The main codes “Coping strategies and protective factors”, “Needs and wishes” and “Barriers in implementing support” were each divided into subcodes as a result of the participants’ statements. A total of 16 subcodes (see Figs. 1, 2 and 3) emerged inductively from the interviews. At the time of the interviews, limited psychological support services were offered to the teams of the participants including team supervision and individual counseling as well as access to pastoral care service, de-escalation management and psychological crisis or group interventions. Additionally, free access to professional psychiatric-psychotherapeutic services was offered and an anonymous telephone helpline was provided. Yoga and mindfulness training, for instance, were offered as recreational activities. While the majority of services are offered on a continuous basis, the pastoral counseling service was only available from February to April 2021. The interview questions on barriers in implementing support specifically refer to the aforementioned support services that were available at the time of the interviews.
Coping strategies and protective factors
This domain, on the one hand, comprises the coping strategies that were found to be particularly helpful in dealing with the challenges and problems amplified by the SARS-CoV-2 pandemic. On the other hand, this domain includes protective factors representing attributes that have a positive impact on the well-being as well as reduce the effects of stress (see Fig. 1 for the frequency of codes).
Staff continued to seek balance in existing coping strategies, such as the use of entertainment as well as exercise and spending time outdoors. Further, special emphasis was placed on social exchange and support, on the one hand in the private sphere through family and friends, and on the other hand in a professional context through colleagues and superiors. While all interview participants from the group of the nurses stated that peer support was a helpful coping strategy, this aspect was only mentioned by five out of the nine interviewed physicians and therefore appeared to be less prominent amongst this group.
“[…] that’s how I draw most of my strength, of course, from a good family life. And that’s why, like I said earlier, I have the luxury of [having a family] compared to someone without a family, for example, who lives alone. Or also the fact that you have […] children is a luxury in a way.” (Example from Physician 7)
While support through private interactions was described as mostly unrelated to the burden of work, sharing the problems exacerbated by the pandemic with like-minded colleagues was a key coping strategy. This was explained by some respondents as a result of feeling better understood by colleagues and being able to give each other advice when needed.
“And because of that, because you realize that the other person feels the same way, you can simply cope with this stress or these difficult fates much better than if you don’t talk about it. So this conversation with colleagues who are on the same wavelength and experience the same thing, that helps me a lot.” (Example from Nurse 4)
In contrast to addressing the burdens at work, some of the interviewees felt that spatial and temporal distancing from work or any pandemic related topic was an important aspect of balance. Frontline HCWs often expressed a desire to return to their former ward to escape the stressors faced on the COVID-19 ward and to rejoin their familiar colleagues. Others described that the only possible way to relax after work was maintaining clear boundaries regarding working hours.
“Yes, so now I draw strength from the fact that I can leave the ward again […] (laughing) and I can be replaced there […], because I have asked to be replaced there by someone else. And that actually gives me strength, because that’s a time that you can bridge.” (Example from Nurse 4)
Being able to draw strength and maintain a positive attitude was seen by some as fundamental protective factors in overcoming the challenges at hand. These abilities were mostly attributed to one’s character traits, such as an optimistic and humorous personality.
Needs and wishes
This domain addresses the needs and wishes of the HCWs, which could serve as support in everyday work and in coping with the prevailing strains and burdens (see Fig. 2 for the frequency of codes).
Staff’s responses about their needs and ideas for improvement were divided, especially when comparing nurses’ and physicians’ answers. Whilst nurses perceived opportunities for optimization primarily at an in-hospital level, such as through the improvement of working conditions and communication processes, the surveyed physicians considered the greatest opportunity for optimization to be an increase in staff.
“Yes, more staff. I believe that in nursing in particular, even without corona, people often wish there was more, more manpower, to support everything. Also to have more time with the patient, which is simply also necessary to actually care [for patients], right?” (Example from Physician 6)
The need for practice-oriented improvements of working conditions in general, such as better planning of staff work schedules, flatter organizational structures and prompt assistance with problems, was particularly emphasized by nurses. Some interviewees described the impression that their concerns were invalidated and not being taken seriously by decision-makers, including both immediate superiors as well as higher-level executives.
“[…] I would have liked to have someone help me when I said something and there is a need, that when something happens that you don’t just have the feeling that everything always disappears into thin air. For example, it would have been very important for me to have someone respond to my workload complaint letter.” (Example from Nurse 1)
When asked about their wishes, the need for improved communication processes, both within and between teams, was frequently talked about by the interviewed nurses. The need for the development of an error culture, that promotes an open, non-judgmental approach to errors,was further addressed by some employees, which has so far been neglected in the hospital system. In addition to improving communication, an important wish for many was to improve team processes and team spirit, in particular through gestures of mutual appreciation.
