How the Center for WorkLife Wellbeing Is Supporting Caregivers During COVID-19

Supporting the wellbeing of caregivers should always be a priority, but the need to care for caregivers has been brought into sharp focus by the COVID-19 pandemic, as caregivers are being asked to turn toward the unprecedented risk and uncertainty they face at work. Caregivers face uncertainty about how to provide effective care while also protecting themselves and their loved ones.(1)

Although the size and scale of the COVID-19 pandemic is much greater than the SARS outbreak or the H1N1 pandemic, lessons can be learned from those global public health disasters. For example, Toronto healthcare workers responding to the SARS outbreak were more likely than other healthcare workers in Hamilton hospitals to experience adverse psychological outcomes in the year after the outbreak. Healthcare workers in the Toronto hospitals who reported experiencing a mental health problem prior to the SARS outbreak also were more likely to develop a depressive disorder.(2,3) But researchers found that a perception of enough training, protection, and support was a protective factor against experiencing negative psychological outcomes for those healthcare workers who were working in the Toronto hospitals one to two years after the outbreak. Therefore, ensuring that caregivers are supported and protected is paramount.

Several articles have emphasized the need for strong, compassionate leadership during a crisis.(4–6) But how can a highly matrixed healthcare organization actually operationalize a nimble response to support caregivers during (arguably) the most frightening time in their careers? Resources must be mobilized quickly and effectively with incomplete information and under significant pressure. We will outline here how a robust wellbeing infrastructure overseen by a C-suite leader can enable health systems to deliver on our moral imperative to care for our caregivers.

ChristianaCare and Caregiver Wellbeing

Headquartered in Wilmington, Delaware, ChristianaCare is one of the country’s most dynamic healthcare organizations, focused on improving health outcomes, making high-quality care more accessible, and lowering healthcare costs. ChristianaCare includes an extensive network of outpatient services, home healthcare, medical aid units, three hospitals (1,299 beds), a Level I trauma center, a Level III neonatal intensive care unit, a comprehensive stroke center, and regional centers of excellence in heart and vascular care, cancer care, and women’s health.

ChristianaCare is a nonprofit teaching health system with 850 medical group clinicians and more than 280 residents and fellows. It is continually ranked as a Best Hospital by U.S. News & World Report.

In recent years, ChristianaCare undertook the daunting yet vital task of redefining its organizational values and behaviors. We are proud to have gained clear alignment around our commitment: “We serve together, guided by our values of Love and Excellence.” These values are one of the reasons we choose to use the term “caregiver” to describe all employees, both patient-facing and nonclinical. These values also evoke a deep commitment to the wellbeing of our caregivers — a commitment that began long before the pandemic.

Our significant investment in caregiver wellbeing began in earnest in 2015 with the implementation of a health systemwide peer support program, Care for the Caregiver. Building on this success, the Center for WorkLife Wellbeing was formally established in 2016 with an initial focus on developing wellbeing programs and services for physicians and advanced practice clinicians, including residents and fellows. Since then, the healthcare system has continued to invest in the Center, enabling expansion of services to all caregivers. The Center is now recognized as one of the most comprehensive healthcare system wellbeing programs in the country.

The Center’s mission is to foster WorkLife meaning, connection, and joy by providing responsive and proactive wellbeing services for 13,000+ caregivers working in a wide variety of roles and capacities across the organization, creating structured opportunities that empower caregivers to enhance the wellbeing of their colleagues, and advocating for and enacting local and system-level changes that promote WorkLife wellbeing.

Today, the Center is staffed by 10 full-time team members and two part-time physician champions who total 10.4 FTEs (see Figure 1). The team is led by a chief wellness officer (CWO) who reports to the chief people officer (CPO) who, in turn, reports to the chief executive officer. In addition to overseeing the work of the CWO, the CPO oversees organizational development, human resources, and system learning.

Figure 1. Organizational chart for the Center for WorkLife Wellbeing

The CWO collaborates closely with leaders in multiple key internal stakeholder areas whose operations impact caregiver wellbeing (leadership in human resources, information technology, nursing, quality and safety, graduate medical education, performance improvement, marketing and communications, patient experience, inclusion and diversity, finance, strategy and planning, and departmental leadership).

This organizational structure has proven beneficial, as the synergies among these workflows are considerable, and effective partnerships have developed among the respective teams. The CWO also interfaces regularly with stakeholders external to the Center such as governmental and regulatory entities, professional organizations, and CWO collaborative networks.

