key: cord-0948823-e941eqq9 authors: Ardebili, Dr. Mehrdad Eftekhar; Naserbakht, Dr. Morteza; Colleen, Dr. Bernstein; Alazmani-Noodeh, Mr. Farshid; Hakimi, Mrs. Hamideh; Ranjbar, Dr. Hadi title: Healthcare providers experience of working during the COVID-19 pandemic: A qualitative study date: 2020-10-06 journal: Am J Infect Control DOI: 10.1016/j.ajic.2020.10.001 sha: 896cbd9057577d7143da7bf35bfaefa824af849f doc_id: 948823 cord_uid: e941eqq9 BACKGROUND: The COVID-19 pandemic has had a far-reaching negative impact on healthcare systems worldwide and has placed healthcare providers under immense physiological and psychological pressures. OBJECTIVE: The aim of current study was to undertake an in-depth exploration of the experiences of health-care staff working during the COVID-19 crisis. METHODS: Using a thematic analysis approach, a qualitative study was conducted using semi-structured interviews with 97 health care professionals. Participants were health care professionals including pre-hospital emergency services (EMS), physicians, nurses, pharmacists, laboratory personnel, radiology technicians, hospital managers and managers in the ministry of health who work directly or indirectly with COVID-19 cases. RESULTS: Data analysis highlighted four main themes, namely: ‘Working in the pandemic era’, ‘Changes in personal life and enhanced negative affect’, ‘Gaining experience, normalization and adaptation to the pandemic’ and ‘Mental Health Considerations’ which indicated that mental ill deteriorations unfolded through a stage-wise process as the pandemic unfolded. CONCLUSIONS: Participants experienced a wide range of emotions and development during the unfolding of the pandemic. Providing mental health aid should thus be an essential part of services for healthcare providers during the pandemic. Based on our results the aid should be focused on the various stages and should be individual-centred. Such interventions are crucial to sustain workers in their ability to cope throughout the duration of the pandemic. The COVID-19 pandemic has had a far-reaching negative impact on healthcare systems worldwide and has placed healthcare providers under immense physiological and psychological pressures. The aim of current study was to undertake an in-depth exploration of the experiences of health-care staff working during the COVID-19 crisis. Using a thematic analysis approach, a qualitative study was conducted using semistructured interviews with 97 health care professionals. Participants were health care professionals including pre-hospital emergency services (EMS), physicians, nurses, pharmacists, laboratory personnel, radiology technicians, hospital managers and managers in the ministry of health who work directly or indirectly with COVID-19 cases. Data analysis highlighted four main themes, namely: 'Working in the pandemic era', 'Changes in personal life and enhanced negative affect', 'Gaining experience, normalization and adaptation to the pandemic' and 'Mental Health Considerations' which indicated that mental ill deteriorations unfolded through a stage-wise process as the pandemic unfolded. Participants experienced a wide range of emotions and development during the unfolding of the pandemic. Providing mental health aid should thus be an essential part of services for healthcare providers during the pandemic. Based on our results the aid should be focused on the various stages and should be individual-centred. Such interventions are crucial to sustain workers in their ability to cope throughout the duration of the pandemic. Covid-19 has been the first respiratory pandemic since the 1918 Influenza which has had a widespread global effect. It has had severe economic, social, political and cultural consequences on human life and these consequences will be experienced well into the future. The emergence of this pandemic has been a massive test for health-care systems in terms of their capabilities and weaknesses. A crucial effect of this pandemic has been its' impact on staff mental health 1 . The high mortality rate, high disease transmission capacity, and the shortcomings of health systems 2 have had a significant impact on the mental health of employees, and these effects are ongoing 3 . In addition, there is a fear that there will be no cure or vaccine for the disease in the near future, which will exacerbate the negative effects on staff physical and mental health and performance. Every wave of the disease may have the same or even exacerbated effects as stressor effects compound over time. While mitigation thorough flattening the curve and raising the line is the main strategy in the control of the pandemic 4 , decreases in healthcare capacity due to poor mental health and frustrations of health care providers can cause significant problems, especially if and when resurgences occurs. The first cases of COVID-19 in Iran were reported on February 19 and the number of new cases and deaths has increased exponentially since then 5, 6 . During the first months of the outbreak, healthcare-providers were exposed to a variety of new and unprecedented events and experienced a range of feelings in response to such events. While the visible expression of their feelings and emotions were largely hidden behind masks, deleterious unprecedented events, high work pressure and little attention paid to psychological aspects have had devastating effects on staff mental health. Since health-care providers' lived experiences during the crisis was the only way to understand what they went through 7, 8 we conducted the current study utilizing a qualitative approach. The aim of the study was to undertake an in-depth exploration of the experiences and the mental health consequences of health-care staff working during the COVID-19 crisis. We conducted a qualitative study using semi-structured interviews with health care professionals during the COVID-19 crisis. Interviews were conducted using telephone and video calls from March 10 to July 4. We used thematic analysis which is one of the most common forms of qualitative data analysis 9 . The emphasis of thematic analysis was on identifying, analysing and interpreting patterns of meaning within qualitative data. Such a method allowed for a rich in-depth exploration of participants experiences. We recruited the study participants through maximum variation sampling. The main variation variables were age, marital status, work experience, medical specialties and seniority. The participants were recruited from three major cities in Iran that were the main hotspots at the time including Tehran, Qom and Rasht. The inclusion criteria were being a health care professional including pre-hospital emergency services (EMS), physicians, nurses, pharmacists, laboratory personnel, radiology technicians, hospital managers and managers in the ministry of health who work directly or indirectly with COVID-19 cases. Healthcare providers who met the inclusion criteria were approached based on the analysis. All people who were approached agreed to participate in the study. A maximum variation sampling strategy was chosen to allow the capture all groups' experience. Participants were approached in the different units based on age, marital status, work experience, medical specialties and seniority. Data gathering and analysis was concurrent with each other to determine when saturation was achieved, that is, when no new data was emerged and all identified themes where sufficiently supported by the data collected. The main method of data gathering was semi-structured, in-depth interviews. Ninety-seven interviews with eighty-six participants were conducted. …, …., …. and …. conducted the interviews. Interviewers (three male and one female) were faculty members (PhD) who were experts in the conduction of qualitative studies. Demographic information of study participants was obtained before the interview. Ten interviews were conducted one month after the original interviews to assess the changes in the experience of participants. The interviews consisted of three main parts based on a guideline introduced by Charmaz 2014 10 namely: opening, intermediate and ending questions. Examples of opening questions included "What did you experience during COVID-19 pandemic" and "What changes did you experience in your work or private life?". In the main part of the interview, the actions, feelings, and thoughts of health-care providers were examined. Questions such as "What did you feel when you taking care of patients with COVID-19?", "How did the pandemic change your life?", "How did your feeling change over time?", "What was the hardest part of work during pandemic?", "What changes in your mental status did you feel?", and "What do you think about the consequences of working in this pandemic?" were used in the intermediate part of the interview. Follow-up questions were asked after each participant's responses in order to engage them in a dialogue. At the end of the interview, the participants were asked if they had anything to add. Interviews last between 34 to 61 minutes. The study design and reporting were according to Consolidated Criteria for Reporting Qualitative research (COREQ). The method that was introduced by Braun 2006 was used 9 . The written transcripts of the interviews were prepared immediately following the interviews. Each and all interviews were reviewed by the entire group of interviewers for accuracy. All interviewers listened the voice recordings and checked it with the transcribed text. Transcribed interviews were sent to interviewees to check for accuracy. To become immersed in the texts and to fully understand them, the transcripts were read from start to the end, several times by the corresponding author and interviewers. When interviewers had read the text carefully and extracted important statements, they labelled each statement with a code. …., ….., ….. and …. analysed the data. …. translated codes and quotations into English and these were further reviewed by ….. in addition, the codes were discussed in virtual meetings by all authors. Similar codes and ones that created a pattern were summarized into themes. Continuous comparison of codes and categories and re-categorization were carried out during the study in virtual meetings with research team members. The results of the study were presented to six participants of the study who agreed with the main observed patterns. Thick description of the methods and representative equations were used to increase transferability. Microsoft® Excel was used in analysing the data. The study protocol was approved by the ethical committee of the Omitted for review (…). An email link to a form with the study objectives and an informed consent were sent to each participant which was signed electronically. The voluntary and confidential nature of the study was explained to participants before each interview and consent was obtained for recording of interview and transcriptions. The mean (SD) of age and work experience of study participants were 35.34 (6.90) and 10.04 (6.08) years, respectively. Forty-four participants (51.2%) were male. Sixtyone participants (70.9%) were married. The COVID status of participants was 23 (26.7%), 16 (18.6%) and 47 (54.7), respectively, positive, negative and unknown. Thirty-six (41.9%) nurses, seventeen (19.8%) managers, nineteen (22.1%) physicians, eight (9.3%) EMS personnel, two (2.3%) pharmacists, two radiologists and two lab technicians participated in the study. Three main themes emerged from data, namely: Working in the 'pandemic era', Changes in personal life and enhanced negative affect, Gaining experience, normalization and adaptation to the pandemic. A further category that emerged was Mental health considerations. The results of the study are presented in Figure 1 as a model. The model consisted of three level including Early exposure, crisis peak and long-term effects. The first two themes, that is: Working in the pandemic era and Changes in personal life and enhanced negative affect contributed to the mental ill health and needs of healthcare providers during COVID-19 crisis. A key aspect of this theme was the experience of inordinately high levels of workload and feelings of losing control over the situation. Subthemes along with related codes and quotations are presented in Table 1 . Eighty-seven percent of the participants said that the workload experienced in the first days of the pandemic was overwhelming. This overwhelming workload manifested in a very high volume of patients, the difficulty of using protective equipment, an ever-increasing number of severe cases and high mortality rates. Among the participants, 73.80% believed that they had received contradictory information from scientific sources. Also, 80.85% expressed dissatisfaction with the frequent change of protocols, prevention and treatment methods and the attendant negative effects of this on their performance. Compounding this ambiguity was an inability to successfully treat patients, and the unpredictable and sudden course of the disease. A total of 70.23% of participants experienced feeling a loss of control and loss of confidence in relation to their current situation. This experience of loss of control was especially evident amongst physicians with all interviewed physicians emphasizing a sense of losing of control over the patient's situation and treatment in the early days of the pandemic. They noted that pre-COVID, except in very severe cases, infectious diseases alone did not cause the death of their patients. However, this disease had exacted a ravaging effect on patients, inducing a sense of helplessness within them. The large number of clients, the high rate of hospitalizations, the high mortality rate, and the fact that there was nothing that they could do to save these patients, escalated their sense of losing of control. The shortage of protective devices and the difficulty of using them were reported by all participants. The scarcity of N95 masks, protective clothing, gloves, shields and gowns was stated by all interviewees, with most of them noting the extreme discomfort of using the protective gear. This suggested that the health care system was not adequately resourced and the usual protective procedures and guidelines to meet the special conditions of a pandemic could not be adequately or comfortably adhered to. Some participants believed that their inability to treat large numbers of patients gave them a sense of engaging in 'futile' care. This feeling was especially evident among nurses in the intensive care units. 73.80% of the participants believed that their care was almost pointless, especially in instances where patients died despite all their interventions. In spite of all the negative experiences endured, another sub-theme that emerged was that of conscientiousness and self-sacrifice. Over the last 10 years, there has been an ever-increasing shortage of healthcare workers, which has been exacerbated by the country's economic sanctions. In addition, at the time, a number of workers were unable to work given that they had comorbid conditions and they therefore withdrew from work during the pandemic. Thus, this staff absence contributed further to employee shortages. In this context, while the majority of staff tried to work longer hours and extra shifts to make up for the shortfall, the health care system was unable to afford to pay extra money and provide protective facilities and these staff were therefore not reimbursed for their extra effort. Yet yehitoayhstyedyttoteotyhtaltdiitaltyeteted seetohtyeht to alheetaodits yityatt detontyeht . Among the participants, 61.90% believed that their professional duty in the current situation was to come to work and do their job. Almost thirty-seven percent (36.90%) of the participants directly declared that their commitment to their medical oath was one of the main reasons for doing their duties in the pandemic situation. Further, among the participants, 17.85 percent said that they had come to work out of a sense of self-sacrifice and religious obligation, that is, for God's sake. The COVID-19 pandemic induced fundamental changes in the life of study participants. It also led to them experiencing a wide range of negative emotions. Subthemes along with related codes and quotations of this theme are presented in Table 2 . All participants in the study believed that with the onset of the disease, their lives had changed fundamentally, and 95.23 percent believed that they would probably never return to normal. These changes included social interactions, family relationships, and work life. One of the results of these fundamental changes in daily life was a significant reduction in emotional relationships and the experience of sensory deprivation. In this regard participants felt that they were prisoners in isolation under enforced separation from their families. Due to the uncertainty about the nature of the disease, its' high transmission rate, and the fear of being an asymptomatic carrier and thereby transmitting the disease to others; 96.42 percent of the participants had completely separated themselves from their family. In all cases, the level of relationship and engagement between the individual and the family was dramatically and suddenly reduced. The fear of being a carrier and transmitting the disease to the family members was the biggest concern of all participants and was conveyed by all participants. Among participants, 76.19 percent said they feared they would become ill, and die alone while separated from their families. In addition, the fear of being buried without traditional religious ceremonies was also experienced. These fears were intensified for healthcare providers who had tested positive, with their first fear being transmission of COVID-19 to their family followed by fears about their own death in isolation and burial without religious rites and ceremonies. 