As COVID-19 Recedes, Infection Preventionists Must Still Battle Stress

When we learn about and train for pandemic response, the focus is often on ensuring we have adequate resources, enough health care workers (HCWs) to respond, and various other nonpharmaceutical interventions. One of the things we frankly do not teach, or even talk enough about, is the posttraumatic stress of living and working in a pandemic.

There has been a wealth of information written about the impact on HCWs and how traumatized they have been by the COVID-19 pandemic, and for good reason. These are the people who are caring for patients in the face of a novel infection that has been poorly managed nationally, is challenging us globally, and has been heavily politicized to further isolate us.

A recent JAMA Network Open study found that 21% of surveyed HCWs considered leaving the workforce and 30% considered reducing their hours.¹

Saskia v. Popescu, PHD, MPH, MA, CIC

The authors noted, “In this survey of 5030 faculty, staff, and trainees of a US health system, many participants with caregiving responsibilities, particularly women, faculty, trainees, and (in a subset of cases) those from racial/ethnic groups that are underrepresented in medicine, considered leaving the workforce or reducing hours and were worried about their career development related to the pandemic. It is imperative that medical centers support their employees and trainees during this challenging time.”

Not Good Enough?

The photography and stories from those working on the front lines have been a window into how devastating and painful this pandemic has been and underscore the health care system’s failure to contain it. The pain of this pandemic has been widely felt, but especially among health care professionals. As we battle waves of surges, isolation, and disconnect in our efforts to help as many patients as possible, we have realized we are running a marathon in which the finish line continuously moves farther out of reach. Formerly stable systems seem to be falling apart as the realization sinks in that your best efforts may not be good enough.

The impact of this pandemic will take years to understand. From long-haul COVID-19 to those preventable deaths and the mental health outcomes, we will be feeling this for a while.

It is important to take a moment to discuss the impact on infection preventionists (IPs). Most people do not know about IPs but we are always there. We work to ensure education and training, support our fellow HCWs, review supply chain challenges, try to prevent health care–associated infections (HAIs), ensure adequate personal protective equipment, and perform myriad other duties in our job descriptions. Helping respond to COVID-19 has been up to IPs.

We are the experts in transmission, prevention, and interpreting nuanced (and often changing) guidance while answering questions from frontline HCWs.

We do this even as a novel pathogen upends our society and challenges us with a unique situation in which we are scrambling to train fellow HCWs in a high-stress environment where the guidance will likely evolve. It is a lot, with testing challenges, a choked supply chain, and politicized response thrown in.

Let us not forget that HAIs do not stop in the face of a pandemic and that things like proning a patient with COVID-19 can make central line care more difficult.

I could probably go on for several pages about the stress and burden placed on IPs regarding how COVID-19 affected our roles. In so many ways, we are the recipients of anxiety, anger, sadness, and frustration for those in health care—not intentionally, but as a by-product of the work we do. Preparedness, like public health, is often not valued until it is needed, and it has certainly been needed the last 15 months.

Stressed Out

There has been increasing conversation about posttraumatic stress disorder (PTSD) for health care workers. Most professionals in health care will experience this. The National Institute of Mental Health (NIMH) defines PTSD as a disorder resulting from experiencing a shocking, scary, or dangerous event. NIMH notes that “while most but not all traumatized people experience short-term symptoms, the majority do not develop ongoing (chronic) PTSD. Not everyone with PTSD has been through a dangerous event. Some experiences, like the sudden, unexpected death of a loved one, can also cause PTSD. Symptoms usually begin early, within 3 months of the traumatic incident, but sometimes they begin years afterward. Symptoms must last more than a month and be severe enough to interfere with relationships or work to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic.”²

In a pandemic that has stretched well over 15 months and will likely continue for several more, the fallout for all of us will be significant. Beyond the horrific number of lives lost, and lives changed forever by COVID-19 even for survivors, the pandemic’s traumatic ramifications bleed into our economy, throwing millions of people out of work and—significantly for the health care system—leaving them without insurance coverage. There is a lot of suffering going on that is not immediately noticeable.

Although there has been a lot of focus on HCW PTSD, it should be noted that IPs have experienced this from the beginning. Last July, Ed Yong of the Atlantic wrote about public health specialists experiencing burnout, noting that pandemic experts are not doing well. Yong wrote that “the same experts who warned of the coronavirus’s resurgence are now staring, with the same prophetic worry, at a health care system that is straining just as hurricane season begins. And they’re demoralized about repeatedly shouting evidence-based advice into a political void.”³

IPs fall into the middle of the Venn diagram that is health care and public health. We are uniquely poised to protect patients and HCWs while ensuring there is a strong bond and link between public health and health care. During the Toronto SARS-CoV-1 outbreak in 2002-2003, there were reports that IPs formed their own phone trees and groups to ensure information was shared across hospitals and to fill gaps that existed.⁴ Despite finding ourselves in this middle area of the Venn diagram, very little attention is paid to IPs.

