Experience from the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak taught thathealthcare workers (HCWs) often experience chronic stress effects for months or yearsafter such an event, and that supporting HCWs requires attention to the marathon ofoccupational stress, not just the sprint of dramatic stressors that occur whileinfections are dominating the news. This study will test if the well-being of hospitalworkers facing a novel coronavirus outbreak is improved by adding either of twointerventions: (1) Peer Resilience Champions (PRC): an interdisciplinary team ofprofessionals who actively monitor for early signs of heightened stress within clinicalteams, liaise between staff and senior management to improve organizationalresponsiveness, and provide direct support and teaching (under the supervision of expertsin resilience, infection control, and professional education). Investigators will testthe effectiveness of this PRC Intervention by rolling it out to different parts of thehospital in stages and comparing levels of burnout before and after the interventionreaches particular teams and units (a stepped wedge design). By the end of the study, PRCSupport will have been provided to all clinical and research staff and many learners (>6,000 people). Note that the provision of PRC support will be directed to the entireorganization. The research portion of the study is the evaluation of PRC support througha repeated survey completed by consenting staff. Investigators will test theeffectiveness of the PRC by measuring trends in burnout and other effects of stress overthe course of the study in a subgroup of hospital workers (as many as consent, target~1000 people) through an online questionnaire (called "How Are You?"). (2) The secondintervention is an enriched version of the "How Are You?" Survey, which providespersonalized feedback about coping, interpersonal interactions and moral distress.Participants will be randomized (1:1) to receive the shorter Express Survey (identifyingdata and outcome measures only), or the Enriched survey (all of the Express measures plusadditional measures with feedback based on responses). It is hypothesized that both thePRC intervention and the Enriched Survey intervention will help prevent or reduceinstances of burnout in HCWs.
This project studies the impact of two interventions, the addition of Peer Resilience
Champions to other hospital supports and an interactive computer-based learning
intervention that provides personalized feedback about relevant interpersonal and
psychological characteristics of participants.
The Peer Resilience Champion (PRC) Intervention Investigators will second or hire an
interdisciplinary team of healthcare professionals (e.g. nurses, social worker, or
infection control professional, total of 1 FTE) to serve as Peer Resilience Champions.
These Champions will receive coaching and then ongoing supervision in the relevant
aspects of stress management, peer support, and resource navigation by expert members of
the research team based on existing evidence. Peer Resilience Champions will act
predominantly at the level of clinical units and departments.
The activities of Peer Resilience Champions will, in part, be modelled on the role that
psychiatrists acting as support coaches have played in during the acute phase of the
pandemic. These include support, identification of needs, education, advocacy and
resource navigation. In doing so, the Champions follow evidence-based principles and
guidelines. The model is to provide quickly responsive, adaptive, peer support because it
is expected that the needs of staff will change over the course of a pandemic and in its
aftermath.
Peer Resilience Champions will work in an expanding selection of hospital locations,
following a randomized cluster (stepped wedge) design until the resource is available to
the entire organization. People who work and learn at Sinai Health do not need to
participate in this study in order to receive the potential benefits provided by Peer
Resilience Champions, which will be provided irrespective of study participation. The
effectiveness of Peer Resilience Champions in reducing burnout and other outcomes will be
tested using outcome measures included in the feedback staff survey (see below), which is
completed by consenting participants in this study.
Interactive Computer-based Learning Intervention A staff survey which includes all
primary and secondary outcomes measures will be completed by consenting participants at
intervals of approximately 3 months seven times (over approximately 21 months).
Participating staff will be randomized 1:1 to receive only these measures with no
feedback (the Express Survey) or these measures plus additional measures of interpersonal
and psychological characteristics, with personalized feedback (the Enriched Survey).
Feedback is based on previous experience from the investigators in providing feedback
from validated measures completed online to both healthcare workers and the general
public. The purpose of feedback is to encourage self-reflection, especially with respect
to coping and interpersonal interactions. The core measures that are common to both the
Express and Enriched surveys serve to tests the effectiveness of the Peer Resilience
Champions Intervention. The effectiveness of the Interactive Computer-based learning
intervention will be tested by comparing the core measures between those receiving the
Express Survey and those receiving the Enriched Survey.
Peer Resilience Champion Support The study design provides a controlled comparison of
support as usual to PRC support. Using a randomized cluster (stepped wedged) design,
usual staff support will be compared to that of PRC. PRC operates largely at the level of
the clinical units and groups, and so a randomized cluster design is preferable to a
randomized controlled trial. The stepped wedge design allows clusters of hospital
staff/volunteers to receive the PRC intervention in a random sequence until the resource
is available to all areas of the hospital.
This intervention will take place at Sinai Health System, including the Mount Sinai
(approximately 4500 employees), Bridgepoint (approximately 1200 staff), and
Lunenfeld-Tanenbaum Research Institute (LTRI) (approximately 1200 staff).
Five clusters of clinical units and departments will be constructed that are
approximately balanced between hospital units and staff groups with (i) high COVID
patient acuity (ICU, Emergency, medical units with negative pressure rooms) or high
exposure to patients from community with unknown COVID status (Family Medicine, Labour
and Delivery), (ii) all other clinical patient care areas, (iii) non-patient care areas,
and (iv) areas in which most or all staff are/were temporarily restricted from attending
the hospital (e.g. LTRI, volunteers).
After survey participants (and their disciplines and clinical units) are identified (T0
survey), their corresponding units, will be grouped into one of the five clusters in
order to meet the above goals. These clusters will then be randomized in order to
determine the order of intervention implementation. Each cluster will either receive
support as usual or PRC for a period of three months, followed by the completion of a
survey questionnaire given at seven different time points (T1-T7) spaced by three months.
NOTE - justification for choosing a non-blind comparison: Since the Express Survey is
shorter than the Enriched Survey, participants are not blind to survey cohort assignment.
Nor does the design control for time spent on an online activity. It would be possible to
control for the duration of the survey by expanding the length of the control condition
and this would also allow for the possibility of a blind comparison. However, a longer
control survey would increase the risk of drop-out among participants in the control
condition because completing surveys without interaction or feedback is not interesting.
Since maximizing continued participation in serial surveys is critical to testing the PRC
intervention hypothesis, a non-blind test of the Enriched Survey intervention hypothesis
is preferable to increasing the risk of being underpowered to test the PRC hypothesis.
Feedback Surveys Immediately after consenting, participants will be asked to complete the
T0 survey that asks about identifying information, and the characteristics of the
participant's work at Sinai Health. The T0 survey also collects an email address, to
which all subsequent surveys (T1 to T7) are sent. Following receipt of the T0 survey,
participants are randomized to receive either the Express Survey (T1 to T7) or the
Enriched survey (T1 to T7). In either case, T1 is sent soon (~1-2 weeks) after T0. All
subsequent surveys are sent at approximately 3-month intervals.
T0 survey - The initial survey collects identifying data (non-binary gender, discipline,
department, age, marital status), years of experience, SARS experience, number of people
in household and information about COVID-19 experience to date (exposure to patients,
experience with isolation of self or family members, testing etc.). Two free optional
text write-in questions provide allow participants to describe more about themselves or
their experience (past experience surveying healthcare workers post-SARS was that many
were keen to write at length about their experience, beyond data collected more formally,
and that insights from this open-ended reporting were valuable for placing quantitative
results in experiential context during analysis and knowledge dissemination phases). The
T0 survey takes about 10 minutes to complete plus whatever time is spent providing
optional free-text answers.
Express Survey: The express survey includes validated measures of the primary outcome,
the emotional exhaustion scale of the Maslach Burnout Inventory. The Express Survey also
includes measures of secondary outcomes: sleep, post-traumatic stress disorder symptoms,
psychological distress, occupational resilience, and COVID-19 prevention and control
self-efficacy (using an instrument revised from a measure of self-efficacy used in
preparation for an expected pandemic. The survey is the same each time it is completed
(T1 to T7) at 3-month intervals. The Express Survey takes about 10 minutes to complete.
Enriched Survey: The Enriched Survey contains all of the measures included in the Express
survey. No feedback is provided from any of these measures (i.e. this portion of the
Enriched survey is identical to the Express Survey). In addition to these core outcome
measures, the Enriched Survey includes measures of personality, interpersonal style and
coping and provides personalized feedback based on scores at time points T1 to T6. The
interactive measures included vary from one survey time point to the next in order to
provide variety, and to cover a larger number of participant characteristics within the
limits of reasonable survey time burden. State-dependent characteristics which may change
over time (coping, interpersonal problems) are measured twice. A measure of lifetime
experience with moral distress and a measurement of attachment, a stable trait, occur
only once. The Enriched T1 to T6 surveys take about 10-20 minutes.
Sample size This study is powered to test hypothesis 1, which is expected to require a
larger sample size than testing hypothesis 2. There are over 6000 staff at Sinai Health.
Assuming a starting proportion of 30.4% of staff with high burnout (based on previous
studies), an 80% power, and an alpha level of 0.05, five clusters of 200 staff providing
measures per cluster is sufficient to detect a drop of ≥ 9.4% (with an intracluster
correlation coefficient [ICC] of 0.01), ≥10.7% (ICC of 0.015), or ≥ 11.9% (ICC of 0.2).
These ICC estimates are congruent with previous studies. These differences are consistent
with a post-SARS study that found high burnout in 30.4% of exposed and 19.2% of unexposed
HCWs. Five clusters of 200 staff (n=1000) would require <17% of staff to consent to
participate and complete the measures.
Behavioral: Peer Resilience Champion
PRC is supplied to everyone and provides support to hospital staff during the COVID-19
pandemic in a stepped-wedge design.
Behavioral: Enriched Survey Feedback
This intervention provides feedback based on answers to questionnaires to those in the
Enriched Feedback arm of the study.
Inclusion Criteria:
- An employee, physician, scientist, employee of a contractor or retail business,
learning, or volunteer of Sinai Health at time of recruitment. Must be able to read
and respond to a survey in English. Need to have access to a computer or device
connected to the internet and be able to use said device.
Exclusion Criteria:
- Failure to meet inclusion criteria.
Sinai Health System
Toronto, Ontario, Canada
Robert G Maunder, Principal Investigator
Sinai Health