Introduction

the outbreak of COVID-19 posed enormous challenges for healthcare systems around the world. The rapid spread of infection and severity of symptoms increased the number of hospital admissions, resulting in a shortage of structural healthcare resources, mainly associated to workforce and medical supplies. In addition, professionals deployed to new areas lacked of competent skills and appropriate protection equipment. Moreover, there was a shortage of intensive care units (ICU) beds and ventilators, to cover COVID-19 patients’ demands ⁽⁽¹⁾. At patient level, the family contact restrictions during hospitalisation emerged emotional reactions which challenged the recovery process of the whole healthcare system.

Healthcare professionals were concerned about their families and their own safety because of the risk of spreading the infection at home, together with their ability to provide competent medical care⁽¹⁾. These concerns were associated with an increase in the workload, the lack of control of patient’s outcomes due to the absence of effective treatments, the severity of the symptoms, isolation of patients and accumulated losses. All these factors exposed staff to high levels of stress. Anxiety, negative thoughts (guilt, shame, etc.), mood disturbance, increased vigilance and reduced sleep quality prevailed among frontline staff,⁽²⁾ which was aggravated by the absence of positive reinforcement from social inputs because of isolation due to confinement restrictions⁽³⁾. The degree that would determine if the healthcare workers’ reactions are transient and adaptive to the events experienced or if they become chronic psychological reactions, would depend on their own resilience. Several modulators for resilience have been described, such as, the nature of distressing experiences, personal vulnerabilities, past experiences, organizational factors related to work climate, and sociocultural factors which may modulate the understanding of events⁽⁴⁾.

Several theories and empirically tested concepts in the field of emergency psychology have succeeded in preventing acute and chronic stress reactions and increasing resilience among professionals. Self-efficacy,⁽⁵⁾ defined as the perception of one’s cognitive capabilities to influence demands from the context and the neuropsychology approach of the stress response,⁽⁶⁾ focuses in cognitive strategies to silent emotionally loaded reactions by the hyperactivity of amygdala have been applied⁽⁷⁾.

From a psychodynamic perspective, defence mechanisms play a facilitator role in managing emotional demands and preventing work-related-anxiety among healthcare professionals⁽⁸⁾. On the other hand, when emotions have been contained for a prolonged period of time they can be activated through projective techniques when individuals try to find causes and explanations for life events⁽⁹⁾. Fantastic Reality⁽¹⁰⁾ is a projective technique, which uses images to transcend the individual into a fantastic reality while feeling in a safe cognitive space. This process can be explained by the neuropsychological mechanism through which images stimulate the visual cortex and the emotional memory simultaneously (when individuals freely associate content to the chosen image) connecting with the prefrontal cortex (when verbalising the perceived images), helping them to narrate traumatic and/or stressful experiences.

In addition, Mindfulness⁽¹¹⁾ and Cognitive Behavioural Therapies (CBT), such as, stress inoculation, anxiety management and exposure therapy have successfully contributed to facilitate self-regulation and preventing an acute stress disorder⁽¹²⁾.

At organizational level, group interventions have proven to be effective in gathering a complete picture of events that individuals have been exposed to and in normalising and sharing emotions among members who have been through the same process. Also, group interventions help cognitive restructuring, by which, individuals acknowledge and understand their experiences, in order to facilitate team cohesiveness, identity, and to repair individual and team confidence⁽¹³⁾. In this line, quality improvement tools to increase professionals communication, such as, TALK for clinical debriefing©⁽¹⁴⁾ and the Schwartz rounds® methodology to normalize and share emotions, have been successfully implemented in group format⁽¹⁵⁾. To maximise effectiveness, a multicomponent approach considering group, individual and environmental interventions have been reported to be more effective when managing traumatic stress at the work setting. Also, when psychological support is immediately available on site during a crisis event, these techniques can help to expose individuals to approximate to the pre-crisis psychological balance⁽¹⁶⁾.

When exposed to a rapid and devastating health emergency, the challenge is to find the relevant elements among all the evidence-based knowledge, and combine them in order to provide significant support to the main actors in a real-world context.

