Managing healthcare worker well-being in an Australian emergency department during the COVID-19 pandemic
Abstract
Emergency Medicine staff in Australia and New Zealand are at the forefront of the healthcare response to COVID-19. This article describes a well-being plan for ED staff that has been devised to mitigate against the negative psychological impact of the COVID-19 pandemic.
Introduction
Emergency Medicine staff in Australia and New Zealand are aware of the immense challenges faced by their colleagues overseas, working in comparable health contexts, where resources have been stretched or overwhelmed. This has contributed to anticipatory anxiety among staff, relating to the moral distress that may ensue when unable to provide the usual standard of patient care.1 The prospect of treating colleagues and friends, contracting the infection oneself and inadvertently passing it on to vulnerable family members has increased this concern. Social isolation and disruption to family life precipitated by public health distancing and ‘lockdown’ measures may exacerbate this anxiety and be of further detriment to staff well-being.2 Nevertheless, as COVID-19 cases continue to be relatively few, Australian and New Zealand EDs have a unique opportunity to meticulously plan staff care to mitigate against the negative psychological impact of this pandemic. Identifying potential stressors at each phase of the epidemic and how these may be mitigated is key.
Intervention
The Royal Melbourne Hospital is the designated state-wide provider for quarantinable diseases, and since 6 January 2020, has instituted tools to identify and isolate patients presenting with COVID-19 risk factors.3 From the outset, staff well-being was recognised as an integral determinant of our ED's pandemic response capability. To address this, The Royal College of Psychiatrists' (UK) recommendations for planning staff care during the COVID-19 pandemic were adapted to form a local well-being framework4 (Table 1). We identified eight cross-cutting well-being considerations, based on overseas experiences and current Australasian College for Emergency Medicine (ACEM) recommendations, and addressed these as follows:4, 5
| Phase of crisis | Staff stressors | Plan | Additional support |
|---|---|---|---|
| Throughout | Fatigue, hunger, dehydration, moral distress, personal care | Regular breaks, rest, available fresh food, appropriate rostering/leave | Protected place to rest Sustain social connectedness |
| Encourage regular feedback | |||
| Preparatory | 1. Anticipatory anxiety | 1. Brief staff in open, honest and frank manner | Identification of vulnerable staff early on Allocated training time for all staff |
• Increased work demands • Dealing with the unknown • Risk to self and others |
2. Provide training on potentially traumatic situations staff may face | ||
| 3. Flow of timely, accurate information from a single source unique to COVID-19. This source should host: | |||
| • Simple, regular short videos offering specific advice/updates | |||
| 2. Stress related to high-level planning/training/education in rapid time-frame. ‘Loss’ of 2020 examinations, annual leave, sabbatical, training | • Well-being related FAQ section • Provision of staff support through phone, or virtual where feasible • Provision of staff access to an Employee Assistance Program |
||
| 3. Distress secondary to excessive communications | |||
| • Departmental | |||
| • Hospital | |||
| • Training college | |||
| • Government | |||
| • Social media | |||
| • Public/family anxiety | |||
| • National/international media | |||
| Active (highest psychological risk) | As above plus exposure to: | As above plus: | Identify key members of team and establish clear roles Enlist one member to liaise with HR services and facilities Flexible working schedules |
| 1. Distress of others | • Establish a team to identify developing physical and psychosocial needs of ED staff • Deliver formal psychological care in stepped ways • Offer staff drop-in sessions |
||
| 2. Public and peer hostility | |||
| 3. Ethical and morally challenging circumstances | |||
| 4. Risks of safety (personal and of loved ones) | • Promote peer supporters | ||
| 5. Work–life tension | • Facilitate access to additional support | ||
| 6. Loss of boundaries – overwork, lack of breaks | • Consistent access to physical safety needs | ||
| 7. Loss of control | |||
| 8. Lack of self-care | |||
| Recovery | As above plus: | As above plus: | Liaise with hospital well-being team to facilitate ongoing monitoring |
| 1. Exhaustion – physical/emotional | • Appropriate leave | ||
| 2. Fragmentation of teams | • Active monitoring | ||
| 3. Staff conflict | • Ongoing peer support | ||
| 4. Post-traumatic stress disorder | • Needs assessment of staff | ||
| • Respond to post-traumatic stress in line with evidence-based guidance |
Leadership and communication
An ED-COVID team has been formed with a clear command structure and identifiable leaders, clear policies and a specific communications team ensuring decision-making anxieties among staff are minimised.4 Weekly COVID-19 updates from the leadership team are live streamed and recorded, encompassing key updates and providing opportunity for staff to raise questions and concerns. A COVID specific multidisciplinary ED well-being team has been established, encouraging inter-professional practice.
