key: cord-0064653-ktzj65ir
authors: O’Hayer, C. Virginia; Nobleza, Deanna N.; Inch, Samantha; Rene, Rachelle; Capparella, Lisa; Vergare, Michael; Lauriello, John
title: Behavioral Health for the Front Line: Lessons from the Covid-19 Pandemic
date: 2021-06-16
journal: NEJM Catal Innov Care Deliv
DOI: 10.1056/cat.21.0109
sha: ab83d7712b95492173b8fc072cbb06e7911c2060
doc_id: 64653
cord_uid: ktzj65ir

Covid-19 has created unprecedented mental and emotional stress on health care workers. Jefferson Health in Philadelphia created a comprehensive tiered program — self-help, peer and managerial support, and professional therapy — to help its staff and in the process has established mindfulness and mental health as a priority in its organizational culture.

support, and second, to refer them to other resources as needed. This training included mental health first aid, 1 a program that has proven effective in workplace settings 2 and has been found to reduce stigma regarding mental health concerns. 3 It teaches how to respond to signs and symptoms of mental health challenges in employees and coworkers.

" The unique and long-lasting challenges posed by the Covid-19 pandemic, and the resulting stress on mental health, required a variety of novel and innovative interventions.

Psychological first aid (PFA), 4 originally created in the 1950s by the World Health Organization, is an empirically supported intervention for managing and preventing the development of Covid-19 Four-Tier Interventional Model

The Covid-19 four-tier interventional model from the Department of Psychiatry and Human Behavior and HR at Sidney Kimmel Medical College. Dept. 5 Department, EAP 5 Employee Assistance Program.

Adapted from UofM peer support model FIGURE 2 Timeline of Covid-19 Behavioral Health Response at Jefferson Health RISE 5 Resilience in Stressful Events, SOS 5 Sign-Out Support. 

April 2020

May -June 2020

July 2020

November -December 2020

Source: Jefferson Health.

NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society trauma among health care workers. PFA has proven effective in addressing both immediate and midterm mental health issues after incidents of mass violence. 5 Given its applicability and effectiveness during the Ebola virus outbreak, 6, 7 PFA was used to inform aspects of our program's Sign-Out Support (SOS) peer support shift-change groups.

Comparison The University of Missouri's forYOU program 8 was one of the first peer support programs in the United States for "second victims" 9 : health care workers impacted by an unanticipated patient event. The program's emphasis on support across many stages of recovery seemed relevant given the long and uncertain nature of the Covid-19 pandemic and the many adverse patient events and deaths.

Tier 1: Self-Help, Well-being, and Coping Support Tier 1 resources focus on prevention and early intervention. They include self-care, self-help, healthy coping resources, and skills-based education programs that are self-guided, accessible in a variety of formats for different learning styles (print, audio, video, and live webinars), and available on our employee portal. They address the evolving challenges of the pandemic and help employees manage anxiety, understand grief, learn when it is appropriate to get help, support children's coping, and build resilience.

Tier 2: Local Unit/Department Support Tier 2 represents local and departmental support. Within an organization, the local unit and departments are in the best position to recognize and respond to team members experiencing challenges. Close colleagues and managers are often the first to notice when a colleague is suffering, to hear about troubles at home, or to become aware of an unanticipated patient event.

They also play important roles in providing collegial support, reassurance, encouragement, and practical help in the workplace. These skills of observation, noticing, mutual support, and team building became even more important during the pandemic. We developed a 4 R's "Caring for Our Own During Covid-19" infographic -Recognize, Respond, Refer, and Revisitto give team members a road map for approaching and assisting colleagues.

We developed five virtual programs to formalize peer support for our employees. Three were peer support groups and the other two used a one-on-one format. Employees may be referred by a colleague or self-refer to participate in these programs. This tier has undergone the most transformation in response to feedback.

Tier 4 resources involve professional help/support, including primary care providers (responsible for referring patients for behavioral health services), mental health professionals, and pastoral counseling. We promoted our employee assistance programs, which offered 24/7 support to employees and their household members and included telehealth services and critical incident response for traumatic events and unanticipated patient events. Our Employee Assistance Program uses an approach called critical incident stress debriefing (part of critical incident stress management 10 ), which has been applied successfully across a variety of incidents, including the September 11 terrorist attacks, 11 natural disasters, 12 ER-related traumas, 13 and combat. 14 " Close colleagues and managers are often the first to notice when a colleague is suffering, to hear about troubles at home, or to become aware of an unanticipated patient event.

Our pastoral care department developed a hotline for employees desiring spiritual support and connection. Our Department of Psychiatry and Human Behavior developed a formalized process to expedite referrals for health care workers and employees to diminish barriers and cut down wait times. We promoted local and national crisis response resources, including the national suicide prevention lifeline, 1-800-273-TALK.

In a combination of Tier 3 and Tier 4 efforts, a small team of Behavioral Health faculty with expertise in suicide prevention urgently came together after New York ED physician Lorna Breen died by suicide in late April 2020. We created a short webinar for employees, department chairs, and unit leaders that addressed warning signs, suicide prevention treatment, and building a life worth living during the Covid-19 pandemic. We followed up the webinar by holding focused conversations with individual departments and teams.

Initial Approach: March-Summer 2020

We created a library of well-being resources on topics including how to breathe for relaxation, manage anxiety, understand difficult emotions, build resilience skills, cope with grief and loss, support children's mental health, and find balance in a remote work environment. We created short videos (ranging from 7 to 30 minutes long) covering topics such as radical acceptance, selfcompassion, coping ahead, committed action, and mindfulness. These are drawn from empirically supported acceptance-based behavioral therapies, including dialectical behavior therapy (DBT) 15 and acceptance and commitment therapy. 16 All content was made accessible by audio alone (offering a chance to listen on one's drive home from work), video alone with subtitles, and audio and video combined. Some of our videos are also posted on YouTube for public consumption and have generated hundreds of views.

The Tier 1 resources were listed on an internal employee portal landing page. From March through August 2020, the page and its contents were viewed 14,903 times. The most-viewed YouTube video was "Self-Compassion: Mental Health for Health Care Providers in the Covid-19 Pandemic," with 845 views. In the same series, videos focused on Radical Acceptance (308 views), Mindfulness (373 views), and Coping Ahead (341 views) were also well received.

The Tier 1 content has been well received throughout the pandemic and has remained mostly unchanged, although we have added more content to address evolving needs. For example, we launched "Enduring the Emotional Aftermath," a series of interviews with experts from our Department of Psychiatry and Human Behavior on how to cope with difficult emotions. A series of Winter Wellness videos was added to address seasonal mental health considerations (for example, how to adjust to holidays during the pandemic).

Jefferson Health's Primary Care Integrated Behavioral Health Team was one of the first teams to launch live wellness group sessions, Jeff Be Well sessions, during the early phases of the pandemic in March 2020. These sessions provided a safe space for employees to share their collective experience and to learn coping skills to better manage Covid-19-related stress and anxiety. They also met employees' need for connection, psychoeducation, and physical and emotional support.

These 30-minute group sessions, offered live via Zoom on a variety of topics (Table 1) , were facilitated by the department's behavioral health consultants (BHCs) who are licensed clinical psychologists, clinical social workers, and marriage and family therapists. 17 Participants were encouraged to engage in the sessions at their own pace, with video on or off, to ask questions, and to use the platform as a source of support and community. Participants were also encouraged to reach out to BHCs if they had any follow-up questions or needed further consultation, support, or resources. The sessions presented an opportunity to pause, breathe, and de-stress. Participants connected with others, talked about shared experiences, created a sense of community, and learned coping strategies for stress, anxiety, and grief. Sessions were advertised via the employee intranet and weekly emails sent to clinical, academic, administrative, and counseling leaders.

Initially, six to eight sessions were offered per day and were very well attended by 137 participants in week 1 (March 23, 2020), rising to 214 participants in week 4 and declining to 100 participants by week 6 ( Figure 3 ).

In late May, as session attendance began to wane, the team reduced the number of sessions offered per day to two or three. Sessions were reorganized by daily themes: "Mindfulness Mondays," "Transformation Tuesdays," "Wellness Wednesdays," "Thankful Thursdays," and "Flexible/FUNtastic Fridays."

To further accommodate the need for support, Jeff Be Well sessions were offered separately to teams and departments whose staff were unable to attend sessions during the times offered throughout the day or the week. Team/department leaders could request live sessions for their teams as the first part of a team or department meeting.

" All content was made accessible by audio alone (offering a chance to listen on one's drive home from work), video alone with subtitles, and audio and video combined.

A total of 388 Jeff Be Well sessions was offered during the 17-week span (March through July 2020), and attendance totaled 1,324. (To preserve employee privacy, we did not track attendance in a way that would tell us how many employees participated, although we know anecdotally that some attended more than one session. By role, 46% were academic administrative personnel, 34% were clinical providers, and 9% were faculty and students.) The best-attended sessions were "Yoga for All" (225 attendees), "Managing Anxiety: Mindful Coping" (101 attendees), and "What I'm Feeling is Normal: Managing Grief, Loss, and Anxiety" (103 attendees). Overall, participants reported that the sessions were "very helpful" and "much needed during this time." Employees reported feeling both supported and amazed that this level of support was available to them within the organization. 

