: The COVID-19 pandemic is producing a huge health care burden with millions of cases and thousands of deaths. The coronavirus' high virulence and contagiousness and the frequent sudden onset of illness is overwhelming critical care and frontline healthcare staff. Frontline professionals are exposed to unprecedented levels of intensive existential threat requiring systematic, specialized psychological intervention and support. New psychological services need to be urgently implemented to manage the mental healthcare needs of frontline medical staff working with patients with COVID-19. The COVID-19 pandemic is a watershed moment: health care systems universally require a step-change to improve our preparedness for future pandemics

Fiorente, Pasquale

Shamloo, Soraya E

Tafuri, Alessandro

Zaka, Agustina

English

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https://doi.org/10.1177/1359105320925148Journal of Health Psychology2020, Vol. 25(7) 883 –887© The Author(s) 2020Article reuse guidelines:  sagepub.com/journals-permissionsDOI: 10.1177/135910532 925148journals.sagepub.com/home/hpqThe novel coronavirus disease (COVID-19) outbreak emerged in Wuhan, China, in December 2019 and on 30 January 2020 was declared a public health emergency of interna-tional concern by the World Health Organization (WHO, 2020). To date countries with confirmed cases are more than 200 (WHO, 2020). Recent trends show an exponential spread of the infec-tious disease especially in the European Region and in the United States. Among these, the United States, Spain and Italy have recently reported the highest numbers of cases (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/) and deaths (as at 10 April 2020; Worldometers, 2020).After China, Italy was the second country facing a massive burden from the COVID-19 outbreak. Like many other countries to follow, Italy’s national health system was overwhelmed by the impossibility of effectively responding to the needs of the multitude of infected patients (Armocida et al., 2020). This excessive burden was mainly due to COVID-19’s high virulence and contagiousness and the frequent sudden onset of severe interstitial pneumonia which COVID-19 pandemic as a watershed moment: A call for systematic psychological health care for frontline medical staffAgustina Zaka1, Soraya E Shamloo2,  Pasquale Fiorente3 and Alessandro Tafuri1,4AbstractThe COVID-19 pandemic is producing a huge health care burden with millions of cases and thousands of deaths. The coronavirus’ high virulence and contagiousness and the frequent sudden onset of illness is overwhelming critical care and frontline healthcare staff. Frontline professionals are exposed to unprecedented levels of intensive existential threat requiring systematic, specialized psychological intervention and support. New psychological services need to be urgently implemented to manage the mental healthcare needs of frontline medical staff working with patients with COVID-19. The COVID-19 pandemic is a watershed moment: health care systems universally require a step-change to improve our preparedness for future pandemics.KeywordsCOVID-19 outbreak, health care workers, mental health, psychological support, stress1Department of Urology, University of Verona, Italy2 Department of Human Sciences, University of Verona, Italy3Italian Red Cross, Committee of Udine and Gorizia, Italy4 Department of Neuroscience, Imaging and Clinical Sciences, “G. D’Annunzio” University, ItalyCorresponding author:Alessandro Tafuri, Department of Urology, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy. Email: tafuri.alessandro@gmail.com925148 HPQ0010.1177/1359105320925148Journal of Health PsychologyZaka et al.editorial2020Editorial884 Journal of Health Psychology 25(7)often requires intensive care support. This is affecting frontline health care workers’ physi-cal and mental well-being. Indeed, they are often under daily pressure due to prolonged work shifts, scarce personal protective equip-ment (PPE) and fear of being infected as well as infecting their familiars being a possible infecting vehicle (The Lancet, 2020). Further- more, every day there is the significant exis-tential stress associated with the loss of many patients, colleagues or loved ones. In addition, the new recruited health care workers for the intensive care unit usually do not have any adequate psychological training to cope with stressful work conditions which may ulti-mately lead them to face extremely difficult situations in terms of managing emotions and existential stress. Frequently, in rationing scarce resources such as ventilator support, medical staff are required to make life-and-death decisions about whose lives to save, younger versus older, healthier versus sicker, or essential worker versus unemployed. In such dehumanizing situations, the most com-mon stress-reducing strategies (Leyens, 2014; Trifiletti et al., 2014) may not be possible in such extreme circumstances due to the possi-bility of medical staff being more emotionally involved in the requirements to keep going.Recently, newspapers have reported suicide cases among nurses working in the intensive care units in Europe that could potentially be related to the COVID-19 emergency, suggest-ing a strong need to invest on health care work-ers’ mental health (World Socialist Web Site, 2020). Protection and psychological support for nurses, doctors and all frontline staff is of extremely high importance given that COVID-19 is now a well-established pandemic and there will be other pandemics in future.The psychological impact of pandemic infectious diseases on health care workersThe exposure to the profound work stressors is expected to have long-term psychological con-sequences on large numbers of health care workers as demonstrated by previous infectious outbreaks. Indeed, during the following 3 years after the severe acute respiratory syndrome (SARS) in 2003, health care workers from Canada and China reported higher levels of burnout, psychological distress, post-traumatic stress disorder and fear of a possible future out-break of infectious diseases (Liu et al., 2012; Maunder et al., 2006). Negative psychological effects on health care workers were also reported after the 2013–2016 Ebola outbreak in Guinea, Liberia and Sierra Leone due to the traumatic course of the infection, fear of death and the experience of witnessing others dying (Van Bortel et al., 2016). Psychological impairments due to work-related stress have been found to affect job performance, leading to a poorer qual-ity of care for patients (Su et al., 2009). However, adequate training, support and protection could protect health care workers from mental health illness (Maunder et al., 2006).The impact of COVID-19 pandemic is detectable at all levels of society, including business, economic, educational and psycho-logical levels; thus, governments should not limit their response to necessary medical and economic actions, but they should implement parallel psychological assistance measures (Wang et al., 2020).COVID-19-related stressors for health care workers: lessons from ChinaPositive examples for mental health care interven-tions come from China as they first experienced the COVID-19 outbreak and fully