Exploring the needs of healthcare workers receiving psychological first aid during the COVID19 pandemic

2.1 Participants

The sample was comprised of 15 HCW from the Montreal Centre Intégré Universitaire de Santé et Service Sociaux de l’Est-de-l’Île-de-Montréal (CIUSSS-EMTL) working during the COVID-19 pandemic (i.e., since March 2020). Participants occupied various professional roles, including social workers (5), beneficiary attendants (3), behaviour technicians (3), a nutritionist, a nurse, a research coordinator, and a research assistant. The COVID-19 pandemic significantly altered HCW’s working conditions, exposing them to tremendous workload [16] and lack of proper protective equipment [17]. Moreover, HCW had to constantly adapt to changing guidelines [18], while also being the most at risk of being infected by the COVID-19 pandemic [19]. All participants were women between the ages of 24 and 60 years (M _age  = 40) who had received from the PFA service within their workplace. With respect to sample size, our aim was to reach data saturation, which occurs when no new information emerges when adding empirical data [20]. According to Guest et al., data saturation can be reached after twelve interviews and basic elements for metathemes were present after six interviews [21]. We used a convenience sampling method, as only a small number of workers had used the PFA service at the time of recruitment.

2.2 Procedure

The present study was approved by the CIUSSS-EMTL’s ethics committee (ethical approval code: 2021-2391). Informed consent was obtained from all participants. This project was part of a larger ongoing implementation study, which evaluates the implementation of PFA through PFA providers within major healthcare organizations in the Montreal area. It is noted that PFA offered by peer supporters was implemented rapidly as a response to the increasing psychological problems among HCW during the COVID-19 pandemic. In the present study, PFA providers were trained to administer the intervention were either peers with experience in providing psychological assistance (e.g., clinical psychologists) or social workers in position of authority (e.g., managers). Moreover, each PFA provider belonged to the same team as the person receiving the intervention. In terms of recruitment, invitations were sent by email to HCW who had received PFA, to invite them to discuss their experience during an interview. At all times, participation to this study remained voluntary and confidential. Participants signed a consent form prior to the start of the interview. All of the interviews were recorded, transcribed, and anonymized for analysis. Each participant was assigned an identification number, which was used throughout the study to anonymize their identity. The list of names containing the identification numbers was password-protected and access was limited to the first author, the supervisor, and project coordinator. Personal information shared by the participants during the interviews were changed to a general statement (e.g., name of PFA provider).

2.3 Interviews

A semi-structured interview grid was created using the grid from larger PFA implementation project, with only questions pertinent to the present study. The interviews were conducted individually by the project coordinator, in French. The project coordinator and participants did not know each other and did not work together; therefore, no power dynamics exited between the interviewer and the interviewees. The interviews were carried out by phone and recorded for further transcription. The grid was used for each interview, and various prompts were planned for further exploration. Questions inquired about various themes: the needs which led participants to ask for a PFA provider, appreciation of the intervention, needs that were met (or not met) by the intervention, and the perceived barriers and/or facilitators regarding the request for help. Exploring the aforementioned themes allowed a rich description of the help-seeking process for HCW who experience psychological distress at work, as well as their perceived satisfaction of the PFA intervention. Individual semi-structured interviews were conducted between January 2021 and June 2022 and lasted on average 24 minutes.

