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.

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.

Evidence on the health needs of UK veterans accessing primary care is limited. Electronic health records (EHRs) offer an opportunity to address this evidence gap if veterans are correctly identified. This study validated the identification of veterans in the Clinical Practice Research Datalink (CPRD) and assessed its feasibility for examining their health compared with non-veterans. We conducted a matched cohort study in CPRD, the largest primary care database in the UK, identifying veterans using military-related codes in patients’ EHRs. Each veteran was matched to one or two non-veterans on age, gender, practice, and index date. Validation was undertaken through general practitioner confirmation of veteran status. We compared demographics, risk factors and recorded health conditions using descriptive statistics. Poisson regressions assessed the association between veteran status and various physical and mental health conditions. 122,484 veterans and 244,573 matched non-veterans were identified. 95

Objectives During the COVID-19 pandemic, National Health Service staff support services were implemented to promote healthcare workers' (HCWs) well-being, alongside informal support from colleagues and managers. Certain groups may be less likely to access support, including HCWs from ethnic minority and migrant groups. These HCWs are more likely to experience discrimination and abuse at work, which may also erode access to positive and protective resources. Therefore, this study examined variation in formal support programme use and perceptions of support from managers and colleagues by ethnicity and migration status.Methods This study analysed survey data from 9769 HCWs in England who completed the baseline survey (launched April 2020) and the 6-month follow-up using descriptive statistics and binary logistic regression.Results At 6 months, 51% of participants met the threshold for probable common mental disorder. HCWs from White Other (Adjusted Odds Ratio (AOR) 0.79; 95% CI 0.64 to 0.99) and Asian ethnic groups (AOR 0.65; 95% CI 0.57 to 0.74) were less likely to feel supported by their colleagues than White British HCWs. Similarly, those born outside of the UK and European Union were less likely to feel supported by their colleagues than UK-born HCWs (AOR 0.70; 95% CI 0.52 to 0.94). No variations in support programme use or manager support were found across ethnicity or migration status.Conclusions The study suggests equitable formal support but identified critical disparities in perceived support from colleagues for HCWs during the COVID-19 pandemic. Improving workplace well-being should address the underlying social and structural factors that influence peer support and belonging.

The role of women in the UK Armed Forces has changed considerably in the last decade. With the aim to increase the number of women serving in the military, research must consider the impact of both service and transition into civilian life on the health and well‐being of service and ex‐servicewomen (female veterans). This paper adds to the field by providing the perspective of service providers supporting ex‐service personnel with their mental health, employment, housing, and other needs in addition to those working in policy affecting ex‐servicewomen. This study aimed to explore their understanding of what constitutes a successful transition into civilian life, the barriers and facilitators to achieving this, and how transition might be impacted by the gender of the individual transitioning. Interviews and roundtable discussions were held with stakeholders ( n = 28) and analysed using framework analysis. Four overarching themes were developed: ‘Successful transition is individual and all‐encompassing’, ‘The conflicting identities of servicewomen’, ‘Sexism: women don’t belong in service’ and ‘The needs of servicewomen’. The first theme describes how the process and result of successful transition is individual to each ex‐servicewoman, whilst the remaining themes outline common challenges faced by ex‐servicewomen in this journey. There was no singular definition of ‘successful transition’, but stakeholders described barriers to a successful transition. They identified prominent gender‐specific barriers rooted in misogyny and inequality during military service that permeated into civilian life and impacted support use and workplace experiences. Ex‐servicewomen were often required to juggle multiple responsibilities, mother and partner, and identities, women and warrior, simultaneously. Policies should look to address elements of military culture that may reinforce gender inequality and ensure veteran services are inclusive, as stakeholders identified that these were factors that negatively affected military to civilian transition for women and could cause poor outcomes. Whilst in‐service and veteran‐focused interventions are needed, entrenched sexism in the general society should not be ignored.

PURPOSE:The relative income hypothesis theorises that one's earnings relative to others exert a greater influence on subjective wellbeing than absolute income. Understanding the relationship between relative income and mental health could contribute to employee wellbeing. This review aimed to summarise the defining features of relative income in relation to mental health and how it is measured in the literature. In addition, it aimed to explore the relationship between relative income and mental health in those currently employed in the UK. METHODS:Nine electronic databases were searched using a pre-defined search strategy: PubMed (including MEDLINE and PubMed Central), PsycINFO, Scopus, Web of Science, Global Health, JSTOR, Business Source Complete (EBSCO), ScienceDirect and Emerald. The protocol was pre-registered on PROSPERO (CRD42023408657). Quantitative and qualitative studies and grey literature, which described the defining features and measurement of relative income and its impact on mental health among UK employees, were included. RESULTS:After screening, 13 studies were included in the review. A conceptualisation of relative income revealed that an income comparison is either researcher-defined using averages or self-assessed based on a person's perception. Having a lower income than the reference group was commonly associated with diminished wellbeing, though moderating factors (gender, income inequality and composition of reference group) were identified. CONCLUSIONS:Having a lower income than the reference group is associated with poorer wellbeing. Implications for practice and policy are considered amidst the UK's 'cost of living crisis' and ongoing pay disputes in various sectors.

BACKGROUND:The military-to-civilian transition can be a challenging period for many service members; however, recent research suggests that female ex-service personnel (veterans) confront additional complexities during reintegration into civilian life. This systematic review aimed to identify and synthesise findings across qualitative studies exploring the impact of gender on this transition process. METHODS:Peer-reviewed literature was drawn from a multi-database search, limited to qualitative studies. The studies included either female veterans or both male and female veterans aged 18 years or older who had previously served in the Armed Forces within the Five Eyes (FVEY) countries (Australia, Canada, New Zealand, the United Kingdom, and the United States). We used a Framework Analysis approach to guide the synthesis of the qualitative data. An assessment of study quality was conducted using the Joanna Briggs Institute (JBI) Qualitative Critical Appraisal Checklist for Qualitative Studies. The study protocol is registered with the Open Science Framework (registration: osf.io/5stuj). RESULTS:In total, 10,113 articles were screened after the removal of duplicates, 161 underwent full-text review, with 19 meeting the eligibility criteria. The review identified eleven themes split across individual's experience whilst serving and after transitioning out of the military service. Both male and female veterans discussed a period of acculturation when they joined service and adapted to military norms, culture and identity. Female veterans faced additional challenges at this stage centred on the conflict between feminine norms and the military masculine ideal. Upon leaving service both male and female veterans experienced a loss of military identity and purpose, and dissonance with civilian norms illustrating a military-civilian divide. For female veterans, adjustments and adaptations learned in the military clashed with civilian feminine norms and stereotypically male veteran culture. Female veterans also struggled with the legacies of gender inequality, discrimination, and sexual assault which affected their development of a female veteran identity and affected the provision of services designed to meet their needs as a female. Despite these challenges, female veterans' expressed pride in their service and accomplishments. CONCLUSIONS:Any effort to improve the military-to-civilian transition should take account of the legacy of gender discrimination, especially within the military service, and the potential mismatch between historical civilian female norms and the more traditionally masculine norms of military life. DISCLOSURES:This project was supported by a grant from the Forces in Mind Trust (FiMT) 2202.

Healthcare systems across Europe face a workforce crisis characterised by staff shortages, high turnover, and psychological distress among healthcare workers (HCWs). To understand the true scope and extent of psychological distress and occupational outcomes among HCWs and key areas to target for actionable solutions to this, a comprehensive overview of the evidence is needed. In this Series paper, we have synthesised findings from existing systematic reviews and meta-analyses to assess the prevalence of psychological distress among HCWs in Europe, examine associated risk and protective factors, and evaluate the effectiveness of interventions targeting these. The Series paper shows that HCWs experience high levels of work-related psychological distress, particularly burnout. Organisational factors, such as staff shortages, high workloads, and poor leadership, are key contributors to HCWs psychological distress. Organisational-level, rather than individual-level, interventions showed greater promise in reducing psychological distress and improving occupational outcomes. Perhaps surprisingly, currently published reviews did not focus on diagnosable mental disorders, instead relying on self-report symptom-based measures, likely overestimating prevalence. Our findings show limited research available on psychological distress and occupational outcomes among non-clinical staff, HCWs from ethnic minorities, and countries outside Western Europe. We recommend long-term investment in fostering safe and supportive workplaces and implementing evidence based multi-level mental health initiatives that are co-produced with HCWs. We also advocate for high quality, longitudinal research and policies that prioritise protecting the mental health and occupational safety of HCWs in order to safeguard their wellbeing and futureproof healthcare system sustainability.

