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Abstract

As HIV/AIDS health care workers (HCWs) deliver services during COVID-19 under difficult conditions, practicing trauma-informed care (TIC) may mitigate negative effects on mental health and well-being. This secondary qualitative analysis of a larger mixed methods study sought to understand the pandemic's impact on HCWs at Ryan White-funded clinics (RWCs) across the southeastern US and assess changes in prioritization of TIC. RWC administrators, providers, and staff were asked about impacts on clinic operations/culture, HCW well-being, institutional support for well-being, and prioritization of TIC. HCWs described strenuous work environments and decreased well-being (eg, increased stress, burnout, fear, and social isolation) due to COVID-19. RWCs initiated novel responses to disruptions of clinic operations and culture to encourage continuity in care and promote HCW well-being. Despite increased awareness of the need for TIC, prioritization remained variable. Implementing and institutionalizing trauma-informed practices could strengthen continuity in care and safeguard HCW well-being during public health emergencies.

Plain Language Summary

Study about the impact of COVID-19 on the well-being of Ryan White health care workers in the southeastern United States and the role of trauma-informed care

This qualitative study aimed to understand COVID-19's impact on HIV/AIDS health care workers (HCWs) at Ryan White-funded clinics (RWCs) across the southeastern US and to assess changes in prioritization of trauma-informed care (TIC). COVID-19 created difficult working conditions for HCWs, and TIC is an evidence-based framework for delivering services that may reduce negative effects on their mental health and well-being. RWC administrators, providers, and staff were interviewed and asked about how clinic operations/culture, HCW well-being, institutional support for well-being, and prioritization of TIC have changed. HCWs described more challenging work environments and poorer well-being (eg, more stress, burnout, fear, and social isolation) due to COVID-19. However, prioritization of TIC varied despite increased awareness of the need for it. This study identified new and innovative ways that RWCs adapted in response to pandemic conditions. Implementing and institutionalizing trauma-informed practices could strengthen continuity in care and protect HCW well-being during future public health emergencies.

Keywords

health care workers well-being COVID-19 HIV/AIDS Ryan White

Introduction

The SARS-CoV-2 (COVID-19) pandemic has raised global awareness of the increased burden on health care systems and its ill effects on the mental health and well-being of health care workers (HCWs).¹ In health care literature, well-being is most often conceptualized as being related to negative moods or emotions, such as burnout–²an occupational phenomenon characterized by emotional exhaustion, depersonalization, and low personal accomplishment.^3–5 Prior to the pandemic, burnout was reported by 35-54% of physicians and nurses.^6–14 Less is known about burnout among other HCWs, who have considerable direct engagement with patients and may be at highest risk.¹⁰ However, the COVID-19 pandemic is a collective trauma that has likely exacerbated baseline burnout among HCWs globally,^15–17 with perhaps greatest impact on resource-strapped clinics caring for the most vulnerable.

In the United States (US), Ryan White-funded clinics (RWCs) provide care for un/underinsured people living with HIV (PLWH), many of whom have complex psychosocial health needs, and who report a disproportionately higher burden of trauma and mental health adversity than the general population.^18–28 These factors are associated with worse engagement in and adherence to HIV care and poor clinical outcomes.^{19,22,25,28–38} Addressing the psychological needs of PLWH is particularly challenging in the southern US, as many PLWH experience the intersectional impact of poverty, un/underinsurance, racism and discrimination, isolation, poor social support, and limited availability and utilization of mental health services.^5,39–51 These circumstances, compounded by COVID-19,^47,52,53 may not only negatively impact patients’ holistic well-being but also fuel burnout among HCWs, due to the increased time and effort required for comprehensive promotion of physical and psychological health among PLWH.

Little is known about the psychological health and wellness of HIV HCWs during the COVID-19 pandemic.⁵⁴ One peer-reviewed study examined factors contributing to mental health disorders, psychological distress, and burnout among this population in China^55–57 and another assessed mental health outcomes and associated factors among HIV HCWs in Mali.⁵⁸ In the US, the Kaiser Family Foundation (KFF) released a survey report pertaining to the pandemic's impact on RWC service delivery and their clients, though HIV HCW well-being was not a main focus.^59,60 To our knowledge, effective strategies to prevent and address COVID-19-related burnout among this population are yet to be determined.

Thus far, studies of HCWs have primarily explored individual-level rather than multi-level factors contributing to burnout and well-being.⁶¹ Trauma-informed care (TIC) is an evidence-based multi-level care framework developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) for comprehensive service delivery, prioritizing incorporation of self-care and other staff support practices in clinical care settings.⁶² TIC is a cost-effective approach that has been shown to improve patient outcomes and increase staff morale,^63–66 and has potential to reduce burnout among HCWs in health care settings serving patients with complex needs (eg, RWCs).⁶⁷ Using a trauma-informed approach involves adherence to six key principles: 1) prioritizing physical and psychological safety throughout the organization; 2) operating in a transparent and trustworthy manner; 3) encouraging peer support among those with lived experiences of trauma to aid in recovery; 4) promoting collaboration across the organization; 5) empowering clients and staff to facilitate healing; and 6) addressing racial, ethnic, and cultural needs, as well as historical trauma.⁶²

To effectively implement TIC, action is required across ten evidence-based domains for organizational change: 1) leadership engagement and investment in TIC; 2) establishment of a trauma-informed approach in institutional protocols and policies; 3) cultivation of a safe and supportive physical environment; 4) involvement of people with trauma histories or exposure to trauma in the development, implementation, monitoring, and evaluation of programs and services; 5) collaboration across sectors to address the complex needs of people with histories of trauma; 6) provision of trauma screenings, assessments, and services; 7) workforce development, training, and employee assistance in the areas of trauma and peer support; 8) continued monitoring of trauma-informed principles and practices; 9) financial support; and 10) trauma-informed evaluation of programs and services using trauma-oriented data collection tools.⁶²

Between December 2019 and April 2021, we undertook a cross-sectional, explanatory sequential mixed methods study aiming to quantitatively and qualitatively identify contextual factors associated with adopting and implementing TIC in RWCs across the eight states that comprise the southeastern US (Department of Health and Human Services Region IV: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee). As data collection for our qualitative aim coincided with the outbreak of COVID-19, we adapted our study to also explore the impact of COVID-19 on RWCs, HCW well-being, institutional support for well-being, and prioritization of TIC. This paper presents findings from that secondary qualitative inquiry.

Methods

The consolidated criteria for reporting qualitative research (COREQ)⁶⁸ guided the reporting of this investigation.

Study Design and Context

This secondary analysis of qualitative data derives from a larger explanatory sequential mixed methods study of TIC adoption and implementation in RWCs across the southeastern US. The first phase of the parent study consisted of an HCW self-administrated online survey to ascertain TIC knowledge, attitudes, and practices, as well as current HCW perception of clinic-level implementation of TIC. Semi-structured, in-depth interviews were conducted with purposively sampled HCWs who had first completed the online survey and then indicated willingness to participate in an individual interview. Qualitative data collection had just begun when COVID-19 emerged in the US. The study team recognized the potential impact the pandemic could have on the study population and their clients, as well as the unique opportunity to collect data about experiences implementing and providing TIC in real time during a pandemic. In response, we added a COVID-19 section to the interview guides to capture the psychosocial experiences and perceptions of RWC administrators, providers, and staff as the pandemic unfolded.

Recruitment

Recruitment was conducted using several methods: 1) distributing flyers at in-person national and local Ryan White conferences and meetings; 2) engaging state and local Region IV Ryan White program coordinators, who agreed to disseminate study information and promote the survey to their clinics and networks through their institutional listservs and newsletters; and 3) using the Ryan White website to identify Region IV RWCs in states and areas with low response rates for targeted outreach (ie, phone calls and follow-up emails to the office manager or Ryan White program coordinator) to encourage participation from HCWs in those places. Participants were offered $30 in compensation for completing the online survey.

Administrators (ie, leadership), clinical providers (ie, physicians, nurses, and paraprofessionals), and staff (eg, social workers, patient/peer navigators, and office/reception workers) in Region IV RWCs were eligible to participate in the study. Participants affirmed their eligibility in the online survey by reporting details about the RWC where they worked, its location, and their role. A total of 321 administrators, providers, and staff representing 46 of the 136 study-eligible Region IV RWCs completed the online survey. Upon completion of the survey, respondents were asked if they would consent to be contacted to participate in a phone interview. Those responding “yes” comprised the qualitative sampling frame. Among all survey participants, 200 consented to be interviewed; those selected were invited to participate via their preferred method of contact (ie, email or phone).

Using the sampling frame, potential interview participants were stratified into two groups by role (ie, administrator and provider/staff). Recruitment was conducted purposively, and the study team made extensive outreach efforts in an attempt to capture the diversity of experience across HCW roles by setting (ie, state, urbanicity, and clinic type), gender identity, race and ethnicity, and level of TIC implementation reported in the survey. Before being interviewed, the participants were informed of the study purpose and objectives by the interviewers before providing verbal consent to take part in a 60-minute interview in the presence of a note taker and to be audio-recorded. Participants were offered $50 gift cards in compensation for completing the interview. Information about emotional support services and resources was provided to participants who requested it and to those who experienced distress during the interview.

Between March 2020 and February 2021, 38 in-depth interviews were conducted, at which point, data collection ceased when the study team determined that saturation had been reached because no new information was emerging from the data. Of these, seven participants were excluded from the present analysis of COVID-19-related impacts on RWCs: five were interviewed before the pandemic-related questions were added to the guide, one did not complete the interview and COVID-19 questions, and one did not consent to be audio-recorded.

Qualitative Data Collection and Analysis

Two interview guides (administrator and provider/staff) were developed based on the five domains of TIC organizational self-assessment (Staff Development, Safe and Supportive Environment, Assessing and Planning Services, Patient Involvement, and Policy Adaptation)⁶⁹ and the five domains of the Consolidated Framework for Implementation Research (CFIR; Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals, and Process)–a multi-level framework for assessing organizational readiness.⁷⁰ Interview guides were pilot-tested with the first five participants (13% of the total interviewed) and modified to include COVID-19 questions prior to the start of interviewing. COVID-19-related questions addressed changes to RWC operations and culture, HCW well-being, institutional support for well-being, and prioritization of TIC.

Interviews were conducted and audio-recorded using a secure Zoom videoconferencing account. Recordings were professionally transcribed verbatim by a third party. Study team members cleaned and de-identified the transcripts. MAXQDA 2020 (VERBI GmbH, Germany) software was used for qualitative coding and data analysis.

Data analysis was conducted using a framework-driven, thematic approach. The study team developed a COVID-19 codebook, consisting of deductive and inductive codes. Deductive codes were derived from SAMHSA and CFIR construct definitions, as well as questions related to the impacts of the pandemic. Inductive codes were developed through a collaborative, iterative process of close reading of transcripts and memo-making, as well as discussing, drafting, and modifying code definitions until the team was satisfied with the codebook's overall structure and contents. We then tested the codes by applying them to a subset of interview transcripts, performing coding checks, and refining inclusion and exclusion criteria for codes. Once the codebook was finalized, all transcripts were coded independently by two study team members. Coding pairs then performed full intercoder agreement by comparing their coding and discussing any discrepancies. A third study team member resolved any remaining disputes in coding, and consensus was reached in all cases. We then examined the coded data to identify and explore both anticipated and emergent themes salient to understanding COVID-19's impact on RWCs and HCW well-being.

All team members involved in data collection (CWK and OCM) and analysis (CWK, OCM, and KMA) identified as female and were in possession of masters (MPH) and/or doctoral (PhD) training in public health, including coursework and experience in qualitative research methods and data analysis. JMS and ASK served as co-principal investigators, OCM was the qualitative research manager, and CWK and KMA were doctoral students at the time of the study.

