Organizational Measures to Protect the Mental Health of Healthcare and Social Services Staff during COVID-19: What Worked and What Didn’t according to Human Resources Advisors?

1. Introduction

The COVID-19 pandemic had major repercussions on the work of the healthcare staff who were mobilized to react to this health emergency without precedent in the 21st century. Healthcare staff had to work in a context where knowledge about the virus and its transmission was constantly evolving, where protective equipment was not always available and procedures changed with the course of the pandemic. In addition, isolation rules that were in effect for COVID-19 infected healthcare workers or those in contact with a COVID-19 case, had an impact on the number of available workers. Even outside the context of an epidemic, healthcare personnel are among those most affected by problems relating to mental health, burnout and staff turnover [1–5]. During epidemics and pandemics like COVID-19, there is a greater burden of mental health symptoms and problems [6,7], especially for healthcare workers [8–11].

In the province of Quebec, Canada, the vast majority of healthcare and social services institutions (HCI) are public and are under the authority of Quebec’s health and social services department. This department shares its responsibilities with 34 public institutions, whose primary role is to provide the public with health and social services [12]. In 2023, the total number of people working in the health and social services network was over 300,000 [13]. This network has undergone numerous transformations over the past 20 years. The most recent one, dating to 2015, involved the passing under closure of Bill 10 under the leadership of Minister Gaétan Barrette. It has been described by some media as the worst reform ever of Quebec’s health and social services network: “Exhausted professionals, increasingly difficult access to care, ultra-centralized management: the effects of “Hurricane Barrette’ are still being felt five years later, and they have weakened the healthcare network” [Translation] [14]. This major restructuring centralized administrative services and decision-making authority by reducing the number of institutions in the network from 182 to 34. These institutions also became known as “integrated centres” or “integrated university health and social services centres”. More than 1,300 managers lost their jobs in the course of this exercise [14].

It was therefore in a context still strongly marked by these major transformations and challenging working conditions in the health and social services network that the COVID-19 pandemic broke out in Quebec in March 2020. In addition to issues like high demands and staffing shortage [1,3,5], healthcare personnel faced numerous stressors associated specifically with the pandemic. These included concerns relating to the lack of personal protective equipment (PPE) or to its protective efficacy (e.g. medical masks versus N95 masks), involuntary deployment, assignment to new teams and tasks outside one’s skill set, increased work-family conflict related to school and daycare closures, and the experience of moral dilemmas when caring for infected patients while risking one’s own health or that of loved ones or when having to compromise care due to resources constraints [6,7,15–19]. Balancing work and personal life was particularly difficult with the additional significant workload caused by the pandemic and was one of the factors mainly associated with psychological distress of the healthcare workers in Quebec during the COVID-19 pandemic [15]. Not only were there major absenteeism issues, but the ratio of insured hours of lost time to the total number of hours worked by personnel rose by 29% on average within HCI between 2014-2015 and 2019-2020 [12]. Mental health problems seem to have generated the highest costs over the past several years, in addition to accounting for the highest number of lost work hours in Quebec’s health and social services network [20,21].

In a recent literature review and meta-analysis, Duchaine et al. [22] demonstrated that workers exposed to psychosocial risks in the workplace had a 23% to 76% greater risk of being absent from work due to a physician-diagnosed mental disorder than did workers not exposed to such risks. A meta-review of 72 literature reviews with meta-analyses over a period of 20 years showed that exposure to various work-related psychosocial risks, such as high psychological demands, lack of decisional autonomy, low support from colleagues and supervisors, low recognition at work, and exposure to violence or threats, increases the likelihood of developing or suffering from depressive disorders and burnout, and having suicidal thoughts [23].

Primary preventive organizational interventions can be effective in reducing workers’ exposure to work-related psychosocial risks such as excessive workload, low job control and poor social support. As such, primary-level interventions, when adequately supported and implemented, can help prevent mental health problems in the workplace [24–27]. In their meta-analysis, Panagioti et al. [28]demonstrated that interventions targeting organizational factors were more effective than individual-level interventions when it comes to protecting physicians against burnout. Other authors have estimated that 44% of employee turnover in hospitals could be prevented by improving the psychosocial work environment [29]. A recent systematic review of 2000 to 2021 scientific literature identified some organizational measures for protecting the mental health of healthcare workers during epidemics and pandemics, based on seven medium-quality studies. These organizational measures include staffing adjustments, work shift arrangements, enhanced infection prevention and control, recognition of workers’ efforts, and psychological and/or logistic support during lockdowns, but the authors confidence in the effectiveness of reviewed interventions is low to very low [30].

Despite the vast extent of studies highlighting the negative effects of being exposed to psychosocial risk on mental health [22,23,31,32], there still is a scarcity of knowledge on strategies that are implemented by organizations during a pandemic to reduce these risks. As HCI around the world were under great pressure during the pandemic, it was difficult to know how prevention was being carried out on the ground, as access for researchers was limited and healthcare workers were overworked. Literature on organizational-level interventions shows how crucial it is to evaluate the process as well as the effects, but a number of methodological shortcomings remain, not least because the context is not systematically studied [27]. Indeed, Aust's systematic review highlights the fact that organizational-level interventions can differ in their complexity regarding implementation, which has an impact on its effects [27]. By calling on key interlocutors who have a good knowledge of which organizational measures were implemented during the pandemic, such as HR advisors, it is possible to have an interesting proxy on implementation and perceived effectiveness.

The purpose of this study is to provide an overview of the measures introduced or maintained by the institutions of the Quebec health and social services network during the COVID-19 pandemic in order to protect the mental health of their personnel. We also sought to document the perceived effectiveness of the measures by HR people responsible, at least in part, for implementing them within their organization.

This study was part of a larger project aimed at developing knowledge on mental health protection strategies for healthcare personnel during the COVID-19 pandemic, with a view to designing a workplace support tool. The two other studies from the larger project are reported in other articles [references omitted for blinded peer-review].

Theoretical framework

Work-related psychosocial risks are factors related to work organization, employment conditions, management practices and social relations at work, that increase the likelihood of an adverse effect on the physical and mental health of persons who are exposed to them [33]. This definition is based on the two recognized theoretical models of job stress, namely, the job demand-control model of Karasek and Theorell [34] and the effort-reward imbalance model of Siegrist [35], which have gained international renown. Over time, other theoretical models have been proposed, such as the Organizational justice model [36] and the Job Demands – Resources model [37–40]. Psychosocial risk factors increase the likelihood of developing mental health problems in exposed workers, suggesting that preventive measures are needed to mitigate their effects in order to protect worker’s mental health. Some studies have led to the proposal of concrete organizational measures that workplaces can implement to act in primary prevention of what are considered modifiable psychosocial risks, which are generally measures targeting workload, recognition at work, social support from colleagues and supervisors, decisional autonomy, communication and information and balancing work and personal life [33,41–44]. The implementation and success of such organizational measures aimed at protecting mental health in the workplace depends, among other things, on the importance and priority given by the organization to psychological health and safety in the workplace, a concept called psychosocial safety climate [45]. This concept refers to the importance and priority that organizations attach to psychological health and safety in the workplace. The psychosocial work safety climate is considered upstream of the aforementioned psychosocial risks [46–48]. Recent work shows that organizations with a strong psychosocial safety climate have better mental health outcomes, not least because the psychosocial safety climate acts upstream of psychosocial risks at work [49].

2. Materials and Methods

2.1. Participants

We targeted Quebec’s 34 HCI that make up the Quebec health and social services network. Each of these institutions has a human resources management team responsible for implementing prevention measures to reduce psychosocial risk factors in the workplace. The size of each team varies based on the number of staff members in the institution to which it belongs [50].

