Experts have sounded the alarm about the potential mental health consequences in the community from the COVID-19 pandemic, but healthcare workers themselves are at particular risk.
Psychiatrists Dr Karen Gaunson and Dr Kym Jenkins, who are part of the #MindingCOVID writing group, outline the importance of professional support networks and a need for further funding to ensure a healthy workforce.
Karen Gaunson and Kym Jenkins write:
Almost overnight the COVID-19 pandemic changed the lives of Australians in a myriad of ways.
With little warning we started doing things differently, garnering solidarity and “staying together apart.”
As we navigated our way through the suppression phase, ongoing uncertainty remained. When will we reach “the new normal” and what will it look like?
Along with our own communal grief and widespread suffering, there was a sudden loss of access to loved ones and familiar institutions, and the grinding halt of industries.
Waves of grief with traumatising images from overseas added to our trepidation and dread of what else might happen.
The short-lived relief, and survivor guilt, as the curve was successfully flattened has subsided, amidst calls to flatten subsequent waves.
Different responses
With social isolation easing, healthcare workers, like the general population, are responding in different ways. Some have a fear of meeting up, reporting feeling apprehensive, saddened or frustrated as people flout social distancing in their eagerness to be together again.
Some feel angry disdain when they hear of colleagues going to work with mild symptoms, especially when awaiting test results.
For those working in healthcare, these feelings are amplified by direct and indirect clinical exposure to COVID-19. Healthcare workers are responding to the pandemic in various ways, reflecting workforce diversity.
Working hard and turning to strategies offering relief and reward can be effective in the short term. However, the high level of grit and effort to sustain performance puts healthcare workers at risk of not noticing the cumulative impact on their wellbeing.
Extraordinary stressors
Healthcare workers have been grouped into #healthcareheroes and those who are more cautious, reflecting different ways of coping with extraordinary stress.
Given the extraordinary stressors, people’s distress should not be unnecessarily pathologised. However, it needs to be acknowledged that some healthcare workers are suffering to an extreme degree and asking for help.
There is a need for greater understanding and appreciation of the stressors facing healthcare workers.
Unexpected rapid transitions are often stressful, especially when accompanied by limited choices or capacity to influence outcomes.
Many have found themselves in different situations to which they are ill-suited. Some hurriedly reorganised familiar terrain, creating confidential productive spaces to work remotely, while others were redeployed or found their workplaces became almost unrecognisable.
In some ways, aspects of our lives now parallel those of children experiencing multiple disruptions, without a sense of time or context.
Many exist without knowing what will happen next with little influence on other’s decisions. They feel stressed by the changes in other’s behaviours and confused about the chaos happening around them.
Behavioural changes
Feeling threatened can lead to aggression and controlling, selfish or distrustful attitudes. Other people can seem less humane, helpful or deserving of help.
Our sense of “being in this together” and gratitude has been tempered with concern about the implications of recent incivility.
Some divisions in society have intensified, along with an unhealthy scepticism for science and public health measures, or a preference for hostile political processes characterised by blaming, shaming whilst privileging the selected few.
Intersectional impacts
Women comprise 70 percent of the healthcare workforce, generally have less autonomy and authority, and often carry a greater caregiving burden. Many are underemployed in lower paid and less prestigious roles with fewer opportunities for career advancement due to gender bias.
Additionally, although it is often stated that COVID-19 does not discriminate, evidence particularly from overseas indicates that Black, Asian and minority ethnic (BAME) healthcare workers have poorer outcomes. Intersectional factors impacting on people’s health can no longer be overlooked.
Heightened risk
Before the pandemic, many healthcare workers experienced vicarious trauma, burnout or compassion fatigue in the course of their usual roles. These are inter-related constructs with a final common pathway which is detrimental to health, performance, and relationships.
People who feel at risk of death at work have a 10-fold increased risk of post-traumatic stress syndrome.
In the pandemic, this risk has been heightened in those who feel unsafe due to inadequate personal protective equipment or have a past history of trauma.
Feeling numb, stressed or persistently fearful can be predictors of secondary traumatic stress.
Healthcare workers in leadership and in public health roles might experience enduring moral injury as they recognise the impact of rationing limited resources or feel powerless to make a significant difference while the pandemic is placing younger generations of healthcare workers at risk of unfulfilled potential.
