Interference: COVID-19 and the Impact on Potential and Performance in Healthcare

1Introduction

The pandemic of the novel coronavirus (COVID-19) placed the U.S. population in a tailspin during spring 2020. The Center for Disease Control and Prevention (CDC) [1] offered guidelines for safety, decreasing the spread of the virus and limiting the demand on the U.S. healthcare system. The challenge of remaining “healthy at home” while simultaneously responding to the demands of work productivity became the defining career event for many employees and business owners establishing and attempting to maintain professional livelihood amid the national pandemic. The World Health Organization [2] reported that the extensive quarantine and isolation methods necessary for the prevention of spreading the disease prompted a problematic balance with staying healthy and mitigating system collapse across various segments of our society. According to Bolea and Atwater [3] interference “can exist within or outside of the organization and can include overwhelmed minds, pessimism, conflicting or ambiguous messages, competition for limited resources, and a disorganized field of play” (p110). Without a doubt, the interference of a world pandemic affects these influences across all aspects of life.

The aim of this article was to discuss the concept of interference and the role that interference plays in productivity and potential across healthcare organizations. The five components of interference are applied along with considerations for counteracting challenges of interference. It will specifically look at the interferences brought about by COVID-19, which has recently been highlighted worldwide as a pandemic, affecting all aspects of life, including the specific element of creating key processes for resilience. The following information will explore how leaders view the effects of the interference of COVID-19 and resulting behavioral restrictions on the potential and the productivity of processes in healthcare systems, and resulting economic social impact.

2Interference as a concept relative to performance

There are many sports coaching books available; however, few relate how coaching skills and learning can be applied to the occupational world, Rock and Page [4] highlight Gallwey’s work on a his formula that explains how performance is affected by interferences. His formula indicates P = p-i where P = performance, p = potential, and i = interference. Potential, is what we are capable of and what organizations are capable of becoming, is a constantly changing factor. Productivity is most changed by interferences. These are elements that shift the attention of the leader away from potential that should be captured and grown. The first point of interference existing within or outside of the organization is that of overwhelmed minds [3]. The state of being overwhelmed can interfere with potential.

Rigleb and Rock [5] indicate that neuroscience research made available from measuring real-time responses to psychological stress shows us that demanding situations can significantly increase pressure, and dramatically reduce memory, attention, and planning abilities. It also increases negativity, reduces communication, and substantially lowers resilience. Their research indicates that as stress levels rise, both creativity and the ability to sustain high-level thinking declines. These stressors adversely impact creative problem-solving skills in difficult situations, thus the ability to multitask in any type of situation is reduced. The cost of stress to one’s potential and overall productivity is captured by the following statement, “Thriving organizations are driven by their mental capital-healthy employees whose brains are functioning at their best: employees who can think clearly, are positive, resilient, and can collaborate optimally with colleagues and customers” [5, p384].

The second point of interference for a leader’s attention, is that of pessimism [3]. Optimism is crucial as it is contagious in an organization and increases the ability of the organization to adapt. Pessimists see setbacks as personal and permanent, and this mindset significantly reduces the ability of the individual to grow through adverse situations. Dweck identified that failure can be a painful experience, but not a defining one [6]. In a fixed mindset, however, the loss of one’s self to failure can be a permanent, haunting trauma. One area pervasively affected by the COVID-19 pandemic is that of the healthcare worker providing therapy services to clients in a different format, such as telehealth. Telehealth, although supported by the American Occupational Therapy Association [7] as mode for service delivery, was perceived as a forced alternative for therapy. Healthcare managers and practitioners may not have fully explored education and training needed to feel successful prior to the pandemic. The daily struggle to empower a growth mindset and deter pessimism through a technology screen can be daunting. Still, it can be exceedingly challenging for healthcare workers who are attempting to provide therapy services in a healthcare setting while managing the extra stress in their life during the COVID-19 sequester. Many life situations have an unfavorable pull towards being overwhelmed, leading to being dominated by negative thoughts, indicating that no matter the effort, it is not enough. With the shutdown of ambulatory therapy services, including home health services, many occupational therapists were furloughed or encouraged to use telehealth from their homes. During the COVID-19 period of separation from the therapy space, healthcare workers struggled to not only deliver their services and help clients understand application in their home settings, it also helped to address the fixed mindset that is prevalent in many of their homes and family relationships. The fixed mindset, the belief that we are born with fixed intelligence and ability, thrives in the face of seemingly insurmountable obstacles and challenges. This mindset type is much easier to counterbalance in the controlled therapy environment but is much more challenging to defeat in new non-habitual settings.