An online questionnaire was administered to HR personnel. When we first contacted each team, we specified that we hoped to enlist the participation of key informants from each institution who were familiar with the measures that had been implemented in their institution to protect workers’ mental health since the start of the pandemic.

There were 31 participating institutions, for a response rate of 91.2%. A total of 223 HR advisors answered the questionnaire, with at least one respondent per institution. The number of respondents per institution ranged between one and 24.

2.2. Measures

The questionnaire was developed by our research team and reviewed for clarity and relevance by an advisory committee, set up at the very beginning of the research and made up of various local stakeholder representatives, including labour unions, employer and department representatives, professional orders in the health and social services network, and user representatives. The questionnaire first assessed the psychosocial safety climate using the validated PSC-4 instrument [45]. The PSC-4 was measured using four questions (e.g. Senior management shows support for the prevention of psychological health problems through involvement and commitment), according to a scale of 1 (strongly disagree) to 5 (strongly agree). The instrument was translate in french language, but this version is not validated yet. The PSC-4 score ranges from 4 to 20 points, with higher scores indicating better psychosocial safety climate.

HR advisors were then asked about the presence of organizational measures in their institution through a series of close-ended questions. For each item, respondents should first indicate if the measure was in place, not in place or if they didn't know. Then, for measure in place, they had to tell if from their standpoint, the measures are efficacious in protecting healthcare workers’ mental health. Of these measures, eight were designed to reduce employees’ workload; seven to increase their recognition at work; six to improve the support of colleagues and supervisors; three to increase decisional autonomy; four to promote the communication and sharing of information; and five to target better work/life-balance. These measures were selected from work on recognized organizational measures for reducing psychosocial risk factors in the workplace as cited in the theoretical framework. Finally, eight COVID-19 measures were included in the questionnaire derived from infection prevention and control (IPC) initiatives in HCI recommended by Quebec public health authorities during the COVID-19 pandemic [51]. Some of these measures touch upon decisional autonomy (e.g. choosing to work in a red zone), others relate to work organization or management practices that may influence the perceived safety of work (e.g. IPC training, PPE access, on-site COVID-19 screening).

The questionnaire also included open-ended questions on measures that HR advisors had deemed successful and those that they had deemed less successful in reducing psychosocial risk factors and protecting mental health. The fact that these questions were open-ended enabled the respondents to explain their answers.

The survey was deployed online through a community of practice in HR management, bringing together advisors from the 34 institutions in Quebec’s health and social services network. The data were collected between May 14 and June 4, 2021. Two reminders were sent by email on May 21 and May 31, 2021.

2.3. Analyses

Answers to open-ended questions were subjected to deductive and inductive thematic content analysis [52]. The themes were identified using the aforementioned theoretical frameworks for psychosocial risk factors in the workplace and the Tool for Identifying Psychosocial Risk Factors in the Workplace adapted to the work context in the health and social services network [53,56]. Other themes could also emerge during the analysis.

For the close-ended questions, we calculated the proportion of the total number of respondents who reported that a particular measure had or had not been implemented in their institution. Among those who reported that the measure had been implemented, we calculated the proportion of respondents who deemed that the measure was efficacious, fairly efficacious or not very efficacious in protecting workers’ mental health, based on the respondent’s subjective assessment. We also calculated the PSC-4 score for each institution, as perceived by HR staff, using the average scores of the respondents in each institution. Since the goal was to obtain an overview of the measures implemented across Quebec’s health and social services network, rather than a portrait of the measures per institution or establishment, we present results based on the overall number of respondents.

3. Results

3.1. Overview of the organizational measures implemented

Respondents had been asked to indicate if listed measures in the close-ended questions had been implemented and their perceived efficacy of implemented measures to protect the mental health of the healthcare staff, based on their personal assessment as key informants. The results are presented in Table 1.

