As the first wave of COVID-19 subsides and many patients physically recover, invisible injuries to the mental health of frontline caregivers are likely to persist.
These injuries are numerous and deep: The reliving of trauma from witnessing suffering at awful scale and feeling helpless to intervene as many patients died without a loved one nearby. Chronic anxiety over ongoing exposure risks for oneself and one’s family. Guilt over moral dilemmas and practicing in ways inconsistent with one’s professional training and values. Stress from returning to deferred responsibilities at home.
The call to care for others often eclipses caregivers’ attention to their own well-being—a longstanding problem in healthcare delivery this crisis has dramatically heightened. For example, the recent suicide of Dr. Lorna Breen, who worked in a New York City emergency room hard-hit by COVID-19, illustrates the tragic implications of crisis-induced stress.
Traditional approaches to supporting employee mental health may be insufficient for the COVID-19 crisis. Existing approaches often put the onus on employees to seek help, and they separate mental health personnel from frontline units. For instance, employees are often instructed to call a hotline number to talk to a social worker over the phone through employee assistance programs, enroll in counseling, or attend mindfulness workshops. Many frontline professionals do not use these services, even if they are suffering.
Organizational research on professionals helps explain why such well-intended services may go unused. Professionals identify strongly with the values and goals of their work, and they hesitate to do things that appear to conflict with those values and goals. In healthcare, these realities are particularly intense—medicine is known for its “iron curtain” culture that prioritizes patient care goals and showing stoicism in the face of trauma, which the pressures for heroics during COVID-19 may exacerbate further.
Because of these deeply experienced conflicts for healthcare professionals, more proactive and customized approaches are needed to deliver mental health supports that are actually used, and found helpful, by frontline caregivers.
In a recent article published in the BMJ Leader, we describe key elements of a more customized and proactive approach, drawing on findings from a multi-year ethnographic study of the U.S. Army’s mental healthcare delivery during wars in Iraq and Afghanistan.
Certainly, there are differences between soldiers trained to endure prolonged traumatic situations at war and caregivers suddenly confronted by unexpected traumatic situations during a pandemic. But there are also striking parallels between medicine and the military. Both fields are known for exposing frontline staff to high-risk and high-pressure situations and for prioritizing stoicism in facing them. And they pose similar challenges in delivering effective mental health support.
We draw on the Army’s experience to describe one research-backed strategy based in principles of organizational design to deliver unit-aligned mental health supports for frontline staff. This was the structure ultimately implemented across the U.S. Army after experimenting with numerous other structures.
Unit-aligned care involves mental health support personnel being assigned to work specifically with a few dedicated frontline units so they develop personalized relationships with unit leaders and staff. This helps to destigmatize mental health and customize offerings to better suit the specific needs of different units. In the case of the Army, by rapidly building relationships with unit leaders and learning about the units they were assigned to, mental health personnel were able to design supports that were sensitive to the specific mental health needs of soldiers in their particular units as well as their career aspirations and unit goals that previously deterred care usage.
Critical to this unit-aligned organizational design is ensuring that mental health support personnel have a regular forum for connecting to keep one another anchored in mental health objectives. This becomes particularly vital when time demands and the cultures within high-risk, high-pressure fields may default to relegating mental health back to the sidelines.
How would this approach be adapted for healthcare during COVID-19? Mental health support personnel could be assigned to work with a manageable number of specific types of frontline units simultaneously (e.g., one mental health support person works with multiple intensive care units; another works with medical surgical units, etc.). This mental health support person would be accountable for learning about and building personalized relationships with those in their assigned units—for example, by leading decompression huddles, holding drop-in hours in a private space on the unit, and delivering customized unit-level interventions, as well as meeting one on one with leaders and specific caregivers in need of support, in person or virtually.
These interactions would help unit caregivers and leaders become more familiar with their dedicated mental health support person so they could together break down stigma and stereotypes. Meanwhile, mental health personnel could jointly devise contextualized ways of supporting unit staff well-being that are customized and minimally disruptive to patient care.
Customization of mental health support is particularly critical in this context because the specific stresses brought on by COVID-19 vary across different departments and units, calling for unique solutions. For example, the mental health needs of a COVID-19 intensive care unit, with nurses isolated behind closed doors with gravely ill patients, may differ from those of emergency department staff interacting with many patients with unknown COVID-19 status. In addition, time constraints across units vary; for example, especially busy units may require more proactive identification of who needs help, such as from assigned peer “buddies” or leaders, while others may require daily decompression huddles ,with their assigned mental health personnel purposefully making themselves available afterward for one-on-one follow-ups.
Promoting resiliency among the frontline caregivers upon whom our society depends is paramount during this pandemic. Proactive, unit-aligned mental health support offers one promising way to take care of those on whom we count to care for us.