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Intensive care unit (ICU) clinicians tend to pride themselves on their ability to care for others, even if it is at the expense of taking care of themselves. Some think of this mantra of "others before me" as a badge of honor, according to James C. Jackson, PhD, PsyD, research professor and assistant director of the ICU Recovery Center at Vanderbilt University Medical Center. Dr. Jackson has a strong message to these clinicians: Now is not the time to dismiss your own needs.
"Whatever it might be to make you feel a little bit better, to make you feel a little more hopeful, to make you feel a bit stronger, do that," he said. “Practice self-care and emphasize it in a way that you perhaps haven't before.” This plea for self-care and renewed focus on wellness came during a recent SCCM webcast titled "Managing Your Mental Health During the COVID-19 Pandemic.".
Above all, institutions should be proactive in providing a safe and heathy workplace for clinicians. This includes providing personal protective equipment and ensuring proper staffing. Keep in mind that no amount of additional perks – such as free lunches or yoga classes -- or even complimentary counseling services – can make up for an unsafe or understaffed workplace.
If you are looking for specific ways to further support frontline staff or enhance the wellness efforts at your hospital, Rush University System for Health in Chicago, Illinois, has published a practical toolkit comprising a collection of experiences from psychiatrists, psychologists, psychiatric nurse liaisons, licensed clinical social workers, and chaplains. The toolkit offers guidance on how to implement programs that have been successful at Rush.
Wellness Rounds
Establish teams to target units with the heaviest COVID-19 clinical burden. At Rush, five standing teams were created, each with a physician leader, a psychologist, a nurse (often a psychiatric nurse liaison), a chaplain, and a licensed clinical social worker. Each team rounds on the same locations at the same time every day to create familiarity and a sense of rapport with the clinical teams.
Wellness Consult Service
A consult service allows any clinical unit or individual to connect directly with a member of the Wellness Response Team for evaluation, triage, and recommendations to improve mental health and well-being. All consults are anonymous and are excluded from a staff member’s medical record. Group sessions are also made available for entire units, departments, or clinical teams in need.
Pathways for Personalized Attention
Rush created an immediate targeted response to individual employees in a mental health crisis. Through a predetermined escalation algorithm, any member of the Wellness Response Team can trigger the pathway. When triggered, the individual is directed to an experienced clinician (typically a physician or other prescriber) and completes a thorough mental health assessment, including identifying an immediate therapeutic intervention and appropriate follow-up.
The great value of peer-to-peer support is in the opportunity to talk with someone who has shared experiences. It is one of the most effective ways clinicians can process stressors, according to Mona Masood, DO, founder of the Physician Support Line, a new helpline established in direct response to the pandemic.
The volunteer psychiatrists who staff the helpline have heard from thousands of clinicians who share their struggles with self-isolation, managing professional, marital and parental responsibilities, moral distress, and the impact of seeing so much death. One of the most common themes is reconciling the hero imagery with perceived reality.
"We are talking about the pandemic like we talk about war, using terms like "front lines," thanking healthcare workers for their services, and referring to them as heroes. That comes with expectations that can be jarring. It can feel very at odds to be called a hero when you may just be thinking about the person you couldn't save. Heroes often are not allowed to feel vulnerable. That's the point of peer-to-peer support. You don't have to play hero for anyone. You can just be you, and the person on the other end gets it," said Dr. Masood.
Signs that a clinician may need support include feelings of depression or sadness, anger and irritability, overeating or loss of appetite, or a desire to be isolated. Some may even become hyperactive to hide symptoms. Be aware of these feelings and behaviors in yourself and your colleagues.
"Clinicians, through their training, are very goal orientated,” said Saul M. Levin, MD, MPA, CEO and medical director of the American Psychiatric Association (APA). “They want to help, and they often push through even though it is to their own detriment. All of us need to remember we are colleagues and—just like family—we should not be afraid to reach out to our colleagues."
Seeking mental health support still carries stigma in our society, and there is no exception in healthcare circles. Physicians in the United States have higher rates of suicide risk than the general population. And, many are concerned with the wellbeing of the multiprofessionals within the critical care community as they navigate the pandemic crisis. Any number of factors contribute to this concern: increased workload, isolation from loved ones, the number of patient deaths related to COVID-19, and seeing colleagues becoming infected and even dying.
One of the best and most basic ways to overcome the stigma of seeking mental health support is to educate yourself and others and to model behaviors that encourage openness and honesty.
"When HIV first appeared, it was stigmatized,” explained Dr. Levin. “As people learned more, the stigma lifted. That happened because some became more educated, and they talked about it."
"One of the hurdles in healthcare culture is the idea that if I show someone I have weakness, it means I’m not deserving of this job," notes Dr. Masood. "We need to overcome this type of thinking. It’s about much more than taking a self-care day or going to the spa. We need to change the culture. To start that, we need to be able talk about mental health."
Better yet, if a leader within a hospital or health system can share the mental obstacles he/she faces, that shows others that it is okay to not feel okay. "These are anxious times, and these are not times for leaders to wear a stiff upper lip," Dr. Jackson said. "These are times for leaders to model authenticity and vulnerability with the people who are working around them and to model that it's acceptable and appropriate to acknowledge struggle. That's the healthiest thing we can do as leaders. In doing that, it gives [others] permission to struggle."
Numerous trusted sources have curated valuable educational resources. Educate yourself, share these resources, and talk about the lessons learned.
At its core, mindfulness is about being aware of what is real in the present moment. Grounding is a mindfulness technique that forces someone to rely on his/her senses to help concentrate on the present moment. Megan Hosey, PhD, provided an example of grounding as a way to implement mindfulness during a period of anxiety. This method involves noticing:
Good sleep and a balanced diet. These alone can have the biggest impact on a person’s mental state. “Without those basics,” Dr. Hosey said, “nobody is going to have a good foundation for mental health.” Good sleep benefits people in countless ways, from helping develop a stronger immune system and a healthy heart to decreasing the chance of obesity.2 Eating the right foods can also prevent obesity and ensure that people have energy to successfully work through the day.3
Limit your media intake. It is important to be knowledgeable about current events, but after spending the day surrounded by patients with COVID-19, it is also important to give yourself a break from the virus to prevent additional tension.
Take inventory of your personal network. Jason M. Satterfield, PhD, talks with Ludwig H. Lin, MD, about wellness in the age of COVID-19 in this SCCM interview. One of the first strategies for managing the new stressors faced by those on the front lines is to take a minute to assess your existing network and to not be afraid to reach out for help.
“What often happens for people who are chronically stressed is that they underestimate their own personal capacity to rise to the challenge or they underestimate the willingness of people around them to provide support or help them get through this difficult time,” Dr. Satterfield says. “One of the most important things to do is to assess the primary stressor and to take a step back and recall times when you have successfully overcome challenges in the past. Think about your own internal resources and think about the network of people around you—friends and colleagues—who might be able to help you through this time.”
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