SOS groups were developed because our frontline health care workers requested support at change of shift. Beginning in early April 2020, these drop-in support groups created a safe and supportive space to share patient-care challenges and strengthen coping skills. Clinicians from the Department of Psychiatry and Human Behavior facilitated each group, after completing the free, online 6-hour training on PFA from the Department of Veterans Affairs National Center for PTSD. The core actions of PFA served as the underlying supportive interventions for the peer support group structure, given the applicability of PFA as a support intervention during the Ebola virus outbreak. 6,7 SOS groups were 45 minutes long and offered daily via Zoom at 7:30 a.m. and 7:30 p.m. at change of shift. We saw low utilization, with only five participants attending between April and June 2020, although those few participants benefited enough that we considered the groups worth continuing. In July 2020, we shifted to scheduling upon request, promoting the groups to managers and leaders as a method to provide support to their units, departments, and staff. This shift led to more robust utilization of the program. We facilitated 27 virtual SOS groups, attended by 317 participants, between July and November 2020. The SOS group structure began with a welcome and some education from the facilitator about normal responses to stress (numbness, feeling overwhelmed, or irritability) followed by 25 minutes of facilitated discussion. The facilitator shared resources with the group, and the meetings ended with resource sharing and affirmations of strength and resilience. SOS groups and schedules were promoted enterprise-wide by email and intranet as well as through team meetings and huddles. We also promoted them to resident physicians through the graduate medical education office.

We began offering this 30-minute live Zoom session in mid-March 2020, three times a week, to all Jefferson workers. Sessions were timed so that different shifts would have access on different days. Sessions were based on the crisis survival/distress tolerance module of DBT skills. 15 They helped workers develop coping skills for immediate problems, such as managing intense emotions, radical acceptance of the current situation, creating meaning by connecting with one's values/life mission, mindfully transitioning from work to home life, reducing vulnerability to intense emotions, attending to self-care, and prioritizing sleep.

Application of DBT skills to a frontline health care worker population is a particularly innovative component of our coordinated pandemic response. To date, the application of DBT skills in this type of setting has not been documented extensively in the literature, although examples exist of such interventions in the context of psychiatric ERs. 18 Pulling specific practical coping skills from both DBT and cognitive behavioral therapy (CBT) has been well received by our population of health care workers.

" Drop-in support groups created a safe and supportive space to share patient-care challenges and to strengthen coping skills.

These sessions drew up to 20 participants each during the first week, but attendance had dropped to about five participants per session by the second week, and some sessions had no participants. We experimented with offering sessions at different times, but attendance continued to wane, and by the third week, only one or two participants were attending a session, with other sessions unattended.

Nurse2Nurse peer support was developed in May 2020, in response to the anticipated need for one-on-one support among frontline nurses caring for patients with Covid-19. Because the stigma of mental health concerns might impact help seeking and because some individuals might feel uncomfortable sharing within a group format, the program was developed as an alternative to group peer support. Nurse2Nurse peer support sessions were hosted by nursing faculty, structured as 30-minute virtual private appointments via Zoom, and offered 7 days a week with morning and evening time slots. Nurses interested in scheduling a Nurse2Nurse peer support session were encouraged to sign up via an online request form. The Nurse2Nurse peer support sessions and sign-up schedules were promoted enterprise-wide by email and intranet, as well as on units. This program was not attended initially, with only one nurse seeking support in June 2020 and one in July 2020.

An embedded consultation and liaison (CL) psychiatrist attends to the mental health needs of Jefferson inpatients. The trusting relationship already established between this provider and the nursing staff across inpatient units proved to be extremely important to our efforts. It allowed for early identification of the needs of patients with Covid-19, other patients, and frontline staff.

Because visitors were allowed only on a limited basis during the initial phase of Covid-19, there was particular concern about and attention given to loneliness and isolation among inpatients, on the basis of prior clinical and research data suggesting the negative impact of isolation. 19, 20 The Department of Psychiatry provided iPads for inpatients with Covid-19 to use to consult with a psychiatrist in another room, eliminating the need for multiple pieces of personal protective equipment (PPE) (masks, goggles, and face shields) that can interfere with an accurate assessment of a patient's mental state and the formation of therapeutic rapport. However, in the case of more severe mental health concerns, such as acute suicidality, the CL psychiatrist would enter the patient room with full PPE in order to perform an in-person assessment. Additionally, all inpatients were offered access to the Zoom webcam platform, allowing them to contact loved ones to reduce loneliness and increase connection.

