Introduction It goes without saying that a top societal priority right now is caring for the workforce caring for people sick with COVID. The safety and well-being of healthcare workers is crucial, noted authors from the Stanford Medicine system in a January 2021 NEJM Catalyst article.
As an early pandemic hotspot, the Stanford system witnessed the extreme demands on the workforce and quickly made workforce well- being their highest priority. They defined their leadership values as connection, collaboration, and caring. New structures were formed to address worker well-being with an intense focus on staffing, staff testing and care if they were infected, the PPE supply chains, infection risk, and safe integration of elective procedures and visits.
To address the workers psychological concerns and needs, the authors noted: “To learn about the unique needs of individual health care workers, we entered into discussions using Schein’s “humble inquiry,” a concept that emphasizes asking and listening, rather than telling.
Because the pandemic was unpredictable in so many ways and anxiety levels were high among many providers and workers, we recognized the importance of strengthening relationships and generating solutions and new ideas from the front lines.The practice of humble inquiry facilitates these outcomes, and we were able to learn many important lessons and gain important insights by hearing what the frontline teams had to share.”
“Furthermore, we were able to provide opportunities through individual conversations and focus groups for deliberate reflection about experiences related to the pandemic, in an effort to foster learning and post-traumatic growth.”
This case study is helpful in the context of a new scientific review explored next on how best to support healthcare workers during the pandemic, which concludes that this endeavor is not yet supported by an evidence base to guide healthcare leaders.
What does the research say on supporting frontline workers during a disease epidemic? Research on disease epidemics on an individual country or global scale has shown that health care workers are at risk for short- and long-term mental health problems. The World Health Organization (WHO) warns that depression, anxiety, stress and additional cognitive and social problems are all possible effects on frontline staff.
Alex Polluck and collaborators in Scotland, in conjunction with the Cochrane Library- the leading journal and database in health care for systematic reviews - got to work in May 2020 to conduct a rapid “Cochrane Review” on the question: What interventions support or deplete resilience and mental well-being in frontline workers during a disease outbreak?
They published their article in November 2020 titled: Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review.
The bottom line: “There is a lack of evidence from studies carried out during or after disease outbreaks, epidemics or pandemics that can inform the selection of interventions that are beneficial to the resilience and mental health of frontline health and social care professionals.
Alternative sources of evidence, such as evidence arising from other healthcare crises, and general evidence relating to the effectiveness of interventions to support mental well‐being during stressful situations, should therefore be used to inform decision making.
The mental health and resilience of frontline workers could be supported during disease epidemics by workplace interventions to support basic daily needs, psychological support interventions, pharmacological interventions, or a combination of any or all of these.”
Cochrane review description
The authors addressed two objectives in their literature review:
Objective 1: assess the effects of interventions to support the healthcare workforce
The study gathered quantitative evidence from randomized trials, non-randomized trials, controlled before-after studies and interrupted time series studies, investigating the effect of any intervention to support mental health or resilience.
Objective 2: identify facilitators and barriers that may impact interventions to support healthcare workforce The study gathered qualitative evidence from studies that described facilitators and barriers to the implementation of interventions during or after a disease outbreak.
The review process, following the rigorous Cochrane review methods, identified 16 studies from 2002 to May 28, 2020, describing interventions to support resilience or mental health of mainly physicians and nurses during disease outbreaks including SARS, Ebola, MERS, and COVID-19. Interventions were mainly workplace-based including training, structure and communication, psychological support, and multifaceted interventions.
The 16 studies measured a variety of outcomes of the interventions: General Mental Health (3 measures)
Resilience (6 measures) Psychological symptoms of anxiety (6 measures)
Depression (3 measures)
Stress (3 measures)
Burnout (2 measures)
Effects on workplace staffing (2 measures)
Mental health disorders caused by distressing events (6 measures)
The strategies in the studies included: rotating workers from high to low stress roles, partnering workers of different experience levels, including work breaks and flexible schedules, and enabling social support.
