How UK Doctors Are Coping With Anxiety/Distress During COVID-19

Anna Sayburn

Disclosures

March 26, 2020

The uncertainty and fear that accompanies disease outbreaks like the coronavirus pandemic puts particular pressure on UK healthcare professionals.

They have to manage increased demand from anxious patients, whether dangerously sick or worried well. They are likely to be working long hours in unpredictable situations and of course they have to manage their own fears about infection and passing on the illness to their families.

But what may make COVID-19 worse than the usual stresses of medical life is the possibility of 'moral injury', when professionals are put in situations where they cannot perform as well as they feel they should, because of lack of resources.

We spoke to doctors who worked in the Ebola outbreak of 2015, to psychiatrists, and to those trying to help their colleagues while working on the front line.

What's It Like Working in a Life-threatening Epidemic?

Dr Umar Ahmad, an anaesthetist who worked with an NGO in Sierra Leone during the Ebola outbreak of 2014/2015, says: "It is difficult and overwhelming and can be scary and there are a lot of unknown factors at play, because you never have enough time to prepare and you are always having to improvise."

However, he also says: "Because everyone is in it together, you work fast, there's a clarity of purpose and you feel very supported by your colleagues." He says that this is happening already in the UK.  "At the moment there's a lot of camaraderie and support for each other."

Many of his colleagues in Sierra Leone were from Italy. "Obviously they were hit [by coronavirus] before us. So I've been in touch to ask for their impressions, and certainly having had that experience in the past brings some context to when you do it again and when it comes home."

Doctors are used to working long hours in stressful situations. However, says Dr Ahmad, the epidemic will be something else.

"I don't think this is the normal thing of doing night shifts and weekends that doctors are used to, this is well beyond that. And I think added to that picture, quite a lot of us will get infected and will take time off. There's going to be unpredictability in terms of demand but also in terms of how many people we have at work. So it's very hard to plan."

Dr Gordon Gancz, a semi-retired GP and senior lecturer in primary care medicine at Oxford University, was among the first tranche of NHS staff who volunteered to go to Sierra Leone in 2014, and stayed for 3 months. "I was treating Ebola patients and also responsible for all staff health there. It was an extremely stressful time for everybody," he recalls. "I spent 3 months continuously on duty – I didn't have a single night off while I was there. There was virtually no assessment of resilience and it's very difficult to assess because you don't know if you have it or not until you are tested."

The Ebola situation was different in two key respects, says Dr Ahmad. "Ebola was a far scarier disease because if you got infected you had a very high chance of dying even if you were very healthy. To me, it was far scarier," he says.

However, working in a pandemic at home is stressful in other ways. "I was there [Sierra Leone] without concerns for my family or sorting out basic things. I did my job, even if it was 16 hours a day, and then I went to sleep, got up and did my job again. Whereas I think people are currently having to deal with childcare, the fact supermarkets don't have supplies, and things like that. I think that becomes much harder because at the end of your work day, even if it's 16 hours, it isn't the end of the story."

Moral Injury

One aspect that concerns psychiatrists anticipating the effects of the coronavirus pandemic is what happens to clinicians' mental health when they are unable to perform as well as they feel they should. 

Neil Greenberg, professor of defence mental health at King's College London, says: "There's going to be a lot of people coming into hospitals who are going to be in very great need, yet unless we manage to flatten this curve properly we're probably not going to have all the resources we need to deal with those patients."

Making decisions about who gets access to life-saving equipment or care when patients are in equal need could be particularly distressing, he says.

"Normally if people die, doctors can explain to relatives that they tried their best and it was really unfortunate. In this case they may well have to be saying there was no equipment to save your loved one because we needed it for someone else.

"That doesn't just cause distress – because it certainly is distressing – but we know that what are called moral injuries, injuries to one's beliefs or expectations or attitudes, can have some really long-lasting impacts."

Sir Simon Wessely, professor of psychological medicine at the Institute of Psychiatry, King's College London, says moral injury is "where you know you didn't do everything you could have done".

He pointed to work done with the military after situations in Rwanda and Yugoslavia, where soldiers had been unable to prevent atrocities because their rules of engagement did not allow them to.

"I think that's going to be the unusual feature, if the predictions [of overwhelmed hospitals] are correct. That's what people will dwell on. Because that makes them feel angry, it makes them feel guilty and it makes them feel ashamed. And that in some respects was more damaging than the classic depression or PTSD," he says.

Preparing for the Situation

Clear leadership, communication and an acceptance that the situation may result in decisions that would not normally be needed are the best way forward, the doctors agreed.

Prof Greenberg says: "Whatever the treatment protocols are that you use to make those incredibly difficult decisions, what is needed is for all the staff to agree on that. Because what you can't do when you're tired and you're stressed is try to apply advice that you don't agree with, when you have relatives and other people there."

