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• To enhance your awareness of how the coronavirus disease 2019 (COVID-19) pandemic has affected mental health service users and nurses
• To recognise the negative effects of the pandemic on nurses’ physical and mental well-being, and how these can be addressed
• To understand the role of mental health service providers and managers in supporting staff and ensuring high-quality care provision
The coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization in March 2020. This article examines the effects of the pandemic on mental health services, service users and healthcare staff, including nurses in the UK. It explores how the pandemic has led to increased demand for mental health services, alongside a concomitant increase in the severity of cases. The authors also consider how the effects of COVID-19 on healthcare staff and service users can be managed, for example by providing mental health services to front-line staff, and by implementing innovative solutions such as increased remote working and digital therapy.
Nursing Standard. doi: 10.7748/ns.2021.e11688
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondencevijay.chuttoo@sussexpartnership.nhs.uk
Conflict of interestNone declared
Chuttoo V, Ramharakh SB (2021) Examining the effects of COVID-19 on mental health services, service users and nurses. Nursing Standard. doi: 10.7748/ns.2021.e11688
Published online: 17 May 2021
The coronavirus disease 2019 (COVID-19) pandemic has not only had a profound effect on people’s physical and mental health, but it has also significantly affected the ability of the NHS to provide high-quality healthcare services (British Medical Association (BMA) 2020a). One longitudinal study of the effects of COVID-19 on the UK population demonstrated that overall mental health had deteriorated after the onset of the pandemic (Pierce et al 2020). In addition, it has been identified that people with mental health issues are particularly vulnerable to COVID-19 due to pre-existing health conditions, social and political inequalities, social exclusion, and stigma related to their conditions (Kaufman et al 2020). Evidence has demonstrated how the COVID-19 pandemic has contributed to deteriorating mental health across all age groups and members of the general population, as well as exacerbating the symptoms of people already living with mental health issues, for example through increased anxiety about their health or that of their family members (Young Minds 2021).
Even before the COVID-19 pandemic, mental health services in the UK were experiencing challenges in providing the appropriate level of care for all service users, in part due to a lack of funding (BMA 2020a). Since the onset of the pandemic, mental health services have been reduced further, and various social restrictions such as lockdowns have come into effect. The pandemic has also meant that many visitors have been restricted from seeing their family members due to social distancing requirements. Furthermore, patients with COVID-19 have been expected to isolate and on occasion have been prevented from leaving wards, or contained in specific ward areas, to minimise the risk of spreading the infection (NHS Providers 2020). These changes to healthcare provision have affected mental health service users and staff, including nurses. For example, Vindegaard and Benros’ (2020) systematic review found that following the start of the COVID-19 pandemic there had been a significant increase in depression and anxiety in service users, healthcare staff and the general public.
• The coronavirus disease 2019 (COVID-19) pandemic has contributed to deteriorating mental health across the general population, as well as exacerbating the symptoms of people already living with mental health issues
• In addition to the physical health effects of COVID-19, there is likely to be an increase in mental health issues affecting front-line healthcare staff, including nurses
• One of the most important elements in managing the COVID-19 pandemic is the maintenance of a healthy NHS workforce. This requires NHS leaders to embed a ‘culture of care’ in healthcare organisations
• To continue to provide effective care for others, it is important for mental health nurses to consider their own needs and well-being, and to take a self-care approach that prioritises compassion
Convenient access to mental health services is vital for service users. However, despite increases in funding and expanded service provision in the UK, significant gaps remain, which has meant that mental health services have not always been available when service users require them (NHS 2019). Similarly, physical health care is often prioritised over mental health care, for example some physical illnesses such as cancer attract more charitable funding than mental health conditions (BMA 2020b).
As a result of the COVID-19 pandemic, mental health service providers have reported a significant increase in demand for services, alongside increased severity of newly referred cases (NHS Providers 2020). This includes people who have experienced personal, social and/or economic losses due to the pandemic, as well as healthcare staff who are finding it challenging to provide care in highly stressful circumstances (BMA 2020b). There are also concerns that people with mental health issues are avoiding mental health services until they reach a ‘crisis point’, which has the potential to increase the demand for mental health treatment following or later in the pandemic (Royal College of Psychiatrists 2020).
During the COVID-19 pandemic, it has often been challenging for mental health nurses to find the balance between maintaining service users’ choices and decisions in relation to their care and treatment, while also being required to urgently treat vulnerable patients and protect front-line staff. One issue that has arisen on mental health inpatient units during the pandemic has been how to ensure that service users who lack mental capacity can be assisted to self-isolate and reduce the risk of infection to themselves and others. New guidance published by NHS England (2021) sets out criteria for managing such challenges, for example the requirement to test patients for COVID-19 and isolating patients who have either tested positive, who are pending test results or who refuse to be tested.
Despite this guidance, in the authors’ clinical experience, mental health nurses continue to find it challenging to balance enforced isolation due to COVID-19 with an individual’s rights enshrined in the Human Rights Act 1998, such as the right to respect for private and family life (Article 8) and the right to liberty and security (Article 5).
Further challenges associated with mental health inpatient units and COVID-19 restrictions have been reported, including how nurses can support service users who have been detained under the Mental Health Act 1983 (amended 2007) to take leave from hospital, while keeping them as safe as possible through social distancing (BMA 2020b, Gold 2020, NHS Providers 2020).
Despite these barriers to providing effective mental health care, advances in remote working and digital therapy that may have otherwise taken years to develop have been hastened by the pandemic (NHS Providers 2020). These technological advances have enabled nurses to engage in remote consultations with service users who have access to digital devices such as laptops and smartphones. Examples include the use of software such as Microsoft Teams and Zoom to take part in talking therapies and clinical reviews.
Aboujaoude et al’s (2015) review of the use of digital therapy for people with mental health conditions demonstrated that it improved access to care and reduced stigma. However, despite these positive advances, some mental health nurses and service users have detailed challenges with using digital technology, for example limited access to equipment and restricted use of non-verbal communication such as body language (Sklar 2020).
The use of body language and non-verbal cues when communicating are important in enabling service users to express themselves and in assisting nurses to provide a psychologically safe environment, which can be challenging during digital communication. The lack of face-to-face contact as a consequence of the COVID-19 pandemic has been a particularly challenging barrier for nurses and service users with hearing impairments (Grote and Izagaren 2020).
Many people with mental health issues may also be excluded from access to digital technology as a result of poverty, physical disabilities, or connectivity issues (Greer et al 2019). Furthermore, women who experience domestic abuse, children who experience abuse or neglect, and lesbian, gay, bisexual, trans, queer and other (LGBTQ+) people who are not ready or able to share these aspects of their identity with others at home, may not be able to engage in digital communication for safety and privacy reasons.
Holmes et al (2020) suggested that the number of people presenting with anxiety and depression, and those engaging in harmful behaviours such as suicide and self-harm, would increase during the COVID-19 pandemic. Elovainio et al (2017) and Matthews et al (2019) also stated that such mental health issues could be exacerbated by the social isolation and loneliness resulting from the pandemic. However, despite this potential increase in mental health issues, Gunnell et al (2020) found that a rise in suicide rates was not inevitable, particularly if appropriate interventions are in place.
An example of one such intervention is the Suicide Prevention National Transformation Programme, which aims to reduce suicide risk in at-risk groups such as men and improve responses to people who self-harm (Royal College of Psychiatrists 2021).
In addition to the increasing prevalence of mental health issues, concerns have been raised that the effects of the pandemic could widen existing social inequalities, particularly for certain vulnerable groups (Public Health England (PHE) 2020a). For example, the pandemic may have exacerbated systemic inequalities affecting individuals from black, Asian and minority ethnic (BAME) backgrounds who are at higher risk of contracting and dying from COVID-19 than those from white ethnic groups (Allwood and Bell 2020). Similarly, the Centre for Mental Health, an independent UK mental health charity, has raised concerns that people from BAME backgrounds – particularly those who are also disadvantaged economically – are at increased risk of experiencing negative effects as a result of the pandemic (Allwood and Bell 2020).
People with schizophrenia are also socially disadvantaged and may be more susceptible to contracting COVID-19. This may be due to several factors including reduced awareness of risk, inadequate infection prevention and control, suboptimal living conditions, substance use, and impairments in judgement and decision-making (Yao et al 2020). People with schizophrenia are also known to be at increased risk of physical health conditions such as cardiovascular disease, diabetes mellitus and chronic respiratory disease compared with the general population, all of which could be further exacerbated by COVID-19 (Correll et al 2017, Guan et al 2020).
These health inequalities are also prevalent in other population groups. For example, a report by PHE (2020b) stated that during the first wave of the pandemic, people with learning disabilities were up to six times more likely to die from COVID-19 compared with the general population. In addition, research has emphasised the potential negative effect of government measures such as isolation and quarantine on people with pre-existing mental health conditions. For example, according to the World Health Organization (2020), older adults with dementia ‘may become more anxious, angry, stressed, agitated and withdrawn during the outbreak or while in quarantine’.
Kozloff et al (2020) suggested that interventions such as video conferencing that assist in maintaining social connections, particularly for people with pre-existing mental health conditions, can be useful in reducing the effects of isolation. It is also useful for mental health nurses to gain an understanding of the social determinants of mental health (the way in which mental health conditions can be influenced by social, economic and physical factors) and how these can affect parity of resources, and access to and outcomes in mental health care (Marmot et al 2020).
Despite the significant challenges presented by the COVID-19 pandemic, mental health services and nurses in the UK have been quick to adapt, formulating policies and fast-tracking interventions to manage patients effectively (NHS Providers 2020). The response to the pandemic is continually evolving, but at the time of writing, healthcare services – including mental health services – instigated a range of measures designed to maintain the quality of care, including (NHS Providers 2020):
• Identifying areas within inpatient units and wards where patients who have tested positive for COVID-19 can be isolated from others.
• Discharging patients who have been classified as ‘non-emergencies’ from hospital and inpatient units safely and quickly to reduce transmission risks.
• Retraining staff so they are equipped to provide high-quality physical and mental health care. This may include providing training in the use of high-grade personal protective equipment (PPE) such as filtering facepiece respirators, or on updating digital skills for remote working.
• Redeploying community mental health nurses to mental health inpatient units to support patients with COVID-19.
• Reducing non-urgent routine follow-up care and unnecessary face-to-face contacts.
• Arranging intermediate care wards for patients recovering from COVID-19.
• Establishing mental health emergency departments and 24 hours per day, seven days per week emergency access support lines for people experiencing a mental health crisis, for example those experiencing suicidal thoughts.
• Implementing local COVID-19-specific visiting guidance. This may include a range of measures, such as ensuring that any visitors: do not have any COVID-19 symptoms; wear face masks; abide by social distancing rules; and use hand sanitisers.
• Providing tablets and smartphones for patients so that they can keep in contact with their family and friends.
• Using virtual assessments to overcome the challenges posed by social distancing, for example when transferring patients between units or at discharge.
• Implementing routine testing of staff for COVID-19, including self-testing using lateral flow devices (PHE 2020c).
• Ensuring that vaccinations are made available to mental health staff, including nurses.
These adaptations to services have required mental health service managers to identify suitable spaces for virtual assessments, arrange the redeployment of staff, and plan the organisation of services with local partners such as local councils and the voluntary sector (NHS Providers 2020). Furthermore, to support the containment of COVID-19, mental health services have accelerated discharges and sought to reduce avoidable admissions by using enhanced crisis care, for example arranging emergency home visits by community mental health nurses (NHS Providers 2020).
Research has indicated that in addition to the physical health effects of COVID-19, there is likely to be an increase in mental health issues affecting front-line healthcare staff, including nurses. These staff are at increased risk of developing mental health issues such as depression, substance misuse and post-traumatic stress disorder if they have themselves contracted COVID-19, or if they are from BAME communities which have been disproportionately affected by the pandemic (BMA 2020a, Durcan et al 2020).
Deteriorating physical health is significantly associated with suboptimal mental health (PHE 2017). Studies have shown a link between healthcare staff members’ unhealthy lifestyle behaviours such as suboptimal diet and a lack of exercise – which are often exacerbated by mental health issues such as work-related stress – and absences from work due to ill-health, which can negatively affect patient outcomes and experiences (Boorman 2009). Compared with other workforces, the NHS has a high level of absences from work due to ill-health, with rates exceeding the national average (NHS 2019). Similarly, data from PHE (2020c) has demonstrated that health and social care staff – including nurses – have an elevated risk of contracting COVID-19. This risk can affect nurses’ mental health, contributing to increased sickness rates, which subsequently exacerbate the existing workforce challenges caused by the number of healthcare staff who are absent from work because they have contracted COVID-19.
A significant proportion of the UK healthcare workforce are from BAME backgrounds and therefore may be disproportionately affected by the COVID-19 pandemic. This is likely to lead to increased levels of trauma and suboptimal mental health for a significant number of healthcare staff, including many nurses (Allwood and Bell 2020).
At a time when healthcare organisations are under-resourced, over-stretched and experiencing significant issues with staff recruitment and retention – in addition to managing the effects of a global pandemic – it is vital to prioritise the well-being of nurses. Not only have nurses experienced the same government-led COVID-19 restrictions as the rest of the population, but they also have had to manage the increased pressures on healthcare organisations. Therefore, identifying strategies and interventions to support and improve nurses’ physical and mental well-being is a priority (Murray 2021).
Occupational health services have an important role in supporting nurses’ well-being by providing access to counselling, absence management and health assessments. However, Boorman (2009) reported concerns about the effective provision and accessibility of NHS occupational health services.
One of the most important elements in managing the COVID-19 pandemic is the maintenance of a healthy NHS workforce. This requires NHS leaders to embed a ‘culture of care’ in healthcare organisations, where managers are empowered to take a proactive approach to staff well-being. To achieve this, the NHS Employers’ (2019) Health and Wellbeing Framework provides guidance for improving staff support in the following areas:
• Prevention and self-management – healthcare services should promote well-being at work by providing optimal working conditions, information about maintaining a healthy work-life balance and training in self-management skills.
• Targeted support – interventions should be provided to NHS staff in need of specific healthcare and support, such as counselling and physiotherapy.
If mental health nurses are to continue to meet the mental health needs of service users, carers and other healthcare staff, they need to consider their own needs and well-being. Therefore, a self-care approach that prioritises compassion is important. Gilbert (2009) described compassion as having a sensitivity to suffering in the self and others, alongside a commitment to attempt to alleviate and prevent that suffering.
While nurses regularly demonstrate compassion in their interactions with service users, some may find it challenging to be compassionate towards themselves. However, there are several techniques that nurses can use to care for themselves effectively, including (Gilbert 2009):
• Developing an awareness of what they experience ‘within themselves’ during the working day, for example their physical responses, thoughts, emotions and behaviours.
• Remaining non-judgemental about themselves, for example by not being overly critical of their decisions.
• Reducing the demands on themselves, for example by trying to avoid negative self-judgement such as that they are ‘letting colleagues down’.
• Acknowledging their limitations, for example by accepting that they might not possess certain skills and instead requesting assistance from colleagues.
• Identifying activities that make them ‘feel good’, for example listening to music, exercising or talking to friends.
By attending to their own needs compassionately, mental health nurses may enhance their ability to respond to others with compassion.
All healthcare staff can benefit from compassionate leadership that involves managers, leaders and nurses at all levels: listening to their colleagues; attempting to understand the challenges they are experiencing; empathising with and validating their experiences; and working collaboratively to provide methods of support. Goleman’s (2004) theory of emotional intelligence is one example of a useful framework that involves using individual reflection to promote compassion in workplace relationships.
Compassionate leadership aims to support a culture of openness, where staff feel psychologically safe to reflect on their experiences, and share their challenges and errors, thereby promoting a learning environment rather than a ‘blame culture’. Encouraging a culture of learning rather than blame may lead to a collective focus and responsibility for ensuring high-quality care (Henderson and Jones 2017, Quinn 2017, Major 2019), particularly during highly stressful periods such as the COVID-19 pandemic.
Mental health inpatient units in the UK were not designed to manage infectious diseases such as COVID-19. Therefore, during the pandemic, reconfiguring the physical space within these units, while ensuring that service users are kept safe, has been a continuous challenge for mental health nurses because of the lack of appropriate resources, such as rooms with en-suite facilities. This has led to increased pressures on primary care, with community services receiving additional patients with complex conditions who have been rapidly discharged from hospital.
Furthermore, social distancing measures have meant it has been challenging to ensure that patients have the necessary community care in place (NHS Providers 2020). In addition, the need to provide appropriate PPE, ensure sufficient capacity for COVID-19 testing, and implement the roll-out of the COVID-19 vaccination programme for staff and patients, has significantly affected the capability of mental health services to provide safe and effective care. Mental health services need to undertake further work to support mental health nurses in areas such as vaccination and testing, providing PPE and meeting the increased demand for services.
While many mental health services have been using digital technology during the COVID-19 pandemic, there are still significant barriers to overcome, including accessibility and information governance issues such as maintaining confidentiality. It is also important to consider whether digital technology is always appropriate for some forms of mental health intervention, such as assessments and counselling. In the future, evaluating the efficacy of delivering mental health services using digital technology will be a priority (NHS Providers 2020).
Mental health services have been significantly affected by the COVID-19 pandemic, with increased demand for these services because people are experiencing deteriorating mental health, alongside healthcare staff who are finding it challenging to provide care during this period. At a time when healthcare organisations are attempting to manage the effects of a global pandemic, it is crucial to prioritise the well-being of mental health staff, including nurses. Therefore, it is essential that strategies and interventions to improve nurses’ physical and mental well-being are identified and implemented, and that mental health service managers engage in compassionate leadership.
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