Sharon A. M. Stevelink

Background: Healthcare can be a demanding career, and there is a rising interest in fostering the well-being of healthcare workers (HCWs). Aims: To examine self-reported use of mental health and well-being support available to HCWs and explore predictors of use. Method: Data were collected by a longitudinal cohort study. The baseline survey was distributed from April 2020, followed by three surveys at 6 months (time 1; n = 10 514), 12 months (time 2; n = 10 429) and 32 months (time 3; n = 6382) post baseline. Use of mental health support (e.g. therapy) was assessed at each follow-up, and 96 supports were measured at time 1 only. Multilevel regression modelling was used to explore baseline predictors. Results: At time 1, we developed seven support categories. Practical supports (e.g. free or discounted food or parking) were the most commonly used (58%), whereas employee assistance programmes were least commonly used (5%). Furthermore, 21% of HCWs reported never using any support. Mental health support access varied: 23% of participants had used support before August 2021 (time 1), 17% between March 2020 and January 2022 (time 2), and 21% between February 2022 and May 2023 (time 3). HCWs who were male, older and/or of Asian ethnicity had lower odds of accessing support, whereas those who reported symptoms of common mental disorders at baseline had higher odds. Conclusions: Most HCWs (79%) reported having accessed some support, whereas 21% had not. Practical and informal supports were most used, whereas uptake of employee assistance programmes was low. Future research should explore and address barriers faced by male, older, Asian and non-permanent staff to improve access and, in turn, the well-being, performance and patient care of these individuals.

BackgroundEvidence on the health of UK military veterans in primary care remains limited, particularly beyond England. Using the Clinical Practice Research Datalink (CPRD), this study identified veterans registered with primary care practices across England, Wales, Scotland, and Northern Ireland, providing the first UK-wide assessment of veterans' demographic characteristics, physical and mental health conditions, healthcare utilisation, and recording practices.MethodsA population-based cohort study was conducted using CPRD Aurum and Gold (January 1987-July 2024), the UK's largest primary care databases. Veterans' sociodemographic characteristics, health risk factors, physical and mental health conditions, healthcare utilisation, and data completeness were described across all four UK countries. Descriptive statistics were presented, and adjusted Poisson regression models examined associations between countries and recorded health conditions.FindingsParticipants comprised 132,086 veterans, most registered in England (122,363; 92·64%). The remainder registered in Wales (5,072; 3·84%), Scotland (4,364; 3·30%), and Northern Ireland (287; 0·22%). Veterans in England, Wales, and Scotland had similar demographic and health profiles. Lower back pain (6·67-11·72%) and depression (6·78-10·78%) were among the most frequently recorded conditions. In contrast, veterans in Northern Ireland had a younger and more gender-balanced demographic profile and reported higher levels of lower back pain and depression (19·16-19·51%).InterpretationThis study demonstrates the value of combining CPRD Aurum and Gold to support UK-wide veteran health research and cross-national comparisons within primary care. Veterans in England, Wales, and Scotland had broadly similar demographic and health profiles. Differences observed in Northern Ireland suggest variation in healthcare delivery, clinical coding practices, or veteran population characteristics. Estimates for Northern Ireland should be interpreted with caution due to the small sample size. These findings support the potential for CPRD to facilitate investigations of regional inequalities in veteran health, as well as longitudinal analyses of healthcare needs.FundingThis research was funded by Forces in Mind Trust (FiMT21/1023KCL).

