By Quality Compliance Systems | June 29, 2020
Quality Compliance Systems (QCS) explores why the Covid crisis could lead to an increase in PTSD.
An introduction by Mat Whittingham, CEO and founder of Quality Compliance Systems (QCS)
“In years to come, when we look back at the coronavirus pandemic, what will be our abiding memories? For many, it will be the courageous efforts of the UK’s 1.5 million care workers, who selflessly risked their own lives to care for others.
In the face of great adversity and sometimes tragedy – they have demonstrated psychological resilience. This has not only helped them to cope with the high levels of stress and trauma that they’ve experienced, but is helping them return to normal life.
However, what is also true, is that in this unprecedented global health crisis, collective resilience has been put under severe strain. Nobody knows by how much. Indeed, that will only become clear when the Pandemic has passed.
But one uncertainty, is that during the next few months, as restrictions are gradually lifted and life returns to normal, care workers will have more time to reflect on their experiences. Some of them will have developed greater resilience, while others, when they have had time to process their thoughts, may need the support of their registered managers, colleagues, and loved ones. While I have no formal clinical training, I’m guessing that, with the right emotional support, most will be okay. However, that said, there be some who go on to develop acute stress disorder (ASD) and – in the most severe cases – post-traumatic stress disorder (PTSD).
To mark PTSD Awareness Day, this article demonstrates the positive steps managers can take to manage staff’s mental health during and after a crisis.
Most importantly, it shines a light on ASD and PTSD. We take a deep dive into this arcane subject, looking at the causes, the symptoms, and finally outlining ways that both can be tackled. To accompany this article, we’ve produced a helpful factsheet, which you can access here.”
Time for reflecting
With the government announcing a set of progressive steps to move out of lockdown, the collective sense of relief felt by people in England was palpable. While some restrictions will stay in place, many were celebrating the fact that hairdressers, pubs, cinemas, museums and art galleries will all open their doors again from July 4th.
But for others, returning to a ‘new normal’ will bring a set of different challenges. Take those in the care sector, for example. For the first time in months, the spectre of COVID-19 is not so prominent. As the first wave of COVID-19 dissipates, very gradually their lives – and the lives of the people they care for – will start to return to normal too.
On one level, that will be a wonderful tonic for many frontline care workers, as it will enable them to switch off their operational mindset and relax. However, in doing so, it will be the first time that many of them will have found time to reflect on their experiences.
ASD and PTSD
It is this period of reflection that can lead some people to develop PTSD, which, ‘usually comes on a month after exposure to one or more traumatic events and almost always manifests by six months,’ according to Professor Neil Greenberg, a PTSD specialist at King’s College London.
Professor Greenberg, who chairs the Royal College of Psychiatrists (RCP) Special Interest Group in Occupational Psychiatry, believes that significant numbers of frontline care workers will develop ASD – which occurs in the first month following a trauma. But he says it ‘is likely that many of those who experience ASD will go on to suffer with PTSD too.’
Just how many cases we could see is unclear, but a recent study by Dr Graham Durcan, Nick O’Shea and Louis Allwood, entitled Covid-19 and the nation’s mental health says that around ‘500,000 additional people could experience mental health problems,’ with ‘care workers at much greater risk of experiencing mental health issues due to COVID-19.’
Nadra Ahmed OBE, Executive Chairman of the National Care Association, thinks that ‘PTSD will be a major issue in the future.’ She says, ‘The past six months have been a very traumatic time for frontline care workers. They are trained in end of life care so can anticipate people dying. That is part of the role they undertake. Bereavement counselling is built into their training to deal with this. But nothing could have prepared them for what they have experienced during this pandemic. Many remain shocked and traumatised and exhausted, both physically and mentally.’
PTSD could magnify recruitment and retention challenges
It is a view shared by Jim Thomas, a former community nurse, who now works for Skills for Care. Mr Thomas believes that PTSD ‘will be a major issue for the care sector – for both those working in care homes and in domiciliary care.’
Mr Thomas, says that trauma they’ve experienced, which could lead to PTSD, is likely to manifest itself in three ways. He explains, ‘Firstly, the frequency of deaths – and the circumstances which led to people’s deaths – is likely to take a toll on mental health.
‘Secondly, the worry and fear of care workers infecting those they are looking after – not to mention their families – will have had an impact on their mental state.
‘Thirdly, due to social distancing rules, care workers have had to curb the liberties of people with dementia, mental health issues and people with learning disabilities. While this was a necessary step, it goes against the whole rationale as to why care workers become care workers. As a result, we may see workers leave the sector when the crisis is over. Many will feel that they’ve given their all and cannot give any more.’
With the care sector already experiencing a shortfall of 110,000 workers according to The King’s Fund, Mr Thomas says it’s vital that the sector is supported to provide the emotional and psychological support that workers need to stay in the sector.
But if you are a manager with no clinical training, how do you begin to help someone you suspect might have ASD or PTSD? The first step is to recognise the symptoms.
Professor Neil Greenberg, who has worked with the UK military for 23 years and was part of the 2018 National Institute for Health and Care Excellence (NICE) PTSD treatment guidelines development committee, explains that PTSD compromises four groups of symptoms, which when combined are life-limiting in that they ‘can interfere with people’s ability to have enjoyable relationships, working effectively, or at all, and from enjoying life.’
Professor Greenberg says, ‘Firstly, it is common for those with PTSD to have re-experiencing or intrusion symptoms. These include nightmares and repeated thoughts of the traumatic incident which they can’t stop and which cause them to feel distressed. People with PTSD also can suffer with a racing pulse, fast breathing or other physical symptoms, and feel on edge whenever they are reminded of the trauma.’
