key: cord-0048006-hfxal05z
authors: Park, Brian; Steckler, Niki; Ey, Sydney; Wiser, Amy L.; DeVoe, Jennifer E.
title: Co-Creating a Thriving Human-Centered Health System in the Post-Covid-19 Era
date: 2020-06-23
journal: NEJM Catal Innov Care Deliv
DOI: 10.1056/cat.20.0247
sha: 3968cccf1d38d382bbf77bc260b964ac1f0efe2c
doc_id: 48006
cord_uid: hfxal05z

The clinical-burnout epidemic meets the Covid-19 pandemic "tail": How health care leaders can respond.

amongst U.S. health care professionals and students, with over half of health care workers and students reporting substantial symptoms of burnout1 , 2 and up to one-third of medical trainees reporting clinical depression.

Lessons from prior epidemics -such as SARS, MERS, and H1N1 -demonstrate that rates of stress, burnout, and post-traumatic stress amongst health care workers significantly increase not only during these episodes, but for over two years following widespread infectious outbreaks as well.3 , 4 Similarly, rates of productivity decreased, illustrating that attention to the well-being of our health professionals is not only a matter of workforce engagement, but also crucial for the health of our nation's population.

We are entering a vulnerable period in which the psyche of the collective health workforce is especially susceptible to psychological distress and burnout, given the pre-pandemic baseline. We find reason for optimism, however, in the significant attention to workforce well-being during the pandemic by the National Academy of Medicine,5 medical associations,6 and health systems leaders.7 How can our collective focus on workforce well-being be sustained beyond the acute phase of the pandemic? How might we not just survive, but thrive?

In the midst of this volatility and uncertainty, health care leaders will likely feel the burden of responsibility to implement solutions to maintain the well-being of the workforce. While these top-down solutions will be critical, they will need to be complemented with leadership that elicits and acts on insights from frontline health care workers. Rather than reestablishing the old health system that led us to an epidemic of burnout, we need to engage all team members in rebuilding new, higher-functioning systems that promote workforce well-being.8 , 9

Health care professionals and leaders are already at-risk for psychological distress and burnout. Health care is not immune to the societal economic recession, with financial impacts already resulting in widespread pay-cuts and layoffs. This reduced workforce coincides with the demands of restarting patient care, the threat of second waves of infection, and research activities that were deferred in order to enact physical distancing. In short, health care teams may be asked to provide even more care with even less time and resources than what existed prior to the pandemic.10 How will this be sustained?

Fortunately, history frames periods following pandemics as opportunities for positive systemic change. The global flu pandemic of 1918 ignited the development of European national health services, while the Great Depression and World War II fortified the United States' welfare state.11 In a similar vein, organizational experts observe that leadership actions following crises tend to define organizational culture for decades, leading either to long-term stress injury and illness or to "posttraumatic stress growth."12 Though no blueprint exists for leading organizations to well-being in the tail of a global pandemic, prior research in team leadership and organizational resilience points toward organizational factors that facilitate growth after crisis.10 , 13 As we rebuild and reimagine our health care delivery organizations, we have the opportunity to implement practices associated with workforce engagement and satisfaction as well as improved financial performance. A successful tail strategy will require attention to enhanced structural, technical breakthroughs (e.g., sustaining telehealth, increased capacity for Covid testing, value-based care delivery models). Equally important, rebuilding thriving health care delivery organizations will require a newfound focus on relational, cultural leadership strategies (e.g., articulating a sense of purpose, cultivating psychological safety).

