Received: 13 July 2020 | Accepted: 28 July 2020

DOI: 10.1111/ppc.12600

COLUMN

Innovative psychological first aid (PFA) in the new normal for

frontliners

Chern Choong Thum MB, BCh, BAO (PU‐RCSI)1 |

2
Yee Chin Chai MD (UNIMAS), DrPsych (UKM) |
Surina Zaman Huri MD (UKM), MMed (Psy) (UKM)1 |
Wan Zafidah Wan Nawawi MB, BCh, BAO, BA (Ire), MMed (Psy) (UKM)1 |
Noorfaizah Ibrahim MBBS (UM), MMed (Psy) UiTM1

1
Hospital Sultan Ismail, Ministry of Health,
Johor Bahru, Malaysia Abstract
2
Hospital Permai Johor Bahru, Ministry of
Purpose: Psychological first aid (PFA) is utilized in the direct aftermath of crisis
Health, Johor Bahru, Malaysia
events. As the world grappled with Covid‐19, PFA was provided for staff members in
Correspondence
Hospital Sultan Ismail. In adherence to the New Normal, innovative approaches had
Chern Choong Thum, MB, BCh, BAO,
(PU‐RCSI), Hospital Sultan Ismail, Ministry to be taken. We engaged clients through virtual communication methods. PFA Solat
of Health, 81100 Johor Bahru, Malaysia.
was organized to assist Muslim staff fulfil religious obligations while being on the
Email: seanthum@yahoo.com
frontlines.
Conclusions: PFA may be useful in helping frontline staff manage stress associated
with the increased workload and general anxiety relating to the pandemic.
Practice Implications: It is recommended all staff members, especially those in-
volved in frontline duty, to be provided PFA.

KEYWORDS

frontliners, new normal, psychological first aid

First developed in the 1950s, psychological first aid (PFA) has been
adopted and applied in the direct aftermath of crisis events in the
hospital setting.1 Alongside adaptations for disaster responders, it is
an evidence‐informed early intervention providing support and re-
2,3
storing social and behavioural functioning for disaster survivors.
The World Health Organization (WHO) establishes the core princi-
ples of PFA to look, listen, link, besides being aware of the limits of
PFA to recognize when professional care is required4
December 2019 witnessed emergence of an unprecedented
pneumonia outbreak of unknown aetiology, later identified as novel
coronavirus SARS‐CoV‐2, otherwise known as Covid‐19.5 Despite
global efforts in containment and mitigation, infection numbers and
death rates rose rapidly both within Malaysia and globally. WHO
subsequently characterized Covid‐19 as a pandemic.6
As part of the national effort in containing the pandemic, Hos-
pital Sultan Ismail Johor Bahru (HSIJB) played an active role by
sending members of its staff to the frontlines of Covid‐19. Along with
it, the HSIJB PFA team was activated to cater for the needs of HSIJB
staff. Planning commenced in March 2020, and the team was com-
posed of all staff members from the Department of Psychiatry and
Mental Health of HSIJB. As Covid‐19 poses a high risk of transmis-
sion and infection, the traditional approach of PFA which involves
direct human‐to‐human contact was deemed to be unfeasible.
In adherence to the new normal, the team developed a virtual
approach to provide PFA to HSIJB staff as well as frontliners. In
addition to a hotline, through which staff members could contact the
team via phone calls, Short Message Service, and WhatsApp mes-
sages, the team explored the use of communications through email,
Facebook, and Zoom. Staff members were able to email their con-
cerns and queries to the team via email.
A Facebook account was set up under the name of Psychological
First Aid HSIJB, where general information on mental health condi-
tions was posted, and queries sought through direct messages and
comments were answered. The Facebook page was helpful for people

Perspect Psychiatr Care. 2020;1–3. wileyonlinelibrary.com/journal/ppc © 2020 Wiley Periodicals LLC | 1

2 |
wanting to make appointment bookings as well, as available time
slots were displayed on the page.
A Zoom account was set up where an initial assessment of staff
members who contacted the team could be held. A video call plat-
form was particularly useful as it allows the Psychiatry team to
provide higher quality services.7
In carrying out PFA, we decided on a multipronged approach.
1 | P A S S IV E A P P R O A C H
First, we provided all staff members with the Malay version of De-
pression Anxiety and Stress Scale 21 questionnaire.8 The questionnaires
were delivered through Google Forms, and were distributed to each
member of staff via their respective Heads of Department.
From there on, we perused the replies of staff members, iden-
tified those who showed high scores in any feature, and assigned an
officer to contact them either via a phone call or an email. Those who
were identified to require more in‐depth intervention would be ar-
ranged for a session of counseling with either the hospital counselor
or the psychiatrist on duty.
Throughout this period, we received feedback and suggestions
from staff members and acted on it after thorough evaluation. For
instance, as barber shops and hair salons were not allowed to con-
tinue operations during the Movement Control Order, there was
plenty of dissatisfaction among staff regarding the discomfort
brought about by long hair. This issue particularly affected healthcare
staff especially the frontliners. They were required to put on multiple
layers of Personal Protective Equipment (PPE) while on duty under
the hot and humid atmosphere in Malaysia. Hence, a head of long
hair was generally uncomfortable for them.
After appraising the situation, and applying the basic principles of
PFA, that is, look, listen and link, the PFA team co‐organized the “Covid
Barber Corner 2020” alongside Persatuan Doktor Doktor Johor, PIJ
Holdings, and Pertubuhan Kebajikan Pertama Johor Bahru. The PFA team
invited a team of barbers to HSIJB and drew up a stringent standard
operating procedure in which both barbers and those getting their
haircut had to follow rigorously (to protect both the barber and the
customer). The response to this initiative was generally positive and out
of our expectations. Over the duration of 3 days, a total of 301 people
benefitted from this initiative, feeling refreshed after having a nice
haircut.
2 | AC T I VE S C RE E N I N G APPRO A C H
The PFA team identified several locations where staff may feel high
stress or pressure working at. This includes at the Covid Mass Screening
Area (CMSA), the Emergency Department, the Intensive Care Units, the
Severe Acute Respiratory Infection wards, and the laboratories.
We made daily phone calls to those identified high‐risk locations in
hospital, enquiring if there were staff members who have displayed
signs of burnout or distress. We tried to understand the basic workflow
THUM ET AL.
and manpower in each location. Besides providing a platform of venti-
lation to those staff over the phone directly, those who required es-
calation of care were referred to the PFA team. As CMSA is a new
temporary location set up separately from our hospital main building,
there was no phone line available there. Hence, we sent team members
to the CMSA on a daily basis to check on the psychological well being of
the staff working there, providing impromptu PFA where needed
To overcome stigma and to promote better emotional well being
among staff who were struggling with the increased workload, we em-
ployed a peer‐to‐peer concept where staff members were educated,
empowered, and entrusted to care for the well being of their colleagues.
We recruited Nursing Sisters (the chief nurse of each ward or depart-
ment) to the role of gatekeepers in identifying either colleagues who
were in distress and in need of help. Training was provided whereby the
Sisters were taught to pick up red flags of distress, and to promptly apply
“rescue methods” which involved the administration of deep breathing
exercises and progressive muscle relaxation techniques. A clear channel
of communication was provided to all staff members, ensuring that they
knew when, and how, to escalate the matter to the PFA team.
3 | PFA S o la t
Part of the feedback we received was concern regarding the fulfillment
of religious obligations while being on frontline duty. Malaysia is a
country with a predominantly Muslim population; which corresponds to
the demography of HSIJB staff. Muslim staff members are required to
pray five times a day. To answer queries among Muslim frontliners
regarding performing daily prayers while being in full PPE, we involved
the resident ustazah (a lady officer in charge of Islamic affairs) of HSIJB
into a project we named PFA Solat. Solat is a term in Islam which means
“to pray.” The ustazah combined religious knowledge in accordance to
guidelines provided by the Johor Islamic Religious Affairs Department
with practical application in addressing the concerns of Muslim staff
members. At the same time, the team allowed participants to ventilate,
providing PFA where needed. The feedback received after staff mem-
bers had the opportunity to clarify their doubts, they felt they were
more comfortable to discharge their duties while donned in PPE.
As the world grapples with the Covid‐19 pandemic, it is im-
portant to develop innovative methods to supply the demand for PFA
required by our frontliners. In Malaysia. while the battle is seemingly
won, it is prudent to keep in mind that the war is not over. As the
country slowly recovers from the impact of the Covid‐19 pandemic,
the services provided from the PFA team was progressively reduced.
Despite that, the team remains on standby mode, ready to get back
into action should the need arise. We continue to receive feedback
from staff members and tailor our practices after careful evaluation.
3.1 | Implications for nursing practice
PFA is utilized widely worldwide in the direct aftermath of a crisis
event. Following the Covid‐19 outbreak, PFA may be useful for
THUM ET AL.
frontline staff members in managing stress associated with the
increased workload and general anxiety relating to the pandemic.
Innovative approaches could be helpful in first identifying staff, and
then subsequently assist in the coping with the situation. It is re-
commended all staff members, especially those involved in frontline
duty, to be provided PFA.
A C K N O W L E D GM E N T S
We would like to thank the Director General of Health Malaysia for
his permission to publish the article. We would like to record our
appreciation to the director of HSIJB together with its administration
team, for their immense support to the PFA team. Finally, a special
mention goes to the late Madam Khairunisa A, counselor officer of
the Psychiatric and Mental Health Department of HSIJB, who had
left our team forever in May 2020. Al‐Fatihah.
CO NFLICT OF I NTERE STS
The authors declare that there are no conflict of interests.
OR CID
Chern Choong Thum http://orcid.org/0000-0002-5032-0980
Yee Chin Chai http://orcid.org/0000-0002-2286-0090
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How to cite this article: Thum CC, Chai YC, Zaman Huri S,
Wan Nawawi WZ, Ibrahim N. Innovative psychological first
aid (PFA) in the new normal for frontliners. Perspect Psychiatr
Care. 2020;1–3. https://doi.org/10.1111/ppc.12600