Insights & Opportunities about Frontline Healthcare Workers’ Mental Health

How might we learn from and support the mental health of frontline healthcare workers during the COVID-19 pandemic?

In poet Sarah Kay’s spoken word poem titled ‘B’, she tells her future daughter about how, sometimes, “the very people you want to save are the ones standing on your cape.” During the COVID-19 crisis, our communities have pinned this “cape” onto the backs of our frontline healthcare workers, who clock hours on end trying to save lives in a pandemic they have little control over, only to feel estranged from and held back by the very people they serve.

News reporters, politicians, and even people like you and me put frontline healthcare workers on a heroic, even superhuman, pedestal to applaud their selfless service. However, we might be able to offer much more than praise if we attend to the deeply human experiences of frontline workers trying to save humanity during the COVID-19 crisis.

At the Emergency Design Collective, we are investigating the mental health impacts of the pandemic on frontline healthcare workers who treat COVID-19 patients. Over the past month, our team of mental health specialists, designers, and innovators has taken a human-centered approach to addressing this challenge. In addition to researching real-time developments affecting healthcare workers, our team conducted 16 in-depth interviews of frontline healthcare workers about their jobs, challenges, and successes during the COVID-19 response.

In particular, we focused on learning from three types of healthcare workers:

1 | Nurses

The nurses we interviewed provide direct care to COVID-19 patients and work within hospital settings. One of our interviewees is even a nursing union leader.

2 | Doctors

The doctors and residents we interviewed provide direct care to COVID-19 patients, work within a variety of specialities, and are based all across the United States.

3 | Administrators

The administrators we interviewed are directors of long-term care facilities.

In this article, we share 6 insights we gathered about frontline healthcare workers’ mental health, followed by 5 opportunities to better support their mental health.

Insight 1 | When hospital leadership did not prioritize the safety of staff, the staff experienced emotional and mental trauma effects.

Throughout our interviews, healthcare workers reported feeling like their administrative leadership is more concerned about profit than looking out for their own people. Ariel, an experienced nurse at Kaiser Permanente in Santa Clara, CA shared, “I feel we’re expendable like a piece of PPE.”

To respond to quickly changing situations and demands, decision-makers at all levels often made policy and procedural choices without feedback from healthcare workers. Furthermore, many of these decisions reflected conflicting value systems and goals.

For example, the lack of personal protective equipment made healthcare workers feel unsafe and unsupported, especially when they were excluded from decisions about distribution and availability. When personal protective equipment is the only layer between healthcare workers and COVID-19, the stakes are high. According to our interviewees, successful decisions about personal protective equipment must address healthcare workers’ safety and involve their perspectives.

Administrators who successfully created safety and trust between leadership and healthcare workers emphasized communication and transparency about ongoing changes during COVID-19. One administrator said her team was able to trust leadership more when they communicated the message, “We know you’re scared, and we’re right there with you.” Met with empathy from their leadership, healthcare workers felt safer, reported higher levels of morale, and increased the quality of patient care.

Insight 2 | Too many unknown factors early on in the COVID-19 experience created a sense of anxiety.

At the onset of the spread of COVID-19 earlier this year, healthcare workers dealt with distress about unknown details related to the impending virus, its transmission, and destructive capacity. One healthcare team we interviewed reported experiencing high levels of suspicion and paranoia about their own colleagues until they had more clarity about the mechanisms of transmission.

Furthermore, as the pandemic ramped up, rapid changes to daily work were largely directed only by administration, which created challenging circumstances for healthcare workers, especially nurses, and stripped them of agency to respond.

Across the range of perspectives shared in our interviews, we noted that doctors and nurses are having different experiences during the pandemic, because of their differing degrees of interaction with patients. While some doctors seemed excited for the challenge, many nurses were concerned that the changes and lack of safety were misaligned with their roles.

For example, one interviewee named Dr. Clifton said, “The day-to-day was less stressful [as there were fewer patients], and probably more exciting…It’s not something every doctor gets to see.” On the topic of COVID-19 care, Dr. Clifton shared “We had a decent understanding, I felt reasonably comfortable. My risk factors were low. It was a good situation.”

In another interview, a nurse named Bella told us, “We trust the nurses. The ones that we had a hard time trusting were the doctors. There’s an invincibility there.” She shared a particular experience that contributed to this sentiment, “We had clean equipment on the table. A doc came out of ICU and he put his dirty PPE on that table. When we called him out, he said, ‘I’m a COVID doctor.’”

One healthcare worker said she faces “anxiety and fear for future waves,” believing that the outcomes will “be more destructive each time.” As parts of the United States get swallowed into a second spike of the pandemic, we can use these learnings to inform change and prepare against traumatic effects on our frontline healthcare workers’ mental health.

Insight 3 | Frontline healthcare workers have had to disconnect from society due to their direct COVID-19 exposure, leading to a sense of division.

Many frontline healthcare workers have taken extra measures to isolate themselves from their families and housemates, out of fear of COVID-19 exposure. To them, the resulting loneliness feels like an inevitable part of their jobs and duty to keep others safe.

Even though public dialogue is celebratory and appreciative of their hard work, healthcare workers also experience isolation and exclusion from the rest of society. Furthermore, some report feeling “feared” by society at large. One informal online poll showed that some nurses were denied dental care, since their dentists were afraid of them being contagious. One nurse shared: “[People] may look at me differently. I think people are afraid that I’m contaminated.”