The CL psychiatry team was understandably concerned about acting as vectors of Covid-19 transmission. They adopted a system of consulting in non-Covid-19 rooms before visiting patients with Covid-19, eliminating transmission risk. Psychiatry resident presence was also reduced by half to reduce exposure risk and to ensure adequate coverage if residents needed to quarantine or became ill.

The CL psychiatry team increased its surveillance of anxiety and distress among nursing units, teams, and staff by checking in with nurses across the hospital system (except for the ICU, where foot traffic was greatly limited). Taking the time to listen to nurses and learn from their experience allowed us to provide direct support and to inform our hospital-wide behavioral health efforts. The CL psychiatry team discovered that most providers were not aware of the many resources available to support them. In response, we made the pyramid ( Figure 1 ) the screen saver on all inpatient unit computers.

We discovered that many of the programs we had assumed would be of use and interest either were not used at all or received initial enthusiasm followed by lack of engagement after a couple of weeks ( Figure 4 ). In response, we stopped some programs and revamped others. In several cases, we placed the burden of request for services on the hospital team or department rather than on the individual. This approach allowed:

protected time at work to attend sessions,

Successful Versus Underutilized Behavioral Health Offerings During Covid-19 Pandemic Successful versus underutilized behavioral health offerings during the Covid-19 pandemic at Jefferson Health.

x Team-based interventions: team-scheduled coping skills groups, mindfulness sessions x Department-based interventions: work-life balance skills, resilience-building, connecting with values x Self-paced learning (videos, interviews)

x Leadership-wide Mental Health Retreats

x Shi-change group interventions x Drop-in coping skills groups x Drop-in process groups x Interventions where the individual is responsible for taking the initiative to sign up

Source: Jefferson Health.

NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society reduction in stigma by providing interventions to a whole team rather than to a specific individual, and the ability to tailor the intervention to the specific team's needs. These factors increased the success of these programs.

The self-care resources on the Covid-19 Well-being page had good usage, and we expanded them. We developed comprehensive "tool kits" for larger emotional complexities, such as our Winter Wellness Guide for managing well-being during the winter months. We also added training resources for managers and leaders to help them help employees. By March 2021, the resources had accumulated 24,257 views.

" The Department of Psychiatry provided iPads for inpatients with Covid-19 to use to consult with a psychiatrist in another room, eliminating the need for multiple pieces of PPE (masks, goggles, and face shields) that can interfere with an accurate assessment of a patient's mental state and the formation of therapeutic rapport.

Jefferson Health's Abington campus had a large volume of Covid-19 cases, and its clinical mental health resources were limited. Many patients were unable to be discharged for a number of reasons, including lack of discharge facility, exacerbation of psychiatric and/or behavioral health needs, and Covid-19-positive status. Between May and June 2020, the Integrated Behavioral Health team collaborated with Abington's Psychiatry Department to provide individual wellness sessions and psychological support to patients affected by Covid-19 both on the inpatient unit and throughout the hospital. We developed an Integrated Behavioral Health Inpatient Response Team (IBH-IRT) consisting of BHCs embedded throughout various primary care practices who were available and on call to respond as needed. Efforts were made to quickly provide the IBH-IRT training and remote access to the unit's electronic medical record system in order to document and coordinate care with the patients' medical team. A number of these patients felt isolated, with no family connection. Patients were offered a 20-to 30-minute individual session with a BHC via Zoom or telephone while awaiting discharge or transfer care to a nursing facility.

BHC sessions were primarily supportive, preventive, and targeted. BHCs identified patients' immediate concerns and needs, coached them in coping skills to manage current emotional and physical stressors, and assessed for suicidality. Any concerns were immediately shared with the patient's provider and clinical team. The team provided 18 sessions to 13 patients during the 1-month span. (A few patients needed multiple sessions.) Overall, patients responded positively to the opportunity to "connect with someone" and to have a BHC listen to them and offer support during a very difficult time in their lives.

Jeff Be Well was launched again in November 2020 as part of the Winter Wellness package, and the daily drop-in sessions were congruent with the emotional health-related themes of that time, including how to manage pandemic fatigue, address seasonal affective disorder, and find joy during the socially distanced holiday season. The program continued through the second surge of the pandemic during the final months of 2020, and participation again began to decrease in January 2021. The series is now paused as we evaluate how best to move forward in support of employees.

