Guidance for planners of the psychosocial response to stress experienced by hospital staff associated with COVID: Early Interventions

The following guidance represents a consensus of trauma clinicians and researchers. The guidance is collated from research, best practice guidelines and expert clinical opinion. This guidance is not an exhaustive list of recommendations but is intended to inform planners, managers and team leaders of the organisational and psychological processes which are likely to be helpful, or unhelpful, in supporting staff during the early stages of the response to COVID.

Staff may experience a range of normal reactions to highly stressful situations. These could vary and may include feelings of anger and irritability, anxiety, low mood, increased alcohol consumption, smoking, eating and sleeping problems, and burn out. Broadly speaking, the aim of the response to ongoing high stress is to support coping, to foster resilience, reduce burnout and reduce the risk of developing mental health difficulties including anxiety, depression and post-traumatic stress disorder (PTSD).

The quantity, and quality, of current research in this area is limited, and most research to date has focused on early interventions after a single major incident and after the crisis has passed. There is also limited knowledge on providing support at a time when those offering support are also exposed to a shared threat. Therefore, we have to extrapolate from this what might be most helpful whilst a crisis is still ongoing. This guidance is also informed by recent research and expert opinion emerging on the COVID crisis. Research will be needed to evaluate the effectiveness of any interventions in the longer term. All resources are available at www.traumagroup.org.

Do's

• Ensure that good quality communication and accurate information updates are provided to all staff. Brief staff in an open, honest and frank way so they are best prepared for what they are going to face and what they might be asked to do.
• Rotate workers from higher-stress to lower-stress functions. Partner inexperienced workers with their more experienced colleagues. Such ‘buddy’ systems help to provide support, monitor stress and reinforce safety procedures. Implement flexible schedules for workers who are directly impacted or have a family member affected by a stressful event.
• Do ensure that the basic physical needs of staff are being met including safety (including appropriate access to personal protective equipment), food & hydration, rest and sleep. Do support staff to take breaks and attend to self-care. Role modelling of these behaviours by senior staff will be important.
• Do provide training on the potentially traumatic situations that staff might be exposed to including honest communication of the facts, developing skills to cope with these and awareness of potential mental health issues. Evidence of the benefits of these interventions being delivered pre-trauma exposure appear promising, so are likely to be particularly important for new staff being mobilised to help with the response, such as final year medical students and student nurses.
• Do be flexible in supporting needs and respond to staff feedback on what is, and is not, helpful. Set up regular feedback mechanisms so messages can reach management quickly. Make sure to act on feedback and where this is not possible, communicate why this can’t be done.
• Do pay attention to staff who may be particularly vulnerable. This may be because of pre-existing experiences or mental health issues, previous traumas or bereavements, or concurrent pressures and loss. Think about how to best monitor these staff and put extra support mechanisms in place for them.
• Do encourage staff to use social and peer support. It’s not enough just to have good support systems in place, staff need to actively use them. Staff may feel guilty or not want to burden or distress others, particularly their family, so think about how peer and management support can be maximised at work.Evidence suggest that when a worker has the informal support of their peers following traumatic exposure, they are less likely to need formal intervention. The efficacy of peer interventions does not come from having a single trauma-informed or trained staff member, but rather comes from the camaraderie and sense of common fate that emerges from a shared experience of trauma.
• Do facilitate team cohesion and try to foster strong supportive links between team members and managers. Allow staff time to be with and support each other and encourage activities and discussions also unrelated to COVID where possible. It will be important for managers and team leaders to role model a caring and cohesive team approach – “we’re all in this together”. Evidence shows that cohesion between personnel is highly correlated with mental health, and that the resilience of a team may be more related to the bonds between team members than the coping style of any individual.
• Do provide an opportunity for staff to talk about their experience, in order to enhance support and social cohesion. This can occur at the end of shifts or at significant points in the response. This may take place individually between a staff member and manager or supervisor, or in teams of people who work together. These sessions should not involve anyone being mandated to talk about their thoughts or feelings. It is important for organisations to provide these opportunities, but for staff to be free to decide whether to attend or not. If offered, these sessions should be provided during a staff member’s shift (not afterwards) so as not to encroach on rest and recovery time.
• Do understand that most people are resilient and will manage to cope with stressful experiences. Nevertheless, do have a low threshold for referring staff members to Wellbeing or Psychology Services if you are concerned about them. Make sure you know who to contact and how.
• Do ensure that people delivering any psychological support are appropriately trained, competent and have clinical supervision. Establish clinically appropriate ‘supervision of supervision’ structures. Ensure that any psychological interventions are evidence-based.
• Do enable staff to access informal psychological support. Such informal support, offered rapidly and in a flexible way according to need, is likely to be helpful for individual staff members who are showing signs of becoming overwhelmed, to reinforce adaptive coping strategies and address unhelpful feelings such as guilt. If formal psychological intervention is indicated after an appropriate assessment, options include generic cognitive-behavioural therapy (CBT) and trauma-focused CBT for Acute Stress Disorder. One month after a major traumatic experience do refer to Psychological Services if staff are showing signs of post-traumatic stress disorder to this event.
• Do continue to actively monitor and support staff after the crisis begins to recede. Where necessary, refer on for evidence-based psychological treatment.

