|Year : 2021 | Volume
| Issue : 1 | Page : 93-97
A qualitative study of the psychological experiences of health care workers during the COVID 19 pandemic
Priyanka Dang1, Naveen Grover2, Prashant Srivastava1, Savita Chahal1, Ashish Aggarwal1, Vishal Dhiman3, Gauri Shanker Kaloiya4
1 Department of Psychiatry, Kalpana Chawla Government Medical College and Hospital, Karnal, Haryana, India
2 Department of Clinical Psychology, Institute of Human Behaviour and Allied Sciences, Rishikesh, Uttarakhand, India
3 Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
4 National Drug Dependence Treatment Centre, AIIMS, New Delhi, India
|Date of Submission||29-Jun-2020|
|Date of Decision||19-Oct-2020|
|Date of Acceptance||28-Nov-2020|
|Date of Web Publication||31-Mar-2021|
Dr. Naveen Grover
Department of Clinical Psychology, Institute of Human Behaviour and Allied Sciences, Delhi
Source of Support: None, Conflict of Interest: None
Background: Health-care workers (HCWs) are at the forefront of managing the massive responsibility of public health response to COVID-19. The aim of the present study was to explore the psychological experiences of these frontline HCWs. Methods: A qualitative study was carried out with 24 frontline HCWs posted in COVID-19 wards, using purposive and snowball sampling methods. Data were collected using focus group discussions and individual interviews, which were transcribed and analyzed using Braun and Clarke's six-phase framework of thematic analysis. Results: HCWs were overburdened. It caused them to experience symptoms of depression and anxiety. Most of them showed positive appraisal coping and believed that people would have to learn to live with it. Conclusions: Continued support for professional help is needed for HCWs at present and in the aftermath of the pandemic.
Keywords: Corona, crisis, distress, psychological burden, stigma
|How to cite this article:|
Dang P, Grover N, Srivastava P, Chahal S, Aggarwal A, Dhiman V, Kaloiya GS. A qualitative study of the psychological experiences of health care workers during the COVID 19 pandemic. Indian J Soc Psychiatry 2021;37:93-7
|How to cite this URL:|
Dang P, Grover N, Srivastava P, Chahal S, Aggarwal A, Dhiman V, Kaloiya GS. A qualitative study of the psychological experiences of health care workers during the COVID 19 pandemic. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Jun 19];37:93-7. Available from: https://www.indjsp.org/text.asp?2021/37/1/93/312864
| Introduction|| |
COVID-19 (caused by the severe acute respiratory syndrome [SARS] CoV-2 and known as the novel coronavirus) is an infectious disease which has been recently declared as a pandemic by the World Health Organization. COVID-19 spreads rapidly and often through proximity to the cases and carers, and there is no vaccine or treatment available to date. As a result, public health scientists across most affected countries worldwide have identified “social distancing,” “self-isolation at home,” and “frequent hand washing” as the strongly recommended measures to contain the spread of the disease. A substantial burden of the clinical treatment and public prevention efforts in hospitals and community settings is on the health-care workers (HCWs). A HCW is one who delivers care and services to the sick and ailing either directly or indirectly. HCWs are at increased risk of being infected because they are at the front line. They have to commute and care for suspected/confirmed cases of COVID-19 for several hours with proximity.
This responsibility has its mental health consequences. It is also anxiety provoking for HCWs when they see their colleagues become patients, which can be physically and mentally draining. Some HCWs, unfortunately, experience avoidance by their family members and community due to the stigma or fear. Thus, HCWs are at significant risk of adverse mental health outcomes during the COVID-19 outbreak.
Leading global health agencies such as the World Health Organization and the Centers for Disease Control and Prevention recommend using qualitative methods in epidemiologic investigations. Increasingly, the qualitative method of triangulation is advocated as a strategy to achieve more comprehensive understandings of phenomena. Triangulation is a technique that facilitates the validation of data through cross verification from the application and combination of several research methods in the study of the same phenomenon. Although focus group discussion (FGD) and individual interviews are independent data collection methods, their combination can be advantageous to researchers as complementary views of a phenomenon may be generated. Studies reveal three broad rationales for this combination: (1) pragmatic reasons, (2) the need to compare and contrast participants' perspectives (parallel use), and (3) striving toward data completeness and/or confirmation (integrated use). Individual interviews may be used to explore personal experiences, whereas focus groups may be used to examine opinions and beliefs about the phenomenon. Keeping the novelty of the current situation in mind, with respect to this being the first pandemic that the current generation has experienced globally (the last one on this scale was the Spanish Flu in 1918), it was decided to use a combination of FGD and individual interviews for the current research. This was done to make the data as rich and trustworthy as possible.
