Barros-Filho, Tarcisio Eloy Pessoa de

Bonfa, Eloisa

Corchs, Felipe

De Rossi, Luciane

Fukuti, Pedro

Kamitsuji, Carla Satie

Lancman, Selma

Mazzoco, Marina Flaborea

Miguel, Eurípedes Constantino

Rios, Izabel Cristina

Uchôa, Caroline Louise Mesquita

English

Cadernos Espinosanos (E-Journal)

How Institutions Can Protect the Mental Health andPsychosocial Well-Being of Their Healthcare Workersin the Current COVID-19 PandemicPedro Fukuti,I Caroline Louise Mesquita Uchôa,I Marina Flaborea Mazzoco0000-0000-0000-0000 ,I,* Felipe Corchs0000-0000-0000-0000 ,I CarlaSatie Kamitsuji,I Luciane De Rossi,II Izabel Cristina Rios,II Selma Lancman,I Eloisa Bonfa,I,II Tarcisio EloyPessoa de Barros-Filho0000-0000-0000-0000 ,I Eurı́pedes Constantino MiguelII Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR. IIHospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade deSao Paulo, Sao Paulo, SP, BR.Fukuti P, Uchôa CLM, Mazzoco MF, Corchs F, Kamitsuji CS, Rossi L, et al. How Institutions Can Protect the Mental Health and Psychosocial Well-Being ofTheir Healthcare Workers in the Current COVID-19 Pandemic. Clinics. 2020;75:e1963*Corresponding author. E-mail: marina.mazzoco@hc.fm.usp.brWhen the World Health Organisation (WHO) declared thespread of the severe acute respiratory syndrome-coronavirus 2(SARS-CoV-2) a global pandemic on March 11, 2020, there wereapproximately 147,000 confirmed cases worldwide. Just onemonth later, the COVID-19 disease had spread dramatically;the number of cases had increased ten-fold (1), with 15% ofinfected patients requiring hospitalization and 5% in intensivecare units (3). This meteoric rise in cases resulted in anoverloaded demand for medical resources, often exceeding theavailable resources of healthcare systems around the world.Although we often conceive of healthcare systems in termsof the physical hospital beds and medical equipment, thesystem’s most fundamental, valuable, and vulnerable assetsare, undoubtedly, its manpower resources. Medical doctors,nurses, physiotherapists, technicians, and countless otherprofessionals must all come together for the system to workeffectively. Indeed, in order to buffer the effect of the pande-mic on our healthcare systems and society as a whole, werely heavily on the extent to which these individuals canfunction in a cohesive, effective manner (5).Healthcare workers are being impacted by the currentpandemic on two fronts. Like all of us, they are navigatingsocial distancing, school and day care closures, the economiccrisis, concerns about the health of their loved ones, andgeneral uncertainty about the future. Also, because of theirprofession, they are likely to be exposed to overloadedworking hours and a higher risk of infection amidst potentialshortages of adequate personal protection equipment (PPE)and other supplies. Further stressful factors include feeling alack of control or sense of helplessness, daily contact withsuffering and death, as well as the need to communicate badnews and establish new communication strategies withfamily members who cannot visit hospitalized patients. Inaddition, concerns about infecting their families has resultedin many professionals leaving their homes and shelteringelsewhere, which may further worsen their psychologicalwell-being. Finally, they are worried about whether they willbe prioritized in care if they become ill and whether they willface ethical dilemmas such as those reported in othercountries where the health system has collapsed (7).Clearly, this pandemic is exerting great stress on the per-sonnel working on the front line of efforts to control the virusin the healthcare system (5). Studies have already shown thatmost health care providers are exhibiting stress-relatedsymptoms such as anxiety, depression, sleep disturbances,and emotional distress, and around 50% of them will fulfilcriteria for a mental disorder (6). It is still not completelyclear who among us is at a higher risk. As an example, earlydata suggest that females nurses may be particularly vul-nerable (6,8), especially those working in direct contact withinfected patients for longer hours. Also, anyone with a pre-existing chronic disease or mental health condition is atgreater risk (5,6).These data demonstrate that we are facing a situation inwhich the backbone of our health system, our personnel,is highly exposed, both physically and psychologically. Therelevance of that unfolds in the consequences: if careproviders are hampered by mental health and psychosocialissues, infection rates will increase (due to lower compliancewith safe practices), which, in turn, would reduce staffnumbers and amplify emotional distress in a vicious cycle.Indeed, this pandemic has already resulted in soaring ratesof absenteeism, medical leaves, and even resignations.For these reasons, any strategy to combat the COVID-19crisis must take the mental health and psychosocial aspectsof its healthcare workers into consideration. The stra-tegy should be established at several levels: governmental,institutional, and individual. In fact, recent studies show thatgovernmental and institutional attitudes toward the pan-demic can directly increase motivation and performancelevels of healthcare personnel, thereby protecting againstnegative mental health effects (8). Simply put, our healthcareDOI: 10.6061/clinics/2020/e1963Copyright & 2020 CLINICS – This is an Open Access article distributed under theterms of the Creative Commons License (http://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in anymedium or format, provided the original work is properly cited.No potential conflict of interest was reported.Received for publication on April 27, 2020. Accepted for publica-tion on April 28, 20201EDITORIALprofessionals must feel that the government and medical insti-tutions understand how stressful the current situation is andthat they are taking actions to take care of them. This inclu-des clear communication with the staff, provision of pro-tective measures and PPEs, and sensitive administrationof work shifts. Governments should also establish publicpolicies that allow institutions to guarantee health care assis-tance, social (e.g. childcare needs, paid time off) and financialsupport to the health care professionals and their families. Inaddition, open access to mental and psychosocial supportand treatment is critical and must be taken into account.To address the aforementioned issues, the University ofSão Paulo School of Medicine and its Health Complex,Hospital das Clínicas, developed the program ‘‘COMVC19:The Mental Health and Psychosocial Well-Being PersonalProtective Equipment to the Health Professionals involved inthe Combat against the COVID-19 Pandemic.’’ This programis designed to offer mental health and psychosocial supportand psychological/psychiatric treatment to approximately20,000 hospital employees. It has been officially broadcastedto members of the whole complex through electronic means(a link to the webpage) and new information is continuouslyupdated. Based on what we have learned from our inter-actions with our professionals, teams, and their leadership,the program comprises three branches: mental health andpsychosocial support, education, and research.The composite term ‘mental health and psychosocial sup-port’ (MHPSS) is used in the Inter-Agency Standing Commit-tee (IASC) Guidelines for MHPSS in Emergency Settings todescribe ‘‘any type of local or outside support that aims to protector promote psychosocial well-being and/or prevent or treat mentalhealth condition’’. The global humanitarian system uses theterm MHPSS to unite a broad range of actors responding toemergencies such as the COVID-19 pandemic, including thoseworking with biological approaches and sociocultural app-roaches in health, social, education, and community settings,as well as to ‘‘underscore the need for diverse, complementary app-roaches in providing appropriate support’’ (4). The IASC Guide-lines for MHPSS in Emergency Settings recommends thatmultiple levels of interventions be integrated within outbreakresponse activities. These levels align with a broad spectrum ofmental health and psychosocial needs and are represented in apyramid of interventions (Figure 1) ranging from embeddingsocial and cultural considerations in basic services to pro-viding specialized services for individuals with more severeconditions. Core principles include: do no harm, promotehuman rights and equality, use participatory approaches,build on existing resources and capacities, adopt multi-layeredinterventions, and work with integrated support systems (4).The MHPSS branch of the COMVC19 program (Figure 1)consists of coordinated measures that range from preventiveactions and therapeutic interventions to rehabilitation, ifrequired. Secondary prevention encompasses the training ofmembers of our medical units following the ‘‘PsychologicalFirst Aid’’ principles (2), as well as support groups forprofessionals working on the frontline – hence, those who aremore likely to develop mental disorders (6). This means thatindividuals who require mental health support will haveaccess to psychological groups acting locally within