The task of the organisation
Principle 1
To avoid duplication of work and fragmentation of services, the range of psychological support options needs to be coordinated with multiple partners across the system.
Principle 2
The physical safety and health of staff needs to be the priority until the threat has passed for that individual person.
Principle 3
Informal support, relationships and connectedness needs to be fostered.
Principle 4
Empathy and normalisation in leaders are the cornerstone of a resilient system.
Principle 5
Strengthen natural supports of staff and capitalise on their knowledge, foster empowerment and value their resourcefulness.
There are a number of practical responses that are needed at different stages. The acute stage represents the busiest period in the midst of the crisis. Then the recovery stage will take place to varying degrees as the crisis is over, bearing in mind that this will be different for different groups of people in situations of ongoing threat. The other dimension is one of severity. Different support responses are required to accommodate different levels of distress at different times. However the principle is that whilst in the midst of a crisis staff need for rest and basic needs should be met first. It is only after they can slow down that they will be able to think.
Prevention of overwhelming distress or ongoing disorder in the first stages of an epidemic
- Adequate infection control in place in line with WHO or government advice.
- Give staff accurate information from credible sources.
- Provide a place to rest or live near the hospital, where staff can isolate themselves from family if they are with infected patients.
- The organisation can arrange for meals to be provided whilst on shift and possibly daily living supplies for staff.
- Training delivered on managing the disease in people who use the services.
- Training delivered in psychological first aid to support each other.
- Peer support networks to be facilitated.
- Provide confidential spaces with people to turn to for informal support that is easy to access and in the moment.
- Allowing personal circumstances and concerns to be considered in deployment.
- Online solutions available for training and support.
- Collaboration with other agencies on support options.
- Specialised advice for leaders on the potential impact of their decisions from mass trauma experts.
- Trained trauma supervisors for those supporting the wellbeing of frontline staff.
- Put in place screening and monitoring for ongoing distress.
The management of severe distress
- It is important to normalise most reactions.
- For ongoing or debilitating distress, there needs to be clear and confidential referral routes for psychological therapy.
- Screening should happen over time and prompt referral to specialist services with clear pathways for when this should happen.
- Most demand will increase after the immediate threat has passed or people start to experience or witness deaths.
- Supervision and training of therapists who conduct therapy needs to be in place before the demand increases.
- This therapy should be provided by existing services, perhaps with enhanced staffing if possible.
- Therapy should follow NICE guidance where appropriate and be matched to the needs and preference of each person.
Immediate responses to support staff in the acute phase
The operational debrief
Why
This is an opportunity to ensure the epidemic is being properly managed. It is about processes and lessons (repeated as often as needed). Do we have enough supplies, staff, what’s working, what is working less well, etc. Who did what and how did it go. What is needed for the service to operate effectively. This needs to be documented and for the effectiveness of the organisational response to be discussed in order to identify lessons learned and good practice and whether any revisions to the Plan are required. A local debrief immediately after the incident allows staff to feedback on their department’s performance and the overall response. This also gives staff information that can resolve the development of emerging ideas, beliefs or emotions that could lead to ongoing psychological issues.
When
A hot debrief can be held regularly during the epidemic, but definitely once the stand down process is complete and could involve all key staff involved in the response.
How
The debrief procedure is a constructive review process which should be undertaken in an open, honest, and ‘no blame’ atmosphere. All issues discussed during the local debriefs should be passed on so that they can be incorporated into the overall debrief and post-incident report. The debrief could thank staff involved for their contribution, highlight issues and problems with procedures, allow staff to provide their perspective on management of the incident as well as identify good practices and procedures, and identify any long-term follow-up needs of staff.
Follow up
Any issues or concerns raised here could be investigated and reported back on at the ‘Cold debrief’ which should take place after the epidemic is over.
Informal psychological support
Why
As social animals we can be helped to regulate the impact of threat by the people around us. We can use our networks and compassionate motivation to connect with people and by doing so lessen the impact of any incident or stress. This form of support and debriefing is best separated from operational issues, because it is for the purpose of the wellbeing of staff. To ensure they have what they need to continue to tolerate their role. Space and time for emotions to be expressed, if wished, without judgement.
When
Ongoing but particularly in the first hours, days or weeks and afterwards if any changes are noticed in how staff are functioning.
How
Make an effort to ask colleagues how they are and create space and time for a conversation, ‘banter’ and slowing down after a busy shift. Formal psychological debriefing is not recommended by the evidence. This is anything that gets staff together at an appointed time to talk about their feelings after an incident. It is also recommended that behavioural reactions and emotions be understood and normalised rather than sending people for therapy or counselling. Systems should be set up for staff to support each other, as they are the valued networks and connections that can help people feel more regulated.
Follow up
Ask what they would like. Don’t leave colleagues isolated.
Information on reactions and support
(Psychoeducation & communication)
Why
To give clear messages so people know what reactions are typical and how to help themselves and others.
When
In first days and then again after a month.
How
Usually written material or videos or online links. This should address a full range of reactions, what people can do to help themselves, how to support others who are affected, what to look out for that might indicate people need additional or specialist support.
Follow up
In the case of all mass casualty events it is good practice to follow-up with screening after one month and at regular intervals.
Ongoing responses to support for staff in the acute phase
Early psychological intervention
(Psychological first aid)
Why
To reduce immediate distress and promote adaptive coping, problem solve with practical issues and feel connected with others.
When
Multiple sessions should be available flexibly and linked to places where people may be, for example staging areas, feeding stations, etc.
How
The emphasis on normalising a whole range of reactions, especially those within weeks of the event. Stages: Protecting from further harm; Opportunity to talk without pressure; active listening; compassion; addressing and acknowledging concerns; discussing coping strategies; social support; offer to return to talk; referral on to other services. This is delivered by a network of staff peer supporters who have had training and are supported by experts in this role.
How
Yes if the person wants to take it up.
Telephone support
Why
A source of confidential support, listening and advice out of hours.
When
These services are available 24 hours a day 7 days a week and can be accessed via telephone, email or other social media platforms (please see websites).
How
Open access to 24 hour help through helplines such as the Samaritans, Red Cross or other services. The services offer a trained listening ear to help you talk about your experiences and think about how best to cope.
Follow up
The person can ring as often as required.
Urgent Mental Health Team Support
Why
To help you or someone you care about if they are in immediate need of psychological help. The incident may have made a pre-existing mental health problem worse, or they may be feeling that they may harm themselves.
When
At any point. Such services are available 24 hours a day 7 days a week.
How
Services available may include out of hours home treatment via crisis teams that are aimed at support for people in extreme distress. Liaison teams can see people who have been physically injured and ended up in acute hospitals or Accident and Emergency as a result of the event. People may be offered a telephone assessment or a face to face meeting with a mental health professional who will assess immediate psychological needs and make a plan with you. They will want to make sure the person is safe, which may include referral for psychiatric admission. Some organisations may have specialists in mental health working alongside their occupational health teams that staff can access.
Follow up
Once assessed, and depending on the outcome, the person may be followed up by the mental health practitioner who assessed them or by their family doctor.
Breaking bad news or discussing death
Why
To give clear messages about the outcome of the illness, whether that is death or disability. To support the person given the message whether it is the person injured or their family member.
When
As soon as possible after the outcome of the illness is clear.
How
Being clear about the message that is given. Supporting someone to understand the impact of the news and tolerate the grief. Allow someone space to react without services or staff panicking about those reactions. Listen empathically, don’t judge. Give normalising information where possible and be alongside someone as they absorb the information and adjust. Remind them of their options for help and support. Help them find and access support from others and check what they have understood. Help them consider practical things that need attention.
Follow up
Yes, if possible. It may be the person who has broken the news or it may be possible to keep a list of people involved in a serious incident that can be follow-up up afterwards. The follow up services for psychological care need to be visible and marketed most intensively for the first six months but for at least two years afterward the epidemic. Access to services and the impact on the community may be life-long.
Longer term actions to support staff in the recovery phase
Screening
Why
To detect people affected by the events whose reactions are not easing off with support or time. These people may need more help in resolving the impact. To pick up specific post event psychological reactions such as depression, post traumatic stress disorder, dissociation.
When
Useful only after the threat is over. This is because many reactions are common during the outbreak but resolve better without active intervention. Screening can take place any time after an event, even up to many years later.
How
Usually via questionnaires or structured interviews. However, this needs to be accompanied by some qualitative information. This should be about the suitability of therapy and what kind of support the person thinks would be acceptable.
Follow up
If screening indicates an ongoing problem with symptoms or coping or functioning or risk then more specialist or intensive support should be offered. This should be within a couple of weeks.
Psychological therapy or treatment
Why
It is provided by a trained practitioner that helps you understand and cope with your worries and bad experiences differently. This may be one to one or in a group. It usually involves talking, although there are other methods, for example art and eye movements. It usually involves a series of regular appointments.
When
If screening indicates it then it is offered at some point four weeks after an event.
How
There are various methods for many post traumatic reactions. NICE recommends ‘trauma focused cognitive behavioural therapy’ (TF-CBT) or ‘eye movement desensitisation and reprocessing therapy’ (EMDR).
Follow up
People should know who to contact or via their GP if problems persist or recur.
The Operational and Organisational Learning Lessons
Why
Report the findings of any investigation. This includes the lessons learnt and the actions taken to improve the system’s response for the future.
When
Usually as soon as possible after the incident.
How
Include people in hot debrief session in conversation as above.
Follow up
All the issues raised in the earlier sessions could be included in the post-incident report. This should be completed after the epidemic is over. The post-incident report can be produced and circulated widely to assure staff. It should include recommendations for improvement in the Incident Response Plan.
Action planning for staff wellbeing in organisations and communities
The following is a list of prompts for organisations. It helps them consider how they can support staff during a major incident, mass casualty event or disaster. It will be useful to outline actions for each of these. This includes outlining any gaps and risks, mitigating actions against these and detailing who is responsible for each. And also ensuring adequate delegation and coordination:
Prompts for organisations
- What are you doing to keep your staff safe and well in line with guidance?
- What do they need to do their role?
- What mechanisms are there for staff feedback and ideas on operational issues?
- How can you facilitate informal staff support and networking?
- What clear early messages are you giving to staff and are communication routes thorough?
- How are you maintaining established support systems and wellbeing services?
- How are you preparing staff to monitor their wellbeing over time?
- How are leaders and managers supported to be empathic and non-judgemental of the range of reactions?
- What information do you have that lets people know what reactions to expect and how they can cope under specific circumstances?
- How are you governing adherence to the evidence base on wellbeing?
- How are you ensuring co-ordination of efforts around wellbeing (including across agencies)?
- What pathways do you have for more intensive or specialist psychological support for those who need it? (And ensuring these are sustained over a 3 year time period?)
- How can you manage staffing so that staff have rest time now. To have rotation away from high stress roles and fewer demands after the crisis?
- What can you do to develop capacity in psychological first aid and peer or mutual support?
- What use are you making of online solutions and technology in the above?
- What trauma expertise can you draw on or develop to provide scaffolding to support the leaders and staff supporters in their efforts?
- How can you show staff they are valued and appreciated?
- What do they need to do their role?
- What mechanisms are there for staff feedback and ideas on operational issues?
- What are you doing to keep your staff safe and well in line with guidance?
- What do they need to do their role?
- What mechanisms are there for staff feedback and ideas on operational issues?
Unhelpful Organisational Responses
- Not allowing or enabling individuals to be active in their own recovery.
- Interrupting the usual support processes in deference to those organised or provided. We should enable the natural support processes as far as possible. Like a lifeboat, most systems or individuals will find ways to self-right.
- Lack of validation or no support offered.
- Going straight back into busy roles and business as usual.
- Management interventions aimed at exploring responsibility and unpicking events are linked to increased self-blame or negative appraisal.
- Not being given a choice regarding attending group debriefing or being told it is mandatory.
- Placing people into a group, who have completely different experiences of the incident than other members.
- Lack of training or competency in early psychological interventions. Feeling forced to talk about things during the crisis.
- Having your reactions pathologized when in fact a range of emotions are normal in abnormal circumstances.
- Getting staff together for the purpose of talking about their emotions to prevent the development of mental health problems (or other one off group based intervention) is not recommended by NICE.
Some things to think about
Let yourself be aware of how you are feeling reading this information
- Thinking about what you have read here, can you identify three key issues that are particularly relevant for you? Why do they stand out?
- Can you describe two responses that can be helpful in the acute phase of a major incident and two that can be helpful in the in the recovery phase?
- How can organisations support staff wellbeing? What represents an unhelpful response? Can you think of positive and negative examples in your own workplace and the impact this had on staff wellbeing?