Many have died and more have been sickened, but the nation’s healthcare workers are grimly holding the line against the worst pandemic in a century. Those who survive may pay a mental health price, a “moral injury” not unlike soldiers returning from war, mental health experts warn.

The Institute for Healthcare Improvement (IHI) is addressing these current and looming issues through a series of webinars and papers on “psychological PPE (personal protective equipment).” The idea is that much as they don masks, gloves, and gowns, medical workers need “barriers” to protect their mental health.1

“Every disaster brings with it a second disaster,” said Donald Berwick, MD, MPP, president emeritus and a senior fellow at IHI. “The first is whatever the insult is — in this case, COVID-19 and the tragedies associated with it. The second is the behavioral health responses that occur both in the community and the workforce.”

The COVID-19 pandemic is exacerbating existing issues with healthcare burnout that will persist even after the pandemic is under control. “We hypothesize that there is this population of staff who are currently operating in crisis mode and they are fully absorbing or experiencing the adverse effects, but over time will begin to show signs of psychological distress and trauma,” said Jessica Perlo, MPH, director of IHI. “[Psychological PPE] includes behaviors and actions to support staff, like reducing fear and anxiety, promoting psychological safety, and facilitating peer support and connections. These behaviors and actions will continue to be critical as the pandemic continues as more staff need mental health support.”

In a recent webinar, IHI explained how it reviewed evidence and interventions to develop the concept of psychological PPE, which can take many forms as it is adapted at the local level. IHI reviewed evidence on mental health techniques to develop a tool based on responses to natural disasters, terrorist attacks, and previous pandemics.

“It is not a checklist per se, but more like a menu of evidence-based options,” says Keziah Imbeah, MSc, a research assistant on the IHI innovation team.

Support of the institution and administration is necessary for these programs to work “so [workers] feel free to take care of themselves as they are on the job and also as they step away,” she said.

IHI recommendations include the following for individuals and team leaders:

Individual

  • Take a day off and create space between work and home life.
  • Avoid unnecessary publicity and media coverage about COVID-19.
  • Receive mental health support during and after the crisis.
  • Facilitate opportunities to show gratitude.
  • Reframe negative experiences as positive and reclaim agency.

Team Leader

  • Limit staff time on site/shift.
  • Design clear roles and leadership.
  • Train managers to be aware of key risk factors and monitor for any signs of distress.
  • Make peer support services available to staff.
  • Pair workers together to serve as peer support in a “buddy system.”

A Personal Stake

Berwick has a personal stake in the issue, as his daughter is a physician at a Boston-area hospital.

“She is OK, but I can see the toll taken on her and many of her colleagues by the stresses of this dreaded disease — the deaths and despair around them and the risks they incur every day,” he said at a recent IHI webinar. “She goes to work knowing she is exposing herself and her family to a very serious risk. She sticks with it and she is doing fine, but one should not underestimate the stress that it takes. My daughter is lucky in that she has a strong social support system, but that is not true of every healthcare worker.”

The pressure goes beyond the clinical staff, as those who support the medical team face similar risks and stress, often with fewer resources. “We have to remember that the vast majority of healthcare workers are not people of high income. They are not people who have the prestige of being physicians or nurses,” Berwick said. “These are people who work to keep the hospital going. They are the people serving the food, cleaning the rooms, and supporting the clinical staff. We know that they are under tremendous stress, including the stress of the economic downturn. Hospitals are not immune. Many healthcare workers, for example, don’t even have health insurance.”

People of color are more likely to have more serious infections with SARS-CoV-2. That means many healthcare workers are at additional risk as they care for COVID-19 patients.

“We also know the racial inequity that we are more and more aware of in the George Floyd era — but should have been aware of all along — selectively affecting African American, Latino, and Native American populations,” Berwick said. “Those are heavily represented in the workforce at lower levels of income. That is another kind of stress, so this is crucial. Just like everything else we do, we need to bring science to bear. We need to understand what actually helps, get the data, and get the resources in place. Then, use the methods of improvement to bring those resources to the healthcare work force.”

As many have noted, the pandemic may get worse before it gets better, with a convergence of novel coronavirus and seasonal influenza approaching in the fall.

“All the signals I’m seeing are that we are going to have a serious resurgence of this disease,” Berwick said. “There are places already having that. I think even communities that have done well are going to be hit with a real serious problem. We still have not organized testing in this country as a strategy, and every other successful country has had totally different levels of surveillance. I think we are going to get hit again and probably pretty hard. I hope not, but we better get ready. This time, we don’t need to be on our heels.”

