*Emma, a social worker in the hospital's Corona Department*

Studies on outbreaks of infectious diseases reveal the profound and broad-spectrum psychological impacts that disease outbreaks can inflict on healthcare professionals [1,2]. Experience with the SARS and Ebola virus outbreaks suggests that healthcare professionals are subject to extremely high levels of stress and emotional turbulence [3–5]. In dealing with the SARS virus, which is similar in some respects to the 2019 novel coronavirus (SARS-CoV-2), healthcare professionals were troubled by intrusive thoughts and images associated with SARS and exhibited symptoms of PTSD and substantial psychological distress [6], if not mental illness [7]. In addition, healthcare professionals feared that they would fall ill from SARS but were equally or more worried about infecting family members and other people [8]. Nonetheless, prior experience with pandemics, disasters, and major traumatic events has indicated that enhanced support for healthcare professionals enabled them to remain efficient and focused during these stressful events [9].

The on-the-job stress and burnout of healthcare workers (HCWs) employed in hospitals [10–12] is one of the key themes in studies of the trauma of these professionals in the corpus of literature on the cost of caring [13]. This recurring motif is not surprising, since the hospital environment is challenging in that it frequently demands holistic treatment of patients that integrates psychological elements with physical treatment: In the course of their routine hospital work, HCWs are required to deal with patients and their families who have experienced traumatic events and life-threatening episodes [14].

It was against this background that hospital HCWs the world over first encountered the global COVID-19 pandemic in December 2019 [15]. Facing this global public health event situated HCWs in an unbearable situation, with them being required to function under extreme physical and psychological pressure on both the professional and personal levels [16]. In parallel, they were often required to make impossible decisions, including how to deal with limited equipment, how to balance their own physical and mental welfare needs with those of their patients, and how to bring into line their responsibility to their patients with their responsibility to their family and friends. In addition, their wish to provide optimal care for severely ill patients was often constrained by inadequate resources. Thus, in the COVID-19 pandemic, frontline HCWs had to work under particularly intense stress levels in unprecedentedly difficult situations [17]—situations that may indeed cause stress, moral injury, and physical and mental health problems [4,17].

The unfolding pandemic has been compared to war, as described in "'The Art of War' in the Era of Coronavirus Disease 2019 (COVID-19)" by Maxwell et al. [18], who claim that the image of war is often used in the field of infectious diseases. Indeed, from the beginning of the pandemic, HCWs in the hospital setting have been faced with caring for patients with an incredibly contagious and life-threatening disease about which nothing was known and for which there was no known lifesaving treatment—a situation similar to a war. They were—and still are—handling life-and-death situations while simultaneously putting their own lives at risk. This factor has contributed to a real sense of danger among hospital staff, who have found themselves in the forefront of defense against the pandemic [19]. In parallel, HCWs are being required to deal with emerging challenges [20]. They are often required to develop, in an extremely short time, novel concepts and new interventions for unpredictable situations. The need for HCWs to be proactive results from the fast-growing numbers of critically ill patients, the lack of treatment modalities, and shortages of critical medical resources and staff. Like the general population, the hospital staff is struggling with the emotional stressors imposed by the pandemic. However, they are also faced with additional stressors and a rapidly evolving work environment that differs significantly from their pre-COVID routines [21,22].

Marchand-Senécal et al. [23] point out that specialized, dedicated COVID-19 teams could quickly be overwhelmed as numbers of cases increase markedly. They also hold that longer shifts and increased work intensity may lead to HCW fatigue and lapses in the use of the correct techniques for handling personal protective equipment (PPE). They illustrate this conclusion by citing initial reports indicating that about 4% of Chinese HCWs caring for COVID-19 patients were infected, with 15% of those HCWs being classified as severe or critical cases. It is thus not surprising that a survey of 1257 frontline nurses, physicians, and other HCWs who treated COVID-19 patients in hospitals in China found that the participants carried a psychological burden, with symptoms related to depression, anxiety, and distress [1]. Earlier studies on epidemic outbreaks have indeed revealed that medical personnel, particularly first responders, including physicians, nurses, ambulance personnel, and other HCWs, become emotionally affected and traumatized and display heightened stress and higher levels of depression and anxiety [24,25]. These findings are to be expected, since anxiety and the fear of being

infected are aggravated as the risk of exposure is elevated. This heightened anxiety is exacerbated even further by the fear of transmission of the infection to loved ones. The need to maintain a sense of balance between professional duty, altruism, and personal fear for oneself and others thus often causes a mental conflict for HCWs [1]. In the guidelines published on 19 March 2020 by the World Health Organization, it was declared that, by virtue of their caring for and close contact with COVID-19 patients, the people most at risk of acquiring the disease are HCWs and that protecting HCWs is of paramount importance.

In light of the above, at the beginning of the COVID-19 outbreak in Israel, we arranged a meeting in our hospital of an ad-hoc group of experts from different disciplines in healthcare and with different types of expertise. The recommendations of this focus group and the results of the interviews that were constructed and conducted as an outcome of these recommendations are described below.

#### *1.2. Theoretical Framework*

The theory of how humans usually function in daily life, as embodied in the ideas of Abraham Maslow, appear to be remarkably relevant to massive crises, especially to the present global crisis resulting from the COVID-19 pandemic [26]. Maslow's theory establishes a hierarchy of human needs [27] and, as such, provides a framework to describe the needs of hospital personnel [28,29]. Maslow's theory divides human needs into five categories. The first category, forming the base of a pyramid of needs, comprises physiological needs, such as air, water, food, shelter, sleep, and clothing. For medical personnel, Hale and his colleges [28] extend this level to include the basic determinants of good physical and mental health and safety. The first category is followed, in order, by four more layers: safety needs, such as personal security, employment, resources, health, and property; love and belonging, which includes friendship, intimacy, family, and a sense of connection; esteem and respect, which includes self-esteem, status, recognition, strength, and freedom; and, finally, at the top of the pyramid, the desire to become the best that one can be, relates to personal growth [30,31]. Maslow described each level as a separate need that relies on the previous need. However, modern-day theorists have modified this conceptualization into an overall concept in which each need coexists with the others [28]. We used semi-structured interviews based on Maslow's pyramid to survey HCWs in our hospital. We then analyzed the interviews by choosing, from the umbrella of narrative analysis, the Listening Guide methodology to analyze the recorded interviews and their transcripts [32,33]. This qualitative research methodology was developed as an alternative analysis to conventional coding schemes used to analyze qualitative data [33]. It differs from other means of analysis in that it places emphasis on the psychological complexities of people through attention to voice as a manifestation of the psyche. The Listening Guide in its attention to voice—and silence—thus provides a way of exploring the interplay of inner and outer worlds and of bringing the inner world out into the open [33–35]. By focusing on different voices, on the dynamics and interplay of these voices within the interview transcript, and on the socio-cultural setting of the research, the Guide establishes a contextual framework for understanding and/or interpreting the narratives of the interviewees and thereby facilitates psychological discovery. The details of methodology are described in the Materials and Methods section [36].

Although every analytical process has its advantages and drawbacks, we chose the Listening Guide, since its intent is to capture the layers of perception and experiences of trauma and stress [37,38] that might otherwise remain unnoticed, thereby broadening the understanding of traumatic situations. By applying this methodology, we aimed to expand knowledge—and to generate new knowledge—regarding the mechanisms and the strategies used by hospital workers to cope with the COVID-19 pandemic. Specifically, we sought to reveal the overt and covert voices [39] emerging from the experiences of front-line workers and to examine how these workers describe and experience their traumas in their struggle to treat patients with COVID-19.

