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Applying the Lessons of SARS to Pandemic Influenza

Applying the Lessons of SARS to Pandemic Influenza COMMENTARY he Severe Acute Respiratory Syndrome (SARS) outbreak Applying the Lessons of SARS to Tdemonstrated that an extraordinary infectious outbreak causes enduring stress Pandemic Influenza 1 in healthcare workers. Currently, health- care organizations are preparing for an An Evidence-based Approach to Mitigating the Stress influenza pandemic. While the occur- Experienced by Healthcare Workers rence of pandemic influenza is considered 1 1 inevitable, neither the timing nor the Robert G. Maunder, MD Nathalie Peladeau, RN, MSc 1 1 severity of the next pandemic can be pre- Molyn Leszcz, MD Donna Romano, RN, MSc 2 1 dicted. A severe pandemic would cause Diane Savage, MSW Marci Rose, OT Reg. (Ont.), OTR high mortality, high healthcare demands, 3 4 Mary Anne Adam Rabbi Bernard Schulman high absenteeism among healthcare work- ABSTRACT ers, rationing of basic healthcare supplies 2,3 and extraordinary stress. Under such cir- We describe an evidence-based approach to enhancing the resilience of healthcare workers in cumstances, the healthcare system could preparation for an influenza pandemic, based on evidence about the stress associated with not afford a further loss of professionals working in healthcare during the SARS outbreak. SARS was associated with significant long-term stress in healthcare workers, but not with increased mental illness. Reducing pandemic-related due to the effects of stress. The purpose of stress may best be accomplished through interventions designed to enhance resilience in this review is to provide an evidence-based psychologically healthy people. Applicable models to improve adaptation in individuals include approach to reducing healthcare workers’ Folkman and Greer’s framework for stress appraisal and coping along with psychological first aid. distress by building resilience prior to the Resilience is supported at an organizational level by effective training and support, development of pandemic. material and relational reserves, effective leadership, the effects of the characteristics of “magnet hospitals,” and a culture of organizational justice. Evidence supports the goal of developing and The stressful impact of SARS on maintaining an organizational culture of resilience in order to reduce the expected stress of an healthcare workers influenza pandemic on healthcare workers. This recommendation goes well beyond the provision The SARS outbreak was associated with of adequate training and counseling. Although the severity of a pandemic is unpredictable, this clinically significant distress in a third to effort is not likely to be wasted because it will also support the health of both patients and staff in 4-7 half of healthcare workers. Greater dis- normal times. tress was associated with quarantine, Key words: Health personnel; communicable diseases; stress, psychological; organizational treating colleagues with SARS, fear of culture; disaster planning 7,10,11 contagion, concern for family 6,11,12 7,11 RÉSUMÉ health, job stress, interpersonal iso- 7,11 7,8,13 lation, and perceived stigma. Two À la lumière des données sur le stress associé au travail dans le domaine des soins de santé aspects of these healthcare workers’ experi- pendant la crise du SRAS, nous décrivons une approche fondée sur les preuves qui vise à ence distinguish the stress of an infectious améliorer la résilience des travailleurs de la santé en prévision d’une pandémie de grippe. Le SRAS a été associé à un niveau significatif de stress de longue durée chez les travailleurs de la disease from other disasters. First, SARS santé, mais pas à une hausse des maladies mentales. Le meilleur moyen de réduire le stress en experience contributed to social isolation cas de pandémie serait de prendre des mesures pour améliorer la résilience des personnes for several reasons: infection control proce- saines sur le plan psychologique. Entre autres modèles intéressants pour améliorer la résilience, dures increased interpersonal distance; citons le cadre d’évaluation et d’adaptation au stress de Folkman et Greer, assorti de premiers stigma and interpersonal avoidance dimin- soins psychologiques. À l’échelle organisationnelle, la résilience est assurée par une formation ished social and community interaction; et un soutien efficaces, la constitution de réserves matérielles et relationnelles, un leadership and being assigned to unfamiliar work efficace, les avantages attribuables aux « hôpitaux-aimants » et une culture de justice 7,12 groups reduced collegial interaction. organisationnelle. Il est prouvé que la création et l’entretien d’une culture organisationnelle de Second, while family support usually résilience sont des objectifs valables si l’on veut réduire le stress attendu d’une pandémie de buffers stress, healthcare workers with chil- grippe sur les travailleurs de la santé. Cette recommandation va plus loin que la simple dren experienced higher levels of distress prestation d’une formation et d’un counseling adéquats. Il est impossible de prédire la gravité d’une pandémie, mais les efforts recommandés ne seront pas vains, car ils favoriseront aussi la during SARS, presumably due to the per- santé des patients et du personnel en temps normal. ceived risk of infecting loved ones and concerns about caring for children if the Mots clés : personnel médical et paramédical; maladies transmissibles; stress psychologique; parent is ill. culture organisationnelle; planification antisinistre Two years after the outbreak’s resolu- 1. Department of Psychiatry, Mount Sinai Hospital, Faculty of Medicine, University of Toronto, tion, healthcare workers in hospitals that Toronto, ON treated SARS patients had significantly 2. Department of Social Work, Mount Sinai Hospital 3. Department of Occupational Health & Safety, Mount Sinai Hospital elevated rates of signs of chronic stress 4. Director of Chaplaincy Services, Mount Sinai Hospital compared to workers in other similar hos- Correspondence and reprint requests: Dr. R.G. Maunder, Department of Psychiatry, Mount Sinai pitals. These included professional Hospital, 600 University Ave., Room 915, Toronto, ON M5G 1X5, Tel: 416-586-4800, ext. 3200, Fax: 416-586-8654, E-mail: rmaunder@mtsinai.on.ca burnout (30 vs. 19%), depressive and anx- Acknowledgement: The authors thank Dr. Allison McGeer for her contributions regarding infection iety symptoms (45 vs. 30%), increased control protocols. 486 REVUE CANADIENNE DE SANTÉ PUBLIQUE VOLUME 99, NO. 6 PANDEMIC STRESS IN HEALTHCARE WORKERS smoking, drinking or problem behaviour Fostering individual resilience tribute to individual resilience, however, (21 vs. 8%) and missing 4 or more work Resilience is the ability to reduce the effect by buffering workplace stressors during shifts over 4 months due to stress or illness of a distressing event by anticipation and and after a crisis. It is a key task of pre- (22 vs. 13%). Importantly, healthcare preparation or to “bounce back” once it pandemic preparation. workers in affected hospitals were more has occurred. Two evidence-based Organizational resilience depends on likely to have decreased face-to-face con- approaches to individual resilience are par- establishing reserves prior to crises. tact with patients (17 vs. 8%) and ticularly apt for pandemic preparation. Pandemic plans note the need for material 3,21,22 decreased work hours (9 vs. 2%) following Folkman and Greer’s framework for main- reserves (e.g., stockpiles of supplies). SARS. However, rates of depression, post- taining psychological well-being during Additionally, business models of resilience traumatic stress disorder or other mental serious illness describes a sequence of emphasize the value of back-up plans and illness were not elevated. Thus, long-term appraisal and coping processes that are succession plans, a culture of flexibility and 23,24 effects of SARS were common but were designed to recover positive emotions and the central role of effective leadership. predominantly in the range of subsyndro- effective adaptation. They describe a Evidence from the SARS outbreak rein- mal stress response syndromes. This should sequential approach to coping that is forces the importance of effective train- shift thinking about reducing pandemic- experience-near for many healthcare work- ing. This may include training in skills related stress away from models of clinical ers: problem solving for events that are that will be required when adaptation to intervention for mental health problems appraised to be within one’s control, the pandemic requires staff to work outside and towards models of adaptation and emotion-based coping to enhance support of their usual area of familiarity, and may resilience in psychologically healthy people. and reduce isolation, and meaning-based also include training in psychological first Mediators of long-term SARS stress coping for events that are unresolved and aid and coping. In SARS, psychosocial could become targets for interventions. cause persistent distress after problem- support was far more effective when pro- Chronic stress was lower in workers with focused efforts. This framework facilitates vided in the context of trusted pre-existing longer healthcare experience and in those flexibility, acknowledging that distress and relationships. We advocate building rela- who felt effectively trained and supported coping are highly individual and depend tional reserves prior to the pandemic, by by their hospital. Greater chronic stress on experience, values and expectations. It which we refer to supportive, collaborative, was reported by workers who coped using also facilitates discussion of the strengths interdisciplinary relationships which can strategies of avoidance and self-blame. and weaknesses of various approaches to provide the basis for formal and informal coping, and the evidence that coping support during a crisis. Healthcare organi- Key differences between SARS and through escape-avoidance and self-blame zations may also benefit from the recovery- pandemic influenza are maladaptive in healthcare workers enhancing power that flows from a shared 14 24 The stress of pandemic influenza will differ responding to infectious disease. sense of moral purpose, such as a shared from SARS because of the inability to con- The second approach that we advocate is dedication to caring for the sick. tain pandemic influenza through infection psychological first aid, an evidence-based Two evidence-supported constructs are control procedures, the potential difference approach to facilitating resilience immedi- particularly applicable to building a culture in scale and severity, and the opportunity ately after trauma. Healthcare workers can of organizational resilience. First, magnet to prepare for a pandemic. SARS was a learn psychological first aid without any hospitals, originally identified by their abil- nosocomial infection with minimal com- prior mental health education. ity to recruit and retain nursing staff more munity transmission and minimal infec- Furthermore, learning to support others effectively than neighbouring hospitals, are tious transmission prior to the onset of may also enhance the resilience of the characterized by decentralized decision- symptoms. Infection control procedures provider. As with Folkman and Greer’s making by caregivers, a nurse among the were key aspects of containing the out- model, psychological first aid does not hospital executive, flexible scheduling, break. Influenza, on the other hand, is pathologize people who are stressed by investment in continuing education and readily transmitted before the onset of clin- extraordinary events. Rather, it assumes unit-level self-government. Magnet hos- ical illness and is prone to mutations that that those who are stressed are competent pitals tend to have lower patient favour the virus’s survival. Thus, pandemic and are able to determine whether or not mortality, and also have lower rates of influenza will be a community-acquired they wish or need assistance. It teaches a burnout among staff. The characteristics disease. This difference may reduce some respectful approach to reducing distress of magnet hospitals echo the findings that of the isolation that was experienced by through enhancing safety and comfort, health is negatively affected by high healthcare workers in SARS due to quaran- helping survivors of trauma to identify demand/low control occupations and 28,29 tine, reduced social contact within the hos- their needs, providing information and effort-reward imbalance. While SARS pital and stigma. In a severe pandemic, facilitating social connection. experience teaches that decentralized decision- however, the benefit of reduced isolation making may need to give way to hierarchi- will be outweighed by the burden of the Fostering organizational resilience cal structures during a crisis, we expect scale of disease. Thus, it is important to The resilience of healthcare organizations that the resilience associated with the cul- fully exploit our opportunity to plan effec- is influenced by factors beyond the ture of magnet hospitals will aid staff in tively and implement resilience-enhancing resilience of people within the organiza- their recovery from the strain of such measures before the pandemic occurs. tion. Organizational