Recommendations for supporting healthcare workers’ psychological well-being: Lessons learned during the COVID-19 pandemic

Abstract

Healthcare workers are at risk of adverse mental health outcomes due to occupational stress. Many organizations introduced initiatives to proactively support staff’s psychological well-being in the face of the COVID-19 pandemic. One example is the STEADY wellness program, which was implemented in a large trauma centre in Toronto, Canada. Program implementors engaged teams in peer support sessions, psychoeducation workshops, critical incident stress debriefing, and community-building initiatives. As part of a project designed to illuminate the experiences of STEADY program implementors, this article describes recommendations for future hospital wellness programs. Participants described the importance of having the hospital and its leaders engage in supporting staff’s psychological well-being. They recommended ways of doing so (e.g., incorporating conversations about wellness in staff onboarding and routine meetings), along with ways to increase program uptake and sustainability (e.g., using technology to increase accessibility). Results may be useful in future efforts to bolster hospital wellness programming.

Introduction

Occupational stress injuries threaten the well-being, staying power, and effectiveness of Healthcare Workers (HCWs). ¹ Historically, HCWs have been responsible for maintaining their own psychological well-being, with organizations offering reactive support to distressed staff. Limited work was done to proactively support HCWs’ psychological health prior to the COVID-19 pandemic. ¹

The pandemic introduced various stressors into the healthcare work environment, from fear of infection to the moral distress associated with policies that prevented patients from seeing their loved ones. ² Organizations identified heightened need to support staff’s psychological well-being and employed various proactive approaches to support those at the frontline.^3-7

Determinants of mental health support utilization are complex. Organizations face challenges to implementation (e.g., lack of resources), and targeted end-users face barriers to participation (e.g., stigma and time demands). Studying the approaches taken to support staff psychological health during the pandemic and the experiences of those who implemented it can inform future efforts to provide wellness programs. Healthcare workers have been interviewed to identify factors that influence the uptake of supportive resources during the pandemic.^8-10 Bleier et al. identified reasons for non-participation including not being aware of the activities, time-fit with shift work, and long commutes to access activities. ⁸ In contrast, reasons for participation included affordability and good communication about available resources. Leadership support and corporate culture were also identified as influencing participation. ⁸ There is a growing body of literature regarding the experiences of targeted end-users of wellness programs, but little is known about the experiences of program implementors and facilitators.

Program implementors are well-situated to provide insight on the effectiveness of strategies used to implement wellness programming, any practical challenges experienced, and the effectiveness of strategies employed to overcome them. This report is part of a larger project that aimed to illuminate the perspectives of facilitators of wellness programming during the COVID-19 pandemic at an Ontario hospital. Specifically, individuals who implemented the Social Support, Tracking Distress, Education, and Discussion community (STEADY) staff wellness program at Sunnybrook Health Sciences Centre, referred to hereafter as STEADY implementors. ⁷ Information about STEADY and implementation during the COVID-19 pandemic can be found in Ellis and Korman, 2022, and Korman et al., 2022. Briefly, STEADY implementors actively engaged multi-disciplinary HCWs from select units in peer support sessions, psychoeducation workshops, critical incident stress debriefs, and community-building initiatives. This paper reports on recommendations from STEADY implementors for future provision of hospital staff wellness programming.

Methods

Methods are summarized in this section; full details can be found in Korman, 2022. ¹¹

An interpretive description methodological approach was employed for this project. ¹² Interpretive description is a flexible qualitative methodology developed for use in clinical environments. Knowledge translation is a key focus in interpretive description, as this type of work generally aims to create findings that will inform clinical understanding and practice. ¹²

All seven STEADY implementors were invited to participate in this study, six of whom were available to participate in the focus groups. Two semi-structured focus groups were held in November 2021 and February 2022; each session lasted 2 hours and was co-facilitated by two members of the research team with experience in qualitative interviewing. One focus group facilitator was the STEADY Program Manager and co-facilitated programming alongside research participants during the pandemic, the other facilitator provided high-level support for the STEADY project and attended group meetings but was not involved in the day-to-day running of the program.

The aim of the first focus group session was to capture the participants’ experiences in facilitating STEADY. Question guide development was informed by the Consolidated Framework for Implementation Research ¹³ (further detail and question guide can be found in Korman, 2022). ¹¹ Focus group sessions were audio-recorded and transcribed verbatim by the primary reviewer. A second reviewer (with experience implementing a staff wellness program in another Toronto hospital during the pandemic) was consulted on decisions made throughout coding and theme development. Preliminary themes identified through an open coding process were organized in mind map and narrative formats. During analysis, the primary reviewer identified a list of recommendations made for future implementation of similar programming into healthcare work environments. These findings informed development of the question guide for the second focus group session (which can be found in Korman, 2022). ¹¹ Preliminary themes and the list of recommendations were both presented to participants during the second focus group session. Before presenting the list of recommendations, participants were asked what they would recommend to individuals doing similar work in the future. Responses were recorded. Participants and focus group facilitators worked together to amalgamate the new list of responses with the recommendations identified during analysis of the first focus group session, resulting in the list presented below. Results of the thematic analysis will be reported elsewhere.