To promote the availability of well-being resources, we formalized Zoom-based "We Care Teams." These are regionally focused (Northeast, Center City, New Jersey, and Abington) and comprise senior site administrators, a nursing leader, and a local HR liaison. The primary team members watch for hot spots and critical events and are encouraged to open the conversation locally about specific needs for support and information. Members of the Department of Psychiatry and other licensed mental health professionals from the College of Nursing are included as part of these teams so they can be available for support when needed. The We Care Teams back up Tier 2 supporters and encourage them to use available resources. Over time, we have also identified formal and informal clinical wellness champions who want to support our mental health initiatives. Updates and relevant information on wellness events or resources are emailed to the We Care Teams and the wellness champions monthly.

Beyond the need for individual support, we recognized the need for support in academic clinical departments and hospital sites and to provide expert consultation to the "We Care Team" membership. Academic clinical departments and hospital sites have unique demands shaped by their professional focus, identities, location, and priorities. We developed departmental assistance matched to specific departments and hospital sites. The behavioral health liaison initiative created linkages and a formalized process by pairing a professional from the Department of Psychiatry and Human Behavior with a point person within a clinical department and hospital site to provide expert consultation, educational programming, and focus groups and to assist with mental health and well-being referrals and resources.

This "Adopt a Department" program began in September 2020 and now serves more than 90% of departments at our Center City (Philadelphia) location. These liaisons make it easy for leaders and employees to receive behavioral health input whenever needed. Recent interventions have included education sessions (Anesthesia and Surgery), coping skills sessions (Oncology and Transplant), and a multitude of one-to-one curbside and formal sessions primarily serving individuals looking for help for themselves, family members, and colleagues. We plan to extend this program to our other locations.

In July 2020, we began to offer coping skills workshops by request to entire teams or units. Available topics include work-life balance, making meaning of work efforts during the Covid-19 pandemic, growing gratitude, mindfulness skills, and coping skills to manage an ongoing crisis.

To date, there have been 12 requests for 45-to 90-minute sessions. In addition, our solid organ transplant unit has requested a series of workshops focusing on mindfulness strategies for stress reduction and mental wellness. Nurses in inpatient care have found mindfulness training particularly effective in reducing stress. 21

We believed that peer support would be important to nurses' mental health and were surprised that the Nurse2Nurse program (described earlier) generated almost no interest. We conducted several focus groups to find out why. Nurses identified several barriers, including lack of awareness of the program, exhaustion, pandemic saturation, family commitments, stigma around getting help, and a general discomfort with the unknown structure of the session. As we had discovered with SOS groups, usage rates were low when responsibility was placed on the individual, rather than management, to sign up for a session. We restructured the sessions to be offered to entire units at once, to give staff the opportunity to participate in an emotional debrief session together. When we piloted this new approach with Jefferson's downtown Philadelphia inpatient nursing units, the team received eight requests for unit-based sessions within the first 48 hours. In October and November 2020, 40 nurses took part in this unit-based approach, and the program continues to get steady use.

" We discovered that many of the programs we had assumed would be of use and interest either were not used at all or received initial enthusiasm followed by lack of engagement after a couple of weeks.

Four separate populations have approached us requesting robust support for their specific member concerns. These include employees of our cancer center, students in our student counseling center, health care providers seeking to serve as peer supporters, and Jefferson leadership seeking tools to best support their employees throughout the pandemic.

The Cancer Support and Welcome Center at Sidney Kimmel Cancer Center requested a twiceweekly ongoing intervention for its health care providers to address self-reported loneliness and distress. These programs are regularly attended by 10 to 20 participants weekly. Each lasts 20 to 30 minutes, is offered at a time convenient to staff, and is facilitated by a licensed clinical psychologist. Coping Effectively Through Covid-19 offers evidence-based strategies to help cope with anxiety, distress, and loneliness, applying skills from DBT, 15 acceptance and commitment therapy, 16 and CBT. 22 Mindful Moments includes a 5-to 20-minute mindfulness practice.

Each session begins and ends with a Zoom poll asking, "How distressed do you currently feel?" Attendees respond on a Likert scale from 0 to 10, with 10 indicating the highest level of distress.

On the basis of 253 responses between March and September 2020, the Coping Effectively Through Covid-19 program decreased distress among staff members, from a mean score of 5.51 at the start of the session to 3.03 afterwards. Using the same scale, the Mindful Moments program decreased distress from 5.36 to 3.48.

On March 13, 2020, the University suspended in-person classes and transitioned to online learning. Our University Student Counseling Center (SCC), serving the mental health needs of medical students and other students across the University, was an early utilizer of telehealth in 2015, having published research on the use of telehealth in college counseling. Thus, the SCC staff had significant telehealth experience and a Health Insurance Portability and Accountability Act of 1996-compliant telehealth platform and could make a swift transition not available to many other college counseling centers. The University SCC provided confidential telehealth services, including individual and couples counseling and psychiatric management for new and follow-up appointments.

