Physicians, nurses, and other healthcare workers who treated patients during the worst of the COVID-19 pandemic may experience post-traumatic stress disorder (PTSD) or similar aftereffects that could threaten patient safety and quality of care if not adequately addressed, according to experts who study the lasting effects of trauma.
Quality improvement and peer review professionals may be among the best suited to detect the signs of PTSD among healthcare workers and to initiate the help they need. Some quality metrics commonly monitored in hospitals can provide an early warning that healthcare workers are in distress.
For some healthcare workers, the COVID-19 experience will produce significant and lasting effects that will cause serious emotional problems and potentially affect the quality of their work, says Shauna Springer, PhD, chief psychologist at Stella Center, a treatment center in Oak Brook, IL, for the relief of mental trauma-related conditions.
“Many of the war fighters I have worked with are physicians. They are now on the front lines of the COVID outbreak. They are telling me this trauma is worse than even many of the combat zones they have been in,” Springer says. “That carries a lot of weight with me. The healthcare workers on the front lines are the new warriors. The kind of trauma they are facing is very similar to what active duty service members and veterans have experienced for years.”
That comparison is apt, Springer says, because healthcare workers addressing the pandemic face some particularly unnerving elements. The virus cannot be seen, and much is unknown about its transmission and how to prevent it. Even the slightest error could be a matter of life and death. Healthcare workers are constantly trying to protect themselves and their colleagues while providing the best care to patients.
“They’re often doing this fight without the necessary protective equipment,” Springer notes. “Because of all of these factors, many of them are going to require long-term treatment once the pandemic ends. I don’t think we’re ready to meet this threat unless we have a new model of trauma care that combines innovative biological intervention with high-quality psychological care.”
Recently, researchers surveyed 1,379 healthcare workers during the peak of the COVID-19 outbreak in Italy. Almost half of frontline healthcare workers who responded to the survey reported PTSD symptoms. One-quarter of respondents reported depression symptoms, and 20% reported symptoms of anxiety.
More than 8% of respondents reported insomnia and 22% said they suffered from “high perceived stress.” The researchers said the results are “in line with previous reports from China, confirming a substantial proportion of mental health issues” among frontline healthcare workers. They recommend further monitoring and interventions “to prevent long-term mental health-related disabilities.” (The research is available here.)
Similar to 9/11 PTSD
Physicians and other frontline healthcare workers will soon show PTSD symptoms similar to what first responders developed after responding to the terrorist attacks of Sept. 11, 2001, says Wilfred G. van Gorp, PhD, ABPP, an expert in neuropsychology based in New York City and Chicago.
He treated first responders for their trauma and stress after 9/11 and has led the neuropsychology testing programs in three of the nation’s leading departments of psychiatry: University of California, Los Angeles, Cornell, and Columbia University. “The effects will be different because with 9/11 there was one single event and ripple effects. With the pandemic, we have this amorphous, ongoing crisis,” he explains. “But just like with 9/11, I would expect to see some trauma-like reactions, either full-blown PTSD or some of the symptoms, along with anxiety and mood disorders. For some people, these symptoms will happen right away. For other people, the response might be delayed by three or six months.”
One of the first symptoms will be difficulty sleeping, van Gorp says. This often is a key indicator of stress and anxiety, he says. They also may be more temperamental and short with colleagues or family members. An increase in alcohol intake or other substance use can indicate that stress is becoming problematic, he adds.
“Intrusive thoughts will be a problem, such as reliving the moment a patient died without family members present or a patient going into cardiac arrest,” van Gorp says. “They may not want to talk about any of this to family or friends, but the thoughts will be intrusive.”
Effects Will Show in Quality Metrics
The stress and aftereffects of the pandemic response will show up in quality metrics, says Eugene Lipov, MD, a board-certified physician in anesthesiology and pain management. He is chief medical officer at the Stella Center and has treated hundreds of military and civilian patients with PTSD, pioneering the adaption of a procedure called stellate ganglion block (SGB) for treating trauma-related symptoms.
Lipov advises paying particular attention to error rates of all types, including diagnosis and medication errors.
“I think those rates are going to go sky high now. I’ve been a physician for 32 years. At the end of the day, I’m tired, so think about how tired your physicians must be when they are working long hours with a high patient volume. At the same time, they are terrified of getting the virus themselves and taking it home to their families,” Lipov says. “No physician can perform at his or her best under those conditions during the pandemic. We will see lasting effects that hinder their performance long after.”
One metric to watch is the conversion rate from a patient’s first visit to continuing care, Springer says. Patients vote with their feet, even if they cannot pinpoint what they did not like about the first visit with a healthcare worker, Springer says. A low conversion rate after an initial visit could signal trouble.
“That is an underexamined metric that I think we should look at. In the context of the COVID-19 experience, patient transfer rates would be a good gauge of whether a physician is consciously engaging trust and getting patients to dig into their care,” she says. “There will always be some doctors who have lots of patient transfer requests, and some who have almost none. If you look at those metrics now, some of those high performers who have done a good job engaging their patients will suddenly have a shift in those metrics.”
Van Gorp also suggests watching for any changes in patient or peer review ratings.
“It’s analogous to how if parents are getting divorced, the child often has a decline in grades. The same thing happens with physicians under extreme stress,” van Gorp says. “Performance appraisals and scores on patient satisfaction surveys often go down because the physician is unable to perform at the usual level of competence, even if he or she does not recognize that drop in performance.”
Intervene When Symptoms Show
A change in performance should prompt an intervention that helps healthcare workers understand how the pandemic experience may have lasting effects, and how to cope, Springer says. Many healthcare workers suffering from pandemic aftereffects will not recognize that as the cause of their ongoing stress or performance issues, she says. Without proper intervention, performance may continue to degrade.
The hospital should seek to help healthcare workers rather than punish them. Administrators should help healthcare workers avoid placing all the blame on themselves as too weak or unable to cope.
“A shift in that kind of metric most likely will be the result of their traumatic experience, rather than core to who they are as a physician,” Springer suggests. “It would be a shame to lose good physicians because we are not supporting them well in this massive trauma they are facing.”
Lipov emphasizes the need to rotate physicians and nurses in and out of the most stressful and demanding patient care positions, a lesson learned in the military. Providing the proper rest periods and opportunities to decompress can make a huge difference in the lasting effects of a traumatic experience, he underscores. Keeping the same physicians and nurses working until they collapse is a recipe for long-lasting traumatic effects and, ultimately, will hurt the hospital when those workers leave or can no longer perform well, Lipov says.
Springer notes most healthcare workers suffering in this way from their pandemic experiences will never receive an actual diagnosis of PTSD, yet the effects on them and their job performance will be the same. They may suffer from “chronic threat response,” which Springer says is the constant feeling of living in survival mode, requiring them to be hypervigilant.
“They are going to have certain clusters of symptoms, one of which is fragmented concentration, which leads to more errors and errors from people who do not typically make them,” Springer says. “Their concentration is affected, their sleep is impacted, and they simply cannot perform at the level they normally do.”
More healthcare worker suicides also are likely, Lipov adds.
Provide Support for Stressed Workers
Hospitals must act proactively to identify stressed workers and provide them relief, Lipov says. During the heavy work periods, that might mean asking a senior physician, senior nurse, or other respected leader walking around to spot those who are overworked and likely to perform poorly, insisting the person take a break and sleep, he says.
That kind of intervention must be supported by scheduling and staffing allowances that make it possible for a physician or nurse to rotate off the floor when necessary, Springer says. Hospitals also should provide space for healthcare workers to connect with each other and talk through their experiences. “They form tribes in these circumstances, just like elite military units do. There is protection in the connection among members of that tribe,” Springer says. “When we connect, we survive. When you look at someone who’s on the frontline with you, you can communicate everything in your heart with one look. They can nod back and know what you mean, and you’re confident they understand.”