resilience may con- adjustments after the pandemic has passed. NOVEMBER – DECEMBER 2008 CANADIAN JOURNAL OF PUBLIC HEALTH 487 PANDEMIC STRESS IN HEALTHCARE WORKERS 15. Lancee WJ, Maunder RG, Goldbloom DS, The Second, organizational justice describes REFERENCES co-authors of the Impact of SARS Study. The prevalence of mental disorders in Toronto hospi- two further characteristics of large organi- 1. Maunder R, Hunter J, Vincent L, Bennett J, tal workers one to two years after SARS. zations that are associated with greater Peladeau N, Leszcz M, et al. The immediate psy- Psychiatric Services 2008;59:91-95. chological and occupational impact of the 2003 physical well-being among employees. 16. Low DE. Why SARS will not return: A polemic. SARS outbreak in a teaching hospital. CMAJ CMAJ 2004;170(1):68-69. Organizational justice includes the degree 2003;168(10):1245-51. 17. National Advisory Committee on SARS and to which supervisors take their employees’ 2. World Health Organization. Pandemic Public Health. Learning from SARS: Renewal of Preparedness. Geneva, 2005. Available online at: Public Health in Canada. Ottawa: Government viewpoints into account, suppress their http://www.who.int/csr/disease/influenza/pande of Canada, 2003. own biases and deal with subordinates in a mic/en.index.html (Accessed July 3, 2007). 18. U.S. Dept. of Homeland Security. Pandemic 3. Public Health Agency of Canada. Canadian fair and truthful manner (relational jus- Influenza Preparedness, Response, and Reovery Pandemic Influenza Plan, 2004. Available online Guide for Critical Infrastructure and Key tice), and fairness in formal decision- at: http://www.phac-aspc.gc.ca/cpip-pclcpi/.html Resources. Government of the United States of (Accessed November 3, 2006). making procedures (decisional justice). America, 2006. Available online at: 4. Tam CW, Pang EP, Lam LC, Chiu HF. Severe www.pandemicflu.gov/plan/pdf/cikrpandemicinfl Thus, organizational goals that serve the acute respiratory syndrome (SARS) in Hong uenzaguide.pdf (Accessed October 12, 2007). interests of both patients and staff during Kong in 2003: Stress and psychological impact 19. Folkman S, Greer S. Promoting psychological among frontline healthcare workers. Psychol Med normal functioning may also build rela- well-being in the face of serious illness: When 2004;34(7):1197-204. theory, research and practice inform each other. tional reserves which bolster resilience in 5. Chan AO, Huak CY. Psychological impact of the Psychooncology 2000;9:11-19. 2003 severe acute respiratory syndrome outbreak the face of a severe pandemic. 20. Brymer M, Layne C, Pynoos R, Ruzek J, on health care workers in a medium size regional Steinberg A, Vernberg E, et al. The Psychological general hospital in Singapore. Occup Med (Lond) First Aid Field Operations Guide, Second ed. CONCLUSION 2004;54(3):190-96. Terrorism and Disaster Branch, National Child 6. Nickell LA, Crighton EJ, Tracy CS, Al Enazy H, Traumatic Stress Network, National Center for Bolaji Y, Hanjrah S, et al. Psychosocial effects of PTSD, 2006. Available online at: Preparing for pandemic influenza requires SARS on hospital staff: Survey of a large tertiary www.ncptsd.va.gov/ncmain/ncdocs/manuals/ care institution. CMAJ 2004;170(5):793-98. attention to hospital processes at both a PFA_2ndEditionwithappendices.pdf (Accessed 7. Maunder RG, Lancee WJ, Rourke S, Hunter JJ, September 17, 2007). macro- and a micro-level, and attention to Goldbloom D, Balderson K, et al. Factors associ- 21. Toronto Academic Health Sciences Network. ated with the psychological impact of severe acute both individual and organizational charac- Pandemic Influenza Planning Guidelines, 2006. respiratory syndrome on nurses and other hospi- Available online at: http://portal.sw.ca/tahsn/ teristics. The evidence supports planning tal workers in Toronto. Psychosomatic Med default.aspx (Accessed October 6, 2006). that goes well beyond the provision of ade- 2004;66(6):938-42. 22. National Strategy for Pandemic Influenza. 8. Bai Y, Lin CC, Lin CY, Chen JY, Chue CM, quate training and counseling. Indeed, the Washington, DC: Homeland Security Council, Chou P. Survey of stress reactions among health Government of the United States, 2005. evidence supports the much broader goal care workers involved with the SARS outbreak. 23. Hamel G, Valikangas L. The quest for resilience. Psychiatr Serv 2004;55(9):1055-57. of maintaining an organizational culture of Harv Bus Rev 2003;81(9):52-63, 131. 