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Going Back to Basics: Health Psychology Core Competencies as a “How To” Guide for Supporting the COVID-19 Response

Margaret Bauer
Margaret Bauer

Margaret R. Bauer, PhD
Palliative Care Psychologist
Health Psychology Service
VA Connecticut Healthcare System

As I scanned my office bookshelves filled with textbooks, treatment manuals, and even binders of graduate school notes, I found myself wishing for something like “Health Psychology during a Pandemic”, or even, “Health Psychology for Dummies: Pandemic Edition.” In March, I was five months out of fellowship in my first job as the palliative care psychologist at the VA Connecticut Healthcare System; the novel coronavirus was erupting in neighboring New York City. I knew it was only a matter of time before it would reach Connecticut and that my palliative care team and I, unfortunately, would have a role in what was to come. Palliative care teams work with individuals with life-limiting illnesses. We anticipated an influx of referrals from patients with coronavirus and were concerned about our existing panel of fragile, frequently immunocompromised, patients. Though I often felt scared and ill-prepared in the early weeks, as the pandemic evolved locally, I realized the unique health psychology skill set ingrained in me throughout my training was the “how to” guide I hoped for. Proficiency in clinical care, interdisciplinary collaboration, research, and program evaluation, leave health psychologists well positioned to ease the burden of the COVID-19 pandemic on patients and hospital systems. I hope that sharing my experience will highlight the many different roles a health psychologist can have when healthcare systems face unprecedented challenges.

Establishing a Protocol for Health Psychology Service Delivery During the Pandemic

The unique pathophysiology of SARS-CoV-2 presented several psychological and emotional challenges. In particular, the person-to-person transmission of the virus required strict isolation precautions and all visitors be banned from the hospital. In addition, COVID-19 could lead to rapid deterioration necessitating sudden escalation of care (Zhang et al., 2020). Concern about the impact on patient and family well-being prompted a coordinated response between the palliative care team and broader health psychology service to address the psychosocial needs of Veterans admitted with COVID-19 and their families. At our facility, I offer inpatient health psychology services to palliative care patients, whereas fellow health psychologist, Dr. Laura Blakley, provides services for individuals who are not followed by the palliative care team. Together with Dr. John Sellinger, Director of the Clinical Health Psychology Service, we designed a health psychology response protocol to ensure psychosocial support for all individuals hospitalized with COVID-19. To do this, typical program development processes were utilized, but at an accelerated pace. We established a plan to contact organizational stakeholders, understand local delivery of COVID-19 care to determine an implementation strategy, and review the literature to establish a clinical protocol. Dr. Sellinger directed the clinical administrative tasks, while Dr. Blakley and I focused on the protocol and strategy for service delivery. A new COVID-19 health psychology consult request was built into the medical record and triggered automatically for each new patient upon admission. Once referred, we created a standard chart review template to identify biopsychosocial risk factors for emotional distress during hospitalization and to facilitate triage to the palliative care service or broader health psychology service based on severity of COVID-19 symptoms and preexisting health conditions. Admitted Veterans were then connected to one of us, or a clinician from a group of willing psychologists who volunteered to assist. We offered psychosocial support to Veterans and families as well as recommendations to medical teams on how to ameliorate stress throughout the hospitalization. It is hoped that early intervention helped decrease the anxiety, depression, and PTSD often seen after difficult ICU and hospital admissions (Hatch, McKechnie, & Griffiths, 2011; Peris et al., 2011).

Working Clinically with Individuals Hospitalized with COVID-19 and their Families

For our multidisciplinary palliative care team, we knew symptom management, emotional support and skilled discussions around goals and preferences for care would be needed during the COVID-19 pandemic (Etkind et al., 2020). Though these are the backbone of our clinical practice, COVID-19 presented new issues requiring adaptations to care. While beeping machines and middle-of-the-night vital checks are common frustrations for patients on the acute medicine service, individuals hospitalized with COVID-19 shared a distinct hospital experience. Seclusion in negative pressure rooms for weeks with only limited interactions with providers donned in head to toe personal protective equipment (PPE) resulted in profound loneliness for many. For both patients and staff, the normal bond that they develop with one another was made more difficult by these necessary, but unfortunate, barriers. To reduce risk of virus transmission and the unnecessary use of PPE, our team converted inpatient care to a virtual model using phone or video. Clustering of nursing care coupled with the significant physical deconditioning and protracted deliriums of many palliative care patients often complicated service delivery. Contact with patients frequently required close coordination with willing and eager nurses who would dial us from patients’ rooms. Our interventions were wide ranging, composed of frequent emotionally supportive phone calls, obtaining diversions (e.g., crossword puzzles, the TV’s relaxation channel), and coordinating phone and video calls with family.

