Experiences of health professionals in EU institutions during the Covid crisis

Abstract

We performed a quantitative and a qualitative study, addressing the experiences of health services of 16 European Union institutions during the Covid-19 pandemic. Among the 165 eligible subjects, 114 (69%) participated in the survey. The biggest problem reported was limitation of social contacts (53%). At work, the biggest problems were workload (50%) and shortage of staff (37%). The majority were positive about teamwork. Teleworking was seen positively by 81%. Most participants felt better prepared for future situations by their recent experience (94%). Participants underlined the importance of strengthening the collaboration with the local health systems (80%), as well as with medical services and internal services within their own institution (75%). The qualitative analysis also reported participants’ fear of becoming infected, and of their family members getting sick. Similarly reported were the sense of isolation and anxiety, the excessive workload and work complexity, shortage of staff, and the benefits of teleworking. Study findings highlight: i) the need to strengthen mental health support to health personnel, not only during crisis situations; ii) the need for sufficient health workers, with swift recruitment strategies in times of crisis; iii) the importance of clear protocols to ensure no shortages of personal protective equipment (PPE); iv) the importance of teleworking, which represents an opportunity for major reorganisation of work within EU medical services; v) the need to strengthen collaboration with local health systems and the medical services of EU institutions.

1. Introduction

The coronavirus disease (Covid-19) crisis has caused turmoil worldwide, with millions of deaths and profound social consequences. The pandemic has revealed serious shortcomings in preparedness and response to health emergencies. Governance at all levels has faced an unprecedented need to interconnect the various complex aspects of society and health systems to manage an appropriate reaction [1,2]. The pandemic similarly affected the functioning of EU institutions in terms of administrative and institutional decision-making. As stated in the treaties, in the EU institutions, the need to ensure business continuity, guaranteeing democratic and transparent decision-making processes, is crucial. The pandemic also deeply impacted the medical services of the EU institutions.

During the pandemic, in addition to public health measures, appropriate occupational health responses have been needed [3]. The medical services of many European institutions and agencies, transformed their services overnight to centre on Covid-19. Different activities were implemented, including case management, contact tracing, vaccination, virtual occupational health, mental health support, risk reduction for Covid-19, and management of essential employees for business continuity. The emergency services provided for on-site employees were kept in place. Non-medical interventions aimed at guaranteeing the best health conditions for employees have been progressively modified, taking into account the national epidemiological situation. The return-to-work approach has been adapted according to individual circumstances, the psychological effects of the pandemic, and varying risks of contamination in different occupations.

Previous studies highlighted the heavy work burden of health professionals and shortage of staff during the pandemic, especially in hospital settings [[4], [5], [6]]. Health care workers caring for Covid-19 patients have increased risk of stress, burnout, and other mental health difficulties [7,8]. Several studies attributed these problems to fears of becoming infected, being a carrier, and spreading the disease to others, particularly among people with dependent children [9,10], stigmatisation [11] and workload [12]. Many severe shortages of personal protecting equipment (PPE) were reported in hospitals and health workplaces, exposing health workers to infection during the Covid pandemic [[13], [14], [15]]. Understanding the dynamics of workload during the pandemic, especially in the peculiar context of the medical services of the EU institutions, can be useful for the formulation of actions that preserve the working conditions of health professionals in future health crises.

Usually, teleworking (TW) requires preparation to be successfully implemented by organizations and employees. The pandemic substantially forced most organizations, including EU institutions, to adopt this way of working, often without providing employees with adequate skills [[16], [17], [18]]. Previous research identified TW as a factor facilitating worker compliance with pandemic control measures [19,20]. During the crisis, millions of employees in the EU adopted TW as a new way of working. Approximately 50% of Europeans worked from home, at least partially, compared with 12% prior to the crisis [21]. At present, even after the peak of the pandemic, many employees and organizations are continuing TW [22].

Reported benefits of TW included lower worker stress levels, improved work-life balance, and a general improved quality of life. However, reported downsides included, lack of communication with co-workers and household members, increased junk food intake, distractions while working, inability to separate home-life from work-life, and lack of opportunities for help and support [16,20,23]. It would be useful to examine how TW has affected the well-being and the work conditions of employees of the medical services of EU institutions.

The crisis exposed many structural weaknesses and vulnerabilities within health systems, at international, national, and local level, including chronic underinvestment, workforce shortages, and vulnerabilities of information systems [1,24,25]. Exploring which measures health professionals working in the EU institutions suggest in preparation for future health crises can better equip EU health services for future crises. After a crisis, there is always a risk that public and political attention will move on, forgetting lessons learned and neglecting the needed reforms [24]. Drawing lessons from the current pandemic, this study aimed to identify and explore the challenges and burdens of health professionals working in the EU Institutions during the Covid crisis. The study examines several aspects, including difficulties faced at work during the pandemic, the TW experience, and future actions to be implemented in times of crisis.

2. Material and methods

2.1. Design

We performed a mixed-method study consisting of two phases (sequential exploratory design), in which the results of the first quantitative method (a questionnaire-based survey), informed the second qualitative method (focus groups with healthcare workers and administrative personnel). To collect the opinions of healthcare professionals spread over different institutions and different EU Member States, a questionnaire was considered the most suitable tool. Another reason for choosing a questionnaire format was that during the data collection period, due to the Covid-19 crisis, the medical services were extremely busy, and a questionnaire was the practical way to gather the data. The focus groups subsequently organised were judged a satisfactory way to further elaborate upon the answers obtained and to strengthen the conclusions.

2.2. Setting

During the pandemic, medical services from various EU institutions had regular exchanges within the Inter-institutional Medical Board (IMB) and the Advisory Scientific Board (ASB) meetings [26]. The questionnaire-based survey was compiled by the health services of 16 different European institutions and agencies who are part of the IMB, spread over 8 European Member States. Participant institutions are detailed in Appendix I. Each institution/agency has a medical service that provides health care to its own staff and personnel. In these medical services, the number of health personnel is variable, going from few dozen operators (including health and administrative personnel) in the European Parliament in Brussels, to a few units working in the health services of European agencies. These medical services each work in their own way. In some institutions, administrative staff took the lead, in others the medical staff. In some institutions, externals were hired to conduct the vaccination campaigns, in others it was organised by the medical staff of the institution. Individual institutions also differently organised the work and activities of doctors and nurses.

2.3. Participant selection of the questionnaire-based survey and data collection

All subjects eligible to participate in the questionnaire-based survey worked during the pandemic in the medical services of the institutions affiliated with the IMB. The IMB secretariat provided the emails of the health and administrative personnel of the medical services. In some cases, the head of the service provided additional email addresses. Subjects first received the consent of the Medical Service in the respective institution/agency before being enrolled and participated voluntarily.

The questionnaire-based survey analysed the following domains (Fig. 1 ): A) socio-demographic characteristics (question 1–8); gender, age, nationality, level of education, parent status, household conditions, type of professional position, and self-care during the pandemic; B) working conditions and vaccination status (questions 9–16); C) difficulties at work during the pandemic (questions 17–25): D) TW experience during the pandemic (questions 26–30); E) future actions which could be implemented in time of crisis (questions 31–32); F) Open questions. The survey included close ended questions and Likert scale questions according to the domains under evaluation (see questionnaire in Appendix II). The anonymous questionnaire was developed in English, made available on the Opinio platform, and the link was sent by email. The final version of the questionnaire was drawn up based on feedback from a pilot test sent to twelve participants. The finalised questionnaire was sent to 165 people, and was accessible online from 3 Ma y to June 19, 2022.

Fig. 1.

Structure of the questionnaire and focus groups.

2.4. Focus groups

Only a selection of those who participated in the questionnaire were contacted for the follow-up focus groups. The selection was made in order to guarantee a satisfactory heterogeneity of the 16 working institutions and the 8 EU Member States where these institutions are spread. On the other hand, the selection of the focus group participants was guided by criteria of homogeneity, in terms of experience in the medical services of the institutions and work during the pandemic. At the same time, an attempt was made to select subjects who have worked in different settings (for example, by inviting subjects who have worked in large medical services or in smaller medical services), thus guaranteeing sufficient variation among participants to allow for contrasting opinions and experiences.

The interviewer contacted each participant to give more information about the procedure and to schedule a focus group with other participants. Four focus groups were organised, for: i) doctors, ii) nurses, iii) social workers and psychologists, and iv) administrative personnel. In total, 13 staff (four doctors, three nurses, three administrative assistants, three psychologists/social workers) were interviewed (Fig. 1). Qualitative data were collected in July–August 2022, after the preliminary analysis of the survey data was available. Focus groups were audio-recorded, and conducted in English remotely via the Zoom application. The moderator made sure that all participants could participate actively in the discussion. It was acknowledged that the participants’ affiliation could possibly hinder willingness to speak freely during discussions. Thus, the focus group moderator emphasised that participation was voluntary and confidential. A thematic analysis using a hybrid of deductive and inductive approaches was used [27]. The deductive approach used codes determined from the quantitative analysis, while the inductive approach identified new themes from the qualitative data. The focus group sessions typically lasted around 2 h, and were concluded when saturation point was reached, and the session was no longer revealing new information. As agreed with the participants of the focus groups, the audio recordings were destroyed after the transcript was secured.

2.5. Statistical analysis

Data were summarized as frequency and percentage. Comparisons among groups were conducted with exploratory purpose using Chi-square test and Fisher's test. No adjustment for multiple testing was included due to the exploratory purpose of such comparisons. Data analysis was performed using R 4.1 (R Foundation for Statistical Computing, Vienna, Austria) [28].

3. Results of the survey

3.1. Socio-demographic data (Q1-Q8)

Among the 165 eligible subjects who were asked to participate in the survey, 114 subjects (69%) participated. Most of the participants were women (74%) and between 40 and 60 years old (77%). Of the participants, 35% were doctors, 30% nurses, 20% administrative staff, 10% social workers and 5% psychologists. Socio-demographic characteristics are shown in Table 1 .

Table 1.

Socio-demographic characteristics.

Variables	N (%)
Sex (n = 114)
Females	85 (74%)
Males	27 (24%)
Declined the question	2 (2%)
Age (n = 113)
20–30 years	1 (1%)
31–40 years	17 (15%)
41–50 years	45 (40%)
51–60 years	42 (37%)
> 60 years	8 (7%)
Job title (n = 114)
Medical doctor	40 (35%)
Nurse	34 (30%)
Administrative assistant	23 (20%)
Social worker	11 (10%)
Psychologist	6 (5%)
Nationality (n = 114)
Belgium	30 (26%)
France	22 (19%)
Italy	16 (14%)
Germany	9 (8%)
Other countries	37 (33%)
Education (n = 114)
Secondary education	5 (4%)
Post-secondary non-tertiary education	4 (4%)
Short-cycle tertiary education	4 (4%)
Bachelor's degree	29 (25%)
Master's degree	49 (43%)
Doctorate	23 (20%)
Parental situation (n = 114)
No child	25 (22%)
Children under 5 in the household	11 (10%)
Children between 5 and 11 in the household	21 (18%)
Children between 12 and 17 in the household	18 (16%)
Children over 18 in the household	17 (15%)
Children living elsewhere	22 (19%)
Household description (n = 114)
Family with children	66 (58%)
Couple living together	24 (21%)
Living alone	14 (12%)
Blended family	4 (4%)
Extended family	5 (5%)
Self-care during the pandemica (n = 109)
Reduced	42 (39%)
Stable	37 (34%)
Increased	30 (27%)

^aSelf-care = physical activity, attention to diet, etc.

3.2. Working conditions and vaccination status (Q9-Q16)

Most participants (59%) were expatriates; 33% had worked in European institutions for 5 years or less. The majority (51%) had an experience in the present workplace equal to or less than 5 years. Concerning the working environment during the pandemic, 36% were involved in preventive medical check-ups (occupational health), 29% in emergency consultation, 24% worked in consultation for vaccination, and 20% in consultation for psychological and social care. Overall, 69% reported a potential contact at work with people infected with Covid-19. Table 2 details information on working conditions and vaccination status.

Table 2.

Working conditions and vaccination status.

Variables	N (%)
Working situation (n = 114)
Expatriate	67 (59%)
Work in the country of origin	47 (41%)
Distance between home and workplace (n = 114)
20 km or less	80 (70%)
Between 21 km and 50 km	22 (19%)
51 km or more	12 (11%)
Experience in the EU institutions (n = 114)
≤5 years	38 (33%)
6–10 years	17 (15%)
11–15 years	35 (31%)
>15 years	24 (21%)
Experience in the current job (n = 114)	58 (51%) 16 (14%) 20 (18%) 20 (17%)
≤5 years
6–10 years
11–15 years
>15 years
Work environment during the pandemic* (n = 113)
Back office	24 (21%)
Front office	37 (33%)
Medical check-up	41 (36%)
Emergency consultation	33 (29%)
Consultation for vaccination	27 (24%)
Consultation for psychological and social care	23 (20%)
Contact with people potentially infected by Covid-19 at work (n = 113)
Never	0
Rarely	23 (20%)
Sometimes	37 (33%)
Often	28 (25%)
Always	12 (11%)
I don't know	13 (11%)
Covid-19 vaccination (n = 114)
Not vaccinated	1 (1%)
2 doses	7 (6%)
3 doses	97 (85%)
4 doses	3 (3%)
Declined the question	6 (5%)
Covid-19 diagnosis (n = 114)
No	59 (52%)
Yes	55 (48%)

Note: * = Up two answers were possible.

3.3. Challenges and difficulties during the pandemic

3.3.1. Pandemic-related fears, limitations on social relations, and difficulties at work (Q17 and Q18)

Concerning fears and social issues, the biggest problem reported was the limitation of social contacts (often/always 53%). Participants reported fear that their family members become infected was greater than the fear of becoming infected themselves (45% and 15% respectively). Concerning difficulties at work, the biggest problems reported were workload (often/always 50%), shortage of staff (often/always 37%), and complexity of work (often/always 28%). A lack of organisation and a feeling of not being sufficiently prepared for the situation were not considered major problems. Additional information is provided in Fig. 2 .

Fig. 2.

Pandemic-related fears, limitations on social relations, and difficulties at work.

3.3.2. Teamwork, and change of workload and work complexity during the pandemic (Q19-Q21)

The majority of participants provided a positive opinion of the teamwork during the pandemic with regard to coordination (good/very good, 71%), collaboration (good/very good 79%), team efficiency (good/very good 79%), and communication between team members (good/very good 69%).

Most participants reported increased workload (higher workload and much higher workload 81%) and increased work complexity (higher complexity and much higher complexity 80%) during the pandemic compared with the situation before the pandemic (Fig. 3 ).

Fig. 3.

Importance of teamwork, and change of workload and work complexity during the pandemic.

3.3.3. Provision of protective materials during the first three months compared with later (Q22 and Q23)

Overall, the participants reported an increase of (almost adequate/adequate/very adequate) protective material from 79% in the first three months to 97% in the following period (p < 0.0001).

3.3.4. Provision of adequate instruction on handling Covid-19 positive people during the first three months compared with later (Q24 and Q25)

Overall, the participants reported an increase in receiving (almost adequate/adequate/very adequate) information on handling Covid-19 positive people from 82% in the first three months to 96% in the following period (p < 0.0001).

3.4. Use of teleworking during the pandemic (Q26-Q30)

Overall, TW was viewed favourably (almost positive/positive/very positive) by 81% of the participants. The technical material provided (almost positive/positive/very positive 96%), functionality (almost positive/positive/very positive 95%) and contacts with colleagues and the hierarchy (almost positive/positive/very positive 92%) were seen as positive (Fig. 4 ).

Fig. 4.

Participants' opinions on TW during the pandemic.

3.5. Feeling prepared for future crises, and looking at actions to manage future crises (Q31, Q32)

Most participants felt better prepared in the event of similar situations thanks to the recent experience (very probably/definitively better prepared, 61%). The survey also explored actions that may be helpful for the service in managing future health crises. The majority of participants underlined the importance of strengthening the collaboration with the local health system (important/very important, 80%), and between medical service and internal services of their institution (75%), to manage future health crises. Most participants underlined the importance of strengthening collaboration between medical services of EU institutions (68%), the usefulness of having a person/team of reference dealing with crisis management in the medical service (68%), and collaboration with international institutions (63%). Provision of training courses and prospective studies on future health crises received less support (46% and 36% respectively) (Fig. 5 ).

Fig. 5.

Actions that may be helpful to manage future health crises.

3.6. Additional analyses

Supplementary analyses were carried out in addition to the descriptive analyses reported above. A summary of statistically significant finding is displayed in Table 3 . Full results of the supplementary analyses are reported in Appendix III.

Table 3.

Summary of statistically significant finding from supplementary analyses.

Variables		Categories				P-value
Females (n = 85)		Males (n = 27)
Fear of getting Covid-19						0.006
Never		16/84 (19%)		10 (37%)
Rarely/Sometimes		51/84 (61%)		17 (63%)
Often/Always		17/84 (20%)		0 (0%)
Fear of a relative getting Covid-19						0.004
Never		5/84 (6%)		6 (22%)
Rarely/Sometimes		34/84 (40%)		15 (56%)
Often/Always		45/84 (54%)		6 (22%)
Self-care during the pandemic						0.03
Less than before the pandemic		36/81 (45%)		6/26 (23%)
As before the pandemic		22/81 (27%)		14/26 (54%)
More than before the pandemic		23/81 (28%)		6/26 (23%)
		Expats (n = 67)		Subjects working in the country of origin (n = 47)
Fear of getting Covid-19 during the pandemic						0.04
Never		14/66 (21%)		13 (28%)
Rarely/Sometimes		46/66 (70%)		23 (49%)
Often/Always		6/66 (9%)		11 (23%)
		Unexposed work environment (n = 47)*		Exposed work environment (n = 67)**
Direct contact with people potentially infected with Covid-19 in the work environment						0.01
Rarely/Sometimes		23/46 (50%)		37 (55%)
Often/Always		13/46 (28%)		27 (40%)
I do not know		10/46 (12%)		3 (5%)
Difficulties about workload during the pandemic						0.01
Never		3/46 (6%)		5 (7%)
Rarely/Sometimes		27/46 (59%)		22 (33%)
Often/Always		16/46 (35%)		40 (60%)
Self-care during the pandemic						0.0008
Less than before the pandemic		13/45 (29%)		29/64 (45%)
As before the pandemic		11/45 (24%)		26/64 (41%)
More than before the pandemic		21/45 (47%)		9/64 (14%)
	Administrative role (n = 23)		Medical doctor or nurse (n = 74)		Psychologist or social worker (n=17)
Direct contact with people potentially infected with Covid-19 in the work environment						0.009
Rarely/Sometimes	13 (56%)		40/73 (55%)		7 (42%)
Often/Always	5 (22%)		30/73 (41%)		5 (29%)
I do not know	5 (22%)		3/73 (4%)		5 (29%)
Difficulties about workload during the pandemic						0.007
Never	3 (13%)		5/73 (7%)		0 (0%)
Rarely/Sometimes	9 (39%)		26/73 (36%)		14 (82%)
Often/Always	11 (48%)		42/73 (57%)		3 (8%)
Feeling of not being sufficiently prepared						0.0006
Never	3 (13%)		30/73 (41%)		2 (12%)
Rarely/Sometimes	14 (61%)		41/73 (56%)		12 (71%)
Often/Always	6 (26%)		2/73 (3%)		3 (17%)
Increased workload	17 (74%)		62/70 (89%)		10 (77%)	0.01
	Self-care as before the pandemic (n = 37)		Self-care decreased than before the pandemic (n = 42)		Self-care increased than before the pandemic (n=30)
Fear of getting Covid-19						0.001
Never	16 (43%)		4 (10%)		4 (13%)
Rarely/Sometimes	19 (52%)		27 (64%)		22 (73%)
Often/Always	2 (5%)		11 (26%)		4 (13%)
Fear of a relative getting Covid-19						0.008
Never	7 (19%)		2 (5%)		0 (0%)
Rarely/Sometimes	18 (49%)		15 (35%)		18 (60%)
Often/Always	12 (32%)		25 (60%)		12 (40%)
Limitation of social relations						0.03
Never	4 (11%)		3 (7%)		0 (0%)
Rarely/Sometimes	20 (54%)		13 (31%)		10 (33%)
Often/Always	13 (35%)		26 (62%)		20 (67%)

* = Including back office, front office and consultation for psychological and social care.

** = Including medical check-up, emergency consultation and consultation for vaccination.

3.6.1. Association of considered variables with gender

Female participants reported higher fear of getting Covid-19 (p = 0.006) or relatives getting Covid-19 (p = 0.004). Moreover, they were more likely to report reduced self-care during the pandemic (p = 0.03).

3.6.2. Association of considered variables with job title

Potential exposure to Covid-19 was different according to job title, with doctors/nurses having more frequent direct contact with people potentially infected with Covid-19 in the work environment, compared with psychologists/social workers and administrative staff (p = 0.009). Difficulties at work during the pandemic also differed according to job title: difficulty due to workload was more frequent among doctors/nurses and administrative staff (p = 0.007). A feeling of not being sufficiently prepared for the situation was more common among administrative staff and psychologists/social workers (p = 0.0006). An increased workload during the pandemic (compared to before the pandemic) was more common among doctors/nurses (p = 0.01). Increased work complexity was more common among doctor/nurses and administrative staff (p = 0.03).

3.6.3. Associations with the work environment (people who have worked in an exposed environment versus people who have not worked in an exposed environment)

Participants working in exposed work environment (including medical check-up, emergency consultation and consultation for vaccination) confirmed more frequent contact with people potentially infected with Covid-19 in the work environment (p = 0.01), reported more workload-associated difficulties at work during the pandemic p = 0.01) and reduced self-care during the pandemic (p = 0.0008).

3.6.4. Associations with self-care during the pandemic

Changes in self-care during the pandemic were associated with fear of getting Covid-19 (p = 0.001), fear of a relative getting Covid-19 (p = 0.008) and limitation of social relations (p = 0.03). For instance, the fear of getting Covid-19 or relatives getting Covid-19 was highest among those who decreased self-care during the pandemic and lowest in those who took care of themselves as before the pandemic. Moreover, the limitation of social relations was more feared by those who changed (both decreased or increased) self-care during the pandemic compare to those who took care of themselves as before the pandemic.

3.6.5. Associations with the working situation (expatriate versus not expatriate people)

Participants working in the country of origin revealed more fear of getting Covid-19 during the pandemic with respect to expatriates (p = 0.04).

3.6.6. Other associations

No statistically significant associations emerged between: i) participants with 5 or less years of experience in the EU institutions, versus those with 6 or more years of experience; ii) participants with 5 or less years of working experience in the current job, versus those with 6 or more years of experience; iii) participants with no children, people with children aged ≤11 years; and people with children aged ≥12 years; iv) participants living alone versus the other household living conditions; iv) Finally, no statistically significant associations emerged between job title (administrative staff, doctors/nurses, and psychologists/social workers) and perceived importance of potential actions that may be helpful for the service to manage future health crises.

4. Results of the focus groups

The focus groups took up the main results that emerged from the survey, but also elaborated on additional themes that emerged from the discussion itself. The points discussed were summarized as follows: i) fear of getting Covid; ii) workload, work complexity, and shortage of staff; iii) teamwork and team spirit; TW; iv) preparing for the future; v) other comments. Selected illustrative quotations are reported in Table 4 .

Table 4.

Selected illustrative quotations from the focus groups.

Theme and subthemes	Illustrative quotations
Fear of getting Covid, fear of relatives getting Covid
Fear of getting Covid	• At the beginning, I was afraid, I did not feel safe when consulting patients (FGD). • At the beginning, the fear and lack of information led to panic. The mass media had an important role on this (FGA). • Pandemic has been an experience that I would not have liked to have in my career, really anxiogenic. However, we have been able to help many people; it was a battle we won (FGN).
Fear of relatives getting Covid	• When you have a professional activity that requires being in close contact with infected people, you are afraid of bringing it back to your family (FGN).
Workload, work complexity, shortage of staff
Workload	• We had different types of workload: one was to organise the response to the pandemic, two to continue with the normal work, third the work related to explanation and communication, and fourth the extra psychosocial burdens, an extra load for the medical team (FGD). • All new tasks were done with last-minute training (FGD). • We carried out many tasks: contact tracing, phoning to positive cases, giving them advice, contacting close contacts. There were days we did this until ten o'clock at night (FGN).
Work complexity	• We needed to respond to the new situation very quickly, preparing group sessions, preparing information, preparing interviews: that was stressful (GFPS). • There was a period when the guidelines changed a lot. We constantly updated our guidelines, checking the reliability of the information, to make sure the information was still accurate. This was a very time-consuming and complex activity (FGN).
Shortage of staff	• We cannot do this again with minimum staffing that has been the case in this pandemic (FGD). • There is an evident link between workload and shortage of staff. Our social work was overload with demands of sick people, isolated at home, mainly alone, far from their country, from family members. For these people we had an extra charge of work (FGA). • In terms of human resources, we need replacements. In addition, the workload - strangely enough - it does not come with any compensatory period. I am not even saying extra leave, I am saying about a period, which we can fit our jobs into 40 h per week, rather than more than this, as was often the case.
Teamwork during the pandemic
	• The group cohesion was really good (FGD). • The workload has allowed us to be closer, to communicate, and to try to help each other, because we all know that we all need support at one time or another (FGN). • D: The crisis was a jump in a black whole, with great uncertainty. The team spirit helped to increase resilience (FGPS). • In the medical service, the management of the complexity improved thanks to the fact that we strongly collaborated among ourselves. The pandemic improved the collaboration and the communication among colleagues (FGA).
Teleworking
Benefit of remote working	• Having a long period with extremely long working days, being able to do most of the work at home helped a lot. I do not know if I would have been able to manage the workload without (FGD). • To stay at home, prepare my agenda, my administrative work, gave me the opportunity to be more focused, more concentrated, saving time, with less stress related to the fear of becoming infected (FGPS). • Keeping some teleworking days per week gives you the opportunity to adapt much more easily in a crisis situation. Maintaining teleworking days can be thought also as a preventive measure in case of a new crisis situation (FGA).
Challenges	• Teleworking for me was difficult [ …] It was just at the level of the organisation of the family life. The working environment at home was not suitable for teleworking. Teleworking put more pressure on me: when I went back to the office, I was more relaxed (FGN). • A lot of staff […] have done their best and have delivered a lot of good work during very difficult times with a lot of teleworking. If administration now revert and say tasks can only be done in office, they do not recognize the efforts, they do not recognize the fact that a lot of work was done at home. So I would advocate for continued recognition for the type of tasks that can be done by teleworking. Our jobs come with many tasks, some of which are perfectly done in telework (FGD).
How to manage future health crises
Institutional collaborations	• It was interesting and useful to build up a collaboration with the local health authorities (FGD). • Local health authorities have been supportive. I never met them in person but we rely on them, jus by telephone, by a virtual conference, we got very useful, important information (FGD). • During the crisis, we had exchanges with other institutions: I discovered procedures that had been adopted by the other institutions. It was great to share new ideas. We learnt things that we put in place: it is important to know how other institutions work (FGN). • More interinstitutional communication between medical services at operational level is crucial (FGA).
Harmonising rules and procedures	• It is important to write clear procedures and guidelines that could be valid for different kinds of health emergencies, pandemics or other problems, to establish clear communication channels, to know how to communicate (FGN). • What we missed were clear procedures: in the future, general procedures and rules would help a lot. It could be useful to put together the experience we have lived in medical services, creating common procedures (FGA). • Clear procedures regarding a crisis could help in the future, both with mobilising personnel and with resources, in order to make human resources and necessary materials quickly available (FGA).
Improving decision-making process	• The information should be shared with lower levels and not only between managers. It could be interesting to understand also how things are going on at upper levels during a crisis (FGA).
Others	• After such a long crisis, you need recovery, to be better prepared for the next crisis. Our administrations are not learning the importance of the recovery (FGD). • [ …] flexibility is important, because we may have different challenges in the future and the institution has to be prepared with specific teams/units of reference dealing with crisis management and preparedness (FGPS). • A key factor is training We know what happened and I think there is room for improvement (FGPS).
Other comments
Communication and misinformation	• Concerning the communication, the explanation we provided, I think we were not sufficiently prepared for that. We were not prepared to deal with misinformation, with the infodemic, and with all the negativity related with the implemented measures (GFD). • We had different sources information: we had rules from our institution that were not consistent with those of the country where our institution was based. People did not understand why different rules occurred between the local health authorities and our institution (FGN).
Interinstitutional medical board (IMB)	• In my institution, I was the single doctor making all decisions. As a doctor, I am so grateful that we had the European network to get the alignment (FGD). • The IMB was also important in strengthening ourselves, feeling supported, and building our own resilience (FGD).

Note: FGD=Focus group doctors; FGN=Focus group nurses; FGPS=Focus group psychologists and social workers; FGA=Focus group administrative personnel.

5. Discussion

The study found that during the pandemic, EU health professionals experienced social isolation, and a challenging work conditions, especially during the first phases of the crisis. They reported feelings of stress and insecurity, and complained of working in a chaotic and turbulent environment. The workload was described as heavy and complex, particularly during the first phases of the pandemic. Institutions must always guarantee adequate and stable health staffing, noting the need for flexible and rapid mechanisms for the recruitment of new staff during times of crisis. Positive findings include an improved sense of team spirit in the workplace, a general feeling of being supported by the community, and satisfaction with the provision of PPE, which was never a serious problem, even in the early stages of the pandemic. TW received generally positive feedback, especially in helping with workload and work-life balance. Even in post-crisis times, EU health services must maintain continuous and structured contact with local health authorities. These actions have shown improved management during the pandemic, making it possible to better exchange guidelines, information, and experiences.

5.1. Fear of getting covid, fear of transmitting infection to others, and social issues

Concerning fears and social issues, the biggest problem reported was limitation of social contacts. Health personnel were isolating themselves from family and friends. The emergence of the pandemic made participants feel anxious and fearful, since they knew that the virus would be present at the workplace, certainly among patients and perhaps among co-workers. In both the survey and in the focus groups, participants expressed fear of transmitting infection to their family and relatives. Symptoms of distress arose during the first phases of the crisis, and decreased as time went on. These results aligned with the conclusions of other studies [[29], [30], [31], [32]]. Participants mentioned that they faced instances of stigma in the community: they reported how some people would keep their distance from them if they knew they were health workers. However, this was counter-balanced by there being an overall feeling of support for health workers from the general community [[31], [32], [33]]. Psychological distress, fear, and stigma can be a predictor of poor mental health [34] and can severely hinder performance at work. Consequent issues include decreased efficiency, more medical errors, a greater staff turnover, and a general lowering of quality in healthcare services [35,36].

To combat such psychological distress, some organizational measures can be implemented. These can include more flexible TW, training on stress management, and improvement in job/leadership support [37]. Promoting mindfulness and team cohesion also showed to be effective [38,39]. Furthermore, infection prevention training was shown to reduce stress [34]. These measures should remain in place for as long as is necessary, even after the crisis has ended. In addition, it must be noted that most personnel working in the health services are female. This is also the case in the EU institutions. In this survey 74% are female. Given that female health workers are more affected by psychological distress, this underscores the importance of the above measures [9].

5.2. Workload, work complexity, shortage of staff, teamwork

Healthcare workers described their workload as heavy and complex, particularly during the first phases of the pandemic. The workload increased for different reasons, including staff shortages, and the introduction of TW, which blurred boundaries between work and private life. Covid infections exacerbated staff shortages, further increasing workload. These outcomes aligned with the results of other reports [[4], [5], [6], [7], [8],12]. As the pandemic intensified, health personnel experienced exhaustion from constantly having to learn and adapt to new procedures and protocols, which frequently meant dealing with conflicting information, and continually changing rules and guidelines. Some responses to the survey's open questions and some participants in the focus groups reported that their managers did not fully understand the situation or were unaware of the workload challenges. The study suggests that communications between levels of hierarchy should be streamlined, with greater engagement at all levels, including consultation in the decision-making processes. The volume and rapidity of dissemination of misinformation made things worse. These results agreed with the conclusions of other reports [29,31,32]. The findings of this study highlight the need to obtain and maintain adequate numbers of health personnel in general, and effective recruitment and preparedness (including training) strategies for times of crisis, with an adequate and stable funding line for the sector. Finally, to help services such as the medical service that need more support in times of crisis, rapid and flexible systems must be put in place to enable staff, including non-medical support staff, to easily move from one service to another.

Heavy workloads and additional stresses can cause conflict among team members. However, participants to this study described how the pandemic brought an improved sense of team spirit to the workplace. The pandemic also brought about greater collaboration among team members and improved team efficiency.

5.3. Personal protecting equipment (PPE)

In contrast to many reports from the beginning of the crisis [31,32], a PPE shortage did not emerge as a major issue during the pandemic. The survey shows that in the first three months only 21% considered PPE insufficient. This dropped to 3% in the following months. A shortage of PPE never arose as a significant difficulty in the discussion groups. Nonetheless, recognising the difficulties of many health institutions in addressing PPE needs during the crisis, the EU institutions must maintain clear protocols to ensure there will be no shortages of PPE during pandemic periods, establishing or enhancing strategic stockpiles to address any future demand. Additional requirements for stockpiling PPE include sufficient warehouse space, trained staff, and inventory management systems.

5.4. Teleworking

Prior to the pandemic, telework in the EU institutions was uncommon [21]. EU staff started compulsory TW on or around March 16, 2020 depending on the place of work (excepting a few services, which had to continue in office, e.g. security and logistics). TW was implemented without much organizational experience or full knowledge of inherent complexity. Numerous unanticipated issues arose from this abrupt, mass transition to a new way of working. The gradual return to office in late 2020 provided different options for the amount of time to be spent in institutional premises.

Depending upon their personal situation, health personnel experienced a range of different issues arising from working from home. They provided positive feedback regarding their overall experience of TW. Most participants felt more productive due to fewer interruptions and greater flexibility of time, with improvements in communication, time management, and their ability to work autonomously. In general, TW had a good impact on their well-being and enabled a healthier work-and-private-life balance. Consistent with the literature [37], participants said that TW felt protective, and relieved some anxiety, since they did not have to go to the workplace, and potentially be exposed to contagion by leaving home. However, several female participants pointed out the difficulties arising from the lack of separation between work and family life. TW took place when schools and day-care centres were closed, meaning children had to be at home. As reported in other studies, it is mainly women that have had to provide this increased need for childcare [9,40].

Telemedicine aided the clinical work of the medical services of the EU Institutions. Teleconsultations maintained physical isolation and avoided direct physical contact, minimising the risk of Covid-19 transmission. Teleconsultations were used in evaluation of suspected cases, referrals to testing, support for the diagnosis and treatment for mild Covid-19 cases, and general personal care. Teleconsultation allowed psychologists and social workers to continue their work, giving welcome advice to a large number of people, especially expatriates, isolated and far from their families.

The telework in the EU institutions during the pandemic cannot be considered typical telework experience. Teleworkers were not doing so voluntarily, and the pandemic crisis occasioned its own additional stresses. However, many teleworkers reported that after some difficulties during the first months of the pandemic, the benefits of TW outweighed any drawbacks. TW represents a positive opportunity for the reorganisation of work within EU medical services. A number of tasks, such as teleconsultations, can be done successfully through TW, not only in times of crisis, but as a general practice. However, TW can be improved. Autonomy and self-leadership have been recognized as having a positive correlation with productivity and work engagement. In light of this, where appropriate, training on these aspects can be given, leveraging skills of individuals, and providing up-to-date technical tools necessary for successful TW. Increasingly, innovations in this direction are geared towards working to objectives, rather than continuous directive leadership processes [16].

5.5. How to manage future health crises

After more than two years of pandemic, most participants reported feeling better prepared for any future similar situations: most participants stated that they would be more competent should another pandemic occur. This aligns with the conclusions of other studies [41,42]. However, over time, this level of preparedness may decrease, and this necessitates adequate ongoing training to mitigate.

Additionally, the study explored courses of action that may be helpful for the medical services in managing future health crises. The majority of participants underlined the importance of strengthening collaboration with the local health systems. During the crisis, this collaboration consistently proved useful and helpful; it made it possible to better harmonise the decisions of the European institutions as employers, scattered across various Member States, with the decisions of local health authorities. This strengthens links between public health and occupational health, achieving better synergies and outcomes [43].

From March 2020, Inter-EU institutional cooperation achieved different objectives in different ways. Most participants noted the importance of strengthening collaboration among the medical services of EU institutions. Medical services from various EU institutions had regular exchanges within the Inter-institutional Medical Board and the Advisory Scientific Board meetings. The inter-institutional Medical Board was regarded as being key to facilitating the coordination of institutions on the medical aspects of the crisis [25]. However, while coordination was welcomed, a full standardisation of processes among health services was neither possible nor desirable. Each service has its own specific constraints, activities, and dimensions, and each needs to implement an approach in line with the specific requirements of its institution and staff. Other actions that were considered important to manage future health crises were a greater collaboration between medical services and internal services within each institution, as well as the need for a person/team of reference dedicated to dealing with crisis management.

6. Conclusions and limitations

The Covid pandemic has greatly tested the capabilities and weaknesses of EU health services. This is the first study to provide an in-depth exploration of the EU health care workers’ experiences and perceptions in the EU institutions during the challenging situation created by the Covid crisis. This study encompasses the pandemic experiences of the health services of the major EU institutions. The study is multi-centre and multi-country, with a good participation rate (69%). The study was not without limitations. In EU institutions, there are 7 major European institutions, (the European Parliament, the European Council, the Council of the European Union, the European Commission, the Court of Justice, the European Central Bank, and the European Court of Auditors) and 7 bodies which play specialised roles (namely, the European Economic and Social Committee, the European Committee of the Regions, the European Ombudsman, the European Data Protection Supervisor, The European Investment Bank, the European Data Protection Board and the European External Action Service). In addition, there are over 30 decentralised agencies spread across the EU. Not all these institutions have an individual medical service, and some of these institutions share medical services [44]. A limited number of EU institutional medical services participated in the study, so the conclusions may not necessarily apply to all EU institutions. The different medical services involved in the study varied greatly in size and organisation, so some caution should be taken not to apply the conclusions too universally. It would indeed have been interesting to analyse differences among the different EU countries, because of the differences in the spreading of the virus and in the different policies and counter measures adopted by each country. However, in order to guarantee anonymity, we did not collect the information on the working institutions of participants: consequently, it was not possible to see if there was any association of considered variables within countries. The study sought to mitigate this limitation by adopting a mixed-method, with a quantitative and qualitative approach. Both quantitative and qualitative research each have weaknesses that to some degree are compensated for by the strengths of the other. The adoption of the final version of the questionnaire was guided by a preliminary pilot study. In addition, a helicopter view to the survey was applied, asking questions that were applicable to all different settings. Finally, since the study gathered feedback only from staff from medical services of EU institutions, the findings may not be applicable to all health care workers, in particular staff working in frontline, hospitals and clinical roles outside EU institutions.

Ethics approval and consent to participate

This study was discussed at and approved by the Interinstitutional Medical Board of the European Institutions (headquarter in Brussels, Belgium). Participants received the consent of the Medical Service in the respective EU institution/agency and participated on a voluntary basis.

Funding

The statistical elaboration was financially supported by the Medical Services of the European Parliament, Brussels, Belgium.

Credit author statement

GQ contributed to the conception of the work, analysis and interpretation of data, and the drafting of this manuscript. GD contributed to the conception and design of the work, collection and interpretation of data. FC provided the statistical analysis and interpretation of data. MGO contributed to the revision of the manuscript and references. PC contributed to the conception and design of the work, analysis, interpretation of data and revising the manuscript. All authors reviewed the final version of the manuscript.

Disclaimer

The views expressed in this publication are the sole responsibility of the authors and do not necessarily reflect the views of the affiliated organizations.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following are the Supplementary data to this article.

Data availability

Data will be made available on request.