Institutional Resilience: The Foundation for Individual Resilience, Especially During COVID-19

Abstract

In the protracted healthcare crisis that the COVID-19 pandemic has become, healthcare professional wellness and resilience are a national concern. Physicians, nurses and medical staff have been profoundly negatively affected due to the inability of institutions to prepare for this pandemic. Institutional fixed point standards such as Eudaemonics, Inherent Value, and Amplifying Assumptions are essential to make it possible to steer an organizational course during a crisis. Fixed point standards must be embedded in hospitals and systems so they are positioned to do the most good. Employees must feel safe, valued and cared for always, so they can be resilient when crises strike. The best way to do that is by viewing the healthcare professionals through the lens of empathy. Institutional values of safety, access to accurate and caring information, human connection, and emphasis on mental health, are hallmarks of resilient organizations and will result in resilient individuals.

In the protracted healthcare crisis that the COVID-19 pandemic has become, healthcare professional wellness and resilience have become a national concern. Physicians, nurses and medical staff have been profoundly negatively affected due to the inability of The US healthcare system and healthcare organizations to prepare for this pandemic. In early 2016 Chancellor Jeffrey Gold wrote,

The greatest health care crisis American physicians and other health professionals face today is not AIDS, Ebola, heart disease, or cancer. It’s an epidemic that few outside our profession have heard of and that few within can articulate in a way that gives a true picture of what we are up against.¹

The epidemic was burnout.

Now that the Covid-19 pandemic has been layered upon the burnout epidemic, efforts to promote wellness and resilience are doubly challenged. The healthcare sector has been charged with fixing the metaphorical plane while re-designing and flying it. And focusing on individual rather than institutional resilience misses the forest for the trees. We must take care of individual healthcare professionals to the best of our ability while diligently examining how organizations can become more resilient and more compassionate. Asking clinicians to meditate and take more yoga classes may help manage daily stress, but until organizational resilience is restored, chronic stress, health challenges and fatigue in the workforce will continue to climb.

Resilience, defined as the capacity to “bounce back” from an insult or trauma, is an organizational, team, and an individual trait. When facing a crisis, a set of fixed point standards, defined as dependable principles or stable benchmarks that guide institutions in times of chaos, must already be in place to deliver optimal responses.² Fixed point standards must be embedded in hospitals and systems so they are positioned to do the most good. Employees must feel as safe, valued and cared for as possible, so² they can be resilient when crises hit.

The best way to embed fixed point standards is by viewing the safety of patients and healthcare professionals through the lens of compassion. A compassionate organization considers its constituents’ needs, fears, and trust in the organization. Attunement to these needs includes: (1) embedding structures for safety, (2) provision of timely and accurate information, (3) support of community cohesion, and (4) emphasis on mental health. Such structures must be in place ahead of time to strengthen trust and confidence that lay the foundation for resilience.

Cameron ties institutional resilience to compassion. What makes an organization compassionate? Cameron identifies three fixed point standards that describe compassionate institutions: (1) Eudaemonics- the inclination toward moral goodness; (2) “Inherent Value”- providing value is an end unto itself; (3) “Amplifying Assumption”- Compassion inspires upward spirals of positive dynamics, including improved relationships, gratitude, and prosocial behavior.²

Fixed point standards are institutional standards that must be incorporated into federal and institutional policies that make it possible to steer an organizational course during a crisis. Without federal preparedness and standards for delivering compassionate care, hospitals are unable to operate proactively to “do the most good,” but instead react to crises by “doing the least harm”. High pressure, high velocity systems lead to avoiding bad, but not always adhering to the most desirable outcomes.³

In spring of 2020, hospitals scrambled to adapt first to take care of patients, then employee health, and lastly, to employee psychological safety and mental health. The latter were often sacrificed in attempts to take care of the former, and this costly sacrifice undermines the healthcare industry’s ability to provide optimal care. While the stress of a global pandemic is too much for any organization to promise relief from all the fear and uncertainty that accompanies such a crisis, most institutions would agree that having fixed standards of care in place would help them respond to a crisis more effectively. Standards such as compassionate patient and employee care and policies for employee wellness would predict desired outcomes such as individuals’ commitment, motivation, physical and psychological health⁴ yet many organizations had few such fixed points in place when the pandemic surged.

Some healthcare organizations have managed the first surge of COVID-19 and may now have more experience to draw upon to reflect on employee safety, physical and psychological health and resilience. Hospital leaders are working to ensure that their stockpiles of personal protective equipment (PPE) and COVID-19 tests, plasma and other treatments. Ventilators stand ready for the current wave of the pandemic so health systems are not ambushed again- but is basic safety enough to be truly resilient?

