Healthcare worker's mental health dilemma during COVID-19 pandemic: A reflection on the KSA experience

The country office of the World Health Organization (WHO), was informed of pneumonia of unknown cause in Wuhan, a city in the Hubei Province of China, on 31 December 2019.¹ All reported cases were associated with Wuhan's seafood market.²

Laboratory investigations indicated that the reported pneumonia was caused by a novel coronavirus.¹ The International Committee on Taxonomy of Viruses (ICTV) named the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The WHO subsequently named the disease caused by the Coronavirus, ‘COVID-19’.^3,4 As the number of COVID-19 cases in China and internationally increased, the WHO held an emergency meeting on 30 January 2020, declaring the COVID-19 outbreak a public health emergency of global concern.^1,5 As of 20 June 2020, the number of internationally reported cases reached 8,525,042, with a 52.90% recovery rate and a less than 10% mortality rate.¹ By then, the largest number of cases had been reported in the United States of America (USA); 2,330,578, with a 41% recovery rate and a 5% mortality rate.¹ In the Eastern Mediterranean Region, the largest number of cases were reported in the Islamic Republic of Iran, followed by KSA. In Iran, 202,584 cases were reported, with a recovery rate of 79.70% and a mortality rate of 4.70%.¹ In KSA, 154,233 cases were reported, with a recovery rate of 64.1% and a less than 1% mortality rate.^1,6

The exponential increase in COVID-19 cases in China caused stress and anxiety among healthcare workers (HCWs). An estimated 3000 HCWs were diagnosed with COVID-19, and 22 deaths were reported.⁷ In KSA, the exact number of COVID-19 cases among HCWs has not been publicly disclosed. However, several regional health directorates issued mourning statements to honour the deceased HCWs. Frontline HCWs have been under intense strain since the beginning of the quarantine.² The pressure on HCWs continued to rise, and a perceived lack of influence on decision-making increases tensions.⁸

Frontline HCWs face multiple challenges. A sudden epidemic outbreak leads to an unexpected increase in workload, rising occupational exposure to violence, and the risk of contracting COVID-19. Supply chain failures jeopardise the availability of personal protective equipment (PPE).⁹ However, while HCWs accept the higher risk of infection as part of their profession, they are concerned about the risk of transmission to their families.⁷ HCWs might suffer from comorbidities that put them at a higher risk of infection and mortality.⁷ HCWs performance may be influenced by feelings of uncertainty, increased psychological pressure, and the risk of stigma. Frontline HCWs psychological response to an increasing workload and stress is fundamental to maintaining the healthcare system's operational efficiency. Due to direct exposure to infected patients, and the demanding nature of their duties, frontline HCWs are at higher risk of developing mental health problems than those indirectly involved in managing the pandemic, and they may need psychological intervention.^5,10,11 Reports of mental health problems caused by COVID-19 among HCWs are increasing. In response, there were calls for comprehensive measures to promote mental health support. On 13 May 2020, the UN Secretary-General launched the COVID-19 and Mental Health Policy brief, which encouraged governments, civil societies, and health authorities to draw up a plan to mitigate mental health problems among HCWs.¹² ‘Mental health services are an essential part of government response to COVID-19’, the UN Secretary-General stated.¹²

KSA has adopted a multidimensional, multisector disaster management plan to mitigate the impact of the COVID-19 pandemic on the healthcare system and the population. The aim is to reduce the disease's economic and social burden. To combat the COVID-19 pandemic and protect the public welfare, KSA implemented drastic preventive measures. These include travel restrictions on all domestic and international flights, the lockdown of cities, total or partial curfews (depending on epidemic status), and the closing of mosques, shopping malls, and recreation centres. Mass events were cancelled, and work was suspended. A virtual operational mode was implemented at all governmental agencies. As the epidemic curve escalated, the anxiety and tension grew among frontline HCWs. Healthcare facilities quickly realised that demanding professional duty in a challenging work atmosphere with an increasing workload would undermine the mental health of frontline HCWs, and mandated the establishment of mental health support programs. On March 19, 2020, the Custodian of the Two Holy Mosques, the King of KSA, addressed the residents of KSA and delivered a message of solidarity between the leadership and citizens. The King's speech honoured the efforts of HCWs and health officials and assured the population that government agencies make every effort to maintain their safety and public services. Ministerial messages expressed appreciation for the efforts of frontline HCWs. The term ‘Heroes of Health’ has become a registered trademark of the COVID-19 era, demonstrating leadership and gratitude for HCWs and health services.

