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COVID-19: Optimizing healthcare provider wellness and posttraumatic growth

Published:August 26, 2020DOI:https://doi.org/10.1016/j.ajem.2020.08.066
      SARS-2003, H1N1 Influenza 2009, MERS-2012, and now the COVID-2019 pandemic disrupt society in unpredictable ways [
      • Kolifarhood G.
      • Aghaali M.
      • Mozafar Saadati H.
      • Taherpour N.
      • Rahimi S.
      • Izadi N.
      • et al.
      Epidemiological and clinical aspects of COVID-19; a narrative review.
      ]. Responses to COVID-19 include remote schooling, limited gatherings and suspension of economic activity [
      • Gaeta C.
      • Brennessel R.
      COVID-19: emergency medicine physician empowered to shape perspectives on this public health crisis.
      ]. Major stressors lead to diverse outcomes, negative and positive. Individuals who lose loved ones, suffer intimate partner violence, serve in violent military operations, and suffer from serious medical conditions can ultimately become stronger.
      At the opposite side of the spectrum from posttraumatic stress disorder (PTSD), posttraumatic growth (PTG) has been described in healthcare workers (HCWs). Though an ancient idea, growth from adversity began receiving serious research attention in the 1990s [
      • Tedeschi R.G.
      • Calhoun L.G.
      The posttraumatic growth inventory: measuring the positive legacy of trauma.
      ]. PTG occurs across three domains: self-perception, interpersonal relationships, and life philosophy. Growth emerges in five realms: improvement in relating to others, greater personal strength, positive spiritual change, greater appreciation of life, and discovering new possibilities [
      • Tedeschi R.G.
      • Calhoun L.G.
      The posttraumatic growth inventory: measuring the positive legacy of trauma.
      ]. A systematic review found that 53% of individuals who endure trauma experienced PTG [
      • Wu X.
      • Kaminga A.C.
      • Dai W.
      • Deng J.
      • Wang Z.
      • Pan X.
      • et al.
      The prevalence of moderate-to-high posttraumatic growth: a systematic review and meta-analysis.
      ], enjoying greater life satisfaction, happiness, psychological, emotional, and even physical wellbeing [
      • Manning-Jones S.
      • de Terte I.
      • Stephens C.
      Vicarious posttraumatic growth: a systematic literature review.
      ].
      Predictors of PTG include active coping, self-control, higher education level, hope, social support, and deliberate rumination (making sense of the trauma) [
      • Wu X.
      • Kaminga A.C.
      • Dai W.
      • Deng J.
      • Wang Z.
      • Pan X.
      • et al.
      The prevalence of moderate-to-high posttraumatic growth: a systematic review and meta-analysis.
      ,
      • Dekel S.
      • Mandl C.
      • Solomon Z.
      Shared and unique predictors of post-traumatic growth and distress.
      ]. Moderate to high PTG occurs more commonly in women, younger subjects, and professionals with training [
      • Wu X.
      • Kaminga A.C.
      • Dai W.
      • Deng J.
      • Wang Z.
      • Pan X.
      • et al.
      The prevalence of moderate-to-high posttraumatic growth: a systematic review and meta-analysis.
      ]. Personality characteristics that predict PTG include extroversion and openness to experience [
      • Harbin A.
      Prescribing posttraumatic growth.
      ]. Individuals experiencing a stressful or traumatic event should adopt a growth mindset, reflect on their experiences, and believe in human resilience.
      HCWs have experienced substantial negative mental health effects during COVID-19. Though nurses and women may be more susceptible to acute psychological stress [
      • Cai H.
      • Tu B.
      • Ma J.
      • Chen L.
      • Fu L.
      • Jiang Y.
      • et al.
      Psychological impact and coping strategies of frontline medical staff in Hunan between January and march 2020 during the outbreak of coronavirus disease 2019 (COVID-19) in Hubei.
      ,
      • Lai J.
      • Ma S.
      • Wang Y.
      • Cai Z.
      • Hu J.
      • Wei N.
      • et al.
      Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.
      ,
      • Badahdah A.M.
      • Khamis F.
      • Mahyijari N.A.
      The psychological well-being of physicians during COVID-19 outbreak in Oman.
      ], they have the most growth potential. A PTG intervention in HCWs in China led to pronounced benefits in nurses and women [
      • Xu X.
      • Hu M.L.
      • Song Y.
      • Lu Z.X.
      • Chen Y.Q.
      • Wu D.X.
      • et al.
      Effect of positive psychological intervention on posttraumatic growth among primary healthcare workers in China: a preliminary prospective study.
      ]. Individuals living in affected geographic regions, and those on the frontline, may be at higher risk of negative emotional effects [
      • Simione L.
      • Gnagnarella C.
      • Simione L.
      Differences between health workers and general population in risk perception, behaviors, and psychological distress related to COVID-19 spread in Italy.
      ,
      • Dai Y.
      • Hu G.
      • Xiong H.
      • Qiu H.
      • Yuan X.
      Psychological impact of the coronavirus disease 2019 (COVID-19) outbreak on healthcare workers in China.
      ]. Interestingly, other studies have demonstrated the opposite: frontline HCWs with lower levels of distress [
      • Li Z.
      • Ge J.
      • Yang M.
      • Feng J.
      • Qiao M.
      • Jiang R.
      • et al.
      Vicarious traumatization in the general public, members, and non-members of medical teams aiding in COVID-19 control.
      ,
      • Wu Y.
      • Wang J.
      • Luo C.
      • Hu S.
      • Lin X.
      • Anderson A.E.
      • et al.
      A comparison of burnout frequency among oncology physicians and nurses working on the front lines and usual wards during the COVID-19 epidemic in Wuhan.
      ].
      While COVID-19 has already resulted in negative outcomes for HCWs, individuals can still strive for greater appreciation of life, improved self-esteem, and positive approaches to daily responsibilities [
