Abstract
We describe an evidence-based approach to enhancing the resilience of healthcare workers in preparation for an influenza pandemic, based on evidence about the stress associated with working in healthcare during the SARS outbreak. SARS was associated with significant long-term stress in healthcare workers, but not with increased mental illness. Reducing pandemic-related stress may best be accomplished through interventions designed to enhance resilience in psychologically healthy people. Applicable models to improve adaptation in individuals include Folkman and Greer’s framework for stress appraisal and coping along with psychological first aid. Resilience is supported at an organizational level by effective training and support, development of material and relational reserves, effective leadership, the effects of the characteristics of “magnet hospitals,” and a culture of organizational justice. Evidence supports the goal of developing and maintaining an organizational culture of resilience in order to reduce the expected stress of an influenza pandemic on healthcare workers. This recommendation goes well beyond the provision of adequate training and counseling. Although the severity of a pandemic is unpredictable, this effort is not likely to be wasted because it will also support the health of both patients and staff in normal times.
Keywords: Health personnel; communicable diseases; stress, psychological; organizational culture; disaster planning
Résumé
À la lumière des données sur le stress associé au travail dans le domaine des soins de santé pendant la crise du SRAS, nous décrivons une approche fondée sur les preuves qui vise à améliorer la résilience des travailleurs de la santé en prévision d’une pandémie de grippe. Le SRAS a été associé à un niveau significatif de stress de longue durée chez les travailleurs de la santé, mais pas à une hausse des maladies mentales. Le meilleur moyen de réduire le stress en cas de pandémie serait de prendre des mesures pour améliorer la résilience des personnes saines sur le plan psychologique. Entre autres modèles intéressants pour améliorer la résilience, citons le cadre d’évaluation et d’adaptation au stress de Folkman et Greer, assorti de premiers soins psychologiques. À l’échelle organisationnelle, la résilience est assurée par une formation et un soutien efficaces, la constitution de réserves matérielles et relationnelles, un leadership efficace, les avantages attribuables aux « hôpitaux-aimants » et une culture de justice organisationnelle. Il est prouvé que la création et l’entretien d’une culture organisationnelle de résilience sont des objectifs valables si l’on veut réduire le stress attendu d’une pandémie de grippe sur les travailleurs de la santé. Cette recommandation va plus loin que la simple prestation d’une formation et d’un counseling adéquats. Il est impossible de prédire la gravité d’une pandémie, mais les efforts recommandés ne seront pas vains, car ils favoriseront aussi la santé des patients et du personnel en temps normal.
Mots clés: personnel médical et paramédical, maladies transmissibles, stress psychologique, culture organisationnelle, planification antisinistre
Footnotes
Acknowledgement: The authors thank Dr. Allison McGeer for her contributions regarding infection control protocols.
References
- 1.Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003;168(10):1245–51. [PMC free article] [PubMed] [Google Scholar]
- 2.World Health Organization. Pandemic Preparedness. 2005. [Google Scholar]
- 3.Public Health Agency of Canada. Canadian Pandemic Influenza Plan. 2004. [Google Scholar]
- 4.Tam CW, Pang EP, Lam LC, Chiu HF. Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: Stress and psychological impact among frontline healthcare workers. Psychol Med. 2004;34(7):1197–204. doi: 10.1017/S0033291704002247. [DOI] [PubMed] [Google Scholar]
- 5.Chan AO, Huak CY. Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore. Occup Med (Lond) 2004;54(3):190–96. doi: 10.1093/occmed/kqh027. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Nickell LA, Crighton EJ, Tracy CS, Al Enazy H, Bolaji Y, Hanjrah S, et al. Psychosocial effects of SARS on hospital staff: Survey of a large tertiary care institution. CMAJ. 2004;170(5):793–98. doi: 10.1503/cmaj.1031077. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Maunder RG, Lancee WJ, Rourke S, Hunter JJ, Goldbloom D, Balderson K, et al. Factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in Toronto. Psychosomatic Med. 2004;66(6):938–42. doi: 10.1097/01.psy.0000145673.84698.18. [DOI] [PubMed] [Google Scholar]
- 8.Bai Y, Lin CC, Lin CY, Chen JY, Chue CM, Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv. 2004;55(9):1055–57. doi: 10.1176/appi.ps.55.9.1055. [DOI] [PubMed] [Google Scholar]
