Authors: Jack Tomlin, Bryan Dalgleish-Warburton, and Gary Lamph

[This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). Front Psychol. 2020; 11: 1960. 2020 Aug 11. Doi: 10.3389/fpsyg.2020.01960.]

Summary

This paper is a guide to managing the mental health burden of the clinical workforce in an attempt to support their mental wellbeing and organizational responses. It introduces the phased model of mental health: preparation, pre, initial and core, and longer-term. This model presents a framework for clinical responses to the pandemic burden and can be a helpful guide for healthcare professionals operating at different stages of the COVID-19 pandemic.

Abstract

The novel corona virus disease COVID-19 was first diagnosed in humans in Wuhan, China in December 2019. Since then it had become a global pandemic. Such a pandemic leads to both short- and long-term mental health burdens for healthcare workers. Recent surveys suggest that rates of psychological stress, depression, anxiety, and insomnia will be high for this group. Numerous organizations have released guidance on ways that both healthcare workers and the general public can manage the mental health burden.

These recommendations, however, focus on specific healthcare workers (e.g., nurses, psychologists), are often not evidence-based, and typically do not address the fact that countries are at different stages of the COVID-19 pandemic.

We propose a phased model of mental health burdens and responses. Building on work by the Intensive Care Society (2020) and the Royal College of Psychiatrists in the United Kingdom (Williams et al., 2020), we present a model that demonstrates how both staff and organizations might respond to the likely stressors that occur at preparation-, pre-, initial and core-, and longer-term-phases of the pandemic. Staff within countries at different stages of the COVID-19 pandemic will be able to use this model.

We suggest practical tips for both healthcare workers and organizations and embed this within up-to-date scientific literature. The phased model of mental health burden and responses can be a helpful guide for both staff and organizations operating at different stages of the pandemic.

Background

This paper collates some of the current guidance on maintaining mental health during the COVID-19 pandemic, with a particular focus on frontline staff and managers working in healthcare settings. It situates these recommendations within the phased model of mental health burden and responses noted above. Our recommendations are based in relevant psychological literature and derived from the clinical experiences of two of the authors.

First, we describe sources of mental health burden for staff. Then we briefly highlight experiences of Chinese staff and interventions implemented there, before moving on to list a range of possible psychosocial interventions and underscore some key principles that can be derived from these. Finally, we present the phased model of mental health burden and responses.

COVID-19 is found in individuals infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This coronavirus can be transmitted between people via droplets—typically in coughs and sneezes. This occurs directly between people, or indirectly by touching mouth, nose, or eyes. SARS-CoV-2 has spread rapidly across the globe and in March 2020 the World Health organization (WHO) classified the outbreak a pandemic (WHO, 2020b).

Emerging literature suggests that psychological distress is a real outcome for staff providing healthcare amidst the COVID-19 pandemic. A study published March 23, 2020 surveyed 1257 healthcare workers in 34 hospitals in China (Lai et al., 2020). It found that rates of psychological stress were high: 50.4% had symptoms of depression, 44.6% for anxiety, 34% for insomnia, and 71.5% for general psychological distress. Nurses, female staff, staff in Wuhan, and staff working directly with patients were more likely to have “severe” scores on these outcomes.

These findings are not unique to COVID-19. Studies into the SARS outbreak in 2003 reported psychological symptoms in 89% of workers in high-risk situations (Lai et al., 2020). This is all the more understandable given 1 in 5 SARS infection cases were healthcare workers (Chan-Yeung, 2004). Long-term psychological distress can result from what is experienced during such a pandemic (Lai et al., 2020). It is likely that the impact of stress associated with managing and providing care in uncertain and ever-changing circumstances may negatively impact the immune system, weakening staff members’ ability to fight off the virus.

Sources of Mental Health Burden for Staff

Currently the world is responding to an unprecedented pandemic and medical crisis that has not been seen for 100 years. Those working on the frontline are exposed to a variety of sources of mental health burden, which we outline next:

Risk of contamination of the virus: compliance with biosecurity measures including constant vigilance; use of equipment; isolation practices; tensions between patients and staff; and stigmatizing of healthcare workers who come into contact with patients who have COVID-19 (Int’l Red Cross, 2020).

Abnormal mourning for the death of a loved one, home quarantine and social isolation, disruptions to work routines, sensitivity to and obsession with cleanliness and hygiene, the closure of public and private institutions, rumors about the disease, and the loss of social capital (Javadi et al., 2020).

Uncertainty. This leads to stress and anxiety (Shanafelt et al., 2020). Stress is higher where staff have high work demands (heavy workload, time pressure, periods of intense concentration) but low work control (low levels of autonomy and decision-making input). Motivation and performance are lower when stressors are perceived as hindrances.

Examples of hindrances include:

Unclear objectives, conflicting requests, red tape, organizational politics, and various other work-related hassles (Bolino, 2020).

Weakened immune system due to high levels of stress (Segerstrom & Miller, 2004).

Staff inquiries, physical exhaustion, sleep disruption, and fear and emotional disturbances (Li et al., 2020).

Staff not knowing they can go home if they are ill or can work from home where appropriate (Beckman et al., 2020).

Feeling vulnerable, loss of control, concerns about health of self and others, changes in working patterns/routine, feelings of personal danger, being isolated, lacking necessary supplies to conduct their work (Lai et al., 2020).

Redeployment of the clinical workforce is challenging. Clinicians are expected to work within unfamiliar territory, often with new teams, new processes, new clinical procedures and equipment. In addition, clinicians are being released from their pre-registration studies early to contribute and work within frontline services (Royal College of Nursing, 2020).

Implicit and explicit racism toward staff of Chinese origin (The Guardian, 2020).

Abuse from detained patients including verbal insults intended to hurt staff members in order to share the pain of isolation from families (personal communication with an ANP, United Kingdom).

Pre-existing mental health vulnerability including previous trauma and mental ill health (Mental Health Foundation, 2020).

Having identified some of the sources of mental health burden in staff, this document describes principles that should underpin the way hospitals and healthcare organizations can implement psychosocial interventions and organizational practices to mitigate these burdens.

Experiences from China

Some of the hospitals in China that were most affected by COVID-19 implemented a three-pronged approach to care for the mental health needs of staff:

1. Psychological intervention medical team to develop online courses to manage common psychological problems.
2. Psychological assistance hotline team to offer guidance and supervision to callers to help solve psychological problems.
3. Individual and group psychological interventions, including activities to release stress. (Chen et al., 2020)

However, staff were hesitant to engage in these. Interviews with staff suggested that this reticence was due to a lack of immediate concern about being infected and feeling they did not need psychological support. They stated they needed more rest and personal protective supplies (PPE), and that they wanted mental health training or mental health staff to assist them when interacting with difficult or aggressive patients.

The Chinese revised their interventions. Hospitals provided space for staff to rest and isolate themselves from families; staff were provided food and daily living supplies. New staff were trained in ways to interact with difficult or aggressive patients; security teams were engaged if necessary. They wrote detailed rules on appropriate use of PPE. Hospitals also established leisure activities; gave training to staff on how to relax; and embedded counselors into the workplace to listen to staff and provide necessary help (Chen et al., 2020).

Responding to Phases of the Pandemic

The Intensive Care Society (United Kingdom) offers several helpful ways of thinking about maintaining staff mental health before, during, and after the COVID-19 pandemic (Intensive Care Society, 2020). Hospitals should think about where their organization is in relation to phases of the pandemic, be cognizant of the issues and impacts these will likely have for them, and take note of the recommended approaches to these phases.

We have expanded on this guidance by incorporating practical tips for organizations and for individual staff. Some changes have been made to the phases outlined by the intensive care society: we have added a preparation phase and combined the initial and core phases and the end and long-term phases. Although these phases are linear, the overall process is cyclical and not rigid or fixed. We have added a preparation phase to address organizations and countries that are encountering this for the first time; however, many international healthcare providers may well have passed this point now.

Our aim is to offer practical mental health support to a range of frontline staff and to organizations internationally who are working on the front line of this global pandemic. We know that services may face a second wave or even a future pandemic.

Preparation Phase

Individual Responses and Building Resilience

We have identified the need for self-reflection in the preparation phase—knowing your own needs and strengths and sharing them with someone you can trust. We need to have a personal understanding of our triggers for stress as well as personal coping strategies for managing distress. As the team develops and membership evolves, time should be taken routinely to discuss wellbeing and self-care in the short-term alongside supervision in the long-term. Be prepared to share:

• See it?
• Hear it?
• Are you feeling it?
• Report it and let someone know.
• Embrace your needs and be a model for others to share.

Organizational Response

Organizationally, leaders are required to understand the needs of their workforce and establish whether any members of the team may be more vulnerable than others to mental health difficulties, including:

• Those with existing needs or current mental health difficulties.
• Those who have caring responsibilities in their home lives.
• Those who may have recently survived a stress or trauma experience.

Identification in the preparation phase will not identify everyone who might experience challenges to their mental well-being during the pandemic. However, it will enable teams to identify those most vulnerable so that plans can be put in place to support them. Consider buddy systems where peer support can be provided, as well as a sharing common mantra that “It’s OK not to be OK” to combat the stigma often associated with mental health difficulties (Highfield et al., 2020; Stuart, 2016).

Encourage resilience and well-being plans for staff. These need to recognize the stressors that present day to day in healthcare but particularly how these are magnified in a pandemic. These plans, written by team leaders, should describe triggers for stress, how one presently copes, early signs of distress (change to baseline), and how team members can help. Well-being plans could include a parachute analogy, where leaders develop a plan like a parachute, there to soften burdens and protect people in crisis instead of waiting until it is too late; you adopt a proactive rather than reactive approach. Support staff to make new mental health disclosures as the outbreak brings these to the fore (Mental Health Foundation, 2020).

Pre-Phase

Individual Responses and Building Resilience

People need to recognize that fears and anxieties are justified and it is natural for them to be present in the face of threat because these fears enable us to identify risk and keep safe (WHO, 2020b). Sometimes the anticipation of stressful events can be worse than when the actual event occurs. During the actual event we might neglect our emotional needs by focusing solely on our current tasks. During the pre-phase we have lots of time to think about what may occur, how it may feel, worst case scenarios, and what the job will be like in the initial and core phase.

We suggest that, while organizational preparations are made, individuals tackle one task at a time, avoiding preoccupation with future threats. Contemplating the whole picture can be overwhelming (Williams et al., 2020). Instead, we advise the focus should be on making sure you are managing your own mental well-being. This is as important as your physical health is for tackling challenges that may present. A worldwide pandemic is an unprecedented scenario; identify and use strategies and positive coping techniques that have previously worked for you. Avoid negative coping such as smoking or drinking alcohol.

Organizational Response

At this pre-stage, team grounding is important. Grounding involves noting the emotional and cognitive information being shared in a group, acknowledging it, and using it to structure an agenda for discussion. This is important because thoughts and emotions can become amplified within a group setting and fear and anxiety can migrate across team members (Smith and Mackie, 2015; Weisbuch and Ambady, 2008). Therefore, in the same way that we ask a client to ground themselves to the present when their distress exceeds their window of tolerance, the team leader may need to offer a greater sense of present-moment awareness. A number of techniques are applicable with groups. For instance, ask the group to clap their hands at the same time or stamp their feet. Hold regular team meetings (making use of virtual tools where necessary) (Red Cross, 2020).

One might also offer realistic reassurance—encouraging team openness, for instance, via adoption of the mantra “It’s OK not to be OK.” Consider how communication will look each team as you remain aware of the team’s current needs. Be sure you think about protected characteristics of staff i.e., do measures affect all staff equally?) (Mental Health Foundation, 2020).

Offer flexible working routines for staff personally affected by the virus e.g., illness or death in the family, childcare duties (WHO, 2020b). Ensure that managers are considerate of their own individual needs as they are not themselves immune to the impact such stressful events they will also be enduring. Part of this is sharing stories with other managers and team leaders (Mental Health Foundation, 2020). Unlike the individual response, the organizational response will require longer term planning in order to respond effectively to worst case scenarios (i.e., access to beds, equipment including PPE, and resources redistribution).

Initial and Core Phases

Individual Responses and Building Resilience

This phase has been identified as having the highest psychological risk (Highfield et al., 2020). Practical ideas are going to be of paramount importance.

Enhance Self-Compassion. In times of high stress and emotional extremes we can become critical of ourselves or our performance. Be compassionate. How would you speak to a friend if they were feeling this way? What advice would you give? How would you hold yourself or hold them? Now, speak to yourself in the same way, say the same things. Use a mantra: “it is fine to feel like this” (Irons & Beaumont, 2017). Identify activities that help you to self-sooth that you can still engage within the comfort of home: the tasks you never got around to completing, the film you’ve been wanting to watch, and so on.

Mindfulness. Mindfulness is being in the present moment, on purpose. Taking such a non-judgmental stance is underpinned by meditation (Kabat-Zinn, 2013). Mindfulness practices to manage stress and emotion are becoming increasingly popular. A variety of Apps including Headspace can be purchased for mobile devices, and providers such as YouTube include narrative examples of mindfulness.

Grounding. Grounding techniques can be used to aid stability in the face of trauma, stress, and dissociation (Foureur et al., 2013). Take stock of what is going on around you and ground yourself in that moment. Some useful techniques include placing both feet on the floor and stomping; clapping your hands; or, looking around the environment to name and describe three objects you can, see or three sounds you can hear, hence using the senses to assist in grounding.

STOP, GROUND, BREATH is another strategy in which we encourage you to use your breath to as a grounding technique such as, breath in through the nose and out of the mouth … breath in, hold, and breath out completely (take three breaths).

Balance home and work. Try to distinguish the two by reducing time spent watching the news, focusing on things away from COVID-19. Taking a break at home is important because work will be dominated by the pandemic.

Social Media. Use credible sources, keep in touch with friends and family, but choose what to read and engage in. “Sandra” on Facebook probably knows much less than you, so do not let her posts further impact on your emotions.

Social Connection. Connect with friends, family, peers. Recent surveys of the UK general public found this to be one of the most helpful coping mechanisms (Holmes et al., 2020). Use video like Zoom to see faces. Engage in virtual games nights and board games. Social connectedness with people experiencing the same difficulties is important. Use buddy systems, check in on each other, but balance this with family and no-work downtime (Williams et al., 2020).

Adopt healthy living strategies. These will reduce your emotional vulnerability and make you better able to manage you own stress and emotions: (1) Take care of physical health and treat physical illness; (2) balance eating; low mood often results in reduced appetite or comfort eating that may make you feel worse; (3) avoid mood altering drugs (including alcohol); (4) sleep well; we all require rest, especially in times of stress and high anxiety; (5) engage in exercise; physical fitness and a release of pressures are essential; and (6) build mastery by finding activities that provide you with a sense of accomplishment (Linehan, 2014).

Routine. Maintain a routine as much as possible. Write a list of the things you would like to do around the house that can now be achieved in your out of work time but balance this with relaxation time.

Act opposite. Don’t watch too much media related to the pandemic or sad themes; act opposite and watch comedic, upbeat, or enlightening programs and films. Don’t listen to music that makes you sad or upset; listen to upbeat songs. Don’t withdraw and isolate from those you love; use this as a chance to reconnect and learn new things about people (Linehan, 2014).

Organizational Response

During this stage, communication is going to be essential. Provide timely, accurate, and evidence-based information on the virus and the hospital’s response, including worse case scenarios (Red Cross, 2020; Mental Health Foundation, 2020; WHO, 2020b). Ensure that present, visible, and easily recognized leadership is present. Be a role model for how you would expect staff to behave (personal health and wellbeing, appropriate use of PPE) (WHO, 2020b).

Ensure regular communications are provided, with the opportunity for regular check-in and discussions. Frame/describe the hospital’s response to COVID-19 as a challenge from which staff can all grow and develop; do not describe it as a hindrance (Bolino, 2020). Give staff autonomy and input into decision-making where possible (Bolino, 2020). Remove bureaucratic hindrances to flexible working, such as blocks on virtual meetings or remote working (Bolino, 2020).

