Strategies to Promote Psycho-social Wellbeing among Health Care Workers during COVID-19 Pandemic

The COVID-19 pandemic, a Public Health Emergency of International Concern, has challenged multiple aspects of human life, such as health, economy, and travel. The current pandemic has provoked an enormous health crisis, posing a burden on the health care system. All the six building blocks of the health system (service delivery; health workforce; information; medical products, vaccines and technologies; financing; leadership, and governance) are strained [1]. This viewpoint focuses on the health workforce building block, especially on its the psycho-social aspect. It is often quoted that in the COVID pandemic “health care workers and Personal Protective Equipment (PPE) are golden” and have to be handled efficiently.

The strategies put forth for control the pandemic, such as testing, intensive contact tracing, health care for infected persons, home quarantine, and follow-up, increase the work burden on health care workers (HCWs). HCWs are individuals who are involved in delivering care and services to the sick and ailing, either directly as doctors, nurses, community health care workers, and medico-social workers or indirectly as aides, helpers, laboratory technicians, and medical waste handlers [2]. Current health crisis involves HCWs at all levels of the system: primary, secondary, and tertiary. HCWs of a hospital treat active cases in COVID wards and Intensive Care Units. HCWs at peripheral health system are involved in surveillance, contact tracing, quarantine, follow-up and risk communication.

HCWs face multiple challenges during COVID-19 pandemic. Inadequate management of these challenges significantly impacts their physical and psycho-social wellbeing. The current pandemic has an undue adverse psychological outcome. It was noted that in China, 34% to 71% of HCW had a psychological disturbance such as depression, anxiety, insomnia [3]. The cause for such psychological distresses could be personal beliefs and conditions at the workplace, family, or society. At the personal level, HCWs fear contracting infection and transmitting the disease to their family, especially in the background of the uncertainties/rumors on the epidemiology of COVID. Furthermore, the grief reaction following illness or death of their peers/family adds to the distress, particularly with a lack of definitive treatment and vaccine.

At the workplace, HCWs encounter the challenge of the sudden and continuous inflow of COVID-19 patients. Hence, they are compelled to work in a naïve environment and work in areas outside their specialization with minimal/no training, rapidly changing burden, while evidence and guidelines for COVID-19 intensify the stress. HCWs may also experience moral injury, that is the psychological distress caused by actions taken by the HCW in a challenging situation that is against their moral/ethical principles [4]. It leads to heavy workload and prolonged duty hours in COVID wards leading to HCW burnout. Burnout is a syndrome of physical and psychological exhaustion that occurs due to chronic workplace stress. It is characterized by feelings of energy depletion, increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job, and reduced professional efficacy [5]. Adverse outcomes in the patients they are caring for add to the stress of the HCWs. Furthermore, unfulfilled requirements at the workplace due to inadequate PPE, shortage of health workforce, poor infrastructure, and logistics negatively impact mental health. These stressors cause deprivation of adequate and quality sleep.

At family-level, lockdown, travel restrictions, closure of schools has led to new challenges in caring for their families with nil/little help from relatives or paid helpers. Quarantine and isolation following an accidental exposure to COVID confirmed cases add to the stress. In the community, HCWs sometimes face violence from public during active surveillance and contact tracing. Some HCWs also encounter stigma at public places such as shops and fruit stalls. Some HCWs also report discrimination such as compulsion to vacate their rented house [6]. The occurrence of such instances in other places gets circulated in social media which adds to their stress and fear of experiencing similar incidents in future.

Poor psycho-social wellbeing could be expressed as physical symptoms and hinder their functioning [7]. Unrecognized and unpaid attention to psycho-social issues and burnout among HCWs will compromise the professional competency and quality of COVID-19 services. The promotion of psycho-social health of the HCWs should be given due importance. Additionally, this will benefit the health care system. Technical arrangements such as upscaling the availability of PPE, capacity building regarding the epidemiology of COVID-19, and universal precautions have assured the HCWs. A few organizations have developed a robust system for meeting the mental health issues of HCWs [8, 9]. A task force at the Mount Sinai Health System (MSHS) in New York City working on HCW crisis support identified three priority areas: arrangements to meet daily needs, enhanced communication between the team, and robust psycho-social health support option [10]. We have described a few measures to overcome psycho-social problems, and these could be done at the level of individual, health system, and community.

At the individual level, HCWs should plan a new routine, incorporating self-care. As sound body confers sound mind, improvement of both physical health and mental health should be ensured. HCWs should engage in relaxation programs and physical activities such as exercise, walking, or jogging. It energizes them to cope up with the increased workload and improves immunity. Exercise induces endorphin release and elevates the mood [11]. Another tool used to uplift the emotional status is ‘journaling’. The HCW is encouraged to reflect and pen down the happening and thoughts during the day. When the thoughts are written down, they get organized and manageable. It is essential that such journaling activity focuses on noticing the positive facts, feelings, and actions [12]. Journaling should be part of their new routine. It is preferably done in the morning or evening when a person is less distracted.

