Introduction
The COVID-19 pandemic has had an unprecedented and long-lasting impact on health systems, individuals and healthcare professionals, with a consequent impact on society, the full extent of which has not yet been revealed.1–3
The response to the pandemic and the initial crisis faced by health services needed a coordinated and sustained approach to reinforce resource availability and provide access to appropriate clinical care. This required many staff to be retrained and redeployed to key clinical areas to provide the necessary support through skilled clinical resource.4 In the UK, as the number of patients hospitalised with COVID-19 increased during the first quarter of 2020, a concurrent rise in sickness levels among healthcare professionals was reported, with 1 in 10 nursing and midwifery absences,5 although it is uncertain if these were attributed to infection, fatigue or isolation. Bird et al6 found that nurses and those working in respiratory care settings had higher rates of infection compared with other professional groups and settings; not surprising as most patients suspected of COVID-19 would be assessed initially by respiratory teams, with nurses most likely to have the longest and most interactions with patients.
Nurses are the largest workforce within the healthcare system, integral to the management of a pandemic, delivering direct patient care and coordinating services.7 8 This often includes performing aerosol generating procedures (AGPs), which may place staff at high risk of exposure to the virus, particularly in the absence of protective personal equipment (PPE), as AGP can produce water droplets which can then be inhaled. Bronchoscopy, sputum induction, provision of high-flow nasal oxygen and manual ventilation are examples of AGP.9 Nurses have been at the forefront of the pandemic response therefore not only in terms of numbers but also in their extensive involvement in coordination of services, screening, vaccination and front-line work in respiratory, emergency and intensive care environments. The nature of this work is often intense and stress-provoking with an inevitable psychological impact on nurses and all healthcare workers.10
Maben and Bridges11 suggest that contributing factors to high stress levels during the first wave of the pandemic included changing protocols and ways of working, increased exposure to end-of-life experiences, redeployment, concerns around personal and family health, long shifts, limited access to COVID-19 testing, and lack of PPE. These personal and professional issues often conflict with healthcare professionals’ perceived professional and moral duty to provide an essential, potentially life-saving service.
The psychological impact on those working with patients during the COVID-19 pandemic and its consequent toll on the mental health of the workforce has been recognised.10 12 13 Healthcare professionals have experienced negative mental health outcomes including depression, anxiety, insomnia and stress.14 A recent UK survey on the mental health of the nursing workforce during the pandemic15 found that over 80% of participating nursing staff experienced increased levels of stress and over 30% stated that their current mental health and well-being were affected. Previously reported findings from our survey (also in the UK) found 21% of a sample of 255 nurses experienced moderate to severe or severe symptoms of anxiety, with similar levels of depression.16 Previous studies relating to the Ebola crisis17 18 also report that the risk to the mental health of those working in pandemic situations is high, with symptoms appearing during, but more often after, the crisis is over. Working in healthcare during the COVID-19 pandemic therefore may be associated with both short-lasting and long-lasting psychological effects.19 Experiences from previous pandemics confirm front-line healthcare professionals may develop poor mental health as a consequence, including formal mental health disorders such as post-traumatic stress disorder (PTSD)17 and moral injury.20 Moral injury refers to the moral distress caused by the powerlessness of healthcare professionals to meet patients’ needs in a situation of high demand and constrained resources, and it has been linked with the development of suicidal thoughts, depression, anxiety, flashbacks or PTSD.21
It is paramount that the importance of the impact on mental health and psychological well-being on all parts of the healthcare workforce is identified, characterised and addressed. In this study, we focus on nurses working in respiratory areas with the aim of identifying and characterising the self-reported issues that exacerbated or alleviated their concerns. We aim to identify areas that individuals, organisations and policy makers can target which may help to alleviate the psychological consequences of the pandemic on nurses and the wider healthcare workforce.