Beyond acute hospital-based settings

Nonetheless, the focus on the psychological challenges of working in acute hospital-based settings during the COVID-19 outbreak has meant that the well-being of HCWs in other sectors of healthcare, such as those situated in primary and community care settings, has been relatively overlooked in the literature (Billings et al. Reference Billings, Biggs and Ching2021). This lacuna may partly stem from a perception that there were fewer demands on both primary and community care settings relative to secondary care, at least in the initial stages of the pandemic. In addition, there may also exist a perception that because many community HCWs were able to switch to remote forms of care provision they therefore avoided some of the psychological burdens typically associated with frontline work. However, HCWs in community settings continued to work directly with healthcare users and the general public, thus experiencing similar risks to those working in acute hospital-based settings. Moreover, numerous quantitative studies surveying HCWs’ well-being across a wide range of jurisdictions during pandemic situations have shown that those deemed to be working in non-frontline settings often experience levels of distress comparable to their frontline colleagues. For example, Conti et al. (Reference Conti, Fontanesi, Lanzara and Rosa2020) carried out a survey-based study to explore the mental health status and psychological care needs of 933 HCWs in Italy during the first COVID-19 outbreak. The study sought to directly compare the incidence of psychopathological symptomatology among frontline workers (defined as those directly involved in the clinical management of healthcare users with suspected or confirmed COVID-19) to those in the secondline. Contrary to their initial hypothesis, working directly with COVID-19 infected healthcare users did not induce more psychopathological symptomatology compared to those not working with COVID-19 healthcare users. A study in China revealed no differences in depressive symptoms among those on the frontline (defined as contact with confirmed COVID-19 infections) compared to those on the secondline (Peng et al. Reference Peng, Meng and Li2021). In a similar study in Oman, frontline workers (defined as those directly engaged in clinical activities such as diagnosing, treating or providing nursing care to healthcare users with elevated temperatures or healthcare users with confirmed COVID-19 infection) were found to have higher levels of anxiety and insomnia; however, levels of depression in both frontline and non-frontline HCWs were found to be the same (Alshekaili et al. Reference Alshekaili, Hassan, Al Said, Al Sulaimani, Jayapal, Al-Mawali, Chan, Mahadevan and Al-Adawi2020). In other studies, it has been suggested that firstline exposure may, in some circumstances, be protective. For example, research carried out in China by Li et al. (Reference Li, Ge, Yang, Feng, Qiao, Jiang, Bi, Zhan, Xu, Wang, Zhou, Zhou, Pan, Liu, Zhang, Yang, Zhu, Hu, Hashimoto and Yang2020) found that vicarious traumatisation was lower among frontline nurses (defined as the process of providing care for healthcare users with COVID-19) compared to non-frontline nurses. The authors speculate that one reason for this may be that frontline workers in China possess more training and hands-on experience in dealing with disaster situations and therefore were more likely to be psychologically prepared for the impacts of COVID-19.

Lived experiences of frontline and non-frontline workers

This emerging body of evidence indicates that the experiences of HCWs, regardless of frontline or non-frontline status, are unlikely to be ‘universal, unidirectional, nor unidimensional’ (Kinsella et al. Reference Kinsella, Hughes and Lemon2022). Indeed, qualitative research both in the United Kingdom (U.K.) and Ireland is helping to elucidate the complexities and nuances of frontline HCWs’ lived experiences during the COVID-19 response. These studies reveal that the complexities of working on the frontline involve both struggle and reward (Kinsella et al. Reference Kinsella, Hughes and Lemon2022). For example, in a recent study that examined the experiences of working on the frontline across a variety of occupations in the UK and Ireland, Kinsella et al. (Reference Kinsella, Hughes and Lemon2022) reported that the psychological struggles of frontline work were often counterbalanced by the more rewarding and enriching aspects of being involved in the COVID-19 response which included ‘empowerment and self-efficacy derived from knowing that you have a role to play and that there is something that you can actually do to help’. Furthermore, Kinsella et al. (Reference Kinsella, Hughes and Lemon2022) also noted signs of positive growth among their participants which included ‘gratitude, savouring, religiosity, changed priorities and enhanced relationships with others’ (Kinsella et al. Reference Kinsella, Hughes and Lemon2022). These findings align with a recently published study that reported pandemic-related post-traumatic growth among frontline workers in Canada (Feingold et al. Reference Feingold, Hurtado and Feder2022).

There have been fewer qualitative studies on the experiences of HCWs deemed to be working in non-frontline settings. However, a small number of studies have begun to highlight the significant challenges faced by HCWs in adapting to new care models and expanded aspects of clinical care provision whilst transitioning to remote forms of care. For example, in a study carried out in the U.K. by Billings et al. (Reference Billings, Biggs and Ching2021), mental health professionals reported that providing emotional support to their NHS colleagues whilst working remotely was often experienced as a significant stressor, with many finding it difficult to dissociate their work from home life. In another study in the U.K., non-frontline staff reported guilt for making less of a contribution to the COVID-19 response (Wilson & Bunn, Reference Wilson and Bunn2021). Thus the experience of providing usual care but deemed ‘non-frontline’ may give rise to unique stressors that could impact on well-being. Furthermore, it is unknown to what extent the rewarding and enriching aspects of the COVID-19 response reported by Kinsella et al. (Reference Kinsella, Hughes and Lemon2022) were also experienced among those deemed non-frontline.

