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Remaining Resilient During the COVID Pandemic: Experience of a Quality Improvement Team

Published:September 15, 2022DOI:https://doi.org/10.1016/j.mnl.2022.08.001

      Abstract

      The Joint Commission published an article to address burnout in health care professionals and identified lack of resilience as 1 challenge that exists amongst health care workers globally. From the quality perspective, an organizational approach to combat burnout and compassion fatigue is an important step to improve performance throughout the continuum. During COVID19, various strategies to improve personal, organizational, and team resiliency were employed. This article provides an overview and gives examples of how quality department professionals quickly adapted to the COVID19 pandemic and utilized interventions to promote personal and organizational resiliency during a crisis.
      Key Points
      • The COVID pandemic has spotlighted the need to have resiliency in health care work teams.
      • Strategies to create individual and department resiliency were shared including frequent huddles, journal club development, educational sessions, and mentoring of staff.
      • Quality improvement professionals are key partners that can assist with identifying best practices and promoting strategies to maintain and improve work force engagement.
      Challenges facing the health care profession during the COVID19 pandemic have been discussed from frontline to the boardroom. One of the main concerns moving forward is the effort to address and prevent health care worker burnout. This has been a great area of focus, not only within the United States, but also globally. In 2019, The Joint Commission, Division of Healthcare Improvement, published a Quick Safety article addressing burnout in health care professionals and identified lack of resilience as one challenge that currently exists amongst workers across the world.
      The Joint Commission, Division of Healthcare Improvement
      Developing resilience to combat nurse burnout. Quick Safety. July 19, 2019.
      Of health care providers impacted by the negative effects of burnout and lack of resilience, the nursing profession has been impacted heavily and staffing has suffered. In 2021, the U.S. News and World Report quoted Dr. Ernest Grant, president of the American Nurses Association, as stating that the United States “will need an additional 1.2 million nurses by next year to meet the growing demand for their services and to replace those leaving.”
      Levine D. U.S. faces crisis of burned-out health care workers. US News and World Report. November 15, 2021.
      It is imperative to the future of the health care profession to implement initiatives that efficiently address the recent increase in healthcare worker burnout.
      Health care worker burnout is a broad term that leads to several additional challenges with a streamline effect on the quality of care an organization can provide and the safety of the patients. Resilience, engagement, physical and emotional health, employee satisfaction, and employee retention are only a few of the areas that contribute to employee burnout within the health care profession. Ensuring health care workers have the resources and support they need in order to provide quality care is valuable, not only to the patient and families affected, but also to the organization in terms of quality outcomes, patient safety, public reporting, and patient satisfaction.
      Quality department professionals, those that specialize in improving organizational performance by analyzing health care outcomes and implementing best practices to improve care, were not immune to the impact of the stress to the system due to COVID19. The challenge to transform health care to meet the customer demands, both internal and external, during the pandemic was daunting. It became essential to quickly pivot activities and strategies to assist the health care team while maintaining a focus on key metrics central to the organizational priorities. Sustaining high functioning team performance and engagement, while avoiding burnout, became one of the most important initiatives for the quality department professionals.

      Comprehensive Literature Review

      In order to understand resiliency and the impact on burnout, a literature search was completed using the key words: resilience, best practices in resilience, nursing resilience, evidenced-based practice in reliance/hardiness, and burnout. The search was restricted to articles published from 2016 to 2021 and in the English language. The restrictions were made for the publishing years due to the impact of the pandemic. Due to the inability to locate articles specific to the quality department professional, a search of impact on nurses was completed. The nurse’s experience ranged from new to experienced nurses.
      A few key themes emerged from this literature review: defining resilience, burnout and compassion fatigue, personal resilience, organizational resilience, team resilience, and resilience during a crisis.

      Key Themes in the Literature and Application Into Practice

      Defining Resilience

      During and post pandemic, resiliency has become a popular topic with many definitions and types of resiliency. The literature often defines resiliency as having the ability to bounce back from a negative event in a person’s life,
      • Loew L.D.
      Creating a caring work environment and fostering nurse resilience.
      but resiliency is more than just bouncing back. It is the ability to grow and develop skills and knowledge because of a negative event. These skills and knowledge assist persons to be effective and successful in future life regardless of threatening, stressful, or negative events.
      • Stevens T.M.
      Building personal resilience.

      Burnout and Compassion Fatigue

      Burnout and compassion fatigue are 2 terms that are often discussed in the literature because health care workers are prone to both due to the nature of their physically, emotionally, and ethically demanding work. Health care workers may feel frustrated and hopeless, and have feelings of futility that comes from perceptions of lack of administration support and staffing, and heavy workloads.
      • Kestler S.A.
      An education intervention to reduce compassion fatigue in a community medical center.
      Burnout can have many implications for patient safety and quality of care delivery such as increased medical errors and negative clinical outcomes. Compassion fatigue may impact staff and patient satisfaction.
      Organizations are challenged to develop strategies to combat burnout and compassion fatigue to maintain a healthy work environment. The strategies to improve the work environment must include not only the individual, but also the team and organization. Bozdağ and Ergun
      • Bozdağ F.
      • Ergun N.
      Psychological resilience of healthcare professionals during COVID-19 pandemic.
      reported that to combat burnout, the individual, team, and organization should develop strategies that improve overall resiliency.

      Personal Resiliency

      Factors that positively influence resiliency are psychological resilience, positive affect, perceived social support, age, taking personal precautions against COVID, nutrition, and quality of sleep. Factors that negatively impact resilience are feeling at risk due to the health care profession and worrying about infection.
      • Bozdağ F.
      • Ergun N.
      Psychological resilience of healthcare professionals during COVID-19 pandemic.
      The ANA Code of Ethics published in 2016 states that the nurse owes the same duties to self as to others, including responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
      American Nurses Association
      Code of ethics for nurses, with interpretive statements.
      The health care worker can become individually resilient through adequate sleep and healthy nutrition, participating in activities outside of work, and exercise. Activities such as yoga, physical activity, and practicing mindfulness can also help to decrease stress and assist with resiliency. Cultivating outside hobbies may also help to build resiliency.
      • Rakesh G.
      • Pier K.
      • Costales T.
      A call for action: cultivating resilience in healthcare provider.
      If the person is experiencing depression or anxiety the person may need to utilize the Employee Assistance Program or seek outside help. The individual must consider what is important to them and place importance on what personally matters.
      • Stevens T.M.
      Building personal resilience.
      By building self-care, the individual can share skills and be a role model for other team members, which may improve teamwork. A factor in resiliency is that the individual must also feel that their work is meaningful. This not only supports the individual’s psychiatric well-being, but also supports the team through positive behaviors.

      Organizational Resiliency

      Organization resiliency begins with supporting the elements for individual resilience. The goal is to decrease burnout and support staff. Some organizations begin to improve resiliency by doing a resilience assessment. By assessing the needs of team members, a plan can be developed to encourage resiliency throughout the organization. One way organizations may choose to encourage resiliency is to provide classes on compassion fatigue, coping strategies, yoga, or mindfulness.
      • Kestler S.A.
      An education intervention to reduce compassion fatigue in a community medical center.
      This supports staff members in developing resiliency by providing time away from work to go to class and improve skills.
      Rewarding or recognizing staff also builds resilience. One way to do this is by providing positive affirmations such as using a bulletin board for positive comments or accomplishments. This helps to promote peer support and recognitions.
      • Harnlek A.
      Maintaining unit resilience during COVID-19. August 10, 2020.
      The use of thank-you cards from leaders can also be used to recognize the good work being done by individuals or teams.
      Empowerment of staff also builds resiliency. Empowerment can be fostered through hospital-wide participation of staff on committees, nursing councils, and unit-based councils. This also serves the purpose of challenging staff to seek ways to improve their practice, which also builds resiliency. Organizations that are resilient create a healthy work environment where team members feel safe and supported.

      Team Resiliency

      Team resiliency is very important within the health care setting. Learning to work together and support each other is key to resiliency. The first objective is to promote teamwork and ensure that everyone is aware and working toward a common goal. This is something that can be established through the collaboration of the manager and staff. One way to build team resiliency is to recognize signs of compassion fatigue. The leader can receive training on signs and symptoms of burnout and compassion fatigue. The manager can then intervene and support staff and recognize team members who are at risk in order to intervene before burnout and compassion fatigue occur.
      • Kestler S.A.
      An education intervention to reduce compassion fatigue in a community medical center.
      Having peer support on the unit is also a beneficial way to show the team how to support each other. With each team member working to support the group, a healthy connection can be built. Connecting with peers may provide emotional first aid when needed.
      • Harnlek A.
      Maintaining unit resilience during COVID-19. August 10, 2020.
      Peer support also helps the team to increase resilience and may help to deter or deal with bullying. Staff who practice self-care can be role models and help other staff members to gain healthy skills.

      Resilience During Crisis

      During times of crisis (i.e., pandemic, increased census, short staffing), fostering resilience becomes even more important as staff feel more vulnerable. Staff need support or reinforcement of coping skills. It is important to assist staff with new support mechanisms or reinforce existing mechanisms. During COVID19, organizations implemented various strategies to positively support staff, such as relaxation areas, so employees could regroup. Some organizations also provided food or services to meet basic needs. These activities fostered the development of a healthy work environment even during a global pandemic.

      Quality Department Interventions to Promote Resiliency

      Quality department professionals had to be adaptable and creative in order to maintain personal resilience and team resilience, while also contributing to the improvement in organizational resilience and resilience during a crisis. Personal resilience and team resilience within the quality department were priority, as both were essential to be able to provide the necessary support for colleagues within the organization. Morning huddles including the quality department, as well as patient safety, infection prevention, regulatory, and safety teams, were a pivotal change that allowed the sharing of weekly schedules, planning for future needs, and collaboration regarding shared work-related issues. Journal club was introduced in the quality department and was a way to discuss evidence-based quality topics, creating a bonding experience with each other and an opportunity for learning and reflection.
      Quality department professionals collaborated to assist fellow nursing colleagues and the organization, promoting organizational resilience through assessing best practices on protective equipment and fit-testing clinical staff with N95 masks early in the pandemic. The quality department professionals were key partners in recommending best practice strategies to key leaders throughout the organization and frontline staff in an effort to appropriately and safely care for COVID19 patients. Participation in community and hospital-wide vaccine clinics was also an area of focus throughout the pandemic.
      Quality department professionals were integral to maintaining organizational resilience during the crisis. During this time, quality projects continued, such as implementation of “soft rounds” to encourage documentation of pain management process, assistance with stroke audits to free up management, and assistance of a nursing unit with an ongoing mentoring project, which was able to provide in-time support and teaching daily. In addition, the quality department professionals implemented the prevention of venous thromboembolism process with electronic medical record monitoring of compliance, which resulted in a 20% increase in the compliance with sequential compression devices and anticoagulation.
      Focusing on internal resilience, the quality team motivated and inspired others to push forward and support the organization. A primary strategy implemented was the introduction of a network-wide quality webinar series, which highlighted the continued importance of quality improvement throughout the COVID19 pandemic, while also providing a consistent space for collaboration and engagement. The quality webinar series was a monthly virtual presentation by content experts on quality improvement topics relevant to the network and the organizational staff. The webinar series promoted inclusivity and education, and provided an open forum for support and discussion. On average, 65 to 70 network employees were in attendance, primarily from quality, safety, nursing, case management, and network leadership teams. Another strategy implemented early in the pandemic was purposeful rounding in the nursing units that enabled the staff to share their feelings and discuss actions that had been implemented to assist in caring for patients.
      A key strategy to maintain personal well-being for quality department professionals and coworkers included frequent check-ins with each other and the frontline teams. Additionally, taking time off from work activity continued to be essential. In order to address well-being with the quality department professional team, the quality director established individual employee meetings to assess engagement and encourage use of personal time off. Although there were many demands on the staff, it was imperative that employees had time away from work to concentrate on personal wellness.
      Additional strategies to combat burnout and promote resilience through support of the staff with active efforts to ensure safety standard and protocols were implemented appropriately throughout the system. Mock code and rapid response scenarios were organized by the quality department professionals and implemented throughout the hospital to ensure staff were maintaining safety and were adequately prepared for critical incidents involving COVID19 patients. The quality department performed daily rounding within the units, especially those with COVID19 patients, to check on staff and patients, providing additional support as needed. Interdisciplinary quality meetings and shared-governance council meetings were continued in virtual format, providing consistent focus on quality improvement and minimizing the impact of the pandemic on routine process improvement initiatives. Staff engagement had previously been fostered through staff involvement at quality meetings; it was important to continue to acknowledge the staff, helping them to feel involved and empowered. Maintaining team engagement, even when members were working remotely, was recognized as integral to organizational success. For example, the quality department professionals researched and presented a professional poster on how to successfully implement a work-from-home model in health care. Support provided by the quality department professionals to the frontline staff during the pandemic not only improved their personal resilience, but also had a downstream positive effect on quality improvement outcomes and patient care delivered by the organization during that time. In addition, providing mentorship to the clinical staff was an important key strategy.
      A key metric in evaluating resiliency and burnout was to monitor engagement scores on the employee survey, which was completed semiannually. The quality department scored in the 94th percentile for employee engagement in the 2021 survey (improved from the 87th percentile in 2020). The key areas of improvement were noted to be in employee development and opinions count sections. There was strong performance in the sections focusing on commitment to quality, learning and growing, and establishing mission and purpose with opportunity noted in the action planning for improvement questions. The strong performance in the employee engagement results could be linked to the action items implemented during the pandemic with the focus on supporting the quality professional staff.

      Conclusions and Recommendations

      According to current reports, the COVID19 pandemic is nearing the post-pandemic era. It is important to reflect on learnings and opportunity for improvement throughout the continuum. Without a doubt, there will be pressure to return to pre-COVID19 status, which could impact the team’s engagement and ability to be resilient. Nursing leaders will need to adapt to the current state and focus on improving clinical outcomes. There will be challenges that will continue post-pandemic, including staffing shortages and reluctance to enter health care professions. In this light, quality improvement professionals can lead the way to foster and promote best practices that engage and excite clinicians, and result in positive outcomes for patients. Resiliency is the key is success.
      There were many actions implemented in the pandemic that will continue to engage and foster a culture of quality improvement. One of the key activities was the ability to gather the team, collaborate on action items, and implement best practices in a short timeframe. This was accomplished by team huddles that focused on the task at hand. Most importantly, the quality department professionals acknowledged their importance by investigating and implementing best practices and supporting the clinical staff throughout the organization.

      References

        • The Joint Commission, Division of Healthcare Improvement
        Developing resilience to combat nurse burnout. Quick Safety. July 19, 2019.
        (Available at:)
      1. Levine D. U.S. faces crisis of burned-out health care workers. US News and World Report. November 15, 2021.
        (Available at:)
        • Loew L.D.
        Creating a caring work environment and fostering nurse resilience.
        Int J Hum Caring. 2013; 17: 52-59
        • Stevens T.M.
        Building personal resilience.
        Am Nurse Today. 2019; 14: 10-15
        • Kestler S.A.
        An education intervention to reduce compassion fatigue in a community medical center.
        Nurs Mgt. 2020; 51: 30-37
        • Bozdağ F.
        • Ergun N.
        Psychological resilience of healthcare professionals during COVID-19 pandemic.
        Psychol Rep. 2021; 124: 2567-2586
        • American Nurses Association
        Code of ethics for nurses, with interpretive statements.
        American Nurses Association, Silver Springs, MD2016
        • Rakesh G.
        • Pier K.
        • Costales T.
        A call for action: cultivating resilience in healthcare provider.
        Am J Psychiatry Resid. 2017; 12: 3-5
        • Harnlek A.
        Maintaining unit resilience during COVID-19. August 10, 2020.
        (Available at:)

      Biography

      Michelle McGonigal, DNP, RN, NE-BC, is the Network Director of Quality and Patient Safety at Allegheny Health Network, in Pittsburgh, Pennsylvania. She can be reached at [email protected] . Darcy Shiner, MSN, RN, is Manager, Quality, and Lori Laux, MSN, RN-BC, CRNP, and Susan Leininger, MSN, RN are Advanced Practice Nurses at Allegheny Health Network, Allegheny General Hospital.