Mental Health COVID-19

 

Supporting mental health and wellbeing through COVID-19: Support for the health workforce

 

Prepared by Ruth Hennessy, Katherine Coote, Dr Shiraze Bulsara, other members of the Taskforce’s Mental Health Cluster Group, and ASHM.

 

UPDATED ON: 6 May 2020

Disclaimer: This ASHM document is designed to provide available, relevant information to clinicians and other healthcare providers to optimise the health and wellbeing of people living with HIV, hepatitis B or hepatitis C and those with Sexual Health needs during the COVID-19 pandemic. The recommendations provided are the opinions of the authors and are not intended to provide a standard of care, or practice. This document does not reflect a systematic review of the evidence but will be revised to include relevant future systematic review findings of the National COVID-19 Clinical Evidence Taskforce and other relevant information.

 

Please note this is the second in a series of resources supporting the blood borne virus (BBVs) and sexual health workforce in relation to COVID-19 and mental health or psychological wellness due to the impact of social distancing or isolation.  

 
  1. Health practitioners are at increased risk of psychological distress, including vicarious trauma and burnout, during pandemics.  
  2. Psychological support should be offered as a normal and expected part of health worker health and safety in response to the additional stresses presented by COVID-19. 
  3. Health practitioners should be supported to prioritise their self-care both to prevent and reduce the risk of psychological trauma associated with COVID 19 
  4. Health practitioners play an important role in both detecting and responding to COVID 19 related distress in other work colleagues.
  5. There are effective strategies to assist health managers and leaders in creating supportive workplaces during times of uncertainty, increased pressure and potential risk.
  • Health practitioners are more important than ever.  COVID-19 has meant health practitioners have had to adjust their practices and learn new ways of working, with new protocols still evolving, whilst continuing to provide crucial services.  Globally COVID-19 has increased anxiety and concerns for health services and health staff. While the Australian health care system has not been overwhelmed by COVID-19, health services and health staff remain on high alert and empathise with their overseas colleagues and communities.  
  • The impact on individuals and services has been variable; many report working harder than ever, adapting to new technologies and service provision. However, for some, a lull in demand, due to postponement of non-essential care, and delays in Medicare rebate for telehealth, has meant a reduction in services and income, and threatened business viability.  Conflicting messages, a lack of information and changing protocols have also contributed to this burden.  
  • The importance of our primary health providers cannot be underestimated; general practitioners (GPs) may be the first point of community contact for future COVID-19 cases and additional resources for practices, such as community respiratory clinics and testing facilities, have been suggested to assist early detection of cases in the community.   
  • Front-line health practitioners may experience higher anxiety than the general community about contracting viruses during pandemics. Equally affected by anxiety are nurses, and administrative staff (reception staff, practice managers), medical doctors, and allied health practitioners. Other key staff members such as cleaners or ancillary clinic staff will also be affected by anxiety about contracting COVID-19.  
  • Furthermore, health practitioners can be concerned about the risk of infecting their loved ones, families, and the community.   Practitioners report needing to constantly assess risk; to identify potential exposure; hypervigilance to possible COVID-19 symptoms; the need to self-isolate; and and/or whether they can continue in their work.  Some health practitioners have felt others in the community distancing from them or had family pressure to discontinue working, and sadly a small minority have even experienced abuse from community members due to their perceived occupational risks.   
  • It is important to normalise a spectrum of responses for health practitioners during the COVID-19 pandemic. Changes in services or addressing patients’ anxieties whilst balancing one's own needs is always a challenge, but in the time of COVID-19 exponential changes have impacted on every aspect of normal life and particularly on health systems.  
  • There are no ‘right’ or ‘wrong’ reactions; some people will find there is a limited impact to their daily lives and functioning, while others will see a huge impact across psychological, social and physical health domains. 
  • For those who are feeling the pressure, normalisation is imperative. This is an unprecedented situation during the past 100 years, and it is natural to experience stress, worry, anxiety, and uncertainty. While Australia is in a relatively good position compared with other countries, this does not detract from the distress that many Australians are feeling in response. For health practitioners, this might include their exposure to traumatic and/or stressful situations in the context of their roles in supporting patients, colleagues and their families through the COVID-19 pandemic. Alternatively, there may be direct or indirect reminders of experiences of past loss for example for those healthcare workers who witnessed or were involved in the response to the AIDS epidemic.
  • In addition, health practitioners may be experiencing increased stress at home, including potential loss of income within the family, the pressures of supporting remote learning for school-aged children, or concern regarding loved ones. Further, images from other countries via the media can amplify this distress and anxiety, especially for health practitioners who may fear a ‘second wave’.  
  • Some staff may be struggling with COVID-19 specific challenges to their clinical role. While many health practitioners have experience delivering unpleasant or unwelcome news, the current situation may amplify an already difficult situation. For example, end-of-life plans for their patients may require adjustment as patient family support may no longer be an option. Health practitioners may struggle with these new processes, which may see them unable to provide the level of care/support to patients and families they have previously offered. In addition, difficult conversations regarding patient care and death are complicated by the context of a relatively new illness, about which we still know relatively little. Health care workers may also feel ill-equipped to deal with psychological issues being discussed with them as a result of changes experienced by patients’ adaptations to COVID-19 – for more on this please see the Task Force’s guidance on Psychological First Aid and COVID-19 
  • Practitioners with health issues may experience elevated concerns about their personal vulnerabilities, including those with BBVs, while working during COVID-19. Their concerns may be heightened by a lack of, changing and/or conflicting information available about their relative risks. See ASHM’s statement on HIV and COVID-19 and the Federal Government’s advice for vulnerable people in the workplace. 
  • Vicarious trauma, also known as secondary traumatisation, is indirect exposure to trauma(s) through first–hand accounts and/or observations of traumatic events.  In the case of a his can be caused by hearing about or witnessing a patient’s trauma.  Health practitioners, along with others in the helping professions such as the police and rescue workers may be at risk.  Vicarious trauma typically involves a shift in the world view of the helper and symptoms parallel those of experiencing direct trauma, although they may be less intense.  Symptoms typically include intrusive sensory perceptions, avoidance, hyperarousal, mood swings, and anxiety and depressive symptoms (3, 4).    
  • Compassion fatigue is stress resulting from ongoing exposure to a traumatised individual; often the result of the cumulative impact of vicarious trauma.  Health practitioners experiencing compassion fatigue can have a reduced ability to feel sympathy and empathy, reduced work satisfaction, increased absenteeism, and an impaired ability to care for patients. Frontline health practitioners are at an increased risk of compassion fatigue during the COVID-19 pandemic (5).  
  • Pandemics can be associated with adverse mental outcomes for health practitioners, both during and after outbreaks.  Anxiety, depression, acute stress disorder, burnout and post-traumatic stress disorder are the most commonly cited outcomes. Reasons for this include long working hours, risk of infection, shortages of protective equipment, loneliness, physical fatigue and separation from families (6).   
  • Other risk factors include: sociodemographic such as younger age, female gender; social including lack of social support and social isolation; and occupational such as working in high risk environments and roles, and lower levels of specialised training (7, 8, 9).        

