essay on impact of covid 19 on health care professionals

• Open access
• Published: 24 March 2022

Health care workers’ experiences during the COVID-19 pandemic: a scoping review

• Souaad Chemali 1 ,
• Almudena Mari-Sáez 1 ,
• Charbel El Bcheraoui 2 &
• Heide Weishaar   ORCID: orcid.org/0000-0003-1150-0265 2  

Human Resources for Health volume  20 , Article number:  27 ( 2022 ) Cite this article

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COVID-19 has challenged health systems worldwide, especially the health workforce, a pillar crucial for health systems resilience. Therefore, strengthening health system resilience can be informed by analyzing health care workers’ (HCWs) experiences and needs during pandemics. This review synthesizes qualitative studies published during the first year of the COVID-19 pandemic to identify factors affecting HCWs’ experiences and their support needs during the pandemic. This review was conducted using the Joanna Briggs Institute methodology for scoping reviews. A systematic search on PubMed was applied using controlled vocabularies. Only original studies presenting primary qualitative data were included.

161 papers that were published from the beginning of COVID-19 pandemic up until 28th March 2021 were included in the review. Findings were presented using the socio-ecological model as an analytical framework. At the individual level, the impact of the pandemic manifested on HCWs’ well-being, daily routine, professional and personal identity. At the interpersonal level, HCWs’ personal and professional relationships were identified as crucial. At the institutional level, decision-making processes, organizational aspects and availability of support emerged as important factors affecting HCWs’ experiences. At community level, community morale, norms, and public knowledge were of importance. Finally, at policy level, governmental support and response measures shaped HCWs’ experiences. The review identified a lack of studies which investigate other HCWs than doctors and nurses, HCWs in non-hospital settings, and HCWs in low- and lower middle income countries.

This review shows that the COVID-19 pandemic has challenged HCWs, with multiple contextual factors impacting their experiences and needs. To better understand HCWs’ experiences, comparative investigations are needed which analyze differences across as well as within countries, including differences at institutional, community, interpersonal and individual levels. Similarly, interventions aimed at supporting HCWs prior to, during and after pandemics need to consider HCWs’ circumstances.

Conclusions

Following a context-sensitive approach to empowering HCWs that accounts for the multitude of aspects which influence their experiences could contribute to building a sustainable health workforce and strengthening health systems for future pandemics.

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Introduction

The COVID-19 pandemic has put health systems worldwide under pressure and tested their resilience. The World Health Organization (WHO) acknowledges health workforce as one of the six building blocks of health systems [ 1 ]. Health care workers (HCWs) are key to a health system’s ability to respond to external shocks such as outbreaks and as first responders are often the hardest hit by these shocks [ 2 ]. Therefore, interventions supporting HCWs are key to strengthening health systems resilience (ibid). To develop effective interventions to support this group, a detailed understanding of how pandemics affect HCWs is needed.

Several recent reviews [ 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ] focus on HCWs’ experiences during COVID-19 and the impact of the pandemic on HCWs’ well-being, including their mental health [ 3 , 7 , 8 , 11 , 12 , 13 , 14 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. Most of these reviews refer to psychological scales measurements to provide quantifiable information on HCWs’ well-being and mental health [ 8 , 13 , 14 , 19 , 21 , 22 , 23 , 24 , 25 , 28 ]. While useful in assessing the scale of the problem, such quantitative measures are insufficient in capturing the breadth of HCWs’ experiences and the factors that impact such experiences. The added value of qualitative studies is in understanding the complex experiences of HCWs during COVID-19 and the contextual factors that influence them [ 29 ].

This paper reviews qualitative studies published during the first year of the pandemic to investigate what is known about HCWs’ experiences during COVID-19 and the factors and support needs associated with those experiences. By presenting HCWs’ perspectives on the pandemic, the scoping review provides the much-needed evidence base for interventions that can help strengthen HCWs and alleviate the pressures they experience during pandemics.

The review follows the Joanna Briggs Institute (JBI) process and guideline on conducting scoping reviews [ 30 ]. JBI updated guidelines identify scoping reviews as the most suitable choice to explore the breadth of literature on a topic, by mapping and summarizing available evidence [ 30 ]. Scoping reviews are also suitable to address knowledge gaps and provide insightful input for decision-making [ 30 ]. The review also applies the PRISMA checklist guidance on reporting literature reviews [ 31 ].

Information sources

A systematic search was conducted on PubMed database between the 9th and 28th of March 2021.

Search strategy

Drawing on Shaw et al. [ 32 ] and WHO [ 33 ], the search strategy used a controlled vocabulary of index terms including Medical Subject Headings (Mesh) of the keywords and synonyms “COVID-19”, “HCWs”, and “qualitative”. Keywords were combined using the Boolean operator “AND” (see Additional file 1 ).

Eligibility criteria

The population of interest included all types of HCWs, independent of geography and settings. Only original studies were included in the review. Papers further had to (1) report primary qualitative data, (2) report on HCWs’ experiences and perceptions during COVID-19, and (3) be available as full texts in English, German, French, Spanish or Arabic, i.e., in a language that could be reviewed by one or several of the authors. Studies focusing solely on HCWs’ assessment of newly introduced modes of telemedicine during COVID-19 were excluded from the review as their clear emphasis on coping with technical challenges deviated from the review’s focus on HCWs’ personal and professional experiences during the pandemic.

Selection process

The initial search yielded 3976 papers. All papers were screened and assessed against the eligibility criteria by one researcher (SC) to identify relevant studies. A random 25% sample of all papers was additionally screened by a second researcher (HW). Any uncertainty or inconsistency regarding inclusion were resolved by discussing the respective articles ( n  = 76) among the authors.

Data collection process

Based on the research question, an initial data extraction form was developed, independently piloted on ten papers by SC and HW and finalised to include information on: (1) author(s), (2) year of publication, (3) type of HCW, (5) study design, (6) sample size, (7) topic of investigation, (8) data collection tool(s), (9) analytical approach, (10) period of data collection, (11) country, (12) income level according to World Bank [ 34 ], (13) context, and (14) main findings related to experiences, factors and support needs. Using the final extraction form, all articles were extracted by SC, with the exception of four German articles (which were extracted by HW), one Spanish and one French article (which were extracted by AMS). As far as applicable, the quality of the included articles was appraised using the JBI critical appraisal tool for qualitative research [ 35 ].

Synthesis methods

The socio-ecological model originally developed by Brofenbrenner was adapted as a framework to analyze and present the findings [ 36 , 37 , 38 ]. The model aims to understand the interconnectedness and dynamics between personal and contextual factors in shaping human development and experiences [ 36 , 38 ]. The model was chosen, because it accounts for the multifaceted interactions between individuals and their environment and is thus suited to capture the different dimensions of HCWs’ experiences, the factors associated with those experiences as well as the sources of support identified. The five socio-ecological levels (individual, interpersonal, institutional, community and policy) of the model served as a framework for analysis and were used to categorise the main themes that were identified in the scoping review as relevant to HCWs’ experiences. The process of identifying the sub-themes was conducted by SC using an excel extraction sheet, in which the main findings were captured and mapped against the socio-ecological framework.

Study selection

The selection process and the number of papers found, screened and included are illustrated in a PRISMA flow diagram (Fig.  1 ). A total of 161 papers were included in the review (see Additional file 2 ). Table 1 lists the included studies based on study characteristics, including type of HCW, healthcare setting, income level of countries studied and data collection tools.

PRISMA flow diagram

Study characteristics

Included papers investigated various types of HCWs. The most investigated type were nurses, followed by doctors/physicians. Medical and nursing students were also studied frequently, while only a small number of studies focused on other professions, e.g., community health workers, therapists and managerial staff. A third of all studies studied multiple HCWs, rather than targeting single professions. The majority of papers investigated so-called “frontline staff”, i.e., HCWs who engaged directly with patients who were suspected or confirmed to be infected with COVID-19. Fewer studies focused on non-frontline staff, and some explored both frontline and non-frontline staff.

Around two-thirds of all papers studied HCWs’ experiences in high-income countries, notably the USA, followed by the UK. Many papers also focused on HCWs in upper-middle income countries, with almost half of them conducted in China. Few papers investigated HCWs in lower-middle income countries, including India, Zimbabwe, Pakistan, Nigeria, and Senegal. Finally, one paper focused on HCWs in Ethiopia, a low-income country. A couple of studies presented data from multiple countries of different income levels, and one study investigating HCWs in Palestine could not be categorised. Overall, the USA was the most studied and China the second most studied geographical location (see Additional file 3 ). Hospitals were by far the most investigated healthcare settings, whereas outpatient settings, including primary care, pharmacies, homes care, nursing homes, healthcare facilities in prisons and schools as well as clinics, were investigated to a considerably lesser extent. Several studies covered more than one setting.

All studies applied a cross-sectional study design, with 54% published in 2020, and the remainder in 2021. A range of qualitative data collection methods were applied, with interviews being by far the most prominent one, followed by open-ended questionnaires. Focus groups and a few other methods including social media, online platforms or recording systems submissions, observations and open reflections were used with rare frequencies. The sample size in studies using interviews ranged between 6 and 450 interviewees. The sample size in studies using Focus Group Discussions (FGDs) ranged between 7 and 40 participants. Further information on the composition and context of the FGDs can be found in additional file 4 . Several studies used multiple data collection tools. The majority of studies applied common analysis methods, including thematic and content analysis, with few using other specific approaches.

Results of syntheses

An overview of the findings based on the socio-ecological framework is summarised in Table 2 , which lists the main sub-themes identified under each socio-ecological level.

Individual level

At the individual level, HCWs’ experiences related to their well-being, professional and personal identity as well as daily work–life routine. In terms of well-being, HCWs reported negative impacts on their physical health (e.g., tiredness, discomfort, skin damage, sleep disorders) [ 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ] and compromised mental health. The reported negative impact on mental health included increased levels of self-reported stress, depression, anxiety, fear, grief, guilt, anger, isolation, uncertainty and helplessness [ 39 , 41 , 43 , 44 , 45 , 46 , 47 , 49 , 50 , 51 , 52 , 53 , 54 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 ]. The reported reasons for HCWs’ reduced well-being included work-related factors, such as having to adhere to new requirements in the workplace, the lack and/or burden of using Personal Protective Equipment (PPE) [ 41 , 44 , 52 , 63 , 64 , 78 , 93 , 124 , 125 ], increased workload, lack of specialised knowledge and experience, concerns over delivering low quality of care [ 42 , 44 , 49 , 52 , 53 , 63 , 69 , 70 , 73 , 74 , 76 , 78 , 79 , 83 , 84 , 85 , 86 , 89 , 90 , 93 , 94 , 101 , 103 , 109 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 ] and being confronted with ethical dilemmas [ 43 , 72 , 76 , 78 , 136 , 141 , 142 , 143 , 144 , 145 ]. HCWs’ compromised psychological well-being was also triggered by extensive exposure to concerning information via the media and by the pressure that was experienced due to society and the media assigning HCWs hero status [ 53 , 72 , 81 , 92 , 97 , 107 , 139 , 146 ]. Factors that were reported by HCWs as helping them cope with pressure comprised diverse self-care practices and personal activities, including but not limited to psychological techniques and lifestyle adjustments [ 47 , 56 , 64 , 71 , 72 , 78 , 90 , 139 , 147 , 148 ] as well as religious practices [ 81 , 112 , 149 ].

Self-reported well-being differed across occupations, roles in the pandemic response and work settings. One study reported that HCWs working in respiratory, infection and emergency departments expressed more worries compared to HCWs who worked in other hospital wards [ 64 ]. Similarly, frontline HCWs seemed more likely to experience feelings of helplessness and guilt as they witnessed the worsening situation of COVID-19 patients, whereas non-frontline HCWs seemed to experience feelings of guilt due to not supporting their frontline colleagues [ 98 ]. HCWs with managerial responsibility reported heightened concern for their staff’s health [ 75 , 110 , 150 ]. HCWs working in nursing homes and home care reported feelings of being abandoned and not sufficiently recognised [ 75 , 123 , 144 ], while one study investigating HCWs responding to the pandemic in a slums-setting reported fear of violence [ 56 ].

HCWs reported that the pandemic impacted both positively and negatively on their professional and personal identity. While negative emotions were more dominant at the beginning of the pandemic, positive effects were reported to gradually develop after the initial pandemic phase and included an increased sense of motivation, purpose, meaningfulness, pride, resilience, problem-solving attitude, as well as professional and personal growth [ 43 , 44 , 47 , 49 , 50 , 51 , 63 , 67 , 68 , 69 , 71 , 73 , 74 , 75 , 76 , 78 , 79 , 87 , 90 , 91 , 92 , 93 , 98 , 102 , 104 , 112 , 114 , 117 , 118 , 119 , 122 , 124 , 131 , 132 , 143 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 , 160 , 161 ]. Frontline staff reported particularly strong positive effects related to feelings of making a difference [ 69 , 92 ]. On the other hand, some HCWs reported doubts with regard to their career choices and job dissatisfaction [ 40 , 46 , 59 , 130 ]. Junior staff, assistant doctors and students often reported feelings of exclusion and concerns about the negative effects of the pandemic on their training [ 40 , 162 , 163 ]. Challenges with regard to their professional identity and a sense of failing their colleagues on the frontline were particularly reported by HCWs who had acquired COVID-19 themselves and experienced long COVID-19 [ 121 , 160 , 164 ]. HCWs who reached out to well-being support services expressed concern at being stigmatised [ 97 ].

HCWs reported a work–life imbalance [ 57 , 97 ] as they had to adapt to the disruption of their usual work routine [ 59 , 62 , 131 ]. This disruption manifested in taking on different roles and responsibilities [ 39 , 49 , 67 , 73 , 83 , 89 , 94 , 97 , 110 , 137 , 139 , 144 , 151 ], increased or decreased workload pressure [ 85 , 128 , 130 , 133 ] and sometimes redeployment [ 57 , 155 , 165 ]. HCWs also reported negative financial effects [ 59 , 86 , 166 ].

Interpersonal level

The findings presented in this section relate to HCWs’ perceptions of their relationships in the private and professional environment during the pandemic and to the impact these relationships had on them. With regard to the home environment, HCWs’ concerns over being infected with COVID-19 and transmitting the virus to family members were identified in almost all studies [ 41 , 44 , 48 , 51 , 54 , 56 , 61 , 68 , 75 , 77 , 80 , 85 , 90 , 128 , 139 , 160 , 167 , 168 , 169 , 170 , 171 ]. HCWs living with children or elderly family members were particularly concerned [ 47 , 65 , 95 , 97 , 163 , 172 ]. In some cases, HCWs reported that they had introduced changes to their living situation to protect their loved ones, with some deciding to move out to ensure physical distance and minimise the risk of transmission [ 39 , 43 , 44 , 89 , 105 , 161 ]. Some HCWs reported sharing limited details about their COVID-19-related duties to decrease the anxiety and fear of their significant others [ 81 ]. While in several studies, interpersonal relationships were reported to cause concerns and worries, some study also identified interpersonal relationships and the subsequent emotional connectedness as a helpful resource [ 47 , 173 , 174 ] that could, for example, alleviate anxiety [ 64 ] or provide encouragement for working on the frontline [ 49 , 106 ]. However, interpersonal relationships did not always have a supportive function, with some HCWs reporting being shunned by family and friends [ 66 , 111 , 175 ].

With regard to the work environment, relationships with colleagues were mainly described as supportive and empowering, with various studies reporting the value of teamwork during the pandemic [ 47 , 51 , 52 , 67 , 71 , 77 , 83 , 91 , 97 , 98 , 108 , 134 , 148 , 151 , 161 ]. Challenges with regard to collegial relationships included social distancing (which hindered HCWs’ interaction in the work place) [ 176 ] and working with colleagues one had never worked with before (causing a lack of familiarity with the work environment and difficulties to adapt) [ 79 ]. HCWs who worked in prisons reported interpersonal conflicts due to perceived increased authoritarian behaviour by security personnel that was perceived to manifest in arrogance and non-compliance with hygiene practices [ 88 ].

In terms of HCWs’ relationships with patients, many studies reported challenges in communicating with patients [ 50 , 55 , 126 , 132 , 133 , 172 ]. This was attributed to the use of PPE during medical examinations and care and the reduction of face-to-face visits or a complete switch to telehealth [ 128 , 139 ]. The changes in the relationships with patients varied according to the nature of work. Frontline HCWs, for example, reported challenges in caring for isolated patients [ 41 , 43 , 52 , 148 ], whereas HCWs working in specific settings and occupational roles that required specific interpersonal skills faced other challenges. This was, for example, the case for HCWs working with people with intellectual disabilities, who found it challenging to explain COVID-19 measures to this group and also had to mitigate physical contact that was considered a significant part of their work [ 71 ]. For palliative care staff, the use of PPE and measures of social distancing were challenging to apply with regard to patients and family members [ 177 ]. Building relationships and providing appropriate emotional support was reported to be particularly challenging for mental health and palliative care professionals supporting vulnerable adults or children [ 117 ]. Challenges for health and social care professionals were associated with virtual consultations and more difficult conversations [ 117 ]. Physicians reported particular frustration with remote monitoring of chronic diseases when caring for low-income, rural, and/or elderly patients [ 169 ]. Having to adjust, and compromise on, the relationships with patients caused concerns about the quality of care, which in turn, was reported to impact negatively on HCWs’ professional identity and emotional well-being.

Institutional level

This section presents HCWs’ perceptions of decision-making processes in the work setting, organizational factors and availability of institutional support.

With regard to decision-making, a small number of studies reported HCWs’ trust in the institutions they worked in [ 143 , 172 ], while the majority of studies revealed discontent about institutional leadership and feelings of exclusion from decision-making processes [ 65 , 178 ]. More specifically, HCWs reported a lack of clear communication and coordination [ 41 , 70 , 144 , 148 , 179 ] and a wish to be provided with the rationales behind management decisions and to be included in recovery phase planning [ 48 ]. They perceived centralised decision-making processes as unfamiliar and restrictive [ 150 ]. Instead, HCWs endorsed de-centralised and participatory approaches to communication and decision-making [ 56 ]. Emergency and critical care physicians suggested to include bioethicists as part of the decision-making on triaging scarce critical resources [ 126 ]. Studies of both hospital and primary care settings reported perceived disconnectedness and poor collaboration between managerial, administrative and clinical staff, which was a contributing factor to burnout among HCWs [ 60 , 83 , 149 , 169 , 180 , 181 , 182 ]. Dissatisfaction with communication also related to constantly changing protocols, which were perceived as highly burdening and frustrating, creating ambiguity and negatively affecting HCWs’ work performance [ 44 , 55 , 59 , 78 , 112 , 183 ].

In terms of organizational factors, many HCWs reported a perceived lack of organizational preparedness and poor organization of care [ 60 , 65 , 120 , 179 ]. Changes in the organization of care were perceived as chaotic, especially at the beginning of the pandemic, and changes in roles and responsibilities and role allocation were perceived as unfair and unsatisfying [ 72 , 97 ]. Only in one study, changes in work organisation were perceived positively, with nurses reporting satisfaction with an improved nurse–patient ratio resulting from organisational changes [ 52 ]. Overall, frontline HCWs advocated for more stability in team structure to ensure familiarity and consistency at work [ 47 , 66 , 72 , 114 , 116 ]. HCWs appreciated multidisciplinary teams, despite challenges with regard to achieving rapid and efficient collaboration between members from different departments [ 41 , 143 , 152 ].

Regarding institutional support, in some instances, psychological, managerial, material and technical support was positively acknowledged, while the majority of studies reported HCWs’ dissatisfaction with the support provided by the institution they worked in [ 46 , 48 , 73 , 84 , 92 , 97 , 114 , 139 , 144 , 174 , 184 ]. Across studies, a lack of equipment, including the unavailability of suitable PPEs, was one of the most prominent critiques, especially in the initial phase the pandemic [ 41 , 46 , 54 , 55 , 61 , 69 , 70 , 72 , 73 , 81 , 84 , 85 , 96 , 97 , 111 , 118 , 144 , 147 , 168 ]. In one study of a rural nursing home, HCWs reported being illegally required to treat COVID-19 patients without adequate PPE [ 39 ]. Specialised physicians, such as radiologists, for example, reported that PPE were prioritised for COVID-19 ward workers [ 65 ]. In another instance, HCWs reported that they had taken care of their own mask supply [ 113 ]. Insufficient equipment and the subsequent lack of protection induced fear and anxiety regarding one’s personal safety [ 64 , 87 ]. HCWs also reported inadequate human resources, which had consequences on increased workload [ 44 , 46 , 54 , 69 , 75 , 85 ]. Dissatisfaction with limited infrastructure was reported overall and across settings, but specific limitations were particularly relevant in certain contexts [ 116 ]. HCWs in low resource settings, including Pakistan, Zimbabwe and India, reported worsening conditions regarding infrastructure, characterised by a lack of water supply and ventilation, poor conditions of isolation wards and lack of quality rest areas for staff [ 41 , 58 , 84 ]. Despite adaptive interventions aimed at shifting service delivery to outdoors, procedures such as patient registration and laboratory work took place in poorly ventilated rooms [ 56 ]. Technical support such as the accessibility to specialised knowledge and availability of training were identified by HCWs as an important resource that required strengthening. They advocated for better “tailor-made” trainings in emergency preparedness and response, crisis management, PPE use and infection control [ 41 , 52 , 61 , 68 , 73 , 127 , 144 ]. HCWs argued that the availability of such training would improve their sense of control in health emergencies, while a lack of training compromised their confidence in their ability to provide quality healthcare [ 47 , 134 ].

Structural factors such as power hierarchies and inequalities played a role in HCWs’ perceived sense of institutional support amidst the quick changes in their institutions. Such factors were particularly mentioned in studies investigating nurses who reported dissatisfaction over doctors’ dominance and discrimination in obtaining PPE [ 54 ] as well as unfairness in work allocation [ 72 , 184 ]. They also perceived ambiguity in roles and responsibilities between nurses and doctors [ 101 ]. A low sense of institutional support was also reported by other HCWs. Junior medical staff and administrative staff reported feeling exposed to unacceptable risks of infection and a lack of recognition by their institution [ 139 ]. Staff in non‐clinical roles, non-frontline staff, staff working from home, acute physicians and those on short time contracts felt less supported and less recognised compared to colleagues on the frontline [ 48 , 139 ].

Community level

This level entails how morale and norms, as well as public knowledge relate to HCWs’ experiences in the pandemic. On the positive side, societal morale and norms were perceived as enhancing supportive attitudes among the public toward HCWs and triggering community initiatives that supported HCWs in both emotional and material ways [ 47 , 78 , 92 , 108 , 140 , 147 ]. This supportive element was especially experienced by frontline HCWs, who felt valued, appreciated and empowered by their communities. HCWs’ reaction to the hero status that was assigned to them was ambivalent [ 146 , 185 ]. In response to this status attribution, HCWs reported a sense of pressure to be on the frontline and to work beyond their regular work schedule [ 51 ]. With community support being perceived as clearly focusing on hospital frontline staff, HCWs working from home, in nursing homes, home care and non-frontline facilities and wards perceived less public support [ 139 ] and appreciation [ 85 , 144 ]. One study highlighted that HCWs did not benefit from this form of public praise but preferred an appreciation in the form of tangible and financial resources instead [ 160 ].

A clear negative aspect of social norms manifested in the stigmatisation and negative judgment by community members [ 72 , 100 , 106 , 186 , 187 ], who avoided contact with HCWs based on the perceptions that they were virus carriers and spreaders [ 43 , 68 , 92 , 111 ]. Such discrimination had negative consequences with regard to HCWs’ personal lives, including lack of access to public transportation, supermarkets, childcare and other public services [ 65 , 80 , 107 ]. Chinese HCWs working abroad reported bullying due to others perceiving and labeling COVID-19 as the ‘Chinese virus’ [ 77 ]. Negative judgment was mainly reported in studies on nurses . In a study of a COVID-19-designated hospital, frontline nurses reported unusually strict social standards directed solely at them [ 122 ]. In a comparative study of nursing homes in four countries, geriatric nurses reported social stigma toward their profession, which the society perceive not worth of respect [ 75 ].

Beyond social norms, studies identified the level of public awareness, knowledge and compliance as important determinants of HCWs’ experiences and emotional well-being [ 147 ]. For example, a lack of compliance with social distancing and other preventive measures was reported to induce feelings of betrayal, anger and anxiety among HCWs [ 41 , 80 , 81 , 111 , 188 ]. The dissemination of false information and rumors and their negative influence on knowledge and compliance was also reported with anger by HCWs in general [ 58 ], an in particular by those who worked closely with local communities [ 129 ]. Online resources and voluntary groups facilitated information exchange and knowledge transfer, factors which were valued by HCWs as an important source of information and support [ 131 , 189 ].

Policy level

Findings presented here include HCWs’ perceptions of governmental responses, governmental support and the impact of governmental measures on their professional and private situation. In a small number of studies, HCWs expressed confidence in their government’s ability to respond to the pandemic and satisfaction with governmental compensation [ 45 , 47 ]. In most cases, however, HCWs expressed dissatisfactions with the governmental response, particularly with the lack of health system organisation, the lack of a coordinated, unified response and the failure to follow an evidence-based approach to policy making. HCWs also perceived governmental guidelines as chaotic, confusing and even contradicting [ 61 , 85 , 86 , 115 , 117 , 118 , 120 , 123 , 147 , 160 , 182 , 190 ]. In one study, inadequate staffing was directly attributed to inadequate governmental funding decisions [ 191 ]. Many studies reported that HCWs had a sense of being failed by their governments [ 60 , 100 , 191 ], with non-frontline staff, notably HCWs working with the disabled [ 71 , 181 ], the elderly [ 39 , 75 , 123 , 151 ] or in home-based care [ 58 ], being particularly likely to voice feelings of being forgotten, deprioritised, invisible, less recognised and less valued by their governments. Care home staff perceived governmental support to be unequally distributed across health facilities and as being focused solely on public institutions, which prevented them from receiving state benefits [ 149 ].

Measures and regulations imposed at the governmental level had a considerable impact on HCWs’ professional as well as personal experiences. In nursing homes, HCWs perceived governmental regulations such as visiting restrictions as particularly challenging and complained that rules had not been designed or implemented with consideration to individual cases [ 62 ]. The imposed rules burdened them with additional administrative tasks and forced them to compromise on the quality of care, resulting in moral distress [ 62 ]. In abortion clinics, HCWs expressed concerns about their services being classed as non-essential services during the early stages of the pandemic [ 190 ]. Governmental policies also had impacts on HCWs personally. For example, the closure of childcare negatively impacted HCWs’ ability to balance personal and private roles and commitments. National lockdowns which restricted travel made it harder for HCWs to get to work or to see their families, especially in places with low political stability [ 95 ]. The de-escalation of measures, notably the opening of airports, was perceived as betrayal by HCWs who felt they bore the burden of increased COVID-19 incidences resulting from de-escalation strategies [ 111 ].

HCWs identified clear and consistent governmental crisis communication [ 97 , 126 ], better employees’ rights and salaries, and tailored pandemic preparedness and crisis management policies that considered different healthcare settings and HCWs’ needs [ 43 , 64 , 81 , 101 , 124 , 160 , 167 , 169 , 188 , 192 , 193 ] as important areas for improvement. HCWs in primary care advocated for strengthened primary health care, improved public health education [ 45 , 130 ] and a multi-sectoral approach in pandemic management [ 129 ].

Our scoping review of HCWs’ experiences, support needs and factors that influence these experiences during COVID-19 shows that HCWs were affected at individual, interpersonal, institutional, community and policy levels. It also highlights that certain experiences can have disruptive effects on HCWs’ personal and professional lives, and thus identifies problems which need to be addressed and areas that could be strengthened to support HCWs during pandemics.

To the best of our knowledge, our review is the first to provide a comprehensive account of HCWs’ experiences during COVID-19 across contexts. By applying an exploratory angle and focusing on existing qualitative studies, the review does not only provide a rich description of the situation of HCWs but also develops an in-depth analysis of the contextual multilevel factors which impact on HCWs’ experiences.

Our scoping review shows that, while studies on HCWs’ experiences in low resource settings are scarce, the few studies that exist and the comparison with other studies point towards setting-specific experiences and challenges. We thus argue that understanding HCWs’ experiences requires comparative investigations, which not only take countries’ income levels into account but also other contextual differences. For example, in our analysis, we identify particular challenges experienced by HCWs working in urban slums and places with limited infrastructure and low political stability. Similarly, in a recent short communication in Social Science & Medicine, Smith [ 194 ] presents a case study on the particular challenges of midwives in resource-poor rural Indonesia at the start of the pandemic, highlighting increased risks and intra-country health system inequalities. Contextual intra-country differences in HCWs’ experiences also manifest at institutional level. For example, the review suggests that HCWs who work in non-hospital settings, such as primary care services, nursing homes, home based care or disability services, experienced particular challenges and felt less recognized in relation to hospital-based HCWs. In a similar vein, HCWs working in care homes felt that as state support was not equally distributed, those working in public institutions had better chances to benefit from state support.

The review highlights that occupational hierarchies play a crucial role in HCWs’ work-related experiences. Our analysis suggests that existing occupational hierarchies seem to increase or be exposed during pandemics and that occupation is a structural factor in shaping HCWs’ experiences. The review thus highlights the important role that institutions and employers play in pandemics and is in line with the growing body of evidence that associates HCWs’ well-being during COVID-19 with their occupational role [ 195 ] and the availability of institutional support [ 195 , 196 ]. The findings suggest that to address institutional differences and ensure the provision of needs-based support to all groups of HCWs, non-hierarchical and participative processes of decision-making are crucial.

Another contextual factor affecting HCWs’ experiences are their communities. While the majority of HCWs experience emotional and material support from their community, some also feel pressure by the expectations they are confronted with. The most prominent example of such perceived pressure is the ambivalence that was reported with regard to the assignment of a hero status to HCWs. On the one hand, this attribution meant that HCWs felt recognized and appreciated by their communities. On the other hand, it led to HCWs feeling pressured to work without respecting their own limits and taking care of themselves.

This scoping review points towards a number of research gaps, which, if addressed, could help to hone interventions to support HCWs and improve health system performance and resilience.

First, the majority of existing qualitative studies investigate nurses’ and doctors’ experiences during COVID-19. Given that other types of HCWs play an equally important role in pandemic responses, future research on HCWs’ experiences in pandemics should aim for more diversity and help to tease out the specific challenges and needs of different types of HCWs. Investigating different types of HCWs could inform and facilitate the development of tailored solutions and provide need-based support.

Second, the majority of studies on HCWs’ experiences focus on hospital settings. This is not surprising considering that the bulk of societal and political attention during COVID-19 has been on the provision of acute, hospital-based care. The review thus highlights a gap with regard to research on HCWs in settings which might be considered less affected and neglected but which might, in fact, be severely collaterally affected during pandemics, such as primary health centers, care homes and home-based care. It also indicates that research which compares HCWs’ experiences across levels of care can help to tease out differences and identify specific challenges and needs.

Third, the review highlights the predominance of cross-sectional studies. In fact, we were unable to identify any longitudinal studies of HCWs’ experiences during COVID-19. A possible reason for the lack of longitudinal research is the relatively short time that has passed since the start of the pandemic which might have made it difficult to complete longitudinal qualitative studies. Yet, given the dynamics and extended duration of the pandemic, and knowledge about the impact of persistent stress on an individual’s health and well-being [ 197 , 198 , 199 , 200 ], longitudinal studies on HCWs’ experiences during COVID-19 would provide added value and allow an analysis across different stages of the pandemic as well as post-pandemic times. In our review, three differences in HCWs’ experiences across the phases of the pandemic were observed. The first one is on the individual level, reflecting the dominance of the negative emotions at the initial phase of the pandemic, which was gradually followed by increased reporting of the positive impact on HCWs’ personal and professional identity. The two other differences were on the institutional level, referring to the dissatisfaction over the lack of equipment and organization of care, mainly observed at the initial pandemic phase. Further comparative analysis of changes in HCWs’ experiences over the course of a pandemic is an interesting and important topic for future research, which could also map HCWs’ experiences against hospital capacities, availability of vaccines and tests as well as changes in pandemic restrictions. Such comparative analysis can inform the development of suitable policy level interventions accounting for HCWs’ experiences at different pandemic stages, from preparedness to initial response and recovery.

Finally, the majority of studies included in the review were conducted in the Northern hemisphere, revealing a gap in understanding the reality of HCWs in low- and lower middle income countries. Ensuring diversity in geographies and including resource-poor settings in research on HCWs would help gain a better contextual understanding, contribute to strengthening pandemic preparedness in settings, where the need is greatest, and facilitate knowledge transfer between the global North and South. While further research can help to increase our understanding of HCWs’ experiences during pandemics, this scoping review establishes a first basis for the evaluation and improvement of interventions aimed at supporting HCWs prior to, during and after COVID-19. A key finding of our analysis to strengthen HCWs’ resilience are the interdependencies of factors across the five levels of the socio-ecological model. For example, institutional, community or policy level factors (such as dissatisfaction with decision-making processes, public non-compliance or failures in pandemic management) can have a negative impact on HCWs at interpersonal and individual levels by impacting on their professional relationships, mental health or work performance. Similarly, policy, community or institutional level factors (such as adequate policy measures, appreciation within the community and the provision of PPE and other equipment) can act as protective factors for HCWs’ well-being. In line with the social support literature [ 201 ], interpersonal relationships were identified as a key factor in shaping HCWs’ experiences. The identification of the inter-dependencies between factors affecting HCWs during pandemics further highlights that health systems are severely impacted by factors outside the health systems’ control. Previous scholars have recognized the embeddedness of health systems within, and their constant interaction with, their socio-economic and political environment [ 202 ]. Previous literature, however, also shows that interventions tackling distress of HCWs have largely focused on individual level factors, e.g., on interventions aimed at relieving psychological symptoms, rather than on contextual factors [ 16 ]. To strengthen HCWs and empower them to deal with pandemics, the contextual factors that affect their situation during pandemics need to be acknowledged and interventions need to follow a multi-component approach, taking the multitude of aspects and circumstances into account which impact on HCWs’ experiences.

Limitations and strengths

Our scoping review comes with a number of limitations. First, due to resource constraints, the search was conducted using only one database. The authors acknowledge that running the search strategy on other search engines could have resulted in additional interesting studies to be reviewed. To mitigate any weaknesses, extensive efforts were made to build a strong search string by reviewing previous peer-reviewed publications as well as available resources from recognized public health institutions. Considering the high numbers of studies identified, it can be, however, assumed that the search strategy and review led to valid conclusions. Second, the review excluded non-original publications. While other types of publications could have provided additional data and perspectives on HCWs’ experiences, we decided to limit our review to original, peer-reviewed research articles to ensure quality. Third, the review excluded studies on other pandemics, which could have provided further insights into HCWs’ experiences during health crises. Given the limited resources available to the research project, it was decided to focus only on COVID-19 to accommodate a larger target group of all types of HCWs and a variety of geographical locations and healthcare settings. Furthermore, it can be argued that previous pandemics did not reach the magnitude of COVID-19 and did not lead to similar responses. With the review looking at the burden of COVID-19 as a stressor, it can be assumed that the more important the stressor, the more interesting the results. Therefore, the burdens and the way in which HCWs dealt with these burdens would be particularly augmented with regard to COVID-19, making it a suitable focus example to investigate HCWs’ experiences in health crises. The authors acknowledge that during other pandemics HCWs’ experiences might differ and be less pronounced, yet this review has addressed stressors and ways of supporting HCWs that could also inform future health crises. In our view, a major strength of the review is that is does not apply any limitation in terms of the types of HCWs, the geographical locations or the healthcare settings included. This approach did not only allow us to review a wide range of literature on an expanding area of knowledge [ 30 ], but to appropriately investigate HCWs’ experiences during a public health emergency of international concern that affects countries across the globe. Providing detailed information about the contexts in which HCWs were studied, allowed us to shed light on the contextual factors affecting HCWs’ experiences.

