STRATEGIES TO REDUCE THE MENTAL HEALTH IMPACTS OF A PANDEMIC

Public mental health measures must address a number of areas of potential distress, health risk behaviors, and psychiatric disease. When anticipating a significant disruption of day-to-day life and loss of life, it is essential that protective public health behaviors be promoted among the entire population. These include:

Issuing accurate, consistent, clear, and easy-to-understand communication regarding risk of contagion, danger to family and pets, and the topic of authority and government
Providing mental health surveillance to estimate levels of mental health problems in order to effectively direct services and funding
Addressing psychological responses people may have to community containment states such as quarantine, movement restrictions, school/work/other community closures
Preparing for a surge in demand for all healthcare services
(CSTS, 2020)

Mental health professionals should coordinate planning and response activities with government and nongovernmental organizations. Such activities may include:

Developing public education tools and materials
Identifying and developing pandemic disease-specific educational tools and materials that describe signs of distress, traumatic grief, coping strategies, and skills for building and sustaining personal and community resilience
Identifying and listing behavioral and psychological support resources
Increasing the awareness of potential mental health implications that occur during a pandemic
Providing information about psychological reactions to public health emergencies and recommendations for positive coping
Maintaining an updated website containing information about the pandemic-related mental health issues
Sharing resources through social media and other appropriate outlets
(Gierer, 2020)

Individual healthcare providers are in a position to offer mental health interventions to patients under their care, which may include:

Answering questions and providing answers based on factual information
Encouraging patients to take breaks from watching, reading, or listening to news stories, including social media (since repeatedly hearing about a pandemic can be upsetting)
Being observant for patients who are experiencing serious distress reactions, assessing their needs, and referring them to appropriate resources
Making efforts to increase effective response behaviors and protective health behaviors such as taking care of one’s own health, limiting potentially harmful behaviors, exercising regularly, getting sufficient sleep, eating a healthy diet, and avoiding alcohol and drugs
Stressing the need to continuing taking one’s own medications and ensure that older adults and children take theirs
Teaching calming skills and maintenance of natural body rhythms, including following a set routine for eating, resting, and exercising
Encouraging connectedness to family and other supports where possible, which may require digital rather than physical presence
Recognizing that certain events (“tipping points”) will occur which can abruptly increase fear and decrease helpful health behaviors or increase risky ones (e.g., death of a family member or a decrease in available healthcare)
(CSTS, 2020)

HEALTHCARE WORKERS AS ROLE MODELS

Healthcare providers are looked upon as “experts.” In addition to how they speak, they can model behaviors that reflect adherence to evidence-based recommendations, to the best of their ability.

Early Mental Health Interventions among Patients

For the general population, early interventions should support normalizing everyday life as much as possible as well as identifying and triaging the seriously mentally ill for psychiatric treatment. The most intensive intervention in this phase is psychological first aid, which consists of listening, conveying empathy and compassion, and ensuring that basic needs are met.

PSYCHOLOGICAL FIRST AID

Psychological first aid (PFA) is an evidence-informed approach to assist children, adolescents, adults, and families involved in a crisis situation. The goal of PFA is to promote an environment of safety, calm, comfort, connectedness, self-efficacy, empowerment, and hope during a crisis such as a pandemic. This can be done by actively listening to patients who want to share their stories and emotions and remembering that there are no right or wrong ways to feel.

Healthcare workers provide psychological first aid by recognizing the importance of communicating calmly and establishing rapport with a person who is experiencing and expressing intense emotions resulting from anxiety, fear, and uncertainty about the eventual outcome. This includes:

Remaining compassionate even when a patient is being difficult
Offering accurate information about the situation and the efforts that are underway to help
Whenever possible, helping patients contact family or friends
Engaging people in meeting their own needs and being prepared to inform them of available government and nongovernment services
Avoiding giving false reassurances such as “everything will be okay”
(FEMA, 2019)

Strategies for Reducing Mental Health Impacts on Healthcare Workers

Healthcare workers include any and all who work in healthcare services. Besides physicians and nurses, this includes first responders, housekeeping personnel, clerical personnel, lab technicians, respiratory therapists, occupational therapists, physical therapists, pharmacists, among many others, as well as community-based workers and those who work in mortuaries.

