Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review.

BACKGROUND: 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. OBJECTIVES: 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. SEARCH METHODS: 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. SELECTION CRITERIA: 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. DATA COLLECTION AND ANALYSIS: 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. MAIN RESULTS: 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. AUTHORS' CONCLUSIONS: 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.

Risk Factors for Severe Alcohol Withdrawal Syndrome in an Acute Hospital Population.

BACKGROUND: The literature lacks consensus to the factors that increase the risk of a patient developing severe alcohol withdrawal syndrome (SAWS). AIM: The study set out to identify the variables that increase the risk of SAWS in patients who have alcohol dependence syndrome. METHODS: A case-control study was designed to investigate the variables associated with SAWS in an acute hospital setting. Three hundred eighty-two case and 382 control patients were randomly selected retrospectively from referrals to the acute addiction liaison nursing service during a 12-month period (January 1, 2015, to December 31, 2015). Statistical significance (p < .05) and association with SAWS were calculated using chi-square, Cramer's V test, odds ratio, and Levene's test. RESULTS: Twenty-four variables have been identified as associated with SAWS development. Five of the 24 variables had a moderate-to-strong association with SAWS risk: Fast Alcohol Screening Test, Glasgow Modified Alcohol Withdrawal Scale score, AWS admission, hours since the last drink, and systolic blood pressure. The study also identified that comorbidity was associated with not developing SAWS. CONCLUSION/RECOMMENDATIONS: These findings confirm that noninvasive variables collected in the emergency department are useful in identifying a person's risk of developing SAWS. The results of this study are a useful starting point in the exploration of SAWS and the development of a tool for use in the emergency department that can stratify risk into high and low and is the next stage of this program of work.

Compassion in emergency departments. Part 3: enabling and supporting delivery of compassionate care.

In the final part of this three-part series, David Hunter and colleagues analyse the factors that enable and support delivery of compassionate care in emergency departments (EDs). Part one reported findings from doctoral-level research that explored nursing students' experiences of compassionate care in EDs, while part two considered the barriers to such care identified by the students. This article highlights and celebrates the ways in which emergency nurses provide compassionate care despite the challenges they face.

A process of developing a national practice assessment document.

This paper will share how one country within the United Kingdom (UK) collaborated on a national partnership approach in developing a consistent pre-registration undergraduate nursing practice learning assessment document. In 2011 the Scottish Heads of Academic Nursing and Allied Health Professionals (SHANAHP, now Council of Deans Scotland, CoDS) agreed to support the development of a Scottish national approach to practice learning assessment document (the "Scottish Ongoing Achievement Record"). Whilst no direct funding was received to support this work, each HEI agreed that this work would be recognised via the release of staff time to enable completion. Utilising a communities of practice approach to collaborative working, the national group incorporated the collective knowledge and experience of representatives from all Higher Education Institutes (HEIs) in Scotland that provided undergraduate pre-registration nurse education. The work of the group will be described in four phases, Mapping of Influential Drivers; Guiding Principles and Good Practice; Document development; and Implementation. Appraisal of the advantages of this approach in light of international literature will be considered alongside challenges encountered during development and implementation.

Perceived stress and depression amongst older stroke patients: Sense of coherence as a mediator?

OBJECTIVE: This study aimed to explore the relationship between perceived stress, sense of coherence, and depression among older stroke patients. METHODS: A demographic questionnaire, the Perceived Stress Scale (PSS), the Sense of Coherence Scale (SOC) and the Center for Epidemiologic Studies Depression Scale (CES-D) were distributed to 3000 older stroke patients from Neurology wards in six large general hospitals, and 2907 individuals completed the survey. Data analysis consisted of correlation, multiple linear regression, and structural equation modeling. RESULTS: The total score of the SOC and perceived stress showed a negative correlation (r = -0.80, P ＜ 0.01), the total SOC of coherence and depression also resulted in a negative correlation (r = -0.77, P ＜ 0.01), and the total score of the perceived stress and depression resulted in a positive correlation (r = 0.82, P ＜ 0.01). The results of multiple regression analyses indicated that SOC mediated the association between perceived stress and depression, and the influence of perceived stress on depression was decreased by 16.0%with in the sense of being out of control dimension and was decreased by 12.3% within the feeling of tension dimension when sense of coherence was added to the model. The structural equation model confirmed that the sense of coherence had a partial mediation effect between perceived stress and depression. CONCLUSION: SOC is the mediating variable between perceived stress and depression, and can reduce the influence of perceived stress on depression.

Compassion in emergency departments. Part 2: barriers to the provision of compassionate care.

