Table 1 Leaders’ actions mapped to trauma-informed principles including specific future actions leadership can take

Safety

Promoting physical protection

“Even though you know that it’s not best practice, it’s better than nothing—but it’s not best practice….It was hard conversations about what is appropriate and what was the best we could do versus best practice.” (Participant 2)

“In the end, we had absolutely zero negative patient outcomes, and our patients got better care. And the nursing staff was extremely satisfied with that, because they were able to not have to sit in that room with a patient shedding the virus.” (Participant 4)

Increase communication to enhance trust and transparency when physical safety is a concern

Not taking complaints personally

“I’d get an angry email from the head of the department and he’s just looking… out for their staff right? And, and their nurses and their other employees. So I totally get it, right. Cause I’m doing the same for mine…” (Participant 8)

Approach complaints from staff with empathy

Missed Opportunity- Providing more attention, space, and time for emotional processing

“Even now, we continue to see that and how people are very short with one another, and they don’t allow mistakes in other people and there’s a lot of unneeded hysteria, and I think that it stems back to us not really dealing with all of these emotions that we went through last year. And how do you deal with that on an administrative level, in a hospital when you have hundreds of people reporting to you? I don’t really know the answer to that, but if there was anything that I could have done better, that would’ve been anything.” (Participant 7

Create safe spaces and when possible, give staff built in time for emotional processing which could include group talking spaces, time for exercise, nutritious food, or rest in the day

Trustworthiness & Transparency

Listening

“I think that there's a value in just listening and acknowledging and we may not have an answer, and no one does. I feel that to recognize that it exists, I think goes such a long way and I think that's why we've developed such a great rapport with many of our frontline teams, because they feel and they see that we hear them.” (Participant 5)

“So what helps… What I need to do is give myself time to listen and to let people know what we're doing for them. So, both those things take time… one kind of helps establish understanding, trust, and the other helps establish … the next level of trust where, ‘oh, he is acting on some of the things I expressed earlier.” (Participant 4)

Listen without judgement to build trust and without immediate intention to solve

Increasing frequency of information dissemination

“When communication breaks down, that’s when rumor control starts. So, I think just being fully transparent with where you’re at, whether you had PPE, whether you didn’t. Whether you had to a process together to reuse N-95 s….[The staff] can trust you. Because it comes down to trust, it really does, it comes down to trust.

Best practices I think is just to be open in your communications and transparent. Helping [staff] see that you're doing this for their best interests and the best interest of our patients and our colleagues. And we all want the same thing.” (Participant 25)

“We made a decision as a command center group that the best that we could do would be to be visible and transparent, and really share… So, it was rough. I’m not going to lie. It was a rough time. But it was really about remaining calm, remaining focused, and being transparent, and being visible.” (Participant 13)

“[Our department chair] would send almost daily email updates to the department faculty and staff, sharing the statistics, "This is how many patients we have on the inpatient unit. This is what the ER looks like," just different stories. "Here’s what’s just happening across [our organization] and the country." That was really helpful for us, to get that communication because even if we didn’t know what was going on, we knew that nobody else did either and nobody was holding things from us. We just didn’t know what was happening. So, he did a good job communicating.” (Participant 25)

Foster transparency through increased information dissemination

Making decisions transparently

“I think also not always being able to answer questions or give our teams the most. Part of it is we don’t know the answers. And so not being able to provide direction to our team sometimes just because the information was changing. I felt a little bit not powerless, but I felt I always wanted to try to do more, and I couldn’t. So, I think that doesn’t feel great.” (Participant 18)

Communicate to staff reasons for decisions and changes

Missed opportunity- Overcommunicating on time off

“When we have the command center set up and there’s these things going, and we say, 'Hey, it’s the weekend. You don’t need to do this.' And then yet on the weekend, we’re sending them texts or emails and all these pieces… I have definitely heard from quite a few of them for feeling like… They tell us to try and work on… taking care of ourselves and resting and removing ourselves. And then yet these emails come in and it definitely comes across as we expect you to respond to these.” (Participant 13)

Be mindful and intentional with sending emails/other communications to staff on their time off. Think critically if it is essential communication

Missed opportunity- Containing leadership anxiety

“The major leadership failure here was that leaders didn’t contain anxiety within their teams. They let that anxiety fuel their own anxiety and threw it out for the organization. So we just all run and collided into each other. It was really damaging, and it took a lot of time to manage. So, how do you help people see, this is about my own like reflection, containment. What’s real, what’s anxiety. Even if I’m anxious, how do I contain my anxious? Because the world is scary right now… In order to be a learning culture. I think we have to be able to have enough insight to separate emotion from the reality or at least know.” (Participant 1)

Leverage support of leadership peers to process personal anxiety as opposed to channeling frustration toward staff

Empowerment

Communicating with flexible times and modalities

“I gave my personal cell phone out in addition to my work cell phone, so that the staff could text or call me at any point in time. And they did, and I answered them back and went down and listened to them and their fears…Very difficult time.” (Participant 4)

Empower staff to choose best mode and time for communication

Mutual support

Checking on Wellness and Creating Personal Touch Points

“We established this routine of almost good morning type emails to where… almost akin to if you were walking down the hallway and going in somebody’s door and just saying good morning. We increased the frequency of our manager touch-bases fourfold. It was good from a project perspective, but it was also good from a wellness perspective, just from the standpoint of 'we got to just talk'.” (Participant 22)

“[The administration] introduced just a lot of conversations, a lot of time on just: how is everyone? What are people thinking about? What are you stressing about? What we learned is uncertainty [is a] cause of stress for people, right? We don’t know when we’ll be back at work, but… they knew that I had a plan.” (Participant 28)

Proactive wellness check-ins prompted by leaders to establish mutual support

Leading by example

“I remember this one time my team doesn’t want to come in back to work, I have a patient I need to discharge. He’s homeless, he refused to wear a mask. He’s coming out to the nursing station, nursing staff, doctors freaked out. I remember, I wear a mask … At that time, we also didn’t have all the PPE that we have, right? I physically went into the room and I have to push the patient’s belongings out, so he can go to a hotel. Somebody has to do the job and at the end, someone has to do it. If nobody does it, a leader has to step in and do it.” (Participant 3)

Model desired behavior of staff to enhance mutual support

Identifying a common goal

“We started to show up day in and day out together with the same group of people that for me, I was really new to the organization that I’m working at now, and so I did not have the long-lasting relationships as my peers had. Many of them grew up in this system together, and so I felt very fortunate that it was a very inclusive environment. Again, I think a lot of that had to do with that shared goal.” (Participant 5)

“I think it was obviously a very scary time, a lot of uncertainty surrounding when the pandemic first became, I guess, an outbreak. And one of those things that I felt like went really well as a hospital administrator is the team got together very quickly. The common goal was definitely our motivator to be able to kind of think things through.” (Participant 5)

Use a common goal to establish communal support, return to common goal as needed when facing challenges

Sharing positive messages

“What I really appreciated about our team was it was as though different people were at a high on different days. And so, those people who were feeling better did a really nice job of just building up the team and supporting us and helping us feel good. Some days, I was scared and anxious and wasn’t sure what to do next. And thankfully, somebody else would be having a better day that day and would have some sort of uplifting story or some way just to motivate us and feel better…” (Participant 27)

“Supporting everybody who was in a different situation. Some people had babies at home, some people had elementary school kids that you can’t just sit in front of a computer and think they’re going to work. There was no two people experiencing the same environment or anxiety, whether it was work-related or not.” (Participant 28)

“And so, the team really did a nice job supporting each other through that. Then it was nice because then the things that we shared, the positive moments, they would take back to their teams. And so, then that team got another uplifting moment. It worked out well. People really rose to the occasion and really supported each other.” (Participant 27)

Leverage and encourage people who are having good days to lift up people who need more support

Supporting middle management

“I think the first thing that comes to my mind is trying to figure out the best way to support middle management. Those people that are sort of in between trying to keep the team of frontline people together, but then also have the demands coming down from them, and trying to figure out with the current situation, how do we support that group, so they don’t feel like they’re supposed to be working 24 h a day, seven days a week, and help them address their own burnout.”(Participant 13)

“I think that’s been a big struggle from our standpoint. We have seen more turnover in that area recently than we really would like to see. When I go out and around and talk with frontline staff, many of them say, 'I stay because of my manager.' Not because of senior leaders, they stay because of the person they have that interaction with. As a result, if we have those people leaving, then we have more potential for losing some of our frontline staff, which at this point we just simply can’t afford.” (Participant 13)

Spend time building structures to support middle management including trauma-informed trainings to protect against burnout

Cultural, Historical and Gender issues

Naming Challenges Outside of the Hospital

“And I think the one that was really scary, but I felt like I had to do it, was to just talk about race. … I could not let that moment in time go by us without acknowledging how much pain many people… were feeling.” (Participant 15)

Engage with challenges occurring outside the hospital to empower staff to raise concerns and recognize depth of each person