FIQ (Fédération Interprofessionnelle de la santé du Québec)

Physical and mental health prevention in the context of a pandemic

The FIQ is taking advantage of 2020 OHS Week to put physical and mental health prevention front and centre, especially in the context of a pandemic.

The current pandemic highlights the importance of prevention in the health network and the challenges different healthcare professionals encounter. Several observations were made following the first wave and it now seems essential to go further and develop, together, a real culture of prevention. Many tools and recommendations have already been developed, and only need to be applied! Let’s act now for a better tomorrow!

Physical health

Not surprisingly, the public health crisis these last few months has aggravated the existing physical health risks in the healthcare professionals’ workplaces. At the forefront, there is of course the biological risks caused by COVID-19 in the workplaces.

The care context in which our healthcare professionals work, already difficult before the declaration of a public health emergency, has deteriorated because of the pandemic and increased the work overload imposed on them. For many of them, the pandemic shock has caused changes in their environment and organization of work.

These changes, imposed by ministerial orders and introduced in urgency and confusion, have weakened individual and organizational defence mechanisms that reduce the risks related to occupational health and safety. The biological risk caused by COVID-19 in our workplace has in turn caused physical and ergonomic risks. At this time, the limited access to information and lack of data prevent us from making a complete assessment of the situation.

The biological risk

Advocate for and demand better protection

The lack of protective equipment and information and communication on its availability have been at the heart of the healthcare professionals’ concerns. This issue has created doubt and confusion about the ability of healthcare professionals to work in a way that is safe for themselves and their patients. This has undermined the authorities’ credibility and confidence in them.

From the beginning of the pandemic, the FIQ alerted the government to the risks linked to poor protection of healthcare professionals. Right from the start, it demanded an organization of the provincial production capacity of protective equipment according to the precautionary principle so that supply problems are quickly resolved. The FIQ and its unions participated in putting the public health recommendations into practice while focusing on good practices in infection prevention and control (IPC). Moreover, the FIQ warned that the shortage of personal protective equipment (PPE) can never justify a reduction in the protection of healthcare professionals.

For the FIQ, COVID-19 remains an emerging infectious disease. Scientific research is still inconclusive and the precautionary principle should always apply.

At the beginning of June 2020, 239 researchers and scientists from various countries alerted decision-makers about the development of research and importance of not jumping to conclusions about the epidemiological characteristics of the virus and the disease[1], especially about the possibility of airborne transmission.

In a context when the media are reporting that nearly 25% of the people contaminated in Québec are health care workers, the FIQ stresses that les mesures communiquées par le MSSS and health authorities should be considered as minimum measures to respect.

Personal protective equipment

For the Federation and its affiliated unions the institutions should implement the following infection control measures to ensure maximum protection for the healthcare professionals in the field.

Protective measures to apply

For all aerosol-generating medical procedures (AGMP), use a motorized air-purifying respirator (APR) or N95 mask and protective equipment for the body.

For all other suspected or confirmed patient cases, apply airborne/contact precautions with an N95 equivalent or superior mask whenever possible.

The FIQ does not recommend reusing masks, expired masks, or using disinfected single-use disposable masks.

Checklist
  • APR particle filter.
  • Single-use eye protection (face shield or protective goggles).
  • Unsterile disposable single-use long-sleeve gown.
  • Unsterile single-use gloves.
Using an N95

Despite all the recommendations limiting the wearing of an N95 filter device, the FIQ recommends healthcare professionals use it and their clinical judgment to justify using an N95 based on criteria such as:

  • The user’s symptomatology.
  • The regional epidemiological context.
  • Crowded conditions (is it possible to be physically distanced (at least one metre) in the care setting?).
  • The length of the procedure (extended or brief contact?).
  • The type of ventilation (negative pressure).
  • The presence of an adequate air exchanger system.
  • The logistical context associated with the supply of equipment and priority given to its use based on critical care units such as intensive care units and emergency departments.
  • The evolution of knowledge about the SARS-CoV-2 (COVID-19) virus.

