key: cord-0820723-5cw1isyq
authors: Hofmeyer, Anne; Taylor, Ruth; Kennedy, Kate
title: Fostering compassion and reducing burnout: How can health system leaders respond in the Covid-19 pandemic and beyond?
date: 2020-06-15
journal: Nurse Educ Today
DOI: 10.1016/j.nedt.2020.104502
sha: 4d447b72bca2e66a36f3d52af49f0e1e9a2586fd
doc_id: 820723
cord_uid: 5cw1isyq

nan

In the book "The Help" (Stockett, 2009) , an African-American nanny living in Jackson, Mississippi whispers to the small child sitting on her knee: "You is kind, You is smart, You is important". In this unprecedented time of the rapid spread of SARS-CoV-2, the virus that causes Covid 19, all nurses need to repeat that phrase to themselves and to others often.

Kindness and compassion not only benefit "those who receive it but also to those who offer it" and is the motivation why many are drawn to healthcare practice (Lown et al., 2019, p. 400) . When empathic communication and compassion exists, clinical teams are more effective, morale is higher, patient safety and satisfaction is higher, and fulfilling the organizational mission is more likely (Lown et al., 2019) . As Rosen (2017, p. 1) 

"Compassion is the foundation of good medical care. It recognises the concerns, distress and suffering of patients and families and taking action to relieve them. It is based on listening, respect, empathy, communication, interpersonal skills, and knowledge and understanding of the patient"s life and preferences. At its core, it means treating patients as people, not just illnesses"

The unprecedented COVID-19 pandemic continues to have a profound impact on nursing and healthcare services. There are media reports of hundreds of patients dying in quarantine without their family present. The need for compassionate nurses and healthcare workers is critical.

Globally, large numbers of retired healthcare workers have returned to workplaces that notably, were overburdened and lacking resources prior to COVID-19. Their altruism and willingness to leave the safety of their homes to care for sick and frightened patients should be met with gratitude and assurances about safe work conditions. Governments are responsible for health policy and funding so must work with health system leaders to urgently address shortages of personal protective equipment (PPE) and structural work conditions known to cause burnout (WHO 2019). Burnout has a destructive effect on clinicians" wellbeing and capacity to provide compassionate and quality healthcare (Lown et al., 2019) .

In this paper, we explain how health system leaders can implement relevant organizational interventions to reduce caregiver burnout and promote engagement and compassionate practice during the COVID-19 pandemic, and beyond. First, we discuss burnout and draw links with the 2018 NHS Staff Survey results about bullying, harassment, and unsafe conditions. We then outline policy responses in the 2019 Interim NHS People Plan. Next, we present nine evidence-based strategies developed by Mayo Clinic researchers to identify areas for organizational improvement and strategies to promote engagement and reduce caregiver burnout. Finally, we explain how "The Schwartz

Rounds" is an organizational strategy for staff to talk about the psychological and emotional challenges of caregiving.

In 2018, burn-out was included in the WHO 11 th Revision of the International Classification of Diseases and described as: a syndrome resulting from chronic work stress (unsuccessfully managed) and features emotional exhaustion, depersonalization (cynicism, loss of idealism, withdrawal), and feeling ineffective (WHO, 2019). Burnout is now a global workforce crisis driven by frustrations with institutional policies, clerical work (Shanafelt and Noseworthy, 2017) , conflict with colleagues, inadequate staffing, unmanageable patient workloads, insufficient time to deliver healthcare, and inadequate wellbeing support (Rosen, 2017) .

More than 50% of US physicians are now burned out (Shanafelt and Noseworthy, 2017) . Despite significant research, the ongoing crisis of a burnt-out workforce continues to have adverse effects on patient safety and satisfaction, clinician productivity, increased absenteeism, turnover, higher rates of treatment errors, and the organizational bottom line (Bauer-Wu and Fontaine, 2015; Francis, 2013; Rosen, 2017) . Taken together with escalating reports of bullying, depersonalization (regarding patients as objects), feeling ineffective and low morale, this negative spiral is destructive to clinicians" wellbeing and ability to care for others (Bauer-Wu and Fontaine, 2015) . In a Mayo Clinic study of 7,905 US surgeons over a 3month period, the proportion of surgeons who committed a major surgical error was three times higher among those with the highest levels of depersonalization (Shanafelt and Noseworthy, 2017) .

Addressing structural deficits is essential to ensure compassionate quality healthcare, patient safety and satisfaction, and retaining engaged caregivers (Shanafelt and Noseworthy, 2017) .

Moreover, "creating cultures and system improvements that support the workforce and diminish burnout are vital leadership skills" (Lown et al., 2019, p. 398 ).

