Winter 2019 was the busiest David, a paediatric nurse, had ever been. In a 12-hour hospital shift his team saw 120 children in facilities built for a quarter of that. “Then whispers grew of this bug in China,” he says. Little did he know it was going to place him and his colleagues under the greatest strains of their careers.
“It hit us in about March,” he recounts, “and in our hospital it ground us to a halt.” David was voluntarily redeployed to adult intensive care, but the PPE situation was “a bit of a joke”. Staff were given contradictory advice, could not get hold of appropriate protection, and at the worst times were told to wipe and reuse PPE when it clearly needed to be replaced. “You just think ‘this just isn’t right’,” he says.
They were also having to use iPads to let family members say goodbye to the dying relatives they were not allowed to see. “That’s probably the hardest thing I’ve had to do,” David says, and that includes his time working in children’s palliative care.
For many staff like David, their jobs in the NHS were exhausting but rewarding. However, when the pandemic hit the UK in 2020, they found themselves under a level of strain and stress they had never seen before. In June, the Health and Social Care Committee published a report that said staff shortages were the biggest single factor in burnout, with Covid having a “big impact” on a system that was already weak. The committee chair and former secretary of state for health Jeremy Hunt warned of an “extraordinarily dangerous risk” to both health and social care services as a result.
“The emotional strain on doctors was significant. That increased as time goes by,” says David Wrigley, a GP in North Lancashire and the well-being lead for the British Medical Association (BMA). On top of concerns about patients, doctors were worried about their own health, he explains, particularly at the start of the pandemic when PPE was in short supply. “It was always on our minds that we might pass this [virus] on to our loved ones,” Wrigley continues. All of these emotional strains compounded each other. “This burden is increasing and it’s a real concern for us,” he adds.
According to the BMA’s most recent survey, 57 per cent of doctors were living with one or more conditions including depression, anxiety, stress, burnout, emotional distress or another mental health condition as a result of work. The BMA offers telephone and face-to-face counselling and support to all doctors and has opened it up to family members too. There is also a peer-to-peer helpline. In July 2021 it was three times busier than for the same period in 2019.
“Nursing is a career that has a lot of emotional labour attached to it,” says Patricia Marquis, director for England for the Royal College of Nursing (RCN). She says it was not unusual for staff to experience “highs and lows” in the course of their day-to-day job in normal times. However, even before the pandemic there were around 40,000 vacancies for nurses in England, according to the RCN. The stress on staff from Covid-19 had a significant impact on nurses as a result. “People are still trying to do a good job, but working in increasingly difficult circumstances, and the impact of that on their mental health has been quite marked,” Marquis says. While staff were able to pull together in a “Dunkirk spirit” effort at the start of the pandemic, the sickness rates from burnout, stress and exhaustion began to rise the longer it went on, she explains.
“It does seem endemic across all staff groups,” says Sara Gorton, head of health at Unison, the UK’s largest union. Less visible staff, such as porters, caterers and cleaners, can be contracted out to private companies and that means a wide variation in terms and conditions for things such as sick pay. “The hangover from the pandemic will be longer and deeper for those staff,” Gorton says. Porters, caterers and cleaners are also more likely to be from a black and Asian background, something that was highlighted by the disproportionate impact of Covid-19 on those groups.
Unison was able to strike a deal with NHS employers where directly employed staff would not lose pay when they were sick or isolating, Gorton explains. However, this was not the case for staff who were contracted out to private companies. She would like to see better pay and remuneration for both directly employed and contracted-out staff, for outsourced staff to be brought back into the NHS, and to ensure safe workloads as the NHS deals with the backlog in care.
Rachel Gemine is the grant and innovation manager at Hywel Dda University Health Board in Wales. It became clear early on that staff were under “enormous pressure” she says and there were concerns about what would happen if they continued to work at that pace. The team decided to survey staff to see how they were feeling and what they were experiencing. The aim was to find out what the factors were for staff burnout and how to prevent it. The research showed there were three main predictors of burnout: working in a Covid-19 role, having concerns about PPE, and not taking proper, restful breaks.
These were all areas employers could do something about. With breaks, Gemine explains, hospitals can work with line managers to ensure staff take time out: “If you’re in a workplace and you see the sister doesn’t take a break, or the consultants aren’t taking a break, then other people think ‘oh, I can’t take a break’.”
The PPE situation in Wales was actually okay, Gemine continues; it was more the perception of a shortage and concern for colleagues that was causing a lot of stress, so making sure staff knew what was happening was vital. Similarly, with working on Covid, they found out through survey comments that staff wanted to be involved in how their roles were changed and have some choice. “Back at the beginning, people were unsure what was happening; they didn’t know if they were being redeployed,” Gemine says.
“It is mind-blowing what staff have been through and how they still have to carry on and dust themselves down and do it all again,” says Andrea Bradley, a nurse of 30 years who works for NHS Wales on staff resilience and recovery. During the first wave she set up a Covid admissions ward before moving into her current role.
Her team started putting together days for nurses that gave them a break from front-line practice to reflect on their experiences and give them space to think about their well-being and resilience. One of the organisations that came in to deliver sessions with the nurses was Performing Medicine, which provides arts-based training and courses.
“I was absolutely blown away by the way they interacted with me, how they made me reflect and supported me,” says Bradley. The days were a big success with the nurses that attended. “They felt cared for, supported, understood and given the permission to reflect and realise they had been through so much.” However, the next two resilience days have been cancelled because the pressure on hospitals means they are not willing to release staff to come to the events. “That’s hard,” Bradley says. “To think they desperately need the support and we can’t give it to them.”
Wrigley says that due to the past 18 months “we are seeing such a record backlog in care – huge waiting lists”. This just “compounds matters”, he adds, and as a result “the strain will continue”. So even if the threat from the pandemic recedes the pressure on staff will be there for years to come.
“There’s no simple solution,” says Marquis, who wants the public and politicians to recognise the scale of the pressures on staff. She wants to see a “realistic” discussion about what is possible in terms of returning to a more normal situation post-pandemic and reducing the backlog in care without putting even greater pressure on the NHS. Pay and support for student nurses through restoring the nursing bursary would also make a big difference in ensuring people continue to join and stay in the profession, she says.
“I love the NHS and I love what it can do for people,” David, the paediatric nurse, says. But he wants to see it change and is thinking about what else he could do having put 12 years into getting to where he is now. Previously, David could never have imagined doing anything else, but he feels differently now. “If I could leave, I would,” he says.
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