Leadership of health workers during the COVID-19 pandemic
Dawn O’Neil, ambassador for the executive mental health program ‘Breathing Space’ interviews authors of a new book on the experiences of health workers during the pandemic: Professor Marie Bismark, Professor Karen Willis, Dr Sophie Lewis, and Associate Professor Natasha Smallwood. The panel covers mental health, gender bias, resilience and the myth of self-care, the cracks in the system and the power of stories to provide a burning platform for change.
The book ‘Experiences of Health Workers in the COVID-19 Pandemic: In Their Own Words’ is available for purchase here.
Associate Professor Natasha Smallwood [0:05]
So I’m a front line worker. And quite early in the pandemic, I could palpably feel the distress around me. Actually, I felt it as well as a, as a physician, as a as a wife. Because I’m married to another physician, I have three children. And the disruption and chaos around us was profound. And everybody was so stressed. And it felt like we were making no progress. And because I’m also a researcher, I kind of thought, you know what, I’m not going to be a guinea pig, I’m not going to let somebody do a study on me when I have the insight to understand what is going on and what we need to measure. And then if we don’t measure this right now, we will miss this moment to understand what this crisis has done to this health workforce. This is really important. Because if we don’t measure it and understand it, we can’t change it. So with that chaotic thought process and trying to manage that a lot of my patients I called Karen, who I have worked with, as a researcher for some time, and I said to her, we have to do this between us, we have to do this, you just have to make a way for it to happen, and Karen probably just thought… but we actually do collaboration, apologies. And so between us, we kind of said, well, we’ll just do it. And there was one very frenetic day when I called a whole bunch of my colleagues who were friends, so Heads of departments and hospitals around Victoria and said, we have to do this, and I need you on board. And I brought 15 people together overnight. And we put in a couple of grants, which we were unsuccessful with, but I’m sort of good at persuading people to give me money. So I persuaded others to help us to do this. And from that this study arose. And I guess what was interesting was, as we were doing this, you know, the first wave came and went, so I was going oh, it’s done its dash, we don’t need to do this. And the second wave came. And actually, our moment was primed, because we were ready to go, we were the only research group that had frontline workers that was actually ready to do this piece of research at exactly the right time in Victoria. And so from there, this, you know, incredible piece of work. That’s why we got 9500 people who responded in eight weeks, which is incredible, from health care workers, because I never take surveys, you got to really persuade me. So people wanted to give us their voices, they want their opinions. And that’s why you know, this book is incredible, because we’ve got so much breadth on the spot. So that’s kind of how it works. That’s my perspective. I want to say that Natasha’s a numbers person, but I’m a words person. And I never thought that we would get but in total. So this is what you’re looking at in the book as primarily just the answers to one question, but we had four free text questions. And we have, I think we can about 20,000 responses in free checks. And for people, most people feel the scores out enough to do the demographics, but to actually get them to write and to write heartfelt words, and is quite amazing. I’ve been doing qualitative research for a long time, like this or have a data set so much to try and analyze.
Dawn O’Neil AM [3:15]
So Marie how did you get involved?
Professor Marie Bismark [3:19]
I’m a researcher and a frontline clinician as well work in psychiatry, providing mental health care. A lot of my work in the last two years has been providing mental health care to patients with COVID on the COVID sports and people with COVID. And the intensive care unit also had mental health or addiction challenges. So it’s pretty challenging two years, but I also do a lot of research around clinician wellbeing so I have never met Natasha before. I remember sitting at the hospital one day in the middle of an incredibly busy clinical day. And Natasha called out of the blue and said, this research needs to be done. We know that you’re really interested in clinician wellbeing. Would you come on board? And I said I wish, I would love to. And then as Karen said, we just never expected the volume of stories that we received. And I was trying to get home to see my family, my husband and my daughter and my parents all in New Zealand during the pandemic so I was trying to get home to see them for Christmas and I had two weeks in managed isolation in a hotel. And since I was going to be locked in a small room for 23 and a half hours a day. Karen saw that this was an ideal opportunity to get somebody to read all of this free text!
Professor Karen Willis [4:29]
Come on Marie, you also wanted to research–
Professor Marie Bismark [4:33]
So for two weeks, I was in managed isolation and I just read these stories and I had just come off this incredibly intense and at times traumatic and distressing experience of being on these COVID wards myself in for two weeks I sit in this hotel room and I cried in some of the stories made me laugh and some of the stories were just so tender and some were really hopeful. And I thought we just can’t leave these sitting in a research data set that, you know, if I’ve had this profound experience that they’ve given voice to some of my experiences, maybe other healthcare workers would feel in the same way. And I thought, in 50 years, if somebody wants to know what it was like for healthcare workers working through the COVID pandemic, we need to have honoured that and witnessed it, and made sure that their stories can be heard. So I think to Karen and Natasha, I don’t think this is going to be a peer review paper or even three peer review papers. I wonder how you would feel about the idea of a book.
Dawn O’Neil AM [5:51]
So as a qualitative researcher, how is this particular study unique? From your experience?
Dr Sophie Lewis [6:01]
Yeah, we were talking about this today, we had never expected to see such rich responses from a survey, we would usually need to view diverse groups. But to see paragraphs and paragraphs, really nuanced and complex, and experience expressed in words was, I was really surprised to see the pages. Absolutely, absolutely. And, of course, the other thing is the volume, really qualitative stuff. So that was quite profound to get such a huge volume.
Professor Marie Bismark [6:44]
And the vulnerability, you know, some of the quotes that resonate with me the most are from senior male doctors, who talk about crying on their way to work. And I’ve been a doctor for a long time. And I’ve never heard a senior male doctor talk about crying on their way to work. And so there was that, that honesty and that trust in us and researchers that people are willing to make themselves very vulnerable. And the number of people who said, I’ve never spoken about this before, nobody’s ever asked me about these experiences. And you know, one health worker said, I haven’t felt able to talk to anyone about this, you know, my friends, my family, even other doctors, they don’t understand what I’ve been through, I’ve been so alone with these experiences because nobody else knows what it’s been like for me as a doctor working on these aged care wards with so many people dying. And so it was a real opening, opening up, I think it felt like a tremendous gift that people would trust us with it. And I think the sense that we had to honour what they had given us.
Dawn O’Neil AM [7:58]
So one of the things that really struck me with reading this was that for a number of people, the telling of the story, and then expressing what they’ve been through, was therapy for them themselves so that they felt like they feel better after telling the story. So as you said, many of them either hadn’t had the opportunity or didn’t want to burden others or for whatever reason hadn’t expressed how they were really feeling, being given that opportunity was a therapeutic response. So obviously, this outpouring of emotion and grief, and fear and all the experiences that are in here is a result of a crisis. So the pandemic has been a crisis, one that for most of us alive, we’ve never experienced anything like that. And for me reading this, I think, what are we going to take away from this? What can we learn from this? What change needs to happen? So I’d love to hear from each of you from your reading and your reflection, what you think that and I think in the introduction, we talked very much about a system that was already under stress, and already knew that, you know, there were things that were known that needs to change, and there’s the things that emerged that need to change.
Professor Marie Bismark [9:25]
I think of the people who told us their stories, the pandemic has shown up all of the cracks, that none of the problems that have arisen during the pandemic, were new, and that it was really an exacerbation of pre-existing problems. And so, for many of us in health, workers issues like the casualisation of the nursing force, the extent to which nurses are underpaid and undervalued. The extent to which junior doctors are overworked and working these huge and unsafe hours you know, problems with really antiquated technology… The fact that in 2022, we’re still using fax machines to communicate! All of these problems were pre-existing but then when the pandemic came these cracks opened to the point to which they were really these gaping chasms and just couldn’t be ignored any longer.