The third far-reaching interference point facing leaders is that of conflicting or ambiguous messages [3]. Bolea and Atwater describe these messages as too many objectives, unclear goals, conflicting or incorrect words, and vague standards. An example of ambiguity occurred in a home healthcare setting during the initial weeks in the pandemic. Early COVID-19 procedures started with clear, organized communication delivered to the work group enabling clarity. Lines of communication were well defined and authority and guidance routes were established. Two months in, when the cases of COVID-19 were increasing, a person that was seen by several therapists was diagnosed with COVID-19 and passed away. This incident led to the closure of the entire home health practice. People were instead sent home to immediately start work using telehealth practices, with minimal direction or training. The therapists exposed to the client were sent home to quarantine for 14 days, by CDC guidelines [1], with minimal guidance from the healthcare organization during this time period. The therapists were then tested for the disease after 1 week and found to be negative. Yet, the thought that they may have been tested too quickly came to mind and plagued their thinking. Once their quarantine was completed and they were found to be negative, they were expected to resume treating clients with very little support emotionally to manage their reentry into providing therapy. Stahl proposes that situational and contextual aspect of returning to the work/therapy setting must be considered, along with guidance for personal protective equipment (PPE) [8]. It was a harsh lesson for the therapists regarding the importance of organizational structure, their perceived value to the company and communication during a chaotic and confusing time. Therefore applying Gallwey’s formula of therapist’s performance (P) = their potential (p) –interferences (i) in this situation interferences are elevated with potential possibly being diminished affecting overall performance.

Communication is essential at this stage of interference. Bower [9] reminds us that the situation we face is so uncertain, there is perhaps nothing more important than the way a leader communicates. When individuals are experiencing a challenging period, people thrive when they have direction that is clear and focused on the facts. Giving people purpose by clearly articulating what you need and how they can help is a foundational skill for a leader and an occupational therapy practitioner. You may ask people to stay focused on customers during this time, or suggest they support their colleagues and look for opportunities to contribute to their well-being. Being relevant and redundant offers employees the assurance that leaders are active and aware. Allowing others to see glimpses of the big picture without straying from the truth is key. Although leaders should sometimes be selective with the information they provide to employees, they shouldn’t stray from the truth of the matter at hand. As humans don’t always know the answer, employees appreciate transparency, even if the answer is not a concrete one. Uniting people through inspirational and empathetic support is also important to the success of any team who is going through crisis.

Competition for limited resources is the fourth type of interruption [3]. This fact has never been more apparent than the current newsworthy issues with the need for personal protective equipment (PPE) in healthcare environments. The PPE shortage is a significant interruption in the efficient and effective delivery of services in the arena of healthcare. The World Health Organization puts some perspective on the problem [2]. Shortages are leaving doctors, nurses, therapists and other frontline workers dangerously ill-equipped to care for COVID-19 patients, due to limited access to supplies such as gloves, medical masks, respirators, goggles, face shields, gowns, and aprons. In addition, since the start of the COVID-19 outbreak, the prices have surged. Surgical masks have seen a six fold increase, N95 respirators have tripled, and gowns have doubled in price. Chails [10] citing Ghebreyesus’ work indicates that the protection of health care workers is first priority. Supplies can take months to deliver, and market manipulation is widespread, with stock frequently sold to the highest bidder. States are vying for supplies for hospitals as well, bidding on supplies that are desperately needed by all the surrounding states.

The fifth and final point of interruption listed is the interference of a disorganized field of play [3]. This interference is perhaps the most encompassing category of disruption during the COVID-19 crisis. This interruption occurs when the general conditions of an environment are excessively volatile, uncertain, complex, or ambiguous (VUCA). The acronym VUCA, most commonly used in the military, describes conditions that can impair optimal actions and decisions in business as well. Though the circumstances of VUCA were initially described in the Cold War, for most people, COVID-19 certainly meets the criteria.

Volatile situations are unexpected and unstable. You understand the variables, but you cannot control them. An excellent example of a volatile situation that we know in general terms, but cannot control is the stock market, which has responded negatively and dramatically following the COVID-19 pandemic. The second element in the acronym the factor of uncertainty has a dominant focus of unpredictability. There is excellent potential for surprise and lots of factors that we can’t control with risk. Complex issues have many interconnected parts and related variables. As COVID-19 is a novel virus, the scientific community knows very little about all of the variables and is in overdrive to study, analyze, test and trial all of the elements. The last factor, ambiguity, is merely playing a game with unknown rules. With COVID-19 and the economic crisis that is unfolding in its wake, the unknown is the most challenging dilemma. Dealing with the unknown produces anxiety and fear, common issues for people and organizations amid the COVID-19 crisis.

The good news, according to Bennett and Lemoine [14], is that most business environments do not actively exhibit all of the components of VUCA at the same time. It is essential to assess the situation and to determine the most critical aspect of the climate of the organization. They recommend organizations invest in information gathering capabilities and to use those insights to build contingencies as the situations evolve. The authors also recommend being transparent with employees, especially when delivering bad news. This transparency is especially important when dealing with the economic effects of the COVID-19 crisis.

When outpatient therapy facilities were ordered to close, they were faced immediately with no revenue, and no recourse other than to have employees file for unemployment. The most positive thing to do was to communicate promptly and truthfully and provide them with the information they would need to register as soon as possible. Keeping in touch with the employees through weekly group texts and emails, responding to employee questions with the best information available follows Bennett and Lemoine’s [14] recommendation and supports their view point that, perseverance is the key to successfully navigating a crisis. [15].

3Performance management to adapt during periods of interference

Bolea and Atwater [3] add to the discussion, four laws of performance management that increase the dynamic performance of organizations while they deal with interferences such as COVID. The laws of management help us to understand how leaders who have direct guiding authority over employees can improve the performance of their organizations. The first of these is the Law of Transparency. For performance to be effective, key players must have access to appropriate metrics within the information system. Though creating systems that get the right information to the right people can be initially challenging, the importance of doing this cannot be overstated [3]. The research echoes this sentiment on managing work related trauma and stress in many healthcare disciplines [16–19]. The COVID-19 crisis may unveil many inefficiencies and gaps concerning technology, systems, products, and processes. The fear surrounding this issue is that trust among employees and customers alike may hit an all-time low if the information is not accessible. Recommendations to increase trust and connections, having leaders deliver information in a clear, straightforward way and avoid giving a false perception that everything is fine [20]. Effective leaders don’t hide bad news, they share facts quickly and take action, so that their credibility remains intact. If leaders become mistrusted, the lack of transparency causes even more panic and overreaction.

Law 2 is the law of measurement. According to Bolea and Atwater [3], if you can’t measure it, you can’t manage it. Ultimately, performance management is about measurement. This measurement applies to many metrics, including soft metrics like employee attitudes and beliefs. In regards healthcare companies, it is easy to measure a loss related to the number of therapy visits per month or number of billable units. What is less easy to measure, but is as equally important, is the perceptions of employees throughout the company during this crisis. Harter [21] indicates that providing a tool for leaders to self-evaluate their response to the crisis in four areas, trust, compassion, stability, and hope help them to be more effective. Edgelow and colleagues [16] reinforce the stressful nature of returning to work after trauma situations. Current tracking indicates that only 39%of U.S. employees strongly agree that their employer has communicated a clear plan of action in response to COVID-19 [15]. This applies not only to managers directing employees at the front lines, but also to leaders in high ranking positions of authority. Measurement of the soft metrics of a leader’s capabilities in response to disaster situations such as the COVID-19 crisis is a positive step in the right direction. During high-stress times, managers need to go back to the basics of clarifying expectations, reviewing material and equipment needs, and readjusting roles so that people can leverage their strengths in new ways [22]. Each employee needs to see how they fit into the big picture relative to the organization’s mission and its purpose. A key predictor of low worry and high confidence is whether each employee believes, and experiences, that the organization is looking out for their best interest

Law 3, the law of frequency, pertains to the number of times a metric is measured, which is prioritized by Bolea and Atwater [3]. This law ties into law 2, just as important and should not be ignored. Most things in the work environment is constantly changing, and like most measurements, a positive indicator today does not necessarily mean that it will be a positive indicator tomorrow. This rule is especially true with soft indicators such as trust, compassion, stability, and hope. The frequency of measurement should be determined by the potential for change with the situation. As the COVID-19 crisis has many unknown variables and is unprecedented in most of our lifetimes, it is a highly volatile situation indicating a need for high frequency with measurements. The importance of this law resides with the fact that employees keep an organization on target relative to their changing or evolving conclusions about reality.

