Cheedy Jaja admitted that before an interview with Nurse.com he felt overwhelming anxiety.
The interview would delve into his experience and lessons learned while Jaja volunteered in Africa during the Ebola outbreak. At first, he thought recalling the experience would be a piece of cake. After all, it's over. But what he has found as he tries to prepare nurses for the mental health toll of such a crisis is that years later, the memories remain troubling. [caption id="attachment_76466" align="alignleft" width="282"]
Cheedy Jaja, APRN[/caption] "Very raw," he said. They come out of nowhere and send Jaja into a depression, even today. Jaja worries about nurses in the COVID-19 pandemic, who like him were woefully unprepared to care for the onslaught of patients, lacked personal protective equipment and were helpless to adequately treat patients as scientists tried to find answers. His goal is to help better prepare nurses for the front lines during this and future crises and pandemics so they remain physically and mentally healthier along with their patients.
Ebola outbreak shakes Jaja to the core
Jaja, PhD, MPH, MSN, PMHNP-BC, APRN, an associate professor of nursing at University of South Carolina, in Columbia, S.C., felt compelled to do something to help during the 2013-2016 West African Ebola outbreak. Jaja was born in Sierra Leone, which was one of the countries affected, along with Guinea and Liberia. The countries had experienced civil war and already had dilapidated healthcare infrastructures.
"I felt like I had to do something," he said. "You see all these negative images of people dying on the street. I just felt like, 'I'm a healthcare worker. This is one of those situations where you have to stand up and be counted. I cannot look at myself in the mirror if I don't do anything.'"
Jaja, who is trained in psychiatry and mental health, wasn't sure what he could offer. "All I knew was I was a nurse and that counted for something," he said. Jaja's first deployment was with a humanitarian organization to Sierra Leone, where he cared for Ebola patients for 6 1/2 weeks. The 14 clinicians from different parts of the U.S. who embarked on the mission were totally unprepared for what they encountered, according to Jaja. "I remember vividly the first day I donned my personal protective equipment -- hooded Tyvek bodysuit, N-95 face mask, boots, theater cap, three pairs of gloves, face shield and apron -- to enter the Ebola isolation unit at Port Loko Hospital early Christmas Day 2014, only to encounter a young patient who had died overnight, lying on the cold concrete floor," Jaja wrote in an article in The Conversation. "The cacophony of emotions I felt -- panic, fear and dread -- were palpable. I thought to myself, 'God, I am no hero. Please get me out of here.'" He said the fears started to fade as his clinical skills kicked in, and he did what he could with what he had. Interestingly, many of the same problems occurred in Africa as have happened in the U.S. during the COVID-19 pandemic. Basic PPE to help protect healthcare workers was always in short supply. And, ironically, wearing the life-saving protective gear that was available prevented him from truly caring for patients. "PPE are difficult to walk and to bend in," he wrote, "With daily temperatures in the region reaching 100 degrees Fahrenheit, we were instantly drenched with our sweat. Our goggles fogged up, hampering visibility. Double gloving interfered with our dexterity, and our hoods made use of a stethoscope impossible." Perhaps worst of all, the PPE inhibited a much-needed human connection.
A mental tug of war
The inherent struggles nurses face during crises such as the Ebola outbreak or the COVID-19 pandemic cause distress. "Ebola and COVID-19 are both called diseases of the caregiver," he said. "What do I mean by that? These are diseases that you, the caregiver, have a much greater risk of contracting. You're on the front line providing care, but you're also cognizant that you need to be very diligent, otherwise you'll be the one in the hospital bed." Fear aside, nurses like Jaja often didn't have what they needed, including medications, to meet patients' basic needs. There was no cure, much like today. "Really, what we were doing was providing palliative care," he said. Unlike U.S. nurses and other healthcare workers who have been heralded as heroes during the coronavirus pandemic, Jaja and U.S. colleagues were looked upon as pariahs when they came back to America to quarantine. "When we came back, we did not have any psychosocial support," he said. "We all descended into psychological trauma." One of his colleagues came up with the idea of having daily Skype meetings to debrief and share their good and bad experiences.
