Nobody is a superhero

Deep concern, mixed with hope about what lies ahead beyond the winter months… the picture around Covid-19 changes by the day. We never imagined things would unfold like this; lockdowns, working remotely, the frontline, unable to hug friends and even close family members. Tens of thousands of people dying in our country. Fear, anxiety, anger have consumed many lives for months. The virus has exposed the inequalities of our society. The financial burden, unemployment rising. We have seen a divide forming within our country on how the pandemic should be managed, with protecting lives pitched against protecting livelihoods.      

For those working in healthcare, another division has been bubbling away. Here, I explore the different perspectives and experiences of health workers, dropping in occasional quotes from them, to understand why. Can we prevent further division and create a more caring culture within the health and social care systems?

The 'superhero' myth

At the beginning of the pandemic, and as we entered our first and most stringent lockdown, a strong narrative emerged of the 'superhero'. We saw superhero slogans all over billboards and television advertisements, and clapping became a unified way of saying how grateful the public were to keyworkers on the frontline, who had no choice but to continue working. This gratitude for heroes was important for morale and unity – health and social care workers put their own lives at risk in order to treat those who had become seriously ill with Covid-19. 

However, many staff felt uncomfortable about this narrative; for them, they were just going to work and doing their job. Colleagues from Black, Asian and Minority Ethnic (BAME) backgrounds were not given a choice about being placed in such potentially dangerous and life-threatening situations. The disproportionate deaths in people from BAME backgrounds raised serious, uncomfortable, questions about why people of colour were more at risk of serious illness if they became infected. Amidst enforced lockdown, with many paying more attention to the news, the dreadful killing of George Floyd resonated with so many people. The activism of the Black Lives Matter Movement has forced societies to re-examine historic and current inequalities, racism and marginalisation. There is a demand for change, not just applause.

We have seen the landscape of an already overstretched NHS being pushed to its absolute limits with Covid-19. At the beginning, frontline staff were desperately trying to manage the risk of treating patients without appropriate and sometimes in complete absence of the required PPE.

Superheroes don't need to eat or sleep or rest. They don't need equipment. They are exceptional, and they tend to be individuals who fight on alone. This is just not reality. Health and social care workers are human beings, mortals. They work in teams and the heroism is a shared endeavour. They need to be safe in carrying out their duties, and their employers have a duty to ensure that they are. Health and Safety law protects employees from being harmed at work. These rights extend to mental health and the right to not be bullied or pressured into working unsafely. Sadly, we hear reports of colleagues feeling unable to exercise this right, either because of their own values, of concern about how it would be perceived by others; or because of messages received by managers informing staff they must turn up for work.

Visible and invisible heroes

The team is often the unit of trust and safety at work. There has been a strong sense of solidarity amongst frontline key workers and we ask how (and why) this has affected relationships and a sense of togetherness for those who have had to work on the frontline. What are the perceptions of those who have had to find ways of carrying on working from their home? Are we all able to come together to support one another regardless of our role, or are the fractures which have started to appear, splitting teams in to an 'us and them?' Anecdotal evidence, sadly, suggests the latter and also that this is patterned.  

"As a psychologist working in a power mad, control obsessed, us v them model of distress, I have rarely felt 'in this [or anything] together'. Proving our worth, sitting on the fence, not burning bridges have all been strategies I've been advised to adopt and have done so with varying degrees of success. Now with Covid-19 it feels that … those who were on the frontline will need the freedom to remember how they survived going over the top, and sadly these narratives will inevitably include reference to those who were not there alongside them. If this is us then we will once again be expected to absorb this shock, this anger, this difference that 'they' feel towards those that are inaccurately believed to be absent – proving our worth, being there for our teams, being prepared to be a head on a desk that can be disconnected from the conversation with one simple move – that is, once again, not 'in it together'."

There are also invisible heroes – those behind the scenes working all hours to try to support their colleagues on the frontline and service users in the community. Desperately trying to find a way of working at home. What are the psychological consequences of this? In the same way some people experience survivor guilt after a traumatic event, there are those keen to be on the frontline, supporting their colleagues, but have needed to be shielded. Feelings of overwhelming guilt are common due to the sense of obligation to support staff. By not being there physically, people can feel that they are letting others down or not 'pulling their weight'. There must be recognition of how incredibly difficult this can be, particularly when working with highly complex clients. 