2.4 Analysis strategy

A thematic analysis was conducted based on the method of Braun and Clarke, which aims to transpose the data into themes that depict the content of the corpus [22]. This process allows to synthesize the participants’ discourse into themes and subthemes. Specifically, the six phases of thematic analysis presented by Braun and Clarke were conducted, and coding was done inductively with a word-processing software (Microsoft Word) [22]. An initial reading of verbatim was conducted to become familiar with the general contents (phase 1). During the second reading, thematization began by assigning codes to each grouping of sentences, which referred to either a need/expectation, the phenomenon of asking for help from HCW, and/or what was involved in the delivery of PFA (phase 2). Each code was listed in a separate document. After coding the verbatim, the code list was analyzed to create initial themes from the combination of codes, with the purpose of forming an overarching theme and subtheme (phase 3). A table was then constructed with all themes, subthemes, and extracts. A review of the themes was realized with the overall table (phase 4). A thematic map was also constructed in the phases 3 and 4 to enable a fast and comprehensive understanding of the data. Next, all of the themes were defined and described in relation to the collected data (phases 5 and 6). An inter-judge agreement of themes with seven participants was carried out with the first and the third authors to validate each theme and subtheme (64%). Data saturation was obtained in terms of general themes with seven participants. To achieve a consensus, themes were redefined, devised and/or combined. For example, the two similar themes: 1) Suffering leads to help-seeking and 2) PFA matches participants’ needs were combined into one (PFA satisfied participants’ psychological needs). Lastly, a final round of validation included all participants and was conducted with the supervisor and the second author. The second author translated all citations put in the result section.

3.1 PFA satisfies participants’ psychosocial needs

Various psychological needs led participants to request the help of a PFA provider. All of the participants expressed they were experiencing psychological difficulties at least once since March 2020. Several participants reported that they needed help to reduce specific manifestations of psychological distress. Various manifestations were reported by participants, ranging from feelings of anxiety to suicidal thoughts:

The most common need reported by participants seeking the PFA service was to obtain tools and strategies to cope with their psychological difficulties. Tools referred to concrete materials that could be given to participants, such as documents that had an educational purposes, while strategies referred to prescriptive advice that participants could apply in concrete ways. Participants reported various tools/strategies provided by the PFA provider including: receiving education on symptoms following a traumatic event, being introduced to relaxation mobile app, educational documentation, learning positive coping strategies, and/or being referred to other specializedresources:

The second most common need reported by participants was to feel validated regarding difficult situations they were experiencing in their work settings. For example, in response to having seen disturbing situations at work during the first wave of COVID-19, it was important for participants to be validated after expressing their feelings. Participants reported that the support received by PFA providers satisfied their need for emotional validation. Specifically, PFA providers offered participants validation through the normalization of the various reactions they were experiencing. Such normalization reassured participants that their reactions were normal within the context:

However, the need for emotional validation was not met for all participants. A participant felt like they were being slapped on the wrist because the PFA provider gave feedback regarding the potentially traumatic event while proposing solutions based on protocols:

For several participants, a third need for seeking the PFA service was to obtain a better understanding of the psychological reactions they were experiencing. For example, some felt emotionally fragile in relation to certain files under their care. The lack of understanding regarding their experiences troubled them, and they felt that acquiring knowledge could help them get better. Participants reported that the information given during PFA helped them understand their psychological and/or behavioral reactions, for example, their intrusive images of the traumatic event:

Another reason participants sought help was to receive guidance on how to deal with difficult situations they encountered at work. Their need for guidance was driven by their desire for reflective support (e.g., advice) regarding work-related concerns. These participants required the PFA provider to have a thorough understanding of the demands of their work in order to effectively assist them through their challenges.:

With respect to the need for guidance, most participants reported that the PFA provider guided them in a practical way through their difficulties. They also perceived this support as being personalized and tailored their needs. A personalized approach helped participants to be more forgiving towards themselves and helped them with their decision-making process. For example, a participant said that “[PFA] responded very well I would say [to my needs]. I think at that point, it really helped me to make decisions. The decisions that were necessary to make afterwards (Participant 11, social worker).

