To the Editor,
As of 31 March 2020, more than 100 000 cases of coronavirus disease 2019 (COVID-19)
have been confirmed in Italy.1 Progressive mitigation measures have been introduced
by the Italian government since 9 March 2020 to undermine and break the virus transmission
chain. However, the COVID-19-associated hospitalisation rate in Lombardy, the epicentre
of the outbreak, has risen since the late days of February 2020, by 30% each day,
and it is only very recently that it slowed down to 5% daily, which still translates
to 500 new patients every day who are in absolute need of hospital care. This has
put enormous pressure on healthcare providers and hospitals, up to the point where
departments and daily shifts have been assigned in either of the following two categories:
COVID-19 and non-COVID-19. In Policlinico, one of the most relevant university hospitals
in Milano, the entire organisation has been transformed in less than 2 weeks, moving
from 900 inpatient beds with 18 intensive care to 110 intensive and subintensive beds
and more than 200 COVID-19 beds, thus completely reorganising the wards.
Health workers and emergency medical technicians are at a high risk of developing
post-traumatic stress disorder (PTSD) and other psychiatric disorders2 3 in standard
operating conditions, and the risk increases during natural disasters.4 Early evidence
suggests that the COVID-19 outbreak may cause adverse psychological reactions in healthcare
workers. Liu et al
4 reported psychological distress (15.9%), anxiety (16%) and depressive symptoms (34.6%)
in 4679 doctors and nurses in 348 Chinese hospitals during the COVID-19 outbreak.
Immediate/rapid measures implemented by the hospital’s administrators may be a protective
factor in these cases.5–7
The COVID-19 pandemic has peculiar characteristics that push the human mind, including
those of doctors and nurses, into the uncertainty zone, given the speculations on
the mode and rate of virus transmission, highly infectious nature and rapid spread
of the disease and difficulties in making previsions of pandemic end, absence of specific
therapies and vaccine, high infection rate of COVID-19 in health personnel and moral
injury. Healthcare personnel might not feel well-equipped in treating patients and
may feel overwhelmed by the discrepancy between patient needs and ventilators available
during peaks. Stressors are also linked to continuous and unannounced organisational
changes, with respect to work spaces and colleagues, to ensure that the hospital is
able to handle the sudden surge in the number of people in need of hospitalisation
or intensive care and quickly adapt to new competencies; for instance, in the event
of shortage of personnel, personnel may be shifted from their specialties to the emergency
department or to COVID-19 wards. Stress and trauma are repeated day after day when
going back to work, and some describe it similar to a feeling of descending to hell
on a daily basis.
Moreover, most aspects of social closeness typical of Italian culture and relevant
for our strategies of resilience and grief have been wiped out by the risk of diffusion
and the strict isolation rules. Patients admitted to the hospital somehow ‘disappear’
from their families for 2 or 3 weeks or may even die without any further direct contact.
Seeing so many people not in contact with their family for such a long time, or even
dying alone, poses a really hard emotional impact on health personnel. In addition,
health workers may themselves be experiencing emotional isolation from their family,
on account of the fear of bringing home the virus, thus do not have enough time to
spend with their relatives and children, facing difficulties in sharing the experiences
they are living at work and feeling apprehensive about what will happen after the
pandemic ends.
To face the psychological pressure during the COVID-19 outbreak in China, Chen et
al
8 reported that an intervention plan was developed at the Second Xiangya Hospital,
based on online courses, a hotline supporting team and group activities to relieve
stress. The plan had to be retailored because of initial staff reluctance to participate.
Intervention plans need to be modulated according to the specific COVID-19 pandemic
variables and different staff needs and preferences, with the possibility to shift
rapidly between different levels of support and intensity. This is even more true
considering that the conditions under which the hospital staff had been working made
the screening for potential mental health problems difficult. Thus, to promote a wide
stress-relieving strategy in Policlinico, various evidence-based stress reduction
interventions were chosen and organised in a modular system that could be accessed
flexibly and on the widest possible scale. Priority was given to interventions easily
deliverable over the intranet or accessible by phone at the health worker’s convenience.
