Thanks to Scientific Advisory Committee members Carmen McLean and Katy Kamkar for creating this resource.
Healthcare staff will likely be exposed to many potentially traumatic events and events leading to significant distress and moral suffering. As frontline workers, they are highly exposed to the virus itself. The risk of getting sick and needing to be quarantined or hospitalized, or even dying are ever-present. Many healthcare workers have already lost numerous patients and even colleagues to COVID-19. The dramatic increase in cases has overwhelmed healthcare systems and hospitals are scrambling to secure the resources to meet the need.

As a result, staff may be forced to make impossible triage decisions about how to allocate limited resources to the patients they are caring for. All of these potentially traumatic experiences are occurring in the context of under extreme pressures, including fear of spreading the virus to loved ones, possible separation from family, mental and physical exhaustion, and limited access to personal protective equipment and needed medical supplies.

Being vulnerable to contracting a life-threatening illness (or spreading it to loved ones) and witnessing suffering and death are all potentially traumatic events that increase the risk for psychological disorders, including post-traumatic stress disorder (PTSD).

PTSD is characterized by four types of symptoms:

1. Re-experiencing the trauma through intrusive distressing recollections of the trauma, flashbacks, and nightmares
2. Avoidance of places, people, and activities that are reminders of the trauma
3. Negative changes in thoughts and emotions associated with the trauma such as viewing oneself, others, or the world in a consistently negative way (e.g., “I’m a failure”, “people will let you down in times of need”, or “the world is extremely dangerous” ), persistent negative emotions such as grief, sadness, or anger, or difficulty experiencing positive emotions such as happiness or joy; feeling emotionally distant from others (i.e., emotional numbness); and less interest in activities
4. Increased arousal including difficulty sleeping and concentrating, being constantly on guard for signs of danger (i.e., hypervigilant), and being easily irritated and angered

Click here for more info on PTSD.

In addition to PTSD, the potentially traumatic events that healthcare workers will likely experience during the COVID-19 pandemic can also lead to depression and anxiety, as well as other significant mental health concerns, including compassion fatigue, moral injury, traumatic grief, and burnout.

• Compassion fatigue occurs when you are in an extreme state of tension and preoccupation with the emotional or physical pain of those you are trying to help.
• Moral injury refers to psychological distress resulting from actions taken or not taken that violate a person’s moral or ethical code. Moral injuries have primarily been described in military personnel and first responders but have also been documented in medical staff. Experiences that can cause moral injury, such as feeling let down by having to work with insufficient resources, having to choose which patients are allocated life-saving resources, or following clinical procedures that go against ethical guidelines are also associated with mental health problems, including PTSD.
• Traumatic grief is a type of grief that overwhelms and does not decrease with time. It is more likely when a loss is sudden or traumatic, as may be the case with COVID-19 related deaths, or when the grieving person lacks needed coping skills or social support.
• Burnout occurs when you feel emotionally, psychologically, or physically exhausted; there may be increasing cynicism and detachment; as well as feeling ineffective.

The prolonged and recurring nature of COVID-19-related trauma may increase risk of subsequent mental health problems. Even the most highly experienced and resilient healthcare workers may become overwhelmed by the fear, isolation, grief, and loss of life to come. Although not all healthcare workers will develop mental health problems, no one is invulnerable or immune, and some healthcare staff will struggle, possibly for an extended time. Our frontline staff need to be supported now. The goal of the recommendations below is to promote mental health and resilience and reduce the risk of psychological health conditions.

• Know that your reactions, thoughts, and feelings are normal. You might feel helpless such that you have control or hopeless such that whatever you are going to do will not change anything or things will remain the same. You might feel sad, down, anxious and guilty. You might even feel so powerless and at times question how much difference you are making, making you having “imposter syndrome”. You might feel the grief of having lost your previous life and past routines to grieving the loss of patients and being afraid of contaminating your family. So it is very important that you normalize however you feel, your worries and thoughts. You are not alone having them.
• Reach out for support. Talk to your family and friends whenever possible about your fears and worries. Allow yourself to be off-duty when at home so that you can rest, and talk about how you are feeling and what you are thinking.
• Catch any negative thoughts about yourself or tendency to judge self. You will have to make decisions that will have a life and death outcome. You would need to accept and trust that you tried your best.
• Fit in self-care. While providing empathy and care for others and focusing on their needs, make sure that you don’t ignore your own needs and emotions. Depending on your shift work and duties, try to include daily self-care such as ensuring your eat meals that you might wish to prepare ahead of time so you don’t work on an empty stomach; stay hydrated; engage in your daily stretching exercises and breathing exercises. Set time for yourself daily, no matter how long it could be. Even 5 minutes several times a day can make a difference to help recharge your batteries between shifts.
• Avoid unhelpful coping strategies. Substance misuse or excessive caffeine or excessive alcohol should be avoided.
• Set boundaries. Limit time spent watching the news and carve out protected time to engage in other relaxing and meaningful activities. The boundary that you might set might differ everyday based on how you feel and your tolerance level.
• Use grounding techniques if you feel overwhelmed. Try to ground yourself daily by using your senses (what you see, hear, touch, smell or taste) to be in the present moment.
• Practice self-compassion. Be kind to yourself, notice your thoughts and emotions without judging them, and take a broader outlook by putting them into perspective, understanding that you are a human being and you are not perfect. Focus on the things that are in your control and try to notice and celebrate successes both big and small.
• Seek professional help if needed. If you feel overwhelmed and feel your symptoms are increasing over time, you feel distressed such that your day to day functioning is impacted and you have difficulty functioning then talk to a heath care professional. It is important that you do not suffer in silence. Protectors need their own protection. Check out our online directory to find help in your area.

• Communicate clearly and often. Provide accurate information to staff about what to expect and the efforts underway to help them work effectively. Encourage open and honest communication, educate them about the possible traumatic experiences they may face, and normalize the reactions they may experience so that they are as prepared as possible for what lies ahead.
• Facilitate peer support and team cohesion. Feeling supported and being part of a united team can protect against the effects of stressful or traumatic experiences. Consider establishing a check-in system for peers and supervisor-supervisee pairs. Let your staff know they are valuable, and that you are all in this together. Modeling support seeking can have a big impact on others’ behavior.
• Support self-care. In the midst of the pandemic, any mini breaks that could include stretching and staying hydrated can become even more significant. This is important for staff of all levels.