Background

The COVID-19 pandemic is an unprecedented and ongoing global public health crisis. As of October 4, 2022, a total of 96,249,466 COVID-19 cases have been reported in the United States [1]. The COVID-19 pandemic has affected all aspects of life, especially for frontline healthcare workers [2] who are exposed to overwhelming pressure with consequential psychological stress [3].

Qualitative researchers have shown that the COVID-19 pandemic has increased healthcare workers’ workload [4–8]. Additionally, frontline healthcare workers lacked essential resources and personal-protective equipment (PPE) required to safely perform their job duties and provide patient care [9–11]. Along with workload and resource-related challenges, the persistent physical and emotional demands of caring for patients during a pandemic have exacerbated previous barriers to workplace well-being [12]. Healthcare workers have experienced high levels of burnout and psychological distress [13–20] as well as adverse physical effects during the COVID-19 pandemic [21–23]. Globally, the numerous challenges caused by COVID-19 have led to increased mental health issues, such as anxiety and depression [12, 24, 25] among healthcare workers [26]. Healthcare workers have experienced post-traumatic stress disorder (PTSD) [27–29] and suicidal ideation [16, 30, 31].

The COVID-19 pandemic has affected the U.S. healthcare system and its workers significantly. A poll from September 2021 completed by 1,000 U.S. healthcare workers revealed that since February 2020, increasing numbers of healthcare workers have either quit (18%) or lost their jobs (12%) during the pandemic, while 19% have considered leaving their employer or the healthcare field entirely [32]. Additionally, some healthcare workers have been fired or resigned over vaccination mandates [33] or have developed “long-COVID” and can no longer work [34]. The American Association of Critical-Care Nurses (ACCN) surveyed more than 6,000 acute and critical-care nurses and found that 66% of nurses have considered leaving nursing after their pandemic experiences, while 92% believe the pandemic has exhausted nurses and will cut their careers short [35]. As healthcare workers are leaving the frontlines, critical staffing shortages are overwhelming hospitals in the United States, which may intensify workplace challenges encountered by frontline healthcare workers who report relentless emotional and physical exhaustion [34, 36, 37].

This study was conducted to obtain a comprehensive understanding of the experiences of essential workers, including healthcare workers, support personnel, and first responders, during the COVID-19 pandemic. This study provides a description of the experiences of essential workers working in healthcare facilities or in the community during the COVID-19 pandemic from May 2020 –June 2021 in the United States.

Methods

This qualitative descriptive study is part of an effort to explore the effects of the COVID-19 pandemic on essential workers employed in settings and interacting with individuals infected with coronavirus (SARS-CoV-2). The study, the COVID-19 Study and Registry of Healthcare and Support Personnel (CHAMPS), was approved by the Villanova University Institutional Review Board (IRB) and conducted through the Internet. Written informed consent was obtained from each participant prior to enrolling in the study and was approved by the IRB. An invitation describing the study was sent by email to essential workers through websites of professional organizations, alumni societies, news media, professional and trade groups, social media, and healthcare facilities that treated patients with COVID-19. The CHAMPS study was initiated in the early acute phase of the U.S. pandemic in the spring of 2020 [38].

Data were collected for the CHAMPS study using an online survey that asked for demographic and professional characteristics, and included measures of anxiety, depression, social support, traumatic distress, and insomnia. Participants were invited to provide a free-text response to the following: “If you wish, please describe your experiences during the COVID-19 pandemic in as many words as you need.” Data analyzed for this paper are limited to the responses to the free-text open-ended survey item.

For the purposes of this study, "essential worker" was defined as those directly or indirectly working with individuals with confirmed or suspected COVID-19, for example, healthcare personnel, support personnel, and first responders [38]. Participants were adult workers ages 18 years or older who self-identified as essential healthcare personnel (e.g., physicians, nurses, phlebotomists, respiratory therapists, pharmacists), support personnel (e.g., laboratory staff, food service), or first responders (e.g., police officers, firefighters, emergency medical technicians, paramedics) working in any healthcare facility or in the community. Enrollment occurred over 13 months, from May 2020 through June 2021, in the United States.

A total of 2,762 essential workers participated in the CHAMPS study and 1,079 (39%) of them provided a response to the open-ended survey item. These responses from the participants were downloaded to a separate text file that allowed the research team to analyze the free-text responses.

Thematic analysis [39] was used to analyze the responses. The first three authors read all text responses to identify meaningful statements provided by participants. Next, the researchers organized and coded those statements with labels that reflected the responses. Throughout the coding process the researchers focused on identification of issues, similarities and differences revealed in the participants’ responses. The researchers met to reflect on the data during the analysis process. Coding was performed by hand on each text response, and each researcher’s individual codes were found to be representative of the participants’ responses.

Three members of the research team met to discuss the preliminary codes or labels and came to consensus on them. The researchers then went back to the responses and categorized meaningful statements they identified that were consistent with the codes. At subsequent weekly meetings over a period of several months, the team discussed examples of meaningful statements and together revised or refined codes. The themes were organized from the codes with a focus on the participants’ quotes. In the process of developing the themes, the researchers worked with the codes in a comprehensive and meaningful way while being faithful to the data. With further discussion, four themes and eight subthemes were identified. Trustworthiness and rigor of the study were addressed by the interaction and collaboration among the researchers throughout the process and in several research team meetings. Since responses were anonymous, member checking was not possible. The researchers followed the COREQ guidelines [40] in this study.

Sample

The demographic characteristics of the 1,079 participants are described in Table 1. Most participants were female (85%, n = 917), White non-Hispanic (85.7%, n = 925), and engaged in clinical or support service activities involving direct care of patients with diagnosed or suspected COVID-19 (86.9%, n = 937). Almost 75% of participants worked in hospital settings during the pandemic (large/metropolitan hospitals (35%, n = 378), suburban/regional hospitals (27.4%, n = 296) and rural/community hospitals (10.8%, n = 116) and had various job roles. All the job categories self-identified by the participants are included in Table 1.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Demographics.

https://doi.org/10.1371/journal.pone.0282946.t001

Results

Four themes and eight sub-themes were identified through thematic analysis of the responses to the open-ended survey item. The themes were: Facing hopelessness, yet looking for hope; Witnessing frequent death; Experiencing disillusionment and disruption within the healthcare system, and Escalating emotional and physical health problems. Participants’ statements were extracted for each theme and subtheme to capture their views, feelings, and personal situations.

Discussion

This study explored the experiences of essential workers from a variety of disciplines, working in multiple healthcare and community settings in the United States. Participants shared their written narratives in May 2020 –June 2021 as they were living and working during the COVID-19 pandemic. It was noted that the length of typed responses ranged from one or two words to 1,407 words. Most of the open-ended responses ranged from 274 to 536 words in length. (Typically, one typed page is appropriately 500 words single spaced.) This information is noteworthy, since essential workers who were engaged in caring for people with COVID-19, experiencing excessive workplace demands, and numerous emotions, took the time to write about their situations and express their feelings.

They felt very overwhelmed and reported hopelessness almost to the point of despair as they faced unprecedented and relentless challenges and expressed concern about the uncertainty of the future. Similar responses have been reported in other studies [4, 10, 19]. The stressful and chaotic situations frequently endured were out of the workers’ control. As participants were working tirelessly in their respective settings, they questioned if they were making a meaningful difference in their efforts, which also contributed to their sense of hopelessness.

Despite the hopelessness and despair the participants experienced; they expressed hope for more effective ways to care for individuals with COVID-19. Participants persevered, searched for hope, and identified some positive aspects of living and working though the pandemic. A sense of camaraderie and teamwork prevailed among workers, which has also been reported in other studies [8, 14, 41]. Also similar to other studies’ findings [18, 41–43] workers in our study identified self-care modalities, such as exercising, that assisted with coping.

Because of the toll of high stress levels on their health, new health problems among study participants developed and existing physical and psychological health issues intensified. Examples of physical conditions, such as asthma, diabetes, hypertension, chronic fatigue syndrome, autoimmune disorders, and dermatological conditions, were exacerbated. As their stress levels increased and were prolonged, some experienced daily episodes of anxiety leading to panic attacks, stress headaches culminating in migraines, bouts of shortness of breath, and terrifying nightmares. These findings reflect the interrelationship of physical symptoms and psychological distress [21] and are similar to those of other studies in which the study participants experienced physical symptoms and mental health issues [2, 10, 13, 22, 23, 27–29].

Experiences related to the deaths and dying of multiple patients with COVID-19 were particularly traumatic and disturbing for participants. This was especially evident among nurses working in hospital settings, as they watched patients in their care die alone without the presence or family or loved ones at the bedside [7, 44]. Other studies have identified the absence of family members at the bedside of acutely ill patients as distressing to healthcare workers even if the patient was not dying [45, 46]. The number of patients who died and the disturbing nature and circumstances of their deaths, without family members present, were particularly distressing to participants. Many felt ill prepared to provide end-of-life care and had little support, except from their co-workers, to cope with the situation. Researchers [47] described the moral distress of healthcare professionals concerned about end-of-life care, who were unable to allow family members at the bedside of dying patients because of imposed visitor restrictions.

Many participants in this study conveyed strong disillusionment with the administrators, the health care system, and the national political response to the pandemic. Although participants were dealing with inadequate PPE, inadequate staffing, lack of support for staff, and fear of contracting or spreading the virus, administrators were largely invisible, unavailable, unresponsive, noncommunicative, and seen as concerned more about the financial risks of healthcare systems rather than the well-being of the workforce. Participants also expressed disillusionment with many in their communities who questioned the seriousness of COVID-19 infection and ignored guidelines designed to minimize risks, such as use of masks and social distancing. Participants reported being ostracized by their communities because they worked with and provided care for patients with COVID-19, which has been reported in other studies [8, 48]. These responses further increased the stress of participants in the study.

An important point related to our data collection strategy is the unique method used to collect responses of essential workers during the COVID-19 pandemic. Data were collected through a single, open-ended survey item, that allowed participants to write about their own personal experiences. The open-ended survey item invited participants to write about any aspect of their experience during the pandemic that they wanted to share, which may have been similar to journaling for some participants as other researchers have found that expressive writing can help mitigate psychological distress [49]. During a time of uncertainty and stress, participants had the opportunity to write about their pandemic experiences and perceptions, as they were happening in real time. Other researchers have reported journaling to be a valuable self-care strategy during the COVID-19 pandemic [43] and an effective strategy to support home care workers [5].

It is also important to note that this method of data collection required participants to write their response, rather than talking about their experiences with another person (i.e., interview), which may have influenced the content and wording included in the responses. Similarly, other researchers [50] launched an anonymous website for community workers that provided an outlet for unprompted and uncensored stories of healthcare workers.

Several limitations of the study included the inability of the researchers to determine the experiences of participants in the CHAMPS study who did not respond to the open-ended survey item and the reasons they elected not to do so. It is unknown if the non-respondents had the same experiences or were too distressed to respond to the item, did not take or have the time to respond, or were fearful that expressing their personal situations may somehow become known to their employers. Since the survey was anonymous, it was not possible to conduct member checks. The study sample was primarily comprised of white females and lacked gender, ethnic, and racial diversity.

The notable strengths of the study included the large number of people (n = 1,079) who responded to the open-ended question and took the time to share their situations candidly, with extensive uninhibited disclosure of detail and without notable reservation. Participants had the freedom and the opportunity to express and convey their thoughts and feelings as they were living through the pandemic. The intensity and timeliness of the participants’ experiences were captured in their written narratives. This may be particularly true in those participants who wrote multiple pages of comments, and our method of data collection may have given voice to those who may not otherwise be heard.

Conclusion

This study revealed major psychological and physical stress among essential workers employed in healthcare and community settings during the early phases of the COVID-19 pandemic in the United States, leading to despair and a sense of hopelessness. High levels of stress and distress resulted from uncertain and often overwhelming working conditions, lack of protocols for caring for patients with COVID-19, threats to participants’ physical safety and mental health, witnessing multiple disturbing deaths, absence of family members at dying patients’ bedside, lack of adequate physical and emotional support from administrators, and a sense of being abandoned by community members. The severity and prevalence of major psychological and physical stress experienced by essential workers during the COVID-19 pandemic may take years before healing and reconciliation can occur. Administrators’ recognition and appreciation of the highly stressful situations experienced by workers are essential to begin to repair the relationships that have been damaged or destroyed as a result of the negative experiences reported by participants in this study. Understanding highly stressful experiences during the pandemic is essential to identify and implement strategies that ameliorate stress and prevent its negative consequences, and to restore confidence and trust of administrators and the healthcare system on the part of healthcare personnel, support personnel, and first responders. Those affected need to be part of the process of developing interventions to address these issues now and in future pandemics. This study adds to the research on the psychological and physical impact of the pandemic on workers, including non-clinical support personnel often overlooked as experiencing major negative effects.

Relevance to clinical practice

Naming and understanding the multitude and magnitude of highly stressful experiences during the pandemic are essential to building strategies that ameliorate stress and prevent its negative consequences. The experiences, exhaustion, and vulnerability of the participants who relentlessly continued to care for very ill patients diagnosed with the COVID-19 virus were not addressed by healthcare administrators. Awareness of the events and challenges that were occurring with essential workers during the pandemic need to be the focus of administrators in real time. The question, who cares for the caregivers? must be addressed and resources must be immediately available during times of crisis. The value of the healthcare and related workforce must be acknowledged through the actions of agencies and institutions to provide strong, effective, and equally important, visible leadership. The most salient characteristics of leadership desired by participants in this study during the COVID-19 pandemic were communication, collaboration, teamwork, flexibility, empathic understanding, and transparency. There was a strong need for involvement of all stakeholders as the healthcare environment experienced both clinical and operational transformation.

Preparation for potential health crises and possible future pandemics, as well as ensuring the availability of both internal and external resources based on the experiences described in this study is essential. Administrators must be actively involved in not only allocating resources for patient care and the safety of the workers, but also for ensuring the availability of relevant human resources required for the psychological and physiological well-being of all staff. Being present and continuing tangible demonstration of their support and commitment is meaningful to workers. This study adds to the identified psychological and physical impacts of the pandemic on essential workers, including non-clinical support personnel who are often overlooked, as experiencing profound negative effects from the on-going COVID-19 pandemic.