Issue:
A health care organization’s ability to respond to the stresses and strains of providing adequate patient care during a crisis — such as the COVID-19 pandemic — is reliant on its workers’ psychosocial well-being. The anxiety, stress, fear and associated feelings experienced by health care workers during challenging times are real, justifiable, and do not indicate weakness or incompetence. To mitigate and respond to the psychological toll of crises such as the COVID-19 pandemic, it is critical that health care organizations have systems in place that support institutional and individual resilience.
The predominant stressors reported by health care workers during the COVID-19 crisis were insufficient resources and lack of personal protective equipment (PPE); fears of infection; feelings of isolation from family; and harassment from the community for enforcing strict protective measures to reduce the spread of the virus.
Other conditions or reactions related to increased health care worker stress were:
- Physical isolation from loved ones and colleagues.
- Anger, anxiety and fear from lack of PPE.
- Burnout, feeling overwhelmed, a sense of helplessness and loss of normalcy.
- Moral distress from experiencing conditions incongruent with normal professional and ethical responsibility.
- Fear of infection and transmission to loved ones.
- Fatigue from longer shifts and altered sleep patterns.
- Pressure to maintain up-to-date knowledge and track fluctuating policies and procedures.
- Physical strain and injury from prolonged use of PPE.
- Physical exhaustion, dehydration, eating unhealthy foods or eating at irregular times.
- Secondary traumatic stress or symptoms resulting from exposure to another’s trauma.
- Grief from witnessing death and suffering of patients and colleagues.
- Reduction in force from staff falling ill, layoffs and furloughs.
- Closure of services and financial strains on the organization.
- Risk of blame, harm or harassment from the community.
- Bombardment from continuous news and social media coverage of the COVID-19 pandemic.
Removing barriers to seeking mental health care
Adding to these stressors on the health care worker is the perception that seeing a mental health professional could adversely affect their career if they are asked about a previous history of mental health issues during the credentialing or licensing process. As a result of the strain put on the health care workforce during the COVID-19 pandemic, on May 12, 2020, The Joint Commission issued a statement affirming its support for the removal of any barriers that inhibit clinicians and health care staff from accessing mental health care services, including eliminating policies that reinforce stigma and fear about the professional consequences of seeking mental health treatment. The statement confirms that The Joint Commission does not require organizations to ask about a clinician’s history of mental health conditions or treatment, and supports the recommendations of the Federation of State Medical Boards and the American Medical Association to limit inquiries to conditions that currently impair the clinicians’ ability to perform their job.
Safety actions to consider:
All team members in health care organizations are impacted to some degree by a crisis like the COVID-19 pandemic. It is critical that health care organizations support all staff through proactive planning and providing systems and infrastructure to support psychosocial well-being and stress management before, during and after a crisis. While the impact on doctors and nurses on the front lines is clear, the impact on other team members is often overlooked. These members include environmental and food service workers, imaging techs, respiratory therapists, pharmacists, physical and occupational therapists, security personnel, social workers, and chaplains, among others.
Below are strategies that health care workers and leaders can take to promote psychosocial well-being, manage stress, and strengthen individual and institutional resilience during times of crisis and recovery. As needs may vary among individuals, respect differences in yourself and colleagues.
Health care worker: Strategies to support oneself
- Practice self-care and engage in healthy coping strategies. Eat healthy foods and exercise regularly. Employ stress-management strategies — spiritual, physical, mental or emotional — that have worked for you in the past.
- Take microbreaks. Take short periods of respite and relaxation from patient care to recharge the body and mind.
- Practice sleep hygiene. Strive for at least seven hours of sleep to counteract fatigue.
- Partner with colleagues. Engage in a buddy system at work to cross-monitor well-being and provide support when needed.
- Stay connected. Stay in regular contact (while practicing social distancing) with friends and family to mitigate isolation.
- Stay informed of reliable information. Seek up-to-date information from reliable sources. Inaccurate information can increase stress and worry.
- Check in with yourself. Self-monitor for increased and prolonged symptoms of depression, stress or hopelessness and seek professional support, if needed.
- Resilience in post-crisis recovery. Continue to employ strategies to support each other during recovery and include debriefing sessions unit by unit to facilitate conversation regarding lessons learned and improvement opportunities for crisis management. Individually, staff should remain mindful of how they are feeling, continue to engage strategies for managing stress, and nurture community among peers toward effective reintegration.
Managers and leaders: Strategies to support your staff
- Communicate regularly. Keep staff abreast of important information. Ensure communication reaches less visible service lines within an organization. Strategies may include conducting communication rounds, holding five-minute debriefs at the end of shifts, and having a central access point to locate and retrieve information. Keep communication honest, sincere, and empathetic. Ensure information is current and accessible to help demystify rumors.
- Model behaviors that promote self-monitoring. Managers and leaders can encourage reflection of one’s own well-being by modeling such behaviors. For instance, before shift changes, leading three minutes of reflection.
- Encourage sharing of concerns. Create a psychologically safe environment and means by which staff can openly share concerns and questions with leadership. Acknowledging and listening to staff concerns even when answers may not be known will help build transparency and mutual trust. Express gratitude for their work, flexibility and sacrifices, and empower staff to share strategies toward improvement and problem-solving. Provide prompt follow-up when possible.
- Demonstrate value of staff. Communicate expectations compassionately and in a non-threatening and non-punitive manner. Promote equity in distribution of supplies. Respect staff’s time off, allowing them to disconnect and recharge. Attempt to reduce extraneous alerts and emails to limit information overload.
