An integrated primary care service to reduce cardiovascular disease risk in people with severe mental illness: Primrose-A. Thematic analysis of its acceptability, feasibility, and implementation. (preprint)

Background Cardiovascular disease among patients with severe mental illness in England is a major preventable contributor to premature mortality. To address this, a nurse and peer-coach delivered service (Primrose-A) was implemented in three London general practices from 2019 (implementation continued during COVID-19). This study aimed to conduct interviews with patient and staff to determine the acceptability of, and experiences with, Primrose-A.Methods Eight patients who had received Primrose-A, and 3 nurses, 1 GP, and 1 peer-coach who had delivered Primrose-A in three London-based GP surgeries. Semi-structured audio-recorded interviews were conducted. Reflexive thematic analysis was used to identify themes from the transcribed interviews.Findings Overall, Primrose-A was viewed positively by patients and staff, with participants describing success in improving patients’ mental health, isolation, motivation, and physical health. Therapeutic relationships between staff and patients, and long regular appointments were important facilitators of patient engagement and acceptance of the intervention. Several barriers to the implementation of Primrose-A were identified, including training, administrative and communication issues, burden of time and resources, and COVID-19.Conclusions Intervention acceptability could be enhanced by providing longer-term continuity of care paired with more peer-coaching sessions to build positive relationships and facilitate sustained health behaviour change. Future implementation of Primrose-A or similar interventions should consider: 1) training sufficiency (covering physical and mental health, including addiction), 2) adequate staffing to deliver the intervention, 3) facilitation of clear communication pathways between staff, and 4) supporting administrative processes.

Experiences of mental health and wellbeing support for NHS staff during the COVID-19 pandemic: a reflexive thematic analysis (preprint)

Staff in the National Health Service (NHS) have been placed under considerable strain during the COVID-19 pandemic; whilst NHS Trusts provide a variety of health and wellbeing support services, there has been little research investigating staff perceptions of these services. Moreover, the research that does exist typically includes only clinical staff, despite a large proportion of patient-facing NHS workers being in non-clinical roles. We interviewed forty-eight clinical and non-clinical healthcare workers from eighteen NHS Trusts in England about their experiences of workplace health and wellbeing support during the pandemic. Reflexive thematic analysis identified that perceived stigma around help-seeking, and staffing shortages due to wider socio-political contexts such as austerity, were barriers to using support services. Visible, caring leadership at all levels (CEO to line managers), peer support, easily accessible services, and clear communication about support offers were enablers. Our evidence suggests Trusts should have active strategies to improve help-seeking. This could involve providing all staff with regular reminders about support options, in a variety of formats (e.g. email, posters, mentioned in meetings), and easily remembered single points of access, delivered by a mix of in-house and externally-provided services, to cater for those more and less concerned about stigma and confidentiality. In addition, managers at all levels should be trained and supported to feel confident to speak about mental health with staff, with formal peer support facilitated by building in time for this during working hours. As others have pointed out, this will require long-term strategic planning to address workforce shortages.

It hurts your heart: frontline healthcare worker experiences of moral injury during the COVID-19 pandemic (preprint)

Background: Moral injury is defined as the strong emotional and cognitive reactions following events which clash with someones moral code, values or expectations. During the COVID-19 pandemic, increased exposure to potentially morally injurious events (PMIEs) has placed healthcare workers (HCWs) at risk of moral injury. Yet little is known about the lived experience of cumulative PMIE exposure and how NHS staff respond to this. Objective: We sought to rectify this knowledge gap by qualitatively exploring the lived experiences and perspectives of clinical frontline NHS staff who responded to COVID-19. Methods: We recruited a diverse sample of 30 clinical frontline HCWs from the NHS CHECK study cohort, for single time point qualitative interviews. All participants endorsed at least one item on the 9-item Moral Injury Events Scale (MIES) (Nash et al., 2013) at six month follow up. Interviews followed a semi-structured guide and were analysed using reflexive thematic analysis. Results: HCWs described being routinely exposed to ethical conflicts, created by exacerbations of pre-existing systemic issues including inadequate staffing and resourcing. We found that HCWs experienced a range of mental health symptoms primarily related to perceptions of institutional betrayal as well as feeling unable to fulfil their duty of care towards patients. Conclusion: These results suggest that a multi-facetted organisational strategy is warranted to prepare for PMIE exposure, promote opportunities for resolution of symptoms associated with moral injury and prevent organisational disengagement.

Mental health of healthcare workers in England during the COVID-19 pandemic: a longitudinal cohort study (preprint)

Objective To examine variations in impact of the COVID-19 pandemic on the mental health of all types of healthcare workers (HCWs) in England over the first 17 months of the pandemic. Method We undertook a prospective cohort study of 22,501 HCWs from 18 English acute and mental health NHS Trusts, collecting online survey data on common mental disorders (CMDs), depression, anxiety, alcohol use, and PTSD, from April 2020 to August 2021. We analysed these data cross-sectionally by time period (corresponding to periods the NHS was under most pressure), and longitudinally. Data were weighted to better represent Trust population demographics. Results The proportion of those with probable CMDs was greater during periods when the NHS was under most pressure (measured by average monthly deaths). For example, 55% (95%CI 53%, 58%) of participants reported symptoms of CMDs in April-June 2020 versus 47% (95%CI 46%, 48%) July-October 2020. Contrary to expectation, there were no major differences between professional groups (i.e. clinical and non-clinical staff). Younger, female, lower paid staff, who felt poorly supported by colleagues/managers, and who experienced potentially morally injurious events were most at risk of negative mental health outcomes. Conclusion Among HCWs, the prevalence of probable CMDs increased during periods of escalating pressure on the NHS, suggesting staff support should be increased at such points in the future, and staff should be better prepared for such situations via training. All staff, regardless of role, experienced poorer mental health during these periods, suggesting that support should be provided for all staff groups.

Capturing the experiences of UK healthcare workers during the COVID-19 pandemic: A structural topic modelling analysis of 7,412 free-text survey responses (preprint)

Background Healthcare workers (HCWs) have provided vital services during the COVID-19 pandemic, but existing research consists of quantitative surveys (lacking in depth or context) or qualitative interviews (with limited generalisability). Structural Topic Modelling (STM) of large-scale free-text survey data offers a way of capturing the perspectives of a wide range of HCWs in their own words about their experiences of the pandemic. Methods In an online survey distributed to all staff at 18 geographically dispersed NHS Trusts, we asked respondents, Is there anything else you think we should know about your experiences of the COVID-19 pandemic?. We used STM on 7,412 responses to identify topics, and thematic analysis on the resultant topics and text excerpts. Results We identified 33 topics, grouped into two domains, each containing four themes. Our findings emphasise: the deleterious effect of increased workloads, lack of PPE, inconsistent advice/guidance, and lack of autonomy; differing experiences of home working as negative/positive; and the benefits of supportive leadership and peers in ameliorating challenges. Themes varied by demographics and time: discussion of home working decreasing over time, while discussion of workplace challenges increased. Discussion of mental health was lowest between September-November 2020, between the first and second waves of COVID-19 in the UK. Discussion Our findings represent the most salient experiences of HCWs through the pandemic. STM enabled statistical examination of how the qualitative themes raised differed according to participant characteristics. This relatively underutilised methodology in healthcare research can provide more nuanced, yet generalisable, evidence than that available via surveys or small interview studies, and should be used in future research.

Moral injury and psychological wellbeing in UK healthcare staff (preprint)

Background Potentially morally injurious events (PMIEs) can negatively impact mental health. The COVID-19 pandemic may have placed healthcare staff at risk of moral injury. Aim To examine the impact of PMIE on healthcare staff wellbeing. Method 12,965 healthcare staff (clinical and non-clinical) were recruited from 18 NHS-England trusts into a survey of PMIE exposure and wellbeing. Results PMIEs were significantly associated with adverse mental health symptoms across healthcare staff. Specific work factors were significantly associated with experiences of moral injury, including being redeployed, lack of PPE, and having a colleague die of COVID-19. Nurses who reported symptoms of mental disorders were more likely to report all forms of PMIEs than those without symptoms (AOR 2.7; 95% CI 2.2, 3.3). Doctors who reported symptoms were only more likely to report betrayal events, such as breach of trust by colleagues (AOR 2.7, 95% CI 1.5, 4.9). Conclusions A considerable proportion of NHS healthcare staff in both clinical and non-clinical roles report exposure to PMIEs during the COVID-19 pandemic. Prospective research is needed to identify the direction of causation between moral injury and mental disorder as well as continuing to monitor the longer term outcomes of exposure to PMIEs.

Protocol: A two-wave cross-sectional study in England investigating suicidal behaviour and self-harm amongst healthcare workers during the Covid-19 pandemic (preprint)

IntroductionThere have been longstanding concerns regarding an increased risk of suicide amongst healthcare workers. The Covid-19 pandemic has placed an additional burden on staff, yet few studies have investigated the impact of the pandemic on their risk of suicide and self-harm. We aimed to investigate the cumulative incidence, prevalence and correlates of suicidal ideation, suicide attempts and non-suicidal self-injury amongst healthcare workers during the Covid-19 pandemic. Methods and AnalysisNHS Check is an online survey that was distributed to all staff (clinical and non-clinical), students, and volunteers in 18 NHS Trusts across England during the Covid-19 pandemic. Data collected in wave 1 (collected between April 2020 and January 2021) and wave 2 (collected 6-month after wave 1) will be analysed. The full cohort of wave 1 participants will be weighted to represent the age, sex, ethnicity, and roles profile of the workforce at each Trust, and the weighted prevalence and cumulative incidence of suicidal ideation, suicide attempts and non-suicidal self-injury will be described. Two-level random effects logistic regression models will be used to investigate the relationship between suicidal behaviour and self-harm, and demographic characteristics (age, sex, ethnicity) and workplace factors (concerns regarding access to personal protective equipment, re-deployment status, moral injury, confidence around raising and the management of safety concerns, support by supervisors or managers, satisfaction with standard of care provided). Results will be stratified by role (clinical/non-clinical).

NHS CHECK: protocol for a cohort study investigating the psychosocial impact of the COVID-19 pandemic on healthcare workers (preprint)

Introduction The COVID-19 pandemic has had profound effects on the working lives of healthcare workers (HCWs), but the extent to which their well-being and mental health have been affected remains unclear. This longitudinal cohort study aims to recruit a cohort of NHS healthcare workers, conducting surveys at regular intervals to provide evidence about the prevalence of symptoms of mental disorders, investigate associated factors such as occupational contexts and support interventions available. Methods and Analysis All staff, students, and volunteers working in each of the 18 participating NHS Trusts in England will be sent emails inviting them to complete a survey at baseline, with email invitations for the follow up surveys being sent 6 and 12 months later. Opening in late April 2020, the baseline survey collects data on demographics, occupational and organisational factors, experiences of COVID-19, a number of validated measures of symptoms of poor mental health (e.g. depression, anxiety, post-traumatic stress disorder; PTSD), and measures of constructs such as resilience and moral injury. These regular surveys will be complemented by in-depth psychiatric interviews with a select sample of healthcare workers. Qualitative interviews will also be conducted, to gain deeper understanding of the support programmes used or desired by staff, and facilitators and barriers to accessing such programmes. Ethics and Dissemination Ethical approval for the study was granted by the Health Research Authority (reference: 20/HRA/210, IRAS: 282686) and local Trust Research and Development approval. Cohort data are being collected via Qualtrics online survey software, are pseudonymised and held on secure University servers. Participants are aware that they can withdraw from the study at any time, and there is signposting to support services for any participant who feels they need it. Only those consenting to be contacted about further research will be invited to participate in the psychiatric and qualitative interview components of the study. Findings will be rapidly shared with NHS Trusts to enable better support of staff during the pandemic, and via academic publications in due course. Strengths and limitations of this study The longitudinal cohort design addresses the lack of long-term data on this population, and the current predominance of cross-sectional evidence available. The availability of Trust HR data means we will be able to calculate response rates, and weight the data appropriately. The diagnostic interview component of the study will allow us to establish the true prevalence of mental disorders, which can be inflated by the measures used in most mental health and wellbeing cohort studies. The qualitative interviews will give deeper insight into the support programmes that HCWs find most helpful, and provide ideas for Trusts to improve their offer to staff. The three components of the study give breadth and depth lacking in much of the mental health and wellbeing research currently available, but there is a risk of over-burdening already stretched HCWs.

The psychosocial impact of the COVID-19 pandemic on 4,378 UK healthcare workers and ancillary staff: initial baseline data from a cohort study collected during the first wave of the pandemic. (preprint)

Objectives This study reports preliminary findings on the prevalence of, and factors associated with, mental health and wellbeing outcomes of healthcare workers during the early months (April-June) of the COVID-19 pandemic in the UK. Methods Preliminary cross-sectional data were analysed from a cohort study (n=4,378). Clinical and non-clinical staff of three London-based NHS Trusts (UK), including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire (GHQ-12). Secondary outcomes are probable anxiety (GAD-7), depression (PHQ-9), Post-Traumatic Stress Disorder (PTSD) (PCL-6), suicidal ideation (CIS-R), and alcohol use (AUDIT). Moral injury is measured using the Moray Injury Event Scale (MIES). Results Analyses showed substantial levels of CMDs (58.9%, 95%CI 58.1 to 60.8), and of PTSD (30.2%, 95%CI 28.1 to 32.5) with lower levels of depression (27.3%, 95%CI 25.3 to 29.4), anxiety (23.2%, 95%CI 21.3 to 25.3), and alcohol misuse (10.5%, 95%CI, 9.2 to 11.9). Women, younger staff, and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of one's moral code) was strongly associated with increased levels of CMDs, anxiety, depression, PTSD symptoms, and alcohol misuse. Conclusions Our findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic.