The recent Medscape UK Doctors’ Burnout & Lifestyle Survey 2020 was carried out between May and August 2020, with a sample of 1082 UK-based doctors. One of the questions was: “Did the ‘Clap for Carers’ boost morale?” The answer was surprising – 69% of doctors said No (17% Yes, and 19% Not Sure).
Clap for Carers took place over 10 weeks in Spring 2020, inspired by a woman in London who wanted to find a way to bring communities together to show their gratitude for all that health professionals and carers were doing during the pandemic. Every Thursday evening at 8pm people were invited to stand on their doorsteps and clap. In recent weeks it has returned, rebranded as Clap for Heroes to acknowledge the workers in other sectors who are playing a vital role in supporting communities through the pandemic. Sadly, the woman who started the movement has had to distance herself from it due to receiving abusive threats. How did this seemingly positive cause inspired by gratitude turn so sour?
I remember the beautiful Spring evenings – standing on the doorstep after another never-ending day of home schooling, listening to my neighbours clap and bang pots and pans. It was an emotional experience, but not always in a good way. I was aware of all sorts of feelings – some annoyance that the noise was preventing my kids from getting to sleep; curiosity at seeing people in real life; joy in hearing a neighbour with serious drumming skills; and sadness at the thought that this was the closest I’d get to live music for who knows how long.
I also sometimes felt very proud, to be able to call myself an NHS worker (although nowhere near the “frontline”). And deeply grateful to those colleagues caring for patients under horrendous conditions. All this was tinged with a poignant sense of loss – for those who had died, or would die, for the people we couldn’t be with, and all the special occasions we were missing.
As time went on, however, I started to feel angry. Not at those clapping, but at how this, and all the talk about NHS “heroes” was beginning to feel very hollow. I knew that behind the rainbow-coloured smoke screen healthcare staff were really struggling – and not getting the support they needed.
With all the heroic expectations was there room for those who wanted to hang up their capes and escape? Or those who felt terrified about going to work every day, and terrified about returning home, in case they got sick or infected someone they love? What about those who never wanted to be heroes at all, suddenly finding themselves in roles they hadn’t chosen or trained for? Or those who were faced with only bad choices for patients, hating themselves for not being able to deliver the quality of care they aspire to? Where did they fit in the narrative? Fallen heroes, traitors? Could their voices be heard above the noise?
The hero narrative not only over-simplifies the issues but can also be harmful. Dr Catriona Cox, of the Healthcare Improvement Studies Institute, published an excellent article in the Journal of Medical Ethics examining the problems associated with this narrative. I explore her argument below.
What is heroism?
Cox’s definition of heroic action has three key elements:
- It is a voluntary choice to help others
- in the knowledge that this action involves a degree of personal risk
- and is beyond the person’s normal duty
Thus, defining all healthcare workers in a pandemic as heroes assumes that they have chosen to do this work at this time and that they are willing to do so in spite of the risks to themselves. It also implies that wider society acknowledges the personal risk staff are exposed to, and that they are being asked to go above and beyond normal expectations. Buying into this narrative stops us examining these assumptions and their impact in three important ways:
1. Stops us asking questions about the limits of duty of care
It is widely accepted that healthcare workers have a “duty of care” to their patients. But what does this mean in a pandemic? We have been lucky enough not to have to face this question for over 100 years in the UK. But it is an important one that requires careful thought. Cox argues that duty of care is a principle grounded in the social contract health workers have with the community – put very simply, doctors look after us in exchange for pay and respect.
However, this duty is not limitless, Cox states. Doctors aren’t expected to donate their own organs to save patients. But where do we draw the line? What level of risk is acceptable for health workers to take on in a pandemic? We need to have meaningful and robust discussions about this complex issue. The hero narrative doesn’t allow this.
2. Avoids reciprocity
Cox describes how health professionals’ duty of care is reciprocal, meaning that while they have a duty to care for us, society has a duty to care for them. Thus, this duty is grounded in a social contract – with institutions that employ and govern them, and with the public. This social contract requires institutions to acknowledge the demands and risks placed on their staff and to provide the right level of support: transparent and clear communication, adequate training and resources to do the work, and decent pay. We know that the government and NHS bodies have failed at this for decades. In the midst of a pandemic with staff facing extraordinary demands and risks these issues are more important than ever. But there are also additional needs: PPE, psychological support and access to vaccination and treatment.
Cox argues that focusing on individual heroism is a politically convenient way to deflect attention when the government and NHS bodies don’t hold up their side of the bargain. “Heroes” don’t complain about poor working conditions or broken promises.
The public also has a moral duty to honour their part in the social contract. Cox states that this takes the form of paying taxes, using their voting powers, and, in a pandemic, following the rules. Again, a focus on individual heroes diverts attention from this fact, rather than reminding us all of our own responsibilities.
It is no wonder, then, that health professionals have pleaded: “Don’t clap for us, just pay us properly/resource our hospitals/stay at home!” They don’t want our praise, they want us to honour our duty to them, as they do to us.
3. Can be harmful to healthcare workers
The pervasive narrative that all healthcare workers are heroes, means that heroic action becomes the expected norm. However, for many staff, exposure to this level of personal risk is not what they signed up for. Constantly praising staff for being heroes, in the media and within the NHS, leaves little room for staff to express fear, ambivalence or anger at what they are being exposed to. Cox argues that staff may feel under great pressure to act beyond what is reasonable. This is likely to contribute to poor self-care and lead to burnout, anxiety and moral injury.
The evidence is clear that staff are really struggling. Recent survey results showed that 45% of intensive care staff have clinically significant mental health difficulties including severe depression and anxiety, PTSD and problem drinking. We need to be able to think deeply and robustly about how to support health professionals, now and in the future. Gratitude may play an important part in that, but we must ensure that it’s not just about making us feel better.
We need to make space to witness the full range of experiences and needs of our healthcare workers, and hold up our part of the bargain by delivering meaningful supportive action – whether we are private citizens, NHS leaders, or politicians.
We know that there are thousands of NHS staff working with dedication and compassion under terrible circumstances, and at heavy personal cost. Let’s show our gratitude by following the stay-at-home rules, attending booked appointments, treating staff with respect, and, whenever we have the opportunity, petition and vote for the resources the NHS needs.