9. Grace SL, Hershenfield K, Robertson E, Stewart 24. Freeman SF, Hirschorn L, Maltz M. The power resilience. This effort will not be wasted, DE. Factors affecting perceived risk of contract- of moral purpose: Sandler O’Neill & Partners in regardless of the timing and severity of the ing severe acute respiratory syndrome among aca- the aftermath of September 11, 2001. demic physicians. Infect Control Hosp Epidemiol Organization Development J 2004;22(4):69-79. next pandemic, because both patients and 2004;25(12):1111-13. 25. Aiken LH, Clarke SP, Sloane DM. Hospital staff will be healthier in a resilient hospital 10. Ho SM, Kwong-Lo RS, Mak CW, Wong JS. staffing, organization, and quality of care: Cross- Fear of severe acute respiratory syndrome (SARS) even during times of normal function. national findings. Int J Quality Health Care among health care workers. J Consult Clin Psychol 2002;14(1):5-13. The complexity of preparing for a pan- 2005;73(2):344-49. 26. Aiken LH, Smith HL, Lake ET. Lower Medicare demic and the inherent value of building 11. Wong TW, Yau JK, Chan CL, Kwong RS, Ho mortality among a set of hospitals known for SM, Lau CC, et al. The psychological impact of good nursing care. Med Care 1994;32(8):771-87. and maintaining inter-professional rela- severe acute respiratory syndrome outbreak on 27. Aiken LH, Clarke SP, Sloane DM, Sochalski J, tionships argue for pandemic planning healthcare workers in emergency departments Silber JH. Hospital nurse staffing and patient and how they cope. Eur J Emerg Med through organization-wide collaboration. mortality, nurse burnout, and job dissatisfaction. 2005;12(1):13-18. JAMA 2002;288(16):1987-93. Planning to reduce psychosocial stress 12. Maunder R, Lancee WJ, Rourke SB, Hunter J, 28. Johnson JV, Hall EM. Job strain, work place Goldbloom DS, Petryshen PM, et al. The experi- should involve representatives from psychi- social support, and cardiovascular disease: A ence of the 2003 SARS outbreak as a traumatic cross-sectional study of a random sample of the atry, psychology, nursing, social work, stress among frontline healthcare workers in Swedish working population. Am J Public Health chaplaincy, employee health, communica- Toronto: Lessons learned. In: McLean AR, May 1988;78(10):1336-42. 21 RM, Pattison J, Weiss RA (Eds.), SARS: A Case tions and hospital administration. The 29. Siegrist J. Adverse health effects of high- Study in Emerging Infections. Oxford: Oxford effort/low-reward conditions. J Occup Health important links between psychosocial University Press, 2005;96-106. Psychol 1996;1(1):27-41. 13. Verma S, Mythily S, Chan YH, Deslypere JP, resilience and other aspects of pandemic 30. Kivimaki M, Ferrie JE, Head J, Shipley MJ, Teo EK, Chong SA. Post-SARS psychological Vahtera J, Marmot MG. Organisational justice planning (e.g., infection control, human morbidity and stigma among general practition- and change in justice as predictors of employee resources, and risk communication) also ers and traditional Chinese medicine practition- health: The Whitehall II study. J Epidemiol ers in Singapore. The Annals, Academy of Community Health 2004;58(11):931-37. benefit from a broad-based planning Medicine, Singapore 2004;33(6):743-48. process. Experience with SARS has provid- 14. Maunder RG, Lancee WJ, Balderson KE, Received: November 1, 2007 Bennett JP, Borgundvaag B, Evans S, et al. Long- ed valuable insight into what to expect Accepted: April 21, 2008 term psychological and occupational effects of from pandemic influenza and how we can providing hospital healthcare during SARS out- best prepare healthcare workers. break. Emerg Infect Dis 2006;12:1924-32. 488 REVUE CANADIENNE DE SANTÉ PUBLIQUE VOLUME 99, NO. 6 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Canadian Journal of Public Health = Revue Canadienne de Santé Publique Pubmed Central

Applying the Lessons of SARS to Pandemic Influenza

Canadian Journal of Public Health = Revue Canadienne de Santé Publique , Volume 99 (6) – Nov 1, 2008

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Pubmed Central
Copyright
© The Canadian Public Health Association 2008
ISSN
0008-4263
eISSN
1920-7476
DOI
10.1007/BF03403782
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Abstract

