COVID-19 has brought enormous stresses to health care workers that not only strain their mental health but also threaten the quality of care they can deliver.
Decades of research in human factors and industrial and organizational (I/O) psychology have shown that exhaustion, frayed emotions, and staffing problems can harm teamwork and impair decision-making.
Between May and October 2020, before the bulk of the winter explosion in COVID-19 cases and the subsequent delta variant surge, health care workers were already reporting high levels of stress, fear, and overwork. A survey of more than 20,000 U.S. health care workers in this time frame found that 43% were suffering from work overload, 38% reported anxiety and depression, and 49% felt burned out (Prasad, K., et al., EClinicalMedicine, Vol. 35, 2021).opens in new window Staffing shortages have been an ongoing problem throughout the pandemic, with hospital systems in hot spots posting hundreds of open positions on any given day, especially for nurses (Goldstein, A., The Washington Post, Aug. 12, 2021opens in new window). Under such stressful conditions, errors creep in. Coordination of patient care suffers. Doctors may even fail to diagnose common conditions with symptoms overlapping those of COVID-19, a kind of tunnel vision many emergency department doctors have taken to calling “COVID brain.”
The reoccurring surges of coronavirus hospitalizations have been like a crucible for many hospital workers, said I/O psychologist Scott Tannenbaum, PhD, who heads a consulting firm called the Group for Organizational Effectiveness. There is less uncertainty now about how best to treat the disease, but many health care workers are exhausted. “Think about their batteries still being drained,” Tannenbaum said. “This is just like a second wave washing over them.”
Fortunately, research suggests ways to lessen the impact—and how to build resilience in teams moving forward.
“We have evidence-based guidance that health care teams and their leadership can use and apply,” said Eduardo Salas, PhD, an I/O and human factors psychologist at Rice University in Houston who coauthored the book Teams That Work: The Seven Drivers of Team Effectiveness (Oxford University Pressopens in new window, 2020) with Tannenbaum.
Stress, strain, and teamwork
Tranquility has been in short supply for hospital workers throughout the COVID-19 pandemic. And psychological researchers who study health care teams have been kept out of hospitals by the need for infection control and limited in their ability to observe teams during the pandemic, Salas said. But evidence from earlier pandemics reviewed by a team led by psychologist Raffaella Calati, PhD, of the University of Milano-Bicocca in Milan, Italy, raised red flags. In studies of health care workers in outbreaks of SARS-1, Ebola, and other infectious diseases, stress, anxiety, and depressive symptoms and post-traumatic stress responses were common (Current Psychiatry Reports, Vol. 22, No. 8, 2020opens in new window). Particularly at risk were health care workers with high levels of contact with infectious patients, workers with a lack of confidence in infection control procedures, and workers who had to quarantine during the outbreak.
A weekly survey of clinicians at seven U.S. emergency departments and urgent care facilities over 6 weeks early in the COVID-19 pandemic led by I/O psychologist Thomas Britt, PhD, of Clemson University, found that hours worked, COVID job demands, and personal demands each raised mental health strain for clinicians independently. A combination of long hours and high personal demands (such as lack of child care) magnified each other, sending strain skyrocketing (Applied Psychology, online first publication, 2020opens in new window).
Stresses that damage teamwork come in three categories, according to a recent review of the literature: stresses intrinsic to the job (such as workload, understaffing, and time pressure), stresses intrinsic to the organization (role ambiguity and interpersonal conflict), and stresses related to work-life balance (family needs) (Razinskas, S., & Hoegl, M., Journal of Organizational Behavior, Vol. 41, No. 2, 2020opens in new window).
The pandemic is a magnifier for all these sources of stress, said Tannenbaum. Hospitals are inundated with patients, front-line workers have taken sick or been quarantined, and staffing problems have increased the workload for everyone.
Under these conditions, team efficacy can break down. “We know that under periods of stress and pressure that task vigilance can decline, and focus gets narrowed,” Tannenbaum said.
