Team and leadership factors and their relationship to burnout in emergency medicine during COVID-19: A 3-wave cross-sectional study.

Objective: We examined the relationship of team and leadership attributes with clinician feelings of burnout over time during the corona virus disease 2019 (COVID-19) pandemic. Methods: We surveyed emergency medicine personnel at 2 California hospitals at 3 time points: July 2020, December 2020, and November 2021. We assessed 3 team and leadership attributes using previously validated psychological scales (joint problem-solving, process clarity, and leader inclusiveness) and burnout using a validated scale. Using logistic regression models we determined the associations between team and leadership attributes and burnout, controlling for covariates. Results: We obtained responses from 328, 356, and 260 respondents in waves 1, 2, and 3, respectively (mean response rate = 49.52%). The median response for feelings of burnout increased over time (2.0, interquartile range [IQR] = 2.0-3.0 in wave 1 to 3.0, IQR = 2.0-3.0 in wave 3). At all time points, greater process clarity was associated with lower odds of feeling burnout (odds ratio [OR] [95% confidence interval (CI) = 0.36 [0.19, 0.66] in wave 1 to 0.24 [0.10, 0.61] in wave 3). In waves 2 and 3, greater joint problem-solving was associated with lower odds of feeling burnout (OR [95% CI] = 0.61 [0.42, 0.89], 0.54 [0.33, 0.88]). Leader inclusiveness was also associated with lower odds of feeling burnout (OR [95% CI] = 0.45 [0.27, 0.74] in wave 1 to 0.41 [0.24, 0.69] in wave 3). Conclusions: Process clarity, joint problem-solving, and leader inclusiveness are associated with less clinician burnout during the COVID-19 pandemic, pointing to potential benefits of focusing on team and leadership factors during crisis. Leader inclusiveness may wane over time, requiring effort to sustain.

How psychological safety and feeling heard relate to burnout and adaptation amid uncertainty.

BACKGROUND: Psychological safety-the belief that it is safe to speak up-is vital amid uncertainty, but its relationship to feeling heard is not well understood. PURPOSE: The aims of this study were (a) to measure feeling heard and (b) to assess how psychological safety and feeling heard relate to one another as well as to burnout, worsening burnout, and adaptation during uncertainty. METHODOLOGY: We conducted a cross-sectional survey of emergency department staff and clinicians (response rate = 52%; analytic N = 241) in July 2020. The survey measured psychological safety, feeling heard, overall burnout, worsening burnout, and perceived process adaptation during the COVID-19 crisis. We assessed descriptive statistics and construct measurement properties, and we assessed relationships among the variables using generalized structural equation modeling. RESULTS: Psychological safety and feeling heard demonstrated acceptable measurement properties and were correlated at r = .54. Levels of feeling heard were lower on average than psychological safety. Psychological safety and feeling heard were both statistically significantly associated with lower burnout and greater process adaptation. Only psychological safety exhibited a statistically significant relationship with less worsening burnout during crisis. We found evidence that feeling heard mediates psychological safety's relationship to burnout and process adaptation. CONCLUSION: Psychological safety is important but not sufficient for feeling heard. Feeling heard may help mitigate burnout and enable adaptation during uncertainty. PRACTICE IMPLICATIONS: For health care leaders, expanding beyond psychological safety to also establish a feeling of being heard may further reduce burnout and improve care processes.

COVID-19-Related Insurance Coverage Changes and Disparities in Access to Care Among Low-Income US Adults in 4 Southern States.

Importance: It is unclear how the COVID-19 pandemic and its associated economic downturn have affected insurance coverage and disparities in access to health care among low-income families and people of color in states that have and have not expanded Medicaid. Objective: To determine changes in insurance coverage and disparities in access to health care among low-income families and people of color across 4 Southern states and by Medicaid expansion status. Design Setting and Participants: This random-digit dialing telephone survey study of US citizens ages 19 to 64 years with a family income less than 138% of the federal poverty line in in 4 states (Arkansas, Kentucky, Louisiana, and Texas) was conducted from October to December 2020. Using a difference-in-differences design, we estimated changes in outcomes by Medicaid expansion status overall and by race and ethnicity in 2020 (n = 1804) compared with 2018 to 2019 (n = 5710). We also explored barriers to health care and use of telehealth by race and ethnicity. Data analysis was conducted from January 2021 to March 2021. Exposures: COVID-19 pandemic and prior Medicaid expansion status. Main Outcomes and Measures: Primary outcome was the uninsured rate and secondary outcomes were financial and nonfinancial barriers to health care access. Results: Of 7514 respondents (11% response rate; 3889 White non-Latinx [51.8%], 1881 Black non-Latinx [25.0%], and 1156 Latinx individuals [15.4%]; 4161 women [55.4%]), 5815 (77.4%) were in the states with previous expansion and 1699 (22.6%) were in Texas (nonexpansion state). Respondents in the expansion states were older, more likely White, and less likely to have attended college compared with respondents in Texas. Uninsurance rate in 2020 rose by 7.4 percentage points in Texas (95% CI, 2.2-12.6; P = .01) and 2.5 percentage points in expansion states (95% CI, -1.9 to 7.0; P = .27), with a difference-in-differences estimate for Medicaid expansion of -4.9% (95% CI, -11.3 to 1.6; P = .14). Among Black and Latinx individuals, Medicaid expansion was associated with protection against a rise in the uninsured rate (difference-in-differences, -9.5%; 95% CI, -19.0 to -0.1; P = .048). Measures of access, including having a personal physician and regular care for chronic conditions, worsened significantly in 2020 in all 4 states, with no significant difference by Medicaid expansion status. Conclusions and Relevance: In this survey of US adults, uninsured rates increased among low-income adults in 4 Southern states during the COVID-19 pandemic, but Medicaid expansion states, that association was diminished among Black and Latinx individuals. Nonfinancial barriers to care because of the pandemic were common in all states.

Masked and distanced: a qualitative study of how personal protective equipment and distancing affect teamwork in emergency care.

BACKGROUND: Newly intensified use of personal protective equipment (PPE) in emergency departments presents teamwork challenges affecting the quality and safety of care at the frontlines. OBJECTIVE: We conducted a qualitative study to categorize and describe barriers to teamwork posed by PPE and distancing in the emergency setting. METHODS: We conducted 55 semi-structured interviews between June 2020 and August 2020 with personnel from two emergency departments serving in a variety of roles. We then performed a thematic analysis to identify and construct patterns of teamwork challenges into themes. RESULTS: We discovered two types of challenges to teamwork: material barriers related to wearing masks, gowns and powered air-purifying respirators, and spatial barriers implemented to conserve PPE and limit coronavirus exposure. Both material and spatial barriers resulted in disrupted communication, roles and interpersonal relationships, but they did so in unique ways. Material barriers muffled information flow, impeded team member recognition and role/task division, and reduced belonging and cohesion while increasing interpersonal strain. Spatial barriers resulted in mediated communication and added physical and emotional distance between teammates and patients. CONCLUSION: Our findings identify specific aspects of how intensified PPE use disrupts teamwork and can inform efforts to ensure care quality and safety in emergency settings as PPE use continues during and, potentially beyond, the coronavirus disease-2019 pandemic.