There is a growing body of emerging literature that suggests that the COVID-19 pandemic is having an adverse impact on the mental health and wellbeing of NHS staff and especially among those who work in critical care units.
Almost daily television news reports during the current wave of the pandemic show NHS staff being stretched to the limit of their endurance as COVID-19 cases soar and intensive care units (ICUs) becoming filled to capacity. Some NHS trusts have declared Operational Pressures Escalation Level 4 (OPEL 4) status, which indicates that pressures within the local health and social care system continue to escalate, leaving organisations unable to deliver comprehensive care to all patients. The OPEL framework is a 4-point scale that sets clear expectations around roles and responsibilities for all those involved in escalation in response to local surge pressures.
Although the pandemic is taking an emotional toll on all grades of staff, it is the frontline nursing workforce that is bearing the brunt. A recent study by Greenberg et al (2021) into the effects of the pandemic among ICU staff found that poor mental health was common, but that it was more pronounced in nurses than in doctors or other health professionals. This could be due to the fact that nurses are in very close contact with patients throughout their shifts. Many ICU nurses and doctors were shown to have met the clinical signs for post-traumatic stress disorder (PTSD), anxiety or alcohol abuse, with some having symptoms that were so severe that they reported contemplating self-harm or suicide.
Comparable to a war-zone casualty station, the situation in NHS acute service trusts during the height of this pandemic is analogous to that faced by Florence Nightingale and her team of nurses when dealing with the flood of seriously wounded soldiers at Scutari after the battle of Inkerman in the Crimean War. It is said that at one stage there were some 4 miles of wounded and sick soldiers on mattresses on the floor of the hospital. Then, as now, such intense long-term care delivery over a sustained period can have devastating consequences for the emotional health of care staff. Nightingale herself was not immune to the strain and was a broken woman by the end of the Crimean War, suffering years of ill health attributable to PTSD.
Background
All NHS trusts have plans in place for dealing with emerging epidemics, which are normally a component of winter pressure preparations and are usually in response to the potential threat of a new influenza strain. Modern medicine is well aware that infectious disease throughout the history of humanity has been responsible for killing far more people than wars and, despite advances in health care, the emergence of SARS-CoV-2 highlights just how vulnerable we are to viral disease.
For decades, as the world population continues to expand, the global health community has warned about the inevitable emergence of new pathogens that would constitute major threats to public health such as SARS (severe acute respiratory syndrome) and MERS (Middle Eastern respiratory syndrome) (Mayer and Davis, 2020). Despite this, the emergence of the novel coronavirus, the cause of COVID-19, appears to have taken the world by surprise, leaving health economies such as the NHS reeling, perhaps exacerbated by ongoing nursing staff shortages and inadequate supplies of personal protective equipment (PPE), which were manifest during the first wave of the pandemic. Numbers reported up to July 2020 revealed that more than 600 health and social care workers succumbed to COVID-19 and died across England, Scotland and Wales (Office for National Statistics, 2020).
The NHS is also witnessing unprecedented levels of staff sickness, amounting to some 30 000 health workers in the second wave of the pandemic.
Strategies to alleviate the emotional effects of the pandemic
The whole country recognises the effort of NHS staff and many groups are endeavouring to show their appreciation in differing ways, such as Deliver Aid, which is an initiative that serves hospital staff 1000 meals a week. In addition to local support for the NHS, there are national initiatives to address the emotional impact of the pandemic on staff. These include:
Improved mental health support
Given the emotional toll on staff, the NHS aims to strengthen mental health support for its COVID-19 frontline workforce. For example, NHS England and NHS Improvement has pledged to invest an extra £15 million to boost mental health support for frontline staff. This includes more rapid assessment after referral and fast-tracking to treatment. This funding package will, in particular, underwrite a national support service for critical care staff who, as identified in ongoing research, are most vulnerable to severe mental health trauma.
Green outdoor spaces
NHS Forest is a project funded by a range of charitable trusts with the aim of improving the health and wellbeing of patients, staff and communities by increasing access to green spaces on or near to NHS land. Many hospitals are participating in this venture, especially since the beginning of the pandemic (Craig, 2020).
