Emergency department leadership considerations for the next phase of the COVID-19 pandemic

Introduction

Early in the COVID-19 pandemic we wrote an article about prioritizing staff safety and supporting those on the front lines of care [1]. We hadn’t anticipated then that the pandemic would cause unprecedented strains on emergency care and lead to waves of resignations, burnout, and moral injury. In this follow-up commentary we explore strategies that emergency department (ED) leaders can use to respond to these challenges, help staff recover and rebuild, and enhance their teams’ abilities to manage future crises.

Staffing and morale

Despite the challenges of the first 2 years of the pandemic, physician, nursing, and paramedic staffing levels remained relatively constant as most providers felt obligated to persevere in a time of crisis. This changed in spring 2022 as health jurisdictions around the globe saw a mass exodus of ED nurses as well as other members of our ED and EMS teams, resulting in a tragic loss of expertise and contributing to sporadic ED closures. Many jurisdictions are seeing alarming wait times and delays in offloading patients from ambulances due to ED resources that are increasingly strained by the burden of boarded patients. This forces providers to take risk and care for patients in suboptimal circumstances. Faced with such challenges, many healthcare professionals are re-prioritizing work-life balance and realizing fulfilling careers with greater flexibility abound outside the 24/7 ED environment.

While these problems go beyond the scope of ED leaders, never has the need for support and allyship with our nursing and other colleagues been so important. The staffing crisis has highlighted disparities in pay and working conditions that threaten the mandate of emergency care in Canada and put patients at risk. Before we discuss possible responses to these issues, let us consider factors driving them (see Fig. 1).

Fig. 1.

Emergency department considerations for the endemic phase of COVID-19

Moral injury

Moral injury is defined as profound psychological distress resulting from actions, or the lack thereof, that violate one’s moral or ethical code [2]. This phenomenon has been prevalent among healthcare providers during the pandemic [3]. Moral injury has been caused by the public through actions such as hospital demonstrations harassing patients and physicians and “freedom rallies” that essentially held some Canadian cities hostage. Moral injury can also occur when circumstances and/or resource limitations require health care providers to care in ways which they feel deviate from acceptable, pre-pandemic, standards. Additionally, leaders in government, hospital systems, and emergency physician groups have caused moral injury through decisions requiring the triaging of resources (such as N95 masks and other personal protective equipment early in the pandemic), triaging of patients for intensive care services, and stretching human resources to the brink.

Leaders in EDs need to be aware of sources of moral injury, both external and internal, and work to mitigate its occurrence. Recognizing its existence is crucial, but that is not enough. Leaders can incorporate the following steps in their practices to repair moral injury [4]:

• Demonstrate unrelenting advocacy at the hospital and system level to improve ED operations and quality of care including harmful quotas on physician hiring imposed by governments.

• Treat the injured party as a moral equal with the ability to recognize moral injury.

• Acknowledge that the injury has occurred and take responsibility for the moral injury.

• Allow the injured party to define what is owed and what can be done to rectify the action that created moral injury.

• Validate anger or negative feelings.

• If a leader recognizes they have inadvertently injured another, their sorrow and regret should be genuine and apparent.

Abusive behavior and burnout

Healthcare workers have reported a surge in abusive behavior as the pandemic has ground on, ranging from verbal abuse to physical violence [5, 6]. Causes behind the increase we are experiencing in EDs are undoubtedly multifactorial but likely include:

• Patients and families frustrated by extremely long wait times.

• General social and economic stress.

• General social and economic stress.

• Infection-control procedures that reduce human connection and may increase wait times, add to registration and triage procedures, and limit visitor/support person access to Eds.

• Closures of and lack of access to key services affecting patients with mental health and addiction issues.

• Politicization of the pandemic and stigmatization of healthcare workers.

In addition to workplace stress, ED staff, like all humans, have their own personal life stressors at home—childbirth, childcare, raising teens, marriage, divorce, bereavement, elder care and many other life stressors. All of these unseen realities place make it difficult to dedicate themselves 100% to their job—despite that seemingly ongoing expectation during this next phase. The confluence of these factors both at work and home is contributing to unprecedented levels of burnout and a crisis in both physician and nurse staffing in EDs across Canada.

Newly visible fractures in equity

Despite the promise of universal access to care, staff in EDs have always witnessed inequities among Canadian patients, in society in general and in the healthcare system. These inequities became more apparent during the pandemic as access to care and shelter deteriorated. Patients experiencing homelessness, food insecurity, or intimate partner violence arrived at our hospitals in even greater volumes and with higher acuity than we had seen previously [7]. Patients experiencing homelessness were more likely to test positive for and die from COVID-19 than those who had stable housing [8]. Whenever possible, we must elevate the voices of those to whom we provide care and work with them to push for societal and healthcare system changes.

Recovery from pandemic trauma

A new way of thinking

Two-plus years into the pandemic, the terms crisis and collapse are frequently used to describe Canadian healthcare. There is much talk of the need for change, so how should that look in emergency care? Some needs are obvious, such as timely inpatient access for admitted patients as well as improving working conditions and pay, especially for nurses. Other needs may require new ways of thinking.

Surges in ED crowding and bed block have highlighted how Canada lags in acute hospital infrastructure, such as beds per capita, compared with other Organization for Economic Co-operation and Development member countries [9]. At the same time, the myth of unnecessary ED visits as a driver of crowding has been resurrected, regardless of the evidence refuting it. Yet visit volumes in Canadian EDs have risen in some locations, perhaps for lack of alternatives, but also because it can be a better option for patients.

One change could be to welcome patients who are voting with their feet by coming to our EDs and stop trying to convince them to go elsewhere. Why not invest in EDs that are well positioned to respond to the demand? This would require a re-imagining of EDs and their services. This will amount to appropriately sized EDs; better integration with primary care, chronic care, mental health, and addiction services; better access to diagnostic testing; enhanced abilities to ensure follow-up; and changes in provider mindset towards a customer-service orientation. In the right settings, this would translate into novel and accessible unscheduled care resources that preserve the ED mission.

This need not undermine continuity of care, which is essential for patients with chronic and complex illnesses but likely far less important to healthy individuals with episodic illness or injury. But ensuring continuity for all patients requires another change: finally building health information systems that let providers share information readily across health system silos.

Staff safety, appreciation, and advocacy

Hospitals have legal and moral obligations to provide safe environments for staff and patients. An inherent challenge is to create safety without compromising clinical standards or compassion [10]. The Canadian Association of Emergency Physicians’ position statement on violence in the ED offers helpful safety strategies [11].

Leaders can also address less visible aspects of safety, such as the needs of staff to feel connected and have some control over decisions that affect them. Leaders should be present in the ED and provide opportunities for staff to vent and share suggestions. They need to recognize the value of teamwork and camaraderie and provide opportunities to meet as a group, engage in quality improvement activities, and hold social or team-building events. Leaders need to be effective advocates for addressing the factors that are specifically compromising delivery of emergency care currently. This means effective communication skills, as well as excellent collaborative efforts with other disciplines, and hospital and health system administrators. For leaders to continue to be effective they must invest in self-care and ensure that they themselves are healthy and able to maintain the resilience necessary to continue in their leadership roles.

Find ways to provide thank-you gestures from the hospital, that are both meaningful and thoughtful and which acknowledge current stressors, such as food or gifts such as food or gifts. They do not need to be expensive. One author (CS) found free coffee for staff (paid for by donations) was incredibly well received. Where collective agreements allow for them, more substantial perks should be considered, yet always ensure staff understand you recognize these are gestures and not solutions.

Engaging in advocacy can help staff regain a sense of control over situations. Encourage those willing to get involved with their provincial or national associations and share their efforts with all staff.

Lessons learned

Leaders in emergency care are well positioned to leverage innovation and make positive changes sustainable. The pandemic has taught us that personal protective equipment is remarkably effective at achieving infection prevention and control. Masking in healthcare settings keeps patients and staff safe not only from new COVID variants but also from other respiratory pathogens. Gone as well are the days of working while “under the weather,” as we now appreciate how this may have made us vectors for the spread of virulent infections. Most ED groups have created back-up coverage mechanisms for those who are unwell or require leaves of absence without the need to feel they are letting colleagues down.

Pivoting to virtual meetings and learning might be one of the most important innovations to emerge from the pandemic. While face-to-face interactions in educational and extra-clinical activities have value, hybrid options should always be considered. The possibilities are liberating and may contribute unexpectedly to wellness and connection, enabling colleagues on leave or with other commitments to join and contribute from anywhere.

Conclusion

Those who have held leadership roles during the pandemic know this responsibility has come with substantial personal sacrifice for some and a departure from leadership roles for others. Sustainable leadership is essential to the future of emergency care. We hope the insights provided in this pandemic leadership update bolster those currently in these roles and draw a future generation to the calling.

Declarations

Conflict of interest

All authors declare that they have no conflicts of interest.