It’s hard to know how to support healthcare staff at the moment. In fact, I can’t think of a time when it’s been as difficult. They seem desperate, despairing and bone-tired. Many of them are tearful and overwhelmed.
We know that large numbers of doctors, nurses, paramedics and allied health professionals have already left the NHS. The reason they give for leaving has become depressingly familiar: they simply don’t feel they can do their jobs properly or sustain their health and wellbeing in the present circumstances.1 Put more bluntly, the NHS has arguably become a dangerous place for staff and patients.
Of course, there are areas that are still offering an exceptional service. But with beds blocked because of the lack of social care and patients waiting for hours to get into accident and emergency (A&E), ‘good enough’ is no longer the norm.
How can we as counsellors and therapists support healthcare staff in a way that makes a difference, when working conditions are so difficult and morale so low? Perhaps the first task is to acknowledge to ourselves the enormity of the stress that healthcare staff are under, and at the very least bear witness. They are working in a system that is cracking at the edges for a multitude of reasons. There has never been a harder time to be a GP, a junior doctor on a medical ward, a nurse in A&E, a paramedic, a midwife – indeed, most clinical roles across the service.
Planning and resources have not kept up with increasing needs, and an ever-growing number of vacancies means staff are more and more stretched. In England alone, there are more than 130,000 vacancies across the NHS, a third of which are nursing posts.2
It is uncomfortable, being on the edge of such a system. There are no easy ways to help. And platitudes about self-care or assigning diagnostic labels can miss the point. By the time these clinicians reach out to someone like me, they have usually covered all the basics: researched their symptoms, downloaded relaxation apps and joined supportive WhatsApp groups.
We can also make sure we understand the impact of the situation on people’s mental health, which is why I want to focus in this article on the concept of ‘moral injury’. In my experience, most healthcare workers who seek psychological support do not have a long-term mental health diagnosis. They are normally well-functioning people, who have been pushed by circumstances to breaking point.
I shall try to summarise the issues and psychological factors that I think are important, concentrating on the acute experience and legacy of the pandemic. But I will also reflect on the impact of systemic pressures that have been around for years, and have continued to build up over the past few months.
Counsellors and psychotherapists know that both individuals and society tend to pay a price if they move on from trauma without the space to process the emotions involved and without understanding the impact of the experience. Of course, it’s not difficult to see why people want to forget about the horrors of the pandemic and shake off memories of lockdowns as quickly as possible. But those who have been hurt by the experience can then be left isolated with their grief and struggling alone with a complex mix of emotions.
Coronavirus affected us all, but already it is all too easy to forget how frightened we were of dying or passing the disease on to others, and how isolated our lives became as our physical links with family, friends and colleagues were fractured. Some of us were lucky and have bounced back relatively easily; others have a strong sense of being scarred and have emerged physically or mentally weakened. Many healthcare staff had a particularly traumatic time. Many also boxed away their more extreme experiences, getting through as best they could, but with no time to process what was happening to them.
It is difficult to know how many staff still struggle psychologically as a result of the pandemic, difficult to disentangle their experience during the worst of COVID-19 from the ongoing stress of recent months. But my sense is that the pandemic continues to take its toll. Many look back at those months of horror and feel good about the way they stepped up to the challenge. Some describe a degree of post-traumatic growth. But, for others, the experience has darkened their outlook, narrowed their expectations and filled them with fear that is easily triggered into panic. It has left them disillusioned and cynical about a society that lacks understanding of the role they played during the pandemic. Many also feel unsupported in the role they continue to play, treating the severely ill.
It is not uncommon for individuals who seemed to demonstrate resilience during the worst of the pandemic to suddenly break down months later, in response to a seemingly minor trigger – sometimes, for example, the failure to be paid on time (an alarmingly common occurrence for trainee doctors, who tend to move between hospital trusts). The trigger is often a harsh, out-of-touch response from someone in the wider NHS system.
For example, one junior doctor – let’s call her Tasha – presented to me recently, after requesting to take some compassionate leave in order to attend the funeral of her aunt. To her disgust, she was asked for evidence that the relative had died. Tasha had worked for five years as a junior doctor, without taking any sick leave. She had also worked extraordinarily long hours during the worst of the pandemic. But this brutal and bureaucratic response, by an administrator she had never met, to her request to attend a family funeral precipitated a psychological breakdown.
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She found she couldn’t get up the next morning. When I saw her about a week later, she had hardly left her bed, hardly eaten. She stared at the floor, just repeating: ‘I’m finished. They’ve done me in.’
It took weeks before she was able to describe the despair she had felt during the first phase of the pandemic – nearly three years before. Tasha had been isolated, having moved just before the pandemic to a peripheral hospital where she knew no one, as part of her training rotation.
Many doctors and nurses working on the frontline in hospitals perhaps got a skewed perspective of COVID-19. Tasha, for example, had only seen the most severely ill, hospitalised patients and did not leave the hospital grounds for months. She had become convinced we were all doomed and she hated the thought of dying alone in this outlying town. Tasha spent a lot of time composing letters to her training lead, asking if she could move back to the main hospital, so she could die with her friends. Tasha never sent the letters; to outsiders, she seemed to be coping fine, rising to the challenge of the pandemic and all the problems it threw up for her clinical practice.
