Lessons learned from adverse outcomes on clinician resilience

1. The bank of staff engagement that health care executives had built up is now drawn down

Steven Berkow, vice president for Advisory Board research over the clinical and workforce programs, said , pre-Covid-19, the engagement of the health care workforce was in an overall fairly strong place. Challenges certainly existed, especially among certain segments, such as nurses and employed physicians. But overall levels of engagement were high compared to out-of-industry sectors, active disengagement was very low, and the overall trend was positive. 

That "bank" of engagement and goodwill is now significantly drawn down, with the emotional exhaustion caused by multiple major public crises making workforce burnout far more prevalent and serious.  

How to determine your frontline staff's risk of emotional burnout

2. Remember that disengagement and burnout are not the same

To begin tackling the burnout problem that the industry faces, it's important to understand that levels of disengagement can be low, but burnout high.  "It's not a 1:1 relationship.  Basically, when someone is disengaged they are saying 'I don't want to do this,' whereas when someone is burned out, they are saying 'I can't do this—at least not in a way that keeps patients safe.'"

Overall burnout levels have risen sharply as the workforce has become emotionally exhausted by multiple major stressors.

3. Address burnout as experienced in both segments of your workforce

To understand conditions on the front line of care and address rising burnout, executives must account for two different workforce experiences created by the pandemic:

• The minority of staff who have been on the front lines coping with Covid-19 patients are stressed by their experience of managing an overwhelming number of patients with a mysterious and deadly disease and limited resources, especially personal protective equipment; and
  
  
• The majority of the workforce has been stressed by being placed on the sidelines, as parts of the health system closed up to safeguard capacity. People in this position were left to contend with feelings of uncertainty and financial insecurity—historically, two of the biggest drivers of disengagement and burnout.

4. To bolster trust, be open about the difficulty of upcoming requests

The challenges faced by the workforce are not over; health care organizations will be forced to repeatedly make major requests of their workforces to survive the ongoing public health and financial crises.

To accomplish this, "We need to do a better job in appreciating and being straightforward about what we're asking of our workforce," Berkow said.  "As we are saying, 'We need to reopen our health system,' we also are also saying, 'We need you to trust that the workplace we are reopening will be safe.'"  And we need to recognize that, "When we make needed cuts, we are also asking our people to be more productive or make do with less and change their practice patterns."

In addition, "[i]f we are going to be straight with our workforce, we have to be comfortable saying, in answer to their questions, 'I don't know', Berkow said. 

This can be challenging for health care leaders, who have built a clinical workforce that tends to value security and predictability.   

5. Focus on a small set of immediate-term actions

Right now health care leaders should focus burnout mitigation efforts on a small set of concrete actions. Specifically:

• Make sure that staff are safe—and feel safe—while working.Clinical changes to promote staff safety are critical—but do not necessarily translate into people feeling safe. Leaders should leverage their existing rounding and polling activities to directly ask "Do you feel safe?" and also "What more can I do? What are we missing?" Surfacing and addressing staff feelings and perceptions will be essential.
  
  
• Talk with staff, not just at them: In response to the crisis, many organizations have put in place an incident command structure, making communication more streamlined than typical. Now is the time to re-balance this with bi-directional communication, re-infusing energy into shared clinical governance groups and other existing forums. "Staff will be more on board with tough measures if they feel like you have heard them and they have had a chance to inflect those decisions,' Berkow said.
  
  
• Treasure your most critical leader currency: trust. Leaders today want to make promises because they want to give the workforce good news. These promises are all too often not sustainable—and the trust broken when that happens is irrecoverable. Leadership teams should identify worst case scenarios, and what actions would be needed to counteract them, so they know what they cannot promise.
  
  
• Don't sugarcoat. The workforce will not be willing to support tough actions if leaders under-sell the challenges that health care organizations face. In addition, staff who already perceive these challenging realities will become even more stressed if the leadership team issues only rosy outlooks—because they will begin to feel that leaders "don't get it." To bring down stress levels, leaders must demonstrate that they do understand the challenges and that they are willing to act, even when those actions are hard.
  
  
• Start re-fueling leaders for the marathon ahead.The halo effect of exhausted leaders on the workforce is dangerous.Executives should move leaders out of "sprint mode," double down on the "stop doing or defer" list, and carve out time for development and well-being support activities.

Rebuild the foundation for a resilient workforce

6. Covid-19 will have a ripple effect on workforce planning for many different clinical job types

As organizations shift from the short-term crisis of averting workforce loss to longer-term workforce planning, they will see in coming months different segments of the clinical workforce impacted in different ways. Many of these effects are too early to predict in full yet—but for example:

• Physician consolidation may pick up pace as independents look for shelter from financial stress; many different specialties may now be more open to telehealth and team-based care;
  
  
• Advanced practice providers will likely see their scope of practice increase, with greater acceptance of their autonomy by patients and physicians;
  
  
• Nurses who are new graduates will be pushed into practice early, with experienced nurses possibly delaying retirement due to financial pressure—creating a short-term window for addressing the experience gap; and
  
  
• Medical assistant churn may increase as new job seekers appear amidst the recession—while others depart the role due to newly perceived risk and low pay.