 

Protecting against vicarious trauma and compassion fatigue 

  • Interventions to address mental health trauma include provision of training and organisational culture changes around support.  Overcoming logistical barriers (e.g. workload, ensuring breaks), cultural barriers (e.g. help seeking) and mandating a wider program of support (e.g. creating a supporting workplace, access to Employee Assistance Programs (EAP) are effective organisational strategies.  (Also see Support for Managers and Leaders below).  
  • To guard against the development of compassion fatigue, health practitioners can prioritise their self-care (see Caring for yourself below) and access peer support from their colleagues in similar roles (see Caring for colleagues below). Health practitioners can also monitor their compassion/caring levels on a day-to-day basis, e.g. on a scale of 1-10. These scores can then flag whether the health practitioner needs to take action to reduce their stress levels or even to seek further assistance such as through the EAP.

 

Self-care is important at all times, but more so when managing a stressful period that does not have a clear end date.  In addition to the tips outlined in the Taskforce’s previous article about providing mental health support to populations living with HIV, BBVs and sexual health needs in Bulletin #4, and webinar slides – here are some further tips:


Access support services

  • e.g. Employee Assistance Programs,  free online and phone counselling service e.g. https://headtohealth.gov.au/covid-19-support/covid-19, Beyond Blue and twenty four hour service such as Lifeline 
  • Practitioners with current or previous mental health concerns should monitor any change in symptoms and seek help accordingly

Focus your attention

  • Try to stay off the topic of ‘what happens next’
  • Be mindful of what is within and outside of your control 
  • Focus mental and physical energy on what you do have control over
  • Balance your perspective – give attention to positive things 

Look after your physical health

 

  • Maintaining social connection with family, friends, work colleagues is important to your mental well-being, including on phone/video calls, online group chats and social media.   Find new ways of connecting with your loved ones - Find out more on caring for your family

 

  • Keep informed - use reputable sources of information. Visit government websites such as NSW Health and visit NSW Health Facebook. Limit exposure to media coverage and second-hand information

 

  • Understand your unique response to types of stressors - different people respond differently to impacts or challenges. HETI has a resource to equip you with the tools necessary to recognise, understand and manage stress effectively

 

Additional Helpful resources

 

  • The above points are important not only for the individual worker and their families, but also to ensure the health workforce remains functioning, healthy and effective in the care they deliver to the community. The analogy of “fitting your own oxygen mask first before helping others” is relevant here.
  • Everyone has a role to play in supporting mental health in the workplace including recognising the signs that a colleague is in distress and responding appropriately.
     

