Every day, health-care workers struggle to protect their patients, their communities, and themselves from the coronavirus, with many working 24-hour shifts in overcrowded hospitals, nursing homes, and other congregate settings, sometimes without appropriate personal protective equipment. Their work environment is dangerous and exhausting. ICU and other front-line nurses don’t begrudge the threat to their own well-being, but many are concerned about transferring that risk—and, potentially, the novel coronavirus itself—not only to those around them (their coworkers and patients) but also to families and friends waiting for them at home.
This blog article addresses three questions:
- Are the stresses of COVID similar to that of SARS?
- What are the major factors contributing to these workers’ mental and physical health challenges?
- What institutional solutions do professional insiders propose to ease their burden?
COVID’s Effects On Health-Care Workers
While not all health-care workers (HCW) are demoralized or undergo terrible strain, anecdotal reports from different countries indicate that many physicians, nurses, personal-care support aides, and other essential-care workers are at physical and mental risk. Principal complaints include inadequate PPE equipment, insensitive management, health risk, inadequate remuneration, inflexible shifts, and non-consultation about working conditions.
|COUNTRY||POPULATION STUDY SIZE||COVID EFFECTS WORST ON||HCW STRESS EFFECTS|
|China||1,257||women, nurses, those caring directly for patients, and those in community at epicenter;||depression (50%), anxiety (45%), insomnia (34%), and distress (72%)|
|Singapore||470||Black, Asian, and minority ethnic health-care workers||anxiety (14.5%), 42 depression (8.9%), stress (6.6%), and PTSD (7.7%)|
|United States||2,200||nurses rather than doctors, females; Black and indigenous workers and people of color, including immigrants||trouble sleeping, exacerbation of chronic conditions, greater drug use and abuse|
According to the CDC, symptoms of infectious disease stress include the following:
- Fear and worry about your own health and the health of your loved ones, your financial situation or job, or loss of support services you rely on
- Changes in sleep or eating patterns
- Difficulty sleeping or concentrating
- Worsening of chronic health problems
- Worsening of mental health conditions
- Increased use of tobacco, and/or alcohol and other substances.
A New England Journal of Medicine study conducted in communities affected by Severe Acute Respiratory Syndrome (SARS) in the early 2000s revealed that emotional distress tempted some health-care workers to consider violating their ordersm even though community members, affected individuals, and health-care workers were motivated to comply with quarantine to reduce the risk of infecting others and to protect the community’s health.
Medical conditions arising from natural causes such as life-threatening respiratory viral infection like COVID do not meet today’s criteria for trauma required for a diagnosis of Post-Traumatic Stress Disorder (PTSD), but other psychopathology, such as depressive and anxiety disorders, may ensue. Researchers say less severe reactions to COVID than SARS could be attributed to increased mental preparedness and more stringent infection control measures in certain jurisdictions like Singapore after the SARS experience.
Health-care worker (HCW) occupations are at higher risk of infections. According to Lancet, reports in the US and UK suggest 10–20% of SARS-CoV-2 infections occur among health-care workers. Health-care workers are severely over-represented in Ontario COVID case data, representing more than 17 per cent of all Ontario cases, with 5,800 positive cases and 13 deaths between January 15, 2020 to June 22, 2020, according to Canadian union Unifor. Public Health Ontario only started collecting data on personal-support workers on May 29, 2020, months after the pandemic began. Many other classifications of workers who work in close proximity of COVID-19 patients, like porters, housekeepers, technicians and technologists, and unit clerks are not tracked at all, referred to only as “unspecified HCW occupation”.
Stresses that researchers think contribute to widespread emotional distress and increased risk for psychiatric illness among HCW’s associated with COVID-19 include:
- uncertain prognoses
- looming severe shortages of resources for testing and treatment and for protecting responders and health care providers from infection
- imposition of unfamiliar public-health measures that infringe on personal freedoms
- large and growing financial losses
- conflicting messages from authorities. Health-care providers have an important role in addressing these emotional outcomes as part of the pandemic response.
Explanations For Adverse Effects Of COVID On HCW Occupations
1. Protective equipment shortages and weakened guidance: There were widespread reports of inadequate supply and quality of the protective equipment desperately needed to safeguard health-care workers and first responders. CDC has gone so far as to recommend that doctors and nurses wear bandanas if there are no masks or respirators available, even though there is no evidence this will provide effective protection for health-care workers. Lancet reports evidence that sufficient availability of PPE, quality of PPE, or both reduce the risk of COVID-19, but reuse of PPE or inadequate PPE might confer comparably increased risk, which is compatible with findings from one of the first studies to specifically investigate PPE reuse.
2. Lax hospital patient-care management: There needs to be more emphasis on better ill-patient identification, clear triage procedures, the use of engineering control and contact barriers, disinfecting guidelines, and provision of rest breaks. Global shortages of masks, respirators, face shields, and gowns, caused by surging demand and supply chain disruptions, have led to efforts to conserve PPE through extended use or reuse, and disinfection protocols have been developed, for which scientific consensus on best practice is scarce.