80.95% of the interviewees stated that they would blame themselves if something happened to one of their family members. Eight members of the health care team who were interviewed and lost a family member because of COVID-19 blamed themselves and felt immense remorse and guilt. Although, a nurse whose husband died of the virus lost much of her sense of guilt after her PCR test turned out to be negative and she was able to attribute his infection to alternative exposure, many others still blamed themselves. The third theme was gaining experience, normalization, and adaptation to the pandemic. This theme represented the growth and development of participants over time. Participants interviewed at the end of the study and those interviewed again after a one-month period stated that they had regained their confidence. This process was the result of overcoming the initial crisis, gaining experience with regard to patient management, reducing referrals and increasing recoveries. Under these circumstances, the pandemic situation had become "normal life" for healthcare providers. However, this adaptation to the pandemic was still accompanied by worries about the future and, for some, eventual 'pandemic fatigue' had begun to set in. Subthemes along with related codes and quotations for this theme are presented in Table 3 . Among participants, 92.85% believed that they had gained experience in managing patients over time. This rate was 100 percent among physicians, and all of 10 participants who were interviewed again after one-month believed they had gained enough experience to adequately manage patients. All physicians and 84.52 percent of nurses stated that, through experience with successful patient management, they had regained their self-confidence. Of the participants, 86.90% said that after the early stages, living and working in new conditions and adoption of new routines had become almost normal for them. All participants who were re-interviewed and participants in the final stages stated that they had adapted to the pandemic situation. Adaptations included learning protective techniques, coping with isolation and social distancing and reducing their fear of illness. Due to the fact that there is no definite end for this pandemic, the healthcare providers had prepared themselves for long-term living under pandemic conditions by taking the necessary precautions. Among the participants, 89.28% stated that they had adapted to living under these conditions. However, 82.14% of participants still had a pervasive sense of worry for the future. This worry included concerns about themselves, their immediate family and relatives and their future economic status. There were also concerns about the neglect and loss of patients to other diseases. In the later interviews we found that some participants were very tired of using protective measures and they were not as vigilant with these measures. Some of our participants stated that they were exhausted by the continuous fear and overvigilance and had started to relax their standards somewhat when it came to the donning of protective gear. The Table 4 . We identified three stages in terms of the manifestation of mental health problems during the coronavirus pandemic crisis. The first stage manifested itself at the onset of the pandemic with fear, anxiety, and a sense of hopelessness and helplessness among healthcare providers. In the first month of the pandemic, extreme fear and anxiety were predominant emotions. At this stage, ambiguity, losing control over the situation and the decline in human interactions, especially in the workplace, increased healthcare providers' anxiety. The second stage was accompanied by the high hospitalization of patients, the high patient mortality rate, and the sense of helplessness and sense of providing futile care felt amongst providers in response to these events. In addition, with prolonged self-quarantine and decreased emotional relationships, healthcare providers had begun to show signs of depression. Further, the deaths of large numbers of patients caused healthcare providers to feel frustrated and physically and emotionally exhausted. In the final mental health stage, that is, in the later stages of the pandemic, healthcare workers started to adapt to pandemic working conditions, but their fears and concerns still lingered. Being worried about patients with other diseases, their own personal future financial problems, having to continue to live in their sensory prisons, and stress due to a lot of patients still dying were acknowledged. Symptoms of post-traumatic stress disorder (PTSD) and depression were the main mental health concerns evidenced at this stage. Evidence of PTSD symptoms became apparent during follow up interviews that were conducted. In this regard, as patient numbers resurged, participants re-experienced earlier stages of panic, fear and helplessness, indicating that just as they thought 'things were getting under control' a resurgence occured and they were 'back to the beginning again'. In this manner it may have been possible that healthcare workers relived the early stages of the cycle of mental ill-health, which may have compounded the stress they had experienced over time. This 'reliving' may also have, to some extent. undone the efficacy of some of the coping mechanisms that they had already adopted. There was also evidence that over time participants, despite their scientific knowledge, were entering into a stage of burnout or 'pandemic fatigue' with many expressing that they simply wanted to get back to their 'normal pre-COVID' lives (See Table 3 ). It became evident from participant's comments here that while they may have adapted to this way of life there were lingering future fears, for example, not being paid due to losses in hospital revenues, and thereby, fearing for their economic future. In addition, a sense of loss that the new way of living implied with regard to their social and familial relationships in many instances left them feeling depressed. Further, they noted the experience of recurrent nightmares and replaying of patients dying, which were typical features of post-traumatic stress disorder. In some instances, reactivation of early fears and panic with patient number resurgences and an overall weariness and pandemic fatigue expressed itself in a desire to abandon the new normal protocols and 'pretend' they could go back to their pre-COVID lifestyle. In dealing with mental health problems, according to participants, especially those who were hospital and ward managers, future interventions should be individualcentered. That is, interventions should not be generic but should rather be tailormade to an individual's unique situation and characteristics Depending on the individual's personality, the amount of stress that he/she can endure, the individual's sources of available support, their work motivation, their sense of control, and the experience that the individual has accrued from previous situations and crises; this can all produce variations in individuals' abilities to currently cope and thereby the level of intervention that they would require. Management and planning for mental health issues should be thus be individual-centered. While all participants expressed variations in the degree of their mental health disturbances, they all acknowledged that they would need time to recover. The results of our study showed high level of stress, fear and anxiety among healthcare providers in the early phases of the pandemic. The sense of helplessness, hopelessness and becoming powerless was prevalent among them. Many expressed fears that they had lost control over the situation and their previous knowledge and skills could not help them in this crisis. They were also worried about their health and their family's health, especially those who had relatives who were old or sick. However, despite these fears, participants continued to work, although they were forced to quarantine themselves and were unable to see their relatives for long Results of a study on nurses in Pakistan showed that while there were negative emotions during working during pandemic some growth was evident in terms of affection and gratefulness, development of professional responsibility, and selfreflection 15 . The presence of both negative and positive feelings were also found in another study 16 . The findings of both these studies aligned to the findings in our study. The changes in psychological characteristics of over time were also shown in previous study on nurses in China 17 . The results of a study on healthcare providers in China showed that intensive work drained health-care providers physically and emotionally but they these providers demonstrated resilience and a spirit of professional dedication to overcome difficulties 18 . Our results showed that there were excessive work demands accompanied by lack of work resources and losing control over work situation. It was also noted that failure to successfully treat patients and the sense of providing futile care in this context could increase the moral distress amongst personnel which has been shown in previous research to be related to burnout and intention to leave (Omitted for Review). The conditions under which staff were working and the resultant outcomes were Although our study provided some interesting insights it was not without limitations. The main limitation of our study was that we could not interview healthcare providers in rural areas. Because most of the hospitals in rural area do not have a sufficient number of ventilators, most patients were referred to the big hospitals in the city. However, the risk of transmission and lack of resources remains a common problem in healthcare facilities all around the country and future research needs to examine the experiences of healthcare workers within rural hospitals as well. The COVID-19 pandemic has not been the first global pandemic disease in current times While earlier generations experienced the Spanish influenza in 1918 followed by two world wars; t for many generations, particularly those born post -1960 and 1970 , who are the current workers of today, this has been the first global disaster that has occurred that has significantly impacted across the globe. Although defined as a health pandemic it may well be regarded as a war, one without end as we await a vaccine and one in which frontline workers, that is healthcare providers, are the soldiers battling an invisible enemy on a daily basis while they may take the enemy home as they return to their family after days spent at work. The aftermath of this war being waged has widespread manifestations that pertain to the mental health of frontline workers, those that lose loved ones, and overall on the future economic stability of countries worldwide. There is thus an urgent need to provide interventions that address the mental health of frontline workers to ensure that as this disease continues to rage, that these workers have some form of mental health support to ensure that they are able to continue in their work of raising and maintaining the line. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The funder of the study had no role in the design of this study and its execution, analyses, interpretation of the data, or decision to submit results. Using protective equipment has become very difficult, I don't think I will be able to continue in the long run, some day I will give up (Nurse)  COVID-19 pandemic caused crucial changes in work and personal life of healthcare providers.  Healthcare providers are the backbone of healthcare systems and their mental health is the Achilles heel in the fight against COVID-19  The impacts of COVID-19 pandemic on work and personal life of healthcare providers life of healthcare providers is unknown  Working in the pandemic era is a unique experience that may happen in the working life of every healthcare provider.  It has enormous effects on personal and working life of them.  Along with providing protective devices and financial support for healthcare workers, it is essential to take into account their mental health status.  In site consulting and providing personalized mental care for the personnel is necessary Mental health care for medical staff in China during the COVID-19 outbreak Potential association between COVID-19 mortality and health-care resource availability. 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