Article Text
PDF
Abstract
Objective To describe the drivers of distress and motivations faced by interdisciplinary clinicians who were on the frontline caring for patients with COVID-19.
Design 50 semistructured interviews. Transcripts were analysed using qualitative thematic analysis.
Setting A safety-net hospital in Denver, Colorado.
Participants Interdisciplinary frontline clinicians including physicians, advance practice providers, nurses, respiratory therapists and paramedics providing inpatient hospital care to patients hospitalised for COVID-19.
Results Fifty clinicians (32 women and 18 men) participated. Five themes with respective subthemes (in parentheses) were identified: depersonalisation and barriers to care (impeding rapport and compassion, focusing on infection risk at the expense of high-quality care, grief from witnessing patients suffer in isolation), powerless in uncertainty (inescapable awareness of personal risk, therapeutic doubt in a void of evidence, confronting ethical dilemmas, struggling with dynamic and unfamiliar challenges), overwhelmed and exhausted (burden of personal protective equipment (PPE), information overload and confusion, overstretched by additional responsibilities at work, compounded by personal life stressors, feeling vulnerable and dispensable, compassion fatigue, distress from the disproportionate impact on socially oppressed communities), bolstering morale and confidence (motivated by community and family support, equipped with data), and driven by moral duty (responsibility to patient care and community, collegial solidarity and collaboration, contributing to the greater good).
Conclusion Frontline clinicians reported distress due to the challenges of PPE, uncertainty and powerlessness, new responsibilities at work and home, losing control of their schedules, grief from witnessing patients suffer in isolation and witnessing healthcare disparities exacerbated by this pandemic. Clinicians feel supported by their colleagues, families, and community and were driven by a sense of moral duty. Healthcare system should adopt strategies to minimise distress faced by interdisciplinary clinicians on the frontline of COVID-19.
- COVID-19
- health policy
- adult intensive & critical care
- qualitative research
- accident & emergency medicine
Data availability statement
Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplemental information. The relevant data including relevant quotations are contained within the manuscript file. Raw data (full transcriptions of interviews) are stored on an encrypted, secure hospital network and can be reproduced upon request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
- COVID-19
- health policy
- adult intensive & critical care
- qualitative research
- accident & emergency medicine
Strengths and limitations of this study
This study explored the perspectives of a diverse group of interdisciplinary clinicians including physicians, advance practice providers, nurses, paramedics and respiratory therapists working in a variety of hospital settings including the emergency department, medical/surgical floor and intensive care unit.
This study generated comprehensive and detailed insights because interviews were conducted until data saturation.
This study assessed the perspectives of clinicians only; future studies may assess the perspectives of environmental staff and food services as they also interfaced with patients hospitalised for COVID-19.
This study included a small sample size and interdisciplinary clinicians were recruited from one safety-net centre.
Transferability of these findings to other hospital settings is uncertain given the unique safety-net patient population, culture and resources available.
Introduction
The COVID-19 pandemic has presented unprecedented challenges for the healthcare system. In anticipation of this crisis, healthcare facilities focused on procurement of testing supplies and personal protective equipment (PPE), creating treatment algorithms, ethical resource allocation guidelines, and expanding bed capacity and staffing among other logistics to keep patients and clinicians safe.1–4 Despite these efforts to protect clinicians, this pandemic has taken a significant toll on the physical, emotional and mental health of frontline clinicians.2 5–10 Given epidemic levels of burnout prior to this pandemic and reports of suicides among frontline clinicians in New York City, it has become increasingly important to understand the driver of clinician distress through this pandemic.11–13
While it is clear that frontline responders to public health emergencies are particularly vulnerable to experiencing acute psychological distress, the underlying drivers of distress can be unique in different populations, cultures, clinical settings and with variable extent of impact and time course.14 During the SARS pandemic, clinicians experienced distress related to uncertainty and fear of the unknown, stigmatisation from becoming infected, social isolation and conflicting moral obligations to treat patients yet keep their families safe.15–17 For some clinicians, this led to long-term mental health problems and burnout.18–20 The COVID-19 pandemic is unique due to its unpredictable course and widespread global impact.21 Frontline clinicians across the world have experienced similar challenges with supply constraints, staffing shortages and risk of infection.22
Despite cultural, political and case rate variances, studies have found high rates of psychological symptoms among clinicians during this pandemic.23–28 However, there are limited qualitative data describing the drivers of distress.29–37 The aim of this study was to describe the drivers of distress and motivation with the goals of informing local and national strategies to reduce avoidable distress in interdisciplinary clinicians on the frontline of COVID-19.
Methods
Study design
Fifty semistructured interviews were conducted with frontline clinicians. All study participants provided informed verbal consent and received financial compensation. Participants were assigned a study identification number and were informed all information provided would remain confidential.
Patient and public involvement
It was not appropriate or possible to involve patients or the public in the design of this research.
Setting and participants
Eligible participants included interdisciplinary frontline clinicians including physicians, advance practice providers, nurses, and paramedics who participated in the care of suspected or confirmed COVID-19-positive patients at Denver Health, a safety-net hospital. Participants were recruited by a standardised, institutional review board-approved email sent by the study principal investigator. The first participants to respond were included and scheduled for interviews. Purposive sampling was used to capture a diverse sample in terms of demographics (sex, age) and clinical discipline. We capped participants within each clinical category to ensure a balanced proportion of clinician training backgrounds and departments.
Data collection
Semistructured interviews were conducted using a telephone or video-conferencing platform from 22 April to 8 July 2020 by authors HR, DM and LC until data saturation. LC has conducted and published qualitative research and has lectured in qualitative methodology. HR and DM completed training in qualitative research analysis and were mentored by LC. All three of these authors are internal medicine-trained physicians who participated in the frontline of caring for patients hospitalised with COVID-19. The interview guide was based on the literature and discussion among the research team (online supplemental table 1).7–10 15–19 Interviews were recorded and transcribed verbatim.
Supplemental material
Data analysis
Using thematic analysis, authors HR, DM, AT and LC read the transcripts and inductively identified initial concepts. Author AT grouped similar concepts into themes and subthemes and coded the data using HyperRESEARCH software (V.4.1.1; ResearchWare, Randolph, Massachusetts, USA). Authors HR and LC reviewed and discussed the coding and themes to make sure that the findings reflected the full range and depth of the data.
Results
The 50 participants included 22 physicians, 18 registered nurses, 4 nationally registered paramedics, 2 respiratory therapists and 4 advance practice providers (two nurse practitioners, one physician assistant and one certified registered nurse anaesthetist), and 1 emergency medical technician. There were 32 (64%) women, 32 (64%) were married and 28 (56%) had children. Twenty-seven (54%) lived with frontline clinicians (table 1). The duration of the interviews ranged from 28 to 92 min.
Patient characteristics (N=50)
We identified five themes: depersonalisation and barriers to care; powerlessness in uncertainty; physical, emotional and mental exhaustion; bolstering morale and confidence; and driven by moral duty. The subthemes are described below with supporting quotations provided in table 2.
Selected supporting quotations
Depersonalisation and barriers to care
Impeding rapport and compassion
The need to use PPE made it difficult for participants to ‘connect with’ and establish trust with patients because they could not communicate properly and were unable to ‘convey emotion’. The PPE stripped away a core dimension of patient care by taking ‘a lot out of the human experience.’ Some felt that it was ‘like a zoo’ because they would ‘look through a glass window and talk about a human being without them being involved.’
Focusing on infection risk at the expense of high-quality care
To minimise exposure, participants spent less time in patient rooms and assessed patients over the phone. Clinicians acknowledged that this was a ‘necessary evil’, which limited their ability to provide high-quality care. Except for in-person physical examination at the time of admission and discharge, clinicians assessed their patients over the phone only: ‘The hardest part is just having very little to offer out of what I would have considered my strongest toolkit.’ Some also questioned if they ‘missed something’.
Grief from witnessing patients suffer in isolation
Due to isolation policies, patients were unable to have visitors. Participants felt ‘indescribable’ grief because they could do little to alleviate the terror and loneliness patients suffered. ‘The family can’t be there; it adds to the sadness of the situation where there’s so much isolation… Patients are isolated from pretty much all support systems.’ It was also emotionally difficult helping patients communicate with their family—‘I had her FaceTime her sister so she could see the baby that she’d never held…I don’t cry, that’s as close as it gets.’ COVID-19 was also considered by some to be ‘the worst possible way that someone could die because you’re surrounded by air, you cannot breathe.’
Powerless in uncertainty
Inescapable awareness of personal risk
Initial concerns about infection dissipated with confidence in PPE. However, this ‘air of invincibility was easily shattered’ as more clinicians became sick and cared for patients who were fit or close to their own age—it’s ‘scary, because when you look at them, you see your own family members and the potential for the people that you care about in your own life’ to suffer the same fate. They were constantly processing ‘terrifying’ and ‘existential questions’ that intensified distress. Participants who contracted COVID-19 worried about their own health and their loved ones.
Therapeutic doubt in a void of evidence
Participants were challenged by uncertainty and guilt stemming from the lack of data to inform prognostication and therapies. Many felt ‘powerless’ and humbled by the unpredictability of the disease. Some felt like trainees again, ‘where everything is new and you think you know what you’re doing but you’re unsure and have self-doubt.’ They accepted that managing COVID-19 was ‘a lot of trial and error.’ Participants worried about medications that ‘weren’t proven’ and ‘that some people ended up on the ventilator that maybe wouldn’t have needed to.’
Confronting ethical dilemmas
Preparing for decisions about rationing resources was ‘incredibly stressful.’ It was horrifying to consider bearing the responsibility of ‘condemning a person to die’ and the possibility of having to ‘sacrifice a few for the greater good.’ Conversations around goals of care were challenging without family members at the bedside; ‘it’s just hard to really understand what your loved one is going through.’ Many clinicians discussed goals of care at the time of admission for all patients regardless of age or comorbidities.
Struggling with dynamic and unfamiliar challenges
Frequent changes in policies, guidelines and conflicting information created a challenging and chaotic environment. They described how ‘every day was a new day. You really had no idea what was happening.’ Participants worked in new settings and felt constant anxiety being outside their ‘comfort zone.’ The uncertain course of the pandemic was challenging as they lost control over their schedules, cancelled vacations and accepted that they ‘might be in this for the long haul.’
Overwhelmed and exhausted
Burden of PPE
Wearing PPE was exhausting. It was ‘difficult to breathe,’ ‘hot and uncomfortable’, and slowed their ability to enter rooms and respond to patient requests for food, water or to use the bathroom. The process of wearing PPE and remembering each step added a new ‘cognitive load’. The ‘hyperawareness’ of risk added stress—‘it’s led to me feeling like I made some silly mistakes, because I had energy devoted to what my hands just did, “did I just use them to touch my face?”’ In making decisions about orderings tests (eg, imaging or labs), they considered if they would be exposing their colleagues. Some were worried about using the same masks all day—‘it says on the box “one-time use”.’
Information overload and confusion
Some participants felt inundated by information—‘it’s like drinking out of a fire hydrant.’ They had ‘informational burnout’ and had difficulty processing new information as it was often changing or conflicting. Even outside of work, information about the pandemic was constantly on the news, social media and in conversations with friends—it was ‘exhausting’.
Overstretched by additional responsibilities at work
Participants took on many new tasks such as coordinating internal communications, creating and managing databases, and following up on discharged patients. Many worked additional shifts—‘two more weeks of work crammed into four weeks of work.’
Compounded by personal life stressors
Participants were concerned about infecting their family and considered whether to isolate from their families. Participants with children had new, time-consuming challenges at home including homeschooling and coordinating childcare. Many felt ‘worn out’ by these responsibilities—‘trying to stay normal, to be the mother and the wife… because they [children] don’t deserve to get less of me because of what’s happening.’
Feeling vulnerable and dispensable
As participants coped with the stress of additional shifts, responsibilities and risk, some began to feel ‘vulnerable’. Some participants felt well supported by their leaders, but others felt a disconnect between clinical and administrative leadership. They felt leaders needed to be more present—‘I think it would be eye opening for them to have to come in and see’ the unique challenges of providing care in PPE. Some were concerned about the burden of mandatory extra shifts and lack of ‘hazard pay’. Hearing about a ‘hiring freeze’ and seeing colleagues lose their jobs made them feel expendable.
Compassion fatigue
As the pandemic progressed, clinicians began feeling emotionally overwhelmed and started developing ‘compassion fatigue’. The grief of caring for patients with COVID-19 was further amplified by what some clinicians felt was the psychological impact of quarantine on the community. They described seeing higher rates of patients presenting due to domestic violence, depression and suicides. Over time, clinicians began to feel emotionally exhausted and described symptoms of burnout—‘my patience is less. My empathy is less.’
Distress from the disproportionate impact on vulnerable communities
The injustice of COVID-19 was traumatic. Witnessing the disproportionate impact of the pandemic on racial and ethnic minorities as well as other vulnerable communities was devastating. It was ‘heartbreaking’ to see multiple members of the same minority family hospitalised and critically ill simultaneously. Many expressed immense grief witnessing the impact on communities that may not have the privilege to isolate, ‘they were probably essential workers, or needing to work, or they were living in homes with multi-generational’ families. They noticed ‘a huge disparity between the rich and the poor.’
Bolstering morale and confidence
Motivated by community and family support
Participants appreciated the ‘outpouring of love and support’ from the community who contributed food and donated PPE. They also relied on support from their families.
Equipped with data
Information could ‘reduce stress and anxiety’ as it provided a ‘picture of where the hospital’s standing.’ Communicating ‘big wins’ such as the number of extubations and discharges inspired optimism. Executives provided transparency around PPE supplies, plans for procurement and curated information from clinical trials. This helped many feel safe and informed. They appreciated clinical updates as they did not have ‘time or bandwidth to search through articles.’
Driven by moral duty
Responsibility to patient care and community
Participants were committed to fulfilling their fundamental responsibility of treating patients who ‘deserve good care’. They held a ‘high level of social justice and responsibility’ and strove to care for the ‘underserved and impoverished’ patients who presented with COVID-19.
Collegial solidarity and collaboration
Participants felt ‘unified around a common goal or a kind of common enemy (SARS-CoV-2)’ and were encouraged by ‘interdisciplinary collaboration’ and ‘sharing of knowledge’. They were ‘in it together’ and needed to ‘have each other’s back’, particularly given the additional staffing required to manage the crisis: ‘We lean on each other, we support each other, we expect each other to be there.’
Contributing to the greater good
Some believed it was their ‘responsibility’ to contribute to the greater good and to be a ‘good and positive force’. They felt stimulated to understand a novel disease and use their training and skills to ‘contribute new knowledge’ in managing patients with COVID-19 and to be ‘part of the solution’.
Discussion
In this study, we report distress and motivations of interdisciplinary clinicians who provided care to hospitalised patients with COVID-19. Clinicians at the frontline of COVID-19 experienced distress from the emotional and physical burden of PPE, increased responsibilities at work and home, witnessing patients dying in isolation and the exacerbation of systemic healthcare disparities. Clinicians also reported feeling fear, guilt and powerlessness stemming from the many uncertainties of this pandemic. Many clinicians described how these emotions progressed to compassion fatigue, vulnerability and exhaustion reflected in the qualitative themes. These findings are consistent with high rates of distress described in quantitative studies during the current pandemic. Clinicians’ fears related to risk of infection, uncertainties of the disease and feelings of exhaustion, as well as being driven by a sense of duty and solidarity, are consistent with studies from the SARS pandemic and qualitative data describing experiences of clinicians in Europe and China during the early stage of this pandemic. However, many clinicians described how the emotional challenges of caring for patients with PPE and hospital isolation policies were compounded by the grief of witnessing an exacerbation of systemic healthcare disparities, which has become more apparent in the COVID-19 pandemic.
Increasing workload and loss of a sense of control have been described as powerful contributors to distress that may lead to burnout.38 39 We identified many facets of uncertainty in the context of COVID-19 including being unable to prognosticate the course of the illness, lack of evidence and therapeutics leading to clinical decisional uncertainty, rapidly changing guidelines and policies, unclear risk of infection, the unknown duration and severity of the pandemic, and a loss of control to their schedules. Clinicians were also distressed by feeling helpless and distressed from witnessing patients suffering in isolation. While clinicians adapted to these uncertain circumstances, there is concern for maintaining this resiliency if long-term solutions around managing workload are not identified by leadership.
There is also concern of increased distress in clinicians who provide care to patients who face complex social challenges.40 41 Clinicians caring for patients with COVID-19 were dismayed and frustrated by how vulnerable groups such as impoverished, racial and ethnic minority communities had disproportionally higher rates of COVID-19 infection than the general population. While it is possible that this impact may be more noticeable in safety-net institutions, several studies have confirmed the increased prevalence and mortality associated with COVID-19 in Latino, black and ‘other’ ethnicities.42 Clinicians felt defeated because there were limited options for safe self-isolation in these communities due to crowded living conditions, use of public transportation and low-wage service jobs. They were frustrated by barriers that precluded in-person language interpreters owing to the limited availability of PPE and having to resort to telephone language interpreters compounding the difficulties of communicating while wearing PPE.
Higher rates of distress during the COVID-19 pandemic have been found among younger age groups, women and nurses (compared with physicians).5–10 This may be because young clinicians with children are burdened by increased responsibilities at work and home compounded by losing control and predictability of their work schedules. Nurses in our study encountered many logistical obstacles as they were required to work additional shifts and often spend more time at the bedside resulting in more time wearing PPE, higher risk of exposure and more time spent witnessing patients suffer in isolation.
Our study has key implications to prevent or minimise distress and risk of subsequent burnout in clinicians (table 3). There is an urgent need to address this, as burnout can lead to poor patient outcomes and will impair the ability of the healthcare system to respond to this crisis.43–46 We suggest that institutional leadership create clear structures for understanding and addressing concerns of frontline clinicians, communicate contingency staffing plans to manage workload and allow frontline clinicians to regain a sense of control of their schedules. Studies have also shown that it is important to support workers’ childcare needs during crisis situations.47 48 We recognise that clinicians may not engage in psychological services on their own accord, and therefore suggest that institutions offer proactive psychological counselling and establish peer-to-peer support mechanisms as these provide the most benefit.49–52 Finally, it is critical to address structural racism and healthcare disparities as this is an important driver of distress highlighted by this pandemic. This includes improving access to testing, equitable resource allocation, enhanced outreach programmes for minority communities, improved access to in-person translation services and cultural humility training for all staff.
Suggested interventions to support frontline clinicians
Limitations
Our study generated detailed insights on the experiences among frontline clinicians caring for patients with COVID-19. However, our study has some potential limitations. Clinicians were from one academic safety-net hospital in Colorado, thus the transferability of the findings to other settings is uncertain. Studies have shown variances in PPE use among different countries and cultures. Our findings of distress related to the burden of PPE use may not be consistent with clinician experiences in other cultures.53 As this study was performed at the early phase of the COVID-19 pandemic, it is also possible that clinician experiences have changed with anticipation of new therapies and the possibility of a vaccine.
Future research is needed to assess the effectiveness of strategies to screen for and reduce psychological distress. While it is clear that clinicians experiencing distress will benefit from multifaceted psychological support, ideal implementation strategies to engage and support clinicians are unclear.54 There is also limited knowledge of the effectiveness of online-based counselling which can be implemented more readily and has been used to support clinicians in China.22 55
Conclusion
Frontline clinicians caring for patients with COVID-19 experience distress related to challenges of PPE, clinical uncertainty and powerlessness, new responsibilities at work and home, losing control of their schedules, and grief from witnessing patients suffer in isolation and witnessing healthcare disparities exacerbated by this pandemic. Providers feel supported by their colleagues, families, and community and were driven by a sense of moral duty. Institutions should further support frontline clinicians by making efforts to understand and address their challenges, provide proactive mental health support and advocate vulnerable communities.
Data availability statement
Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplemental information. The relevant data including relevant quotations are contained within the manuscript file. Raw data (full transcriptions of interviews) are stored on an encrypted, secure hospital network and can be reproduced upon request.
Ethics statements
Ethics approval
This study was approved by the University of Colorado Multi-Institutional Review Board #20-0709.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors Authors HR, DM, AT and LC contributed to the conception, design, acquisition and interpretation of the data. Author HR drafted the work, while authors HR, DM, LC, AT and HK revised the work with critically important concepts. Authors HK, BSG and WM contributed to critically important data acquisition and interpretation. Authors AT and AC contributed to data analysis. Authors HR, DM, AT and LC contributed to the final approval of the version published and ensured that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.