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Healthcare workers around the world—physicians, nurses, technicians, EMTs, and other front-line hospital staff members—are facing unprecedented demands, professionally and personally, as they strive to meet the challenges of the current pandemic.
These workers are exposed not simply to an insidious novel virus but to unrelenting traumatic stress. This stress needs to be named and worked with to ensure that healthcare workers do not become casualties of traumatic stress disorders.
Stress and Emotional Fallout
There is secondary traumatic stress (also known as vicarious trauma or compassion fatigue). Healthcare workers cannot help but absorb others’ suffering; their empathy becomes the conduit for the unconscious transfer of distress. This occurs in ways that are both sharp (as healthcare workers work with particularly painful cases) and cumulative (as their constant exposure to others’ suffering mounts). Healthcare workers cannot absorb others’ trauma and remain unaffected, even as they seek to remain professionally detached. The secondary traumatic stress adds to their primary traumatic stress. And both types of stressors are joined by workers’ stress, related to anxiety about their health and wellbeing and that of their families, friends, and community.
Primary, secondary, and personal traumatic stresses leave healthcare workers with inescapable emotional realities, marked by anxiety, fear, sadness, uncertainty, loss, despair, grief, frustration, anger, and guilt. Even as healthcare workers strive to remain focused on their work, doing the best that they can with the resources and skills they have, these emotions remain just under the surface, painful and vast. When such realties are left unexamined and untended, people risk the fallout associated with post-traumatic stress disorders. They can become plagued by intrusive imagery or psychic numbing; somatic complaints; impairment of daily functioning; a sense of isolation and alienation; decreased morale and engagement at work; and lack of compassion for patients, colleagues, and their own families.
They also risk losing compassion for themselves. Self-compassion is a valuable resource, necessary for caregivers to remain engaged in the work of combatting the pandemic. Kristin Neff, a professor at the University of Texas, considers self-compassion as occurring when people respond to their pain, failure, or guilt with kindness rather than judgment; understand their predicament as part of the human experience rather than personally shameful; pay attention to suffering in a mindful rather than over-identified manner.
When caregivers struggle with self-compassion, they compound their distress. They can hurt themselves and possibly others. As Parker Palmer, founder of the Center for Courage and Renewal, writes, “Violence is what happens when we don’t know what else to do with our suffering. Sometimes we aim that violence at ourselves, as in overwork that leads to burnout or worse, or in the many forms of substance abuse. Sometimes we aim that violence at other people.” The pandemic is wreaking an untold amount of violence on the world’s population; healthcare workers compound that violence when they are unable to show compassion—kindness, forgiveness, caring concern—for themselves amidst their very human struggles to hold it all together.
The Possibility of Resilience
Left untended, these symptoms worsen, with healthcare workers increasingly unable to care for themselves and their patients, families, and one another. It is crucial to develop ways to ameliorate the effects of traumatic stress. Ideally, of course, the traumatic stress itself would cease, providing time and space for healthcare workers to recover. And healthcare systems would have the necessary infusions of resources, staff members, and physical space to relieve stress. At this moment in time, the pandemic renders much of this impossible.
The goal shifts from getting rid of the stressors to enabling healthcare workers to remain as resilient as possible amidst ongoing traumatic stresses. In this context, resilience involves the capacity for healthcare workers to absorb, contain, work with, and release the emotional fallout of traumatic stresses and keep on going, without lasting damage. I think of resilience in terms of the elasticity of a rubber band, enabling it to stretch and strain without breaking. Our healthcare workers are overly stretched, asked to do far more with far less, in circumstances that are exhausting and frightening. How can they stay as resilient as possible, given all that cannot be controlled?
There are four sources of resilience that become possible, none mutually exclusive. First, individual healthcare workers can care for themselves. They can engage in self-care activities—exercise, therapy, friendships, meditation, healthy habits, intimate relationships—that help them regularly feel better and provide a base for compassion for self and others. This requires them to make time and space for noticing what they need and then taking the steps to meet those needs. It requires them to put their oxygen masks on as the prerequisite for being able to do so for others.
Second, they can engage in work interactions with others that enable them to give and receive a sense of dignity, respect, and appreciation; such interactions regularly replenish rather than deplete them emotionally. The pictures and stories of healthcare workers laughing together hearten me, even if their humor is dark and bleak. I am reminded of the television series M*A*S*H* in which Hawkeye Pierce and his fellow physicians and nurses in the Korean War hospital unit used humor as a way to make sense of and survive the surreal assembly line of wounded and dying soldiers. It was in their relations with one another that they were able to hang onto whatever humanity they could.
Third, they can regularly convene in small groups of like-minded others. While healthy denial has a short-term utility, enabling people to focus on the urgent tasks in front of them, it can also lead to self-destructive defense mechanisms in which people detach from themselves and others, leaving them misshapen rather than elastic. Psychologist Judith Herman, in Trauma and Recovery, writes that attending to a traumatic experience is the active ingredient in healing. Small groups of people with shared experiences and understanding offer the possibility of such healing. Such settings (which I describe a bit more below) allow people to process and release painful emotional fallout; they can leave healthcare workers connected rather than isolated by distressing experiences.
