Psychological interventions for healthcare professionals during the COVID-19 pandemic: A systematic review

Abstract

Healthcare professionals were especially vulnerable to pandemic, both to become infected and to develop a psychological problem. The aim of this systematic review is to analyze the effectiveness of psychological interventions for healthcare professionals in reducing the experienced psychological impact. From the 405 identified studies, 10 were included in this review. Four databases were searched and the risk of bias of included studies was assessed. The studies considered were randomized controlled trials. The screening and selection process was conducted by two independent reviewers. All studies presented results related with depression, anxiety, and stress during pandemic. Six were delivered using new technologies. The most effective were two psychological interventions with frequent contact and feedback provided by a mental health professional. The psychological interventions compared with non-intervention groups presented more significant results than those compared with another intervention. The highlights of this systematic review were the urgency of designing effectiveness psychological interventions for healthcare professionals to reduce the emotional burden associate with this job. These interventions should be maintained over the time, supported by a professional and provided from the workplace. These proposals presented promising results but were more psychological resources than psychological interventions.

Full text

Received: 29 September 2022
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Revised: 22 February 2023
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Accepted: 1 April 2023
DOI: 10.1002/smi.3246
REVIEW ARTICLE
Psychological interventions for healthcare professionals
during the COVID‐19 pandemic: A systematic review
Carmen Varela
1,2
|Mikel Montero
3
|Elena R. Serrano‐Ibáñez
4
|
Ariadna de la Vega
5
|M. Almudena Gómez Pulido
3
1
Universitat de Barcelona, Barcelona, Spain
2
Universidad de Burgos, Burgos, Spain
3
Universidad Isabel I, Burgos, Spain
4
Universidad de Málaga, Málaga, Spain
5
Universidad Rey Juan Carlos, Madrid, Spain
Correspondence
Carmen Varela, Paseo de Comendadores, s/n,
Burgos 09001, Spain.
Email: carmen.varela07@gmail.com
Abstract
Healthcare professionals were especially vulnerable to pandemic, both to become
infected and to develop a psychological problem. The aim of this systematic review
is to analyze the effectiveness of psychological interventions for healthcare pro-
fessionals in reducing the experienced psychological impact. From the 405 identified
studies, 10 were included in this review. Four databases were searched and the risk
of bias of included studies was assessed. The studies considered were randomized
controlled trials. The screening and selection process was conducted by two inde-
pendent reviewers. All studies presented results related with depression, anxiety,
and stress during pandemic. Six were delivered using new technologies. The most
effective were two psychological interventions with frequent contact and feedback
provided by a mental health professional. The psychological interventions compared
with non‐intervention groups presented more significant results than those
compared with another intervention. The highlights of this systematic review were
the urgency of designing effectiveness psychological interventions for healthcare
professionals to reduce the emotional burden associate with this job. These in-
terventions should be maintained over the time, supported by a professional and
provided from the workplace. These proposals presented promising results but
were more psychological resources than psychological interventions.
KEYWORDS
COVID‐19, healthcare professional, mental health, psychological intervention, randomized
controlled trial
1
|
INTRODUCTION
Since December 2019, the novel coronavirus or COVID‐19 has spread
rapidly across the whole world, becoming a global pandemic on March
2020 according to the World Health Organization (WHO, 2020).
New coronavirus infection has had a major impact on mental
health. Population received an increasing amount of uncertain
information about the disease (Torales et al., 2020). The immediate
consequences were fear of uncertainty, panic, distress, a feeling of
losing control, anger, frustration, and vulnerability (Bao et al., 2020;
Brooks et al., 2020; Rajkumar, 2020). Accordingly, psychological
problems like depression, anxiety and stress have increased during
this period in general population (Salari et al., 2020). Additionally, an
increase of suicidal thoughts and behaviours have been observed in
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Stress and Health. 2023;1–12. wileyonlinelibrary.com/journal/smi
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1

relation to the appearance of infectious diseases epidemics (Rodgers
et al., 2021).
Healthcare professionals were especially vulnerable to this
health crisis, presenting 12 time more risk than general population to
get infected (Nguyen et al., 2020). These workers had an essential
role in the quality of healthcare system during the pandemic (Bao
et al., 2020). Disease exposure, the lack of protection and the satu-
ration of sanitary resources forced these professionals to work in
precarious conditions (García‐Iglesias et al., 2020; Vieta et al., 2020).
These situations had a direct impact on the mental health of these
workers and, consequently, an indirect effect on the well‐functioning
of the sanitary system (Shultz et al., 2016; Yang et al., 2020).
COVID‐19 pandemic increased the prevalence of psychological
problems like anxiety, depression, stress, post‐traumatic stress dis-
order (PTSD), insomnia, and burnout between healthcare pro-
fessionals (Lazzerini & Putoto, 2020; Li et al., 2020; Vieta et al., 2020).
According to these results, previous systematic reviews reported high
levels of anxiety (Pan et al., 2020) and PTSD (Carmassi et al., 2020) for
this population. Other stressful experiences were the grief for rela-
tives and/or patients, self‐blame for not being able to save them, and
fear of getting sick and infecting their families (Wallace et al., 2020).