Our SCC follows a Comprehensive Counseling Center model used by many university and college counseling centers. It has four pillars: direct clinical services, outreach, consultation, and training. 23 We developed a variety of virtual student outreach programs to engage students who had shifted to remote learning. Synchronous, virtual group program topics included mindfulness-based stress reduction, how to maintain connection during the pandemic, loving kindness, coping with anxiety, creating a "new normal," grief and loss, affirmations, gratitude, and celebrating milestones during the pandemic. The Jeff Be Well sessions were made available to students. Drop-in support groups were offered for students of color and the LGBTQIA1 student community. Creative virtual programs such as creative writing, coloring, and journaling were also offered. Instagram was used to promote photo wellness challenges. All group programs were facilitated by a mental health professional. Outreach programs were promoted through multiple channels, including email blast, a newly created wellness e-newsletter, social media, and a Covid-19 wellness tips website.

We borrowed the "eight dimensions of wellness" model developed by the Substance Abuse and Mental Health Services Administration (SAMSHA)physical, emotional, social, intellectual, occupational, financial, environmental, and spiritualto create a Covid-19 wellness tips website with internal and external resources for each wellness dimension. Developed in collaboration with student counseling, student affairs, university health, fitness and recreation, student engagement, financial aid, marketing, and IT, the site included such essential resources as the Centers for Disease Control and Prevention website, SAMSHA's disaster distress helpline, and the National Suicide Prevention Lifeline.

" The primary team members watch for hot spots and critical events and are encouraged to open the conversation locally about specific needs for support and information.

We addressed the well-being of faculty as well, with resources to promote self-care, create safe and engaged online teaching practices, raise awareness about student and faculty vulnerabilities during Covid-19, and build competencies among faculty to identify and address student needs. These resources included several short videos, easily accessible and digestible, on topics such as promoting student wellness in the virtual classroom, healing-centered teaching practices, understanding student experiences of the Covid-19 pandemic, and how to help a student in distress. One addressed "microstrategies": brief introductions to evidence-based wellness interventions for when students or faculty need a "brain break" for self-care. Examples include box breathing, gratitude practices, self-compassion, social connectedness, sleep hygiene, and mindful breathing.

Staff members from student affairs and student counseling offered a "Student Support Sidebar": virtual faculty drop-in sessions held 4 days a week to give advice on how to support students in need and to provide a figurative space for "curbside" conversations that typically would have happened in person on a college campus.

Adverse medical events create "second victims": the health care providers present at the event.

Although system errors are evaluated following these events, little attention is given to the emotional impact on the health care workers involved. The Covid-19 pandemic has created a second pandemic of second victims, who often experience anxiety, doubt, restlessness, and fear. Some question their ability to take care of patients, some quit their jobs, and others leave the profession. A few kill themselves. 24 To help our second victims, an interdisciplinary team led by Quality & Safety, Enterprise Risk, HR, the Department of Psychiatry, and Nursing created a peer support program based on the model originated at Johns Hopkins known as Resilience in Stressful Events (RISE). 8 The program trains providers in PFA skills to support fellow clinicians in a nonjudgmental environment. RISE responders also equip caregivers with healthy coping strategies to promote well-being, provide wellness resources and referrals, and guide individuals to continue thriving in their roles. Providers in need can call a hotline to connect with a RISE responder for a one-onone confidential session. We piloted RISE at the downtown Philadelphia hospitals beginning in February 2021 and will launch at other campuses later this year. As of this writing, 90 providers have signed up as RISE responders, and 13 providers have already asked for RISE assistance.

Although they are not directly involved with patient care, our organization's leaders face their own strains while managing the concerns and fears of their staff. To support them, Jefferson HR produced several resources based on existing literature. 25 The "Leading in Challenging Times" series comprised 30-minute modules, part instruction and part workshop discussion, regarding real-life situations and practical solutions to leadership challenges. The HR team also created a simple 25-minute training for managers and executives on how to navigate our well-being resources. A segment on the 4 R's framework -Recognize, Respond, Refer, and Revisithelped our leaders learn how to offer support to a colleague. Finally, a manager guidebook outlined how to have difficult conversations with staff about their stress and mental health, emphasizing the importance of modeling well-being in a vulnerable way and the value of proactive outreach and empathic listening. It also reviewed Jefferson's four-tiered pyramid (Figure 1 ).

