A colleague helps healthcare worker Shama Shaikh, 53, put on her PPE equipment before working with patients who have Covid-19 in an ICU ward at the government-run St. George hospital on May 27, 2021 in Mumbai, India. India's prolonged and devastating wave of Covid-19 infections has gripped cities and overwhelmed health resources
Image: Fariha Farooqui/Getty Images
Apandemic ominously brings forth news of death, morbidity, and inescapable despair. Carrying out routine duties on the frontline of the pandemic as a frontline healthcare worker (FLHCW), non-frontline healthcare worker (NFLHCW) or a social care professional during a global pandemic such as Covid-19 can be excruciatingly stressful.
It is reminiscent of war-time stress and necessitates appropriate coping and supportive mechanisms. FLHCWs have unwaveringly continued to provide healthcare to patients despite personal risk of infection, fear of transmission to their own families, exhaustion, sickness and death of friends and professional colleagues and being witness to the loss of lives on a routine basis.
Many healthcare workers have been working in unfamiliar clinical settings
and holding the fort with insufficient skills, inadequate clinical experience, or training in tune with the demand. Long hours of working wearing uncomfortable and unfamiliar personal protective equipment (PPE), working with insufficient resources and the absence of specific treatments for Covid-19 has made healthcare workers overwhelmed.
Providing comfort, handling grief, consoling patient’s family members, being caught up in ethical dilemmas of rationing resources amid shortages have added to the burden of the FLHCW. Many of these workers had to isolate themselves away from their families for weeks and months for fear of transmitting Covid-19 and this cased a severe interruption in family life and relationships.
It is recognised that over time frontline health workers who reel under the intense workload are faced with myriad psychological stressors and the negative effects of stress often lead to anxiety
, depression, insomnia, moral distress, can induce burnout or even lead to post-traumatic stress symptoms (PTSS).
Outcomes of the stress
often result in unhealthy behaviours such as the use of tobacco, alcohol or other substances leading to substance use disorders, can result in stress-related absence from work or a reduced ability to work productively and can also increase the risk of suicide among frontline health care workers (FLHCWs).
In the current Covid-19 context, these adverse fallouts can mean there can be compromised quality and safety of care, possible breach of guidelines and protocols, increased risk of re-infections, and decreased capacity of the health system to deal with emergencies. The long-persisting effects to the mental well-being and mental health of healthcare workers
can also affect their personal lives, family situations and other social relationships.
Admirably, the urgent need to prioritise, set strategies and advocate for the increased protection of frontline healthcare workers’ mental well-being is reflected in the World Health Organization (WHO) designating the year 2021 as the International Year of Health and Care Workers (YHCW) in appreciation and gratitude for their unwavering dedication in the fight against the Covid-19 pandemic. This recognition acknowledges the extremely challenging working conditions faced by healthcare workers since the pandemic began and research indicating that frontline healthcare workers (FLHCWs) are particularly vulnerable to a deterioration in their physical and mental health
It is understood that HCWs are at a higher risk of experiencing tremendous psychological pressure because of accumulated stress, physical exhaustion, stigma, and fear of infecting themselves or their loved ones compared to the general population. Several evidence-based reviews have found that stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear were the major mental health manifestations of the Covid-19 pandemic especially among FLHCWs. There is hence an established need to develop and implement strategies that can provide resilience support for FLHCWs and NFLHCWs’ mental wellbeing.
Recognition, acknowledgement and response is the key
As in the case of all emerging diseases, the initial relatively uncertain pathophysiology, transmission, and lack of specific treatments instils underlying fear of the pandemic can lead to the development of new psychiatric symptoms in people without mental illness, can precipitate the condition of those with pre-existing mental illness and cause increased distress to the caregivers of affected individuals.
Regardless of whether they were exposed to the condition or not, FLHCWs potentially experience fear and anxiety regarding falling ill, being helpless, dying and tend to divert their stress by blaming people who are ill—all of which indicate potential signs of a mental breakdown being triggered. Anxiety and fear related to the infection can also lead to acts of discrimination and apathy and can severely affect the care offered by these workers to the patients.
The spectre of anxiety and fear psychosis can be exacerbated by the lack of appropriate and validated information and knowledge at their disposal. Frontline HCWs receive a plethora of information from various medical associations, online support groups, social media, and professional colleagues, which can create undue uncertainty and can be overwhelming for many HCWs. It is recommended that up-to-date, valid, and accurate information on Covid-19
be delivered in simple, easy-to-comprehend language in a timely fashion to FLHCWs to mitigate the stress stemming from uncertainties regarding this disease.
As foretastes of underprioritized, underfinanced, and understaffed public health facilities struggling to stitch together and face up to COVID-19’s burgeoning caseload become commonplace, the mental health needs and need for resilience support to frontline healthcare workers are increasingly being recognised. As the pandemic continues unabated, it is not altogether the immediate requirement of ICU beds, ventilators, and oxygen that is more concerning, though rather portentous in present tangible terms, but what looms larger at the end of the tunnel is the imminent paucity and deficiency of mentally resilient and supported human resources in health (HRH) that will be the bigger challenge to address in the very near future.