Ethical Approval and Informed Consent

The Emory University Institutional Review Board approved this study (IRB 00114750). To participate in the study, all study participants completed an e-informed consent, agreed to be contacted for interview at the time they completed the online survey, and provided oral consent to participate in the in-depth interview, as well as for the study team to audio-record their interview. Participants were offered compensation for their time at each phase of the study.

Results

Interviews averaged 117.8 minutes (median: 80; range: 44-137) in duration. Of the 31 participants, there were 8 (26%) administrators, 13 (42%) providers, and 10 (32%) staff members, representing 18 clinics. Interviewees predominantly identified as White (n = 23, 74%) and female (n = 19, 61%). Most worked in hospital-based HIV/infectious disease (ID) clinics (n = 18, 58%) and in urbanized areas (n = 27, 87%) (Table 1).

Table 1.

Participant Characteristics by Primary Role (N = 31).

	Administrator(n = 8)	Provider(n = 13)	Staff(n = 10)	Total(N = 31)
Age in years, mean (SD)*	35.3 (8.5)	42.8 (7.8)	45.6 (9.7)	41.7 (9.2)
Clinic tenure in years, median (IQR)	5.0 (7.0)	6.0 (11.5)	5.5 (6.0)	5.0 (8.0)
Clinic type
Community-based clinic, federally qualified health center, or health department	2	1	1	4
Hospital-based HIV/ID clinic	2	10	6	18
Specialized stand-alone care	4	2	3	9
Gender**
Male	2	3	4	9
Female	5	9	5	19
Transgender or gender queer	0	1	1	2
Race
Black/African American	0	1	4	5
White	7	11	5	23
Multiracial	0	1	0	1
Unknown/not reported	1	0	1	2
Ethnicity***
Latino/a/x	1	1	0	2
Non-Latino/a/x	6	12	9	27
State
Alabama	1	1	1	3
Florida	2	0	1	3
Georgia	2	3	3	8
Kentucky	1	1	1	3
Mississippi	0	1	0	1
North Carolina	1	4	3	8
South Carolina	1	0	1	2
Tennessee	0	3	0	3
Urbanicity
Rural (<2500 people)	0	1	0	1
Urban cluster (2500-49 999 people)	1	2	0	3
Urbanized area (≥50 000 people)	7	10	10	27

Note: In this table, means and standard deviations (SDs) are reported for continuous variables with normal distributions, while medians and interquartile ranges (IQR) are reported for continuous variables with non-normal distributions. Categorical variable frequencies (n's) are also reported. Due to missing survey data, some variables have an n less than the overall total number of participants (N = 31). *Age has an n of 27 (missing responses from one administrator, one provider, and two staff members). **Gender has an n of 30 (missing one response from a staff member). ***Ethnicity has an n of 29 (missing responses from one administrator and one staff member).

RWC Administrator/Provider/Staff Well-Being

Participants reported experiencing increased stress, burnout, and fear due to COVID-19. HCWs’ concern for others, operational challenges, and social isolation and lack of public support further contributed to their decreased sense of well-being (Table 2).

Table 2.

Exemplar Quotes of RWC Administrator/Provider/Staff Well-Being by Theme.

Themes	Quotes
Increased stress(eg, more sources of stress, higher level of stress, increased anxiety, and collective stress)	Nobody's sleeping very well including me. People are having COVID dreams [laughs]. People are stressed about balancing, juggling the working and the homeschooling [of] their children, and … being emotionally available to their families, and not getting COVID, and not bringing it home to their families, and dealing with anxious spouses, and you know, all that kind of stuff … it's definitely been really stressful, especially because of all the changes that have happened so rapidly at work, and the new tasks, and things that we’re being asked to do. It's just– it's just been quite unsettling. (P-205)
	I think [COVID-19 has] led to a lot of anxiety for sure. Early on in the pandemic, I would spend time after clinic to address like nursing staff, answer questions. I provided them with my cell phone number and would field calls with case managers, social workers, nurses, who had concerns about anything ranging from potential exposures to concerns about going grocery shopping, or just as a resource to them. But it definitely, I think, has made everyone anxious. (P-117)
	I don’t know that we’re burned out but I think just the levels of stress that all of us experience–including our patients–is just higher than I think I’ve ever seen it. And it's collective, right? Like often in the past, one of us is going through a stressful thing, and now all of us are going through these really stressful events. And the sort of collective stress, which is very different than one or two people on staff being stressed or challenged by something. (P-434)
Burnout(eg, feeling tired, overwhelmed, or exhausted due to overwork or lack of relief; and prevention or mitigation of symptoms)	It helps that we’re really busy because we’re not sitting around dwelling. But it also is exhausting. We’re tired at the weekends. We all talk about–we joke–how we all binge-watch TV all weekend long. Because you know, we’re exhausted…. (A-498)
	I haven’t had any time off since Christmas. And you get tired, you know, you need a break from the trauma. And I don’t foresee–I don’t know when I’m gonna take any real time off right now because–just ‘cause–we’re just not at a point where we can do that. And so I think it's had a little bit of an impact there on just feeling really just drained, emotionally…. (P-057)
	… some of the work can be done from home and I think that in terms of mental health and preventing burnout um, it would be helpful for our staff to be able to do that more often … Um, because it kinda limits the given stressors of just having to go into the office sometimes um … and it allows you [to] just like work in a more relaxed state. (A-487)
	… I think like every job, especially in the medical field, HIV-related or not, there's burnout … For my team I would say burnout more so occurs like from the amount of weekend work or evening work that we do … Events, testing events out in the community prior to COVID that would be more of a cause of burnout. (A-513)
Fear(eg, feeling afraid due to risk of exposure or transmission and experiencing uncertainty due to changing circumstances)	… if you’re not seeing patients, then you’re not charting anything so I’m not getting anything from the charts … So, what does this mean for me overall? So, I’ve come to just be expecting of being on furlough or something of that [nature]…. (A-470)
	… the calls [patients are] making, some people seem to be a lot less nervous … Very aware that they’ve opened a lot of stuff up here too. So the more I think, I think because the media is starting to show that they’re opening things up, people are less scared … I think health care workers are a little bit more scared now. (A-498)
Concern for others(eg, worries about high-risk patients, reduced quality of patient care, disruptions to routine and preventive care, patients falling out of care, exposing friends and loved ones to COVID-19, and rising death toll)	… we have to isolate because we know we care for a high-risk population. Most of us are not really doing any social things outside of work. So when we go home on the weekends, most of us are in for the duration of the weekend and that's–so that's tough mentally to be isolated from your family and the people you love. (P-345)
	… [licensed practical nurses] are doing most of our testing as far as COVID. So they’re seeing COVID patients who possibly could be positive, who possibly could be negative, on a daily basis, and testing sometimes five and six patients a day…if not more than that, depending. And so that, too, can be mentally draining, because you never know if you’re packing it home to your family. One LPN that's in our clinic has an elderly mother, so he's staying at a hotel now, away from his mom. (P-481)
	And then a sort of feeling of, ‘Well, wait, aren’t we supposed to be committed to our HIV patients?’ … And … shifting of visits to other providers who don’t know those patients is something that we’ve all been stressed about because our leadership seems to think that's no big deal but we all feel very invested in our patients. (P-205)
	… I do get concerned ‘cause I’ve had a lot of patients who have continued to want to do telemedicine but then they’re not getting their blood pressure checked. They haven’t gotten their flu shot. They’ve had new sexual partners but we haven’t been able to screen them for STIs. (P-113)
	I think as providers, they’re really concerned and probably feeling a certain way because their patients are … sometimes out of care because of situations happening, such as this. And then also, the patient who will just forget about it. If I can’t go into the doctor's office, then just forget about it. I’m not getting in front of a camera, I’m not getting–you know. I’m not getting on the phone. So, the impact is very, very, very hard. (A-470)
	We do a staff meeting once a month, and in doing our staff meeting, we put the names of all the people that we have lost in that months’ time … we also give a moment for whoever wants to, to say something about the members on that list, the person on that list. And you know, sometimes the list is very short, maybe one or two people. Unfortunately, with COVID, the list is growing. (A-348)
Operational challenges(eg, difficulty adapting, lack of communication or transparency from leadership, and staffing issues)	… back in March, it was pretty frustrating because I felt like our institution was maybe a little bit behind and they weren’t taking some of the proactive steps like the neighboring hospital. And so knowing that, that … lack of quick response behind the scenes was happening but then also trying to reassure our patients that it was going to be okay and if they were taking the proper steps to protect themselves, they should be fine. So there was a lot of like internal … turmoil for myself … just having those two experiences happen simultaneously. Like wanting to be calm and reassuring for the patients when they’re calling in but then knowing behind the scenes that we’re kind of scrambling to figure out what to do. (S-466)
Social isolation and lack of public support(eg, loss of social connection and sense of community in the workplace, physical separation from colleagues, and public opposition to protective public health measures and policies)	… it has made me, at times, feel like I am just a workhorse of the institution, and not necessarily like a participant in it. So you know, part of what makes our work rewarding is that camaraderie and that sense of community that we oftentimes get with our fellow colleagues. And so with COVID, you know, our lunch hours together are now in isolation. And some of us are working from home, and we don’t get to see each other. And so it makes you feel like your job is really just the clinic visit. And the clinic load. Does that make sense? (P-168)
	… as a social worker, I didn’t realize not being able to touch some of my colleagues … really affects me. I didn’t realize that not being able to hug my supervisor, you know, when something's going on … it has affected me dramatically. I–I didn’t think about it, that it would but it does. (P-223)
	Morale is low. People are tired. We live in a state [where] the governor won’t have a mask mandate. There's a lot of parents that are struggling with childcare and virtual homeschooling. One of our nurse practitioners, I asked her how she was doing when they announced virtual school was going longer and she burst into tears. (P-113)
	I’m a mess, I just can’t hardly stand it so I just don’t go out, you know. And our brilliant governor just removed the mask mandate about two weeks ago and our numbers are still continuing to go up and I just don’t understand. There was no clear explanation. (P-345)

Note: Quotes appear in the order in which they are referenced in the results.

Increased Stress

Overall, HCWs experienced a significant increase in stress. As one RWC staff member estimated, “… the stress level is like–what–10 times bigger if not 20 [compared to before the pandemic]?” (S-484) Sources of personal stress included concerns about being at higher risk of exposure to COVID-19 at work, potential ramifications of being exposed to and contracting COVID-19, and work-life balance. Work-related stress was attributed to clinic policies and protocols changing, roles and responsibilities shifting, and routines being disrupted. (Table 2; P-205) This experience was pervasive, regardless of clinical role. (Table 2; P-117) HCWs recognized commonality in the challenges they faced. Not only did they experience stress individually but also collectively when other members of their team were affected. (Table 2; P-434)

While some HCWs were able to work remotely, those required at the clinic faced unique stressors, such as taking on extra work to cover for at-home, sick, or medically vulnerable colleagues. These conditions were “taxing,” (P-158) “put more clinic demand” (P-168) on people in the building, and were a source of dissatisfaction. As one provider noted, introducing telework opportunities at the clinic “created some stress within the clinic in staff who cannot work from home some days, such as nurses, because they feel like they are taking over the work of the [advanced practice provider] who's working at home.” (P-043)

Burnout

HCWs also reported high levels of burnout as a result of the pandemic. Feeling tired, overwhelmed, and exhausted was commonplace. (Table 2; A-498) Some HCWs recognized changes in behavior or ability to function in themselves and their colleagues. As one provider observed, “Some of us are overwhelmed…some of us may not be optimal at, you know, communicating like we normally would be.” (P-465) Others noted changes to colleagues’ personalities, “mannerisms and their behavior, and temperament.” (A-348)

As the pandemic progressed and they lost an increasing number of patients to COVID-19, some HCWs experienced compassion fatigue: “I mean my staff and I cried for days … it burns people out … you have a heart for doing good, and wanna do good, and you wanna see a result from your good but that doesn’t always happen, because you have no control of how that person receives it or what they do with it. And it gives you … first responders something-something. And basically, it drains you.” (A-348)

Yet more often, HCWs cited structural and leadership challenges as causing burnout. Feelings of burnout were “more around the bureaucracy of the system” (P-057) and “…a lack of communication from the top to the bottom…that can cause a lot of stress in our agency at times and that could lead to burnout and frustrations.” (S-504) Not being able to take leave was also commonly cited as a source of burnout. (Table 2; P-057)

In some cases, feelings of burnout were mitigated by how clinics responded to COVID-19. As one administrator noted, “So it's warped how we kind of conduct business … but also, I think it has kind of eased some of that burnout, at least temporarily … because at least right now we’re operating under a kind of … do the best you can kind of a thing instead of, you know, meet this deliverable or else sort of idea.” (A-487) Additionally, the ability to work remotely benefited some affected individuals, removing them from a stressful environment. (Table 2; A-487) At times, COVID-19 forced clinics to halt activities that previously contributed to burnout among HCWs, which lowered the workload and provided some relief to HCWs. (Table 2; A-513)

Fear

Many HCWs described experiencing fear due to COVID-19 and were particularly concerned by exposure at work. As one provider explained, “… there's definitely a lot of anxiety. Every time someone comes in who's sick and has to get swabbed for COVID, everyone's waiting to see if they get sick.” (P-113) Several participants described being “on high alert” (A-348) because colleagues were getting sick and changing how they interact within the clinic environment to minimize their risk. As one provider explained, “… I think the anxiety about–am I gonna get sick at work or am I gonna make somebody sick at work? I think has been heightened … we’re trying to avoid too much touch, and we were touchy people, you know, before. So that is just a big change for us.” (P-345)

Additionally, HCWs experienced fear due to uncertainty COVID-19 created, worrying about retaining their jobs. (Table 2; A-470) Some found themselves taking on roles and responsibilities at work they were not used to performing. As one provider explained, “We promised that we’re gonna staff the mobile integrated health units. So now we need people who are willing to just go into people's homes and ride with the paramedics when, you know, it's just nothing like what we’ve done before … And so, it's just change. Change is scary.” (P-205) HCWs also struggled with navigating waves of COVID and the re-opening of states as the general public became less concerned with the virus and began to take more risks. (Table 2; A-498)

Concern for Others

The emotional well-being of HCWs was tied not only to challenges adapting to pandemic conditions but also concern for others’ well-being. HCWs generally acknowledged that they were at higher risk through patient care, and despite preventive measures they were taking, worried about exposing family members to the virus: “I take all precautions to prevent from getting sick … but I’m kind of resigned … like, if I get sick, then what can I do? … I do worry about my kids getting sick or my husband getting sick.” (P-043) Some felt the need to take extra precautionary measures to limit their interactions, at times to the detriment of their own emotional well-being, (Table 2; P-345) including living away from home to protect high-risk family members. (Table 2; P-481)

Generally, there was widespread concern about quality of patient care and continuity of care during the pandemic, especially among providers. As many providers assumed additional roles and responsibilities, separating them from their patients during the pandemic, they worried their patients’ needs might get lost in the shuffle of task shifting (Table 2; P-205). And while the transition to telehealth was generally viewed positively, providers worried that their patients were not receiving comprehensive care (Table 2; P-113), would not adapt well to remote care, or might fall out of care completely. (Table 2; A-470)

These concerns took an emotional toll on HCWs, especially as the death toll mounted. (Table 2; A-348) HCWs felt that COVID-19 added to the trauma they already experience in their normal work: “… this pandemic doesn’t just affect our patients. It affects us and our lives and our loved ones … this job feels like you’re already carrying a very heavy trauma load, and then add this, and it sometimes feels quite crushing.” (P-168)

Operational Challenges

HCWs encountered numerous structural challenges at work that impacted their well-being. Operational changes at the organizational/clinic-level in response to COVID-19 were a common source of frustration, and some participants felt their institutions lacked initiative and struggled to adapt to operating within pandemic conditions. (Table 2; S-466)

HCWs reported a lack of transparency and poor communication from leadership, which made their jobs more difficult. The onus was “a lot on them” (P-481) to keep up with changes in protocol and routine, which was “really stressful, especially because of all the changes that have happened so rapidly at work, and the new tasks, and things we’re being asked to do. It's just–it's just been quite unsettling.” (P-205)

Clinics often lacked sufficient staff on-site, either due to turnover or COVID-19-related capacity restrictions, meaning those present were “working twice as hard” (P-158) because “… on any given day, there's 40-50% less people in the building. And when, you know, you need someone and you yell out for help, there may not be someone in earshot that can get there.” (P-168) Providers, especially, were “pretty stretched thin” (S-484) and struggled to manage an increased workload, “working at three times the job that they were probably trying to work two and a half months ago and still keep up.” (P-481) Many, as infectious disease specialists, were put in the position of juggling COVID-19-related research, educational, and service activities, in addition to their usual tasks. According to one provider, “COVID, in general, has increased my workload a lot. I am working on COVID-related research trials. So, I’ve been very busy, so that has brought additional stress to the household.” (P-043)

And although less commonly observed, burnout was sometimes cited as related to higher staff turnover rates during COVID-19, especially among nurses. As one provider noted, “I think [COVID-19] has led to some burnout. We’ve had higher turnover rates with our nursing staff. And whether that's because of COVID, or who knows what … I would like to think that's at least in part due to COVID. I think we all have COVID fatigue.” (P-117)

Social Isolation and Lack of Public Support

HCWs found little respite from the emotional burden they carried. They felt the loss of social and team-building activities at work that had alleviated burnout and made their jobs more enjoyable prior to the pandemic. (Table 2; P-168) Collegial relationships were integral to HCW well-being, and losing the ability to physically express their support due to social distancing was difficult. (Table 2; P-223)

