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Newsletter September 2020: Stress and Mental Health in Healthcare Workers During Crises

By Alex Rawlings

ESAIC Patient safety and Simulation Project Manager



September 17, 2020, will be the second World Patient Safety Day. The theme for this day will be the safety of health workers and of patients under their care.

The COVID-19 crisis that has been unfolding over the last six months has brought this issue to the forefront of patient safety. The impact on staff has been huge. Countries and institutions have only recently been able to take stock and to assess what measures to implement as the crisis continues. The impact of this crisis on the safety of patients is still to be fully assessed.

For the continued care of patients and the functioning of institutions, protecting staff is a priority. This goes beyond the physical safety of staff through the provision of adequate equipment, PPEs, and training. It also requires that we consider the mental and emotional wellbeing of staff.

A recent study, to be published in the Frontiers in Psychology/ Psychology for Clinical Settings (1), will reveal that healthcare workers in the United States are facing an increased risk of serious mental health issues, including chronic stress, anxiety, depression, post-traumatic stress disorder and burnout. As the crisis continues, it will compound these issues. Such a rate of risk is not sustainable. Resilience, the ability of health workers to cope and maintain the safe practice, is dropping.

In my experience of teaching crisis stress management to groups of doctors, nurses, and multidisciplinary healthcare staff in the UK, I found staff often reluctant to discuss stress, especially senior staff. Perhaps, as leaders, they were concerned about how it could harm their reputation or standing with their teams (2). “I don’t do stress”, was the comment of one senior nurse. If that was the attitude at the top of the team, would a junior member feel that they could come forward and receive support for stress-related health problems?

Training in stress resilience for staff was low on the list of priorities. A lack of funding and time for training in what is often considered a ‘soft’ skill, adds to this challenge.

The result is that we are not preparing staff adequately to face crises on the scale that we have seen this year. We know that performance levels are related proportionally to the level of preparedness.  Inadequate preparation can only lead to increased issues for both staff and patients.

What staff have achieved so far under almost impossible conditions has been remarkable. However, we still do not fully understand the full cost, for staff and patients, of having to cope without sufficient preparation.

In May 2020, the Italian Network for Safety in Healthcare (INSH), along with the International Society for Quality in Healthcare (ISQua), produced Patient Safety Recommendations for the COVID-19 Epidemic Outbreak (3). These recommendations come directly from experience gained on the frontline during the peak of the crisis in Italy. The report offers general recommendations including team building tasks and skills, PPEs (Personal Protective Equipment), and other related equipment.

It also covers the psychological safety of staff and the mental wellbeing of patients. It offers important recommendations such as:

  • Creating a healthy work ethos and environment during crises.
  • Offering interventions to staff.
  • Reducing the stigma surrounding mental health
  • Educating healthcare workers about the effects of cumulative stress.
  • Maintaining teamwork and effective leadership while at the same time providing individuals with the opportunity to provide input.
  • The administration needs to be supportive of the staff and not be seen as pedantic and overly controlling.

It is significant that it recognises systemic solutions. As well as educating staff about the effects of cumulative stress, it should also recommend training that teaches them what to do when they become aware of it. These include cognitive processes to engage directly with the stress response, developing mental attitudes to build resilience and becoming proficient in lessening the stress response under the intense conditions of a crisis.

The WHO recommends “ensuring sufficient rest and respite during work or between shifts, eat sufficient and healthy food, engage in physical activity, and stay in contact with family and friends…. You are the person most likely to know how you can de-stress and you should not be hesitant in keeping yourself psychologically well.” (4)

This advice is not nearly sufficient. Stress during a sustained crisis is a complex effect. Multiple factors impact on each other. Administration, leadership, team dynamics, and training all intersect in the individual along with their levels of tolerance, fatigue, perception, emotional response, and experience of past stressors. Techniques to respond to the levels of stress that occur in a crisis are not common knowledge. They are specialised skills that require training, absorption, practice and the development of ‘learned resourcefulness’, a confidence in the skills you have gained. Ideally, they should be assimilated before a crisis occurs.

High-reliability organisations have already acknowledged the importance of this issue.

“High reliability mainly involves concern over failure, reluctance to accept simplified interpretations, sensitivity to operations, commitment to resilience and detailed structure specifications.” (5)

They are aware of how a moment of stress can negate hours of other training. Adequate crisis stress management training, including stress exposure training, is given alongside training in other non-technical skills such as teamwork, communication, situational awareness, and decision making (6). They remove the stigma surrounding stress through reinforcing a culture that is based on performance and that is also very empathetic of the human condition.

We owe it to staff and patients to become better informed about the impact of stress during crises on mental health and performance. We need to offer training in the wide range of skills available to empower them to manage both chronic and acute stress, to protect their long and short-term mental health and allow them to perform to the best of their ability. We need to make support for staff easily available and work to remove all boundaries to such support being accessed. (7) (8)

2020 is the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology. In the Heads of Agreement, it highlights the importance of education in improving patient safety. It urges the development, dissemination, and delivery of patient safety training. These recommendations are as valid today as when they were first conceived. We still have much work to do.

More information on the Helsinki Declaration on Patient Safety in Anaesthesiology.

The ESAIC will co-host the International Forum on Perioperative Safety and Quality (ISQ), along with the ASA, WFSA and APSF on World Patient Safety Day, 17th September 2020. The focus of this event will be the safety of healthcare workers and patients. Details to be announced.



  1. MacKenzie L. Hughes, Georgia Institute of Technology; Emily L. Smith and Shevaun D. Neupert, North Carolina State University. “Mental health challenges of U.S. healthcare professionals during COVID-19”, Ann Pearman and Accepted July 27, Frontiers in Psychology | Psychology for Clinical Settings DOI: 10.3389/fpsyg.2020.02065
  2. Knaak S, Mantler E, Szeto A. Health Manage Forum. 2017;30(2):111-116. doi:10.1177/0840470416679413
  3. PATIENT SAFETY RECOMMENDATIONS FOR COVID19 EPIDEMIC OUTBREAK v2.0, ISQua, INHS. https://isqua.org/blog/covid-19/covid19-resources/patient-safety-recommendations-for-covid19-epidemic-outbreak.html. https://isqua.org/images/COVID19/PATIENT_SAFETY_RECOMMENDATIONS_V2.0_04052020.pdf
  4. WHO Mental health and psychosocial considerations during the COVID-19 outbreak: https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf?sfvrsn=6d3578af_2
  5. Meyer Jr, V., Cunha, M.P.e., Mamédio, D.F. and Nogueira, D.P. (2020), ” Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/DPM-08-2019-0245
  6. Driskell, J. E., & Johnston, J. H. (1998). Stress exposure training. In J. A. Cannon-Bowers & E. Salas (Eds.), Making decisions under stress: Implications for individual and team training (p. 191–217). American Psychological Association. https://doi.org/10.1037/10278-007
  7. Brooks SK, Dunn R, Amlôt R, G. et al. BMC Psychology (2019) 7:78 https://doi.org/10.1186/s40359-019-0360-6
  8. COVID-19 Mental Health Toolkit: Mental health guide and coping strategies for healthcare staff during the COVID-19 pandemic. https://www.jhah.com/healthstaff-covid-coping


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