Forgotten Heroes

Given that the scientific literature about burnout and resilience in medical personnel during the COVID-19 pandemic is regarding physicians and nurses, there is a lack of information regarding the experiences of healthcare support workers. Our study contributes to filling a void in knowledge concerning mental health in healthcare support workers.

Objectives

Health care support workers have been facing several challenges due to the stressful environment in COVID-19 pandemic. Because of the gap in literature, it is mandatory to explore their experiences to identify burnout, predisposing factors, and possible interventions.

Methods

We conducted qualitative research with a hermeneutic phenomenological method. Participants belonged to cleaning services, security, and hospital administration areas at a hospital in Bogotá. We used semistructured individual interviews. The analysis approaches were deductive and inductive.

Results

As main concepts, we found the following: fear of infection and coping mechanisms, dealing with COVID-19 and being part of the health care support system, overwhelming workload and motivation to keep going and socioeconomic conditions.

Conclusions

We found burnout predisposing factors; however, the participants did not express symptoms of burnout syndrome. We believe protective factors such as resilience are influential concerning this outcome.

COVID-19 global pandemic has generated a stressful environment for medical staff members around the world due to multiple factors such as the fear of getting infected and being a vector of transmission to family and friends, discrimination and stigma among the community, limited resources of hospitals, availability of personal protective equipment, longer shifts, augmented demand from patients, the indifference of personal and family needs with an increased workload, disruption in work-life balance, and lack of sufficient communication and updated information.^1–4 Consequently, many authors like Chen et al,¹ Giorgi et al,² Adams and Walls,³ and Raudenská et al⁵ have observed implications with the development of burnout on this special population.^1–4 The concept of burnout has been widely used to describe this relation between workplace and mental health, it was first coined in the 1970s by Maslach,⁶ and it can be defined as an excessive reaction to stress caused by one's environment that may be characterized by feelings of emotional and physical exhaustion, coupled with a sense of frustration and failure.

Since Maslach⁶ described burnout in 1970, studies have been conducted, demonstrating burnout as a factor related to poor outcomes on work, personal life, and health. At work, burnout has been related to job dissatisfaction, absenteeism, intention to leave the job and poor job performance. In personal life, workers experiencing burnout have higher levels of unsatisfactory marriage, and have reported work as having a negative impact on their family.⁷ Poor health outcomes are related to symptoms of prolonged stress, such as headaches, physical exhaustion, gastrointestinal problems, back pain, hypertension, colds and flu, and sleep disturbances.^6,8

On the other hand, other authors, such as Heath et al,⁹ Rangachari and Woods,¹⁰ studied the concept of resilience as a response mechanism toward these distressing events faced by medical staff members during the COVID-19 pandemic. These studies have been conducted mainly on medical professionals (MPs) defined as physicians, nurses, and therapists. However, health care support workers (HSWs) defined as clinical assistants, patient services assistants, volunteers, security personnel, and ward clerks, are key to keeping hospitals working and have been facing similar challenges during the pandemic.¹¹ Nevertheless, there is a lack of knowledge about their experiences, and they have not been reported previously in the literature. For this reason, it is important to explore how they have been experiencing the pandemic through the burnout approach and identify possible mechanisms of resilience in this specific population.

World Pandemic Context

In December of 2019, an outbreak of a novel coronavirus pneumonia occurred in Wuhan, China, captivating the whole world's attention.¹ The World Health Organization declared it a Public Health Emergency of International Concern on January 30, 2020, and a global pandemic on March 11, 2020. This caused worldwide concern and has forced all countries to take action to contain the virus.¹² To date (June 15, 2021), there have been 176,303,596 confirmed cases of COVID-19, including 3,820,026 deaths.¹³

Colombian Pandemic Context

Colombia had the first confirmed case on March 6, 2020. To date (February 15, 2022), there have been 6,023,257 cases, including 137,301 deaths. The most affected city is the capital, Bogota, with 1,104,052 cases and 21,123 deaths. During this period, the government has imposed many measures to decrease the number of infected people, and therefore, hospitalizations and deaths. Nevertheless, to the month of June 2021, the country and the capital were facing the toughest moment of the pandemic, having their worst numbers.¹⁴

In Colombia, the COVID-19 crisis and lockdown have severely hit those employed in the informal sector who constitute half of the labor force, and it is estimated that 3.5 million people have fallen into poverty because of the COVID-19 pandemic, bringing the number of those living in poverty from 17.5 million in 2019 to 21 million (42.5% of the population) in 2020.^15,16 We consider that the socioeconomic situation that Colombia is going through is a factor to consider when talking about the implications of mental health in all workers including HSWs.

