This spring, every day at 7 p.m., New Yorkers opened their windows. They gathered on fire escapes and rooftops. They cheered, clapped, blew horns, sung, and banged pots and pans.

Largely confined to their homes, they were showing their support for health care providers on the front lines of the COVID-19 pandemic who were risking their own lives to save others. Cities across the country performed similar tributes as the coronavirus spread and lockdown orders followed. Now, as rates of disease remain high in the United States, health care providers continue to risk their safety to care for others.

In an ongoing effort to produce critical information about different aspects of this health crisis, Women’s Health Research at Yale has funded a new study that will examine differences by gender, race, and ethnicity in the factors linked to psychological resilience of frontline health care providers, shedding light on how they can adapt to the stress of the environments in which they live and work.

With funding from the Wendy U. and Thomas C. Naratil Pioneer Award, this study uses a newly developed model of assessing psychological resilience that quantifies the difference between actual and predicted levels of distress under exposure to highly stressful conditions. This approach allows an objective assessment of an individual’s psychological distress to create a reliable measure of resilience. The nature and determinants of trajectories of resilience and distress over time will also be examined. Moreover, this study will employ what is known as a socio-ecological model, which assesses psychological distress and coping strategies in the context of other ongoing real-world factors that could add to or reduce the potential for resilience to the primary stressor of concern — in this case, working on the front lines of the pandemic.

Other real-world factors include sources of both personal and professional stress, as well as potential protective factors, such as work pride and meaning, a sense of camaraderie and team spirit, perceptions of social support at work and at home, a sense of one’s capacity to bounce back from setbacks, thinking optimistically but realistically, gratitude, a purpose in life, and religiosity and spirituality. In addition, the researchers will study a broad range of adaptive (e.g., seeking support) and maladaptive (e.g., excessive substance use) strategies used to cope with stress.

In efforts to ensure their data can be optimally understood in terms of representative groups within our frontline health care providers, the researchers will also examine the data at the intersection of gender and race. Based on prior and current data, we know that types, magnitude, and effects of stress can vary by gender and race, and unique challenges need to be taken into account when considering how to optimize resilience.

“We know from previous disasters that people who are out there facing the greatest levels of devastation and distraction are at the highest risk for mental health problems,” said one of the study’s lead researchers, Dr. Sarah Lowe. “Most people are resilient and have effective coping strategies, but maybe these strategies don’t work as well under the severe, combined, and enduring stressors of the COVID-19 pandemic. So, we need to determine what works and help build on effective coping strategies to ensure resilience — take what you have and capitalize on it.”

Data from a COVID-19 Epicenter

Dr. Lowe, a clinical psychologist and Assistant Professor of Social and Behavioral Sciences at Yale School of Public Health, is partnering with Dr. Robert Pietrzak, Associate Professor of Psychiatry and of Public Health, who is leading the collaboration with researchers at Mt. Sinai Hospital in New York City.

Drs. Lowe and Pietrzak will analyze data obtained from 2,579 frontline health care providers, which were initially collected during the April-May pandemic surge at Mt. Sinai Hospital. The researchers are gathering additional data at six and 12 months after the baseline assessment to track symptoms of COVID-19-related distress over the full 12-month study period. The goal is to identify individual, interpersonal, institutional, and community factors associated with resilience in the acute phase of the pandemic surge and over time. This information will then be used to inform personalized and targeted approaches to prevent and reduce risk for disorders such as post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) in frontline health care providers.

Dr. Pietrzak, Director of The Translational Psychiatric Epidemiology Laboratory for the U.S. Department of Veterans Affairs National Center for Post-traumatic Stress Disorder, compared the burden of frontline health care providers to threats faced by soldiers trained for combat. The military spends significant time and resources to prepare troops for the types of stress they are likely to encounter. For example, they provide rigorous training of recruits, educate and train personnel to carry out specific military roles, and routinely conduct simulated battle exercises in preparation for and during deployment. But despite this training, the highly traumatic and grim realities of combat can result in serious and even long-term psychological consequences for some military personnel.

“Frontline health care providers have endured rigorous training, and they are accustomed to demanding schedules and emotionally and physically difficult working conditions” Pietrzak said. “But the pandemic has brought new challenges, with providers seeing an enormous surge of symptomatic patients; dealing with severe illness, death, and dying on a daily basis; and balancing demanding work and home responsibilities. The stress resulting from these challenges can be uncontrollable for some workers, and that is what leads to the psychological difficulties we are seeing in this population.”

Unique Challenges

Health care providers possess an elevated risk for contracting COVID-19. A study published by The Lancet this summer found that 2,747 out of 100,000 doctors, nurses, and other health care professionals working directly with COVID-19 patients in the United States and the United Kingdom reported positive tests for the disease compared with 242 out of 100,000 members of the general population.

A report by the U.S. Centers for Disease Control and Prevention (CDC) released in October found that 6 percent of adults hospitalized from March to May across 13 states were health care providers. Women comprise 76 percent of the country’s overall health care workforce, including 85 percent of all registered nurses and 91 percent of all nursing assistants.

Furthermore, COVID-19 has taken a disproportionately high toll on people of color, particularly Black Americans, including among populations of health care workers. A study from Harvard Medical School found that health care providers who are Black and caring for patients with or suspected of having COVID-19 tested positive for the disease at rates almost twice as high as their colleagues who are White. Black health care providers were also more likely to report having to reuse protective gear or use equipment that provides insufficient protection.

Beyond the concern of falling ill themselves and facing patient and co-worker deaths, health care providers can face a proliferation of emotional conversations with dying patients’ families and having to comfort patients in their last moments because visitors are not permitted. They also face extended periods of isolation to protect their families, exhaustion from long hours treating a large volume of patients, and potentially limited access to personal protective equipment (PPE). Women, who have been shown to have more childcare and family obligations, can face different and more frequent sources of stress than men.

Preliminary research among health care providers during the pandemic has revealed higher-than-average rates of generalized anxiety disorder, MDD, and PTSD — which can involve nightmares, flashbacks to a traumatic event, anger and irritability, negative thoughts, shame, and a prolonged state of constant vigilance.

“Some people might have a preconception that because the pandemic has gone on for so long, that frontline health care workers have adjusted to stressful working conditions and so are able to endure,” Lowe said. “But the research is showing that stressors can accumulate and erode mental health. People may not necessarily adjust to a ‘new normal.’ The wear-and-tear may be having a pernicious effect.”

Drs. Lowe and Pietrzak see their study as an opportunity to re-center the discussion of resilience on what leads to optimal mental health outcomes for frontline health care providers.

“In our field, we often focus on fixing what’s wrong but not necessarily on building what’s strong,” Pietrzak said. “We need to do both. And we need to learn how health care providers successfully build and maintain psychological resilience so that we can develop targeted strategies to help promote the mental health of these heroes on the front lines of the pandemic.”