Health crisis, such as COVID‐19, have required the use of
adaptative coping strategies. However, many healthcare pro-
fessionals presented problems in dealing with the pandemic due to
the uncertainty of the situation and the lack of knowledge about the
disease. To cope with psychological distress health workers reported
the use of exercise (44.9%), social connections (31.7%) and alcohol
(26.3%) (Smallwood et al., 2021). New technologies, especially psy-
chological wellbeing applications, were also a resource used by this
population (Smallwood et al., 2021).
Previous studies found an association between burnout in health
workers and patient safety, COVID‐19 represented an extreme sit-
uation with the presence of these two variables (Hall et al., 2016). For
all these reasons, healthcare professionals should be considered as a
population risk to suffer psychological problems, especially in a
health crisis like COVID‐19 pandemic. Accordingly, the creation of
psychological programs adapted to their needs is an urgency.
During the first year of the pandemic, 6.4% of adult population
requested psychological attention in Spain (Confederación Salud
Mental, 2021). Different resources like phone assistance with brief
psychological intervention were available. During quarantine the
number of calls was 15,170, 75.3% needed an intervention (Berdul-
las‐Saunders et al., 2020). However, the evidence for specialized
psychological programs for healthcare professionals was limited.
Muller et al. (2020) presented a rapid systematic review at the
beginning of the pandemic. Results showed that the most frequent
strategies and resources used by health workers were social/family
support, lifestyle adjustments, mindfulness, or distraction. A minority
of professionals asked psychological assistance (Muller et al., 2020).
The design of mental health resources and interventions for
healthcare professionals has become an urgency. This population
needs easy access to psychological programs adapted to their char-
acteristics to deal with psychological problems and the emotional
burden related with the workplace, especially during health crisis
(Mira et al., 2020).
The main aim of this systematic review is to perform an update of
the psychological interventions designed for healthcare professionals
and delivered during pandemic and analyzed their effectiveness in
reducing the psychological impact experienced by the participants.
2
|
METHOD
This systematic review follows the guideline of Preferred Reporting
Items for Systematic Reviews (Page et al., 2021). The international
prospective register for systematic reviews (PROSPERO) accepted
the protocol of this study on 16 March 2022, registration number
CRD42022318685.
2.1
|
Eligibility criteria
The Population, Intervention, Comparator and Outcome framework
was used to report the eligibility criteria of this systematic review
(O’Connor et al., 2008).
‐Population. Healthcare professionals who worked during the
COVID‐19 pandemic.
‐Intervention. Psychological interventions, provided from de work-
place, addressed to reduce the psychological impact of healthcare
professionals who worked during the COVID‐19 pandemic.
‐Comparator: Any comparator, including pharmacological treat-
ment, control group or no treatment group.
‐Outcome. Validated questionnaires used to measure pre‐and
post‐intervention comparisons in any variable related with mental
health.
‐Studies. Randomized Controlled Trials (RCT).
2.2
|
Information sources
The search was conducted using the electronic databases: Web of
Science, Scopus, Cochrane Central Register of Controlled Trials
(CENTRAL) and PubMed. The search was closed on 28 January 2022.
An updated of the search was conducted on 12 September 2022.
2.3
|
Search strategy
The search presented some limitations: the study design had to be
RCT, the language had to be English or Spanish, and years 2020 on-
wards. The combination of keywords used to conduct the search was:
(covid‐19 OR “covid 19” OR sars‐cov‐2 OR coronavirus OR “se-
vere acute respiratory syndrome coronavirus 2” OR “corona virus”)
AND (“healthcare professional*” OR “health care professional*” OR
“health care worker*” OR “health worker*” OR “healthcare worker*”
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OR “health professional*” OR “health personnel” OR “medical staff”)
AND (intervention OR “psychological intervention” OR “psychological
support” OR “program” OR “psychological program” OR treatment OR
“psychological treatment” OR prevention OR preventive) AND
(“mental health” OR “burnout” OR “psychol*” OR anxiety OR depres-
sion OR depressive OR stress OR “psychological wellbeing” OR “psy-
chological impact” OR “post‐traumatic stress disorder” OR “PTSD” OR
“posttraumatic stress disorder”) AND (“randomized controlled trials”
OR “randomized controlled trial” OR “controlled clinical trial” OR
“controlled‐clinical trial” OR randomly OR RCT OR “controlled‐trial”
OR “controlled trial”)
2.4
|
Selection process
A total of 254 studies were identified from the different databases.
These studies were imported into Rayyan, a research tool designed to
work with systematic reviews. After automatically removing dupli-
cates with Rayyan, 157 studies by title and abstract were screened
by two independent reviewers, based on eligibility criteria. The
remaining articles were full text assessed by the same independent
reviewers. Finally, to resolve disparities between the two reviewers
the chosen method was discussion.
During the search update, 151 new studies were identified be-
tween 28 January and 12 September 2022. A total of 67 duplicates
were identified and removed, the remaining 87 studies were screened
by title and abstract. Finally, only four were full text assessed and three
met the inclusion criteria. The entire process was conducted by the
same independent reviewers responsible of the initial search.
2.5
|
Data collection process
Two independent reviewers collected data from the included studies.
