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Bill Klaproth: Leadership Beyond the Pandemic: Care Delivery Innovations is supported by an unrestricted grant from the Johnson & Johnson Foundation in partnership with the Johnson & Johnson Center for Health Worker Innovation.

Many leaders acknowledged that COVID-19 was causing anxiety, stress, and provoking fear in caregivers. There are those who developed proactive strategies to offset the emotional unrest. So let's talk with Mary Ann Donohue-Ryan, Executive Consultant at Chilton Medical Center, part of the Atlantic Health System, and Maureen Schneider, Chief Nursing Officer and Chief Operating Officer at Chilton Medical Center, also part of the Atlantic Health System, about resiliency rounds and other strategies to boost morale.

This is Leadership Beyond the Pandemic: Care Delivery Innovations. I'm Bill Klaproth. Mary Ann and Maureen, thank you so much for your time. It is great to talk with you on this important topic. So Maureen, COVID-19 certainly has had a profound impact on the entire healthcare environment. Can you please describe when you first knew that this was going to be as serious as situation as anything you've ever encountered in your work history?

Maureen Schneider: Having been living in New Jersey, we were hearing all the reports coming in from New York City and actually from New York State. And we although did not have all those cases coming to New Jersey, on March 9, 2020, we wound up having our first few patients coming in through the emergency department. As a matter of fact, it happened to be on the day when it was going to be our first Magnet visit, which is of course Magnet is a recognized accreditation nationally for nursing practice.

And we had several patients coming in who actually worked in New York, but actually lived in our neighborhood here around the hospital. So these patients became very, very ill, very, very quickly. were in our ICU and we realized that these were patients that were coming in with COVID-19 virus. And we just, from there, exponentially grow and really reached out to ensure that we have the protocols and the management of care that we needed to.

And it came upon us so quickly that the response from our staff was wonderful, but we realized that we were the epicenter of the pandemic, having lived in the tri-state area of New York, New Jersey and Connecticut. And we reached out realizing that this was now a very serious issue because probably within a week, we went from zero patients to probably about 15, 16 of those patients and beyond that as time went on.

So, as I stated, one of our very first patients lived in New Jersey here and actually was a healthcare worker and actually came from work very, very sick. And that started really for us the idea that our frontline team would be surrounded by taking care of the patients, not only in their own neighborhood, but our own patients and our own neighborhoods were going to be effected by the pandemic as well.

Bill Klaproth: So you were hit with this pandemic, something we have never seen in our lifetime. So what did you see happening with your staff then? What sorts of stories were you seeing or hearing?

Maureen Schneider: Well, we obviously were listening to our New York counterparts and we were listening to the news and our staff would be talking about it. But however, when we started to get our own patients coming in, there was certainly feelings of overwhelmingness and despair for the daily occurrences of our numbers going up and a lot of the patients that were experiencing death and dying.

We were actually restricting visitors. We were now donning protective equipment. We were educating our staff to step out of areas that they had a comfort zone in to take on some additional responsibilities and areas that they had not been involved in before. We had family members that were wanting information very quickly and we didn't have all that information. We had physicians who wanted to ensure that the management of the patients, we were all on the same page.

And the staff really responded here at Chilton amazingly, but the numbers were growing so exponentially that we needed to continue to open up more ICUs, prepare our staff, and really work with our families and our loved ones in the communities, because it was very, very difficult for them to actually appreciate and understand and the worry and the tremendous concerns about what the future would lie for their family members.

And the same thing was happening for the staff as well. Many of them were fearful about going in and seeing the patients, although they understood the emotions and the care that was being rendered. They were worried about going home themselves to their families. They were worried about spreading it amongst each other or spreading it home with the families.

And we had to quickly develop guidelines with the staff, we called it playbooks, so that wherever the nurse might be practicing with patients, that they were following the proper guidelines to ensure that the standards were adhered to as best as we could and that the staff felt comfortable taking care of the patients and being involved the way they needed to for ensuring that the care was up to the highest quality and accepting the challenges that COVID was going to be presenting to us.

Bill Klaproth: Yeah, the emotional toll is kind of the silent pandemic that has affected all of us, especially our nurses on the frontline. So Mary Ann, how did you create a plan for a direct approach to emotionally supporting your team?

Mary Ann Donohue-Ryan: It's a great question. I have to say that Maureen had brought me on here early, I think it was 2019, to really help with Magnet application and some other leadership functions. However, I'm also a nurse practitioner and adult psychiatric mental health nursing. So that first weekend where we began to see the incoming patients for COVID-19 is when I began to reach out to Maureen over that particular weekends and say, "You know, we can create a plan together to address the frontline clinical caregivers." And when I constructed that plan with Maureen, she said, "You know what? Go right ahead and do everything in that plan."

So the key point that I think is important to emphasize is that we did realize early on, that nurse to nurse interactions and my being a nurse and a mental health professional in my background would net much more benefit than if nurses were to call an anonymous helpline or to contact a nonclinical professional, given the many nuances that COVID-19 was representing.

And as Maureen said earlier, we were beginning to hear from our colleagues in New York and of course in China through the literature that this was to be severe and profound, and we knew that we had to head it off early on.

