Introduction

During the SARS-CoV-2 pandemic (COVID-19) officially declared a "Public Health Emergency of International Concern" by the World Health Organization (WHO) [1] in May 2023, the accelerated imbalance between supply and demand in a short period particularly stressed healthcare services. Healthcare services became one of the key aspects to be evaluated during the pandemic and its subsequent evolution [2,3]. For healthcare workers (hereafter referred to as workers), stressful conditions were generated, such as the increased risk of infection inherent to their work, changes in their working conditions to adapt to the population’s demand, and difficulties due to the sanitary emergency measures.

In previous epidemic outbreaks, workers experienced increased psychological stress, anxiety, depression, and post-traumatic stress [4,5,6,7]. The COVID-19 pandemic has been massive and complex. For this reason, it is not surprising to witness a larger scale of these findings, which have been documented since the initial phases of the pandemic [8,9], including global systematic reviews [8,9,10]. In Latin America, the impact on workers' mental health could be even worse [11]. In general, female workers reported more negative mental health outcomes and a higher frequency of stressors during the COVID-19 pandemic [12].

This complex situation keeps a worldwide concern about the evolution of workers' mental health [13], together with the development of possible interventions [14,15]. Workers' stress levels have been observed to have decreased with the overcoming of the pandemic. However, it is essential to consider the negative effects in the medium and long term.

In a nationwide study in Chile [16] in mid-2020, several mental health disorders were reported in workers, with higher figures than those found in studies of the general pre-pandemic population [17,18]. Moreover, they are similar to those reported in workers during pandemics in other countries in the studies already cited [7,19]. It also documented higher substance use [20] and a considerable difference in the prevalence of depressive symptoms according to work status, affecting mostly non-professionals [21]. Many workers in Chile, especially women, experienced changes in their usual functions during the pandemic. A possible gender-mediated association between this change and depressive symptoms is proposed here [21].

There is a growing development of qualitative research on the effect of the pandemic on the mental health of workers. In general, these consist of surveys and interviews that took place in various countries to diagnose mental health problems and the needs of workers. They also evaluate workers' stress coping mechanisms or relatively structured organizational interventions [22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39].

A less explored area is the organization of care [40] during the pandemic, at the domestic and occupational levels, and its relationship with workers' mental health. Both in its paid and unpaid facets, caring for oneself and others seems to constitute a continuum of various risks, particularly for women with fewer resources. These situations have a potential impact on healthcare. For example, professional female workers had a disproportionate increase in caregiving responsibilities at home when schools and childcare services were restricted [41].

This study is innovative since it identifies additional factors that influence workers that have not been studied in our country. In addition, this information may help to improve support initiatives aimed at this population in the future. This paper provides a narrative description of the main findings, aiming to enrich the understanding of caregiving tasks based on the experience of workers and their relationship with their perception of their mental health during the pandemic.

Methods

The present study arises from The Health Care Workers Study (HEROES) initiative [42]. The Chilean team of the HEROES study worked on a qualitative approach to the phenomenon, trying to deepen the understanding of some findings of the national survey conducted [16] and to explore some issues not addressed so far.

A cross-sectional study was conducted with a thematic analytical approach [43], using semi-structured interviews based on three types of experiences defined a priori regarding the organization of care at work, the organization of care at home, and the relationship they perceive between both types of care and their own mental health. An initial script was constructed based on the quantitative results of the survey. This script was validated by expert judgment after internal piloting with workers. This analytical approach made it possible to learn about the experiences and feelings of the participants to find common patterns that were structured into themes and sub-themes.

The sampling frame for this study was the universe of workers from the national HEROES study database [16], which includes both clinical and non-clinical workers. Purposive sampling was performed, supported by the following three characteristics:

1. Sex: male/female.

2. Institution: primary healthcare center/hospital.

3. Professional level: professional or non-professional.

This scheme was replicated in the Metropolitan area and other regions to collect differential aspects. With this, 32 theoretical interviews were estimated for more than one participant per characterization.

