David Shulkin, M.D. FACP
Ninth Secretary, US Department of Veteran Affairs

With the coronavirus (COVID-19) actively spreading, and so many uncertainties about its course, it may seem like we are in unchartered territory. The declaration of a national emergency at both state and federal levels has clearly focused attention on the readiness of our medical infrastructure and workforce. While the COVID-19 virus is novel, there is still much we can learn from prior infectious outbreaks.

It is crucial to note that the spread of viral illness depends on a number of factors such as the virulence of the pathogen, adherence to public health precautions and measures, and the readiness of the healthcare system to address these outbreaks, to name a few. The resilience of healthcare professionals is a critical element of the system’s ability to respond.

In the 1918 influenza pandemic, hospitals were overflowing with patients. Many had to double or triple their usual bed capacity and used hallways to accommodate the demand. Already experiencing a severe nursing shortage from military demands of World War I, civilian hospitals were left with minimal staff. As a result, nurses and other healthcare workers were often on duty from early morning to the late hours of the night. Workloads were dramatically expanded, and staff often worked without proper supplies, equipment or medications. Even worse, large numbers of healthcare workers themselves got sick, and many died.

The stress on nurses, physicians and others dealing with the 1918 pandemic was considerable. Yet few voluntarily left their assignments, instead caring for patients even when it meant a risk to their own health. There may have been many reasons for this, but it is my opinion that the response from organized professional societies and the public at large played an important role.

In support of nurses and others during the 1918 pandemic, the Red Cross organized motor brigades for transportation to help get healthcare professionals to work and home. Community groups organized food pantries and other staples to support staff who did not have time to go to markets and attend to ordinary household chores. Supervisors in hospitals, even those not clinically trained, helped gather supplies for nurses and would assist on rounds. Volunteers came to help with staffing shortages. Professional societies worked on education and communication campaigns. But maybe most important, government officials and community leaders publicly offered their gratitude and support for what the healthcare professionals were doing to try to lessen the catastrophic nature of the pandemic.

Since 1918, our healthcare system has responded to many other challenges and we’ve been able to quantify the impact of infectious outbreaks on healthcare workers. In the A/H1N1 pandemic in 2009, 56% of healthcare workers expressed worry for their own safety and that of their families. Absentee rates of up to 35% were observed during this outbreak due to healthcare workers’ concerns, their own illness, or needing to care for sick family members.

Staffing shortages only add to the stress of those that continue to work, often at times of high patient demand. Those that remain face additional stress in the workplace. During times of crisis, healthcare workers often report a sense of ethical duty and many put their responsibility to help others above their concerns for their own health or that of their family. This professionalism must both be admired, but at the same time, must be supported with meaningful responses from health system leaders and the community at large.

As we’ve learned from past infectious outbreaks, how our staff are treated and supported during a pandemic can have a big impact on our workforce and ultimately on our patients. With the most challenging times for dealing with coronavirus likely still ahead of us, thinking through how we lessen the stress on our staff and address their concerns will be of critical importance.

Ensuring that staff know that leaders are concerned about their safety and health is vital. This can be done by explicitly stating that this is an institutional priority. Before a pandemic occurs, staff must have the time to prepare for situations like this and ensure they have the skills to respond accordingly. In the face of a pandemic, staff must have the right protective equipment and supplies for them to feel safe and to deliver safe, quality care. Training and education about the infectious agent, and the epidemiology of the disease, is essential for staff members to feel well-informed and supported to do their jobs well. Additionally, emergency preparedness trainings and resilience trainings are useful in preparing staff for these often-unpredictable situations.

Recognizing staff for the courageous way they respond to the challenges faced, and professionalism in which they meet these demands, is impactful. Far too often, staff are not recognized for the work they do and the differences they make. Recognition from leaders, co-workers, and patients and their families are all essential for reinforcing the reason why healthcare professionals step up in times of crisis. Real-time feedback is the best possible way to tap into the reason why people remain committed and dedicated to their work.

Systems that demonstrate the impact of recognition, where patients and families can leave real-time recognition and feedback for their care team, are showing very real increases in staff morale. It is important for staff to be recognized for their valiant efforts during times of crisis, such as responding to this current pandemic. Amid staff feeling concerned and fearful of the many unknowns surrounding COVID-19, this approach makes staff feel like their work doesn’t go unnoticed, but is instead valued and appreciated.

Regular updates and communications about the current situation facing a community or an organization are helpful in allowing staff to feel more control of their situation. The use of technology and social media platforms to share information can be an effective form of communication. Moreover, forming committees, or other organized forums, to get input from staff and others on how best to address the situation and the environment is a good way to ensure feedback from those often being affected the most. Providing forums to have exchanges of information is a vital part of addressing these needs.

Providing transportation, telephone or device access, and food is often effective in reducing some of the stress that can be seen with increasing job demands. In times of pandemics, options such as public transportation may be limited, making getting to and from work for some more challenging. Being able to stay in communication with family and friends is often a concern as well with more hours being spent at work.

Stress and burnout of healthcare workers has been growing for years, but during times of crisis, we must be especially vigilant in addressing the needs of our staff. Addressing these issues is an essential part of a healthcare organizations’ emergency preparedness. Even more than 100 years since the last great pandemic, let’s hope that we can learn from that experience and do an even better job in supporting those that are doing such important work.