Intensive care units and theatres are known for high medical complexity and working pressures (Ward and Chijoko, 2018). Since the start of the COVID-19 pandemic, such services were forced to adapt and maintain resilience, in addition to coping with existing pressures. Frontline roles are recognised as being directly associated with chronic illness (Caruso, 2014), including mental health issues, which can adversely affect a health professional's ability to care for patients (Moss et al, 2016).
Pandemic frontline work
Research from previous pandemics has shown that working with additional pressures has both a physical and psychological impact on healthcare workers. For example, about 10% of those working in health care during the SARS pandemic had post-traumatic stress symptoms (Wu et al, 2009) and up to 35% experienced emotional distress (Maunder, 2004). Furthermore, during a pandemic there is a risk of staff developing moral injury, which is a term used to describe psychological distress caused by failure to prevent or act in a situation that results in a violation of moral values (Greenberg et al, 2020).
COVID-19 has had an overwhelming impact in hospital systems and has highlighted the issue of staff welfare. A survey of healthcare workers in Wuhan, China (Barzilay et al, 2020), revealed high proportions of staff with anxiety (22-45%), insomnia (34%) and depression (16-50%). Another study found higher rates of these conditions among staff in critical areas (Lai et al, 2020). Recent reports show that staff meet the criteria for post-traumatic stress disorder (PTSD) as a direct result of working during the COVID-19 pandemic (Raudenská et al, 2020).
Factors such as unpreparedness, lack of communication, limited resources, threat of exposure and disruption of work-life balance, dilemmas regarding patient duties versus fear of exposure, and lack of communication all have a psychological impact. Furthermore, dealing with the death of patients also contributes to the psychological burden faced by staff (Shorter and Stayt, 2010).
Responding to COVID-19
The adverse consequences of caring for patients with COVID-19 mean it is imperative to develop support systems (Xiang et al, 2020). Learning from previous pandemics, as well as the impact on healthcare workers in Wuhan, provided us with insights into how to manage the first wave of the novel coronavirus outbreak in the UK.
During a pandemic, the strength of social bonds between hospital workers and their colleagues has been found to be a notable protective factor (Tam et al, 2004). Sufficient rest, clear communication, availability of suitable protective equipment, as well as access to practical and psychological support, are key to maintaining staff wellbeing (Kisely et al, 2020). Medical and nursing staff in Wuhan, in addition to using a range of online psychological resources, sought out and engaged positively with therapy services (Liu et al, 2020).
Maintaining resilience relies on having a healthy lifestyle, work-life balance, engaging in hobbies and recreation, as well as general wellbeing practices. The impact of lockdown has reduced the ability to maintain some of these strategies and has further contributed to a deterioration in staff mental health (Bai et al, 2004; Hossain et al, 2020).
Even with existing resources in place, including occupational health and local psychology services, hospitals in the UK were not set up to manage work-related distress caused by a pandemic. Clinical psychologists are not typically included in the commissioning of NHS staff support services (NHS Employers, 2019), but would generally be employed within specialist services to carry out complex therapeutic work with patients; part of their role is to support staff in their respective department.
As part of a rapid response to rising infections in Liverpool, a temporary psychology service was set up specifically for critical care and theatres and anaesthetics. This service provided flexible psychological support for staff who were experiencing COVID-19-related distress. The service also had implications for patient care by ensuring that staff, where possible, were able to continue to work effectively.
The service evaluation aimed to understand the degree to which a temporary clinical psychology service for staff in critical areas benefited both staff and managers. It is important to highlight that staff support services were already in place with the expectation that there would be high referral rates as the pandemic grew. This service was supplementary and enrolled a professional from clinical psychology who had not been part of the established occupational health service, or part of the support in place for critical care or theatres.
Service set-up and capacity
A full-time clinical psychologist (KH) from the Pain Medicine Department was allocated to provide six staff-support sessions that amounted to 22.5 hours per month.
