Introduction

The worldwide pandemic caused by the SARS-CoV-2 virus has put intensive care units (ICUs) around the world under unprecedented pressure, as they provide front-line care for the most severely ill individuals, notably those with acute respiratory distress requiring mechanical ventilation. The clinical and technical expertise of ICU staff across the globe has been widely recognized during the present crisis. However, many hospitals were (and remain) submerged by the various waves of COVID-19, and in many places, there were shortages of beds, ventilators and medications in ICUs, but also a shortfall of staff to meet the needs of these severely ill patients receiving life-support therapies. In this context, ICU staff have been faced with exceptionally high levels of stress, while at the same time, their working environment has undergone profound upheaval. Additionally, healthcare workers experienced exposure to constant media coverage (so-called “infodemic”). They had doubts and uncertainties surrounding the right treatments to give patients. They were at risk of contamination at work and at home, and experienced serial lockdowns and social restrictions. The repercussions of these factors on all healthcare professionals are becoming evident, and particularly the impact on healthcare workers in the ICU. Azoulay et al. reported that 50.4% of healthcare workers in the ICU had symptoms of anxiety, 30.4% had symptoms of depression, while 32% had peritraumatic dissociation [1]. In a recent review of the literature that included 13 studies totalling 33,062 (mostly Chinese) healthcare workers, the authors found a pooled prevalence of around 23% for both anxiety and depression across studies [2].

In the PsyCovid-ICU study, our group previously showed during the first pandemic wave in 2020 that healthcare professionals working in zones where the pandemic intensity was highest were at greater risk of mental health issues, with higher levels of perceived stress [3]. Risk factors for this psychological distress identified in the study, regardless of the pandemic intensity, were female sex, having a relative at risk of COVID-19, and working in geographical zones where the pandemic was of greatest intensity. Furthermore, certain categories of ICu professionals, such as those closest to the patient (nurses, medical interns, nurses’ aides), but also staff who did not usually work permanently in the ICU (i.e. reinforcements deployed to the ICU during the crisis) were also found to have higher levels of stress.

To complement and elucidate the quantitative findings of the PsyCOVID-ICU study, we sought to explore the perceptions of frontline ICU staff about the first wave of the COVID-19 pandemic, and how this experience impacted on their personal and professional lives, in a qualitative study using semi-structured interviews.

Methods

This qualitative study was performed as part of the larger PsyCOVID-ICU study, whose methods and results have previously been reported [3]. Briefly, the PsyCOVID-ICU study was a large, prospective study conducted in 77 hospitals across France from 22 April 2020 to 13 May 2020. The population of the main PsyCOVID-ICU study comprised ICU frontline healthcare workers directly involved in the diagnosis, treatment, and care of patients with COVID-19 (i.e., physicians, residents, nurses, nurses’ aides, medical students and nursing managers) who consented to participate. An online questionnaire was sent using the Limesurvey platform, and participants first provided demographic data, then completed the 12-item General Health Questionnaire (GHQ-12) for the evaluation of the primary endpoint, which was mental health. Participants also completed the Perceived Stressors in Intensive Care Units (PS-ICU) scale to measure sources of stress in ICU during the COVID-19 crisis. A total of 2,643 healthcare professionals were included, of whom 72.6% were females, and 53.2% were nurses.

The PsyCOVID-ICU study received approval for all participating centers from the Ethics Committee of the French Intensive Care Society (N°20–33), for both the quantitative and qualitative parts. Consent to participate in the main PsyCOVID study was implied by the fact that all participants voluntarily connected to the study website and completed the forms. Participants also agreed to participation at the beginning of the survey before proceeding with completion of the forms, and provided consent to be contacted for a qualitative interview to explore their responses in greater detail.

For the present qualitative study, a random sample of 5 hospitals (Strasbourg, Dijon, Vesoul, Metz-Thionville, Argenteuil) were drawn from among all the participating centres. Then, among these centres, a random sample of 10 participants (nurses and nurses’ aides) was drawn from among the participants who had consented to be contacted for an interview. It was estimated that the response rate from a sample 50 (10 participants to be contacted from each of 5 centres) would be sufficient to achieve data saturation. Participants from each centre were contacted by a researcher from the Psy-COVID-Qualitative team (NMB, male; FE, SP, SL, female) to organize an individual semi-structured interview at a time convenient for the interviewee. We developed an interview guide focused on three main topics, namely: (1) experience of the pandemic crisis and its effects on their personal life (e.g. domestic life, social and family relations); (2) effect of the pandemic on their professional life (e.g. work organisation, resource management, relationship with the hierarchy/ administration/ colleagues); (3) societal aspects of the pandemic (e.g. role of the media and/or experts, public opinion). The interview guide was developed by our group based on a review of available literature, plus a focus group with a sociologist, qualitative researchers, and ICU physicians and nurses.

Due to the ongoing pandemic during the study period, all interviews were performed by telephone. Interviews were performed until data saturation was reached. Interviews were recorded and fully transcribed (in French) for later analysis. Data were encoded to guarantee the anonymity of the participants.

The transcripts of all interviews were analysed using thematic analysis, as previously described [4, 5]. The first level of analysis was first performed independently by each researcher (FE, SL, AP, NMB) on their own interviews, then meetings were held to harmonize the categories and themes to be retained. Results were discussed until consensus on interpretation was reached. Translation was performed after the results were finalized. Participants were informed that citations from their discourse may be used (translated into English) to illustrate the results of the study in a scientific publication, and all participants consented to this.

Results

Data saturation was reached and verified after a total of 18 interviews, which were performed from 13 August to 6 October 2020; 13 were nurses, and 5 were nurses’ aides. The characteristics of the study population are shown in Table 1.

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Table 1. Characteristics of the study population (N = 18).

https://doi.org/10.1371/journal.pone.0274326.t001

Thematic analysis of the interviews revealed three major themes.

Illustrative quotes are given in italics for each point. The conceptual framework describing the themes and their interrelations is illustrated in Fig 1.

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Fig 1. Conceptual framework describing the main themes and the relations between them.

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Discussion

This qualitative study investigating the sources and repercussions of the psychological distress suffered by healthcare workers during the COVID-19 pandemic, provides novel insights into the perceptions and experiences of ICU staff, and how this affected them in their daily personal and professional lives. There is paucity of data on this topic, yet the health of these professionals seems to be in jeopardy, with a level of psychological stress that has been cumulating over the course of pandemic, and reports of a fear of dying and an elevated risk of suicide [2].

Reports to date about the mental health in healthcare professionals have mainly relied on quantitative data, with wide heterogeneity across studies due to the large number of different scales and tools used. As a result, comparisons are difficult, and it is difficult to draw conclusions about the individual effects of various factors in generating anxiety, depression or post-traumatic stress disorder [1–3, 6]. This is an important issue, because although quantitative scales and validated instruments are necessary to identify and quantify the severity of psychological distress in specific populations and environments, they do not take account of each individual’s personal context, thereby also precluding individualized follow-up, as has been proposed by some authors in the framework of mental health service reforms [7, 8]. Our study therefore aimed to explore the individual consequences of the psychological distress perceived by healthcare workers during the pandemic in France, exploring both their personal and professional lives, and to put these consequences in perspective with literature data and avenues for instigation of mental health support services.

Our findings underline that the personal and professional domains are intricately linked, and difficult to dissociate. The respondents reported their fear of carrying contamination from the workplace to the home and family. This fear was compounded by the national lockdown, which forced families to reduce contacts outside the home, with children on home-schooling. The restrictions obliged many healthcare workers to improvise solutions to meet the family’s needs within the limits of the resources available to them. Some, but not all were able to count on the presence of a spouse or other family member to help out in the home. Many healthcare workers reported having instituted their own “decontamination zone” in the home, where they would shower and change on arrival after work to avoid contaminating their entourage. The role of the media, and the COVID-19 “infodemic”, stands out in our results as a new phenomenon faced by healthcare workers on their days off, making it difficult for them to disconnect from their work, thereby compounding their sense of fatigue, stress and anxiety, and hampering their ability to rest and “refuel”.

Many of these fears have been shared by healthcare workers worldwide since the beginning of the crisis, notably with the first reports from China soon after the onset of the pandemic [9, 10]. These studies identified the feeling of uncertainty and insecurity as being problematic, with healthcare workers afraid of being contaminated in the workplace, and also afraid that they would in turn contaminate their entourage [11]. This fear is even greater for healthcare workers who have vulnerable individuals in their entourage, such as family members with a chronic disease, and this may translate into symptoms such as insomnia or anxiety [12].

The lockdowns imposed in many countries to limit the spread of the pandemic may have led to feelings of loneliness and isolation, which can in turn generate anxiety and/or depression [13]. The COVID-19 infodemic, with its abundance of information on all the media outlets and social networks, may have engendered fear, or even panic, inciting forms of suspicions, discrimination and stigmatization due to the risk of contamination [14]. All these circumstances have had direct repercussions on the personal lives of healthcare workers [15–17].

Conversely, some positives effects have also been reported, including the benefits of social support, correlated with self-efficacy (the individual’s belief in their ability to accomplish a given task), and sleep quality, and a decrease in anxiety and stress [18]. The scientific advisory board advising the French government through this crisis was quick to recommend the implementation of psychological support units in hospitals nationwide in collaboration with the existing network of medico-psychological emergency units, usually mobilized to help victims of large-scale events such as terrorist attacks or natural disasters [19–21]. Other ad hoc solutions also emerged, notably the recognition that mental health services should be provided for the family and friends of people affected by the COVID-19 crisis [22]; the online delivery of psychotherapy or psycho-educational services, or the use of internet and social media to share strategies for coping with psychological stress [7, 8, 23]. Recent research has indicated the Eye Movement Desensitization and Reprocessing (EMDR) and cognitive behavioural therapy may be efficacious for reducing the symptoms of post-traumatic stress disorder [24, 25]. However, it is not unreasonable to consider that the services provided are likely insufficient, in the face of such a monumental pandemic. A more holistic approach to mental health at work is needed, with institutional support for resilience, and a hierarchy that takes account of emotional distress, as well as organisational and relational difficulties among the caregiving staff [26].

Within the workplace, the reorganisation of care delivery (in terms of structure and human resources) was sometimes viewed in a positive light, with extra staff brought in to help, and more relaxed rules (greater presence of management, additional supplies etc). Conversely, others perceived these changes in a more negative light, due to the increased workload from having to train support staff, or due to the absence of the patients’ families during the lockdown. Lost opportunities for care due to a shortage of ICU beds were rapidly identified by many healthcare workers as possible major issue for the pandemic, leading the French Intensive Care Society to issue recommendations about admission criteria to the ICU for the pandemic context as well as recommendations for allowing family visits in the ICU (www.srlf.org) [27].

Healthcare workers received a good degree of recognition from the public during the first wave of COVID-19 infections, and in France, there was applause in public places every evening at 8pm. It has been reported that social support can help build resilience and promote recovery after stressful encounters [28, 29]. As underlined by Chen et al., concrete measures to provide support to healthcare workers (e.g. specific break rooms, and the possibility to have some “down-time”) are the most appropriate for healthcare workers during a crisis [19]. The development of preventive strategies is also necessary to support healthcare workers continuing to care for severely ill patients, thereby protecting a resource that is increasingly precious in this ongoing crisis [30, 31].

All the participants in this study underlined the strong solidarity and team spirit they experienced, with a renewed sense of purpose and an “adrenaline rush” that motivated them to keep going when things were difficult. Some healthcare workers use this as a coping strategy in the face of stress and demanding situations. In the PsyCOVID-ICU study, the use of positive re-evaluation as a coping strategy was shown to have a positive effect on mental health. Indeed, experiencing positive emotions promotes resilience, and reinforces certain cognitive functions, such as attention, creativity and flexibility [3, 19, 26, 28].

This study has some limitations. First, the questions asked during the interview may not have covered all the aspects of the crisis, or the full spectrum of repercussions that the pandemic may have had on all areas of their personal and professional lives. Secondly, only healthcare workers who had participated in the quantitative PsyCOVID-ICU study and who agreed to participate in the qualitative study were interviewed. Third, due to the lockdown and restrictions in place, the interviews were performed by telephone, which may have influenced the respondents’ responses as compared to face-to-face interviews. Lastly, only French healthcare workers were included, and the experiences of front-line workers in other countries would undoubtedly be different.

Conclusion

The healthcare workers in this qualitative study expressed their personal concerns and perceptions of the COVID-19 crisis, as experienced during the first wave of the pandemic. There were far-reaching effects on both the personal and professional lives, linked to a fear of contamination, and to the re-organisation of working conditions, against a background of the media “infodemic”. Positive effects, such as renewed motivation for their work, closer team spirit, and greater resilience, were also mentioned. Impact studies, both in the prevention and treatment of mental health issues among healthcare workers could be useful to avoid long-term psychological distress due the ongoing pandemic in this category of professionals.