Interventions for Improving Health Care Workers’ Retention in Epidemics – a Scoping Review

Introduction: Generally, in Epidemics, such as COVID-19, health care workers (HCWs) faces many problems which lead to a shortage and weakening of human resources in the health system. Therefore, using effective strategies to retain human resources is one of the most important issues during outbreaks. This study aims to collect and classify the proposed interventions to strengthen human health resources and their sustainability during epidemics through scoping review. Methods: In this scoping review study, 2300 studies were retrieved through searching international databases –PubMed, Embase, Scopus and Web of Science. The retrieved studies were screened, and nally, 50 studies were included for analysis. The strategies were classied using inductive qualitative content analysis. Results: Most of the studies were conducted in the United States and the United Kingdom. The target population in 39 studies was all health workers; ve studies were on physicians, ve studies on nurses, and only one study on dentists. The proposed interventions were classied into ve categories: preparation, protection, support, treatment, and feedback. Discussion: Most studies focused on providing interventions in one or two dimensions of human resources, but these interventions were summarized and categorized in this review. Therefore, this study has a holistic view of various dimensions of strengthening and maintaining human health resources during epidemics by providing a thematic map. Considering that human beings are multidimensional, policymakers and managers of the health system should use a set of interventions that simultaneously cover different aspects of their needs to strengthen and maintain HCWs.


Introduction
During the spread of epidemic diseases, many physical and psychological stress affect healthcare workers (HCWs) (1). Stress, anxiety, depression, insomnia, anger, and fear are just a small number of reported injuries among HCWs worldwide (2,3). According to published reports, nearly 7,000 HCWs have died from the Covid-19 pandemic (4). Although that HCWs account for about 1-3% of the population in different countries, about 14% of the Covid-19 cases reported to the World Health Organization were HCWs. Also, in some countries, this ratio can be up to 35% (5). On the other hand, human resources play a vital role in creating resistance and resilience of communities and health systems in response to various natural and human crises. Typically, the aftermath of such events is an increase in HCWs' mortality, injury, disease, and the overall weakening of human health resources (6). Besides, work challenges and psychological stress due to increased workload, lack of personal protective equipment, observation of death of colleagues and patients, fear of contracting and transmission of disease to the family, tolerating quarantine and social isolation, moral dilemmas of prioritizing the allocation of drugs and hospital equipment and making decisions for patients in the absence of their family members put double pressure on the medical staff (3,(7)(8)(9)(10)(11)(12)(13)(14)(15)(16).
In this situation, many HCWs decide to leave their job. This problem has been reported in the United States (17) and is expected to worsen in low-income countries (18). HCWs' death, infection, or their decision to leave their job leads to a shortage of service providers. This vicious cycle puts renewed pressure on the present human resources, leading to the organization's collapse (19,20). Therefore, one of the most critical interventions during epidemic diseases is to try to maintain and strengthen the human health resources; so that the health systems do not face a shortage of health service providers (21). Although many scattered suggested or experienced interventions -to strengthen and sustain human resources in the outbreak of epidemic diseases -have been recommended, it seems that a comprehensive study has not been done in this regard. This study aims to collect and classify the proposed intervention to strengthen human health resources and their sustainability in the face of epidemics using the scoping review method.

Method
In this scoping review study, we aim to determine the extent, range, nature of research activities, summarizing and presenting their results in strategies to strengthen and sustain the HCWs during the outbreak of epidemic diseases (22). Scoping review was chosen as a preferred method because of the lack of comprehensive studies in this eld and the extended domain of the research question. For this purpose, the 5-step framework proposed by Arksey and O'Malley in 2005 has been used. These steps are as follows: 1) identifying the research question and the purpose of the study, 2) searching for related studies, 3) selecting studies, 4) charting data, and 5) collating, summarizing, and reporting the results (22).

Search strategy
The research question was "What are the strategies to strengthen and sustain HCWs during the outbreaks?". To nd the answer, the search was conducted on the international databases including PubMed, Embase, Scopus, and Web of Science. The research question was divided into three areas of strengthening and sustainability, health workforce, and epidemics. After initial searches, related studies were reviewed to select the nal keywords for search. The details of search strategy and keywords are as shown in Table 1, which resulted in retrieving 2386 papers.   1) The simultaneous presence of three areas of strengthening and sustainability, epidemics, and human health resources 2) Suggesting intervention(s) or recommendation(s) At this stage, to reduce the possibility of error, all the titles and abstracts of the studies were reviewed by two researchers independently (A.J. and Z.Z.). In case of disagreements, the nal decision were made according to the third researcher's (S.V.) opinion. Out of 59 selected studies, three were excluded due to inaccessibility of the full text and eight due to being unrelated to the research question. Finally, by adding two studies from hand searches, the nal 50 studies were included. A summary of this process is shown in Figure 1.

