Psychological clap back

It was only when Emma took some leave in June that the horror of the previous few months really hit her.

“It is simply heartbreaking to see the toll this virus is taking on our frontline staff.”

An experienced critical care nurse at a busy northern hospital, what she saw during the first wave of the pandemic contributed to a mental health breakdown that resulted in her being sectioned. She remains off work, having raised money via a crowdfunding campaign to speed up access to specialist treatment for her complex post-traumatic stress disorder (PTSD).

She says: “Off work, I suddenly had time to think about it all. I started getting flashbacks from previous domestic violence and I couldn’t stop thinking about specific patients and interventions which went against how we normally worked.

“It got more and more intense and I was in a hyper-vigilant state. My GP gave me a two-week sick note but I was still feeling on the edge and constantly crying. One day I phoned my matron and told her how I was feeling. They called an ambulance and I ended up being sectioned.”

Emma’s experience is not unique. Concerns about the impact of burnout on an over-stretched and exhausted NHS workforce are now widespread.

Years of under-investment and staff shortages have made the winter surge an annual challenge for the NHS. Covid-19 created a perfect storm, the impact of which could be devastating.

Worries about the availability of PPE, the deaths of colleagues and the fear of passing the virus onto loved ones all contribute to the mental burden for those working at the frontline, along with evolving job roles, new working patterns and intense workloads.

Those who feel they are having to do things that transgress their ethical codes of conduct can experience what is known as moral injury. This can just as easily affect people working in non-clinical positions, who are forced to make difficult decisions about care.

In May, the shadow minister for mental health, Rosena Allin-Khan, a doctor, called for greater access to PTSD support and talking therapies for health workers.

“NHS and care staff are breaking down – I see it first hand, working shifts. It is simply heartbreaking to see the toll this virus is taking on our frontline staff,” she wrote in a letter to health secretary Matt Hancock.

“Our frontline NHS and care staff are doing fantastic work in extremely difficult circumstances. They risk their lives every day in order to protect us. Unless our staff are protected, they cannot continue their vital work of keeping us all safe.”

NHS data shows the North West has the highest sickness absence rate across NHS England, at 4.7 per cent in July. The North East and Yorkshire rate was 4.2 per cent and the average 3.88 per cent.

The three northern trusts with the highest sick rates were Mersey Care NHS Foundation Trust at 6.74 per cent, North West Ambulance Service at 5.78 per cent and Bradford Teaching Hospitals NHS Foundation Trust at 5.75 per cent.

Anxiety, stress, depression or other psychiatric illnesses are consistently the most common reason for absence – accounting for 32 per cent of sick leave nationally.

In a survey of more than 1,300 staff by the NHS Confederation’s Health and Care Women Leaders Network, 72 per cent said working through the pandemic had led to a decline in their emotional wellbeing. The Royal College of Surgeons found more than 60 per cent of the 900 doctors it surveyed had felt down, depressed or hopeless during this period.

The universities of Hull, York and Durham are tracking the experiences of more than 50 critical care nurses in a longitudinal study.

Nicki Credland, head of the paramedical, peri-operative and advanced practice department at Hull – and chair of the British Association of Critical Care Nurses – says many are struggling.

“During surge one we cancelled other services and moved staff to support those nurses but this time the government doesn’t want to stop the routine surgery,” she says. “We understand the reasons for that – except you can’t have it both ways. There’s a finite number of staff. You either have your staff doing routine care and surgery or you have them there to manage the escalating situation.”

They are also physically exhausted. “Unless people have worked in an ICU under this kind of stress, wearing full PPE and dealing with the full complexity of patients, they don’t understand what it means,” she says. “And when you’re doing that for days and weeks and months on end, that’s physically and mentally exhausting.”

Credland knows of numerous nurses who have been diagnosed with PTSD – including some, like Emma, who have been sectioned under the Mental Health Act.

“We are asking our staff to go above and beyond what anyone would expect,” she says. “It’s so important that we look after them. It doesn’t matter how many ventilators or beds we have if we don’t have the staff to look after the patients.”

Professional bodies have been pushing the government on this issue and things have been happening. NHS workers have access to a dedicated phone and text support service and there is a bereavement service for those who have lost friends or family to Covid-19 or otherwise. There are also online resources and free-to-access mental health apps.

The NHS Clinical Leaders Network (CLN) is partnering with the Manchester University on a study of North West staff who are working directly with Covid-19 patients.

Participants answer a series of questions, and are then provided with
a list of local support services tailored to their needs. The anonymous data will be analysed by trust, area of practice, gender, ethnicity and banding. It is hoped trusts may use this information to develop appropriate support for their staff.

Jan Lawry of the CLN says: “The results should be really interesting because we don’t really know who is having the greatest trauma by seeing these patients. We think we know but we don’t.

“It could be the healthcare assistant who goes into work day after day and sees these patients, goes home and has no one to offload to. It may be a respiratory consultant. It may be the nurse who has to turn off all the machines and then phone the relatives when someone dies. Staff haven’t recovered from the first wave and now here we are, in the thick of it again.”

Some trusts have put in support for their employees but access is a postcode lottery. Greater Manchester Resilience Hub offers staff support from mental health clinicians, therapists, recovery workers and psychologists. Derby Royal created a so-called wobble room – a time-out place for staff to go and have a cry if they need during the day. Other places are hosting mindfulness and yoga sessions – often initiated by employees themselves – while some staff find private Facebook groups a useful way to offload their feelings.

