COVID-19: stress management among healthcare workers
Since the beginning of the health emergency caused by the spread of COVID-19, health professionals have been on the frontline fighting the epidemic within all settings of our healthcare system. They are at risk of becoming infected and experiencing emotional overload fuelled by the shortage of suitable personal protective equipment, relentless work shifts, physical fatigue, reduction in human resources and sometimes poor organization. With the healthcare system under increasing pressure, other circumstances can contribute to increasing the emotional burden on health professionals: being asked to work in disciplines other than their own, or urged to continue working despite being in contact with COVID-19 patients and potentially becoming infected; newly-qualified doctors and those still in training having to deal with critical situations that would normally require more experience; general practitioners having to visit patients with milder symptoms at home to provide them with the care and support they need.
The examples above show that all healthcare and emergency workers providing their services in healthcare settings or in the community (hospitals, emergency departments, prevention departments, epidemiological services, ambulance services, long-stay residential care homes, but also civil protection volunteers) are currently facing organizational, relational, psychological and safety challenges that are likely to become a source of stress.
A good snapshot of the current situation is offered by doctors at the Papa Giovanni XXIII hospital in Bergamo, in an article published on 21 March 2020 in NEJM Catalyst Innovations in Care Delivery, and by a letter from the National Federation of the Associations of Doctors and Dentists (FNOMCeO) published in the BMJ on 26 March 2020.
The scientific literature on work-related stress has largely confirmed the presence of psychosocial risk factors in the healthcare sector that are closely linked to staff’s working conditions, safety and health: shifts, availability, emergency management, staff shortages, dealing with situations of extreme suffering on a daily basis, potential risk of verbal and/or physical abuse. The current emergency is amplifying these factors, especially those related to workers’ safety, namely preventive and protective measures.
The World Health Organization (WHO) points out that the first step in protecting the health of healthcare workers in an epidemic is taking all necessary measures to ensure their occupational safety. Employers and healthcare facility managers must ensure that all necessary preventive and protective measures are taken, providing adequate supplies of personal protective equipment in sufficient quantity to healthcare or other staff caring for suspected or confirmed patients. They must also consult with healthcare workers on occupational safety and health aspects of their work. However, it is important to remember that in an epidemic, even when suitable preventive and protective measures are available, healthcare workers remain exposed to high levels of psychological and physical stress: fear of becoming infected and infecting their families, high mortality rates, grieving the loss of patients and colleagues, separation from families (often for long periods of time), changes to working practices and procedures, the need to provide patients in isolation with essential emotional support, physical strain from wearing personal protective equipment.
Some studies seem to confirm that in an epidemic (compared to other health emergency situations, like natural disasters), psychological and physical stress among healthcare workers can be increased by social isolation, due to social distancing and quarantine measures or even discrimination, and the lack of family support due to fear of infection. The fear of becoming infected or infecting their families, especially young children, sometimes forces healthcare workers into self-imposed isolation. The increased workload also reduces interaction with their colleagues, and their relationship with patients is radically changed. As a result, they can often feel angry, hostile, frustrated or helpless, experience symptoms of depression and anxiety accompanied by physical complaints, suffer from insomnia, and increase their consumption of caffeine and tobacco.
Studies on psychosocial risk factors for stress among healthcare workers during the SARS and Ebola epidemics, the A/H1N1 influenza pandemic and the COVID-19 epidemic in China have observed the occurrence of symptoms that can be associated with post-traumatic stress.
A cross-sectional study conducted in China on a sample of 1257 healthcare workers in medical facilities treating COVID-19 patients, observed symptoms of depression and anxiety. It also found that women, nurses and those working in areas with the highest number of cases (that is the workers most involved in the emergency response) were suffering more intense symptoms and therefore could need psychological support or interventions.
The Inter-Agency Standing Committee (IASC) issued a briefing note summarizing key mental health and psychosocial support (MHPSS) considerations in relation to the COVID-19 pandemic. The document describes behaviours that healthcare workers can adopt to prevent and reduce stress caused by the specific situation that they are facing. On 6 March 2020, the WHO issued some recommendations to help people cope with stress during the COVID-19 global health emergency, including specific messages for healthcare workers.
Practical advice drawn from the literature
Below are presented some recommendations to help prevent emotional stress among healthcare workers during the COVID-19 emergency.
Advice for health authorities and healthcare facility managers
- Ensure that good quality communication and accurate information updates are provided to all staff. This can help alleviate worries caused by uncertainty and make them feel in control.
- Provide positive feedback to stress the value and importance of the role they play
- Promoting team work. The “buddy system”, for example, involves colleagues working in pairs, so that they can ensure each other’s safety and provide mutual support when dealing with challenging situations.
- Facilitate access to psychological support services, ensuring that staff are aware of where and how they can access them, including telephone or other remote support services when available.
When demand for care is especially high, the professional engagement of healthcare workers directly involved in the emergency response is such that it leaves no room for them to process a psychological response or ask for help. It is therefore essential that employers facilitate this process. Several health authorities have already taken concrete steps in this direction, by making a psychological support service available over the phone (or via Skype), setting up specialist mental health clinics to support their professionals (for example, AUSL Romagna, Azienda Sanitaria di Trento, Azienda Ospedaliera Universitaria Pisana, ASLTO3, ASL di Viterbo, ASL Umbria 2) and by promoting communication between healthcare workers and citizens over the Internet (AUSL Piacenza, ASL Bergamo, and others).
Advice for healthcare workers
- Wherever possible, work a reasonable number of hours and take breaks. During the acute phase of the emergency, it is essential that you allow yourself some respite to rest and reflect on what you’re experiencing. Managing stress and taking care of your mental health is important to preserve your physical health.
- Use coping strategies that have worked for you in other situations as this can prove useful also in a unique and unprecedented scenario like the current COVID-19 emergency.
- Interacting with colleagues is crucial to coordinate activities, but also to share your own perceptions and benefit from mutual support, while respecting different ways to respond to the crisis. Acknowledging a colleague’s professional contribution can boost motivation and mitigate stress.
- Try to maintain a healthy lifestyle, eating and drinking well and enough, to be able to cope with the accumulated pressure. Reduce the consumption of caffeine, nicotine and alcohol. Allow yourself enough sleep and rest to restore your energies, and engage in physical activity.
- Pressure, stress and the feelings associated with it can make you feel helpless and unable to do your job. Therefore, it is important that you realize what you are really capable of doing to help others, and appreciate also the small achievements; consider the positive results and accept outcomes that don’t meet your expectations, acknowledging your limitations under the exceptional circumstances. It is also important that you be aware of your mood and the emotional burden, learning to recognize physical and psychological symptoms linked to stress. Taking care of yourself and encouraging your colleagues to do the same is the best way to continue being of help to patients.
- Stay in contact with your friends, family or other people you trust to talk and receive support, also remotely.
Healthcare workers who are dealing with the current emergency in healthcare settings or in the community are the pillars of the SARS-CoV-2 epidemic response. It is therefore essential to invest as much as possible to protect their physical and mental health. Implementing psychological support resources to help those who are tackling the emergency on a daily basis, and ensuring their availability also when the emergency is over, can contribute to boosting coping skills and promoting personal empowerment.