This has manifested as “COVID brain,” during the pandemic, said Pat Croskerry, PhD, MD, an emergency department physician who also trained as a psychologist and studies decision-making in medicine at Dalhousie University in Nova Scotia, Canada. Because of the all-consuming nature of the coronavirus, doctors are subject to availability bias when making diagnoses. In one case Croskerry was familiar with, a young man called the local emergency department health line complaining of a fever. He was sent to the COVID clinic, tested, and sent home. Soon after, he worsened and returned to the clinic. He was nearly sent home again, Croskerry said, but the staff decided to send him to the emergency department for further assessment. There, he was diagnosed with meningitis, which may have been caught on the first clinic visit if COVID weren’t at the forefront of everyone’s minds, Croskerry said.
“You can see how the fixation on COVID was suppressing the thinking required to allow that some other things were happening,” Croskerry said.
This kind of rigid thinking can also occur when the emotional environment of a workplace starts to fray. Just witnessing rudeness in the workplace can increase the risk of anchoring bias, in which someone overly relies on limited information or initial impressions when making a decision rather than sufficiently exploring all available information.
This type of anchoring bias seems to occur because experiencing or witnessing rudeness causes a state of highly arousing negative emotion, which then leads to a sort of tunnel vision: People fixate on just a few salient bits of information and miss the big picture. In one study of medical residents who were taking part in a patient care simulation, residents who witnessed rudeness between two other coworkers in the exam room before the simulation began were almost 15 times more likely to get “stuck” on a diagnosis that was originally hinted at for their patient but that was ultimately incorrect. The accurate diagnosis was life-threatening, so this mistake could have deadly consequences in a real treatment environment (Journal of Applied Psychology, online first publication, 2021opens in new window). “If you’re walking through the forest and you happen to see a tiger, you naturally narrow your attention to the tiger and ignore everything else,” said study lead author Binyamin Cooper, PhD, a postdoctoral fellow in organizational behavior and theory at Carnegie Mellon University. “While not a life-or-death scenario, rudeness works in much the same way.”
Stress may make coworkers in hospitals snappy and irritable. Health care workers have also reported that patients themselves can be a source of rudeness. Some patients believe COVID-19 to be a hoax, and there have been reports of verbal abuse from patients who refuse to believe they are infected.
Finally, the pandemic has scrambled work schedules and brought in new team members who aren’t familiar with working together but must collaborate in the high-stakes, life-and-death environment of emergency departments and intensive care units. How well teams handle this upheaval likely determines how well they perform, Salas said. “The number one killer of teamwork in any kind of situation, in any kind of industry that I have studied, is the lack of clarity of roles and responsibilities: who is supposed to do what, with whom, under what circumstances,” he said.
Tools for supporting teams
There are real limitations to resources in a pandemic that seems determined to drag on. Because of the highly transmissible delta variant combined with low vaccination rates, some areas have seen spikes in hospitalizations in summer and fall 2021 that rival or exceed those of previous coronavirus waves.
However, hospital administrators are cognizant that their teams are at risk of burnout, Salas said, and many have reached out to him for advice. He and his colleagues have published two journal articles summing up the evidence and best practices for protecting teams in times of stress. One is a comprehensive look at decades of research (American Psychologist, Vol. 76, No. 1, 2021opens in new window) and the other is a tip sheet of recommendations on ways to protect teams from burnout (BMJ Quality & Safety, Vol. 30, No. 1, 2021opens in new window).
The first of these recommendations is to make sure that teams recognize wins even in moments when they’re exhausted and struggling to save dying patients. Focusing on successes is a way to build collective efficacy, or the shared belief that a group can do good work and make a difference. Studies stretching back decades have found that perceptions of recent team performance feed into this belief and that teams with a higher sense of efficacy perform better (Watson, C. B., et al., Personality and Social Psychology Bulletin, Vol. 27, No. 8, 2001opens in new window).
Leaders should also work to ensure that teams develop what’s known as a “shared mental model,” which is a team’s common understanding of its scope and the roles of its team members. The pandemic has created a lot of ambiguity both within health care workplaces and in general, said Frank Drews, PhD, a professor of cognitive psychology at the University of Utah who studies medical decision-making. “If you have this high level of situational ambiguity, this is always bad for individuals,” he said. “But it is worse for teams.”
Ambiguity can play out in hospital personal protective equipment (PPE) protocols, in quarantine rules, and in shifting vaccine requirements, all of which make work in a health care setting more complicated. Especially relevant to teams is ambiguity in staffing. Unfamiliar faces on a team can challenge that team’s shared mental model. Newcomers may not know who to ask for help, and a team may lose its institutional knowledge about how to run most smoothly.
