Coronavirus disease 2019 (COVID-19) first emerged in Wuhan, China, in December 2019. 1 As of September 13, 2023, there are 770 563 467 confirmed cases of COVID-19 globally, with 61 203 510 from Southeast Asia. 2 As a result of the global vaccination effort, the number of COVID-19 cases has significantly declined since the beginning of 2023. Nevertheless, the pandemic has underscored the psychological impact it can have on health-care professionals (HCPs), emphasizing its significance in pandemic preparedness.
Stress induced by increased health-care demand, coupled with a lack of resources during a pandemic, can lead to adverse psychological outcomes, such as heightened anxiety and depression. These, in turn, result in suboptimal patient care, burnout, and reduced morale.Reference Pearman, Hughes and Smith 3 , Reference Panagioti, Geraghty and Johnson 4 The importance of morale as a distress-reducing factor is often referenced in the military context, where high morale among troops predicts fewer casualties and victory.Reference McNabb Cochran and Long 5 This suggests that higher morale leads to better resilience and coping capabilities during challenging times. In the context of health care and pandemics, maintaining good team morale is crucial for the psychological well-being of HCPs, ensuring the delivery of higher quality, safer, and more satisfactory care to patients.Reference Salyers, Bonfils and Luther 6 Therefore, it is paramount to understand how COVID-19 affects the morale of HCPs to mitigate negative downstream effects such as decreased productivity and staff absenteeism.Reference Greenberg and Tracy 7
However, the majority of existing literature primarily focuses on the psychological implications of COVID-19 on HCPs, with a limited number of qualitative studies specifically addressing morale. To the best of the authors’ knowledge, none have been conducted in the Southeast Asian context.Reference Beckwith, Nimmo and Savino 8 , Reference Yasin, Barlow and Milner 9 This study aims to address this gap by adopting a fully qualitative approach to understand the experiences of frontline HCPs in Singapore and their morale.
Singapore experienced its first spike in COVID-19 cases in March 2020, attributed to Singaporeans returning from overseas travel.Reference Tan, Cook and Logan 10 The second spike occurred shortly after, in the second half of April 2020, with the majority of cases among migrant workers residing in local dormitories, making them the largest community affected by COVID-19 at that time.Reference Tan, Cook and Logan 10 Volunteer HCPs from Sengkang General Hospital (SKH), an acute regional hospital in Singapore, were deployed to one of the local dormitories to perform swab tests and provide medical care for migrant workers. This study aims to explore and understand the experiences and impact of COVID-19 on the morale of HCPs who served the migrant workers in Singapore.
Methods
Study Design
This study adopted an exploratory, cross-sectional, qualitative design involving one-on-one semi-structured interviews.
Sampling and Recruitment
Study participants were recruited through purposive and snowball sampling. HCPs, including doctors, nurses, allied health professionals, and ancillary staff employed by SKH, who volunteered to serve migrant workers in the dormitories, were eligible. HCPs who were unwilling to be audio-recorded were excluded. The sample size was not predetermined, and recruitment stopped upon data saturation. Data collection and analysis were carried out concurrently.
Potential participants received an email introducing the research study and were invited to express their interest via email. Interviews were then scheduled at their convenience.
Data Collection
Participants received a detailed participant information sheet explaining research objectives, processes, and the need for audio recording before informed consent was obtained. Participants also completed a demographic data collection form before interviews began. Eleven semi-structured interviews, lasting 40 to 60 minutes each, were conducted over 2 months. To ensure consistency, all interviews were conducted by the same researcher using an interview guide. The interview guide was tested prior to data collection in a pilot interview to establish whether questions were clear and understandable, and whether changes were required. Questions in the interview guide were drafted with the research team’s consensus and comprised open-ended questions that focused on exploring HCPs’ experiences, feelings, and perception of their morale during the deployment. HCPs were asked questions like, How was your experience serving the migrant workers in the dormitory?, How was your morale at the end of your duty?, and By understanding what COVID-19 is, how did it affect your morale as a health-care worker?
Data Analysis
As many participants spoke Singlish, a colloquial form of English, audio recordings were transcribed verbatim to accurately capture the intended meaning of responses.Reference Tan 11 Thematic analysis, following Braun and Clarke’s framework, was used for transcript analysis.Reference Clarke and Braun 12 Transcripts were read and coded manually by the primary researcher. Similar codes generated across transcripts were then combined and collapsed where appropriate, giving rise to subthemes. Similar subthemes then merged to generate themes. Demographic data were manually analyzed separately using descriptive statistics.
In the context of this study, morale was analyzed based on HCPs’ responses to open-ended questions specific to morale that were posed to them during the interviews. Descriptors used by HCPs such as “high,” “low,” and “good” provided a general sense of their morale during dormitory deployment.
Ethical Considerations
Ethical approval was obtained from the Centralised Institutional Review Board of Singapore (CIRB Ref: 2020/2689). Participants were reminded of voluntary participation and the ability to withdraw consent at any point without repercussion. Data collected were kept strictly confidential and anonymized.
Results
Description of Participants
A total of 11 study participants, referred to as HCPs from hereon, participated in this study. Characteristics of the HCPs are shown in Table 1. Of the HCPs, 54.5% were nurses. The average age was 35, and most were Singaporean Chinese males. Most HCPs had at least a bachelor’s degree, with only one who had a diploma.
Table 1. Characteristics of participants (N = 11)
a PR= Permanent resident
* Health-care administrator
Results of Thematic Analysis
Results of thematic analysis of interview transcripts are presented in Table 2. Four main themes emerged; HCPs shared what motivated them to serve and the challenges they faced, while emphasizing the importance of support and leadership on boosting their morale.
Table 2. Themes and subthemes generated
Theme 1: motivators
Most HCPs volunteered to go to the dormitory, citing personal growth and gaining experience as motivators. About half (n = 6) were motivated by a sense of professional duty, commenting that they were unable to “sit by and watch this happen.” Similarly, some (n = 4) revealed altruistic intentions and were eager to help as it “makes (them) happy.”
Theme 2: challenges
All HCPs (n = 11) faced challenges while working in the dormitory. One of the key challenges faced by HCPs (n = 9) was a language barrier. The majority of the migrant workers in Singapore come from Bangladesh and spoke Bengali, a language that is foreign to most Singaporeans.Reference Wee, Lam and Yeoh 13 HCPs recounted having great difficulty communicating with the migrant workers in English. Additionally, having to be geared in full personal protective equipment (PPE) compounded frustrations because it impeded the conveyance of emotions and nonverbal cues. Most HCPs (n = 9) also commented on the difficulties of working in full PPE and described it to be “suffocating” and “very hot.”
The lack of clarity and frequent changes in workflows created uncertainty and affected the confidence of HCPs. Many HCPs (n = 7) were fearful of contagion and were worried about bringing the virus back to their families. Another challenge that surfaced was coping with negative emotions such as helplessness and powerlessness while witnessing the harsh living conditions in the dormitory. Interestingly, despite feeling helpless, a few HCPs described that they had overall “good” morale, suggesting an element of psychological resilience.
Theme 3: support
Having support was a recurring factor identified by HCPs to be important in sustaining morale. In particular, peer support and teamwork helped moderate HCPs’ frustrations. Despite the challenges faced, HCPs shared that they enjoyed their work nonetheless because they got to work alongside their peers. A few HCPs (n = 3) also brought up the role of family support in sustaining them.
Acknowledgments such as appreciation and gratitude from the migrant workers, encouragement from health-care leaders, and recognition from the public boosted the morale of HCPs greatly as they felt that their effort was worthwhile. Other support from the public in the form of food donations and encouraging messages on social media also improved morale.