Physical safety needs
Staff safety has been central to all clinical recommendations. Staff are provided with appropriate personal protective equipment in accordance with government and evidence-based recommendations, which has been consistent throughout the pandemic. Staff concerns are communicated to and addressed by the dedicated ED-COVID communications team.
Safe rest area
Literature from China indicates that many staff felt the need for uninterrupted rest in a safe environment, rather than psychological aid.6 Within our ED this has been achieved by expanding our non-clinical staff area for rest, with the addition of mindfulness and yoga sessions that accommodate for social distancing.
Rostering
To protect doctors from chronic stress and poor mental health, full-time staff have been rostered for no more than four consecutive shifts followed by a minimum of 3 days off.1 A recommendation of 1 week annual leave per 4–5 weeks through the peak of the pandemic has been made to ensure optimal recovery time for staff, maintaining their capacity to fulfil their roles.7 Rotating between higher and lower areas of stress in a team-based system has also been implemented. This ‘buddy system’ is in-line with the World Health Organization recommendations to provide support, monitor stress and reinforce safety procedures.7
On the floor
A pre-shift consultant-led team based huddle has been implemented, focused around a ‘4S’ structure (Table 2). The last 30 min of a shift will be a protected time to debrief and carry out optional reflective self-care. In line with ACEM COVID-19 guidelines, all staff will rotate through breaks at least 4 hourly and a formal ‘tap-out’ process for staff will be taught and normalised to become part of our cultural vernacular.5
| Staff | Identify team members and roles, physical and emotional well-being check |
| Safety | Run through PPE guidance and review training material ensuring team members are PPE competent |
| SOP | Review SOP for updates including changes to case criteria, testing guidelines, isolation recommendations and treatment pathways |
| Sitrep | Review the national and local epidemiology, hospital bed state, current ED occupancy, current COVID admissions |
- PPE, personal protective equipment; SOP, Standard Operating Procedure.
Training/education
It is recommended that relevant training be maintained throughout the pandemic to sustain resilience of staff.4 The provision of regular education has been adapted to conform to social distancing. Regular skills-based drills specific to COVID-19 take place and are live streamed to those not present in person. Established fellowship and college-based education has continued.
Peer supporters
During the COVID-19 crisis the provision of psychological first aid (PFA) by appropriately trained staff will be crucial. PFA encompasses basic principles of support to promote natural recovery to those affected by crisis or traumatic events.8 The preparatory phase of the COVID-19 crisis has allowed for training of additional peer supporters to provide PFA within our ED.
Well-being drop-in sessions
The importance of recognising and supporting our most vulnerable staff was paramount during the planning phase of this crisis. Well-being drop-in sessions between 08.00–09.00 hours and 17.00–18.00 hours are being developed as an additional avenue for staff to voice their concerns. This service aims to mitigate the impact of social isolation on staff, ensuring those who are unable to utilise their usual networks of support have an accessible alternative.
Conclusion
The association between improved staff care and positive patient outcomes has recently been emphasised.1 If staff feel supported and confident in overarching pandemic planning, the recovery phase is likely to be less protracted.4 While the COVID-19 pandemic will likely challenge even the most well prepared hospitals, it is envisaged that much of the impact on staff well-being can be mitigated with adequate preparation, and that a post-pandemic shift towards prioritising and maintaining the well-being of frontline staff ensues.
Acknowledgements
The authors would like to acknowledge the work of The Royal Melbourne Hospital COVID-19 Well-being Team, Associate Professors Jonathan Knott and Mark Putland.
Author contributions
All authors contributed to development of the ED well-being plan. All authors were responsible for drafting, revising, approval and accountability of the manuscript.
Competing interests
None declared.