The mental and psychological well-being of healthcare workers is imperative to their ability to function effectively, particularly when exposed to extreme conditions. Such exposure could result in negative mental health consequences, which may in turn affect the functioning and productivity of entire healthcare organizations. Keeping all healthcare workers from chronic stress and poor mental health means that they will have a better capacity to fulfill their roles (Surya et al., 2017). This can be quite difficult to accomplish during a pandemic. Following are some strategies that can be applied to help reach this goal.

EDUCATION

It is essential for healthcare workers to be educated and to remain up-to-date about the risks, symptoms, and precautions to be taken in order to provide factual information about a pandemic to their patients. Such education can be effective in calming patients who are experiencing fear and panic, discouraging the dismissiveness by others of the risks, and reducing annoyance caused by necessary precautions.

Healthcare workers should be prepared to dispel misconceptions people have gleaned from inaccurate sources and to provide them with facts and accurate information in an honest, direct, concise, and understandable manner. Healthcare providers can also direct patients to informational resources such as the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) (Terrie, 2020).

SUPPORTING COWORKERS

During a crisis situation such as a pandemic, it is necessary for coworkers to care for each other to ensure everyone’s physical and mental safety and to provide safe patient care. It can be helpful to partner with another for support and to monitor one another’s stress levels and safety. During the work shift, partners can set up times to check in and to listen carefully while sharing experiences and feelings. Partners can offer each other help, monitor their workloads, and encourage breaks. It is helpful to share opportunities for stress relief using deep breathing and other relaxation techniques.

When a coworker exhibits exhaustion, irritability, inability to concentrate or remember important things, or begins making errors, displays lack of confidence, and withdraws from contact, it is necessary to communicate these concerns to management (CDC, 2018).

WORKING IN “PODS”

In order to best utilize available personnel, healthcare workers can be organized into “pods” consisting of a group of individuals skilled at different levels who work together throughout a shift. For example, when caring for a COVID-19 patient in the ICU or on a ventilator, such a pod may include a skilled ICU nurse to care for those specialized needs, a nurse without ICU experience to provide skilled nursing care, a respiratory therapist to manage respiratory care, and nursing assistants to provide other basic skills.

SELF-CARE STRATEGIES

During the increased stress of a pandemic, it is vitally important for healthcare workers to be active in taking good care of themselves. The following are recommendations to help reduce stress levels among frontline workers:

Schedule time to destress and engage in enjoyable activities, even for brief periods of time.
Schedule and take brief breaks to care for basic needs.
Take a short, 5-minute walk to improve energy and focus.
Maintain a healthy diet.
Exercise (e.g., bike or walk to work if possible).
Get outdoors in the sunlight.
Get news and information from reputable sources (such as the CDC) but limit the amount of news consumed so as not be become overwhelmed.
Pace oneself and monitor for excessive fatigue, irritability, poor focus, or anxiety.
Take time to breathe slowly before entering a patient room or a work area, since slow breathing is calming and helps the body cope with symptoms of stress.
Reframe anxiety-provoking statements (e.g., say, “A great many people get sick and recover” instead of “I might get sick and die.”).
Seek out services from a mental health professional when needed.
For those who regularly see a mental health professional, inquire about video or phone services if needed.
Look for support from friends, families, and colleagues, and problem-solve together.
Find ways to connect virtually with friends and family (e.g., social media, phone, FaceTime, Skype), since meaningful interactions with those we are close to are important for well-being.
(Benyon, 2020; NCCN, 2020)

PANDEMIC-RELATED TRAINING

Formal and informal training during a pandemic can prepare healthcare workers to face the stressors involved in working under such conditions. Such training can include:

Specific and accurate information about transmission of the infectious agent and methods of containment
When and how to screen patients and, potentially, family members
When to appeal for quarantine and isolation
Ethical decision-making about triage and surge capacity issues

