The authors have declared that no competing interests exist.
Novel virus outbreaks, such as the COVID-19 pandemic, may increase psychological distress among frontline workers. Psychological distress may lead to reduced performance, reduced employability or even burnout. In the present study, we assessed experienced psychological distress during the COVID-19 pandemic from a self-determination theory perspective.
This mixed-methods study, with repeated measures, used surveys (quantitative data) combined with audio diaries (qualitative data) to assess work-related COVID-19 experiences, psychological need satisfaction and frustration, and psychological distress over time. Forty-six participants (nurses, junior doctors, and consultants) completed 259 surveys and shared 60 audio diaries. Surveys and audio diaries were analysed separately.
Quantitative results indicated that perceived psychological distress during COVID-19 was higher than pre-COVID-19 and fluctuated over time. Need frustration, specifically autonomy and competence, was positively associated with psychological distress, while need satisfaction, especially relatedness, was negatively associated with psychological distress. In the qualitative, thematic analysis, we observed that especially organisational logistics (rostering, work-life balance, and internal communication) frustrated autonomy, and unfamiliarity with COVID-19 frustrated competence. Despite many need frustrating experiences, a strong connection with colleagues and patients were important sources of relatedness support (i.e. need satisfaction) that seemed to mitigate psychological distress.
The COVID-19 pandemic resulted in an increase of psychological distress among frontline workers. Both need frustration and need satisfaction explained unique variance of psychological distress, but seemed to originate from different sources. Challenging times require healthcare organisations to better support their professionals by tailored formal and informal support. We propose to address both indirect (e.g. organisation) and direct (e.g. colleagues) elements of the clinical and social environment in order to reduce need frustration and enhance need satisfaction.
In March 2020, the World Health Organisation declared the coronavirus disease 2019 (COVID-19) outbreak as a pandemic [
Based on previous research, there are strong indications that novel virus outbreaks may increase psychological distress among frontline workers during COVID-19. Emerging research on COVID-19 from several countries indicates that frontline workers report symptoms of depression, anxiety, and stress [
A useful lens to explore frontline workers’ experiences of psychological distress is self-determination theory (SDT). This theory on human motivation and socialisation distinguishes three basic psychological needs (i.e. autonomy, competence, and relatedness) that are essential for healthy development and growth [
Changing circumstances due to COVID-19, such as more shifts, new roles, and highly protocolled care, may impede psychological need satisfaction and may evoke psychological need frustration. Research indicates that need satisfaction and need frustration should be treated as different constructs [
To better understand these anticipated effects of the COVID-19 pandemic on frontline workers’ psychological needs and psychological distress, we conducted a mixed-methods study–with both quantitative and qualitative measurements. Combining quantitative and qualitative data is important to gain more insight into frontline workers’ experiences and perceptions in a dynamic and complex work environment. Specifically, in our quantitative study, we predicted a positive relation between need frustration and psychological distress (
We adopted an explorative longitudinal design with both repeated surveys (quantitative data) and audio diaries (qualitative data). Data were collected at six time points (T1, T2, T3, T4, T5, and T6) from April to November 2020. Frontline workers from two hospitals (one university medical centre and one general teaching hospital) in the Netherlands were recruited for participation in this study. Inclusion criteria were met if the participant was a consultant, junior doctor, or nurse, and worked on a ward or intensive care unit that provided care for COVID-19 patients. From April to May, participants were recruited via e-mail and by flyers on the wards by WEvdG, WFWB, EK, JET, and AJJL. If they were willing to participate, they contacted WEvdG and/or followed a web link to the first survey. All participants received an information letter about the study. An informed consent form preceded the first survey, in which participants indicated whether they would participate in the surveys only or both the surveys and audio diaries. After this survey, participants filled out a contact form for follow-up surveys and/or the audio diaries. The survey was designed by WEvdG, RJD, NWVY, ADCJ, and WFWB. The measures reported in this paper are part of this survey. Please refer to the supporting information for the survey items (
The Ethical Review Board of the University Medical Center Groningen gave approval for this study, because it did not fall within the scope of the Medical Research Involving Human Subjects Act (METc 2020/186).