The FIQ recommends the following measures, if a procedure or surgical mask is used in treating suspected cases

  • Mask adjusted properly.
  • Choose a three-micron filter.
  • For this mask to perform at its optimum level, the healthcare professional and patient must face each other (during procedures when the patient is placed on his-her side, droplets and aerosol particles may reach the sides of the healthcare professional’s face).
  • It is important to change this mask when it becomes damp, because it loses its effectiveness, unless it is waterproof.
  • A mask must ensure protection against biological fluids.

Basic universal practices applicable to COVID-19

Systematic application of basic practices for every patient is the rule to prevent the transmission of infections. The FIQ recommends the following practices in the context of the COVID-19 pandemic:

Information about PPEs
  • APR: fit test and properly adjusted.
  • Eye protection: prescription glasses are not considered adequate protection. They can be used for an entire shift, subject to the healthcare professional’s clinical judgment on the possible contamination of the eye protection.
  • Gown: plan to use a waterproof gown if there is a risk of contact with biological fluids (for example: vomit, severe cases.). It is recommended to change the gown between every patient.
  • Gloves: ensure they fit properly and cover the wrists.
  • Refrain from touching the eyes, nose or mouth with potentially contaminated hands.
  • Automatically remove the gown and gloves when leaving the examination room.
  • Practice hand hygiene procedures before donning and after doffing PPEs according to the IPC procedure. It is important to remove the protective equipment in such a way as to avoid contaminating yourself then wash and dry your hands well (a damp environment may be a contamination factor).
  • Use disposable items or, if not possible, clean and disinfect the equipment between every patient.
  • Dispose of PPEs according to the IPC procedure.
  • Whenever possible, care must be performed in individual negative pressure or closed rooms and suitably ventilated with an anteroom.
Hand washing

This is the most important measure for preventing the spread of the infection. The FIQ recommends washing hands:

  • Before and after every contact with a patient.
  • After any contact with blood, biological fluids, secretions, excretions, surfaces, contaminated or soiled items or equipment.
  • Between interventions with the same patient.
  • Right after removing gloves.
  • After blowing your nose or going to the bathroom.
  • Wash hands for 15 to 30 seconds.
Care items

Equipment

  • Disinfect or sterilize reusable equipment between every patient.
  • Refer to the waste disposal procedure in effect in the institution for single-use non-serrated and non-sharp material.

Bedding

  • Handle soiled bedding without abrupt movements to avoid particle dispersion.
  • Put in an airtight bag.
  • Slip the bag into a second bag in the event of a liquid leak.
Housekeeping
  • Ensure the room is cleaned every day (furniture, bathroom and floor) using a virucidal disinfectant.
  • Clean the room as soon as the patient leaves.
  • Ensure the room is disinfected according to established procedure.
Wearing a uniform and responsibility

Actions as simple as putting on and taking off a lab coat, uniform and shoes at work may have a major impact on preventing the spread of COVID-19

Ensure that:

  • Your work clothes are worn only at work. This means you change them in the locker room provided by the employer on arriving and leaving work and leave wearing your civilian clothing.
  • You change your work clothes every day.
  • Your work clothes are cleaned regularly and properly.

The IPC team

During the Clostridium difficile (C. difficile) outbreak in 2004, the Comité sur les infections nosocomiales du Québec recommended a standard ratio[1] for ensuring an effective IPC intervention.

Nurse clinicians specialized in IPC are the expert resources in IPC outside of the medical body. The FIQ hopes that the current pandemic is an electroshock so that nurse ratios specialized in IPC are introduced in all care settings.

Union action in IPC

The healthcare professionals are entitled to working conditions that respect their health and safety, and protect against the dangers linked to biological substances. The employer must take all necessary measures to ensure this protection.

For its part, the union is a major player in IPC because its role is, among others, to ensure members’ rights are defended, improve their working conditions and protect their health. If you see a problem linked to IPC in your institution, tell your union as soon as possible. They can intervene with the employer so that corrective measures are taken.