A rest place immediately outside the COVID-19 area for easy access to water, nuts
and dehydrated fruit at the end of the shift was created, with nutritional tips to
avoid dehydration during work shifts and support healthy nutrition. Information on
strategies to reduce stress and foster psychological flexibility, messages of support
by patients, carers and prominent national actors and actresses (#you are not alone),
and mindfulness exercises were posted on the intranet. An easy-to-access psychological
hotline and access to psychopharmacological and psychiatric support were also offered.
Previous experiences (groups and debriefing in one of the intensive care wards) were
continued and potentiated.
Acceptance and commitment therapy-based booklet to foster psychological flexibility
Acceptance and commitment therapy (ACT) is a mindfulness-based cognitive–behavioural
therapy based on a theory of cognitive functioning called relational frame theory
(RFT).9 According to the ACT and RFT conceptualisations, cognition and language are
the source of psychological suffering: the same tools we use to solve everyday problems
can trap us in the quicksand of suffering. Research shows that ACT can be effective
with adults in clinical, as well as non-clinical settings, and in patients with PTSD
and chronic medical conditions.10 In addition, it has been proven effective when delivered
indirectly with books or via web or apps. The main goal of ACT is to improve psychological
flexibility: the ability to keep in touch with our own thoughts and emotions and to
behave effectively according to what is important in our life. ACT protocols target
six core processes: defusion, acceptance, self-as-a-context, present moment, values
and committed action.
After interviewing key role personnel by phone to identify and target most common
thoughts and emotions they were fighting with under such stressful conditions, an
ACT-based psychoeducation booklet was designed and made available over the hospital
intranet. The script targeted all six ACT processes normalising experienced thoughts
and emotions, putting them in a defusion perspective, promoting acceptance and valued
action. Thoughts and emotions were presented following an RFT framework. The basic
premise of RFT is that the core of human language and cognition is a network of mutual
relations called relational frames. Thus, putative thoughts were presented, for example,
in a frame of coordination with emotions, or in opposition with idealised past or
future events, or in comparison with other experiences. In RFT terms, language is
the whole set of symbols that human use, manipulate and react to and act on, and includes
not only words, but also images, sounds, facial expressions and gestures. Therefore,
vignettes were also used to offer perspective and promote transformation of stimulus
functions of cognitive networks that at the end of the shift could otherwise evoke
difficult emotions. By providing such a context at the end of the booklet, patterns
of committed action that promote self-care and prosocial behaviours were suggested.
Mindfulness exercises
Mindfulness-based interventions have been proven effective as a work-related stress
reduction practice to promote well-being in healthcare personnel,11 even when delivered
in the form of brief protocols.12 To offer healthcare staff options compatible with
very high workloads, a selection of mindful practices of variable duration, ranging
from 1 to 20 min, were posted in a specific intranet section. Each track was available
as a text and audio file to be selected and practised at the convenience of the health
worker. A brief rationale to mindfulness practices was also provided at the beginning
of the related intranet section.
Phone hotline
A team of more than 70 psychotherapists volunteered in shifts scattered all over the
week to offer telephone support when requested by the health worker. They were selected
on the basis of their clinical experience after a call by the authors to the Istituto
Europeo per lo Studio del Comportamento Umano, a non-profit association, and other
colleagues from various hospital departments and wards (ie, child and adolescent neuropsychiatry,
family consultation clinic, occupational medicine and others). An online training
was organised to standardise the intervention and to share interview content. Training
video and instructions were also sent via email. In addition, the authors coordinated
with the psychotherapists, who were under constant supervision of the authors.
Health workers accessed the hotline sending an email of request to a back office team
of six psychologists who managed all the applications, linking health workers to psychotherapists.
