"It's Been Ugly": A Large-Scale Qualitative Study into the Difficulties Frontline Doctors Faced across Two Waves of the COVID-19 Pandemic.

This study aimed to gain an uncensored insight into the most difficult aspects of working as a frontline doctor across successive COVID-19 pandemic waves. Data collected by the parent study (CERA) was analysed using conventional content analysis. Participants comprised frontline doctors who worked in emergency, anaesthetic, and intensive care medicine in the UK and Ireland during the COVID-19 pandemic (n = 1379). All seniority levels were represented, 42.8% of the sample were male, and 69.2% were white. Four themes were identified with nine respective categories (in parentheses): (1) I'm not a COVID hero, I'm COVID cannon fodder (exposed and unprotected, "a kick in the teeth"); (2) the relentlessness and pervasiveness of COVID ("no respite", "shifting sands"); (3) the ugly truths of the frontline ("inhumane" care, complex team dynamics); (4) an overwhelmed system exacerbated by COVID (overstretched and under-resourced, constant changes and uncertainty, the added hinderance of infection control measures). Findings reflect the multifaceted challenges faced after successive pandemic waves; basic wellbeing needs continue to be neglected and the emotional impact is further pronounced. Steps are necessary to mitigate the repeated trauma exposure of frontline doctors as COVID-19 becomes endemic and health services attempt to recover with inevitable long-term sequelae.

Highlights from this issue

Correspondence to Dr Edward Carlton, Emergency Department, North Bristol NHS Trust, Westbury on Trym BS10 5NB, UK;eddcarlton@gmail.com Evidence and mass casualty events “I sat among the dead, dying and those fighting for life, I observed the pain and suffering and endured my own. Skryabina and colleagues, provide an alternative form of evidence in their mixed methods study involving interviews with healthcare staff who took part in responses to three terrorist attacks in the UK. [...]an interesting Short Report from Davies and colleagues in Scotland explores the utility of exercise induced hypoxia in evaluating patients with COVID-19 and offers a standardised approach to this using a 1 min sit-to-stand test.

The COVID-19 Clinician Cohort (CoCCo) Study: Empirically Grounded Recommendations for Forward-Facing Psychological Care of Frontline Doctors.

This study aimed to develop empirically grounded recommendations and a coherent model of psychological care derived from the experiences and psychological care needs of COVID-19 frontline doctors, using semi-structured interviews and thematic analysis. Participants were UK frontline doctors specialising in Emergency Medicine, Anaesthetics, or Intensive Care (n = 31) purposively sampled for maximum variation on gender, specialty, ethnicity, and trauma-related distress; most worked in ICU during the pandemic (71%). Four themes were derived: (1) 'coping strategies', participants used many, including exercise, mindfulness, and "wait until it gets really bad"; (2) 'sources of support', participants valued embedded psychological support, digital services, and informal conversations with colleagues or family, though there was little opportunity; (3) 'organisational influences on wellbeing', participants reported a love-hate relationship for concepts like 'wellbeing', seen as important but insulting when basic workplace needs were unmet; (4) 'improving engagement with support', analysis suggests we must reduce physical and psychological barriers to access and encourage leaders to model psychologically supportive behaviours. Doctors' frontline COVID-19 working experiences shine a 'spotlight' on pre-existing problems such as lack of physical resources and access to psychological care. Empirically grounded recommendations and a model of incremental psychological care are presented for use in clinical services.

Psychological distress and trauma in doctors providing frontline care during the COVID-19 pandemic in the United Kingdom and Ireland: a prospective longitudinal survey cohort study.

OBJECTIVES: The psychological impact of the COVID-19 pandemic on doctors is a significant concern. Due to the emergence of multiple pandemic waves, longitudinal data on the impact of COVID-19 are vital to ensure an adequate psychological care response. The primary aim was to assess the prevalence and degree of psychological distress and trauma in frontline doctors during the acceleration, peak and deceleration of the COVID-19 first wave. Personal and professional factors associated with psychological distress are also reported. DESIGN: A prospective online three-part longitudinal survey. SETTING: Acute hospitals in the UK and Ireland. PARTICIPANTS: Frontline doctors working in emergency medicine, anaesthetics and intensive care medicine during the first wave of the COVID-19 pandemic in March 2020. PRIMARY OUTCOME MEASURES: Psychological distress and trauma measured using the General Health Questionnaire-12 and the Impact of Events-Revised. RESULTS: The initial acceleration survey distributed across networks generated a sample of 5440 doctors. Peak and deceleration response rates from the original sample were 71.6% (n=3896) and 56.6% (n=3079), respectively. Prevalence of psychological distress was 44.7% (n=1334) during the acceleration, 36.9% (n=1098) at peak and 31.5% (n=918) at the deceleration phase. The prevalence of trauma was 23.7% (n=647) at peak and 17.7% (n=484) at deceleration. The prevalence of probable post-traumatic stress disorder was 12.6% (n=343) at peak and 10.1% (n=276) at deceleration. Worry of family infection due to clinical work was the factor most strongly associated with both distress (R2=0.06) and trauma (R2=0.10). CONCLUSION: Findings reflect a pattern of elevated distress at acceleration and peak, with some natural recovery. It is essential that policymakers seek to prevent future adverse effects through (a) provision of vital equipment to mitigate physical and psychological harm, (b) increased awareness and recognition of signs of psychological distress and (c) the development of clear pathways to effective psychological care. TRIAL REGISTRATION NUMBER: ISRCTN10666798.