Implications for policy and practice

Areas of future interventions that improve HCWs’ resilience at individual level could aim towards alleviating stress and responding to their specific needs during pandemics, in line with encouraging self-care activities that can foster personal psychological resilience. Beyond that, accounting for the context when designing and implementing interventions is crucial. This can be done by addressing the circumstances HCWs live and work in, referred to in German-speaking countries as “Verhältnisprävention”, i.e., prevention through tackling living and working conditions. Respective interventions should tackle all levels outlined in the socio-ecological model, applying a systems approach. At the interpersonal level, creating a positive work environment in times of crises that is supportive of uninterrupted and efficient communication among HCWs and between HCWs and patients is important. In addition, interpersonal support, e.g., by family and friends could be facilitated. At institutional level, organizational change should consider transparent and participatory decision making and responsible planning of resources availability and allocation. At community level, tracing rumors and misinformation during health emergencies is crucial, as well as advocating for accountable journalism and community initiatives that support HCWs in times of crisis. At policy level, pandemic regulations need to account for their consequences on HCWs’ work situations and personal lives. Governmental policies and guidelines should build on scientific evidence and take into account the situations and lived experiences of HCWs across all levels of care.

This scoping review of existing qualitative research on HCWs’ experiences during COVID-19 sheds light on the impact of a major pandemic on the health workforce, a key pillar of health systems. By identifying key drawbacks, strengths that can be built upon, and crucial entry-points for interventions, the review can inform strategies towards strengthening HCWs and improving their experiences. Following a systems approach which takes the five socio-ecological levels into account is crucial for the development of context-sensitive strategies to support HCWs prior to, during and after pandemics. This in turn can contribute to building a sustainable health workforce and to strengthening and better preparing health systems for future pandemics.

Availability of data and materials

All data generated during this study are included in this published article and its supplementary information files, except for a detailed extraction sheet for all studies included, which is available from the corresponding author upon request.

Abbreviations

• Health care workers

Joanna Briggs Institute

Focus Groups Discussions

Personal Protective Equipment

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HW and AMS conceived and designed the scoping review. SC extracted, analyzed and conceptualized the data as well as drafted the initial version of this manuscript. HW and AMS provided quality checks for the methodology and analysis. HW, AMS and CEB substantively revised each version of the manuscript and provided substantial inputs. All authors read and approved the final manuscript.

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Additional file 1.

: Table S1. Search strategy. The document includes the search strings for the review.

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: Table S2. List of included papers. The file lists the 161 included papers, detailing the title, authors, publication year and DOI link.

Additional file 3

: Table S3. List of countries studied. The file includes a table listing the countries in which the included studies were conducted according to frequency.

Additional file 4

: Table S4. Detailed information on FGDs. This document provides information extracted from studies that used FGDs as a qualitative data collection tool. The table lists the overall number of focus group discussion’s participants in each of those studies, the number of FGDs per study, whether FGDs were conducted online or offline, the type of study participants, and any other information on the methods that could be extracted.

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Chemali, S., Mari-Sáez, A., El Bcheraoui, C. et al. Health care workers’ experiences during the COVID-19 pandemic: a scoping review. Hum Resour Health 20 , 27 (2022). https://doi.org/10.1186/s12960-022-00724-1

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Experiences of frontline healthcare workers and their views about support during COVID-19 and previous pandemics: a systematic review and qualitative meta-synthesis

• Jo Billings   ORCID: orcid.org/0000-0003-1238-2440 1 ,
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• Talya Greene 1 , 2 &
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Healthcare workers across the world have risen to the demands of treating COVID-19 patients, potentially at significant cost to their own health and wellbeing. There has been increasing recognition of the potential mental health impact of COVID-19 on frontline workers and calls to provide psychosocial support for them. However, little attention has so far been paid to understanding the impact of working on a pandemic from healthcare workers’ own perspectives or what their views are about support.

We searched key healthcare databases (Medline, PsychINFO and PubMed) from inception to September 28, 2020. We also reviewed relevant grey literature, screened pre-print servers and hand searched reference lists of key texts for all published accounts of healthcare workers’ experiences of working on the frontline and views about support during COVID-19 and previous pandemics/epidemics. We conducted a meta-synthesis of all qualitative results to synthesise findings and develop an overarching set of themes and sub-themes which captured the experiences and views of frontline healthcare workers across the studies.

This review identified 46 qualitative studies which explored healthcare workers’ experiences and views from pandemics or epidemics including and prior to COVID-19. Meta-synthesis derived eight key themes which largely transcended temporal and geographical boundaries. Participants across all the studies were deeply concerned about their own and/or others’ physical safety. This was greatest in the early phases of pandemics and exacerbated by inadequate Personal Protective Equipment (PPE), insufficient resources, and inconsistent information. Workers struggled with high workloads and long shifts and desired adequate rest and recovery. Many experienced stigma. Healthcare workers’ relationships with families, colleagues, organisations, media and the wider public were complicated and could be experienced concomitantly as sources of support but also sources of stress.

Conclusions

The experiences of healthcare workers during the COVID-19 pandemic are not unprecedented; the themes that arose from previous pandemics and epidemics were remarkably resonant with what we are hearing about the impact of COVID-19 globally today. We have an opportunity to learn from the lessons of previous crises, mitigate the negative mental health impact of COVID-19 and support the longer-term wellbeing of the healthcare workforce worldwide.

Peer Review reports

COVID-19 has placed extreme demands on healthcare workers. They have faced genuine threats to their own physical safety and indirectly to that of their families. They have had to manage higher numbers of patients with high mortality rates in a high-pressure environment. They have dealt with challenges in delivering care with strict infection control measures in place and not always with adequate personal protective equipment (PPE). Many have been redeployed into new roles, teams or newly purposed wards so have been working in unfamiliar settings and without established social support from colleagues.

As COVID-19 has progressed around the world, we have heard repeatedly about the mental health burden faced by frontline healthcare workers globally as they have worked to treat patients affected by the virus. Media representations have described frontline healthcare workers “on their knees” in response to the crisis, leading to forewarning of an ensuing mental health epidemic amongst the healthcare workforce [ 1 , 2 ].

Healthcare workers are, for the most part, psychologically resilient professionals, trained and experienced in dealing with illness and death [ 3 ]. However, the mental health and psychological wellbeing of this group prior to the current COVID-19 pandemic was already being identified as a major healthcare issue, evidenced by the growing incidence of stress, burnout, depression, drug and alcohol dependence and suicide across all groups of health professionals, in many countries [ 4 ]. High stress roles coupled with the unique demands of the COVID-19 crisis have undoubtedly placed frontline healthcare workers at additional risk for mental health problems, with early reports from around the world indicating elevated rates of depression, anxiety, post-traumatic stress disorder (PTSD) and suicidality [ 5 , 6 , 7 , 8 ].

In response to such emerging data and many a military metaphor of healthcare workers “waging war on the front line” against COVID-19, there have been growing calls to mobilise mental health support for healthcare workers. However, there is also currently a lack of evidence about what interventions are most helpful for staff working in such high-risk occupational roles, with what evidence there is about effectiveness being mixed, and often demonstrating that well intentioned interventions (i.e. debriefing) can actually increase the likelihood of developing mental health problems such as PTSD [ 9 , 10 ]. Emerging literature from around the world has also demonstrated that staff may not prioritise psychological interventions in the peak phase of the crisis and may even be reluctant to engage with services offered to them [ 11 ].

Early research on COVID-19 has been mostly quantitative in nature, reporting on a proliferation of surveys, and mostly measuring rates of distress in specific samples. Whilst important, this research does not help us to understand the complexities and nuances of healthcare workers’ experiences of working on the frontline nor their views about what support is most helpful to them and when. Better understanding this will enable us to develop and provide support for frontline workers in ways which are acceptable and timely, in line with healthcare workers’ own stated views and preferences.

So, what is it like to work on the frontline and what support do frontline healthcare workers want during a pandemic such as COVID-19? We set out to answer this question by conducting a systematic review and meta-synthesis of qualitative literature describing healthcare workers’ experiences of working on the frontline and their views about psychosocial support, during COVID-19 or previous pandemics and epidemics, such as Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS) or Ebola. Understanding healthcare workers’ views, experiences and needs is critical now more than ever, as countries around the world continue to battle with ongoing waves of COVID-19, but will also be essential in the future, as we face further inevitable healthcare crises.

We have adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 12 ] guidance throughout this review.

Search strategy and selection criteria

We identified eligible papers through searches on Medline, PsychINFO and PubMed. All searches took place from inception, with final searches taking place on September 28, 2020. Key search terms were related to the population (i.e. healthcare worker*, health professional* nurse*, doctor*, hospital staff), the intervention (i.e. psychosocial, psychological or emotional and experiences, support, intervention or help) and a number of disease specific key terms (i.e. COVID-19, SARS, MERS, H1N1, Ebola). (See supplementary material for our full list of search terms). We also hand searched reference lists of included papers, grey literature and pre-print servers to identify other potentially relevant studies.

We included papers that reported original, published, qualitative research describing frontline healthcare workers’ experiences of working during a pandemic or epidemic, and/or views of psychosocial support offered to them. This included mixed-methods studies where data on the qualitative component of the study was available. We included studies on all healthcare professionals, including students and trainees and qualified professionals working in a voluntary capacity. We excluded studies where less than 50% of the participants were frontline healthcare workers or where we could not extract data for healthcare workers alone. Due to the rapidity required for this review, only papers published in English were included.

Data screening and extraction

We removed duplicate articles then two reviewers independently screened titles and abstracts of retrieved papers for relevance. The texts of selected articles were then read in full by the two independent reviewers. We resolved any discrepancies about papers to be included at any stage through discussion between the two reviewers and the first author. Data from the selected papers were extracted onto a pre-designed data extraction template by the two reviewers (see Table  1 ). We included all papers in the qualitative meta-synthesis.

Quality appraisal

We assessed the quality of the studies included in the meta-synthesis using the Critical Appraisal Skills Programme (CASP) [ 13 ] qualitative research checklist (see Table  2 ). The quality appraisal was carried out by the two independent reviewers and discrepancies were resolved through discussion. The CASP checklists are designed to be used as educational pedagogic tools and therefore are not intended to derive a quantitative rating for quality. In this review, we have followed CASP guidance and the methods described by Lachal et al. [ 14 ] to describe whether studies met, partially met, or did not meet the CASP criteria. This information is provided to enable the reader to judge study quality for themselves (see supplementary materials ). Of note, these ratings reflect what is included in the available report of the study and may not necessarily reflect detail that was attended to in the research process but not necessarily written up in the presented paper.

We did not exclude any studies from the meta-synthesis based on their quality or sample size. This is a new and emerging topic of concern and we did not want to exclude smaller scale studies from less well-established settings given the insight they could potentially offer to this review question.

• Meta-synthesis

We followed guidance provided by Lachal et al. [ 14 ] on synthesising qualitative literature in psychiatry. We extracted data from the results sections of papers (or general text in the case of published commentaries or reflective accounts) where information was given about healthcare workers’ experiences and/or views of any form of psychosocial support provided during their work in response to a pandemic. This information was exported into NVivo Pro version 12 and analysed thematically [ 15 ].

In keeping with traditional thematic analysis, we sought initial immersion in the data by reading and re-reading all the papers. We developed an initial coding frame from ten of the most immediately relevant and current papers. The coding frame was further developed and refined through coding of the full 46 papers, looking for shared themes, but also nuances and exceptions within the themes. Adhering to the principles of inductive methodology, we sought to derive our themes from the data, in this case the themes and examples given in the original papers, but then to synthesise these findings and develop an overarching set of themes and sub-themes which captured the experiences and views of frontline healthcare workers across the studies. Examples and illustrative quotes are provided throughout to evidence our analyses.

Reflexivity

Reflexivity is important in all qualitative research and enables the reader to consider the validity of any qualitative analysis by better understanding the composition and position of the research team who have produced it. This research team is made up of a diverse group, representing different clinical specialities, career stages and cultural backgrounds. JB is a Consultant Clinical Psychologist and Associate Clinical Professor, specialising in trauma, PTSD and the mental health and wellbeing of high-risk occupational groups. BCFC and VG are MSc graduates in Clinical Mental Health. TG is a Senior Lecturer specialising in PTSD and responses to mass traumatic events. MB is a Principal Clinical Research Fellow and Consultant Psychiatrist. As such we brought a mix of different perspectives and experience to this topic.

A total of 1019 records were initially returned. 37 articles were identified through other sources (hand searching of reference lists, grey literature, and pre-print servers). After de-duplication, the titles and abstracts of 808 articles were screened by the two reviewers. Of these, 665 were agreed to be irrelevant, resulting in 143 studies which were read in full by the two reviewers. At this stage, 97 studies were excluded as either the wrong study design ( n  = 86) or not having relevant outcomes ( n  = 11). This resulted in 46 papers which we included in the review and meta-synthesis (see Fig. 1).

Characteristics of the 46 studies included in the meta-synthesis are shown in Table 1 .

Out of the 46 studies included in the meta-synthesis, 21 studies were based on participants in Asia, 12 in Africa, seven in North America, four in Australasia and two in Europe. Fifteen studies looked at experiences of Ebola, 14 at SARS, five at COVID-19, four at unspecified influenza pandemics, three at MERS, three at H1N1, one at Avian flu, one at swine flu and one at general public health emergencies (one study looked at both SARS and H1N1). Most participants were described as healthcare workers, nurses or medical staff. All studies were published between 1999 and 2020. In most studies data were collected through individual interviews or focus groups, although one study was a personal reflective account and one paper a commentary citing interviews which had been conducted. A variety of analytic methods were used including thematic analysis, content analysis, framework analysis and phenomenological analysis, although many papers did not state the specific method used to analyse their data.

The quality of studies varied, although most were of moderate quality. Many studies included in this synthesis were rated as only partially meeting criteria due to issues of clarity regarding recruitment strategies, data collection and methods of analysis, ethical issues and consideration of the relationship between participants and researchers. The results of the quality assessment of included studies using CASP [ 13 ] criteria are shown in Table 2 (please see supplementary materials for individual study quality ratings).

Themes derived from the meta-synthesis are shown in Table 3 .

1. Physical health, safety and security

Themes related to physical health, safety and security pervaded nearly all included papers.

1.1 Concerns for self

The predominant concern across most staff groups, across all pandemics, was becoming infected with the virus themselves. For example, Gershon et al. [ 16 ] writing about healthcare volunteers’ experiences of treating Ebola in Emergency Treatment Units (ETUs) in West Africa describe:

Thoughts of getting infected were the uppermost concern for most, especially during the beginning of the deployment when they were still becoming acclimated to the ETU and whenever there was a breach in infection control protocol and practice. For some, fear was constant. One participant recalled constantly thinking, “Don’t let me get Ebola, don’t let me get Ebola.” (pp. 9–10)

Fears of contamination were exacerbated by experiences of inadequate PPE which was a recurrent theme across many papers, transcending different countries and pandemics. Shih et al. [ 17 ] explored nurses’ experiences of treating SARS in Taiwan in the early 2000s and noted:

In this beginning stage, the factors contributing to the nurses’ fear about fatal infection by SARS were based on a lack of defensive protection against the disease (p. 173)

Thirteen years later, Yin & Zeng [ 18 ] document nurses’ experiences of treating COVID-19 in China and quote one of their participants:

“I hope that personal protective equipment is available every day so that I don’t have to worry as much about myself or my colleagues getting infected.” (p. 2)

1.2 Concerns for others

A few studies provided exceptions where frontline workers reported less concern over their own immediate health, but nevertheless still expressed significant concerns for others [ 11 ]. Workers were preoccupied about their families becoming ill and were particularly concerned that they themselves might transmit the illness to their loved ones. For example, talking about nurses’ experiences of SARS in Singapore, Koh et al. [ 19 ] reported that:

Some participants were not concerned about themselves, rather they were concerned that they would, because of their exposure to infected patients, colleagues or visitors to the organization, inadvertently infect their family. (p. 199)

Many made sacrifices and sought to protect their loved ones by staying away from them. For example, Yin and Zeng [ 18 ] quote a nurse in China in the early stages of COVID-19:

“I stay at a hotel every day and am afraid of getting my family sick. I’m afraid to go home and haven’t seen my mom and dad for a long time.” (p. 3)

Fellow healthcare workers falling ill with the virus was a significant cause for preoccupation and distress amongst participants [ 20 ]. Chung et al. [ 21 ] describe nurses’ experiences of treating colleagues affected by SARS in Hong Kong:

All of the participants described being particularly vulnerable when caring for patients who were healthcare workers, whether doctors, nurses or support staff who had contracted the disease at work. That the patients were colleagues in a similar situation in life gave a more personally emotive dimension of the experience (p. 513)

1.3 Practical and environmental issues

Healthcare workers were also impacted by practical and environmental issues in the settings in which they worked. Whilst, for the most part, healthcare workers’ fears were allayed by adequate PPE, it was also noted in several papers how the PPE caused discomfort and impacted on communication. For example, Broom et al. [ 22 ] describe the experience of doctors and nurses in an Australian hospital:

The equipment was described as cumbersome and hot, and staff reported finding it difficult to communicate with others who were wearing the PPE. Basic clinical procedures were deemed impossible by participants while wearing the recommended PPE . (p. 106)

Some studies commented on the pay off between staff safety and patient care. For example, Moore et al. [ 23 ] describing the treatment of SARS in Canada quote one participant:

“What we’ve been told is...that [in] triage, you change your goggles, gloves, mask and gown between every patient and its 100% not feasible. It can’t be done. Patients would be dying waiting at the triage desk.” (p. 265)

Many studies also commented on the settings in which healthcare workers treated those affected by the pandemic being unfit for purpose and lacking in essential resources. Talking about nurses’ experiences of the Ebola crisis in West Africa, Gershon et al. [ 16 ] state:

By any measure and at multiple levels, the early humanitarian response to the Ebola epidemic was extraordinarily challenging. Health care facilities and systems, already severely under-resourced in the affected areas, were strained to the limit. (p. 8)

This was not unique to developing countries, with similar challenges reported in Canada [ 23 ] and Australia [ 22 ].

2. Workload

Healthcare workers commonly reported elevated workloads, which impacted on their psychosocial wellbeing. They cited increased hours and weekend shifts, additional time taken to manage PPE and increased paperwork as frequent sources of stress [ 24 ]. This was compounded by staff shortages (due to inadequate staffing or staff absences because of ill health or caring responsibilities) resulting in requirements for staff to work overtime. This led to the workers feeling fatigued and risking mistakes. A nurse from Toronto in the study by Moore et al. [ 23 ] described her experiences:

“I work 12-hour shifts in emergency, rarely got a break, we were not permitted to have fluids at the desk. None. None in the care area. So we were going for five or six hours with nothing to drink. We were so exhausted. So at the end of your 12 hour shift by 6 or 7 hours you’re so exhausted that you’re crazy. That is now leading to sloppy practice.” (p. 265)

However, because of staff shortages, some participants were noted to describe feeling guilty for taking time off to rest [ 16 , 25 ]. Even when able to take a break, this was not always possible. Several studies described staff being unable to leave the hospital or hotel environment, feeling isolated outside of work or having little access to other activities [ 25 , 26 ].

Financial consequences of working, or not working, during the pandemic were also discussed. For some, sickness entitlements were considerably less than usual salaries and some staff were not paid at all if unable to work. This led to significant financial hardship and a motivation for some to work even when unwell [ 27 ]. Some were offered a ‘risk allowance’ for the work that they undertook, which was a source of motivation for some, although professional duty of care usually outweighed financial incentives for most. Nevertheless, when financial remuneration was offered but delayed or not provided, workers felt abandoned and betrayed. Such betrayals of trust exacerbated pre-existing disaffection amongst healthcare workers. For example, Bergeron et al. [ 24 ] quote one participant in their sample of community nurses working on SARS:

“The SARS epidemic changed my view of nursing in Ontario. I finally realized that nurses were undervalued, underappreciated and undercompensated for the risks they take on daily to provide adequate healthcare to their clients.” (p. 49)

Participants in many of the studies talked about experiencing stigma as a result of working on the pandemic. This was greatest in the earlier phases of the outbreaks or in contexts where less was understood about transmission of the virus.

In addition to their own fear of becoming infected with Ebola, the midwives also had to deal with the public fear of the contagious disease. Ebola was an unknown disease in Sierra Leone prior to the outbreak, and lack of knowledge resulted in rumours and misunderstandings among the general population [ 28 ] (p. 25)

Stigma also appeared in the studies of COVID-19. Fawaz and Samaha [ 29 ] quoted one of the nurses in their sample from Lebanon:

“My aunt was standing way far from me when I saw her in the street…she felt like I was infected…treated me as if I am the virus.” (p. 563)

This stigma extended to the families of healthcare workers with some reporting their children being discriminated against [ 30 ]. Other studies pointed to the hypocrisy that some healthcare workers experienced when they were publicly commended for their work but privately discriminated against [ 26 ].

4. Ethical, moral and professional dilemmas

One of the greatest sources of tension was the competing obligation healthcare workers felt between providing good patient care and protecting their own physical safety. Strict infection control procedures meant that staff were not always able to intervene in the way they wanted, resulting in them feeling like they fell short of their usual standards of care. For example, Lamb [ 31 ] quotes a healthcare worker in West African during the Ebola outbreak:

“The biggest conflict within me, was the lack of ability…to put your hand on a shoulder…or hold their hand.” (p. 132)

Further constraints due to lacking resources exacerbated healthcare workers distress and led to a sense of futility. Comments such as “I couldn’t do anything to stop it” [ 32 ] p. 107 and “we could not do enough” [ 33 ] (p. 2884) pervaded many narratives. Several studies discussed the undignified manner of patient deaths and healthcare workers’ lack of ability to provide access to adequate pain medication due to limited resources or give them any measure of comfort due to PPE and safety measures as a great source of distress. For example, Liu and Liehr [ 33 ] in their study of nurses caring for SARS patients in China describe:

Another source of pressure for the nurse was the demise of patients and the coexisting feeling that they could not do enough. Wards to isolate and care for SARS patients were often created from available space, such as outpatient centres, which lacked optimal equipment to manage the complexity of SARS patient care. The feeling of not being able to do enough occurred partly because of the limited resources of the environment. “Things we did for patients, such as cleaning patients, were not enough…the thought that I didn’t try my best for patients could not disappear.” (p. 2884)

Staff shortages and the associated lack of support meant workers were left to make difficult, often life and death, decisions on their own, which were noted to cause serious ethical dilemmas. Inequalities and decisions about who should get access to resources; beds, medication and vaccines also caused staff significant upset. The impact of these dilemmas appeared to continue after the crisis had passed. Gershon et al. [ 16 ] describe the experiences of US healthcare volunteers after returning from the Ebola crisis in West Africa:

Participants reported feelings of grief, mourning, sadness, depression, remorse, and regret upon their return. As one participant said, “Oh, we could have done much, much more.” (p. 15)

Nevertheless, for the most part, workers felt inherently motivated to undertake this work and held a strong conviction that not doing so would be unethical. The idea of not treating patients affected by the virus was seen as “cowardly” [ 34 ] (p. 244) and “morally unacceptable” [ 35 ] (p. 6) and staff who avoided this work were viewed with scepticism.

5. Personal and professional growth

Concurrent to the pressures noted above, many healthcare workers described aspects of the work as enjoyable and rewarding and appeared to derive job satisfaction from work that they felt was “important” and “meaningful” [ 36 ] p. 648.

These sentiments seemed more pronounced when workers saw patients improve and leave the ward, and over time as the number of infections and deaths declined [ 36 ]. The gratitude of others; patients, their families and wider society was noted to increase their sense of fulfilment [ 25 ].

Even in some of the most challenging moments, many healthcare workers found meaning in their work, for example, Erland and Dahl [ 28 ] describe midwives caring from pregnant women dying from Ebola in Sierra Leone who “found it meaningful to be there and care for the women in their last moment of life.” (p. 25).

Overcoming such immense challenges tested the participants and imbued some with a sense of greater professional confidence and competency [ 37 ]. Several studies described staff gaining new knowledge and skills which they felt would equip them in their future work, especially if they ever worked in a pandemic situation again. Some also reported personal growth and developing confidence in their own resilience [ 38 ].

Nevertheless, deriving meaning and taking pride in their achievements did not render healthcare workers immune from the longer lasting impact of the work.

“I’ve just lost my way. When I got back, the problems were still there…Reforming a new life has been tough. I guess you could call it PTSD. I’m proud of what I did…. but in my personal life, I’ve paid a heavy price.” [ 16 ]. (pp. 16–17)

6. Support to and from others

Sources of support were discussed in many of the papers, although healthcare workers’ experiences demonstrated that many potential sources of support could also be additional sources of stress.

6.1 Family and friends

Families and friends were important sources of support but could place pressure on the healthcare workers. Some tried to dissuade them from working on the pandemic, leading the workers, in some cases, to withhold from their families what they were doing [ 16 ].

For the most part, healthcare workers appreciated the opportunity to stay in touch with friends and family, usually over the phone. This was reported to bring them comfort as well as allay the worries of their loved ones. However, this could still place an emotional burden on the workers:

“Sometimes, I was too tired to talk over the phone but I still wanted to switch on the mobile because I was concerned about my family’s condition…I found I could not control my temper during that period. After two sentences of talk with my family, I felt short of breath and became very frustrated. I understood that my family would like to listen to my voice, but I just could not talk.” [ 39 ] (p. 157)

The competing demands of managing work and family life during a pandemic was also a source of stress. As described by Bergeron et al. [ 24 ] during SARS in Canada:

The juggling of work/family demands often had personal costs: “I rarely saw my husband and when I did I had little energy left for him. The strain almost cost me my marriage.” (p. 50)

Reintegrating into normal family life after their work on the pandemic was over was also problematic for some. Several studies described workers missing colleagues and struggling to re-engage with previous work. For example, Gershon et al. [ 16 ] describe US healthcare workers struggling to readjust on returning from volunteering in West Africa:

Others mentioned feeling isolated because the only people that they felt they could really talk to and who understood what they were feeling were the people who had deployed with them. “You breathe, you eat, you sleep it, for 24 hours of every day. It’s not like you can come back home and relax with your family. Your heart is just not into it.” . (p. 16)

6.2 Colleagues and peers

For the most part, working with colleagues during the pandemic was noted to provide an important source of mutual support, opportunities to learn from each other and facilitate camaraderie.

Buddying systems, whereby more experienced staff supported newer staff, seemed appreciated, as were opportunities for informal group reflection. This seemed to enable staff groups to normalise difficult responses and provide appropriate reassurance. As described, in Lamb’s [ 31 ] study of Ebola:

Participants described how they would simply sit down together at the end of a shift, share a cup of tea and discuss the events of the day: “quite a few of them [juniors] had never seen a dead body before, certainly never dealt with dying patients. .. but we would just sort of just sit down and chat about it and about how they were feeling…it was ok to feel upset, it’s just a perfectly normal reaction.” (p. 133)

Some healthcare workers also spoke about the value of social media platforms for keeping in touch with colleagues, such as WhatsApp groups. Some did nevertheless lament the loss of previous opportunities to socialise with colleagues face to face and outside of work [ 18 ].

Colleague and peer relationships could also be the source of some stress. Unfair distribution of work and the refusal of some colleagues to treat patients affected by the virus caused notable tensions.

“There was real division created amongst staff. We’d all be working in the ICU and there was a long list of people who said they’re not going in because of so and so…And this created resentment, hostility because there were a core group of us who went in there more often than we would have had to otherwise had all of us been sharing that responsibility. We carried a burden that wasn’t equally shared.” [ 40 ] (p. 2570)

This was exacerbated by inequities in pay and conditions for what healthcare professionals perceived to be equivalent work with the same risks.

6.3 Organisations

Healthcare workers valued support from their organisations but gave many examples of not feeling adequately supported. Some workers reported feeling coerced into working with infected patients or in inappropriate conditions [ 40 ]. Participants across most studies felt that their organisations had an institutional duty to provide staff with sufficient protection to work safely.

Workers reported feeling supported by their organisations when there was clear alignment and shared decision making between senior managers and frontline healthcare workers but less supported when staff safety was not a clear priority. Workers also valued their organisations supporting them to take time off from their roles.

Workers’ perceptions of their organisation’s preparedness varied with workers in several studies reporting a lack of established protocols. Staff in some studies commented on hoping that their organisations would learn from these experiences and be better prepared in the future.

Workers wanted their hard work and sacrifices to be recognised by their organisations, although the degree to which they expected to be additionally rewarded varied. Nevertheless, they expected a degree of support in return for the sacrifices they made that not all felt was met. For example, Guimard et al. [ 41 ] commenting on a focus group discussion amongst nurses write:

It was revealed during discussions that most of the nurses who volunteered to care for Ebola patients were very disappointed about the recognition they received for their actions. Most of them felt abandoned by the managers of the hospital and felt they received insufficient financial and psychologic support during the epidemic (p. 272)

6.4 Media and the public

The media’s portrayal of the pandemic had both positive and negative impacts. Some studies described the role of the media in perpetuating stigma. Al Knawy et al. [ 42 ] writing about MERS in Saudi Arabia commented:

All participants referred to consistent and pervasive negative media commentary on the MERS-CoV outbreak…These negative commentaries were evident across local mass media (television, radio and newspapers) and social media - particularly Twitter. The negative media reporting was cited as negatively impacting staff morale and affecting workers socially and psychologically. (p. 7)

Many healthcare workers felt that catastrophic portrayals of the pandemic on the news compounded families’ concerns [ 31 ]. Such representations were also argued to be partly responsible for discouraging people to attend hospitals for other health concerns, to the detriment of public health and with financial repercussions for hospital departments [ 43 ].

The media, however, was often a source of information which healthcare workers found helpful, especially when they felt they were not party to information from their organisations. The media was also noted to be helpful in advocating for healthcare workers and mobilising resources, such as exerting pressure to provide more PPE.

The support of the wider public was considered vital and where the public did not comply with related directives this caused the healthcare workers anxiety and frustration. Bergeron et al. [ 24 ] quoted one nurse from their study of SARS in Canada:

“My experience in the workplace regarding lack of compliance from clients in quarantine orders also makes me angry and afraid. I feel that even after all the work of ALL health care professionals, this issue may be impossible to be contained without support of the public.” (p. 47)

Healthcare workers also sought recognition and validation from the public.

They wanted the public to know what they had been through and how they had put their own lives at risk to help protect others [ 16 ] (p. 14)

Knowledge and information

A pervasive narrative amongst the healthcare workers across all the pandemics was that of uncertainty, which precipitated and perpetuated fear and anxiety. Knowledge was key in decreasing uncertainty and many participants sought information, clarity and consensus with the purpose of achieving greater certainty.

Communication

Communication was vital to the healthcare workers, however, not always experienced as helpful. Many reported inconsistent and ineffective messaging and a lack consensus between sources of information. Ives et al. [ 35 ], for example, report a lack of communication in their study of healthcare workers in the UK:

The majority of participants said they had been given neither information about pandemic influenza, nor been made aware of what would be expected of them during such a crisis, and this gave many the impression that their employing Trust did not care about them or take their needs seriously. (p. 9)

Equally prevalent were comments about there being too much information. Rapidly changing and inconsistent information “increased frustration and uncertainty” [ 21 ] (p. 514). This resulted in “confusion and lack of trust in the information received” and subsequently “dismissal of the information as clinicians were unable to assimilate the information in the limited time they had” [ 22 ] (p. 104).

Communication was valued when it was centralised and co-ordinated and came from reliable authorities. Participants also valued leaders who were available and visible during the crisis.

How information was shared was also an important point, with healthcare workers pointing out that many staff did not have the time or access to be repeatedly checking emails. Clearly visible posters and information cascaded through team leaders at shift handovers were cited as helpful.

Healthcare workers also believed that communication is a two-way process and that their feedback and knowledge should be recognised and acted upon. They felt they should be consulted and involved in decision making and that their learning from doing this work on the frontline was vital for responding to the current as well as future pandemics.

Healthcare workers’ experiences of training were variable. For many, training imparted important information, allayed anxiety and facilitated greater confidence. Participants in the studies valued training in infection control procedures and safe use of PPE as well as more general training about the virus.

Participants in several studies, however, felt that they had not received adequate training. As one healthcare worker in Gershon et al.’s [ 16 ] study of Ebola in West Africa described:

“They (the sponsoring agency) handed me a viral haemorrhagic fever guide. I read it on the plane, showed up, but I had no real idea of what I was doing.” (p. 7)

Even though some participants described feeling unprepared, there was a sense in some studies of limited or superficial engagement with training. Training seemed better received when it was deemed as relevant, realistic and timely. Practical simulations increased workers’ confidence. Workers also highlighted the importance of learning through experience and commented on competence and confidence increasing over time.

Formal support

The psychological impact on healthcare workers was acknowledged in many papers, however, few studies reported on workers’ experiences of any formal psychological interventions. The idea that mental health support would be available seemed to be important and helped to alleviate workers’ anxiety. For example, Yin and Zeng [ 18 ] quoted one nurse in the early phase of the COVID-19 outbreak in China:

“I hope that the hospital sets up a psychological support task force to ease our tension and fears.” (p. 3)

When psychological support services were mentioned, they seemed to be of most value when available on site, were flexible and informal, and were offered individually or in small groups which fitted around the workers’ shifts. Workshops on coping and emotional support were also described positively in some studies. Some participants appreciated the availability of helplines, although others described these as too impersonal.

Even when formal support was available, some staff were ambivalent about engaging. Chen et al. [ 11 ] in their commentary on medical staff in China in the early stages COVID-19 described:

The implementation of psychological intervention services encountered obstacles, as medical staff were reluctant to participate in the group or individual psychology interventions provided to them. Moreover, individual nurses showed excitability, irritability, unwillingness to rest, and signs of psychological distress, but refused any psychological help and stated that they did not have any problems (p. 15)

After the peak of the pandemic, the emotional impact of the work appeared to be acknowledged more. Workers in several papers were noted to report difficulties sleeping, experiencing invasive memories and ongoing hyper-arousal as well as struggling to adjust to being back at home and their normal work. Few described access to any kind of formal follow up, although when this was offered, this appeared to be appreciated. Even amongst those who described coping well and who did not want to engage with formal services, informal follow ups and check ins from their organisations and colleagues were valued.

After deployment, they stressed the need for mental health and psychosocial support, and they requested deeper knowledge about coping strategies. The respondents reported being focused on their duties and safety during deployment, and only allowing emotional reactions afterwards [ 44 ]. (p. 6)

In this review we sought to better understand healthcare workers’ experiences of working on the frontline and their views about support during COVID-19 and previous epidemics. We found 46 qualitative papers which met our inclusion criteria, and which covered a number of different pandemics and epidemics over the past 20 years. Studies were heterogenous in their sample sizes, locations and samples. However, meta-synthesis revealed eight key themes which largely transcended temporal and geographical boundaries. Participants across all the studies were deeply concerned about their own and/or others’ physical safety. This was greatest in the early phases of pandemics and exacerbated by inadequate PPE, insufficient resources, and inconsistent information. Workers struggled with high workloads and long shifts and desired adequate rest and recovery. Many experienced stigma. Healthcare workers’ relationships with families, colleagues, organisations, the media and the wider public were complicated and nuanced and could be experienced concomitantly as sources of support but also sources of stress.