The five measures reported to have been implemented according to the largest proportion of respondents are those that were intended to foster civility and respect (95% of respondents), resolve interpersonal conflicts (89% of respondents), promote the use of appropriate means of communication (e.g. message boards, meetings, emails, videoconferences, newsletters) (89%), offer flexible hours, shorter work weeks or part-time positions (84%) and ensure sufficient access to PPE (e.g. medical masks, respiratory protection devices (RPDs), visors) (83%).

The five measures least reported to have been implemented were those to provide COVID-19 staff with meals (occasionally or always) (26%), give them access to lounge areas (31%), increase manager-to-staff ratios (32%), provide training in communications (37%) and offer on-site daycare facilities or daycare service agreements (42%).

As for the perceived efficacy of the measures, those that were deemed efficacious in mental health protection by the vast majority of respondents declaring that a particular measure had been implemented, included four specific COVID-19 measures: COVID-19 screening tests available in the workplace (deemed efficacious by 84% of respondents who reported that this measure was in place); sufficient access to PPE (e.g. medical masks, RPDs, visors) (deemed efficacious by 79% of respondents who reported that this measure was in place); financial compensation measures during isolation/quarantine and training in PPE measures, respectively deemed efficacious by 76% and 74% of respondents who reported that these measures were in place. The fifth measure reported to be efficacious by the vast majority of respondents was facilitation of telework (deemed efficacious by 62% of respondents who reported that it was in place).

The measures considered to be not very efficacious by the vast majority of respondents were those to provide access to lounge areas (considered not very efficacious by 43% of respondents who reported that the measure was present); offer corporate rebate programs (43%); hire new staff or increase staff-to-patient ratios (38%); limit overtime (38%) and reduce mandatory overtime (37%). It is interesting to note that the measures likely to have a direct impact on the workload of healthcare workers, i.e. those targeting staffing and overtime work, were perceived as being not very efficacious by HR staff. This may be because the measures were applied in a number of different ways, for a limited time period or intermittently, or because they were offered to only a small number of healthcare workers. Since these paradoxical results are based on the perception of the advisors surveyed rather than on that of the staff who cared for patients, they must be interpreted with caution. They highlight the relevance of using a participatory approach to identify risks and elaborate solutions, so that the needs on the ground are aligned with the solutions proposed by employers.

It is also interesting to note that a fairly large proportion of the HR staff said that they were not aware of the existence of certain measures in their institutions. Regarding COVID-19 measures, 42% of respondents did not know that workers could choose whether or not they wanted to work in red zones, 38% did not know if meals were offered and 37% did not know if accommodations were provided to infected or isolated staff assigned to COVID-19 wards or if financial compensation measures were in place for isolated or quarantined workers.

4. Discussion

This study provided an overview of the measures reported by HR advisors to have been implemented by HCI in Quebec during the COVID-19 pandemic. These organizational measures aimed to reduce workplace psychosocial risks and protect healthcare worker mental health. Since there was a limited access to HCI during the crisis, understanding how psychosocial risks were prevented is highly relevant given their impact on mental health, absenteeism, and turnover. Although most respondents highlighted mainly individual measures as having been successful, they also reported that several organizational measures had been implemented, with varying perceived efficacy from the point of view of the HR staff. The wide variety of reported measures across the health and social services network could be related to the fact that, in 2017, Quebec’s health and social services department had initiated a shift toward mental health prevention in the workplace. This approach had been incorporated into a national action plan to prevent workplace hazards and promote comprehensive health for the period 2019-2023 [50]. This plan provided for the training of HR professionals and for the implementation of preventive organizational interventions in institutions throughout the network. This change in preventive culture may have had a positive impact on the number of organizational measures put in place during the pandemic. Organizational measures usually allow for primary prevention intervention. In other words, they are designed to reduce exposure to psychosocial risks in the workplace by modifying the work environment and thereby reducing risks to mental health at the source. Primary prevention strategies are usually those that must be given priority in a public health approach. A systematic review and meta-analysis suggested that organizational interventions are more effective than individual measures in preventing physician burnout [28]. Others have suggested that combining organizational and individual interventions is a more integrative approach that would make it possible to act at the level of primary, secondary and tertiary prevention, and thus generate more potential health benefits [25].

The main strength of this study is that it enlisted the participation of 31 of the 34 institutions in Quebec’ health and social services network, making it possible to obtain a province-wide overview of the measures that the respondents said were put in place during the pandemic. Another strength of this project is that, through an advisory committee, all stakeholders in the Quebec health and social services network were involved from the outset of the research and at every important stage, thus achieving one of the fundamental objectives of participatory research: to produce relevant, useful and usable results. Meetings with the advisory committee played a significant role in guiding the development of the questionnaire used to survey HR staff. Also, an additional strength of this study is that it presented a series of organizational measures categorized according to targeted psychosocial risk factors in the workplace, which led to a better understanding of prevention targets in this public network. That being said, this approach also had certain limitations. Since more than one person from each institution could answer the questionnaire, it is possible that some measures were reported more than once. However, due to the way in which responsibilities are shared within HR management teams in the health and social services network, the same measure may have been applied differently across the establishments of a given institution (e.g. review of work schedules in a hospital centre versus a long-term care centre of the same institution). Since our objective was to obtain a global view of the measures put in place in the health and social services network, it was not essential to know exactly how many measures were implemented in each institution or its establishments. Moreover, even though HR advisors were credible informants, it was hard for them to answer for their institution as a whole in some cases. This explains why a fairly large proportion of respondents said that they were not aware of certain measures within their institution. Furthermore, the efficacy of measures was assessed solely on the basis of the respondents’ opinions. Therefore, the results cannot be used to comment on the actual effectiveness of measures on workers’ mental health, since no data to that effect were gathered from healthcare workers.

Lastly, the results pertaining to the psychosocial safety climate, particularly, the strong correlation between the PSC-4 indicator and the number of measures reported to have been implemented in various institutions have opened up new avenues of inquiry. Studies have shown that the implementation and success of organizational interventions aimed at protecting mental health in the workplace depend on, among other things, the importance and priority accorded by an organization to workplace psychological health and safety [45]. This concept of psychosocial safety climate refers to the practices, policies and procedures in place within an organization for the purpose of acting on psychological health problems [53]. Recent work has shown that organizations with a strong psychosocial safety climate have better results in mental health, particularly because it acts upstream from workplace psychosocial risk factors [49]. It would be interesting to study the correlation between the PSC-4 indicator and the number of implemented measures according to the type of measure (e.g. workload reduction measures, recognition measures). However, we must consider that the cross-sectional data in this study provide less conclusive support for a causal hypothesis. In addition, the data are based on the input of key informants rather than on that of all staff members in each institution (or a representative sample of them). Nonetheless, these analyses might serve as an exploratory first step toward proposing more in-depth study of the role of psychosocial climate safety, so as to understand the mechanisms whereby that climate, when favourable, can help to reduce mental health problems and burnout among managers, among other things [54]. Furthermore, the concept of psychosocial climate safety is still not used very often to understand intervention-related issues (processes, implementation, health effects) [49], highlighting the need for more studies in this area.

5. Conclusions

This research has provided an overview of the measures initiated or maintained in the institutions of Quebec’s health and social services network during the COVID-19 pandemic in order to protect workers’ mental health. Many of these measures have the potential to be effective in the post-pandemic COVID-19 era, when staffing shortages and work overload remain issues, because they target work organization and the psychosocial work environment. The study contributes to the literature on intervention processes by illustrating how perceptions of the effectiveness of interventions can be captured to some extent by surveying key interlocutors rather than by measuring perceived exposure to interventions directly with participants. However, for effective mental health protection, workplaces must engage in participatory prevention approaches involving workers to identify the specific risks in their workplace and the solutions best-suited to their needs.