In the late spring of 1940, thousands of soldiers stranded on the beaches of northern France were spent, demoralized, and facing near-certain defeat at the hands of Nazi forces. The British government undertook one of the boldest rescue operations in military history. Using military ships, merchant navy vessels, and, famously, a flotilla of civilian watercraft, more than 330,000 British, French, and Belgian troops were rescued and evacuated to Britain.
Because of this “miracle of Dunkirk,” Great Britain’s military got a chance to fight another day.
Today, on the west side of the Atlantic, the U.S. health care system is facing its own Dunkirk moment. Covid-19 has left health care workers exhausted, traumatized, and increasingly disengaged. Like the British military, American health care faces an existential threat. Without a swift and bold rescue operation, the ranks of America’s health care workers will quickly dwindle, diminishing the ability to provide care in both outpatient and hospital settings. The nation’s citizens will suffer.
Our decade of experience developing strategies to decrease burnout and increase clinician job satisfaction by fostering deeper connectedness in clinical health settings offers some direction for what a health care rescue mission might look like.
The view from the beach
Over the past decade, responses by the health care industry to what many have called an epidemic of burnout have largely missed their mark. They’ve been technical and process-oriented, focused on changes to electronic health records and workflows, or they’ve been overly therapeutic, attempting to address the problem with offers of vacations, yoga, and resilience training. In the case of the latter, researchers clearly found the approach lacking, noting that “physicians are not collectively deficient in resilience and even the most resilient physicians are at substantial risk of burnout.”
A major factor in the general failure of these approaches is that they did not acknowledge and address the needs of health care workers for meaningful connections with their patients, their institutions, and their colleagues.
And then came Covid-19, and whatever small progress had been made toward improving these relationships evaporated. Dr. Victor Dzau, president of the National Academy of Medicine, reported in a webinar hosted by U.S. News that 60% to 75% of physicians say they’re experiencing symptoms of exhaustion, depression, sleep disorders and PTSD. Adding to the existing losses, a USA Today/Ipsos poll conducted in mid-February 2022 found that 23% of health care workers say they “are likely to leave the field in the near future.”
“This was a problem to begin with,” Dzau said, “and Covid’s made it much worse.”
Indeed, amid shortages of personal protective equipment, the shift to remote work, and the widely held view that there never was a plan in place to confront a once-in-a-century pandemic, trust — among providers and between them and their institutions — was annihilated by Covid. Providers feel traumatized by their experiences of the last two years. Many also feel that this trauma has gone unacknowledged.
Which brings us back to the beach. It’s hard to believe that the soldiers at Dunkirk didn’t feel in some sense that they had fallen short of their nation’s expectations. They’d failed to stop Nazi forces on the continent and had abandoned significant matériel along the way. On the other hand, part of what’s so inspiring about the Dunkirk rescue is that it was as relational as it was physical. The civilians who put their own lives on the line to cross the English Channel signaled loud and clear that the soldiers on the beach had value and that they were needed more than ever.
Likewise, America’s health care workers today find themselves on a more metaphorical beach, facing few good options and feeling a depreciation of their own worth and a detachment from their institutions. It’s time for a relational rescue of America’s clinicians. Here’s a blueprint for how it can be accomplished:
Acknowledge the trauma and accept responsibility. There were failures at every level of every health care system when Covid-19 first became pandemic. Supplies of PPE, ventilators and other crucial equipment needed to care for critically ill patients were inadequate. Health care workers were asked to do exhausting work and often undercompensated for it. Years of doing more with less had led to understaffed clinical teams, leaving them unable to properly care for waves of infected patients.
In the aftermath of this emergency, leaders and team members need to acknowledge the horrible set of options they collectively had and the costs and consequences of decisions that were made. There’s learning to be had from that exercise, from which policy changes should result, like mandating staffing ratios and ensuring reimbursement accurately reflects work.
Equally important is the individual and interpersonal healing that can occur from such “reset” conversations. Without such healing, it will be next to impossible to rebuild health care institutions and connections between stakeholders.
Create an atmosphere that fosters relationships. It is essential to create cultures focused on the human interactions and the social and relational needs that all humans share and that are the bedrock of thriving health care teams. To do this, health institutions must prioritize three goals for their internal cultures and systems:
Foster psychological safety. Team members who genuinely feel that they matter and that their contributions are needed for team success are more engaged. Organizational behavioral scientist Amy Edmondson calls this “team psychological safety,” and her research shows it leads to “a shared belief held by members of a team that the team is safe for interpersonal risk taking.”
Foster self-awareness. Health care team members are generally aware of their leaders’ strengths and weaknesses. But they can also build an awareness of their own tendencies for learning, communication, and collaboration by using tools like Simpli5, DiSC, or Myers-Briggs. These help teams leverage individual strengths in service of particular work and help team members better align their approaches when working together.
Foster a sense of “we.” The pandemic trauma heightened everyone’s sense of “me.” That’s natural in survival mode, but to be successful for the long-term, health systems need to re-establish the communal feeling of “we” that is the heart of successful teams. Leaders should allocate time for personal check-ins at the start of meetings and invite health care workers to talk about their lives as well as their frustrations with patients, systems, and work flows. These are all ways to create a deeper understanding of team members’ lives and to construct a shared sense of value and purpose.
Weave together cultural and functional changes. Melding cultural changes that focus on interpersonal relationships with functional ones that solidify those relationships in the context of everyday processes can help improve both the quality of care and the quality of the clinical environment. Michael Anne Kyle, Emma-Louise Aveling, and Sara Singer examined 12 academically affiliated primary care practices that sought to move toward team-based care models. These researchers discovered that some approaches prioritized “functional” issues, such as roles and how systems were set up for collaboration. Other approaches prioritized “cultural change processes,” meaning how team members related to each other.
Neither approach was better than the other. When the approaches were combined, however, “Cultural changes created an environment conducive to functional changes, and functional changes furnished support systems for cultural changes,” the researchers reported.
Likewise, in our work before the pandemic’s onset, we led retreats for clinical teams to bring people together and foster a sense of community and camaraderie. Unfortunately, when diverse groups of interprofessional participants went back to work after those retreats, they often discovered the progress they made couldn’t withstand the realities of their work environment: they sat together at the retreat during breakfast but sit far apart in the clinic; they had earnest discussions about patient care on the retreat but in the office individually enter all of their communication in the electronic health record. Schedules shifted, and two people who discovered a mutual affinity for musical theater rarely passed one another in the corridor.
Using lessons learned by the Kyle/Aveling/Singer study, we have adjusted our approach to retreats so the progress that’s made on them is more readily extended into the clinical environment. Schedules, office layouts, and protocols are adjusted in order to foster communication and collaboration at work. By blending the cultural work that teams do on retreats and in workshops with more functional work, our partners and clients are able to create a positive mix that supports and reinforces a more relational workplace culture.
Similarly, several institutions have successfully melded functional and cultural strategies to reduce burnout and improve patient outcomes. The Mayo Clinic, for example, reduced the burnout rate among its physicians by 7% even as the national rate went up 11% by weaving together technical strategies like unit-based process and workflow improvements, and adjusting rewards and incentives, with relational strategies focused on leadership, culture, and community.
Integrate virtual and in-person work modes. As we’ve discovered from our work with large health care systems, it’s impossible to build a culture over Zoom. But it is possible to remotely conduct interdisciplinary team rounds, manage chronic disease, and provide quick consults, among other daily tasks. Going forward, it is essential that health systems clearly delineate what work can and should be handled virtually without sacrificing the need for clinicians to interact and relate to both patients and one another on a personal level.
Begin the relational rescue
The U.S. health care workforce needs rescue — both practical and relational — much like the British, French, and Belgian forces did in the spring of 1940. Health professionals might not be sitting cold, tired, and largely defenseless on a beach, but they are in their own desperate situation and their leaders, their colleagues, and their patients are at risk of losing them and facing a profoundly dark future without them and their critical service.
The country can’t address this dark moment with a flotilla of ships. But it can be addressed by a commitment to building a relational foundation that better supports patients and care teams. Through this approach, the nation can ensure that patients receive the care they need and providers have a work environment conducive to delivering that care, day in and day out.
Andrew Morris-Singer is an assistant professor in the Oregon Health & Science University’s department of family medicine and the founder and chair of Intend Health Strategies. Brian Souza is the chief executive officer of Intend Health Strategies.