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KELLY O'SHEA CARNEY, PhD, ABPP
Long-Term Care Consultant

Illustration by Jon Lezinsky

Since the onset of COVID-19, no one has been unaffected. Each of us has experienced some degree of stress, loss, isolation and anxiety. As documented in the American Psychological Association's quarterly Stress in America survey, COVID has resulted in a national mental health crisis evidenced by increases in unhealthy coping mechanisms, for instance, increased weight gain and excess alcohol intake, dramatic upticks in depression and anxiety, particularly among people of color, and even difficulties in making day-to-day decisions that would have been otherwise simple prior to the pandemic.¹

For those who work in health care, the impact has been even greater due to the daunting demands of caring for those who are frail and vulnerable in the midst of constant change and uncertainty. For some, work has been a source of psychological trauma due to witnessing the heartbreaking deaths and illnesses of residents, which have occurred at unprecedented levels during the pandemic.² As leaders in long-term care, we recognize that our team members are struggling as much as — and likely more than — others as the pandemic wears on. In response, we must ask ourselves two important questions: How can we be sure that we do not make the challenges of this moment more difficult than they must be for staff? And more importantly, how can we foster emotional well-being among our team members, who are so critical to the care and welfare of those we serve?

SOURCES OF STRESS FOR STAFF
COVID and the demands it has placed on staff require that we reconsider how we support our colleagues who are so critical to fulfilling the goals of our ministries. In most settings, we offer education and support for healthy living, access to an Employee Assistance Program (EAP) for those who need emotional support and strive to create cultures in which people feel valued and appreciated. However, the assumption has been that maintaining emotional well-being is the responsibility of the individual staff member. In truth, while personal difficulties certainly compound and exacerbate stress at work, it is the unique demands of the health care environment that contribute to the unprecedented levels of burnout, fatigue and job turnover occurring in our industry. Studies of health care workers facing crises prior to COVID demonstrate that staff cycle through stages in their response to a crisis.³ Beginning with anticipatory anxiety and moving through a period of mobilization and a surge to solutions, as the crisis persists health care staff enter a stage of fatigue and disillusionment. In most other crises, however, there was a terminus when the demands of the crisis diminished and life returned to normal. When this occurs, people tend to recover their equilibrium and energy and are therefore able to work through the trauma they have experienced. However, with COVID there has been no end point. Rather, staff have repeatedly cycled through these stages as the pandemic has waxed, waned and morphed, placing constantly changing demands on providers and resulting in recurrent experiences of trauma. Consequently, many staff remain in a state of disillusionment and fatigue and sometimes even catch their breath briefly in a phase of recovery, only to be thrust back into the cycle again when a new case of COVID is identified in their setting.

Moreover, this experience is layered on top of the demands and challenges that are commonly present across health care settings. Societal and environmental factors that wear on staff have been well documented as the primary sources of stress and burnout among providers.⁴ Environmental factors that contribute to or take away from staff well-being include everything from shared societal stressors like COVID and racial inequities as well as more endemic contributors common in health care, like paperwork, difficult supervisory relationships, unpleasant physical environments and workload.

SYSTEM-BASED SOLUTIONS
By understanding that our team members are struggling mightily as they strive to care for those we serve, we have the opportunity to alter the environmental factors that diminish emotional well-being in this time of persistent crisis. Ideally, we can also be intentional about building strategies that foster emotional health within the workplace. Our goal should be to enhance the well-being of our workforce so that they can be at their best, first, for their own health and to serve those we care for. Doing so requires a systems-level approach within our care settings, targeting facets of the organization to make the working environment conducive to one's welfare despite the challenges inherent in this moment. Equally important, we must strive to eliminate any aspects of the physical, interpersonal and operational environment that deplete well-being or create undue burden on staff.

The diagram below depicts the various levels within a long-term care system that can be altered and mobilized to support the emotional health of staff.⁵ At each level there are evidence-informed approaches that can be adopted to foster well-being among staff that will in turn enhance the welfare of the elders and their families who we serve.

The shape of the pyramid conveys the extent to which interventions will have an impact on greater (bottom of the pyramid) or fewer (top of the pyramid) number of people. Note that our traditional mechanisms for supporting emotional well-being are found at the very top of the pyramid. The benefits that we offer to support the welfare of staff — such as an EAP — are helpful. But, in truth, only a fraction of all employees will access and use these services. To impact the well-being of our staff in a comprehensive, systems-based manner, we need to implement strategies at each echelon of the organization. The following are a few simple strategic ideas that can be employed at each level depicted on the pyramid.

Promote Environmental Wellness
Within the environment, the goal is to build in pleasant experiences while also striving to eliminate jarring stimuli, such as unnecessary noises, smells and visuals. Pleasant environmental experiences may include aromatherapy; designated outdoor spaces where staff can enjoy nature; bringing plants, flowers and animals into the workplace, either through live or visual methods; and inviting staff to contribute to decorating for special occasions, especially holidays that may be important to specific cultures or ethnic groups.

Encourage Employee Feedback and Colleague Support Systems
At the process level, it is helpful to ask staff for input on systems and processes that either facilitate or diminish their ability to meet the goals of their job. Unnecessary paperwork, redundancies in processes, tasks that are not aligned with each discipline's scope of expertise and demands that extend beyond the scheduled workday are the kinds of process factors that contribute to stress and burnout. Reducing these kinds of pressures within the work environment will help to enhance individual well-being and job performance. Processes that enhance one's welfare, such as setting up a buddy system in which staff support designated partners, or using huddles as a chance to check in and share stress management techniques, can also be implemented.

Enhance Teamwork
At the level of teamwork, staff well-being is enhanced when individuals feel like they are valued, integral and empowered members of their team. Within long-term care settings, we engage in required care team activities regularly, but the effectiveness of the interdisciplinary collaboration may or may not be ideal. Resources like Geriatric Interdisciplinary Team Training or the Rush University's Center for Innovative and Lifelong Learning interprofessional training provide evidence-informed approaches to ensure that teams communicate, collaborate and integrate services effectively.^{6, 7} When teamwork is more evolved and engaging, the individuals who are part of the team feel greater satisfaction and inclusion in their day-to-day activities.

Provide Leaders With Tools to Foster Emotional Support
There is an adage that "people don't leave jobs, they leave bosses." This saying reminds us that supervisors are the liaisons to our valued employees. In these particularly challenging times, when supervisors themselves are experiencing an inordinate level of stress, it is important that they also have the knowledge and skills to sensitively manage and support their employees. Training for supervisors should include understanding the concepts of self-compassion, recognizing the signs and symptoms of emotional distress and burnout, learning effective communication skills and attaining conflict resolution skills. Given the demands within our industry, there can be a tendency to drive employees harder and expect more of them, but when we do this without sensitivity to the demands and pressures they are already facing, we risk contributing to burnout and job turnover. Fostering supportive, compassionate leaders who acknowledge and address the needs and life experiences of their employees within supervisory interactions will enhance emotional well-being for staff and their supervisors.

Utilize Available Psychosocial Resources
It is also important to remember that we have professionals trained to support the psychosocial well-being of all within health care organizations. Psychologists, social workers, chaplains, recreational therapists and even occupational therapists are trained from a psychosocial point of view. By drawing upon the expertise of these professionals, we have the potential to create systems and structures that will support the emotional welfare of staff and residents alike. For example, consider creating a psychosocial well-being care team made up of these professionals and charge them with the task of reviewing the organizational systems that support or detract from the emotional health of the stakeholders within your system. This team might offer microtrainings for staff on stress management, plan creative activities available to employees on their breaks or even schedule outdoor walks as a "stress buster" during the day. Chaplains can offer prayer and meditation for staff during huddles and also encourage and support staff to use the chapel for reflection. By drawing upon the skills of those already present in our systems, there is no limit to the creative strategies that may emerge to foster emotional well-being among the people who live and serve in your communities.

CALL TO ACTION
We live in a time of unprecedented challenges, particularly for long-term care providers. Our team members are subject to the same stressors that we all encounter amid the ongoing COVID pandemic, and they are also impacted by the difficulties and demands unique to our field. While we all have ultimate responsibility for our own well-being, it is also important to acknowledge and address the unique, exacerbating stressors inherent in our systems. Our goal must be to find ways to reduce unnecessary stress and burdens on our staff while also enhancing their experiences of connection, empowerment and enjoyment in the workplace. When we do so, we minimize the added strain we place on our valued colleagues who are already weary and wounded by their work. Moreover, with the proper programs in place, work can serve as a source of well-being and respite amid our current challenges.

KELLY O'SHEA CARNEY is a licensed psychologist and board certified in geropsychology. She has served as a leader in long-term care for more than 25 years.

NOTES

1. "Stress in America October 2021: Stress and Decision-Making During the Pandemic," American Psychological Association, October 26, 2021, https://www.apa.org/news/press/releases/stress.
2. Elizabeth M. White et al., "Front-line Nursing Home Staff Experiences During the COVID-19 Pandemic," Journal of Post-Acute and Long-Term Care Medicine 22, no. 1 (November 2020): 199-203, https://doi.org/10.1016/j.jamda.2020.11.022.
3. Julie Highfield et al., "The Psychological Needs of Healthcare Staff as a Result of the Coronavirus Pandemic," The British Psychological Society, March 31, 2020, https://www.bps.org.uk/sites/www.bps.org.uk/files/News/News%20-%20Files/Psychological%20needs%20of%20healthcare%20staff.pdf.
4. "Clinician Well-Being Knowledge Hub," National Academy of Medicine, https://nam.edu/clinicianwellbeing/about/.
5. Kelly O'Shea Carney, "Fostering Emotional Well-Being Among Team Members," LeadingAge Learning Hub, https://learninghub.leadingage.org/courses/covid-19-fostering-emotional-wellbeing-among-team-members.
6. "Geriatric Interdisciplinary Team Training 2.0 Toolkit," Hartford Institute for Geriatric Nursing, https://hign.org/consultgeri-resources/guides-and-competencies/gitt-20-toolkit.
7. "Center for Innovative and Lifelong Learning Leadership Development," Rush University, https://www.rushu.rush.edu/education-and-training/center-innovative-and-lifelong-learning/leadership-development.