Nurses, physicians and allied professionals answer a vocational calling when entering healthcare. But even the most passionate healthcare workers (HCW) lose their “joy in work” when they have little control over their work or are missing human connections in the workplace. HCW burnout was at a record high in Canada even before the COVID-19 pandemic began a year ago.
Joy in Work is the oft-discussed – but oft-elusive – “fourth aim” described by the Institute for Healthcare Improvement (IHI) in its recognized framework, The Quadruple Aim. This term can be distilled to mean a positive work environment where HCWs feel physically and psychologically safe and can experience the meaning and purpose that drew them to their profession in the first place. The Joy in Work approach suggests that HCWs who feel joy at work invariably provide higher-quality care for patients, even during times of duress. Even during a pandemic.
At Trillium Health Partners, a large community hospital in Mississauga, we recognized the need to build elements of the joy in work into our newest pandemic service: our COVID wards.
HCWs were nervous at the beginning of the pandemic, given the minimal published research on the behaviour and impact of the virus. “I have been a nurse for 22 years,” shared Shelly Petruskavich, director of professional practice at the hospital, “and this was the first time that I saw a real fear in healthcare.”
The leadership team knew that without creating a safe environment for our HCWs – both physical and psychological – we would not achieve the goals we had set for the newly implemented COVID wards: Intensive Care Unit (ICU) avoidance; absence of nosocomial viral spread; staff and patient safety; and patient and family satisfaction.
Inpatient COVID populations are complex and acute. The inter-professional teams would need to work together closely, responding quickly and effectively with an unwavering focus on infection prevention and control practices (IPAC).
Staff for the new wards were recruited from the top clinical talent across the hospital’s acute platform. With the constantly evolving knowledge about the virus, practice standards of care were established with the most current available information and supported with toolkits and procedures to reinforce the skill and judgement of providers. Most importantly, we created the infrastructure needed to enable a strong, inter-professional care team. The team was willing to learn together and be engaged in changes needed to respond to new learnings.
“We stayed true to the foundations of care,” explained Petruskavich. “Everyone on the team knew what each patient’s needs were and how, as a clinician and a team, to move each patient through to discharge. We were in continuous improvement mode every day.”
Daily communication protocols were adhered to, anchored by bedside transfer of accountability with the entire team, discharge-focused bullet rounds with internists and quality improvement huddles. A standardized care pathway and order set formed the scaffolding for more accurate length-of-stay estimates along with a more seamless road for patient discharge. Standard practices to support patients and their families were developed to facilitate their engagement in care planning and the journey to post-acute care. Educational materials also were developed to support orientation on admission and discharge.
Anticipating the need to scale COVID wards to other units during the pandemic, a toolkit was developed by the Medicine and Professional Practice leaders at the hospital, with tools and standard operating procedures for everything from opening a COVID ward to running every aspect of it, including PPE supplies.
Nurses had positive things to say to colleagues in other wards. “At first, everyone was terrified,” recalled Andrea Wood, registered nurse and a clinical lead on a COVID ward. “And then we had more and more success stories. Patients whom we didn’t think would pull through got better and started being discharged home. It really boosted everyone’s morale. We felt pride in our care.”
And the internists working shifts on the COVID wards had nothing but praise.
“For the first time in my career, I experienced true, inter-professional team rounding,” explained Amir Ginzburg, an internist at the hospital and the senior vice president of Quality, Practice and Medical Affairs. “We built camaraderie while providing better care to patients during a very challenging time. I walked away from each shift with a sense of accomplishment.”
Preparing staff through education, and supporting them on an ongoing basis, was critical. A staff readiness checklist was created to ensure nursing and allied team members felt confident beginning their deployment. IPAC specialists were readily available to address the PPE concerns of the team and provide infection prevention coaching.
Continuous improvement through rapid quality improvement cycles (plan-do-study-act) was practiced from the wards’ inception. The inter-professional team was fully engaged, sharing ideas and trialing changes to workflow and model of care in the early days to improve care processes. One of the outcomes was ICU avoidance from the new COVID wards. During the first wave of the pandemic, we found that compared to influenza and respiratory medicine patients from the same period in 2019, ICU admission rates were lower, 14.9 per cent compared to 18.5 per cent. For every age group, despite longer average total length of stay in hospital, COVID patients cared for on a COVID ward were less likely to deteriorate and require ICU admission.
“We had the opportunity to practice medicine the way we always wanted to practice,” said Dhanjit Litt, internist and chief of medicine at the hospital. “We rallied around a common vision, during a truly historic time in health care, and we made a difference.”
The inter-professional care team extended beyond nursing and medicine. Allied health professionals were a part of the core team: physiotherapists, occupational therapists and pharmacists. The extended team included speech and language pathologists, pharmacists, social workers, dieticians and spiritual care. All professionals were treated as important equals in the care of patients and the model of care advanced over time to optimize all team members.
Within the psychological safety of a positive inter-professional care team, staff felt supported and empowered. As a result, we postulate that performance and practice were better than on the average acute care hospital ward.
At the root of the success was a deep commitment to cultivating a joy in work amidst fear and despair. The leadership team set, and stuck to, a set of guiding principles to “develop and support a psychologically safe and engaged team.”
Tools to support psychological safety were developed, including a checklist for use at end-of-shift that guided staff members to take a moment and acknowledge the good and the difficult in the day; to check in on colleagues to see how they are coping; to ask for help and support when needed; and to rest and recharge after every shift.
Far from being a magnet for anxiety and despair, word got around the hospital about how great it was to work on the COVID wards.
“Our staff are asking to go back and work on a COVID ward again!” exclaimed Petruskavich.
Thanks to the hardwiring of practices within our COVID wards, the hospital was able to rapidly pivot to deal with the pandemic’s second wave. Regular medicine wards were once again shifted to address the influx of COVID patients and finding staff to work on the wards was easier this time around.
“Now, we are a COVID unit again,” said Anmolpreet Kaur, a charge nurse on a COVID ward. “This time, we know what to expect. Everyone is prepared. Everyone knows what to do. It has been a very smooth transition because we know that we will work together to adapt.”
Increasingly, workplaces are realizing the need to urgently address the mental health and well-being of their HCWs. We hope in earnest that this trend continues well beyond the pandemic.