Mental health impacts of COVID-19 on NHS healthcare staff

Key factors influencing NHS staff well-being

The COVID-19 pandemic has placed many NHS staff under extreme pressure. Staff have had to balance their personal and professional commitments and values, for example in considering their risk of infection to themselves and their family, alongside their duty to care for patients. At times, staff have had to isolate themselves from family and friends. Some staff have also had to make difficult decisions around the allocation of limited resources. In the UK there have been reports of inadequate provision of personal protective equipment (PPE) and COVID-19 testing for healthcare staff and unclear infection control policies in some healthcare settings.

Another source of stress has been changes to the working environment, with some staff redeployed to new roles. In outpatient settings, general practitioners and other community-based practitioners have had to adapt to supporting patients remotely. In a survey of over 2,000 staff working in mental health services during the pandemic, over half of those working in community services declared their biggest challenge to be the delivery of care using digital platforms. Some staff felt unable to adequately assess patients in the absence of face-to-face contact.

Such tensions have prompted some to raise concerns about the potential for distress among NHS staff who have been forced to make decisions or take actions that they find morally challenging. This may be accompanied by negative feelings of guilt or worthlessness. This could increase the risk of mental ill health, including anxiety, depression and post-traumatic stress disorder (PTSD).

However, some staff may have thrived during the pandemic, responding to positive challenges in an atmosphere of increased team cohesion. Some healthcare professionals working in the community have reported improved work-life balance (article not yet peer-reviewed) due to reduced travel when working from home. This creates a complex picture of differing effects on various groups of staff.

What effect is the pandemic having on NHS staff mental health?

Evidence from previous outbreaks suggests that up to a third of staff will experience high levels of distress. Healthcare workers in countries that experienced the peak of COVID-19 infection earlier than the UK were more likely to experience symptoms of anxiety and depression than before the pandemic. Evidence of the effect of the outbreak on the mental health and well-being of UK healthcare staff is still emerging. In order to draw meaningful conclusions, data about the mental health of NHS staff before the pandemic started are needed, in addition to a clear overview of how this compares with other occupations and if there are any significant differences between healthcare professionals in different specialities (intensive care medicine or general practice) or roles (such as nurses, paramedics or administrative staff).

In the NHS, pre-pandemic reports indicate high levels of staff stress and burn-out. Features of burn-out include exhaustion, detachment and cynicism, which can reduce the healthcare provider’s capacity for empathy and in turn negatively impact on their ability to provide high quality care. It can also increase the risk of mental ill health. In the decade preceding the onset of the pandemic, symptoms of anxiety and depression were reported in between 17 to 52% of doctors, with potentially higher levels among nurses.

Many of the usual coping mechanisms previously used by staff may have been removed during the pandemic, such as socialising with friends and family. Results of surveys conducted among NHS staff early in the outbreak indicate that the risk of mental ill health and burn-out may have been higher during this time. 996 health and social care staff (75% of whom were employed by the NHS) were surveyed by the Institute for Public Policy Research; 50% of staff felt that their mental health had declined during the first two months of the pandemic. 45% of doctors across the UK surveyed in May 2020 by the British Medical Association (BMA) reported experiencing depression, anxiety, stress, burn-out or other mental health conditions relating to or made worse by the outbreak. The BMA has reported that well-being support services have seen an increase in calls from doctors who are feeling anxious about going to work to face increasingly challenging situations.

Several studies have compared the mental health of keyworkers during the pandemic to that of the general population. In one study, health and social care staff had significantly higher levels of PTSD, depression and anxiety symptoms (article not yet peer-reviewed) than other occupational groups. However, another study found no difference in reported levels of anxiety and depression symptoms (article not yet peer reviewed) between healthcare workers and the general population.

Understanding groups at risk in the NHS

Research from previous outbreaks provides insights into which staff may be more at risk of mental ill health during the current pandemic. Frontline workers directly engaged in diagnosis and treatment of COVID-19 are particularly vulnerable to the negative impacts of the current pandemic on mental health and well-being. This includes nurses, paramedics and those working in frontline specialities, such as emergency medicine and intensive care.

Six months into the pandemic, 76% of almost 42,000 nurses surveyed by the Royal College of Nursing (RCN) reported an increase in their stress levels since the advent of the pandemic, with 52% concerned about their mental health.

There is also evidence emerging that pre-existing structural inequalities in health outcomes have likely been magnified by the pandemic. Staff from minority ethnic backgrounds comprise a significant proportion of the NHS workforce and have been disproportionately affected by the pandemic relative to their White colleagues, including deaths from COVID-19. They may also experience specific challenges to their mental health related to racism and discrimination, socioeconomic disadvantage and mental health stigma. Yet minority ethnic groups have been under-represented in recent surveys of NHS staff during the pandemic.

The experiences of female staff during the pandemic were explored in a survey of women carried out by the NHS Confederation. The emerging theme was the conflict between personal and professional caring responsibilities by female healthcare workers, who also reported the pressure of additional responsibilities at home, such as caring for children and other dependents.

Trainee healthcare workers may also be particularly vulnerable to the uncertainty associated with changes to their working patterns and training programmes. Being a more junior healthcare worker was a risk factor for psychological distress during previous outbreaks of Ebolavirus and 2003 SARS-CoV. In a survey of over 200 trainee doctors working in London during the current pandemic, 41.9% reported concerns about their mental health (article not yet peer-reviewed).