Burnout and Resilience in HSWs During the COVID-19 Pandemic

During the pandemic, the social media and the scientific community have given special attention to the well-being of MP, taking into account additional stress factors they have to face that are intrinsic to their workplace such as the fear of getting infected and being a vector of transmission to family and friends, discrimination and stigma among the community, limited resources of hospitals, availability of personal protective equipment, longer shifts, augmented demand from patients, the indifference of personal and family needs with an increased workload, disruption in work-life balance and lack of sufficient communication and updated information.^2–4 It is believed or it seems that these factors contribute to creating a poor working environment that may cause negative outcomes such as burnout, among MP and HSW.^3,4

Studies conducted in China and Italy have shown that during the coronavirus outbreak the rate of burnout has increased among MP, and symptoms of burnout such as anxiety and depression were more common among those working directly with COVID-19 patients or in areas with major burden of disease like the intensive care units.^17–19

Wood et al²⁰ described the relationship between burnout and four potential protective factors: grit, social support, psychological flexibility, and resilience. They found that grit had the strongest protective relationship to burnout, attached to social support and psychological flexibility while resilience was not included as a protective factor. Grit is a term introduced by Duckworth and colleagues²¹ in 2007, they defined it as perseverance and passion for long-term goals and addresses working strenuously toward challenges, maintaining effort and interest over years despite failure, adversities, and plateaus in progress. Wood et al²² also suggests a harmful effect on “gritty” persons based on their qualitative data, getting to the conclusion that participants with these characteristics can sacrifice their well-being for long-term goals as well. However, during the pandemic, studies of the protective factors of burnout in MP were carried out, and it was concluded that the model proposed by Wood and colleagues needed to be re-evaluated since it would probably increase the importance of protective factors such as resilience and social support.

In this context, it is important to talk about the concept of resilience, which has been defined as the ability to resist disruption of normal functioning in the face of a distressing event (in this case, the COVID-19 pandemic), by anticipation and preparation.⁹ Even though every person has different experiences and perspectives, it is very important to provide a variety of strategies to promote overall well-being in health care workers. Within these measures it is shown that, providing adequate amounts of personal protection equipment, sufficient rest, nutrition, and hydration, limiting overworking (e.g., shifts >16 hours), allowing MP to seek help if needed without stigma or repercussion, offering individualized emotional support plans, support groups (e.g., peers) and reading materials, were identified to be useful to reduce the burnout syndrome and other mental health problems in support health care workers.^4,10,23

Rangachari and Woods¹⁰ described the components of a resilient organization in three interconnected levels in which resilience can be present: Individual, team and organizational level. All of them have three key elements that allow and strengthen the process of resilience, these being: Foresight (ability to predict something bad could happen), coping (ability to prevent something bad from becoming worse) and recovery (ability to recover from a bad occurrence). Other authors, like Wreathall, describe seven different themes characteristic of a highly resilient organization: top-level commitment (recognition of human performance concerns and the capability of addressing them), culture (reporting of issues up through the organization, yet not tolerating culpable behaviors), learning culture (ability to respond to events with denial vs repair or true reform), awareness (data gathering that provides information about people's performance, the grade of a problem, and the state of the solutions), preparedness (being aware of the problems, anticipating and being prepared for them), flexibility (adapting to new situations, maximizing the ability to solve, preserving the overall functions), and finally opacity (knowing the limits of the barriers and the defenses).²⁴

As previously mentioned, resilience is an essential competence that support health care workers must develop to provide the best attention to their patients, so it is very important that employers and health centers offer the appropriate tools for the enhancement of this skill.¹⁰

Because multiple studies, Adams and Walls,³ Raudenská et al⁵, Trumello et al,¹⁷ Liu et al,¹⁸ and Kok et al,¹⁹ have shown the relationship between burn-out and essential workers in the pandemic, as well as the resilience capacity among them, we aim to explore and describe this phenomenon in HSW since they are not included in the scientific literature, in addition, this population was a crucial part of the first line of attention for the patients during the pandemic. Even though it has been widely described in the media to the point of calling them “forgotten heroes,”^25,26 it is the reason why our study has the imperative to identify and describe how the HSW have experienced the pandemic and based on the results recognize improvement opportunities in the Colombian context.