HCW should develop an optimistic attitude. It is noted that optimism improves the quality of life of a HCW, especially during challenging situations [13]. Gratitude journal inculcates an optimistic attitude [14]. In gratitude journal, the person counts the blessing he/she received in the day. It triggers a positive outlook at his/her life circumstances, thereby encouraging the HCW to savor the good events [15]. It is found, those in a gratitude emotion experience a high level of well being and satisfaction. The gratitude journal is written daily when the person reflects and notes down 5 to 10 events/persons/situations he/she is grateful for or takes up one grateful event/person/situation and elaborates on how it supported him/her. During the crisis the HCW should strengthen his existing belief on any higher being. The ‘Supreme Being’ could be a religious belief, universe, or self. HCWs should be encouraged to follow the practices that they usually follow to connect with their spiritual beliefs. It could be meditation or breathing exercises or affirmations or belief in the law of attraction.

At the level of health system, certain action plans could be formulated using the model of Maslow’s hierarchy of needs and executed to overcome psycho-social impact on HCWs [16]. Work schedule has to be planned upfront so that HCWs have adequate time for meeting their basic needs and adequate rest before they are exhausted [17, 18]. Safety needs have to be fulfilled by training sessionson workplace safety and proper use of PPE. The training session should also include various self-care and coping strategies. Webinars could be used to take care of social distancing. Furthermore, a list of online resources on managing psychological stress, including those from the World Health Organization, could be provided [19, 20]. This information augments their self-efficacy. Follow-up actions such as monitoring the health and PPE breach of HCW gives the assurance that thesafety need is ensured by the health system. The third need for love and belonging with peers could be achieved by arranging for reserve health workforce, re-designate work with proper training. This need becomes more important during quarantine for any accidental exposure to COVID confirmed patient. Arrangements to connect with family and peers should be made during quarantine and during breaks amidst working hours. Support and empathy from the colleagues, supervisors, and administrators, protect HCW from mental health problems [21]. The next need of self-esteem could be met by words of appreciation from the head of the institute or health system. Frequent short talks of the leader with their team with clear, honest messages make the HCW feel respected. These talks should also include aspects of various activities done to promote the health of HCWs. The above measures remove fear due to uncertainties and boost the positive attitude and emotion of the staff [19]. If a person needs assistance to overcome their psycho-social problems, it needs to be respected and such person should be provided counseling facilities. Psychological health is often associated with stigma and fear of confidentiality, hence helpline from external agency needs to be identified and communicated to the HCW.

At the level of the health system, the psychological health of the COVID task force, which plans the COVID control activities, should also be addressed. Due to the changing scenario and guidelines, this team is involved in continuous planning and formulation of new strategies. This leads to mental fatigue. The COVID task force should have a dedicated person who looks into the welfare of the team members and motivates the administrators. He/she would have informal talks with the members and should look out for any distress among them, especially when there are lapses in their roles. Taskforce meetings should also have some fun, this can be done by adding humor or having talks on non-COVID things. All members should consciously take time to appreciate and motivate their team members. Here the team leader plays a significant role. He/she should be open to suggestions, have trust in his/her team, and give them the confidence that they are understood. On the other hand, the team leader is under tremendous stress due to the critical comments and also due to pressure from their superiors. He/She also should be supported, understood, and motivated.

At the level of the community, activities such as those demonstrating support and appreciation of the HCW’s endeavor are essential. Public gestures such as the lighting of a lamp, clapping at specified date and time, messages such as “Thank You Corona Warriors” enhances the mental health of HCW.The government of India has rightly implemented insurance schemes for health care workers (Pradhan Mantri Garib Kalyan Package). Apart from the financial support, it gives a massive positive thought and encouragement to the HCWs that the government and leaders are concerned about them. Multiple associations have come forward to provide psychological counseling for the public and also extend their service to HCWs, similar to that of peer support offered through social media to Chinese HCWs [22]. Multiple strategies need to be implemented to suit various types of HCWs.

Conclusion

The strategic measures to improve the psycho-social health of HCW should be aimed at the individual and health system, community level. At the individual level, optimism should be inculcated. At the health system level, strategies to address the various levels of Maslow’s hierarchy of needs have to be formulated. Special attention has to be given to the COVID task force team and the leader of the health system. At the community level, HCW should be supported and encouraged.

Conflict of Interest

Nil declared

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