COVID-19: The Impact of a Pandemic on Mental Health

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will have gained an understanding of ways to mitigate the mental health impacts of a pandemic. Specific learning objectives to address potential learning gaps include:

• Define the term “pandemic.”
• Describe the psychological effects of a widespread infectious illness and effects unique to healthcare workers.
• Summarize strategies to reduce mental health impacts among healthcare workers.
• Discuss the “duty of care” concept.

DEFINING PANDEMIC

Epidemic and pandemic are closely related terms:

• An epidemic is an outbreak of a disease occurring over a wide geographic area and affecting a high proportion of the population. It is an event in which a disease is actively spreading. Examples include the recent Zika, Ebola, and SARS epidemics.
• A pandemic is an epidemic that has spread to multiple countries or regions of the world. The most recent pandemic is the COVID-19 pandemic that began in 2020.

Pandemics can cause significant social, economic, and political disruption. On an individual level, a pandemic may also exacerbate anxiety and psychosis-like symptoms and lead to nonspecific mental health problems such as mood problems, sleep problems, phobia-like behaviors, panic-like symptoms, anger, substance use, or feeling overwhelmed both in the general population and among healthcare professionals. It is therefore important to be alert for the effects of mental distress so that early interventions can take place (Moukaddam & Shah, 2020; Fischer, 2020).

MENTAL HEALTH EFFECTS OF A PANDEMIC

Mental health, as conceptualized by the World Health Organization, is a state of well-being in which the individual realizes their own abilities, can cope with the normal stress of life, can work productively, and is able to make a contribution to their community (PAHO/WHO, n.d.).

Pandemics disrupt the mental health of individuals and society on many different levels, one of them being widespread panic and increasing anxiety in people subjected to the real or perceived threats of the infectious agent. The mental health effects of a pandemic can impact health for many years, well past the precipitating event. These effects can compound the many challenges facing people who are already prone to mental health problems (Galea, 2020).

During a pandemic, it is common for people to feel stressed, anxious, worried, and fearful. Fear of the unknown or fear of uncertainty may be the most debilitating of the psychological effects of a pandemic. As a pandemic begins to spread, people may experience:

• Fear of contagion and death of self or loved ones
• Fear of contracting illness while caring for sick loved ones
• Fear of infecting a loved one
• Guilt regarding being the source of illness for a loved one
• Inability to intervene to prevent illness or death of loved ones
• Witnessing the illness or death of family members
• Bereavement and grief from loss of loved ones
• Psychological trauma due to quarantine and social distancing
• Difficulty maintaining self-care activities
• Domestic pressures caused by school closures, disruptions in daycare, or family illness
• Sense of ineffectiveness and powerlessness
• Loss of faith in health institutions, employers, or government leaders
• Belief that medical resources are not fairly distributed
• Restrictions on civil liberties that are perceived to be inequitable
• Frustration with lack of information and available resources
• Loss/disruption of job, financial hardship

As the pandemic decelerates, additional stressors begin to arise, which may include:

• Multiple losses
• Personal and population-wide bereavement
• Fear of recurrent waves of the pandemic returning
• Recuperation from illness
• Long-term medical complications
• Continued scarcity of basic necessities
• Massive economic disruptions
• Delays in reopening schools, daycare centers
• Ongoing stress on healthcare infrastructure
• Dealing with dependent family members who have lost their caretaker
• Changes in social support due to death and illness
  (Shultz, n.d.)

Psychological Stressors among Healthcare Professionals

Because of their prominent role in responding to a pandemic, healthcare professionals are at high risk for mental health effects. Studies following the MERS and SARS epidemics found high rates of depression and PTSD among physicians and frontline healthcare professionals. More recent research describes similar increased levels of mental stressors during the COVID-19 pandemic. These included:

• Fear
• Anxiety
• Depression

Stress levels were higher among those working in a clinical capacity, particularly frontline healthcare professionals in infectious disease, respiratory, and emergency departments. Lower stress scores among intensive care and anesthesiology specialists may be explained by their higher level of training in treating COVID-19 patients. Similarly, those who were confident of infection control strategies and training showed lower stress levels (Hassan et al., 2022).

Additional stressors among healthcare workers on the frontline (i.e., those who provide direct care and services to the sick or injured) may include:

