As we near the end of 2020, we also near another milestone: It’s been a year since we began living through a global pandemic. The last year has brought us much uncertainty. We have questioned things such as the efficacy of lockdowns and how stringent they should be; concerns about the pandemic’s economic impact will ultimately have; the overall effect the pandemic will have on our healthcare systems on the individuals working within that system.
Perhaps one of the most significant stressors throughout this pandemic has been the politicization of the pandemic itself. However, not all jurisdictions have shared this experience. Some would agree there have been varying levels of stubbornness by political leaders when it comes to cooperatively work to ensure society’s health and safety first and foremost, followed by adequate and updated treatment guidelines in addition to proper funding of those in need. This political obstinance has left practitioners feeling abandoned, misled, and even expendable . This lack of leadership has also affected the public’s response to social distancing and the use of masks. Because the public response has been so varied, practitioners have often found themselves caught between promoting scientific evidence and the belief by many individuals that “the pandemic and the response to it are overblown, a political ploy or an attempt to deny personal rights” .
We often find a notion in the healthcare system of altruism. Practitioners feel a sense of professional responsibility or duty, the idea of turning toward danger rather than away from it despite our fear and innate sense of self-preservation. The “heroes’ welcome” that became standard across many cities in the world at the onset of the pandemic in recognition of those on the frontlines, also, the people coming up face-to-face with practitioners to thank them for their service can lead to imposter syndrome and dissonance, further increasing one’s stress .
The next significant stressor throughout the pandemic has been the availability of adequate personal protective equipment (PPE). While Canada has not seemed to experience the same fate as the United States, many practitioners South of the 49th parallel wear the same PPE for days or even months at a time . Practitioners experience cleaning equipment recommendations otherwise regarded as ‘disposable’ using methods such as light therapy . These new standards have raised concerns about its efficacy, which seems counter intuitive and is contrary to standard procedures . The new way of life has contributed to increased stress in the workplace (personal safety aspect) and at home (as practitioners, maybe parents, siblings, children of aged parents, friends, and partners of those who can be negatively impacted by the unintentional transmission of the coronavirus). The result has led to the “voluntary separation from family members up to and including living apart” . In turn, it has raised care-related issues of family and children in addition to other logistics .
Medical practitioners often lack autonomy in the decision-making processes that involve their safety. Some practitioners feel they have an inability to voice their dissent surrounding many of these practices  (Humphreys & Joseph, 2019). Protests have occurred in many parts of the world, with practitioners demanding adequate PPE. Unfortunately, responses or solutions are not always sufficient. The United States, where the healthcare system is relatively private and profit-driven compared to our universal design, has been an example .
Add to this the stressor of making ethically tricky decisions, which can eventually lead to moral distress, the onset of which can occur from the need to allocate limited resources, such as medications, ventilators, and or beds . This stressor, compounded by the phenomenon of patients dying who otherwise might have recovered under different circumstances. An example from the hospital setting might include a patient who requires inpatient or intensive care but does not have COVID-19 and is, therefore, not admitted . The pandemic has also further compounded social disparities in healthcare access and the ability to self-isolate and social distance. Unfortunately, this ladled to a disproportionate number of deaths, the lack of treatment associated with this further demographic compromises a practitioners’ moral distress . These deaths and lack of treatment also seem to create a pervasive sense of unfinished care, further damaging one’s moral pain .
Practitioners can often manage single, short-term stressors without long-term impact. On the other hand, the multiple stressors practitioners have been facing for months in addition to a high-pressured work environment as well as high-risk scenarios have without a doubt harmed the emotional, physical, and psychological health of practitioners . The reality of the situation is that the ongoing austere working conditions coupled with the expectations and need for high-level care can often require more than practitioners are capable of delivering for extended periods, ultimately leading to compassion fatigue . Compassion fatigue can be defined as “emotional and physical exhaustion resulting from heightened demands of the practice environment, as well as experiencing the suffering of others without an opportunity to process, decompress or debrief” . Contributing factors of compassion fatigue include a reluctance to turn to social support networks, the responsibility for determining who receives limited resources, being in the profession less than five years, high acuity patients, and a lack of administrative support .
Secondary Traumatic Stress
Secondary traumatic stress (STS), referred to as vicarious traumatization, a term coined by Laurie A. Pearlman and Karen W. Saakvitne, is a component of compassion fatigue. STS is a stress response experienced by medical practitioners who care for patients suffering from emotional, spiritual, and physical trauma [2, 3] (Craigie et al., 2016).
STS describes a significant shift in a practitioner’s worldview and a decrease in the person’s sense of safety and connectedness to others while increasing anhedonia when there is a traumatic experience. Practitioners who have experienced STS report that ‘their fundamental beliefs about the world are changed and possibly damaged”  through repetitive exposure to traumatic experiences or material . The Manifestations of STS rapidly occur following trauma and may include: difficulty sleeping, nightmares, anxiety, and intrusive thoughts of the patient [1, 3]. Protective factors against vicarious trauma include the: ability to separate the self emotionally from patients and control the physiological response to others’ suffering .
Burnout is also a component of compassion fatigue. The onset is a gradual response to prolonged work-related stressors. It is associated with a loss of sense of self and emotional, mental, and physical exhaustion [1, 3] (Craigie et al., 2016). The result is a decreased ability to work effectively, accompanied by feeling powerless, hopeless, and frustrated . Practitioners are likely to end up with a sense of disconnectedness from their profession at large and their colleagues .