theirwards or to a hotline held by supervised residents of psy-chiatry on call, 24/7. In both cases, mental health professionalswill provide empathic listening in the short term. This supportstage will allow us to identify individuals who require referralto psychiatric and/or psychological (brief psychotherapy)treatments, or a psychiatric ER if the situation constitutes anemergency. Finally, specific occupational therapy will beprovided for those in quarantine or on medical leave.The educational branch of the initiative focuses on thetraining of residents in all these actions and will includesix hours of short video-classes prepared by our group ofexperienced assistants. Critically, these videos will targetboth health professionals and the general public, therebyscaling up the impact of the program. They are freely avail-able online (https://sites.google.com/hc.fm.usp.br/comvc-19/comvc-19),Finally, a research branch was developed to monitor ouremployees’ mental health regularly through an online plat-form. Our aim is to investigate and identify risk and deviseprotective interventions for specific groups. Further, usingstandard instruments, each intervention will be evaluated inreal time. Hereafter, the analyses, interpretation, and pub-lication of these experiences will allow us to improve theFigure 1 - Intervention pyramid for mental health and psychosocial support.2Protecting healthcare workers’ mental healthFukuti P et al.CLINICS 2020;75:e1963whole program, as well as share our failures and successeswith the scientific community.Specialists estimate that the world will endure a long battleagainst the COVID-19 pandemic and its consequences. Toensure success, it is essential to keep our healthcare workersactive, motivated, and healthy. Thus, we hereby recom-mend that all health institutions pay special attention tothe mental health and psychosocial well-being of theirworkers. If our frontline health soldiers should suffer dueto mental health and psychosocial burdens, all our otherweaponry will be compromised and the war will be lost.These actions will mitigate a second wave of high incidenceof mental health and psychosocial problems as a sequelae ofthis pandemic that could otherwise be prevented by theseinterventions.’ AUTHOR CONTRIBUTIONSFukuti P, Uchôa CLM and Miguel EC were responsible for the manuscriptoriginal draft. Mazzoco MF, Corchs F, Kamitsuji CS, Rossi L, Rios IC,Lancman S, Bonfa E and Barros-Filho TEP were responsible for themanuscript writing, editing and review.’ REFERENCES1. Dong E, Du H, Gardner L. An interactive web-based dashboard to trackCOVID-19 in real time. Lancet Infect Dis. 2020;20(5):533-4. https://doi.org/10.1016/S1473-3099(20)30120-12. Everly GS Jr, Lee McCabe O, Semon NL, Thompson CB, Links JM. Thedevelopment of a model of psychological first aid for non–mental healthtrained public health personnel: the Johns Hopkins RAPID-PFA. J PublicHealth Manag Pract. 2014;20 Suppl 5:S24-9. https://doi.org/10.1097/PHH.00000000000000653. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features ofpatients infected with 2019 novel coronavirus in Wuhan, China. Lancet.2020;395(10223):497-506. https://doi.org/10.1016/S0140-6736(20)30183-54. Inter-Agency Standing Committee (IASC) (2007). IASC Guidelines onMental Health and Psychosocial Support in Emergency Settings. Geneva:IASC.5. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated WithMental Health Outcomes Among Health Care Workers Exposed to Cor-onavirus Disease 2019. JAMA Netw Open. 2020;3(3):e203976. https://doi.org/10.1001/jamanetworkopen.2020.39766. Perlis RH. Exercising Heart and Head in Managing Coronavirus Disease2019 in Wuhan. JAMA Netw Open. 2020;3(3):e204006. https://doi.org/10.1001/jamanetworkopen.2020.40067. Shanafelt T, Ripp J, Trockel M. Understanding and Addressing Sources ofAnxiety Among Health Care Professionals During the COVID-19 Pan-demic. JAMA. 2020. https://doi.org/10.1001/jama.2020.58938. Zhu Z, Xu S, Wang H, Liu Z, Wu J, Li G, et al. COVID-19 in Wuhan:Immediate Psychological Impact on 5062 Health Workers. 2020. medRxiv.https://doi.org/10.1101/2020.02.20.200253383CLINICS 2020;75:e1963 Protecting healthcare workers’ mental healthFukuti P et al.

How Institutions Can Protect the Mental Health and Psychosocial Well-Being of Their Healthcare Workers in the Current COVID-19 Pandemic

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How Institutions Can Protect the Mental Health and Psychosocial Well-Being of Their Healthcare Workers in the Current COVID-19 Pandemic

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