In a nationwide study of HCWs, we undertook an in-depth exploration of healthcare worker’s experiences while working during the pandemic, and the impact of this on their mental health. The findings from this research generally align with the emerging evidence base that there is an increased psychological burden on HCWs during the COVID-19 pandemic and this is likely due to the staff reorganization, the working intensity, and the anxiety of being exposed to the virus in the healthcare setting and, in turn, of bringing the infection home [13].Other research also points to increased hours and exposure to COVID-19 patients as factors contributing to poorer mental health among HCWs [14], in line with our findings.

However, the findings from this research also suggest that organisational responses to the pandemic were inconsistent. There was a distinct absence of well-defined and consistent policy in regard to pandemic planning and preparedness. The lack of clear and consistent guidance left HCWs at risk of physical as well as mental harm. Our research shows that HCWs were acutely aware of this increased risk. People with different roles within the healthcare workforce were provided with different guidance and different levels of protection. This included (lack of) access to PPE. Some research suggests that NHS staff were put at risk due to insufficient delivery and provision of appropriate PPE, reporting that by April 2020, only 12% of hospital doctors felt fully protected from the virus at work [15].

There are specific circumstances which relate to the experience of ethnic minority HCWs, which our research highlights. These findings align with other research [16] which identified less access to adequate PPE for ethnic minority HCWs. This situation is associated with decreased trust in employers (as evidenced in this research), which in turn is associated with poorer mental wellbeing for ethnic minority HCWs [14]. Inconsistencies in policy guidance may leave HCWs at increased risk of infection from COVID-19, and combined with a lack of trust in employer, may lead to a fundamental sense of betrayal, which can exacerbate existing marginalisation and inequities [17]. This loss of trust and sense of betrayal has been measured in previous research (e.g. using the moral injury event scale, [18]), and provides further evidence of the detrimental psychological impact on the mental health of ethnic minority HCWs during COVID-19.

Furthermore, the findings in this research highlight a wider potential gap in national policy responses to COVID-19. Historically, a number of government commissioned reports have placed patient safety at the heart of quality of healthcare service provision [19,20]. However it seems that when responding to COVID-19, the government’s primary strategy was to retain the required critical care capacity during surges in demand [21]. This meant that existing problems like the longstanding shortage of nurses and other HCWs in the NHS [22] may have thus negatively impacted on patient safety and staff to patient ratios during COVID-19, as evidenced in our findings. Although the NHS has consistently resisted the imposition of minimum staffing ratios [23] in 2019, guidelines from the Faculty of Intensive Care Medicine (FICM) and Intensive Care Society (ICS) described the levels of care required by critically ill patients in hospital according to their clinical needs. The guidance was clear that ventilated patients must have a registered nurse/patient ratio of a minimum 1:1 to deliver direct care [24]. As the second wave of COVID-19 hit the UK in Winter of 2020, NHS England advised hospitals to temporarily suspend the 1:1 ratio for level 3 critically unwell patients [24]. The findings in this paper show the impact of that decision on ethnic minority HCWs and their mental wellbeing. Participants in our research reported how these national decisions resulted in extremely challenging increases in workload and working hours for these HCWs.

The emerging evidence base suggests that ethnic minority communities are more likely to experience poor health outcomes and higher mortality rates due to COVID-19 [25]. Our findings demonstrate that across diverse ethnic groups, HCWs are experiencing mental distress and trauma due to experiencing significant amount of loss and increased exposure to death at work and bereavement of friends and family. This is likely to exacerbate existing structural and systemic inequities, and disparities in the impact of COVID-19 within the health system. Furthermore, for HCWs from ethnic minority backgrounds, these occupational stressors are likely to be compounded with the wider loss and bereavement they are experiencing at the intersections of their professional and personal communities. Despite consistent evidence that people of minority ethnicity backgrounds are at higher risk of catching COVID-19 and dying from it [6,26], and the increased risk of exposure HCWs from these communities face due to their frontline roles, few solutions have been communicated or actioned [27,28]. The findings in this paper evidence the cumulative effect of these relative risks on the mental health of this population.