See, they are best first people to tell us what needs to happen. And I think what they really pointed to in the survey, and in the study, will need more than just fixing individuals. They don’t need to be more resilient, we actually don’t. They’re very resilient. But we actually need to do some things about the way they’re working, making this an occupational health issue. And so, the next stage is actually taking what they’ve told us in all the free text questions. And we’ve been funded by a charitable foundation so we’re going to do a study to actually look at two really important parts of helping to address the issues that were raised. And one is actually looking at Leadership, and looking at what leaders need and want. And how we support leaders and how they manage other crises because of course there will be other crises. And then working with health workers to codesign the solutions that they want. So there are two phases, and really our job – because the data will come easily to this project – our job is to look at what’s feasible. Say to health care organisations that are massive organisations and structuring really difficult to change. One of the bits that we could say, well, this is feasible, these are the things that perhaps you can try and do. And we’ve got a lot of great information from one of the other projects, questions. more informed because of our practices.
Dawn O’Neil AM [9:33]
Natasha, do you want to talk to that?
Associate Professor Natasha Smallwood 12:21
I think the other thing that comes up is a huge element of Leadership. And obviously, that’s an area that we want to explore more. But what comes up very clearly in the surveys, is the failure of Leadership, and that came across at every single level. So these health care workers felt there was no visible Leadership from the senior executive who was highly absent. And some of the departments headed up and headed for the hills, particularly because they were older and felt that they were more vulnerable. So the workers on the floor felt completely neglected, and actually wrote that they thought they were cannon fodder. And that matters, because that workforce then said, You know what, why should I take it, I’m not going to put myself at risk. And some talked quite a lot about leaving the workforce. And I think that there are really important messages around, you can only do so much to people before they’ll say they’ve had enough and they do leave. And there’s data from the SARS epidemic in Canada, where the workforce that was stressed actually left. And there’s data from the US recently that shows the physician workforce has moved as well because of the stress. So we sort of run the health service and I’m British, I’ve worked in the NHS, we run the health service on good luck and goodwill. But actually, people won’t take that anyone, particularly the current generation of junior doctors and nurses, they won’t take it. And so we really had to learn from the results of the study and say, we have to invest in our health system and take a very long term approach because people will leave the workforce. And I think, you know, people really talked about that there was no acknowledgement of the stress, they are under and in fact I gave a talk last week and someone said to me, I’m so angry that nobody’s ever apologised to me. What’s happened, you know, people are still carrying that anger from two years that they just wanted acknowledgement apology. That’s amazing how much that makes a difference. They wanted people to do something, that they actually did not want things that they thought were inauthentic. And we got quite a few chocolate frogs. You know, I’m worth a little more than a chocolate frog. I now give this talk because I’m worth more than a chocolate frog, I think I am. But these workers did as well. So we have to learn from that message. And just going back to this point in leadership, most medical leaders have never done any leadership training. They are technical experts. I have done a leadership course, I’m doing another one and it opens my eyes to go Oh, God, why have none of my colleagues done this? They’re all technical experts, think along this, but actually, you cannot be a research expert, a technical expert and actually a medical leader. And until we have leaders who are trained to be leaders, are supported and you know, understand the results that come out of work like this nothing will change. So actually you know, this piece of work that we’re doing around leadership is key, but we actually need to get medical leadership into health education curriculum, so that we can actually train the workforce for the future to understand what their role is when they are leading. And so they don’t feel vulnerable and head to the hills and know where the workforce is coming from.
Dawn O’Neil AM [15:18]
It’s fantastic. And it’s so often the case in any, any crisis, it’s Leadership either steps up, and that’s what people notice. And that’s what makes the difference, it might enable them to get through it, or they back away, disappear. And it’s, it’s chaos. And it’s so disheartening, it adds to the burnout of that feeling of being alone in the struggle.
Professor Marie Bismark [15:44]
So the reflections on good leadership as well.
Professor Marie Bismark [15:48]
Some felt that the manager had their back and the manager was in there with them. And it was just so important, you know, one nurse working in the intensive care unit spoke about her nurse unit manager coming past the window outside an isolation room, where she was caring for COVID patient and just giving you the thumbs up through the window in how much that one tiny gesture made you feel seen and valued and appreciated.
