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Case Studies: How First Aid Made a Real Difference

First aid knowledge and skills can be the difference between life and death in critical situations. Real-life case studies highlight the invaluable impact of prompt and effective first aid interventions. In this article, we'll explore a few case studies that demonstrate how first aid made a real difference in emergencies, underscoring the importance of being prepared to respond when it matters most.

1. Cardiac Arrest Saved by CPR

Case: A middle-aged man collapsed suddenly at a local park. A bystander with CPR training quickly assessed the situation and started performing chest compressions while another person called for emergency medical services (EMS). The first aider continued CPR until paramedics arrived with an automated external defibrillator (AED). The AED was used to deliver a shock, and the man regained a heartbeat before being transported to the hospital.

Impact: Immediate CPR and access to an AED significantly increased the man's chances of survival. The bystander's quick and effective response played a crucial role in saving his life.

2. Choking Child Rescued

Case: At a family gathering, a toddler suddenly started choking on a piece of food. A relative who had taken a first aid course recognized the signs of choking and immediately performed back blows and abdominal thrusts on the child. The object was dislodged, and the child began breathing normally.

Impact: The relative's knowledge of choking first aid prevented a potentially life-threatening situation. Swift action and the correct technique ensured the child's safety.

3. Severe Allergic Reaction Averted

Case: During a school event, a teenager with a known severe allergy was accidentally exposed to a triggering allergen. A school staff member administered an epinephrine auto-injector before emergency medical help arrived.

Impact: The quick administration of epinephrine prevented the teen's allergic reaction from escalating into a medical crisis. Proper use played a pivotal role in stabilizing the situation.

4. Bystander Support After Car Accident

Case: A motorcyclist was involved in a serious accident, and multiple bystanders rushed to help. One bystander, who had taken a basic first aid course, kept the injured person still and immobilized until EMS arrived. Others called for help and provided comfort.

Impact: The collective efforts of the bystanders ensured that the injured motorcyclist received timely and appropriate care, preventing further harm until professional medical assistance arrived.

5. Hypothermia in Hiking Group

Case: During a winter hiking trip, a member of a hiking group began experiencing symptoms of hypothermia, including confusion and shivering. Another hiker recognized the signs and immediately started rewarming the person by providing warm clothing, blankets, and hot liquids.

Impact: The quick recognition of hypothermia and the application of appropriate first aid measures prevented the condition from worsening and ensured the hiker's safety.

These case studies vividly illustrate the critical importance of first aid knowledge and skills in emergency situations. From cardiac arrest to choking incidents and allergic reactions, being prepared to respond effectively can save lives and prevent further harm. These stories underscore the value of first aid training and highlight the vital role that trained individuals play as first responders. Whether it's administering CPR  or recognizing the signs of a medical condition, the impact of first aid in real-life scenarios cannot be overstated.

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Full Scenario List

First Aider Easy	1
Secondary Survey,  Respiratory Conditions,  Communication,  History Taking,  Teamwork,

First Aider Easy	1
Primary Survey,  Unconscious Casualty,  Teamwork,

First Aider Moderate	1
Chest Pain,  Cardiovascular Conditions,  Resus/CPR,  Unconscious Casualty,

First Aider Easy	1
Primary Survey,  Unconscious Casualty,

Ambulance Crew (non HCP)	1
Cardiovascular Conditions,  Airway Management,  Heat Extremes,

First Aider Moderate	1
Unconscious Casualty,  Head Injury,  Trauma,  Communication,  Teamwork,

Ambulance Crew (non HCP)	1
Abdominal Pain,

First Aider Difficult	3
Unconscious Casualty,  Resus/CPR,  Fractures,  Stroke,  Shock,

First Aider Easy	1
Airway Management,  Allergies,

Ambulance Crew (non HCP)	1
Bleeds,  Cardiovascular Conditions,  Fractures,  Resus/CPR,  Trauma,

First Aid Scenarios and Discussion Answers

5. Check the victim for other injuries and keep him calm until help arrives.

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Case studies

This guidance for employers contains examples of first-aid needs assessments for a variety of workplaces.

First aid at work The Health and Safety (First-Aid) Regulations 1981 Guidance on needs assessments

The scenarios should be read in conjunction with the guidance on first-aid needs assessments in First aid at work (L74) .

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Cases of Blended First Aid Training in Red Cross National Societies

This short resource brings together the blended learning stories and experiences of seven National Societies in the RC/RC network practicing blended first aid training.

Each case study highlights an element of the innovation that is happening in first aid training in RC/RC National Socieites. It is clear that there is a good deal of innovative practice that others can learn from. Key staff in the National Socieites have shared their perspective on blended first aid training and given insights into the benefits they have achieved and the challenges they have faced. They also offer advice to any National Society currently considering adapting to a blended first aid training model.

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Ronald A. Bergman, PhD Emeritus Professor Department of Anatomy and Cell Biology

The University of Iowa

Peer Review Status: Internally Peer Reviewed First Published: November 2004 Last Revised: November 2004

Table of Contents

• Research article
• Open access
• Published: 03 June 2020

An educational pathway and teaching materials for first aid training of children in sub-Saharan Africa based on the best available evidence

• Emmy De Buck   ORCID: orcid.org/0000-0003-4498-9781 1 , 2 , 3 ,
• Jorien Laermans 1 ,
• Anne-Catherine Vanhove 1 , 2 , 4 ,
• Kim Dockx 1 ,
• Philippe Vandekerckhove 3 , 5 &
• Heike Geduld 6  

BMC Public Health volume  20 , Article number:  836 ( 2020 ) Cite this article

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First aid training is a cost-effective way to decrease the burden of disease and injury in low- and middle-income countries (LMIC). Since evidence from Western countries has shown that children are able to learn first aid, first aid training of children in LMIC may be a promising way forward. Hence, our project aim was to develop contextualized materials to train sub-Saharan African children in first aid, based on the best available evidence.

Systematic literature searches were conducted to identify studies on first aid education to children up to 18 years old (research question one), and studies investigating different teaching approaches (broader than first aid) in LMIC (research question two). A multidisciplinary expert panel translated the evidence to the context of sub-Saharan Africa, and evidence and expert input were used to develop teaching materials.

For question one, we identified 58 studies, measuring the effect of training children in resuscitation, first aid for skin wounds, poisoning etc. For question two, two systematic reviews were included from which we selected 36 studies, revealing the effectiveness of several pedagogical methods, such as problem-solving instruction and small-group instruction. However, the certainty of the evidence was low to very low. Hence expert input was necessary to formulate training objectives and age ranges based on “good practice” whenever the quantity or quality of the evidence was limited. The experts also placed the available evidence against the African context.

Conclusions

The above approach resulted in an educational pathway (i.e. a scheme with educational goals concerning first aid for different age groups), a list of recommended educational approaches, and first aid teaching materials for children, based on the best available evidence and adapted to the African context.

Peer Review reports

In sub-Saharan Africa, approximately 5·1 million deaths each year are attributable to conditions that could have potentially been addressed by prehospital and emergency care [ 1 ], which is however underdeveloped in the majority of low- and middle-income countries (LMIC) [ 2 , 3 ]. Hence, first aid training is promoted by the World Bank as a very cost-effective way to decrease the burden of disease and injury, with a cost of only 8 USD per disability-adjusted life year averted [ 1 ]. Although most studies demonstrating the effectiveness of first aid training programmes for adults were conducted in Western contexts [ 4 , 5 , 6 , 7 , 8 ], some studies from sub-Saharan Africa are also available [ 9 , 10 , 11 ], and several African Red Cross National Societies organize first aid trainings for adult laypeople. These trainings were mostly based on materials from Western former colonisers (e.g. the UK, France), which provided a useful basis, but did not take into account the distinct African context. The need for contextualized African materials was expressed by several African Red Cross National Societies in response to a survey sent out by the Belgian Red Cross in 2009, that aimed to collect information on the availability and source of first aid training materials in African Red Cross societies [ 2 ]. In an attempt to meet these needs, contextualized and evidence-based African First Aid Materials (AFAM) were developed and released in 2011, providing guidance on up-to-date first aid techniques, as well as injury and disease prevention advice specific for the African context [ 2 ].

Since emerging evidence from Western countries has shown that children and adolescents from 5 to 18 years old are able to learn certain first aid techniques and are willing to provide help [ 12 , 13 , 14 , 15 , 16 ], first aid training of children seems a promising way forward in order to maximize impact. However, to our knowledge evidence-based guidelines or teaching materials concerning first aid training to children in LMIC are currently non-existent. As we believe that context is of paramount importance (e.g. to decide on which topics to include, to take into account local habits and beliefs, to take into account local resources and available equipment) we decided to develop materials specifically for the African context.

To support the development of materials to train children in first aid, and to facilitate the integration of first aid training into the school curriculum, an educational pathway may be a useful tool. An educational pathway is an instrument that indicates how children can achieve necessary competences over a certain period of time. It is based on the spiral cognitive theory of learning, stating that “any subject can be taught effectively in some intellectually honest form to any child at any stage of development” [ 17 ]. Within an educational pathway (or “spiral curriculum”) basic facts of a topic are taught first, and complexity gradually increases as the child’s age and learning progresses. Reemphasis (“repeated exposure” or “scaffolding”) helps to reinforce and solidify the learning content, so that it can enter the learner’s long-term memory. In the field of first aid, such repetition could help to automate actions, so that learners no longer have to think about each step during stressful first aid situations.

In addition to the importance of the child’s age, the teaching strategy used during the first aid training also affects the child’s knowledge, skills, and attitude. Evidence-based education research, based on many meta-analyses, has shown that classroom methods such as cooperative learning, and feedback or problem-solving methods are effective educational methods that improve learning [ 18 , 19 ]. However, the evidence base mainly consists of Western studies, and less is known about effective educational methods in LMIC.

The aims of this project were: (1) to develop an educational pathway for first aid training to children (5–18 years) in sub-Saharan Africa making use of the best available evidence, and (2) to create an overview of effective educational methods in the sub-Saharan African context, with the overall aim of developing teaching materials for first aid training of sub-Saharan African children.

To provide a basis for the educational pathway and teaching materials, several systematic literature searches were performed. The reporting of the systematic literature reviews was done according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statements (Additional File  1 ) [ 20 ]. No protocol for the systematic literature searches was published beforehand.

Selection of first aid topics

The following topics were included in the educational pathway: ‘general principles’, ‘four main steps in first aid’ (including the assessment of consciousness, and knowledge about fainting), ‘resuscitation’, ‘choking’, ‘skin wounds’, ‘burns’, ‘bleeding’, ‘poisoning’, ‘injuries to bones, muscles or joints’, ‘stings and bites’, ‘fever’, ‘diarrhoea’, and ‘epilepsy’. This choice was based on the content of the previously developed AFAM [ 2 ], epidemiological data on disease burden for sub-Saharan Africa, and expert input. The topic ‘disaster principles’ was added after the consensus meeting (see 2.5), since the expert panel considered it a highly relevant topic in the sub-Saharan African context.

Systematic literature searches and study selection

Our first research question concerned the effectiveness of first aid education to children of different age groups, on first aid knowledge, skills, and attitude. A similar and previously published systematic review (search date: 2012) was used as a basis for the current searches [ 12 ]. New first aid topics were added and selection criteria were adapted to the African context (e.g. training on the use of an automated external defibrillator was not included due to limited resource availability).

Several parallel literature searches were performed for each of the different first aid topics mentioned above, either by updating the existing literature searches (publication date between previous search dates (January 2012, 12) and the current search date (March 232,017)) or by developing new search strategies for new topics. All searches were run in two databases (MEDLINE and Embase). Search strategies and selection criteria can be found in Additional files  2 and 3 , respectively.

Our second research question concerned the effectiveness of different educational approaches on children’s knowledge, skills, and attitude in LMIC. Instead of focusing on first aid education, we broadened this research question to education in general. We searched for existing systematic reviews published between 2012 and 2017 (The Campbell Library, MEDLINE, Embase, ERIC and the 3ie Database of Systematic Reviews), since we only wanted to include the most recent educational approaches. Search strategies and selection criteria can be found in Additional files  4 and 5 , respectively. The scope of the educational interventions of interest was narrowed to three categories: (1) the provision of traditional hardware instructional materials (e.g. text books, flip-charts), (2) use of ‘structured pedagogy interventions’ (i.e. a combination of newly developed structured lesson content and teacher training in delivering such materials, whether or not in combination with teacher and/or student materials), and (3) use of alternative pedagogical methods (e.g. cooperative teaching, constructivist-based teaching, problem-solving method of teaching).

Study selection was done by 1 reviewer for both research questions, based on title and abstract, and subsequently based on full text.

Data extraction, data synthesis and quality assessment

For both research questions, the following data were extracted by a single reviewer: study design; characteristics of the population (number of participants, age range); characteristics of the specific programmes (content, duration); methods of outcome measurement; means, mean differences (MDs)/standardized mean differences (SMDs), and confidence intervals (CIs) for continuous data, and risks/odds, risk ratios (RRs)/odds ratios (ORs), and CIs for dichotomous data. In addition, a risk of bias assessment of all individual studies, and an assessment of the overall certainty of evidence (per outcome for question one, and per intervention for question two) was performed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach [ 21 ]. For research question one, the evidence was synthesized in a narrative way, because meta-analysis was not possible due to heterogeneity at population, intervention and outcome level. For research question two, effect sizes were extracted from the meta-analyses performed in the identified systematic reviews.

Making a first draft of the educational pathway

Based on the best available evidence collected under research question one, a first version of the educational pathway was drafted for 2-year age groups (5–6 years, 7–8 years etc.). When evidence was scarce or of low quality, we only formulated training objectives without a specific proposal for the age ranges. For each of the first aid topics, different training objectives were listed and categorized as competences at one of the three following levels (based on the 3 learning domains of Bloom’s Taxonomy of Educational Objectives [ 22 ]): (1) Knowledge: defined as the acquired information stored in the memory in an organized manner, (2) Skill: defined as the ability to practically apply the acquired information into a certain action, or (3) Attitude: defined as the willingness/self-efficacy to show a particular behavior. In line with the idea of gradually increasing complexity (according to Bruner’s spiral cognitive theory of learning [ 17 ]), we indicated at what age each of the objectives should be: (1) encouraged: the trainer actively pays attention to a certain goal and encourages the children to achieve the goal, (2) known: the trainer makes explicit efforts so that all the children can acquire a certain knowledge item, skill or attitude, or (3): repeated: the trainer repeats and emphasizes the purpose consciously for the children who have already reached the objective and strives to reach the learners who have not yet achieved the objective.

Consensus meeting and finalizing the educational pathway, based on the best available evidence

In a next step, a panel of experts, consisting of 4 first aid practitioners of several African Red Cross National Societies, as well as 6 academic educational experts and clinicians from sub-Saharan origin (French and English speaking countries), and chaired by HG, was gathered for consultation in Johannesburg, South Africa (17-18 November, 2017). Before the start of the meeting, the draft educational pathway and specific preparatory questions were sent to the panel members. The goal of the meeting was two-fold: (1) to discuss the draft educational pathway (age ranges and training objectives), especially where evidence was scarce or of low quality, to adapt the educational pathway to the local context, and to reach consensus on the final pathway; and (2) to compile a list of effective educational approaches for children, tailored to the sub-Saharan context. More details on the preparatory questions to the panel and on how consensus was reached to achieve these goals can be found in Additional file  6 . In short, for each question/item asked to the panel, opinions were collected and a discussion was held in case of disagreement. Next, a proposal was made by the chair, and consensus was sought by hand-raising. If consensus was not reached (i.e. no unanimous agreement), concerns were further addressed in a second discussion and the proposal was further adapted until full consensus was reached.

During the consensus meeting, the expert panel argued that ‘disaster principles’ would be very relevant to add as a first aid topic in the pathway. As none of the identified studies looked at disaster principles as part of the first aid training, it was decided to only formulate knowledge objectives and to agree on appropriate age ranges based on expert opinion only (without searching for additional evidence).

Development of teaching materials

In a last phase, teaching materials were developed, taking into account: (1) the educational pathway, showing which first aid competences can be achieved at a certain age, (2) the list of effective educational methods, and (3) the content of the evidence-based AFAM, which was updated in 2016 (i.e. the specific first aid interventions) [ 2 ]. These teaching materials were circulated electronically for feedback from the expert panel, and a final conference call was organized to discuss this feedback and finalise the materials in November 2018.

Study identification and study characteristics

For research question one, 58 studies were identified (see Fig.  1 ). Of these, 43% (25 studies) was performed in Europe, whereas only 4% (two studies) were conducted in Africa. For the first aid topics other than ‘resuscitation’, evidence was scarce or even non-existent. Detailed characteristics of the 58 included studies are listed in Additional file  7 .

PRISMA study selection flowchart for research question one

For research question two, 819 references were screened and finally two systematic reviews were included (see Fig.  2 ). The first systematic review included 238 (quasi-)experimental studies, conducted in LMIC, studying a large range of interventions aimed at improving school enrolment, attendance, drop-out, completion and learning as primary outcomes [ 23 ]. Of interest to our research question were four studies looking at the provision of instructional materials (e.g. textbooks, flip-charts), and 19 studies investigating structured pedagogy interventions (as defined above). The second systematic review was a PhD thesis of 66 (quasi-)experimental studies, conducted in sub-Saharan Africa, that looked at the same interventions as listed above, as well as interventions focused on improving repetition and retention rates [ 24 ]. Of these, we included 16 studies on the use of alternative pedagogical methods, of which three were also included in the category of structured pedagogy interventions. Detailed study characteristics are presented in Additional file  8 .

PRISMA study selection flowchart for research question two

Best available evidence on the effectiveness of first aid training to children

In the paragraphs below, the findings concerning the effectiveness of first aid training interventions for ‘burns’, ‘bleeding’, and ‘skin wounds’ are discussed in detail. The detailed findings on the other first aid topics, as well as the risk of bias and certainty of evidence, can be consulted in Additional file 7 .

In total, we identified six studies that included burns in their training programme (see Table  1 for study characteristics, and Table  2 for study findings; detailed study characteristics can be found in Additional file 7 ) [ 25 , 26 , 27 , 28 , 29 , 30 ]. A statistically significant increase in first aid knowledge was shown after attending a first aid training course, compared to the baseline situation or control group without training, in children of 6–7 years old (MD(%): 27, 95% CI [11;40]) [ 27 ], 10–11 years old (MD: 0.2, 95% CI [0.08;0.32]) [ 26 ], 10–15 years old (OR: 1.83, p  = 0.026) [ 27 ], and 11–15 years old (RR: 19.80, p  < 0·001, immediately after the course; RR: 20.00, p  < 0.001, after 2 months follow-up) [ 30 ]. Two studies also measured the children’s skills, by providing an audio-recorded scenario with a severe burn injury in a toddler or a description of a situation requiring first aid for burns [ 25 , 30 ]. In a pre-post study with 11- to 15-year-olds, a significant increase in first aid skills was found (RR: 189.00, p  < 0·001, immediately after training; RR: 149.00, p  < 0·001, after 2 months follow-up) [ 30 ]. However, in a study with 11- to 16-year-olds that used a placebo training (on tobacco and alcohol prevention) as a control, no increase in skills concerning the order of first aid responses and listing the correct procedures, could be demonstrated (RR: 7.52, 95% CI [0.89;63.69] and RR: 1.05, 95% CI [0.91;1.21], respectively) [ 25 ].

Three studies reported on the effectiveness of first aid training concerning bleeding and skin wounds [ 25 , 29 , 30 ]. A statistically significant increase of knowledge concerning first aid for bleeding or skin wounds was found in children of 11 years onwards. The study by Campbell et al. in 11- to 16-year-olds showed a significant improvement in skills concerning the order of first aid responses in case of bleeding or skin wounds, but not in listing the correct procedures [ 25 ]. The certainty of the evidence was very low for the three topics.

Best available evidence on the effectiveness of educational interventions in LMIC

We identified four studies on the provision of instructional materials to primary schools or their individual students in three different LMIC (India, Kenya and Sierra Leone), from the meta-analyses by Snilstveit et al. (2015) [ 23 ]. It could not be demonstrated that the provision of textbooks, flip-charts, or grants used directly for the purchase of materials, results in a statistically significant increase in composite test scores (SMD: 0.01 ± 0.01, 95% CI [− 0.01;0.02], p  = 0.23), language arts test scores (SMD: 0.00 ± 0.01, 95% CI [− 0.02;0.02], p  = 0.78) or mathematics test scores (SMD: − 0.02 ± 0.02, 95% CI [− 0.06;0.02], p  = 0.26). The final certainty of evidence was low.

In total, 17 (quasi-)experimental studies provided 41 effect sizes on using alternative pedagogical methods on learning or testing outcomes of students attending primary or secondary schools across seven African countries (Nigeria, Kenya, Ghana, South Africa, Uganda, Liberia and Mali) [ 24 ]. Compared to the use of conventional teaching methods (mostly lecturing), the use of alternative pedagogical methods, such as problem-solving instruction, small-group instruction, guided-inquiry instruction, cooperative instruction and constructivist instruction, was shown to significantly increase the students’ learning or testing outcomes (Cohen’s d: 0.918 ± 0.314, 95% CI [0.25;1.59], p  < 0.05). The certainty of evidence was rated as low.

Concerning structured pedagogy interventions, we obtained evidence from 19 studies in primary and secondary school students in 12 LMIC (Sudan, Kenya, Uganda, South Africa, Liberia, Mali, India, Cambodia, The Philippines, Chile, Brazil and Costa Rica) [ 23 ]. When comparing these interventions to no or other small educational interventions, a statistically significant increase in composite test scores (SMD: 0.06 ± 0.01, 95% CI [0.03;0.08], p  < 0.0001), language arts test scores (SMD: 0.23 ± 0.05, 95% CI [0.13;0.34], p  < 0.001) and mathematics test scores (SMD: 0.14 ± 0.03, 95% CI [0.08;0.20], p  < 0.001) was observed. Significant changes in cognitive test scores could not be demonstrated (SMD: 0.01 ± 0.03, 95% CI [− 0.04;0.07], p  = 0.66). The certainty of evidence was downgraded to low.

Study findings are provided in Table  3 , whereas study characteristics, references of the studies included in systematic reviews, and determination of the certainty of evidence can be found in Additional file 8 .

Educational pathway on first aid for sub-Saharan Africa

The best available evidence on the effectiveness of first aid training to children was used to draft the educational pathway, which was then discussed with the expert panel for context adaptation. Since the certainty of evidence was low to very low, the expert panel had a very important role in formulating and approving training objectives and age ranges. Overall, the panel did not often disagree on the specific age ranges at which certain learning objectives should be encouraged, known or repeated. However, for some topics there was more disagreement among the panel members and a more extensive discussion was necessary, e.g. the inclusion of major incidents/disaster management as a topic, the inclusion of psychological first aid as an intervention, the management of fever, the competence of putting on gloves, the objective of willingness to touch a stranger. In each case of disagreement, arguments were listed and discussed, and a proposal was made by the chair until full consensus was achieved.

An example of how the pathway was adapted to the African context deals with seeking help from a medical care provider. In the draft pathway, it was proposed that children should know how to seek help from a medical care provider at the age of 7–8 years. Since medical care is less accessible in Africa than in high income countries, the expert panel decided to postpone this to the age of 9–10 years, and to keep on repeating until the age of 18 years. A second example deals with the general first aid competence of handwashing before and after administering first aid. Because of the higher prevalence of infectious diseases in the African context, the panel proposed to repeatedly train children until the age of 18 years.

For the topic of burns, evidence showed that children of 6–7 years old can be taught how to correctly provide first aid [ 28 ]. The expert panel extrapolated the evidence on burns knowledge in a consistent way to the topics of bleeding and skin wounds, since evidence on the latter topics for children under 11 years was lacking, hence concluding that children should have acquired the basic knowledge at the age of 7–8 years. More advanced knowledge should be attained at the age of 11–12 years (e.g. children know the link between tetanus and skin wounds), or at the age of 13–14 years (e.g. children know the different types of burns). Based on the opinion of the experts, only one knowledge item should already be acquired at the age of 5–6 years: the most common causes of burns (i.e. hot water, fire, flames). Skills competences were set in accordance with the knowledge items.

The final version of the pathway can be found in Table  4 (for the topics ‘burns’, ‘bleeding’, and ‘skin wounds’) and Additional file  9 (for all topics).

Teaching materials for first aid training to children in sub-Saharan Africa

The panel members agreed to cluster the 2-year age ranges of the educational pathway into 3 broader age groups for the development of separate teaching materials (5–8 years old, 9–12 years old and 13–18 years old). Also, they agreed on a number of recommended educational methods, applicable to the African context. An overview of these methods, the age groups for which they are (most) appropriate, as well as their strengths and weaknesses, is presented in Table  5 . The top three of most appropriate and successful teaching methods for each age group is presented in Fig.  3 . Text messaging and the use of individual worksheets for children were perceived as non-feasible or non-desirable educational methods.

Top three of most appropriate and successful teaching methods for each age group

Following the panel meeting, teaching materials were developed for the age group of 9- to 12-year-olds, incorporating the recommended teaching methods for this age group. The competencies to be achieved when following a training using these materials were based on the content of the educational pathway, again for this specific age group.

Our educational pathway on first aid, based on the best evidence available, links key learning objectives concerning first aid to a child’s specific age range (see Additional file 9 ). It denominates which topics can be covered when training children in first aid, visualizes the time points at which certain items should receive attention, and it is adapted to the African context. The final educational pathway has been laid out in an easy-to-use version, including explanations on how to use it (both the pathway and AFAM are freely downloadable from the Belgian Red Cross website after registration) [ 31 ]. One of the successes of this project is that the educational pathway, together with the list of effective educational methods, was immediately used to develop teaching materials for first aid training to African children. The final training materials were piloted in Zimbabwe, where 6 trainers were trained (Train-the-Trainer model) and then went to 6 different schools in 2 provinces (a rural, urban and semi-urban school in each province) to provide 2-h trainings to 12- to 16-year-old children. Those trainings have been observed and the trainers and children were asked to give feedback on the manual and the used educational methods (in terms of satisfaction, feasibility, appropriateness etc.). Based on this feedback, some final changes were made to the training manual. The project is currently being implemented in Zimbabwe, Malawi, Zambia and Lesotho, and further roll-out in other countries is being planned.

Our project has some important limitations. First, the systematic literature searches we performed are not systematic reviews, which is translated into the fact that only 1 reviewer conducted the study selection and data extraction, only two databases were searched for evidence on first aid training of children, and a very focused set of selection criteria was used. The reason behind this choice, which is made by many guideline developers because of feasibility reasons, is that these reviews were part of a larger guideline project in which the evidence conclusions were translated into recommendations and teaching materials. Although this can be considered a limitation of the used review method, we believe that including an expert panel can serve as a back-up for this limitation.

Second, for several first aid topics, including ‘skin wounds’, ‘burns’, ‘bleeding’, ‘injuries to bones, muscles or joints’, and ‘poisoning’, a very limited amount of evidence or no evidence was found. Therefore, many gaps had to be filled by the expert panel, based on their expertise and consensus. In addition, almost half of the studies were European studies, and only four African studies are currently included in the evidence base, which can be seen as a source of indirectness. For the educational studies, the majority of the studies looked at mathematics and language courses, which again is a source of indirectness. Third, the quality/certainty of the obtained evidence was in most cases low to very low. This is mainly due to the less rigorous study designs that are typically used to study educational programme effectiveness, including many uncontrolled before-after studies. There was also a high degree of heterogeneity between the studies, especially at the intervention level (with many differences in the content, delivery and duration of the training programme), and outcome level (measured in many different ways and at different time points). Again, this led to a very prominent role for the expert panel, and many recommendations (learning objectives/age ranges) had to be based on expert opinion.

Nevertheless, this project has several important implications for practice. First, the educational pathway on first aid can be used by first aid trainers to help them decide which content to teach to children of certain age ranges. Second, the educational pathway may be a useful tool for advocating the importance of first aid in health education with the Ministry of Health/Ministry of Education of sub-Saharan African countries. In Zimbabwe, it was recently decided by law to integrate first aid education in the school curriculum. Third, the evidence on the effectiveness of first aid training to children (Additional file 7 ), which is independent of any geographical region, can be used to develop similar first aid educational pathways, and accompanying training materials, for other contexts or countries, but appropriateness and feasibility for the specific context or target group should be discussed, and adaptations to the context should be made with local experts.

Since we identified several gaps in research and the certainty of the available evidence was low to very low, we also want to advocate for higher quality future research, that uses appropriate control groups, on the effectiveness of first aid training to children in different geographical regions on several learning outcomes. This will allow further development of improved first aid materials.

The available evidence we identified, together with input from a multidisciplinary expert panel, was used as a basis to (1) develop an educational pathway for first aid training of sub-Saharan African children (5–18 years), and to (2) create an overview of effective educational methods in the sub-Saharan African context. The educational pathway shows which educational goals can be achieved within specific age groups, and represents a useful tool to design a first aid curriculum for children. Both the pathway and the overview of educational methods were used to develop teaching materials for first aid training of children in sub-Saharan Africa. The quantity and certainty of the evidence was low but provided a framework for the pathway and teaching materials, and highlights the clear need for higher quality research in the future.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

low- and middle income countries

African First Aid Materials

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

mean difference

standardized mean difference

confidence interval

Grading of Recommendations Assessment, Development and Evaluation

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Acknowledgements

This work was made possible through funding from the Foundation for Scientific Research of the Belgian Red Cross. We would like to thank the members of the multidisciplinary expert panel who did not co-author this paper, but have made invaluable contributions to this project by providing their expert insights and opinions: Wenceslas Nzabalirwa (School of Education, College of Education, University of Rwanda, Rwanda), Sarah Kiguli (Makerere University, Kampala, Uganda), Beatrice Musindo (VVOB (Flemish Association for Development Cooperation and Technical Assistance), Harare, Zimbabwe), Wayne Smith (Emergency Medicine Cape Town, Cape Town, South Africa), Rosalie Bikorindagara (Institut de pédagogie appliquée, Université du Burundi, Bujumbura, Burundi), Henriette Ramanambelina (Ecole Normale Supérieure de l’Université d’Antananarivo, Madagascar), Maël Rabemananjara (Madagascar Red Cross Society, Madagascar), Golden Mukwecheni (Zimbabwe Red Cross Society, Zimbabwe), Didier Dusabe (Burundi Red Cross Society, Burundi), Elke Weyenbergh (Belgian Red Cross-Flanders, Belgium). We also thank An Vanderheyden (Belgian Red Cross) for facilitating some sessions during the expert panel meeting, and for her valuable input on educational aspects.

This work was funded by the Foundation for Scientific Research of the Belgian Red Cross, but the Foundation was not involved in the study design, in data collection, analysis and interpretation, and in writing of the manuscript.

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Emmy De Buck, Jorien Laermans, Anne-Catherine Vanhove & Kim Dockx

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PV conceived the research project. ACV and KD conducted the systematic literature search for research question 1, and JL for research question 2. EDB supervised the project, revised all literature searches, composed the expert panel and drafted the educational pathway. EDB, JL and HG prepared the expert panel meeting. EDB and JL presented the evidence during the expert panel meeting, which was chaired by HG. HG was reponsible for reaching consensus among the panel members. EDB and JL revised the educational pathway based on the expert input and drafted the manuscript, which was critically revised by all other co-authors. All authors read and approved the final manuscript.

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All authors, except HG, are in employment at Belgian Red Cross and receive no other funding. The activities of the Belgian Red Cross include the provision of first aid training to laypeople, and the support of African Red Cross National Societies in the development of first aid materials.

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Additional file 2.

Search strategies research question 1

Additional file 3.

Selection criteria research question 1

Additional file 4.

Search strategies research question 2

Additional file 5.

Selection criteria research question 2

Additional file 6.

Description of consensus methods used during expert panel meeting

Additional file 7.

Characteristics of included studies, synthesis of findings, risk of bias and certainty of evidence for research question 1

Additional file 8.

Characteristics of included studies, synthesis of findings, risk of bias and certainty of evidence for research question 2

Additional file 9.

Evidence-based educational pathway on first aid for sub-Saharan Africa 221

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De Buck, E., Laermans, J., Vanhove, AC. et al. An educational pathway and teaching materials for first aid training of children in sub-Saharan Africa based on the best available evidence. BMC Public Health 20 , 836 (2020). https://doi.org/10.1186/s12889-020-08857-5

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Adapting the Stress First Aid Model for Frontline Healthcare Workers during COVID-19

Mayer h. bellehsen.

1 Center for Traumatic Stress, Resilience and Recovery at Northwell Health, Great Neck, NY 11021, USA; ude.llewhtron@neshellebm (M.H.B.); ude.llewhtron@maahsp (P.S.); ude.llewhtron@1snrubd (D.B.); ude.llewhtron@9grebdloga (A.G.); ude.llewhtron@setnomahcawa (A.W.-M.); ude.llewhtron@hcivoreznezg (G.Z.); ude.llewhtron@3ztrawhcsr (R.M.S.)

2 Department of Psychiatry, Zucker Hillside Hospital at Northwell Health, Glen Oaks, NY 11004, USA; ude.llewhtron@ocimadp (P.D.); ude.llewhtron@arpasm (M.S.)

3 Behavioral Health Service Line, Northwell Health, New York, NY 10022, USA; ude.llewhtron@sunamcmm

Haley M. Cook

4 Department of Occupational Medicine, Epidemiology and Prevention, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY 11021, USA

Pooja Shaam

Daniella burns, peter d’amico, arielle goldberg, mary beth mcmanus, manish sapra, lily thomas.

5 Institute for Nursing, Northwell Health, New Hyde Park, NY 11042, USA; ude.llewhtron@samohtl

Annmarie Wacha-Montes

George zenzerovich, patricia watson.

6 National Center for PTSD, White River Junction, VT 05009, USA; [email protected]

Richard J. Westphal

7 School of Nursing, University of Virginia, Charlottesville, VA 22903, USA; [email protected]

Rebecca M. Schwartz

Associated data.

The data presented in this study are available by request and sent to the corresponding author.

The coronavirus pandemic has generated and continues to create unprecedented demands on our healthcare systems. Healthcare workers (HCWs) face physical and psychological stresses caring for critically ill patients, including experiencing anxiety, depression, and posttraumatic stress symptoms. Nurses and nursing staff disproportionately experienced COVID-19-related psychological distress due to their vital role in infection mitigation and direct patient care. Therefore, there is a critical need to understand the short- and long-term impact of COVID-19 stress exposures on nursing staff wellbeing and to assess the impact of wellbeing programs aimed at supporting HCWs. To that end, the current study aims to evaluate an evidence-informed peer support stress reduction model, Stress First Aid (SFA), implemented across units within a psychiatric hospital in the New York City area during the pandemic. To examine the effectiveness of SFA, we measured stress, burnout, coping self-efficacy, resilience, and workplace support through self-report surveys completed by nurses and nursing staff over twelve months. The implementation of SFA across units has the potential to provide the workplace-level and individual-level skills necessary to reduce stress and promote resilience, which can be utilized and applied during waves of respiratory illness acuity or any other healthcare-related stressors among this population.

1. Introduction

The COVID-19 pandemic placed an unprecedented burden on healthcare workers (HCWs). It also highlighted pre-existing stressors that exacerbate challenges within hospital systems across the country [ 1 , 2 ]. HCWs experience high levels of stress due to the nature of their job responsibilities, including caring for critically ill and injured patients, patient deaths, increased workloads, and long hours [ 3 ]. These occupational stressors are often exacerbated during periods of higher healthcare demand, such as during a disaster or public health emergency [ 4 , 5 ]. Occupationally, HCWs are particularly vulnerable to workplace stressors, conferring increased risk for posttraumatic stress reactions [ 5 , 6 ]. Indeed, an analysis of the 2008 American Community Survey and National Death Index records through 2019 found that healthcare workers were at increased risk of suicide compared with non-healthcare workers, specifically registered nurses, healthcare support workers, and health technicians [ 7 ]. National and international studies of HCWs’ occupational and health outcomes during the COVID-19 pandemic have shown increased rates of psychopathology including anxiety, depression, and posttraumatic stress; behavioral changes including sleep disturbance, relationship difficulties, and substance use; and increased rates of burnout, compassion fatigue, and job dissatisfaction [ 1 , 2 , 6 , 8 , 9 , 10 ].

Approximately two years after the first wave of the pandemic, the US Bureau of Labor Statistics estimated that there were over three million employed registered nurses, the largest healthcare occupation in the US, of which nearly 88% identify as female [ 10 , 11 ]. Nursing staff report increased rates of moral injury stemming from treatment decisions based on limited resources, increases in stress from the volume and intensity of their work, and a new sense of vulnerability and fear for their safety and the safety of their loved ones [ 12 , 13 ]. Similar outcomes were found among nurses across triage and non-triage hospitals in Egypt during the pandemic, wherein occupational stressors including high workload, exposure to death, personal fears, and stigma were associated with higher stress, decreased job satisfaction, and increased intent to leave their current position [ 14 ]. In a longitudinal study of Italian healthcare workers between May 2020 and July 2021, the authors found subclinical levels of psychiatric symptoms, including stress, depression, state anger, and emotional exhaustion, across the three time points measured in the study, hypothesized to indicate a higher baseline level of resilience among HCWs [ 15 ]. Related measures of emotional and occupational wellbeing, however, were found to be negatively impacted in a another sample of Italian healthcare workers, during (July 2021) and post (July 2023) pandemic [ 16 ]. Specifically, while rates of job burnout and symptoms of depression remained high between time points, rates of compassion fatigue increased following the pandemic [ 16 ]. Findings may be suggestive of negative ongoing impacts to emotional and occupational wellbeing experienced by healthcare workers. The collective impact of trauma from COVID-19, as well as subsequent responses to the pandemic at the provider level, contribute to the emotional toll experienced in the wake of COVID-19 on healthcare providers [ 1 , 2 ]. With an understanding of the unique risks experienced by HCWs generally and those experienced explicitly by nurses during the COVID-19 pandemic, targeted interventions are needed to address provider wellbeing.

1.1. Peer Support Intervention

The relationship between occupational stress and adverse psychological outcomes is well established [ 17 , 18 , 19 , 20 ]. Peer support programs have been cited as potentially effective for addressing HCW wellbeing in the context of COVID-19 [ 21 ]. Generally, positive relationships with supervisors and coworkers have been associated with lower workplace stress [ 22 ]. Social support is recognized as a leading driver for this positive association [ 23 ]. Specifically, in Karasek’s 1982 job strain model, coworker and supervisor support is understood to moderate associations between general occupational stressors, job control, and mental strain [ 24 ]. In a further examination of the role of supervisor and coworker support, after controlling for negative affect, high levels of supervisor support reduced the negative effects of job strain on level of job satisfaction, while coworker support mitigated the association between job strain and work performance [ 25 ]. Peer support models aid in the deconstruction of mental health stigma through increasing awareness and verbal expression of stress individually and as a team [ 23 ]. This is particularly relevant for HCWs whose occupation requires attention to and caring for others, often at their own expense [ 13 ]. Studies indicated that HCWs grappling with stressors from COVID-19 are interested in obtaining support, but few employees currently utilize emotional support resources [ 24 ].

The expansion of peer support services to address HCW needs during the COVID-19 pandemic represented an essential shift in occupational health [ 25 , 26 , 27 ]. In response to the pandemic, several hospitals and health systems have implemented hotlines and brief individual- or group-based supportive telehealth sessions for employees [ 28 , 29 ]. Support services have focused on the screening for and provision of mental health services at the individual, small group, and department levels, providing in-house stress-inoculation and resilience-promoting training, and, when clinically indicated, connecting HCWs to external referrals for ongoing care [ 25 , 26 , 27 ]. Additional services have included the dissemination of resources through online platforms (i.e., websites, apps), wherein employees can access online resources to support mental and physical health, psychosocial stressors (e.g., parenting and caregiving during COVID-19), and resilience maintenance. Initial qualitative findings from a hospital-based peer support program found shifts in organizational culture, staff skill building for recognizing and supporting coworkers in distress, and support for individuals already providing psychosocial peer support [ 30 ]. While the introduction and utilization of these services is a crucial step, the need for comprehensive, evidence-informed interventions remains.

A growing understanding of the negative impacts of COVID-19 on HCWs highlights the need for the development and evaluation of comprehensive, effective, and sustainable interventions to address the acute and long-term health needs of healthcare providers. To date, research exploring the use of empirically supported, individual-level treatments (e.g., cognitive behavioral therapy (CBT)) to improve mental health and wellbeing during the pandemic stop short of addressing resilience processes and contextual factors that impact wellbeing, such as perceptions of workplace support [ 17 , 26 , 28 , 29 , 31 ]. A systematic review published in the Cochrane Database determined there is a paucity of evidenced-based effectiveness research on interventions aimed at supporting the resilience and mental health of HCWs during and after disasters, asserting a strong need for studies examining comprehensive interventions for HCWs during COVID-19 [ 32 ]. The Systems Model theoretical framework delineates the various workplace levels that are impacted by stress and burnout, such as unit/team, leadership, and the healthcare industry [ 33 ]. For instance, at the workplace level, the Systems Model posits that stress and burnout will also be associated with negative consequences such as increased absenteeism, turnover, and lower engagement. The Systems Model also highlights individual and work system factors that might mediate stress and burnout, including coping strategies and coping self-efficacy, resilience, and organizational social support.

1.2. Stress First Aid

SFA is a peer support and self-care model involving the promotion of social support and resilience-building to mitigate stress reactions, individually and within teams [ 34 , 35 , 36 , 37 ]. Initially developed in the context of high-risk occupations (i.e., military service, fire and rescue, law enforcement), SFA has shown positive preliminary results for improving perceived ability to respond to behavioral health issues among teams [ 38 ]. SFA has, more recently, been adapted to meet the needs of HCWs. Specifically, SFA for HCWs is designed to promote peer-support interventions that have the potential to impact SFA self-efficacy, or the ability to recognize stress reactions in oneself and colleagues, encourage increased awareness and utilization of occupational wellbeing resources, improve perceptions of workplace support, and shift workplace stress and burnout levels. Stress First Aid is inherently compatible with Karasek’s model; when demand is high, as was seen among HCWs during the pandemic, SFA seeks to increase control and social support within the workplace by enabling more effective communication around stressors and procurement of support, with the intent to decrease the negative impacts of job strain, including burnout. Stress First Aid acts as an effective mechanism for aligning efforts between programs as well with the goal of facilitating knowledge and awareness of employee supports such as EAP. This connection and cooperation promote resource-sharing and aid in the implementation of informed and efficient efforts in supporting our employees and the community.

SFA utilizes empirically informed elements that guide efforts for offering peer support actions in response to ongoing adversity, trauma, or disasters [ 34 , 39 , 40 , 41 ]. The five empirically informed elements include the promotion of a sense of (1) safety, (2) calm, (3) connectedness, (4) self- and community-efficacy, and (5) hope [ 42 ]. These directly map onto five of the seven Core Actions (7 C’s) of SFA: cover, calm, connect, competence, and confidence. Check and coordinate are added as continuous core actions for situational monitoring of stress and linkage into care as needed. SFA’s seven core actions directly impact coping self-efficacy, resilience, and perceptions of organizational support. Self-efficacy in terms of one’s ability to cope with stress, has been linked with psychological stress itself as well as stress-related burnout, mental health symptoms, and workplace turnover intentions [ 43 , 44 , 45 , 46 ]. SFA is designed to generate increased individual and team coping and self-efficacy skills, in addition to improvements in leadership, workplace resilience, improved knowledge of and use of resources, and organizational social support. The SFA framework posits that stress injuries often result in decreased self-awareness of stress. This gap widens further for HCWs, who, by nature of the occupation, employ ‘other’ rather than ‘self’ focus and, therefore, are more likely to provide peer support than self-care. Thus, the provision of services within SFA includes direct peer support, wherein team members learn how to identify, communicate, and respond to stress. Initial research findings support the feasibility and acceptability of SFA among firefighter and nursing populations [ 40 ]. Figure 1 provides an overview of the anticipated impact of SFA.

Impact of Stress First Aid.

The ability to test the impacts of SFA on the aforementioned constructs in the healthcare setting is important as there is limited research on its impact in the healthcare setting. SFA was developed with input from HCWs so that it would be feasible and acceptable for use with this population. SFA’s flexible structure easily allows for these types of adaptations. For example, the lives of HCWs, particularly during a pandemic, are hectic and intensely busy. It was imperative that learning the basic framework of SFA would be a quick process. Healthcare settings can implement Stress First Aid setting-wide with 15 min briefings to raise awareness and educate about the importance of using SFA principles for stress mitigation. SFA champions or coaches can then train, mentor, and provide ongoing resources in their units. They also regularly assess the unit’s overall stress levels on the stress continuum and shape the dialogue about the resources that exist to build resilience and capacity. This type of implementation is consistent with the EU Field Guide to Managing Complexity (and Chaos) in times of crisis, which recommends using a flexible approach built upon research- or theory-informed frameworks that empower adaptive actions in the context of complex public health situations [ 47 ]. It is also consistent with qualitative findings from a Cochrane review regarding work-related resilience interventions in the context of disease outbreaks [ 34 , 47 ]. This review noted that the successful implementation of programs depends upon flexible interventions that are culturally appropriate and adaptable to local needs. Also important are effective communication, cohesion through networks, a positive learning climate where team members feel valued and a part of the change process, and sufficient time and space for reflective thinking and evaluation. When HCWs are overwhelmed, they appreciate a “map” that can guide them through a variety of circumstances at whatever level they have the capacity for. SFA also allows for a long-term approach that includes multiple strategies for self-care strategies based on stress levels and current concerns, as well as sharing and learning from colleagues, consulting with mentors, and making time for the small actions that provide support.

1.3. Present Study

This study aims to address a gap in the current literature regarding the implementation and efficacy of a comprehensive, evidence-based peer support program in a cohort of HCWs at a large psychiatric hospital during the COVID-19 pandemic. The current study uses a longitudinal design to best capture fluctuations in outcomes over time and to understand both the short and longer-term potential impacts of SFA. The authors hypothesize that, over 12 months, SFA will be highly utilized, well-received, and efficacious in increasing participants’ (a) self-efficacy, (b) resilience, (c) awareness and utilization of wellbeing resources, and (d) perceptions of organizational support. Secondary/distal outcomes will also be explored, including SFA’s impact on stress and burnout.

2. Materials and Methods

2.1. participants.

To evaluate the effectiveness, implementation, and maintenance of the SFA program, 562 nurses and nursing support staff in a psychiatric hospital in the metropolitan New York area were given measures that were collected at baseline (before implementation), three, six, nine, and twelve months post SFA implementation to examine how each of the proximal and distal outcomes changes over the five-time points. Convenience sampling approaches were utilized to send each of the identified 562 HCWs the electronic survey. All data were collected and stored in a Research Electronic Data Capture (REDCap) database, which is a HIPAA-compliant database that requires a password and only allows access to specific individuals added by the CTSRR team. Data were collected between May 2021 and June 2022 via a REDCap electronic health questionnaire that was directly emailed to eligible participants. All study measurements, including SFA self-efficacy, wellbeing resource awareness/utilization, perceptions of organizational support, resilience, stress, and burnout, were contained within this questionnaire. Nurses and nursing staff who were working in an inpatient capacity at the hospital between May 2021 and June 2022 were included. Of the 562 nurses and nursing staff that were sent the survey, 150 participants completed the survey at baseline, 128 at the 3-month follow-up, 111 at the 6-month follow-up, 92 at the 9-month follow-up, and 116 at the 12-month follow-up. Table 1 shows the role breakdown of the 266 participants who completed the survey at any time point. Of the total sample, 77% consisted of mental health workers and registered nurses, with survey participants across 14 units of a single psychiatric hospital.

Occupational role breakdown of unique respondents.

	Frequency	Percent
RN—Registered Nurse	96	36.1
Mental Health Nursing Staff	90	33.8
Unit Receptionist	20	7.5
ANM—Assistant Nurse Manager	14	5.3
Other	12	4.5
Nursing Administrator	9	3.4
NM—Nurse Manager	9	3.4
Scheduler	4	1.5
PCA—Patient Care Associate	3	1.1
Director	3	1.1
Nursing Attendant	2	0.8
Nurse Educator	2	0.8
NA—Nursing Assistant	1	0.4
Certified Nursing Assistant	1	0.4
Total	266	100

2.2. SFA Procedure

Implementation of SFA into a large hospital system entailed a four-step process that included preparation of teams, training, integration, and sustainment. SFA program staff included designated SFA Coaches expertly trained in SFA by two developers of SFA and project management support. The SFA program staff prepared a particular hospital team by orienting them to a process for implementation. Hospitals would identify an SFA site coordination and other personnel to support operations and report to executive sponsors. The SFA program team would help the hospital coordination team identify personnel that could facilitate training and team members that would support integration. Additional awareness raising activities such as briefings, newsletter announcements, and kickoff events were conducted during the preparation phase. SFA Coaches also prepared two levels of training- one for leaders and one for remaining staff. The coaches then provided master training for site trainers to deliver these trainings in more intimate settings to their staff and the coaches met regularly with the trainers to monitor them and provide feedback. SFA Coaches were also available to support responses to critical incidents. Critical to the SFA roll out was an integration process to embed SFA into daily team operations to moderate ongoing and exceptional occupational stressors across hospital units. Once about 50% of a site was trained, a 12-week integration phase was initiated in which leaders were asked to begin practices of “Raising Awareness”, “Growing the Green”, and “Stopping the Burn”. This corresponded onto actions of posting signage, actively engaging in SFA practices (like a color check in and calming activities), and responding to elevated stress levels, respectively. The process of integration was monitored with self-report surveys through REDCap and a process of auditing. Lastly, sustainment was achieved by embedding check-ins on progress with SFA into hospital-wide administrative meetings, embedding practices like color checks into daily safety checks and weekly rounding, and by embedding training into new hire orientation so that new staff were trained. Progress with each step of the process was monitored with various process metrics.

2.3. Measures

We utilized a secure, HIPAA-compliant database, REDCap, for all data collection. The Human Resources department provided the contact information of all eligible nurses and nursing staff to the CTSRR team, which was then used to create a unique ID for each participant within REDCap. All study measurements were contained within the electronic baseline questionnaire, which was emailed directly to eligible participants through a secure and unique REDCap link at each time point. Responses are linked to a participant’s record, where they can be tracked and analyzed.

2.3.1. Proximal Outcomes

Proximal outcomes include resilience, SFA self-efficacy, and perceptions of workplace support at each time point. The Connor–Davidson Resilience Scale 2© (CD-RISC 2) is a two-item scale that is useful as a brief measure of resilience to assess one’s ability to adapt to change and bounce back after hardship [ 48 ]. The two items include “I am able to adapt when changes occur” and “I tend to bounce back after illness, injury, or other hardships”. Each item on the CD-RISC 2 has responses that range between 1–5 ( 1 = not true at all , 2 = rarely true , 3 = sometimes true , 4 = often true , 5 = true nearly all the time ). Item scores are summed for a total score range of 2–10 with higher scores on this screener indicative of greater levels of resilience.

The SFA self-efficacy score was developed by the research team to better understand SFA implementation (confidence in addressing the seven core actions of SFA), including confidence in one’s ability to identify stress in co-workers, take action to reduce stress in co-workers, and link stressed co-workers into care. Items include “How confident are you in your ability to identify the level of risk/distress of an impacted person (i.e., self or co-worker) during and following a stressful event?”; “How confident are you in your knowledge of resources to link a stress-impacted person to needed supports?”; and “How confident are you in your ability to take action to reduce the stress of an affected person/s (i.e., calm, cover, connect, competence, confidence)?”. Item responses ranged from 1–4 ( 1 = not confident , 2 = a little confident , 3 = confident , 4 = very confident ). Scores were summed for a total range of 3–12 with higher scores hypothesized to indicate greater SFA self-efficacy.

Perceived organizational support was measured using the Deployment Risk and Resilience Inventory-2 (DRRI-2), unit support subscale, adapted for use with frontline HCWs, which is a 12-item instrument with each item response between 1 and 5 (1 = strongly disagree; 5 = strongly agree) [ 45 ]. Total DRRI-2, Unit Support subscale score is created by summing each item rating with higher scores indicative of greater perceived social support from co-workers/unit members/unit leaders (range: 12–60). We aimed to measure co-worker and manager interest in employee wellbeing. Participants were asked whether “co-workers on my unit are interested in my wellbeing” and “the leaders of my unit are interested in my personal welfare”, with responses between 1 and 5 ( 1 = strongly disagree , 2 = disagree , 3 = neither agree nor disagree , 4 = agree , 5 = strongly agree ).

2.3.2. Distal Outcomes

Distal outcomes included stress and burnout levels. The Stress Continuum Model is a foundational part of the SFA model that helps with the assessment of stress response levels, ranging from Green (exceptionally low stress and stress reactions) through Yellow and Orange to Red (significant exposure to stress and experience of stress reactions) categories. Participants were asked to rate their level of stress for the past two weeks on a scale of 1–4, with 1 being the least stressful and 4 being the most stressful, and with the following corresponding colors: 1—green; 2—yellow; 3—orange; 4—red.

The Adapted Maslach Burnout Inventory (MBI) measured nine emotional exhaustion (EE) items, for example, “I feel burned out from my work”, and five depersonalization (DP) items, including “I’ve noticed that I’ve become more callous (i.e., less sympathetic/compassionate) toward patients/customers”. Burnout domains were evaluated on a scale of 1–5 ( 1 = strongly disagree , 2 = disagree , 3 = neither agree nor disagree , 4 = agree , 5 = strongly agree ). For both subscales, higher mean scores are indicative of higher degrees of burnout.

To better understand the utilization of wellbeing resources, participants were asked to endorse a list of fourteen hospital-provided wellbeing resources that they are aware of and have utilized or directed a coworker to in the last three months. Examples of responses include the Employee & Family Assistance Program (EAP) , Team Lavender , Chaplain on-site support , and the Emotional Support Resource Call Center.

Lastly, demographic data were collected including, position/job role, primary worksite/hospital, and primary work unit/department.

2.4. Statistical Analyses

All longitudinal analyses were conducted using the Generalized Estimating Equations (GEE) approach [ 49 ] under the assumption that the missing values were missing completely at random (MCAR). The working correlation structures considered for fitting GEE models for each variable were ‘Independent’, ‘Exchangeable’, ‘AR-1’, ‘3-Dependent’, and ‘Unstructured’. The criteria used for selecting the best covariance structure for each variable included both the Quasi Likelihood Information Criterion (QIC) values as well as a comparison between the model-based estimates and the empirical estimates of the correlation matrix [ 50 ]. Empirical estimators were obtained using the sandwich estimator [ 50 ]. PROC GENMOD in SAS version 9.4 was used for all GEE analyses. Marginal means for the continuous dependent variables and the odds for the binary dependent variables across all time points were estimated using the ‘least squares means’ option within the GENMOD procedure.

3.1. Longitudinal Descriptive of Study Variables

Table 2 provides descriptive characteristics for participants’ levels of self-efficacy, resilience, perceptions of organizational support, stress, burnout, and awareness of resources from baseline through 12-month follow-up.

Outcome measures based on the least square means across all time Points.

	Baseline		3-Month Follow-Up		6-Month Follow-Up		9-Month Follow-Up		12-Month Follow-Up
	M	SE	M	SE	M	SE	M	SE	M	SE
SFA Self-Efficacy *	9.10	0.15	9.15	0.13	9.36	0.14	9.21	0.14	9.54	0.14
Resilience **	8.28	0.11	8.13	0.12	8.13	0.13	8.17	0.12	8.47	0.11
Perceptions of Organizational Support	7.89	0.16	7.94	0.15	7.99	0.15	8.16	0.16	8.29	0.14
Stress	2.18	0.07	2.11	0.06	2.07	0.07	2.14	0.07	2.10	0.07
Burnout	5.11	0.13	4.99	0.14	5.20	0.17	5.85	0.15	4.82	0.14
Resource Awareness **	4.32	0.26	4.61	0.25	4.98	0.28	4.99	0.28	5.28	0.29
Any Resource Utilization (OR; 95% CI)	0.27	(0.18–0.40)	0.28	(0.19–0.43)	0.31	(0.20–0.48)	0.33	(0.21–0.53)	0.40	(0.27–0.60)

Note: * p = 0.05, ** p < 0.01.

3.2. Generalized Estimating Equation (GEE) Analysis of Study Variables

The overall comparisons of least square means were conducted across time points for each variable, presented in Figure 1 , Figure 2 and Figure 3 . Proximal outcomes of and SFA self-efficacy ((χ 2 , 4) = 9.45, p = 0.051) and resilience ((χ 2 , 4) = 11.47, p < 0.05) significantly differed across time points. In addition, the average number of resources participants are aware of significantly differed across timepoints ((χ 2 , 4) = 9.55, p < 0.05). All outcomes generally increased over time (see Figure 2 , Figure 3 and Figure 4 ).

SFA self-efficacy across all time points.

Resilience across all time points.

Awareness of wellbeing resources across all time points.

Mean differences across time points did not significantly differ for the perception of organizational support ((χ 2 , 4) = 5.67, p = 0.225), stress ((χ 2 , 4) = 2.44, p = 0.656), burnout ((χ 2 , 4) = 6.03, p = 0.197), or utilization of resources ((χ 2 , 4) = 2.57, p = 0.632). When examined for change between the two-time points of baseline and 12 months, there are two additional significant results. Perceptions of organizational support significantly increased from baseline to 12 months (Mean difference = 0.396; p = 0.0278), and there was a borderline significant decrease in burnout (Mean difference = −0.287; p = 0.057).

4. Discussion

Workplace stress, emphasized during the COVID-19 pandemic, remains a prominent issue among healthcare professionals. The authors of the present study sought to examine the use of Stress First Aid (SFA) as a targeted, self-care, and peer-support intervention to address healthcare worker wellbeing. Proximal outcomes were hypothesized to increase from baseline to 12-month follow-up, including self-efficacy, resource awareness and utilization, resilience, and perceptions of organizational support. At the same time, potential decreases in distal outcomes of stress and burnout were also explored. Generalized estimating equations (GEE) highlighted significant increases across three-month intervals from baseline to 12-month follow-up for self-efficacy, resource awareness, and resilience rates. Additionally, when considering only changes from baseline to 12-month follow-up, a significant increase was found in perceptions of organizational support and a borderline significant decrease in rates of burnout. In the present study, significance was not found for the utilization of resources or rates of stress.

This longitudinal study reveals unique shifts in the data across the 12 months. Rates of SFA self-efficacy increased, then decreased at month nine, followed by an increase at the twelve-month follow-up. A similar pattern emerged for rates of burnout, where, though not significant, participants reported higher rates at month nine before dropping in month twelve. Survey participation was also notably lower at month nine; however, response rates increased again at the twelve-month follow-up. There was a significant spike in COVID-19 cases in January 2022 [ 51 ], which may be reflected in the relative decrease in participation and feelings of self-efficacy at month nine, according to data that were collected in February and March 2022. Natural fluctuations in external stressors may account for some of the observed variability; however, a time-matched control group would be needed to further assess this hypothesis.

Another a point of interest is that the rates of resilience stayed fairly consistent during months 3–9, with a marked increase at the 12-month follow-up. Given the extended period of high-acuity work at the height of the pandemic for this sample of nurses, it is feasible that there was less capacity for resilience building initially, when the focus was required to be on addressing basic needs (i.e., fear of contamination) [ 52 ]. Resilience, as a construct, is generally measured as a state characteristic, not a trait characteristic, and may require more time under intervention exposure to see a quantifiable shift [ 53 ]. A larger sample size and dose/response analysis may be beneficial in determining this threshold for change. It is also likely that the threshold is variable-dependent, with SFA self-efficacy showing its greatest increase at the six-month time point.

4.1. Theoretical Implications

SFA aims to build protective factors to increase resilience and mitigate stress reactions. These factors can hopefully contribute longitudinally to decreased distress and burnout, and in this study, some significant change was found between baseline and 12-month follow-up for distal outcomes. However, the authors generally expected to see less change in measures of stress and burnout in the context of implementing SFA during a pandemic. Because significant change was found for distal outcomes even in this context, we are hopeful that in less stressful circumstances, the use of SFA can further contribute to a reduction in stress and burnout, mainly when the organization uses the model to build leadership’s capacity to assess and address systemic issues which may have a more direct impact on stress and burnout. This focus should have an additive effect on the SFA goal of increasing awareness of stress injuries, helpful self-care, and peer support actions, resources, and access to care, as well as its goal of helping to identify, assist, and link into care those individuals who may be at risk for developing stress injuries that could predispose them to longer-term mental health conditions. Future studies should inspect the longer-term impact of SFA utilization across a healthcare system and potential company-wide cultural shifts in the discussion of stress and burnout.

4.2. Practical Implications

The findings from this study are significant because, in contrast to prior studies [ 33 , 35 ], this study protocol committed to implementing SFA in the recommended flexible way, with local SFA Coaches supported by more experienced supervisors. This approach yielded greater self-efficacy, resilience, and resource knowledge than studies with a more controlled, rigid format with less supervision [ 33 , 35 ]. This makes the current findings and guidelines more generalizable to the recommended implementation of SFA in high-stress work environments. Organizations that have the time and dedicated resources to follow up with multiple training opportunities, support from SFA Coaches, and multi-tiered ways to implement SFA actions should find better results in reduction in stress, increased coping self-efficacy, and perceived social and organizational support, mainly when initiated before public health emergencies rather than during a pandemic.

As noted previously, SFA is in alignment with implementation principles recommended for complex environments and public health emergencies, such as using research- or theory-informed frameworks to empower adaptive actions within a flexible approach to solve problems that a system cannot yet anticipate [ 47 ]. Building upon existing informal networks of support with a built-in level of trust allows for faster implementation, and greater trust allows HCWs to adapt actions to their moment-to-moment capacity. SFA, implemented this way, allows individuals and systems to define and move towards reduced stigma and enhanced communication about the ongoing necessary actions toward greater wellbeing and system effectiveness.

4.3. Limitations and Future Directions

The results of this study should be interpreted considering several limitations, with implications for future research. First, the present study had a relatively small sample size. Power was sufficient for the proposed statistical analyses; increasing the sample size in future studies may allow for group differentiation such as by role type, gender, and other variables. Additionally, a larger sample size or oversampling for additional demographic variables or variables of otherwise interest would have allowed for a more nuanced understanding of the effects of SFA among healthcare workers. The current study focused on healthcare workers in a behavioral health setting without specific control or comparison groups. For example, comparing study findings to control groups of other healthcare workers outside of a psychiatric setting may have been advantageous. While our outcomes assessment followed the proximal and distal outcomes of the Stress First Aid intervention, future repeated assessment of variables would strengthen causal inference and potential temporal mediation models. Whereas the present study focused on several proximal outcomes associated with occupational stress and burnout, future research might investigate additional outcomes. Research has found associations between occupational stress and other behavioral health outcomes, including substance use disorders and depression [ 54 ] among healthcare workers.

5. Conclusions

This study sought to extend the use of the peer support intervention, Stress First Aid, to healthcare workers during the COVID-19 pandemic. Findings provide preliminary support for the potential efficacy of SFA as a means of shifting culture around the discussion of emotional wellbeing, as well as an awareness and utilization of employee health resources. It will be important to continue to observe the potential impact of SFA during non-pandemic times as it has been used as a resilience-building, prevention strategy in military and first responder settings. It is possible that in less critical times, the impact on the more distal outcomes would be easier to observe because there would be fewer competing stressors. Further, results support the need to investigate implementation, dissemination and sustainability indicators as those will be integral in wider adoption of the model.

Acknowledgments

We would like to express our gratitude to the healthcare providers for their unwavering commitment to their work. We thank them for their partnership in the Stress First Aid program.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, M.H.B., D.B., P.D., M.B.M., M.S., L.T., A.W.-M., P.W., R.J.W. and R.M.S.; methodology, H.M.C., P.S., G.Z. and R.M.S.; software, G.Z. and R.M.S.; validation, R.M.S.; data curation, G.Z. and R.M.S.; writing—original draft preparation, M.H.B., H.M.C., P.S. and R.M.S.; writing—review and editing, M.H.B., H.M.C., P.S., D.B., P.D., A.G., M.B.M., M.S., L.T., A.W.-M., G.Z., P.W., R.J.W. and R.M.S.; visualization, H.M.C. and G.Z.; supervision, M.H.B., M.S., L.T., P.W., R.J.W. and R.M.S.; project administration, M.H.B. and A.G. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Ethical review and approval were waived for this study based on the determination that it constitutes non-human subjects research, specifically focusing on quality improvement-oriented programmatic evaluation.

Informed Consent Statement

Informed consent was waived as the study primarily focused on the analysis of existing program evaluation data and was determined to be non-human subjects’ research.

Data Availability Statement

Conflicts of interest.

The authors declare no conflicts of interest.

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