COVID-19: Healthcare workers face moral injury, financial stress, combative patients

These are extraordinary times brought out by a merciless pandemic, the psychological impacts of which are beginning to show on medical and non-medical health personnel, especially the frontline workers.

Their stories voice their stress and anxiety, of moral injury, of dealing with combative patients and financial concerns. As the workload rises by the day, they hope of not being assaulted, await PPEs, ‘hazard pay’ and clear guidelines.

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A critical care consultant in a private hospital in the city, who requested anonymity, says, “PPEs are in short supply and working eight hours at a stretch is not easy. The plight of the nursing staff is even worse. They spend the maximum time with isolated COVID -19 suspects in the ICU without food, water and sleep.”

“Nurses are usually at the receiving end as they are paid the least. They are having panic attacks, chest pain and anxiety. The most important worry for all of us is spreading infection to our families.”

“That’s not all. Patients sometimes resist and get combative. People have still not accepted the magnitude of the problem,” he avers. He says ‘Hazard Pay’ needs to be given on the lines of what the armed forces are given and the government should also provide proper guidelines so that there is no confusion about where to send the patients.

It is quite a cocktail of concerns, some of which do not have easy solutions. While mental wellness is often pushed into the backseat, the pandemic is laying bare the anxieties of a community that is already suffering burnout.

“Overwork burnout, chronic stress fatigue, moral injury trauma and anxiety, feeling of inadequacy and self-doubt has increased ten times now than ever,” says Dr Nilima Kadambi, chairperson, Doctors4Doctors, IMA National Committee for the Emotional Well being of the Doctors.

“The anxiety also arises out of the confusion about the illness itself and learning how to manage it on the go even as the data around treatment options is changing constantly,” opines Dr Ashlesha Bagadia, psychiatrist and psychotherapist, Green Oak Initiative.

“There is the real anxiety of catching the infection, or worse, passing it on to their family,” she says.
Young health care workers are also worried as they anticipate calls in such a situation where there is increased demand. “They are worried about being under skilled and under prepared. There are genuine worries in doctors caring for non-COVID high-risk patients -- in being able to provide adequate care during lockdown,” she adds.

The financial stress is not often talked about but it is there, looming large and adding to the emotional exhaustion. “There is a very real financial stress in those on the frontline and those who are not. Frontline workers are worried their limited insurance (if any) will cover their own medical bills if they fall sick,” informs Dr Ashlesha.

She said physicians running small clinics and startups rely on daily footfall to pay their staff and the lockdown is affecting them just as much as other businesses.
“Many doctors, who are small hospital owners, are struggling to keep their services open and staff paid. There is also the added expenditure on PPEs,” informs Dr Nilima.

Meanwhile an emergency consultant in a private hospital, who did not wish to be named, narrates her experience in the midst of the pandemic. “Most of the time, patients hide the fact that they have travelled, even if it is domestically. This is adding to the anxiety of the frontline workers. Patients deny having fever or cough for fear of being isolated and being branded as a COVID suspect,” she says.

“Sometimes, the patients in the general category (who do not have any respiratory issues) come back to us saying that government hospitals are not receiving them and are only treating COVID suspects,” she says.

She said nurses were more affected and they have repeated counselling sessions for them. Their hospital, she informed, has planned to reduce the number of people on the floor.
So they work for two to three days and take off for 48 hours, to de-stress. “Apart from that there is counselling in the office,” she says.

Ever since the pandemic broke out, the healthcare workers are facing extremely high workload, especially the nurses, residents and interns. “Health care workers are at a significantly increased risk of compassion fatigue and anticipatory grief during these times. Most of them prefer to be self-reliant, rarely asking for help on their own. This leads to a widening of the gap between seeking and availing mental health services.” says Dr Suhas Chandran, Assistant Professor, Department of Psychiatry, St John’s Medical College Hospital.

The usual clinical practice routines have changed, he said, and many have been deployed in areas outside their clinical expertise, due to a need for more frontline staff.

“In many hospitals, resources are so scarce that patients may have to be triaged, and resources used selectively, which creates a great moral dilemma in health care workers,” he added.
There is also the concern of wearing the PPEs the right way. Some of the young health care workers are using the PPEs for the first time.
“One of their biggest anxieties is around getting the right kind of PPE which offers sufficient protection, learning how to use it properly and freely work without hesitation,” says Dr Ashlesha.

Dr Nilima said that the need of the hour is to provide adequate PPEs and hands-on training for young doctors, encouraging them to speak up if they are unable to take the pressures or if they see any other colleagues struggling.

With the lockdown shutting off the public transport system, the community is also finding it difficult getting to the hospitals. Many of them have had to stay on campus full time.
“This is due to the fear of infecting family members as well as non-availability of public transport to travel between hospital and homes. Some have even lost important sources of income, due to loss of jobs of other family members and spouses as a result of the economic crisis the pandemic has produced,” added Dr Suhas.

A large section of health care workers are also facing difficulties with child care. “These difficulties increase exponentially if they have children with special care needs. The government should consider providing childcare and community support to health care workers,” Dr Suhas adds.

Talking about reducing the heightened anxiety, Dr Ashlesha pointed out how not ostracizing them in the neighbourhood that they live in would be a good start. On April 23, the Centre had promulgated an ordinance to amend the Epidemic Act 1897. At a time when the assaults on health care workers and forceful evictions are increasing, Dr

Suhas feels the ordinance to amend the Epidemic Act needs to be taken forward even after the pandemic crisis ends. While the crisis seems to be going for a long haul, the frontline workers are looking for some respite from their stress.

Dr Ashlesha wants frontline workers to have a senior doctor handhold them. She said they should be provided safe transport, accommodation with F&B as well as laundry services, child support and elder care support for their families, adequate health and life insurance as well as additional remuneration as ‘hardship pay’.

By all counts, the pandemic has been highlighting the gaps in public health care. In more ways than one, it has been a clarion call to pay more attention to the health care system and the workers.

The government should provide guidelines about which doctors who should not be attending or treating COVID positive cases, Dr Nilima says. “For instance, doctors above 65 years, those with any comorbidities or with immune suppression are at a high risk of succumbing to serious Corona complications. Death of doctors who are colleagues, adds a lot to mental health issues for others,” she says.

“Stationing counsellors at every hospital, in non-contaminated staff rest areas, would help frontline workers address mental health concerns in an easier manner. It is going to be important that these measures are sustained even after the pandemic ends,” Dr Suhas advises adding that a dedicated government task force or committee could also be formed to ensure the facilitation of the same.