In statistics that are admittedly undercounts, the Centers for Disease Control and Prevention (CDC) reported as of Oct. 1, 169,063 healthcare workers have been infected with COVID-19 and 733 have died. The data were collected from 5.3 million people, but healthcare personnel status was only available for about 1.3 million. For the 169,063 cases of COVID-19 among healthcare personnel, death status was only available for 122,440. The CDC has previously estimated the actual number of infections may be tenfold higher than counted cases, meaning that more than a million healthcare workers have been infected in the pandemic and well over a thousand have likely died as a result.2

Protecting HCWs a ‘Precondition’

Arpan Waghray, MD, a geriatric psychiatrist at Providence St. Joseph Health in Oakland, CA, said protecting healthcare workers was an immediate concern when the pandemic began.

“Our system had to deal with a lot very early,” he said. “As this started, our leaders made a strong commitment that the emotional well-being of our workforce is not just a priority; rather, it is a precondition for us to deliver excellence. This was brought into the command center discussions right from the very beginning.”

Waghray and colleagues developed an electronic interactive stress meter with a range of emoji faces representing increasing levels of mental struggle. A range of resources are displayed depending on the stress level. Healthcare workers also can describe their specific problem and a preferred method of learning.

“You can say, ‘I want help with anxiety and parenting during the pandemic, and my preferred method of learning is a podcast,’” he said. “The most commonly viewed topic in the last few months has been compassion fatigue. We found that telespiritual health was one of the most commonly used resources by those in the mild and moderate stress range.”

The hospital also created a program allowing same-day access to therapists, which resulted in 2,945 sessions by 850 caregivers.

“One would imagine healthcare workers as somewhat more sophisticated consumers of healthcare than the rest of the population, and yet 46% of them said without this service they would not have sought help for themselves or would not have known how,” Waghray said. “Like every other health system, we have had EAPs [employee assistance programs] and all of that forever, and yet this is something that has come up over and over again.”

There is a kind of hero syndrome in healthcare that prevents some from showing vulnerability. During wellness checks, workers in the crowded Providence intensive care unit would always say they were doing fine, so Waghray reframed the question.

“We tried an exercise at the end of the day where they were asked what was something that made them smile that day, thus reframing the question to a positive light,” he said. “I can say that is one of the richest experiences I’ve had. People were crying, they were talking a lot. The negative framing changed to positive.”

For example, one nurse told a story about a patient who had been struggling and was trying to get out of bed, he said. The nurse helped him connect with a close relative, and he became relaxed and content.

Reinforce Rituals

Simplification and ritual have proved valuable in helping distressed healthcare workers at Geisinger Commonwealth School of Medicine in Scranton, PA.

“The donning and doffing of PPE is something that is automatic in many of us who work in healthcare institutions,” said Justin Coffey, MD, chair of the department of psychiatry and behavioral health at Geisinger. “Maybe there is some way we can apply that ritual to our own psychological well-being.”

To reinforce the program, healthcare workers were given different roles in addition to their regular jobs. These included tele-enablers, emergency department (ED) enablers, wellness rounders, peer supporters, communicators, and celebrators.

“Some of our frontline caregivers enabled a rapid shift to a ‘virtual first’ ambulatory [care],” Coffey said. “[The idea is] if we dedicated a small number of people to that role, they could do the learning and share that learning much more rapidly and effectively with a larger team.”

ED enablers made sure incoming patients were triaged safely for staff and other patients. Clerical, financial, and office workers were the designated celebrators and communicators, publicizing the positive effects of the team effort. An outreach effort for remote staff emphasized social connection during physical distancing.

“The goal was to bring resilience to people rather than having to ask for it and seek it out,” Coffey said. “We had some powerful interactions with those doing wellness rounds. We asked them a simple question: ‘Are you OK?’”

Asked what he does to keep himself centered during difficult times, Coffey described a personal ritual. “One of the things I do every morning is take a few minutes and ask myself, ‘What is most important?’ I spend my time on the answer to that question. The second thing that I do every day — at the end of the day — are meditation exercises to clear my mind so that when I go home I can be fully present. That is pretty ritualized donning and doffing for me. Different folks have different strategies, using exercise or social activities the same way they wash their hands one more time before they leave the facility.”

REFERENCES

  1. Institute for Healthcare Improvement. “Psychological PPE”: Promote health care workforce mental health and well-being. http://www.ihi.org/resources/Pages/Tools/psychological-PPE-promote-health-care-workforce-mental-health-and-well-being.aspx
  2. Centers for Disease Control and Prevention. CDC COVID data tracker: Cases & deaths among healthcare personnel. Oct. 1, 2020. https://covid.cdc.gov/covid-data-tracker/?CDC_AA_refVal=https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html#health-care-personnel