What is ‘resilience’?
Working as a 'frontline' health or social care professional during a global disease pandemic, like COVID-19, can be very stressful. Over time, the negative effects of stress can lead to mental health problems such as depression and anxiety, which, in turn, may affect work, family and other social relationships. ‘Resilience’ is the ability to cope with the negative effects of stress and so avoid mental health problems and their wider effects.
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.
What did we want to find out?
First (objective 1), we wanted to know how successfully any interventions improved frontline health professionals’ resilience or mental well-being.
Second (objective 2), we wanted to know what made it easier (facilitators) or harder (barriers) to deliver these interventions.
What did we do?
We searched medical databases for any kind of study that investigated interventions designed to support resilience and mental well-being in healthcare professionals working at the front line during infectious disease outbreaks. The disease outbreaks had to be classified by the World Health Organization (WHO) as epidemics or pandemics, and take place from 2002 onwards (the year before the severe acute respiratory syndrome (SARS) outbreak).
What did we find?
We found 16 relevant 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. The studies mainly looked at workplace interventions that involved either psychological support (for example, counselling or seeing a psychologist) or work-based interventions (for example, giving training, or changing routines).
Objective 1: one study investigated how well an intervention worked. This study was carried out immediately after the Ebola outbreak, and investigated whether staff who were training to give other people (such as patients and their family members) 'psychological first aid' felt less ‘burnt out’. We had some concerns about the results that this study reported and about some of its methods. This means that our certainty of the evidence is very low and we cannot say whether the intervention helped or not.
Objective 2: all 16 studies provided some evidence about barriers and facilitators to implement interventions. We found 17 main findings from these studies. We do not have high confidence in any of the findings; we had moderate confidence in six findings and low to very low confidence in 11 findings.
We are moderately confident that the following two factors were barriers to implementation of an intervention: frontline workers, or the organisations in which they worked, not being fully aware of what they needed to support their mental well-being; and a lack of equipment, staff time or skills needed for an intervention.
We are moderately confident that the following three factors were facilitators to implementation of an intervention: interventions that could be adapted for a local area; having effective communication, both formally within an organisation and informal or social networks; and having positive, safe and supportive learning environments for frontline healthcare professionals.
We are moderately confident that the knowledge and beliefs that frontline healthcare professionals have about an intervention can either help or hinder implementation of the intervention.
We did not find any evidence that tells us about how well different strategies work at supporting the resilience and mental well-being of frontline workers. We found some limited evidence about things that might help successful delivery of interventions. 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.
How up-to-date is this review?
This review includes studies published up to 28 May 2020.
There is a lack of both quantitative and qualitative evidence from studies carried out during or after disease epidemics and pandemics that can inform the selection of interventions that are beneficial to the resilience and mental health of frontline workers. Alternative sources of evidence (e.g. from other healthcare crises, and general evidence about interventions that support mental well-being) could therefore be used to inform decision making. When selecting interventions aimed at supporting frontline workers' mental health, organisational, social, personal, and psychological factors may all be important. Research to determine the effectiveness of interventions is a high priority. The COVID-19 pandemic provides unique opportunities for robust evaluation of interventions. Future studies must be developed with appropriately rigorous planning, including development, peer review and transparent reporting of research protocols, following guidance and standards for best practice, and with appropriate length of follow-up. Factors that may act as barriers and facilitators to implementation of interventions should be considered during the planning of future research and when selecting interventions to deliver within local settings.
Evidence from disease epidemics shows that healthcare workers are at risk of developing short- and long-term mental health problems. 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. Symptoms of mental health problems commonly include depression, anxiety, stress, and additional cognitive and social problems; these can impact on function in the workplace. The mental health and resilience (ability to cope with the negative effects of stress) of frontline health and social care professionals ('frontline workers' in this review) could be supported during disease epidemics by workplace interventions, interventions to support basic daily needs, psychological support interventions, pharmacological interventions, or a combination of any or all of these.
Objective 1: to assess the effects of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic.
Objective 2: to identify barriers and facilitators that may impact on the implementation of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic.
On 28 May 2020 we searched the Cochrane Database of Systematic Reviews, CENTRAL, MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, Global Index Medicus databases and WHO Institutional Repository for Information Sharing. We also searched ongoing trials registers and Google Scholar. We ran all searches from the year 2002 onwards, with no language restrictions.
We included studies in which participants were health and social care professionals working at the front line during infectious disease outbreaks, categorised as epidemics or pandemics by WHO, from 2002 onwards. For objective 1 we included quantitative evidence from randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies, which investigated the effect of any intervention to support mental health or resilience, compared to no intervention, standard care, placebo or attention control intervention, or other active interventions. For objective 2 we included qualitative evidence from studies that described barriers and facilitators to the implementation of interventions. Outcomes critical to this review were general mental health and resilience. Additional outcomes included psychological symptoms of anxiety, depression or stress; burnout; other mental health disorders; workplace staffing; and adverse events arising from interventions.
Pairs of review authors independently applied selection criteria to abstracts and full papers, with disagreements resolved through discussion. One review author systematically extracted data, cross-checked by a second review author. For objective 1, we assessed risk of bias of studies of effectiveness using the Cochrane 'Risk of bias' tool. For objective 2, we assessed methodological limitations using either the CASP (Critical Appraisal Skills Programme) qualitative study tool, for qualitative studies, or WEIRD (Ways of Evaluating Important and Relevant Data) tool, for descriptive studies. We planned meta-analyses of pairwise comparisons for outcomes if direct evidence were available. Two review authors extracted evidence relating to barriers and facilitators to implementation, organised these around the domains of the Consolidated Framework of Implementation Research, and used the GRADE-CERQual approach to assess confidence in each finding. We planned to produce an overarching synthesis, bringing quantitative and qualitative findings together.
We included 16 studies that reported implementation of an intervention aimed at supporting the resilience or mental health of frontline workers during disease outbreaks (severe acute respiratory syndrome (SARS): 2; Ebola: 9; Middle East respiratory syndrome (MERS): 1; COVID-19: 4). Interventions studied 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).
Objective 1: a mixed-methods study that incorporated a cluster-randomised trial, investigating the effect of a work-based intervention, provided very low-certainty evidence about the effect of training frontline healthcare workers to deliver psychological first aid on a measure of burnout.
Objective 2: we included all 16 studies in our qualitative evidence synthesis; we classified seven as qualitative and nine as descriptive studies. We identified 17 key findings from multiple barriers and facilitators reported in studies. We did not have high confidence in any of the findings; we had moderate confidence in six findings and low to very low confidence in 11 findings. We are moderately confident that the following two factors were barriers to intervention implementation: frontline workers, or the organisations in which they worked, not being fully aware of what they needed to support their mental well-being; and a lack of equipment, staff time or skills needed for an intervention. We are moderately confident that the following three factors were facilitators of intervention implementation: interventions that could be adapted for local needs; having effective communication, both formally and socially; and having positive, safe and supportive learning environments for frontline workers. We are moderately confident that the knowledge or beliefs, or both, that people have about an intervention can act as either barriers or facilitators to implementation of the intervention.