Don'ts

• Don’t offer Psychological Debriefing (PD), Critical Incident Stress Debriefing (CISD) or any other single session intervention which involves mandating staff to talk about their thoughts or feelings. There is evidence that these interventions may be ineffective or even increase the likelihood of developing PTSD.
• Don’t offer non-specific training programmes such as ‘mental strength’ training as these do not have a beneficial impact on reducing mental health problems or PTSD and are likely to have high dropout rates
• Don’t rush to offer formal psychological interventions too soon without careful assessment, including active monitoring. Although well intentioned, intervening in people’s natural coping mechanisms too early can be detrimental.
• Don’t offer any unproven approaches to psychological treatment. Any psychological intervention should be provided by an appropriately qualified and supervised clinician, at the appropriate time.

About the COVID trauma response working group

The COVID Trauma Response Working Group has been formed to help coordinate trauma-informed responses to the COVID outbreak. We are made of psychological trauma specialists, coordinators of the psychosocial response to trauma and wellbeing leads at NHS Trusts. The working group is being coordinated by staff at University College London and the Traumatic Stress Clinic based at St Pancras Hospital in Camden and Islington NHS Trust. We are very grateful to our clinical and scientific colleagues in other NHS trusts and universities who are contributing to this work. We hope that this work is helpful to our colleagues involved in the care of patients affected by the COVID pandemic.

Guidance Authors

Dr Jo Billings – University College London and Foreign & Commonwealth Office (UK).
Dr Tim Kember – Traumatic Stress Clinic.
Dr Talya Greene - University College London and University of Haifa.
Dr Nick Grey - Sussex Partnership NHS Foundation Trust and University of Sussex.
Dr Sharif El-Leithy - Traumatic Stress Service, South West London & St George's Mental Health NHS Trust.
Dr Deborah Lee - Berkshire Healthcare NHS Foundation Trust.
Dr Helen Kennerley – Oxford Cognitive Therapy Centre and University of Oxford.
Dr Idit Albert – South London & Maudsley London NHS Trust and Kings College London
Dr Mary Robertson - Traumatic Stress Clinic.
Prof Chris Brewin – University College London.
Dr Michael Bloomfield - Traumatic Stress Clinic, University College London and UCLH NHS Trust.

Key references

Carratu, E., Günak, M. and Billings, J (in preparation). The effectiveness of interventions for the prevention of post-traumatic stress disorder (PTSD) in emergency service personnel: a systematic review.
Chen, Q. et al. (2020). Mental health care for medical staff in China during the COVID-19 outbreak. Lancet.
Greenberg, N., Dochertry, M., Gnanapragasam, S. and Wessley, S. (2020). Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ.
Greenberg, N., Wessley, S. and Wykes, T. (2015). Potential mental health consequences for workers in the Ebola regions of West Africa – a lesson for all challenging environments. Journal of Mental Health.
National Institute for Health and Care Excellence (2018). Post-traumatic stress disorder. NG116. https://www.nice.org.uk/guidance/ng116
Richins, M., Gauntlett, L., Tehrani, N. et al (2019). Scoping Review: Early Post-Trauma Interventions in Organisations.
United Kingdom Psychological Trauma Society. (2014). Traumatic stress management guidance: For organisations whose staff work in high risk environments. Leeds: UK Psychological Trauma Society/ European Society of Traumatic Stress Studies