From moral injury to mental illness: we must protect the wellbeing of frontline covid-19 staff
A recent article in The BMJ highlighted the mental health challenges faced by healthcare workers in the covid-19 pandemic. The authors discussed the risks of “Moral injury” which may become the signature injury for healthcare staff dealing with the covid-19 pandemic. Derived from the military, it describes the ethical and moral suffering arising from experiences which strongly clash with one’s moral code. It is likely to be particularly prevalent in psychologically and practically ill-prepared, inexperienced, poorly supported personnel. These situations are now manifesting across healthcare as healthcare workers manage the covid-19 pandemic. Staff have insufficient personal protective equipment (PPE) to protect themselves or to do their job effectively. They are unable to easily communicate with patients or colleagues when wearing full PPE. Many are working in an unfamiliar clinical environment, caring for large numbers of very unwell patients (many of whom die), and may find themselves questioning their competency and training for the role. All of this is likely to exacerbate the risk of moral injury.
Providing care in such situations can understandably create complex feelings of guilt, remorse, and shame; it can also lead to mental illness in some. Yet most individuals facing trauma do not develop mental illness, and many will show post-traumatic growth. How then, should the NHS help staff avoid illness and experience growth instead? At the London Nightingale hospital the welcome letter sent to prospective staff congratulates them on undertaking a rewarding role, assuring them of appropriate support, but also directly notes that the work will be challenging, people may die despite staff’s best efforts and the environmental situation can be uncomfortable.
Well, despite the unprecedented nature of the pandemic, we actually do have precedent in managing traumatic events—indeed a strong evidence base from military experiences, terrorist attacks and natural disasters. The key points, from a psychological perspective, are properly preparing people for the tasks ahead, ensuring that everyone, but most importantly supervisors, are able to have supportive conversations, and having tiered levels of appropriate support.
Induction, or early briefings, should not sugar coat what staff will face: it won’t fool anyone in today’s climate, and it’s the wrong thing to do. Rather than trying to “scare” people, frank preparation affords an opportunity of honest reflection about role-suitability, taking one’s own vulnerabilities and personal-life responsibilities into account. This is also a time to “normalise” in advance what can be unpleasant emotions, and to remind us all of the strengths we carry despite such feelings: it is quite normal to feel both proud and anxious about one’s duties. At the Nightingale, those who do not feel that they fit the role are supported with an exit interview and in looking for other roles.
Staff should be encouraged to support each other: from “buddying” systems to shift-end supervisor-led reviews (quite different from “psychological debriefing” for which there is no convincing evidence of benefit). Attention should be paid to appropriate environmental modification: from the basics of adequate nutrition, rest gaps and furnishings, to easily located, up-to-date local and national support offerings—whether posters, phone-lines, apps, or other digital resources. Many “resilience-building” resources, some covid-19 specific, are being promoted, including a raft of “wellness” approaches, from yoga, through mindfulness, to various other activities. It’s worth noting that whilst usually well-intentioned, the evidence base behind most of them is rather weak. This is not to discourage their use, but more a caution in active recommendation of any particular ones.
After these initial efforts, sometimes known as “primary prevention,” which aim to stop problems developing, a “secondary preventative” level then aims to identify those who may be developing problems so they can be “nipped in the bud.” There are several ways of approaching this, including supervisors having psychologically-savvy supportive conversations with team members or peer supporters directly tasked with “walking the floor” to offer a chance to chat and access informal assistance. Such individuals are likely to need appropriate training to identify those in distress (including indirectly, such as via “presenteeism” and missing meetings) and should be supervised to ensure that they, too, do not become overwhelmed. They also must have awareness of available stepped-up support. There are evidenced peer-to-peer protocols; an example is the “TRiM” (Trauma Risk Management) programme developed by the UK military that teaches awareness of stigma, recognition of signs of mental ill-health, and pathways to care.
Finally, access to professional help will be necessary for some as distress progresses to mental illness. A range of presentations are expected from anxiety and depression to post-traumatic stress disorder (PTSD). Some will be a reactivation of a pre-existing problem, others a new development. Care provision might involve primary care, occupational or mental health services, and the links with, and protocols for, each of these will vary across organisations. What is essential is clarity of accessing these pathways. For mental health services, we strongly advocate a “nimble” rapid approach, not just “more of the same.” The PIES model can be usefully invoked: Proximity, Immediacy, Expectancy, and Simplicity. It does what it says on the tin: ready, fast access, encouraging staff to stay on the frontline where they can, and “de-medicalising” normal responses. Most with early traumatic stress symptoms will find these settle-down spontaneously – though active contact should be maintained to ensure this is the case. However, some will undoubtedly need treatments instigated and formal follow-up commenced.
Covid-19 is testing our clinicians and their wellbeing: nevertheless, we predict that most will avoid illness and experience personal and professional growth. Organisations have an obligation to reduce the former and promote the latter. They should also actively monitor staff wellbeing and treat early where indicated. In truth, “unprecedented” is not a phrase one can use when it comes to the understanding of human responses and needs to enormously challenging times. We already have the evidence base on how to best support people, we need to use it.
Derek K Tracy, Mark Tarn, Neil Greenberg
The authors are consultant psychiatrists currently working at the NHS Nightingale London, where they established and lead the mental health team that provides support to staff. Besides this work, Derek Tracy is a Consultant Psychiatrist and Clinical Director at Oxleas NHS Foundation Trust, London, and a Senior Lecturer at King’s College London, UK. Mark Tarn is a forensic psychiatrist. Neil Greenberg is Professor of Psychiatry at King’s College London, UK.