The results of this review show that the current experiences of frontline healthcare workers are not without precedent. The themes identified in this review from previous pandemics and epidemics are remarkably resonant with what we are hearing about the impact of COVID-19 on healthcare workers across the world at the current time. This points to a potential mental health impact on staff that is comparable to that experienced in previous pandemics. A recently published review and meta-analysis of the mental health impact of working on pandemics including SARS, MERS, Ebola and COVID-19 [ 45 ] suggested that healthcare workers exposed to virus-related work are 1.7 times more likely to develop psychological distress and PTSD compared to non-exposed workers. Our review sheds light on potential risk factors and their mechanisms of effect including fear associated with threat to life, uncertainty due to inconsistent or rapidly changing information, and threat to integrity due to discrimination.

This review also shows that accessing social support, a previously well-established protective factor against mental health difficulties such as PTSD [ 46 ], was complex. Workers often self-isolated to protect their loved ones, did not disclose details of their work to them, struggled to manage the competing demands of work and family life and felt like the people in their usual support systems could not relate to what they had been through. This compromised healthcare workers use of social support, which may potentially have a longer-term adverse impact on their mental wellbeing.

The ethical, moral and professional dilemmas that healthcare workers faced also increases their risk of ‘moral injury’. Moral injury has been defined as the psychological distress caused by actions, or inactions, which violate an individual’s moral code, or a sense of betrayal by others, and has been highlighted as a potentially significant concern for healthcare workers during COVID-19 [ 47 ]. The healthcare workers in this review were often unable to deliver the level of care they felt professionally and morally obliged to provide and many felt betrayed by their colleagues, organisations and society. Moral injury is not in itself a mental health disorder but is a risk factor for further mental health problems and may be particularly pernicious in the context of a pandemic.

The results of this review also highlight potential protective factors. Healthcare workers valued clear, consistent, and compassionate communication. They engaged well with training when it was practical and specific. The felt valued by their organisations when they prioritised their safety and supported them with manageable workloads and time out from work. The wanted to be consulted and included in decision-making. Staff appreciated peer support and tended to seek emotional guidance from their colleagues. This draws attention to potential opportunities to further develop peer support systems and increase mental health awareness in the workplace. However, colleagues could also be a source of tension, so peer support interventions in this workforce warrant careful evaluation. We also need to carefully consider how peer-based interventions may work in such a crisis so as not to place an additional burden on the healthcare workers providing them when, by definition, they are going through the same stressors.

This review also demonstrates that psychological growth was possible. Most healthcare workers were inherently motivated to undertake this work due to a sense of professional duty. Many derived meaning and satisfaction from their work and reported learning and professional development. They also frequently reported strong team cohesiveness and camaraderie. As suggested by Gerada [ 48 ] in a recent editorial comment, “some good must come out of COVID-19” (p. 1) and there is potential for greater recognition and appreciation of healthcare work.

Public attitudes and the media had both positive and negative impacts on the healthcare workers in these studies but have the potential to provide support and validation of their work. Nonetheless, gestures of solidarity, such as applause for healthcare workers which have been taking place around the world during COVID-19, have the potential to feel meaningless and hypocritical if support for healthcare workers from the public and government is not sustained after the pandemic. Similarly, calls for adequate pay and conditions for healthcare staff continue to be echoed in the current crisis, as they were with previous epidemics and pandemics.

One potential difference between previous pandemics and COVID-19 is that there is now greater acknowledgement of the mental health impact on healthcare workers and increasing recognition of the need to support their wellbeing [ 49 ]. However, there is yet little evidence about what is effective and what healthcare workers themselves want. The studies included in this review focused little on formal psychological interventions. It is therefore difficult to establish whether this was not of primary importance to the healthcare workers, whether they were not aware of sources of mental health support, or whether these interventions were simply not available to them. When mental health support was mentioned, participants tended to speak of it as desirable. However, some studies suggested a reluctance to engage. This is perhaps indicative of potentially enduring stigma amongst healthcare workers, exacerbated by militaristic metaphors and heroic narratives in the media, which make it harder for them to admit when they are struggling. This is an additional area that warrants exploration in order to better understand workers’ ambivalence and to ensure that they feel able to engage with appropriate mental health support when needed.

The results of this review also suggest that healthcare workers’ mental health needs may change over time. In the early stages of these crises, workers prioritised more basic human needs, such as physical safety and rest. At the peak, workers seemed to focus on the work at hand and rely on colleagues for support. After the crisis had passed, there seemed to be greater recognition of the impact of working on the pandemic on mental health and an associated recognition of the need for more support. At the current time, whilst attention is being paid to the impact on frontline healthcare workers’ mental health, there is still a paucity of research into psychosocial interventions specifically for frontline healthcare workers. Future research with this population can helpfully focus on what works for whom and when.

We also know that the global healthcare workforce was experiencing high levels of distress and disaffection prior to COVID-19 [ 4 ], so we need to consider what should be set up as standard support for healthcare workers in the longer term. This will be particularly important as we deal with further waves of COVID-19, but also in the face of other, inevitable, future healthcare crises. We need to ensure that we maintain a psychologically healthy workforce, not just for the wellbeing of the workers, but also for the sustainability of healthcare services globally.

Implications

The findings of this review highlight a number of important implications which are relevant globally.

Provision of adequate safety equipment is a priority to enable safe and effective working but also to mitigate negative mental health outcomes.

Workloads need to be manageable, and sufficient periods of rest and recovery mandated to mitigate fatigue and burnout.

Training should be relevant, practical, and timely. Learning on the job is valued alongside formal training.

Communication needs to be clear and consistent and decision making shared. Leaders should be accessible and visible.

Mechanisms to facilitate staff peer support should be put in place, including ringfenced time and mental health awareness training.

Competing demands between work and family life should be acknowledged and staff supported in maintaining family roles as much as possible. Staff should be supported in taking time off from work.

Anxiety, guilt, and moral injury may be mitigated by reducing lone working, encouraging buddying systems, facilitating ethical forums which allow workers to discuss difficult decisions and focusing on the meaningfulness of the work.

Mental health follow-up will be imperative for the early detection and treatment of emerging mental health problems and to ensure staff feel supported by their organisations. Ongoing peer support is likely to be important.

Strengths and limitations

This review should be considered within the context of its strengths and limitations. This paper offers a rapid but systematic review of a comprehensive body of literature, for the purposes of providing urgent feedback and guidance for those planning the support of frontline healthcare workers during the current COVID-19 crisis. We conducted our search across three major databases and hand searched reference lists of key papers, grey literature and pre-print servers. We used two independent reviewers for searching, screening, data extraction and quality appraisal. We conducted a meta-synthesis for the reader to highlight overarching themes in relation to healthcare workers’ experiences of working on the frontline during a pandemic and their views about support.

There are a number of limitations inherent in the papers included. This review has highlighted a dearth of research exploring healthcare workers own views, needs and preferences. What research there is has focused predominantly on doctors and nurses with little or no identified research on other key frontline healthcare groups including physiotherapists, pharmacists, receptionists, porters or cleaners. Nearly all of the studies were of moderate-quality, with particular limitations regarding clarity of data collection and methods of analyses, therefore caution must be observed when considering the transferability of the findings.

There are also some limitations of the current review. Due to the rapidity required we did not pre-register a study protocol on Prospero. We also only searched a limited number of databases; therefore, some papers could possibly have been missed, which may have provided more detail or contradicted the findings summarised here. While research from across the world was included in this review, we were only able to include studies published in English. This review may therefore be subject to some publication bias. Ongoing attention is warranted as papers reporting on this phenomenon continue to be published, which may reveal experiences more unique to COVID-19.

The experiences of healthcare workers during COVID-19 are not unprecedented. We have an opportunity to learn from the lessons of previous pandemics and provide better support for frontline healthcare workers. More high-quality qualitative research is urgently needed in order to better understand the experiences, needs and preferences of the healthcare workforce, particularly those frontline healthcare workers whose voices have not yet been adequately represented. We need to develop clinical guidance specific to supporting this workforce. This guidance should be developed in consultation and collaboration with the healthcare workers themselves. Interventions to prevent and treat mental health distress in healthcare workers need to be developed and their timing, effectiveness and acceptability carefully evaluated. We have an opportunity to mitigate the negative mental health impact of COVID-19 and support the longer-term wellbeing of the healthcare workforce across the world.

Availability of data and materials

Data included in this review is already available in the public domain.

Abbreviations

Critical Appraisal Skills Programme

Personal Protective Equipment

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Post Traumatic Stress Disorder

Severe Acute Respiratory Syndrome

Middle East Respiratory Syndrome

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JB conceived of the idea for this review, conducted the meta-synthesis, wrote the draft of the manuscript and incorporated contributions from all the other authors. BCFC and VG completed the literature searches, screening, data extraction and quality appraisal under supervision of JB. TG and MB provided peer consultation on the design of the review. All contributed to validity checks on the meta-synthesis of the data. All authors commented on drafts of the paper and approved the final manuscript.

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Billings, J., Ching, B.C.F., Gkofa, V. et al. Experiences of frontline healthcare workers and their views about support during COVID-19 and previous pandemics: a systematic review and qualitative meta-synthesis. BMC Health Serv Res 21 , 923 (2021). https://doi.org/10.1186/s12913-021-06917-z

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Speech | Virtual

Event Title The Critical Role of Health Care Professionals During the COVID-19 Pandemic August 10, 2020

(Remarks as prepared for delivery)

I’m pleased to have the opportunity today to speak with you about COVID-19, the FDA’s role in responding to this public health emergency, and the continuing challenges the agency and the medical profession face as it continues to evolve.

I’d like to begin by thanking Dr. Susan Bailey and the American Medical Association for hosting and moderating this event today, as well as the Reagan Udall Foundation for their continuing support of the FDA.   

And I’d like to thank all of the physicians and health care professionals on this call today for your hard work, thoughtfulness, and commitment during this challenging time.  Among the heroes who have emerged from this crisis are the health care professionals who have risked their own health to serve their patients.  The nation is indebted to you.   

As we move forward, we know that the pandemic continues to evolve and the health care community must continue to deliver high-quality care to all patients. 

Fortunately, we’ve made significant progress in our understanding of this disease, our ability to combat it, and our efforts to help patients suffering with it. 

As health care professionals and scientists, we understand there are no easy answers.  We still have much more to learn about this disease, with many unanswered questions.  And we need to not only treat patients with the disease, but also to prevent the spread of the disease as we seek effective therapeutics and safe and effective vaccines.

Today, I want to talk to you about some of these challenges and about the nature and importance of science and data as we search for answers. 

I also want to speak with you in your role as doctors and other health professionals, who are dealing with very practical questions involving patients – an experience I understand and empathize with from my own practice as an oncologist. 

Most importantly, I want to reassure you that the decisions that FDA will have to make in the coming months, with regard to new tests for COVID-19, new therapeutics, and new vaccines, will be based on good science and sound data.

Because of the speed with which we need to make decisions, there has been discussion about whether FDA will compromise any of our scientific principles in reviewing data and making decisions about new products.  Let me assure you that we will not cut corners. 

All of our decisions will continue to be based on good science and the same careful, deliberative processes which we have always used when reviewing medical products.

It is important that you as medical practitioners not only understand this commitment, but also that you reassure your patients. 

We have seen surveys reporting that significant percentages of the public would be reluctant to take a vaccine once available.  We hope that you will urge your patients to take an approved vaccine so that we can seek to establish widespread immunity.

We can emerge from this emergency only by working together.      

We know that the overwhelming quantities of COVID-19 information and data that seem continually to be expanding can place a significant burden on you as clinicians seeking to respond to patient questions and, when appropriate, modify treatment recommendations.

Indeed, COVID-19 is affecting the practice of medicine in many ways, and the FDA has an important role to play in supporting providers and patients through this evolution.    Although it seems as if we’ve been engaged in the battle against COVID-19 for a very long time, in the broader context of disease and science, it’s actually been a relatively short period.

Consider that as recently as this January – just eight months ago – few people, other than a limited group of health care professionals and infectious disease experts, had even heard of the novel coronavirus.

It’s easy for me to recall just how recently SARS-CoV-2 appeared on our national radar.  That’s because the first reports of the outbreak began just a few weeks after I was sworn in as FDA commissioner. I’d like to share with you my own experiences and what I have learned in the past six months.

From the very beginning, this has been a perplexing and challenging medical mystery, presenting far more questions than answers. Even for those who have followed this public health crisis from its earliest days, little information or understanding of the disease was available. 

We didn’t know, for instance, basic things, such as how aggressive, virulent, or contagious the virus was.

That’s not a comfortable position for health professionals who like to be well informed, particularly when we work at agencies charged with protecting the American public. 

I learned quickly that despite the relative lack of knowledge, we at the FDA had to make decisions about relative benefits and risks with the data we had.

The FDA regulates the safety, effectiveness and quality of all medical products – drugs, vaccines, and medical devices.  We also regulate food safety, which of course also is critical during a crisis like this. 

There is always a steep learning curve in the response to a public health emergency, particularly when it involves a new disease. But this learning curve has been especially steep for all of us. 

I am trained, as many of you are, as a scientist.  And when this pandemic emerged, I conveyed to the leadership and staff at the FDA that even in the face of the public response to this emergency, we at the FDA needed to apply scientific rigor to any decisions being made, no matter how quickly they needed to be made,

It was reassuring to me that the FDA leadership and staff agreed whole-heartedly with this approach.  This is how the FDA has always functioned in its role as a federal agency that makes regulatory decisions based on scientific rigor.  

We at the FDA, and you as health care professionals have had to respond to challenges like these in real time. 

For this pandemic, in particular, for the FDA this has meant supporting the development of safe and effective medical countermeasures.

These actions also included ensuring that our front-line health care workers had and will continue to have the necessary protective equipment.

Since the beginning of this pandemic, FDA scientists have been immersed in providing essential regulatory advice, guidance, and technical assistance needed to advance the development of tests, therapies, and vaccines.

And it’s meant that we have been vigilant in seeking to prevent the sale of fraudulent products that could harm the public.  

To be successful in each of these efforts, we’ve been working hard to strengthen the scientific response.  We’ve done this by supporting collaborative efforts, creating open communication channels, and building public-private partnerships.

For example, the FDA has created resources like reference-grade sequence data for SARS-CoV-2 to support research and reference panels for COVID-19 diagnostic tests to support continued developments in testing.

The agency has supported the National Institutes of Health’s public-private partnership for therapeutic and vaccine development.

The FDA has also partnered with a number of external partners to gather real world evidence to help inform our understanding of the natural history of COVID-19, drug utilization and performance of COVID-19 diagnostics and therapeutics.

I’m pleased that so many of you -- and the professional organizations you are part of -- have been involved in some of these collaborative efforts. 

It’s essential that we bring forward the best ideas and innovations to support the development of new and effective treatments.  Working together has been an instrumental part in our ability to come so far, so fast.  

Our approach is consistent with and, indeed, goes to the core of the FDA’s mission; we constantly gather new information and evidence about the disease to inform our actions. 

As we learn, we discover more answers.  But that, in and of itself, is not enough.  We must continue to be vigilant and aggressive, constantly reviewing and evaluating the data as they emerge.    

The principle underlying this -- that our decisions must not only be informed by the most rigorous data and best science, but also that the evidence on which we base our continuing review is regularly refreshed and expanded through new experiences and opportunities -- is a basic approach of science. 

It’s certainly a  personal principle that has been a priority for me throughout my career as a physician and researcher.

We are learning more every day.  For example, as doctors have treated more cases of COVID, it has become clear that it is not just a respiratory ailment but can affect many organ systems, including the kidneys and heart, and can also cause vascular complications.

And although initially, many of us believed children were not significantly affected by the COVID-19 virus, subsequent reports from across the United States and Europe showed that some young COVID patients were found to have Pediatric Multisystem Inflammatory Syndrome or PMIS. 

These cases exhibited clinical features similar to Kawasaki Disease, a rare inflammatory disease primarily affecting young children, which causes blood vessels to become inflamed or swollen throughout the body.

Similarly, some dermatologists revealed that some of their patients who were later diagnosed with COVID-19 had symptoms that could be due to vasculitis, including frostbite like pain, small itchy eczema-like lesions on their extremities. and reddened patches of skin.

We are all concerned about the reports of rising case counts in different locations across the U.S., particularly in the Sunbelt states. 

We have also learned that common sense public health measures such as the wearing of masks, social distancing, hand-washing, protection of the vulnerable, and avoidance of large indoor gatherings particularly in bars, do help stop the spread and mitigate community outbreaks.  This is our country’s path forward.

The emerging data also continue to confirm the disproportionate impact of the disease on different communities, based on age, ethnicity, and race. 

The Coronavirus Task Force, of which I am a member, continues to carefully analyze and monitor the prevalence of the virus throughout the U.S., using the best available science to track, predict and mitigate the curve of the outbreak. We are closely watching the entire country and working to determine the reason behind any new outbreaks or the spread of the disease.

At the FDA, our work goes beyond analyzing the numbers.  Our responsibilities involve a range of efforts relating to the diagnosis, response, and treatment of COVID-19 and supporting solutions to bring an end to this crisis. 

This includes facilitating the development of tests, both diagnostic and serologic, supporting the advance of treatments and vaccines for the disease, and working to ensure that health care workers and others have the personal protective equipment and other necessary medical products needed to combat it.

Since day one of this emergency, our focus in addressing these challenges has been to meet the need for speed. 

To facilitate the development of new treatments and effective tests, and to make sure we have adequate supplies of essential medical equipment such as ventilators, we’ve redoubled our efforts to employ regulatory flexibility and streamlined processes where needed and appropriate, without compromising science.

The goal has been to use every available tool in our arsenal to move new treatments to patients as quickly as possible while helping ensure safety and efficacy. 

We’re moving equally fast in our efforts to help support the development of COVID-19 vaccines. 

As this audience is well aware, preventive vaccines for infectious disease are foundational to modern public health.

The FDA is committed to ensuring that potential vaccines for COVID-19 are safe and effective.

In June, the agency issued a guidance outlining key recommendations for vaccine development.

In particular, the agency emphasized the importance of recruiting diverse populations, especially those patients who have been disproportionately affected by the pandemic.

The FDA also recommended in the guidance that sponsors use an endpoint estimate of at least 50%, which could have an important impact on individual and public health, while vaccines with lower efficacy might not.

Several COVID-19 vaccine candidates have recently initiated large-scale clinical trials. While I cannot predict when the results from these studies will be ready, I can promise that when the data are available, the FDA will review them using its established, rigorous, and deliberative scientific review process.

We all understand that only by engaging in an open review process and relying on good science and sound data can the public have confidence in the integrity of our decisions.

One important tool we have used during public health emergencies to support the scientific investigation, is to employ our authority for Emergency Use Authorization (EUA). 

An EUA allows the use of unapproved medical products or unapproved uses of approved medical products to diagnose, treat, or prevent serious or life-threatening diseases or conditions when certain criteria are met, including that there are no adequate, approved, and available alternatives. 

These EUA decisions have been an important part of FDA’s efforts to shape an effective and timely response.

Though EUA decisions are based on emerging scientific evidence, we are continually evaluating and reevaluating that evidence in order to ensure that the known and potential benefits of products outweigh the known and potential risks.

Since the earliest days of the pandemic, we’ve issued EUAs for tests, ventilators, and drug treatments. The FDA has granted more than 190 EUAs for COVID-19 tests and has reviewed more than 200 clinical trials for potential therapies.

Nevertheless, we understand that the pace of FDA announcements and decisions can cause confusion for the public and providers.

For instance, some of you may be wondering whether an EUA changes the approach being used to develop drugs and vaccines.  What should doctors tell their patients about what’s going on?  What drugs are under development?  Which are the safest or most effective?  

This is a good opportunity to reiterate that although EUAs may be made on this emergency basis, they are guided by science and by continuous review of the most recent up-to-date evidence available.  

Even after an EUA is issued, we regularly review that decision based on emerging information. We make any necessary changes as appropriate. This dynamic process is continually being informed by new data and evidence, and it always seeks to balance the risks with the benefits of every COVID-19 treatment.

Take testing, for example.  Since day one, tests have played a key role in the ability to understand and manage this disease.  Good, accurate, and reliable tests can help reveal who has the disease or, by virtue of the antibodies in someone’s system, who has been infected with the virus.

We’ve worked with hundreds of test developers, many of whom have submitted emergency use authorization requests to the FDA for tests that detect the virus or antibodies to it.

In light of the circumstances, FDA’s goal has always been to provide the necessary regulatory flexibility to support developers and to provide what patients and the public need as quickly as possible without compromising safety or scientific review.

Early on in this pandemic, the FDA posted a policy that explained that under certain circumstances, FDA did not intend to object to the use of tests that were developed and validated by laboratories prior to authorization of an EUA request.  There was a national demand for such tests and we felt it was an appropriate decision to exercise regulatory flexibility concerning the use of these validated tests.

It was soon evident that some of the self-validated tests were not reliable and FDA moved quickly to update the policy in response to the available information.     

Today, we have nearly 200 reliable, authorized tests.  And we continue to monitor the performance of these tests and encourage the development of new and better tests that will enable us to understand this disease and help patients and the medical community address the challenges. 

As we have done since the beginning of the pandemic, we will continue to balance the pressing need for access to diagnostic and antibody tests with our helping to ensure that available tests are accurate and reliable. 

This same approach applies to potential treatments for COVID-19.  We work closely with partners throughout the government, academia, and drug and vaccine developers to explore, expedite, and facilitate the development of products, and provide guidance and technical assistance to drug manufacturers to expedite clinical trials.  

Our Coronavirus Treatment Acceleration Program, or CTAP, which we launched in March, has helped to focus the scientific and technical expertise of the agency’s staff to review potential products according to their scientific merit.

By providing enhanced regulatory support, the FDA has been able to support the initiation of more than 200 trials for COVID-19 therapies over the past few months.

This work is essential to returning us to some semblance of normalcy.  After all, we need treatments and cures.

But there’s a corresponding aspect of the FDA’s work that is also essential. 

This role is to support you, as physicians and medical providers to help answer your patients’ questions. Certainly, explaining the process, as complicated as it is, is an important piece of the response.

To understand this, it may be instructive to look at some actions we’ve taken with several drugs, each of which were granted an EUA, and that received significant public attention.

Back in March, the FDA granted an EUA to allow the drugs chloroquine phosphate and hydroxychloroquine sulfate to be used to treat certain hospitalized COVID-19 patients when a clinical trial was unavailable, or when participation in a clinical trial was not feasible.  Early but limited research indicated that the drugs, which are approved to treat malaria and have a well-understood safety profile, might be effective in treating COVID.

After the EUA was issued, FDA continued to monitor the emerging clinical evidence on the use of these drugs in COVID-19 patients.

Based on null results from randomized controlled trials and further analysis of clinical pharmacology information, the FDA determined that chloroquine and hydroxychloroquine are unlikely to be effective in treating COVID-19 in the patient population covered by the EUA and no longer met the legal criteria for emergency use.  As a result, we revoked the EUA in June.

Separately, the FDA issued an EUA for the antiviral drug remdesivir in May.

A randomized trial led by the National Institutes of Health found that remdesivir helped to reduce the length of hospitalization for COVID-19 patients. Additional trials have been completed or are planned to help us understand the appropriate role for remdesivir in this COVID crisis.

Because of the nature of the pandemic, there may be confusion or a lack of understanding about the actions we have taken on therapeutics. 

We rely on you in the medical community to answer patients’ inevitable questions about treatments and vaccine development. It is our responsibility at the FDA to provide you with the information you need for your patients.

The fundamental message that we need to communicate is that the FDA’s decisions are based on science, that decisions sometimes change based on our careful review of the most recent evidence, and that we are committed to ensuring that the drugs we approve are safe and effective based on reliable data.   

Physicians and other health care professionals have other important roles and responsibilities. One they share with the FDA is to help ensure that the public gets the products they are being promised and to be aware of and avoid scams being perpetrated on them.

The FDA regularly warns consumers to be cautious of websites and stores selling products with unproven claims to prevent, treat, diagnose or cure COVID-19 or unauthorized test kits. The FDA has not evaluated these fraudulent products for safety and effectiveness, and these products might actually be dangerous to patients. 

To help tackle the issue of health fraud during the pandemic, the FDA launched Operation Quack Hack, which monitors online marketplaces for fraudulent products and identifies misinformation about COVID-19.

The agency has identified more than 700 fraudulent and unproven medical products related to COVID-19 and has collaborated with the Federal Trade Commission to issue warning letters to firms marketing products with misleading claims, and sent more than 150 reports to online marketplaces, and more than 250 abuse complaints to domain registrars to date.

We make most of this information available on our website and encourage doctors to become familiar with this resource and share this information with their patients.

Physicians have an important role in this area because of your ability to identify and track patients who take illegitimate or black-market drugs.

There is currently no cure for the coronavirus, and it is important for doctors to help inform patients about dangerous products and unscrupulous marketers who may be selling products with false or misleading claims.

Eight months into the pandemic, we have made important progress. Yet with cases continuing to rise, it is evident that further action is needed for our country to chart a course for recovery.

The FDA is launching the COVID-19 Pandemic Recovery and Preparedness Plan (PREPP) to help apply best practices and lessons learned from the emergency response to date. Our goal is to make needed adjustments to support the ongoing COVID-19 response, while also strengthening our resilience and improving our capacity to respond to public health emergencies in the future.

As doctors, we ensure that our treatment plans for our patients are adjusted according to the latest evidence.

I believe this same principle applies to the FDA, which as a science-based agency, is committed to continuous improvement by examining the data and modernizing our approaches when needed.

As we identify lessons and make subsequent changes, we are committed to proactively communicating any forthcoming regulatory changes to doctors and other health professionals.

Though we don’t have all the answers, we do know is that the COVID-19 virus will be with us for the foreseeable future.  We are still far from understanding every aspect of this disease.

But the FDA will continue to operate with patient safety and scientific integrity as our North Star. It is this approach that continues to guide the development of new technologies and necessary regulations for safeguarding public health for the present and future. 

Our goal is to provide you with the information and understanding you need to ensure that patients receive the support, attention and treatment they deserve.  We look forward to working with you to achieve that goal.

ORIGINAL RESEARCH article

Challenges faced by healthcare professionals during the covid-19 pandemic: a qualitative inquiry from bangladesh.

• 1 Sociology Discipline, Khulna University, Khulna, Bangladesh
• 2 Development Studies Discipline, Khulna University, Khulna, Bangladesh
• 3 Institute for Physical Activity and Nutrition, Deakin University, Melbourne, VIC, Australia
• 4 Discipline of Public Health, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
• 5 Epidemiology, School of Health Sciences, Mekelle University, Mekelle, Ethiopia

Background: The coronavirus disease 2019 (COVID-19) pandemic has caused increasing challenges for healthcare professionals globally. However, there is a dearth of information about these challenges in many developing countries, including Bangladesh. This study aims to explore the challenges faced by healthcare professionals (doctors and nurses) during COVID-19 in Bangladesh.

Methods: We conducted qualitative research among healthcare professionals of different hospitals and clinics in Khulna and Dhaka city of Bangladesh from May 2020 to August 2020. We conducted 15 in-depth telephone interviews using a snowball sampling technique. We used an in-depth interview guide as data were collected, audiotaped, and transcribed. The data were analyzed both manually and using QDA Miner software as we used thematic analysis for this study.

Results: Seven themes emerged from the study. Participants experienced higher workload, psychological distress, shortage of quality personal protective equipment (PPE), social exclusion/stigmatization, lack of incentives, absence of coordination, and proper management during their service. These healthcare professionals faced difficulty coping with these challenges due to situational and organizational factors. They reported of faith in God and mutual support to be the keys to adapt to adversities. Adequate support to address the difficulties faced by healthcare professionals is necessary for an overall improved health outcome during the pandemic.

Conclusion: The findings highlight the common challenges faced by healthcare professionals during the COVID-19 outbreak. This implies the need to support adequate safety kits, protocols, and support for both physical and mental health of the healthcare professionals.

Introduction

The COVID-19 outbreak was declared as a global pandemic on March 11, 2020 ( 1 ). Although social distancing is the most effective way to contain the outspread of this virus, this is not easy to implement for healthcare professionals who require direct contact with COVID-19 patients and puts them under a high risk of being infected themselves ( 2 ). Frontline healthcare professionals are particularly vulnerable during this pandemic owing to their commitment to contain the disease ( 3 ). As of October 15, 2020, there were around 4,797 COVID-19 cases for doctors and nurses with more than 100 deaths of physicians in Bangladesh ( 4 ). Besides physiological threats, such public health emergency affects the psyche of healthcare workers, including professional stress, fear of infection, and feeling helpless ( 5 ).

The number of doctors in Bangladesh government healthcare facilities is scarce (5.26 doctors/10,000 people). Hence, many healthcare professionals worked around 17 h, including long tele-counseling shifts each day ( 6 ). To mitigate this challenge, the government appointed an additional 2,000 doctors on May 2020 ( 7 ). Further, healthcare professionals faced acute shortage of masks, hand gloves, and personal protective equipment (PPE) to protect themselves from COVID-19 infection ( 8 ). Moreover, locally produced PPEs, masks, and other kits provided by the authority are being reported to be of low quality and unable to protect the medical workforce from being infected ( 9 ).

Healthcare professionals also suffered from insomnia, loneliness, sleep disorder, and mental depression as a result of the workload and related stress ( 10 ). They were experiencing anxiety attacks as well as frustration due to a lack of knowledge, environmental changes, and fear of infection both by themselves and by their family members ( 11 ). Currently, healthcare professionals are also bound to maintain physical distance from their family members to reduce the risk of contagion, which results in further psychological distress ( 12 ). Hence, a special attention to monitor the psychological issues of high-risk population exposed to COVID-19 becomes more essential ( 13 ).

When it comes to the challenges faced by the healthcare professionals of Bangladesh during COVID-19 pandemic, concerns raised from bad governance cannot be ignored. The number of PPEs provided by the government was insufficient for healthcare professionals, and they were mostly untrained regarding how to use them. This resulted into an alarming rate of infection among the medical workforce ( 14 ). Recent studies emphasize on strengthening the healthcare governance in Bangladesh by properly distributing healthcare facilities between urban and rural areas, public and private facilities, enhancing the role of media, increasing the recruitment of healthcare workers, and concentrating on the provision of necessary healthcare equipment such as intensive care units and oxygen supply ( 15 – 17 ).

Doctors are facing tremendous difficulties at work during the COVID-19 pandemic ( 18 ). Despite these obstacles, healthcare professionals have adapted to deal with the prevailing health crisis. A previous study ( 19 ) has shown that meditation, relaxation as well as music therapy can help to mitigate the daily stress. During the severe acute respiratory syndrome (SARS) outbreak in 2005, healthcare professionals took some initiatives to cope with the stress associated with the pandemic. The coping mechanisms included avoidance of news about the SARS pandemic, small gatherings after work where problems can be shared as well as participating in other recreational activities ( 20 ). Proper training, PPE, and medical assistance are important to support healthcare providers ( 6 ); however, these are not available in Bangladesh. A number of studies have been conducted on COVID-19-related issues in Bangladesh; however, there are no qualitative studies on the challenges faced by healthcare professionals during the current COVID-19 pandemic. As qualitative research is known for generating rich information in health research ( 21 ), we attempted to address this research gap to get a more in-depth knowledge of the individual experiences, beliefs, opinions, behaviors, and feelings of the healthcare professionals during the pandemic ( 22 ).

Theoretical Framework

We used the stress theories to understand the challenges healthcare professionals in Bangladesh are facing during the COVID-19 pandemic. The COVID-19 outbreak has generally caused public stress ( 23 ) as people go through a series of physical and mental challenges both inside and outside which affects their own subjective evaluations ( 24 ). Ursin and Eriksen (2004) provide a further explanation on how people go through stress during a crisis. The authors used the term “stress” to denote four different views, namely, “stress stimuli,” “stress experience,” “non-specific general stress response,” and “experience of the stress response” ( 25 ). According to Cognitive Activation Theory of Stress (CATS) theory, people acquire knowledge when handling adversities, and a normal, well-balanced stress at such situations should be common. Response to stress is important as this provides the energy that enables them to fight against the odds. However, when there is a disparity between the expected and actual circumstance, the stress response mechanism starts struggling ( 26 ). While stress response is essential to face challenges, higher levels of sustained stress can lead to physical and mental disorders. We argue that the sustained workload and mental stress of the healthcare professionals during the pandemic originate an acquired expectancy referred to as “hopelessness”( 27 ).

An exploratory qualitative inquiry was employed to understand the in-depth knowledge of challenges dealt by health workers from Khulna and Dhaka city in Bangladesh from May to August 2020. Doctors and nurses who are willing and provided treatment at different hospitals and clinics in Bangladesh during the COVID-19 pandemic participated in this study. We selected 15 respondents for the in-depth interviews through the snowball sampling technique. The participants were recruited through referrals of healthcare professionals from our previous acquaintances. We used this technique as healthcare professionals who were willing to participate in this study were extremely hard to find during the pandemic. The in-depth interview was conducted through telephone. We developed an in-depth interview guide to probe questions for the interview process. The items for the interview guide were generated through searching the relevant literature. Only contents related to the present study were considered, while pieces of pure medical literature were excluded from the review. The guide consisted of questions on barriers related to workload, severity of the illness and associated stress, availability and quality of PPE, COVID-19-related challenges, and coping strategies to manage the barriers.

SRR, TY, TBA, and MSI (academicians who completed their second degree) conducted the interviews and collected data through multiple sessions and with the convenience of the participants. The duration of each session was 30–40 min in general, and the interviews were recorded through an audio recording application/device, which was transcribed in the next stage. We used the follow-up questions to extract rich information during the interviews. Verbal probes such as repeating the ideas and phrases of participants and showing enthusiasm to a particular topic during the interviews were part of the probing strategy. Apart from the authors, two trained research assistants were appointed to manage the data collection and transcription. TBA and MSI independently coded the data from verbatim transcript as the process included the development of a code structure initially. The whole coding procedure was reviewed and finalized with the consent of all authors. We applied a deductive approach suggested by Miles and Huberman (1994) ( 28 ) using thematic analysis technique ( 29 ). The most recurring and significant quotes were selected to exemplify the predetermined themes. While analyzing, we focused on the meaning, context, phrases, frequency, and intensity of the statements of our participants. We analyzed the data both manually and using QDA Miner (version 5) software. The QDA miner is useful in managing a large volume of qualitative data extending the scope of manual analysis. It is largely used by researchers and experts for conducting qualitative research worldwide.

We maintained standard ethical protocols to conduct this research. The study protocol was approved by the person who blinded for peer review. At the beginning of the interviews, informed consent was sought from each participant after a briefing about purpose of the research was done. The identities of the respondents were kept confidential, and they assured that the information provided by them would only be used for academic research.

Characteristics of Study Participants

Fifteen respondents were included in the in-depth interview. The summary of the participants and their details are provided in Table 1 .

Table 1 . Sociodemographic profile of participants.

Seven themes emerged from the unstructured interviews, i.e., workload, PPE, social acceptance, mental health, incentives, coping strategies, coordination, and direction of the respondents during the COVID-19 pandemic.

High Workload

Participants indicated that the health sector faces a shortage of medical workers. Moreover, many registered doctors do no practice medicine, resulting in higher workload by the active medical workforce in public as well as in private facilities. In the private facilities, doctors were usually provided with a 1-day break each week. Doctors were working for long shifts in their working days and during holidays via telecommunication. For example, Participant 3 said,

You are asking the doctors about their workload! When people were busy partying at the eve of Eid-ul-Fitr festival, we were working in the hospital. I had a shift even on Eid day. Moreover, I was diagnosed as COVID-19 positive on 15 th of June 2020, which demands for at least a 21 days recovery process after being further tested as being COVID-19. But we cannot afford that luxury as the hospital does not have enough human resources. Consequently, I had to join my work right after accomplishing my recovery from the virus .

Apart from enduring tremendous physical pressure, excessive workload also leads to increased mental stress. Medical facilities also have few nurses, who had to work 16–17 h shift per day. Additionally, fear of infection prevented workers from joining their workplace. Participant 5 said,

Since we have completed our nursing degree, so we are supposed to be psychologically well equipped to serve people in any medical emergency. But at the very beginning of the coronavirus outbreak, many of us suffered from a fear of infection and were too afraid to come to work. This decline in the regular number of nurses created too much workload for us .

Healthcare professionals who were younger and working in Dhaka-based hospitals reported of higher workload in this study. This might be due to a higher work assignment for younger people and a greater outbreak of COVID-19 in the capital city. When asked about workloads, Participant 12 shared with frustration,

Dhaka is hit most severely during the first wave of COVID-19. It is the capital city of the country with 20 million population and the largest international airport. People are landing here from countries with high infection rate every day and the disease is spreading like bushfire. We are admitting a large number of patients each day and having a really difficult time dealing with it .

Lack of PPE

Participants repeatedly pointed out that PPE supplied by their hospitals were either inadequate or of low-quality. Though the government demanded on the mass media that every hospital has been provided with the required numbers of PPEs, the fact on the ground was different. Especially, study participants in private medical facilities need to buy their own PPEs as they were not sure of the availability in the health facilities. Participant 1 corroborated the issue.

Despite the need to have a regular supply of PPEs, the hospital does not have enough of them in its possession. I have received one PPE per week from Japan Bangladesh Friendship Hospital, which is not sufficient. Consequently, I am needed to buy PPE at my expenses to ensure my safety during work. Another threatening fact regarding PPEs came into my notice from a number of national newspapers. Some corrupt businessmen are generating new PPE's from the ones that have been dumped as medical wasted in Keraniganj, Dhaka. This issue gave me quite a shock and made me question my oath to serve the mass people in any given situation .

The PPEs provided by the authority were made of plastic-type material. The shortage of PPE also declined to some extent with time. An additional complaint came from the nurses that they had to face acute shortage of PPEs as doctors were the primary focus here and the need for an adequate supply of PPEs for nurses was relatively ignored. Participant 6 noted,

At the first slot, we were provided with a huge number of poor-quality PPEs which made the pandemic situation more vulnerable for health professionals like us. But as of now (month of June), we have a steady supply of good quality PPEs which can efficiently protect us from this virus. From my perception, there is no lack of PPE in the present condition .

Low Social Acceptance

Social stigma was another challenge for the healthcare professionals during the COVID-19 pandemic. The neighbors perceived them as a nuisance and usually avoided communication for fear of infection. In some cases, landlords raised monthly house rents of the medical workers and evicted them from their property if they were tested COVID-positive. Sometimes, their maintenance of social distance became rather cruel, and this disturbed the healthcare professionals. Two of the statements represent this condition:

Participant 3: “ Haha! Mass people always perceive us doctors as “butchers” in this country. We are shown some respect over social media posts, but there is no respect for doctors in the real-world. Red flags are used to mark the zone containing COVID positive patients, but from my perspective, these flags are playing the role of barriers. While we need more psychological support from general people, working within the red zone has completely excluded us from society.”

Participant 5: “ Actually, I feel deeply disturbed when I talk about the issue of social acceptance. When I started serving contagious patients during this pandemic, people of my community treated me in a way which made me feel like I was a raped woman… (Crying). But I have taught myself to endure that pain and work as a frontline fighter against this deadly virus.”

Parents of healthcare professionals remained concerned about their children working in such a risky environment. They often tried to bargain with them to stay home, but it was merely parental concern, and the participants continued work after pacifying them. Generally, their relatives maintained a social distance and refrained from visiting their houses. But participants considered this as positive to ensure the safety of both their relatives and their family members.

Mental Health Problems

People working in the medical sector are trained to think and act steadily in any medical emergency. Regardless of that training, participants mentioned that they had to cope with different psychological challenges, including anxiety, depression, insomnia, and fear of sudden death during the COVID-19 pandemic. Participant 2 said,

Being a doctor has taught me to have full control over my mind. Despite that control, the current pandemic makes me anxious sometimes as many doctors are being infected during their service toward COVID-19 patients. There is one incident worth mentioning in this context. Witnessing the death of patients is part of the job for us, but I had to witness the death of a medical doctor in Sylhet due to COVID-19, which was a first for me. It was the most shocking thing during my lifetime working experience. After this experience, I started having trouble sleeping .

Healthcare givers serve in an atmosphere where the fear of infection prevails at its largest. Despite that, participants were more concerned about family members being infected by them rather than themselves being infected, leading to further mental stress. Participant 4 mentioned,

To me, psychological pressure mainly consists of anxiety regarding the safety of my family. I am a widow, and my daughters are dependent on me both economically and for the sustenance of their daily lives. This familial condition puts me in a lot of pressure and forces me to think about what would happen to my daughters if I was diagnosed as a corona virus-positive and died. The constant thought of leaving my daughters all alone in this world is quite stressful .

Witnessing sudden death of colleagues created a feeling of helplessness among the healthcare professionals, leading to many of them to experience insomnia. The lack of appreciation by colleagues also caused psychological pressure. One of the nurses mentioned that doctors do not appreciate them enough.

Participant 6: We work with extreme fear and risk of infection risking our lives, but we get no appreciation. People think only doctors are contributing to save lives. We (nurses) are always ignored and underpaid in this country. It's nothing new .

Lack of Incentives

All participants were aware that there was no extra-incentive for them despite working extra hours. Some incentives were promised by the government, such as providing treatment cost in case of infection and providing an isolation room to ensure safe inhibition. But none was implemented in the real life. Further, participants strongly believed that these initiatives were not going to be implemented shortly. For example, Participant 3 said,

Government announced that if anyone got infected by coronavirus during their service, the authority would provide some money for treatment. Surprisingly, I did not receive any monetary support to bear my treatment cost when I was diagnosed as COVID-positive. Their announcement is void as always, and it is never going to be implemented. Though we are getting two basic salaries of around 50,000, which is not enough for us .

While the incentives provided by the authority for the employees in the government facilities were not satisfactory, the condition of the healthcare professionals working in private facilities was even worse. There was no monetary incentive for the healthcare professionals working in private facilities if they got infected or died during their service. The participants were depressed about this discrimination between public and private employees. Moreover, they were also deprived of basic amenities such as break between work shifts or provision of meals raising frustrations. Participant noted,

We have seen that roster system is in place to arrange the shifts of the health professionals in the government hospitals. As a result, government doctors get seven days off after completing a seven-day shift with Corona patients. Unfortunately, we, the private clinic workers, do not get any incentive like that. I don't even get my meals from the hospital .

Lack of Coordination and Direction

The WHO and government guidelines were changing continuously given the disease is new and previous knowledge is little. Consequently, doctors remained uncertain about the line of treatment. These uncertainties created additional mental stress for medical professionals.

The participants reported that patients were unaware of any safety protocols. COVID-19-positive patients often come to medical facilities to receive standard medical consultation, which put COVID-negative patients as well as the medical workers at-risk. In several cases, doctors and nurses got infected because patients did not reveal that they were COVID-19-infected. A high-level coordination failure was prevalent in the healthcare administrations.

Moreover, healthcare workers were dissatisfied about some discriminatory initiatives taken up by the authority. Participants mentioned the case of the bank sector, where employees worked for only 20 days in April and May. In contrast, healthcare professionals did double or triple shifts, which was frustrating. Besides, they did not have any training regarding how to function correctly in a virus outbreak. It was also perceived that the authority involved more administrators and fewer specialists to tackle down this pandemic. For example, Participant 3 mentioned,

I want to mention one more issue here. It is needed to create a committee containing doctors as well as virologists who are specialized in providing guidelines in the context of how to handle the current COVID-19 situation in Bangladesh best. Instead, the government has created a task force containing DCs, UNOs and other administrative personnel who possess no knowledge about the virus .

Coping Strategies

All of the participants expressed that belief upon God kept them relaxed. Support from family members and colleagues was also an essential coping mechanism. The healthcare professionals maintained regular conversations with colleagues maintaining social distance and tried to be benevolent with each other in their workplace. This supportive environment helped them a great deal in reducing their mental stress. Keeping their sacred oath in mind, they were always more concerned about their patients than their well-being. This concern for the well-being of mass people served as a coping mechanism on its own. For instance, Participant 4 said,

I cope with the challenges faced in my workplace with the support of my family, colleagues and a firm belief on the almighty's plans for all of us. The support of my close ones and trust in the almighty provides me with a sense of mental strength encourages me to stay positive any crisis. I also take mental notes that this is my job, and I must do it. If I become nervous in performing my duties, then how would the general people survive?

Apart from taking mental support from friends and families, healthcare professionals tried to follow every medical rule and regulation in their ability to keep safe from infection. The study protocol was approved by the Ethical Clearance Committee of Khulna University. Other participants reported meditation as means to increasing mental strength. Overall, participants put faith in a greater force in this crisis and keep reminding themselves that as they were working for the well-being of humanity.

Our results showed that frontline healthcare professionals in Bangladesh had an increased workload during this crisis and a potential system failure in the healthcare sector. Lack of sufficient healthcare workers, knowledge about the virus, and basic training were some of the reasons leading to excessive workload, which consequently gave rise to psychological stress. This finding is consistent with some of the existing literature ( 30 , 31 ). A previous study also showed that excessive work pressure was responsible for mental distress, insomnia, physical weakness as well as fear of infection of the healthcare professionals ( 32 ). Our study also focused on the lack of quality PPEs prevalent in the healthcare facilities. It was reported that the insufficiency consequently led to an increasing rate of infection among healthcare professionals in Bangladesh. Several studies have found that insufficient PPE triggered the spread of the viruses among healthcare professionals ( 33 , 34 ). Besides, wearing PPE for a long time was a crucial challenge for participants, subsequently resulting in drinking less water than necessary, which might have affected their immunity ( 35 ).

Coordination failure was prevalent among different administration sections in each facility where the respondents worked, resulting in a chaotic environment. Consequently, both doctors and patients were unsure about the protocols needed to maintain safety, which further increased the risk of infection. Insufficiency of medical staff and equipment was common, resulting in excessive workload and safety hazard ( 36 ). This workload and constant fear of infection both for themselves and for their family members put participants under substantial psychological stress ( 11 ). Social acceptance from neighbors, colleagues, and peer groups could act as a lifeline in removing this psychological stress. But the social reaction of most cases was still adverse toward the medical workforce, and they were shunned from their social life. Hence, the experience of medical professionals was pretty challenging during the pandemic. They still took coping strategies such as putting their faith in God, treating each other with kindness, and soothing conversation with a peer group to cope up with the stress to some extent.

We observed that most of the participants in this study required adequate protective supplies and proper rest, which is consistent with the present study ( 37 ). Psychological stress faced by healthcare professionals during public health emergencies included constant worries about infecting children and parents of an individual, fear of death, anxiety about critical patients, and personal danger ( 38 , 39 ). Healthcare professionals felt anxious when their colleague was infected by COVID-19 ( 9 ). We also observed that healthcare professionals who had children were emotionally distressed to maintain distance from their loved ones due to a higher risk of being infected by COVID-19. The finding was similar to another previous research ( 20 ). Nurses expressed dissatisfaction with the workload as they are not appreciated enough, although it is evident that they often provide quality healthcare services like the doctors ( 40 ).

Healthcare professionals also faced stigma from their neighbors and relatives. Neighbors perceived that the health workers carry a higher risk of infection from their exposure to patients. As a result, healthcare professionals were shunned from society and treated harshly, which sometimes demotivated them to serve patients. However, previous study documented that healthcare professionals need social support from their family members, relatives, and neighbors. Being devoid of that, support can result in anxiety and depression for healthcare professionals ( 41 , 42 ). We predict that incentives such as economic support, constant supervision, sufficient protective equipment, and adequate workforce could motivate health workers to contribute more during pandemic situations. Unfortunately, Bangladeshi healthcare professionals are mostly deprived of these facilities. Some of the infected healthcare professionals of this study mentioned that though the government announced some financial incentives, they did not receive it in reality.

When comparing our finding with the SAARC countries, we see some striking similarities. These countries already have a vulnerable economy characterized by weak medical infrastructure that rarely managed to provide its people with sufficient medical care, at least providing the healthcare professionals with necessary psychological help ( 43 ). Inadequate PPEs, social stigma, and being victims of violence added extra psychological stress for healthcare professionals in the middle of their already hectic schedule ( 44 ). Besides, healthcare professionals from different age, gender, and socioeconomic background suffer from different psychological issues. A specialized set of interventions are required for healthcare professionals depending on their mental health condition ( 45 ). Although the National Health Policy of Bangladesh (2011) promises an adequate supply of logistics and manpower in government healthcare facilities, and coordination between different healthcare services-related departments ( 46 ), the reality is different. We observed that the lack of coordination and skilled manpower still remains a key problem affecting the healthcare services quality in the country, which corresponds to the existing literature ( 47 , 48 ).

The spread of an epidemic can cause psychological trauma for healthcare professionals ( 10 , 35 ). Therefore, effective coping strategies are required. Studies suggest that self-care, confidence, teamwork, and gathering among coworkers are some practical ways to alleviate mental pressure, work stress, and posttraumatic experiences amid emergencies of caregivers ( 49 , 50 ) which was consistent with the results of this study. The stress theories also argue that the sustained response to stress for the healthcare professionals may lead to physical illness through proven pathophysiological ways ( 51 , 52 ). We suggest as the pandemic prevails, healthcare professionals will face further physical and mental adversities; therefore, they will need a special attention to avoid this helpless situation.

Strengths and Limitations

A strength of this study is using the exploratory qualitative inquiry to analyze what challenges the healthcare professionals in Bangladesh are facing and how they managed these adversities during the COVID-19 pandemic. However, the large volume of data was difficult to collect, analyze, and maintain. The researchers put a greater amount of effort and time to offset the limitations. We followed the consolidated criteria for reporting qualitative research (COREQ) checklist for our in-depth interviews and for reporting this study. The interviews were not restricted to specific questions and topics which helped producing rich and detailed information. We used the snowball sampling technique as we were unable to find a large number of healthcare professionals who were willing to allow us sufficient time and cooperation during the pandemic. Because of the hectic schedule of the healthcare workers, interviews had to be kept short in some cases. However, we managed to reach the desired number of participants required to complete the study. As qualitative research relies on the depth of information instead of the number participants, 15 healthcare professionals who participated in this study were enough for data saturation. Besides, executing a qualitative study through telephone interviews had its own limitations, although the researchers put their best effort to respond to the situation. We acknowledge that direct observation and methodological triangulation might have provided further insight into the topic.

Conclusions

The present study explores the challenges faced by healthcare professionals during COVID-19 pandemic in Bangladesh. We found that insufficiency of medical staff as well as medical equipment was common and resulted in increased workload. Apart from this, shortage of PPE, fear of being infected, social exclusion, and mismanagement contributed further to put the healthcare professionals in adversity. Although the National Health Policy of Bangladesh (2011) recommends enhancing skilled manpower and logistic support, we found the actual scenario to be different. Especially during the COVID-19 outbreak that put the healthcare sector into unprecedented challenge, the promised coordination and support in the healthcare sector rather reflects a disparity between the policy and the practice. Despite the recently introduced National Infectious Diseases Act (2018), lack of a standardized COVID-19 protocol kept the medical professional under constant risk of infection and mental pressure. We conclude that the healthcare professionals need to be supported with adequate resources for both physical and mental health. While workloads need to be lessened, a proper coordination and access to information as promised in the National Health Policy during this public health emergency should be put in practice to ensure quality healthcare services.

Data Availability Statement

The original contributions presented in the study are included in the article/ Supplementary Material , further inquiries can be directed to the corresponding author.

Ethics Statement

The studies involving human participants were reviewed and approved by Ethical Clearance Committee, Khulna University. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

Author Contributions

SR conceived the idea. SR, TY, TA, and MI analyzed the data. SR and TY drafted the manuscript. SR, SI, HG, and PW critically reviewed and approved the final version of the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We express our gratitude to all the healthcare professionals who participated in this study despite their busy schedule during the pandemic. We are also thankful to the administrations of health facilities for their kind cooperation throughout the data collection.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2021.647315/full#supplementary-material

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Keywords: COVID-19, health professionals, workload, mental health, Bangladesh

Citation: Razu SR, Yasmin T, Arif TB, Islam MS, Islam SMS, Gesesew HA and Ward P (2021) Challenges Faced by Healthcare Professionals During the COVID-19 Pandemic: A Qualitative Inquiry From Bangladesh. Front. Public Health 9:647315. doi: 10.3389/fpubh.2021.647315

Received: 29 December 2020; Accepted: 25 June 2021; Published: 10 August 2021.

Reviewed by:

Copyright © 2021 Razu, Yasmin, Arif, Islam, Islam, Gesesew and Ward. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Shaharior Rahman Razu, razusocku@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Research article
• Open access
• Published: 09 January 2021

A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being

• Johannes H. De Kock   ORCID: orcid.org/0000-0002-2468-5572 1 , 2 ,
• Helen Ann Latham 3 ,
• Stephen J. Leslie 4 ,
• Mark Grindle 1 ,
• Sarah-Anne Munoz 1 ,
• Liz Ellis 1 ,
• Rob Polson 1 &
• Christopher M. O’Malley 1  

BMC Public Health volume  21 , Article number:  104 ( 2021 ) Cite this article

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Health and social care workers (HSCWs) have carried a heavy burden during the COVID-19 crisis and, in the challenge to control the virus, have directly faced its consequences. Supporting their psychological wellbeing continues, therefore, to be a priority. This rapid review was carried out to establish whether there are any identifiable risk factors for adverse mental health outcomes amongst HSCWs during the COVID-19 crisis.

We undertook a rapid review of the literature following guidelines by the WHO and the Cochrane Collaboration’s recommendations. We searched across 14 databases, executing the search at two different time points. We included published, observational and experimental studies that reported the psychological effects on HSCWs during the COVID-19 pandemic.

The 24 studies included in this review reported data predominantly from China (18 out of 24 included studies) and most sampled urban hospital staff. Our study indicates that COVID-19 has a considerable impact on the psychological wellbeing of front-line hospital staff. Results suggest that nurses may be at higher risk of adverse mental health outcomes during this pandemic, but no studies compare this group with the primary care workforce. Furthermore, no studies investigated the psychological impact of the COVID-19 pandemic on social care staff. Other risk factors identified were underlying organic illness, gender (female), concern about family, fear of infection, lack of personal protective equipment (PPE) and close contact with COVID-19. Systemic support, adequate knowledge and resilience were identified as factors protecting against adverse mental health outcomes.

Conclusions

The evidence to date suggests that female nurses with close contact with COVID-19 patients may have the most to gain from efforts aimed at supporting psychological well-being. However, inconsistencies in findings and a lack of data collected outside of hospital settings, suggest that we should not exclude any groups when addressing psychological well-being in health and social care workers. Whilst psychological interventions aimed at enhancing resilience in the individual may be of benefit, it is evident that to build a resilient workforce, occupational and environmental factors must be addressed. Further research including social care workers and analysis of wider societal structural factors is recommended.

Peer Review reports

Health and social care workers (HSCWs) continue to play a vital role in our response to the COVID-19 pandemic. It is known that HSCWs exhibit high rates of pre-existing mental health (MH) disorders [ 1 , 2 , 3 ] which can negatively impact on the quality of patient care [ 4 ].

Studies from previous infectious outbreaks [ 5 , 6 ] suggest that this group may be at risk of experiencing worsening MH during an outbreak. Current evidence examining the psychological impact on similar groups [ 7 , 8 , 9 ], suggest that this group may be at risk of experiencing poor MH as a direct result of the COVID-19 pandemic. Compounding the concerns about these data are that HSCWs will be likely to not only be at a higher risk for experiencing MH problems during the pandemic, but also in its aftermath [ 5 ].

There are some specific features of the COVID-19 pandemic that may specifically heighten its potential to impact on the MH of HSCWs.

Firstly, the scale of the pandemic in terms of cases and the number of countries affected has left all with an impression that ‘no-one is safe’. Media reporting of the pandemic has repeatedly focused on the number of deaths in HSCWs and the spread of the disease within health and social care facilities which is likely to have amplified the negative effects on the MH of HSCWs.

Secondly, usual practice has been significantly disrupted and many staff have been asked to work outside of their usual workplace and have been redeployed to higher risk front line jobs.

Finally, the intense focus on personal protective equipment (PPE) is likely to have specifically heightened the impact of COVID-19 on the MH of HSCWs due to the uncertainty surrounding the quantity and quality of equipment, the frequently changing guidance on what PPE is appropriate in specific clinical situations and the uncertainty regarding the absolute risk of transmission posed. While other workers will have been impacted by COVID-19, it is highly likely that the above factors will have disproportionately affected the MH of HSCWs [ 9 , 10 ]. Indeed a British Medical Association survey on the 14th May 2020 during the pandemic showed that 45% of UK doctors are suffering from depression, anxiety, stress, burnout or other mental health conditions relating to, or made worse by, the COVID-19 crisis [ 11 ].

Although evidence based psychological interventions are available for this population [ 12 ], there is a paucity of evidence about interventions for the MH of HSCWs during pandemics. Recent calls to action mandated the need to provide high quality data on the psychological impacts of the COVID-19 pandemic [ 13 , 14 ]. This pandemic has rapidly changed the functioning of society at many levels which suggests that these data are not only needed swiftly, but also with caution and scientific rigour [ 13 , 14 ].

These data are needed in order to equip HSCWs to do their job effectively – high levels of stress and anxiety have been shown to decrease staff morale, increase absenteeism, lower levels of work satisfaction and quality of care [ 6 , 15 ]. It is therefore a priority to understand the psychological needs of our HSCWs in order to provide them with the appropriate tools to mitigate the negative effects of dealing with the COVID-19 pandemic.

While HSCWs have been identified as vulnerable to the negative psychological impact from the current pandemic, they do not form a homogeneous population. It may therefore be appropriate to identify particularly vulnerable groups within the larger population of HSCWs and target psychological support to them. This review seeks to understand whether any group of HSCWs could be confidently excluded from psychological support interventions because they are deemed to be at a low risk. Holmes et al. [ 14 ] have warned that a one-size-fits-all approach to supporting HSCWs might not be effective. This, together with the lack of evidence around tailoring psychological interventions during pandemics [ 1 ], highlights the importance of identifying vulnerable groups, to ensure appropriately personalised interventions are made available.

Aim of the review

The aim of this review is to identify the psychological impact of the COVID-19 pandemic on the health and social care professions, more specifically to identify which sub-groups are most vulnerable to psychological distress and to identify the risk and protective factors associated with this population’s mental health.

This review, looking exclusively at the psychological impact of the COVID-19 pandemic on HSCWs will therefore contribute to informing where mental health interventions, together with organisational and systemic efforts to support this population’s mental health could be focussed in an effort to support psychological well-being [ 14 ]. Rapid but robust gathering of evidence to inform health decision-makers is vital and in circumstances such as these, the WHO recommends rapid reviews [ 16 ].

Search strategy

Planning, conducting and reporting of this study was based on the guidelines for rapid reviews [ 17 ], set by the WHO [ 16 ] and the recent COVID-19 Cochrane Collaboration’s recommendations [ 18 ].

Data sources and searches

Two authors (CoM & RP) searched across a broad range of databases to capture research from potentially relevant fields, including health, mental health and health management. Within the OVID platform of databases Medline, EMBase, HMIC and PsychInfo were searched. Within the EbscoHost platform of databases, CINAHL, Medline, APA PsychInfo, Business Source Elite, Health Source and Academic Search Complete were searched. Beyond the OVID and EbscoHost platforms, SCOPUS, the King’s Fund Library, Social Care Online, PROSPERO and Google Advanced were also searched, making 16 databases searched (14 unique databases and two having been searched twice on separate platforms).

Owing to the rapidly changing landscape of the COVID-19 pandemic, and in an effort to include as many eligible papers as possible, the search strategy was executed on 23 April 2020 and again 2 weeks later on 6 May 2020 using a combination of subject headings and keyword searching (see Additional file 1 ). The bibliographical database was created with EndNote X7™.

Search criteria

The design of the search criteria was intended to draw together research both for this rapid review, and to contribute to the design of a digital mental health intervention to enhance the psychological well-being of HSCWs. The design of the search criteria is discussed in further detail in the Additional file 1 .

Types of participants

Participants were restricted to HSCWs during the COVID-19 pandemic.

Types of studies included

Published observational and experimental studies that reported the psychological effects on HSCWs during the COVID-19 pandemic were included. The study designs included quantitative and qualitative primary studies. Studies relating to previous pandemics and epidemics (such as SARS, MERS, H1N1, H5N1, Zika, Ebola, West Nile Fever) were excluded as these results have been reported elsewhere [ 7 ]. Reviews, theses, position papers, protocol papers, and studies published in languages other than English were excluded.

Screening and selection of studies

Searches were screened according to the selection criteria by JDK. The full text of potentially relevant papers was retrieved for closer examination. The reviewer erred on the side of inclusion where there was any doubt, to ensure no potentially relevant papers were missed. The inclusion criteria were then applied against full text versions of the papers (where available) independently by JDK and HL. Disagreements regarding eligibility of studies were resolved by discussion and consensus. Where the two reviewers were still uncertain about inclusion, the other reviewers (RP, CoM) were asked to provide input to reach consensus.

Data extraction and quality assessment

Relevant data were extracted into structured tables including country, setting, population, study design, number of participants, mental health conditions and their measurement tools and main study results. Where available, we extracted risk factors and protective factors. HL, LE and JDK extracted all the data while JDK checked for accuracy and completeness.

Table  2 presents an overview of the validated tools used per study type to assess study quality and risk of bias. JDK and HL assessed the quality of cross-sectional studies with the Joanna Briggs Institute tool [ 48 ] and JDK assessed their risk of bias using the Evidence Partners [ 49 ] appraisal tool. JDK assessed the risk of bias for the longitudinal study with the Critical Appraisal Skills Programme (CASP) appraisal tool [ 50 ] and the uncontrolled before-after study with the ROBINS – I [ 51 ]. SAM utilised Joanna Briggs Institute tool to assess the qualitative studies [ 38 ] and the Mixed methods appraisal tool (MMAT) [ 41 ] to assess mixed methods studies.

Data synthesis and analysis

Current best practice guided the tabulated and narrative synthesis of the results [ 52 , 53 ]. The studies’ outcomes were categorised according to the psychological impact of COVID-19 on HSCWs of:

general psychological impacts

the risk factors associated with adverse mental health outcomes

the protective factors against adverse mental health outcomes

Previous studies’ logical syntheses [ 6 ] were adapted by organising the risk and protective factors into psychosocial, occupational, sociodemographic and environmental categories. The GRADE method from the Cochrane Collaboration [ 54 ] was used to assess the quality of evidence of outcomes included in this rapid review. Varied study quality, together with study type and outcome heterogeneity precluded performing a meta-analysis.

Patient and public involvement

Some members of the author team are frontline healthcare staff during the COVID-19 pandemic and contributed to the design of the review.

Search results

The 677 records of interest were found from the two searches (429 in search 1 and 529 in search 2). After 148 duplicates were removed, 529 records were screened. Of these, 82 full texts of potentially relevant studies were assessed for eligibility (see Fig.  1 ). Twenty-four published studies met the inclusion criteria for the rapid review.

Prisma Flow Diagram

Study characteristics

The 24 studies included in this review consisted of 18 cross-sectional, 2 mixed methods, 2 qualitative, 1 longitudinal and 1 uncontrolled before-after study. The total number of participants in these studies was 13,731. In the cross-sectional studies, participant numbers ranged between 59 and 2299. Participant numbers in the two mixed method studies were 37 and 222 respectively, whilst the qualitative studies included 10 and 20 participants, respectively. The longitudinal study included 120 participants and the uncontrolled before-after study, 27 participants. See Table  1 for sampling methods within the included papers. The majority of papers utilised non-probability sampling methods, limiting generalisability of findings. One exception was Lai et al., who used region stratified 2-stage cluster sampling.

Eighteen of the studies were from China, of which 8 were based in Wuhan, where the COVID-19 outbreak began. The rest were from America (1), Israel (1), UK (1), Singapore (1), Pakistan (1), multicentre - Singapore & India (1), Global (1). Several validated measures were used to assess anxiety, depression, insomnia, stress and burnout. Table 1 provides an overview of the included studies.

Risk of bias assessment

The quality of the cross-sectional studies was fair, with 16 studies scoring 6 or higher on the JBI appraisal tool and eleven scoring 7 or higher (a score of 7 and above is an indicator of study quality). The majority of the studies indicated a low risk of bias when assessed with the Evidence Partners’ appraisal tool. The uncontrolled before-after study indicated a high risk of bias. The qualitative studies indicated a good level of quality (JBI scores of 9 & 10 respectively) while mixed methods studies showed varied quality. In the cross sectional studies, the most common problem affecting study quality was failure to deal with confounding factors. Failure to locate the researcher culturally or theoretically affected the qualitative papers, whilst the two mixed methods papers’ study quality was affected by lack of explicitly articulated research questions. A summary of the risk of bias and quality assessments are provided in Table 2 .

Psychological toll on healthcare workers

Of the 24 studies included, 22 directly assessed the psychological toll on healthcare workers and all found levels of anxiety, depression, insomnia, distress or Obsessive Compulsive Disorder (OCD) symptoms [ 24 , 25 , 26 , 27 , 29 , 30 , 31 , 33 , 34 , 35 , 36 , 37 , 39 , 40 , 42 , 43 , 44 , 46 , 47 , 58 , 59 , 60 ].

Psychological symptoms were assessed using various validated measures as outlined in Table  3 – the summary of included studies. The most common outcomes assessed were sleep, anxiety and depression. The prevalence of depressive symptoms varied greatly, ranging between 8.9% [ 39 ] to 50.4% [ 31 ]. These findings suggest marked differences in the prevalence of depressive symptoms across the studies. The prevalence of anxiety in cross-sectional studies ranged between 14.5% [ 39 ] to 44.6% [ 31 ]. Sleep was also assessed in several studies. Lai et al. [ 31 ] found the prevalence of sleep disturbances to be 34%, whilst another, nationwide survey in China found that HCWs had significantly worse sleep than the general population [ 29 ].

Risk factors associated with adverse mental health outcomes

Table 3 provides the GRADE evidence profile of the certainty of evidence for the risk factors associated with adverse MH outcomes during the COVID-19 pandemic identified through the review. These risk factors can be grouped into the three thematic areas of i) occupational, ii) psychosocial, iii) environmental.

Occupational factors

Medical hcws.

Two studies showed that medical HCWs (nurses and doctors) had significantly higher levels of MH risk in comparison to non-medical HCWs [ 34 , 47 ]. Zhang et al. [ 47 ] found that medical HCWs had significantly higher levels of insomnia, anxiety, depression, somatization and OCD symptoms in comparison to non-medical HCWs. This was also reflected in a large study in Fujian province, China, in which medical staff had significantly higher anxiety than admin staff [ 34 ]. In contrast, Tan et al. [ 39 ] found that in a population of 470 HCWs in Singapore, the prevalence of anxiety was significantly higher among non-medical HCWs than medical.

Healthcare groups

In three studies nurses were found to be at risk of worse MH outcomes than doctors [ 24 , 26 , 31 ]. One large study in China found nurses were at significant risk of more severe depression and anxiety than doctors [ 31 ]. Another found that nurses had significantly higher financial concerns than doctors and felt significantly more anxious on the ward when compared with other groups. There was no significant difference between professionals regarding stopping work or work overload [ 24 ]. A mixed method paper also showed that nurses had a higher rate of depressive symptoms than doctors. Whilst this was a small sample size, it echoes the findings from larger studies [ 26 ].

With regard to other HCWs, there were two studies which assessed dentists and other dental workers and found them to be at risk of anxiety and elevated distress. Neither study found any difference based on gender or educational level [ 36 , 59 ]. There were no studies comparing dental workers to other HCWs. We did not find any studies that focussed on the primary care workforce or that assessed social care workers.

With regard to seniority, one paper found that having an intermediate technical title was associated with more severe MH symptoms [ 31 ].

Frontline staff/direct contact with COVID-19

Four high-quality studies found being in a ‘frontline’ position or having direct contact with COVID-19 patients was associated with higher levels of psychological distress [ 30 , 31 , 34 , 42 ].

Increased direct exposure to COVID-19 patients increased the mental health risks in health care workers in one study in Wuhan [ 30 ]. This finding is backed by Lai et al. [ 31 ], who found that being a frontline worker was independently associated with more severe depression, anxiety and insomnia scores. In addition, a cross sectional survey of staff in a paediatric centre found that contact with COVID-19 patients was independently associated with increased risk of sleep disturbance [ 42 ]. Lu et al. [ 34 ] found that medical HCWs in direct contact with COVID-19 patients had almost twice the risk of anxiety and depression than non-medical staff with low risk of contact with COVID-19.

There were conflicting results found in two studies. A study in a cancer hospital in Wuhan found burnout frequency to be lower in frontline staff [ 43 ]. The authors identified confounding factors which may have led to this result, but it is of interest as it is one of the only studies that assessed HCWs outside of the acute general medicine setting. Li et al. [ 32 ], also found that frontline nurses had significantly lower levels of vicarious trauma scores than non-frontline workers and the general population.

Personal protective equipment (PPE)

PPE concerns were the most common theme brought up voluntarily in free-text feedback in a study by Chung & Yeung [ 60 ], and a survey in Pakistan revealed that 80% of participants expected provision of PPE [ 40 ]. H.Cai et al. [ 24 ] also found that PPE was protective when adequate, but a risk factor for stress when inadequate. This finding appears to be bolstered by a qualitative study of frontline nurses in Wuhan, which found that physical health and safety was one of their primary needs. This study also reported PPE as a protective factor [ 46 ].

Heavy workload

Longer working time per week was found to be a risk factor in a study by Mo et al. [ 35 ] This, together with increased work intensity or patient load per hour, were themes in a mixed methods study of 37 staff of a clinic in Beijing [ 26 ] and a qualitative study of nurses in China [ 37 ], also suggesting heavy workload as a risk factor.

Psychosocial factors

Fear of infection.

A fear of infection was a highlighted in a qualitative study by Cao et al., (2020, 31), and brought up as a theme in free-text feedback in a cross sectional survey by Chung & Yeung [ 60 ]. Ahmed et al. [ 59 ] found that 87% of dentists surveyed described a fear of being infected with COVID-19 from either a patient or a co-worker.

Concern about family

This was brought up as one of the main stress factors in a study by H.Cai et al. [ 24 ], particularly amongst staff in the 31–40 year age-group. Knowing that their family was safe was also the greatest stress reliever [ 24 ], whilst fear of infecting family was identified in 79.7% of 222 participants in a study in Pakistan [ 40 ]. It was also a theme highlighted in the qualitative data [ 26 , 37 ].

Sociodemographic factors

Younger age.

One Chinese web-based survey which included the general population and HCWs, showed that younger people had significantly higher anxiety and depression scores, but no difference in sleep quality. Conversely, the same study found that HCWs were significantly more likely to have poor sleep quality, but found no difference in anxiety or depressive symptoms based on occupation. The study did not examine the effect of age group on HCWs [ 29 ].

H. Cai et al. [ 24 ] suggested that age was more complex. They found that all age groups had concerns, but that the focus of their anxieties were different (for example: older staff were more likely to be anxious due to exhaustion from long hours and lack of PPE while younger staff were more likely to worry about their families).

Women were found to be at higher risk for depression, anxiety and insomnia by Lai et al. [ 31 ] This was also found to be an independent risk factor for anxiety in another large nationwide Chinese study [ 47 ]. However, a global survey of dentists found no differences based on gender [ 59 ].

Underlying illness

We found two studies which identified that having an underlying organic illness as an independent risk factor for poor psychological outcomes. A study of dentists in Israel found an increase in psychological distress in those with background illnesses as well as an increased fear of contracting COVID-19 and higher subjective overload [ 36 ]. In medical HCWs in China, organic illness was found to be an independent risk factor for insomnia, anxiety, OCD, somatising symptoms and depression in medical HCWs [ 47 ].

Being an only child

This was independently associated with sleep disturbance in paediatric HCWs in Wuhan [ 42 ]. Being an only child was also found to be significantly associated with stress by Mo et al. [ 35 ].

There was also a significant association between physical symptoms and poor psychological outcomes in a large multicentre study based in India and Singapore. It is unclear if this represented somatization or organic illness and the authors suggest the relationship between physical symptoms and psychological aspects was bi-directional [ 27 ].

Environmental factors

Point in pandemic curve.

One longitudinal study carried out in China in a surgical department, found that anxiety and depression scores during the ‘outbreak’ period were significantly higher when compared to a similar group assessed after the outbreak period [ 58 ]. This was a small sample of 120 and only assessed surgical staff, but this longitudinal data was supported by a qualitative study in China which suggested that anxiety peaks at the start of the outbreak and reduces with time [ 37 ].

Living in a rural area was only assessed by one study which showed that it was an independent risk factor for insomnia and anxiety in medical HCWs [ 47 ]. This may reflect a need to further investigate the effect of rurality on psychological wellbeing during this pandemic.

Protective factors against adverse mental health outcomes

The review identified protective factors against adverse mental health outcomes during COVID-19. Table  4 provides the GRADE evidence profile of the certainty of evidence for this. The protective factors can be grouped into the three thematic areas of: i) occupational, ii) psychosocial and iii) environmental.

W. Cai et al. [ 25 ] found that previous experience in a public health emergency (PHE) was protective against adverse mental health outcomes. Staff that had no previous experience were also more likely to have low rates of resilience, and social support.

A small cohort study of 27 surgeons, who were given pre and post training surveys, suggested that training alleviates psychological stress [ 22 ]. Good hospital guidance was identified to relieve stress in a study by H.Cai et al. [ 24 ], and increasing self-knowledge was a coping strategy deployed by staff. Dissemination of knowledge was also mentioned in a qualitative study by Yin & Zeng [ 46 ]; participants described subjective stress reduction after their seniors explained relevant knowledge to them.

Adequate PPE

As mentioned above, PPE was found to be a protective factor when adequate and a risk factor for poor mental health outcomes when deemed to be inadequate [ 24 , 46 ].

One study assessed self-efficacy in dental staff and found that it was a protective factor [ 36 ]. Self-efficacy was also found to improve sleep quality by Xiao et al. [ 44 ], whilst W.Cai et al. [ 25 ] measured resilience using a validated measure and found it to be a protective factor against adverse MH outcomes.

Being in a committed relationship

This was found to be protective by Shacham et al. [ 36 ] This was not directly assessed in other studies.

Safety of family

This had the biggest impact in reducing stress in a cross-sectional study by H. Cai et al. [ 24 ] This was also not assessed in other studies.

Support and recognition from the health care team, government and community was identified as a protective theme in several studies. Social support, measured using the Social Support Rate Scale (SSRS) was found to indirectly affect sleep by directly reducing anxiety and stress and increasing self-efficacy [ 44 ].

Team support was identified as a protective factor in a qualitative study by Sun et al. [ 37 ] Good hospital guidance was also identified as a stress reliever by H. Cai et al. [ 24 ], who found that HCWs expected recognition from the hospital authorities. This was echoed in a qualitative study of nurses in Wuhan where the desire for community concern was a strong need and tightly linked to the need for PPE and knowledge [ 46 ]:

‘ To be honest, I was very apprehensive before coming to the infectious department as support staff, but on the first day here, the head nurse personally explained relevant knowledge such as disinfection and quarantine, and that helped me calm down a lot . ”

“I hope that our society and government pay more attention to lack of personal protective equipment’ [ 46 ] .

As a communicable disease, and now a global public health emergency (PHE), COVID-19 places a unique challenge on our health and social care workforce that will disrupt not just their usual workplace duties but also their social context [ 62 ]. As we adjust to new ways of living and working, HSCWs are likely to continue to face challenges ahead. Our review confirms that the psychological impact of COVID-19 on health care workers is considerable, with significant levels of anxiety, depression, insomnia and distress. Studies revealed a prevalence of depressive symptoms between 8.9–50.4% and anxiety rates between 14.5–44.6% [ 31 , 39 ]. This is in keeping with other reviews and findings from previous viral outbreaks [ 7 , 8 , 63 ]. The majority of studies published to date come from China, particularly Wuhan - the epicentre of COVID-19. There is minimal evidence published to date on the psychological impact on HCWs in Europe or the US, which have been highly impacted by the pandemic. The studies included in this review were predominantly concerned with hospital settings – we found no studies relating to social care staff or primary care staff. This is a concern, as we have increasing evidence that a large proportion of Western deaths are happening in the community and specifically in care homes [ 64 ].

Our review aimed to identify whether there were any groups particularly vulnerable to poor mental health outcomes during COVID-19. We found some evidence that nurses may be at a higher risk than doctors [ 24 , 26 , 31 ]. This is similar to findings which take into account previous viral outbreaks [ 7 ]. Confounding factors were not robustly addressed however, and there were no studies that compared nurses with the primary care workforce or social care workers. There was some evidence that clinical HCWs may be at higher risk of psychological distress than non-clinical HCWs [ 34 , 47 ], but this was not absolute. Tan et al. [ 39 ] found a higher prevalence of anxiety among non-medical HCWs in Singapore. The prevalence of poor MH outcomes varied between countries. Chew et al. [ 27 ] revealed that in data from India and Singapore, there was an overall lower prevalence of anxiety and depression than similar cross-sectional data from China [ 27 , 31 , 39 , 60 ]. This suggests that different contexts and cultures may reveal different findings. It is possible that being at different points in their respective countries’ outbreak curve may have played a part, as there was evidence that this may be influential [ 58 ]. Tan et al. [ 39 ] postulated that the medical HCWs in Singapore had experienced a SARS outbreak in the past and thus were well prepared for COVID-19 both psychologically and in their infection control measures. What we can deduce is that context and cultural factors are likely to play a role, not just cadre or role of healthcare worker. It also highlights the importance of reviewing the evidence as more data emerges from other countries.

Several risk factors emerged, many in keeping with what has been found in other reviews [ 7 , 8 ]. Those with the strongest evidence were inadequate PPE [ 24 , 40 , 46 , 60 ], fear of infection [ 26 , 59 , 60 ] and heavy workload [ 26 , 35 , 37 ]. Consistent with prior outbreak data [ 7 , 63 ], there was also good evidence that close contact with COVID-19 cases was a predictor of higher levels of anxiety, depression and insomnia [ 30 , 31 , 34 , 42 ], although two studies appeared to show conflicting results [ 32 , 43 ]. Studies suggested that being younger in age [ 24 , 29 , 33 ] or being female [ 31 , 47 , 59 ] may be a risk factor, however this should be treated with caution. An alternative explanation for this study’s findings may be greater risk of frontline exposure amongst women, who are predominantly employed in lower status roles within healthcare globally according to the WHO [ 65 ]. It is important to note that respondents to all studies, when disaggregated by gender, were predominantly female and this may have impacted findings. The consistently higher mortality rate and risk of severe COVID-19 disease amongst men would suggest that the full picture regarding gender and MH during this pandemic is incomplete [ 66 , 67 ]. Although other risk factors were also identified, their certainty of evidence was deemed to be low.

The majority of cross-sectional studies focussed on measuring adverse MH outcomes which explains the lack of quantitative data on protective factors or coping mechanisms. Of the studies that did assess this, there were protective factors which were associated with adaptive psychological outcomes. Experience of prior infectious disease outbreaks and training were protective against poor mental health outcomes [ 22 , 24 , 25 , 46 ]. Adequate PPE was a protective factor when adequate and a risk factor when inadequate [ 24 , 46 , 60 ]. There was good evidence that resilience (measured by self-efficacy or resilience scales) was protective against poor mental health outcomes [ 25 , 36 , 44 ]. This is of importance when assessing how to positively contribute to reducing the psychological burden on our health and social care staff. There was strong evidence that community support was a protective factor [ 24 , 37 , 44 , 46 ]. Community support was important in a number of studies, referring to social support as well as recognition and support from the healthcare team, government and wider community [ 24 , 37 , 44 , 46 , 68 ]. Other adaptive behaviours emerged from qualitative data, including gratitude and the ability to find purpose and growth from the situation [ 37 ]. These findings are in keeping with a recent study which identified key domains of risk for burnout in healthcare. They highlighted that being part of a supportive team community is a strong protective factor as are clear values and meaningful work [ 69 ]. They advise that organisational-level interventions creating a healthy workplace are the key to preventing burnout [ 69 ]. This is echoed in a recent systematic review and meta-analysis of the effectiveness of interventions designed to reduce symptoms and prevalence of MH disorders and suicidal behaviour among physicians. This review concluded that, whilst individually directed interventions are associated with some reduction in symptoms of common MH disorders, there needs to be increased focus on organisational-level interventions that improve the work environment [ 2 ].

Whilst our findings showed evidence that occupational and environmental factors at the workplace level played a key role for MH outcomes, there was no mention of wider societal structural issues that have been emerging during this pandemic. Of particular importance is the evidence that black and ethnic minority people of all ages in the global north are at greater risk of contracting and dying from COVID-19 [ 70 , 71 , 72 ]. A recent large study in the US found that non-white HCWs were at increased risk of contracting COVID-19 and were disproportionately affected by inadequate PPE and close exposure to COVID-19 patients [ 3 ]. This suggests wider structural factors are at play and need to be investigated.

The paucity of empirical studies investigating the mental health of social care and primary care staff during the COVID-19 pandemic should also be rectified. With the majority of studies taking place in China, where ageing in place rather than residential care is the norm [ 73 ], it is unsurprising that none investigated care homes, where it is estimated around 40–50% of all deaths related to COVID-19 occur in Europe and the US [ 64 ]. Moreover, there is evidence that front-line HCWs who work in nursing homes are among the highest at risk of contracting the virus [ 3 ]. With the majority of studies taking place in urban hospital settings, and particularly in Wuhan – the epicentre of the outbreak – the generalizability of findings to other settings may be limited, particularly as countries pass through different points in the outbreak curve. However, this review does highlight the considerable psychological impact that COVID-19 has played so far on health care workers and, therefore, adds to the recent calls to take notice of this important issue [ 14 ]. Yet the evidence also suggests that, although predictors for psychological distress exist, these are not absolute and context may play an important role on the manifestation of adverse MH outcomes.

Strengths and limitations

This rapid review has synthesized and discussed the current literature on the psychological impact of the COVID-19 pandemic on health and social care workers. A major limitation was that no empirical studies investigating this impact on social care workers could be found – limiting generalisability to the population reviewed. Recent evidence also suggests that having an ongoing connection to a paid job, may be protective against poor MH outcomes during the pandemic [ 74 ]. It would therefore be useful to compare MH outcomes amongst HCWs, or the general population, who were not actively employed during the pandemic. Unfortunately, none of the studies included this data. Furthermore, job retention schemes have varied widely between countries worldwide, thus limiting the generalisability of findings if this data had been available [ 75 ].

However, to our knowledge, this is the first review investigating this population group in the context of COVID-19, without including prior viral outbreaks in its analysis and synthesis. We see this as a strength because this outbreak is different, and worth assessing in its own right. It has affected every country across the globe and disrupted everyday living in a way no other outbreak has in living memory [ 14 ]. A major strength of our review is that it endeavoured towards greater inclusion, during the rapidly changing COVID-19 landscape, by completing two runs of the search strategy spaced 2 weeks apart. Whilst we adhered to high methodological standards by assessing study quality and risk of bias, together with using the GRADE approach to evaluate the certainty evidence and following best practice principles [ 52 , 53 ] to present a narrative and tabulated synthesis, our review remains a rapid one with further clear limitations. The majority of the studies included in this review, for example, were from China and our selection criteria did not include studies from low-income countries or studies in languages other than English - limiting the generalizability of our findings. Being a rapid review, the protocol was not registered on PROSPERO and only one reviewer was responsible for the initial screening of papers and for several of the quality assessments. Finally, as the current review’s searches were carried out early in the pandemic, it will be valuable to consider emerging research from the global arena in the light of this review’s findings.

This rapid review confirms that front line HCWs are at risk of significant psychological distress as a direct result of the COVID-19 pandemic. Published studies suggest that symptoms of anxiety, depression, insomnia, distress and OCD are found within the healthcare workforce. However, most studies draw only from work in secondary care and none draw from the primary care or social care setting. Published studies so far are predominantly from China (18 out of 24 included studies) and most of these have sampled hospital staff in Wuhan - the epicentre. Findings in this review suggest that the study of different contexts and cultures may reveal different findings and we recommend more research in primary care and social care settings and to monitor rapidly emerging evidence from across the world. This should include analysis of wider societal factors including gender, racial and socio-economic disparities that may influence mental health outcomes in HCWs.

Although risk factors did emerge that were in keeping with evidence from other infectious disease outbreaks, our findings were not absolute. This review suggests that nurses may be at higher risk of adverse MH outcomes during this pandemic, but there were no studies comparing them with social care workers or the primary care workforce. Other risk factors that recurred in the data were heavy workload, lack of PPE, close contact with COVID-19, being female and underlying organic illness. Inconsistencies in findings and lack of data on staff outside hospital settings, suggest that targeting a specific group within health and social care staff with psychological interventions may be misplaced – as both presence of psychological distress and risk factors are spread across the healthcare workforce, rather than associated with particular sub-groups.

A recent call to action for mental health science during COVID-19 recommends research be undertaken to identify interventions that can be delivered under pandemic conditions to mitigate deteriorations in psychological well-being and support mental health. This call to action advised that personalised psychological approaches are likely to be a key [ 14 ]. Data from this review suggests that interventions which bolster psychological resilience may be of benefit because this was found to protect against adverse mental health outcomes. Due to the nature of the pandemic which prevents face-to-face interventions, this is likely to be digitally based. A recent systematic review, pre-dating COVID-19, suggested that individualised interventions can have modest effect on reducing adverse mental health outcomes amongst physicians [ 2 ]. However, our findings suggest that occupational and environmental factors in the workplace play a key role as risk factors and protective factors for mental health outcomes during this pandemic. Heavy workload, proximity to COVID-19 and inadequate PPE were risk factors for poor mental health, whereas good knowledge of COVID-19, a supportive work environment and adequate PPE were protective factors. It would appear from our findings that adequate PPE may be protective not just against infection, but also against adverse mental health outcomes. Individually targeted digital interventions are unlikely to address these factors [ 2 ]. We postulate that strengthening psychological resilience in a personalised approach may be effective in protecting our health and social care workers from adverse mental health outcomes but this must not defer responsibility from wider organisations and systems. We suggest that a holistic approach to HCWs psychological wellbeing is needed that includes personalised interventions alongside necessary structural changes to create a healthy, safe and supportive work environment. Further research including social care workers and analysis of wider societal structural factors is recommended.

Availability of data and materials

The datasets during and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

Connor-Davidson Resilience Scale

Centre for Epidemiologic Studies Depression Scale (CES-D)

Coronavirus disease 2019

Depression, Anxiety and Stress Scale

Generalised Anxiety Disorder Questionnaire

The Grades of Recommendation, Assessment, Development and Evaluation Working Group

Generalised self-efficacy scale

Hamilton Anxiety Rating Scale

Hamilton Depression Rating Scale

Healthcare workers

Health and social care workers

Impact of Event Scale

Insomnia Severity Index

Maslach Burnout Inventory (MBI)

• Mental health

Public Health Emergency

Patient Health Questionnaire-4

Patient Health Questionnaire

Personal protective equipment

Pittsburgh Sleep Quality Index

Zung Self-Rating Anxiety Scale

The Stanford Acute Stress Reaction questionnaire

Symptom checklist depression scale

The Symptom Checklist-90-R

Zung Self-Rating Depression Scale

Short Form Health Survey (SF-36)

Stress Overload Scale

Social Support Rating Scale

World Health Organisation

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Thank you to Abbie Oman (University of Aberdeen) for critically reviewing our manuscript.

This project is funded by the Chief Science Office of the Scottish Government: RAPID RESEARCH IN COVID-19 PROGRAMME REF: COV/UHI/Portfolio. The funding sources had no role in the design or conduct of the study nor in the collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

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De Kock, J.H., Latham, H.A., Leslie, S.J. et al. A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being. BMC Public Health 21 , 104 (2021). https://doi.org/10.1186/s12889-020-10070-3

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Health Care Workers’ Mental Health and Quality of Life During COVID-19: Results From a Mid-Pandemic, National Survey

• Kevin P. Young , Ph.D. ,
• Diana L. Kolcz , Psy.D. ,
• David M. O’Sullivan , Ph.D. ,
• Jennifer Ferrand , Psy.D. ,
• Jeremy Fried , M.D. ,
• Kenneth Robinson , M.D.

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The authors sought to quantify the rates of psychological distress among health care workers (HCWs) during the COVID-19 pandemic and to identify job-related and personal risk and protective factors.

From April 1 to April 28, 2020, the authors conducted a national survey advertised via e-mail lists, social media, and direct e-mail. Participants were self-selecting, U.S.-based volunteers. Scores on the Patient Health Questionnaire–9, General Anxiety Disorder–7, Primary Care Posttraumatic Stress Disorder Screen, and Alcohol Use Disorders Identification Test–C were used. The relationships between personal resilience and risk factors, work culture and stressors and supports, and COVID-19–related events were examined.

Of 1,685 participants (76% female, 88% White), 31% (404 of 1,311) endorsed mild anxiety, and 33% (427 of 1,311) clinically meaningful anxiety; 29% (393 of 1,341) reported mild depressive symptoms, and 17% (233 of 1,341) moderate to severe depressive symptoms; 5% (64 of 1,326) endorsed suicidal ideation; and 14% (184 of 1,300) screened positive for posttraumatic stress disorder. Pediatric HCWs reported greater anxiety than did others. HCWs’ mental health history increased risk for anxiety (odds ratio [OR]=2.78, 95% confidence interval [CI]=2.09–3.70) and depression (OR=3.49, 95% CI=2.47–4.94), as did barriers to working, which were associated with moderate to severe anxiety (OR=2.50, 95% CI=1.80–3.48) and moderate depressive symptoms (OR=2.15, 95% CI=1.45–3.21) (p<0.001 for all comparisons).

Conclusions:

Nearly half of the HCWs reported serious psychiatric symptoms, including suicidal ideation, during the COVID-19 pandemic. Perceived workplace culture and supports contributed to symptom severity, as did personal factors.

A considerable percentage of health care workers (HCWs) reported serious psychiatric symptoms during the COVID-19 pandemic.

Perceived workplace culture, availability of supports, and static and dynamic personal factors contributed to the symptom severity experienced by HCWs.

Health care administrators and HCWs share responsibility to design and implement programs that best support HCWs during crisis events; these interventions should be pragmatic, flexible, and responsive to unique system pressures as modified by individual needs.

Disease outbreaks such as COVID-19, which has resulted in >1.3 million deaths worldwide ( 1 ), cause broad effects on society’s psychological functioning, including depression, anxiety, panic attacks, somatic symptoms, posttraumatic stress disorder (PTSD), psychosis, and suicidality ( 2 ). In a Chinese study, researchers found that 54% of respondents rated the psychological impact of the COVID-19 outbreak as moderate to severe, 17% reported moderate to severe depressive symptoms, and 29% endorsed moderate to severe anxiety ( 3 ). Huang et al. ( 4 ) found that levels of anxiety and stress were high among health care workers (HCWs) during the COVID-19 pandemic.

HCWs often have to respond to demanding and unforeseen medical emergencies, which may be compounded by staff shortages, worry about contracting and spreading the disease, competency concerns when redeployed without adequate training, inadequate and cumbersome personal protective equipment (PPE), and frequent exposure to patients’ suffering and dying. Additionally, quarantine may result in prolonged separation from family and other support systems. Many HCWs feel conflicted between their sense of duty and their willingness to work during a pandemic ( 5 – 8 ), and trying to strike a balance between professional responsibility and altruism and personal fear and anxiety can result in further dissonance and moral distress ( 9 ).

HCWs are at risk for increased psychological symptoms and burnout (e.g., emotional exhaustion, depersonalization, and reduced professional efficacy) during a crisis ( 10 ), but their response is unique and multifactorial. Li et al. ( 11 ) investigated signs of vicarious traumatization (e.g., loss of appetite, fatigue, physical decline, sleep disorder, irritability, inattention, numbness, fear, and despair) in China during the COVID-19 pandemic and compared incidence of these signs among the general public with those among both frontline and non-frontline nurses. Frontline nurses had fewer symptoms than the public and their non-frontline colleagues, who both exhibited signs of elevated vicarious traumatization ( 11 ). This finding suggests that some frontline workers have unique psychological endurance, at least while in the midst of the crisis, whereas others are more vulnerable.

Physicians are a high-risk group for suicide, with male physicians having a 40% higher risk and female physicians a 130% higher suicide risk than members in the general population ( 12 ). Depression is a significant suicide risk factor for both groups ( 13 ), and >50% of physicians have reported at least one symptom of burnout at some point ( 14 ). Reger et al. ( 15 ) suggested that suicide rates could increase nationwide during and after the COVID-19 pandemic because of myriad factors, including social isolation, reduced access to supports such as mental health treatment, illness and fear of illness, and increased depression and anxiety.

Delineating the rates of psychological pain in HCWs related to pandemic stress is useful and necessary. Even more important is identifying the underlying causes of emotional pain to accelerate creation of distress-mitigating interventions. Burnout and psychological distress among HCWs severely affect personal health and wellness, patient safety and quality of care, and health care system costs ( 16 ). Research has highlighted the importance of social support, communication, training, and effective coping ( 17 ). It has been reported that creating resilience in the health care industry, either during or in the absence of a crisis, is a responsibility shared between HCWs and their organizations ( 14 , 18 ).

Further investigation of the complex relationships among specific job tasks and responsibilities, work conditions and culture, personal and situational risks, protective factors, and general mental health is critical. The objectives of this study were to evaluate the prevalence and extent of the negative psychological impact of the COVID-19 pandemic on a self-selected sample of U.S.-based HCWs surveyed in order to determine whether the professionally diverse HCW sample displayed variation in responses to this health crisis and to identify the factors associated with adverse psychological effects.

A 125-item survey, approved by the Hartford HealthCare Institutional Review Board (HHC-2020-0069) and administered through the online survey platform REDCap, was sent to participants via professional e-mail lists and social media (i.e., health care groups on Facebook, with moderator permission) and to individuals who were specialists or applying for board certification by the American Board of Professional Psychology. Electronically obtained informed consent was required to participate. The survey was sent out up to three times, as permitted by list rules between April 1 and April 28, 2020.

The survey included questions concerning demographic characteristics, perceived risk factors, medical history, COVID-19 exposure, workplace environment and culture, and standard brief screens of emotional health, including the Patient Health Questionnaire–9 (PHQ-9) ( 19 ), General Anxiety Disorder–7 (GAD-7) ( 20 ), Primary Care Posttraumatic Stress Disorder Screen (PC-PTSD) ( 21 ), and the Alcohol Use Disorders Identification Test–C ( 22 ).

Inclusion Criteria

Respondents were included in this study if they identified (or were identified by membership on a professional roster or e-mail list) as a health care provider, were ages 18–89 years, were working in the United States, and communicated in English.

Statistical Analysis

The REDCap data were exported to and analyzed with IBM SPSS Statistics, version 26. Categorical comparisons were evaluated with a chi-square test. Continuous data were evaluated for distribution and analyzed with one of the following, depending on number of groups and normality of distribution: Student’s t test or Mann-Whitney U test for two groups and analysis of variance or Kruskal-Wallis H test for more than two groups. Correlations were evaluated with a Spearman rank correlation coefficient. A forward, conditional logistic regression model was constructed to evaluate the strength of contribution of many of the variables with univariate differences on outcomes indicating at least moderate anxiety and depression. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

All results with p<0.05 were deemed statistically significant. Because the number of responses was not known initially, no a priori power analysis was performed.

The demographic data of the survey participants are shown in Table 1 . In total, 1,685 individuals consented to participate in the survey. Of those who responded, 76% identified as female, 88% identified as White, and 69% were married. Nearly half (778 of 1,685; 46%) identified as mental health professionals (psychiatrist, psychologist, or social worker), 15% identified as emergency medicine providers, and 11% identified as pediatric providers. Of the sample, 33% (464 of 1,399) were at least age 60, and 1% had returned from retirement to serve during the COVID-19 crisis.

TABLE 1. Demographic data of U.S. health care workers who responded to a nationwide, mid-pandemic survey in April 2020

a Percentages are based on the totals for each characteristic subcategory.

TABLE 1. Demographic data of U.S. health care workers who responded to a nationwide, mid-pandemic survey in April 2020

Emotional Functioning: Overview

About 22% (N=374) of the survey participants did not respond to items on the GAD-7, resulting in 1,311 respondents on this screen. Almost two-third (63%, N=831) of these respondents scored ≥5 on the GAD-7 (range 0–21; a score of 5–9 indicates mild anxiety), with 31% (N=404) endorsing mild anxiety and 33% (N=427) having scores of ≥10 (i.e., in a clinically significant range), much higher than the 3% of adults in the general population with generalized anxiety disorder in the past year ( 23 ).

Of the participants who completed the PHQ-9, 47% (626 of 1,341) scored ≥5 (range 0–27; a score of 5–9 indicates mild depressive symptoms), and 17% (N=233) scored ≥10 (representing clinically significant scores). For comparison, 7% of U.S. adults have at least one major depressive episode annually ( 23 ). Women had higher PHQ-9 scores than men (median=4, interquartile range [IQR]=1–8 vs. median=2, IQR=0–5, respectively), and a significantly greater percentage of women scored ≥10 on the PHQ-9 (p<0.001).

About one of seven (184 of 1,300; 14%) respondents answered “yes” to at least three questions on the PC-PTSD (range 0–4; a score of ≥3 is considered positive for PTSD), about four times the estimate of PTSD prevalence in the United States (i.e., 3.5%) ( 24 ). In total, 39% (507 of 1,288) of the surveys indicated clinically significant symptoms on the PHQ-9 or GAD-7 or indicated a positive PC-PTSD screen.

Suicidal Ideation

In response to the PHQ-9 question, “How often do you have thoughts that you would be better off dead or of hurting yourself in some way?” 4% (46 of 1,326) of the respondents answered “several days”; 1% (13 of 1,326), “more than half the days”; and 0.4% (5 of 1,326), “almost every day.”

Those respondents with a self-reported psychiatric history reported more frequent suicidal ideation than those without such history (48 of 572 [8%] vs. 16 of 754 [2%], respectively; p<0.001). Mental health workers endorsed less frequent ideation than did non–mental health workers (20 of 707 [3%] vs. 44 of 619 [7%], respectively; p<0.001).

Emotional Functioning: Cohort Effects

We noted a statistically significant difference in the degree of anxiety across the response spectrum among those in a pediatric profession versus all others. Compared with nonpediatric professionals, pediatric professionals reported a lower level of minimal anxiety (446 of 1,164 [38%] vs. 34 of 147 [23%], respectively), an approximately equal level of mild anxiety (358 of 1,164 [31%] vs. 46 of 147 [31%], respectively), and higher levels of both moderate (192 of 1,164 [16%] vs. 35 of 147 [24%], respectively) and severe (168 of 1,164 [14%] vs. 32 of 147 [22%], respectively) anxiety (p=0.001).

Comparing the responses of emergency medicine workers (including emergency medical services) with those from other respondents, we found no significant differences in the GAD-7 or the PHQ-9 responses. Among HCWs who reported using at least one of seven common coping skills, emergency medicine workers reported using significantly more of these skills than nonemergency medicine workers (mean±SD=3.23±1.24 vs. 2.97±1.21, respectively; p=0.004). Compared with non–mental health professionals, mental health professionals were less likely to endorse severe anxiety (134 of 609 [22%] vs. 66 of 702 [9%], respectively; p<0.001), moderate depression (38 of 625 [6%] vs. 23 of 716 [3%], respectively; p<0.001), severe depression (28 of 625 [4%] vs. 6 of 716 [1%], respectively; p<0.001), or significant PTSD symptoms (124 of 605 [21%] vs. 60 of 695 [9%], respectively; p<0.001).

Impact of Perception

Respondents were asked whether they had any of the medical conditions on a list of identified risk factors for serious COVID-19 illness curated by the Centers for Disease Control and Prevention (CDC). They also rated their perceived risk for developing a serious illness should they become infected with COVID-19. Those who endorsed a CDC-defined risk factor did not have elevated GAD-7 scores (p=0.315). However, those with a perceived risk for a serious complication due to a COVID-19 infection also endorsed more severe anxiety (p<0.001).

The severity of depression symptoms endorsed on the PHQ-9 differed between those who did and did not endorse a CDC risk factor (p≤0.003), such that having a risk factor was associated with higher depression scores. Similarly, the perception of greater risk for a serious complication after COVID-19 infection was consistently associated with increased depression (p<0.001).

Those with a PC-PTSD score of ≥3 had significantly higher levels of anxiety, depression, and perceived risk for developing serious complications resulting from a COVID-19 infection than those with a PC-PTSD score of ≤2 (p<0.001). Endorsing the presence of a CDC-defined risk factor did not significantly affect a report of PTSD (p=0.185). Individuals with a PC-PTSD score of ≥3 were significantly more likely to respond that they were unable to say no to work demands that made them feel uncomfortable than those who did not screen positive for PTSD and to disagree with items asking whether their training related to COVID-19 was adequate, whether their organization was dedicated to safety, whether their organization cared about employee health and wellness, and whether they had adequate access to PPE (p<0.01). Individuals with a positive PC-PTSD screen were more likely to have worked outside of their area of expertise and to have lost a colleague to COVID-19 (p≤0.01).

Substance Use

To examine whether psychiatric symptoms were associated with increased alcohol use, we first correlated anxiety symptoms with ethyl alcohol volume consumed when drinking (Spearman’s ρ=0.07, p<0.05) and with number of days consuming five or more drinks (Spearman’s ρ=0.08, p=0.01). We found similar results when levels of depressive symptoms were associated with drinks per drinking day (Spearman’s ρ=0.12, p<0.01) and frequency of drinking five drinks (Spearman’s ρ=0.09, p=0.003). In addition, the reported frequency of having at least five drinks in a day correlated with PTSD symptoms (Spearman’s ρ=0.11, p<0.001), as did the number of drinks consumed on days drinking (Spearman’s ρ=0.11, p<0.001).

Logistic Regression Models

We evaluated several factors that had both clinical and statistical significance in univariate analyses by using a logistic regression model to examine the main outcomes of anxiety (as measured by the GAD-7) and depression (as measured by the PHQ-9), both dichotomized by presence or absence of at least moderate symptoms (scores of ≥10).

The factors used in the multivariate model were mental health professional (vs. all others), emergency medicine worker (vs. all others), any preexisting health conditions, any mental health history, perceived risk of getting infected with COVID-19 or experiencing complications, age ≥60 years, endorsing any supports, increased use of precautions, any barriers to working during this time (e.g., personal risk for infection [all among 1,685 respondents], N=738 [44%]; risk of spreading infection, N=711 [42%]; and responsibilities of caring for others such as children [N=329, 20%], older adults [N=86, 5%], or pets [N=58, 3%]), access to PPE, belief that one’s organization cared about one’s health and wellness, perception of ability to say no to work demands, and whether the respondent had been isolated or quarantined for at least a week.

Table 2 shows significant findings for anxiety, and Table 3 summarizes significant findings for depression. Notably, among other factors, having a history of mental health issues (a static factor) increased the risk for experiencing anxiety (OR=2.78, p<0.001) or depression (OR=3.49, p<0.001). This finding was fairly consistent with the effects of a single modifiable factor, presence of barriers to willingness to work, which affected presence of at least moderate anxiety (OR=2.50, p<0.001) and presence of at least moderate depression (OR=2.15, p<0.001).

TABLE 2. Symptoms of anxiety among U.S. health care workers responding to a nationwide, mid-pandemic survey in April 2020

a Likelihood of symptoms among health care workers. Anxiety was assessed with the General Anxiety Disorder–7 scale; a score of ≥10 indicates at least moderate anxiety symptoms.

b PPE, personal protective equipment.

TABLE 2. Symptoms of anxiety among U.S. health care workers responding to a nationwide, mid-pandemic survey in April 2020 a

TABLE 3. Symptoms of depression among U.S. health care workers responding to a nationwide, mid-pandemic survey in April 2020

a Likelihood of symptoms among health care workers. Assessed with the Patient Health Questionnaire–9; a score of ≥10 indicates at least moderate depressive symptoms.

TABLE 3. Symptoms of depression among U.S. health care workers responding to a nationwide, mid-pandemic survey in April 2020 a

Consistent with findings in previous studies of HCW functioning during pandemics, more than half of our sample of HCWs endorsed at least mild psychiatric symptoms, and approximately 40% endorsed symptoms suggesting a clinically significant emotional disorder. HCWs with a history of mental illness were at greatest risk for significant emotional symptoms. Other risk factors were related to beliefs (e.g., not believing in the values and actions of their organization, thinking one is in a high-risk group if infected with COVID-19, and being concerned about barriers to working), perceptions (e.g., feeling unable to say no to specific organizational demands), and events (e.g., limited access to PPE and isolation from family).

A concerning finding embedded in the depression data is the rate of individuals reporting positive responses to PHQ-9 item 9 (“How often do you have thoughts that you would be better off dead, or of hurting yourself in some way?”). Of the respondents, about 5% reported any thoughts of suicide, 1% reported suicidal ideation half of the days, and 0.4% reported experiencing them nearly every day. This finding indicated elevated suicidal ideation in light of national estimates that 4% of U.S. adults experience suicidal thoughts annually ( 23 ).

Working with a clinical sample, Simon et al. ( 25 ) reported that individuals with positive responses to PHQ-9 item 9 were six times more likely to attempt suicide and five times more likely to die by suicide within 1 year than those who did not report such thoughts. Rossom et al. ( 26 ) later showed that patients with any level of suicidal ideation on PHQ-9 item 9 were approximately three times more likely to attempt suicide in the next 30 days and were nearly twice as likely to attempt suicide in the following year. Depression severity, substance use disorders, and comorbid anxiety (all of which were seen to some degree among participants in our sample) are significant predictors of suicide attempts among individuals with suicidal ideation ( 27 – 29 ).

Proactive interventions may reduce the negative impact of the COVID-19 pandemic on the mental health and quality of life of HCWs. As noted by Petterson and colleagues ( 30 ), many more Americans could lose their lives unless the United States immediately takes “meaningful and comprehensive action as a nation.” We know that unaddressed mental health conditions among HCWs have an impact on burnout rates, which, in turn, affects a health care system’s capacity to provide safe and effective care. We expect that HCWs who proactively address their mental health are better able to care for patients and maintain resilience in the face of stress.

In the health care setting, solutions to professional burnout should be a shared responsibility of HCWs and their workplace ( 13 , 31 ), which necessitates awareness of leaders to the potential for adverse effects on HCWs. Team cohesion and a strong social support network should be encouraged, and peer support should be readily available ( 26 , 32 , 33 ). Shanafelt et al. ( 34 ) suggested that specific steps should be taken before, during, and after a crisis to care for HCWs and to create a resilient organization. During a crisis, organizations must assess needs at regular intervals, change course when necessary, develop new support services and resources, and connect with other organizations to learn from and grow together ( 17 ). Many approaches can improve resilience among HCWs during a crisis, including keeping them informed, teaching them to monitor their own stress reactions, and facilitating triage to formal behavioral health treatment when necessary ( 35 ).