HR and the Department of Psychiatry created a program to feature in a special Leadership Meeting on Mental Health & Coping for the organization's top 300 leaders, conducted via Zoom, the first of its kind at this level for our institution. A short video with testimonials from various employees who have used our mental health and wellness services (mostly at Tiers 1 and 3 of the pyramid) was followed by testimonials from our top executives regarding the importance of attending to mental health and wellness during these challenging times.

Leaders from across the Jefferson enterprise then spoke live on Zoom with behavioral health experts from the Department of Psychiatry about management challenges they have faced during the pandemic.

Our executive leadership is committed to integrating holistic wellness as an attribute of Jefferson's culture, and meeting attendees strongly endorsed the mental health topic. We were invited back to the next executive leadership meeting. We presented a program less elaborate than the first one, featuring a panel of behavioral health experts answering questions from the attendees about how to attend to the wellness of their staff.

Executive leaders encouraged their colleagues to practice self-care by protecting time at home/ away from work and to lead by example by not emailing employees during family/home/ relaxation time. These measures, designed to reduce and prevent burnout and improve mental health, represent a marked departure from the norm in many hospitals.

Discussion of mental health and well-being is planned as a regular feature of future leadership meetings.

As of this writing, we plan an increase in mental health services for health care providers, patients, caregivers, and students. We have previously launched recorded, self-paced content on coping with isolation, managing painful emotions, preparing for a different kind of holiday season, managing pandemic fatigue, understanding seasonal affective disorder, giving as a wellness strategy, and getting the most out of the new year.

Along with self-paced Tier 1 self-care resources, we launched various Tier 3 peer support programs and interventions, particularly during shift-change times. However, these were generally not well attended. We now offer programs and interventions by request, particularly targeting units and departments with a high number of Covid-19-related deaths. As a comparison of Figures 3 and 4 reveals, when Covid-19 hospitalization rates are high, mental health interventions targeting health care providers are well attended.

" We addressed the well-being of faculty as well, with resources to promote self-care, create safe and engaged online teaching practices, raise awareness about student and faculty vulnerabilities during Covid-19, and build competencies among faculty to identify and address student needs.

We have discovered that putting the responsibility on management, rather than on the individual, to request a wellness session will help health care providers attend and engage. Using this method of scheduling, we have seen an increase in attendance across all of our programs during the most recent surge.

Usage rates over 2020 showed consistent use during and immediately after the first surge of Covid-19 in the spring, with a lull over the summer, and an increase again as the second surge progressed in late 2020. Our workers still face barriers accessing these resources, including overall time constraints, scheduling conflicts (for example, how to enable nurses to attend Zoom events while ensuring adequate staffing for patient care), overall exhaustion, technology issues, and family and childcare challenges. We continue to adjust our strategy. A combination of asynchronous, self-paced videos and synchronous team-based workshops seems to be optimal.

We are encouraged by the extent to which our health care system, especially its leadership, has embraced mental health and wellness. Two recent executive leadership meetings have included mental health and wellness skills training, and we expect that leadership development initiatives will continue to include this type of content.

Throughout this journey to bolster the mental health of health care workers during the Covid-19 pandemic, we have emphasized employee confidentiality. Employees were welcome to attend our online (Zoom) offerings however they chose: with video on and full name stated, with video on and first name only or nickname stated, without video with name only, and completely anonymously (no video and no name). Self-paced videos (on the Jefferson Intranet and on YouTube) were not tracked to individual employees. All data were gathered anonymously. Employees uncomfortable seeking mental health services in a group format could request oneon-one sessions, and those reluctant to seek services within Jefferson could be referred out.

During team-based mental health workshops, all attendees were asked to keep any information shared by other attendees confidential and were reminded that they were welcome to participate at any level in which they felt comfortable (including listening only or private messaging the clinician leading the workshop).

As researchers, we certainly wish we could have gathered more data and linked them to outcome measures such as absenteeism, effectiveness at work, and use of outside resources, but this type of linking would have jeopardized confidentiality, and gathering data beyond attendance and brief measures of distress would have risked overburdening our already stressed employees. We have since launched more in-depth surveys of employee morale and satisfaction, and results are pending.

In the meantime, several employees have offered public testimonials about their experiences of our programs. These were shown at our Jefferson-wide leadership mental health retreat. Excerpts include:

"I was having a panic episode and I thought about [the self-paced video] 'Accepting Fear' … I sat there and felt myself calm down, knowing 'It's ok to be afraid.'" "[Jeff Be Well] was really beneficial and practical; they gave us the resources to use these skills on our own, starting the day off with this gave me peace and was soothing."

"At the end of a [Effective Coping Skills for Health Care Workers] session, after we do a mindfulness or learn a new coping strategy … without a doubt, every single session my distress was lowered."

