Insights Series Issue 9: "How to manage the impact of caregiver stress and trauma in the COVID-19 era"

Insights Series Issue 9 siemens-healthineers.com/ improving-patient-experience The New Normal Relief Stress Anxiety Depression Trauma Managing the impact of caregiver stress and trauma in the COVID-19 era: a strategy toward resilience-building A thought leadership paper on “Improving patient experience” co-authored with James S. Gordon, MD, The Center for Mind-Body Medicine SIEMENS Healthineers Preface The Insights Series The Siemens Healthineers Insights Series is our preeminent thought leadership platform, drawing on the knowledge and experience of some of the world’s most respected healthcare leaders and innovators. The Series explores emerging issues and provides you with practical solutions to today’s most pressing healthcare challenges. We believe that increasing value in healthcare – delivering better outcomes at lower cost – rests on four strategies. These four principles serve as the cornerstones of the Insights Series. Expanding Transforming Improving Digitalizing precision care patient healthcare medicine delivery experience The New Normal The New Normal is a special edition of our Insights Series focusing on the COVID-19 pandemic. This series provides recommendations on how to confront the current SARS-CoV-2 outbreak and its implications, as well as strategies and ideas on how to emerge from the current crisis stronger, more resilient, and better prepared to address the healthcare challenges that lie ahead. Please visit siemens-healthineers.com/insights-series Executive summary The COVID-19 pandemic has had a devastating global treatment. Still others fear the impact of stigma and the impact and one of the sectors that has been hit possibility their mental health concerns might make hard is healthcare. Its leaders and staff have, at times, it harder for them to obtain licensure in the future. This been asked to make unthinkable life and death makes it even more critical – and difficult – to offer decisions. For many, this has come at an overwhelming them the support they need to ensure their long-term physical, mental and emotional price – the extent well-being. of which will not be fully realized for years to come. The ability of healthcare leaders to address their For almost 30 years, the Washington DC-based Center for staff’s trauma and stress will be essential to their Mind-Body Medicine (CMBM) has been a leader in developing organization’s long-term viability and the future of strategies and techniques to successfully address population- patient care. wide psychological trauma. Their international faculty has trained more than 6,000 health professionals, educators, and community leaders around the world in their Trauma and healthcare pioneering mind-body medicine model of self-care, self- awareness, and group support.5, 6 The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), defines trauma as “an event, At a time like this, as the world struggles with the COVID-19 a series of events or a set of circumstances that is pandemic, the CMBM’s proven techniques and expertise experienced by an individual as physically or emotionally are of particular value. This paper looks at some of the harmful or life threatening.”1 Stress, trauma, and related innovative ways in which the CMBM has helped individuals “burnout” are not new phenomena for healthcare providers. and communities in the past, and the insights they have According to the National Academy of Medicine as acquired. It also presents practical suggestions on how many as half of the doctors and nurses in the United States these evidence-based techniques can be applied and what have experienced it, resulting in increased risks to healthcare providers can, and should, learn from them. patients, malpractice claims, worker absenteeism and turnover costing the medical industry billions of dollars in losses every year.2 While it’s impossible to determine the full impact stress-related trauma from COVID-19 will have on frontline staff, initial studies from China indicate it has already taken a great toll there with some 50.4% of those surveyed reporting symptoms of depression, 44.6% reporting symptoms of anxiety and 34.0% reporting symptoms of insomnia.3 Doctors and nurses are notoriously skeptical patients and can be particularly resistant to addressing their own mental health issues.4 Many have been “programmed” to cope alone or may not feel they have the time to seek Siemens Healthineers Insights Series · Issue 9 3 The challenge The COVID-19 pandemic has already had devastating global healthcare leaders and their staff. There was a lack of consequences. Few foresaw how quickly it would spread, basic personal protective equipment (PPE). In countries leaving many countries unable to fully address the around the world, ICUs reached capacity and concerns public