3. Failure of federal safety and health enforcement: U.S. federal agencies, OSHA and CDC have issued voluntary guidelines recommending policies and procedures for employers. Employers can choose to follow them or ignore them. OSHA has made it clear it is not enforcing these guidelines. Because the federal government has abandoned its role in enforcing protections to safeguard workers in this crisis, some analysts propose that workers and their advocates should turn to state policymakers to adapt the voluntary federal guidance into state-enforced requirements
4. Poor guidance and training: With limited official guidance, health-care workers have had to make tough calls about how and how often it’s safe to move between hospitals and clinics and homes full of people who might otherwise never be exposed to the disease. Depending on location, there have been offers of practical advice for limiting exposure, like switching from contact lenses to glasses so workers don’t have to touch their eyes, or tying back long hair so it doesn’t need to be adjusted.
5. Long-term-care facilities funding and staffing crisis: Ontario and Quebec have had long-term care staffing crises, and cuts have left health-care services over-crowded and at risk. Ontario Bill 195 has been criticized for its potential to wreak havoc on front-line workers’ schedules, vacation and even their ability to earn their pre-pandemic wages as it pertains to having more than one workplace.
Forthcoming Workplace Occupation Solutions
In anticipation of a second wave of infections, health-sector experts propose or recommend some of the following solutions:
1. Flexibility in where and when to work: Employers should explore whether they can establish policies and practices such as flexible worksites (telecommuting) and flexible work hours (staggered shifts) to increase physical distancing among employees and between employees and others. Justified cause quit rules should include work assignments that violate workers’ health and safety, and a workers’ need to care for quarantined or sick family members.
2. Non punitive emergency sick leave policies: Recommended sick leave policies should be:
- (a) flexible;
- (b) consistent with public health guidance;
- (c) efficacious; and
- (d) ones that employees are aware of and understand.
They would permit employees to stay home to care for a sick family member or take care of children due to school and childcare closures, as well as include giving advances on future sick leave and allowing employees to donate sick leave to each other.
3. Notification when co-worker is ill: If an employee is confirmed to have COVID-19 infection, employers should inform fellow employees of their possible exposure to COVID-19 in the workplace but maintain confidentiality as required by law. The fellow employees should then self-monitor for symptoms (such as fever, cough, or shortness of breath).
4. Team isolation without penalty: As noted in EthicScan Blog The Future: Returning Manufacturing Workers (May 17), same shift or team employees should be able to self-isolate and receive appropriate testing and advice without financial penalty as long as is required.
5. An effective, timely and confidential complaint system: Health-care workers should have the right to complain and have that complaint promptly and fairly heard and addressed, with protection against retaliation.
6. Wage replacement coverage under workers’ compensation or insurance or government safety net: Wage-replacement benefits should be paid to any first responder or medical employee who is quarantined because of direct exposure to anyone diagnosed with COVID-19.
7. Broad direct support for all essential personnel: All essential workers should be considered first responder heroes during the pandemic with access to
- (a) free child care while working,
- (b) free health-care coverage for all COVID-19 treatments,
- (c) enhanced danger pay, and
- (d) paid leave for a broad set of reasons related to the pandemic and for caregiving.
Minnesota, Michigan, Massachusetts, and Vermont have already designated grocery workers as “first responders” similar to health-care workers and other essential personal, which will give them access to free child care.
8. Integrated evidence-based resources and communications strategy: Appropriate education and training including psychosocial counselling should be provided to health-system leaders, first responders, and health-care professionals. The mental health and emergency management communities should work together to identify, develop, and disseminate evidence-based resources related to:
- (a) disaster mental health,
- (b) mental-health triage and referral,
- (c) needs of special populations, and
- (d) death notification and bereavement care.
Risk-communication efforts should:
- (e) anticipate the complexities of emerging issues such as prevention directives, vaccine availability and acceptability, and
- (f) needed evidence-based interventions relevant to pandemics and should
- (g) address a range of psychosocial concerns.
Protecting health-care workers’ health is central to protecting everyone’s health. All workers who are on the job during this pandemic, from frontline, health-care workers and emergency responders, to those working in supermarkets, delivery, pharmacies, factories, transportation, sanitation, and all other essential workplaces, must be protected from disease transmission. This in turn will protect the public.
Health-care providers are particularly vulnerable to both infection and emotional distress in the current pandemic, given their risk of exposure to the virus, concern about infecting and caring for their loved ones, shortages of personal protective equipment (PPE), longer work hours, and involvement in emotionally and ethically fraught resource-allocation decisions. A number of pre-COVID wave two solutions are reviewed, including prevention efforts such as screening for mental-health problems, recognition of heroic choice profession needs, and psychosocial counselling support for these and other groups at risk for adverse psychosocial outcomes.
JWatch – Mental Health Effects of COVID-19 on Healthcare Workers in China:
National Employment Law Project – WORKER SAFETY & HEALTH DURING COVID-19 PANDEMIC: RIGHTS & RESOURCES:
EthicScan Blog: Why are we failing Health-Care Workers?https://ethicscan.ca/blog/2020/04/22/why-are-we-failing-health-care-workers/
The Lancet – Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study:
Newswire- P ublic Health Ontario data reveals devastating pandemic effects for health care workers