19 response has evolved, public health workers have tirelessly and courageously contributed to the daunting tasks of protecting the communities that they serve. As noted in prior Management Moment columns, they have provided situational awareness, made difficult decisions in the face of uncertainty, communicated with the public, struggled to manage their energy, and learned from the lessons of experience.2,11 These stellar contributions to our collective health must be acknowledged and recognized. Thus, meaningful celebrations of the “small victories” to which public health workers have contributed may play a role in building cohesion and improving morale.

Furthermore, leaders must model ways in which they themselves seek occasions to restore their own spirit (eg, by finding ways to simply find joy in everyday life) and to reflect on their own commitments to serving the health of the public. Obviously, this step is very difficult, given the continued COVID-19 challenges with ever-increasing quantities of work demands. Nevertheless, despite these unrelenting demands on the leader's time and energy, the quality of work suffers if leaders do not find ways to foster their own renewal of spirit and model these behaviors for others to emulate.3

Implement best practices

To assist in this process, we offer a few practical tips for public health leaders committed to addressing the mental health crisis in the public health workforce. Some of these tips may fit into an attempt to recapture fundamental best practices for a healthy workplace culture that served well prior to the COVID-19 pandemic or were lacking before the pandemic but to which we are now committed.

  1. Manage time/set limits: Since meetings are often a major time commitment, we refer to our suggestions from an earlier Management Moment column2 to emphasize that meetings should have a clear purpose, an agenda that tracks the purpose (with specific time limits on components of the meeting), and be scheduled for as little time as needed. Rather than the typical 1-hour meeting, leaders should encourage scheduling meetings lasting for 15, 25, or even 42 minutes; meetings should start on time and end early when possible and not run over! And when feasible, have walking meetings. Each day should have time set aside to take stock of daily tasks as well as time to think (a rare commodity). Finally, workers should be encouraged to “uninvite themselves” to meetings that are of low priority without the “fear of missing out [FOMO].” Setting limits on how time is spent is an essential workforce skill that must be cultivated to combat burnout.
  2. Set priorities: Each day presents more work opportunities and tasks than can be reasonably accomplished. All too often public health workers fail to distinguish between the “must dos,” “the good to dos,” and the “nice to dos.” As a result, everything seems to be equally important and thus overwhelming. COVID fatigue then results from a sense of being overwhelmed with too much to do and not enough time and energy to “do what needs to be done.” We advocate that public health leaders encourage staff to set aside time regularly to list and then categorize work activities into these 3 categories: “must dos,” “good to dos,” and “nice to dos.”2 Obviously, the criteria for deciding what goes where will vary and the process will be challenging. However, failing to adopt a priority setting routine will further contribute to the mental health challenges faced by public health workers. Finally, cultivating the “power of a positive no”12 should become common practice among overloaded public health workers.
  3. Celebrate small successes: Simply stopping to celebrate small successes can be encouraged and orchestrated by leaders. Doing so in an intentional, meaningful, and regular way by leaders can promote a sense of shared pride and shared purpose throughout the organization. Current virtual work arrangements do represent a barrier for celebration and will require creative approaches. As more in-person situations arise, time set aside to celebrate can become a more tangible reality.
  4. Seek support: The mental health challenges we describe here are too often faced alone. We strongly advocate that all public health workers (not just those suffering from the mental health challenges noted here) commit to supporting one another as the lingering effects of responding to the pandemic continue to play out. Since each situation is different, we can only suggest that leaders themselves model behaviors needed for their own recovery and restoration and doing so publicly, while fostering an organizational culture that affirms the value of restoration and recovery.
  5. Develop a code of conduct: Leaders should communicate consistently, through word and deed, a set of behaviors needed to address the mental health crisis that we describe here. In some instances, a formal code of conduct may be useful as a tool to specify and reinforce those desired workplace practices that can contribute to improved worker mental health.
  6. Monitor self and the organization: Leaders might also encourage a more formal approach to self-monitoring by individual workers and, if possible, create aggregate measures that can be monitored over time. As we know, “what gets measured gets done.” So, as in other contexts, public health leaders may wish to create an index or a tool that can be used over time to monitor progress in addressing these mental health challenges. In doing so, organizations might encourage workers to end each day by answering a few questions such as: “What was your toughest activity today?” “What was one thing you did really well?” “What is one thing you will do to take care of yourself?” or “What can you do to support your peers?”9 By aggregating responses to these or other questions, leaders may “take the pulse of the organization” with respect to the organization's collective mental health status.

Conclusion/Summary

No simple summary or set of suggestions can do justice to the complexities of the moral injuries and mental health crisis being experienced by the public health workforce. Nevertheless, public health leaders can play a very positive role by first acknowledging the nature and significance of this crisis, followed by advocating for and modeling those behaviors that may contribute to restoring routine, fostering recovery, and promoting renewal of spirit and commitment. Clearly, addressing this challenge will be no less daunting than addressing the extraordinary challenges of the COVID-19 response itself. In doing so, however, public health leaders can renew the sense of dedication and commitment to service that has characterized the public health workforce for decades and will be central to success for many decades to come.

References

1. Baker M, Ivory D. Public health crisis grows with distrust and threats. The New York Times. October 18, 2021:1, 14.
2. Baker EL, Irwin R, Matthews G. Thoughts on adaptive leadership during the COVID-19 pandemic. J Public Health Manag Pract. 2020;26(4):378–379.
3. Morrow C. Moral injury on the frontlines in public health: balancing the needs of our communities and ourselves. J Public Health Manag Pract Blog. Posted August 19, 2021. https://jphmpdirect.com/2021/08/19/moral-injury-on-the-frontlines. Accessed October 17, 2021.
4. Doheny K. Moral injury: pandemic's fallout for health care workers. https://www.webmd.com/lung/news/20210201/moral-injury-pandemics-fallout-for-health-care-workers. Published 2020. Accessed October 17, 2021.
5. American Psychiatric Association Committee on the Psychiatric Dimensions of Disaster and COVID-19. COVID-19 pandemic guidance document: moral injury during the COVID-19 pandemic. https://www.psychiatry.org/File%20Library/Psychiatrists/APA-Guidance-COVID-19-Moral-Injury.pdf. Accessed October 17, 2021.
6. Bryant-Genevier J, Rao CY, Lopes-Cardozo B, et al. Symptoms of depression, anxiety, post-traumatic stress disorder and suicidal ideation among state, tribal, local and territorial public health workers during the COVID-19 pandemic. Morb Mortal Wkly Rep. 2021;70(26):947–952.
7. Stone KW, KIntzinger KW, Jagger MA, Horney JA. Public health worker burnout in the COVID-19 response in the US. Int J Environ Res Public Health. 2021;18(8):4369.
8. Kotter J. Leading Change. Boston, MA: Harvard Business Review Press; 1996.
9. National Association of County and City Health Officials. Upstream approaches to build resiliency: organizational and leadership strategies [webinar]. https://www.naccho.org/uploads/downloadable-resources/Upstream-Approaches-to-Build-Resiliency.pdf. Published August 24, 2021. Accessed October 13, 2021.
10. Association of State and Territorial Public Health Officials. Leading in public health: COVID-19 and PTSD in the workforce: a conversation with Sebastian Junger. https://www.astho.org/events/insight-and-inspiration-series. Published October 20, 2021. Accessed October 20, 2021.
11. Keen PK, Gilkey R, Baker EL. Crisis leadership—from the Haiti earthquake to the COVID pandemic. J Public Health Manag Pract. 2020;26(5):503–505.
12. Ury W. The Power of a Positive No. New York, NY: Bantam Books; 2007.
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