Responder Wellbeing

This resource is written for all responders. 

It aims to:

• provide an overview of responder wellbeing
• de-stigmatise common experiences to encourage seeking help if needed
• highlight opportunities for individual responders, teams and leaders at all levels to improve responder wellbeing. 

The effects of resuscitation exposure are described. Resuscitation exposure can affect responder wellbeing in different ways. It might make you feel good, neutral or bad, and all of these feelings are common. There are also mental health conditions associated with resuscitation exposure such as Post Traumatic Stress Disorder (PTSD), depression and anxiety. Knowing about these conditions allows you to recognise them more readily and to access early support.

A ‘post-resuscitation procedure’ is suggested for use after resuscitation exposure. This consists of:

1. Conducting an Operational Debrief (OD). An OD is led by the clinical team and primarily focuses on the performance and learning of the team. It also represents an opportunity to psychologically support responders.
2. Actively monitoring responders for the development of resuscitation-associated mental health conditions for an extended time period.
3. Referring responders for further assessment and support if required.
4. Periodic team reflection sessions to share experiences that may otherwise go unspoken and process emotional challenges together.

This resource will provide information about organisational factors that can influence responder wellbeing and empower individuals, teams and leaders wishing to effectively address responder wellbeing. 

Organisational factors include shift work, resourcing, staffing, rest provision, bullying, infection risk, support, autonomy and supervision. 

All interventions should be designed with stakeholder involvement. Preventative interventions are most effective when followed by mitigation and targeted support for responders who become unwell. 

Team leaders can influence wellbeing as well as colleagues by modelling self-care and post-resuscitation procedures, checking up on colleagues and signposting support when it is required.

As an individual, you should nurture adaptive coping mechanisms and seek help if required. Most importantly, please speak to someone if you are struggling.

Authors, peer reviewers, editors, acknowledgements

Thank you to all those who have given their time and expertise to help create this resource so that others may benefit.

Written by
Dr Matthew Walton, Professor Neil Greenberg and Dr Mike Christian.

Peer reviewed by
Dr Esther Murray, Dr Kevin Teoh and Professor Richard Williams.

Edited by
Resuscitation Council UK members Dr Jasmeet Soar and Adam Benson Clarke

With thanks to
Dr Craig Walker and the team at Edinburgh Emergency Medicine and the Scottish Centre for Simulation and Clinical Human Factors for permission to use an adapted version of the STOP5 Hot Debrief Model

Essex and Herts Air Ambulance for supporting the use of the case study images and quotations featuring members of their critical care team. 

Tony Stone (Critical Care Paramedic) for his permission to use his image and quotations for the case study. 

How might exposure to a resuscitation event affect you?

At the beginning, you might feel great. 

Involvement in a resuscitation event can be an incredibly positive and profoundly meaningful experience. It might even be why you first chose to work in healthcare – resuscitating a patient is one of the most immediate and rewarding ways to (literally) save a life and it is an aspect that makes it truly unique from other occupations.

You may gain satisfaction from many elements of being involved in resuscitation, for example through:

• a good patient outcome
• a good performance by you and your colleagues, or, 
• gratitude from patients and their families. 

Sometimes your feelings might not be affected by exposure to a resuscitation event. For example:

• the case may not resonate deeply with you on a personal level
• you might be focused on your job (‘in the zone’), or,
• you might simply feel neutral about the events of that day.

In a job where you see such events regularly, you may feel this way on a more frequent basis – but it is hard to predict.

Resuscitation can however of course, be, at times, shocking, upsetting and disturbing. It might make you feel bad, just as well as it might make you feel good. It might also make you feel so upset that you question your choice of career. 

Any immediate distress you experience may be because, for example:

• the outcome for the patient is bad, e.g. pain or disability
• the mechanism may be especially distressing, e.g. trauma 
• you felt that you and your team could have done something different
• the person reminded you of someone you know
• something about the case was particularly tragic, e.g. a paediatric patient with safeguarding concerns
• there may be overt anger or frustration expressed by relatives or colleagues. resuscitation can be emotive. 
• the profound responsibility for human life may also weigh heavily on you during a single event or over a prolonged period of time. 

There are many elements of being involved in resuscitation that may make you feel bad. 

But the important thing to know is that feeling good, neutral, or bad after a resuscitation event is common. The complexity of human beings and the dynamic environments in which we operate means that we cannot currently predict at what time, in what event and why we might react in a given way. For example, different people attending the same resuscitation event may have completely different reactions from each other. Junior staff members might be unaffected by a case, while a senior staff member might be profoundly affected; someone might be affected by one case but not the next one, and so on. 

What we do know is that exposure to resuscitation has the potential to be a profoundly impactful event for anyone, healthcare worker or otherwise. 

Mostly, we are concerned with the negative psychological effects of resuscitation exposure and how to mitigate them. This is because some negative reactions can be severe and serious and may benefit from some further action. In order to be able to look after our colleagues and ourselves effectively, we need to be familiar with the spectrum of negative reactions we might experience after exposure to resuscitation.

What are some of the negative reactions you might have?

Some negative reactions are considered to be ‘non-pathological’ and do not require any specialist treatment. Distress (feeling upset) after a resuscitation event is common, and there are many ways in which you can feel distressed. The effects of the distress may be categorised as physical, behavioural, emotional, or cognitive ^{(TABLE 1)}. Acute stress reaction is a commonly described pattern of distress. Simply put, you might not feel yourself for a little while. 

TABLE 1: Acute stress reactions (adapted from Walton, Murray & Christian 2020) 

These feelings should start to subside after a few days but it is worth seeking further advice and help when:

• symptoms persist beyond four weeks³, or, importantly,
• at any time if symptoms are severe and significantly impacting your life; especially if they are getting worse over time.

Talk to someone you trust about it, and consider involving your supervisor, staff wellbeing support service and/or GP so they can keep an eye on you. 

A lot of the distress we experience surrounding these negative reactions is actually from the guilt, embarrassment or shame about reacting in the first place. It is, therefore, crucial to be aware that feeling like this is common for a while after a resuscitation exposure. It is also common to have a few lingering symptoms, particularly when triggered to recall the event.  

However, when distress is severe and persistent it may crossover into pathology or more serious mental health conditions. You need to be aware of the signs and symptoms of these conditions in order to seek help if this happens to you or your colleagues.⁴  

These negative reactions are considered to be pathological, and they have specific diagnostic criteria and treatments. You need to be aware of these conditions in order to seek help if you suspect you or your colleagues are suffering from them. Note that some, but certainly not all, people who appear distressed may have a mental health condition. 

Depression

Depression usually consists of lowered mood, sadness and inability to gain pleasure from ordinarily enjoyable aspects of your life that lasts longer than two weeks and significantly impacts your life. Depression can present in different ways and may involve physical symptoms, such as tiredness, loss of appetite, loss of sex drive, or aches and pains in the body. It may also involve anxiety (which is covered in the next section). It can range from mild (persistently low in spirit) to severe, where you feel that life is no longer worth living (suicidal). Unfortunately, depression and suicidal thoughts are not uncommon in healthcare workers. 

Many of us wait a long time before seeking help, so the crucial message is: Talk to someone you trust about how you feel sooner rather than later. 

Your GP will also be able to assess your symptoms and decide if there are any treatments that you might benefit from or if there are any adaptations to your work that can help you recover. Sometimes this simply involves watchful waiting; other times, it might involve self-help resources, talking therapies or medication. In some cases, a specialist psychological team may become involved in your care to provide you with additional support.⁵ 

Suicidal thoughts

You do not need to be depressed to be suicidal. 

As healthcare professionals, we often feel shame for having these thoughts or for bothering our colleagues with them. However, these thoughts are surprisingly common.   We carry a lot of assumptions about the systems in which we work, which may form a barrier to us seeking help. If you talk to someone about how you are feeling, you can expect they will listen and help you.

If you are thinking about hurting or killing yourself, please tell somebody or call: 

• 111 - NHS
• 116123 – Samaritans 
• Text "SHOUT" to 85258 – SHOUT crisis line
• Call 999 or come to the nearest Emergency Department if you do not feel safe by yourself. ⁷ 

Generalised anxiety disorder (GAD)

Feelings of anxiety are common in day-to-day healthcare work and are part of our body’s natural response to life-threatening situations. Undoubtedly, you will understand that anxiety comes with the pressure of trying to save a life. A degree of anxiety about performing resuscitation is common and helps us perform at our best. 

There are some tools you may find helpful to use in these circumstances:

• mental rehearsal (think through the steps of what you might need to do next in advance of having to do them) ^8,9
• box breathing (fear is sometimes called ‘excitement without breath’ and responding to it by slowing down your breathing can be helpful)^9,10
• mindfulness (for example, focussing your mind on your breathing and shutting out the ‘noise’ around you, or visiting a ‘happy place’ in your head)¹¹

Most of these techniques can be done without others even knowing that you are doing them, or in a brief moment such as on a break or in the lavatory! 

However, sometimes anxiety becomes hard to control and starts to become more constant, significantly affecting our lives and job performance. 

You may struggle to remember the last time you felt relaxed and be unable to keep your mind from racing thoughts.

Just like depression, anxiety is often accompanied by physical symptoms, such as restlessness, palpitations, dizziness, nausea, poor concentration, poor appetite and poor sleep. Anxiety is incredibly common in healthcare workers, with 5% of the UK general population estimated to have General Anxiety Disorder¹², and it can co-exist with depression. Talking to someone you trust and involving your GP can help. They will assess your needs and support you towards recovery so that you can feel more like yourself again. 

Post Traumatic Stress Disorder (PTSD)

Any situation that you find traumatic, including resuscitation events, can cause Post Traumatic Stress Disorder (PTSD), a condition that is frequently referenced by the media. PTSD is an anxiety-based condition and anxiety is a key symptom. 

As well as this, you may experience nightmares and intrusive re-living of the traumatic event. Some people also see, hear, and smell the incident as if it is happening again. This is known as a flashback. You may experience feelings of isolation, guilt and irritability. PTSD can develop shortly after a traumatic event, or less commonly, it can develop much later (months or years). 
It is not completely clear what causes some people to develop PTSD after a traumatic event, but up to 1/3 of people who experience severe trauma will develop the condition.¹³

However, the way the trauma is experienced is important; for instance, someone who has been assaulted on the street will experience trauma very differently from a healthcare professional involved in a resuscitation.

Evidence suggests that around 10% of healthcare workers in acute settings exhibit symptoms of PTSD, according to a recent study. ¹⁴

You should seek help for these symptoms if they last longer than four weeks or if they start significantly impacting on your life. As well as understanding that PTSD is common, it is also important to know that there are successful treatments available for it. Watchful waiting is the right initial approach, and psychological therapies (e.g. in some cases, antidepressant medicines) have been shown to be effective treatments for PTSD. Your GP will be helpful in making the diagnosis and determining what recovery plan will be most appropriate for you. 

As always, if you are struggling, talk to someone you trust.

There are some other syndromes that are worth being aware of because they are also common in resuscitation providers. Note that none are mental health conditions, but they can be profoundly impactful.

Burnout

Burnout describes the cumulative sense of fatigue or dissatisfaction that comes from chronic workplace stress. Regular exposure to stressful situations such as resuscitation is a risk factor. You may notice feeling cynical about your job, low on energy and have trouble performing to the same level as usual. The most common cause of burnout in healthcare is the demands of the job not being met by the personal or organisational resources available, e.g. working overtime in an understaffed environment. This is all too common in healthcare. It is important to recognise this and try to look after yourself before looking after others. 

If you are struggling, talk to someone you trust, consider seeing your GP and employer, who will offer support. Sometimes, taking time away from work, reducing your hours or working conditions can be helpful to address burnout.¹⁵ 

Compassion fatigue 

Compassion fatigue describes the ‘wearing thin’ of your ability to cope and remain caring in the face of repeated exposure to others’ trauma. 

Each time you are exposed to resuscitation, high levels of emotional labour are required. 

Because you, as a healthcare worker, are likely to be good at empathising and showing compassion for others, you are at high risk of compassion fatigue. Compassion fatigue is linked to burnout but describes a more specific syndrome, sometimes termed a ‘secondary stress reaction’.

Feelings of numbness, helplessness and irritability can develop towards situations where you would have previously found satisfaction in being the caregiver.

Physical symptoms such as poor sleep, poor concentration, aches, pains and social symptoms such as withdrawal can follow. It is a contributor to poor job satisfaction and absenteeism. 

If you feel this way, talk to a trusted person and know that there is support available. Often recognising the issue and the impact that it is having is the most important step, after which you can begin self-help by seeking support from your GP or mental health services or your employer, who may be able to alter your work pattern in order to reset the balance.^16,17,18

Moral injury

Moral injury is a relatively new concept to transfer into the world of medicine,  you may not have even heard of it before now, but it is worth being familiar with. It describes an act or omission that transgresses deeply held beliefs or moral code, either by yourself or witnessing it in others. It may be a betrayal of what is right by someone in a position of authority in a high-stakes situation. ²⁰ Often it can be summarised by you not feeling able to provide the level of care you would like to give.  

For example, this might be:

• end-of-life care issues
• exclusion of family during the resuscitation of an infectious patient
• lack of resources in a resuscitation
• non-accidental injury and safeguarding concerns.

There are also more systemic issues, such as: 

• understaffing affecting patient care 
• lack of time for patients
• national policies that fall short of the gold standard.

These matters and many more can trigger moral injury. ²¹ 

The main symptoms of a moral injury are guilt, anger, disgust and shame. 

Although moral injury is not a mental health condition (and, as yet, has no clear diagnostic criteria or treatment), the emotional, behavioural, somatic and cognitive impact can be profound. Additionally, moral injury is significantly associated with depression, PTSD and suicidal thoughts.

Often the shame or guilt that is felt is so strong that you might not want to talk to anyone about it, e.g. you may feel ashamed about what you did or what someone else did. 

However, it is crucial that you do talk to someone you trust about these symptoms if they are persistent and impairing. 

Practicing self-compassion, acceptance and forgiveness may help and you can also access support from your employer, your GP and other mental health services.  

Peer-to-peer reflection is important, too. Schwartz rounds, for example, create a space to process such experiences.²² Sharing your experiences with peers allows collective learning, and where appropriate, an issue may be raised and addressed to bring about positive change. 

What should you do after attending a resuscitation event?

There are some things that should be routinely done after each resuscitation event, especially if the outcome is unsuccessful.

While currently, there is no conclusive evidence that post-resuscitation interventions prevent the development of serious mental health problems, we do know a lot about how to identify and support people who are negatively impacted as early as possible. 

Operational debriefing

Operational debriefing (OD) is a post-resuscitation debrief that focuses on the team’s performance, i.e. how can we learn from this event and improve on our performance for next time? It also provides an opportunity for those people involved to try and make sense of the incident, which can help to clarify misperceptions or misunderstandings and prevent moral injuries.

Meta-analysis²³ shows that an OD can improve performance by 20-25%, and some studies show improved CPR performance and patient outcomes²⁴; the positive mental health impact of an OD is likely to be at least part of the reason for this positive outcome. Note that there is little evidence for ODs formally preventing the onset of mental health conditions²⁵, however, responders report feeling psychologically supported after ODs²⁶, and evidence that is currently available does indicate that well conducted ODs are unlikely to cause psychological harm.²⁷

Possible indirect benefits of OD on responder well-being may include:

• Identifying distressed responders and signposting them to support or follow up.
• Opportunistic education for responders on possible psychological reactions.
• Reassurance on performance limits, futility and diffusing individual guilt for a poor outcome.

It is important to contextualise the post-resuscitation procedure in the wider range of organisation, leadership, team and individual factors that influence responder wellbeing.

Research shows that organisational factors have a significant impact on responder wellbeing, far more so than previously understood. ^35,36

They can potentially be more impactful than the exposure to the human suffering and distress associated with resuscitation events. The focus for responder wellbeing has shifted recently from the individual to the organisation. ³⁷

There are many organisational factors that impact responder wellbeing, including: 

• workload 
• working hours
• staffing levels
• exposure to resuscitation 
• emotional demands of the job
• rest periods
• shift working and sleep deprivation
• overstaying shift ends
• missing breaks
• perceived or actual bullying and harassment
• autonomy
• professional values
• support and supervision
• resources
• flexibility of work arrangements and rotas
• rotas allowing teams to stick together and bond over time
• role ambiguity
• recognition and feedback
• food, drink and rest facilities
• transport after hours
• protection from infection
• verbal and physical abuse.

There are also important non-work stressors such as relationship problems, illness within the family, caring responsibilities and financial difficulties that affect wellbeing at work as well. 
 

Primary intervention

Primary intervention aims to address the stressors at the source, as prevention is better than cure. Successful organisations do what they can to reduce exposure to stressors and proactively offer support. Simply put, successful organisations do all they can to protect their most valuable resource; their staff.

Examples of preventative organisational measures include:

• reducing working hours
• genuine protection of breaks, shift ends and leave
• extended recovery periods for night shift work 
• providing food, drink and rest facilities
• Schwartz rounds³⁸
• crafting rotas to fit lifestyles
• employing more staff and ‘overstaffing’ at baseline
• zero tolerance policies on bullying, harassment, verbal and physical abuse
• ensuring effective PPE
• praise and rewards for responders.

Note that physician-organisation collaboration³⁹ to effect these changes is preferable if possible. 

Secondary intervention

This type of organisational intervention aims to help individual staff members to change their perception or ability to cope with existing stress. It mitigates the effects of existing stressors. This is not a substitute for primary prevention, but it is important to provide. 

Examples of a secondary intervention are:

• TRiM^30,47 peer support training 
• active monitoring and regular check-ins by supervisors
• offering active coping skills training
• stress and time management training.

Operational Debriefing falls into this category.

Tertiary intervention

Tertiary intervention describes targeted support, usually once individuals have developed (or require assessment for) a mental health condition. 
Of course, some responders do develop mental health conditions despite the best preventative and early intervention approaches, and intervention is required to help them to recover. It is important that the organisation has a contingency to provide professional psychological assessment and management, as well as occupational health services, for responders who become mentally unwell. 

Often responders experience stigma and decide not to declare their illness due to fear of being perceived as ‘not coping’ and possible restrictions on work and job loss. Discreet and confidential services that allow the responder the most autonomy over their work is preferable. 

An example of tertiary intervention is:

• self-referral to occupational mental health services, for example, NHS Wellbeing Hubs or Employee Assistance Programs
• occupational health assessment support with work adjustments 
• availability of timely, professional, evidence-based mental health treatments.

Leaders, at all levels from the most junior supervisor upwards, can act to influence the wellbeing of their teams in several ways:⁴⁰  

• Be a good leader – this sounds trite, but doing a good job in the role with which you are tasked is the priority. Be confident in your ability. 
• Communication – this must go both ways; make sure to listen to your team and allow team members to share their feelings and concerns.
• Kindness and compassion – leaders (supervisors) need to be approachable and feel confident to have psychologically savvy conversations with team members.  
• Humility and humanity – acknowledge and validate stigmatised feelings, and don’t be afraid to share your own vulnerabilities. This provides psychological safety for your team members to disclose theirs when it counts.
• Model – good self-care and help-seeking behaviour.
• Champion - best practice of post-resuscitation procedure (OD, active monitoring, reflective practice) for your teams and empower others to lead this.
• Know - what to do if any members of your team are struggling.  Be familiar with what is common, what is concerning and how to signpost them to resources.

Studies in soldiers show us that good team leadership, morale and cohesion may reduce the development of trauma-related mental health pathology. ^41,42
 

Peer support is the cornerstone of responder wellbeing. Often, we feel it the most when we find ourselves without it, working with a new and unfamiliar team or isolated across shift patterns or physical distance from those we know well.

This is because truly knowing each other, ‘on and off the pitch’, so to speak, and developing trust, has an immeasurable effect on our wellbeing. You might be the only person in your workplace who can really recognise if your colleague is struggling, despite appearing fine (or even ‘just a bit grumpy’) to everyone else. 

Having said this, it is definitely possible to extend support to colleagues you have just met. Talking openly and non-judgementally about the psychological difficulties of the job and wellbeing strategies is a way to discover common ground and forge new bonds.

Because of their shared experiences at work, peers have the ability to communicate with each other, in a sort of shorthand, ⁴³ in a way that they may not feel able to share with friends and family who are not familiar with their work environment. 

Often, we find that we can speak more freely to our peers than we can to any other people about how we are feeling at work. This alone, makes your role as a colleague potentially lifesaving. 

If in doubt, ask twice:

“Are you OK?”

“Yeah not too bad, thanks”

“Are you really OK?”

“Is there anything else going on?”

“Is there something on your mind?”

“No pressure to talk about it to me if you don’t want to, but I just thought I’d check in and ask how you’re doing?”

Here are a few practical tips for what you can do to support your colleagues: 

TABLE 2: Ways colleagues can support each other (adapted from Walton, Murray & Christian 2020).

There are also courses on psychological/stress first aid that you can take to learn more about supporting your colleagues (you can find these courses online).

Here is a video showing a pre-hospital team supporting each other following a traumatic case⁴⁴: 

Now, you. 

How do you look after yourself? What habits have you developed? What works for you and what doesn’t? 

There are some little things we can all do in our day-to-day lives to ensure we maintain our wellbeing, which includes:

• keeping in touch with family and friends
• doing things you enjoy
• ensuring adequate sleep, hydration, nutrition and exercise
• noticing what is in your control and what is not
• being grateful and focusing on the positives
• taking your breaks and leaving on time
• taking time to recognise the impact of your work.

Importantly, recognise in yourself when you are nearing your limit. At times in our lives, we are all likely to experience this and require help. There is no shame in feeling overwhelmed or not coping. You may have spent too long being strong, and it is time to focus on yourself instead of others for a while until you start feeling more like yourself again. 

Seeking professional advice early on may well mean that the interventions needed to recover are less complex.

We all have coping styles and strategies, whether we are aware of them or not, to help us get through tough times.^45,46

Some (adaptive) coping strategies we should nurture, include:

• accepting the situation
• talking to trusted people about our problems
• asking for help 
• using humour when and where appropriate
• practicing religion for those who are religious
• positive reframing
• practicing self-compassion.

Some (maladaptive) coping strategies we should try to avoid:

• denial of the situation
• avoidance or repression
• substance abuse and self-harm
• rumination
• self-blame
• negative self-talk
• venting
• withdrawal or disengagement
• resignation (giving up).

If there is one message to take away, it is this:

If you are struggling, tell somebody you trust and who might be able to help you. 

Having taken the initiative to read this resource, you have already demonstrated that you have taken an important step towards caring for yourself and people around you. 

You now have the knowledge about how you may feel after a resuscitation event and the possible ways in which you might be impacted by prolonged exposure. 

You know that as well as positive reactions, there are neutral and negative reactions. 

You know that these are common, and you know how to recognise when more support is required and where it can be found. 

You know about helpful post-resuscitation procedures and how to support your colleagues. 

You know about the influence of the organisation and leadership on your wellbeing and that there are opportunities to help at every level. 

Most importantly, you know how to look after yourself.

1. Cardiac arrest - out of hospital care: What is the prognosis? (NICE, 2018)
   https://cks.nice.org.uk/topics/cardiac-arrest-out-of-hospital-care/background-information/prognosis/ 
    
2. Mental health and help seeking among trauma-exposed emergency service staff: a qualitative evidence synthesis (BMJ Open, 2022) 
   https://www.proquest.com/docview/2624835797?pq-origsite=primo
    
3. Overview - Post-traumatic stress disorder (NHS, 2022) 
   https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/overview/
    
4. QE84 Acute stress reaction (ICD, 2023)
   https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/505909942 
    
5. Overview - Clinical depression (NHS, 2019)
   https://www.nhs.uk/mental-health/conditions/clinical-depression/overview/
    
6. Preventing suicide in England: Fifth progress report of the cross- government outcomes strategy to save lives (HM Government, 2020)
   https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/973935/fifth-suicide-prevention-strategy-progress-report.pdf
    
7. Where to get urgent help for mental health (NHS, 2023)
   https://www.nhs.uk/nhs-services/mental-health-services/where-to-get-urgent-help-for-mental-health/
    
8. Effect of mental rehearsal on team performance and non-technical skills in surgical teams: systematic review (BJS Open, 2020)
   https://academic.oup.com/bjsopen/article/4/6/1062/6136130
    
9. Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress (American College of Emergency Physicians, 2017)
   https://emcrit.org/wp-content/uploads/2017/05/PEP-under-Stress.pdf
    
10. What Is Box Breathing? (Web MD, 2023)
    https://www.webmd.com/balance/what-is-box-breathing 
     
11. Mindfulness Meditation and Interprofessional Cardiopulmonary Resuscitation: A Mixed Methods Pilot Study (Teaching and Learning in Medicine, 2018)
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6240489/ 
     
12. Overview - Generalised anxiety disorder in adults (NHS 2022)
    https://www.nhs.uk/mental-health/conditions/generalised-anxiety-disorder/overview/
     
13. Overview - Post-traumatic stress disorder (NHS, 2022)
    https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/overview/ 
     
14. The presence of psychological trauma symptoms in resuscitation providers and an exploration of debriefing practices (Resuscitation, 2019)
    https://pubmed.ncbi.nlm.nih.gov/31251894/
     
15. Occupational burnout (Wikipedia, 2023)
    https://en.wikipedia.org/wiki/Occupational_burnout
     
16. Compassion Fatigue among Healthcare, Emergency and Community Service Workers: A Systematic Review (International Journal of Environmental Research and Public Health, 2016)
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924075/  
     
17. Compassion fatigue (Wikipedia, 2023)
    https://en.wikipedia.org/wiki/Compassion_fatigue
     
18. Compassion Fatigue: Symptoms to Look For (Web MD, 2022)
    https://www.webmd.com/mental-health/signs-compassion-fatigue
     
19.  The Mental Health and Wellbeing of Healthcare Practitioners: Research and Practice (Murray & Brown, 2021) 
     
20. Moral injury: the effect on mental health and implications for treatment (The Lancet, 2021)
    https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(21)00113-9/fulltext 
     
21. Moral distress in the NHS and other organisations (BMA, 2021)
    https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/creating-a-healthy-workplace/moral-distress-in-the-nhs-and-other-organisations
     
22. Schwartz Rounds (General Medical Council, 2019)
    https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/reflective-practice/schwartz-rounds
     
23. Do team and individual debriefs enhance performance? A meta-analysis (Human Factors, 2013)
    https://pubmed.ncbi.nlm.nih.gov/23516804/ 
     
24. Debriefing of Resuscitation Performance (EIT #645): Systematic Review (ILCOR, 2021)
    https://costr.ilcor.org/document/debriefing-of-resuscitation-performance-eit-645-systematic-review
     
25. Single session debriefing after psychological trauma: a meta-analysis
     (The Lancet, 2022)
    https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)09897-5/fulltext 
     
26. The presence of psychological trauma symptoms in resuscitation providers and an exploration of debriefing practices (Resuscitation, 2019)
    https://pubmed.ncbi.nlm.nih.gov/31251894/  
     
27. The presence of psychological trauma symptoms in resuscitation providers and an exploration of debriefing practices (Resuscitation, 2019)
    https://pubmed.ncbi.nlm.nih.gov/31251894/  
     
28. STOP5: a hot debrief model for resuscitation cases in the emergency department (Clinical and Experimental Emergency Medicine, 2020)
    https://pubmed.ncbi.nlm.nih.gov/33440103/ 
     
29. Debriefing of Resuscitation Performance (EIT #645): Systematic Review (ILCOR, 2021)
    https://costr.ilcor.org/document/debriefing-of-resuscitation-performance-eit-645-systematic-review
     
30. Trauma Risk Management (Wikipedia, 2023)
    https://en.wikipedia.org/wiki/Trauma_risk_management
     
31. Debriefing of Resuscitation Performance (EIT #645): Systematic Review (ILCOR, 2021)
    https://costr.ilcor.org/document/debriefing-of-resuscitation-performance-eit-645-systematic-review
     
32. Use of briefing and debriefing in neonatal resuscitation, a scoping review (Resuscitation Plus, 2020)
    https://pubmed.ncbi.nlm.nih.gov/34223331/ 
     
33. Improving Newborn Resuscitation by Making Every Birth a Learning Event (Children (Basel). 2021)
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8700033/
     
34. Schwartz Rounds (General Medical Council, 2019)
    https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/reflective-practice/schwartz-rounds
     
35. What could make a difference to the mental health of UK doctors? A review of the research evidence  (Journal of Occupational Medicine, 2018)
    https://www.som.org.uk/sites/som.org.uk/files/What_could_make_a_difference_to_the_mental_health_of_UK_doctors_LTF_SOM.pdf
     
36. The Mental Health and Wellbeing of Nurses and Midwives in the United Kingdom (Journal of Occupational Medicine, 2020)
    https://www.som.org.uk/sites/som.org.uk/files/The_Mental_Health_and_Wellbeing_of_Nurses_and_Midwives_in_the_United_Kingdom.pdf
     
37. Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic (European Heart Journal. Acute Cardiovascular Care, 2020)
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189614/   
     
38. Schwartz Rounds (General Medical Council, 2019)
    https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/reflective-practice/schwartz-rounds
     
39. Physician-Organization Collaboration Reduces Physician Burnout and Promotes Engagement: The Mayo Clinic Experience (British Journal of Healthcare Management, 2016)
    https://pubmed.ncbi.nlm.nih.gov/27111930/ 
     
40. Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic (European Heart Journal. Acute Cardiovascular Care, 2020)
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189614/   
     
41. Cohesion, leadership, mental health stigmatisation and perceived barriers to care in UK military personnel (Journal of Mental Health, 2018) 
    
    https://www.tandfonline.com/doi/abs/10.3109/09638237.2016.1139063?journalCode=ijmh20 
42. Leadership, cohesion, morale, and the mental health of UK Armed Forces in Afghanistan (Psychiatry, 2012)
    https://pubmed.ncbi.nlm.nih.gov/22397541/
     
43. Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic (European Heart Journal. Acute Cardiovascular Care, 2020)
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189614/   
     
44. Resilience - One Team's Trauma (Matthew Walton Medical, 2017)
    https://youtu.be/DY60ZOWBvDc 
     
45. Good Cope, Bad Cope: Adaptive and Maladaptive Coping Strategies Following a Critical Negative Work Event (Applied Psychology, 2005) 
    https://psycnet.apa.org/doiLanding?doi=10.1037%2F0021-9010.90.4.792  
     
46. Coping With Staff Burnout and Work-Related Posttraumatic Stress in Intensive Care (Pediatric Critical Care Medicine, 2017)
    https://pubmed.ncbi.nlm.nih.gov/28459762/
     
47. Psychological peer support for staff: implementing the Trauma Risk Management model in a hospital setting (Nursing Management, 2021)
    https://journals.rcni.com/nursing-management/evidence-and-practice/psychological-peer-support-for-staff-implementing-the-trauma-risk-management-model-in-a-hospital-setting-nm.2021.e1977/abs

List of resources for healthcare worker help-seeking

• England only - NHS England staff wellbeing Hubs (email self-referral)
• England & Scotland - Practitioner Health (self-referral)
• Scotland - NHS Wellbeing Resources (resources)
• Scotland - National Wellbeing Hub for Healthcare Workers (resources)
• Scotland - “NHS 24” Wellbeing Resources (app, phone) & Charities (phone) 
• Wales & England  - Health & Care professions council resource list (phone) & charities (phone)
• Northern Ireland - Health and social Care Public Health Agency (phone)

Self-assessment

• Mental Health self-assessment tool (Anxiety, Depression, PTSD, Alcohol & Substance, Work Adjustment)
• Burnout simple self-test that can be useful to monitor your risk of burnout and direct you to some steps to reduce your feelings of burnout.  

Video resources

• ‘One team’s trauma’ – debriefing, de-stigmatisation & peer support. 

Other

• Downloadable Responder Wellbeing PDF
• Debriefing reading link