Mental health challenges for healthcare workers during the COVID-19 pandemic – Psychological Impact and management strategies
Time to read: 7 minutes
In December 2019, an outbreak of the novel coronavirus occurred in Wuhan, China. To date, this has spread to 192 countries across the globe, raising a number of significant challenges for health care workers.
As the health system prepares itself to deal with the COVID-19 pandemic, it is more important than ever that we safeguard the welfare of our medical workforce. The Ebola outbreak which occurred in West Africa in March 2014 and subsequently spread to neighbouring countries is a cautionary tale.
As the health system became inundated with patients, the resources needed to protect healthcare workers from infection became increasingly scarce. By the end of the [Ebola] outbreak, over 50% of infected healthcare workers died and, of those that survived, countless were left with post-traumatic stress disorder. Healthcare workers became martyrs; but the repercussions for patients and providers were catastrophic. [Diamond and Woskie, 2002]
Over the past decade, there has been an increasing awareness of the physical and psychological challenges doctors face.
Long and irregular hours, continuous performance evaluation and heavy workloads can all contribute to increased levels of stress and ultimately precipitate burnout. In the coming weeks and months, doctors will face numerous additional stressors. It is important that proactive efforts are made to address the impact of the pandemic on their mental health.
IMPACT OF COVID-19 PANDEMIC ON MEDICAL WORKFORCE
Decision making under conditions of uncertainty can create significant psychological pressure. The decisions that health care workers will face broadly fall under 4 categories.
There have been several recent studies examining the impact of COVID-19 on medical staff in other parts of the world. These studies can help us anticipate the impact of the pandemic on our medical workforce.
The Chinese experience [Chen Q eta l., 2020] reported that the main fears of the staff were the following:
- Surprisingly, becoming infected was not an immediate worry for staff; however, they were concerned about their families being worried about them, and were afraid of taking the virus home and infecting family members.
- Staff were worried about a shortage of protective equipment and when faced with critically ill patients.
- Many staff mentioned that they needed more uninterrupted rest
- Staff struggled to deal with patients who were unwilling to be quarantined.
A cross-sectional study of 1257 frontline health care workers in COVID-19 affected regions of China describes the challenging conditions faced by medical staff, with the significant stressors summarised as follows: [Kang L et al., 2020]
Frontline medical staff surveyed in the above study were found to have considerable rates of depression (50.4%), anxiety (44.6%) and insomnia (34.0%); 71.5% of participants reported non-specific symptoms of psychological distress.
The study also identified that women and those in frontline roles in the most severely affected regions had a greater risk of depression, anxiety and increased distress.
OTHER IMPORTANT PSYCHOLOGICAL IMPACTS
Burnout:
The concept of burnout describes a state of extreme physical and psychological exhaustion brought on by the demands of certain professions.
While not a formal psychiatric diagnosis, burnout can be associated with a range of conditions including anxiety, depression and post-traumatic stress disorder, all of which can reduce the quality of life of affected individuals.
Burnout is also linked to an increased risk of medical errors and unplanned absences from the workforce, both of which adversely impact patient care.
In recent years, the emotional welfare of junior doctors has been a topic of widespread discussion in the media, triggered in part by the tragic suicides of several medical trainees.
In November 2017 NSW Health responded to the public outcry over this issue, launching a $3 million Junior medical officer (JMO) Wellbeing and Support Plan. Initiatives such as the CrazySocks4Docs movement have also helped raise awareness of the prevalence of mental illness amongst medical professionals.
While there have been promising signs of a cultural shift within the medical profession itself, many would argue that doctors experiencing psychological distress continue to face significant stigma. This can act as a barrier to help-seeking and further isolate those already in a vulnerable state.
This is an important consideration as we prepare to address the psychological impact of COVID-19 pandemic on the medical staff. Junior doctors may be particularly vulnerable.
Moral injury:
Moral injury is defined as psychological distress that results from actions, or lack of them, which violates someone’s moral or ethical code.
Moral injury is not considered a mental illness but can lead to negative thoughts, feelings of guilt, shame or disgust. On the other hand, decision making in difficult situations can lead both to resilience and post-traumatic growth.
