DURING THE OUTBREAK of severe acute respiratory syndrome (SARS) from 2002 to 2004, almost half of healthcare workers involved in the response experienced significant levels of clinical distress, with evidence of lingering effects 2 years later.1 Today, the COVID-19 pandemic has had similar effects. In 2020, when parts of New York went beyond surge capacity, healthcare professionals had to make triaging decisions for lifesaving care. Some patients could be offered only comfort measures. Inadequate personal protective equipment (PPE) also meant some nurses had to choose between protecting themselves and their families and taking care of critically ill patients.
In any crisis, having to make difficult decisions can cause moral injury, which can have long-lasting psychological implications. In addition, high levels of prolonged stress promote maladaptive coping behaviors that exacerbate the situation and undermine health, such as smoking, increased alcohol consumption, substance abuse, and sleep and/or eating disorders.1
Training in psychological first aid (PFA) is one strategy that can mitigate these adverse reactions and improve nurses' ability to cope. This article describes how to apply PFA principles to support nursing staff during periods of high stress.
Mitigation strategies: Laying the groundwork
In anticipation of catastrophic events involving demands on the healthcare system that are at or beyond surge capacity, mitigating efforts should be implemented immediately. Effective overall leadership, management structure, and a well-established chain of command should already be in place. Rationales for ethical guidelines that will be followed for triage decision-making in these circumstances should be clearly communicated with all healthcare workers.
Effective leadership should prioritize having adequate PPE and other essential equipment and supplies available and managers should intervene before workloads and stress levels reach a crisis level. In addition, healthcare systems should plan for and provide psychological support for healthcare workers experiencing overwhelming expectations with the potential for moral injury.
PFA is an evidence-based rapid intervention that may mitigate acute distress during a crisis while developing hope and supporting future recovery.1,2 Designed jointly by the federally funded National Child Traumatic Stress Network and the US Department of Veterans Affairs' National Center for Posttraumatic Stress Disorder, PFA addresses a person's acute reactions and immediate needs during and immediately following a crisis.3 PFA measures include providing safety and comfort, identifying immediate needs and concerns, offering practical assistance, promoting self-efficacy, reducing stress-related symptoms, and linking personnel to collaborative resources and social support.4 The goal is to address the immediate needs of staff and to facilitate the natural homeostatic process of returning to a precrisis level of functioning.5
Healthcare workers and others impacted by the COVID-19 pandemic or another crisis may find that PFA can help them return to a precrisis level of physiologic and psychological functioning faster than they might without it.2 Simply talking with others in an unstructured manner is not as effective as PFA in developing a hopeful perspective.2
Training in the specific techniques involved in PFA is available from a variety of resources (see For more information...). The training helps nurses recognize the signs and symptoms of distress and begin the process of providing PFA (see A brief example from the author's experience).
In 2011, the Johns Hopkins Health System instituted a peer responder program, called the Resilience in Stressful Events (RISE) program, to provide PFA to healthcare workers.6 When healthcare workers called for assistance after a traumatic clinical event, PFA-trained peers responded. The program not only improved participants' well-being, but it also improved patient safety. Additionally, the cost-benefit analysis found an estimated savings of more than $22,000 per nurse assisted by the program.6 Johns Hopkins continues to offer the RISE program today.7
Another study trialed administering PFA to small groups and found it to be effective.2 This may be more feasible within individual units and shifts at a hospital. Group administration of PFA may be considered during periods of high stress over an extended period of time.
Who can provide PFA?
One does not have to be a mental health professional to provide PFA, just as one does not have to be a nurse to provide first aid. During a crisis, nurses and other healthcare team members may simply not have the emotional capacity or availability to provide PFA. Training individuals outside of the immediately involved teams to administer PFA is a wise strategy.
