Strategies for Supporting Healthcare Workers’ Resilience and Mental Health During A Pandemic: A Scoping Review

As a group, health workers are at risk of experiencing stress and mental health problems at work, which may negatively affect their resilience. This study assessed the effectiveness of mental health support strategies for health workers during the COVID-19 pandemic. This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines in searching through three journal databases, such as: EBSCO, Scopus, and PubMed. The quality of the studies was assessed with the Crowe Critical Appraisal Tool, and the results of the review emerged from a process of synthesis that identified common themes. The search yielded five main articles. The results of the synthesis process inspired several recommended strategies to support the resilience and mental health of health workers during a pandemic, including personal management, psychoeducational, and counselling approaches. It is important to work in partnership with stakeholders and across sectors to derive the maximum benefit from these interventions.


Introduction
Evidence shows that healthcare workers are a group at risk for short-and long-term mental health problems during an infectious disease pandemic.The factors affecting mental health during a pandemic include burnout syndrome, depression, post-traumatic stress disorder, anxiety, increased family responsibilities, increased workload, decreased access to necessary tools and equipment, guilt, uncertainty, and a-dapting to unfamiliar workplaces or schedules (Centers for Disease Control [CDC], 2019; Chinvararak et al., 2022;Houghton et al., 2020;Shanafelt et al., 2020).
During a pandemic, healthcare workers may experience concerns about the risk of being infected with an infectious disease, which negatively affects the mental health of staff, the quality of care provided to patients, and the capacity of the healthcare system to respond to in-creased care needs during the pandemic (Kang et al., 2020).The symptoms that may be experienced by health workers include stress, anxiety, reduced motivation, fatigue, sadness, depression, and difficulty sleeping or concentrating.This situation can result in unhealthy behaviors, such as drug and alcohol abuse, that may contribute to a decreased ability to function in the workplace.In addition, these unhealthy behaviors may be associated with impaired family functioning and domestic violence, further exacerbating depression, anxiety, and stress and negatively affecting the ability to function in the workplace.Healthcare workers with mental health problems may have high rates of absenteeism (Robertson et al., 2020).
Stress at work can negatively affect healthcare workers' resilience, but personal development and learning to adapt have the potential to build resilience and enhance the ability to cope with stressful situations in the future.Strategies to maintain resilience in the workplace may incorporate relationship development (e.g., through mentoring) and maintaining a healthy work-life balance (CDC, 2019;Robertson et al., 2020).
Healthcare workers throughout the world have had to deal with challenges, such as increasing patient mortality, growing healthcare demands, medical supply shortages, and tremendous physical and emotional stress.Furthermore, the duration of this unpredictable crisis and the extent of its effect on normal life remain unknown.Health statisticians anticipate that COVID-19 will continue to be a public health disaster in the future.Aside from the acute challenges caused by this crisis, the ripple effect of postponed medical procedures, research, and clinic visits will continue to put strain on healthcare workers and the health system in the future.It is becoming easier, however, to find information on topics such as the epidemiology of the disease, its etiology, and infection control and prevention (Sorbello et al., 2020).
The current understanding is that healthcare workers need resilience to handle difficult situ-ations.Although workplace resilience is drawing more attention, the topic of resilience among healthcare professionals needs further research, particularly in relation to employee retention.Recently, more attention has been given to the concept of developing resilience, defined as the ability to resist the disruption of regular functioning by expecting and preparing for a painful experience.Furthermore, it has been proposed that resilience may be a key distinguishing characteristic between health workers who experience burnout and those who do not (Fox et al., 2018;Schreiber et al., 2019;Walsh, 2015).
Future healthcare crises will induce the same psychological pain as the present pandemic.To address this psychological anguish, it is critical that measures be developed and implemented to promote healthcare workers' resilience (Heath et al., 2020).Several interventions promote resilience among healthcare workers to prevent the development of ill health among them, such as relaxation, stress management, psychological services, regular rest, healthy eating, adequate physical activity, support from family and coworkers, controlling maladaptive coping strategies, limiting the use of online social media, and encouraging the expression of gratitude (Baskin & Bartlett, 2021;Verbeek et al., 2019).
It is necessary to pay attention to the potential long-term impact on healthcare workers.Healthcare providers can implement strategies such as rotating employees, partnering experienced and inexperienced employees, monitoring work breaks, offering flexible schedules, and providing social support.This study assessed the effectiveness of strategies to support the resilience and mental health of healthcare workers during the COVID-19 pandemic.The results provide further recommendations of effective strategies for healthcare institutions to maintain the mental health of health workers on the front line in the pandemic era.

Methods
This study adopted a scoping review method based on the Joanna Briggs Institute's JBI Manual of Evidence Synthesis to address the predetermined objectives (Peters et al., 2020) by discovering and synthesizing representative literature to establish new frameworks and views on the chosen topic.The process includes (1) defining the purpose, (2) defining inclusion criteria, (3) defining a strategy for seeking, selecting, and extracting articles, (4) analyzing evidence, (5) presenting results, and (6) summarizing the evidence.
Three authors (IMMYS, GAB, and EO) simultaneously searched the selected databases, namely PubMed, EBSCO-Medline, and Scopus.The search was limited to articles published in English in the past five years for which the full text was available.The authors also established inclusion criteria for the selecting articles: (a) the article described strategies/interventions to support the mental health and/or resilience of health workers, and (b) the study design was an observational or clinical trial.The exclusion criteria were letters, abstracts, and research taking the form of a review.
The strategy to determine search terms for articles was based on the population/patient, intervention, comparison, and outcome (PICO) method and used the following parameters: population: professional health workers, intervention; technique/intervention: to support mental health and resilience; comparison: no comparison; and outcome: mental health and resilience.These PICO parameters yielded the following search terms: ("healthcare professional," OR nurse OR doctor OR midwife OR "healthcare worker") AND ("mental health promotion" OR "mental health intervention" OR "resiliency promotion" OR "resiliency intervention") AND (stress OR depression OR resilience OR "quality of life" OR "burnout syndrome").Data synthesis was performed by extracting important attributes in the articles, which were then elaborated into structured points, including sample size, type of intervention, time of observation, measurement, and study result.Table 1 shows the results of the synthesis.
Before the data extraction process, the quality of the articles was reviewed using the Crowe Critical Appraisal Tool (CCAT) to determine the suitability of their content.A CCAT assessment is conducted by looking at the points yielded by each of eight categories to disqualify research articles that earn a high score overall but a very low score in a given category.The form consists of 8 categories and 22 items, each category having a possible score between 0 and 5, which is awarded based on the item descriptors presented.The more descriptors checked, the higher the score.However, the evaluation is not solely based on the descriptors, as the importance of each item is also taken into account.To calculate the total CCAT score as a percentage, the sum of the eight category scores is multiplied by a maximum score of five and then divided by 40.The CCAT assessment ensures that each category is considered to avoid a high overall score masking poor performance in specific areas.Neglecting to assess each category would result in poor performance in one or more areas being hidden by the overall score.Ultimately, the appraiser's judgment determines the entire appraisal procedure (Crowe, 2013).

Results
The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020, by Page et al. (2021), guided the search for articles, which returned five articles as the main sources of this paper.Figure 1 shows the PRISMA flow diagram.All the studies were conducted in different places, including the USA (Nathan et al., 2021), Portugal (de Pinho et al., 2021), Germany (Mache et al., 2017), Australia (Rees et al., 2020), andSpain (Blanco-Donoso et al., 2021).
The studies varied in their sample size (13-821), study design, measures, and recommended strategies.Table 1 shows the descriptive characteristics of the five included studies, while Table 2 provides the results of the article quality assessment.The average total score for each assessment category is close to the maximum

Discussion
This study assessed the effectiveness of strategies to support the mental health of healthcare workers during the COVID-19 pandemic.The findings reveal that training programs that support mental health and resilience effectively improve the emotional health of healthcare workers.The most recent research, however, focuses on counseling, psychoeducational therapies, and mindfulness-based therapy, which may be used to lessen the psychological toll that the COVID-19 crisis has had on all healthcare workers.
The results of the synthesis identify several strategies that are known to be effective in im-proving the mental health of health workers.These may take the form of personal management, including taking breaks during shift changes, initiating and maintaining a healthy diet, maintaining mineral water consumption, exercising, employing self-relaxation techniques, engaging in recreational activities, maintaining social relationships with family and friends, expressing emotions constructively, and avoiding hoax information related to COVID-19.In addition, counseling activities with experts and training/education related to stress management are known to have good effectiveness (Blanco-Donoso et al., 2021;de Pinho et al., 2021;Nathan et al., 2021;Rees et al., 2020).
Stress management training can be provided to improve the mental health of nurses and other health workers, and offering an understanding of mental health efforts is a crucial element in  The experimental group showed a significant reduction in their levels of depression and stress compared to the control group.
people.The authors found that six of the seven doctors experienced a decrease in burnout and psychological stress.
High levels of stress and depression in healthcare workers existed long before the COVID-19 pandemic, but the pandemic has made it increasingly clear that healthcare workers' emotional stress is a real problem.Effective intervention requires a comprehensive approach that is able to integrate various complementary and interrelated aspects.The severity of the CO-VID-19 pandemic is exposing healthcare workers to a unique cause of stress, which requires healthcare institutions to respond and support their workers in new and innovative ways (Hall et al., 2020;Irfan et al., 2020;Vizheh et al., 2020).
Workplace administrators and managers need to ensure that health workers can actively use available resources.Generally, despite the pandemic, health workers are known to experience high rates of mental health problems but show reluctance to seek help.To carry out professional responsibilities during difficult workplacerelated events, such as death and illness, healthcare providers frequently disregard their emotions and adopt an impersonal attitude, which can damage their long-term emotional well-being (Bohlken et al., 2020;Shanafelt et al., 2020).
The reluctance of health workers to seek mental health assistance reflects concerns over stigma in the workplace and negative professional consequences (Chirico et al., 2021;Wessely & Gerada, 2013).This behavior was demonstrated by health workers during the COVID-19 pandemic as shown in the inadequate use of psychological support resources by hospital staff (Huffman et al., 2021;Krystal et al., 2021).A study found a low awareness among health workers about the use of mental health improvement services provided by healthcare institutions; health workers stated that they preferred hospital managers to prioritize resources that met their physical needs over their psychological well-being (Cheng et al., 2012).
The impact of persistent stressors causes many health workers to experience chronic stress, but the availability of mental health professionals for healthcare workers has proven beneficial in promoting treatment-seeking behavior.In addition, ensuring the sustainability of the intervention is a very important mechanism that merits consideration.Managers of healthcare institutions must have the infrastructure to identify people with mental problems related to stress and similar factors.People can strengthen longterm resilience by following healthy lifestyle, diet, and exercise habits as well as by re-engaging in activities that bring them a greater sense of personal meaning (Croghan et al., 2021;Gray et al., 2021;Spoorthy et al., 2020;Tan et al., 2020).
There is currently insufficient experimental data to report on strategies for boosting healthcare workers' resilience (Delgado et al., 2017 (Tomlin et al., 2020).Encouraging the expression of appreciation is another method that may be effective in fostering individual healthcare personnel resilience (Kim et al., 2019).Tomlin et al. (2020) describe the COVID-19 pandemic's stages and the steps that healthcare organizations can take to help their staff become more resilient based on the stage of the pandemic.The stages include the preparation phase, pre-phase, initial/core phase, and longerterm phase of the pandemic.During the preparation phase, it is necessary for managers to comprehend the requirements of their workforce and identify if any team members may be more susceptible than others to experiencing mental health issues.Additionally, during the team grounding plays a vital role.This involves recognizing the emotional and cognitive information shared within a group, acknowledging it, and utilizing it to create an agenda for discussion.Furthermore, in the initial/core phase, effective communication will be crucial.It is important to deliver timely, precise, and evidence-based information about the virus and the hospital's response, including worst-case scenarios.Finally, longer-term phase, after the COVID-19 pandemic has subsided, organizations are expected to evaluate what happened and how they responded to it.
The results present some beneficial mental health and resilience programs and may be useful to hospital managers when managing healthcare workers.Despite our best efforts, our review has significant limitations that must be considered, for instance, a paucity of sources and bias in the selected publication and reports, including selection bias that occur when the inclusion and exclusion criteria are not applied consistently, and reviewer bias that occur when the reviewers have pre-existing beliefs or preferences that influence the interpretation of the evidence, as these aspects may impact both the quality and quantity of the studies and constrain this study's conclusiveness.

Conclusion
The COVID-19 pandemic has made it clear that mental health problems in healthcare workers are real.It represents a turning point to accelerate the progress needed to reduce stigma and expand access to mental health support for health workers.Future healthcare crises will continue to cause psychological distress among healthcare personnel, so it is imperative to develop and implement strategies to strengthen healthcare workers' resilience to alleviate this psychological suffering.To ensure that healthcare workers feel valued and heard, organizations may need to hire additional support staff or reallocate staff, change their revenue distribution, revise reimbursement and compensation models through negotiations with internal and external stakeholders, and take other actions.
Due to the present success in slowing COVID-19's spread in many countries, there is now more time and opportunity to be proactive in putting measures into place that will improve, restore, and preserve health workers' resilience now and in the future.The current literature on techniques for mitigating the psychological problem caused by the pandemic may be useful for healthcare professionals while also exploring proactive holistic measures.
It is of paramount importance to conduct studies to assess the effectiveness of interventions in supporting the resilience and mental health of health workers during a pandemic.Further studies should be carried out with proper planning, including development, peer review, and planning for follow-up.Given that many health workers will experience stress and anxiety, it is important to work with stakeholders and across sectors to derive the maximum benefit from interventions.

Figure 1 .
Figure 1.Literature Search Flow Based on the PRISMA Guideline

Table 1 .
Characteristics of the Articles