A model for occupational stress amongst paediatric and adult critical care staff during COVID-19 pandemic.

PURPOSE: The coronavirus 2019 pandemic has placed all intensive care unit (ICU) staff at increased risk of psychological distress. To date, measurement of this distress has largely been by means of validated assessment tools. We believe that qualitative data may provide a richer view of staff experiences during this pandemic.
METHODS: We conducted a cross-sectional, observational study using online and written questionnaires to all ICU staff which consisted of validated tools to measure psychological distress (quantitative findings) and open-ended questions with free-text boxes (qualitative findings). Here, we report our qualitative findings. We asked four questions to explore causes of stress, need for supports and barriers to accessing supports. A conventional content analysis was undertaken.
RESULTS: In total, 269 of the 408 respondents (65.9%) gave at least one response to a free-text question. Seven overarching themes were found, which contribute to our proposed model for occupational stress amongst critical care staff. The work environment played an important role in influencing the perceived psychological impact on healthcare workers. Extra-organisational factors, which we termed the "home-work interface" and uncertainty about the future, manifested as anticipatory anxiety, had a proportionally larger influence on worker well-being than would be expected in non-pandemic conditions.
CONCLUSION: Our findings have important implications for appropriate allocation of resources and ensuring well-being of the ICU multidisciplinary team for this and future pandemics.

Introduction and objective

Prior to the coronavirus 2019 (COVID-19) pandemic (Zhu et al. 2020; World Health Organisation 2020), Ireland had never managed a widespread national infection outbreak and critical care staff had no prior experience of working under pandemic conditions. Furthermore, Irish healthcare staff were working in an already over-burdened and under-resourced health system with recognized shortages of 2590 acute care hospital beds, 190–300 critical care beds and 500 hospital consultants (IMO 2020; An Roinn Sláinte 2018).

Therefore, in addition to amplifying existing workplace shortcomings, the pandemic has exposed Irish healthcare workers to new workplace stressors. These include the fear of infection and infecting others (Cook 2020), wearing of personal protective equipment (PPE) (Hignett et al. 2020), quarantining (Huremović 2019), working beyond usual scope of practice in unfamiliar environments, and the moral injury of witnessing the mismatch between the health needs of patients and the capacity to address those needs (Sorbello et al. 2020; Greenberg et al. 2020). It is not surprising therefore that psychological issues have been more common in healthcare workers than in the general population during the COVID-19 pandemic (Zhang et al. 2020; Heath et al. 2020).

Internationally, there has also been early recognition of, and attempts to mitigate, the mental health impacts on healthcare workers during this crisis. Online psychological counselling services, cognitive behaviour therapy and self-help interventions were promptly established (Billings et al. 2020; University College London 2020; Liu et al. 2020), and international and local health organisations published resources and guidance for frontline workers and their managers (Heath et al. 2020; Intensive Care Society 2020; Williams et al. 2020; Highfield 2020). Notwithstanding these efforts, healthcare workers have been historically reluctant users of psychological supports; they are either too busy, they have concerns about confidentiality, utilise their self-reliance or they perceive a stigma utilising these supports (Brooks et al. 2011; Gerada 2008; Shanafelt et al. 2020).

To date, measurement of psychological issues related to the pandemic has largely used validated assessment tools. Qualitative data may provide a more in-depth and detailed view of staff experiences with exploration of the complex human issues during this pandemic (Shelton et al. 2014; Teti et al. 2020). It may also provide greater insights into the specific needs of staff during this challenging time.

The objective of this study therefore was to qualitatively evaluate the perceptions and experiences of intensive care staff who worked during the pandemic. We believe this to be the first qualitative analysis of the experiences of the multidisciplinary team working in both paediatric intensive care units (ICUs) and adult ICUs throughout the COVID-19 pandemic.