In the second part of this three-part series, David Hunter and colleagues discuss the barriers to the provision of compassionate care in emergency departments (EDs). Part one reported findings from doctoral-level research exploring nursing students' experiences of compassionate care in EDs. Many of the findings related to what the students considered as barriers to the provision of compassionate care in this clinical environment. Six barriers to compassionate care were identified and this article considers them in detail.

Compassion in emergency departments. Part 1: nursing students' perspectives.

Compassion is a topical issue in clinical nursing practice, nurse education and policy, but a review of the literature reveals that nursing students' experiences of compassionate care receives little attention. In this three-part series David Hunter and colleagues explore compassion in emergency departments (EDs) from nursing students' point of view. Part 1 provides findings of a professional doctorate study of nursing students' experiences of compassionate care in EDs, part 2 explores the barriers to compassionate care in this clinical setting that emerged from the study, and part 3 considers factors that enable and support compassionate care provision in EDs. AIM: The aim of the study was to explore nursing students' experiences of the provision of compassionate care in EDs. METHOD: The underpinning methodology was an exploratory-descriptive qualitative design. A total of 15 nursing students from across the west of Scotland, who had been placed in eight different EDs, participated in face-to-face interviews which were audio recorded, transcribed and analysed. FINDINGS: Two major themes emerged 'doing the little things' and 'a strange, new world: the uniqueness of the ED'. The students also identified barriers and enablers to providing compassionate care which are discussed in parts two and three. CONCLUSION: Despite the challenges of working in the most acute of clinical settings, nurses can provide compassionate care to patients and their relatives. However, this is not universal because certain groups of patients considered 'challenging' do not receive equitable compassionate care.

Testing and comparing two self-care-related instruments among older Chinese adults.

OBJECTIVES: The study aimed to test and compare the reliability and validity, including sensitivity and specificity of the two self-care-related instruments, the Self-care Ability Scale for the Elderly (SASE), and the Appraisal of Self-care Agency Scale-Revised (ASAS-R), among older adults in the Chinese context. METHODS: A cross-sectional design was used to conduct this study. The sample consisted of 1152 older adults. Data were collected by a questionnaire including the Chinese version of SASE (SASE-CHI), the Chinese version of ASAS-R (ASAS-R-CHI) and the Exercise of Self-Care Agency scale (ESCA). Homogeneity and stability, content, construct and concurrent validity, and sensitivity and specificity were assessed. RESULTS: The Cronbach's alpha (α) of SASE-CHI was 0.89, the item-to-total correlations ranged from r = 0.15 to r = 0.81, and the test-retest correlation coefficient (intra-class correlation coefficient, ICC) was 0.99 (95% CI, 0.99-1.00; P<0.001). The Cronbach's α of ASAS-R-CHI was 0.78, the item-to-total correlations ranged from r = 0.20 to r = 0.65, and the test-retest ICC was 0.95 (95% CI, 0.92-0.96; P<0.001). The content validity index (CVI) of SASE-CHI and ASAS-R-CHI was 0.96 and 0.97, respectively. The findings of exploratory and confirmatory factor analyses (EFA and CFA) confirmed a good construct validity of SASE-CHI and ASAS-R-CHI. The Pearson's rank correlation coefficients, as a measure of concurrent validity, between total score of SASE-CHI and ESCA and ASAS-R-CHI and ESCA were assessed to 0.65 (P<0.001) and 0.62 (P<0.001), respectively. Regarding ESCA as the criterion, the area under the receiver operator characteristic (ROC) curve for the cut-point of SASE-CHI and ASAS-R-CHI were 0.93 (95% CI, 0.91-0.94) and 0.83 (95% CI, 0.80-0.86), respectively. CONCLUSION: There is no significant difference between the two instruments. Each has its own characteristics, but SASE-CHI is more suitable for older adults. The key point is that the users can choose the most appropriate scale according to the specific situation.

Preparing registrants for mentor roles: the chicken or egg conundrum.

The Nursing and Midwifery Council's (NMC) Standards to Support Learning and Assessment in Practice ( 2008 ) outline requirements for the preparation of those who support nursing and midwifery pre-registration students in practice, formally known as mentors. Pre-registration nursing and midwifery programme providers, and practice learning environments (PLEs), work collaboratively to prepare registrants to undertake this role, and to help them maintain mentor status. An important NMC requirement is that registrants, when undertaking mentor preparation programmes, must be supported by experienced mentors in their workplace. This is challenging for programme providers and PLEs if there is lack of experienced mentors in the area concerned. This article discusses support for registrants when preparing to become mentors, suggests some alternative solutions and makes recommendations for the future of mentor preparation in the UK.

Mentorship practice and revalidation.

