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ERIN ARCHER, RN
Contributor to Health Progress

Illustration by Jon Lezinsky

COVID-19 emerged onto the world stage in January 2020. In the two years since, it has become a nearly constant presence in the jobs and personal lives of health care workers. Intermittent surges in infection rates have left many health care systems and workers overwhelmed, traumatized and morally conflicted. Meanwhile, others working in health care have reported feeling hopeful and that they have an increased sense of purpose.¹

As individuals and as organizations, are there evidence-based interventions that can be used to help increase those feelings of hopefulness and gratification for those working in health care, even during difficult times? Is it possible to make this pandemic period a galvanizing era for staff morale, actually increasing joy in work and creating a more resilient organization going forward?

Organizations like the Institute for Healthcare Improvement (IHI), the American Medical Association (AMA) and the American Psychiatric Association (APA) argue that it is not only possible, but imperative to immediately address the issues of burnout, to increase joy in work and also attend to the "moral injury" that so many health care workers have suffered and are continuing to endure. In the two years since the pandemic began, multiple evidence-based frameworks and resources have been utilized to help individuals and organizations proceed on that journey, some of which are discussed in this article. (For a list of resources related to supporting individuals and organizations, see sidebar.)

BURNOUT BEFORE THE COVID-19 PANDEMIC
Even before the COVID-19 pandemic, burnout among those working in health care was high. In their 2019 report "Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being," the National Academy of Medicine (NAM) reported that between 35% and 54% of U.S. nurses and physicians had substantial symptoms of burnout, as did 45% to 60% of medical students and residents. The National Academy of Medicine characterizes burnout as "a syndrome characterized by high emotional exhaustion, high depersonalization (for instance, cynicism) and a low sense of personal accomplishment from work." Furthermore, NAM argues that burnout is driven by systemic issues, and it therefore needs to be addressed at the organizational level.²

By focusing on fixing the workplace rather than "fixing the worker," NAM argues that leaders can advance the well-being of health care workers and increase the resiliency of organizations. NAM divides their recommendations across six domains: 1) organizational commitment, 2) workforce assessment, 3) leadership (including shared accountability, distributed leadership and the emerging role of a chief wellness officer), 4) policy, 5) efficiency in the work environment and 6) support.

Another framework that attempts to address burnout is IHI's "Framework for Improving Joy in Work." Launched in 2017, the model has measurable actions for organizations to take in order to increase joy in the health care workforce. It has been adapted by the AMA for its Joy in Medicine framework and also for use by IHI and the AMA during the COVID-19 pandemic.

The "IHI Framework for Improving Joy in Work" breaks down four basic steps for leaders to take to increase staff engagement and joy. Like a staircase, the steps build upon each other. The first step is to sincerely ask individual employees "What matters to you?" in their work. Second, leaders identify impediments to obtaining those goals, often things that wear away at the employee's enjoyment in work, day after day, much like a "pebble in the shoe." These first two pieces often happen in the same conversation, helping the employee and leader to develop honesty and trust. The employee must feel listened to, assured that their ideas and opinions matter and that there will be a genuine effort to address their concerns, otherwise the leader-employee relationship will become even more damaged. Therefore, leadership must be enabled and genuinely willing to enact changes. The third step is that (ideally multidisciplinary) teams need to come together to address the removal of the impediments found in step two. Fourth, tools to track performance improvement should be used to measure whether interventions are truly being implemented, are useful and are meeting the goals of increasing individual and organizational joy in work.³

HEALTH CARE WORKERS DURING THE COVID-19 PANDEMIC
In March 2020, the AMA launched the Coping with COVID-19 for Caregivers Survey to evaluate the level of stress experienced by health care workers.⁴ Data collected between May 28 and October 1, 2020 (two months before vaccines became available) had 20,947 respondents, representing 42 organizations. The survey data showed that 49% of health care workers had burnout and 38% reported anxiety and/or depression. The risk of burnout was 40% lower for those who felt valued by their organizations.⁵

The Kaiser Family Foundation (KFF) and The Washington Post conducted their "Frontline Health Care Workers" survey via phone and online in English and Spanish from February 11 to March 7, 2021, after COVID-19 vaccines had become available. Classified as frontline health care workers were 1,327 Americans in a variety of inpatient and outpatient settings who had direct contact with patients and their bodily fluids. Through responses collected at that time, 76% of health care workers reported feeling "hopeful" when going to work, even though over half said they also felt "burned out" and 21% reported feeling "angry" when going to work. Even during this relatively hopeful period in the United States, one third of them contemplated no longer working in health care.⁶

By the summer of 2021, many care providers were surprised when the Delta variant of COVID-19 again led to full ICUs and inpatient units across the country and much of the world. In the United States, the overwhelming number of those admitted for COVID-19 care were people who had declined to be vaccinated. The implementation of "crisis levels of care" meant that providers sometimes had to decide who was most likely to live and deny care to people more likely to die, regardless of vaccination status or medical condition. Many providing care found themselves exhausted, angry and even resenting their unvaccinated patients.⁷

Data was not yet available (as of December 2021) on the frame of mind of health care workers on the heels of the Delta variant surge in the United States, but it is apparent that many are experiencing more than stress reactions and burnout — they are now experiencing stress injuries, much like people experience during natural disasters and other mass casualty events. Unfortunately, there is no known end to the COVID-19 pandemic. We are also unable to come together to see the scope of the problem and to grieve as communities.⁸ Unlike with a mass casualty event like a tornado or flood, much of the pandemic stress has occurred behind the walls of health care facilities, creating a surreal double life for many outside of work, where many members of the public proceed as if the pandemic does not exist.⁹

If left without support from their organizations, those working in health care can progress from having stress reactions (like muscle tension or feeling down) to having stress injury (such as excessive guilt or feeling out of control) to having a chronic stress illness (such as PTSD, depression or substance abuse). The AMA's "Creating a Resilient Organization" module discusses four kinds of stress injuries: traumatic injuries from life threats, grief injuries from loss, moral injuries from inner conflict and fatigue injuries from accumulated stress. It argues that stress reactions and injuries need not proceed to stress illness. By initiating proactive institutional supports before a crisis, delivering "stress first aid" during the crisis and "recovery aid" after the crisis, the odds are increased that workers will recover and thrive, leading to "post-traumatic growth." The module lays out 17 steps for before, during and after a crisis to help with that process, fostering resilience.¹⁰

WHAT IS MORAL INJURY?
Many of the guidance documents emerging during the COVID-19 pandemic include the need to address "moral injury" in the workforce. First described in Vietnam War combat veterans, moral injury is not the same as burnout or PTSD. Originating neither from exhaustion nor existential threats to ourselves, moral injury can actually make us wonder if we are still moral human beings. It occurs when we "perpetrate, bear witness to or fail to prevent an act that transgresses our deeply held moral beliefs."¹¹ In a combat situation, moral injury can arise from an event such as being ordered to kill civilians. In health care during the pandemic, moral injury has the potential to arise from multiple sources, including having to implement crisis standards of care, providing inadequate personal protective equipment to staff due to supply shortages, not allowing family to visit dying COVID-19 patients and so on. If left untreated, moral injury can lead to the types of stress illnesses previously noted.

WHAT CAN BE DONE?
Increasing joy in work and decreasing burnout and moral injury in the workplace begins with leadership commitment to improvement and to making necessary changes to systems that may be broken or no longer functional. Key to all of these models is the acknowledgement that it is not people who are broken and who lack resilience, but the systems in which they work. Evidence-based frameworks exist to address these issues, but leadership needs to be aware of them and to utilize these models. After all, there will be other crises after the COVID-19 pandemic subsides, and the best time to craft a resilient organization is before a crisis. The second best time is now.

ERIN ARCHER is a freelance health care writer and nurse in Tucson, Arizona. She has written for Everyday Health, Institut Pasteur and AuntMinnie.com.

NOTES

1. Kriti Prasad et al., "Prevalence and Correlates of Stress and Burnout Among U.S. Healthcare Workers During the COVID-19 Pandemic: A National Cross-Sectional Survey Study," EClinicalMedicine 35, no. 100879 (May 2021): https://doi.org/10.1016/j.eclinm.2021.100879.
2. Christine A. Sinsky et al., "Organizational Evidence-Based and Promising Practices for Improving Clinician Well-Being," NAM Perspectives (November 2020): https://doi.org/10.31478/202011a.
3. Jessica Perlo, "Four Steps Leaders Can Take to Increase Joy in Work," Institute for Healthcare Improvement, http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/Jessica-Perlo-Four-Steps-Leaders-Can-Take-to-Increase-Joy-in-Work.aspx.
4. Mark Linzer et al., "Preliminary Report: US Physician Stress During the Early Days of the COVID-19 Pandemic," Mayo Clinic Proceedings: Innovations, Quality & Outcomes 5, no. 1 (February 1, 2021): 127–36, https://doi.org/10.1016/j.mayocpiqo.2021.01.005. This article notes that the APA's Coping With COVID survey initially included a first wave of data collected from April 4 to May 27, 2020 (representing 2,373 physicians in 17 organizations) prior to the second wave of data collected from May 28 to October 1, 2020.
5. Prasad et al., "Prevalence and Correlates of Stress and Burnout."
6. Ashley Kirzinger, Liz Hamel, and Mollyann Brodie, "KFF/The Washington Post Frontline Health Care Workers Survey," KFF, April 6, 2021, https://www.kff.org/coronavirus-covid-19/poll-finding/kff-washington-post-health-care-workers/.
7. Ed Yong, "Delta Is Driving a Wedge Through Missouri," The Atlantic, July 16, 2021, https://www.theatlantic.com/health/archive/2021/07/delta-missouri-pandemic-surge/619456/.
8. "A Guide to Promoting Health Care Workforce Well-Being During and After the COVID-19 Pandemic," Institute for Healthcare Improvement, http://www.ihi.org:80/resources/Pages/Publications/guide-to- promoting-health-care-workforce-well-being-during-and-after-the-COVID-19-pandemic.aspx.
9. Yong, "Delta Is Driving a Wedge."
10. Tait D. Shanafelt et al., "Creating a Resilient Organization: Caring for Health Care Workers During Crisis," American Medical Association, May 8, 2020, https://www.ama-assn.org/system/files/2020-05/caring-for-health-care-workers-covid-19.pdf.
11. Wendy Dean, Simon Talbot, and Austin Dean, "Reframing Clinician Distress: Moral Injury Not Burnout," Federal Practitioner 36, no. 9 (September 2019): 400–402, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6752815/.