For weeks, our health care workforce has been on the frontlines of the COVID-19 pandemic staring straight at mortality – their patients and their own. They have been single-mindedly focused on the task at hand, doing what needs to be done while instinctually suppressing their emotional response. The job requires this, and they have done it well.
Yet, the tragic suicide of Dr. Lorna Breen has brought focus in a devastating way to the emotional impact of caring for patients on the frontline of the pandemic. Like Wuhan, Italy, and Spain, NYC was quickly overwhelmed by the sheer volume of critically ill and terminal patients at an alarming rate. The stories describe people dying in their homes and hospitals. The providers rushing to the sides of these people had spent their careers focused on saving lives, but instead, the health care workers are cast in the role of supporting characters in the drama of chance, with the inability to anticipate who will live and who will die and what treatments will help.
We have rightly been focused on the very concrete and essential need for literal personal protective equipment that includes masks, shields, gloves, and gowns to protect the physical wellness of our health care community. Yet, we soon will be faced with another critical epidemic from COVID-19 if we don’t act urgently to prepare for and prevent further injury and assault on our health care teams.
Health care workers are acclimated to routines that are filled with standard protocols, calibrated systems, and hierarchies around clinical decision-making. But that world has evaporated. Our physicians, nurses, and staff are managing unchartered territory without a plan. We know that the impact of high-intensity survival experiences accumulates and we cannot avoid the lasting injuries of this relentless work.
Based on the evidence of the effects of trauma, we can predict that our health care teams, patients and families will exhibit signs of this assault through a variety of symptoms–sleeplessness, apathy, depression, and anxiety. The warning signs are already here. We read the desperate accounts and pleas of frontline workers describing the indescribable, holding the hands of patients dying alone, communicating with stunned and distraught families isolated away from death beds of their loved ones. Dr. Breen is symptomatic of a larger undercurrent of the fatal moral injury of the system currently at work. We need to face it head-on or risk additional losses as tragic as this.
Fortunately, numerous organizations have created and directed the health care world to a host of mental health resources, including free therapy services, helplines, and suicide prevention crisis lines. While these resources are important and welcomed, they miss a critical personal protective equipment lacking in this evolving pandemic–Personally Protected Emotions- another form of PPE. In the medical community, providers are conditioned to consider their own needs and emotions last. Even the act of seeking help can feel like a sign of weakness. The narrative in our heads is always that someone else has it worse, and they are “handling it” fine. We have learned how to numb emotional responses. But no one in this pandemic is “handling it” fine. The psychological burdens, particularly for those on the “frontline” will have a profound and devastating impact for years beyond the pandemic.
There is no reason for those health care providers to move through this trauma alone. This experience is shared. The trauma and moral injury it causes is played out again and again in emergency rooms and intensive care units throughout the country and throughout the world. We need to harness the supportive powers within our health care team’s own cohesive community to bond and heal together. It needs to be prioritized as a part of the job, just as important as morning rounds and signout.
We have an obligation to structure in required time and space for frontline providers to share the impact of these emotionally demanding experiences with one another. Fostering the healthy resources that exist with human connection, shared experiences, and attentive listening should be the next wave of Personally Protective Emotions for our workforce. Without this step, our teams will suffer from the impact of witnessing human suffering and moral injury.
How will this look?
1. Mandatory individual sessions check-ins. Much like police officers who are involved in a shooting must undergo a psychological evaluation prior to returning to work. Health care workers who witness brutal and devastating experiences with death should have an assessment to determine readiness to continue or return to work.
2. Daily emotional temperature-taking “check-ins” during sign out or rounds. These can be brief interactions to gauge a provider’s emotional state. Teams can hear about challenging patient care scenarios and offers time to acknowledge the emotional toll of patient care.
3. Monthly or biweekly “Balint type” or moral suffering-resiliency rounds. These sessions would allow time for team members to discuss particularly devastating clinical encounters. This will allow for reflection and cohesion that comes from shared witnessing of suffering.
4. Mandated protocols whereby workers are able to rotate on and off intensive COVID care services at scheduled intervals of time. Stretches of time worked should be cushioned with equal amounts of time off to allow for recovery, both physical and emotional.
The success of any of these measures requires buy-in at the highest levels of leadership. Leaders need to champion these efforts. It needs to be embedded in clinical time, so it does not interfere with precious personal time. Offer your team members an opportunity to be involved in choosing the kind of support that would work for them. Ensure that these opportunities are not “voluntary” but rather are expected as part of the culture of medicine. No one is escaping the frontlines of this pandemic unscathed, and it is our responsibility to ensure we are attentive to their emotional health rather than risk the fall out down the road.
Trust that meaningful action can come when the PPE — personally protected emotions — of time and space for telling, hearing, and healing becomes a priority for your teams.
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