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COVID-19: Beyond Tomorrow
October 8, 2020

Pandemic-Driven Posttraumatic Growth for Organizations and Individuals

Author Affiliations
  • 1Yale School of Medicine, New Haven, Connecticut
  • 2Yale New Haven Health, New Haven, Connecticut
  • 3Stanford University School of Medicine, Stanford, California
  • 4Icahn School of Medicine at Mount Sinai, New York, New York
JAMA. 2020;324(18):1829-1830. doi:10.1001/jama.2020.20275

Many physicians and other health care workers have been experiencing enormous levels of stress and uncertainty while providing care for patients with coronavirus disease 2019 (COVID-19). Those who work in epicenters of the virus may care for high numbers of critically ill patients and experience psychological trauma related to exposure to many deaths in a short period of time or threat of death for themselves, colleagues, or loved ones. These clinicians may have encountered various challenges, such as not having enough personal protective equipment, being assigned to practice in areas outside their expertise, dealing with a lack of known therapeutics, making difficult decisions about rationing or prioritizing care, and facing disruptions affecting many aspects of health care and daily life. This acute stress among health care professionals is superimposed on preexisting high levels of occupationally related psychological and occupational stress.1

Health care organizations and society have a responsibility to help address these stresses and challenges.2 Examples of psychological support include peer support and individual mental health services. In addition to these traditional forms of support for acute distress, there may be potential for accelerated personal and organizational change and growth that would often take years to occur.

Posttraumatic growth has been defined as “positive psychological change experienced as a result of a struggle with highly challenging life circumstances” and through establishing perspectives for a “new normal” when the old normal is no longer an option.3,4 Posttraumatic growth includes 5 domains: development of deeper relationships, openness to new possibilities, greater sense of personal strength, stronger sense of spirituality, and greater appreciation of life. The Posttraumatic Growth Inventory has been translated into 22 languages, and research using the inventory has found strong evidence for posttraumatic growth across numerous cultures and many different traumatized populations including among those surviving bereavement, natural disasters, motor vehicle and other crashes, medical conditions (eg, cancer, myocardial infarction, HIV), sexual and physical assault, refugee and hostage situations, and in combat veterans.3

Typically, posttraumatic growth develops following a physical or psychological trauma that is disruptive enough to the affected individual’s perspectives and values that it stimulates reassessment and rebuilding of psychological and philosophical beliefs and approach to living.3,4 Such traumas often force affected individuals to recognize they are not invincible, consider what they do and do not control, and reassess their personal and professional priorities.

After some traumatic events, it is a normal response for those affected to recall and relive the traumatic event. This is characteristic of posttraumatic stress. When the recollections of the trauma become involuntary, intrusive, and unresolved, they can become a core feature of posttraumatic stress disorder.3 In contrast, when recollections are no longer precipitated by the trauma, but rather are directed by the individual, deliberate reflection can facilitate posttraumatic growth.3 The affected individual might begin to explore the domains of posttraumatic growth by considering a series of questions (eTable in the Supplement). This deliberate reflection and the resulting posttraumatic growth are active processes that involve awareness, transparency, motivation, creativity, and dedication to improvement. While challenging, the process can also be highly rewarding.

Some research has shown that posttraumatic growth is common among individuals who experience traumatic events (such as those related to natural disasters, car crashes, assaults, medical crises, and bereavement), with prevalence rates ranging between 30% and 70%, and that it may be possible to facilitate this process.5 Studies conducted with patients who have or had cancer demonstrated that interventions designed to facilitate posttraumatic growth resulted in a statistically significant improvement relative to controls, with 1 study involving 126 patients with cancer showing posttraumatic growth sustained at 1 year.6

In facilitating posttraumatic growth, it may be possible to reduce the negative influence of future psychological traumas and potentially create a more resilient health care workforce and stronger health care organizations. When the Swedish Health System in Seattle became an epicenter for some of the first cases of COVID-19 in the United States, they attributed their preparedness and resilience to deliberate reflection, learning, and growth catalyzed by a major labor strike several months earlier. That experience helped transform their approach to communication, delegation of authority, and supporting their caregivers that they credit with facilitating a more optimal organizational response across their 5 hospitals when the COVID-19 pandemic occurred several months later.7 Similarly, after Hurricane Katrina incapacitated the New Orleans health care system, the medical community created “pop-up” clinics to deliver health services to the community in need. Through subsequent reflection and learning, New Orleans reimagined health care delivery and the new patient-centered model developed from this process has inspired and served as a model for others across the country.8 In addition to the specific learnings from a given event, studies in military veterans suggest that posttraumatic growth in response to 1 trauma reduces the likelihood of developing posttraumatic stress disorder after subsequent traumas, a finding that may apply to posttraumatic growth in other contexts.9 Posttraumatic growth can be measured in individuals within the organization using the Posttraumatic Growth Inventory. Organizational posttraumatic growth could be assessed by the quantity and quality of the lessons learned in an after-crisis review process.7,8

When organizations are affected by adversity, they often use crisis management with the goal of restoring the system back to its normal level of functioning. In contrast, organizational posttraumatic growth refers to a process by which organizations are not only restored, but achieve a higher level of functioning as a result of addressing and learning from a traumatic event. Organizations or leaders should not pressure individuals to seek growth shortly after the trauma or it could inadvertently increase distress.3 After meeting the basic needs and coming to terms with the circumstance, the following steps may help catalyze the posttraumatic growth process:

  1. Deliberately take time to assess how the individual or organization has been affected by the pandemic and what can be learned from the experience. Engage a supportive, dedicated, and transparent team of leaders and frontline health care professionals who work collaboratively to reimagine a “new normal.”

  2. Identify role models (individuals or organizations) that have grown through adversity. In overcoming conditions of extreme adversity, such as experienced during the COVID-19 pandemic, role models demonstrate that posttraumatic growth is possible, how such growth occurs, and how an organization of affected individuals can emerge from the pandemic stronger, inspired, and more resilient.

  3. Learn to view the current situation as both a trauma with consequences, as well as an opportunity to “reinvent” or improve on the status quo. Ask, “How can the pandemic serve as a catalyst or springboard for growth and change?” Creativity is an important driver of growth. What new ideas, attitudes, procedures, and structures can individuals and organizations generate as an outgrowth of their experiences with the pandemic?

  4. Assess how this experience may have served to connect the individual or organization to humanity and the broader society, and provide clarity and foster altruistic solutions. Organizationally, reimagine how to demonstrate a sincere commitment to the people of the organization and to reconnect to altruistic organizational values.

  5. In dealing with a sense of loss and grief, during the pandemic and other times of crisis, realize that it may be possible to notice that which is missing, what is most important, and for what organizations are truly grateful. Are leaders sufficiently taking care of the people of the organization to an appropriate extent? Are there reasons to be optimistic?

Ultimately, it is not the trauma that causes growth, but rather how individuals and organizations interpret and respond to it. Growth may occur by responding to the trauma in a manner that focuses on learning how the trauma might serve as a positive catalyst for the future of medicine to be greater than the previous status quo. When the acute phase of the pandemic subsides, after crisis management and initial psychological support, there is often an opportunity to choose a coping strategy to facilitate growth. Maladaptive “avoidance coping” may involve withdrawing through denial and distraction, disengagement, depersonalization, anger, blaming others, substance abuse, reduced work effort, withdrawal, and isolation.3,10 Self-punitive behavior, low self-valuation, and lack of self-confidence can impede the processs.3 Adaptive coping does not withdraw but rather engages with the experience and with others. Adaptive coping is optimistic, flexible, social, action-oriented, and focused on problem-solving. Such approaches can lead to new perspectives, creative solutions, and stress-related growth for both individuals and organizations. Sharing lessons learned can result in the realization colleagues and peer organizations can rely on each other for support and can help overcome obstacles to growth.3

Posttraumatic growth does not minimize the seriousness and severity of what has happened but can emerge from adversity through active management following the important process of grieving. Can the current pandemic set the stage for beneficial personal and organizational change that creates a better future and brings renewed meaning and purpose to medicine? This is a question that only health care professionals and organizations can answer.

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Article Information

Corresponding Author: Kristine Olson, MD, MSc, Yale School of Medicine, 20 York St, New Haven, CT 06510 (kristine.olson@yale.edu).

Published Online: October 8, 2020. doi:10.1001/jama.2020.20275

Conflict of Interest Disclosures: Dr Shanafelt reported receiving royalties for the book Mayo Clinic Strategies to Reduce Burnout: 12 Actions to Create the Ideal Workplace, being co-inventor of Well-being Index instruments and the Participatory Management Leadership Index, and at times receiving honoraria for providing grand rounds/keynote lectures and advising for health care organizations. Dr Southwick reported receiving royalties for the book Resilience: The Science of Mastering Life’s Greatest Challenges. No other disclosures were reported.

References
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    1 Comment for this article
    EXPAND ALL
    COVID-19 Enabled Improvement
    Robert Phillips, MD, PhD | Houston Methodist and Weill Cornell Medical College
    Olsen et al. provide the framework for a related phenomenon that we would like to term "COVID-19 Enabled, Empathy-Driven, Accelerated Operational Improvement". The driver of this organizational growth for Houston Methodist, an 8-hospital system in Houston, Texas, was the need to iteratively embrace and incorporate data-driven and rapidly emerging clinical and operational COVID-19 knowledge (1). Empathy among stakeholders blossomed so that friction between groups was greatly reduced, silos were broken down, and consensus-driven improvements in operations and clinical care happened quickly (2). While these are most likely "intra-stress" enhancements, as the pandemic is on-going, it is our hope that these will be sustainable in the "post-traumatic" period since they occurred in a high-reliability learning healthcare organizational framework which we have been building for nearly a decade. Stakeholders deferred to expertise and incorporated the experience of front-line providers to accelerate innovation; they were sensitive to operations and changed workflows based on nurse, physicians and staff experience; they were always mitigating against failure and found the best and innovative ways to protect against this virus; when failures occurred they looked upstream for the cause; and they were resilient. While this pandemic has been a scourge on our nation and the world, it has also been a laboratory for demonstrating that when the framework for improvement is anchored in solid process improvement principles, and when empathy is unleashed, healthcare organizations can rapidly adjust, grow and deliver the care that our patients and communities require and deserve.

    Reference

    1. Vahiddy FS et al, JAMA. 2020;324(10):998-1000, doi:10.1001/jama.2020.15301
    2. Tittle S et al., NEJM Catalyst, 2020;1(4), DOI 10.1056/CAT.20.0287
    CONFLICT OF INTEREST: None Reported
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