The coronavirus disease 2019 (COVID-19) pandemic led to fundamental changes in the workplace for many, particularly healthcare workers.
This study explored healthcare workers’ (ophthalmologists, nurses and support staff) experiences of anxiety, depression, burnout, resilience and coping strategies during lockdown Levels 2 and 3 in an Ophthalmic consulting practice and hospital in South Africa.
The increased workplace stress and vulnerability associated with working during the COVID-19 pandemic introduced an unprecedented level of risk for healthcare workers. Factors contributing to psychological distress must be identified and appropriately mitigated, to prevent dire human and economic costs.
A survey was sent out at two separate times to a convenience sample of 31 and 15 healthcare workers respectively. The survey consisted of a demographics section, Hospital Anxiety and Depression Scale, Burnout Measure short-version, Brief Cope Inventory, Connor Davidson Resilience Inventory and six open-ended questions investigating personal health and support experiences during COVID-19. Descriptive analyses and thematic analysis were used for data analysis.
The sample of healthcare workers experienced some degree of psychological distress, including anxiety, burnout and a lack of social support on both surveys. However, these symptoms were alleviated by personal factors, including positive coping mechanisms, high resilience and organisational support.
Healthcare facilities should consider in-house structures focusing on building resilience and positive coping mechanisms, whilst ensuring that workplace conditions are optimal for staff members.
This study provides some insight into both the risk and protective factors experienced by health workers during the COVID-19 pandemic.
On 30 January 2020, the coronavirus disease 2019 (COVID-19) pandemic was declared as a public health emergency of international concern (World Health Organization,
This study aims to contribute to an understanding of the psychological states, resilience and coping mechanisms of South African healthcare workers during the COVID-19 pandemic.
In an attempt to curb the spread of the coronavirus, extreme measures have been imposed globally, including restricting travel, quarantining citizens and social distancing measures. With this regard, South Africa is no exception, with the country experiencing an extensive countrywide lockdown from the 23 March to 23 April 2020 (South African Government,
Whilst the literature primarily describes HCWs as healthcare professionals (doctor, nurse, psychologist, etc.), for the purposes of this study, ‘healthcare worker’ is broadly defined to include anyone involved in care and/or healthcare work, for example, health professionals, student clinicians, cleaners and receptionists. All healthcare staff are at risk and as such, it is necessary to understand the challenges experienced by all in this context and the subsequent effect that this may have on their work performance.
Prior to the COVID-19 pandemic, the South African healthcare system was burdened and under severe strain as a result of the lack of resources, personnel and critical facilities, as well as the considerable number of patients living with human immunodeficiency virus (HIV), tuberculosis, malnutrition and diabetes (George, Quinlan, Reardon, & Aguilera,
With the continued spread of the virus globally, patients, HCWs and the general public around the world are facing unprecedented psychological stress, as well as pressure to adapt to new working conditions (Benítez et al.,
Contributing factors to HCW’s psychological stress include working with a poor understanding of the virus and new and frequently changing protocols, increased use of personal protective equipment (PPE), prolonged working hours and inadequate hospital equipment (George et al.,
Healthcare professionals appear to experience great psychological stress whilst at work but are also faced with social isolation and quarantine measures when at home. This represents another contributing factor to HCW’s psychological stress (Chersich et al.,
Despite these challenges, there is evidence that positive coping skills, organisational support and resilience may mitigate the risk of burnout and PTSD (Howlett et al.,
The following questions were considered to conduct this study:
What are the levels of depression, anxiety, burnout, resilience and coping mechanisms amongst healthcare workers actively working during the COVID-19 pandemic?
What are the qualitative, lived experiences of healthcare workers actively working during COVID-19?
The study followed a longitudinal, non-experimental research design, where staff members from the East London Eye Centre completed an online questionnaire via Survey Monkey. The first survey commenced on 01 June 2020 and closed on 31 July 2020. The follow-up survey occurred on 10 August 2020 and closed on 20 September 2020, which corresponded with the lockdown Levels 3 and 2 in South Africa.
This study was conducted in a private, urban ophthalmic clinic in East London, which caters for much of the rural population in the Eastern Cape. A non-probability convenience sample of 31 of the available 50 staff members of the Eye Centre participated in the first survey and 15 staff members participated in the second survey (see
Demographic variables for time 1 and 2.
