On The Cover
Liz Haberkorn, Zubin Austin, Cynthia Knapp Dlugosz, and Suzanne Harris
What the world needs now is strength.
And that’s exactly what health professionals have been providing during the global health crisis. But reports of those on the front lines taking their own lives, and confrontations with patients, mostly verbal but some that have turned physical, are undeniably on the rise.
What long-term effects will the pandemic have on health care workers, and when will those effects begin to show? What can health workers do today to take care of their mental health and well-being tomorrow?
A new way of life
Long shifts at work. Social distancing. Isolation. On television, the internet, and the radio: bad news, with no end in sight. Body counts. Panic. Fear.
For those on the front lines, COVID-19 is more than just news, it’s a new way of life. Daily routines and rituals are gone. There is no work–life balance anymore. It’s enough to make even the most mentally fit health professional feel disheartened and downtrodden.
You need to know you are not alone in your feelings.
“The whole world right now is sharing the experience of losing that sense of guarantee,” said Cynthia Knapp Dlugosz, BSPharm, NBC-HWC, in a phone interview with Pharmacy Today. Knapp Dlugosz is a long-time practitioner and supporter of mindfulness (see sidebar on page 23). “Most of us have lost something, whether it was something simple like an anticipated trip or event or the devastating loss of someone we love. It is easy to be consumed by wishing things were different or catastrophizing about what is yet to come.”
And, although many health professionals receive training in school on how to deal with grief and death, chaotic situations, or uncooperative patients, the COVID-19 pandemic is far from your average “busy day at the office” scenario.
Preparing for PTSD
The criteria for developing posttraumatic stress disorder, or PTSD, includes witnessing death. How can anyone be expected to be prepared for the emotional responsibility that comes with witnessing death on unprecedented levels? “Health care providers are accustomed to death, but not to this capacity,” said Dianna Dresser-Heckman, LCSW, CST, CSCT, a behavioral health expert. “One of the more traumatic aspects of the COVID-19 pandemic is that patients don’t have their families or companions with them, and you are potentially one of the last people they will see.”
The pressure of constant death, constant triaging, or constant decision making is enough to wear down even the most seasoned professional. Wondering over and over, “Am I doing the best I can to care for my patients at this critical time?” has become another haunting constant in the life of the frontline health care worker.
According to Dresser-Heckman, debriefing for 15 minutes after each shift can help a person process what they’ve just been through. Discuss the challengesof that shift with someone, and what you are currently feeling. Part of being resilient means keeping yourself from internalizing any negative thoughts or feelings.
A time for crisis counseling
If you find yourself in emotional distress, and talking to a friend or colleague is not enough, the Suicide Prevention hotline at 800-273-TALK (8255) will connect you with a trained crisis worker. It can also be as simple as sending a text. Text HOME to 741741, the crisis text hotline.
“The sooner you process trauma, the less likely it is to stick with you,” Dresser-Heckman said. It’s a big part of building your resiliency: recognizing you need help and asking for it.
COPING MECHANISM
Plan for the worst, hope for the best
First, be patient, with yourself and those around you. These are challenging times, and everyone is on a steep learning curve.
Second, manage your expectations. That goes for all of us. Things can’t be the way they were a few weeks ago.
Third, plan ahead even though planning ahead isn’t really possible. There’s an old saying: “Plan for the worst, hope for the best.” It applies now more than ever. Even though things appear chaotic and disorganized, we still have to find ways to think ahead and plan. The key is not to abandon the idea of planning but instead find a way to always think about Plan A, Plan B, Plan C, and Plan D for everything and hope that some of these contingencies work out!
Fourth, figure out what you can control—and do your best to control that. So much is out of our hands right now, and it is easy to feel like we are completely adrift. The good news is that we’re not. There are things we can still manage and control on our own, even if it is something like making your bed every day or mowing your lawn. The feeling of satisfaction that comes with completing a job and controlling the outcome can help you manage the anxiety of today.
Fifth, don’t forget the small but vitally important things that keep us healthy. Sleep well, eat properly, try to get exercise, get dressed (especially on Zoom meetings even if you think no one can see you!).