Contact was made through e-mails from the database and randomly selected among those who responded. Trained students and professionals conducted telematic interviews that were transcribed verbatim. The interviews were conducted between May 13th, 2022, and June 2nd, 2023. Two researchers coded the information using data spreadsheets. With the semi-structured interview design, iteration of questions and responses was encouraged as they emerged, allowing for adaptation of the original script and reorganization of the data. The analysis was based on the method proposed by Clarke & Braun [44], using an inductive coding procedure, organizing themes related to the guiding questions and bibliographic background. The QDAMiner® software was used.

The confidentiality and privacy of the participants and the institution they belonged to were protected and only their type was recorded. The principal investigators kept the information anonymous. All participants underwent the informed consent process under a research protocol approved by the Ethics Committee of the Faculty of Medicine of the University of Chile.

Results

Thirty-five interviews were conducted. Table 1 shows the main characteristics of the participants, including the greater presence of women, participants from the Metropolitan Region, and types of hospital work.

The emerging theme of "beliefs and values in the context of the effects of the pandemic" was added to the three initially proposed themes within the interview script. Likewise, within the theme "organization of care at work," five sub-themes emerged and were included in the script’s adaptations as the interviews progressed. This classification can be reviewed in Table 2. We present a synthesis of the findings ordered according to these themes.

Organization of care at work

The first sub-theme is the change in the usual tasks of the interviewees in their jobs. All the people reported some relevant degree of modification of their daily tasks, from changes in shift rotation to changes in the place and population to assist, as well as various ways of carrying out an increasing administrative work. Some participants temporarily worked remotely. We reflect on the depth of these changes, the periods of great uncertainty, and the adjustments made over time. Participants agree that the situation did not have a significant financial impact, mainly due to full compliance with the contract.

As for work climate, there is consensus that the complexity of circumstances led to closer and more frequent relationships, especially among peers in the healthcare teams, which is positively valued. This was despite friction and fights within the teams and with other units. Participants report that the fear of being infected by another worker was a relevant element, which generated feelings of guilt and distrust among the teams.

When asked about the care received from the organization, depending on the type of worker, personal protection elements are generally well perceived in terms of coverage. Teleworking is then mentioned as a tool employed to care for more vulnerable personnel or their families. This is valued, although its implementation formats show degrees of heterogeneity. The reinforcement of jobs is also mentioned as a way to meet the needs of regular workers in the context of high demands for care. Different initiatives to collect information on workers' mental health are also mentioned, understood as an effort by the organization to take care of its personnel. Finally, there is a range of mental health interventions for workers, the most frequent being the availability of individual hours of access to psychological therapy and a range of collective interventions, including some usually considered "complementary" (Mindfulness, Bach flowers). There is a certain difference between people at a higher managerial level who have in-depth knowledge of the efforts made and some participants who, although they have notions about the initiatives, refer to a certain lack of knowledge in terms of their personal experience. There are also differences concerning those who had the right to access these initiatives, mainly due to the different contractual statuses of the workers.

The recommendations proposed by the participants to the organization address the shortcomings they detected in their work interventions. Regarding access to specialized care, they suggest that it should be provided within working hours by institutions outside the place of work.

From the perspective of institutional arrangements for dealing with pandemic-related mental health problems, gender differences emerge as a relevant and generally recognized element. The social structure, in terms of gender, is mentioned as an aspect that differentially affects mental health. Aspects of positive discrimination are indicated, such as the higher proportion of women who accessed telework because of child care, as well as negative discrimination perceived in relational problems of women exposed to task changes when interacting with older male bosses.

The personal experience of stigmatization and discrimination of healthcare workers during the pandemic period is mentioned, but it is not widespread, and there is no major account of actions taken by the institutional framework to deal with it. The contagion among workers was initially associated with non-compliance with the established standards and protocols, but this was diluted over time.

Problems in dealing with patients and relatives are mentioned. However, they are not considered relevant. In general, there is empathy with the initial anger of people regarding the implications of case contacts and the uncertainty regarding the evolution of the disease in the early stages. The absence of dialogue with sedated patients in primary care settings is also problematic. The specific dynamics of the relationship with higher authorities are described, highlighting the difficulties associated with following instructions from a centralized management and the impact of frequent rotation of authority figures in short periods. In addition, some professional organizational strengths are highlighted, particularly the development of teamwork "mystique" and resilience in an uncertain environment.

Organization of care at home

In general, different ways of modifying the organization of domestic work among the participants are described, depending mainly on who they live with (extended families, couples with child/children, single couples, people living alone) and on the need for care (mainly small children, but also older adults). The arrangements include divisions of tasks by mutual agreement, according to possibilities of interrelation with work activities, or even physical separations in response to labor demands. The evolution of these changes went hand in hand with the knowledge of the mechanisms of contagion and the measures of population restrictions imposed by the authorities during the period.

Caring for others is the central axis of domestic work. In this sense, the difficulty of visiting close relatives, sometimes outside the city, is a key factor in deciding to make this arrangement. This lasted for several periods, even longer than a year. The non-attendance of children at educational institutions due to imposed restrictions marks a particular dynamic in the compatibility of work and support in the learning process of minors in a context in which telematic classes were not completely adequate.

Similar to the organization of care at work, gender differences in the domestic sphere appear, although not in a generalized manner, alluding to the concept of the "double burden" in which, together with professional tasks, women are in charge of domestic work in practice. The mention of teleworking is valued positively by women, while at the same time, it is problematic for domestic care work.

Relationship with one’s mental health

Participants report a range of emotions related to the pandemic and various stressors. In general, they recognize some degree of mental health impairment. One of the most frequently reported emotions is anxiety related to the uncertainty of the early stages of the pandemic. Something similar occurs with ways of coping with the possibility of contagion, although it is recognized as exaggerated in retrospect. Different interpretations are also expressed regarding the work overload associated with an "epic" considered unique or special in work teams. Anger is occasionally mentioned without a specific object ("the situation") and sometimes directed at demanding patients or those who did not comply with rules regarding protection from contagion.

In addition, the development of mental health conditions among workers in the medium term is mentioned, mainly sadness and discouragement. It is also mentioned that the emotional process experienced during the pandemic triggered structural changes in personal and family life (cohabitation or marital status, organization of child or elderly care, diet, physical activity, etc.).

In general, participants recognize several factors related to mental health problems, with varying degrees of specificity. One of them is a change in their usual tasks. Both long working hours and increased shift frequency meant a medium-term stressor for some participants. On the other hand, assigning tasks with self-perceived deficiencies in required competencies was a common concern, especially during the first periods. Another source of negative emotionality mentioned was the restrictions of individual freedoms that required population measures.

The self-care spaces and/or protective factors mentioned are diverse. Although many do not openly state that they have carried out self-care activities during the pandemic, practices in this direction can be identified in their accounts. Among these are systematic physical activity (yoga, gym, walking), meditation spaces with a certain degree of structure, consumption of audiovisual content, seeking solitude, and disconnection from the news media or conversations about work. Meetings with groups of friends are also mentioned. Conversations with colleagues, especially those directly related to work, are also positively valued.

Other factors are recognized as elements that could help protect workers' mental health. Family support is mentioned, ranging from very concrete activities such as support in caring for others or active listening during family breaks to fluid communication remotely and various arrangements of family dynamics. Other initiatives on the part of the educational systems and the work organization itself are also considered beneficial for protecting mental health.

Beliefs and values about the pandemic and its effects

Participants share a variety of ideas and reflections on the pandemic’s impact on their mental health. A recurring idea is the widespread profound psychological distress among workers, albeit with varied individual responses. The importance of organizational culture in terms of resilience and sacrifice is highlighted, which could have led to postponing one’s health, especially mental health.

Additionally, it is observed that the initial uncertainty and disbelief about the implications of the disease and the social phenomenon evolved over time, from absolute denial of its existence to gradual acceptance through milestones such as the first infections, deaths, personal infections, population restrictions, and the demand for care.

A frequently mentioned element, with differences due to the personal characteristics of the interviewees, is the presence of some similarities with previous periods of social upheaval. In particular, reference is made to the military dictatorship initiated in 1973 and the months in which the recent social outbreak of 2019 occurred.

Finally, there are comments regarding how the pandemic showed equality among people in terms of vulnerability to the disease, regardless of their socioeconomic position. This finding is reported as surprising for some participants.

