ASPR TRACIE: Module 2B - Organizational Wellness From the Top: Stress Mitigation and Work Satisfaction for Healthcare Providers

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[The video begins with the HHS logo. Descriptive Text for the title slide: Logo for the US Department of Health and Human Services. ASPR Saving lives, Protecting Americans.]

SLIDE 1

Narrator: Welcome to “Organizational Wellness from the Top: Stress Mitigation and Work Satisfaction for Healthcare Providers.“ This webinar is part of a series of modules sponsored by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, or ASPR’s Technical Resources, Assistance Center, and Information Exchange, or TRACIE.

ASPR TRACIE works closely with healthcare facilities, coalitions, ASPR Recovery staff, and HPP partners across the country and has repeatedly heard from disaster affected communities that disaster behavioral health recovery has been challenging for the healthcare providers involved in recent natural disasters and no-notice events.

Each of the modules we’ve developed includes a micro-learning module and a longer webinar.

The three topics are:

1. Addressing Compassion Fatigue and Behavioral Health Needs for Healthcare Providers
2. Organizational Behavioral Health and Wellness for Executive Level Healthcare Facility Staff,
   and
3. Healthcare Provider Cognitive Strengthening Preparedness Program

SLIDE 2

Narrator: ASPR TRACIE launched on September 30th, 2015. The development and functionality of ASPR TRACIE are collaborative, involving multiple HHS Operating Divisions and other federal government departments and agencies; local, state, and regional government agencies; national associations; nonprofit organizations; and private sector partners.

TRACIE is comprised of three domains: Technical Resources, which houses our Resource Library and subject matter expert-reviewed Topic Collections, the Assistance Center, where users can receive personalized support and responses to requests for information and technical assistance, and the Information Exchange, an area for password-protected discussion among vetted users in near real-time.

ASPR TRACIE has also developed several resources specific to disaster behavioral health; these are housed in our Select Disaster Behavioral Health Resources page.

Now, I’ll turn it over to Dr. April Naturale, who developed and will lead all of these modules.

SLIDE 3

April: Hello and thank you for joining us today. My name is Dr. April Naturale and I am a traumatic stress specialist who provides disaster and emergency preparedness and response consultation to responders and community members.

Today, I’ll be discussing Organizational Wellness from the Top: Stress Mitigation and Work Satisfaction for Healthcare Providers.

Our goals for today’s webinar will be to identify what we mean by organizational wellness specifically related to healthcare providers, a unique population of helpers in our society. We will describe the types of behavioral health concerns that we see in organizations such as compassion fatigue and secondary traumatic stress and burnout, a serious problem for organizations overall.

And we will look at what we know about how professionals can implement interventions for themselves and their coworkers to increase their own well being and how the organization can help move towards wellness.

This webinar was developed specifically for healthcare professionals, including those who work in the medical and behavioral health fields and those who are called upon to respond to disasters and the organizations that support them.

SLIDE 4

April: There are many dimensions of wellness. Most programs that exist in workplace organizations focus primarily on the physical health like nutrition and exercise, smoking cessation, disease prevention and management. These programs are often offered to employees as part of their workplace benefits. And while these aspects of wellness might be part of your organizational culture and are indeed, ways to contribute to employee health, this webinar will focus on the ways by which organizations - and specifically healthcare agencies - can support the emotional wellbeing of their staff, particularly in terms of work-related stress mitigation and management and boosting work satisfaction.

It may seem somewhat simplistic, but we consistently hear that this cluster of organizational aspects, that is, a culture of care led by executive management and strengthened by policy, has a positive effect on employees and the business as a whole. The aspects include leadership, a team that is able to impart this culture of care for their employees, not just the work that is done, but for each person who contributes.  The culture of care is strengthened and has more legitimacy when it’s backed by guidance or actual policies and procedures that support the health and wellbeing of employees. This includes activities that address employee satisfaction with their work - beyond surveys, addressing stress mitigation, really helping staff to reduce stress rather than just telling them to handle their stress. A healthy organization helps its team learn how to manage stress in the workplace itself.

It’s particularly important to create a sense of value and tailor organizational wellness before a disaster strikes to ensure that staff can tap into what they’ve learned during the response phase and beyond.

SLIDE 5

April: The World Health Organization defines wellness as an optimal state of health addressing seven aspects of a person’s life: physical, emotional, intellectual, environmental, occupational, social, and spiritual. Along with other components such as the socioeconomic status, trauma history, and education, wellness is referred to as the psychosocial view of an individual.

In terms of occupational wellness, particularly in healthcare organizations, there is this interplay of the physical environment - which is very powerful in settings like hospitals, examination areas in clinics, and treatment centers - and the overlay of emotions that accompany both being a patient or a client and being a caregiver. Attached to this is the intellectual aspect, or what I would refer to here as the extensive level of knowledge and skills that healthcare providers have to offer. It is extraordinary, and in some cases is considered actually life saving, even miraculous. Naturally, this often brings providers an added sense of occupational pride or what we call compassion satisfaction.  And of course, because so much of what is done in healthcare involves a team of providers and other professionals, the social aspects of wellness there is important as well.

This creates quite a complicated interactivity, with a lot of influences that can add to organizational wellness, and the wonderful thing about that is that opportunities for supporting wellness abound in this environment, on many levels, and I’ll discuss those as we move forward. 

SLIDE 6

April: This webinar is geared towards executive level managers, administrators, and supervisors in the healthcare field who create the culture under which the staff members work for the over 2,000 hours that most will put into your organization this year. That’s a lot of time to be spending together and creating culture is another reason we are talking about organizational wellness today.

The first webinar in this series focuses on individual stress management. Today we will look at how organizational stress management can improve worker satisfaction, mitigate excessive stress, decrease staff health and mental health concerns that are related to work, and decrease worker turn over. 

SLIDE 7

April: Some organizations can show signs of “dis-ease,” both in the staff and in the patients and clients they serve. That is, in an organization a sense of things not being right, not being at ease. We see the development of poor morale and a resulting increase in errors when there is organizational dis-ease and this can lead to high staff turnover, poor patient and staff relations, and poor interactions among the staff.
Those of you who oversee or directly supervise a number of staff, from physicians, nurses, public health, mental health, administrative staff and other types of employees know that sometimes when an employee takes a sick day, it is likely a mental health day due to fatigue, frustration, or even anger at some organizational policy or change that they find unacceptable. In certain cases, human resources staff can observe patterns of people working under certain managers or in certain departments who use more sick time or even file complaints about how the stress of the work is impacting them negatively.

Leaders are always looking at the quality of services that their agency provides and at those concerns that take an extensive amount of a manager’s time, eating into budgets. For example, high turnover rates require continuous orientation and basic training. This can decrease the amount of time available for advanced training.  Less advanced training may contribute to increased errors, patient injury, and even legal suits related to poor or inadequate care.

Organizational problems can escalate to widespread dissatisfaction amongst staff in how the organization functions, loss of trust, loyalty to the organization and to its leadership, less belief and dedication to the mission, even abandoning the group’s commitment to meeting their goals of high quality care delivered in a compassionate manner. These can be serious and expensive problems.

Overall organizational wellness can positively influence these concerns and may even be a useful part of your quality assurance plans that aim to reduce errors and improve staff morale, patient and client satisfaction, and, in the end, overall quality of care

SLIDE 8

April: In Module 1, we talked about the work-related stressors that can affect staff’s stress levels and their performance. These issues are some of the underlying causes for organizational dis-ease that we just described.

Let’s briefly look here at the terms of some of these distress conditions that staff can experience in the healthcare industry as they are constantly exposed to the trauma of their patients, clients, and loved ones. We will highlight each term in the following slides.

The most common condition called Compassion Fatigue, or CF, the next term, which is quite similar to CF, is Secondary Traumatic Stress, or STS. You may have also heard the term Vicarious Trauma and then there is Burnout, which is quite different from the other three in that it is most directly connected to problems with the organization itself rather than client or patient care. But these terms are often used interchangeably with the others.

The conditions listed here are behavioral health concerns but they also contribute to physical stress-related problems like high blood pressure, heart disease, immune system illnesses, substance misuse, and relationship problems.

SLIDE 9

April: The word trauma is derived from the Greek word for wound, so it makes sense that those in the healthcare industry refer to it in the physical sense. In this webinar series, we are referring to trauma and traumatic stress primarily in the emotional or behavioral health sense. SAMHSA notes that more than half of men and women report exposure to at least one traumatic event in their life and 90 percent of clients in public and behavioral healthcare settings have experienced trauma.

SLIDE 10

April: Compassion Fatigue is a sense of work-related exhaustion and feeling overwhelmed, usually very evident to the worker themselves and to their colleagues.  It’s often accompanied by a feeling of not being able to make the situation any better, a sense of hopelessness, and a lack of control.

SLIDE 11

April: Secondary Traumatic Stress is the experience of trauma symptoms in the healthcare providers as a result of, and in direct relationship to their exposure to the trauma of their patients and clients, seeing and listening to the trauma material and experience of others and the pain of that person’s family as well. STS distress symptoms usually mirror those of their patients and clients, especially in relation to posttraumatic stress disorder.  STS can also occur with only one exposure, so it is a bit different than CF in that regard, and it can be more serious, especially when the symptoms include signs of posttraumatic stress disorder.

SLIDE 12

April: Vicarious Traumatization is similar to CF and often includes some signs of STS, but an important difference is that it seems to negatively change one’s view of the world, belief systems, and perception of personal safety. So for example, if you’re caring for a child who has been abused, you might have the experience of feeling very sad, even depressed, and unable to sleep at night without visions of the abuse flashing before your mind’s eye and you additionally feel unsafe in your own environment, regardless of the actual situation of being in a safe living space.

Another difference between vicarious trauma and STS is that vicarious trauma occurs over time with repeated exposure to patient and client trauma, whereas, as we mentioned earlier, STS can occur with even just one exposure to another’s trauma.

SLIDE 13

April: Burnout manifests differently than the other distress conditions that contribute to organizational dis-ease and is often expressed in ways that are almost opposite from the others. Instead of an intense feeling of not being able to help or sad at not being able to do so, burnout is a condition that creates a void - a lack of feeling or empathy towards patients, clients, and their families, an indifference, a disinterest in the work altogether.

The causes of burnout are less concerned to the work of caring for patients and clients and/or attending to their families.  As a matter of fact, when we ask staff what the source of the problem is, anecdotally, the majority say it is not the patients or clients, it’s not caring for them that they perceive as a problem. They note the problems are the reams of paperwork after patient or client care, and time constraints that don’t allow them to spend as much time with their patients and clients as they feel is necessary. Staff also cite administrative problems like not having a helpful supervisor, or not agreeing with some of the organization’s policies and not getting along with peers as other workplace challenges. This is an important difference in the cause of the dis-ease.

So, the problem is different but it still has a strong impact on the organization.  This means to mitigate burnout requires a different set of interventions.  If not successful, staff experiencing serious burnout often need to make significant changes, like switching to a new supervisor, moving to a different department, leaving the agency, or they may decide to leave the profession altogether.

A problem in the field is that many people use these terms interchangeably and don’t understand what they need to do to help themselves.

SLIDE 14

April: Here you can see a summary of the prominent signs of the various disorders looking at differences in compassion fatigue, posttraumatic stress, and secondary traumatic stress and the negative thinking in vicarious trauma, then the indifference in burnout. In the bottom area, you can see some of the symptoms shared across each of the disorders including high blood pressure, immune system weakness, substance misuse and relationship problems.

SLIDE 15

April: As we mentioned at the start, these impacts of work-related stress have a direct negative organizational impact.

The work performance problems that staff experience have additional negative impacts on the organization as a whole.  When staff are experiencing compassion fatigue, secondary traumatic stress and burnout, we see a much lower staff morale, and this results in decreased productively. It takes distressed staff longer to get the work done and often it is not done well. 

Individually distressed staff who are also working in an environment where there is low morale, will more likely leave the workplace resulting in higher turnover rates, which as we know, costs the organizational significant funding in hiring and training new staff.
For those staff who stay in distressed environments, we see higher error rates, poor communications among the staff themselves, and an increase in error rates overall.  And distressed staff are often more short tempered, resulting in increased conflicts at all levels of line and management staff.

Distressed staff also seem to lose their confidence, even though they might not show it to colleagues, they may be second guessing themselves. Use of poor judgment, that includes, not collaborating with coworkers, not checking with supervisors, not checking on their own decision making, can lead to some of the most serious errors and problems in patient and client care.

And then we see organizations where the staff are disconnected from each other, working in isolation, not collaborating, not communicating properly and not functioning in the best interest of their patients and clients.

So you can see how all of these things impact the organization in ways that you may not see when your quality improvement programs focus only on tasks and tallies rather than staff and organizational wellness. 

SLIDE 16

April: There are positives aspects of working in the emergency and other healthcare setting field including medical care facilities, behavioral health agencies, those who are called upon to respond to disasters.

While some experience compassion fatigue and secondary traumatic stress, more actually experience what is termed compassion satisfaction, or CS. And the research shows us that CS can be very useful in mitigating the effects of compassion fatigue, so in addition to helping staff feel good about their work it can also protect them from negative symptoms.

Healthcare staff often report a very strong sense of meaning in their work. They know they’re making a difference in most people’s lives, sometimes in dramatic and literally life saving ways. So we want to make sure this messaging is strong and staff are reminded of what good work they do every minute of every day. 

Staff also report what is referred to as traumatic growth - they learn important and positive life lessons when working with people experiencing traumatic events.  Many indicate they’re more authentic in their relationships because they recognize how fragile and precious life is when they are exposed to patients and clients in trauma on a daily basis, but especially after a disaster.

Others talk about how their work reminds them of the importance of relationships and that they need attention regularly. They report feeling closer to their loved ones and their coworkers. Many become more connected to their communities, whether in the faith arena, or their children’s school activities, or in neighboring activities which contribute to community building.

And ultimately, when you combine all of these aspects with the organizational-specific activities designed to help staff recognize and build positive impacts of their work, you see the development of organizational wellness.

SLIDE 17

April: The question for you to consider about the people working within your organization is whether they’re actually thriving or just surviving. Are they experiencing satisfaction from their work and the environment in the workplace, or are they suffering with the stress of a negative environment that stops them from having a sense of meaning in the work that they do? Worse, are they close to burnout, a condition that will likely lead them to poor job functioning, negative coping, and even leaving their profession?

This question is of particular importance during a disaster when it is critical for staff to be ready and available to carry out the mission of your organization under very stressful conditions.

SLIDE 18

April: So let’s look at the key aspects of organizational wellness.  As we mentioned at the start, leadership that supports and recognizes this effort creates the culture for all.  And there needs to be a clear mission that everyone can follow, that provides a sense of meaning in the work. A mission like, improving our income doesn’t tend to motivate staff or make them feel good about the work they do.  Providing the best care we can for our patients and clients is more likely to support organizational wellness.

Healthcare agencies are not self led or peer support type operations. They need active managers who show strong leadership and who understand the business and the staff who implement their programs. Healthcare is a 99.9% accuracy business and that doesn’t happen without continuous, available managers and visible, interactive supervisors.  Leadership sets the structure and policies, and management has to help the staff to appropriately organize all the rules, from the organization’s policies to the state and federal regulations and the Joint Commission on the Accreditation of HealthCare Organization's standards. Staff cannot and should not be expected to meet all of these regulations without intensive support from management.

This speaks to the need for staff to have training that provides them the knowledge and skills they need to do their jobs including duties assigned during a disaster. Learning and having a sense of competency and confidence in how to perform their job decreases stress and increases job satisfaction. And professional development boosts this even further.

Opportunities for staff to address their own health and wellness, such as having screenings for physical illnesses like diabetes and cancers are common concerns. Weight control, smoking cessation, these increase their sense of being cared for and cared about, things that increase an overall sense of wellbeing.  Thus, looking at all of these aspects of organizational wellness can help to achieve it.

SLIDE 19

April: Both employers and employees have a responsibility to manage individual and work-related stress. The two must be in agreement and support each other to obtain organizational wellness.

Managers need to own their role, you set the tone, provide the resources and give the support and feedback needed to those under your supervision. Executive and middle-level managers can create a culture of compassion satisfaction in many different ways, some of them surprisingly simple.

Employees need to own their own responsibilities - bringing their best selves to the workplace, being honest about skills, strengths and challenges, and engaging in help seeking when it’s needed.

SLIDE 20

April: A study from the Beth Israel Deaconess Medical Center informs us that while stress may be a factor in 60 to 80 percent of all visits to primary care physicians, only about three percent of patients actually receive stress management counseling. What this really says to us is that if we are not teaching or recommending stress management to our patients, we are not likely practicing it either.

SLIDE 21

April: The old adage that organization’s culture is created from the top down still stands. Organizational wellness does begin at the top. Leadership needs to show that you’re serious and dedicated to this cause of organizational wellness.  Leadership needs to come together with all managers and staff supervisors to provide information and training where needed about how to help their helpers - healthcare providers - in terms of managing the stressors that can cause compassion fatigue and secondary traumatic stress and burnout.  Once the organization has trained all management staff about these concerns, they can begin to work towards a plan for implementing organizational wellness.

What kind of a culture do you have in your organization?  Are you managing your staff or just the tasks that they perform? Do you foster competition or collaboration? Do you focus on improving weaknesses or developing strengths?

Have you ever looked at these serious questions as a manager or an organization as a whole, other than through standard staff satisfaction surveys, most of which don’t get to the heart of these issues?  If you haven’t asked these questions, consider doing so now.

SLIDE 22

April: Organizational wellness does begin at the top. Once the leadership determines this is the direction they’ll support, work can begin at the administrative level. As many organizations already do, staff need to be aware of the mission statement, and more importantly, what their role is in meeting that goal. What are their responsibilities in the effort?  As importantly, every staff member should be presented with clear lines of authority. There should be no hesitation, they need to know who they report directly to and that should not be more than one person.

In terms of concerns, are staff empowered to make corrections or bring problems to the attention of management? Do you have a policy that states that staff are aware of that allows confidentiality in case they are concerned about repercussions of reporting a problem? Can staff make suggestions for improvement where they see a need - a quick fix as they call it in the quality assurance world - and if so, what’s the process? 

No assumption should be made about what staff know or don’t know. They know what you formally present to them and this is an important area that requires formality, clarity, ease and protection, and this may need to be in the form of policy.

Organizations can also help employees by supporting and participating in emergency management planning, mitigation, and response efforts and training on a regular basis.  

SLIDE 23

April: Some hospitals choose to implement critical incident response teams which work closely with hospital incident command to ensure that staff, patients, and clients needs are being met. This figure, taken from an advisor who works with the Orlando Health, illustrates the components of their team, including behavioral health components, subject matter experts, guest and volunteer services, pet therapy, care management, integrative medicine, bereavement, and nutrition services.

These teams can assist during the first few weeks after an emergency, a disaster, or other incident and can extend services beyond a month, as needed. You might want to consider such a model for your organization.

SLIDE 24

April: Supervision needs to be more associated with a manager who is supportive and not just checking to ensure staff are punching in on-time, completing their paperwork and meeting quotas.  As a matter of fact, when we ask line staff if they are receiving supervision on a regular basis, that is weekly, biweekly or even monthly, many state that they don’t even know what that means. Oversight of staff needs to include opportunities, whether you call it supervision or check-ins or workshops, whatever term you choose, to engage staff via a structure by which they can bring up problem patients and clients or cases to the attention of their manager, to receive guidance, recommendations or suggestions for addressing the difficulties. They may just need reassurance that they’re working in the right direction, but they do need an outlet and a sense that there is someone who can help if they need it. Just the perception of help that is available can decrease the anxiety and support a healthcare worker’s sense of well being.

And especially in emergency healthcare settings, immediate access to a supervisor’s advice or support is vital. A surge in patients or clients all needing immediate attention, including a surge of psychological causalities in hospital and other healthcare settings, can rattle even a seasoned nurse, physician or other healthcare staff. Assistance with triage, treatment, preparations and monitoring in the immediate aftermath of a mass violence or mass casualty incident often requires more than the assigned working groups. Staff need to know that their next level of support is right there with them.

SLIDE 25

April: Supervisors can vary caseloads so that the same staff are not always getting the most difficult cases or all the trauma patients. This is sometimes difficult as we tend to rely on our best workers and always assign them the tough cases. It’s a sure way to cause distress over time such as vicarious trauma or even burnout. Using a rotation system and sticking to it is important. Allow staff to say no if they do not feel competent to handle a specific case, but suggest that you can provide oversight or pair them up with a skilled worker to help them so that they can learn and begin to become competent and handle more difficult cases.

Monitor staff for CF and STS symptoms; suggest they use the ProQOL to self-assess and let them know that you’re happy to discuss the results if they would like to share. This is also a time to provide what we call psychoeducation, that is informing them of the common reactions to these stressors that all humans experience, to normalize these responses to help staff avoid feeling like they are becoming unstable, and allow them to recognize that they will be ok with the proper coping and support.

Role play boundary settings as a way of helping healthcare staff understand the importance of boundary setting and how to do it.

Make sure staff understand projective identification, that is taking on the feelings of others, and help them to identify personal ways that they may use to protect themselves from patients and clients projections of their pain, anger, fear, frustration, trauma, and grief.  Practice is the best way to prepare staff to act during emergency and disaster situations - actually taking them through scenarios and allowing them to determine the best skills for managing their emotions so they become better at doing it quickly when the emergency arises.

We will be looking at some of these skills later on in the webinar series.

And of course, we have to model what we teach. Let your team see you doing things like taking a break, stretching, breathing or de-stressing somehow after an intense session including, when possible, during disaster response and emergencies.

Refrain from discussing work with staff during breaks and lunch times. 

I can hear some eyes rolling. I know this is a culture shift for healthcare professionals, but I must insert here that these simple actions are not going to be that difficult to enforce if you are attentive and dedicated to changing the usual perspective.

SLIDE 26

April: If you have never heard of organizational wellness or compassion fatigue or traumatic stress, then maybe you don’t have an idea of what you can do to counter these concerns. This webinar will help inform you about the risks to your organization and individual staff through the use of various assessment tools, recommendations from the current research and information from the field of traumatic stress that suggests some basic, daily interventions that can help with mitigation as well as recommending  broader more formal structures to address serious risks to the daily operations of your organization.

When we talk about designing and implementing organizational wellness, we’re not talking about bringing in the troops for a complete overhaul of how you run your business, unless of course you are on your last legs and really need an overhaul. Truthfully though, most managers have a good idea of what’s needed to ensure that your organization and the staff who work with you are performing well, with a sense of satisfaction and meaning.

The significant problem we generally see is dismissing the recognition of some of the most simple and basic means to support staff wellness and thus optimizing the work of the organization.  This denial and often avoidance of taking any action can lead to the problems becoming systemic and so invasive throughout the workplace, that it can feel like making any changes would be too difficult without implementing some major culture shift.  So as we move through the webinar which will outline details of what can be helpful in mitigating individual and organizational stress - moving towards organizational wellness, you’ll be asked to think about those things that you know can be implemented now before poor morale and serious problems plague you and your staff.

SLIDE 27

April: Once the executive level staff are dedicated and understand the concept of organizational wellness, they can introduce the idea to middle management, that is directors, supervisors and other healthcare staff who are in positions that require them to be interacting with staff, direct care staff in various ways.  Information sessions, training events these can identify stress, distress, organizational dis-ease and organizational wellness.
Line staff training is best delivered in a way that allows staff to first learn about how to identify compassion fatigue, secondary traumatic stress, vicarious trauma, and burnout and how these concepts might be affecting them personally. Then share how the organization is planning how to set up supports and structures that can help mitigate the effects of these types of stress - both personally and professionally - and increase staff’s buy-in.

After information and training, start with small steps to understand first how the organization is functioning and then look at designing the structures needed to move towards organizational wellness.

To get these processes going, we recommend looking at the organization’s readiness. 

SLIDE 28

April: Readiness is about having enough information to determine what your organization as a whole and what the staff individually may need to start movement towards organizational wellness.

We recommend conducting an organization-wide assessment to start, which can be supported by the following tools:

A stress audit checklist, which is a brief self-assessment that organizations can use to start looking at the issues that may be impacting their staff.

The Professional Quality of Life Version 5, or the ProQOL-5, is a great tool individuals can use to assess their work-related stress.

And the Office for Victims of Crimes Vicarious Trauma Toolkit, which is a compendium of resources that address the issues of work related stress caused by the continuous exposure to traumatic events.

SLIDE 29

April: Management may already conduct organizational assessments through satisfaction surveys or employee workgroups. These may be tailored to ensure that you gather input and ideas at the leadership, middle management, and line staff levels about what kinds of stress-related problems they’re seeing in each department or line of business and how to increase organizational wellness in each of those areas.

