Psychiatric Annals

CME Article 

Development of Wellness Programs During the COVID-19 Pandemic Response

Amanda M. Spray, PhD; Nikhil A. Patel, MD, MPH, MS; Ashvin Sood, MD; Stephanie X. Wu, BA; Naomi M. Simon, MD, MSc; Rachel Podbury, BPubHealth&HealthProm; Ariela Vasserman, PsyD; Rachel A. Caravella, MD; Yona Silverman, MD; Randi Pochtar, PhD; K. Ron-Li Liaw, MD; Marra G. Ackerman, MD

Abstract

Health care workers are on the front lines of the recent pandemic, facing significant challenges to their physical and mental health. This article details the efforts undertaken by a health care system and two academically affiliated hospital systems to provide emotional support to their frontline staff. The multipronged approach describes coordinating efforts to decrease duplication of services and to increase centralization of information. This included enhancing pathways for faculty, staff, and trainees to obtain individual and group treatment and to have access to high-quality self-help resources. Continuous feedback has been elicited to ensure that efforts are consistent with expressed needs and in turn services undergo modifications as needed. This article seeks to provide an overview of how one health system has thus far approached the important issue of staff support as well as the challenges experienced and lessons learned along the way. [Psychiatr Ann. 2020;50(7):288–294.]

Abstract

Health care workers are on the front lines of the recent pandemic, facing significant challenges to their physical and mental health. This article details the efforts undertaken by a health care system and two academically affiliated hospital systems to provide emotional support to their frontline staff. The multipronged approach describes coordinating efforts to decrease duplication of services and to increase centralization of information. This included enhancing pathways for faculty, staff, and trainees to obtain individual and group treatment and to have access to high-quality self-help resources. Continuous feedback has been elicited to ensure that efforts are consistent with expressed needs and in turn services undergo modifications as needed. This article seeks to provide an overview of how one health system has thus far approached the important issue of staff support as well as the challenges experienced and lessons learned along the way. [Psychiatr Ann. 2020;50(7):288–294.]

The coronavirus disease 2019 (COVID-19) pandemic has become the most significant health crisis of this century, affecting every aspect of the health care system and society. Health care workers (HCWs), especially those working on the front line, are at heightened risk for significant psychological consequences. Many factors contribute to well-being risks including potential for personal infection, fear of spreading infection to and separation from loved ones, insufficient personal protective equipment (PPE), redeployment, and exposure to an onslaught of patients with high illness acuity and mortality within an overtaxed health care system.1 Reports from Wuhan, China, have indicated a surge in depression, anxiety, insomnia, and distress among HCWs managing COVID-19 in both academic and community hospitals.2

Based on listening sessions held with health care professionals during the first week of the COVID-19 pandemic, Shanafelt et al.3 highlighted the need for listening to and both practically and emotionally supporting HCWs as: “hear me, protect me, prepare me, support me, and care for me” (Figure 1). After a disaster, a vast majority of people will experience transient psychological and behavioral symptoms that represent normal responses to an abnormal event.4 Psychiatric interventions should aim to minimize exposure to trauma; educate about normal responses to disaster; deliver support to HCWs and community leaders; provide guidance on when to seek professional treatment; and identify and treat people with risk factors.5

Stressors that health care providers are facing. Adapted from Shanafelt et al.3

Figure 1.

Stressors that health care providers are facing. Adapted from Shanafelt et al.3

To respond to the mental health needs of HCWs at New York University (NYU) Langone Health, a cross-departmental, interdisciplinary Frontline Staff Support Taskforce (FSST) was launched to oversee the development of virtual and in-person support. This article presents the strategies employed by the FSST, which includes representatives from the NYU Department of Psychiatry and Department of Child and Adolescent Psychiatry across the Manhattan, Brooklyn, and Winthrop Campuses of NYU Langone Health (NYULH), in addition to two academic affiliates, the VA NY Harbor Healthcare System, and Bellevue Hospital. We summarize the collaborative efforts undertaken by this taskforce over the first 6 weeks of the COVID-19 pandemic. At the time of this writing, the program continues to evolve and currently includes coordination with wellness programs through the Department of Nursing, Integrative Health, Health Promotion, Social Work, Chaplaincy, and Human Resources.

Online Resources and Website Development

Since the outbreak of COVID-19 across the globe, many resources have emerged to disseminate information, ranging from governmental bodies, academic medical centers, and professional organizations. The FSST convened a website content curation work group comprised of volunteer clinical and research faculty, house staff, and medical students. This group identified, reviewed, and redesigned online resources to address the needs and concerns of frontline HCWs through the multiple phases of pandemic response and recovery.

Fatigue and limited time are central concerns for frontline staff in a crisis. As such, the website work group focused on building a repository of information that would be easily accessible, digestible, and user-friendly. An informal needs assessment for support resources was conducted with a group of existing wellness champions across units and disciplines. Early on, HCWs reported difficulties with sleep, anxiety, managing stress, and juggling work and family responsibilities. To make resources more visible and accessible, an internal website was launched, which highlights pathways for mental health services and virtual support groups as well as online resources for HCWs and their families. This site, titled, “Mental Health Resources for Frontline Health Workers,” received 1,277 unique visits in the first 24 hours after it went live (utilization data below).

Online tools include multimodal resources: webinars, articles, tip sheets, and de novo infographics created by medical student volunteers. A “Coping Card” was created to highlight quick skills that people could use in real time (Figure 2). The card includes practices that can be incorporated while working or during off hours, such as mindfulness techniques and verbal affirmations. HCWs also reported high levels of self-blame for decisions and outcomes that were beyond their control. Thus, working with a medical student, house staff, and psychology volunteer team, we created an accessible, brief infographic addressing these issues through cognitive approaches, which was disseminated via the website (Figure 3). Given tremendous patient and community losses, targeted resources for exposure to death and dying were also highlighted.

Coping card resource. Figure used with permission of Dr. Charles R. Marmar (Chair, Center for Alcohol Use Disorder and PTSD, Department of Psychiatry, NYU Grossman School of Medicine, NYU Langone Health).

Figure 2.

Coping card resource. Figure used with permission of Dr. Charles R. Marmar (Chair, Center for Alcohol Use Disorder and PTSD, Department of Psychiatry, NYU Grossman School of Medicine, NYU Langone Health).

(A and B). Engaging in self-compassion resource. Figure used with permission of Dr. Charles R. Marmar (Chair, Center for Alcohol Use Disorder and PTSD, Department of Psychiatry, NYU Grossman School of Medicine, NYU Langone Health).

Figure 3.

(A and B). Engaging in self-compassion resource. Figure used with permission of Dr. Charles R. Marmar (Chair, Center for Alcohol Use Disorder and PTSD, Department of Psychiatry, NYU Grossman School of Medicine, NYU Langone Health).

Website development required effective collaboration and coordination across our health system's Information Technology, Communications, Human Resources, and clinical departments, including but not limited to child and adult psychiatry, emergency medicine, internal medicine, nursing, integrative health, social work, and chaplaincy. Ongoing challenges include (1) updating online resources to address the evolving needs and concerns of HCWs and their families through short- and long-term pandemic recovery and subsequent waves; and (2) creating a public website to share resources across institutions and audiences.

Communication and Engagement Strategies

To promote staff awareness and utilization, posters and postcards promoting the staff support website and featuring a mobile device readable barcode, known as a QR code, were created. These materials were displayed in high-traffic, staff-facing areas on each unit and distributed in-person during breaks and shift changes by an interdisciplinary staff support team. Senior leaders shared information about staff support offerings with each unit's leadership including medical director and nurse manager dyads and service chiefs. In person and virtual presentations on staff support resources were delivered broadly at administrative and nursing leadership meetings, department grand rounds and town halls, and interdisciplinary team meetings.

Since the outset of the pandemic, the health system proactively communicated updates through a COVID-19 daily enterprise-wide email, as well as a dedicated COVID-19 intranet hub. Through a partnership with the Internal Communications Department, staff support resources were featured with regularity in the COVID-19 daily email, which has an average 39% unique open rate, and in several articles hosted on the intranet, including features on the website launch, curated resources, and support groups. Over the 25 days from launch of the staff support resources, the website landing page had 7,423 hits and 2,425 unique users, illustrating the effectiveness of the communication strategies deployed in engaging HCWs.

Lessons learned include the importance of engaging unit-based, local team leaders early and often when designing, implementing, and evaluating staff support efforts. Their “boots on the ground” perspective and existing relationships with people provide an invaluable source of understanding HCW needs and concerns and most effective ways of bi-directionally sharing information and gathering feedback.

Individual Services

The staff support website highlighted resources available for mental health treatment through the NYU Department of Psychiatry's Faculty Group Practice (FGP), the Department of Child and Adolescent Psychiatry's Child Study Center (CSC), and the Employee Assistance Program. The Adult FGP and CSC have collaborated to provide expanded access for frontline health care workers with expedited triage and linkage to care via telehealth within the day of outreach. This was facilitated by an already robust telemental health program in place in both departments, which was rapidly expanded to all virtual care within days of the onset of the pandemic. Notably, the FGP has seen a 20% increase in visits postpandemic. Additionally, both departments put forth a call for faculty volunteers for individual and group support. A database of volunteers' faculty credentials, availability, expertise, and services offered (types of psychotherapy and/or medication management) was created, and a lead psychologist with expertise in trauma served as a liaison to match employees with volunteers.

Challenges include maintaining staff availability to accommodate new referrals while continuing to provide care to current patients. Efforts are underway to leverage mental health expertise and resources from across the health system to continue to build and sustain capacity for consultation and ongoing care for HCWs and their families.

Building Upon Existing Programs for Residents

Resident physicians from various departments were redeployed to the medicine wards and intensive care units to assist their colleagues during the COVID-19 pandemic. The House Staff Mental Health Service (HSMH) developed interventions to decrease the expected emotional and psychological toll on our physicians at the front lines. HSMH services have been maintained and expanded via telehealth during the pandemic, including the addition of several targeted support and process groups. Balint groups and Schwartz rounds exemplify a long tradition in organized group-based discussions among physicians. Both groups provide the platform for physicians to explore complex clinical cases and the resulting personal consequences.6,7 Using these principles, on-site support groups and virtual drop-in groups were implemented to reach house staff across all hospital sites.

Providing support groups to house staff has posed significant logistical challenges given that there are 1,700 trainees in Graduate Medical Education (GME) programs across the entire health system. For example, the internal medicine (IM) department has over 200 residents across five different hospital sites posing challenges for virtual group times and locations for on-site support. Given the necessity of social distancing, the decision was made to have all group leaders work remotely and facilitate sessions via secure video-conferencing platform. To improve group utilization, the HSMH team liaised with IM service chiefs and chief residents across all hospital sites to develop group sessions integrated into weekly noon conference time. Group sessions provided an opportunity for reflection, connection, and psychoeducation about resources for free, individual treatment through HSMH.

Additional drop-in groups were created for unique resident cohorts based on feedback from the GME Wellness Coordinator and requests from house staff including residents quarantined due to exposure or known infection with COVID-19; parents and expecting parents; Asian and Asian American house staff; and pediatric residents redeployed to adult COVID units. Efforts were made to vary the timing of groups, allowing for house staff who were working both day and night shifts to participate. Groups were modified in structure and theme to accommodate evolving needs including the addition of a closed process group for house staff across specialties.

Creating Groups and Tailoring Needs

In addition to house staff groups described above, groups were provided for faculty, nurses, staff, and medical students across the health system. In efforts to minimize infection and conserve PPE, the majority of support groups were delivered virtually and served as opportunities for reflection, grief, community, psychoeducation, and self-care.8,9 Psychiatry leadership liaised with on the ground service leads across disciplines to continuously monitor and revise group structure to meet needs.

A group facilitator guide was developed to provide a framework for group leaders in their delivery of support groups for health care professionals across disciplines and settings (Pochtar et al., unpublished data, 2020). The guide aimed to provide a flexible, yet structured approach to facilitation and to strike a balance between sharing relevant content on coping, grief, and self-care while also addressing individual needs. It was developed by adapting material from psychological first aid (PFA), an evidence-informed intervention developed by the National Child Traumatic Stress Center and National Center for PTSD (posttraumatic stress disorder), aimed to help people after a disaster or crisis.10

It includes an opening that both validates participants' current experiences and offers time to share experiences and reflections. It also incorporates psychoeducation about chronic stress and activation of the sympathetic nervous system; the importance of distress tolerance skills in reducing heightened arousal; strategies for managing stress and worry about loved ones; self-care approaches; acknowledgment and normalization of their experiences of grief and loss; and encouragement of group cohesion through expressions of gratitude and recognition. Groups are often co-facilitated with one facilitator serving as the lead and the other monitoring group process and participant engagement. The content of the facilitator guide is continuously evaluated and revised incorporating feedback collected during weekly group leader huddles.

A team of psychiatrists, psychologists, social workers, nurse practitioners, psychiatry residents and fellows, and chaplaincy volunteered to lead group sessions. Support groups ran daily at different times to accommodate staff work schedules. Almost 40 weekly groups were offered across NYULH Manhattan and Brooklyn campuses, and group leaders along with psychiatry leadership met on a weekly basis to assess and determine the need for modifications. Groups had varying participation, with highest use occurring the week of March 30, 2020. Almost 500 people have participated in support groups offered to date. In week 1 of the pandemic response, groups were rolled out to nursing and house staff. Nursing group use was initially low; feedback indicated nurses were most in need of bedside, brief support. Nurses expressed difficulty finding time for group sessions and concerns that groups were general drop-in and not team-specific. This was addressed by bedside, brief PFA support delivered by the consultation-liaison (CL) team (see section below).

Overall, participation in support groups was noted as a challenge. The taskforce made several modifications to increase use and tailor interventions (Figure 4), by increasing discipline-specific groups and modifying days and times to meet evolving needs. To date, the most successful virtual and in-person support groups have been those facilitated for existing teams and cohorts, such as our house staff and faculty groups for emergency medicine, internal medicine, and pediatrics. Notably at the local VA Medical Center, on-site groups led by chaplaincy, psychologists, and nurse practitioners have gained traction over the last few weeks with more consistent use than virtual groups. At the affiliated community hospital, several mental health clinicians have been staffing the respite rooms adjacent to medical inpatient units and intensive care units. Groups have followed social distancing practices, and all participants wear masks.

Support group utilization.

Figure 4.

Support group utilization.

Ongoing challenges include providing easily accessible, specially tailored support for nursing, respiratory therapy, building services, and other frontline HCWs significantly affected by the pandemic but who are not currently using existing support offerings. Our next iteration of staff support must address mental health-related stigma and HCWs privacy concerns and embed informal, in-person support touch points within an individual and team's daily work. Future directions include rebranding the groups as “recharge sessions” or “wellbeing workshops” to decrease stigma related to participation and to ramp up on-site groups.

Support In-Person Through Consultation-Liaison

In response to an expressed need for in-person emotional support on the units for staff, psychiatric nurses were redeployed from the inpatient psychiatric unit to the CL psychiatry team. The CL team created the “Clinician Support Access Algorithm,” which featured these psychiatric nurses in a role akin to a mental health “medic.” The redeployed psychiatric nurses, fluent in bedside supportive interventions from their experience as inpatient psychiatric nurses, delivered PFA to frontline clinical staff. PFA is a proven framework that pulls together evidence-based best practices from the fields of trauma-informed care, disaster response, emergency psychiatry, developmental psychology, and military research.11 PFA promotes a sense of safety, reduces distress, bolsters calming and coping strategies, and normalizes emotional responses through use of ultra-brief somatic therapies, stress management, self-care coaching, solution-oriented counseling, and grief support. A hospital-specific PFA practice manual was compiled integrating existing PFA best-practices with elements from mindfulness-based stress reduction, cognitive-behavioral therapy, dialectical-behavioral therapy, and the collective psychiatric nursing experience of NYU Langone Health's inpatient psychiatric and integrative health nurses (Eastburn et al., unpublished, 2020). The individualized, personal, and live encounters with frontline staff allowed the psychiatric nurse to refer those clinicians in need of additional support to the formal mental health resources provided by the institution. For additional description of CL-delivered support services offered, see Caravella at al.12 (this issue).

Conclusions

Over the course of the first 6 weeks of the COVID-19 pandemic in New York City, the depth and breadth of staff support programming developed and delivered by our interdisciplinary staff support team was remarkable in many ways. The rapid pace of program development was fueled by an urgency to support and care for our frontline colleagues and sustained through intentional, near seamless coordination and collaboration across a lattice of departments across our health system, city, state, and an international network of academic medical centers and professional organizations. Strong leadership, timely communication, investments in technology, teams, and mental health predating the pandemic all contributed to the success of the evolving staff support efforts. As the New York City region sees the number of COVID-19 cases on the decline at the time of this writing and health systems gradually return to a “new normal,” the upcoming challenge will be to find innovative approaches in continuing to provide a range of accessible staff support offerings for HCWs while simultaneously ramping up and reopening the continuum of psychiatric care, including inpatient, emergency, consultative, and outpatient care. As this pandemic will likely last between 18 and 24 months and the recovery process far beyond, robust collaborations must continue both within and across health systems, and investments must be made toward new resources to design, deliver, and sustain support for HCWs and their families for the long road ahead.13

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Authors

Amanda M. Spray, PhD, is a Clinical Associate Professor of Psychiatry, New York University (NYU) Grossman School of Medicine. Nikhil A. Patel, MD, MPH, MS, is a Clinical Fellow of Child and Adolescent Psychiatry, NYU Langone Health. Ashvin Sood, MD, is a Resident Physician, NYU Langone Health. Stephanie X. Wu, BA, is a Medical Student, NYU Grossman School of Medicine. Naomi M. Simon, MD, MSc, is a Professor of Psychiatry, NYU Grossman School of Medicine. Rachel Podbury, BPubHealth&HealthProm, is a Senior Project Manager NYU Langone Health. Ariela Vasserman, PsyD, is a Clinical Assistant Professor of Psychiatry, NYU Grossman School of Medicine. Rachel A. Caravella, MD, is the Interim Director, Consultation-Liaison Psychiatry Service, New York University Langone Health; and a Clinical Assistant Professor of Psychiatry, NYU Grossman School of Medicine. Yona Silverman, MD, is a Clinical Assistant Professor of Psychiatry, NYU Grossman School of Medicine. Randi Pochtar, PhD, is a Clinical Assistant Professor of Child and Adolescent Psychiatry, NYU Grossman School of Medicine. K. Ron-Li Liaw, MD, is the Director, KiDS of NYU Foundation Center for Child and Family Resilience, Sala Institute for Child and Family Centered Care; the Chief of Service, Child and Adolescent Psychiatry, NYU Langone Health/Bellevue Hospital Center; and a Clinical Associate Professor of Child and Adolescent Psychiatry, NYU Grossman School of Medicine. Marra G. Ackerman, MD, is a Clinical Assistant Professor of Psychiatry, NYU Grossman School of Medicine.

Address correspondence to Amanda M. Spray, PhD, Department of Psychiatry, NYU Grossman School of Medicine, One Park Avenue, 8th Floor, New York, NY 10016; email: Amanda.Spray@nyulangone.org.

Grant: Ashvin Sood received funding for earlier, selected house staff support groups from the Committee of Interns and Residents, Bellevue Chapter.

Disclosure: Naomi M. Simon receives royalties from Wolters Kluwer; consults for Vanda Pharmaceuticals Inc, Massachusetts General Hospital Psychiatry Academy, Axovant Sciences, Springworks, Praxis Therapeutics, Aptinyx, and Genomind; serves as Deputy Editor for the journal Depression and Anxiety; and does contracted research for the American Foundation for Suicide Prevention, the Department of Defense, Patient-Centered Outcomes Research Institute, Highland Street Foundation, National Institutes of Health, and Janssen; receives payments from Wiley-Blackwell for work as the deputy editor of the journal Depression and Anxiety; and her spouse/partner owns stock in G1 Therapeutics. The remaining authors have no relevant financial relationships to disclose.

K. Ron-Li Liaw and Marra G. Ackerman contributed equally to this article and should be considered equal authors.

The authors thank the additional members of the Frontline Staff Support Taskforce including William G. Frankle, MD, Eriko Dunn, PhD, Meera Balsubramaniam, MD, Aaron Pinkasov, MD, and Carole Filangieri, PhD; support group leaders including Christin Drake, MD, Gabriella Safyer, MD, Joy Choi, MD, Rachel Guerrero, PhD, Joshua Scott, PhD, D. Harshad Bhatt, MD, Deepti Anbarasan, MD, Siddhartha Nadkarni, MD, Victoria Dinsell, MD, Aimy Rehim, MD, Aneil Shirke, MD, Jane Rosenthal, MD, Joanna Wolfson, PhD, Hope Mowery, PhD, Lauren Fiedler, PsyD, Mary Rzeszut, LCSW, Charu Sood, PsyD, Kelly Yu, PhD, Lia Okun, PhD, and Kathleen Isaac, PhD; leadership of the Department of Psychiatry including Charles Marmar, MD, and David Ginsberg, MD; members and leadership of the Department of Child and Adolescent Psychiatry including Helen Egger, MD, Glenn Hirsch, MD, Jeanne Greenblatt, MD, Becky Lois, PhD, Marnie Higlett, Yamalis Diaz, PhD, Hanifa Cavanna, MSN, RN, Lauren Knickerbocker, PhD, Adam Brown, PsyD, Erica Willheim, PhD, Ross Goldberg, MD, Ashley Ford, MD, Lambert Lewis, MD, Tia Mansouri, MD, Jason Chavarria, and Lily Chin; members of the HSMH team including Julie Ackerman, PhD, Jessica Kraus, PhD, Annie Robinson, MS, Robert Mazgaj, MD, Andrew Chansky, MD, and Nina Wylonis, MD; members of the C-L team including Allison Deutch, MD, H.K. Eastburn, MS, RN-BC, PMHNP, Emily Fries, RN, and Adam Kozikowski, PMHNP-BC; and members of NYU Langone Health including Kathleen DeMarco, MSN, NE-BC, CPHQ, RN, Taryn De Sio-Garber, Isabelle Marcelin, MD, Paraskevi Noulas, PsyD, Mike Mainiero, Patricia Sotelo, Daniel Caceres, Rashmi Dwivedi, Mathew Watts, and Debra Forte.

10.3928/00485713-20200613-01

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