Managing Stress During COVID-19

Formal peer support teams in the prehospital environment have long been utilized for support after critical incidents,¹ and their use will continue. However, COVID-19 has presented a new series of problems. As infections and deaths increase, healthcare workers face additional stressors that previously might have been difficult to imagine. In times like this it is essential for peer support teams to take a proactive approach to supporting the health and well-being of staff.  

Experience during previous outbreaks indicates the psychological burden placed on healthcare workers is significant. A study of hospital workers during SARS noted that more than two-thirds reported psychiatric symptoms, including anxiety, worry, depression, and interpersonal difficulties—a rate three times higher than the general population’s.² Recent reports from Wuhan, China, where the COVID-19 virus originated, noted that just over a third of medical and nursing staff caring for patients had subthreshold mental disturbances, approximately one-third had mild symptoms, and of the remainder 22% had moderate and 6% severe symptoms.³

These effects on healthcare workers during SARS were not appreciated. Only after the fact was the need for psychological support response teams recognized.⁴ During the current COVID-19 outbreak, China anticipated this and integrated crisis intervention into its medical response plan with a goal to “minimize psychological damage.”⁵

Peer support teams should form the backbone of this psychological support network for prehospital providers. Contact each frontline employee, especially the ones too busy to reach out, to develop a wellness plan. The plan can be formal or informal but should include information and skills for each provider across several different areas. The message should be the same: Personnel need to become intentional about self-care.

Wellness at Home

Encourage EMS personnel to create structure at home. Creating structure in the midst of the unknown helps create certainty. Creating certainty normalizes the home, which is vital for the whole family unit. The schedule should include time to continue regular exercise or activity as well as stay connected with friends and family. Working collaboratively to find creative solutions is integral. Scheduling can also include limiting news coverage to a few trusted sources and scheduling times throughout the day for personnel to access information. 

Many members of the general public do not know about good infection-control practices in the home.⁶ Keep an open dialogue with nonmedical family members. Do not be afraid to talk about COVID-19, but it is imperative to take cues from your family. This is especially important with children, to make sure they don’t feel at fault for parents’ feelings such as fear or anger about the pandemic. 

Wellness at Work

In previous outbreaks healthcare workers described a positive attitude from colleagues as the most crucial factor in reducing stress.⁷ Managing relationships between coworkers and partners is critical. Form agreements at work about time spent talking about COVID. Constant talk of worst-case scenarios is not helpful to your health and well-being. Don’t be afraid to invite people to have different discussions or change the subject.

Ensuring all personnel have easy access to clinically relevant information is essential. Provide clear guidelines surrounding infection control practices and personal protective equipment and update information regarding clinical outcomes with infection help to decrease stress.^7,8 

Wellness on Calls

Regardless of their experience, all EMS providers have faced stressful calls and developed their own methods for dealing with stress. Remind personnel they already have a significant stress management skill set! Adding or reminding crews of other situational skills and coping strategies such as preplanning becomes more important as treatment protocols and protective equipment guidelines remain dynamic. 

One framework shown to decrease stress-related work symptoms is the problem-solving approach. Most prehospital providers use a similar approach already. Teaching personnel this approach will provide a formalized structure to problem-solving or remind them they can draw on these skills they already possess. It is based on the following steps:⁹

1. Define the problem and goal;
2. List possible solutions;
3. Identify consequences with each solution;
4. Develop an action plan by prioritizing the solution list.

Additionally, providers can learn skills to manage stress while on calls. Visualization, breath control, and attention focus have proven benefits.¹⁰

Moral Injuries

The scale of the COVID-19 outbreak has forced decisions surrounding allocation of resources and triage in a way rarely seen in modern medicine. This may force EMS and other healthcare providers to make decisions that conflict with their morals or ethics. These situations are referred to as moral injuries.

It has been suggested that prehospital and emergency workers may be at particularly high risk for these during the pandemic. Addressing this potential should be part of a proactive approach by peer support teams. Open and honest discussions about possible situations may help, including open lines of communications with supervisors and medical oversight so expectations can be established.¹¹

References

1. Gouweloos-Trines J, Tyler MP, Giummarra MJ, et al. Perceived support at work after critical incidents and its relation to psychological distress a survey among prehospital providers. Emerg Med J, 2017 Dec; 34(12): 816–22.

2. Chong MY, Wang WC, Hsieh WC, et al. Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital. Brit J Psych, 2004; 185: 127–33.

3. Kang L, Ma S, Chen M, et al. Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study. Brain Behav Immun, 2020 Mar 3; 0889-1591(20)30348-2.

4. Wenzel RP, Bearman G, Edmond MB. Lesson from Severe Acute Respiratory Syndrome (SARS): Implications for Infection Control. Arch Med Research, 2005; 36: 610–6.

5. Jiang X, Deng L, Zhu Y, et al. Psychological crisis intervention during the outbreak period of new corona pneumonia from experience in Shanghai. Psychiatry Res, 2020 Feb 28; 286: 112903.

6. Hawryluck L, Gold W, Robinson S, et al. SARS Control and Psychological Effects of Quarantine, Toronto, Canada. Emerg Infect Dis, 2004; 10(4).

7. Khadlid I, Khalid TJ, Qabajah MR, et al. Healthcare Workers Emotions, Perceived Stressors and Coping Strategies during a MERS-CoV Outbreak. Clin Med Res, 2016 Mar; 14(1): 7–14.

8. Panagiota G, Mantas C, Dimistroula D, et al. General hospital staff worries, perceived sufficiency of information and associated psychological distress during the A/H1N1 influenza pandemic. BMC Infect Dis, 2010; 10: 322.

9. Bergstrom G, Lohela-Karlsson M, Bodin L, et al. Preventing sickness absenteeism among employees with common mental disorders or stress-related symptoms at work: Design of a cluster randomized controlled trial of a problem-solving based intervention versus care-as-usual conducted at the Occupational Health Services. BMC Public Health, 2017; 17: 436.

10. Page JW, Asken MJ, Zwemer CF, Guido M. Brief Mental Skills Training Improves Memory and Performance in High Stress Police Cadet Training. J Police Crim Psych, 2016; 31: 122–6.

11. Greenberg M, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare wokers during Covid-19 pandemic. BMJ, 2020; 368: m1211.

Jonathan Lee is a critical care paramedic with 20 years of experience working in roles such as 9-1-1, air medical, and pediatric critical care transport. He has a significant background as an educator, including his current role with the paramedic program at Ontario’s Georgian College. Jonathan is also a member of the peer support team at Ornge. Contact him at jlee@kindermedic.com.

Tom Walker has a master’s degree in social work and is a trained clinical traumatologist and certified compassion fatigue specialist. He is the human factors specialist at Ornge, where we has implemented both peer support and stress management programs. His work also includes therapeutic interventions for staff suffering from trauma, addictions, and mental health/illness. Contact him at twalker@ornge.ca.