Post-Traumatic Stress Disorder and Depression
COVID-19 has also contributed to an increased incidence of PTSD and depression. Jackson (2014) noted that both of these conditions could “develop within a few weeks of the outbreak of a pandemic” . The manifestations of PTSD and depression may include persistent and disturbing thoughts accompanied by hypervigilance. Often, individuals will experience altered means of coping – substance use disorders, damaged relationships, as well as chronic illness, according to Altman (2020) and have identified PTSD as “the third wave of the epidemic”  (Altman, 2020). An important observation regarding the manifestations of depression is that they can overlap those of PTSD and include anhedonia, guilt, self-criticism, in addition to a low sense of self-worth. Frequently, individuals experience difficulty thinking and processing information. Suicidal ideation may accompany these symptoms .
Psychological Personal Protective Equipment
The idea of psychological PPE encompasses actions taken by an individual or at an organizational level to support and enhance practitioners’ self-care, wellness, and mental well-being.
Many organizations have failed to provide adequate physical PPE, resulting in anger and frustration, leading practitioners to feel unsafe and expendable. Individual practitioners and employers must address the physical and psychological aspects of PPE. For the individual, practitioners can make deliberate choices to ensure they are eating healthy foods regularly and getting enough sleep and exercise. Additionally, the practice of mindfulness with relaxation techniques while seeking a work-life balance will help mitigate the negative stressors associated with the pandemic . An essential activity for practitioners to complete is a self-assessment of coping abilities followed by taking action to improve those areas lacking. Other strategies may include using apps for meditation and relaxation– such as the “Waking Up App,” in addition to regularly engaging with social support networks. To bolster personal resilience, practitioners should consider discussing their experiences with colleagues, allowing for recognizing each other’s responses to the incident . It is equally important to allow time to process emotional reactions by naming and acknowledging what you, the practitioner, feel. Again, the practice of mindfulness for short periods throughout a shift may help some practitioners, taking time to pause and focus on one’s breathing for 15-30 seconds . This activity is best done in isolation while not multi-tasking. Practitioners need to acknowledge their limits concerning human suffering and trauma. Limiting concerns is best done by reflecting and finding positive aspects in an experience, such as personal or emotional growth . While not a novel idea, it is essential to decompress every day by exercising, playing with pets, journaling, meditating (again), or laughing with children, all while limiting exposure to additional trauma, including the news, television, movies, and social media.
Lastly, practitioners would benefit from the practice of the “Three Good Things” approach can have a significant positive impact. In this approach, the practitioner identifies three things that went well throughout the day and “their role in making them happen” . Lambert et al. (2012) noted that when healthcare practitioners used this approach at a health system in Michigan, the positive reframing had terrific results, including increased happiness measures and a decrease in depression 
At the organizational level, the best ways to improve psychological PPE include team building and mentoring/coaching programs, which provide social and clinical support for practitioners and provide a way to monitor the stress levels of each other. Huddles (commonly referred to as ‘parade’ or ‘roll call’ in paramedicine and law enforcement) at the beginning of the day or debriefing at the end of a shift can provide opportunities to practice mindfulness and further increase the social support framework for each practitioner. It may be beneficial to include a behavioral health practitioner in parades or debriefings to facilitate discussion of mental health issues or the provision of psychological first aid . Ensure that everyone has an opportunity to speak during roll call or debriefings. As an organization, model open, and respectful communication. It is equally important to acknowledge and model vulnerability while emphasizing humanity and humility to normalize the emotions practitioners experience. Ensure positive affirmations, appreciations, and gratitude for each other and recognize successes . Lastly, ensure practitioners are taking advantage of employee assistance programs. Work to avoid stigmatizing the need for counseling. Organizations should consider providing paid time off for self-quarantining if necessary; if a practitioner develops a COVID-19 infection while at work, regard it as a work-related injury [7, 8, 9, 10].
As we move out of 2020 and into 2021, there is light at the end of the tunnel. Individual practitioners must first take action to safeguard themselves, their families, and their futures. Working with their respective organizations, through collaboration, practitioners can help guide the system in the right direction for the greater good.
- Robin A. Hertel. The Use of Psychological PPE in the Face of COVID-19. MedSurg Nursing. 2020;29(5):293-296.
- Jennifer Thew. COVID-19 creates vicarious trauma among healthcare workforce. Health Care Leadership Review. 2020;39(8):1-3.
- Craigie M, Osseiran-Moisson R, Hemsworth D, Aoun S, Francis K, Brown J, et al. The influence of trait-negative affect and compassion satisfaction on compassion fatigue in Australian nurses. Psychol Trauma. 2016;8(1):88–97.
- Great Valley Publishing Company, Inc. Social worker self-care — the overlooked core competency [Internet]. Socialworktoday.com. Available from: https://www.socialworktoday.com/archive/051214p14.shtml
- Managing the stress impact of COVID-19 [Internet]. Aacn.org. Available from: https://www.aacn.org/blog/managing-the-stress-impact-of-covid-19
- Lambert NM, Fincham FD, Stillman TF. Gratitude and depressive symptoms: the role of positive reframing and positive emotion. Cogn Emot. 2012;26(4):615–33.
- Alharbi J, Jackson D, Usher K. The potential for COVID-19 to contribute to compassion fatigue in critical care nurses. J Clin Nurs. 2020;29(15–16):2762–4.
- Ho CS, Chee CY, Ho RC. Mental health strategies to combat the psychological impact of COVID-19 beyond paranoia and panic. Ann Acad Med Singapore. 2020;49(3):155–60.
- Lakioti A, Stalikas A, Pezirkianidis C. The role of personal, professional, and psychological factors in therapists’ resilience. Prof Psychol Res Pr [Internet]. 2020; Available from: http://dx.doi.org/10.1037/pro0000306
- Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA. 2020;323(21):2133–4.