'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

Do errors in the GHQ-12 response options matter?

Background: The twelve item General Health Questionnaire (GHQ-12) is a widely used measure of psychological wellbeing. Because there are seven different sets of response options across the twelve items, there is scope for transcription errors to occur when researchers assemble their study materials. The impact of such errors might be more important if they occur in the first set of response options than if they occur later in the questionnaire, once participants have become aware that options to the right of the GHQ-12 response sets always indicate worse wellbeing. Aims: To test the impact of introducing errors into the first and eighth set of response options for the GHQ-12 that render those response sets partially illogical. Methods: We used a double-blind randomised controlled trial, pre-registered with Open Science Framework (osf.io/syhwf). Participants were recruited by a market research company from their existing panel of respondents in Great Britain. Participants were randomly allocated to receive one of three versions of the GHQ-12: a correct version (n=500), a version with a mistake in the first item (n=502), or a mistake in the eighth item (n=502). Mistakes replaced ‘better than usual’ (item one) or ‘more so than usual’ (item eight) with ‘not at all.’ Results: We found no differences between the versions in terms of number of participants with possible poor psychological wellbeing (χ2=0.32, df=2, p=0.85) or in mean GHQ-12 scores for the three groups (F(2, 1501)=0.26, p=0.77). Conclusions: Small deviations from the standard GHQ-12 wording do not have a substantive impact on results

Data files supporting "<b>Do errors in the GHQ-12 response options matter?"</b>

Background: The twelve item General Health Questionnaire (GHQ-12) is a widely used measure of psychological wellbeing. Because there are seven different sets of response options across the twelve items, there is scope for transcription errors to occur when researchers assemble their study materials. The impact of such errors might be more important if they occur in the first set of response options than if they occur later in the questionnaire, once participants have become aware that options to the right of the GHQ-12 response sets always indicate worse wellbeing.Aims: To test the impact of introducing errors into the first and eighth set of response options for the GHQ-12 that render those response sets partially illogical.Methods: We used a double-blind randomised controlled trial, pre-registered with Open Science Framework (osf.io/syhwf). Participants were recruited by a market research company from their existing panel of respondents in Great Britain. Participants were randomly allocated to receive one of three versions of the GHQ-12: a correct version (n=500), a version with a mistake in the first item (n=502), or a mistake in the eighth item (n=502). Mistakes replaced ‘better than usual’ (item one) or ‘more so than usual’ (item eight) with ‘not at all.’Results: We found no differences between the versions in terms of number of participants with possible poor psychological wellbeing (χ2=0.32, df=2, p=0.85) or in mean GHQ-12 scores for the three groups (F(2, 1501)=0.26, p=0.77).Conclusions: Small deviations from the standard GHQ-12 wording do not have a substantive impact on results.</p

Data files supporting "Do errors in the GHQ-12 response options matter?"

Background: The twelve item General Health Questionnaire (GHQ-12) is a widely used measure of psychological wellbeing. Because there are seven different sets of response options across the twelve items, there is scope for transcription errors to occur when researchers assemble their study materials. The impact of such errors might be more important if they occur in the first set of response options than if they occur later in the questionnaire, once participants have become aware that options to the right of the GHQ-12 response sets always indicate worse wellbeing.Aims: To test the impact of introducing errors into the first and eighth set of response options for the GHQ-12 that render those response sets partially illogical.Methods: We used a double-blind randomised controlled trial, pre-registered with Open Science Framework (osf.io/syhwf). Participants were recruited by a market research company from their existing panel of respondents in Great Britain. Participants were randomly allocated to receive one of three versions of the GHQ-12: a correct version (n=500), a version with a mistake in the first item (n=502), or a mistake in the eighth item (n=502). Mistakes replaced ‘better than usual’ (item one) or ‘more so than usual’ (item eight) with ‘not at all.’Results: We found no differences between the versions in terms of number of participants with possible poor psychological wellbeing (χ2=0.32, df=2, p=0.85) or in mean GHQ-12 scores for the three groups (F(2, 1501)=0.26, p=0.77).Conclusions: Small deviations from the standard GHQ-12 wording do not have a substantive impact on results

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

sj-docx-1-hpq-10.1177_13591053221140255 – Supplemental material for ‘You get looked at like you’re failing’: A reflexive thematic analysis of experiences of mental health and wellbeing support for NHS staff

Supplemental material, sj-docx-1-hpq-10.1177_13591053221140255 for ‘You get looked at like you’re failing’: A reflexive thematic analysis of experiences of mental health and wellbeing support for NHS staff by Corinne Clarkson, Hannah R Scott, Siobhan Hegarty, Emilia Souliou, Rupa Bhundia, Sam Gnanapragasam, Mary Jane Docherty, Rosalind Raine, Sharon AM Stevelink, Neil Greenberg, Matthew Hotopf, Simon Wessely, Ira Madan, Anne Marie Rafferty and Danielle Lamb in Journal of Health Psychology</p

Psychosocial impact of the COVID-19 pandemic on 4378 UK healthcare workers and ancillary staff:Initial baseline data from a cohort study collected during the first wave of the pandemic

OBJECTIVES: This study reports preliminary findings on the prevalence of, and factors associated with, mental health and well-being outcomes of healthcare workers during the early months (April–June) of the COVID-19 pandemic in the UK. METHODS: Preliminary cross-sectional data were analysed from a cohort study (n=4378). Clinical and non-clinical staff of three London-based NHS Trusts, including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire. Secondary outcomes are probable anxiety (seven-item Generalised Anxiety Disorder), depression (nine-item Patient Health Questionnaire), post-traumatic stress disorder (PTSD) (six-item Post-Traumatic Stress Disorder checklist), suicidal ideation (Clinical Interview Schedule) and alcohol use (Alcohol Use Disorder Identification Test). Moral injury is measured using the Moray Injury Event Scale. RESULTS: Analyses showed substantial levels of probable CMDs (58.9%, 95% CI 58.1 to 60.8) and of PTSD (30.2%, 95% CI 28.1 to 32.5) with lower levels of depression (27.3%, 95% CI 25.3 to 29.4), anxiety (23.2%, 95% CI 21.3 to 25.3) and alcohol misuse (10.5%, 95% CI 9.2 to 11.9). Women, younger staff and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of one’s moral code) was strongly associated with increased levels of probable CMDs, anxiety, depression, PTSD symptoms and alcohol misuse. CONCLUSIONS: Our findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic