FRANKFORT The ferocity, duration, and unpredictability of the current pandemic leave healthcare providers particularly vulnerable to negative psychosocial impacts: COVID-19 is an occupational hazard. This is no surprise: past pandemics have had similar effects, and healthcare workers have long suffered from burnout, compassion fatigue, and secondary traumatic stress, albeit to a lesser extent. This pandemic has exacerbated, not created, these stressors. But, the COVID-19 pandemic also offers an opportunity to address the toll of healthcare work in more effective and evidence-informed ways to build and sustain a resilient workforce.
System Responsibility
First, it is critical to recognize this as a system responsibility. For years, self-care has been promoted as an individual act, and suffering from burnout seen as indication that somehow you were not cut out for the job. We now understand how wrong-headed this view is. Organizational systems must create a culture that understands, recognizes, and actively seeks to prevent and mitigate burnout, secondary trauma, compassion fatigue, and moral distress in its staff. This level of transformative change requires clear understanding, buy-in, and engagement across all levels of healthcare, especially among leadership, to promote a multi-tiered system of supports integrated into the organizational structure and fabric of healthcare systems. This should include confidential mental health coverage and support through health insurance and EAP resources, including crisis response and a way for physicians and all staff to seek support for themselves and others. Resilience-building practices and policies must recognize staff well-being as a critical driver for a successful and sustainable healthcare system.
Public Awareness and Recognition
This starts with public awareness and recognition that, yes, it’s actually okay to not be okay, even among physicians. A robust body of literature concludes past pandemics created a plethora of negative psychosocial responses for healthcare professionals: depression, anxiety, symptoms of traumatic stress, sleep and appetite disturbances, and somatic aches and pains.1 Emerging data confirm that this pandemic is no exception,2 with consistently elevated self-reports of depression, anxiety, traumatic stress, overwhelm, emotional exhaustion, and burnout noted across all healthcare professions, transcending geographical and cultural borders. Risk factors are also consistent with past pandemics: being female, younger, newer to the field, working as a nurse, working on the “front line,” and having any pre-pandemic mental health concerns increases vulnerability. And, not surprisingly, there is also a direct correlation to dose exposure from working with the sickest patients. Leaders, agencies, organizations, and professionals must normalize the occupational hazard of COVID-19 for the mental health and well-being of workers; feeling even extreme stress is well within normal limits. This should occur through regular information about normal stress responses and supportive resources provided at staff meetings and through regular staff communications in newsletters, email blasts, and other social media outreach. Past pandemics indicate that posting information for staff to access as needed is not enough when they are working long hours and experiencing pandemic-related additional stress; information must be actively, routinely, and repeatedly pushed out through personal and media communication channels.3
Screening is a Must
To that end, regular and continuous screening is a must. Physicians and all healthcare professionals must be encouraged and expected to check in with themselves and one another as part of their practice. Staff meetings, huddles at the start or end of shifts, and one-on-one supervision should address not only patient needs but include a routine check-in with staff about the emotional impact of the work, how they are coping, and what they need. Casual conversations and relationship-building, critical for connection especially when PPE obscures our most human features, should be encouraged among staff. A number of validated screeners for burnout, compassion fatigue, secondary stress, depression, anxiety, and PTSD are available4 and should be offered and integrated into supervisory and staff meetings and crisis response protocols to promote early detection and intervention and normalize the emotional toll of the work.
Re-imagined Self Care
Self-care must be reimagined from big escapist activities to relax outside of work, to small, routine parts of even the busiest days that promote emotional self-regulation and well-being. This includes ensuring that staff have access to scheduled breaks and meals, healthy food, fresh air, and a supportive and affirmative leader who recognizes and thanks them for their efforts. Staff should be educated and encouraged to use short deep breathing and grounding strategies regularly between tasks throughout the day, to step outside for 5–10 minutes each shift, and to take care of their own bodily needs while at work. Staff meetings or shift huddles can start or end with three breaths, one-minute grounding activities, or a short stretch.
Manage Exposure
Leaders, especially physicians, must recognize the cumulative toll of exposure to trauma and consider how to reduce or manage high levels of exposure for themselves and their staff. Designating specific staff to COVID units permanently is not recommended; instead, creative rotating schedules to minimize the number of staff exposed while also ensuring that the highest risk and most grueling work is not falling on only a few individuals, is critical. While bonus pay and relying on volunteers may attract some, the organization and physician-leaders must still titrate exposure to the most stressful conditions to sustain the workforce physically and psychologically. Resilience-promoting supports to staff working in the highest-exposure areas are even more critical. They must be allowed and encouraged to take breaks and have access to nutritious food, and supervisors must monitor staff well-being through daily group check-ins, regular individual supervision, and routine staff screening.
Model Leadership
Leadership must actively support and model care for worker well-being. Incorporating supportive practices and policies to care for staff requires ongoing and public support and modeling by leadership at all levels. As senior clinicians, physicians must acknowledge the toll of this pandemic, and shed the superhero, tough-upper-lip stance they have been taught, instead revealing their own humanity, exhaustion, distress, and needs. Floor managers and clinic supervisors will only support staff if physicians and all top leadership do as well. Executive meetings and supervision should include check-ins, administrators should utilize mindful minute strategies, and above all, leaders, including physicians, must acknowledge the toll of pandemic work and regularly thank and affirm their staff individually and collectively. Leaders should promote a culture of engagement and participation and empower staff in creative and collaborative problem-solving, powerful antidotes to the profound sense of powerlessness endemic to the current uncertainty of this pandemic. Leaders should also model and encourage collegial connection to reduce isolation and promote constructive sharing and support.