Most participant reported that the PFA intervention supported them by improving their knowledge of how to take care of themselves. Self-care took various forms, including realizing the importance of setting regular time for them, making themselves a priority, and/or starting new activities to support their well-being:

3.2 PFA provided by peers allows feeling understood and supported

Another overarching theme that emerged from the interviews with HCW was that peer-delivered PFA led to feeling understood and supported. Most participants stated that having peer-delivered PFA contributed to better understanding and support, as the PFA provider was familiar with their work. As a staff member, the PFA provider was familiar with the requirements and tasks related the job, allowing them to understand the participants’ problem more easily and identify their needs rapidly. Other participants highlighted that having a shared work jargon helped, as it facilitated communication with the PFA provider. Moreover, having a peer acting as the PFA provider allowed participants to focus on themselves rather than having to explain the various problems that may occur within the occupation and organization. Participants were previously confronted to such a difficulty when requesting support from the Employee Assistance Program (EAP), where workers came from outside of their institution:

3.3 High availability and multiple modalities facilitate PFA access

Next, HCW identified key features of the PFA delivery that facilitated access to the service. Most participants greatly appreciated the accessibility of the PFA service: making appointments was easy and the PFA providers were available multiple times a week and/or even on weekends. Knowing that they could contact their PFA provider as soon as they felt the need and that they could receive help quickly was reassuring:

However, a few participants mentioned that there were no follow-ups or appointments offered to them. They had to contact their PFA provider, which may have limited their exchanges:

Some other participants mentioned that accessibility to the PFA service was also enhanced by its multiple modalities, as PFA could be done by telephone, videoconference, or in person, depending on the workers’ preference. This flexibility allowed the PFA service to be adapted, namely to the context of the pandemic:

3.4 Comparison of support received depending on the PFA provider position

The type of support that was provided differed according to the position occupied by the PFA provider, in relation to the person being helped. On the one hand, participants who received the PFA service from a colleague reported that the intervention guided and supported them. The support was often characterized by guidance in a decision-making process or provision of personalized advice, which was easily applicable to the participants’ specific problems:

On the other hand, participants who received the PFA service from their manager mentioned mostly receiving accommodations in their work. These ranged from task adjustments, file transfers, and structural changes:

This was coherent with the participants’ fear about confidentiality breaches and the possibility that their PFA provider (i.e., manager) uses the information in a future evaluation of performance at work.

However, the need to obtain tools and/or strategies as well as the need to have information to better understand post-traumatic reactions were met by all PFA providers, whether they were managers or colleagues. Thus, participants seeking guidance and support for their issues or validation of their feelings following their incident at work were most satisfied when the PFA provider was a colleague, whereas those seeking accommodations at work were more satisfied when the PFA provider was their manager.

3.5 Occupational and organizational cultures hinder PFA access

HCW also stated that occupational and organizational cultures hinder PFA access. Despite the accessibility of the PFA service, it remains that for most participants, the organizational culture towards psychological difficulties at work is still trivialized, which may hinder their help-seeking process. Several participants identified this as an important organizational barrier, as many perceived their organization being against them rather than with them. Participants mentioned that in the past, such a culture had left them feeling criticized and judged, although what they truly needed at that time was support:

Another barrier reported by participants was their general reluctance to seek psychological help. Some participants said that pride explained their reluctance to seek help, while others perceived that it was their job to help others and not the other way around. Moreover, a few participants considered asking for psychological help as a sign of weakness that diminishes their strength to cope with work-related challenges. Others did not comprehend the usefulness of talking about their problems to a professional when they could already talk about it with their loved ones. The lack of time to pause and reflect about oneself was also mentioned. However, some participants stated that the pandemic had made workers more aware of the need for psychological help, potentially encouraging more individuals to seek help.

Participants mainly feared a potential breach of confidentiality by the PFA provider, which represented a major obstacle for the provision of the PFA service. Specifically, participants reported that their colleagues were afraid of their supervisors finding out what they had told the PFA provider, and that it would “backfire on them” (Participant 04, beneficiary attendants). Also, several participants doubted the confidentiality within their organization, especially since their PFA provider was a peer.