Quantitative data were collected at all six time points (T1 –T6). Between April and June, participants received four surveys (T1 –T4) with an interval of seven days between each survey. In this period, regular, non-COVID care was largely downscaled in the participating hospitals. After the fourth survey, all participants received a digital voucher (€10) for their participation. In August, participants received the fifth survey (T5). At this time, non-COVID hospital care had mostly upscaled again. In October, participants received the sixth and final survey (T6). Around this time, the number of hospitalised COVID-19 patients was progressively increasing, accompanied by partial downscaling of non-COVID care.
The study population (N = 46) consisted of eight consultants (17.4%), 15 junior doctors (32.6%), and 23 nurses (50.0%). Participants were on average 35.4 years old (SD = 9.8), and 78.3% were female (n = 36). One participant withdrew their participation after T1. Thirty-seven participants completed all six surveys (T1 –T6), four participants completed five surveys, and four participants completed four surveys. Forty participants completed the last survey (T6). In total, we received 259 surveys, resulting in 6.16% (17/276) missing data. An additional number of 14 (5.41%) surveys did not include the basic need satisfaction and frustration scale, because this scale was only assessed if the participant had worked during the previous week (i.e. some participants were off-duty during one of the measurements). The completion rate was 88.8% (245 out of 276 surveys).
Descriptive data analysis was performed with SPSS version 26. We used MLwiN version 3.05 [
The qualitative data (audio diaries) were collected during the first four time points (T1 –T4). The participants were instructed to record 1 to 3 audio diaries per week over a period of four weeks (see
We used a constructivist perspective to analyse the qualitative data, assuming that each participant shared their perspective on reality [
Variable | M | SD | 1 | 2 | 3 | 4 | 5 | 6 | |
---|---|---|---|---|---|---|---|---|---|
3.48 | 0.67 | – | |||||||
4.02 | 0.57 | .24 |
– | ||||||
3.86 | 0.72 | .18 |
.25 |
– | |||||
2.13 | 0.73 | -.48 |
-.11 | -.22 |
– | ||||
1.93 | 0.68 | -.33 |
-.36 |
-.22 |
.27 |
– | |||
1.62 | 0.56 | -.23 |
-.18 |
-.57 |
.26 |
.24 |
– | ||
1.80 | 0.30 | -.25 |
-.19 |
-.26 |
.32 |
.36 |
.27 |
*
**
Our data were hierarchically structured, with six repeated measures (T1 –T6, Level 1) nested in participants (Level 2). We created seven null models (see
Our first hypothesis predicted a positive relation between need frustration and psychological distress (
Parameter | Model 1 | Model 2 | Model 3 | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
b | SE | t(42) | b | SE | t(42) | b | SE | t(39) | ||||
1.80 | 0.02 | 75.08 | < .001 | 1.80 | 0.03 | 66.70 | < .001 | 1.80 | 0.03 | 72.04 | < .001 | |
0.07 | 0.02 | 2.96 | .005 | 0.06 | 0.03 | 2.27 | .029 | |||||
0.13 | 0.03 | 4.68 | < .001 | 0.12 | 0.03 | 3.97 | < .001 | |||||
0.09 | 0.03 | 2.67 | .011 | 0.04 | 0.04 | 0.92 | .363 | |||||
-0.08 | 0.03 | -2.82 | .007 | -0.02 | 0.03 | -0.63 | .530 | |||||
-0.05 | 0.03 | -1.74 | .089 | -0.03 | 0.03 | -1.00 | .323 | |||||
-0.10 | 0.03 | -3.85 | < .001 | -0.07 | 0.03 | -2.33 | .025 | |||||
8.99 | 1.12 | 5.62 | ||||||||||
8.99 | 7.87 | 12.36 | ||||||||||
34.01 | 49.14 | 26.29 | ||||||||||
45.81 | < .001 | 30.68 | < .001 | 53.54 | < .001 | |||||||
7.73 | .052 | |||||||||||
22.85 | < .001 |
b = unstandardised coefficient, SE = standard error, t(df) = t-test statistic with degrees of freedom within brackets,
Second, we tested the variance in psychological distress that was explained by need satisfaction (
Third, we combined Model 1 and Model 2 to assess if frustrated and satisfied needs explained additional variance in psychological distress (
In our second hypothesis, we predicted that the level of perceived psychological distress among frontline workers was higher than before the COVID-19 pandemic
Measurement | N | Likert M (SD) | Bimodal M (SD) | Range | GHQ-score > 1–2 | GHQ-sore > 2 |
---|---|---|---|---|---|---|
T1 | 46 | 1.85 (.33) | 1.87 (2.28) | 0–9 | 6 (13.0%) | 13 (28.3%) |
T2 | 45 | 1.76 (.25) | 1.11 (1.51) | 0–7 | 7 (15.6%) | 6 (13.3%) |
T3 | 43 | 1.78 (.27) | 1.14 (1.70) | 0–7 | 7 (16.3%) | 7 (16.3%) |
T4 | 43 | 1.75 (.27) | 1.00 (1.61) | 0–7 | 3 (7.0%) | 9 (20.9%) |
T5 | 42 | 1.81 (.34) | 1.31 (2.07) | 0–10 | 6 (14.3%) | 8 (19.1%) |
T6 | 40 | 1.86 (.34) | 1.85 (1.99) | 0–9 | 8 (20.0%) | 12 (30.0%) |
N = number of participants, M = mean, SD = standard deviation.
Note that
Our thematic framework included six themes to categorise and describe the recordings, namely ‘autonomy support’, ‘competence support’, ‘relatedness support’, ‘autonomy frustration’, ‘competence frustration’, and ‘relatedness frustration’. Nearly all experiences illustrated an interplay between different needs. Therefore, we divided the results into need supportive and need frustrating experiences. Relatedness support was predominantly described in the need supportive experiences, while autonomy frustration and competence frustration were especially illustrated in the need frustrating experiences. In addition, the actors in need supportive and frustrating experiences differed. Need supportive experiences often included specific people (e.g. colleagues, patients, family members). Need frustrating experiences, however, often included COVID-19 itself, or groups as actors or systems (e.g. organisations, teams, or society).
In many need frustrating experiences, the unpredictable course of COVID-19 or organisational logistics played a role. In particular, the need for autonomy was frustrated, illustrated by participants who felt unable to support patients or organise their work effectively. Limited experience with COVID-19 (competence frustration) and frequently changing teams (relatedness frustration) further frustrated their needs. The use of personal protective equipment (PPE) complicated collaboration between colleagues or communication with patients and family members. Organisational logistics (e.g. work schedules, rules and regulations, communication) led participants to experience little control and influence over their work and work-life balance (autonomy frustration).
These worries increased when participants worked in frequently changing teams or when teams were stressed or frustrated. This hampered the connection and trust among colleagues. Some participants reflected that they needed some time to feel comfortable in a new role and new team. Others experienced more difficulty relying on the skills of colleagues they did not know, which impeded their feelings of trust.
Another example from a nurse illustrated how they felt helpless to comfort a patient who just returned from the ICU to the COVID-ward. This patient woke up panicked, and started to hyperventilate. Despite all their efforts, the doctors and nurses were unable to comfort the patient and take their shortness of breath and anxiety away. The nurse reflected afterwards:
This feeling of inability to comfort patients was strengthened by the use of PPE, which impeded contact and communication with patients, but also made daily care more tiring than normal: “
First, the strict visiting arrangements frustrated participants’ autonomy and competence. Many participants shared experiences where they needed to bring bad news. Normally, family members would visit the hospital for this and get the opportunity to say goodbye to their loved ones. During COVID-19, many participants had to bring bad news to family members under time pressure–because the patient deteriorated quickly and needed to be transferred to the ICU–and by telephone–because of the strict visiting arrangements: “
Second, limited involvement of the staff in organisational logistics especially frustrated participants’ autonomy. Many participants felt insufficiently involved in decision-making or incompletely informed by the organisation. Regulations from the hospital organisation led to (some degree of) uncertainty, unrest, or frustration for many participants. For example, it was unclear if or when participants would return to their own specialty to provide care for non-COVID patients. Some participants felt uncomfortable, useless or bored during quiet COVID-shifts with very few hospitalised patients. Multiple narratives included participants not being able to influence scheduling and rosters being available only last minute, in combination with frequently working on different wards with different teams. Some participants described a feeling of being ‘toyed with’:
When miscommunications occurred about such regulations, nurses and junior doctors experienced no choice but to accept it because they stood lower in the overall hierarchy. In one case, participants heard that they needed to take care of more patients in the near future. This resulted in doubts about the future quality of care and impaired work satisfaction of nurses:
In many need supportive experiences, a feeling of connectedness with colleagues, patients, or family members played a central role. It seemed that the need for relatedness was vital to cope with emotionally demanding situations, such as deteriorating patients or the changes and uncertainties that were caused by COVID-19. Relatedness satisfaction seemed to promote competence and autonomy in the workplace, possibly due to an open and positive atmosphere within teams. Examples of autonomy support were more implicit and often related to a sense of competence. For example, knowledge and practical experience of dealing with COVID-19 (competence satisfaction) stimulated participants to organise care for patients in a way they felt was best (autonomy satisfaction).
