The World Health Organization pandemic preparedness plans have long highlighted the need to provide psychosocial support for healthcare workers (HCWs) as part of the pandemic response (1). Despite these recommendations existing at the start of the first wave of the United Kingdom (UK) COVID-19 outbreak in March 2020, there was limited planning, evidence and, implementation guidance on what this support should look like and who should deliver it.
Pandemics are known to have a significant impact on HCWs. These stem from distinct stressors including exposure to severely ill patients, fear of contagion, longer work hours, physical fatigue, redeployment practices and associated changes in role, disruption of normal supportive structures, separation from families, loneliness and staff retention issues (2–4). All of these factors can contribute to increased workload and acute stress related to not being unable to cope effectively with external demands. Without intervention, this acute stress response can become chronic and is associated with a range of physiological and psychological impacts such as burnout, occupational stress and depression (5).
Literature from previous pandemics report a high incidence of acute and post-traumatic stress (6) and longer term sequalae with potential impact on service provision such as reduced patient contact hours, symptoms of burnout and behavioural consequences of stress (7, 8). Early evidence from HCW studies during COVID-19 document a range of adverse psychosocial outcomes including symptoms of depression, anxiety, insomnia and general psychological distress (9–11). Concerns have also been raised about the risk of moral injury (12). Reassuringly, there is some evidence that clear communication, access to adequate personal protective equipment, sufficient rest, and both practical and psychological support have been associated with reduced HCW morbidity and relatedly that effective interventions are available to help mitigate the psychological distress experienced by healthcare staff in an infectious disease outbreak (6).
It has been reported that healthcare organisations and systems world-wide have undertaken steps to ameliorate the acute stress response and support the mental health and wellbeing of HCWs (13–17). The nature and extent of these interventions will be variable and likely influenced by local health system resource and pre-pandemic values and attitudes towards staff well-being and mental health. Such programmes have likely incorporated approaches such as increasing access to psychological first aid, adequate rest, peer and social support, building team and organisational resilience (16, 18) and, avoiding harmful interventions such as psychological debriefing (19). More effectiveness studies and evaluations of these COVID-19 responses will certainly be published in the coming months and years.
What is less well understood or evaluated is the evidence base regarding how precisely such programmes were implemented; what supported and hindered their implementation; and how or if they are maintained following the initial acute COVID-19 crisis phase into the medium and subsequently longer term – i.e. whether and how they are sustainable. Such gaps in understanding how complex interventions are implemented tend to exist throughout healthcare and contribute to the so-called ‘implementation gap’. The ‘implementation gap’ refers to the challenge whereby numerous evidenced interventions fail to be successfully implemented routinely and at scale, simply because no one really knows how to do so (20, 21).
COVID-19-related staff wellbeing interventions within King’s Health Partners (London, UK)
In this study, we will evaluate the implementation of three connected but distinct staff support and wellbeing programmes (SSWP) launched during the COVID-19 pandemic response in King’s Health Partners (KHP) in London (UK), starting in March 2020 and currently still being offered. KHP is a large academic health science centre that includes three National Health Service (NHS) Foundation Trusts: Guy’s and St Thomas’ NHS Foundation Trust (GSTT), King’s College Hospital Foundation Trust (KCH) and South London and Maudsley NHS Foundation Trust (SLaM). KHP provide a range of clinical services - GSTT and KCH are Acute NHS Trusts and SLaM is a Mental Health NHS Trust. A total of 37,870 clinical and non-clinical staff work across these three institutions, providing care for an estimated patient population of eight million.
Each of the three staff support programmes derived from one set of recommendations created from a rapid review of literature and expert consultation during the week of 10th March 2020 at the start of the first wave of COVID-19. The programmes involved multidisciplinary collaborations within each organisation between departments of psychiatry, psychology, occupational health, and other stakeholders. Key objectives of the programmes were to meet the acute psychosocial health and wellbeing needs of individual staff members, support staff at work, minimise the impact of the pandemic on staff wellbeing where possible and, build structures, cultural change and resource that would remain available for post-outbreak staff needs.
Given the rate of increasing clinical acuity with the evolving first wave of COVID-19 and the impact on staff, the programmes were designed and implemented at significant speed. Approximate roll out time from the first request for staff support to implementation of each core aspect of the programmes occurred in under four weeks. Implementation of the first staff support intervention occurred as quickly as two days after organisation sign off in one of the organisations. Iterative adjustments to the programmes were made throughout the first wave which lasted approximately four months. Work to transition these crisis response initiatives to a next stage response aligning with the organisations’ rest and recovery programmes commenced in June 2020. This transitional work was conducted concurrently with a reduction in staffing of all the different elements of the programmes.
The programme designs involved a tiered and targeted framework for staff support, created to provide primary, secondary, and tertiary levels of intervention depending on the level of need (Fig. 1). This tiered model recognised that access to psychological interventions would need to co-exist alongside an organisational-wide effort to build resilience and mental health literacy in psychologically healthy people (Tier 1). Several interventions were developed in each organisation to deliver the tiered model. The exact interventions delivered differed between organisations determined by pre-existing structures and resource. These included:
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Resources and interventions to increase self-care, self-management, and mental health literacy and, to meet practical needs (food, rest, social connection, and peer support).
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Resources and interventions to support leadership and team functioning including uptake and implementation of staff support and well-being practices within teams and departments.
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Rapid access to psychological support including onward referral to more specialised or formal mental health care as required e.g. through embedded mental health experts in the hospitals or based remotely and accessible through phone or videoconference off site.
Methods to access these tiers of support, and to build resilience were then targeted strategically towards key operating units of the organisation namely individuals, teams and leaders using a range of different strategies.
Study aims
The study will address the following research questions:
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What factors hindered (barriers) and enabled (facilitators) the implementation of three inter-linked staff support and wellbeing programmes in three London NHS Trusts during the first wave of the COVID-19 pandemic? Sub-question: how and to what extent have these programmes been sustained since?
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Are implementation science frameworks applicable and useful in conceptualising and understanding crisis-driven and rapidly implemented interventions, such as the staff support and wellbeing programmes in this study? Sub-question: in what ways, if any, do they need to be adjusted when used in unprecedented circumstances such as the COVID-19 pandemic?
The research questions will be answered by addressing the following objectives:
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Identification of the implementation strategies used to introduce the staff wellbeing programmes across the three hospitals. This will allow determination of which strategies might have been more successful to-date; and identify which components of the programme were delivered, and how, across the different Trusts.
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Analysis of whether/how these strategies have changed as the implementation progressed from initial crisis response into transitional and more medium-term forms.
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Appraisal of what has remained / been sustained of the staff support programmes since inception to-date, and the perceptions of staff regarding the need for such programmes to exist (and in what format) in the future.
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Identification of lessons and recommendations for informing policy makers, managers, and providers on developing, implementing, and sustaining staff support and wellbeing programmes during a pandemic or other major incident.
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Application of three implementation science frameworks (see Methods) to data collection and analysis throughout the study to inform, structure and interpret the study findings.