Managing mental health challenges faced by healthcare workers during covid-19 pandemic

Dear Editor

Greenberg et al have suggested that the impact of the COVID19 pandemic on some health professionals is more closely related to Moral Injury than to mental disorder. This assertion seems to be correct, especially in critical services such as ICU, internal medicine or infectious medicine.

This idea warns us of the inadequacy of the planning efforts conducted by many health systems in Europe to address with the foreseeable consequences for these professionals, which are only based on interventions for mental disorders such as adaptive, affective or anxiety disorders. The emphasis is on the professional (individual) and not on the organization (health system).

In many cases, what we are witnessing is that the cause of psychological distress is related to the lack of resources such as ventilators, the breakdown of pharmacy stock, the lack of sufficiently trained staff, receiving contradictions in instructions, the lack of guidelines, interruption of continuity of care in the majority of non-COVID19 related diseases except in case of an emergency, and witnessing patients die in isolation, and far from their loved ones.

Professionals are not able to provide the level of quality of care to which they were accustomed. Patient safety has been compromised and professionals have been powerless in these situations. An increase in litigation, which will be initiated by family members who have lost a loved one or by patients who might have been infected in health centers, is expected in the coming months. This situation, which affects work morale and personal ethics, may represent a new blow to these professionals.

To this situation we must also add that other healthcare professionals have experienced overload, have been infected, have remained in isolation or have been admitted in ICU for a long periods (like other patients), such as the Spanish case. This fact, according to individual differences and environmental support, may give rise to adaptive, affective or anxiety disorders associated with fear of infecting others or with the lived experience.

In Spain we have used the term second victim of SARS-CoV-2 when describing the impact of COVID19 on professionals. Similar outlook is expected in other countries. The challenge for all of us is to recover health systems and address the effects of the pandemic on our healthcare workforce. Patients need them.

What happens to professionals is directly and closely related to the raison d'être of any health system: the patients. Caring for those who care is an old recipe but not an outdated one. Otherwise, patient safety and quality of care will be compromised.

Thinking about what we can do and, in the light of the available evidence, identifying in which cases it is appropriate to intervene individually and in which not, seems necessary. Although Moral Injury and Post-Traumatic Stress Disorders share symptoms, it does not seem that interventions are equally effective in both cases. Approaching the problem as if it is only a mental disorder seems wrong. This approach will likely be rejected by most professionals.

It is probably time to bet, once and for all, on increasing well-being at work, on granting greater autonomy to clinicians, on strengthening the role and capacity of middle managers, and conceptualizing what happened. It is also the time to provide understanding the suffering of the healthcare professionals’ relatives during this period. Lastly, it is time to identify the problem clearly so as not to miss the solutions.

Dear Editor,

Neil Greenberg and distinguished colleagues give a great overview of psychological consequences of trauma. The concept of moral injury which has been in the medical literature since the 1990s came originally from military PTSD literature. It now has entered fully into the medical lexicon with the war on Covid and all its military metaphors. Moral injury, however, has been around as long as man has, because once you have a conscience you can get morally injured. Cain suffered moral injury when he killed Abel (unless his conscience was hardened by evil), prisons are full of moral injury, and people with guilt obsessions are pathological cases of the same experience.

As such it is a normal human experience which like pain is there to tell us there is something wrong. In the present setting of the pandemic health professionals are more likely to suffer because something wrong is happening all the time. The overarching positive aspect for these and all health workers is that they set out to serve and help and do good to others. Their intention is good. This can be a saving grace and consolation when harm happens. There is no malice aforethought. The wound can be healed.

The process of healing a wounded heart or conscience begins with acknowledgement that something happened. The grieved person may be so "numbed" (as in PTSD) initially that a comforting supportive non-judgemental presence of another friend or relative or colleague may be all that is possible and appropriate. In due course with thawing of emotions and cognition a clearer impression and picture may appear. A person may then want to talk to a trusted friend or mentor. The acknowledgement of events, the cause of the mistake and the guilt and shame surrounding it is allowed to be ventilated. Empathy and understanding and comforting the grieved person will allow them to see reality and how they possibly were not to blame at all, but in fact were also victims.