The lack of social interaction led to “personal breakdowns” (S-511) as well as “depression and loneliness” (P-104). Emotional well-being decreased “if their support system is their family and friends and they're not getting to do those things.” (P-113) HCWs that lacked an external support system (eg, single individuals) “expressed loneliness and boredom” (P-104) when not at work. Some felt the physical separation and social isolation of telework to be difficult to the extent that “we've even had a couple of providers who have asked, and other staff, who have asked to go back in the office, because they were not coping with being alone at home so well.” (P-146)

Additionally, HCWs felt angry due to the lack of public support for their work: “It's so frustrating when you walk into a place and people aren’t following protocol … everybody kind of feels angry when you’re like trying to do important work, then other people could care less.” (A-116) They felt discouraged and confused by the lack of political and governmental support, (Table 2; P-113) and were frustrated with how government leaders were responding to COVID-19, as they seemed to be making the situation worse rather than helping. (Table 2; P-345)

Solutions and Innovations

In addition to describing the challenges they faced, HCWs also described how their clinics addressed these problems. These solutions included novel approaches to institutional support for providers, use of telehealth, and changes in clinic operations (Table 3).

Table 3.

Exemplar Quotes of Solutions and Innovations by Theme.

Themes	Quotes
Provider support(ie, institutional efforts to provide employee assistance, eg, support groups)	We did start a COVID support group for our staff … I think our director has been a couple of times but not so many other providers, like as far as MD providers. But that's been a really good group. It meets once a month virtually. And it just is sort of an open format for people to talk about how they’re doing. And it can be more like in regard to work and how that's working, or it can be more like personally. (A-116)
Telehealth(ie, perceived benefits and concerns related to virtual appointments, eg, effectiveness, retention in care, and accessibility)	… some patients do benefit from virtual appointments. I have some patients who are doing just great [on their HIV treatment]. They don’t need to see me every four months. They can just see me maybe once a year, and we can do another visit virtually, and then that's it. And they can move on with their lives. (P-043)
	… part of what's happening too is we're not seeing patients in person very much at all. We're doing more phone visits and video visits, which, on some level our patients have responded very well to and seem to like that, and at the same point in time, I think our big concern is of people falling out of care because of this. (P-057)
	… [we were] just saying, “Hey, we won't be able to see you in person but we could do it virtually”–some patients are probably excited about that but then other clients are like, “Well, I don't have a phone. I don't have Internet. How am I gonna do that?” (P-104)
Changes in clinic operations(eg, implementing COVID-19 education and screening initiatives, altering structure of patient visits and delivery of services, and limiting contact with patients to reduce exposure)	Our patient navigators are calling anyone and everyone that is on their radar for social needs and financial assistance needs and they're tackling that. There [are] also multiple pre-screening calls to kind of call patients before their appointments are coming up to ask them how they are, to give them COVID education, to share our protocol, our policies, how we're walking patients through so that they don't feel kind of in the blind as they're coming to appointments. And then, of course, in the appointments they're given–the education is reiterated. So they're almost getting that education three to four times when it starts with the patient navigators about two weeks out, and then a week out, the provider may call and then the triage team will call, and then they'll get it again in the clinic. (P-465)
	… the structure of patient visits changed and meaning that um, you know, the decisions have to be made as far as which patients could come in versus which patients would do telehealth. Also, the mental health aspect of it, being very, very concerned … and so we had to move quickly, fast to try to make sure that we didn't lose anybody, not as far as life and death but engaging–just keeping them engaged in care. So, [COVID-19] was a significant impact to our clinic operation, how we impact or provide or deliver services, impact going to the telehealth piece, also limiting the number of staff you know, that has come on campus. It has impacted us tremendously. (A-203)
	I do think there are a few silver linings that COVID put in perspective. For example, the pharmacy moved most of the patients to mail delivery of drugs. So I know that that increased the cost of the clinic but it's something that can be done and it's incredibly helpful to patients. So why do patients need to come to the pharmacy in person to pick up their meds when they can just be delivered to their homes? I hope that continues post-COVID. (P-043)
	If they don't feel comfortable coming in the office, we're going to try to have them come … and a nurse will bring out a tablet to do a telehealth visit from the parking lot. [They] will be blood pressure checked or something. There's a nurse there but we won't put them inside the building … they don't have to be, you know, concerned about, you know, getting sick or getting a virus from somebody else. (A-498)
	Well, [COVID] has affected our clinic dramatically, because anybody with a compromised immune system is at risk. So, we try to … reduce exposure as much as possible … providing [less contact as much] as possible. (P-223)

Note: Quotes appear in the order in which they are referenced in the results.

Provider Support

As COVID-19 persisted, HCWs emphasized that their patients’ needs had expanded as a result, as had their own. Clinics strove to make HCWs aware of existing employee assistance programs and mental health hotlines. As one participant noted, “… my personal experience of it before [COVID-19] was like, these are the things that you can do when you’ve gotten to that point of burnout. And I feel like now what I’m hearing from the top down is, ‘Please do these things now to prevent burnout.’ “ (P-168) Organizations also established new support groups for employees, offered support for self-care through video conference yoga and subscriptions to mindfulness apps, and provided food to on-site HCWs. (Table 3; A-116)

Telehealth

As work rapidly shifted to remote, work-from-home, and hybrid formats, HCWs found that telehealth addressed multiple concerns about patient well-being, improving their own. Telehealth enabled providers to limit in-person interaction with patients with COVID-19, protecting other patients, as well as themselves. It allowed providers to see their patients, encourage them to stay in care, and assess their service needs; it was a particularly favorable service delivery model for those retained in care. (Table 3; P-043) Yet, for other patients, it did not address concerns about routine testing and other needed health checks. (Table 3; P-057) For some patients, telehealth was simply not feasible due to resource constraints. (Table 3; P-104)

Changes in Clinic Operations

To address hardships for both providers and their patients, RWCs made alterations to the clinic environment to provide more effective care, thereby reducing burnout and improving HCW well-being. RWCs attempted to increase access to and deliver services efficiently and safely, implementing new tactics to create a safer physical and emotional space for patients and providers who were coming in.

