Healing the healers - vital to saving healthcare systems

Poor well-being, burnout, depression, anxiety, compassion fatigue, and, in some instances, inhumane working conditions and hours have become words that have become increasingly familiar when healthcare professionals (HCPs) are mentioned in conversations. It has resulted in doctors and nurses leaving the profession they once considered a calling. It is impacting the quality of care they deliver, decreasing empathy towards their patients, and causing a myriad of other problems that are having a direct knock-on effect on already overburdened health systems worldwide, leading to growing calls on governments and health institutions to prioritise the mental and physical health of HCPs.

Healthcare workers (HCWs) in Africa are worst affected – a growing disease burden and patient population, a shrinking health workforce, a shortage of life-saving equipment and medicines, and limited access to mental health support are taking a heavy toll on their mental and physical well-being.

It was the letter¹ written by Dr Tim de Maayer, paediatric gastroenterologist at the Rahima Moosa Mother and Child Hospital in Johannesburg last year that really brought home the unbearable everyday struggles of healthcare workers at South Africa’s public healthcare facilities. The letter was pleading for help from government to address the desperate conditions in a hospital that is supposed to save the lives of mothers and children. But it was not just highlighting the plight of the patients. It was also a cry for help for their carers who are risking their mental and physical well-being in trying to do what they are supposed to do in a system that is preventing them to do so.

It was the sentence: “If your healthcare workers are the centre of providing care, we cannot hold,” in the letter that so succinctly conveyed the position doctors and nurses are increasingly finding themselves in.

Already at breaking point – then came Covid

The burden of caring for patients and saving lives in a system that is so broken that even the most basic of resources are not available or have to be fought for has been draining healthcare professionals for years. They were already running on empty when Covid struck and still, there is no end in sight… loadshedding, a debilitating strike that prevented them from getting to severely ill patients, broken - or non-existent equipment, overflowing hospital wards and the list goes on and on.

An interview with Dr Alicia Porter, psychiatrist and board member of the South African Society of Psychiatrists (SASOP) confirms that the country’s healthcare professionals are in trouble.

“The situation is dire. Prior to Covid, HCPs were already in a bad space from a mental point of view. They were suffering from burnout, anxiety, depression, post-traumatic stress and in some cases, substance addiction. Covid just exacerbated these conditions, also adding moral injury as decisions had to be made that challenged their moral beliefs and that of the profession,” Dr Porter explains.

Recognising and anticipating the compounding impact of the pandemic on an already overstressed and burnt-out health workforce, psychiatrists like Dr Porter and Dr Antoinette Miric supported by several healthcare professional bodies such as SAMA, the South African Society of Anaesthesiologists (SASA) and the South African Depression and Anxiety Group (SADAG) established the Healthcare Workers Care Network (HWCN)*. Providing mental health support, the network comprises a 24-hour helpline offering free online counselling and individual - and group support, as well as training to leaders of teams to assist in identifying and supporting struggling HCWs.

HCWs reluctant to seek help

While the HWCN reached an estimated 5 000 healthcare workers from April 2020, the actions of individuals seeking help and surveys conducted by the network showed that in a way HCWs are their own worst enemies when it comes to asking for help. Stigma associated with HCWs seeking help for mental health issues, fear of being judged by colleagues and management, and a perception that not coping was a weakness, prevented many from accessing the services. Also, many of those who did manage to make that call to the helpline just ‘disappeared’ afterwards, not taking the calls for follow-up counselling.

“Obviously, they were reaching out at a time they were feeling vulnerable, but then when you actually got them to help, it was another story and resistance and reluctance came in,” Dr Porter says.

A survey aimed at finding the reasons for this aversion to seeking help showed that more than 80% of those surveyed feared that they will be judged by their colleagues, managers, and the profession. More difficult to deal with is self-stigma - HCWs believing that they should be able to cope, and that failure to do so render them incompetent or weak and unfit to do their job because of expectations that they should be resilient and better equipped to deal with their stressors than the general public.

Respondents revealed a need to “be seen as human beings behind the lab coat or uniform”, with one saying that “there needs to be an understanding that despite our profession we are still human beings and need just as much, if not more, support, as we take on so much – we hold everyone but ourselves”.

“We need to highlight the humanity of the person in the lab coat or nursing uniform. We are humans first, with emotions and challenges as much as everyone else. Our qualifications and skills do not shield us from psychiatric illness; hence we are not immune and should not be viewed as ‘less than’ when we have challenges,” said another.

Can HCWs heal themselves?

There are many self-help guides and other resources available for HCWs on self-care and managing their stress, but in a world where the need is overwhelming, the hours are long and the expectations are huge, the time to really study them and follow the advice is limited.

So where should people start when the car has run out of petrol and there is just no motivation left to carry on with the journey? Should they just suffer in silence or throw in the towel, admitting that they are not up for the job and walk away?

No, says Dr Porter, the first step is to learn to normalise the experience – acknowledging that “it is okay not to be okay” and recognising when stress levels are increasing. If this is not done, it can lead to maladaptive behaviours and eventual burnout, depression and anxiety that can take years to recover from.

Preventing it requires everyday awareness of the stressors’ impact on emotional and physical well-being and trying to mitigate it by starting with small adjustments. Just allowing yourself a few moments to step away from your busyness, sitting down to have something to eat or drink and becoming mindful of what your body is telling you can make a difference, says Dr Porter.

The obligation of having to put patients first is ingrained in doctors from the first day they enter medical school with many regarding self-care as being selfish or fearing that they will be judged for attending to their own needs. However, without self-care, coping with the demands of the profession can become a burden too hard to bear. Striving for a better balance between work and life outside the working environment is therefore imperative to protect their health and well-being. As Nietzsche said, “Physician, heal thyself: Then wilt thou also heal thy patient.”

Changing the culture

But it is not just up to individuals to make changes aimed at promoting their well-being. The culture of the health system also needs to change. Governments, managers and other health leaders should understand how the mental and physical health of HCWs is impacted by the circumstances of their work and that offering help in a safe, destigmatised environment is vital to improve the well-being of their workforce and the patients they are serving. They must ensure that discussions about mental health in the workplace and solutions to address it are taking place with the input of those affected.

A research article published in the journal Frontiers for Public Health² in May 2021 emphasised that HCWs should be respected for the vital work they are doing to keep populations healthy, “meaning that there is a duty to find ways to meet their psychological needs and improve their welfare.

“World leaders and other decision-makers need to fully realise the crucial importance and value of investing in the mental health and well-being of the healthcare workforce, on individual, organisational, and societal levels. As well as the personal, economic, and societal benefits of doing so. Let us learn from our past and thank our essential healthcare workers by demanding and promoting real reforms within our healthcare systems. We cannot afford the cost of failing in this aim,” the article concluded.

*The HWCN’s 24-hour helpline is available on 0800 21 21 21 or SMS 43001. For more information on the HWCN go to: https://www.healthcareworkerscarenetwork.org.za/

References:

1. https://www.dailymaverick.co.za/article/2022-05-22-a-wake-up-call-for-health-department-heads-children-are-dying-because-of-horrendous-state-of-our-public-hospitals/
2. Lene E. Søvold, John A. Naslund, Antonis A. Kousoulis,Shekhar Saxena, M. Walid Qoronfleh, Christoffel Grobler. Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority. Front Public Health. 2021; 9: 679397. Published online 2021 May 7.