NHS organisations can also procure supplementary occupational health support for their staff, until the end of this year.

Paul, a former mental health nurse, is part of this expanded support at one northern trust, where staff can refer themselves to the service. He provides up to six sessions of cognitive behavioural therapy to those who need it, while those who require more specialist intervention get referred to an external service. His clients include managers, healthcare assistants, community health staff, porters and kitchen staff, and the demand is huge.

He says: “What they are all struggling with is the way the system has changed due to Covid. Many are working in different roles and that’s difficult. If their job involves risk assessment, which they now have to do remotely, the consequence of getting it wrong is that people could suffer.”

When people become stressed, the symptoms of any underlying physical or mental conditions can worsen, he says. Normally, staff based in the community receive informal support from their colleagues but due to remote working this is now absent, which is causing problems for many.

“It’s hard having to support people over the phone as it’s like having one hand behind my back, but we do the best we can,” he says. “Most of the time we’re giving them strategies for self-management of their stress but, long
term, it depends whether people
maintain them.”

While staff wait for their bosses to catch up, some outside the NHS have taken matters into their own hands.

In March, counsellor Claire Goodwin-Fee took to Facebook to invite colleagues to volunteer a few hours a week to support NHS and social care staff who may be struggling emotionally. Eight months on, her organisation Frontline 19 has 3,500 therapists on its books and has worked with thousands of people – around 1,200 are currently accessing the service.

They fill out a simple online form and Frontline 19 aims to match them with a counsellor within 24 hours. There are also trauma specialists who can talk to health workers who have had a particularly difficult shift and the service has access to a psychiatrist if needed.

She says: “Unfortunately a lot of NHS staff have really struggled during this period. Legally I can’t diagnose PTSD but we are seeing signs in some people. Few of us would be emotionally equipped to deal with the intensity of what they’re facing at the moment, I think.”

Within the NHS, if an employee is unwell there is a process to follow, with a manager required to make a referral to occupational health, which can take weeks. But when someone is in crisis they need support quickly – something a grassroots organisation such as Frontline 19 is able to offer.

Goodwin-Fee says: “When we began, we were hearing of NHS trusts which had no emotional health service at all. They just told their staff to go to their GP or Mind. If you can get to someone who is experiencing trauma quickly, the long-term impact is lessened so this is really important. If there’s a 20-week wait for support, what are people meant to do with that?”

Her experience during the pandemic has convinced her the NHS needs to think more long term and she is considering ways to get involved in
this work later down the line.

“Staff tell us what they really want is to feel supported,” she says. “Putting structured, long-term support in place would probably be cheaper than a pay rise. It blows my mind that there isn’t more mental health training in the NHS. People could learn basic things like how to speak to colleagues to make sure they’re okay, and how to talk about thoughts and feelings.”

Others also hope there may be a culture change. The CLN plans to take its study findings to the government following evaluation early next year, to push for more mental health support.

Lawry says: “If you had suggested doing mindfulness to hospital staff five years ago there may not have been much interest but we are now seeing creative ways of being supportive of each other.

“We’re hopeful that after we’ve dealt with Covid, health trusts will do more to proactively look after staff health and wellbeing – not reactively like they have been doing, but from the day they join.”

The government says NHS staff will get rapid access to expanded mental health services that are being rolled out across the country as part of efforts to deal with the second wave of coronavirus and that £15 million is being invested into this work.

Staff referred by themselves or colleagues will be rapidly assessed and treated by local mental health experts. Those with the most severe needs will be referred to specialist services and there will be outreach work among those deemed most as risk, such as critical care staff. And wellbeing and psychological training is being developed and is set to be rolled out this winter.

A Department of Health and Social Care spokesperson says: “Supporting the mental health and wellbeing of our staff is a top priority, and we understand the huge pressures they face – particularly during this unprecedented pandemic.

“The NHS recently injected £15 million to strengthen mental health support for NHS staff and ensure rapid access to mental health services as we head into winter. A range of services are already available, including a mental health hotline, practical support, financial advice, and specialist bereavement and psychological support.

“We would urge anyone struggling to come forward and speak to a colleague, their occupational health team, or to call the helpline so that they can get the help they need.”

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Patients became ‘just a body’

The weeks before Emma was signed off work were hugely emotional. One day, six patients died.

“The worst part for me is when you have to cover their head with a sheet,” says the critical care nurse. “These were patients but as soon as they had died, they had just become a body. I was in full PPE and cried.”

The hospital where she works normally has around 20 intensive care beds and 20 high dependency beds. Other areas were opened up as the number of Covid patients rose, until they had more than 75 patients.

A single parent, Emma had to fit in work with school hours – but this meant she missed handovers and debriefs. At home with her young child, she was unable to process what was happening.

The way working practices had been altered by Covid bothered her and she found it difficult to shake feelings of guilt towards her patients.

“Normally we get to know them through their relatives so it was difficult not being able to do that,” she says.

With Covid patients, staff used certain drugs differently from how she had been taught and the turning of patients onto their fronts – known as proning – was tough.

She says: “We usually see good results with proning but there is more risk of pressure sores and of damaging people’s eyesight. We usually ventilate people without any issues but with a lot of our Covid patients we had to use paralysing agents, which meant they needed more sedation. But this can cause peripheral shutdown in fingers and toes.”

She knows understanding of Covid and how to treat it has improved while she’s been off. “But that makes me sad about my patients,” she says.