King's College London

The National Institute for Health and Care's Emergency, Preparedness and Response Health Protection Research Unit (EPR HPRU) is a partnership between King’s College London, Public Health England and the University of East Anglia.

This piece is taken from an essay collection showcasing the unit’s critical role in the UK's response to Covid-19.

A defining theme throughout the pandemic has been the expression of gratitude toward the country’s healthcare workers, recognising their incredible work during such trying times. However, the high pressure and novel circumstances of the crisis have placed a significant mental health burden on the healthcare workforce.

If those trained to look after us when we are sick are themselves demoralised and unwell due to mental illness, it means trouble for already strained health systems. For those who care about healthcare workers, and indeed our health system, protecting the mental wellbeing of our healthcare workforce during the pandemic and beyond is both an ethical duty and a practical necessity.

During the pandemic, frontline healthcare workers have risked infection of themselves and their families, borne the trauma of witnessing excessive death and morbidity, and contended with significantly increased workloads. This has knock on effects for job performance and quality of patient care. The mental health burden is particularly high for those working in intensive care units (ICUs). 

A recent study found that 45 per cent of ICU staff report symptoms of severe depression, severe anxiety, or problem drinking. Of this number, 40 per cent reported symptoms of post-traumatic stress disorder (PTSD). A further 13 per cent had reported frequent thoughts of being better off dead or hurting themselves within the previous two weeks. What these numbers show is that the risk of mental illness posed by chronic distress, trauma and excessive workloads, is indeed being realised.

Even before the pandemic, women have reported higher rates of anxiety and depression compared to men, and women are also highlighted as being at greatest risk of pandemic-related mental health problems.

Given that women make up 78 per cent of the NHS workforce and 89 per cent of nurses and health visitors – who bear a higher mental health burden than doctors – it’s clear that Covid-19 has disproportionately affected female healthcare workers.

Aside from mental illness, working in unprecedented circumstances poses a significant risk of moral injury. This concept is derived from military settings, in which overwhelming demands for which one feels unprepared can lead to actions or inactions that challenge an ethical code. The question of “did I do the right thing?” arises, often triggering negative thoughts and emotions, which in turn increase the risk of developing mental illnesses, such as depression and PTSD.

This huge burden, and even susceptibility to it, warrants an urgent need to protect the mental wellbeing of healthcare staff. Failure to do so will only put further strain on an already struggling healthcare system. In order to tackle this, evidence based treatment to protect staff is vital and remains a responsibility of both managerial staff and policymakers.

Managers and supervisors play a pivotal role in implementing evidence-based interventions to tackle this mental health burden. Research shows that supportive managers foster better mental health of their staff. Within the complex and highly pressured context of the pandemic, the attitudes and behaviours of managers are crucial to identify and protect staff from the potential damage to their mental health.

Our research highlights the effectiveness of active listening skills training for healthcare managers in the UK. After this training, more than 80 per cent of healthcare managers enrolled felt confident in being able to identify, speak to, and support potentially distressed staff, compared to less than half beforehand.

Managers’ confidence in supporting staff is linked to improved productivity, emphasising that these skills should be imperative for those in supervisory roles. Managers can therefore play an important role in improving staff mental health, reducing sickness absence, and improving quality of care for patients.

While managers play a key role, evidence-based interventions must go further still. An all-encompassing recovery plan is needed to prevent and mitigate the pandemic-related mental health burden among healthcare workers. This can be achieved through a three-tiered approach.

Primary prevention – interventions to avert mental illness onset; secondary prevention – focusing on those with early signs of illness; and tertiary prevention – treatment of those with such problems. Primary prevention should include provision of realistic information regarding the risks and challenges of working in the pandemic. It should also make clear what support is available, from self-help techniques, to apps and online resources. Social support systems are also crucial. For example, “buddy” systems with other colleagues to encourage monitoring of wellbeing. Furthermore, the work environment should be optimised to support appropriate nutrition, rest and sleep periods.

Secondary prevention should be supported with welfare-focused staff trained to identify predisposing risk factors and follow up with individuals who may be facing difficulties. Following this, appropriate measures can be taken, such as signposting to wellbeing resources, assessment via a GP, or engagement with occupational health or mental health services.

Finally, the tertiary level should be characterised by assessment of the staff member’s current work schedule by available professionals. A useful tool for this is the PIES model – Proximity, Immediacy, Expectancy, and Simplicity – which is an evidence based occupational health approach. It can help to support individuals in their work and build self-esteem so that they can cope with distress. 

T his can help encourage healthcare staff to get help before distress escalates into crisis. This reflects a positive, strengths-based approach that keeps interventions simple and “de-medicalised” during difficult times. Without this proactive tiered approach, the psychological consequences of the pandemic on healthcare staff could be devastating and long-felt.  

The existing evidence of pandemic-related mental health issues among healthcare workers is concerning, even before knowing the full scope and clinical need of resultant psychological distress. There is a clear requirement for evidence-based approaches as implemented and sustained by managerial and supervisor roles, both to address the damage already done and to prepare for future impact. A three-tiered approach is an effective way of providing targeted interventions for different groups among healthcare workers with different psychological needs, depending on how they have been affected. Protecting our health workforce is a moral obligation. By developing these care plans and policy initiatives for mental health, we can ensure a better working environment and a more resilient workforce.  

Neil Greenberg is a Professor of Defence Mental Health at King’s College London.