International Critical Incident Stress Foundation, Inc.
International Critical Incident Stress Foundation, Inc.
By: Sherry Todd, Phd, LPC, Jennifer Hartman, EdS, LPC, Ashley Laws, LPC
University of the Cumberlands
Since the World Health Organization declared COVID-19 a global pandemic in March 2020, healthcare workers and systems worldwide have been strained in unprecedented ways (Benfante et al., 2020). The pandemic is a collective trauma due to the intense threat the virus poses to the global community and the stress that results from isolation, health and safety concerns, reduced access to resources, unpredictability, and lack of control (Holmes et al., 2021; Horesh & Brown, 2020). Healthcare workers are vulnerable to the pandemic’s collective trauma as well as the stressors inherent in their professional work (Holmes et al., 2021; Werner et al., 2020). This “double exposure” can leave healthcare workers vulnerable to moral injury, vicarious trauma, psychological distress, insomnia, anxiety, depression, substance use problems, Acute Stress Disorder, and Post-Traumatic Stress Disorder (Werner et al., 2020). Healthcare workers in pulmonology, emergency services, and intensive care are particularly at risk due to potential exposure to the virus, treating seriously ill patients, witnessing suffering and death, facing ethical dilemmas, and working long hours (Danet, 2021).
Organizational support can buffer the effects of stress, vicarious trauma, and burnout through feelings of safety and good supervision (Holmes et al., 2021). Williams et al. (2020) recommends collaborating with healthcare leaders to implement “psychological first aid” (PFA) at the organizational level through education and interventions that address moral distress and prevent moral injury in healthcare workers. Brown et al. (2020) recommends applying principles of trauma-informed care (TIC) with frontline workers and organizations to mitigate the impact of the pandemic. CISM is a comprehensive, integrative, multicomponent crisis intervention system (Everly & Mitchell, 1997) that is trauma-informed and utilizes tenants of Psychological First Aid.
A resurrection of the respite center is the recommendation of the authors to mitigate the impact of the pandemic for our healthcare workers. Although not called respite centers, the idea of a space for responders to decompress occurred during the Murrah Federal Building bombing in Oklahoma City (Myers & Wee, 2005). The respite center concept was based on the Oklahoma City response and further developed because of the length of time 9/11 Ground Zero responders were on scene, often spending months being exposed to the horrors of the terrorist attacks (Meyers & Wee, 2005). Several groups including the Red Cross, the City of New York, and numerous charities tweaked the demobilization intervention creating the “respite center” for disaster response (Myers & Wee, 2005). Myers and Wee (2005) suggested “studying this [respite center] prototype model for application in other large-scale disasters” (p. 165). However, there is limited information on respite centers outside of the 9/11 attacks and recoveries. It seems that more of the language is going towards mobile mental health services (Wyte-Lake et al., 2021). This negates the idea of compassionate presence and provides a medical model mindset of disorder rather than a resilience model of restore and replenish. Instead of pathologizing what is a likely an expected reaction to the pandemic stress, burnout, vicarious trauma, and other related problems, it is imperative to provide our healthcare workers a space away from the job, family, and daily life to just be still, if only for ten minutes.
Gard & Ruzek (2006) describe respite centers used after the 9/11 attacks and during the recovery phase as “drop in” space where the mental, emotional, spiritual, and physical needs of first responders, and in this case healthcare workers, may be addressed. Teahan (2012) recommends having a “staff respite area” on “operational sites” that involve lengthy response periods (p. 228). The respite area or center should be safe, secure, comfortable, and quiet space (Teahan, 2012). Our healthcare workers have been responding to this pandemic for an unprecedented amount of time that seems to be paralleling the experience of 9/11 responders or other groups deployed for long stressful periods such as the military. Therefore, applying some lessons learned from previous disasters requiring long-term response seems reasonable.
