Tony Nyumba Apindi

Qualitative Research Methods 1 A RESEARCH ON DISCERNMNETS AND EXPERIENCES OF HEALTHCARE PROVIDERS ON THE CRITICALLY SICK INDIVIDUALS DURING THE INITIAL WAVE OF THE COVID-19 PANDEMIC IN CHINA Qualitative Research Methods 2 Introduction Approximately three years ago, the world was faced with the covid-19 pandemic that crippled the world and its activities, making the normal daily activities having to be reevaluated and new methods of how things were to happen being explored and adopted. Within the healthcare centres around the world, the intensive care units (ICU) were under considerable pressure on handling the arriving patients, many of which were under notable respiratory distress that needed mechanical ventilation. This situation brought forth the critical and mostly overlooked expertise of the ICU units and how important they were during such times of need. During that period, there were bed shortages and a reduced number of staff available to tend to all the patients. It led to increased levels of stress with a huge change within the working environments of the ICU staff. Furthermore, the staff was ever being exposed to the media constantly (infodemics). During this period, there was increased doubt about the medication to provide to patients due to the virus being new to the people and also an increased risk of contamination at their work stations and also at home and they also went through tight lockdowns and reduced social interactions amongst people. Due to this factors, the repercussions of these events have been evident on the healthcare providers especially those working in the ICUs. According to a report by Azoulay et al., 50.4% of ICU workers exhibited signs of anxiety, 30.4% exhibited signs of depression whereas the percentage of individuals who displayed signs of peritraumatic dissociation stood at 32%. In recent studies mainly focusing on Chinese health workers showed that there was a 23% chance of these individuals being anxious and depressed from the pooled prevalence obtained (Pappa et al., 2020). In light of these issues, the practical rationale for this paper is be able to obtain an in depth understanding regarding the experiences of the healthcare providers across the period of the covid-19 pandemic that will be used to make decisions and assist strategies for healthcare providers caring for the critically ill individuals in future. For this paper, the theoretical rationale being applied is centred on the framework of Conservation of Resource theory that implies that people have limited amount of resources like time, emotional support resources and energy that get utilised to manage the sources of stress within their own environments. Furthermore, this study explores how healthcare providers are able to manage and conserve their resources when they were caring for the critically ill during the covid-19 pandemic. Therefore, this paper will seek to answer the following research question: “what Qualitative Research Methods 3 are the perceptions and experiences of healthcare providers caring for critically ill patients during the covid-19 pandemic?” Literature Review The covid-19 pandemic placed a lot of pressure on healthcare system in the world. China was the first country to announce the citing of people with the virus, placing it under a lot of pressure to contain the disease and stop it from spreading to its vast population. Healthcare providers had been at the forefront of the response to the virus, thus, they were among the first individuals to experience the pressure. During this period, there was an unprecedented increment in the demand for critical healthcare together with the increased mortality rates caused by the covid-19 pandemic made more significant challenges for the healthcare providers taking care of the sick people. Numerous studies have been conducted by different authors in regards to trying to understand the research question: What are the perceptions and experiences of healthcare providers caring for critically ill patients during the covid-19 pandemic? This literature review has the aim of exploring the perceptions and experiences of the healthcare providers caring for the critically ill patients during the covid19 pandemic. According to Wong et al. (2020), their investigation revealed that healthcare providers were faced with significant and emotional problems that included exhaustion, stress and the fear of being infected by the virus. This qualitative study was conducted by healthcare providers in Singapore working in the covid-19 isolation wards. In regards to preventing the spread of the infection, the hospitals had to undergo changes in their infrastructure to be able to increase the accommodation of the ill patients while simultaneously providing the best care for the patients. Additionally, there was a need for the infection control measures being communicated as well as proper personal protective equipment (PPE) being provided at regular intervals. Some of the issues that brought stress on the staff was the limited number of staff in the operating rooms while the number of patients increased over time and shifting the