The service ran for 21 weeks between March and August 2020. Posters were placed in staff rooms and details emailed to unit managers. Anyone within critical care and theatres and anaesthetics experiencing psychological COVID-19-related distress could be referred. Telephone and face-to-face consultations were offered with social distancing. Follow-up was provided as needed and appointments were 60 minutes.
Referral and activity data were collated for service evaluation purposes. This included staff role, working area, intervention required and number of sessions. Staff presenting issues and reported benefits were requested at the end of the first consultation and grouped into categories as presented in the results section. Personal demographical information was not collected.
An anonymous feedback survey was emailed to staff and managers following referral. Response choices comprised ‘yes’ or ‘no’, a 5-point Likert scale (a great deal/considerably/moderately/slightly/not at all) and a free-text option.
Sessions with a clinical psychologist followed the protocol below:
- Introduction of the clinical psychologist role, confidentiality outline and purpose of intervention
- Applying a standard clinical psychology assessment outline and enquiring further about the staff member's key areas, such as mental health history, risk, physical health and previous experiences of work-related distress
- Developing a shared formulation to identify contributing factors to the person's distress and develop ways forward
- Making recommendations, coping strategies and signposting to resources as appropriate
- Where required, making onward referral and following up
- Invitation to provide feedback.
This report is based on the data obtained from a trust-registered service evaluation and adheres to the processes required. All staff had the opportunity to withdraw their anonymous data.
A total of 51 staff accessed the service, with 50% of referrals made by managers on behalf of staff. At the time of referral, 57% of staff were working, 35% were signed off, 6% were isolating and 2% were on unpaid leave. Figure 1 shows the initial peak of referral rates as new COVID-19 cases increased. The subsequent drop in referrals suggests that staff might have been too busy and focused on the task in hand. At the beginning of July, referrals peaked again following which the situation improved, which could suggest that staff felt the need to access support and had had the time to process the difficulties experienced during the previous peak.
A total of 60% of referrals came from theatres and anaesthetics, with the remainder coming from the intensive care unit (ICU), post-operative critical care and high-dependency unit (HDU). HDU constituted 80% of critical care referrals, which could have occurred for several reasons. We were aware that information about the usefulness of the support service was shared between the peer groups of those working on HDU. It is also likely that HDU was subject to drastic changes and worse patient outcomes compared with usual clinical practice. It was also considered that ICU had additional support systems in place.
Most referrals were for nurses (43%), followed by theatre practitioners (36%), healthcare assistants (9%), consultants (8%), support staff (2%) and administrative staff (2%). Of theatres and anaesthetics staff, 11% had been redeployed to the ICU.
Of the 51 referrals, 41 staff attended a first-assessment appointment, with most requesting a telephone consultation. Almost 60% of staff required a single session. The maximum number of sessions was 11, with a mean of two.
Clinical issues at assessment
Presenting issues were grouped into 20 categories (Table 1) including mental health symptoms and other commonly reported difficulties. Symptoms of burnout, generalised anxiety and low mood were among the most common issues. Panic and sleep disturbance was experienced by 20% of these staff. Interestingly, 20% feared for their family's safety, with only 9% fearing for their own; 20% said they considered leaving their jobs. Few staff reported trauma symptoms, however this could have been because it was too early to determine or because traumatised staff may have been diverted to mental health services and were therefore not among staff who accessed this service. Pre-existing mental health symptoms were triggered in 22%.
Table 1. Percentage reported difficulties for 41 staff who accessed the one-to-one service
|Exacerbated pre-existing mental health issues||22|
|Physical health affected||20|
|Fears for family safety||20|
|Deskilled/loss of confidence||13|
|Fears for self-safety||9|
|Increased alcohol use||7|
|Managing well in circumstances||2|
It is important to highlight that 13% of staff felt that they had lost confidence in their role since being redeployed or being asked to take care of COVID-19 patients. This is understandable, given the uncertainty related to learning new ways of working. It suggests that, under such circumstances, it would be beneficial to provide more support to staff to normalise the likelihood that practising outside their perceived skills level might cause difficulties.
