Balancing Patient Health, Personal Risk, and Family Responsibilities During the COVID-19 Pandemic

Publication Date: 2020

Abstract

As the coronavirus continues to spread worldwide, doctors, nurses, and other providers have been on the front lines tending to an increasing number of infected people. These healthcare professionals also have families of their own and must balance competing responsibilities in a time of unprecedented adjustments. Current research rarely examines how healthcare workers balance patient care, personal risk, and family responsibilities during a pandemic. To address this gap, we measured these collective experiences using a qualitative open-ended survey of 60 healthcare professionals in Los Angeles, California; New York, New York; Montreal, Quebec; and Vancouver, British Columbia. The following six thematic areas were identified: Personal Protective Actions; Professional Challenges; Health Consequences; Burnout; Work-Life Challenges; and Proposed Solutions for Future Waves. The most common protective action was wearing personal protective equipment (PPE) in both work and non-work settings. Social distancing or isolating from families and friends was another common protective strategy. Providers described inadequate PPE as the biggest challenge toward professional performance. The participants also emphasized that misinformation, lack of training and plans, and other administrative issues negatively influenced their job performance and personal and family well-being. Taking care of their family, especially children, led to fears of spreading the virus. Mental health consequences and associated physical health symptoms were highlighted by most participants. Accordingly, most providers reported high levels of burnout due to these challenges, as well as longer shifts and lack of additional support and compensation. Participants identified possible solutions towards the next wave(s) of COVID-19, including improving healthcare delivery models, developing a vaccine, stockpiling more PPE, and establishing clear protocols. These results suggest that better pandemic preparedness at both the government and institutional level is needed to protect providers. Better organizational planning and support services can help enhance mental health and reduce worker burnout.

Introduction and Literature Review

Since the beginning of the COVID-19 outbreak in late 2019, over sixty-eight million cases have been reported to the World Health Organization (WHO) from almost every country on earth (Kaiser Family Foundation (KFF), 2020¹). The pandemic is widespread and deadly—over 1.2 million people have perished to date with no vaccine currently available (KFF, 2020). Around the globe, healthcare professionals have been on the front lines tending to a rapidly increasing number of infected people. Working tirelessly to combat this new virus, healthcare providers, although equipped with professional knowledge and skills, are particularly vulnerable to exposure due to extreme shortages of medical facilities, human resources, and personal protective equipment (PPE), including respirator masks, face shields, gloves, and protective garments (CDC, 2020). Tens of thousands of healthcare workers have become infected, fallen into critical condition, and have even died (Andriyanto & Rikin, 2020²; Mole, 2020³). Furthermore, these workers also have families of their own and must balance competing responsibilities in a time of drastic adjustments to everyday life, including school and business closures, economic uncertainties, and social isolation. With the WHO requesting that international communities prepare for future waves of this global public health emergency (Weikle, 2020⁴), we are left asking: how can healthcare workers effectively balance patient care, personal risk, and family responsibilities?

Decades of research suggest that hospitals have limited capacity to handle the surge of patients resulting from a pandemic (Feinberg, 2014; Kenney & Osterholm, 2017⁵). In the United States, studies have found inconsistencies and major limitations across hospital preparedness plans for responding to public health emergencies, including epidemics (Niska & Shimizu, 2011⁶; Sheikhbardsiri et al., 2017⁷). For instance, a recent study in New York found that nearly three quarters of community hospitals could not operate for more than a week without relying on external resources (Vick et al., 2018⁸). In Canada, despite having a public system that is more centralized than the U.S., similar accounts of discrepancies in epidemic preparedness have been noted. The Canadian healthcare system suffers from significant emergency department overcrowding, which is largely due to the inability of admitted patients to access inpatient beds (Affleck et al., 2013⁹). Overcrowding, coupled with limited protective supplies, substantially impacts the ability to address an epidemic due to increased risk of exposure and transmission (Lin et al., 2020¹⁰).

Many of these deficiencies have already come to light during the COVID-19 pandemic. In major hospitals across North America, there have been reports of rationing surgical masks, with healthcare providers forced to use one mask for an entire shift or reuse single-use masks (Canadian Broadcasting Corporation News, 2020¹¹; Karlamangla & Ryan, 2020¹²; Lancaster & Baksh, 2020¹³; Scott et al., 2020¹⁴). The inability to effectively treat patients while following safety protocols has resulted in a backlash from healthcare providers. In the Canadian province of Alberta, a group of nurses refused to perform coronavirus tests without N95 face masks (CTV, 2020¹⁵). Other nurses and frontline staff expressed that hospitals were treating them as if they were “disposable” because of shortages of medical supplies (Lancaster & Baksh, 2020). Research from past events, including the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak and the Ebola epidemic of 2014-2015, suggests that pandemics can have a substantial negative impact on the overall health and well-being of medical providers. During the SARS epidemic in Canada, Maunder and colleagues (2006) found that healthcare workers in Toronto, the center of the outbreak in North America, reported higher levels of burnout, psychological distress, and posttraumatic stress than a comparison group. In a survey of physicians across the U.S. and Canada who were responding to patients during the Ebola outbreak, many respondents expressed concern about physician and spouse safety as well as the negative impacts their work had on their family life (Lewis et al., 2017¹⁶). Despite these findings, there is limited research examining how healthcare professionals effectively balance patient care, personal risk, and family responsibilities during a pandemic.

This study will address gaps in the literature by qualitatively measuring holistic well-being among healthcare workers during the COVID-19 pandemic using a cross-national sample. We are interested in learning from the experiences of healthcare providers across four cities in the U.S. and Canada: (1) Los Angeles, California, (2) New York, New York, (3) Montreal, Quebec, and (4) Vancouver, British Columbia. We aim to identify specific challenges that healthcare workers are facing to inform emergency preparedness planning for potential future waves of the novel coronavirus. This knowledge can ultimately support the improvement of healthcare infrastructure across international borders by collectively enhancing healthcare workers’ capacity to prepare for and respond to future public health emergencies.

Research Design

Research Questions

Our overarching research question guiding this research is: How can healthcare professionals effectively balance treatment of patients with their personal risk and family responsibilities during the next wave(s) of COVID-19?

To answer this question, we will explore the following specific research questions (RQs) in five components:

Role in COVID-19 Response

RQ1: What is your role in the healthcare system?
RQ2: How have you been involved in responding to the COVID-19 pandemic?

Work Performance

RQ3: How have shortages in personal protective equipment impacted your ability to perform your job?

Personal Health

RQ4: How are you protecting yourself from COVID-19?
RQ5: What challenges are you experiencing to protect yourself from COVID-19?
RQ6: How has your mental health been impacted by the pandemic?

Family Obligations

RQ7: How are you protecting your family from COVID-19?
RQ8: What challenges are you experiencing to balance your work and family responsibilities (e.g., childcare, family support)?

Preparedness for Future Wave(s)

RQ9: How could your workplace better prepare for a second wave of COVID-19?
RQ10: What do you require to feel better prepared for your family for a second wave of COVID-19?

Study Site Description

Our study site consisted of four large cities in the U.S. and Canada: New York, New York; Los Angeles, California; Montreal, Quebec; and Vancouver, British Columbia. These large, densely populated bicoastal cities have experienced major outbreaks of COVID-19 and are threatened by shortages in medical supplies (Allday, 2020¹⁷; Laframboise, 2020¹⁸).

Data, Methods, and Procedures

We used qualitative methods consisting of a survey of 10 open-ended questions (listed above) administered via Qualtrics. Participants were invited to complete the survey via an email that included a description of the study and a link to the questionnaire. Participants were asked to complete the informed consent in Qualtrics before being able to start the survey. Data collection occurred between June and August 2020. After completing the survey, participants received an Amazon e-gift card in the value of U.S. $50 as an incentive.

Sampling and Participants

We recruited 15 healthcare workers from each of the four study sites (N=60). The small sample size is consistent with recommended sample size for qualitative studies (Dworkin, 2012¹⁹). Our sample consisted of nurses, physicians, physician and nurse assistants, mental health care professionals, and other healthcare support staff who are either directly involved in treating or testing for COVID-19 or indirectly involved in providing healthcare in an environment impacted by COVID-19. We were interested in learning from the diverse perspectives of currently working healthcare providers and thus did not use stringent exclusion criteria in terms of practitioners we included in the sample.

Participants were recruited through a snowball sampling approach. The initial seed samples were based on the Principal Investigator’s pre-established contacts in the healthcare field in the U.S. and Canada. An email containing a description of the study and a link to the questionnaire was sent to these initial contacts and then forwarded to other eligible participants that the seed contacts identified.

Ethical Considerations

To minimize participant burden among busy healthcare professionals, the survey was designed to be completed within 15 minutes. Respondents completed an online informed consent form before starting the survey. The study design and data collection methods were approved by the Institutional Review Board of the University of Colorado Boulder on May 7, 2020, and the Research Ethics Board of Dalhousie University on June 15, 2020. Once this report is published on the Natural Hazards Center’s website, we will share the link with all 60 participants via email.

Preliminary Findings

Data Analysis

After recruitment was complete, the data was downloaded from Qualtrics onto a password-protected computer, de-identified, and analyzed using thematic content analysis in ATLAS.ti. Two members of the research team read through all transcripts and developed a thematic code book. Together they coded two surveys and updated the code book based on their experience. Each of the researchers then coded the remaining surveys independently and made real-time updates to the codebook as they continued to refine codes. They also met a second time after the initial coding to clarify some additional codes and update the code book.

Data

Our sample consisted of 40% physicians, 12% nurses, 10% physician assistants, 3% nursing aides, 25% mental health care providers, and 10% in another role within the healthcare system (e.g., social worker, clinical support staff). About half of participants were working on the front lines directly testing or treating COVID-19 patients (52%) whereas the other half (48%) was working in a healthcare facility that was impacted by COVID-19 or involved in telehealth due to limited in-person visits resulting from the pandemic.

We identified six main thematic areas of responses: (1) Personal Protective Actions, (2) Professional Challenges, (3) Health Consequences, (4) Burnout, (5) Work-Life Challenges, and (6) Proposed Solutions for Future Waves. A summary of the findings within each of these themes is presented below.

Respondents described a variety of protective actions that they used to protect themselves from getting infected with the novel coronavirus. The most common action was wearing PPE, such as N95 masks, gloves, goggles, and face shields. Respondents reported wearing PPE both inside and outside the hospital to protect themselves from infection. The second most common action was regular washing of hands and body, followed by cleaning surfaces, avoiding crowds, and removing/changing clothes when they arrived home from work using the “don and doff” procedure.

Respondents also engaged in protective actions to prevent themselves from potentially infecting their family and friends. A vast majority practiced physical distancing or isolating from their loved ones. A small minority of participants (N=4) also got regularly tested to ensure they were not infected and spreading the disease to others.

I ensure I am wearing the appropriate PPE for all situations and donning and doffing as per the protocol. I practice good hand hygiene. I wear a mask when in public places and distance myself as much as possible. I limit my shopping to once every two weeks and shop online whenever possible. I don't have social gatherings. My husband and I limit our social bubble to our son, daughter-in-law, grandson along with one or two other family members who we visit in an outdoor setting and distance ourselves 2 meters. (Nurse, Montreal)

I am wearing protective goggles, gloves, surgical masks, and sometimes face shields when seeing patients in clinic currently, as well as wearing disposable gowns when seeing patients in the hospital. At work, I am practicing social distancing, avoidance of contact with other co-workers, limiting patient contact if possible (deferring an extensive exam for example, avoiding oral exams if appropriate). At home and personal life, I am wearing masks outdoors always, especially when I am indoors shopping; I am also not seeing my family and only communication via phone or video call. We are also not participating or hosting social events with large gatherings of people. We [are] staying home for the most part, unless we need to shop for food or other household items. (Physician, Los Angeles)

Professional Challenges

The study participants noted a number of challenges to protecting themselves and their loved ones from infection. The biggest challenge was the lack of PPE or the requirement to reuse PPE in their workplace.

In the beginning of the pandemic I did not have access to supplies to maintain in-office sessions for those that needed it. Currently, the shortage of supplies means that I will also need to extend the time until I am able to return back to in-office sessions. (Mental Health Care Provider, Vancouver)

There was a significant re-use of PPE (using the same disposable mask for several days rather [than one] per each patient encounter, reusing gowns to enter a patient's room several times) which increased my risk of exposure to COVID-19. (Physician, New York)

Many respondents also voiced work-related challenges surrounding their organization’s handling of the pandemic. Confusion surrounding protocols, lack of training, and limited resources were among the top challenges cited. In Canada, where there is a national healthcare system, the discussion was mostly focused on the government’s failure.

It took a long time to be able to go for a [COVID-19] test. Health Canada kept changing rules as to who should be tested. Workplace health and safety would ask a questionnaire and would often tell you to monitor your symptoms. (Rehabilitation Aide, Montreal)

First and foremost, the leadership within my staffing company, the hospital, and the government has not inspired any confidence. It feels like the wild west with everyone doing whatever they want and looking out for themselves. There is [a] lot of anxiety and hostility throughout the hospital. People's wages are down, families are sick, [etc.] and you feel that. (Nurse Practitioner, Los Angeles)

Other challenges included misinformation about COVID-19 and people not wearing a mask in public or practicing social distancing.

Health Consequences

A variety of mental health consequences associated with responding to the COVID-19 pandemic were discussed in detail. Respondents described stress, anxiety, depression, and post-traumatic stress disorder as outcomes resulting from long work hours, isolation, and fear of the unknown. Some of these mental health consequences also manifested into physical symptoms, such as insomnia, fatigue, and migraines.

During the worst part of the outbreak on our floor, seeing residents get sick and some dying, coworkers getting sick, some seriously and fearing I will catch the disease myself, I had a "breakdown" where I cried and felt like I could quit. During the worst of it, I also couldn't be near or hold my infant grandson which affected me tremendously and just feeling overwhelmed and tired at times. (Nurse, Montreal)

I experienced a depressive slump for about 3 weeks - I believe this is from not having many boundaries in working from home (many group chats, work related calls outside of business hours). I became very overwhelmed with constant use of technology and screens - I develop migraines and would find myself exhausted frequently. Not being able to go to my fitness classes or camping/hiking as self-care was impacting me. it took time before I found balance that fit for me in this environment. I also felt "stuck" in my sense of purpose, with being disconnected from nature. Finally, carrying the weight of my clients and team because of how [COVID-19] was impacting them felt heavy, in addition to what I was struggling with. (Mental Health Care Provider, Vancouver)

Many of the mental health care providers also noted the deteriorating mental health of their patients amidst the pandemic, which consequently impacted their ability to do their job.

In a way, vicariously, as I have been supporting people's mental health and many people's mental health has deteriorated or declined. So it has been harder, heavier work. (Mental Health Care Provider, Vancouver)

Burnout

Burnout was a common theme that emerged from the analysis. This was particularly apparent among healthcare providers working on the front lines. Several respondents expressed having to work longer hours than usual without additional support or compensation. The inability to take vacation was also noted.

We have been expected to work extra hours and in higher risk situations without any compensation. Essentially, we have taken all the risk and associated anxiety, with no tangible support from the administration. (Physician, New York)

Work has been more exhausting [than] usual with the looming possibility of contracting [COVID-19]. (Nurse Practitioner, Los Angeles)

Work-Life Challenges

Among work-life challenges, childcare was the most common issue discussed, with respondents citing the difficulty of balancing their work with caring for their children. A number of participants also cited fear about spreading COVID-19 to their family members, making it difficult to care for loved ones.

My partner and I collaborate every night and on [Sundays] to determine scheduling around home schooling and childcare ourselves while fitting in work. We laid off our nanny due to concerns that she was coming from her home on public transit. This is stressful and means that we do not have any downtime until the children are in bed. We are lucky to both have somewhat flexible work schedules, however. The younger children are having some difficulty with the lack of stimulation due to being socially and physically isolated and are acting out in ways that they haven’t before. The older child carries some stress and concern around [COVID-19] and misses his friends, so needs us more than usual. (Mental Health Care Provider, Vancouver)

I was on maternity leave at the height of it and returned shortly thereafter, which was very anxiety-provoking. I was nervous to come back to work and was scared I would bring home the virus to my 2-month old. (Physician, New York)

Proposed Solutions for Future Waves

When asked about potential solutions to better prepare for future waves of the pandemic, the responses were quite varied. Among the responses provided were better health care delivery systems (e.g., telehealth, separation of hot/cold zones in hospitals), more advanced research/development of a vaccine, better organizational planning (e.g., training, clear protocols, more staff), increased financial support, better mental health support, more PPE, and more testing available.

I definitely feel like we should have more nurses and support staff such as PABS [patient attendants], porters, housekeeping available to mobilize if needed. I feel like there needs to be more sims [simulations] and education available for the nurses about high risk scenarios such as [intubations]. The ICU needs to be ready to accept admissions quickly from the ER to free up more beds and increase patient flow. There needs to be more psychological support available for health care professionals and fighting [COVID-19] is traumatic and can cause PTSD and burnout, as I have experienced. (Nurse, Montreal)

I think setting up a system where residents from other specialties are not the first line of back up called would be a good start. Although I understand in a pandemic options are limited so I am happy to help if and when needed during a second wave. I think better coordinating resident and fellow deployment in our hospital system is key. I was initially informed of my "deployment" 3 hours before the start of my shift. (Physician, New York)

Discussion of Preliminary Findings

This qualitative study demonstrates a number of important themes related to how healthcare providers balance patient health, personal risk, and family responsibilities during the COVID-19 pandemic. In order to protect themselves from exposure to COVID-19, as well as prevent the potential spread to others, participants followed a number of recommended actions, including wearing PPE, washing hands frequently, changing clothes, and social distancing. Despite engaging in these protective behaviors, there were a number of challenges reported to safely conducting healthcare practice. These included protective challenges surrounding a lack of PPE in their workplace or having to reuse single use masks and gowns. Limited PPE was noted in all four study locations, suggesting the need for urgent resource planning for pandemics in both the U.S. and Canada. There were also a number of organizational challenges where respondents unveiled that leadership was not supportive and that there was a lack of clear protocols at the organizational level. In Canada, the organizational challenges often stemmed from the government, whereas in the U.S. the focus was more on the health care facility’s administration. The differences across the two counties are likely the result of having a national healthcare system in Canada. Nevertheless, better pandemic preparedness at both the government and healthcare institutional level is needed to ensure that providers have adequate support to better fulfill their professional responsibilities.

Similar to findings from prior research from the SARS epidemic, a majority of respondents described poor mental health outcomes resulting from working during the pandemic (Maunder et al., 2006²⁰). The symptoms described ranged from stress and anxiety to diagnosable conditions including post-traumatic stress disorder and depression. Given the prevalence of these outcomes, hospitals and clinics should invest more in mental health support services for their staff. In addition to these services, providers could also benefit from organizational strategies to reduce worker burnout, particularly among frontline workers, such as mandated rest periods/days off, more control over their work schedule, better compensation for the higher risk work, and additional support for childcare. Implementing organizational policies to reduce poor mental health and burnout can both enhance the health of providers and improve their ability to work and keep the general population healthy.

The unique circumstances surrounding the COVID-19 pandemic have led to unprecedented challenges. Based on their experiences, the healthcare workers surveyed in this study provided a number of recommendations to better prepare for future waves of the pandemic. Among the most compelling of these recommendations was to change the way healthcare services are provided. Specific suggestions included having very strict protocols to separate COVID and non-COVID areas, increased use of telemedicine for those providing non-emergency care, and having enough nursing and support staff ready to be deployed during a surge. Another important suggestion was to provide adequate compensation for extra work at higher risk, including the availability of loans and other financial aid. Respondents noted that increasing compensation would both help motivate them to conduct risky work while also providing additional resources to help support their families.

Conclusions

Implications for Practice

As described in the discussion, there are a number of implications that the results have for practice. Recommendations to improve practice are summarized in the bullet points below:

• Greater stockpile of personal protective equipment;
• A pandemic playbook with clear protocols to follow;
• Provision of mental health support services for healthcare staff;
• Organizational strategies to reduce worker burnout;
• New healthcare service delivery models to address pandemic needs; and
• Financial support for extra work at higher risk.

Limitations and Strengths

While this study demonstrates how healthcare professionals balance treatment of patients with their personal risk and family responsibilities during the COVID-19 pandemic, there are certain limitations that need to be acknowledged. First, while this study was designed to examine the perspectives of healthcare professionals in four cities across two countries, the snowball sampling method is not representative, so the results are therefore not generalizable to all providers in each region. This sampling method also contributed to a higher proportion of certain types of providers in certain regions. For instance, all of the participants in Vancouver were mental health care providers so this was a more homogenous sample than desired. Furthermore, due to COVID travel restrictions, an online survey was believed to be one of the safest data collection approaches. However, since a survey only allows a one-way information flow, it is not the best method to generate rich qualitative data in comparison to other methods such as focus groups and in-depth interviews.

Future Research Directions

This quick response study is an exploratory pilot study that will be used to apply for future grants (e.g., the U.S. National Science Foundation Rapid Grants, the Canadian Institutes of Health Research Team Grants, and the Social Sciences and Humanities Research Council Partnership Development Grants). The results will help to inform a larger international study that will use a mixed methods approach and probability sampling to better understand how a representative sample of healthcare providers are responding to the challenges of the ongoing pandemic and balancing their work responsibilities with their personal lives.

References