Understanding the traumatic experiences of healthcare workers responding to the COVID-19 pandemic.

Since the December 2019 reports of a life‐threatening pneumonia in Wuhan, China, COVID‐19 has become the most widespread pandemic since the 1918 influenza pandemic. Fear of emerging infectious diseases – particularly for those with no clearly identified treatment – raises anxiety levels in healthy individuals, and may manifest in a range of psychological, behavioral, and/or psychosomatic conditions (Shigemura, Ursano, Morganstein, Kurosawa, & Benedek, 2020). Healthcare workers around the globe – physicians, nurses, care home staff, and those who maintain the food and laundry services in the hospitals and ICUs – are working on the frontline of this battle, and they are among the most at risk of exposure and illness. Given their high demand and at‐risk working environments, mental/behavioral health support for these workers is a core component of protecting their health and sustaining the protection of our communities (Lai et al., 2020). There are several considerations for healthcare leaders to comprehend workers' experiences and provide the necessary support.

First, healthcare workers experience the greatest risk of life‐threatening viral infection: Death reports of healthcare workers around the world reveal just how realistic this threat is. Shortages of personal protective equipment heighten this risk and exacerbate feelings of fear as well as uncertainty and anger towards their organizations and/or leaders. Leaders should take an active role in advocating for the acquisition of needed personal protective equipment and remind workers of steps being taken to mitigate risk, both of which can enhance feelings of safety for workers. Leaders can also assist healthcare workers by educating them on ways of coping with stress and ensuring they have access to resources that help with stress management, which allows workers to feel a sense of control over their circumstances.

Second, many healthcare workers are directly working with suffering patients and families, and they are subsequently exposed not only to their patients' death, but also to the grief of the bereaved. These workers may have to call the families and hear the power of the family's loss and sadness at not being able to be present at their loved one's death. In some settings, when patients overwhelm the capacity of the clinical setting, these workers may have no choice but to triage the patients and make difficult decisions regarding who will or will not receive scarce resources (Emanuel et al., 2020). These experiences can create feelings of guilt, shame, helplessness, and powerlessness. This combination of feelings has been called moral injury – a notion used in the military mental health context to describe the distress derived from actions that violate one's moral or ethical standards (Greenberg, Docherty, Gnanapragasam, & Wessely, 2020). Mental health interventions normalizing the workers' posttraumatic responses are essential. Education is needed to assist healthcare workers to avoid excessive psychological identification with deceased patients, which might increase posttraumatic stress symptoms (Ursano, Fullerton, Vance, & Kao, 1999). Death notification training and preparation in anticipation of this challenging role may also reduce the workers' notification‐related distress (Center for the Study of Traumatic Stress, 2020a, 2020c).

Thirdly, workers may be required to work under increasingly demanding conditions as co‐workers become ill, and the shortage of workers becomes more pronounced, with long working hours and unscheduled shifts. In general, people can recover from even the most intense stressful experiences. Still, deprivation of the workers' basic needs (e.g. sleep, food, and water) impedes their recovery from physical and psychological fatigue. Also, concerns about exposing loved ones at home to infection after returning from work shifts may heighten anxiety and limit social support needed for their recovery. Furthermore, medical students and retired professionals in many countries have been called in to provide additional support, but these populations are also of concern, because volunteer status, lack of preparedness and/or prior experience are risk factors for work‐related trauma (McCarroll, Ursano, Fullerton, Liu, & Lundy, 2002; Perrin et al., 2007). It is crucial for healthcare leaders to be aware of working conditions at the frontline (e.g. shift duration) and watchful of the workers' coping strategies, both adaptive (e.g. support seeking) and maladaptive (e.g. work over‐dedication and substance use). Leaders can use actionable resources to provide information and guide decision‐making to address healthcare workers basic physiological needs to enhance well‐being and sustainment (Center for the Study of Traumatic Stress, 2020b; Walter Reed Army Institute of Research, 2020).

Lastly, healthcare workers may encounter the extremes of being seen as heroes and yet also experience discrimination and stigmatization by the public. Both of these roles can be a burden over time. When the public views healthcare workers as heroes, it may be difficult for these workers to speak out about their distressing experiences (Nursing Standard, 2020). The burden of discrimination and stigmatization is more explicit. In Japan, for example, a medical society had to issue a protest statement because the healthcare workers responding to the cruise ship COVID‐19 outbreak in Yokohama suffered from these experiences. Specifically, the workers were treated as “germs” and were asked not to take their children to preschools (Japanese Association for Disaster Medicine, 2020). These negative experiences may aggravate stressors on healthcare workers and their families. These stressors may also be complicated by pre‐existing discrimination and stigma in society (e.g. discrimination against ethnic/racial minorities). Therefore, it is critical that healthcare workers are recognized for their professionalism by hospital management and that healthcare leaders identify ways to acknowledge gratitude for this professionalism. Political and health service leaders, as well as the media, should provide the general public with realistic information and avoid sensationalism to ensure that health workers and their families receive practical help rather than discrimination.

In conclusion, healthcare leaders can provide direct mental health support to the affected healthcare workers and take an active role in advocating for organizations and communities. These steps are crucial to mitigate the burden on frontline workers and enhance their morale and motivation. Leaders may also educate and train future frontline workers to deal with the effects of the mental health aftermath of the pandemic, including (but not limited to) posttraumatic stress disorder (PTSD), complicated grief reactions, and suicide.

CONFLICTS OF INTERESTS

The authors declare that they have no competing financial interests that could have appeared to influence the work reported in this paper.