Protecting the mental health and wellbeing of healthcare workers during the COVID-19 outbreak.

Protecting the mental health and wellbeing of healthcare workers (HCWs) should be a priority in the current crisis, as they are at the core of the fight against the COVID-19 pandemic.

HCWs are people engaged in actions whose primary intent is to enhance health, such as medical doctors and nurses. According to the International Labour Organization (ILO, Publication 2020), around 135 million workers worldwide are in the health and social work sectors. In most countries, women make up the vast majority of the health care workforce. For instance, in the European Union (EU), women make up 76 per cent of this sector (COVID-19 and gender equality, EIGE).

There can be no doubt that strong health systems need a well-prepared health workforce under appropriate working conditions. According to the World Health Organization (WHO, Publication 2020), even before the current crisis, many countries already had to deal with health workforce challenges affecting everyone working to improve health in their community. The WHO estimates a shortage of 18 million health workers worldwide by 2030. Also, the distribution of the workforce is uneven, and regions facing the highest burden of disease present the lowest densities. For instance, according to the WHO Global Health Observatory (GHO), as of 2020, over 55% of WHO Member States report to have less than 20 medical doctors per 10 000 population (almost 40 countries in the African region; GHO, Health Workforce: Medical doctors).

The COVID-19 pandemic has led to an overburdening of health systems all over the world, including Europe. Many resources have been redirected to COVID-related treatment at the expense of other health care services (e.g. mental health support). On the report of the pulse survey conducted by WHO in August 2020, many responding countries informed about the following disruptions of health services: 49% because of deployment of staff to respond to COVID-19, 44% because of insufficient personal protective equipment for health workers, and 29% because of insufficient staffing level to provide services.

HCWs, especially those working at the frontline, have a higher risk of being infected with COVID-19. By April 2020, more than 20,000 cases of COVID-19 in HCWs from 52 countries had been reported to WHO (ILO, Briefing Note, June 2020). According to Amnesty International (AI, News, March 2021), at least 17,000 HCWs have died worldwide from COVID-19 over the last year. However, these figures could be underestimated due to underreporting in many countries or the absence of systematic reporting. Also, health professionals have to deal with a high workload, long working hours and, a lack of protective materials. On top of that, during the COVID-19 pandemic, hundreds of incidents of violence and harassment towards HCWs have been reported (Devi S., 2020).

On the other hand, HCWs are exposed to intense emotional stress; the negative effects of stress can impact mental health and can contribute to depression and anxiety.  For instance, early reports in China showed that a considerable proportion of HCWs experienced symptoms of depression, anxiety, insomnia, and distress, especially women, nurses, and frontline health workers (Lai, J. et al., 2020). A systematic review also reported early evidence of mood and sleep disturbances during the COVID-19 crisis among these professionals (Pappa, S. et al., 2020).

Another factor that can impact the mental health of HCWs is the presence of burnout syndrome. Burnout is defined in ICD-11 (International Classification of Diseases; WHO, Departmental News, May 2019) as an occupational phenomenon resulting from chronic workplace stress that has not been successfully managed. It is characterised by feelings of energy depletion or exhaustion,  increased mental distances from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy. According to the American Psychiatric Association (APA, Wellbeing and Burnout), burnout is very common among health professionals and it is important to address it as it affects the quality of care and patient safety, it can impact the health workforce by increasing turnover and early retirement, and it can overlap with mental health. Emergency settings can drive emotional exhaustion and lead to burnout (Kim and Choi, 2016). Furthermore, a recent study carried out in Italy reported that HCWs had high levels of burnout, as well as psychological symptoms during the COVID-19 crisis (Giusti, E. M. et al., 2020).

