Healthcare Providers and the Lingering Influence of the COVID-19 Pandemic

doi:10.21203/rs.3.rs-4875002/v1

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Healthcare Providers and the Lingering Influence of the COVID-19 Pandemic 

https://doi.org/10.21203/rs.3.rs-4875002/v1

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Purpose

To gain a better understanding of the experiences of healthcare providers caring for adult patients during the second year of the COVID-19 pandemic.

Methods

A descriptive, qualitative design was conducted using semi-structured interview questions. Eleven participants were recruited from a sample of 28 healthcare providers to participate in video interviews. Thematic analysis was used to analyze data.

Results

Healthcare providers experienced continued distress related to concerns about the long-term effects on themselves, their families, and society. Three themes emerged from the data: (1) exhausted and emotionally numb; (2) vaccinated versus the unvaccinated; and (3) stressors and misguided supports.

Conclusion

The lingering COVID-19 pandemic led to continued distress among healthcare providers. Themes highlight the challenges faced by healthcare providers as they continued to care for patients during the lingering pandemic. Leadership must continue to prioritize support for healthcare providers for the duration of healthcare disasters to promote quality of life, reduce burnout, and increase job satisfaction. Findings from this study can inform the development of much needed institutional support for front line healthcare providers during times of crisis.

Healthcare providers

COVID-19

distress

support

The coronavirus disease (COVID-19) was declared a public health emergency in the United States on February 3, 2020, and became a pandemic on March 11, 2020. The COVID-19 pandemic and public health emergency persisted for more than three years, finally reaching its end on May 11, 2023. Unexpected, prolonged disruptions in the provision of healthcare in the United States (U.S.) and worldwide remain in its wake.[1] Older patients, the unvaccinated, and patients with pre-existing medical conditions remain most at risk of detrimental disease progression.[2] Repeated mutations in the virus have resulted in the continuous emergence of subtypes reported to differ mainly in their infectivity,[2] underscoring the potential for continued widespread impacts on population health.[1] As of July 2024, new lineages of the Omicron variant have continued to evolve and surge worldwide, with over 770 million confirmed cases of COVID-19 and 7 million deaths. The U.S. comprises over 103 million confirmed cases and 1.3 million deaths.[3]

On December 11th, 2020, the Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for the Pfizer BioNTech COVID-19 vaccine. Three days later, the first patient outside a clinical trial received the vaccine.[4] By April 21st, 2021, the U.S. surpassed 200 million vaccinations administered and, in the fall of 2021, the CDC began endorsing booster shots for individuals who received the original vaccine six months prior.[4] Even as the vaccine became available in countries around the globe, new cases continued to emerge, placing increased strain on hospitals, nurses, and other healthcare providers (HCPs).[5] While the COVID-19 vaccines were developed and distributed rapidly; there was immediate resistance and controversy regarding the vaccine due to a lack of approval from the FDA and continued uncertainties surrounding COVID-19 and associated treatments. However, as of July 2024, over 270 million people in the U.S have received at least one dose of a COVID-19 vaccine (including children 5 years of age and younger).[3]

The duration of the COVID-19 pandemic and ongoing controversy of the COVID-19 vaccines led to detrimental psychological and physiological impacts on our nation's HCPs. Vaccination among HCPs is viewed as a security measure, thought to offer a welcome layer of protection for themselves and patients while also reducing their stress, anxiety, and depression; many HCPs viewed vaccination as their duty in providing optimal care to others.[6] Yet vaccinated HCPs often cared for patients who were influenced by social, cultural, or political contexts and hesitant to receive the vaccine,[7] the impacts of which have been underexplored. Previous studies conducted by the authors indicated that HCPs struggled with fear and experienced limited resources as well as a perceived lack of support at the start of the pandemic.[8] Since the onset of the pandemic, many HCPs report exhaustion, burnout, fear, anxiety, misery, fatigue, low morale, anger, and frustration leading them to consider leaving the bedside which may exacerbate the looming nursing shortage.[9, 10] As the coronavirus disease (COVID-19) pandemic lingered into its second year, evidence of its long-term influence on our nation’s HCPs remained largely unknown; therefore, the purpose of this study was to gain a better understanding of the perspective of the continued challenges faced by HCPs caring for adult patients during the second year of the COVID-19 pandemic.