Theme 4: leadership
Another important theme that emerged from the data was the importance of leadership in uplifting morale. Many HCPs (n = 6) mentioned that having leaders work alongside them boosted their morale immensely. It created a sense of camaraderie and friendship between leaders and ground staff. HCPs were appreciative of their leaders “leading by example,” which inspired and motivated them because “you know you are not alone.”
Discussion
Demographic Data
Demographical data were unremarkable except for profession and race; there were more nurses (n = 6) and Chinese (n = 11) HCPs in this study. The impact of ethnicity and profession on study results was unremarkable; no distinct trends were observed. This differs from previous studies where nurses were reported to have higher rates of anxiety and depression compared to other professions as a result of closer and higher frequency of patient contact.Reference Lai, Ma and Wang 14 This disparity could be because all the HCPs in this study worked under the same environment with similar hours and patient contact time, regardless of profession, resulting in similar experiences.
Experiences of HCPs Who Served the Migrant Workers in the Dormitory During the COVID-19 Pandemic in Singapore and Its Impact on Morale
Theme 1: motivators
Several HCPs shared that the motivating factor for them to volunteer to work in the dormitory was to gain experience. This might correlate with the demographics of the study population, where the average age is only 35 years old. However, studies exploring motivators and predictors of volunteerism during the COVID-19 pandemic found that a younger age was not always predictive of the likelihood to volunteer.Reference Geng, Cheung and Huang 15 Thus, the propensity to volunteer is more likely to be correlated with the desire to gain experience or personal growth and not solely due to a lack of it.
Another crucial motivator among the HCPs to serve was a sense of professional duty and obligation to perform their duty of care. Pahlman et al. postulate that legal duties and obligations of HCPs toward patients under normal circumstances should not be expected during a pandemic.Reference Pahlman, Tohmo and Gylling 16 Hence, the decision to volunteer despite the increased risks suggests an altruistic component, given the liberty of choice in this context.
Theme 2: challenges
HCPs faced difficulties in adapting to a new environment, with rapidly changing workflows adding to their frustrations and decreasing confidence. This is consistent with current literature, where HCPs reported feeling anxious or stressed as a result of ambiguous and conflicting policies.Reference Billings, Ching and Gkofa 17 However, changes in guidelines and policies are inevitable to keep up with the rapidly changing situation and information due to the emergence of new variants during a pandemic. Thus, efforts should be targeted at improving communication channels so that the latest guidelines and information can be relayed to ground more effectively to minimize confusion.
Another common finding between this study and other published studies was HCPs’ fear of contagion. The lack of PPE was identified as a key contributor in other studies but was not reflected in this study.Reference Fernandez, Lord and Halcomb 18 Despite having an adequate supply of PPE, HCPs in this study still expressed fear of contracting the virus. Inaccurate or sensationalized portrayal of the COVID-19 pandemic, and fear mongering on mainstream media or social media platforms, could have generated anxiety among HCPs.Reference Ng and Kemp 19 Therefore, in addition to ensuring an adequate supply of PPE, stakeholders should also address common fears among HCPs and ensure accurate dissemination of information to mitigate fear.
HCPs also expressed difficulty in coping with negative emotions. The majority of HCPs recounted feeling helpless when witnessing the hardships faced by migrant workers. Nearly half of the migrant workers’ accommodations failed to meet minimum hygiene standards and living space regulations, with each worker estimated to have only 4.5 square meters of living space.Reference Cheong 20 With migrant workers often falling through the cracks of protection systems and social safety nets, they are rendered vulnerable with limited accessibility to health care during a pandemic. In the study by Rao et al., participants expressed immense grief witnessing the impact of COVID-19 on vulnerable communities, much like the migrant worker situation in Singapore.Reference Rao, Mancini and Tong 21 Although empathy and compassion are the essence of health care, repeated interaction requiring high levels of empathy—like working with vulnerable groups—is more likely to cause compassion fatigue and emotional exhaustion.Reference Sorenson, Bolick and Wright 22 Therefore, psychological support is vital to boost morale.
