Ebola pushes nurses stress, anxiety levels higher as many doubt their hospital is prepared
Psychological first aid is the mental health equivalent of CPR’
Nurses nationwide recently expressed fear and anxiety over the possibility of having to treat Ebola patients in hospitals they claim are poorly equipped. In a national teleconference call in October, thousands of nurses called in to hear and share information about how health systems are responding to the Ebola crisis.
The teleconference was sponsored by National Nurses United, a union that has criticized hospitals and government health officials for not preventing Ebola infections in two nurses who treated the index U.S. Ebola case at Texas Health Presbyterian Hospital in Dallas.
"Nurses from Dallas called us with horrendous stories — what happened in Dallas could happen anywhere," RoseAnn Demoro, executive director of National Nurses United told the teleconference audience.
Nurses on the call shared fears that their hospitals were ill-prepared to handle Ebola, despite having designated units for patients with the disease. They spoke of hospitals that lacked units with proper isolation and negative air pressure and hospitals that could not even provide goggles to nurses and other health care workers.
Ebola education was described as cursory or nearly nonexistent, with nurses saying they were largely excluded from the decision-making process. Some said their hospitals should put the resources in place to bring their infectious disease care up to the standards set by the Omaha-based Nebraska Medical Center’s biocontainment unit, which has successfully treated Ebola patients without endangering workers.
While Ebola ultimately might impact little more than a handful of hospitals nationally, fear of the disease became widespread after the two Dallas nurses contracted the virus. Both survived and are out of treatment but the index case, Thomas Duncan, died on Oct. 8.
Fear is highly transmissible
"Thus far, the fear component has greatly outpaced the infectious disease’s transmission," says Daniel Barnett, MD, MPH, an associate professor in the department of environmental health sciences at Johns Hopkins Bloomberg School of Public Health in Baltimore, MD.
It’s important to provide psychological resources to health care workers who are on the front lines of this frightening scenario, he says.
"Psychological first aid is the mental health equivalent of CPR," Barnett says. "It allows a non-psychologist or psychiatrist to identify acute or long-term mental health distress in coworkers, patients, families, and others."
Psychological first aid is an evidence-based approach to helping children and adults in the immediate aftermath of disaster or trauma, according to the National Child Traumatic Stress Network, which provides a psychological first aid toolkit on its website. (http://www.nctsn.org/)
Employees trained in psychological first aid learn techniques of active listening and how to identify early signs of psychological trauma, he explains.
Using psychological first aid can mitigate some of the concerns of health care workers on the front lines of a crisis, Barnett adds.
Once these changes are made, hospitals need to make sure workers know that specific help, training, and programs are available.
For example, hospitals will not be able to reassure employees and reduce fear and stress until they have adequate personal protective equipment (PPE) available and train staff on how to use it, he says.
"Hospital administrators need to let their employees know what protections are in place for their staff, and they need to emphasize that employee safety is the first priority for the hospital," Barnett says. "That may sound like an obvious statement, but what we’ve found in our research is employees need to know there is a plan in place, what the plan is, and how it relates to them specifically as workers."
Research shows that health care workers are more likely to respond to a dangerous medical situation if they have "self-efficacy," meaning they feel confident in their ability to handle the situation and play a major role in a successful public health response.1
In a study that looked specifically at health care workers’ willingness to work during an influenza pandemic, investigators found that hospital workers with a perception of high efficacy were nearly six times more likely to respond than other workers.2
"A variety of factors influence willingness to respond, separate from the disease itself," Barnett says. "Some are related to psychological preparedness."
Two factors greatly influence how health care workers respond psychologically to Ebola or a similar infectious disease threat, he notes. First, hospital workers need training that focuses on giving them a sense of confidence that they can perform their jobs effectively in a given scenario, he says.
"That is an essential ingredient missing in preparedness training generally," Barnett says.
Hospital administrators often assume staff will work with Ebola or anthrax or any other frightening case if they’re given basic training and told to do so.
"Historically, preparedness training has focused on knowledge and skills exclusively," Barnett explains. "But what this training has missed is the human dimension that pertains to employees’ fears and concerns about the risk [of] doing their jobs in an infectious disease environment."
Secondly, staff need to get the message that they matter as individuals and are not just a part of an overall response to a crisis, he says. "They need to know that their presence in a given preparedness response helps with the overall response," Barnett says.
There’s a phenomenon, called "diffusion of responsibility," in which a group of people might not respond to a crisis because each individual assumes it is someone else’s responsibility. The New York City murder of Kitty Genovese in 1964 is a classic example of this, Barnett says.
Genovese was stabbed to death around 3 a.m. near her home in Queens. Although there were dozens of neighbors and others nearby as she screamed, no one intervened or brought her indoors until it was too late.
"People in the apartment building who were watching this attack assumed someone else would pitch in and help out or call the police," Barnett says.
"So giving hospital workers a sense that they matter will reduce likelihood of diffusion of the sense of responsibility," he adds.
These two pieces are often not addressed adequately in preparedness training, Barnett says.
"You cannot just train people for knowledge and skills and expect attitude to follow suit," he adds.
Hospitals should make ongoing training in the use of personal protective equipment a priority. One good example is the ongoing training provided to biocontainment unit staff at the Nebraska Medical Center, Barnett notes. First the Nebraska Medical Center sought highly-qualified volunteers to receive training for dealing with highly contagious and/or highly dangerous infectious diseases. Then they trained the volunteers on a regular basis, reinforcing training with a partner system in which one HCW would put on and take off PPE while another watched.
"The example of Nebraska is an example of having exercises, drills, repetition, and honing skills to develop expertise," Barnett says. "If they don’t know [about] these programs they won’t access them. Make it a priority to create the programs and then inform employees what mental health resources are available to them."
- Barnett DJ, Thompson CB, Semon NL, et al. EPPM and willingness to respond: the role of risk and efficacy communication in strengthening public health emergency response systems. Health Comm 2013;12(26):
1-12.
- Balicer RD, Barnett DJ, Thompson CB, et al. Characterizing hospital workers’ willingness to report to duty in an influenza pandemic through threat- and efficacy-based assessment. BMC Public Health 2010;10:436.