- 9.Grace SL, Hershenfield K, Robertson E, Stewart DE. Factors affecting perceived risk of contracting severe acute respiratory syndrome among academic physicians. Infect Control Hosp Epidemiol. 2004;25(12):1111–13. doi: 10.1086/502352. [DOI] [PubMed] [Google Scholar]
- 10.Ho SM, Kwong-Lo RS, Mak CW, Wong JS. Fear of severe acute respiratory syndrome (SARS) among health care workers. J Consult Clin Psychol. 2005;73(2):344–49. doi: 10.1037/0022-006X.73.2.344. [DOI] [PubMed] [Google Scholar]
- 11.Wong TW, Yau JK, Chan CL, Kwong RS, Ho SM, Lau CC, et al. The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope. Eur J Emerg Med. 2005;12(1):13–18. doi: 10.1097/00063110-200502000-00005. [DOI] [PubMed] [Google Scholar]
- 12.Maunder R, Lancee WJ, Rourke SB, Hunter J, Goldbloom DS, Petryshen PM, et al. The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers in Toronto: Lessons learned. In: McLean AR, May RM, Pattison J, Weiss RA, et al., editors. SARS: A Case Study in Emerging Infections. Oxford: Oxford University Press; 2005. pp. 96–106. [Google Scholar]
- 13.Verma S, Mythily S, Chan YH, Deslypere JP, Teo EK, Chong SA. Post-SARS psychological morbidity and stigma among general practitioners and traditional Chinese medicine practitioners in Singapore. The Annals, Academy of Medicine, Singapore. 2004;33(6):743–48. [PubMed] [Google Scholar]
- 14.Maunder RG, Lancee WJ, Balderson KE, Bennett JP, Borgundvaag B, Evans S, et al. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis. 2006;12:1924–32. doi: 10.3201/eid1212.060584. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Lancee WJ, Maunder RG, Goldbloom DS, The co-authors of the Impact of SARS Study The prevalence of mental disorders in Toronto hospital workers one to two years after SARS. Psychiatric Services. 2008;59:91–95. doi: 10.1176/ps.2008.59.1.91. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Low DE. Why SARS will not return: A polemic. CMAJ. 2004;170(1):68–69. [PMC free article] [PubMed] [Google Scholar]
- 17.National Advisory Committee on SARSPublic Health. Learning from SARS: Renewal of Public Health in Canada. Ottawa: Government of Canada; 2003. [Google Scholar]
- 18.U.S. Dept. of Homeland Security. Pandemic Influenza Preparedness, Response, and Reovery Guide for Critical Infrastructure and Key Resources. Government of the United States of America. 2006. [Google Scholar]
- 19.Folkman S, Greer S. Promoting psychological well-being in the face of serious illness: When theory, research and practice inform each other. Psychooncology. 2000;9:11–19. doi: 10.1002/(SICI)1099-1611(200001/02)9:1<11::AID-PON424>3.0.CO;2-Z. [DOI] [PubMed] [Google Scholar]
- 20.Brymer M, Layne C, Pynoos R, Ruzek J, Steinberg A, Vernberg E, et al. Terrorism and Disaster Branch, National Child Traumatic Stress Network, National Center for PTSD. Second ed 2006. The Psychological First Aid Field Operations Guide. [Google Scholar]
- 21.Toronto Academic Health Sciences Network. Pandemic Influenza Planning Guidelines, 2006. 2006. [Google Scholar]
- 22.National Strategy for Pandemic Influenza. Washington, DC: Homeland Security Council, Government of the United States, 2005.
- 23.Hamel G, Valikangas L. The quest for resilience. Harv Bus Rev. 2003;81(9):52–63. [PubMed] [Google Scholar]
- 24.Freeman SF, Hirschorn L, Maltz M. The power of moral purpose: Sandler O’Neill & Partners in the aftermath of September 11, 2001. Organization Development J. 2004;22(4):69–79. [Google Scholar]
- 25.Aiken LH, Clarke SP, Sloane DM. Hospital staffing, organization, and quality of care: Cross-national findings. Int J Quality Health Care. 2002;14(1):5–13. doi: 10.1093/intqhc/14.1.5. [DOI] [PubMed] [Google Scholar]
- 26.Aiken LH, Smith HL, Lake ET. Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care. 1994;32(8):771–87. doi: 10.1097/00005650-199408000-00002. [DOI] [PubMed] [Google Scholar]
- 27.Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987–93. doi: 10.1001/jama.288.16.1987. [DOI] [PubMed] [Google Scholar]
- 28.Johnson JV, Hall EM. Job strain, work place social support, and cardiovascular disease: A cross-sectional study of a random sample of the Swedish working population. Am J Public Health. 1988;78(10):1336–42. doi: 10.2105/AJPH.78.10.1336. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol. 1996;1(1):27–41. doi: 10.1037/1076-8998.1.1.27. [DOI] [PubMed] [Google Scholar]
- 30.Kivimaki M, Ferrie JE, Head J, Shipley MJ, Vahtera J, Marmot MG. Organisational justice and change in justice as predictors of employee health: The Whitehall II study. J Epidemiol Community Health. 2004;58(11):931–37. doi: 10.1136/jech.2003.019026. [DOI] [PMC free article] [PubMed] [Google Scholar]