Research Findings In addressing the first objective, only one study (during Ebola) investigated the impact of an intervention. Frontline staff were trained to deliver psychological first aid, including to patients and their families, as a way to reduce their own burnout. The study was deemed inconclusive.
For the second objective, there were four factors with moderate confidence (none with high confidence) serving as facilitators to implementation:
1. Interventions were flexible, culturally appropriate, and could be tailored and adapted for the needs of a local area.
2. Effective communication was delivered, formal and informal, to improve team cohesion and resilience.
3. Positive, safe, and supportive learning environments were provided for frontline workers.
4. Good education on the intervention - the knowledge and beliefs of frontline workers about an intervention can help (or hinder) the intervention.
There were two factors serving as barriers to implementation with moderate confidence levels:
1. Insufficient awareness by one or both of the workers and their organizations of what frontline workers needed, as well as their available resources, to support their mental well-being.
2. The intervention was limited by resource constraints such as a lack of equipment, staff time or skills needed for implementation.
In the absence of robust findings in the literature, the authors offer the below set of questions that may support the selection and implementation of helpful interventions.
Selecting an intervention
Is the intervention flexible, with the ability to be tailored to meet local needs?
Are the needs and resources of the frontline workers known (known to the frontline workers and to their employers/organizations)?
Planning organizational factors
Are there effective networks of communication (both formal and social networks)?
Is there a positive, safe and supportive learning environment for the frontline workers (for example, for learning new skills related to caring for patients with the disease)?
Is there adequate resourcing, including necessary equipment, staff time and skills, for the intervention?
Individual characteristics of frontline staff
Do frontline staff have adequate knowledge relating to, and belief in, the intervention?
Other considerations emerged from the review:
Organization
Strategic planning prior to implementation of an intervention or changes to practice
Complexity of the intervention (low‐complexity interventions maybe easier to implement)
Intervention costs and associated costs of implementing the intervention
Education, training and access to information for frontline workers about the intervention
Confidence of people delivering the intervention
Individual personal characteristics of workers, such as attitudes and motivation
Meaningful engagement of, and collaborations with, people involved in the delivery of the intervention, and opinion leaders who can champion the intervention
Providing frontline workers with opportunities to reflect on the implementation of an intervention
Societal
Organizational incentives and rewards for frontline workers may facilitate engagement in the intervention
Government and political leaders' awareness of mental health needs of frontline workers
Networking and coordination of different relevant organizations
Takeaways for Coaches The experience of Stanford Medicine published by NEJM Catalyst along with the Cochrane Review conclusions support a coaching approach to helping frontline workers improve or maintain their well-being under extreme and often traumatizing demands.
On the optimal outcome, the Standard authors note: “Rather than using a crisis-management approach to restore the organization back to normal functioning after the pandemic, our goal is to achieve a higher level of functioning as a result of addressing and learning from adversity.”
Here are some tips for coaches that serve healthcare leaders and workers:
1. Engage in open, humble inquiry that raises self-awareness and organizational awareness of individual and team needs and resources, and also generates ideas and insights on how to address these needs.
2. Provide opportunities to reflect and process experiences well in order to uncover a path to learning and post-traumatic growth.
And for all Coaches:
Step up in your community to show deep gratitude and support the needs of healthcare workers including meals, transportation, child-care, small gifts, and anything else you think would be helpful and appreciated.
Citations
Frush, K., Lee, G., Wald, S. H., Hawn, M., Krna, C., Holubar, M., ... & Maldonado, Y. (2020). Navigating the Covid-19 Pandemic by Caring for Our Health Care Workforce as They Care for Our Patients. NEJM Catalyst Innovations in Care Delivery, 2(1).
Pollock, A., Campbell, P., Cheyne, J.,Cowie, J., Davis,B., McCallum, J., ... & Torrens, C. (2020). Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review. Cochrane Database of Systematic Reviews, (11).