Prior to the local onset of COVID-19 in Connecticut, the majority of frontline providers in this study identified caring for critically ill children (89.7%), mass casualty events (84.6%), and death of a patient (69.2%) as critical incidents that would render usual coping mechanisms ineffective. These findings are consistent with a descriptive, cross-sectional study conducted in 13 pediatric emergency departments across Australia and New Zealand, which found 81% of senior nurses and physicians believed death of a patient was a critical incident warranting debriefing.(27) At baseline, critical incidents were predominantly reported at a frequency of only once per week by 81.6% of providers. Perceptions of what clinical events are critical incidents may also be impacted in the post-COVID-19 landscape. Specifically, “caring for a patient with a condition that you or a loved one has,” which had the lowest respondent selection (30.8%), may increase in prevalence due to rising fears amongst healthcare providers regarding contracting or transmitting COVID-19 to family members. The duration and sheer volume of increased critical incidents during the pandemic, compounded by the uncertainty in clinical decision making and isolation, may further contribute to the ineffectiveness of usual coping methods.(43–45)
The majority of participants indicated a desire to discuss a critical incident with their team in the past 12 months, demonstrating a receptiveness to in situ stress interventions like post-event discussions or debriefings. There was a statistically significant difference between the proportion of providers who wanted to discuss a critical incident across years of practice; with the 3–10 years of practice group reporting the lowest proportion (56.3%), compared to 100% of providers with < 3 and 11–20 years of practice or 91.7% of providers with 20 + years of practice. There was no difference in openness to post-event discussion across clinical roles, further indicating potential for high uptake by interprofessional teams. Previous studies conducted in pediatric emergency department nurse populations have reported similar preferences for peer based support following critical incidents.(22) Given the use of travel nurses and outside medical providers to supplement care teams in overwhelmed hospitals, easily self-implemented, low-resource debriefings may provide foundation for building peer support amongst less familiar teams.
Roughly half of all medical workers surveyed experienced borderline or abnormal anxiety (45.7%), moderate burnout (55.9%), or moderate to high secondary traumatic stress (55.8%). This level of burnout is consistent with previously reported levels of physician burnout. A call to action by the Massachusetts Medical Society in 2019 already considered the state of physician well-being a public health crisis.(9) Considering the likelihood of increased negative mental health impacts from COVID-19, this data may indicate a particularly vulnerable position for providers. Acute and potentially enduring moral injury sustained from the initial shortage of appropriate proper protective equipment (PPE), lack of evidence based data guiding informed decision making, crisis standards of care, and the trauma of witnessing large numbers of individuals experiencing serious illness and death in the absence of family all contribute to high levels of stress among frontline healthcare providers during and after the pandemic.(28, 30, 46, 47) The protracted mass casualty experience of COVID-19 is compounded by the necessary social isolation and lack of appropriate human interactions that would help to mitigate the associated stress. Healthcare workers facing disillusionment as a result of this pandemic would benefit from wider accessibility to various forms of stress interventions.(48) Researchers will likely find significant impairments in anxiety, burnout, and secondary traumatic stress as the lingering effects of COVID-19 effect frontline workers.
To our knowledge, this study is the first to report baseline well-being, opinions of critical incidents, and openness to debriefing amongst emergency department clinical staff immediately prior to the local onset of COVID-19. Several limitations of the study should be noted. The small sample size collected at a single site reduces the power to detect group differences and the ability to generalize from the findings. Additionally, nonresponse bias may have influenced our findings. Providers who completed surveys may have had stronger feelings regarding mental health support compared to providers who declined, resulting in an unrepresentative sample. Baseline well-being may diff for emergency departments with institutionalized peer support programs.
At present, a longitudinal study aims to capture weekly impacts from critical incidents within this same population in order to assess how evolving COVID-19 cases manifest as critical incidents and effect provider well-being through time. Future plans include reassessment of HADS, ProQOL, and perceptions of critical incidents and debriefings after COVID-19 cases decrease to directly assess the impact of the pandemic on providers. Hospitals should also aim to collect local data on provider well-being, implement post-event stress debriefings, and assess stress mitigation interventions for efficacy.