Leadership Support is Vital: If We Fail to Support Caregivers, There Will Be Few Left to Support Care

Problem: During the coronavirus (COVID-19) pandemic, healthcare workers often place the needs of others above their own. Yet, they themselves face unimaginable anxiety, stress, and depression caused by the burden of such a profound illness and the prolonged pandemic response. Taxing workloads and the constant vigilance of maintaining infection control procedures while caring for incredibly sick patients is physically and emotionally exhausting. Watching helplessly as a cytokine storm ravages a patient’s body takes an enormous toll on both the patient and the healthcare worker. This unrelenting stress and overwhelming grief is worsened by the need to isolate patients from their loved ones, leaving only healthcare workers at the bedside at the end of life.

Add in the anxiety of working in an under-resourced environment, where even the most basic personal protective equipment (PPE) may not be available, and healthcare workers are, without a doubt, putting their lives on the line more than ever. Shortages of PPE are leaving workers dangerously ill-equipped to care for patients. In a survey conducted last month by the Association for Professionals in Infection Control and Epidemiology (APIC) to which more than 1,000 US infection preventionists responded, 20% said they have no N95 respirators, and 28% said their supplies were dangerously low.¹ Almost one-third stated they are nearly out of surgical face masks, and 17% reported resorting to do-it-yourself (DIY) measures such as sewing their own cloth masks. Nearly half lack enough face shields, and two-thirds have insufficient gowns. When PPE is available, the physical strain of wearing the equipment all day has led to dehydration, backaches, headaches, and skin injuries. But the consequence of not having proper PPE is substantially worse and has impacted the rate of COVID-19 infections in healthcare workers. 

Between February 12 and April 9, the Centers for Disease Control and Prevention (CDC) found that 9,282 US healthcare workers who had the potential for direct or indirect exposure to patients or infectious materials have contracted COVID-19.² More than half of these healthcare workers reported contact with a COVID-19 patient only in a healthcare setting. With a median age of 42 years, about 10% of healthcare workers have been hospitalized and 27 have died across all age groups. The number of infected healthcare workers is likely underestimated since most reports of confirmed cases do not include whether the person worked in healthcare. Some healthcare workers have watched their colleagues become sick with the virus, yet they still come to work the next day despite their anxieties. Furthermore, healthcare workers live in constant fear of bringing the disease home and infecting their loved ones; many have adopted self-imposed isolation from their loved ones to protect their family’s health.

Leaders need to support healthcare workers through this turmoil—indeed, the trauma of caring for patients with COVID-19 could affect more people than those seriously ill from the infectious disease itself. However, a recent online Gallup Panel survey conducted between March 13 and April 14 revealed some troubling findings.³ Only about half of healthcare workers strongly agreed that their employer has communicated a clear plan of action for COVID-19, and nearly one in five feel their employer has communicated too little about COVID-19. Furthermore, only one in three are confident that they will be safe if they follow their organization’s policies during this public health crisis. 

Safe Practice Recommendations: First and foremost, healthcare workers need to know that hospital leaders have their back during the pandemic. Leaders do not need to have all the answers or immediately solve the myriad of complex problems associated with the pandemic; however, they need to be effective listeners and transparent communicators, make collective decisions that support workers’ needs and safety, and visibly demonstrate their trust, respect, and appreciation for the workforce. During a recent webinar sponsored by TMIT Global, Stephen Swensen, MD, MMM, Professor Emeritus at the Mayo Clinic College of Medicine, described specific areas of leadership support to urgently safeguard healthcare workers’ physical and emotional needs, provide necessary resources during the COVID-19 pandemic, and develop positivity.⁴

Create a Safe Haven

Each of us needs to withdraw from the cares which will not withdraw from us.

­^{—Maya Angelou}

Leaders need to create safe quiet spaces for healthcare workers to retreat, reflect, and talk to each other away from the hustle and bustle of taxing workloads—a place for introspection and meditation, laughing and crying, taking a quick nap, and accessing peer support without stigma or barriers. When possible, psychological counselors should be available for private and confidential sessions as well as proactive group sessions covering a range of topics. In the safe havens, workers should be encouraged to use social media to connect with loved ones and friends. While work schedules are typically hectic and long, leaders should enable workers to spend time in a safe haven each shift.     

