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The Impact of Pandemic-Related Stress and Trauma in Post-Acute and Long-Term Care Settings

      For those of us working in post-acute and long-term care settings during the COVID-19 pandemic, we vividly recall where we were when we heard that a novel coronavirus was detected in a nursing home in Kirkland, WA. We recall the video footage of the ambulances taking residents to the hospital. We remember when the directive of mandatory visitation restrictions was put in place and watched the impact it had on residents.
      We’ve been tested for COVID-19 more times than we can count and have tried to engage in meaningful conversations through masks and face shields. We remember the feeling of walking up to our patient’s room only to find an empty bed — and sometimes an entire wing of empty beds. Some of us have tested positive and hoped we would survive unchanged. We have lost patients, colleagues, family, and friends. We remember the feelings of helplessness, sadness, grief, and anxiety of the past two years and continue to experience these feelings.
      A majority of PALTC residents watched the nonstop news coverage of the virus while confined to their rooms. Their social interactions were limited to staff, who often displayed anxiety and fear despite their best intentions to minimize it. Many residents experienced being abruptly moved from their long-term rooms to a wing behind closed doors after testing positive for COVID-19. During that time, they often experienced decreased social interaction, change in their normal routine, and less access to their usual mental health care. Often they never saw some of their nursing home friends or family again. They longed for physical contact and to be reunited with their significant others. This is if they survived.

      Defining Trauma

      Anyone who has worked or lived in PALTC settings during the past two years has been exposed to traumatic stress. Whether or not an individual is traumatized by the exposure depends on a variety of factors. By definition, a trauma, which produces traumatic stress, occurs when outside events overwhelm our coping mechanisms and have a negative impact on our well-being (“Trauma-Informed Care in Behavioral Health Services: Quick Guide for Clinicians,” Substance Abuse and Mental Health Services Administration [SAMHSA], No. SMA 15-4912, 2015, https://bit.ly/3I4iyJ0).
      Vicarious trauma refers to the indirect trauma that can occur with repeated exposure to the traumatic stories of others; this type of trauma can also negatively impact our overall mental health. In a survey of mental health professionals working in PALTC settings during the first seven months of the COVID-19 pandemic, 32% believed they had been traumatized as a result of working in this setting during the pandemic, and 33% of providers reported contemplated working in a different environment altogether (“Providing Psychological Care to Older Adults During COVID-19: Recommendations for Clinical Practice,” American Psychological Association, Aug 11, 2021, https://bit.ly/3GPkiWi). In a recent survey of frontline health care workers, 62% indicated that pandemic-related worry or stress negatively affected their mental health (Ashley Kirzinger et al., “KFF/The Washington Post Frontline Health Care Workers Survey,” Kaiser Family Foundation, April 6, 2021, https://bit.ly/331OUon).
      When a natural traumatic event occurs such as a pandemic, the responses of survivors can be affected by factors such as the degree of impact or devastation, the extent of losses, disruption in normal activities such as travel, media attention, and the effort needed to re-establish daily routines (“Coping Tips for Traumatic Events and Disasters,” SAMHSA, updated Nov. 8, 2021). That we are still dealing with the pandemic — having experienced unprecedented loss with no known end point in sight — can certainly contribute to continued increased stress for all of us.
      Although it is normal to experience a wide range of emotions during and after a traumatic event, many will recover naturally. However, some individuals may continue to feel anxious and even experience severe distress that significantly interferes with daily life. In these cases, their symptoms may best be described as an acute stress disorder (as defined by the U.S. Department of Veterans Affairs, https://bit.ly/3HBR5xP). If symptoms — including intrusive memories, avoidance, negative thinking, difficulty maintaining close relationships, and ongoing fear, among many others (“Post-traumatic Stress Disorder [PTSD],” Mayo Clinic, July 6, 2018, https://mayocl.in/3t0Oj1l) — continue to “interfere with daily life and last for more than a month after the trauma,” then a diagnosis of posttraumatic stress disorder (PTSD) is considered (“What Is Posttraumatic Stress Disorder?” American Psychiatric Association, Aug. 2020, https://bit.ly/3zx4PHp).
      PTSD is historically associated with combat exposure because research about veterans returning from combat was often referenced in the creation of the diagnosis. However, PTSD can be associated with any event that is perceived as threatening one’s sense of self and safety. Prevalence studies have found that while almost 90% of Americans have been exposed to a traumatic event, only about 8% meet the criteria for PTSD in our lifetime (J Trauma Stress 2013;26:537–547). A 2021 meta-analysis and review found that “the overall pooled prevalence of post-pandemic PTSD across all populations was 22.6%,” with health care workers having “the highest prevalence of PTSD (26.9%)” (Mol Psychiatry 2021;26:4982–4998). Although individual or personal factors can impact the development of PTSD, the study found that “pandemic-related factors were associated with increased risk of developing PTSD,” including social isolation, economic loss, impact on livelihood, perceptions of risk, and negative psychological responses to the infection.