Sixth, make a choice to be positive. It’s easy to succumb to negativity right now. Don’t let yourself do that. Accentuate the positive, look for things that make you smile, and avoid things that bring you down. Limit your consumption of news, and manage carefully the negative relationships in your life that can drag you down. Part of being positive also means respecting public health guidance and accepting scientific expertise—however imperfect—and not succumbing to charlatans or others who might say what you want to hear but don’t have an evidence base to stand upon.
Seventh, smile. This will end.
Blame the stigma
As health professionals, pharmacists no doubt feel the pressure of being the epitome of health, not just for their patients but for their peers, as well. But what everyone needs to remember is that no one is immune to this amount of pressure. No one should expect you to be, either.
People are hesitant to ask for support or seek help because of the stigma attached to fear, anxiety, and depression. When faced with emotions like these, it’s easy to become paralyzed with confusion, shame, or a combination. It doesn’t help that some people view admitting these emotions as a weakness.
One way to transform your perspective is to view the current crisis as a challenge, not as a threat.
“We have an opportunity to find purpose amidst these times of uncertainty. We each individually can choose how we want to approach and react in this situation and find a lesson in all of it,” said Suzanne Harris, PharmD, in an e-mail to Today. Harris is a clinical assistant professor and incoming director of well-being and resilience at the University of North Carolina (UNC) Eshelman School of Pharmacy. She also serves as a clinical pharmacist practitioner, specializing in psychiatry, at the UNC Medical Center.
“When we emerge on the other side, we can reflect on how we set an example for our coworkers, our students, our patients, and our children. How did we grow individually and collectively? We can learn from this challenge and hopefully be better prepared to respond when the next crisis occurs.”
As the most accessible health professional, pharmacists are in the best position to lead the rest of the health care industry in the fight to remove the stigma associated with mental health issues. “We can serve as role models, share our own stories, and help normalize [the belief] that our profession is not immune to mental health concerns,” said Harris.
Teaching well-being
In an industry that demands perfectionism, student pharmacists need to hear that it’s okay to ask for help as they manage stress. “It could be really helpful if pharmacy professors and pharmacy leaders set an example by being forthcoming about their own challenges,” Knapp Dlugosz said.
Within an already jam-packed curriculum, is there room for the addition of courses that teach well-being and how to productively process stress-inducing situations so trauma can be avoided?
Harris thinks so. “We have an opportunity to improve the training for pharmacists and student pharmacists on addressing mental health issues.
“To be successful, leaders of our profession and within our institutions can support a culture that promotes help-seeking behaviors and openly talks about mental health. Let’s strive to increase awareness and mental health knowledge for students, pharmacists, faculty, staff, and administrators,” she said.
It may be a challenge to find time to care for yourself, but health care work can be a challenge, too. And just as in health care work, investing the time makes a difference.
COPING MECHANISM
It won’t always be this way
I was introduced to mindfulness practices by a therapist as a way to help manage generalized anxiety disorder. One of the definitions of mindfulness that I’ve found to be most helpful comes from meditation teacher James Baraz. He describes it as “being aware of what is happening right now without wishing it were different; enjoying the pleasant without holding on when it changes (which it will); being with the unpleasant without fearing it will always be this way (which it won’t).”
In their Mindful Self-Compassion program, Kristin Neff and Chris Germer teach the concept of “common humanity.” When we are frustrated that things aren’t exactly as we want them to be, we have “an irrational but pervasive sense of isolation,” as if we were the only person suffering. Self-compassion involves recognizing that suffering is part of the shared human experience—something we all go through. It seems easier now than ever to understand this concept.
One thing we can do is focus on offering compassion to ourselves and others. For ourselves, we can practice the “self-compassion break.” Whenever you notice stress, fear, or other difficult states arising, stop and say to yourself, “This is a moment of suffering.” (You also can be more specific to your experience by saying something like “This is fear” or “This hurts.”) Then acknowledge common humanity by saying “Suffering is a part of life,” or “Many other people feel this way,” or “I’m not alone.” Finally, put your hand over your heart in a gesture of gentle touch and say, “May I be kind to myself,” or “May I be strong,” or “May I give myself the compassion I need.”