The General Health Questionnaire (GHQ), particularly the GHQ-12, is widely used in epidemiological research to detect symptoms of probable psychiatric disorders.1Goldberg DP The detection of psychiatric illness by questionnaire. Oxford University Press, London1972Google Scholar Questionnaire transcription errors can occur in multiple ways, including when converting a printed version to an online version. In March, 2023, we discovered we had made a transcription error in several waves of data we collected as part of a longitudinal study among health-care workers. The GHQ-12 has twelve items, each answered on a four-point Likert scale, with answers indicating better wellbeing on the left and worse wellbeing on the right. In creating response options for item eight of the GHQ-12 in our survey, the first response option was mistakenly labelled "not at all" when it should have been labelled "more so than usual", resulting in responses at both ends of the scale potentially indicating worse wellbeing. Several of our publications included results derived from the GHQ-12,2Lamb D Gnanapragasam S Greenberg N et al.Psychosocial impact of the COVID-19 pandemic on 4378 UK healthcare workers and ancillary staff: initial baseline data from a cohort study collected during the first wave of the pandemic.Occup Environ Med. 2021; 78: 801-808Crossref PubMed Scopus (70) Google Scholar, 3Williamson V Lamb D Hotopf M et al.Moral injury and psychological wellbeing in UK healthcare staff.J Ment Health. 2023; 32: 890-898Crossref PubMed Scopus (8) Google Scholar including an Article in The Lancet Psychiatry.4Scott HR Stevelink SAM Gafoor R et al.Prevalence of post-traumatic stress disorder and common mental disorders in health-care workers in England during the COVID-19 pandemic: a two-phase cross-sectional study.Lancet Psychiatry. 2023; 10: 40-49Summary Full Text Full Text PDF PubMed Google Scholar Following this realisation, we conducted analyses to ascertain whether our results might have been affected across various data waves. We examined the data with and without the erroneous item, comparing prevalence rates with mean and median substitution for the flawed item. Neither substitution method affected the results. Removing borderline cases (ie, cases with scores of three or four following the 0–0-1–1 scoring method, with a score of four indicating caseness) also did not alter prevalence. We hypothesised that as the error featured towards the end of the questionnaire, individuals had learnt responses on the left meant better wellbeing and continued to tick responses on the basis of this logic, negating the wrong wording in item eight. To test this hypothesis definitively, we used a market research panel to establish whether item errors would make a difference in a new population. Participants (N=1504) were randomly allocated to one of three groups and provided with one of the following GHQ-12 versions: a correct version (n=500); a version with an error in item eight (n=502); or a version with a purposeful error in item one (n=502). We included an error in item one to test whether the position of the error had any effect. The results, reported in a preprint,5Croak B Bhundia R Lamb D et al.Do errors in the GHQ-12 response options matter?.OSF Preprints. 2024; (published online Feb 27.) (preprint).https://doi.org/10.31219/osf.io/34a6pGoogle Scholar were clear that there was no difference in mean GHQ-12 scores or the proportion of cases for any of the three groups. These results confirm that our transcription error made no difference to the conclusions of our Article in The Lancet Psychiatry or any others. These findings can also reassure other researchers who might have made similar mistakes. We declare no competing interests. Prevalence of post-traumatic stress disorder and common mental disorders in health-care workers in England during the COVID-19 pandemic: a two-phase cross-sectional studyThe prevalence estimates of common mental disorders and PTSD in health-care workers were considerably lower when assessed using diagnostic interviews compared with screening tools. 21·5% of health-care workers met the threshold for diagnosable mental disorders, and thus might benefit from clinical intervention. Full-Text PDF Open Access