Restore Fair and Just Compassion

A restorative just culture asks: Who are hurt, what do they need, and whose obligation is it to meet that need? The entire community needs to be involved in resolving that need.

­^{—Sidney Dekker}

In the face of daily pain and suffering, it is easy for healthcare workers to feel “empathic burnout” or to blame themselves for less-than-ideal outcomes. They may feel they have failed a patient, second-guessing their clinical skills and knowledge. Leaders need to guard against this by encouraging workers to feel compassion for self and others, and by creating an environment of trust and fairness despite adverse outcomes. Much like a rapid response infrastructure to provide “emotional first aid” for second victims of errors, leaders need to create a rapid response-like safe zone for worker support, with trained peer supporters who can console workers who are suffering from empathic burnout or self-blame. Leaders need to help workers deal with their reaction to the pandemic chaos, including treatment failures, and rebuild compassion for self and others. 

Establish a Positive Mindset

Happiness makes up in height for what it lacks in length.

­^{—Robert Frost}

To promote healthcare workers’ wellbeing, the far-reaching ripples of positive emotions and the protective properties of optimism and resilience can be underscored during daily leadership interaction with healthcare workers. The benefits of positive emotions, despite their fleeting and subtle nature, echo long after their momentary pleasures have dimmed.⁵ They improve physical health, foster trust and compassion, buffer against depression, help people recover from stress, and build resilience and resourcefulness. They can even undo the undesirable effects of negative emotions. Moments of positivity accumulate over time, remind people that their work is meaningful, and help build resources for survival. And the opportunities for sharing positivity are quite prevalent.

For example, leadership information sharing with healthcare workers typically occurs daily to communicate the rapid and evolving changes that are occurring due to the pandemic. While this information might include the number of COVID-19 cases, including deaths, in the facility, community, state, US, and the world, it is equally critical to balance this information with the number of COVID-19 patients discharged and the positive steps that are being taken to support workers, patients, and communities. News about revised policies and procedures and special guidance for specific departments should be balanced with specific acknowledgment and sincere appreciation of workers.  

During clinical unit rounds or safety huddles, leaders should be as positive and compassionate as possible, meting out random acts of kindness to workers and patients, and sharing at least one positive story of success, whether it is a story about especially compassionate care for a dying patient or celebrating the recovery of another patient. Leaders should remind workers of what they loved about their job before the pandemic, and consistently ask workers which aspects of their current situation they might consider a gift to be cherished. 

Communicate Transparently

It isn’t the mountains ahead to climb that wear you out; it’s the pebble in your shoe.

­^{—Muhammad Ali}

Transparent communication is one leadership behavior that is staggeringly important because it creates an environment of trust and loyalty, avoids secrets and surprises, creates expectations for follow-up about concerns, facilitates actions in such a way that others can easily see them, and ensures everyone is on the same page. While leaders should always share their knowledge freely and honestly, one of the most important skills involved in transparent communication is listening to the workforce. Leaders should seek to understand by listening. Avoid guessing or assuming, and do not try to defend or solve problems immediately. Leaders should encourage all workers to express their opinions, offer suggestions, and get everyone involved as a partner in collective decisions. They should specifically ask about frustrations and challenges, and ask workers to prioritize any raised issues. They should get to know their workers, asking them about isolation and loneliness, difficulties with work-life integration, and what saps meaning from their work. Being transparent about limitations, honest about consequences, and acknowledging each expressed concern, is of paramount importance in coalescing around meaningful, actionable challenges and addressing them together.   

Be Visible as a Leader

When someone is going through a storm, your silent presence is more powerful than a million empty words.

­^{—Mahatma Gandhi}

Nothing does more to engage and inspire healthcare workers than leadership visibility in the trenches. Leaders must be visible to frontline workers, not just roaming the halls to say hello, but face-to-face (with a mask), prepared for the vulnerability of being WITH workers, even if they don’t have all the answers.⁶ They don’t play it safe and stay in an office so they can’t be questioned. Instead, they invite questions and concerns, take the time to appreciate meaningful work and to recognize and thank workers, take an interest in their wellbeing, and create a supportive environment that promotes innovation, trust, and teamwork.