We can extend compassion to others by offering similar phrases. Keep in mind that many people are experiencing fear right now; if you are on the front lines of the pandemic, people may be directing their fear at you by acting out in unpleasant ways. You can combat that fear by silently offering the phrases that a person seems to need most—“May you be safe” or “May you be free from fear.”
Another thing we can do is engage in practices that help to mitigate anxiety. Psychologists increasingly are recognizing that anxiety has both a physical component and a mental component, and it’s important to address both. Breathing exercises and a mindfulness meditation known as progressive muscle relaxation can help to relax the body; you can find guided practices online and in apps such as Headspace and Calm.
To calm the mind when you’re consumed by anxious thoughts, try the “3 x 3 practice.” Drop in to three of your senses and name three things you notice—for example, three things you can see, three things you can touch, and three things you can hear. This helps to bring your attention out of your head and into the present moment.
Measure your emotions with the Well-being Index tool
April Shaughnessy, BSPharm, CAE, project manager for APhA’s well-being initiative, believes pharmacists must take care of themselves so they are able to offer the best care to their patients.
That’s where the Well-being Index, or WBI, comes in. The Pharmacists Well-being Index is a research-validated online screening tool invented by Mayo Clinic. In nine questions, it measures the six dimensions of distress and well-being: likelihood of burnout, severe fatigue, quality of life, meaning in work, satisfaction with work–life balance, and likelihood of medication error.
“The goal of the tool is to help the assessor (pharmacists, student pharmacists, pharmacy technicians) understand which of the six dimensions are affecting their well-being and contributing to their overall risk of distress. The assessors will also learn how their distress level compares to that of their peers,” Shaughnessy said.
The Pharmacists Well-being Index is available at https://app.mywellbeingindex.org/signup (Invitation Code: APhA). The tool is 100% anonymous, confidential, and free. You do not have to be an APhA member to use the WBI.
COPING MECHANISM
When self-care is not enough
The outbreak of COVID-19 is increasing our stress and anxiety. Finding ways to cope and manage stress will make you stronger. At this time, you may be having feelings of loss, loneliness, or isolation. It is important to be aware and accepting of these emotions. By focusing on what you can control, you can continue to promote self-care and build your internal reserves. Staying connected with loved ones and friends, practicing gratitude, giving oneself grace, taking a 20-minute walk outside, or setting clear boundaries for work versus home life are a few ways to get anchored.
Many companies have been generous in offering free online self-care resources to help you through this difficult time. It’s also important to know when self-care is not enough. Use your crisis response resources (e.g., text support by texting HOME to 741741), and share them with others. The better we can care for ourselves, the more we can give care and support to others.
What can pharmacy expect post-pandemic?
Not too long ago, the pharmacy profession had a lot weighing on its figurative shoulders: provider status, the opioid epidemic and substance use disorders, and the battles against fatigue and job burnout. Within just a few weeks, all that was swept away by the waves of a new pandemic, one that would test—and for some, break—the spirit of the strongest and most committed health professional.
Now, as pharmacists juggle new concerns—dispensing medications under different regulations, providing patient care without adequate personal protective equipment, navigating drug shortages, and expanding into new territories such as home deliveries and telehealth sessions—the future of pharmacy is very much like the present: uncertain.
The pandemic has brought national attention to the pharmacist’s integral role in the health care system. Pharmacists are taking on more responsibilities, such as prescribing authority for common conditions in order to relieve pressure on family doctors and other primary care providers.
“I would imagine pharmacists will be a lot more comfortable interacting with patients virtually—doing consultations, education, monitoring, follow-up by video conferencing, e-mail, etc. I suspect this is the way we will be interacting with other health professionals, too,” said Zubin Austin, professor at the Leslie Dan Faculty of Pharmacy and the Faculty of Medicine at the University of Toronto, Canada, in an e-mail to Today.
“Some services, such as physical assessments or vaccinations, may be deemed too dangerous to do in community pharmacy for a while longer.”
Whatever may happen, remember: You are resilient. You are a pharmacist.