Valuing mental health care
There have been repeated calls for mental health to be valued as highly as the rest of healthcare, often by courageous healthcare professionals with lived experience.
Overcoming the stigma held by our colleagues goes a long way in tackling the barriers to early access across communities.
The pandemic is shifting cultural norms, as leaders recognise the value of evidence-informed public health policy and investment in mental health.
Healthcare workers would like to feel safe and respected, as they strive to provide humane compassionate care. Both are more likely when mental health has greater parity with physical health.
This current opportunity for bold transformation, where mental health expertise, knowledge and skills are valued as core and enduring components of healthcare must not be missed. In the Australian context, we are fortunate that governments are listening.
Mitigating the impact
Staff wellbeing is now firmly a priority for the medical colleges and societies. The Federal Government has provided funding to the Black Dog Institute for digital health resources.
New services and resources for healthcare workers are emerging in the context of the pandemic. The Minding COVID writing group – comprising Margie Stuchbery, Dr Kym Jenkins, Professor Brett McDermott, Dr Karen Gaunson – came together out of concern for our fellow healthcare workers.
Together we bring a range of complementary skills, knowledge, and expertise not readily available in our often ‘siloed’ healthcare system.
Our intention is to provide a framework along with some tangible, nuanced and accessible resources which have wide reach. The first Minding COVID guide addresses issues of peer support, and a second guide – covering burnout, trauma and vicarious trauma, compassion fatigue, and satisfaction – will soon be released. The handouts are available via @KarenGaunson.
Our work commenced in parallel with the enthusiastic efforts of altruistic colleagues who have set up support structures such as the Pandemic Kindness Movement, the Hand-n-Hand Healthcare Workers Peer Support Network, and Mentate (referral system supported by the Tasmanian Government).
The systemic leadership, governance and extensive networking provided by Dr Kym Jenkins and Professor Brett McDermott, of James Cook University, has enabled these groups to interconnect.
In Victoria, local psychiatrists are sharing innovations, of which there are many, and a tiered pathway is being set up to provide timely support.
As the momentum grows and the barriers of silence and shame becoming progressively overcome, it is wonderful to be one cog in the wheel of systemic change.
Sustainable support
This good start remains heavily reliant on pro bono work by mental health clinicians who themselves are working in an overstretched and relatively poorly remunerated mental health system.
The investment in DigiHealth can only ever supplement what works best, namely human contact. We hope there will be further investment enabling sustainable improvements in staff wellbeing and resilience over time.
It is essential for government to invest in the mental health workforce to meet the predicted wave of mental ill-health across communities and mitigate the potential trauma of working in a service system that could still become overwhelmed.
Public health needs to be above partisan politics. There is a need for working together, rather than a re-emergence of politics focused on exerting power by reducing opponent’s credibility.
The structural inequities, in keeping with intersectionality – racism, ableism, sexism, ageism – and the social gradient need to be addressed.
There has been a lack of parity and inadequate investment over decades, with those most in need missing out. This has been perpetuated by neatly packaged, appealing solutions to complex problems. The Marmot report 2020 provides convincing evidence that proportionate universalism is the right thing to do.
The pandemic has provided us all with an opportunity for cultural change and integration, where compassionate care, humanism and a deep valuing of people’s experiences becomes central to workplaces: ultimately optimising systemic functioning, patient care and transforming community wellbeing.
Dr Karen Gaunson is a parent–infant, child and family psychiatrist who is currently in private practice. Dr Gaunson is on a six-month sabbatical to Mindful Centre for Training and Research in Developmental Health, which is jointly auspiced by the University of Melbourne and Monash University.
Dr Kym Jenkins is Chair of the Chair Council of Presidents of Medical Colleges and Immediate Past-President of the Immediate past-President Royal Australian New Zealand College of Psychiatrists. She has an adjunct appointment as a senior lecturer at Monash University and is an Honorary Senior Fellow at the University of Melbourne. Dr Jenkins leads the psychological safety team at the Pandemic Kindness Movement and is on the executive of the Hand-n-Hand Healthcare Workers Peer Support Network. She is also a Board Director of Mental Health Australia.
