Building Resilience Among Frontline Health Care Workers: Strategies to Consider for Implementing Evidence-Based Practices

See brief report by Pietrzak et al

The coronavirus disease 2019 (COVID-19) pandemic has placed an exceptional strain on health care systems and frontline health care workers (FHCWs) around the world. As of December 30, 2020, 84 million COVID-19 cases and 1.8 million deaths had been identified.1 FHCWs have undergone extreme stressors including lack of personal protective equipment, high levels of exposure to the virus and to death, continuously changing working conditions, difficult care decisions as a result of limited resources, and management of the fluctuating needs of their families (eg, homeschooling). As a result, FHCWs have reported high rates of mental health symptoms. A seminal study conducted across 34 hospitals in China from January 29, 2020, to February 3, 2020, found that the majority of health care workers surveyed were experiencing distress (71%) and depression (50%), with increased risk of symptoms reported among FHCWs.2

Despite the overwhelming reports of mental health burden among FHCWs, in a recent JCP brief report, Pietrzak and colleagues3 astutely considered resilience and investigated the psychological protective factors among FHCWs in New York City. Analyzing data from 2,579 FHCWs during the onset of the pandemic, when New York City was the epicenter of the outbreak in the United States, the authors found that multiple factors including positive emotions, self-efficacy, purpose in life, and social support were strong correlates of psychological resilience. These findings lead to a timely and important question: How can we boost resilience among health care workers? To answer this question, we must first consider the characteristics of resilience and practices that have been shown to increase resilience.

Psychological resilience can be broadly defined as the capacity to adapt and thrive while facing adversity or challenging circumstances.4 The concept of building resilience, or improving one’s ability to maintain functioning during distressing times, has gained popularity among broad audiences including the general public and the research community. Evidence-based programs for boosting resilience have focused on increasing habits that protect against the development of problematic mental health symptoms, teaching positive coping skills, or both. A recent narrative review of resilience programs specifically for health care workers showcased a variety of practices for increasing both individual and organizational resilience.5 Individual practices included exercise, sleep hygiene, social support, and mindfulness. Organizational resilience programming included psychoeducation training, leadership support, feedback or small group discussions, and mental health counseling services, in addition to supporting the development and maintenance of individual resilience practices. Faced with an array of options for supporting FHCWs, health care organizations are tasked with deciding which practices are going to best fit the mental health needs of their staff during and after the COVID-19 pandemic.

Determining how to invest time, resources, and finances to support the mental health of FHCWs amid ongoing pandemic stressors is a daunting task for many organizations. Poor implementation of evidence-based programs can dilute intended effects and discourage staff. The risk the current crisis poses to the mental health of FHCWs necessitates a systematic implementation of evidence-based skills for resilience. Strategies from implementation science can be used to improve uptake of evidence-based practices into health care systems.6 We provide 3 implementation strategies that health care systems could consider leveraging to improve mental health support for FHCWs amid the COVID-19 pandemic.

Education and Training

Perhaps one of the most common strategies for implementing evidence-based programs is training. Resilience training for FHCWs as a response to infectious outbreaks has included psychoeducation related to the stress response and adaptive coping strategies such as promoting actions toward values, reducing avoidant behaviors, and problem solving.7,8 Due to the constraints of the COVID-19 pandemic, much of this training has been delivered to FHCWs virtually. Utilizing online platforms to host training content can enable FHCWs to flexibly engage with the content at times that fit their needs. Online training also has high scalability potential—a critical characteristic given the extraordinary number of health care workers around the world who have been on the front lines during the COVID-19 pandemic. Nevertheless, single-session webinars, workshops, or brief online courses may fail to address the evolving needs of FHCWs over time. In addition to addressing the widespread immediate need among FHCWs, strategies to build resilience should consider the potential long-term psychological burden resulting from the COVID-19 pandemic.

Ongoing Support

Research suggests that adoption and sustainability of an intervention improve with ongoing support.9 In response to the SARS 2003 outbreak, 3 versions of an online resilience program of varying length were developed and tested at Mount Sinai Hospital in Toronto, Canada. Results from a randomized controlled trial suggested that health care workers enrolled in the longest version of the course experienced greater improvements in interpersonal problems than health care workers enrolled in the 2 shorter versions of the course.7 Although the length of courses differed only by a magnitude of hours, findings from this study support consideration of dosage in resilience programming for FHCWs. Ongoing training or support can increase the dose that FHCWs receive of resilience building skills. Supplemental sessions can also be tailored to the needs of specific individuals or used to train internal “champions” who can provide additional support to peers. The training of peers can significantly aid the uptake of resilience building skills and sustainability of programming within health care organizations.