An organizational assessment can include a review of policies and procedures that address stress management - and also identify areas where it is clear that some help is needed. So look at both strengths and weaknesses.  Consider an all-staff survey that focuses just on these issues.
Take a look at how some of the most stressful work is carried out. For example, healthcare staff in the Emergency Department cannot use a rotational assignment structure to help avoid any staff from having all the difficult cases, so instead, what types of support do they need to have in place that allows them to reach out and receive assistance when overwhelming cases occur? Such as the Critical Incident Response Team noted in slide 23.

Staff can be empowered to support this process by providing information about how work is done at the line staff level and suggest new ideas for implementing self care in the workplace, team level supports and resources that may be needed, for example, providing a space for on-site AA meetings, nutritional counseling, or access to daycare.

In addition, organizations should put systems in place to support employees during and following a disaster response.  For example, organizations can assign health and behavioral health staff to provide disaster mental health supports.  Organizations may also consider adding an Employee Health and Well Being Unit Leader, a position to their Emergency Operations Center and Incident Command Post to assist with providing support to employees during and following disaster and emergency response operations.

SLIDE 30

April: This is a screenshot of the Stress Audit Checklist, which can be used to track the implementation of recommendations that can help mitigate secondary traumatic stress on three levels: the organizatio or administrative level, the supervisory and team levels and the individual worker level. This worksheet was developed by Dr. Mary Pulido and is available free for download as part of this webinar. It’s copyrighted, so the document should not be changed and when using it you should give the proper author citation. 

SLIDE 31

April: There are several ways that staff can monitor and assess themselves for compassion fatigue, secondary traumatic stress and burnout.

A scientific way for staff to assess if they’re struggling with compassion fatigue or secondary traumatic stress or burnout is to use the Professional Quality of Life Scale or the ProQOL. This is a tool that is accessible online and free to use. You’re just asked not to change it and must provide proper citation when you refer to it.  This scale is broken into three subscales -compassion fatigue and secondary traumatic stress is the first subscale, the second is compassion satisfaction which is known to counter some of the negative effects of compassion fatigue and the third is burnout, which is a measure that looks at how much the administrative issues may be interfering with the satisfaction that staff get from the work itself.

The link to the ProQOL is www.proqol.org  and it’s recommended that staff use this tool every few months or so to help monitor how they’re doing. The interesting thing that I’ve observed about people engaging in this assessment is that they are often very pleased to find that they are managing better than they thought they were and this seems to spur them to commit to a stress management plan.

SLIDE 32

April: The Office for Victims of Crimes Vicarious Trauma Toolkit offers an Organizational Readiness Guide that covers leadership, management and supervision, the employee’s work environment, and training issues all related to organizational stress.

It’s a great tool to help look at these issues in your agency. The toolkit also includes information on resources specifically those who work with victims of crime. And while healthcare professionals work with a much broader population, there are many useful aspects of the toolkit for your review. 

SLIDE 33

April: The research is also very clear that those staff who suffer more with compassion fatigue and secondary traumatic stress are often the staff who have the least amount of experience and training in their professions including training and experience responding to emergencies and disasters.  They need more than orientation and a description of their basic and their disaster response duties.

Everyone needs to feel a sense of professional accomplishment, confidence and most importantly, a sense of competency in their work. This comes with experience and as mentioned in the last slide, positive support and feedback from one’s direct supervisor or manager, even modeling and mentoring when need be, and when appropriate, the next level of advanced training.

SLIDE 34

April: Many organizations offer staff wellness programs like smoking cessation, weight loss, and exercise. Often these are individual activities conducted at home or online. One of the most effective means of supporting people participating in these programs is to offer them in group formats where peers can come together to support each other. Staff are more likely to participate when programs are offered at the worksite during breaks or at the end or beginning of a shift. Peer support is by far more effective for most people. It lets everyone know they are not alone and that others have learned and can share ways through difficult times. Online access to these programs can also increase utilization, but again, if group conferencing is available, that’s ideal.

But expecting staff to manage the consequences of work stress strictly through personal improvement programs is insufficient. In fact, it can put a burden on staff and lead them to believe that if they are not managing their work stress successfully, they are in some way deficient or weak, or at fault for their failure.  These programs must be combined with leadership and management supports in the workplace, including providing support to employees in the wake of a disaster or other health emergencies.

SLIDE 35

April: We know from the research in the stress management and crisis intervention fields that being directive can be more effective in helping people in high stress or crisis situations. So when staff are highly stressed, a manager’s ability to intervene via an accepted culture or policy can be very helpful. 

A Directive Policy can start with processes that help staff prepare for and wind down from a range of highly stressful incidents, to include exposure from abusive patients or clients, or an excessive amount of bodily fluids due to an infectious disease or other causes, dismemberment, injury or death to children, and patient or client surges including those with psychological causalities,  in healthcare settings as a result of human caused intent to harm from mass casualty events or other emergencies. These are types of incidents that can increase the risk of staff experiencing compassion fatigue, secondary traumatic stress, and vicarious trauma.

For example, when a staff member has been abused, hit, pushed, or screamed at by a patient or client, a manager can impose a 10 minute break so they can gather themselves. Otherwise, most healthcare staff will just soldier through and use the famous line, “I’m fine,” not wanting to appear weak to their colleagues. But their brain is pumping stress hormones through the body and they would benefit both physically and emotionally from a short walk, a stretch, a long drink of water and maybe a colleague doing a quick assessment to see if they were injured without realizing it during the incident.

It’s also highly recommended that every staff member have a buddy who works in the same area - buddies should be on the lookout for each other, check-in with each other regularly, and work together in the aftermath of a stressful event. Isolation can be a dangerous thing for people who are very stressed out and a buddy’s help and support helps to keep people to keep track of each other and ensure safety and appropriate follow up.

Directive policies may be needed in some situations where managers and supervisors are not doing their best to support staff. For example, when guidance indicates that leadership would like to see people take their breaks away from their desk or nurse’s station when possible, this is a support that discourages staff from working through what is supposed to be a time to take their break, take deep breaths, stretch, call home and gather themselves.

We often hear staff say that when they go to take a walk outside at break, they see their supervisors looking at the clock or watching them, counting every minute. This sends a message that use of break time is not encouraged and can add to burnout as well as compassion fatigue.  Instead of walking by staff who are sitting and eating lunch at their desks and saying to yourself, “Yay, everyone is so committed, they’re working through lunch,” supervisors should be saying out loud, “I’m turning off the lights, so take a minute to finish up your note and please get up and get away from the workplace for the remainder of your break or lunch time.” Consider sanctioning a 15 to 20 minute walking group at your work location, that can help set the tone of self care.

