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“I found myself alone” – A phenomenological study of the home care workers' experience during the COVID‐19 pandemic

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Abstract

Home care workers (HCWs) are a highly heterogeneous population in Italy in terms of their professional qualifications. HCWs play an important role in helping patients affected by chronic diseases and their families. While many investigators have studied the lived experiences of family caregivers, few have been conducted ‘to give a voice’ to HCWs and even fewer have examined the experiences of HCWs during the present COVID‐19 pandemic. We investigated the lived experiences of HCWs during the first wave of the pandemic in Italy. Cohen's phenomenological research approach was used to conduct this study. In our study, we enrolled and interviewed 19 HCWs who were female, and most were married, with an average age of 52 years. The participants were enrolled from September 2020 to November 2020, after the first COVID‐19 wave in Italy. Four main themes emerged from the analysis of the data: (1) ‘I found myself alone’; (2) From invisibility to visibility; (3) A fear of getting sick and infecting others; and (4) ‘Health or work? That is the question’. Understanding HCWs' lived experiences, especially those related to the COVID‐19 pandemic, is a first step in giving a voice to this important but vulnerable population in the healthcare workforce. This article is protected by copyright. All rights reserved.
RESEARCH ARTICLE
I found myself aloneA phenomenological study of the
home care workers' experience during the COVID-19
pandemic
Silvio Simeone RN, PhD
1
| Ercole Vellone RN, PhD, FESC, FAAN
2
|
Michele Virgolesi RN, PhD
3
| Madeline R. Sterling MD, MPH, MS
4
|
Rosaria Alvaro RN, MSN, FESC, FAAN
2
| Gianluca Pucciarelli RN, PhD, FAHA
2
1
Department of Clinical and Experimental
Medicine, University of Catanzaro Magna
Graecia, Catanzaro, Italy
2
Department of Biomedicine and Prevention,
University of Rome Tor Vergata, Rome, Italy
3
Emergency and Urgency Department, ASL
Naples 2, Naples, Italy
4
Department of Medicine, Weill Cornell
Medicine, New York, New York, USA
Correspondence
Silvio Simeone, Department of Clinical and
Experimental Medicine, University of
Catanzaro Magna Graecia, Campus
Universitario Salvatore Venuta, Viale Europa,
88100, Catanzaro, Italy.
Email: silviocecilia@libero.it
Abstract
Home care workers (HCWs) are a highly heterogeneous population in Italy in terms
of their professional qualifications. HCWs play an important role in helping patients
affected by chronic diseases and their families. Although many investigators have
studied the lived experiences of family caregivers, few have been conducted to give
a voiceto HCWs and even fewer have examined the experiences of HCWs during
the present COVID-19 pandemic. We investigated the lived experiences of HCWs
during the first wave of the pandemic in Italy. Cohen's phenomenological research
approach was used to conduct this study. In our study, we enrolled and interviewed
19 HCWs who were female, and most were married, with an average age of 52 years.
The participants were enrolled from September 2020 to November 2020, after the
first COVID-19 wave in Italy. Four main themes emerged from the analysis of the
data: (1) I found myself alone; (2) from invisibility to visibility; (3) a fear of getting
sick and infecting others; and (4) Health or work? That is the question.Understand-
ing HCWs' lived experiences, especially those related to the COVID-19 pandemic, is
a first step in giving a voice to this important but vulnerable population in the
healthcare workforce.
KEYWORDS
care workers, COVID-19, live experiences, pandemic, phenomenological study
Key points
Numbers of home care workers (HCWs) in Italy are generally migrant women from Eastern
European without training and their works were invisible.
During COVID-19 pandemic they feel lonely, stressful, and helpless, even though their cli-
ents' family members awarded of their importance.
Feeling of ambivalence and fear are on the way.
Received: 24 November 2021 Revised: 17 February 2022 Accepted: 19 February 2022
DOI: 10.1111/nhs.12935
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2022 The Authors. Nursing & Health Sciences published by John Wiley & Sons Australia, Ltd.
Nurs Health Sci. 2022;24:395404. wileyonlinelibrary.com/journal/nhs 395
1|INTRODUCTION
In December 2019, an unknown coronavirus, severe acute respiratory
syndrome coronavirus 2, deemed to be the cause of coronavirus dis-
ease 2019 (COVID-19), was identified in China (Li et al., 2020;Wang
et al., 2020). The virus quickly spread around the world, causing a global
pandemic (The Lancet Infectious Disease, 2020). A specific estimate of
the number of victims is difficult as the data change quickly (World
Health Organization, 2020). Among the European countries, Italy was
one of the hardest hit (Bordi et al., 2020) probably because, compared
with the other European countries, Italy has a greater older adult popu-
lation affected by several chronic diseases (Tur-Sinai et al., 2020).
Many families required a homecare worker (HCW)'s services also
before the COVID-19 pandemic. Indeed, as described by a report
(VITA, 2019), it is estimated that in Italy there are approximately
865,000 HCWs, prevalently female and located in the north and cen-
ter. Not being a service offered by the state, hiring an HCW has a big
impact on families. Indeed, on average a year, the total overall expen-
diture is estimated at around 7 billion.
Because of the fear of getting infected (de Leo & Trabucchi, 2020),
many home-dwelling older people who needed care hired HCWs, a type
of informal caregiver paid for their services by the patient. HCWs pro-
vide personal caregiving services, including assisting their clients in activi-
ties of daily living, carrying out medically oriented tasks such as helping
their older clients take their medications, and in some cases providing
companionship to their clients (Grasmo et al., 2021). In Italy, where this
study was conducted, HCWs are generally Eastern European women
whodonothavethequalificationsfororformaltrainingtobeHCWs.
2|BACKGROUND
Studies conducted in the United States have shown that HCWs
played a crucial role during the first wave of the COVID-19 pandemic
because of their proximity to clients and their provision of caregiving
services (Sterling et al., 2018). Although these people spend a signifi-
cant amount of time helping their clients manage their chronic dis-
eases, navigating the healthcare system (Ashley et al., 2010; Franzosa
et al., 2018) and providing long-term assistance and post-hospitalization
care for them (Jones et al., 2015,2017;Madigan,2008), they are still
an invisible and vulnerable workforce and are seldom the focus of
research (Sterling et al., 2018).
Indeed, although there have been many studies on the lived experi-
ences of family caregivers (Simeone et al., 2016; Young et al., 2019),
most of these studies focused on unpaid caregivers such as family mem-
bers, friends, and significant others. As for the few studies that have
been conducted to give HCWs a voice by analyzing their lived experi-
ences, almost all of them were conducted before the COVID-19 pan-
demic (Ayalon et al., 2015;Ohtaetal.,2018,2020; Sterling et al., 2018,
2020). Indeed, to the best of our knowledge, only one study before ours
has examined the experiences of HCWs during the present COVID-19
pandemic (Sterling et al., 2020). This represents a research gap because
it is well known that COVID-19 has had a big impact on people's lives,
engendering feelings of isolation and fear in many and affecting their
psychological state. The HCWs in Italy may have experienced these
more intensely because most of them are migrants and because they
have always been considered a high-risk subpopulation due to their poor
health and social conditions and the absence of government regulations
to promote their welfare. A full understanding of their lived experiences
so far during the present pandemic will help clinicians and researchers
develop tailored interventions to protect them and to better understand
their relationships with their clients. This lack of attention represents a
research gap because it is well known that COVID-19 has had a big
impact on the healthcare workforce.
A full understanding of HCWs' lived experiences during the pre-
sent COVID-19 pandemic might help clinicians and researchers
develop tailored interventions to protect this population and to help
them work better with their clients.
In light of the foregoing, the aim of the study was to analyze the
lived experiences of HCWs during the first wave of the pandemic in
Italy.
3|METHOD
3.1 |Design
This study used Cohen et al.'s phenomenological research approach
(Cohen et al., 2000), which combines descriptive (Husserlian) and
interpretative (Gadamerian) phenomenology, because it could enable
a deeper understanding of the lived experiences of the participants
and of the meanings attributed to such experiences. Cohen's phenom-
enology combines Heidegger's thought, which can be considered
purely descriptive, with that of Gadamer, who contended that herme-
neutics is the study of texts. He used that term broadly to mean lan-
guage. He included not only what people write down but also, more
important, what they say and the symbolic activities in which they
engage. He stated that to have a world is to have a language: Our
experience of the world is bound to language.The approach is rooted
in a motivation to gain access to the nature of consciousness itself,
and the resulting position is based on the meaning of the individual's
experience. The same approach has been successfully used by authors
in previous studies designed to describe the lived experiences of care-
givers and their clients (Simeone et al., 2016,2018). In addition, phe-
nomenology is particularly useful for examining topics that are
complex, ambiguous, and emotionally laden (Smith & Osborn, 2015).
3.2 |Setting and participants
Convenience snowball sampling was used for participant recruitment.
We started recruiting HCWs at employment agencies. Once we con-
tacted the first HCWs, we asked them if they knew any other HCWs.
Through this network, we met other HCWs who were asked to be
willing to participate in the study. This made it possible to get in touch
with a HCW network and facilitate sampling. Participants were
396 SIMEONE ET AL.
enrolled in this study from October to November 2020, after the first
wave of COVID-19 in Italy. The participants' informed consent to par-
ticipate in this study was obtained before collecting the data.
For inclusion in the study, the participants were required to
(1) have been an HCW for at least 6 months before the study; (2) cur-
rently be providing care to an older person with or without a chronic
disease; (3) understand spoken and written Italian; and (4) consent to
participate in the study.
3.3 |Data collection
Following the chosen research approach, all the researchers involved in
this study performed bracketing(i.e., putting aside or enclosing in paren-
theses their preconceptions of the phenomenon that was the object of
the study). In the said research approach, it is important for researchers to
identify and write down their hypotheses and beliefs about the phenome-
non in question (a fundamental technique of critical reflection)sothat
data analysis will not be influenced by the researchers' preconceptions.
By carrying out this reflective technique before data collection and analy-
sis, the researchers can deliberately avoid introducing their own biases
into the analysis process (Cohen et al., 2000).
After the researcher/interviewer explained the nature and pur-
pose of the study to all participants, the latter chose the date and time
of their interviews. In full compliance with the restrictive measures
issued to protect Italian citizens' health, this study used video call
interviews, which, as described in the literature (Janghorban
et al., 2014), can fully substitute for the classic face-to-face interviews
because they allow for the perceptions of nonverbal language. Video
call interviews were conducted using the platform suggested by par-
ticipants (i.e., Skype, teams or zoom). Each participants had access to a
computer, and we did not meet any technical problems with the digi-
tal internet connection during the interview.
The interviews were conducted by the first, third, and last authors
using a single open-ended question to guarantee the participants'
maximum freedom of expression. In this way, the worldof each par-
ticipant became the focus of the research (Polit & Beck, 2018). The
participants had previously had no contact with the researcher who
conducted the interviews. To ensure that the participants would be
able to freely relate and describe their lived experiences, the inter-
views were held at the venues and times chosen by the participants
(where it was assumed they were most comfortable and without the
presence of other people), and the interviewer maintained a welcom-
ing attitude during the interview, showing utmost cordiality and
impartiality. During the interviews, the researcher wrote field notes
(i.e., personal reflections and notes relating to the context and nonver-
bal language used by the interviewees). Each interview was concluded
when the participants expressed that they no longer had anything
more to add. Data saturation was considered to have been reached
when no more new themes were identified from the participants'
interviews (Polit & Beck, 2018). As required by Cohen's methodology
(2000), the interview data and the fieldnotes should be converted into
digital form as soon as possible after they are gathered. Audiotapes of
each interview need to be transcribed verbatim, and the accuracy of
the transcription should be thoroughly checked.
This procedure allows you to identify possible themes immedi-
ately. The interviews are converted as soon as they are acquired, and
this allows to identify the themes early and consequently observe if
the themes become redundant or saturated.
All the interviews were only audio recorded and lasted 30
50 min. This decision was made because in a classic phenomenological
interview, the methodology suggests to audio-record only the inter-
views in order to analyze them and identify any common themes. By
video recording the interview, we could no longer guarantee confi-
dentiality and anonymize/de-identify their data. Information about
participants and their clients are reported in Table 1.
3.4 |Data analysis
Every interview was transcribed verbatim, and the field notes made
during the interview were integrated with the interview transcripts.
Each interview transcript and the associated field notes were first read
in their entirety to obtain an overview of the participant's experiences.
Consistent with the method described by Cohen et al. (2000), each
researcher then reread each transcript line by line and assigned broad
themes to the various passages of the text. Indeed, Cohen et al. (2000)
defined three phases in the data analysis. The first phase is called
immersing oneself in the data,which aim is the establishment of an
initial interpretation of data that will drive later coding of the data in
subsequent phases of analysis. In this first phase, researchers identify
the essential characteristics in the data from each interview. Conse-
quently, researchers proceeded with second phase, called data transfor-
mation or data reduction. This process is like editing, where researchers
deleted digressions that could be clearly off topic. In the third phase of
the data analysis, data were subjected to the line-by-line coding, neces-
sary for thematic analysis. Thereafter, the researchers compared their
extracted themes. No discrepancies among the researchers' findings
were found at this stage. The participants were informed of the identi-
fied themes in a second meeting (via video call) to confirm the
extracted themes. They confirmed all the themes and did not add any
further to the experience they had told. This process, called also mem-
ber checking, results being fundamental in Cohen's phenomenology
(Cohen et al., 2000). Indeed, as described by Cohen et al. (2000)and
Lincoln & Guba (1985), themes should be verified with participants to
ensure that the themes appropriately capture the meaning that partici-
pants sought to convey. Disagreements in interpretation should send
the researcher back to the field text for clarifications.
3.5 |Rigor
We also adopted Lincoln and Guba's criteria (Lincoln & Guba, 1985)
for qualitative research to further guarantee the scientific rigor of this
study. Continuing sampling with data collection until the same is satu-
rated has ensured credibility. In qualitative research, credibility
SIMEONE ET AL.397
TABLE 1 Sociodemographic and working characteristics of the homecare workers (n=19)
Code Gender Age
Home
country
Marital
status Education
Healthcare
training
Years in
Italy
HCW experience
(in years) Living situation
Uses public
transport
Patient
gender
Patient
age Patient clinical condition
AZ01 F 54 Russia Married High school No 11 10 House of patient Yes M 75 Alzheimer
BV02 F 47 Ukraine Married Middle school No 7 5 House with friends Yes M 68 Diabetes, hypertension
CU03 F 49 Moldova Married High school No 9 9 House with friends Yes M 67 Dementia
DT04 F 54 Russia Single Middle school No 13 9 House with family Yes M 71 Diabetes
ES05 F 56 Bangladesh Married Primary school No 10 7 House with family Yes M 63 Stroke, hypertension
FR06 F 59 Italy Married Middle school No 59 15 House with family Yes F 73 By-pass, diabetes
GQ07 F 57 Italy Married High school Yes 57 1 House with family Yes M 67 Hypertension, diabetes
HP08 F 51 Moldova Single High school No 10 9 House of patient No F 64 Alzheimer, diabetes
IO09 F 52 Ukraine Married Middle school No 7 5 House with friends Yes M 77 Dementia, hypertension
LN10 F 48 Moldova Married High school No 9 9 House with friends Yes M 71 Chronic obstructive
pulmonary disease
MM11 F 54 Moldova Single Middle school No 13 9 House with friends Yes F 78 Dementia, diabetes
NN12 F 51 Peru Married Middle school No 8 5 House with friends Yes F 75 Parkinson's, Alzheimer
OM13 F 56 Moldova Married Middle school No 12 9 House of patient No F 70 Alzheimer
PL14 F 51 Romania Married High school No 11 9 House with family No M 68
QI15 F 53 Ukraine Married Bachelor's degree No 13 11 House of patient Yes M 71 Parkinson's, dementia
RH16 F 46 Ukraine Married Middle school No 7 5 House with friends No M 75 Dementia
SG17 F 51 Moldova Single Middle school No 10 7 House with friends Yes M 67 Heart attack
TF18 2 51 Ukraine Married Middle school No 7 9 House of patient Yes M 76 Alzheimer
UE19 2 49 Ukraine Single High school No 9 7 House with friends Yes F 74 Visually impaired
Abbreviations: F, female; HCW, home care worker; M, male.
398 SIMEONE ET AL.
corresponds to internal validity and is a criterion for ensuring that the
study examines what it is intended to (Lincoln & Guba, 1985;
Shenton, 2004). In our study, we used a technique called triangulation.
Triangulation method involves the participation of two or more
researchers in the same analysis to provide multiple observations and
conclusions (Lincoln & Guba, 1985). This method can bring both confir-
mation of findings and different perspectives, adding breadth to the phe-
nomenon of interest. Triangulating the analysis among the researchers
ensured the reliability criterion. Asking the participants for confirmation
about themes extracted and the use of bracketing by researchers made
it possible to satisfy the criterion of confirmability. Reporting a thorough
description of the experience of our participants with a description of
their sociodemographic characteristics ensured compliance with the
transferability criterion. Transferability is communicated, in part, through
description of sampling factors such as geographical location of the
study, number and characteristics of participants, and the time frame of
data collection and analysis (Shenton, 2004). Such descriptions also con-
tribute to the credibility of the results and readers' determination of
transfer to their and other contexts.
3.6 |Ethical considerations
The institutional review board of University of Rome Tor Vergata
approved the study. The study conforms to the principles outlined in
the Declaration of Helsinki. Before signing the informed consent form,
the HCWs were informed of the study's aim and nature and advised
that their interviews would have been used with confidentiality,
ensuring that no single participants could not be traced in the
reporting study. Confidentiality was addressed during the research
planning and at three points during the research process: data collec-
tion, data cleaning and dissemination of research. At the data collec-
tion, researchers make assurances of confidentiality, typically via
consent form statements. During the data cleaning, researchers
removed identifiers to create a clean data set, which did not contain
information such as a name or address. In the dissemination of
research, participants were coded. The participants were also told that
they could withdraw from the study at any time. They did not receive
any type of payment for contributing to the study.
4|RESULTS
From the analysis of the data, four principal themes emerged: (1) I found
myself alone; (2) from invisibility to visibility; (3) a fear of getting sick
and infecting others; and (4) Health or work? That is the question.
4.1 |Theme 1: I found myself alone
All the study participants said that they remembered their feeling of
sudden isolation during the first wave of the pandemic, particularly
because of the government measures of total restriction to arrest the
spread of COVID-19. Their relationships with their compatriots and/or
with the other members of their clients' families were suddenly cut. As
they continued to work during the pandemic, the people who were
normally around them before the pandemic disappeared. The members
of their clients' families, who often used to help them accomplish
household chores, suddenly stopped doing so. Suddenly, all responsibil-
ities fell into their laps, making them feel alone and isolated in their
new reality, quite different from what they had been used to.
At the beginning I suddenly found myself alone [sit-
ting, with the palms of her hands at chest height, paral-
lel to the legs, she spreads her arms and hands
outwards], with no one ever coming home. Suddenly,
everything depended on me it was just my client and
I. I had to think of everything . (AZ01)
My patient and I found ourselves alone. The family was
not really completely gone, but I rarely saw them .At
that time, I worked even at night because I couldn't go
home to my family as I also had to protect them from
the virus in case I had been infected by it. That made
me feel even more alone . I had to think here and at
work, to assist, but I had to think about them too .I
was sad and I felt bad. I felt alone. (MM11)
The network of friendships that had been established by the partici-
pants also suffered due to the pandemic and the restrictions that were
imposed by the government to limit the spread of the virus. There-
fore, what they thought they had gotten a foothold on proved to be
unstable after all, which increased their sense of isolation.
For the first time [with her right hand half open, she
makes a gesture that can be likened to throwing some-
thing behind], suddenly I was alone and had to look
after myself and my client. I had to do everything
myself, even more than before . I felt really alone
then because even in my own house, where I lived, no
one left his or her room, and nobody wanted to talk
too much because we all didn't know if everyone used
masks where they worked . Sometimes, you didn't
know if you were alone in the house or not.(BV02)
Suddenly, even your friends didn't want to see you,
you know We decided to live together so we could
share the expenses, and we often ate together in the
evening or did some things together. When the pan-
demic began, it seemed that they too were far away .
We sometimes spoke by videophone, almost as if they
were in Ukraine, like my real family . Even with the
other HCWs we sometimes went shopping together
or did chores together, you know, for company but
ever since the pandemic began, nobody had wanted to
be with other people . (IO09)
SIMEONE ET AL.399
4.2 |Theme 2: From invisibility to visibility
Despite their sense of total isolation, the study participants found a
new social consideration of their role. They felt appreciated and noticed
a new or increased interest in them and their work. They understood
that their clients were often more vulnerable than others, and they saw
how their work was being viewed in a different light not only by the
members of their clients' families but also by healthcare professionals.
Suddenly, they perceived people's recognition of the strategic impor-
tance of their role, which people had seen in a different light up to that
moment. The new attention to their work was well received. All the
participants declared that they no longer felt invisiblein the commu-
nity because they noted that many people started to understand the
importance of their role, especially during this pandemic.
From the almost invisible people we were before, we
became more important. It's as if they had turned a
light on us . Now, in addition to everything that we
did before, we also saw other symptoms, and we
checked more. It seems that our clients' families and
friends saw this.(OM 13)
I also see now how everyone is more interested in me,
in what I'm doing. People compliment me regarding
how I do my job, how I behave [in a sitting position, he
suddenly straightens his back and widens his shoul-
ders; a smile appears on his face]. Now, everyone is
thanking me. For example, when the doctor called me
to ask about my client's medicines, he also wanted to
know how my clients and I were and how I organized
my tasks . (ES05)
After the first wave of COVID-19, however, it seems that the role of
HCWs has been slightly downsized.
Things now almost seem to be going back to how
they were before The work that I do is always the
same. I stay close to my client, I help him, I work at home,
I take care of him It seems, however, that my ideas,
my thoughts, and I are disappearing again. (FR06)
4.3 |Theme 3: A fear of getting sick and infecting
others
The study participants described their fear of acquiring COVID-19
and of making people around them (e.g., their family and friends) sick.
They described how their fear of being infected and of infecting
others, especially their clients and/or their families, was always con-
stantly present in their minds. They also felt that they could not
always comply with the recommendations given by the government
to protect themselves from being infected, and that this would not
always be because they were negligent.
Before,Iwasmuchmoreafraidnotonlyformyselfbutalso
for those who were close to me. Every day I took public
transport to go to work . It was therefore impossible to
be careful . I always wore a mask, but keeping a wide dis-
tance between two people was impossible. I thought that
if my client got sick, especially at the beginning, the fault
could only be mine even when I just went to buy medicines
or other things for my client's house. I was always afraid of
getting sick and making him sick.(CU03)
At first, I was afraid of bringing the disease not only to
work but also to my home, to my son.I was the one
who went to work, did the shopping and went to get
the medicines and everything else. I was responsible if
something happened because I was the only one who
was going out . I was therefore always worried that if
my client or my son got sick it would be my fault [puts
her hand on her chest].(NN12)
4.4 |Theme 4: Health or work? That is the
question
The study participants described how many of the choices they had
made during the first wave of the present pandemic were a compro-
mise between safeguarding their and others' health and the need to
work. It was as if there was a tug of war between their fear of con-
tracting the virus and of conveying it to their clients and loved ones
on the one hand and knowing they needed to work on the other.
However, as HCWs often do not have a regular contract with their cli-
ents with the specific protections provided by law, the economic
aspect prevails over their personal feelings.
I was really afraid, and I still am, but we have to work;
otherwise, we can't stay alive [she puts her right hand
on her belly and then moves it quickly up and down].
I came here to give my family a better future, and for
this I allowed myself to face many difficult things, and
I'm still doing that now . I've turned my back on my
personal protection, and I go on .(LN10)
The fear was so much, very much, and now it's still
there But we have to work; otherwise, we can't stay
alive [she puts her right hand on her belly and then
moves it up and down in quick succession] I came
here to give my family a better future, and for this I
allowed myself to face many difficult things, and I'm
still doing that now . I've turned my back on my per-
sonal protection, and I go on. (LN10)
Fear was always there, but what should I do? Health or
work? That is the question. If you reject the work, then
how do you stay alive?(DT04)
400 SIMEONE ET AL.
5|DISCUSSION
In this study, we explored the lived experiences of HCWs in Italy who
cared for patients during the first wave of the COVID-19 pandemic.
To the best of our knowledge, this study is only the second to focus
on the HCWs' lived experiences during the present COVID-19 pan-
demic (Sterling et al., 2020) and the first to be conducted in a
European country. We discovered important issues that should be
considered by investigators, clinicians, administrators, and the public.
Despite the present and future importance of HCWs, little is known
about their lived and work experiences, especially the crucial role that
they have played so far in this pandemic.
The first theme that we identified was I found myself alone.
The study participants described the feeling of isolation that they had
experienced during the first wave of the pandemic because of the
restrictive measures taken by the government to arrest the spread of
the virus. In many cases, the participants found themselves isolated in
their client's home, without any support. In Italy, it is very common for
HCWs to live 24 h a day with their clients (Bilotta & Vergani, 2008).
The measures issued by the Italian government to contain the spread
of the COVID-19 pandemic led to a drastic reduction in visits to fri-
ends and family. As described by some of the HCWs interviewed in
this study, it seemed as if everything depended on them. This feeling
of being abandoned by everyone, not having support, and having the
overwhelming responsibility (everything weighs on me) of having to
take care of their client without ever letting go may have increased
the burden and loneliness of HCWs (Del-Pino-Casado et al., 2018;
Dich et al., 2019; Simard & Volicer, 2020). The feelings of being over-
burdened and loneliness can have many deleterious consequences; it
has been shown that higher burden levels can decrease HCWs' quality
of life (Lo et al., 2019; Perpina-Galvan et al., 2019).
The feeling of no longer being invisible was the second theme that
was identified in the study participants' interviews. HCWs constitute an
invisible and vulnerable group in society, especially when they are
migrant workers. In many countries, they are considered guest
workersand will not be given the benefit of citizenship at any time in
the future. HCWs are usually invisiblein society (Ahonen et al., 2010),
and many family employers are also unaware that domestic labor and
caregiving may have negative impacts on one's health. Intimacy with
one's employers and a variety of psychosocial, physical, biological, and
chemical conditions have been shown to be important risk factors for
the health and safety of HCWs (Muramatsu et al., 2019;Orrenius&
Zavodny, 2009). A live-in regimen could mean more working hours, lack
of privacy, social isolation, and little rest (Hewko et al., 2015).
However, for many, this pandemic represented an opportunity
for change (no longer invisible,) as the study participants found a
new social consideration of their role. They felt appreciated and per-
ceived a new or increased interest in them and their work from the
members of their clients' families and from health professionals. Con-
trary to what was found in this study, however, Sterling et al. (2020)
observed that the HCWs in their study still felt invisible to the
healthcare community and society during the present pandemic
despite their efforts to keep their clients healthy and safe.
The fear of getting sick or infecting others, especially their clients
and their families, was a constant feeling among our sample of HCWs.
Fear is an adaptive response in the presence of danger. With the spread
of COVID-19, national polls have indicated a sharp increase in fear and
worries relating to the virus (Arora et al., 2020). In previous studies on
healthcare professionals (Apisarnthanarak et al., 2020; Taylor
et al., 2020), fear was found in almost all the participants. Researchers
(Taylor et al., 2020)haveobservedthatpeople'sfearofacquiring
COVID-19 could be related to different topics, including fear of danger
and contamination, fear of the social and economic consequences of
such, coronavirus-related xenophobia, compulsive checking and reas-
surance seeking, and traumatic stress symptoms. However, although
the feeling of fear can be common during a pandemic or dangerous
event, if it is not kept in check, it may have serious health conse-
quences. For example, previous studies have identified the conse-
quences of fear at the individual level, such as mental health problems,
anxiety, and phobias (Shin & Liberzon, 2010), or at the societal level,
such as panic shopping or xenophobia (Sim et al., 2020). Once again, it
is evident how strong the impact of this pandemic has been on the
study participants, making them increasingly vulnerable. These findings
suggest the need to provide psychological support not only for
healthcare professionals but also for HCWs.
Not knowing whether to give more importance to their health or to
their work was the final theme as identified in the interviews with the
study participants. One participant described this theme in a somewhat
Shakespearean form: Health or work? That is the question,which rep-
resents a real problem. Having to decide whether to prioritize health or
work puts one at an even greater risk. However, it is not news that
HCWs typically have precarious contracts (Hill et al., 2019), as in Italy,
HCWs are often underpaid and living in difficult conditions (Bilotta &
Vergani, 2008). For migrants, such work often represents the only form
of sustenance available. Our findings in this study showed that despite
the risks involved for fear of losing their jobs and not being able to sup-
port their families, many HCWs worked and thus set aside their health
aside for work. In addition, the living conditions and multigenerational
households of migrant HCWs may increase their risk of being infected
with COVID-19.As described in the literature (Burstrom & Tao, 2020),
work-related exposure is heightened for people in occupations that
cannot work from home and that entail physical proximity to or direct
contact with other people. Precarious employment and a lack of social
insurance are also more common among low-income earners, which
can limit their financial ability to stay home during sickness.
This study has several implications. First, the results obtained
from the interviews highlighted the extent to which HCWs are at risk
from a psychological viewpoint and from the viewpoint of acquiring
the disease. Second, it is known that HCWs have an effect on their
clients' perceived quality of life; thus, anything that affects HCWs
may also have implications for their clients. The COVID-19 pandemic
has underscored the loneliness of HCWs. Loneliness can increase the
risk of depression, alcoholism, suicidal thoughts, aggressive behaviors,
anxiety, and impulsivity (Cacioppo et al., 2015; Yanguas et al., 2018).
Some studies found that loneliness is also a risk factor for cognitive
decline, recurrent stroke, obesity, elevated blood pressure and
SIMEONE ET AL.401
mortality (Hawkley et al., 2010; Lara et al., 2019). Future studies
should therefore longitudinally analyze the impact of the current
COVID-19 pandemic on HCWs' physical and mental health.
The HCWs' mental health influences their performance and there-
fore the health of the assisted subjects and has repercussions on the
family unit. Nurses and physicians also have a responsibility toward the
preparation of HCWs. Understanding how they dealt with the COVID-
19 pandemic will allow nurses to understand how to relate to the
HCWs, increasingly of reference for older patients and their families.
6|CONCLUSION
This study provided a comprehensive and in-depth understanding of
the lived experiences of HCWs caring for patients during the current
COVID-19 pandemic. As observed in our study, the Italian HCWs'
psychological health has been severely affected by the first wave of
the COVID-19 pandemic. Countries should pay greater attention to
HCWs and should provide them with greater work security. These
results should induce researchers and clinicians to give greater visibil-
ity to HCWs by undertaking longitudinal research projects aimed at
analyzing their quality of life and the effects of their work on them.
Greater attention should be paid to HCWs and to their role toward
patients and the family unit.
7|RESEARCH LIMITATIONS
This study had several limitations. First, it focused on only one
European country (Italy), which limits its generalizability to other
countries that may have different labor policies for HCWs. Another
limitation is possible selection bias. Many subjects, especially migrant
workers with precarious jobs and who fear work repercussions, could
have chosen not to participate in this study, and only those who had
more favorable working conditions could have chosen to participate.
Finally, this study used video call interviews, which, as described in
the literature, could substitute for the classic face-to-face interviews.
In reality, however, the video call interviews in this study might have
failed to capture nonverbal information, which could have been easier
to capture in face-to-face interviews. Many of the authors are experts
in qualitative interviewing and analysis and have instructed less expe-
rienced colleagues. Two pilot interviews were conducted to ensure
correct familiarity with data collection and data analysis.
ACKNOWLEDGMENTS
The authors are grateful for the contribution of HCWs who gener-
ously shared their experiences of working during the COVID-19
pandemic.
Open Access Funding provided by Universita degli Studi Magna
Graecia di Catanzaro within the CRUI-CARE Agreement.
CONFLICT OF INTEREST
The authors declare that they have no conflicts of interests.
AUTHOR CONTRIBUTIONS
Study design:: Silvio Simeone, Ercole Vellone, Madeline R. Sterling.
Data collection: Silvio Simeone, Michele Virgolesi, Gianluca Pucciarelli.
Data analysis: Silvio Simeone, Ercole Vellone, Michele Virgolesi, Mad-
eline R. Sterling. Rosaria Alvaro, Gianluca Pucciarelli. Manuscript writ-
ing: Simeone, Ercole Vellone, Michele Virgolesi, Madeline R. Sterling.
Rosaria Alvaro, Gianluca Pucciarelli.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on
request from the corresponding author. The data are not publicly
available due to privacy or ethical restrictions.
ORCID
Silvio Simeone https://orcid.org/0000-0001-9266-0185
Gianluca Pucciarelli https://orcid.org/0000-0001-6915-6802
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