Combat Stress Management and Resilience: Adapting Department of Defense Combat Lessons Learned to Civilian Healthcare during the COVID-19 Pandemic.

Abstract

Health SecurityVol. 18, No. 5 CommentaryFree AccessCombat Stress Management and Resilience: Adapting Department of Defense Combat Lessons Learned to Civilian Healthcare during the COVID-19 PandemicEric K. Wei, Jeremy Segall, Rebecca Linn-Walton, Monika Eros-Sarnyai, Omar Fattal, Olli Toukolehto, Charles Barron, Alison Burke, David M. Benedek, James C. West, Michael Fisher, David Shmerler, and Hyung J. ChoEric K. WeiEric K. Wei, MD, MBA, is Chief Quality Officer; Jeremy Segall, MA, RDT, LCAT, is Chief Wellness Officer; and Hyung J. Cho, MD, is Chief Value Officer; all in the Office of Quality and Safety, New York City Health and Hospitals, New York, NY.Search for more papers by this author, Jeremy SegallEric K. Wei, MD, MBA, is Chief Quality Officer; Jeremy Segall, MA, RDT, LCAT, is Chief Wellness Officer; and Hyung J. Cho, MD, is Chief Value Officer; all in the Office of Quality and Safety, New York City Health and Hospitals, New York, NY.Search for more papers by this author, Rebecca Linn-WaltonRebecca Linn-Walton, PhD, LCSW, is Assistant Vice President; Omar Fattal, MD, MPH, is Deputy Medical Director; and Charles Barron, MD, is Deputy Medical Officer; all in the Office of Behavioral Health, New York City Health and Hospitals, New York, NY.Search for more papers by this author, Monika Eros-SarnyaiMonika Eros-Sarnyai, MD, MA, is a Best Practices Specialist, New York City Department of Health and Mental Hygiene, New York, NY.Search for more papers by this author, Omar FattalRebecca Linn-Walton, PhD, LCSW, is Assistant Vice President; Omar Fattal, MD, MPH, is Deputy Medical Director; and Charles Barron, MD, is Deputy Medical Officer; all in the Office of Behavioral Health, New York City Health and Hospitals, New York, NY.Hyung J. Cho and Omar Fattal are also Clinical Associate Professors, Department of Medicine, NYU Grossman School of Medicine, New York, NY.Search for more papers by this author, Olli ToukolehtoOlli Toukolehto, MD, is a Major, Medical Corps, United States Army, and Deputy Department Chief, Adult Behavioral Health, Fort Belvoir Community Hospital, Fort Belvoir, VA.Search for more papers by this author, Charles BarronRebecca Linn-Walton, PhD, LCSW, is Assistant Vice President; Omar Fattal, MD, MPH, is Deputy Medical Director; and Charles Barron, MD, is Deputy Medical Officer; all in the Office of Behavioral Health, New York City Health and Hospitals, New York, NY.Search for more papers by this author, Alison BurkeAlison Burke, JD, is Vice President, Regulatory and Professional Affairs, Greater New York Hospital Association, New York, NY.Search for more papers by this author, David M. BenedekDavid M. Benedek, MD, is Professor and Chair; and James C. West, MD, is an Associate Professor; both in the Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD.David M. Benedek is also a Colonel, United States Marine Corps. Michael Fisher, MSW, is Chief Readjustment Counseling Officer, Veterans Health Administration, Washington, DC.Search for more papers by this author, James C. WestDavid M. Benedek, MD, is Professor and Chair; and James C. West, MD, is an Associate Professor; both in the Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD.Search for more papers by this author, Michael FisherDavid M. Benedek is also a Colonel, United States Marine Corps. Michael Fisher, MSW, is Chief Readjustment Counseling Officer, Veterans Health Administration, Washington, DC.Search for more papers by this author, David ShmerlerDavid Shmerler, PhD, is Director of Counseling Service Unit, Fire Department of the City of New York, New York, NY.Search for more papers by this author, and Hyung J. ChoAddress correspondence to: Hyung J. Cho, MD, Chief Value Officer, New York City Health + Hospitals, 125 Worth Street, Suite 507, New York, NY 10013 E-mail Address: harryjcho@gmail.comEric K. Wei, MD, MBA, is Chief Quality Officer; Jeremy Segall, MA, RDT, LCAT, is Chief Wellness Officer; and Hyung J. Cho, MD, is Chief Value Officer; all in the Office of Quality and Safety, New York City Health and Hospitals, New York, NY.Hyung J. Cho and Omar Fattal are also Clinical Associate Professors, Department of Medicine, NYU Grossman School of Medicine, New York, NY.Search for more papers by this authorPublished Online:12 Oct 2020https://doi.org/10.1089/hs.2020.0091AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail At the time of this writing, severe acute respiratory syndrome coronavirus 2 has caused over 7.6 million cases and over 423,000 deaths worldwide.1 New York City confirmed its first positive case on March 1, 2020, and quickly became the center of the pandemic, with over 214,000 confirmed cases to date.2 To provide support to overwhelmed New York City hospitals, the Department of Defense (DOD) was deployed to provide medical care for patients at the Javits Center Field Hospital (Javits) and United States Naval Ship Comfort (USNS Comfort) in April 2020. Due to low patient populations at Javits and USNS Comfort, many DOD personnel redeployed to the city's public healthcare system, New York City Health and Hospitals (NYC H+H), to provide frontline care within emergency departments, intensive care units, and medical/surgical wards.3 Additionally, Javits changed its admission criteria to include patients who tested positive for COVID-19, which ultimately led to the acceptance and treatment of over 1,000 patients with COVID-19. From this experience, DOD healthcare workers reported to their leadership that what they witnessed was the closest approximation to mass-casualty events during combat operations that they have experienced in a civilian setting.The United States military has deployed in combat operations in Afghanistan, Iraq, and Syria almost continuously since 2001. Sustained combat deployments taught many hard lessons about the effects of prolonged combat stress on the emotional and psychological wellbeing of service members. In response, the DOD created comprehensive combat stress management and resilience programs that include recurring interactive trainings, unit and service member needs assessments, periodic mental health evaluations, and treatment before, during, and after operational deployments.4 The stigma associated with obtaining behavioral health care continues to be addressed at all levels of the military. For instance, service members can often obtain combat and operational stress control support during deployments without receiving annotations or notes in their medical records. Furthermore, behavioral health care for deployment-related symptoms does not have to be reported during security clearance evaluations.Through the New York City Office of Emergency Management and the Office of the First Lady of New York City, the DOD offered to collaborate with NYC H + H to share lessons learned from their combat stress management and resilience programs. NYC H + H is the largest municipal healthcare system in the United States with 11 acute care hospitals, 5 skilled nursing facilities, and over 70 ambulatory care sites, providing care for the 5 boroughs. Positive COVID-19 cases and deaths have been disproportionately higher in Black and Latinx New Yorkers, which has deepened the traumatic impact of the pandemic.5,6 NYC H + H was on the frontline of the surge in New York City, providing care for the most vulnerable communities, as the “epicenter of the epicenter.”7 Because of similarities to the emotional and psychological trauma experienced by medical providers during combat operations, the partnership aimed to support civilian frontline healthcare workers through the pandemic disaster. In this commentary, we describe the Healing, Education, Resilience, and Opportunity for New York's Frontline Workers (HERO-NY) initiative, a multiagency, multidisciplinary collaboration to merge civilian and military expertise on supporting healthcare workers.HERO-NY InitiativeGoing into the COVID-19 pandemic, NYC H + H already operated 2 behavioral health programs: Behavioral Health Services (BHS), which provided over 60% of behavioral health care in the city, and Helping Healers Heal (H3), a program to support healthcare workers with the second victim syndrome—the psychological trauma experienced by a healthcare provider as the result of the providing care during a traumatic event—through 1-to-1 peer support, group debriefs, and consultations with behavioral health specialists. Together, these 2 teams jointly provided emotional and psychological support to frontline healthcare workers throughout the COVID-19 surge. However, disaster- or pandemic-level emotional and psychological trauma may require additional layers of support, possibly similar to combat stress management and resilience. In a study of combat-deployed medical personnel in Iraq, medical stressors appeared to be more impactful on military medical personnel than combat stressors, with approximately 5% to 10% at risk for clinically significant levels of posttraumatic stress disorder. Civilian healthcare workers are not trained in combat stress management and resilience and may be even more susceptible to these medical stressors.Exploratory meetings were held between NYC H + H and DOD. Quickly, other stakeholders and partners were identified, and the taskforce grew to include 7 agencies: NYC H+H, DOD, United States Veteran Affairs, Fire Department of New York City, Uniformed Services University of the Health Sciences, the Greater New York Hospital Association, and Department of Health and Mental Hygiene. The taskforce included members from the leadership and frontline staff. The taskforce goals included: (1) adapting the DOD unit-based mental health needs assessment for civilian healthcare units battling COVID-19; (2) adapting the DOD individual mental health needs assessment for civilian healthcare workers battling COVID-19; (3) reviewing lessons learned by medical and behavioral health communities from previous pandemics, such as H1N1 and severe acute respiratory syndrome, and their impact on healthcare staff; and (4) adapting the DOD behavioral health curriculum on combat stress management and resilience to a train-the-trainer program that could be deployed across all New York City and Greater New York hospitals and healthcare systems. Given the urgency of adapting DOD needs assessments and curriculum to an effective skill and knowledge building program, the task force met daily for 4 weeks to accomplish its goals. The adapted materials were used for a train-the-trainer series for frontline workers to bring back to their organizations and use in response to the current crisis and beyond.The training was organized into 5 1-hour webinar-based modules: (1) Stress, Trauma, and Resiliency: Tools for Use Now, Later, and Long Term; (2) Personal and Professional Wellness; (3) Impact, Effect, and Outcome on Frontline Workers; (4) Seeking Help for Ourselves and Others; and (5) Resilience and Wellness Program Development. The first 4 modules focused on understanding resiliency and the impact of public health emergencies on psychological wellbeing of frontline healthcare workers, while the fifth module focused on developing and implementing programming. Each module incorporated skills building to give frontline workers the tools to cope during a crisis. By modeling skills within training sessions, trainers were then able to leave each module with actionable skills to share with their colleagues and support networks.As the modules progress, participants are exposed to deeper concepts on cognitive, emotional, behavioral, physical, and spiritual responses to psychosocial events on the stress continuum and trauma reactions. All modules start with a grounding technique called box breathing—a relaxation technique that helps the person doing it feel more grounded and relaxed—and include other helpful stress management and coping tools and exercises. These coping tools are framed in a practical way: what can be done now on social (eg, talk to a colleague), emotional (eg, positive self-talk), and physical (eg, take a short walk) levels; what can be done later on social (eg, increase your support network), emotional (eg, set boundaries with the news), and physical (eg, prioritize getting enough sleep) levels; and, finally, what can be done in the long term on social (eg, try new activities), emotional (eg, take time to yourself), and physical (eg, maintain a healthy diet) levels. Later in the series, coping skills are lumped into 6 main evidence-based categories: staying connected to others (by being proactive and creative in communication methods used), keeping up physical activity (for its physical and mental health benefits), maintaining regular sleep patterns (with modifications for shift workers), healthy eating, limiting excessive exposure to distressing media, and practicing stress management techniques (yoga, breathing, and meditation).The modules also include helpful tips and tools that can help break barriers and create a culture that openly promotes mental health and wellbeing among a workforce traditionally reluctant to discuss mental health and often perceives seeking support as a weakness. For example, self-assessment tools for compassion fatigue and burnout can enhance staff engagement in their own wellbeing. Definitions of the mental health consequences of responding to the pandemic, such as moral and spiritual injury, can increase awareness about the unique challenges faced by frontline workers and the importance of addressing them. Tips on when to seek help, including identifying complicated grief and symptoms of traumatic reactions to stress that interfere with functioning, can facilitate timely interventions and better long-term outcomes. An overview of the various factors that can be barriers to getting help, such as stigma and lack of leadership engagement, can help frontline workers identify and find ways to overcome them. Moreover, this process can identify specific steps that individuals can take—such as making a decision, reaching out, following through, and personal goal setting—and can help staff members seek support and recover.Extensive resources, including tip sheets and supplemental training documents, were adapted from various sources (eg, DOD, Uniformed Services University of the Health Sciences, New York Department of Health and Mental Hygiene) to ensure that trainers receive a comprehensive overview of research, techniques, and guidelines for supporting frontline workers. These documents also include an extensive list of local and national resources for support and help. In order to ensure the program's success, the final module focused exclusively on evidenced-based guidance for effective program development and implementation.To reach a broad audience, the Greater New York Hospital Association hosted the webinar series and included the New York City and Greater New York healthcare systems as well as related city agencies and organizations, such as the New York Police Department and Office of the Chief Medical Examiner. Webinars were scheduled weekly over a 1-month period. The HERO-NY initiative used the train-the-trainer model, and participants were encouraged to adopt the training at their respective agencies. The training had 2 primary aims: to reach as many frontline workers as possible and to facilitate lasting changes in the mental health support provided to staff during crises. The first webinar had over 700 participants from 16 facilities. The HERO-NY initiative was organized into 3 phases to prepare participating organizations for successful adoption: (1) optimizing preestablished infrastructure to best prepare the organization for adding the HERO-NY training, (2) conducting macro- and micro-level needs assessments that incorporate DOD tools to identify gaps and opportunities, and (3) improving support and treatment, informed by the needs assessments and strengthened by the HERO-NY training.Phase 1: Optimizing Preestablished InfrastructureThis phase prepares healthcare facilities and systems for the HERO-NY