Persistent crisis in healthcare : psychological stress reactions and psychological support for healthcare workers during the COVID-19 pandemic

Background: Even before the COVID-19 pandemic, healthcare workers were affected by high job demands and had an increased risk of developing psychological stress symptoms. During the COVID-19 pandemic, the prevalence of psychological stress symptoms increased among healthcare workers and healthcare organizations implemented psychological support to help their staff cope with the crisis. However, due to the fast development of the pandemic, the support needed to be rapidly implemented and knowledge was lacking on what type of psychological support is meaningful to implement in healthcare during a persistent crisis. Further, it was unclear how psychological stress reactions would unfold among healthcare workers during the persistent crisis of the COVID-19 pandemic, and if increased symptoms may also be related to negative long-term health effects such as sickness absence (SA).

Aim: The overall aim of the thesis was to investigate the meaningfulness and feasibility of psychological support (Study I-II), as well as the psychological stress reactions among healthcare workers (Study III-IV) during the persistent crisis of the COVID-19 pandemic (Study I-II). Study I evaluated the acceptability and feasibility of an implemented psychological support model at an Intensive Care Unit (ICU) during the first wave of the COVID-19 pandemic. Study II identified patterns of help-seeking behavior in relation to available psychological support among healthcare workers during the early and mid-phases of the pandemic. Study III examined the association between high burnout symptoms early in the COVID-19 pandemic and high burnout and depressive symptoms later in the crisis. Study IV investigated how different symptoms of psychological stress were interrelated during the COVID-19 pandemic and their relationship with mental health-related sickness absence (SA).

Methods: Study I was an observational study using survey data (N = 123 healthcare workers), support participation reports, and interviews with support providers. Descriptive statistics were presented, and interviews were analyzed with thematic analysis. Study II was an observational person-centered study, using survey data from healthcare workers collected in the early (N = 681) and mid-phase (N = 396) of the COVID-19 pandemic. Data on participation in different forms of psychological support were used as indicators of class membership, work-related characteristics as class predictors, and ratings of burnout and sleep disturbance as outcomes. Study III had a case-control design using survey data collected at four timepoints during the COVID-19 pandemic. Participants were healthcare workers (N = 581). Logistic regression tested the association between case group membership (high levels of burnout symptoms) in the early pandemic and high symptoms of burnout and depression at three follow-ups. Frontline work, changes in work tasks, and participation in psychological support were controlled for in separate models. Study IV used survey data on symptoms of psychological stress and register data on SA from the Swedish Social Insurance Agency (N = 1245 healthcare workers). Personcentered analysis was used to investigate the interrelations between different symptoms of psychological stress. Tests of group-level differences were used to analyze the association between symptoms and SA.

Findings: Most healthcare workers in Study I were aware of and used group support sessions. Providing support within working hours and engaging in-house psychologists increased the feasibility of the support, but it was difficult to maintain its sustainability over time (Study I). Patterns of help-seeking behavior found in Study II revealed that when engaging in psychological support, healthcare workers leaned more toward different social or group-based activities. During the persistent crisis, the availability of the support declined, and not all occupational groups were equally engaged in it (Study II). Healthcare workers with high burnout symptoms at the beginning of the pandemic (21%) were more likely to report high symptoms of both burnout and depression also later in the pandemic (Study III). Study IV identified that 6.3% of participants were on SA related to mental health and had higher symptoms of psychological stress during the COVID-19 pandemic. Different symptoms of psychological stress were also highly interrelated (Study IV).

Conclusions: The findings of this thesis suggest that healthcare organizations will likely benefit from focusing on the implementation of a few psychological support formats that are based on social support. During a persistent crisis, organizational resources should be attributed to the sustainability of the support and making it accessible for all occupational groups of staff. In terms of mitigating the psychological stress reactions among healthcare workers during a persistent crisis, healthcare organizations should be mindful of the development of symptoms of psychological stress among staff early in the crisis. Symptoms of psychological stress were highly interrelated and increased among healthcare workers in Sweden during the COVID-19 pandemic. Although symptoms of psychological stress were related to SA, future research may determine whether this increase in symptoms also led to a rise in mental health-related SA following the crisis.

List of scientific papers

I. Appelbom, S., Bujacz, A., Finnes, A., Ahlbeck, K., Bromberg, F., Holmberg, J., Larsson, L., Olgren, B., Wanecek, M., Wetterborg, D., & Wicksell, R. (2021). The rapid implementation of a psychological support model for frontline healthcare workers during the Covid-19 pandemic: A case study and process evaluation. Frontiers in Psychiatry. 1460.
https://doi.org/10.3389/fpsyt.2021.713251

II. Appelbom, S., Finnes, A., Wicksell, R. K., & Bujacz, A. (2024). When Crisis Hits, Send in the Psychologists? A Latent Transition Analysis of HelpSeeking Behavior Among Swedish Healthcare Workers During the COVID19 Pandemic. Scandinavian Journal of Work and Organizational Psychology. 9(1), 2.
https://doi.org/10.16993/sjwop.224

III. Appelbom, S., Nordstršm, A., Finnes, A., Wicksell, R. K., & Bujacz, A. (2024). Healthcare worker burnout during a persistent crisis: A case-control study. Occupational Medicine. 74(4), 297-303.
https://doi.org/10.1093/occmed/kqae032

IV. Appelbom, S., Finnes, A., Wicksell, R. K., & Bujacz, A. Symptoms of psychological stress and sickness absence among healthcare workers during a persistent crisis. [Submitted]