Professor Greenberg says that avoidance is second classic symptom, in that a person with PTSD will ‘seek to avoid talking about the trauma at any cost, nor will they want to go the place where it occurred.’
He goes on to say that PTSD ‘dramatically changes the way a person thinks about the world; put another way it can distort people’s perceptions of reality.
‘Many people presenting with PTSD believe that the world is no longer safe and is a dangerous place to be,’ he says.
Finally, Greenberg says that PTSD leaves a person in a hyper-aroused state. ‘A person with PTSD can find it difficult to sleep, be constantly on edge, suffer bouts of irritability and experience poor levels of concentration too,’ he explains.
How to tackle PTSD in your service
In terms of tackling PTSD, Professor Greenberg says that many scientific studies demonstrate that care teams do not need to rely on mental health professionals for the initial stages of dealing with trauma. He says that ‘being part of a supportive team can protect someone’s mental health’ after exposure to a traumatic incident.
Professor Greenberg says that supervisors, or managers, have a crucial role to play in ‘ensuring that ASD is identified at an early stage and try to ensure it doesn’t lead to PTSD.’ Doing this, however, requires a culture of early intervention and psychological support.
Greenberg suggests, ‘Building a psychological scaffold around the organisation is the first step. In other words, that means preparing staff for the worst-case scenario and ensuring that you are best prepared to deal with it. This involves having a frank, honest and open conversation with staff to mentally prepare them for the pandemic. Next, supervisors should ask staff to write down a list of activities that keep them psychologically safe in challenging times. That could be taking a walk, going for a run or talking to a family member. Managers need to support and encourage their staff to actively engage in those particular activities whenever they feel distressed.’
Leadership, teamwork and communication are key
In a health pandemic, Professor Greenberg says that leaders need to regularly engage with staff to check on their mental health.
‘We know that moral injury is one of the key triggers of ASD and PTSD. Through the lens of the COVID-19 crisis, an example of a morally injurious act might be when someone passes away when a care worker, through no fault of their own, didn’t have the correct PPE and felt unable to intervene in the way they would have wished to.’
There is also very good evidence around managers feeling confident in speaking to staff about mental health. Greenberg says there is ‘plenty of evidence that a psychologically savvy manager is really important for protecting their team’s mental health. Whatever the issue, good leaders will get to the root of people’s anxieties at an early stage and then they’ll introduce practical steps that can be taken to help safeguard care workers, and the people they look after, from infection.’
Learning from the military
Professor Greenberg also believes that the care sector could learn a great deal from the military in terms of preventing and managing serious mental health conditions like PTSD. He advocates the PIES (Proximity, Immediacy, Expectancy and Simplicity) principle, which has been used effectively in military settings for over 100 years, saying that it could be adapted for the care sector.
Explaining the acronym in greater detail, he says, ‘In terms of “proximity”, if as a manager you notice that somebody is having a tough time, you should not simply send them home. Instead, you can support them by temporarily altering their job role. If, say, for example, a person is worried that, despite having the correct PPE, they might infect an elderly person, you might simply re-deploy them in a non-client facing role for a few days.
‘”Immediacy” is about identifying that someone has a mental health issue and nipping it in the bud early, while “expectancy” is reaching out to staff and reassuring them that it is perfectly normal to be distressed at times. It’s also about letting them know that while the expectation is that they will be okay, if for some reason they’re not, then you will get them the right help.’
Greenberg adds, ‘”Simplicity” is incredibly important. Sometimes all people need is a good night’s sleep, to speak to a loved one or to take a proper break. These are all practical steps managers can take without disrupting work patterns. Collectively, however, they make a big difference.’
That said, there will be frontline care workers who go on to develop PTSD. In these circumstances, Professor Greenberg recommends that managers support that staff member to access help through any appropriate source such as a trauma-aware employee assistance programme, the company’s occupational health team, or their own GP.
Unequal distribution of services
In a sector as diverse as social care, where funding is an issue, Skills for Care’s Jim Thomas says many organisations ‘won’t have access to employee assistance programmes, occupational health departments or even wobble rooms.
‘The sector is diverse and my fear is that cognitive therapy could be unevenly distributed in the future. It is not right that some organisations may be in a position to provide its staff with a course therapy to help them with PTSD, while a care worker in a different organisation, who has taken the same risks, has to join a waiting list before they can access support.’
It is a subject that Karolina Gerlich, Chief Executive of the Care Worker’s Charity (CWC) is well versed on. Karonlina says, ‘If a care worker is diagnosed with ASD or PTSD, they may have to wait for six to nine months to get help and when they finally receive it, they may find that they are only entitled to six sessions, which may not be enough to help them to overcome their trauma.’
Overcoming funding issues
So how do we avoid a social care mental health catastrophe? Jim Thomas says that the solution is to make better use of the services that already exists in primary care settings. Secondly, he thinks that organisations need to have a clear vision as to how the NHS and local government can work collaboratively to ensure that care workers have access to occupational support services in their local area.
Professor Greenberg goes much further. He believes that care workers should be protected by a covenant similar to the one that supports and safeguards ex-military personnel and their families.
He says, ‘I think all essential workers, who have sacrificed so much during the pandemic, should be protected by a covenant, which ensures, just like military veterans, that they are at no disadvantage because of the vital work they do. This means that they should have rapid access to professional treatment services if their work has damaged their mental health. In caring for millions of people, many have suffered great trauma, and being able to access timely and effective services is a basic and necessary pre-requisite.’
With a perfect storm brewing, perhaps it’s time the government gave serious thought to implementing revolutionary ideas like these, before a major mental health crisis that everyone knows is coming, makes landfall.