An organizational approach to improve staff resiliency and wellness during the COVID-19 pandemic.

Healthcare worker burnout is a well-established phenomenon known to affect an individual's mental state, and has been shown to be diminished amongst individuals with higher levels of resilience. From a leadership perspective, practices that drive and inspire others to demonstrate resilience and surpass their own expectations fosters a resilient culture and allows employees to view adversity as an opportunity while knowing that support is omnipresent. In this paper, we describe and evaluate the outcomes of a virtual organizational intervention during the COVID-19 pandemic aimed to reduce healthcare staff burnout, and improve their levels of resilience, well-being, and self-compassion. Participants reported the workshops were relevant and provided strategies for wellness that were easy to incorporate into their daily routine. By nurturing one's own personal well-being through resiliency strategies learned in this educational series, staff can enact strategies to care for themselves, which in turn can contribute to organizational wide healthy work environments, improved health system outcomes, and enhanced patient care.

Introduction

Healthcare worker burnout is a well-established phenomenon known to affect an individual's mental state [1], negatively impact clinician retention [2], and increase presenteeism and absenteeism [3]. Beyond its effects on healthcare workers, burnout in this career sector is known to result in reduced quality of patient care and satisfaction [4,5]. While various explanations for burnout exist, the most commonly accepted definition [1] indicates that it includes feelings of emotional exhaustion (EE, the depletion of one's emotional resources where they can no longer mentally or psychologically give of themselves), depersonalization (DP, sense of cyclical negative attitudes and feelings one develops regarding those for whom they provide care), and feelings of either low or no personal accomplishment (PA, the negative evaluation of oneself in relation to their work with clients, including a sense of unhappiness or dissatisfaction with their job accomplishments). Prior to the onset of the COVID-19 pandemic, several studies had already reported elevated burnout levels amongst various groups of healthcare workers (e.g., [6], [7], [8], [9], [10]. Globally, research showed that as the COVID-19 pandemic progressed, burnout continued to be a significant problem impacting healthcare workers [11,12], and in some cases had become present at higher rates than previously reported [13].

Resilience is a modifiable factor that refers to one's ability or personal qualities that allow an individual to cope well with adversity and deal with the stress of a situation [14]. Wellness aims to enhance one's overall well-being as it encompasses multiple aspects such as mental and spiritual well-being, and is a self-conscious process with the intention of bolstering a healthy lifestyle [15]. Resilience training is associated with increased wellness and mental health outcomes among healthcare staff [16]. Prior to the COVID-19 pandemic, research had demonstrated that higher resilience was related to reduced healthcare worker burnout and supported the need for resilience training [17], [18], [19]. Furthermore, in recent years, resilient leadership has emerged as a key theme in the leadership literature. Specifically, it suggests that behaviors and relationships at work are part of a complex interconnected system of people [20]. Resilient leadership also maintains that leadership practices drive and inspire others to demonstrate resilience and surpass their own expectations, and that fostering a resilient culture allows employees to view adversity as an opportunity while knowing that support is omnipresent [21]. O'Shea Carney [22] (p. 5) raises the question “how can we [as leaders within healthcare] foster emotional well-being among our team members, who are so critical to the care and welfare of those we serve?”. The author further describes the COVID-19 pandemic and the additional demands it has placed on staff, indicating that it requires an organizational response in reconsidering how staff who carry out the work of the organization are supported in their well-being.

With these factors in mind (i.e., increased healthcare staff burnout since the outset of the COVID-19 pandemic, perceived limited organizational support, and the known benefits of resilience), organizationally it was necessary to provide our staff with support to improve resilience and reduce stress. In order to address this need we established a resilience and wellness educational program. While calls to increase resilience and bolster training programs exist, the number of short effective training programs that build resilience and various aspects of well-being are limited [23]. To address this gap, we created a virtual resilience and wellness educational program comprised of a five-part series of 20 – 25 minute sessions entitled the “Resiliency Recharge Series”. The program's focus was to provide staff with short learning sessions that they could attend either individually or as part of a larger team. It outlined resiliency and wellness strategies that exemplified our core organizational values with an emphasis on our value of compassion. This series aimed to help participants be compassionate towards themselves in the same way they provide compassionate care to others. The series was very intentional in offering various strategies that participants could easily incorporate into their daily home and work routines to boost resiliency and enhance their overall wellness. Sessions were made applicable to both staff required to remain on-site working, as well as those working remotely. In this paper, we outline how we rapidly developed and facilitated our virtual resiliency training program with an interdisciplinary healthcare team. We also evaluated the preliminary outcomes of this program, in order to understand the benefits and drawbacks to such a program.

Methods

Intended audience and setting

Unity Health Toronto is a tri-site university-affiliated Catholic healthcare network serving patients, residents, and clients across the spectrum of care; our organization also encompasses research and education facilities. Our target audience for this resiliency program was healthcare workers across the three sites of our organization. Staff across our organization were notified about the workshop via organizational email communications (containing a link to join the sessions virtually), the hospital's twice-weekly newsletter, promotion from unit managers, and through word-of-mouth.

We delivered each of the five workshops at noon on Wednesdays. Staff were not required to register to participate as the event link was made openly available to all hospital employees in order to reduce the burden on interested participants and allow them to feel they had the flexibility to join sessions if and when their schedules permitted. Each meeting link opened at noon, at which point, participants had a 10 minute window before the presentation began to give them a chance to join the sessions, listen to relaxing music, and share messages with other attendees in the meeting group chat. Following the 10 minutes sessions, the workshop presentation began. Participation by session varied from between 30 to over 80 attendees per session.

Workshop logistics & summary

When the need for a program to bolster staff resilience and well-being within our organization became clear, we assembled an interprofessional team with expertise in the areas of resilience, well-being, burnout, healthcare provision (i.e., clinicians), and research. We met over an approximately four week period to establish a clear overall message of the program (i.e., the need for resilience building, and the importance of simple strategies that could easily be incorporated into one's daily routine in order to assist with building resilience and well-being), and plan session content. In our 25 min synchronous education sessions, we introduced the concept of resilience, and outlined the meaning of the specific concept of wellness being covered in that workshop. The individual workshops focused on: emotional wellness, intellectual wellness, spiritual wellness, social wellness, and physical wellness. At each session, the benefit of the individual wellness construct was outlined, and strategies to enhance wellness and resilience were provided. When possible, participants were encouraged to share their thoughts and input to create an interactive experience.

Workshops were hosted over Zoom©, and participants were encouraged to enable their video feature to create a sense of community, help participants feel connected in real time, and nurture the concept of social wellness. Slides for sessions were created in advance using a standard template. It was possible to facilitate sessions as one individual; however, typically sessions were co-led by the presenter (who led the majority of the discussion), and a co-presenter (who provided additional detail, helped to cue participants to activities, and supervised the smooth transmission of media to participants).

The workshops began with a 10 minutes music introduction, giving participants time to tune into the session, settle into a more relaxed mindset, and connect virtually through the chat function with other attendees if they wished. The first portion of the session featured didactic learning, highlighting the overall definition and value of resilience, and the meaning of and need for the specific aspect of wellness. The second portion of each session included one or two activities that were aimed towards enhancing the particular area of wellness (e.g., strategies to balance one's daily activities, simple solutions to improve social connections, ways to mindfully incorporate daily work activities such as handwashing into a mindfulness routine, etc.). At the end of each session, participants were given the opportunity to complete a brief evaluation to provide feedback.

Workshop evaluation

At the beginning of each session, participants were told that an evaluation would be available for them to share feedback. The QR code and web address for the evaluation were provided to participants at the end of each session. Participants were encouraged to complete the evaluation if they had been able to attend the session for its entire duration. In accordance with our organization's policies, formal institutional research ethics board (REB) approval to conduct and analyze these evaluation surveys was not required because surveys were collected as part of a program evaluation initiative. No identifying information was collected from participants. Prior to completing the evaluation, participants were told what the purpose of the evaluation was (i.e., to understand what people gained by attending these workshops, and how to improve workshops in future iterations).

As part of the evaluation, we asked participants to respond to a series of open-ended written feedback questions regarding key take-away strategies, applications in the workplace, suggestions for improvement and additional topics, and any additional details they wanted to share. The same evaluation measure was provided to participants at the end of each session. Completion of the evaluation at each session was voluntary and anonymous, using a secure virtual data collection platform (SurveyMonkey), and was completed the same day the sessions were offered. The survey was intended to take approximately two minutes to complete. Due to timing constraints, we could not provide designated time at the end of each workshop, and instead asked participants to complete the evaluation if time permitted before going back to work, or at a minimum before the end of the day. Furthermore, in a virtual environment, we suspect that the onus to complete an evaluation might be diminished, whereas in-person, one might feel compelled to complete a survey when surrounded by others who are also doing so.

Data analysis

A qualitative content analysis [24] was performed on the five open responses to the end-of-session evaluation survey. One investigator (NW) independently reviewed the qualitative feedback to develop theme categories that were later confirmed by a second reviewer (DB). Each of the five data sets were analyzed and coded independently to determine patterns in the themes related to key learnings from the workshops, applicability to the workshop content in the workplace setting, and participant suggestions for improvements and/or additions to the workshop content and structure. A second round of coding was performed by both reviewers (NW and DB) to assess which themes ran across all five workshops.

Results

Participants were not required to register for sessions in advance, and the number of participants per session varied. Given the nature of the healthcare profession (i.e., urgent unplanned patient-care matters, unplanned interruptions, etc.), it was not always possible to tally an exact number of participants that joined each Zoom© session as people were at times called away, and some would rejoin and/or step in and out of the session. Exact numbers were recorded for the sessions on Emotional (66 participants) and Spiritual (51 participants) Wellness. The numbers fluctuated for sessions on Intellectual, Social and Physical Wellness with some people able to remain for the entire session, while others joined in and left as required; 80+ participants completed the Intellectual Wellness session, 40+ participants completed the Social Wellness session, and 30+ participants completed the Physical Wellness session. Furthermore, in some cases, participants signed in with one login for a group of people (e.g., some clinical areas joined as a team); as such, at times the participation rate per session was actually higher than indicated here.

Qualitative analysis

Various participants provided feedback at the end of each session; feedback at each session was not necessarily always provided by the same group of respondents, as some respondents attended multiple sessions, while others only completed specific individual sessions. Qualitative feedback indicated that overall, the workshop sessions were well received. Analysis demonstrated that while individual sessions each had their own key learnings or takeaways, there were common themes that ran across all five session feedback surveys.

Key themes by individual session

The key learnings as reported by the participants in the emotional wellness workshop included the importance of self-care, the value of small, incremental changes or practices to bolster resilience, and the need for self-compassion. As one participant states regarding a key takeaway from the workshop was that, “baby steps are just as important as big steps, that something as simple as getting out my exercise equipment and/or dusting off my treadmill is enough for day one and I can work my way up”. In addition, participants noted that the information and strategies provided in this session were of particular value in the context of the pandemic, and went beyond highlighting the need for work-life balance. The resilience and coping strategies were deemed beneficial, particularly as one participant noted “especially when we have become anti-social in the time of COVID-19”. Participants from the intellectual wellness workshop spoke to topics such as regulating emotions and the role of emotion in resilience building. A participant documented that the workshop taught them “to be aware of our emotions and to stop before reacting by meditation, breathing etc.”. Physical wellness workshop participants highlighted their improved understanding of dedicated exercise time, daily stretching and time for self-care as their primary message. Feedback on how participants would use workshop learnings in the workplace included those who stated they would “take short breaks”, “incorporate stretches into my daily routine” and “take a few minutes to walk instead of sitting in front of the computer”. Spiritual wellness participants discussed how they better understood how mindfulness could be used daily to remain calm and focus oneself: “we can find time for short moments of self-care and meditation to help us find calm and resiliency”. A participant explains they will strive to “find moments to incorporate mindfulness to help reduce stress at work and ensure I'm interacting calmly with patients”. Finally, the social wellness participants stressed a clearer understanding of the importance of both initiating and maintaining connections with others. One participant highlights that after taking the workshop they will “reach out to my colleagues more and check in to see how they are doing and hope to strengthen our social connections”. Another states that they will be purposeful and “connect with friends from other departments”. In addition to highlighting the need for making and maintaining social connections, the social wellness session was identified by participants in their own words as outlining “how to maintain social connection during COVID-19”. Another participant specifically indicated that the strategies in this session would be beneficial for helping them give staff direction or solutions for maintaining social connections during the pandemic, which would help to mitigate the potential sense of isolation that might arise when staff are continuously told to physical distance from one another and also from friends and family outside work in order to prevent spreading.

Common themes across sessions

Participants were asked how the learnings of the session would be applied at work. Many participants indicated they would take breaks during the workday as mindful moments to disconnect. As one participant stated, “[I will] take my breaks, use them to connect and remind others of the same.” Another comments that at work they plan to “go for a walk, exercise or [do] yoga when feeling tired or stressed.” The feedback highlighted the intention of sharing session content with one's colleagues as well as applying resilience teachings to work with both team members and patients. Stress management and relief practices in the workplace were also noted as applications of learnings.

The workshop feedback indicated overall satisfaction with both delivery and content. Targeted activities to address and improve each type of wellness were well received as each session had its own exercises to practice, such that participants could improve their wellness in that area i.e., stretching exercises for physical wellness. The concise nature of the workshop and real world applicability of the session content was noted across all sessions. The synchronous learning model of the workshops was appreciated and participants requested increased options for interactivity such as polling participants and offering breakout rooms during the session. Participants suggested enhancing sessions by having a complementary asynchronous component which could be referred to after the synchronous learning concludes. In particular, the recording of the session and/or slides that could be made available to both participants of the session and those who wanted to attend but could not.

Additional topics to cover in future workshop sessions were put forward by participants. Suggestions included adding more breathing and meditation exercises, tools for coping with stress and anxiety, resources to talk to one's team about wellness, and material on healthy eating, diet and nutrition.

Participants noted not only individual benefits to the Resiliency Recharge Series, but also benefits at the organizational level. As one participant reflected, “I really enjoyed this session and appreciate the organization caring for our mental health”. Another commented, “It's nice to feel that the organization cares”. There was a sense of gratitude among participants for the organization, and in particular the organizational leadership, addressing the mental health and well-being of staff.

Discussion

Individual and organizational outcomes

In response to high burnout levels amongst healthcare staff, we saw the need to provide strategies to improve resiliency and wellness. While data was not available within our organization on burnout levels prior to the COVID-19, one year into the pandemic, many of our staff were increasingly noting that they felt very burned out from working under such emotionally and physically stressful conditions. To address the absence of an organizational resilience and wellness educational program for healthcare staff, we developed a five-part resilience training program that focused on various aspects of wellness. In these short workshops, our goal was twofold: (1) to teach healthcare staff about key areas of wellness, and (2) to help them learn simple exercises that could be easily incorporated into their daily personal and work routines to increase their overall resilience and well-being in these particular areas. We used a holistic approach reflective of our organizational mission by covering the different areas of wellness (i.e., emotional, spiritual, intellectual, social and physical wellness). We qualitatively evaluated participants’ experiences with the workshops, including their key learning points, how they planned to incorporate their learning into their daily activities, and the level of comfort they felt with being able to incorporate the new strategies into their daily schedule. In each session, the themes that emerged from the qualitative data showed the participants’ perceived individual and organizational benefits of the program. Participants across all sessions highlighted the importance of self-care (e.g., managing stress, taking mindfulness moments at work, etc.), both in pandemic and non-pandemic circumstances. At a personal level, we characterized self-care as a process that could be accomplished as a series of small changes to one's routines by incorporating the practices or exercises learned in the workshops. Overall, participants stated that small or incremental changes are valuable and make a notable contribution to bolstering resilience. Finally, the relationship between resilience and self-compassion, or having a kind attitude to oneself, was a key takeaway for many participants across all sessions. This is in accordance with previously published work that highlights the need for self-compassion as part of resilience building programs, particularly those aimed at mitigating the stress experienced by healthcare workers during the COVID-19 pandemic [25].

At the individual level, participants perceived that they were given tools to mitigate burnout and augment resilience and well-being. Participants from the emotional wellness workshop reported the importance of self-care, the value of small, incremental changes or practices to bolster resilience, and the need for self-compassion. Emotional intelligence is known to be beneficial as it can aid people in reducing fear and worry, as well as enhancing resilience and recovery during the COVID-19 pandemic and the years that will follow [26]. Following the intellectual wellness workshop, participants indicated that they learned about regulating emotions and the role of emotion in resilience building, in both pandemic and non-pandemic times. Participants in the spiritual wellness workshop highlighted that they would use the learnings of this session to remember to take pauses in the day in order to calm the mind, perhaps through taking small breaks to pause and breathe, or even to recite a short meditation. Evaluations of the spiritual wellness workshop also indicated that participants were made aware of the need to be present and focus on the relevant tasks at hand in their workday. Participants indicated that the social wellness workshop taught them the importance of initiating and maintaining connections with others. People felt they learned the importance of making a conscious decision to connect with others (both colleagues, and personal contacts), as a strategy to bolster wellness particularly in the context of a socially isolating pandemic. When evaluating the physical wellness workshop, participants highlighted that they were reminded about the importance of dedicated exercise time, daily stretching, and time for self-care. Specifically, participants indicated that they were reminded about the need to incorporate some form of movement into their daily routines, and would work towards this. The need to maintain a healthy diet and obtain quality sleep were also noted as key takeaway points from this workshop, even though these were not exclusively related to one's workplace; this suggests that participants were also able to consider other ways to apply the workshop teachings to their personal lives outside of work.

In general, following participation in the workshops, participants noted that they approached their professional role in a way that impacted not only their own resilience and well-being, but also that of the broader organization community. For example, as noted in the results section, following the social wellness session, participants noted in their evaluation that the strategies provided were especially beneficial in the context of a particularly isolating time and could be shared with colleagues. Overall, this ripple effect of being able to approach one's professional role in a way that impacted not only their own resilience and well-being, but also that of the broader organization community served to improve interactions, communications and care with colleagues, patients and families.

Organizationally, the program is aligned with our values, strategic objective and commitment to help employees find joy in their work by continuing to support staff and learners with their health and wellness throughout the COVID-19 pandemic and beyond. Developing a resilient workforce reduces the effects of stress across all levels of the environment. Resilient employees are more likely to manifest organizational citizenship, i.e., work happiness and organizational commitment [27,28]. Our program participants described a general sense of gratitude for the organization, and in particular the organizational leadership for addressing the mental health and well-being of staff. Rangachari and Woods [29] described the importance of organizational leadership during the COVID-19 pandemic, indicating that meaningful support by leaders to mitigate emotional distress can enable healthcare workers to trust that their organization is putting its people first. Aspects of leadership and positive work culture that are protective against the risk of burnout include the provision of resources to promote resilience and self-care [21,22,30].

Importance of resilience and wellness development in healthcare

We recognized that burnout levels among healthcare staff were noted to be increased globally, and that resilience, a recognized, dynamic, multifaceted solution, is a construct that one develops and refines over time. In an effort to help our staff protect themselves and continue to persist despite obstacles and challenges, we felt it was important to provide this additional learning opportunity. The qualities of resilience and a state of well-being are imperative for developing clinical staff and leaders who can embrace continually evolving change and uncertainty within the healthcare system [23], and continue to provide high quality, compassionate patient-centered care.

Limitations

While our workshop series had several positive outcomes, as with any new initiatives there were also limitations. Our sessions were only able to be offered once a week; to mitigate this scheduling issue, we tried to select a time that could work for most people. As this was the first offering of the sessions, we did not provide recordings which required those wishing to partake to have availability in their schedule at the set time. Furthermore, while each session was well attended, only a limited number of respondents completed the evaluations. We recognize that due to time constraints, we were unable to offer participants designated time during the workshop to complete the evaluation; in an online workshop format, even if time is offered during the session, there is always the possibility that participants will leave whenever they wish. To try to encourage completion of the survey, we offered a small prize draw. If sessions were to be switched to an asynchronous learning format, a potential solution to encourage feedback is to have the feedback built into the module. Finally, we recognize that our attendees likely had prior interest in resilience and well-being, which means our calls for registration and participation in the workshop series may have been of greater interest to those who had a preexisting interest in this area. In future, when offering and evaluating such a project, it will be important to gauge people's actual interest prior to sessions, and compare this with their program evaluation after the sessions in order to understand who is benefiting more/less.

Future directions

A future direction is to recruit a group of people who are willing to attend all workshops and embed the practices into their daily personal and work routines. These individuals would be followed to track their resilience and well-being outcomes longitudinally and understand their outcomes in these areas over time. We would also be interested in learning the ease with which these exercises can become embedded into one's daily routine; while the exercises are intentionally kept simple in the hopes they can be easily incorporated, this remains to be seen in real world circumstances. As the pandemic is still ongoing at this time, we are specifically interested in completing future work to examine the long-term benefits of partaking in a resilience building workshop as a means to reduce burnout in the COVID-19 context.

In addition, our program was offered at a set time, and required participants to attend synchronously. This was done with the specific intention of establishing a sense of community amongst participants. Future evaluations need to determine whether people felt a benefit from joining as a group, or if instead participants would prefer to access the sessions asynchronously and complete the learning at their own pace, if and when necessary.

Conclusion

We found that our educational training program enforced the need and value for an organizational response to staff emotional and resiliency, particularly under pandemic conditions when burnout has been noted to be elevated beyond pre-pandemic levels (e.g., [13]). It also highlighted that healthcare staff are open to, and recognize the importance of improving their own resilience and well-being with simple strategies. Furthermore, it underscores the need for healthcare workers to demonstrate compassion for themselves, in order to be compassionate to the diverse populations they serve. Now more than ever in the midst of an ongoing global pandemic, healthcare leaders and their teams face stressors and complexities in maintaining their own wellness. By fostering one's own well-being, through resiliency and wellness strategies learned in this educational series, staff can take steps to care for themselves, which in turn can also contribute to organization-wide healthy work environments, improved health system outcomes, and enhanced patient care.

CRediT authorship contribution statement

Donna Romano: Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Natalie Weiser: Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Cecilia Santiago: Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Chantal Sinclair: Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Susan Beswick: Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Rosalyn Espiritu: Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Daniela Bellicoso: Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing.