Fifth edition, 14 July 2020

First lessons learnt at the Sheba Medical Center

Setting up a service

The Social Services Department is part of the Sheba Medical Center task force established to form the first medical response in Israel to Covid-19. The first arrivals exposed to the Covid-19 were quarantined in a separate facility on the hospital campus. Thereafter as patient numbers grew and medical needs changed, additional varied facilities were added, with a total capacity of up to 300 beds, the highest in Israel.

Faced with the challenge of providing psychosocial care to patients with an unknown illness, social workers selected the concepts of appraisal and social support as determinants of emotion and coping as a conceptual framework (Brooks et al., 2020). 

Background information illuminates personal factors affecting patients’ subjective perception (appraisal) and consequently the emotional impact of imposed isolation (Lazarus, 2001). The effects of isolation and physical distance on the vital role of social support during adversity, (Sippel et al., 2015; Pengilly and Dowd, 2000; Pierce, Sarason, and Sarason, 1996), provided an additional premise for our intervention mode.

Psychosocial intervention

Psychosocial interventions focus on therapeutic support within the social context of the individual. Psychosocial care is offered to all Covid-19 patients, given the intensity of the experience for both patients and families dealing with the implications of separation and the unknown, with limited access to medical staff who treat patients with a “hands off” approach and technological devices. The vast majority of patients accept the service, some decline at first but engage later. 

The extent of family involvement in the psychosocial care is determined by the expressed will of the patient and his medical condition, so when the patient is non-communicative, the family becomes the main recipient. 

The social worker reaches out telephonically or digitally and continues in this mode throughout the intervention process, delineated into three stages, described below, varying according to the features of the facilities and patient illness characteristics.

Pre-admission

In the interval between notification of testing positive and arrival at the hospital, objectives include alleviation of anxiety related to enforced evacuation to an isolation facility, formations of a beneficial perception of the situation and background information gathering. The intervention involves realistic expectation formation, practical information on the means of evacuation, facility and counselling in communicating change to children. This stage was implemented routinely during the initial stage of activity, when most patients’ arrivals were coordinated with community services. Since patients are now admitted mainly via, the E.R or other in -hospital departments, routine application of this intervention is no longer feasible.

During hospitalisation

The objective is to promote optimal adaptation of the patient and family members to the period of physical separation by optimising social contact through alternative means. Each patient is designated a counsellor, and continuation of care is provided in an intensive treatment setting of 2-3 sessions a week, with access to the counsellor in between sessions, in the event of crises. The intervention is important in containing and mitigating feelings of stress and frustration, which might erupt into disruptive behaviour difficult to manage in isolation.

Discharge planning

Finally, the psychosocial intervention aims at facilitating the return to regular family life and former social roles, as a healthy person who no longer poses a health threat to others. In sessions leading up to discharge, the patient is counselled in the transition from social isolation to involvement and continuing care is arranged with community services.

Central themes

Common subjects brought up by patients in the sessions include the impact of isolation and anticipatory anxiety given the possibility of developing symptoms of an illness unknown to the medical community. Other themes include feelings of loss of control, helplessness, uncertainty, shame, guilt for contracting the virus, putting others at risk, inability to carry out responsibilities, loss of privacy and autonomy and yearning for close family contact. 

Family members speak of the difficulties related to the physical distance, concern for dependents, financial worries, the need for familial reorganisation and assistance from other sources. These themes reflect those described during the SARS quarantine in 2003 (Cava, Fay, Beanlands, McCay, and Wignall, 2005).

Intervention practices

In order to modify the cognitive appraisal of the situation as a challenge rather than a threat, to reduce anxiety and improve coping and adaptation (So, 2013; Harvey, Nathens, Bandiera and LeBlanc, 2010), practical information on the facility is provided proactively when possible (Brooks et al., 2020), frequently through mediation between the patient and the medical team. Other techniques used include breathing exercises, guided imagery and mindfulness meditation. 

Strength based therapy is applied to develop a sense of efficacy by drawing on internal strengths and resourcefulness (Scheel, Davis and Henderson, 2012) while cognitive behavioural techniques are employed to ease feelings of guilt (Hedman, StrÖm, StÜnkel and MÖrtberg, 2013; Hepburn McGregor, 2012). 

Continuation of involvement in family life and other social and occupational roles is encouraged with digital means, where possible, to enhance a sense of control and certainty. Patients are guided into a daily routine involving getting out of bed, dressing, doing physical activity and hobbies. Finally, the social worker accompanies the patient in search for meaning in the current situation to develop new insights and understandings (Park, 2011; Folkman and Greer, 2000) for personal growth.

Central professional challenges

Rapid organisational changes require continual review and modification of the psychosocial service to ensure efficacy and relevance. Staffing changes take place daily, with emphasis on organisational needs and low priority given to employee preferences and specialised skills, as opposed to routine management practice, which strives to balance these factors. 

Since social workers and patients are not physically together, tele-medicine practice by video and audio connection technologies has become the order of the day and social workers have developed skills to engage patients and conduct sessions often without a visual image, eye contact, mimicry and facial expressions. 

Despite these constraints, the level of intimacy and involvement achieved is noteworthy, possible due to intense patient emotional needs and timely interventions. Some patients however, have reported a sense of intrusion into their personal space during camera-conducted sessions, and social workers have described a feeling of intrusiveness.

Additional challenges include continuing containment of intense negative emotion, setting boundaries and problem selection for counselling, amongst a plethora of pre-morbid issues typically evoked by the isolation. The predominant challenge however, lies in the question of whether families should be present at the time of death, or allowed to visit before, given the danger of contamination. 

Alternative means of contact by technological means are implemented, whereby families can send audio or video messages to the patient. The Social Services Department has taken on a leading role in discussion and policy on this subject in light of its short and long-term psychosocial implications.

Lessons learnt so far

The psychosocial aspect in coping with Covid-19 isolation is clearly evident. Appropriate and timely psychosocial intervention is crucial for effective organisational and personal management of the isolation and in developing coping abilities. Recipients have openly expressed how they have benefited from our involvement.

On the job training was essential through the dissemination of professional literature, development of psychosocial intervention protocols and training. We utilised the Israel Center for Medical Simulation (MSR), located on the Sheba Campus training. The social workers contributed to the skills and knowledge of other professionals in the behavioural and emotional aspects of isolation with particular focus on bereavement. The involvement of the Social Services Department in hospital policy decisions and rapid organisational changes facilitated a relevant psychosocial service, closely linked to the medical treatment.

Wendy Chen, PhD, MSW, Director of the Social Services Department

Ayelet Abramovich, MSW, Vice Director of the Social Services Department

References

Lazarus, R. S. (2001). Relational meaning and discrete emotions. In K.R. Scherer, A. Schorr, et al. (Eds.), Appraisal Processes in Emotion: Theory, Methods, Research (pp. 37-67). New York: Oxford University Press.

Park, C.L. (2011). Meaning, coping, and health and well-being. In S. Folkman (Ed.), The Oxford Handbook of Stress, Health, and Coping (pp. 227 – 241). Oxford: Oxford University Press.

Pierce, G. R., Sarason, I. G., and Sarason, B. R. (1996). Coping and social support. In M. Zeidner and N. S. Endler (Eds.), Handbook of coping: Theory, research, applications (p. 434–451). New York: John Wiley & Sons.