Results

Participants were from nursing, psychiatry, spiritual care, and social work, and had varying levels of experience in their clinical roles (3-24 years).

The following list of twelve recommendations is a product of the focus group (rather than that of data analysis by a researcher). Recommendations were retroactively categorized by the authors as relating to the process of program planning, implementation, and/or sustainment and spread.

Planning

1. Include frontline staff in the planning process: Working with staff provides the opportunity to get to “know the people on the ground,” thereby helping implementors tailor the program to the needs of each target group. By engaging targeted end-users in the planning process, program implementors can ensure “that it’s what the people on the frontline want,” which was perceived as an enabler of program uptake.

2. Have a comprehensive package of interventions to provide support in various ways: In discussing what should be included within a wellness program, a participant noted that it is important “not to pick it apart and only do one element. It needs to be a comprehensive package.”

3. Address both physical and psychological wellness, highlighting their equal importance: Participants reported confusion early in the pandemic about what “wellness” is, explaining that organizational leaders were “focused on physical wellness, like a break room, or water… and what we were talking about was emotional wellness.” They expressed feeling that there was “a divide around what we were talking about… everyone was using the word ‘wellness,’ but we weren’t talking about the same thing.” Participants felt that the psychological piece “needs to be highlighted more at the organizational level,” and that addressing physical and psychological wellness together would signify the importance of mental health, helping staff to feel that “accessing [mental health] resources, [is not] a sign of weakness, [it’s] promoting your health.”

4. Consider ways to support staff who are not affiliated with specific units: The STEADY project targeted specific groups of staff (e.g., the emergency department) because it was “easier to just tap into existing unit structures” and target programming for groups who work together in one area. We quickly learned that many staff work with various teams across the organization. It was sometimes more challenging to reach the “floating staff, who are everywhere.”

5. Create capacity for scale up/down to deal with future crises: Though participants recommended having resources available indefinitely, they acknowledged that needs would be greater in times of crisis. To prepare for future crises, they recommended that organizations “have a cadre of trained resources and supports that you can access or scale up… like your army reserve.”

Implementing

6. Build buy-in from leaders to increase modelling from top-down: Participants discussed many ways that leaders influenced staff participation in STEADY programming. Participants emphasized that leaders at different levels should participate in programming to support “their own wellness,” explaining that “unless you really genuinely believe in it, it would just seem to be sort of an add on.” By buying into wellness programming themselves, leaders could make genuine recommendations for staff to participate, that would not look like “lip service.” “Modelling by leaders” was described as key to encouraging staff uptake, and as a method of increasing “organizational resilience.”

7. Include wellness in onboarding for all new staff: Participants suggested that conversations regarding psychological wellness begin as soon as staff are hired.

8. Create a calendar of ongoing, facilitated drop-in peer support groups and other wellness sessions: This way staff would know where to look for information about wellness programming, making sessions more easily accessible to staff across the organization.

9. Use technology to increase access to wellness sessions or information and messaging related to wellness: Though participants acknowledged the benefits of in-person programming (including increased uptake), they described ways that technology could be used to increase accessibility and reach a wider audience. One challenge with remote programming was that clinical staff did not necessarily have computer access in their work area. Participants recommended providing “mobile technology, like iPads… or more places where people can gather [with] shared audiovisual equipment.” Even with adequate equipment, there is the challenge of finding time to participate during a busy clinical workday. To help make lessons from the psychoeducation workshops more accessible, we created ‘minimal-text’ slides that were auto-played on a loop in central areas with large screens. One participant noted that “a lot of the people that didn’t attend [the workshops] saw [the slides] and it reached a huge, huge [audience].” It was recommended that this strategy be used hospital-wide, and that slides about wellness should be played in central spaces because “patients would benefit too.”

Sustainability and spread

10. Make wellness a recurring topic on the agenda for all existing group meetings: Participants felt that conversations about psychological wellness did not need “to be a separate conversation, but an ongoing conversation” throughout existing team meetings or group gatherings.

