Hospital Physicians' Perspectives on Occupational Stress During COVID-19: a Qualitative Analysis from Two US Cities

Experiences of U.S. frontline physicians during the COVID-19 pandemic: a qualitative study

BACKGROUND

The COVID-19 pandemic caused profound and rapid changes in patient care and healthcare system organization. There is a compelling need for insight into the challenges that confronted physicians during the early phase of the pandemic to identify successful adaptations and strategies that minimize disruption to patient care and protect clinician wellbeing. The purpose of this study was to understand physicians' lived experiences of providing patient care during the early COVID-19 pandemic.

METHODS

This qualitative, descriptive study used a thematic analysis approach. The sample included 17 physicians from five specialties with direct care experience of COVID-19 patients (infectious disease, primary care, emergency medicine, critical care, and hospitalists). Participants were identified through snowball sampling. Data were collected through focus groups and interviews in May and June 2020 and analyzed with an inductive and deductive approach using thematic analysis.

RESULTS

Three overarching themes relating to patient care delivery during the ongoing COVID-19 pandemic were identified: facilitators, barriers, and acute stressors. Facilitator subthemes included: organizational logistical and operational support, organizational support for self-care and wellness, and peer and family support/debriefing. Barrier subthemes included: lack of clear and consistent governmental guidelines and organizational support, uncertainty resulting from poor communication or lack of information, and interpersonal barriers to physician self-care and wellbeing. Stressor subthemes included: concern about exposure, feeling unprepared, and anticipating the worst.

CONCLUSIONS

Physicians reported that both patient care and their own wellbeing were greatly impacted by organizational and systems level facilitators and barriers. Findings from this study can inform the creation of best practices, tools, and strategies that can assist with future emergency preparedness and pandemic response planning efforts.

Navigating the COVID-19 crisis: a study of healthcare leadership response in India and the USA

PURPOSE

The COVID-19 pandemic has reignited the debate on effective leadership during a crisis. The study examined healthcare leaders' experiences, challenges and responses amid the COVID-19 crisis in India and the USA.

DESIGN/METHODOLOGY/APPROACH

Thematic analysis culminated in developing a thematic framework that encapsulates the behavior of operational healthcare leaders in India and the USA to illustrate how they responded to the global pandemic. Twelve hospital leadership experiences were collected through in-depth Interviews.

FINDINGS

The study highlighted comparable experiences and leadership responses from the USA and India. Thematic framework induced from three themes and eight sub-themes to illustrate how leaders handled unknown challenges of the pandemic, which they countered with increased accountability as a leader, extended need-based networking with inevitable experience of self-role distance, leading to their pragmatic approach and reinforcement of self-belief.

RESEARCH LIMITATIONS/IMPLICATIONS

The study findings provide a way forward for revisiting existing crisis management frameworks and cross-cultural leadership theories in terms of behavioral aspects integration with the technical or operational aspects of crisis management.

PRACTICAL IMPLICATIONS

Healthcare leaders aiming to rebuild hospital systems would benefit from the study by incorporating identified skills such as coping with emotional labor, self-role distance, perseverance, pragmatic approach, networking with extended stakeholders, and extra-role behaviors into training and mentoring programs.

ORIGINALITY/VALUE

Using a thematic analysis approach, the study's two-country research design identified a homogeneous leadership response despite a distinct countrywide context.

Moral Stress and Moral Distress: Confronting Challenges in Healthcare Systems under Pressure

Stresses on healthcare systems and moral distress among clinicians are urgent, intertwined bioethical problems in contemporary healthcare. Yet conceptualizations of moral distress in bioethical inquiry often overlook a range of routine threats to professional integrity in healthcare work. Using examples from our research on frontline physicians working during the COVID-19 pandemic, this article clarifies conceptual distinctions between moral distress, moral injury, and moral stress and illustrates how these concepts operate together in healthcare work. Drawing from the philosophy of healthcare, we explain how moral stress results from the normal operations of overstressed systems; unlike moral distress and moral injury, it may not involve a sense of powerlessness concerning patient care. The analysis of moral stress directs attention beyond the individual, to stress-generating systemic factors. We conclude by reflecting on how and why this conceptual clarity matters for improving clinicians' professional wellbeing, and offer preliminary pathways for intervention.

Impact of the COVID-19 pandemic on acute cardiology and neurology services in a secondary peripheral hospital

The indirect impact of the COVID-19 pandemic on clinical services in peripheral hospitals has not been fully described. We compared the impact of COVID-19 on Cerebral Vascular Accident (CVA) and ST-elevation myocardial infarction (STEMI) management and outcome in an Israeli peripheral hospital. We included 1029 CVA and 495 STEMI patients. Patients who arrived during (15/3/2020-15/4/2022) and before (1/1/2018-14/3/2020) the pandemic, were demographically comparable. During the pandemic, median time for CVA patients from arrival to imaging was longer (23 vs. 19 min, p = 0.001); timing from arrival to tissue Plasminogen Activator administration was similar (49 vs. 45 min, p = 0.61); transfer to another hospital was more common (20.3% vs. 14.4% p = 0.01) and median length of stay (LOS) was shorter (3 vs. 4 days, p < 0.05). Among STEMI patients, median time from arrival to intervention intra- pandemic was shorter (45 vs. 50 min p = 0.02); Mean LOS shorter (3.86 vs. 4.48 p = 0.01), and unplanned re-admission less frequent (7.8% vs. 14.6% p = 0.01). Mortality did not change significantly. Our data shows no major negative impact of the COVID-19 pandemic on CVA outcomes, and improved care for STEMI patients. Interviews with the neurology and cardiology staff are performed to investigate how quality of care was maintained during the crises.

Forces to Be Reckoned with: Countervailing Powers and Physician Emotional Distress during COVID-19

The "countervailing powers" framework conceptualizes health care as an arena for power contests among key stakeholders, drawing attention to the moves, countermoves, and alliances that have challenged physicians' dominance since the 1970s. Here, we focus on one of the lesser known micro-level consequences of such forces for physicians: emotional distress. We draw on 145 interviews with frontline physicians across four U.S. cities during the COVID-19 pandemic to trace physicians' experiences with three countervailing forces: the state, health care organizations, and patients. We find that threats to physician dominance eroded physicians' sense of mastery (perceived personal control) at work, thereby prompting emotional distress, including anger and moral conflict. Conversely, in certain cases, acts of resistance may have helped increase mastery, thus moderating distress. Our findings advance the countervailing powers framework by elucidating some of the micro-level, personal consequences of macro-level power struggles and offer practical implications for understanding contemporary threats to physician dominance.

A systematic review of studies on stress during the COVID-19 pandemic by visualizing their structure through COOC, VOS viewer, and Cite Space software

Background

The COVID-19 epidemic generated different forms of stress. From this period, there has been a remarkable increase in the quantity of studies on stress conducted by scholars. However, few used bibliometric analyses to focus on overall trends in the field.

Purpose

This study sought to understand the current status and trends in stress development during COVID-19, as well as the main research drives and themes in this field.

Methods

2719 publications from the Web of Science(WOS) core repository on stress during COVID-19 were analyzed by utilizing Co-Occurrence (COOC), VOS viewer, and Cite Space bibliometric software. The overall features of research on stress during COVID-19 were concluded by analyzing the quantity of publications, keywords, countries, and institutions.

Results

The results indicated that the United States had the largest number of publications and collaborated closely with other countries with each other. University of Toronto was the most prolific institution worldwide. Visualization and analysis demonstrated that the influence of stress during COVID-19 on the work, life, mental and spiritual dimensions is a hot research topic. Among other things, the frequency of each keyword in research on stress during COVID-19 increased from 2021 to 2022, and the researchers expanded their scope and study population; the range of subjects included children, nurses, and college students, as well as studies focusing on different types of stress, and emphasizing the handling of stress.

Conclusion

Our findings reveal that the heat of stress research during COVID-19 has declined, and the main research forces come from the United States and China. Additionally, subsequent research should concern more on coping methods with stress, while using more quantitative and qualitative studies in the future.

How Should We Allocate Divisible Resources? An Overlooked Question

AbstractThe ethical allocation of scarce medical resources has received significant attention, yet a key question remains unaddressed: how should scarce, divisible resources be allocated? We present a case from the COVID-19 pandemic in which scarce resources were divided among patients rather than allocated to some patients over others. We assess how widely accepted allocation principles could be applied to this case, and we show how these principles provide insufficient guidance. We then propose alternatives that may help guide decision-making in such cases, and we evaluate the possibility of treating patients equally by dividing resources equally. Resource scarcity is not limited to pandemic situations, and many healthcare resources are divisible. This question-how to allocate these divisible resources-deserves greater attention from bioethics.