      Where Do We Go From Here?

      Drawing from my clinical experience as a geropsychologist working in PALTC settings and administrative experience working with clinical and facility staff, I offer the following suggestions.
      Shift your trauma-informed approach beyond trauma identification. Shifting the focus from identification to taking universal precautions will support efforts to prevent the possibility of retraumatization by changing our interactions and policies, and ensuring we are neutralizing our facility environments.
      Be aware that the disruption in visitation with family and friends, fears around health and illness, sudden loss and grief, and general loss of normalcy created by the COVID-19 pandemic can contribute to a perceived lack of safety for many PALTC residents. Practice using nonviolent communication while interacting with residents and colleagues (see Erasmus, p.13 this issue; Caring for the Ages 2021;22[3]:16-17). Engaging in dialogue with compassion and empathy upholds the trauma-informed care principles of trust and transparency, collaboration, empowerment, and choice, all of which contribute to a feeling of safety.
      Acknowledge that most of us have experienced huge losses during the past two years. Not only is grieving expected, but it is also paramount to healing. However, we can simultaneously focus on cultivating the relationships we currently have with our colleagues, residents, and staff. It has been suggested that for every negative interaction that occurs you may need five positive interactions to balance it. Ways to increase positive interactions include responding to others with constructive feedback, displaying appreciation, being respectful, and showing gratitude. Improving relationships with others can also be a primary mechanism for establishing a culturally responsive environment where individuals feel their needs can be heard and addressed. Ensuring social connectedness can prevent social isolation while promoting resiliency.
      Become cognizant of the signs and symptoms of emotional sequalae related to the pandemic and ensure you are providing your residents the opportunity to be treated by a mental health provider (see the handout from Psychologists in Long-Term Care, “Mental Health Recovery During the COVID-19 Pandemic in LTC Settings: A Guide for LTC Staff,” July 12, 2021, https://bit.ly/3pWvJW3). Being proactive and making a referral to a mental health clinician in the early stages can assist with a better prognosis.
      Be aware of signs and symptoms of burnout in yourself and practice self-care. Proactively assess your physical and psychological health and find time to engage in restorative activities. Self-assessment tests are available online for depressive and anxiety symptoms (Mental Health America, “Find Tools That Help,” https://screening.mhanational.org/). Take a break from news and social media, engage in mood-promoting and anxiety-reducing activities, and connect with loved ones. Engaging in personal and professional self-care can reduce the potential for burnout, which in turn can improve quality of caring, assist in building resiliency, and model healthy behavior for our patients and colleagues. Additional self-care resources are available from the American Psychology Association (“COVID-19 Self Care Resources for Healthcare Professionals,” https://bit.ly/3ztuTmG).
      Although the pandemic may be taking a toll on us, our colleagues, and our residents for different reasons, it is important to keep in mind that some distress is normal and we are resilient beings. In fact, many of us will experience what is referred to as posttraumatic growth (PTG) as a result of the pandemic.
      Positive psychological changes can occur after a traumatic event. A 2019 review of the prevalence of PTG found that “half of the investigated individuals reported moderate-to-high PTG after experiencing a traumatic event” (J Affect Disord 2019;243:408–415). PTG can buffer the negative effects caused by distress and can lead to positive growth following adversity. For example, the transformation that can occur following trauma can lead to positive changes, such as having a new appreciation for life, a shift in focusing more attention on helping others, increased motivation to take better care of oneself, or a newfound sense of personal strength. And with all of the adversity we have faced during the past several years, having potential for positive growth would be welcomed by many of us.
      Dr. Lind is a board-certified geropsychologist who serves on the Chief Clinical Leadership Team of Deer Oaks Behavioral Health. She also serves as the president of Psychologists in Long-Term Care and is a member of AMDA’s Behavioral & Mental Health Advisory Council.

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