Work environment and organization of work

As of April 2020, the health authorities began setting up complete medical structures fully dedicated to COVID-19 to separate COVID-19 patients from others.

On one hand, the idea behind this organization of care was to take care of patients with COVID‑19 in a closed circuit, without any exchange of patients or staff between outbreak and non-contaminated areas. On the other hand, this organization of work was intended to ensure that health institutions did not become places of propagation. It is an efficient organization of care method, designed in such a way as to apply all elements of the plan in a complementary way.

Ensure that organization of care allows for a health care corridor. Be alert and demand that closed circuit care is applied. Demand:

  • That infected or suspected patients are isolated from other patients in hot, intermediate, cold zones or by bubble.
  • That your work team is stable and composed of colleagues assigned to a specific clientele for the same 24-hour period.

A checklist for practicing during COVID-19

The FIQ developed a checklist to give you useful information on practicing during COVID-19 especially if you are asked to practice in a new centre of activities (including a modular unit outside of the institution).

Physical risks

La violence

Another result of the increase in physical risks due to COVID-19 is the rise in workplace violence. Workplace violence is intrinsically linked to a work overload and psychosocial risk factors. As reported by the Institut national de santé publique du Québec, studies have shown a rise in violence against women during periods of crisis or public health crises in society in general[1]. Studies also tend to establish a link between the context of the pandemic and a rise in conjugal violence.

Rising risk factors related to violence in society is mirrored in the workplace. Moreover, the Association paritaire pour la santé et la sécurité du travail du secteur affaires sociales produced a checklist called COVID‑19 – Intervenir en situation de violence (in French only) to prepare health care workers for situations when a user, through his violent or threatening behaviour, is a danger for his safety or that of others. The Association paritaire pour la santé et la sécurité du travail, secteur Administration provinciale also produced a document reminding employers about best practices in violence prevention in client services.

Workplace violence has a multifactorial dimension. It cannot be reduced to the link between employees and users alone. Moreover, this is what the House of Commons Standing Committee on Health concluded in its report, Violence facing health care workers in Canada published in June 2019. In the words of Ms. Margaret Keith, the Committee wrote

« The culture of silence around the issue of violence is a major barrier to acknowledging its existence and consequently, addressing it. However, although the public has been kept in the dark about this issue, it is not a problem that is unknown within the health care community »

If you are a victim of workplace assault or violence

  • Inform your immediate superior.
  • Fill out an incident/accident form AH-223.
  • Contact your union team.
  • Fill out a work accident form even if there is no obvious injury.
  • Contact your family doctor.

List of resources for obtaining help or support

Agencies working with victims of assault and conjugal violence

Mental health

In the midst of the pandemic, the Ministry of Health and Social Services contacted the Institut national d’excellence en santé et en services sociaux (INESSS) to obtain a réponse rapide (quick response) on the measures to put in place to counteract the harmful effects of the pandemic on the mental health of network personnel. Among the INESSS findings are the personnel’s concerns and fears related to the context of the pandemic, the mental distress and mental health problems.

A few elements taken from the INESSS document are:

What concerns can the healthcare professionals have?
  • Concerns related to their physical and mental capacities.
  • Concerns related to the health of their loved ones and risks of contamination.
  • Fears about contracting the disease or dying.
What are the mental health problems in the context of a pandemic?
  • Fatigue and stress.
  • Aggravation of pre-existing physical or mental health problems.
  • Increase in alcohol consumption and other mood-altering substances.
  • Moral suffering and psychological distress related to clinical decisions to prioritize access to care.
  • Sleep, concentration and appetite disorders.
  • Anxiety and depression.
  • Post-traumatic stress disorder.

Some of you are possibly at higher risk to experience psychological distress or mental health problems, due to personal or family characteristics:

  • If you feel pressure from loved ones to leave the profession.
  • If you have difficulty balancing professional and family requirements.
  • If there are members of your family with COVID-19, suspected to have it or seriously ill.
  • If you experienced grief recently.
  • If you have a chronic disease or a history of mental disorders.

