What healthcare leaders need to do to protect the psychological well-being of frontline staff in the COVID-19 pandemic

Health care workers' qualitative descriptions of ethically challenging situations evoking moral distress during Covid-19

Background: The high public demand for healthcare services during the COVID-19 pandemic and strict infection control measures, coupled with threat of severe illness and death, and limited resources, led to many healthcare workers (HCWs) experiencing ethically challenging situations (ECSs). Objective: To systematically explore first-hand accounts of ECS-evoking moral distress among HCWs during this public health emergency. Research design: This was an open cohort study. All participants were asked whether they had been in ECS-evoking moral distress during the pandemic. Those who had were asked to describe these situations. Answers were systematically analyzed according to three levels of root causes for ECSs, using thematic analysis. Participants and research context: In January 2022, 977 HCWs from four Norwegian university hospitals participated. Ethical considerations: The study received ethical approval from the Norwegian Ethical Review Authority (No. 130944). Results: In total, 508 participants (52%) reported that they had experienced ECS-evoking moral distress during the pandemic, whereof 323 provided a qualitative description. We found that while a few reported ECSs caused at the patient level, and some described situations at the unit/team level, the vast majority reported situations caused at the system level, predominantly related to resource scarcity, particularly poor staffing. Conclusion: Our findings strongly indicate that efforts to mitigate moral distress among HCWs should be targeted at the system level. More specifically, the study findings highlight resource limitations, particularly poor staffing, as a major cause of moral distress during the pandemic.

The role of psychologists in supporting illness-related dying and death: A systematic mixed studies review

Psychologists remain underrepresented in end-of-life care, and there is limited understanding of their role among healthcare professionals, patients, and caregivers. This systematic mixed-studies review, prospectively registered on PROSPERO (CRD42020215775), explored the role of psychologists, and the facilitators and barriers they experience, in supporting clients with illness-related dying and death. A search of six research databases was conducted in October 2023. Fifty-one studies, mainly qualitative and from the perspectives of psychologists, met inclusion criteria. Thematic synthesis highlighted how psychologists provided expertise across various contexts. They supported clients with preparing for death, and adjusting to dying, provided professional consultancy and support, and undertook leadership in enhancing psychological end-of-life care. Results illustrated the sustaining factors and ongoing challenges working in end-of-life care, namely, the unique nature of navigating the death space, recognition and awareness of psychologists' contribution, and the support, training and development required. Given the universality of dying and death, this review is relevant to psychologists working within and beyond more traditional end-of-life care contexts, such as employee assistance programs, private practice, schools, and other psychological services. Policy, clinical and research implications are discussed, including the need for greater engagement and training of psychologists in the dying and death space.

Listening to the Voices of Health Care Workers During the COVID-19 Pandemic: A Qualitative Study Providing In-Depth Insights Into Ethical and Individual Challenges

In their daily practice, health care workers (HCWs) experience the effects of tensions between professional ethos and work realities, which can lead to ethical dilemmas. We aim to explore the ethical dilemmas that affected HCWs in Germany during the COVID-19 pandemic and to understand these in the context of the German health system. Between April and December 2022, we interviewed HCWs from various levels of care and key informants responsible for decisions related to HCWs in Germany. Three themes were identified in the data analyzed from 78 participants. The first highlighted the potency of pre-existing health system problems during the COVID-19 pandemic. The second captured the ethical dilemmas that were described as having arisen due to the tension between professional ethos and structural constraints. The third included factors related to increasing or diminishing the implications of ethical dilemmas. A lack of opportunities for HCWs to participate in political and managerial decisions was suggested to result in policies that do not meet the needs of HCWs and patients. Positive interpersonal interactions were described as helpful when coping with dilemmatic decision-making situations. In order to avoid negative consequences caused by unresolved ethical dilemmas, including moral distress, among HCWs, staff shortages and decision-making in the German health system urgently need to be addressed. HCWs' working conditions regularly evoke ethical dilemmas, particularly during public health emergencies. Together with HCWs, decision-makers must develop new models for working in health care settings that are in line with HCWs' professional ethos.

Changes in the diagnosis of depression among nursing professionals during the COVID-19 pandemic: A longitudinal study

AIMS

To identify changes in mental health status among nursing professionals in a Brazilian municipality during the COVID-19 pandemic.

DESIGN

An observational and longitudinal study.

METHODS

Using the Patient Health Questionnaire-9, the presence of depressive symptoms was evaluated among 690 nursing professionals in the city of Pelotas, Brazil, at two moments: June/July 2020 and June/July 2021.

RESULTS

13.0% incidence of depressive symptoms was identified; as well as 12.2% remission; 24.1% persistence and 50.7% absence. Among the factors associated with the worst prognoses we can mention female gender, greater workload, feeling of overload, illness of family members or friends due to COVID-19 and use of psychotropic drugs CONCLUSIONS: There was significant mobility in the diagnosis of depression among the professionals studied during the period analysed, with incidence of new cases of significant depression and greater than the number of remissions. In addition to sociodemographic aspects, traumatic experiences and exposure to continuous overload were associated with persistence and incidence of new cases.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

With the advent of the COVID-19 pandemic, several studies have shown an increase in depressive symptoms among nursing professionals; however, understanding the long-term effects of this scenario is still a challenge.

IMPACT

What problem did the study address? This study investigates changes in the mental health status of nursing professionals working at different care levels, taking the prevalence of screening for depression as a proxy, during a period of a year during the COVID-19 pandemic. What were the main findings? Between both data collection moments, 2020 e 2021, there was a significant percentage of professionals with persistent depression, in addition to a significant proportion of incident cases that slightly exceeded the number of remissions and the factors associated with the worst prognoses were sociodemographic aspects such as gender and emotional stressors like illness of family members or close friends due to COVID-19, in addition to those related to the organisation and support provided by the services, such as workload and feeling of overload. Where and on whom will the research have an impact? This study will impact the nursing professionals and in role of the health services in order to establishing actions that contribute to minimising the deleterious effects of the pandemic on the mental health of their Nursing teams.

REPORTING METHOD

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were adopted in this study.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Moral injury and psychological wellbeing in UK healthcare staff

BACKGROUND

Potentially morally injurious events (PMIEs) can negatively impact mental health. The COVID-19 pandemic may have placed healthcare staff at risk of moral injury.

AIM

To examine the impact of PMIE on healthcare staff wellbeing.

METHODS

Twelve thousand nine hundred and sixty-five healthcare staff (clinical and non-clinical) were recruited from 18 NHS-England trusts into a survey of PMIE exposure and wellbeing.

RESULTS

PMIEs were significantly associated with adverse mental health symptoms across healthcare staff. Specific work factors were significantly associated with experiences of moral injury, including being redeployed, lack of PPE, and having a colleague die of COVID-19. Nurses who reported symptoms of mental disorders were more likely to report all forms of PMIEs than those without symptoms (AOR 2.7; 95% CI 2.2, 3.3). Doctors who reported symptoms were only more likely to report betrayal events, such as breach of trust by colleagues (AOR 2.7, 95% CI 1.5, 4.9).

CONCLUSION

A considerable proportion of NHS healthcare staff in both clinical and non-clinical roles report exposure to PMIEs during the COVID-19 pandemic. Prospective research is needed to identify the direction of causation between moral injury and mental disorder as well as continuing to monitor the longer term outcomes of exposure to PMIEs.

A thematic analysis of staff perspectives on the impact of a mental health nurse (RMN) in a critical care unit

Background

Recent guidelines in the UK have shaped Critical Care Units (CCUs) to bring the mental health needs of patients, and staff wellbeing to the forefront of service provision. A health board based in NHS Wales has trialled the secondment of a Mental Health Nurse (RMN) within a CCU to help service provision adhere to such guidelines.

Methods

Critical care staff were invited to attend focus groups to share their experiences of how the RMN influenced service provision.

Results

Thematic analysis identified five main themes; including 'smoother care pathways', 'a holistic approach to care', 'co-production', 'knowledge and confidence' and 'staff wellbeing'. Each of these themes reflected how the RMN had both direct and indirect benefits on patient and staff wellbeing.

Conclusion

This qualitative exploration suggests that staff perceived value in the role of the RMN for both staff and patient outcomes, although further measures were considered necessary to improve staff-wellbeing within a critical care environment. This service evaluation supports recommendations for commissioning a RMN permanently in a CCU.

Does meaningful work mediate the relationship between empowering leadership and mental health? Evidence from Malaysian SME employees

Introduction

In Malaysia, small and medium enterprises (SMEs) account for more than half of all employment and 98.7% of all businesses. There is little research on empowering behaviors in SMEs, despite leadership empowerment being often practiced. Therefore, the study aims to investigate how empowering leadership affects employees' mental health. The study also reveals meaningful work's role in mediating the relationship between empowering leadership and employees' mental health.

Methods

A stratified random sample approach was used to collect data from 516 employees of Malaysian SMEs. The data was analyzed, and the hypothesis was tested using structural equation modeling (AMOS 21.0) with bootstrap confidence intervals computed to evaluate the mediating effect.

Results

The results demonstrate that empowering leadership significantly improves employees' mental health. Furthermore, the association between empowering leadership and mental health is partially mediated by meaningful work.

Discussion

This study contributes to the present empowering leadership-meaningful work-mental health model for SME employees, which reduces stress and anxiety at the workplace and positively impacts psychological empowerment and their capacity to control their overall emotions in instances of success.

Challenges of being a maternity service leader during the COVID-19 pandemic: a descriptive analysis of the journey

BACKGROUND

In Australia, maternity care services provide care for pregnant and postpartum women and their newborns. The COVID-19 pandemic forced these services to quickly adapt and develop policies and procedures for dealing with transmission in health care facilities, as well as work under public health measures to counter its spread within the community. Despite well-documented responses and adaptations by healthcare systems, no studies have examined the experiences of maternity service leaders through the pandemic. This study aimed to explore the experiences of maternity service leaders, to understand their perspectives on what happened in health services and what was required of a leader during the COVID-19 pandemic in one Australian state.

METHODS

A longitudinal qualitative study collected data from 11 maternity care leaders during the pandemic in the state of Victoria. Leaders participated in a series of interviews over the 16-month study period, with a total of 57 interviews conducted. An inductive approach to developing codes allowed for semantic coding of the data, then a thematic analysis was conducted to explore patterned meaning across the dataset.

RESULTS

One overarching theme, 'challenges of being a maternity service leader during the pandemic', encompassed participant's experiences. Four sub-themes described the experiences of these leaders: (1) needing to be a rapid decision-maker, (2) needing to adapt and alter services, (3) needing to filter and translate information, and (4) the need to support people. At the beginning of the pandemic, the challenges were most acute with slow guideline development, rapid communications from the government and an urgent need to keep patients and staff safe. Over time, with knowledge and experience, leaders were able to quickly adjust and respond to policy change.

CONCLUSION

Maternity service leaders played an important role in preparing and adapting services in accordance with government directives and guidelines while also developing strategies tailored to their own health service requirements. These experiences will be invaluable in designing high quality and responsive systems for maternity care in future crises.

Exploring staff perspectives on caring for isolated hospitalised patients during the COVID-19 pandemic: a qualitative study

BACKGROUND

Strict isolation of COVID-19 patients to prevent cross infection may inadvertently cause serious adverse outcomes including psychological harm, limitations to care, increased incidence of delirium, deconditioning and reduced quality of life. Previous research exploring the staff perspective of the effect of isolation on patients is limited. The aim of this study is to understand staff perceptions and interpretations of their experiences of the care and treatment of isolated patients and the impact of isolation on patients, families, and staff.

METHOD

This qualitative, exploratory study is set in a major metropolitan, quaternary hospital in Melbourne, Australia. Data was collected in focus groups with clinical and non-clinical staff and analysed using content analysis. The hospital ethics committee granted approval. Each participant gave informed verbal consent.

RESULTS

Participants included 58 nursing, medical, allied health, and non-clinical staff. Six main themes were identified: 1) Communication challenges during COVID-19; 2) Impact of isolation on family; 3) Challenges to patients' health and safety; 4) Impact on staff; 5) Challenging standards of care; 6) Contextual influences: policy, decision-makers and the environment.

CONCLUSION

Isolating patients and restricting visitors resulted in good pandemic management, but staff perceived it came at considerable cost to staff and consumers. Innovative communication technology may facilitate improved connection between all parties. Mental health support is needed for patients, families, and staff. Further research using a co-design model with input from patients, families and staff is recommended to determine appropriate interventions to improve care. Preventing the spread of infection is essential for good pandemic management, but the cost to consumers and staff must be mitigated. Preparation for future pandemics must consider workforce preparedness, adapted models of care and workflow.

Mental health burden for NHS healthcare staff during the COVID-19 pandemic: First results of a longitudinal survey

Background

The current investigation aimed to assess the mental health burden on healthcare workers during the early stages of the COVID-19 pandemic.

Methods

A link to an online survey was sent to an estimate of 18,100 employees of Sheffield Teaching Hospitals NHS Foundation Trust (STH) who had access to email. The survey was completed between 2nd and June 12, 2020.1390 healthcare workers (medical, nursing, administrative and other professions) participated in the first survey. Data from a general population sample (n = 2025) was used for comparison. Severity of somatic symptoms was measured by the PHQ-15. Severity and probable diagnosis of depression, anxiety, and PTSD were measured by the PHQ-9, GAD-7, and ITQ. Linear and logistic regressions were performed to determine if population group predicted the severity of mental health outcomes, and probable diagnosis of depression, anxiety, and PTSD. Additionally, ANCOVAs were performed to compare mental health outcomes between occupational roles in HCWs. Analysis was performed using SPSS.

Findings

Healthcare workers are more likely to experience greater severity of somatic symptoms, as well as severity and probable diagnosis of depression and anxiety, compared to the general population, but not increased traumatic stress symptoms. Scientific and technical, nursing and admin staff were more likely to experience worse mental health outcomes, compared to medical staff.

Interpretation

The COVID-19 pandemic has led to increased mental health burden in some, but not all healthcare workers during the first acute phase of the pandemic. The findings from the current investigation provide valuable insights into which healthcare workers are particularly vulnerable to developing adverse mental health outcomes during and after a pandemic.

Under pressure - The working situation of Swedish healthcare managers during the first wave of COVID-19

Introduction

The aim of this study is to provide insight into the psychosocial work situation of hospital managers during the first wave of the COVID-19 pandemic.

Methods

Mixed-effect modelling was used on survey data on job demands, job resources, job motivation, and work-life balance among over 500 managers working in 55 departments of a large Swedish university hospital in 2019 and 2020. Responses from 6011 employees were then used to stratify the analysis for COVID-19 exposure. Inductive content analysis was applied to open-ended questions on the managers' views on organisational prerequisites during the onset of the pandemic.

Results

The proportion of managers reporting difficulties with role clarity, quantitative demands, decision-making authority, and emotional support, time for recovery at work, motivation deficits, or problems with work-life balance clearly increased during the first wave of the pandemic. The proportion of managers reporting negative responses was higher in departments with high COVID-19 exposure. The qualitative analysis shows that overall governance in terms of clear, fair, and well-communicated routines, resource allocation, and division of responsibilities constituted an important framework for managerial during the crisis. First-line managers also require a mandate to re-organize their roles and their teams to successfully adapt to the situation. Organisational and social support was also important resources.

Discussion

This is the first study investigating healthcare managers' work situation during the first wave of the COVID-19 pandemic in a Swedish context. As expected, it indicates an increasingly strained work situation during the crisis, but it also provides findings on organisational prerequisites that allow healthcare managers to cope with stressful situations. In line with previous research on organisational resilience, the study provides suggestions for how higher-level managers can act in order to provide front-line managers with the organisational prerequisites they need to adapt, learn and develop successfully during times of unpredictability, insecurity, and rapid change in order to offer the best possible support to health care workers.

Leadership in breast screening and the importance of appropriate communication during the early onset of the COVID-19 pandemic

INTRODUCTION

In England, the NHS National Breast Screening Programme (NHSBSP) offers routine breast screening to all women, some trans men and non-bionary people, between the ages of 50 years and up to their 71 st birthday, every 3 years. The unfolding Covid-19 pandemic in early 2020 was understandably a time of great anxiety and concern. Culturally we were seeing strong behavioural shifts such as social distancing and a general change in all our daily life patterns. Conceptually, and as leaders, we understood the vulnerability we observed, but felt that we did not have the 'right language' and in fact lacked the relevant experience of how to address and communicate with staff and clients during this crisis.

METHODS

A semiotic, observational research project was utilised that aimed at providing insight how cultural behaviour was being shaped and expressed during the early onset of the Covid-19 pandemic in England. The recommendations of the project were then integrated and implemented into an action plan and subsequent practice.

RESULTS

Semiotic analysis revealed that several factors (positive and negative) impacted on peoples' confidence and had practical and emotional implications. Eleven main codes which are belief systems about oneself and others were identified and expressed in a multitude of different ways revealing three main themes or needs i.e. Reassurance, Trust and Clarity. An action plan was developed in response to the project findings and recommendation were implemented.

CONCLUSIONS

Effective leadership relies on situational awareness. Our semiotic project enabled us to find the 'right' language and communication style so that we could connect with staff at the time of crisis. Using our own expert staff, we empowered them by providing the correct, easily digestible resources to facilitate confidence across the service teams which in turn supported the delivery of high-quality breast screening at a time of great uncertainty.

IMPLICATION FOR PRACTICE

We must learn to be agile and adaptive, both in our operational delivery and our communication styles.

Strategies deemed important by frontline healthcare providers for their mental wellbeing during first wave of COVID-19 pandemic

Background

Global research so far has demonstrated a significant psychological impact on frontline healthcare workers and the need to support them. Mitigation strategies are vital to ensure psychological wellbeing of healthcare workers and should take healthcare workers experiences and views into consideration. However, qualitative research on this topic has been limited from the Arab world and we set out to fill this research gap. The objective was to understand participants’ emotional experiences and identify their valued aspects of support, to inform potential mitigation strategies for their psychological wellbeing.

Methods

Content analysis of free-text comments of a web-based survey of healthcare workers associated with the COVID-19 designated hospital and quarantine sites in Qatar, during the first wave of COVID-19 pandemic. Extracts and phrases were used to identify potential themes, with relevant quotes gathered within identified themes.

Results

A total of 779 staff members were invited to participate in this study and 286 responded. The results indicate that strategies around infection control practice, personal protective equipment, SARS-CoV-2 testing, workload, financial compensation, religion, psychological support and engaged leadership are deemed important by frontline healthcare workers to maintain their mental wellbeing.

Conclusions

Mitigating factors identified by healthcare workers to protect their psychological wellbeing should inform the organizational strategy. Resources which enhance mental wellbeing should be easily and consistently available to all staff.

ENACT study: What has helped health and social care workers maintain their mental well-being during the COVID-19 pandemic?

A growing body of research has highlighted the adverse impact of COVID-19 stressors on health and social care workers' (HSCWs) mental health. Complementing this work, we report on the psychosocial factors that have had both a positive and negative impact on the mental well-being of HSCWs during the third lockdown period in Scotland. Using a cross-sectional design, participants (n = 1364) completed an online survey providing quantitative data and free open-text responses. A multi-method approach to analysis was used. The majority of HSCWs were found to have low well-being scores, high levels of COVID-19 stress, worry, burnout and risk perception scores and almost half of HSCWs met the clinical cut-off for acute stress (indicative of PTSD). HSCWs with higher scores on adaptive coping strategies and team resilience reported higher scores on mental well-being. HSCWs were significantly more likely to seek informal support for dealing with personal or emotional problems compared to formal supports. Barriers to formal help-seeking were identified including stigma and fear of the consequences of disclosure. HSCWs mostly valued peer support, workplace supports, visible leadership and teamwork in maintaining their mental well-being. Our findings illuminate the complexity of the effects of the COVID-19 pandemic on HSCWs' well-being and will inform future intervention development seeking to increase positive adaptation and improve staff well-being. Addressing barriers to mental health help-seeking among HSCWs is essential. The implications emphasise the importance of lessons learned across health and social care contexts, planning and preparedness for future pandemics.

Supporting nurse leaders to recognise and mitigate the effects of moral injury

The concept of moral injury has been around for several decades, yet its effect on nurses remains under-recognised. Moral injury is defined as the biopsychosocial harm that arises from a violation of one's moral code, meaning that a person is powerless to uphold and enact what they believe is morally right. The coronavirus disease 2019 (COVID-19) pandemic has brought the issue of moral injury into focus because many nurses and other healthcare professionals have encountered potentially morally injurious events, resulting in increased pressure and emotional demands. It is essential that nurse leaders recognise moral injury if its effects are to be addressed. This article describes moral injury and its effects on nurses, and offers nurse leaders a practical framework for mitigating this issue. The framework aims to support nurse leaders to increase their understanding of moral injury, address any ethical challenges, ensure they are adequately prepared to provide support to nurses, and enhance their awareness of various interventions that can mitigate moral injury.

“See us as humans. Speak to us with respect. Listen to us.” A qualitative study on UK ambulance staff requirements of leadership while working during the COVID-19 pandemic

Background

The COVID-19 Ambulance Response Assessment (CARA) study aimed to enable the experiences of UK frontline ambulance staff working during the first wave of the pandemic to be heard. Specifically, CARA aimed to assess feelings of preparedness and well-being and to collect suggestions for beneficial leadership support.

Methods

Three online surveys were sequentially presented between April and October 2020. Overall, 18 questions elicited free-text responses that were analysed qualitatively using an inductive thematic approach.

Findings

Analysis of 14 237 responses revealed participants’ goals and their requirements of leadership to enable those goals to be achieved. A large number of participants expressed low confidence and anxiety resulting from disagreement, inconsistency and an absence of transparency related to policy implementation. Some staff struggled with large quantities of written correspondence and many desired more face-to-face training and an opportunity to communicate with policymakers. Suggestions were made on how best to allocate resources to reduce operational demands and maintain service delivery, and a need to learn from current events in order to plan for the future was stressed. To further support well-being, staff wanted leadership to understand and empathise with their working conditions, to work to reduce the risks and if required, to facilitate access to appropriate therapeutic interventions.

Conclusions

This study demonstrates that ambulance staff desire both inclusive and compassionate leadership. Leadership should aim to engage in honest dialogue and attentive listening. Resultant learning can then inform policy development and resource allocation to effectively support both service delivery and staff well-being.

Relationship between working conditions and psychological distress experienced by junior doctors in the UK during the COVID-19 pandemic: a cross-sectional survey study

OBJECTIVES

This paper explored the self-reported prevalence of depression, anxiety and stress among junior doctors during the COVID-19 pandemic. It also reports the association between working conditions and psychological distress experienced by junior doctors.

DESIGN

A cross-sectional online survey study was conducted, using the 21-item Depression, Anxiety and Stress Scale and Health and Safety Executive scale to measure psychological well-being and working cultures of junior doctors.

SETTING

The National Health Service in the UK.

PARTICIPANTS

A sample of 456 UK junior doctors was recruited online during the COVID-19 pandemic from March 2020 to January 2021.

RESULTS

Junior doctors reported poor mental health, with over 40% scoring extremely severely depressed (45.2%), anxious (63.2%) and stressed (40.2%). Both gender and ethnicity were found to have a significant influence on levels of anxiety. Hierarchical multiple linear regression analysis outlined the specific working conditions which significantly predicted depression (increased demands (β=0.101), relationships (β=0.27), unsupportive manager (β=-0.111)), anxiety (relationships (β=0.31), change (β=0.18), demands (β=0.179)) and stress (relationships (β=0.18), demands (β=0.28), role (β=0.11)).

CONCLUSIONS

The findings illustrate the importance of working conditions for junior doctors' mental health, as they were significant predictors for depression, anxiety and stress. Therefore, if the mental health of junior doctors is to be improved, it is important that changes or interventions specifically target the working environment rather than factors within the individual clinician.

Moral Injury during the COVID-19 pandemic: A delphi model survey of family medicine residents

OBJECTIVES

The objective is to investigate the primary factors that created experiences leading to moral injury in family medicine residents during the COVID-19 pandemic and also to identify any barriers keeping these residents from seeking or receiving help when they experienced moral injury.

METHOD

A DELPHI model study utilizing three rounds of surveys was conducted at four family medicine residency programs in the United States. Resident responses to Survey 1 generated factors perceived to be causing them moral injury or constituting barriers to their seeking help. Thematic analysis identified common themes which were presented to residents in Survey 2 for rating and justification. Results and feedback from Survey 2 were shared with residents in Survey 3, where residents were prompted to reevaluate their ratings for factors and barriers for the purpose of generating consensus among themselves. A ranked list of factors and barriers was thereby created for the participating sites.

RESULTS

Residents shared several stories about the factors that most pressured them to violate their moral values. The most severe and frequent factors contributing to moral injury involved disruptions to doctor-patient relationships, patient-family relationships, and relationships with other healthcare professionals. Time was the major barrier to residents seeking help.

CONCLUSION

During times of crisis, moral injury among residents may be minimized by protecting and promoting important clinical and professional relationships with patients, colleagues, and other medical professionals. While residents report that lack of time was the most significant barrier to seeking help, it is unclear how this complicated and ubiquitous problem would be resolved or mitigated.

Frontline healthcare workers' experiences of providing care during the COVID-19 pandemic at a COVID-19 centre in Bulawayo, Zimbabwe: A phenomenological study

Background

The coronavirus disease 2019 (COVID-19) pandemic has had a far-reaching, negative impact on healthcare systems worldwide. Healthcare workers play a critical role in the country’s healthcare delivery system, as they facilitate a continuum of care and containment of diseases such as the COVID-19 pandemic.

Objectives

The aim of this study was to explore and describe the experiences of healthcare workers who provided care to COVID-19 patients at a central hospital in Zimbabwe.

Method

The researchers used an interpretative phenomenological analysis design. In-depth interviews were conducted virtually with 10 frontline healthcare workers working at a COVID-19 centre in Zimbabwe. Data collection was guided by an interview guide. All audio-recorded interview data were transcribed verbatim into written text. Data analysis was conducted using an interpretative phenomenological analysis framework. An expert in qualitative research acted as an independent co-coder and conducted the open coding of each transcript.

Results

Findings reveal inadequate preparation and training of healthcare providers before the commencement of duty, resources-related challenges and a lack of support as significant experiences of healthcare providers. Moreover, healthcare providers have been subjected to stigma and discrimination attached to COVID-19, resulting in psychological effects on frontline healthcare providers.

Conclusion

The COVID-19 pandemic brings unique and challenging experiences for frontline healthcare workers, resulting in a physically and emotionally drained workforce. This study calls for comprehensive support in the form of counselling, reasonable work schedules, training and adequate provision of personal protective equipment.

Staff support in a National Health Service mental health trust in response to the COVID-19 pandemic: qualitative study

BACKGROUND

The COVID-19 pandemic has highlighted the impact work can have on healthcare workers and the importance of staff support services. Rapid guidance was published to encourage preventive and responsive support for healthcare workers.

AIMS

To understand mental healthcare staff's help-seeking behaviours and access to support at work in response to the COVID-19 pandemic, to inform iterative improvements to provision of staff support.

METHOD

We conducted a formative appraisal of access to support and support needs of staff in a National Health Service mental health trust. This involved 11 semi-structured individual interviews using a topic guide. Five virtual staff forums were additional sources of data. Reflexive thematic analysis was used to identify key themes.

RESULTS

Peer-based, within-team support was highly valued and sought after. However, access to support was negatively affected by work pressures, physical distancing and perceived cultural barriers.

CONCLUSIONS

Healthcare organisations need to help colleagues to support each other by facilitating open, diverse workplace cultures and providing easily accessible, safe and reflective spaces. Future research should evaluate support in the evolving work contexts imposed by COVID-19 to inform interventions that account for differences across healthcare workforces.

Experiences of staff working in a mental health trust during the COVID-19 pandemic and appraisal of staff support services

Purpose

The health and well-being of healthcare staff came into focus during the coronavirus disease-2019 (COVID-19) pandemic as already strained workforces responded to new and additional challenges. Organisational support services made efforts to adapt staff support provision. However, most literature and recommendations are centred on surveys of medical and clinical staff. The present study included staff across clinical and non-clinical workforces within a mental health trust over the course of the COVID-19 pandemic to date, and aimed to understand workforces' access to and experiences of organisational support.

Design/methodology/approach

The current study was a qualitative one using convenience and purposive sampling. Semi-structured individual and group interviews were conducted using a topic guide. Reflexive thematic analysis was used in a phenomenological framework to analyse data.

Findings

35 staff, broadly representative of the trust workforce, were recruited. Six global themes summarised the experiences of staff in relation to work practices, personal well-being and support access over the first year of the COVID-19 pandemic: COVID-19 disease, interpersonal relationships, individual considerations, change, working environment and support.

Practical implications

The findings from the study have implications for organisational support provisions for healthcare workers and the dissemination of these services.

Originality/value

Acknowledging the multi-various experiences of different workforces within National Healthcare Service organisations and how these change over time will facilitate innovative changes to staff support provision.

Sources of Resilience in Frontline Health Professionals during COVID-19

BACKGROUND

While the challenges for psychological well-being for Australian healthcare workers have been documented, there has been a dearth of qualitative research on the sources of resilience that sustained workers during the COVID-19 pandemic. This study identified sources of resilience that clinicians used to cope with frontline challenges during the COVID-19 pandemic.

METHODS

Semi-structured interviews were conducted with 20 frontline health professionals, across five Australian hospitals, between October 2020 and April 2021. The interviews were recorded and transcribed, and the results were analysed using thematic analysis based on a phenomenological approach.

RESULTS

Three sources of resilience were identified by respondents: personal, relational, and organisational. A positive mindset, sense of purpose, and self-care behaviours emerged as key sources of personal resilience. Teamwork, altruism, and social support from family and friends contributed to relational resilience. Leadership, effective communication, and effective implementation of COVID-19 policies were associated with resilience at the organisational level. Frontline healthcare workers also voiced the need for the implementation of further strategies to support personal resilience whilst nurturing resilience within clinical teams and across entire healthcare organisations.

CONCLUSIONS

Trust in healthcare systems, organisation leaders, colleagues, and personal support teams was an overarching theme supporting resilience.

Reinforcement and Maintenance of Human Resources for Health Systems during Long-Term Crises: A Systematic Review of Systematic Reviews

BACKGROUND

Human resources are one of the most critical organizational resources, the reinforcement and maintenance of whom require much energy in health organizations, particularly in long-term crises. Many methods have been suggested in this regard; however, there is a need for their integration and clarification.

METHODS

We systematically searched the international databases, including PubMed, Scopus, and Web of Science, from 2003 to April 2021by using some relevant keywords. The quality of the included studies was assessed using the AMSTAR checklist.

RESULTS

The search resulted in 1613 papers, among which there were 16 systematic reviews. The studies addressed a wide range of problems and solutions. Twelve items and four items were classified with moderate quality (AMSTER score 5-8) and high quality (AMSTER score 9-11), respectively. Half of the studies (n = 8) dealt with mental and psychological problems resulting from crises as the most important factor in the decline of health system staff's durability in organizations. They also provided different solutions such as mental health counselling during and after the crisis, flexible work schedule, promoted trust in the organization, support of staff's family, and enhanced awareness to support employees. And the other articles addressed managerial problems as the most critical factor in the decline of health system staff's durability in organizations and proposed solutions such as suitable planning before, during, and after the crisis and the use of material and spiritual incentives to increase the employees' motivation and organizational resilience to maintain the staff.

CONCLUSION

In the present review study, three dimensions (namely, resilience, motivation-hygiene measures, and development of manager's soft skills) are considered as the main factors reinforcing and maintaining human resources in the health systems in long-term crises and disasters.

'Fix the issues at the coalface and mental wellbeing will be improved': a framework analysis of frontline NHS staff experiences and use of health and wellbeing resources in a Scottish health board area during the COVID-19 pandemic

BACKGROUND

Frontline healthcare staff working in pandemics have been reported to experience mental health issues during the early and post-peak stages. To alleviate these problems, healthcare organisations have been providing support for their staff, including organisational, cognitive behavioural and physical and mental relaxation interventions. This paper reports the findings of a study commissioned by a Scottish NHS health board area during the initial outbreak of COVID-19. The study aimed to understand the experience of NHS staff relating to the provision of wellbeing interventions between March and August 2020.

METHODS

Data were gathered from free-text comments of eight surveys completed by a wide range of staff across sites within one NHS health board in Scotland. We conducted a framework analysis of the data.

RESULTS

Our findings show that despite the provision of relaxational and cognitive behavioural interventions to support staff wellbeing during the early months of the COVID-19 pandemic, there were barriers to access, including heavy workload, understaffing, inconvenient locations and the stigma of being judged. Organisational factors were the most frequently reported support need amongst frontline staff across sites.

CONCLUSIONS

While relaxational and cognitive behavioural interventions were well received by staff, barriers to accessing them still existed. Staff support in the context of organisational factors, such as engagement with managers was deemed as the most important for staff wellbeing. Managers play a key role in everyday organisational processes and therefore are in the right position to meet increasing frontline staff demands due to the pandemic and removing barriers to accessing wellbeing support. Healthcare managers should be aware of organisational factors that might increase job demands and protect organisational resources that can promote wellbeing for frontline staff.

Personal protective equipment utilization practice and psychological preparedness of health care workers against COVID-19 pandemic in Eastern Ethiopia

OBJECTIVES

Effective implementation of prevention and control actions by health professionals is substantial to contain the deadly COVID-19 pandemic. Thus, this study aimed to assess health care worker's practice of using personal protective equipment and psychological preparedness against the COVID-19 pandemic in Eastern Ethiopia.

METHODS

A facility-based cross-sectional study design was used. The health care workers (HCW) who were working in the selected health facilities were randomly selected. Variables that had p-value of < 0.15 were transformed to multivariable logistic regression model. Finally, the significance level was declared at the p-value < 0.05 with a 95% confidence interval (CI).

RESULTS

A total of 418 HCWs were randomly selected and included in this study. The study participants mean age was 27.96 years with a ±5.6SD. HCWs who were male (adjusted odds ratio(AOR) = 2.21, 95% CI: 1.29-3.79), regularly using sanitizer, accessing COVID-19 management guideline (AOR = 2.83, 95% CI: 1.46-5.47), trained on COVID-19 prevention methods (AOR = 2.6, 95% CI: 1.4-4.7), hopeless of eventually getting COVID-19 at workplace (AOR = 1.9, 95% CI: 1.13-3.28), and feeling unsafe at work when using standard precautions (AOR  = 0.46, 95% CI: 0.27-0.79) were associated with good PPE using compared to their counterparts. Moreover, nursing/midwifery professionals practiced good personal protective equipment compared to physicians (AOR = 3.7, 95% CI: 1.8-7.7).

CONCLUSION

The study demonstrated that being a male, being a nurse/midwifery, regularly sanitizing hands/medical equipment, having COVID-19 management guidelines, trained on COVID-19, and feeling of eventually getting COVID-19 at workplace had a positive association with PPE utilization. Besides, the study revealed that not feeling safe at work when using standard precautions was negatively associated with PPE utilization of HCWs. Therefore, the prevention priorities should be given to frontline HCWs by providing all possible support and strictly implementing the prevention and control guidelines of COVID-19 to prevent the health system from collapse.

COVID-19 recovery: implications for cancer care clinicians

The wellbeing of clinicians delivering cancer care needs to be considered and included in recovery roadmaps from the COVID-19 pandemic. In this paper, we refer to a report undertaken by Cancer Australia to review and reflect on the impact of COVID-19 in the delivery of cancer care. The report focused on post COVID-19 recovery and asked 3 questions: What changed? What has been the impact of that change? And how can high-value changes be embedded or enhanced? We suggest the same three questions should also be asked of cancer care clinicians. Using the three Cancer Australia questions, we draw from clinicians’ insights collected through the Victorian COVID-19 Cancer Network (VCCN) and from the wider health professional literature. We summarise key features of the COVID-19 experience for cancer care clinicians, highlighting moral distress, fatigue and disrupted practice. We then discuss how pandemic-related ethical values might guide health leaders and administrators to balance support for clinician wellbeing with ongoing delivery of cancer care for patients.

The Differences in Experiences Among Multi-Level Healthcare Leaders, Between the First and the Second Wave of the COVID-19 Pandemic: Two Cross-Sectional Studies Compared

PURPOSE

To identify the differences in experiences during wave I and II of the COVID-19 pandemic among healthcare leaders.

BACKGROUND

It is expected, that working conditions for COVID-19-pandemic frontline staff will change, as health care organizations have gained experience with handling the consequences of the disease.

METHODS

An online survey was sent out to Danish health care leaders during the first and the second pandemic wave. Comparative analyses were performed in relation to three key characteristics: management level, management education and experiences as a leader.

RESULTS

Eighty-nine health care leaders completed both surveys. Significant differences were found within the entire group across the key characteristics as they felt more prepared for each stage of the situation, they had more influence on the decisions taken, and they felt more concerned about the quality of treatment and care and their own health. Further significant results related to the three key characteristics were found at 1) Management level: The heads of department experienced being better informed, having more overview of their tasks and that these were meaningful. The ward managers experienced being more able to work in consistency with own beliefs and values, though they felt more overloaded. 2) Level of management education: Leaders, without a formal management education, experienced being more supported by staff. 3) Years of experiences as leader: Leaders with more than five years of experience, experienced being more prepared and informed, had more influence on decision-making, and were more worried about their own health.

CONCLUSION

The learning from experience that happens naturally in crisis situations is the reason why the leaders feel more prepared. However, there is a need for further leadership and practice development, to create contexts where leaders feel more ready for all aspects of their role.

Experiences of frontline healthcare workers and their views about support during COVID-19 and previous pandemics: a systematic review and qualitative meta-synthesis

BACKGROUND

Healthcare workers across the world have risen to the demands of treating COVID-19 patients, potentially at significant cost to their own health and wellbeing. There has been increasing recognition of the potential mental health impact of COVID-19 on frontline workers and calls to provide psychosocial support for them. However, little attention has so far been paid to understanding the impact of working on a pandemic from healthcare workers' own perspectives or what their views are about support.

METHODS

We searched key healthcare databases (Medline, PsychINFO and PubMed) from inception to September 28, 2020. We also reviewed relevant grey literature, screened pre-print servers and hand searched reference lists of key texts for all published accounts of healthcare workers' experiences of working on the frontline and views about support during COVID-19 and previous pandemics/epidemics. We conducted a meta-synthesis of all qualitative results to synthesise findings and develop an overarching set of themes and sub-themes which captured the experiences and views of frontline healthcare workers across the studies.

RESULTS

This review identified 46 qualitative studies which explored healthcare workers' experiences and views from pandemics or epidemics including and prior to COVID-19. Meta-synthesis derived eight key themes which largely transcended temporal and geographical boundaries. Participants across all the studies were deeply concerned about their own and/or others' physical safety. This was greatest in the early phases of pandemics and exacerbated by inadequate Personal Protective Equipment (PPE), insufficient resources, and inconsistent information. Workers struggled with high workloads and long shifts and desired adequate rest and recovery. Many experienced stigma. Healthcare workers' relationships with families, colleagues, organisations, media and the wider public were complicated and could be experienced concomitantly as sources of support but also sources of stress.

CONCLUSIONS

The experiences of healthcare workers during the COVID-19 pandemic are not unprecedented; the themes that arose from previous pandemics and epidemics were remarkably resonant with what we are hearing about the impact of COVID-19 globally today. We have an opportunity to learn from the lessons of previous crises, mitigate the negative mental health impact of COVID-19 and support the longer-term wellbeing of the healthcare workforce worldwide.

What support do frontline workers want? A qualitative study of health and social care workers' experiences and views of psychosocial support during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has placed a significant burden on the mental health and wellbeing of frontline health and social care workers. The need to support frontline staff has been recognised. However, there is to date little research specifically on how best to support the mental health needs of frontline workers, and none on their own experiences and views about what might be most helpful.

AIMS

We set out to redress this research gap by qualitatively exploring UK frontline health and social care workers' own experiences and views of psychosocial support during the pandemic.

METHOD

Frontline health and social care workers were recruited purposively through social media and by snowball sampling via healthcare colleagues. Workers who volunteered to take part in the study were interviewed remotely following a semi-structured interview guide. Transcripts of the interviews were analysed by the research team following the principles of Reflexive Thematic Analysis.

RESULTS

We conducted 25 interviews with frontline workers from a variety of professional groups working in health and social care settings across the UK. Themes derived from our analysis showed that workers' experiences and views about psychosocial support were complex. Peer support was many workers' first line of support but could also be experienced as a burden. Workers were ambivalent about support shown by organisations, media and the public. Whilst workers valued psychological support services, there were many disparities in provision and barriers to access.

CONCLUSIONS

The results of this study show that frontline health and social care workers are likely to need a flexible system of support including peer, organisational and professional support. More research is needed to fully unpack the structural, systemic and individual barriers to accessing psychosocial support. Greater collaboration, consultation and co-production of support services and their evaluation is warranted.

Supporting cancer care clinicians to 'hold' their patients during and beyond the COVID-19 pandemic: a role for reflective ethics discussions

The COVID-19 pandemic has placed an overwhelming burden on healthcare delivery globally. This paper examines how COVID-19 has affected cancer care clinicians' capacity to deliver cancer care in the Australian context. We use the lens of 'holding patients' (drawing from attachment theory, psychology and from Australian Indigenous knowledge) to conceptualise cancer clinicians' processes of care and therapeutic relationships with patients. These notions of 'holding' resonate with the deep responsibility cancer care clinicians feel towards their patients. They enrich ethical language beyond duties to benefit, avoid harm, respect patients' autonomy and provide just treatment. We consider the disruptive effects of COVID-19 on care delivery and on clinicians themselves. We then show how models of clinical ethics and other similar reflective discussion approaches are a relevant support mechanism to assist clinicians to process and make sense of COVID-19's disruptions to their professional ethical role of holding patients during and beyond the pandemic.

Health and social care professionals' experiences of providing end of life care during the COVID-19 pandemic: A qualitative study

BACKGROUND

Health and social care professionals' ability to address the needs of patients and their relatives at end of life is likely to have been impacted by the COVID-19 pandemic.

AIM

To explore health and social care professionals' experiences of providing end of life care during the COVID-19 pandemic to help inform current/future clinical practice and policy.

DESIGN

A qualitative interview study. Data were analysed using thematic analysis.

SETTING/PARTICIPANTS

Sixteen health and social care professionals working across a range of clinical settings in supporting dying patients during the first wave (March-June 2020) of the COVID-19 pandemic in the United Kingdom.

RESULTS

Participants reported emotional and practical challenges to providing end of life care during the pandemic, including increases in patient numbers, reduced staffing levels and relying on virtual platforms for sensitive, emotive conversations with relatives. Participants were central to promoting connections between patients and their families at end of life and creating opportunities for a final contact before the death. However, the provision of support varied as a consequence of the pressures of the pandemic. Results are discussed under two themes: (1) challenges and facilitators to providing end of life care, and (2) support needs of relatives when a family member was dying during the COVID-19 pandemic.

CONCLUSION

There is a need for flexible visiting arrangements at end of life during a pandemic. A systems-level approach is necessary to promote the wellbeing of health and social care professionals providing end of life care during and after a pandemic.

Impact of the COVID-19 pandemic on the mental health and well-being of UK healthcare workers

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has had a significant psychological impact on healthcare workers (HCWs).

AIMS

There is an urgent need to understand the risk and protective factors associated with poor mental well-being of UK HCWs working during the COVID-19 pandemic.

METHOD

Shortly after the April 2020 UK COVID-19 peak 2773 HCWs completed a survey containing measures of anxiety, depression, post-traumatic stress disorder and stress, as well as questions around potential predictors such as roles, COVID-19 risk perception and workplace-related factors. Respondents were classified as high or low symptomatic on each scale and logistic regression revealed factors associated with severe psychiatric symptoms. Change in well-being from pre- to during COVID-19 was also quantified.

RESULTS

Nearlya third of HCWs reported moderate to severe levels of anxiety and depression, and the number reporting very high symptoms was more than quadruple that pre-COVID-19. Several controllable factors were associated with the most severe level of psychiatric symptoms: insufficient personal protective equipment availability, workplace preparation, training and communication, and higher workload. Being female, 'front line', previous psychiatric diagnoses, traumatic events, and being an allied HCW or manager were also significantly associated with severe psychiatric symptoms. Sharing stress, resilience and ethical support for treatment decisions were significantly associated with low psychiatric symptoms. Front-line workers showed greater worsening of mental health compared with non-front-line HCWs.

CONCLUSIONS

Poor mental well-being was prevalent during the COVID-19 response, however, controllable factors associated with severe psychiatric symptoms are available to be targeted to reduce the detrimental impact of COVID-19 and other pandemics on HCW mental health.

Mental health of staff working in intensive care during Covid-19

BACKGROUND

Staff working in intensive care units (ICUs) have faced significant challenges during the COVID-19 pandemic which have the potential to adversely affect their mental health.

AIMS

To identify the rates of probable mental health disorder in staff working in ICUs in nine English hospitals during June and July 2020.

METHODS

An anonymized brief web-based survey comprising standardized questionnaires examining depression, anxiety symptoms, symptoms of post-traumatic stress disorder (PTSD), well-being and alcohol use was administered to staff.

RESULTS

Seven hundred and nine participants completed the surveys comprising 291 (41%) doctors, 344 (49%) nurses and 74 (10%) other healthcare staff. Over half (59%) reported good well-being; however, 45% met the threshold for probable clinical significance on at least one of the following measures: severe depression (6%), PTSD (40%), severe anxiety (11%) or problem drinking (7%). Thirteen per cent of respondents reported frequent thoughts of being better off dead, or of hurting themselves in the past 2 weeks. Within the sample used in this study, we found that doctors reported better mental health than nurses across a range of measures.

CONCLUSIONS

We found substantial rates of probable mental health disorders, and thoughts of self-harm, amongst ICU staff; these difficulties were especially prevalent in nurses. Whilst further work is needed to better understand the real level of clinical need amongst ICU staff, these results indicate the need for a national strategy to protect the mental health, and decrease the risk of functional impairment, of ICU staff whilst they carry out their essential work during COVID-19.

An evaluation of REACTMH mental health training for healthcare supervisors

BACKGROUND

Healthcare workers (HCWs) are vulnerable to developing mental ill-health. Prior research has shown those in managerial or supervisory positions have pivotal roles in creating a healthy work environment, as well as recognizing and supporting HCWs with mental health symptoms to improve occupational outcomes and reduce sickness absence.

AIMS

To evaluate the effectiveness of active listening skills training (REACTMH) for UK healthcare managers.

METHODS

Managers of HCWs were voluntarily enrolled on a REACTMH active listening skills training package. Attendees anonymously completed questionnaires before and immediately after attending the 1-h remote training session and again 1 month later. The questionnaire asked about confidence in recognizing, conversing with and supporting distressed colleagues as well as perceived usefulness and importance of the training and how often they had used the taught active listening skills.

RESULTS

Fifty-eight healthcare managers enrolled onto the REACTMH programme in July 2020 and 32 (55%) completed the 1-month follow-up. Just less than half reported feeling confident in being able to identify, speak to and support potentially distressed staff before the training; significantly more (>80%) reported feeling confident 1 month afterwards (P < 0.001). Around three-quarters of attendees reported the REACTMH programme as highly useful, highly important and said they had frequently used the learned skills.

CONCLUSIONS

A brief active listening skills training package was associated with significant improvements healthcare manager's confidence in recognizing, speaking with and supporting HCWs with suspected mental health conditions. Further research is needed to investigate the longer term effectiveness and acceptability of REACTMH training.

The effects of COVID-19 on sickness of medical staff across departments: A single centre experience

INTRODUCTION

COVID-19 presents a risk to healthcare workers, incurring harm to staff physical and mental wellbeing and difficulties in provision of care and service planning.

METHODOLOGY

Doctors' anonymised demographic and staff sickness data were collected between 16 March and 26 April 2020, corresponding with the single centre's greatest COVID-19 caseload.

FINDINGS

128 (39%) of doctors experienced at least one sickness episode. Episodes totalled 1,240 days, equating to a sickness absence rate of 9.1%. Rates varied between departments and grades. High levels of sickness were seen in medicine and both adult and paediatric emergency departments with the lowest levels seen in intensive care.

DISCUSSION

COVID-19 caused a burden of sickness on the medical workforce which must be accounted for in future workforce planning. The disparity in sickness rates across departments is likely to be multi-factorial. Further study is needed to investigate these factors to protect healthcare staff and their patients.

Health Professional Frontline Leaders' Experiences During the COVID-19 Pandemic: A Cross-Sectional Study

PURPOSE

The aim was to identify the differences in experiences of Danish healthcare leaders in the beginnning of the coronavirus (COVID-19) pandemic and to generate knowledge for future leadership during and post crises.

BACKGROUND

The global spread of COVID-19 has affected healthcare systems worldwide and has forced healthcare leaders to face challenges few were prepared for. It is expected that the pandemic may hit in several waves within the next year and therefore healthcare leaders must be prepared for these waves.

METHODS

An online survey was developed, and comparative analyses were performed.

RESULTS

One hundred and sixty hospital leaders were invited, and 72% completed the questionnaire. Significant differences were found within three selected characteristics: 1) Management level: significantly more heads of departments experienced taking complex decisions (P=0.05), being able to work in a way consistent with their beliefs and values (P=0.05), and they were less likely to experience that collaboration with other leaders was adversely affected by the COVID-19 situation compared to ward managers (P=0.04). On the other hand, ward managers were significantly more often worried about both their own health (P=0.01) and their family's health (P=0.04). 2) Management education: those with a formal management education more often experienced having the managerial competences to effectively manage the COVID-19 situation (P=0.00), and performing meaningful tasks during the situation (P=0.04). 3) Years of experience: significantly more leaders with more than five years of experience identified having the managerial competences to effectively manage the situation (P=0.01).

CONCLUSION

Leadership support during a healthcare crisis like the COVID-19 pandemic should strategically focus on ward managers, leaders with no formal management education and leaders with less than two years of experience. Hospital leaders may use this knowledge to re-contextualize what is already known about targeted leadership support during healthcare crises and to act accordingly.