There is already a body of literature on so-called forest bathing, mindfulness, woodland walking and the therapeutic effects of bird watching on individual wellbeing. People who are exposed to more natural environments are thought to have significantly fewer feelings of stress, depression and anxiety. This has been shown to raise positive emotional feelings and help people to feel happier in themselves and the world around them.
National parks such as the New Forest offer many opportunities for the pursuit of outdoor activities, including bird watching. I walk in the forest daily and at least twice a week I see a goshawk, or the ‘ghost raptor’, silently gliding through the trees looking for prey. Seeing one in flight never fails to amaze me.
A Forestry Commission report (Ambrose-Oji, 2013) showcased the holistic benefits of walking in rural and wooded environments; one of the concepts discussed in the report is the notion of mindfulness and forest bathing. There is no doubt that even before the pandemic many nurses were prone to stress, and mindfulness meditation has been shown to manage this effectively (Galantino et al, 2005).
Forest bathing, or the Japanese philosophy of shinrin-yoku, which means ‘taking in the forest atmosphere’, is an important aspect of preventive health care in Japanese medicine (Tsunetsugu et al, 2010). Attributes of the forest such as the odour of wood, the sound of running water, and the scenery can play their part in mindful walking, allowing the individual to become emotionally connected to the forest.
A new research project led by the Centre for Sustainable Healthcare is exploring the value of green spaces and outdoor activities for health staff. Participating trusts are members of NHS Forest and are actively using their on-site green spaces to raise the quality of life for staff. The ongoing project seeks to evaluate how staff experience green spaces in and around their workplaces, in addition to any barriers that prevent them from making use of them to relax or recharge (NHS Forest, 2021).
Although this initiative is laudable, and undoubtedly helpful, it is difficult to envisage how stressed nurses and others will be able to enjoy these green spaces in the winter months. Nurses are working 12-hour shifts wearing visors, gloves, gowns and masks, an experience that is hot and uncomfortable, and they may not get a break for many hours. Additionally, every time a nurse enters or leaves the ICU clinical area, the protracted routine of putting on and taking off PPE is in itself stressful.
The role of the Royal College of Nursing in supporting nurses' emotional health
As the pandemic worsened, the RCN became increasingly concerned about the emotional wellbeing of staff as ICUs became overwhelmed. Even before the pandemic the college was aware that the emotional health of its members was being undermined by acute staff shortages in many clinical areas. As part of the RCN's ongoing commitment to alleviate staff stress, it has developed wellbeing resources and campaigns (https://tinyurl.com/3akzlmfs), including.
Project Wingman first-class lounges
Project Wingman is an independent NHS support initiative launched by members of the airline community in April 2020. Operated by a group of current and former air crew from across the aviation industry, many of whom are furloughed, the charity is dedicated to providing hospital staff with space to unwind, de-compress and de-stress before, during and after hospital shifts to support their wellbeing. Their mission is predicated on giving NHS workers a first-class lounge experience in recognition of the first-class service they provide to patients.
One of the charity's latest initiatives is a mobile lounge built into a coach, which is touring the country to deliver a first-class resting space for NHS staff and which made its first stop at Maidstone Hospital in December (Maidstone and Tunbridge NHS Trust, 2020).
Conclusion
It is now obvious that we must not underestimate the impact of COVID-19 on the physical and mental health of our NHS workers and the mounting pressure that is affecting the emotional wellbeing of frontline staff. We know that exposure to the SARS-CoV-2 virus is a strongly reported correlate of subsequent emotional health issues among nurses and other health professionals (Muller et al, 2020) and all efforts to alleviate this must be undertaken across the entire NHS.
The Prime Minister, in his televised address to the nation on 3 February, asked viewers to clap for frontline staff and to recognise the contribution of Captain Sir Tom Moore, the centenarian who sadly died from COVID-19 and who raised nearly £33 million for the NHS during the first lockdown last year.