Moreover, health care personnel would be more likely to experience psychological distress or mental health problems, because of certain characteristics specific to this sector of activity:

  • The personnel with direst exposure to the suffering of infected people and must deal with the users’ anxiety or concerns.
  • The one working in a high-risk setting.
  • The one working in a geographic epicentre.

Harmful effects on health

Before the pandemic, being exposed to one or several psychosocial risk factors involved

  • 4 to 4 times greater risk of work accidents.
  • Twice the risk of psychological distress.
  • 5 to 4 times greater risk of musculoskeletal disorders.
  • 2 to 2.5 times greater risk of cardiovascular disease.
  • 5 times greater risk of cerebral vascular accidents (CVA).

Preventing a single case of a mental health problem could reduce costs:

  • Absenteeism: $18,000 (or 65 workdays on average).
  • Presenteeism: the estimated cost is almost twice the cost of absenteeism.

Presenteeism is a phenomenon characterized by employees’ presence at their workstation, even if they have symptoms (e.g. fatigue and difficulties concentrating) or a disease that should cause them to take time off work and rest. Why does presenteeism generate costs? Presenteeism may result in lower levels of productivity and risk of errors, breakage or work accidents.

Psychosocial risk factors at work

The psychosocial risk factors at work are defined as factors related to organization of work, management practices, employment conditions and social relations, that increase the likelihood of adverse effects on physical and psychological health of the people exposed (INSPQ, 2016).

The main psychosocial risk factors at work recognized in the scientific literature are:

  1. The work load
  2. Social support from the superior and colleagues
  3. Decision-making autonomy
  4. Recognition
How do psychosocial risk factors act?

In its document on psychosocial risk factors, the Institut national de recherche et de sécurité pour la prévention des accidents du travail et des maladies professionnelles (INRS), a French scientific body, explained that:

(…) according to work situations, the psychosocial risk factors may compensate (for example higher requirements, but good quality social support) or, on the other hand, strengthen itself (for example higher requirements and lack of recognition of efforts made). Different studies show the more “toxic” they are on health when :

  • They are part of the long term
    The sustained psychological risk factors may in fact create a stage of chronic stress that that represents a health risk.
  • They are sudden
    Sudden psychosocial risk factors are more difficult to deal with.
  • They are numerous
    An accumulation of risk factors is a compounding factor.
  • They are incompatible
    The coexistence of certain “aggravating” factors particularly affects health, for example a high demand for productivity and little room for manoeuver.

Even though the INSPQ refers to 4 main psychosocial risk factors, this number is not exhaustive. For example, the National Standard of Canada for Psychological Health and Safety in the Workplace refers to 13 psychosocial risk factors. For its part, in its publication Mental Health: Is your workplace safe? “Mental Health – Is your workplace safe? ”, the FIQ referred to 8 psychosocial protective factors more representative of the healthcare professionals’ work reality.

Preventive measures for employers

The Federation wants to take advantage of the 2020 OHS Week to inform and equip the healthcare professionals. However, because occupational health and safety is everyone’s business, it’s a good idea to repeat the recommandations de l’INSPQ à l’intention des employeurs (INSPQ recommendations for employers – in French only) on the psychosocial risk factors in the context of a pandemic. On reading these recommendations, the healthcare professionals can also verify the employer properly applies them in their work environment

Presence of psychosocial risk factors at work

A few examples of factors that could contribute to the emergence of psychosocial risk factors for healthcare professionals are:

Workload

With respect to workload, are healthcare professionals, for example, subject to:

