On the frontline of inpatient psychiatry we are used to the complex and challenging, but Covid-19 has completely changed the way we practise and how our patients experience care. We meet patients where they are and often those who are severely distressed will hold our hands. It is not customary for staff to hug patients, but we do sit alongside them. That is difficult to do from two metres away. At other times, patients will fist-bump us to show appreciation, acknowledgement, affection. We can’t do that anymore, and inevitably some experience it as rejection.
Many patients lack the emotional regulation to process why last month we seemed present, and now we are distant. Those who are floridly psychotic lack insight; add a global pandemic to entrenched belief systems and you have a perfect storm. Some believe coronavirus is a conspiracy; some think it is biological warfare; some are convinced it is staged. Some see messages in news broadcasts meant for them. In psychosis, beliefs are so fixed there is no shifting them. Patients do not believe what we tell them is real, they believe their version is real.
Personal hygiene is often a struggle for those who are acutely unwell. Gentle prompting has been replaced with urgent instruction. Our difficulty is conveying the importance of hand-washing and showering to patients too unwell to care. For those with OCD we are telling them the opposite of what we told them before: to act on compulsions they have worked hard to conquer. Existing fears of contamination are now validated. Many patients are high-risk: obesity and diabetes are common consequences of long-term use of psychiatric drugs, and co-morbid physical health issues can often be the trade-off for mental stability.
Psychiatric wards are not designed for physical distancing. They are contained environments with people in close proximity. Communal spaces are arranged to bring people together, not separate them – tables are not two metres apart, nor is there room for them to be.
We do not wear uniforms, which is usually a good thing – a breaking down of barriers. But in this climate it feels dangerous. There are no sterile scrubs. We wear our own clothes, praying we don’t bring the virus in with us, and aware that if we do, transmission will be swift.
We are not equipped for complex physical health issues. We are hospitals, but we stand apart from general medicine. We do not have medical equipment on standby, or adequate spaces to nurse in isolation. This seems paradoxical given that some patients are detained, but segregation is not what we’re about. We promote inclusion, participation, connection. All things we must now restrict.
We have limited PPE. We get it, we are not priority – but we are scared because we are locked into spaces with people who find it almost impossible to physically distance. We know that if one goes down, we all do.
Lockdown has ended patients’ leave and visits. This affects their stability, and to many feels punitive. If self-harm increases, our patients will not be a priority on general wards. We worry for them.
As emotions ignite, staff are blamed, putting us at higher risk of assault. Therapeutic and group activities – art, psychology, occupational therapy – are off limits. All but essential staff are working from home. Only medical staff remain, and as more self-isolate, we are less able to deal with volatile situations on wards that were woefully understaffed to begin with. Calling the police if situations escalate is not tenable, because their resources are stretched. Behind locked doors, we feel like sitting ducks.
Staff anxiety is high. We are absorbing the fear and distress of our patients while trying to contain our own. We all feel vulnerable. It is no longer shocking to see colleagues break down on shift, and the exhaustion of holding everyone’s emotions is taking its toll.
The emotional fallout for mental health services will continue long after lockdown has ended. It will be then that our battle will begin.