**5. The impact of COVID-19 on healthcare workers**

The analogy of the COVID-19 pandemic as a kind of global war is now very familiar, with the frontline medical staff akin to foot soldiers in the trenches, fighting back against a voracious, viral enemy. Much has been written about the challenges facing healthcare workers in the midst of this pandemic: extended working hours, risk of exposure to the virus, fear of transmitting the virus to family members, insufficient supplies of personal protective equipment, adaptation to new work practices and changing roles, to name but a few. In addition to such practical challenges facing healthcare workers during the pandemic, a vast array of workers has been faced with emotionally fraught, moral and ethical dilemmas. Immeasurable moral injury may have occurred as healthcare workers have been forced to make difficult decisions regarding resource allocation, something which most workers likely never anticipated having to face.

Also worthy of consideration are the feelings of fear and guilt which may arise following infection with the virus. In light of the fact that countless frontline workers contracted the virus in the course of their work, it is plausible that many of these workers grappled with self-blame and a sense of shame about having become infected. Tragically, such feelings, coupled with heavy stress and fear of having contaminated others, are thought to have resulted in the suicides of a number of healthcare workers. Indeed, Reger and colleagues have discussed the possibility of

suicide rates increasing across the general population, in the aftermath of the pandemic: they caution that a surge in suicides may occur among people who struggle to cope with the realities of the pandemic [14]. Coupled with the fact that in 2018, the U.S. had its highest age-adjusted suicide rate since 1941, it is not difficult to imagine that the personal and interpersonal struggles presented by the pandemic could exacerbate the situation. It could be argued that frontline working bestows an even higher risk, given the vicarious trauma which many of these workers have sustained.

Notwithstanding these considerations, there is at least some cause for hope: there has been a decrease in suicide rates in the short-term aftermath of previous national disasters, such as the 11th September terrorist attacks [15], although the data on longer-term effects is, admittedly, somewhat mixed. The "pulling-together" effect, wherein members of society have a shared experience of testing times and learn to support each other through their difficulties, is one hypothesis for the downward trend in suicide after national disasters. In addition, a pandemic may give pause for thought and reflection on our mortality, and force us to consider how precious life is, and as a result, possibly make suicide less likely. However, a word of caution: history has taught us that the impact of outbreaks on suicide rates tends to be a negative one. Although there is little data regarding the previous pandemic of Spanish Flu (1918), the general consensus is that suicide rates increased at that time. More recent data following the SARS epidemic showed an increase in the suicide rate of older adults in Hong Kong in 2003, a 31.7% increase from 2002 [16, 17].

The mantra of "we're all in this together" was quickly adopted in order to inspire a sense of community in the fight against the virus. This well-meaning drive to foster a sense of community would chime with Emile Durkenheim's [18] seminal work on the theory of suicide, which postulated that linking suicide almost exclusively with mental illness, and effectively ignoring social connectedness, was inadequate. He linked a rise in suicides at the time to modernity and the associated weakening of family and community bonds, and ultimately asserted that as social integration decreases, people are more likely to die by suicide. In this time of social and physical distancing, it is not difficult to comprehend how people could feel less socially connected and perceive themselves as being more alone than ever before [19], meaning that a rise in suicides is a very real possibility.

On the other hand, a pandemic is not the same as a natural disaster or an act of terror. Although comparative in terms of the mass loss of life and the sense of a loss of control, a pandemic contrasts with manmade or natural disasters in terms of the duration and magnitude of the event; a pandemic is a prolonged crisis, and it is known that prolonged stressors can be especially challenging to adapt to [20]. However, it is not beyond the capabilities of the human condition to overcome unimaginable suffering: Viktor Frankl's account of life and the search for meaning in a Nazi concentration camp springs to mind as a shining example of human courage in the face of difficulty and suffering [21]. This pandemic has given rise to levels of unemployment not seen for decades, and it is widely anticipated to result in a global economic downturn. It is known that rates of suicide tend to increase during periods of recession [22]: it was estimated that a 22.8% increase in suicide occurred in the United States during the Great Depression of 1929–1933 [23]. Similarly, following the Asian economic crisis of 1997–1998, male suicide rates soared by 39% in Japan, 44% in Hong Kong and 45% in South Korea from 1997 to 1998 [24]. More recently, Irish data found that by the end of 2012, the suicide rate for men was 57% higher than if the pre-recession trend had continued [25], while self-harm rates were 31% higher for males and females. Of note, Stuckler [26] found that countries with the most severe economic downturns had the greatest increase in suicides, while countries such as Austria, with strong social support structures and protective

#### *Perspective Chapter: Fallout from the Pandemic – A Social and Psychological Description… DOI: http://dx.doi.org/10.5772/intechopen.101499*

labour markets, had a net decrease in deaths by suicide. It remains to be seen what the impact of this economic downturn will be on suicide rates.

