After the COVID-19 surge abated in New York City, many were optimistic that stay-at-home orders and social distancing could spare the rest of the country the kind of crisis experienced there. Field hospitals set up in convention centers and stadiums were disassembled, and a collective sense of relief accompanied the hope that perhaps most of the country had avoided the devastation New York City faced. But as states have reopened, cases have skyrocketed, particularly in the Sun Belt region and now the Midwest. Hospitalizations are rising, and ICUs in some areas are filling to capacity and beyond. In the face of this surge, attention to the physical and psychological health needs of residents and other health care workers is vital. Medical centers must work in strategic, comprehensive ways to address these needs and mitigate the potential harm to their residents and other clinical and non-clinical staff. Two guides have recently been posted that can help inform that work. The first, the Accreditation Council for Graduate Medical Education's (ACGME's) Guidebook for Promoting Well-Being During the COVID-19 Pandemic, is based on trauma-informed, evidence-based interventions drawn from the work of humanitarian organizations such as the World Health Organization, Doctors Without Borders, and the Red Cross, as well as from work in the military and the Veterans Affairs system.1 The second resource, from the Mount Sinai Health System, is evidence-based and informed by direct experience from those on the frontlines of the COVID-19 surge in New York City.2
While the virus is surging nationally, local impact remains highly variable. Some health centers are already overloaded, while others may be relatively quiet—and many hospitals are somewhere along this continuum. No matter the local circumstances, multifaceted interventions are necessary to support residents and other health care staff as the pandemic shows no sign of abating. Some institutions may have implemented many of the approaches suggested in the guides already, but potential gaps in support warrant immediate and concerted action from administration.
Strategic Areas
Efforts need to target 7 areas: (1) meeting the basic needs of residents and other health care workers; (2) delivering coordinated planning and communication; (3) promoting staff coping skills and ability to support colleagues; (4) identifying and assisting distressed staff; (5) promoting connectedness; (6) providing robust, accessible mental health services; and (7) optimizing the clinical environment.
Meeting the Basic Needs of Health Care Workers
Steps should be taken to meet staff's basic needs: ensuring that healthy food is available, arranging schedules that allow for sufficient rest, supporting staff who have childcare needs, and arranging off-site housing for frontline workers when necessary.
Delivering Coordinated Crisis Planning and Communication
Leadership should issue clear, concise, honest communication, and have a calm, active presence in the clinical setting. Leaders should create supportive spaces where people can express their needs, worries, and fears without retaliation.
Promoting Staff Coping Skills and Ability to Support Colleagues
Preventive mental health techniques such as cognitive reframing strategies should be taught to support individuals in managing potential (and perhaps inevitable) worry, anxiety, fear, sorrow, and feelings of inadequacy or guilt. These are particularly important given the prevalence of problematic mindsets in medicine, including maladaptive perfectionism, impostor phenomenon, and tendencies to see adverse events through the lens of personalization and self-blame.3
Everyone should receive instruction in simple breathing techniques that decrease limbic system activation and reduce alarm. One technique called tactical breathing, involving cycles of breaths to the count of 4, has been used in the military and takes mere seconds to practice and employ.4 All staff, clinical and nonclinical, should be given at least brief instruction in communication skills from Psychological First Aid (PFA; see the box).5
Be sincere in offering your help and care. Try to find a quiet place to talk and minimize outside distractions if you can.
Respect privacy and keep the person's story confidential.
Be patient and calm.
Let them know you're listening; for example, nod your head or say “hmmm….”
Allow for silence.
Acknowledge how they are feeling and any losses or important events they tell you about. “I'm so sorry. I can imagine this is very sad for you.”
Help them brainstorm positive ways to deal with their reactions.
Acknowledge that this type of distress can take time to resolve and offer to talk or spend time together as many times as is needed.
Importantly, believe that the person is capable of recovery.
Don't pressure someone to tell their story.
Don't interrupt or rush someone's story.
Don't rush to tell someone that they will be okay.
Don't think and act as if you must solve all the person's problems for them.
Don't judge what they have or haven't done, or how they are feeling.
Don't say: “You shouldn't feel that way.”
Don't talk about your own troubles.
Don't give false promises or false reassurances.
Identifying and Assisting Distressed Staff
All staff should receive basic information and, if possible, brief training on recognition of acute stress reaction and acute stress disorder, as well as communication tips drawn from PFA, to support those in distress. Resources related to this are available on the VA website, and one-page e-flyers are available from the ACGME.6,7 The e-flyers are easily adaptable for local use and distribution. More extensive training can be given to peer support leads and those in supervisory roles.
Promoting Connectedness
Mechanisms to ensure connection and check-ins are needed. Buddy systems or small “pods” can be created for this purpose and shift transitions can be designed to include one-on-one psychological handoffs. Group huddles that involve psychological debriefing should be used with caution, if at all. These approaches are not endorsed by the military or aid organizations and have been shown to be ineffective or potentially harmful. Everyone processes trauma differently, and a one-size-fits-all approach may be counterproductive, especially if it gives false assurance that everyone's psychological needs are being met.
Check-ins and handoffs should use basic principles from PFA and peer support. Perhaps the most important skill, quite simply, is making individuals feel heard, understood, and supported. These skills may not be intuitive for physicians given their tendency to interrupt and their inclination to want to “fix” the problem.
Time in peoples' days—even small moments when residents and other health care workers can share brief stories of wonder, grace, or beauty—can be integrated into rounds or shift transitions to keep people connected to a sense of meaning and purpose, which can be protective for mental health.
Providing Robust and Accessible Mental Health Services
Adequate in-house and virtual mental health support for staff in acute psychological distress is critically important. Resources must also be adequate to meet the potential surge in distress that may accompany a surge in COVID-19 hospitalizations.
Optimizing the Clinical Environment
Efforts to provide sufficient personal protective equipment for residents and all health care workers and support staff remain essential. Residents who are redeployed to COVID-19 wards and ICUs also need to be trained and appropriately supervised. Policies to limit unnecessary exposure to COVID-19 patients while still optimizing care need to be promulgated.
Conclusions
Tremendous uncertainty remains about how the pandemic will unfold in the coming months. The fall in cases seen in other countries has yet to happen here in the United States. The first wave, after flattening, is rising again, and fears persist about a potential second wave in the fall. While there is much that medical centers cannot control, everyone must take concerted, comprehensive action to support the physical and mental health of residents and all health care staff. Our residents and health care workers deserve nothing less.
References
Author notes
Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME.
