As some of us start to enjoy the first tentative signs of spring and try to manage our tiredness and frustration with the last few months of lockdown, spare a thought for the clinicians trying to keep things going in the specialities most affected by Covid19.
There is no recovery plan for them at service level or as individuals. Shockingly, medical training numbers in both ICU and respiratory medicine are being reduced this year. This was planned before the pandemic hit, and it seems that no-one has thought to reverse the decision, despite surveys showing the large numbers in these specialties suffering from anxiety and depression, the toll of new Covid infections and Long Covid in the future, and the backlog of postponed treatments. A significant number of staff are talking about retiring early or leaving the profession. Some of them will change their mind about this, but some won’t and if people leave, this will make it even worse for those left behind.
Many of the individuals I speak to are more exhausted that they ever thought possible. They were exhausted back in early summer at the end of the first wave, and it’s got far worse since. Remember that military personnel and clinicians working in disaster zones have long periods of time being rotated away from the frontline: their down-time is commensurate with the pressures of their work. The staff on our Covid19 frontline in hospitals have been working for over 12 months with minimum annual leave and constant pressure to do overtime.
The shortage of specialist nursing staff is particularly desperate. Some of the people I see have been forced to take time off sick because their anxiety symptoms have got the better of them, the conscious effort to minimise the fear and stress eventually erupting in frightening and disabling panic attacks. Senior nurses spend an inordinate amount of their time just trying to cover the rota, and never quite managing it. I know of staff dragging themselves into work to cover shifts, despite struggling with significant Long Covid symptoms; and surveys tell us that the majority continue to work despite significant symptoms of burn-out. In normal times, I would be encouraging many of the people I see to take time off work, but this is not something they are asking for. They know better than anyone how stretched the service is and everyone knows of colleagues who are in a worse state than they are, but still reporting for duty.
Quite apart from the sheer number of deaths and the nature of this horrible illness, the actual work is full-on to a degree most of us find hard to imagine. The environment is extremely high tech and involves an almost impossible amount of multitasking. I find myself worrying about their over-stimulated brains and have noticed that the people who seem to function best are those who manage to sleep more than they usually would – lots more in some cases.
Nurses who chose to work on ICU because they enjoyed the concentrated focus on a single patient find themselves supervising staff from other specialties and having to spread their attention over a number of patients, racing in many cases, trying, but failing to get through the list of things that need doing and constantly distracted by clinical emergencies. The gratification that came from knowing their patient was getting the best possible care is often absent; the sense of working sensitively with families to ease the trauma of critical illness and death, impossible in the present circumstances – although they try their very best.
I have written before about ‘moral injury’, the distress people feel when they have to work in a way that contradicts their personal and professional ethic. The nurses referred to earlier grieve for the families and blame themselves for keeping them at a distance even though it’s beyond their control. They worry that they can’t remember the names of the patients. They watch their feelings becoming numb as they deal with one death after another. They wonder if enjoyment of the job will ever return. Some of them ask me if I think they’re bad people.
They can see no end in sight. Although the number of Covid patients is starting to reduce, ICU and other frontline specialties will continue to work at full capacity (by ‘full’ I mean well over 100% occupancy) for the foreseeable future as they push ahead with the backlog of delayed treatment.
There doesn’t seem to be much optimism or happy anticipation of lockdown easing. I get the impression that many of these conscientious clinicians are keeping going by taking it a day at a time, not daring to raise their eyes to a bigger vista, fearful of having their hopes disappointed – even more so than the rest of us, More worrying, one nurse told me last week that she no longer found it helpful to see friends: “It feels like this experience has set me apart, I wouldn’t know how to start to talk about it, but other things, ordinary things, just don’t register.”
I’ve not written anything that’s new or original today – indeed, since the measly ‘pay-rise’ was announced, such stories have been well covered in the media – but it feels important to continue to bear witness. I’m aware that I’m only seeing a self-selected few. I’m also aware that other groups within the population are struggling in different ways. But no-one entered the healthcare professions expecting to have to work like this. True, there have been some Trusts and team leaders who have been imaginative in promoting initiatives that relieve and reward their staff. But this is the exception. There is no ‘plan’ that gets anywhere near facing the reality of the situation. No real understanding that good healthcare depends on the carers feeling well cared for themselves.
How are these individuals and these services going to recover? How will we look after them? Are the newly announced ‘Resilience Hubs’ sufficient? What does resilience mean in such a context? Is it possible to grow through such adverse circumstances? Some of our future blogs will address these critical issues.