“Surviving to thriving”: a meta-ethnography of the experiences of healthcare staff caring for persons with COVID-19

Background The emergence of the Coronavirus disease has heightened the experience of emotional burden among healthcare staff. To guide the development of support programmes, this review sought to aggregate and synthesise qualitative studies to establish a comparative understanding of the experiences of healthcare staff caring for persons with the disease. Design A meta-ethnography approach was used to aggregate and synthesise primary qualitative studies. Database search was undertaken from January to November 2020. A standardised tool was used to extract data from the identified primary studies. The studies were translated into each other to formulate overarching concepts/ metaphors which formed the basis of undertaking a narrative synthesis. Results Eight qualitative studies met the inclusion criteria. Two overarching metaphors/ concepts were formulated from the primary studies: 1) surviving to thriving in an evolving space and 2) support amid the new normal. The initial phase of entering the space of caring during the outbreak was filled with psychological chaos as healthcare staff struggled to survive within the context of an illness which was not fully understood. Gradually, healthcare staff may transition to a thriving phase characterised by resilience but still experienced heavy workload and physical/ emotional exhaustion predisposing them to burnout and compassion fatigue. Fear persisted throughout their experiences: fear of contracting the disease or infecting one’s family members/ loved ones remained a key concern among healthcare staff despite infection precaution measures. Healthcare staff who contracted the disease felt isolated with additional fears of dying alone. The sources of support were varied with a strong emphasis on peer support. Conclusions Healthcare staff caring for persons infected with the Coronavirus disease are at risk of burnout and compassion fatigue and require ongoing mental health support commensurate to their needs. Staff who contract the disease may require additional support to navigate through the illness and recovery. Policies and concerted efforts are needed to strengthen support systems and build resilience among healthcare staff.


Background
The emergence of the novel Coronavirus disease  across the globe has led to various healthcare systems becoming overwhelmed with clinicians facing significant emotional strain and physical pressure [1,2]. Evidence from several countries suggest an increasing rate of depression, anxiety, and insomnia among healthcare workers caring for persons with COVID-19 [3][4][5]. These emotional/ physical pressures, if left unresolved, may lead to a higher incidence of suicide and substance abuse among healthcare workers [6][7][8][9].
Caring for critically ill persons is often associated with emotional and physical exhaustion [10][11][12][13]. The sudden occurrence of the COVID-19 pandemic, which healthcare systems were seemingly unprepared for alongside increasing mortality rates in some areas have contributed to the development of fear, worry and uncertainty [14]. These concerns are likely to increase the burden experienced by healthcare staff creating the need for ongoing support [15]. Various settings are implementing several programmes for healthcare staff but there appears to be an ever increasing need to provide ongoing evidence-based psychosocial support [16][17][18][19].
The pandemic is gradually becoming the 'new normal' implying that we may have to live with it for an unknown period [20][21][22]. In the absence of adequate/ context-specific support programmes for our healthcare providers, their well-being may be adversely affected which can affect the overall availability of human resource and even translate to poor patient care [23][24][25]. So far, primary studies exploring the experiences of healthcare staff caring for patients with COVID-19 are emerging which offers some insight into their lived experiences. However, to gain a broader perspective and facilitate the design of interventions (timing and nature/ components), there is a need to establish a comparative understanding of these experiences. Besides as the pandemic evolves, there is a need for robust evidence regarding clinicians' experiences in navigating through the pandemic to understand the variations and similarities across contexts and attain a deeper breadth of the phenomenon. Such broad perspective can contribute significantly to global healthcare policy and practice particularly as it remains uncertain when the COVID-19 pandemic may end. Thus, this review sought to identify the available primary studies, aggregate, and synthesise their findings to understand the phenomenon of caring for persons diagnosed with COVID-19. The review question was "what are the experiences of healthcare professionals caring for persons with COVID-19?"

Aim
The aim of this review was to develop a comparative understanding of the experiences of healthcare staff caring for persons with COVID-19.

Review design
Noblit and Hare's approach to meta-ethnography was utilised for this review [26]. Meta-ethnography is an aggregative method of synthesis which seeks to integrate separate parts to form a whole. It involves induction and interpretation, thus resembling the primary studies it aims to synthesise [27]. In simple terms, metaethnography is the qualitative alternative to quantitative meta-analysis [26]. The product of a meta-ethnographic synthesis is the interpretation of the primary studies into one another to generate an in-depth/ new understanding of a phenomenon [28]. This meta-ethnography was reported according to the eMERGe reporting guidelines [29]. Additionally, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart [30] was used to guide the process of study selection.

Search strategy/ study identification
A limited search in CINAHL, EMBASE and PubMed was initially undertaken which informed the development of a detailed search strategy. The full search sources included Cochrane Reviews Library, EMBASE, CINAHL, PubMed, OVID, Scopus, and Web of Science from December 2019 to November 2020. The following key words were used: "healthcare professionals" OR "healthcare practitioners" OR "healthcare staff" OR "healthcare workers" AND "COVID-19" OR "Coronavirus disease" OR "clinical respiratory illness" OR "clinical respiratory infection" OR "influenza-like illnesses to identify qualitative studies focusing on the phenomenon. The reference lists of identified articles were manually searched for potential studies.

Study selection and screening
Upon completing the search, all identified articles were exported into Endnote X9.2 and duplicates removed. This was followed by a selection procedure to identify primary studies for inclusion in the review. The inclusion criteria were 1) primary studies exploring the experiences of healthcare professionals caring for patients with COVID-19 2) qualitative studies irrespective of the design and 3) reported in English. Preprints, grey, nonqualitative studies, commentaries, editorials, and unpublished literature were not considered for inclusion in this review. Title screening was initially carried out to ensure that the study is relevant to the review. Abstract screening was then carried out. Full texts of the studies meeting the inclusion criteria were retrieved. These studies proceeded to the critical appraisal stage before including them in the review. The results of the search are presented in the PRISMA flow diagram below as Fig. 1.

Quality assessment/ appraisal
Studies considered for inclusion were critically appraised using the Joanna Briggs Institute (JBI) standardized critical appraisal checklist for qualitative studies. Potential studies that received an overall appraisal as 'include' were retained in the review (see Table 1).

Data extraction and synthesis
Data extracted from selected studies included standard information such as authors, setting, study findings and verbatim from participants reported (see Table 2). To synthesise the data, codes in the form of first and second order constructs were formulated from each primary study. These codes were organized into categories through a process of constant comparison across the studies [31]. This facilitated either translation of the studies into one another (areas of agreement across the studies) or refutational synthesis (areas of disagreement across the studies) based on the emerging categories. Following the translation process, the categories were re-interpreted to formulate overarching concepts/ metaphors. These overarching concepts/ metaphors formed the basis for undertaking a narrative synthesis [31]. The interpretive process was iterative with reference to the primary studies.

Concepts/ metaphors
The interpretation of the data and translation of the studies into each other led to the emergence of two overarching concepts/ metaphors: surviving to thriving in an evolving space and support amid the new normal (see Table 3). The relationship between the emerging concepts/ metaphors was noted to be reciprocal which facilitated the development of a line of argument to understand the phenomenon of caring for patients with COVID-19.