Methods

Setting and sample

This project was part of a larger multicentre cross-sectional, descriptive observational study in two adult ICUs and two paediatric ICUs. Data collection took place between 7 May and 12 June 2020. Qualitative and quantitative data were collected concurrently in this study. The quantitative data have been presented elsewhere (ffrench-O’Carroll et al. 2020).

All staff working within the four participating ICUs were invited to take part. This included doctors, nurses, allied health professionals, administrative staff and managerial information and communication technology staff.

Survey outline

The survey consisted of 28 questions, four of which sought free-text answers and form the basis of this qualitative study. Questions for free-text responses are shown in Table 1. A copy of the questionnaire is shown in “Appendix 1”.

Table 1

Questions with free-text responses

Questionnaire number	Free text questions
Q. 23	Are there any other factors related to the current crisis causing you stress currently?
Q. 26	What other supports would you or your colleagues benefit from but are currently not provided?
Q. 27	Are there any barriers or obstacles to making use of available supports?
Q. 28	Do you have any other comments/information about your experiences you would like to share?

Data analysis

Data were analysed using conventional content analysis. (Hsieh and Shannon 2005) This method allows for derivation of codes, and subsequently themes, from the verbatim accounts of respondents. Thus, it allowed the authors to utilise the written word of the respondents to describe the range of issues experienced by the staff at the four ICUs participating in this study. All data were analysed independently by two of the three investigators (Feeley and L’Estrange or Magner), with subsequent discussion to agree on final codes and themes. Final themes were discussed by Feeley and O’Connor.

Results

Participant characteristics

A total of 408 staff (196 adult ICU, 212 paediatric ICU) from the four sites participated in this survey. In total, 269 (65.9%) respondents gave at least one response to a free-text question, resulting in 300 free-text answers. Breakdown of response rate according to profession, location and gender is shown in Table 2. Table 3 shows the number and profession of respondents to each question.

Table 2

Response rate according to profession, location, gender

Respondent category	Number of respondents (% of total number of survey respondents)
Doctor	71 (17.4)
Nurse	273 (67)
Allied healthcare professional, e.g. physiotherapist, Dietician	35 (8.5)
Support staff working in critical care, e.g. health care assistants, administrators	28 (6.8)
Paediatric intensive care healthcare workers	196 (48)
Adult intensive care healthcare workers	212 (52)
Female	331 (81.1)#
Male	76 (18.6)#

#One data point missing

Table 3

Number and profession of respondents to each of the four free-text questions

Question	Number of respondents (percentage of total survey respondents)	Numbers of respondents (%) doctor vs nurse vs other
Q. 23 Are there any other factors related to the current crisis causing you stress currently?	159 (38.9)	31 (19.5) vs 104 (65.5) vs 24 (15)
Q. 26 What other supports would you or your colleagues benefit from but are currently not provided?	147 (36)	23 (15.6) vs 96 (65.4) vs 28 (19)
Q. 27 Are there any barriers or obstacles to making use of available supports?	172 (42.2)	31 (18) vs 119 (69.2) vs 22 (12.8)
Q. 28 Do you have any other comments/information about your experiences you would like to share?	110 (27)	15 (13.6) vs 76 (69.1) vs 19 (17.3)

Themes and subthemes

Following analysis, the qualitative data were coded to subthemes, each in turn contributing to seven overarching themes (see Table 4). Within these themes, the work environment played an important role in influencing the perceived psychological impact on healthcare workers. Issues concerning personal factors, the home-work interface and perceptions about an uncertain future also emerged in the survey responses.

Table 4

Overarching themes and subthemes from qualitative analysis, (+ and –) represents both positive and negative comments

Overarching theme	Subthemes
Environment—work structures	Team structure (+ and −), senior staff guidance (+ and −)
	Availability of resources
	Time-poor staff
Environment—social	Communication (+ and −), inescapable nature of COVID communications
	Colleague support (+ and −)
	Perceived unfairness
Environment—the nature of the work	Altered roles
	Quality of training
	Moral distress—barriers to usual practice
	High workload
Environment—safety	Personal protective equipment—guidance, quality and quantity (+ and −)
	Contracting COVID-19 and/or transferring COVID-19 to colleagues and family
	Structured psychological support
Personal	Response to public recognition (+ and −)
	Stigma to seeking supports
	Financial
Home-work interface	Alteration of usual stress-relieving activities/supports
	Altered interaction with friends/family
	Childcare and accommodation issues
Uncertainty about the future	Global illness trajectory
	Social interventions
	Government/institutional changes
	Further redeployment to COVID-19 patient care

Environment—work structures

Team structure, senior staff guidance

Strain in collegial relationships was evident, with “negativity in the workplace” and a “lack of teamwork from nursing managers” both receiving frequent comment. It is evident that some staff felt poorly supported, that “there was not enough staff to help” redeployed nurses. This resulted in heightened emotions, with one respondent noting their colleagues were “not coping and ‘lashing out’ at other staff”.

Availability of resources

Respondents linked their anxiety to resource constraints: financial, clinical equipment, personal protection equipment, and staffing. A doctor noted “not (being) able to take leave or rest days, knowing if myself or a colleague get sick, it will lead to intolerable increase of workload”. One nurse synopsized the prevailing concern about lack of resources, saying that the best supports they could have would be, “Clinicians, ICU beds, Staff, ICU nurses.” Comments, such as “Medical preparation was excellent in ICU—staff and equipment was there,” were in the minority.

Time-poor staff

Time was repeatedly given as a barrier to accessing well-being supports. One allied health professional stated, “(Hospital-provided) supports require you to do counselling on days off rather than on work days, means you have to think about it on days off rather than relax. Working day much too busy to do this.” In addition, increased non-work commitments were a barrier to accessing available supports.

Environment—social

Communication, inescapable nature of COVID-19 communications

Respondents raised concerns about the contrast between the paucity of workplace information from hospital managers and the ubiquity of COVID-19 references from news outlets, social media and in personal discussions. For example, “staff all express frustration at lack of information or knowing what was going on,” and “continuous information given via (social media) messages…you cannot fully escape it”.

Colleague support

Positive collegial interactions were a useful support in the workplace. This was evidenced by responses, such as “Having supportive colleagues and getting through it together is really important. Being able to meet and talk through it all and let off steam,” and “I am lucky to be working in a fantastic ICU where everyone supported each other. Manager was very good minding everyone…”

Perceived unfairness

Perceptions of unfairness were a notable source of workplace dissatisfaction and stress. One nurse commented, “Doctors/consultants/physios/dietician/pharmacists all got to avoid coming near patients, but nurses stuck for 13 h/day breathing in potential virus.” Another nurse raised a concern about unfair clinical allocation; “same nurses (providing care for) COVID patients every time.”

Environment—the nature of the work

Altered roles

Both medical and nursing staff commented on the additional burden caused by altered conditions of work. One staff nurse commenting; “I have never been so stressed in my life…I was given a patient on a ventilator and dialysis. I was so scared I would cause harm to this patient.” Respondents at management grade also expressed difficulties with their altered roles, with one stating, “as a manager I find it stressful keeping everyone safe (…) I don’t want staff to say I let them down or put them at risk”.

Quality of training

Medical staff expressed concern at interruption to their training and being asked to work in service provision roles rather than their allocated training areas, with commentary, such as “teaching and training (…) all stopped when COVID hit.” Medical and nursing staff were concerned they had not had the required training to care for critically ill COVID-19 patients.

Moral distress—barriers to usual practice

The measures taken to reduce transmission of the virus have had unexpected consequences for many staff, “Social distancing and PPE, while completely necessary, I have found to be a barrier to providing compassionate care to parents of critically ill or end of life children.”

High workload

The impact of onerous working conditions on staff health and safety was evident from comments from all members of the multidisciplinary team. The cognitive impact of the workload prompted one nurse to suggest a “mental health day—not sick leave day”. A doctor explained; “Working hours for doctors are long—you get to a point of exhaustion and burnout.”

Environment—safety

Personal protection equipment—guidance, quality and quantity

PPE issues were prominent in the survey responses. It was uncomfortable (“wearing the painful uncomfortable tight face masks, gowns and headgear visors resulting in a headache and overheating”), guidance about use was inconsistent [“changing or mixed information at times regarding the need for full PPE (and) advice regarding donning PPE in arrest/emergency situations”] and concerns about supply chain issues were commonplace.

Contracting COVID-19 and/or transferring to colleagues and family

A common concern in the responses related to the risk of causing infection, “(I feel) stress associated with risk of exposure but also the stress of possible spreading of the virus to co-workers and patients when asymptomatic”.

Structured psychological support

The need for routine psychological support for staff working in critical care was noted, “(there is) a huge lack of needed support in ICU, regardless of COVID!” There was frequent free-text commentary with suggestions regarding the in-work provision of psychological supports, such as one nurse’s, “debriefing on unit; more support in work as opposed to outside of work.” Debriefing was a common suggestion for supporting staff’s well-being.

Personal

Response to public recognition

An interesting cause of stress noted by doctors and nurses was the public perception of health care workers as heroes, “(I am) finding it stressful/embarrassing that people are calling us heroes when I feel like I'm doing nothing to benefit anyone”. Others expressed a desire for more practical recognition; “additional PAY would be great. It would be a little more reassuring…than just being tagged as heroes and getting claps”.

Stigma to seeking supports

Respondents expressed concern at being stigmatised for accessing well-being support services. This was explained as “feeling embarrassed to access support/access help”, a “natural reluctance for medical professionals to seek emotional/psychological support”, “judgement from colleagues that they may think I am not able to cope if I utilised support available” and “the general culture in Irish hospitals”.

Financial

A change in working patterns for trainee doctors has led to reduced income in some centers, with one noting, “(I am) a graduate entry doctor with lots of debt”. Several responses described concern about being able to continue mortgage repayments, many due to a partner’s loss of income. Long-standing dissatisfaction with pay has been exacerbated, “I believe pay parity with other public service jobs would be a great show of support towards nurses.”

Home-work interface

Alteration of usual stress-relieving activities and supports

The disruption to work-life balance was highlighted as “when you can’t go out and enjoy yourself on the downtime it makes it worse” and the “loss of social or exercise outlets”. People who were able to continue their usual activities seemed to benefit, “Starting the duty with prayer helps a lot to cope with stress”, in contrast to those with a major change to their established routine, “I have had to develop a support system external to my normal supports…it’s been challenging and not as effective.”

Altered interaction with friends/family

Healthcare workers and support staff noted that they experienced “not being able to see (their) partner”, and “separation from young family”, highlighting the sacrifices made during this pandemic. Non-Irish respondents had an additional stress from not being able to visit their home country or family. Conversely, a small number noted increased time spent with family members, “this pandemic has brought us all together.”

Childcare and accommodation issues

For many healthcare workers, childcare was a frequently listed cause for added stress. Responses included, “No Childcare. Minding two very small babies at home and then going into an ICU setting to give my all. No downtime. Very, very stressful” Another parent stated, “I feel so upset that I am expected to work in ICU and I have no childcare as crèche is closed. I feel so let-down by the government in this matter”. Furthermore, respondents endured the insecurity of rental accommodation, in one case a landlord evicting a healthcare worker because of the risk that “you may import virus into my property”.

Uncertainty about the future

Global illness trajectory

This pandemic has affected the certainty of the future for the individual, the healthcare system, the country and internationally. One respondent’s greatest stressor was “not knowing when I can travel home to see my family”. One allied health professional stated they “worry about winter, less reserve, government finances, etc.” The tragic international scenes prompted one nurse to respond, “I had huge anxiety about what was going to happen; would we have to deal with overcrowding we had seen in Italy and Spain”.

Social interventions

Concern was expressed about the public not adhering to social restrictions and the impact of this on the community levels of COVID-19, with the attendant effects on staff workload, hospital admissions and ICU capacity.

Government/institutional changes

The importance of clear, consistent communication was evident as was the stress experienced when this was lacking; “A feeling of ‘cognitive overload’ seems very common due to changing practice—information on how to best deal with this could be useful.” Frequent changes of institutional guidelines were a significant stressor that was noted. The solution was suggested of, “weekly written updates from the COVID ICU team to outline where we are as a service and what plans are being put in place for the next weeks”.

Further redeployment to COVID-19 patient care

Some of our respondents were staff who had been redeployed from non-critical care clinical roles, objected to “being redeployed and having to stay in the ICU when there is more than enough staff, putting everyone in risk”.

Discussion

Our results highlight the issues that matter most to healthcare workers seeking satisfaction and fulfilment at work; these are categorised into themes and subthemes in our results. While many of these issues are likely to be important in any workplace at any time, the pandemic has amplified their importance in the healthcare setting, and in particular in an ICU, where specialised care of the most unwell patients occurs, often under adverse and time-critical circumstances.

From a social perspective, our survey respondents want work in an environment that affords them a sense of belonging, to be integrated in a team that emphasises guidance and education and access to psychological supports without fear of ignominy. They seek reassurance about occupational safety. They want to be recipients of updates and information relevant to their job. These preferences are not unique to our study population, and a lack of these elements in the work environment has been shown to contribute to healthcare worker burnout during the current pandemic (Algunmeeyn et al. 2020). Critical care staff vary in their profession, therapy preferences and personal attributes, but they share a strong a professional identity, and strive to pursue activities that are consistent with this self-concept—especially during periods of increased professional demand (Ervin et al. 2018; Yadav et al. 2019). A strong determinant of satisfaction in the workplace relates to justice, the perception by staff that they are being treated fairly. Managers can improve staff perception of organisational justice by concentrating on fair reward, optimising policies and procedures and ensuring good communication and distribution of information (Hashish 2020). It is clear from our study that pandemic-related problems disrupted many of the factors that promote workplace satisfaction.

Our findings concur with an overarching principle of psychological stress, that it occurs as a consequence of the interaction between an individual and their environment. According to this cognitive-relational theory, an environment that is perceived to be excessively onerous or hazardous is one that creates stress in the individual (Lazarus and Folkman 1984). Inter-individual variation is seen in personal responses to such an environment, influenced by factors, such as gender, socioeconomic status, professional role, mental and physical health, personality and social support (Conversano et al. 2020). Experiences of moral distress were evident from responses from all professions in our study; the person specific, workplace specific and external factors that combine to produce conditions in which moral distress develops all increased during the COVID-19 pandemic (Burston and Tuckett 2012). Moral distress has been recognised as an international problem for frontline healthcare workers throughout the 2020 global pandemic (Cacchione 2020; Menon and Padhy 2020).

Our study findings also overlap with more specific models of occupational stress which help explain why pandemic work conditions in an ICU may promote negative psychological outcomes. Three models appear most pertinent to our study: the person-environment fit (PE-Fit) model, the job-demand-control model and work intensification theory.

The PE-Fit model highlights the importance of matching the skills, knowledge, and limitations of a worker with their job and work environment (Tinsley 2000). Increasing discordance between these variables will have a proportionally negative impact on workers’ health and psychological well-being. Our survey revealed many of the drivers for increased stress related to the healthcare workers’ environment, disrupting the person-environment balance for ICU-trained staff, and to a greater extent, for staff redeployed to the ICU. For managers, this highlights the importance of pre-empting and ameliorating environmental stressors, thereby minimising additional stress for workers (Billings et al. 2020). By taking these actions, managers may contribute to the physical health of their staff; an association between psychological stress and physical symptoms of headache, throat pain, insomnia and joint pain has been found in healthcare workers working during the COVID-19 outbreak (Chew et al. 2020).

The job-demand-control model asserts that occupational well-being is at its lowest when workers have a high workload combined with a low level of control over their work (Karasek 1979). The requirements of healthcare workers to optimise their well-being have been distilled by Shanafelt et al (2020) to “hear me, protect me, prepare me, support me, care for me.” For medical and nursing staff deployed to the ICU from other clinical hospital areas, as well as junior ICU-trained healthcare workers, the experience of high work load and low levels of control can be ameliorated by managerial use of this simple framework of support developed by Shanafelt et al. (2020).

Finally, work intensification theory describes the amount of work to be undertaken and the time pressure to complete this work in a fixed period of time; the theory holds that work intensification predicts greater work–life interference, reduced well-being and greater stress for the worker (Fein et al. 2017). This is the backdrop to the findings of our study: a global pandemic of a contagious and lethal virus which meant that obligations, both at home and at work, were increased for many healthcare workers.

In addition to the three established models of occupational stress discussed above, our study highlights two unique aspects of the pandemic that may have exacerbated workers’ stress and which do not easily fit traditional models of occupational stress; home–work interface and future uncertainty. Prominent in our findings were extra-organisational factors, which we termed the ‘home–work interface’. The COVID-19 pandemic has been characterised by major social changes in the realms of social interaction, family, childcare, accommodation and recreation. These issues at the home–work interface may have had a proportionally larger influence on workers’ well-being than would be expected in non-pandemic conditions; increased professional demands were exacerbated by a disruption to social supports, financial stability, family routines and recreational activities.

The final stressor unique to the pandemic was future uncertainty, focused locally (in healthcare workers’ workplace or home) as well as broadly on a national and global scale. This uncertainty was expressed as anticipatory anxiety by many of our respondents. To illustrate this novel combination of factors affecting healthcare workers during the COVID-19 pandemic, we have proposed a model of occupational stress (Fig. 1) drawing from existing models and from the unique findings of our study.

Fig. 1

A model of occupational stress during the COVID-19 pandemic

Limitations

This study was conducted across four clinical sites and included healthcare workers caring for adult and paediatric critical care patients—our results are applicable therefore most accurately to critical care staff. The timing of this survey, which started 2–3 weeks after the peak of intensive care COVID-19 activity may have influenced the responses. However, the adult ICUs continued to have bed occupancies of > 100% at the time of data collection. All the data for this study were derived from only four free-text questions; follow-up qualitative interviews would have added to the insights gained from the questionnaire. Furthermore, staff who were ‘cocooning’ at home had no access to work email and could not contribute to the study. On the contrary however, both of these concerns are balanced by a high response rate and a broad representation from the critical care multidisciplinary team of clinical and non-clinical staff.

Conclusion

Our study findings identified numerous factors contributing to the psychological impact of working in an intensive care setting during the on-going COVID-19 pandemic. The home, work and social environments; personal factors; the home–work interface and uncertainty about the future were the major themes derived from this qualitative study. In large part, the work environment—its structure, the type of work done, and perceptions of safety and interpersonal relationships therein—dictated the emotional and psychological responses of healthcare staff. In addition, the unique nature of the pandemic presented additional stressors to healthcare workers, in particular the effect of societal restrictions on home life. Our survey confirms the theory of Shanafelt et al. (2020) that asking staff about their needs is a simple but effective means of determining what measures can be implemented by management to reduce the burden on healthcare staff. By doing this, we have identified important factors that contribute to occupational stress for healthcare workers working through the on-going COVID-19 pandemic; we believe our proposed model of occupational stress (Fig. 1) which portrays the interplay between these factors can be utilised to aid further research in this area. The findings have been forwarded to the participating clinical sites, and have already been utilised to develop additional psychological supports for the critical care staff.