Minding your mental health as a front-line healthcare worker

Senior Counselling Psychologist Dr Damien Lowry presents psychological advice targeted at front-line healthcare workers in the Irish health system for coping in the current environment of a COVID-19 pandemic.

Dr Damien Lowry

It might easily be assumed that the majority of those reading this article are medical practitioners, but much of the content will be equally applicable to a range of other healthcare professionals (HCPs), including nurses, health and social care professionals, and other allied health professionals, many of whom also work on the front-lines of our national health service. In my view, it is essential that all of our healthcare workers (HCWs) receive the acknowledgement and credit that they deserve, for the invaluable work they are doing, particularly at a time when society finds itself gripped by a crisis that has affected every continent on this planet.

Objectives
The objectives of this article, which it is hoped might help any of the aforementioned HCPs, even in some modest way, in the work that they do, are as follows: Firstly, to put some context on the general psychological health and well-being of HCPs, independent of pandemics. Secondly, to highlight what effects pandemics can have on HCWs, particularly those who are more exposed to these crises by virtue of working on the frontlines of health services. Thirdly, to examine the specific effect that COVID-19 has had on HCPs, even though there are still some knowledge gaps in this area, mainly because of its recent onset. Finally, to raise some recommendations for consideration, in relation to how HCPs might cope effectively with the stressors brought about by COVID-19 which add to the existing stressors that front-line service carries.

How psychologically healthy are healthcare staff?
In many ways, this is an area in need of further research. The two main reasons this author would like to identify include, a) most of the existing research focuses predominantly on the psychological well-being of doctors, and b) most of this research literature pertains to healthcare systems abroad, not Ireland specifically. There is a growing amount of research on the psychological well-being of nurses, which is to be welcomed, though little on nurses working within the Irish health system. Perhaps most surprising is the relative absence of high-quality research evaluating the psychological well-being of other HCWs, which may well highlight the opportunity that exists for those with an interest in examining this further, particularly as it relates to the Irish context.

The available data indicates that doctors and nurses appear to be at a discernibly higher risk of developing mental health problems, relative to counterparts in the general population(1,2). In one of the largest studies conducted on physician burnout to date, it was reported that 45 per cent of 7,288 physicians had at least one clinically significant symptom (out of 3) of burnout(1). By way of contrast, over 65 per cent of nurses were found to display at least one symptom of burnout in a study of nurses working within a Brazilian hospital in Sao Paulo, with over one in 10 nurses displaying all three symptoms of the syndrome(3). In another study, the ‘odds’ of sickness-related work absence being reported by nurses working in the UK (whilst controlling for different factors that may influence sickness) were far greater for nurses working in public sector roles, particularly those in large organisations, or indeed those working in more junior roles(4).

In terms of suicide risk, a rather drastic metric of how vulnerable these HCWs are to their job demands, a meta-analysis of 24 studies conducted across 10 different countries (in the US and Western Europe), found male doctors were 1.4 times more likely to die by suicide than members of the general population(2).

Of arguably greater concern was the finding that female doctors were 2.27 times more likely to die by suicide than their non-physician counterparts(2).

An Australian study also found that female nurses were four times more likely to kill themselves compared to non-nursing females(5).

All these statistical indicators beg the question, “why”? Whilst it is not exactly clear, and the true answer is unlikely to be straightforward, excessive workloads, burdensome work hours, complaints from patients, inadequate access to administrative supports, and extraneous factors have all been suggested as relevant. The psychological well-being and health of healthcare staff would benefit from more, well-designed research, on this issue.

What impact do pandemics have on healthcare staff?
This is where the research gets interesting. There have been numerous epidemic and pandemic events over recent years, and many studies have been conducted on how they have impacted HCWs exposed to the associated risks of contracting these various conditions.

These events have included SARS (2003), H1N1 otherwise known as ‘swine-flu’ (2009), MERS (2012), Ebola (2014/5), and more recently COVID-19 (2019/20). One resource for examining this issue is a live, open software, meta-analysis of the various pandemics(6), in relation to their potential mental health impact on front-line clinical staff. This analysis, which is ongoing, suggests that pandemics only add a small additional mental health burden on front-line medical staff, particularly with regard to anxiety, depression, and traumatic symptoms.

It concludes, rather shockingly, that this is probably because baseline rates of poor mental health are already very high within these HCW cohorts, and a point which runs contrary to prevailing narratives that it is the pandemic event itself that causes observed mental-health problems. One important inference from this dataset is that observed rates of mental health symptomatology in healthcare staff are not to be viewed in cross-sectional isolation, but rather within the broader context of HCW well-being, generally.

That said, not all pandemic events are the same. Some are distinct, and indeed COVID-19 has been described as a “once in a century event”, demarcated from anything we have witnessed in living memory, largely because of its reach across the globe coupled with its threat to societal mortality rates. It has been suggested that the 2003 SARS pandemic was its most direct recent comparator, and we know from that pandemic that the risk factors for HCWs’ distress during SARS included issues such as: having to quarantine, interpersonal isolation, treating colleagues who became infected, fear of contagion, job stress, perception of stigma, and concerns for family well-being(8).

Two aspects differentiated its psychological impact from other disasters(8,9), namely social isolation(9,10) and fears of contaminating family members(11,12,13), particularly for those with children. It has been suggested that both of these factors are likely to contribute to the elevated levels of psychological distress among healthcare staff being reported in Covid-19(8).

How has COVID-19 affected healthcare staff?
We know that HCWs on the frontlines of this pandemic have been one of the most affected groups. They represent one-in-four of those infected by the COVID-19 virus and have had to work under unprecedented demands, including the need to ration personal protective equipment, the threat of a surge that could overwhelm the public health system, and having to navigate profound ethical dilemmas, such as having to ration ventilators and other medical resources, for example. Healthcare staff have also had to carry their own personal worries, in particular, the very real threat that they could become vectors for the disease and potentially infect loved ones and elderly relatives.

Whilst research on COVID-19 is still in its infancy, we know that a recent Chinese study on 1,257 HCWs (doctors and nurses) in 34 different hospitals, proximal to Wuhan Province, found 50 per cent reporting symptoms of depression, anxiety and traumatic stress(14).

Interestingly, traumatic stress was the most prevalent symptom issue, with approximately 70 per cent of respondents endorsing it. However, we know that mild elevations across these domains are to be expected amongst HCWs. Drilling down further into the data suggests that 10-15 per cent of HCWs experience clinically significant distress across depressive, anxiety, and post-traumatic distress-related domains, with those working on the front-line being most at risk of these experiences.

It is also worth noting that preliminary data emerging from Singapore and the UK appears to paint a similar picture, and UK data suggests that those in the earlier stages of their career are more vulnerable to the psychological effects of this pandemic than their more experienced colleagues.

How can healthcare staff cope?
Individuals who choose to work in healthcare are likely to be capable, resilient, caring individuals, with an ability to adapt to challenging environments. Therefore, it is probable that many readers of this article are already coping well with the current environment and everything it has brought to bear on them and their own situation. Any suggestions that follow are intended to simply remind healthcare practitioners of what is typically recommended at times of crisis, particularly within the context of viral pandemics such as COVID-19. Recommendations also draw from the Psychological First Aid model (RAPID-PFA) designed to assist those who have been through traumatic experiences, including viral pandemic events. It seeks to build and/or reinforce resilience at the local level, given that psychosocial support is the strongest predictor of post-traumatic resiliency.

Adaptation typically needs to happen across three levels, the individual, the team, and the organisation itself. Individually, people have their own styles of coping. The main recommendation here is to be attuned to your own emotional thermometer, and responsive to it when it becomes at risk of getting ‘overheated’.

Symptoms to be particularly vigilant around include, autonomic nervous system features, such as palpitations, heightened physiological arousal, hastened breathing, panicky feelings, and other cognitive symptoms such as hopelessness and suicidal ideation in particular, or behaviours including (but not limited to) persistent patterns of avoidance, self-medicating, or outbursts that are out-of-character. Any of these symptoms might signal the need to prioritise self-care or even seek external assistance in restoring psychological balance.

Anecdotally, medical and nursing colleagues in the Mater Misericordiae University Hospital in Dublin highlighted the following needs as priority: being able to “control the controllables”, “switch off” after one’s shift was completed (reflected in the CEO’s daily updates on those working on the front-lines), and the importance of retaining perspective, in terms of what one’s efforts are ultimately in service of, and how this will feature in the course of one’s entire lifespan. Carl Sagan’s ‘Pale Blue Dot’ speech springs to mind, in relation to that last point. Worth looking up if you are not familiar with it.

