On May 7, 2020, the Action Collaborative on Clinician Well-Being and Resilience (Clinician Well-Being Collaborative) hosted a webinar on Supporting Clinician Well-Being During COVID-19. The objectives of the webinar were to:
Describe the existing clinician burnout crisis prior to the COVID-19 pandemic and the goals of the Clinician Well-Being Collaborative
Identify the critical needs and priorities to support the well-being of clinicians, including those in their formative years of training, during the COVID-19 era
Spotlight programs, resources, and leadership efforts currently underway to address and monitor the acute and long-term mental health and well-being of clinicians on the frontlines of COVID-19
Voice the need for a coordinated, national strategy to care for the acute and long-term health and well-being of frontline clinicians delivering health care during this public health crisis
Victor Dzau, President of the National Academy of Medicine, introduced the Clinician Well-Being Collaborative, a network of more than 200 organizations committed to achieving three goals:
Raise the visibility of clinician anxiety, burnout, depression, moral injury, stress, and suicide
Improve understanding of challenges to clinician well-being
Advance evidence-based, multidisciplinary solutions that will improve patient care by caring for the caregiver
Dr. Dzau said that the COVID-19 pandemic could be compared to cataclysmic events such as September 11, as health care providers risk their lives on the frontlines and serve as heroes to many Americans. He also noted the surges of emotional distress and exacerbated burnout among clinicians will likely lead to long-term impacts of post-traumatic stress disorder (PTSD) from the pandemic.
Frontline Clinician Leadership in Highly Impacted Institutions
Jonathan Ripp, Chief Wellness Officer at the Icahn School of Medicine at Mount Sinai, and Deborah Dang, Chief Nursing Director for Well-Being at Johns Hopkins Medicine, discussed their institutions’ approaches to addressing the COVID-19 impacts on their clinicians’ emotional health and well-being. Dr. Ripp has been on the frontlines in New York, one of the states hardest hit by COVID-19, and Dr. Dang has been leading nurses who engage in direct patient care. They highlighted major stressors about meeting basic survival needs, uncertainty of the pandemic, and the experiences of physicians and nurses such as:
Fear of contracting the virus and spreading COVID-19 to their loved ones, especially with concerns over the inadequacy and lack of consistent availability of personal protective equipment (PPE)
Loss of family presence at patients’ end-of-life during hospitalizations, along with grief from the increase in patient deaths
Disruptions in their daily life with child and elder care
Being assigned to work in unfamiliar roles without adequate preparation
Their institutions have responded to these stressors by:
Having champions (e.g., chief wellness officers) in the workplace call attention to the emotional needs of employees in their organization
Developing strategies and providing tangible resources tailored to meet each stressor
Providing food, childcare services, and immersive spaces for clinicians to rest and recharge at Mount Sinai Health System
Creating an employee worker relief fund at Johns Hopkins Medicine
Providing clear, transparent communication through wellness messages and town halls
Partnering with departments of psychiatry, social work, and spiritual care to provide robust psychosocial and mental health care on an individual level
Building an integrated structure to optimize use of emotional support services for the full range of psychological needs across all phases of the disaster (disaster phases are referenced in detail below)
Establishing triage communication across all services to identify the most appropriate type of care, from psychological first aid care to psychiatric care
Removing barriers to accessing mental and emotional support
Monitoring resource utilization and frontline observations to address any unmet needs
Community Phases of Psychological Response to Disaster
Dr. Dang and Joshua Morganstein, Assistant Chair of the Department of Psychiatry at the Uniformed Services University of the Health Sciences, referenced the community phases of disasters as a framework for understanding the impact of the COVID-19 pandemic on clinician well-being. The framework illustrates the progression of disaster effects and emotional reactions of communities in six phases:
Pre-Disaster Phase: the amount of warning a community receives depends upon the type of disaster and affects how they perceive the threat
Impact Phase: the greater the scope, destruction, and personal losses from a disaster, the greater the psychosocial impacts
Heroic Phase: characterized as the increase in the selfless concern for the well-being of others among survivors and emergency responders
Honeymoon Phase: survivors in the community feel a short-lived sense of optimism
Disillusionment Phase: survivors recognize the limits of available disaster assistance and come to grips with the reality of their situation; the anniversary of a disaster can trigger survivors to re-live these negative emotions
Reconstruction Phase: survivors work through grief and experiences setbacks, eventually readjusting to their new surroundings and situation
Dr. Dang and Dr. Morganstein said the stages of community psychological response to disasters have predictable and observable behaviors that can be used to guide institutions’ responses on individual, organization, and community leadership levels. Considerations include:
A continuum of coordinated psychosocial care is required for staff in order to support their resilience.
The most emotional support is needed in the disillusionment phase, as this is when communities realize the limits of disaster assistance and the stress takes a toll.
COVID-19 disrupts these phases as the natural community cohesion in the honeymoon phase is affected by social distancing and quarantine measures.
Tipping points, which are modest events that trigger disproportionate community responses, such as the death of a beloved staff member in a health care organization, tend to occur when risks are unfairly distributed or there is a belief that leadership is failing to provide reasonable and realistic protective measures.