Find Hope and Positivity
Finally, it is imperative to find hope and positivity. Although compassion fatigue and secondary traumatic stress may be inherent costs of caring for others, they are mitigated when providers also feel a sense of compassion satisfaction from their work – the sense that we are making a difference, that our work is valuable, and that there is meaning to our work. Physicians must share and celebrate the successes, prize even small victories, and remind themselves and one another of their core values and their inspiration for choosing this “noble profession.”
There is no doubt, the duration, severity and uncertainty of COVID-19 has had a deleterious impact on the mental health of healthcare professionals. There is also no doubt that it offers a unique opportunity to learn valuable lessons about resilience and transform healthcare practice to be more sustainable long after this pandemic has resolved. This must become a part of our work if we are going to be able to continue to do our work.
Miriam Silman, MSW, is Project AWARE/Trauma Informed Care Program administrator, Department for Behavioral Health, Developmental and Intellectual Disabilities, Cabinet for Health and Family Services.
NOTES
1
For information about the mental health impact of past pandemics see:
Salazar de Pablo, G., Vaquerizo-Serrano, J., Catalana, A., Arangob, C., Morenob, C., Ferred, F., Shine, J.I., Sullivan, S. Brondinog, N., Solmia, M., & Fusar-Poli, P. (2020). Impact of coronavirus syndromes on physical and mental health of health care workers: Systematic review and meta-analysis. Journal of Affective Disorders, 275.
2
For current research and reviews of the literature to date on the mental health impact of the COVID-19 pandemic on healthcare providers see:
Braquehais, M.D., Varga-Cáceres, S., Gómez-Durán, E., Nieva, G., Valero, S. Casa, M. & Bruguera, E. (2020). The impact of COVID-19 pandemic on the mental health of healthcare professionals. QJM: An International Journal of Medicine, 1–5.De Kock, J.H., Latham, H.A., Leslie. S.J., Grindle, M., Munoz, S-A, Ellis, L. Polson, R. & O’Malley, C.M. (2021). A rapid review of the impact of COVID-19 on the mental health of healthcare workers: Implications for supporting psychological well-being. BMC Public Health, 21(104).Mental Health American, (2021). The mental health of healthcare workers in COVID-19. Available at: https://mhanational.org/mental-health-healthcare-workers-covid-19
Prasad, A., Civantos, A.M., Byrnes, Y., Chorath, K., Poonia, S., Chang, C., Graboyes, E.M., Bur, M., Thakkar, P., Deng, J., Seth, R., Trosman, S., Wong, A., Laitman, B.M., Shah, J., Stubbs, V., Long, Q., Choby, G., Rassekh, C.H., Thaler, E.R., & Rajasekaran, K., (2020). Snapshot impact of COVID-19 on mental wellness in nonphysician otolaryngology health care workers: A national study. OTO Open 4(3).Serrano-Ripoll, M.J., Meneses-Echavez, J.F., Ricci-Cabello, I., Fraile-Navarro, D., FioldeRoque, M.A., Pastor-Moreno, G., Castro, A., Ruiz-Perez, I., Zamanillo Campos, R., & Goncalves-Bradley, D.C. (2020). Impact of viral epidemic outbreaks on mental health of healthcare workers: A rapid systematic review and meta-analysis. Journal of Affective Disorders, 277, 347–57.Shaukat, N., Mansoor Ali, D. & Razzak, J., (2020). Physical and mental health impacts of COVID-19 on healthcare workers: A scoping review. International Journal of Emergency Medicine, 13(40).Søvold, L.E., Naslund, J.A., Kousoulis, A.A., Saxena, S., Qoronfleh, M.W., Grobler, C., & Münter, L. (2021). Prioritizing the mental health and well-being of healthcare workers: An urgent global public health priority. Frontiers in Public Health, 9.
Spoorthya, M.S., Pratapab, S.K. & Mahant, S. (2020). Mental health problems faced by healthcare workers due to the COVID-19 pandemic: A review. Asian Journal of Psychiatry, 51.
3Evidence-informed guidelines for pandemic response including support to healthcare providers can be found at: https://www.uky.edu/ctac/sites/www.uky.edu.ctac/files/evidence_informed_guidelines_for_child_focused_ pandemic_planning_and_response.pdf
Miotto, K., Sanford, J., Brymer, M. J., Bursch, B., & Pynoos, R. S. (2020). Implementing an emotional support and mental health response plan for healthcare workers during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000918
Additional information and resources can be found at the University of Kentucky Center on Trauma and Children Well@ Work website: https://www.uky.edu/ctac/wellatwork
AMA well-being resources are located here: https://clinician.health/
4Psychometric screeners can be found at the UK Center on Trauma and Children Well@Work website: https://www.uky.edu/ctac/tier3screening