Qualitative Research and Its Relevance in This Study

Qualitative research entails an interpretative and naturalistic approach to the world, which allows the researchers to interpret different events by observing, describing, interpreting, and analyzing the way that people experience, act on, or think about themselves and the world around them.²⁷ The aim of a qualitative study is to get a complex and detailed understanding of the issue through direct conversations with people, visits to their homes or places of work, and allowing them to tell their stories. The collection of this data is achieved by empowering individuals to share their stories, hearing their voices, and minimizing the power relationships that exist between the researcher and the participants. All above for the purpose of avoiding bias from what the researchers expect to find or what is in the literature.²⁸ We used qualitative research on this study because we wanted to make an interpretation of the meaning of the lived experiences of this workers to guide organizations in the creation of policies for the benefit of their workers and collaborators through the analysis of their subjective experiences.

METHODS

This is a qualitative study that uses a hermeneutic phenomenological analysis, which aims to identify the “essence” of a phenomenon through an individual's experience of that phenomenon²⁸; in addition, the objective is to explore an under-researched topic with the purpose to acquire preliminary insights into key problems regarding resilience and burnout in HSW to aid future research.²⁹ Even though HSW includes a variety of workers,¹¹ in this study, we will focus on the administrative, cleaning, and security personnel.

Setting and Participants

We conducted qualitative research in a health care facility in a main Hospital in Bogota Colombia. Participants belong to the areas of cleaning services, security, and hospital administration and the majority were women of working age. We used as inclusion criterion, people older than 18 years working on the previously mentioned jobs at the Hospital Universitario San Ignacio, at least since the beginning of the pandemic, and we did not have exclusion criteria.

Recruitment, Data Collection, Data Analysis

We invited participants to be part of the research using a snowball sample, starting with key informants of the personnel who work at a University Hospital. Participants were part of the research as volunteers. We conducted eight interviews with a duration of about half an hour and nonparticipant observation during an estimated period of 4 months, from this moment we reached our saturation point, defined as “when no new information was added to coding categories.”³⁰ We explored their experience working in a hospital during the pandemic and the changes compared with the past, their feelings (sadness, tiredness, overburdened), the economic and family dynamics changes, and interventions they considered appropriate to ease problems observed at the job. As gathering tools, we used semistructured individual interviews in Spanish, where we enquired about their experiences and the changes working in the hospital during the pandemic, their feelings, their families, the socioeconomic factors involved, and some interventions that could help them during this time. For the purpose of the article, quotes were translated into English. The interviews were recorded, and then, they were transcribed verbatim, with a hidden encoding procedure that consisted in changing the names of the participants.

In addition to this, we used nonparticipant observation to perceive the different behaviors exposed by the participants in their daily routine in a hospital setting to subsequently carry out a triangulation of these different methods. The information from the nonparticipant observation was collected by the investigators in field journals. Finally, we analyzed the information with an abductive approach, finding these preset categories: fear of getting infected, experiences with COVID-19, overwhelming workload, and economic issues. Also, these emergent categories: support from the institution, motivation to keep going, and the power of accurate information.

Ethical Framing

Research and ethical approval were granted by the Ethics Committee of the School of Medicine of the Pontificia Universidad Javeriana, Bogotá (FM-CIE-03359-20, Act 09/2020). In the same way, research protocol and methods were consistent with Colombian Law. The participants were asked to provide and sign informed consent. We took care that the participants were fully informed about all aspects of the project and were aware that they could withdraw at any moment without providing reasons, and that eventual withdrawal would not affect their jobs in any way. We destroyed the recordings of the interviews, and we will store the transcripts and notes in a protected location at Pontificia Universidad Javeriana for 10 years.

RESULTS

In this section, we will present the analysis of the experiences of eight HSWs in a University Hospital in Bogota, Colombia. For the purposes of the study, the participants' names were changed to preserve their privacy. Participants belong to the areas of cleaning services, security, and hospital administration and the majority were women of working age (six women and two men). These results show how they have lived through the pandemic and how they have been affected, as well as the tools they have used to get through the difficult moments. We found these preset categories: fear of getting infected, experiences with COVID-19, overwhelming workload, and economic issues. Also, these emergent categories: Support from the institution, motivation to keep going, and the power of accurate information.

• 1. Fear of infection and coping mechanisms, including institutional support.

For most of our participants getting infected or possibly bringing COVID-19 home generated fear, however, all of them mentioned a diversity of personal and organizational strategies that helped them cope with this.

Most of the feelings related to a possible COVID-19 infection that they expressed, and that we perceived in non-participant observation included fear, nervousness, stress, desperation, and anxiousness. Cristina, a security guard, described the virus as a mortal entity to which she was completely vulnerable, making her consider quitting her job.

“No, I'm going to quit, there's too much covid here, a lot of illness here, I don't want to get infected, I don't want to be sick…... I can't be here, I don't tolerate this, I'm not capable of doing this...I'm not staying here because I have children at home.” She even said that for some of them, it was their first day at work. (Cristina, 51 years old).

In addition to what was expressed by Cristina in the interview the non-participant observation unveiled how cleaning service personnel were feeling about their work in a hospital during the pandemic.

Researcher 3 (Field journal): “During lunch, I overheard a conversation between the participants in which they talked about their fear about cleaning the COVID rooms ICU.”

In addition to the risk of personal infection, the fear of infecting family members or people living with them was always present. Martha, a customer service counselor said it was very hard to be away from her family members to prevent their infection.

“It is your close family and having to get away from them for fear that something will happen to them is hard. You know that you also do it for their good, but it affects a lot not seeing them, not having them around or not being able to give them a hug” (Martha, 29 years old).

Despite what Cristina and Martha said, Julia, who belongs to the cleaning staff of the hospital, mentioned some individual characteristics that reduce the fear of getting infected, like following all the instructions of self-care and having a healthy lifestyle (exercising and healthy nutrition).

“I have always been calm in this issue of covid because more than anything we have to continue, put on the mask, wash our hands, take precautions [...] I consider myself a healthy person; from what I have seen this virus attacks obese people, who do not eat well and do not exercise. And well, I try to stay healthy, that is, eat well, exercise every day and be very careful with that virus” (Julia, 25 years old).

All our participants agreed that receiving training on how to use personal protective equipment and following personal biosecurity measures, as well as knowing that their contractor would always provide the equipment needed made them feel protected and dramatically reduced levels of fear. Juan who works in the hospital's cleaning route explained:

“Let's not talk about terror, stress, fear, or anguish. It is about precaution, about taking biosecurity measures and making sure they are followed at home and at the workplace. Here at the hospital, we have had virtual meetings on different topics like what are the biosecurity measures we should follow and how to ask for help [...] that helps because it makes us feel calm and like one is being taken care of” (Juan, 41 years old).

Researcher 1 (Field journal): “I assisted to a biosecurity meeting in which the lecturer explained to the staff where to find the personal protective equipment and how to use it properly. At the end of the meeting, the lecturer asked the attendees for feedback on the meeting, which was very positive because most of the attendees thanked the hospital for this learning space.”

In addition to what was mentioned about personal protective equipment, transportation was a common concern in these participants, considering that going on a public bus could be a source of infection. For example, Inés, a security guard, highlighted that the support with transportation provided by the hospital was a very significant action taken by the hospital.

“It seems to me a very, very good idea what the hospital did to place us routes to get to our houses because the transmilenio does not work well [...] you are less exposed, you know that you are going with the workers who are people that you always see with their protective elements at all times, so at least it gives me more confidence than leaving with a lot of people that I don't know, who go with their masks down, talking on the phone, eating, the vendors” (Ines, 27 years old).

Even with the support of the hospital, various participants expressed that the actual public order situation going on in the country, made it difficult to arrive safely to their homes even using the exclusive hospital buses.

• 2. Dealing with COVID-19 infection and being part of the health care support system

Most of our participants either got infected or had a family member who got sick from COVID-19. When asked about how they experienced this, some positive factors of being a hospital staff member came up.