#### **2. Materials and Methods**

As mentioned above, being aware of the necessity to address the needs of the hospital's HCWs, we conducted a study aimed to expand the knowledge of these needs during the first phase of the covid-19 outbreak. Specifically, the goal of the study was to enable the contrapuntal voices emerging from the hospital staff's experiences to be "heard" and thereby to provide recommendations as to how to meet their changing needs as the crisis unfolded. By paying close attention the narratives of the hospital staff, we were able to address an additional aim, namely, to initiate the establishment of a data-based foundation for both immediate and future interventions, thereby expanding knowledge regarding the psychological mechanisms and strategies that front-line personnel use to cope with exposure to traumatic situations.

The first step of the research comprised the establishment of a focus group of HCWs, all trauma experts, in the hospital. On 18 March 2020, the focus group met to exchange thoughts about the evolving crisis conditions in the hospital and to find the means to evaluate—and indeed alleviate—the situation. The focus group comprised an Emergency Department physician and five medical-social workers with specializations in mental health and trauma. The decision to constitute a focus group of experts as the opening stage for this research project derived from the perspective that the novel coronavirus poses an unmet challenge to medical treatment and hence challenges HCWs in many unknown ways. The focus group was charged with delineating the new situation in the hospital and with deciding on the exact research methodology and research tool(s) that could be applied in a research project and possibly later as adjunct practical tools for dealing with the evolving crisis. The final question put to the focus group was: What is the next step in the research project?" The participants pointed out the need to conduct bottom-up interviews at all levels and sectors in the hospital as a means of understanding the emerging needs of the hospital personnel [40]. The focus group suggested conducting a survey based on semi-structured in-depth interview based on Maslow's Pyramid of Needs' model. The survey and results are described below.

The interview protocol involved questions designed to capture the HCWs' ways of describing their unique experiences. To this end, the interview protocol comprised a standard set of questions, beginning with a request to share with the interviewer thoughts on what it meant to be an HCW in a hospital at the time of the corona crisis. This opening question was followed by encouragement to share thoughts on personal needs. More specific questions were used to clarify the stories as the interviews proceeded, such as: What do you need—physically or anything else? What distresses you at work? What would make you feel safer? What helps you to feel better? What helps you to know that you are appreciated? What motivates you to get up every morning for work? In a year from now, what do you think will have changed in your family, at the hospital, within yourself? Do you have something that you think important to add to the body of knowledge specifically about coronavirus or about trauma situations in general?

Four hundred and fifty semi-structured interviews were conducted in three waves: the first in the middle of March 2020, before recognition of COVID-19 as a global pandemic (163 staff members; 36.2% of the interviewees); the second, two weeks later (157; 34.9%); and the third in the middle of May 2020, at the end of Israel's national lockdown (130; 28.9%). Interviews were conducted with personnel [87 (20.2%) men and 344 (79.8%) women] serving a variety of functions in the hospital: physicians, nurses, pharmacists, respiratory therapists, department supervisors, laboratory technicians, social workers, and administrative workers from various sectors and with different levels of seniority (average 16.6 years; median 15 years, range:0-50) The breakdown of sectors and departments is given in Table 1. The interviews each lasted approximately 20 min to 1 h and were conducted under conditions of assured confidentiality.

As we indicated above, the interview narratives (in audio form and as transcripts) were analyzed by applying Gilligan's Listening Guide methodology [41], which is comprised of four stages, as follows [37,42].


The reported study conformed to internationally accepted ethical guidelines and relevant professional ethical guidelines and was approved by the institutional review board (IRB) of Kaplan Medical Center, Rehovot, Israel. To assure confidentiality, each participant was identified by a pseudonym.


**Table 1.** Distribution of the interviewees according to sector and Department.

Note: Values in the table are number (%) of interviewees that answered the specific question. The numbers do not add up to 450, because, in some cases, interviewees refrained from answering. \* Paramed includes social workers, dietitians, physiotherapists, etc. Other includes kitchen workers, pharmacists, security personnel, housekeeping workers, etc. \*\* Department—OBGYN—Obstetrics and Gynecology; other includes hospital kitchen, pharmacy, security, housekeeping, administration, data and computing, etc.