According to an analysis published in the BMJ journal (Greenberg, N. et al., 2020), HCWs battling COVID-19, are at risk of experiencing moral injury (i.e. psychological distress that results from actions or lack of actions, which violate a person’s moral or ethical code) as they have to make difficult decisions and work under extreme pressures. Moreover, those who experience negative thoughts about themselves, and intense feelings of shame or guilt (symptoms of moral injury), can develop mental health problems such as depression, post-traumatic stress disorder or even suicidal ideation. The authors suggest the following measures to protect the mental health of HCWs that have to face morally challenging decisions during the COVID-19 crisis: Healthcare managers need to proactively take steps to protect the professional health workers’ mental wellbeing; HCWs can be supported by reinforcing teams and providing regular contact to discuss decisions and check on wellbeing; finally, once the crisis recedes, they must be actively monitored, supported and provided with evidence-based treatments if necessary.

All in all, there is an urgent need to improve the resilience, wellbeing and mental health of HCWs. This can be done by mitigating mental health risks and adjusting evidence-based psychological interventions to the context of the pandemic. In this regard, conducting good research is key to understanding which factors influence mental health in the COVID-19 context, and to identify and test interventions that promote the health and wellbeing of the health workforce. For instance, efforts have been made to study the feasibility of brief mindfulness-based interventions to reduce stress for frontline health workers during the COVID-19 crisis in Spain (Rodríguez-Vega, B. et al., 2020).

At a larger scale, the European Union has funded several projects to investigate the long-term behavioural and health effects of the COVID-19 pandemic. One of them is RESPOND (Improving the PREparedness of Health Systems to Reduce Mental Health and Psychosocial Concerns resulting from the COVID-19 PaNDemic), which offers the opportunity to implement scalable psychological interventions developed by the WHO into a stepped care system that could respond to the psychological needs of frontline health workers affected by the pandemic in European countries. The RESPOND project also aims to provide evidence-based policy recommendations that will be presented through different Policy Briefs and will be available on the project’s website (https://respond-project.eu/). Moreover, the project has completed its immediate delivery phase and has published a rapid report on vulnerable groups for COVID-19 related psychological distress, which includes frontline HCWs (RESPOND, Deliverable D2.1., February 2021).

EU’s research funding is a fantastic opportunity to foster collaboration, allowing researchers across different countries to work together. Several interventions have been developed to promote wellbeing and prevent or treat mental disorders in the workplace, including EMPOWER (The European Platform to Promote Wellbeing and Health in the workplace). Although the EMPOWER consortium is not focused on the health service sector, it is in close contact with other projects that have been funded under the same research topic, and therefore, share common goals. An example of which is Magnet4Europe, an initiative that aims to improve mental health and wellbeing in the health care workplace. Magnet4Europe redesigns work environments in health care to promote the mental health and wellbeing of health professionals, enhance their productivity, and in doing so to improve outcomes of the patients under their care.

Finally, the WHO has published a guide that identifies recommendations to protect, support and empower health professionals during the COVID-19 crisis that will be updated on regular basis (WHO, Interim guidance, December 2020). It takes into account recommendations from organisations and institutions active in the response to COVID-19, such as international organisation or academia, amongst others. The guide presents recommendations at individual, management, organisational and system levels:

• Interventions to support health workers at an individual level: infection prevention and control, decent working conditions, mental health and psychosocial support, and remuneration and incentives.
• Interventions to build capacity and optimize the role of health workers: building competencies required for the COVID-19 respond through training, optimising roles, and leveraging community-based health workers.
• Interventions targeting the organisational environment: improving health worker availability, activating partner networks, rationalising the health workforce distribution, and ensuring a supportive work environment.
• Interventions targeting system-wide health workforce enablers: improving health workforce information systems, assessment and planning of health workforce needs, licensing and regulation reforms, and strengthening governance and intersectoral collaboration mechanisms.

In sum, the COVID-19 crisis is having a great impact on healthcare workers all over the globe. Health workers must be supported, protected and equipped to deliver safe health care at all times. To honour their dedication, the 73rd World Health Assembly of the WHO declared 2021 as the International Year of Health and Care Workers (YHCW).

Kerry Rodríguez McGreevy, Psychologist, PhD
WHO Collaborating Centre for Mental Health Services Research and Training.
Department of Psychiatry. School of Medicine. Universidad Autónoma de Madrid. 
https://www.ccomsuam.org/

References

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