      • Brooks S.
      • Amlôt R.
      • Rubin G.J.
      • Greenberg N.
      Psychological resilience and post-traumatic growth in disaster-exposed organisations: overview of the literature.
      ]. After SARS 2003, respondents in Hong Kong reported increased care for family, more focus on mental health, and more time devoted to relaxation [
      • Lau J.T.
      • Yang X.
      • Tsui H.Y.
      • Pang E.
      • Wing Y.K.
      Positive mental health-related impacts of the SARS epidemic on the general public in Hong Kong and their associations with other negative impacts.
      ]. Effective practices reframe stressful events to help one find meaning in hardships. In constructing a coherent narrative, one transforms uncontrolled rumination into a “more deliberate, reflective form of thinking” [
      • Harbin A.
      Prescribing posttraumatic growth.
      ].
      Prior to COVID-19, half of physicians experienced emotional fatigue, burnout, depression and suicide [
      • Santarone K.
      • McKenney M.
      • Elkbuli A.
      Preserving mental health and resilience in frontline healthcare workers during COVID-19.
      ]. COVID-19 has added new physical and psychological pressures that will ripple through the entire healthcare system [
      • Ehrlich H.
      • McKenney M.
      • Elkbuli A.
      Protecting our healthcare workers during the COVID-19 pandemic.
      ]. According to a recent review of publications on healthcare workers in COVID-19, the number one way to reduce stress levels was provision of safeguards to prevent transmission [
      • Spoorthy M.S.
      Mental health problems faced by healthcare workers due to the COVID-19 pandemic – a review.
      ]. HCWs should only reuse PPE as a last resort, which is associated with higher rate of infection [
      • Nguyen L.H.
      • Drew D.A.
      • Joshi A.D.
      • Guo C.-G.
      • Ma W.
      • Mehta R.S.
      • et al.
      Risk of COVID-19 among frontline healthcare workers and the general community: a prospective cohort study.
      ]. While Telehealth requires resources for planning, implementing, and evaluating, it limits nonessential exposure to infected patients and allows for convenient mental healthcare for providers.
      Despite obvious obstacles, HCWs must maintain social connections, which improve health outcomes [
      • Holt-Lunstad J.
      • Robles T.F.
      • Sbarra D.A.
      Advancing social connection as a public health priority in the United States.
      ]. HCWs should schedule calls and video chats with friends and family, reinforcing community roles. Outreach especially benefits those who struggle in isolation. Prompt, individualized psychological support is vital. Drop-in sessions with mental health professionals showed benefit in one Toronto hospital during the SARS-CoV-1 outbreak [
      • Walton M.
      • Murray E.
      • Christian M.D.
      Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic.
      ]. Leaders should reduce stigma for those who access these resources, as HCWs may not seek professional help due to perceived impact on career opportunities [
      • Bansal P.
      • Bingemann T.A.
      • Greenhawt M.
      • Mosnaim G.
      • Nanda A.
      • Oppenheimer J.
      • et al.
      Clinician wellness during the COVID-19 pandemic: extraordinary times and unusual challenges for the allergist/immunologist.
      ].
      Healthcare administrators could implement wellness initiatives to provide physical and mental growth opportunities. Strength conditioning, aerobic work, and high intensity interval training provide direct physiologic long-term health benefits [
      • Simpson R.J.
      • Campbell J.P.
      • Gleeson M.
      • Krüger K.
      • Nieman D.C.
      • Pyne D.B.
      • et al.
      Can exercise affect immune function to increase susceptibility to infection?.
      ]. A nutritious whole foods (unprocessed) diet, with proper intake of micronutrients, becomes even more important during an infectious outbreak. A healthy diet improves energy, brain functioning, mobility, and immunity [
      • Gombart A.F.
      • Pierre A.
      • Maggini S.
      A review of micronutrients and the immune system-working in harmony to reduce the risk of infection.
      ]. HCWs have experienced poor sleep during COVID-19 [
      • Huang Y.
      • Zhao N.
      Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey.
      ]. Adequate sleep regulates emotions and overall mental health, along with strengthening the immune system [
      • Besedovsky L.
      • Lange T.
      • Haack M.
      The sleep-immune crosstalk in health and disease.
      ] [
      • Tempesta D.
      • Socci V.
      • De Gennaro L.
      • Ferrara M.
      Sleep and emotional processing.
      ]. Mindfulness interventions facilitate self-awareness and presence, with studies repeatedly demonstrating positive effects of meditation on sleep and other mental and physical health outcomes [
      • Creswell J.D.
      Mindfulness interventions.
      ].
      The COVID-19 worldwide pandemic continues to challenge billions of people, with healthcare workers especially vulnerable. Maintaining wellness during COVID-19 requires solidarity and civic mindedness [
      • Simons G.
      • Baldwin D.S.
      Covid-19: doctors must take control of their wellbeing.
      ]. Rather than downplaying the appropriate stress and fear from COVID-19, this discussion of PTG intends to empower HCWs. We must actively reflect, utilize coping skills, and approach our lives with positive mindsets. We can educate patients on PTG as we help them navigate the fear and tangible damage from the pandemic. We can embrace the potential enhancement stress can have on overall health, harnessing opportunities to learn from our experiences and achieving PTG [
      • Crum A.J.
      • Salovey P.
      • Achor S.
      Rethinking stress: the role of mindsets in determining the stress response.
      ].

      Funding

      None.

      Declaration of Competing Interest

      None.

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