Provide Opportunities for Connectedness

This is the power of gathering: it inspires us, delightfully, to be more hopeful, more joyful, more thoughtful: in a word, more alive.

­^{—Alice Waters}

Leaders should strive to build community among healthcare workers, encouraging social relationships and meaningful connections. COVID-19 has caused a collective trauma, and workers could be suffering from social isolation due to separation from their family and friends. Whether it is arranging periodic catered events so groups of workers can share an occasional meal together, or gathering small groups of workers in a safe haven, the resulting commensality, camaraderie, and social interactions will have a positive effect on work-group performance and psychological and physical health.⁷ Whereas the life and death nature of healthcare during the pandemic encourages bonding among workers, social connectedness inspires joy and hope, creates resilience, and is an important part of the cultural fabric that helps successfully functioning healthcare systems operate.⁸

Encourage Self-Care

It’s time to start focusing on what strengths pulled you up when the entire world had knocked you down.

­^{—Nikki Rowe}

Leaders should cultivate in healthcare workers self-care habits and attitudes that promote physical and psychological wellness despite the difficult challenges at work. In addition to promoting the typical self-care strategies such as adequate sleep, movement, exercise, meditation, sunlight, and a healthy diet, leaders should also encourage constructive attitudes in healthcare workers that promote wellbeing, such as gratitude, kindness, forgiveness, and care for each other. Leaders may want to start a “gratitude journal,” documenting each day the many things (or workers) they are grateful for; things that bring joy and meaning to their work; messages from grateful patients, families, and communities; and how they as leaders can be of service to the workforce. By expressing gratitude and sharing these salutations, “shout-outs,” and thoughts with healthcare workers each day, leaders can serve as a role model for constructive attitudes that promote wellbeing.

Conclusion

Never in the field of human conflict was so much owed by so many to so few.

­^{—Winston Churchill}

COVID-19 is proving to be a long, uphill battle, with an end that is barely visible on the horizon. While many healthcare workers are operating in “hero” mode right now, please recognize that they may also be suffering from significant depression caused by the horrific loss of life with this illness, which is worsened by exhaustion and isolation from much-needed support. Heartbroken, we just learned about the suicide of a 49-year-old physician, Dr. Lorna Breen, medical director of the emergency department (ED) at NewYork-Presbyterian Allen Hospital, amid the COVID-19 crisis. Prior to her death, Dr. Breen had been treating COVID-19 patients and contracted the illness herself. During her convalescence, she became detached, often speaking of the traumatic sights she had witnessed in the ED. She was a hero among many who should never be forgotten.

Healthcare leaders have a significant role to play in a world that will be forever changed by this pandemic. They need to create a safe haven for workers, restore compassion, establish a positive mindset, communicate transparently, be visible as a leader, and provide opportunities for connectedness. In addition, leaders need to prepare now for the complex aftermath as we begin to deal with healthcare worker “heroes” suffering from depression and post-traumatic stress disorder. Because this pandemic has brought about many unprecedented mental health concerns, leaders must continually build support systems for healthcare workers to hold onto both during and after each wave of this storm. 

References

1. Association for Professionals in Infection Control and Epidemiology (APIC). Protecting healthcare workers during the COVID-19 pandemic: a survey of infection preventionists. Published March 27, 2020. Accessed April 28, 2020.
2. CDC COVID-19 Response Team. Characteristics of health care personnel with COVID-19 – United States, February 12–April 9, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(15):477-81.
3. Ratanjee V, Foy D. What healthcare workers need from leaders in COVID-19 crisis. Gallup Workplace. Published April 22, 2020. Accessed April 28, 2020.
4. Swensen SJ. Burnout and crises: joy in the face of chaos. In: High Performer Webinar. TMIT Research Test Bed. Published April 16, 2020. Accessed April 28, 2020.
5. Pogosyan M. Positive emotions and wellbeing: insights from positive psychology. Psychology Today. Published November 6, 2016. Accessed April 28, 2020.
6. Holloway M. Visibility as a leader. Courageous Leaders. Published May 28, 2013. Accessed April 28, 2020.
7. Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Med. 2010;7(7):e1000316.
8. Kniffin KM, Wansink B, Devine CM, Sobal J. Eating together at the firehouse: how workplace commensality relates to the performance of firefighters. Hum Perform. 2015;28(4):281-306.