Burnout Among Hospitalists During the Early COVID-19 Pandemic: a National Mixed Methods Survey Study

BACKGROUND  : Hospitalist physician stress was exacerbated by the pandemic, yet there have been no large scale studies of contributing factors.

OBJECTIVE

Assess remediable components of burnout in hospitalists.

PARTICIPANTS, STUDY DESIGN AND MEASURES

In this Coping with COVID study, we focused on assessment of stress factors among 1022 hospital-based clinicians surveyed between April to December 2020. We assessed variables previously associated with burnout (anxiety/depression due to COVID-19, work overload, fear of exposure or transmission, mission/purpose, childcare stress and feeling valued) on 4 point Likert scales, with results dichotomized with the top two categories meaning "present"; burnout was assessed with the Mini Z single item measure (top 3 choices = burnout). Quantitative analyses utilized multilevel logistic regression; qualitative analysis used inductive and deductive methods. These data informed a conceptual model.

KEY RESULTS

Of 58,408 HCWs (median response rate 32%), 1022 were hospital-based clinicians (906 (89%) physicians; 449 (44%) female; 469 (46%) White); 46% of these hospital-based clinicians reported burnout. Work overload was associated with almost 5 times the odds of burnout (OR 4.9, 95% CIs 3.67, 6.85, p < 0.001), and those with anxiety or depression had 4 times the odds of burnout (OR 4.2, CIs 3.21, 7.12, p < 0.001), while those feeling valued had half the burnout odds (OR 0.43, CIs 0.31, 0.61, p < 0.001). Regression models estimated 42% of burnout variance was explained by these variables. In open-ended comments, leadership support was helpful, with "great leadership" represented by transparency, regular updates, and opportunities to ask questions.

CONCLUSIONS

In this national study of hospital medicine, 2 variables were significantly related to burnout (workload and mental health) while two variables (feeling valued and leadership) were likely mitigators. These variables merit further investigation as means of reducing burnout in hospital medicine.

Physicians as shock absorbers: The system of structural factors driving burnout and dissatisfaction in medicine

American physicians disproportionately suffer from burnout. Despite calls for systemic solutions, however, few studies have actually examined how 'the system' works-i.e. how structural factors intersect in real-time as a system to shape wellbeing. I borrow a systems theoretical approach, which explicitly recognizes the dynamic relationships and interdependencies between different actors and factors in healthcare, to examine how structural factors work together to shape physicians' wellbeing. Drawing on an eight-month ethnography in a pediatrics clinic, I show how respondents experienced pressures from multiple structural levels: societal (including broader social inequality and changing doctor-patient relationships); organizational (centralized decision-making, economic pressures, and unresponsive leadership); and professional (specialty cultures and unhealthy norms). I find that individual physicians effectively served as shock absorbers, routinely absorbing countless, interconnected structural demands ("shocks") and converting them into competent medical care, at significant cost to their mental health. In so doing, I intervene in sociological debates about the broader fate of the medical profession and conclude that if medicine remains resilient against threats to its dominance, it may well be at the expense of individual physicians' mental wellbeing.

Multidimensional stressors and protective factors shaping physicians' work environments and work-related well-being in two large US cities during COVID-19

INTRODUCTION

Clinician burnout and poor work-related well-being reached a critical inflection point during the COVID-19 pandemic. This article applies a novel conceptual model informed by the Total Worker Health® approach to identify and describe multilevel stressors and protective factors that affected frontline physicians' work environments and work-related well-being.

METHODS

We conducted a qualitative study of hospital-based physicians from multiple hospital types in Los Angeles and Miami who cared for COVID-19 patients. Semistructured interviews lasting 60-90 min were conducted over Zoom. Interview transcripts were thematically coded using Dedoose qualitative software.

RESULTS

The final sample of 66 physicians worked in 20 hospitals. Stressors in the social, political, and economic environment included dealing with the politicization of COVID-19, including vaccine hesitancy; state and federal governmental COVID-19 policies and messaging; and shifting CDC guidance. Employment and labor pattern stressors included the national nursing shortage, different policies for paid time off, furloughs, reduced pay, and layoffs. Organizational-level stressors included institutional policies, staffing constraints and high patient volume (i.e., increased number of cases and longer lengths of stay), and perceived poor leadership. At the individual worker level, stressors included concerns about viral transmission to family, strained personal relationships, and work-life fit, particularly for those with young children. Respondents identified promising protective factors at multiple levels, including responsive state leadership, job security, concrete opportunities to provide input into institutional policy, strong leadership and communication, and feeling cared for by one's institution.

CONCLUSION

Findings support a multi-level strategy that acknowledges internal organizational and external factors shaping clinicians' work-related well-being, consistent with the Total Worker Health® approach.

The impact of health inequities on physicians' occupational well-being during COVID-19: A qualitative analysis from four US cities

OBJECTIVE

The aim of this study is to describe frontline physicians' perceptions of the impact of racial-ethnic and socioeconomic disparities in COVID-19 infection and mortality on their occupational well-being.

METHODS

One hundred and forty-five qualitative, semistructured interviews were conducted between February 2021 and June 2022 with hospital medicine, emergency medicine, pulmonary/critical care, and palliative care physicians caring for hospitalized COVID-19 patients in four US cities.

RESULTS

Physicians reported encountering COVID-related health disparities and inequities at the societal, organizational, and individual levels. Encountering these inequities, in turn, contributed to stress among frontline physicians, whose concerns revealed how structural conditions both shaped COVID disparities and constrained their ability to protect populations at risk from poor outcomes. Physicians reported feeling complicit in the perpetuation of inequities or helpless to mitigate observed inequities and experienced feelings of grief, guilt, moral distress, and burnout.

CONCLUSIONS

Health inequities are an under-acknowledged source of physicians' occupational stress that requires solutions beyond the clinical context.

Conflict in the EMS Workforce: An Analysis of an Open-Ended Survey Question Reveals a Complex Assemblage of Stress, Burnout, and Pandemic-Related Factors Influencing Well-Being

Emergency Medical Services (EMS) clinicians provide patient care within a high-stakes, unpredictable, and complex work environment in which conflict is inevitable. Our objective was to explore the extent to which added stressors of the pandemic exacerbated EMS workplace conflict. We administered our survey to a sample of U.S. nationally certified EMS clinicians during the COVID-19 pandemic in April 2022. Out of 1881 respondents, 46% (n = 857) experienced conflict and 79% (n = 674) provided free-text descriptions of their experience. The responses were analyzed for themes using qualitative content analysis, and they were then sorted into codes using word unit sets. Code counts, frequencies, and rankings were tabulated, enabling quantitative comparisons of the codes. Of the fifteen codes to emerge, stress (a precursor of burnout) and burnout-related fatigue were the key factors contributing to EMS workplace conflict. We mapped our codes to a conceptual model guided by the National Academies of Sciences, Engineering, and Medicine (NASEM) report on using a systems approach to address clinician burnout and professional well-being to explore implications for addressing conflict within that framework. Factors attributed to conflict mapped to all levels of the NASEM model, lending empirical legitimacy to a broad systems approach to fostering worker well-being. Our findings lead us to propose that active surveillance (enhanced management information and feedback systems) of frontline clinicians' experiences during public health emergencies could increase the effectiveness of regulations and policies across the healthcare system. Ideally, the contributions of the occupational health discipline would become a mainstay of a sustained response to promote ongoing worker well-being. The maintenance of a robust EMS workforce, and by extension the health professionals in its operational sphere, is unquestionably essential to our preparedness for the likelihood that pandemic threats may become more commonplace.

Administrators' preparedness to address physician burnout before and during COVID-19

Occupational burnout has become widespread. The syndrome can be especially harmful in health care settings, affecting clinicians, organizational effectiveness, and patient safety. Certain approaches have proven helpful in some cases in combatting the syndrome. The coronavirus pandemic presented physicians with unique challenges, which appeared to have magnified work stress This national survey specifically explored interventions used by health care leaders to reduce burnout and whether these interventions proved effective during a pandemic. We also discuss effective and appropriate organizational measures to reduce physician burnout and its associated risks during crises.