health crisis to follow. Early on, it became apparent over ventilators and related life and death decisions left that many hospitals in the hardest hit areas were not staff overwhelmed. Difficult choices had to be made. adequately prepared to protect their staff and safely care Fear grew and stress levels increased. for patients, leading to increased anxiety in both Simultaneously, healthcare leaders watched as their revenue plummeted. Elective surgeries were cancelled, and patients were either told to or chose to stay at home to minimize the possibility of contracting the virus. Meanwhile, in the United States, a Health Affairs study COVID-19 found that a single hospitalized case would cost a impact on healthcare median of $14,366 during the course of the infection.7 system* For those hospitals already struggling financially, the consequences may prove disastrous. Stories quickly began to circulate online about layoffs and staff $ being moved into new roles in ICUs without sufficient training, while the numbers of infections and deaths A single hospitalization continued to rise. would cost a median of $14,366 during the course of the infection.7 * Figures from U.S. 4 Issue 9 · Siemens Healthineers Insights Series The impact It is clear, healthcare systems will not be the same after Each person’s experience of trauma is unique. It affects COVID-19. Healthcare professionals have faced them differently and at different times. Even prior to unprecedented challenges at a tremendous personal cost. COVID-19, post-traumatic stress disorder (PTSD) was more In addition to overwhelmingly stressful and sometimes prevalent in healthcare providers (about 15%) than in traumatic work situations, many faced loneliness and the general population (3% to 4%).8 Some healthcare isolation at home, as they were forced to distance themselves providers have already begun to exhibit visible indications from loved ones whom they feared they might infect. The of it, becoming emotionally avoidant, or having bouts healthcare systems and the way they did things before of uncontrollable anxiety, sadness or shame.9 The impact of were disrupted. In the wake of this crisis many have been traumatic events can be deceptive and even destructive – left feeling uncertain of what the future holds. but what is certain is they will have an impact. COVID-19 impact on healthcare workers* + + 44.6% 50.4% 34% Anxiety3 Depression3 Insomnia3 Consequences include: • Increased rates of illness • Operational troubles at healthcare facility • Personal consequences (motivation, enthusiasm for job, …) * Figures from China Siemens Healthineers Insights Series · Issue 9 5 Those able to cope now, may suddenly find it difficult to The Limeade Institute’s 2019 white paper “The Science of function later. It may become increasingly hard for them Care”, found that some 60% of workers who said they to focus and regulate their emotions. They may begin felt cared for planned to stay with their companies for three to take more sick days as their immune systems and general or more years, compared to only 7% of those who said well-being are compromised by the persistent stress. they don't feel cared for.11 The report defined "care" As the National Academy of Medicine noted, the effects of as providing what's necessary for the "health, welfare, stress are not only worrying for healthcare professionals maintenance and protection" of someone or something but also for its effect on patient care and outcomes. Staff and their needs. This feeling of being “cared for” translates who feel they were not well-protected or cared for during not only to higher retention rates, but also greater the pandemic may become disgruntled or disengaged. engagement in work (94% v. 43%); improved stress Some may choose to leave. Prior to COVID-19 many management (50% v. 14%) and lower burnout rates were already considering it. A survey of 23,000 hospital (56% v. 16%). This demonstrates that how health leaders nurses in 10 countries in Europe reported that 9% of support their staff now will likely have a lasting effect the nurses intended to leave their profession, varying from on health systems and the level of care they provide in 5 to 17% between different countries.10 the future. During the pandemic many clinical settings and health systems were forced to change their longstanding Intended to leave practices and engage in or ramp up new initiatives, like their profession new technologies, new processes, and new hygiene protocols, to protect patients from possible infection from COVID-19. While done to ensure patient safety, the required redesign and in some cases new technology, at times, added to the stress healthcare providers were already under, potentially placing patients at 9% of the nurses in 10 European greater risk.12 countries intended to leave their profession,10 potentially harming patient care and increasing organisational costs. 