If they were culpable due to circumstances, etc, acknowledging the truth can bring closure and healing. They may feel that compensation or making-up to injured parties is required and so be it. In many ongoing situations it is a prolonged war and moral hurt may be heaped upon moral hurt to consolidate a chronic state of guilt and unhappiness. These prolonged episodes require ongoing vigilance and support. The world of general psychiatry is full of moral injury and it usually does resolve as above, provided the person abstains from further morally offensive behaviour and understands how they got into this situation in the first place. Moral injury may get into the DSM 5 as a precipitant to other DSM diagnoses.

Moral injury is more suited to the moral philosophy literature than the medical literature because it has a longer tradition of dealing with it as what could be called a moral evil. World cultures and religions often divide it into culpable and non-culpable and apportion sentences or treatments accordingly. Medical moral injury secondary to Covid has to be predominantly non-culpable because it it is due to circumstances out of the health professionals control. As such comforting, consoling and support should be the mainstay of "treatment."

Dear Editor,

In their recent article on moral injury (BMJ 2020; 368:m1211), Neil Greenberg and colleagues defined this as ‘the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code.’ Might the current covid-19 pandemic be creating a special kind of moral injury for staff working in mental health services at this time?

At the current stage of the pandemic its effects are mostly being felt in acute hospital services which are rapidly becoming over-stretched. This leaves those working in mental health services in a difficult position. Feeling part of ‘Team NHS’, there is a desire to be a part of the crisis response. But it seems that the response doesn’t quite need us, yet. There is important work to be done in keeping our patients safe during this incredibly difficult time but we are not in the eye of the storm.

As we see other medical staff across the health service being asked to do more and more, exposing themselves to the heat of the front line in fighting this pandemic, how might our sense of being slightly removed from this affect staff working in mental health? And are mental health trusts being whipped up into an inappropriate response? At times it seems like there has been an attempt to create a crisis in a part of the system where one doesn’t currently exist. With the likelihood that the pandemic will lead to recession and knock on effects on the mental health of the population, it is likely that our time will come but it may not be now. We should be saving our energy, and resources for when it does.

Greenberg and colleagues highlight the challenges faced by medical students, and the effect on their mental health due to exposure to pre-hospital and emergency care(1). It is hard to differentiate whether the cause of deteriorating mental health is due to moral injury or other factors, however it is imperative this is addressed in the future workforce.

Medical students especially are at an increased risk of deteriorating mental health due to the pressures of the course. A recent survey of more than 4,300 doctors and medical students found that 27% had at some point been diagnosed with a mental health condition, with 90% of respondents stating the reasons for this were significantly or partly due to their work or study environment(2). These worrying statistics, which support the concept of moral injury, are likely to worsen as pressure on the NHS increases.

The following experiences are from the perspective of students at one UK medical school. Students are expected to attend clinical placements daily, simultaneously revise for exams, whilst maintaining a healthy work-life balance. The first point of call for students struggling with their mental health is often the university or the course specific well-being team. This latter service is part of a wider team that includes members of staff overseeing students’ fitness to practice. Although one may argue a student’s deteriorating mental health may eventually effect their competency as a doctor, the joint service discourages students from accessing help.

Many medical students feel that sharing their mental health concerns with course specific well-being services may have a direct impact on their degree. For example, it’s not unheard of for students struggling with the stresses of final year to repeat clinical placements or to be encouraged to sit their exempting exams at a later date. This in turn causes extreme anxiety amongst students already struggling. The same scenario is observed in the context of academic advisors whom are intended to be student’s pastoral support, but also mark the student’s academic portfolio, the passing of which is a mandatory part of the degree. Academic advisors are another potential source of support effectively taken away from the student, as the relationship resembles that of an examiner.

The position of the medical school seems reactive rather than proactive. Students experiencing mental health difficulties are pushed into the same cruel system concerning absences and resits rather than one which should embody support and flexibility.

1. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ [Internet]. 2020 Mar 26 [cited 2020 Apr 4];368:m1211. Available from: http://www.bmj.com/lookup/doi/10.1136/bmj.m1211
2. Sykes C, Borthwick C, Baker E. Mental Health & wellbeing in the medical profession. Br Med Assoc [Internet]. 2019;1–77. Available from: https://archive.bma.org.uk/collective-voice/policy-and-research/educatio...