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Four Key Questions Leaders Can Ask to Support Clinicians During the COVID-19 Pandemic Recovery Phase

Published:October 26, 2021DOI:https://doi.org/10.1016/j.mayocp.2021.10.015
      Individual clinicians are typically able to step up for a temporary crisis, but when crisis becomes steady-state, the stress can be unsustainable. As a nation, the levels of concern about clinician burnout resulting from the stresses of the coronavirus disease 2019 (COVID-19) pandemic are rising. There is an increased focus on supporting clinicians during the pandemic recovery phase and beyond. This requires health care leaders to authentically and effectively develop strategies to address these stressors and support their clinicians.
      • Shanafelt T.
      • Ripp J.
      • Trockel M.
      Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic.
      In doing so, they may improve the organizational culture and promote post-traumatic growth in the pandemic recovery phase by showing their clinicians that they are valued and appreciated.
      • Olson K.
      • Shanafelt T.
      • Southwick S.
      Pandemic-driven posttraumatic growth for organizations and individuals.
      This perspective provides language and guidance for how to set the stage for honest and open conversations between organizations and their clinicians, and how to begin to strategize in response to what is shared in these conversations.
      Before the pandemic, clinician burnout had already been identified as a public health crisis.
      • Noseworthy J.
      • Madara J.
      • Cosgrove D.
      • et al.
      Physician Burnout Is A Public Health Crisis: A Message To Our Fellow Health Care CEOs. Published March 28, 2017.
      Triennial national surveys over the past decade have shown that nearly half of all physicians experience some sign of burnout.
      • Shanafelt T.D.
      • West C.P.
      • Sinsky C.
      • et al.
      Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.
      A fourth survey, launched in late 2020, will shed light on changes in the rates of burnout during the pandemic. Since March 2020, the American Medical Association (AMA) has surveyed clinicians and other health care workers as part of the COVID Caring for Caregivers initiative. In a cohort of 20,947 health care workers, those who moderately or greatly endorsed “I feel valued by my organization” had 40% lower odds of burnout (P<.001).
      • Prasad K.
      • McLoughlin C.
      • Stillman M.
      • 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.
      In a cohort of 2373 physicians, those who answered the same question similarly had significantly lower summary stress scores (P<.001). Feeling valued explained 11% of stress summary score variance at the physician level and 31% of variance at the organizational level.
      • Linzer M.
      • Stillman M.
      • Brown R.
      • et al.
      Preliminary report: US physician stress during the early days of the COVID-19 pandemic.
      Massachusetts General Hospital’s Department of Medicine held facilitated listening sessions for hundreds of clinicians between May 2020 and March 2021 to support employee well-being during the COVID-19 pandemic. While these sessions were semistructured and responded to the needs raised with each group, several questions and approaches emerged that led to more engaging conversations with participants. Informed by these experiences, and review of the AMA COVID Caring for Caregivers data, we developed four questions health care leaders at all levels can ask to show value and appreciation to their clinicians: How has the pandemic impacted your life? What does value and appreciation look and feel like at work? What gets in the way of doing a job you’d feel proud of? What do you need to move forward? The Table details potential examples one might expect to hear in response to these questions.
      TableFour Key Questions Leaders Can Ask to Support Clinicians During the COVID-19 Pandemic Recovery Phase
      QuestionExample responses
      What are the ways your life has been impacted by the COVID-19 pandemic?Loss of all kinds (family, friends, patients, human connection)

      Loneliness

      Limited emotional reserve, exhaustion

      Altered routines

      Change in work roles/responsibilities

      Lack of work-life balance

      Sense of languishing

      Extreme workloads

      Moral dilemmas of care

      Uncertainty and worry — professional, health, personal, financial, family
      What does value and appreciation at work feel like for you?Transparent communication

      Communicating early and often (don’t wait until its perfect)

      Including their experience into future planning

      Flexibility (telehealth, remote work, schedule, redeployment environment)

      Eliminating unnecessary burden (documentation, password updates, and mandatory quality and safety trainings)
      What prevents you from doing a job that you are proud of?People cannot continue to do all they were doing before plus more, so things need to be removed from their plate, resources need to be built in, or expectations need to change

      Leaders need to show more flexibility and grace in expectations and acknowledge that this time is not normal

      Need to adjust our expectations for ourselves — my patients still need me, but I also may have kids screaming in the background
      What can be done to move forward and help you do a job you are proud of?Rather than ask someone how they are doing, ask “how can I help make your day better?”

      Meet one-on-one with clinicians to identify what they have lost academically or monetarily and help create an action plan to get that back on track (and check back in regularly!)

      Create financial relief programs for those affected by unforeseen costs or who have suffered funding losses

      Respect work and home boundaries

      Encourage self-care

      Encourage time off

      Adjust clinical volume expectations and job descriptions to reflect post–COVID-19 workload

      Create opportunities for grieving and sharing loss
      We learned that simply asking clinicians “how are you” or “how can we help” did not generate much input or provide direction — the mental and emotional lift of coming up with ideas proved to be an unwanted additional burden, particularly when loss and grief seemed to cloud creative problem solving. In contrast, using this semistructured approach framed with the four questions can help leaders connect with their workforce and walk clinicians through a process where they can articulate loss and impact of their experiences, identify what value feels like, what doing a job they feel proud of looks like, and what is getting in the way of that vision. The final step takes this new perspective and creates a space to provide recommendations for how leadership can respond.

      What Are the Ways Your Life Has Been Impacted by the Covid-19 Pandemic?

      Acknowledging the many losses people have experienced is a first step in helping them feel seen and heard by leaders. Some losses may have gone unrecognized in the chaotic experiences of the workplace during crisis. In fact, until this conversation, many may not have realized what they were feeling was loss or grief. Naming those losses begins the process of grieving and can promote post-traumatic growth through development of one’s narrative.
      • Kruskal J.B.
      • Shanafelt T.
      Radiologist Well-Being and Professional Fulfillment in the COVID-19 Era: Fostering Posttraumatic Growth.
      It also provides an opportunity for leaders to understand the areas of greatest need for resource development and support.

      What Does Value and Appreciation at Work Feel Like for You?

      Hearing directly from people what value and appreciation feels like will give leaders a clearer understanding of their needs and help to ensure values alignment. Guided by their responses, a mutually agreed upon vision for future success can be crafted and referenced back to in the future.

      What Prevents You From Doing A Job That You Are Proud Of?

      Is it enough to “just try to survive”? Or, even in crisis, should leaders look for ways to help the workforce thrive? Providing space to focus on what an individual clinician needs to do a job they can feel proud of sends a message of being valued by leadership. It also creates a space to promote self-compassion rather than self-condemnation during a time when the workforce is overwhelmed, both at work and at home.

      What Can Be Done to Move Forward and Help You Do a Job You Are Proud Of?

      This is the opportunity question. Now that they have named their losses, the barriers to doing work that makes them feel proud, and how being valued at work looks, clinicians can ask leaders for what they need. Consider a follow-up question of “what can we take off of your plate?” The AMA has developed a “de-implementation checklist” as a resource to remove unnecessary burdens and improve clinician well-being through subtraction, rather than addition.
      AMA Steps Forward De-Implementation Checklist. American Medical Association; :2.
      How leaders respond shows their investment.
      The requests to leadership that result from these conversations do not need to be realistic or well thought out. Rather, this is a brainstorming place where even the grandest idea that seems impossible may have something that can be drawn from to show value and appreciation. This is helpful to keep in mind as many health care organizations are operating in a resource-constrained environment due to the impact of the COVID-19 pandemic. Although this reality can be acknowledged during these conversations to identify areas that may be “off limits” (ie, changes in salary, benefits, space, staffing, etc), to create a generative space, participants should be encouraged to not be hindered by financial constraints when sharing ideas, nor should leaders promise to be able to fulfill all the wishes shared.
      We recommend providing a range of opportunities for clinicians to engage with these questions and respond, including open listening sessions with skilled facilitators, one-on-one meetings with clinicians, hallway conversations during leadership walk rounds, or in qualitative surveys. Meeting clinicians where they are, such as typical practice meetings, rounds, or conferences can be particularly useful, so as not to ask “one more thing” of them or their time. Consider providing the questions in advance so people have time to consider their responses or consult with their colleagues.
      Following these discussions, it is important for leaders to share what they heard with those they listened to and those who are part of the leadership teams. These conversations should open an ongoing dialogue, not a one-time offering. Small working groups can be formed to engage those who are passionate and have ideas, which can serve to reinforce value and appreciation in these clinicians. Many resources exist and can be used to support the response to these discussions, particularly in the AMA’s website
      American Medical Association
      Caring for our caregivers during COVID-19. Published January 25, 2021.
      and the National Academy of Medicine’s Clinician Well-being website.
      National Academy of Medicine
      Strategies to support the health and well-being during the COVID-19 outbreak.
      Consider adding “value and appreciation” to a standing leadership meeting agenda to ensure you are not forgetting the importance of this issue. Finally, measuring value and engagement before and after this process can provide useful data on the impact of these efforts.

      Conclusion

      Many clinicians readied themselves alongside their organizations in the first waves of the COVID-19 pandemic, but now worry about their resilience and rising burnout as a result. Health care organizations may find themselves struggling financially and focusing on the fiscal needs, but now more than ever, leaders must invest in their health care workforce to express their organizational values and individual appreciation to clinicians.

      Acknowledgment

      The opinions expressed in this article are those of the authors and should not be interpreted as American Medical Association policy.

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      1. AMA Steps Forward De-Implementation Checklist. American Medical Association; :2.
        • American Medical Association
        Caring for our caregivers during COVID-19. Published January 25, 2021.
        • National Academy of Medicine
        Strategies to support the health and well-being during the COVID-19 outbreak.