The COVID-19 pandemic brought unforeseen, unprecedented challenges to healthcare staff well-being. It also elicited compassion, a sense of community and belonging, and strong interdisciplinary collaboration at NYC Health + Hospitals/Kings County. Kings County is a Level I trauma center, one of the 11 acute care facilities of New York City Health + Hospitals. Designated a Center of Excellence for stroke, diabetes, perinatal care, AIDS, Parkinson disease, behavioral health, and Sexual Assault Forensic Examiner (SAFE), the facility houses 624 certified beds, employs more than 5,000 people, and serves 2.6 million residents of Brooklyn.
In pursuit of nursing excellence, Kings County implemented a creative and evidence-based wellness program that supports the health and well-being of its most valuable asset—the staff—especially during the COVID-19 pandemic.1,2 The innovative program, in alignment with the Pathway to Excellence® framework, helped sustain a positive practice environment for all of its stakeholders.
Problem statement and process
At the wellness program's inception in 2018, the initial aim was to address: the acute reaction to unanticipated and adverse work-related events; stress; secondary, vicarious, complex, and collective trauma; compassion fatigue; and burnout. The goal was to provide staff with the opportunity to discuss difficult experiences they encounter daily, allowing them to bring their entire selves to work and feel comfortable doing so.1
From the onset of COVID-19 pandemic in 2020, the interdisciplinary well-being steering committee recognized a need to provide real-time identification and response to staff exhibiting signs of stress, burnout, and exhaustion. With nurses at the forefront, the committee decided to expand the capacity of existing well-being program services to meet a wider range of needs.3,4 We implemented a more holistic approach embracing other aspects of well-being, including physical, psychological, socioeconomic, spiritual, and cultural.5
Engagement and collaboration with other disciplines was critical. We welcomed the help of everyone—licensed therapists, psychologists, psychiatrists, RNs, peer counselors, creative arts therapists, dance/art/drama/yoga/meditation instructors, and even finance personnel. This ready-to-respond team provided psychological first aid and education on grief, trauma, stress management, substance use disorder, and healthy coping strategies applicable at work and at home. They facilitated connection to resources such as the employee-assistance program (EAP), mental health services, pastoral care, child mental health support services, and domestic violence assistance.6
With the increasing demand for support, the well-being team met with staff throughout the facility to acknowledge their challenges and provide assistance in building their inner strength and resilience. The team began each day with a meditation to center and prepare themselves for challenging situations. Debriefs and meditations helped the well-being team to let go, feel refreshed, and continue their work the next day.
Implementation of initiatives
Kings County leadership and nursing teams implemented sustainable interventions and strategies to support staff well-being. Wellness rooms were enhanced with soothing music, gratitude cards, comfort snacks, water, and aromatherapy, provided 24/7. Volunteers were available to provide debriefs and informational resources to staff members. In response to the unfortunate passing of colleagues, wellness rooms were expanded to include mourning and remembrance spaces where staff could go at any time to leave photographs and notes on the board, write their name and thoughts in the guest book, light electronic candles, and spend quiet contemplative moments in comfortable chairs. Other implemented well-being initiatives are detailed below.
Meditation hours: Held every Tuesday afternoon in a wellness room, staff can participate in 10-minute meditation sessions facilitated by hospital pastoral staff in collaboration with the well-being steering committee.
Stress, trauma, and resiliency training: Rolled out by nurse trainers, this initiative provided education that leaders and staff could use to address their personal challenges or help support their colleagues and family members. There were 133 participants in the training series.2,7
Wellness rounds: Conducted on units, these check-ins with individuals (1:1) or groups foster ongoing dialogue on wellness and help identify burnout, exhaustion, stress, trauma, and moral distress. Rounds could transition to much-needed debriefs (group or individual).
One-to-one or group debriefs: These impromptu or scheduled conversations (1:1 or groups) with a trained wellness supporter hold a safe space for reflection and processing. During these debriefs, facilitators share informational and therapeutic resources and schedule follow-ups.
Compassion carts: The well-being team rounded with carts to deliver healthy snacks, beverages, and hygiene kits to various areas where staff couldn't leave the unit. Rounding with the compassion cart opened opportunities to engage staff in on-the-go debriefs or check-ins and offer support, resources, and follow-up visits. There were also nourishment stands located outside the units where staff could get a cup of coffee or tea and decompress.
We-Time Wednesdays: These offerings involve creative relaxation and self-care activities for groups in common areas or on the units. Through We-Time, employees from nursing and other disciplines can engage in mindfulness/meditative activities such as beading, painting, coloring, listening to relaxing music, and box breathing.
Dance, movement, and stretch: This is a weekly event with a volunteer artist-in-residence who promotes physical well-being by reducing body tension and exhaustion, as well as inspiring staff to feel mentally, emotionally, and psychologically rejuvenated through movement.
Creative arts sessions: Sessions include beading, knitting, painting, and planting to support compassion fatigue. Evidence suggests art-based interventions are effective in reducing adverse physiologic and psychological outcomes.8
Schwartz Rounds: As a member of The Schwartz Center for Compassionate Healthcare, Kings County conducts Schwartz Rounds sessions for teams that experienced an adverse event at work. Participants listen in a nonjudgmental way to each other's stories about a specific emotionally traumatic case, recognizing similarities and differences across job roles, departments, cultures, religions, and individual beliefs. This fosters and supports empathy, collaboration, and compassion for self and others.9
Boxing COVID-19: Staff can release frustration, anxiety, anger, or fear by “boxing” a cardboard wall.
Memorial services: Memorial services are held in open air spaces within the campus where coworkers and bereaved family members come together to share testimonies, honor, and celebrate the lives of those lost to COVID-19.