Study Design

This descriptive, qualitative study is a follow-up to a mixed-methods study that aimed to understand the influence of personal and professional experiences caring for patients during the COVID-19 pandemic on HCPs quality of life (QoL) and moral distress (MD).[8] Thematic analysis allowed for a rich, textural description of HCPs experiences in their own words to understand the challenges that they continued to experience as the pandemic endured.[11, 12]

Participants and Sampling

Our sample consisted of 11 HCPs from a sample of 28 participants from a prior study focused on HCP and COVID-19 that agreed to be contacted for future research. Eligible participants were included if they: (1) were HCPs who provided direct patient care throughout the duration of the COVID-19 pandemic; (2) were able to read, write and speak English; and (3) had access to an electronic device with internet and video chat capability.

Data Collection

Participant recruitment, enrollment and interviews took place between February 2022 and March 2022. Electronic recruitment materials were emailed to potential participants. A Qualtrics database was created to screen for participant eligibility and obtain electronic informed consent, demographic data, and COVID-19 practice survey data. Upon completion of the database, participants were contacted to schedule a virtual interview with the first author (X.X.) A semi-structured interview guide with open-ended questions (see Table 1) was developed to explore the challenges faced by HCPs as they cared for patients throughout the COVID-19 pandemic. Interviews were conducted in a private office, recorded using cloud-based technology and lasted approximately one hour. Probes were used to foster a deeper understanding of the participant's experience, and they were encouraged to speak freely beyond the interview questions. Interviews continued until data saturation was achieved and no new themes emerged. Interviews were transcribed verbatim using an automatic transcription service and verified by the first author (X.X.). Participant confidentiality and anonymity were protected.

Data Analysis

Thematic analysis was used to identify emergent ideas prior to beginning the coding process.¹³ Concurrent data collection and analysis allowed both processes to influence each other.[12, 13] Transcribed interviews were organized by the first author and independently reviewed by the first and second authors (X.X. and X.X.) to identify emergent ideas and concepts in preparation for the coding process.[14] An inductive coding system was applied after initial interpretation of the data to further develop and refine emerging themes.[14] A list of 25–30 tentative codes were applied across the interview transcripts to enhance initial interpretation and conceptual development of themes.[14] Emergent concepts included vaccine issues, continuing exhaustion, and shifting fears forming the basis of the themes.[14] An iterative process of re-coding, re-reading, and re-analysis of transcripts supported intercoder reliability and yielded three final themes.[14] If intercoder agreement was not achieved, discrepancies were resolved with the second author (XX) who is a clinician. In the final phase of thematic analysis, the authors chose participant examples for each theme that best related to the purpose of this study. Each final theme was evaluated to ensure data clarity and accuracy of interpretations and findings.[15]

Ethical Considerations

Approval to perform this study was granted by the Towson University Institutional Review Board in October 2021 (approval no. 1407). This project was conducted in accordance with the Declaration of Helsinki. Participants were provided with written informed consent prior to initiation of data collection.

Rigor

Trustworthiness was established based on three principles set forth by Lincoln & Guba[15]: 1) Data triangulation of qualitative codes and COVID-19 practice survey data and prolonged engagement between participants and the research team corroborated findings; 2) Detailed operating procedures for data collection and analysis increased the dependability of findings; and 3) Two researchers confirmed all findings, interpretations, and recommendations. The consolidated criteria for reporting research (COREQ) checklist was used to assure reporting quality of these study findings.[16]

Respondents (n = 11) were primarily registered nurses (n = 8, 73%), with the majority employed in the acute care setting (n = 8,73%). Three respondents were male (27%) and five participants had advanced degrees (45%). Eight respondents were practicing in the same area they practiced prior to the pandemic (73%) with ten respondents reporting that their hours worked each week had remained the same or increased since the start of the pandemic (91%).

Thematic analysis of the qualitative data yielded three major themes highlighting the continued challenges healthcare providers faced during the second year of the pandemic. Themes included: 1) Exhausted and emotionally numb; 2) The dichotomy between the vaccinated and the unvaccinated; and 3) Shifting stressors and misguided supports.

Exhausted and Emotionally Numb

As the pandemic lingered into its second year and COVID-19- related fatigue persisted, HCPs in our study described feeling emotionally numb. Our previous research highlighted the fear of the unknown during the early pandemic as COVID-19 ran rampant among healthcare facilities, adding insurmountable stress to infrastructure, systems, and HCPs alike. Information about the disease was sparse and changed rapidly, leaving most HCPs fearful of getting sick or transmitting the virus to their patients or loved ones. In follow up interviews, HCPs in this study described a series of shifts in how they navigated and perceived the pandemic over time. These ongoing shifts left participants feeling exhausted as they struggled to stay informed of guidelines, recommendations and protective measures to keep themselves and their patients safe. This exhaustion led to feelings of numbness as viral mutations continued to wreak havoc on people attempting to return to life before COVID-19. One participant said,

We've limited our restaurants and bars and stuff like that. In the grocery stores, I'm wearing a mask. I've always kept hand sanitizer in my car, so that hasn't changed for me. In the summertime I felt more free. When we would go out, it would be to open air restaurants, and we weren't inside very often. So, I was truly living my best life. I have to trust the vaccine…but I also have to be aware that I can still catch it and pass it on.

While some HCPs described COVID-19 assimilation into daily life and how they felt less concerned about contracting COVID-19, several continued to worry about older patients and/or the unvaccinated. Participants shared insight into similar shifts in daily living as people "got on with the business of living". But as restrictions lessened, cases increased again, leaving HCPs feeling weary and numb as there appeared to be no end to the COVID-19 pandemic in sight.

The joy has pretty much gone out of my job. You don't know what the future's going to hold, especially after all this. So, I don't really want to spend my whole life working, but now it's like, what can I do to get out early, as early as possible?

These sentiments were not restricted to feelings about healthcare and the workplace. As the pandemic continued, HCPs expressed concerns about the long-term effects of the pandemic on their families and society in general. A participant with a young child shared,

I worry more about more of the psychosocial issues that are coming along with it than anything else. Like, I never thought I would have to wear a mask and now we're practicing wearing a mask with my daughter during the pandemic. So, I think I worry more about that kind of stuff now as well as the long term divides it's causing in our communities more.

Several participants reported increased dissatisfaction with hospital leadership related to COVID-19 policies, which led to exhaustion and an increased sense of helplessness. One participant said, “Overall I think we're exhausted; I think there is some dissatisfaction. People check the job postings every week looking for something, some kind of alternative”. As hospitals grappled with staffing shortages, nurse to patient ratios increased, leading some participants in our study to seek employment elsewhere due to concerns about safety. One nurse, who moved to a different hospital, described how an enhanced sense of security in her new position restored her overall job satisfaction:

I’m so much more secure as a new nurse [at my new hospital] having people who actually know what they're doing. I can't get any more than two ICU patients and COPD patients are one to one. Here you're actually trained to do dialysis and you only can have one dialysis patient and that's Union mandated. My manager is much more accessible, he's honest with us…so I’m much happier.

The Dichotomy Between the Vaccinated and the Unvaccinated

Vaccine availability proved to be a turning point for HCPs. As the vaccine uptake increased, concerns about contracting and transmitting COVID-19 to loved ones and patients decreased among HCPs. One participant shared, “before I used to just be so afraid about bringing it home to my family and spreading it to other people, and I think now obviously being vaccinated helps with that, knowing that it doesn't transmit via contact”. Other HCPs highlighted how overall levels of vaccinations in the community provide better protection against contracting COVID-19.

I guess I'm less worried because I think it helps that I'm in Chicago, which is very well vaccinated so…maybe 10% of our patients, at most, right now are COVID patients. I think I'm really benefiting from that, in terms of my fears; that this community is so well vaccinated for the most part, that we're not getting that surge again.

Despite the availability of a vaccine and advances in disease management, patients continued to present with significant sequelae from COVID-19. Providing care for unvaccinated patients led to increased feelings of distress and decreased quality of life as nurses attempted to balance their personal and professional beliefs and maintain their relationships with patients and their families.

A lot of us are struggling. You know, there's no way to really help them and we don't really know what works. What works for one person, isn't working for another person. And we try everything to keep them off the ventilator because once they get on the ventilator, that's pretty much it.

HCPs in our study were frustrated and concerned as they witnessed the impacts of vaccine hesitation and reluctance in the public in the workplace. In initial interviews with participants at the beginning of the pandemic, HCPs were optimistic and hopeful about the potential effects of a vaccine. In follow up interviews, however, HCPs were angry that so many people chose not to be vaccinated. One participant said, “you know, we thought the vaccine would be our life saver and unfortunately it's not been”. Participants indicated that conflicting information about vaccine credibility–especially when spread through political debate, technological, and social media platforms–had a negative impact on the general public’s willingness to vaccinate. These feelings of conflict left participants frustrated as they cared for patients who refused vaccination and subsequently required hospitalization.

…the vaccine changed everything. The suffering that could have been prevented has not been. We've had unvaccinated (patients) come in and they're a whole new can of worms. They're exhausting on every level; the families still don't believe in the science of that (the vaccine) and they come in and demand ivermectin."

Lack of effective treatment modalities led HCPs to become increasingly frustrated with patients and families who refused to comply with vaccine mandates, which many felt were the only true way to find a cure for COVID-19. When discussing experiences caring for patients during this time, one participant shared,

I think the patient got good care, but there were honest things said, like ‘if this guy makes it, like it's going to be very hard and will just fuel his fire’. He didn't make it and there was such a huge amount of …moral distress. As a nurse, I don't wish harm on people. These are awful, awful things to be confronting about myself.

Shifting Stressors and Misguided Supports

Findings from our initial study revealed concerns that leaders were out of touch with the struggles faced by HCPs caring for patients on the front-line amidst an evolving pandemic. These same concerns persisted in our current study. In both studies, participants stressed the importance of authentic leadership; however, HCPs in our current study described a shift in workplace stressors. While vaccine mandates were largely supported by HCPs in this study, some remained concerned about colleagues and vaccine refusal. One participant stated,

My facility has a vaccine mandate and we only lost one nurse…if you don't believe in the science then there's another spot for you. We're not giving exceptions to anybody, and I would have been very hurt had they made exceptions.

Many described how hospital leadership worked to support HCPs who were continuing to toil at the bedside, but still harbored feelings that these efforts lacked authenticity and transparency. One participant (a physician) said,

If they had proper staffing and administration and at least said, here's the game plan. Here's why we can't do it that way. Like we are just not taking in enough money to even do this. We really want to keep all of you employed, but if we wanna do this, we're gonna have to fire a couple people. I think if we knew the situation outside of our departments…we would all tolerate it a lot more.

There was a sense of laissez faire leadership as some hospital systems moved towards contract (travel) nursing as a solution to address ongoing staffing crises. While help from contract nurses was appreciated, many hired HCPs felt the sting of earning lower wages when compared to their contracted colleagues. One participant has even thought of pursuing contract work, “I'm considering doing travel nursing, because a lot of my coworkers are making [an] insane amount of money doing that…”.

Several HCPs shared concern over a potential “mass exodus” of colleagues and reported “a trickle loss of nurses and now it's a complete hemorrhage.” This potential nursing shortage, related to deteriorating conditions at the bedside and concerns about hospital leadership led to concerns about who will fill the gap. One participant noted,

The nursing shortage is coming because those of us who are in it were seasoned and we're way closer to leaving than we were. I don't see the great candidates coming up behind us, who are going to have the longevity that we have had. I think there's a lot less commitment to staying at the bedside.

While open positions could be filled by the graduate nurse workforce, participants feared that the void of experienced nurses would leave them unprepared to care for patients in the post-pandemic world. One participant, a nursing instructor, said, “...we are really doing them a disservice, I think ethically, morally, we're putting them out there, not ready. They're not ready, not only for nursing, but nursing how it is right now.”

Nurses and other HCPs reported ongoing distress and negative impacts on caregiving during the COVID-19 pandemic despite vaccine availability and changes in disease trajectory. Current concerns about HCP burnout, persistent lack of support from administration, and a potential mass exodus of HCPs from the bedside were key factors in HCPs overall morale and job satisfaction. These findings are consistent with increased reports of psychological distress and burnout among HCPs since the onset of COVID-19.[17–19] Our initial studies indicated concern about leadership being out of touch with the realities of bedside care during the pandemic as HCPs feared for their safety at the bedside.[8, 9] Follow up interviews from this study revealed that this fear has evolved into concern for the future of healthcare. Although the fear of contracting and spreading COVID-19 diminished, vaccine refusal, negative media coverage, and continued distrust from the public has led to exhaustion among HCP participants. Participants reported challenges finding the "joy" in work in the face of rising COVID-19 cases and concerns about leadership that were compounded by necessary reliance on contract nurses. The duration of the pandemic has led to sustained frustration, feelings of burnout, and decreased quality of life among HCP participants.

Despite improvements in the management of COVID-19 patients, HCPs continued to struggle to deliver care in the absence of a cure. Many participants spoke of an underprepared graduate nursing workforce due to impacts from the COVID-19 pandemic. Nursing students who graduated during the pandemic often had abbreviated or virtual clinical training as opposed to on-site, which limited opportunity to provide supervised patient care in real-time clinical training environments.[20, 21] Instead, graduate nurses were caring for their first patients in the height of a pandemic with limited support and resources.[22, 23] Like their experienced peers, graduate nurses were at risk for the same feelings of despair, uncertainty, and MD. Yet they also reaped the opportunity of rich learning opportunities and a wealth of employment possibilities that may not have been available before the pandemic.[24]

The hope that the vaccine would "fix" everything diminished as wave after wave of increased COVID-19 cases impacted patient care. Our initial studies indicated that HCPs were concerned about misinformation and the political climate.[8, 9] In this study, HCP participants described profound effects from adverse, divisive political climates and persistent misinformation, both of which have eroded the public's trust in healthcare. Participants reported feeling significant distress that is compounded by moral and ethical dilemmas, especially when caring for patients who are not vaccinated.

Although ethical dilemmas have been reported in other studies of HCPs in the COVID-19 era[25–27], the persistent dichotomy between vaccinated and unvaccinated people described in our study introduces a new, less explored concept of HCPs who chose to vaccinate caring for patients who chose not to. Current evidence describes HCPs as more likely than the general population to vaccinate against COVID-19[28], which held true among the majority of HCPs in our study having received at least one dose of the COVID vaccine at the time of interview. There is still hesitancy among some HCPs to vaccinate.[28–30] Participants shared stories of their juxtaposed feelings of relief by being protected and concern for their unprotected patients. These HCPs embraced their duty to provide empathetic, individualized, person-centered care to diverse communities that included people who were “vaccine hesitant”, “vaccine resistant” and “anit-vax”.[31, 32] Yet, they needed to appreciate and understand these different points of view to establish and maintain a trusting relationship with each patient.[32] HCPs in our study often described visceral-type reactions to “vaccine hesitant”, “vaccine resistant” and “anti-vax” points of view that arose from wanting to correct misinformation and help convince their patients to seek vaccination out of concern for their health and wellbeing.[1] Shifting their reaction to one that was more empathetic in order to maintain open communication and a trusting relationship with their patients may have contributed to their moral conflict/distress.[33]

As the COVID-19 pandemic continued to evolve until its end in May 2023, so did the availability of information and resources. The sample size for this study was limited; therefore, the themes and conclusions from this study may not be readily transferable. Additionally, data were collected during the third wave of the pandemic, when HCPs were once again working at peak capacity. While eager to share their stories, participants were emotionally and mentally exhausted. Research describing residual impacts of the 2020–2023 COVID-19 pandemic is needed to fully appreciate the challenges faced by HCPs during this time.

Implications for Policy and Practice

Despite Gallup poll reports of nursing as the most trusted profession, HCPs in our study sensed a shift in this honorable standing since the onset of the pandemic. Some of this shift may be the product of misinformation that shaped the media and political environment and is difficult to eradicate. Concerns about a looming nursing shortage may not be unfounded, and nurse leaders should take proactive steps to support staff on the front lines. Staffing resources were an ongoing pain point among our sample, and nurse leaders can advocate for adequate compensation packages to attract and maintain staff. Hospitals and schools of nursing can collaborate to ensure adequate preparation of the next generation of nurses. More importantly, nurse leaders can advocate for health policies and programs in the workplace that support health and overall wellbeing for the HCP workforce.

The COVID-19 pandemic had unique impacts among our sample of HCPs. Feelings of uncertainty should be anticipated during the initial onset of any pandemic and when changes arise. Unlike other diseases with more predictable trajectories, COVID-19 changed constantly for the duration of the pandemic. HCPs in our study consistently shared their struggles to make sense of the healthcare environment throughout the pandemic, affirming the idea of a career divided by a COVID-19. Strategies that help mitigate the ongoing impacts from the media and politics and staffing shortages are critical to reduce burnout, increase job satisfaction, and promote quality of life among the HCP workforce.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Competing Interests

The authors have no competing interests relevant to this article's content.

Author Contribution

M.N.: conceptualization (lead); investigation (lead); formal analysis (equal); writing – original draft preparation (equal); writing – review and editing (equal). L. D.: formal analysis (equal); writing – original draft preparation (equal); writing – review and editing (equal).

Data Availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Table 1 is available in the Supplementary Files section.

No competing interests reported.

Table1.docx

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Healthcare Providers and the Lingering Influence of the COVID-19 Pandemic

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Abstract

Purpose

Methods

Results

Conclusion

Introduction

Methods

Study Design

Participants and Sampling

Data Collection

Data Analysis

Ethical Considerations

Rigor

Findings

Exhausted and Emotionally Numb

The Dichotomy Between the Vaccinated and the Unvaccinated

Shifting Stressors and Misguided Supports

Discussion

Implications for Policy and Practice

Conclusion

Declarations

Funding

Author Contribution

Data Availability

References

Table 1

Additional Declarations

Supplementary Files

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