Why It Matters
The following was adapted from remarks made by Sodzi Sodzi-Tettey, MD, MPH, FISQua, at the IHI Africa Forum 2021.
Each day during the COVID-19 pandemic, health care providers are faced with high-risk environments that exact huge demands, especially on our health. One of the most neglected areas is the toll of our work on our own mental health. In certain cultures, so high is our tolerance for suffering that complaints about stress, chronic fatigue and depression are likely to be dismissed as the rantings of a lazy person.
Knowing this, how do we recognize and urgently manage this critical public health issue?
As Dr. W. Edwards Deming argued, “People are entitled to joy in their work.” This means the overall aim of managers of our health care systems is joy in the health care workforce.
Health care providers cannot have joy when their hospitals regularly run short of personal protective equipment (PPE) or when they cannot be sure when they will be vaccinated. In an example of moral injury, a colleague at the forefront of COVID-19 management said she sometimes felt she was deciding who should live and who should die. She had to choose between who to put on a ventilator and who not to, which patient to refer and which patient not to “waste” time referring because their chance of survival was so slim. This became her burden at the height of the second wave of the pandemic when patients were queuing for oxygen to be supplied.
Are you able to recognize when you are stressed? Are you experiencing poor sleep, fatigue, avoidance, or procrastination? Does forgetfulness, pessimism, emotional outbursts, or feeling overwhelmed seem all too familiar?
What happens when workplace stress becomes chronic and leads to burnout, leaving you emotionally exhausted, with negative feelings about your work, and reduced professional effectiveness? In addition to the personal costs, all of this can result in a greater likelihood of medical errors, less satisfied patients, and a higher turnover.
As journalist and author Jennifer Moss pointed out, “Burnout is more than just an employee problem; it’s an organizational problem that requires an organizational solution.” These organizational solutions must necessarily tackle three things: 1) basic needs, such as food, water, and rest; 2) psychological needs; and 3) ways to enable staff to achieve their full potential at work.
What actions can health care managers and other leaders take now?
- Prioritize our own care. We must change our thinking around certain deeply held beliefs that ultimately harm us. We need to shift away from mental models that automatically assume that more money and benefits are the answer to everything for a tired workforce. While higher remuneration is certainly important, it is not sufficient. We need to push for more meaning, greater purpose, stronger camaraderie or solidarity among colleagues. We must see the link between all this and better health outcomes for patients and families.
At a very personal level, we each have a responsibility to exercise self-care. This means taking deliberate actions to care for our physical, mental, emotional, spiritual, and financial well-being. Basically, take care of yourself, as you would your child.
Self-care may mean going for massages or taking a vacation — an alien concept to some of us who go on leave to take a temporary role at another facility, using our free time to work more. Self-care may also mean spending more time with family, undergoing thorough medical checkups, exercising more, or using the funds put aside by our organizations for professional development. - Proactively manage fear and anxiety. Daily huddles are a simple technique used during IHI’s staff care project in South Africa and in hospitals like Nyaho Medical Centre in Accra, Ghana, where management and multidisciplinary teams come together briefly to surface top-of-mind issues and problem solve. This is an opportunity for honest and transparent conversations. Some of these huddles have kickstarted interventions like flexible work patterns, support with data for internet access, new skills training, rapid supply of essential equipment, and childcare and housing support when staff need to be quarantined.
- Elicit timely feedback on staff well-being. Be open to this feedback and act on it. To understand what matters to staff, managers in the Western Cape Province in South Africa administered an emotional well-being survey. More importantly, they acted upon responses provided by the staff. One statement stayed with me most from the survey: “I worry that I — or my family — will get COVID because of my work.”
- Ensure psychological safety. Provide opt-out mental health and well-being support. The Royal Free Hospital in London had a high turnover of staff (47.7 percent). Their data also showed many staff members were considering leaving. Leaders set out to reinforce teamwork and support new staff. They developed, tested, and implemented change ideas, including holding coffee catch-ups with matrons (senior nurses), increasing the number of shift choices (so staff were not stuck with stressful 12-hour shifts with no end in sight), celebrating the employee of the month, and starting an electronic system for requesting shifts. These changes halved the turnover rates among the nursing staff.
- Create opportunities for staff to reconnect with meaning and purpose. Especially in times of crises, health care leaders need to build a psychologically safe environment where individuals feel safe speaking up about risks or discussing fears openly. These fears may relate to inadequate numbers of hospital beds or ventilators. It could be concerns about PPE or protocols around the use of face masks. Leaders can achieve a lot by being humble, curious, and empathetic. Leaders must communicate to staff that their mental health and well-being are vitally important. It is okay to be vulnerable and speak about your own experiences within the crisis. Leaders have also found it beneficial to create access to mental health support or treatment for all staff and management.
In this COVID-19 era, clinicians face moral distress. This is defined as knowing the right thing to do but facing constraints that make doing it nearly impossible. To help clinicians acknowledge these experiences and find comfort knowing their peers feel the same way, John Hopkins University introduced what they call Moral Resilience Rounds. Twice a week for an hour, a multidisciplinary group of clinicians meet (mostly virtually) to discuss recent ethical challenges. These confidential rounds provide space to acknowledge the distress caused by ethical challenges and to support focusing on finding solutions.
By reframing and prioritizing our care, documenting staff well-being, managing fear and anxiety in a psychologically safe workplace, and connecting to our core purpose, we can take better care of ourselves and each other.
Sodzi Sodzi-Tettey, MD, MPH, FISQua, is a Vice President at the Institute for Healthcare Improvement.
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