As she wrapped up an online town hall with staff at Massachusetts General Hospital (MGH) recently, Physician-in-Chief Katrina Armstrong, MD, decided to confront a personnel problem: Staff were exhausted from the COVID-19 surge that engulfed MGH in the spring, but now during the post-crisis lull, many workers just kept working. They were not taking time off to recharge, and Armstrong felt that was not healthy.
“I am going to say right here and now: We all need to take a vacation,” Armstrong said firmly, albeit with a smile. “If anybody is having trouble planning how they will do that this summer, I want you to reach out directly to me. I am now the vacation travel planner for the Department of Medicine.”
Her words found their target in Jose Florez, MD, PhD. For months, Florez had been running on a virtual treadmill with little pause: treating COVID-19 patients and coordinating staff as chief of the Endocrine Division; scrambling with his wife (an ophthalmologist) to care for their four children, who were suddenly always home because their schools shut down; and seeing two family vacations canceled because of the pandemic. All were resigned to a summer of work and pandemic-restricted activities around Boston.
But then Florez attended the MGH town hall.
“Katrina was emphatic: ‘You need to take a vacation. I will help you plan a vacation,’” Florez recalls. “This mandate from my chief was liberating. It really pushed us.” His family planned a week at a beach in early July.
Urging staff to literally go away is among the simplest of myriad wellness strategies being employed by academic medical centers that were in the first COVID-19 epicenters, as administrators try to alleviate providers' emotional and mental exhaustion.
“Everyone’s adrenaline was very high” during the initial crush of cases in early hot spots, which enabled them to push through mounting stress to stay on mission, says Bernadette Melnyk, PhD, chief wellness officer at Ohio State University (OSU). “What we are expecting now is almost like a crash-and-burn scenario. I worry about depression. We’ve got to get ahead of it.”
“We’re in a phase of the crisis where many of the staff, especially those on the front line, are just exhausted — emotionally and physically exhausted,” says Saadia Akhtar, MD, associate dean for trainee well-being and resilience and an emergency medicine physician at the Icahn School of Medicine at Mount Sinai (ISMMS) in Manhattan.
A United Nations policy brief issued in May identified front-line health care workers and emergency responders as the first among six “populations of concern” for mental and emotional distress from working and living through this pandemic. Early surveys provide indications of how health care workers might be affected: A study of 1,200 doctors and nurses who tended to COVID-19 patients in China found high levels of distress (72%), depression (50%), and anxiety (45%). In a Canadian Public Health Association survey of nearly 600 health workers involved with COVID-19 care, 47% said they need psychological support as a result of that work.
“It's important for hospitals and health systems to be aware that the workforce may be hurting,” says Jonathan Ripp, MD, MPH, senior associate dean for well-being and resilience at ISMMS.
They are: Hospitals in the first epicenters of the outbreak have been creating and expanding wellness initiatives to assess staff, increase workplace supports, and provide longer-term mental health services.
“We’ve been spending a lot of time doing listening sessions with people,” says Kerri Palamara, MD, who directs the Center for Physician Well-being in the Department of Medicine at MGH.
Now is the time to reflect, disconnect, and restore, because institutions that were hit hard in the spring see this summer as a critical transition period — to the start of school this fall, a possible resurgence of the virus in their communities, or a slower period of more routine medical care.
“Recharging is especially important now, as we prepare to transition to a new academic year, with new house staff and trainees, and figuring out the new normal to practice clinical medicine and train our learners,” says Martine Sanon, MD, director of inpatient geriatric medicine clinical services at ISMMS.
Adding to that challenge, however, is that the environment outside the hospital seems ill-suited for respite; the nation feels awash in stress. There’s an economic recession that threatens job security, civil unrest spurred by racial tensions over police brutality, and new COVID-19 outbreaks around the country that are fueled in part by culture war clashes over social restrictions designed to contain the virus. One psychology professor likens the national mood to an “anger incubator.”
Robust Wellness Strategies
The new and revised wellness strategies provide resources and services at various levels to serve a multitude of needs. “We can all benefit from support,” Ripp says. “Some may need mental health treatment. We’re providing support and treatment at various levels of intensity.”
Those supports aim to cover several broad areas.
Getting staff input: At many institutions, the first steps involved outreach to staff through surveys, support call lines, and webpages for people to share, suggest, and vent. At OSU, Melnyk says, a weekly survey to gauge whatever was on the minds of staff drew up to 40 pages of responses a week, with some people writing dozens of pages. “That was therapeutic for them,” she says.
Moving up the ladder of engagement, hospitals are using regular staff meetings and creating special sessions, both in person and online, for workers to discuss what they’ve been through personally and how their institutions can use what they learned during the crisis to improve health care across the board.
“This is a great time to reflect on what we’ve learned, because we’ve certainly learned a lot,” says Sanon at Mount Sinai.
