Caring For The Caregivers

COVID-19 exposed and exacerbated the mental toll of being a healthcare worker especially in low-resource settings in Asia. As we move toward a new normal, governments, hospitals and mental health experts are beginning to support the neglected community of health care workers, but many challenges are yet to be addressed.

Asian Scientist Magazine (Apr. 06, 2023)

By Jill Arul and Denise Gonsalves

One morning, just after sunrise in August 2021, Wong walked back to her rental apartment after working throughout the night. The moment Wong stepped inside her home, she burst into tears.Wong, who prefers to not reveal her last name to protect her identity, took some time to gather herself before preparing a meal and catching some rest. Her next shift at 7pm that evening was staring at her. Wong is a nurse at one of the largest hospitals in Singapore. She, like many healthcare workers, was thrust into caring for an influx of patients at the beginning of the COVID-19 pandemic, which overwhelmed hospitals across the country.

Since then, Wong who is in her twenties, has been working odd shifts and long nights away from her family overseas.

She was due to graduate from her nursing school in Singapore in May 2020. But a month before that, as COVID-19 infections began to rise, her entire cohort was called in to plug the staff shortage that hospitals were facing.

Suddenly thrown into a new high- pressure environment, Wong did her best to stay afloat. Often, the hospital would ask the staff to take on shifts in the COVID-19 wards without any discussion. Within a year she began to feel burnt out and unhappy. It took her two years to finally seek help in 2022.

Wong’s experience is shared by many healthcare workers across Asia and rest of the world. Studies show that healthcare workers tend to face high levels of stress and burnout that intensify in times of crises.

Throughout the COVID-19 pandemic, as communities expressed gratitude for healthcare workers through art, applause and awards, these workers continued to struggle with massive workloads, emotional stress and strained mental health resources. Over time, these struggles came boiling to the surface with protests in the Philippines and Japan, and online activism in Singapore following a nurse’s suicide in 2021.

Such action alerted governments, hospitals and the research community to the crises, which had been brewing even before the pandemic began. Finally, the unique mental health challenge faced by healthcare workers is being addressed.

Social Discrimination

According to one review published in Brain, Behaviour, and Immunity in 2020, at least one in five healthcare professionals in COVID-19 affected countries experienced symptoms of depression and anxiety within the first few months of the pandemic. The rates were higher among female healthcare workers.

On top of heavier workloads, the workers faced social discrimination borne out of fear that they were carriers of the virus. In the Philippines, reports of healthcare workers losing their apartments and being denied access to public transport flooded the news.

“Once people found out we worked in a hospital, they avoided us, even when we weren’t caring for patients directly,” Lyra Advincula, an administrative officer at a small hospital in the Philippines, told Asian Scientist Magazine.

To assess the post-traumatic impact of COVID-19 among allied health professionals at The Medical City, one of the biggest private hospitals in the Philippines, researchers conducted psychometric tests and interviews with healthcare workers who reported back for duty shortly after recovering from COVID-19. The research revealed that the pandemic had instilled heightened feelings of uncertainty, distress, fatigue, and dissociation among the study participants, who also questioned whether remaining in their jobs was still worth it.

According to Mark Carascal, a research specialist who led the study, social discrimination was one of the biggest stressors.

“We didn’t want people to associate us as the harbinger of death in our local communities,” Carascal told Asian Scientist Magazine.

Similarly, a study from Japan published in Public Health Ethics found that stigmatization and the shaming of healthcare workers isolated them from the public.

Such experiences compelled some healthcare workers to take leave or quit their jobs even when their hospitals were facing spikes in COVID-19 infection. According to a report published in Japan Times, in one hospital in Tokyo, over 20 staff members reportedly quit when it became a suspected COVID-19 cluster.

Common Humanity

Generally, workers including those in the healthcare industry tend to find solace in the company of their colleagues after work hours, whether over dinner, drinks or a cup of tea.

“Ranting a bit to my friends in the ward does take off some steam. It helps a little that they know what I’m going through,” shared Wong. “But they can’t relate to everything—they don’t understand how alone I feel being away from my family.”

Turning to colleagues who understand your situation may be particularly important in Asian countries, where this is both a coping mechanism and a form of self-care, explained Professor Yasuhiro Kotera from the University of Nottingham, UK, whose work involves studying the mental health of healthcare workers in Japan.

“Self-care and self-compassion are about showing understanding towards yourself and your inadequacies and knowing that the difficulties you experience are being experienced by others as well,” Kotera told Asian Scientist Magazine. “When you know you’re not the only one, you don’t feel so isolated.”

Researchers refer to this act of reaching out to others who are likely to understand their condition as ‘common humanity.’ Among the different pillars of self-care, including self-kindness and mindfulness, common humanity is most significant in collectivistic societies like those in Asia.

Being unable to access common humanity could affect people’s mental health, an issue that Kotera found in his interviews with healthcare workers in Japan. Instead of engaging in casual conversations in hospitals, the workers rely heavily on socializing after work to cope with daily stressors as part of a cultural practice called nomikai. As lockdowns began, many overwhelmed healthcare workers found themselves alone in their struggles. Common humanity was suddenly unavailable to them at the time they needed it most, said Kotera.

Deeper Issues

Emerging research shows that crises like pandemics often expose or exacerbate existing challenges faced by healthcare workers.

For example, in 2019, the Philippines’ Department of Health estimated a shortage of about 290,000 Filipino healthcare workers— the majority of which consisted of Filipino nurses. Data from the Philippine Overseas Employment Administration also reveals that nearly 19,000 Filipino nurses have left the country to pursue better financial opportunities abroad since 2014.

“In the past, I have had patients who were healthcare professionals. They felt shame or guilt for wanting to leave the country, but during the pandemic, these feelings minimized because they felt mistreated,” said Rowalt Alibudbud, a nurse turned psychiatrist who works at a counseling health center in Makati City.

Alibudbud added that paying healthcare workers a decent wage matters because if a person is constantly struggling to make ends meet, it will affect the way they behave. Alibudbud’s sentiment is backed by an in-depth study by the World Health Organization, which found that people with low socioeconomic background tend to face a higher risk of mental health disorders. Realizing the problem, the Philippine government has announced that it plans to increase the wages of nurses. Singapore has already begun to do so.

Moving The Needle

Healthcare institutions have also begun to initiate changes. For example, The Medical City in the Philippines has introduced weekly check-in sessions with a licensed psychologist for its healthcare workers. According to Shirley Maclipay, chief human resource officer at the hospital, ward leaders have also been trained to spot early warning signs among their staff members.

However, smaller hospitals in the country are not able to provide such resources. Advincula, who works at one such hospital, noted that although their hospital offers counseling services through the Human Resource department, employees have to find assistance elsewhere if their mental health condition grows severe.

Meanwhile Singapore’s government has introduced policies like mandatory access to counseling services and peer support schemes to reduce burnout among public healthcare workers. Technology-supported initiatives such as self-assessment tools and artificial intelligence (AI) chatbots have also been added to the country’s growing pool of healthcare solutions, as well as systems for staff to raise concerns about their and colleagues’ mental well-being.

It is worth noting that such internal systems may not work for everyone. For example, Wong did not feel comfortable accessing the peer-support system where she would have to share her concerns with senior members of staff. She did not want her colleagues to know the details of her anxieties and could not be sure that they would be kept confidential. So, she approached a non-profit organization to find herself a counselor.

Since speaking to the counselor regularly, Wong has found that she is more able to manage her emotions and provide better care for her patients.

Back in Manila, Carascal said that people need to understand that healthcare workers are not superhuman, and experience distress like any other person. “When our needs are listened to and being prioritized by local governments and institutions, we can continue to deliver the best healthcare for everyone.”

This article was first published in the print version of Asian Scientist Magazine, January 2023.
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Copyright: Asian Scientist Magazine. Illustration: Shelly Liew

Jill Arul graduated with a degree in Communication Studies from Nanyang Technological University, Singapore, with a keen interest for science and a passion for storytelling.

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