Triaging Infrastructure

The short-term, and potentially long-term, mental health consequences of the current pandemic indicate the need for a multitiered care system that includes prevention and intervention efforts.10 Health care workers within emergency departments are accustomed to triaging patients based on the severity of patients’ conditions. A similar logic can be applied to addressing the mental health needs of FHCWs. In alignment with the findings from Pietrzak et al,3 some FHCWs may already be engaging in resilience-promoting activities and require minimal support to prevent the development of mental health problems. Other FHCWs may be experiencing greater distress and benefit from skills training with ongoing support. A small, but meaningful, proportion of individuals are also expected to experience mental health problems that necessitate clinical care. The duration of the pandemic and multiple waves of infections increase the likelihood that the severity of FHCW mental health needs will fluctuate over time. A multitiered care system should be able to sufficiently address any such changes. One example of a care system created to support health care workers during the pandemic is the Center for Stress, Resilience, and Personal Growth (CSRPG) at Mount Sinai Hospital in New York.11 Services provided at the CSRPG were informed by system-wide stakeholder feedback and include mental health screening, resilience-promoting workshops, and personalized referrals.

In conclusion, identification and promotion of resilience factors among this population are important for mitigating the psychological consequences of the COVID-19 pandemic. Pietrzak and colleagues3 identified several key correlates of resilience (eg, positive emotions, self-efficacy, and social support) that are important targets for resilience programs within an organization. Yet, implementing resilience-building programs in a timely and sustainable manner remains a challenge, particularly in underresourced settings. Systems of care that include resilience training, ongoing support, and specialized services hold promise for improving mental health outcomes among FHCWs.

Published online: January 19, 2021.

Potential conflicts of interest: The authors have no potential conflicts of interest to disclose.

Funding/support: None.

REFERENCES

1.Roser M, Ritchie H, Ortiz-Ospina E, et al. Coronavirus pandemic (COVID-19): statistics and research. Our World in Data. March 4, 2020. Accessed January 1, 2021. https://ourworldindata.org/coronavirus.

2.Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3(3):e203976. PubMed CrossRef

3.Pietrzak RH, Feingold JH, Feder A, et al. Psychological resilience in frontline health care workers during the acute phase of the COVID-19 pandemic in New York City. J Clin Psychiatry. 2021;82(1):20l13749. PubMed

4.Fletcher D, Sarkar M. Psychological resilience: a review and critique of definitions, concepts, and theory. Eur Psychol. 2013;18(1):12-23. CrossRef

5.Heath C, Sommerfield A, von Ungern-Sternberg BS. Resilience strategies to manage psychological distress among healthcare workers during the COVID-19 pandemic: a narrative review. Anaesthesia. 2020;75(10):1364-1371. PubMed CrossRef

6.Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10(1):21. PubMed CrossRef

7.Maunder RG, Lancee WJ, Mae R, et al. Computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training. BMC Health Serv Res. 2010;10(1):72. PubMed CrossRef

8.Weiner L, Berna F, Nourry N, et al. Efficacy of an online cognitive behavioral therapy program developed for healthcare workers during the COVID-19 pandemic: the REduction of STress (REST) study protocol for a randomized controlled trial. Trials. 2020;21(1):870. PubMed CrossRef

9.Edmunds JM, Beidas RS, Kendall PC. Dissemination and implementation of evidence-based practices: training and consultation as implementation strategies. Clin Psychol (New York). 2013;20(2):152-165. PubMed

10.Marques L, Bartuska AD, Cohen JN, et al. Three steps to flatten the mental health need curve amid the COVID-19 pandemic. Depress Anxiety. 2020;37(5):405-406. PubMed CrossRef

11.DePierro J, Katz CL, Marin D, et al. Mount Sinai’s Center for Stress, Resilience and Personal Growth as a model for responding to the impact of COVID-19 on health care workers. Psychiatry Res. 2020;293:113426. PubMed CrossRef

aDepartment of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

*Corresponding author: Luana Marques, PhD, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, One Bowdoin Sq, 6th Fl, Boston, MA 02114 (lmarques@mgh.harvard.edu).

J Clin Psychiatry 2021;82(1):21com136869

To cite: Bartuska AD, Marques L. Building resilience among frontline health care workers: strategies to consider for implementing evidence-based practices. J Clin Psychiatry. 2021;82(1):21com136869.

To share: https://doi.org/10.4088/JCP.21com136869

© Copyright 2021 Physicians Postgraduate Press, Inc.