Communication and Transparency as a Means to Strengthening Workplace Culture During COVID-19

March 1, 2021

Introduction

What individuals think, say, and do produces workplace culture. In health care, the COVID-19 pandemic has reshaped every aspect of this framework. Today, people think and talk through screens and do so in isolation. When clinical care delivery, operational processes, and work environments have all transformed so rapidly, the demands and stresses on our clinician workforce are bound to mount. So how do leaders facilitate optimal communication among frontline teams?

Culture refers to the set of shared and widely accepted beliefs, values, and social practices of a group [1]. Effective communication that integrates complete transparency on the dynamic nature of operations, particularly during times of crisis, forms the foundation for building a culture of wellness for clinicians. With the onset of the COVID-19 pandemic, however, clinical care delivery, operational processes, and work environments have all transformed rapidly to adapt to the remote world. Such changes have markedly amplified the demands and stresses on clinicians [2]. Though large-scale deployment of telehealth has facilitated access to convenient medical care, the virtual medium may diminish the perception of humanism within the patient encounter. Mass home-confinement directives such as quarantines and social distancing have amplified social isolation. Remote work environments reducing interaction among colleagues have placed camaraderie and peer support at risk. Work-life balance has shifted: with children attending school remotely in the home environment, clinician parents are struggling with the concurrent tasks of working and child-rearing. While entire medical systems have rallied to support clinicians during a time in which clinicians have demonstrated increased altruism, the long-term risk of burnout has risen substantially [3]. To nurture trust, achieve values alignment, and strengthen workplace culture—all core elements of a strategy to prevent burnout [4]—communication of a shared mission in a time of crisis must be clear, consistent, and sincere. So how do leaders facilitate optimal communication among frontline teams, generating the inclusion, intentionality, and interactivity that achieves such trust and sustains engagement [4]?

This article discusses the role of optimizing transparency and communication within the framework of medical teams as an essential component of a strategy to address clinician burnout, particularly during COVID-19. Using interventions in the department of psychiatry at Brigham and Women’s Hospital as a representative case study, the authors of this paper discuss strategies implemented for frontline clinical teams consisting of physicians, nurses, medical assistants, and social workers. This article aims to address the following:

• 1.Characterize solutions that harnessed advancements in technology and facilitated a two-way flow of information in a time of crisis;
• 2.Highlight the role of communication in maintaining trust, engagement, and social connectedness; and
• 3.Discuss the role of information sharing and transparency between clinical leadership and frontline clinicians in mitigating both uncertainty and ambiguity but also the challenges to generating participative decision making during a time of crisis.

Moving Beyond E-Mail

With the onset of the COVID-19 surge, goals for communication were first influenced by the entity of e-mail burnout. E-mail burnout has been demonstrated to be a long-standing source of administrative burden to clinicians [5]. Within our own department, feedback had indicated that mass distribution e-mails from varied sources had inundated inboxes, causing clinicians to overlook critical communication. In addition, sufficient information on changes in essential policies and practices had to be provided in a timely fashion. In a time of great uncertainty, information was a source of potent reassurance. Faculty needed timely updates not only on operational changes within the department (e.g., deployment of virtual care) but also on details of the hospital’s response to the COVID-19 surge. But how could administrative leaders be assured that clinicians were indeed perusing the critical information made available to them without overwhelming clinicians themselves? The balance in this tension was established through the chair’s announcement that a daily COVID-19 emergency planning update distributed to all members of the department would become the hub to circulate information requiring simultaneous dissemination to everyone. This change significantly consolidated the number of e-mails faculty received on a daily basis. Examples of information included COV-ID-19 patient admission censuses, numbers of employees tested and verified as having COVID-19, personal protective equipment distribution, mental health resources to support employees, and details on the transition of inpatient, ambulatory, and research programs to a completely virtual modality.

Moving beyond information distribution, the chair of the department also e-mailed all members of the department on a weekly basis. These messages served as a personalized reflection on the events and emotional landscape of the week, provided realistic yet uplifting assessments, adopted a conversational tone, and minimized organizational distance.

Chiefs and team leaders maintained all ongoing administrative meetings via Zoom videoconferencing, which addressed both administrative and clinical challenges. Ongoing academic meetings were also preserved and adapted to address topics related to psychological first aid and other crisis response and resilience themes. These meetings provided both clinical and administrative staff with additional support in navigating the care of distressed patients and addressing their own challenges with adjusting to the pandemic. Additional virtual huddles enabled leaders to provide frequent updates, maintain dialogue on upcoming changes, and optimize collaboration, preventing formation of silos. Moreover, virtual town hall events organized by division chiefs and attended by the chair provided support for members of the department to discuss concerns and questions and further nurture discourse. These events broadened reach throughout the department and supported messages about transparency and approachability of leadership. Within such town hall meetings, use of the group chat-based function of Zoom enabled questions to be visible to all and ensured that all questions were answered. In medicine, lack of voice around decision making or reduced autonomy regarding increases in workload have been demonstrated to be elements of organizational culture that lead to burnout [6]. Participative management with collaborative action planning is a leadership style that empowers clinicians to become partners in the analysis of problems and create solutions for issues that directly affect them [6]. In navigating the transition of the department through the COVID-19 surge, collaborative action planning was critical. Our experience also highlights the challenge with such a form of decision making: in times of crisis, information can be uncertain, and decision making must be rapid. There is always a tension between sharing dynamic information, which may cease to be true shortly thereafter, and maintaining optimal transparency.

Technology is a means to disrupting the traditional one-way structure of organizational communication but needs to be implemented in a social way, so as to promote interactivity [4].

During the initial stages of the COVID-19 surge, multiple divisions in psychiatry used communication platforms that implemented persistent chat functions, allowing for such social interactivity. One such example, Microsoft Teams, proved to be particularly useful for our department. Microsoft Teams is a chat-based collaboration tool that enables remote teams to share information and work together in a common space. An example of the utility of Microsoft Teams during CO-VID-19 was its potential for real-time problem-solving around implementation of telehealth. Using the chat function, faculty were able to troubleshoot interactively. The element of a shared workspace also enabled faculty to improvise collaboratively on adapting clinic operations to the remote setting. Technology, however, poses challenges, including ease of use. For instance, our initial experience with Microsoft Teams was that a number of tip sheets needed to be designed and easily accessible to ensure initial uptake.

Communication as a Means to Social Connectedness

Relatedness, or a sense of connectivity and community with one’s peers, not only contributes to intrinsic motivation and psychological well-being but also enhances professional fulfillment in medicine [6]. Community building activities that nurture relatedness fulfill a need for camaraderie and build a high-functioning team. Social gatherings with an intentional design to generate dialogues about meaningful experiences in medicine have also been shown to nurture a culture of wellness [6].

In our geographical area, the initial COVID-19 surge took place in April. In navigating the time period following this rise, from May 2020 through now, the department fostered enhanced relatedness through the use of virtual peer support groups. These groups served as an extension of the strategy to enhance communication within the department by creating niche forums for faculty to articulate their needs and connect with one another.

An example of such a peer support group within the department is a faculty mothers’ group. The group meets on a weekly basis and discusses a wide range of topics including the highs and lows of parenting in the age of COVID-19. Participants also collaborate on ways to further professional equity for women. Peer support among physician women, for instance, has been demonstrated to enable academic advancement, particularly during the child-bearing and child-rearing years, by providing a sounding board for coping with stressors unique to the medical field and solidifying both horizontal and vertical networks for collaboration [7].

Additional forms of peer support that have been well attended in the department include a group for review of high-risk patient cases, focusing on complex patient cases with unclear solutions. “Second victim syndrome” describes the emotional response of shame and guilt that clinicians can experience in the event of a medical error [8]. Because the culture of medicine emphasizes perfection and equanimity, emotional reactions to adverse events are generally not acknowledged or openly discussed, leaving clinicians highly vulnerable [8]. The peer support group for high-risk patient cases in our department provides emotional support in the setting of stressful or adverse events and strengthens resilience and positive coping.

Time, however, has been a consistent barrier to increased participation in such supports. In health care, as in all industries, time available to complete the sum of all clinical, research, and teaching responsibilities continues to be a challenge.

Conclusion

One implicit aspect of the culture of medicine is influenced by the practice of evidence-based medicine, which uses the best available valid and relevant empirical data to make health care decisions. Faith or anecdotal evidence does little to build trust. For instance, physicians, acting as professionals, approach ambiguity with a scientific zeal to uncover factual truths. Thus, a dynamic essential to establishing a culture of wellness is one in which trust is earned. Bidirectional communication between leaders and clinicians that brings clinicians into the fold on decision making is a strategy that earns such trust by offering evidence of authenticity and straightforwardness. Entrusting frontline clinicians with “insider” knowledge such as strategic information on financial operations, particularly during a time of unrest, is a path toward not only listening effectively but also building engagement. Thus, effective communication and transparency, a key component of a strategy toward reducing burnout, is enhanced through the use of language, values, and behavior that mirror value for the team.

Funding Statement

The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies.