Caring for patients can be a highly rewarding experience for nurses. In the course of delivering care, however, nurses may be exposed to situations or events that can be extremely stressful, even traumatic. These can include making a significant or fatal medication error; facing a difficult patient death; becoming involved in contentious interdisciplinary discussions; navigating difficult interpersonal relationships; or experiencing workplace violence, burnout, compassion fatigue, or moral distress. Under such circumstances, nurses, pharmacists, physicians, and other members of the health care team may become what Albert Wu has termed "second victims."1 They are forgotten, silent sufferers-even possibly contemplating suicide.2-4
Recognizing the many harmful effects that adverse patient events, poor outcomes, and other stressful clinical situations may have on health care providers,5 we introduced a Care for the Caregiver program across the MedStar Health System, which includes 10 hospitals and more than 200 ambulatory sites. This evidence-based program emphasizes peer support, a central aspect of the Scott Three-Tiered Integrated Model of Interventional Support, through which a peer is the first to reach out and provide one-on-one reassurance to a clinician who has been involved in an event likely to cause emotional distress.6 The Scott model and the ongoing research that Susan D. Scott and her colleagues continue to conduct through the "forYOU Team" program they instituted at University of Missouri Health Care has been critical to several successful second-victim support programs,7-9 including the Care for the Caregiver program we introduced at MedStar. Scott served as a mentor to our health system team when we participated in the Communication and Optimal Resolution (CANDOR) collaborative funded by the Agency for Healthcare Research and Quality. (For information about the CANDOR process, go to http://www.ahrq.gov/patient-safety/capacity/candor/acknowledgements.html.10)
This article describes the three tiers of the Scott model, the Care for the Caregiver program we developed based on that model, and the program adaptations that were required following the emergence of the COVID-19 pandemic.
SCOTT'S THREE TIERS
Tier 1 peer support is the first level of emotional triage in the Scott model.6 This is a local response by an associate who has received training in basic awareness of the second victim phenomenon and works in the same unit or department as the clinician who has undergone the emotionally distressing experience. Immediately following a potentially perilous clinical event, the Tier 1 responder reaches out to the colleague involved to provide "emotional first aid" (that is, to offer one-on-one reassurance and to ensure that the clinician is "OK").
Tier 2 peer supporters are often embedded within high-risk departments to provide one-on-one or group support and to monitor coworkers for signs of distress. Tier 2 supporters comprise patient safety officers, risk managers, nurses, physicians, social workers, and chaplains.
Tier 3 services are offered when the second victim's emotional needs exceed the expertise of a Tier 1 or Tier 2 responder. Tier 3 services include professional counseling, which may be available through an employee assistance program.6 Situations that warrant Tier 3 support include a concern for harm to self or others and new onset or worsening mental health issues. Our Care for the Caregiver program trains colleagues who wish to provide Tier 1 and Tier 2 support. Those who provide Tier 3 support, however, are trained, credentialed professionals, such as counselors, psychologists, and psychiatrists. Tier 3 is known as our expedited referral network of care.
OUR CARE FOR THE CAREGIVER PROGRAM
In accordance with Scott's three-tiered model, the Care for the Caregiver program we introduced at MedStar in August 2014 included three levels of response; was available 24 hours a day, seven days a week; and could be requested by any associate. Our program leaders were selected from among the senior nurses, physicians, pharmacists, educators, chaplains, palliative care team members, social workers, occupational health care workers, and members of the employee assistance program within our 10 hospitals on the basis of the following criteria11:
* has exceptional communication skills
* displays high level of emotional intelligence
* demonstrates leadership acumen
These CANDOR-trained program leaders recruit and train others in the CANDOR process to serve as peer supporters. Together, the leaders and peer supporters form a local "Go Team," which offers support to caregivers when an unanticipated, distressing event occurs in one of our hospitals.11 The size and composition of each local peer support team depend on the staff and clinical services provided at the particular hospital. Senior leaders determine and allocate the resources needed to sustain their hospitals' caregiver support programs.
The prepandemic program. Historically, our Care for the Caregiver program used a reactive approach: When notified by telephone, e-mail, or through the filing of an incident report of a potentially distressing situation or event, a Go Team member was dispatched to triage the event and provide "emotional first aid" (Tier 1).11 These initial actions were followed by continuing associate support and monitoring (Tier 2). In the event that the Go Team member determined that the involved caregiver required professional attention, a visit by a chaplain, social worker, or behavioral health specialist or referral to the employee assistance program was arranged (Tier 3).11
Changes in response to the pandemic. The duration, unpredictability, severity, and consequences of the COVID-19 pandemic required us to rethink our formerly reactive approach and introduce a proactive strategy. Beginning in March 2020, instead of awaiting notification of an event or a request for services, we preemptively sought out clinicians and associates in the workplace to establish connections, realizing that in the current crisis most are enduring a degree of stress they had not previously experienced in their careers.
PANDEMIC CHALLENGES CAREGIVERS FACE
A surge in hospitalizations. A highly contagious disease with an unpredictable, protracted course, COVID-19 has caused a surge in hospitalizations. Not surprisingly, this has proved extraordinarily challenging for caregivers. Clinicians caring for patients with COVID-19 have seen the disease swiftly cause clinical decompensation, with patients requiring rapid intubation, prolonged mechanical ventilation, multiple continuous vasopressive infusions, deep sedation, proning, hemodialysis or continuous renal replacement therapy, and extracorporeal membrane oxygenation. In addition, treating the virus requires clinicians to administer unfamiliar medications; repeatedly don and doff physically uncomfortable personal protective equipment (PPE); and contend with drug, equipment, and staffing shortages, while being hypervigilant for abrupt and recurring episodes of clinical instability in their patients.
Exposure to severe illness and death. Clinicians are now witnessing severe illness and death on a previously unforeseen scale. Those treating COVID-19 have seen the virus cause grave and irreversible illness, often in patients in whom severe symptoms would be completely unanticipated, such as a recently postpartum mother who suddenly requires intubation, deep sedation, mechanical ventilation, prone positioning, and vasopressive infusions. Too often they discover that a cherished and respected colleague became infected with the virus and didn't survive.
Visiting restrictions. To prevent spreading the virus among patients, visitors, and staff, visitation is restricted to extreme circumstances, such as during a patient's active death. Restrictions apply even to laboring mothers' spouses, significant others, and support persons. Such restrictions place strains on clinicians as they seek alternative ways to connect and communicate with patients' loved ones.
Communication challenges. Communicating with infected patients is complicated by several factors. To convert the environment to negative pressure, patient rooms may be modified with a high-efficiency particulate air filtration system, which can be very loud, forcing clinicians, whose voices are already muffled by an N95 respirator, to raise their voices in order for patients to hear them. Masks further interfere with communication in that they prevent patients from seeing, reading, or following the clinicians' lips, making it impossible for a clinician to relay a message with a smile.
SOURCES AND CONSEQUENCES OF PANDEMIC STRESS
Between January and February 2020, Tan and colleagues conducted a qualitative study to describe the experiences of 30 frontline nurses caring for patients in a COVID-19-designated hospital in Wuhan, China.12 Stressors endured by these nurses included the following:
* working eight hours without a bathroom or hydration break
* fear of infection and transmission
* unfamiliarity with the COVID-19 disease process
* working with new colleagues without critical care experience due to the patient surge
* working with a shortage of PPE
These stressors translated into feelings of powerlessness, ineffectiveness, insomnia, and depression. The researchers recommended strengthening psychological interventions to help frontline nurses manage such stressors.
Hu and colleagues conducted a cross-sectional, descriptive, correlational study of 2,014 frontline nurses caring for patients with COVID-19 at two hospitals in Wuhan from the 13th to the 24th of February 2020.13 These nurses experienced high levels of burnout, anxiety, depression, and fear of both their own infection and death and infecting their loved ones.13 Citing Zhu and colleagues, the authors acknowledged the benefits inherent in providing psychological support to frontline nurses, particularly as nurses have higher rates of psychological stress compared with physicians, likely due to nurses' closer contact with patients.13, 14
In the United States, between April 9 and 24 of 2020, Shechter and colleagues conducted a web survey of physicians, advanced practice providers, residents, fellows, and nurses working at a large medical center in New York City during a peak in COVID-19 admissions.15 Of the 657 respondents who completed the survey, 375 were nurses and advanced practice providers. As in the Wuhan studies, the sources of highest distress for all respondents included concerns about transmitting the virus to family members and loved ones, maintaining social distancing from family, perceived lack of control, uncertainty about colleagues' COVID-19 status, national PPE and COVID-19 test shortages, and the lack of national guidelines. Nurses and advanced practice providers were significantly more likely to screen positive for acute stress, depressive symptoms, anxiety, and severe sleep disturbances than their physician colleagues.15 When asked about their preferred type of support during this pandemic, respondents preferred two modes: online self-guided counseling with access to individual therapists and individual counseling or therapy. A proactive caregiver support program or other sources of respite were not included among the choices offered.
In our experience, the stressors caregivers often report include
* the inability to concentrate.
* grief and remorse for not possessing the knowledge and skill to combat COVID-19.
* anxiety related to their health and that of their families.
* insomnia.
* anger, with sources typically including community nonadherence to masking and social distancing policies, staffing constraints, and the need to wear PPE throughout all shifts.
PANDEMIC CARE FOR THE CAREGIVER
In changing our program's course, we considered how clinicians and others who work in health care have been affected by the pandemic. Our new proactive Care for the Caregiver program provides around-the-clock services, wellness spaces, online resources, and team members who maintain a regular presence on clinical units to support frontline clinicians and other associates battling the repercussions of the COVID-19 pandemic.
Through our encounters and experiences and the reports of caregivers, we've learned that clinicians frequently respond to multiple distressing events during the pandemic rather than to any specific one. They are weathering ongoing stress, which may be associated with any of the following factors:
* the care they provide
* personal concerns for their health and that of their families
* financial strain when family members are furloughed, laid off, terminated, or forced to shutter their small businesses
Furthermore, with the increase in remote learning, many clinicians end one shift only to start a second shift homeschooling their children. And given restrictions on socializing, outlets formerly used to relieve stress, such as getting together with friends and colleagues, going to the gym, and having dinners out, are no longer possible.
With our current proactive approach, trained Tier 1 and Tier 2 peer supporters who visit our hospitals to seek connection with caregivers are present during morning and evening safety huddles or rounding and spend time in designated "wellness spaces." These spaces were created to provide caregivers a place in which to stop and talk with peer supporters and other colleagues. We realized such spaces can reduce stress and promote emotional and spiritual well-being. Since traditional break rooms, which serve as meeting, meal, and consultation spaces, can be chaotic, we opted to use empty visitor waiting rooms and office spaces for wellness and respite.
We partnered with our employee assistance program to provide live sessions on relaxation techniques, breathing exercises, and other stress-reducing strategies, and reserved spaces in our hospitals close to dedicated COVID-19 units in which we post open hours for Care for the Caregiver sessions. Some of our providers now offer just-in-time mental health services, and in collaboration with our established physician wellness team, we extend comparable services to nurses and other clinicians and associates.
Creative approaches by staff. We have witnessed some impressive unit-based staff creations to contend with the emotional reverberations of COVID-19. One critical care unit conducts a weekly remembrance ceremony in which they honor clinicians and patients who have died on their unit or reflect on patients who have survived critical illness and been transferred to a medical-surgical unit. In another critical care unit, a memorial mural was painted to acknowledge every patient who contracted COVID-19. Those patients who succumbed to the illness are represented as stars and those who were discharged from the hospital as flowers (see Figure 1). "Clap lines" have formed spontaneously to celebrate patients who have survived COVID-19 and are being discharged to their homes and loved ones. In our hospitals, Nurses Week 2020 was filled with celebrations for patients and the nurses caring for them. In addition to clap lines often involving the local community, members of police and fire departments, and even news crews, campuses were decorated with signs and chalk drawings, and donated meals for day and night shifts arrived from across the country. There was a fanny pack-decorating competition, nursing awards, bagpipe tributes, and gift bags for every nurse containing items that promote wellness (healing lotions, lip balms, and healthy treats). And all 8,700 MedStar nurses were named with special thanks from MedStar Health in full-page ads in the Baltimore Sun and Washington Post.
RESOURCES FOR CLINICIANS AND ASSOCIATES
Our system has consolidated all of our Care for the Caregiver resources on an internal webpage that our caregivers may access through their web browser or by scanning a bar code printed on business cards available in the wellness spaces and distributed to our associates as they entered our hospitals. Other resources available through the program's internal webpage include lodging options, grocery support, day-care and childcare services, and a chatbot application providing outreach to 30,000 associates to gauge their well-being. The MedStar Health system had negotiated substantial cost savings for all MedStar associates, including physicians, who chose to use these services, and some were prepaid by MedStar Health.
Professional resources for nurses are numerous. Although some are specific to COVID-19, in celebration of National Nurses Month, the American Academy of Nursing assembled one of the most comprehensive repositories of resources dedicated to self-care, recognition, professional development, and community engagement, as well as nurse well-being, moral distress, resilience, ethics, clinician burnout, and prevention of nurse suicide (see http://www.aannet.org/yearofthenurse/week1).16 Additional resources to support nurses and promote nurse well-being are offered by professional organizations, universities, and others (see Online Resources for Nurses and Other Clinicians).
AN EXERCISE IN RESILIENCE
In combating COVID-19, our clinicians have demonstrated remarkable resilience and creativity. Countless stories from clinicians, associates, and hospital leaders demonstrate that all have united to find innovative ways to conserve PPE, provide care, and help families connect with their loved ones virtually.
To conserve PPE, and also decrease the opportunity for self-contamination, nurses strategically placed monitors and other equipment such as IV pumps outside patient rooms, which allowed them to monitor and provide care to patients without having to continually don and doff PPE. In addition, they implemented sustained reuse and extended use protocols for donning, doffing, and storing N95 respirators, which allowed for safe reuse and conservation of PPE. The protocols varied, depending on whether nurses were seeing multiple persons under investigation (PUIs) or COVID-19-positive patients, or were moving from those patients to patients who were neither under investigation nor COVID-19 positive.
When seeing multiple PUIs or COVID-19-positive patients, nurses would wear an N95 respirator covered with a surgical or procedural mask in addition to goggles or a face shield. They would doff gown and gloves in the previous patient's room and perform hand hygiene before proceeding to the next patient's room where they would again perform hand hygiene and don new gown and gloves. They would continue wearing the same N95, surgical, or procedural mask, and goggles or face shield.
For final doffing, when moving from COVID-19-positive patients to PUIs or from PUI to PUI, nurses would remove gown and gloves inside the room of their last potentially COVID-19-positive patient, perform hand hygiene, and exit the room. Once outside the room, nurses would maintain their N95 respirator, repeat hand hygiene, don new gloves, and remove and disinfect their goggles or face shield with an approved disinfectant wipe. They would then sanitize their gloves, remove and dispose of the surgical or procedural mask covering their N95 respirator, and sanitize the gloves again. They would carefully remove the N95 respirator and place it into a large, clean paper bag, sanitize the gloves once again, and disinfect the goggles, which would be placed in the paper bag opposite the N95 respirator (if a face shield was used instead of goggles, it would be hung on the outside of the bag). Nurses would then don a surgical or procedural mask per universal masking.
Goggles and N95 respirators may be used until they become soiled, damaged, or otherwise compromised (if the N95 could no longer provide an adequate seal, for example).
To encourage a personal connection with patients, nurses had their pictures taken and wore them on the outside of their PPE so the patients would know what they looked like beneath their masks. Using dry-erase markers, they wrote notes on the windows of patient rooms and doors, often including drawings and words of encouragement.
To help family members connect with hospitalized loved ones, nurses used their own phones to enable patients to video chat with their families. After the system purchased tablets for patients, nurses anchored the tablets on IV poles so they could be moved from room to room without being handled by patients.
RECOVERY TO THE NEW NORMAL
As the surge of patients begins to recede, hospital tents are dismantled, and hospital operations start planning to reinstate elective surgery and other services, recovery efforts begin. Nurses who were redeployed to other units or departments with the cancellation of patient visits or procedures will begin to head back to their home units. Medical-surgical units that were converted to critical care units will go back to their original state. Nurses who have been working frenetically for months will start to experience changes in their daily rhythm.
Industry experts suspect that the shift from unpredictability to more stability may still carry a sense of uncertainty, leading to an "interim" or "new" normal.17 As we've already witnessed, a second wave of COVID-19 infections arose in many countries and areas of the United States when social distancing was relaxed. Services previously provided in person may be replaced with telehealth services that proliferated during this pandemic. Economic recovery may be slow or severely constrained. This pandemic will leave some nurses questioning their career choice, reducing their work hours, changing jobs, or leaving the nursing profession altogether.
Eight chief nursing officers from California, New Jersey, and New York recently reflected on the COVID-19 pandemic and offered their observations and advice for moving toward the new normal.18 The COVID-19 pandemic was compared to running a marathon with nurses nearing the finish line, but it is a finish line that may reveal a different environment requiring new models of nursing care. Nurses' pandemic experiences will shape priorities going forward, including emergency preparedness training and infection prevention education. Frontline nurses who observed the extent of critical illness and numerous patient deaths will continue to need emotional support. Some nurses are experiencing symptoms suggestive of posttraumatic stress disorder (PTSD).19 Since PTSD symptoms may not appear for months after an event,20 the full extent of the toll of caring for desperately ill patients during the pandemic may not be known for some time.
Prior to COVID-19, we were in the planning stages of evaluating our Care for the Caregiver program. Now, as the initial surge of COVID-19 patients has abated and we watch the small but consistent uptick in patients following the relaxation of restrictions, we're planning to evaluate the impact of our program by quantifying hotline calls and chatbot data to guide near-term and future actions and priorities. We've seen a notable increase in employee assistance program referrals and consultations and are seeking feedback from those who participated in our Care for the Caregiver sessions.
As of March 22, 2021, data from the Centers for Disease Control and Prevention indicate that among U.S. health care workers there have been 450,123 cases of COVID-19 and 1,494 deaths.21 Our personal observations when rounding at our hospitals and ambulatory locations, and remarks offered by our colleagues working in those locations, have led us to conclude that the COVID-19 pandemic has required agility, commitment, and skill on the part of our caregivers. It has also magnified the stress associated with patient care. Our Care for the Caregiver program offered support to clinicians to help them cope with the stress. To do that effectively during the pandemic, we had to appreciate that caregiver distress may be precipitated not by a single event but by continuous pressure and anxiety that requires using a proactive rather than a reactive approach.
Online Resources for Nurses and Other Clinicians
* 305 Fitness (https://305fitness.com): Offers dance videos and workouts that can be performed in the privacy of your own home, as well as a free seven-day trial subscription.
* American Academy of Nursing (http://www.aannet.org/yearofthenurse/week1): Provides nurses with comprehensive resources on self-care, well-being, mental health, and COVID-19 coping strategies.
* American Psychiatric Nurses Association (http://www.apna.org/m/pages.cfm?pageID=6682#SelfCare): Psychiatric-mental health nurses provide information on mental health and self-care to support nurses coping with COVID-19.
* Department of Veterans Affairs (VA; https://mobile.va.gov/app/covid-coach): COVID Coach is an app designed by the VA to support self-care and mental health during the pandemic.
* Excel at Life (https://play.google.com/store/apps/details?id=com.excelatlife.depression&hl=en_U): Depression CBT Self-Help Guide is a cognitive behavioral therapy app that provides educational information to be used by consumers of mental health services in collaboration with a mental health professional. Designed to help people manage stress through self-care behaviors, it contains a depression severity test, audios, articles, a cognitive diary, and motivational points.
* Flow Yoga Center (http://www.flowyogacenter.com/video): Provides access to livestream and video yoga classes.
* Happify (http://www.happify.com): Provides techniques and activities in the fields of positive psychology, cognitive behavioral therapy, and the practice of mindfulness.
* Headspace (http://www.headspace.com): An app that provides tools and resources for meditation, sleep, and movement exercise to help support mental health.
* Johns Hopkins Berman Institute of Bioethics Resources for Frontline Clinicians (https://bioethics.jhu.edu/research-and-outreach/covid-19-bioethics-expert-insigh): Provides frontline clinicians with personal and professional resources to face challenges posed by COVID-19. Includes videos from the Johns Hopkins School of Nursing and links to webpages and articles that promote health and well-being.
* Mindful (http://www.mindful.org/mindfulhome-mindfulness-for-healthcare-workers-during-cov): Provides mindfulness and meditation practices for health care workers.
* Moodfit (http://www.getmoodfit.com): An app that provides suggestions for improving mood, increasing awareness of mood, and identifying mood patterns.
* MoodMission (http://moodmission.com): An app for dealing with stress, depression, and anxiety.
* National Academy of Medicine (https://nam.edu/initiatives/clinician-resilience-and-well-being): Offers links to resources that support the health and well-being of clinicians providing care during the pandemic.
* Ohio State University (https://wellness.osu.edu/covid-19-resources/wellness-tips): Provides virtual fitness classes, wellness webinars, coping strategies, mindfulness practices, and resources for families.
* Sanvello (http://www.sanvello.com): An app designed to provide four types of support: self-care; peer support; coaching; and therapy to reduce stress, anxiety, and depression.
* YMCA (http://www.ymcatriangle.org/virtual-ymca): Provides virtual access to group fitness classes and resources for children for use when school is not in session.
REFERENCES