Psychological distress during the acceleration phase of the COVID-19 pandemic: a survey of doctors practising in emergency medicine, anaesthesia and intensive care medicine in the UK and Ireland.

OBJECTIVE: To quantify psychological distress experienced by emergency, anaesthetic and intensive care doctors during the acceleration phase of COVID-19 in the UK and Ireland. METHODS: Initial cross-sectional electronic survey distributed during acceleration phase of the first pandemic wave of COVID-19 in the UK and Ireland (UK: 18 March 2020-26 March 2020 and Ireland: 25 March 2020-2 April 2020). Surveys were distributed via established specialty research networks, within a three-part longitudinal study. Participants were doctors working in emergency, anaesthetic and intensive medicine during the first pandemic wave of COVID-19 in acute hospitals across the UK and Ireland. Primary outcome measures were the General Health Questionnaire-12 (GHQ-12). Additional questions examined personal and professional characteristics, experiences of COVID-19 to date, risk to self and others and self-reported perceptions of health and well-being. RESULTS: 5440 responses were obtained, 54.3% (n=2955) from emergency medicine and 36.9% (n=2005) from anaesthetics. All levels of doctor seniority were represented. For the primary outcome of GHQ-12 score, 44.2% (n=2405) of respondents scored >3, meeting the criteria for psychological distress. 57.3% (n=3045) had never previously provided clinical care during an infectious disease outbreak but over half of respondents felt somewhat prepared (48.6%, n=2653) or very prepared (7.6%, n=416) to provide clinical care to patients with COVID-19. However, 81.1% (n=4414) either agreed (31.1%, n=2709) or strongly agreed (31.1%, n=1705) that their personal health was at risk due to their clinical role. CONCLUSIONS: Findings indicate that during the acceleration phase of the COVID-19 pandemic, almost half of frontline doctors working in acute care reported psychological distress as measured by the GHQ-12. Findings from this study should inform strategies to optimise preparedness and explore modifiable factors associated with increased psychological distress in the short and long term. TRIAL REGISTRATION NUMBER: ISRCTN10666798.

Highlights from this issue

Too much of a good thing Over the past decade safe oxygen prescribing in patients with Chronic Obstructive Pulmonary Disease (COPD) attending the emergency department has vastly improved. In the LoDED qualitative analysis (disclaimer: I led this work and having had limited experience in qualitative work this was a challenge in terms of both delivery and write-up!) we explored the acceptability of very rapid discharge to both patients and clinicians (with an interesting juxtaposition) and highlight the importance of discharge communication. [...]in a systematic review and meta-analysis published this month by Squizzato and colleagues, which explores the diagnostic accuracy of inferior vena cava ultrasound for heart failure, the authors question its accuracy as a stand-alone test (mean specificity of 81.8%, in 7 studies including 591 patients in total).

COVID-19 emergency response assessment study: a prospective longitudinal survey of frontline doctors in the UK and Ireland: study protocol.

INTRODUCTION: The COVID-19 pandemic is putting an unprecedented strain on healthcare systems globally. The psychological impact on frontline doctors of dealing with the COVID-19 pandemic is currently unknown. This longitudinal professional survey aims to understand the evolving and cumulative effects of working during the COVID-19 outbreak on the psychological well-being of doctors working in emergency departments (ED), intensive care units (ICU) and anaesthetics during the pandemic. METHODS AND ANALYSIS: This study is a longitudinal questionnaire-based study with three predefined time points spanning the acceleration, peak and deceleration phases of the COVID-19 pandemic.The primary outcomes are psychological distress and post-trauma stress as measured by the General Health Questionnaire-12 (GHQ-12) and Impact of Events Scale-Revised (IES-R). Data related to personal and professional characteristics will also be collected. Questionnaires will be administered prospectively to all doctors working in ED, ICU and anaesthetics in the UK and Ireland via existing research networks during the sampling period. Data from the questionnaires will be analysed to assess the prevalence and degree of psychological distress and trauma, and the nature of the relationship between personal and professional characteristics and the primary outcomes. Data will be described, analysed and disseminated at each time point; however, the primary endpoint will be psychological distress and trauma at the final time point. ETHICS AND DISSEMINATION: Ethical approval was obtained from the University of Bath, UK (ref: 4421), and Children's Health Ireland at Crumlin, Ethics Committee. Regulatory approval from the Health Regulation Authority (UK), Health and Care Research Wales (IRAS: 281944).This study is limited by the fact that it focuses on doctors only and is survey based without further qualitative interviews of participants. It is expected this study will provide clear evidence of the psychological impact of COVID-19 on doctors and will allow present and future planning to mitigate against any psychological impact. TRIAL REGISTRATION NUMBER: ISRCTN10666798.