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RANZCR: Maintaining Your Wellbeing in Public Health Crises
The Royal Australian and New Zealand College of Radiologists (RANZCR) Inside News June 2020
An Examination of the Demands on the Professions
With each passing day, as the pandemic progresses beyond the acute phase of a major public health emergency to the persistent symptoms of an uncertain aftermath, the focus of medical attention shifts gradually from the physical to the mental.
Many health workers spearheading the community pandemic response—such as doctors and nurses who have borne the risks of treating infected patients in less-than-ideal circumstances, as well as disruption to their workloads, practices and home lives—have now entered an indefinite, uneasy period of recovery and reflection, combined with a raised level of alertness in anticipation of a resurgence in activity. Some are exhausted by the experience, most feel stressed, and it seems a few may be feeling much worse than that.
The impact of the coronavirus pandemic on the mental health of medical and allied health professionals has attracted anecdotal attention in the mainstream media and serious research in medical and scientific circles.
Doctors participating in Facebook and radio discussions have spoken of their and colleagues' fears and emotional responses to the pandemic. In an ABC Radio National program aired in April, a group of GPs, specialists and nurses noted a sudden rise in burnout, heightened anxiety, inability to relax or sleep, excessive drinking and depression among medical practitioners dealing with the pandemic. 1
Among them, Dr Caroline West, an East Sydney GP and health broadcaster, said that doctors who felt energised in the short term as they coped with the crisis, would have difficulty in sustaining this level of intensity, and she warned it would be unwise to do so. 'When you remove all the things in your life which have kept a sense of balance, including decent sleep, nutritious meals on time, connecting with friends, and exercise, it's easy to become quite emotionally depleted.' Without 'recharge time', healthcare workers would eventually struggle to concentrate and bring their best to the job each day, she said.
Dr Emma Adams, a Canberra psychiatrist, felt that, while a few doctors had spoken to her of resigning their jobs or even experiencing suicidal thoughts, their tendency was to keep going.
'Doctors aren't going to collapse and put patient care at risk—they are more likely to put their own health at risk,' she told the ABC. 'There are a lot of barriers for doctors seeking help, and one is being seen as not coping. They are worried about being reported to the medical boards and the Australian Health Practitioner Regulation Agency if they admit they have depression or anxiety,' she said.
Adams's observations are supported by the findings of Beyond Blue’s national mental health survey of doctors and medical students in 2013. This study found that 40 per cent of Australian doctors felt that medical professionals with a mental health history were perceived as less competent than their peers. The survey also revealed that, while rates of 'very high psychological distress' among doctors were similar to those in the general population (but higher than other professionals), doctors were less likely to seek treatment because of a preference to self-rely or due to embarrassment and/or concerns over loss of privacy, impact on the right to practise and career prospects.2
In the medical literature, academics and clinicians at home and overseas began to warn as early as February of the mental health risks that COVID-19 poses for health professionals. A research team at the University of Bristol described the mental health impact of the pandemic as potentially 'profound,' especially among healthcare workers operating at the leading edge of a response.
The UK team argued that mental health consequences were 'likely to be present for longer and peak later than the actual epidemic,' and that suicide prevention needed 'urgent consideration.'3
In these warnings, researchers have drawn on a body of compelling evidence gathered in the aftermath of the SARS and MERS epidemics in 2003 and 2015. For example, a study of 550 doctors, nurses and other hospital staff at a Beijing hospital in 2006 found that 10 per cent of respondents had experienced symptoms of posttraumatic stress (PTS) at 'high levels' since the SARS epidemic in 2003. Those who had been quarantined, had worked in SARS wards, or had relatives or friends with the disease were two to three times more likely to have PTS symptoms than those who did not have these experiences. 4
Similar findings were obtained in Taiwan, Hong Kong and Singapore. At three hospitals in Hong Kong, over two-thirds of health workers reported high stress levels within months of the outbreak, and over half reported feeling 'psychological distress.' 5
In Taiwan during the SARS epidemic, five per cent of staff in a teaching hospital suffered an 'acute stress disorder,' with experience of quarantine the most strongly correlated factor. The study also found that 20 per cent of staff felt stigmatised in their neighbourhoods for their hospital work, and nine per cent had considered resigning or had experienced a reluctance to go to work. 6
With the MERS outbreak in 2015, a study of 1,800 hospital practitioners in South Korea found that those who undertook MERS-related tasks recorded the highest risk of PTS symptoms among staff in the aftermath of the outbreak, and this risk was even higher if they had been quarantined. 7
What is most evident from these and similar studies is that pandemic and epidemic events have significant mental health implications, and in this, our healthcare workers, including doctors and nurses, are vulnerable.
Image courtesy of the Pandemic Kindness Movement
In late March, the Australian government launched a national health plan and a website (www.headtohealth.gov.au) to address concerns about the mental health and wellbeing of Australians during the pandemic. At the end of April, the Pandemic Kindness Movement was created by clinicians across Australia to support and enhance the health and wellbeing of all health workers during the pandemic. The Pandemic Kindness Movement website by the NSW Agency for Clinical Innovation (ACI), directs users to helpful resources that are respected and evidence-informed, curated by teams of clinicians and wellbeing experts. Adapting Maslow’s hierarchy of needs to reflect potential challenges on the health workforce, resources are organised under six key areas; leadership actions and behaviours, contribution, esteem, love and belonging, safety and basic needs. The multi-state initiative is supported by the ACI, the Commission on Excellence and Innovation in Health South Australia, Safer Care Victoria, and Queensland Government.
The Pandemic Kindness Movement website: a clinician-led initiative for health workers
What is needed in addition to these sites and other general mental health resources such as Beyond Blue is first an acceptance in our ranks that medical staff and other health workers bear the brunt of the response to the virus. Further, we need to accept that this burden—which may result in overwork, disrupted routines, fear of contagion for themselves and their families—is likely to increase the risk of psychological stress, burnout, anxiety, depression and suicidal ideation.
The College also recognises these needs and the role we have in protecting the mental health of our members and recognising the promotion of mental health as an important aspect of our mission. A College webpage on your wellbeing offers resources for Fellows, Educational Affiliates and trainees, including online self-care learning modules developed by The Royal Australian and New Zealand College of Psychiatrists which attract CPD points.
Given that doctors have a tendency to prefer self-help over asking others for assistance, it is worth considering what they might do for themselves to release psychological stress caused by work and improve their mental health. In a year-long study of work engagement and wellbeing in Germany and Switzerland in 2010, researchers found that psychological detachment, informally known as 'switching-off,' outside of work buffered social workers and allied healthcare employees against emotional exhaustion and burnout. The study concluded that 'job demands . . . are less harmful when employees mentally disengage from their job during off-job time.' 8
Of course, switching-off and sharply demarcating work life from home life has added difficulty during a public health crisis, as many workers have opted to work remotely, usually from home, to help minimise the spread of the virus. How is one to psychologically detach from work in the evening when the day's efforts surround you and the phone continues to buzz with emails and texts?
Reflecting Maslow’s hierarchy of needs, resources are organised under six key areas
In examining the factors which helped cancer workers avoid burnout and recover from work stress, a Queensland team emphasised the value of psychological detachment outside of work and the risk factors which degrade mental health. 9 These included hours worked each week, age (35 to 45 being the worst decade), children, marital status and frequency of strenuous exercise. Of these factors, only one is readily modifiable—that of exercise. The researchers noted a strong positive influence on psychological detachment and its benefits among those who exercise four or more times a week, and even a statistically significant effect for those who exercise once a week.
The evidence clearly indicates that, in addition to seeking help from others, when your stress levels get too high, members can use exercise to improve not just your physical health but also boost your own ability to safeguard your mental health.
Scaffolding our wellbeing with mindfulness, meditation and good sleep hygiene also boosts our physical and mental staying power. All of these can sound like small measures in the face of a large challenge. They can also prove surprisingly difficult to actually maintain, even if seemingly small. But the sum total of developing self-preservation habits of seeking help; accessing available resources; exercising regularly; practising mindfulness and meditation; and just simply getting enough sleep can make the crucial difference to our ability to pull through.
To access useful resources visit:
www.ranzcr.com/fellows/general/ your-wellbeing
www.aci.health.nsw.gov.au/ covid-19/kindness
References
1 ABC Radio National, "Mental health on the Covid frontline," All in the Mind, [radio program] 19 April 2020, https://www.abc.net.au/radionational/programs/allinthemind/covid-frontline/12147598
2 Fei Wu, Michael Ireland, Katherine Hafekost, and David Lawrence, The National Mental Health Survey of Doctors and Medical Students [report] (Melbourne:beyondblue, Oct. 2013), https://tinyurl.com/ra85vxd
3 Yu-Tao Xiang et al., "Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed," The Lancet, vol. 7, March 2020, 228–229; David Gunnell et al., "Suicide risk and prevention during the COVID-19 pandemic," The Lancet, [online] 21 April 2020, https://doi.org/10.1016/S2215-0366(20)30171-1
4 Ping Wu et al., "The psychological impact of the SARS epidemic on hospital employees in China: Exposure, risk perception, and altruistic acceptance of risk," The Canadian Journal of Psychiatry, vol. 54, no. 5, May 2009, 302–311.
5 Cindy W. C. Tam et al. " Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: stress and psychological impact among frontline healthcare workers,"Psychological Medicine, vol. 34, 2004, 1197–1204.
6 YaMei Bai et al., "Survey of stress reactions among health care workers involved with the SARS outbreak," Psychiatric Services, vol. 55, no. 9, September 2004,1055–1057.
7 Sang Min Lee et al., "Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients," Comprehensive Psychiatry,vol. 87, 2018, 123–127.
8 Sabine Sonnentag and Carmen Binnewies, "Staying well and engaged when demands are high: The role of psychological detachment," Journal of Applied Psychology, vol. 95, no. 5, 2010, 965–976.
9 Michael G. Poulsen et al., "Recovery experience and burnout in cancer workers in Queensland," European Journal of Oncology Nursing," vol. 19, 2015, 23–28. The study's authors contributed a feature article to Inside News in September 2018.