My role during the pandemic was to support frontline staff, mostly from the intensive care units (ICUs). I shall concentrate on their experience. It tells an extreme story, but many of the factors that made the experience so difficult – the high death rate, distressing nature of the illness, the personal risk and the number of people who died without the support of loved ones – were shared across health and, indeed, social care.
The death rate was higher than during normal times in ICU. Staff were sometimes having to process three or even four deaths during a single shift. A huge number of very ill patients were arriving in quick succession, all with this frightening new illness that we knew so little about. Guidelines were changing all the time, creating a great deal of uncertainty. Makeshift wards were being set up overnight in operating theatres, recovery rooms, seminar and coffee rooms. Junior clinicians were therefore more spread out, often left to manage things on their own for hours.
Clinicians themselves were dying in large numbers. After a few weeks, it became clear that clinicians from ethnic minority groups were dying in higher numbers, although no one knew why. A high body mass index, diabetes, diminished immunity and, of course, age were also risk factors – and everyone was supposed to be risk assessed. But there was a desperate shortage of staff with the right skills. I met a number of vulnerable clinicians with diabetes or on immunosuppressants, who continued to work all the way through, despite their heightened risk.
It was often the youngest nurses who had the highest exposure to COVID-19 patients, because they were seen as the least physically vulnerable. But they were sometimes frightened and overwhelmed by what was expected of them; senior nurses felt full of conflict that they were not leading by example. Remember how badly protected these staff were. For the first few months, personal protective equipment (PPE), including properly fitting masks, was unavailable. Staff had to protect themselves as best they could with bin liners and masks from local hardware stores.
A lot of clinicians talked to me about their fear of dying, particularly during the first phase. We live in a culture that sees positive thinking as the solution to most problems. And the communication across the NHS trust was relentlessly positive: buddy schemes, free relaxation apps, lots of talk about resilience, mindfulness training, free streaming of jolly films. But it didn’t work during the pandemic, when healthcare staff died across the world in large numbers. People needed to talk about how frightened they were, the fact that their masks didn’t fit properly, the fear of having to care for ‘one of their own’.
With most of the people I worked with, the fear of their own death was small compared to the fear that they might infect other people. Some sent their children away; others stayed apart from their families, often in cheap hotels. Many described elaborate homecoming rituals that involved no contact until they’d stripped off, showered, disinfected their clothes, car, mobile and keys.
I gradually became aware that there was also a fear of contaminating others with the horrors they were witnessing. It felt too dangerous to talk to their families about their experiences. They were frightened of traumatising them. I was particularly surprised that so many young, female nurses
were protective of their male partners, who they felt were too squeamish to be told what was really going on.
A senior nurse told me that she no longer found it helpful to see friends: ‘It feels like this experience has set me apart. I wouldn’t know how to talk about it, but other things, ordinary things, just don’t register anymore.’
In my recent book,3 I write about Stacey, a nurse who came to see me because she was worried by the behaviour of Tammy, her nine-year-old daughter. Tammy had become very clingy and was struggling with nightmares, waking up at night, screaming with fear and refusing to sleep, except in bed with her mother.
Stacey had banned all talk of the pandemic in the household, wanting to protect her daughter. But, paradoxically, this enforced silence had made the child’s anxiety worse. We discussed how Stacey might make it possible for Tammy to ask the questions that were on her mind. It emerged that Tammy was indeed terrified that Stacey would catch COVID-19 at work and die.
Stacey found it easier than she had imagined to talk in a way that a nine year old could understand. She showed Tammy a photo of herself in full PPE, looking like an astronaut – a photo that Tammy was later to show proudly to her teacher and her classmates, explaining what everything was for and how it kept Stacey safe. Tammy’s anxiety symptoms resolved within a few weeks.
In our first meeting, I often ask a new client if they are haunted by a particular memory. Some describe a gruesome death; some a patient they particularly identified with. Kevin, for example, was eventually able to link the start of his disabling, severe panic attacks to the time he had to nurse another healthcare worker, a man who had two children who were the same age as his own. ‘I couldn’t get over the fact that he’d been perfectly well three weeks earlier. And it was awful, a really horrible death... I can still remember his eyes when he was first admitted to the unit and realised where he was. They seemed to be fixed on me and so full of fear, like every breath was killing him... he was begging me to do something.’3
The swift progression of the infection meant that people could suddenly present as acutely ill and die frightening deaths, despite everyone’s efforts. And it was a stark lesson in helplessness for many clinicians.
A particularly distressing issue for all the clinicians I saw during the pandemic was the fact that many people died without their loved ones at hand. The absence of family and friends went against everything they felt was important. Moreover, they found communication with the families utterly harrowing, despite being experienced and skilled communicators of bad news. They found it deeply disturbing to have to convey to people they had never previously spoken to or seen face to face that the patient, perfectly well a few days ago, was about to die.