A different form of fear emerges among participants whose PFA provider is their manager. Certainly, not everyone feels comfortable confiding to their supervisors, which represents an important barrier to seeking help from a PFA service. For example, participants reported that they were not comfortable talking about the negative emotions they experienced with their supervisors because of the possible consequences:

Another barrier to seeking PFA was the lack of awareness about the PFA service. Indeed, a few participants suggested that some of their colleagues did not use the PFA service because they were not aware of its existence nor of its benefits.

3.6 Recommendations to promote the use of the PFA service

Several participants suggested recommendations to encourage the use of the PFA service among HCW. These recommendations fall into two main categories. First, participants stated that the PFA service should be promoted and accessed more systematically. Specifically, they recommended that the service should be integrated into organizational psychological health protocols (e.g., referrals to the PFA service should be a mandatory process after an employee experiences a distressful event). It should also be offered systematically to employees who experience a potentially traumatic event at work. Finally, a well-maintained record of work-related incidents should be in place to offer psychological assistance easily to those who need it. Some participants also mentioned that integrating the PFA service into the institution’s protocol could help raise awareness about the various psychological support resources available within and outside the organization.

Secondly, participants recommended that the PFA service diversify its providers’ profiles to meet their different needs. For some participants, it meant having a colleague available for emotional support, while for others, it involved having access to a colleague from another unit due to concerns about confidentiality breaches and potential repercussions on their managers’ evaluation. In short, offering diverse profiles of PFA providers would be important when implementing the service within an organization. Diversifying the profiles of PFA providers could enhance the utilization of the service across the organization as it would better respond to the workers’ specific needs.

4.1 Study limits

A few limitations put the results of this study into perspective. First, it is possible that a recall bias affected participants’ perceptions during the interviews, given that they had received PFA several months earlier. Thus, participants may have forgotten many details of the intervention they received. Our sample was also composed of women only. Hence, we did not have access to men’s perceptions of the PFA service, which could be different from that of women. Findings of Geoffrion et al. indicated that men were more likely than women to use normalization of posttraumatic reactions as a cognitive coping strategy [33]. Therefore, it would be relevant to have their perceptions towards PFA, which includes this type of strategy. Also, the sample was not representative of all professions of HCW. The current study did not have access to specific challenges experienced by each professional role that prompted participants to seek PFA. All these elements constitute potential limitations to the representativeness of the sample, with respect to the population of HCW.

Although data saturation seems to have been reached, it remains possible that certain themes could have emerged with a greater number of participants. In fact, only two participants received PFA from their manager and only one participant received the PFA group intervention. With more participants, it could have been possible to collect supplementary information from those who received PFA through one of these modalities. It is also worth noting that the findings of the current study are rooted in Montreal’s context and culture, therefore limiting the generalizability to other populations. Despite these limitations, the rigorous thematic analysis we conducted provides insights into the potential adaptability of the PFA intervention to a novel group, its perceived usefulness among HCW, and possible implementation among healthcare organizations.

4.2 Future studies

The present study has illustrated that the PFA approach helped participants decrease their general psychological distress, and helped them take better care of themselves, regardless of the source of their difficulties. Accordingly, symptom reduction should not be the only criterion for evaluating the effectiveness of such an intervention. To gain a comprehensive understanding of a PFA approach, researchers should consider conducting feasibility studies following the model presented by Bowen et al. [39]. This process evaluates all aspects of an intervention, thus going beyond standard therapeutic effectiveness evaluations [38]. Such a design would allow to evaluate the full range of benefits of PFA, including improved longer-term adaptive functioning of workers who have been exposed to potentially traumatic events at work. With the growing in PFA, researchers must consider including mixed methods (i.e., quantitative and qualitative research) to document the context in which PFA successfully responds to participants needs. To understand optimal delivery of PFA, further research should be conducted to compare the effects of a peer-delivered PFA intervention to a stranger-delivered PFA intervention. Shedding light on the role of peer providers could have important implications for organizations seeking to implement structured support services for its members.