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Viewpoint
April 7, 2020

Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic

Author Affiliations
  • 1Stanford University School of Medicine, Stanford, California
  • 2Icahn School of Medicine at Mount Sinai, New York, New York
JAMA. 2020;323(21):2133-2134. doi:10.1001/jama.2020.5893

The coronavirus disease 2019 (COVID-19) pandemic has become one of the central health crises of a generation. The pandemic has affected people of all nations, continents, races, and socioeconomic groups. The responses required, such as quarantining of entire communities, closing of schools, social isolation, and shelter-in-place orders, have abruptly changed daily life.

Health care professionals of all types are caring for patients with this disease. The rapid spread of COVID-19 and the severity of symptoms it can cause in a segment of infected individuals has acutely taxed the limits of health care systems. Although the potential shortage of ventilators and intensive care unit (ICU) beds necessary to care for the surge of critically ill patients has been well described, additional supplies and beds will not be helpful unless there is an adequate workforce.1,2

Maintaining an adequate health care workforce in this crisis requires not only an adequate number of physicians, nurses, advanced practice clinicians, pharmacists, respiratory therapists, and other clinicians, but also maximizing the ability of each clinician to care for a high volume of patients. Given that surges in critically ill patients could last weeks to months, it is also essential that health care professionals be able to perform to their full potential over an extended time interval. At the same time they cope with the societal shifts and emotional stressors faced by all people, health care professionals face greater risk of exposure, extreme workloads, moral dilemmas, and a rapidly evolving practice environment that differs greatly from what they are familiar with.2-5

This Viewpoint summarizes key considerations for supporting the health care workforce so health care professionals are equipped to provide care for their patients and communities. Few of these considerations and suggestions have substantial evidence to support them; they are based on experience, direct requests from health care professionals, and common sense.

Sources of Anxiety Among Health Care Professionals

Before effective approaches to support health care professionals can be developed, it is critical to understand their specific sources of anxiety and fear. Focusing on addressing those concerns, rather than teaching generic approaches to stress reduction or resilience, should be the primary focus of support efforts.

The best way to understand what health care professionals are most concerned about is to ask. Eight listening sessions with groups of physicians, nurses, advanced practice clinicians, residents, and fellows (involving a total of 69 individuals) held during the first week of the COVID-19 pandemic explored 3 key concerns: what health care professionals were most concerned about, what messaging and behaviors they needed from their leaders, and what other tangible sources of support they believed would be most helpful to them. These discussions consistently centered on 8 sources of anxiety: (1) access to appropriate personal protective equipment, (2) being exposed to COVID-19 at work and taking the infection home to their family, (3) not having rapid access to testing if they develop COVID-19 symptoms and concomitant fear of propagating infection at work, (4) uncertainty that their organization will support/take care of their personal and family needs if they develop infection, (5) access to childcare during increased work hours and school closures, (6) support for other personal and family needs as work hours and demands increase (food, hydration, lodging, transportation), (7) being able to provide competent medical care if deployed to a new area (eg, non-ICU nurses having to function as ICU nurses), and (8) lack of access to up-to-date information and communication.

Although these sources of anxiety may not affect everyone, they can weaken the confidence of health care professionals in themselves and the health care delivery system precisely when their ability to stay calm and reassure the public is most needed. Recognizing the sources of anxiety allows health care leaders and organizations to develop targeted approaches to address these concerns and provide specific support to their health care workforce. The 8 concerns can be organized into 5 requests from health care professionals to their organization: hear me, protect me, prepare me, support me, and care for me. The principal desire of each request, how the 8 sources of anxiety relate to each dimension, and how organizations can respond to them are summarized in the Table.

Table.  Requests From Health Care Professionals to Their Organization During the Coronavirus Disease 2019 Pandemic
Requests From Health Care Professionals to Their Organization During the Coronavirus Disease 2019 Pandemic

Health care professionals want unambiguous assurance that their organization will support them and their family. This includes the organization listening to their concerns, doing all that is possible to protect them and prevent them from acquiring COVID-19 infection, and assuring them that if they do become infected, the organization will support them and their family on all fronts, both medically and socially.

Messages and Actions Health Care Professionals Desire From Their Leaders

In addition to tangible actions to address their concerns, health care professionals desire visible leadership during this turbulent time. Leaders, such as hospital executives, nursing leaders, department chairs, and division chiefs, may need to consider innovative ways to be present and connect with their teams given the constraints of social distancing. It is critical that leaders understand the sources of concern, assure health care professionals that their concerns are recognized, and work to develop approaches that mitigate concerns to the extent that they are able.

Health care professionals indicate they appreciate leaders visiting hospital units that are caring for patients with COVID-19 regularly to provide reassurance. They do not expect leaders to have all the answers, but need to know that capable people are deployed and working to rapidly address the issues. Leaders should ask team members “What do you need?” and make every effort to address those needs. Health care professionals do not expect the leader to be able to provide everything asked for, but having them ask, listen, and acknowledge requests is appreciated. Health care professionals also want to have confidence that their voice and expertise are a part of the conversation as organizations develop their emergency preparedness plans to respond to the pandemic.

Health care professionals are often self-reliant and many do not ask for help. This trait may not serve them well in a time of burgeoning workload, redeployment outside of a clinician’s area of clinical expertise, and dealing with a disease they have not previously encountered. Leaders must encourage team members to ask for help when they need it and emphasize that health care professionals and leaders need to rely on each other. Leaders should ensure that no one feels they must make difficult decisions alone. Health care professionals should also feel empowered to defer less important and time-sensitive activities.

