Kimberly Marselas

As the saying goes, it’s often darkest just before dawn.

But as the sun rises on a new era of COVID-19 — one in which cases and deaths are down and nursing homes seem on the precipice of some return to normalcy — another crisis may very well emerge from the shadows.

Caring for beloved patients and losing colleagues during the pandemic has been nothing short of traumatic for many in healthcare. Somehow, devoted professionals have stayed on their feet and on the frontlines — maybe out of sheer will or because they developed impressive coping skills or had invaluable support from colleagues and loved ones.

But mental health professionals warn that easing out of crisis mode will likely allow the delayed and incredibly varied effects of all that trauma to surface. 

“On one hand, we’re going to experience a lessening of psychiatric burden,” Bill Mansbach, Ph.D., CEO and president of CounterPoint Health Services told LeadingAge members last week. “But I’m afraid that, as things get better, I think the workforce will fully experience the weight of what the last 10 months have been like.”

It’s now that staff may become overwhelmed by the weight of what they’ve carried: patient lives lost, a national mainstream media that villainized nursing homes and their workers, fears about their own health. That weight may combine with anxiety related to a different kind of wait: waiting for tests, for supplies, for a vaccine, for COVID-19 to end.

It’s a likelihood skilled nursing providers need to be ready to address. They also need to recognize that trauma isn’t the same experience for any two survivors.

“We knew COVID would align with sort of a PTSD model,” said Mansbach, noting different symptoms tend to emerge over time. In surveys by CounterPoint and its sister company, BCAT, in May and November, nearly 50% of respondents in skilled nursing, assisted living or independent living communities reported they experienced psychological burden, such as anxiety, that was significant enough to interfere with everyday function. That’s compared to about 20% pre-pandemic.

Beware the 4-headed monster

Anxiety is just the tip of this iceberg. Mansbach’s studies reveal what he calls a “four-headed monster” of symptomatology, with many caregivers also reporting depression; physical symptoms such as headaches, backaches and gastrointestinal upset; and increasingly, cognitive concerns.

In another study from the University of Utah, researchers found more than half of medical workers and emergency responders involved in COVID-19 care — akin to domestic combat — could be at risk for mental health problems, most notably alcohol use, insomnia and depression.

“In the heat of combat, as a metaphor, we have to ignore things to do our job well,” corresponding author Andrew J. Smith, Ph.D., told McKnight’s. “We adapt to that biology and what it brings. When that is no longer required, there are all kinds of manifestations of stress. … Those things, if not recalibrated during this come-down period, could become more chronic, persistent problems.”

Symptoms could promote irritability, affect marital quality, and lead to alcohol use, sleep disruptions and broken friendships.

Without intervention of some kind, Mansbach pointed out, these experiences can lead to clinical diagnoses and threaten the health of healthcare organizations themselves.

Direct care workers who felt undervalued or inadequately supported reported more COVID-19-related stress and may be more likely to resign, according to a research brief issued last month by the LeadingAge LTSS Center.

Invest in care for their strength, and yours

In addition to continuing wrap-around services that help with daily needs such as groceries and laundry, the report encouraged providers to offer access to individual counseling, support groups, mental health resources from community partners, “de-stress rooms” featuring quiet music, and activities that cultivate a spirit of fun and camaraderie.

Mansbach suggests exercises for working memory, which have been tied to mood improvement. His company’s version was already in use by rehab patients at some large LTC chains. During COVID-19, they’ve increasingly been snapping up copies of workbooks intended to help frontline staff.

Earlier this year, CounterPoint created five, one-minute exercises on behalf of FutureCare LTC. The Maryland chain wanted basic-but-proven stress-relief strategies to send its workers. CounterPoint will use data from a third study of about 1,200 senior care workers to inform more interventions. 

Moving forward, Smith says healthcare leaders must acknowledge it’s challenging for any of us to feel “normal” again. Some coping strategies might include providing time and pay for employees to exercise, providing sleep hygiene education and helping employees reduce alcohol use.

Supporting workplace social gatherings, even by teleconference, also can help provide needed social connection. These could be 10 minute one-on-ones or 30-minute group coffee klatsches.

Smith encourages those who hold the purse strings to view mental health interventions as a “nuts and bolts economical and logical” argument for investment. They can reduce risk of burnout and, potentially, the need for costly rehiring.

Likewise, the LTSS Center report called for sustained attention on staffing levels and new policies that bolster individual workers, whether supplementing staff with temporary aides to “support the work of experienced CNAs” or creating flexible schedules.

The goal of these interventions should be to help alleviate the burdens of the last year and give employees the tools they need to provide care — and feel better doing it — in trying times yet to come. If that happens to make your organization more resilient, well, all the better.

Kimberly Marselas in senior editor of McKnight’s Long-Term Care News.