The LOOK–LISTEN-LINK was described in the previous article 

 

See the Signs

  • Feelings – fear, sadness, frustration, short-tempered, lacking confidence, lacking motivation
  • Actions- difficulty concentrating, making errors, conflict with colleagues, indecisiveness, increased work absences, not completing tasks, alcohol and/or drug misuse
  • Physical well-being - weight changes, stomach/digestive issues, headaches, fatigue, change in appearance (e.g. appearing untidier) 

Responding to distress

  1. Choose a good time to speak to your colleague, in a quiet and confidential space
  2. First ask permission e.g. I’ve noticed you have been distressed/not your usual self lately. Would you like to talk about it?
  3. Express your concern for your colleague and specifically acknowledge the distress signs you have observed (e.g. I’ve noticed you have been quieter than usual?) 
  4. Resist the urge to immediately challenge or problem-solve what your colleague tells you, rather prioritise understanding and showing empathy (e.g. It sounds like you are feeling…?)Discuss practical steps such as accessing the EAP or resources available on-line such as The Black Dog Institute’s The Psychological Toolkit or Healthdirect Australia Managing work related stresses
  5. Arrange with your colleague to check-in with them again at a later date to review how they are managing and whether further assistance is needed

1.    Keep up the communication with your team

  • Honest and regular communication is essential in periods of uncertainty and stress 
  • Listen to concerns raised by staff members and lead and support staff with compassion
  • Ensure feedback is constructive and remember to reinforce / compliment staff for their efforts and achievements
  • Everyone will respond to COVID-19 differently and managers/leaders need to be aware of this. Some people in teams may excel in their duties/lives as a result, whereas others may struggle with day to day tasks
  • For further information about communication with staff during Covid-19 see The Centre for the Study of Traumatic Stress

 

2.    Supporting front-line staff

  • As a manager it is important to walk the talk - demonstrate you are using self-care strategies 
  • If possible, roster staff across high and low stress work activities so that they have opportunity to rest and recharge
  • Ensure that staff take their work breaks (and as a manager, model this behaviour also)
  • Check-in with staff about energy levels and encourage them to be open about their thoughts and feelings with you
  • For more information and resources see Headspace and WHO  
     

3.    Daily well-being check-ins

  • Can be face-to-face (ensuring social distancing) and/or virtual (online, phone)
  • Can be conducted with each staff member by manager 1:1 or with the whole team at once, e.g. a huddle
  • Notice if any staff members are avoiding check-ins or not participating, this could be a sign that further support is needed, or a different approach
  • Consider activities to improve team bonding and cohesion during this tress period – For ideas see The Mental Health Foundation and Workplace Strategies for Mental Health
  • Not all individuals who experience a traumatic stress will necessarily go on to develop symptoms of a psychological diagnosable disorder; many will find they manage the situation without requiring support from external sources. However, for others, the experience of this situation will be interpreted as traumatic, and their response to it will be the same. In some cases, the symptomatology associated with acute stress disorder (ASD) or posttraumatic stress disorder (PTSD) may surface and require more formal psychological intervention. It is important that health practitioners at this end of the spectrum are not shamed in any way for their reactions; in both these disorders, their symptoms are considered a normal reaction to an abnormal event.
  • Clinical guidelines developed by experts in the field can provide guidance regarding how to approach and support those at different stages of the response.

Stepped Care (11)  – Not everyone exposed to traumatic events will experience symptoms associated with a diagnoseable disorder; some will experience sub-clinical symptoms and others no symptoms at all. Stepped care is important to ensure all individuals receive the care appropriate to their presentation

 

Image 1

 

The Stepped Psychological Response (3) 
 
Psychological debriefing (12) - Psychological debriefing involves the principles of ventilation, normalisation of distress, and psychoeducation regarding symptoms. It is sometimes referred to as Critical Incident Stress Management (CISM) and can be delivered as a group-based intervention to teams of health practitioners. There are five distinct phases associated with psychological debriefing:

  • Preparing workers for a possible critical incident in the workplace
  • Demobilisation – provision of rest, information and time out as a means of calming the workforce following a critical incident. This phase should happen as soon as possible after the incident, and is important to ensure the immediate needs of the workforce are met
  • Defusing – immediate small group support designed to review the event, clarify workers’ questions and concerns, identify needs, and provide support/resources/follow-up as needed
  • Debriefing – assisting workers to explore and understand the sequence, causes and consequences of events, as well as managing the emotional responses as a result of the incident
  • Follow-up support – recognises that stress responses can develop over time and follow-up support may be required some time after the event has passed. External support referrals may be appropriate here

Psychological First Aid (PFA) (13) – this was discussed in detail in Bulletin #4, and outlines the Look-Listen-Link principles to PFA.
 

At all times, but especially during a pandemic, we need to be mindful that people may be unable to achieve ‘higher order’ needs such as psychological well-being, if their basic (‘lower order’) needs are not met. In this context, this means that people must have needs such as food, water, safety, financial security, and shelter addressed before they can consider the impact of the situation on their psychological well being. It is important that those providing support to health practitioners take note of this so as not to push people too far, too fast.

 

Image 2

 

Telehealth was discussed in the previous in Bulletin #4 but here’s an additional resource: 

https://insightplus.mja.com.au/2020/12/telehealth-and-covid-19-a-guide-for-gps/  

Additional Resources are available to assist the mental health and wellbeing of health professionals:

 

1.  Mental Health Ramifications of COVID-19: The Australian context, The Black Dog Institute https://blackdoginstitute.org.au/docs/default-source/default-document-library/20200319_covid19-evidence-and-reccomendations.pdf
https://www1.racgp.org.au/newsgp/clinical/risk-of-infecting-others-with-covid-19-a-key-conce
Chua, S.E., et al., Stress and psychological impact on SARS patients during the outbreak. Can J Psychiatry, 2004. 49(6): p. 385-90.
https://www.abc.net.au/news/2020-04-02/nsw-healthcare-workers-leaving-families-in-coronavirus-crisis/12111218
https://www.sbs.com.au/news/minister-slams-unacceptable-abuse-of-healthcare-workers-wearing-uniforms-in-public
https://www.abc.net.au/news/2020-03-10/coronavirus-covid-19-gps-doctors-chief-medical-officer-letter/12039200
2.  World Health Organization (2020). Mental health and psychosocial considerations during the COVID-19 outbreak. Available at https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf
3.  Anja Greinacher, Cassandra Derezza-Greeven, Wolfgang Herzog, and Christoph Nikendei, Secondary Traumitization in first responders: a systematic review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6346705/
4.  Interventions for Secondary Traumatic Stress With Mental Health Workers: A Systematic Review, Melissa L. Bercier, Brandy R. Maynard
5.  Cocker, F., & Joss, N. (2016). Compassion Fatigue among Healthcare, Emergency and Community Service Workers: A Systematic Review. International journal of environmental research and public health, 13(6), 618. https://doi.org/10.3390/ijerph13060618
6.  Kang L., Li Y., Hu S., Chen M., Yang C., Yang B.X., Wang Y., Hu J., Lai J., Ma X., Chen J., Guan L., Wang G., Ma H., Liu Z. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry. 2020;7(3):e14. 
7.  Cabello, impact of viral epidemic outbreaks on mental health of healthcare workers: a rapid systematic review https://www.medrxiv.org/content/10.1101/2020.04.02.20048892v1
8.  Chong, M-Y., et al. (2018) Psychological impact of sever acute respiratory syndrome on health workers in a tertiary hospital, British Journal of psychiatry https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/psychological-impact-of-severe-acute-respiratory-syndrome-on-health-workers-in-a-tertiary-hospital/726E5229A319D1B68BC01B4544901D73
9.  Wang C., Pan R., Wan X., Tan Y., Xu L., Ho C.S., Ho R.C. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int. J. Environ. Res. Public Health. 2020;17(5):E1729. [PMC free article] [PubMed] [Google Scholar]
10.  Phoenix Australia – Centre for Posttraumatic Mental Health. (2013). Australian guidelines for the treatment of acute stress disorder and posttraumatic stress disorder. Available at https://www.phoenixaustralia.org/wp-content/uploads/2015/03/Phoenix-ASD-PTSD-Guidelines.pdf
11.  The British Psychological Society (2020). The psychological needs of health staff as a result of the Coronavirus pandemic. Available at https://www.bps.org.uk/sites/www.bps.org.uk/files/News/News%20-%20Files/Psychological%20needs%20of%20healthcare%20staff.pdf
12.  The British Psychological Society (2020). The psychological needs of health staff as a result of the Coronavirus pandemic. Available at https://www.bps.org.uk/sites/www.bps.org.uk/files/News/News%20-%20Files/Psychological%20needs%20of%20healthcare%20staff.pdf
13.  The Australian Red Cross (2013). Psychological First Aid: An Australian guide to supporting people affected by disaster. Available at https://www.redcross.org.au/getmedia/23276bd8-a627-48fe-87c2-5bc6b6b61eec/Psychological-First-Aid-An-Australian-Guide.pdf.aspx
14.  Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-96.