recognized the importance of psychological assistance in emer-gency situations with more than 40,000 mental health professionals to support the population (Wang et al., 2020). Specifically, within hospitals psychological services were offered to medical staff and patients in the form of psychological education and face-to-face psychological inter-ventions (Wang et al., 2020).As a case in point, the Second Xiangya Hospital of Central South University in Wuhan province offered online courses, a psychological Zaka et al. 885assistance hotline and group activities to release stress (Chen et al., 2020). Such interventions were initially refused by the medical staff. In a subsequent interview carried out by mental health professionals, the same medical staff clarified some of the reasons for this reluctancy that ultimately allowed professionals to accept the psychological interventions. The major issues were reported as follows.A first dimension related to health care work-ers’ families. Medical staff expressed the fear of bringing the virus to their homes and so putting loved ones into danger as well as managing the apprehension of family members concerning their safety at work. In response, the hospital provided a place where staff could temporarily rest and isolate themselves from their families. Moreover, they allowed the entire staff to record a video on their hospital routines to share with their families.A second issue concerned the difficulty man-aging psychological problems experienced by patients affected by COVID-19 as anxiety, panic or lack of compliance to specific medical measures. Mental health staff reacted by organ-izing pre-job training on skills to deal with the psychological problems expressed by patients with COVID-19.A third aspect was associated with the psy-chological impact of the COVID-19 emergency on Chinese health care workers. The first issue referred to the lack of rest as well as the worry about the shortage of PPE. In addition, health care workers expressed feelings of incapacity when facing critically ill patients. In this regard, the hospital provided a place where medical staff could rest, ensured PPE supplies and developed detailed rules on the use and man-agement of PPE to reduce their anxiety levels. The mental health staff organized training on how to relax and offered psychological counsel-lors to support health care workers and listen to their experiences and suffering.Another important issue which did not emerge from the Chinese COVID-19 experience is the quarantine arrangements for dying patients that prohibit family members or close friends from saying ‘goodbye’ to their loved ones. Medical staff are required to face this extremely negative situation of seeing patients dying alone and having to communicate this to their fami-lies, which can be dehumanizing, traumatizing and produces a high risk of extreme stress and burnout (Patel et al., 2018).Call for action: a need for systematic psychological health care and support for frontline medical staffInterventions aimed at enhancing mental health care for frontline medical staff should start with the satisfaction of the primary needs of rest and health safety to overcome initial and more obvi-ous obstacles and then move to other psycho-social needs consistently with the Maslow’s hierarchy of needs (Benson and Dundis, 2003). A new General Theory of Behaviour has explained the hierarchy of needs in terms of physiological and psychological homeostasis (Marks, 2018). The universal drive of psycho-logical homeostasis pulls all human beings towards the restoration of normalcy, balance and equilibrium. Psychological interventions are needed to reduce the main stressors associated not only with basic physiological and psycho-logical needs but also with the special difficulties encountered by medical staff during their COVID-19 pandemic working activities. For instance, mental health staff could organize video training for health care workers on com-munication skills, coping styles and problem-solving strategies to deal with the possible psychological problems of patients with COVID-19 and, if possible, they could be on hand to manage these patients directly or by use of digi-tal platforms. In addition, psychological support should be offered to willing health care workers as individual counselling or group training on how to relax using mindfulness interventions to reduce stress (Botha et al., 2015).886 Journal of Health Psychology 25(7)Worldwide health systems are under high pressure and systematic interventions for men-tal health care for medical staff are urgently needed (The Lancet, 2020). These actions could represent a way to better control the COVID-19 outbreak considering that health care workers’ psychological problems could affect their atten-tion, understanding and decision-making, but they also could prevent more serious psycho-logical impairments. Working towards this aim is of crucial importance. Experience with previ-ous epidemics teaches us that the most frequent consequences of public health emergencies such as the 2003 SARS outbreak or the 2014 Ebola epidemic in 2014 for frontline workers were post-traumatic stress symptoms, anxiety, depression, fear and frustration (Rubin et al., 2016; Wu et al., 2009).ConclusionGiven the evidence for risk of short- and long-term psychological consequences on health care workers and their impact on job perfor-mance and quality of care (Su et al., 2009), psychological programmes should be urgently implemented to manage mental health care for medical staff working in the frontline against COVID-19. In addition, the new recruited health care workers involved in the re-organization of health care systems require a specific psycho-logical support in order to manage stressful situ-ations which may likely occur. In this context, China provides one model for conducting psy-chological assistance in an orderly manner. The deployment of epidemic prevention and control should not rely on isolated initiatives, but be based on shared multidisciplinary guidelines and joint actions at international level.The COVID-19 pandemic is a watershed moment for health care systems that are mani-festly ill prepared for pandemics on this scale. Healthcare systems require a step-change in preparedness to deal with future pandemics. Psychological systems as well as medical sys-tems of health care require huge investment and major upgrading in readiness for future pandemics.Declaration of conflicting interestsThe author(s) declared no potential conflicts of inter-est with respect to the research, authorship and/or publication of this article.FundingThe author(s) received no financial support for the research, authorship and/or publication of this article.ORCID iDAlessandro Tafuri  https://orcid.org/0000-0003 -1404-2925ReferencesArmocida B, Formenti B, Ussai S, et al. 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COVID-19 pandemic as a watershed moment: A call for systematic psychological health care for frontline medical staff

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COVID-19 pandemic as a watershed moment: A call for systematic psychological health care for frontline medical staff

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