initiative. The goals in this phase include identifying existing tools and resources, optimizing existing staff support infrastructure, and determining how to best leverage combat stress management and resilience support. For example, NYC H + H identified that the HERO-NY initiative should augment the H3 and BHS teams as they supported frontline healthcare workers. The targets for the HERO-NY training were H3 peer support champions and BHS providers across multiple levels of the organization as well as other staff in allied disciplines and departments, including patient safety, pastoral care, nursing, and quality.Phase 2: Needs AssessmentThe goal of a needs assessment is to gather organizational, structural, and workforce-specific emotional health-, wellbeing-, and resilience-related information, in order to coordinate the provision of needed mental health support services and inform related policy and program development and improvement. This needs assessment augmented existing BHS and H3 programs because of its specific focus on stress responses during a wide-spread crisis, notably apparent during this pandemic. It can also help identify programmatic gaps to support resilience-building across the system. Collected data can inform: (1) systems readiness, including resources and gaps; (2) policy development that supports staff emotional health and wellbeing; (3) general and event-specific assessment of impact on and needs of the entire workforce and unique subgroup needs; and (4) satisfaction with existing programs for gap analysis and program development and improvement. In this phase, hospitals and health systems leverage the adapted DOD unit-based and individual needs assessments for healthcare facilities and systems—from the leadership to the frontline staff. The macro or unit-based assessments are anonymized and provide a high-level, facility-specific, and system-wide gap analysis to identify resource opportunities. The micro or individual assessments are voluntary and lead to a gap analysis to support the ability to customize and establish individualized opportunities for healthcare workers. Resource opportunities are then disseminated through electronic survey, with BHS and H3 oversight at each facility. This information will direct the support and treatment in Phase 3.Phase 3: Improved Support and TreatmentIn this phase, the train-the-trainer model partners with and runs parallel to enhanced staff support resources and services, both internal and external to the organization. Internally provided services within each facility and across the healthcare system would operate more from a trauma-informed care lens as posttraumatic stress management and resilience-building would be part of the peer supporters' competencies as they provide ongoing 1-on-1 and group debriefs. In NYC H+H, this means the H3 peer support champions and BHS providers would be able to leverage lessons learned from the DOD on how medical operations during times of war have affected frontline healthcare workers.Discussion and Next StepsThe COVID-19 pandemic has taken a significant emotional and psychological toll on healthcare workers across the globe, and especially in New York City, where it claimed the most lives in the United States to date.8 Posttraumatic stress disorder, depression, and suicide are real risks to frontline healthcare workers. The tragic suicides of New York City-based frontline workers brought fear and anxiety to the prehospital and healthcare workforce. Healthcare systems have an obligation to frontline workers to do everything in their power to avert a mental health crisis on top of the public health crisis of COVID-19. As the first surge fades, healthcare workers are confronting the emotional and psychological trauma that they suffered on the frontlines. HERO-NY came to fruition because DOD medical personnel shared with their leadership the stark similarities to combat deployment and felt that healthcare workers in New York needed their expertise. Even in the middle of a “once-in-a-century” pandemic, leaders from 7 agencies came together and efficiently and effectively created a unique training program tailored for civilian healthcare. The task force involved in creating this series worked hard to create a training that could provide support to those in the eye of the storm and to share their expertise with frontline workers of all disciplines in an accessible, actionable modality.Next steps include completing the train-the-trainer series and having trainers go back to their facilities to train existing behavioral health providers and staff support program leads. Wide adoption of the program would make our first responders better prepared to address the mental health needs of those providing essential services and to change the culture and eliminate barriers of seeking and providing needed care. Assessment and continuous improvement cycles on the program, training materials, and integration into existing infrastructure will ensure the adapted DOD expertise will continue to have a positive impact on New York healthcare systems. It is our hope that after full local adoption in New York City, we will disseminate the materials and lessons learned across the nation and globe, in anticipation of future surges and crises. We owe this to our healthcare heroes who bravely risked their lives to save others from COVID-19.