Background Self-harm and suicide behaviours are a major public health concern. Several factors are associated with these behaviours among military communities. Identifying these factors may have important implications for policy and clinical services. The aim of this review was to identify the risk and protective factors associated with self-harm and suicide behaviours among serving and ex-serving personnel of the United Kingdom Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force. Methods A systematic search of seven online databases (PubMed, Web of Science, Embase, Global Health, PsycINFO, PTSDpubs and CINAHL) was conducted alongside cross-referencing, in October 2022. Following an a priori PROSPERO approved protocol (CRD42022348867), papers were independently screened and assessed for quality. Data were synthesised using a narrative approach. Results Overall, 28 papers were included: 13 from Canada, 10 from the United Kingdom, five from Australia and none from New Zealand. Identified risk factors included being single/ex-relationship, early service leavers, shorter length of service (but not necessarily early service leavers), junior ranks, exposure to deployment-related traumatic events, physical and mental health diagnoses, and experience of childhood adversity. Protective factors included being married/in a relationship, higher educational attainment, employment, senior ranks, and higher levels of perceived social support. Conclusion Adequate care and support are a necessity for the military community. Prevention and intervention strategies for self-harm and suicide behaviours may be introduced early and may promote social networks as a key source of support. This review found a paucity of peer-reviewed research within some populations. More peer-reviewed research is needed, particularly among these populations where current work is limited, and regarding modifiable risk and protective factors.

Background: The twelve item General Health Questionnaire (GHQ-12) is a widely used measure of psychological wellbeing. Because there are seven different sets of response options across the twelve items, there is scope for transcription errors to occur when researchers assemble their study materials. The impact of such errors might be more important if they occur in the first set of response options than if they occur later in the questionnaire, once participants have become aware that options to the right of the GHQ-12 response sets always indicate worse wellbeing.Aims: To test the impact of introducing errors into the first and eighth set of response options for the GHQ-12 that render those response sets partially illogical.Methods: We used a double-blind randomised controlled trial, pre-registered with Open Science Framework (osf.io/syhwf). Participants were recruited by a market research company from their existing panel of respondents in Great Britain. Participants were randomly allocated to receive one of three versions of the GHQ-12: a correct version (n=500), a version with a mistake in the first item (n=502), or a mistake in the eighth item (n=502). Mistakes replaced ‘better than usual’ (item one) or ‘more so than usual’ (item eight) with ‘not at all.’Results: We found no differences between the versions in terms of number of participants with possible poor psychological wellbeing (χ2=0.32, df=2, p=0.85) or in mean GHQ-12 scores for the three groups (F(2, 1501)=0.26, p=0.77).Conclusions: Small deviations from the standard GHQ-12 wording do not have a substantive impact on results.

This editorial comments on the paper by Martin McBride and the UK REACH team (published in 2023) investigating financial concerns in UK healthcare workers and depressive symptoms. The research concludes that reporting future financial concerns at baseline increased the odds of depressive symptoms at follow-up around 18 months later. We discuss these findings in the context of the cost-of-living crisis and pay disputes within the NHS, important policy implications and directions for future research.

The relative income hypothesis theorises that the earnings of an individual relative to others exert a greater influence on subjective wellbeing than absolute income. Understanding the relationship between relative income and mental health could contribute to employee wellbeing. This review narratively synthesised the defining features and measurement of relative income, and its impact on mental health among UK employees. Systematic searches of qualitative and quantitative research evidence identified 13 studies. A conceptualisation of relative income revealed that an income comparison is either researcher-defined using averages or self-assessed based on the perception of an individual. Having a lower income than the reference group was commonly associated with diminished wellbeing, though moderating factors (gender, income inequality and composition of reference group) are discussed. Implications for practice and policy are considered amidst the cost of living crisis in the UK and ongoing pay disputes in various sectors. ### Competing Interest Statement BC, LEG and DL have no competing interests. SW is a non-executive director at NHS-England. KK is the deputy director and part funded by the NIHR Policy Research Unit in Health and Social Care Workforce. SAMS is supported by the National Institute for Health and Care Research (NIHR), Maudsley Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and the National Institute for Health and Care Research NIHR Advanced Fellowship (Dr Sharon Stevelink NIHR300592). The views expressed in this publication are those of the authors and not necessarily those of the ESRC, the NHS or the NIHR. ### Funding Statement This work is part of a PhD nested within the NHS CHECK study and funded by the ESRC (ES/P000703/1). This report is independent research supported by the National Institute for Health and Care Research ARC North Thames. The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care. LEG is funded by the Armed Services Trauma Rehabilitation Outcome (ADVANCE) Charity. Key contributors to this charity are the Headley Court Charity (principal funder), HM Treasury (LIBOR Grant), Help for Heroes, Nuffield Trust for the Forces of the Crown, Forces in Mind Trust, National Lottery Community Fund, Blesma - The Limbless Veterans and the UK Ministry of Defence. For the purposes of open access, the authors have applied a Creative Commons Attribution (CC BY) licence to any Accepted Author Manuscript version arising from this submission. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript

Background: Partners and family can play a key role in encouraging military service and ex-service personnel to seek help for their mental health. Community Reinforcement Approach and Family Training (CRAFT) was developed to equip concerned significant others (CSOs) of those experiencing substance use disorders with skills to encourage their loved one to enter treatment and improve their own well-being. It was adapted in the US for CSOs of ex-service personnel with post-traumatic stress disorder (PTSD) (VA-CRAFT).Objective: This study aimed to evaluate an adaptation of VA-CRAFT for use with CSOs of serving and ex-service personnel experiencing PTSD and Common Mental Disorders in the UK (UKV-CRAFT).Method: Acceptability of UKV-CRAFT was assessed with interviews with experts, namely key stakeholders (n = 15) working in support provision for serving and ex-service personnel. In addition, individuals who took part in a small-scale demonstrative trial of UKV-CRAFT (three CSOs and three facilitators who delivered UKV-CRAFT) provided feedback.Results: UKV-CRAFT was viewed positively, with interviewees highlighting that programmes like UKV-CRAFT filled a gap in provision for UK Armed Forces families as most services were only available to the serving or ex-service personnel. Interviewees praised how UKV-CRAFT enhanced CSO well-being and communication with their loved one. Concerns over the confidentiality of taking part in UKV-CRAFT were raised due to the perceived negative effects of highlighting a loved one's mental ill health, especially for CSOs of serving personnel. Ideas for improvement included broadening access to all CSOs regardless of whether their loved one was seeking treatment.Conclusion: Interviewees regarded UKV-CRAFT as a potentially useful intervention suggesting it could be proactively offered universally to support timely help-seeking if required. We recommend further evaluation of UKV-CRAFT on a wider scale, incorporating our recommendations, to assess its effectiveness accurately.

BACKGROUND:In the UK military, adjustment disorder (AjD) is reported as one of the most diagnosed mental disorders, alongside depression, in personnel presenting to mental health services. Despite this, little is understood about what may predict AjD, common treatment or outcomes for this population.AIM:The systematic review aimed to summarise existing research for AjD in Armed Forces (AF) populations, including prevalence and risk factors, and to outline clinical and occupational outcomes.METHOD:A literature search was conducted in December 2020 to identify research that investigated AjD within an AF population (serving or veteran) following the PRISMA guidelines.RESULTS:Eighty-three studies were included in the review. The AjD prevalence estimates in AF populations with a mental disorder was considerably higher for serving AF personnel (34.9%) compared to veterans (12.8%). Childhood adversities were identified as a risk factor for AjD. AjD was found to increase the risk of suicidal ideation, with one study reporting a risk ratio of 4.70 (95% Confidence Interval: 3.50-6.20). Talking therapies were the most common treatment for AjD, however none reported on treatment effectiveness.CONCLUSION:This review found that AjD was commonly reported across international AF. Despite heterogeneity in the results, the review identifies several literature gaps.

Background Previous research demonstrates that less than 50% of military veterans experiencing mental health difficulties seek formal support. Veterans often struggle to identify problems as mental health difficulties. In addition, they may fail to recognize the need for support before reaching a crisis point and face difficulties navigating care pathways to access support. Objective A feasibility trial was conducted to assess a novel digital smartphone app (Mental Health Toolkit for Veterans Project [MeT4VeT]) for UK Armed Forces (UKAF) veterans experiencing mental health difficulties. The trial aimed to explore the feasibility and acceptability of trial procedures for a later randomized controlled trial (RCT) and to assess the acceptability of the MeT4VeT app. Methods Participants were recruited at UK military medical centers, by advertising on social media, and through veteran third-sector organizations between February and November 2021, and assessed for eligibility (male, owned a smartphone, served at least 2 years in the UKAF, left the UKAF within the last 2 years, not undertaking formal mental health treatment). Eligible participants were assigned, on a 1:1 ratio, to either the intervention group (full app) or a control group (noninteractive app with signposting information). Three key objectives were determined a priori to assess the practicality of running an RCT including an assessment of recruitment and retention, evaluation of the technical app delivery and measurement processes, and acceptability and usability of the intervention. Results In total, 791 individuals completed the participant information sheet, of which 261 (33%) were ineligible, 377 (48%) declined or were unable to be contacted for consent, and 103 (13%) did not download the app or complete the baseline measures. Of this, 50 participants completed baseline measures and were randomly assigned to the intervention group (n=24) or the control group (n=26). The trial was effective at enabling both the technical delivery of the intervention and collection of outcome measures, with improvements in mental health demonstrated for the intervention group from baseline to the 3-month follow-up. Recruitment and retention challenges were highlighted with only 50 out of the 530 eligible participants enrolled in the trial. The acceptability and usability of the MeT4VeT app were generally supported, and it was reported to be a useful, accessible way for veterans to monitor and manage their mental health. Conclusions The results highlighted that further work is needed to refine recruitment processes and maintain engagement with the app. Following this, an RCT can be considered to robustly assess the ability of the app to positively affect mental health outcomes indicated within this trial. Trial Registration ClinicalTrials.gov NCT05993676; https://clinicaltrials.gov/ct2/show/NCT05993676

BACKGROUND:Healthcare workers (HCWs) have provided vital services during the COVID-19 pandemic, but existing research consists of quantitative surveys (lacking in depth or context) or qualitative interviews (with limited generalisability). Structural Topic Modelling (STM) of large-scale free-text survey data offers a way of capturing the perspectives of a wide range of HCWs in their own words about their experiences of the pandemic. METHODS:In an online survey distributed to all staff at 18 geographically dispersed NHS Trusts, we asked respondents, "Is there anything else you think we should know about your experiences of the COVID-19 pandemic?". We used STM on 7,412 responses to identify topics, and thematic analysis on the resultant topics and text excerpts. RESULTS:We identified 33 topics, grouped into two domains, each containing four themes. Our findings emphasise: the deleterious effect of increased workloads, lack of PPE, inconsistent advice/guidance, and lack of autonomy; differing experiences of home working as negative/positive; and the benefits of supportive leadership and peers in ameliorating challenges. Themes varied by demographics and time: discussion of home working decreasing over time, while discussion of workplace challenges increased. Discussion of mental health was lowest between September-November 2020, between the first and second waves of COVID-19 in the UK. DISCUSSION:Our findings represent the most salient experiences of HCWs through the pandemic. STM enabled statistical examination of how the qualitative themes raised differed according to participant characteristics. This relatively underutilised methodology in healthcare research can provide more nuanced, yet generalisable, evidence than that available via surveys or small interview studies, and should be used in future research.