Dawn O’Neil AM [16:21]
So that’s a great example of just how important that leadership is. But as you’re saying, Natasha, generally speaking, health professionals don’t get that full training or support. Some people they maybe have it but it’s certainly something for most of us to have to learn. So that’s fantastic that you’re doing this new studying or that my understanding of of translating out researching practices that on average, it takes about 17 years? So how can we speed this up?
Professor Karen Willis [16:56]
I think some of the things we try to do is to engage with leaders now because the experience is also fresh with them. Yes. So we’ve got a project advisory board, because they’re the people who are likely to be the instigators and so and this is very practice based this research. As a health sociologist I do say, the health system, you know, having a broken system has been great for my career, but I think there are things that people can do to make their workplaces more humane, to recognise that this is an occupational health issue, and the mental health of the workers in the system is now law, and we need to be attentive to that, and we need to do more. Some people do want the individually focused responses so that when health services do that, we actually have the structural components and so I think trying to bring key leaders along with us, into change learning policies, is an that’s a very powerful, so we look at things that can be done.
Professor Marie Bismark [17:30]
The issue with self-care is something that Sophie’s done a lot of wonderful work, and really deep, thinking about to try and shift the narrative of self-care and from something that, you know, somehow deficient health practitioners are supposed to self-care themselves back into being more resilient people and, and really thinking about self-care as being very embodied within your relationships and within the organisation and within your interactions with other people. Sophie if you wanted to speak a little bit?
Professor Marie Bismark [18:54]
I think I heard someone say that even with collectively traumatised people, and we continue to go down the path of trying to build individual resilience, we’re never going to get very far. You know, there’s there are things that people told us in the study that would help them for example, if they were part of a team, where the culture was really caring, and they looked after each other and debriefed and checked in with each other that made an absolute world of difference versus teams, which were, you know, disparaging or not allowing space to talk about feelings which were both positive and negative. Moving push to try to be positive and friendly, resilient when we really just wanted space to talk about how we are really feeling, with each other.
Dawn O’Neil AM [19:44]
And what a lot of difference that made for those teams did enable that. This might be a good chance – there’s a lot of leaders in the room. Has anyone got a question or comment?
I’d like to make a comment, and say thank you. Having worked in people and culture in a public hospital. And it’s very emotional hearing all of this because it’s still quite raw. And I think one of the things that we really achieved in change was breaking down the silos between clinical and non clinical and working together, and learning about leadership and getting the clinical like people to kind of go, I’ve never really had time to invest in leadership. And I want to be a leader that I’ve never had time to practice on that, how I made that happen now? And they lent into it, and they were amazing. And they weren’t, oh, it was just a really felt like it broke down silos, basically. And then to be able to share a space where, you know, they’d be able to come in and go, I want to cry right now. And I’d be like well I want to cry too. So let’s cry together and I felt like it really joined up something that I think… Well, you mentioned here that has always been clinical, non clinical, like these silos in workplaces in public health. And I feel like, it’s a real opportunity now to leverage of that, and bring it down and work together. So I thank you for, you know, pulling all together. Because I know, in people and culture how hard it is to get people to take the time to write and talk about their experiences.
Dawn O’Neil AM [21:28]
And we know for systems Change to happen, there has to be a burning platform to be voted on. And really something for people to rally around. This is the change we want to make. And I think there’s, there’s so much to be learned from the information you’ve gathered, the stories and experiences. And it’s really been focusing that so that the change does happen.
Professor Marie Bismark [21:55]
And Natasha’s a real numbers person and the book is also complemented by these peer-reviewed scientific papers, which actually quantify the level of distress. And I’ve always thought that quantitative research is the skeleton and the bones and that qualitative research, puts the flesh on the bones, and that you need both to use a number of stories to drive change. And so one of the quantitative papers, one of the team health practitioners have thoughts of self-harm and suicide in two weeks before. And then you also have the stories in this book of people saying I would have jumped out the window of my apartment, except that the window wouldn’t open. You know, you hear these really heartbreaking stories, but also the quantitative research to back them up.
Dawn O’Neil AM [22:44]
And that the other thing that’s that jumped out at me was the number of people talking about burnout and the experiences of burnout. And it was not just as a result of the pandemic, but there was already a feature of the workplace. And we know that burnout is a workplace issue. And it is very much something a failure of management to provide a safe workplace. So. So there’s work to be done, for sure. And you know, that burning platform, I hope becomes the lever to really push change,
Associate Professor Natasha Smallwood [23:17]
Two things that actually haven’t come up that I think are really critical. And that needs to be acknowledged, or one, gender discrimination has got worse as a result of the pandemic, which comes out extremely clearly in the study, and in fact, would never have come out through our quantitative research if we hadn’t had the qualitative side. And it’s particularly relevant given the massive international women’s day that we take that focus into our lens. So there is so many stories of women of all different disciplines and roles and seniority, saying the gender divide has just massively increased. I’m not visible, I’m given these appalling roles. Whereas typically, the white male leader is held up and gets all the glory. And I’m being pushed to one side. So again, we have to acknowledge that gender bias gets worse during a crisis, we have to be proactive in addressing that because more than 50% of the workforce is women, in fact, 70 to 80% of them because of women being the nursing and allied health and well being. So if we ignore that, we’re ignoring 80% of the health workforce who has actually profound skills and can contribute. So gender bias is really important. The other thing I just want to talk about this burnout, because the reason women get more burnout. And this comes from data from the UK, is that on average, women do an extra 11 hours of unpaid work at home. And if there’s one thing I regret, we didn’t ask about unpaid hours at home, because you can only ask people so many questions before they get annoyed with you. So I really had to balance that when I designed the survey quantitatively, but we know that there’s an extra 11 hours you know I had three children, homeschooling mothers working as a physician. So I’m like everybody else who had to manage that. And that is a real risk for the female members of the workforce. And yet, we don’t actually take that into consideration an awful lot And the other thing around burnout, it’s it’s wonderful. We’ve got technology, and we can do telehealth, and we have email. But frankly, I get emails in the middle of the night. I’m sick of having emails at midnight thinking, what were you doing, you know, all across the weekend. And I’m just as guilty because I work six days a week doing a lot of research and other bits and pieces. And, you know, you increasingly start seeing on people’s email signature saying, I work strange hours, that doesn’t mean I expect you to, but actually, you know, telehealth at home patients calling us know how all this stuff, actually, where is the work, life divide? The balance is gone. So in embracing technology in this new world, we actually need to put some safeguards in because we’re only gonna make it worse for the workforce. And again, the workforce then says, I’ve had enough. I’m out of here. So I think that just important points that we have touched on.
Dawn O’Neil AM [25:47]
A very big leadership challenge, she said, and require great Leadership to really give permission for people to be able to have their own space, time to recover.
Professor Marie Bismark 26:01][
And I think once people have that severe burnout, or really, clinically significant levels of psychological distress, the services that are available to help you workers are not meeting the needs. You know, we saw how few of these health care workers were accessing employee assistance programs, they were getting emails every week, telling them to call the employee assistance programs. You know, and there’s a chapter in the book, you know, for people saying it just felt like another thing to do on my to do list, I was exhausted, I knew that I needed help, I was having suicidal thoughts, I wasn’t coping, and trying to find someone who could help me who was available during hours when I wasn’t working. Someone who understood my experience of being a healthcare worker, it just felt too hard. And we’ve seen some amazing initiatives. So as young psychiatrists, we just started Tahne Brinson set up a peer support network called Hand in Hand, which is now a national peer support network for healthcare workers. But she’s done all of that as a volunteer, you know, a smell of an oily rag trying to pull volunteers and to speak to distressed healthcare workers in the middle of the night. And I think we really need to think about funding health services for health practitioners that meet their needs are available when they need them and staffed by people who really understand the challenges of being a health worker.