However, physical distance was perhaps most hard on loved ones. Keeping families as a centerpiece of care was critical, even when visitation restrictions precluded their presence at bedside. Families of ICU patients often develop symptoms of PTSD, depression, and anxiety (Fumis, Ranzani, Martins, & Schettino, 2015). To try to buffer against the negative effects of separation during their loved one’s hospitalization, our team called families several times per week for emotional support and to facilitate communication with medical teams. Issues of grief were compounded for families. As the disease swept through households, it was common for several family members to get ill and even to succumb to the disease. Our palliative care team extended our usual bereavement support program for families whose loved ones died from COVID-19. However, given that these interventions targeted the short-term consequences of COVID-19 hospitalizations, more time is needed to determine what the intermediate and long-term impact might be and how health psychologists can intervene.

Supporting Frontline Staff

Throughout the COVID-19 pandemic, frontline healthcare workers continually faced great personal risks, making them vulnerable to increased anxiety, depression, and stress (Kang et al., 2020). The hospital’s Employee Assistance Program (EAP) coordinator, Christine Bihday, APRN, organized a comprehensive, multidisciplinary response team, including subgroups that provided support to different hospital services with distinct needs (e.g., acute service, primary care, teleworkers). Our subgroup for acute service providers designed a wide-ranging support program based on the principles of Psychological First Aid (PFA; Brymer et al., 2006). The focus of PFA is not on psychological debriefing, but rather on enhancing a sense of safety, addressing practical needs, and promoting effective coping strategies and social connection. Completing walkabouts on the acute service floors was a primary intervention. These visits were informal and aimed at engaging staff members, hearing concerns, normalizing emotional reactions, and connecting staff with resources on coping, accurate information about the virus, and practical needs (e.g., childcare concerns). Additionally, fliers were created and posted throughout the hospital floors on a range of topics, including at-work coping strategies, monitoring burnout levels, and available resources. Conversations during walkabouts and resources provided were grounded in the existing literature on healthcare workers during epidemics, and were tailored to the specific demands within each epidemic response stage (i.e. preparation, first patient, etc.) (Highfield, 2020). Currently, we are developing an evaluation of the program to determine which components of our EAP intervention were perceived as most helpful by staff. Not only will this allow for dissemination of what was beneficial at our facility, but also it will leave us better-positioned to address staff needs rapidly and effectively, if additional waves of the virus hit.

Lessons Learned

The lessons learned from an event as historic and devastating as the COVID-19 outbreak are too innumerable to list, or even to comprehend at this time. What is for certain, however, is that responding to COVID-19 was an iterative process that required close collaboration. Reacting to something novel and evolving required constant reevaluation and input from individuals with diverse training and skill sets. Nothing discussed herein would have been possible without the partnerships of my health psychology service, interdisciplinary palliative care team, or multiprofessional EAP support team. Rapid and flexible use of health psychology proficiencies, in concert with interdisciplinary expertise among colleagues, can have significant impact in extraordinary circumstances.

Going forward, health psychologists will continue to have important roles in the fallout from COVID-19 and the many issues magnified by the novel coronavirus. For example, COVID-19 underscored deep-rooted health inequities in the United States, including disproportionate death rates in racial minority groups and concerns about inadequate reporting of racial and ethnic demographic information of individuals with COVID-19 (Chowkwanyun & Reed, 2020; Vahidy et al., 2020). The VA has been in the forefront of researching health inequities and providing equitable care for Veterans from under-served minority groups both before and during the pandemic (U.S. Department of Veterans Affairs Health Services Research & Development, 2015; Rentsch et al., 2020; Trivedi & Grebla, 2011).  In the VA and other healthcare systems, health psychologists can help characterize, spotlight, and intervene around the economic inequality and other social determinants of health that underlie the racial disparities observed in COVID-19. As has been made critically clear to me in the past few months, foundational health psychology competencies in research, collaboration, program development, and intervention leave us uniquely positioned to assist in addressing complex global issues.

