'You get looked at like you're failing': A reflexive thematic analysis of experiences of mental health and wellbeing support for NHS staff.

Staff in the National Health Service (NHS) are under considerable strain, exacerbated by 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. We interviewed 48 healthcare workers from 18 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, such as manager training and peer support facilitated by building in time for this during working hours, but this will require long-term strategic planning to address workforce shortages.

Prevalence of post-traumatic stress disorder and common mental disorders in health-care workers in England during the COVID-19 pandemic: a two-phase cross-sectional study.

BACKGROUND: Previous studies on the impact of the COVID-19 pandemic on the mental health of health-care workers have relied on self-reported screening measures to estimate the point prevalence of common mental disorders. Screening measures, which are designed to be sensitive, have low positive predictive value and often overestimate prevalence. We aimed to estimate prevalence of common mental disorders and post-traumatic stress disorder (PTSD) among health-care workers in England using diagnostic interviews. METHODS: We did a two-phase, cross-sectional study comprising diagnostic interviews within a larger multisite longitudinal cohort of health-care workers (National Health Service [NHS] CHECK; n=23 462) during the COVID-19 pandemic. In the first phase, health-care workers across 18 NHS England Trusts were recruited. Baseline assessments were done using online surveys between April 24, 2020, and Jan 15, 2021. In the second phase, we selected a proportion of participants who had responded to the surveys and conducted diagnostic interviews to establish the prevalence of mental disorders. The recruitment period for the diagnostic interviews was between March 1, 2021 and Aug 27, 2021. Participants were screened with the 12-item General Health Questionnaire (GHQ-12) and assessed with the Clinical Interview Schedule-Revised (CIS-R) for common mental disorders or were screened with the 6-item Post-Traumatic Stress Disorder Checklist (PCL-6) and assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) for PTSD. FINDINGS: The screening sample contained 23 462 participants: 2079 participants were excluded due to missing values on the GHQ-12 and 11 147 participants due to missing values on the PCL-6. 243 individuals participated in diagnostic interviews for common mental disorders (CIS-R; mean age 42 years [range 21-70]; 185 [76%] women and 58 [24%] men) and 94 individuals participated in diagnostic interviews for PTSD (CAPS-5; mean age 44 years [23-62]; 79 [84%] women and 15 [16%] men). 202 (83%) of 243 individuals in the common mental disorders sample and 83 (88%) of 94 individuals in the PTSD sample were White. GHQ-12 screening caseness for common mental disorders was 52·8% (95% CI 51·7-53·8). Using CIS-R diagnostic interviews, the estimated population prevalence of generalised anxiety disorder was 14·3% (10·4-19·2), population prevalence of depression was 13·7% (10·1-18·3), and combined population prevalence of generalised anxiety disorder and depression was 21·5% (16·9-26·8). PCL-6 screening caseness for PTSD was 25·4% (24·3-26·5). Using CAPS-5 diagnostic interviews, the estimated population prevalence of PTSD was 7·9% (4·0-15·1). INTERPRETATION: The prevalence estimates of common mental disorders and PTSD in health-care workers were considerably lower when assessed using diagnostic interviews compared with screening tools. 21·5% of health-care workers met the threshold for diagnosable mental disorders, and thus might benefit from clinical intervention. FUNDING: UK Medical Research Council; UCL/Wellcome; Rosetrees Trust; NHS England and Improvement; Economic and Social Research Council; National Institute for Health and Care Research (NIHR) Biomedical Research Centre at the Maudsley and King's College London (KCL); NIHR Protection Research Unit in Emergency Preparedness and Response at KCL.

Multicentre, England-wide randomised controlled trial of the 'Foundations' smartphone application in improving mental health and well-being in a healthcare worker population.

BACKGROUND: Healthcare workers (HCWs) have faced considerable pressures during the COVID-19 pandemic. For some, this has resulted in mental health distress and disorder. Although interventions have sought to support HCWs, few have been evaluated. AIMS: We aimed to determine the effectiveness of the 'Foundations' application (app) on general (non-psychotic) psychiatric morbidity. METHOD: We conducted a multicentre randomised controlled trial of HCWs at 16 NHS trusts (trial registration number: EudraCT: 2021-001279-18). Participants were randomly assigned to the app or wait-list control group. Measures were assessed at baseline, after 4 and 8 weeks. The primary outcome was general psychiatric morbidity (using the General Health Questionnaire). Secondary outcomes included: well-being; presenteeism; anxiety; depression and insomnia. The primary analysis used mixed-effects multivariable regression, presented as adjusted mean differences (aMD). RESULTS: Between 22 March and 3 June 2021, 1002 participants were randomised (500:502), and 894 (89.2%) followed-up. The sample was predominately women (754/894, 84.3%), with a mean age of 44⋅3 years (interquartile range (IQR) 34-53). Participants randomised to the app had a reduction in psychiatric morbidity symptoms (aMD = -1.39, 95% CI -2.05 to -0.74), improvement in well-being (aMD = 0⋅54, 95% CI 0⋅20 to 0⋅89) and reduction in insomnia (adjusted odds ratio (aOR) = 0⋅36, 95% CI 0⋅21 to 0⋅60). No other significant findings were found, or adverse events reported. CONCLUSIONS: The app had an effect in reducing psychiatric morbidity symptoms in a sample of HCWs. Given it is scalable with no adverse effects, the app may be used as part of an organisation's tiered staff support package. Further evidence is needed on long-term effectiveness and cost-effectiveness.