Building on post-pandemic research, RAPID-PFA also suggests team-level debriefing sessions, along with buddy systems (perhaps for junior colleagues in particular), being desirable, and likely to be of help in building resilience at this level(15). At an organisational level, helplines and support groups for professionals have also been found helpful(15), which is corroborated by accruing evidence from a psychology-led staff drop-in clinic at the Mater Hospital, catering to demand from a range of disciplines including catering, administration, social work, medical, and security.

Thanks to health workers
My gratitude again to you all for performing your invaluable roles within the health system. Many of you find yourselves at the coalface of this crisis and that cannot be easy. Never has such support been witnessed, from every office in the land, to every person on the street, for the health system and its employees, particularly those of you at the front-line.

Should additional resources be of interest, please feel free to review a website constructed by National Health Service (NHS) workers, for NHS workers, in response to COVID-19 (www.beatcovid.co.uk), or indeed a page of resources created by the Psychological Society of Ireland for healthcare workers, psychologists and the general public.

Author
Dr Damien Lowry is a Chartered member of the Psychological Society of Ireland and Senior Counselling Psychologist in the Mater Misericordiae University Hospital’s Psychology Department.

References
(1) Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward. JAMA 2017;317:901-2.
(2) Schernhammer ES, & Colditz GA. Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis). The American Journal of Psychiatry. (2004) Dec;161(12):2295-302. Available online.
(3) Ribeiro VF, Filho CF, Valenti VE, Ferreira M et al. Prevalence of burnout syndrome in clinical nurses at a hospital of excellence. Int Arch Med. 2014; 7-22.
(4) Leaker D, & Nigg W. Sickness absence in the UK labour market: Sickness absence rates of workers in the UK labour market, including number of days lost and reasons for absence. Office for National Statistics. (2018). Available online (June 4, 2020).
(5) Milner AJ, Maheen H, Bismark MM, & Spittal MJ. Suicide by Health Professionals: A Retrospective Mortality Study in Australia, 2001-2012. Med J Aust. (2016). Sep 19;205(6):260-5. Available online.
(6) Bell & Wade. Live meta-analysis: Mental Health of Clinical Staff Working in High Exposure Compared to Low Exposure Roles in High-Risk Epidemic and Pandemic Health Emergencies (last updated 2020.05.27). Online open software meta-analysis. Accessed 4.6.20.
(7) Maunder RG, Lancee WJ, Balderson KE, Bennett JP, Borgundvaag B, Evans S, et al. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerging Infectious Diseases. (2006). Dec;12(12):1924.
(8) Gavin B, Hayden J, Adamis D, & McNicholas F. Caring for the Psychological Well-Being of Healthcare Professionals in the Covid-19 Pandemic Crisis. Ir Med J; Vol 113; No. 4; P51.
(9) Maunder RG, Leszcz M, Savage D, Adam MA, Peladeau N, Romano D, et al. Applying the lessons of SARS to pandemic influenza. Canadian Journal of Public Health. 2008 Nov 1;99(6):486-8.8.
(10) Maunder RG, Lancee WJ, Rourke S, Hunter JJ, Goldbloom D, Balderson K, et al. Factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in Toronto. Psychosomatic Medicine. 2004 Nov 1;66(6):938-42.
(11) Tam CW, Pang EP, Lam LC, Chiu HF. Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: stress and psychological impact among front-line healthcare workers. Psychological Medicine. 2004 Oct;34(7):1197-204
(12) Maunder RG, Lancee WJ, Balderson KE, Bennett JP, Borgundvaag B, Evans S, et al. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerging Infectious Diseases. 2006 Dec;12(12):192
(13) Beauregard N, Marchand A, Blanc M-E. What do we know about the non-work determinants of workers’ mental health? A systematic review of longitudinal studies. BMC Public Health 2011;11(1):439.
(14) Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated with Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Network Open. 2020 Mar 2;3(3):e203976-.
(15) Pekevski J. First responders and psychological first aid. Journal of Emergency Management (Weston, Mass.). 2013;11(1):39-48.

Disclaimer: This content has been produced by Irish Medical Times and its production/distribution is funded by Lundbeck Ireland Ltd.
While Lundbeck had the opportunity to comment on the content, responsibility for the final editorial resides with the author/s and the publisher.The views and opinions expressed in the article are those of the author/s, and do not necessarily reflect those of Lundbeck or Irish Medical Times.
IE-NPDEP-0005 Date of preparation: June 2020

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