Nurses and midwives who are registered with the Nursing and Midwifery Council (NMC) are required to renew their registration with the NMC. In April 2016, the NMC introduced revalidation, which replaces the requirements for renewal of registration set out in the post-registration education and practice standards. Every registrant should be aware of the revalidation process and requirements. Revalidation is linked to the professional standards for nurses and midwives set out by the NMC and known as The Code. Mentorship is an essential component of The Code; therefore, mentorship practice will assist registrants in meeting some or all of their revalidation requirements. As registered nurses, mentors will be required to reflect on their practice and update their preparation for mentorship. This article provides guidance on how mentorship preparation and practice can contribute to meeting revalidation requirements.

Mentors in waiting.

A four stage framework, developed by the Nursing and Midwifery Council for the preparation of nurses and midwives who support learners within practice and educational settings was implemented in the United Kingdom in September 2007. Since then the focus of debate and discussion within the literature has centred on stage 2 of the developmental framework i.e. the mentor role. The three other stages of registrant, practice teacher and teacher have received little attention. This paper argues that currently, the provisions made within the developmental framework in relation to the stage 1 registrant's role in supporting students within practice settings, has yet to be realised. The paper begins by contemplating both the pros and cons of the 'should all nurses be mentors' debate. The argument for embracing and utilising the stage 1 role more fully in practice is then presented. The paper concludes by underlining the need to recognise the stage 1 registrants as 'mentors in waiting' and the need to support the full potential of their contribution to students' learning and assessment in practice.

First year undergraduate nursing students and nursing mentors: An evaluation of their experience of specialist areas as their hub practice learning environment.

Specialist environments have traditionally not been considered as practice learning environments for year one nursing students. Through implementation of the hub and spoke model of practice learning this was implemented across one health board and Higher Education Institution in Scotland. Sixty nine students from specialist and 147 from general areas out of a total population of 467 students (46.2%) and thirteen mentors from specialist and 26 from general areas out of a total 577 mentors (6.7%) completed a questionnaire. The findings support this initiative and suggest in some cases student experiences are more positive in specialist environments.

Are theoretical perspectives useful to explain nurses' tolerance of suboptimal care?

AIM: This paper explores two theoretical perspectives that may help nurse managers understand why staff tolerate suboptimal standards of care. BACKGROUND: Standards of care have been questioned in relation to adverse events and errors for some years in health care across the western world. More recently, the focus has shifted to inadequate nursing standards with regard to care and compassion, and a culture of tolerance by staff to these inadequate standards. EVALUATION: The theories of conformity and cognitive dissonance are analysed to investigate their potential for helping nurse managers to understand why staff tolerate suboptimal standards of care. KEY ISSUES: The literature suggests that nurses appear to adopt behaviours consistent with the theory of conformity and that they may accept suboptimal care to reduce their cognitive dissonance. CONCLUSION: Nurses may conform to be accepted by the team. This may be confounded by nurses rationalising their care to reduce the cognitive dissonance they feel. IMPLICATIONS FOR NURSING MANAGEMENT: The investigation into the Mid Staffordshire National Health Service called for a change in culture towards transparency, candidness and openness. Providing insights as to why some nursing staff tolerate suboptimal care may provide a springboard to allow nurse managers to consider the complexities surrounding this required transformation.

Getting published: reflections of a collaborative writing group.

BACKGROUND: Writing for publication, in the nursing profession, is considered essential for the development of the profession and individual career advancement. In education there is also the increasing pressure to produce University research output. OBJECTIVE: To develop a collaborative writing group to develop and write articles relating to our teaching practice. METHOD: The idea of forming a writing group was discussed at a module team meeting where five academics expressed an interest. The process of forming the group involved an initial meeting to discuss and agree to the aims, interests, expertise and areas of responsibility for each member. Regular meetings are held and each member takes on responsibility for an aspect of work towards completing the articles. RESULTS: Three articles and one editorial have been published and another is under peer review. We have endeavoured to develop and maintain a theme, this being supporting nursing students' development with an emphasis on an aspect of their decision making skills. Also, importantly, we have created a supportive environment and friendships. CONCLUSIONS: The demands made upon the nurse educator to be clinically, educationally and research active can be difficult to meet. Collaborative writing groups may be one way to fulfil the scholarly activity element.

Developing a national computerised absence monitoring and management system to reduce nursing student attrition: evaluation of staff and student perspectives.

BACKGROUND: Reducing avoidable nursing student attrition is an international challenge. A pattern of falling attendance is recognised as a frequent precursor to withdrawal from nursing programmes. To address concerns regarding nursing student attrition, the Scottish Government implemented a pilot project for a centralised Computerised Absence Management and Monitoring System (CAMMS). The CAMMS adopted an 'assertive outreach' approach, contacting students every two weeks via colour coded letters to tell them whether their attendance was 'excellent', 'good, but potentially causing concern'; or 'warning; attendance concerns/contact academic staff for support'. This article reports key findings from an evaluation of CAMMS. OBJECTIVES: To explore the perceived impact of CAMMS on student support and attrition, from the perspectives of academic and administrative staff and students. DESIGN: Mixed methods evaluation design. SETTINGS: Three large geographically dispersed Schools of Nursing in Scotland. PARTICIPANTS: 83 students; 20 academic staff; and 3 lead administrators. METHODS: On-line cohort survey of academic staff and students; structured interviews with lead administrators. RESULTS: Findings reflected a spectrum of negative and positive views of CAMMS. Students who are attending regularly seem pleased that their commitment is recognised. Lecturers who teach larger groups report greater difficulty getting to know students individually and acknowledge the benefit of identifying potential attendance concerns at an early stage. Conversely, some students who received a 'warning' letter were frequently annoyed or irritated, rather than feeling supported. Increased staff workload resulted in negative perceptions and a consequent reluctance to use CAMMS. However, students who were causing concern reported subsequent improvement in attendance. CONCLUSIONS: CAMMS has the potential to identify 'at-risk' students at an early stage; however, the system should have flexibility to tailor automatically generated letters in response to individual circumstances, to avoid student frustration. Further research on the longer term impact of CAMMS on attrition rates is warranted.

Live register of mentors and practice teachers.

A working group comprising university academics and practice education facilitators from three NHS Scotland service provider areas has developed guidance to improve the management and maintenance of live mentor and practice teacher (PT) registers. The document, specifically targeted at improving the systems that underpin live-register management, provides managers with information to guide the collation of accurate mentor and PT records, helping to ensure timely uptake of annual updates and triennial reviews. Adopting these approaches can improve the management and retention of mentors and PTs in practice learning environments and enhance the management of student support in practice.

Developing nursing students' decision making skills: are early warning scoring systems helpful?

This paper is presented to contribute to the emerging debate on Early Warning Scoring Systems. The Early Warning Scoring System was introduced, and has been implemented internationally, to aid in the identification of the patient whose condition is deteriorating. Early identification of patient deterioration is of vital importance for patient safety. Therefore how we teach this skill to students and how they become competent and confident in its utilisation, interpretation and subsequent clinical decision-making is crucial. The paper initially explores the competence of student nurses in this area. The discussion then focuses on three models of clinical decision making to illustrate why the introduction of Early Warning Scoring Systems has hindered student nurses in the development of the decision-making skills required to identify and manage the patient whose condition is deteriorating.

Supporting students in clinical practice: pre-registration nursing students' views on the role of the lecturer.

Learning in clinical practice is an essential aspect of student nurse education yet debate persists in the United Kingdom regarding the role of the lecturer in supporting the student within clinical practice. This debate has been rekindled with developments in mentorship and establishment of a clinical role designed to facilitate and support mentors; the Practice Education Facilitator. Hence it is timely to re-examine the role of the lecturer in providing clinical support to students. This article discusses nursing students' views of clinical support provided by lecturers on a Diploma/Degree programme. Qualitative and quantitative data was obtained from an online questionnaire which indicated that students thought the most important part of the lecturers' role was to provide academic support for assignments. The students also appreciated lecturers visiting them in clinical placement to facilitate the student-mentor relationship and to provide personal support. It is argued, that with the enhancement of other supportive mechanisms for students and mentors and the current economic climate, lecturers should work in partnership with mentors and practice education facilitators to avoid duplication of effort. The students in this evaluation suggested that academic support for assignments should be the main focus for lecturers.

Exploring nursing students' decision-making skills whilst in a Second Life clinical simulation laboratory.

AIM: To explore nursing students' decision-making skills through the use of a 3D virtual environment such as Second Life. METHOD: An exploratory qualitative evaluation of the students' experience of learning decision-making skills whilst in a Second Life clinical simulation laboratory. A convenience sample of five third year student nurses entered a simulated world environment where they cared for six patients over 1h. The written communication text from the Second Life scenario was saved into a Microsoft Word document. Additionally a semi-structured tape-recorded one to one interview was conducted immediately after the Second Life simulation in order to explore the students' decision-making skills. RESULTS: The communication text illustrated that the majority of decisions (n=21) were made in response to a situation or a patient request, therefore 'reactive' rather than proactive (n=9). Only one student carried out a vital signs assessment on a newly admitted patient (Willie). The interviews produced two themes, performing decision-making and improving learning. The absence of 'visual cues' such as pre-operative checklists, vital sign observation charts and 'Nil by Mouth' signs may offer a rationale for why students were more reactive. CONCLUSION: Further work is required for students to practice decision-making skills. With further development the innovative 3D virtual worlds such as Second Life could provide this experience.