The crucial tool to build up a shared mental model is prebriefing, said Salas. A team prebrief sets up expectations for a shift, allows people to ask questions and clarify roles, and addresses any likely challenges the team might experience that day. Prebriefing can benefit any team, but it may be particularly helpful for teams with rotating membership, as is often the case in health care (Fiore, S. M., et al., Theoretical Issues in Ergonomics Science, Vol. 4, No. 3–4, 2003opens in new window).
Debriefing after a case or a shift is also important for building shared mental models and improving performance. A 2012 meta-analysis led by Tannenbaum found that teams that engage in debriefs outperform other teams by 25%, on average (Human Factors, Vol. 55, No. 1, 2013opens in new window).
Prebriefings and debriefings are also opportunities to promote mutual monitoring among teammates. Successful teams engage in what is called backup behavior—noticing when individual members are struggling and stepping in to help. Examples might be filling in for a team member who needs a break or actively monitoring who is overloaded and who is underused and redistributing the workload accordingly. This kind of helping behavior, though, isn’t possible without trust and psychological safety. In a psychologically safe team, members feel comfortable asking for help, speaking up when they have questions, and bringing up problems. “The team lead plays a very important role in instilling the feeling of psychological safety within the team because they set the norms for how people treat one another,” said Laurie Weingart, PhD, a professor of organizational behavior and theory at Carnegie Mellon.
Employers can also support teams from the top down by helping alleviate work-life conflicts and by remembering to recognize support staff, according to Salas, Tannenbaum, and their colleagues. During the pandemic, some hospitals have helped their employees find temporary housing to reduce their risk of bringing the virus to their families, according to the American Hospital Associationopens in new window. Others have collaborated with community groups to bring food donations into hospitals for workers grinding out long shifts. Some have set up meditation rooms or increased employee access to mental health professionals.
Preparing for future crises
Though the end of the pandemic is still in the distance, researchers are looking toward the future—including how to help teams bounce back after the crisis. The most resilient teams engage in a three-part process that I/O psychologists call “minimize, manage, and mend,” Tannenbaum said.
“Minimize” refers to anticipating and preparing for future challenges by using lessons learned from hard experience. This might involve making a contingency plan for staffing in the face of future COVID waves, for example. “Manage” refers to the role of leadership in taking action to meet challenges as they emerge. One example of management might be monitoring employee stress as hospitalizations rise to head off problems before they deepen. Finally, “mend” refers to actions taken after the situation improves. A resilient team mends by conducting debriefings, acknowledging team members’ hard work, and addressing any concerns about what might have gone wrong in the heat of a crisis.
Psychologists will need to observe and assess teams once COVID-19 infection rates level off. Salas said he and his team were just starting to return to Houston-area hospitals when hospitalizations spiked again, stymying their research plans. There is also much to do on the intervention and implementation front. For example, a recent review of research on interventions meant to improve psychological safety and speaking up found mixed results (O’Donovan, R., & McAuliffe, E., BMC Health Services Research, Vol. 20, No. 1, 2020opens in new window). The researchers concluded that future interventions should target multiple levels of organizations and that health care workers should be involved in the development of programs. Teamwork training should also be woven throughout medical education, Tannenbaum said. He and his colleagues are working with a medical school to embed teamwork skills such as multidisciplinary coordination and communication in regular class exercises.
The reality of health care, Croskerry said, is that hospitals have increasingly moved toward a “lean” operating mode that slashes extra capacity and staff. This saves money in the good times but damages resiliency in the bad. There are some broad policy efforts to strengthen team resiliency among health care workers. For example, the Merit-based Incentive Payment System, which attempts to use quality-of-care measures to determine what Medicare pays providers, gives a bonus to those who participate in the Agency for Healthcare Research and Quality’s Team-STEPPS program, which was developed by I/O psychologists to improve team efficacy. Still, the pressures on health care workers are unlikely to ease significantly. “At the end of the day in medicine, the problem is your resources are limited,” Croskerry said. “Nobody says, ‘We understand you’re having an epidemic, so we’ll send you an extra 10 staff to deal with the extra challenges and we’ll make your shifts shorter.’”
Given that reality, psychologists should brace for health care workers struggling with post-traumatic stress symptoms and burnout for years to come, Croskerry said: “We may find a considerable toll down the road.”
