Prevention of occupational stress in health-care workers during COVID-19 pandemic

Abstract

In a humanitarian crisis, healthcare workers are on the frontline in providing their services. Despite being crisis management personnel, healthcare workers may get exposed to occupational stress due to unprecedented circumstances, challenges in delivery of high-quality care, lack of resources, and most importantly for being at high risk to suffer from the impact of the situation itself. Therefore, it is imperative to maintain the mental health of healthcare workers on a regular basis and more so during a pandemic like COVID-19. For addressing the occupational stress in healthcare workers, a Cognitive Behaviour Therapy (CBT) based intervention is suggested, also supported by a Cochrane review, which can build/ improve/ enhance resilience, needed to shield individuals against the development of psychopathology, at the public health level in humanitarian crises. In addition to developing resilience, which will be helpful in combating anxiety, depression, somatization, and incapacitation, CBT will also help in dealing with the social isolation which has been part and parcel of COVID-19 and similar pandemic situations.

INTRODUCTION

Health-care professionals are the frontline workers in dealing with the humanitarian crisis. There is sufficient research to highlight the level of stress faced by the health-care workers under routine clinical care, which is increased under unusual circumstances such as a pandemic. Although the best approach under such circumstances is not entirely clear, it is imperative to maintain the mental health of health-care workers, to control infectious diseases in an effective way. The initiative of public psychological counseling through telephone helplines proved very effective in combating psychological issues during the severe acute respiratory syndrome (SARS) epidemic. However, only limited literature is available on support services for health professionals during a humanitarian crisis.

Exposure to stressors at work is believed to provoke stress among health-care workers in routine care, the effects of which are thought to be mitigated by one's ability to personally deal with them. Several factors such as increased workload, low social support, lack of skills, organizational conflicts and problems, and emotional reaction to dying and suffering patients contribute to occupational stress in health-care workers. In a hospital setting, psychological working environment (inappropriate behaviors and verbal abuse), physical environment (space, lighting, disruption, and temperature), work overload, inadequate allocation of work, working long hours, repetitive duties, new technology, and management issues among others cause most of the stress. This stress might damage professional efficacy, thereby decreasing attention, weakening decision-making skills, reducing concentration, and negatively affecting the worker's ability to develop a professional relationship with their patients. The data on turnover and absenteeism indicate the high economic impact of such conditions. More than 10% of total claims for occupational diseases are attributed to stress at work.[1]

Physicians may suffer from negative outcomes of work stress, including adverse psychological well-being, alcohol dependency, a rise in suicide attempts, job burnout, and many other psychological issues. The report of the American Foundation for Suicide Prevention laid further emphasis on the enormity of the situation, claiming that compared to other professionals, death by suicide is 70% higher among doctors on an average, and female doctors are 250%–400% more likely to be affected.[2]

Even though a large number of review articles have been published detailing the efficacy of interventions for prevention and/or treatment of stress, only a few of them specifically focus on interventions targeting stress prevention among health-care workers. A recent Cochrane review of 58 studies, with 7188 participants regarding interventions used for health work-related stress concludes that stress is moderately reduced by cognitive-behavioral training and physical and mental relaxation. Changing work schedules might also be effective, but no clear effects are inferred from other organizational interventions against stress. However, there is no reported evaluation of an intervention to help health workers dealing with humanitarian crises such as floods, tsunamis, or pandemics.[3]

We suggest that cognitive behavior therapy (CBT)-based intervention might be the way forward. CBT is recommended by the national guidelines to treat mental and emotional health problems in most developed nations. CBT can be provided in a self-help or guided self-help format in either paper or electronic format. There is evidence from research that CBT can improve resilience[4] and therefore can be used and might be an ideal choice in building resilience at the public health level in humanitarian crises. Similarly, developing evidence-based approaches for enhancing the resilience of those health-care workers that help patients during a pandemic has already been emphasized.[5]

Resilience is the ability to recover readily from adversity. Treatment of diverse chronic diseases such as systemic lupus erythematosus, Chagas disease, diabetes, and rheumatoid arthritis has been reported to be impacted by the virtue of resilience. A recent systematic review indicates a negative relationship between resilience and anxiety, depression, somatization, and incapacitation and shows that resilience acts as a shield against the development of psychopathology among those facing challenges.[6]

The COVID-19 pandemic is currently putting substantial stress on everyone; however, health-care workers among other targeted groups remain most affected. Studies have reported a high prevalence of posttraumatic stress related to SARS among health-care workers and other employees of hospitals in Canada, Singapore, Taiwan, China, and Hong Kong. According to the World Health Organization, SARS infected health-care workers who represented more than 20% of all the people who contracted the infection, at a higher rate than any other group. Literature has documented that a person's possibility of developing PTSD is influenced by the perceived risk levels which might be affected by factors like unfamiliarity with and perceived uncontrollability of the hazards associated with an event. Fear, anxiety, stress, depression, and burnout have been commonly reported among frontline health-care and support staff working in COVID-19. There has been no time to train frontline workers on building resilience to deal with the situation causing various psychological issues. Although there have been online interventions including CBT for depression, anxiety, and insomnia and artificial intelligence-based programs for the psychological crisis for the general public, there is a scarcity of interventions for the improvement of mental health (including the building of resilience) of frontline health-care workers during the COVID-19 pandemic. A recent publication outlining a psychological intervention plan to help health-care workers with COVID-19-related stress mainly aimed at three areas that included: (a) generating a psychological intervention medical team which to prepare medical staff to deal with common psychological issues, conducted online courses; (b) generating a psychological assistance hotline team that supervised and guided in solving psychological problems; and (c) psychological interventions, for mitigating stress, that included a diverse set of group activities. The program was modified based on feedback from the staff.[7]

COVID-19 is posing a challenge to the psychological resilience of both health-care managers and health-care workers, for which some tips are shared in Box 1. However, formulating psychological interventions for improving psychological resilience and mental health is of utmost importance during COVID-19 and similar situations in times to come. We feel that CBT for dealing with social isolation and developing resilience may be the way forward.

Box 1.

Tips and resources

For the health funders and the health managers

1. Preparation and training in dealing with COVID-19 infected

2. Regular screening of stress, depression, and anxiety among the health-care workers and their families who might be worried about their loved ones working with COVID-19 patients

3. Provide CBT/mindfulness-based stress management training as a prevention measure. This can be delivered in groups, self-help, or online format

4. Develop a team to provide online counseling

5. Provide rooms for rest for the staff in hospitals

For health workers

1. Self-awareness – self-care starts with self-awareness

2. Develop a routine – proper sleep/diet and regular exercise

3. Connect and communicate with people around – both at work and home

4. Spirituality – religion, mindfulness, and yoga

5. Build on existing coping skills

6. Psychological techniques – CBT to help change your perspective, e.g., rather than focusing on the number of casualties consider the number of people who are recovering from COVID-19

Note: If you are providing telemedicine services – consider maintaining a routine, do physical exercise, and have appropriate calories intake

Useful online resources for health professionals

https://www.who.int/publications-detail/mental-health-and-psychosocial-considerations-during-the-covid-19-outbreak

https://www.wpanet.org/covid-19-resources

https://www.psychiatry.org/psychiatrists/covid-19-coronavirus

https://www.rcpsych.ac.uk/about-us/responding-to-covid-19

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html

https://wfmh.global/mental-health-considerations-during-covid-19-outbreak

CBT – Cognitive behavior therapy

Financial Support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.