Surviving to thriving in an evolving space
Initial psychological/ emotional chaos The COVID-19 emerged as an infection to which healthcare staff initially had limited knowledge. Thus, being asked to work on a ward for persons with the infection created an initial sense of inner tension/ psychological chaos and an 'internal' struggle to survive in an uncertain dimension of a rapidly evolving disease [32][33][34][35][36][37][38][39]. Psychological responses such as anxiety, helplessness, fear of contracting the infection and spreading to one's loved ones, and uncertainty characterised the initial survival space and trickled to the thriving phase [32][33][34][35][36][37][38][39]: "Although I volunteered to work in the Department of Infectious Diseases, I still feel very scared. After all, it is a new infectious disease and there are no specific drugs at present. I was scared to see reports of the sacrifice of medical staff in other cities." [32] " … we are fearful of being infected. Anyone who coughs in the office causes panic. If one is infected, all medics in the unit are in danger, then the unit will be paralysed... I recently contacted a colleague without any protection, who was later diagnosed with COVID-19. Although my CT results did not show any abnormality, I am anxious and waiting to do the throat swab." [33] "I'm not calm at all, and I do not know what's going on" [35] The fears of some healthcare staff came to fruition as they contracted the COVID-19 disease. This led to  • Growth under pressure: this theme describes the personal growth experienced by participants which include the opportunity for selfreflection, gaining a deeper sense of professional identity and increased affection and feelings of gratefulness.
"I used to work to earn a salary, but now it feels like a responsibility." "Maybe there was a discrimination against nurses in the society but now I am proud of my choice." "After work I find the sky is blue and everything is beautiful." "I never thought I could be so strong." • Positive emotions occurring simultaneously or progressively with negative emotions: the theme describes the positive emotions that emerged in the process. These included feelings of confidence in the hospital environment, happiness from multiple sources of support and calmness during the care delivery process.
"I feel that the government has strong prevention and control measures, and the epidemic will be controlled very soon. But after all, we have a large population, and it is a process." "Patients are very cooperative with our work. Although some patients have emotions due to illness, they show great respect to us." "My mood is much better after starting pre-job training." "Many colleagues called me to encourage me and I felt that there were many people who cared about me." Liu et al., (2020) [33] Descriptive Three themes with 10 "We must try our best to    Being diabetic the government has placed responsibility on my employer to make suitable safe working arrangements which is difficult. A female learning disability nurse I am really worried with ever changing information from government on how to act during this pandemic …. Honestly, it really makes me anxious" "We have been using agency staff to maintain staff numbers, but we don't know where else they have been working and this brings so much anxiety." Fear, anxiety, worry; lack of guidelines; limited human resources "When I was hospitalized in the ICU, I had very severe shortness of breath. When the shortness of breath was present, I thought I was dying (Nurse) I was thinking, I will die alone, without seeing my family, they will not see my body. I will not have a proper funeral" [37] The initial psychological chaos experienced by the healthcare staff heightened as they witnessed varying mortality rates [32,33,[35][36][37]. The most challenging aspect for healthcare staff appeared to be contracting the illness themselves or witnessing the death of a colleague following a diagnosis of COVID-19 [37][38][39]: "When our colleagues got infected, we all suffered physically and emotionally" [38] "It is agonizing to see a person deprived of breath, his heart failing, and you can't do anything about his suffering .... it sometimes causes me to feel agitated and distressed and becoming really sad and confused about what I'm going to do?" [36] Living and functioning in a 'new body' The survival phase was also characterised by struggling to live and function in a 'new body', that is the personal protective equipment (PPE) which appeared to be uncomfortable, yet indispensable [32,33,37,38]. These concerns notwithstanding, healthcare professionals felt a sense of responsibility to fight the illness, care for the persons diagnosed with COVID-19, protect themselves and their loved ones from contracting the "deadly virus" [32][33][34][35][36][37][38][39]: "After putting on protective clothing, nursing duties are awkward to carry out. Protective clothing needs to be worn for 8 hours or more without drinking water and eating food and urinating was done with adult diapers." [32] "Wearing the whole set of PPEs is very uncomfortable. I have difficulty breathing and feel very hot and my heart rate speeds up. We keep on sweating and the clothes are soaked." [33] "It's very difficult to wear N95 masks for twelve hours, I feel short of breath and I will definitely have problems later" [37] "We must try our best to win this battle. As healthcare providers, we are at the forefront. I fight for my family, and I fight more for this society. This is my duty because I am a medical worker. No matter what will happen" [38] Thriving amidst chaos As healthcare staff continued to navigate through the evolving space of care provision, received training, and identified strategies of survival, there was a gradual move from survival to thriving which was characterised by resilience [32][33][34][35][36][37][38]. In the thriving phase, participants did not still understand the nature of the infection fully but felt more at ease working with the affected persons. The thriving phase was also characterised by personal and professional growth in the face of adversity with a feeling of being in a supportive environment, although resources were still limited [32][33][34][35][36][37][38]. Further within the thriving phase, healthcare staff began to appraise the negative experiences in a positive manner as a means of coping within a context that was not fully understood [32][33][34][35][36][37][38]. Irrespective of the phase healthcare staff found themselves, they were still faced with fear, increasing workload which led to exhaustion as they navigated through patient care and their own experiences [32][33][34][35][36][37][38][39]: "My method is not to think about stress, I shield it out of my life...I forget everything when I am busy..." [38] "In the early days, our workload was very high, we had to move the wards and hospitalized corona patients in the non-infectious wards" [37] Support amid the 'new normal'
Beyond the confines of the hospital, some healthcare staff also received support from families and friends [32,33]. Aside managing the 'self', healthcare staff also required support in utilizing the limited resources, ongoing training to stay updated about the disease and how best to protect oneself and family [32][33][34][35][36][37][38]: "When I feel stressful, I complain to my boyfriend.
He is also a nurse, and we are in the same department. We communicate with and understand each other." [35] "The head nurse knows we come from different departments and infectious disease is not our specialty, so she sent us some educational videos and materials, and we can learn after work." [33] Clinical guidelines Rapidly changing guidelines were challenging for healthcare staff and they required more support regarding operational procedures [39]: "Unfortunately, there have been so many changes on the guidance to COVID-19. Being diabetic the government has placed responsibility on my employer to make suitable safe working arrangements which is difficult. A female learning disability nurse I am really worried with ever changing information from government on how to act during this pandemic … . Honestly, it really makes me anxious" [39].

Discussion
The review sought to gain a comparative understanding of the experiences of healthcare staff in caring for persons with the novel COVID-19 disease. The findings highlight an initial sense of psychological chaos with healthcare staff struggling to survive as they navigated through the outbreak. Overtime, healthcare staff transitioned from survival to thriving as they continued to provide care but still experienced heavy workload, emotional exhaustion, and fear of contracting the disease or transmitting to family members/ loved ones. Some healthcare staff who contracted the disease also experienced fear of dying alone. Besides, though healthcare staff may experience growth under pressure, the presence of heavy workload and emotional exhaustion may highlight the potential of burnout, secondary traumatic stress, and subsequently, compassion fatigue. The impact of these psychological experiences emphasises the need for early and ongoing psychosocial support as well as maintaining high standards of infection prevention and control measures to make healthcare staff feel safe. Continuing professional education on emerging trends of the disease, ensuring the availability and utilisation of safety materials, promoting team morale, and providing avenues of release for healthcare professionals are also needed to support staff caring for persons with COVID-19.
The initial phase of working with persons infected with the novel virus is a critical period of transitioning to an unknown context with varied emotional responses heightening around a week of entering this unfamiliar space [19,[32][33][34][35][36][37][38][39]. In a previous study among Korean nurses during the era of the Middle East Respiratory Syndrome (MERS), the unfamiliar space of the infection was described as a dangerous field filled with psychological and physical stressors [40]. Additionally quantitative studies that evaluated the presence of mental health issues during the ongoing pandemic have underscored the presence of high levels of anxiety, depression, and fear among healthcare staff [41][42][43][44][45]. As previously mentioned, healthcare staff who work with critically ill persons already face several stressors which predispose them to burnout and compassion fatigue [46,47]. Extrapolating these stressors and experiences to the context of an unknown illness suggest the existence of a significant psychological and emotional challenge among healthcare staff caring for persons with COVID-19. It is worth mentioning that though healthcare staff may experience personal and professional growth under pressure, they are still faced with significant workload levels and emotional exhaustion. Thus, the risk of burnout, traumatic stress, and compassion fatigue are still present. Without professional support, healthcare staff are at a risk of several issues such as insomnia, mood and eating disorders, in both short and long term [1,48]. These findings should therefore direct our attention towards early mental health intervention to identify, acknowledge and offer support commensurate to the needs of healthcare staff [19]. For instance, a brief onsite mindfulness-based intervention has been reported to be feasible, safe, and potentially helpful in supporting frontline workers [49]. Other cognitive-based therapies need to be evaluated to ascertain their impact in improving outcomes [50].
Further to the above, fears about contracting the COVID-19 disease and/ or infecting one's family members/ loved ones emerged as a major source of stress among healthcare staff. Even when the initial experience of psychological chaos was low with existing high standards of infection prevention strategies, fear of contracting the disease remained a significant concern among healthcare staff [51][52][53][54][55][56][57]. Healthcare staff who contracted the disease were faced with additional fears of dying alone with feelings of being socially isolated from colleagues and family/ loved ones as they underwent treatment. The findings strengthen the need for policies to make clinicians well-being a priority across healthcare settings and countries [58]. Healthcare staff need to feel safe within the healthcare setting whilst ensuring adherence to best infection prevention and control practices [15]. Avenues for healthcare staff to express their fears are needed to help them navigate through their emotions [59]. Additionally, healthcare staff who contract the illness may require extra support to deal with emerging psychological/ emotional impact of the illness.
Despite the emergence of several stressors, some facilitators to surviving/ thriving emerged. Key among these facilitators is the support offered by peers within one's team and family. Previous studies have highlighted the significant role played by peers at the workplace as there seem to be a shared concern among these persons who are journeying together within unfamiliar territories [40,60]. In fact, lack of social support has been linked to the development of anxiety, insomnia, and depression [57,61,62]. Peer support develops overtime and creates a sense of connectedness which may be difficult to quantify. This form of unique support requires further attention to determine ways of facilitating their development and improvement particularly in this era of journeying through a common ground.
The review findings offer insights into the experiences of healthcare professionals caring for persons with COVID-19. A notable strength is the translation of the primary studies into each other to generate a comparative understanding of the phenomenon of caring for persons with COVID-19. Some limitations are however noteworthy. Majority of the participants in the primary studies were nurses which creates the need to engage other healthcare staff such as laboratory technicians and mortuary attendants to understand their experiences. Additionally, although the review findings facilitated a reciprocal interpretation, the findings may not necessarily apply to other settings. Besides, generalizing the findings to the wider healthcare population may not be possible. It is also worth mentioning that only studies reported in English were included in this review.

Conclusion
Navigating through the experiences of healthcare staff during the outbreak highlight the existence of several concerns warranting attention. Although professional/ personal growth may be experienced, healthcare staff are still faced with heavy workload and emotional exhaustion which can predispose them to burnout and compassion fatigue. The findings have significant policy and practice implications such as a need for early and ongoing psychosocial support, support in handling fears, ensuring the availability of required equipment and identify strategies to boost team morale. As noted in a recent editorial, a period of rebuilding, resetting, and recovery is needed placing frontline healthcare staff at the front and centre of recovery measures [63].