Many have reported overcompensating by over working, blurring their boundaries of home and work life, and increasing the chances of burnout. Bringing traumatic material into the home environment can 'toxify' what should be a place of sanctuary. There may be no dedicated 'safe' place for work at home, juggling competing demands of caring for others, home schooling, feeling 'detached' from the wider team and service.  

The risk of moral injury

Essential non-clinical key workers are also desperately trying to continue performing vital roles and work in an intensely demanding environment. There is no doubt that the conditions people have been placed in will, to some, cause significant distress and possible moral injury (Williamson et al., July 2020). Moral injury, as defined by The King's Centre for Military Health Research (KCMHR), is 'the psychological distress which results from actions, or the lack of them, which violate your moral or ethical code'. The example they give of a humanitarian aid worker not being able to provide adequate treatment to all patients, due to lack of resources, is so pertinent to today's world (Williamson, Murphy, Greenberg and Stevelink, 2019).

Alongside the strong narratives of 'in it together' and 'heroes', comes an undercurrent of easy judgement for those not seen to be 'doing their bit'. With the frequent news reports and high emotions, come many varying opinions about what we should do and when. In the stress of trying to keep safe, we perhaps can forget that everyone has different situations, requirements and resources (both internal and external). The likelihood is the vast majority of us are just doing our best with a very uncertain situation, inconsistent and rapidly changing advice and widely varying circumstances which mean that what we 'should do' is different for each of us. 

Isolation is also an issue for those working from home – some of whom perhaps have not had any close physical contact with another human being for weeks, with no end in sight. This isolation will have a very real impact on team and working relationships. How do people re-integrate into a team where they may feel they have missed so much? Perhaps there will be residual feelings of guilt, shame, or resentment? What are the long-term impacts of this isolation? How do we weave each person's narrative back together to form a group one? The language being used throughout the pandemic is key to developing a sense of teamwork and cohesion for us all to feel we are 'in it all together'.  

"The message seems clear enough… 'If you can work from home, work from home'. However, clinicians appear to encounter different experiences based on where they work, be it psychology departments, MDT settings, inpatient wards etc. The latter two settings where clinicians work within an MDT may bring additional challenges such as 'guilt' that psychologists do have the ability to work remotely, leading to perceived/actual resentment from colleagues ('It's OK for them, they can work from home') and 'pressure' to be visible like some of their colleagues. I also wonder if those clinicians that are able to work remotely have inadvertently highlighted the unhelpful narratives around hierarchy within MDT's?"

It is helpful to recognise these different experiences and also the varying response styles to Covid-19; despite over 60,000 deaths in the UK, minimisation and denial have been observed. This has been compounded by some clinician's experiences of being fortunate enough to either be asymptomatic or have a mild illness from a positive test. This seems to have perpetuated the narrative "you need to understand that this virus isn't this big, bad thing", and creating an assumption that everyone else should just get on with and not worry either. 

Lessons about language

We must really critically examine the language which is used around this pandemic, to guard against thinking biases, such as minimisation, emotional reasoning, and optimism bias. Subtleties of language can exert pressures on how people think, feel and behave. For instance, the term 'recovery phase' which was used until very recently for system and strategic planning has now been recognised as premature during a period of considerable adjustment, uncertainty and anxiety. It implies that people should be 'recovering' from an acute incident (which a pandemic certainly isn't) and feeling better. We now see that this is something that is likely to continue for some time with ongoing tricky feelings and possible long term symptoms (Long Covid) associated with it. 

There must be also recognition that the pandemic may reactivate previous traumas, not only for our clients, but also our staff. Again, we are talking human narratives here; nobody is a superhero. Clinicians have their own life histories and are trying their best to navigate this global pandemic. We're all human beings. Many on the frontline went in to 'fight' mode trying to deal with the day-to-day trauma of nursing sick people with this highly contagious virus. Some made huge sacrifices to do this, to protect the patient but also to protect their families, by staying away from home for periods of time. Many may not have chosen to do this, but saw no other option and felt pressure to put themselves in potential danger. There may also be those who are 'hero innovators', putting themselves in the midst of the war on the virus at a cost to their own wellbeing.

"I don't even think we have begun to digest the 'losses' of this period and future change and loss to all our lives. It is all quite extraordinary."

