Amid COVID-19, frontline medical workers take their trauma home

Medical personnel experiencing mass trauma, studies show

A woman is seen sitting in the hallway at Ashdod's Samson Assuta Hospital. (photo credit: MARC ISRAEL SELLEM/THE JERUSALEM POST)
A woman is seen sitting in the hallway at Ashdod's Samson Assuta Hospital.
Nurses and doctors are facing mass trauma as a result of the COVID-19 pandemic, according to several recent reports. The challenge is putting healthcare workers in immediate risk, which could impact the future of Israel and the world’s healthcare systems.
“It’s very complicated,” said Dr. Jacob Haviv, Director-General of Herzog Medical Center in Jerusalem, on treating COVID-19 patients. “There is an emotional stress from which you cannot disconnect.”
He said that in most jobs, people can leave the office and put their work aside, come home and go to the grocery store or see a movie. But in the last several months of the pandemic, there has been little if any relief from the intensity of the COVID-19 wards.
“There are so many events, so many very difficult patients – a lot of people’s lives are dependent on you and it is very hard to disconnect,” he told The Jerusalem Post. “When you go to the supermarket or sit in front of the TV, thoughts follow you. You ask yourself, ‘Did I give the correct treatment? What is happening with that patient?’ You are always questioning.”
A new study soon to be published in the peer-reviewed journal Depression and Anxiety found that, in fact, healthcare workers treating COVID-19 patients face high levels of psychological stress that has led to post-traumatic stress symptoms (PTSS), depression and anxiety far greater than even those hospital workers who serve outside the COVID-19 wards.
“Twenty-five percent of first-line workers had PTSS,” Mariela Mosheva of Sheba Medical Center, Tel Hashomer, told the Post. Mosheva, who led the study titled “Mental health outcomes in frontline healthcare workers,” said that these workers also have a three-times higher chance of developing PTSS than their non-COVID-19-facing peers.
The most common symptoms were dissociation and intrusiveness.
The study examined 828 healthcare workers (42% physicians and 58% nurses), including 189 from Sheba’s COVID-19 team.
The COVID-19 team reported significantly more anxiety about infecting their families (54.3% vs 47.0%) and had higher rates of mental exhaustion (36.4% vs 25.6%).
MOSHEVA SAID that there were many reasons that could contribute to the increased PTSS. One idea was that when the pandemic started, these doctors and nurses did not have protocols or guidelines for how to deal with coronavirus patients.
“These were lacking and they did not always know what to do, and this added to their stress,” she said.
Another reason seemed to be that a significantly higher proportion of the COVID-19 team witnessed one or more patient deaths as compared to the non-COVID-19 team. She said that witnessing a patient’s death appears to be a risk factor for PTSS unique to those directly engaged in treating COVID-19 patients.
According to Mosheva, many COVID-19 patients died unexpectedly and they were younger than others that died in hospitals at the same time – age 70 versus 79, many without preexisting conditions. She said that it has been shown that healthcare workers are more distressed by the death of patients that are closer to them in age.
Finally, because family members cannot be with the dying patient, the healthcare workers have to fill that role, too.
The families “are disconnected from the sick and so the doctors and nurses bring the patients special things and try to help them,” according to Osama Badran, a head nurse in one of Herzog’s coronavirus departments. “We worry about them, and feel like we are part of their families and therefore it is hard to disconnect.”
He said watching a person suffer alone is a “terrible thing” and that Herzog tries to allow around 10 first-degree relatives to visit a patient every day – but this is a lot of work.
“Of course, you take all of this home,” he added.
AN INTERNATIONAL study published last week by the International Council of Nurses (ICN) found similar issues worldwide. According to the study, reports from national nursing associations in every region stated that they are “somewhat or extremely concerned about the issues of burnout, increased stress and other psychological demands.”
“The emerging evidence suggests that there is a global phenomenon of mass trauma experienced by nurses working in the COVID-19 response,” according to the report.
“The phenomenon is complex and intertwined with various issues including persistently high workloads, increased patient dependency and mortality, occupational burnout, inadequate personal protective equipment, the fear of spreading the virus to families and relatives, an increase in violence and discrimination against nurses, COVID-19 denial and the propagation of misinformation, and a lack of social and mental health support.”
It is also based on hard data.
As of December 31, the deaths from COVID-19 of 2,262 nurses in 59 countries had been reported, ICN said, noting that this figure is likely a “significant underestimation,” and that the number has continued to rise.
Moreover, ICN data showed that more than 1.6 million healthcare workers in 34 countries had been infected with the virus from the beginning of the pandemic until the end of 2020.
“We are witnessing a unique and complex occupational trauma that is affecting the global nursing workforce,” said ICN CEO Howard Catton. “Nurses are dealing with relentless, unprecedented demands from their patients, resulting in physical exhaustion. But they are also facing enormous mental health pressures leading to serious psychological distress.
“Around the world, looking after COVID-19 patients involves dealing with an increased number of deaths, having to stand in for relatives who are not able to be with their loved ones – even as they are dying – being concerned over the lack of personal protective equipment, facing abuse from members of their communities and pandemic deniers, and fearing transmitting the virus to their loved ones at home,” he said.
ICN’s data shows that since the first wave of the pandemic, the proportion of nurses reporting mental health distress has risen by a third, from 60% to 80% in many countries.
“In the beginning it was much easier,” Herzog’s Haviv said. “But for the last five or six months, we have been overwhelmed and overcrowded.”
He explained that coronavirus units tap into large amounts of staff who need to provide aid on all fronts, from washing and dressing patients, turning them over, and getting them to sit up if they can.
“If you don’t do that, they deteriorate quickly,” he said.
TZVIA LEVY, the director of nursing and paramedical services at Herzog said that hospitals will only really know the impact of COVID-19 on their staff in the next six months or year.
“Right now, we just need to keep going,” she said.
But according to Mosheva, all of the stress is likely to have a long-term impact – action should be taken sooner than later.
“We need to raise the flag now, already identify the doctors who are in danger of developing post-trauma and get involved with them and give them support and therapy to prevent this from impacting them in the future,” she said.
ICN suggested that the situation could have “potentially devastating consequences in both the short- and long-term for individual nurses and the healthcare systems they work in,” including that it could lead to an increase in the number of nurses leaving the profession in the future.
Already, in Israel, there is a deficit of nurses. The country has only 5.1 nurses per 1,000 people, as opposed to the OECD average of 8.8, according to data provided in 2019 to the Post by the Shoresh Institution for Socioeconomic Research.
“The pandemic risks damaging the nursing profession for generations to come unless governments take action now to address the COVID-19 effect, which our survey suggests could trigger an exodus from the profession,” ICN wrote in its report.
“The world is already short of six million nurses, with another four million due to reach retirement age in the next 10 years,” the council said. “With the COVID-19 effect potentially leading to even more nurses leaving the profession, governments must act now to protect the nursing profession and our already fragile healthcare systems, or jeopardize the health of their nations.”
According to ICN’s Catton, “COVID-19 has exposed the fault lines in our healthcare systems, but if nations do not take immediate action to shore them up, unbreachable chasms will be created with potentially devastating effects.”
Haviv expressed similar sentiments: “This is not something that will go away on its own.
“We learn in the IDF, with PTSD [post-traumatic stress disorder], the main thing is to deal with it as fast as possible, otherwise you reduce the possibility that it will get better,” he continued. “We learned this lesson from the Yom Kippur War: We did not help people, and later we learned they had PTSD and then it was hard to treat them.
“If we deal with this immediately, the results will be much better.”