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With repeated attacks on medical facilities and staff shortages, Ukrainian healthcare providers are grappling with a burnout crisis driven by direct and secondary trauma, according to experts.

International medical aid organizations have been working with the country's ministry of health to develop interventions to help Ukrainian physicians and nurses combat these challenges. One group, , recently completed the pilot phase of a new training program to help providers who had endured an unexpected and personally devastating series of events during the war with Russia.

"There was a shortage of physicians all over Ukraine and more specifically of psychiatrists and mental health workers," Maya Bizri, MD, MPH, who created the training program, told 番茄社区app. "[We] wanted to train physicians that had no mental health background on how to provide adequate care to patients that have been exposed to trauma."

Bizri, who is also the founding director of psycho-oncology at the American University of Beirut Medical Center, spent 6 months developing the curriculum before traveling to Lviv to conduct the pilot training with a small group of healthcare workers at a pediatric oncology hospital.

A by human rights groups found that there were over 700 attacks on healthcare infrastructure in Ukraine in 2022, including hospital bombings. From the start of the war on Feb. 24, 2022, to the end of the year, 86 attacks targeted healthcare workers, killing 62 people and injuring 52 others. The attacks on healthcare facilities and workers greatly reduced the country's capacity to meet people's medical needs, and the report noted that by December 2022, one in every three Ukrainians experienced loss of access to medical services.

"How do you account for the shortages in human resources? You can't tell someone to go see a therapist when there are no new therapists taking patients," Bizri said.

"It creates a lot of moral distress because you know you could do better if you had more resources," she added. "I think a lot of the experience as a physician is really coming to terms with and not feeling guilty about not providing, but really making sure that what you're giving your patients are sustainable and viable solutions."

Fighting Burnout

In an effort to address the burnout crisis, Bizri said the training focused on giving providers ideas on how to identify burnout and trauma in themselves and in their colleagues, and on how to handle those issues with few supporting resources.

The program used a model called Skills for Psychological Recovery, a manualized, evidence-based approach that helps providers teach patients to manage severe emotional reactions and create a social support system.

The training consisted of four modules that were chosen to provide ideas and resources unique to healthcare workers.

The first of the four modules targeted hospital leaders and executives to address the systemic causes of burnout. The second and third modules focused on healthcare workers as patients, and the fourth module focused on helping providers deal with challenging patients who had experienced trauma.

"Honestly, it's a lesson in humility," Bizri noted. "It's an eye-opener on how similar these experiences are across different cultures, and it just goes to show you that it does work, regardless of what you're trying to teach them, going through basic skills, like problem solving, managing reactions, building social networks. These really are skills that would prevent mild symptoms from developing into disorders."

Bizri highlighted the unique challenge of dealing with providers who had much different experiences within the war, including those who were dealing with trauma and survivor's guilt, as well as secondary trauma when dealing with patients.

"These were physicians or nurses who early on in the war had moved to the safer area of Ukraine from combat or frontline areas, and they had the added burden of feeling survivor's guilt, meaning they had left their families behind," Bizri said. "They were taking care of strangers where they felt they should be taking care of their own families. They felt they had disappointed their families."

"[What] I found very humbling was how open everyone was about sharing their experiences in a group setting," she added. "People [were] crying, sharing their stories; it was extremely humbling."

Though the overall feedback from participants was positive, Bizri said there were challenges as well.

For example, while Bizri was accompanied by an interpreter who translated her lessons simultaneously and program participants said they understood her meaning through her gestures, they also felt that important concepts were lost in translation.

Bizri plans to rework the program to better address the needs of participants like the ones she worked with in Lviv. The new approach will have Ukrainian mental health professionals conducting the training to meet their colleagues' needs with empathy and understanding, as well as cultural and language-based efficiency.

From Personal Experience to International Aid

Bizri came to the project with a personal perspective on the challenges of providing healthcare in a crisis. In 2019, she moved from the U.S., where she trained in psychosomatic hospital consultation at the Cleveland Clinic, to Beirut to start the psycho-oncology program at the American University of Beirut Medical Center.

In August 2020, a storage hangar near the city's port holding more than 3,000 tons of ammonium nitrate exploded, . The blast, as Bizri refers to it, damaged the hospital where she worked, but she said the real effect of the crisis was the enduring toll it took on her fellow healthcare workers, many of whom left Beirut for good. She learned how to manage as a mental health provider and rebuilt her program at the hospital with fewer colleagues and resources.

"I had not deliberately, I would say, chosen to go into disaster psychiatry, it just ended up being that I worked in a disaster setting," Bizri said. "It hits very close to home, and when you see your colleagues going through rough times, it's really something that is interesting to you as a mental health provider."

She noted that this experience helped her develop this training for providers in Ukraine. The work she has started in Lviv is hopefully just the beginning of developing approaches to help Ukrainian healthcare providers deal with the challenges they are facing now and in the future as the war continues.

"Global health has changed," Bizri said. "We no longer have the concept of taking funding ... and going to low-resource settings and applying them. It's really about capacity-building, meaning working with what's present there. And if you can come to terms with that, then I think it's a much, much more scalable and sustainable healthcare system."

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