Demographics | Variable | Time 1 | Time 2 | ||
---|---|---|---|---|---|
Frequency | Percentage | Frequency | Percentage | ||
Gender† | Female | 22 | 78.6 | 11 | 73.3 |
Male | 6 | 21.4 | 4 | 26.7 | |
Home language‡ | Afrikaans | 9 | 32.1 | 5 | 33.3 |
English | 15 | 53.6 | 10 | 66.7 | |
IsiXhosa | 2 | 7.1 | - | - | |
Setswana | 2 | 7.1 | - | - | |
Highest level of education | Other | 2 | 6.7 | - | - |
Pre-school | 1 | 3.3 | - | - | |
Primary school | 1 | 3.3 | - | - | |
Some high school | 2 | 6.7 | - | - | |
Matric | 5 | 33.3 | 3 | 20.0 | |
Undergraduate degree or diploma | 7 | 23.3 | 5 | 33.3 | |
Honours | 4 | 13.3 | 3 | 20.0 | |
Master’s | 3 | 10.0 | 4 | 26.7 | |
Religious affiliation | Other | 2 | 6.5 | - | - |
No religion | 3 | 9.7 | 2 | 13.3 | |
Christianity | 26 | 83.9 | 13 | 86.7 | |
Number of children | 0 | 7 | 22.6 | 4 | 26.6 |
1 | 6 | 19.4 | 3 | 20.0 | |
2 | 9 | 29.0 | 4 | 26.6 | |
3 | 5 | 16.1 | 3 | 20.0 | |
4 | 4 | 12.9 | 1 | 6.7 | |
Relationship status§ | Yes | 16 | 53.3 | 10 | 66.7 |
No | 14 | 46.7 | 5 | 33.3 | |
Marital status | Yes | 16 | 51.6 | 9 | 60.0 |
No | 14 | 48.4 | 6 | 40.0 | |
Chronic condition | Yes | 10 | 33.3 | 4 | 26.7 |
No | 20 | 66.7 | 11 | 73.3 | |
Chronic medication | Yes | 11 | 35.5 | 4 | 26.7 |
No | 20 | 64.5 | 11 | 73.3 | |
Living condition | Alone | 3 | 9.7 | 1 | 6.7 |
With a partner | 6 | 19.4 | 6 | 40.0 | |
With a partner and child | 11 | 35.5 | 5 | 33.3 | |
With children | 4 | 12.9 | 2 | 13.3 | |
With immediate family | 6 | 19.4 | 1 | 6.7 | |
With other relatives | 1 | 3.2 | - | - |
Note:
The online questionnaire consisted of three sections, namely, demographic, mental health screening instruments as well as open-ended questions. The following demographic variables were requested from the participants: age, gender, home language, highest level of education, current occupation, chronic psychical or mental health condition, chronic medication, marital status, relationship status, place of professional training, number of years practising at the site as well as number of years practising since graduating.
Depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS). The HADS has two subscales, namely, anxiety and depression. Both subscales consisted of seven items each and a four-point response-format. Each item had a unique anchor (0–3). The HADS has been validated on a sample of HIV and/or acquired immune deficiency syndrome (AIDS) patients in South Africa (insert ref). The internal consistency reliability coefficients for the anxiety and depression subscales were excellent at 0.86 and 0.81, respectively. The HADS has been validated in a community setting (Snaith,
Burnout was measured utilising the Burnout Measure – Short Version (BMS-S). The measure consists of 10 items which assess the frequency of experiencing symptoms of mental, emotional as well as physical exhaustion. Participants were required to respond to the items using a seven-point Likert scale (
Coping skills were assessed using the brief COPE inventory, which consists of 28 items, and 14 subscales, namely, Self-Distraction, Active Coping, Denial, Substance Use, Use of Emotional Support, Use of Informational Support, Behavioural Disengagement, Venting, Positive Reframing, Planning, Humour, Acceptance, Religion and Self-Blame. Each subscale consists of two items. A four-point Likert scale response format was used for participants to rate how they utilised a particular coping mechanism during a stressful situation. As a result of this study being conducted during lockdown Level 4, item 19 relating to going to the movies was removed. Kotzé, Visser, Makin, Sikkema and Forsyth (
Resilience was measured using the CD-RISC-10 (Connor-Davidson Resilience Scale) (Campbell-Sills & Stein,
Six open-ended questions were presented to the participants to gain a more in-depth understanding of their lived experiences of working during the COVID-19 pandemic. The questions were concerned with the participants’ experience of work as the COVID-19 outbreak began in South Africa, their general health during this time and their support mechanisms at home and at work. The last question asked what the participant would tell the Minister of Health, if given the opportunity.
The surveys were distributed online as well as in hard copy for the convenience of the staff members who did not have access to the internet or a computer. Initial contact with participants was initiated via an email disseminated to both consulting and hospital staff. The email gave a brief overview of the study and offered a link to a SurveyMonkey survey. Once informed consent was given, the participants had access to the survey. Participation was anonymous unless participants provided contact information for a follow-up interview. Lastly, the participants were provided with details of free telephonic counselling if they experienced any distress whilst completing the survey. The survey comprised three sections, which took approximately 20–25 min to complete. Once the data were collected, they were analysed and coded by one of the researchers and the appropriate analyses were conducted.
Quantitative data were analysed using SPSS Version 27 (IBM Corp,
The study was approved by Human Ethics Committee (Medical) at the University of the Witwatersrand (clearance number: M200461) and permission was granted by the board of the clinic. Surveys were distributed online as well as in hard copy to help the staff members who did not have access to the internet or a computer. Initial contact with the participants was initiated via an email disseminated to both consulting and hospital staff.
The email gave a brief overview of the study and offered a link to a SurveyMonkey survey. Once informed consent was given, the participants had access to the survey. The survey comprised three sections, which took approximately 20–25 min to complete. Once the data were collected, they were analysed and coded by one of the researchers and the appropriate analyses were conducted. Participation was anonymous unless participants provided contact information for a follow-up interview. Lastly, the participants were provided with details of free telephonic counselling if they experienced any distress whilst completing the survey.
Overall, as evidenced, healthcare workers at the East London clinic present with good psychological health (
Descriptive statistics for time 1 and 2.
Mental health variable | Time 1 | Time 2 | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
Minimum | Maximum | Mean | SD | Minimum | Maximum | Mean | SD | |||
31 | 0 | 17 | 7.678 | 4.423 | 15 | 1.00 | 13.00 | 5.887 | 3.226 | |
HADS depression subscale | 31 | 0 | 14 | 5.355 | 3.937 | 15 | 0.00 | 12.00 | 4.667 | 3.716 |
Self-distraction | 31 | 0 | 6 | 3.129 | 1.839 | 15 | 1.00 | 6.00 | 2.800 | 1.613 |
Active coping | 31 | 1 | 6 | 4.000 | 1.633 | 15 | 0.00 | 6.00 | 3.267 | 1.831 |
Denial | 31 | 0 | 6 | 1.226 | 1.309 | 15 | 0.00 | 5.00 | 0.867 | 1.457 |
Substance use | 31 | 0 | 6 | 0.903 | 1.660 | 15 | 0.00 | 6.00 | 0.533 | 1.552 |
Use of emotional support | 31 | 0 | 6 | 2.742 | 1.861 | 15 | 0.00 | 5.00 | 2.733 | 1.792 |
Use of instrumental support | 31 | 0 | 6 | 3.000 | 1.862 | 15 | 0.00 | 5.00 | 2.600 | 1.454 |
Behavioural disengagement | 31 | 0 | 6 | 1.032 | 1.581 | 15 | 0.00 | 4.00 | 0.467 | 1.060 |
Venting | 31 | 0 | 6 | 2.613 | 1.498 | 15 | 0.00 | 4.00 | 1.800 | 1.265 |
Positive reframing | 31 | 0 | 6 | 3.355 | 1.664 | 15 | 0.00 | 6.00 | 3.733 | 2.052 |
Planning | 31 | 0 | 6 | 3.742 | 1.673 | 15 | 0.00 | 6.00 | 3.267 | 2.052 |
Humour | 31 | 0 | 6 | 1.677 | 1.620 | 15 | 0.00 | 5.00 | 1.933 | 1.981 |
Acceptance | 31 | 0 | 6 | 4.387 | 1.606 | 15 | 2.00 | 6.00 | 4.600 | 1.121 |
Religion | 31 | 0 | 6 | 3.581 | 2.078 | 15 | 0.00 | 6.00 | 3.400 | 1.920 |
Self-blame | 31 | 0 | 6 | 1.323 | 1.514 | 15 | 0.00 | 4.00 | 0.9333 | 1.100 |
30 | 9 | 40 | 26.733 | 8.820 | 14 | 15.00 | 39.00 | 30.000 | 6.680 | |
30 | 11 | 48 | 27.90 | 10.142 | 15 | 12.00 | 42.00 | 25.600 | 8.492 |
HADS, Hospital Anxiety and Depression Scale; SD, standard deviation.
Overall, the qualitative data highlighted that the majority of healthcare workers experienced anxiety because of personal and occupational stressors whilst working during the COVID-19 pandemic. However, their anxiety seemed to be buffered by positive organisational support, high levels of resilience and positive coping mechanisms.
Across both the consulting practice and hospital staff, anxiety was a considerable stressor during their experience of providing healthcare during the time 1 (
Focussing on personal distress, majority (
Furthermore, some participants (
Lastly, financial concerns arose for some participants (
Occupational stress was evident in many of the sample (
‘Nothing is normal anymore. Business is not the same as usual. Life changing moments and a sense of responsibility for your own safety and taking care of your colleagues, customers and doctors to be safe.’ (Participant 21, female, 53 years old)
The new routines, processes and added responsibility seemingly added occupational stress onto staff members.
At time 2, personal stressors, particularly financial viability of the site was still a central point of anxiety (
Occupational distress during time 2 was alluded to by majority of the healthcare workers (
Furthermore, COVID-19 safety protocols required that the staff have less contact with patients and other staff members, which meant that they had to adjust their daily habits, routines and procedures in their job roles. For instance, Participant 5 (male, 56 years old) commented on how they resented the ‘tedious’ procedures, such as the cleaning. However, other participants (
However, implementing and adjusting to these changes appeared to be central to alleviating anxieties and mitigating uncertainty. At time 1, this was evident as Participant 6 (female, 29 years old) noted how the process was ‘challenging initially, but once we had all the correct processes in place, it was a lot easier’. At time 2, participants seemed to demonstrate a stronger acceptance of the ‘new normal’ of operations under COVID-19 and many of the staff (
Excellent organisational communication, good personal health and social support were identified as psychosocial buffers mitigating the distress experienced by working during COVID-19 (time 1
Central to this was the leadership of the doctors and managers, particularly with regard to sharing and accessibility of information and resources. Participants recognised the value of having a part-time consultant coach at the site, because of her offering much in the way of workshops, training and opportunities to debrief during this time. Furthermore, participants reported being grateful for their good health and the social support offered to them by colleagues and co-workers. There was little doubt about the support mechanisms provided by the organisation as exhibited by Participant 13 (female, 31 years old), who commented on the ‘Good communication with staff and coping strategies/availability with our in-house coach’.
The constant support that doctors, managers and colleagues offered in creating a safe and supportive environment was instrumental in helping HCWs to cope with the challenges. Participant 30 (female, mid-50s) indicated, ‘We can speak to anyone who is prepared to listen. Our managers are amazing. Always have time for us’. Such organisational support is likely to function as an important protective buffer for participants. This was particularly evident because of a relatively high number of HCWs who reported that they have no social support other than what they get at work, which was consistent at both time 1 (
This study investigated mental health experiences of healthcare workers at a private ophthalmic clinic in the Eastern Cape. Overall, the results indicated differences between quantitative results and those obtained through qualitative methods. The quantitative results indicated that HCWs generally experienced generally good psychological health. In addition, from time 1 and 2, it was evident that anxiety, depression and burnout levels decreased, but this could not be tested significantly in the small sample. However, the qualitative responses suggest that HCWs experienced considerable anxiety at both times, particularly at time 1. The HCWs’ ability to cope with the new normal at work is attributed to organisational factors, including organisational support and clear communication, as well as personal factors, including coping strategies and resilience.
Based on the quantitative scales, the HCWs presented with good psychological health and seemed to be relatively unaffected by anxiety, depression and burnout. The qualitative responses were examined with a particular focus on work performance, which indicated that some HCWs were in fact experiencing considerable anxiety and experiencing challenges in their daily roles. The qualitative experiences of mental health are consistent with literature that posits that HCWs are vulnerable to anxiety during times of transition and difficulty (Labrague & De los Santos,
The qualitative results offered further insight, into the very real experience of anxiety that resulted from personal and occupational stressors of working during the COVID-19 pandemic. Personal stressors included concerns related to HCWs’ health, potential of transmission, finances and family balance across time 1 and 2 of the study. This finding is aligned with current research, which suggests that HCWs experience considerable anxiety around becoming infected or unknowingly infecting others (Mo et al.,
Occupational stressors included operational difficulties, insufficient personnel, change in job roles, procedures and routines and the increased use of PPE. An interesting dilemma was introduced in that increased protective procedural steps and process were implemented to manage much of the uncertainty HCWs were experiencing; however, these were resented and perceived as tedious. According to the literature, new operational procedures and increased use of PPE can be stressful to HCWs and may become detrimental to their performance (Benítez et al.,
Despite the existence of considerable stressors identified in the qualitative responses, HCWs did not display high levels of stress, anxiety and burnout in the quantitative measures. This finding was not in line with expectations, but may be attributed to the various forms of support that this sample of HCWs received.
One form of support available to this sample included positive leadership by management, who focussed on communication and support of the HCWs. Transparent and honest communication of the realities of the situation, including the finances, and provision of informational resources seemed to play a positive role in making HCWs feel informed. Accessibility to a coach and the managers was essential in making participants feel that their concerns were heard. This seems to have been a constant theme within COVID-19 research, as the importance of communication with HCWs regarding challenges, uncertainties and strategies seems to play a major role in helping them cope with the unprecedented circumstances (Walton et al.,
Organisational support seemed to be particularly pertinent, as this influences the provision of resources, reinforcement, encouragement and communication with employees (Labrague et al.,
Participants drew on positive coping strategies at both points in this study. At both time 1 and 2, active coping was positively endorsed by HCWs, but this was the only common coping strategy. At time 1, participants relied on the coping styles of planning and religion, whilst at time 2, participants reported relying on coping styles of acceptance and positive framing. This finding is interesting, as participants relied heavily on active coping, but also adopted new strategies in different phases of the pandemic. For instance, at time 1, uncertainty ‘ruled’ and participants relied on religion and planning. However, at time 2 when there was slightly more certainty, participants seemed to accept reality and try to see it in a positive manner. This can inform future coping strategy interventions to target these coping strategies at different phases of a crisis in future (Zhu et al.,
This finding is consistent with previous literature, as positive coping strategies have been associated with decreased psychological distress, anxiety and stress amongst HCWs (Zhu et al.,
Participants displayed good levels of resilience at both measurement opportunities. In fact, participant’s resilience increased across the two measurements. Research suggests that resilience, or an individual’s capacity to ‘bounce back’ from stress (Hart, Brannan, & De Chesnay,
Healthcare workers have been exposed to significant occupational and situational stress whilst working during the COVID-19 pandemic. It is suggested that organisational and individual interventions play a role in helping healthcare workers manage this stress. In this study, the institution, leadership and management played a key role in creating an environment where HCWs felt safe and supported, especially in times of crisis. This finding indicates that these stakeholders are core in protecting HCWs and ensuring a productive workplace (Di Tella, Romeo, Benfante, & Castelli,
On an individual level, HCWs should undergo training or receive support in developing resilience and positive coping strategies as these seem to act as a buffer against anxiety, depression and burnout. For instance, it may be useful to encourage different coping mechanisms at different stages of a threatening situation to aid employees in coping and responding optimally to the situation. Developing positive coping strategies and resilience could be supported by short-term interventions or regular check ins with colleagues and management to maintain accountability and a sense of a support structure (Labrague et al.,
Whilst this study offered useful insight into HCWs real lived experiences of working during COVID-19, it must be acknowledged that this is a small sample of HCWs who worked in a private consulting and hospital context. Of the 50 available staff members, only 62% (
This study highlights the importance of organisational support and indicates why protecting HCWs’ well-being is a crucial tool in ensuring an effective and sustainable response to the public health emergency South Africa is currently facing. In this study, HCWs were able to maintain a normal level of mental health and although they faced challenges, their performance did not seem to be significantly impacted. Personal resilience, positive coping strategies and organisational support were identified as vital factors protecting against anxiety, depression and burnout in HCWs. This study indicates how the accessible organisational support and communication helped the staff members to draw on positive coping skills and resilience so that they did not exhibit unhealthy levels of anxiety, depression or burnout and were likely to have continued to work at an appropriate level. This study can be used as a case study for other medical facilities, or any other institution, to follow in protecting their employees’ mental health and ability to perform their roles, which ultimately protects their business viability. Furthermore, if used as a case study, perhaps this represents an opportunity to build a more compassionate and sustainable healthcare system in South Africa.
The authors would like to acknowledge the doctors and the staff members at the Eye Centre for being so co-operative.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
L.J.C. was the primary investigator on site who collected the data, wrote up the literature review and discussion. T.H. set up the survey, analysed the data and wrote up the methods and results. S.L. conceptualised the bigger project of which this study was a part and provided input at all points of the study from data collection through to the write up. T.V. and E.S. assisted with reviewing the article and offering input.
The authors received no financial support for the research, authorship, and/or publication of this article.
The data that support the findings of this study are available from the corresponding author, L.J.C., upon reasonable request.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the author.