Background: Moral injuries (MIs) may result from individuals being exposed to potentially morally injurious events (PMIEs). PMIEs have been a feature of work within much of the National Health Service (NHS) for many years, and the understanding of MI is now more commonplace, having been highlighted during the COVID-19 pandemic; however, understanding of how such events affect workers over the long term is lacking. Objective: To understand the development of healthcare workers’ (HCWs) experiences of PMIEs over a period of 3 years. Design and participants: We carried out follow-up semistructured qualitative interviews with 15 NHS staff who were previously interviewed on the same topic in 2021. All interviews were recorded, transcribed and analysed using reflexive thematic analysis following an inductive approach. Results: Three main themes and six subthemes were identified: (1) internal context and subjective experiences, (1.i) control in a rigid system, (1.ii) psychosocial dynamics, (2) external context and the moral cost of culture, (2.i) organisational culture, (2.ii) sources of MI, (3) responses to PMIEs, (3.i) maladaptive responses, (3.ii) adaptive responses. Key issues identified included perceptions of insufficient control over their work and work environment, low psychological safety and perceived misunderstanding of the value of their work from patients and colleagues, leading to a challenging organisational culture. We found that in the 3 years between the interviews many staff reported developing ‘secondary’ feelings of betrayal as a result of perceived ongoing governmental neglect of recognition for HCWs’ sacrifices during the pandemic and a lack of acknowledgement of governmental mistakes made in the acute period. Conclusion: Findings show an interplay between individual and organisational factors that HCWs faced while working in the NHS, underlining the need for wide-ranging intervention strategies. Since the HCWs’ original interviews in 2021, a secondary betrayal has developed, emphasising the need for interventions that can restore trust in the system.

Background: Moral injury (MI) can arise when individuals experience events that violate their moral beliefs. During the COVID-19 pandemic, MI gained attention among healthcare workers (HCWs). Reflective practice (RP) may help prevent or mitigate MI but remains underexplored. This narrative review examines existing literature on RP interventions addressing MI in HCWs. Aims: To synthesize existing literature on RP interventions to prevent or mitigate MI in HCWs. Methods: A semi-structured literature search was conducted in July 2024 and updated in August 2025 across four databases. Twelve studies evaluating RP interventions, including three studies identifying barriers to RP, were included. Across the 12 studies, the sample size was n = 793, involving nurses and other HCWs. Results: Most studies implemented structured workshops combining RP with psychoeducation and group discussion. Of the studies, 11 studies lacked control groups, three used pre-/post-test designs, while others relied on self-reported helpfulness. These studies provided preliminary evidence for the feasibility and perceived value of RP in addressing MI. The only study with a control group was limited by a small sample size, and the results were non-significant. Reported barriers to implementing RP included individual-level factors (e.g. lack of experience) and institutional obstacles (e.g. limited managerial support). Conclusions: Findings suggest RP holds promise as an intervention for MI in HCWs. However, the evidence base is limited by small samples and weak study designs. Further research using robust methodologies, including randomized controlled trials (RCTs) and longitudinal studies, is needed to evaluate RP across diverse HCW roles, including administrative staff.

Background: The COVID-19 pandemic raised concerns about the mental health of an already burdened healthcare workforce. This study examined mental health trajectories among healthcare workers (HCWs) across the pandemic and identified personal and employment factors associated with different symptom patterns. Methods: Longitudinal data were drawn from the NHS CHECK cohort, including clinical and non-clinical staff from 18 NHS Trusts in England (April 2020–April 2023). Growth curve and growth mixture models identified latent classes of HCWs characterized by distinct trajectories of probable common mental disorders. Secondary outcomes included anxiety, depression, alcohol misuse, and post-traumatic stress symptoms. Logistic regression examined associations between baseline personal and employment characteristics and class membership. Results: The analytical sample included 22,764 participants. For each outcome, growth mixture models identified two latent classes. Approximately 31% of HCWs experienced persistently high symptoms of probable common mental disorders, while 69% experienced persistently low symptoms. Similar patterns were observed for secondary outcomes, with small subgroups demonstrating worsening symptoms followed by improvement. Logistic regression analyses showed that being female, younger, single, working as a nurse, or having a pre-existing mental health diagnosis increased the odds of belonging to a high symptom class. Perceived support from colleagues and managers was protective. Conclusions: While many HCWs reported consistently low mental health symptom levels, almost a third belonged to a latent class characterized by persistently high symptoms across all time points. These findings underscore the need for mental health support for vulnerable HCW groups, embedded within routine NHS practice rather than limited to crisis periods.

Structured Background: Post-Traumatic Stress Disorder (PTSD) is a mental health condition affecting people who experience traumatic events. Trauma-exposed occupational groups report higher rates of PTSD than the general population. Current treatments, and access, often take months and may cause distress when people are required to talk about the trauma. Objective: To determine the proof of concept of FIRST, a brief, non-trauma focussed therapy, in two separate populations with employment-associated PTSD. Method: Two independent, single-arm, experimental therapy pilot trials were conducted. Trial one recruited 20 military veterans who received FIRST therapy via trained third-sector therapists. Trial two recruited 16 health and social care workers with FIRST therapy delivered by healthcare provider therapists. All participants were adults with PTSD (confirmed via CAPS-5 in trial one, and symptom score of ≥33 on the PCL5 in trial two). Primary outcomes were recruitment feasibility, retention, data quality and reduction in PTSD symptoms. Secondary outcomes were anxiety and depression symptoms, daily life functioning and perceived health status. Veterans were followed up at 12 weeks post-enrolment and healthcare workers at 8 weeks. Results: The veteran trial progression criteria to main trial were met. Seventy-nine people screened eligible, 43 attended a CAPS-5 assessment; 20 had confirmed PTSD and were enrolled. Seventeen completed therapy and 12-week outcome measures. Mean PCL-5 scores decreased from 48.7 (SD = 13.02, n=20) at baseline to 23.5 (SD = 15.30, n=17) at 12-weeks. The healthcare worker trial obtained informed consent from 16 participants, 10 commenced therapy and were included in analysis with eight completing therapy. Mean PCL-5 scores decreased from 42.60 (12.23, (n=10) at baseline to 22.00 (19.92, n=8) at 8-weeks. Conclusions: Proof of concept of FIRST was established. PTSD symptom reductions exceeded the PCL-5 minimal clinically important difference. Undertaking a fully powered randomised controlled trial of FIRST therapy is feasible within both healthcare and third sectors. Highlights: Post-traumatic stress disorder (PTSD) is more common in military veterans and health workers than the general population Therapy can be challenging to commence and complete when it requires a focus on the trauma incident FIRST offers a promising, brief, non-trauma focused therapy for the treatment of PTSD

Background: Exposure to trauma is associated with poor mental health, but little is known about how trauma profiles differ between ex-servicewomen and civilian women. Differences in trauma exposure may arise before, during, and after military service. Objective: To characterise trauma profiles in ex-servicewomen and civilian women in the UK using separate latent class analyses, and to examine associations between trauma class membership and mental health outcomes within each group. Methods: Data were drawn from the UK Biobank and stratified by serving status. Ex-servicewomen (n = 446) were compared with civilian women (n = 54,068). Within each group, sixteen lifetime traumatic experiences were assessed, and latent class analysis was applied to identify trauma profiles. Multinomial logistic regression examined associations between class membership and sociodemographic characteristics, and logistic regression assessed associations between trauma classes and mental health difficulties. Results: Five trauma classes were identified for both ex-servicewomen and civilian women. Ex-servicewomen were less likely than civilians to belong to the low-trauma class (33.0% vs 62.8%) and reported higher exposure to childhood trauma and intimate partner violence. Among civilians, all trauma classes were associated with elevated odds of depression, anxiety, self-injurious thoughts and behaviours (SITB), as well as reduced meaning in life. Among ex-servicewomen, associations were less consistent; only severe cumulative trauma was linked to all adverse mental health outcomes, while other classes showed no differences in anxiety compared to ex-servicewomen with low trauma exposures. Conclusion: Trauma profiles and their mental health correlates differ between ex-servicewomen and civilian women. These differences may reflect early life vulnerabilities, military experiences, and post-service exposures. Although ex-servicewomen reported higher levels of trauma, the associations between trauma classes and mental health were less pronounced than among civilians. Highlights: Ex-servicewomen showed substantially higher prevalence of trauma exposure compared to civilian women, with the greatest differences in childhood adverse events and intimate partner violence Separate latent class analyses identified five distinct trauma profiles in both groups, with ex-servicewomen considerably less likely to belong to the low-trauma class than civilian women (33.0% vs 62.8%). The association between trauma exposure and mental health outcomes was less consistent among ex-servicewomen than civilian women, suggesting that military service may involve resilience factors that moderate the trauma–mental health relationship.

Objectives Twenty years since the start of UK Armed Forces participation in the Iraq and Afghanistan conflicts post-2001, the extent to which these deployments continue to impact mental health outcomes and alcohol misuse in UK military personnel is unknown. This is the reporting of the fourth phase, cross-sectional study of a longitudinal cohort study that has assessed the health and well-being of UK serving and ex-serving personnel since 2004. Methods Participants were eligible for the most recent phase (2022–2023) if they took part previously (2014–2016) and consented to recontact. Primary outcome measures included symptoms of common mental disorders (CMD), such as depression and anxiety, probable posttraumatic stress disorder (PTSD), complex PTSD (C-PTSD) and alcohol misuse. Results In the overall sample (n=4104, response rate=54.6%), CMD were the most prevalent outcome (27.8%), followed by probable PTSD (9.4%) and alcohol misuse (8.4%). The majority of PTSD experienced met the criteria for C-PTSD (72.7%). Ex-serving Regulars compared with serving Regulars reported a higher prevalence of PTSD (10.5% vs 7.4%, adjusted OR (AOR)=1.68, 95% CI 1.12 to 2.51) and C-PTSD (6.5% vs 3.9%, AOR=1.80, 95% CI (1.07 to 3.05); a higher prevalence of both disorders was also reported in serving/ex-serving Regulars whose last deployment to Iraq/Afghanistan was in a combat role. Conclusion Although the majority of those who deployed to Iraq or Afghanistan remain well, there is an enduring impact of combat deployment on PTSD. Attention should continue to be directed towards the prevention, early detection and treatment needs of this cohort.

Objectives: To examine differences in physical health conditions among female veterans compared with male veterans and female civilians. Design: Cohort analysis using data from the UK Biobank, incorporating self-reported and hospital-derived health information. Participants: Veteran status was identified using Standard Occupational Classification codes. The study included female veterans (n=546), male veterans (n=2722) and female civilians (n=66 305). Outcome measures: Physical health conditions were identified through self-report and hospital records. Multivariable logistic regression models estimated associations between veteran status and selected health conditions, adjusting for age, sociodemographic factors, time in service, body mass index and current smoking status. Results: Compared with female civilians, female veterans had increased odds of chronic obstructive pulmonary disease (adjusted OR (aOR) 1.79, 95% CI 1.04 to 3.08) and lower odds of hypertension (aOR 0.74, 95% CI 0.59 to 0.93), with no significant difference in musculoskeletal conditions or osteoarthritis. Compared with male veterans, female veterans had significantly higher odds of osteoarthritis (aOR 1.61, 95% CI 1.25 to 2.08), migraine (aOR 2.63, 95% CI 1.66 to 4.19) and thyroid disorders (aOR 4.42, 95% CI 2.83 to 6.89). Conclusions: Female veterans have distinct physical health profiles, including a greater burden of musculoskeletal and respiratory conditions compared with male veterans and female civilians. These findings highlight the need for targeted prevention and clinical interventions for women with a history of military service.

Background: Moral injury (MI), characterized by psychological distress from morally transgressive events, has been predominantly studied in military personnel but has gained increased attention in healthcare workers (HCWs) since the COVID-19 pandemic. Sources of data: In this review, we narratively synthesize literature on the causes, risks, consequences, and interventions of MI in HCWs. Areas of agreement: There is consensus that the COVID-19 pandemic presented HCWs with unique challenges such as fear of infection and patients dying without family, which increased the risk of MI in HCWs. Areas of controversy: Broader healthcare experiences, not unique to a pandemic, are less well understood. In this review, we discuss evidence of such experiences including restrictive practices in psychiatric settings and experiences of discrimination. Growing points: Recent studies have highlighted the importance of addressing MI through organizational change, training, and peer support initiatives. Emerging evidence also underscores the need to consider broader systemic factors, such as workplace culture and leadership, in mitigating MI. Areas timely for developing research: Future research should focus on longitudinal studies to explore in more detail risk factors for MI in HCWs. Additionally, there is a need for robust evaluations of interventions to prevent and treat MI and related disorders, including randomized controlled trials. Investigating the morally injurious effects of systemic issues like understaffing is particularly urgent as the field evolves beyond pandemic-specific challenges.