6 Issue 9 · Siemens Healthineers Insights Series The solution What can be done for stress and trauma relief? Traumatic events, such as facing a pandemic or the diagnosis Outcome measures for of a life-changing disease, can trigger the body's participants of stress and sympathetic nervous system (SNS), releasing stress hormones and causing physical reactions, like a racing trauma relief programs: heartbeat, inhibited immune function, and high blood pressure. This is known as the “fight” (stay and react • Improved mood, quality of life, to the problem) or “flight” (escape the threat) response. and professional satisfaction Normally, the parasympathetic nervous system or • “rest and digest” response is soon activated, and the Significant decrease in levels of vagus nerve tells the heart to slow down and conserve stress, burnout, depression energy, calming the body after the danger has passed, • Improved job satisfaction and usually within 20-30 minutes. working relationships • Positive impact on health symptoms • Greater sense of meaning and purpose Rest and digest response The vagus nerve tells the heart to slow down and conserve energy, calming the body after the danger has passed, usually within 20-30 minutes. 5, 6, 16 Siemens Healthineers Insights Series · Issue 9 7 When fight-or-flight persists long after the threat is over, The Center for Mind-Body Medicine (CMBM) has frontline or the threat is continuous, it may cause long-term physical experience in developing and implementing trauma and psychological damage and disorders, including relief programs in places deeply affected by catastrophic hypertension, type II diabetes, major depressive disorder, events. They created one of the world’s largest trauma rand post-traumatic stress disorder (PTSD). Symptoms relief programs in Gaza. In addition they worked in Haiti, of PTSD may begin within weeks of the triggering event, helping to control the emotional toll of the devastation or can take months, even years to manifest. They can after the earthquake of 2010 and after Hurricane Matthew be disabling, and include anxiety, irritability, difficulty destroyed large parts of the island in 2016. Their first- sleeping and concentrating, or persistent emotional hand experience has provided them with deep insights numbing and withdrawal. When these symptoms continue into the complex ways in which people react to situations for long periods of time, they can significantly interfere of stress and trauma, and in how to develop successful with a person’s work and home life.5, 6, 16 stress and trauma relief programs. Mind and body reaction to an experience.19 Anxious Relaxed K Reduces Increases • Mental processing • Mental focus capacity • Biomarkers in blood • Digestion and or saliva: ACh nutrient absorption • Immune response K K Increases Reduces • Emotionally • Emotional reaction sensitive and • Heart rate reactive • Respiration rate • Biomarkers in blood and saliva: • Blood pressure Catecholamines ‒ Cortisol level ‒ Alpha-amylase ‒ • Heart rate • Respiration rate • Blood pressure 8 Issue 9 · Siemens Healthineers Insights Series A three-part strategy for developing successful stress and trauma relief programs Part 1: Guided imagery has been found to be particularly helpful. Incorporating mind-body techniques The brain centers where images are formed are as self-care for stress and trauma relief connected with the limbic or emotional brain, including the amygdala and hippocampus, and with the hypothalamus Mind-body techniques like mindful breathing with the which controls the autonomic nervous system and its abdomen soft and relaxed, biofeedback, and guided fight-or-flight and freeze responses. These connections imagery have been shown to be effective antidotes to the make it possible to improve physical and mental fight-or-flight response. Regular, daily mindful breathing functioning and reverse the damage done by trauma. These activates the vagus nerve, quieting the fight-or-flight techniques have also been found to be particularly response, lowering blood pressure, improving immunity, effective in reducing patients’ preoperative and postoperative decreasing anxiety, enhancing the person’s capacity for anxiety and pain after surgical procedures or when getting concentration, and making them more compassionate an MRI scan.13, 14 toward themselves and others. The value of incorporating self-care techniques has been well-documented. After a near fatal ski accident Mark T. Bertolini, the former CEO of Aetna, the international health insurer, used self-care techniques to heal. After having experienced the benefits first hand, he decided to Mind-body offer a similar program to Aetna employees. This led to techniques a change in culture and subsequent increase in productivity, which translates to staff gaining on average of 62 minutes per week, which Aetna estimates is worth $3,000 per employee per year. Additionally, the company’s healthcare costs fell 7.3 percent the first year, representing about Techniques for $9 million in savings.15 self-awareness, self-care, and self-expression for stress and trauma relief. Siemens Healthineers Insights Series · Issue 9 9 Part 2: Furthermore, CMBM has worked with small groups at Benefiting from healthcare facilities and medical schools. Since 1993, their expert-led small groups trained faculty have been providing Mind-body Skills Groups (MBSG) for students at the Georgetown University The Center for Mind-Body Medicine has found that being School of Medicine. The program has since expanded to a part of a facilitated group significantly enhances 15 U.S. medical schools with many other schools recognizing participant outcomes. In their work with U.S. veterans, the benefits and including mind-body practices in participants said they found it far more comfortable their curriculum. A study of medical students who practiced to engage with a group of peers than in individual sessions these techniques showed many health benefits, including in which they often felt objectified and stigmatized. lowered levels of stress, improved mood, sleep, and Over the years, many spoke of the camaraderie and of academic performance, greater hopefulness about becoming the benefits of feeling like they were “all in it together,” physicians, and, importantly greater compassion for learning from and supporting each other. each other. Many noted that they were also able to use the skills they learned with the patients with whom they were working.16, 17 In response to the unprecedented stress and trauma of the COVID-19 pandemic, CMBM launched an online program Expert-led of self-care and social support for healthcare workers small groups and others afflicted by COVID-19. The majority of participants said that the techniques they learned gave them the balance they needed to deal with the fears and challenges of the pandemic, and that the group has been their single most important source of support. Promoting a feeling of trust, learning and supporting each other. 10 Issue 9 · Siemens Healthineers Insights Series “Almost anyone who is committed to helping others can do this work. They have to be willing to learn the material and to use it to deal with their own psychological and emotional issues. We then teach them to share what they’re learning with others and provide ongoing supervision and mentorship.” James S. Gordon, MD Part 3: stress-reduction, mind-body medicine, nutrition, exercise, Sustaining mind-body health and group support. The organization saw a substantial by training the trainers reduction in their previously escalating healthcare costs, which went from 5% growth per year to just 1% per year Everyone, from radiologists to emergency medical after the program was implemented.18 technicians, go through the same, rigorous, evidence-based training program. They initially learn the science of mind-body medicine, and practice the skills themselves in the small, faculty-led groups that are a core part of the training and preparation required to lead the groups. In the advanced training, after intensive coaching sessions, Training the the participants themselves lead the small groups, trainers taking responsibility for teaching the science, as well as facilitating the group process. They then enter an intensive process of supervision and self-reflection, as they integrate the CMBM model into their ongoing work with individuals and families, and into the small groups they form. Sustaining mind-body health among care teams and improving the patient experience In 2015, Eskenazi Health (Indiana), one of the largest safety by training the trainers. net health systems in the U.S., partnered with CMBM to create a comprehensive wellness program for more than 4,500 employees and more than 100,000 patients in their care. More than 300 staff were trained in self-care, Siemens Healthineers Insights Series · Issue 9 11 Conclusion Healing after trauma In the wake of the COVID-19 pandemic healthcare providers 2. Incorporate stress and trauma relief and the communities they serve will need programs to into the workplace provide trauma relief and address ongoing stress. Without proper coping skills, many are likely to develop long-term Healthcare systems that incorporate proven and psychological and physical disorders. scientifically-based mind-body medicine programs in small group formats and support their staff now A deeper understanding of how stress and trauma can will have more positive long-term outcomes. Effective affect healthcare professionals is essential to protecting trauma relief and resilience building is essential them – just when they are needed most. Taking steps not only for staff well-being, but also that of the to safeguard their health and well-being not only helps organization itself. them safely navigate their own way through this crisis, it also helps ensure that patients can receive the care they 3. Develop a true culture of caring so urgently need. and well-being Institution-wide programs in self-care, based in facilitated small groups, give healthcare leaders the means to Three specific strategies healthcare providers can help their staff manage their stress. Working together, implement toward resilience-building: organizations can create a culture that values the well-being of all and promotes feeling “cared for” as 1. Promote mental and physical self-care an organizational principle, potentially reducing Healthcare professionals need to know that it’s okay, burnout, increasing retention rates and improving the not to feel okay. They also need to feel that their patient experience. well-being matters to their organization. Healthcare leaders should ensure that all staff have the skills The COVID-19 pandemic has put our healthcare system they need to be mentally and physically well and under unprecedented strain. It is essential that we resilient, so they can provide the best care possible understand the stress and trauma that healthcare workers for their patients – under any circumstance. Mind-body experience and take steps to deal with it. The proposed techniques such as mindful breathing, active meditation, strategy provides a roadmap of how stressful situations can movement, biofeedback, and guided imagery are be effectively overcome and how the debilitating effects part of the program to teach self-awareness, self-care, of trauma can be reduced. and self-expression skills. 12 Issue 9 · Siemens Healthineers Insights Series References 1. SAMHSA's Concept of Trauma and 7. Bartsch SM, Ferguson MC, McKinnel JA, 13. Tusek D, Church JM, Fazio VW. Guided Guidance for a Trauma [Internet]. O’Shea KJ, Wedlock PT, Siegmund SS, Imagery as a Coping Strategy for Substance Abuse and Mental Health et al. The Potential Health Care Costs And Perioperative Patients [Internet]. 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Physicians Postgraduate Press, 12. PatientEngagementHIT. How Does Provider [cited 2020 May 4]. Available from: Inc.; 2008 Sep 30 [cited 2020 May 2]. Burnout Impact Patient Care Quality, ncbi.nlm.nih.gov/pmc/articles/ Available from: Care Access? [Internet]. 2018 Sep 06 PMC4372185/ psychiatrist.com/JCP/article/Pages/2008/ [cited 2020 May 2]. Available from: 18. MIND-BODY MEDICINE: The Heart of v69n09/v69n0915.aspx patientengagementhit.com/news/ Ancient Healing, the Frontier of Modern 6. Staples JK. Mind-body skills groups for how-does-provider-burnout-impact- Healthcare [Internet]. 2018 [cited 2020 posttraumatic stress disorder and patient-care-quality-care-access May 24]. Available from: org/wp-content depression symptoms in Palestinian uploads/2018/05/20180510-james- children and adolescents in Gaza [Internet]. gordon-mind-body-medicine-webinar.pdf International Journal of Stress 19. Carlson NR. Physiology Of Behavior. 11th Management. 2011 [cited 2020 May 2]. ed. Boston, MA: Pearson Custom Available from: Publlishing. 2013. Chapter 17: Anxiety psycnet.apa.org/record/2011-13205-001 Disorders and Stress Disorders; p. 601-612. Siemens Healthineers Insights Series · Issue 9 13 About the authors James S. Gordon, MD Andrea J. Miller CEO and Founder at Principal Consultant, Patient Experience and The Center for Mind-Body Medicine (CMBM) Trend Scout at Siemens Healthineers James S. Gordon, MD, author of “The Transformation: Discovering Andrea J. Miller is a Principal Consultant, nationally recognized as an Wholeness and Healing After Trauma”, is a world-recognized expert in patient experience, engagement, and caregiving. She is authority on post-traumatic stress and a mind-body medicine also a specialist in behavioral health and the related use of digital pioneer. A long-time researcher at the National Institute of Mental health technology. Before her work with Siemens Healthineers, she Health and a Clinical Professor at Georgetown Medical School, he consulted the WHO, UNAIDS, the UN Refugee Agency, the CDC and was chairman (under Presidents Clinton and GW Bush) of the White New York City Department of Health and Mental Hygiene, as well as House Commission on Complementary and Alternative Medicine numerous health tech startups. Her policy papers and thought Policy. As Founder and Executive Director of The Center for Mind- leadership have been published by the UN, Entrepreneur.com and Body Medicine in Washington, D.C., Dr. Gordon, a psychiatrist, has Thrive Global, among others. Andrea holds a Master in International created and implemented the world’s largest and most effective and Intercultural Management from the School of International program for healing population-wide psychological trauma and Training (SIT) and completed post-graduate studies at the