Many nurse leaders already routinely round on their staff during high-stress times to touch base and see how they are doing. This may create an opportunity to provide PFA to a nurse in crisis. Ideally, PFA is administered during or immediately after a traumatic event occurs, but even with time delays, nurses report PFA can be a helpful means for providing support for previous clinical incidents that are still causing them distress.6
The first step a manager or other PFA provider can take is to express concern for the nursing staff and offer help. Acknowledge the nurses' point of view and identify immediate opportunities for assistance whenever possible. This can be as simple as pairing up nurses to ensure that each nurse can take a bathroom break in a reasonable period of time.
Address fear and any inappropriate measures taken to avoid the concern generating that fear.1 Provide accurate and timely information, offer truthful answers, and avoid making promises you cannot keep. Acknowledge that the stress level is extremely high for everyone and reinforce the overall good that the team is accomplishing, even though much may not be going according to plan.
Employ active listening while remaining nonintrusive and understand that some nurses may not wish to participate.1 PFA providers must also recognize that PFA may not be sufficient for some individuals. Some red flags that warrant immediate intervention or referral to a mental health professional include the potential for harm to self or others, longstanding or severe distress, and an inability to function in daily life.1 It is important to recognize that if mental health disorders do develop, it is not simply due to individual deficiencies but rather reflects the need to examine the system and environment in which the individual is functioning.
Despite not being the ideal providers of PFA, peers and unit leaders may be the first to become aware of a colleague's distress. As peers are perceived as being able to relate to a distressing situation, peers and unit leaders are often the first line of support that healthcare workers seek. As such, all healthcare workers should be prepared to offer PFA to each other as part of their professional role.6 However, recipients of PFA should feel comfortable freely sharing their thoughts, and this may not be the case if unit leaders are the ones attempting to provide PFA.
In the event that a leader attempts to provide PFA and is ineffective, consider involving a PFA provider who is not associated with the immediate leadership team. If that is not an option, the leader should try to look beyond the anger and frustration that may be inappropriately directed at management. Focus instead on what the frontline nurses are feeling in order to intervene and provide meaningful support as discussed below (see PFA principles and techniques).
Addressing basic needs is an important way to provide group PFA and decrease stress. Sensory overload associated with long shifts in layers of PPE without adequate breaks can be exhausting and overwhelming. Try to mitigate the effects of temperature, sound, and lighting in the environment as much as possible. Managers can advocate for stress-reducing options for staff, which may involve alternative housing for nurses exposed to high-risk infectious diseases, emergency childcare for essential workers, or security escorts to vehicles after atypically scheduled shifts.
If feasible, staff can be rotated between the most stressful roles and the less stressful roles. Managers should avoid overscheduling and be cautious about rotating day/night shifts as much as possible. Providing opportunities for adequate sleep are essential to continued functioning.8 Managers should also advocate for additional staffing as needed and protect the staff from burnout by prioritizing their physical and mental well-being.
Nurses who have experienced significant trauma should be supported and encouraged to take time off. When they return, they should be reintegrated into less stressful roles at first if possible.
If observed, stigmatization of staff by other members of the healthcare team should be addressed. For example, stress can induce unexplained physical symptoms in nurses, who may be stigmatized by peers for calling in sick or not functioning as well as normal with a heavy patient load. These nurses may be perceived as not carrying their fair share of the burden, or they may be accused of contributing to a generalized sense of anxiety among the rest of the staff. Assess and address any concerns fairly and discourage an “us versus them” mentality among the staff. Patient outcomes and morale are undermined if some individuals feel isolated or stigmatized by other team members.9
Staff and leaders alike should be encouraged to use time off to decompress whenever possible. Self-care is extremely important, but leaders must also recognize the limited options available to many nurses. Telling overworked and overwhelmed nurses they should practice self-care when they are assigned six 12-hour shifts in a row places blame on the nurses for their distress instead of the system. Providing bathroom breaks, hydration resources, opportunities to eat, and adequate air conditioning or fans for cooling during long shifts may seem insignificant, but such accommodations can make a substantial difference in the long run. After the crisis resolves, a program called skills for psychological recovery (SPR) may be useful for nurses who continue to have emotional or psychological challenges (see What is SPR?).