COMMENTARY he Severe Acute Respiratory Syndrome (SARS) outbreak Applying the Lessons of SARS to Tdemonstrated that an extraordinary infectious outbreak causes enduring stress Pandemic Influenza 1 in healthcare workers. Currently, health- care organizations are preparing for an An Evidence-based Approach to Mitigating the Stress influenza pandemic. While the occur- Experienced by Healthcare Workers rence of pandemic influenza is considered 1 1 inevitable, neither the timing nor the Robert G. Maunder, MD Nathalie Peladeau, RN, MSc 1 1 severity of the next pandemic can be pre- Molyn Leszcz, MD Donna Romano, RN, MSc 2 1 dicted. A severe pandemic would cause Diane Savage, MSW Marci Rose, OT Reg. (Ont.), OTR high mortality, high healthcare demands, 3 4 Mary Anne Adam Rabbi Bernard Schulman high absenteeism among healthcare work- ABSTRACT ers, rationing of basic healthcare supplies 2,3 and extraordinary stress. Under such cir- We describe an evidence-based approach to enhancing the resilience of healthcare workers in cumstances, the healthcare system could preparation for an influenza pandemic, based on evidence about the stress associated with not afford a further loss of professionals working in healthcare during the SARS outbreak. SARS was associated with significant long-term stress in healthcare workers, but not with increased mental illness. Reducing pandemic-related due to the effects of stress. The purpose of stress may best be accomplished through interventions designed to enhance resilience in this review is to provide an evidence-based psychologically healthy people. Applicable models to improve adaptation in individuals include approach to reducing healthcare workers’ Folkman and Greer’s framework for stress appraisal and coping along with psychological first aid. distress by building resilience prior to the Resilience is supported at an organizational level by effective training and support, development of pandemic. material and relational reserves, effective leadership, the effects of the characteristics of “magnet hospitals,” and a culture of organizational justice. Evidence supports the goal of developing and The stressful impact of SARS on maintaining an organizational culture of resilience in order to reduce the expected stress of an healthcare workers influenza pandemic on healthcare workers. This recommendation goes well beyond the provision The SARS outbreak was associated with of adequate training and counseling. Although the severity of a pandemic is unpredictable, this clinically significant distress in a third to effort is not likely to be wasted because it will also support the health of both patients and staff in 4-7 half of healthcare workers. Greater dis- normal times. tress was associated with quarantine, Key words: Health personnel; communicable diseases; stress, psychological; organizational treating colleagues with SARS, fear of culture; disaster planning 7,10,11 contagion, concern for family 6,11,12 7,11 RÉSUMÉ health, job stress, interpersonal iso- 7,11 7,8,13 lation, and perceived stigma. Two À la lumière des données sur le stress associé au travail dans le domaine des soins de santé aspects of these healthcare workers’ experi- pendant la crise du SRAS, nous décrivons une approche fondée sur les preuves qui vise à ence distinguish the stress of an infectious améliorer la résilience des travailleurs de la santé en prévision d’une pandémie de grippe. Le SRAS a été associé à un niveau significatif de stress de longue durée chez les travailleurs de la disease from other disasters. First, SARS santé, mais pas à une hausse des maladies mentales. Le meilleur moyen de réduire le stress en experience contributed to social isolation cas de pandémie serait de prendre des mesures pour améliorer la résilience des personnes for several reasons: infection control proce- saines sur le plan psychologique. Entre autres modèles intéressants pour améliorer la résilience, dures increased interpersonal distance; citons le cadre d’évaluation et d’adaptation au stress de Folkman et Greer, assorti de premiers stigma and interpersonal avoidance dimin- soins psychologiques. À l’échelle organisationnelle, la résilience est assurée par une formation ished social and community interaction; et un soutien efficaces, la constitution de réserves matérielles et relationnelles, un leadership and being assigned to unfamiliar work efficace, les avantages attribuables aux « hôpitaux-aimants » et une culture de justice 7,12 groups reduced collegial interaction. organisationnelle. Il est prouvé que la création et l’entretien d’une culture organisationnelle de Second, while family support usually résilience sont des objectifs valables si l’on veut réduire le stress