References:

Brymer, M., Layne, C., Jacobs, A., Pynoos, R., Ruzek, J., Steinberg, A., … & Watson, P. (2006). Psychological first aid field operations guide (2nd ed.). National Child Traumatic Stress Network.

Chowkwanyun, M., & Reed, A. L., Jr. (2020). Racial health disparities and Covid-19—caution and context. New England Journal of Medicine. Advance online publication. doi: 10.1056/NEJMp2012910

Etkind, S. N., Bone, A. E., Lovell, N., Cripps, R. L., Harding, R., Higginson, I. J., & Sleeman, K. E. (2020). The role and response of palliative care and hospice services in epidemics and pandemics: a rapid review to inform practice during the COVID-19 pandemic. Journal of Pain and Symptom Management. Advance online publication. https://doi.org/10.1016/jpainsymman.2020.03.029

Fumis, R. R. L., Ranzani, O. T., Martins, P. S., & Schettino, G. (2015). Emotional disorders in pairs of patients and their family members during and after ICU stay. PLoS One, 10(1), e0115332. doi: 10.1371/ journal.pone.0115332

Hatch, R., McKechnie, S., & Griffiths, J. (2011). Psychological intervention to prevent ICU-related PTSD: who, when and for how long?. Critical Care15(2), 141. doi: 10.1186/cc10054

Highfield, J. (2020). Advice for sustaining staff wellbeing in critical care during and beyond COVID-19. Retrieved from https://www.ics.ac.uk/ICS/Education/Wellbeing/ICS/Wellbeing.aspx

Kang, L., Ma, S., Chen, M., Yang, J., Wang, Y., Li, R., … & Hu, S. (2020). Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study. Brain, behavior, and immunity. Advance online publication. https://doi.org/10.1016/j.bbi.2020.03.028

Peris, A., Bonizzoli, M., Iozzelli, D., Migliaccio, M. L., Zagli, G., Bacchereti, A., … & Bendoni, E. (2011). Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress disorders, anxiety and depression symptoms in critically ill patients. Critical care15(1), R41. doi: 10.1186/cc10003

Rentsch, C. T., Kidwai-Khan, F., Tate, J. P., Park, L. S., King Jr, J. T., Skanderson, M., … & Re III, V. L. (2020). Covid-19 by race and ethnicity: A national cohort study of 6 million United States Veterans. medRxiv. Advance online publication. https://doi.org/10.1101/2020.05.12.20099135

Trivedi, A. N., & Grebla, R. C. (2011). Quality and equity of care in the Veterans Affairs Health-Care System and in Medicare advantage health plans. Medical care, 49(6), 560-568.

U.S. Department of Veterans Affairs Health Services Research & Development. (2015). Evidence brief: Update on prevalence of and interventions to reduce racial and ethnic disparities within the VA. Available: http://www.hsrd.research.va. gov/publications/esp/HealthDisparities.cfm. Accessed: June 29, 2020.

Vahidy, F. S., Nicolas, J. C., Meeks, J. R., Khan, O., Jones, S. L., Masud, F., … & Nasir, K. (2020). Racial and ethnic disparities in SARS-CoV-2 pandemic: Analysis of a COVID-19 observational registry for a diverse US metropolitan population. medRxiv. Advance online publication. https://doi.org/10.1101/2020.04.24.20073148

Zhang, W., Zhao, Y., Zhang, F., Wang, Q., Li, T., Liu, Z., … & Zeng, X. (2020). The use of anti-inflammatory drugs in the treatment of people with severe coronavirus disease 2019 (COVID-19): The experience of clinical immunologists from China. Clinical Immunology, 214. https://doi.org/10.1016/j.clim.2020.108393