key: cord-0865344-a1zu6czm authors: McCallum, Blake Andrew; Dunkley, Kay; Hotham, Elizabeth; Suppiah, Vijayaprakash title: Bushfires, COVID-19 and Australian community pharmacists: ongoing impact on mental health and wellbeing date: 2021-01-30 journal: Int J Pharm Pract DOI: 10.1093/ijpp/riaa020 sha: ba6ef9c77556ab8e32497bea5ed15de79509ec82 doc_id: 865344 cord_uid: a1zu6czm OBJECTIVES: The nation was recovering from the aftermath of the catastrophic 2019–2020 bushfires when the first cases of the COVID-19 pandemic emerged in Australia. During the peak of the pandemic, Australia closed both its state and international borders to all travelers and interstate travel was very tightly regulated. Community pharmacists and pharmacy staff were one of the very few primary healthcare workers still serving their communities during these periods of strict lockdown. In this personal view article, the challenges and their toll on the mental health and wellbeing of these “essential workers” are described. KEY FINDINGS: Community pharmacists and pharmacy staff were under immense pressure to remain open and serve their communities amidst rapidly changing legislation and, at times, conflicting advice from the range of Australian health agencies. Rapid changes to workload and workflow were combined with the dilemma of balancing professional obligations with the personal duty of keeping themselves and their sometimes geographically distant families safe. Fluctuating demands and traumatic situations found community pharmacy staff often feeling distressed and underprepared. SUMMARY: Despite a global pandemic following a season of extraordinary bushfires, it has barely been acknowledged that community pharmacy staff are one of the highest risk groups for long-term psychological impacts. To our knowledge, very little research has addressed the toll of these cataclysmic events on this group of essential healthcare workers. A pandemic of unprecedented consequence is currently affecting almost every corner of the globe. The COVID-19 pandemic began in December 2019 in Wuhan, China, and by March 2020 had spread across the globe affecting nearly every country. [1] As of 4 May 2020, approximately 3.44 million cases and 240,000 deaths worldwide have been confirmed and attributed to this virus by the World Health Organisation. [1] The first Australian case was reported on 25 January 2020 in the state of Victoria. While the world had been dealing with the COVID-19 crisis since December 2019, Australia had barely emerged from another crisis -the 2019-2020 Australian bushfires. Australia was severely affected by hundreds of bushfires which started in September 2019 and raged through to early March 2020, resulting in 18.6 million hectares of land and 2779 homes being destroyed, and death of at least 34 people and about 1 billion animals. Emerging from one crisis into another without adequate recovery time has been very challenging for Australian society generally; however, the primary healthcare sector has faced specific challenges of its own. The evacuation of people from bushfire affected areas saw the need for afterhours dispensing as well as emergency supply to people who had lost their homes to fires with necessary changes to the legislation. [2] Generous pharmacy owners were reported to have provided essential items either at heavy discounts or at no cost for those who had lost everything in the fires. [2] Pharmacy staff also continued to work despite having lost their own homes and without electricity at affected pharmacies. [3] Whilst hailed as heroes and applauded for incredible community-mindedness during the bushfires, community pharmacies were soon after hit hard by the COVID-19 pandemic. Like in many other countries that are either in lockdown or have heavy restrictions of social isolation, Australian community pharmacies are one of the few outlets to remain open to service their clients throughout this crisis. Community pharmacy staff were placed in a unique role, being frontline healthcare professionals with a high accessibility in their communities. However, the ability for anyone to be able to walk in and ask for advice, places pharmacists not only in a vital position in community education and healthcare but also at significant risk. Many community pharmacies have seen an increase in demand for extra services, including deliveries as well as the standard client care. These demands have been supported by the Australian Government's initiatives encouraging telehealth appointments with prescribers who are then able to send digital copies of prescriptions to pharmacies in some Australian states. [4] These initiatives, whilst vital for those who are vulnerable and need to stay at home, have increased the workload and put further strain on community pharmacists who are already considered to be 'overworked'. [5] The main burden of all these changes came from confusion and frustration around what was legal and what was not. In Australia, different states have slightly different legislations for the supply of medications. So, changes were often made at the state level with factsheets often not clearly explaining expectations and allowances to pharmacists. [6] Allowance of emergency supply for prescription medicines were often restricted to a specific timeframe and location. For example, emergency supply of medications was only allowed in the most bushfire affected area of Kangaroo Island in South Australia until the end of March. [7] However, this has since been extended in the wake of COVID-19 pandemic. [6] Community pharmacists have been required to rapidly adapt and alter how they work whilst being surrounded by confusion about what protocols they should be following and uncertainty of what the next day will bring. [8] Conflicting advice from the Australian Department of Health (2020) [9] and other agencies has also led to increasing frustration, particularly surrounding the use of face masks or other personal protection equipment (PPE). Pharmacists have been mostly unable to access PPE due to supply shortages, [10] forcing many pharmacies to install Perspex 'splash-screens' at their own expense in an effort to protect themselves, their staff and clients. [11] Understandably, an overarching feeling of panic, confusion and frustration has set into the public's mind over the last few months. Concurrently, news outlets have been reporting unfortunate instances of abuse in community pharmacies