Operational changes included limiting the number of people on-site by rearranging staff schedules and reducing in-person patient appointments, restructuring clinic flow to reduce opportunities for contact, triaging patients outside of the clinic, and spacing appointments apart physically and temporally. Some RWCs stopped seeing patients in person altogether and held patient visits virtually. Others only held in-person visits with newly diagnosed patients, patients with uncontrolled viral loads, and/or patients most at risk for falling out of care. Many clinics increased phone contact with patients to educate them about changes in services, prepare them for appointments, identify those needing additional mental health and/or social services support (eg, emergency financing for household expenses and addressing food insecurity), or provide additional social support. (Table 3; P-465 and A-203)

Additionally, some RWCs shifted to contactless, patient-centered service delivery models, implementing drive-thru services for testing, drive-thru and mail services for prescriptions, and creative appointment formats (eg, parking lot appointments) to limit potential COVID-19 exposure for patients who may be immunocompromised. (Table 3; P-043, A-498, and P-223) These efforts catered to patient needs, promoted continuity of care for patients who may have otherwise fallen out of care, and facilitated care that providers felt was essential. They also eased HCW concerns about patient well-being that were negatively affecting their own, enabling them to check-in more frequently with patients for reassurance. As one provider recalled telling their patient, “… ‘if you want [to receive care] like this, we're gonna do it ‘cause I just want to see that you're okay and get some labs on you, ‘cause it's been like eight months since we've had labs.’ “ (P-345)

Prioritization of TIC

A final key alteration HCWs discussed was the recognition of trauma caused by the COVID-19 pandemic. Many testified to the presence of more trauma, and with that, a need for more awareness of and responsiveness to trauma within the clinical setting; however, they cautioned that the true extent of trauma is yet unknown. As one staff member explained, “We've been talking about this for a while … What does it look like going back, dealing with our patients, because we all are where we can't go back the same way? It's not like you've been on vacation and then you come back. The patients have a lot more needs but then again, we will have a lot more needs. People's families have been affected by this. People working from home, people's norm changed … So we are having those discussions as we speak.” (S-210)

Despite this increased awareness, HCWs provided varied assessments of the perceived prioritization of TIC by their institutions, currently and in the future. Some reported that they didn’t know of any conversations around TIC taking place in their clinics, citing continued lack of investment and awareness: “You know, I still think the senior leadership have to have skin in the game, and I think … if they see it as important, it won't matter whether it's while COVID's here or when COVID's gone.” (P-146) Others stated that COVID-19 had changed the conversation around trauma, reinforcing the importance of TIC in clinical settings: “I think this has opened their eyes even more to how important a trauma-informed care approach is.” (S-466)

Additionally, COVID-19 served as a catalyst for practicing TIC: “[It's] teaching us to … work outside the box and even be more flexible when it comes to patient care.” (P-223) Still noting that barriers to implementation (eg, cost, online training fatigue, and lower priority status) have not gone away, some HCWs asserted that the increased visibility of trauma due to COVID-19 will prompt positive change, advancing TIC as the new standard. As one provider shared, “I do think that if we’re going to build a new clinic structure or policies because of COVID, then trauma-informed care should be one of the things that is put in place.” (P-053)

Discussion

In-depth interviews with RWC administrators, providers, and staff revealed that HCWs and their patients struggled to cope with individual, interpersonal, organizational, and systemic changes they encountered as a result of the pandemic. Fear, stress, burnout, concern for others, work-related challenges, social isolation, and lack of public support negatively impacted the well-being of HCWs. Of particular note was our finding that HIV HCW well-being was further strained due to their keen awareness of the effect COVID-19 was having on the complex psychosocial factors that can affect their patients,^{5,39,41,42,44–46,49–51,71} such as a food/income/housing insecurity and ancillary care needs.

Similar to studies focusing on burnout among HIV providers,^5,39 we found that HCWs experienced aspects of burnout during the COVID-19 pandemic. While emotional exhaustion was clearly evident, some HCWs also experienced compassion fatigue, which can lead to depersonalization,⁵ and by extension, the potential for less empathetic and potentially less-trauma-informed care. However, these participants generally did express empathy towards patients. HCWs also expressed feelings of insufficiency due to factors beyond their control, and some noted higher turnover rates, which can be a result of feelings of diminished personal accomplishment.³⁹

To promote the well-being of HCWs, we found that some institutions encouraged use of employee assistance programs and strove to create opportunities for work-based self-care, team-building, and social interaction and support in virtual environments. One prior study at an RWC in the southeastern US conducted a needs assessment prior to the COVID-19 pandemic, which found an absence of formal self-care services and mechanisms for support to reduce stress and prevent burnout among administrators, providers, and staff.⁶⁷ Its study authors suggest that adopting TIC could lead to healthier HCWs, as well as better patient care and outcomes.

It was encouraging to find that most, if not all, HCWs and RWCs were already practicing some elements of TIC to alleviate the pandemic's psychological impact on their patients and on their clinic staff. HCWs increased efforts to provide practical assistance and emotional support to their patients and colleagues, and adapted clinic practices to address their concerns and promote health and safety. Telehealth emerged as an important resource for RWCs as they strove to continue providing health services to patients, despite limitations related to physical examinations and lab testing. Innovations like drive-thru services helped overcome some of these challenges, ensuring that comprehensive care was still being provided. COVID-19 served to heighten awareness of trauma and the need for trauma-informed services among HCWs, although some were uncertain whether clinics would institutionalize changes to practices made during the pandemic or return to business as usual, particularly around practices that promoted well-being of HCWs.

Our findings contribute to the limited knowledge of HIV HCW well-being during the COVID-19 pandemic. In China, a cross-sectional study based on an online survey of HIV HCWs found that during COVID-19, 38.7% experienced psychological distress, and that prevalence of depression and anxiety was 13.31% and 6.61% respectively.^55,57 Additionally, individuals’ coping behaviors offered protection from harmful mental health effects of COVID-19 stressors,⁵⁵ while resilience, workplace social support, and institutional responsiveness were found to be protective against burnout from COVID-19 stressors (eg, lack of personal protective equipment, fear of infection, work burden, and concern for loved ones) and HIV service delivery challenges (eg, staffing shortages and dueling pandemic and usual care responsibilities).⁵⁶ Our study partially supports these findings within the context of the US, as we found that interventions enacted at the clinic-level to promote well-being of HIV HCWs were perceived as helpful to a certain extent, though perhaps not sufficient to prevent them from experiencing psychological distress caused by the pandemic or to fully mitigate its effects.

In Mali, a cross-sectional study based on a self-administered questionnaire conducted two weeks after the first two cases of COVID-19 were recorded found that most HCWs reported at least one symptom of depression (71.9%) and anxiety (73.3%).⁵⁸ Uncertainty due to COVID-19, particularly concerning the availability of masks, was related to mental health; the authors found that HCWs working in care centers where masks were available were less likely to suffer from these conditions.⁵⁸ Depression was associated with HCW role, with doctors and midwives, community health workers, and administrative and logistical staff being at higher risk than nurses.⁵⁸ Our findings partially support concern around COVID-19 uncertainty affecting HCW well-being but concerns lay more with the lifting of mask mandates and reduced mask wearing among the general public rather than their availability. Although we did not observe major differences related to HCW well-being based on role, a few participants in our US-based study noted higher turnover among nurses, potentially indicating the opposite: that nurses may be more impacted by COVID-19 than other HCWs, though further research would be necessary to examine this more thoroughly.

Although its focus was not on HCW well-being, the KFF survey report noted similar operating challenges, highlighted the resiliency of clinic staff, and identified patient and staff well-being as a particular concern to Ryan White-funded providers given the stress and trauma these groups were experiencing.⁵⁹ Our results corroborate and elucidate many of its key findings⁶⁰ by contextualizing them within the framework of HCW well-being, and present trauma-informed strategies used by RWCs that may be effective at mitigating the effects of COVID-19 moving forward.

Strengths

Our qualitative investigation had several strengths. We analyzed a robust sample of interviews to achieve saturation required to fully identify and understand themes in our data. Our study extends knowledge about provider burnout and well-being to include all HCWs (not just physicians and nurses) in southeastern RWCs and identifies potential multi-level contributing factors. Additionally, solutions and innovations identified in this study can inform the way health care organizations respond to future public health emergencies using a TIC approach to ensure that the needs of HCWs and patients are being met and that services continue to be delivered safely and effectively in a rapidly changing environment.

Limitations

Our study had limitations. Although interviews began at the start of the pandemic and continued for a substantial period, we did not purposively sample participants at different timepoints throughout the pandemic to make comparisons of how clinics fared over time or during notable events (eg, vaccine development, re-openings, and lifting of masking requirements). Thus, our findings should only be considered as general observations of what to anticipate in health care settings and suggestions for HIV HCW support during a public health emergency. Additionally, our study was qualitative and not generalizable to other patient populations, primary care settings, or geographic areas. We were unable to verify whether our interview sample was demographically representative of RWC personnel in Region IV as that information is not publicly available; however, it mostly aligns with the demographic composition of our survey respondents⁷² and the study team made every attempt to attain variability within the sample through targeted recruitment of traditionally underrepresented racial, ethnic, and gender minorities. Still, we believe that the novel ideas pertaining to delivery of health services, presented here, can be applied and tested in other contexts.

Conclusions and Future Directions

The COVID-19 pandemic has created a collective trauma, experienced by both PLWH and HCWs, and measures taken to curtail the virus have resulted in disruptions in access to social support resources typically engaged during times of stress or trauma. Innovatively, RWCs have employed multiple strategies to address the emotional toll of COVID-19 for patients and HCWs. As clinics return to normal operations, it is unclear to what extent these new practices will be maintained and additional trauma-informed practices will be employed to address trauma among patients, as well as stress and burnout among HCWs; however, it is a question for future research. The effectiveness of institutional staff support strategies should also be explored.

Supplemental Material

sj-docx-1-jia-10.1177_23259582241235779 - Supplemental material for Providing Trauma-Informed Care During a Pandemic: How Health Care Workers at Ryan White-Funded Clinics in the Southeastern United States Responded to COVID-19 and Its Effects on Their Well-Being

Supplemental material, sj-docx-1-jia-10.1177_23259582241235779 for Providing Trauma-Informed Care During a Pandemic: How Health Care Workers at Ryan White-Funded Clinics in the Southeastern United States Responded to COVID-19 and Its Effects on Their Well-Being by Caroline W. Kokubun, Katherine M. Anderson, Olivia C. Manders, Ameeta S. Kalokhe and Jessica M. Sales in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Supplemental Material

sj-docx-2-jia-10.1177_23259582241235779 - Supplemental material for Providing Trauma-Informed Care During a Pandemic: How Health Care Workers at Ryan White-Funded Clinics in the Southeastern United States Responded to COVID-19 and Its Effects on Their Well-Being

Supplemental material, sj-docx-2-jia-10.1177_23259582241235779 for Providing Trauma-Informed Care During a Pandemic: How Health Care Workers at Ryan White-Funded Clinics in the Southeastern United States Responded to COVID-19 and Its Effects on Their Well-Being by Caroline W. Kokubun, Katherine M. Anderson, Olivia C. Manders, Ameeta S. Kalokhe and Jessica M. Sales in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Footnotes

Acknowledgements

This study was supported by the National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health. The authors have no conflicts of interest to disclose. All study procedures were approved by the Emory University Institutional Review Board. We thank the study participants for openly sharing their perspectives,as well as the Southeast AIDS Education and Training Center,Ryan White conference/meeting organizers,and Region IV Ryan White program coordinators who helped us publicize this study. We would also like to thank Shanti Kozuch,MPH,and Mahitha Murali,MPH,for their contributions to recruitment,data collection,and analysis while graduate research assistants at Emory University’s Rollins School of Public Health.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: This work was supported by the National Institute of Mental Health (grant number: R56MH119903).

ORCID iDs

Caroline W. Kokubun

Olivia C. Manders

Jessica M. Sales

Supplemental Material

Supplemental material for this article is available online.

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