The information extracted was: (i) study characteristics: authorship,
year and country; (ii) sample characteristics: sample size, gender, age,
occupation; (iii) characteristics of the interventions and comparators:
type of psychological intervention, sample size of each intervention
arm, length of the intervention; (iv) outcome characteristics: ques-
tionnaires used to measure the variables of interest, pre‐and post‐
intervention difference in variables of interest.
2.6
|
Study risk of bias assessment
To ensure the methodological quality of the study, two independent
reviewers assessed the included studies according to the criteria of
Cochrane Collaboration Handbook (Higgins & Altman, 2008). This
tool contained the following domains to assess sequence allocation,
blinding of the participants and personnel, blinding of outcome
assessment, incomplete outcome data, selective outcome reporting
and other sources of bias. Each domain could be assessed for high,
low or unclear risk of bias (Higgins & Altman, 2008).
3
|
RESULTS
The number of identified studies between the initial search and the
update was 405. After removing duplicates and the first screening of
title and abstract by two independent reviewers, 20 full‐text studies
were screened. Finally, 10 articles, 7 at the initial search and 3 at the
update, met the pre‐specified inclusion criteria and were included in
the review (Figure 1).
3.1
|
Description of included studies
The main characteristics of included studies are summarized in
Table 1. Six articles were published in 2021 and four in 2022. Studies
were carried out in Spain (n=2), Italy (n=1), India (n=1), Iran
(n=2), United States (n=1) United Kingdom (n=1), Turkey (n=1)
and Canada (n=1). The total number of participants was 2099. In
two studies women represented the 100% of the sample, in five
studies represented more of the 50%, in two studies this percentage
was below 50% and one did not specify the number of women or men
neither the age. Studies did not present the associations between
gender and job roles. Following the inclusion criteria, the entire
sample worked as healthcare professionals during COVID‐19
pandemic. All studies presented at least one psychological interven-
tion arm, 11 intervention arms and 10 control arms were identified.
Interventions were delivered using new technologies (phone, web
applications or video), except three. One of them used ordinary mail
to send the materials (Procaccia et al., 2021). The other two admin-
istrated their interventions in person (Ferreres et al., 2022; Yildirim &
Yildiz, 2022). The length of interventions ranged between 1 day and
8 weeks, only 3 studies reported follow‐up data (Amsalem
et al., 2022; Ferreres et al., 2022; Fiol‐DeRoque et al., 2021).
3.2
|
Risk of bias
Figure 2shows the risk bias assessment for the included studies. All
the studies presented low risk for bias except for one, which showed
unclear risk of bias in three of the six assessed areas (Otared
et al., 2021). In general, there is a clear explanation about the entire
research procedure (recruitment, group allocation, intervention, data
extraction and statistical analysis) followed by the studies included in
this review. Providing reliability to the information analyzed in this
study.
3.3
|
Primary outcomes
Since all but one of the studies reported (Amsalem et al., 2022) re-
sults on depression, anxiety, stress, and symptoms of PTSD, these
were classified as primary outcomes of this review.
Five studies used web applications to deliver psychological in-
terventions (Fiol‐DeRoque et al., 2021; Ghazanfarpour et al., 2021;
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Gnanapragasam et al., 2022; Gupta et al., 2021; Otared et al., 2021).
Two studies did not show significant differences between groups for
the primary outcomes (Fiol‐DeRoque et al., 2021; Gupta et al., 2021).
Fiol‐DeRoque et al. (2021) used the PsyCovidApp, a self‐
managed psychoeducational intervention focused on working
emotional skills, health lifestyle behaviour, social support, work
stress and burnout. Control group used an informational mental
healthcare application during COVID‐19 pandemic. Adjusted stan-
dardized between‐group mean differences (aMD) were not signifi-
cant when comparing PsyCovidApp and ControlApp groups
(depression, aMD =0.00, 95% confidence interval [95% CI] = −0.07
to 0.08, p=0.47; anxiety, aMD = −0.04, 95% CI = −0.12 to 0.04,
p=0.15; stress, aMD = −0.06, 95% CI = −0.14 to 0.01, p=0.06;
PTSD symptoms, aMD =0.00, 95% CI = −0.06 to 0.06, p=0.47).
Significant differences were only observed in the subgroup analysis,
considering the treatments received before the web applications.
PsyCovidApp +psychotropics, showed significantly lower scores for
anxiety (aMD = −0.26, 95% CI = −0.45 to −0.08; p=0.004), stress
(aMD = −0.30, 95% CI = −0.50 to −0.09, p=0.003) and PTSD
symptoms (aMD = −0.20, 95% CI = −0.37 to −0.03, p=0.01) than
ControlApp group. PsyCovidApp +psychotherapy, significantly
improve symptoms of anxiety (aMD = −0.24, 95% CI = −0.48 to 0.00,
p=0.03) and stress (aMD = −0.27, 95% CI = −0.55 to 0.001,
p=0.02) compared to ControlApp group. Gupta et al. (2021) also
found no significant MD between groups for depression
(MD = −1.56, 95% CI = −8.4 to 15.2, p=0.126), anxiety
(MD = −0.163, 95% CI = −3.8 to 2.9, p=0.872) or general stress
(MD = −2.16, 95% CI = −13.9 to −0.40, p=0.23). The intervention
consisted of tele‐counselling sessions conducted through audio
telephone conversation. The content of these sessions consisted of
empathy, psychoeducation about COVID‐19, relaxation, problem‐
solving, life skill training and motivational interviewing. Control
group received tele‐counselling on standard information related to
COVID‐19. Only the intervention group presented significantly lower
scores for stress related to COVID‐19 (MD = −2.16, 95% CI = −13.9
to −0.40, p=0.036).