Since the beginning of this pandemic healthcare leaders have had opportunities requiring transparency and have experienced the need to provide measurement on the impact of COVID-19. As leaders in the profession, it is imperative to educate occupational therapy practitioners with reliable and trustworthy information. Interferences can interfere with initiating and guiding practitioners but rising above them amidst fear and uncertainty is critical for professional success. Providing information on telehealth, reimbursement, intervention suggestions and daily to weekly communications is a critical tool to support people and practice. Leading with transparency, moving forward and communicating so practitioners can see how and where they fit into the bigger picture, educating to empower fostered their resiliency. Limiting the influence of the interferences (i) with greater potential (p) = Optimal performance (P).

Law 4, the law of unintended consequences, is that people will do what they are incentivized to do, but not more, even if it is the right thing [3]. The first point of clarity for this law is that conflicting or ambiguous messages are some of the most negative interferences that spur unintended consequences. Clarity in the message is akin to kindness [24]. The potential for poor messaging is great as organizations maneuver through the COVID-19 crisis, especially when face to face communication is rare, and people are using teleconferencing, emails, and texting for the primary contact. Poor messaging can contribute to larger interferences (i) limiting the potential of the educator (p) = leading to reaching a ceiling level of performance, unless educators demonstrate their full potential to overcome interference and have good performance.

The second aspect of rule 4, goalodicy, leads to unintended consequences when achieving a metric becomes a fixation, for example, more than just hitting a target but a part of the identity of the organization and the workers [3]. In this situation, a metric becomes “hardwired” into the organization’s identity and is difficult to change. We see this potential problem as significant to healthcare in the months ahead as telehealth and telemedicine are more at the forefront of a delivery method for providing healthcare services. Frequently, the means for billing with telehealth is measured by units of time that clients are engaged on a telehealth visit, particularly true with therapy. It is anticipated that as therapists try to expend the right amount of minutes to expand into another billable unit, consumers will become bored with the redundancy of the information shared during these visits. They may begin to view telemedicine as less worthwhile than face-to-face interactions. Thus, a new method for billing for telehealth visits rather than through time increments is needed. The potential for providers to stretch billable time units spurs an unintended consequence with perceived value decrease by the consumer. The literature indicates that patients, though open to the concept of telehealth for chronic issues, still prefer face-to-face delivery of services.

In a survey completed by Software Advice [25] 11 percent of the respondents cited quality of care as the determining factor in choosing a doctor who uses telehealth, indicating that consumers are not convinced that quality is comparable to office visits.

In contrast, only about 9 percent indicate that they are concerned about using technology for a visit. Despite the national trend of hospitals and health systems that were launched into telehealth delivery amid the COVID-19 crisis, without changes, patients will likely continue to prefer in-office care.

4Recovery for the healthcare professions

It is now clear that in thinking about professional impact in occupational therapy, practitioners will be relating time periods as before COVID-19 and after COVID-19. It leads one to ask the question, “What will our new normal look like?” Sneader and Sinhal, [26], attempt to answer that question with five stages that demonstrate the path back to healthy social and economic business existence. Imagining the future post-pandemic is an exercise in hope and strategy, and ultimately the best way that we, as leaders, can direct our organizations through this unprecedented time. The first stage, resolve, is in full-blown crisis response, and especially for healthcare systems. Businesses have either closed entirely, furloughed employees and asking them to file unemployment, or are attempting to do business remotely, with employees participating virtually from home offices. The truth is that this health crisis has turned into a financial one, with companies, trying to stay afloat.

The second stage of returning to a new normal is resilience. The shock of COVID-19 to our financial health, as well as our personal health, could be the largest impact in nearly a century. Sneader and Singhal indicated that in Europe and the United States, this is likely to lead to a decline in economic activity in a single quarter that proves far greater than the loss of income experienced during the Great Depression [25]. Cash management, liquidity, and access to money for payroll, mortgages, and utilities is of great importance. Many businesses have cash on hand for the short term, but as this stage stretches into weeks and months, resilience will be more difficult. Businesses that have competed in a hierarchical system will be reset, with many playing fields evened for the first time in decades. The population will experience personal and professional financial distress across the system, with only a segment likely surviving in the long term.

The third stage of returning to normal is that of return [22]. The return of organizations to business, as usual, will likely be a slow and arduous process. As the rate of returning to business will vary by structure, companies will not look like they once did. New employees will be hired, training will likely have to take place, and systems will modify, based upon experiences. Leaders will be assessing their various systems to determine if the old way of leading will look the same as the new. Many people will likely fear to return to the workforce because of anxiety that the virus will resurge. An important aspect at this stage is supporting the health of workers, understanding their stress. Use of informational tools can support the mental health of the workplace [16, 19]. This hesitancy can potentially cause yet another economic crisis. Once again a need for transparent leadership is apparent.

The fourth stage is that of re-imagination. As the population and workforce shift when businesses go back to work, leaders will be required to re-imagine what success looks like in the future. All crises include opportunity, and COVID-19 will undoubtedly spur practitioners to think of current systems and processes very critically. Supplies will likely need to get closer to the point of use, and technology will be even more prevalently used than before, pushing therapists into a period of rapid learning. This period will be significant as there will be new players on the field, and the most innovative organizations with strong leaders will likely be the ones to survive and thrive.

The fifth and final stage in determining our new normal is that of reform. Sneader and Singhal use the metaphor of a “black swan event” to describe the COVID-19 crisis [26]. A black swan event is a hard to predict, as it is an extreme outlier that is psychologically biased, blinding us from the potential for the event actually to take place. Few could consider the magnitude of the effect of the COVID-19 crisis. To survive this event, structures and systems will need to change. Large businesses will need to become more self-reliant, capability for technology will need to improve, and barriers to science will need to decrease. How the crisis evolves is yet to be seen; however, as leaders maneuver through the next stages of recovery supporting employees with reliable and current information is key to survival.

5Conclusion

The interference of conflicting and ambiguous messages has been prevalent while experiencing and responding to the COVID-19 crisis. Competition for limited resources is an interference that is always present but is significantly more prevalent now than ever before. In the healthcare setting, organizations are providing services with fewer staff and fewer supports than ever before. Everyone in the equation is hurting, and the desperation for work is evident. The final type of interference, a disorganized field of play, is a given. No one knows the rules of a game never played before, and no one knows the outcome. Organizations cannot make promises of continued employment to staff, and they can’t pretend that they know the fate of businesses. The conditions of VUCA are authentic to all through this period, and organizations must remain hopeful that they can sustain practice to have continuity in contributing to the health and wellbeing of clients.

Bolea and Atwater’s four laws of performance management are particularly helpful in guiding leaders throughout this period [3]. Working hard to be transparent with employees, colleagues and students, measuring metrics with appropriate frequency, and avoiding unintended consequences such as flawed messaging and goalodicy are key strategies. As leaders move into the new stage of what normal looks like, the authors suggest utilizing the organized staging of this process offered by Sneader and Singhal [26]. As organizations are still in the stage of resolve, leaders look forward to climbing the difficult ladder of resilience, return, re-imagination, and reform. These stages will each be difficult, but as a profession, occupational therapy is ready for the challenge. Like many private practice owners, healthcare settings and academic settings practitioners have no choice. Therapists must weather this storm in order to contribute for so many to have ongoing occupational success.

6Clinical implications

Living through COVID-19 has been hard. Maintaining a private practice, leading a state association and teaching through COVID-19 has been a journey that has taught many things, and through study and reflection and working daily to return and re-imagine our potential, practitioners will persevere.

A return to Gallwey’s formula for performance where P = p –i (Performance = potential –interference) [4] deserves review. “From a leadership perspective, performance results from building the greatest possible potential for the organization and minimizing interference, i.e., anything that gets in the way of delivery potential” (3 p109). The COVID-19 pandemic has produced many interferences across seemingly every sector of society, leaving in its wake a healthcare, economic, social, and educational crisis. The recovery from this pandemic will be difficult for all organizations, and for some, may not be a possibility. With the strategies of transparency, frequent metric measurement, and focused avoidance of unintended consequences, the goal is that the potential for organizations will be higher than the interferences of COVID-19.

Though the future is unknown following the COVID-19 pandemic, the structure for measuring the stages of recovery is helpful. Admittedly, healthcare professionals are currently between the stages of resolve, where the pain of the effects of COVID-19 is fresh and moving towards resilience. As practitioners reach the stage of resilience, the hope is to use every avenue available, including the Payroll Protection Program made possible by the CARES Act [27]. As our community re-imagines a new world of healthcare, occupational therapists are uniquely prepared to reform our organizations into competitive and resilient settings that will withstand the tests of our times, being made better by the interferences brought by the COVID-19 pandemic.

Conflict of interest

None to report.