To lead through these unprecedented times, health care leaders need to think differently, lead thoughtfully, and harness the power of teamwork. Learn more about our virtual classroom offerings.

7. The overall clinical labor market will eventually tighten again

While Covid-19 may have a transformative impact on how and where we provide care, the macro supply and demand trends that made for a tight clinical labor market pre-Covid will continue.

• On the demand side, while Covid-19 mortality among older patients is clearly the highest among all population segments, "it's not going to change the fact that we are getting older and sicker as a population," Berkow said." We will continue to see increasing demand for care and more complex care, particularly for more medical (as opposed to surgical) patients,"
  
  
• On the supply side, according to Berkow, "it is possible some baby boomers will put off retirement a little because of financial stress as well as mission. But they are still at the tail end of their careers—and as we backfill them with less experienced students, the gap between rising patient complexity and decreasing provider experience will continue to widen."

"Yes, we will need more mental health professionals," Berkow said, "but we already knew that.  Yes, we have a problem of over-specialization and we need more cross-credentialing—that too was a trend before, that has just been highlighted by Covid-19."

8. Focus on the challenge of navigating disruptive innovation with a workforce accustomed to incremental improvement

Prior to Covid-19, the biggest overall strategic issue for health care leaders was determining how to dramatically overhaul care to provide consumer value.  This mandate for disruptive innovation has posed a major workforce challenge, particularly for clinicians. Clinicians are not only accountable for safeguarding their patients' wellbeing, but also have "accomplished remarkable things" through incremental improvement. 

"But now, incremental change is not fast enough," Berkow said. "So, we see lots of leaders falling in between these two lines—the market saying you need fast transformation, and the clinical workforce being a brake on the needed pace of change."

9. The crises has sparked a spirit of innovation among staff—which will benefit the organization if leaders act now

One positive effect of the pandemic has been opening the window for transformation among clinicians, who have dramatically changed in response to a public health crisis.  Clinicians—and front-line clinicians in particular—have leaned into evolving their role, reactivating privileges, moving into other specialties, altering their sites of practice, and more.   

"Clinicians stepped up and said, 'here is where I can add value,'" Berkow said. "Changes that health systems had been trying for years to get them to embrace, they were suddenly running past those goals and saying, 'Here is a different way I can practice.'"

This is where the workforce opportunity is in health care. "We can't stop our population from aging, nor baby boomers from retiring," Berkow said. "But we can capitalize on this changed spirit we see in clinicians in terms of how to respond to Covid-19 … But the opportunity is time limited. You can already see some Covid-19 response softening.  Financial stability of clinicians will return. We will go back to the tight labor market. This window of opportunity will eventually close."

10. Identify opportunities, codify positive changes, and find the potential in this challenging time

Many forward-looking executives are already trying to capitalize on the changed spirit among clinicians. Research interviews with these organizations point to a subset of actions that seem to be working well:   

• Normalize how clinicians are now flexing to provide care.Have leaders sit down and consider all the shifts that clinicians have naturally made, identify the ones that should endure, and move them from crisis norms to standard operating procedures.Working in partnership with unions and professional associations can be especially critical here.

• Focus engagement efforts on bolstering emotional support.  To free up both leader and staff bandwidth for the most important issues, leaders should prioritize addressing burnout before resolving other kinds of engagement issues.
  
  
• Pick your clinical workforce now. The labor market is not quite as tight as it has been or will be—making now the time to reset baseline expectations for staff members. "You can say to people, this is what we need from you as a clinician who works here.  I need you to be more agile, more accepting or out in front when it comes to change. And we need to align that in incentives," Berkow said. Also, ensure those requirements are reflected in hiring filters to help the organization bring in people with the outlook that it needs.
  
  
• Leverage the spotlight. For now, national and local media are still focused on the amazing job frontline clinical workers are doing—but not necessarily the larger organization, and not in ways that necessarily tell the story leaders most need to publicize to the workforce.  "I am encouraging provider organizations to find ways to put that spotlight on how safe we are making our sites. The sacrifices we are making to do that.  The agility that workers are showing in response to the challenge. And also deliberately trying to highlight the work of some of the professionals we know will be hard to backfill in the months and years ahead," Berkow said.

In closing, Berkow asked leaders to remember the fundamentals of employee recognition—essentially, "When you go to recognize people, really try to recognize specific great things they have done.  Not just my workforce is great.  Call out when a unit hits a certain survival rate or, think back across the last week and the most impactful changes a unit made, and recount specific stories—that helps your workforce know that you are truly aware of and value what they are doing.  Acknowledge them as professionals—not just for being wonderful people."

Slide deck: Support staff and build resiliency in an era of great turbulence

Frontline caregivers have been bearing much of the responsibility for caring for patients with Covid-19. How can health systems, payers, and other players in the health care sector meet the financial, emotional needs of these essential members of our workforce while acknowledging the continuing business challenges that most of the industry still faces during the ongoing pandemic?

Last Thursday, we hosted Advisory Board Vice President Steven Berkow to analyze the nature of the challenge, its strategic consequences for hospitals and health systems, and mitigation steps to take today.

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