Abstract
Background
The COVID-19 pandemic has significantly increased stress and strain on health professionals. With a focus on paediatric cardiac care, this study explored health professionals’ concerns about COVID-19, perceptions of the impact of pandemic on healthcare, and experiences of psychological stress.
Methods
Paediatric health professionals working at a large quaternary hospital in Australia were invited to complete a survey between June 2020 and February 2021. Demographic factors, clinical role characteristics, and anxiety and depressive symptoms were assessed. Qualitative data on experiences and perceived effects of the pandemic on paediatric cardiac care were also collected.
Results
228 health professionals (152 nurses, 37 medical doctors, 22 allied and mental health professionals, 17 medical research and administrative staff) participated in the survey (54.4% response rate, 85% women). Half the sample (52.2%) endorsed ‘moderate’ to ‘extreme’ worry about COVID-19 and 38% of participants perceived healthcare services as adversely impacted by the pandemic to a ‘great’ or ‘very great’ extent. Almost one in five health professionals reported anxiety (18%) and 11% reported depressive symptoms indicative of a need for clinical intervention. Six themes were identified in the qualitative data: (1) Concern about the consequences of visitor restrictions and disrupted patient services, (2) Intensified strain on healthcare workers, (3) Feelings of fear and loss, (4) Social isolation and disconnection, (5) Adapting to change, and (6) Gratitude.
Conclusion
Timely, tailored policies, supports, and interventions are needed to address health professionals’ mental health needs during and beyond the pandemic, to minimize the far-reaching impact of situational stressors.
Keywords: COVID-19, Pandemic, Congenital heart disease, Paediatrics, Health professionals, Psychological stress, Mental health
Highlights
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This is the first study reporting qualitative data from Australian paediatric health professionals during COVID-19 pandemic.
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Concern for patients and families, intensified work strain, feelings of fear, loss, and social isolation were common themes.
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38% of health professionals perceived the pandemic as impacting healthcare provision to a “great” or “very great” extent.
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This study highlights the need for tailored mental health supports for health professionals during and beyond the pandemic.
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This study also stresses on importance of health system preparedness to reduce the burden of care on health professionals.
1. Introduction
Over 510 million cases and 6 million deaths have been reported globally as a result of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) since the coronavirus disease (COVID-19) pandemic began in Wuhan, China [1]. In addition to preventive measures, such as stay-at-home orders [2], physical distancing [3], and mask-wearing [3], Australia closed international borders in March 2020 and implemented diligent contact tracing to inhibit the spread of the virus, resulting in a lower caseload compared with other countries during the first wave.
While paediatric morbidity and mortality associated with COVID-19 has remained relatively low [4], the pandemic has had a major impact on children and paediatric healthcare [2]. Paediatric emergency department (ED) presentations across four hospitals in Victoria, Australia decreased by 47% between 2019 and 2020 [5], while paediatric health service use for mental health disorders increased by 30–55% between June 2020 and Feb 2021 [6]. For specialisations like paediatric cardiology, the redeployment of even a few health professionals from this skilled workforce and reallocation of resources to manage the COVID-19 caseload can significantly disrupt service provision [7]. With approximately 25% of infants with congenital heart disease (CHD) requiring critical operations within a narrow time window for optimal outcomes [7], cancelled surgeries [8], temporary cessation of follow-up services [7,8], restricted hospital visitation [9], and replacement of in-person visits with telehealth consultations can precipitate moral distress among health professionals [10]. With direct exposure to the virus, frontline workers including health professionals, are also at increased risk of COVID-19 infection and associated psychological stress [11].
According to qualitative studies across the U.S. and U.K., health professionals report concerns about contracting COVID-19,12 transmitting it to family and friends [13], providing sub-optimal care to patients [9], media scrutiny [14], and gaps in communication between organizational leadership and staff [15]. In England, reported rates of post-traumatic stress disorder (PTSD) doubled from a pre-pandemic incidence of 17%–39% among intensive care unit (ICU) and anaesthetic staff (N = 709), with 13% of respondents endorsing thoughts of self-harm [16]. A systematic review and meta-analysis of 15 studies of frontline healthcare workers (N = 7393) during previous pandemics, such as the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003 and Middle East Respiratory Syndrome (MERS) outbreak in 2012, found 20%–75% of healthcare workers reported anxiety and depressive symptoms, with up to 19% reporting persisting traumatic stress symptoms at one to three-year follow-up [17].
