This section applies the organizational resilience framework to the hospital ICU context, to provide a more nuanced illustration of the potential impact of a stoic approach to healthcare worker support (i.e., absence of leadership support for emotional distress during COVID-19), on organizational resilience, patient safety and staff retention, during and beyond the pandemic. The application in turn, helps to develop recommendations for HCOs to overcome these challenges, ensure patient safety, and retain a resilient healthcare workforce during and beyond the pandemic.
Potential Impact of the “Stoic Approach” on Resilience, Patient Safety, and Staff Retention in ICUs
In areas most affected by pandemic, hospital ICUs are experiencing rapid changes in practice environments to meet the pressures of increased demands for ICU beds, with limited resources, e.g., conversion of observation units into makeshift ICUs, use of “float-pool” (non-ICU) nurses to function as ICU nurses, and in some cases, placing two patients on a single ventilator, all within the context of acute shortage (limited supply) of essential PPE [6
]. In this scenario, frontline ICU nurses are faced with having to implement dynamic tradeoffs and workarounds to patient care processes on a daily basis, to resolve problems and ensure patient safety under challenging conditions [22
For example, during COVID-19, a number of ICU patients are placed on medications (such as fentanyl, propofol, and pressor drugs) that require titration (dose adjustment) on an ongoing basis, sometimes every 5, 10, or 15 mins, to ensure effective dosage and prevent side effects. Drugs requiring titration are typically administered intravenously (IV). Under normal circumstances, drug titration requires frontline nurses to enter and exit the patient’s room multiple times within the span of an hour, to adjust dosage on the patient’s IV bag, as needed. However, amidst acute PPE shortages during the COVID-19 pandemic, the higher the frequency of entering and exiting patient rooms, the greater the risk of exposure to the virus for nurses (healthcare workers), which, in turn, increases their risk of spreading the virus to other coworkers, patients, and their families. Therefore, to mitigate their own risk of exposure amidst PPE shortages, ICU nurses are faced with having to identify innovative ways to titrate IV medications as often as needed, while limiting the frequency with which they enter and exit patient rooms. In this scenario, one potential solution could be to bring all patient IV bag-stands outside the patient rooms into the ICU hallway, to enable drug titration without entering patient rooms. However, the flip side to this dynamic trade-off, is that it poses an increased risk to patient safety by making it difficult to concurrently verify two unique identifiers prior to medication changes, one for the medication and one for the patient. Under normal circumstances, both medication and patient would be verified (scanned) every time dosage is changed, to ensure that the correct medication reaches the correct patient, in accordance with international patient safety protocols for prevention of medication errors [49
]. However, bringing the IV bag-stand outside the patient room makes it difficult for the patient to be concurrently verified. Additionally, since the IV bag-stands for all COVID-19 patients are placed next to each other in a common hallway, there is greater scope for confusion as to which IV bag-stand belongs to which patient, and hence, a higher risk of medication error by way of wrong medication to the wrong patient. To mitigate this patient safety risk prior to drug titration, an individual ICU nurse may call upon a nurse colleague in the ICU to double-check that the IV bag-stand being titrated, corresponds to the correct patient (which in turn, is an example of resilience on the frontlines that enables safe care to be provided in the ICU, despite obstacles during COVID-19).
However, this novel workaround developed by some ICU nurses would need to become standard protocol at the unit level to ensure safety of all patients receiving titrated medication on the ICU. For this to happen, the nurses who developed the workarounds need to be able to freely communicate their safety concerns and workarounds with their peers and managers. However, under rapidly evolving pressures created by COVID-19, a number of barriers to communication could arise due to trust issues. For example, regular ICU nurses who originally devised the workarounds may not trust float-pool (non-ICU) nurses new to the ICU to properly implement practice changes due to inadequate training. This lack of trust, in turn, may serve as a barrier to involving float-pool nurses in workarounds that have been designed to ensure patient safety amidst rapid process changes. Such a situation in turn, has the potential to increase variation in drug titration practices in the ICU, thereby increasing the opportunity for error and patient harm.
Similarly, communication between regular ICU nurses and managers could suffer due to lack of visibility of managers on the frontlines of ICU care. In the absence of any efforts from managers and senior hospital leaders to be present on the frontlines to understand the challenges, ICU nurses may feel betrayed by lack of emotional support from the leadership, for the unprecedented risks, pressures, and moral distress experienced on the frontlines during COVID-19. This lack of trust, in turn, has potential to considerably hinder communication related to patient safety between ICU nurses and managers. In the absence of systems for learning from individual error recovery (problem-solving) at the organizational level, resilience remains reactive (brittle) and restricted to the frontlines, with no way of advancing to team and organizational levels. This prevents the safety-benefits of novel workarounds (developed by some ICU nurses) from being applied to all patients on the unit. When resilience remains restricted to the individual level, it has potential to engender practice variations on the frontlines, thereby increasing the likelihood of unsafe practices and preventable errors.
Another example of a workaround implemented by ICU nurses to ensure patient safety during COVID-19, may be the use of written handoff sheets (to supplement verbal handoffs) during the end-of-shift clinical handover process. Owing to large volumes of high-severity patients and time constraints in the handoff process during COVID-19, regular ICU nurses may have worked to develop a template for written handoffs to supplement verbal handoffs during the shift handover process. The written handoff sheets, in turn, may be crucial for incoming nurses to gain a quick overview of patients’ medical histories (that are used to calculate patient risk scores). The risk scores, in turn, could be vital in helping nurses determine the priorities for patient care in the unit (e.g., in responding to changes in patient conditions resulting from medication changes), which, in turn, may be crucial for patient safety. However, owing to interpersonal trust issues (discussed earlier), the regular ICU nurses who devised these novel workarounds (written handoff templates), may refrain from sharing them with their peers (e.g., float-pool nurses) and their managers, thereby propagating a pattern of reactive (brittle) resilience on the frontlines that has no way of advancing to team and organizational levels. The latter in turn, has potential to increase the potential for practice variation, errors, and preventable deaths in the ICU.
As discussed earlier, being forced to witness unsafe practices, preventable errors, and large volumes of deaths on the frontlines, has potential to create chronic emotional and interpersonal stress, leading to exhaustion and cynicism, the classic symptoms of nurse burnout [4
]. Burnout resulting from chronic emotional distress in turn, has potential to result in high staff turnover and low retention not only during COVID-19, but beyond the pandemic period [2
]. For example, burnout may prompt healthcare workers to contemplate moving to a different HCO (e.g., ICU in a different hospital) or to a different setting of care (e.g., from the ICU to outpatient clinic practice) or to pursue an alternate career altogether, which in turn, could endanger society’s ability to sustain an adequate healthcare workforce to fulfill HCO operations in the short run, and to meet to public health needs in the longer run, should a similar pandemic recur in the future.
In summary, a stoic approach to healthcare worker support during the pandemic has the potential to severely restrict organizational resilience needed to recover from setbacks in patient care, by eroding trust and mitigating communication from healthcare workers to managers regarding safety concerns. The latter, in turn, has the potential to adversely impact patient safety, staff retention, and HCO operations, during and beyond the pandemic period.