IHI TOOL

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Conversation and Action Guide

to Support Staff Well-Being and

Joy in Work

During and After the COVID-19 Pandemic

Institute for Healthcare Improvement • ihi.org 2

Authors:

 Barbara Balik, EdD, MS, RN: Leadership Faculty, Institute for Healthcare Improvement;

Aefina Partners

 Kate Hilton, JD, MTS: Leadership Faculty, Institute for Healthcare Improvement;

Atlantic Fellows for Health Equity, George Washington University

 Kris White, MBA, RN: Aefina Partners

IHI TOOL: Conversation and Action Guide to Support Staff Well-Being and Joy in Work During and After the COVID-19 Pandemic

Institute for Healthcare Improvement • ihi.org 3

Purpose and Use of This Guide

During the coronavirus pandemic, health care organizations worldwide face unprecedented, high-

paced change. Health care leaders are working to support staff who are experiencing anxiety,

stress, and intense demands, especially with shortages of personal protective equipment (PPE),

concerns about personal and family risks from caregiving, delivering care that does not feel patient

centered, or loss of jobs. Leaders strive to address sources of staff anxiety and support well-being

and joy in work for the benefit of both staff and patient care.

The guide is intended to supplement and build on the IHI Framework for Improving Joy in Work1

and prompted by the April 2020 article, Understanding and Addressing Sources of Anxiety

among Health Care Professionals During the COVID-19 Pandemic.2 The guide includes actionable

ideas that leaders can quickly test during the coronavirus response, and which can build the

longer-term foundation to sustain joy in work for the health care workforce.

This resource is intended to help leaders guide conversations with colleagues to:

 Provide and elicit needed information and problem-solving to ensure staff well-being and the

best care possible

 Use this time during the COVID-19 pandemic to break unnecessary rules and build more

robust systems

 Tap into creative solutions identified by staff for both immediate needs and in an ongoing way

 Promote joy in work through healthy relationships and environments that support teams and

personal growth while diminishing, as much as possible, current and future stress

In using this guide, leaders are encouraged to use any opportunity to frequently communicate with

team members — using brief in-person huddles, electronic methods, or other approaches — to

promote staff well-being.1 Leaders are also encouraged to measure the impact of these

interventions on staff well-being and joy in work.3

Principles

The guide is designed to support health care leaders to:

 Work in partnership with all staff to contribute to the essential evidence-based needs for joy

in work (even in stressed times) that are required for healthy work environments:1

○ Physical and psychological safety

○ Meaning and purpose

○ Autonomy and control

 Address COVID-19 pandemic-related working conditions:4

○ Time pressure

○ Chaos and control

○ Culture, including trust in the organization, with an emphasis on communication and

information, cohesiveness, and values alignment with leadership

 Support staff with pandemic-related sources of anxiety1

IHI TOOL: Conversation and Action Guide to Support Staff Well-Being and Joy in Work During and After the COVID-19 Pandemic

Institute for Healthcare Improvement • ihi.org 4

Actionable Ideas to Test

This guide helps leaders get started quickly with conducting effective conversations, learning as

they go, and resolving issues that arise from such conversations. The tables that follow include

actionable ideas that leaders can quickly test during the COVID-19 pandemic and should support

sustained actions in alignment with a joy in work strategy after this pandemic subsides.

Physical and Psychological Safety

Hear Me: Listen and act on lived experience to understand and address concerns to the extent organizations and leaders are able

Do Don’t Steps to Try Sustain Joy in Work

Conduct frequent, brief well-being huddles (at the beginning and end of work shifts) to learn about current pressing issues

Listen, do not interrupt

Learn what is going well, not just problems

Acknowledge the complex emotions of delivering care in the face of uncertainty

Assume you know since concerns may vary by individual

Ignore the strengths and bright spots

Underestimate the learning required (and time it takes) to care for patients with COVID-19 in addition to other patients

 Ask: “What concerns do you have for patients, yourself, or the team?”

 Ensure you understand by confirming: “Here’s what I hear you saying — do I have that right?”

 Ask: “What do we still need to learn?”

 Ask: “What can we do together that would help right now?”

Continue well-being huddles to learn about current pressing issues for staff and focus on what matters most to care teams

Try different small tests to identify the huddle time, agenda, and facilitation structure that works for each group

Recognize that frustration and anger are part of the upheaval, not a personal attack

Promise to fix an issue when you may not be able

Make decisions that affect staff without their contribution

 Ask: “Are there steps we can take right now, as a team?”