So the Chilton Medical Center plan or the plan that we developed was for me to hold one-to-one sessions with staff. We conducted huddles and debriefing sessions, either in groups or in one-to-one sessions. I gave my personal cell phone number to everybody. Some staff really needed for me to text them every day for daily check-ins and that made them feel secure, knowing that some help was at the end of that text message or they would say, "Can you meet me at 7:30 when I come in? Or can you meet me at 8:00. I just want to talk to you for a few minutes." and we found that to be very helpful and very constructive for them. And some of them, I still contact to this day.

We referred staff obviously to the extensive amount of resources that we have here in Atlantic Health or external private therapists who are conducting or beginning to conduct virtual visits at that point. We did publish a couple of mental health newsletters with information, tips, and resources, so that was pretty helpful. People posted it in their lounges. They posted it in their lockers and they just included such things as free podcasts they could get a hold of and put on their cell phones that they could listen to on the way going home. And some other resources that they found particularly helpful.

And then pretty much towards the middle and the end of the pandemic in our area, we began, and still existing today, providing ongoing resiliency huddles with our system resiliency advocate who's a wonderful psychiatrist on staff. So we began to go through the entire hospital unit by unit, shift by shift to be able to address any lingering concerns that the staff would have.

Now Maureen, in her role as chief nurse and operating officer, she met with the night and weekend staff, I met with the night and weekend staff and we conducted daily staff rounds on all units. And that was also a touchpoint. We provided for days off in terms of the self-care, self-compassion. And in some cases, very necessary LOAs for staff that were starting to feel that they were becoming a little unraveled at the edges and needed to take some time away to get that breathing space.

So Maureen and her team and the leaders here at Chilton have done rounding with the staff on all shifts and also with their snack carts. And they've also done and expanded this to include resiliency cart rounds, which is when they round with upgraded snacks, you might say, with snacks that are healthy and also include mental health resources. So that way, they can see the staff and they can just mention, "By the way, we don't know if you've ever contacted any of these resources we have here in Atlantic Health, but you might want to consider that. Here's a little card where it contains all of the resources."

And then the concern team, which is our EAP, employee assistance program, they made themselves available for up to 12 free sessions per staff member, which was really great because then I could make that referral and then they could be seen by someone who is a mental health professional that very day or the very next day. So that was also very helpful.

And then finally, the compassion team sprung out of this effort. And the compassion team were trained or trained staff members or peers on the units, and they're trained to recognize signs and symptoms of anxiety, depression, and coping issues. So we found all of these things really fit the bill for being not far beyond one-size-fits-all. We really believe that very firmly in that philosophy.

Bill Klaproth: Well, it's easy to see how valuable your efforts have been in this area, especially the one-on-one meetings and how important those touch points, like the things you did with the resiliency cart rounds and, of course, the compassion team. I think that's really great. And Maureen, can you tell us about how you support and encourage resiliency in yourself and also your team?

Maureen Schneider: Well, I can tell you, Bill, that as leaders, we must prioritize self-care and days off and make sure that our staff members, including our leaders are getting their lunch and meal breaks and that we can actually congratulate each other for doing a good job. I actually did give some of the managers the opportunity to work from home on days when it was easier for them to do that so that they could have a break away from the hospital.

We made sure that our staff actually were taken off the units and given not only some of the guidance that Mary Anne would provide and our concern team would provide, but also that they would be away from the situation on the units and that they could debrief themselves and they could collect their thoughts.

We also held Teams meetings, which everyone now needed to learn how to get onto, working with telediscussions and get some education on cell phone touch points with all the nursing leaders. We had meetings every morning, so that this way I could get a pulse check on how the leadership was doing.

We also had staffing meetings in the afternoon and the evening because we want to make sure that all of our staff was exactly what it should be, so that we were not putting undue pressure on the staff, that we had discussions about keeping people up-to-date and what was going on with the pandemic, not only certainly globally, certainly nationwide and in New Jersey, but we also wanted to talk about what was going on at the hospital as well as in our system.

We wanted to make sure that we're as well as informed, because in many cases we were still getting information hot off the press, as we all were experiencing it. So it was best that they'd all be involved. We did pulse surveys with our Human Resource Department. We wanted to really understand how the staff nurses and all of the team members in the organization were feeling so that this way we could home in on what would be much more helpful for them.

We kept them well communicated too. We sent out a lot of literature of updates. We actually had our chief medical officer going out and making sure that they were well-informed. That provided for them a constant understanding of where the hospital was at. We knew how many patients were in the hospital at the time, what the determinations of what were going on with our cases.

We were doing clap outs, making sure that when the patients were going home, we engaged all the staff to participate in that. And that was a great, feeling for the nurses because that gave them inner strength to know all the good work that they had done was producing a positive outcome for many of the patients and their families as they were leaving the organization.

And this was not a time for any of our leaders for leading behind a desk. There was a great need to be visible, to be talking to each other, to be interacting with each other. Even if we couldn't hug each other, we were doing elbow hugs and making sure that people understood we were all in this as a team and that, through their work as good servants, they were doing the right things for our patients and our community.

