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Mental health supports help rural care providers weather a COVID surge

“We know that we could hit another surge. When we talk about what the staff has gone through, they feel like they’re more prepared. We’ve got this now, ” said Jodi Hillmer, director of patient care services at CentraCare – Long Prairie Care Center.

The staff at CentraCare-Long Prairie Care Center, shown during a regular "huddle" meeting, where managers meet with staff to discuss the upcoming work day, and provide tips for strengthening mental health.
The staff at CentraCare-Long Prairie Care Center, shown during a regular "huddle" meeting, where managers meet with staff to discuss the upcoming work day, and provide tips for strengthening mental health.
Courtesy of CentraCare

As this fall’s COVID surge took hold, staff at CentraCare – Long Prairie Care Center, a nursing home and long-term care center in the central Minnesota town of Long Prairie, began to show clear signs of strain.

“They were getting overwhelmed with small things,” said Jodi Hillmer, director of patient care services and interim director of long-term care. “Something small would happen and quickly it would start to seem really big.”

In the scheme of things, Hillmer explained, these were mostly little incidents, but for staff, the strain was building and they’d blow up at the slightest provocation: “People were getting stressed out about things they wouldn’t normally get stressed out about. They were having a hard time letting things go.”

These overreactions to small incidents were a symptom that the cumulative stressors of fighting a contagious and sometimes deadly virus were adding up, Hillmer said. Working in this kind of high-stress environment wasn’t something staff at the care center felt they had signed up for.

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“I’ve not seen that kind of impact on the long-term care staff ever,” she said. “It was something they just needed to get through but it was so hard to witness. In long-term care, usually things are pretty day-to-day. There usually isn’t a lot of disruptions. COVID disrupted everything.”

Jodi Hillmer
Jodi Hillmer
Hillmer and other managers at CentraCare, a system of hospitals, clinics, nursing homes and long-term care facilities based in Central Minnesota, knew that they had to find a way to help their employees cope with the extreme stress that came with having their work and personal lives upturned by COVID-19.

They’d begun the process of developing mental health supports for employees long before the pandemic had made its way to their communities, and when COVID-19 it hit Greater Minnesota with a vengeance, the new programs were put to the test.

Lisa Bershok, team leader for CentraCare’s COVID-19 staff-support response team, explained that planners based much of their programming on information they’d learned from health care workers in other regions of the country.

“We started working on this in early- to mid-March as it was becoming more evident that COVID was coming,” Bershok said. “We were watching what was happening in New York. At that point, we knew there was a possibility that what was happening there was going to happen everywhere. So we prepared for that kind of COVID surge.”

The most obvious part of preparing for a COVID surge is to ready hospital beds, stock up on supplemental oxygen and PPE. But Bershok and other members of the staff support response team knew that supporting the mental health of employees was going to be nearly as important as protecting their physical health.

Lisa Bershok
Lisa Bershok
“Our executive leadership and our internal department leadership wanted to make sure that employees would have the emotional resilience needed to face COVID,” Bershok said. It took several months for a major surge to hit the Midwest, so she and her colleagues had time to prepare.

During that buildup to the first surge, Bershok said, “We were able to create stakeholder groups and frontline-staff leader groups. It’s been a real learning process. We created a range of programs designed to hold up staff during stressful times. And they’ve evolved as COVID has evolved.”

Mental health support suite

Just as members of the staff-support response team feared, when COVID-19 hit Central Minnesota, it hit hard. By early November, ICU beds at CentraCare St. Cloud Hospital were nearly full, with more than half of those cases related to the virus. Nursing homes and long-term care facilities in the region were also shaken by COVD infections. Many residents had fallen ill, and a significant number died.

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This turn of events shook many CentraCare workers to the core.

“People started to numb out a little bit,” Bershok said. Like Hillmer, she noted that staff seemed to have “a low frustration tolerance. People are having difficulty letting go of work.” They’d bring it home with them, impacting the lives of their family and friends.

“They are in the middle of what I’ve heard other people describe as ‘COVID war zones,’ where there’s a sense you’re letting down your colleagues if you are not working constantly,” Bershok said, “but constantly being ‘at work,’ even if it is just in the back of your mind, can be hard on a person’s mental health.”