Associate Professor Natasha Smallwood [27:25]
And just on that point, we have Patrick Johnson in the room here and he’s the Medical Director for the Victorian Doctor’s Health Program, so wonderful. And I would declare my conflict of interest, because I’m a board director at VDHP. And doing all this work in the surveys, why I decided that I would actually step up and offer to be on my board. But you know, I’ve been to this country for 20 years, when I trained overseas and I worked overseas, I didn’t even know that that program exists. And in fact, a lot of doctors don’t know what’s easiest, and most health professionals actually don’t know. And also, the funny thing is, sometimes those programs become quite stigmatised, and you think well that’s where the naughty doctors go. And so we do see that people know something exists, but think that’s not for me. And so having initiatives that are actually desired by the workforce is quite critical. Because again, one of the things that kind of grated on people at the start of the pandemic was here have an app. Here’s a wellbeing app, to meditiate. And, you know, for some people, that’s correct. So that 10 to 12% of people in our survey, loved the app, you know, and we developed, but for a lot of them, they said, Well, thanks, but that’s really tokenistic, I really wanted to talk to someone, and I want that person to listen to me. So I think peer support debriefings are absolutely critical. And we need to be innovative, but not just rely on sort of simplified measures, like apps.
Professor Karen Willis [28:49]
The other thing that comes up really strong data, is the need to be proactive. Because all that helps seeking is putting the onus back on the individual, when you’re stressed. But our view is, you know, all the support for you just need to go. That’s the last thing. And so being proactive and the stuff around Leadership, checking in, I think, Gosh, however, how many times is checking in and being visible mentioned throughout the comments, it’s really, really great and checking in and, and having the authentic supports in place.
Dawn O’Neil AM [29:27]
And it’s not that hard to do. But I think for leaders to know how important that is.And what a difference that could make. Could be a game changer. And we’ve got I think we could talk about very conscious you’re standing on your feet. So maybe just one final comment from each of you as we wrap up. Maybe just the thing that you take home message or the thing that struck you as being I guess the most influential
Professor Marie Bismark [30:00]
To it was the idea that this is not the last crisis that we’re going to face, and that there were other crises coming, like Climate Change, and that we owe it to our children into the next generation of nursing students and medical students to have a healthcare system that’s really, for those next crises that are coming.
Professor Karen Willis [30:26]
For me, I think it’s thinking about the hierarchies that exist in the healthcare system. And when I read, deeply traumatised of a senior doctor, or I can think about is, what about the rest of the workers, this is supposed to be somebody who is positioned higher in the hierarchy. And that speaks volumes to me about all the other healthcare workers.
Dr Sophie Lewis [30:51]
I think it’s for me again, probably the been saying, like that was the thing that struck me the most, is being seen, being valued, and they recognised. Yep, it just kept coming out. Being invisible, feeling you were forgotten about. Particularly, after the public support kind of subsided, and time went on, they just felt like I would just completely forgotten. Some people did. How do we help people to feel validated and really actually recognised for what they’re doing?
Associate Professor Natasha Smallwood [31:30]
Thanks, me feel like I’m patting myself on the back here. But I think what comes out is how amazing the health workforce is. And that this is a really precious asset, you cannot replace the health workforce. It is highly skilled, highly accomplished. These are just really good people. You know, they are they were normal people like all of us. I mean, top of most incredible stories, about their lives, their professional lives, and you just get this sense of this thought of wow, I’m so grateful to these people who I work with. They’re fabulous, and we need to value them and care for them long term.
Dawn O’Neil AM [32:05]
Well, that’s a wonderful note to finish on. You know, I concur completely. You know, we are so appreciative of the health system and health care workers at all different levels. But very rarely do we actually express that. So I think it’s something for us all to be very conscious of and let’s hope it becomes something that is just part of the norm, so that all of us are known to be seen and heard and valued. And that leadership is trained to support and acknowledge those workers so that we’re prepared for the next crisis. This won’t be the last. Thank you all so much for coming.