3.3.3. The Voice of Attachment

As could be predicted from Maslow's hierarchy of needs, the dominant needs for security and knowledge were replaced by the needs for belonging, love, recognition, and respect from supervisors and the hospital management as the pandemic progressed. The HCWs stated that a sense of family in the departments and the departments and friendship within their teams provided the much-needed sense of support during the pandemic. Moreover, the HCWs stated that without friendship, comradery, and a sense of belonging to a larger family, they would not have been able to work under such difficult conditions. For example, Sisi, a secretary at the hospital, said:

We were all a big family helping each other. I felt so close to all my peers; working together in such a tough time was different from what I had known in the last 26 years that I have been working in the hospital. As a team, we have become closer to each other, and I have discovered additional angels in my team ... . In our department there is a sense of "togetherness" and comradery. Professionally, there will be changes; there are thoughts about modifying procedures in light of the current pandemic ... . Relating to each other, currently feeling that we are a united and cohesive group.

#### Tova, a nurse in the ICU, said:

This period is a mixture of emotions. The reality is that everything is so new and unfamiliar. Nevertheless, the staff are so devoted to each other and struggling to do their best to help each other and changing shifts due to the lack of nurses. Sometimes they asked about treatment and I did not have an adequate answer. How I will say it? This is the period that we are re-inventing the protocols and rules of treatment. I am telling them that I am so sorry but there are no guidelines yet.

In addition, the interviewees expressed a need for recognition—appreciation and reinforcement from their direct supervisors. For example, Tomer said: "*A good word, a compliment, and a positive*

*attitude made me feel valued and* ... *reassured.*" Orna said: "*A kind word makes my day* ... *. It is essential for me to get feedback on my work and to know that I am doing my job well.*"

Another narrative relating to attachment was the need for a managerial presence, manifested as "managing by walking around." This practice is considered one of the most important ways to build good manners and performance in the workplace and emphasizes the importance of interpersonal contact, open appreciation, and recognition [46]. The HCWs did indeed voice their desire for appreciation in the form of the need to meet management representatives in the various departments. Alma, for example, said: "*The presence of management in all departments and during all shifts made the sta*ff *aware that there was someone with them*." She added: "*Personal appreciation by the management increases motivation and reduces concern* ... *.I would like to see more direct communication with management* ... *in my team, I feel appreciated. I don't feel I'm getting feedback from management*." Lili said that when management came into the Corona Department to visit the staff and the patients, they asked her personally how she felt, and this was what helped her to feel valued. The HCWs were in agreement in their approval of the actions taken by the hospital management, judging the management's conduct during the crisis to be appropriate and effective. Opinions of the following type were expressed: *Management worked well during the crisis*; *I want to thank the management for the adaptions that were made by mobilization of sta*ff *and change of policies and for taking the time to listen*; and *in my opinion, the hospital and management are doing well*.

#### 3.3.4. The Voice of Meaningfulness

The importance of feeling meaningful was verbalized by Hanna: "*Patients with coronavirus helped me to feel valued and meaningful, [especially] the conversations with the patients and the phone conversations with their families out there in their homes, so worried about their loved ones. I was there for the patients and their families, and it allowed me to feel meaningful and to want to continue treating patients.*"

#### **4. Discussion**

The global COVID-19 pandemic has challenged scholars and practitioners to find the means to alleviate stress and to treat the trauma experienced by members of the healthcare professions. Our study was designed to examine the experiences of HCWs during the first weeks of the COVID-19 pandemic, which may be considered as a massive traumatic event. The HCWs in this study, like other medical professionals caring for COVID-19 patients [40], have found themselves in a battle on two fronts: as hospital-based professionals fighting for their patients' lives, giving rise to their perspective of themselves as combatants fighting on the frontline of a war, and as family members fighting to protect their families from exposure to the virus and paying the price for fighting the "new war." As mentioned in the Introduction and Results sections, the image of war has become a common motif in discussions about the COVID-19 pandemic. Medical experts have even suggested that military strategies to be applied to outbreak management and have highlighted the importance of prioritizing healthcare staff capacity, as is done in military scenarios [18]. By documenting knowledge about HCWs, we thus contribute to a scholarly assessment and understanding of various elements of the new war—that against COVID-19. By seeking a dialogue with HCWs and, particularly, by engaging hospital staff in a genuine dialogue that deepens our understanding of the new battlefield and the "new health combatants," we are now in a position to raise questions about "conventional wisdom" in the health system and to expand the knowledge about understudied topics in the new war [12,46].