Gnanapragasam et al. (2022) used the Foundations smartphone
application, the main aim of this tool was to promote well‐being
habits and behaviour change, promoting mental well‐being,
improving sleep and managing stress. Participants in the application
group presented a significant reduction of psychiatric morbidity
symptoms (aMD = −1.39, 95% CI = −2.05 to −0.74, p<0.001) as
FIGURE 1 Flow diagram of study selection.
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TABLE 1Characteristics of included studies.
Study
Age M
(SD)/range Females
Professional
group Intervention/length Comparator
Outcome
measures Main results
Amsalem et al. (2022)
United States
38.8 (11.5)
18–70
74% Nurse, 68%
Physician, 15%
EMT, 9%
Other, 9%
Video +booster (n=115)
Video (n=114)
14 days
Non‐intervention (n=121) ATSPPH‐SF
GAD‐7
PC‐PTSD‐5
PHQ‐9
The two video interventions group showed greater increases in treatment‐seeking
intentions than CG, especially video +booster group
Ferreres et al. (2022)
Spain
45.7 (7.7)
26–62
100% Nurse, 100% Train emotional regulation skills
(n=13)
5 days
Non‐intervention (delayed
intervention) (n=14)
DASS‐21
DERS
NEO‐FFI
MBI
IES‐R
EuroQoL
A significant reduction of depression and anxiety scores was observed in the IG but not
in CG
Significant differences were observed between groups. IG showed lower emotional
exhaustion and better personal accomplishment after the intervention than the CG
Fiol‐DeRoque
et al. (2021)
Spain
42.4 (10.4)
23–63
83.2% Doctor, 31.7%
Nurse, 33.4%
Nurse assistant, 30.5%
Other, 4.6%
PsyCovidApp (n=248)
14 days
Control app (n=234) DASS‐21
DTS
MBI‐HSS
ISI
GSE
No significant differences were observed between IG and CG group for main (DASS‐21)
or secondary outcomes
Ghazanfarpour
et al. (2021)
a
Iran
<30 (n=65)
≥30 (n=30)
15.8% Medical staff, 100% Tele‐counselling WhatsApp
(n=44)
7 days
Non‐intervention (n=51) HADS
SHAI
Anxiety related to coronavirus and likelihood to illness were significant lower in the IG
than CG. Depression related to coronavirus and anxiety of negative consequences
did not show significant differences
Gnanapragasam
et al. (2022)
United Kingdom
44.3
20–76
84.3% Healthcare professionals,
60.9%
Healthcare workers,
39.2%
FoundationsApp (n=425)
8 weeks
Control group (n=469) GHQ‐12
BRS
SWEMWBS
SPS‐6
GAD‐7
PHQ‐9
WSAS
MISS
Participants of IG reported a significant reduction in psychiatric comorbidity,
improvement in well‐being and reduction in insomnia compared to participants in
CG
Gupta et al. (2021)
a
India
≤30 (n=16)
>30 (n=3)
63.2% Nurse, 26.3%
Intern trainee, 68.4%
Senior resident, 5.3%
Brief eclectic psychotherapy
(n=9)
7–10 days
Standard treatment (n=10) DASS‐21
IES‐R
No significance difference was found between groups for depression, anxiety, or stress.
Only stress related to COVID‐19 showed lower significance differences in IG
compared with CG
Moench and
Billsten (2021)
Canada
‐ ‐ Mental health clinicians,
100%
STEP (n=16)
7 days
Wait list (n=17) DASS‐21
GSE
Pre‐and post‐comparisons showed a significant decrease in depression, anxiety and
stress in IG compared with CG. There was also a significant increase for self‐efficacy
in the IG
Otared et al. (2021)
b
Iran
IG =33.4
(4.5)
CG =31.5
(5.4)
IG, 45%
CG, 50%
HECWs, 100% Online‐group ACT (n=20)
8 sessions
Wait list (n=20) BDI
BAI
QOLI
GAF
AAQ‐II
ACT group showed significant lower scores in depression and anxiety, as well as an
improvement in quality of life compared with CG
Procaccia et al. (2021)
Italia
46.4 (9.9)
28–61
74.5% Nurse, 54.5%
Physician, 27.3%
Allied HECWs, 18.2%
Expressive writing (n=30)
3 days
Neutral writing (n=25) BDI
LASC
SCL‐90
MSPSS
Post‐traumatic disorder symptoms were significantly reduced in IG. Otherwise,
depression symptoms and SCL‐90 punctuation were significantly lower in IG group,
while increased in CG group
(Continues)
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well as a significant increase in well‐being (aMD =0.54, 95%
CI =0.20–0.89, p=0.002) compared to control group.
