Problem

The WHO declared the COVID-19 outbreak as pandemic status on 11 March 2020 following the rapid global spread of cases, originating from Wuhan, Hubei Provence, China. At this point in time there were over 17 000 cases reported in Europe, with trends mirroring that of the initial peak in China in mid-January 2020.1

The risk of healthcare capacities being exceeded for the National Health Service (NHS) was considered an inevitable event, causing uncertainty and anxiety among healthcare workers across Britain. Particular concerns pertained to perceived own personal health, the well-being of family and loved ones, the stresses of increasing workloads, delays and changes to training and overall perceived emotional hardships.2 Junior-level doctors were deemed a vulnerable group and comprised the majority of the cohort that were redeployed to areas such as the emergency department (ED), intensive care units (ICU) and medical wards to lend a helping hand during peak times of the pandemic. Providing a strong support network for the junior doctor cohort in aims to reduce psychological burden and adverse mental health outcomes is imperative during such unprecedented times.

Background

Literature reveals that during major disease outbreaks, healthcare workers in EDs, ICUs and isolation wards are at a greater risk of developing adverse psychiatric outcomes as compared with those working in other departments.3

This is theorised to result from direct exposure to infected patients and the workload itself being highly demanding.4 A systematic review revealed risk factors for healthcare workers in developing psychological comorbidites during the course of the SARS outbreak included lack of social support, maladaptive coping strategies and insufficient training.5 Moreover, a cross-sectional analysis in China following the announcement of the epidemic revealed that young people and healthcare workers were at the highest risk for experiencing mental health illness, namely generalised anxiety disorder, depression and poor sleep quality.6 It was additionally found that women and those healthcare workers with relatives of confirmed or suspected infection with COVID-19 were more susceptible to anxiety and depression.6 Moreover, healthcare staff in a Beijing hospital working in high-risk COVID-19 clinical areas had been found to show increased rates of post-traumatic disorder symptoms.7

The utilisation of online mental health education sites, counselling and telephone services have been widely encouraged since the initial outbreak in China8 to provide a source of well-being to workers at ensuing stressful times.

The emerging adverse mental health effects experienced by health workers around the world during the COVID-19 pandemic highlight the fact that it is imperative to promote well-being and provide adequate support for all healthcare staff amidst this unprecedented time.9 Promoting strong teamwork ethics and maintaining cohesiveness between colleagues serves to build a robust support network and allows team members to share similar experiences during difficult periods of time.10 Timely contact with senior supervisors provides additional modalities of support for junior doctors, particularly with regard to anxieties about limited training opportunities and potential hindrances in career progression during this time. This is particularly true of surgical trainees where cancellations of many elective operating lists, clinics and reduced exposure to a variety of surgical pathologies as a direct result of the pandemic threatens a lower standard of training for aspiring surgeons. The scope to explore these premises further with psychological monitoring tools in the surgical environment could serve as a guide to provide trainees with appropriate well-being and support resources during challenging times.

Measurement

Eighteen surgical trainees within a Burns and Plastic Surgery department in Manchester, UK, were included in the project; this comprised 9 specialty registrars and 9 core surgical-level trainees. Core surgical-level trainees had recently embarked on their surgical training careers (previously known as senior house officers) and therefore were less experienced in the field of plastic surgery as compared their specialty registrar counterparts. Specialty registrars had completed their core competency surgical training and were on the plastic surgery specialty training programme. The majority of trainees were redeployed to ICU, ED or medical wards. The intervention period coincided with changes to standard working schedules for doctors within the plastic surgery department due to the COVID-19 pandemic.

Data were collected between April and July 2020. Trainees completed an online quantitative survey at approximately 2–3 weekly intervals. A 14-point psychometric scale aimed at measuring symptoms of anxiety and depression, the Hospital Anxiety and Depression Scale (HADS)11 was completed by each trainee. This was completed a total of 4 times by trainees during the course of the project. The HADS comprised seven items to screen for anxiety symptoms and seven items to screen for symptoms of depression, taking an average time of 2–5 minutes to complete. A total score of 0–7 was regarded as ‘normal’, 8–10 as ‘borderline abnormal’ and 11–21 as ‘abnormal’, this was calculated for each individual, every time the survey was completed. The HADS tool has been recommended by the National Institute for Health and Care Excellence for diagnosing anxiety and depression.12

Participants completed surveys anonymously and chose not to reveal their age or gender due to the small sample size of participants and this was respected by the project leads.

The use of the HADS in this quality improvement intervention was based on the premise that anxiety and depression often coexist, and that anxiety often precedes depression in response to a stressor. This has allowed occupational health professionals to predict outcomes in order to plan interventions for vulnerable employees and prevent mental health morbidities.13 The HADS has been validated in many countries and languages, and has been used widely for initial diagnoses of anxiety and depression as well as monitoring the progression of these disorders over time.12 14 This is an essential consideration for tutors and/or educational supervisors in attempts to provide a robust support network for their trainees and a standardised modality in monitoring rates of mental health in trainees during difficult times.

Design

During the period of the intervention, both a core surgical trainee-level doctor and consultant were assigned as ‘well-being officers’ for the group and stood as the first point of contact for trainees to reach out to. Well-being officers maintained regular contact with all trainees and ensured surveys were disseminated and completed within the specified time periods. A personal departmental psychologist maintained regular contact with the consultant throughout the course of the project and advised on well-being resources and offered individual support for trainees, if required.

A ‘COVID-19 Care Package’ was provided for all trainees (found in online supplemental materials section). This included resources aimed at promoting good mental health for trainees (see table 1). The care package encouraged regular contact with the parent team via weekly ‘zoom check-ins’, a doctors Whatsapp group maintaining contact with peers, optional one-to-one sessions with an assigned consultant supervisor, a 24-hour anonymous employee well-being helpline as well as various online mental health resources. All trainees received an adequate induction regarding teaching and training in their new job roles prior to the start date of the redeployment period.

These interventions were based on literature reviews outlining that a lack of peer support predicts higher rates of anxiety, depression and burn-out15 16 and that predominant risk factors for developing psychological comorbidites during these times include lack of social support, maladaptive coping strategies and insufficient training5 in job roles.

Prior to this quality improvement project, there were no formal pathways sign-posted for trainees in difficult times; it was expected that trainees would consult with their assigned educational supervisor if they required additional support during times of work-related stress or personal hardship.

Strategy

Lessons and limitations

This quality improvement project shows that the average anxiety scores in junior surgical doctors exceeded that as regarded as ‘normal’ as predicted by the HADS. This can be assumed to be due to the burden of the COVID-19 pandemic, however, it is difficult to draw causative inferences due to multiple confounding factors and a small participant sample size. Due to the sensitive nature of the project as well as the high turn around of doctors rotating to new jobs, additional data could not be collected after participants had left the department. Furthermore, it was decided by well-being officers before the commencement of the quality improvement project not to record the age and gender of participants; this was requested by participants prior to data collection and was respected by the project leads. This was a recognised limitation in this intervention and it would be suggested by the authors that similar studies conducted on a larger scale could further explore differences in mental well-being in doctors with consideration to their age, gender as well as other demographics.