Health Ministry draws framework for mental stress among healthcare workers

As several reports surface of frontline healthcare workers losing their lives while battling against the Covid-19 pandemic, a detailed report of a study which was jointly done by the Ministry of Health and Family Welfare and National Institute of Mental Health and Neuro-Sciences (NIMHANS) in Bengluru was jointly released by the ministry on Wednesday.

As per experts, the novel coronavirus pandemic has thrown an unprecedented challenge for mental health across the country. The possibility of getting infected with Covid-19, an illness with no clearly defined treatment protocols and uncertain outcomes, has shook the world. With the illness now spreading more and more in different parts of the country, the existing healthcare systems are really stretched.

As per Health Ministry officials, this battle becomes long-drawn, the healthcare workers (HCWs) at the frontline have become particularly vulnerable to mental stress. Worried about risk of infection to themselves and their families, adequacy of protection, long working hours, being in quarantine/isolation, and separation from families can lead to severe psychological distress among health professionals. If not effectively recognised and treated, such stress can transform into more persistent illnesses, even leading to suicidal thoughts and feelings. Psychological difficulties have been consistently linked to reduced competency at work and the stress faced at work can worsen mental distress.

Different studies are being done and reported by different units of the Indian Medical Association (IMA), which have revealed that around 100 doctors died while on Covid-19 duty in India. As per the IMA’s own reports, at least 771 doctors who are less than the age of 35 years, 247 doctors above 35 and 261 doctors above 50, have been infected so far and these numbers are increasing. This figure does not include healthcare workers such as nurses and other healthcare-related staff.

The widespread social and economic disruption has also impacted most HCWs. This has created a cycle of concern, worry and distress. If not effectively recognised and handled, this can transform into more severe distress, even leading to suicidal thoughts and feelings. Thus, as per Health Ministry officials, it’s a matter of priority to address these concerns to ensure positive mental health and early interventions for frontline personnel in Covid-19 treatment settings.

Here’s a comprehensive guide to causes of anxiety and distress in healthcare workers and how it can best be dealt with:

SOURCE OF ANXIETY

– Fear of exposure to self and transmitting to family

– Concern regarding personal protection equipment (PPE)

– Fear of family welfare if requiring quarantine/isolation

– Uncertainty of extent of support from the organisation

– Support for personal and family needs with increasing work demands

– Lack of information and communication

INDICATORS OF MENTAL HEALTH DIFFICULTIES AT WORKPLACE

– Absenteeism

– Reduced job performance and productivity

– Rapid changes in mood, anger outburst, crying spells

– Reporting to work intoxicated (drug/alcohol)

– Poor memory

– Restlessness/irritability

– Drowsiness

– Changes in communication with co-workers

– Impaired physical capability and daily functioning

Rule out rule: When there is a performance concern, rule out the possibility that it may be related to a mental health issue before you consider action.

PRESENTATIONS OF MENTAL HEALTH ISSUES AMONG FRONTLINE WORKERS

Most frontline personnel presenting with psychological disturbances are ‘normal people’ who have been overwhelmed by an extraordinary stressor. Most may show more than one psychological presentation. For example, anxious people may also have features of depression and drink alcohol to reduce symptoms.

These psychological disturbances may be linked to the many psychosocial stressors in the wake of the pandemic. Hence, management strategies primarily need to focus on mitigating the psychosocial stressors to the extent possible. Lastly, a vast majority of people recover spontaneously over time or with brief psychological inputs.

Therefore, presence of psychological disturbances does not necessarily imply a psychiatric diagnosis. However, clinical descriptions of particular domains help ensure appropriate selection of intervention.

KEY SYPMPTOMS

A. Burn-out (the most common)

– Emotional exhaustion

– Depersonalization (loss of one’s caring, empathy, and compassion)

– Decreased sense of accomplishment

B. Distress and Anxiety related to Covid-19

– Excessive worry about contracting the infection even when all precautions have been taken

– Not being able to stop or control worrying

– Feeling sad, crying spells

– Feeling nervous, anxious, or on edge

– Being so restless that it is hard to sit still

– Feeling incompetent at work

– Becoming easily annoyed or irritable

– Excessively following social media about Covid-19

– Feeling afraid as if something awful might happen

– Lack of sleep and decreased appetite

– Wanting to end it all (suicidal thoughts and plans)

C. Sleep disturbances

Extremely common. Subjects may present with difficulty in :

– Initiating sleep

-Frequent awakening

-Early morning awakening

-Excessive sleep

Distress, anxiety, exhaustion, shift work, substance use can all present with sleep disturbances. It is important to clarify these aspects when frontline personnel report with sleep disturbances.

PRE-EXISTING MENTAL HEALTH ISSUES: WHAT IS ‘NORMAL’ AND WHAT IS ‘ABNORMAL’

Frontline personnel with pre-existing mental health issues may relapse or experience worsening of symptoms.

Most frontline personnel presenting with psychological disturbances are ‘normal people’ who have been overwhelmed by an extraordinary stressor.

Most may show more than one psychological presentation. For example, anxious people may also have features of depression and drink alcohol to reduce symptoms.

These psychological disturbances may be linked to the many psychosocial stressors in the wake of the pandemic.

Hence, management strategies primarily need to focus on mitigating the psychosocial stressors to the extent possible.

Abnormal psychological reactions are characterised by dysfunction in personal/social/ occupational functioning (in any or all or in varying proportions).

ASSESSING YOUR COLLEAGUE IN DISTRESS

– Active listening

– Have eye contact

– Acknowledge what is being said with appropriate nodes and gestures

– Occasionally repeat what is said

– Ask questions but do not compel to give more details

– When the conversation ends, summarise what was discussed and agreed upon.

– Give appropriate contacts including helplines if required

– Managing own feelings

– Treat what is said with respect

– Do not react with surprise or judgement

– Do not immediately suggest solutions. Always ask what they want before giving your suggestions

ARRANGEMENTS AT WORKPLACE

– As per the report, HCWs need to be aware of the guidelines for testing, quarantine, treatment and any other issues. The state government issues periodic guidelines which can keep changing depending on the situation, and it is important that healthcare workers are made aware of the same.

– Prepare staff for the job

– Do not give false assurance, a full and frank assessment will be helpful to retain trust

– Focus on the long-term, ensure as much as training for their staff to fulfil roles

– Mix and match, ensure that juniors with limited experience work with their senior colleagues

– Ensure staff rotation from jobs of higher stress to lower stress and vice-versa

– Duty/shift breaks/holidays to be agreed within the team and ensured as far as possible

– Enhance support to family

Employees (especially women) putting in long working hours worry about their family responsibilities especially towards their children/elders. It is necessary that the administration support them to the extent possible.

> Child care with safety protocols

> Flexible work schedules

> Procurement of essential supplies

> Assurance on family being supported if quarantined/infected

– Other points to note:

> Paid leave to be ensured for any staff member in quarantine/isolation

> Ensure your team is credited for their work

> Simple expressions like praise, a cake cutting ceremony after a team’s achievement, etc. will maintain morale and team bonding on the long term.

> Personnel working in hospitals in times of pandemic often experience stigmatising attitudes from the general public. It is important that the staff be supported by the organisational leadership as these can be immensely stressful.

-Fifteen-minute Yoga programme at workplace for stress reduction
This includes:

> Neck movement,

> Shoulder rotation,

> Hand stretching & breathing

> Side bending

> Ardhacharkrashan

> Nadishuddhi

> Bharmari

SELF-CARE

All personnel at the frontline should be made aware of the principles of self-care. Self-care includes those activities to promote our emotional, physical, relational and spiritual/religious wellness. These include the following:

– Have a routine

– Ensure breaks and adequate sleep

– Keep in touch with relatives/friends

– Carry out some activities and hobbies unrelated to work

– Exercise regularly and have a healthy diet

– Practice relaxation exercises like yoga

– Spiritual or religious activities (if you are a religious person)

– Make time for yourself and your family

SUICIDALITY: WHO NEEDS TO BE ASSESSED?

– The behaviours described below represent “warning signs” that the person may be contemplating suicide and will require assessment.

– Sufficient time and privacy should be ensured during assessment

– Experiencing vs acute stress

– Anxious or agitated (Do you feel more anxious while working with patients with Covid-19? Are you worried about your personal health?)

– Feeling/talking vs feeling isolated or lonely, boredom (Q. Are you missing your family members/friends these days? Do you feel alone/isolated since quarantined?)

– Feeling of helplessness, hopelessness and worthlessness; guilt. (Q. Do you worry about the uncertainty of the future, a sense of lack of control for your situation? Do you think you will pass through this phase without much issues? If Infected: Do you think your health condition will improve? Do you feel like a burden to others? Do you feel worthless about yourself?)

– Suicidal ideations/plans: Talking about wanting to die, talking about feeling hopeless or having no reason to live, feeling trapped or in unbearable pain (Q. Do you feel it is better to end your life? Do you wish you were dead? Are you thinking about suicide? Do you have any suicidal plans? If so enquire about the method, any preparatory acts vs If having suicidal ideas- explore intensity, persistence and likelihood of acting on it.)

SUGGESTED STEPS IN TELEPHONICALLY SUPPORTING YOUR COLLEAGUES IN QUARANTINE/ISOLATION

– Colleagues feel better supported when conversations are informal and reflecting the closeness of their relationship

– However, the steps detailed below may be taken as a broad guidance for those unsure on what needs to be done

– Start with neutral issues, preferably topics of mutual interest or of current relevance (preferably unrelated to Covid-19).

– Use humour if that could make the conversation lighter
-Explore how they are spending their time in quarantine

– If they would like to talk about the incident that let to infection, allow them to speak

– Ask them, “How are they feeling?” This in most cases will help them to express themselves

– Allow them to express all their emotions. Do not interrupt

– Acknowledge and validate their feelings (I can fully understand what you are going through)

FEAR ABOUT OWN HEALTH AND HEALTH OF LOVED ONES

– Stress of being monitored or anger and frustration of being stigmatized

– Guilt feelings about not being able to perform normal work

– Worries about family members and their safety

– Reemphasise on why they are in quarantine and why it is needed. If they do not want to discuss, do not compel

– Reassure that their children/family are being supported (Ensure the same)

– Ask them to focus on keeping a routine for themselves while in isolation
– Encourage to do physical exercises

– Encourage to access information from only reliable sources (ICMR, Government of Karnataka, Government of India)

– Always remind: All people who are exposed do not get infected (if exposed waiting for test). Vast majority of people infected will remain asymptomatic or develop only mild symptoms (after having tested positive)

– DO NOT:

> Overload them with Covid-19 related information

> Do not initiate discussion on fatalities or other media stories related to Covid-19

> If the discussion is initiated from the clients side, discuss it in the larger context (for example, only 2- 3 per cent die, the rest 97 per cent recover fully). – India Today