COVID-19: New Guidance to Stem Mental Health Crisis in HCPs

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A new review offers fresh guidance to help stem the mental health toll of the COVID-19 pandemic on frontline clinicians.

Investigators gathered practice guidelines and resources from a wide range of healthcare organizations and professional societies to develop a conceptual framework of mental health support for healthcare professionals (HCPs) caring for COVID-19 patients.

"Support needs to be deployed in multiple dimensions — including individual, organizational, and societal levels — and include training in resilience, stress reduction, emotional awareness, and self-care strategies," lead author Rachel Schwartz, PhD, health services researcher, Stanford University School of Medicine, California, told Medscape Medical News.

The review was published August 21 in the Annals of Internal Medicine.

An Opportune Moment

Coauthor Rebecca Margolis, DO, director of well-being, Children's Hospital of Los Angeles, Division of Medical Education and Faculty Development, said that this is "an opportune moment to look at how we treat frontline providers in this country."

Studies of previous pandemics have shown heightened distress in HCPs, even years after the pandemic, and the unique challenges posed by the COVID-19 pandemic surpass those of previous pandemics, Margolis told Medscape Medical News.

Schwartz, Margolis, and co-authors Uma Anand, PhD, LP, and Jina Sinskey, MD, met through the Collaborative for Healing and Renewal in Medicine (CHARM) network, "a group of medical educators, leaders in academic medicine, experts in burnout research and interventions, and trainees working together to promote well-being among trainees and practicing physicians."

"We were brought together on a conference call in March, when things were particularly bad in New York, and started looking to see what resources we could get to frontline providers who were suffering. It was great to lean on each other and stand on the shoulders of colleagues in New York, who were the ones we learned from on these calls," said Margolis.

The authors recommend addressing clinicians' basic practical needs, including ensuring essentials like meals and transportation, establishing a "well-being area" within hospitals for staff to rest, and providing well-stocked living quarters so clinicians can safely quarantine from family, as well as personal protective equipment and childcare.

Clinicians are often asked to "assume new professional roles to meet evolving needs" during a pandemic, which can increase stress. The authors recommend targeted training, assessment of clinician skills before redeployment to a new clinical role, and clear communication practices around redeployment.

Recognition from hospital and government leaders improves morale and supports clinicians' ability to continue delivering care. Leadership should "leverage communication strategies to provide clinicians with up-to-date information and reassurance," they write.

"Uniquely Isolated"

Margolis noted that clinicians "are uniquely isolated, especially those with children" because many parents do not want their children mingling with children of HCPs.

"My colleagues feel a sense of moral injury, putting their lives on the line at work, performing the most perilous job, and their kids can't hang out with other kids, which just puts salt on the wound," she said.

Additional sources of moral injury are deciding which patients should receive life support in the event of inadequate resources and bearing witness to, or enforcing, policies that lead to patients dying alone.

Leaders should encourage clinicians to "seek informal support from colleagues, managers, or chaplains" and to "provide rapid access to professional help," the authors note.

Furthermore, they contend that leaders should "proactively and routinely monitor the psychological well-being of their teams," since guilt and shame often prevent clinicians from disclosing feelings of moral injury.

"Being provided with routine mental health support should be normalized and it should be part of the job — not only during COVID-19 but in general," Schwartz said.

"Battle Buddies"

Margolis recommended the "battle buddy" model for mutual peer support.

Co-author Anand, a mental health clinician at Mayo Clinic College of Medicine and Science, Rochester, Minnesota, elaborated.

"We connect residents with each other, and they form pairs to support each other and watch for warning signs such as withdrawal from colleagues, being frequently tearful, not showing up at work or showing up late, missing assignments, making mistakes at work, increased use of alcohol, or verbalizing serious concerns," Anand said.

If the "buddy" shows any of these warning signs, he or she can be directed to appropriate resources to get help.

Since the pandemic has interfered with the ability to connect with colleagues and family members, attention should be paid to addressing the social support needs of clinicians.

Anand suggested that clinicians maintain contact with counselors, friends, and family, even if they cannot be together in person and must connect "virtually."

Resilience and strength training are "key" components of reducing clinician distress, but trainings as well as processing groups and support workshops should be offered during protected time, Margolis advised, since it can be burdensome for clinicians to wake up early or stay late to attend these sessions.

Leaders and administrators should "model self-care and well-being," she noted. For example, sending emails to clinicians late at night or on weekends creates an expectation of a rapid reply, which leads to additional pressure for the clinician.

"This is of the most powerful unspoken curricula we can develop," Margolis emphasized.

Self-Care Critical

Commenting on the paper for Medscape Medical News, Marcus S. Shaker, MD, MSc, associate professor of pediatrics, medicine, and community and family medicine, Children's Hospital at Dartmouth-Hitchcock in Lebanon, New Hampshire, and Geisel School of Medicine at Dartmouth in Hanover, New Hampshire, said it was "a much appreciated, timely reminder of the importance of clinician wellness."

Moreover, "without self-care, our ability to help our patients withers. This article provides a useful conceptual framework for individuals and organizations to provide the right care at the right time in these unprecedented times," said Shaker, who was not involved with the study.

The authors agree, stating that clinicians "require proactive psychological protection specifically because they are a population known for putting others' needs before their own."

They recommended several resources for HCPs, including the Physician Support Line; Headspace, a mindfulness Web-based app for reducing stress and anxiety; the National Suicide Prevention Lifeline; and the Crisis Text Line.

The authors and Shaker have disclosed no relevant financial relationships.

Ann Intern Med. Published online August 21, 2020. Full text

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