We know that, for many of us, our job plays a key role in our identity and sense of self. Consider being dismissed from a job or unexpectedly losing a job: most people would consider either of these events upsetting at best, traumatic at worst, and there is a real risk to mental well-being involved. One study showed that long-term (more than 52 weeks) unemployment was significantly correlated with large negative effects on mental health, with even greater effect sizes observed in minority groups [27]. Having a job fosters self-confidence, and, for many, inspires a sense of purpose. Many healthcare workers will say they entered the field of health in order to help others in a real and meaningful way. If trauma is a rupture in "meaning-making" [2], then the pandemic was perhaps the greatest rupture these healthcare workers will witness in their careers: the way they viewed themselves, the world, and others was overturned by this frightening event which was unprecedented in living memory. The concern is that a gap has now arisen between what these workers knew, or their "orienting systems", and the traumatic event. As we emerge gradually from the pandemic and healthcare workers have some time to reflect on their experiences, some will undoubtedly process events, harness their resilience, and move past the trauma. Others will likely struggle to process the magnitude of what they have experienced amidst the pandemic, and are at risk of developing mental health difficulties.

In attempting to plan adequately for the increased need for mental health supports for healthcare workers in the aftermath of this pandemic, we should regard it as inevitable that an increase in mental health needs will arise. We need only look to the outcomes for healthcare workers who have worked through previous, smaller outbreaks. One study [28] found that more than three-quarters of healthcare workers who cared for patients during the SARS outbreak reported experiencing mental health difficulties, such as sleep disturbance, anxiety and low mood. Various authors have lamented the paucity of training in mental health care delivery for healthcare professionals in the context of working in a pandemic [29]. Others have argued that it is imperative that healthcare managers take steps to protect the mental health of their staff and to correctly identify those who suffer psychological injury as a result of the pandemic [30].

Regarding the psychological sequelae to trauma, it is widely accepted that a lack of post-trauma social support and exposure to stressors during recovery constitute the two risk factors which confer the highest risk in terms of long-term mental health status [30]. On a positive note, we know that healthcare managers can play an instrumental role influencing the experience of workers, in that they can foster a supportive environment for workers and take steps to reduce workplace stressors following the acute crisis period. Once again, history has taught us that supportive managers can have a powerful effect on the mental well-being of their staff, as demonstrated in research from previous outbreaks [31].

Greenberg discusses six elements, based on the best evidence available, which are necessary in the protection of healthcare workers' mental health [30]. Firstly, it is felt that healthcare workers should be thanked, because resilience is thought to be nurtured through an appropriate acknowledgement of the difficult work carried out by frontline workers. Greenberg suggests that potential psychological and emotional issues should be acknowledged and information should be forthcoming as regards support options which are available to healthcare workers. Secondly, it is advised that healthcare workers who are absent from work be actively followed up by managers. Given that avoidance is a cardinal symptom of traumatic stress, this may manifest as being absent from work. Healthcare managers should engage with workers who have unplanned absences from work, in order to ascertain if the

workers are experiencing mental health difficulties and to facilitate signposting to appropriate support services. Thirdly, the case is made for "return to normal work" interviews, as healthcare workers journey from crisis roles back to the "new normal". Such meetings should facilitate a supportive conversation regarding mental health needs, and should be conducted by managers who are experienced in and comfortable with speaking about mental health needs. Research in trauma-exposed occupations has demonstrated that workplace mental health training of managers can reduce employee sick leave [32].

In addition, Greenberg argues that healthcare managers ought to be particularly cognisant of the potential mental health needs of healthcare workers who belong to high-risk groups, including black, Asian and ethnic minority people, as well as junior or inexperienced staff [30]. The identification of ongoing stressors, such as bereavement, is of paramount importance. There is also a need for special focus on those healthcare workers who have taken on roles and responsibilities beyond their usual role, e.g. workers who were redeployed to novel roles.

The UK National Institute for Health and Care Excellence endorses the active monitoring of anyone who has experiences a potentially traumatic event, especially those who are already considered to be at increased risk of mental health difficulties. In the aftermath of the 2005 London bombings, Brewin and colleagues demonstrated that proactively reaching out to people about their mental health can result in an increased take-up of mental health care [33].

Healthcare workers being able to make sense of and derive meaning from their traumatic pandemic experiences is the final piece in the puzzle of protecting their mental health. It is widely believed that it is not events per se have the most significant impact on our coping, but rather how we think about, interpret and perceive events and ascribe them a meaning [20]. Healthcare managers should strive to assist workers in developing a meaningful narrative of their experiences, one that does not apportion blame to the self or others for the distressing challenges they faced amidst the pandemic. Schwartz rounds and Balint groups are two methods by which healthcare workers may process the trauma they have experienced and foster a sense a purpose. After all, oft-quoted in the words of the Friedrich Nietzsche, "he who has a why to live for can bear almost any how".