• Stigmatization and ostracization due to caring for infected patients and their remains
• Shaming oneself about voicing one’s own fears and concerns
• Fear of passing the infectious agent on to family and friends and the need to isolate oneself from them
• Tension between public health priorities and the wishes of patients and their families regarding quarantine
• Strain of strict bio-security measures:
• Physical strain of having to constantly use protective equipment (e.g. dehydration, heat, exhaustion)
• Physical isolation, which makes it difficult to use touch to provide comfort to a sick or distressed patient or to give/receive comfort after working hours
• Need to be constantly aware and vigilant regarding infection control procedures
• Strict procedures that prevent spontaneity and autonomy
• Psychological effects when the system fails to provide adequate personal protective equipment (PPE):
• Fear of increased risk of infection
• Extreme stress around disregarding usual practices for caring for oneself in order to remain uninfected and to continue to provide safe patient care
• Higher demands both professionally and personally:
• Long hours
• Increased patient numbers
• Working in unfamiliar areas
• Keeping up to date with best practices and developing information
• Possible separation from and concern about family members
• Inner conflict about competing needs and demands (e.g., “I want to take care of my patients; it’s my calling and I am expected to; but I know I am taking great risks by doing so.”)
• Witnessing human suffering and dealing with life-and-death decisions
• Reduced capacity to use social support due to intense work schedules and stigma within the community toward frontline workers and the need for social distancing
• Insufficient ability to carry out adequate self-care because of work demands and time constraints
• Lack of information about long-term exposure to infected individuals related to insufficient scientific knowledge about the infectious agent
• Burnout and compassion fatigue
  (IASC, 2020)

STRATEGIES FOR REDUCING MENTAL HEALTH IMPACTS ON HEALTHCARE WORKERS

Healthcare workers include any and all who work in healthcare services. Besides physicians and nurses, this includes first responders, housekeeping personnel, clerical personnel, lab technicians, respiratory therapists, occupational therapists, physical therapists, pharmacists, community-based workers, those who work in mortuaries, among many others.

The mental and psychological well-being of healthcare workers is imperative to their ability to function effectively, particularly when exposed to extreme conditions. Such exposure could result in negative mental health consequences, which may in turn affect the functioning and productivity of entire healthcare organizations. Keeping all healthcare workers from chronic stress and poor mental health means that they will have a better capacity to fulfill their roles. This can be quite difficult to accomplish during a pandemic. Following are some strategies that can be applied to help reach this goal.

Supporting Coworkers

During a crisis situation such as a pandemic, it is necessary for coworkers to care for each other to ensure everyone’s physical and mental safety and to provide safe patient care. It can be helpful to partner with another for support and to monitor one another’s stress levels and safety. During the work shift, partners can set up times to check in and to listen carefully while sharing experiences and feelings. Partners can offer each other help, monitor their workloads, and encourage breaks. It is helpful to share opportunities for stress relief using deep breathing and other relaxation techniques.

When a coworker exhibits exhaustion, irritability, inability to concentrate or remember important things, or begins making errors, displays lack of confidence, and withdraws from contact, it is also necessary to communicate these concerns to management.

Self-Care Strategies

During the increased stress of a pandemic, it is vitally important for healthcare workers to be active in taking good care of themselves. The following are recommendations to help reduce stress levels among frontline workers:

• Schedule and take brief breaks to care for basic needs.
• Schedule and take brief relaxation breaks at work. A few minutes of a break during a shift can be calming. Even a 5-minute walk can improve energy and focus.
• Take time each day to do something that brings joy, even if just for a brief moment.
• Maintain a healthy diet; bring your own meals to work.
• Keep your schedule of daily activities as regular as possible.
• Get some sunlight.
• Try chair yoga or stretching at work.
• Get regular exercise, such as walking or biking to work.
• Avoid or limit the use of alcohol and caffeine.
• Monitor yourself for excessive fatigue, irritability, poor focus, or anxiety.
• Pace yourself.
• Take a moment for a slow breath before entering a work area, entering a patient room, or clocking out. This can be difficult while wearing personal protective equipment like a mask, but breathing is calming and helps the body cope with physical symptoms of stress.
• If you regularly see a mental health professional, video visits or a phone call may be a good idea.
• If you do not regularly see a mental health professional but feel doing so could be helpful at this time, many mental health providers are offering free sessions for healthcare workers.
• If a spiritual practice is important to you or has been in the past, work it into your regular routine.
  (NCCN, 2021)

Pandemic-Related Training

Formal and informal training during a pandemic can prepare healthcare workers to face the stressors involved in working under such conditions. Such training can include:

• Specific and accurate information about transmission of the infectious agent and methods of containment
• When and how to screen patients and, potentially, family members
• When to appeal for quarantine and isolation
• Ethical decision-making about triage and surge capacity issues

In order to increase the sense of confidence in one’s work-related performance, workers can also take part in training and/or planning exercises such as:

• Management of limited resources
• Implementation of various levels of quarantine
• Enforcement of movement restrictions
• How to handle mass fatalities
• How to conduct mental health screening
• How to cope with high stress demands
• Ways to prepare for family needs when required to be more involved at work or when in quarantine
• Ways to provide psychosocial support to colleagues
  (VA, 2022)

Management Strategies to Support Staff

Team leaders or managers in a health facility also face similar stressors and additional pressures due to the level of responsibility inherent in their roles. It is important that stress-relief provisions are in place for both workers and managers, and that managers serve as role models for strategies to mitigate stress. The following measures can be taken by management to help reduce the impact of stress on healthcare frontline staff:

• Ensure a clear system for coordination and communication with frontline workers to keep them apprised of the current recommendations for patient care and personal protection.
• Establish policies regarding work hours, duration of deployment, shift rotation, and rest periods, rotating workers from higher-stress to lower-stress functions.
• Train all frontline workers, including nonhealthcare workers in quarantine sites, in essential psychosocial care principles, psychological first aid, and how to make referrals when needed. Online training can be used if it is not possible to bring staff together due to infection risks.
• Partner inexperienced workers with more experienced colleagues, and ensure that outreach personnel enter the community in pairs. A buddy system can help provide support, monitor stress, and reinforce safety procedures.
• Develop stress-management protocols for frontline medical personnel and ensure that time is built in for colleagues to provide social support to one another.
• Create psychological supports for healthcare workers, including hotlines and access to trained mental health professionals.
• Once the pandemic begins to recede, actively monitor, support, and (where necessary) provide all staff with evidence-based treatments.
• Once the pandemic is over, allot debriefing time to reflect on and learn from the difficult experiences to create a meaningful rather than traumatic narrative.
  (Sadeghi & Wen, 2020; IASC, 2020; Greenberg et al., 2020)

DUTY OF CARE

During a pandemic, thousands of frontline healthcare providers are called to care for infected patients, placing their own health and lives at risk. Because healthcare providers are critical to an effective response during a pandemic, it is important for them to be aware of the rights and responsibilities around caring for patients in such an emergency.

Duty of care is defined as the ethical and legal responsibility of a person or organization to avoid any behaviors or omissions that could reasonably be foreseen to cause harm to others (LD, 2017). Healthcare professionals have an ethical duty to provide care. They have an obligation to treat all patients and are not at liberty to abandon them.

Considerations during a pandemic involve weighing the potential harm to a healthcare worker against the potential benefit to a patient. Where risk to the worker is low and benefit to the patient is high, the duty of care obligation increases. However, where the risk to the healthcare worker is high and the benefit to the patient is low, the obligation to care for the patient decreases.

Governments and healthcare employers also have duties and obligations to healthcare professionals. They have a responsibility to ensure safe working conditions, including making certain there are appropriate safety precautions in place to protect those healthcare professionals and to ensure that counseling and mental health supports are available during such a crisis (Gruben & Czarnowski, 2020).

There are also limits to the personal risk of harm that healthcare personnel can be expected to accept as an ethical duty. Harm includes emotional, psychological, physical, or spiritual. Balancing their professional demands with the need to protect and care for self and family may therefore introduce a dilemma. Some may feel the personal risks are too great and choose not to care for infected patients. When this happens, the effects on the healthcare system can be profound.

The American Nurses Association, as one example, provides guidance for decisions about care made during extreme circumstances, including pandemics. In such situations, “a utilitarian framework usually guides practice decisions and actions, with special emphasis on transparency, protection of the public, proportional restriction of individual liberty, and fair stewardship of resources” (ANA, n.d.). Specific ANA guidance to nurses states:

• Professional nurses have a duty to care during crises like pandemics. Their employers and supervisors have a corresponding duty to reduce risks to nurses’ safety, plan for competing priorities like childcare, and address moral distress and other injuries to personal and professional integrity such crisis events can cause.
• No crisis changes the professional standards of practice, Code of Ethics, accountability for clinical competence, or values of the registered nurse. However, the specific balance of professional standards and crisis standards of care will be based on the reality of the specific situation, such as the presence or absence of necessary equipment, medications, or colleagues.
• Decision-making during extreme conditions can shift ethical standards to a utilitarian framework in which the clinical goal is the greatest good for the greatest number of individuals, but that shift must not disproportionately burden those who already suffer healthcare disparities and social injustice. Sacrifices in desired care must be fairly shared. This means that care decisions are not about “the best that can be done” under normal conditions. They are necessarily constrained by the specific conditions during the crisis. Any move to crisis standards of care must be done within the institution’s response structure and ideally in collaboration with other healthcare professionals, policymakers, and the community.
• Registered nurses may be asked to delegate care to others, such as students, staff displaced from another institution, or volunteers. This will require a rapid assessment of the skills of the others available to assist in patient care. Nurses must continue to emphasize patient safety and appropriate delegation.
• An increased reliance on a nurse’s own or the collective accumulated competence may be needed, as the usual range of colleagues, experts, or support services may not be available (ANA, n.d.).

CONCLUSION

A pandemic is, without a doubt, an extremely stressful situation for everyone. It is especially difficult for healthcare workers who are responsible for the provision of safe and effective care to those who have become infected.

The general population is faced with many mental health challenges, including fear, anxiety, and uncertainty. Healthcare professionals are also faced with overwhelming demands to provide care for others, care for their families, and care for themselves.

It is important to remember, however, that for healthcare providers who risk their lives for the good of many, there is a reciprocal obligation that society keep them safe and ensure they are provided with everything they require to maintain their own safety. At the same time, it is important for everyone to be involved in actively caring for their own well-being.