Fourth, healthcare workers can feel connected to an institution that helps them feel regularly respected, appreciated, and cared for. Hospital and clinic leaders can go a long way to help their front-line caregivers feel secure even amidst the uncertainties of this pandemic. Leadership matters here, a lot. Trustworthy leaders are important. They tell their members what they know and what they don’t know; what steps they’re taking to provide resources and relief; and how exactly they are personally involved in the struggle. Their words mesh with actions and progress. They instill trust when members see results, in the form of more resources and better outcomes, and when they see their leaders alongside fighting with and for them. This too is a source of resilience, as healthcare workers feel securely attached to institutions that protect and care about them.
Resilience Groups
Hospitals can most directly support front-line staff by providing whatever relief they can: more beds, ventilators, personal protection gear, and relief staff. They also have a significant role to play in terms of healthcare workers’ mental health during the crisis. These workers are often inundated with wellness resources, such as websites devoted to meditation, nutrition, fitness, yoga, and other self-care activities. These resources certainly help those who make the time and find the energy to develop regular routines.
Such self-care activities, however, do little to help people attend directly to the painful emotional fallout of their work. As much as we might like to think of these front-line caregivers as protected by their professionalism and training, or exempt from emotional pain by their heroism, the truth is starker: They can suffer a great deal in their work. Painful emotions can grip them. They need help shifting to the place where they have emotions, not the other way around.
Resilience groups can help here. These are facilitated groups in which people join together to share their experiences with understanding others, to the point that they are not so preoccupied with those experiences (and the attendant emotional fallout) that they cannot remain resilient. The groups are reasonably small, six to eight workers whose common experience is to be on the front lines of the pandemic. They meet virtually for an hour or so each week. They focus on what they are “carrying” emotionally from their experiences, and what doing so means for their work and personal lives.
The facilitator ensures that members name, share, and release disturbing feelings; that they are allowed to share particularly difficult experiences; that their responses to those experiences are validated and affirmed; and that they are helped in their efforts to remain compassionate with others and with themselves. Facilitation is crucial. So-called support groups without facilitation often end up causing more harm than good: As members vent, they invoke a language of complaint, blaming others (leaders, patients, colleagues, other departments), and reinforcing a victim narrative that leaves them feeling even more helpless. Resilience group facilitators are trained to ensure that the focus is on what the work does to the healthcare worker as a human being. The worker becomes seen, valued, and affirmed, helped to understand what it means to make choices within distressing circumstances.
Hospitals and clinics are not used to such groups. They are more familiar with huddles, in which interdisciplinary teams pause to develop care strategies for patients. There are M&M conferences, in which cases with bad outcomes are examined to determine causes and improvements. There are EAP consultations, in which outsiders are brought in to debrief difficult events, such as a workplace shooting or healthcare worker’s suicide, that affect a department. And there are Schwartz Rounds, which, in the spirit of grand rounds, are public discussions of cases that had a significant emotional impact on care team members. None of these, however, offer regular forums for healthcare workers to safely, regularly excavate and examine their emotional experiences. None help prevent traumatic stress disorders.
From Here to There
The various ways in which healthcare workers are now being supported are all important. Hospital administrators do their best to give them time off whenever they can. Colleagues from other departments help out. All over the world, they are thanked and cheered, sent pizza and flowers, handed masks and gloves. These actions give healthcare workers moments of respite, to help them feel appreciated and valued. Yet these acts need to be complemented with efforts to offset the traumatic stress that front-line caregivers are soaking up and which pose a real danger for them, now and later.
There are quite understandable barriers to instituting resilience groups and similar interventions. Time is scarce. With the surge now affecting some parts of the country and moving toward other parts, healthcare workers have little time for activities not directly related to caring for patients or their own families. Group “therapy” seems like an awful waste of time when there is real work to be done. The immediate cost of spending time on non-essential matters seems too high for those on the front lines.
A not-unrelated barrier is a personal vulnerability that resilience groups require their members to be truly helpful. Such vulnerability can be difficult in healthcare professions, where the expression of emotion is too often considered a sign of weakness. Indeed, the typical healthcare worker’s answer to the question of “How are you?” is “Fine,” even though no one can truly be “fine” in the current levels of anxiety, stress, fear, and uncertainty that mark the lives of these workers. Hiding beneath that interchange is the unspoken fear that the truth of how difficult this is would be too much to bear for all involved.
Perhaps, the thinking goes, it is better to just wait until the current crisis has subsided. Then there will be time to attend to the mental health and emotional realities of these real-life M*A*S*H* doctors, nurses, technicians, EMTs, and other front-line workers. And they will be in a better place to approach the vulnerability that they’ll need with one another to attend directly to their traumatic stress.
The challenge here is that it is not clear when and how there will be slack enough in their lives—when the “post” in PTSD becomes viable—to focus on what this work is doing to them emotionally. Our circumstances might be chronic rather than temporary. More to the point, the longer that healthcare workers go without direct attention to their traumatic stress, the more damage is done. We also know that wishful denial being what it is, once the crisis has abated, hospital leaders will be tempted to believe that everything is back to normal. They will be less likely to look for the casualties that hide in plain sight among their workers.
A middle ground here is to start the lay the foundation for resilience groups and similar interventions, which can then become introduced in moments of slack. In practice, this means developing the healthcare organization’s emotional capability: identifying and training facilitators from among the ranks of available healthcare workers, administrators, social workers, and others suited for this kind of facilitation. This not only readies the system to handle its walking wounded but brings other hospital members together on an initiative over which they have some control, on behalf of colleagues and a mission that matters to them. Traumatic stress is another invisible, insidious enemy that our healthcare system is fighting with the potential to do serious damage to those who are needed to save lives. Our hospital leaders need to ramp up now to start to save their workers’ lives as well.