#### **3. Results**

### *3.1. The First Step: "Listening to the Plot"*

The narratives of the healthcare professionals covered a description of their experiences, explaining in detail their engagement with corona patients and their families and their relationships with members of the hospital staff. Two main themes emerged from the analysis of listening to the plot, the first of which was *preparing for war* in that the participants compared the situation in the hospital to the experience of preparing for war. Sara, for example, said: "*In our country, we know what a war is, and in the healthcare system we know how to function in the hospital during times of war, but still, this is a new war, a war that we have never handled, an invisible enemy, and it is frightening all of us*." In similar vein, Doron said: "*to be significant, to be at the front is important. Before it was the army that was at the front, now it is the turn of the healthcare system to be at the front."*

The second theme to emerge was that of *security and insecurity*, which related to two main aspects of the situation—fear of contamination and uncertainties derived from the assignment of HCWs to new teams and departments whose purpose and essence were unfamiliar. The idea of working in new and unfamiliar teams distressed the personnel, and their narratives reflected their feelings of insecurity. The changing reality was reflected by Dikla a nurse: *"In the Internal Medicine Department, I have been working for the past 18 years with my team, physicians, nurses, secretary—we have a common language. I felt especially secure in those days. How I will be able to use, in an e*ffi*cient way, a new situation and new sta*ff*? This is ridiculous*." Similarly, Tania, a social worker, said: "*This will increase the feeling of insecurity* ... *think that the entire situation is new and scary; so, what will I do without my friends who I have been working with for years?"* In particular, the need to be protected during shifts was pronounced. As Sara told us: "*In order to continue to come here, I need to feel that someone is taking care of me. I do not care who in charge of that in the hospital, but I need to feel safe; it is essential for me."*

According to the Listening Guide protocol, at this stage of the analysis, the interviewer should document his/her own reflexive emotional responses. We found that listening to the interviewees and reading the transcripts induced emotional concern for and feelings of empathy with our colleagues who were struggling with unbearable situations and ethical dilemmas. We were full of tears when we heard about the burdens of caring for patients and the cost of that caring. The interviews and the transcript readings thus gave rise to a range of emotions, including sadness, anger, compassion, and frustration, but also to pride in the devoted teams and to an appreciation of their devotion.

#### *3.2. The Second Step: The "I Poem"*

The second phase of the Listening Guide involves composing the "I Poem," which is a core feature of the approach that serves to identify the active self. The process of composing the "I Poem" [44] can best be understood by examining some examples. Let us start by examining the transcript of the interview with Julie, a nurse in the ICU: *"I cannot believe it* ... *because of the workload* ... *it is only because of the workload* ... *I have to tell you that I haven't eaten for whole days* ... *I grab something. It is not that there isn't any food, but we don't have the time and the needs of the sta*ff *draw you and you can't ignore them; you need to respond to each one. At other times its di*ff*erent, of course. Here you can't say anything to them. It's the mask; it creates wounds on their noses, so I brought them cream. This kind of mask or any other; so, I saw masks in the grocery store and I bought them pink surgical masks so they would feel joy. Every day I am bringing something to make them happy. All the time. Yes, the protective equipment is a problematic issue by itself* ... *I understand since I am involved in that; it depends on the equipment that comes to Israel, but it is not always suitable* ... *this equipment is insane."* In her "I Voice," Julie demonstrated her personal difficulties in the Corona ICU and her difficulties in taking care of herself, even with regard to basic needs, such as food. However, as a manager in the ICU, her "I Voice," expressed her competency in taking care of her ICU staff, as reflected in her "I Poem":

> Julie's "I Poem" I cannot believe I have to tell I haven't eaten I grab something [to eat] I brought them cream I saw face masks I bought them masks I am taking out [something to make them happy] I understand I am involved

Michal, a nurse, said: "I love my job, and I love the feeling of contributing. People around me, outside the hospital, talk about us [the HCWs]. I am in the frontline. It is pleasant and heartwarming." Michal's "I Poem" demonstrates her need to feel meaningful. In her "I Voice," she expressed her caring and empathy for patients and fellow team members. She also expressed strength and resilience.
