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Kuhlmann E, Falkenbach M, Brînzac MG, Correia T, Panagioti M, Ungureanu MI. The mental health needs of healthcare workers: When evidence does not guide policy. A comparative assessment of selected European countries. Int J Health Plann Manage 2024; 39:614-636. [PMID: 38193752 DOI: 10.1002/hpm.3752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 12/15/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND The healthcare workforce (HCWF) globally is facing high stress levels and deteriorating mental health due to workplace, labour market and policy deficiencies that further exacerbate the existing crisis. However, comprehensive and effective action is missing. AIMS We adopt a health system and governance perspective to address the mental health needs of healthcare workers (HCWs), considering the nature of interventions and the levels and actors involved in governance. The aim is to move the debate forward by identifying governance gaps hampering the implementation of health workforce policies and exploring strategies to effectively increase mental health support. MATERIAL AND METHODS A qualitative comparative methodology is applied based on a case study design utilising a multi-level intersectoral governance matrix. We conducted a rapid assessment of HCWF developments in the European context (Germany, Portugal, Romania, Switzerland and the United Kingdom), drawing on secondary sources and country experts. RESULTS AND DISCUSSION Awareness of mental health threats among HCWs increased, but policy discourse is driven by service delivery and labour market demands. The attention to HCWs' needs is stronger on the international level and weakest at national/regional levels. Although organisations and professions demonstrate varying degrees of activity, their efforts are scattered and lack sustainability. Similar challenges were identified across healthcare systems, including limited action, disconnected actors, missing coordination, and a lack of attention to governance gaps and system weaknesses. CONCLUSION Adopting a health system approach is important but not sufficient. Successful mental health policy implementation needs multi-level governance and coherent coordination mechanisms.
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Affiliation(s)
- Ellen Kuhlmann
- Institute for Economics, Labour and Culture, Goethe-University Frankfurt, Frankfurt, Germany
- WHO Collaborating Center for Health Workforce Policies and Planning, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa, Lisbon, Portugal
| | - Michelle Falkenbach
- European Observatory on Health Systems and Policies, Brussels, Belgium
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica-Georgiana Brînzac
- Faculty of Political, Administrative and Communication Sciences, Department of Public Health, Babeș-Bolyai University, Cluj-Napoca, Romania
- Faculty of Political, Administrative and Communication Sciences, Center for Health Workforce Research and Policy, Babeș-Bolyai University, Cluj-Napoca, Romania
| | - Tiago Correia
- WHO Collaborating Center for Health Workforce Policies and Planning, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa, Lisbon, Portugal
- Global Health and Tropical Medicine, Associate Laboratory in Translation and Innovation Towards Global Health, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Maria Panagioti
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Marius-Ionut Ungureanu
- WHO Collaborating Center for Health Workforce Policies and Planning, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa, Lisbon, Portugal
- Faculty of Political, Administrative and Communication Sciences, Department of Public Health, Babeș-Bolyai University, Cluj-Napoca, Romania
- Faculty of Political, Administrative and Communication Sciences, Center for Health Workforce Research and Policy, Babeș-Bolyai University, Cluj-Napoca, Romania
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Guilabert M, Sánchez-García A, Asencio A, Marrades F, García M, Mira JJ. [Challenges and strategies to recover and dynamize primary care: SWOT-CAME analysis in a Health Department]. Aten Primaria 2024; 56:102809. [PMID: 38029655 PMCID: PMC10716492 DOI: 10.1016/j.aprim.2023.102809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE To identify strengths, obstacles, changes in the environment, and capabilities of primary care teams and support units, with the aim of providing high-quality care in an integrated healthcare area. DESIGN Mixed methods study based on the SWOT matrix and CAME analysis. LOCATION Primary care, Valencian community. PARTICIPANTS A total of 271 professionals from different collectives and patient association representatives participated. 99 in the idea generation phase, 154 in the SWOT matrix development phase, and 18 in the CAME analysis development phase. INTERVENTIONS A SWOT-CAME analysis was conducted, from which action lines were established. Information capture was carried out through nominal groups, and the consensus phase involved integrating all professionals through Delphi and consensus conference techniques. MAIN MEASUREMENTS Prioritization of proposals to maintain strengths, address threats, exploit opportunities, and correct weaknesses within the framework of an integrated healthcare area action plan. RESULTS A total of 82 different ideas were proposed (20 strengths; 40 weaknesses; 4 threats; 12 opportunities; 6 threats-opportunities), which, once prioritized, were translated into 7 lines and 33 prioritized actions/interventions (CAME analysis). CONCLUSIONS Integrated care, seeking collaborative approaches between care levels, redefining roles, digital solutions, staff training, and improvements in equipment and support processes, along with measures to address the aging population and the needs of socio-sanitary centers, constitute the challenges to be addressed.