Again, I can feel some of you rolling your eyes.  You know, it’s interesting to note that no other country, in no other country do staff work more hours and overtime than here in the U.S. We encourage overwork rather than self care and stress management.  It’s a culture shift that we need to and can make and need to start now.

Other simple ways to support the health of your organization is to look at replacing high calorie, sugary snacks with healthful options and ensuring that staff have access to water at all times. Stressful events and the responses that they incite in people can cause dehydration and imbalances in the human body. Water is critical and a simple way to help staff feeling well.  Another simple support is to have blankets or other forms of warmth like pillows, sweaters, and sunlamps available in staff break areas and wherever else extra warmth is needed. Stress can cause a loss of body temperature along with chills and other forms of distress. The sense of feeling cold is a noted stressor. Just as we offer these options for patients and clients, we can consider them for our staff. These are items that are relatively available for little expense. Creating break areas with calming pictures, music and lighting are also very simple ways to help de-stress staff.

These kinds of soft directives or policies and procedures can send a clear message that management is concerned about staff and support self care to help solidify the culture of organizational wellness that you are trying to create.

SLIDE 36

April: Research tells us that when people are prepared, that is when they have an idea of what to expect, they feel more in control and less stressed and less anxious about their work. And while we cannot always be prepared for everything, we know from anecdotal reports that lessons learned over the past two decades tell us that healthcare workers indicate they’re not prepared to handle the stress of some of the events they’ve been faced with. To be clear, they handle the events, but then suffer some serious consequences later on.

I have heard many emergency room directors, surgeons, nurses and hospital administrators and other key staff in mental health and health settings say, “We deal with trauma all the time. Our staff are prepared to handle these situations.”  Well, are they really? How do you know? Have you seen them in action and monitored what happens to them afterwards? 

In every mass violence incident that I have responded to  - from 9/11, to the Boston Marathon, San Bernardino, Pulse, Las Vegas, Parkland, Thousand Oaks, Tree of Life shootings, I hear over and over and over again from emergency medical physicians, directors, nurses, EMTs, behavioral health staff and even maintenance staff that they were overwhelmed with distress responses, some of which negatively influenced their decisions about who to treat first, how to keep track of patients or clients, what to document.

And then the stories of what happened to themselves in the days, weeks and months following their attendance to these patients and the scene in general, they clearly elucidate what compassion fatigue and secondary traumatic stress experiences are.

In a few cases, burnout happened very quickly because there were no policies or procedures in place to both care for patients or clients and protect staff. There has been tremendous staff turnover in several of these incidents - some very early on after the trauma. Additionally, some hospitals were unable to track patients and clients accurately, making it difficult for those patients and clients to access any physical or mental health supports that were provided by the federal agencies that provide these types of supports because they could not prove that they went to or were treated in a hospital.

Information sessions that aim to prepare staff for highly stressful incidents should include details about what to expect in terms of the incidents themselves and the details about what type of stress reactions they might encounter and how to deal with them. It’s imperative that they understand that some quite severe stress reactions are actually common, and will generally subside by themselves in a fairly short period of time. The staff should not consider themselves weak or unprofessional and they should be reassured that they are not likely mentally ill either, this is still a resounding concern with many people due to stigma, even with healthcare professionals.

SLIDE 37

April: So let’s just take a quick look at the change in body functions that stressful incidents and environments create as we just mentioned. They are very real and can highly impact how staff are feeling, thinking and functioning.

Notice the heart beating faster - a very common response - blood vessels constricting, chills, sweating, blood pressure increases and muscles becoming tense. These are just a few examples.

If we do not allow staff the opportunity to turn down these stress responses and return to normalcy, we are adding to their physical and emotional distress.  Training should include a stress management course that allows them to learn about the body and the mind’s reactions to stressful events and their stressful work, as well as teach them good coping skills. The first webinar in this series provides a basic overview of stress and stress management. Then the Cognitive Strengthening webinar offers evidence-based recommendations for mitigating and decreasing stress responses.  Do take advantage of these free learning opportunities from ASPR TRACIE.

SLIDE 38

April: If you read any of the after action reports from hospitals, clinics and other healthcare providers who were in the area of large scale disasters and emergencies you will hear from most of them that even though they had training, a lot was missed and the incident overwhelmed them beyond what they could have imagined.  Not only did they miss a lot, but just planning for emergency response activities by sitting in a classroom or at the computer did not prepare them well. They report not feeling confident and competent in their ability to respond. This contributes to compassion fatigue and secondary traumatic stress. If staff do not feel prepared, sufficiently trained and competent to apply what they’ve learned, they suffer more.  Additionally, the distress of not knowing what to do with all of these feelings and the concern that they might be developing an emotional disorder can increase their anxiety and their fear responses.
For that reason, it is suggested that all staff, regardless of their discipline are trained in Psychological First Aid, the only evidence informed intervention for the acute response phase which is applicable to both survivors and responders. We will take a little time in the next slide to quickly review what Psychological First Aid is for those of you who are not familiar and you will see a link you to the online training.

Preparedness means that role playing and drills are essential. Team members that usually work together within a specific department should drill together. They should take time to become familiar with each other’s roles so they know who to go to for what type of patient care needs during an emergency. And conducting these drills with other entities that your organization is likely to encounter is key, for example, include law enforcement, fire and emergency management directors at the state, county and local levels, as well as local providers -ambulance companies, equipment companies, even your PRN staff and suppliers and others. Everyone possibly involved should be at the preparedness and training table.

SLIDE 39

April: Psychological First Aid is an evidence-informed approach that helps children, adolescents, adults, and families in the aftermath of disaster and terrorism to reduce stress and foster adaptive functioning and coping.

The goals of Psychological First Aid are to promote and sustain an environment of safety, calm, connectedness, a sense of self-efficacy and hope. PFA can be applied to many different populations and in the field as well as in the classroom environment.

The eight core actions of Psychological First Aid include: Contact and Engagement, Safety and Comfort, Stabilization, Information Gathering, Practical Assistance, Information on Coping and Linkage to Collaborative Services.

One does not need to be a behavioral health professional to learn and engage in Psychological First Aid. To learn more and take the free CEU course on Psychological First Aid, you can go to the National Child Traumatic Stress Network site at https://learn.nctsn.org, or just Google “Psychological First Aid online course.”

