Introduction
The WHO1 categorises COVID-19 as an infectious disease caused by a newly discovered coronavirus. In March 2020, COVID-19 was declared a pandemic2, prompting the UK government to restrict movement across the country and the National Health Service (NHS) to mobilise emergency protocols. Consequently, many staff working in the NHS were redeployed to combat the developing pandemic. Previous research has highlighted the negative impact viral pandemics can have on healthcare workers’ (HCWs) psychological well-being, thus making supporting staff a priority.3 4
Impact of pandemics on HCWs
Previous viral outbreaks serve as effective templates for understanding how COVID-19 may potentially affect HCWs. In particular, SARS, an outbreak of a coronavirus strain, has notable parallels with COVID-19. Research on HCWs working through SARS has shown identifiable patterns of those at risk of poor psychological well-being, which are informative as we work towards creating interventions to support HCWs.3 4 It is important to note that high levels of psychological distress do not automatically result in long-term affective disorders (ie, depression) or post-traumatic stress disorder. Nonetheless, an increase in compassion fatigue and a depowered workforce is a marked concern.5 6 As such, measuring rates of clinical diagnoses in the absence of factors such as psychological distress, burnout and moral distress may limit our understanding of the impact the pandemic is having on staff well-being, particularly in the early phases.
During the severe acute respiratory syndrome (SARS) pandemic, staff working in high-risk areas showed high levels of post-traumatic stress7, emotional exhaustion4 and self-imposed social isolation due to stigma and fears of contamination.8 Systematic reviews have identified that female staff, particularly nurses and more junior staff, were among those most at risk due to overwhelming workloads, having the highest exposure to infectious patients or having less experience compared with more experienced staff.6 9 10 Regardless of profession, fears of contamination were common and were concentrated on fear of transmission to others, particularly among those with children.6 It has also been highlighted that experiences such as redeployment, increased workload, social distancing, social stigma and self-imposed isolation increased the risk of psychological distress.9 10 Such factors are therefore crucial to assess during the COVID-19 pandemic.
During the SARS outbreak no difference was observed in levels of psychological distress between staff with low exposure to patients with SARS and those with high exposure.4 However, 1 year later, stress levels within the high-exposure group were significantly higher than those classed as low exposure. The perceived stress levels in the high-exposure group were associated with higher rates of depressive, anxious and post-traumatic stress symptoms even 1–2 years after outbreak.3 4 Similarly, there was little difference in terms of psychological distress between HCWs who contracted SARS and those who did not.9 After the outbreak was contained psychological distress seemed to increase; with 90% of HCWs who contracted SARS showing significant psychological distress. Up to 2 years after outbreak, levels of HCW psychological distress remained elevated.6 10 This was associated with higher levels of burnout, depressive and anxious symptoms, poor health behaviours (eg, increased drinking), increased sick leave, decreased working hours and disengagement with patient facing work.
Impact of COVID-19: what’s known
Early reports emerging from China and Italy suggested a similar and potentially more severe impact of COVID-19 on HCWs compared with the SARS pandemic.11 12 In Italy, high levels of emotional exhaustion among HCWs were reported.12 In China, reports of poor psychological well-being regardless of exposure to COVID-19 were found.13 However, HCWs with symptoms of COVID-19 display higher psychological distress than non-infected colleagues.14 The relative lack of early understanding of COVID-19’s origin, viral transmission and prevention undoubtedly contributed to HCW psychological distress.15 Moral distress and injury has also emerged as a concern among HCWs as they face psychologically distressing situations that may violate their moral/ethical code.16
High levels of psychological distress have been observed among allied health professionals exposed to patients who tested positive for COVID-19, as well as those redeployed to provide emotional support to patients, family and staff.17 Infrequent viral testing of staff has been linked to elevated stress and fears of unknowingly spreading the virus to family, friends and the general public.18 Furthermore, a seemingly universal profile of HCWs exhibiting poorer psychological well-being has been reported: younger, female, nurses, having children, being redeployed or limited access to personal protective equipment (PPE).14 17 18
Given the residual effects of SARS on HCW well-being, concerns have been raised during the COVID-19 pandemic.13 A recent study in the UK highlighted a risk of service-level burnout in the workforce should the increased clinical pressures arising from COVID-19 continue without intervention.19 Predictors of individual outcomes among HCWs during COVID-19 have yet to be explored18; however, studies have demonstrated a need for strategic and urgent psychological intervention, both on a national and international level, to prevent HCWs becoming secondary victims and leading to mass burnout in the clinical community.12 13 18 19
Current responses to COVID-19
Evidence-based recommendations have been made to protect the psychological well-being of HCWs in the wake of another pandemic which focuses on supporting and building adaptive coping responses at an individual and organisational level.3 4 10 In the early stages of the pandemic, the British Psychological Society (BPS)20 released guidance for supporting the mental well-being of HCWs. The BPS recommended a stepped approach to psychological care proposing that psychological interventions should aim to be built on a strong foundation of communication, safety and leadership. Furthermore, during the preparation and action phases of the pandemic, it was recommended to focus on effective training and support for staff, development of supportive materials and the use of transparent, decisive and effective leadership.6 10 Their approach further called for maintaining peer support networks where possible and to normalise feelings of anxiety.
The BPS guidance outlined that prolonged exposure to the stress of the pandemic may result in exhaustion, leading staff to become disillusioned with the drastic change to their work. During this period, staff may neglect their own well-being and needs, deeming themselves not to be a priority. In response to the COVID-19 pandemic, psychological support services within a London-based hospital were adapted in order to provide timely and responsive care to support HCW well-being. This was aimed to support staff during the acute action phase until a transition into a recovery phase was possible.
In line with BPS guidelines, the hospital’s psychological support services established respite areas on-site and off-site, provided support groups on the wards, offered training workshops, as well as one-to-one support to staff during the acute phase of the pandemic. Additional resources and bespoke toolkits were also developed targeting staff psychological welfare and made available online and via hard copy handouts. All hard copy toolkits and leaflets provided on-site were infection control compliant.
The impact of the COVID-19 pandemic on staff well-being, as well as uptake of supportive services put in place remains unknown. Thus, the main purpose of this rapid evaluation was to assess HCW psychological welfare at one of London’s biggest university hospitals during the acute phase of the COVID-19 pandemic, as well as their use of available supportive services. The secondary objective was to explore factors associated with psychological welfare (eg, personal characteristics) in order to identify potential at-risk groups of HCWs.