Compassion as medicine

So how do we all continue to work in this environment for the long term? The outpouring of help, support and guidance produced by organisations and colleagues on 'How to cope in a pandemic' has been instrumental in helping us to hold on to the sense of hope that we can get through this. For teams to support one another there must be compassion and understanding of others' difficult roles, whether they are on the frontline or working remotely.   

Michael West (2017) talks passionately about teamwork and compassionate leadership and caring for the health and well-being of NHS staff. He explains: "I think we have to go back to the heart of what this is all about. When the NHS was set up in 1948 by a deeply traumatised post-war society, it was with a commitment to caring for everybody in the country, regardless of wealth, status prestige, background. A compassionate and inclusive system. NHS staff have virtually all made a decision to dedicate an enormous part of their precious, unique, mysterious lives, to caring for their fellow human beings, so they too have a core work value of compassion."

Now more than ever, we need to show compassion towards one another. 

"One fact that is certain is that everybody's experience is going to be different, and how they respond will be different too. We need to understand that we will all be working differently but with the same goal – to help and support each other through the difficult times, and to those who need it. Give each other space to breathe when we need it to gain strength and build resilience for the long haul of this virus."

We have seen so many positives which have come out of this pandemic; some teams have felt more connected with the use of remote video meetings, allowing them to attend more often than usual. Some staff working remotely report a much better work life balance and are more productive and motivated as a result of this flexible way of working. As ever, there is not one narrative, one size does not fit all experiences.

It is possible that we can make team life better? The use of the word 'recovery' has perhaps led to a focus on a rapid return to 'business as usual', perhaps at any cost. For those in management roles, such a drive may foster a sense of control, productivity and familiarity. But the world we are living in is far from 'business as usual'. We have a chance to change, grow and re-evaluate practices. Reshaping how we work could improve our work-life balance.

"It struck me this morning on the meeting when discussing how a support worker had a 'list of reviews to complete'. This practice didn't really take into account the changed context and circumstances, the needs of the patient or even the value of the assessment itself at this time and under those circumstances. I wondered whether this might be symptomatic of a craving for a … sense of control, productivity and familiarity I guess we might all have to some extent…"

This pandemic has shown the power of narratives, and the unintended consequences of framing clinicians as superheroes, rather than dedicated, compassionate human beings who need support and care. Our work rests on the idea of teams – it is foundational. The pandemic has disrupted this in both harmful and helpful ways. If we can reshape the narratives and create an understanding that all the different roles have equal value, and retain a sense of each other as human beings, then we can get through this pandemic and create a strong, caring culture with team cohesion and solidarity.

We will restore the relational power of healthy teams, the unit of trust in which we work. Together.

"The boat / storm metaphor really resonated with me throughout this in thinking about myself, my friends and our service users. There has been so much pressure from so many sides – even just with people feeling pressured to 'use this time to be get creative' or 'there's no excuse not to have a tidy house now' or to be on call 24/7 because 'it's not like you're doing anything else'. I've been really privileged to be in a nice sturdy boat and to be trusted to hear these difficulties that come from the wider narratives from various people."

"There has been a lot of talk in the media and from the government drawing on parallels with conflict and using wartime language. I see the nation standing together once again at a time when we face what has been described as the biggest 'threat to our country at times of peace'. I would like to hope that once this pandemic is over and is no longer the central focus of the media, the national Government will still be supporting our 'heroes' and they will not be forgotten."

- Dr Kathryn Lloyd-Williams, Clinical Psychologist working in Older People's Mental Health. [email protected]

'Sincere thanks must go to all colleagues nationally across services who have contributed. You shared your experiences so honestly and openly, and helped to provide such a rich reflection of how the pandemic has impacted on people's lives. With special thanks to my friend and mentor, Dr Khadj Rouf. This article would not have been possible without your support, encouragement and creative editorial guidance.'

References

Litz BT, Stein N, Delaney E et al.  Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev 2009;29:695–706.

West, M. (2017). Collaborative and Compassionate Leadership.

Williamson, V., Murphy, D., Greenberg, N. and Stevelink, S (2019). Moral injury: violating your ethical code can damage mental health – new research.

Williamson, V., Murphy, D., Greenberg, N. (July 2020), Occupational Medicine, 70, 317–319.