UPenn dealing with chronic stress. He and his 140 international faculty School of Social Policy and Practice. have brought this evidence-based program of self-care and group support to more than 6,000 health professionals and the institutions in which they work, including VISN-8, the largest division of the US Veteran’s Administration and Eskenazi Health, Indiana’s premier safety-net system, as well as to communities in the U.S. and overseas that have been devastated by war, climate-related disaster, the opioid epidemic, school shootings, and historical trauma. Isabel Nieto Alvarez, MSc Christina Triantafyllou, PhD Senior Key Expert on Improving Vice President Head of Improving Patient Experience at Siemens Healthineers Patient Experience at Siemens Healthineers Isabel Nieto is passionate about innovating and transforming the Christina Triantafyllou began her journey in healthcare at experience of care to be human-centered. She is part of the Massachusetts General Hospital, Boston, U.S., where she worked as Siemens Healthineers Global Innovation Network as expert on a medical physicist, developing imaging technology for the study of patient stressors in the experience of care. Isabel has lead and brain anatomy and function in disease. Thereafter she joined supported cross-functional teams in marketing and innovative Siemens Healthineers as the Director of Global Ultra High Field (UHF) projects on patient experience. She is a biomedical engineer from Business Management in the Business Line MR, focusing on business Universidad Iberoamericana in Mexico, holds a Master in Science on strategy, KOL-based collaboration projects in innovation/clinical Mind and Body Medicine from Saybrook University in California, and translation, and product management for the first worldwide clinical a Certification on Leadership in Healthcare without Harm. 7T MR system. Christina holds a PhD in the field of Medical Physics from Kings College, University of London, UK. Prior to joining Siemens Healthineers, she held appointments as faculty at Massachusetts General Hospital, Harvard Medical School and as the Associate Director of the Imaging Center at the Brain and Cognitive Sciences Department at Massachusetts Institute of Technology (MIT), Boston, U.S.. 14 Issue 9 · Siemens Healthineers Insights Series Suggested follow-up on Siemens-healthineers.com/news Improving Patient Experience • Siemens Healthineers Insights Series, issue 3: What has real impact on the patient experience, and what doesn't? Available at: siemens-healthineers.com/insights/ news/insights-series-issue-3.html • Siemens Healthineers Insights Series, issue 5: Reducing fear and anxiety by re-designing the patient experience. Available at: siemens-healthineers.com/insights/ news/redesigning-patient-experience.html • Siemens Healthineers HBR white paper: Improving the patient experience: a four part-approach to delivering the care patients want and need. Available at: siemens-healthineers.com/insights/ news/mso-hbr-improving-patient-exprience.html • Siemens Healthineers Talks with Jason A. Wolf, President of the Beryl Institute: How can we improve the patient experience in healthcare? Available at: siemens-healthineers.com/insights/ news/shs-talks-wolf.html Information: The Siemens Healthineers Insights Series is our preeminent H. thought leadership platform, drawing on the knowledge and experience of some of the world’s most respected healthcare leaders and innovators. It explores emerging issues and provides practical solutions to today’s most pressing healthcare challenges. All issues of the Insights Series can be found here: siemens-healthineers.com/insights-series M Contact: For further information on this topic, or to contact the authors directly: Christina Triantafyllou, PhD Vice President Head of Improving Patient Experience [email protected] Siemens Healthineers Insights Series · Issue 9 15 At Siemens Healthineers, our purpose is to enable healthcare providers to increase value by empowering them on their journey towards expanding precision medicine, transforming care delivery, and improving patient experience, all enabled by digitalizing healthcare. An estimated five million patients worldwide every day benefit from our innovative technologies and services in the areas of diagnostic and therapeutic imaging, laboratory diagnostics and molecular medicine as well as digital health and enterprise services. We are a leading medical technology company with over 120 years of experience and 18,500 patents globally. With about 50,000 dedicated colleagues in over 70 countries, we will continue to innovate and shape the future of healthcare. Siemens Healthineers Headquarters Siemens Healthcare GmbH Henkestr. 127 91052 Erlangen, Germany Phone: +49 9131 84-0 siemens-healthineers.com Published by Siemens Healthcare GmbH · Printed in Germany · 9236 0720 · ©Siemens Healthcare GmbH, 2020