SLIDE 40

April: One of the most difficult aspects of any training and skills development is ensuring that staff have time to apply their learning, to practice and to get a real sense of the applicability of what they have learned. This is why it’s important to give all staff an opportunity to practice new professional skills, even though they may need some oversight in the early stages of their trials.  In addition to increasing their professional skills, follow on training and opportunities to practice their personal stress management skills and increasingly deepen their abilities to control their stress responses is important. Here we offer some key means to do so. In the next webinar in this series, we will go deeper into cognitive strengthening using tools like restructuring as well as resilience building.
Staff should be encouraged to use supervisors to identify difficult experiences and strategize and to bring authentic concerns to their supervisor or manager, and even to top leadership if they are feeling unheard by those in their immediate chain of command, whether this is done through a human resources liaison or a confidential suggestion process.

We need to be instructing staff to avoid working too long by themselves or without checking in with any coworkers or supervisors. Or working long hours on a routine basis and working longer than their assigned shift, especially in disaster response operations when they’ve not been assigned to do so. Also, they need to avoid returning to work or not taking days off when they are scheduled to do so especially during disaster and emergency response work.

SLIDE 41

April: It is important to talk a bit here about briefings and informational sessions. In the past, we used debriefings which were typically offered to healthcare staff following a critical incident or disaster response.  Today, staff resiliency support usually involves more than one strategy for supporting staff, giving them options which they’re more likely to take advantage of.

One of the primary ways to help anyone exposed to emergencies and disasters is to provide information about what to expect in terms of their reactions, since we know that information decreases anxiety this is important.  It is recommended that all staff hear the same information, thus attending informationals or psychoeducational briefings may be helpful.

Participation by disclosing how one feels or telling details of a stressful or traumatic event is not necessary at all.  Informational meetings are found to be useful when they start with a psychoeducational component. Informing people of what some of the most common stress and distress signs are and what kinds of coping skills are found to help the most.

Behavioral health professionals in charge of staff care on disasters should provide a variety of interventions for staff support that are more pro-actively adapted to the situation including: monitoring worker stress during the disaster, offering the psychoeducation sessions we just mentioned, convening specific separate groups for those who were more highly exposed to the disaster and offering those staff individual crisis intervention. In some cases setting up a drop-in center staffed with behavioral health and spiritual care staff in a location that’s convenient might be helpful. And always, behavioral health staff need to be equipped with appropriate referrals for the most impacted who need follow up, whether that is to employee assistance programs or a local listing of emergency and disaster informed professionals. Organizations should also plan to integrate staff health and mental health and wellness into their emergency operations center and incident command posts, such as staffing an “Employee Health and Well Being Unit Leader” position so that staff support becomes an integrated and expected part of the overall disaster management system of an organization

And as mentioned earlier, staff should be participating in drills, exercises, and role plays, those activities that can prepare them for how to best perform on some of the most stressful work environments.  As part of those training events, they should be informed as to what to expect in terms of potential behavioral health responses in themselves  - what we identified earlier as  psychoeducation. This includes what types of symptoms are typical in each of the domains.

SLIDE 42

April: This grid gives a good picture of what psychoeducational material to cover. These are the various domains of human responses where we see serious stress symptoms occur.

You can see here that many of these signs are ones that may parallel those of the patients and clients.

Physical stress indicators most commonly include a rapid heartbeat, stomachaches or headaches that have no physiological basis, sleep problems, lowered immune systems which make you more susceptible to illnesses that can spread in the workplace.  Organizations pay for this in terms of sick days, medical insurance claims, reduced function at work and staff shortages as examples.

In the emotional domain, we see that anxiety symptoms are common in addition to signs of depressive like sadness and crying.

On a personal or behavioral level, staff may find they’re much more cynical and negative in general, maybe having mood swings, often isolating and even seeking out alcohol and other substances to change their mood.

In the cognitive area forgetfulness and confusion are very common, as are poor decision making and poor judgment. These problems often result in more risk taking.  They can even go as far as paranoia that others are out to get them, watching them or a potential threat.
In the spiritual domain we see people questioning their sense of meaning in both their personal and work life choices. Some even question their beliefs; and others who suffer with depression and are often isolated and may develop a sense of hopelessness, which puts them at risk for suicide.

The important thing about this is that people know they’re not likely to be developing a mental illness if they have some of these symptoms, especially in the intermediate aftermath, many are common and most of these symptoms will subside in a short amount of time with some good self care, good coping and positive social supports.  If the symptoms remain for more than about 30 days, or if they bother the staff at any point, then a referral for short term crisis intervention, cognitive behavioral therapy, which usually entails about 10 to 12 sessions can help decrease the symptoms. But for about 80 to 90 percent of the staff, their symptoms will likely go away on their own over a reasonable period of time. People report that this information is very helpful, that it is good to know that they are not having a mental health disorder and that these symptoms are common, that they are not alone and that they will likely get better on their own soon. 

So that briefly is what general psychoeducation looks like. In some circumstances, we share more information about different types of stressful events, which is good to do if you are preparing for specific incidents. We also try to engage in discussion with staff about what kinds of coping skills they already use to help them and encourage them to use these activities as well as peer support, and especially in the immediate time frames after emergencies and disasters.

SLIDE 43

April: In addition to information about what to expect, training all staff on basic coping skills for stress management techniques that can help during and after stressful, traumatic events, and disasters is important. Everyone has different ways of coping, and they should be encouraged to try different ones, use them, staying away from negative coping like alcohol and mind altering substances. 

And for those of you who don’t know what coping means or who cannot identify good coping, we try to recommend what the research indicates can be most helpful.  The first of these is breathing. Since one of the most common distress symptoms is rapid heartbeat or dizziness, we teach people at least one model for breathing in a way that will reduce stress and move toxic stress hormones out of the body. The 3-5-7 method of breathing is quite easy, it entails counting to 3 while taking in a breath, holding it for 5 seconds and then releasing the breath slowly for at least 7 seconds. People should be instructed to repeat the breathing exercises several times often during the day. The same is recommended for another simple type of breathing called box breathing, this is similar, it involves taking in the breath at the count of 4, holding it for the count of 4, releasing to the count of 4 and then holding to the count of 4 before taking the next breath.  And then again repeating the box breathing. I suspect many of you know other models  - it doesn’t really matter which you use  -  just as long as you use them.

