Supporting the well-being of healthcare workers during and after COVID-19

At the time of writing, Coronavirus Disease 2019 (COVID-19) is disrupting nearly every aspect of everyday life and placing unprecedented demands on our society. A rapid increase in stress and mental health problems is being documented as the pandemic progresses. A large-scale study conducted in China found more than half of the sample (54%) rated the psychological impact of the outbreak as moderate or severe, with 29% and 16% reporting moderate to severe symptoms of depression and anxiety, respectively [1]. Preliminary findings of research on the effects of COVID-19 on the UK population found that levels of depression and anxiety in the UK population increased markedly after the lockdown was announced [2]. These effects are likely to be particularly pronounced in those with existing mental health problems. Moreover, as the pandemic progresses, financial worries and employment uncertainty are likely to compound feelings of anxiety, hopelessness and frustration.

Although a rise in distress has been documented among the general population, unsurprisingly given their key role in managing the outbreak, healthcare professionals seem to be more vulnerable. Recent research findings confirm that many are experiencing symptoms of depression, anxiety, insomnia and distress, with those working directly with COVID-19 patients at particular risk [3,4]. While the predictors of distress for healthcare workers are as yet unknown, research that has explored their psychological responses to previous epidemics of infectious disease found that the key predictors included working long hours, lack of support and vital equipment, feelings of vulnerability or loss of control, concerns about health of oneself and one’s family and feeling isolated factors.

The current and projected scale of distress among healthcare professionals, while understandable, is of grave concern. Recent reviews of the mental health and well-being of the healthcare workforce in the UK conducted prior to the outbreak showed that staff were already demoralized and mentally and physically depleted [5–7]; they were found to be at particularly high risk of work-related stress and burnout in response to increasing demands and diminishing staffing levels and other resources. The risk of trauma and suicide were particularly high among some groups of healthcare staff. Clearly, the existing risks to the well-being of healthcare professionals will be compounded under the current highly pressurized conditions.

Front-line healthcare staff are not only experiencing a rapid increase in the volume and intensity of their work but are also having to cope with additional challenges such as encountering unfamiliar working environments, changing protocols and an unprecedented exposure to trauma with little opportunity for orientation and training. They may also feel conflicted between their duty to care for patients and their need to protect themselves and their loved ones from a potentially lethal disease. Healthcare professionals are also likely to experience moral and ethical conflicts that challenge their beliefs and personal standards of care. The resulting psychological distress (also known as moral injury) can have profound and long-lasting effects on their mental health, identity and personal relationships.

It is widely recognized that healthcare professionals are in particular need of evidence-informed support initiatives to help mitigate the effects of the COVID-19 pandemic on their current and future well-being. Staff have access to an array of resources such as helplines, online therapy and group counselling sessions, and access to online tools to help manage symptoms such as anxiety and sleeping difficulties is often provided. Healthcare professionals should also be aware of the early signs of stress and burnout and ensure they practice self-compassion and prioritize self-care. Individual coping strategies, such as acceptance, behavioural activation and mindfulness, are thought to be particularly effective during crises or disasters as they foster resilience and recovery by increasing tolerance to distress, enhancing feelings of connectedness and support and encouraging actions that are goal-directed and value-driven [8]. It should be recognized, however, that the uptake of support among healthcare professionals is frequently stigmatized and this can be a barrier to seeking support [5].

Although undoubtedly helpful, many support initiatives that are available aim to increase the stress tolerance and coping skills of individual employees. Organizations also have a critical role to play in supporting the well-being of healthcare professionals and other essential workers. Leaders and managers need to be emotionally resilient and have the appropriate knowledge, skills and tools to support their staff during these challenging times. Wu and colleagues [9] have set out three strategic principles for good leadership during the COVID-19 pandemic: effective crisis management, planning and action; communication that provides up-to-date information and encourages individual empowerment; and the provision of a ‘continuum of staff support’ that offers a range of initiatives, normalizes feelings of distress and encourages their expression. Leaders and managers also need to be empathic, compassionate and understanding; they also need to be aware of their employees’ personal circumstances and that they may change rapidly.

Support from colleagues is particularly important when work is highly stressful and emotionally demanding. Peer-support programmes can help normalize psychological reactions to the unprecedented challenges healthcare professionals are facing. Nonetheless, the limitations of ‘formalized’ peer-support structures should be recognized; although initiatives such as Mental Health First Aid can help raise awareness of mental health conditions, there is little evidence that it can help improve their managements [10]. They may be less effective under current conditions than initiatives that foster cohesion and social connectedness between staff and ‘buddy’ systems.

It is generally acknowledged that all types of organization should assess and manage the risk of work-related stress using a framework such as the Health and Safety Executive Management Standards approach. This is particularly important under current conditions when demands will increase for many, opportunities for control and support may be constrained, and job roles are likely to become more fluid. Key workers such as healthcare professionals typically feel a strong sense of duty to continue working even when they are exhausted. It is therefore crucial to encourage staff to take time out to recover mentally and physically from the demands of their job in order to sustain their well-being and capacity over the longer term. Although managers have a key role to play in monitoring and supporting the mental health of their staff, they need the opportunity, time and resources to do this effectively and to prioritize their own well-being and seek help if required.

Occupational health (OH) professionals are well placed to provide staff and organizations with support during and after the COVID-19 pandemic. They can provide guidance on key issues such as staying safe while working on the front line and how to support people who are working at home, as well as work alongside line managers to identify adjustments to help people back to work. The findings of a recent report commissioned by the Society of Occupational Medicine (SOM) [11] that examined how OH practitioners and providers can add value to workplace well-being initiatives are particularly relevant under current conditions. They can make a strong contribution to coordinated workplace health and well-being programmes that seek to build management capabilities, enhance job quality and improve social relationships. OH professionals can also support healthcare staff by highlighting the risk factors for burnout and effective self-care strategies. Nonetheless, urgent upskilling is needed as many feel they lack the knowledge and skills required to address mental health issues among staff [5]. It is also crucial to ensure that OH professionals have the capacity to meet what will likely be an unprecedented demand for their services, as a pre-COVID-19 survey of OH staff found that many were stressed and exhausted by the intense time and workload pressures placed upon them [12].

At the time of writing, a wealth of guidance to help address the population’s well-being needs during the COVID-19 outbreak is available or under development. The SOM is in the forefront by providing OH personnel with accurate and up-to-date advice to pass on to patients and clients who are working in healthcare and other sectors. With input from a multidisciplinary expert group, the Society is also developing a toolkit for OH and HR professionals to identify what constitutes a ‘good return to work’ in terms of ensuring a healthy physical and psychological environment. The British Psychological Society (BPS) has recently developed a guide [13] that offers healthcare services practical recommendations on how to respond to the pandemic at individual, management and organizational levels. Other resources that are available include guidance to manage moral distress among healthcare workers [14].

It is important not to pathologize people’s fears and anxieties, as these are stressful and frightening times. Many people will cope well and most of those who experience distress will not require formal intervention or experience long-term effects. It is nonetheless crucial to ensure that adequate and appropriate services are in place to support healthcare staff during the acute phase of the pandemic and are sustained during the aftermath when demand will undoubtedly grow.