Now is the time to redefine safety in healthcare

Now is the time to redefine safety in healthcare

Author
Bridget Duffy, MD
Date Published

Throughout the COVID-19 pandemic, frontline healthcare workers around the globe provided exceptional patient care despite fears of infection, shortages of staff and supplies, and the frustrations of trying to treat a novel pathogen. At the same time, COVID-19 exposed deep and systemic risks to healthcare team members’ physical, psychological, and emotional safety driving burnout to crisis levels. Burnout is arising not only from the emotional toll of caring for sick and dying patients, but COVID-19 also exposed flaws in our health system and infrastructure. Systemic inequities were amplified as COVID-19 disproportionately impacted people of colour and Indigenous community members. A renewed and expanded definition of safety is needed to restore trust, recruit, and retain individuals to the healing professions, enable care to be provided with the greatest skill and humanity, and ensure the well-being of every person working in healthcare. In collaboration with CEOs of a diverse group of health systems in the United States, the author drafted a Declaration of Principles that expands the definition of safety to include safeguarding psychological and emotional well-being of team members, promoting health justice by declaring equity and anti-racism as core components of safety, and ensuring physical safety, which includes a zero-harm program to eliminate workplace violence, both physical and verbal. We invite Canadian leaders to embrace these concepts and commit to supporting team member safety and well-being as an essential foundation for public health. We must humanize healthcare and the time to act is now.

Introduction
Throughout the COVID-19 pandemic, healthcare workers around the globe exhibited courage, compassion, and resilience in the face of an invisible enemy. Frontline team members have come to work and provided care for patients despite fears of infection, shortages of staff and supplies, and the frustrations of trying to treat a novel pathogen. They have held the hands of the sick and the dying, and orchestrated video calls for final farewells between patients and their loved ones who were not allowed to visit in person. Day after day, care team members face the reality that just doing their job means they could place their own safety and the safety of their families at risk.

All of this is happening on top of a system that was already struggling with access, financial strains, and clinician burnout before the pandemic. The tug between public and private sector healthcare services, with their differences in wages, schedule flexibility, and autonomy, was already putting pressure on Canada’s critical public health sector. And differences in healthcare access and outcomes for the most vulnerable and those with historic reason to distrust government services were only heightened by COVID-19.

These and other challenges are taking a toll on frontline healthcare team members, from doctors and nurses to environmental services and food services professionals. A study conducted at the University of New Brunswick found an elevated level of depressive symptomology among Canadian healthcare workers1 substantiating other research that found healthcare professionals working in the first wave faced pandemic-related stressors including depression, anxiety, and Post-Traumatic Stress Disorder (PTSD).2-5

If Canadians do not act collectively and swiftly to redefine and restore safety and well-being for healthcare team members—at the local, provincial, and national levels—our healthcare system will be the hardest hit casualty of the COVID-19 pandemic.

Discussion
COVID-19 exposed deep and systemic risks to healthcare team members’ physical, psychological, and emotional safety driving burnout to crisis levels. In a UBC study of 302 internal medicine physicians working at Vancouver General Hospital and St. Paul’s Hospital from August to October 2020, more than two-thirds experienced burnout. Rates were highest among female physicians, younger physicians, and visible minority physicians.6 This is even higher than levels of burnout among US physicians.7

The same study exposed burnout levels among nurses and allied health professionals at levels of 78% and 73%, respectively. Issues such as forced overtime, violence, and poor working conditions are causing new nursing graduates to leave public sector positions for private sector jobs in which they have more control and better pay.8

Burnout is arising not only from the emotional toll of caring for sick and dying patients struggling against a novel pathogen for which treatment protocols are still emerging. COVID-19 also exposed flaws in our health system and infrastructure. Not only did we experience shortages of Personal Protective Equipment (PPE) and expose supply chain inadequacies, we also discovered that our definitions of PPE (gowns, gloves, and masks) failed to ensure that frontline care team members could communicate effectively with their teammates and with patients and families without risking infection. That meant more contamination risk in donning and doffing PPE that hands-free communication tools could have prevented.