Renowned cardiac surgeon, Dr Devi Prasad Shetty
, was quick to point out recently that India will need an extra five lakh ICU beds, two lakh nurses and 1.5 lakh doctors in the next few weeks (circa mid May 2021) if we are to manage this pandemic, and these numbers call for radical solutions to meet the mountainous challenge. As the government spend on healthcare as a percentage of Gross Domestic Product (GDP) is still very low at around 1.6 percent, the burden on the system is only bound to increase.
The system needs to recognise that healthcare workers are under unprecedented stress at this moment, acknowledge the deleterious effects of this stress sequelae that can devastate the health system itself and respond by providing the FLHCWs with mental health support, resilience support and work-life benefits. How to provide resilience support to FLHCWs?
There is a need to prioritise and tailor primordial preventive interventions that are aimed at protecting and mitigating the psychological impact of traumatic events related to the pandemic that can potentially cause PTSS. Hence, immediate attention of the policy makers to develop and implement healthcare policies that offer preventive and management strategies toward avoiding PTSS and the related psychic sequelae in FLHCWs is the need of the hour.
A recent Cochrane review has assessed the effects of strategies that aimed at supporting the resilience and mental health of frontline health and social care professionals during or after a disease outbreak, epidemic or pandemic. Several factors were identified here that probably influenced implementation such as knowledge and beliefs that people had about these strategies, the extent to which they were aware of what they needed to support their mental wellbeing, access to and knowledge of using personal protective equipment (PPE), staff time and skills, adaptation to local needs, effective health communication, and providing access to a positive, safe, and supporting learning environment.
It is important to manage the fallout of the Covid-19 pandemic on healthcare workers and monitor the mental health care needs of FLHCWs between the waxing and waning of each wave of the pandemic. Undoubtedly, the mental health of the FLHCWs needs to be addressed as a priority and given equal weightage along with other strategies to manage and control the disease and the pandemic at large.
There currently is an absolute need for specialised psychological intervention and proper and consistent health risk communication and crisis communication. The concept of health risk communication can be underscored by how we all have witnessed efforts during the initial stages of the pandemic, when there existed no form of protection or immunity against the pathogen and when there was uncertain use of effective drugs or vaccines, the focus was on social and behavioural strategies such as physical distancing and frequent handwashing. As scientific discovery evolves and treatment and management plans are getting clearer, health risk communication strategies should include need-based interventions keeping in par with the evolving knowledge about Covid-19.
Since hospitals were now focusing on Covid-19 related care to meet the surge of patients, there had been a serious disruption in routine health care services in many countries across the world, the brunt of which is faced by FLHCWs who are answerable to the community in the forefront.
However, it is not that this kind of burden on the health system or the stress induced by the pandemic on the mental wellbeing of FLHWs is relatively new. The world has witnessed similar distressing sequelae during all notable outbreaks, namely—severe acute respiratory syndrome (SARS), Ebola, Middle East Respiratory Syndrome (MERS); and now of course with the Covid-19; however, the learnings from each new outbreak have been rarely used to guide future healthcare spending and equipping the exposed public health system. This is one mistake we can avoid this time.
To appropriately support our frontline healthcare workers, we must firstly recognise that they are the irreplaceable assets of our health care system. Governments of the day need to understand their life challenges and needs, develop and institute a multi-level strategy that recognises the stress faced by healthcare workers, value the efforts of the workforce and support the mental wellbeing of these FLHCWs.
The selection of an appropriate strategy will have to be based on the knowledge about the mental health needs of the frontline workers and the resources currently available to them, be culturally appropriate, and consider the equipment available, staff-time and skills available to carry out the strategy. Easy to implement practice-level strategies can include work-based strategies such as changing routines, improving the access to safety equipment and psychological support strategies such as the provision of counselling services. The provision of a national helpline number is a right step in providing access to mental health support for FLHCWs.
Appropriate continuing education, protection measures and provision of adequate compensation will redefine the recognition of the valued contribution of all healthcare workers. Ensuring financial and employment security to vulnerable healthcare workers, ensuring adequate social protection provisions for these workers who might contract the infection at work and will be isolated from their families, be responsive to the needs of women who form the bulk of the health care workforce, build in risk protection measures including health insurance, provide a supportive regulatory and legal framework that protects and supports healthcare workers, destigmatise mental health, and reduce mistrust and hostility towards healthcare workers will be essential steps in this direction. Frontline healthcare workers need respite, access to proper breaks and mental health support to ensure that none of them feel forced to think of shifting from a career that they have worked so hard to build. Prof. Allen P Ugargol is faculty in the Centre for Public Policy at IIMB
[This article has been published with permission from IIM Bangalore. www.iimb.ac.in Views expressed are personal.]