By Melinda Young

EXECUTIVE SUMMARY

Healthcare workers, including case managers, face the risk of post-traumatic stress disorder (PTSD) during the COVID-19 pandemic.

Hospital staff experience cumulative grief and a great deal of uncertainty as the pandemic continues with no set end in sight.

Even before the pandemic, about half of nurses experienced burnout.

Case managers are vulnerable to PTSD as they have seen their jobs changed to help frontline nurses.


Mental health professionals are warning hospitals that staff could face emotional challenges as the COVID-19 pandemic increases their susceptibility to anxiety, depression, moral distress, and helplessness.

“Hospital staff are starting to experience the cumulative grief of this pandemic. The uncertainty of its conclusion is only making things worse,” says Gaila Palo, MN, ARNP-CNS, AGCNS, CWON-AP, travel wound nurse at Kindred Hospital in Seattle. “The need for emotional support is starting to show itself as strongly as for physical needs.”

While hospitals and cities are in crisis mode, hospital nurses, physicians, case managers, and others stay focused on their daily work. But as the crisis period ends and the post-crisis period begins, they face the possibility of post-traumatic stress disorder (PTSD) symptoms.

“PTSD is a real thing. We used to think of it as just affecting soldiers coming home from battle, but we now think about nurses and case managers, who see the very same thing: gunshot wounds, people dying every day, and it has a lasting impact on the staff,” says Garrett P. Salmon, DNP, RN, APN, CRNA, assistant professor at Middle Tennessee State University School of Nursing.

Salmon’s research outlined PTSD’s complex, debilitating effect on nurses, leaving them anxious, depressed, burned out, and with compassion fatigue.1

Before COVID-19, PTSD symptoms were on the rise in healthcare workers because of the growing intensity of hospital care. Hospitalized patients are sicker, and there is increasing comorbidity, Salmon notes.

“If we don’t take care of our workers, we can’t take care of patients,” he adds. “We can’t just say, ‘Suck it up and get over it.’”

Offer Staff Social, Emotional Support

Case management and other leaders need to support their staff and invest time and energy into preventing PTSD. For instance, they can create a social network, where employees can talk with one another outside of work, Salmon says. (See tactics for preventing PTSD in this issue.)

“We have to realize that even before the pandemic hit, burnout among physicians, nurses, and pharmacists was averaging about 50%,” says Bernadette Melnyk, PhD, APRN-CNP, vice president for health promotion, chief wellness officer, and dean of the College of Nursing at The Ohio State University. Melnyk has researched clinician mental health, including a recent paper on the mental health of healthcare workers during the global pandemic.2

Research shows that about one in four nurses reported depression before the pandemic, Melnyk says. “My prediction is we’re going to have a tsunami of mental health problems in our healthcare providers during the rest of the pandemic, and in the months following.”

Without intervention, these issues could culminate in PTSD, moral distress, and suicide, she adds.

Hospitals have focused on the emotional health of their frontline staff during the pandemic, but others — including case managers — also can be affected, says Maureen Brogan, LPC, ACS, DRCC, statewide program manager of Traumatic Loss Coalitions for Youth at Rutgers University Behavioral Health Care.

For instance, some case managers were trained during the crisis to become frontline staff in the event of a surge of COVID-19 patients. Even if they never were called to work in the critical care units or provide direct care to infected patients, they might experience symptoms of PTSD because the uncertainty and job changes can lead to increased anxiety and depression, she says.

“We may see more symptoms where people do not meet the entire diagnostic criteria for post-traumatic stress disorder,” Brogan says. “We may see more symptoms when people are pulled out of their area of expertise and into an area where they do not feel 100% competent. They may be willing to help or want to help, but there’s self-doubt.”

When people feel uncertain and are not confident in their work, they are prone to more anxiety and mental health issues, she adds.

Case Managers Exposed to Trauma

Case managers who remained in their roles also can experience PTSD from working in hospitals where so many patients are sick and dying from the novel disease. It is a secondary exposure to trauma.

“Case managers are still exposed to it,” Brogan says. “They’re still hearing the stories, and they have colleagues who have been exposed.”

It is similar to when a town is ravaged by a tornado and some houses are left standing among the houses that are destroyed. The people who still have their homes can be traumatized by the devastation that did not touch them personally, but is all around them.

“Even if you’re in case management, you’re hearing the details of the losses,” Brogan explains. “It’s quite normal to feel a little anxious, depressed, and to have some insomnia at this time because we’re dealing with so much uncertainty.”

There are aspects of the pandemic that make the situation more difficult to handle than the more common disasters of fires, tornados, hurricanes, and earthquakes that can strike hospitals and cause similar levels of upheaval and emotional distress.

One important difference is the uncertainty about how this crisis will unfold. With other disasters, there is a predictable pattern and course of action. The disaster occurs, and everyone goes through a period of grief and anxiety as they work to help their patients under trying circumstances. But they know this difficult time will end in weeks or months, and they will eventually regain a sense of normalcy. No one knows when the pandemic will end because there are no exact parallels to other natural disasters. This uncertainty contributes to emotional distress and PTSD symptoms, Brogan explains.

“In the world of trauma, we assess the length of exposure and the intensity of exposure,” she says. “In this pandemic, we have had heightened length and intensity.”

A second difference involves typical human coping mechanisms. During other crises, hospital workers will pull together and support each other with hugs, sharing meals, and helping those who have lost their homes.

“When we work with people exposed to trauma, we tell them to support themselves and each other,” Brogan says. “The pandemic is interfering with that.”

Social connectedness is vital, but everyone in the hospital must maintain physical distancing. Some staff members will go into isolation because of their exposure to the disease, she adds.

“This pandemic is putting a wrench into the coping mechanisms we have developed,” Brogan says.

REFERENCES

  1. Salmon G, Morehead A. Posttraumatic stress syndrome and implications for practice in critical care nurses. Crit Care Nurs Clin North Am 2019;31:517-526.
  2. Jun J, Tucker S, Melnyk BM. Clinician mental health and well-being during global healthcare crises: Evidence learned from prior epidemics for COVID-19 pandemic. Worldviews Evid Based Nurs 2020. doi: 10.1111/wvn.12439.