Jennifer Brown and Yvonne Shell discuss the possibility of healthcare workers experiencing post-traumatic stress disorder and other similar conditions as a result of dealing with COVID-19. They write that the antidote includes clarity in chain of command, effective supplies of equipment, and good communication.

A perfect storm is gathering for the experience of psychological consequences by frontline staff during this world health crisis. Essential for key workers’ mental health in the face of a disaster such as that presented by the COVID-19 pandemic is resilience. This is the lesson learnt by Doctors Without Borders – an international medical humanitarian organization – for the welfare of its staff working in disaster areas. Resilience is personal, organisational, family and community. Resilience happens in a context and is a shared experience. That’s why our ‘clap for carers’ on a Thursday evening may have such significance for frontline workers beyond the immediacy of expressed appreciation.

We already know that medical staff, social and care workers as well as emergency personnel can suffer symptoms of stress in normal circumstances and may be especially vulnerable in extremis. It is widely accepted that those who undertake such roles may experience Post-Traumatic Stress Disorder (PTSD), a condition we readily associate with veterans from war. PTSD occurs when a person is confronted by actual or threatened exposure to death or serious injury to themselves or others. PTSD is distinguished from burnout, which tends to progress gradually through the cumulative wear and tear from excessive work-related demands and is manifest by disillusionment, mental, and physical exhaustion or compassion fatigue. PTSD is accompanied by feelings of fear, horror, helplessness and manifests in a degree of emotional numbing, feelings as if things are not quite real (dissociation) or that things are happening outside yourself (depersonalisation). Typically, there is a re-experiencing of distressing images, hyperarousal, withdrawal and irritability.

Such symptoms are not unusual in those facing rising death tolls, excessive workloads, and potentially ethically demanding decisions of who may or may not receive lifesaving treatment. PTSD occurs if these symptoms persist. If they do, it is likely that the person is unable to process what they have seen and integrate the experience thereby making sense of it. They become emotionally exhausted trying to cope and images return unbidden to haunt them. Being able to search for some positive meaning and grow from the experience is part of personal resilience.

Perhaps less well articulated and less known about is the potential for these frontline health workers to experience ‘moral injury. This is a distinct condition when a person “perpetrates, fails to prevent, bears witness to, or learns about acts that transgress deeply held moral beliefs and expectations”.  It has three important components: 1) betrayal of what the person knows is right, 2) by someone who holds authority, 3) occurs in a high-stake situation.

Historically, the term has been utilised in military contexts, but it is now appreciated that it applies to other groups. In the current pandemic, of significant interest is the bellicose language we see utilised – ‘the invisible enemy’, the ‘fight’ against the virus with our healthcare workers being positioned on the ‘frontline’ as ‘heroes/heroines’ on a metaphorical ‘battlefield’. These professionals are having to deal with situations that are unprecedented and extreme and give rise to psychological inner conflict. Faced with the upward trajectory of those dying, healthcare workers are confronted with this unrelenting distress, alongside the shortages of vital equipment for both patients and themselves.

Frustration at the government’s supplying of PPE, testing and tracing regimes, accompanied by exhaustion in the face of long, physically, psychologically and emotionally demanding shifts can result in feelings of powerlessness for those who have trained to provide care and healing. They may well feel compromised not only by the unknown nature of this virus but also from the feelings of ‘betrayal’ by what is perceived to be an inadequate and slow response by politicians.

Three prescriptions are available to mitigate the potential for psychological ill-health – predictability, controllability, and threat reduction.  Predictability is the need to know about the details, timing, and course of the disastrous event to allow the key worker to marshal their coping resources and expend them effectively. Medicin Sans Frontières advice is that preparedness is critical here. Drills and role play exercises, mimic real events and point out shortcomings and weakness that can be anticipated and remedied – clearly this did not happen as a result of the UK’s pandemic simulation. Codenamed Exercise Cygnus, a comprehensive exercise took place  in October 2016, although its recommendations were not made public. It apparently highlighted shortages of intensive care beds, vital equipment, and mortuary space yet little appears to have be done to fix these shortcomings. Additionally, Doctors Without Borders’ advice is to pre-prepare policies and communication strategies particularly briefing and de-briefing protocols.

Controllability is about the frequency, intensity of exposure. Organisations/systems can create both barriers and facilitators for individuals to develop and ‘grow’ their resilience. Resilience is an iterative and intuitive process. Organisational resilience can intervene by instituting screening for staff, providing high-grade feedback on performance, recognising concerns from the front line, and normalising reactions rather than displaying punitive judgements. Matt Hancock’s comments about ’proper’ use of PPE equipment when staff were experiencing severe supply problems were unhelpful as these were taken as an insult to their professionalism. Staff are more likely to experience a sense of threat if they do not believe they will have the resources to deal with events. As Doctors Without Borders says, it is better to prevent staff suffering adverse symptoms in the first place; but if experienced, it is beholden on organisations to strengthen their capacity to recuperate.

The clearest message from research is that key to prevention and recovery is support: social support from peers; advice and feedback from supervisors; emotional support from families; being valued by communities. Psychological first aid includes listening and absence of fake or inappropriate reassurance. It is not a case of crass political platitudes to “feel your pain” or Priti Patel saying ‘sorry if people feel there have been failings’ over PPE rather than actually apologising for obvious shortages.

Conflicting expectations, lack of personal autonomy, hostile and defensive atmosphere, mixed messages are a recipe for PTSD and moral injury casualties. The antidote is effective leadership, accurate job profiles relevant to required tasks, clarity in chain of command, effective supplies of equipment, timely, proactive communication, accurate information and a non-judgmental culture.

The presence of distrust in systems and policymakers all contribute to the profundity of the aftermath, devastating individuals, organisations, and the community. We need a multifaceted response to both psychological and moral suffering, paying attention to ethical values, moral distress and injury, deep demoralization, and  the emergence of shame and survivor guilt if we are to mitigate psychological injury as a result of the pandemic.


About the Authors
Jennifer Brown is co-director of the LSE’s Mannheim Centre, and was previously the Deputy chair of the Independent Police Commission looking into the future of policing.



Yvonne Shell is Senior Clinical Teaching Fellow at the University of Portsmouth, and a Consultant Clinical and Forensic Psychologist working with offenders with identified mental health challenges.



All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science. Featured image credit: by Luke Jones on Unsplash.


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