COVID-19 health workers may require psychological support to deal with witnessing ‘unacceptable’ situations, according to a review co-authored by Queen Mary University of London academics.
The paper, published in the European Heart Journal, looks at the psychological wellbeing of medical staff, and includes recommendations for individuals, teams and leaders in the COVID-19 pandemic.
The authors say that during the COVID-19 pandemic there are many opportunities to support staff. The paper is structured as a guide and has easy to read sections and tables so that individuals can focus on the section most relevant to them. The paper will be useful for any individual involved in the front line healthcare response.
The review highlights the increased pressure staff are under, while having to deal with fears of catching the illness themselves or passing it on to their families, working with new and frequently changing protocols, and caring for very sick and quickly deteriorating patients – all of which can result in ‘moral injury’.
Moral injury is a concept emerging from work with military veterans, and is used to describe the psychological impact of bearing witness to unacceptable things. In medicine, unacceptable life-changing and life-ending occurrences are witnessed as part of daily practice. Many of these are beyond health workers’ control, and the inability to prevent bad things happening can result in huge feelings of guilt and shame.
During the COVID-19 pandemic, clinical decisions are made which contravene the morals of those making them. For example, following new protocols about which patients will not receive life support if there are resource scarcities. Moral injury can therefore result from health workers doing something they see as wrong, such as not being able to ventilate a COVID-19 patient just because they are the wrong age.
The authors say that already staff report being worried about having to make these decisions, having seen the experience of their colleagues in other countries, and they are experiencing anticipatory guilt while they wait for the peak to hit in their own countries.
Dr Esther Murray, Senior Lecturer in Health Psychology at Queen Mary said: “Moral injury can also result from bearing witness to the devastating effects of failures in leadership in high stakes situations. NHS staff feel that the government have let them down and then lied about it – so this is another form of moral injury which NHS workers are having to deal with.
“The hero and angel tropes which we see bandied about are also highly problematic because it makes it look as if people signed up to die, like a hero does, but they didn’t. It also makes it harder for NHS staff to talk about how they really feel because opinions get polarised - are you a hero or a coward? A lot of staff feel like cowards but they are not at all, they’re just quite justifiably frightened and angry.”
The authors argue that it will be essential for leaders at all levels to remind staff that they are not making decisions alone, that there is protocol, and also to recognise that these decisions go against the grain for many. It will be necessary to offer ongoing support to all staff, in order for these experiences to be processed for some time after the most difficult phase of this pandemic has passed.
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