Table 2 shows that all staff found the input helpful. Anecdotally, many reported wishing they had accessed support sooner and that their perceived barriers to accessing support had been unfounded. More than half (51%) noticed an improvement in their presenting issue at the first session. It is important to note that many accessed the service only once. Therefore we cannot fully access whether their presenting issue improved following the clinical psychologist's recommendations.
Table 2. Percentage of staff who reported the following outcomes since accessing the one-to-one service
|Reported finding sessions helpful||100|
|Improvement in presenting issue (in first session)||51|
|Remained in workplace||36|
|Signed off and returned to work during intervention||20|
|Short time off (<2 weeks)||4|
|Sustained time off||2|
Although 36% of staff continued to work during the intervention, 2-4% required time off as advised, to aid mental health recovery. One-fifth of those who were signed off were able to return to work during the intervention. Staff returning to work often gave the clinical psychologist permission to provide their manager with recommendations on how they could be better supported in the workplace.
Of the 51 staff who accessed the service, 13 (25%) completed the optional anonymous feedback questionnaire (Box 1). An analysis of responses showed that 62% had accessed staff support previously and that most had found it helpful. An interesting point is that 53% of the 13 staff had found out about this service through their manager rather than via departmental advertising. This suggests that publicising it solely through advertising might not an effective way to reach staff.
Box 1.Feedback forms sent to staff and managers following intervention (response options shown in brackets)
Have you accessed staff support services in the Trust previously?
|Questions for staff (n=13)|
|Questions for managers (n=10)|
Following intervention, nine of the 13 staff responded ‘yes’ or ‘maybe’ when asked if they felt it was important for work-related issues discussed in sessions with the psychologist to be raised with their manager. Figure 2 shows that the intervention was useful in helping to reduce in the severity of the concerns. Furthermore, just over half the staff respondents reported being concerned that the support service was temporary. Free-text comments feedback from staff provided the following insights:
‘The stress and burnout I was harbouring could have got so much worse if I hadn't had professional help that helped me realise that my own health is so important and that I needed to have time off before it got progressively worse.’
‘I did not understand why I felt so bad and thought I was ill, I did think that I was having a breakdown as I could not think straight or logically. I think I would have become a lot worse without having the support and learning that what happened to me was a culmination of events that all just became too much.’
Ten managers completed the anonymous feedback questionnaire, all of whom rated the service as ‘considerably’ (10%) or ‘a great deal’ (90%) of help (Box 1). Prior to this service, most managers would have referred their staff to occupational health (90%), the GP (80%) or advised self-referral to psychological therapies (100%). Figure 3 shows that they noticed a range of improvements in their staff, including more conversations about wellbeing. Eighty per cent reported noticing a change in how they would approach their staff and the majority were concerned that this service was temporary.
Examples of managers' free-text comments included:
‘I feel that without this support a lot of staff would have not been able to continue to work or resume … work due to the psychological distress that COVID-19 has caused for frontline workers.’
‘It has reassured me that when staff were at their most vulnerable we were able to respond quickly to support them. Because this was identified so promptly, I was able to support most of the staff with adjustments to their work patterns to avoid them having to take time off sick.’
Staff required encouragement to take a break or time off work due to guilt. Putting others first, including patients, colleagues and family, was reflected in this. Some interventions required staff to develop self-compassion and make choices that benefited them as well as others.
It was also noted that many staff struggled to communicate their feelings to their manager, through fear of being perceived as weak or not good enough. Therefore speaking with a psychologist, in a confidential space, was important to allow staff to be honest about how they were feeling. Therapeutic strategies were therefore used to facilitate effective communication between staff and their managers.
Furthermore, the impact of lockdown, changes in family life and removal of usual coping strategies for an already stressful job were common contributors to work distress.
