Abstract
It is no secret that many health care workers are struggling. And it is not just COVID-19 that is to blame. While the pandemic was indeed a catalyst for inevitable breakdowns in the global health care system, the compounding issues certainly did not appear anew in 2020. Realistically, pressures had been building in the field for years.
One of the areas of most strain was, and continues to be, the mental well-being of health workers. Health care providers are often called to their occupation because they are caregivers at heart, empathetic to the plight of others. When complications in the system, whether internal or external, cause difficulties for patients, their caregivers suffer too.
Caregiving is an inherently stressful profession, one in which workers encounter daily suffering and are called upon to make incredibly difficult decisions that can directly result in life or death. This can create an immense amount of stress. Even before COVID-19, doctors and nurses were already more likely than the general population to die by suicide. 1 While health care is not the only demanding field, research has shown that health care workers suffer disproportionate rates of stress and burnout, putting them at greater risk of developing mental health issues, including anxiety, depression, insomnia, and post-traumatic stress disorder (PTSD).
One explanation for the higher ratio of mental health conditions among health care workers is that they often take on the role of caretaking but are left little time and ability to care for themselves. Even in well-funded systems, medical facilities are often understaffed and under-resourced, forcing workers to manage high patient volumes without adequate support. These conditions only intensify during public health emergencies such as the COVID-19 pandemic, especially in low- and middle-income countries, where health care workers are scarce, and each serves a large number of patients. Medical workers are being pushed to their breaking points, creating a self-perpetuating cycle of burnout and stress.
Globally, the pandemic has resulted in dramatic changes to health care professionals' work environments and workload. Caregivers have witnessed increases in patient mortality all while facing significant risk to their own physical health to care for patients infected with a novel virus and having little access to appropriate protective equipment.
Recent studies are beginning to paint a picture of exactly how much the pandemic has impacted providers' mental health. One systematic review of health care workers' well-being found a high prevalence of anxiety (23.3%), depression (22.8%), and insomnia (38.8%). 2
In another survey, 20% of respondents stated they had considered leaving the field because of how COVID-19 has affected their working conditions.
These effects are reminiscent of those found in studies carried out after the 2003 SARS epidemic, which indicated that at 5 years post outbreak, at least 10% of workers still reported high levels of PTSD symptoms, 3 highlighting the need for interventions that protect health care workers from the psychological impacts of major health care crises, some of which can be long-lasting. 4
One surprising finding to note is that exposure to patients with COVID-19 was not significantly correlated with the emotional distress that health care workers experienced. 5 That is to say, medical providers felt the psychological impact of the pandemic regardless of whether they had had direct exposure to patients infected with the virus, indicating that the need for care be wide-ranging and ongoing. 6
Although most governments and hospitals worldwide do have plans in place to handle physical health needs during a disaster, the mental health needs of survivors, especially those of medical workers, are often overlooked. Added to this, physicians, nurses, and other health care providers are often especially likely to suffer in silence because they are concerned about confidentiality issues and the potential impact seeking help will have on their careers. It is clear that even once the COVID-19 outbreak wanes, many doctors, nurses, and other medical professionals—who are used to dealing with emergencies but may have never experienced this level of demand and uncertainty—will need accessible and easy treatment for mental health conditions.
Fortunately, there is good news in all of this. Research conducted during prior epidemics suggests that even brief psychosocial interventions delivered to health care workers during emergencies can improve mental health outcomes. 6 A new study has shown that psychological first aid (PFA), training first developed by the World Health Organization for those who support others during emergencies, can also be used to help health care workers improve their own mental well-being. 2
PFA was developed as a brief training course that equips workers or volunteers in disaster situations to comfort victims and help reduce negative mental outcomes. The program teaches helpers to reduce victims' initial distress, meet their psychological and physical needs, and encourage flexible coping, all while fostering feelings of safety, calmness, hopefulness, connectedness, and accomplishment. 2 The three main actions that make up PFA are to look (for safety or for who needs help), to listen (to those that are in distress), and to link (to further support). Unlike the now largely discredited psychological debriefing technique, PFA does not focus on discussions about the traumatic events but instead works to provide humane and practical help.
In June 2020, as a response to the COVID-19 pandemic, the UK issued free online PFA training to support frontline health care staff. 7 Results showed that while the uptake of PFA training was low among health care workers (<10% of those surveyed had undertaken the training), those who had completed the program were coping better with their increasingly stressful work environments. Findings from this early program indicate that PFA training has the potential to (a) strengthen resilience, (b) promote anti-stigma messages and normalize help-seeking behavior, and (c) minimize the risk of developing more serious psychological problems. Evidence also suggests that PFA has the potential to reduce both the initial effects of trauma and prolonged and chronic stress. 2
Despite PFA's early promising results for health care workers, the low participation rates are alarming. Some posit that issues around accessibility may be to blame. During a global mass casualty disaster such as the COVID-19 pandemic, it is impossible to deploy enough mental health professionals to assess and treat medical professionals quickly enough to prevent a surge in subsequent cases of PTSD. Not only do physical practicalities make in-person treatment difficult, but as is the case with protective equipment, there is a problem of scarcity. There are simply not enough professionals in the right locations trained to assess and treat all of the people who need it.
However, we can use technology to expand the reach of PFA programs. Advanced technologies such as virtual reality (VR) deployed on mobile devices, along with training in their use, are the key to preventing and treating mental health disorders that arise from high-stress situations. Since its inception, VR has proven itself as a useful technology for many aspects of behavioral health care. It has been used to treat anxiety disorders and other psychological disturbances. It has also played a role in PTSD rehabilitation, with studies revealing treatment success rates of 66–90%. 8
Technology can also be used to enhance a training program's effectiveness. In a recent randomized controlled clinical trial, 9 results indicated that nurses and teachers who received technology-enhanced stress management training (cognitive–behavioral therapy [CBT] in combination with wearable biosensors, smartphones, and virtual worlds) had better outcomes in terms of reduced anxiety and increased coping skills than those who received only CBT.
Because traditional communication systems may be unreliable or untenable in some types of disasters, self-contained, multimedia, interactive systems designed for mobile devices can play an important role in treatment solutions. And because studies show that a small screen is no hindrance to presence (the feeling of “being there”), treatment provided on these devices remains effective.
For the health care field, the situation is serious, but there is help available. PFA, distributed widely (and potentially electronically), can go far toward giving health care workers an opportunity to recover their mental health after disasters. However, it is important to note that programs such as this, as useful as they may be, are treatments for the consequences of a flawed system. Minimization of trauma, by ensuring that health care providers receive the support and care they need to do their jobs each day, will go a long way toward ensuring that caregivers are able to care for themselves effectively.