Out of the 46 studies included in the meta-synthesis, 21 studies were based on participants in Asia, twelve 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. 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).
Table 2
Quality of selected studies – number of studies meeting each CASP criteria.
| | Totally met | Partially met | Not met |
|---|
1. Was there a clear statement of the aims of the research? | 44 | 1 | 1 |
2. Is a qualitative methodology appropriate? | 45 | 1 | 0 |
3. Was the research design appropriate to address the aims of the research? | 43 | 3 | 0 |
4. Was the recruitment strategy appropriate to the aims of the research? | 24 | 18 | 4 |
5. Were the data collected in a way that addressed the research issue? | 28 | 17 | 1 |
6. Has the relationship between researcher and participants been adequately considered? | 11 | 10 | 25 |
7. Have ethical issues been taken into consideration? | 24 | 12 | 10 |
8. Was the data analysis sufficiently rigorous? | 31 | 10 | 5 |
9. Is there a clear statement of findings? | 39 | 7 | 0 |
10. How valuable is the research? | 36 | 10 | 0 |
Meta-Synthesis
Tthemes derived from the meta-synthesis are shown in Table 3.
Table 3
Overarching themes from meta-synthesis
Themes (sub-themes) |
|---|
1. Physical health, safety and security 1.1 Concerns for self 1.2 Concerns for others 1.3 Practical and environmental issues |
2. Workload |
3. Stigma |
4. Ethical, moral and professional dilemmas |
5. Personal and professional growth |
6. Support to and from others 6.1 Family and friends 6.2 Colleagues and peers 6.3 Organisations 6.4 Media and the public |
7. Knowledge and information 7.1 Communication 7.2 Training |
8. Formal support |
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. Gershon et al. [26] 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.”
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. [54] 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.
Thirteen years later, Yin & Zeng [60] 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.
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. 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. [33] 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.
Many made sacrifices and sought to protect their loved ones by staying away from them. For example, Yin and Zeng [60] 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.
Fellow healthcare workers falling ill with the virus was a significant cause for preoccupation and distress amongst participants.
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. [24].
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.
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. [21].
Some studies commented on the pay off between staff safety and patient care. For example, Moore et al. [44] 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.
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. [26] 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.
This was not unique to developing countries, with similar challenges reported in Canada [44] and Australia [21].
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. 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. [44] 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.
However, because of staff shortages, some participants were noted to describe feeling guilty for taking time off to rest [26, 50]. 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 [30, 50].
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. 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.
“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.” [20].
3. Stigma
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. [24].
Stigma also appeared in the studies of COVID-19. Fawaz and Samaha [25] 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.
This stigma extended to the families of healthcare workers with some reporting their children being discriminated against [32]. Other studies pointed to the hypocrisy that some healthcare workers experienced when they were publicly commended for their work but privately discriminated against [30].
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.
“The biggest conflict within me, was the lack of ability…to put your hand on a shoulder…or hold their hand.” [34].
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 help” [55] and “we could not do enough” [38] 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 or give them any measure of comfort as a great source of distress.
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.
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.” [26].
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] and “morally unacceptable” [31] 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” [19].
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. The gratitude of others; patients, their families and wider society was noted to increase their sense of fulfilment.
Even in some of the most challenging moments, many healthcare workers found meaning in their work, for example, Erland and Dahl [24] 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.”
Overcoming such immense challenges tested the participants and imbued some with a sense of greater professional confidence and competency [56]. 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.
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.” [26].
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.
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.” [43].
The competing demands of managing work and family life during a pandemic was also a source of stress. As described by Bergeron et al. [20] 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.”
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.
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.” [26].
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 [35] 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.”
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 [60].
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.” [20].
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 examples of not feeling adequately supported. Some workers reported feeling coerced into working with infected patients or in inappropriate conditions. Participants across the 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. [27] 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.
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. [17] 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.
Many healthcare workers felt that catastrophic portrayals of the pandemic on the news compounded families concerns. 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.
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. [20] 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.
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 [26].
7. 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.
7.1 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. [31] 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.
Equally prevalent were comments about there being too much information. Rapidly changing and inconsistent information “increased frustration and uncertainty” [23]. 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” [21].
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.
7.2 Training
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 [26] 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.
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.
8. 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 [60] 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.
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.
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. [58].