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METASYNTHESIS (REVIEW)

Lived experience of health-care providers during COVID-19: A meta-synthesis

Chandy, Ponnambily,; Kanthi, Esther1; Pradeep, Preetha2; Sathianathan, Prasannakumari3; Jebakamal, S.4; Narchaithi, Meetpin5; Anbarasi, S.6

Author Information
doi: 10.4103/indianjpsychiatry.indianjpsychiatry_1403_2
  • Open

Abstract

INTRODUCTION

Health-care providers are indispensable assets for each nation. Their well-being and security are significant for uninterrupted and safe patient care and additionally for control of any disease outbreak.[1] However, it is reported during the severe acute respiratory syndrome (SARS) and the Middle East Respiratory Syndrome outbreaks[2] that the health-care providers were under exceptional pressure due to high risk of infection, social stigmatization, staff shortage, vulnerability, and lack of extensive support during the epidemic crisis.[3]

Quantitative and qualitative studies have indicated that health care staff who are in the frontline treating patients with COVID-19 have a higher risk of physical, mental, and social health issues.[4] Moreover, physicians and nurses from all departments were mobilized to care for patients with COVID-19 other than those working in infectious or respiratory departments to combat the pandemic effectively, and this way of approach has created a stressful situation among them as they are working in a new environment with strangers. To help frontline health workers successfully, it is important to gain insights into their lived experiences.[5]

It is known that pathogenicity and treatment of COVID-19 are unknown to date and is under investigation.[6] Currently, basic medicine and nursing care principles are found to be effective to increase the survival rate of these patients.[7] Patients with severe symptoms of COVID-19 are admitted to the intensive care unit for receiving special care and treatment.[8] The majority of the intensive care units are negative pressure wards under strict isolation to prevent cross-contamination.[9] These patients are isolated from the family members for further care and support for more than 2 weeks, which means that the health-care providers are forced to deliver the treatment, care, and support for activities of daily living on behalf of family members that give an additional burden to the health-care providers, especially nurses.[10]

Currently, nurses are at the edge of the front row giving the closest contact care to patients with COVID-19.[11] Nurses need unique skills to save patients from rapid clinical deterioration, as it is a complex process tangled between delivering the medical treatment,[12] supporting patients for activities of daily living and giving them emotional support. All the COVID-19 treatment strategies are symptomatic and the nurses need an energized body, critical thinking ability to respond rapidly in an emergency[13] and a focused mind to deliver care without any interruptions and mistakes. However, the long working hours[14] for more than 12 h due to shortage of personal protective equipment (PPE) and staff, lack of equipment, confusion with the treatment modalities, unpredictable spread and severity of the disease, self-isolation and lack of training to those who were pooled out from various departments other than respiratory or infectious disease departments to combat epidemics[15] created an intensive pressure on health care providers, especially on nurses in more than 200 countries globally. It is reported that the nurses and their quality of care are essential tools to combat COVID-19 pandemic successfully.[16] Nurses themselves are exposed to infection and succumbed to death while providing care for patients with COVID-19. Thus, it is very essential to examine the current experiences of combating the COVID-19 pandemic for the policy-makers to plan strategies to prevent such outbreaks and not to let pandemics happen.[17]

The aim of this meta-synthesis is, therefore, to draw on the findings of qualitative research studies worldwide that have investigated the lived experience of health care providers during COVID-19 to provide a better understanding, thereby incorporating their views and perspectives to provide recommendations for formulating healthcare policies and for research practice[18] to combat the outbreaks effectively without pressurizing health-care providers further.

MATERIALS AND METHODS

Meta-synthesis is a deliberate strategy for collecting and analyzing the various qualitative studies on a specified theme; planning to develop satisfactory interpretive clarifications of these findings[19] and we have used the combined methodological model (Noblit and Hare and Sandelowski and Barroso), which is a frequently applied model with seven stages. This model helped us to synthesize heterogeneous studies and extract the interpretation as a “whole.”[20]

Step 1 – Deciding the phenomenon of interest

The purpose was to identify the current issues and looking for how to fill the gap in practice by developing conceptual models of the existing phenomenon. This session followed the guidelines of meta-synthesis suggested by Finfgeld.[21] Therefore, to attain the study objectives, all studies were chosen through a systematic review of literature by asking the accompanying exploration inquiries: (1) What philosophical and hypothetical viewpoints are reflected in the present status of information concerning the COVID-19 pandemic experience? (2) What is the methodological status of the selected studies? and (3) what are the key themes identified in the selected studies?

Step 2 – Deciding and identifying what is relevant

The particular method applied in the meta-synthesis included steps illustrated by Sandelowski and Barroso[22] and is presented in the section below.[23]

Search strategy

The abstracts and full-text papers in PubMed, CINAHL, MEDLINE, Proquest, and Google Scholar Index were searched. The key terms used were: (“COVID-19” OR “Coronavirus disease”) AND (“experience,” “attributions,” “lived experience,” “patient care experience,” “beliefs,” “real-life experience,” “perceptions,” “perspectives,” “understanding,” and “values”) AND (“qualitative,” interpretive,” “phenomenology,” “hermeneutics,” and “phenomena”). MeSH headings, free text searching, Boolean operators, and truncations were utilized to extend the search.

Inclusion criteria

  • Population: Samples were health-care providers caring for patients with COVID-19
  • Main focus: Lived experience in treating the confirmed COVID-19 cases
  • Design: Qualitative
  • Time frame: Articles published between January 2020 and October 2020 (during the first wave of COVID-19).

Exclusion criteria

  • Population: Home health workers, resident nurses, and other health care providers who did not have direct contact with patient care
  • Main focus: Studies on illness experience, job dimensions, rehabilitation, evaluation of any treatment experience, and patients’ own experiences
  • Design: Quantitative, case study, and other opinion pieces.

Step 3– Careful reading and re-reading

This section focused on the analysis of the quality of included studies and their findings. We did extensive reading and re-reading of included studies. This helped us to identify what the data to extract and convert into themes. Each study was systematically analyzed to identify the country, discipline, domain, and methodology which were tabulated to facilitate analysis. The quality of each study was evaluated using the Standards for Reporting Qualitative Research (SRQR)[24] Figure 1.

F1
Figure 1:
Standards for Reporting Qualitative Research

Step 4 – Determining how themes are related

This step dealt with searching for the association between the themes by looking across the data multiple times. We have used the WFWCF (warming I-freezing-warming II-comparing-filtering) analysis[25] process to extract more rigorous and trustworthy findings. We have done thematic synthesis[26] in warming I and II stages. We have coded the data line-by-line and converted the codes into sub-descriptive and descriptive themes. The “even” themes were confirmed and the “odd” themes were filtered based on the relevance in both stages of warming I and II. The freezing time was 2 weeks. The purpose of the step was to finalize the limited number of concepts with variation.[2527] Then, the descriptive themes were categorized under analytical themes. The analytical, descriptive, and sub-descriptive themes were named overarching themes (3), sub-themes (6), and primary themes,[28] respectively [Table 1].

T1
Table 1:
Extracted key themes

Step 5 – Translating studies into one

This stage was most challenging to develop a thorough understanding of the details of each study. We have used three approaches-conceptual translation (identified the main concepts); refutational translation (examined the presence of contradictory findings and we finalized that there were no contradictory findings present in the included studies, which enhance the weightage of quality of selected studies); and line of argument (we built up the conceptual models with all the aspects of the synthesized parts).

Step 6 – Synthesizing the translation

This step involves a higher level of understanding to give a new interpretation. We brought all themes together in a conceptual model with data support.

Step 7– Expressing the synthesis

This is the final stage of drafting the report for the publication process.

RESULTS

We have identified 81 articles from PubMed (36), CINAHL (5), MEDLINE (7), Proquest (6), and Google Scholar Index (27). From this, we have removed 32 articles (homecare-2, palliative care-6, other outbreak experience-16, and the patient’s lived experience-8) based on inclusion and exclusion criteria. We carefully screened 49 studies by coding “the primary author’s name, the origin of country, name of journal and publisher, and date of submission and publication.” 17 duplicate articles were identified and removed from the list. Then, we have filtered the articles again by coding “original papers in English.” Resultantly, we have removed 6 concept/case study papers and 4 papers, in which full text was available only in the Chinese language. After that, we have read the articles carefully by coding “main focus of the study, design, setting, and type of samples.” Thus, we have excluded seven studies (mixed-2, job dimension-4, and home care workers-1) and finalized 15 studies for SRQR analysis [Figure 1], and the process is outlined in Figure 2.

F2
Figure 2:
PRISMA flow chart

The majority of the selected studies were completed from China 7 (48%) and Iran 6 (40%). Most of the included studies were authored from nursing 5 (34%), public health 4 (26%), and social science 4 (26%). The total sample size was 383 and the majority of samples were nurses 282 (74%). Of the 15 studies, 8 (52%) adopted face-to-face in-depth interviews as a mode of data collection and 7 (47%) focused on exploring the lived experience of health care providers during COVID-19 [Supplementary Table 1]. The characteristics of the selected studies are detailed in Table 2.

T2
Supplementary Table 1:
Background information of the selected articles (n=15)
T3
Table 2:
The characterizes of the selected studies (n=15)

The experiences of health-care providers during COVID-19 were extracted from the 15 articles. We combined and grouped them into overarching themes (3), sub-themes (6), and primary themes (28) [Table 1] using thematic analysis with the WFWCF approach.

Theme 1: “It is my duty”

Health-care providers felt that they were most needed by the country and society to save lives.[5] They could quit the job on the pretext of taking care of family and self-protection, especially in a COVID-19 outbreak. However, all the participants showed professional commitment.[34] “We must try our best to win this battle. As health-care providers, we are at the forefront. I fight for my family, and I fight more for this society.” “This is my duty because I am a medical worker. No matter what will happen…” (Nurse).[5] They felt proud that they had the opportunity to serve people who were sick and fulfil the professional commitment. They joined the war without hesitation to save patients from clinical deterioration; provided them hope of living by repeatedly telling them that “we are not leaving you, you can make it.” A nurse articulated, “As a health-care worker, I have the obligation and responsibility to treat patients who are suffering. As a nurse, my education prepares me with the ability to care and comfort patients and families.” Nurses, as a major workforce in the fight against the epidemic, are duty-bound to care for others, who are respectfully called “anti-epidemic heroes.”[38]

Theme 2: “I am exhausted and about to fall”

This theme describes the challenges faced by the health care providers during COVID-19. They agreed that the preparations for the pandemic within the sector were inadequate and they had a shortage of staff, PPE, and equipment, which gave additional burden to carry out the duty. “Most of the PPE ran out within 2 days and we had to wait for days to get some only to last for 2 days. Honestly, this was the most difficult time to work in health and social care. The few PPE available was not fit for purpose as everyone had little knowledge about COVID-19” (Nurse).[28] On one hand, they had reported that wearing PPE restricted their mobility, was not able to drink or eat or urinate for more than 12 h. They felt like a prisoner in a fence of protective equipment. On the other hand, they had used the adult diapers while working and reported that PPE increased their body temperature caused discomfort due to heavy wet diapers and sweating, made them feel suffocated, became exhausted and delivery of nursing care was difficult.[40] Data analysis showed that the dimension of the disease is unknown and has currently no vaccine or treatment. “…. Not all COVID-19 patients have severe clinical symptoms … there is no correlation between a patient’s death and clinical symptoms … a patient with mild symptoms may die whereas another with severe symptoms recover … the unknown dimensions of the disease are numerous…” They were anxious while witnessing the unexpected death of patients and corpse burial. One participant addressing this issue mentioned that: “… It is said that given the type of their death, families cannot manage to choose the type and place of burial and even cannot attend the event…”[30] They are also worried about being infected and becoming a source of infection for others.[37]

Theme 3: “I have overcome it”

All study participants activated their psychological defense mechanisms and used self-coping and reflection. The participants expressed confidence in hospital management and government for providing psychological counseling sessions, training programs, bonuses, promotion, and health insurance. The hospital has provided a bonus for us and we have priority in the promotion. The union also gave us gifts and expresses sympathy to us.” “(institution) also actively paid for our anti-epidemic health insurance; it feels like everyone is supporting us.” All participants acknowledged the support received from society through in-person and social media. “Many colleagues called me to encourage me and I felt that there were many people who cared about me.” “Online reviews say we are heroes…”[29]

Meta-synthesis: Models of the lived experience of health-care providers during COVID-19

The evolved model of the COVID-19 management experience emphasized “treat the patient, not just the disease.”[41] It also suggested that basic medicine and nursing care principles are found to be effective during COVID-19.[34] Some of the selected studies revealed the distinct but ambiguous roles and responsibilities between doctors and nurses. They have told that doctors might need to take rounds once or twice a day to visit the patients, whereas nurses were with patients round the clock for implementing prescribed treatment and providing continuous nursing care on behalf of family members.[5] The doctors’ role in patient cure was limited to assessing, choosing, deciding and evaluating respiratory support regimen because of the uncertainty of treatment, whereas nurses have to be in continuous contact with the patients for continuous monitoring, management of respiratory support, assisting in activities of daily living, etc.[29] [Figure 3].

F3
Figure 3:
Model of COVID 19 management experiences of health care providers

The model [Figure 4] illustrates the procedures followed by the health-care providers while entering COVID-19 duty, nature of work, challenges faced, support received, and how they coped. They received pre-job and negative pressure ward training before entering the clinical area, which helped them to enhance the quality of care during the crisis. At most, they had struggled a lot to fit within the fence of PPE for more than 12 h and they were anxious while witnessing the continuous deaths of patients despite their hard work.[3133] All studies quoted the challenges faced due to a shortage of PPE, equipment, and staff. However, they were happy with the support provided by the hospital and the government. Holding the hands of support from family, friends, peers, colleagues, society, media, hospital management, and government, they could cope with the COVID-19 crisis till date and named it as “self-transcendence.”[353639]

F4
Figure 4:
Model of the lived experience of health care providers during COVID-19

DISCUSSION

There is currently no meta-synthesis focused on the lived experiences of health care providers during COVID-19. This meta-synthesis adds to the evidence-based literature with an in-depth exploration of how health care providers responded to the COVID-19 crisis. The findings from meta-synthesis reveal that most of the health care providers were between the age group of 25–40 years and young health care providers were the backbone of the COVID-19 crisis in most of the countries.[5] They have shown a sense of responsibility and sacrificial commitment to safeguard the patients from the virus attack. The nurses played a crucial role in treating chronically ill patients, similar to any new infectious diseases such as Ebola, where no medicines exist and patient care is the only option for them.[41] According to the isolation policy in place during the COVID-19 outbreak, family members could not accompany the patients and nurses had heavy workloads providing nursing care to these patients.[42] In addition to providing care to patients, wearing PPE for long hours made them sick and at risk of decreased immunity. Authorities need to emphasize the importance of self-prevention, self-health, set maximal working hours, and arrange shifts to protect them from exhaustion.[43]

Many health-care workers were pooled out from other departments for COVID-19 duty. They had no clinical experience in the infectious diseases department and not ready to handle the outbreak. It is necessary to have continuous training, education, and counseling sessions to make them prepared to deal with public health emergencies.[44] Workforce safety is the highest priority for the nation. Health-care providers experienced persistent fear of infection due to the contagious nature of the virus, uncertainty about pathogenicity, transmissibility, and treatment of the COVID-19. During the SARS epidemic, nurses had trust in equipment and infection control initiatives, which were associated with lower levels of fear and exhaustion.[45] To help health-care workers in COVID-19 outbreak, hospitals should provide a safe working environment, sufficient PPE, refreshment services, continuous training, and monitor infection control activities. The health-care providers who lived at home expressed concern about transmitting the disease to family members, especially children and aged members. The hospital needs to provide supportive recommendations and training sessions such as living separately, disinfecting clothes, and taking shower after duty, which might help to reduce their anxiety.[2]

In the long run, health-care providers showed great strength and resilience. They have received multiple ways of social support to relieve stress. They used self-coping skills to combat the crisis because they knew that it is their professional responsibility. However, during the SARS epidemic, they were found to be very stressed, fearful, and anxious and were at higher risk of mental health issues after the outbreak.[2] In treating patients with COVID-19, health-care providers showed a great sense of commitment and stood in the frontline to save their lives. The nurses were placed with difficult tasks and played an important role in the recovery of patients. The intensive duty had drained their energy physically and emotionally. Therefore, hospitals should provide comprehensive support to safeguard the well-being of frontline health-care workers to manage public health emergencies.[46]

Common methodological limitations and how they could be overcome in the current study

The present study faced some limitations during the process of searching and classification of studies, which were resolved logically by the investigators.

  1. Understanding of the data − The investigators read and discussed the data repeatedly
  2. Subjective interpretation − This limitation was solved by impartial assessment and validation of findings using the investigator-triangulation approach
  3. Skills of the assessors and their professional erudition and experience − All investigators have qualitative research experience and used their knowledge and skills to collect, gather, break down findings, discover essential features, and combined phenomena as a “whole.” We also discussed the steps of synthesis and findings with national and international qualitative research experts.

Research gaps and suggestions for future research priorities

We have not found any published articles on COVID-19 lived experience of health care providers in the Indian setting till October 31, 2020. There is a very limited understanding of the COVID-19 lived experience of health-care providers in the national context. The models of the current paper stand as global frameworks on the lived experience of the COVID-19 health-care providers because of the origin country of the selected studies. It will help to compare the challenges of health-care providers during unknown outbreaks or pandemics between global and national contexts. These models will act as a guide for future research on the lived experience of the Indian health-care providers during unexpected outbreaks or pandemics with unknown pathogenicity and treatment. Thus, policymakers can be informed regarding the challenges of health-care providers with policy recommendations in the Indian context.

Policy recommendations during an outbreak

The recommendations put forward by the study findings are;

  1. Designing and engineering effective PPE
    1. Lightweight protective suit with long-lasting durable diapers
    2. Face mask with a portal for drinking juice or water.

  2. Set minimal working hours due to heavy workload or keep resting hours in between or increase the number of shifts
  3. Sleep hours during night duty on a rotation basis
  4. Arrangements for live-in care with protection for the family, especially for children and aged members
  5. Bonus and priority in promotion
  6. Health insurance schemes
  7. Exclude aged, pregnant and health care providers with chronic illnesses for outbreak duty
  8. Frequent outbreak training sessions for all department staff
  9. Train the managers for efficient leadership without burn out during outbreak crisis.

CONCLUSION

The study provided a comprehensive and in-depth understanding of the lived experiences of health care providers during COVID-19 duty through a meta-synthesis approach. We found that during the pandemic, they were drained out and exhausted in the earlier stages. However, they grew psychologically under pressure and partook in self-reflection of their values and found positive forces such as expressing more appreciation for health and family and gratitude for social support, which was consistent throughout the study process. These study findings provide fundamental data for authorities for policy formulation during an outbreak crisis.

Contribution

All authors had full access to all the data used in this study and took responsibility to maintain the accuracy of the study findings. All authors contributed to reviewing and editing the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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Keywords:

COVID-19; epidemic; health-care providers; lived experience; metasynthesis; outbreak; pandemic; qualitative; systematic review

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