Discussion
This study used a participatory research method to explore hospital-based HCW experience 1 year after the start of the pandemic. The photovoice submissions were shown in a hospital-based art exhibit and viewer feedback was collected and analysed. Thematic analysis of the submission narratives emerged six themes: (1) hopeful and resilient, (2) pandemic fatigue-negative mental and physical states, (3) PPE is our armour but masks who we are, (4) human connection, (5) responsibility, preparation and obligation and (6) technology surge. The art exhibit survey identified that viewers enjoyed the creative method–photovoice to personalise the experience and acknowledged their perceptions about the difficulties faced by HCW were validated. Viewers empathised with the challenges that came with increased clinical workload and additional stressors. Mental health assistance, HCW peer support, self-reflection14 and using creative outlets such as artistic programmes for self-expression and social connection15 were among the suggestions made by viewers to support HCW during the pandemic. The viewers also mentioned that the hospital administration should help develop programmes to support workers in the afore-mentioned areas identified. To improve future art exhibits on this topic, viewers’ indicated that a broad representation of multidisciplinary HCW are needed and to use digital artistic platforms.
There are a number of existing studies examining the topic of resilience in HCW during the pandemic.1 4 5 16–19 Similar to our study, many of these studies have found that HCW often face increased physical and mental demands, leading to feelings of isolation, stress and burnout.1 4 19 Studies also mention a sense of personal duty, responsibility and resilience, which emerges particularly during the subsequent ‘de-escalation’ phase of a pandemic.5 This was true of our participants as well, wherein the themes of loneliness, a strong theme of resilience and hope emerged. This is likely attributable to the timing of our study, as we collected responses during the de-escalation phase between two ‘waves’ of the pandemic. In general, studies reviewing pandemic response agree that systematic or organisational-level interventions are needed to support the health of HCW,4 5 but unfortunately there is insufficient evidence to help prioritise interventions for implementation.5
Based on our study themes (table 1) and viewer feedback, the research team suggest the following 10 intervention/strategies: (1) vaccination accessibility for patients; (2) mental health supports offered via digital platforms and a hospital-based councillor; (3) collaborate with existing programmes following local infection prevention guidance to reintroduce safe staff interaction/activities (ie, pet and music therapy), to promote safe social events and regain a sense of normalcy; (4) proactively address HCW fatigue through ongoing recruitment into regular, casual, temporary and new graduate positions in addition to redeployment strategies; (5) staff safety as a top priority (ie, PPE supplies accessible and PPE coaches are present on the units to provide assistance); (6) technology accessible and training provided, via digital medical interpretation, and virtual appointments; (7) encourage staff self-reflection (ie, ‘Pause and Reflect’—a peer-to-peer debriefing support activity or self-reflection questioning) on ethical issues arising from the pandemic, such as caring for unvaccinated patients, highly emotional and traumatising events; (8) hospital-based HCW peer support group; (9) centralise and reduce COVID-19 communications using daily and weekly update summaries, preventing information overload; and (10) wearable buttons to show staff faces. By December 2021, many of the recommended strategies identified in this study had been successfully implemented at this study hospital with the help of our senior executive team member.
Public Health Ontario recently published a synthesis assessing potential interventions and offered guidance for prioritisation. In an assessment of the existing literature and literary reviews, it was felt that individual mental health interventions were more prevalent in the literature than organisational interventions, but it was the organisational interventions that were often more effective.4 A rapid review by Magill et al suggested that organisational activities, even those not associated with mental health, had helped to improve psychological outcomes among HCW.17 The afore-mentioned align with our suggestions, whereby the authors feel that organisational activities such as on unit PPE coaches, peer support activities and safe staff interaction programmes be prioritised, in addition to increasing access to personal mental health counselling.
One of the most common recommendations in previously published literature is the management of staffing and workload management for the staff.1 19 Particularly during a pandemic, staffing shortages arise from staff sick leaves, staff redeployment and increased workload due to increasing patient volume. A systematic review by Muller et al reported a common preference of workers for manageable and safe working conditions (eg, Adequate rest time, safe resting spaces, adequate PPE, contingency plan for management of staffing shortages) over individual counselling or psychological interventions.1 Furthermore, a rapid review by Kisely et al found that clear and prompt communication from leadership regarding latest guidelines, and facilitated discussions (such as listening groups, town halls, managers visiting staff, etc) are effective for staff engagement.16 This was felt to minimise the psychological burden of pandemic response on front-line staff.16 This aligns with the themes of our analysis as well; emerging themes identify in this study that included the availability and use of PPE, and sense of human connection, including teamwork, effective communication/directives and comradery with peers. The photovoice method was a successful platform for initiating discussion between HCW and management. The feedback received from art gallery visitors indicated that having pictorial representations of HCWs’ realities helped to empathise and clearly illustrate HCW struggles in a way that narrative language alone could not capture. Furthermore, the resulting themes from this study led to development of interventions, which were implemented by management. Photovoice could serve as an alternate communication medium in addition to traditional communication approaches (ie, staff meetings) between staff and management.
In addition, providing the opportunity for a creative reflective practice of taking a photograph and writing a narrative is a supportive intervention in and of itself.8 Wang, who initially described the practice of photovoice in scientific literature, implied that the practice empowers the participants through documentation and portrayal of their realities.6 In doing so, it allows participants to come to terms with their struggles, and also reflect/document their resources and strengths.6 7 The authors perceive that photovoice is intrinsically a valuable exercise to HCW in the time of the COVID-19 pandemic.
Limitations
This study provided interesting findings but it was not without limitations. Low hospital staff participation, viewer survey response rate and the recruitment process of hospital and physician leaders disseminating the study information may have introduced a power imbalance. Potential participants may have felt intimidated or worried about anonymity and selected not to participate, as they may have perceived participation could compromise their professional role. An alternative recruitment process could have been to send all hospital HCW the study information via a hospital wide email communication with the submission sent to the hospital-based art gallery. Other strategies would include having recruitment posters displayed throughout the hospital with a QR code that linked to the study information, or using a photovoice study kiosk in a public area of the hospital such as the cafeteria, where art gallery personnel explain the study. All the afore-mentioned may have improved participation and anonymity. In addition, during the recruitment timeframe, the hospital faced various difficulties where clinical priority may have preceded study participation. Participant submissions lacked many of the challenges faced during this timeperiod. This means the depth and breadth of our study findings may be limited. Another potential limitation is the use of an artist for enhancement of the final images, participants were not given the option to contribute to the artistic enhancement of the submissions. However, colloquially, image enhancement offered an added interest and made the submissions more suitable for presentation at the art gallery. Geographical and hospital context may affect the generalisability of our findings. Regardless of these limitations, the use of photovoice to capture HCW lived experience was a powerful method to visually share unique viewpoints of the pandemic from hospital-based staff.