The six psychologists were purposely chosen to strengthen the empathic tone of messages
via email or replies by phone. To consider different intervention methods, a default
option procedure was also adopted13: psychotherapists directly contacted health workers
with coordinating functions to offer the support service, always leaving the choice
to decline the proposal. To nudge access to the hotline, QR codes were placed on the
leaflets announcing the service and posted close to time recorder machine, and ‘mailto’
links were sent in text messages. Both QR codes and links generated a preformatted
email message with the relevant information to be filled for the contact. All staff
who became COVID-19 positive were also proactively called and received the same support,
while isolated at home. In the phone call, a psychotherapist oriented the person to
her/his personal resilience strategies and to the materials posted on the intranet.
When needed, a second call was agreed between the psychotherapist and staff. If additional
psychotherapeutic support was needed, COVID-19 positive staff was referred to the
psychological services of the Policlinic Hospital.
One of the authors developed the phone call interview based on exploratory calls with
key hospital personnel. A protocol for psychological support was designed for a 30
min single consultation. It consisted of active empathetic listening, normalisation
of symptoms and reorientation to own personal resilience resources and values; interviews
were also aimed at identifying effective coping strategies to better deal with stress
arousal. Further sessions could be agreed on request with the therapist.
Conclusions
Maintaining mental health in hospital staff is crucial to help them operate under
the high-pressure conditions experienced during the COVID-19 pandemic, and actions
are needed also in a prevention perspective, given the proportion of medical staff
that showed symptoms of mental health disorders at the end of the emergency period
in China.4 However, in view of the exceptional circumstances under which hospitals
are operating, what is the best evidence-based approach to maintain mental health
in hospital staff remains unclear.8 All known psychological support models, elaborated
for acute emergencies, at a smaller scale and with different characteristics, to be
implemented for a short duration of any traumatic episode are probably unfit to deliver
prompt and system-wide interventions when resources may be limited, compromised or
inaccessible, in a scenario in which COVID-19 prevalence and pressure may differ between
sites, evolve very quickly, and screening for mental health issue could be difficult.
Only close to the end of the pandemic wave, when emergency conditions were less demanding,
it was possible for the Occupational Medicine Department, responsible for mental as
well as general health checks to hospital workers, to elaborate on a testing protocol,
which is still ongoing at the time of writing of the paper.
The modular evidence-based approach adopted at the Policlinico is embedded in, and
flexibly responds to, the individual and social culture and context which, according
to a recent editorial by The Lancet Psychiatry
14 ‘… should also be considered when devising plans for delivering mental health care
in disaster settings, but are rarely discussed in calls to action during emergencies’.
In addition it can be rapidly scaled and tuned in other regions with different COVID-19
prevalence.
As of today, the programme is in its early stages and data on its effectiveness are
scarce and incomplete. Continuous and immediate feedback from addressees is needed
to progressively adjust it: direct calls to nursing coordinators during the first
week of programme implementation allowed us to find more effective communication tools
(ie, WhatsApp informal group chats) in addition to the traditional intranet channel
to inform about the programme and nudge participation. In the earliest days of COVID-19,
given the numbers of health workers involved to cope with the pandemic, the continuous
reorganisation of the wards and the occasional shortage in personal protection equipment,
support at distance seemed a viable, flexible and rapidly deliverable solution at
individual convenience. Thus the reported model leveraged on the internal resources
available and a network of psychotherapists who volunteered to support staff. Given
that mental exhaustion and exposure to moral trauma have raised awareness in health
workers about the need for psychological support in such types of emergency situations
and the changes in the Italian pandemic scenario, other different options, such as
‘face-to-face’ contact for small groups in large rooms with a psychotherapist, using
adequate measures of protection, might be considered and tested in future.
Though empirically grounded in available evidence, trial-and-error learning is expected
in this phase to help inform and shape best practices and modulate them according
to the varying COVID-19 pressure in different sites. Rapid, though inevitably incomplete,
worldwide sharing of models and even partial data are nevertheless essential to learn
in face of the rapid diffusion of the virus and increasing number of hospital interventions.