Individual and Organizational Stress During the Pandemic
Using the stress continuum framework, chief wellness officers from several health systems have written a report of their experiences during the pandemic. These physicians had been concerned about burnout prior to the pandemic, and noted four stages during the pandemic, which they called pre-surge, surge, flattening, and post-surge. I will summarize their observations, but recommend the full report.
During the pre-surge, or preparation phase, existing literature was reviewed, but most health care organizations were focused on building capacity (beds, ventilators, PPE, etc.,) but little attention was paid to staff psychological distress “even though the healthcare workforce was already manifesting high rates of burnout and was stretched to capacity prior to the pandemic.” One organization already had programs in place to deal with workplace mental health and found they had better short-term responses to the pandemic. “By strategically establishing a system-wide program of workplace well-being, the organizations…were able to pivot quickly to ensure support for their HCWs during the pandemic.” Of course, they politely fail to note most organizations don’t have such procedures and process in place either then or now.
During the surge, the organizations organized incident command teams, using models they had for dealing with natural disasters. Those with wellness programs also included people from these programs in the command team, but the degree of involvement varied. Most organizations sent home “non-essential workers.” The authors noted: “An unintended side effect during the pandemic was the distinction that emerged between essential and non-essential staff, including those who could work from home. This led some staff who worked remotely to feel devalued, guilty, and isolated from their peers.” This is analogous to the tension in the military between soldiers in frontline units exposed to enemy fire and those in rear-echelon support positions who are less exposed. Whether this is good or bad depends upon whether it is used to build esprit de corps in the frontline units or to denigrate the work of other echelons. Given the long-standing distrust between clinicians and “suits,” I fear the latter may have been a more common response.
Although aware of the principles of stress “first aid,” few organizations developed an institutional response in the first days. Some used mental health persons, some used chaplains, and some used clinicians who had been given basic training. Regardless of methods, they found six common requests from the front-line clinicians: “hear me; protect me; prepare me; support me; care for me; and honor me.” They also found leaders experienced increased stress, as they were expected to remain calm, empathetic, and supportive despite long stretches of duty, making decisions with minimal data, dealing with constantly changing data, and last, but not least, financial stress associated with cancelling elective surgery. One organization surveyed their leaders and found 70% thought they were doing a good job dealing with the emotional well-being of their direct reports, but only 50% of the reports agreed. They found one of their key functions was conducting meetings with staff and finding ways to anonymously report their observations to leaders.
One barrier to communication is the normal clinician response to distress of compartmentalizing their emotions. “Many providers reported they did not have time to process their emotions at the height of the pandemic and anticipated needing to do so once they were no longer in survival mode. While such an adaptive response allows them to work while compartmentalizing their emotions, the risk occurs that they may deny their feelings or never allow themselves the opportunity to process their emotions.”
The authors note that emotional self-care is a weak point for clinicians, especially physicians, in the first place. I can think of numerous examples of good doctors who ended up damaging themselves because of their inability to find a safe way to “vent” or defuse their stresses. As I noted in the discussion of the stress continuum, many physicians operate in “yellow” mode all the time, and rarely get to “green.” My medical group had a sabbatical program which allowed physicians two months away with pay. One month was to be spent in educational pursuits, self-defined programs for the most part, but the other month was spent on vacation. Almost everyone noted upon return from sabbatical that they resented the pressures of “the system” to get them back into yellow mode, but within a week, most were.
It is important to note, though, this “normal” set point in the yellow zone has a multifactorial etiology. Yes, the organizations and the providers are in production mode, and some physicians and organizations are motivated to maximize present earnings no matter what. But some prefer it because if makes them feel “important.” The psychic benefit of being “in demand” is something many fail to acknowledge. Third, after a while, being somewhat stressed begins to seem normal, and we fail to recognize the toll on us, our families, and our co-workers. Only when things go “orange” or worse, “red,” do we have a momentary pause. But too often, we are like passersby at the scene of a car wreck with injuries—we slow down for a few miles, but are soon back up to speeding along, oblivious to the risk again.
The authors note the post-surge stress associated with increasing demand for regular services occurred simultaneously with fiscal cost-cutting to cover the shortfall created by suspension of those operations during the height of the pandemic. Many healthcare workers expressed the feeling the went “from heroes to zeros” in their organizations once the surge was past. Both those employees still working and those laid off experienced stress, albeit somewhat different ones. From my perspective, the biggest problem, though, was the diminution of team function. “The cohesion and efficacy of some teams was disrupted by the unanticipated loss of coworkers.” But since many organizations lack recognition of the value of stable teams, particularly ways to measure it, this loss is not calculated as part of the financial damage.
So, what is their bottom-line conclusion?
“The fact that the COVID-19 pandemic has been universal and prolonged provides an opportunity for lasting change in how HCOs support their workforce, even in a post-pandemic environment. Engaged individuals and teams working in a healthy organization that supports their needs and well-being is the foundation that leads to optimal patient care and financial success.”
3 May 2021
 Brower KJ, Brazeau CMLR, Kiely SC, Lawrence EC, Farley H, Berliner JI, Bird SB, Rip J, Shanafelt T. The Evolving Role of the Chief Wellness Officer in the Management of Crises by Health Care Systems: Lessons from the COVID-19 Pandemic. NEJM Catalyst, 14 April 2021. Accessed the same day at https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0612.
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