Pandemic Resilience

STAFF

Hospitals are collections of people and technologies, housed somehow, focused on diagnosis, treatment and care. Within that mix, any hospital director will tell you that the most important element is the staff. The quality of the buildings, the availability of medical devices, diagnostic tools and pharmaceutical therapies, good governance and financial management all make essential contributions to patient outcomes, but the staff – appropriately educated, trained and led – matter above all else.

Team

Innovative Processes

Changes to clinical processes and the built environments, how staff do their work and how they relate to their patients and to each other. 

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Personal

Well-being

Behaviours, relationships and expectations, at the level of individuals, teams, departments and the whole organisation.

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Teams

Areas of challenge

 

All these challenges affect all staff in hospitals – the clinicians, the scientists, the administrators, the technicians, the support staff, the managers and the directors – but how they have been addressed has varied from hospital to hospital, from region to region and from country to county. This part of the field guide illustrates each group of challenges in turn, from a range of different perspectives, and offers some learning points and questions about future adaptations

1. Effects of dislocation

  • working in different environments
  • following unfamiliar protocols and rules
  • changing training practice
  • operating within different teams, departments or even organisations

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2. Isolation

  • Lack of normal means of communication
  • Social distancing
  • Quarantine


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3. Changes to working practices

  • Taking on new responsibilities
  • Having to act fast with partial information
  • Implementing new clinical guidance at pace
  • Rapid estates reconfiguration
  • Managing infection prevention and control
  • Pushing the boundaries of professional competence.
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4. Management structures disruption

  • Stepping over traditional boundaries
  • Adopting different command and control measures
  • Managing up and down

 

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Inside the triage unit, Erasmus MC, Netherlands.(Photo courtesy of the Erasmus MC image bank and Liesbeth van Heel)

Introduction

If the COVID-19 pandemic has had profound implications for the capacity and capability of health systems in general, and hospitals in particular, this is notably the case in terms of how staff do their work and how they relate to their patients and to each other. The pandemic has forced very rapid changes to clinical processes and the built environment, but it has had just as much impact on behaviours, relationships and expectations at the level of individuals, teams, departments and the organisation as a whole. Desk research and the case studies examined during the Repurpose, Relocate, Reorganize webinar series show that many of the challenges for staff can be grouped into some key areas: dislocation, isolation, rapid and radical changes to working practices, and disruption to established management structures.

Single patient rooms in ICU and MC wards allow staff to don PPE in the corridor.(Photo courtesy of Erasmus MC image bank and Liesbeth van Heel)

1

The effects of dislocation

We know from peer reviewed, published literature [1][2][3] and from case studies that many hospital staff had to work in very different environments during the course of the first and second waves of the pandemic.
  • They experienced the unfamiliarity of field hospital structures
  • Rapid conversions of emergency departments, ICUs, operating theatres, general wards and public spaces
  • Socially distanced restrictions on rest and social areas
  • Different circulation arrangements (one-way systems)
  • And even the loss of basic amenities such as car parking spaces
Challenges

Such rapid and profound changes to familiar environments, and therefore to the usual processes of care, are psychologically dislocating[4]. Furthermore, as widely reported, these physical changes were accompanied by the introduction of robust protocols on infection prevention and control and the steep learning curve needed to understand a new disease and to care for COVID-19 patients. The normal routines of mandatory training and clinical education were often disrupted – troubling for staff who want to maintain their professional accreditation and concerning for organisations that are answerable to regulatory authorities. Many staff members were asked or required to retrain quickly to support colleagues in different specialties and were frequently relocated within the organisation for weeks or months. Multidisciplinary teamwork, which brought together colleagues who were previously unknown to each other, became the norm, and some hospital organisations also rapidly put in place new partnerships with other public and private sector agencies [5].

In the face of these challenges, senior clinicians and managers had to find innovative ways to maintain morale, to protect their staff, to ensure high professional standards and safe patient care and, crucially, to preserve a sense of common purpose.

Mitigations

There is no ‘one size fits all’ approach to resolving the dislocating effects on staff of the hospital response to the COVID-19 pandemic. However, the measures taken by North Tees and Hartlepool NHS Foundation Trust, a medium-sized district general hospital serving around 400,000 people in the northeast of England, are typical of many of the measures adopted elsewhere. In response to the dislocating pressures of wave one of the pandemic, the hospital focused on a series of key responses:

  • Infection prevention and control to reassure staff, with a particular emphasis on providing the correct personal protective equipment (PPE)
  • Limitation of shift hours and provision of rest areas
  • Skills workshops and supervision
  • Mental health support through multidisciplinary teams, including psychologists
  • Psychology Team available to front-line staff
  • Rapid deployment of a 7-day specialist palliative care team (to take pressure off staff coping with the increase in sudden deaths from COVID-19)
  • Enhanced visibility of senior staff/directors, with regular ward visits
  • Listening to staff, using an app (Listening in Action) to hear their views
Solutions

There were other, practical solutions rapidly adopted to help staff cope with the changes to environment and processes, such as:

  • Communicating to staff that planning was informed by international and local intelligence and active research
  • Optimising patient flow, infection prevention and control, and oxygen provision to build confidence in the whole system
  • Early interdepartmental collaboration and planning
  • Early support for national COVID-19 clinical trials
  • Upskilling of nursing and medical workforce
  • Rapid assessment and communication of ‘what worked and what didn’t work’
  • Clarity over triggers for escalation and de-escalation
  • Planning for recovery and restoration

The above measures cannot remove all sense of dislocation and turmoil, but they can, collectively, potentially help staff to adapt successfully to a challenging working environment.

staff-innovation

The rapidly reconfigured entrance to Urgent and Emergency Care, North Tees and Hartlepool NHS Foundation Trust. (Photo courtesy of North Tees and Hartlepool NHS Foundation Trust)

Socially distanced, screen-equipped reception area. (Photo courtesy of North Tees and Hartlepool NHS Foundation Trust)

2

Isolation

Healthcare is a profoundly social activity. Doctors, nurses and therapists are, by nature and by training, team players who spend much time communicating directly with patients, family members and colleagues, often using warm phrases such as ‘ward huddles’ to describe their direct interactions with each other. Many healthcare staff, in hospitals and primary and community care settings, speak of belonging to a ‘family’, and they include in that group all the support, managerial and administrative staff who work alongside them. The pandemic-related outpouring of support from the public – for example, the UK’s ‘clap for carers’ evenings during the first wave of COVID-19 (which even has its own website) [6] – demonstrated a deep, affective bond with health and social care workers.

Examples

The recent literature relating to the effects of changes to ‘normal’ processes on hospital/healthcare staff has often reflected on the challenges to staff caused by disruption to the usual means of communication and professional and social interaction [7][8]. In many cases, this amounts to a form of isolation: staff left without the means to talk directly with colleagues and patients; mealtimes spent alone; meetings held remotely; messages passed on by text rather than a conversation; seating re-arranged to be distant from colleagues. Some examples:

Work & Home Balance
In the case of one of the case study hospitals, ICU staff expressed deep concern and unhappiness about feelings of psychosocial distance from their own family members. ‘I can’t talk about my work at home anymore,’ said one nurse. ‘It’s just too difficult and it causes tension if I do.’
Distant Communications

At the Sheba Medical Centre in Israel, research into the radical increase of ICU beds, and the relocation of some of this service during the first wave of the pandemic, shows how frustrating and difficult it was for staff to communicate through the barriers of full PPE and physical separation from each other.

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Overall Performance
Extensive research originating from the Danish Psycho-Social Preparedness Unit shows clearly the effects of isolation on staff, linked to concerns about their competence, their ability to process information, professional interactions with colleagues and patients, and even their physiological needs while at work.
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3-pics

The surge ICU has been fitted with windows in the doors (with blinds), permanent cameras have been installed with images routed to monitoring stations and communication devices stand at the ready, photographed in September 2020, when this ward was not in use. (Photos courtesy of Erasmus MC image-bank and Liesbeth van Heel)

Cases

Göteborg, Sweden

Sahlgrenska University Hospital

Providing staff with extensive and easy-to-use testing facilities built a sense of confidence and solidarity. 

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North Tees and Hartlepool, UK

NHS Foundation Trust

This case study demonstrated the importance of giving staff a space to be together, outside their work environment, to reduce stress and to rebuild some of the usual social interactions.

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3

Radical changes to working practices

The early weeks of the first wave of the pandemic demonstrated a broad range of clinical and organisational risks in relation to COVID-19: lack of knowledge about the pathology of a new disease, a limited and often ineffective range of treatment options, a lack of local or national testing capacity (in most countries), hospitals without adequate quarantine facilities and ICU capacity, and the prospect of staff shortages due to illness and/or self-isolation.[9] To mitigate the key risk of a lack of ICU beds, many hospitals were expected to adapt quickly to provide ‘surge capacity’, often beyond any previous planning assumptions.

3-pics-2

Surge ICU room on the 8th floor ready for ICU care, photographed in September 2020, when the ward was not in use. (Photos courtesy of Erasmus MC image bank and Liesbeth van Heel)

These high-level primary areas of risk were linked to a series of equally problematic secondary risks. In hospitals and in health systems that were operating according to existing pandemic guidelines, staff found that they were very rapidly asked to:

  • Embrace new and additional responsibilities
  • Make decisions with limited data and information
  • Implement new and frequently changing clinical guidance
  • Work at the limits of their professional competence

Cases

Learning System model

A study of some of the field hospitals that were widely constructed as an emergency ‘back stop’ in case of overwhelming numbers of acutely ill Covid-19 patients reported on the adoption of a formal ‘Learning System’ to enable staff to cope with all four of these major challenges[10]. The authors speak of the challenge of “… the rapid pace at which medical evidence was evolving and … the onslaught of rumor, unconfirmed hypotheses, and anecdotes delivered daily via social media, but also … several practical problems in getting data from, and returning change to, the bedside.” The Learning System model allowed for rapid risk mitigation and – usually – resolution, through deployment of a multi-disciplinary Quality and Learning Team. A daily Clinical Forum meeting was used to ensure rapid and collaborative decision-making, with the aim of delivering rapid change to processes where appropriate.

Upskill & Reassign

Existing, reconfigured and repurposed hospitals also responded to these challenges. The head of an ICU in a UK case study reported that anaesthetists were rapidly retrained to take on responsibilities as intensive care or respiratory consultants. Nurses were redeployed and upskilled in ICU practice. To cope with the mix of partial and sometimes conflicting advice and guidance, the unit decided to nominate one member of the staff per day to act as the ‘single source of truth’ – sifting through and analysing the official health department communications, the emerging peer-reviewed literature and the professional opinions generated in a variety of forums.

Environment redesign

At local level, individual hospitals made enormous efforts to mitigate these risks through process and environmental redesign – for example, the Mount Sinai Hospital case study, from New York, USA. But in many cases, it was evident that a response from larger geographies was needed. A study of the New York City Health + Hospitals group typifies this approach[11]. This integrated consortium of public hospitals, neighbourhood health centres, nursing homes and home care services set up multidisciplinary teams and a suite of online tools to coordinate the deployment of emergency care clinicians to hot spots across the city. Additional agencies, including human resources, occupational health and private healthcare staffing organisations, were also included in the full-spectrum response. Expertise in training and induction was centralised, new staff roles and training tools were introduced, and a full range of communication services were used to disseminate best practices.

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Senior managers at a masked, socially distanced meeting.(Photo courtesy of North Tees and Hartlepool NHS Foundation Trust)

4

Changes to management structures

Challenges, mitigation and solutions

Most of the case studies reported on significant changes to command and control structures during wave one of the pandemic and anticipated that similar measures would be required during subsequent surges in infection rates and demand.

Although most health systems, and hospitals, anticipate crises of varying kinds, modelling often focuses on short-term emergencies. The COVID-19 pandemic upended these assumptions and has tested the operational and strategic response of public and private sector agencies to the limit.

Cases

North Tees and Hartlepool, UK

NHS Foundation Trust

The usual processes of reporting were replaced by a more agile model, and operational decisions were devolved downwards.
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Netherlands

Erasmus MC

A Crisis Management Team was deployed from the beginning of wave 1 of the pandemic, supplanted later by a COVID Coordination Team.

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Teams

Questions about future adaptations

There are no easy answers to these questions, which in many cases have a long history, but COVID-19 has made it all the more important to ensure that hospitals have management structures that can capably flex between crisis response and ‘business as usual’. If there is a lesson from 2020 and the pandemic, it is that hospitals and health systems were, in the main, under-prepared and under-resourced to ensure a resilient response over a long period. This should be the focus of future considerations in relation to the recruitment, education, training and support of staff, not only in the hospital sector but also across the wider health and care system.

The responses from the hospital sector during waves one and two of the pandemic have led to rethinking of how health and hospital services operate now, and will in the future, in relation to many questions:

Outpatients
  • Can hospitals offer virtual appointments, using multidisciplinary teams to manage patient needs, without compromising the quality of care?
  • How can infection prevention and control be better implemented in outpatient areas?
  • What forms of digital communication are best suited to different patient groups?
Diagnostics
  • If infectious disease screening is the ‘new normal’, how will this impact the time taken to process patients?
  • How can hospitals best use available resources, where there are known limitations?
Planned care
  • After each wave of the pandemic, how are normal services resumed?
  • How do hospitals ensure that there are enough suitably trained staff to offer elective services?
  • How can the independent or private sector contribute to the pandemic effort?
Emergency care
  • Should operating theatre designs accommodate multi-use functionality?
  • How can hospitals flex up and down in relation to emergency response?
  • Can digital technologies contribute more to patient flow?
  • What is the role of triage services in preventing inappropriate emergency care attendance?
Community care
  • What the future contribution of primary and community care to hospital admission avoidance?
  • How can hospitals contribute to a ‘single point of access’ model?

Individual

Well-being

COVID-19 is an acute threat to resilience

Healthcare staff are generally already exposed to various demands (e.g., continuously high workload and staff shortage, irregular working hours, working with highly sick patients and comparatively few opportunities for recovery). These demands can often not be matched with sufficient resources to balance out the ratio of demands and resources. As a result, jobs in healthcare have often been described as high-strain jobs. Moreover, poor mental health is higher among healthcare workers compared to other sectors.

Challenges

Employees currently have to handle the challenges that COVID-19 precipitates along with these ‘everyday’ demands. Staff has to deal with the following extreme work conditions[12].

Increased security measures
  • wearing many layers of personal protective equipment (PPE)
  • continuous need for concentration and alertness
  • strong behavioral regulation that reduces autonomy and spontaneity
  • reduction in physical contact
Increased demands
  • longer working hours
  • more patients
  • requirements to quickly train for new tasks
  • work in new or re-built spaces adapted to COVID-19
Uncertainty regarding consequences
  • Consequences as of exposure to COVID-19-infected patients for a long duration

Staff may also experience stigmatisation and reduced social support due to their fear of being infected as well as long working hours.

Not only does COVID-19, as an acute extra-organisational stressor[13], have dramatic effects on how front line staff work; it also poses an eminent threat to the health and well-being of staff[14]. Studies have shown that staff exhibit higher cortisol levels, and this psychophysiological response negatively affects cognitive functioning, disrupts sleep and decreases the immune response[15][16]. Moreover, studies have uncovered high levels of anxiety and depression in frontline staff working with COVID-19 patients[17]. This diminished employee well-being is a central threat to the resilience of healthcare organisations. Particularly in healthcare, human capital is a central factor and if contextual factors such as an acute crisis like COVID-19 threaten the well-being of employees, then the entire system is in danger.

Hence, organisational resilience can be perceived as dependent on the general individual resilience of staff. Organisational resilience is a multilevel construct.

Staff Resilience

Employees’ individual resilience can be defined as the ability to modify goals and behaviours to cope with environmental challenges and ultimately to recover from crises.e.g.[18], There is a substantial inter-individual difference regarding individual resilience; however, these differences have been found to converge over time within a workplace. This indicates that organisations may be able to support staff in their reactions to adverse situations by making resources available and providing psychosocial risk management.

Typically, the reaction after experiencing an acute stressor such as COVID-19 for the first time is characterised by team cohesion, impact, and meaning, which has also been referred to as the ‘heroic’ or ‘honeymoon’ period[19]. However, as with COVID-19, which has been ongoing for about one year, employees are often exposed to these aversive conditions over a longer period. Here in particular, the actions of organisations matter to support staff handling the combined burden of the acute stressor and the daily stressors.

How can resilience be promoted?

Solutions and progress towards solutions

It is of key importance to provide necessary resources both related to the job and the person. This support can be provided to primarily deal with the acute stressor, such as with COVID-19, or support can also be arranged on a continuous basis as part of initiatives to develop a healthy work environment. Although both types of initiatives differ in their scope as well as timing and duration, a considerable overlap related to content can be found.

Workplace

Factors that promote resilience in the workplace include the provision of development opportunities, peer- and leadership support[19][20], clear communication, continuous feedback, role clarity, participation in decision-making, a learning culture and flexibility[21][22][23]. Many of these factors are included in the organisational crisis preparedness strategy but have also been shown to enable organisations’ post-crisis recovery[24][25]. One challenge that healthcare organisations currently face in light of COVID-19 is the scarcity of guidelines for stress and resilience management in the context of acute organisational stressors.

Individual

The general recommendations by the WHO, IASC, as well as the Red Cross recommend the following to healthcare employees to reduce stress related to COVID-19[26][27][28]:

  • Consider basic needs (e.g., take breaks, eat healthy, be physically active)
  • Avoid unhealthy coping strategies (e.g., smoking, alcohol consumption or substance use)
  • Make use of previously used coping strategies (e.g., reuse previously effective strategies)
  • Talk to colleagues who have similar experiences
  • Maintain social contact with friends and family (e.g., use digital tools)
  • Having strong emotional reactions is normal (e.g., feeling overwhelmed, feeling pressure, difficulties to relax, etc.)
  • Seek support when feeling overwhelmed
  • Maintain routines from your everyday life that provide control and security
Managers

Managers play a particularly important role in supporting their staff in dealing with the challenging situations they are confronted with due to COVID-19. The following recommendations have been made[12]:

  • Be supportive of the mental health and well-being of staff by providing an atmosphere and opportunity for staff to confide in you about the challenges they experience
  • Encourage clear communication and provide all relevant information for staff to reduce uncertainty and increase control
  • Provide a structure that enables staff to take breaks to recover during the shift
  • Provide structure for collegial support wherein the team can exchange experience and provide social support to one another
  • Make psychosocial support available and reduce the potential stigmatisation around making use of this support
  • Be a role model and take care of yourself so that you are able to effectively manage the stress you experience
  • Make flexible work hours possible for employees who experience a challenging time
  • Take staff’s experiences of stress and poor mental health seriously, and, if possible, reduce potential causes of these
  • Recognise and show appreciation for staff’s extraordinary performance in times of crisis
  • Ensure role clarity and appropriate distribution of tasks that is continuously adapted to the changed circumstances

Cases

Below, different organisational initiatives are described to provide concrete examples of what can be done to foster employees’ wellbeing. These initiatives are primarily aimed at fostering individual resilience and organisational resilience among healthcare organisations during COVID-19.

Northern region of Denmark

Central psychosocial response team

To provide support for staff, a regional joint team consisting of psychologists, nurses, security managers, etc.

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UK

NHS Foundation Trust

The special circumstances around caring for COVID-19 patients and the altered shift schedule required for new rest areas.

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Research

To provide a broader overview of strategies to increase the psychosocial well-being of healthcare staff, a recent narrative review of existing research has been published.

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In addition to these initiatives to foster a positive supporting psychosocial work environment, COVID-19 has forced healthcare organisations to modify and/or create new spaces to care for the patients and their special requirements. Hence, most hospitals have repurposed or relocated the health organisations’ built environment.

Of course, the mental health and well-being of staff is not only affected by psychosocial factors but also the physical work environment, which has gained more attention during the autumn and the second wave of COVID-19, as potential negative effects of the built solutions that were utilised during the spring have become evident.

 

Ramat Gan, Israel

Sheba medical center

COVID-19 intensive care unit has been built in an underground parking structure.

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Cataloina, Spain

Emergency Medical System of Catalonia (SEM)

To enhance this built environment into a healing space, the design is based on scientific evidence and neuro-architectural principles.

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Conclusion

In summary, the well-being of staff is of utmost importance for a resilient healthcare organisation. Although there are many initiatives that can support staff in the acute situation of crisis, the organisational work with staff well-being must be provided continuously and must be increased, particularly after such an intense period, to bolster resources and provide the chance to recover from the challenges that staff endured.

References

[1] McCabe R et al., ‘Adapting hospital capacity to meet changing demands during the COVID-19 pandemic’, BMC Medicine 18 329 (2020).

[2] Stephens KK et al., ‘Collective Sensemaking Around COVID-19: Experiences, Concerns, and Agendas for our Rapidly Changing Organizational Lives’, Management Communication Quarterly, June 2020.

[3] Glover T et al, ‘Radiology department preparedness for COVID-19 – experience of a central-London hospital’, Future Healthcare Journal, 2020 Jun; 7(2): 174-176.

[4] Cipolotti et al., ‘Factors contributing to the distress, concerns, and needs of UK Neuroscience health care workers during the COVID-19 pandemic’, Psychology and Psychotherapy: Theory, Research and Practice. July 2020.

[5] Keeley et al., ‘Staffing Up For The Surge: Expanding The New York City Public Hospital Workforce During The COVID-19 Pandemic’, Health Affair 39, No. 8 (220): 1426 – 1430.

[6] https://clapforourcarers.co.uk/

[7] Chen et al. ‘Touch Me Not: Safe Distancing in Radiology During Coronavirus Disease 2019 (COVID-19)’, Journal of the American College of Radiology, Volume 17, Number 6, June 2020.

[8] Wosik et al. ‘Telehealth transformation: COVID-19 and the rise of virtual care’, Journal of the American Medical Informatics Association, 27(6), 2020, 957-962.

[9] https://www.nuffieldtrust.org.uk/resource/chart-of-the-week-sickness-absence-rates-in-the-nhs-in-april-were-at-their-highest-since-records-began

[10] Bohmer et al. ‘Learning Systems: Managing Uncertainty in the New Normal of Covid-19’, NEJM Catalyst, July 2020.

[11] Keeley et al. ‘Staffing Up For The Surge: Expanding the New York City Public Hospital Workforce During the COVID-19 Pandemic’, Health Affairs 39, No. 8 (2020): 1426-1430.

[12] Petzold, M. B., Plag, J. & Ströhle, A. Dealing with psychological distress by healthcare professionals during the COVID-19 pandemia TT - Umgang mit psychischer Belastung bei Gesundheitsfachkräften im Rahmen der Covid-19-Pandemie. Nervenarzt 91, 417–421 (2020).

[13] Biggs, A., Brough, P. & Barbour, J. P. Exposure to extraorganizational stressors: Impact on mental health and organizational perceptions for police officers. Int. J. Stress Manag. 21, 255–282 (2014).

[14] Morgantini, L. A. et al. Factors Contributing to Healthcare Professional Burnout During the COVID-19 Pandemic: A Rapid Turnaround Global Survey. medRxiv Prepr. Serv. Heal. Sci. 2020.05.17.20101915 (2020) doi:10.1101/2020.05.17.20101915.

[15] Heath, C., Sommerfield, A. & von Ungern-Sternberg, B. S. Resilience strategies to manage psychological distress among healthcare workers during the COVID-19 pandemic: a narrative review. Anaesthesia 75, 1364–1371 (2020).

[16] Helton, W. & Head, J. Earthquakes on the Mind. Hum. Factors 54, 189–194 (2012).

[17] Zhu, J. et al. Prevalence and Influencing Factors of Anxiety and Depression Symptoms in the First-Line Medical Staff Fighting Against COVID-19 in Gansu. Front. psychiatry 11, 386 (2020).

[18] Sutcliffe, K. & Vogus, T. Organizing for resilience. in Positive organizational scholarship (eds. Cameron, K., Dutton, K. J. & Quinn, R.) 94–121 (Berrett‐ Koehler, 2003).

[19] Brooks, S. K., Dunn, R., Amlôt, R., Rubin, G. J. & Greenberg, N. Protecting the psychological wellbeing of staff exposed to disaster or emergency at work: a qualitative study. BMC Psychol. 7, 78 (2019).

[20] Kisely, S. et al. Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. BMJ 369, m1642 (2020).

[21] Cooke, F., Cooper, B., Bartram, T., Wang, J. & Mei, H. Mapping the relationships between high-performance work systems, employee resilience and engagement: a study of the banking industry in China. Int. J. Hum. Resour. Manag. 1–22 (2016) doi:10.1080/09585192.2015.1137618.

[22] Kuntz, J., Malinen, S. & Naswall, K. Employee resilience: Directions for resilience development. Consult. Psychol. J. Pract. Res. 69, 223–242 (2017).

[23] Lim, D. H., Hur, H., Ho, Y., Yoo, S. & Yoon, S. W. Workforce Resilience: Integrative Review for Human Resource Development. Perform. Improv. Q. 33, 77–101 (2020).

[24] Bader, B., Schuster, T. & Dickmann, M. Managing people in hostile environments: lessons learned and new grounds in HR research. Int. J. Hum. Resour. Manag. 30, 2809–2830 (2019).

[25] Walker, B., Malinen, S., Näswall, K., Nilakant, V. & Kuntz, J. Organizational resilience in action: A study of a large-scale extended disaster setting. in Research Handbook on Organizational Resilience (Edward Elgar Publishing, 2020).

[26] World Health Organization. Mental Health Considerations during COVID-19 Outbreak. (2020).

[27] International Federation of Red Cross and Red Crescent Societies. Mental health and psychosocial support for staff, volunteers and communities in an outbreak of novel Corona virus. (2020).

[28] Inter-Agency Standing Committee. Briefing note on addressing mental health and psychosocial aspects of COVID-19 Outbreak-Version 1.1. (2020).