Body movement is a very effective way of moving stress out of the body, stretching or processes like yoga can be very helpful. Even walking is a good way to reduce stress. Because body movement is so helpful, taking a few minutes to practice breathing or doing a few simple stretches during staff meetings, and during disaster assignments can be a helpful way that organizations can encourage staff towards wellness. Music is emerging in the research as a helpful way to change one’s mood quickly. Music should be timed to the breath as rapid music like heavy metal or rap will likely increase the heart rate rather than relax it.  So, again, music that is timed to the breath.

Social support has emerged in the research as one of the most effective ways to cope with distress, being with others who understand and accept how you feel is very important. People who invalidate that you’re distressed or tell you to snap out of it aren’t really very helpful. You want to talk with people who can encourage good coping skills.

Narrative work such as writing for recovery or journaling is often found to be very effective for many people.  There are so many different types of good coping, people should be encouraged to use what they like: reading, sitting quietly, taking a bath, walking in nature, whatever they know has worked for them in the past.

SLIDE 44

April: I promised to show you a couple of simple breathing techniques. One of the most important stress management skills is breathing in a way that helps get rid of toxic stress. Are you a shallow breather? That is someone who normally doesn’t take in full breaths, thus, not really ever getting a good amount of oxygen in the body. This is so important because full and deep breaths help us to get toxic stress hormones out of our body.

You should know how to breathe fully and deeply, and practice this. It’s especially helpful when under the stress of a disaster because it controls the nervous system, it keeps the rapid heartbeat under control, which is so uncomfortable when it happens and usually makes us think we are having a heart attack. You cannot have an anxiety driven rapid heartbeat and breathe deeply at the same time. It’s physically impossible. So learn some breathing exercises.

On the screen is a simple one that tells you to take in a normal breath through your nose with your mouth closed and then to exhale very slowly through your mouth, concentrating on a calming word like ‘calm’ or ‘relax’; and then count to 4 before taking the next breath. Do this about 10 times, and it will reduce the rapid heartbeat from anxiety and stress and slow your breathing.

Alternately, you can do another one that’s very simple to remember, it’s called the box breathing because it is 4x4x4x4. Start by counting to 4 slowly while breathing in, hold it for 4 seconds, release the breath to the count of 4 and then count slowly to 4 before beginning again. Doing this several times a few times a day will help keep stress down and get oxygen flowing through your body, pushing toxic stress out. Working on a disaster can be an extraordinarily busy and stressful assignment for healthcare professionals.  You may not have time for much, however taking a few moments to focus on simple breathing techniques is doable in a disaster setting.

SLIDE 45

April: That brings us to the concept of a stress management plan. One of the problems we hear from healthcare workers is that while they know what stress management and coping skills can help them, they don’t have time to implement them.  When psychologists look at this issue, we find that people are more likely to follow a plan when it is written out, when it is very specific and when it is tied to a way of keeping track, such as using a calendar, or a daily planner or dated activities that actually list the day and time that you will enjoy that activity. 

It’s recommended that people write out their own stress management action plan and start fairly small with one or two activities and then grow into a more comprehensive plan once the early planning goals are met.  So, taking staff through an exercise asking them to write down three leisure activities that will allow them to destress - then have them put a date next to each activity with the coming week when they expect to engage in it and lastly putting the exact time next to the event when they plan they would be able to engage in it is a way to start.  It doesn’t matter if they actually conduct the activity at the exact time - they can easily change it if need be, but the act of creating these details are what will help them to follow onto the plan.
Now identify a way to remind them to use these strategies during and following a disaster or a traumatic stress response.

SLIDE 46

April: Try it now. Take a few minutes to look at your calendar. Identify two or three 20 to 30 minute intervals that you can use to destress. Write down what specific stress management activity you will do in this timeframe. For example, will you take a walk? Can you close your office door or find a quiet, private space to breathe deeply or meditate?  The research tells us we are likely to carry out these activities when we identify what we will do and actually schedule it. Give it a try.

SLIDE 47

April: Many staff in healthcare professions look to increase their knowledge and skills in their current job function as well as looking for opportunities to expand what they know with training. 
Part of organizational wellness is encouraging and wherever possible, supporting staff’s desire for more learning.  Human resources staff as well as supervisors should be empowered to provide information and resources for professional and personal improvement opportunities. 
And while many organizations use Employee Assistance Programs or EAPs as referrals for behavioral health needs in staff, we are well aware that many do not know the evidence based interventions for acute stress and post traumatic stress disorder. Because of the important role of EAP programs, organizations should talk with their EAP provider about their capacity to provide assistance and with potentially larger numbers of staff following a disaster.

The field is moving very rapidly in our understanding and the development of the types of treatments that are most effective in treating stress related symptoms.  HR, the departments, and EAP programs should be prepared to refer an appropriately -- recommend licensed services or resources that provide the information that staff need within their geographic living and working areas. 

SLIDE 48

April: We’ve gone through a lot of information here. In summary, concerns such as compassion fatigue, secondary traumatic stress, vicarious trauma and burnout can negatively impact healthcare providers individually and the organization as a whole. The good news is that there are structures and recommendations that organizations can support and encourage on both personal and professional levels to help staff move towards organizational wellness. These include assessing and monitoring, policy development regarding preparedness, briefings and informational sessions, self care and supervision, and individual stress management and action plans as examples.  All of these can be accomplished when organizational leadership gets behind the goal of organizational wellness and leads the way.

SLIDE 49

April: There are many resources that can inform you further about acute stress, posttraumatic stress, compassion fatigue and secondary traumatic stress that can increase your knowledge and understanding about how these disorders can occur and more in-depth means to counter their negative effects. ASPR TRACIE has a wealth of resources on these issues as well as planning, preparedness and response activities for healthcare providers addressing disasters, disease outbreaks, biohazard events and more.  For those of you who are researchers, the National Center for Post Traumatic Stress Disorder’s website will bring you to the Pilots database which is the most comprehensive collection of literature on these subjects. The materials are free with Pilots registration.

SLIDE 50

April: Thank you for joining this ASPR TRACIE sponsored webinar on Organizational Wellness. We hope this will be useful to you as you look for ways to achieve wellness in your organization and in your valuable and precious healthcare provider staff.

Voiceover: Produced using taxpayer funding by the U.S. Department of Health and Human Services.

 [The video ends.]