Ironically, the same HCPs who shared that they felt helpless also said they had overall “high” morale—similar to the findings reported by other studies.Reference Cai, Lian and Song 23 , Reference AlKudsi, Kamel and El-Awaisi 24 This suggests an element of psychological resilience or efficacy of protective factors such as peer support in moderating negative emotions. Psychological resilience and positive emotions can, in fact, enhance adaptive coping and reduce anxiety in individuals experiencing stress.Reference Gloria and Steinhardt 25 Recognizing the significance of psychological resilience and the efficacy of protective factors can thus inform interventions and strategies aimed at enhancing the psychological well-being of HCPs.
Conversely, it is also possible that the HCPs interviewed for this study might have had “high” morale and self-efficacy to begin with. Volunteerism is often associated with having high morale, accompanied with a sense of efficacy and self-perceived control over occurrences in the environment.Reference Lu, Xu and Shelley 26 HCPs who had volunteered themselves to serve the migrant workers might therefore have already been inherently better at managing their emotions and maintaining morale.
Theme 3: support
A significant recurring theme in this study was the importance of support in maintaining morale. Peer support as a coping mechanism was especially prominent, which is in line with current literature.Reference Sun, Wei and Shi 27 In the context of a pandemic, peers provide mutual empowerment because they share a common understanding of the situation and thus are able to offer emotional and practical support for one another. Fostering peer support networks can therefore be an essential strategy in maintaining morale and minimizing psychological distress in HCPs.
Support from the public also helped sustain morale among HCPs during the pandemic. This was congruent with findings of the meta-synthesis by Bilings et al., where HCPs sought support and recognition from the public.Reference Billings, Ching and Gkofa 17 Appreciation and recognition from the public increases confidence through validation while creating a sense of social acceptance. In contrast, a lack of appreciation can lead to HCPs feeling undervalued and disrespected.Reference Yıldırım, Aydoğan and Bulut 28 Giving validation and recognition to HCPs’ hard work can thus potentially boost work motivation and morale.
Theme 4: leadership
Another finding of this study is the importance of leadership. Visible leaders motivated and inspired ground staff. Leaders or senior members working together on the ground with junior members or colleagues from other professions blurs inherent hierarchical segregation among HCPs, enhancing team cohesion and boosting morale. This is especially relevant to Singapore’s context, where hierarchical structures are prominent among HCPs, especially in nursing.Reference Loke, Lee and Laurenson 29 Leading by example effectively flattens the hierarchy and motivates HCPs by creating a sense of community and camaraderie.
Moreover, effective leadership instills confidence in frontline HCPs during a pandemic.Reference Kaul, Shah and El-Serag 30 In times of pandemics, when there is volatility and uncertainty, leaders act as a beacon to provide directions and help maintain operations. Therefore, competent leadership during a pandemic is vital to sustain morale among HCPs.
Limitations
This is a cross-sectional study involving a small sample size of volunteer HCPs from a single regional hospital in Singapore. Generalizability is hence difficult and should be carefully considered. Furthermore, the long-term effects of being on the front line on HCPs’ morale cannot be determined. Data such as the number of years of work experience of HCPs were also not collected for this study. In addition, HCPs who worked in other environments during the COVID-19 pandemic as a means of livelihood rather than voluntarism may have different responses than the HCPs in this study.
Conclusion
This study explored the experiences of frontline HCPs who served migrant workers in a local dormitory, a COVID-19 hotspot, during the COVID-19 pandemic. HCPs shared that they had an overall “high” morale despite the challenges they faced, suggesting the protective effect of good psychological resilience, a peer support system, and leadership. Stakeholders should therefore aim to enhance these buffers to maintain morale among HCPs in a pandemic. Further studies involving a larger sample size across different settings are needed.
Competing interests
None to declare.
Acknowledgments
We would like to convey our gratitude toward our study participants for taking time off to attend the interview and to SKH ED’s nursing management for facilitating this study, especially our nurse clinician, Mr. Ahmad Khai.
Funding statement
None to declare.