The importance of simple and genuine expressions of gratitude for the commitment of health care professionals and their willingness to put themselves in harm’s way for patients and colleagues cannot be overstated. A final overarching request of health care workers—even if only implicitly recognized—is “honor me.” The genuine expression of gratitude is powerful. It honors and thereby could serve to reinforce the compassion of health care workers who risk their lives to help patients infected with this deadly disease. Reinforcing health care professional compassion helps them overcome empathetic distress and fear to provide care under extraordinarily difficult clinical circumstances every day.6 Organizations need not and should not outsource gratitude entirely to the public. This process starts with leadership. Yet, gratitude from leaders rings hollow if not coupled with efforts to hear, protect, prepare, support, and care for health care professionals in this challenging time.

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Article Information

Corresponding Author: Tait Shanafelt, MD, Stanford Medicine, Stanford School of Medicine, 500 Pasteur Dr, Stanford, CA 94305 (tshana@stanford.edu).

Published Online: April 7, 2020. doi:10.1001/jama.2020.5893

Conflict of Interest Disclosures: Dr Shanafelt reported being the co-inventor of Well-being Index instruments and the Participatory Management Leadership Index and receiving a portion of any royalties paid to Mayo Clinic, the copyright owner, for their use and receiving honoraria for giving presentations and advising health care organizations on the well-being of health care professionals. No other disclosures were reported.

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    2 Comments for this article
    EXPAND ALL
    Association Between Insufficient PPE and Depressive Symptoms
    Simon Ching Lam, PhD, RN, FHKAN | Squina International Center for Infection Control, School of Nursing, The Hong Kong Polytechnic University.
    The above viewpoint includes many important and valid requests from informants in line with what we observed in Hong Kong. For the concerns of “Protect me”, the shortage of Personal Protect Equipment (PPE) in clinical settings gave rise to the development of adverse mental status of frontline HCWs. (1)

    We our conducting a survey study of 300 healthcare workers (HCWs) (100 from Hong Kong and 200 from Guangdong, China) asking about their mental status and working environment (this study is still on progress). Most of demographic characteristics between two groups were similar: clinical experience, gender distribution, marital status, and
    number of contacts with COVID cases. The preliminary results indicate more depressive symptoms in Hong Kong (37%) than in Guangdong (11%) HCWs by the measurement of Patient Health Questionnaires-9 (PHQ-9; range = 0-36, cutoff of 10 for depression). The perception of insufficiency of PPE provided by the working organizations of Hong Kong HCWs was 60% while that of Guangdong counterpart was only 25.5%. HCWs did not perceive that they are under sufficient and appropriate “protection”. Surprisingly, over 50% of HCWs in Hong Kong indicated they were dissatistfied with the infection control training provided by the working organization vs only 3.5% HCWs in Guangdong. These findings also reflect the importance of one of the requests, “Prepare me”. However, a representative from one of the hospitals claimed that the PPE storage was enough for 3-months of usage, which he regarded as “sufficient”. This contradictory opinion may reflect simply mistrust or communication gap. The above preliminary findings and the responses from hospital representative has been broadcasted in local news programme (https://news.tvb.com/programmes/newsmagazine/5e881867335d196c3e7aacca/%E9%9D%9E%E5%B8%B8%E6%8A%97%E7%96%AB).

    Sufficient PPE (hardware), training (software) and communication (caring) would be fundamental and essential for fighting against the COVID epidemics, particularly in clinical settings. Taking care of mental status of HCWs is vital to sustain their adequate capacities for this outbreak over an extended time period.

    References:
    1. Chang D, Xu H, Rebaza A, Sharma L, & Cruz CSD. Protecting health-care workers from subclinical coronavirus infection. The Lancet Respiratory Medicine, 2020; 8(3), e13.
    CONFLICT OF INTEREST: None Reported
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    Psychological Interventions for Front-line Health Care Workers
    Emma Yun-zhi Huang, DPH, MPH | Alumni, Macau University of Science and Technology
    Thank you for this comprehensive summary of the five requests from health care workers to their organization (i.e., hear me, protect me, prepare me, support me, and care for me) and of the messages and actions health care professionals desire from their leaders (i.e., honor me). China was the first country facing the outbreak of COVID-19 in the world. Moreover, the epidemic occurred during the most important festival of China – Chinese Festival, which means to all Chinese people to be together with family members. The Chinese government advocated that all health care workers in China volunteer to aid Hubei provinces to relieve the health care worker shortages in the area. Moreover, within one month after the COVID-19 outbreak, the China National Disease Control Bureau issued a principle guideline for psychological intervention for COVID-19, which covers four classes of population. Front-line health care workers were the first population which should receive the most attention and support, and the third-class population were relatives, friends, and colleagues of health care workers. Chinese scholars have also conducted many psychological studies on health care workers (around 10% of published articles of COVID-19 were related psychological studies of medical staffs in the CNKI database).

    Providing psychological intervention for front-line health care workers included: (1) professional training for stress reduction, (2) reminder of proper diet, rest and sleep, (3) supporting environment providing from family members, friends and colleagues for health care workers, (4) providing professional assistance and counselling when occurring emotional anxiety. The above guideline has been issued on the government website at 
    http://www.nhc.gov.cn/jkj/s3577/202001/6adc08b966594253b2b791be5c3b9467.shtml.

    Moreover, the mass media in China positively reported news about health care workers and continually attracted social support from the public. The heroic image of health care workers was one important social support, which reflected the request of ‘honor me’.
    CONFLICT OF INTEREST: None Reported
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