As the U.S. health care system gears up to confront the rapidly accelerating COVID-19 pandemic, a mental health crisis could be looming on the horizon. Frontline health care workers in emergency rooms and intensive care units around the country face multiple unprecedented challenges, including difficult decisions about the allocation of limited resources, long and physically demanding working hours, staff shortages due to fear and illness, and lack of adequate protection from the virus. The consequences of this on health care workers' short- and long-term mental health could be significant and could weaken the U.S. health care system's ability to resolve the current pandemic and survive over the long term. Already, there is evidence of the substantial psychological burden that frontline health care workers in Wuhan are now carrying. We must take appropriate action now, and quickly, to protect our health care workforce.
Health Care Workers Are Facing Multiple Challenges
Their bleakest challenge may be the difficult decisions health care workers have to make about which patients get ventilators. It has been estimated that up to 1 million Americans may need ventilator support during this pandemic, but with only 160,000 ventilators across the nation's hospitals (PDF) and 9,000 in the National Strategic Stockpile, it is certain that some COVID-19 patients will not get ventilator support. Health care workers will be forced to ration ventilator use and then watch as patients die without necessary medical care simply because of a lack of available resources.
In the face of the sheer numbers of patients expected to get sick with the coronavirus and require hospitalization, it is clear that there are not enough health care workers to adequately manage the impending tsunami of patients. Even as hospitals get creative by relaxing credentialing rules, instituting crisis staffing ratios, redeploying doctors and nurses from other specialties, and asking some to come out of retirement to help in ICUs and ERs, the system is facing a major shortage of the necessary health care workers to deal with the pandemic. Those remaining will be asked to work long and physically demanding hours to make up for staffing shortages, often extending themselves beyond their expertise, scope, and comfort level.
The very real safety risks facing health care workers during this pandemic contribute to justifiable fear and anxiety.Share on Twitter
Health care workers are also working under conditions of fear and uncertainty regarding their own safety. Lack of personal protective equipment and limited testing capacity are increasingly raising worries among health care workers that they could get infected while providing care and could unknowingly infect their families and other patients. As evidence mounts of the growing numbers of health care workers infected with the virus, the very real safety risks facing health care workers during this pandemic contribute to justifiable fear and anxiety.
Health Care Workers Are at High Risk for Short- and Long-Term Mental Health Problems
These combined challenges could create working conditions that put health care workers at high risk for acute burnout and longer-term psychological morbidity. Studies following the SARS and MERS outbreaks showed that frontline clinicians experienced high levels of fear, worry, and anxiety during the outbreaks, and higher depression, anxiety, and posttraumatic stress over time, underscoring the long-term impacts on health care workers during a pandemic. These negative health impacts may be even greater for some, like those with children/family at home, those at higher risk of exposure, and particularly those who are older, immunocompromised, or chronically ill.
Health Care Workers Will Face Considerable Moral Distress
In addition, the moral and ethical dilemmas that health care workers will face will undoubtedly take a terrible toll on their emotional well-being. Moral distress among ICU clinicians is well-documented and quickly leads to emotional and psychological burnout. Evidence from other resource-constrained disaster events including the 2004 Indian Ocean tsunami and the 2010 Haiti earthquake highlight the significant moral distress of responders, often co-occurring with lack of ethical and consistent guidance for allocation of scarce resources. Unique to the current crisis may be the moral distress and injury experienced by health care workers due to the lack of preparedness and responsiveness by state and federal leaders—for example, the failure to procure adequate tests and personal protective equipment (PPE). Moral distress stemming from feelings of betrayal of this sort can lead to anger, resentment, and unhealthy coping strategies.
Morale Will Be Low
It is likely that morale among health care workers will decline over the course of this pandemic. Even now, as many hospitals sit on edge waiting for the first wave to hit, news from New York is affecting morale among health care workers. Despite aggressive efforts to prepare and rallying cries of “all hands on deck” and “we're in this together,” requests to continue working in uncertain, unsafe, and morally distressing conditions with limited resources may leave health care workers feeling exposed, unsupported, and drained. Chronically low morale among health care workers during this pandemic may impact retention and absenteeism over the short term and burnout and psychological burden over the longer term.
Immediate Action Is Required to Mitigate This Mental Health Crisis
Health care workers at the frontline of the COVID-19 pandemic are at high risk for burnout, depression, anxiety, PTSD, substance abuse, even suicidal ideation. Specific interventions to promote psychological well-being now should be implemented as part of current response efforts.
For example, frequent shift rotations and breaks can reduce physical impacts as well as emotional stress. Providing an isolated and dedicated place for staff to rest and ensuring staff have enough time to recover between shifts could be critical; medical staff fighting the pandemic in China have stressed the need for uninterrupted rest even more than access to a psychologist. Providing resources such as childcare support or alternative living arrangements for health care workers could help to minimize the real and perceived risk of viral spread to families.
Health care workers at the frontline of the COVID-19 pandemic are at high risk for burnout, depression, anxiety, PTSD, substance abuse, even suicidal ideation.Share on Twitter
Deploying consistent interdisciplinary care teams who rotate on and off together can foster peer support and morale, help to diffuse the existential burden of caring for these complex patients, as well as minimize viral spread and support containment when necessary. Encouraging a team-based approach to decisionmaking from the start of care might also ensure that no one health care worker feels responsible for an ethically challenging decision. Proactively involving an ethics team or palliative care team where available could also offset the emotionally difficult task of communicating with families about treatment plans, prognosis, and decisions about life-prolonging treatments, while distributing workload.
It is important for health system and hospital leadership to be visible and accessible to their staff during this time. They should continue their aggressive and visible efforts to ensure the safety of their health care workers, for example by advocating for more PPE and systematically implementing policies to encourage rest and recovery between and during shifts. Regular communication with staff and providing opportunities to contribute to higher-level planning efforts could help health care workers feel acknowledged, supported, and protected. Floor supervisors could regularly walk through the unit to provide real-time support, identify immediate staff needs, remind staff to monitor themselves for stress reactions, facilitate handoffs when a break is needed, and even lead quick “huddles” after a stressful event or procedure to provide social support.
Hospitals could also provide access to evidence-based crisis mental health support, such as psychological first aid or stress first aid, first developed to support service members with combat and operational stress. Organizations such as the National Fallen Firefighters Foundation, the Red Cross, the National Center for PTSD, Coursera, and the John Hopkins School of Public Health all provide training in these interventions and could be engaged immediately. Hospitals could call upon hospital chaplains and community mental health providers to provide services such as one-on-one therapy, support groups, mindfulness sessions, and to routinely assess burnout and other psychological outcomes to provide timely access to appropriate treatments.
Protecting the Mental Health of Our Frontline Health Care Workforce Is an Urgent Priority
While adequate PPE is critical to immediate survival for health care workers, supporting the resilience of health care workers could be just as important, both in the short and long term. Evidence-based solutions, such as providing training in psychological first aid, access to counseling, and allowing adequate rest, could be incorporated into the regular planning and preparation every hospital in the country is undertaking. Failing to support the resilience of health care workers who are risking themselves to protect public health could threaten the last line of defense against this pandemic.
Sangeeta C. Ahluwalia and Carrie M. Farmer are senior policy researchers and Mahshid Abir is a senior physician policy researcher at the nonprofit, nonpartisan RAND Corporation.
Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.