Dr. Morganstein elaborated on the need to understand risk as a part of managing clinician well-being by:
Collecting surveillance data that identify what clinicians are facing, what they are exposed to, and the impact of these risk factors to develop measures determining how best to support the health care workforce
Noting interventions that promote recovery after a disaster, which enhance a sense of safety, calming, social connectedness, community reliance, and hope or optimism
Additionally, he mentioned factors to consider for team, organization, and community leaders who are key to sustaining the health care workforce especially through grief leadership:
Grief will be a near universal aspect that the workforce will be dealing with long after the pandemic subsides.
Leaders can promote healing in their communities by facilitating processes that honor losses, communicate and openly acknowledge grief, and promote hope in the future among personnel. These processes help to recognize opportunities for growth and sustain health care communities.
A Focus on the Burden and Unique Needs of Learners
Eileen Sullivan-Marx, Dean and Erline Perkins McGriff Professor of Nursing at the New York University (NYU) Rory Meyers College of Nursing, and Jordyn Feingold, a medical student at the Icahn School of Medicine at Mount Sinai, shared their experiences as current learner and faculty at their institutions. Dr. Sullivan-Marx particularly focused on the impact of the pandemic on two phases of health care professional learners in nursing: pre-licensure and post-professional stages. While there was a goal to continue nursing education programs for these students even with the state of emergency declared, it became clear to NYU that normal support processes were insufficient, and adjustments were made in order to balance rigorous academics without imposing a greater risk for burnout. Some adjustments included:
Suspending usual ways to measure testing in classrooms by creating creative classrooms and finishing courses as early as possible
Reducing the burden of studying for frontline students who are working
Supporting learners that come from multigenerational households
Recognizing losses of personnel, and still holding celebrations, such as graduations, to boost morale
Ms. Feingold outlined some of the challenges and academic concerns from the perspective of health professions students, particularly medical students, who embody the dual roles of being part of the emergency response while still being learners. These challenges included:
The disruption to clinical learning environments
Students forced to adapt to new learning styles through e-learning
Mentors and faculty who are now less available to students because they are on the frontlines of the COVID-19 response
Sources of stress for students from various academic milestones (such as those completing summer research or studying for major exams)
The uncertainty of cancelled exams
The psychological and financial burden of testing
The inability to complete rotations and needing to connect with faculty after being pulled from their wards
Early graduates now dealing with fears about the adequacy of PPE or fears of judgment from not wanting to join the frontlines
House staff, or resident physicians of a hospital, dealing with fears of being inadequately trained in certain subspecialties
Ms. Feingold also identified key opportunities for institutions and its leaders to respond, such as:
Guaranteeing PPE for all frontline clinicians, including trainees
Administrators providing clear, constant communication even if only to communicate their awareness of uncertain or incomplete information
Providing leniency and compassion for academic work to alleviate undue burden
Providing opportunities for learners to contribute to COVID-19 response efforts without stigmatizing decisions not to participate
Creating peer hotlines and other outreach around mental health services
A Long-Term View Toward a National Strategy
Nicole Lurie, Strategic Advisor to the CEO for the Coalition for Epidemic Preparedness Innovations, concluded the presentations by talking about the behavioral health crisis that occurs after every major disaster and the response needed to address it. These elements include:
Population level impacts of anxiety, depression, substance use, and domestic abuse
Disproportionate level of PTSD in first responders that could spill over to their families and workplaces
Incomplete knowledge of appropriate interventions at the population level vs. individual impacts
To address such crises, Dr. Lurie highlighted the need for a national behavioral health plan and prevention strategy that touches upon all parts of society and includes the following components:
Incident command centers at the federal, state, local, and institutional levels
Surveillance for well-being that documents issues like anxiety, depression, cases of domestic/child abuse and organizes interventions before they escalate
Early warnings for sub-populations at heightened risk, such as minority communities and health care workers
A national prevention plan incorporating an incident management system, surveillance, and multimodal interventions
A national research agenda for prevention during a public health crisis
Combining natural experiments from individual health facilities to get lessons, tools, and evidence to prepare for future epidemics
Darrell Kirch, President Emeritus of the Association of American Medical Colleges, and Thomas Nasca, President and Chief Executive Officer of the Accreditation Council for Graduate Medical Education, facilitated a discussion with the panelists.
Dr. Kirch noted the epidemic curve and predicted stages that each panelist alluded to in some aspect, whether they were stressors or responses; furthermore, he said it currently seems to be the early phase of celebrating clinicians’ heroism, but there are disillusionment and trauma challenges to come.
Dr. Nasca asked panelists to address the heroism of critical care nurses, the potential backlash against heroes, and the challenges of adequate PPE and protections.
Dr. Dang said while critical care nurses are not necessarily overcoming unique challenges, they are facing fatigue and uncertainty over how long they can survive the pace and intensity, in addition to the financial impacts on hospitals and health systems.
Dr. Morganstein emphasized the importance of team-, department-, and hospital-level leaders to tend to their clinicians’ moral injury and feelings of inadequacy that can occur alongside the backlash.
Dr. Ripp and Dr. Sullivan-Marx both reiterated having open, authentic communication with their frontline clinicians and students to manage expectations and awareness of efforts underway to protect them. Ms. Feingold also said her data indicated students’ career choices were not affected by inadequate PPE, and they were generally eager to help once adequate PPE is secured.