The 2018 NHS Staff survey results indicated 12.8% of nurses experienced workplace discrimination and 28.3% of nurses experienced bullying or harassment from patients or the public in the past year. A further 13.2% of nurses reported managerial bullying and harassment and 19% from colleagues. Regrettably, 33% of nurses said they are unable to deliver the care they aspire to provide and 27.8% said they witnessed an unsafe event within the last month that could have harmed a patient.

Of concern, 56.5% of nurses said they had reported for work in the past 3 months despite not feeling well enough to work. The highest number of nurses in the past 5 years reported feeling unwell as a result of work-related stress at some time in the past 12 months (39.8%). Moreover, 27.6% of nurses reported musculoskeletal problems due to work activities in the past year.

Almost 3 in 5 nurses (57.8%) routinely worked additional unpaid hours on a weekly basis to deliver essential patient care. Staff shortages affects nurses" wellbeing and contributes to exhaustion, burnout and low morale. Respondents indicated they want more done to support their health and wellbeing. Fewer nurses (28.7%) felt their organization took positive action to support staff health and wellbeing in 2018 than in 2017. Nearly 30% of nurses said they regularly considered resigning. Less 

The Rounds are an education strategy to foster "shared purpose, interdisciplinary communication, teamwork, and support" Manning 2010, p. 1079) . The Rounds take place on a monthly basis for an hour, preceded by refreshments. It begins with a brief presentation by a person who reflects upon their emotional experience/impact of caring for patients and families and working with team members (Robert et al., 2017) . Then others discuss their experiences of caregiving (not clinical issues). Discussing the psychosocial and emotional experiences of caring with others who may have similar experiences can increase compassion for self, colleagues and patients.

Maben led the UK evaluation of The Rounds in 2018. Findings showed participation in The Rounds cut the psychological distress of attendees in half compared with non-attendees, attendees felt less isolated and stressed, and their wellbeing and relationships with colleagues and patients improved (Taylor et al., 2018) . Expectations to adopt may explain the rapid spread in UK, although evaluation evidence was scant (Robert et al., 2017) . Many institutions offered wellbeing interventions, so it was difficult to attribute improvements to any particular intervention. Taylor et al., (2018, p. 1) reviewed eleven interventions to support staff in the emotional J o u r n a l P r e -p r o o f (see review by Taylor et al., 2018) . Quality evidence for the effectiveness of all interventions, including The Rounds was sparse, so attributing improvements in staff outcomes to any intervention is contentious. However, Taylor et al., (2018, p. 12) argued, "given the high rates of work-related stress and mental health issues among healthcare staff, it is not acceptable for employers not to act, despite a weak evidence base for most approaches and interventions." In the current reality of COVID-19, nurses need regular opportunities to talk about the psychosocial and emotional impact of caring for patients with COVID-19. The Rounds is a proven institutional strategy to bring us together to debrief and care for others and ourselves.

As the COVID-19 pandemic continues to escalate at the time of writing, nurses struggle to obtain suitable and sufficient supplies of PPE from their employers. The lag in the provision of PPE leaves nurses and other health workers vulnerable, and shows an utter disregard for their health and safety. Moreover, the rise of infections and deaths among these groups further strains health systems and compromises the response. It is the responsibility of Governments worldwide to develop policies and to provide adequate funding for health system leaders so they can meet their statutory obligations to provide essential resources to fight the COVID-19 pandemic and provide healthcare services. On 1 April, 2020, RCN general secretary Dame Donna Kinnair demanded action over the "unconscionable" lack of PPE.

That said, we conclude with four tips for health system leaders and managers in these turbulent and grief-stricken times so they remain well and can lead the repair and revitalization of their organizations into a post-Covid-19 world, namely:

1. We are told to put on our own oxygen "mask" before helping others during a flight emergency. What self-care strategies constitute your "mask" so you can live more bravely and stay well in the months ahead so you can be there for others? Do remember: You is kind, You is smart, You is important".

2. Respond to staff grief, sadness and burnout with patience, kindness, empathy and compassion

The Pause

Prioritizing Clinician Wellbeing: University of Virginia"s Compassionate Care Initiative. Global Advances in Health and Medicine

Compassion satisfaction, compassion fatigue, anxiety, depression and stress in registered nurses in Australia: Phase 2 results

Can Organizational Leaders Sustain Compassionate, Patient-Centered Care and Mitigate Burnout

The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support

National NHS Staff Survey Results www

Interim NHS People Plan

Exploring the adoption of Schwartz Center Rounds as an organisational innovation to improve staff well-being in England

Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout

Establishing a string culture of compassion improves quality of care, bottom line. Schwartz Centre for Compassionate care

The secret to leading organizational change is empathy

The Help

Can Schwartz Centre Rounds support healthcare staff with emotional challenges at work, and how do they compare with other interventions aimed at providing similar support?

Burn-out as an "occupational phenomenon