Institutionalised initiatives to meet the increasing demands for psychological support among HCWs focused on four domains; education, therapy, awareness, and prevention. The Ministry of Health, in collaboration with the private health sector, academic institutions, and providers of health services to government, launched a national awareness campaign. The focus was on the population's psychological needs during the pandemic and its impact on mental health. Special attention was paid to raising the level of awareness among HCWs of the psychological burden of serving during the pandemic. Various institutions and professional societies organized educational webinars to introduce mental health professionals, occupational health specialists, and hospital administrators to the fundamentals of mental healthcare. Psychiatrists, psychologists, and social workers needed to be equipped with the tools to assess mental health and deliver the appropriate care. The Ministry of Health designated a hotline to support HCWs and address their concerns. Academic institutions and military hospitals established a wellness program for employees whose primary focus is on mental health. The program provides options for care in clinical settings or telemental health services.

Specialized clinics were designated for employees to meet the increasing demand for mental care and prevent burnout or mental breakdown. Telemental health services enable employees to voice their concerns and receive the necessary support and referral if required. The reluctance of HCWs to utilize wellness services led to the establishment of an anonymous online support group where HCWs could share their reservations. Wellness programs helped hospital administrators to improve the work atmosphere and establish a culture of embrace.

The Saudi Commission for Health Specialties (SCFHS) launched the ‘IMTINAN’ (gratitude) initiative. The ‘IMTINAN’ aims to express the leadership and society's appreciation for the efforts of HCWs. Frontline HCWs received a personal phone call from the SCFHS General-Secretary thanking them for their efforts and contributions. The SCFHS temporarily extended professional registration for all HCWs. The risk of licenses being suspended was thus eliminated. Over 81,000 HCWs have benefited from the temporary extension of registration. Free-access to the webinar platform was granted to all HCWs to ensure the delivery of updated information. The SCFHS also launched the second phase of the ‘DA’EM’ (supporter) program. The DA’EM is a 24-hour web-based wellness program that provides psychological support to HCWs across the Kingdom and to Saudi health trainees abroad. The program aims to reduce the psychological burden of COVID-19.

The COVID-19 pandemic sheds light on the fragility of mental resilience and the need for a national mental health intervention plan. In collaboration with public health experts and population health researchers, mental health professionals have to conduct epidemiological research that provides the structure for a national wellness program, with the focus on occupational mental health. Furthermore, the research findings should inform the national response plan for public health protection and amend the mental health protection chapter. Identifying needs and demands and addressing problems is at the heart of a targeted mental health intervention. To maintain the mental health wellness program's effectiveness, periodic review and continuous monitoring are essential for evaluation, improvement, and correction. Wellness initiatives launched in response to the COVID-19 pandemic in KSA could serve as a prototype for a national program. Experienced evaluation is pivotal to complementing strengths and identify shortcomings. It is important to protect the mental health of HCWs to ensure the safety, efficiency, and effectiveness of health services. Administrators need to realise that feelings of inadequacy are understandable. A non-judgmental approach is necessary to maintain the mental health integrity of HCWs. Transparent and thoughtful communication will contribute to trust and a sense of control. By holding regular discussions and stand-up meetings with frontline HCWs, the professional bond between them and the facility would be strengthened, and it will assure that administrators are considerate and appreciative. Open communication channels are needed to resolve concerns and conflicts. When the pandemic has passed, there will be an open dialogue with all relevant stakeholders about staffing, secure resources, and a safe, modern system of care. The involvement of mental health professionals in developing human capital planning and the design of occupational health programs are essential to maximise wellness programs' effectiveness. A review of the national disaster management plan should consider targeted mental health intervention as a mandatory chapter. It should ensure the safety of the population safety and the continuity of service delivery.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of Interest

The authors do not have any conflict of interest to declare.

Ethical approval

This to confirm that this editorial had been prepared in accordance to COPE roles and regulation. Given the nature of the editorial, IRB review is not required. MKA developed the conceptual framework of the editorial, collected evidence, extracted information, provided logistic support, and critically evaluated literature. WMB jointly developed the conceptual framework of the editorial, analyzed the data, conducted literature, and wrote the initial and final draft. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.