11. Have permanently funded staff to provide administrative and psychosocial support to the program: STEADY was implemented as a quality improvement project, made possible by COVID-specific funding. It was not intended to be a permanent program. De-implementation was challenging for STEADY implementors, who felt that such programming should be offered indefinitely “because you don’t want to raise expectations and then not be able to continue to meet them.”

While STEADY was being offered, a well-being committee was established as part of an organizational strategy to support ongoing staff needs. Committee members did not have paid, protected time for participation. Focus group participants felt that this model was unsustainable, explaining that it “takes a lot of energy and consistency to be able to successfully offer this,” so without both psychosocial and administrative staff who can focus their time on the initiative “it will dissipate fairly quickly.” There was also concern regarding the “burden” on staff.

Beyond the pragmatic need for a dedicated program manager, participants discussed how the existence of this role resulted in a “recognition [by] staff that the hospital administration was sending someone in to care for them.” As many of the implementors already worked with the units they were supporting, unit staff “expect[ed them] to be there.” Having someone new who was there solely to support staff seemed to increase the sense that the organization “cares about what happens to us.”

12. Establish a reporting structure that includes a committee of stakeholders and organizational sponsors from multiple departments who report to one lead: As a quality improvement project, the team was not part of the formal organizational reporting structure. Participants found their role in the organization “hard to navigate.” They recommended that organizations house wellness programming under the “Quality Improvement” portfolio, guided by input from “a committee that’s got representation from different [departments].” This could increase the group’s ability to tap into resources across the organization and gain support from more leaders who could encourage uptake of the initiative, while mitigating the potential “conflict of interest” leaders might face when trying to balance the goals of their department with that of the program.

Discussion

STEADY implementors took a proactive approach to support staff wellness during the COVID-19 pandemic. In this study, STEADY implementors and focus group facilitators co-created a list of twelve recommendations for the planning, implementation and sustainability/spread of wellness programming, based on experiences during the pandemic. Four key concepts were identified across recommendations:

1. Leaders’ roles in programming and their influence on program success were emphasized. Participants discussed the importance of leaders participating (either with their employees or in a group with other leaders) to genuinely encourage others to attend programming and model vulnerability. This aligns with reports of barriers and enablers to participation in workplace wellness programs from the perspectives of end-users and the National Standard for Psychological Health and Safety in the Workplace, which highlight the importance of leadership support and corporate culture.^8-10,14 By participating themselves, leaders can counteract the negative stigma ingrained in healthcare culture and nurture an environment conducive to discussing distress and seeking support. Leaders’ routine reminders to their teams about programming can lower pragmatic barriers to accessing wellness programming, including lack of awareness. ⁸

2. Leadership and organizational priorities and attitudes impact local culture, which is an important consideration in implementation. Culture can act as a barrier to help-seeking, reinforcing stigma and stoicism. Staff often worry about judgement, discrimination, ¹⁵ or repercussions to licencing, creating a reluctance to participate in mental health programming which leads staff to suffer in silence. Lack of discussion of distress may also lead HCWs to misjudge how others are coping, creating an internal pressure to be resilient, which perpetuates stoicism. ⁹ Our results emphasize that leaders and organizations should model openness to, and highlight the importance of, discussing psychological well-being. Organizations should consider discussing psychological wellness when onboarding staff and routinely in group meetings, encourage leaders to engage with programming, and include program implementors and wellness programs in the formal organizational reporting structure.

3. A program cannot be created or sustained without adequate resources. Available resources determine parameters including scope and duration. Therefore, ensuring “permanently funded staff to provide administrative and psychosocial support to the program” was a major emphasis in focus group discussions. This is consistent with literature describing a lack of resources and competing demands as barriers to the implementation of HCW mental health programming. ¹

4. Many recommendations were described as strategies for increasing reach, accessibility, and uptake of programming. Specifically, sharing educational information via public- and unit-facing monitors across the organization could reach a wider audience of staff (and patients). Similarly, establishing more spaces with audio-visual technology where staff can remotely connect to programming would address identified barriers related to lack of time to participate. ⁸

Limitations

This work focuses on STEADY implementors at a single teaching hospital in Canada; results are not necessarily generalizable to other contexts. Not all participants were able to participate for the entirety of the focus group sessions, so results represent the experiences of those who were in attendance whilst recommendations were developed. E-mail confirmation was utilized as a means of member checking to mitigate this issue.

Conclusions

Through their experiences during the pandemic, STEADY implementors developed an understanding of the challenges associated with offering psychological wellness programming to HCWs in a hospital environment. Focus group facilitators assisted them in developing twelve recommendations for future implementation and sustainment of similar programming, including ways to increase awareness and engagement, leverage the influential role of leaders, utilize existing opportunities, and create new means of reaching staff.