We believe that to produce a deeper understanding of the experiences of frontline workers, whoever they may be, we should listen to them attentively [47]. Thus, the Listening Guide methodology provides a tool that can capture subconscious expressions through investigation of voices that are not usually otherwise revealed. By implementing the Listening Guide method in this study, we were able to explore more deeply the ways in which the HCW's represent themselves and others—the ways in which they tell their story of the situation. In addition, we suggest that this methodology be integrated

into the methods utilized in the healthcare arena and should be further explored in additional healthcare contexts.

During the interviews, the HCWs emphasized the high level of emotional intensity associated with long hospital shifts, the constant fear of death and of exposure to new and unfamiliar traumatic events, and the constant feeling of insecurity. The HCWs indicated that to cope with these emotional facets of their working environment, they needed a secure base. Issues of security and insecurity were revealed in different ways at different stages of the evolving crisis: At the beginning of the interviews, a clear majority of the staff emphasized the need for physical protection and the need to fulfill basic requirements, such as adequate food, a place to rest between long shifts, protective equipment, and showers in the Corona Department for use after their shifts. Another level of insecurity was emphasized by the need for personal recognition from direct supervisors and from hospital management. We found, however, that these needs changed as the pandemic progressed. At the beginning of the pandemic, when work environments were subject to change and scheduling remained uncertain, basic needs and physical safety were emphasized. In particular, respondents noted a shortage of protective equipment. The rapidly changing situation and the lack of supplies at the beginning of the pandemic crisis increased feelings of insecurity and intensified the importance of basic needs. However, as the crisis evolved, the need for security at the physical level was supplanted by a basic craving for security at the psychological and spiritual levels: The respondents focused on interpersonal relationships with their peers and their supervisors and their need for appreciation from their colleagues within their Departments and beyond and from management. The focus thus transitioned from personal health and well-being to a sense of social belonging, a need for respect and appreciation, and even a sense of personal and professional self-fulfillment as predicted by Maslow's theory of needs [27].

Horesh and Brown [48] have encouraged trauma researchers "in the age of COVID-19" to employ all methods of scientific practice, including unique study designs and creative collaborations between disciplines with the aim to deepen the understanding of the health implications of the global coronavirus crisis. In particular, they indicated the need to develop novel methods for empowering and supporting medical personnel, as was done in the current study. Our status as researchers in the field of trauma and health and our particular, and perhaps unique, insider/outsider status as hospital personnel may raise questions about our specific situation and positionalities with regard to this study [46]. In response to such questions, we note that fieldwork, by its very nature, situates researchers among the community that they are researching, either as active participants or as observers or as a combination of the two [49]. As "researchers from within" [48], who are also HCWs, we felt obliged to study the experiences of HCWs in this unpredictable crisis. We were surprised by the high volume and the intensity of the traumatic experiences reported by the hospital personnel. We did not anticipate that HCWs who are accustomed to treating patients in the healthcare system would experience such insecurity and vulnerability. Importantly in this regard, we found that the anonymous qualitative interview—being conducted by skilled social workers—also served as a therapeutic tool and as a proactive means of communication with staff about their needs. The interviews enabled the HCWs to express their vulnerability and to acquire a sense of visibility and value. Brown [49] claims that vulnerability is the source of resilience and that vulnerability allows us to feel the emotions that we really crave—the need for human connection and the ability to belong and to "be seen" is something that every human being wants and needs. Brown holds that for us to be seen, we need to let others see us in a vulnerable state. Thus, the study framework—by enabling HCWs to express their concerns about "not been seen by friends or management" during the battle against the coronavirus—instilled a sense of confidence in the personnel with regard to their ability to communicate their vulnerability, needs, and concerns, particularly the need for personal and psychological security [49]. Bowlby [50], in his influential book "A Secure Base," expands on the need for psychological security when he states that a basic component of human nature is the need for intimate emotional bonds and attachment. By enabling the hospital personnel to give voice to their needs and their insecurities, the interview itself became an intimate and

emotional tool and a route of communication that ultimately allowed management to tailor various interventions to the needs of the employees and to increase the feeling of security in an extremely nonsecure situation.

Following the analysis of the data, the following practical interventions were developed by the hospital's Social Work Department:


The rationale for these interventions is embodied in the ideas of Santarone, McKenney and Elkbuli [51] that "maintaining the mental resilience of frontline workers involves offering solutions that allow them to perform their duties." The study showed that the interventions reinforced the concept of the hospital as a protective organization, learning from the knowledge and experience of its staff rather than making assumptions to define these needs. We note that the interventions were not the main intention of the research but evolved from the needs of the HCWs, as expressed in the interviews. The need to generate immediate solutions to an acute crisis informed our decision to conduct a qualitative narrative analysis study. Nonetheless, as a "side-benefit" we have accumulated rich data, which we are now analyzing in greater depth in a mixed-methods study.