"For me, [Mental Health First Aid] helped to give me some tools and confidence for helping my own employees."

"[Nurse2Nurse] really took a weight off to be able to talk to people who were nurses and knew exactly what we were talking about and could relate on a different level … and the tools to help us cope were catered to our specific role as nurses."

Previous models, including PFA, mental health first aid, and critical incident stress debriefing, largely involve training of non-mental health experts in interventions designed to detect and intervene to prevent deterioration of health care workers' mental health. While our approach uses this strategy at various levels of the pyramid, our blueprint also includes the deployment of mental health experts (psychiatrists and clinical psychologists) to ensure that all employees have access to mental health resources at any desired level of engagement. The variety in level of expertise, engagement, and modality of intervention is a major innovation of our program.

Our workers can choose their own pace and proximity of engagement with mental healththrough audio/video content created by expert clinicians, a Jeff Be Well session taught by a licensed clinical psychologist, or a Nurse2Nurse session with a fellow nurse who will understand without much explanation needed.

In addition, our model involves both access at the individual level (employees seeking the mental health intervention of their choice) and at the team level (team leaders and members signing whole teams up for a mindfulness training). We strive to destigmatize the seeking of help for mental health issues through widespread marketing (pyramid on every hospital computer workstation), modeling by leadership, gatekeeper training, and peer support. Another innovation is our approach of integrating skills from various empirically supported treatments, including DBT, acceptance and commitment therapy, and CBT. We use these approaches to address the specific needs of health care workers in a practical, achievable manner.

We anticipate a mental health pandemic following the viral pandemic. The literature on previous disasters (such as September 11, natural disasters, and civil wars) demonstrates that pain and difficult feelings emerge after the immediate crisis is past. 26, 27 We need to attend to the psychological well-being of our workforce as we navigate this extraordinary global challenge. HR and the Department of Psychiatry and Human Behavior will continue to develop long-term programs and processes to promote a culture of well-being within Jefferson. We plan to expand RISE and to embed well-being checks into daily operations. We will educate both leadership and staff on how to promote well-being and transform our workplace culture to one of wellness.

As unprecedented, confounding, and difficult as these times have been, they have also been filled with gratitude. The pandemic challenged our Jefferson team to be better clinicians, leaders, colleagues, residents, students, administrators, and supervisors. We have had to be resourceful and to master Zoom technology and telehealth. We have embraced innovation and reimagined care delivery for both staff and patients. We have given ourselves permission to focus on wellness and self-care. Our goal is to nurture mental health for patients and providers alike and to ensure that the knowledge and skills we have developed will endure and grow even after the pandemic is behind us.

Mental health first aid training for the public: evaluation of effects on knowledge, attitudes and helping behavior

Mental health first aid training in a workplace setting

Mental health first aid training by e-learning: a randomized controlled trial

The effectiveness of psychological first aid as a disaster intervention tool: research analysis of peer-reviewed literature from 1990-2010

Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence

World Vision International, and UNICEF. Psychological First Aid During Ebola Virus Disease Outbreaks (Provisional Version)

Introduction to and overview of group psychological first aid

Caring for our own: deploying a systemwide second victim rapid response team

Supporting involved health care professionals (second victims) following an adverse health event: a literature review

When disaster strikes...the critical incident stress debriefing process

Helping the helpers: the role of critical incident stress management

Postdisaster psychosocial intervention: a field study of the impact of debriefing on psychological distress

Emergency nurses' perceptions of critical incidents and stress debriefing

Preventing psychological trauma in soldiers: the role of operational stress training and psychological debriefing

Cognitive-behavioral treatment of borderline personality disorder (diagnosis and treatment of mental disorders)

Acceptance and commitment therapy, relational frame theory, and the third wave of behavior therapy

The primary care behavioral health (PCBH) model: an overview and operational definition

The use of dialectical behavior therapy strategies in the psychiatric emergency room

Loneliness and social isolation as risk factors for mortality: a meta-analytic review

The psychological impact of quarantine and how to reduce it: rapid review of the evidence

The effectiveness of mindfulness based programs in reducing stress experienced by nurses in adult hospital settings: a systematic review of quantitative evidence protocol

Cognitive therapy of depression

The comprehensive counseling center model

Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study

Caring for the caregiver during COVID-19 outbreak: does inclusive leadership improve psychological safety and curb psychological distress? A cross-sectional study

What good are positive emotions in crises? A prospective study of resilience and emotions following the terrorist attacks on the United States on September 11th

Decision making in crisis: a multilevel model of the interplay between cognitions and emotions