The primary goal with all of these interventions is to help healthcare team members develop stress management skills both in the moment and after the immediate event resolves.10 This applies to nurse managers and other leadership as well. Sacrificing one's well-being for the sake of the unit does not benefit anyone. Reach out for assistance.
The COVID-19 pandemic is ongoing, and other extended crises are inevitable in the future. Planning must include strategies for coping with extended durations of high patient-care needs with regular cycles of intense stress and demanding work, even as vaccination rates rise. Preventing and mitigating stress and trauma among healthcare workers is critical to the long-term success of pandemic control efforts. Taking care of the caregivers must be a national priority if we are to sustain our efforts for the long haul.
For more information...
- Additional training modules and resources are publicly available atwww.albany.edu/sph/center-public-health-preparedness-cphp.
- The American Psychological Association has a webpage with extensive resources regarding PFA atwww.apa.org/practice/programs/dmhi/psychological-first-aid/resources.
- For those preparing to offer PFA in the field, there is an app freely available atwww.nctsn.org/resources/pfa-mobile.
- The American Red Cross offers a free 1-hour online course with certificate in PFA training atwww.redcross.org/take-a-class/coronavirus-information/psychological-first-aid-online-course.
A brief example from the author's experience10
I provided PFA to a former student who had become a nurse leader and was immersed in the COVID-19 surge in New York City. She called me at 2330 hours from work one night. We had not spoken in years, but my former student remembered a pandemic exercise she had completed in one of my courses. We focused on creating a safe psychological space, stabilizing her response, addressing her immediate needs with very practical steps, and establishing connection as a support available to her. She later told me the 15 minutes we spent on the phone allowed her to regroup and refocus her efforts that evening and going forward. The situation was extremely stressful, and our conversation did not change that, but it did help her find a protective perspective that allowed her to face the adversity with a resilient mindset.
PFA principles and techniques
The list below lays out several principles and techniques of PFA that are key to positive outcomes.
- Identify those who need help and engage with them in a calm and tolerant manner. Introduce yourself and ask if you can help.
- Establish safety. Identify and contain any immediate threats and communicate this to the recipient of PFA. Emotional and physical support can be provided to stabilize individuals who may be having difficulty managing the experience.
- Identify the most pressing immediate needs and identify practical, feasible measures to address those needs. Involve the recipient as a problem-solving team member, identifying strengths and promoting as much agency with the posttraumatic environment as possible.
- Connect the recipient with others who provide support and assistance. This can be other friends and family or outside agencies who can help address pressing concerns and provide emotional support.
- Teach the recipient about normal stress reactions and steps that can help facilitate stabilization.
- Model hope. Focus on specific but accurate facts and realistic steps. Maintain and communicate empathy.
What is SPR?11,12
Skills for psychological recovery (SPR) is an evidence-informed modular intervention designed to follow PFA and give individuals of all ages the skills they need to cope with postdisaster stress and adversity. Developed by the National Child Traumatic Stress Network and the National Center for PTSD, SPR may be accessible through the employee-assistance program, or an institution may wish to consider making these services available after an episode that is likely to traumatize healthcare workers. SPR is designed to be administered by mental health or other healthcare professionals and is delivered after the immediate needs of safety and security are met and recovery has begun.
SPR requires the provider to build a collaborative and empathetic relationship with the affected team member and should be completed in private quiet sessions that last for about 45 minutes. SPR differs from counseling in that it is more like a coaching session to help individuals identify their most pressing needs and concerns, build problem-solving skills, promote positive activity and thinking, manage distressing reactions, and build healthy connections. During follow-up visits, the SPR provider and the individual focus on the specific goals and steps while enhancing motivation and preventing setbacks.
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