key: cord-0937793-ppae5fao authors: Hall, Patricia L title: Mitigating the Impact of Reemergence From a Pandemic on Healthcare date: 2021-07-17 journal: Mil Med DOI: 10.1093/milmed/usab265 sha: b87b0c59883179986636f1a86c7bc57ce12c1941 doc_id: 937793 cord_uid: ppae5fao Healthcare workers have never faced a medical crisis that compares to the coronavirus disease-2019 pandemic. This modern-day pandemic fight draws parallels to a war. Because of these similarities, it would make sense that the experiences frontline providers have when transitioning to a normal healthcare routine would emulate experiences service members voice when reintegrating home from a battlefield. These common experiences include a unified mission, an exhausting, adrenaline-packed responsibility, and a celebrity-like status to the public. The pandemic response consumed healthcare with one united mission, but as we reemerge from the pandemic and restore other aspects of our healthcare system, multiple missions develop and compete. Returning to a common routine and regular status can manifest feelings of disappointment in healthcare workers’ everyday lives and career choices and lead to a reexamination of priorities and professions. As an organization with a focus on high reliability, mitigating the harm to staff and delivery system may be our new priority. The risk of not facing this situation head on is a potential exodus of seasoned professionals contemplating their future and selecting other career paths, thus draining the current institutional knowledge and potentially deterring future generations from healthcare. Leaders in the healthcare industry need to take a proactive stance in addressing this reemergence. Integrated, proactive programming is needed utilizing evidence-based resiliency training from professional organizations such as the National Alliance on Mental Illness, the Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration, as well as the existing Department of Defense programs. The Veterans Affairs has the backbone to develop and offer these programs and make a positive difference with Employee Whole Health efforts. Organized, evidence-based programming such as second victim education, mindfulness, and other personal skill building could be key to improving the lifelong well-being of our caregivers. As healthcare workers, we have never faced a medical crisis as we have during this coronavirus disease-2019 (COVID-19) pandemic. Some even harken it to fighting an invisible war right here at home against an unseen virus that has killed thousands. However, with worldwide vaccine availability, we may experience a reemergence to a more normal life. Healthcare is getting back to routine care; students are returning to in-seat classes; and stores, restaurants, and recreation are opening again. This would seem to be a hope-filled and joyous moment, but frontline healthcare workers may have difficulty with fully embracing this new phase in the pandemic. This pandemic fight draws many parallels to a war with an invisible enemy-an enemy that has no discretion for its victims; lurks where you cannot see; is full of unknowns; and is cruel, violent, and deadly. Serving on the frontlines of such a pandemic, responding to and coping with deaths, has long-lasting psychological consequences. Because there are such similarities between fighting war and combating COVID, it would make sense that the experiences frontline workers have when transitioning to a more normal healthcare environment would emulate experiences service members voice when reintegrating from a battlefield. As the world hunkered down and prepared for a pandemic, healthcare workers practiced, rehearsed, and executed a single mission-seek out COVID-positive patients, care for them, and do your very best to keep them alive while trying to remain safe yourself. This was the one mission and the same mission every day. As we reemerge from the pandemic and restore other aspects of our healthcare system, multiple missions develop. These conflicting priorities cause tension and apprehension. Literature informs us of the similar experiences service members have when returning from a combat zone. A unified mission is replaced with the feeling of chaos trying to fit in all the competing priorities. 1 For a frontline healthcare worker, these competing priorities now include preventative care checks and elective procedures layered on top of continuing to care for those who continue to contract COVID. This is a new stressor that creates internal turmoil for healthcare professionals to work through. Coronavirus disease-2019 slowly rolled across the globe as a universal enemy and the world banded together to take on this silent killer. Every healthcare worker soon realized the seriousness of their mission-serve and care for those who were stricken by this virus. Collectively and universally, healthcare workers were solidly unified by this goal. Some medical activities slowed down; others stopped. There was only one focus-the coronavirus. Reemerging to a new normal steady state in healthcare brings back those other activities. Although this can incite pockets of excitement, with "normal" routines, some activities that were ceased may now be magnified as wasteful or unnecessary. Much like service members returning home to hear people whine about lukewarm food or the 2-cent rise in gas prices, healthcare workers experience this with paperwork or reports that were paused during the height of the virus that are now reinstated. "Things that were once acceptable or important … now seem very insignificant or unimportant." 