Strengths and weaknesses of different research approaches

The differential effects of the pandemic on staff groups may partially explain the apparent absence of significantly higher levels of mental ill health among healthcare workers compared with the general population in some of the surveys conducted during the pandemic. Many surveys, while providing a rapid overview of the experiences of a large population such as healthcare staff as a whole, lack the detail required to detect potential differences between staff groups. There may also be sampling biases as a result of the opportunistic sampling employed by some survey investigators, which relies on respondents willing and available to take part. This may result in particularly distressed individuals being over-represented as they may be more likely to complete a survey about their well-being. Studies are also cross-sectional, which only provides an insight into mental health at one point in time; impacts on mental health and well-being may be transient.

The most robust method of identifying staff particularly susceptible to adverse impacts is to carry out in-depth, longitudinal studies of the pandemic’s effect on the mental health of NHS healthcare workers during the course of the outbreak. This would allow support to be tailored and directed to different groups of healthcare staff with different needs.

How can staff be supported during the pandemic?

Supporting staff mental health and well-being is seen as vital in securing sustained capacity of the NHS workforce. Sickness rates in April 2020 for NHS staff in England were at their highest in a decade, with the most common reason reported as anxiety, stress, depression or another psychiatric illness. Premature morbidity and mortality associated with mental ill health may also be associated with longer-term impacts on the NHS workforce.

In April 2020, the Institute for Public Policy Research published a report based on a survey of 996 health and social care staff (75% of whom were employed by the NHS). At the beginning of the pandemic they asked participants what they felt the Government should prioritise for the coming weeks. Further support for the mental health of healthcare staff was selected by 60% of respondents. However, the nature of this support may differ depending upon the level of distress experienced; some stress will be transient and not all will lead to mental disorder. When surveyed in July 2020 by the Royal College of Nursing (RCN), 36% of nurses were contemplating leaving the profession. When asked what they would like to see done to make them feel more valued, respondents most frequently quoted increased pay and staffing levels; 73% said improved pay and 50% said better staffing levels would make them feel more valued.

Evidence from previous outbreaks indicates that NHS healthcare staff’s current experiences are not unique to the COVID-19 pandemic (article not yet peer-reviewed). These similarities highlight that there is already a reasonable body of evidence from which to design effective interventions to support staff. Staff in previous outbreaks have benefitted from psychological support and also practical support, such as adequate provision of PPE. Much of the support for NHS healthcare workers early in the current pandemic was practical, for example restaurant discounts, dedicated hours for grocery shopping and free NHS parking. There have been calls for further support, such as flexible working when possible, particularly for those with dependents. Therefore, the mainstay of support for staff has been ensuring their safety and securing a high standard of working conditions. Supporting staff to take care of their own well-being, including sleeping, eating well and exercising, enhances their ability to care for others.

Current understanding of how to mitigate the adverse mental health impacts of the current pandemic emphasise the importance of adequately preparing staff for the challenges ahead. There is evidence that ‘operational training’ on changes to protocols within an organisation can bolster staff resilience and enhance their capacity to cope during times of increased stress. A review of employees in disaster-exposed organisations such as the NHS suggests that psychological resilience may actually be bolstered in the face of challenges such as those currently facing healthcare workers when staff are adequately supported. Resilience is the ability to recover from adversity. There is evidence that resilience training can enhance staff resilience. It is less clear whether or not this translates into a reduced risk of mental ill health, for example anxiety and depression. Likewise there is limited evidence that psychoeducation for staff on managing stress improves mental health outcomes. In June 2020, Public Health England launched their ‘psychological first aid’ training course to equip NHS staff with tools to manage their own and their colleagues’ mental health during the pandemic.

NHS England and NHS Improvement have developed a staff support programme that allows staff to access more informal psychological support. This includes access to a telephone support line and free access to self-help online apps. Several other representative bodies, such as the British Medical Association (BMA) and Royal College of Nursing (RCN), provide online and telephone support. Staff may also benefit from the psychological support of talking with colleagues about difficult experiences, either individually or as a group. These group discussions are known as ‘Schwartz Rounds’ and have been widely adopted across the NHS; a recent evaluation indicates that they are an effective space for reflection by staff. Virtual staff common rooms have been developed to facilitate further peer support. Open channels of communication between senior managers and frontline clinicians can also facilitate dialogue, allowing staff to voice concerns. NHS staff in leadership positions can receive training in managing conversations about mental health and well-being with staff who they supervise.

Recognising that some staff may be more at risk of mental ill health, there have been calls for more intensive psychological support for such individuals as the pandemic continues. For example, staff experiencing adverse mental health impacts of exposure to trauma may benefit from evidence-based psychological interventions. The NHS Practitioner Health Programme offers free and confidential healthcare but is only available to doctors and dentists in England.

Continued research into the stresses experienced by different groups of healthcare staff could help to guide the support provided and further inform initiatives to promote the future mental health and well-being of NHS healthcare staff. The following section summarises current research projects.

Research projects on mental health of NHS healthcare staff

• Frontline-COVID
• NHS CHECK
• COVIDA
• CV19 Heroes
• COVID-19 Doctor Wellbeing Study

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