Ghazanfarpour et al. (2021), proved the effectiveness of
WhatsApp tele‐counselling compared to non‐intervention group.
Only anxiety related to coronavirus (MD =1.52, 95% CI =0.63–
2.4, p=0.001) and anxiety of likelihood to illness (MD =0.87, 95%
CI = −0.11 to 1.87, p=0.001) significantly decreased compared to
non‐intervention group. Depression and anxiety of coronavirus
negative consequences did not show significant differences. Otared
et al. (2021) provided online group acceptance and commitment
therapy (ACT) versus waiting list. Anxiety (F=155.07, p<0.05,
effect size [ηp
2
]=0.81) and depression (F=39.54, p<0.05,
ηp
2
=0.52) presented significantly lower scores in ACT group than
waiting list.
Two studies used video to deliver the psychological intervention
(Amsalem et al., 2022; Moench & Billsten, 2021). One study used the
DASS‐21 to measure the variables of interest, however it only re-
ported general score. The results showed significantly lower differ-
ences on Self‐Care Traumatic Episode Protocol (STEP) group
compared to the wait list for general DASS‐21 score [MD = −7.68, F
(2, 30) =5.22, p<0.05]. STEP programme consisted of watching a
series of videos about different techniques to handle possible situa-
tions related to COVID‐19 (e.g., EMDR, breathing, handling disturb-
ing memories) (Moench & Billsten, 2021).
Amsalem et al. (2022) presented as main outcome treatment‐
seeking intentions. However, this outcome was associated with
depression, anxiety and PTSD because the 80% of the sample
screened positive for these variables. Video‐based interventions
(group �time interaction: Wald χ
2
=59.4, p<0.001), showed
significantly higher scores in treatment‐seeking intentions than non‐
intervention group. Both video +booster intervention (from mean
[M]=7.9 [95% CI: 7.3–8.4] to M=9.2 [95% CI: 8.7–9.7], p<0.001,
Cohen's d=0.50) and video intervention (from M=8.3 [95% CI 7.9–
8.8] to M=9.4 [95% CI 9.0–9.7], p<0.001, Cohen's d=0.46)
significantly increased treatment‐seeking intentions from baseline to
post‐intervention.
Only three studies did not use new technologies to deliver the
intervention (Ferreres et al., 2022; Procaccia et al., 2021; Yildirim &
Yildiz, 2022). In one of them, the psychological intervention con-
sisted of expressive writing and the comparator was neutral writing.
PTSD symptoms (F=13.72, p=0.002) and depression (F=6.12,
p=0.02) were significantly lower in expressive writing group
compared to neutral group (Procaccia et al., 2021). In other study,
participants in the intervention group received a 30‐min session of
mindfulness and music therapy. Intervention group showed a sig-
nificant reduction of stress (MD = −7.46, 95% CI = −12.79 to 2.13,
p=0.01) and work‐related stress (MD = −3.39, 95% CI = −6.04 to
0.72, p=0.36) compared to control group. Moreover, a significant
improvement of psychological well‐being was found (MD =5.15,
95% CI =1.27–9.03, p=0.30) in the intervention group compared
to control group. The control group did not show significant dif-
ferences in the intragroup pre and post‐test comparisons (Yil-
dirim & Yildiz, 2022).
TABLE 1(Continued)
Study
Age M
(SD)/range Females
Professional
group Intervention/length Comparator
Outcome
measures Main results
Yildirim and
Yildiz (2022)
b
Turkey
IG =27.6
(5.2)
CG =29.1
(6.6)
100% Nurse, 100% Mindfulness and music therapy
(n=52)
1 session
Control group (n=52) STAI
PWBS
WRSS
IG showed significant lower scores for stress and work‐related strain than CG. Moreover,
IG presented significant higher scores for psychological well‐being than CG.
Intragroup comparisons were significant for the three variables only in IG group
Abbreviations: AAQ‐II, Acceptance and Action Questionnaire; ACT, Acceptance Commitment Therapy; ATSPPH‐SF, Attitudes Toward Professional Psychological Help Scale; BAI, Beck Anxiety Inventory; BDI,
Beck Depression Inventory; BRS, Brief Resilience Scale; CG, Comparator Group; DASS‐1, Depression Anxiety Stress Scale; DERS, Difficulties in Emotion Regulation Scale; DTS, Davison Trauma Scale; EMT,
Emergency Medical Technician; EuroQoL, European Quality of Life; GAD‐7, Generalized Anxiety Disorder; GAF, Global Assessment of Functioning Scale; GHQ, General Health Questionnaire; GSE, General
Self‐Efficacy Scale; HADS, Hospital Anxiety Depression Scale; HECWs, Healthcare Workers; IES‐R, Impact of Event Scale Revised; IG, Intervention Group; ISI, Insomnia Severity Scale; LASC, Los Angeles
Symptom Checklist; MBI‐HSS, Maslach Burnout Inventory Human Services Survey; MISS, Minimal Insomnia Symptom Scale; MSPSS, Multidimensional Scale of Perceived Social Support; NEO‐FFI, NEO Five
Factor Personality Inventory; PC‐PTSD‐5, Primary Care Post‐Traumatic Stress Disorder; PHQ‐9, Patient Health Questionnaire; PWBS, Psychological Well‐Being Scale; QOLI, Quality of Life Index; SCL‐90,
Symptom Check List; SHAI, Short Health Anxiety Inventory; SPS‐6, Short Presenteeism Scale; STAI, State Anxiety Inventory; STEP, Self‐Care Traumatic Episode Protocol; SWEMWBS, Short
Warwick‐Edinburgh Mental Well‐Being Scale; WRSS, Work Related Strain Scale; WSAS, Work and Social Adjustment Scale.
a
Frequencies by groups of age.
b
Mean age by intervention arm.
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Finally, Ferreres et al. (2022) proved the effectiveness of a pre-
ventive programme to train emotional skills in healthcare pro-
fessionals. In the pre‐and post‐test intragroup comparisons, only the
intervention group presented significant differences for depression
(MD = −2.16, p=0.024, Cohen's d= −0.40), stress (MD = −2.08,
p=0.039, Cohen's d= −0.48) and personal accomplishment
(MD = −5.77, p=0.036, Cohen's d= −0.76).
3.4
|
Secondary outcomes
Some studies reported supplementary measures to the main out-
comes. Fiol‐DeRoque et al. (2021) assessed insomnia (aMD =0.01,
95% CI = −0.05 to 0.07, p=0.38) and self‐efficacy (aMD =0.01, 95%
CI = −0.06 to 0.09, p=0.36) but no significant differences were
observed between groups. In the subgroup analysis insomnia showed
FIGURE 2 Graphic for risk bias.
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significantly lower differences in PsyCovidApp +psychotropics
(aMD = −0.16, 95% CI = −0.30 to −0.02p=0.01) and PsyCovi-
dApp +psychotherapy (aMD = −0.20, 95% CI = −0.42 to 0.02,
p=0.03) compared to ControlApp. Another study found a significant
reduction for insomnia scores (adjusted odd ratio =0.36, 95%
CI =0.21–0.60, p<001) compared to the control group (Gnanap-
ragasam et al., 2022).
Moench and Billsten (2021) found a significant increase of self‐
efficacy (MD =4.12, F(2, 30) =5.22, p<0.05) in STEP group
compared to wait list. One study reported a significant increase of
quality of life (F=27.35, p<0.05, ηp
2
=0.42) and acceptance and act
skills (F=44.96, p<0.05, ηp
2
=0.55) in ACT group compared to wait
list (Otared et al., 2021).
Ferreres et al. (2022) observed significant intergroup differences
in emotional exhaustion (MD = −7.48, F=4.66, p=0.042) and
personal accomplishment (MD = −5.27, F=4.96, p=0.036), with
lower scores for the intervention group.
3.5
|
Follow‐up outcomes
Finally, three studies reported follow‐up results (Amsalem
et al., 2022; Ferreres et al., 2022; Fiol‐DeRoque et al., 2021).
Video +booster intervention showed a significant increased,
compared to video and non‐intervention groups (Wald χ
2
=7.2,
p=0.028), for treatment‐seeking intentions from post‐intervention
to 14 days follow‐up (from M=9.2 [95% CI 8.7–9.7] to M=9.8
[95% CI 9.3–10.3], p=0.026, Cohen's d=0.24) (Amsalem
et al., 2022). Fiol‐DeRoque et al. (2021) did not find significant dif-
ferences in any assessed variable at 2 weeks follow‐up.
Ferreres et al. (2022) measured the evolution of variables over
time (1‐, 3‐and 6‐month follow‐up), once the intervention has been
administrated in both groups. Statistically, effects were found for the
time variable with reductions in personal accomplishment (F=3.95,
p=0.005, Cohen's d=0.80), neuroticism (F=2.58, p=0.043,
Cohen's d=0.64), intrusion (F=4.91, p=0.001, Cohen's d=0.89)
and avoidance (F=4.81, p=0.001, Cohen's d=0.88) at 6‐month
follow‐up.
4
|
DISCUSSION
To the best of our knowledge, this is the first systematic review about
the effectiveness of psychological interventions for healthcare pro-
fessionals during COVID‐19 pandemic. Previous studies were con-
ducted to identify the psychological resources available for this
population (Hooper et al., 2022) or/and patients with COVID‐19
(Legakul et al., 2022; Tasleem et al., 2022).
However, the vulnerability of healthcare professionals to health
crisis (García‐Iglesias et al., 2020; Nguyen et al., 2020; Vieta
et al., 2020), the observed psychological impact (Shultz et al., 2016;
Yang et al., 2020) and the lack of resources (Muller et al., 2020;
Smallwood et al., 2021) revealed the urgency of designing
psychological interventions adapted to the needs of health workers.
The number of women was superior in most of the included studies.
There was no evidence for the relation between gender and job roles,
except for the two studies where the entire sample was composed by
women nurses. However, it has been observed that women represent
70% of workers in social and health sector. Especially, there was
observed more female presence between nurses than other roles
(Boniol et al., 2019). Nurses participated in six of the included studies.
In previous studies, nursing was the occupation with the highest
levels of psychological problems, like anxiety or depression, due to
the close contact with patients for long working hours (Boniol
et al., 2019; Danet, 2021; Shaukat et al., 2020).
Ten studies accomplished the inclusion criteria of this review.
The main assessed variables were depression, anxiety, stress, and
PTSD because they were identified as the most prevalent between
healthcare workers (Lazzerini & Putoto, 2020; Li et al., 2020; Vieta
et al., 2020). Work‐related stress was also analyzed because burnout
was a relevant variable during the pandemic (Yildirim & Yildiz, 2022).
Most of the interventions were delivered using new technologies
because of the safety regulations imposed due to COVID‐19. Ehealth
interventions, defined as the combination of electronic communica-
tion and new technologies in the health area, showed positive results
according to previous studies (Oosterveen et al., 2017). Presenting
advantages like less cost, more flexibility, anonymity and reaching
more people at the same time (Beleigoli et al., 2019). However, two
of the included studies did not show significant differences between
groups. The proposed interventions were psychoeducational web
applications (Fiol‐DeRoque et al., 2021) and tele‐counselling by
phone (Gupta et al., 2021). The length of the interventions could be
another aspect to consider being 14 and 7 days respectively (Fiol‐
DeRoque et al., 2021; Gupta et al., 2021).
In these two studies, the interaction with a mental health pro-
fessional was not enough, considering the severity of the situation. In
fact, Fiol‐DeRoque et al. (2021) observed that the intervention group
showed significant differences compared to control group, when the
applications was combined with an additional method like psycho-
therapy or psychotropics. Therefore, these proposals (Fiol‐DeRoque
et al., 2021; Gupta et al., 2021) could be considered additional re-
sources more than psychological interventions by themselves. Fiol‐
DeRoque et al. (2021) found same results for the secondary out-
comes, insomnia, and self‐efficacy. Moreover, there was no significant
differences for any variable at 2 weeks follow‐up. These results
revealed that interventions should be more personalized, supported
by a mental health professional and maintained over time to prove
their effectiveness (Sherrington et al., 2016).
However, Gnanapragasam et al. (2022) used an application not
only to reduce psychiatric morbidity symptoms, also to increase well‐
being between health workers obtaining positive results for the
intervention group compared to control group. Yildirim and Yil-
diz (2022), used mindfulness and music therapy, instead of new
technologies, to reduce work‐related stress but also to increase
psychological well‐being, obtaining positive results for the interven-
tion group.
8
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Currently, the definition of health implies a state of complete
physical, mental and social well‐being, and not just the absence of
disease (WHO, 2022). Programs that promote wellness at the
workplace, instead of removing symptoms, could be more beneficial
both individuals and organizations by optimizing the functioning of
health care systems in the long term (Shanafelt et al., 2019).
Another study used tele‐counselling during 7 days for the
intervention groups and obtained significantly lower scores for anx-
iety related to COVID‐19 and likelihood to illness compared to non‐
intervention group (Ghazanfarpour et al., 2021). The main difference
with Gupta et al. (2021) was the control group, without intervention
and basic information respectively (Ghazanfarpour et al., 2021;
Gupta et al., 2021). The evolution of the pandemic and the arrival of a
new normality, could influence these results. Previous studies found
that the impact of pandemic was maintained over time, even
increasing levels of anxiety and depression (González‐Sanguino,
et al., 2020). For these reasons, ensuring the psychological well‐being
of health workers has become a sanitary priority, as well as, imple-
menting organizational measures to protect the mental health of
healthcare workforce (Mira et al., 2020; Søvold et al., 2021). Pro-
posing policy suggestions could be a useful tool to achieve long‐term
effectiveness results in this field (Søvold et al., 2021). Additionally,
teaching self‐care strategies, like emotional skills training (Ferreres
et al., 2022), provides long‐term tools to face stressful situations
during the lifespan. If psychiatric symptoms reappear, the individual
will be able to manage the situation (Søvold et al., 2021).
Otared et al. (2021) delivered a group‐based online ACT. The
results showed significantly lower scores in ACT group compared to
wait list for anxiety and depression. Moreover, participants in the
intervention group reported significantly higher scores for quality of
life and acceptance and act skills compared to wait list. Supporting
the relevance of promoting well‐being, rather than treating the
symptoms, to achieve long‐term individual and organizational results
(Shanafelt et al., 2019; Søvold et al., 2021). The multi‐protocol ACT
was elaborated from the information provided by Hayes et al. (2012).
According to previous studies, this intervention was guided by mental
health professionals, providing instructions with frequent and
personalized feedback (Sherrington et al., 2016). This intervention
presented the advantage of the group format. Group therapy pro-
vided a space to share common fears, provide solutions, show
empathy and not feel alone. Besides, participants provided feedback
to each other, strengthening group cohesion. Especially relevant in
crisis like COVID‐19 outbreak (Rodríguez‐Zafra & García‐
Galeán, 2022).
Moench and Billsten (2021) used another complete programme,
teaching different techniques to cope with difficult situations related
to pandemic. Significantly lower scores were observed for interven-
tion group compared to wait list. The intervention group also showed
a significant increase of self‐efficacy compared to wait list. The
presence of self‐regulation skills and active coping strategies, such as
problem solving, were associated with better mental health (Teixeira
et al., 2015). Promoting these skills from the workplace will result in
fulfiled workers, therefore more effectiveness, better system
functioning and less organizational costs (Shanafelt et al., 2019;
Søvold et al., 2021).
Amsalem et al. (2022) used video to encourage participants to
seek psychological treatment. The 80% of the participants presented
depression, anxiety, or PTSD. Intervention groups scored significantly
higher on treatment‐seeking intentions than the non‐intervention
group. These results were replicated in the 14‐and 30‐day follow‐
up. However, like in previous studies (Fiol‐DeRoque et al., 2021;
Ghazanfarpour et al., 2021; Gupta et al., 2021) these videos were
complementary resources. In fact, this proposal was a programme to
seek comprehensive psychological intervention, proving that mental
health is a priority for this population.
Procaccia et al. (2021) proposed an intervention delivered
without new technologies. Expressive writing group obtained signif-
icantly lower scores for PTSD and depression than neutral writing.
These results supported that focusing on deeper feelings and
thoughts, rather than avoiding them, reduces the psychological
impact of COVID‐19 pandemic (Teixeira et al., 2015). Therefore,
psychological interventions are needed to learn to handle the emo-
tions resulting from working in limit situations (Shanafelt
et al., 2019).
Finally, most of the proposed interventions lasted between 3 and
14 days, were self‐manage or with minimal contact with the mental
health professional and were based on psychoeducation. These pro-
grams were not comprehensive enough to be considered effective
psychological interventions, the results were promising but more
research is needed. Especially, longitudinal studies to ensure long‐
term effects and demonstrate that mental health programs could
be a beneficial organization investment (Søvold et al., 2021). Some of
these programs were oriented to well‐being rather than removing
symptoms, supporting the WHO concept of health to achieve long‐
term effectiveness results (Ferreres et al., 2022; Gnanapragasam
et al., 2022; Moench & Billsten, 2021; Otared et al., 2021; Yildirim &
Yildiz, 2022).
The health international crisis around the world by COVID‐19
outbreak has change healthcare system in every country. The re-
sults of this review, according with previous studies (Shanafelt
et al., 2019; Søvold et al., 2021), reveal the urgency of designing
quality psychological interventions for healthcare professionals. The
poor working conditions have caused many psychological disorders in
this community. Normally, these workers are in close contact with
people struggling with difficult situations and the emotional burden is
high. COVID‐19 pandemic has enhanced these factors, increasing the
psychological impact and the precarious conditions (García‐Iglesias
et al., 2020; Mira et al., 2020; Nguyen et al., 2020; Vieta et al., 2020).
For these reasons, psychological well‐being of health workers should
be a global priority, as well as, providing comprehensive, high quality
and personalized psychological interventions from the workplace and
the institutions (Mira et al., 2020; Shanafelt et al., 2019; Søvold
et al., 2021). In fact, psychological programs could increase the
satisfaction with the workplace and, consequently, a better labour
performance with less sick leaves (Yslado‐Méndez et al., 2019). This
psychological approach should be accompanied by an improvement
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of the labour conditions, reducing marathon days and stabilizing
working conditions.
This systematic review also presents some limitations. The small
number of included studies and the time elapsed since the start of
COVID‐19 pandemic. Besides, all included studies are cross‐
sectional, longitudinal studies will be necessary to prove the long‐
term effectiveness of the proposed interventions. In fact, 2 years is
a short period of time to performed psychological interventions and
prove their effectiveness through RCT. Another limitation was het-
erogeneity presenting the outcomes through the different included
studies. Further investigative research should be driven to supply
these limitations.
AUTHOR CONTRIBUTIONS
All authors participated and revised the design and the purpose of
this systematic review. Carmen Varela conducted the search. Carmen
Varela and M. Almudena Gómez Pulido conducted the research:
screen the titles and abstracts, review the full‐text, and extract the
data. Carmen Varela and AG drafted the manuscript with contribu-
tions from all authors. The authors read and approved the final
manuscript.
ACKNOWLEDGEMENTS
This research received no specific grant from any funding agency,
commercial or not‐for‐profit sectors.
CONFLICT OF INTEREST STATEMENT
The authors declare that the research was conducted in the absence
of any commercial or financial relationships that could be construed
as a potential conflict of interest.
DATA AVAILABILITY STATEMENT
This is a systematic review and is registered in the international
prospective register for systematic reviews (PROSPERO), the pro-
tocol of this study was accepted on 16 March 2022, registration
number CRD42022318685.
ORCID
Carmen Varela
https://orcid.org/0000-0002-3009-0348
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How to cite this article: Varela, C., Montero, M., Serrano‐
Ibáñez, E. R., de la Vega, A., & Pulido, M. A. G. (2023).
Psychological interventions for healthcare professionals
during the COVID‐19 pandemic: A systematic review. Stress
and Health, 1–12. https://doi.org/10.1002/smi.3246
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15322998, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3246 by Readcube (Labtiva Inc.), Wiley Online Library on [13/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License