In order to increase the sense of confidence in one’s work-related performance, workers can also take part in training and/or planning exercises such as:

Management of limited resources
Implementation of various levels of quarantine
Enforcement of movement restrictions
How to handle mass fatalities
How to conduct mental health screening
How to cope with high stress demands
Ways to prepare for family needs when required to be more involved at work or when in quarantine
Ways to provide psychosocial support to colleagues
(VA, 2020)

MANAGEMENT STRATEGIES TO SUPPORT STAFF

Team leaders or managers in a health facility also face similar stressors and additional pressures due to the level of responsibility inherent in their roles. It is important that stress-relief provisions are in place for both workers and managers, and that managers serve as role models for strategies to mitigate stress. The following measures can be taken by management to help reduce the impact of stress on healthcare frontline staff.

Ensure a clear system for coordination and communication with frontline workers to keep them apprised of the current recommendations for patient care and personal protection.
Establish policies regarding work hours, duration of deployment, shift rotation, and rest periods, rotating workers from higher-stress to lower-stress functions.
Train all frontline workers, including non-healthcare workers in quarantine sites, in essential psychosocial care principles, psychological first aid, and how to make referrals when needed. Online training might be used if it is not possible to bring staff together due to infection risks.
Partner inexperienced workers with more experienced colleagues and ensure that outreach personnel enter the community in pairs. A buddy system can help provide support, monitor stress, and reinforce safety procedures.
Develop stress-management protocols for frontline medical personnel and ensure that time is built in for colleagues to provide social support to one another.
Create psychological supports for healthcare workers, including hotlines and access to trained mental health professionals.
Once the pandemic begins to recede, actively monitor, support, and (where necessary) provide all staff with evidence-based treatments.
Once the pandemic is over, allot debriefing time to reflect on and learn from the difficult experiences to create a meaningful rather than traumatic narrative.
(Sadeghi & Wen, 2020; IASC, 2020; Greenberg et al., 2020)

CASE

Ginger is a 40-year-old RN who is divorced and lives with her two young children and her elderly mother. Ginger has a history of treatment for anxiety and depression in the past and has been doing well for quite some time. She is a fairly recent nursing graduate and works in a large hospital in a major metropolitan area. There is a global pandemic occurring, and Ginger has been working 12-hour shifts for the past 12 days in a row. The hospital has no more beds available for the large influx of patients needing care, and protective equipment supplies are being severely rationed.

As Ginger tends to her duties, she finds herself feeling more and more isolated from her coworkers, since they are all very busy. She becomes extremely fearful of making an error, becoming infected herself, and “killing my mom.” As the days pass, Ginger is no longer sleeping well, has lost her appetite, and has difficulty staying focused. She now feels irritable, hopeless, and fatigued, and she begins to severely doubt her abilities as a nurse.

Elizabeth is a coworker who has been covering the same unit and shift along with Ginger. While she, too, is under a great deal of stress, she has begun to notice that Ginger is not doing well. She approaches Ginger in the hallway and asks her how she is coping. When Ginger begins to cry, they go to the breakroom, where Elizabeth encourages her to talk about how she is feeling and asks her what she can do to help her.

Ginger tells her she does not think she can continue to come to work anymore. Ginger explains that there are so many ill patients and that they are scared. They cannot see their families, and she wants to help them cope with the isolation and fear. Elizabeth reassures Ginger that she is doing a good job and that she will be there to help her when needed. After their discussion, Elizabeth talks to her supervisor, who approaches Ginger, talks with her, and promptly refers her to employee assistance for mental health management.

Discussion

Ginger provides an example of how someone with preexisting mental health issues can quickly succumb to stress and become symptomatic once again. Her situation might have been improved if she had been assigned to work in a team along with a more experienced nurse. Together they could have supported each other, monitored each other’s stress level and safety, and perhaps avoided the present situation. When a coworker, Elizabeth, does recognize Ginger’s signs of inability to continue to cope with stress, she immediately intervenes to assess her status and to refer her so that she can receive mental health support.