“[…] so primarily, I think, communication among each other […] I think I would like to see fixed times and rules in the team. So especially with regard to the handover, that it is simply obligatory to say that there will now be a verbal handover. Simply that one speaks a few more words with each other and less [information] is lost.” (Example from Nurse 6)
“But I think we need to learn a few things together again. I think we need to learn about the culture of making mistakes. I think we have to learn appreciation.” (Example from Physician 5)
While the workers appreciated the existing course and therapy offers, some respondents wanted more varied, low-threshold offers, such as visits by psychological staff to the wards without prior appointments. An extension of supervision sessions, in terms of frequency and participation rate,was particularly asked for, with some respondents considering an obligatory participation necessary.
Barriers in implementing support
Due to various barriers, existing support services offered by the participants’ employer were often not accessed. Furthermore, the participants reported negative influencing factors that had a detrimental effect on their daily work life in general (see Fig. 3 for the frequency of codes).
Although most nurses and physicians perceived peer support as one of the most helpful coping strategies, some staff described a lack of cohesion and exchange within their teams. This was mentioned primarily in connection with the atmosphere on the COVID-19 ward and the discrepancy between the COVID-19 ward and the interviewee’s respective former ward, which was exclusively mentioned by the interviewed nurses. Nurses reported as important stress factors, first, that the newly formed teams for COVID-19 wards were randomly formed from stable teams without respecting previous team structures and needs. Second, nurses defined the lack of a uniform standard of work regarding the execution of work tasks in these new teams as a second important stress factor.
“The new colleagues, I can’t really call them colleagues. Because they were [just] people I worked with. We never had time to really get to know each other, so to speak. […] So I only ever worked with some of them at the end, and I actually saw them maybe twice because of this jumping between the wards.” (Example from Nurse 1)
Regarding participation in course and therapy offers, there was a great variety of experiences among the surveyed staff, especially in terms of awareness of the existence as well as the benefits of offered services. While most participants felt that offers were well advertised, others were unaware of the available support and its potential benefits. Other employees expressed that while they were aware of the existence of such offers, they were uncertain about whether support services could be beneficial for them in terms of coping with the challenges and burdens.
“[…] that you don’t see the awareness or the chance that through such an offer, or that things could get better. Wanting to sort it out with yourself is, I think, a hindrance.” (Example from Physician 7)
Further, one frequently reported barrier was the lack of free time among the workers, which many of the participants explained as being due to increased workloads, numerous hours of overtime and shift work that prevents regular attendance at fixed appointments. Simultaneously, several respondents mentioned a lack of motivation as a possible inhibiting factor, as the limited free time and the high workload resulted in a reduced interest in participating in activities after the end of a workday.
“I also believe that because of the workload, now the pure timely workload, many employees in the house are also very happy when they just finish their shift and clock out and go home. Because then it’s over and done with, they leave and go home and that’s it.” (Example from Physician 4)
Additionally, several participants in both groups stated that the fear of opening up and the disclosure of personal, intimate information was a major barrier to seeking psychological support services. On the one hand, some employees expressed concern about admitting and realizing their own mistakes and alleged weaknesses and subsequently dealing with them; on the other hand, they described that the confrontation with burdening or traumatizing experiences might only complicate and prolong the process of moving on. Some interviewees seemed to hold the perception that everyone must cope with the stressors and strains themselves and that it was a matter of “getting a hold on yourself”.
“And that [seeking help] is certainly the more strenuous way, it leads to feeling and having feelings in this profession is perhaps more—yes, it is simply more strenuous.” (Example from Nurse 6)
“[…] I’m sure that there are some outdated role models that suggest: This shouldn’t affect me so deeply; after all, I am—and they wouldn’t consider such offers in order not to show any weakness.” (Example from Physician 5)
In addition, several of the employees feared negative consequences as a result of seeking psychological support services. This aspect was more dominant among the group of nurses compared the interviewed physicians. Workers were particularly concerned about the potential lack of anonymity within the hospital and any resulting disadvantages, as well as the fear of being stigmatized by their colleagues and superiors.
“[…] you will be stigmatized a bit. If I were to seek psychological help now, I would keep that to myself. This is a hard business, without criticizing anyone here, but the psychological care after a covid infection or any other psychological support; that stigmatizes you, I must say that quite clearly. […] but in our tough business, where the demands are quite high, you are quickly stigmatized or somehow seen differently.” (Example from Physician 8)
In line with the aforementioned fear of acknowledging one’s own need for support, several of the workers described their main fear as being perceived as weak or mentally unstable by their colleagues and thus making themselves vulnerable.
“I think that a lot of people are constantly afraid that some of their weaknesses or mistakes will come to light and that this will make them more vulnerable.” (Example from Nurse 11)
Further, the presence of colleagues during supervision sessions in team settings was an obstacle for some workers, who feared possible interpersonal conflicts because of expressing their opinions and thoughts.