Will I Be Hurt by Going to Work Today?
By Siddharth Ashvin Shah, MD, MPH

COVID-19 responders are in a high-threat environment: two strategies to help mitigate their increased, unnecessary risk

Photo credit: Steve Sanchez Photography

Already struggling in a system-wide burnout crisis, COVID-19 responders in healthcare now have reason to worry: Will I be hurt by going to work today? It’s no secret that many healthcare workers are lacking adequate PPE, a critical situation this recent Time magazine article highlights. Those shortages of PPE and ventilators, along with the delays in testing, sporadic mob-like aggressions, and watching so many patients die, jab four fingers into an already tender wound.

Operating in an environment where it must be accepted that something grievous or violent could happen brings unique operational stresses into play. Healthcare workers are now in a high- threat environment akin to personnel working in combat arenas or fearing an imminent terror attack. Personnel who routinely work in high-threat environments face two categories of pre-traumatic operational stress: “Near Misses” and what I call “Threat Cognizance”. Both are subcategories of what many behavioral health professionals call “Pre-Traumatic Stress.” And both apply to healthcare professionals during the COVID-19 crisis.

Working without protective equipment such as N95 masks and gowns is like going into battle without armor. The fear of taking contagion home to families, or seeing those around you fall ill, or simply the sight of colleagues with no choice but to be sub-optimally protected – these all increase the otherwise preventable stress among healthcare professionals. The impact of this cumulative stress was described to me by Dr. Robert Zarr, a Washington DC-based physician I’ve known for 25 years:

“Morale in healthcare was already chronically low, [and] now you add this acute stressor to the mix,” said Dr. Zarr. “Speaking to colleagues is painful because their words reflect so much stress. You know it’s gotten bad when you can detect that a highly trained professional is struggling to hold it together.”

Over the years, I’ve written a good deal about secondary traumatic stress in helping professions, but make no mistake, having to work without adequate PPE is itself primary trauma. Every time a healthcare professional has had to re-use rationed PPE or work with improvised PPE, it will take several days following of being free of COVID-19 to qualify for what people in high-threat environments would classify as a “near miss.” In a combat zone, a near miss is experienced along with the relief of still being alive in a matter of seconds. In our current crisis, workers have to wonder for days whether they will be spared.

While rare, being confronted by even one angry protest sign, or maybe angry fingers pointed in one’s direction, is a stimulus for a worker to have a biological stress reaction of fight-flight-freeze. In hospital safety parlance, these near misses are thus akin to sentinel events, in which something happens that shouldn’t have happened. These workers shouldn’t have to work unprotected.

Although certain healthcare professionals have always faced physical threats in their work environments, COVID-19 has increased the frequency and amplitude of these events. And with mob-like aggressions, anyone perceived to work in healthcare – wearing scrubs or not – has become a potential target of senseless acts of violence. If a healthcare worker sees media footage of a lockdown protester, even if it is in another city far away, the mirror neuron system and empathy centers of that worker can easily add to threat cognizance.

Workers’ near misses and threat cognizance are not no-harm events

I want to focus a little more on threat cognizance because the fear of coronavirus transmission, in an environment in which PPE must be rationed, takes threat cognizance to a whole new level.  This is an occupational threat often mixed with moral injury as healthcare workers realize they have little material support and see a societal failure in the lack of preparation. Disillusionment can run deep because the moral injury is piled on top of burnout in already failing systems. Therefore, threat cognizance is not emotionally neutral. Near misses and threat cognizance, in the parlance of hospital safety, are not no-harm events.

From my experience working with different frontline workers, near misses and “threat cognizance” must be tracked and addressed. And the tracking is purely to hone services and give attention to whom it is needed – not ever to identify an individual as a problem to be solved – otherwise the fear of getting into trouble will sabotage the ethical intent behind tracking.  These operational stresses cannot be dismissed as insignificant. And healthcare leaders are missing the point of occupational health if they are simply hoping that an incident does not occur. The mere absence of critical incidents (such as a death) in a high-threat environment does not equate to protecting a workforce.

Threat cognizance physically affects the body through neuroendocrine responsiveness. A worker whose job involves protective gear is operating with an amygdala, the brain’s threat detection region, on alert. Such preparedness for threat takes its toll as cortisol molecules are dripped into the bloodstream to adapt to perceived threats. This biological effect is just one reason why someone in each healthcare center must track the degree of pre-traumatic stress exposures and openly communicate an organizational response to this problem.

Two key strategies to help mitigate risks for workers

Until every shortfall in PPE is addressed, until the risk of mob-like aggression is back to almost zero, I suggest healthcare leaders:

(1) repeatedly express compassionate “risk communication” to their frontline workers; and
(2) actively foster a non-punitive culture such that workers will not be stigmatized or retaliated against if they are emotionally expressive about their experiences.

Risk communication must bluntly acknowledge what everyone knows privately, and it could look something like:

“Many in healthcare joined the profession knowing there could be threats to us. Manageable threats. But we never expected this level of exposure and feeling unprotected. We want you to know that we are working hard to close the gaps that burden you with threat. While you came into this profession with an understanding that there are risks, the unnecessary risks to your own person that you’ve faced are unacceptable. We have seen too many near misses and failures in the pandemic response, and we will remain open to your concerns as we respond to this and other crises.”

Actively fostering a non-punitive culture is reflected through positive management behaviors of support and acceptance of diverse coping behaviors. When an inconvenient or raw expression of emotion occurs, it helps to remember that everyone is doing their best to cope in a tough situation. Often, the best person to hold such a stance of acceptance is someone who has no other job but to support teams or to support wellbeing in the organization.

Many people have saluted our healthcare heroes. I want to add to that salute. In addition to increasing general awareness for the healthcare workers’ pre-traumatic stress, I wanted to provide healthcare leaders two available strategies to mitigate this burden they are quietly enduring. Let’s close the gaping hole that exposes our healthcare workers to unnecessary and excessive threat.