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McCall RK, Al-Sinawi H, Al-Kharusi N, Al Rawahi S, Al Balushi R, Al-Lawati N, Rizzo M, Al-Rasadi K, Al Maniri A. Retrospective study on the emotional status of healthcare workers in a COVID-19 field hospital in Oman. Front Public Health 2024; 12:1339703. [PMID: 38835615 PMCID: PMC11149611 DOI: 10.3389/fpubh.2024.1339703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/30/2024] [Indexed: 06/06/2024] Open
Abstract
Overview To combat the overwhelming demand for medical services and care during the COVID-19 Pandemic, the Sultanate of Oman launched the COVID-19 Field Hospital in 2020, designed to respond and alleviate the burden on the medical infrastructure. Several studies globally and from the Middle East suggested that frontline healthcare workers (HCW) were at risk of developing markers of psychological distress. It was further understood through research findings that HCW were resilient during times of crisis. However, there is a dearth in studies evaluating the emotional status of frontline HCW posted in the COVID-19 field hospitals in Gulf Countries, including Oman. This study attempts to shed light on the emotional status of HCW that were on the frontlines in the field hospital in the Sultanate of Oman. Aim This study aims to quantify and evaluate the emotional status of HCW in the frontline field hospital by screening for symptoms of depression, anxiety, and sleep quality. Method The data was collected by a local private mental healthcare facility as part of digital feedback to design and implement supportive strategies. Data was collected between September 2021 and October 2021 from 121 HCW in the COVID-19 Field hospital in Oman via 'WhatsApp'. Results Chi square and binary logistic regression tests were administered to evaluate the data. The participants comprised of 63.6% females and 79.3% were between 30 and 39 years of age. Majority of the participants (65.2%) described themselves as 'financially unstable' and possess an average of 7.5 years of work experience. Of the participants 73.6% of the HCW were based solely in the field hospital for 6-9 months at the time of the survey. Majority of the participants denied the presence of emotional distress expressed through depression (92.6%), anxiety (92.6%) and poor quality of sleep (59.5%). Conclusion The findings of the present study reflect the HCW ability to cope during challenging situations likely owing to a variety of environmental, social and personal protective factors. The findings of this study can translate into further research on identifying and addressing stressors and targeting the enhancement of protective factors to safeguard the well-being of HCW.
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Affiliation(s)
| | - Hamed Al-Sinawi
- Al Harub Medical Center, Muscat, Oman
- Department of Behavioral Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Sulaiman Al Rawahi
- PDO Clinic, Corporate Health & Safety, MSEM, Petroleum Development of Oman, Muscat, Oman
| | | | | | - Manfredi Rizzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (Promise), University of Palermo, Palermo, Italy
| | - Khalid Al-Rasadi
- Department of Biochemistry, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
- Medical Research Centre, Sultan Qaboos University, Muscat, Oman
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Ambrose JW, Catchpole K, Evans HL, Nemeth LS, Layne DM, Nichols M. Healthcare team resilience during COVID-19: a qualitative study. BMC Health Serv Res 2024; 24:459. [PMID: 38609968 PMCID: PMC11010334 DOI: 10.1186/s12913-024-10895-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Resilience, in the field of Resilience Engineering, has been identified as the ability to maintain the safety and the performance of healthcare systems and is aligned with the resilience potentials of anticipation, monitoring, adaptation, and learning. In early 2020, the COVID-19 pandemic challenged the resilience of US healthcare systems due to the lack of equipment, supply interruptions, and a shortage of personnel. The purpose of this qualitative research was to describe resilience in the healthcare team during the COVID-19 pandemic with the healthcare team situated as a cognizant, singular source of knowledge and defined by its collective identity, purpose, competence, and actions, versus the resilience of an individual or an organization. METHODS We developed a descriptive model which considered the healthcare team as a unified cognizant entity within a system designed for safe patient care. This model combined elements from the Patient Systems Engineering Initiative for Patient Safety (SEIPS) and the Advanced Team Decision Making (ADTM) models. Using a qualitative descriptive design and guided by our adapted model, we conducted individual interviews with healthcare team members across the United States. Data were analyzed using thematic analysis and extracted codes were organized within the adapted model framework. RESULTS Five themes were identified from the interviews with acute care professionals across the US (N = 22): teamwork in a pressure cooker, consistent with working in a high stress environment; healthcare team cohesion, applying past lessons to present challenges, congruent with transferring past skills to current situations; knowledge gaps, and altruistic behaviors, aligned with sense of duty and personal responsibility to the team. Participants' described how their ability to adapt to their environment was negatively impacted by uncertainty, inconsistent communication of information, and emotions of anxiety, fear, frustration, and stress. Cohesion with co-workers, transferability of skills, and altruistic behavior enhanced healthcare team performance. CONCLUSION Working within the extreme unprecedented circumstances of COVID-19 affected the ability of the healthcare team to anticipate and adapt to the rapidly changing environment. Both team cohesion and altruistic behavior promoted resilience. Our research contributes to a growing understanding of the importance of resilience in the healthcare team. And provides a bridge between individual and organizational resilience.
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Affiliation(s)
- John W Ambrose
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA.
| | - Ken Catchpole
- Department of Anesthesia and Perioperative Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Heather L Evans
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Lynne S Nemeth
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Diana M Layne
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Michelle Nichols
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
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Eichenberg C, Schneider R, Auvera P, Aranyi G, Huber K. Risk and protection factors of mental stress among medical staff in the third year of the COVID-19 pandemic. Front Psychiatry 2024; 15:1334552. [PMID: 38585477 PMCID: PMC10995372 DOI: 10.3389/fpsyt.2024.1334552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/04/2024] [Indexed: 04/09/2024] Open
Abstract
Background The COVID-19 pandemic placed an extraordinary burden on health care workers (HCW), who are reported to suffer from great mental stress. The current study investigates the mental health of HCW in the later phases of the pandemic. Methods HCW completed the following questionnaires online (06/2021-02/2022, N=159): demographics (age, gender, profession, ward), Impact of Event Scale (IES-R, posttraumatic stress), State Trait Anxiety Inventory (STAI-S, state anxiety), stress-coping questionnaire (SVF-78), and bespoke corona-specific stress and protective-factor questions (5 items each). We used factor analysis to test scale properties and regression-type methods (t-tests, ANOVA, multiple regression) for hypothesis tests and effect-size estimation. Results/discussion Mental stress in HCW is influenced by similar factors as described for earlier phases. However, differences to earlier phases were found in ward affiliation which is no longer a variable of concern for explaining differences in mental health of HCW. Further, even if nurses are the occupational group with the highest mental stress as in prior research, detailed analysis shows that medical specialists with close proximity to patients with a high-level of responsibility are the most burdened sub-group. Unlike nurses, they suffer from high levels of anxiety in addition to high levels of post-traumatic and COVID-specific stress. Analyses showed further that COVID-specific stress is the strongest predictor of mental stress, wherein COVID-specific stress factors remain the same as reported in literature on the early pandemic phases. HCW showed to use still more positive than negative coping strategies. Negative strategies increased as expected mental stress, whereas positive strategies alleviated only anxiety. Additionally, we found that doctors benefited from many protective factors while nurses had access to fewer protective factors like earlier waves. Conclusion Data show that HCW still suffer from mental stress in the third year of the pandemic. HCW of all hospital wards may be affected by mental stress and need attention and protective measures. Medical specialists are the most burdened subgroup. Detailed analyses show that properties other than occupation, gender, or ward affiliation are more appropriate to evaluate mental stress of HCW. The findings have implications for developing specialized protection strategies for the post-pandemic phase and future pandemics.
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Affiliation(s)
- Christiane Eichenberg
- Faculty of Medicine, Institute of Psychosomatics, Sigmund Freud Private University, Vienna, Austria
| | - Raphaela Schneider
- Faculty of Medicine, Institute of Psychosomatics, Sigmund Freud Private University, Vienna, Austria
| | - Phillip Auvera
- Sigmund Freud Private University, Medical Faculty, Vienna, Austria
| | - Gabor Aranyi
- Faculty of Psychotherapy Science, Sigmund Freud Private University, Vienna, Austria
- Institute of Education and Psychology at Szombathely, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Kurt Huber
- Sigmund Freud Private University, Medical Faculty, Vienna, Austria
- 3rd Dept. of Medicine, Cardiology and Internal Intensive Care Medicine, Clinic Ottakring (former Wilhelminenhospital), Vienna, Austria
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Katz C, Jacobson M, Priolo Filho SR, Goldfarb D, Liu J, Zibetti MR, Varela N, Attrash Najjar A, Bérubé A, Collin-Vézina D, Maguire-Jack K, Massarweh N, Munir A, Tiwari A, Wekerle C. Examining resilience among child protection professionals during COVID-19: A global comparison across 57 countries. CHILD ABUSE & NEGLECT 2024:106659. [PMID: 38326165 DOI: 10.1016/j.chiabu.2024.106659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 12/03/2023] [Accepted: 01/18/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND The COVID-19 pandemic led to numerous challenges for child protection professionals (CPPs). However, limited research has investigated the interwoven concepts of coping, resilience, and mental distress among CPPs during COVID-19 on a global scale. OBJECTIVES This study aimed to explore CPPs' practice, resilience, and mental distress during COVID-19, the relationship between their resilience and mental distress, the global stability of the Multi-System Model of Resilience (MSMR), and how CPPs' resilience varied according to the Human Development Index (HDI). METHODS Data were collected from 420 CPPs in 57 countries across five continents between July and September 2021. Participants completed an online questionnaire on demographics, resilience, mental distress, coping, and perceptions of child protection during the pandemic in their native languages. The analyses compared the countries grouped according to HDI using means comparisons, correlations, and multiple linear regressions. A two-path analysis was also performed to identify variables associated with behavioral resilience engagement and mental distress. RESULTS The findings indicated that CPPs' perceptions of COVID-19's impact on child maltreatment varied in correlation with their country's HDI. There were also significant HDI-based differences regarding the perceived opportunity to engage in resilient behavior and its helpfulness. Years of professional experience, internal resilience, and external resilience were shown to be significant predictors of mental distress among CPPs during the pandemic, and resilience mediated how years of experience predicted mental distress. CONCLUSIONS This study emphasized the importance of experience and internal resilience for CPPs' psychological well-being. It also provides empirical evidence to support the MSMR theory on a global scale. Additionally, it demonstrates how the perceived changes in child maltreatment during COVID-19 may be associated with regional HDI. Lastly, the opportunities CPPs had to engage in resilient behavior and how much this helped them was associated with regional HDI, but not in the way originally predicted. Study results also hold implications for how practice and policy may be altered to help CPPs cope better during times of crisis and generally.
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Affiliation(s)
- Carmit Katz
- Bob Shapell School of Social Work, Tel Aviv University, Ramat Aviv, 69978, Israel.
| | - Ma'ayan Jacobson
- Haruv Institute, The Hebrew University of Jerusalem, Mount Scopus, Jerusalem, Israel.
| | - Sidnei R Priolo Filho
- Laboratório de Pesquisa, Prevenção e Intervenção em Psicologia Forense, Universidade Tuiuti do Paraná, Curitiba, Brazil.
| | | | - Jenny Liu
- Schulich School of Medicine and Dentistry, Western University, London, Canada.
| | | | | | - Afnan Attrash Najjar
- Bob Shapell School of Social Work, Tel Aviv University, Ramat Aviv, 69978, Israel.
| | - Annie Bérubé
- The Department of Psychoeducation and Psychology, Université du Québec en Outaouais, Canada.
| | - Delphine Collin-Vézina
- The Centre for Research on Children and Families, McGill University, Suite 106, Wilson Hall, 3506 University Street, Montreal, Quebec H3A 2A7, Canada.
| | - Kathryn Maguire-Jack
- School of Social Work, University of Michigan, 1080 S. University Ave., Ann Arbor, MI 48109, USA.
| | | | - Akhtar Munir
- Department of Social Work, Kohat University of Science and Technology, Kohat, Pakistan.
| | - Ashwini Tiwari
- Augusta University, CJ2300 1120 15th Street, Augusta, GA 30912; USA.
| | - Christine Wekerle
- The Offord Centre for Child Studies, McMaster University, 1280 Main St. W. - MIP 201A, Hamilton, ON L8S 4K1, Canada.
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Mupambireyi Z, Cowan FM, Chappell E, Chimwaza A, Manika N, Wedderburn CJ, Gannon H, Gibb T, Heys M, Fitzgerald F, Chimhuya S, Gibb D, Ford D, Mushavi A, Bwakura-Dangarembizi M. "Getting pregnant during COVID-19 was a big risk because getting help from the clinic was not easy": COVID-19 experiences of women and healthcare providers in Harare, Zimbabwe. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002317. [PMID: 38190418 PMCID: PMC10773929 DOI: 10.1371/journal.pgph.0002317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 12/04/2023] [Indexed: 01/10/2024]
Abstract
The COVID-19 pandemic and associated measures may have disrupted delivery of maternal and neonatal health services and reversed the progress made towards dual elimination of mother-to-child transmission of HIV and syphilis in Zimbabwe. This qualitative study explores the impact of the pandemic on the provision and uptake of prevention of mother-to-child transmission (PMTCT) services from the perspectives of women and maternal healthcare providers. Longitudinal in-depth interviews were conducted with 20 pregnant and breastfeeding women aged 20-39 years living with HIV and 20 healthcare workers in two maternity polyclinics in low-income suburbs of Harare, Zimbabwe. Semi-structured interviews were held after the second and third waves of COVID-19 in March and November 2021, respectively. Data were analysed using a modified grounded theory approach. While eight antenatal care contacts are recommended by Zimbabwe's Ministry of Health and Child Care, women reported only being able to access two contacts. Although HIV testing, antiretroviral therapy (ART) refills and syphilis screening services were accessible at first contact, other services such as HIV-viral load monitoring and enhanced adherence counselling were not available for those on ART. Closure of clinics and shortened operating hours during the second COVID-19 wave resulted in more antenatal bookings occurring later during pregnancy and more home deliveries. Six of the 20 (33%) interviewed women reported giving birth at home, assisted by untrained traditional midwives as clinics were closed. Babies delivered at home missed ART prophylaxis and HIV testing at birth despite being HIV-exposed. Although women faced multiple challenges, they continued to attempt to access services after delivery. These findings underline the importance of investing in robust health systems that can respond to emergency situations to ensure continuity of essential HIV prevention, treatment, and care services.
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Affiliation(s)
- Zivai Mupambireyi
- Department of Children and Adolescents Centre for Sexual Health HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
| | - Frances M. Cowan
- Department of Children and Adolescents Centre for Sexual Health HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Elizabeth Chappell
- Medical Research Council (MRC) Clinical Trials Unit at University College London, London, United Kingdom
| | - Anesu Chimwaza
- Department of AIDS/Tuberculosis, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Ngoni Manika
- Department of AIDS/Tuberculosis, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Catherine J. Wedderburn
- Medical Research Council (MRC) Clinical Trials Unit at University College London, London, United Kingdom
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Hannah Gannon
- Institute of Child Health, University College London, London, United Kingdom
| | - Tom Gibb
- Picturing Health, London, United Kingdom
| | - Michelle Heys
- Institute of Child Health, University College London, London, United Kingdom
| | - Felicity Fitzgerald
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Simbarashe Chimhuya
- Department of Child and Adolescent Health, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Diana Gibb
- Medical Research Council (MRC) Clinical Trials Unit at University College London, London, United Kingdom
| | - Deborah Ford
- Medical Research Council (MRC) Clinical Trials Unit at University College London, London, United Kingdom
| | - Angela Mushavi
- Department of AIDS/Tuberculosis, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Mutsa Bwakura-Dangarembizi
- Department of Child and Adolescent Health, Faculty of Medicine and Health Sciences University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
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Brown JA, Harvey CL, Byrne AL, Hegney DG. Nurse and midwife navigator resilience, well-being, burnout, and turnover intent: A multi-methods study. Public Health Nurs 2024; 41:77-89. [PMID: 37787742 DOI: 10.1111/phn.13256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 09/04/2023] [Accepted: 09/17/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE To explore levels of Navigator resilience, well-being, burnout, and turnover intent. DESIGN A longitudinal, multi-methods study concurrently collected quantitative and qualitative data over three years. METHODS A survey and Action Learning Groups. FINDINGS No statistically significant change in resilience, well-being, burnout, or turnover intent. Supports, self-care and leaving the position, were used to maintain well-being. CONCLUSIONS While quantitative measures did not change, qualitative data demonstrated how adaptive coping mechanisms maintain well-being. Recommendations for nurses working in Navigator, or similar community/public health roles include work-based programs targeting support, good leadership, governance systems including their impact on turnover intent. CLINICAL EVIDENCE Job turnover intent can be used as a mechanism to monitor resilience and well-being.
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Affiliation(s)
- Janie A Brown
- Curtin University and Senior Research Fellow St John of God Midland Public and Private Hospitals, Perth, Australia
| | | | - Amy-Louise Byrne
- School of Nursing, Midwifery and Social Sciences, CQUniversity, Townsville, Australia
| | - Desley G Hegney
- School of Nursing, University of Adelaide, Adelaide, Australia
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Cunningham T, Caza B, Hayes R, Leake S, Cipriano P. Design health care systems to protect resilience in nursing. Nurs Outlook 2024; 72:101999. [PMID: 37481349 DOI: 10.1016/j.outlook.2023.101999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/30/2023] [Accepted: 06/11/2023] [Indexed: 07/24/2023]
Abstract
This panel paper is the fourth installment in a six-part Nursing Outlook special edition based on the 2022 Emory Business Case for Nursing Summit. The 2022 summit was led by Emory School of Nursing in partnership with Emory School of Business. It convened national nursing, health care, and business leaders to explore possible solutions to nursing workforce crises, including the nursing shortage. Each of the summit's four panels authored a paper in this special edition on their respective topic(s) of discussion, and this panel paper is focused on resilience in nursing. It addresses the importance of organizational culture in nursing retention, the role of leadership in reducing nurse turnover, and strategies for how to build resilience systems that counteract or eliminate sources of moral distress. Cost rationales are discussed as part of 'the busienss case' for investing in resilience systems.
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Affiliation(s)
| | - Brianna Caza
- University of North Carolina Greensboro, Greensboro, NC.
| | - Rose Hayes
- Emory University School of Nursing, Atlanta, GA.
| | - Sandy Leake
- The University of Tennessee Medical Center, Knoxville, TN.
| | - Pamela Cipriano
- University of Virginia School of Nursing, Charlottesville, VA.
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Goniewicz M, Włoszczak-Szubzda A, Al-Wathinani AM, Goniewicz K. Resilience in Emergency Medicine during COVID-19: Evaluating Staff Expectations and Preparedness. J Pers Med 2023; 13:1545. [PMID: 38003861 PMCID: PMC10672282 DOI: 10.3390/jpm13111545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/26/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic brought about significant challenges for health systems globally, with medical professionals at the forefront of this crisis. Understanding their organizational expectations and well-being implications is crucial for crafting responsive healthcare environments. METHODS Between 2021 and 2022, an online survey was conducted among 852 medical professionals across four provinces in Poland: Mazovia, Łódź, Świętokrzyskie, and Lublin. The survey tool, based on a comprehensive literature review, comprised dichotomous questions and specific queries to gather explicit insights. A 5-point Likert scale was implemented to capture nuanced perceptions. Additionally, the Post-Traumatic Stress Disorder Checklist-Civilian (PCL-C) was utilized to ascertain the correlation between workplace organization and post-traumatic stress symptoms. RESULTS A noteworthy 84.6% of participants believed their employers could enhance safety measures, highlighting a discrepancy between healthcare workers' expectations and organizational implementations. Major concerns encompassed the demand for improved personal protective equipment (44.6%), structured debriefing sessions (40%), distinct building entrances and exits (38.8%), and psychological support (38.3%). Statistical analyses showcased significant variations in 'Avoidance' and 'Overall PTSD Score' between individuals who had undergone epidemic safety procedure training and those who had not. CONCLUSIONS The results illuminate the imperative for healthcare organizations to remain agile, attentive, and deeply compassionate, especially during worldwide health emergencies. Despite showcasing remarkable resilience during the pandemic, medical professionals ardently seek an environment that underscores their safety and mental well-being. These findings reinforce the call for healthcare institutions and policymakers to champion a forward-thinking, employee-focused approach. Additionally, the data suggest a potential avenue for future research focusing on specific demographic groups, further enriching our understanding and ensuring a more comprehensive readiness for impending health crises.
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Affiliation(s)
- Mariusz Goniewicz
- Department of Emergency Medicine, Medical University of Lublin, 20-081 Lublin, Poland
| | - Anna Włoszczak-Szubzda
- Faculty of Human Sciences, University of Economics and Innovation, 20-209 Lublin, Poland;
| | - Ahmed M. Al-Wathinani
- Department of Emergency Medical Services, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh 11451, Saudi Arabia;
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Khatooni M, Ghorbani A, Momeni M, Ghapanvari F. Resilience of first-line nurses during adaptation to the COVID-19 pandemic: A grounded theory study. Jpn J Nurs Sci 2023; 20:e12548. [PMID: 37329161 DOI: 10.1111/jjns.12548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 06/18/2023]
Abstract
AIM Nurses are a vital resource in providing care to COVID-19 patients. During adaptation to the pandemic, the mental health of nurses was disturbed. The present study aimed to explain the resilience development process and adaptive strategies of first-line nurses during the COVID-19 pandemic. METHODS This study was conducted based on the grounded theory qualitative approach. Twenty-two Iranian first-line nurses, who were employed in one teaching hospital in Qazvin city, were included via purposive and theoretical sampling. The data were collected through semi-structured interviews and were analyzed based on the Corbin and Strauss approach 2015. RESULTS The resilience development process of nurses had three stages including initial confrontation with changes, managing conditions and reorganizing, developing resilience. Professional commitment was identified as a core category that affected all stages of resilience development. Negative emotions, nurses' characteristics, and caring challenges were identified as contextual factors which affected the adaptation of nurses to the COVID-19 pandemic and the development of resilience. CONCLUSION Regarding the importance of professional commitment in the nurses' resilience development and not leaving the profession in the COVID-19 pandemic, it is important to emphasize the ethical values and principles of the nursing profession in practice and especially in the education of nursing students. It is necessary to monitor mental health and provide professional psychological counseling by the healthcare systems; also, nursing managers should follow a supportive leadership style and consider first-line nurses' worries.
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Affiliation(s)
- Marzieh Khatooni
- Metabolic Diseases Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Azam Ghorbani
- Metabolic Diseases Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Maryam Momeni
- Metabolic Diseases Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Fatemeh Ghapanvari
- Intensive Care Nursing, Qazvin University of Medical Sciences, Qazvin, Iran
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10
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Simões de Almeida R, Costa A, Teixeira I, Trigueiro MJ, Dores AR, Marques A. Healthcare Professionals' Resilience During the COVID-19 and Organizational Factors That Improve Individual Resilience: A Mixed-Method Study. Health Serv Insights 2023; 16:11786329231198991. [PMID: 37736335 PMCID: PMC10510343 DOI: 10.1177/11786329231198991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/17/2023] [Indexed: 09/23/2023] Open
Abstract
Healthcare workers are a susceptible population to be psychologically affected during health crises, such as the recent COVID-19 pandemic. Resilience has been pointed out in the literature as a possible protective factor against psychological distress in crisis situations. This can be influenced by internal and external factors, such as individual characteristics and organizational factors. Thus, this study aims to characterize the overall resilience levels among healthcare professionals in Portugal and to understand the perspectives of this healthcare workers regarding organizational factors that improve individual resilience. This is a mixed-method study: a first quantitative study using a cross-sectional design to administer the Resilience Scale for Adults (RSA) to 271 healthcare professionals (Mage 33.90, SD = 9.59 years, 90.80% female), followed by a qualitative study through 10 in-depth interviews. The mean score for the total RSA was 178.17 (SD = 22.44) out of a total of 231. Qualitative analysis showed 4 major themes on factors that enhance resilience: "Professional's Training," "Support and Wellbeing Measures," "Reorganization of Services" and "Professional Acknowledgment." The findings may contribute to the development of targeted interventions and support systems to enhance resilience and well-being among healthcare workers.
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Affiliation(s)
| | - Ana Costa
- LabRP-CIR, ESS, Polytechnic University of Porto, Porto, Portugal
| | - Inês Teixeira
- LabRP-CIR, ESS, Polytechnic University of Porto, Porto, Portugal
| | | | - Artemisa Rocha Dores
- LabRP-CIR, ESS, Polytechnic University of Porto, Porto, Portugal
- Laboratory of Neuropsychophysiology, Faculty of Psychology and Education Sciences, University of Porto, Porto, Portugal
| | - António Marques
- LabRP-CIR, ESS, Polytechnic University of Porto, Porto, Portugal
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11
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Davoren N, McEleney A, Corcoran S, Tierney P, Fortune DG. Refugees and asylum seekers who have experienced trauma: Thematic synthesis of therapeutic boundary considerations. Clin Psychol Psychother 2023. [PMID: 37658701 DOI: 10.1002/cpp.2894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE Therapeutic boundaries are limits to appropriate behaviours within a therapist-client relationship (e.g. related to accepting gifts, self-disclosures, therapist neutrality and advocacy). Therapeutic boundary considerations are fundamental in the care of refugees and asylum seekers. Research on the experiences of therapists navigating such boundaries is sparse and warrants further exploration. The aim of this qualitative systematic review was to thematically synthesise literature regarding therapists' (psychologists, psychotherapists, counsellors) experiences of implementing flexible therapeutic boundaries with refugee and asylum seeker clients and determine how such applications have been helpful for therapeutic interventions. METHOD Six databases were searched. Following full-text screening, 21 papers were included in the analysis. Boundary theory underpinned the analysis. RESULTS Three major themes were developed: (i) Changes to Therapeutic Practice & Therapeutic Intervention, (ii) Re-Conceptualisation of Therapy as 'Clinical Political' and Re-Conceptualisation of Therapist Identity and (iii) Careful Monitoring of Personal Boundaries-Not becoming 'Hardened' or 'Haunted'. Papers described how, when used in a reflective, considerate way, flexible therapeutic boundaries can strengthen the therapist-client alliance and positively impact therapeutic interventions. Many therapists acknowledged making conscious efforts to re-conceptualise therapeutic work with refugee and asylum seeker clients from advocacy standpoints. However, systemic constraints, and lack of guidance, made this difficult to navigate and contributed to therapist burn-out. CONCLUSIONS Boundary considerations manifested as interpersonal, structural and cultural changes to practice. These have implications for clinical practice and developing guidelines on boundary practices with refugees and asylum seekers. Future research should explore promoting therapist well-being and training needs for therapists supporting this population.
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Affiliation(s)
- Niamh Davoren
- Department of Psychology, University of Limerick, Limerick, Ireland
| | - Alice McEleney
- Department of Psychology, University of Limerick, Limerick, Ireland
| | - Santhi Corcoran
- Department of Psychology, Mary Immaculate College, Limerick, Ireland
| | - Phelim Tierney
- Department of Psychology, University of Limerick, Limerick, Ireland
| | - Dónal G Fortune
- Department of Psychology, University of Limerick, Limerick, Ireland
- Health Service Executive, Mid-West Region, Limerick, Ireland
- Health Research Institute, University of Limerick, Limerick, Ireland
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12
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Atkins K, Cooney EE, Park S, Closser S, Surkan PJ, Marker HC, Schneider-Firestone S, Kalb LG, Thrul J, Veenema TG. Day to Day and Environmental Risk Factors for Psychological Distress Among Healthcare Workers: A Mixed Methods Analysis. J Occup Environ Med 2023; 65:e593-e603. [PMID: 37367694 DOI: 10.1097/jom.0000000000002909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Despite a growing literature on mental health among clinical staff during COVID-19, factors shaping distress for nonclinical staff are understudied and may be driven by inequalities at work. We aimed to discuss the role of workplace factors in shaping psychological distress for a diverse group of clinical, nonclinical, and other health and hospital workers (HHWs). METHODS This convergent parallel mixed-methods study with HHWs in a US hospital system included an online survey ( n = 1127) and interviews ( n = 73) collected from August 2020 to January 2021. We thematically analyzed interviews; findings informed log binomial regression estimating risk factors for severe psychological distress (Patient Health Questionnaire - 4 item version [PHQ-4] scores of 9 or greater). RESULTS Qualitatively, day-to-day stressors fostered fear and anxiety, and concerns about work environments manifest as betrayal and frustration with leadership. Distress was associated with burnout, financial concerns, and feeling betrayed or unsupported by the institution and leadership. Staff in service versus clinical roles had higher risk for severe distress (adjusted prevalence ratio = 2.04, 95% confidence interval = 1.13-2.66); HHWs receiving workplace mental health support had lower risk (adjusted prevalence ratio = 0.52, 95% confidence interval = 0.29-0.92. CONCLUSIONS Our mixed-methods study underscores how the pandemic brought inequalities to the surface to increase distress for vulnerable HHWs. Workplace mental health activities can support HHWs now and during future crises.
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Affiliation(s)
- Kaitlyn Atkins
- From the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.A.); Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.A., E.E.C., S.P., S.C., P.J.S., H.C.M.); Johns Hopkins School of Nursing, Baltimore, Maryland (S.S.-F.); Department of Mental Health, Johns Hopkins Bloomberg School of Public Health (L.G.K., J.T.); Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland (L.G.K.); Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (T.G.V.); and Center for Health Security, Johns Hopkins University, Baltimore, Maryland (T.G.V.)
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13
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Turner BJ, Welch BE, Legg NK, Phiri P, Rathod S, Paterson TSE. Psychological Impacts of the COVID-19 Pandemic on Canadian Healthcare Workers: A Case Control Comparison From Three Cross Sectional Surveys. J Occup Environ Med 2023; 65:e580-e586. [PMID: 37340692 DOI: 10.1097/jom.0000000000002913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE The aim of the study is to describe mental health impacts of the COVID-19 pandemic and identify roles that predict distress among Canadian healthcare workers (HCWs). METHODS Using data from three cross-sectional Canadian surveys, we compared 799 HCWs to demographically matched controls and compared HCWs with and without COVID-19 patient contact. Participants completed validated measures of depression, anxiety, trauma-related stress, alcohol problems, coping self-efficacy, and sleep quality. RESULTS Non-HCWs reported more depression and anxiety in Fall 2020 and more alcohol problems in Fall/Winter 2021 than HCWs. In Winter 2020-2021, HCWs reported more trauma-related stress than non-HCWs. As of early 2021, HCWs with direct patient contact reported worse symptoms across nearly all measures than HCWs without. CONCLUSIONS Although Canadian HCWs did not report worse mental health than demographically similar peers, mental health supports are needed for HCWs providing direct patient care.
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Affiliation(s)
- Brianna J Turner
- From the Department of Psychology, University of Victoria, Victoria, Canada (B.J.T., B.E.W., N.K.L., T.S.E.P.); Southern Health NHS Foundation Trust, Southampton, United Kingdom (P.P., S.R.); School of Primary Care, Population Sciences, and Medical Education, Faculty of Medicine, University of Southampton, Southampton, United Kingdom (P.P.); and Faculty of Science, University of Portsmouth, Portsmouth, United Kingdom (S.R.)
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14
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Giusti EM, Veronesi G, Callegari C, Borchini R, Castelnuovo G, Gianfagna F, Iacoviello L, Ferrario MM. Pre-pandemic burnout and its changes during the COVID-19 outbreak as predictors of mental health of healthcare workers: A lesson to be learned. Psychiatry Res 2023; 326:115305. [PMID: 37331071 PMCID: PMC10261975 DOI: 10.1016/j.psychres.2023.115305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/08/2023] [Accepted: 06/11/2023] [Indexed: 06/20/2023]
Abstract
The aim of this study was to identify how previously existing burnout and its changes during the pandemic contributed to PTSD symptoms and psychological distress in a cohort of 388 healthcare workers (HCWs). Each HCW was surveyed in Sep 2019 (before COVID-19) and again in Dec 2020-Jan 2021 (during the pandemic) to assess burnout (MBI); and in the second wave only to assess PTSD (PCL-5-SF), psychological distress (GHQ-12) and resilience (CD-RISC-10). Changes in emotional exhaustion (EE) and depersonalisation (DEP) were stronger in HCWs with lower EE and DEP baseline values. HCWs with higher baseline poor personal accomplishment (PPA) improved more than those with lower baseline values. In multivariable-adjusted models, pre-pandemic EE and its changes were equally associated to both outcomes: standardised-βs of 0.52 and 0.54 for PTSD, respectively; and 0.55 and 0.53 for psychological distress. Changes in DEP were associated with PTSD only (0.10). Changes in PPA had a higher association with psychological distress (0.29) than pre-pandemic PPA (0.13). Resilience was associated with lower psychological distress (-0.25). Preventive actions aimed at reducing EE, e.g., addressing organisational dysfunctions, are needed to mitigate the impact of future crises, whereas improving personal accomplishment levels is a key target to protect HCWs from mental health disorders during a pandemic.
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Affiliation(s)
- Emanuele Maria Giusti
- EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Giovanni Veronesi
- EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Camilla Callegari
- Division of Psychiatry, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Gianluca Castelnuovo
- Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy; Psychology Research Laboratory, Istituto Auxologico Italiano IRCCS, Verbania, Italy
| | - Francesco Gianfagna
- EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Licia Iacoviello
- EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy; Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Italy
| | - Marco Mario Ferrario
- EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
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15
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Paterson E, Paterson NAB, Ferris LJ. Mental health and well-being of anaesthetists during the COVID-19 pandemic: a scoping review. Anaesthesia 2023; 78:197-206. [PMID: 36314294 PMCID: PMC9874483 DOI: 10.1111/anae.15879] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 01/27/2023]
Abstract
The COVID-19 pandemic has imposed substantial burdens on clinicians and there is a need to better understand the impact on mental health and well-being. This scoping review investigates the prevalence of mental health concerns in anaesthetists, risk and protective factors for mental well-being, and anaesthetists' pandemic-related concerns and support. We searched online databases for articles published between January 2020 and May 2022, using search terms related to: anaesthesia; burnout, well-being, mental health or stress; and COVID-19. We identified 20 articles comprising 19 different populations of anaesthetists (n = 8680) from 14 countries. Studies identified the prevalence of the following condition in anaesthetists: burnout (14-59%); stress (50-71%); anxiety (11-74%); depression (12-67%); post-traumatic stress (17-25%); psychological distress (52%); and insomnia (17-61%). Significant risk factors for poorer mental health included: direct COVID-19-related issues (fear of self and family exposure to infection; requirement for quarantine); practitioner health factors (insomnia; comorbidities); psychosocial factors (loneliness; isolation; perceived lack of support at home and work); demographic factors (female gender; non-white ethnicity; LGBTQIA+); and workplace factors (redeployment outside area of clinical practice; increased work effort; personal protective equipment shortages). Protective factors identified included: job satisfaction; perceived organisational justice; older age; and male sex. Anaesthetists' self-reported concerns related to: personal protective equipment; resource allocation; fear of infection; fear of financial loss; increased workload; and effective communication of protocols for patient treatment. Support from family, colleagues and hospital management was identified as an important coping mechanism. Findings from this review may support the design of interventions to enhance anaesthetists' psychological health during pandemic conditions and beyond. Future research should include consistent psychological outcome measures and rigorous experimental design beyond cross-sectional studies.
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Affiliation(s)
- E. Paterson
- School of PsychologyUniversity of QueenslandBrisbaneQLDAustralia
| | - N. A. B. Paterson
- School of Clinical MedicineUniversity of QueenslandBrisbaneQLDAustralia,Anaesthesia and Pain Management ServicesQueensland Children's HospitalBrisbaneQLDAustralia
| | - L. J. Ferris
- School of BusinessUniversity of QueenslandBrisbaneQLDAustralia,School of PsychologyUniversity of QueenslandBrisbaneQLDAustralia
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Ravaghi H, Khalil M, Al-Badri J, Naidoo AV, Ardalan A, Khankeh H. Role of hospitals in recovery from COVID-19: Reflections from hospital managers and frontliners in the Eastern Mediterranean Region on strengthening hospital resilience. Front Public Health 2023; 10:1073809. [PMID: 36743170 PMCID: PMC9889830 DOI: 10.3389/fpubh.2022.1073809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/28/2022] [Indexed: 01/19/2023] Open
Abstract
Background COVID-19 highlighted the critical role that hospitals play throughout the prolonged response and continuous recovery stages of the pandemic. Yet, there is limited evidence related to hospitals in the recovery stage, particularly capturing the perspectives of hospital managers and frontliners in resource-restrained and humanitarian settings. Objective This paper aims to capture the perspectives of hospital managers and frontliners across the Eastern Mediterranean Region on (1) the role of hospitals in recovering from COVID-19, (2) Hospitals' expectations from public health institutions to enable recovery from COVID-19, (3) the Evaluation of hospital resilience before and through COVID-19, and (4) lessons to strengthen hospital resilience throughout the COVID-19 recovery. Methods A multi-methods approach, triangulating a scoping review with qualitative findings from 64 semi-structured key-informant interviews and survey responses (n = 252), was used to gain a deeper context-specific understanding. Purposeful sampling with maximum diversity supported by snowballing was used and continued until reaching data saturation. Thematic analysis was conducted using MAXQDA and simple descriptive analysis using Microsoft Excel. Findings In recovering from COVID-19, hospital managers noted hospitals' role in health education, risk reduction, and services continuity and expected human resource management, financial and material resource mobilization, better leadership and coordination, and technical support through the provision of updated clinical evidence-based information from their public health institutions. Qualitative findings also indicated that hospital managers attributed considerable changes in hospitals' resilience capacities to the pandemic and suggested that strengthening hospitals' resilience required resilient staff, sustainable finance, and adaptive leadership and management. Conclusion Hospitals are the backbone of health systems and a main point of contact for communities during emergencies; strengthening their resilience throughout the various stages of recovery is critical. Hospitals cannot be resilient in silos but rather require an integrated-whole-of-society-approach, inclusive of communities and other health systems actors.
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Affiliation(s)
- Hamid Ravaghi
- Department of Universal Health Coverage and Health Systems, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Merette Khalil
- Department of Universal Health Coverage and Health Systems, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt,*Correspondence: Merette Khalil ✉
| | - Jehan Al-Badri
- Health Emergencies Program, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | | | - Ali Ardalan
- Department of Universal Health Coverage and Health Systems, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Hamidreza Khankeh
- Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran,Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
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Zhang H, Wu Y, Wang N, Sun X, Wang Y, Zhang Y. Caregivers' experiences and perspectives on caring for the elderly during the COVID-19 pandemic: A qualitative systematic review. J Nurs Manag 2022; 30:3972-3995. [PMID: 36208194 PMCID: PMC9874760 DOI: 10.1111/jonm.13859] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/19/2022] [Accepted: 10/02/2022] [Indexed: 01/27/2023]
Abstract
AIMS The goal of this study was to explore caregivers' experiences, perspectives, emotions, knowledge and needs in caring for older people during the COVID-19 pandemic. These included, but were not limited to, experiences in hospital care, home care and nursing home care. BACKGROUND Because of the high mortality rate associated with the COVID-19 pandemic, senior care is critical. During the COVID-19 pandemic, caregivers caring for older people have had unique experiences potentially affecting the quality of care provided. This topic has received substantial attention since the start of the pandemic and has been studied by numerous researchers. However, experiences may differ among countries and time periods. In addition, no qualitative systematic reviews on this topic appear to have been published. EVALUATION In this systematic review of qualitative studies, data were collected from the following electronic databases: PubMed, Web of Science, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Science Direct and PsycINFO. Titles and abstracts were screened according to the inclusion and exclusion criteria, full texts were screened and the methodological quality of included studies was assessed with the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research by two independent reviewers. KEY ISSUE(S) A total of 141 findings were extracted and aggregated into 20 categories; 6 synthesized findings were identified. CONCLUSION This review indicates caregivers' experiences and perceptions regarding caring for older people during the COVID-19 pandemic. The results of a qualitative systematic review show that caregivers' emotions, cognitions and knowledge have affected the quality of caregivers' senior care services during the pandemic. Caregivers caring for older adults should practise self-awareness, understanding their knowledge and attitudes to improve the quality of senior care. Moreover, health care administrators and policymakers should make concerted efforts to cultivate a better working environment. IMPLICATIONS FOR NURSING MANAGEMENT Managers should formulate timely and effective management strategies. During the COVID-19 pandemic, the workload of caregivers has increased, thus requiring better scheduling by managers. Furthermore, managers should consider the negative emotions of caregivers and prevent negative emotions from affecting their work. Besides, virtual technology should be applied to senior care and psychological support be provided for caregivers in this special care setting.
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Affiliation(s)
- Huichao Zhang
- School of NursingNanjing University of Chinese MedicineNanjingJiangsuChina
| | - Yuan Wu
- School of NursingNanjing University of Chinese MedicineNanjingJiangsuChina
| | - Nannan Wang
- School of NursingNanjing University of Chinese MedicineNanjingJiangsuChina
| | - Xuhan Sun
- School of NursingNanjing University of Chinese MedicineNanjingJiangsuChina
| | - Yuqing Wang
- School of NursingNanjing University of Chinese MedicineNanjingJiangsuChina
| | - Yuxi Zhang
- Geriatric Hematology/Radiotherapy Wardthe First Affiliated Hospital of Nanjing Medical University300 Guangzhou RoadNanjingJiangsuChina
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