The robust infrastructure in place before the onset of the pandemic was fundamental to ChristianaCare’s ability to pivot, scale up, and respond rapidly to the needs of the caregivers. Existing relationships between the Center’s leaders and other system leaders also proved invaluable. For example, the participation of the CWO in daily system leader communication calls was essential, ensuring that needs of frontline caregivers were heard and effective partnerships were leveraged to meet those needs expeditiously. The Center was prepared for this moment and we were uniquely positioned to provide unparalleled support to caregivers during the COVID-19 crisis.

The Center’s existing resources were adapted to meet the needs of caregivers using a multipronged approach informed by the principles of hear me, protect me, prepare me, support me, care for me, and honor me as outlined by Shanafelt and colleagues.(7) While some of the strategies were outlined in a profile by the American Medical Association, a more detailed overview of how the Center provided leadership and sought to support other leaders during the response to COVID-19 is provided here.(8)

Listening to Caregivers

Regular in-person rounding on all shifts by members of the Center in the emergency departments, COVID units, and throughout the organization has helped us learn how to support caregivers on the front line. Caregivers are not only eager to receive snacks and comfort items (e.g., 3D-printed ear savers, anti-fog lens cleaner, hand lotion, and hand sanitizer) from the Wellbeing Wagon that attends to their basic needs, but also to share their observations of what it is like to be a caregiver during this challenging period and to communicate needs unmet by the health system. Caregivers are grateful for these visits that allow them to process and express their emotions, receive peer support, and share their concerns to inform advocacy efforts.

Setting up the in-person rounding during COVID-19 built upon our pre-existing rounding model and resources but required substantially more support from leaders and effort from the team than previous rounding practices.

Prior to COVID-19, the Center’s team performed rounding throughout the health system on a quarterly basis to promote our programs and check in with caregivers. We already had a cart, limited provisions for stocking the cart, and organizational support for the rounding. To round during COVID-19, we collaborated with infection prevention and system and local leadership to understand the procedures they would need to follow to keep the cart clean, ensure caregiver safety, and minimally interfere with clinical tasks while rounding. We had support from local leadership, C-suite leadership, and managers of the rounding volunteers (psychologists, physicians, nurse educators, etc.) who joined the team for this work.

We had access to funds to support continued stocking of the cart and collaborated closely with departments collecting donations for healthcare workers to distribute items given by the community. We designed a rounding schedule that prioritized the high-risk areas (EDs, ICUs, COVID units) and allowed our team to round on each eight-hour shift at least once a week in these areas and less frequently in other areas of the health system.

The rounding team was divided into those rounding in high-risk areas and other areas of the hospital to limit the potential exposure of the team. The schedule and the team of rounders were continuously modified based on needs, resources, and feedback.

The information collected through in-person rounding prompted intensive, effective collaboration among leaders in the Center, human resources, system learning, infection prevention, clinical operations, behavioral health, our communications team, and leadership from several other clinical and essential services areas to rapidly implement necessary improvements to practices, policies, and available services for caregivers.

The improvements enacted are too numerous to describe comprehensively here, but include clarifying policies about accommodating requests for caregivers with underlying medical conditions, using PPE appropriately, creating a disposable scrub service and changing area, providing recognition of caregivers in the environmental services and patient escort departments, and refining the implementation of the Twistle app, which caregivers use for daily symptom monitoring.

Transparent communication by the organization is also essential in meeting the “hear me” request from caregivers. Caregivers expressed a need to understand whether ChristianaCare had the necessary resources to respond to COVID-19, so the organization quickly created a Tableau dashboard that is updated every six hours with information about the number of hospitalized patients with COVID-19, number of ventilators in use (and total available), and number of patients with COVID-19 being managed in the ambulatory settings. There also are weekly updates about the numbers of caregivers who have tested positive for COVID-19, townhall meetings for leaders and frontline caregivers, and talking points to be brought up at daily huddles. This was particularly useful early in the pandemic to quiet concerns regarding available additional capacity for a surge.

Virtual Rounding

In the weeks following the initial response to COVID-19, in-person rounding was augmented by virtual rounding, which involves staff members of the Center and champions, who are typically trained mental health providers partially redeployed from direct patient-care roles, holding regular meetings with leaders by phone or video conference.

The Center’s leadership also decided that virtual rounding was a useful complement to the in-person rounding. In-person rounding allowed for convenient check-ins with the caregivers who are present, but leaders often support caregivers who might not have been working when an in-person rounder visited. Virtual rounding enabled leaders to obtain resources and support for all caregivers on their team.

The pandemic posed significant new challenges for leaders, and the leaders themselves often benefitted from having more dedicated time for check-ins and support than could be provided during in-person rounding sessions. Having a consistent virtual rounder allowed leaders to build a relationship with a supportive peer during the pandemic. Virtual rounding was also more efficient and allowed many supportive caregivers in the Center who were working from home during the peak of the pandemic to provide effective support through phone or video meetings.

The areas targeted for virtual rounding include acute, ambulatory, clinical, and nonclinical settings where caregivers provide direct care to patients with COVID-19 or where their work places them in close and frequent proximity to these patients. Virtual rounders aim to develop supportive relationships with leaders, provide education about the Center’s services, and help leaders and their teams access appropriate support services as needed. In some instances, this involves connection to contacts in other teams (human resources, employee health) and in others, information gleaned by virtual rounders is used to engage leaders on enacting system-level change.

Finally, virtual rounding provides an opportunity for leaders to reflect on their own wellbeing; as leaders develop relationships with virtual rounders, they frequently become more comfortable expressing their own experiences and identifying personal and professional needs. Virtual rounding has enabled the Center to provide consistent and proactive support to more than 40 teams, including caregivers from departments such as food and nutrition services, environmental services, and facilities and maintenance who are providing vital services during the pandemic response. We know that caregivers from these areas can feel especially vulnerable and therefore need tailored support.

The strategies outlined demonstrate the need for a coordinated approach that creates organizational trust, and a virtuous cycle of bidirectional transparency among leaders and frontline staff. Creating a reliable system for multimodal, multidirectional, timely communication is essential in promoting psychological safety and ensuring that healthcare professionals feel heard.

Protecting Caregivers

Our efforts to protect caregivers have involved various initiatives, one of which is ensuring that caregivers can safely provide care with adequate training on the donning and doffing of PPE, which was facilitated by educators from nursing professional development rounding on patient-care units on all shifts. These rounders collected unanswered questions from caregivers about the use of PPE and contributed to the guidance provided systemwide.

Early in the pandemic, the CDC’s recommendations on use of PPE were changing and ChristianaCare responded by employing conservation strategies (to be prepared for a surge) as well as providing clear and regular updates about why changes were being adopted. Caregivers have voiced that they want to be properly informed about how to keep their family safe during this time, so we have published resources on the best practices for leaving work to reduce the risk of carrying the virus into the home.

For a while, disposable scrubs and scrub changing stations were provided to help caregivers working on COVID units feel safer when they left work. ChristianaCare also offers free hotel accommodations to those caregivers who are providing care to patients with COVID-19. Job reassignment options exist for caregivers with underlying medical conditions that put them at increased risk or for caregivers who have a member of their household with a medical condition. Importantly, these accommodations also apply to pregnant caregivers.

In stressful environments, clinicians may be more likely to uptake “micro-practices” that are beneficial to their wellbeing.(9) Recognizing that caregivers likely do not have excessive amounts of free time, the Center has provided simple-to-use strategies for self-care that include mindfulness exercises and a daily wellbeing text message with inspirational, supportive, and humorous content that helps caregivers begin their day in a positive manner. To receive the daily wellbeing text message, caregivers opt in from their mobile device. They also receive information about how to access all the Center’s services on their mobile device.

Additionally, caregivers can access brief podcasts on demand that address topics related to coping and thriving during and after the pandemic. Ensuring easy access to materials via personal mobile phones has been a cornerstone of the Center’s communication strategy because a significant portion of the caregivers we serve do not have regular access to computers at work.

Preparing Caregivers

ChristianaCare has undertaken a wide range of efforts to prepare caregivers for the response to COVID-19, including in-person and online training for redeployed caregivers, care standardization evaluation and treatment protocols, robust telehealth resources and training, and appropriate guidance for the code status of patients with COVID-19.

Supporting leaders and helping them to be effective has been identified as essential for the response to COVID-19.(6) It is a difficult time to be a leader and leaders need assistance in balancing empathy with their teams while ensuring that system-level decisions — including those that may be controversial — are carried out.

Leaders receive resources such as FAQs for supporting their team and for navigating conversations when a team member tests positive for COVID-19. There also are regular discussion forums where leaders can discuss their concerns with their peers, share ideas, and take away successful strategies for leadership during the pandemic. Information shared in these forums is available in the organizational learning management system and can be accessed by a broad audience.

Additionally, the Center partnered with nursing and organizational development leaders to offer biweekly webinars focused on the development of leadership skills in the context of crisis and uncertainty.

Supporting and Caring for Caregivers

Supporting the emotional and mental health needs of caregivers has long been a focus of the Center, and the organization has greatly expanded its efforts to support caregivers during the COVID-19 pandemic. We are not waiting for caregivers to come to us, but are rather using our in-person rounding, hard-wiring of peer support into the event-review process, multiple embedded champion networks, and standing wellness rounds during protected education time for residents to proactively reach out to caregivers in distress.(10) Employee assistance programs have not reported a major increase in use, but it cannot be assumed that caregivers are not in distress.

Care for the Caregiver, a peer support program with more than 60 members, has expanded its services and is playing an active role in supporting caregivers during the pandemic. The program was profiled in the New York Times.(11) In addition to continuing to offer individual and group peer support, the Care for the Caregiver program has onboarded several volunteers from behavioral health to support the increased needs of caregivers who test positive for COVID-19 and their teams.

Leaders integrated these additional support services in a structured way. For example, colleagues from behavioral health, out of a desire to provide support to others, wanted to make themselves personally available to caregivers in distress. Leaders helped to put in place a program that would ensure that requests for support would not “fall between the cracks” if one volunteer was unable to provide support. Thus, we have successfully added a backup team of peer supporters to provide additional support to the on-call team if the caseload surges.

We now have a large team of behavioral health caregivers providing urgent 24/7 phone support to caregivers and their colleagues who self-refer for support related to COVID-19 distress. Behavioral health colleagues reserve several clinical slots for next-day appointments for caregivers wanting to connect to mental health assessment, medication management, and/or therapy.

To address the physical needs of caregivers, as discussed above we visit the units with our Wellbeing Wagon and deliver supplies such as snacks and other items that can help caregivers attend to basic needs and be more comfortable during their shifts. Donations of food and supplies from the community have been accepted and added to the materials being distributed to the employee work areas. When caregivers need to relax and recharge, they can use one of 10 dedicated OASIS rooms, which are relaxation environments with massage chairs, calm lighting, and other features that make them inviting and restorative places during a stressful time.

To support caregivers financially, the organization has not furloughed or laid off any employees to date. It also has implemented hazard pay for caregivers who meet criteria (based on amount of time caring for COVID-19 patients). ChristianaCare has also implemented a PTO cash-out procedure and continues to provide access to the food pantry that is open to all caregivers. The health system provides pre-paid childcare to caregivers who have requested assistance, and there were, at one time, about 180 children in subsidized daycares.

The Center developed just-in-time resources for leaders when a team member tests positive for COVID-19. The resources provide guidance on how to communicate compassionately with the team. Multiple individual support options are available to caregivers who are infected, including round-the-clock 1:1 support. Caregivers with COVID-19 are given the opportunity to connect with a peer supporter who contacts them weekly and follows them through the duration of their recovery and return to work. Hotel accommodations, provided by ChristianaCare, are offered to caregivers with COVID-19 who cannot effectively self-isolate in their homes while they recover.

Honoring Caregivers

There have been overwhelming outpourings of support for the caregivers at ChristianaCare, including donations of PPE, meals, and other items. While the Center for WorkLife Wellbeing worked in partnership with other system leaders to develop an array of options for ensuring caregivers have the resources they need to be effective, attention was also turned toward enlisting help from the community.

A Caregiver Relief Fund was created to collect monetary and material donations for programs that help the caregivers.(12) Children in the community began submitting their drawings to show support for ChristianaCare caregivers. These drawings and expressions of gratitude have a prominent place on the website. Using the #healthcareheroes hashtag, caregivers have been posting selfies to generate awareness of what healthcare workers are doing to protect the community.

Leadership in Upcoming COVID-19 Response

The current strategies for supporting caregivers during the pandemic have emphasized a proactive approach based on information learned from caregivers by in-person and virtual rounding efforts, as well as other means of learning first-hand what caregivers are experiencing. The Center’s existing relationships with other leaders and frontline caregivers across the health system have augmented the effectiveness of such efforts, ensuring rapid, coordinated responses to evolving needs and consistent, appropriately reassuring messaging. This coordinated approach creates organizational trust, a virtuous cycle of bidirectional transparency among leaders and frontline staff, and commitment to serving together to deliver on our mission.

From the beginning, it has been critical to emphasize that the Center will be shoulder to shoulder with caregivers during the response to COVID-19, providing proactive and responsive support, listening to their concerns, and advocating for and enacting system change on their behalf. The Center has been at the vanguard in the growing wellbeing movement, and the experiences prior to the pandemic have positioned it to be optimally effective during COVID-19.

Leveraging our experience while also remaining nimble will enable the Center to continue to meet the evolving needs of caregivers in the coming months and years. The team will also continue to lean on the strong thought partnerships the CWO and team have developed with other CWOs nationally and internationally, enabling sharing of best practices and real-time observations that inform our strategy. For example, information gleaned from such partnerships confirmed that use of passively available support services was surprisingly low in many health systems, lending further credence to the decision to undertake a more proactive approach.

In the coming months, making enduring changes, expanding access to behavioral health services, and reaching out to caregivers who may be experiencing PTSD, anxiety, depression, compassion fatigue, or other reactions from prolonged exposure to COVID-19 will continue to be important. As the states in the ChristianaCare system begin to re-open, the Center will need to move quickly to support caregivers as the health system gradually re-starts services, minimizing the potential negative impact on caregivers by anticipating their concerns and collaborating creatively with system partners to help caregivers adjust to the new normal. Creating opportunities for teams to reflect on their experience during the acute phase, to heal, and to rebuild will be essential.

Much has been learned from our fight with COVID-19 — most importantly, the need for a robust wellbeing infrastructure and a comprehensive systems-based approach. We are smarter, we are stronger, we have a renewed purpose, and we are more committed than ever to fostering WorkLife connection, meaning, and (yes) joy.

References

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2. Maunder RG, Lancee WJ, Balderson KE, et al. Long-term Psychological and Occupational Effects of Providing Hospital Healthcare During SARS outbreak. Emerg Infect Dis. 2006;12(12):1924–32. doi:10.3201/eid1212.060584.

3. Lancee WJ, Maunder RG, Goldbloom DS. Prevalence of Psychiatric Disorders Among Toronto Hospital Workers One to Two Years After the SARS Outbreak. Psychiatr Serv. 2008;59(1):91–5. doi:10.1176/ps.2008.59.1.91.

4. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing Mental Health Challenges Faced by Healthcare Workers During COVID-19 Pandemic. BMJ. 2020;368:m1211. doi:10.1136/bmj.m1211.

5. Wu AW, Buckle P, Haut ER, et al. Supporting the Emotional Well-being of Health Care Workers During the COVID-19 Pandemic. J Patient Saf Risk Manag. Published online June 17, 2020:2516043520931971. doi:10.1177/2516043520931971.

6. Wu AW, Connors C, Everly Jr. GS. COVID-19: Peer Support and Crisis Communication Strategies to Promote Institutional Resilience. Ann Intern Med. 2020 Jun 16;172(12):822–3. doi:10.7326/M20-1236.

7. Shanafelt T, Ripp J, Trockel M. Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic. JAMA. 2020 Jun 2;323(21):2133–34. doi:10.1001/jama.2020.5893.

8. Berg, Sara. 6 Ways a Health System Attacks Stress During the COVID-19 Crisis. American Medical Association Physician Health Blog. Published online May 6, 2020. www.ama-assn.org/practice-management/physician-health/6-ways-health-system-attacks-stress-during-covid-19-crisis .

9. Fessell D, Cherniss C. Coronavirus Disease 2019 (COVID-19) and Beyond: Micropractices for Burnout Prevention and Emotional Wellness. J Am Coll Radiol JACR. 2020 Jun;17(6):746–8. doi:10.1016/j.jacr.2020.03.013.

10. Taylor S. The Psychology of Pandemics: Preparing for the Next Global Outbreak of Infectious Disease. Newcastle upon Tyne, UK: Cambridge Scholars Publishing; 2019.

11. Hoffman, Jan. “I Can’t Turn My Brain Off PTSD and Burnout Threaten Medical Workers. The New York Times. May 16, 2020. www.nytimes.com/2020/05/16/health/coronavirus-ptsd-medical-workers.html .

12. ChristianaCare. COVID-19 Caregiver Support. https://christianacare.org/donors/covid/ . Accessed August 10, 2020.