Raising the Standard: Healthcare Worker Wellbeing During COVID-19: The State of The Literature: Part 2

| April 1, 2022

by Kristen Demertzis, PhD, ABPP-CN; Rebecca M. Schwartz, PhD;
and Dominick Gadaleta, MD, FACS, FASMBS

Dr. Demertzis is the Chief of Neuropsychology at South Shore University Hospital and the Director of Resident and Fellow Mentorship and Faculty Development for Northwell Health’s OB/GYN Departments at South Shore University Hospital and Huntington Hospital. She is an Assistant Professor of Physical Medicine and Rehabilitation and of Psychiatry at the Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. Dr. Schwartz is Director of Research and Evaluation for Northwell Health’s Center for Traumatic Stress, Resilience and Recovery. She is the Chief of Social Behavioral Sciences and an Associate Professor of Occupational Medicine, Epidemiology, and Prevention at the Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. She is also an Associate Investigator at Northwell’s Feinstein Institutes for Medical Research. Dr. Gadaleta is Chair, Department of Surgery, South Shore University Hospital; Director, Metabolic and Bariatric Surgery, North Shore and South Shore University Hospitals, Northwell Health in Manhasset, New York; Associate Professor of Surgery, Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York.

Funding: No funding was provided for this article.

Disclosures: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2022;19(4):16–18

This is Part 2 of a two-part Raising the Standard article series that examines the wellbeing of healthcare workers surrounding the COVID-19 pandemic. 

The COVID-19 pandemic has taken a tremendous toll on the wellbeing of healthcare workers (HCWs),1,2 prompting significant augmentation of healthcare industry efforts to address HCW wellbeing.3–5 Part 2 of this series explores some of these intervention efforts. 

Adequately addressing HCW wellbeing during the COVID-19 pandemic requires multipronged interventional strategies. Various intervention classification systems are employed across studies, with most differentiating between “organizational practices/supports” and “individual interventions/supports.”3–9 Some articles also specify presurge to postsurge intervention relevance dependent upon changing operational pressures and mental health drivers.4,10

Organizational Practices/Supports

COVID-19 organizational practices/supports have been extensive, including organizational role establishment/clarification; inclusive stakeholder-guided strategies; transparent and bidirectional communication of multimodal, timely, and accurate information; up-to-date, evidence-based, ethical, and equitable policies and procedures promoting patient and staff safety and wellbeing; supplies, space, and staffing issues; executive leadership training, mentorship, education, and support; and expansion and mobilization of mental and physical health resources, instrumental supports (e.g., childcare, lodging), and staff recognition practices (e.g., deployment bonuses).4,6,9,11–13 Successful execution of such multifaceted organizational responses requires highly capable and empowered leadership throughout cascading organizational levels. For some health systems, Chief Wellness Officers have played pivotal roles in advocacy, collaboration, and implementation efforts surrounding many of these practices/supports.4 

HCW wellbeing during the COVID-19 pandemic has been associated with presence and quality of and interrelationships among many above-referenced organizational practices/supports.14–16 For instance, a cross-sectional study of 921 HCWs during the COVID-19 pandemic found that abusive leadership attenuated positive effects of staff recognition and decision-making autonomy on psychological wellbeing and contributed to increased intention to quit.17 Thus, presence of various organizational practices/supports is not sufficient in the face of other factors that undermine their value, particularly when considering the elevated and protracted stress levels of HCWs and increased postpandemic turnover intention.18

Individual Interventions/Supports

Individual interventions/supports have rapidly evolved during the pandemic to include individual and group, in-person and virtual/other digital technology (e.g., mobile application), and guided and nonguided psychological interventions/supports.3,4,6,8,11,19–21 Dedicated hotlines, mental health teams, and facilities have been formed or adjusted to meet pandemic-phase and HCW needs. Though individual HCW circumstances and preferences support continued variety and adaptability of individual support options, quantitative and qualitative data can assist in curtailing interventions to those most impactful from utilization and wellbeing outcomes perspectives. A comprehensive review of specific interventions and delivery modalities is beyond the scope of this column, but some interventions are noted below. 

Psychological First Aid (PFA)22–25 and Skills for Psychological Recovery (SPR)26,27 are widely used, evidence-informed, modular approaches based on risk and resilience literature. They were developed by the National Child Traumatic Stress Network and the National Center for Posttraumatic Stress Disorder (PTSD), respectively. PFA focuses on supporting individuals in the immediate aftermath of disasters to promote short- and long-term adaptive coping and functional outcomes, whereas SPR targets postdisaster distress management and coping in the weeks and months following disaster or trauma. Both approaches can be offered in a single encounter and in individual or group format, and in-person, telephone, and other virtual and mobile applications have been trialed during COVID-19, with some promising results.24,28–30 Those without a mental health background can be trained as PFA and SPR providers, adding to organizational sustainability. 

Stress First Aid (SFA)31,32 is an organizational support model based on the same disaster and mass trauma intervention principles as PFA and SPR.33 The SFA model promotes identification of stress in oneself and one’s coworkers and engagement in supportive and preventive self-care, coworker support, and leadership strategies to mitigate adverse mental health impacts.34 Upstream referral to psychological and psychiatric services are made, as needed, for PFA, SPR, and SFA. Of note, additional efficacy and effectiveness data are needed surrounding these models’ impact on HCW wellbeing during the pandemic, but studies are ongoing.35

With respect to other psychological interventions, evidence-based treatments are being offered for PTSD (e.g., prolonged exposure therapy, cognitive processing therapy), depressive (e.g., cognitive behavioral therapy), and other mental health symptoms to assist HCWs along the temporal continuum of the pandemic.36–41 Delivery modalities of these interventions have involved within-hospital mental health teams or internet-based interventions,3,19,20,42,43 with some programs specifically developed for HCWs during this pandemic.30,44,45 

To date, many COVID-19-related individual intervention/support studies consist of narrative intervention descriptions, with some studies reporting operational data (e.g., intervention utilization metrics) and/or HCW feedback and wellbeing-measure impact. However, methodologically rigorous studies are largely lacking surrounding HCW individual interventions/supports, in controlled and real-world environments, during the acute to long-term stages of this and other epidemics and pandemics.7,9,46

Individual Support Delivery: One Health System’s Experiences

Northwell Health in New York implemented robust organizational and individual supports during the pandemic. The Center for Traumatic Stress, Resilience, and Recovery (CTSRR) was formed during the pandemic to provide resilience, clinical, and educational services to support Northwell employees and their families, and to advance our understanding of the impact of traumatic stress on HCWs. CTSRR offers various clinical services, including in-person and virtual individual and group treatments, as well as resilience services to Northwell departments, teams, and leaders. In partnership with the behavioral health service line, human resources, and other stakeholders, CTSRR has also adapted and launched SFA to promote resilience and reduce stress and burnout throughout the health system. 

In addition to CTSRR, Employee and Family Assistance (EAP) and numerous mental health providers throughout the health system offer telehealth and in-person individual psychotherapy and psychiatric services. Behavioral health service navigators are available, psychoeducation and support services are posted on our website and covered at department/training program meetings, digital support options are available at no cost, and virtual Balint and other peer support forums have been held. 

Given potential barriers to HCWs accessing individual interventions/supports (e.g., pandemic-related factors like extended work hours or stigmatization concerns),47,48 frontline leadership promotes the use of support services among their teams and within-hospital support services exist. Team Lavender is an HCW peer-support team offering on-unit support following adverse clinical events. Unit-based Schwartz Center rounds are facilitated, multidisciplinary, safe spaces to process psychological/spiritual/ethical elements of actual cases and their impact on HCWs and HCW-patient relationships to foster compassion, collaboration, and healing and ground HCWs in humanistic elements of their work.49 Additional supports have included psychological support rounding within the intensive care unit (ICU), COVID-19 units, and for leadership; unit mindfulness/relaxation/aromatherapy sessions where leadership would cover frontline staff to attend; indoor and outcome wellness areas for rest/relaxation/peer support; and nondenominational spiritual support and remembrance services through chaplaincy. 

Serving as a provider of psychological support services within the hospital, one of the authors (KD) experienced a universally positive reaction to unit rounding and support sessions. HCWs often noted that despite struggling, they might have not reached out for support had there not been proactive, on-unit, psychological support. This anecdotal report is consistent with recommendations and reported findings in the COVID-19 literature.30,50 Leaders also expressed gratitude for having a place to process stressors and immense pressures they were facing and strategize ways to optimize their leadership and wellbeing. They also reported benefits of conveying real-time concern about staff in need of support and arranged coverage to allow for that to occur. 

Conclusion

Significant efforts surrounding organizational practices/supports and individual interventions/supports have been made to comprehensively and creatively address the pandemic’s significant impact on HCW wellbeing. The literature base surrounding best practices and temporal staging of practices continues to evolve, with a clear need for more methodologically rigorous studies and continued longitudinal tracking of wellbeing outcomes.51 Such data will allow for elucidation of universal supports needed (e.g., policies/procedures, access to needed supplies/staff), as well as support customization in sustainable and flexible ways (e.g., diverse delivery modalities of psychological supports, specific support indicators based on workforce characteristics/risk stratification, temporal trends in help-seeking stigmatization affecting resource utilization).

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