From the whole team's perspective of the hospital, there was just a joint effort to be strong as we could be, to be supporting all of our team members wherever they were, to do the best job they could do when they came to work every day. And we were grateful for that. And we thank them enormously, including my CEO, Stephanie. She was there to support all of us in terms of the work that had to be done for the patients and our staff.

Bill Klaproth: Well, I love the creativity and the things you came up with, all of the multiple touch points for the nursing staff that obviously were very valuable to them and help them through this very trying time. So Mary Ann, we have heard a lot about short-term strategies to deal with the COVID crisis. Tell us what do you recommend that will work in the long-term to mitigate the psychological trauma caused by the pandemic.

Mary Ann Donohue-Ryan: Sure. The first thing is to really be aware of the literature and to constantly get into the electronic media. Most of the COVID-19 literature is free and available without subscription from the leading mental health journal. So we've all been very deep into those to see what other organizations are doing, not only here in the US but around the world.

One of the first things that we've looked at really is to think a lot about what the term resiliency really means. And it's perhaps overused at this point. And this is a saying of mine that there's a certainly a fine line between the so-called resiliency and what may be either a very healthy denial or a very unhealthy denial.

So what we mean by that is to really make sure that someone who's having this tough exterior, that it's not actually masking what could be a very real anxiety or some other problem that's going on. So you have to really understand and know your staff and you can't understand and know your staff until you go through all of the various means and modalities that Maureen and Stephanie have been doing here at Chilton and throughout the Atlantic Health System.

The bottom line, if there is a bottom line, is that the key to an effective stress management plan is recognizing and knowing your staff. And it will not rise to the surface unless you as the leader are out there on the units, looking specifically for these signs of the impact of stress upon your own team members. Because if you don't know what their normal baseline is, how are you going to know when there's some deviation from that norm? That's a big key of it.

I was just upstairs in one of our ICU's this morning. And one of the nurses said, "Do you remember me? You brought me a sandwich about a year ago, six months ago. And you asked me, was I hungry?" And I said, "I don't know if that was the nurse in me or was that was the mom in me." But it didn't matter. It was what that nurse remembered about how important the leadership here at Chilton was to her at that moment of time when she was working at our hardest to save lives in the ICU here.

And it is almost impossible for us as we sit here to figure out, "Well, what's going to be the long-term pandemic impact upon our collective consciousness nationally and again globally?" But very early in the pandemic, which was March of 2020, was that in China, they were reporting exorbitant amounts of depression, anxiety, and insomnia. And when that study was repeated here in this country, we found that the results from the ANA and ANOL collaborative research was that it really was mirroring that information, that 87% of American nurses were afraid to go to work and only 11% believed they were well-prepared to care for patients with COVID-19.

So we knew from the literature what the nation's nurses were most fearful of. So then Maureen and I got to work and her leaders to really address them and to circumvent that and to cut off those fears, so that way our nurses wouldn't be feeling the same way.

Maureen mentioned the supply chain and the command center huddles. And that was to assure for the nurses, reassure them that they would have PPE, that they knew where their next masks would be coming from, that we had enough ventilators and that information really helped to tamp down whatever fears. So certainly keeping your team in the loop is very, very important.

Once the basic supply and education needs are satisfied and, again, we had very, very innovative supply chain preparedness here, we also want to make sure that we foster this whole idea of oxygen first, similar to on an airplane when you're going through the emergency preparedness speech from the flight attendants. You're always instructed to put on oxygen to yourself first before you help others. And that's something that Maureen and her team have always spoken very highly of and very clearly to in their communications to the rest of their team, to make sure that everyone is looking for those formal and informal celebrations that I think nurses are well-known for, keep them coming and, as much as possible, make sure your team feels nurtured, supported, and certainly assessed at every turn.

It's another thing, and there's always one more thing, to remember that staff are also feeling those home pressures. And especially for nurses who are the gen X and millennials especially, they're the ones who are paying mortgages and paying taxes and also, unfortunately, juggling work, financial pressures, multigenerational households and oh, yes, homeschooling. So there's a lot going on with them and particularly that generation. And again, the only way to recognize and do anything about it is to make sure that you're frequently rounding and knowing your staff and providing these plentiful programs to help support them and then, finally, to make referrals for mental health help when they need them.

Bill Klaproth: Yeah, that is so true and you're right about that. This has been a great discussion. Thank you both for bringing up all of the great information that you did and sharing all of that with us. And thank you for the stories and sharing your experiences and your strategies to help elevate morale. This is really been great, Mary Ann and Maureen. Thank you so much for your time. We appreciate it.

Maureen Schneider: Thank you, Bill. I appreciate sharing it with you.

Mary Ann Donohue-Ryan: Thank you so much.

Bill Klaproth: That's Mary Ann Donohue-Ryan and Maureen Schneider. And for more information, please visit AONL.org. And once again, this podcast is supported by an unrestricted grant from the Johnson & Johnson Foundation in partnership with the Johnson & Johnson Center for Health Worker Innovation. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Leadership Beyond the Pandemic: Care Delivery Innovations. Thanks for listening.