The fall surge was the perfect time to make sure that staff knew about the range of mental-health support tools that Bershok and her colleagues had assembled, but in the midst of a crisis, it was hard to get people to make time to care for themselves.

“It was difficult for leaders and staff to find time to figure out what resources they could use,” Bershok said. “We had so many resources that we built. We advertised the options to staff and leaders, but people didn’t have time to utilize them.”

Programs available to support the mental health of CentraCare workers include a virtual presentation detailing symptoms of chronic stress, fliers detailing the importance of “emotional PPE,” daily 15-minute “wellness reset” meetings, spiritual care support, free mental health video visits with behavioral health providers, virtual guided meditations focused on finding balance, mini-presentations on self-care during stressful times, and a comprehensive webpage loaded with links to all resources.

Amber Silva
Amber Silva
Amber Silva, wellness coordinator at Carris Health, a CentraCare-based health care system providing care in west central and southwest Minnesota, noted signs of rising anxiety and stress among workers when cases of COVID-19 began to rise in their facilities. In coordination with Bershok, she developed a “resiliency series,” a suite of presentations designed to help exhausted workers learn emotional survival tips for trying times.

“Burnout is very easy to see among our colleagues,” Silva said. The team asked Corey Martin, a physician from Buffalo, Minnesota, who runs Innovations in Resilience, an organization that helps people rediscover joy and  meaning in their personal lives and work environments, to lead a series of live presentations designed specifically for health care workers.

One of Martin’s presentations, Silva said, “will be titled ‘From Surviving to Thriving.’ We’ll also have another, called, ‘Mindset Matters,’ where he will be talking about how where your mindset is determines how you are going to be able to cope with different stressors.”

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The live presentations will be made available to staff in two-week patterns, Silva said: “We’ll also have access to some short video clips that Dr. Martin has created if they are unable to attend the live sessions.”

People absorb information in a variety of ways, Bershok said. Some prefer to watch videos, or participate in live virtual meetings. Others like to read information online or hold it in their hands in a printed form. And there are those who best understand information when it is delivered directly, in a face-to-face setting.

Members of the COVID-19 staff-support response team have tried to let workers and supervisors know about the many different support options that are available.

“People are starting to get very tired,” Bershok said. “There are signs of burnout and empathy or compassion fatigue. We’re opening up options within teams for people to engage in debrief sessions around what they are experiencing.”

At CentraCare, team leaders are asked to hold regular “huddles,” short 10-to-15-minute meetings to check in with staff and provide updates about the workday. Early in the crisis, the COVID-19 staff-support response team made the decision to distribute “huddle tips” to team leaders that focused on staff mental health in the midst of a pandemic.

“A way to get through stigma is talking about it on a consistent basis and embedding good self-care in your day-to-day routine,” Bershok said. The huddle tips range, she said, ”from a promotion of resources to directly discussing coping skills for mental health symptoms. It only takes a minute or two. It is something that the manager can put in the huddle at the very start to say, ‘We are going to create a culture of well-being.’”

Finding what works

The success of the different mental health support programs has been hit-or-miss, Silva said. Some initiatives were a clear hit with staff; others, for no clear reason, felt more like a flop.

One example is the “Buddy Project,” she explained, “where you’d communicate with a coworker before you left work so you can air out any stressors. We tried to roll that out within our rehab program and our care center. I had two people express interest, but no one else said they were interested in participating.”

One reason more staff weren’t interested in the Buddy Project might be cultural, Silva allowed.

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“I would definitely say that we live in an area of the state where talking about your feelings isn’t frowned upon — but it isn’t really encouraged that much, either.” That reluctance to open up was also seen when staff was offered an opportunity to attend “psychological debriefing sessions,” Silva added. “We’ll have five to seven people that attend them out of 900-plus employees.”

In non-COVID times, Bershok said, she’d set up “a bunch of metrics” to gauge staff response to the different programs her team has launched, but the speed and fury of the crisis has forced them to think on their feet, throwing programs at a wall to see what sticks. “This is COVID, and things are fast and furious,” she said. “It’s the nature of the times we are living in now.”

One way Bershok and her fellow COVID-19 staff-support response team members have been able to measure the success of their mental health support programs has been through tracking the use of online support pages.