He says there is a small window of opportunity for hospitals to address this. "At the moment, when things aren't in as much crisis as they are going to be, these are the times people really need to get their heads round them and recognise that doing the best that they can doesn't always mean that people who should survive always will," he says.

Sir Simon concurred, saying that every layer of management in the NHS and in hospitals "need to tell people this is going to happen and this will be tough and they are with them and they are sharing blame as it were, and this is not something you can shoulder on your own. And it's best to be prepared for these ethical terrible dilemmas that our front line staff are going to be put in."

Teams and Leaders

The doctors who had faced Ebola agreed that good leadership was crucial in helping people manage stress.

Dr Ahmad says: "One of the key important things that I was very fortunate to have in Sierra Leone is very clear leadership. Because in this setting you are part of a huge team effort, so if you have a very clear direction, a set of rules and policies that are clear, then it's much easier to stop worrying about the bigger picture and do what needs to be done."

"You have to have a proper command structure. That is essential. You need a good leader who will make decisions and is capable of telling you what to do.  That's the background to managing your own anxieties," says Dr Gancz.

"This is a time when more than ever in the history of the NHS, good, clear, sensitive leadership is required," agrees Sir Simon.

Good leadership enables teams to support each other, says Prof Greenberg: "Mostly when you're looking at how people cope in teams, the resilience doesn't lie in the individuals, it often lies between the individuals. If you can support the social networks that ordinarily exist in healthcare settings, but really can put in the effort to make sure they are as supportive and proactive as they can be, that should help all the medics come through this."

Working Together

So is this happening? Dr Roopa McCrossan, locum consultant in anaesthesia at Freeman Hospital (Newcastle) and honorary secretary of the Association of Anaesthetists Trainee Committee (AATC), says it is in her trust.

"I work in a brilliant and supportive anaesthetic department at the Freeman Hospital and together we are planning our response to the current pandemic. As well as producing practical standard operating procedures, we realised staff morale and wellbeing were going to be critical to our efforts. Within our department we have a group of consultants with an interest in wellbeing and we knew now was an important time to act," she says.

Through her work with the AATC she had trained as a mentor and worked on a campaign to fight fatigue. She worked with colleague Dr Emma Plunkett at University Hospitals Birmingham to produce an infographic encouraging good mental health during the coronavirus pandemic within her department, which has been shared widely across the hospital and the UK as an example of good practice, and has been met with an "overwhelmingly positive response".

"It seems to have struck a chord with people," she says.

She adds that the hospital is running training sessions which include simulation training for ICU and theatre care of the COVID patient as well as wellbeing and psychosocial support.

"These sessions are making a huge difference to everyone, allaying anxieties and reinforcing that we are a team. We know there is a storm coming, but whatever the next few months brings, we will weather the storm together and repair and rebuild afterwards," she says.

Peer Support

Sir Simon and Prof Greenberg agree that peer support is what will get people through the crisis.

"I think it's important this message gets through, that this is not the time to be flooding the place with trained counsellors. This is a time to be bringing the team together, enabling them to talk through these experiences," says Sir Simon. "Some seem to think that any individual showing signs of stress needs to see a mental health professional. They don't. They first of all need to talk to their group and talk to their boss." He points out that "anxiety is completely normal" in the current circumstances.

Time to reflect – as highlighted in Dr McCrossan's infographic – is difficult but important as the crisis builds, says Prof Greenberg.

"I think another thing is to make sure as the situation develops and people are dying and care is not as excellent as you would like it to be… that time in the day is found for some reflection on that," he says.

"The only way [health care professionals] are going to get some sense of meaning out of this is to have discussions with others who are in a similar situation and who can help them come to some sort of understanding that in these really challenging or difficult circumstances, they did their best."

Inevitably, Prof Greenberg says, "even with the best support and supervision and good preparatory briefings," some people will find that the pressure becomes overwhelming. He recommends a "nip it in the bud" approach.

"It might be they just need one shift off and then they will be able to reset. Or it might be they need to move from one particular role to doing something different. Make sure active efforts are made to get help yourself if you need it, or if you see someone else struggling to reach out to them to make sure they are OK."

Conclusion

The current crisis will put healthcare professionals under unprecedented stress. Good leadership, supportive teams, and clear communication will help. But there's no escaping the huge pressure that the coming weeks will exert on the resilience of individuals and teams working in the health service. As Sir Simon says, in days like these "if you're not anxious, there's something wrong with you".

Source of Support

The Royal College of Psychiatrists has resources for managing mental health during the coronavirus outbreak on its website

The charity Mind has information and planning advice for people anxious about coronavirus and self-isolation.

The NHS has general advice and support on mental wellbeing while staying at home.

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