'It hurts your heart': frontline healthcare worker experiences of moral injury during the COVID-19 pandemic.

Background: Moral injury is defined as the strong emotional and cognitive reactions following events which clash with someone's 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. Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646-652] 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. HIGHLIGHTS Clinical frontline healthcare workers (HCWs) have been exposed to an accumulation of potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic, including feeling betrayed by both government and NHS leaders as well as feeling unable to provide duty of care to patients.HCWs described the significant adverse impact of this exposure on their mental health, including increased anxiety and depression symptoms and sleep disturbance.Most HCWs interviewed believed that organisational change within the NHS was necessary to prevent excess PMIE exposure and promote resolution of moral distress.

Antecedentes: El daño moral se define como las fuertes reacciones emocionales y cognitivas que siguen a los eventos que chocan con el código moral de una persona, sus valores o expectativas. Durante la pandemia de COVID-19, el aumento de la exposición a Eventos Potencialmente Dañinos para la Moral (PMIEs, por su sigla en inglés) ha puesto a los trabajadores de la salud (HCWs, por su sigla en inglés) en riesgo de daño moral. Aún se conoce poco sobre la experiencia vivida de la exposición acumulada a PMIE y cómo el personal del Servicio Nacional de Salud de Inglaterra (NHS en su sigla en inglés) responde a esto.Objetivo: Buscamos rectificar esta brecha de conocimiento a través de la exploración cualitativa de las experiencias vividas y perspectivas del personal clínico de primera línea de NHS que respondió al COVID-19.Métodos: Reclutamos una muestra diversa de 30 HCWs clínicos de primera línea de la cohorte del estudio CHECK del NHS, para entrevistas cualitativas de una sola vez. Todos los participantes aprobaron al menos un ítem de los 9 de la Escala de Eventos de Daño Moral (MIES) [Nash y cols., 2013. Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646­652] en el seguimiento a los 6 meses. Las entrevistas siguieron una guía semi-estructurada y fueron analizadas utilizando análisis temático reflexivo.Resultados: Los HCWs describieron estar expuestos de forma rutinaria a conflictos éticos, creados por exacerbación de problemas sistémicos pre-existentes que incluían falta de personal y de recursos. Encontramos que los HCWs experimentaron un rango de síntomas de salud mental primariamente relacionados a percepciones de traición institucional y al sentirse incapaces de cumplir con su deber de cuidado hacia los pacientes.Conclusión: Estos resultados sugieren que se requiere una estrategia organizacional multifacética para preparar para la exposición a PMIE fomentar oportunidades de resolución de los síntomas asociados al daño moral y prevenir la separación organizacional.

Psychosocial Interventions to Reduce Compulsory Psychiatric Admissions: A Rapid Evidence Synthesis.

BACKGROUND: Compulsory mental health hospital admissions are increasing in several European countries but are coercive and potentially distressing. It is important to identify which mental health service models and interventions are effective in reducing compulsory admissions. METHODS: We conducted a rapid evidence synthesis to explore whether there is any evidence for an effect on compulsory admissions for 15 types of psychosocial intervention, identified by an expert group as potentially relevant to reducing compulsory admission. A search for randomised controlled trials (RCTs) reporting compulsory admission as a primary or secondary outcome or adverse event was carried out using clinical guidelines, recent systematic reviews, and database searches postdating these reviews. FINDINGS: We found 949 RCTs reporting on the interventions of interest, of which 19 reported on compulsory admission. Our narrative synthesis found some evidence for the effectiveness of crisis planning and self-management, while evidence for early intervention services was mixed. We did not find evidence to support adherence therapy, care from crisis resolution teams and assertive community treatment, but numbers of relevant studies were very small. We found no trials which tested effects on compulsory admission of the nine other intervention types. INTERPRETATION: Crisis planning and self-management interventions with a relapse prevention element are most promising for preventing compulsory admissions. Given our broad search strategy, the lack of evidence demonstrates that there is an urgent need for more research on interventions which may reduce compulsory admissions. FUNDING: Independent research commissioned and funded by the National Institute for Health Research Policy Research Programme.