On 1 April, Minister of Health Zweli Mkhize warned South Africans that we were in “the calm before the devastating storm”, and that there might not be many further warnings “before the pounding descends”.
Communicable disease experts and other healthcare workers have been in a state of preparation and heightened anticipation for many weeks. An advantage of being “behind the curve” in our case trajectory, compared to many other countries, is that we can learn from their experiences and research. An overview of that experience suggests that the mental health impacts on healthcare workers will unfold in phases. These will include:
- The current preparation phase: characterised by anticipatory anxiety;
- The active phase: heroics and a surge to solutions, followed by a high-risk time of disillusionment and exhaustion; and
- The recovery phase: recovery and the emergence of long-term psychological impact.
The preparation phase has been prolonged in South Africa due to the relatively slow start of our epidemic and our global vantage point. This phase has been experienced differently across our health-care sectors.
Community healthcare workers are now at the forefront of testing, while many hospital staff have lighter caseloads but unfamiliar logistical challenges. They are busying themselves preparing space for the expected flood of the severely ill, while wondering about the welfare of their usual daily patients. Out-patient clinics and practices are scrambling to develop protocols that will provide acute and chronic care while limiting risk.
Some health care workers are already treating active coronavirus infections, and are overwhelmed by new treatment challenges and fearful for their own safety and that of their families. It is not yet clear whether this prolonged first phase will worsen mental health risks or confer some protection.
Healthcare workers are vulnerable to immediate and long-term mental health consequences of this pandemic. A survey of over 3,000 respondents in South Africa conducted by EMGuidance, a clinical reference platform for medical professionals, found that over 70% reported feeling anxious, overwhelmed, frustrated or angry in early April.
Current trauma research recognises not only that these are expected responses to an extraordinary stressor, but also that specific forms of support can mitigate long-term negative health outcomes.
Drawing on the expertise of international colleagues, including Dr Alys Cole-King and Professors Simon Wessely and Neil Greenberg, a project was launched by private sector volunteers to assist colleagues in the state healthcare sector in Gauteng – though of course it may be expected that the boundary between public and private will blur as the epidemic gathers momentum.
The project has evolved into a responsive partnership between the state and private sector, with a database of 275 volunteers, 227 of whom are in Gauteng.
The team of psychiatrists and psychologists offering mental health support to healthcare workers is in collaboration with the South African Medical Association, the South African Depression and Anxiety Group (SADAG), the South African Society of Psychiatrists (SASOP), the South African Society of Anaesthetists (SASA), and supported by the Psychological Society of South Africa (PsySSA).
SASOP is implementing national replication of the initiative. SAMA will be hosting the portal through which healthcare workers can request direct assistance.
Activities have included giving training and support through the National Institute of Occupational Health (NIOH), individual hospitals, and community health departments; conducting workshops with about 450 healthcare workers, CEOs, managers, and other non-clinical hospital staff in the past two weeks. The project assists with both preventative strategies and treatment services.
The first stage is the ideal time for managers and supervisors to psychologically prepare their teams for what may be coming. International research indicates that trauma-exposed frontline staff are likely to benefit from being sensitised to the realities of the work they will be asked to do and the associated psychological challenges. This requires those in positions of responsibility to be upfront about what the likely occupational exposures might be, and not to either over- or under-state the traumatic nature of a particular role.
Preparatory briefings should include discussion of:
the moral and ethical challenges of the current situation;
likely workplace pressures and traumatic exposures;
the challenges of wearing PPE for extended periods;
fears of becoming infected and by implication infecting others; and
the support options that will be made available to mitigate the potential distress that individuals may experience.
There is very strong evidence that psychologically savvy supervisors play a critical role in supporting the mental health of team members. Teams operating in even the most arduous of environments are more likely to function well, and avoid the onset of serious mental health difficulties, if their supervisors create the right team ethos.
This ethos should not be about “positive attitudes” or heroics. Sober assessment of challenges, knowledge that team leaders are advocates for the working conditions of their teams, including safety issues such as PPE, testing, and adequate sleep, and good communication create protective and productive environments.
Alongside the preventative team- and management-oriented service, volunteers are providing pro bono services to any individual healthcare worker seeking support or treatment. Group therapeutic services are also offered.
In addition to the phases model, the team has found a second paradigm particularly helpful in developing an evidence-based model to support health-care workers: the most up-to-date research cautions against medicalising traumatic exposure prematurely. The model of debriefing and other early professional psychological interventions has been shown to be counterproductive and, in some cases, damaging. Instead, it is best to restore safe conditions, adjust workplace demands, normalise difficult emotional experiences, harness peer and community support, and allow peoples’ instinctive defences to operate. Therapeutic intervention is indicated only in cases of escalating distress or impaired functioning.
Managers will benefit from knowing which factors make their staff more vulnerable to mental health complications of trauma. People with pre-existing mental health conditions and chronic illnesses, people (often women) doing double shifts as carers at work and at home, and those who have suffered previous severe or cumulative trauma including workplace discrimination and racism, are some examples of higher-risk groups.
The team is rolling out services across Gauteng and assisting with national implementation. Find references and useful resources on this website:www.covidcaregauteng.co.za.
Views expressed are not necessarily those of GroundUp.
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