Pragmatically, staff benefit from feeling heard; therefore, creative and alternative feedback loops should be developed. Staff should be involved in decision making, feel adequately protected, have sufficient training, and must understand why an organization cannot meet their needs. The reasons underlying decisions need to be communicated frequently, clearly, and transparently. Work cultures that do not allow for honesty, vulnerability, or openness lead to feelings of nonsupport and increased risk.

Successful organizations should remember that each HCW is different; psychological and emotional support should be offered from both internal and external providers and from various modalities (e.g., group and individual, education, validation, skills, and process). Help with basic needs, such as ensuring hydration and nourishment while HCWs work, and proactively scheduling breaks in the workday to “reset” can also reduce stress. Organizations should also aim to assist in other aspects of workers’ lives, such as child care, transportation, and providing places to rest ( 18 ). In the event of HCW illness or quarantine, staff and their families must feel cared for, and preferential access to care should be considered.

Our study offers a tool and justification for surveying HCWs within an organization. By assessing attitudes and psychosocial experiences at multiple time points, leaders can assess the needs of their staff in real time, differentiate between the specific needs during and after the crisis, and utilize this information to better prepare for future crises. Attention to HCWs’ emotional experiences allows organizations to better engage, assist, and retain their staff. These data may help guide leaders as they develop methodologies for mitigating the emotional impact on HCWs during a pandemic or similar health emergencies.

The survey was sent out nationally during the worst pandemic to hit the United States (and indeed, the world) in a century. We knew that our response rates would be affected by various factors, so we used a self-selecting sample to gain access to a diverse set of health care professionals. The data may have been skewed by who was willing and able to complete the survey, but we note that the survey was open for 4 weeks to mitigate the effects of time constraints. Our study was not as racially diverse as we had hoped. Still, our survey indicated similar rates of psychiatric symptoms as were reported in recent studies from China, and we had additional details of our participants’ personal and work lives, enabling novel analyses. We therefore anticipate that many HCWs may benefit from our findings.

Conclusions

Our survey was conducted 2–3 months into the first COVID-19 wave, and approximately 40% of HCWs who responded reported serious psychiatric symptoms. HCWs with preexisting mental health issues are at increased risk for experiencing psychiatric symptoms, and it is critical that organizations find meaningful interventions for those at greatest risk. HCW culture must change to allow for discussion and addressing of emotional needs with the aim of increasing workforce resiliency.

Dr. Young was supported by the American Academy of Child and Adolescent Psychiatry Senior Scientist Travel Award, 2018 and 2019.

The authors report no financial relationships with commercial interests.

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Open Access

Peer-reviewed

Research Article

Identifying the impact of COVID-19 on health systems and lessons for future emergency preparedness: A stakeholder analysis in Kenya

Contributed equally to this work with: Dosila Ogira, Ipchita Bharali, Joseph Onyango

Roles Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected] (DO); [email protected] (IB)

Affiliation Institute of Healthcare Management, Strathmore Business School, Strathmore University, Nairobi, Kenya

Roles Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing

Affiliation Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America

Roles Formal analysis, Investigation, Methodology, Supervision, Validation, Writing – review & editing

Roles Methodology, Supervision, Validation, Writing – review & editing

Roles Project administration, Validation, Writing – review & editing

Roles Conceptualization, Investigation, Methodology, Project administration, Supervision, Writing – review & editing

Roles Conceptualization, Funding acquisition, Methodology, Supervision, Writing – review & editing

• Dosila Ogira, 
• Ipchita Bharali, 
• Joseph Onyango, 
• Wenhui Mao, 
• Kaci Kennedy McDade, 
• Gilbert Kokwaro, 
• Gavin Yamey

• Published: December 21, 2022
• https://doi.org/10.1371/journal.pgph.0001348
• Peer Review
• Reader Comments

The coronavirus pandemic (COVID-19) has triggered a public health and economic crisis in high and low resource settings since the beginning of 2020. With the first case being discovered on 12 th March 2020, Kenya has responded by using health and non-health strategies to mitigate the direct and indirect impact of the disease on its population. However, this has had positive and negative implications for the country’s overall health system. This paper aimed to understand the pandemic’s impact and develop lessons for future response by identifying the key challenges and opportunities Kenya faced during the pandemic. We conducted a qualitative study with 15 key informants, purposefully sampled for in-depth interviews from September 2020 to February 2021. We conducted direct content analysis of the transcripts to understand the stakeholder’s views and perceptions of how COVID-19 has affected the Kenyan healthcare system. Most of the respondents noted that Kenya’s initial response was relatively good, especially in controlling the pandemic with the resources it had at the time. This included relaying information to citizens, creating technical working groups and fostering multisectoral collaboration. However, concerns were raised regarding service disruption and impact on reproductive health, HIV, TB, and non-communicable diseases services; poor coordination between the national and county governments; shortage of personal protective equipment and testing kits; and strain of human resources for health. Effective pandemic preparedness for future response calls for improved investments across the health system building blocks, including; human resources for health, financing, infrastructure, information, leadership, service delivery and medical products and technologies. These strategies will help build resilient health systems and improve self-reliance, especially for countries transitioning from donor aid such as Kenya in the event of a pandemic.

Citation: Ogira D, Bharali I, Onyango J, Mao W, McDade KK, Kokwaro G, et al. (2022) Identifying the impact of COVID-19 on health systems and lessons for future emergency preparedness: A stakeholder analysis in Kenya. PLOS Glob Public Health 2(12): e0001348. https://doi.org/10.1371/journal.pgph.0001348

Editor: Veena Sriram, The University of British Columbia, CANADA

Received: February 28, 2022; Accepted: November 10, 2022; Published: December 21, 2022

Copyright: © 2022 Ogira et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: This paper has included all the data used in the analysis.

Funding: This study is part of the ongoing project “Driving health progress during disease, demographic, domestic finance and donor transitions (the “4Ds”): policy analysis and engagement with six transitioning countries”, under the project award No. OPP1199624, funded by The Bill and Melinda Gates Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared no competing interests.

Introduction

Since the beginning of 2020, the COVID-19 pandemic has spread rapidly worldwide, causing devastating consequences for patients, health care workers, health systems, and economies [ 1 ]. As of January 14 th 2022, more than 318 million cases had been confirmed and more than 5.5 million deaths were recorded worldwide [ 2 ]. Out of this, the African continent recorded 10,201,488 cases of COVID-19 and 232,770 deaths [ 3 ]. This represents approximately 3% of the total cases worldwide. In a bid to protect the population and mitigate the impact of COVID-19 infection, various efforts have made in research and development of vaccines, several of which have since been rolled out [ 4 , 5 ]. With over 11.9 billion doses administered worldwide, 817 million doses were received in Africa out of which 577.8 million were issued as of May 2022 [ 2 , 6 ].

The pandemic has put considerable strain on national health systems worldwide, including in relatively highly resourced settings [ 1 , 7 ]. For instance, high-income countries (HICs), including those in Asia, Europe and North America recorded initial high morbidity and mortality rates [ 8 ]. This resulted in a surge in hospitalization rates, which saw the strain of healthcare workers and healthcare infrastructure, shortages in medication believed to alleviate COVID-19 symptoms and personal protective equipment (PPEs) [ 9 – 11 ].

The COVID-19 pandemic has also had profound consequences for resource-poor settings in low- and middle-income countries, including African countries [ 12 ]. The region is challenged by limited access to safe water and sanitation facilities, urban crowding and a large informal economy, creating added health risks [ 13 ]. Additionally, vulnerabilities in the health care system including, scarcity of resources such as oxygen and poor health infrastructure in the region create multiple health challenges in the era of the COVID-19 pandemic [ 14 ]. Many countries in Sub-Saharan Africa are also donor dependent. Large segments of their health systems are financed through external donors, leading to difficult trade-offs about interventions to prioritize [ 15 – 17 ]. In a bid to control infections, initial mitigation measures aimed at limiting the movement of people through lockdowns and quarantines were put in place. However, these policy directions also affected the access to other health services such as HIV, tuberculosis (TB), and malaria reversing the gains made in curbing these diseases [ 18 ].

COVID-19 in Kenya

Kenya reported its first case of COVID-19 on 12 th March 2020 [ 19 ]. Since then, the numbers have risen and as of January 16, 2022, almost two years after the confirmation of the first case, Kenya had recorded 317,634 cases and 5,488 deaths [ 20 ]. Like most countries globally, Kenya embarked on a countrywide vaccination program on March 5, 2021 [ 21 ]. As of January 16, 2022, the country had administered over 11 million vaccinations with the Country’s capital Nairobi presenting the highest percentage uptake of 36% [ 20 ].

Throughout the COVID-19 pandemic, the Kenyan government has responded through various health and non-health strategies to mitigate the impact of the pandemic on its population [ 22 , 23 ]. Some of the public health and socio-economic policies included; establishing the National Emergency Response Committee, international travel ban, closure of schools and workplaces, dawn to dusk curfew, provision of food aid, tax relief, and expansion of health insurance for healthcare workers [ 24 – 27 ]. Based on the Oxford Coronavirus Government Response Tracker, a composite measure of nine metrics calculating the stringency index of policy measures undertaken by countries to control the COVID-19 pandemic [ 28 ], Kenya’s responses were considered moderate at the beginning. However, the measures progressively became high, peaking at 93.52 out of 100 from early May 2020 to late June 2020 with an increase in the number of cases [ 29 ].

Despite the government of Kenya putting the mitigation measures in place, concerns were raised over their effectiveness. For instance, due to the physical distancing measures, some groups were disproportionately affected including; those living in informal settlements, pregnant mothers, school going children, persons living with disability among others [ 30 – 34 ]. Additionally, cases of misappropriation of funds designated for COVID-19 were witnessed. This was believed to have a ripple effect, including crippling the country’s ability to acquire sufficient medical supplies and employ an adequate number of human resources for health [ 35 , 36 ].

Although major strides have since been made in fighting the COVID-19 pandemic with the development of vaccines, various lessons have been learnt for long-term health system strengthening to build resilience, including; global collaboration in crisis response, surveillance, stockpiling, health work force surge capacity, among other measures [ 37 – 39 ]. While diverse frameworks have been used to evaluate health system strengthening practices by countries, we adopted the Word Health Organization (WHO) health system building block framework to present the Kenyan case [ 40 ]. The framework outlines the interaction across the core components of the health system and has been widely applied for crisis response [ 41 – 43 ]. This study aimed to understand the key measures adopted in Kenya to tackle the COVID-19 pandemic, how the pandemic impacted the health sector and the population more broadly, and how future policy priorities and health emergency preparedness can be strengthened through the lessons learnt from the COVID-19 pandemic response.

Study setting and participants

We used purposive sampling to identify Kenya stakeholders from different national and county fields [ 44 ]. This included those who had a firm understanding of how the COVID-19 pandemic has affected the Kenyan healthcare system and were willing to take part in the study. A total of 15 virtual interviews were conducted with key informants, out of which, 5 represented government institutions (3 from the national level and 2 from the regional level), 3 represented donors and development partners, 5 representatives from healthcare professionals (3 providers and 2 from professional bodies) and 2 representatives from non-governmental organizations (NGO) and civil society organizations (CSO), respectively.

Study design and data collection

The study used a qualitative cross-sectional design. We conducted 15 in-depth interviews using a semi-structured interview guide ( S1 Appendix ) which was developed to ensure that the desired area of inquiry was covered during individual interview sessions and to aid comparability of information obtained across the respondents. The interviews were conducted virtually between September 2020 and February 2021 by two research members of the team (JO and GK) with experience in conducting qualitative interviews. All supplementary notes were taken by one researcher (DO). All interviews were conducted in English and took an average of one hour. Interviews were recorded after obtaining oral consent from respondents.

Data management and analysis

All interviews were transcribed and coded for analysis using NVivo software. Data analysis was done using the Framework approach [ 45 ]. Deductive content analysis was used for this study. We started with the WHO building blocks framework to guide the analysis and further modified it based on findings to develop new themes not covered by the framework but mentioned in interviews. One researcher (DO) initially read through all the transcripts, line by line to develop an initial coding framework with input from (JO). This was then shared with (IB) who read through and double coded five transcripts, selected across the participant’s category to refine the coding framework. With input from other study team members (GY, GK, WM, KKM), the differences in the coding framework were then reconciled and coding was done on the themes and sub-themes identified in the final framework. Two researchers (DO and IB) then applied the final coding framework to present results, which were then reviewed by the other study team members (GY, GK, JO, WM, KKM). The data was stored in a password protected shared directory on the Strathmore server based on Strathmore University ICT data protection policy. Additionally, since the study was collaborative research with Duke University, it approved data back up and sharing by Duke IT Security Offices. All personal identifiers were removed from the dataset prior to archiving in the Duke University data repository.

Ethical approval and consideration

Ethical approval was obtained from Strathmore University’s Institutional Review Board (0891/20) and the Duke University Campus Institutional Review Board (2019–0366). Informed consent was sought from participants send in advance through email. Since all the interviews were done virtually, verbal informed consent was obtained from all the participants after providing information about the study and the potential benefits and risks of their involvement. The interviews were conducted virtually to mitigate the risk to participants due to the COVID-19 pandemic.

The stakeholders discussed various dimensions of the COVID response in Kenya and identified key challenges and opportunities for future preparedness and response efforts. While taking into account the WHO’s health systems building block framework [ 40 ], the findings are categorized into three broad themes: (1) Stakeholder perceptions on the country’s COVID-19 response, which captures the views on the adequacy of resources used and the measures taken by the government to effectively in fighting the COVID-19 pandemic; (2) Impact of the pandemic on Kenya’s health system and the population; (3) Opportunities to improve future pandemic preparedness and health system strengthening based on stakeholders’ recommendations.

Stakeholders’ perceptions on Kenya’s COVID-19 response

Provision of emergency supplies..

Majority of the respondents noted that the availability of supplies, such as personal protective equipment (PPEs), testing kits and reagents, was inadequate. This was attributed to the disruption of the international supply chain due to travel bans and border closures, which created a global shortage. Additionally, the high demand across countries resulted in an initial spike in prices of supplies rendering them expensive to acquire. However, while the country resorted to local manufacturing of PPEs to avert the shortages, concerns were raised about the poor quality and, therefore, the potential risk to healthcare workers exposed to infections.

“ So , in terms of the supply chain , we notice that the availability of PPEs was a problem , the cost was just out of this world , I think that at this point in time possibly we are buying PPEs at 10% or less of the cost that was reported in the beginning of the pandemic . And especially most of the countries did not have access to COVID-19 test kits , so I would say our biggest challenge at that point was supplies .” Key Informant 1

Rigid procurement processes both at the national and county levels during the pandemic was faulted as one of the challenges that led to shortage of supplies. Respondents recommended that exceptions and favorable provisions should be made for emergencies.

Surveillance and health information systems.

Several concerns were raised regarding the robustness of the health information systems in the country at the beginning of the pandemic. It was noted that historically, the healthcare information system has been fragmented and most of the information, including patient records and files, are still paper based. This posed an initial challenge in receiving real-time information that could have been used for critical decision making, especially with the surge in COVID-19 cases. Few respondents pointed out that there is also an opportunity to embrace technology and digitize data that can be leveraged in critical decision-making.

“ Digital surveillance platforms are easier to analyze and could be producing all these dashboards in real time . I think we adopted it at some stage but in the earlier stages , I think we really were on paper-based approach which sometimes is hard to put on digital platforms and analyze and be able to make decisions .” Key Informant 15

Although there were efforts to undertake mass testing at the initial stage of the pandemic, the process was largely faulted by most of the respondents. First, the initial turnout was low, and the information received was not sufficient to make concrete policy recommendations. Secondly, it was noted that the tests were not being analyzed locally, causing delays and risks of transmission during the wait period. In terms of contact tracing, inaccurate contact information provided by some tested people presented a challenge in reaching them. One of the respondents attributed the provision of wrong information to the initial stigma associated with handling positive cases.

“ I think a lesson that we can learn , right from the initial stages , how do we approach contact tracing without necessarily coming closer to criminalizing it , I think that was the bigger challenge in the initial stages .” Key Informant 15

Almost all the respondents acknowledged that the country responded well in terms of sharing information on the COVID-19 pandemic with the public. They lauded the Ministry of Health for continually informing the public on developments regarding the pandemic. Some of the respondents felt that cross-border exchange of information from countries that were already experiencing the pandemic, such as China, provided an opportunity for Kenya to put stronger mechanisms in place and improve preparedness.

“… I must commend the government and the Ministry of Health in terms of giving information to the public . We had enough materials circulated in the media and even through the facilities . We had regular memos from the Ministry of Health and particularly the acting director-general informing the healthcare workers in terms of what needs to be done .” Key Informant 3

Availability of human resources for health.

Several challenges were highlighted regarding human resources for health during the pandemic. First, respondents pointed out that the available workforce was inadequate and misallocated and poorly trained on the management of COVID-19. While there was a bid to increase the workforce through temporary hiring and redeployment from other programmes to COVID isolation and quarantine sites, some of the respondents felt that this move was not well thought out since: (i) the hiring was done on a short-term basis and posed a challenge to sustainability in the long run; (ii) the few workers left in the facilities were stretched and not working efficiently. Secondly, the inadequate supply and poor quality of PPEs created fear of infection among the healthcare workers, taking a toll on their mental health due to concerns about exposing themselves and their families to the COVID-19 infection.

“ The number of the healthcare workers that were available , number two the protection of healthcare workers by offering quality protective PPEs , and number three in terms of training . You realize from the Ministry of Health data , most counties were below per in terms of the number of people that were training for COVID-19 , and you notice in some areas we had some health workers running away when they heard patients had signs of COVID and this shows anxiety among them because of lack of training …” Key Informant 1

Adequacy of health infrastructure.

There was consensus most respondents regarding the inadequacy of healthcare infrastructure. Some of the respondents’ challenges were the government’s capacity to provide adequate quarantine facilities, leading to overcrowding in the few designated and posing a more considerable infection risk. Additionally, the pandemic revealed the initial insurmountable capacity gap of Intensive Care Units (ICU), with approximately 500 ICU beds available across the entire country to care for critical patients. As a result, some patients lost their lives due to lack of hospital bed space for critical care services.

“.. the public health system is not well equipped in terms of the facilities , in terms of the equipment … The challenge which the Kenyan health system has faced mainly is number one capacity to accommodate those people requiring admission … We don’t have capacity in terms of hospital beds , in terms of ICU capacity and then the number of facilities we have are very limited .” Key Informant 3

Adequacy of financing for COVID-19.

Most of the respondents felt that the health sector in Kenya is significantly underfunded and was further strained by the COVID-19 pandemic. Some argued that the onset of the COVID-19 pandemic created competing needs in the healthcare sector, thereby necessitating efficient and effective way of prioritizing and coordinating the financial resources.

“ The outright answer is our resources have not been enough; both financial , supplies and by a large extent … If you look at the budget allocation in the health sector , we have been oscillating between 5 . 6% and 6% or about 6 . 7% over the last 4 to 5 years , against the Abuja Declaration of 15% . If you look at it from the GDP point of view , we have to push for about 5% of GDP going into the health sector , I think we are oscillating between 1 . 5% and 2% , which means we are still way below the financing and therefore if anything comes on board that destabilizes the balance …” Key Informant 14

A few of the respondents raised concerns regarding the misuse of funds that had been mobilized domestically and from donors to curb the pandemic. Coordination of funding priorities between national and county levels was also highlighted as a challenge. Other issues including improper utilization of funds, delayed disbursements, skewed priorities and lack of expertise among officials were said to impact health financing decision-making.

“ I think for COVID , and we don’t know how many other pandemics we are yet to get into , is how efficient we are in our Public Finance Management , especially in fund flows to getting the money to where it is needed in good time . … we failed in terms of timely disbursements . This serves a lesson for in future how do we get such emergencies taken care of in good time , to get the money where it is needed .” Key Informant 15

When asked about the role of external aid and support in facilitating the COVID response in Kenya, respondents talked about instances where various local and international actors, and agencies offered financial and technical support to the country, including supplies such as PPEs and testing kits. Some agencies, such as USAID were said to have repurposed some of the funds to optimize the fight against the pandemic, while others such as the World Bank offered technical and financial support.

“ From the World Bank , we have these multilateral agreements … one of them was activated very quickly to make that 5 billion Kenya Shillings (Approximately 50 million USD) available . There was support from the EU for example , there was support from DANIDA , and then there was some support from the US government also through USAID and others but working through their implementing partners . And of course the local contribution from the private sector through the resource mobilization committee .” Key Informant 8

Coordination between the national and county governments.

Despite the initial move to set up an inter-governmental and multi-sectoral emergency response committee comprising of the health, security, education, transport, finance and trade sectors, some respondents felt that it was poorly executed in the beginning, with unclear roles and each arm operating autonomously in a situation that called for collaboration. Concerns were also raised by some of the respondents regarding the coordination between the national and county governments. For instance, the COVID-19 isolation centers were initially set up at three hospitals in the country’s capital. Patients who lacked alternatives in their own counties were turned away due to poor referral systems and overcrowding.

“ When surveillance was devolved , contact tracing and all these things , we saw that hampered very much by the ability of the county to activate or facilitate response teams . When the county failed , they said the county failed and yet this is a national emergency .” Key Informant 12

However, opportunities were also leveraged through enhanced county level responses as illustrated by one of the respondents;

“… and borrowing the lessons of COVID-19 , we must remain alert , prepared and be able to work together . And I can give you an example . In my county , my governor set up different committees and I chair one committee where all development partners with a county commissioner and the governor himself , we all sit down to track how the pandemic is moving and mobilize additional resources .” Key Informant 5

Impact of COVID-19 on the health sector, population and the economy

Impact on health services provision..

The onset of the COVID-19 pandemic in Kenya presented a shift in the provision of some healthcare services deemed non-essential. This saw the government closing some of the outpatient clinics and peripheral facilities and reallocating resources, including human and financial, to cater to the COVID-19 response. Majority of the respondents cited that health services, including maternal and child health (MCH), non-communicable diseases (NCDs), HIV, TB and elective surgeries were negatively affected. Under MCH services, sexual reproductive health, family planning services and immunization had to be stopped periodically. Additionally, it was pointed out that some counties converted their maternal units to COVID-19 isolation units, which impacted mothers’ access to care. Although various policies were developed and put in place, some of them lacked clarity, including those for essential and emergency services, hence negatively affecting service provision and health seeking behaviours among the public. Fear of contracting COVID-19 and seeking services past curfew hours as well as capacity and supplies gaps were also highlighted as some of the reasons as to why most people avoided seeking care at health facilities, with others resorting to home based care.

“ You find that antenatal care is considered elective therefore , mothers did not go , even immunization was considered elective , therefore , children did not go for immunization , so those services were affected . And also , family planning access may have been seen as elective and further on surgery , elective surgeries , NCDs , checkups and clinics , medical clinics and surgical clinics may have been considered elective .” Key Informant 12

Some of the respondents also reported that the pandemic highly impacted patients, especially those who needed continuous and routine care (i.e., cancer patients seeking care in the country’s capital Nairobi), due to the imposed lockdown and cessation of the provision of these services that were now considered elective.

“ Many people , including cancer patients who used to come and get their chemotherapy , and get their radiotherapy , those services went down dramatically … some people who were waiting to be given chemotherapy , cancer patients , could have missed several cycles and perhaps lost their lives .” Key Informant 3

Impact on the pathway towards UHC.

While discussing the long-term impacts of the COVID-19 pandemic on the country’s journey towards achieving Universal Health Coverage (UHC), respondents felt that progressively, this would result in decline in coverage and reverse the gains that have been made in these fronts in the country, especially in the case of NCDs and routine care services, like cancer treatments, dialysis etc. Respondents also pointed out that the government was not providing health insurance for the larger population, including the healthcare workers at the onset of the pandemic. Individuals were expected to make out of pocket payments which led to instances of financial hardship. This also affected the willingness of individuals to come forth to get tested or seek treatment at designated COVID-19 facilities.

“ One of the big impact of COVID is the fact that some of the other health conditions , have fallen back behind and therefore it means that in our attainment of UHC there is a lot more that will need to be done because now . I am sure we will have more people affected by different conditions and most notably I would say the NCDs , one , either because people have not then been seeking care at the health facility because of the perception that they will actually get infected , and maybe not taken their medication in the right way that they should .” Key Informant 13

Impact on vulnerable population groups.

Almost all respondents acknowledged that although the COVID-19 pandemic affected the whole population, there were certain sub-sets that were more negatively impacted. One of groups singled out by majority of the key informants were those working in the informal sector or daily wage earners, who constitute almost 80% of the Kenyan population and mostly reside in informal settlements. This is because some of the initial containment measures put in place including lockdown and closing some sectors of the economy such as bars and restaurants, increased their vulnerability by affecting their jobs and livelihoods. Additionally, public health measures that required the purchase of masks and sanitizers presented a challenge to those living in informal settlements and with limited resources.

“… we are aware that with that [COVID-19 pandemic] came quite a number of restrictions that of course closed the economy and we know that over 80% of Kenyans are either poor or near poor , meaning they are one incident away from poverty , so any single incident will push them into poverty and COVID-19 is one of such incidences where if they don’t get a salary for one month then they would be literally be below the poverty line .” Key Informant 14

Some stakeholders pointed out that women and girls were disproportionately affected by the pandemic. Cases of gender-based violence, especially against women, were on the rise due to economic stress in households and social isolation resulting from movement restrictions. Additionally, some stakeholders pointed out that the school system offered security to girls from communities that practice early marriages and female genital mutilation, and school closure resulted in an increase in these cases.

“ On one side , communities that practice early child marriage and female genital mutilation , we saw these things increasing because now girls were at home , they were more vulnerable , they were not going to school … girls who come from poor families and rural communities who would depend on the government supply of sanitary commodities could no longer access them because now they were at home and those sanitary commodities are largely supplied through schools .” Key Informant 12

Commenting on the pandemic’s impact on school and education, a few of the respondents mentioned that children in rural and remote settings were affected by the temporarily closure of learning institutions due to lack of access to the internet and laptops. Additionally, some of the children in the rural counties relying on government-supported school feeding programmes saw reduced access to food. Few respondents noted that children with special needs, who mostly rely on teachers with special needs training, affected their learning. Additionally, people with disability were also affected due to the social distancing measures put in place.

“… and then you have persons who are disabled so they need physical support , they actually need someone to pull and to push their wheelchair , or they need someone to hold them and help them get into a matatu [minibus used for transport] , and so on … so , this physical distancing measures were disproportionately affecting people that are blind , people that cannot walk , people that cannot talk; so , the disabled were disproportionately affected . Key Informant 4

Impact on donor transitions in the health sector.

Due to the heavy reliance on donor funding in the health sector, majority of the respondents expressed their concerns about its impact on the health sector more generally, and the impact of COVID-19 on donor transitions in Kenya. Some of them felt the donor countries are likely to shift their resources to focus more on their own needs in dealing with the pandemic. In contrast, others felt that donors would reevaluate transition timelines and be more forthcoming to boost investments in a bid to curb the pandemic and strengthen health systems.

“… most countries having experienced the pandemic and economic crisis which they have not had in the past , we expect that they will focus more on their individual country’s needs as opposed to donations , and of course lower middle-income countries like Kenya , we need to prepare for that and set priorities in the health system to ensure that the little funds that we have are used in an efficient way .” Key Informant 2

Opportunities to improve future pandemic preparedness

Greater financial flexibility and improved coordination to respond to pandemics..

Various recommendations were made to improve health financing arrangements and strengthen financial prioritization and coordination to tackle future health emergencies. First, there were suggestions to create an emergency fund within the Ministry of Health that can be tapped and easily accessed in emergencies. Second, stakeholders urged for reforming the public financial management laws to allow flexibility and improve financial decision-making during an emergency. Third, respondents called for introducing financial laws and regulations that are responsive to unique situations such as pandemics that would facilitate improved fund utilization at the national and county levels. Respondents argued that counties and facilities should be given the financial autonomy to carry their duties, such as hiring more health workers during an emergency without overtly relying on the national government. Respondents also called for fostering stronger public private partnerships to mobilize resources to tackle future pandemics.

“ For financing , we must have an emergency fund that is backed by law , that this percentage must be put for emergencies even though it keeps revolving every year . Because , if we have to start forming committees to get funds or to start fundraising now , you see the delays in the response .” Key Informant 9

Improving self-reliance through increased domestic health investments.

Respondents generally agreed that Kenya should prioritize resource mobilization and spend efficiently to minimize the financial strain and service gaps resulting from the COVID-19 pandemic and impending donor transitions. Respondents urged for better donor transition planning and improved accountability in using available external resources to build a resilient health system. Apart from improved resource mobilization, few respondents cited that the country should emphasize efficiency improvements in the health sector by adopting mechanisms such as health technology assessments. Additionally, there were views to foster a more robust consultation between African countries, the national and county governments in resource allocation, and leveraging on public-private partnerships to seal the gap that will result from donor exit.

“ I would ask that especially in the health sector , we adopt health technology assessment as a key intervention that helps us understand where we have the highest return on investment . We do not need to add more resources maybe right now , but we need to ensure that we know where our money is and what our money is doing and looking at how best can we maximize on our efficiencies . " Key Informant 14

“ 25% of the Kenyan healthcare sector is financed by donors … we have transitioned into a lower middle-income country … when you look at HIV AIDS , vaccines , malaria in the country , the dependency is much higher . If we don’t have a plan for how we will replace the funds that we get from donors , then we are going to lose the gains that we have made on those specific disease …” Key Informant 4

Improved financial protection for individuals to achieve UHC.

Given the catastrophic health expenses borne by families at the onset of the pandemic due to lack of coverage by both public and private insurance schemes, there were suggestions to increase protection through social and private insurance that can be adjusted to accommodate the larger population in instances of a pandemic. Additionally, to increase the country’s health system resilience, there were suggestions to increase equity in resource allocation, coupled with political goodwill in a bid to achieve UHC.

“ In terms of health financing and UHC , COVID presents a fantastic opportunity for us to reengineer our health systems ;… no one is safe until everyone is safe … if we don’t bring everyone under a mechanism of ensuring that they have access to care then it does no good to all of us because the fact that your neighbor is not covered or is unable to access a treatment on COVID or preventive measures on COVID , then that means you are not protected in the first place .” Key Informant 15

Addressing gaps in health infrastructure.

Despite the challenges linked to infrastructural gaps, some of the respondents reported that setting up urgent health facilities created an opportunity for increased structural capacity that can still be used post-COVID. There was also recommendation to increase investments in health systems infrastructure such as ICU to cater to future pandemics and other ailments.

“ Now , we have been able to put capacity in most of our health facilities , there are counties which would not have had ICUs in many years to come . I am sure even after COVID , those ICUs will be used for other ailments going forward .” Key Informant 2

Strengthening human resources health.

There were suggestions to rethink human resources development sustainably, including expanding the health workforce and greater focus on tackling health emergencies. Additionally, some respondents also highlighted the need to continuously train the healthcare workforce on emergency preparedness by embedding it in their curriculum to create better and timely response in case of future pandemics.

“ The workforce , the preparedness among our people to deal with the pandemic needs to be done well in advance … I mean , we know this might happen . It should becomes part of our curriculum in our medical schools and nursing schools and schools of public health …” Key Informant 6

Fostering cross-sectoral collaborations for maintaining essential health services during health emergencies.

Several respondents mentioned that despite these challenges, the pandemic provided an opportunity for multisectoral collaboration, which helped ease the pandemic’s impact. In terms of progressive response, respondents mentioned that, through partnerships fostered between the Ministry of Health and private sector players, guidelines and outreach for MCH, TB and HIV programs filled the initial service provision gaps created by the pandemic. There were recommendations for the government to invest in the delivery of essential services during a pandemic in two major ways; prioritization of continuity of services and dedication of funds for the provision of essential services.

“.. we have to put a lot of effort towards maintaining the essential healthcare services that have been going on . Indeed services were negatively affected , not that people stopped being sick , but people feared the pandemic , they did not seek healthcare services . So , even as we respond to any pandemic , we also need to be aware that we need to respond to the existing conditions …” Key Informant 10

Various opportunities were witnessed in the country’s policy response and measures, including creating local testing capacity by leveraging technology and innovation and strengthening public and private sector collaborations. Additionally, some of the respondents recommended that there should be a deliberate effort to map and support the vulnerable population since their economic and social state directly correlates with the larger health outcomes.

“ Our second level of preparedness should now be looking at the impact of each sector of the economy and mobilize those multi sectoral responses for mitigation . Those mitigation measures in each of those sectors of the economy are what is going to put in place a firm foundation for dealing with potential long-term impacts , making sure that there are certain policy changes that may have to be addressed .” Key Informant 8

Stakeholders also noted that there is an opportunity to strengthen local manufacturing of healthcare commodities to help reduce import costs and mitigate shortages in instances where the global supply chain is affected.

“ We have also realized that in the very initial stages we were importing some of the very simple materials from China and other countries . As we talk now , in the country , actually we deliberately decided to take a route where we are creating capacity to be able to produce things locally . The net effect is that there was serious significant reduction of cost in terms of what we were spending to access some of those things !" Key Informant 2

Incorporating lessons learnt from previous health emergencies and other country experiences.

The majority of the respondents acknowledged that lessons learnt from previous pandemics, including SARS, Ebola, and HIV were progressively incorporated and helped Kenya leverage the existing systems and policies to fight the COVID-19 pandemic.

“ But as it were , before the pandemic , we had the laws and the policies which were actually supposed to direct us on what to do in case of any new emerging disease . And they are very many , as you can recall , we had SARS , we had Ebola … Although the initial reaction was not immediate and some services had been disrupted , we quickly adopted some of the strategies we had .” Key Informant 9

Most of the respondents felt that the capacity of all health systems across the world was tested during the pandemic. However, some mentioned that countries in the continent such as Senegal, the Democratic Republic of Congo, and Uganda had dealt with previous pandemics such as Ebola in earlier years and had better surveillance and response to the pandemic since they leveraged existing systems. Respondents suggested that Kenya should use a blend of lessons from all the countries to develop a solution that will work best in the Kenyan context.

“ If you talk around institutionalizing disease surveillance as a long-term thing , I think Uganda is a country we can learn from . They have a reasonably good disease surveillance process , virology centre they have built , and I think this is because of their Marburg and Ebola outbreaks in the past . Senegal started off with a very early lab information system where all tests were put onto a lab information system , you could see who is testing , how the tests are followed . So , we may not learn the whole response from one country , but we can learn aspects country by country . Key Informant 12

This study explored perspectives of key stakeholders in Kenya’s health system on the country’s response to the COVID-19 pandemic, its impact on the health sector, and implications for future pandemic preparedness. The COVID-19 pandemic presented Kenya with multiple challenges that disrupted the health system and had ripple effects on the entire economy. Shortcomings related to the WHO building blocks were mentioned frequently in our study. Given their complex interaction, there is need to strengthen the healthcare system in the event of a future pandemic of similar magnitude. Addressing these challenges can contribute to improved responsiveness, risk protection of the population and delivery of quality and efficient health services.

The initial negative impact of the pandemic on continuity of essential and non-essential/general health services was revealed in our study. MCH, TB, HIV, assistance for patients requiring routine and continued care were some of the categories highlighted, with attribution to factors such as government directives to discontinue these services and redeployment of staff to offer COVID-19 relief and support services being mentioned. These findings were comparable with other studies from both high and low resource settings which saw a significant disruption in health service provision [ 31 , 39 , 46 – 50 ]. However, not all services were affected as outlined in these studies from Kenya [ 51 ] and Ethiopia [ 52 ]. As a COVID-19 post recovery strategy for protecting the public health gains made for these services, it is pertinent to strengthen governance, coordination and informed decision making across the health service delivery network [ 53 – 55 ]. This will help in promoting provision of quality health services that are essential in ensuring achievement of UHC even in times of public health crisis [ 55 ].

Reduction in individuals’ health-seeking behavior, as seen in our study, was also seen in other countries [ 56 , 57 ]. This was associated with the discontinuation of some health services, lockdowns, curfews, and the fear of infections. Previous studies undertaken in past pandemics such as Ebola have also outlined changes in health seeking behaviors [ 58 , 59 ]. As recommended by our key informants and seen in other studies, a key measure to ensuring continuity of services in the event of a pandemic is to foster multi-sectorial collaboration and developing a resilient health system that is able to cater for needs from a pandemic while maintaining routine health services [ 41 , 60 , 61 ].

Apart from the gaps in effective pandemic response, our study highlights several existing issues such as inadequate healthcare financing, lack of infrastructure, and human resource capacity constraints that have important implications for achieving UHC in Kenya. These challenges can severely impact overall health system resilience, especially as Kenya is undergoing a transition from concessional donor assistance and needs to become more self-reliant in providing services for its population [ 62 ]. Strengthening primary health care and adopting the right mix of Global Health Security (GHS) and UHC domains has been argued as an approach to resolve the health system gaps [ 63 , 64 ]. Additionally, improving public financial management for improved budget allocation and accountability can be integrated by the Country to enhance its future preparedness [ 65 , 66 ].

The respondents in our study revealed the authorities’ initial shortcomings to manage adequate provision for testing, isolation, and quarantine services. However, these services are seen at the heart of effective public health responses to COVID-19. Respondents noted that while the government took appropriate public health measures to curb the pandemic, it fell short on several fronts owing to overwhelmed health facilities and personnel, lack of adequate resources, and issues with capacity and coordination. These findings mirror those from an analysis to understand lessons that Kenya can learn from the pandemic while linking it to historical gaps in the country’s health system [ 67 ]. The resource shortages were attributed to long-standing gaps in the health sector stemming from poor leadership and governance that have preceded the pandemic. Good leadership and governance form part of the key ingredients that determine how a country respond’s to public health emergencies [ 68 ].

Our findings highlighted the prompt response of the government to introduce measures to curb the spread of the virus, share information and raise awareness about the pandemic among the public. These findings are similar to that of two other studies aimed at assessing the knowledge, attitude and practices among the youth and households in informal settlements in Kenya [ 69 , 70 ], and a scoping review assessing the same for Sub-Saharan Africa [ 71 ]. In the three studies, the results indicated that there was high knowledge of the COVID-19 symptoms and preventive strategies, owing to active awareness campaigns by various governments. However, these studies also revealed that a high level of knowledge does not necessarily translate to preventive measures. Respondents raised concerns about the robustness of the HIS and mentioned that its fragmentation hindered timely relay of information for critical decision making at the onset of the pandemic. The use of information technology has been seen to act as an enabling factor for health care utilization by increasing the availability and accessibility of health services, especially for people from rural and remote areas, which will also make it more affordable and less time constraints [ 72 – 74 ]. Additionally, adopting a framework that collects the right data that can be used for future forecast in the event of a pandemic, both at the national and subnational level, is essential in strengthening the country’s health security [ 75 , 76 ].

Strengths and limitations

This study focused on Kenya’s health system’s early responses and overall preparedness to tackle COVID-19. The interviews were conducted during the second wave of the COVID pandemic in Kenya while response measures were still evolving. While the study focuses on various public health measures and controls adopted to curb spread of the pandemic, it does not focus on COVID-19 vaccination strategies, which is critical to ending the pandemic. Participants in the study do not include health care service recipients during the pandemic.

This is among the first studies in Kenya that focused on understanding the impact, response, and policy implications of the COVID-19 pandemic in Kenya through interviews with key stakeholders who were involved first-hand in handling the pandemic in Kenya. The study results provide important insights for future policy and planning to respond more effectively and deliver health services during future health emergencies in Kenya.

This study provides an overview of the early responses to the COVID pandemic in Kenya, pointing out the impact and key challenges that affect how Kenya can improve preparedness for dealing with future pandemics. Improving health sector investments by identifying strategies to minimize the effects of essential health systems could help improve pandemic response in the future. Stakeholders also called for better coordination, more flexibility in financial decision-making, and improved self-reliance to manage the pandemic better.

Supporting information

S1 appendix. topic guide for key informant interviews..

https://doi.org/10.1371/journal.pgph.0001348.s001

Acknowledgments

We would like to acknowledge Dr. Indermit Singh Gill, current Vice President for Equitable Growth, Finance and Institutions at the World Bank and former Professor of Public Policy at Duke University and Dr. Osondu Ogbuoji of Duke University, Center for Policy Impact in Global Health for providing valuable insights and guidance in designing this study. The authors also wish to thank all key informants who provided valuable information for the study.

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Underlying Medical Conditions Associated with Higher Risk for Severe COVID-19: Information for Healthcare Professionals

What you need to know.

• An updated list of high-risk underlying conditions, along with their associated evidence, is provided below. The conditions are grouped by the level of evidence, with the highest level shown in the top section.
• The list of underlying medical conditions is not exhaustive and will be updated as the science evolves.
• This list should not be used to exclude people with underlying conditions from recommended measures for prevention or treatment of COVID-19.

Summary of Conditions with Evidence

Actions healthcare professionals can take, key findings from one large cross-sectional study.

This webpage provides an  evidence-based resource for healthcare professionals  caring for patients with underlying medical conditions who are at higher risk of experiencing severe outcomes of COVID-19. Severe outcomes of COVID-19 are defined as hospitalization, admission to the intensive care unit (ICU), intubation or mechanical ventilation, or death.

This page summarizes data from published reports, scientific articles in press, unreviewed pre-prints, and internal data that were included in literature reviews conducted by subject matter experts. Evidence used to inform the list of underlying conditions was determined by CDC reviewers based on available literature about COVID-19 at time of review. The information reflects evidence regarding underlying medical conditions and is intended to help healthcare professionals make informed decisions about patient care and to increase the awareness of risk among their patients.

The methods used to assess the conditions have changed during the pandemic as the amount of literature and types of studies increased. For instance, preliminary versions of this list focused on providing the latest information based on descriptive data. As the literature grew, CDC investigators categorized the literature by study design.

Since May 2021, the process has been updated to include a CDC-led review process that uses rigorous systematic review methods. To learn more about the process of CDC’s systematic reviews, see CDC systematic review process .

Age is the strongest risk factor for severe COVID-19 outcomes. Patients with one or multiple of certain underlying medical conditions are also at higher risk. ( 1 – 3 )

Additionally, being unvaccinated or not being up to date on COVID-19 vaccinations also increases the risk of severe COVID-19 outcomes.

Providers should consider the patient’s age, presence of underlying medical conditions and other risk factors, and vaccination status in determining the risk of severe COVID-19-associated outcomes for any patient.

Demographic Factors

Studies have shown that COVID-19 does not affect all population groups equally. Three important factors are age, race, and ethnicity.

Age remains the strongest risk factor for severe COVID-19 outcomes, with risk of severe outcomes increasing markedly with increasing age. Based on data from the National Vital Statistics System (NVSS) at NCHS ( Risk for COVID-19 Infection, Hospitalization, and Death By Age Group ), compared with ages 18–29 years, the risk of death is 25 times higher in those ages 50–64 years, 60 times higher in those ages 65–74 years, 140 times higher in those ages 75–84 years, and 340 times higher in those ages 85+ years. Notably, these data include all deaths in the United States that occurred throughout the pandemic, from February 2020 to July 1, 2022, including deaths among unvaccinated individuals.

Risk of severe outcomes is increased in people of all ages with certain underlying medical conditions and in people who are 50 years and older, with risk increasing substantially at ages >65 years. 4,5  Residents of long-term care facilities are also at increased risk, making up less than 1% of the U.S. population but accounting for more than 35% of all COVID-19 deaths. 6-10

Race and Ethnicity

The COVID-19 pandemic has highlighted racial, ethnic, and socioeconomic disparities  in COVID-19 illnesses, hospitalizations, and deaths. 11-13  Some racial and ethnic minority groups are also more likely to face multiple barriers to accessing health care including lack of insurance, transportation, child care, or ability to take time off from work.

Studies have identified racial and ethnic differences in at-home COVID-19 test use, vaccination coverage, and access to outpatient therapeutics.14-16 Data has shown that compared to non-Hispanic White people, people from racial and ethnic minority groups are more likely to be infected with SARS-CoV-2 (the virus that causes COVID-19). Once infected, people from racial and ethnic minority groups are more likely to be hospitalized, be admitted to the ICU, and die from COVID-19 at younger ages. 17

We are still learning about how the environments where people live, learn, and work  can influence the risk for infection and severe COVID-19 outcomes.

Evidence used to inform the list of underlying medical conditions that increase a person’s risk of severe illness from COVID-19 is presented in alphabetical order by study design section. Conditions are categorized as higher risk, suggestive higher risk, and mixed evidence.

Higher Risk (conclusive)

Higher risk is defined as an underlying medical condition or risk factor that has a published meta-analysis or systematic review or underwent the CDC systematic review process . The meta-analysis or systematic review demonstrates a conclusive increase in risk for at least one severe COVID-19 outcome.

Evidence of Impact on COVID-19 Severity [Reference number]

CDC Systematic Review [K]

• Hematologic Malignancies

CDC Systematic Review [O] Meta-Analysis/ Systematic Review 18-22 Cohort Study 23-25 Case Series 26-28 Case Control Study 29

Cerebrovascular disease

Meta-Analysis 30-33 Synthesis of Evidence 34 Cohort Study 35-37

Chronic kidney disease*

• People receiving dialysis 38,39 ^

Meta-Analysis 33,40 Cohort Studies 36,41-62, 63 * Case Series 64-66

Chronic lung diseases limited to:

• Bronchiectasis
• COPD (Chronic obstructive pulmonary disease)
• Interstitial lung disease
• Pulmonary embolism
• Pulmonary hypertension
• CDC Systematic Review [A]
• CDC Systematic Review [L]
• CDC Systematic Review [D]
• CDC Systematic Review [G]

Chronic liver diseases limited to:

• Non-alcoholic fatty liver disease
• Alcoholic liver disease
• Autoimmune hepatitis

CDC Systematic Review [B]

Cystic fibrosis

CDC Systematic Review [M]

Diabetes mellitus, type 1

Meta-Analysis 67 Case Series 65 Cohort Study 35,68-73

Diabetes mellitus, type 2*

Meta-Analysis 74 Systematic Review 75 * Gestational Diabetes Systematic Review 76 * Case Series 65 Longitudinal Study 77 Cohort Study 67,71,77-82

Disabilities‡, including Down syndrome

For the list of all conditions that were part of the review, see the module below

CDC Systematic Review [C]

Heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies)

Meta-Analysis 83-85 Cohort Study 35,36

HIV (Human immunodeficiency virus)

Meta-Analysis/ Systematic Review 86 Cohort Study 54 , 87-89 Case Series 90-92

Mental health conditions limited to:

• Mood disorders, including depression
• Schizophrenia spectrum disorders

Meta-Analysis/ Systematic Review 93 , 94

Neurologic conditions limited to dementia‡

Meta-Analysis/ Systematic Review 95-98 Cross-Sectional Study 99 Cohort Study 36,100

Obesity (BMI  > 30 kg/m 2  or  > 95 th  percentile in children)

Meta-Analysis 101-103 Systematic Review 75 * Cohort 46 , 104-112 ;   63,113-116 *

Physical inactivity

CDC Systematic Review [E]

Pregnancy and recent pregnancy

Meta-Analysis/ Systematic Review 75,117 Case Control 118 , 119 Case Series 120-122 Cohort Study 123-126

Primary immunodeficiencies

CDC Systematic Review [F]

Smoking, current and former

Meta-Analysis 83,127 , 128-135

Solid organ or blood stem cell transplantation

Meta-Analysis 108 Case Series 136-147 Cohort 148-151

Tuberculosis

CDC Systematic Review [H]

Use of corticosteroids or other immunosuppressive medications

Meta-Analysis/ Systematic Review 152 Cohort Study 153 Cross-Sectional 154 Case Series 155-157

• Attention-deficit/hyperactivity disorder (ADHD)
• Cerebral palsy
• Charcot foot
• Chromosomal disorders
• Chromosome 17 and 19 deletion
• Chromosome 18q deletion
• Cognitive impairment
• Congenital hydrocephalus
• Congenital malformations
• Deafness/hearing loss
• Disability indicated by Barthel Index
• Down syndrome
• Fahr’s syndrome
• Fragile X syndrome
• Gaucher disease
• Hand and foot disorders
• Learning disabilities
• Leber's hereditary optic neuropathy (LHON) or Autosomal dominant optic atrophy (ADOA)
• Leigh syndrome
• Limitations with self-care or activities of daily living
• Maternal inherited diabetes and deafness (MIDD)
• Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) and risk markers
• Mobility disability
• Movement disorders
• Multiple disability (referred to in research papers as “bedridden disability”)
• Multisystem disease
• Myoclonic epilepsy with ragged red fibers (MERRF)
• Myotonic dystrophy
• Neurodevelopmental disorders
• Neuromuscular disorders
• Neuromyelitis optica spectrum disorder (NMOSD)
• Neuropathy, ataxia, and retinitis pigmentosa (NARP)
• Perinatal spastic hemiparesis
• Primary mitochondrial myopathy (PMM)
• Progressive supranuclear palsy
• Senior-Loken syndrome
• Severe and complex disability (referred to in research papers as “polyhandicap disability”)
• Spina bifida and other nervous system anomalies
• Spinal cord injury
• Tourette syndrome
• Traumatic brain injury
• Visual impairment/blindness
• Wheelchair use

Suggestive Higher Risk

Suggestive higher risk is defined as an underlying medical condition or risk factor that did not have a published meta-analysis or systematic review or did not undergo the CDC systematic review process . The evidence is supported by mostly cohort, case-control, or cross-sectional studies. (Systematic reviews are available for some conditions for children with underlying conditions.)

Children with certain underlying conditions

Read More: Information for Pediatric Healthcare Providers

Systematic Review 158,159 Cross-Sectional Study 99 , 160,161 Cohort Study 100 , 162-169 Case Series 170,171

Overweight (BMI > 25 kg/m 2 but <30 kg/m 2 )

Cohort Study 111 Case Series 110

Sickle cell disease

Cohort 170-173 Case Series 170,173-188

Substance use disorders

Case-Control Study 189-191 Cohort Study 192,193

Mixed Evidence (inconclusive: no conclusions can be drawn from the evidence)

Mixed evidence is defined as an underlying medical condition or risk factor that has a published meta-analysis or systematic review or underwent the CDC systematic review process . The meta-analysis or systematic review is inconclusive, either because the aggregated data on the association between an underlying condition and severe COVID-19 outcomes are inconsistent in direction or there are insufficient (or limited) data on the association between an underlying condition and severe COVID-19 outcomes.

• Limited: The evidence consists of one study, or several small studies with no comparison group, limiting the conclusions that can be drawn.
• Inconsistent: The evidence suggests no clear direction of association, meaning no firm conclusions can be drawn.

Alpha 1 antitrypsin deficiency

Limited: CDC Systematic Review [I]

Bronchopulmonary dysplasia

Limited: CDC Systematic Review [J]

Hepatitis B

Inconsistent: CDC Systematic Review [B]

Hepatitis C

Limited: CDC Systematic Review [B]

Hypertension*

Inconsistent Meta-Analysis 83,194-197 Systematic Review 198 , 75 * Cohort Study 35,36,41,199-205 Case Series 206

Thalassemia

Limited: CDC Systematic Review [N]

Footnotes: * Indicates presence of evidence for pregnant and non-pregnant people

‡ Underlying conditions for which there is evidence in pediatric patients

^ Risk may be further increased for people receiving dialysis

• Recommend vaccination with approved and authorized COVID-19 vaccines (updated 2023-2024 COVID-19 vaccine), which are safe and effective. Check out the Interim Clinical Considerations for Use of COVID-19 Vaccines as well as Stay Up to Date with Your Vaccines and locations for COVID-19 vaccination for patients  for more information.
• Prescribe antivirals , which have been shown to significantly decrease the risk of hospitalization and death when treating patients with mild to moderate illness and risk factors for severe illness. Outcomes are improved if therapeutics are started within the first 5-7 days of symptom onset.
• Consider pemivibart (Pemgarda™), a monoclonal antibody for COVID-19 pre-exposure prophylaxis in people who are moderately or severely immunocompromised and unlikely to mount an adequate immune response to COVID-19 vaccination and who meet the FDA-authorized conditions for use . Pemivibart may provide another layer of protection against COVID-19 in addition to vaccination and can be given at least 2 weeks after receiving a COVID-19 vaccine. For more information, please see the FDA Fact Sheet for Providers .
• Remind older patients and those with underlying medical conditions that wearing a mask is an additional prevention strategy  they can choose to further protect themselves.
• Encourage patients to keep appointments for routine care and adhere to treatment regimens for their medical conditions.
• Consider use of telehealth when appropriate.
• Check out additional information for your patients .

Considerations for Patients Within Racial and Ethnic Minority Groups

• Ask patients about their concerns about vaccines and therapy. Consider using an evidence-based and culturally sensitive approach, such as motivational interviewing . Try to provide trusted sources of information and other resources.
• Encourage testing, as well as early treatment , for patients who are eligible.
• Facilitate access to culturally and linguistically appropriate resources.
• Reduce barriers to accessing current outpatient treatments.

CDC strongly encourages healthcare professionals, patients and their advocates, and health system administrators to regularly consult the Infectious Diseases Society of America (IDSA) COVID-19 Treatment Guidelines .

Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020–March 2021

This study  used data from the Premier Healthcare Database, which represents approximately 20% of all inpatient admissions in the United States since 2000. This cross-sectional study of 540,667 adults hospitalized with COVID-19 included both inpatients and hospital-based outpatients with laboratory-diagnosed COVID-19 from March 1, 2020, through March 31, 2021. The database included reports from 592 acute care hospitals in the United States. The study was designed to examine risk factors associated with severe outcomes of COVID-19 including admission to an ICU or stepdown unit, invasive mechanical ventilation, and death.

Main Findings:

• Certain underlying medical conditions were associated with an increased risk for severe COVID-19 illness in adults.
• Having multiple conditions was also associated with severe COVID-19 illness.
• Obesity, diabetes with complications, and anxiety and fear-related disorders had the strongest association with death.
• The number of frequent underlying medical conditions (present in ≥10.0% of patients) increased with age. 207

Adapted from Sources:

• Kompaniyets L, Pennington AF, Goodman AB, Rosenblum HG, Belay B, Ko JY, et al. Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020–March 2021. To learn more, visit the Preventing Chronic Disease article: https://www.cdc.gov/pcd/issues/2021/21_0123.htm
• Pennington AF, Kompaniyets L, Summers AD, Danielson ML, Goodman AB, Chevinsky JR, Preston LE, Schieber LZ, Namulanda G, Courtney J, Strosnider HM, Boehmer TB, Mac Kenzie WR, Baggs J, Gundlapalli AV, Risk of Clinical Severity by Age and Race/Ethnicity Among Adults Hospitalized for COVID-19—United States, March–September 2020, Open Forum Infectious Diseases , Volume 8, Issue 2, February 2021. To learn more, visit: https://doi.org/10.1093/ofid/ofaa638

Source: Kompaniyets L, Pennington AF, Goodman AB, Rosenblum HG, Belay B, Ko JY, et al. Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020–March 2021. To learn more, visit the Preventing Chronic Disease article: https://www.cdc.gov/pcd/issues/2021/21_0123.htm

• Methods for the Underlying Conditions ICD-10 List [PDF, 2 pages, 112K]
• COVID-19 Treatment Guidelines: What’s New
• COVID-19 Therapeutics
• Clinical Care Considerations
• COVID-19 Treatment in Outpatients
• COVID-19 Cases, Deaths, and Laboratory Testing (NAATs) by State, Territory, and Jurisdiction
• Demographic Trends of COVID-19 Cases and Deaths in the U.S. by Race and Ethnicity
• Health Equity: Promoting Fair Access to Health 
• How Do I Find a COVID-19 Vaccine
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Motivational interviewing as a strategy to improve adherence in ibd treatment: an integrative review amidst covid-19 disruptions.

1. Introduction

2. materials and methods, 2.1. identification of the research question.

RQ1: Can Motivational Interviewing improve therapeutic adherence and/or compliance in adult patients with IBD?

2.2. Search Strategy

2.3. inclusion and exclusion criteria, 3.1. study selection, 3.2. quality appraisal, 3.3. key characteristics of included studies.

3.4. Results of the Included Studies

4. discussions, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Mercuri, C.; Catone, M.; Bosco, V.; Guillari, A.; Rea, T.; Doldo, P.; Simeone, S. Motivational Interviewing as a Strategy to Improve Adherence in IBD Treatment: An Integrative Review Amidst COVID-19 Disruptions. Healthcare 2024 , 12 , 1210. https://doi.org/10.3390/healthcare12121210

Mercuri C, Catone M, Bosco V, Guillari A, Rea T, Doldo P, Simeone S. Motivational Interviewing as a Strategy to Improve Adherence in IBD Treatment: An Integrative Review Amidst COVID-19 Disruptions. Healthcare . 2024; 12(12):1210. https://doi.org/10.3390/healthcare12121210

Mercuri, Caterina, Maria Catone, Vincenzo Bosco, Assunta Guillari, Teresa Rea, Patrizia Doldo, and Silvio Simeone. 2024. "Motivational Interviewing as a Strategy to Improve Adherence in IBD Treatment: An Integrative Review Amidst COVID-19 Disruptions" Healthcare 12, no. 12: 1210. https://doi.org/10.3390/healthcare12121210

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• DOI: 10.1097/NNE.0000000000001681
• Corpus ID: 270514061

Reimagining the Future of Clinical Nursing Education: A Cohort Partnership Model.

• Bill Buron , Cassy Abbott Eng , Alison Eagleton
• Published in Nurse Educator 12 June 2024
• Education, Medicine

5 References

Examining the impact of the covid-19 pandemic on burnout and stress among u.s. nurses, the ambulatory dedicated education unit (deu): an important example of academic practice partnership in ambulatory care., investigating the challenges of clinical education from the viewpoint of nursing educators and students: a cross-sectional study, dedicated education units: a unique evaluation, exploring the challenges of clinical education in nursing and strategies to improve it: a qualitative study, related papers.

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How COVID-19 is reshaping supply chains

In May 2020, much of the world was still in the grip of the first wave of the COVID-19 pandemic. Lockdowns, shelter-in-place orders, and travel restrictions were disrupting activity in every part of the economy. Demand evaporated in some categories and skyrocketed in others. As they struggled to keep their businesses running, companies were planning significant strategic changes to the configuration and operation of their supply chains. When we surveyed senior supply-chain executives  from across industries and geographies, 93 percent of respondents told us that they intended to make their supply chains far more flexible, agile, and resilient.

Twelve months later, in the second quarter of 2021, we repeated our survey with a similarly diverse group of supply-chain leaders. This time, we asked respondents to describe the steps they had taken to shore up their supply chains over the past year, how those changes compared with the plans they drew up earlier in the crisis, and how they expect their supply chains to further evolve in the coming months and years.

It’s quicker to build inventories than factories

In our 2020 survey, just over three-quarters of respondents told us they planned to improve resilience through physical changes to their supply-chain footprints. By this year, an overwhelming majority (92 percent) said that they had done so.

But our survey revealed significant shifts in footprint strategy. Last year, most companies planned to pull multiple levers in their efforts to improve supply-chain resilience, combining increases in the inventory of critical products, components, and materials with efforts to diversify supply bases while localizing or regionalizing supply and production networks. In practice, companies were much more likely than expected to increase inventories, and much less likely either to diversify supply bases (with raw-material supply being a notable exception) or to implement nearshoring or regionalization strategies (Exhibit 1).

Different industries have responded to the resilience challenge in markedly different ways. Healthcare players stand out as resilience leaders. They applied the broadest range of measures, with 60 percent of healthcare respondents saying they had regionalized their supply chains and 33 percent having moved production closer to end markets. By contrast, only 22 percent of automotive, aerospace, and defense players had regionalized production, even though more than three-quarters of them prioritized this approach in their answers to the 2020 survey. Chemicals and commodity players made the smallest overall changes to their supply-chain footprints during the past year.

Some of these differences among sectors can be attributed to the structural characteristics of the industries involved: for example, chemicals and metals are asset-intensive sectors with large, expensive production sites. Investments in new capacity can take years to complete. Other respondents told us that they had struggled to find suitable suppliers to support their localization or near-shoring plans.

Despite these challenges, regionalization remains a priority for most companies. Almost 90 percent of respondents told us that they expect to pursue some degree of regionalization during the next three years, and 100 percent of respondents from both the healthcare and the engineering, construction, and infrastructure sectors said the approach was relevant to their sector.

Almost 90 percent of respondents told us that they expect to pursue some degree of regionalization during the next three years.

Risk management: More breadth, not enough depth

The pandemic pushed risk to the top of virtually every corporate agenda. For the first time, most respondents (95 percent) say they have formal supply-chain risk-management processes. A further 59 percent of companies say they have adopted new supply-chain risk management-practices over the past 12 months. A small minority (4 percent) set up a new risk-management function from scratch, but most respondents say they have strengthened existing capabilities.

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The actions taken by companies varied according to the precrisis maturity of their supply-chain risk-management capabilities. Companies with little or no risk-management experience tended to invest in new software tools, while higher-maturity organizations mainly focused on the implementation of new practices.

The proactive monitoring of supplier risks was the primary focus of these efforts, yet significant blind spots remain in most companies’ supply-chain risk-management setups. Just under half of the companies in our survey say they understand the location of their tier-one suppliers and the key risks those suppliers face. But only 2 percent can make the same claim about suppliers in the third tier and beyond. That matters because many of today’s most pressing supply shortages, such as semiconductors, happen in these deeper supply-chain tiers (Exhibit 2).

Supply-chain planning: A test for technology and organization

The transition to remote working was one of the most immediate and pronounced effects of pandemic-era restrictions on mobility and access to workplaces. Broadly, respondents to our survey believe they managed that transition well, with 58 percent reporting good supply-chain-planning performance over the past year. The remaining 42 percent of respondents told us that remote working had led to delays in supply-chain decision making.

The success of an organization’s planning was strongly linked to its use of modern digital tools, especially advanced analytics. Compared with organizations that reported problems, successful companies were 2.5 times more likely to report they had preexisting advanced-analytics capabilities. Of the companies that had difficulties managing their supply chains during the crisis, 71 percent say they are ramping up their use of advanced analytics.

The benefits of advanced analytics in supply-chain management are now being recognized across industries. With the sole exception of the healthcare sector, more than 50 percent of respondents in every industry say they have implemented additional analytics approaches during the past 12 months (Exhibit 3). The biggest shifts occurred in industries that were the lowest users of these approaches before the pandemic. In commodities, for example, 75 percent of companies are currently increasing their use, with the remaining 25 percent saying they plan to do so in the future. The only sector in which the race to adopt advanced analytics techniques shows signs of slowing down is in advanced electronics and high tech, where their adoption is already very high.

Digitization surges but could tail off

With so much interest in advanced analytics, it comes as little surprise that the crisis has been a catalyst for further digitization of end-to-end supply-chain processes. An overwhelming majority of survey respondents say they have invested in digital supply-chain technologies during the past year, with most investing more than they originally planned. While automotive and commodity players were reluctant to commit to additional investments amid the uncertainty of early 2020, for example, 100 percent of the respondents in those sectors eventually did so (Exhibit 4). Almost every company also plans for further digital investment in the future. Construction is the only sector in which respondents say they are less likely to invest in digital supply chain technologies in the coming years.

Today’s ongoing and planned digitization efforts are most likely to focus on visibility, as companies strive for a better picture of their supply chains’ real-time performance. For example, since May 2020, 30 percent of respondents had implemented new digital performance-management systems—an important enabler of supply-chain visibility. Improved planning tools, either for specific aspects of the supply chain (such as logistics management) or broader end-to-end planning systems, come a close second among the companies in our survey, with more than three-quarters saying they were a priority. Just under half of all respondents also say they are looking at network-modeling tools to help them improve supply-chain design in the longer term. Nevertheless, despite the prevalence and impact of supply-chain shocks over the past two years, only 39 percent of companies are investing in tools to monitor risks and disruptions (Exhibit 5).

Next steps: Supply chains at an inflection point

The COVID-19 crisis put supply chains into the spotlight. Over the past year, supply-chain leaders have taken decisive action in response to the challenges of the pandemic: adapting effectively to new ways of working, boosting inventories, and ramping their digital and risk-management capabilities. Yet despite that progress, other recent events have shown that supply chains remain vulnerable to shocks and disruptions, with many sectors currently wrestling to overcome supply-side shortages and logistics-capacity constraints. Most worryingly, these new problems are emerging just as senior leaders are turning their attention away from supply-chain issues. In many sectors, there are signs that the rate of investment in digital supply-chain technologies is slowing down. Talent gaps are wider than ever, end-to-end transparency remains elusive, and progress toward more localized, flexible supply-chain structures has been slower than anticipated.

The coming months could turn out to be critical for supply-chain leaders. Some companies will build upon the momentum they gained during the pandemic, with decisive action to adapt their supply-chain footprint, modernize their technologies, and build their capabilities. Others may slip back, reverting to old ways of working that leave them struggling to compete with their more agile competitors on cost or service, and still vulnerable to shocks and disruptions.

Knut Alicke is a partner in McKinsey’s Stuttgart office, Ed Barriball is a partner in the Washington, DC, office, and Vera Trautwein is an expert in the Zurich office.

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• v.14(5); 2022 May

The Well-Being of Healthcare Workers During the COVID-19 Pandemic: A Narrative Review

Hisham mushtaq.

1 Critical Care Medicine, Mayo Clinic Health System, Mankato, USA

Shuchita Singh

2 Obstetrics and Gynecology, Shanti Hospital, Agra, IND

3 Internal Medicine, University of Minnesota School of Medicine, Minneapolis, USA

Aysun Tekin

4 Critical Care Medicine, Mayo Clinic, Rochester, USA

Romil Singh

5 Critical Care Medicine, Allegheny Health Network, Pittsburgh, USA

John Lundeen

6 Psychiatry, TriStar Centennial Medical Center, TriStar Division, HCA Healthcare, Nashville, USA

Karl VanDevender

7 Internal Medicine, Frist Clinic, TriStar Centennial Medical Center, HCA Healthcare, Nashville, USA

8 Psychiatry, Hennepin County Medical Center, Minneapolis, USA

Syed Anjum Khan

Salim surani.

9 Anesthesiology, Mayo Clinic, Rochester, USA

10 Medicine, Texas A&M University, College Station, USA

Rahul Kashyap

11 Critical Care Medicine, TriStar Centennial Medical Center, TriStar Division, HCA Healthcare, Nashville, USA

The coronavirus disease 2019 (COVID-19) pandemic has turned into a global healthcare challenge, causing significant morbidity and mortality.Healthcare workers (HCWs) who are on the frontline of the COVID-19 outbreak response face an increased risk of contracting the disease. Some common challenges encountered by HCWs include exposure to the pathogen, psychological distress, and long working hours. In addition, HCWs may be more prone to develop mental health issues such as anxiety, depression, suicidal thoughts, post-traumatic stress disorder (PTSD), sleep disorders, and drug addictions compared to the general population. These issues arise from increased job stress, fear of spreading the disease to loved ones, and potential discrimination or stigma associated with the disease. This study aims to review the current literature to explore the effects of COVID-19 on healthcare providers' physical and mental well-being and suggest interventional strategies to combat these issues. To that end, we performed a literature search on Google Scholar and PubMed databases using combinations of the following keywords and synonyms: "SARS-CoV-2", "Healthcare-worker", "COVID-19", "Well-being", "Wellness", "Depression", "Anxiety", and "PTSD."

Introduction and background

As of May 5, 2022, more than 510 million confirmed cases of coronavirus disease 2019 (COVID-19) have been reported worldwide, including more than 6.25 million fatalities [ 1 ]. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19, emerged when unexplained pneumonia cases were reported in the city of Wuhan, China [ 2 ]. On December 31, 2019, China reported an outbreak of pneumonia connected to the Huanan Seafood Wholesale market in Wuhan, Hubei Province. China's health officials confirmed on January 7, 2020, that a novel coronavirus, 2019-nCoV, was the cause of the outbreak [ 2 ]. Shortly thereafter, it was confirmed that COVID-19 had spread to several countries, including the United States, Iran, Italy, Germany, France, and Spain [ 2 , 3 ]. As more and more cases of the infection were confirmed, and necessary care began to be rendered at healthcare facilities, healthcare workers (HCWs) emerged as a particularly vulnerable group for acquiring this infection. In a group of 138 patients treated at a Wuhan hospital, 40 patients were HCWs. Of the affected HCWs, 77.5% worked in general wards, 17.5% worked in emergency departments, and 5% served in intensive care units. A patient infected with the SARS-CoV-2 virus who was admitted primarily for abdominal symptoms was found to be the source of infection transmission to 10 HCWs [ 4 ].

China’s National Health Commission reported that Over 3,300 HCWs had been infected with COVID-19 as of March 2020. Based on reports from the local media, 22 HCWs had already died by the end of February [ 5 ]. In Italy, it was reported that 20% of the responding HCWs had been infected with COVID-19, and some of these HCWs had died. Along with the infection risk, medical staff reported physical and mental exhaustion, the challenge of difficult triage decisions, and the devastation of losing their patients and co-workers. HCWs also expressed significant fear of spreading the virus to their families [ 6 ]. A questionnaire-based study conducted in Pakistan in May 2020 had similar findings: 94% of HCWs expressed fear of spreading the virus to their family members and friends [ 7 ]. As of May 8, 2020, Spain had reported 30,663 cumulative COVID-19 infections, which were the highest among all countries in the world at the time and accounted for 20% of the total cumulative HCW infections [ 8 ]. Italy and the Netherlands followed with 23,718 and 13,884 HCW infections, respectively. The United States was fifth on the list with 9,282 cumulative HCW infections [ 8 ].

In research conducted prior to the emergence of COVID-19, wide-ranging studies had indicated that HCWs were under severe stress due to a multitude of factors, including issues related to work-life balance, insurance and billing problems, electronic health record duties, and patient dissatisfaction [ 9 ]. At the beginning of the outbreak, HCWs were at increased risk of contracting COVID-19 due to inadequate protective measures and a lack of knowledge about the virus. Additionally, the sudden, extreme demand for protective equipment, such as gowns and N95 masks, significantly jeopardized the well-being of the HCWs. Developing standard protocols or procedures for infection prevention and control, occupational safety, and patient safety across the entire health system was necessary to ensure the safety of both HCWs and patients. Studies on severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS) have provided insights into the stresses, traumas, and psychological illnesses associated with communicable respiratory diseases and successful interventions made to combat them [ 10 ]. While these studies may provide insights relevant to the current outbreak, the COVID-19 pandemic has introduced unique challenges that require further investigations. This study was conducted to aggregate information from the current literature regarding the impact of COVID-19 on HCWs' well-being with the goal of developing practical interventions. Due to the evolving nature of the pathogen, new evidence regarding the negative impact of COVID-19 on the health of HCWs is constantly emerging.

We searched the databases PubMed and Google Scholar by using the keywords "SARS-CoV-2", "Healthcare-worker", "COVID-19", "Well-being”, “Wellness", "Depression", "Anxiety" and "PTSD" from December 2019 to March 2022. Eligible studies included in this review were articles published in English, whose primary focus was the effect of COVID-19 on the physical and mental well-being of HCWs. Studies that were excluded were articles published in languages other than English, articles related to other pandemics, and articles that studied the well-being of non-HCWs.

Physical Well-Being

Between January 3-11, 2020, 30 infected HCWs with novel coronavirus were referred to the Jianghan University Hospital. There were 10 men and 20 women, including 22 physicians and eight nurses, aged 21 to 59 years. All these HCWs had come into close contact (within 1 meter) with a patient infected with COVID-19, and the 30 patients were classified into 26 mild or moderate cases and four severe cases. This study concluded that HCWs are at higher risk of contracting COVID-19 and that the risk of infection increases with prolonged contact times with infected patients [ 11 ]. A retrospective cohort study further analyzed the risks associated with COVID-19 infection among HCWs. They examined 72 frontline HCWs aged 21-66 years and concluded that working in Pulmonology and Infectious Disease departments was associated with an elevated risk of contracting the infection [ 12 ]. This study also found that exposure to patients without proper personal protective equipment (PPE), long hours of daily contact (≥15 hours), close patient contact (12 times/day), inadequate hand hygiene, and diagnosis of COVID-19 in a family member were associated with an elevated risk of contracting COVID-19. The prevalence of COVID-19 viral respiratory illnesses in HCWs was reported at 1.6-44% [ 12 ]. The most commonly reported symptoms were fever, cough, fatigue, and myalgia. Other symptoms were headache, chest symptoms, dyspnea, diarrhea, nausea/vomiting, and hemoptysis [ 12 ]. A study from Germany reported that 0.33% of healthcare staff acquired symptomatic disease [ 13 ]. The SEMI-COVID-19 registry in Spain analyzed a cohort of 4,393 patients, out of which 419 were HCWs. It revealed a 9% hospital admission rate for HCWs. Sepsis (3.9% versus 1.7%) and in-hospital heath (4.8% versus 0.7%) were lower in HCWs compared to the general population, but other complications such as pneumonia, thromboembolism, and ICU admission showed no difference [ 14 ]. Professional exposure did not seem to increase the severity of the disease. The severity was attributed to known risk factors and comorbidities.

There is a unanimous consensus that the use of N95 decreases the chances of contracting viral respiratory illnesses [ 15 ]. Studies suggest that better protection is obtained with coveralls and long gowns, but it made donning and doffing difficult, leading to low user satisfaction and overall greater contamination [ 16 ]. Prolonged use of N95 and PPE kits has reportedly led to device-related pressure injuries, which can be combated with foam and hydrocolloid dressing [ 17 ]. Polyurethane foam-lined respirators have reduced injuries from 84.7% to 11.1%. They also improved pain scores and redistribution of pressure across the face [ 18 ]. Protection with barrier boxes and an air-purifying respirator with a hood has helped in decreasing the transmission during intubation [ 19 ]. In low-resource settings or in cases of shortages, a well-washed cloth mask can be effective [ 20 ]. Handwashing adherence can be improved by the health action process approach (HAPA) [ 21 ]. Video-based instruction in PPE donning and doffing for medical students and junior doctors provides fast and resource-efficient training [ 22 , 23 ].

Dermatological Manifestations

Dermatological manifestations have been widely reported among COVID-19 patients [ 24 ]. The most common dermatologic problems experienced by HCWs involved in treating patients with COVID-19 were associated with the use of PPE. The nasal bridge was most commonly affected, followed by hands, forehead, and cheeks. The most common symptoms included desquamation and tightness [ 25 ]. The risk of skin damage in the corresponding site was greater for medical personnel who had worn their devices for six hours or longer. However, wearing a face shield for a long time was not a significant risk factor for skin manifestations over the forehead [ 25 ]. More frequent hand hygiene (>10 times per day) may be associated with increased risks of hand skin damage compared to longer glove-wearing time [ 25 ]. Other than allergic or irritant contact dermatitis, cutaneous vasculopathy, micro thrombus-related changes, urticaria or angioedema, morbilliform/maculopapular exanthems, erythema multiforme, and vesicular eruptions have been reported at a rate of 5-20% [ 26 ].

Mental Well-Being

A. Anxiety and Depression

With the outbreak of the COVID-19 pandemic, its immense impact on the mental well-being of HCWs has become evident [ 27 , 28 ]. Most of the initial studies were from China; however, in the course of one year, studies from various other healthcare systems have reported comparable outcomes. Pappa et al. analyzed 13 cross-sectional studies with 33,062 participants and found a pooled prevalence of anxiety at 23.2% and depression at 22.8% [ 29 ]. Luo et al. incorporated 62 studies in their analysis and reported a prevalence of 33% (28-38%) and 28% (23-32%) of anxiety and depression, respectively [ 30 ]. The primary cause leading to this was the enormous and unanticipated workload causing physical exhaustion. Moreover, the lack of adequate personal equipment and the consequent risk of nosocomial transmission compounded the anxiety among HCWs. The need to make ethically difficult decisions like triage and life support was also a contributing factor. Sociodemographic factors like younger age and being female were associated with a higher prevalence. Individuals involved in specific occupational roles such as those working in direct care and nurses have had an increased occurrence of symptoms as compared to administrative staff [ 31 ]. Similar conclusions were also seen in the study by Al Maqbali et al., where the pooled prevalence of anxiety, depression, and insomnia in nurses was 37%, 35%, and 43%, respectively [ 32 ]. The prevalence was higher in HCWs than in the general public. This was in contrast with the SARS epidemic in 2012. The mental wellness of the public deteriorated over time, while that of HCWs improved after the peak of the epidemic, which could be due to a lack of knowledge and sociopolitical impact. The protective factors identified are social support, financial stability, and resilience [ 33 , 34 ].

B. Stress and Insomnia

Wu et al. have investigated the prevalence of depression, anxiety, stress, and insomnia during the COVID-19 pandemic. Stress was reported in 41.5% of HCWs, which was less than in patients with comorbidities such as cancer, diabetes, or chronic kidney disease (49.1%). Also, 47.3% of HCWs reported insomnia, which surpassed the rate observed among the general population and students including university, college, and middle school students [ 28 , 35 ]. This may be due to the fear of the consequences of infection or anxiety about being stigmatized or discriminated against due to COVID-19. The length of quarantine duration and fear of getting infected could be the deep-rooted factors behind stress [ 36 ]. The prevalence of acute stress disorder has been reported to be as high as 40% in HCWs during and after epidemics; however, the increased prevalence in female HCWs is not seen [ 37 ]. Fear of contamination could result in obsessive-compulsive manifestations [ 38 ].

C. Post-traumatic Stress Disorder

In a systematic review including 97,333 HCWs, two out of every 10 HCWs were noted to have PTSD [ 39 ]. PTSD was more common among quarantined physicians [ 39 ]. Another study reported a prevalence of about 30% in COVID-19-symptomatic cases in the general population and 20% in HCWs [ 40 ]. The possibility of delayed-onset PTSD (after three years) during the COVID-19 pandemic cannot be overlooked, and HCWs at high risk should be followed up in the coming years, as the outcomes observed during the earlier SARS pandemic are indicative of its prevalence [ 41 ].

D. Obsessive-Compulsive Disorder

Fear of contamination could result in obsessive-compulsive manifestations. French et al. have described a patient whose obsessive-compulsive disorder (OCD) symptoms were acutely exacerbated by the COVID-19 pandemic and the media coverage surrounding it. These symptoms resulted in significant functional limitations and included increased ritualistic handwashing and cleaning, unwillingness to leave home due to fear of spreading infection, dropping out of an educational course, having minimal or no social interaction with friends or family, and only eating canned foods since they are perceived to have a lesser contamination risk of COVID-19 [ 38 ].

E. Occupational Burnout

When comparing the frequency of burnout between HCWs in usual wards (UWs: non-COVID-19) and HCWs on the frontline (FL: COVID-19) wards, researchers have noted that the latter experienced a lower frequency of burnout and were less worried about becoming infected. According to the available data, closer proximity to decision-makers could benefit FL workers, who may feel more empowered over their situation than other HCWs. Based on the study results, it is certain that both UW staff and those working in FL wards must be kept in mind when drafting policies and procedures to support the well-being of HCWs in response to the COVID-19 crisis [ 42 ]. A striking contrast was seen in the study, which used the abbreviated Maslach Burnout Inventory (aMBI) to assess burnout and career satisfaction among neurosurgeons in the United States. They found that rates of burnout were actually lower when compared with the pre-COVID-19 era [ 43 ]. The authors of this study suggest that decreased working hours due to the pandemic may have contributed to decreased burnout and increased career satisfaction [ 43 ]. Another study from the United States examined the effect of the COVID-19 pandemic on burnout among physicians in outpatient interventional pain management practices using a survey that assessed physicians’ concerns and outlooks regarding their careers [ 44 ]. This study found that most responding physicians expressed concerns about finances, reduced staffing, and maintaining adequate PPE availability due to the pandemic. Additionally, this study found that 60% of respondents felt that the COVID-19 pandemic had a negative impact on their practice, and 52% of respondents currently felt burned out [ 44 ]. These studies suggest that the COVID-19 pandemic may have disproportionately increased burnout among outpatient providers. In healthcare, burnout harms patients, HCWs, and the healthcare system itself. With the emergence of the COVID-19 pandemic, burnout has increased to the point that it poses a threat to the proper functioning of the healthcare workforce. It is predicted that elevated burnout and other indicators of stress will persist well after the pandemic [ 45 ].

As of May 6, 2022, there were more than one million HCW cases and more than 4,000 HCW deaths related to COVID-19 in the United States [ 46 ]. Previous epidemics have provided significant insights into what can be done to reduce the psychological distress of HCWs during a pandemic. The most important strategy is to provide HCWs with adequate PPEs and train them on using them properly. It is essential that adequate staffing be made available to clinicians to receive necessary self-care while remaining vigilant [ 47 ]. Several hospitals had already experienced severe nursing shortages before COVID-19; the situation was much worse during the first few pandemic waves. This can be addressed by practical measures such as telemedicine and postponing elective procedures to relieve some burden. In addition, authorities should focus on providing a one-day licensure approval process for nurses and other medical professionals promptly to tackle the surge [ 48 ].

Since the outbreak of SARS in 2003, direct-care providers have reported high rates of recurrent PTSD, even years after the crisis had ended. Therefore, short-term and long-term mental health services need to be made available to all healthcare professionals [ 47 , 49 ]. Research has shown that active coping, acceptance, cognitive-behavioral skill-building, deep breathing, stress reduction strategies, mindfulness, gratitude, health coaching, and positive framing can help achieve better mental health [ 47 ]. The MINDBODYSTRONG integrated mental health and physical health skill-building program that combines cognitive and behavioral strategies targeting mental and physical well-being has proven beneficial [ 50 ]. Trials are ongoing to analyze the beneficial effects of biweekly psychotherapy sessions on burnout using the Death Café model, which includes informal discussions focusing on death, loss, grief, and illness [ 51 ].

The Med-Stress internet intervention study included self-efficacy and social support enhancement modules to improve outcomes in HCWs. Job stress decreased with self-efficacy exercises, and burnout was alleviated with additional therapy of mindfulness, relaxation, and lifestyle and cognitive restructuring [ 52 ]. We must eliminate stigma and raise awareness about and screen for depression and PTSD in hospitals and HCWs and implement systems to handle them effectively. In light of the ongoing COVID-19 crisis, we must include encrypted screening tools for suicidal ideation and depression and evidence-based interventions [ 53 ]. It is critical to maintain unit cohesion during times of crisis so that social support can be provided, help can be found effectively, and the stigma associated with stress can be reduced. These practices nurture coping skills, promote adaptation, and foster resilience [ 54 ].

Occupational health and safety policies and procedures should be followed effectively, including staff screening and testing, staff illness protocols, and safe return-to-work policies to allow staff to stay home if unwell, without loss of income; reports and investigations of unprotected exposures and contacts with suspected or confirmed COVID-19 cases that are blame-free - management protocols to ensure sufficient staff; appropriate shifts, safe staff-to-patient ratios, and ventilation; rest periods in areas with adequate space and reminders to staff to continue adherence to IPC procedures [ 55 ].

Strategizing interventions is necessary for improving HCWs' physical and mental well-being. These interventions can help provide necessary guidelines for organizations to protect the well-being of HCWs. These measures can also be protective in the future in times of acute need.

Based on the available literature, the following strategies appear essential for HCWs' well-being (Table ​ (Table1 1 ).

Limitations

Due to the rapidly evolving nature of the pandemic, updated reviews are required in the upcoming months. Many psychological difficulties experienced by workers during the initial days of the pandemic will change over time, and hence the considerations for the future well-being of workers are difficult to assess. Each study conducted on the subject involves a population that may be biased in certain ways or not fully representative of the working population. Moreover, findings in terms of study responses to stress and crisis may vary from country to country based on economic conditions, the system of healthcare assistance, and culture.

Conclusions

Their active role in providing care for patients with COVID-19 places HCWs at immense risk of physical and mental health complications. The risks include exposure to the pathogen, psychological distress, occupational burnout, fatigue, long working hours, and stigma. Improved workplace infrastructure and effective and shared anti-contagious measures for HCWs, including regular PPE supply and provision of mental health and support services, are possible actions to ensure that HCWs do not experience adverse psychological and physical effects. It is a challenge to live and work in the age of COVID-19. Prioritizing physical and mental well-being is the first step to getting back to normalcy. We should strive to learn from this pandemic to prepare for the next pandemic to avoid preventable deaths.

Acknowledgments

Hisham Mushtaq and Shuchita Singh contributed equally to the work and should be considered co-first authors. This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare-affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

• Open access
• Published: 12 June 2024

An integrative review of the impact of allied health student placements on current staff’s knowledge and procedural skills in acute and primary care settings

• Mohammad Hamiduzzaman   ORCID: orcid.org/0000-0001-6027-1564 1 ,
• Sarah Miles   ORCID: orcid.org/0009-0007-5574-3409 1 ,
• Sarah Crook 1 ,
• Lewis Grove 1 ,
• Jennie Hewitt   ORCID: orcid.org/0000-0003-2736-005X 1 ,
• Frances Barraclough   ORCID: orcid.org/0000-0001-9230-7277 1 ,
• Peter Hawkins 1 ,
• Erika Campbell 1 ,
• Nicola Buster 1 ,
• Kate Thomson   ORCID: orcid.org/0000-0001-9661-299X 2 ,
• Christopher Williams   ORCID: orcid.org/0000-0001-8896-0978 1 &
• Vicki Flood   ORCID: orcid.org/0000-0001-5310-7221 1  

BMC Medical Education volume  24 , Article number:  657 ( 2024 ) Cite this article

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Metrics details

Staff shortages limit access to health services. The bidirectional benefits of allied health clinical placements are understood in the domains of student learning, health service delivery, and future workforce development. Still, the benefits to current workforce outcomes remain unknown. This review provides insights into the effects of allied health student placements in acute and primary care settings, particularly on healthcare staff's knowledge and procedural skills.

This search was based on the integrative review process established by Whittemore and Knafl in 2005. In October 2023, the first author (MH) searched five major electronic databases: Medline-EBSCO, PubMed, CINAHL, Embase, and Scopus. The CLUSTER model was used to track additional references. The first three authors (MH, SM, and SC) were involved in screening, quality appraisal, and synthesis of the studies. Data were thematically synthesised and analysed.

MeSH headings and keywords were used in key search areas: health education, health professional training, clinical placements, and allied health professions. The systematic search yielded 12 papers on allied health student placements across various healthcare settings in rural and metropolitan areas, with no high-quality methodologies measuring student placements' impact on staff knowledge and skills. Four main themes were identified from the analysis: meaningful student integration in service delivery, targeted educational support to healthcare staff, development of staff procedural skills and confidence, and the mechanisms of why student placements work in this aspect.

Conclusions

This review suggests that offering allied health student placement could be a promising approach to supporting rural healthcare staff in performing patient assessments and treatments proficiently and collaboratively. However, this requires further investigation to confirm.

Peer Review reports

Introduction

Healthcare staff shortages limit access to health services [ 1 ]. Four key areas for immediate attention in the Australian health context are food and nutrition, dementia care, the use of restrictive practices, and palliative care [ 2 ]. Allied health professionals have an important role to play in each of these areas. However, there is a critical shortage of allied health professionals and a higher turnover rate among allied health workers across Australia [ 2 , 3 ]. This shortage becomes more pronounced as the number of healthcare staff decreases with increasing remoteness [ 3 ]. Health service disparities persist between rural and metropolitan areas in Australia, with a gap in life expectancies (78 years compared to 82.5 years), a prevalence of chronic disease (21% vs 18% per 100,000 population), and potentially avoidable death rates (775.9 deaths vs 587.9 deaths per 100,000 population) [ 1 , 4 ]. Current funding and employment models have led to issues with recruitment and retention of allied health professionals and a shortage of staff [ 5 , 6 ]. For example, in 2018–19, only 29% of Australians used allied health services [ 7 ]. An additional challenge to upskilling healthcare staff is a lack of professional development opportunities [ 8 , 9 ]. Student placements have been identified as a potential approach for health workforce capacity building and support of health services delivery, especially in rural areas [ 9 , 10 , 11 ].

Various clinical training placement models exist to facilitate learning opportunities for medicine, nursing, and allied health students by integrating them into health service delivery for patients [ 12 ]. These placement models include practice-based learning [ 13 ], experiential learning [ 14 ], service-learning [ 15 ], work-integrated learning [ 16 ], and integrated clinical placements [ 17 ]. Clinical placements benefit students, educational institutions, and healthcare organisations in different ways, including personal growth and professional experience for students, academic rigour and service to the community for universities, and a workforce fit to practice in healthcare organisations. Evidence shows that clinical placements of students with exposure to acute and primary healthcare contexts are associated with better impacts in terms of students’ intellectual transformation [ 18 , 19 , 20 ], workforce capacity building [ 21 , 22 , 23 ], and patient health outcomes [ 24 , 25 ]. There remains a notable gap in research on allied health student placements that builds staff capability.

Educational and training resources designed for clinical supervision of allied health students during their placements can also serve as professional learning opportunities for healthcare staff. Professional development is imperative for healthcare staff to stay up to date with knowledge and technical skills and create innovative treatment planning. Complex and infrequently used clinical skills often deteriorate among health professionals, as confirmed in a systematic review by Main and Anderson [ 25 ] in Australia [ 26 ]. The National Health Workforce Strategy advocates for continuing professional education and training for health professionals so that professionals “maintain, improve, and broaden their knowledge, expertise, and competence, and develop the personal and professional qualities throughout their professional lives” [ 27 ]. Healthcare professionals have reported that ongoing education and training opportunities have improved their knowledge and procedural skills in client (e.g., patients, residents in aged care homes) care [ 28 ]. Since the COVID-19 pandemic, access to online professional development modules and training has improved [ 29 ]. However, a lingering question persists: can the co-creation of training programs and educational modules effectively contribute to the knowledge and skills development of both allied health students and healthcare staff?

A compelling association exists between student placements, health workforce capacity and capability building [ 30 ]. As noted earlier, student placements contribute to workforce recruitment and retention in rural and metropolitan areas by immersing them in health and social care settings. Throughout placements, students benefit from access to tutorials and clinical supervision [ 12 , 15 , 16 ]. Additionally, students and healthcare staff from different disciplines work collaboratively in a team during placements [ 31 ]. Pedagogical frameworks, including social learning theory [ 32 ], social constructivism [ 33 ], interprofessional learning [ 34 ], and community of practice [ 35 ] suggest that individuals working together learn with and from one another. The Royal Commission into Aged Care Quality and Safety in 2021 recommends strengthening allied health services [ 2 ], particularly in rural areas; therefore, a review of existing literature is important to inform how and why the placements work to enhance the capability of healthcare staff in service delivery.

Aims of the study

This review aims to synthesise the effects of allied health student placements on healthcare staff's knowledge and procedural skills in acute and primary care settings.

Two main questions guided this review:

Q1: How do the studies describe the integration of allied health students in services design and delivery in acute and primary care settings? Q2: How do these studies describe the effectiveness of allied health student placements for current healthcare staff’s knowledge and procedural skills in acute and primary care settings?

This review adhered to the five steps of an integrative review process as its foundation, established by Whittemore and Knafl in 2005 [ 36 ]. These steps included problem identification, literature search, data evaluation, data analysis, and presentation. We systematically searched the literature and employed the Mixed Method Appraisal Tool (MMAT) to assess the quality and rigour of the selected papers [ 37 ]. The extracted data were then analysed and presented thematically.

Search strategy

The systematic search for published documents was conducted following the PRISMA guidelines [ 38 ]. In October 2023, the first author (MH) searched five electronic databases: Medline-EBSCO, PubMed, Embase, CINAHL, and SCOPUS. A combination of MeSH headings and relevant concepts was used in crucial search areas: health education, health professional training, clinical placements, and allied health professions (the full search strategy is available in Table  1 ). The CLUSTER model was also employed to track sibling studies and citations for supplementary references.

Inclusion and exclusion criteria

The clinical placements are typically designed to immerse health students in real-life experience in acute and primary care settings with the aim of future workforce recruitment. Given the specific focus of this review on the impact of allied health student placements on the knowledge and procedural skills of existing healthcare staff, medical and nursing professions were not included in the search. The search was also limited to certain allied health disciplines based on the discussion with allied health clinicians and health service providers, such as physiotherapy, occupational therapy, dietetics, speech pathology, exercise physiology, social work, optometry, podiatry, psychology, and osteopathy. The inclusion criteria were articles and reports published in English, publication year 2001 to the present, descriptions of actual allied health student placements, and the placements aimed at enhancing the capacity and capabilities of current healthcare staff. Aligning with this review’s objectives and considering the scarcity of studies conducted in rural locations, the search was not restricted solely to rural placements. While the primary outcomes of allied health student placements predominantly centred on student learning, patient health and wellbeing, and workforce recruitment and retention, the studies that explored these aspects as their primary focus were not excluded when they identified the placements’ contribution to healthcare staff. Two reviewers, MH and HG independently screened the records retrieved by title, abstract, and full text. Discrepancies were discussed with a third reviewer, SM.

Quality appraisal

The MMAT criteria were used to assess the quality of studies, using a scale that spanned from 0, indicating no criteria met, to 5, indicating all criteria met, as detailed by Hong et al. in 2018. [ 37 ] To evaluate the studies, two reviewers, MH and HG, conducted separate assessments, allocating scores out of 5 (0—Unclear/No and 1: Yes). Through a consensus-driven process, it was determined that the papers included in this review exhibited a quality level that ranged from moderate (with a score of 3) to high (with a score of 5), as indicated in Table  2 .

Data extraction and analysis

Three reviewers, MH, SM, and SC, read the papers meeting the inclusion criteria multiple times to extract data. The extracted data were recorded separately by these three reviewers into Excel spreadsheets, with any discrepancies carefully cross-checked (Table  2 ). The extracted data included the study characteristics (author, year, country of origin, study design, study participants); characteristics of allied health student placements (placement setting, focus, participants, type of placement, the level of student involvement in service delivery); outcome data for existing healthcare staff’s knowledge and skills, as well as the limitations of these placements. Given that the selected studies were heterogeneous in methodologies, a thematic data synthesis was deemed the most appropriate approach [ 45 ]. The categories and sub-themes were independently identified by the reviewers, MH, SM, and SC, and were subsequently deliberated upon during review team meetings to determine the final themes and validate interpretations.

Figure  1 illustrates the selection process of the studies reviewed. Twelve papers that met the inclusion criteria represented the highest number over the past decade. Among these, eight studies used mixed methods for evaluating the placements, while two were qualitative and two were quantitative methodologies. The selected placements were mainly in Australia (10), with all papers originating from high-income countries, including the USA (1) and Canada (1). The healthcare settings were diverse across the placements; half were in residential aged care homes, while the rest were in hospitals, community health services, clinical skills centres, patient training centres, and non-government health organisations. The study participants included students, patients/residents, healthcare staff, health service managers, clinical educators, and relevant key stakeholders like family members and community organisations. Rural placement was reported in the majority of studies (7), but no studies compared the effects of different locations.

PRISMA 2020 flow diagram of systematic search and selection process

All twelve studies focused on either allied health student learning outcomes or service delivery across a range of settings by placing students. Most placement programs narrowly focused on the professional development of existing healthcare staff, while exclusive focus on this aspect was identified in four placement programs facilitated in hospitals, residential aged care homes, and community health services [ 39 , 47 , 49 , 50 ]. Undergraduate and postgraduate students from different allied health disciplines participated in the placements, including physiotherapy, occupational therapy, nutrition and dietetics, social work, and speech pathology. Some studies featured the collaboration between medicine, nursing, and allied health students [ 40 , 46 , 47 , 50 ]. Various types of placements were discussed, such as clinical placement [ 41 , 48 ]; work-integrated learning [ 42 ]; interprofessional team placement [ 40 , 43 , 49 ]; service-learning placement [ 39 , 44 , 47 , 50 ]; and simulated learning [ 51 ]. Interprofessional education was reported in most of the studies (8), and four studies provided information on the duration of placements, which ranged from four to ten weeks; in addition to detailing the types and focuses of the placements, the synthesis of outcome data revealed four key themes.

Meaningful student integration in service delivery

The integration of allied health students in health service delivery for patients was identified as a powerful and essential part of all placement programs. Student involvement in health service delivery was described by their engagement in a wide range of activities, from administration tasks and priority assessments to developing and implementing treatment plans and evaluating interventions. Eight studies reported direct engagement of students in developing treatment plans and designing and delivering services. Examples included person centred exercise programs, developing a sensory garden, implementing craft and cooking sessions for residents with dementia and training and upskilling care staff [ 39 , 40 , 44 , 46 , 47 , 48 , 49 , 50 ]. In contrast, four placement programs were restricted to organisations’ priority assessments [ 41 , 42 , 51 ]; shadowing a care worker and spending time with residents [ 43 ]; and planning and evaluation of interventions [ 41 , 42 , 51 ]. Student involvement in delivering direct health services to patients was identified in both urban and rural healthcare settings.

The extent of students’ involvement in delivering health services to patients was somewhat related to the degree to which the placement supported the capacity and capability building of existing healthcare staff. Integrating students in administrative tasks, priority assessments, and evaluation of the treatments contributed to staffing management and timely task completion, as well as a cultural shift towards collaboration among the staff [ 41 , 42 , 43 , 51 ]. Direct engagement of students in treatment plans and patient/resident care management was highly beneficial to a healthcare staff’s reflection and clinical reasoning [ 39 , 40 , 44 , 46 , 47 , 48 , 50 ]. Of note, none of the studies measured the causal relationships between the level of student integration in service delivery and the professional development of healthcare staff.

Targeted education support to healthcare staff

All studies reported that the placements led to an increase in knowledge, or had the potential to do so, for both students and healthcare staff. During these placements, various learning activities were offered to students, which, in turn, enhanced the knowledge of healthcare staff. For instance, learning activities like Grand Rounds and interprofessional education were implemented [ 44 , 46 , 47 , 50 , 51 ]. Key areas of learning for healthcare staff were identified in one evaluation study of interprofessional team placement in residential aged care homes [ 50 ], including mealtime positioning, post-stroke positioning, and medication management in palliative care. Additionally, one qualitative study described how the placements allowed healthcare staff to reorient themselves with the theories and methods behind the treatments [ 46 ]. Attending education and training sessions also helped the rural healthcare staff become familiar with the roles and responsibilities of other health disciplines [ 44 ].

Three studies reported that students generated new data and knowledge based on local evidence during their placements [ 41 , 42 , 50 ]. Two of the studies included rural placement of students [ 41 , 50 ], but all the studies confirmed that the students provided healthcare staff with current and innovative knowledge. This new knowledge supported the staff in strategic planning and prioritising patient assessments and treatments.

Development of staff procedural skills and confidence

Eight studies highlighted that allied health student placements were useful in developing procedural skills among healthcare staff. In four of these placements, student training sessions enhanced the healthcare staff’s efficiency in service delivery by reorienting them with the standards and procedures of the treatments [ 39 , 46 , 49 , 50 ]. Healthcare skills development various skills, including critical reflection, clinical reasoning, patient flow management, timely assessment and treatment of patients, continuity of care, clinical communication, patient safety, and evidence-based practice. The Delphi study conducted by MacBean et al. [ 43 ] in inpatient training centres in Australia provided insights into how the placements broaden the healthcare staff’s scope of practice in speech pathology, which was further complemented by the qualitative study of Kemp et al. [ 41 ] in Australian community health services. [ 42 , 51 ] Healthcare staff also gained confidence in performing clinical tasks during the student placements, with their abilities being questioned and affirmed [ 46 , 47 , 50 ]. Interprofessional team placements were found to be effective in two studies for team skills development [ 49 , 50 ]. Both rural and urban healthcare staff benefited equally from student placements in healthcare settings.

Why do student placements work? Insights into the mechanisms

This review identified the mechanisms underlying how the allied health student placements supported the professional development of healthcare staff in seven studies. While a cross-sectional study indicated non-statistically significant disadvantages of student placements in regional and rural residential aged care homes [ 48 ], six studies, spanning various healthcare settings, reported functional improvements in health service delivery attributed to student placements [ 39 , 40 , 42 , 46 , 49 , 50 ], regardless of the locations. These functional improvements in service delivery were because of additional training and resources, as well as active engagement in teaching, facilitating, and managing students within healthcare settings, which were identified as supportive for healthcare staff’s professional development [ 40 , 46 , 50 ]. Collaborative practice was found to be instrumental in reducing hierarchical culture among healthcare staff [ 43 , 49 ]. Additionally, the placements contributed to early patient readiness for discharge, providing staff with flexibility in using client care modalities, and questions from students increased staff awareness of evidence-based practice [ 39 , 50 ].

In order to facilitate discussions, the findings of this review are positioned within a general system theory framework (Fig.  2 ), enabling the assessment of inputs, transformational processes, outputs, and the environment within acute and primary healthcare settings.

Integration of allied health students in healthcare settings and its impact within a system theory framework

The role of allied health student placements in fostering professional development of healthcare staff is promising, with most of the studies in this review showing positive evidence. Service-based placements, with a meaningful integration of students in health service delivery, show the most potential. Service-based placements might work by offering Grand Rounds and interprofessional education sessions to healthcare staff in critical areas of client care, generating new knowledge that can form powerful local evidence, and enhancing healthcare staff's understanding of other health professionals and service providers that can promote the collaborative practice. Regardless of the locations, active engagement in supervising and educating students and increasing awareness of training sessions have proved to be beneficial for healthcare staff in developing their professional knowledge and skills in client care.

There is a strong evidence base for the integration of allied health students into various aspects of client care, but engagement has varied. Student involvement in service delivery can be particularly powerful as it primarily emphasises the improvement of patient accessibility and utilisation of health services that are otherwise not accessible to them, especially in rural communities [ 52 , 53 ]. In the studies included in this integrative review, students played vital roles in the development of treatment plans, treatment of patients, and evaluation of interventions, and this integration was found to be beneficial to current health workforce capacity and capability building. Previous placement programs involving medical and nursing students corroborate the positive outcomes, citing the development of confidence and proficiency in both students and healthcare staff [ 54 , 55 ]. These programs recognised the bi-directional benefits of clinical placements. Since 2021, the Rural Health Multidisciplinary Training (RHMT) in Aged Care Program has supported University Departments of Rural Health (UDRHs) in Australia to expand their capacity to facilitate health student placements in aged care settings. This review is timely to inform clinical educators by providing insights to design education sessions that meet the learning needs of students and staff.

Within the limited number of studies available for review , education sessions during student placements appear to be important for developing professional knowledge and skills of healthcare staff. This review strengthens the previous study findings in medicine and nursing placements in acute care settings, stating that Grand Rounds and interprofessional education opportunities increased healthcare staff and students’ awareness of different aspects of client care and expertise of their own and other professions [ 56 , 57 , 58 , 59 ]. These ongoing sessions cover various aspects of client care and are likely to equip staff with theories behind the treatments. Rural healthcare staff often have limited access to professional development opportunities, as well as supervision of students that has the potential to add a new perspective to the staff workloads [ 11 , 59 , 60 ]. Rural healthcare staff in community settings may also have limited time to engage with professional learning opportunities in their normal work routine, so embedding opportunities for ongoing education in the workplace through student placements may be beneficial. Opportunities must be explored in collaboration with healthcare and community partners to ensure professional development and training is co-designed and co-delivered to meet their staff’s unique needs. Creating ongoing learning opportunities for staff and engaging them in student supervision is vital to the success of placements.

In terms of creative learning, the student placements’ contribution to generating new and local evidence emerges with some supporting findings. Many studies explored how students are engaged in reciprocal learning relationships with peers and healthcare staff in the domains of clinical knowledge and procedural skills [ 58 , 61 ]. Students bring new or different perspectives, up-to-date knowledge of evidence-based practice, do not have the workload expectations, and are not restricted by funding requirements. This allows students to bring a different perspective. Students often have more time to complete projects and create resources, and when co-designed with staff and patients, such resources can enhance both staff learning and patient outcomes. However, these bi-directional learning benefits receive less attention from educators and rural health service providers. It may be unclear what students could add to the knowledge and skills of staff who are already registered and experienced in delivering services. Evidence is limited on how to design education sessions for different learner groups.

The review suggests that active engagement of healthcare staff is often absent in student placements. While clinical educators currently take the responsibility for student supervision and management, a potential improvement could involve active engagement of healthcare staff in these aspects during placements, which may help address the two remaining questions. First, whether it is important to create collaborative learning environments before offering student-led education of staff. This could enhance understanding and knowledge of both staff and student roles, increasing collegiality and co-design of learning and knowledge. A second question is whether adding a co-supervision role for healthcare staff in the allied health student placements (by adapting the models of medicine and nursing placements in rural communities) is a viable option to enhance staff engagement. This role could upskill the current health workforce in rural areas, increasing the capacity to take student placements. This role may combine rural knowledge with an understanding of student models and seek to implement changes in practices developed from student placements.

Limitations

Developing the search strategy was challenging because of the diversity in placements, disciplines, settings, and associated terminology. This resulted in a search that yielded only 12 eligible studies for review. Since allied health student placements in rural healthcare settings have expanded across high-income countries in recent years, there will likely be articles under review about unsuccessful placements that could have provided additional insights. Further rigorous investigations are required to strengthen the evidence surrounding student placements’ contribution to improving rural health staff knowledge and procedural skills in client care. These investigations could delve into the unique workforce outcomes associated with individual allied health disciplines and consider the different levels of study among students (undergraduate vs postgraduate).

This review is the first synthesis of the impact of allied health student placements on the professional development of our current health workforce. To enhance staff knowledge and skills and address shortages, particularly in rural and remote communities, this review indicates the importance of student integration in the delivery of health services. A collaborative learning approach to increase the knowledge of students and staff and improve staff engagement in placements that promote interprofessional learning is key to the professional development of current staff in any healthcare setting. While there is little evidence of the generation of new knowledge by students during their placements, there is no indication that these placements disadvantage healthcare staff in relation to their professional development. Clinical educators may consider establishing co-supervision roles for rural healthcare staff to foster interactions between staff and students and to enhance positive learning experiences for both parties. Individually tailored and co-designed professional development opportunities could be important, for instance, to assist rural healthcare staff in reducing adverse events and ensuring adequate health services and the quality of integrated care.

Availability of data and materials

All data generated or analysed during this study are included in this article.

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MH, SM, SC synthesised and analysed the data regarding the impact of allied health student placements and prepared initial draft of the manuscript. LG, JH, FB, PH, EC, NB, KT, CW, and VF contributed to the conceptualisation and was a major contributor in writing the final manuscript. All authors read and approved the final manuscript.

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Hamiduzzaman, M., Miles, S., Crook, S. et al. An integrative review of the impact of allied health student placements on current staff’s knowledge and procedural skills in acute and primary care settings. BMC Med Educ 24 , 657 (2024). https://doi.org/10.1186/s12909-024-05632-7

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