After facing these hurdles, frontline healthcare workers found it especially disheartening to observe individuals break safety rules and not take the pandemic seriously. From our interviews, it is clear that frontline workers see and bear the consequences of the pandemic in more ways than one.

Insight 4 | Micro-networks and activities among colleagues have been fundamental for mental resilience.

As frontline healthcare workers deal with new feelings of loneliness, some frontline workers find solace in connecting more with their colleagues. One healthcare worker explained, “Nobody else quite understands it except other healthcare workers.”

Some institutions and programs, like doctor residency programs, offer formalized support. Other groups of healthcare workers rely on creating these support systems for themselves. Our interviewees shared that peer support was most effective when woven into the fabric of their daily workflows, rather than off-the-clock buddy systems and forced breaks.

Social media is another medium healthcare workers have leveraged to build community during the pandemic, in spite of the risks of employer backlash for being public about working conditions. For example, one nurse took to social media to publish his journey of contracting COVID-19 on the job, which he illustrated with striking “before” and “after” photos that showed COVID-19’s devastating effects on the body.

Insight 5 | These experiences may have caused individual trauma that may have broader systemic effects.

Over the past few months, healthcare workers have had many potential trauma-inducing experiences, like witnessing suffering and death in mass. According to the National Center for Posttraumatic Stress Disorder, these experiences result in moral injury, which includes “having to make decisions that affect the survival of others, having to make decisions where all options will lead to a negative outcome, engaging in an act of wrongdoing, failing to prevent serious unethical behavior, witnessing or learning about such an act, or betrayal by trusted others.”

Taking the time to address the healing of their extraordinarily distressing experiences may enable healthcare workers to move forward without compounding their emotional and mental harm. As nurses everywhere contemplate leaving their careers in healthcare, our interviewees feel that the healthcare system must play a role in helping heal the trauma that it has helped create during the pandemic.

Insight 6 | Self care is seen as a luxury, as healthcare workers face a pressure to be strong and infallible.

The public perception of healthcare workers as “heroes” fans the flames of preexisting healthcare culture, which involves taking care of everyone but themselves. The public messaging about healthcare heroes has led workers to feel like they must be strong at all costs. One nurse shared, “Nurses don’t know how to talk about stress.”

When asked about self-care, our interviewees indicated that self-care is seen as more of a luxury than a necessary part of health maintenance. However, self-care might be crucial for healthcare workers now more than ever, as they experience demands on their mental resources from so many directions.

One doctor shared, “Stress comes from being so busy that you can’t give due diligence.” Instead of fueling this reality, we can use these insights to create solutions that empower healthcare workers to care for themselves. In a time of uncertainty, caring for themselves is the singular act that will surely enable them to care better for others.

Opportunity 1 | Ensure physical, mental, and emotional safety of frontline staff.

COVID-19 will continue to impact our healthcare systems in the foreseeable future. Improving our systems and processes to prevent recent levels of trauma and endangerment is an opportunity to help guard against some of the harms we have already observed.

Opportunity 2 | Help healthcare workers address the trauma that has resulted from their experience to date.

Taking the time to effectively process their experiences can help healthcare workers return to their full capacity. There is an opportunity to directly address immediate needs of healthcare workers and also help healthcare systems scale to meet incoming challenges posed by the COVID-19 pandemic.

Opportunity 3 | Help connect hospital leadership with frontline staff in meaningful ways.

The COVID-19 pandemic has exposed gaping issues in the communication pipelines of our healthcare system. There is an opportunity to enact new systems now, as we meet the second wave of COVID-19.

Opportunity 4 | Create shared understanding and empathy between the public and frontline healthcare workers.

Another opportunity to help alleviate stressors to healthcare workers is to open up a channel of communication between healthcare workers and the public. Peeling back the layers of bureaucracy and media between these two parties will help improve public safety compliance and develop new outlooks toward public health responsibility.

Opportunity 5 | Enable healthcare workers to share personal stories about their experiences.

In the process of our interviews and research, we learned that sharing stories is a powerful way for healthcare workers to relieve effects of their trauma, process their experiences, and connect with the public. There is an opportunity to build more tooling and platforms to support this.

Healthcare providers who are working on the frontlines of COVID-19 patient care are some of the people closest to the pandemic. However, as they work tirelessly to save lives, their own mental and emotional wellness has been jeopardized by the unique nature of their work. For many healthcare workers, it feels like there is always more work to do, more lives to save, and more grief to absorb.

In Sarah Kay’s poem ‘B’ about what she’d tell her future daughter, she says, “I’ll make sure she knows she does not have to wear the cape all by herself because no matter how wide you stretch your fingers, your hands will always be too small to catch all the pain you want to heal.” People like you and me might not be able to join the fight against COVID-19 on the frontlines, but we have opportunities to support those who are there, working, and struggling.

Our Emergency Design Collective team is currently ideating ways to develop potential solutions based on the opportunities that surfaced through this research. We are actively looking for collaboration partners who are also focused on creating initiatives to support the mental health and wellbeing of frontline healthcare workers.

If you’re interested in getting involved with our team, get in touch with us here: https://emergencydesigncollective.com/get-involved

Project: Synapse

Team members: Tracy DeLuca, Natasha Fong, Rob Lister, Marina Terteryan, Whitley Kemble-Williams, Xenia Apena, Dr. Christopher Berger

Note: The names mentioned in this article are pseudonyms to preserve anonymity of interviewees.