 Ask: “How can we do this together?”

 Ask: “What can we stop doing? What makes no sense to continue?”

Empathize with staff when they encounter change and invite them to co-design it

Partner with staff in decisions that affect them

Recognize that individuals respond differently to stress, and fear may be expressed as concerns (e.g., with regard to PPE: “…not enough, wrong sort, too flimsy…”)

Judge or deny  Acknowledge and support: “No one has ever gone through what we’re dealing with now. Together as a team we will take steps that make sense for us and we’ll learn from others.”

 Listen to the concerns and the emotion — “It sounds like you are very worried right now” — then address the facts

Create a peer support and coaching network

Promote psychological safety

Be threatened by staff speaking up

 Affirm: “Never worry alone — if you have a question, so do others.”

 Ask: “What are you most worried about right now?”

Develop conversation skills that create a psychologically safe space for team members to share what matters and what’s getting in the way of more good days

Invite staff to share positive stories with one another

Assume people have a way to process their unique experiences

Ask: “What good thing happened today?”

Conduct both one-on-one and team conversations about “What Matters to You”

IHI TOOL: Conversation and Action Guide to Support Staff Well-Being and Joy in Work During and After the COVID-19 Pandemic

Institute for Healthcare Improvement • ihi.org 5

Physical and Psychological Safety

Protect Me: Reduce the risk of acquiring COVID-19 and/or being a transmitter to family

Do Don’t Steps to Try Sustain Joy in Work

Be fact-based Make things up just to have an answer

Reassure and inform:

 “We have X days’ supply of PPEs on hand.”

 “Here’s what we’ve learned from other health systems (or states). Which of these ideas do you think we could test?”

 “Testing is available for staff — here’s how you get it.”

 “Steps to protect your family before you go home are…”

Establish and support a physically safe work environment

Conduct hazard assessments

Create simple, trusted workplace injury and violence reporting systems

Focus on what we can control

Use quality improvement methods and conduct small tests of change

Assume everything is chaos

 Ask: “What decisions can we make together about how we manage the volume of patients we expect (or have) using the PPE available?”

 Ask: “What can we test this morning?”

Engage staff and patients/families in co- designing safe systems

Offer realistic hope Provide false assurances: “We’ll be through this in 2 weeks”

Inform: “We have PPE shipments arriving tomorrow. Local companies are making PPE shields for us that will be ready in X days.”

Share all data transparently

Physical and Psychological Safety

Care for Me: Provide holistic support for team members and their families, if isolation is required (or other sources of distress occur)

Do Don’t Steps to Try Sustain Joy in Work

Identify what support looks like for staff and their families

Mobilize efforts to obtain support: use volunteers, social workers, community members

Ignore the personal and family toll on staff

 Ask: “What would support look like for you today?”

 Address the basics: Food, medicine, safe housing, PPE, child care

Assess effective support systems for all

Recognize that mental illness may increase during times of intense stress

Ignore that staff may have mental health needs

Offer assistance: “Our mental health is vital for all of us and our patients. Let me or your provider know if you need help.”

Provide accommodations for mental health needs

Create a peer support and coaching network

Find ways for staff to support colleagues who are (or have family members who are) sick or have died from COVID-19

Assume that stress will not affect everyone’s well- being

Provide support:

 “Here are resources to support one another.”

 “Let’s take a minute to think of Louis’ family.”

Build on learnings about effective support in times of great stress

Ensure staff know about resources if they are furloughed

Assume that staff know how to navigate HR or government agencies on their own

Inform: “HR partners will provide the information you need and make sure you get all your questions answered.”

Develop more robust HR systems based on learnings

IHI TOOL: Conversation and Action Guide to Support Staff Well-Being and Joy in Work During and After the COVID-19 Pandemic

Institute for Healthcare Improvement • ihi.org 6

Autonomy and Control

Prepare Me: Provide training and support for high-quality care in different settings

Do Don’t Steps to Try Sustain Joy in Work

Be honest Assume you know what each person needs to be competent in new roles or work

Acknowledge:

 “I know this is scary to change roles this quickly.”

 “We have training plans and want to hear how it’s going for you every day.”

Provide training based on lessons learned and in relationship-centered communication skills

Be clear

Provide information that staff do not need or will not use

Ask: “Here are the steps we have planned to help you give quality ICU care. What else do you think you’ll need today?”