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Affiliation(s)
- Mercedes Guilabert
- Departamento Psicología de la Salud, Universidad Miguel Hernández, Alicante, España.
| | | | - Alberto Asencio
- Departamento de Salud Alicante-Sant Joan d'Alacant, Alicante, España
| | - Fabiola Marrades
- Departamento de Salud Alicante-Sant Joan d'Alacant, Alicante, España
| | - Mónica García
- Departamento de Salud Alicante-Sant Joan d'Alacant, Alicante, España
| | - José Joaquín Mira
- Departamento Psicología de la Salud, Universidad Miguel Hernández, Alicante, España; Departamento de Salud Alicante-Sant Joan d'Alacant, Alicante, España; ATENEA investigación. FISABIO, Sant Joan d'Alacant, Alicante, España; Red de Investigación sobre Crónicidad, Atención Primaria y Promoción de la Salud (RICAPPS), España
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Strametz R. Second and double victims - Achievements and challenges in ensuring psychological safety of caregivers. J Healthc Qual Res 2023; 38:327-328. [PMID: 37236907 PMCID: PMC10206588 DOI: 10.1016/j.jhqr.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023]
Affiliation(s)
- R Strametz
- Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP), RheinMain UAS, Wiesbaden, Germany.
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Carrillo I, Poblete R, Serpa P, Martin-Delgado J, Giménez A, Mira JJ. Social support for overcoming fear of contagion at the start of the COVID-19 pandemic. Cross-sectional study in Latin America. Front Psychol 2023; 14:1215693. [PMID: 37780156 PMCID: PMC10536181 DOI: 10.3389/fpsyg.2023.1215693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
Background The psychological impact of the COVID-19 pandemic on healthcare professionals has been widely studied, along with different strategies to minimize it. However, professionals' assessment of the social support received and the factors that mitigated their fear of contagion have not been described. This study aimed to assess healthcare professionals' satisfaction with the social support and information received and their efforts to self-isolate to avoid infecting loved ones in Chile, Colombia, and Ecuador. Methods A cross-sectional online survey, conducted from July to September 2020 in three Latin American countries, elicited healthcare professionals' satisfaction with social support from colleagues, their community, the media, and scientific societies; as well as the information received about the evolution of the pandemic and measures to avoid contagion. The EASE scale was used to measure acute stress. Results Survey responses were received from 700 professionals. The response rate per country exceeded the estimated sample size except in the case of Colombia, which was 81.4%. In general, peer support was highly valued, though satisfaction was lower in high-risk units (p < 0.001). Those who directly assisted COVID-19 patients perceived the least community support (p = 0.023). Professionals from high-risk units (p = 0.013) and those who experienced greater acute stress (p = 0.05) assigned the lowest rating to the information offered by the centre on the pandemic. Men perceived more support from colleagues and better information from the centre than women (p < 0.05). Just 10.7% of professionals changed their residence during the pandemic, but those who worked in high-risk areas self-isolated more frequently (p = 0.026). Conclusion In the early stages of the COVID-19 pandemic, healthcare professionals in Chile, Colombia, and Ecuador greatly valued the support received from their peers. Being infected with COVID-19, working in high-risk areas, experiencing higher self-reported acute stress, and having an infected co-worker were predictors for self-isolation to protect their relatives. These results point to the appropriateness of putting in place institutional resources based on peer support and specific communication strategies and action protocols to build resilience and responsiveness to future health crises.
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Affiliation(s)
- Irene Carrillo
- Department of Health Psychology, Miguel Hernández University of Elche, Elche, Spain
| | - Rodrigo Poblete
- Pontificia Universidad Católica de Chile, Facultad de Medicina, Departamento de Medicina Interna, Dirección de Calidad y Gestión Clínica Red de Salud UC CHRISTUS, Santiago, Chile
| | - Piedad Serpa
- Department of Clinical Management and Patient Safety, School of Medicine, Universidad de Santander, Bucaramanga, Colombia
| | - Jimmy Martin-Delgado
- Hospital Luis Vernaza, Junta de Beneficencia de Guayaquil, Guayaquil, Ecuador
- Instituto de Investigación e Innovación en Salud Integral, Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador
| | - Alejandro Giménez
- ATENEA Research Group, Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Sant Joan d’Alacant, Spain
| | - José Joaquín Mira
- Department of Health Psychology, Miguel Hernández University of Elche, Elche, Spain
- ATENEA Research Group, Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Sant Joan d’Alacant, Spain
- Hospital Provincial-Pla Health District, Health Department of Alicante-Sant Joan, Alicante, Spain
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Vicente MA, Gil Hernández E, Carrillo I, Fernández C, López-Pineda A, Guilabert M, Martín-Delgado J, Solis C, Camba K, Cañizares Fuentes WR, Mira JJ. Coping Strategies Used by Health Care Workers in Ecuador During the COVID-19 Pandemic: Observational Study to Enhance Resilience and Develop Training Tools. JMIR Hum Factors 2023; 10:e47702. [PMID: 37672317 PMCID: PMC10512111 DOI: 10.2196/47702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/21/2023] [Accepted: 07/28/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has generated immense health care pressure, forcing critical decisions to be made in a socially alarmed environment. Adverse conditions have led to acute stress reactions, affective pathologies, and psychosomatic reactions among health personnel, which have been exacerbated by the successive waves of the pandemic. The recovery of the entire health system and its professionals has been hindered, making it essential to increase their resilience. OBJECTIVE This study aimed to achieve 2 primary objectives. First, it sought to identify coping strategies, both individual and organizational, used by health care workers in Ecuador to navigate the acute stress during the early waves of the pandemic. Second, it aimed to develop training materials to enhance team leaders' capabilities in effectively managing high-stress situations. METHODS The study used qualitative research techniques to collect information on institutional and personal coping strategies, as well as consensus-building techniques to develop a multimedia psychological tool that reinforces the resilience of professionals and teams in facing future crises. RESULTS The findings from the actions taken by health care workers in Ecuador were categorized into 4 types of coping strategies based on Lazarus' theories on coping strategies. As a result of this study, a new audiovisual tool was created, comprising a series of podcasts, designed to disseminate these strategies globally within the Spanish-speaking world. The tool features testimonials from health care professionals in Ecuador, narrating their experiences under the pressures of providing care during the pandemic, with a particular emphasis on the coping strategies used. CONCLUSIONS Ensuring the preparedness of health professionals for potential future outbreaks is imperative to maintain quality and patient safety. Interventions such as this one offer valuable insights and generate new tools for health professionals, serving as a case study approach to train leaders and improve the resilience capacity and skills of their teams.
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Affiliation(s)
| | - Eva Gil Hernández
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Sant Joan d'Alacant, Spain
| | - Irene Carrillo
- Health Psychology Department, Miguel Hernandez University, Elche, Spain
| | - César Fernández
- Health Psychology Department, Miguel Hernandez University, Elche, Spain
| | - Adriana López-Pineda
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Sant Joan d'Alacant, Spain
| | | | - Jimmy Martín-Delgado
- Hospital Luis Vernaza, Junta de Beneficencia de Guayaquil, Guayaquil, Ecuador
- Instituto de Investigación e Innovación en Salud Integral, Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador
| | - Carlos Solis
- Endocrinology Service, Hospital IEES Norte Los Ceibos, Guayaquil, Ecuador
- Facultad de Medicina, Universidad de Guayaquil, Guayaquil, Ecuador
| | - Karla Camba
- Facultad de Ciencias de la Salud, Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador
| | - Wilson Ricardo Cañizares Fuentes
- Instituto de Investigación e Innovación en Salud Integral, Facultad de Ciencias Médicas, Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador
| | - José Joaquín Mira
- Health Psychology Department, Miguel Hernandez University, Elche, Spain
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Sant Joan d'Alacant, Spain
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Mira JJ. [Errores Honestos y Segundas Víctimas: Hacia una Cultura Justa para la Seguridad del Paciente]. J Healthc Qual Res 2023; 38:259-261. [PMID: 37657855 DOI: 10.1016/j.jhqr.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 09/03/2023]
Affiliation(s)
- José Joaquín Mira
- Chair ERNST Consortium (funded by European Cooperation in Science and Technology, COST Action 19113). ATENEA Research Group Director, FISABIO. Professor at Miguel Hernández University of Elche.