attendu d’une pandémie de buffers stress, healthcare workers with chil- grippe sur les travailleurs de la santé. Cette recommandation va plus loin que la simple dren experienced higher levels of distress prestation d’une formation et d’un counseling adéquats. Il est impossible de prédire la gravité d’une pandémie, mais les efforts recommandés ne seront pas vains, car ils favoriseront aussi la during SARS, presumably due to the per- santé des patients et du personnel en temps normal. ceived risk of infecting loved ones and concerns about caring for children if the Mots clés : personnel médical et paramédical; maladies transmissibles; stress psychologique; parent is ill. culture organisationnelle; planification antisinistre Two years after the outbreak’s resolu- 1. Department of Psychiatry, Mount Sinai Hospital, Faculty of Medicine, University of Toronto, tion, healthcare workers in hospitals that Toronto, ON treated SARS patients had significantly 2. Department of Social Work, Mount Sinai Hospital 3. Department of Occupational Health & Safety, Mount Sinai Hospital elevated rates of signs of chronic stress 4. Director of Chaplaincy Services, Mount Sinai Hospital compared to workers in other similar hos- Correspondence and reprint requests: Dr. R.G. Maunder, Department of Psychiatry, Mount Sinai pitals. These included professional Hospital, 600 University Ave., Room 915, Toronto, ON M5G 1X5, Tel: 416-586-4800, ext. 3200, Fax: 416-586-8654, E-mail: rmaunder@mtsinai.on.ca burnout (30 vs. 19%), depressive and anx- Acknowledgement: The authors thank Dr. Allison McGeer for her contributions regarding infection iety symptoms (45 vs. 30%), increased control protocols. 486 REVUE CANADIENNE DE SANTÉ PUBLIQUE VOLUME 99, NO. 6 PANDEMIC STRESS IN HEALTHCARE WORKERS smoking, drinking or problem behaviour Fostering individual resilience tribute to individual resilience, however, (21 vs. 8%) and missing 4 or more work Resilience is the ability to reduce the effect by buffering workplace stressors during shifts over 4 months due to stress or illness of a distressing event by anticipation and and after a crisis. It is a key task of pre- (22 vs. 13%). Importantly, healthcare preparation or to “bounce back” once it pandemic preparation. workers in affected hospitals were more has occurred. Two evidence-based Organizational resilience depends on likely to have decreased face-to-face con- approaches to individual resilience are par- establishing reserves prior to crises. tact with patients (17 vs. 8%) and ticularly apt for pandemic preparation. Pandemic plans note the need for material 3,21,22 decreased work hours (9 vs. 2%) following Folkman and Greer’s framework for main- reserves (e.g., stockpiles of supplies). SARS. However, rates of depression, post- taining psychological well-being during Additionally, business models of resilience traumatic stress disorder or other mental serious illness describes a sequence of emphasize the value of back-up plans and illness were not elevated. Thus, long-term appraisal and coping processes that are succession plans, a culture of flexibility and 23,24 effects of SARS were common but were designed to recover positive emotions and the central role of effective leadership. predominantly in the range of subsyndro- effective adaptation. They describe a Evidence from the SARS outbreak rein- mal stress response syndromes. This should sequential approach to coping that is forces the importance of effective train- shift thinking about reducing pandemic- experience-near for many healthcare work- ing. This may include training in skills related stress away from models of clinical ers: problem solving for events that are that will be required when adaptation to intervention for mental health problems appraised to be within one’s control, the pandemic requires staff to work outside and towards models of adaptation and emotion-based coping to enhance support of their usual area of familiarity, and may resilience in psychologically healthy people. and reduce isolation, and meaning-based also include training in psychological first Mediators of long-term SARS stress coping for events that are unresolved and aid and coping. In SARS, psychosocial could become targets for interventions. cause persistent distress after problem- support was far more effective when pro- Chronic stress was lower in workers with focused efforts. This framework facilitates vided in the context of trusted pre-existing longer healthcare experience and