Resilience for Frontline Health Care Workers: Evidence-Based Recommendations

In the battle against COVID-19, frontline health care workers are dealing with enormous levels of stress and uncertainty. They are facing fears about infecting their patients, colleagues, and family, being re-assigned to practice in settings where they feel insufficiently prepared, having to make life-and-death decisions based on limited availability of resources, knowing that some of their colleagues, or they themselves, will become ill and perhaps die, and watching patients die alone without being able to say good-bye to their loved ones.

In this Commentary, we share evidence-based strategies known to enhance resilience and decrease the likelihood of developing burnout, depression, and post-traumatic stress disorder during times of adversity. These strategies come from research with stress-hardy civilian men and women, including physicians, as well as military personnel, including former prisoners of war and Special Forces instructors. The strategies and recommendations are strongly supported by a large body of peer-reviewed psychosocial and neurobiological research.¹

Face Fear

Primary drivers of fear include loss of a sense of control and lack of predictability, so it is natural to feel afraid in the current medical climate. Moderate levels of anxiety and fear enhance performance. However, when left unattended, fear can escalate into panic. When this happens, the prefrontal cortex becomes flooded with catecholamines and loses its capacity to inhibit the limbic system's fight or flight response.² While this may be advantageous during acute danger, it can be harmful in medical settings where rational decision-making is required. Methods to help maintain fear and the fight or flight response within an adaptive range include: acknowledge and monitor your reactions to fear; obtain accurate information about what you fear from reliable sources; manage inflow of negative information whenever possible; follow evidence-based procedures to protect against the virus; share your concerns and fears with trusted colleagues and support one another; practice relaxation techniques such as deep belly breathing and mindfulness meditation even for brief periods; try to reframe fearful situations as a challenge in addition to being a threat; train for likely scenarios whenever possible. Courage is not the absence of fear but the ability to act despite the fear. If you currently are a health care worker on the front lines, you are acting courageously, even if you feel afraid.

Realistic Optimism

Realistic optimism and positive emotions repeatedly have been associated with resilience, and good mental and physical health. Methods to increase realistic optimism include: train sufficiently to feel prepared for the specific challenges that you will face; cognitively reappraise overly negative thoughts by challenging them and searching for more constructive ways to view the situation; embrace humor when appropriate; increase behaviors commonly associated with positive emotions because behaviors affect mood and are under more direct control of the will than emotions; and try to associate with optimistic colleagues because emotions can be contagious.

Social Support

Positive social support consistently is among the strongest psychosocial predictors of resilience and well-being. On the other hand, social isolation negatively impacts mental and physical health, with effects on longevity equal to those of cigarette smoking, obesity, and sedentary lifestyle.³ With the current need for social distancing, it is critical for health care workers to find creative solutions to stay socially connected, such as virtual group meetings where physicians and health care teams use video conferencing to discuss what they are experiencing and suggestions for effective coping.

For leaders of frontline caregivers in the battle against COVID-19, it is imperative to create an atmosphere of camaraderie, respect, and psychological safety where fear, shame, and guilt are acknowledged and discussed; where responsibilities and resources are shared; where peer and mentor support are fostered; and where team members feel valued and understood.⁴ Navy Seals and Special Forces soldiers often attribute their own courage and resilience to the power of team members who “have each other's back” and will even risk their life for one another. The message from healthcare leaders should be clear: “Team, Team, Team. You are your brother and sister's keeper. We are all in this together, fighting for a common noble cause. It is a privilege to be working alongside such a remarkable group of colleagues.”

Businesses, communities, and government agencies can also support frontline workers by providing medical supplies (eg, personal protective equipment, ventilators), financial resources (eg, hazard pay, free lunches), and emotional support. Early in the pandemic, at 7 PM every evening, New Yorkers would scream, shout, clap, bang pots and pans, and play musical instruments for 2 minutes as a way to honor and say “thank you” to the thousands of frontline workers who ‘walk into the fire’ and risk their lives every day.

Coping

Resilience is associated with active and flexible coping (eg, gathering information, acquiring skills, problem solving, seeking out social support) rather than passive coping (denial there is a problem, avoiding, procrastinating or withdrawing, using substances, repetitive negative venting, blaming someone else). Active coping includes self-care through exercise, good nutrition, relaxation strategies, and restorative sleep. Strategies to modulate sympathetic and parasympathetic tone, such as mindful meditation, deep belly breathing, and yoga are also effective, because regularly bringing the stress response back to baseline is an essential component of resilience.

Cognitive Strategies

Acceptance involves acknowledging the reality of a situation even if painful or frightening, accepting what you cannot change, abandoning goals that are no longer feasible, and intentionally redirecting efforts toward goals that can be achieved. Acceptance is not a passive giving up but, instead, a conscious decision not to waste effort on pointless attempts to change the unchangeable. Acceptance forms the basis of the well-known Serenity prayer.

Positive reappraisal refers to the intentional effort to reassess the meaning of an event from negative to more positive, leading to more adaptive emotional and behavioral responses, partly by increasing activation of the executive region of the brain (prefrontal cortex) and attenuating limbic system alarm reactions. You might ask, “Is there a more constructive way I can think about this situation?” Trauma may force us to learn something new or possibly even grow as a person.

Religious and Spiritual Practices

Religious and spiritual practices have repeatedly been associated with physical and emotional well-being, partly through a focus on altruism, gratitude, supporting one another, prayer and meditation, meaning and purpose, and connection with a higher power or with something far larger than the self. Faith-based beliefs and practices are especially powerful during times of crisis and provide great strength for many health care workers and their families.

Meaning and Purpose

Having a clear and valued purpose, and committing to a worthy mission, can markedly strengthen one's resilience, even if that mission entails danger and suffering. In the words of psychiatrist and Holocaust survivor Viktor Frankl, “There is nothing in the world I would venture to say that would so effectively help one to survive even the worst conditions as the knowledge that there is a meaning to life.”⁵ This is especially true at a time of great need, like the present pandemic, and when meaning is connected to a calling, like medicine.

It is our sincere hope that one or more of these strategies will prove helpful to the courageous health care workers who are fighting in our hospitals to save lives.