The outbreak of COVID-19 and the subsequent pandemic brought unprecedented worldwide challenges born out of a rapidly escalating health and economic crisis. From emergency planners to healthcare workers on the front line, and everyone in between, the pandemic, and the uncertainty surrounding it, was likely to become a significant stressor, one with no immediate solution but with the potential to cause enduring distress beyond its conclusion. The UK Defence Medical Services recognised the need to provide an evidence-based programme of care intended to support personnel transitioning from assisting the national response back to normal duties. This was informed by a narrative review that targeted literature exploring strategies for supporting the mental health and well-being of healthcare workers during 21st-century infectious disease outbreaks. The literature identified the experiences most likely to cause enduring distress, which comprised morally challenging decisions, vulnerability, death and suffering, professional and personal challenges, and expectations. The opportunity to find meaning in these experiences, by discussing them with peers who share a contextual understanding, is important to limit the longer-term psychosocial impact of such events. This paper will discuss the design considerations and planned implementation strategy of the Recovery, Readjustment and Reintegration Programme to limit the incidence of distress or longer-term mental ill health among military personnel.
- trauma management
- mental health
- organisational development
This article is made freely available for personal use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.https://bmj.com/coronavirus/usage
Statistics from Altmetric.com
A significant number of healthcare workers are likely to experience some form of psychological outcome following their role in supporting the COVID-19 response.
There is a need for strong visible leadership, peer support and legitimised time for individuals to reflect and find meaning in their experiences.
The Recovery, Readjustment and Reintegration Programme provides a formal opportunity for reflective discussion, which enables coping and promotes help-seeking.
Discussion of shared experiences should also recognise the positive impact of individuals’ personal contribution to the COVID-19 response.
The emergency response to contain the spread of COVID-19, from its origins in China,1 created an unprecedented need for human behaviour to dramatically change across the globe. Despite the implementation of governmental guidelines and strict constraints on movement over the last year, the numbers of new cases and daily deaths, reported by every news channel, make COVID-19-related headlines inescapable from human consciousness. Reports of distress and data from recent widespread disease outbreaks suggest that significant numbers of healthcare workers (HCWs) responding to COVID-19 would experience some form of adverse psychological outcome.2 Indeed, the longer the pandemic ensues, the greater the potential for the emotional toil to impact personnel’s well-being.3
Job strain, characterised by high demands and low control,4 and work-related stress, defined by the Health and Safety Executive as ‘the adverse reaction to excessive pressures or demands placed upon individuals’,5 increase the risk of suffering with mental health disorders, higher staff turnover and presenteeism.6 7 The latter relates to staff remaining in work despite being unwell. This poses a particular concern for those in safety critical roles, including HCWs delivering life-saving interventions. However, the normal mechanisms by which individuals would deal with potentially stressful situations, often through social gatherings of family and friends, continue to be denied due to enforced social distancing. Indeed, this extended period of restricted human contact is likely to render individuals more susceptible to the negative psychosocial impact of a particular stressor.8
The UK Defence Medical Services (DMS) had been tasked with providing support to the UK NHS. Military leaders, aware of their moral and legal duties to support their staff, required a support process that would enable personnel to more effectively cope with their transition back to normal duties. Previous UK Armed Forces research has emphasised the need for a carefully managed transition from an area of high operational tempo to a steady state life back at home, detailing the pitfalls.9 Indeed, a process called psychological decompression was introduced by many nations to enable military personnel to transition from a combat environment to life back at home.10 This would often take place at a third location to promote a physical separation between the battlefield and family life.11 It aimed to provide the space and opportunity for personnel to share their experiences with peers in a relaxed and cohesive atmosphere and to feel more able to seek help should that be necessary. However, the benefits of third location decompression are inconclusive. Despite certain components of the decompression process being regarded positively by participants, namely being among peers who understood what they had experienced,12 improving their attitude to seeking help13 and providing a reduced pace of activity to enhance relaxation14 prior to being reunited with their family and friends, there remains little evidence that it improves an individual’s ability to readjust after the deployment.9
Determining what is already known
In order to inform the establishment of a programme that would enable a seamless transition from COVID-19-facing work to normal duties, a synthesis of evidence was undertaken focusing on relevant published literature. This narrative review targeted literature that explored strategies for supporting the mental health of HCWs during the pandemics and epidemics of the 21st century. Electronic literature databases, MEDLINE, PsycINFO and Web of Science, were used with the following search terms: ‘pandemic’, ‘epidemic’, ‘COVID-19’, ‘SARS’, ‘MERS’, ‘Ebola’, ‘mental health’, ‘healthcare staff’, ‘medical staff’, ‘support’ and ‘intervention’. A study was deemed eligible for inclusion if it was published in a peer-reviewed journal within this century and was written in English. The search strategy initially yielded 323 papers. Those that focused on anything other than the impact on HCWs of caring for patients during an infectious disease outbreak were excluded. This reduced the number of papers included in the review to 17.
Impact of caring during 21st-century infectious disease outbreaks
Since the turn of the century there have been outbreaks of severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), influenza, Ebola and COVID-19, and the experiences and lessons learnt from each have been summarised chronologically and are outlined in Table 1.
SARS and MERS
A cross-sectional study of 652 HCWs involved in the 2002 SARS pandemic described 68% as having high levels of distress associated with fear of contagion, inadequacy of personal protective equipment, and feelings of powerlessness, self-doubt and guilt.15 They were also reported as having poor perceived level of support, feeling undervalued, ambiguous policies and lack of opportunity for feedback to seniors. The authors noted that support, effective communication and feedback enabled staff to recognise post-traumatic growth, with a new appreciation for life and relationships, revised priorities for their futures and a more balanced view of their contribution to the response effort.
Providing care within this environment was shown to cause enduring stress, burnout and absenteeism in HCWs; however, effective leadership emerged as a key factor in organisational resilience.16 Leaders were encouraged to discuss stressors and facilitate meaning-based coping for unresolved issues, for example, fear of contagion, interpersonal isolation, treating sick colleagues and the perceived stigma associated with caring for infectious patients.16 The provision of resources that facilitate reflection in this way and the delivery of practical interventions demonstrate tangible organisational support.17 18 Indeed, lower levels of chronic stress were found in those who felt effectively prepared and supported throughout the pandemic and greater in those using avoidance and self-blame.16 17 While it is acknowledged that HCWs tend to be motivated by a sense of obligation, a lack of trust and goodwill towards those employers perceived not to listen, or who did not acknowledge employees’ contributions, was reported to be a clear barrier to staff retention.16
A study of 941 nurses during the MERS outbreak found that 66% described frustrations about increasing workload and administrative burden, inadequate resourcing and changing directives.19 Inconsistent messaging and ineffective communication by leaders were described by 21% of participants, combined with perceptions they had been taken advantage of by their employers. Despite many nurses indicating the experience was positive due to having established close personal bonds with coworkers, others felt undervalued, unappreciated and undercompensated for the risks they were taking. The authors noted a need for an integrative support network and clear, consistent communication from leaders. A further study surveyed 769 HCWs up to 26 months after the SARS outbreak and reported significantly higher levels of burnout, psychological distress and post-traumatic stress disorder when compared with a control group.20 The study recommended effective moral and psychological support among peers with programmes enduring beyond the duration of the incident.
Similar concerns were identified among 1031 HCWs during the MERS outbreak. Among these were the risk of contracting the virus or sense of inevitability about doing so, fear of infecting family members or sensing their avoidance, feeling standard precautions were unsafe and concerns about insufficient resources and preparedness.21 This study recommended a leader-led model in addressing these concerns, which was echoed by others.18 22
The experiences of 469 front-line HCWs during the influenza A/H1N1 virus outbreak were explored and found that 56.7% described moderately high anxiety relating to infection risk for themselves, family and friends.23 Studies found the degree of worry was associated with the clarity and consistency of information provided by managers.23–25
Following the 2014 outbreak of Ebola in West Africa, the experiences of 35 HCWs were explored.26 Several themes defining their distress were identified, including hypervigilance and being less trusting of others, grief, loneliness, feeling stigmatised by their community, frustrations associated with constraints placed on patients’ access to care, and feeling unable to comfort patients.26 The authors recommended an environment be created that promotes tools for managing stress and grief, which must endure beyond the immediate crisis. A study of 51 UK medical staff involved in this Ebola response added the need for readjustment after the response to the familiar stressors of caring during an infectious disease outbreak.27 The study emphasised the importance of clear communication from leaders, organisational recognition, team support, highlighting the positive benefits from their contribution and a formalised follow-up post response. In depth interviews of 14 members of the UK DMS recently returned from the Ebola response highlighted a range of stressors such as fear, uncertainty, ethical dilemmas and poor communication.28 Study participants described the need for strong visible leadership, peer support and discussion of shared experience, with recognition of the positive impact of their contribution.