Data extraction and analysis
After reviewing the nal selected studies, their related ndings were summarized in a table available in the appendix. The table includes the title of the research, country, type of study, focus/purpose, and related ndings in the studies. Thematic analysis method had been used to categorize and integrate the obtained results (23).

Results
In this study, the results of articles that provided interventions to retain and sustain human resources in epidemics were reviewed. Most of the studies were conducted in the late second decade and the era of the Covid-19 pandemic. As well, most studies were conducted in the United States and the United Kingdom. Among them, the study population in 39 studies were general HCWs, ve studies of physicians, ve studies are dedicated to nurses, and only one study is about dentists. This data, with other features of included studies, can be seen in Table 2. The suggested interventions were categorized by thematic analysis into 15 sub-themes from ve themes of preparation, protection, support, care, and feedback (Table 3). Also, in some reviewed articles, the proposed interventions were presented in the form of a model. The Witness to Witness (W2W) model in the United States during the Covid-19 pandemic (24) and the The Anticipate, Plan and Deter(APD) model in Africa and China (25) during the Ebola and Covid-19 pandemics simultaneously cover training and psychological support sub-themes. Therefore, the models do not require extensive infrastructure to implement. • Providing easy access to healthy water and food for HCWs (13,29,36,39,47,54) Professional support • Establishing explicit, effective, and honest communication from the manager with the staff (9, 10, 27, 39) • Delegation of powers for decentralized decision-making (7) • Involvement of HCWs in the decision-making process (9) • Sending supportive and motivational messages to patients, managers, and prominent social activists (29,30,50) • Establishing organizational justice and creating a exible organizational culture (10,11) • Rewards and nancial support (10,11) • HCW support during disputes with patients' families (17) • Facilitating communication between the patient and his family to reduce the workload caused by the supportive role of the treatment staff (34)

Theme Subthemes Interventions
Smart human resource utilization • Developing a clear and realistic plan to reduce workload (7,15,27,30) • Organizing volunteer forces to compensate for labor shortages (13,28) • Strategic distribution of human resources by reviewing the work shift program (13,37,39) • Using a support team consisting of specialists ready to work in various elds, including palliative medicine and dental team (1,17,26,55) Care Providing psychological care services • Using health applications to provide medical services(38, 56) • Holding group therapy sessions and using special treatment techniques such as CBT (9,29) • Retraining counselors and psychologists and teach them treatment techniques to provide adequate human resources (9) Providing nonpsychological care services • Prioritizing HCWs and their families in treatment and drug allocation (17) • Providing services through narrative medicine (9) Feedback Getting Active feedback Providing remote care with telemedicine can reduce physicians' risk of infections by creating social distance and preventing the hospital from crowding. This platform provides the initial screening and treatment of patients without the presence of a physician (9, 12, 44-46).

Revising and adjusting work shifts
One way to reduce the shortage of HCWs during a pandemic is to use sta ng models that take disease epidemiology into account (1). Furthermore, to minimize casualties in the medical staff, the strategic distribution of human resources and not using vulnerable people (elderly, people with underlying diseases, etc.) in the front-line is recommended (1, 28, 32, 37).

Early detection
Monitoring the HCWs' infection status for early diagnosis and considering measures for quarantine of positive and suspicious cases is one way to take care of the health status of HCWs (1, 21, 48).

Organizational psychological support
In order to reduce burnout and fatigue, it is useful to gather a specialized psychological team (consisting of psychologists and psychiatrists) to care for front-line staff. In some studies, setting up hotlines (31,38,41,52) and telemedicine (13) to communicate with this team has been suggested (24-27, 36, 50, 51). Other organizational psychological support includes: celebrating patients' recovery, allocating space to keep alive the memory of dead HCWs, allocating centers for caring for HCW's children during school closures(36, 47), and holding breathing sessions to reduce work stress (3).

Peer support
In order to reduce the psychological burden caused by crises, it is necessary to create a communication network and a cordial atmosphere between HCWs in order to support each other, increase interactions between them and express sympathy. This network also provides peer support during quarantine (

Welfare support
The physical health of HCWs in epidemics and their well-being seem essential. Therefore, providing basic needs such as break time and restrooms, su cient time off, and easy access to water and food has been suggested (13, 14, 26, 29, 35, 36, 39, 47, 54).

Professional support
Establishing explicit, effective, and honest communication from the manager with the HCWs causes and increases security, unity, teamwork (37), and resilience in the HCWs. (9,10,27,39) In this regard, HCWs involvement in the decision-making process and delegating the necessary authority for decentralized decision-making are suggested (9,33). Other ideas and methods proposed to strengthen and maintain human resources include sending supportive and motivational messages from patients, managers, and prominent social activists to instill a sense of empathy (29,30,50), establishing organizational justice (such as ensuring tolerable workloads) and creating a exible organizational culture (7, 10), rewards and nancial support (34,57) and supporting HCWs in times of con ict with patients' families (17), Furthermore, to reduce the work and psychological pressure caused by the epidemic on nurses, the possibility of communication between the patient and his family can be facilitated or mediated by someone else, taking this burden off their shoulders. (34)

Smart human resource utilization
Strategic distribution of human resources is essential to compensate for labor shortages, reduce workload, and prevent burnout. To achieve this goal, developing a clear and realistic plan (7,15,27,30), organizing volunteer forces (13,28), revising the work shift program, and taking measures to provide remote care are essential (13,37,39). It is also reasonable to use a support team consisting of ready-towork specialists in various elds, including palliative medicine and dentistry, in emergencies (1,17,26,55).

Providing psychological care services
In the case of psychological trauma, the commitment of managers to provide treatment is critical. Therefore, it is necessary to establish mechanisms to assess and evaluate HCWs' mental health and, consequently, to consider specialized teams for early intervention and treatment of injured people (9,29,31,34,41,53). In this regard, the proposed interventions are as follows: health applications with the possibility of screening and providing specialized medical services for the ones in need (38, 56), holding group therapy sessions (29), and using special treatment techniques such as Cognitive behavioral therapy (CBT) to solve and deal with psychological problems (59). To provide the human resources for these interventions, it is possible to reeducate counselors and psychologists and teach them treatment techniques (59).

Providing non-psychological care services
The two proposed interventions in this sub-theme prioritize HCWs and their families in treatment and drug allocation and provide services through narrative medicine (30,49).

Getting Active feedback
Managers need to be aware of their HCWs' concerns and respond to them accordingly. HCWs expect to be heard and understood. They also expect to be psychologically supported by managers. According to reviewed studies, effective communication with HCWs is a prerequisite for having stable and resilient HCWs (8,57). In this regard, managers' visits of hospital wards (29,34) and getting active feedback for solving the problems have been discussed (17,21,51).

Getting Passive feedback
Setting up hotlines to hear and meet the HCWs' needs and requests quickly and immediately (2,8,32) and creating a communication network to receive feedback are some of the suggested interventions in this sub-theme (23,47).

Discussion
This study aimed to collect interventions for strengthening and sustaining HCWs in epidemics. Most studies have not been conducted in a speci c geographical area, and most of them were on all health workers. In a bird's eye view of the ndings of the study, preparation, protection, and support categories could prevent harm. On the other hand, interventions related to care and feedback categories could be suggested to treat potential injuries to HCWs sustainability. It was found that interventions related to support, preparation, and protection were more than the ones related to the care and feedback categories. This stark difference could suggest the preference of prevention over treatment to strengthen and sustain human health resources. Also, the most frequent subthemes included training programs, protection and equipment provision, professional support, peer support, and the intelligent use of human resources, respectively.
The emergence of a new disease and its rapid spread among different society sections often confront health systems with a new problem that they have not encountered before. In such a situation, preparing the system and its staff to face the new circumstance seems vital. Staff preparation is the only way to reach this goal. On the one hand, in an epidemic situation, physicians and nurses need to learn up-to-date knowledge related to the disease. On the other hand, due to this period's high workload and psychological stress, the staff must be educated in different subjects such as positive lifestyle and individual resilience (31). In this regard, it is possible to provide suitable educational packages for different HCWs in the form of digital packages (42). Also, due to the increasing development of social networks in communities, using this platform to share HCWs' experiences in different parts of the world seems useful (8, 26).
Because HCWs are at the front-line of ghting epidemics, they can become infected at any time. Therefore, one of the practical and emphasized strategies is to Protect HCWs and reduce their risk of disease infection. In these circumstances, personal protective equipment (PPE) is one of the HCWs' essential needs (32). Another useful issue in this theme is the early detection of infected HCWs. For example, in Singapore's largest medical hospital, a three-stage pilot model includes establishing a self-reported reporting system based on HCWs with suspicious symptoms, identifying and screening groups in contact with suspected cases, and starting quarantine besides the necessary treatment which has been performed for infected HCWs. The model's results indicate this process' effectiveness: the covid-19 tests of only 14 HCWs were positive among 4,411 hospital staff over 16 weeks. In addition, telemedicine, by reducing face-to-face visits to clinics and providing high-quality medical services, can reduce the chances of disease transmission among HCWs (45). This strategy also plays an in uential role in the themes of support and treatment by reducing the workload and facilitating the provision of medical services to the health personnel in need (21). However, the high cost, the need for building multiple infrastructures, the possibility of system disruptions, and the current workforce's resistance are some of the limitations of this intervention (46).
Although how human health resources prepared to cope with the new outbreak and to take protective measures to reduce their risk of disease are important, we still cannot expect any of them to be able to withstand the workload alone, without the need to receive special help and support of the organization, managers, and colleagues. Therefore, most of the proposed interventions are in the theme of support of health care workers. Human health resources in epidemics need various types of support, including psychological, welfare, and professional, and the responsibility of providing these needs rests on managers' shoulders. The existing workload has psychological consequences that cannot be dealt with except by managers' action to form teams of psychological experts and provide counseling services to HCWs.(26) Also, HCWs can help and support each other independently of their managers to reduce the stress of these problematic situations (39); Undoubtedly, the role of management in creating such a supportive culture and sincere atmosphere cannot be ignored. Another signi cant intervention is the intelligent use of human resources and their strategic distribution by reviewing HCWs' work shift schedules and considering the recruitment of volunteer workers.(28, 37) Given that in the theme of HCWs support -especially psychological -many interventions have been proposed and implemented, it is recommended to conduct systematic review studies in this eld.
As mentioned above, the proposed interventions in the three themes of preparation, protection, and support of HCWs are more in line with preventing injury. Despite these measures, some HCWs suffer from severe injuries to the point that they get physical or mental illnesses. Meanwhile, caring for mental injuries, which is more common than physical problems and more challenging to diagnose, should be given more attention. Additionally, prioritizing medical facilities for the HCWs' families can be an effective measure in this theme.(58) If we have a systematic point of view on the strengthening and sustainability of human resources, one of the special components of this subject is constant feedback from the situation. It is necessary to get feedback to gain awareness of the current situation, evaluate the implemented strategies, and apply alternative strategies appropriate to the circumstance. Another essential point is that feedback should not be a cross-cutting action and is implemented as a permanent process. Therefore, it is recommended to facilitate this process with proposed interventions to receive feedback, both actively and passively. This theme is considered a complementary arm and a tool for evaluating the interventions in other themes.
One of the practical interventions to getting feedback, which seems to have desired feasibility and at the same time does not require much cost and infrastructure, is setting up a hotline (8, 32) to hear the HCWs' needs immediately and provide consulting services to them. To implement this strategy, it is necessary to consider issues such as the existence of a transparent communication program, providing the required human resources, and considering the principle of con dentiality (2).
Conducted studies generally offered various interventions in a scattered manner. But, in this study, as one of our main strengths, we summarized and put together these interventions by providing them in the form of a thematic map and categorized model. Furthermore, because humans seem to be multidimensional beings with different needs, most studies have usually focused on one or two aspects of strengthening and maintaining human resources, whereas we tried to take a more comprehensive look at this issue. Therefore, the results of this study are likely to help policymakers to design more effective programs for strengthening and sustaining human health resources during epidemics, to meet the various needs of different dimensions of human existence.
One of the exciting points in reviewing this set of studies is the contradiction in some of the ndings. For example, in a study conducted by Elsafty et al. in Egypt (57), nancial incentives have been suggested as an effective way to strengthen and sustain human resources in the face of epidemics; In another study by Martin et al. in the United States, increased pay harmed HCWs' willingness to attend work (43).
Finally, it is recommended that researches can be conducted to evaluate the feasibility of the interventions and determine their effectiveness. It is also necessary to conduct cost-effectiveness studies due to limited resources such as human resources, time, and budget. On the other hand, given that most studies have been conducted in high-income countries, it is recommended to evaluate the feasibility and e ciency of available interventions in lower-income countries. Furthermore, conducting systematic review studies to analyze con icting ndings and conducting studies to provide interventions that simultaneously cover more themes of preparation, protection, support, care, and feedback are suggested.

Limitations
Overall, although a rich set of ideas and interventions have been proposed to strengthen and sustain human resources, most of these interventions have not been implemented or, if implemented, the details of the required infrastructure and implementation process are not mentioned. Lack of long-term assessment of interventions' effects, a control group, and cost-effectiveness studies were other limitations of the existing studies.

Conclusion
In this study, strategies to increase the sustainability of human resources in pandemics were summarized and presented. According to the analysis, the interventions were classi ed into ve themes (preparation, protection, support, care and, feedback) and 15 sub-themes (creating communication networks, providing education programs, telemedicine, protective measures, and equipment supply, revising and adjusting work shifts, early detection, organizational psychological support, peer support, welfare support, professional support, smart human resource utilization, providing psychological care services, providing non-psychological care services, getting active feedback, and getting passive feedback). Finally, it seems that to strengthen and sustain human resources in the face of epidemics, we must pay attention to various dimensions. Therefore, taking action in each of these themes cannot be helpful independently. It is recommended that managers and decision-makers implement strategies that cover more themes and are adjusted to their context.

Declarations
Ethics approval and consent to participate Not Applicable.
Adherence to national and international regulations Not Applicable.

Consent for publication
Not Applicable.

Competing interests
The authors declare they have no competing interest regarding to this research