Transcendental meditation (TM): This is a simple, natural technique that allows the active-thinking mind to experience quiet levels of thought, promotes deep relaxation, and reduces stress levels. TM can be practiced for 20 minutes on one's own time, twice daily, when sitting comfortably with eyes closed.10 A formal TM training session by a trained instructor is provided to all new participants.
Recognition events: Kings County sees recognition as an essential element of a positive practice environment and joy at work. Many recognition events take place throughout the year. For example, each year the organization hosts a volunteer recognition event where nursing staff who render volunteer and community work are recognized, honored, and given the opportunity to share their personal stories and experiences.
Nursing leaders' wellness retreats: These events create the environment to build meaningful connections, strengthen relationships among leaders, and model a culture of wellness. We conduct separate retreats for nurse leaders (directors of nursing and assistant directors of nursing) and for nurse managers/assistant nurse managers. Topics include work-life balance, understanding a culture of wellness in the healthcare community, how gratitude improves overall well-being, identifying and addressing stressors, modeling self-care, showing how vulnerability and emotional availability are strengths that benefit patients and staff, and bringing more meaning and personal value to work. Nurse leaders also support their staff to take time off or use their annual leave days to rest and rejuvenate or spend more time with their families.
Outcomes and ongoing interventions
The latest research underscores the need for, and the success of, well-being interventions. The World Health Organization defined burnout as “a disease of the 21st century” and the Occupational Safety and Health Administration declared stress a workplace hazard.11-13
From 2021 through 2022, the demand for Kings County's well-being support services continued to grow and strategies evolved. Our focus continued to prioritize addressing burnout, compassion fatigue, emotional pain, trauma, moral injury, and distress.14 Nurse supervisors and unit managers showed sensitivity to the well-being needs of their staff. They generated the largest number of referrals for both 1:1 peer support and group debrief sessions in the past 2 years. Managers allowed staff to attend group well-being events by arranging coverage on the units, even if it was only for 15 minutes. According to staff, this is often enough for them to feel rejuvenated and able to reset.
It's vital to regularly evaluate our wellness initiatives for their value and usefulness to staff, and based on the findings, initiatives are revised to meet current staff needs. Some feedback and evaluation findings on select well-being initiatives are included below.
Dance, movement, and stretch: We've learned that brief sessions (intervals of 10 to 15 minutes) are more realistic for busy nurses working on the units; therefore, sessions would turn over every 15 minutes. Participants articulated that the activity greatly reduced their stress levels.
Schwartz Rounds: Some comments in postactivity surveys included:
- “I have a new appreciation of my colleagues from other disciplines.”
- “I feel more compassion toward patients and families.”
- “I was on the unit during this event which I don't think I will ever forget. I am very appreciative that this space was created to speak about/process this.”
- “I feel greater support for my efforts to provide care in difficult emotional and social situations.”
- “I have better sense of belonging to a team.”
We-Time Wednesday creative arts sessions: Participants expressed relief from stress after the activity stating:
- “It's okay to take time for yourself.”
- “This activity reminds me that no matter how busy we are, we still have time for ourselves to unwind and be creative. I enjoyed the activity and look forward to more of this.”
Support group sessions: A team member wrote: “Staff are able to move from fear, helplessness, anger, and perceived defeat, to celebrating their strength, unity, positive impact, and successes,” and “I had an over-an-hour long group processing session with four nurses who are recovering from COVID themselves, grieving for the loss of their patients/colleagues/personal relations, and coping with changes in their workplace—people felt comfortable enough to shed tears in front of me and one another, and through the group they are beginning to rely on each other as their support system.”
TM: Based on survey feedback from those who received the training, 100% reported, “I have experienced a greater clarity of mind,” and 83% reported, “I have less fatigue.” A participant commented, “It has taught me more patience and compassion. I have more empathy for others and listen more attentively to what others tell me. Instead of reacting immediately, I learned to just listen and acknowledge what they say.”
Mostly from what proved to be effective and appreciated interventions during the pandemic, together with other evidence-based approaches, we've developed a tool kit that's now ingrained into what we do every day to support staff well-being as a Pathway to Excellence-designated organization. Table 1 shows support programs and strategies provided as part of the well-being tool kit.
Table 1: -
Well-being support programs and strategies
Dance, movement, and stretch
Movement therapy and mindfulness
Stress, Trauma, and Resiliency Training
Referrals to Behavioral Health services and the EAP
Child mental health services
Domestic violence assistance
Financial personnel support
Meditation hours with pastoral staff
Pastoral care services
Creative arts sessions
Support for cultural groups affected by disasters
Pathway to Excellence Nursing Volunteer Appreciation Day (honoring volunteer services provided within cultures and communities)
Pathway to Excellence
Kings County achieved Pathway to Excellence designation in October 2022. The Pathway standards of shared decision-making, leadership, and well-being are evident and instrumental to the culture and success of the initiatives referenced in this article. Through shared decision-making, the well-being steering committee members plan and implement initiatives. Organizational leaders are provided tools and training to prepare them to support their teams for their well-being needs.
A positive practice environment
In keeping with Pathway to Excellence standards, Kings County integrates employee well-being and resilience into our organization's strategic and operations plan. Senior and nursing leadership serve as educators, coaches, and role models for well-being. Led by a nurse, our multidisciplinary steering committee team spearheads and collaborates with the hospital community to implement and evaluate well-being initiatives. With the Pathway to Excellence Program, Kings County is committed to creating and supporting a positive practice environment: an environment in which nurses are empowered, their values are validated, interprofessional collaboration is a norm, and worker health and well-being are prioritized.