They were only too aware, particularly in the first year of the pandemic, that many of these family members were also socially isolated, with no one around to offer comfort. A junior doctor described a heart-breaking situation where she had to break the news through a small child, the only person in the household who spoke English.
So far, I have described some specific aspects of the traumatic nature of working on the frontline during the pandemic. I was also surprised to find that only a relatively small number of people I saw fit the diagnostic label of post-traumatic stress disorder (PTSD). Perhaps clinicians are used to working with trauma and have become adept at protecting themselves emotionally when necessary. I was enormously impressed to witness the creativity and courage of ICU staff.
On the other hand, almost everyone I saw described some level of what is now called ‘moral injury’, with significant symptoms of depression: helplessness, hopelessness, despair and, in some cases, suicidality.
Moral injury4 occurs when people encounter situations that force them to tolerate circumstances or act in a way that goes against their ethical and professional values. It has been shown to be a major contributor to stress and can cause impaired function and feelings of shame, guilt, disgust and anger, sometimes leading to suicidal thoughts and longer-term psychological harm, particularly if the circumstances are prolonged. The levels of anguish, and the sense of alienation that people experience, distinguish it from other mental health diagnoses, such as PTSD.
Moral injury became common parlance during the pandemic. Previously, all severe work stress was subsumed under the term ‘burnout’ – a concept that hints at a lack of resilience, individual weakness or, at best, overwork. I find the idea of moral injury useful, because it places the problem at the intersection of the individual and the organisation within which they work. It lays bare the price that is paid by individuals when institutionally required behaviour fails to align with one’s moral principles and professional standards. Increasingly, this is about lack of resources.
For example, many clinicians are attracted to work in ICU because of the one-to-one care they can give to a patient. They might be treating the most severely ill patients in the hospital, but there is satisfaction in knowing that they are doing everything possible to help them. All of this changed in the first weeks of the pandemic. Nurses who were used to focusing on one patient were now expected to attend to six patients, often supervising inexperienced staff who had volunteered from other areas of the hospital. It was more like working in a war zone than anything they had previously experienced.
A few months on, it is A&E departments that are likened to war zones. Almost every day we hear of queues of ambulances waiting for hours to unload the critically ill, patients in trolleys lined up in corridors and emergency operations taking place in store cupboards. Outside my local hospital in Leicester, the work of A&E has extended into a permanently parked bus and a tent.
In my experience, most healthcare workers are fierce supporters of the concept of the NHS. But their fury, grief and sheer exhaustion run deep. So, it is perhaps not surprising that the risk of suicide in healthcare workers is rising. It is also significantly greater than in the general population, prompting Professor Clare Gerada, President of the Royal College of General Practice, to describe suicide as an occupational hazard.5
Counselling and support services for clinical staff tend to focus on triage, the importance of spotting those who are seriously mentally ill and in danger of making a suicide attempt. But that is not what this article is about.
My experience doing this work during the pandemic brought home to me, as a psychiatrist and psychotherapist, how ordinary, hard-working, resilient people can be pushed over the edge by adverse conditions, particularly if they are prolonged.
Charities involved in disaster work overseas have generous leave arrangements and carefully rotate their staff away from the frontline every few weeks, mindful that the sheer volume of death and gruesome illness, the frustration at being able to do so little for patients and the moral distress caused by the far-from-ideal conditions push their workers to their limits. There was not only no recovery time for NHS staff between the various waves of the pandemic, but they are also emerging nearly three years on to find the NHS itself fighting for its life.
To return to the question I posed at the start: what does this situation mean for those of us trying to support healthcare staff who seek the help of counsellors and therapists? I shall finish by picking out the salient points:
- sometimes the best we can do is bear witness, as we help the staff member face and process their feelings
- resist the pressure to ‘move on’, forget or minimise past and present trauma
- recognise the systemic climate and conditions
- acknowledge the erosive effect of moral injury
- help them regain some sense of agency
1 Thomas R. Record levels of NHS staff resign as nurses say they are ‘broken’. The Independent 2023; 13 January. [Online.] www.independent.co.uk/news/health/nhs-staff-resign-record-b2261689.html (accessed June 2023).
2 Campbell D. NHS vacancies in England at ‘staggering’ new high as almost 10% of posts are empty. The Guardian 2022; 1 September. [Online.] www.theguardian.com/society/2022/sep/01/nhs-vacanciesin-england-at-staggering-new-high-as-almost-10-of-posts-empty (accessed June 2023).
3 Campling P. Don’t turn away: stories of troubled minds in fractured times. London: Elliott & Thompson; 2022.
4 British Medical Association. Moral distress and moral injury: recognising and tackling it for UK doctors. [Online.] London: British Medical Association; 2021. www.bma.org.uk/media/4209/bma-moraldistress-injury-survey-report-june-2021.pdf (accessed April 2023).
5 Gerada C. ‘Psychological PPE’ is what Britain’s health professionals urgently need now. The Guardian 2020: 16 October.