In order to prevent chronic maladaptive psychological reactions among hospital healthcare professionals facing first wave of COVID-19, a tailored ad hoc preventive psychological programme named Support Tools for Emergency Psychology (STEP) was developed. This preventive psychological programme was based on the theories mentioned above and implemented in our hospital setting. Our hypothesis was that professionals would value the possibility of accessing psychological support at the time of complex decision-making processes for patient care and workforce re-organization.

The objective of this study was to analyse the STEP programme in order to identify the key elements required to implement a psychological support service for frontline healthcare staff who faced the COVID-19 emergency.

Methodology

the study had a qualitative design, and it was carried out between March andJune 2020 in a public hospital in Girona, Spain, which has a capacity of 337 beds and provides healthcare coverage to 147 000 inhabitants. The workforce of our hospital setting is composed of approximately 733 healthcare professionals and 85 non-healthcare staff⁽¹⁷⁾.

At the peak of the first pandemic wave, the whole hospital required a reorganization to cope with the rapidly increasing demands. Most of hospital beds were allocated to patients with COVID-19 and many healthcare professionals, including the psychologist, were relocated to different areas. A voluntary multidisciplinary frontline team of 8 psychologists was created to provide support to hospital staff, patients and their families. The background of the voluntary psychology team varied from clinical psychology, palliative care, emergency psychology, neurodegenerative disorders and neuro-rehabilitation psychology. This team developed the STEP programme, aimed to provide support to hospital staff. This programme was implemented in areas in which frontline clinical care is provided and included both, individual and group interventions.

Results

three hundred professionals participated in the study, 100.0% in STEP 1.0 group interventions, 27.3% in STEP 1.5, 2.7% in STEP 2.0 and 10.0% in individual interventions (Table 5). Twenty two professionals out of 110 (20.0%) self-requested for group interventions to be conducted. Line managers or hospital prevention services requested the rest of group interventions. Within STEP 1.0 (concerns, needs and support required), risk of infection and self-confidence on managing patients’ symptoms were the most common concerns at the beginning. Professionals received self-care advice and training on effective communication with patients’ families and with team members, such as, protocols for breaking bad news and for making condolence calls⁽¹⁸⁾. Working in a supportive team was the key factor more often associated with resilience by professionals. . Learning points included to share and normalise concerns, to identify supportive colleagues, and to prioritise demands were the learning points emerged with STEP 1.0Regarding STEP 1.5 variables (road pictures, resilience and learnings), on average, each professional chose to conduct this exercise using one picture. Several characteristics of road pictures facilitated participants’ projection of emotions (Figure 1), and a list of associated thoughts and reported coping strategies was identified, allowing participants to implement and learn from them (Table 6). Pictures facilitated the ventilation of emotions and were associated with thoughts when professionals rememorized the outbreak experience. For instance, fear and rage were associated to isolation when coping with the requirements of new roles. Distress and anxiety were associated with lack of protective equipment. Insecurity and anger were associated with lack of consistency in the information provided to professionals. Emotional lability, hopelessness and sadness were associated with their perception of a lack of validation from managers. Hopelessness and impotence were associated with frustration about deceases.

Figure 1: Road Pictures. A sample of the most frequently road pictures* selected by professionals to describe how they perceived their experience during the COVID-19 outbreak. STEP programme targeted to staff of a public hospital in Girona, Spai. 

Regarding professionals who suffered COVID-19 infection, emotions and thoughts did not differ from the rest of participants. However, resilience was different, as it was more difficult for them to adapt on their return to work because of the persistence of COVID-19 symptoms, and some reported symptoms of agoraphobia. They acknowledged that the infection process made them aware of the importance of positive thinking skills and stop being self-demanding. They also valued sharing their experience with other colleagues who had been through the same process.

STEP 2.0 variables showed that confronting professionals with a quick body scan was intended to help them to experience the benefit of 5 minutes break to focus their attention on the present circumstances, moment-by-moment, observing without interpreting to achieve self-control. This tool was introduced to just one group who had not been through the STEP 1.5, and the initial benefits were rapidly dismantled by a need to ventilate. No further implementation of this tool was possible, as de-escalation started and STEP programme was interrupted.

A total of 203 professionals (response rate 67.7%) responded to the questionnaire, including doctors, nurses, nursing assistants, admin support, pharmacists, radiologist, social workers and hotel services. Professionals stated that they needed emotional support (71.0%), particularly on feelings (59.0%) rather than thoughts (26.0%). In addition, they preferred group format during working-shifts (61.0%) rather than online workshops after work (9.0%) or paper-based materials (33.0%); 24% preferred individual sessions.