In the case of Cristina, a security guard, her cousin died as a result of getting infected by COVID-19, but the fact of being surrounded by health care professionals allowed her to ask her doubts about the disease, getting trustworthy information. Also, we observed that having peers constantly asking her about her mood and her feelings, made her feel better. These became very important elements to live her grief process. Here, we have some of the experience she shared:

“There were very tough moments here at work…I tried to get over that, that I talk too much with the doctors, I ask them, so ask and avoid being quiet, makes you get off your chest a lot of things. That allows you to continue with your life and prevents marks... It's very useful...the first days the world came over me” (Cristina, 51 years old).

Another factor expressed by many of the participants that made them feel capable of dealing with sickness was the support from the hospital. Participants explained how they received the days off or the time they needed to deal with sick family members. The hospital also included among their online meetings, a space to talk about grief, loss, and managing emotions during tough times. The participants from the hospital's administration perceived a sense of relief and solidarity, Juan explained:

“The hospital also offers meetings regarding duel and psychological support to its workers, and when I was sick, they called me every day to see how I was doing [...] in the emotional part the hospital has being very supportive” (Juan, 41 years old).

• 3. Overwhelming workload and motivation to keep going

The participants also said that the workload increased during the pandemic, a result of the increase of infections and patients who require critical care units or medical management. Julia mentioned that not only doctors and nurses have had more workload due to the pandemic, but the cleaning staff has also had more decontaminations and at the same time, these must be deeper and take more time.

“More sick people have entered and there has been more work in this regard. In other words, before covid there were three cleanings, now there are ten, twelve [...] We have had to be more careful in doing the cleanings, making them deeper, as well as being more careful with the patients” (Julia, 25 years old).

Researcher 2 (Field journal): “Today in the emergency room I heard three calls at the same time to the cleaning services of the hospital to do decontaminations.”

Altruism was found as a key factor to keep going during the pandemic in some of our participants. One of the examples, Martha, mentioned that despite the increase in workload they have always felt good because of the impression of helping other people and their country in this difficult moment.

“It makes me very happy when I help these people because it makes me feel very good to help the families, especially when I help them to achieve their objectives. In general, it makes me feel very satisfied.” (Martha, 29 years old).

Related to altruism, some of the participants said that religious beliefs were always present to guide their actions, and therefore, it became a motivation to continue doing their job everyday. It is remarkable the expressions that people use when they talk about this topic, it seems to be a very strong conviction in their lives. Cristina is one example of this previous:

“My motivation to go to work, I am given to God's hands, I never let his hands go, and before anything else, I asked him for help for everybody. And that is my job, you know that if you don't work you don't survive. Thank God everything has been good for us” (Cristina, 51 years old).

• 4. Socio-economic conditions

Lastly, many participants expressed that the economic stability provided by the institution was a very important factor in the well-being during the pandemic, even Alejandro, a billing and portfolio assistant, expressed that the hospital was a good employer and has always fulfilled its legal obligations.

“The hospital is a good employer, it has paid us all that is mandatory by law, so really I haven't been affected by that.” (Alejandro, 46 years old).

Other employees mentioned that in different establishments, payments were retarded or even some of them were fired at the beginning of the pandemic.

“Well, at first a little bit because I was working elsewhere, and they fired all the women who were there. I went on vacation and spent about two months at home, but then the company called me to work here in the hospital about 8 months ago and since then I have had no problems.” (Ines, 27 years old).

On the other hand, participants said that the quarantine and measures taken by the government to prevent new cases, have affected many small businesses, and as Julia said, making it very difficult to create new ways to generate money. In addition to this, the actual socio-political situation occurring in Colombia has affected their economic situation by making food more expensive and increasing the crime rates.

“It has fostered a lot of crime and intolerance. Now it is up to you how to take care of yourself more. That little you have; you have to save it there in the meantime. That one cannot look at another form of progress yet because with this virus one does not know if they will close businesses again or those things. You think about starting a business or something like that to change your job, but then you can't do it yet. You continue with the uncertainty that there is no progress for something better.” (Julia, 25 years old).

Feedback From the Participants

Once the analysis of the information was finished, we communicated with the participants by telephone to receive feedback from them on the results. All participants agreed with the information we found and the conclusion about how they coped with the challenges of the pandemic. Julia remarked on the relevance of actions taken by the hospital aiming to help the HSW, and Cristina considered that the information found in this study could guide the hospital in particularly the Occupational Health and Environmental office and other organizations on the making of politics related to this population.

DISCUSSION

It is worth mentioning that there is a lack of information concerning the HSW. In this article, we explore experiences during the pandemic of this population.

The analysis of the behaviors identified in the non-participant observation combined with the experiences expressed by our participants showed that our participants identified stress factors that were previously mentioned in the literature. Among the most frequent, we found increased workload, family needs, and lack of sufficient communication or updated information. However, negative mental health outcomes or symptoms of burnout associated with these alterations in the working environment that have been previously described in the literature by Giorgi et al,² Adams and Walls,³ and Raudenská et al⁵ were not suggested by our participant's experiences which turned out to be a new insight of this study.

When asked about their experience working in a hospital during the COVID-19 pandemic, HSWs mentioned that although having an increased workload, they were not in direct contact with COVID-19 patients, and they related this to be less emotionally affected. We can relate these results to what was found by Trumello et al,¹⁷ who describes how the professionals working with COVID-19 patients and health professionals working in the most affected areas are at higher risk of burnout than those who are not, which was an expected finding.

When discussing protective factors of burnout, as Ellinas and Ellinas²² described, these may have changed due to the context of the pandemic, thus changing the model proposed by Wood et al.²⁰ We found in our study that most of the participants expressed resilience as a protective factor, followed by the other factors that they describe as social support, psychological flexibility, and grit, so we consider that it is worth delving into these factors to propose models where it is considered.

Resilience was one of the main findings in all the participants, who expressed that the hospital was a big source of help in the context of this pandemic, even some of them said that they were feeling “excellent,” and that the hospital was an “excellent employer”; however, this could be a socially accepted answer since the hospital is their direct employer and the interviewers are hospital employees. As Raudenská et al⁵ mentioned, different strategies can be useful in preventing burnout syndrome, depending on every person's perspective and experience, which is reflected in the variety of experiences we obtained from the interviewees. Factors, such as having adequate amounts of personal protection equipment and the easy access to seek help, were mentioned by these authors and were also found in the interviews registered in this article. Both of these previously mentioned factors are part of what Rangachari and Woods call organizational resilience. Moreover, our participants also mentioned the ease of access to secure conveyance and having a stable economic income as essential components of the contingency measures taken by the hospital, which were new findings of our study and that can relate to the actual public order situation in Colombia.^8,18 The participants mentioned that they had difficulty getting to their homes due to blockades and riots, which worsened their transport conditions. Furthermore, the cost of life is getting more expensive because of the increase in prices and the impossibility to create new ways of earning money.

Organizational resilience measures were mentioned in the previous paragraph, nevertheless, individual resilience is also a very important component as Rangachari and Woods¹⁰ described, which is reflected in this study in situations like altruism and religious beliefs, elements that were not specified in the literature. Lastly, team resilience was evidenced in the experiences mentioning the importance of support groups composed of health care professionals and peers with the aim to express their emotions or share trustworthy and updated information to solve doubts in all the staff.

According to the researchers' concept and that the literature mentioned that burnout rates have increased during COVID-19,^23,25 it is surprising that all the participants appeared to have plenty of tools individually and organizationally, allowing them to develop a successful resilience process that ends up being an advantage for patient safety and in general, for the hospital functioning, as Rangachari said.¹⁰

Limitations

We found as limitations in this research the fact that as researchers we are part of the Hospital community, in which the interview participants operate, which can cause some fear when answering some of the questions posed, however, by ensuring the anonymity of the participants and establishing rapport through an atmosphere of psychological safety, we try to minimize this to the maximum.

CONCLUSION

The information found in scientific literature about burnout and resilience in medical personnel is regarding physicians and nurses. Therefore, our study contributes to fill a void in knowledge concerning mental health in HSW.

In the experiences of our participants, we identified burnout predisposing factors, however the participants did not express explicitly symptoms of burnout syndrome. We believe protective factors as resilience, in all its levels (individual, team and organizational), are clearly influential concerning this outcome and that as Ellinas et al suggested, burnout protective factor models during the COVID 19 pandemic should include the concept of resilience.