Psychological debriefing is not advised during traumatic events because it can make things worse (NIH & Care Excellence, 2018). Engage the workforce in peer support and buddying practices and, within this, consider partnering experienced people with those who may be less experienced or new (Red Cross, 2020; WHO, 2020b). Adopt a mantra and compassionate response to staff in that “Its OK not to be OK” and allow opportunity for people to discuss their own needs, concerns, and feelings.

Post resources like psychological first aiders and drop-in sessions for staff support; you might even assign a single member of staff to do this (Red Cross, 2020; Mental Health Foundation, 2020). Ensure, positively monitor, and encourage work breaks (WHO, 2020b). Mindfulness practices within the workplace have been shown to produce positive results (Irving et al., 2009).

End and Longer-Term Phase

Individual Response and Building Resilience

Once the COVID-19 pandemic has passed, things are unlikely to return to normal. You will no doubt be reflecting on what has occurred and your responses to it. Make sure you stay connected with colleagues and that you share your experiences. Feeling distressed after your experience is normal and understandable. This is all the more likely if you have been moved into a new role or redeployed into a new working environment where routines, rules and colleagues are unfamiliar.

The Adaptive Information Processing model (AIP) proposes that new information taken into the brain through our senses is assimilated into existing memory networks. This allows us to make sense of this information when we recall it in the future. It is important to give yourself time to process experiences into your existing cognitive structures (memory networks).

The latest guidance for the assessment and treatment of trauma proposes “watchful waiting” rather than psychological debriefing (NIH, 2018). This is because many individuals exposed to trauma do not develop post-traumatic stress disorder (PTSD). Most people recover from the early experience of traumatic stress symptoms without formal intervention (Grey, 2009). However, a minority can develop symptoms and it important to recognize symptoms.

The Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM-V) refers to pre-, peri-, and post-factors that influence the risk of PTSD (including prior trauma, prior health needs, inappropriate coping strategies, and negative appraisal), and is a good source to consult (APA, 2013). Continue to use the strategies you have found that work for you. Observe and notice changes in sleep, feeling unreal, feeling disconnected, or re-experiencing things that have happened. Be aware if there are things you are avoiding in case they trigger negative emotions. Report any of these, as you may need further support, to your supervisors or supportive friends and family.

Organizational Response

Afford time for all in the team to process their experiences and reset. The crisis might be over in terms of immediate threat but the psychological after-effects on staff may leave them with little confidence that they are ready if a second wave were to occur.  In the face of this, you still need to ensure that the organization is ready should such happen. Look to thank, acknowledge, and reward the workforce.

Reflect on the lessons learned using a known model of reflection, such as Description, Feelings, Evaluation, Analysis, Conclusion, Action plan (Gibbs, 1988). Take a watchful, waiting approach and check in for any emerging symptoms of PTSD in staff, making sure appropriate referrals are made. Adopt the stance that “It may be over but it is not forgotten.” Continue regular communications with staff following shifts, to see if anyone requires further support. The UK National Institute for Health and Care Excellence (2018) guidelines on the treatment and management of PTSD suggest looking out for the following signs:

• Hyper arousal;
• Sleep disturbance;
• Flashbacks or re-experiencing;
• Avoidance of triggers.

If staff present with any of these offer them direction to support services or simply propose a talk in protected time.

Conclusion

There is plenty that hospitals and healthcare providers can do to help healthcare staff manage mental health burden. Early experiences from China and more recently in Europe suggest that healthcare staff will likely experience negative mental health outcomes due to the pandemic and their employment. This paper is a guide to managing the mental health burden of the clinical workforce in an attempt to support their mental wellbeing and organizational responses. The phased model of mental health burden and responses can be a helpful guide for both staff and organizations operating at different stages of the COVID-19 pandemic. Organizations and individuals implementing this model in whole or in part should also consider undertaking a suitably powered evaluation of both staff and organizational outcomes. This would help to develop a body of evidence that supports embedding the model in routine practice or making signposting alterations.

References

For these references, please go to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431467/.