Reflections on Israeli hospital-based social work with COVID-19 patients and their families

When the pandemic first started in Israel, each person who tested positive for COVID-19 was sent for hospital admission. During the first 5 weeks of the outbreak, our hospital operated a Special Quarantine Unit (SQU) designated for the admission of patients with mild symptoms. Patients functioned independently and were required to attend to their own needs. Communication with the medical team was done using telemedicine technologies, and when needed medical treatment was provided by designated staff who entered the unit wearing PPE.

The main difficulties that arose in this stage were compatible with (1) the need to cope with a new, unfamiliar pandemic, which brings about fear and uncertainty (Maunder et al., 2003), and (2) being isolated and separated from home, which can be an extremely disturbing experience (Abad et al., 2010; Hawryluck et al., 2004; Purssell et al., 2020). Patients were dealing with guilt over the fact that they were infected and may have infected others, and with a feeling of ‘leprosy’ that they were the first to contact this unfamiliar disease.

The prolonged admission under quarantine, the inability to meet family members, and the distance from home were accompanied by a sense of longing, loneliness, and feeling guilty about leaving family members at home. Some patients who had young children at home required guidance on how to explain the situation to their children and felt helpless in face of this ‘distant’ parenting. This complex emotional experience was often accompanied by anxiety about their own medical condition and fear of deterioration.

A social worker was appointed to the unit and contacted every new admitted COVID-19 patient whose medical condition necessitated intake. The intake was done over phone and had three main purposes:

During intake, the social worker mapped out patients’ personal, familial, functional, and medical situation and the resources available to them, and provided as much information as possible on the SQU, including the daily schedule and means of contact with the hospital staff. Orientation to the unit intended to help patients gain a sense of control, thereby decreasing their anxiety of the unknown, and to assist in creating a sense of continuity which was often interrupted by diagnosis and admission. Finally, patients were asked to appoint a contact person, which would be of particular importance in cases where the patient’s health deteriorates.

Psychosocial interventions in the early days of admission focused on helping patients find their place and feel comfortable in the unit, and on decreasing anxiety by providing information and emotional support. In addition, psychosocial problems at the patients’ home were addressed by the hospital social workers as well. For instance, when children were left alone at home because of the parent’s admission, the social worker reached out to relevant community organizations, making sure their needs were attended to.

As admissions became longer, the emotional difficulties related to uncertainty about the time to recovery, as well as anxiety, arose as a response to seeing deterioration of other patients. In addition, loneliness, longing, and boredom increased and became part of many patients’ emotional experience.

At this stage of admissions, interventions mainly focused on creating a daily routine together with the patient. Having a routine provided a sense of control in the new reality of uncertainty and created anchors throughout the day that relieved the boredom. Addressing anxiety was done using distress management techniques such as sharing feelings and emotional support, as well as mindfulness exercises. Aid offered to patients who had witnessed deterioration in the health of other patients included identifying and reducing social comparisons that had negative effects, refocusing on the patient’s situation, and emphasizing signs of improved health.

All communication between the social workers and patients was over the phone. This was an unfamiliar therapeutic setting for the social work team which faced the need to assess patient’s needs, build a therapeutic rapport, and provide psychosocial support remotely and without the ability to express closeness and empathy face to face.

As the disease spread, the location of medical treatment changed. Patients with mild symptoms were referred for treatment in the community and moderate/severe patients were admitted to either intensive care units or designated COVID-19 units. Since many patients admitted to the hospital were dealing with severe symptoms, some sedated and intubated, they were engaged less in emotional help-seeking.

Hospitalized patients who were in need of psychosocial support were mostly those who woke up disoriented and depressed after being sedated and intubated. Providing support to these patients was challenging since the social workers could not enter patients’ areas and they were usually too weak to use digital means for communication. This created a very frustrating reality to the social work team, who could not offer direct support to these patients. Hence, the focus turned to training and supporting the designated staff who enter the units on how to address these patients’ emotional needs. Training focused on regaining patients’ orientation by providing information regarding their whereabouts, ways to assist patients regain a sense of control, emphasizing their medical improvement, and positive reinforcement.

COVID-19 units were closed to visitors, yet given the importance of saying goodbye to patients on their deathbed by their families, the Tel-Aviv Sourasky Medical Center was the first hospital in Israel and one of the first worldwide that enabled first-degree family members to be beside patients in their last moments (Halbfinger, 2020). A special protocol was designed for this matter in order to keep all parties safe and to assist families throughout this difficult moment, and the social worker had an important role throughout this process. According to the protocol, the treating physician contacted the family when it was estimated that a patient had several hours left to live, updated them on the patient’s medical condition, and offered them the opportunity to come at the hospital and stay beside him or her. The social worker contacted the family before arrival, checked whether they had any additional questions, and provided information regarding arrival at the hospital and meeting her. At this point, she became the case manager and the family’s contact at the hospital, offering emotional support throughout their stay in the hospital. Family members met the social worker upon arrival at the hospital and she accompanied them to and through their meeting with the doctor when they were updated about the patient’s medical condition and were given information about entering and visiting the unit. Escorted by the social worker, families then continued to a special room where the nursing staff assisted them in wearing PPE. She did not enter the unit with them but met them as soon as they came out for initial bereavement work. Although these situations enabled face-to-face encounter, physical contact such as a hug or laying a hand on a family member’s shoulder for support was restricted and was a difficult experience for the social worker.