Underappreciated

My research has primarily focused on this, and one thing I find myself continuously saying is that we are often seen as a cost center and not a revenue generator. That attitude hinders us as IPs take on COVID-19. We are expected to ensure hospitals can respond to novel pathogens and yet still maintain our daily duties. Too soon after undergoing the stress of dealing with the Ebola virus disease in 2014, we find ourselves once again in the situation of managing preparedness, response, and anxiety. With COVID-19, though, this is not an isolated case. It is felt in nearly every facet of our lives.

When people were frustrated by working from home and feeling isolated, many of us felt the opposite—wanting a quiet moment at home away from the stress of hospitals and having to deal with surges and wave after wave of patients with COVID-19. Being at this intersection means we fail to realize how much COVID-19 affects us. Missing from our discussions: the oddness of de-escalation. That quiet between storms, when the adrenaline and craziness of responding to surges eases a bit and IPs are expected to just switch back to normal. That has been one of the most challenging things for me.

We ramp up and work to ensure things are functional in order to keep HCWs and patients safe, but then come those moments when cases decrease and patient numbers drop…and there is a desperate need to go back to normal. “Normal” is what got us here, and there is a fundamental need for us in both infection prevention and health care—but also nationally—to establish a sustainable approach to COVID-19 and novel pathogens. During this time, as hospital case counts drop, IPs are expected to just switch back to normal while still ensuring a readiness to respond to COVID-19. This, quite frankly, has been the hardest part for many IPs.

The Association for Professionals in Infection Control and Epidemiology has been focusing on this more, emphasizing that our work and roles within communities often wipe out our reserves. The attention to ancillary people in health care, like IPs, is so critical. Fundamentally, we are a team in hospital response. There has been a concerted effort to provide well-being services and ways to recharge. As I write this, though, I think about my own process in doing so.

Truth be told, in health care we are often trained to just keep going and get the job done. It is important though, that now we focus on our well-being. The Centers for Disease Control and Prevention has reiterated this with resources for coping with stress.

Resources

More and more, it is important that we take the time to do this. Difficulty sleeping or changes in energy are normal byproducts of stress and not always easy to deal with. There are several resources, such as mental health specialists, online guides, and confidential crisis resources, available to help guide people through these challenging times. Utilizing the resources available can help. They are free and reiterate many things that, frankly, we all need to start doing, like taking deep breaths and a moment to stretch, making time to unwind, and ensuring we are exercising and eating healthy (doing our infection prevention rounds does not count).

Moreover, these tips routinely emphasize the importance of connecting with others and taking time to unwind. Some strategies I have really latched onto as a way to cope (and these are by no means perfect) include taking a walk outside during lunch with a colleague to discuss how we are feeling about it all, virtual coffee happy hours with friends, unplugging from TV and social media for the weekend, and, frankly, talking to other IPs.

More and more, we need to care of ourselves during all of this. Seeking help for mental well-being and PTSD is vital and something we all need to invest in. It might be odd to prioritize yourself during a pandemic, but this is the exact time to do so.

COVID-19 is not the only infectious disease we face, and as they tell you when you are flying on a plane, you have to put your oxygen mask on first before caring for others. I am eternally grateful for the infection prevention community during this pandemic, and now is the time we need to prioritize our health and well-being because PTSD is truly more prevalent than we realize. Care for yourself with the dedication you put into protecting patients and other health care workers.

SASKIA v. POPESCU, PHD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University in Fairfax, Virginia, where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in pediatric and adult acute care facilities.

References:

1. Delaney RK, Locke A, Pershing ML, et al. Experiences of a health system’s faculty, staff, and trainees’ career development, work culture, and childcare needs during the COVID-19 pandemic. JAMA Netw Open. 2021;4(4):e213997. doi:10.1001/jamanetworkopen.2021.3997
2. Post-traumatic stress disorder. National Institute of Mental Health. Updated May 2019. Accessed April 7, 2021. https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
3. Yong E. The pandemic experts are not okay. The Atlantic. July 7, 2020. Accessed April 3, 2021. https://www.theatlantic.com/health/archive/2020/07/pandemic-experts-are-not-okay/613879/
4. ARCHIVED: Learning from SARS: renewal of public health in Canada – report of the National Advisory Committee on SARS and Public Health. Public Health Agency of Canada. Updated November 8, 2004. Accessed April 12, 2021. https://www.canada.ca/en/public-health/services/reports-publications/learning-sars-renewal-public-health-canada.html