Keeping the frontline healthcare workers well must be a priority during the COVID pandemic. Creating a safe space for healthcare workers where they can access “heathy food and water, relax in a quiet room, and select from a variety of support services” (Teahan, 2012, p. 267) is a starting point. Gard & Ruzek (2006) discussed having massage therapists, pastors/chaplains, and mental health professionals available in an informal and formal capacity to provide services “as needed”. Because of the enormity of the need, space constraints in medical facilities and confidentiality, providing a referral list for mental health professionals, massage therapists, and other individual services may be more realistic. Stress reduction options like music (Teahan, 2012) and pet therapy should be included. Guided visual imagery, cranial electrotherapy stimulation, and audio-visual entrainment devices may also be useful in stress management. Reclining chairs or a hospital bed for cat naps may be beneficial. A section of the wall with mental health, physical health, and other resources such as hotline numbers and phone apps posted will be helpful. Post a yoga pose of the day. Green Cross Academy of Traumatology posts empowering and uplifting messages for responders while providing disaster mental health on deployments. The messages are generally posted in restrooms at eye level to catch people when they are still for a moment. Aroma therapy diffusors offer another level of stress reduction. A white board to post positive status updates or information and a flip chart may provide space to communicate feelings. Mandalas and other adult coloring may provide some stress relief through bilateral movement and containment. Fill the room with non-work-related opportunities. Post pictures of favorite vacation spots, kids, pets, goofiest faces. For best results, include all the senses (sight, smell, sound, taste, and touch) in your respite room.
Based on intervention strategies used with frontline healthcare workers during the Ebola virus epidemic, briefings and peer training reduce mental health stigma and increase access to supportive resources (Werner et al., 2020) among other benefits. Respite centers may provide a space to post briefings and offer peer support training. Psychological First Aid (Williams et al., 2020) and TIC (Brown et al., 2020), as well as CISM interventions may be offered as ancillary services with contacts provided in the respite area. Pink (2021) conducted a study in the UK and determined first responders are more resilient and less impacted by the stressors of the pandemic versus the control group of “average” citizens during the pandemic. Resilience is an innate characteristic in most first responders and frontline medical workers. Respite centers offer the opportunity to rest, restore and replenish without judgment, shame, or pathologizing. Finally, respite centers or respite areas provide resources and ultimately promote resilience. For more information on establishing a respite area for frontline or healthcare workers, please contact the authors.
References
Benfante, A., Di Tella, M., Romeo, A., & Castelli, L. (2020). Traumatic stress in healthcare workers during COVID-19 pandemic: A review of the immediate impact. Frontiers in Psychology, 11, 569935-569935.
Brown, C., Peck, S., Humphreys, J., Schoenherr, L., Saks, N. T., Sumser, B., & Elia, G. (2020). COVID-19 lessons: The alignment of palliative medicine and trauma-informed care. Journal of Pain and Symptom Management, 60(2), e26-e30.
Danet Danet, A. (2021). Psychological impact of COVID-19 pandemic in western frontline healthcare professionals. A systematic review. Medicina Clinica, 156(9), 449-458.
Everly, G.S., & Mitchell, J.T. (1997). Critical Incident Stress Management (CISM): A New Era and Standard of Care in Crisis Intervention. Ellicott City, MD: Chevron.
Gard, B. A., & Ruzek, J. I. (2006). Community mental health response to crisis. Journal of Clinical Psychology, 62(8), 1029–1041. https://doi.org/10.1002/jclp.20287
Holmes, M. R., Rentrope, C. R., Korsch-Williams, A., & King, J. A. (2021). Impact of COVID-19 pandemic on posttraumatic stress, grief, burnout, and secondary trauma of social workers in the United States. Clinical Social Work Journal, 1-10.
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Myers, D. & Wee, D. (2005). Disaster Mental Health Services. Brunner Routledge. New York, NY.
Pink, J. (2021). Psychological distress and resilience in first responders and health care workers during the COVID‐19 pandemic. Journal of Occupational and Organizational Psychology, 1–19. https://doi.org/10.1111/joop.12364
Teahan, P. R. (2012). Mass Fatalities: Managing the Community Response. Taylor & Francis Group: Boca Raton, FL.
Werner, E. A., Aloisio, C. E., Butler, A. D., D’Antonio, K. M., Kenny, J. M., Mitchell, A., Ona, S., & Monk, C. (2020). Addressing mental health in patients and providers during the COVID-19 pandemic. Seminars in Perinatology, 44(7), 151279-151279.
Williams, R., Brundage, J., & Williams, E. (2020). Moral injury in times of COVID-19. Journal of Health Service Psychology, 46, 65-69.
World Health Organization. (2019, May 28). Burn-out an ‘occupational phenomenon’: International Classification of Diseases. Departmental News. https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases.
Wyte-Lake, T., Schmitz, S., Kornegay, R.J. et al. (2021). Three case studies of community behavioral health support from the US Department of Veterans Affairs after disasters. BMC Public Health, 21, 639. https://doi.org/10.1186/s12889-021-10650-x
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