COVID-19: Guarding against burnout, compassion fatigue and trauma in frontline healthcare workers
As the number of cases continues to rise, Tan Tock Seng Hospital’s psychiatrists, psychologists and medical social workers are ensuring its healthcare workforce remains resilient - for the long haul.
SINGAPORE: It was a Saturday evening in late February and Dr Gareth Lim was at home, scrolling YouTube mindlessly. Out of the blue, he received something on his phone that made him jolt off his couch. A text message.
“It was from one of the senior doctors who plans rosters. She was very apologetic, but she told me manpower is needed at the National Centre for Infectious Diseases (NCID). They had to activate me on quite short notice.”
He was told he could say no if he did not want to be deployed. But if he said yes, he would be on the frontlines of the fight against COVID-19 in a couple of days’ time. It would be the 29-year-old’s first experience working in an outbreak scenario.
Dr Lim is two years into his National Healthcare Group residency at Tan Tock Seng Hospital (TTSH), where doctors are rotated from one department to another every three months to gain experience. “I'm actually quite a junior doctor,” he said bashfully.
Even so, he stepped up to the plate without hesitation. “I was excited to be part of the frontline effort, it would give more meaning to what I’m doing. It’s like, this is what we are meant to do as doctors,” he said.
But as Dr Lim settled into his new role at NCID, the excitement was quickly superseded by anxiety.
“It was quite daunting at that time because everything was so new, protocols were changing every day and the turnover of instructions was so fast,” he said. He worried about his ability to perform on the job and whether he could keep up with new procedures such as putting on the personal protection equipment (PPE).
“There's always that fear of, what if I didn't wash enough? What if I didn't put the PPE on properly or what if I have contact with patients unknowingly?”
By mid-March, the World Health Organization (WHO) said that COVID-19 could be characterised as a pandemic - the number of countries affected had tripled and numbers were expected to climb.
Dr Lim, while coping with a high level of stress at NCID, found himself “doing little things” that he usually would not do.
“Like reading the news, checking almost two to three times a day to see the number of cases,” he said. As he read reports on the virus causing major strains on critical care facilities around the world, questions like ‘What if our ICU became like that?’ and ‘How would we cope?’ filled his head.
KEEPING FRONTLINERS HEALTHY - MENTALLY
Such apprehension and state of mind are not uncommon for healthcare workers at the frontlines, said Dr Lim Wen Phei, a consultant from TTSH’s Department of Psychiatry.
“They are exposed to a multitude of challenges in their work. Firstly, they bear the brunt of the public's expression of fear, uncertainty and difficulties coping with change. They also have to manage their personal and very real fears of being infected in the line of work,” she explained.
“And they have to do all these while navigating the present nebulous climate.”
This is why TTSH and NCID have ramped up its efforts in preventive and early mental health interventions, to look out for staff members who “face the risk of burnout, compassion fatigue and trauma”.
“We have of course started noticing these symptoms with health care workers. But everybody has stress thumbprints - which means everybody's stress responses will be unique,” added Dr Lim.
The earliest signs of psychological distress would include burnout, which could manifest in the form of feelings of “helplessness and low accomplishment”.
“For example, people who have worked for 10, 11 consecutive shifts - the constant changes in workflows may reduce a feeling of mastery in their work.” Other warning signs of burnout include social withdrawal, where individuals may isolate themselves from their peers or even family.
READ: COVID-19 circuit breaker extended until Jun 1 as Singapore aims to bring down community cases ‘decisively’: PM Lee
While frontliners fight to keep patients alive and physically well, the Staff Support Staff (3S) programme guards the mental health of healthcare workers. It is helmed by representatives from various departments, such as Psychology, Care & Counselling, HR Wellness and Psychiatry - and has its roots in the peer support given to frontline staff of the SARS epidemic 17 years ago.
“We learnt from SARS that healthcare workers can experience symptoms of post-traumatic stress disorder from working in the frontlines,” said Dr Lim Wen Phei.
“It was an important lesson in underscoring the need for mental health in ensuring a resilient healthcare workforce.”
PAINTING A MENTAL PICTURE OF WHAT TO EXPECT
A toolkit put together by her in 24 hours was among the initiatives that have sprung up during the COVID-19 pandemic. Based on feedback on the ground, she saw the need to psychologically prepare staff members who are newly deployed to the screening centre and outbreak wards.
“Because of the urgency of the situation and how things were moving really dynamically, we had to come up with it as soon as possible. I asked a few of our colleagues working in NCID, if you were to advise a colleague who's going to be deployed, what would you tell them?”
To her pleasant surprise, word got around quick and “random people” contacted her to share their stories. Everyone had a valuable experience to share, she said. “It was quite touching for me to hear fellow staff saying, we were the first to be deployed, we didn't know what we were getting into. But if you're gonna write this up, please tell our people what to look out for.”
The document now covers a range of topics - from what to expect when you wear your PPE, the long hours and the number of people tested, to how to manage stress. Some stories that made it to the toolkit were:
“Be prepared to get really warm in the PPE! I wore the PPE for three hours and I was soaked in sweat right down to my undergarments. But everyone understands it’s for our own protection.”
“Little pockets of time you can find, like during lull periods or when commuting to work, can be used to be with your thoughts. Be mindful of your thoughts and see what is frustrating you so that you can sit with those feelings.”
While tips like how the mask is going to hurt and the goggles will give friction injuries seem “trivial and menial”, they cannot be overlooked.
“Those are actually very real pain points, but it's not intuitive for us to talk about it in a formal capacity. It helps people to paint a mental picture of what to expect, even if these are not really pleasant things to be expecting,” said Dr Lim.
“This helps to allay fear and anxiety in whatever capacity possible. The concept of the toolkit is to be practical and applicable.”
The toolkit came in handy for Dr Gareth Lim when he realised he was getting lost in his thoughts.
“It had tips on techniques to prevent burnout and how to practice self-care,” he said. “These were helpful reminders along the way - to take a deep breath and remember to spend time doing other things if I’m getting too stressed.”
24-HR HELPLINE AS “PSYCHOLOGICAL TRIAGE”
Another morale-booster for staff is the 3S Helpline, which exists to help them through personal crises. It was available during peacetime or before the COVID-19 outbreak during office hours, but it has since been transformed into a 24-hour helpline.
Ms Lek Jie Ying, the senior executive of TTSH’S HR Wellness department, once helmed the helpline alone, but she now works with a team of 13 medical social workers, psychiatrists and psychologists to respond to calls.
“Before the outbreak, the majority of the concerns were about their personal issues, for example sudden loss of loved ones or abusive patients,” said Ms Lek.
“But in this period of time, staff’s concern mainly revolves around the uncertain situation. They can be concerned over job deployment because of the nature of the crisis, it can be anxiety or frustrations over the many changes in policies," said Ms Chai Su Wi, a senior medical social worker on the helpline team.
Healthcare staff also seek advice for other challenges like childcare and eldercare arrangements. “The helpline gives them a safe outlet to voice out their concern and seek support," said Ms Chai.
Much like in the Accident & Emergency (A&E) department, the helpline functions like a psychological triage, where patients are assessed by the severity of their conditions, said Ms Lek.
“For some of them, maybe in this period, they need a little bit more help than usual. We will then do a formal referral for them to see a psychiatrist or psychologist."
COVID-19: A MARATHON WITH A COMMON GOAL
While Dr Gareth Lim’s one and half month long deployment at NCID’s ICU was shorter than his residency rotations, the warmth and camaraderie of his colleagues there left a lasting impression on him.
“I remember one of our department heads who spends many sleepless nights planning all the rosters, sending me text in the midst of everything to ask me how I’m doing, what I’ve learned and if I’m enjoying the experience,” he said.
“That reassured me a lot ... I was very moved by that. It makes me want to do more, in spite of the tiredness and uncertainties.”
In times of crisis, staff support within the hospital is important - given that many healthcare workers on the frontline are not able to be with their families, said Dr Habeebul Rahman, chairman of the 3S Executive Committee.
“They may face some degree of isolation or not be able to interact with their usual support systems.”
For Ms Lek and Ms Chai, peer support is crucial because talking to a fellow staff member is “less daunting than seeing a professional”.
Ms Lek said: “Sometimes it may be very hard to explain to our family members or friends outside the hospital. When our staff talk to someone in the hospital, they do feel that the other person can relate to a lot more.”
Since 2009, the 3S programme has held psychological first aid classes, which trains staff to “help themselves help other people”, said Ms Lek. To date, about more than 1,000 staff members in TTSH have been trained in psychological first-aid and some of them volunteer to attend to helpline cases as well.
With these psychological safety nets in place, it is with hope that frontliners would be able to regulate emotions of distress and “keep themselves well for the long haul”.
“Frontliners always try to push the limits to do more, but they are only human. They are the ones who see how patients deal with the disease and how families have to deal with their loved one being sick and that can be quite traumatising,” said Ms Chai.
“Our job is to let them know what support is available. Battling COVID-19 like running a marathon - there’s always an end point and we will move towards there together.”