workflow that minimised the contact between the staff and patients that caused more stress on the healthcare workers. Additionally, the healthcare workers were supposed to undergo more training to ensure that all of them were aware of the outbreak response measures and were able to implement them effectively. Qualitative Research Methods 4 In another study focussing on the effects of covid-19 on the healthcare providers conducted in New York, Shechter et al. (2020) sought to find out the experiences and perceptions of healthcare providers caring for patients with covid-19. The authors of the paper carried out a qualitative study and found out some of the issues that faced the healthcare workers included fear of contagion, stigma, social isolation from other people who are not involved in the field and the increased uncertainity in regards to the effectiveness of protective measures provided to the healthcare worker. Additionally, this paper explored the similarities of the covid-19 pandemic and how it was handled to other disease outbreaks like the SARS outbreak in 2003 and the H1N1 pandemic in 2009. These three outbreaks all shared similar issues, with the paper mentioning that there was a need for interventions to support healthcare providers during outbreaks that included counselling and mental health services. In a study conducted in Saudi Arabia, it was discovered that 87% of the nurses were extremely worried about transmitting the disease to their family members due to their work. Additionally, 73% of the healthcare workers stated that their work made it a stressful process for them. This stress was mostly caused by the knowledge that any small an unintentional mistake during the process of them giving care to the covid-19 patients could place a high risk on the nurses and the patients. Furthermore, 62.8% of the individuals that got interviewed stated that they underwent a great deal of stress whenever they saw their infected patients die while under their care (Al Muharraq, 2021). Research Method Sample This study obtained its data from 30 hospitals across China from 10 cities in the country. For the final analysis, five cities were selected; Shanghai, Guangzhou, Wuhan, Beijing and Chengdu with a total of 16 hospitals through simple random sampling. From the hospitals, 42 healthcare providers from these hospitals were selected comprising of ICU frontline healthcare providers, residents, assistants to nurses, nurses, doctors and nursing managers. An online questionnaire was provided through the use of Google sheets, with the healthcare professionals giving out information on demographic data. After which, the participants finished answering the 12-item General Health Questionnaire (GHQ-12) to get an understanding of the primary endpoint, i.e. mental health. Furthermore, the participants Qualitative Research Methods 5 also provided responses on the Perceived Stressors in Intensive Care Units (PS-ICU) scale get the sources of stress during the covid-19 crisis in the ICU. Finally, 72% of the respondents were females while 53% of the respondents were nurses. Data Collection and Analytical Technique The data collection technique that was used was semi-structured interviews that provided the participants with the opportunity to provide information on their experiences and perceptions of caring for the critically ill patients during the covid-19 pandemic. The interviews were conducted in Mandarin Chinese and fully transcribed. The analytical technique used in this study was thematic analysis that would assist in identifying themes and patterns present within the collected data which would be important and interesting, using the themes to address the research questions. It was brought forward by Braun and Clarke (2006). Measure of Reliability For this study, the measures of reliability that got used included member checking. For this method, the researcher reviewed the themes with the participants to make sure that the accuracy and validity of the collected data was in line with what they had provided. Furthermore, the authors utilised peer debriefing and audit trails to improve the rigr and trustworthiness of the findings from the interviews. Results During the study, data saturation got arrived at after a total of 18 interviews that got conducted from 15th January to 27th February 2023. From the results, 13 were nurses whereas 5 of the respondents were assistants to the nurses (nurses’ aid). This ensured that the study is comprehensive, with the results being reliable and accurate. Additionally, it also ensures that not prolonged unnecessarily and the research does not waste resources in the collection process (Mwita, 2022). Their characteristics are depicted in the table: Qualitative Research Methods 6 Figure 1: Population characteristics; N=18 The thematic analysis from analysing the responses depicted three main themes: i) Managing the home life ii) Conditions in the workplace iii) Meaning of the profession Qualitative Research Methods 7 Figure 2: a conceptual framework showing the main themes and how they relate to one another i) Managing the Home Life This was the first and most predominant theme that was brought up by the participants; managing their personal/home lives. This section depicted the many problems associated with maintaining home schooling for their children and working at the same time. Some respondents did not have assistance either by choice or due to the pandemic. "My husband and I shared the household chores like for instance, when he was working from home; he would do the cleaning and look after our son while I looked after the girls. The chores available in the house would be done by whoever was available.” Qualitative Research Methods 8 “I rarely slept. I stayed at my place alone but it wasn’t a long distance from my parent’s house. Due to their elderly age, I did not want to take chances by visiting them since I did not know if I was a carrier of the virus or not. To save their lives the best way I could, I chose to stay away for at least 2 months.” The participants focused on their hygiene like changing clothes and bathing. “Many of the times I took a shower at work before heading home. I placed the clothes in a bag before heading home each evening.” Finally, the participants with children noted many questions emanating from their children with some being unable to answer. “I have three children, with the eldest being 11 understanding the situation. The middle one asked many questions, with me making sure I gave the best possible response” In regards to the personal life, the participants stated that the physical and mental effects that the covid-19 pandemic had on them were displayed through fatigue and other symptoms, with some requiring psychological assistance. “My wife did not have a good experience, and was constantly moody with a painful stomach. He couldn’t sleep nor eat” “In the house, we all underwent physical and mental suffering… most of the time I lost hope especially when viewing the news coming out of Wuhan.” ii) Conditions in the Workplace The main point which got stated by the participants was an increased workload by the growing and rapid number of patients and the availability of lack of resources within the hospitals. “When the main hospital was full of patients, we had to take in more of those extra patients. At a point we were also overwhelmed by their number…” “All my patients had a similar disease, all arriving at the same time forcing us to change our operations. There was a similar problem but the numbers were too high to manage easily.” The logistics of the different hospitals were overburdened in regards to the hygiene and personal protection measures. Rationing was a common thing when there were little PPEs in some hospitals, even though the participants did not have to go through this issue. Qualitative Research Methods 9 “There was enough equipment, with dressmakers providing gowns whenever they were remaining in short supply” The schedule of the nurses was improved by the increment of more staff that reduced the pressure on the current staff making working conditions better. “It was the responsibility of the doctors to call the families of the patients. It really assisted us not to deal with the families on top of everything else.” Training the new arrivals medical personnel was seen as increasing the burden on the participants since they had to train them. Also, once the lockdowns were lifted, the additional staff would be re-deployed making more work to be distributed to the original healthcare providers. “We worked comfortably while they were around, but as soon as the lockdowns got lifted, that was the first thing they took away.” “There were some nurses who had experience in the ICU and they came back. But some who were brought did not have any experience and it was hard to train and work at the same time.” For majority of them, they stated their solidarity and teamwork efforts and the cohesion that they created during the crisis. “Many of my workmates are like family. I believe that this response resonates with everyone in the team.” The interaction between the hierarchy and the ICU workers was also brought up, with them stating that they were present and supportive as much as possible and assisting with whatever they required. Most of the respondents stated that there was increased teamwork and cohesion amongst everyone. On the other hand, the staff had a hard time in contacting and dealing with the families in providing negative news. There was a feeling of disconnect when they stopped the family members from accessing their loved ones bodies. “During the day, visits would be allowed but there would be no overnight visits. That became a stressing moment having to deal with them daily. Finally, there was a complete restriction from visits and everyone else had to wait by the phone for information. It would be hard just waiting by the phone for information with nothing else to live for.” Qualitative Research Methods 10 There was an increased intensity of care forming a strong relationship between the healthcare providers and the patients. Due to the time spent in the ICU, some of the participants formed and maintained communication with them, with some coming back to provide feedback. There was an emotional context that got detected by mediating between home life and workplace. The participants were fearful of contaminating their families if they carried the virus from the hospital creating a lot of anxiety and stress. This meant that they could no longer engage in their leisure activities. “With the changing instructions, it would be hard to keep up hence making us anxious and nervous.’ “I had to sleep a lot more since the gym and the swimming pool I used to attend were all closed down.’ The media outlets had a huge role in perpetuating fear and uncertainty. This situation made the participants’ families to ask them questions regarding what they had heard earlier from the media. This situation meant that they would still be caught up in the pandemic even in their free time which was minimal. “Many people were not able to observe what was happening on the ground. They only got their information form the media…it reached a point some of my relatives insulted me since I couldn’t do something, or if they managed to hear what another doctor said previously.’ iii) The Meaning of the Profession The health workers were had combined experience of managing home life, working during the pandemic, all within the confines of the lockdown made them to think about at a more abstract level about the real meaning of their work. It made them really think about what being a healthcare worker was. Therefore, it did not sit well with some of the terminology by the media, referring to them as ‘heroes’, with many stating that they were just doing their work. “It’s our job, just like any other. Whenever other do their jobs under pressure we don’t call them that…” Additionally, some participants stated that the job brought forward the excitement of being a healthcare worker, with some stating that they would consider changing their professions Qualitative Research Methods 11 after the pandemic. In some instances, some mentioned that their activities went against their values. “It was hard for me to witness people dying in such poor conditions. Some of them would not have died if the situation was normal. At some point, it felt like we had to choose who lived and who died.” There was a belief that the positive media attention should be used to span a new level of recognition for the professionals in that area. “When the situation was bad, we were highly revered and respected, now it’s like we do not exist.” “The government should take action and recognise us especially for our speciality.” The public had a lot of generosity directed towards the participants with them being able to receive free services and goods at times. Discussions The literature in the sources ad repercussions of the psychological stress that the healthcare workers faced during the covid-19 pandemic gives new information in regards to the perceptions and experiences of the ICU staff together with how their daily activities got affected, both personal and professional. There is a lot of data and studies yet their health is in problems due to high levels of stress accumulating since the pandemic increasing the risk of death and suicide (Pappa et al., 2020). Most of the reports that have been used have relied on quantitative data having he heterogeneity caused by different scales and tools. This situation makes comparisons difficult hence, making conclusions about the topic hard. The quantitative studies do not account for the personal context of individuals. Therefore, this study explored the consequences faced by the individuals on their psychological stress affecting the healthcare workers affecting both the personal and professional lives paving way for mental health support (Troglio da Silva and Neto, 2021). The findings show that the personal life and professional lives are connected which is depicted with how the respondents were afraid of bringing home the virus. The restrictions made it hard for the people to live comfortable with some counting on their family members for assistance. Some workers made their decontamination areas in which they would bathe and changes clothes before entering their houses. Additionally, the media Qualitative Research Methods 12 compounded the participants with more pressure while at home adding to the pressure, stress and fatigue while at home. Feeling of loneliness and isolation grew rampant in the country due to the restrictions imposed (Liu et al., 2012). This had the ability of increasing the depression and anxiety. More information about the disease could also increase fear and panic and also increase discrimination and stigmatization since they could risk contaminating others (Arabi, Murthy and Webb, 2020). On the other hand, there were some positive outcomes like social support from the community, improved sleep quality with a drop in the anxiety and stress. The health sector in the country provided psychological support services to their healthcare providers in hospitals (Xiao et al., 2020). Furthermore, mental health services were also provided to the families of the patients, but further holistic approaches need to be adopted in this area (Lesieur et al., 2021). Reorganising the workplace to provide better care was appreciated with more workers being brought making it more relaxed. Other people saw the negative impact by having to train the new worker while also working causing more pressure. The health workers were recognised for their efforts in combating the virus, with an increased focus being placed to providing social support to the health workers. There was also a strong team effort reported and solidarity across the entire hierarchy (Schierberl Scherr, Ayotte and Kellogg, 2021). Some of the limitations include: some of the questions may not have been covered in the interview and questionnaire hence complete spectrum could not be covered. The interviews were conducted over the phone which could have influenced them as opposed to a face-to-face interview. Finally, only Chinese participants got used which locked out the views of others from different countries. Conclusion The interview reflected the concerns of the healthcare workers and their views caused by the crisis. The pandemic had effects on both the personal and professional lives of the individuals, culminating in fear of being infected and changing their working conditions. Some of the positive outcomes include there was improved teamwork and increases motivation. Finally, impact studies should be used to assist I reducing stress and anxiety in both spaces. Qualitative Research Methods 13 Reference List Al Muharraq, E.H. (2021). The Psychological Impact of Coronavirus Disease 2019 on Nurses in Saudi Arabia and Their Coping Strategies. SAGE Open Nursing, 7, p-. doi:https://doi.org/10.1177/-. Arabi, Y.M., Murthy, S. and Webb, S. (2020). COVID-19: a novel coronavirus and a novel challenge for critical care. Intensive Care Medicine. doi:https://doi.org/10.1007/s-. Azoulay, E., Cariou, A., Bruneel, F., Demoule, A., Kouatchet, A., Reuter, D., Souppart, V., Combes, A., Klouche, K., Argaud, L., Barbier, F., Jourdain, M., Reignier, J., Papazian, L., Guidet, B., Géri, G., Resche-Rigon, M., Guisset, O., Labbé, V. and Mégarbane, B. (2020). Symptoms of Anxiety, Depression, and Peritraumatic Dissociation in Critical Care Clinicians Managing Patients with COVID-19. A Cross-Sectional Study. American Journal of Respiratory and Critical Care Medicine, 202(10), pp-. doi:https://doi.org/10.1164/rccm-oc. Braun, V. and Clarke, V. (2006). Using Thematic Analysis in Psychology. Qualitative Research in Psychology, [online] 3(2), pp.77–101. doi:https://doi.org/10.1191/-qp063oa. Lesieur, O., Quenot, J.P., Cohen-Solal, Z., David, R., De Saint Blanquat, L., Elbaz, M., Gaillard Le Roux, B., Goulenok, C., Lavoué, S., Lemiale, V., Mercier, E., Mezher, C., Misset, B., Penven, G., Poujol, A.L., Quentin, B., Quéré, R., Van Der Linden, T. and Rigaud, J.P. (2021). Admission criteria and management of critical care patients in a pandemic context: position of the Ethics Commission of the French Intensive Care Society, update of April 2021. Annals of Intensive Care, [online] 11(1), p.66. doi:https://doi.org/10.1186/s--z. Liu, X., Kakade, M., Fuller, C.J., Fan, B., Fang, Y., Kong, J., Guan, Z. and Wu, P. (2012). Depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic. Comprehensive Psychiatry, 53(1), pp.15–23. doi:https://doi.org/10.1016/j.comppsych-. Qualitative Research Methods 14 Mwita, K. (2022). Factors influencing data saturation in qualitative studies. International Journal of Research in Business and Social Science -), 11(4), pp.414–420. doi:https://doi.org/-/ijrbs.v11i4.1776. Pappa, S., Ntella, V., Giannakas, T., Giannakoulis, V.G., Papoutsi, E. and Katsaounou, P. (2020). Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain, Behavior, and Immunity, 88, pp.901–907. doi:https://doi.org/10.1016/j.bbi-. Schierberl Scherr, A.E., Ayotte, B.J. and Kellogg, M.B. (2021). Moderating Roles of Resilience and Social Support on Psychiatric and Practice Outcomes in Nurses Working During the COVID-19 Pandemic. SAGE Open Nursing, 7, p-. doi:https://doi.org/10.1177/-. Shechter, A., Diaz, F., Moise, N., Anstey, D.E., Ye, S., Agarwal, S., Birk, J.L., Brodie, D., Cannone, D.E., Chang, B., Claassen, J., Cornelius, T., Derby, L., Dong, M., Givens, R.C., Hochman, B., Homma, S., Kronish, I.M., Lee, S.A.J. and Manzano, W. (2020). Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic. General Hospital Psychiatry, 66, pp.1–8. doi:https://doi.org/10.1016/j.genhosppsych-. Troglio da Silva, F.C. and Neto, M.L.R. (2021). Psychiatric disorders in health professionals during the COVID-19 pandemic: A systematic review with meta-analysis. Journal of Psychiatric Research, 140, pp.474–487. doi:https://doi.org/10.1016/j.jpsychires-. Wong, J., Goh, Q.Y., Tan, Z., Lie, S.A., Tay, Y.C., Ng, S.Y. and Soh, C.R. (2020). Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore. Canadian Journal of Anesthesia/Journal canadien d’anesthésie, 67, pp.732–745. doi:https://doi.org/10.1007/s-. Xiao, H., Zhang, Y., Kong, D., Li, S. and Yang, N. (2020). The Effects of Social Support on Sleep Quality of Medical Staff Treating Patients with Coronavirus Disease 2019 (COVID-19) in January and February 2020 in China. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, [online] 26, p.e923549. doi:https://doi.org/-/MSM.923549.