in those flexibility, acknowledging that distress and relationships. We advocate building rela- who felt effectively trained and supported coping are highly individual and depend tional reserves prior to the pandemic, by by their hospital. Greater chronic stress on experience, values and expectations. It which we refer to supportive, collaborative, was reported by workers who coped using also facilitates discussion of the strengths interdisciplinary relationships which can strategies of avoidance and self-blame. and weaknesses of various approaches to provide the basis for formal and informal coping, and the evidence that coping support during a crisis. Healthcare organi- Key differences between SARS and through escape-avoidance and self-blame zations may also benefit from the recovery- pandemic influenza are maladaptive in healthcare workers enhancing power that flows from a shared 14 24 The stress of pandemic influenza will differ responding to infectious disease. sense of moral purpose, such as a shared from SARS because of the inability to con- The second approach that we advocate is dedication to caring for the sick. tain pandemic influenza through infection psychological first aid, an evidence-based Two evidence-supported constructs are control procedures, the potential difference approach to facilitating resilience immedi- particularly applicable to building a culture in scale and severity, and the opportunity ately after trauma. Healthcare workers can of organizational resilience. First, magnet to prepare for a pandemic. SARS was a learn psychological first aid without any hospitals, originally identified by their abil- nosocomial infection with minimal com- prior mental health education. ity to recruit and retain nursing staff more munity transmission and minimal infec- Furthermore, learning to support others effectively than neighbouring hospitals, are tious transmission prior to the onset of may also enhance the resilience of the characterized by decentralized decision- symptoms. Infection control procedures provider. As with Folkman and Greer’s making by caregivers, a nurse among the were key aspects of containing the out- model, psychological first aid does not hospital executive, flexible scheduling, break. Influenza, on the other hand, is pathologize people who are stressed by investment in continuing education and readily transmitted before the onset of clin- extraordinary events. Rather, it assumes unit-level self-government. Magnet hos- ical illness and is prone to mutations that that those who are stressed are competent pitals tend to have lower patient favour the virus’s survival. Thus, pandemic and are able to determine whether or not mortality, and also have lower rates of influenza will be a community-acquired they wish or need assistance. It teaches a burnout among staff. The characteristics disease. This difference may reduce some respectful approach to reducing distress of magnet hospitals echo the findings that of the isolation that was experienced by through enhancing safety and comfort, health is negatively affected by high healthcare workers in SARS due to quaran- helping survivors of trauma to identify demand/low control occupations and 28,29 tine, reduced social contact within the hos- their needs, providing information and effort-reward imbalance. While SARS pital and stigma. In a severe pandemic, facilitating social connection. experience teaches that decentralized decision- however, the benefit of reduced isolation making may need to give way to hierarchi- will be outweighed by the burden of the Fostering organizational resilience cal structures during a crisis, we expect scale of disease. Thus, it is important to The resilience of healthcare organizations that the resilience associated with the cul- fully exploit our opportunity to plan effec- is influenced by factors beyond the ture of magnet hospitals will aid staff in tively and implement resilience-enhancing resilience of people within the organiza- their recovery from the strain of such measures before the pandemic occurs. tion. Organizational resilience may con- adjustments after the pandemic has passed. NOVEMBER – DECEMBER 2008 CANADIAN JOURNAL OF PUBLIC HEALTH 487 PANDEMIC STRESS IN HEALTHCARE WORKERS 15. 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Journal

Canadian Journal of Public Health = Revue Canadienne de Santé PubliquePubmed Central

Published: Nov 1, 2008

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