Share what you know and what you don’t know

Share good and news

Encourage rapid tests of change and learning

Blame when failure happens

Ask: “These are the three tests we have going right now — any ideas on them?”

Highlight learning gained to decrease fear of failure

Communicate via real- time methods: instant messaging, huddles, video conference

Ensure that staff can easily communicate to leadership

Rely on email

Assume people have all the information they need if they are not asking questions

 Inform: “We have huddles two times each day; regular COVID-19 updates are available online.”

 Ask: “What questions do you have?”

Harvest lessons learned about effective communication to a range of staff

Develop “safety nets” for staff

Expect people in new roles to function quickly with limited support

Offer assistance:

 “This shift Diana is your support person. You can ask her anything.”

 “Team members are here to help one another. Never worry alone.”

Harvest lessons learned about effective staffing, new workflows, and successful tests; see change package for specific examples

IHI TOOL: Conversation and Action Guide to Support Staff Well-Being and Joy in Work During and After the COVID-19 Pandemic

Institute for Healthcare Improvement • ihi.org 7

Meaning and Purpose

Support Me: Acknowledge demands and human limitations in times of great patient needs

Do Don’t Steps to Try Sustain Joy in Work

Be positive and present in as many ways as possible (including virtually)

Avoid staff  Ask: “How are you?” — then listen

 Ask: “What do you need right now?”

 Ask: “What is a source of joy for you right now?”

Ask team members “What matters to you?” to connect their sense of meaning and purpose to the team and the organization

Use consistent value statements to connect staff to core needs: 1) purpose and meaning, 2) control, and 3) physical and psychological safety

Be silent

Assume staff know what you’re thinking

Give confusing messages

Provide assurance and support:

 “As a team, we will figure out how to best care for this patient.”

 “This is when we are at our best — working together for patients.”

 “Never worry alone.”

 “This is all new ground, so no one has the all the answers. We’ll figure this out together.”

Model the way: Leaders develop narratives about the meaning of their own work and share widely

Focus on who is being served by the daily work, and link that work to the organization’s mission

Endorse self-care

Provide emotional and psychological support

Ignore self-care

Assume stress reduction is an individual responsibility alone

Provide gentle reminders:

 “We work together to keep each other safe.”

 “Food, fluid, bathroom breaks.”

 “Silence is our enemy — if you have questions or ideas, please speak up.”

 “Take 5 minutes for a well-being break."

 “Take 10 deep breaths and picture a calm place.”

 “The employee assistance program (EAP) services are available to all staff. EAP can identify online apps to reduce stress.”

Build on lessons learned about self-care among teams

Express gratitude

Link appreciation to meaning and purpose

Promote and praise teamwork at every opportunity

Link daily work to the values of senior leaders and the organization

Assume leaders do not also express their thanks to staff just because the public is already thanking them

Be silent about essential requests and concerns with senior leaders

Say “thank you” and be specific:

 “The support you provided to Ms. Jones to communicate with her family showed the best of who we are as a care team.”

 “This is what we are called to do, and the community is seeing that by thanking us.”

 “What we’ve done the past X hours is exactly how great teams work! Thank you!”

 “The senior team is very receptive to hearing the concerns you have.”

Express gratitude

Link appreciation to meaning and purpose

Link appreciation to shared identities

Promote and praise teamwork, testing, failing, and learning and at every opportunity

Ensure support systems are in place to ease burdens (e.g., prompt IT response to EHR needs)

Expect usual problem- solving by overburdened or anxious staff

Inform: “Our IT partner is available to address issues that come up. The best way to contact them is…”

Harvest lessons learned about support systems that do and do not work

IHI TOOL: Conversation and Action Guide to Support Staff Well-Being and Joy in Work During and After the COVID-19 Pandemic

Institute for Healthcare Improvement • ihi.org 8

References

1 Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving

Joy in Work. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2017.

http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspx

2 Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health

care professionals during the COVID-19 pandemic. JAMA. 2020 Apr 7. [Epub ahead of print]

3 See the “Measuring Joy in Work” section and Appendix C in the IHI Framework for Improving

Joy in Work white paper.

4 Linzer M, Poplau S, Grossman E, et al. A cluster randomized trial of interventions to improve

work conditions and clinician burnout in primary care: Results from the Healthy Work Place

(HWP) study. Journal of General Internal Medicine. 2015 Aug;30(8):1105-1111.