The impact to date of delivering care during the COVID-19 pandemic has also been explored and informed contextually relevant mitigation strategies. One study recommended that leaders designate well-being champions and facilitate peer points of contact, while encouraging clinicians to discuss vulnerability and the importance of protecting one’s emotional health.3 A further study identified that a range of morally challenging decisions may arise during the COVID-19 response, which could lead to psychological distress among HCWs.29 Recommendations focused on leader-led interventions, developing strong team cohesion and promoting help-seeking. Following the crisis, leaders were recommended to set time aside within working hours to reflect on, and learn from, their experiences, with clear signposting available for those who require further assistance.29 30
A thematic analysis of the reviewed literature identified five main issues that HCWs continued to find distressing after an infectious disease outbreak response was concluded. These comprised morally injurious experiences, which include ‘perpetrating, failing to prevent, bearing witness to and learning about acts that transgress deeply held moral beliefs and expectations’.31 Such experiences may lead to strong emotions such as guilt, shame, anger and disgust. Despite moral injury not being a mental illness, the significant distress, negatively altered self-identity and self-worth that follow may affect daily functioning and lead to the development of a mental health disorder, such as depression or post-traumatic stress disorder. There is also an anxiety and fear associated with operating in a highly infectious environment. This sense of vulnerability, while understandable and usually proportionate, may lead to individuals experiencing heightened stress levels for protracted periods with insufficient downtime to truly return to a resting state. Personnel might also experience compassion fatigue, which is a state of tension that might develop after repeated exposure to the death and suffering of others and their incessant desire and actions in attempting to relieve this suffering.32 Loss is always an emotive subject but is often in a relatively controlled environment that permits sufficient preparation. An individual would usually have enough time afterwards to grieve. It is hoped that the majority of personnel gain significant pride from the unique personal and professional challenges this response presents; however, there are likely to be many that experience frustration and anxiety stemming from a perceived lack of control or influence. Despite there being some potential difficulties within this transition, discussion is an ideal opportunity to reflect on any post-traumatic growth that may develop following exposure to highly challenging situations.33
A nation’s military forces are ideally placed to deliver emergency assistance during a crisis because of their ability to plan and resource a rapid, coherent and coordinated response. During a health crisis there is an overwhelming motivation, fuelled by a strong sense of duty, for clinical practitioners to help.21 24 However, there are many consequences to their willingness and ability to offer enduring support. Lessons from this narrative review, combined with recommendations from the UK Psychological Trauma Society (2014) guidance on supporting trauma-exposed organisations,34 provided a contextually relevant model to underpin the development of a psychological support programme entitled the Recovery, Readjustment and Reintegration Programme (R3P).
R3P design and delivery
A one-day R3P will form part of a graduated return to ‘normal’ or more recognisable shift patterns, either between each potential wave that witnessed a significant increased workload and/or after the outbreak to formally draw a close to the response. An example programme structure can be found in online supplemental file 1. The one-day duration is a pragmatic balance between realising its intended effect and the likelihood of being achieved within the increased workload associated with a military unit’s return to ‘normal’ functioning. Therefore, this timeframe can be adapted to suit the context of each organisation. The programme aims to celebrate achievements, promote continued networking, manage expectations and provide a safe space to discuss and make sense of the experience.
Opening remarks by the head of the organisation or senior member of the executive, either in person or by video link, will communicate a strong message of strategic support for personnel’s well-being. It will also help to standardise the message of thanks across each unit or region for everyone’s invaluable contribution to the national emergency response, irrespective of their role. Most importantly, R3P would be leader-led, not medically led, providing a strong message of organisational support. The associations between positive mental health and perceived stronger leadership and group cohesion have been identified in a number of studies of UK Armed Forces’ personnel working on demanding operations and exercises.35 36 The programme would follow and build on other leader-led interventions recommended throughout the COVID-19 response, much of which fall under the term ‘behavioural health leadership’, focusing on mental health-related behaviours such as promoting healthy sleep, encouraging the use of resilience skills and providing peer support.37 The latter relates to ‘prevent’ interventions, which aim to avert the onset of mental ill health, and ‘detect’ interventions, which focus on those who have early signs of distress. These interventions are summarised in Boxes 1 and 2.