  • A heavier workload, pressure to pick up the work not done.
  • Long work hours (e.g. no breaks, mandatory overtime).
  • A staff shortage.
  • Poorly defined work mandates, tasks or instructions or subject to many interpretations or changes.
  • A lack of tools necessary to do a good job (e.g. personal protective equipment).
  • A lack of training for the tasks she is asked to do when resources are shuffled.
  • Greater complexity of work related to respecting the instructions for protection (e.g. distancing, use of personal protective equipment).
  • A feeling of not being able to do quality work.
  • Ways of doing things that clash with their personal or professional values.
  • Emotional traumas (e.g. agonizing care decisions, patients’ deaths).
  • Inappropriate behaviour by patients or their loved ones.
  • Fear of being contaminated by COVID-19 and contaminating their loved ones
  • Difficulty in balancing work, family, and personal responsibilities (e.g. telework, daycare).
Social support from superiors

Is social support from superiors currently marked by:

  • A lack of availability to provide the useful or essential information for carrying out the work.
  • Less time for discussion and sharing (e.g. lack of team meetings).
  • Greater difficulty in clarifying everyone’s mandates and roles.
  • Little listening or empathy for the staff’s concerns (e.g. request for time off, needs in organization of work).
  • Tensions, conflicts or rudeness not managed on the work teams.
Social support from colleagues

Social support from colleagues currently marked by:

  • Greater instability on the work teams.
  • Fewer or lack of team meetings.
  • Greater distance between a healthcare professional and the members of her team.
  • Lack of informal opportunities to meet, exchange, share and help each other.
Recognition

With regard to recognition, is the current work situation characterized by:

  • Lack of respect and esteem for staff.
  • Difficulty in adequately recognizing staff efforts.
  • Lack of recognition of the risks incurred by staff.
  • Existence of iniquities or favoritism between sectors or individuals.
  • Tensions related to remuneration in a context of a pandemic (e.g. premiums, salary improvements).
  • The staff’s sense of job security in keeping their jobs and working conditions.
Decision-making autonomy

For decision-making autonomy, can we, for example, see in the healthcare professionals:

  • A lack of opportunities to participate in decisions that affect them.
  • A lack of opportunities to use their skills and develop new ones.
  • Little possibility to show creativity and take initiatives.
Organizational conditions

Certain organizational conditions also affect the work climate and staff’s mental health, including the lack of:

  • Team cohesion.
  • Planning and organization of work.
  • Confidence in colleagues.
  • Preparation of the institution.
  • Training and equipment for avoiding contamination.
  • Psychological support.

Courses of action

Here are a few examples of courses of action whose positive impacts on the staff’s health are widely recognized. Each setting can adapt them based on their reality. This list is not exhaustive, and can be improved according to the psychosocial risk factors specific to each workplace.

Facilitate the exchanges between immediate superiors and staff by establishing communication procedures (e.g. regular team meetings, electronic exchanges)
  • Communicate regularly and transparently as to what needs to be done and how to do it.
  • Being attentive to staff concerns and suggestions and follow up on them as soon as possible.
  • Pay attention to the staff’s issues of work-family balance (e.g. childcare, telework).
Reinforce the culture of support and mutual aid in the workplace
  • Lead by example.
  • Encourage empathy and compassion on the work teams.
  • While respecting the physical distancing measures and using technological tools, provide opportunities for workers to be together, express themselves, help each other and reflect on the solutions for the challenges encountered.
  • Pay attention to the conditions conducive to the emergence of psychological harassment at work (e.g. unresolved conflicts, rudeness) and implement, as soon as possible, the necessary measures to prevent it and, if applicable, stop it (see the documentation de la CNESST) (CNESST documents on this subject).
  • Equip/give the staff the appropriate means so they can do their work, safely and satisfactorily (e.g. telework tools, personal protective equipment, clear procedures in the event of the presence of symptoms).
  • As needed, provide one-off training to acquire the minimum critical knowledge to carry out the work required.
  • Encourage the staff to take the full scheduled break.
  • Foster daily recognition, reward everyone’s efforts and make a positive assessment of the work.
  • Consult the employees about the decisions affecting their work.
  • Invest in the participation of people and groups and stimulate initiatives.

Are there risks in your workplace?

