Canaries Don’t Belong in Coal Mines

Originally Published on CHAUsa.org

By Heather Schmidt, DO, Nicole DeWitt, MA, and Tom Bushlack, PhD

The phrase “canary in the coal mine” is used to describe an early warning signal for danger. The canary played an important role in both American and British mining history. Coalminers took caged canaries into the mines with them to monitor for toxic gases. When the canary showed signs of distress, miners took this as a signal to promptly leave the mine to avoid asphyxiation. While the practice was discontinued in 1986, the phrase is often used in health care when it comes to well-being and professional burnout. It leads us to ask the following questions: Do we toughen up the canaries to make them more resilient to the toxic environment? Or do we fix the coal mine to decrease the risk of harm to humans and canaries? In other words, is employee well-being a problem of individual resiliency, or is it a problem with organizational culture or with the health care industry as a whole? Or is it some combination of all three?

Canaries Don’t Belong in Coal Mines

Professional burnout was first described nearly 50 years ago and is characterized by emotional exhaustion, a sense of reduced personal and professional accomplishment and feelings of cynicism and detachment from the job. Professional burnout in health care is far from a new phenomenon. The prevalence of burnout among health care workers is alarming and has been described by many as a national epidemic, impacting between 40% to 50% of doctors, nurses and other clinicians. Beyond their personal well-being, studies have shown that burnout negatively affects patient care, results in increased turnover, and is projected to exacerbate physician and nurse shortages.1 The canaries are no longer singing and yet, as an industry, we have not sufficiently heeded the warning signals of impending danger.

Risk factors for mental health concerns worsen during times of acute crisis or in response to prolonged stress. The COVID-19 pandemic presents challenges on both fronts. In a recent survey by the Kaiser Family Foundation, 51% of Americans thought the coronavirus pandemic negatively impacted their mental health, including 25% who felt the impact was major.2 The critical nature of the situation cannot be overstated. And yet, there is a bright spot. We are seeing a growing number of discussions about the importance of mental health in the workplace.3 As part of that discussion, we have an opportunity to rethink well-being at work. Let’s move beyond the “canary in the coal mine” metaphor. Canaries don’t belong in coal mines. We find a better metaphor in Jesus’ discussion about how God cares for the birds of the air in the Sermon on the Mount and suggest we take these cues from creation in how we can rethink well-being at work.

Finding Our Way Out of the Coal Mine

We imagine a future where our north star is not just the absence of burnout, but the presence of well-being and flourishing. SSM Health established an aspirational goal in 2017 to “be nationally recognized as the ministry where people can reach their greatest potential and fulfill their calling to serve others.” For people to reach their greatest potential, the workplace must be an environment designed to promote health and well-being. Finding our way out of the coal mine will take time and concentrated effort.

In 2019, guided by the belief that our employees’ well-being matters, the SSM Health senior leadership team directed the development of a world-class wellness program. From its inception, the program was developed to avoid revisiting all the ways the canaries (that is, our health care workers) have been told they just need to “toughen up.” Rather, the goal is to build an innovative, system-wide effort that aligns with our mission and values and is guided by evidence-based interventions and industry best standards. Our goal is ambitious — to make wellness the lens through which we approach all our work as a ministry. In order to accomplish this goal, we collaborated with the Harvard Lifespan Research Foundation to develop a best-in-class wellness program grounded in the science of healthy relationships. Working with the Harvard Study of Adult Development (the 80-year-long multigenerational study led by Dr. Robert Waldinger), we conducted a needs assessment and developed a comprehensive plan. However, the emergence of the coronavirus pandemic challenged us to rapidly reconsider our approach.

When SSM Health’s Incident Command Centers were staffed to respond to COVID-19, focus was primarily related to safety and security. Like health care workers everywhere, our employees were very worried about their safety, and the topic of personal protective equipment (PPE) became part of every conversation. We also needed to attend to the needs of those with a high potential for exposure to the virus, such as families and support staff. We wanted our support to be comprehensive, which led us to focus on financial, emotional and professional safety. We needed fast, innovative action to support a staff of about 40,000 employees across four states; and we wanted to attend not only to the short-term crisis, but also prepare to care for employees who suffer from more long-term stress and trauma.

As the crisis grew, we identified the need to address the psychological needs of our workforce. We acted quickly to mobilize a Healthy Work and Wellness Steering Committee, which was a multidisciplinary group with members from nursing and medical staff, human resources, mission, wellness and various other support departments. The steering team led the effort to identify the areas of greatest social, emotional and spiritual needs and determine what our organization could do to meet those needs in order to promote better health and well-being. The steering team leaned on clinical, mission and human resources leadership for weekly pulse checks with staff to understand workforce needs.

