Healthcare Support Workers Research Articles

Positive impact of a telemedicine education program on practicing health care workers during the COVID-19 pandemic in Ontario, Canada: A mixed methods study of an Extension for Community Healthcare Outcomes (ECHO) program

Introduction In addition to shifting and expanding clinical responsibilities, rapidly evolving information and guidelines during the COVID-19 pandemic has made it difficult for health care workers (HCW) to synthesise and translate COVID-19 information into practice. This study evaluated whether a COVID-19-specific telemedicine education program (ECHO COVID) would impact health care workers’ self-efficacy and satisfaction in the management of patients with COVID-19. Methods A prospective mixed methods parallel-design study was conducted among ECHO COVID participants using pre-post questionnaires and a focus group discussion. Questionnaire results were examined for changes in health care workers’ self-efficacy and satisfaction. Focus group discussion data were analysed to explore health care workers’ experience in ECHO COVID and the context of their practice during the COVID-19 pandemic. Results 239 health care workers registered in ECHO COVID and 114 (47.7%) completed questionnaires and attended at least one ECHO COVID session. Median self-efficacy scores increased from 5 (IQR 4–6) to 6 (IQR 6–6) (p < 0.0001), independent of profession, years in practice, age group, or practice environment. Participants were highly satisfied with ECHO COVID sessions with a median score of 4 (IQR 4–5). Focus group discussion data indicated that health care workers gained knowledge through ECHO COVID and revealed facilitators for ECHO COVID program success, including the transition to virtual care, the practicability of knowledge provided, and a ‘perspective from the trenches.’ Discussion This study demonstrated that a telemedicine education program aimed to support health care workers in managing patients with COVID-19 had a positive impact on health care workers’ self-efficacy and satisfaction. This impact was specifically mediated by the ECHO COVID program.

5 Core Care Skills Simulation Training for Undergraduate Medical Students

Throughout the coronavirus pandemic, healthcare professionals have needed to rapidly adapt to changing demands. For some, this has involved adapting a ‘task-sharing’ approach which means that professionals undertake tasks that are not usually considered part of their job role, for example, Junior doctors giving medications and many were ‘redeployed’ completely to areas of greater need. In the same vein, the role of the medical student was expanded and explored and some medical students were given the opportunity to undertake paid work as healthcare support workers (HCSWs). It can be argued that the education and training of medical students are heavily focussed on a medical model of healthcare and often lacks depth insight into the caring aspects of patient care.The aim of the study was to create an interactive practical care skills simulation training aimed at medical students.We designed a practical simulation training programme based around the ‘fundamentals of care’ as defined by the nursing and midwifery council Early versions of this course were used as part of a comprehensive induction programme that included testimony from HCSWs working within the site hospital, who were able to share real-life experiences and offer peer support. This helped influence the development of this course to shape it into an innovative multi-disciplinary training. The training course was developed reactively to meet the developing need of students to prepare for redeployment by April of 2020 and since then has grown and developed into the half-day simulation training that is outlined above. It has now been incorporated into the in-hospital clinical skills curriculum for third-year medical students passing through the trust on the understanding that, this course has helped medical students to better understand the role of other professionals and will enable closer multi-disciplinary working in future. Anecdotally, it is obvious from interacting with students that there is a need to incorporate training in basic care into the medical curriculum to prepare students for task-sharing in the future as well as to better understand the caring professions and improve multi-disciplinary working. However, there is not enough post-course data to establish a true effect from this course at present. We continue to run this training course as part of the year 3 undergraduate clinical skills programme and aim to collect more survey data to evaluate and adapt it.

Strategic Framework for Strengthening Health System Response to Covid -19 Pandemic

The novel Covid-19 pandemic has emerged a new sequel of distributing scarce resources according to a critical triage system and has put the healthcare management into a greater difficulty in allocating resources. Different countries have addressed these issues in different manners but highlighted on having a good response framework. The Covid operation cell was established during the first wave of Covid-19 in Base Hospital Horana and it was consisted of all relevant stakeholders. It was expanded during the second wave and the functions were done according to the strategic response framework. Decisions were made through several subcommittees. The framework outlined the objective of addressing issues on resources management in health care services at the Base Hospital Horana and to propose strategic actions to strengthen health care services during the Covid-19 pandemic. The strategic response framework included institutional policies, continuation of patient care, human resource management, logistic management, caring and emotional support for Health Care Workers (HCWs) and environment cleanliness. Most of the developments within the hospital were done to continue healthcare services to the patients while safeguarding the staff. The outcome of the response framework was to give the maximum service for patients without any intra-cross infections among HCWs.

COVID-19 vaccine hesitancy and anti-vaxxers – supporting healthcare workers to navigate the unvaccinated: Reflections from clinical practice

An important step in preparation for the fourth COVID-19 wave is to provide healthcare workers (HCWs) with skills to facilitate behaviour change in vaccine-hesitant patients. Convincing members of the public who are vaccine hesitant rather than anti-vaxxers should be the focus of our efforts. Our experience is that vaccine-hesitant individuals and anti-vaxxers are generally distinct cohorts, with differing reasons for their vaccine reluctance. If we are to truly address hesitancy, we must take time to understand the reasons for an individual’s hesitancy. Developing a conceptual framework and skills for HCWs during encounters with unvaccinated individuals will be important not only for shifting some to get vaccinated, but also to manage the complex emotions that HCWs will undoubtedly be forced to confront during the fourth wave.

In Case You Haven't Heard…

The American Psychological Association (APA) applauded passage of federal legislation to prevent substantial Medicare reimbursement cuts from taking effect next year, and to promote mental health programs aimed at supporting health care workers, according to a Dec. 10 news release. Psychologists and other health care providers had faced millions of dollars in Medicare payment losses starting next year due to the combined effects of three separate, coinciding budget cuts to the program. “We are grateful Congress acted against these proposed cuts that would have put Medicare beneficiaries in peril, people who are older, more isolated and experiencing significant levels of stress due to the COVID‐19 health emergency,” said APA CEO Arthur C. Evans Jr., Ph.D. The Protecting Medicare and American Farmers from Sequester Cuts Act would largely eliminate cuts triggered by Medicare coding structure changes adversely affecting psychologists and would delay the application of other automatic reductions scheduled to take effect Jan. 1.

Understanding career development and progression from a healthcare support worker perspective. Part 1/2

Understanding career development and progression from a healthcare support worker perspective. Part 1/2

Optimizing The Resilience of Healthcare Workers Against The COVID-19 Pandemic

Introduction: During the COVID-19 pandemic, healthcare workers have physical and psychosocial pressure in carrying out their work. The requirement for healthcare workers in dealing with the pandemic is so high, the identification process for the resilience of healthcare workers is not going well. The purpose of this article is to review about how to optimize the resilience of healthcare workers exposed to COVID-19 outbreak working conditions. Methods: This literature review is conducted in October 2021. Research related to the resilience of healthcare workers during COVID-19 Pandemic by using valid keywords, including resilience, healthcare workers, COVID-19 through ProQuest, ScienceDirect and SpingerLink. Results: A total of 10 articles were selected for the literature review. The process of self-reflection is one of the important things for healthcare workers. Optimizing relisience of healthcare workers by carrying out an efficient division of tasks to reduce workloads, give more attention to their needs, provide training and knowledge about digital applications to increase capacity in carrying out their work, provide mental health support for healthcare workers and creating a safe and comfortable work environment for them. Conclusions: Maintaining health during the COVID-19 pandemic is an important thing that needs to be done by healthcare workers. Stress management is an important factor in dealing with a pandemic. Create an assessment of the resilience of healthcare workers by detecting gaps, determining priorities, developing plans to prevent psychosocial hazards at all levels both individual and organizational levels.

Preparedness for Ebola amongst healthcare workers in public health facilities in Nairobi city county, Kenya

Background: The most devastating epidemic of Ebola virus disease (EVD) in Guinea Bissau, Sierra Leone and Liberia in 2014-2021 caused over 11,000 deaths prompting WHO to declare it a public health emergency of international concern. Kenya on its part heightened preparatory measures in eight high-risk counties and at the nationally manned facilities such as Kenyatta national hospital. However, little attention was given to the healthcare workers in periphery public health facilities in high-risk Nairobi-county. This study identified socio-demographic characteristics, risk perceptions and organizational support for health care workers (HCWs) associated with Ebola preparedness in Nairobi-county.Methods: A cross-sectional analytical design and Fisher's with finite correction formula for population &lt;10000 were adopted to sample 165 HCWs performing non-administrative roles from eight health facilities in Kibra. Public health facilities stratified into level 2, 3, 4 strata before subjecting to probability proportionate to size to get the required number from respective cadres. Simple random sampling was used to sample within respective cadres. Qualitative and quantitative data collected and entered in SPSS version 23. Chi-square test used to establish associationsResults: A significant majority (66%) of the HCWs felt unprepared for Ebola. Age and professional cadre found to be significant predictors (p=0.001). HCWs with low perceived risk established to be more prepared for Ebola (χ2=6.854, df=1, p=0.009). Access to hand sanitizers, pairs of gloves, sharing Ebola briefs and preparedness plan contents were established to be associated with preparedness.Conclusions: Socio-demographic, risk perceptions and organizational support for HCWs were established to be associated with Ebola preparedness.

Effects of Acupuncture and Acupressure on Burnout in Health Care Workers: A Randomized Trial.

Health care workers face occupational stressors that may lead to burnout and secondary traumatic stress. Strategies to mitigate the negative psychological impact on frontline workers are urgently needed. The purpose of this study was to evaluate the effect of auricular acupuncture or acupressure, as compared with ear massage, on anxiety, burnout, and caring capacity in health care workers. Results were stratified on the basis of subject's level of belief in traditional Chinese medicine. This prospective randomized trial with an open, parallel-group design was conducted at a 334-bed Level II pediatric trauma center. Participants were randomized to one of three groups: (1) auricular acupuncture, (2) auricular seed acupressure, or (3) auricular massage. Interventions were delivered over 3 weeks. Self-reported State-Trait Anxiety Inventory (STAI), Professional Quality of Life (ProQOL), and Caring Ability Inventory (CAI) scores were analyzed using a pre-/posttest design. Univariate analysis, Fisher's exact test, and analysis of variance (ANOVA) were performed to assess group differences. A total of 117 (36%) of 325 eligible participants consented to participate in the study. Seed acupressure treatment (n = 14, 35.9%, one male, 13 females) was associated with a reduction in burnout (ANOVA, p = .04) and secondary traumatic stress (p = .03). This effect remained significant after adjusting for individual pretest scores (ANOVA, p = .05). The studied interventions did not have a significant effect on STAI, ProQOL, or CAI scores. Auricular acupressure is a safe, effective, and practical strategy to reduce burnout and secondary traumatic stress and may support health care workers' ability to develop caring relationships with patients and families.

The impact of the second victim phenomenon in an Italian Academic Hospital: a cross-sectional study

Abstract Background Adverse patient safety events (AEs) can negatively impact on healthcare workers (HCWs) by causing emotional distress and affecting professional ability. The challenge of healthcare organizations is to support HCWs involved in AEs. This study aims to investigate the second victim phenomenon in a large Italian Academic Hospital (AH). Methods A cross sectional survey was conducted from June to November 2019 involving all HCWs working at the AH of Udine. HCWs' demographic characteristics and answers to the Second Victim Experience and Support Tool, Italian version (IT-SVEST; 29 items representing 7 dimensions and 2 outcome variables; Likert-scale: 1-5) were collected. Higher scores indicated a greater negative impact of the AEs and a perceived inadequacy of support resources. Median (M) and interquartile range (IQR) were assessed for each item. The agreement (AGR) (respondents with a mean score ≥4) was assessed for each dimension. Relationship between items score and demographic aspects was analyzed with non-parametric tests. Results A total of 349 HCWs joined the survey. Women were 79.4% and mean age was 39.4±10.7 years. 58.7% of respondents referred to be involved in a AEs. Lots of HCWs expressed feelings of psychological distress (AGR=26.9%) and less experienced HCWs were more affected by feelings of shame than senior ones (M = 4, IQR=1.5 vs M = 3, IQR=2; p &amp;lt; 0.01). Physical distress (AGR=10.9%) and professional self-efficacy (AGR=11.8%) did not had a great impact on HCWs, but younger (M = 3, IQR=2 vs M = 2, IQR=2; p &amp;lt; 0.01) and female (M = 3, IQR=2 vs M = 2, IQR=2; p &amp;lt; 0.01) HCWs were more inclined to question their skills. Support services offered by Hospital organization may be improved (AGR 8,9%). Conclusions Psychological impact of the AEs is relevant in our cohort and less experienced and female HCWs resulted more inclined to doubt their professional abilities when involved. Improvements in support resources should be desirable to create a safer working environment. Key messages HCWs’ psychological dimension and perceived professional self-esteem can be negatively affected by adverse events, especially for less experienced and female professionals. Healthcare organizations need to develop and to implement a second victim support program designed to provide emotional, psychological and professional support for HCWs.

Supporting Health-Care Workers and Patients in Quarantine Wards: Evidence From a Survey of Frontline Health-Care Workers and Inpatients With COVID-19 in Wuhan, China.

Objective: Frontline health-care workers and patients with COVID-19 have been identified as high-risk groups for psychological problems. Experience of working or staying in quarantine wards generated psychological stressors for health-care workers and patients with COVID-19. The present study aimed to investigate the psychological symptoms of hospitalized patients with COVID-19 and the health-care workers treating them during the outbreak period, examine the effects of psychological stressors on mental health in both populations and perceived coping resources for both sides.Methods: Three hundred and eleven health-care workers working in a COVID-19 designated hospital in Wuhan, China, and 148 hospitalized patients with COVID-19 in the same hospital participated in this cross-sectional survey conducted in February 2020. Psychological symptoms, psychological stressors, and perceived coping resources were reported by both groups.Results: Thirty-three percent of health-care workers and 35.2% of patients with COVID-19 had significant psychological symptoms that were indicative of a high risk for psychological disorders. Pandemic-related psychological stressors contributed to psychological symptoms for both populations. Concern about patients was one aspect of psychological stressors of frontline health-care workers and both groups perceived support from the opposite side as an important external coping resource.Conclusion: The results shed light on the need to provide psychological support to both frontline health-care workers and patients with COVID-19 and suggest enhancing the treatment alliance might be effective to improve mental health for both populations during the crisis.

COVID-19 Pandemic Support Programs for Healthcare Workers and Implications for Occupational Mental Health: A Narrative Review

This narrative review aims to summarize initiatives developed during the COVID-19 pandemic to support healthcare workers’ emotional well-being within the context of a pre-existing framework of occupational mental health guidelines. This occupational mental health framework integrates principles from multiple disciplines to optimize prevention and management of mental health issues among employees. We conducted an online search on Medline/PubMed, Cochrane Library, and Embase for studies that reported on design or execution of medical institution-based interventions, aiming to support healthcare worker mental health during the COVID-19 pandemic. Inclusion criteria was intentionally broad in order to incorporate as many types of interventions at varying stages of development or evaluation. We included 31 studies in our review that reported on newly designed psychological support interventions for healthcare workers (HCW) during the COVID-19 pandemic. We found that most programs commonly supported HCW mental health through offering one or more of the following initiatives: expanded basic need resources/services, additional workplace training programs that bolstered professional preparedness while also indirectly boosting HCW emotional health, and/or expanded psychological support programs, such as peer support programs, psychoeducational or counseling services. Most programs, however, did not consider methods to ensure program longevity or sustainability. The COVID-19 pandemic has underscored the acuity of HCW mental health issues and is likely to leave long lasting mental health strains among HCW. This pandemic is a critical point in time to catalyze much needed progress in reducing stigma and expanding HCW mental health care access.

Supporting Healthcare Workers during COVID-19 Pandemic and beyond.

Supporting Healthcare Workers during COVID-19 Pandemic and beyond.

Healthcare Workers' Emotions, Stressor Experiences and Coping Strategies During the COVID-19 Pandemic in Vietnam.

PurposeHealthcare workers (HCWs) are a crucial resource in the battle against the COVID-19 pandemic but are vulnerable to both SARS-CoV-2 infection and negative psychological consequences. This study evaluated HCWs’ emotions, stressor experiences and coping strategies during the pandemic.MethodsA cross-sectional study was conducted among HCWs at the University Medical Center in Ho Chi Minh City. The questionnaire was adapted from the MERS-CoV Staff Questionnaire to measure HCWs’ emotions, stressor experiences and coping strategies during the COVID-19 pandemic.ResultsAmong the 1423 participants eligible in the data analysis, the majority were female (71.1%) with a mean age of 34.2 (standard deviation 7.8) years. While most participants reported that they did their job because of their professionalism and duty as HCWs (87.4%), a high number reported feeling nervous and scared (86.0%). Most participants reported worry about transmitting SARS-CoV-2 to their families or friends (76.6%) and concern that a small mistake or lapse in concentration could infect themselves and others (76.7%). The most common coping strategies were following strict personal protective measures (95.3%), avoiding going out (92.5%) and reading about SARS-CoV-2 (92.3%). Females who had a higher educational level and less than 5-years work experience and those who worked at clinical departments and subclinical departments were more vulnerable.ConclusionThis study indicates an urgent need for psychological support for HCWs, especially for those at high risk of having stress. Interventions and support should utilize psychological resources and approaches effectively to adapt to the new situation during the COVID-19 pandemic.

Anxiety, Depression and Risk of Post-Traumatic Stress Disorder in Health Workers: The Relationship with Burnout during COVID-19 Pandemic in Italy.

During the COVID-19 pandemic, healthcare workers (HW) have faced an extremely difficult work environment, with an increased workload and traumatic events. Our study aimed to investigate the impact of COVID-19 pandemic on HW’s mental wellbeing. We analyzed the correlations between levels of burnout and other mental health disorders and we searched for the presence of specific risk factors of post-traumatic symptomatology related to the pandemic. A structured an on-line questionnaire and validated instruments were completed by a sample of HW from some hospitals in Genoa, Italy. Anxious, depressive, post-traumatic and other psychological symptoms were assessed and risk factors, related to the pandemic, were considered. Then, we investigated the correlation between levels of burnout and the risk of developing psychopathology. A total of 731 HW were screened, and we found increased levels of anxiety (61%), depression (62%), PTSD (34%) and high levels of burnout; especially emotional exhaustion (37%). A statistically significant association between burnout and insomnia, depression, anxiety, and post-traumatic symptoms was demonstrated. This study indicates that during the COVID-19 pandemic, HW showed high levels of psychological distress and that burnout is an important predictor of sufferance. These findings support the idea to provide psychological and psychiatric support for HW.

How to lead health care workers during unprecedented crises: A qualitative study of the COVID-19 pandemic in Connecticut, USA.

Health Care Leaders (HCLs) faced unprecedented challenges during the initial phases of the COVID-19 pandemic. Leaders played an important role in shaping the experiences of Health Care Workers (HCWs) during this time. However, research is needed on how HCWs experienced and characterized HCLs' response and support. The aim of our study was to examine HCWs' experiences with leadership and to identify aspects of HCLs' response that were effective in supporting HCWs in their roles during the early phases of the pandemic. This was a qualitative study based on open-ended semi-structured interviews conducted (June 1- July 18, 2020) with frontline HCWs during the first wave of the COVID-19 pandemic in Connecticut, USA. Participants (N = 45) included physicians, nurses, respiratory therapists and patient care assistants who worked in inpatient and outpatient settings in various specialties, roles and 3 health systems across Connecticut, USA during the COVID-19 pandemic. Participants were offered a $25 gift card as an incentive for participation. We used inductive techniques derived from grounded theory to develop themes. We identified 6 main themes related to leadership response and support of HCWs during the pandemic namely: 1) Effective communication and transparency; 2) Prioritizing their health and safety; 3) Employee scheduling considerations: autonomy, assignment support and respite; 4) Appreciation- financial and nonfinancial; 5) Showing up and listening and 6) Stepping up with resources. Our findings can inform leadership responses to future pandemics and other unanticipated crises leading to strengthening of the health care system as a whole.

Implementing technology to support the deteriorating patient in acute care: evaluating staff views.

Early warning scores (EWS) have been widely used to aid in the detection of deterioration. The use of technology, alongside EWS, may improve patient safety and lead to improvements in the accuracy of documentation. The aim of this service evaluation was to understand nurses' and healthcare support worker views around the implementation of handheld electronic devices for documenting care related to the deteriorating patient. Before the implementation of an electronic handheld device, in-depth semi-structured interviews with nursing staff and healthcare support workers were undertaken to explore the context for improvement. The Consolidated Framework for Implementation Research was used to analyse, organise and present data, to ensure systematic inquiry across the range of potential facilitators and challenges perceived by staff. In all, 11 interviews were undertaken across three speciality areas (four wards). Challenges to the use of new technology included staff apprehension around training and education needs and the uncertainty of technological reliability in the clinical setting. Potential facilitators to support the implementation of this technology were: the potential for improved communication across the individual ward and hospital setting and the potential for more streamlined processes for escalation of concerns. Three main recommendations for practice emerged. First, nurses should be involved in the development of the systems. Appropriate time is required to embed the technology in practice. Finally, thought must be given not just to the absolute number of devices required and their reliability, but also how new technology interacts in each individual context.

1347Mental health status of health care workers during the COVID-19 outbreak: An International Study

BackgroundThe COVID-19 pandemic is a massive health crisis affecting our planet, with over 166,346,635 confirmed cases and 3,449,117 deaths globally till 24 May 2021. The COVID-19 pandemic is a massive health crisis which has brought enormous physical and psychological pressure. Mental health care for health care workers (HCWs), should receive serious consideration. The aim of this study was to determine mental health outcomes of HCWs and to examine known predictors of outcomes during the first pandemic wave.Methods1,556 HCWs who participated in the COVID-19 IMPACT project, an international online survey examining the behavioral and psychological impacts of COVID-19 among 9,565 people from 78 countries/regions and 18 languages. Outcomes assessed were stress, depression symptoms and sleep changes. Predictors examined included sociodemographic factors, and perceived social support.ResultsResults demonstrated that, half of the HCWs had moderate levels of perceived stress and depression symptoms. Predictors associated with higher HCWs’ stress and depression symptoms included female gender, not having children, living with parents, lower educational background and having lower social support. Half of the HCWs (n = 800, 51.4%) continued to sleep about the same and one in four slept more or slept less. Positive predictors of sleep changes were being older, widower, not working, living with parents, and having children. Surprisingly, HCWs had less perceived stress and depression and higher levels of perceived social support than the general population.ConclusionsThe need for establishing ways to mitigate mental health risks and adjust psychological intervention and support of HCWs, seems to be significant as the pandemic continues.Keywords: health care workers, COVID – 19, pandemic, mental health, psychological problems

Mental Health Status of Healthcare Workers During the COVID-19 Outbreak

Abstract. Background: The COVID-19 pandemic is a massive health crisis that has exerted enormous physical and psychological pressure. Mental healthcare for healthcare workers (HCWs) should receive serious consideration. This study served to determine the mental-health outcomes of 1,556 HCWs from 45 countries who participated in the COVID-19 IMPACT project, and to examine the predictors of the outcomes during the first pandemic wave. Methods: Outcomes assessed were self-reported perceived stress, depression symptom, and sleep changes. The predictors examined included sociodemographic factors and perceived social support. Results: The results demonstrated that half of the HCWs had moderate levels of perceived stress and symptoms of depression. Half of the HCWs ( n = 800, 51.4%) had similar sleeping patterns since the pandemic started, and one in four slept more or slept less. HCWs reported less perceived stress and depression symptoms and higher levels of perceived social support than the general population who participated in the same project. Predictors associated with higher perceived stress and symptoms of depression among HCWs included female sex, not having children, living with parents, lower educational level, and lower social support. Discussion: The need for establishing ways to mitigate mental-health risks and adjusting psychological interventions and support for HCWs seems to be significant as the pandemic continues.

Building resilience for healthcare professionals working in an Italian red zone during the COVID-19 outbreak: A pilot study.

The COVID‐19 pandemic has placed considerable strain on healthcare workers showing high rates of stress and psychological health problems. Interventions are urgently needed to help healthcare workers perform under conditions of great risk and uncertainty. In particular, healthcare leadership is known to be critical to supporting healthcare workers to deal with an uncertain and distressing healthcare environment. This pilot study evaluated the impact of the R2 resilience program tailored for healthcare leaders working in a highly affected COVID‐19 area in Italy. Through two group cohorts, 21 healthcare leaders completed the intervention, with 17 participants providing pre‐ and post‐intervention assessment data. Sixty‐two staff members who benefitted from their coordinators' resilience‐focused leadership were also included in the study. Findings show that participation in R2 was associated with reduction in levels of perceived stress and burnout symptoms, and increases in rugged qualities, self‐efficacy and in social‐ecological resilience. Significant changes in rugged qualities, self‐efficacy and perceived stress were also detected in staff members. High rates of participants' program satisfaction have been detected. R2 is a promising intervention for healthcare professionals working in emergency settings designed to enhance the rugged qualities and resources required to deal with heightened exposure to stress.