In summary, it is clear that there was a significant degree of psychological strain experienced by HCWs across the healthcare system during the COVID-19 pandemic. For some, the psychological distress experienced may be short-term and should not be pathologised (Greene et al. Reference Greene, Harju-Seppänen and Adeniji2021). Indeed, there is a sense that many HCWs may derive meaning and satisfaction from the COVID-19 response despite (or perhaps even because of) the severe emotional and cognitive demands it entailed (Billings et al. Reference Billings, Biggs and Ching2021; Kinsella et al. Reference Kinsella, Hughes and Lemon2022). However, for others, there is a risk that this distress may become chronic and deleterious. Therefore experiences of distress need to be considered from an individual perspective and across time.

Moreover, the evidence presented above also suggests that, when applied across different sectors, the binary categorisation of HCWs into ‘frontline’ and ‘non-frontline’ becomes increasingly tenuous and potentially unhelpful in identifying those at risk of chronic distress and longer-term burnout. This is particularly the case in community and primary care, where many HCWs had direct contact with healthcare users but also provided remote forms of care during the pandemic. Seen in this context, the line between frontline and non-frontline becomes somewhat blurred. Moreover, as we transition out of the pandemic, it is widely anticipated that there will be a surge of referrals to primary and community care in the medium- and longer-term (Lyne et al. Reference Lyne, Roche and Kamali2020). In Ireland, there is expected to be a significant increase in demand for primary and community care services due to non-COVID healthcare issues, such as mental health, not being sufficiently managed during the pandemic crisis (O’Connor et al. Reference O’Connor, Wrigley and Jennings2021).

Thus, there is now, more than ever, an urgent need to identify ways of protecting the well-being of individual HCWs in all sectors of the healthcare system as a means to prevent burnout and ensure the sustainability of health services in the post-pandemic environment.

Alleviating the mental health burden of HCWs: what are the next steps?

Given the issues highlighted above, it is worth reflecting on what provisions are being put in place to support the mental well-being of HCWs in an Irish context. In the document, ‘HSE Psychosocial Response to the COVID-19 Pandemic’, (HSE, 2021) a commitment is made to ‘sustain and develop psychosocial awareness and expertise by building on existing psychosocial materials and initiatives to address the emerging training and educational needs of healthcare staff’. In this regard, a range of ‘key supporting actions’ are identified to increase the resilience of HCWs, including ‘psychological first-aid’, a ‘workplace wellness app’, ‘psychosocial peer support’, and ‘self-help tools such as CBT-based modules’. While the increased interest in the mental well-being of healthcare professionals is to be welcomed, a growing body of literature has highlighted some of the more problematic aspects of relying on individual-level interventions alone to improve the mental well-being of HCWs. A Cochrane review has shown limited evidence for the effectiveness of interventions aimed at increasing HCWs resilience during COVID-19 and comparable pandemics (Pollock et al. Reference Pollock, Campbell and Cheyne2020). There is also an emerging body of qualitative evidence providing clues as to why such well-being programmes may not have worked as intended. For example, Billings et al. (Reference Billings, Biggs and Ching2021) elucidated the lived experiences of NHS health and social care workers during the COVID-19 pandemic and the specific forms of psychosocial support they perceived to be valuable. The study showed that while participants were in general positively disposed towards employee workplace initiatives, many participants did not know how to access such services, while others reported that the intensity or timing of their work schedule prevented them from attending. Furthermore, many cited stigma and fears about being perceived as weak by colleagues as a key barrier to uptake.

In another U.K. based study, Vera San Juan et al. (Reference Vera San Juan, Aceituno and Djellouli2020) examined HCWs’ perceptions of clinical guidelines on workplace well-being during the COVID-19 outbreak. As a whole, the guidelines focused on well-being at an individual-level, while HCWs placed greater emphasis on structural conditions at work, such as understaffing and time-off. These studies align with a significant body of literature that has pointed to the crucial role that social and organisational dynamics play in the onset of psychological distress both prior to and during COVID-19 (Montgomery et al. Reference Montgomery, Panagopoulou and Esmail2019, Reference Montgomery, Humphreys and McCulloch2021; De Kock et al. Reference De Kock, Latham and Leslie2021; Panagioti et al. Reference Panagioti, Panagopoulou and Bower2017; Shanafelt & Noseworthy, Reference Shanafelt and Noseworthy2017; Regenold & Vindrola-Padros, Reference Regenold and Vindrola-Padros2021). For example, De Kock et al. (Reference De Kock, Latham and Leslie2021) conducted a rapid review of studies that examined the mental health of HCWs during the early stages of the COVID-19 pandemic. They found that occupational and environmental factors such as heavy workload, proximity to COVID-19, and inadequate PPE were among the most significant risk factors for poor mental health outcomes. They argue that there is a significant need to redirect research activities towards identifying systemic level changes that might enhance the well-being of HCWs (De Kock et al. Reference De Kock, Latham and Leslie2021).

A similar programme of research is critically needed in Ireland to document the work-related experiences of HCWs during the pandemic and establish what psychological supports they perceive as potentially valuable. Particular efforts should be made to amplify the voices of those who have been less heard during the pandemic. With this in mind, the authors are currently conducting a two-year qualitative study examining the work-related experiences of HCWs and the particular supports they consider as valuable (if any), with a focus on community psychiatrists and community pharmacists (UCD, 2021). This is one piece of a much broader body of work to ensure that the needs of those HCWs based in community settings are put on the map and brought to the attention of policymakers.