We also saw broad systemic inequities exposed as COVID-19 disproportionately impacted people of colour and Indigenous community members, both from a mortality and economic perspective. These community members often fill essential work positions, live in multi-generational households, or lack access to resources such as clean water that leave them more vulnerable to infection.9,10

Action
The challenges outlined above are not unique to Canada. In the United States, my team and I are collaborating with CEOs of health systems across the country and other industry leaders to spark a movement to redefine safety in healthcare to include health justice and make psychological and emotional safety as important as the physical safety of healthcare team members around the globe.

After watching my colleagues suffer through patient surges, limited PPE, visitor restrictions, and death after death, I felt a sense of urgency to do more to protect the physical, psychological, and emotional safety of the nation’s healthcare workforce. With support from the leadership team at Vocera, we started a movement to galvanize people and organizations around this mission. I reached out to a few influential CEOs from my personal contacts. They were immediately on board and recommended other CEOs to join. I offered to put resources toward building a Coalition, creating a Declaration of Principles, and driving a plan of action. The result was 10 founding members—a diverse group of health leaders representing: clinical and operational backgrounds; a mix of genders, races, and ethnicities; institutions including academic medical centres, public safety net institutions, for-profit and non-profit organizations; and systems span urban and rural geographies.

To create the Declaration of Principles, my team and I conducted in-depth interviews with executive partners identified by the CEOs as having responsibility for team member well-being. Roles spanned medicine, nursing, quality, HR, technology, and team member experience. Some of the executive partners are still involved in frontline caregiving practice. Based on those interviews, we drafted the Declaration and then worked with the executive partners and convened the CEOs for collective feedback until all agreed on a final version.

We believe a renewed and expanded definition of safety is needed to restore trust, recruit, and retain individuals to the healing professions, enable care to be provided with the greatest skill and humanity, and ensure the well-being of every person working in healthcare.

The Declaration expands the definition of safety to include safeguarding psychological and emotional well-being of team members, promoting health justice by declaring equity and anti-racism as core components of safety, and ensuring physical safety, which includes a zero-harm program to eliminate workplace violence, both physical and verbal. This Declaration extends to all team members, from frontline clinicians to environmental services workers and back-office employees.

We are working with the Institute for Healthcare Improvement and others to turn that Declaration into action so that we can ensure that healthcare team members are safe at work. If we don’t do this, we will face an exodus of healthcare talent and compassion that will cripple our ability to care for patients.

As a physician whose career has been centred on making sure every human being has access to humane, compassionate, and competent care I invite you, my Canadian colleagues, to embrace this movement and join us to broaden the definition of workplace safety to elevate team member safety and well-being as a top strategic priority so that the lives of healthcare workers around the globe will be improved. I believe this is the most important issue that healthcare will face over the coming decade.

Getting started
Canadian leaders can get a start on protecting and connecting team members even as the delta variant brings a new surge of patients and challenges. To get started:

1. Rebuild trust. The pandemic has shaken the trust of team members—trust that they will be safe at work, and that they will get the support and resources they need. Leaders in the health services, government, and community need to focus on rebuilding that trust.

2. Redefine and recommit to team member safety. The pandemic amplified pre-existing issues such as injustice and workplace violence—and it introduced new safety concerns around infection and death. We are working on a new definition of team member safety that encompasses safeguarding team members’ emotional and psychological safety, promoting health justice, and protecting their physical safety. We need all leaders, as well as national and local governments to commit to healthcare team member safety and well-being or we will face a crisis in healthcare that will last for years if not decades to come.

3. Expand the definition of PPE to include communication tools. When team members had to adopt new infection prevention approaches to protect themselves and other patients from COVID-19, too many of them found that donning PPE left them cutoff from colleagues. They risked infection by using devices like cell phones in contaminated areas. We need to expand the definition of PPE to include communication technology so no team member has to risk contamination to communicate with their peers.

4. Embrace human-centred leadership. Put simply, human-centred leadership is leading people with humanity. More specifically, it is leadership that explicitly supports team members’ cognitive, emotional, physical, and spiritual well-being so they can maximize their human and healing potential.

5. Reimagine human connection. One of the lessons of the pandemic is that we need human connection to thrive. Never did we imagine a time when we would strip loved ones away from each other upon admission to the hospital. When in-person connection is not possible, we learned that purpose-built technology is essential to keep patients connected with their loved ones and their care teams. We need to reimagine human connection so that essential connections can happen via technology without disrupting nursing workflows or creating burdens on team members or loved ones.

Conclusion
COVID-19 is a novel virus. Early on, we needed to determine how it was transmitted requiring the adjustment of process, technologies, and physical environments to mitigate infection spread. We learned our supply chains need to be more resilient to a global crisis to ensure that we have adequate access to personal protective equipment to keep members safe and to demand communication technologies be included so team members don’t risk contamination for communication.

We initially lacked treatment protocols so care team members who professionally identify with helping others were unable to help, unable to support healing of their patients, feeling isolated, and helpless. We learned that healthcare teams need greater emotional and psychological support than we had traditionally provided because of the inherent trauma in the system heightened by the pandemic.

There are countless stories of healthcare workers being heroes during the COVID-19 pandemic. Overcoming their own fear, we have seen how their dedication to their patients meant going into COVID isolation wards over and over again not sure how much they were endangering themselves or their families.

We have heard about nurses creating video calls between dying patients and their families and even more heartbreaking stories of nurses holding and comforting their patients so that they need not die alone. Healthcare team members have carried an enormous emotional burden as they experienced unprecedented levels of death and bearing witness to the passing of patients. But all this has taken a tremendous toll on healthcare workers.

We must ensure that we never are unprepared for future pandemics. We must ensure that we not miss this opportunity to redefine healthcare safety under the three pillars: psychological and emotional safety, physical safety and health justice, and strive for meaningful change. We must humanize healthcare. If we do not, we will witness an exodus of caring, compassionate, and exhausted team members who leave their profession and their calling. The time to act is now.

Declaration of principles
We witnessed selfless acts of courage, care, and compassion from our nation’s healthcare team members during the COVID-19 pandemic. Safety is at the heart of protecting our healthcare workforce, which means being safe from physical and emotional harm and free from all forms of inequity and racial injustice. Workplace violence, burnout, and disparities existed long before the outbreak of COVID-19. The pandemic has, however, exacerbated the factors contributing to workplace violence, created an environment of unprecedented stress, and exposed the impact of systemic inequities and racial injustice on the well-being of healthcare team members.

We believe a renewed and expanded definition of safety is needed to restore trust, recruit, and retain individuals to the healing professions, enable care to be provided with the greatest skill and humanity, and ensure the well-being of every person working in healthcare. We commit to:

Safeguarding Psychological and Emotional Safety

1. Investing in processes and technologies that reduce emotional and cognitive burdens on team members and restore human connection to the healthcare experience.

2. Creating practices and policies that advance open communication between team members and leaders so people feel safe to speak up, bringing their full selves to work.

3. Providing resources to assess and support team members’ emotional, social, and spiritual health, and alleviating the stigma and deterrents to seek support.

Promoting Health Justice

1. Declaring equity and anti-racism core components of safety, requiring explicit organizational and health equity-focused policies and practices to advance diversity, inclusion, and belonging.

Ensuring Physical Safety

1. Implementing a zero-harm program for care team members to eliminate workplace violence, both physical and verbal, whether from team members, patients, families, or community members.

2. Ensuring that all healthcare organizations can procure and provide evidence-based personal protective equipment, technology, tools, and processes that healthcare team members need to do their jobs safely and care for patients.

Our ability to build trust and provide the care patients require and deserve is dependent on the physical and emotional safety and the just treatment of all those who provide or support patient care. We commit ourselves to this new definition of safety to ensure that no healthcare team member will have to sacrifice their personal safety, health, identity, or well-being to do their jobs and care for patients.

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