The COVID-19 pandemic has left an indelible mental health impact globally, but an oft under-discussed group is frontline workers. One 2022 study indicated that in 2020 and 2021, emotional exhaustion has substantially increased among frontline healthcare workers — which is unsurprising given the weight of new, emerging COVID variants, the arrival of monkeypox in the U.S., and the staffing shortages that continue to plague the healthcare system. Mental health is critical to a person’s overall health. It impacts how we think, feel, behave, and relate with others.
I work in the field of disaster mental health and crisis management, and it’s a given that frontline workers’ mental health will be affected by working intimately in response to a disaster or crisis. Whether you’re a first responder or another frontline healthcare worker, there will be residual and possibly vicarious trauma.
Anecdotal reports from our encounters with frontline workers and national surveys at this stage in the pandemic are already pointing to evidence that healthcare workers are experiencing stress, anxiety, depression, and sleep disturbances, raising concerns about risks to their mental health. A high prevalence of depression, anxiety, and PTSD among healthcare workers during the pandemic has also been identified.
The unique mental health challenges of the COVID pandemic
In general with disasters, there is a divide between the group that is impacted and the group stepping in to help. Here, frontline workers can be impacted by the very same virus for which they are providing assistance. This pandemic has shaken the healthcare industry, and healthcare workers on the front lines have faced significant levels of illness and death and have been operating in an atmosphere of pervasive uncertainty.
Frontline workers bore the burden of figuring out how the system could handle the massive influx of critically ill patients. They had to quickly come up with brand-new rubrics and systems to face this challenge. When things are unknown — as they were at the height of the pandemic — people want something to rely on, a system or process that reassures us that we’re doing the right thing. When those systems or processes are not in place or if they break, then it feels like decisions are arbitrary. Beyond these ethical challenges, the scarcity of personal protective equipment (PPE) added additional confusion within the already complex decision‐making landscape. Your role is to provide care, but you are not protected yourself.
Challenging conditions like these result in moral distress and moral injury. Moral distress comes when individuals are unable to preserve their integrity due to value conflicts. Moral injury results from engaging in action contrary to a person’s value system, and it leaves a permanent impact.
Cases and deaths were mounting, and public reactions to frontline workers were split: There were the claps and cheers across neighborhoods in New York City and Italian apartment complexes that went viral on social media, but there was also the daily reality of telling a patients’ family that their loved one was dying and they couldn’t see them, dealing with the family’s mental health burden, and dealing with continuous loss. Some healthcare workers reported harassment and verbal abuse from concerned family members who wanted to see their loved ones. That’s one of the challenges about highly distressful times: People can resort to thinking simplistically and in binaries. There is no nuance.
Now, with the new variants and the re-introduction of monkeypox to the Western world, people are fatigued. If monkeypox were coming up at a different time, I believe there would have been a different public response, but most people were so exhausted by the COVID-19 pandemic that the introduction of another virus sparked avoidance. For others, we saw a trauma response when they heard the monkeypox news and immediately were brought back to March 2020. It doesn’t matter that they’re different diseases with different pathologies, where the current risk of getting the monkeypox is low, it mutates slower and is less contagious, the feeling of “Oh no, not another one,” was present among many.
How BMC tackled the mental health crisis
Research and data on disaster work shows us that, at the start of a crisis, people operate in “fight or flight,” survival mode — which doesn’t mean that very real, present mental health issues don’t crop up amid the disaster. But, it’s when the crisis has subsided that mental health impacts are seen even more clearly.
We saw it after 9/11. A study of more than 36,000 New York residents and rescue workers revealed that more than 14 years after the attack, 14% still had post-traumatic stress disorder and 15% experienced depression. Similar to those first responders on 9/11, we have witnessed the depression and full impact of the COVID-related trauma settle in among frontline care workers now that things have slowly started to subside. COVID-19 certainly hasn’t gone away, but as it becomes a reality within our healthcare system, what frontline workers have been through is sinking in, leading to burnout, depression, suicidal ideation, and more. Given what we know about the impact of disasters, these negative mental health impacts are likely to continue for many years to come.
“Given what we know about the impact of disasters, these negative mental health impacts [on frontline workers] are likely to continue for many years to come.”
I conducted psychological first aid and stress first aid trainings for our staff. We talked about what happens when you’re in disaster mode and what you can expect moving forward — the pre-disaster, disaster, and post -disaster expectations. I informed staff of the Professional Quality of Life Scale surveys and additional ways of self-assessing the impact of being in disaster settings, along with how to access supports and possible protective factors they can use.
Additionally, we created spaces for people to gather and talk about what was happening, and we conducted rounds offering support and basic needs for frontline workers in the crisis settings. We started a family support center that welcomed BMC employees and their families, offering behavioral health supports, grief and bereavement support, and basic psychological first aid services. A toll-free number was also created, which led directly to the family support center, and we set up a pager that went to BMC Health System Occupational Health Clinic. Experts, including myself, responded to the calls and provided stress first aid or brief behavioral health support for immediate distress.
First responders’ complex feelings on raising mental health concerns
Candidly, there were not a significant number of calls from frontline workers. We received feedback that those services were useful and helpful, but we saw that frontline workers were conflicted about whether they wanted to address their own mental health — understandably so, for multiple reasons.
First responders often report that they feel if they raise their own mental health to the surface, make their unconscious feelings more conscious, it will disrupt how they operate in their job. It is often not feasible for them — especially in a disaster situation and, more specifically, a disaster situation that requires intimate healthcare involvement. What’s more is that a lot of the techniques we teach people — setting better boundaries, sleeping more, rooting down in self-care — are not as immediately feasible for clinicians who are working erratic hours in high-stress crisis situations.
As such, the field of disaster behavioral health has been shifting away from models of critical incident stress management and debriefings.
“Sometimes knowing that you’re not alone is half the battle.”
What ended up working really well for our staff at Boston Medical Center was the buddy system. The buddy system is a model adopted from the military field: “the battle buddy system.” We aimed to get workers in the crisis settings to have a daily buddy (a peer/co-worker) with whom they could check in with throughout or at the end of the day to share, if desired, their experience in the high-stress work environment. Rev. Jennie Gould, PhD, BCC, director of Clinical Pastoral Education, was often my buddy, and having her there to talk about the kinds of traumatic and challenging encounters we each had was relieving. It tackled the sense of loneliness and disconnect that we can feel being alone with traumatic encounters and created a human connection with someone who is experiencing the crisis in the same setting.
Overall, it allowed frontline workers to lean on each other while they sift through the emotionally and mentally taxing realities of crisis intervention work.
Sometimes knowing that you’re not alone is half the battle. It sounds so simple, but as healthcare workers, we don’t often think of that. Life as a frontline worker is incredibly hectic, and you are often in the process of doing. Building in time to check in with each others’ wellbeing is often seen as secondary or unimportant. But the pandemic taught us that it’s essential that frontline workers have this support system among each other.
