How many times have you heard the phrase “unprecedented circumstances” over the past 9 months? The Covid-19 pandemic has put everyone, but particularly health and social care professionals across the world, in unprecedented situations, having to make impossible decisions and work under extreme pressures. This has included allocation of resources (or lack thereof) to patients equally in need, as well as balancing their own physical and mental healthcare needs with those of patients (Greenberg et al., 2020).
Moral injury is a term that originated in the military, and is defined as the psychological distress that results from actions which violate someone’s moral or ethical code (Litz et al., 2009). Providing care in such situations can understandably create complex feelings of guilt, remorse, and shame; it can also lead to mental illness in some (Tracy et al., 2020). Pollock et al.’s Cochrane review seeks to investigate interventions that would prevent moral injury in healthcare workers.
Pollock et al. (2020) state that the World Health Organization (WHO) has warned about the potential negative impact of the COVID‐19 crisis on the mental well‐being of health and social care professionals, and set out to ask what the best way to support the resilience and mental well-being of frontline healthcare professionals during and after a pandemic is.
Healthcare providers can use various strategies (interventions) to support resilience and mental well-being in their frontline healthcare professionals. These could include work-based interventions, such as changing routines or improving equipment; or psychological support interventions, such as counselling.
The authors set out objectives to find out how successful these interventions are in disease outbreaks, as well as to identify any particular “facilitators” or “barriers” to implementing these interventions.
The authors searched medical databases (Cochrane Database of Systematic Reviews, CENTRAL, MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, Global Index Medicus databases and WHO Institutional Repository for Information Sharing) for studies that outlined interventions that were “designed to support resilience and mental-wellbeing in healthcare professionals”, and kept their search specific to those “working on the frontline during infectious disease outbreaks”, as classified by the World Health Organisation as epidemics or pandemics from 2002 to 28 May 2020.
The authors included a total of 16 studies in their review that “included workplace interventions, such as training, structure and communication (6 studies); psychological support interventions, such as counselling and psychology services (8 studies); and multifaceted interventions (2 studies).”
These studies came from different disease outbreaks ‐ two were from SARS; nine from Ebola; one from Middle East respiratory syndrome (MERS); and four from COVID‐19.
They did not find any evidence about how well different strategies work at supporting the resilience and mental well‐being of frontline workers. However, they identified limited evidence on barriers and facilitators to implement such interventions.
|Interventions that could be adapted for a local area||Unawareness of frontline workers (or the organisations in which they worked) in terms of supporting their own mental well-being|
|Effective communication||Lack of resources, such as equipment, staff, time or skills needed for a particular intervention|
|Positive, safe and supportive learning environments for frontline healthcare professionals|
Pollock et al. (2020) called for more:
properly planned research studies to find out the best ways to support the resilience and mental well‐being of health and social care workers are urgently required.
The authors concluded that there is a “lack of quantitative and qualitative evidence” about how beneficial well-being interventions are for frontline workers from studies carried out during (or after) pandemics and epidemics. They highlighted the importance of selecting “interventions aimed at supporting frontline workers’ mental health, organisational, social, personal, and psychological factors”.
They also stated that they were “moderately confident” that they had identified two barriers to implementation of intervention, and three factors that were able to act as facilitators for the interventions.
The researchers did not find any evidence on how each different strategy works at supporting the resilience and mental well-being of frontline workers, identifying a gap in the literature. Therefore, they concluded that further properly planned research studies to explore the best ways to support the resilience and mental well-being of health and social care workers are urgently required.
Strengths and limitations
This study is a great addition to the literature as:
- It highlights key issues in the gaps they have identified as a result of the Covid-19 pandemic and allows us to better understand the efficacy of interventions for future unprecedented situations relating to healthcare frontline workers’ moral injury.
- The methodology was logical and searched a broad set of databases, without any language barriers.
- The study has the potential to inform future research and policy, as it urges for further research to be done.
However, the study itself recognises that participants in the majority of studies were healthcare professionals (mainly doctors and nurses), and that they found no studies focused on social care professionals, and no studies that considered health or social care professionals who were returning to practice after a period of absence (this group of professionals being actively recruited to return to work during the COVID‐19 crisis). The authors acknowledged the need for future research to address the mental health and resilience of social care workers, professionals returning to practice after a period of absence, and students entering practice early during a disease pandemic.
Implications for practice and research
The authors developed a set of questions for the selection and successful implementation of interventions to support the mental health and resilience of frontline health and social care professionals. They noted that these implications are based on findings that are delivered in a variety of contexts, and that the importance may differ with different interventions, and indifferent settings. Pollock et al. (2020) laid out their questions for the selection and successful implementation of interventions in three different categories: 1) selecting an intervention (i.e. flexibility); 2) planning organisational factors (i.e. formal and informal networks, adequate resources) and 3) individual characteristics of frontline staff. In detail, they identified the following additional factors:
- Complexity of the intervention (low‐complexity interventions may be easier to implement)
- Intervention costs and associated costs of implementing the intervention
- Government and political leaders’ awareness of mental health needs of frontline workers
- Networking and co‐ordination of different relevant organisations
- Organisational incentives and rewards for frontline workers may facilitate engagement in the intervention
- Education, training and access to information for frontline workers about the intervention
- Confidence of people delivering the intervention
- Individual personal characteristics of workers, such as attitudes and motivation
- Strategic planning prior to implementation of an intervention or changes to practice
- Meaningful engagement of, and collaborations with, people involved in the delivery of the intervention, and opinion leaders who can champion the intervention
- Providing frontline workers with opportunities to reflect on the implementation of an intervention
This study highlighted a lack of research evidence relating to the effectiveness of interventions to support the resilience and mental health of frontline workers during disease epidemics or pandemics. Despite the continued challenges of the global COVID‐19 pandemic, there are “unique opportunities for robust evaluation of interventions”. The authors conclude:
It is essential that any future studies are developed with appropriately rigorous planning, including development, peer review and transparent reporting of research protocols, following guidance and standards for best practice (e.g. SPIRIT and CONSORT reporting guidelines for randomised trial protocols and studies), and planning for appropriate follow‐up.
Statement of interests
Pollock A, Campbell P, Cheyne J, Cowie J, Davis B, McCallum J, McGill K, Elders A, Hagen S, McClurg D, Torrens C, Maxwell M. Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review. Cochrane Database of Systematic Reviews 2020, Issue 11. Art. No.: CD013779. DOI: 10.1002/14651858.CD013779. Accessed 20 December 2020.
Greenberg Neil, Docherty Mary, Gnanapragasam Sam, Wessely Simon. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ 2020; 368:m1211.
Litz BT, Stein N, Delaney E et al. (2009).Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev2009;29:695-706. doi:10.1016/j.cpr.2009.07.003
Tracy D K, Tarn M, Greenberg N. From moral injury to mental illness: we must protect the wellbeing of frontline covid-19 staff. BMJ. 2020.
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