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

 

Prepared by ASHM & Members of the Taskforce’s Psychological Health Cluster Group, supported by Hepatitis Australia, AFAO and NAPWHA.  Adapted to the Asia and Pacific Region by the BBV, SH and COVID-19 Regional Advisory Group including Chair Dr Nicholas Medland and Associate Professor Maria Isabel Melgar.

UPDATED ON: 3 November 2020

 

 

Disclaimer: 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.(1) The recommendations are not intended to replace national guidance. 

 

 

  • Health practitioners and community or peer support workers are at increased risk of psychological distress, including vicarious trauma and burnout, during pandemics. 
  • 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. 
  • Health practitioners and community or peer support workers  should be supported to prioritise their self-care both to prevent and reduce the risk of psychological trauma associated with COVID 19 
  • Health practitioners and community or peer support workers  play an important role in both detecting and responding to COVID 19 related distress in other work colleagues.
  • 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 and community or peer support workers are more important than ever.  COVID-19 has meant health practitioners and community, or peer support workers   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 and some health care system in Asia and the Pacific 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. 
  • Front-line health workers may experience higher anxiety than the general community about contracting viruses during pandemics. Equally affected by anxiety are nurses, administrative staff (reception staff, practice managers), medical doctors, and allied health practitioners and community or peer support workers . Other key staff members such as cleaners or ancillary clinic staff will also be affected by anxiety about contracting COVID-19.  
  • Furthermore, health practitioners and community or peer support workers 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 or stigma from community members due to their perceived occupational risks.   

 

Key points

  • It is important to normalise a spectrum of responses for health practitioners and community or peer support workers 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 and it is natural to experience stress, worry, anxiety, and uncertainty.  For health practitioners and community or peer support workers , 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 past loss, such as, for example, those healthcare workers who witnessed or were involved in the response to the AIDS epidemic.
  • In addition, health practitioners and community or peer support workers  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. 
  • 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 and community or peer support workers  may struggle with these changes, 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 Regional Advisory Group’s guidance on Psychological First Aid Approaches and COVID-19.

 

  • 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 health practitioner this can be caused by hearing about or witnessing a patient’s trauma.  Health practitioners, along with others in the helping professions such as community and peer workers, 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 results from ongoing exposure to a traumatised individual and is often the result of the cumulative impact of vicarious trauma.  Health practitioners and community or peer support workers experiencing compassion fatigue can experience 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 psychological outcomes for health practitioners and community or peer support workers, 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. (7-9)        

 

Protecting against vicarious trauma and compassion fatigue 

  • Interventions to address psychological 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).  See Support for Managers and Leaders below.  
  • To guard against the development of compassion fatigue, health practitioners and community or peer support workers 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 and community or peer support workers  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 support.
     

 

Self-care is important at all times, but more so when managing a stressful period that does not have a clear end date.  

Access support services in your country 

If you would like to share details of mental health support services in your country to be included here please send these to taskforce.rag@ashm.org.au

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 psychological and physical energy on what you do have control over
  • Balance your perspective – give attention to positive things 

Look after your physical health

  • Ensure sufficient sleep 
  • Try and maintain a healthy diet 
  • Be aware of an increase in alcohol consumption.  Practitioners with current or previous substance use issues may experience a desire to return to or increase substance use and should seek help if necessary.
  • Get regular exercise 
  • Ensure some fresh air and sunshine everyday 

 

Maintaining social connection with family, friends, work colleagues is important to your psychological well-being, including on phone/video calls, online group chats and social media and in person if possible using social distancing and hygiene practices.  

Keep informed - use reputable sources of information. Visit WHO, UNAIDS, your local government and NGO COVID-19 websites. 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 psychological 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 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 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 required
  • Consider activities to improve team bonding and cohesion during this stress 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 reflect this. 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 and community or peer support workers  at this end of the spectrum are not shamed in any way for their reactions; in both these disorders, the 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
 

 

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.

 

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 and community or peer support workers  take note of this so as not to push people too far, too fast.

Maslow’s hierarchy of needs

 

 

COVID-19: Managing Your Mental Health Online During COVID-19 (eMHprac)

 

Mental Health Hotlines in Asia and the Pacific
Timor-Leste 
Mental Health Helpline 12123 7am to 7pm

Fiji
 COVID-19 Helpline - 158
Empower Pacific Helplines 2937141 and 7765626 

Papua New Guinea
Lifeline Port Moresby – 675 326 0011

Thailand
Thai Department of Mental Health Hotline Tel. 1323 
 The Samaritans of Thailand
Bangkok Tel. (02) 713 6793 (Thai) 12:00 noon to 22:00 hours/day, 7 days a week
Tel. (02) 713-6791 (English call back service within 24 hours) 24 hours/day, 7 days/week
Chiang Mai Tel. (053) 225-977/8 (Thai) 19:00 - 22:00 hrs (Mon, Tues, Thurs, Sat)

Philippines 
Free Suicide and Crisis Helpline - Landline:(02) 8893-7603Globe:0917-8001123 Sun:0917-8001123
Tawag Paglaum crisis hotline (0939)937-5433 ext (0939)936-3433
Philippines NCMH Crisis Helpline 09178998727 – 9897272

Philippines Mental Health Association - FB: https://www.facebook.com/PMHAofficial/; Mobile: 09175652036; Email: pmhacds@gmail.com
Mental Health First Responders – Free self referrals - Google Form: https://forms.gle/DN49AwPw4X4VwvFR7

Indonesia
 National COVID-19 Hotline number inc Mental health — 119

Singapore 
National Care Hotline: 1800 202 6868 (8am – 12am daily)

Malaysia
Befrienders Hotline
KL: 03-7956 8145 (24 hours)
Ipoh: 05-547 7933 (4pm to 11pm)
Penang: 04-281 5161 (3pm to midnight)

If you would like to share details of mental health support services in your country to be included here please send these to taskforce.rag@ashm.org.au
 

 

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