"We realized we're soldiers," he said. "We went to battle. We're brothers and sisters. It was those daily Skype meetings that helped us navigate the trauma and isolation and stigma that we experienced when we came back."
The trauma he experienced didn't stop Jaja from going back in 2015. This time, he spent nearly three months supervising two Ebola treatment centers in Sierra Leone. The West African Ebola outbreak killed more than 11,300 people. In December 2016, the World Health Organization confirmed the rVSV-ZEBOV vaccine was effective, ending the epidemic. But Jaja was left feeling angry, sad and helpless. "You're angry at yourself because you're thinking, 'I wish I had this and that, and that would have helped me make a difference. This person wouldn't have died,'" he said. "You're angry with yourself. You're angry at not having the resources. You're angry that you're back home and in quarantine and looked at as a pariah. "You go through bouts of sadness because you remember patients you bonded with," he continued. "Especially the kids, the children you bonded with and they would die. You have those images of these kids taking their last breaths, with sweat on their brow. You have images of holding kids and taking them to the morgue."
Preparation lacking, needed
As Jaja thought about the Ebola outbreak experience and how it affected him, it struck him how unprepared he was. Being prepared, according to Jaja, is not only having the clinical skills needed for the job but also an understanding of its challenges. "I think most of us who went from the States to help with Ebola did so because of a sense of duty," he said. "But I'm sure none of us had an idea of what we were walking into. It was not surprising that when we came back, each of us had experienced psychological trauma. It's something that hits you from left field. I wouldn't wish it on my enemy." Today, Jaja is advocating for preparedness in terms of what he believes should be required training for nurses in pandemic situations. He said the training has to address conflicting duties in these situations.
"The conflict centers around our duty to care, and the duty that we owe to ourselves and to our families to be well," he said. "That's a question that front-line workers have to negotiate on a daily basis."
Clinicians and the institutions for which they work need to be clear on whether they can perform the tasks at hand and what they need to perform those tasks, Jaja said. Healthcare institutions should not only provide nurses with needed training to care for patients, but also have psychosocial support in place. Jaja recommends having a wellness champion in each unit who can help nurses debrief at the end of the shift and check in with nurses. Another need is PPE innovation since today's protective equipment can create a barrier between patients and nurses. "We are trained to show empathy," he said. "We need to make the patient feel human. We need to make them feel that nurses can empathize with them and provide assurance that they're going to do the best they can to help patients get better." Nurses being put on a pedestal during COVID-19 is good in some ways, but also concerns Jaja. "On the one hand, I am happy that society gets to see the value of the nursing profession," he said. "Society gets to see us on par with soldiers, armed forces. But I'm also apprehensive because it almost gives the impression that nurses have it all. Nurses know what to do. Nurses are prepared. And that might not be the case." The superhero designation is a reality for many on today's front lines, according to an article in the Washington Post. That's while many healthcare workers confide that the pandemic has left them feeling lost, alone and unable to sleep, the article states. "They second-guess their decisions, experience panic attacks, worry constantly about their patients, their families and themselves, and feel tremendous anxiety about how and when this might end," according to the article. In reality, nurses have a steep learning curve in a pandemic such as COVID-19, and they will make mistakes, Jaja said. Not paying attention to the needs of today's healthcare workers could come at great cost. Nurses and physicians were struggling with stress even before the pandemic, the Washington Post article noted. "A study of 1,257 doctors and nurses in China during that country's coronavirus peak found that half reported depression, 45% anxiety and 34% insomnia. Another, looking at 1,400 healthcare workers in Italy and published in JAMA Network Open, found half showed signs of post-traumatic stress, a quarter depression and 20% anxiety," according to the Post. There is hope, however. Jaja said despite the trauma during the Ebola outbreak, good things came out of his experience in Sierra Leone. Today, for example, he focuses on helping others. He feels strongly that better preparation and more resources might have prevented lasting mental health challenges from the trauma. "I think at the end of the day, going to Sierra Leone made me a better person," he said. "It gave me a focus, a new lease on life and a new direction."
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