Although some participants, at first, felt incompetent to care for COVID-19 patients, their confidence was built through training, using protocols, and open consultation with colleagues. There seemed to be an increased level of equality among colleagues because everyone at times struggled with the unpredictable course or treatment of COVID-19. An open atmosphere and a strong team spirit made it easier to ask colleagues for advice, build trust in each other, and address areas of improvement in daily care. Moreover, participants felt free to share their expertise with colleagues from a different professional background.
The strong bond that participants felt with their patients seemed to stimulate autonomous behaviour. Participants used visiting policies, although they were strict and not always clearly communicated, to arrange short moments of contact between patients and their family members, or organised that patients were transferred to (rehabilitation) clinics near their families. They also used technical innovations, e.g. video calling, to establish valuable contact between patients and their families. As a participant (P6) stated,
In this study, we quantitatively assessed frustration and satisfaction of basic psychological needs, and psychological distress during COVID-19, and qualitatively explored experiences of frontline workers. Our results provide insights about different elements of the social environment that affected psychological distress among frontline workers. While frontline workers experienced need frustration and increased levels of psychological distress, relatedness support seemed to help them deal with the challenges of the COVID-19 pandemic. In many narratives, we observed an interconnectedness between needs. In the next paragraphs, we discuss both quantitative and qualitative findings, their meaning from a theoretical and empirical perspective, and the implications for practice.
The connection between quantitative and qualitative data yielded some interesting findings. COVID-19 resulted in an increase in perceived psychological distress compared to pre-COVID-19. Over time, 7.0% - 20.0% of participants experienced somewhat more psychological distress, and 13.3% - 30.0% of the participants experienced more severe levels of psychological distress. This is problematic, because these workers are at risk for mental health disorders [
Work-related autonomy and competence frustration were associated with higher levels of psychological distress, while work-related relatedness satisfaction was associated with lower levels of psychological distress. The qualitative audio diaries endorsed and strengthened these findings. However, the quantitative levels of autonomy and competence frustration were relatively low. One explanation may be that qualitative and quantitative measures tap into different experiences. The surveys focussed on overall frustration or satisfaction of work-related needs over the past seven days, while the narratives focussed on specific work-related incidents that provoked emotional responses. The narratives illustrate that especially the need for autonomy was frustrated during COVID-19, frequently in close connection with competence frustration. Competence frustration was often related to unfamiliarity with COVID-19. Through increased knowledge about and experience with COVID-19, frontline workers regained a sense of control and self-efficacy in their work. Nevertheless, contagiousness of COVID-19 and all precautions (e.g. PPE) that they needed to take impeded them to organise their work effectively. Frontline workers’ autonomy seemed frustrated most by organisational logistics. Frequent and last-minute changes in work schedules and unclear communication within the organisation limited their possibilities to manage their work-life balance, and decreased the stability within teams. Both the quantitative and qualitative data clearly suggest that support of relatedness is valuable to reduce perceived psychological distress among frontline workers. Relatedness support, especially by colleagues, seemed vital to cope with emotionally demanding situations or work-related challenges during COVID-19. Often, relatedness support seemed to act in a reciprocal way. Frontline workers in our sample also supported relatedness of their colleagues’ relatedness (e.g. provide help, share experiences), patients, or family members (e.g. take time to connect and talk).
Our findings illustrate that both need satisfaction and need frustration explained unique variance in psychological distress, specifically autonomy and competence frustration, and relatedness satisfaction. The effects of relatedness frustration, and both autonomy and competence satisfaction were less clear in our quantitative data, but our qualitative data suggest that these variables may also play a role in explaining psychological distress in our sample, although less obvious. Our findings add to the growing body of SDT literature that also takes the role of need frustration into consideration [
An important contribution of our findings to recent empirical studies is the combination of qualitative and quantitative data assessed multiple times, while many recent studies are cross-sectional and quantitative in nature [
Psychological distress among frontline workers is problematic and requires attention from healthcare organisations to reduce the burden on the clinical staff during a pandemic [
In addition, our findings illustrate that need support is frequently impeded and need frustration is evoked. To better support professionals’ autonomy, organisations need to become more flexible and responsive to their staff. Most importantly, the crisis management team(s) should actively collect and be responsive to feedback from professionals regarding the management of the crisis, work schedules (e.g. shifts, hours, professional roles), workload, work-home balance, and emotional demands of the crisis. We suggest creating stability within teams and providing flexible training and education when new insights arise in treatment and for new team members joining the team later on. This helps to promote professionals’ competence and to foster reciprocal relationships and belongingness within teams. Especially in an intermittent crisis, where successive waves of increased infection rates alternate with catching up with regular care, it is vital that organisations provide all the support they can to professionals to keep their work balanced and keep them psychologically healthy and engaged. These changes should be developed, evaluated and incorporated continuously to make healthcare organisations ready to act, not only for the next COVID-19 wave, but also for future challenges and healthcare crises that may severely impede professionals’ well-being.
Early in the pandemic, we were able to collect experiences from frontline workers in a time-efficient manner. With audio diaries, participants could spontaneously record and share work-related experiences with their own devices. These recordings were not guided to fit a particular perspective and were recorded shortly after the experience, thereby preventing recall bias [
We used SDT’s basic psychological needs for both our quantitative and qualitative analysis. This provided valuable insight into frontline workers’ experiences. To prevent a too narrow thematic focus by our theory-driven qualitative analysis, we started with an inductive analysis. Through frequent team discussions and memo writing, we created a thorough overview of the dataset. The subsequent deductive thematic analysis provided a focussed description of the basic needs, wherein the role of the work environment was taken into consideration. Moreover, the research team included diverse professional backgrounds. This promoted reflexivity to interpret the findings from a theoretical perspective as well as for clinical practice. While a different theoretical lens or analytical approach may have resulted in different findings, we believe that the results represent the data in a theoretically and practically valuable way.
Our relatively small quantitative sample size and nurses’ overrepresentation in our audio diaries limit the generalisability and transferability of our findings. The reliabilities of our need satisfaction and frustration scales were poor for autonomy and competence support. Moreover, a full multilevel analysis requires a larger sample size. While our qualitative dataset was sufficient for thematic analysis, these results were mainly based on nurses’ and, to a somewhat lesser extent, junior doctors’ experiences, but did not seem to encapsulate consultants’ experiences. Therefore, our results remain exploratory in nature. Future research is needed to assess the unique value of each predictor variable on psychological distress.
Our study illustrates that both psychological need frustration as well as psychological need satisfaction are needed to effectively investigate frontline workers’ psychological distress. Different methods shed additional light on the elements of the direct and indirect social environment that influence need satisfaction and need frustration of people in complex and dynamic naturalistic settings. Challenging times, such as COVID-19, require healthcare organisations to better support their professionals by tailored formal and informal support networks.
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Instructions and prompts for participants to record and share their entries.
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The six steps of thematic analysis and the reflexivity paragraph.
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We would like to thank dr. A. Niemeijer, statistician of the scientific institute of the Martini Hospital in Groningen, for her invaluable statistical help and advice on the multilevel analyses. We also want to thank all nurses, consultants, and junior doctors who participated in the study and shared their experiences.