When dealing with an outside person trying to help, like a counselor brought in by the hospital, he or she has to first explain their experience. Then, he or she probably still will not be confident the other person understands.
“Right now, we need to do the most potent thing we can to support them. That means making time for them to be with each other,” Springer says. “Not when they are on duty, but just in a safe space where they can decompress and recharge.”
However, employee assistance programs still can be helpful, van Gorp notes. When providing counseling to healthcare workers stressed by their COVID-19 experience, they often respond best to someone completely outside the hospital or health system, he notes.
“Providing them with a list of therapists who are in-network for the insurance but not employed by the facility is the best scenario,” van Gorp says. “Physicians have a hard time opening up about their work experience to a counselor who is employed by the same organization. That will be especially true if part of their stress is rooted in how the employer responded to the crisis or failed to support employees in some way.”
The Stella Center produced a brief video for frontline healthcare workers to discuss ways to cope with the stresses of pandemic. The video can be provided to healthcare workers, but also provides guidance on how administrators can support them. The video can be viewed here.
Skepticism About Hospital Support
Springer and Lipov are doubtful about the ability of hospitals and health systems to respond adequately to the potential for PTSD in healthcare workers. Nevertheless, they say it is worthwhile to try, even from a purely economic standpoint. Without addressing the issue, hospitals will lose workers to burnout and early retirement. Replacing physicians and nurses can be costly, Lipov notes.
Van Gorp agrees with that point, saying that paying attention to mental health needs of healthcare workers can head off a crisis in staffing. “If they don’t, we’re going to have more people calling in sick, more people taking leaves of absence, and we’ll see resignations,” van Gorp predicts. “Don’t be shortsighted and only worry about the number of beds. It’s important to pay attention to the mental health needs of staff. Otherwise, it will affect your organization when physicians find ways to leave the place that is causing them stress.”
Springer also cautions hospital quality leaders need to be supportive when they discover use fluctuations in performance metrics.
“I hope hospital administrators take a critical look at performance measures, but use them to support their people rather than using them to make them feel more inadequate,” she says. “There are a lot of feelings of helplessness on the frontlines right now. Hospitals are in danger of losing some of their best people if they don’t support them with the data.”
Pandemic Will Exacerbate Burnout
The pandemic experience will be particularly hard for healthcare workers who already may have been nearing burnout, says Sharona Hoffman, JD, LLM, SJD, professor of law, bioethics, and jurisprudence, and co-director of the Law-Medicine Center at Case Western Reserve University School of Law in Cleveland. They will be more susceptible to all the symptoms of burnout, including less engagement with patients, less satisfaction with their work, insomnia, marital problems, anxiety, and depression.
“If the clinicians were in a hospital that was overwhelmed, with patients in the hospital and very sick but you couldn’t find beds for them, they are more likely to have actual PTSD,” she says. “This is also a whole new ballgame where physicians have to worry so much for their own health in addition to all the stress of typical work in a hospital.”
Healthcare workers experiencing burnout self-report they make more mistakes because they cannot concentrate, Hoffman says. She recommends using tools like the Maslach Burnout Index to assess those with a higher rate of errors.
Staff on the verge of burnout often benefit when employers offer assistance with practical issues such as child care. However, Hoffman cautions against pushing physicians to participate in wellness activities such as meditation or yoga. Although well-intended, pressing staff to participate in those activities can backfire if they feel it is just another demand on their time and energy. Any strong encouragement to attend such offerings can make healthcare workers feel they have to go, or else they will appear not to support the culture of wellness, she explains.
“We’re not adequately addressing this, and it has only gotten worse during this crisis. I don’t think burnout has been on the radar screen on a lot of healthcare employers as a real problem,” Hoffman explains. “There are unprecedented pressures and worries that we’ve never had before.”
Monitor After Pandemic Subsides
Hospital leaders should be careful to continue monitoring healthcare workers even after the initial wave of the pandemic subsides, says Tasha Holland-Kornegay, PhD, LPCS, a licensed counselor and founder of the platform Wellness In Real Life, which assists healthcare providers who are looking to destress to prevent burn out.
Healthcare workers were celebrated as heroes during the worst of the pandemic response, but their stress will not go away instantly once the patient load decreases and the public attention wanes, Holland-Kornegay cautions. “When health professionals are bravely taking on the crisis with a problem-solving mentality, working around the clock under terrible conditions, with increasing patient mortalities, it is expected that stress levels are high. What occurs afterward is more difficult to deal with,” she says. “As the pandemic drags on, people get sicker, and more colleagues, patients, and families are affected, healthcare workers will need help dealing with anxiety, depression, and symptoms of [PTSD].”
Whether the COVID-19 crisis continues to grow or diminishes in coming months, the workforce will soon show signs of their experiences, Holland-Kornegay says. Hospital quality leaders should be prepared with a plan for keeping healthcare professionals healthy, effective, and on the job:
• Consider using more locum tenens. Locum tenens healthcare providers help provide continuity of care to patients who need it most while alleviating burnout for their permanent colleagues. This gives healthcare workers time to step back and process the experience, rest, and recharge.
• Maintain a culture of wellness. This can be accomplished by including leaders in the well-being needs of healthcare workers. They can help reduce stress in the clinicians. The system also must watch out for the physicians’ needs to refresh and sustain. Institutional policies must be stable. Ensure paid time off and sick days remain unaffected for all employees for COVID-19-related illnesses. Ensure no out-of-pocket expenses for employees with COVID-19-related illnesses.
• Maintain balance. During these times, it is imperative to monitor the time and effort that healthcare delivery teams are spending in direct patient care.
Respect the time when providers are away. Recognize the 24/7 virtual environment in which everyone lives. Do not disturb staff or expect them to participate in virtual meetings. Encourage them to disconnect and recharge.
Watch for Substance Abuse
The unusual stress of the pandemic also can make healthcare workers more susceptible to substance abuse, says Charles Smith, MD, an addictionologist at Recovery First Treatment Center in Hollywood, FL.
“When you add in the pressure of living up to the hero image and concerns about their own health status, it’s a perfect storm that puts doctors at increased risk for issues like PTSD and substance use,” Smith says. “For some, alcohol and/or drugs become a coping mechanism.”
Investigators found 69% of doctors abused prescription drugs to manage stress and emotional or psychiatric distress, Smith says. (The study is available here.)
“Sadly, doctors may be less likely to reach out for help right away because of social stigma and a fear of losing their license to practice medicine,” Smith observes. “It’s likely we may not see the true impact of the crisis on these frontline workers for months or even years down the line when their addiction spirals out of control or leads to an overdose or death.”
Smith says he is most concerned about emergency physicians or any other provider on the frontlines consistently exposed to extreme levels of stress.
Quality leaders need to be mindful that some staff may be struggling to cope and turning to substances, Smith says. “Part of that awareness should include taking a proactive approach to providing ongoing support for those on the frontlines, such as virtual peer support groups and online counseling services,” he says. “Staff should also be trained on the warning signs of addiction and on what to do if they suspect a physician is struggling. It is critical that colleagues and employers not turn a blind eye.”
- Sharona Hoffman, JD, LLM, SJD, Professor of Law, Bioethics, and Jurisprudence; Co-Director, Law-Medicine Center, Case Western Reserve University School of Law, Cleveland. Phone: (216) 368-3860. Email: firstname.lastname@example.org.
- Tasha Holland-Kornegay, PhD, LPCS, Raleigh, NC. Email: email@example.com.
- Eugene Lipov, MD, Chief Medical Officer, Stella Center, Oak Brook, IL. Phone: (866) 535-0258.
- Charles Smith, MD, Addictionologist, Recovery First Treatment Center, Hollywood, FL. Phone: (888) 857-4829.
- Shauna Springer, Chief Psychologist, Stella Center, Oak Brook, IL. Phone: (866) 535-0258.
- Wilfred G. van Gorp, PhD, ABPP, Psychologist, New York City and Chicago. Phone: (212) 247-1350.