Summary of findings
| Author | Country | Participants | Findings |
| Maunder et al 16 | Canada | Narrative review of SARS lessons learnt | Main stressors: fear of contagion, a perceived risk of infecting their children, family health status, treating colleagues, stigma, interpersonal isolation, burnout, depression and anxiety up to two years after the outbreak. Leaders encouraged to discuss stressors and facilitate meaning-based coping for unresolved issues. |
| Tam et al 15 | Hong Kong | 652 HCWs: SARS |
Main stressors: fear of death and disease, risk to self and infecting families, distress at HCWs becoming infected, powerlessness to support colleagues, guilt for surviving, inadequate protective measures, ambiguous infection control policies, lack of appreciation, poor communication, public’s high expectations, doubts about self-efficacy, lack of control and high workload. Positive impacts: improved relationship with colleagues, greater value for family, fulfilled ambition and greater empathy. Through support, effective communication and feedback, leaders encouraged to facilitate staff exploration of the positive aspects of the outbreak, such as their contribution. |
| Maunder17 | Canada | 1557 HCWs: SARS | Main stressors: fear and hypervigilance of their own symptoms, risk of contaminating family and providing care if they became unwell, isolation from peers and reduced informal support networks, stigma, unfamiliar tasks, inadequate support, value of role and comparison between essential and non-essential staff, increased workload, difficult communication and reduced interpersonal contact, uncertainty, scrutiny by the public and avoidance of social situations. Leaders encouraged to give clear and effective communication, to provide resources that facilitate reflection on stressors faced during the outbreak and deliver practical interventions that demonstrate clear support from the organisation. |
| Wong et al 18 | Hong Kong | 466 HCWs: SARS | Main stressors: vulnerability, loss of control, health of self, contagion. Maladaptive coping identified, including self-blame, denial, substance use, behavioural disengagement and self-distraction. Positive coping strategies included acceptance, active coping, positive reframing, emotional support, consistent communication, tackling interpersonal isolation and promoting peer support. |
| Bergeron et al 19 | Canada | 941 HCWs: SARS |
Main stressors: fear of contagion and infecting family, coworkers becoming infected, staff shortages, workload, management taking advantage of staff and being unsupportive, uncertainty, ineffective communication, inconsistent resource allocation and lack of professional recognition, ambiguous infection control measures and protocols, lack of emotional support and reassurance, stigma, isolation and avoidance of social situations. Positive impacts: increased sense of cohesion, honing nursing skills, challenging and exciting opportunities, institutional and global learning, opportunities for gaining insight into policy and professional development. Leaders should use clear communication and an integrative support network to provide staff the opportunity to learn at the professional, personal and institutional level. |
| Maunder et al 20 | Canada | 769 HCWs: SARS | Main stressors: fear of contagion, concerns for family, interpersonal isolation and avoidance, perceived stigma, working outside of comfort zone and adequacy of training, moral support and self-blame. Moral and psychological support in the context of institutional relationships and long-term support programmes were recommended. Leaders should promote adaptive coping through problem solving, seeking support and positive reappraisal. |
| Abolfotouh et al 21 | Saudi Arabia | 1031 HCWs: MERS | Main stressors: fear of contagion, feeling unsafe using standard precautions, fear of infecting family, avoidance of social situations, being overwhelmed by regulations, increased workload and insufficient staffing, concerns about policies and about media portrayal. Leaders should proactively address the range of staff concerns raised during the outbreak which may otherwise lead to physical and mental exhaustion. |
| Khalid et al 22 | Saudi Arabia | 150 HCWs: MERS | Main stressors: fear of contagion, seeing colleagues unwell, infecting family or friends, hypervigilance of symptoms, hypervigilance/concentration at work, death, uncertainty about pandemic end, lack of treatment, media coverage, emotional exhaustion, conflict between duty and own safety, staff shortage, PPE, seeing colleagues stressed/afraid, fatigue. Recommendations made for recognition from management, family support, positive attitude within workplace, consistent communication and availability of equipment/guidelines. |
| Goulia et al 23 | Greece | 469 HCWs: A/H1N1 | Main stressors: fear of contagion and impact on functional ability, fear about family’s health, stigma and social isolation, planned absenteeism despite sense of duty, emotional exhaustion, overburdened healthcare system, poor communication and media scrutiny. Staff anxiety was moderated by the clarity and consistency of information provided by leaders. |
| Ives et al 24 | UK | 64 HCWs: influenza pandemic | Main stressors: fear, risk to self, mortality, introducing risk to family, balancing duty towards the common goal and caring for family, protective equipment concerns, lack of reciprocity of loyalty, feeling undervalued, lack of support for ethical dilemmas such as resource allocation and fear of subsequent litigation, insufficient training and extended roles, lack of direction and inconsistent information. In order to tackle absenteeism, leaders should reciprocate staff efforts, encourage discussion of stressors arising during the outbreak and listen to their needs. |
| Matsuishi et al 25 | Japan | 1625 HCWs: H1N1 influenza | Main stressors: contagion, wider implications of becoming ill, infecting family, infection while commuting, exhaustion and increased workload, avoidance, isolation, inconsistent information, perceived lack of protection by the organisation. Recommendation for rapid sharing of accurate information. |
| McMahon et al 26 | USA | 35 HCWs: Ebola | Main stressors: fear, hypervigilance, undermined trust within health facilities and wider community, inability to bond with patient and support relatives, loneliness and isolation, grief, sadness and stigma. Leaders should create an environment that promotes tools for managing stress and grief, with support continuing in the months after the crisis. |
| Rubin et al 27 | UK | 51 HCWs: Ebola |
Main stressors: fear of contagion, death and suffering, delivering bad news, realisation of risk, colleagues becoming unwell, guilt and worry about how the family will cope, guilt about not doing more, censoring information for families, bureaucracy and loss of motivation after medical response to the outbreak. Positive impacts: moral reasons for caring, excitement of challenge, professional development, tangible impact of work, messages of thanks and camaraderie. Recommendations were made for clear communication from leaders, recognition from the organisation, highlighting the positive benefits from staff contributions and a formalised follow-up post response. |
| Lamb28 | UK | 14 military HCWs: Ebola | Main stressors: fear of the unknown and balancing risk, concerns about care standards, desire to give more, desire to bond with patient, difficulty in showing compassion, sick children, uncertainty about treatment pathways, ethical concerns about resource management. These were mitigated by peer support, strong leadership, having a common purpose, making a difference, having confidence in training and supervision. Leaders should be clearly visible, enable peer support and discussion about the shared experience and the positive impact of their contribution. |
| Billings et al 30 | UK | Editorial about supporting staff during COVID-19 | Leaders should provide opportunities for staff to talk about their experiences in order to enhance support and social cohesion. |
| Dewey et al 3 | USA | Narrative review of COVID-19 lessons learnt | Main stressors: vulnerability and emotional health. Leaders should monitor clinician wellness and provide the opportunity for them to discuss vulnerability and the importance of protecting their emotional health. |
| Greenberg et al 29 | UK | Narrative review of challenges of COVID-19 | Main stressor: potentially morally injurious experiences. Leader-led interventions should be introduced to help staff make sense of the morally challenging decisions being made, including setting aside time to reflect and learn from their experiences. |
HCWs, healthcare workers; MERS, Middle East respiratory syndrome; PPE, personal protective equipment; SARS, severe acute respiratory syndrome.