Medical experts are expecting a second wave of mental health issues to hit healthcare workers after the novel coronavirus abates. Some are warning that a “parallel pandemic” of post-traumatic stress will beset healthcare workers who witnessed COVID-19 deaths and suffering in patients and colleagues.
“These courageous people are risking their lives, threatened not only by exposure to the virus but also by pervasive and deleterious effects on their mental health,” the authors of a recent perspective article wrote. “Tragically, we are already seeing reports of clinicians dying by suicide amid the pandemic, including the highly publicized death of a prominent emergency medicine physician in Manhattan, the epicenter of the U.S. COVID-19 outbreak. Before the virus struck, the U.S. clinical workforce was already experiencing a crisis of burnout. We are now facing a surge of physical and emotional harm that amounts to a parallel pandemic.”1
An immediate step employee health professionals can take is to establish an anonymous reporting system for workers to voice concerns for themselves and their patients. This can provide a critical element of “psychological safety” during the pandemic, says Darrell Kirch, MD, co-author of the article and president emeritus of the Association of American Medical Colleges.
“For any organization to improve, there need to be ways for employees to feel that they can safely bring concerns forward without fear of retaliation,” he says. “There is no place more important for this to occur than healthcare, especially during a time of extreme stress on the system from COVID-19. Even more importantly, workers need to see their leaders responding positively to expressed concerns in order to improve safety and quality.”
Kirch and co-authors described the “moral injury” of people called to heal seeing their patients sicken and die. They warned of an “acute and long-lasting” harm, particularly to those facing COVID-19 in the early years of their healthcare careers.
“We work very hard to help medical students, residents, and fellows learn how to cope with the loss of patients and help families grieve,” he says. “The COVID-19 pandemic has made that nearly impossible. There are so many patients who are critically ill and must be isolated from their families. This has deprived learners of the opportunity to learn in a measured way how to emotionally process death both for themselves and with the patient’s family and friends.”
In this pandemic, anxiety has many sources: shortages of personal protective equipment (PPE), lack of testing, and fear of bringing the virus home to a family member.
“Clinicians have expressed uncertainty about whether employers would support them if they got sick,” Kirch and colleagues reported. “Amid extra-long work hours, many are also being asked to fill emergency roles for which they feel underprepared. As the COVID-19 crisis stretches on, the burden of stress will only mount.”
The authors cited several high-priority measures organizations can take to protect their workforce during the pandemic and its aftermath.
“Integrate the work of chief wellness officers or clinician well-being programs into COVID-19 ‘command centers’ or other organizational decision-making bodies for the duration of the crisis,” they suggested. “Sustain and supplement existing well-being programs.”
The authors called for federal funding to care for clinicians who experience physical and mental health effects of the coronavirus. This program should include national surveillance to measure worker well-being and document the outcomes of interventions.
“The COVID-19 crisis has revealed with painful clarity the fraying threads of the U.S. clinician workforce,” they noted. “There has never been a more important time to invest in the clinician workforce. We have a brief window of opportunity to get ahead of two pandemics — the spread of the virus today, and the harm to clinician well-being tomorrow.”’
Concurring with this concern was Jim Kendall, LCSW, CEAP, manager of Work/Life Connections at Vanderbilt University.
“What always happens in disasters — and I’ve done a lot of disaster work — is that the first thing you pay attention to is your own Maslow Hierarchy of needs,” Kendall says. “How am I doing, am I safe, and so on. We’re expecting a bigger wave of mental health issues to come as the uncertainty passes a little bit and the fatigue sets in.”
This wave likely will hit in the next few months, causing some level of staff trauma in healthcare settings that have lacked resources, been inundated with COVID-19 cases, and faced moral distress about how to allocate equipment and supplies.
“Those workers are going to experience post-traumatic stress in a much different way than folks who have had a little bit more resources,” Kendall says. “Though that isn’t to say that they also won’t experience it. They have been in day-to-day situations of not knowing — ‘Have I been exposed? Am I exposing my family?’ That adds an element of mortality that has not of been part of everyday healthcare.”
While there have been reports of physician suicide related to COVID-19, nurses also are at high risk, says Judy Davidson, DNP, RN, FCCM, FAAN, nurse scientist at the University of California, San Diego. There were two documented cases of nurse suicides when the pandemic hit Italy, she says.
“We haven’t seen any [reports] in the news in the United States,” she says. “We do not currently monitor that in the U.S. Sometimes, you don’t really know [about suicides] until years later. My message to the community is not to wait for those numbers to be known. We will have more suicides if we don’t take action using preventive strategies. Pandemics cause panic attacks, anxiety, depression, and post-traumatic stress. If these things are not dealt with, they could lead to suicide.”
Many healthcare workers already were operating at the thin margins of stress and burnout, meaning they were at higher risk when the pandemic hit, says Davidson, a nurse suicide researcher and co-leader of a prevention taskforce at the American Nurses Association. “The whole focus is to protect the mental health of the nursing workforce nationwide,” she says.
A female-dominated profession, the nursing workforce carries a higher overall risk of stress disorders than male-dominated professions.
“We have the pre-existing risk of being a nurse, the added risk of a pandemic, and then the risk of being female,” Davidson says. “There is a gender-driven issue here. We can’t ignore these risks tumbling all over each other. We can’t ignore the fact that we are at great risk. We need to take preventive measures.”
These measures, including counseling, work support, and frequent communication with colleagues, can help some people emerge from stress and trauma feeling stronger.
“It is known that not everybody responds to stress the same way,” she says. “Some end up with ‘post-traumatic growth.’ They actually feel stronger and more resilient later because they got through this. How does that really happen? First, it is a spiral down into depression, and then a lot depends on the support you’re getting in the work environment: support of colleagues toward each other, support in the moment, and support by the leadership team.”
Davidson encourages staying in contact with workers placed in home quarantine due to suspected or confirmed COVID-19.
“Keep contact with them virtually so they are not isolated and lonely, which can increase the risk of suicide,” she explains. “We need to stay connected socially as a preventive strategy.”
Break the Stigma
There is a long-standing stigma about seeking mental healthcare for medical workers, in part because they fear it will affect their licensing and future employment. The Joint Commission (TJC) recently emphasized that it has no requirement to seek such information, and it should not be a barrier to mental health therapy.
“[C]linicians have concerns that seeing a mental health professional could adversely affect their career if they are asked about a previous history of mental health issues during the credentialing or licensing process,” TJC stated. “We strongly encourage organizations to not ask about past history of mental health conditions or treatment.”2
As an alternative, TJC supports the recommendations of the Federation of State Medical Boards and the American Medical Association to limit inquiries to conditions that “currently impair the clinicians’ ability to perform their job.”
It is critical that healthcare workers feel free to access mental health resources, TJC stated. It is encouraging accredited facilities to remove policies that “reinforce stigma and fear about the professional consequences” of seeking counseling.
The evidence indicates mental health therapy prevents harm, so it is time to move past the issue of stigma in healthcare even was we struggle to overcome it as a nation, Davidson says.
“I have been [at Vanderbilt] 20 years,” Kendall says. “We talked about stigma then, and I think stigma still exists. But we have managers who encourage [counseling], and it is part of our infrastructure to talk about mental healthcare. We have not had the horrible issues that New York has had. We have had PPE and equipment. I think the mental health of our staff has been spared from some of the stories I see nationally.”
Although Vanderbilt has fared well in terms of supplies and available beds, one of the initial sources of healthcare worker angst was not allowing family members to visit loved ones with COVID-19. The nursing staff developed a system using electronic devices to allow some visibility and communication.
“It creates great distress for the nurses when families can’t be there,” he says. “The nurses worked very hard to bring that humanity in even when visitors were not allowed.”
Vanderbilt routinely contacts workers in home quarantine, including medical checks and counseling.
“We do regular checks with the employees who have tested positive,” Kendall explains. “Our counselors call and check — not just how you are doing physically, because there are a bunch of people checking on that. We say, ‘What do you need? How are you doing psychologically?’ We follow up the first contact with an email that lists resources for family issues. Then, we schedule a time a week later to get back with them. We want them to know this is about them personally as well as their physical and mental health.”
In addition, Kendall and staff are continuing support programs, like an ongoing meeting with the cardiac intensive care unit to discuss challenging incidents. They added wellness checkups for all workers on COVID-19 units, but noticed a surprising development.
“We haven’t had as many takers on that as I would have imagined — maybe a drop-in here and there,” he says. “I think they feel supported because we offer it. I have to remember sometimes it is not how many people attend — it is the fact that the organization offers it. People can say, ‘They care about my well-being, and I’m OK.’”
Building on many existing worker wellness programs in place, Vanderbilt now is holding online meetings with all groups and departments.
“One of the things that we are finding is that this is dynamic and fluid in terms of how it hits different employees through the workforce. You have your frontline workers in hospitals who have experienced this in a much different way than some of the folks who were asked to work remotely,” he says. “While working remotely sounds like a panacea on the front end, it is a lot more complicated if you have not done it much.”
In addition to those who must work with their children at home, there is a tendency to start work earlier, lose track, and find yourself on the office computer at 10 p.m.
“We are reminding people that you cannot inundate yourself with COVID-19 24 hours a day and stay sane,” Kendall says. “You have to turn the TV off. Decide where you are going to get your information. Take some breaks. We encourage mindfulness as one of the methods, but we also are encouraging people to get outdoors and walk using masks and safety precautions.”
- Dzau, VJ, Kirch D, Nasca T, et al. Preventing a parallel pandemic — a national strategy to protect clinicians’ well-being. N Engl J Med 2020. doi: 10.1056/NEJMp2011027. [Epub ahead of print].
- The Joint Commission. Joint Commission statement on removing barriers to mental health care for clinicians and health care staff, May 12, 2020. https://www.jointcommission.org/-/media/tjc/documents/covid19/statement-on-removing-barriers-to-mental-health-care-for-clinicians-and-health-care-staff.pdf