“We know that we have a high volume of traffic to our employee support and leader support pages,” Bershock said. “Our huddle tips are utilized at a high volume by leaders. The ‘Emotional PPE’ document that lists available resources gets accessed quite a bit.” When COVID-19 staff-support response team members promote services offered by CentraCare’s Employee Assistance Program (EAP), they note an uptick in visits to the EAP page, she added: “When we highly promote EAP resources we get a direct correlation with how many staff are utilizing them.”

At CentraCare – Long Prairie Care Center, there were times when staff felt too overwhelmed to even think about taking advantage of the available mental health resources.

“We were in the midst of a COVID outbreak. What that means is it is ‘all hands on deck,’” Hillmer said. While she and her colleagues know that there are mental health resources available to them, “There can’t be a lot of stopping to care for ourselves and our teammates. It is all about caring for the residents.”

During the worst of the recent surge, Hillmer added, “People were working multiple hours and picking additional shifts to help their coworkers. I was right there with them and I didn’t even realize the impact it was having on our team.”

As surge-induced stress started to pile on, Bershok reached out to remind Hillmer about the importance of promoting self-care programs during regular team meetings like huddles. Hillmer decided to give it a try.

“The huddles really started as a way to open up the conversation, to ask, ‘How are you really doing?’ or say, ‘It’s OK that you’re not doing OK,’” Hillmer said. “It opened up that dialogue and made it OK to talk about it. We did see a change in people’s attitudes and morale.”

‘We know what to expect’

These days, Hillmer said that she and her staff have seen case numbers ease up a bit. This pause has given them enough breathing room to focus on creating a culture that is supportive of self-care.

“As nurses and nurses’ aides, we’re used to caring for other people, but we’re not so used to caring for ourselves,” Hillmer said. In recent weeks, she and her colleagues have made a point of creating care plans for one another, talking about how they can access resources and materials that support their mental health.

Their chosen approach emphasizes positive reinforcement.

“We put out fliers around the facility that said, ‘You’re awesome,’ and pointed out all the good work they’re doing,” Hillmer said. During staff huddles, she added, “I tried to point out the resources that CentraCare has for mental health support and self-care tips like, ‘Take a break. Take a breath.’”

Because releasing steam early is better than letting anxiety build to a boiling point, Hillmer said that she and other supervisors have tried to emphasize the importance of expressing emotions when they arise.

“We worked on giving them permission to let that go,” Hillmer said.

Text of a ritual that CentraCare - Long Prairie staff developed to engage in after the death of a resident.
Courtesy of CentraCare
Text of a ritual that CentraCare - Long Prairie staff developed to engage in after the death of a resident.
Resident deaths have been particularly hard on staff. During the height of the crisis, there was fear that marking each individual passing would get lost in chaos of the moment. To make sure that each death was marked with the reverence it deserved, Hillmer and her colleagues developed a ritual.

“When a resident died, staff would all come together and say a little goodbye prayer-type thing,” she said. “It was a pre-written prayer, not necessarily religious.”

The goodbye ritual was a way for staff to honor the resident who had died, Hillmer said.

“That was really helpful for the staff. The impact of that and doing that together as a team was helpful.” In many cases, technology made it possible to include families in the goodbye ritual.

“One of the first residents that we lost,” Hillmer said, “his family was on Skype with us when we did the ritual. They were able to see that and witness the impact that the resident’s death had on the staff.”

With a bit of breathing room comes the opportunity to think about the importance of focusing on continually supporting staff mental health — even after the COVID crisis has passed, Hillmer said.

“I’ve decided that it would be useful and helpful to continue to focus on these things, even when we are not working in crisis mode. These techniques and resources have a place for us going forward. It creates a culture where it is OK to talk about the things that make us uncomfortable and it gives the employee the confidence to say, ‘I’m not OK,’ and feel safe about that.”

Hillmer said that engaging with some of the mental health supports has given her and her colleagues confidence that they now have access to tools that could help make the likely next surge more manageable.

“We talk about it daily,” she said. “We know that we could hit another surge. When we talk about what the staff has gone through, they feel like they’re more prepared. We’ve got this now. We can handle it. We know what to expect. They are in a better place, and they’re in that place because of what we went through and the supports we were able to provide them with. They are better prepared for the next one.”