The uncertainty over how to treat fatally ill patients and the ever-evolving knowledge about how COVID-19 progresses had emotional and practical consequences that need to be addressed, says Larissa Thomas, MD, MPH, director of well-being for graduate medical education at the University of California, San Francisco.
“Doctors were not able to practice medicine the way they were trained,” says Thomas, who directs a national network of medical education well-being leaders through the Collaborative for Healing and Renewal in Medicine. “That can cause moral distress.”
Some examples of the gatherings:
- The Geriatrics and Palliative Medicine Department at Mount Sinai Hospital holds team debriefings facilitated by therapists, psychologists, and chaplains “to pause and reflect on the patients we’ve cared for and ourselves,” Sanon says.
- MGH runs Zoom meetings several times a week for different groups of staff (such as primary care, hospital medicine, and research). Palamara says each meeting is typically attended by several dozen people, who break into groups facilitated by coaches, then convene in full. She says the conversations have ranged from supporting staff with emotional struggles and special responsibilities at home to controlling infections on wards and explaining the financial condition of the Harvard University-based health care system.
- OSU ran a weekly series of 30-minute webinar sessions, Staying Calm and Well in the Midst of the COVID-19 Storm, that used evidence-based techniques to cope with stress. Melnyk says more than 3,000 people registered for the eight-week series.
“This is a great time to reflect on what we’ve learned, because we’ve certainly learned a lot.”
Martine Sanon, MD
Icahn School of Medicine at Mount Sinai
Working conditions: Near the end of the town hall at MGH in May, Palamara — whose academic focus includes physician coaching and well-being — interviewed Armstrong about staff wellness. Her last question was about ways to de-stress, which set up Armstrong’s push for people to go on vacation.
“People were scared they wouldn’t be able to take time off because of the backlog of cases and the financial uncertainty” of their institutions, Palamara says. “There are procedures to be done, patients to be seen, volume that needs to be generated that hasn’t been generated.”
Besides, if “you ask for time off, that means somebody else has to work more.”
To allay those concerns, hospital administrators have upped their coordination of staff to assure everyone that a slot will be covered if they take time off. For shorter breaks from the workplace, they’ve expanded work-at-home opportunities — even for clinical staff.
Northwell Health, which reports having treated more than 13,000 COVID-19 patients through its hospitals in New York, went even further: It offered up to 45,000 of its front-line workers a $2,500 recognition bonus and an extra week off.
“It will make such an impact for me and my family,” one nurse wrote to Northwell Health Chief Executive Officer Michael Dowling. “I am a single Mom of 3 kids, and I have been working and doing OT as I can. I appreciate this more than you know.”
Yet taking a break from the hospital doesn’t erase the risk of contracting the disease when workers return. The novel coronavirus still infects people in the early epicenter communities, and the rise of new hot spots fuels fears that the disease could return on a big scale. Those who worked on the front lines in early hot spots will not soon get past what the disease did to both patients and colleagues nor that the disease hit so hard and fast that many hospitals didn’t have sufficient personal protective equipment in place.
The Centers for Disease Control and Prevention reports that, based on admittedly incomplete data, more than 88,000 “health care personnel” have tested positive for the coronavirus and nearly 500 have died from COVID-19.
Hospitals have used this recovery period to more fully build out staff safety protocols and resources that are clear, thorough, and well-communicated. Mount Sinai’s wellness resource pages for staff cover everything from how to get hand sanitizer for a meeting to how to quickly get a COVID-19 test.
Expanding wellness services: The COVID-19 crisis has spurred hospitals to launch new wellness initiatives, with more extensive supports than previously offered and with an eye toward the days beyond this pandemic. Northwell Health built a recovery workgroup focused on a strategy of “Recognition, Resilience and Engagement,” which includes dozens of activities and services, including peer-to-peer outreach programs to reduce stress, campaigns to memorialize health care workers stricken by the disease, fundraisers for workers in financial need, various forms of gathering staff input (such as social media campaigns and interviews), and online and in-person therapy. At OSU, Melnyk developed a package of COVID-19 wellness resources that includes standard wellness strategies as well as others developed specifically for coping with the risks of the disease.
Aside from boosting its wellness resources, including through a toolkit focused on COVID-19, the Mount Sinai Health System launched the Center for Stress, Resilience, and Personal Growth last month to provide a wide array of services, including mental health screening, resilience training, wellness coaching, and mental health referrals. It will also conduct research studies to understand mental health needs arising from the pandemic.
These efforts “prove the value of having a high-level executive who is focused on the well-being of their colleagues,” says Darrell Kirch, MD, co-chair of the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience and president emeritus of the AAMC. “None of us wanted COVID-19 to happen, but the fact that it did proves how important the emphasis on clinical well-being has to be.”
Ripp is optimistic that through the well-being services and their own resilience, “the great majority” of front-line workers in COVID-19 hot spots “will come through this and be okay.
“Some may even see this time as a period of great fulfillment, where they made a meaningful impact for patients in a time of utmost need."