While these studies highlight the profound psychological effects of the COVID-19 pandemic for health professionals, a deeper understanding of their experiences is needed to inform policies and supports that equally prioritize high quality healthcare delivery and the wellbeing of health professionals. Thus, with a focus on paediatric cardiac care, the aim of this study was to explore health professionals’ perceptions of the positive and adverse effects of the pandemic on healthcare delivery and to describe the lived emotional experiences of health professionals during this time.
2. Methods
2.1. Participants
Health professionals from diverse disciplines providing clinical care to or conducting research with children with heart disease at a large quaternary hospital service in New South Wales (NSW), Australia were identified via hospital databases. Health professionals on extended leave and those who completed less than 70% of the survey were considered ineligible.
2.2. Procedure
Approval was granted by the appropriate institutional review board prior to study commencement. The WithCare Health Professional Survey Study was launched in June 2020 and responses were captured until February 2021. The survey launch was announced via a series of brief information sessions for staff on the cardiac ward, neonatal and paediatric intensive care units, close observation unit, and anaesthetics department. With support from department heads and team leaders, a range of other strategies were employed to increase awareness of the study, including distribution of customised cookies, chocolates, and mugs as well as flyers, posters, and digital slides.
All eligible individuals were sent a personalised email invitation to the study, including a study information sheet and customised link to the web-based survey, hosted on the secure Qualtrics platform (Qualtrics, Provo, UT). Survey submission was taken to indicate informed consent. For those who did not complete the online survey after three reminders, a paper-based survey was provided. A total of four reminder emails were sent. Participants who reported elevated levels of anxiety or depression, based on established cut-offs,25 were contacted by a psychologist via email to provide support options.
2.3. Measures
Four areas were assessed via survey: (1) Clinical role characteristics (10 items; see Table 1); (2) Sociodemographic characteristics (9 items); (3) Anxiety and depressive symptoms (4 items) during the past 2-weeks assessed using the Patient Health Questionnaire (PHQ-4) [18], with scores of ≥3 on either subscale (anxiety, depression) indicative of a need for clinical intervention; and (4) Experiences of the COVID-19 pandemic (5 items), including worry about COVID-19, assessed using a 5-point scale from 0 (‘Not at all’) to 4 (‘Extremely worried’). Participants also rated the extent to which they perceived the pandemic as adversely affecting healthcare delivery for children with heart disease using a 5-point scale, from 0 (‘Not at all’) to 4 (‘A very great extent’). A qualitative prompt encouraged participants to share any professional or personal challenges and/or opportunities arising from the pandemic.
Table 1.
Clinical role and demographic characteristics presented for the total sample (N = 228) and separately for participants who did (n = 54) and did not (n = 174) provide qualitative responses.
| Variable | Level | Total |
Qualitative Responders |
Qualitative |
|---|---|---|---|---|
| n (%) | n (%) | |||
| Clinical role | Medical doctor* | 37 (16·2) | 8 (14·8) | 29 (16·7) |
| Nurse | 152 (66·7) | 38 (70·4) | 114 (65·5) | |
| Allied or mental health professional | 22 (9·6) | 4 (7 4) | 18 (10·3) | |
| Administrative staff | 10 (4·4) | 1 (1·9) | 9 (5·2) | |
| Researcher | 7 (3·1) | 3 (5·6) | 4 (2·3) | |
| Area of work | Paediatric ICU | 62 (27·2) | 12 (22·2) | 50 (28·7) |
| Neonatal ICU | 47 (20·6) | 15 (27·8) | 32 (18·4) | |
| Cardiac Ward | 40 (17·5) | 10 (18·5) | 30 (17·2) | |
| Operating Suite | 31 (13·6) | 8 (14·8) | 23 (13·2) | |
| Outpatient Clinic | 22 (9·6) | 1 (1·9) | 21 (12·1) | |
| Office or Research Lab | 20 (8·8) | 6 (11·1) | 14 (8·0) | |
| Catheter Lab | 5 (2·2) | 2 (3·7) | 3 (1·7) | |
| Other | 1 (0·4) | – | 1 (0·6) | |
| Employment status | Permanent | 195 (85·5) | 47 (87·0) | 148 (85·1) |
| Fixed-term contract | 26 (11·4) | 6 (11·1) | 20 (11 5) | |
| Casual, locum, or leave relief | 4 (1·8) | 1 (1·9) | 3 (1·7) | |
| Other | 2 (0·9) | – | 2 (1·1) | |
| Night shifts | Yes | 25 (11·0) | 6 (11·1) | 19 (10·9) |
| No | 198 (86·8) | 46 (85·2) | 152 (87·4) | |
| Gender | Woman | 194 (85·1) | 49 (90·7) | 145 (83·3) |
| Man | 30 (13·2) | 5 (9·3) | 25 (14·4) | |
| Non-binary | 1 (0·4) | – | 1 (0·6) | |
| Prefer not to say | 3 (1·3) | – | 3 (1·7) | |
| Age (years) | Under 20 | 1 (0·4) | – | 1 (0·6) |
| 20–29 | 63 (27·6) | 12 (22·2) | 51 (29·3) | |
| 30–39 | 68 (29·8) | 16 (29·6) | 52 (29·9) | |
| 40–49 | 51 (22·4) | 17 (31·5) | 34 (19·5) | |
| 50–59 | 28 (12·3) | 3 (5·6) | 25 (14·4) | |
| Over 60 | 10 (4·4) | 4 (7·4) | 6 (3·4) | |
| Prefer not to answer | 1 (0·4) | 1 (1·9) | – | |
| Aboriginal or Torres Strait Islander identity | Yes | 3 (1·3) | 1 (1 9) | 2 (1·1) |
| No | 224 (98·2) | 53 (98·1) | 171 (98·3) | |
| Birthplace | Australia | 162 (70·9) | 36 (66·7) | 126 (72·4) |
| Overseas | 62 (27·1) | 17 (31·5) | 45 (25·9) | |
| India | 14 (6·2) | 3 (5·5) | 11 (6·3) | |
| UK | 8 (3·5) | 4 (7·4) | 4 (2·3) | |
| Philippines | 5 (2·2) | 1 (1·9) | 4 (2·3) | |
| South Africa | 5 (2·2) | 3 (5·5) | 2 (1·1) | |
| Other | 30 (13·2) | 6 (13·0) | 24 (13.8) | |
| Language primarily spoken at home | English | 202 (88·6) | 49 (90·7) | 153 (87·9) |
| Other | 26 (11·4) | 5 (9·3) | 21 (12·1) | |
| Marital status | Never married | 53 (23·5) | 12 (22·2) | 41 (23·6) |
| Married or partnered | 159 (70·4) | 40 (74·1) | 119 (68·4) | |
| Divorced or separated | 14 (6·1) | 2 (3·7) | 12 (6·9) | |
| Children | Yes | 116 (51·1) | 31 (57·4) | 85 (48·9) |
| No | 109 (47·6) | 23 (42·6) | 86 (49·4) | |
| Educational attainment | No university degree | 19 (8·3) | 2 (3·7) | 17 (9·8) |
| Undergraduate degree | 65 (28·5) | 15 (27·8) | 50 (28·7) | |
| Postgraduate degree | 139 (61·0) | 37 (68·5) | 102 (58·6) | |
| Gross annual household income^ | Below national average | 91 (39·3) | 22 (40·7) | 69 (39·7) |
| Above national average | 101 (44·3) | 25 (46·3) | 76 (43·7) | |
| Prefer not to answer | 33 (14·5) | 7 (13·0) | 26 (14·9) |
*Fields of specialisation include fetal or paediatric cardiology (n = 11), neonatology (n = 7), paediatric cardiothoracic surgery (n = 5), paediatric intensive care (n = 6), and anaesthesiology (n = 7), with levels of experience ranging from consultants (n = 26), fellows (n = 8), and registrars (n = 3).
§ Nursing staff include 21 nurse specialists, 13 educators, 9 clinical nurse consultants, 6 nurse managers, and 5 nurse practitioners.
¥ Some percentages do not add to a 100 due to missing data.
^ National average gross annual household income based on reports from Australian Bureau of Statistics 2022. Below average < $120,000 per year; above average ≥ $120,000 per year.
2.4. Data analysis
A mixed-methods analytical approach was adopted. Descriptive statistics were used to explore sociodemographic and role characteristics. Potential differences in clinical role and area of work between participants and non-participants were examined using Chi-squared and Fisher's Exact tests, respectively. Potential differences in sociodemographic factors, clinical role characteristics, and COVID-19 experiences between participants who did or did not provide qualitative data were examined using Independent Samples t-tests. All statistical analyses were carried out using IBM Statistical Package for the Social Sciences (SPSS, Mountain View, CA, USA) version 27.0. Responses to the qualitative prompt were managed within Microsoft Excel and analysed using an iterative four-phase process: (1) Broad coding of responses into positive and negative affective themes was carried out by one coder, (2) Major themes with tentative sub-themes were identified with relevant data classed under each theme, (3) Themes and sub-themes were refined via discussion with three coders (two psychologists, one physician) and data were re-classified by the initial coder accordingly; and (4) In the final phase, the researchers reviewed all themes and sub-themes to ensure consistency of code definitions and finalise organisation of the qualitative data.
3. Results
3.1. Response rate and sample characteristics
Of the 419 eligible and contactable health professionals, a total of 228 respondents (152 nurses, 37 medical doctors, 22 allied and mental health professionals, and 17 research and administrative staff) completed the survey, yielding a response rate of 54·4%. Participants and non-participants did not differ in terms of clinical role (χ2 = 5·2, p = ·12); however, a higher proportion of health professionals working in non-intensive clinical areas completed the survey compared with health professionals providing intensive care (p = ·001). Most participants were women (85%) and over half the sample (57%) were aged between 20 and 50 years. Over one-quarter (27%) of participants were born overseas and most (89%) primarily spoke English. Other demographics and sample characteristics are presented in Table 1.
3.2. Health professionals’ experiences of COVID-19 and psychological stress
Over one-third (39%) of participants had been tested for COVID-19, none had received a positive result, and all participants completed the survey prior to Australia's implementation of a COVID-19 vaccination (initial roll-out commenced February 22, 2021). A small subset (11·5%) had a relative or close friend diagnosed with COVID-19 and three participants (1·3%) experienced the death of a family member due to the virus. More than half the sample (52%) reported ‘moderate’ to ‘extreme’ worry about the personal and professional consequences of the COVID-19 pandemic (Mean[M] = 1·69, Standard Deviation[SD] = 0·96), with mean scores for each clinical group illustrated in Fig. 1. Over one-third of the sample (40%) perceived healthcare delivery as adversely affected by the pandemic to a “great” or “very great” extent (Mean[M] = 2·23, SD = 0·98); mean scores for the total sample and each clinical group are illustrated in Fig. 2.
Fig. 1.
Worry or concern regarding COVID-19, as endorsed by different groups of health professionals and assessed using a 5-point scale from 0 (‘Not at all’) to 4 (‘Extremely worried or concerned’).
Fig. 2.
Perceived adverse impact of the COVID-19 pandemic on healthcare delivery for children with heart disease, assessed using a 5-point scale from 0 (‘Not at all’) to 4 (‘A very great extent’).
Overall, 18% of participants reported anxiety (Mean[M] = 1·48, SD = 1·64), and 11% reported depressive symptoms (Mean[M] = 1·03, SD = 1·44), indicative of a need for clinical intervention. Participants who provided qualitative responses reported greater anxiety (t = 2·18, p = 0·03) and perceived a greater adverse impact of the pandemic on healthcare delivery than those who did not provide qualitative responses (t = 2·61, p = 0·01; Table 2).
Table 2.
Clinical role characteristics, COVID-19 worry and perceived impact, and PHQ-4 anxiety and depression scores presented for the total sample (N = 228) and separately for participants who did (n = 54) and did not (n = 174) provide qualitative responses.
|
Variable |
Total Sample |
Qualitative Responders |
Qualitative Non-Responders |
Test Statistics |
||
|---|---|---|---|---|---|---|
| Mean (SD) | Mean (SD) | Mean (SD) | t | df | p | |
| Work experience (years) | 11·71 (10·04) | 14·01 (10·86) | 11·00 (9·69) | 1·815 | 79.21 | 0·07 |
| Experience working in CHD (years) | 8·29 (7·89) | 10·02 (8·94) | 7·75 (7·48) | 1·687 | 77·71 | 0·10 |
| Hours worked per week | 38·20 (9·21) | 36·68 (9·13) | 38·69 (9·21) | 1·408 | 89·68 | 0·16 |
| Days on call in past month | 2·13 (4·22) | 2·06 (3·96) | 2·15 (4·30) | 0·616 | 26·36 | 0·54 |
| COVID-19 worry# | 1·69 (0·96) | 1·91 (1·03) | 1·62 (0·93) | 1·851 | 81·53 | 0·07 |
| Perceived adverse effects of COVID-19 on healthcare# | 2·23 (0·98) | 2·54 (1·00) | 2·13 (0·96) | 2·605 | 85·25 | 0·01 |
| PHQ-4 Anxiety^ | 1·48 (1·64) | 1·91 (1·69) | 1·34 (1·61) | 2·180 | 85·12 | 0·03 |
| PHQ-4 Depression^ | 1·03 (1·44) | 1·19 (1·66) | 0·98 (1·37) | 0·814 | 76·83 | 0·42 |
# Potential score range: 0_4.
^ Potential score range: 0–6.
Fifty-four health professionals (24%) responded to the optional qualitative prompt. Six major themes (4 negative, 2 positive) were identified, with subthemes and exemplar quotes shown in Table 3. Negative themes included: Concern about the consequences of visitor restrictions and disrupted services for patients and families (n = 23/54), which was raised primarily by nursing staff (n = 20/23). Rescheduling of surgeries due to cancellation of elective procedures, travel restrictions, parental hesitancy to visit hospitals, and implementation of policies limiting visitors to a single caregiver at the bedside was distressing and detrimental for patients, families, and health professionals. Support services, like bedside volunteers, hospital-based childcare and clown doctors, were also either limited or closed during the pandemic, placing further strain on nursing staff to ‘step into’ supportive roles for patients and families. Disruption to cardiac neurodevelopmental assessment and follow-up services was also reported, with concerns regarding the potential immediate and longer-term consequences for children with complex CHD.
Table 3.
Major themes and exemplar quotes in health professionals' qualitative responses (n = 54).
| MAJOR THEME n = number of participants who reported theme | SUB-THEMES | EXEMPLAR QUOTES |
|---|---|---|
| NEGATIVE EXPERIENCES | ||
| Concern about the consequences of visitor restrictions and disrupted services on patients and families (n = 23) | Concern for patient and family health and wellbeing | “The impact on families is enormous. Only one parent [in the hospital] per patient and not allowing siblings or other visitors is having a huge impact on families' mental health.” (ID236) |
| Disruption of cardiac neurodevelopmental evaluation and follow-up services | “I am concerned about the significant delays in neurodevelopmental evaluation for young children with CHD due to the cessation of in-person neurodevelopmental assessments.” (ID224) | |
| Intensified strain on healthcare workers (n = 21) | Increased workload | “Huge additional load placed on clinicians to respond to the acute needs of the pandemic in drafting guidelines, educating, changing work practices, and participating in meetings while also dealing with risk to self and followed by a request to work to catch up on waitlists even before full services resume, followed by an imminent second wave without a break.” (ID631) |
| Providing support to colleagues and patients | “They (patients) are isolated from their usual support systems including the capacity for parents, siblings, grandparents, and extended family to provide support. Healthcare workers need to fulfill this support role and it has an impact on families and staff.” (ID138) | |
| Blurring of boundaries between work and home life | “Working from home was extremely challenging. I found it very difficult as it blurred the lines between work and home, and home lost its sense of the place where you rest and recover.” (ID235) | |
| Stress related to government or health system response to COVID-19 | “The general experience has been one of central authorities being slow to respond. Little recognition of non-frontline workers' stress and combination of increased work and significant stress from threats to personal and staff wellbeing.” (ID631) | |
| Feelings of fear and loss (n = 19) | Fear of COVID-19 exposure and transmission | “Increased stress and worry about spreading it through the unit and becoming a news headline, cancelling social events so not to risk catching coronavirus.” (ID536) |
| Personal financial strain | “Financial strain with loss of income and needing to do extra shifts.” (ID486) | |
| Impact of the media | “Personally, I was extremely stressed during the height of the pandemic. Most of this stemmed from community responses (e.g., panic buying) and seeing news reports from around the world.” (ID187) | |
| Concern about family and friends | “I have serious concerns for overseas family from a health and financial well-being perspective and how COVID has impacted their lives, and when next I will be able to see my immediate family and elderly parents who live overseas.” (ID207) | |
| Social isolation and disconnection (n = 16) | “Can't visit family back home and cannot attend any functions. Not able to attend church mass and holy communion.” (ID635) | |
| POSITIVE EXPERIENCES | ||
| Adapting to change (n = 5) | Finding new ways to support patients | “The COVID-19 pandemic has influenced the way I prepare and support patients for heart surgery as surgeries have been cancelled and rescheduled multiple times.” (ID377) |
| Improved work environment and working relationships | “Although it has caused an enormous amount of stress, the change on work practices and working arrangements has positively improved and shaped how we care for patients and work with colleagues.” (ID211) | |
| Improved work-life balance | “I feel bad for saying this and am very careful who I admit this to (as I know many have suffered greatly) but for me, the pandemic has slowed life down (including on the work front) which has actually been good and allowed me to come up for some much needed ‘air’ amid the usual work-life stresses.” (ID195) | |
| Gratitude (n = 4) | Social support | “While I miss travelling overseas and seeing some of my family, I have noticed how lucky I am with my friends, neighbours, and colleagues. I have been surrounded by caring people. I am spending an inordinate amount of time supporting struggling colleagues. I have found inner strength and resilience.” (ID261) |
| Greater time with family and friends | “I have enjoyed the family time that the lockdown enabled.” (ID260) | |
Intensified strain on healthcare workers (n = 21/54): This theme was reported by professionals across all clinical roles, highlighting the wider impact of COVID-19 on healthcare delivery and workers. First, the screening of critically ill patients for COVID-19 and implementation of changing COVID-19 safety protocols, alongside ongoing surgical demands, increased job strain. Second, changes to usual family-centred care practices in accordance with COVID-19 safety guidelines and increased patient and family psychological distress caused by the pandemic, contributed to moral distress among many health professionals. Seven participants felt that government initiatives to contain COVID-19 transmission did not consider the importance of timely intervention for CHD patients and the stress associated with health system changes for families. For health professionals, there was pressure to cancel procedures during peak periods of the pandemic and then to catch up on the backlog of cases, without addressing staffing or resource shortages. Three participants disclosed difficulties working from home and the blurring of boundaries between personal and professional life.
Feelings of fear and loss (n = 19/54): Fears about contracting or transmitting COVID-19 were common. Participants also reported concerns regarding potential media scrutiny, including fears of being unfairly criticised if a COVID-19 case was to occur on the ward. Some disclosed heightened financial stress, especially in terms of partners’ potential loss of employment and income.
Social isolation and disconnection (n = 15/54): During periods of lockdown, restrictions on social activities led to loss of much-needed support from friends and families. With the transition from in-person to virtual meetings, many participants reported feeling increasingly disconnected and isolated at work and in their personal lives.
Positive themes were rarely reported, with nine participants (17%) reporting upsides associated with the pandemic. All nine participants were women, most of whom were married or partnered (n = 8/9), earned above the national average gross annual household income (n = 6/9), and reported anxiety below the clinical cut-off (n = 9/9). Positive themes included adapting to change (n = 5/54), such as changes in clinical care practices, increased use of telehealth, and successful diversion of resources from paediatric care to COVID-19 management. Finding new ways to support patients and families was a source of pride for some. Improved working relationships and work environment, resulting in better work-life balance, was also reported. Participants expressed gratitude (n = 4/54) for the lack of disruption to their lives, recognition of personal resilience while supporting others during this stressful time, and appreciation of greater time with family and friends.
4. Discussion
In this mixed-methods study, Australian health professionals reported increased fear for themselves, loved ones, patients, and families in the wake of the COVID-19 pandemic, as well as disconnection and isolation in their personal and professional lives. Changes to regular patterns of healthcare delivery and follow-up for children with heart disease, coupled with limited access to supportive services for patients and families within the hospital, influenced health professional stress and wellbeing. In addition to survey findings, our thematic analysis of qualitative responses provides insights into a range of immediate and long-term challenges experienced by healthcare workers during the pandemic.
Over half our sample reported COVID-19 worry (52%) and psychological stress, with symptoms of anxiety and depression warranting clinical evaluation endorsed by 18% and 11% of participants, respectively. This is consistent with findings from other studies; for example, 20% of 320 health professionals from a tertiary hospital in Melbourne reported pandemic-related anxiety and/or depressive symptoms [19]. While anxiety among Australian health professionals seems to have increased from pre-pandemic prevalence estimates of approximately 9% [20], conclusions are limited due to the lack of direct comparisons. Studies around the world also show increased psychological stress among health professionals; for instance, a cross-sectional survey of healthcare workers from 25 medical centres across the United States in May 2020 found 23% reported PTSD symptoms, 14% reported major depression, and 15.8% reported symptoms consistent with generalized anxiety [21]. A major stressor is the fear of transmitting COVID-19 to family and friends, as reported by 90% of ICU nurses across six hospitals in England [13]. Concern for one's family and broader community was voiced more commonly by health professionals in our study and took precedence over concern for one's own health, which can be attributed to the generally altruistic nature of health professionals [12,14]. Findings from a national Australian study indicated higher levels of COVID-19 related fear among health professionals born overseas relative to those born in Australia, which was ascribed to lower familiarity with the Australian healthcare system and smaller support networks [22]. Our qualitative data also highlight the concerns health professionals have about the health and wellbeing of family and friends overseas, and the stress caused by international travel restrictions prohibiting visits to see loved ones living abroad.
Thematic analyses revealed media to be an aggravating factor for health professional stress due to a consistently negative portrayal of the COVID-19 pandemic focusing on global and national death tolls [11], negative effects of lockdown on the economy, and adverse mental health outcomes of social isolation [23]. Some health professionals in our study also noted the stress of being presented as a cause of the outbreak and being ostracized by the community as a result. Additionally, 76% of health professionals in our study perceived a “moderate” to “very great” adverse impact on healthcare provision to patients with CHD. In response to the pandemic, healthcare care for this patient population was at times limited to surgery for critical cases and essential cardiac procedures [7]. Division of the workforce into smaller teams, as preventive measures or redirection to COVID-19 care, led to feelings of isolation and disconnection at work, precipitating psychological stress [8].
Many health professionals expressed concern about providing suboptimal care to patients and families during the pandemic. Increased workload and closer proximity to the suffering of families can precipitate moral distress in health professionals, especially nurses, having to step in as substitutes for much-needed familial support, as highlighted in our qualitative findings as well as previous studies [9]. Health professionals cited disruption of allied and mental health services and interruptions in cardiac neurodevelopmental care as additional stressors, commenting on the immediate and longer-term psychological toll on patients and families [6,24].
While rapid changes in healthcare policies and practices were identified as stressors for health professionals, timely communication of clear directives and regular updates from government and within health services were recognized as critical to reducing stress [13,22]. Health professionals in our study expressed concern regarding policies that affected patients directly, such as restricted hospital visitation and cancelled surgeries, and the resultant distress associated with communicating these policies to families, while organizational leaders were seen as “staying in the background” [15]. Participants did not express concerns regarding the government or hospital's ability to implement prevention and management strategies, unlike studies conducted in the U.S. and Pakistan [14,21]; however, health professionals did comment on the lack of initiatives from hospital authorities to support their mental health during this time. Studies have stressed the need for debriefing opportunities, peer support, and psychological services for all health professionals [15,16], regardless of their contact with COVID-19 patients, due to the increased stress and trauma during the pandemic [19]. Given the multiple and chronic sources of stress experienced by Australians throughout the period 2019 to 2021, including the 2019–2020 devastating bushfires in NSW [23], and the COVID-19 pandemic, organizations would do well to implement active surveillance and screening mechanisms to identify health professionals at risk of poor mental health and provide appropriate and timely prevention, treatment, and management measures.
4.1. Study strengths and limitations
The study findings should be interpreted in light of a few limitations. We surveyed health professionals at a single paediatric cardiac service in NSW during the spread of the Delta variant of COVID-19. Given the variation in COVID-19 case numbers and lockdown durations in different states of Australia, these findings may not be generalisable to all health professionals caring for children with heart disease across Australia or other countries and more studies are needed to understand the experiences of this population. Due to changes in operative loads, it is possible that health professionals with greater stress and workload demands may not have responded to the survey, contributing to moderate response rate (54%); however, a strength of the study is the robust sample size achieved. To our knowledge, this is the first qualitative study in Australia providing a deeper understanding of quantitative data being reported regarding COVID-19 related worry and perceived consequences on healthcare in a subset of paediatric specialists. While COVID-19 vaccination was not available in Australia at the time of data collection for this study, and experiences of the pandemic have changed over time, the study findings, especially the qualitative data, provide insight into the varied aspects of psychological distress faced not only by health professionals, but also the patients and families they serve, and can be used by team leaders, system managers, and organizations to strengthen health system and health professional pandemic preparedness, as well as improve healthcare policies and practices.
5. Conclusion
Our results provide insight into the emotional experiences of paediatric health professionals as they worked to provide care and support for patients and families affected by heart disease during the COVID-19 pandemic. This study highlights the need for increased active psychosocial surveillance of mental health outcomes among health professionals with timely provision of psychological services, regular debriefing opportunities, peer support, and resilience training within teams, and improving resource supply and allocation. Enhancement of health system preparedness and advocacy for evidence-based healthcare practices, like increased familial support at the patient bedside can reduce the burden of care on health professionals. Further research is needed to design customised support interventions targeting each clinical group and inform policies to improve outcomes for patients, families, and healthcare workers in the context of situational stressors.
Funding
Farah Akram is the recipient of an Australian Postgraduate Award (2019–2023). Michelle Farrar is the recipient of an NHMRC Investigator Grant (APP1194940). Nadine Kasparian is the recipient of a National Heart Foundation of Australia Future Leader Fellowship (101229) and support from the Heart Institute Research Core (HIRC) at Cincinnati Children's Hospital. This work was also supported by a National Health and Medical Research Council (NHMRC) of Australia Project Grant (Kasparian, APP1081001).
Author statement
NK conceptualized the study, developed the study protocol, and secured study funding. NK, FA, MP, DO developed the study questionnaire and collected data. FA, DO, NK contributed to quantitative data analysis and interpretation. FA, NK, MP, MF contributed to qualitative data analysis and interpretation. FA prepared the first draft of the manuscripts. NK, MF, MP, DO, GS contributed to critical review and revision of the manuscript. All authors read and approved the submitted version of the manuscript.
Declaration of competing interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Nadine A. Kasparian reports financial support provided by the National Health and Medical Research Council (NHMRC) of Australia, the Cincinnati Children's Heart Institute Research Core, and the National Heart Foundation of Australia. Michelle A. Farrar reports financial support provided by the NHMRC. Farah Akram reports financial support provided by an Australian Postgraduate Award. Nadine A. Kasparian reports a relationship with Australian National Standards of Care for Childhood-onset Heart Disease Steering Committee. Nadine A. Kasparian also reports a relationship with the Conquering CHD Scientific Advisory Committee, the Mended Little Hearts Medical Advisory Board, and with the Office of the Surgeon General of California Perinatal ACES Task Force.
Acknowledgments
We extend our sincere gratitude to the health professionals who participated in this research and to the clinical leaders in the Paediatric Intensive Care Unit, Neonatal Intensive Care Unit, Edgar Stephen Cardiac Ward, and the Departments of Cardiology and Anaesthetics, who generously donated their time to raise awareness of the study and support recruitment.
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