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What’s different about the stress clinicians are facing, and what can help

Physicians, nurses and other clinicians are under huge and increasing amounts of stress as COVID-19 threatens to overwhelm the US health care system, and the people who care for us need care and support of their own from health care systems, national leaders and the public, as well as from themselves. 

Nurses, physicians and other clinicians face a new reality that demands not only Herculean labor but isolation, financial loss and danger for themselves, their families and loved ones.

What's changing?

More work. Shift length, consecutive shifts and on-call times are increasing, and break times may not be adequate. Kendra McMillan, a senior policy adviser for nursing practice and work environment for the American Nurses Association, said nurses are being asked to work up to six consecutive shifts and three on-call days. 

“If nurses are continuing to work at this rate,” McMillan said, “we’re going to see our nurses and clinicians really burn out in the days and weeks ahead.”

Fear for safety and health. Physicians and nurses are falling ill. In the US and abroad, some have died. More lives will be lost, especially given shortages of masks, face shields and other supplies that can limit exposure among clinicians. 

“The stresses for physicians, nurses and other frontline providers are very different in a situation where they are not provided adequate personal protective equipment,” said Janae Sharp, founder of the Sharp Index, a nonprofit that works to prevent physician suicide and offers online resources. “In an emergency, physicians are intensely loyal to patients, but we are asking them to put their own lives at risk and their families.”

Lack of personal protective equipment was a top concern shared by nurses with the American Nurses Association in social media chats and polls, McMillan said. 

“It is like going into battle without armor,” said Dr. Jessica Gold, an assistant professor in the Department of Psychiatry at Washington University in St Louis. “You feel helpless and unsupported.”

Compounding the issue, people have been threatened with job loss for speaking out about the lack of PPE or for using gear they bought themselves. 

Isolation. Like everyone else with jobs deemed essential to public health, clinicians are taking risks that don’t accrue just to themselves but to their families. Clinicians are subject to stay-at-home orders in their off hours and have to think hard about how to navigate safely from their loved ones to the patients they care for and back again.

Some physicians are distancing themselves from their own families, living in RVs or other accommodations away from home for the duration, said Dr. Clif Knight, a senior vice president for the American Academy of Family Physicians. Though isolation mitigates infection risks, it also reduces the emotional, spiritual and physical support that can sustain people through hard times.

Threats to livelihoods and careers. For physician-owned practices, Knight said, the pandemic is an existential threat as annual checkups and care for chronic conditions may be deferred to help prevent the spread of disease. At the health system level, organizations are cutting hours, salaries and even jobs in response to the cancellation of elective procedures and non-urgent care, National Public Radio reported.

The risk of being redeployed. Like all of us, health care professionals have chosen specific careers that suit not just their interests and training but their psychology. “Being asked to do things we don't have the skills or temperament for in a crisis is going to be compounding and traumatizing,” Gold said.

The unknown, the unclear and the uninformed. Right after staffing and PPE, the top concern for nurses was the need for clear, concise and consistent information from national leaders, ANA’s McMillan said. 

Much remains unknown about how to prevent transmission and treat COVID-19. Meanwhile, state and national politicians are asking people to keep their distance to reduce the spread of disease, but some people have been resistant to the guidance. President Donald Trump has called for people to take steps to reduce the spread but also at times downplayed the risks.

Compounding the uncertainty is the unknown duration of this crisis -- another source of stress, Knight said. 

New technology to navigate. The rapid adoption of telehealth to provide care remotely has been staggering, but how and even whether all that care will be reimbursed remains an open question. 

The AAFP has set up online forums in which family physicians are answering questions for one another as they navigate new ways of connecting with patients, Knight said. In addition to video, he added, some physicians are providing care through the only technology their patients have: telephones. 

Not enough care. The focus on “flattening the curve” is intended to prevent shortages of ventilators and critical-care beds and the difficult decisions such shortages would force. If that effort fails, professionals could face a grave risk of moral injury. 

That’s the term for the distress people feel when they see, cause or cannot stop something that goes against deeply held moral beliefs, psychiatrist Wendy Dean and reconstructive plastic surgeon Simon Talbot wrote in STAT last year. Moral injury can lead not only to distress, but also depression and self-harm, according to Syracuse University’s Moral Injury Project

“When there are not enough ventilators, physicians and other providers are deciding who will get life-saving medical care,” Sharp said. Having to weigh the risks to family and personal health against the duty to patients can carry the risk of moral injury as well.

“We are inflicting irreparable harm on physicians,” Sharp said. “This crisis highlights a medical system which is broken enough to cause burnout in the best of times. In the worst of times, medicine and physicians will never be the same.”

What can help?

To be clear, these ideas are about addressing and mitigating the harm, not solving it or making it go away.

Look for ways to say thank-you. Check in on neighbors, friends and family who work in health care while keeping physical distance. You can use social media, texting, phone calls and video chats.

Hearing support and solidarity from the public is important for nurses, physicians, respiratory therapists, support staff and everyone working to keep the public safe, McMillan said. “They have the same fears related to their families. They’re having to homeschool their children, too. … They need to know that they are supported.”

Listen to what health care professionals have to say. The public can stay home, wash hands and call before going to seek care to reduce the risk of transmission. We can also be open to listening to what people on the front lines are experiencing. 

Be an advocate for the people who care for you. The provision of adequate PPE is a national emergency and needs to be a national priority. State leaders are putting out calls for retirees and other former health care professionals to return. AAFP members say they need help and advocacy to make sure they are paid for care given in video chats or by telephone, Knight said.  

None of that can happen without support from the public. 

“We can help by calling our political leaders and asking why physicians aren't provided with personal protective equipment,” Sharp said. “We can also help by providing child care assistance and help with debt. Health care systems can help by not furloughing physicians and nurses.”

Time and support from health care systems. In addition to PPE, overwhelmed clinicians need space to adjust to a new world. “Allow time for nurses to have breaks, to have time to don and doff PPE,” ANA’s McMillan said. “We’re asking for nurses to have time.” 

Don’t neglect mental health care. The stress of dealing with the pandemic comes on top of high rates of depression, substance use and burnout, Gold said. Clinicians who are receiving mental health care should not stop it. 

Institutions need to invest in mental health “now and not later and not just for acute resources but long- term access as well,” and they need to “normalize and destigmatize those resources and getting help,” Gold said.

Talking is important, too, whether to friends or family or a therapist. “It is completely normal to have emotions and have strong ones right now,” Gold said, “and we have to say that and normalize that and allow that, to be able to feel ok and have self-compassion.”

Practices that promote the health of health care professionals. Getting enough sleep, exercise and the right nutrition as well as remaining socially connected even at a physical distance are difficult habits to maintain when we need them the most. But they do help.

In addition to these “macropractices,” there are micropractices that provide support, said University of Michigan professor of radiology Dr. David Fessell, co-author of a Journal of the American College of Radiology article about prevention of burnout during the pandemic and beyond.

Micropractices are “things you can do in the moment when you notice stress or a tightening of the jaw,” Fessell said. Things like taking a few deep breaths, writing in a journal and staying in touch with someone important to you. If you’re inclined, you can meditate or pray. Or notice your feelings and name your emotions. These can all bring calm, Fessell said.

“Name the good things that are happening, the things you appreciate and are grateful for,” Fessell said. “Naming it out loud is helpful, and so too is writing about it in a journal. It may sound small and inconsequential, but it can be really helpful and invaluable.”

Tom Parks is a health editor at SmartBrief who focuses on health care, leadership and nursing as well as care at the beginning and end of life.

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