Health service COVID-19 wellbeing and support initiatives: a mixed-methods evaluation.

BACKGROUND: Health services implemented a range of initiatives during the COVID-19 pandemic to support employee wellbeing and assist employees to manage the professional and personal challenges they experienced. However, it is not known if such initiatives were acceptable to employees or met their needs. AIMS: To evaluate the wellbeing and support initiatives implemented at an Australian health service during the COVID-19 pandemic from the perspectives of employees (both users and non-users) and key stakeholders.
METHODS: A mixed-methods design (survey, interviews and data audit) to investigate employees' and key stakeholders' perceptions, experiences and use of the wellbeing and support initiatives implemented at a large tertiary metropolitan health service in Melbourne, Australia.
RESULTS: Ten employees participated in an interview and 907 completed a survey. The initiatives were well used and appreciated by staff. There was no significant difference in the proportion of clinical staff who had used the initiatives compared to non-clinical staff (44% versus 39%; P=0.223). Survey respondents reported the initiatives improved their mental health (n = 223, 8%), ability to cope with COVID-19 related stress and anxiety (n = 206, 79%), do their work (n = 200, 77%) and relationships with colleagues (n = 174, 67%). Staff would like many of the initiatives (with some modifications) to continue after the COVID-19 pandemic.
CONCLUSIONS: The findings suggest a high level of staff satisfaction with the implemented wellbeing and support initiatives, and confirm the need for, and importance of, developing and implementing initiatives to support health service staff during outbreaks of infectious diseases such as the COVID-19 pandemic.

What is already known about this subject:

The COVID-19 pandemic has had a considerable impact on the professional and personal lives and psychological wellbeing of health service staff.

What this study adds:

Organizational wellbeing and support initiatives are well used and appreciated by health service staff, and have a positive impact on their mental and physical health and relationships with others.

What impact this may have on practice or policy:

Health service staff need ongoing, acceptable, and effective organizational initiatives to support their wellbeing, assist them to manage their occupational and personal responsibilities, and enable them to provide high quality patient care during a pandemic.

Introduction

During the COVID-19 pandemic, health service employees experienced increased levels of psychological distress and reported a considerable impact on their occupational and personal lives [1-4]. Concerns about contracting COVID-19, putting family members at risk and caring for infected patients have been described as well as professional challenges including the use of personal protective equipment (PPE) and being redeployed to different work roles [2, 5, 6]. Health service staff have also identified difficulties managing their paid work and family responsibilities, including supporting school-aged children with remote learning [2]. Other occupational risks faced by staff during the pandemic include perceived stigma, discrimination, long and irregular work hours, and heavy workloads [7].

The importance of mental health and psychosocial support for health service staff during a pandemic has been recognized by health services, researchers, governments and other organizations internationally [8-16]. Inadequate levels of individual support offered by health services to their employees are likely to reduce the ability of health service staff to cope and function effectively and result in increased rates of employee illness, absenteeism and turnover, and reduced quality of patient care [2, 14, 17–21]. In contrast, employees who have positive perceptions of their organizations’ support initiatives are less likely to experience depression, anxiety and stress [1].

Little is known about specific organizational wellbeing and support initiatives implemented for health service staff during the COVID-19 pandemic and whether they meet employees’ needs, are beneficial for their mental health and assist them to manage the occupational and personal challenges they have experienced. Recent international reviews of organizational initiatives implemented during the pandemic found that only a few have been published (mainly helpline and psychological services); none had been implemented in an Australian health service, and few have been evaluated or modified based on feedback from staff themselves or investigated differences between clinical and non-clinical staff who undertake different roles within a health service but are both essential for its effective operation [7, 22]. Further research is required to identify the most acceptable, feasible and effective ways to provide psychosocial support to health service staff, including among different professional groups, and to understand the distinct benefits of different types of initiatives [7, 19, 22]. Initiatives are unlikely to be successful or used unless they are appropriate to the needs and expectations of the staff to whom they are offered [18].

The aim of this study was to evaluate the suite of wellbeing and support initiatives implemented by an Australian health service during the COVID-19 pandemic to determine if they met employees’ needs. The specific objectives of the study were to assess: (i) awareness of the initiatives; (ii) use of the initiatives; (iii). satisfaction with the number and type of initiatives; (iv) impact on staff wellbeing; and (v) determine if there were any differences between clinical and non-clinical staff.

Methods

A convergent mixed-methods design (survey, interviews and data audit) was used. All staff (both clinical and non-clinical) employed at the study health service during the COVID-19 pandemic (n = approximately 7113 fulltime equivalent) were invited to complete a survey and/or participate in an interview. Employees identified by the health service’s human resources division as having played a key role in the development or implementation of the initiatives, and those with a supervisory role were invited to participate in a ‘key stakeholder’ interview.

The study was conducted at Western Health, a large metropolitan health service in Melbourne, Australia, which provides acute tertiary services, subacute care, specialist ambulatory clinics and community health services.

At the time the study began (December 2020), over 28 000 COVID-19 cases including 908 deaths had been reported in Australia [23]. The first COVID-19 positive patient was admitted to the study health service in March 2020 and the health service provided inpatient care for 46% of all cases in Australia and 24% of all ICU cases during Wave 1 and Wave 2 of the pandemic [24]. During the study period, Melbourne and the state of Victoria experienced their third lockdown (February 2021), with schools and many businesses closed and residents required to stay at home except for essential purposes [25].

Recognizing the potential psychosocial and occupational impact of the pandemic on its employees, the study health service implemented a range of wellbeing and support initiatives, including wellness hubs, daily staff bulletins, a COVID-19 information and wellbeing microsite (website), and an expanded employee assistance program (EAP) (Table 1). The purpose of these was to support employees’ mental and physical health, assist employees to manage their work and family/personal responsibilities and maintain employees’ sense of purpose and capability to provide high-quality patient care. The initiatives were available and communicated to all employees including clinical and non-clinical support staff.

Table 1.

Staff COVID-19 wellbeing and support initiatives

Initiative	Description	Purpose
Wellness hubs	Quiet rooms in each hospital which were attended by counselling staff; food/drinks provided.	A place for rest and relaxation away from usual workplace (eg wards); psychological support offered.
CEO forums	Online live (Zoom) regular briefings by the Chief Executive Officer (CEO) of the health service for all employees (regardless of discipline); also recorded for those who could not attend on the day.	Communicated COVID-19 and other information; answered employee questions.
COVID-19 Wellbeing Microsite	Online COVID-19 information and support (https://coronavirus.wh.org.au/).	Provided information and links to health service and external COVID-19 information and wellbeing support.
Meditation rooms	Quiet calm spaces with appropriate furnishings.	Provision of a restful quiet space to enable mindfulness and meditation.
Daily staff bulletins	Daily staff updates.	Provided COVID-19 and operational information via email to all employees.
Peer support program	Trained internal staff available to listen, debrief and refer on – a form of psychological first aid.	To provide immediate in-situ support to employees from skilled and trusted peers.
Employee assistance program	Usual employee assistance program offered and expanded to include on-site support.	Provided psychosocial support to staff and family members.
Compassion champions	A community of supportive kind peers who check in on others and listen to understand experiences and offer assistance.	Calls made to leaders as a personal check in to see how others were travelling, if they needed support etc.

Employees were invited via email to complete a self-report anonymous online survey. The email included a link to the survey and a participant information sheet. The survey was open from mid-December 2020 to early-March 2021. Completion was taken as informed consent.

The study-specific survey took approximately 15 min to complete and was available on Qualtrics (an online survey platform). It consisted of six sections with mainly fixed-response questions and assessed respondents’ sociodemographic and employment characteristics; awareness, utilisation, level of satisfaction and perceptions of the initiatives, and impact on personal wellbeing. Space was provided at the end of the survey for respondents to make free-text comments about their experiences and perceptions of the initiatives (Survey—available as Supplementary data at Occupational Medicine Online).

For analysis, responses to Likert-scale items were recoded to binary variables for level of satisfaction (‘dissatisfied’ or ‘satisfied’), perceptions (‘disagree’ or ‘agree’), and impact of the initiatives (‘no’ or ‘yes’).

Staff employed at the health service since January 2020 (i.e. the beginning of the COVID-19 pandemic) were invited by email to participate in an interview. The semi-structured interviews were conducted by the research team and an interview guide was used. Employees’ reflections and experiences of the initiatives, and perceived barriers and enablers to participation were sought. The key stakeholder interviews also investigated their perceptions of the health service’s response to and support of employees during the pandemic, their experiences of implementing the initiatives, and perceptions about the success and communication of the initiatives (Interview guides—available as Supplementary data at Occupational Medicine Online). Data about participants’ sociodemographic and employment characteristics were also sought. Interviews were conducted either via telephone or zoom between January and March 2021. The interviews were audio-recorded and transcribed for analysis.

Data about the use (number of uses, visits or times accessed) of each of the initiatives was collected from relevant health service databases.

The qualitative (interviews) and quantitative (survey and data audit) data were collected concurrently but analysed separately. The results were considered together in order to address the study’s objectives [26]. Using triangulation, the findings from each component were assessed to determine similarities, complementary information and contradictions [27]. The findings were then integrated and interpreted, and overall conclusions were drawn.

Descriptive statistics were used to describe and summarise survey variables. Chi-square tests identified differences in employees’ levels of awareness and utilisation of the initiatives with regards to sociodemographic characteristics such as professional role (clinical versus non-clinical). Quantitative data analysis was conducted using IBM SPSS Statistics.

To identify the presence and meaning of certain themes or concepts, the interview transcripts and survey free-text comments were analysed using content (conceptual) analysis [28]. The analysis was conducted by the research team and interpretations discussed until consensus was reached. Illustrative quotes have been included to highlight the findings.

The project was approved by the Western Health Low Risk Ethics Panel (QA Project Number: QA2020.78; ERM ID Reference Number: 69190; QA Approval Date: 09 December 2020).

Results

Nine hundred and seven completed surveys were received; a response rate of 13%. Seven employees and three key stakeholders participated in an interview; most using Zoom (n = 8). On average, the interviews lasted 27 min (range: 11–47 min).

Most survey respondents and interview participants were female, aged in their forties, employed in a clinical role and had worked at the health service for over 8 years; approximately half were part-time employees (Table 2). About a third of the survey respondents (n = 252, 29%) had been diagnosed with COVID-19 or had contact with someone who had been diagnosed; almost a quarter (n = 205, 24%) reported they were experiencing high to severe levels of work-related stress.

Table 2.

Participants’ sociodemographic characteristics

Characteristic	Study sample n (%)		Total health service employees
	Survey respondents (n = 907)	Interview participants (n = 10)	(%)
Female	726 (83)	9 (90)	78
Age (mean, range)	41.2 (19-72)	48.8 (33-63)
Born in Australia	588 (65)
Employment status (part-time)	434 (50)	5 (50)	52
Professional role
Clinical	600 (69)	6 (60)	77
Non-clinical	264 (31)	4 (40)	23
Nursing employee	356 (41)		51
Medical employee	58 (7%)		15
Allied health professional	114 (13)		8
Other health professional	72 (8)		3
Personal service worker	6 (1)		2
Management/administration	228 (26)		11
Support services	30 (4)		10
Supervisor of staffa	373 (44)
Years employed at health service (mean, range)	8.3 (0-45)	8.7 (11.2-47.2)

aThis information was not collected for interview participants.

Most survey respondents (n = 747, 86%) were aware of the initiatives and heard about them from staff bulletins (n = 522, 58%), their manager/supervisor (n = 317, 35%) or the health service’s human resources division (n = 302, 33%). The proportion of clinical and non-clinical staff who were aware of the initiatives was similar (86% versus 88%, P = 0.446); the level of awareness by professional role is outlined in Table 3. Interview participants also reported hearing about the initiatives from staff emails and colleagues.

Table 3.

Awareness and use of wellbeing and support initiatives by professional role (survey respondents)

Professional role	Aware n (%)	Used n (%)
Allied health professional	111 (98)	66 (60)
Management, administration and corporate support	205 (90)	84 (41)
Medical employee	44 (76)	15 (34)
Nursing employee	298 (84)	112 (39)
Other health professional	59 (83)	30 (51)
Personal service worker	5 (83)	0 (0)
Support services	21 (70)	5 (25)

Nevertheless, fewer than half (n = 314, 43%) of the survey respondents had used the initiatives. Reasons for not using the initiatives included not having enough time and already having adequate support (Table 4). The proportion of clinical and non-clinical staff who had used the initiatives was similar (44% versus 39%; P = 0.223); the proportion of respondents by professional role is provided in Table 3. Of those who had used the initiatives, more than three-quarters would use them again (n = 203, 78%) and recommend them to colleagues (n = 200, 77%).

Table 4.

Reasons for not using the initiatives (could select all that applied) (survey respondents)

Reason	n (%)
Didn’t have enough time—too busy at work	176 (19)
Have enough support already	156 (17)
Get support from family and friends	78 (9)
Not interested	75 (8)
Prefer to access support outside of work	61 (7)
Didn’t think they would be helpful	52 (6)
Support options not appropriate for needs	42 (5)
Worried they weren’t confidential	31 (3)
Manager/supervisor might find out had used them	15 (2)
Manager/supervisor not very supportive of staff using them	8 (1)
Colleagues might find out had used them	7 (1)
Hadn’t heard about them	5 (1)
Partner/family didn’t think it was a good idea	3 (0)
Other	54 (6)

The most commonly used initiatives by survey respondents were the daily staff briefings, wellbeing and support updates, and wellness hubs,. The data audit demonstrated high usage of the COVID-19 Wellbeing Microsite, the wellness hubs (the number of visits by professional role is outlined in Table 5), and the EAP (Table 6).

Table 5.

Number of times used Wellness Hubs by role and site (data audit)

Professional role	Total uses  N (%)
Nursing employees	3566 (44)
Management, administration and corporate support	1473 (18)
Other health professional	1470 (18)
Allied health professional	846 (10)
Support services	494 (6)
Medical employees	341 (4)
Volunteer	1 (0)
Total	8191

Table 6.

Number of times each initiative used (data audit)

Initiative	Number of times used
COVID-19 microsite (page views from February 2020 to March 2021)	23 238
Working at WH website (page views)	6858
Kindness matters website	3932
Video views
Coping with patient death—support for staff	159
Managing stress	133
Effort recovery	103
Wellbeing	328
Wellbeing—short video	320
Wellbeing—long video	11
EAP (March 2020—December 2020)	505
Individual counselling sessions	926
Critical incident debriefs	61
Wellbeing Inbox (queries from 6/4/2020 to 9/11/2020)	51
Donations
Food	28 117
Cosmetics	25 621
Other (incl PPE)	164 937
Wellness and support hubs (March—July 2020)	8,191

Survey respondents (free-text comments) and interview participants shared their perceptions and experiences of the initiatives. The wellness hubs were identified as a place to ‘get away’, ‘escape [their] clinical space’ and have a break. They felt the hubs had a ‘good feeling’ and particularly liked their set up including the ‘soft lighting’ and the respect staff showed each other by having ‘quiet not cafeteria conversations’.

‘[The wellness hub allowed] me to get out of my workspace for a little while and give me a bit of a reprieve [and time to] regroup and go back to my [normal] place with a little bit more sanity.’ (Interview participant)

Although some employees reported difficulties accessing counselling and the EAP in a timely manner, those who had used these services reported that they were a ‘life saver’ and the support they received was ‘invaluable’.

‘Found the [EAP] at work counselling very useful and made me feel supported and listened too. Felt that [the health service] cares about staff.’ (Survey respondent)

Many employees discussed the importance of accurate and regular communication from the health service particularly from senior management. Overall staff felt that there had been ‘strong leadership’ and good communication from the senior executive team; the staff bulletins were informative; and many felt the CEO forums were important in keeping them updated about what was happening in the organisation and helping them ‘feel connected’.

‘I think [the CEO’s] webinars were really really good, … I logged in every time if I could, I really wanted to be kept up to speed with what was going on, because … things were moving so fast that they changed on a daily basis.’ (Interview participant)

The initiatives the survey respondents were most satisfied with included the wellness hubs (n = 201, 79%), wellbeing and support updates (n = 181, 73%), the daily staff briefings (n = 166, 66%), and the COVID-19 Wellbeing Microsite (n = 158, 63%).

Feedback about the initiatives from survey respondents and interview participants was mostly positive; staff agreed the initiatives were easy to use (n = 193, 75%), provided the information (n = 196, 77%) and support (n = 160, 63%) needed, and a sufficient variety of initiatives were available (n = 182, 71%).

Most survey respondents reported the initiatives improved their wellbeing specifically their mental health (n = 223, 86%), response to and ability to cope with COVID-19 related stress and anxiety (n = 206, 79%), and ability to do their work (n = 200, 77%).

Several barriers to using the initiatives were identified including high workload, difficulties accessing the initiatives (e.g. not working on-site, night shift), and a perception the initiatives were only for clinical staff. Participants were also concerned that not all employees were aware of the initiatives or that they were available for everyone to use.

It’s just too hard for clinical staff to take time to access these initiatives. Especially during a pandemic when we were so busy and physically drained. (Survey respondent)

The wellness hub, although a great initiative, had hours … not compatible to ICU 12-hour shifts. Finding the time to get down to the hub during a shift was impossible. (Survey respondent) Many participants felt communication about the initiatives could have been improved and targeted to particular employee groups. Some suggested further communication in a variety of formats would be beneficial for employees who do not have access to a computer (eg cleaners, kitchen staff) or time during their normal shift to access one (e.g. nurses and midwives), or whose first language is not English, or who do not have appropriate literacy levels.

We’re in … an admin role and a lot of the stuff that goes hospital wide I think sometimes misses us or isn’t geared towards us. (Interview participant)

For example, cleaners that are aligned to wards … They didn’t get a lot of this information … And for some of them English isn’t their first language. (Interview participant)

Discussion

This evaluation of occupational health initiatives implemented by an Australian health service during the COVID-19 pandemic for its employees found that the initiatives were well used and appreciated by staff and had a positive impact on their wellbeing. Staff reported the initiatives provided them with the information and support they required, a sufficient variety of initiatives were available, and they would use the initiatives again and recommend them to their colleagues. Although several barriers to their use were identified including difficulties accessing due to heavy workload and shift work and a perception that the initiatives were only for clinical staff, employees indicated they would like the initiatives to continue after the pandemic and suggested improvements to ensure they met their needs and were available and accessible to employees from different professional groups and sites.

A large and diverse sample of health service employees including clinical and non-clinical staff and users and non-users of the initiatives participated in the study enabling the identification of the barriers and enablers to use as well as exploration of the needs of employees from different professional roles. Nevertheless, it is possible that staff who did not participate may have different experiences or perceptions of the initiatives or have not used them. Participants were recruited from only one large metropolitan tertiary Australian health service. Due to the pandemic, many staff were focussed on providing essential clinical care; this may have contributed to the low response rate. Therefore, the findings may not be generalisable to other health services or different settings. The study included a self-reported assessment of the impact of the initiatives on participants’ mental health; no baseline assessment was conducted. Due to the unique and time-sensitive nature of the pandemic and the implementation of initiatives, it was not possible to use a validated psychometric instrument(s). Despite the potential loss of information and protect the confidentiality of respondents, responses to the Likert scale survey questions were recoded into binary variables for ease of interpretation and presentation of results. This was a cross-sectional study; longer-term evaluations are required to determine if employees’ needs and preferences change during and post pandemic.

Similar to the findings of others [7, 19, 20, 29, 30], employees in this study appreciated clear, timely and accurate communication from their health service and management team about the organization’s COVID-19 response especially given changing operational requirements. The CEO Forums were particularly valued as they provided an opportunity to ask questions; they also enabled the organisation to demonstrate visible leadership and give regular open communication of important information and recognition to staff. A recent rapid review identified that staff perceptions of organisational support, recognition of staff efforts and clear communication were all factors that decreased the risk of adverse psychological outcomes during an infectious disease outbreak such as the COVID-19 pandemic [7].

The provision of on-site dedicated spaces for psychological support and respite away from busy clinical areas was valued by the staff in this study. The wellness hubs implemented at the study health service were similar to those offered at health services in other countries during the COVID-19 pandemic [15, 18]. The high usage rates of these hubs demonstrate they are well received by staff [15].

Future research should include the use of validated psychometric instruments in longitudinal studies in order to conduct more rigorous evaluations. Future studies should also investigate the impact of wellbeing and support initiatives on staff retention, absenteeism and the provision of high-quality patient care as well as any differences by professional group, years of experience and other sociodemographic and employment characteristics. Both individual and organisational level initiatives are important in supporting staff wellbeing during an infectious diseases outbreak such as the COVID-19 pandemic [7]. The current study focused on individual level initiatives. Evaluation of organisational level initiatives such as the provision of adequate staffing levels and changes to work schedules should also be conducted.

Although organizational commitment and resources are required, it appears that health service staff have an ongoing need during an infectious disease outbreak for wellbeing and support initiatives such those evaluated in this study. A range of initiatives, which include effective communication, quiet spaces easily accessible but separate from usual workplaces, and are available for all employees (regardless of professional discipline and work hours) are particularly appreciated by staff. Potential barriers to access, such as those identified in this study could be overcome by ensuring initiatives are available for staff working different shifts and targeting promotion through multiple channels for difficult-to-reach professional groups. Similar to the findings of others [16, 20, 29], the initiatives examined in this study were perceived as having had a positive impact on staff wellbeing and assisted staff to manage the occupational and personal challenges they experienced during the COVID-19 pandemic.