This service evaluation demonstrates that a staff support service delivered by a clinical psychologist was effective for staff in critical care and theatres. The skill and experience of a clinical psychologist was useful because it not only provided a rapid intervention, but also offered the support that enabled staff to remain in the workplace.
Identifying those at risk
The high use of the service by HDU staff shows that these areas require outreach work, as well as continued manager engagement. This service evaluation also suggests that health professionals who are asked to work outside their normal clinical practice are vulnerable to increased distress. Similar to previous reports, those with existing mental health conditions are more likely to experience a relapse (Mental Health Foundation, 2022).
‘I wish I'd seen you sooner’
Many staff acknowledged barriers to accessing help. We suggest that this could be due to stigma within health care, and during a pandemic some staff take have the attitude that ‘you must get on with it’ and that ‘struggling is a sign of weakness’ (Traynor, 2017). Given that referrals via managers accounted for half of the total of those seen by the service, this highlights their key part in helping staff who have reservations about seeking support. Furthermore, word of mouth among colleagues was found to increase the number of referrals. It also suggests that relying on noticeboard publicity should not be the only method of advertising such services to staff.
Although it is likely that consultants and senior leads face similar stigma to those reported above in the case of other staff, we do not fully understand why referral rates were low among this cohort. Similar to the support provided by the clinical psychologist, senior staff can assist staff needs by attempting to listen and contain any distress presented by staff; this also requires personal resilience on the part of senior staff. Ensuring that senior leads are supported is therefore important and further research into the needs of senior staff groups is advisable. Another important issue to explore would be why these staff groups are less likely to access such services.
This service evaluation has shown that work changes led to staff feeling that they did not possess the skills to work in a new clinical area when redeployed or to deal with the new disease. For example, HDU staff were required to take care of ventilated patients and required rapid training in the relevant skills. HDUs typically support a lower category of critically ill patient with better prognosis, and staff were therefore less exposed to patient deterioration in condition and death, which have been characteristic in those with COVID-19. Furthermore, redeployed theatre staff had been moved to work in new areas within new teams, and were having to learn how to care for complex patients with COVID-19. Although staff training was provided prior to the influx of COVID-19 admissions, it is difficult to prepare for a pandemic is, especially in a context when there is a lack of appropriate resources and with likely COVID-associated staff absences.
Clinical psychologists frequently helped staff to normalise feeling deskilled given the unprecedented circumstances and helped them to cultivate realistic expectations, as well as self-kindness. This suggests that preparing staff psychologically is just as important as practical training, for example, warning staff that it is normal to feel deskilled when, in reality, they are being upskilled.
A striking result of this study is that 20% of staff stated that they considered leaving. This suggests that staff require the opportunity to raise concerns and for trusts to model the importance of psychological safety in the workplace. Maunder et al (2004) highlighted the importance of leadership through providing time and space for support and reflection during a pandemic, including the provision of input from occupational health teams. A compassionate leadership style can also support staff during a pandemic (Bailey and West, 2020). A sense of coherence among teams in critical care and theatres, including effective communication, has been identified as an important mediator for mental health (Schäfer et al, 2018).
Given the high referral rates for the present service evaluation, investment is clearly required in staff support services on a permanent basis in order to continue the observed benefit from this evaluation. Although the pandemic had not abated at the time that this service evaluation was completed, it is likely that psychological distress will continue to be experienced by staff through subsequent waves of the disease, including its detrimental impact on those who have not yet accessed services.
Although the majority of staff did not require formal mental health services, we can argue that the intervention reduced the likelihood of deterioration in their health. This would require further studies to follow up. Some of the less complex work could be undertaken by health professionals other than clinical psychologists, for example in situations where containment through providing a space to talk and offering supportive listening is required rather than psychological therapy. Other health professionals can be trained in Psychological First Aid (PFA), which was developed in response to other large-scale crises, and can equip non-psychologists with the skills to actively listen, respond to distress, identifying risk, and promote positive health behaviours. PFA could be used to extend support services during the COVID-19 pandemic (World Health Organization, 2011). Environmental support and adequate rest have been shown to be beneficial (Chen et al, 2020), highlighting the importance of honest communication to help senior leads allocate resources accordingly.