Workforce well-being and burnout prevention benefit from individual resilience practices, but are particularly influenced by organizational and leadership practices.10 Leaders' words and actions can, albeit inadvertently, create a mindset of scarcity, where workforce attention is focused on survival and safety rather than thriving. Initial Covid-19 responses appropriately focused on providing essential needs such as personal protective equipment, food, temporary housing, and professional support for mental health. At the same time, agile task forces mobilized innovative and expert responses to emergent pandemic needs, including developing new Covid-19 tests and supply chains and implementing telehealth and other creative methods for patient care. Now, leaders have an unprecedented opportunity to prioritize organizational arrangements that support workforce well-being. We call on leaders at all levels to implement the following six evidence-informed leadership practices during the post-acute phase of pandemic response:

Humanize yourself, humanize others. The acute phase of the Covid pandemic has changed our lives in unprecedented ways, leading to widespread human experiences of grief, anxiety, sadness, guilt, fatigue, and fear.14 The evidence on resonant leadership suggests that, in the face of uncertainty, effective leaders find the courage to be frequently available to their teams, and directly acknowledge their shared human vulnerability. Interpersonally, during times of grieving at work, effective leaders create space for, and serve as witnesses to, team members' pain.15 And organizationally, effective leaders are transparent about sharing the known alongside the unknown, hopes alongside fears, and opportunities alongside realities.16 , 17 Physical distancing protocols will require leaders to creatively maintain presence and connection with team members. As the uncertainty lingers in the tail, visible, vulnerable, and humanistic leadership will be crucial to demonstrate to health care professionals that leaders are identifying with frontline experiences and emotions.

We call on leaders to help team members reconnect with purpose by integrating meaningful projects into regular role expectations rather than relegating them to volunteer efforts outside of work or requiring a loss of productivity-based compensation." Aim high, and encourage others to do the same. Leaders have the opportunity to integrate well-being into our "new normal," optimizing the radical disruption to reimagine both our " workflows and our working relationships for greater human sustainability. Effective leaders both soberly acknowledge the significant challenges that lie ahead and express cautious optimism about our ability to respond to the challenges.18 , 19 We call on leaders to help team members reconnect with purpose by integrating meaningful projects into regular role expectations rather than relegating them to volunteer efforts outside of work or requiring a loss of productivity-based compensation. Effective leaders also find ways to acknowledge and reinforce the positive actions of others (for example, including a "spreading good" feature in regular e-mail or team meetings as an accessible, shareable way to publicly acknowledge positive efforts in a relational forum).20 , 21 Effective leaders signal through their words and actions that people and relationships are prioritized amidst crises.

Care for yourself, and encourage a culture of self-care. The pandemic highlighted essential needs of health care professionals (regular breaks, food during long shifts, respite spaces) and reminded us that well-intended gestures to foster self-care might be insufficient or impractical in certain frontline settings.22 Identifying practical opportunities for self-care requires engagement of front-line team members, given the potential for well-intended initiatives to lack practicality and foster discouragement, or even cynicism (e.g., giving team members a water bottle to encourage hydration without providing time for bathroom breaks).10 Leaders have the opportunity not only to verbally encourage self-care, but to model it themselves, prioritizing integrated time and space for these practices, including seeking professional support if needed. Inviting team members to share something personal, such as an uplift or joy, leads to greater engagement, creative problem solving and a sense of connection.23 Now, more than ever, health care professionals and staff benefit from opportunities to share positive and meaningful experiences.

Flatten hierarchies and spur innovation. As health care organizations emerge from centralized, hierarchical "emergency response" structures, a shift in leadership practices will be required in order to innovate into the new normal, integrating perspectives of all team members. Grassroots innovation requires that front-line team members be empowered with authority and resources to respond quickly without layers of approval. Leaders create a sense of being valued and empowered when they find ways to say "yes," acknowledge not having all the answers, invite and value all voices, express appreciation for divergent views, and make conversational equity the norm.24 These hierarchy-flattening leadership behaviors increase the odds that team members feel psychologically safe to take interpersonal risks, such as sharing new ideas, challenging groupthink, or admitting mistakes, all of which foster creative thinking.25 , 26 Cultivating psychological safety for both emotional well-being and to spur innovation will increase engagement from frontline team members to redesign and realign workflows. Leaders may further consider redesigning compensation practices to include improvement as part of team members' core paid work.