The various stakeholders in the workplace are asked to answer the following short questionnaire, which aims to raise awareness of the preventive measures and organizational constraints that may be harmful to health.

The answers given will provide an initial insight into aspects of work organization and management practices that should undergo a risk assessment. This assessment can be done with the help of the Tool for Identifying Psychosocial Risk Factors in the Workplace developed by the INSPQ.

If you agree with most of these statements, the presence of psychosocial risk factors in the workplace should be assessed. Talk to the OHS officer for your local union.

Strategies for taking care of yourself during the pandemic

Look after essential needs

Healthcare professionals are accustomed to thinking that they have to be available for others and their own needs are secondary, without taking into account the fact that failing to eat or rest causes exhaustion. Be sure to eat, drink and sleep regularly. Not doing so jeopardizes mental and physical health and in the end, it compromises the capacity to care for patients.

Plan a routine outside of work

Try to maintain some of your habits despite the new restrictions imposed by the current context. Explore creative ways for other options at home: daily exercise routines, personal care, reading, communicate with loved ones, etc.

Respect differences

Some people need to talk while others need to be alone. Recognize and respect these differences for your patients, work colleagues and yourself.

Talk with family and loved ones

Talk with loved ones, if possible. They are your support outside the health network. They may be able to give you more support if you share with them. Feeling useful to each other is a protection factor.

Limit exposure to means of communication

Explicit images and disturbing messages will increase your stress and may lower your efficiency and general well-being. Protect yourself psychologically setting limits on the demands that can come from WhatsApp groups or other digital means asking for personal information or advice. Hence, you can preserve your rest time and capacity to get through this endurance race.

Vent your feelings

Professional competence and strength are consistent with feelings of confusion, concern, feeling of a loss of control, fear, guilt, exhaustion, sadness, irritability, desensitization, instability, etc. These feelings are precisely those that make us human. Sharing one’s feelings with someone who inspires safety and trust helps us tolerate these feelings better and resolve them.

Apply recognized emotional management strategies

Breathing, awareness techniques, physical exercise, among other things, may be useful in defusing negative thoughts, emotions and physical symptoms.

Take a break

When possible, take part in activities that are comforting, fun or relaxing for you. Listening to music, reading a book or talking to a friend may help. Some people may feel guilty not working all the time or if they take the time to relax when so many are suffering. However, taking a break will also help in giving better care to patients.

Talk with work colleagues

Talk with your work colleagues and support each other. Isolation due to the pandemic may produce fear and anxiety. Talk about your experience and listen to that of others.

Share constructive information

Talk to your colleagues clearly and encourage them. Identify errors and failures constructively in order to be able to correct them. They all complement each other: praise can be a powerful motivator and stress reducing. Share your frustrations and solutions. Problem solving is a professional aptitude that provides a feeling of accomplishment even for little incidents.

Keep your skills up to date

Rely on trusted sources of knowledge. Participate in meetings to keep informed of the situation and find out what is planned.

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Allow yourself to ask for help

Recognizing our signs of stress, asking for help and learning to stop to take care of oneself is an internal regulation mechanism that fosters stability in a situation of enduring stress.

Self-observation of feelings and perceptions

Feeling unpleasant emotions is not a threat: it is our mind’s normal defence mechanism when faced with danger. However, be watchful that symptoms of depression and anxiety do not develop: lingering sadness, difficulty sleeping, invasive memories, despair. Talk with your colleagues, superiors, or seek professional help if necessary.

Remember that just because it’s possible doesn’t mean it is bound to happen

Healthcare professionals are constantly exposed to the darker side of this dramatic pandemic: suffering and death in terrible conditions. Obviously, it can create an emotional charge that makes you think of the worst. However, it is important not to lose hope and remember that many of the infected people develop milder forms of the disease.

Acknowledge your team

Remember that, despite the obstacles and frustrations, you are on a great mission: providing care to those in need. Recognize your colleagues, formally and informally. Remember that all those currently working in care settings are doing their best and are the real heroes for the population.

Available resources