Resilience-Need of the Hour for the "Frontliners".

Samavedam S. Resilience-Need of the Hour for the "Frontliners". Indian J Crit Care Med 2022;26(2):157-158.

The pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues its relentless march across the world. Socioeconomic and geopolitical barriers have been transcended with far-reaching repercussions. Governments, health agencies and organizations, scientists, social service organizations, and healthcare service providers are all working shoulder to shoulder in combating the ever-mutating virus and the consequences thereof. The connecting bridge between these partners and the patients is the healthcare workers (HCWs). Exposure to this highly infectious coronavirus has resulted in significant infection rates among the HCWs across the world. The infection rates among HCWs are higher with the coronavirus disease-2019 (COVID-19) pandemic when compared to pandemics of the recent past.[1,2] While the physical impact of infection with multisystem manifestations is anticipated, the current pandemic has drawn attention to the impact on the mental health of HCWs.

Certain aspects of the COVID-19 make it more likely to effect the mental health of HCWs. The sheer magnitude and spread of the pandemic have created a large cohort of exposed HCWs. Constant attention on the numbers of infected HCWs and on those who succumbed is bound to have a negative impact on the mental health of the HCWs.[3] The extreme focus on personal protection equipment (PPEs) and their lack of availability in different healthcare setups across the world also has a definite negative impact on mental well-being of the end users. In addition, owing to constraints of manpower, HCWs are required to work in unfamiliar areas of their own hospital or in new hospitals. They may also be required to attend to a new subset of patients. This change, coupled with longer working hours and longer periods away from family, will no doubt perpetuate the adverse mental impact of the pandemic. This impact is bound to be heterogeneous, given the varying levels of experience and expertise of the HCWs who are drafted for pandemic care. Occupational, psychosocial, socioeconomic, and environmental factors are additive to this impact.

Of all the streams of HCWs, doctors and nurses—technically the “frontliners”—were bound to have significantly higher levels of mental health issues compared to other HCWs. Zhang et al.[4] reported a higher incidence of anxiety, insomnia, depression, and somatization among frontliners. Other authors[5] have reported higher levels of anxiety among nonmedical HCWs. Marzo et al.,[6] reporting on an Asian cohort, reported higher anxiety levels among doctors. However, when moderate anxiety was specifically sought for, nurses outnumbered the doctors. In addition, moderate depression was more common among nurses. Among those diagnosed with depression, female gender, single status, and working in intensive care units (ICUs) had lower odds of identifying those with severe depression. In a meta-analysis, evaluating the mental health outcomes among HCWs during the pandemic, Dutta et al.[7] reported an incidence of 32–42% for depression, depending on the clinical tool used. Similarly, anxiety prevalence was reported to be among similar rates. Insomnia was also a major disorder reported among HCWs. The incidence was reported to be around 36%. Burnout, social isolation, and obsessive-compulsive disorder completed the list of disorders reported among HCWs during the two waves of the pandemic.[6] Nurses were more likely to experience severe depression when compared to doctors.[8] In addition, nurses had more concerns about financial safety. Availability of PPEs and access to the same was another aspect contributing to the anxiety and concern among all categories of HCWs.[9] Younger staff had higher concern and anxiety regarding the safety of their family, when compared to older HCWs.

Different aspects of support and adaptation have also been deployed and studied in relation to the mental health issues arising due to the pandemic. Support from the local team, local community, and government was the most effective in terms of mitigating anxiety and depression.[3] Resilience to the situation arising from the pandemic was equally effective. Most societies and governments have attempted to boost resilience by labeling the HCWs as “heroes” and “warriors.” While this may improve the morale temporarily, long-term resilience can only be boosted by leveraging scientific interventions to overcome the mental impact of the pandemic. The pandemic has clearly proven that a long-term planning and investment is needed on the mental well-being of the HCWs. In this issue of the journal, Jose et al.[10] published the results of their survey focusing on the mental health outcomes of frontline ICU nurses caring for critically ill COVID-19 patients. The authors reported using standard tools for assessment of stress, anxiety, and fear and for measurement of resilience among this single-center cohort. This survey is a Web-based cross-sectional survey performed during the first wave of the pandemic in India. The participants were informed about the purpose of this survey, which could confound the results of what seems to be an eye-opening and informative study. The mean age of the respondents was 30 years and the response rate was close to 90%. Three quarters of the nurses surveyed herein were fairly experienced. This does have an influence on the way they handled the mental aspect of the pandemic. Younger HCWs have been shown to be more vulnerable to stress and anxiety. Despite this, the incidence of distress and anxiety was high, which draws attention to the magnitude of the problem. This cohort exhibited high levels of resilience, which showed a negative correlation to the severity of the mental impact. Older staff had higher levels of insomnia while stress was higher among the younger ones. Prior exposure to COVID-19 appeared to mitigate some of the aspects of stress associated with the care of patients. It would therefore be interesting to see a follow-up of the same survey among the same cohort during the second wave. It also seems that the COVID-19 pandemic has set off a parallel pandemic of mental health disorders not only among those infected, but also among those caring for the afflicted. Since the “frontliners” are a precious and scarce commodity, all healthcare systems should invest resources in making this force more resilient as an insurance against the mental health impact of the pandemic, which shows no signs of abating.