We risk hastily reintegrating team members into their typical responsibilities, at the expense of allowing time for them to reflect on their pandemic experiences and look for meaning and healing." " Prioritize time for individual and collective recovery and reflection. As rates of Covid-19 infections fall and non-urgent health services resume, we risk hastily reintegrating team members into their typical responsibilities, at the expense of allowing time for them to reflect on their pandemic experiences and look for meaning and healing. Many team members will have experienced the illness or loss of a beloved colleague or family member, moral conflict, or ongoing distress around pervasive changes to work and life. No single psychological support resource will address all individuals' needs. Rather, leaders are encouraged to advocate for accessible support resources, including psychological first aid, ongoing professional counseling,27 formal peer support,28 and reflective group activities29 (e.g., narrative medicine or "Schwartz rounds" that focus on the emotional impact of patient care on the provider). Mandatory single-session group debriefings about traumatic experiences are not a recommended practice for addressing trauma and may actually cause more distress among some attendees.30

In addition to providing individual-level opportunities for learning from the crisis, leaders can also encourage ongoing collective reflection by inviting team members to check in emotionally with their colleagues, reflect on their experiences, and distill learnings.12 Appreciative inquiry practices can yield important lessons about how to strengthen our response to stressors in the future. These reflective practices could become imprinted into a longer-term culture of enhanced organizational resilience.

Invest in relationship-based forms of leadership development. An increasing body of evidence documents the mutually reinforcing impact of combining investments in relational capacity alongside investments in technical systems (e.g., quality and process improvement methodologies).31 Enhanced relationship skills are crucial for leaders at all levels, given evidence that middle managers account for at least 70% of the variance in employee satisfaction and engagement at work,32 and that emotional intelligence, humility, and a strengths-based approach to leadership are associated not only with workforce satisfaction,33 but with improved quality of care.34 Senior leaders can play a critical role in fostering workforce well-being during the tail by supporting leadership development opportunities for mid-level leaders in the organization who directly influence the experience of the front-line workforce.35 Leaders may also appreciate being able to receive confidential coaching on ways to promote these relational practices and to learn from other leaders through facilitated group discussions on team and organizational resilience.

The Covid-19 tail offers an unprecedented opportunity to enhance health care organizations' human and financial sustainability. Our aligned purpose during Covid-19's acute response phase can be extended to support long-term workforce well-being by creating new workflows and cultures that integrate both relational and technical best practices. Without team and cultural practices that explicitly invite and value all voices, we risk losing crucial and timely front-line data and perspectives.33 Work units that have previously invested in team culture can lead the way and serve as models.

Implementing these recommendations will require vision and perseverance on the part of leaders at all levels, as well as clarity and discipline regarding which decisions need to be made centrally and which can be entrusted to front line team members who are doing the work. During this period of physical distancing and forced over-use of technology for communication, it is both additionally challenging -and all the more crucial -for leaders to find ways to connect with, recognize, and humanize individuals throughout the organization.

Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being

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From triple to quadruple aim: care of the patient requires care of the provider

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Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout

We can't go back to normal': how will coronavirus change the world? The Guardian

Caring for Health Workers During Crisis: Creating a Resilient Organization

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The Psychology Behind Effective Crisis Leadership

Resonant leadership: Renewing yourself and connecting with others through mindfulness, hope, and compassion

The Russell Sage Foundation series on trust

Teaming to innovate

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A critical examination of the role of appreciative inquiry within an interprofessional education initiative

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Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level

The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions

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Feasibility of a Comprehensive Wellness and Suicide Prevention Program: A Decade of Caring for Physicians in Training and Practice

COVID-19: Peer Support and Crisis Communication Strategies to Promote Institutional Resilience

World Health Organization. Psychological debriefing in people exposed to a recent traumatic event

A Mixed Methods Study of Change Processes Enabling Effective Transition to Team-Based Care

State of the American manager: Analytics and advice for leaders

Relationships and Resilience: Care Provider Responses to Pressures From Managed Care

Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients