The COVID-19 pandemic has presented unprecedented challenges for healthcare workers, highlighting critical vulnerabilities in the ability to manage the mental health consequences. This serious issue could have long-term ramifications for those affected—and for our healthcare system more broadly.
The healthcare sector may consider shifting its focus away from short-term mental health “fixes” in the aftermath of acute events and toward the development of an integrated framework to address clinician mental health and the long-term effects of trauma. While the precise formulation of individual programs will vary, there are a set of principles that should inform any new mental health framework. Providers can consider embedding mental health training through education, deploying regular risk assessments for all students and staff, establishing new structures within the organizational hierarchy to prioritize mental health and well-being, and procuring resources dedicated to supporting clinicians who require safety net services.
In figuring out the details of mental health services and structures they will offer, providers may undertake a robust internal monitoring and evaluation program, and learn from other sectors and organizations. There has been considerable recent innovation in mental health and well-being programs outside of the healthcare sectors—particularly in fast-paced industries with high turnover, such as technology and financial services, and settings where there has been exposure to trauma. Providers can consider investigating whether these new programs and services might be effective in a healthcare setting.
This more extensive, better integrated mental health framework represents a departure from the current level of mental health provision for healthcare workers, and providers may need additional funding and resources from both federal and local governments. Private sector partnerships may be a way for public sector stakeholders to offer support to healthcare workers.
COVID-19 has exacerbated existing issues around the mental health of frontline healthcare workers
Prior work has established the myriad mental health challenges faced by healthcare works endure, including suicidal thoughts, depression, and burnout.1 Multiple studies have reported higher rates of suicide among physicians compared to the general public, with work dissatisfaction and burnout considered to be major factors.2
COVID-19 has amplified these existing issues, affecting healthcare workers at both work and home (Exhibit). In addition to the inherent stressors of addressing a pandemic, clinicians have faced increasing work hours and a simultaneous decrease in compensation, with 62 percent of US-based physicians reporting a decrease in pay or retirement contributions.3 Simultaneously, healthcare workers face considerable stress related to the risk of acquiring COVID-19 and transmitting it to their families,4 and many are also seeing less of their family and friends. Around the world, the virus has therefore heightened the risk of clinician burnout, anxiety, depression, and potential trauma-related stress disorders. In China, for example, 50 percent of healthcare workers who were exposed to the virus in 2019 reported depression and 45 percent reported anxiety.5 In Italy, a May 2020 study found almost half of healthcare worker respondents reported post-traumatic stress symptoms, and almost 25 percent reported systems of depression.6
Before COVID-19, healthcare worker burnout and mental illness were underdiscussed, underrecognized, and undertreated. One silver lining of the crisis is a greater degree of external recognition of the challenges that healthcare workers face. These have ranged from messages of gratitude and support (such as television commercials, aerial salute flyovers, and designated hours in which citizens “clap for carers” in many countries) to discounts and perks (for example, retail discounts or free coffees offered for healthcare workers). Some providers have expanded access to mental health and well-being services (such as mental health counseling and expanded child care) or taken significant steps to increase awareness of mental health issues and where to go for support.
Healthcare providers can develop an integrated framework to address clinician mental health
The changes to mental health provision that have been made since the outbreak of the crisis have, for the most part, been temporary. They are designed to address the effects of an acute surge on an already burdened system. The sector may consider using the momentum of the current pandemic to fundamentally rethink the long-term mental health provision for healthcare workers. A new paradigm can help organizations support the mental health needs of their workers in the “next normal.”
Existing evidence suggests that mental health and well-being programs can have a significant positive impact. Impaired well-being, such as burnout, is a key driver of physician turnover. In addition to the human cost, this also have a considerable financial cost to the health system; replacing a physician costs two to three times a physician’s annual salary.7 Programs with a focus on mental health resilience, for example, have been shown to improve clinician morale and job satisfaction, and to engender a sense of purpose.8 These initiatives can also have a positive impact on the financial performance of providers, though outcomes have varied; one meta-analysis showed that medical costs were lowered by approximately $3 (and absentee day costs fell by about $2) for every dollar spent on well-being programs.9 However, other studies have failed to show positive financial returns.10
Individual health systems differ enormously—as do healthcare workers themselves—which means that there will be no simple one-size-fits-all solution. There are, however, some core principles for a new healthcare framework.
Embed mental health and resiliency training throughout education
Mental health awareness could be integrated into the curriculum of all healthcare worker training programs (for example, medical school, dental school, nursing school, counseling programs, and technician training) from day one. This is critical in ensuring that mental health is understood to be a fundamental part of overall health, and treated with the same urgency, skill, and compassion as other health conditions.
We propose establishing longitudinal tracks (for example, a mental health and well-being track) that move beyond the current model of providing periodic one-off lectures (once a quarter or annually, for example) and instead span the entire duration of medical training. Modules could be designed to focus on particularly challenging experiences (such as the daily realities of the poorest patients, interpersonal violence, and patient death) and could be standardized across systems and regions or—where necessary—tailored to the local context. Training would ideally include both a detailed introduction to mental health principles and interactive simulations on how to deal with potentially traumatic scenarios.
Deploy regular risk assessments for students, trainees, and staff
Clinical departments and educational programs could identify staff, trainees, and students at risk of mental health issues by assessing a variety of factors including personal background, work environment, and underlying heath conditions. Such efforts should incorporate robust privacy protection measures that meet Health Insurance Portability and Accountability Act of 1996 guidelines. The goal is to help workers who may be experiencing trauma at an early stage and to highlight actionable issues that may have a negative impact on mental health (such as unsuitable housing). Some resident training programs already deploy assessments of this type to try to counteract increasing burnout and mental health issues. In one instance, a Resident Wellness Scale was designed to track residents’ wellness longitudinally and was found to be a psychometrically strong measure.11
Risk assessments may be conducted in partnership with an external organization. An initial assessment would establish a baseline level of mental health and well-being on metrics, which should then be tracked over time, and all results should be integrated into a single, longitudinal data set. The information should be confidential, but the individuals themselves should be able to access the data and—when they wish—to share an anonymized version.
The frequency of assessments would vary. It may be appropriate, for example, to have mandatory assessments at each major transition (or once every three years) and offer optional annual assessments. These could be supplemented by shorter, more frequent surveys. As an example, a pharmacy student could have a baseline evaluation, a follow-up during their third year of pharmacy school, another assessment the following year when they enter their first residency, and another a year later if they enter a second residency. They would then have another test when they take a job, with follow-ups at least every three years thereafter.
Anonymized, longitudinal data sets would serve as a basis for much-needed research into mental health and treatments among healthcare professionals. They would also—within the bounds of what is possible while protecting privacy—help to identify those most in need of prevention or treatment efforts at the earliest possible juncture.
Establish new structure within the organizational model/hierarchy to prioritize mental health and well-being
One factor distinguishing effective programs from ineffective ones is the extent to which they are embedded into a new organizational model and prioritized by leadership. A number of structures can work, so providers will need to determine the best model—or mixture of models—for them.
Establish an office of well-being: Embedding new programs within a dedicated office has been a successful strategy for a number of organizations. The Stanford School of Medicine, for example, has established WellMD, which deploys a wellness survey, offers self-testing resources, and teaches a course aimed at chief wellness officers (CWOs).12 Mount Sinai recently launched a new Center for Stress, Resilience, and Personal Growth, which is designed to address the psychosocial impact of COVID-19 on the mental health of healthcare workers. It will offer resiliency training, stress and mental health self-screening services, and a range of interventions, including eight-session support groups, individual assessments, and mental health treatments.13 Keck Medicine of the University of Southern California launched the “Care for the Caregiver” program, which offers free housing, other amenities such as groceries and toiletries, and mental health support to staff at high risk of job-related stress.14 These programs operate in parallel to the traditional organizational hierarchy, reinforce confidentiality as essential and develop operating models that enable financial independence (such as by obtaining grant or fellowship funding).
Create a CWO position: Many academic institutions have CWOs to address staff burnout and mental health. CWOs would be an addition to the C-suite, where they would be equipped with the authority, budget, and staff to deliver enterprise-wide solutions for staff burnout and mental health. They should be accountable for organizational outcomes. There is a risk that CWOs are seen as a way to merely tick a box on an organizational checklist, and it is therefore vital that the CWO cultivates a close relationship with on-the-ground clinicians, has the support of the CEO to ensure that mental health and well-being is a top priority across the organization rather than a disjointed silo, and is able to demonstrate the value of any new initiatives to both the organization and frontline staff.
Train clinical department heads and chairs on burnout and mental health: Where the creation of a CWO is not necessary (or not sufficient), heads of department could be trained to play a similar role for the staff within their units. Spreading responsibility in this way can be beneficial, as these issues risk getting lost among the many other competing priorities of these heads of department. Performance evaluations could include metrics such as employee burnout and mental health scores.
Procure dedicated safety net resources to support clinicians navigating logistical challenges
Providers need to offer comprehensive support, which means recognizing that robust mental health is not just about what happens at work, and that the unique demands placed on frontline healthcare workers can create—and be exacerbated by—issues outside of the hospital. Providers should establish dedicated safety new resources to help both in the acute setting of a traumatic event and for long-term needs.
Resources needed during an acute setting or after a traumatic event
- Increased access to counseling services and on-the-ground support in healthcare facilities, which should include well-being stations for nourishment, rest, and stress relief. Rush University System for Health, for example, offers a centrally located Wellness Resource Hub, where “any staff member can receive confidential, on-site counseling support, escape busy clinical areas, process their emotions, and relax.”15
- Logistical support, which should include assistance with childcare (perhaps through establishing on-site centers) and home management and housing assistance (including guidance and dedicated staff resources on how workers can avoid exposing their households to excessive risk).
- Agile and flexible working models that allow for healthcare workers to be transferred between departments when their situations require or schedule either a smaller number of longer blocks of time to work in an acute trauma setting or multiple shorter stints, as required.
- Hazard pay, to compensate clinicians for dangerous and difficult working conditions. Some states also have addressed hazard pay. In December, Vermont legislators approved additional funding for the Vermont Frontline Employees Hazard Pay Grant program, which means up to 20,000 Vermonters who work in healthcare, grocery stores, and other sectors in the spring will receive checks of $1,200 or $2,000.16
Long-term, baseline resources needed: In addition to the above, a better baseline support model should be developed that allows for regular breaks for both trainees and fully trained staff. Schedules should be flexible enough to allow healthcare workers to take burnout and mental health breaks. Increasing work hour flexibility—which means building in additional coverage to ensure that there is some slack in the system—not only improves mental health but also increases productivity, commitment to the organization, and retention.17
Designing a robust mental health and well-being program
Ensuring robust mental health will require an ongoing commitment to improving the understanding of the science underlying the prevention, diagnosis, and treatment of mental health illnesses and the related challenges that healthcare workers face—and to integrating new findings into existing program offerings.
Robust monitoring and evaluation efforts can track the impact of existing mental health programs. This effort should include regular surveying and testing to identify the impact of each individual service on key outcomes, and to understand differential affects by role, seniority, or demographic group. Results should then be used to iterate on the available set of interventions and to develop new offerings, as necessary. Agile principles are being adopted across a number of clinical operational topics and these principles should not be forgotten when it comes to clinician mental health and well-being programs.18
The medical establishment also can learn from other industries. In recent years, technology companies have been at the vanguard in terms of offering their employees innovative opportunities aimed at improving well-being. Some technology companies have, for example, created “napping rooms” to help employees recharge, while others have offered virtual therapy apps.19 Gitlab developed initiatives that aim to maximize connectivity and minimize isolation for those working outside of an office environment.20 Financial services and consulting companies, where employees typically work long hours, may also provide important lessons for the healthcare industry. The financial services company, Blend, for example, enables employees to balance their professional and social obligations by offering flexibility to take additional leave or vacation between projects.21
Healthcare providers should also draw inspiration from existing programs within other public service occupations. The US National Association for Social Work, for example, has recently increased its focus on compassion fatigue and secondary trauma. It provides regular self-assessments to members and has created a culture in which not addressing mental health challenges is considered an ethical violation.22 Similarly, health systems and communities have rallied in support of frontline healthcare workers who suffered primary and secondary trauma as a result of terrorist attacks. COVID-19 itself is already helping to push the frontiers of essential worker support; First Responders First is a partnership between the Harvard T.H. Chan School of Public Health, Thrive Global, and Creative Artists Agency Foundation—supported by a number of large private sector companies—that comprehensively addresses frontline healthcare worker needs. The program addresses everything from food and childcare to behavioral health interventions, including training, workshops, and coaching.23 Providers can look to these existing efforts for inspiration in building their own mental health and well-being programs.
The path forward
The COVID-19 pandemic is far from over, and other challenges will emerge; providers need to find comprehensive, innovative models to ensure that they are capable of identifying, evaluating, and supporting workers who need help. In addition, there will be real costs with addressing the mental health needs of clinicians, and it should be a goal of all stakeholders to identify and institute appropriate funding mechanisms. Lessons can be taken from other sectors: only by adopting best practices and innovations from a wide range of settings can providers hope to transition healthcare worker mental health and well-being from reactive to proactive, treatment to prevention, and surviving to thriving.