key: cord-0747196-h0a7p6a4 authors: Kuhlmann, E.; Behrens, G.; Cossmann, A.; Homann, S.; Happle, C.; Dopfer-Jablonka, A. title: Healthcare workers perceptions and medically approved COVID-19 infection risk: understanding the mental health dimension of the pandemic. A German hospital case study date: 2022-03-30 journal: nan DOI: 10.1101/2022.03.28.22273029 sha: 5e8271b50e5712ab697455dc4cf88fddb2cc4fe4 doc_id: 747196 cord_uid: h0a7p6a4 Introduction. This study analyses how healthcare workers (HCWs) perceived risks, protection and preventive measures during the COVID-19 pandemic in relation to medically approved risks and organisational measures. The aim is to explore blind spots of pandemic protection and make mental health needs of HCWs visible. Methods. We have chosen an optimal-case scenario of a high-income country with a well-resourced hospital sector and low HCW infection rate at the organisational level to explore governance gaps in HCW protection. A German multi-method hospital study at Hannover Medical School served as empirical case; document analysis, expert information and survey data (n=1163) were collected as part of a clinical study into SARS-CoV-2 serology testing during the second wave of the pandemic (November 2020-February 2021). Selected survey items included perceptions of risks, protection and preventive measures. Descriptive statistical analysis and regression were undertaken for gender, profession and COVID-19 patient care. Results. The results reveal a low risk of 1% medically approved infections among participants, but a much higher mean personal risk estimate of 15%. The majority (68.4%) expressed some to very strong fear of acquiring infection at the workplace. Individual protective behaviour and compliance with protective workplace measures were estimated as very high. Yet only about half of the respondents felt strongly protected by the employer; 12% even perceived no or little protection. Gender and contact with COVID-19 patients had no significant effect on the estimations of infection risks and protective workplace behaviour, but nursing was correlated with higher levels of personal risk estimations and fear of infection. Conclusions. A strong mismatch between low medically approved risk and personal risk perceptions of HCWs brings stressors and threats into view, that may be preventable through better information and risk communication and through investment in mental health and inclusion in pandemic preparedness plans. The COVID-19 pandemic put a spotlight on the importance of healthcare workers (HCWs) and their contribution to health system resilience. Investment in the health workforce and prioritisation of HCW needs in health policy and pandemic recovery plans is therefore called for by WHO (1, 2) , the European Commission (EC) (3, 4) , public health organisations (5) and researchers (6, 7) , including greater attention to the mental health requirements of the health workforce (8, 9, 10, 11, 12, 13) . Data gathered during the pandemic in different regions of the world revealed a high risk of COVID-19 infection and death among HCWs, as well as an increase in stress and burn-out syndromes in many health professional groups (14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29) . Individual stories of HCWs furthermore illustrate the severity of mental health risks and extremely high workload (30,31). Lack of attention to the health and wellbeing of HCWs (32) directly impacts in health workforce recruitment and retention (33, 34) and weakens health workforce resilience. Every new wave of COVID-19 increased the pressures on HCWs and worsened the health labour market situation and the delivery of patient care. However, the intersecting dynamics and their negative effects on pandemic preparedness and health system resilience are not well understood. As Bourgeault et al. reported in the first year of the COVID-19 pandemic, ' [P]andemic response plans in country after country, often fail to explicitly address health workforce requirements and considerations' (35) . In year 2, investment in the health workforce ranked still low on the agenda of national 'coronavirus politics' (36) , but some change can now be observed, as developments in Europe show. A recent Companion Report, a joint project of the European Commission, the OECD on the European Observatory on Health Systems and Policies, mentioned the future health workforce as one out of three health policy priorities (3, 37) . The recommendations highlighted that 'more detailed information on the impact of COVID-19 on health workers' wellbeing' is 'crucial to designing better support measures' (3:p.31). Similarly, the European Union Expert Panel (38) , as well as scholarly debate into building back better after the pandemic mentioned the important role of the health workforce for health systems (4, 30, 39, 40, 41, 42, 43) . EU expert recommendations and international scientific evidence do not easily translate into policy changes in the member states. Health workforce development is still poorly developed and focused on planning and surge capacities. 'The 'human face' (44) , the individual person behind every HCW and their wellbeing and needs, is rarely considered. A comparative assessment of HCW protection and preparedness in selected European Union (EU) All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 30, 2022. ; https://doi.org/10.1101/2022.03.28.22273029 doi: medRxiv preprint countries revealed, that 'action has been taken to improve physical protection, digitalisation and prioritisation of healthcare worker vaccination, whereas social and mental health support programmes were weak or missing' (12) . The findings raise the question, whether health workforce policy and the COVID-19 pandemic protection measures effectively support the needs and requirements of HCWs. This study seeks to analyse HCWs' estimations of the personal likelihood of having acquired COVID-19 (infection risk), their fear of infection and their perceptions of protection and preventive measures during the COVID-19 pandemic in relation to medically approved risks and institutional