Discussion

In reviewing the findings, the assumptions regarding the various conditions of increased stress experienced by workers during the pandemic period included in the study are corroborated. At the same time, it confirms the existence of areas of the caregiving phenomenon that are worthy of study under the proposed categorization. This is because they would be relevant to the mental health of workers.

Regarding the area of institutional care, the generalized presence of changes in work tasks with diverse implications and the concern about contagion were widely present in the workers' experience, highlighting the collective "mystique" during that period. Other elements, such as experiences of stigma due to their condition as workers and conflicts with patients, were sporadic. As for domestic care, various arrangements were reported, with a strong determination by cohabitation with other people and their needs. This and the workplace dynamics made the "double burden" a relatively normalized situation in many cases.

The relationship between these aspects and mental health is perceived quite directly by workers and other unexplored factors. In general, the impact on mental health is clearly recognized, with stress derived from situations of change and uncertainty being the most common triggers for these problems. This stress is often linked to the perception of an increased workload. In addition, feelings of guilt or responsibility for possible contagion to family members are particularly relevant in this group and contribute to the deterioration of mental health. All this adds to the stressful situations that most of the population has faced.

Five elements that emerge from this work are interesting and deserve to be discussed and, eventually, deepened in future studies. Firstly, the female gender [4,12,45] firmly emerges in paid work care and, more subtly, in domestic care. The pandemic has been early identified as a major threat to gender equality, particularly for female healthcare workers [46]. Although it is possible to infer differential effects between men and women from the quantitative analyses known worldwide and in Latin America, as well as potential interactions with many variables [12,47], a qualitative approach such as the one used in this study is necessary. There are forms of gender segregation and inequity within healthcare systems that are well-known in the international literature. These forms were exacerbated during the pandemic and require innovative solutions [48]. This would allow us to examine aspects related to the processes that workers experienced during the pandemic, which participants reported at work and home.

Second, previous exposure to crisis situations could act as a protective factor [7,49]. Some participants addressed this situation by referring to the country’s recent history. This is relevant in medium- and long-term planning for new comparable situations, which are expected to become more frequent [50]. It is plausible to suggest that those who developed resilience competencies during this pandemic could be considered references in future situations. At the same time, a particular focus should be placed on younger workers, who may face a greater risk to their mental health.

On the other hand, self-care spaces are diverse. Self-care techniques have been recommended during the pandemic as a mental health tool for workers to help them process stress and anxiety [51]. Although not clearly recognized by workers, mental health self-care is imbued in the practice of different techniques that are not necessarily structured. This opens the possibility of interventions in this regard. It is important to highlight the barriers that may exist for a better development of this approach in the future.

Fourthly, the relevance of family and social ties in the construction of mental health is well known, highlighting the importance given by workers to the usually non-institutionalized spaces of "peer support" with their colleagues, which would account for a rather horizontal protective factor, which could have comparative advantages over other strategies. Although there are experiences of peer-based psychological support programs for workers, in the context of the great burden of stress they usually bear in specific services, there is little evaluation of their effectiveness even before the pandemic. It seems that for their adequate development, these programs should be accompanied by structural changes in the healthcare system as a whole [49].

Finally, it is essential to analyze the institutional response in addressing workers' mental health [50]. Several initiatives are mentioned, depending on the type of interviewee, generally evaluated positively. Some common difficulties in their implementation process are also identified. Considering the current state of the pandemic, the particularities of the organization of the Chilean healthcare system, the current political climate, and the possible changes to the healthcare system, among many others, these difficulties should be considered. These elements strongly impact the experience of workers. Moreover, they should be studied in depth to better understand them and, eventually, translate them into public policies.

Among the study’s limitations, and following the criteria of rigor in qualitative studies, we can mention two specific areas. Credibility is limited since the findings have not been triangulated with other sources. On the other hand, the generalizability of the results is also limited, although it is possible to transfer the findings, particularly those saturated in their content, to similar contexts. Despite the above limitations, both the profile of the interviewees and the findings are consistent with the researchers' experience.

Conclusions

The caregiving perspective is useful for studying the relationship between some stressors and healthcare workers' mental health in the context of the pandemic. Descriptive and systematized results are presented in terms of care at work and care at home, one’s relationship with one’s own mental health, and beliefs and values about the pandemic and its effects.