In view of the above, the present study aimed to assess the psychological experiences of frontline HCWs during the COVID-19 pandemic using a thematic analysis of the qualitative data collected by FGDs and individual interviews. The psychological experience was assessed in terms of their cognitive, behavioral, physiological, and emotional response to the role of being a frontline HCW.
The study was conducted with 24 frontline HCWs for COVID-19 across North India in April–May 2020. There were ten males and 14 females in the age range of 25–49 years. It was a mixed group of health workers – 14 doctors, 6 nurses, and 4 helpers. It followed a phenomenological research design. The participants were recruited through purposive and snowball sampling approach. Written informed consent was obtained from participants. All of them were directly involved with treating suspected/confirmed cases of COVID-19, either during sample collection (nose swab and throat swab) or in the isolation wards. FGDs were conducted with 14 participants in three groups (n = 5, 5, and 4). Each session lasted for about 40 min. The individual interviews were conducted telephonically with ten participants and lasted from 20 to 25 min. All the interviews were audio recorded with consent. The interviews were conducted in English/Hindi.
The ethical guidelines were followed in the present study. The study objectives and voluntary nature of the study were explained to participants, and informed consent was obtained during each FGD and individual interview. Confidentiality was assured by assigning alphanumeric codes instead of names and removing identifying information from the transcripts. No remuneration was provided for participating in the study. They had the choice to opt-out of the study at any point of time. A broader interview guideline was developed after discussions among the authors. Two pilot interviews were done. The insights were utilized for refining the interview guide. Participants' age, marital status, designation, and number of days they worked on the COVID-19 ward was obtained at the start of the interview. A broad data-generating question was used to initiate the discussion/interview: “Please tell me about your experience of dealing with patients with COVID-19.” Open-ended follow-up questions were used to obtain detailed descriptions, and examples were: “what was your biggest challenge during this phase;” “how did you deal with it?”; “how did your family support you in this?” The relevant probing questions were asked to get more information about the phenomenon under observation. Data collection was stopped once no new themes were emerging from the interviews, i.e., when data saturation was reached.
| Results|| |
Braun and Clarke's six-phase framework of thematic analysis was utilized for analyzing data from both the methods. The analysis included becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining themes, and write-up. The main themes emerged from the analysis were – work pressure, personal vulnerabilities, coping, and the future of the pandemic. The findings are described below with excerpts from the interviews (with numeric codes).
Discussions focused around three key areas which formed the subthemes – shortage of workforce, long duty hours while wearing personal protective equipment (PPE), and uncooperative patients. Most participants validated and supported each other's experiences related to being overburdened and facing shortage of workforce for collecting samples. Venting interactions were seen when participants discussed about difficulties faced with PPEs, fear of infecting family members, and being discriminated against and facing stigma for being a HCW.
Shortage of workforce
Most of the participants agreed that there was an acute shortage of workforce because of which the existing workforce was heading toward burnout. As one participant reported and others echoed the same sentiment:
1- “it's just 3 of us who take samples of around 100 people every day. It is very exhausting.”
Long duty hours while wearing personal protective equipment
According to most of the participants, working in PPEs was very uncomfortable, the quality of the PPEs they wore was poor, and they could not eat or drink anything for a minimum of 8 h, sometimes even more.
16- “the PPEs would get torn when we wore them.……. we wore one PPE on top of another.”
18- “... wearing PPE was the most troublesome. No food or water for 12 h.”
21- “…. due to fogging of glasses, I could not see clearly while examining patient.”
17- “I would be drenched in my own sweat by the end of it.”
Participants shared how some patients threatened to harm themselves if they were not sent back home immediately; they refused food and water, were anxious for their report and violated social distancing norms while talking to the HCWs.
20- “one patient was threatening to jump from the window. I counselled him. Even if we ourselves are stressed, we must counsel them. Some of them are cooperative but others are not, especially those who take drugs.”
Most of the participants reported experiencing symptoms of anxiety and depression. They reported discrimination by colleagues and neighbors, fear of catching, and spreading the virus.
Depressive and anxiety symptoms
They reported having sleep disturbance and feeling irritable, lonely, helpless
5- “I am not able to sleep at all and even if I do then by that time it is already time to wake up…”
3- “I cannot meet anyone else. Life is restricted between hospital and hostel. It gets frustrating…”.
The participants reported feeling stressed, horrified, confused, angry, having palpitations, and having doubts of contamination
19- “…initially felt confused and angry because this was a new situation for everyone. We dint know what to do”
12- “I experience palpitations when I go for duty.”
Discrimination by colleagues and neighbors
Most of the participants, especially the nurses, were of the opinion that their friends would refuse to sit and eat food with them after duty hours. When describing the discrimination they faced from fellow colleagues, some participants said that they were treated as untouchables and that it made them feel angry and upset.
11- “…stand at a distance and talk. Do not come near us otherwise you will infect us”
9- “neighbours tell me to park my car separately, away from everyone else's houses. Are we untouchables?”
14- “…despite being a HCW it is unacceptable that they treat their own colleagues like this,”
This experience was highly distressing for them as they felt marginalized for doing their duty and being designated as “infected,” while others attributed it to their colleague's method of coping with the fear of COVID-19
2- “… maybe that is the safest way they thought would be correct to protect themselves. I don't blame them…”.
Fear of catching and transmitting the virus
All the participants were fearful of contracting the virus and transmitting it to their families
5- “I always feel fearful of being infected and passing it onto my family “
8- “even after wearing PPE I feel scared because I have to take the patient's sample and in that there is no social distancing”
4- “a colleague of mine tested positive for COVID. At that time, I was really scared.”
This according to them caused sleep disturbance
2- “…because of fear I would attend to the patient from a distance”
3- “even after washing hands nicely, I felt that I had not cleaned them properly and should wash them again……
13- “…. I am worried that I would pass it onto my children…”
Amid anxiety, depression, and the uncertain nature of the pandemic; most participants reported that they were doing certain things to cope with their situation. Two subthemes of coping emerged-
Many participants coped by positively appraising the situation. They interpreted it as a learning experience
15- “this is my first experience of working in a pandemic. Even our seniors would not have experienced anything like it….learnt a lot.”
Some of them saw it as a part of their duty and felt that they were contributing to society during these uncertain times
23- “it feels good to know that I am being able to contribute my bit at this time.”
Some participants reported developing greater appreciation for life and practicing simple living
18- “the pandemic has taught me that we complicate life too much. We can cook restaurant like food at home and do not need to go to the market frequently. This way we can save petrol also.”
Some participants reported watching movies, listening to music, doing household chores, talking to friends and family over video calls, studying, following a hobby, exercising, and praying as being helpful in dealing with the stress of a HCW during this pandemic.
10- “I watch movies on Netflix and prime”
17- “I am taking piano lessons online”
24- “I speak to my children once on video call everyday.”
Future of the pandemic
According to some participants, the pandemic would last for at least 1 more year. According to the others, it could last for another 5–6 months. However, all of them agreed to taking the necessary precautions and making it a part of daily routine. All the participants were of the opinion that people would have to get used to living with it even after the vaccine is developed. According to them, it would eventually become like malaria or seasonal flu, for which people would develop immunity and vaccinations, but that would take a lot of time. Following government directives would be the key to prevention.
1- “learn to live with it”
5- “We have to deal with it till vaccination is made”
19- “Covid will take 1–2 years to go away. But we should be cautious.”
| Discussion|| |
The methodology of the present study was directed toward the optimal integration of individual interview and focus group data. Comparisons of transcripts from both the methods revealed data which were mutually informative and gave complementary findings that contributed to a coherent and more nuanced understanding of the psychological experiences of HCWs during the COVID-19 pandemic. The specific types of interactions among participants served to further delineate patterns of psychological experiences of HCWs. The types of interactions identified across the focus groups included: validating, supporting, and venting interactions. Most participants validated and supported each other's experiences related to being overburdened and facing a shortage of workforce for collecting samples. Venting interactions were seen when participants discussed about being discriminated against and facing stigma for being a HCW. These patterns were described in greater detail in individual interviews by some participants.
In the present study, many participants reported experiencing significant distress. One important source of the distress was long working hours with PPE. A recent study also reported that working with wearing PPE for long hours was a major physical and professional challenge. Recent studies also showed that frontline HCWs have greater risks of mental health problems. During the SARS outbreak, a study found that HCWs who were at high risk of contracting SARS appear to have higher levels of depression and anxiety. It is of concern that the same may be true for COVID-19.
Participants reported feelings of sadness due to discriminatory behavior by colleagues and neighbors. Social stigmatization and contact with infected patients have previously been shown to be associated with increased levels of stress and anxiety in medical staff. Some participants engaged in personalization and threatening appraisal of these behaviors whereas others were able to engage in nonthreatening appraisal. The data obtained in the present study bears some resemblance to what they describe as “same story, different interpretations, when a different meaning to the same phenomenon is ascribed as happened in the case of discrimination in the present study. The nonthreatening appraisal method has better mental health outcomes.
Discriminatory behavior could be a result of adaptive behavior activation. According to the concept of behavioral immune system, human antipathogen defense is characterized by proactive behavioral mechanisms that inhibit contact with pathogens in the first place. When a superficial cue connoting infection risk is detected (e.g., a frontline HCW for COVID-19), it triggers a cascade of adaptive psychological responses. These responses include not only the emotional experience of disgust but also the activation of aversive cognitions into working memory and the arousal of a motivational system that guides decision-making strategies and motor movements in ways that minimize the infection risk, leading to behavioral avoidance and social condemnation of people – HCWs in the present scenario.
The present study participants also reported fear of being infected and chances of transmitting the infection to their family members. It has been reported to be significantly associated with their risk of developing posttraumatic stress disorder. Participants in the qualitative study of HCWs in China reported being constantly in fear of becoming infected. They had concerns whether they had contact with any patients or colleagues who were diagnosed with COVID-19.
The present study participants used positive appraisals to deal with the stress. According to the Schematic Appraisals Model of Suicide, positive self-appraisals are protective, providing a source of resilience in the face of stress. It was encouraging to find, in the present study, that positive appraisal was supplemented with effective coping behaviors, a key to better mental health. The findings were consistent with the study on nurses in the SARS wards.
The present study has certain limitations. The individual interviews were conducted telephonically owing to the lockdown. Thus, data with respect to nonverbal cues such as facial expressions, eye contact, and body movements could not be recorded. Future studies can collect as much nonverbal information as possible, which could enrich the descriptions of HCWs experiences.
| Conclusions|| |
The present study provides insight about the psychological experiences of HCWs during the COVID-19 pandemic in India through a qualitative method. These insights can be valuable in developing intervention programs to cater to the mental health needs of HCWs during the pandemic and in its aftermath.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Director-General's Opening Remarks at the Media Briefing on COVID-19. Geneva: World Health Organization; c2020. Available from: https://www.who.int/
. [Last accessed on 2020 Apr 11; Last updated on 2020 Mar 11].
Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet 2020;395:931-4.
Joseph B, Joseph M. The health of the healthcare workers. Indian J Occup Environ Med 2016;20:71-2.
] [Full text]
Nemati M, Ebrahimi B, Nemati F. Assessment of Iranian Nurses' knowledge and anxiety toward COVID-19 during the current outbreak in Iran. Arch Clin Infect Dis 2020;15:e102848.
Huynh G, Nguyen TN, Tran VK, Vo KN, Vo VT, Pham LA. Knowledge, and attitude toward COVID-19 among healthcare workers at District 2 Hospital, Ho Chi Minh City. Asian Pac J Trop Med 2020;13:260-5. [Full text]
Wolff B, Mahoney F, Lohiniva A, Corkum M. Collecting and analyzing qualitative data. In The CDC field epidemiology manual, Sonja A. Rasmussen, Richard A. Goodman (Eds). Fourth edition. | Oxford; New York: Oxford University Press,  |Available from: https://www.cdc.gov/eis/field-epi-manual/chapters/Qualitative-Data.html
. [Last accessed on 2020 May 11].
Carter N, Bryant-Lukosius D, DiCenso A, Blythe J, Neville AJ. The use of triangulation in qualitative research. Oncol Nurs Forum 2014;41:545-7.
Lambert SD, Loiselle CG. Combining individual interviews and focus groups to enhance data richness. J Adv Nurs 2008;62:228-37.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77-101.
Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behav Immun 2020;88:901-7.
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al
. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA New Open 2020;3:e203976.
Lee SM, Kang WS, Cho AR, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry 2018;87:123-7.
Chua SE, Cheung V, Cheung C, McAlonan GM, Wong JW, Cheung EP, et al.
Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers. Can J Psychiatry 2004;49:391-3.
Sands RG, Roer-Strier D. Using data triangulation of mother and daughter interviews to enhance research about families. Qual Soc Work 2006;5:237-60.
Schaller M. The behavioural immune system and the psychology of human sociality. Philos Trans R Soc Lond B Biol Sci 2011;366:3418-26.
Tam CW, Pang EP, Lam LC, Chiu HF. Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: Stress and psychological impact among frontline healthcare workers. Psychol Med 2004;34:1197-204.
Liu Q, Luo D, Haase JE, Guo Q, Wang XQ, Liu S, et al.
The experiences of health-care providers during the COVID-19 crisis in china: A qualitative study. Lancet Glob Health 2020;8:e790-8.
Johnson J, Gooding P, Tarrier N. Suicide risk in schizophrenia: Explanatory models and clinical implications, the schematic appraisal model of suicide (SAMS). Psychol Psychother 2008;81:55-77.
Lee SH, Juang YY, Su YJ, Lee HL, Lin YH, Chao CC, et al.
Facing SARS: Psychological impacts on SARS team nurses and psychiatric services in a Taiwan general hospital. Gen Hosp Psychiatry 2005;27:352-8.