To gain further insight, we administered the AMA “Coping with COVID-19 for Caregivers” survey to staff at some hospitals in our system. Based on staff feedback, the multidisciplinary wellness steering committee worked with leaders in mental health, pastoral care and mission to develop interventions focusing on social, emotional and spiritual support. Interventions included increasing Employee Assistance Program awareness, leader rounding and encouraging participation in SSM Health’s internal peer support program known as Care for Caregivers. Additionally, a spiritual support hotline was set up, along with recorded webinars led by a trained mental health expert. A wellness care package was developed and released monthly to highlight resources, programs and health observances that were available to all employees.

We also partnered with the Schwartz Center for Compassionate Healthcare and quickly trained over 20 facilitators to hold virtual Schwartz Rounds. These rounds create a safe environment in which health care professionals connect virtually with one another and discuss challenging experiences, offer and receive support and decrease their sense of isolation. Unlike other forms of rounding that focus on clinical or ethical analyses of cases, Schwartz Rounds invite caregivers to discuss the social and emotional dimensions of providing care, to encourage mindful self-care and to practice compassionate care for each other as colleagues and for our patients. As one example, Kathy Geib, a nurse informaticist who also volunteers as a wellness champion within the organization, said the Schwartz Rounds elicit honest conversations on specific topics for care providers during the pandemic. “It has given me an outlet for voicing my struggles, and to listen to others’ struggles. The information is helpful for me to better understand that I am not alone, and that there are clinically proven ways to help manage my feelings, and ultimately help with my overall well-being.”

We offered additional support by partnering with experts from the Harvard Lifespan Research Foundation to develop a series of mini-webinars for leaders on how to respond to and deal with common emotions like anxiety, anger, grief, fear and guilt. We kept interventions short and practical, with plenty of time for conversation and questions, to ensure employees felt heard, appreciated and supported by their leaders and colleagues. “Lavender carts,” stocked with snacks, beverages and inspirational resources, were taken to inpatient COVID units to show appreciation and support for those unable to access other resources due to work schedule.

Rethinking Well-Being at Work

Over time we have shifted from an “all hands-on deck” approach to focusing resources on those interventions identified as the most effective and that have the greatest impact. For example, we found higher levels of engagement by offering unit-based Schwartz Rounds, as compared to the system-wide, drop-in, virtual model of Schwartz Rounds with which we began. These unit-based Schwartz Rounds are integrated into a department’s scheduled meeting time, making it easier to incorporate them into employees’ existing work schedule. We are now partnering with Volunteers of America to adapt their veterans’ Resilience Strength Time program, and we are incorporating this model into our graduate nurse residency curriculum. By introducing well-being habits early in our nurses’ career development, and by encouraging them to build intentional, supportive relationships with colleagues, we are infusing support that will also sustain a long-term culture shift toward healthy work relationships, self-care and resiliency.

We have created a pilot program with the Harvard Lifespan Research Foundation in order to train “wellness champions” across our system. The next phase of this program involves training wellness champions to spread word-of-mouth awareness of wellness resources, to build a support infrastructure to help share resources, and to advocate a holistic well-being mindset among all staff. Our marketing team also has worked with employees identified as having expertise in various facets of wellness to create a series of videos promoting “Peace in the Pandemic.” And mission leaders created podcasts during our annual Mission and Heritage Week. Podcast episodes focused on integrating spiritual practices, wellness and connection to purpose. These media have been extremely well-received by our colleagues and among members of the communities we serve.

We are committed to shifting our health care system’s culture to one that is supportive, aware and inclusive. This has meant intentionally developing an interdisciplinary network, and working directly with leaders in our Mission Integration and Diversity and Inclusion departments. We have adopted a philosophy of wellness that is holistic and personalized: one that is both grounded in our spiritual traditions as a Catholic health care system, informed by the Franciscan charism of our foundresses, and inclusive of people of all backgrounds. We know that a sense of belonging and inclusion is critical to ensure that all employees feel supported and believe they can thrive in our organization. To do this we also need to shift the conventional thinking that wellness is only for those in certain roles or of certain socioeconomic statuses or certain races, or that all wellness interventions will work equally well for persons from diverse cultural backgrounds.4 We are challenged to create resources that will appeal to a diverse workforce from many cultural and religious backgrounds. Healthy work and wellness is for all employees and all those we serve.

One of our goals for 2021 is to reduce the stigmas that prevent health care professionals from seeking help — letting them know “It’s OK not to be OK.” The mission statement for SSM Health calls us to “reveal the healing presence of God,” and we embody this by building a culture of healthy relationships, encouraging being truly present to each other by practicing reflective and active listening, promoting mental health awareness and integrating spirituality as an essential dimension of wellness interventions.

We are also leveraging the Well-being Index, developed by the Mayo Clinic, which is a self-assessment tool with customized resources. The tool is available for all employees, and they are encouraged to return and take the assessment at least once each quarter. Each participant receives immediate feedback and results that encourage self-awareness and suggest actions and interventions to improve health and well-being. As a system, we are also able to collect anonymous, aggregate data that will enable us to better understand our employees’ challenges and provide support that is focused on areas of greatest need. Results of the Well-being Index will be monitored and shared with leaders and employees over time to make sure our interventions are effective.

Taking Cues from Creation

Our first intuition as we set out to build a best-in-class wellness program was informed by a belief that our employees will thrive when we can support canaries while they are in the coal mine. This basic intuition about focusing on both individuals and the work environment remains true, but we have also seen the limits of the canary-in-the-coal-mine metaphor. In the classic scenario, there is only one canary, working in an inherently toxic coal mine. Our Catholic heritage insists that human persons are radically social creatures. Our vision of the common good is not a simple model of lone individuals influenced by their environments. Rather, the Catholic tradition offers a view of human flourishing that recognizes how we are embedded in dense networks of complex, overlapping and interdependent relationships that in turn are embedded in the broader systems and environments in which we work, live and play.

This theological vision is also congruent with the most significant finding of the Harvard Study of Adult Development. Grounded in more than 80 years of research, the single greatest predictor of long-term happiness and resilience is the individual’s perception of support through healthy, quality relationships. Our goal, therefore, is to develop a network of inter-connected and engaged employees who feel supported by colleagues and leadership, and where systemic support is delivered quickly, easily and in real-time as employees’ needs rise.

In the Sermon on the Mount, Jesus comforts his followers’ anxieties by inviting them to “Look at the birds of the air; they neither sow nor reap nor gather into barns, and yet your heavenly Father feeds them. Are you not of more value than they?” (Matthew 6:26). Jesus reminds us that God provides for all “the birds of the air” — indeed, for all of creation — and for each and every precious human person. We owe it to our employees to build the most comprehensive and supportive wellness program that we can. Indeed, our goal is to make wellness the lens through which we do all our work as a ministry. If we can accomplish this goal, then we will have moved well beyond the debate between “tougher canaries” vs. “healthier coal mines.” Instead, just as God provides for the birds of the air in the natural environment where they are created to thrive, so too we are working to infuse our health care system with all the elements that will enable our employees to thrive in their “natural” environment. Our employees choose to work in the field of health care because they experienced a calling to care for patients and communities. Creating a best-in-class wellness program is not simply a matter of setting goals and measuring key performance indicators. As in all Catholic health care organizations, the healing ministry of Jesus lives through people. When our employees feel they are supported, just as God provides for the birds of the air, then they will be empowered to live their vocation and thrive as human beings doing God’s work.

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Heather Schmidt is a family medicine physician in Fond du Lac, Wisconsin, and serves as the system medical director for Healthy Work and Well-being for SSM Health.

Nicole DeWitt serves as the system manager for Healthy Work and Well-being in Madison, Wisconsin.

Tom Bushlack serves as regional director of mission integration in St. Louis.

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Notes

Thomas P. Reith, “Burnout in United States Healthcare Professionals: A Narrative Review,” Cureus 10, no. 4 (December 4, 2018): https://dx.doi.org/10.7759%2Fcureus.3681.

Lunna Lopes et al., “KFF Health Tracking Poll – December 2020: COVID-19 and Biden’s Health Care Agenda,” Kaiser Family Foundation, December 18, 2020, https://www.kff.org/coronavirus-covid-19/report/kff-health-tracking-poll-december-2020/.

Jeffrey Pfeffer and Leann Williams, “Mental Health in the Workplace: The Coming Revolution,” McKinsey & Company (December 8, 2020): https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/mental-health-in-the-workplace-the-coming-revolution#.

For a related resource, see the National Wellness Institute website, Multicultural Wellness Wheel, https://nationalwellness.org/resources/multicultural-competency-in-wellness/.