Summary of ‘prevent’ interventions
‘Prevent’ interventions: delivered in preparation for military response, comprising the following:
A series of briefings delivered by leaders, which are explicit about the realities of the role.
Leader-led discussions about clinical challenges.
Leader-led discussions about moral and ethical challenges.
Leader-led (in particular junior leader-led) strategies to foster team cohesion, horizontally between colleagues and vertically between colleagues and leaders.
Enabling a work structure that uses a buddy–buddy system, team members paired up at the start of shifts to monitor welfare.
Enabling a structure where leaders facilitate supervision, including a continued discussion about clinical, moral and ethical challenges.
A leader-led stigma campaign and enabling access to a range of positive well-being interventions.
Summary of ‘detect’ interventions
‘Detect’ interventions: delivered throughout the period of the response, comprising the following:
Comprehensive supervision by leaders, ensuring healthy shift patterns and adequate sleep and meaningful activity away from the shift.
Regular supervision which allows a continuing discussion about clinical, moral and ethical challenges.
An ongoing leader-led stigma campaign, enabling access to a range of positive well-being strategies that might target sleep and anxiety in particular.
Access to military or NHS (for civilian colleagues) peer-led support networks in the event of an incident that caused significant distress.
Access to a welfare team.
The day would commence with a general overview of the COVID-19 pandemic, the aims of the UK response, the diverse skills of those involved, their motivations for becoming involved and acknowledging the achievements of all. The commonly occurring causes of enduring distress after exposure to a traumatic event have been arranged into five themes, namely morally challenging decisions, vulnerability, death and suffering, professional and personal challenges, and expectations, which include post-traumatic growth. Each of the five themes provides the basis of small facilitated discussion groups allowing personnel, with a shared contextual experience, to reflect on their thoughts and feelings. Such an opportunity has been associated with a reduced level of psychological stress for those returning from a deployment.38 These themes and their significance to the programme are outlined in Table 2.
Active participation in the discussion is not mandated, but for those wishing to take a more passive role it is likely that many of the conversations they will hear will resonate with their own experiences. The priority is the provision of a formal opportunity for peers to share their experiences, which might cross one or several of these themes, to develop their own meaningful narrative in which they are not the victim or the perpetrator. It will also enable the creation of new social networks and provide an appreciation of the organisation’s support in doing so. Hearing others discuss their feelings will enable less confident participants to still share the benefits of knowing they are not alone in their reactions to a very abnormal situation. While the majority of individuals involved in a stressful situation will suffer no long-term mental health consequences, a significant number may continue to suffer distress.39 The reviewed literature identified links between an individual’s level of resilience and having a more positive and balanced view of themselves, the world around them and the future.40 41 In this instance, this may be forming a balanced view of their own contribution to the nation’s response, acknowledging their positive personal attributes and actions and less rumination around those aspects out of their control, all of which underpin the principles of positive self-esteem.42 The latter also defines a sense of hope, an essential motivator throughout the response to this pandemic. Should peers cross organisational boundaries then they are encouraged to attend the R3P together. The programme would preferably precede a social event during which networking, reflections and discussions could continue within its relaxed atmosphere; however, this will clearly depend on government guidance at the time.
Therefore, an opportunity to explore the personal meanings behind experiences of supporting the pandemic response, in a supportive environment, is essential to longer-term mental well-being. The R3P aims to enhance the extant postoperational stress management extended to UK military personnel. It would take place once personnel had been formally ‘stood down’ from their contribution to the national pandemic response and before any subsequent period of leave. Subsequent waves of the outbreaks, should they occur, could mirror the sequencing of the R3P to establish an ongoing support mechanism.
The DMS has long recognised the considerable stress under which its personnel work, especially on operations. The chain of command has always endeavoured to mitigate against the stressors they face, whether that be through individual training designed to foster resilience or organisational interventions designed to support personnel’s emotional well-being. R3P promotes appraisal and coping processes: problem solving for events within an individual’s control, emotion-based coping to enhance support and reduce isolation, and meaning-based coping for events that are unresolved and cause persistent distress. It represents the latest evidence-based iteration of a package of care designed to aid the transition from high tempo operations to the firm base, in this case offering every individual a supportive environment in which to discuss and make sense of their personal experiences. The R3P model may well have applicability to non-military organisations which have been operating at the front line, including HCWs and social care staff.
Patient consent for publication
Contributors DL and AS developed the R3P concept and drafted the manuscript. NG and RW provided their subject matter expertise as the concept developed and editorial assistance for the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.