Foreword by Gita Bhutani, PPN North West Chair
I am delighted to introduce a blog by Susan Salt. Susan and I met (virtually) in Lancashire as part of scoping out the support available for staff within the context of the coronavirus pandemic. I was fascinated to hear about the work she has been doing and keen to learn how this could inform the development of staff support and interventions from a psychological point of view. Susan kindly wrote this piece to support the development work around staff support in Lancashire & South Cumbria. Having read it, I asked Susan if we could share this more widely. Susan has agreed to this and also provided an introduction which I’ve added below too. I hope you find it moving and informative.
In response to the government's request for recently retired doctors to return to clinical practice I agreed to leave my role as a curate in the Church of England and return to the Trust where I had previously worked as a Consultant in Palliative Medicine. On my return, I had the privilege of providing support to staff, patients and relatives dealing with the uncertainty of providing care during the first few weeks of the pandemic. The following is a reflection on the importance of creating safe spaces for people to tell their stories.
The stories of COVID
These are my reflections on the myriad stories I witnessed as I supported patients and staff in one Teaching Hospital in the North West of England.
The eerie emptiness of the hospital corridors hits you when you first enter the hospital building. There are moments when there is no one walking along the main thoroughfare, even on a Monday morning. It is almost as though reality is hidden behind locked ward doors. Only those with a justifiable reason to enter can have access. Clinical teams, along with their support teams are operating in bubbles. The canteen is open but only for you to take food out and find a place to eat it, appropriately socially distanced. There are no visitors and no patients wandering the corridors. It feels as if the building is holding its breath.
And each ward bubble is vaguely aware of the bigger picture, but because they are asked to avoid too much contact with others when at work and cannot socialise when they get home, social media becomes a preferred way of communicating. The nuances of stories become soundbites and there is little opportunity to explore their meaning, both for the person telling the story and the person reading it. The lack of face to face conversation means there is no moderation of the intensity of emotion or ability to ground those feelings in reality. Some bubbles appear to be blissfully unaware of the intensity of the experiences on a neighbouring ward. It is remarkably easy to trigger a sense of resentment of being overwhelmed by the busyness of it all, or bewilderment about what all the fuss is about and resentment of the restrictions imposed by an unexperienced threat.
Wearing full personal protective equipment (PPE) as part of a role is a badge of honour conveying a status that means you are officially on the front line and so a hero in the eyes of the wider public. It also means that you are living with considerable personal risk over which you have limited control. Yes, you can don and doff the equipment correctly and follow all the protocols and procedures, but you are reliant on the assessment of others regarding the level of protection you are entitled to wear and the quality of that equipment. Endless public debates within all the professional bodies and the media mean that there are constant questions of what is right and, even more challenging, what is best. Yet individuals are also aware that the virus does not respect the locked ward doors or the negative pressure ventilation systems, so what about the risk leaving work and going home? Equally what about the risk to those deemed to be on COVID-free wards or those not deemed to be on the front line? What is it my right to demand - and what are the consequences for my colleagues if I make such a demand when there are well documented shortages of some bits of PPE? PPE also discriminates between core members of clinical teams and those who are important, but not seen as essential to direct patient care. Cleaners and chaplains, physiotherapists and other occasional visitors who are not ward based are to some extent left to their own devices about what is best for them to do.
The effect of wearing PPE is seen physically, with visible pressure sores for some on their nose, around their ears and under their eyes. The impact socially is clear for all to see as individuals try to communicate with terrified breathless patients wearing a mask, visor, gown and gloves. There are few non-verbal cues, while the reassurance of touch is limited and mediated by a glove. Patients do not know what the person caring for them looks like: all they see is a masked and gowned stranger speaking with a muffled voice. It is alien and scary, with both participants in every interaction working at the limit of their skills, in an atmosphere of uncertainty and overwhelming fear. No one would choose to care or receive care like this.
The closing of hospitals to visitors means security guards having to turn away desperate relatives at the door whilst maintaining social distance. It means families cannot see or experience the care their loved ones are receiving or ask questions, or provide additional support. Family and friends are excluded from a key part of their loved one’s story. So even if the person goes home having recovered, there is no one within their network with whom they can share the experience. The individual patient holds the only version of that experience and that is a heavy and traumatic responsibility. Equally, nurses in particular, are the guardians of the last days, hours and minutes of someone who has died. They are forced to hold those precious moments of mystery around dying and death on behalf of families and friends they have never met. They become privy to deeply intimate and personal moments which would normally be witnessed in private by those close to the person. Now they are public and shared with a stranger.
Living with uncertainty is not just about who has the virus and who will catch it, but also about how ill the virus will make the individual and how to support them if they become very ill. Not knowing the “right” approach or having a clear and evidence-based plan of management means that there is uncertainty about whether the “best” was done. There is little sense for patient, those important to them or those caring for them about what are good approaches and what are less helpful approaches to helping someone survive. Did we do enough? Could we have tried something else? What if we had..? Those dilemmas are hidden from those close to the individual and so they cannot be helped by them to make complex and potentially life-limiting decisions, nor can the professionals gauge the impact of such debates, particularly as so much of those debates is played out in the anonymous world of the media where generalisations trump the uniqueness of every individual.
The removal or at least the serious reduction of social networks by lockdown had a major impact on the resilience of staff. No longer able to offload with friends and colleagues and unable to see family (in some case separated from family in order to protect them) situations that would not normally faze those professionals became insurmountable barriers. For many, the pressure of long hours and the desire not to let their colleagues down meant that many had little time to find new routines of self-care. Using “wobble rooms” and accepting that it was “OK to not be OK” was not easily embraced by many, especially medics, who traditionally take pride in being seen to be calm in a crisis. For some having a space just to sit and be for a few minutes felt more like a sticking plaster, but it did give many sufficient respite that they were able to complete a shift or return to work the next day.
For many, the thing that helped them to get through the day was being listened to by someone they trusted, who they felt shared their experience and who would not judge or fix them. They knew they were struggling but did not want a label or to be patted on the back and told what an amazing job they were doing. They wanted a place where they could talk about their pain and distress, their fears for themselves and their families, and know they were heard and their stories held safely and confidentially. They did not seek to have those chats, but when offered the opportunity many used the space to rediscover their own sense of purpose and validation.
There are so many stories to be told. A unique consequence of this pandemic is that artificial spaces need to be created where stories can be told, for the usual spaces were not there when needed or were only present in the virtual world.