EXECUTIVE SUMMARY

With frontline healthcare workers across the country facing unprecedented burdens, there is ample evidence of stress, anxiety, and other behavioral health concerns. Experts note it is critical for leaders to prioritize workforce well-being, and to facilitate connections to treatment and other forms of support, as needed.

The COVID-19 pandemic’s effects on workers is complicated, but experts note one way to think of this stress is like exposure to a toxin like lead or radon.

 • One way leaders can reduce stress and improve functioning following trauma is by using psychological first aid, an evidence-based framework for supporting resilience.

 • Considering the range of needs, organizations must tailor their interventions. For example, practical supports such as food, transportation, and childcare assistance may be most helpful early on.

 • Regular communication is a pivotal tool for addressing uncertainty and anxiety in the workforce.


Clinicians have long understood they should put their patients first. However, in recent years, as there has been more focus on clinician burnout and fatigue, the importance of clinician wellness has come into sharper focus.

Today, with the country depending on the healthcare workforce like never before, it is vital for leaders to consider the burdens placed on frontline clinicians. They must be prepared to respond to employees’ physical and mental health needs.

“I think we have learned more and more that if we don’t attend to the emotional and psychological needs of the caregiver, the clinician, then patients don’t get a fair shake,” noted Donald Berwick, MD, MPP, FRCP, the president emeritus and a senior fellow at the Institute for Healthcare Improvement (IHI). Berwick recently spoke as part of an expert panel discussion on precisely what it means to “care for the caregiver” during times of crisis.

Berwick shared there has been some evolution in how this concept has been interpreted over the years. With patient volumes surging in many regions of the country, he observed healthcare leaders have witnessed how this stress affects the workforce.

In one tragic example, Berwick referred to the suicide of Lorna Breen, MD, who was emergency department director (ED) at NewYork-Presbyterian Allen Hospital in Manhattan. In addition to contracting and then recovering from COVID-19, Breen, 49, saw dozens of patients with the virus pass through her ED, including many who died from the ailment.

“We are even more in touch than we have been before of the behavioral burdens, the mental health issues that arise when dealing with a health crisis like this,” Berwick said. “We have definitely broadened our view of what the workforce is and realize the stressors are just as great, and even greater in some ways, for people who don’t have an MD or a degree as an RN.”

View Stress as a Toxin

What can research tell us about how this pandemic is affecting the psychological health of clinicians and other healthcare workers? During the IHI panel discussion, Joshua Morganstein, MD, shared that much of what we know on the subject comes from the study of disasters.

“It is important to remember that for the vast majority of people, including those who experience difficulties during the pandemic, they will ultimately do well,” explained Morganstein, assistant director of the Center for the Study of Traumatic Stress in the Uniformed Services University of the Health Sciences in Bethesda, MD. “Many people will even experience an increased perception of their ability to manage future stressors.” Morganstein noted that while communities typically go through well-established phases following disasters, pandemics like COVID-19 disrupt these phases.

For example, he noted there is a honeymoon phase during which there is a natural coming together of people following a disaster. But Morganstein said some have turned physical distancing requirements into a fear of others. He also noted communities are affected at different times to varying degrees.

Such factors complicate response efforts. “Public health emergencies open the fault lines in our society. They lay bare divisions across race, religions, and socioeconomic status,” he said. “Leaders and other institutional elements within our organizations really play an important role in shaping community response and behaviors.”

The effects of the pandemic on healthcare workers is complicated. Morganstein thinks of stress as like a toxin, similar to lead or radon. “To understand risk and intervene effectively, we have to understand aspects of exposure,” he noted. “Caregivers who are involved in prolonged patient care, those exposed to extremes of suffering as well as human remains and mass death, may certainly be at increased risk.”

Further, Morganstein observed healthcare workers not involved in direct patient care can experience other types of stresses such as heavier work demands, less recognition of their work in the community, a devalued sense of meaning from their work, and even feelings of guilt for not serving on the front lines.

Prioritize Communication

Morganstein observed one way leaders can reduce stress and improve functioning following exposure to trauma is by employing psychological first aid, an evidence-based framework for supporting resilience. He noted the elements that form this framework include:

  • enhancing a sense of safety;
  • calming;
  • self and community advocacy;
  • social connectedness;
  • hope and optimism.

“The scope of this event really requires a whole-of-healthcare approach to caregiver sustainment,” Morganstein added.

Considering the range of needs, organizations must tailor their interventions, according to Morganstein. For instance, he noted practical supports are needed most often early on.

“Emotional support is helpful as well, but the reality is that it is often difficult to talk about feeling sad when your stomach is growling and you don’t know if you can pay the rent,” he said.

Consequently, interventions that provide access to food, transportation, and childcare can be particularly helpful at this stage.

Also helpful is a system that facilitates peer support. Morganstein noted so-called “buddy systems” can be used to promote safety, efficacy, and social support — all protective elements.

“The ‘battle buddy’ system, which was popularized by the U.S. Army, has actually been adopted in some healthcare settings to support the safety and well-being of caregivers,” Morganstein explained. “Whether you call it a battle buddy or something else that works better for your organization, having someone with whom caregivers commit to maintaining a regular, ongoing connection for mutual encouragement can be an invaluable source of support during a crisis.”

Morganstein added that during the pandemic, leaders need to prioritize keeping workers informed, checking in with them frequently. “Communication is not only a means by which we deliver interventions, but it is in and of itself a behavioral health intervention,” he said. “Messaging during a crisis has a profound impact on community well-being. It influences people’s perceptions of risk and, ultimately, the willingness of society to engage in recommended health behaviors.”