The huge current effort to ensure adequate staffing and resources may be successful but it looks likely that, during the COVID-19 outbreak, many health care workers will encounter situations where they cannot say to grieving relatives “we did all we could” but only “we did our best with staff and resources available but it was not enough”. That is the seed of moral injury. [Greenberg et al, 2020]
INTERVENTIONS TO ADDRESS THE IMPACT OF THE COVID-19 PANDEMIC ON MEDICAL STAFF
It is useful to consider how other countries have attempted to deal with the psychological impact of the pandemic upon medical staff. The interventions below are summarised from 4 recently published studies. [Chen Q eta l., 2020] [Kang L et al., 2020], [Dewey C et al., 2020], [Greenberg N et al., 2020]
These can be broadly divided into three categories, as summarised below:
1. Strategies to reduce specific work-place stressors:
- Early intervention: Preparing staff for a job and associated challenges; avoiding false reassurances and giving a frank account of what staff may face.
- Reflection for health care staff, to discuss emotional and social challenges (Schwartz Rounds).
- Reaching out to staff, especially vulnerable staff, as avoidance can be present during traumatic situations, avoiding single-session psychological debriefing as this may cause additional harm.
- An alternating shift system was established to allow frontline medical workers periods of rest and ensure that there was a rotation of workers in high-pressure roles
- Development of online platforms to provide medical advice to the public to reduce pressure on medical workers in hospitals
- More training was provided in terms of managing psychological problems in patients; security staff were also made available to help manage patients who were aggressive or uncooperative
- Policies regarding the use of protective equipment were clarified to reduce anxiety about this issue
- Providing access to on-call rooms for staff who are working long shifts
- Reduce non-critical work activities such as routine follow-ups and non-essential administrative tasks
- Well defined and easily accessible protocols and expectations for staff
- For clinicians who are unable to attend work due to mandatory isolation but are not unwell consider the possibility of computer and phone-based activities
2. Supports for the general welfare of medical staff:
- Accommodation facilities were made available to allow staff to temporarily isolate themselves from their family and reduce concerns around transmitting the virus
- Supplies of basic provisions such as snacks, water, phone chargers and toiletries for staff
- Designated break times for staff
- Staff were encouraged to create a video record of their daily routine; this could be shared with concerned family members to provide some reassurance
- Leisure activities were coordinated for staff to promote relaxation when not at work
- Encourage open discussion of emotional responses, create a normalising culture for disclosures of vulnerability
- Provision of adequate information on stress management, identification of burnout and available support services for staff
- Designated “wellness champions” to provide a point of contact for staff concerns, advocate for welfare initiatives and distribute messages of support and gratitude
- Promoting communication of challenges and successes through a range of different forums
- Aftercare: Once the crisis is over, ensure that there is adequate time made to reflect on and learn from the stressful situation. Consider active monitoring of staff and early intervention for those staff who become unwell.
3. Specialised psychological support services for medical staff:
- Dedicated hotlines were created to provide support and advice to medical staff experiencing psychological distress; these hotlines were predominantly staffed by volunteers who received training from mental health professionals.
- Online courses were created to help medical staff manage common psychological problems
- Counsellors were stationed at staff rest areas to provide face-to-face support
- Peer support programs
CONCLUSION
There is significant uncertainty for all health professionals and key decision-makers in navigating the challenges posed by the pandemic. The impacts of the pandemic on the community and health workers will be identified over the coming years.
Psychiatrists play an important role as advocates for mental health. In these uncertain times it becomes especially important that the mental health of front line health care workers is a key consideration.
These are extraordinary times. There is pressing need to ensure that they do not cause long-lasting damage to health care staff. They will be the heroes of the day but we will need them for tomorrow.
For hundreds of years, the military has recognised the critical role of junior leaders in maintaining the will and capability of troops to continue to fight, even in the most arduous of conditions.
Similarly, health care managers in supervisory positions must now acknowledge the challenges staff face and minimise psychological risk inherent in dealing with difficult dilemmas and those in charge of resources need to provide them with the opportunity to do so. [Greenberg N et al., 2020]
Read about the Neuropsychiatric manifestations of COVID-19.