PTSD and insomnia: mitigating the psychological effects of COVID-19 on nurses
The workforce has been overwhelmed, but pressed on – now nurses need more support, say experts
- British Association of Critical Care Nurses warns stressed nurses are at risk of developing post-traumatic stress disorder
- For some, the psychological impact of COVID-19 pandemic was ‘like a war zone’, and staff need better support in general, experts warn
- How organisations and staff can help colleagues recognise and seek help for the early signs of PTSD, anxiety and depression
The NHS and its staff have been bombarded with love throughout the pandemic.
There were the weekly claps, the free meals and a mountain of shopping vouchers and discounts. But none of these help nurses deal with the psychological scars left by the experience of being on the front line of the pandemic.
‘Pandemic has been like a terrorist attack that goes on and on’
Around 100,000 patients have been treated in hospital for COVID-19 – with almost a third of them dying. The pressure on staff in the community has also been intense.
The British Association of Critical Care Nurses (BACCN) says this has had a profound impact on staff and left them at risk of post-traumatic stress disorder (PTSD).View our COVID-19 resource centre
BACCN chair Nicki Credland likens the pandemic to dealing with a terrorist attack that goes on and on.
‘The sheer scale of deaths that were seen has been difficult to deal with,’ she says. ‘Nurses in critical care were seeing five or six people dying every shift at points when normally it would be no more than one. Emotionally that is hard.’
She says this has been compounded by a sense of not being able to provide the sort of care they would have liked.
Staffing levels left nurses working in critical care during the outbreak traumatised
Nurse-to-patient ratios went from one to one to one to four or even higher in places, Ms Credland says, while senior critical care nurses have had the added stress of trying to support junior colleagues and nurses redeployed to help them – some of whom had no critical care experience at all.
‘That has all caused stress for critical care nurses. And, of course, for those who were thrown into it from general medical wards and outpatients, it has been traumatic,’ she says.
In recognition of this, the BACCN has taken on a trauma counsellor to support its members.
‘In three months, there’s not been one day he has not had a referral,’ Ms Credland says.
The critical care nurse: ‘I’m profoundly tired, I struggle to sleep’
Karin Gerber has worked as a critical care nurse for more than 20 years.
She says the pandemic has been the most challenging period of her life.
‘We’re used to seeing people die, but the numbers were overwhelming. It was like dealing with a major incident that never ends,’ she says.
‘Wearing PPE was physically hard. It was hot and uncomfortable. It was also hard not being able to see the families of the patients we were caring for. Normally we would get to know the patients through their families – we go on the journey together.
‘But we could not do that. We had to talk to them on the phone. That was unbelievably hard for families – and as a result it felt like we could not do our job as well as we would have liked.’
She says she has found it particularly hard to switch off – and that is still having an effect on her now.
‘I got coronavirus at one point and had to stay away. All the time I was thinking about what was going on’
‘Normally you can separate your work life from your home life. But during this you couldn’t,’ she says. ‘All the things you may do to relieve stress – go to the gym or for a swim or out for a drink – were not possible.
‘I got coronavirus at one point and had to stay away. All the time I was thinking about what was going on.
‘When it was hectic the adrenaline kicked in, but now the first peak is over I feel profoundly tired, I struggle to sleep and you are constantly worrying what will happen if we get a second wave.
‘There is so much worrying news in the media. It is impossible to switch off.’
Study finds signs of depression, anxiety, stress and PTSD among nursing staff
Ms Credland’s concerns are echoed by research looking into the psychological impact of the pandemic on staff.
Academics are monitoring this as part of the Impact of COVID-19 on the Nursing and Midwifery workforce (ICON) study.
It is being undertaken by experts from universities including King’s College London, Warwick and Surrey, with the backing of the RCN Research Society.
A survey of 4,000 staff carried out during the April and May UK peak found evidence of depression, anxiety, stress and the emerging signs of PTSD among nursing staff.
Support, though, has started flooding in from psychologists and therapists keen to offer their services.
Support services and dealing with problems at an early stage
Two psychotherapists, for example, set up emotional support service Frontline 19 during the early days of the pandemic. It is now a hub for more than 3,000 experts who have volunteered their time to NHS and care staff.
Co-founder Ellen Waldren says the venture has helped more than 1,000 staff so far, and most of these have been nurses.
‘We’re seeing people come forward with the early signs of PTSD, anxiety and depression. They have been overwhelmed. It has been like a war zone.
‘Normally, your own safety is not compromised as a nurse. But that has been a big issue for some – they worry about their own health and that of their families, along with the other concerns.’
She says it is crucial for nurses and other staff to seek help when they start developing the signs of PTSD, such as negative thoughts, nightmares, feeling sick and sleeping problems.
‘Getting help early stops it becoming a chronic problem. But the problem is the services that are available – we are hearing of long waiting lists in some places.’
The psychotherapist: ‘We need better support for staff’
Matt Broadway-Horner is a mental health nurse and psychotherapist, who has been providing voluntary support to nurses through the British Association of Critical Care Nurses.
He says some nurses are, and have been, struggling.
‘It has been a difficult time for nurses. There was a lot of loneliness. Nurses may have been away from their families during what has been a stressful period.’
In the main, he has been using the technique of psychological first aid, which encourages positive coping mechanisms. It is designed for use in the immediate aftermath of a disaster and is aimed at preventing psychological problem from having long-term consequences.
But, for some, extra support has been needed, including cognitive behavioural therapy.
‘Some nurses have been showing signs of depression, others struggling to sleep. One nurse had recurring nightmares of children dying from COVID-19, and of her children dying of COVID-19. It was making it difficult for her to work.
‘Being a nurse myself helped. I understood the environments staff work in and the working patterns and schedules they have.
‘We need to get better support for staff, psychologically, especially through something like COVID-19.’
Government says mental health of NHS staff is a ‘top priority’
The Department of Health and Social Care in England says work is under way to increase support, saying the mental health of staff is a ‘top priority’.
It pointed to a staff helpline run by the Samaritans that was already in place, and free access to a range of health and well-being apps that offer help with everything from mindfulness to sleeping.
A framework has also been set up to allow NHS organisations to purchase supplementary occupational health support for their staff.
But many believe there are limits to the usefulness of national helplines and apps. The ICON research found just 12% of staff had used the NHS well-being apps.
Where to get support
Basing services at a local level could increase take-up
University of Surrey professor of health services research and nursing Jill Maben, who is involved in ICON, says getting the right support to staff is going to be crucial.
‘Learning from previous pandemics, we know the timing of access to support and type of support available for nursing staff is crucial for their overall well-being,’ she says.
‘But the results suggest few are accessing such services for the stress and anxiety they are experiencing. It is important to find out why this is, to protect the workforce.’
University College London psychiatrist Michael Bloomfield says he believes offering support at a more local level may help.
Dr Bloomfield is part of the COVID Trauma Response Working Group , which brings together mental health experts from a range of organisations. It is looking at the emotional and psychological impact of the pandemic on staff and patients.
‘If people have support from staff they know and develop a relationship with, who understand the local circumstances, that can make a big difference,’ he says. ‘Most employers have staff well-being leads that can arrange this – and there is lots of good work being done – but it is still patchy. We need more.’
NHS should make use of the experience and skills of mental health nurses
But it is not just about providing support, Dr Bloomfield says.
The working group has been looking at how the risk of psychological harm can be mitigated and has recommended working practices, including ensuring staff get proper breaks and time away from work, and are rotated in and out of COVID-19-related responsibilities.
The group also says support from colleagues and peers can play an essential role too, but it cautions against forcing staff into debriefings where they have to talk about their feelings or participate in programmes that are based on developing mental strength.
RCN professional lead for mental health Catherine Gamble says creating support networks in organisations and between staff is vital.
She would like to see NHS employers tap into the expertise of mental health nurses.
‘We have the skills in the profession to help each other and now is the time to act. I like the analogy of the marathon – the hardest bit is when you are on your own, away from the crowds and the clapping has stopped.
‘We are at this stage now – this is where staff feel it emotionally and psychologically. We need to help them.’
The public: ‘We want to be there for healthcare staff’
In Gloucestershire, the public have come together to help raise money to support the mental health of hospital staff.
A total of £350,000 was raised for the Cheltenham and Gloucester Hospitals Charity – nearly a third of which has been put towards providing emotional and well-being help for health workers.
The funds are paying for peer support training for staff, dedicated support for black, Asian and minority ethnic staff, and a clinical psychologist.
Head of fundraising Richard Smith says: ‘We want to be there for staff who were there for us.
‘Sometimes it is when you come up for air after working so intensively that the enormity of what you have done hits you.’
‘I remember at the start feeling we were stepping into the unknown, into something where we did not know what would happen or how long it would go on for’
Professor Steve Hams, chief nurse, Gloucestershire Hospitals NHS Foundation Trust
Gloucestershire Hospitals NHS Foundation Trust chief nurse Steve Hams says the support is much needed.
‘There were some difficult and challenging times where we have wobbled,’ says Professor Hams. ‘I remember at the start feeling we were stepping into the unknown, into something where we did not know what would happen or how long it would go on for.
‘There were many points as a nurse and as a human where I was scared.’
Nick Evans is a health journalist