Address Basic Needs

When the COVID-19 pandemic began, there already was an office of well-being and a chief wellness officer at The Mount Sinai Health System in New York City. These resources enabled the organization to respond quickly to caregiver needs in many of the ways Morganstein described.

“We could bring to bear resources ... that we already had in place because of the recognition [here] of the importance of the well-being of clinicians,” explained Jonathan Ripp, MD, MPH, senior associate dean for well-being and resilience and the chief wellness officer at the Icahn School of Medicine at Mount Sinai.

While cases of COVID-19 in New York City have declined markedly, the city was, for a time, the epicenter of the pandemic, placing unprecedented demands on the healthcare workforce.

“Just as there is a pandemic curve, there are phases of stress response and stressors that become priorities in the midst of the pandemic that we observed firsthand,” noted Ripp, alluding to Morganstein’s observations about how different interventions are required depending on the crisis phase. In the early days of the pandemic, Ripp noted there were huge disruptions in society that took place even before hospitals began to see a surge in patients. Thus, things that were taken for granted, such as arriving to work safely or owning enough personal protective equipment (PPE), emerged as core concerns in the workforce.

“We tried to match in real time a response to each stressor as it was unfolding. In the beginning, it was all about creating resources to meet basic daily needs,” Ripp observed. “We brought food, we secured PPE, we created childcare resources, and we addressed transportation.”

Echoing Morganstein’s comments about the pivotal role of communication, Ripp said he was struck by “how incredibly important” it was for leadership to provide “honest, authentic, and regular” communications to healthcare personnel. Steady communication proved to be an invaluable tool for addressing uncertainty and anxiety in the workforce. As the health system faces a significant uptake in requests for leave, Ripp said communication remains just as vital.

The health system also moved early to ensure a broad array of support and treatment resources were readily accessible to staff. “Some things that were already in existence we made more accessible, and other things we ramped up in real time,” Ripp said.

One example of this was the deployment of proactive mental health liaisons from the system’s department of psychiatry who spent time contacting clinical units to check in on staff. The health system also maintained phone lines workers could call for support on a 24/7 basis.

As all these resources were leveraged, the system’s digital health team quickly created a new website to make it easy for personnel to find out what well-being resources were available.

“We organized [the resources] by basic needs, mental health, psychosocial support, and on-the-ground resources,” Ripp said.

The site was designed to make it easy for someone to find the type of support they were looking for, whether that was one-on-one counseling, group-based discussions, or spiritual care.

One of the most well-received interventions that Mount Sinai deployed was the creation of recharge rooms. The idea behind these rooms came to fruition under the direction of a team in the Department of Rehabilitation and Human Performance. In rapid fashion, they created a series of spaces where in the course of busy shifts clinicians could spend time away from their intense work environment, Ripp explained.

“They provide immersive — sights, sounds, smell, taste — experiences where in a matter of 10 minutes you are completely removed from the clinical setting, and you have recharged,” Ripp shared.

Room designers incorporated music, scents, lighting, meditative visual elements, rest areas, and nourishing food to give clinicians an opportunity to destress for a few minutes before returning to work. There even was a facility dog who would come by to visit staff spending time in the recharge rooms, Ripp shared.

“The extent to which this [concept] resonated with our workforce was truly astonishing,” he observed. “This just highlighted how in times of crisis, it is basic needs [that need to be prioritized]. You just need that break.”

The recharge rooms have proven so popular that the biggest problem has been making sure people maintain appropriate distance from each other when they visit the rooms to destress.

“We have had to have people in there continually ... managing flows,” Ripp said. “There has just been a steady flow [of staff], and that continues. We now have [the recharge rooms] in six of our eight hospitals. Pretty soon, we will have them at [all our] hospitals.”

Now that COVID-19 has partially retreated from New York City, Ripp said Mount Sinai is in the process of pivoting back to normal operations — but not entirely, because there are some lingering effects.

“We sent surveys measuring symptoms of PTSD [post-traumatic stress disorder], depression, and anxiety, and found significant burden, as anticipated, within our workforce,” he explained. “Some will need treatment. We are continuing many of our initiatives into this next phase with lots of resources and ongoing efforts to make sure that communication is central.”

One focus of this next phase is a mental health destigmatization campaign. “We are encouraging our leaders to speak openly, honestly, and authentically about the impact this [crisis] is having on them,” Ripp said. “We are fortunate that some philanthropic dollars have now been dedicated to a new center for stress resilience and personal growth, another effort that is underway that will really focus on the mental health needs of our workforce as a result of COVID-19.”

Sustain Wellness Interventions

The challenge for leaders now is to make the case that many of the interventions used to support workers during the pandemic need to continue beyond this crisis. “There are so many variables that influence the ability to put things in place in the first place, and then to keep them,” Ripp said.

He added that as chief wellness officer, a big part of his job is demonstrating where there are priorities and how they overlap in the institution. “The top leaders of institutions have multiple priorities, so we need to be able to speak that language,” he said. “I think now more than ever the well-being of the workforce is recognized. [It is important] to make that case.”

Ripp explained there were plenty of reasons to focus resources on workforce well-being before the pandemic. These include the moral imperative, the regulatory environment, and the business case.

“But now, more than ever, it is concern about the mental health consequences to our workforce working through a pandemic. Collect data to show that ... and get up there as if you are in a courtroom and argue for what you need,” Ripp suggested.

For more information on supporting personnel during the pandemic, see The Joint Commission’s guidance: “Promoting the psychosocial well-being of health care staff curing a crisis.”