Healthcare workers from across the globe have been at the forefront of Covid-19, faced with daily challenges and the harshest reality of working during an infectious disease outbreak.
Enduring long shifts, high pressure environments, limited PPE supplies, fear of infecting relatives, adapting to (dare I say it) unprecedented circumstances. Many healthcare workers also saw relatives and colleagues die.
The long-term impact on mental health is yet to be realised, but healthcare workers represent a group at risk of experiencing mental health issues (Maben and Bridges, 2020). Previous pandemics indicate that healthcare workers may experience anxiety, depression, post-traumatic stress disorder, exhaustion (O’Sullivan et al., 2007), insomnia, relationship difficulties, behavioural changes (Waterman et al., 2018) and burnout (Maben & Bridges, 2020).
The potential impact on the mental health of healthcare workers has been widely discussed during Covid-19. This recent review by Zaçe et al (2021) looked to understand the potential interventions to tackle mental health problems in healthcare workers, summarising interventions from previous disease outbreaks and reporting their effectiveness.
The systematic review protocol was pre-registered on Prospero (CRD42020196383) and covered a range of published literature databases looking at studies describing experiences of any intervention on mental health (including resilience and stress) of healthcare workers during disease outbreaks.
Included studies could use any study design, with healthcare workers working inside and outside the hospital during Covid-19 or previous pandemic disease outbreaks. Studies were excluded if they involved infected healthcare workers or were personal activities or coping mechanisms. The studies quality was reviewed and rated, but no studies were excluded based on these findings.
After 5,128 articles were screened from across the databases, 21 studies were included in the review. Another three studies were included after the reference lists of the included studies were hand searched for additional eligible studies.
Studies used cross-sectional (33.5%), before-after (20.8%), cohort (8.4%) and qualitative (4.1%) designs. The designs of 33.5% of the included studies were not specified and were narrative descriptions.
Over 70% of the studies were based in Covid-19. Other outbreaks included SARs (12.5%), Ebola (8.4%) and Influenza A H1N1. The sample size ranged from 25 nurses to 10,240 staff members across China in Covid-19.
Interventions available to support healthcare worker mental health were grouped into four categories. This covered information, equipment and supplies, organisational support and a range of emotional and psychological interventions.
Disappointingly, only 30% of the included studies investigated the efficacy of the interventions. In Covid-19, training (including psychological counselling and mindfulness) improved nurses rescue ability and anxiety, although there was no change in depression (Zhou et al., 2020). Music therapy for hospital staff in Italy was associated with improved mental status (perceived sadness, fear, worry) (Giordano et al., 2020). A psychological health support scheme offered to staff in China (including Balint groups and after-work support team) was associated with a generally positive mood over 6 weeks of continuous work (Cheng et al., 2020).
Because the approaches were so varied across the studies, they could not be grouped to combine or compare effectiveness. Generally, the follow-up periods were short (e.g., two weeks – three months) meaning the long-term impact of the interventions is also difficult to assess.
This review presents a variety of interventions to support the mental health of healthcare workers in pandemic disease outbreaks. Interventions ought to address the breadth of support that is required for staff, including informational support, equipment and supplies, organisational support approaches as well as emotional and psychological interventions. More research is needed to determine the effectiveness and long-term impact of the interventions described.
Strengths and limitations
This review is timely and presents an important overview of the multifaceted nature of mental health and support that healthcare workers require in pandemic disease outbreaks. Importantly, the authors present interventions in terms of a holistic approach, encompassing both the individual needs and the organisational or instrumental requirements. This approach nicely recognises that the onus of mental health lies beyond the individual and that many areas can be considered as a responsibility of the organisation, to best support healthcare workers in their role.
It is a limitation of the nature of the available published studies, but the review shows a very limited view of the effectiveness of mental health interventions for healthcare workers. Acknowledging the rapid nature of emerging evidence from Covid-19, more research is needed to truly evaluate both the impact on mental health and the best approaches for support provision (e.g., high quality randomised trials with long-term follow-up).
The findings included a good breadth of healthcare staff. However, the review did not address the role that staff working in social care (e.g., care or nursing home staff, social workers) played in providing frontline care and support to people who were vulnerable across the pandemic. Estimations vary, but around 22% of Covid-19 deaths were in care or nursing homes in England (Office for National Statistics, 2021a, 2021b). The disparities in the provision of support (e.g., financial, resources, PPE) from primary to secondary care were brought to the forefront of our minds during Covid-19 and the gap in provision was, in many cases, increased. Staff working in social care or secondary care environments also require access to resources, training and mental health support, particularly when they are working on the front-line of a pandemic outbreak.
Implications for practice
Broadly, this review provides useful background information and a potential framework for practice. As highlighted in another Mental Elf blog on Greenberg et al. (2021), the perspectives of staff, such as through qualitative methods, will be useful in providing more in-depth understanding of the challenges faced and how interventions may help. In preparation and planning for pandemics, healthcare worker mental health (and how this can be supported) needs to be addressed. Moreover, the approach presented in this review (taking a multifaceted approach) can provide a useful starting point for shaping planning. Therefore, this will include training, access to equipment and supplies, staffing protocols, clear communication, good leadership and emotional, psychological and peer support mechanisms. However, without good quality evidence of the effectiveness of interventions for healthcare worker mental health, specific recommendations cannot be made.
Statement of interests
Bryony Porter has led on a systematic review of the impact of providing end-of-life care on the mental health of health and social care staff, during pandemics or humanitarian disasters. This study is under review for publication.
Zaçe D, Hoxhaj I, Orfino A, Viteritti A, Janiri L, Di Pietro M. (2021). Interventions to address mental health issues in healthcare workers during infectious disease outbreaks: a systematic review. Journal of Psychiatric Research.
Cheng, W., Zhang, F., Liu, Z., Zhang, H., Lyu, Y., Xu, H., Hua, Y., Gu, J., Yang, Z., Liu, J., 2020. A psychological health support scheme for medical teams in COVID-19 outbreak and its effectiveness. Gen. Psychiatry 33, 100288.
Giordano, F., Scarlata, E., Baroni, M., Gentile, E., Puntillo, F., Brienza, N., Gesualdo, L., 2020. Receptive music therapy to reduce stress and improve wellbeing in Italian clinical staff involved in COVID-19 pandemic: A preliminary study. Arts Psychother. 70, 101688.
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Office for National Statistics, 2021b. Number of deaths in care homes notified to the Care Quality Commission, England. Off. Natl. Stat. URL
Waterman, S., Hunter, E.C.M., Cole, C.L., Evans, L.J., Greenberg, N., Rubin, G.J., Beck, A., 2018. Training peers to treat Ebola centre workers with anxiety and depression in Sierra Leone. Int. J. Soc. Psychiatry 64, 156–165.
Zhou, M., Yuan, F., Zhao, X., Xi, F., Wen, X., Zeng, L., Zeng, W., Wu, H., Zeng, H., Zhao, Z., 2020. Research on the individualized short‐term training model of nurses in emergency isolation wards during the outbreak of COVID‐19. Nurs. Open 7, 1902–1908.
Greenberg N., Weston D, Hall C. et al. (2020). The mental health of staff working in intensive care during COVID-19. medRxiv 2020.11.03.20208322.