Short and long term mental health of front line health care workers raises red flags for current crisis in Australian hospital system

The largest, multi-professional study in the world investigating moral distress and mental health outcomes in frontline health care workers in primary and secondary care during last year’s second wave of the COVID-19 pandemic raises some serious concerns for the short and long term mental health impact for the current crisis experienced by health care workers in NSW, Victoria and the ACT.

A national survey of nearly 10,000 healthcare workers (with results reported for 7846) led by Monash University and Royal Melbourne Hospital (RMH), during the second wave of last year’s COVID-19 pandemic has revealed significant emotional consequences of working in a health system under stress.

The study looked at health care workers’ moral distress relating to resource scarcity, patient care, burdening of co-workers, and perceptions of both stigma and appreciation in the broader community during the COVID-19 pandemic.

The survey, published recently in the International Journal of Environmental and Public Health, found that almost 60 per cent reported moral distress due to resource scarcity such as hospital beds; more than 30 per cent were distressed by PPE limiting their ability to care for patients; more than 60 per cent felt that excluding family from seeing patients went against their values and 55 per cent were worried  they would let their colleagues down if they became infected.

Importantly, these moral distress triggers were associated with mental health outcomes such as burn-out, PTSD, emotional exhaustion, anxiety and PTSD, the study found.

The study was led by Associate Professor Natasha Smallwood, Respiratory physician from Monash University’s Central Clinical School and The Alfred hospital, and Professor Karen Willis, sociologist from RMH and Victoria University. The study was an online survey of self-identified frontline healthcare workers across Australia conducted between 27 August and 23 October 2020.

According to Associate Professor Smallwood, the survey revealed “many personal and workplace predictors of moral distress with those working in certain frontline areas, metropolitan locations, and with prior mental health diagnoses at particular risk of distress”.

Moral distress was associated with increased risk of anxiety, depression, post-traumatic stress disorder, and burnout.

“Importantly and conversely, feeling appreciated by the community protected against these risks in healthcare workers, the survey found,” Associate Professor Smallwood said. Moral distress, also referred to as ‘moral injury’, is defined as ‘perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations’.

The study’s authors conclude that “understanding factors of moral distress prevalence and impacts on mental health is important to inform targeted interventions to safeguard frontline workforces during current and future crises”.

The study reveals the moral distress triggers experienced by healthcare workers last year are associated with  significant mental health impacts. Wearing PPE affected their ability to care for patients with COVID-19; being worried about letting down colleagues if they needed to quarantine were significant; being worried about excluding family members from COVID-19 patients’ bedsides were all significant, independent predictors for all adverse mental health outcomes.

The survey also found worrying that patients would not receive appropriate care due to scarcity of health care resources was a significant independent predictor for experiencing PTSD and both the emotional exhaustion and depersonalisation domains of burnout. Believing that the community was concerned health care workers  would spread COVID-19 to other people was a significant, independent predictor for experiencing anxiety, PTSD, and both the emotional exhaustion and depersonalisation domains of burnout.

Importantly, believing that the community was appreciative of health care workers during the pandemic was a significant, independent predictor for experiencing fewer mental health symptoms on all scales and greater personal accomplishment.

In detail, the study found:

  • Participants were mostly female (over 80%) with an even spread of age ranges, residing primarily in Victoria (85.2%), with the remainder spread across other Australian states and territories. Most participants were nurses (39.4%), doctors (31.1%), or allied health professionals (16.7%), with the remainder holding administrative (6.2%) or other health roles (6.7%). Almost one third of participants (30.4%) reported having a pre-existing mental illness diagnosed prior to the pandemic.
  • Of those for whom felt that  resource limitation impacted on patient care – including workers in primary, community, or aged care, ICU (relative to emergency department), working in metropolitan areas (relative to regional or remote), and those with a pre-existing mental health diagnosis. Participants who worked as nurses or allied health professionals (compared to doctors) were less likely to worry about resource scarcity.
  • Regarding the need to wear PPE - individuals who worked in nursing, allied health, and other health roles (compared to doctors), or who were confident using PPE (compared to not confident) were significantly less worried about the effects of wearing PPE on patient care.
  • Participants who worked in primary, community care, and aged care (compared to ED), those living in metropolitan areas (compared to regional or remote areas), who had pre-existing mental health diagnoses, or who desired more training regarding PPE or managing patients with COVID-19 (compared to those who did not) were significantly more likely to be worried about burdening their co-workers if they needed to quarantine
  • Nurses and allied health professions (compared to doctors) and people working in ICU (compared to ED) were significantly less likely to worry about the effects of quarantine on co-workers’ caseloads.
  • Independent predictors for believing that excluding family from the bedside of COVID-19 patients went against their values as health care workers included female gender (relative to male), having a pre-existing mental health diagnosis, and indicating need for more training in care for patients with COVID-19 or use of PPE. Non-medical staff (in comparison to doctors) and participants who worked in ICU, anaesthetics and surgery, medical specialties, and other frontline areas (in comparison to ED) were significantly less likely to worry about excluding family from the bedside of COVID-19 patients.
  • Older participants (compared to those aged 20–30 years) were significantly more likely to believe that the community was worried that health care workers would spread the virus to others.
  • People who worked in ‘other’ non-medical roles (including paramedicine, radiology, pharmacy, pathology, maintenance, clerical and admin staff, and COVID-19 screening) compared to doctors were 47% less likely to believe that the community was worried health care workers would spread the virus.
  • Participants aged 31–40 years (compared to aged 20–30 years) and nurses (compared with doctors) were significantly less likely to believe the community was appreciative of health care workers during the pandemic. Participants who were confident using PPE, trained in using PPE, and participants from other health roles (compared to doctors) were more likely to believe the community was appreciative of health care workers during the pandemic.

References

  • Smallwood N, Pascoe A, Karimi L, Willis K. Moral Distress and Perceived Community Views Are Associated with Mental Health Symptoms in Frontline Health Workers during the COVID-19 Pandemic. Int J Environ Res Public Health. 2021 Aug 18;18(16):8723. doi: 10.3390/ijerph18168723.
  • Smallwood N, Willis K. Mental health among healthcare workers during the COVID-19 pandemic. Respirology. 2021 Aug 31. doi: 10.1111/resp.14143.
  • Smallwood N, Karimi L, Pascoe A, Bismark M, Putland M, Johnson D, Dharmage SC, Barson E, Atkin N, Long C, Ng I, Holland A, Munro J, Thevarajan I, Moore C, McGillion A, Willis K. Coping strategies adopted by Australian frontline health workers to address psychological distress during the COVID-19 pandemic. Gen Hosp Psychiatry. 2021 Aug 20;72:124-130. doi: 10.1016/j.genhosppsych.2021.08.008.