- Orient staff to psychosocial resources. Educate staff on available psychosocial support resources and services and how to access them. Train staff on the basics of psychological first aid.
- Proactively monitor and provide active outreach. Engage staff regularly to recognize and respond to emerging issues. Consider deploying trained peer support teams to provide outreach and psychological support.
- Encourage peer support. Create partnerships among colleagues (e.g., pairing experienced with inexperienced staff) to increase support, cross-monitoring for stress, and to support work functions and compliance with procedures.
- Share positive feedback. Incorporate ongoing ways to share positive or encouraging news with staff, such as kudos to staff members and uplifting patient care stories.
- Adapt staffing where possible. Monitor staff’s psychosocial well-being and rotate staff from higher- to lower-stress functions, if possible.
- Resilience in post-crisis recovery. Following the crisis, there will be a period of readjustment as staff are reintegrated and operations restored. Stress responses may persist among staff with continued fear of exposure and fatigue from prolonged stressful conditions. It is important that health care organizations have a systematic plan and infrastructure in place to continue to monitor and adapt to emerging issues and areas of need as resources may need to be reconfigured rapidly.
Resources:
- American Medical Association. “Managing mental health during COVID-19.” Apr. 3, 2020.
- Centers for Disease Control and Prevention. “Emergency responders: Tips for taking care of yourself.” Emergency Preparedness and Response resources. Mar. 19, 2018.
- World Health Organization. “Mental health and psychosocial consideration during the COVID-19 outbreak.” March 18, 2020. WHO: Geneva. WHO reference number: WHO/2019-nCoV/MentalHealth/2020.1
- U.S. Department of Veterans Affairs. National Center for Posttraumatic Stress Disorder. “Managing healthcare workers’ stress associated with the COVID-19 virus outbreak.” March 2020.
- National Academy of Medicine. “Strategies to support the health and well-being of clinicians during the COVID-19 outbreak.”
- The Joint Commission. “Mental wellbeing for healthcare workers during the COVID-19 pandemic.”
- American Medical Association. “Caring for our caregivers during COVID-19.” Apr. 22, 2020.
- Hittle BM, Wong IS, and Caruso CC. “Managing fatigue during times of crisis: Guidance for nurses, managers and other healthcare workers.” NIOSH Science Blog. Apr. 2, 2020. Centers for Disease Control and Prevention.
- Wu AW, Connors C, and Everly GS Jr. “COVID-19: Peer support and crisis communication strategies to promote institutional resilience.” Annals of Internal Medicine, Apr. 6, 2020. doi:10.7326/M20-1236
- U.S. Department of Labor. Occupational Safety and Health Administration. Guidance on Preparing Workplaces for COVID-19. OSHA publication no. 3990-03 2020.
- Agency for Healthcare Research and Quality. “Debriefing for clinical learning.” PSNet, Patient Safety Primer. September 2019.
- U.S. Department of Veterans Affairs. National Center for Posttraumatic Stress Disorder. “Types of debriefing following disasters.”
- U.S. Department of Labor. Occupational Safety and Health Administration. Critical Incident Stress Guide.
- Shanafelt TD, Ripp J, Brown M, and Sinsky CA. “Caring for healthcare workers during crisis: Creating a resilient organization.” April 2020. American Medical Association.
- Centers for Disease Control and Prevention. Stress and Coping. Coronavirus Disease 2019 (COVID-19) resources.
- World Health Organization, War Trauma Foundation and World Vision International. Psychological First Aid: Guide for Field Workers. 2011. WHO: Geneva.
- American Psychiatric Nurses Association. “Managing stress & self-care during COVID-19: Information for nurses.” APNA: Falls Church, VA.
- Institute for Healthcare Improvement. COVID-19 Guidance & Resources. IHI: Boston, MA.
- U.S. Department of Health & Human Services, Assistant Secretary for Preparedness and Response. Individual resilience: Factsheet for responders. April 10, 2015.
- American Association of Critical Care Nurses. AACN Position Statement: Moral Distress in Times of Crisis. March 23, 2020.
Other resources:
The Joint Commission: Coronavirus (COVID-19) Resource webpage provides information to support health care organizations and professionals on the frontlines of the COVID-19 pandemic.
Hospital Peer-To-Peer Support: Resilience in Stressful Events (RISE) is a confidential peer support program developed by Johns Hopkins Medicine that provides psychological first aid and emotional support to health care workers who have experienced stressful clinical situations.
forYOU: This program is led by Sue Scott at the University of Missouri Health and is oriented toward caring for caregivers, providing peer support and resources for the second victim.
First Responders First: Sustaining Yourself During the Coronavirus Crisis tip sheet provides information on microsteps health care professionals can take for self-care and to manage stress and mental well-being.
Centers for Disease Control and Prevention: Secondary traumatic stress management strategies can be found on the CDC’s Coronavirus Disease 2019 (COVID-19) resources for Stress and Coping.
Psychological First Aid: Guide for Field Workers: Provides information on social and psychological aid strategies in response to crisis.
The Joint Commission: Workplace Violence Prevention Portal provides resources for health care organizations to support staff facing aggression or violence in the workplace.
Note: This is not an all-inclusive list.
Disclaimer notice: As a matter of policy, The Joint Commission and its affiliates do not endorse third party products or services. Readers should not infer that any specific products or services named in these resources are superior to those of other comparable companies.