Finally, focus group with psychologists showed professionals’ characteristics associated to individual therapy. Psychologists reported that 30 professionals received individual interventions, 10 (33.3%) of which were requested by professionals’ themselves. The average number of sessions per professional was three. The factors present in those professionals who required individual therapy were caring for dependants, lack of access to childcare, being deployed to a new professional role, communication difficulties among the members of the team, excessive clinical workload, pre-existing anxiety and/or other mental health disorder, grief process due to a deceased in the family, being infected by COVID-19, lack of a social network or living alone. In relation to defence mechanisms emerged at STEP 1.0, psychologists identified that initially, when professionals were high on adrenaline, the most frequently observed defence mechanisms were dissociation and denial of physical signs and emotions associated to stress.

Discussion

this study showed that initially, when demand overloaded capacity, self-protection and self-efficacy, particularly on managing patient families’ demands and improving communication with new team members, appeared to be the main concerns. Subsequently, a request for emotional support, particularly on managing feelings contented, was needed. In addition, working in a supportive team was associated to increased resilience. On the other hand, caring for dependents, a lack of social network, living alone, experiencing a grief process, being infected by COVID-19, pre-existing mental health conditions, and non-adjustments within the team were vulnerabilities for a referral to individual therapy.

The STEP programme helped to identify these needs and to tailor interventions based on sound knowledge on stress management at the workplace during a healthcare emergency. For instance, WHO recommendations focus on the need to normalize strong emotions and stress, to address self-care, social support, clear communication and distribution of tasks and the utilization of psychosocial and psychological help without stigmatization⁽¹⁹⁾. The clinical tool STEP 1.0 provided professionals with self-care guidance, improving team communication and professionals’ self-efficacy to confront patients’ isolation and the requests from families. Self-efficacy¹ and self-care⁽²⁰⁾ have also been reported as major concerns in professionals deployed into new roles. The implementation of STEP 1.0 facilitated the development of targeted educational materials accordingly in order to empower professionals. The clinical tool STEP 1.5 facilitated the emotional healing which literature reports as necessary to achieve adaptive responses after the outbreak⁽¹², ²¹⁾. It was a professionals’ request the need to ventilate emotions, and the STEP programme facilitated to bring contented emotions to the surface and ventilate while helping to process potentially traumatic experiences at the same time. The group intervention format helped to stress the normalisation of those reactions and contributed to a constructive, rather than traumatic, narrative of the experiences that professionals had been through.

Although, STEP 2.0 could not be implemented widely, as the de-escalation process was initiated, the experience reassured us that interventions were supportive when followed a chronological phases approach with specific needs and concerns required to address. At the beginning of the “Cognitive” phase, infection and self-efficacy were major concerns, and dissociation and denial of stress physical signs were the defence mechanism more active. The “Ventilation” phase was characterised by the expression of contented emotions when it was required, and the “Recovery” phase occurred when the clinical overload decreased and professionals were able to focus on emotions management training. Emotional ventilation was not found to be useful when introduced during the cognitive phase, and training on emotions management should only happen after ventilation. In addition, the implementation of face-to-face psychological support at frontline and during working shifts were the preferences reported by professionals

Our study has strengths and limitations. The fact that an external and blinding evaluation of measurements was not possible and a more elaborated statistical analysis was not conducted may bias the interpretation of our results. However, data were evaluated by two psychologists and training sessions were conducted previously to group interventions to unify criteria. This contributed to reduce variability and potential bias. In addition, professionals’ participation on STEP programme activities was high, we had a large sample including both healthcare and non-health workers, which increased representativeness and external validity, making it more pragmatic and applicable. STEP programme contributed to overcome professionals’ stigma linking psychological support to mental health weakness, therefore rejecting any psychological aid. For instance, interventions based on self-administrated computer-based educational programmes have reported high levels of attrition of about 40%⁽²²⁾.

In conclusion, the STEP programme showed that professionals’ needs and demands changed along with the outbreak overload so interventions had to be tailored accordingly. Future research should analyse the impact of professionals’ resilience in patients’ outcomes and their satisfaction.