conditions. We have chosen an 'optimal-case' scenario of a high-income country with a very well-resourced hospital sector (3, 45, 46, 47) and a low HCW infection rate at the regional (state of Lower Saxony) and the organisational level (48, 49) compared to other European countries (16) . This research design provides opportunity for exploring the relationship between medically approved risks and physical protection -the 'objective' realities and organisational conditions -and the individual perceptions of HCWs, the 'subjective' realities and mental health conditions. We aim to reveal 'blind spots' of contemporary health workforce governance and COVID-19 pandemic protection, arguing the need for new participatory approaches that integrate the perceptions of HCWs and pay greater attention to mental health requirements. We use Hannover Medical School (50) as an explorative case study, a large university hospital (academic medical centre) in Lower Saxony, a state in the Western part of Germany. Theoretically, our analysis is informed by multi-level health workforce governance (51, 52) . More specifically, our approach places the perceptions of HCWs in the context of institutional conditions, taking system, sector and organisational levels into account (12) . Empirically, we draw on material from the COVID-19 Contact (CoCo) Study, a multi-method study carried out at Hannover Medical School. The study comprised SARS-CoV-2 serology testing of HCWs All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. with patient contact in low-prevalence settings and an additional questionnaire-based online survey; inclusion criteria were all HCWs working in patient care or in units with possible COVID-19 contact, e.g. emergency services (Box 1). For the purpose of our analysis, we used survey data gathered during November 2020 to The CoCo Study is an ongoing, prospective, longitudinal, observational study in healthcare professionals/workers and individuals with potential contact to SARS-CoV-2, aiming to improve data and knowledge of effective HCW protection. It monitors anti-SARS-CoV-2 immunoglobulin serum levels and collects information on symptoms of respiratory infection, All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 30, 2022. ; https://doi.org/10.1101/2022.03.28.22273029 doi: medRxiv preprint work and home environment, and self-perceived SARS-CoV-2 infection risk through a standardised questionnaire survey (German Clinical Trial Registry, DRKS00021152; study protocol: https://doi.org/10.1101/2020.12.02.20242479). Starting in March 2020 as a convenience sample among employees at Hannover Medical School from the healthcare sector with direct patient contact, it has continuously been expanded. As of December 2021, the sample included a total of more than 1,000 participants (HCWs younger than 18 years were not included in CoCo). Initially, the HCWs were examined every six months and a subsample of 200 HCWs weekly; subsequently, frequency was adapted to general infection rates. Participation was entirely voluntary. The data base and questionnaire are administered at Hannover Medical School in accordance with German data protection law. Sources: (48, 53) The governance of HCW protection must be placed in the context of Germany's social health insurance system, based on partnership governance of statutory health insurance funds and physicians' associations and nearly universal health coverage (46, 47) . It is also shaped by EU law and health workforce regulation (6) . The recent Country Health Profile (47) highlighted that Germany was relatively well prepared in terms of infrastructures and resources. It spends a greater proportion of its GDP on health (11.7%) than any other EU country (47: p.3) and health workforce staffing levels are among the highest in OECD countries (3: Figure 3 .1). During the first wave of the pandemic health workforce capacity was scaled-up through a number of measures (39, 47) , yet HCW shortage still remained a major problem. Köppen et al. concluded from their review, that health workforce planning was limited in the pandemic response plan and 'actions during the peak of the pandemic varied considerably across states' (54) . HCW protection policy focused on physical protection, vaccination prioritisation of HCWs and bonus payment for frontline HCWs (12) . The German hospital sector has high resources and political power. The pre-COVID-19 intensive care unit (ICU) capacity was already the highest among EU countries and quickly expanded by 20% after the start of the pandemic (47: Figure 19 ). For the HCWs, this expansion reinforced the problems of the pre-pandemic conditions of generally 'high All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 30, 2022. ; https://doi.org/10.1101/2022.03.28.22273029 doi: medRxiv preprint workloads in ICU and other wards, as well as nursing shortages, reflected in low rates of nurses per ICU bed' (47, 55) . Similarly, minimum requirements of nurse staffing levels in intensive care and geriatric care were suspended between March and August 2020 and for high-maintenance areas until end of 2020 to help hospitals (47) These policy changes may have increased pressures on HCWs to ensure quality of care with less well educated staff. Policy efforts focussed on structural resources and technical equipment, including ensuring appropriate personal protective equipment (PPE) and surveillance measures especially for the hospital sector (12, 39) . The governance attempts towards strengthening HCW protection were nested in a system of high-quality hospital hygiene, infection control and regulatory frameworks of occupational health in the hospital sector (56). The organisation generally plays an important role in the governance of HCW protection. In Germany, it has legal responsibility for infection protection of its employees ( §23 Infektionsschutzgesetz) (57) . To a large degree, the organisation is also accountable for surveillance and for health workforce planning and deployment. Weak governance efforts on the system level reinforce the responsibility of the organisation. This situation was observed in Germany during the pandemic (54) . Shifting responsibility for operational governance to the organisational level creates flexibility and high variation between organisations, but also opens new opportunities for investing in HCW protection and preparedness. Hannover Medical School is placed in the category of the largest German hospitals that are legally obliged to provide emergency treatment and may therefore be better equipped and prepared for maintaining flexibility and resilience during the pandemic. As an academic medical centre it can also draw on first-hand research and knowledge production. In 2020, when the CoCo Study was initiated, routine capacities of hospital beds accounted for 1,520 beds and 7,500 employees, including 3,100 HCWs (head counts) (53) . COVID-19 protection All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Hannover Medical School established their own vaccination centre, supported by the occupational health service unit and many volunteers. Vaccination was offered during work hours to all employees and students regardless of their involvement in patient care. Our sample comprised approximately one third of the total HCW workforce stock at Hannover Medical School, covering a wide range of health professions and occupational All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. More than half of the respondents (58%) estimated their own infection risk -operationalised as likelihood of having been infected -higher than 5% and 12.7% even higher than 30% ( (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 30, 2022. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (22, 35, 63, 64, 65) , confirming previous observations that new emergent management structures may bypass gender equality guidelines on the organisational level (66) . It should be noted that other factors not measured by our data, e.g. the migration status, might intersect with the professional status and sex/gender categories (23, 24, 67) . Future pandemic preparedness plans and COVID-19 management should improve both inclusion of nurses in decision-making bodies and female leadership. Finally, our optimal-case scenario shows low levels of infection compared to other countries [3, 16, 18, 24, 26, 68] , as well as within Germany [17, 47, 57, 69] . These optimal conditions may not easily be translated to other contexts, yet there are some important lessons emerging All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. These threats may be preventable, at least to some degree, through innovation in the governance of pandemic preparedness and health workforce protection (10, 36, 52) , that take the 'dual pandemic' (9) dimension of COVID-19 and the 'human face' of the health workforce (44) more systematically into account. Our study reveals important gaps in HCW protection and health workforce governance. However, it has several limitations, which have been described in relation to the clinical part of the study (48, 49) . To summarise the major arguments: data on anti-SARS-CoV-2 IgG is only partially representative for Hannover Medical School and we do not know the source of infection in anti-SARS-CoV-2 IgG-positive HCWs (49) . More specifically related to our selected survey data, the respondents might be biased; employees who are more concerned about their health and a COVID-19 infection might have been more interested in the study than those who do not care about potential health risks. We also do not know how the experience of an organisational environment characterised by low infection rates intersects with the individual sphere, and how different sources of information impact in individual perceptions. Further research and qualitative methodology would be necessary to provide indepth information. Finally, the lessons that can be learned from an 'optimal-case scenario' in relation to individual perceptions and institutional/organisational conditions of HCW protection are generally limited and must be viewed with caution, because cross-country comparative data and in-depth organisational comparison are lacking. Our results may help to highlight the need for, and benefit of more comprehensive research and policy investigation into mental health of HCWs. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. We set out to make 'blind spots' of health workforce protection during the pandemic visible and to highlight the need for greater attention to the individual perceptions and mental health requirements of HCWs. Our findings reveal a strong mismatch between technical measures and individual perceptions of HCWs. Applying a 'dual pandemic' approach to COVID-19 (9) opens new opportunities to explore this mismatch in more detail and develop governance approaches, that respond more effectively to health workforce needs and resilience (2, 8, 12, 39) . Notwithstanding the importance of country-specific contexts and the privilege of a high-resourced healthcare system and low-risk setting, we believe that our case study may support much needed investment in the health workforce and help build back better and fairer after the pandemic. Our findings highlight that improving health workforce funding and planning are not enough, but greater attention to mental health and wellbeing of HCWs could make a difference. What lessons for pandemic recovery plans and investment in the health workforce? • Invest in mental health and HCW's wellbeing, improve research evidence and create new mental health and social support services as part of future pandemic plans. • Improve transparency and develop information and risk communication as part of COVID-19 infection prevention and HCW protection management. • Establish inclusive multi-professional governance models based on participatory governance and strengthen the role of nurses in HCW protection and pandemic management. • Strengthen women's inclusion and female leadership in future pandemic plans to improve mental health protection and ensure equal opportunities in all areas of decision-making. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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