1 This can create frustration and impatience in everyday activities that were once quite acceptable. This internal conflict also manifests as compassion fatigue. After a prolonged exposure to patients who are critically ill, struggling to breathe, some feel it is hard to provide compassion to those who have less dramatic care needs. This too can cause internal turmoil, because, as healthcare providers, it is known that every person's experience is unique, and all patients deserve consistent care and compassion. Emotionally though, it is more difficult to be there in the moment with some of the less ill patients who have complaints and concerns. Both feelings-trivial requirements and compassion fatigue-may contribute to irritability or a short temper. It is understood that people choose healthcare mostly for noble, caring reasons. Medical professionals work long hours in less than glamorous conditions to care for the population. The limelight has never glared brightly at these usually unsung heroes. Under this response, society could not do enough to express their utter gratitude. Businesses sent meals, gave away shoes, provided care packages, and even sent chosen ones to the Superbowl. Medicine was the forefront of the daily news, and caregivers had almost celebrity status. As the world reemerges, the spotlight on healthcare workers dims and they return to their previous status as the unsung heroes. High adrenaline, laser-focused efforts returning to "commonplace" routines can become disappointing and even create some desire to return to the faster-paced mission. 2 This can manifest as feelings of disappointment in their everyday life and career choice and even exacerbate feelings of depression. Healthcare workers knew and excelled in their mission to combat COVID and heroically attempt to save the lives of those critically ill from the virus. They gave long hours, days on end, caring for large volumes. Besides being patients' caregivers, they were also their sole support system at times due to no visitation. Although not one healthcare provider would say they chose their profession to participate in a pandemic of this nature, this was medicine at its finest and rawest. Healthcare innovated, collaborated, and banded together against this common enemy. This is not much different than a service member who trains for years and finally goes to the combat zone to execute the mission they have rehearsed. As the dust settles and the world returns to a new normal, healthcare professionals return to their previous roles. Where they may have been providing care in an overflow unit for COVID patients, they now go back to their clinic role, medicine unit, or administrative office. This has surfaced feelings such as "I miss my purpose … I miss the sense of worth." 3 A parallel with those returning from a combat zone, this questioning of purpose of mission, can cause a professional inner turmoil leading to some professionals reexamining their entire career choice and rethinking what is most important personally and professionally. It may even be more difficult to emerge from this war on a virus with an undefined battlefield for several reasons. First and foremost, this is an invisible war with a muchunknown enemy whose complexities are not yet fully realized. Although we learn more about the COVID-19 virus and its mutations daily, there are still more unknowns than knowns. Do we really know when we will be able to be fully mask free? Do we really know if the current vaccines will be effective against the next strain? The unknowns far outweigh most knowns. The reemergence from this pandemic is also slower and without fanfare compared to returning from a combat zone. I can clearly remember packing up, wedging into an airplane seat for a long sleepy ride, and awakening to stride off the plane and run my fingers in the soft grass on American soil and hug my cheering family. There was a defined beginning, middle, and end. As the world moves forward from our pandemic response, we can acknowledge that there was no clear-cut beginning and the recovery is still foggy. To complicate things further, reemergence is not occurring everywhere at once. The prevalence of COVID-19 throughout the country and the world sometimes feels like playing a game of "whack-a-mole." As one region appears to be recovering, others surge, only for the pendulum to swing the other direction further in the future. This lends to the question of if we are really reemerging from COVID-19 or if an area is just on a temporary reprieve. This unknown is comparable to service members returning home from deployment. The difference is that the enemy and the actual battle are invisible so there are more unknowns. During our over 20 years of war in the Middle East, when service members return from a combat theater, they know their current mission is complete, but they are also fully aware that they could get called back. They just do not know when. Similarly, our healthcare workers are reemerging and adjusting to their new normal, but do not feel comfortable to completely commit. This unknown also creates self-reflection in all aspects of their life, including career options and personal life choices. The concern is, as a healthcare delivery system leader, how do we care for our caregivers to help them successfully transition and recharge their resilience? As an organization with a focus on high reliability, mitigating the harm to staff and delivery system may be our new job number 1. The risk of not facing this head on is a potential exodus of seasoned professionals contemplating their future and selecting other career paths. This, of course, not only drains the current institutional knowledge, but also has the potential to snowball into next generations not seeking healthcare professions as their chosen path. How is this information useful? The Department of Defense along with other nations' militaries has spent decades learning about reintegrating service members. What can we draw from lessons learned about reintegrating service members to help our healthcare workers? What can employers do to acknowledge and assist this transition? Can the Veterans Affairs use Employee Whole Health as a tool in this effort? As leaders in the healthcare industry, it is incumbent on us to take a proactive stance in addressing this reemergence. Without our expert professionals being fully present in the delivery of healthcare, we will not be successful. Many self-help programs and apps have already been launched to start mitigating the difficulty our healthcare professionals often face with the abovementioned concern. I would say, providing self-help is only the beginning in our needed response. The military learned that reintegration for service members was extraordinarily difficult. Addressing this with all service members proactively, regardless of their self-disclosed stress levels, statistically helped to mitigate the negative sequela of reintegration. One example of reintegration training is BATTLEMIND training that all U.S. Army soldiers participated in upon returning from Middle East combat zones. Adler et al., 2011, report that in their study, BATTLEMIND training led to fewer stress symptoms and sleep disturbances than stress education or debriefings. 4 This training takes a cognitive and skillsbased approach and reframes transition difficulties to a natural consequence of their experience and provides effective coping mechanisms. After understanding some of the success of this program, it was then expanded to Comprehensive Soldier Fitness Training, a series of foundational modules provided at the unit level across the deployment cycle. Not only did the training provide decreased physical health concerns, but soldiers reported that they perceived the training was important for their mental health outcomes. 5 The USA is not the only military to utilize a proactive resilience training much like psychological skill training for elite sports. Both the UK and Australia report success with mindfulness-based training to enhance mental resilience among their soldiers. 6 The military also learned that after long and repeated stressful deployments, assignments to other units to teach, recruit, or provide administrative services provided service members time and space to mentally heal. Healthcare has this opportunity to provide enriching detailed opportunities to reignite the passion for healthcare. I reflect on a very emotionally tired Intensive Care Unit nurse that was detailed for a week to the vaccine clinic. She tearfully expressed her gratitude and said, "Thank you. You relit my passion for healthcare that I thought died. It is so wonderful to provide this ray of hope for so many thankful Veterans after I saw so much-repeated tragedy with COVID." As an organization on a high-reliability journey, the heart of zero harm is proactively caring for our caregivers. By drawing from evidence-based resilience education from multiple sources including the Department of Defense, the National Alliance on Mental Illness, and the Department of Health and Human Services' Substance Abuse and Mental Health Services Administration Disaster Technical Assistance Center, a program needs to be developed and offered to all healthcare workers proactively to facilitate resiliency in the workforce and mitigate losses. These professional entities have resources for resiliency training specific to crisis intervention and the pandemic. The National Alliance on Mental Illness addresses evidence-based strategies to build individual resiliency to include embracing optimism, reframing negative thoughts, problem solving, adaptive resilience, and radical acceptance. 7 The Substance Abuse and Mental Health Services Administration Disaster Technical Assistance Center offers resiliency resources related to the COVID-19 pandemic specific to healthcare professions. These include signs of compassion fatigue and stress, self-care techniques such as physical activity, sleep and diet, visualization, relaxation, mindful movement, meditation, breathing exercises, and journaling. 8 The Veterans Affairs has the backbone to build a robust program and make a positive difference through Employee Whole Health programing. Organized, evidence-based programming that include these already available, evidence-based topics such as second victim education, mindfulness, and other personal skill building could be key to improving the lifelong well-being of our most precious resource, our caregivers. None declared. None declared. Military nurses' experiences returning from war Post-deployment reintegration experiences of female soldiers from national guard and reserve units in the United States Identity adjustment among Afghanistan and Iraq war veterans with reintegration difficulty Battlemind debriefing and battlemind training as early interventions with soldiers returning from Iraq: randomization by platoon Soldiers' perceptions of resilience training and post-deployment adjustment: validation of a measure of resilience training content and training process Mental resilience training Coronavirus: building mental health resilience Department of Health and Human Services Substance Abuse and Mental Health Services Administration: Tips for healthcare professional: coping with stress and compassion fatigue None declared.