over new regulations limiting the number of some items able to be purchased as well as medication shortages, real or perceived. Acute effects of rapid changes to workload and workflow can result in increased anxiety and stress. Community pharmacists are working under immense pressure trying to balance the professional obligations of serving their communities appropriately with their own personal and mental healthcare needs. They not only have the duty of providing for their communities but also a personal duty of keeping their families safe. Working in situations where they are exposed to trauma for which they feel unprepared, as in the case of the bushfires and now the pandemic, community pharmacists may also experience moral injury described by Greenberg et al. [12] as the psychological distress that results from actions, or the lack of them, which violate someone's moral or ethical code. Working under immense pressure for the last 11 months (since the bushfires in September 2019), has placed community pharmacy staff in one of the highest risk groups for long-term psychological impact. In those predisposed, symptoms of acute and long-term psychological trauma are likely to emerge. Insomnia, anxiety and distress are most prominent as an acute response to trauma. Additionally, there are feelings of loneliness, imposter syndrome or survivor's guilt if they feel like they are not doing enough. In the longer term, these could evolve into major depressive disorder or post-traumatic stress disorder (PTSD) in some individuals. Pharmacists experiencing a mental health diagnosis such as anxiety, depression or PTSD are likely to require treatment from a GP or a mental health practitioner in addition to peer support from a colleague. In Australia, the Pharmacists' Support Service (PSS) provides anonymous and confidential peer support over the telephone using a model of crisis support similar to Lifeline Australia [13] using the skills of trained volunteers who are all pharmacists (currently practising or retired). During both the bushfires and the COVID-19 pandemic, the service has provided support to all frontline pharmacy staff. The support provides the opportunity to debrief with someone who understands community pharmacy practice (crisis counselling and peer support), gives vital information and 'signposts' other sources of assistance and treatment. However, this service does not provide clinical assessment, psychological or pharmacological treatment. During the most acute 6-week period of the COVID-19 pandemic (between 12 March and 24 April 2020), the PSS received a massive 88% increase in calls from distressed pharmacists when compared with the same time period in 2019. [14] The most common reasons for calling related to COVID-19 were regarding own physical and mental health including, stress and anxiety, clinical matters relating to patient care, employment conditions and workload. [14] Other reasons included, legal issues relating to medication supply, conflict with either the pharmacy manager or owner, perceived bullying and conflict with patients. [14] On World Pharmacists' Day (25 September 2020), the Australian Federal Health Minister, Mr Greg Hunt, made a public statement acknowledging the 'outstanding work of Australia's pharmacists and pharmacy staff in communities across the nation, specifically keeping their doors open to support Australians throughout some of the most challenging times in our history, including bushfires, floods, drought and a global pandemic.' [15] In the long term, governing bodies and professional agencies should come together and provide a forum for community pharmacists to safely discuss the emotional and social challenges that they had faced during the bushfires and the COVID-19 pandemic. This cathartic process should allow for reflection and learning in identifying issues specific for the community before formulating appropriate actions using the 'community needs assessment model' as a guide. [16] This process can also identify other support mechanisms that can be put in place for the future, should another crisis arise. Implementing changes and training frontline healthcare workers, especially in the community setting, should be actively done to ensure that regardless of their setting all frontline healthcare workers will not be caught out again. Additionally, future studies must be designed to include community pharmacists and their staff, enabling greater understanding of the immediate effect that pandemics can have on these key frontline health professionals. An elucidation of potential triggers in these situations will help direct planning for future disasters. Pharmacy staff are essential workers and it is important to ensure that they maintain their mental health and wellbeing so that they can continue their vital role as the medication experts and provide essential professional services to their communities. BAM: performed the literature search, designed the table, data interpretation and wrote the article; KD: data interpretation and wrote the article; EH: data interpretation and wrote the article; VS: performed the literature search, designed the table, data interpretation and wrote the article. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sector. World Health Organisation Pharmacy services in bushfire crises Amid the ruins of the NSW bushfires this pharmacist is keeping his doors open Prescription rule changes to support telehealth Pressure rising for overworked pharmacists National President's Message: COVID-19 Update Bushfire update and emergency dispensing provisions. Australian Pharmacist Here's how community pharmacies are adapting to COVID-19. Australian Pharmacist Novel coronavirus (COVID-19): Information for clinicians. Australian Government Pharmacists call for more protective equipment to deal with potential coronavirus cases On coronavirus frontline, pharmacists face assault, abuse and threats. The Sydney Morning Herald Managing mental health challenges faced by healthcare workers during covid-19 pandemic Research and evaluation of crisis lines There is still a higher-than-normal level of anxiety in pharmacy World Pharmacists Day 2020: $25 million investment to improve the safe use of medicines through pharmacy. Australian Government Community needs assessment Mrs Kay Dunkley is the Executive Officer of the Pharmacists' Support Service. The other authors declare that they have no conflicts of interest.