Benefits for patients
Staff shortages have a significant impact on patient care. The temporary psychology service evaluated in the study helped our staff to feel supported and enabled them to remain in work, which had direct benefit for patients. In addition, by improving the self-care of staff, we are contributing to a lower likelihood of work-related errors (Johns, 2010). Anecdotally, staff frequently noticed that patients were concerned about staff wellbeing and frequently enquired about their support needs.
This service evaluation has limitations that affect the generalisability of the findings. Using arbitrary categories reduces richness of data, so further research that includes qualitative interviews could provide a more in-depth understanding of the benefits of providing such a dedicated service. It is also important to consider potential bias on the part of the clinical psychologist who delivered the intervention, who also sought to clarify the outcome of sessions with staff for service evaluation purposes. There is a possibility that staff providing feedback within the session itself may have adjusted their views in the presence of the psychologist due to concerns about how negative feedback might be received. The anonymous feedback forms yielded small numbers, thus reducing potential for statistical analysis. The involvement of an independent researcher would have reduced the potential for bias, as well as being able to plan a follow-up measure to detect length of benefit. Future studies would benefit from using validated tools and applying statistical analyses to detect clinically meaningful change.
Demographical data were not collected as part of the service evaluation, which would have been helpful in providing an understanding of the demographical data of those who accessed the service.
Given the context, the evaluation was conducted in the best way possible, and presented an opportunity to assess the UK response to the first global pandemic in decades, which required a rapid response from the clinical psychology discipline. Future studies, including the service evaluated for the purposes of this study, would benefit from reassessing the teams who received input from the clinical psychologists. This would help identify whether the noted clinical gains remained over the longer term and whether further input would be required.
The following recommendations emerged as a direct result of this service evaluation:
- Staff support services require expansion, including in skill set and resources. There is a need to integrate existing support mechanisms with effective models such as PFA
- It is vital to encourage and model open communication about psychological wellbeing across organisations
- Staff need encouragement to access such support services and to recognise symptoms of worsening mental health. Being proactive can help prevent deterioration
- Any health professional delivering staff support needs to be flexible around each individual's needs
- Managers must be mindful of the stigma that may be present in their teams and foster an open culture of normalising the importance of talking about mental health
- It is important to be familiar with wellbeing resources at a trust, regional and national level.
With reference to the final point, across the UK many resources have been developed to promote the wellbeing of staff. Many trusts have their own intranet resources, such as that from the Critical Care Team at Cardiff University Hospital of Wales (https://cardiffcriticalcare.co.uk/staff-information), which is widely used.
Finally, COVID-19 has had a significant impact on staff working in critical care and theatres, including on their mental and physical health, on their willingness to remain in the role and has affected communication with managers. It was therefore important to rapidly use available clinical psychology capacity to identify and attempt to address some of these issues and to undertake an initial evaluation of the efficacy of this additional support. The unique skills of a clinical psychologist can facilitate the assessment, formulation and rapid, yet effective, treatment for staff in distress. This is an efficient option to consider as part of wider staff support teams within the NHS.
- Staff reported high rates of burnout, anxiety and low mood with 22% experiencing exacerbation of pre-existing mental health problems
- Staff in high-dependency units and staff who are redeployed may require more support
- Staff require encouragement and prompting to attend support sessions
- Managers and senior leads have a key role in recognising the impact of COVID-19 on staff mental health and emphasising the importance of accessing resources
- Clinical psychology provides a useful skill to meet the needs of staff working on the frontline during the COVID-19 pandemic
CPD reflective questions
- What would you notice about yourself and your colleagues that could indicated that accessing help is required?
- How do you feel about communicating difficult feelings about your role with your manager, and what might stop you?
- Are you aware of any resources that can help improve psychological wellbeing in the workplace?