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Allsopp K, Varese F, French P, White H, Chung P, Hassan AA, Wright SA, Young E, Barrett A, Bhutani G, McGuirk K, Huntley F, Sarsam M, Ten Cate H, Watson R, Willbourn J, Hind D. Implementing psychological support for health and social care staff affected by the COVID-19 pandemic: a qualitative exploration of staff well-being hubs ('Resilience Hubs') using normalisation process theory. BMJ Open 2023; 13:e071826. [PMID: 37612138 PMCID: PMC10450134 DOI: 10.1136/bmjopen-2023-071826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/11/2023] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVES Evaluate the implementation of Hubs providing access to psychological support for health and social care keyworkers affected by the COVID-19 pandemic. DESIGN Qualitative interviews informed by normalisation process theory to understand how the Hub model became embedded into normal practice, and factors that disrupted normalisation of this approach. SETTING Three Resilience Hubs in the North of England. PARTICIPANTS Hub staff, keyworkers who accessed Hub support (Hub clients), keyworkers who had not accessed a Hub, and wider stakeholders involved in the provision of staff support within the health and care system (N=63). RESULTS Hubs were generally seen as an effective way of supporting keyworkers, and Hub clients typically described very positive experiences. Flexibility and adaptability to local needs were strongly valued. Keyworkers accessed support when they understood the offer, valuing a confidential service that was separate from their organisation. Confusion about how Hubs differed from other support prevented some from enrolling. Beliefs about job roles, unsupportive managers, negative workplace cultures and systemic issues prevented keyworkers from valuing mental health support. Lack of support from managers discouraged keyworker engagement with Hubs. Black, Asian and minority ethnic keyworkers impacted by racism felt that the Hubs did not always meet their needs. CONCLUSIONS Hubs were seen as a valuable, responsive and distinct part of the health and care system. Findings highlight the importance of improving promotion and accessibility of Hubs, and continuation of confidential Hub support. Policy implications for the wider health and care sector include the central importance of genuine promotion of and value placed on mental health support by health and social care management, and the creation of psychologically safe work environments. Diversity and cultural competency training is needed to better reach under-represented communities. Findings are consistent with the international literature, therefore, likely to have applicability outside of the current context.
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Affiliation(s)
- Kate Allsopp
- Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Psychology and Mental Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Filippo Varese
- Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Psychology and Mental Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Paul French
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, UK
- Pennine Care NHS Foundation Trust, Ashton-under-Lyne, UK
| | - Hannah White
- Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Priscilla Chung
- Lancashire and South Cumbria Resilience Hub, Lancashire and South Cumbria NHS Foundation Trust, Lancashire, UK
| | - Alysha A Hassan
- Cheshire and Merseyside Resilience Hub, Mersey Care NHS Foundation Trust, Liverpool, UK
| | - Sally-Anne Wright
- Lancashire and South Cumbria Resilience Hub, Lancashire and South Cumbria NHS Foundation Trust, Lancashire, UK
| | - Ellie Young
- Greater Manchester Resilience Hub, Pennine Care NHS Foundation Trust, Ashton-under-Lyne, UK
| | - Alan Barrett
- Greater Manchester Resilience Hub, Pennine Care NHS Foundation Trust, Ashton-under-Lyne, UK
- School of Health Sciences, University of Salford, Salford, UK
| | - Gita Bhutani
- Lancashire and South Cumbria Resilience Hub, Lancashire and South Cumbria NHS Foundation Trust, Lancashire, UK
- School of Psychology, University of Liverpool, Liverpool, UK
| | - Katherine McGuirk
- Greater Manchester Health and Social Care Partnership, Manchester, UK
| | - Fay Huntley
- Cheshire and Merseyside Resilience Hub, Mersey Care NHS Foundation Trust, Liverpool, UK
- Doctorate of Clinical Psychology, School of Health in Social Science, University of Edinburgh, Edinburgh, UK
| | - May Sarsam
- Cheshire and Merseyside Resilience Hub, Mersey Care NHS Foundation Trust, Liverpool, UK
| | - Hein Ten Cate
- Lancashire and South Cumbria Resilience Hub, Lancashire and South Cumbria NHS Foundation Trust, Lancashire, UK
| | - Ruth Watson