Heinz Kohut, founder of the school of Self-Psychology described empathy as “psychological oxygen” because without empathy human s beings cannot function optimally.⁵ An empathic and compassionate organization anticipates the needs of its employees and ensures four foundational principles: (1) safety, (2) access to information about the threat that is factual and caring, (3) maintenance of human connections and (4) emphasis on mental health.

Safety

The healthcare system’s experience with the COVID-19 pandemic will hopefully prevent organizations from becoming blindsided by future crises because epidemics will continue to emerge in our interconnected world. Ensuring safety in organizations requires being prepared. The current pandemic has laid bare life-threatening risks to healthcare professionals’ safety and institutions must be prepared, not only for the next surge, but for future epidemics.

Access to Accurate and Caring Information

Channels of accurate communication and anticipating employees’ emotional responses to a threat are vital to managing a crisis. A designated communications team and mechanisms for distributing information quickly and accurately should be in place at all times. A mental health professional should be a member of healthcare communications team to ensure information is delivered with care and empathy. There is no place for demanding employees to come to work in a crisis with threats. If employees are afraid to come to work, their concerns must be heard, and they mustn’t be dismissed or stunned into silence. These tactics may increase symptoms of burnout, and exacerbate anxiety and depression. Similarly, if salary reductions are required for the survival of an organization, this context should be shared so that the immediate threat of lower pay is understood as a longer-range strategy to keep the workforce employed, rather than as an additional threat.

Maintenance of Human Connection

One of the most difficult challenges for healthcare workers during the lock down period was separation from colleagues, and for some, a tendency to isolate and lose connection to their colleagues. Managers have an opportunity and responsibility to check in with everyone on their teams to assess needs and maintain the sense of belonging.

Human connection is critical for both individual and organizational resilience. Some people feel safest in small group gatherings where they can share feelings and concerns, while others prefer to speak up or join a town hall and find connection in a larger group. There is no one size fits all approach to human engagement, but isolation can lead to loneliness, depression and even suicidal thoughts or plans. Teaching the tools of perceiving and responding to the emotions of others can help with emotional accuracy.⁶ Resilience rounds offer an opportunity for healthcare workers to meet anonymously in small groups and discuss how they are suffering from moral distress and moral injury in a safe and holding environment.⁷

Emphasis on Mental Health

A compassionate organization understands that it functions optimally when workplace wellness and mental health are a priority. Because symptoms of burnout were already affecting up to 58% of physicians and nurses before the pandemic,⁸ the COVID-19 crisis creates a malignant tipping point into severe anxiety and depression. For too long, organizations have expected employees to self-refer to employee assistance programs, risking the stigma of revealing mental health suffering, and these expectations have largely not been met.

Destigmatizing mental health is critical considering that, even before the pandemic, depression and anxiety were costing the global economy $1 trillion each year, not to mention the suffering, loss of self- efficacy and lost wages by those afflicted. There are five approaches that organizations can implement to address stigma.⁷ They include (1) openly and frequently talking about mental health instead of allowing employees to suffer in silence; (2) training managers to recognize signs when employees are struggling with anxiety or depression, and training them to check in when virtual meetings may mask symptoms; (3) understanding that different age groups face different mental health challenges. Those living alone face different stressors from those working while raising families or taking care of elderly parents; (4) redesigning employee benefits to vigorously support mental health; and (5) showing an authentic commitment to talking about the benefits of seeking mental health help.

When healthcare institutions are prepared to meet the safety, communication, community and mental health needs of their organization they are poised to become resilient organizations. For too long the practice of medicine has emphasized the values of selflessness, stoicism, excellence, and moral commitment without providing support to maintain and sustain these lofty values. Instead, healthcare professionals have been expected to manage their own mental health needs or to come forward with needs for which they may feel shame and weakness and fear of being stigmatized. They may feel guilt for not living up to unrealistic and selfless ideals, and stand in judgement of themselves and of those who need help. Such standards do not promote resilience. Rather, they promote suppression of legitimate mental health needs, which contribute to further to burnout and mental health suffering.

The time has come for healthcare organizations to prioritize their own resilience as much as the resilience, safety and wellbeing of the individuals in their work forces. A compassionate organization instills the principles of eudaemonics, inherent value and amplifying assumptions. A set of well-planned institutional fixed standards will produce more resilient organizations, and when coupled with wellness programs that are sensitive and responsive to mental health issues, workforces will become more resilient. These practices promise to deliver not only a more resilient healthcare system but also a positive return on the investment.^9,10