At the recent, June 2022, WONCA (World Organisation of National Colleges, Academies and Academic Associations of General Practitioners / Family Physicians) conference in Limerick, Ireland, Dr Mike Ryan, Executive Director of the World Health Organisation (WHO)’s Health Emergencies Programme postulated that as we learn to live with COVID-19, the next pandemic is a mental health pandemic, and it is already here.
New and innovative interventions are required to support and rebuild resilience front line health and social care workers who are experiencing the phenomenon of burnout.
In 2021, The UK House of Commons Health and Social Care Committee suggested that this support is,
“…not just needed during the waves of covid-19: it will be needed through the recovery as the health and care sector returns to ‘business as usual’.”
Researchers including Holmes et al (2020); Pollock et al (2020) and Martin et al (2021)) report that mental health (MH) apps have gained in popularity among healthcare workers (HCWs) and social care workers (SCWs) during COVID-19. Their evidence supports the acceptability of mental health (MH) apps, but not yet their effectiveness, validity nor affordability. Few researchers differentiate between HCWs and SCWs. They are not homogenous.
The NHS Data Model and Dictionary defines Social Care Workers (SCWs) as persons who
“…may be home care assistants, work in residential care homes, or be working with older people, children and families and people with disabilities.”
This article concerns itself with the phenomenon of burn out among SCWs.
Early on in the COVID-19 pandemic, a report in Community Care (2020) noted that deaths among SCWs in England and Wales from COVID-19 were far exceeding deaths both among HCWs and those in the wider working population.
Media (Guardian, 2021), trade union (GMB, 2021) and government reports (UK House of Commons Health and Social Care Committee, 2021) suggest that this trend has continued and given rise to unacceptable levels of stress and anxiety among all frontline SCWs. A survey in 2021 by the GMB, a UK trade union representing care home workers, found 75% of 1,200 respondents saying that the COVID-19 pandemic has had a serious negative impact on their mental health. The care home workers sum it up as having experienced burnout. The World Health Organisation (WHO) defines burnout as:
“… a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed.”
A survey in April 2020 by carehome.co.uk reported that 32% of staff felt a need for support with their mental health to help them cope with the stress and anxiety they were experiencing during lock-down.
Since the designation by the WHO of COVID-19 as a pandemic in March 2020, there has been much written and broadcast about care home workers experiencing heightened levels of stress and anxiety. Writing in the Lancet, Wang et al (2020) observed that,
“…under the dual stress of fear of infection and worries about the residents’ condition, the level of anxiety among staff in nursing homes increased and they developed signs of exhaustion and burnout after a month-long full lockdown of the facilities.”
Writing in the Lancet, Holmes et al (2020) expressed the opinion that a digital response was crucial in mitigating the concerns raised by Wang et al (2020). Holmes et al (2020) also noted that the delivery of such interventions was negatively impacted upon by the digital poverty among potential beneficiaries of such approaches. That is to say that despite the ubiquity of smart phones, the cost of data could pose a barrier to uptake by poorly paid care home workers.
According to the Guardian (2021), this experience of burnout, combined with the mandatory policy (in England) of “no jab, no job” for care home workers led to many leaving for unskilled jobs in retail and distribution. There they can earn up to 30%, more, with less stress. Therefore, valuable, yet undervalued, employees are being lost to the care home sector.
A recent UK Health Foundation blog by Shembavnekar et al (2021), compares contrasting attitudes to the perception of NHS staff (HCWs) as heroic whilst there is less media coverage about the significant emotional distress among care home workers (SCWs). Hines et al (2021) in a report for the European Commission, note that social care research is not an area that is perceived by the general-public as being as valuable as investigations into preventing or treating chronic illnesses such as cancer, COPD, or diabetes.
The UK House of Commons Health and Social Care Committee (2021) published a report on workforce burn out and resilience among NHS and Social Care sector. The report articulates how Covid-19 has put social care teams and in particular care home workers under immense pressure. The parliamentary committee report conjectures that this high level of burn out presents a real and present danger to the future operation of social care services in the UK.
These UK reports are corroborated in the USA by a 2021 survey conducted by the MHA trade union of 1119 of its HCW and SCW membership. The MHA survey concluded that members working on the frontline were experiencing conditions comparable to a war zone. The MHA report (MHA, 2021) that followed the survey, concluded that it was essential that the MHA worked with state governments to provide the means to support both HCWs and SCWs cope with this impact on their mental health. The MHA report did not distinguish between HCWs and SCWs.
Martin at al (2021) provide insights into the impact of COVID-19 of the mental health on Spanish care home workers. Their descriptive study involved engagement with 210 Spanish care home workers. The authors believe that theirs is the only study to have been conducted, using validated mental health questionnaires, to identify factors that lead to burnout among a cadre of care home workers. Earlier, in an opinion piece, Guerrini et al (2020) asked readers to consider whether MH apps are, at least part of the answer to findings such as those of Martin et al (2021) and whether such apps are,
“Essential not peripheral in addressing mental health concerns during the COVID-19 pandemic?”
Guerrini et al (2020)’s comprehensive literature review concluded that MH apps do hold out promise to reduce the symptoms associated with burnout. They also highlight a need for further research to find conclusive evidence around the efficacy and acceptability of MH apps.
Morton et al 2020 emphasise that MH apps based on users’ lived experience can enhance development and implementation of these apps. They urge researchers and developers to adopt User Centred Design (UCD) and Participatory Action Research (PAR) methodologies to work with the intended users to co-create new MH apps. Ravalier et al (2020) describe how they adopted a PAR approach to work with SCWs in seven local authority areas across England. Their purpose was to co-develop a MH App for stress management. The approach that Ravalier et al (2020) took was based on three phases:
“1: To co-design and disseminate a series of app- and toolkit-based mental health and well-being initiatives for UK SCWs
2: To evaluate the efficacy of the initiatives via a pre- and post-intervention survey of working conditions and well-being.
3: to evaluate the efficacy of the interventions with post-intervention semi-structured interviews. “
Ravalier et al (2020) describe the working conditions of UK front line social workers (FCWs) as being “chronically stressful”. It is unclear what the roles of these FCWs were and care home workers are not specifically mentioned. Ravalier et al (2020) do explain how a PAR approach based on participants’ knowledge and self-awareness of their own mental wellbeing contributed to the development of a prototype of the Healthier Outcomes at Work app. It is branded as HOW.
Ravalier et al (2020) describe the co-creation of HOW as an iterative process. It involved pre and post intervention focus groups and interviews that led to the development of psycho-educational content. They report on how they followed a rigorously monitored series of steps to co-develop HOW. The first step was set out a thematic framework to guide data collection and analysis. Participants’ mental health was measured at various stages using the validated General Health Questionnaire (GHQ). Quantitative data was subsequently analysed to assess the impact of HOW in workplace environments.
Pollock et al (2020) note that HCWs and SCWs are much more likely to engage with new MH apps if they have had some involvement in developing them or customising them to meet local needs. They also suggest that some form of organisational incentives and rewards for frontline workers may help to engage frontline staff with such interventions. Pollock et al (2020), also report on the efficacy of MH apps to support the resilience and mental health of frontline HCWs and SCWs during and after a pandemic such as COVID-19. In a mixed methods systematic review, they found evidence that the key to implementing successful MH apps was ensuring that they were appropriate and adaptable to the prevailing cultural contexts.
Nonetheless there are barriers, not least the lack of any conclusive evidence as to the efficacy of the adoption of MH apps in the social care sector. Schueller & Tourous (2020) cite affordability as an important barrier that requires to be considered. End users have come to expect apps to be free. Yet, developers of such interventions require to be funded in the first instance to develop the interventions and then to be paid to make them available to the users for whom they are intended. Whilst end users appear to be happy to download free MH apps that have no obvious evidence base, employers or organisations are unlikely to be willing to purchase MH apps where there is no evidence of their efficacy.
Regulation and Validation
The regulation and validation of MH apps is a topic of some debate. There is however broad agreement among researchers that users’ trust in health apps is likely to be increased if the content of an app is based on quality assured evidence Indeed, when Albrecht and von Jan (2017) commented on the European Commission’s draft guidelines on the validation of health apps, they acknowledged that many app developers do not have a professional background in healthcare. Developers need to work with subject matter experts (e.g., Behavioural Psychologists) to understand and respect the needs of the end-user. Despite this broad consensus, and according to de Sola et al (2020) there is still,
“…no specific regulation procedure, accreditation system, or standards to help the development of the apps, mitigate risks, or guarantee quality.”
Meanwhile in the USA, Marshall et al (2020) published an opinion piece that argued the case for developing New Approaches Towards Safe and Efficacious MH apps. This article critically reviewed the issues of safety, regulation, efficacy, and effectiveness of MH apps. Marshall et al (2020) argued that research into the effectiveness of mental health apps needs to meet common standards that result in an internationally recognised quality assurance mark. Marshall et al (2020) concede that this would involve additional costs to app developers, and it is not known if consumers would pay to download a quality assured app over one that was free but lacked any certification.
Since the onset of the COVID-19 pandemic, other authors including Luceno-Moreno (2020) in Spain, and Longyear & Kushlev (2021) in the USA have noted a rise in the popularity in the use of MH apps among both HCWs and SCWs. This appears to correlate with the increased levels of stress and anxiety that HCWs and SCWs are experiencing on the frontline. Both groups of researchers recognise that these apps are being used by vulnerable populations. Longyear & Kushlev maintain that whilst the popularity of these MH apps seems to demonstrate a high level of acceptability, the claims made by the app developers as to the efficacy of their products require more regulatory oversight. Longyear & Kushlev emphasise that there is,
“…a need for a well-defined pathway for pre-market regulatory approval…”
to underpin any quality assurance mark that provides users with guidance as to the appropriateness and efficacy of MH apps. Meanwhile, Leigh et al (2021) in the UK, postulate that the ORCHA (Organisation for the Review of Care and Health Applications) library might provide such a solution.
Detailed multidisciplinary research involving clinicians, app developers and social care practitioners is needed to develop, evaluate, and validate the value of innovative digital interventions in order to integrate them into the delivery of mental healthcare to support frontline SCWs experiencing burnout. Moreover, as Pollock et al (2020) noted, if end-users were involved from the outset in the development of any MH apps, they would be much more likely to use them.
The House of Commons Health and Social Care Committee (2021) suggests that this support is
“…not just needed during the waves of covid-19: it will be needed through the recovery as the health and care sector returns to ‘business as usual’.”
Any new research that contributes to filling the knowledge gaps around the efficacy of MH apps in supporting the mental health of care home workers should be seen as significant. Especially so if this can be generalised to help those in the wider population who are living with the phenomenon of burnout.
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