- Greater Manchester Resilience Hub, Pennine Care NHS Foundation Trust, Ashton-under-Lyne, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Jenni Willbourn
- Greater Manchester Resilience Hub, Pennine Care NHS Foundation Trust, Ashton-under-Lyne, UK
| | - Daniel Hind
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
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Härkänen M, Pineda AL, Tella S, Mahat S, Panella M, Ratti M, Vanhaecht K, Strametz R, Carrillo I, Rafferty AM, Wu AW, Anttila VJ, Mira JJ. The impact of emotional support on healthcare workers and students coping with COVID-19, and other SARS-CoV pandemics - a mixed-methods systematic review. BMC Health Serv Res 2023; 23:751. [PMID: 37443003 DOI: 10.1186/s12913-023-09744-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Pandemics such as COVID-19 pose threats to the physical safety of healthcare workers and students. They can have traumatic experiences affecting their personal and professional life. Increasing rates of burnout, substance abuse, depression, and suicide among healthcare workers have already been identified, thus making mental health and psychological wellbeing of the healthcare workers a major issue. The aim of this systematic review is to synthesize the characteristics of emotional support programs and interventions targeted to healthcare workers and students since the onset of COVID-19 and other SARS-CoV pandemics and to describe the effectiveness and experiences of these programs. METHOD This was a mixed method systematic review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the review was registered on PROSPERO [CRD42021262837]. Searches were conducted using Medline, CINAHL, PsycINFO, Cochrane Library, and Scopus databases. The COVIDENCE systematic review management system was used for data selection and extraction by two independent reviewers. The JBI (Joanna Briggs Institute) critical appraisal tools were used to assess the quality of selected studies by two additional reviewers. Finally, data extraction and narrative analysis were conducted. RESULTS The search retrieved 3161 results including 1061 duplicates. After screening, a total of 19 articles were included in this review. Participants in studies were nurses, physicians, other hospital staff, and undergraduate medical students mostly working on the front-line with COVID-19 patients. Publications included RCTs (n = 4), quasi-experimental studies (n = 2), cross-sectional studies (n = 6), qualitative interview studies (n = 3), and systematic reviews (n = 4). Most (63.4%) of the interventions used online or digital solutions. Interventions mostly showed good effectiveness (support-seeking, positive emotions, reduction of distress symptoms etc.) and acceptance and were experienced as helpful, but there were some conflicting results. CONCLUSION Healthcare organizations have developed support strategies focusing on providing emotional support for these healthcare workers and students, but it is difficult to conclude whether one program offers distinct benefit compared to the others. More research is needed to evaluate the comparative effectiveness of emotional support interventions for health workers.
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Affiliation(s)
- Marja Härkänen
- Department of Nursing Science, University of Eastern Finland, Yliopistoranta 1c, Kuopio, Finland
| | - Adriana López Pineda
- Department of Clinical Medicine, Miguel Hernandez University, San Juan de Alicante, Spain
- The Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Alicante, Spain
| | - Susanna Tella
- LAB University of Applied Sciences, Lappeenranta, Finland
| | - Sanu Mahat
- Department of Nursing Science, University of Eastern Finland, Yliopistoranta 1c, Kuopio, Finland
| | - Massimiliano Panella
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, Novara, Italy
| | - Matteo Ratti
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, Novara, Italy
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, Department of Public Health & Primary Care, University of Leuven, Leuven, Belgium
- Department of Quality Management, University Hospitals Leuven, Leuven, Belgium
| | - Reinhard Strametz
- Wiesbaden Business School of RheinMain University of Applied Sciences, Wiesbaden, Germany
| | - Irene Carrillo
- Health Psychology Department, Miguel Hernández University, Elche, Spain
| | - Anne Marie Rafferty
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College, London, UK
| | - Albert W Wu
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - José Joaquín Mira
- The Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Alicante, Spain.
- Health Psychology Department, Miguel Hernández University, Elche, Spain.
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