The purpose of the study was to develop and describe a psychosocial model for enhancing psychosocial support for healthcare workers during COVID-19 and other public health emergencies.

According to Moule, Aveyard and Goodman (2016), trustworthiness refers to a method of establishing or ensuring scientific rigour in qualitative research, without sacrificing relevance. The researchers complied with measures aimed at ensuring credibility, dependability, confirmability and transferability. Moule et al. (2016) defined credibility as the degree to which the study’s findings are a true reflection of the experiences and perceptions of the study’s participants. To enhance credibility, the researchers made every effort to build rapport and a relationship of trust with the research participants through prolonged engagement, bracketing and peer debriefing. Transferability was ensured through the use of dense descriptions of the participants’ lived experiences, as well as demographic information and the use of direct quotes. To further enhance trustworthiness, the model was shared and reviewed by nurse managers, nurse educators and nurses who had either suffered from COVID-19 or conducted COVID-19 response activities.

The design of the model took the form of three sequential phases, namely presentation of the empirical foundation of the model, development of the model, and description of the model. Donabedian’s theory (Donabedian 1980a, 1980b) and the work of Dickoff et al. (1968) constituted the theoretical framework guiding the model development process. The model further drew on study’s findings by Moyo (2022) and Moyo et al. (2022). Figure 1 shows the processes followed in developing the model.

Perspectives from divergent frameworks as well as empirical findings were integrated to facilitate theory development, which was informed by the work of Donabedian (1980a, 1980b), Dickoff et al. (1968), Walker and Avant (2018), Chinn, Kramer & Sitzman (2021), Veugelers et al. (2020) and Wilkes (2015). The basis of the concept analysis, synthesis and derivation was provided by the work of Walker and Avant (2018) and Chinn and Kramer (2018). The modified Delphi technique was utilised for evaluation and refinement of the model (Veugelers et al. 2020; Wilkes 2015). The process that was followed in developing the model is illustrated in Figure 1, and a detailed description of the key steps of the process follows.

In order to understand how services can be improved, the researchers found it important to identify how healthcare services were being implemented in the context of COVID-19. Therefore, the model is based on the findings of interpretive phenomenological analysis studies conducted in Zimbabwe by Moyo (2020) and Moyo et al. (2022).

The interpretative phenomenological analysis (IPA) design (Smith & Osborn 2015) was employed to gain insight into the lived experiences of healthcare workers who either provided care to COVID-19 patients or themselves contracted COVID-19. This approach enabled the researcher to gain an in-depth understanding of individual healthcare worker’s experiences during the COVID-19 period. Purposive sampling was utilised to gain access to study participants (Alase 2017). A sample size of 20 participants, aged between 25 and 40 years, was attained following data saturation. Of the healthcare workers who participated in the study, 10 were providers of care, while the other 10 had contracted COVID-19. Data were collected using in-depth interviews that were audio-recorded. Data analysis were performed using the IPA framework. The following steps, as identified by Smith and Osborn (2015), were followed: (1) reading and re-reading the transcript; (2) note taking and developing emergent themes; (3) clustering the emergent themes; (4) crafting a master table of themes composed of superordinate themes, subthemes, and extracts from the interviews; (5) examining and identifying the similarities between the master tables of the themes; and (6) compiling a single master list comprised a superordinate theme, themes, and sub-themes. This resulted in themes and sub-themes describing the experiences of healthcare workers as either providers of care or as patients having contracted COVID-19 (see Box 1, summary of research findings and the outline that follows). The gaps that emerged are associated with the burden created by COVID-19 in an already fragile and overextended healthcare system (Makoni 2020).

Donabedian’s structure–process–outcome framework (Donabedian 1988) was utilised to evaluate service provision in the context of COVID-19 from the perspective of healthcare workers at the frontline. The research findings reflect the gaps identified in the context of providing care. These gaps are discussed under each element of Donabedian’s model (structure, process and outcome) (Box 1).

The overall research findings showed the presence of healthcare delivery system inefficiencies and/or gaps in the study setting. The authors developed the model to close the identified gaps, guide the provision of psychosocial support for healthcare workers at the frontline as well as enhance health service delivery during the COVID-19 and other public health emergencies.

The researchers chose Donabedian’s theory (Donabedian 1980a, 1980b) and the practice theory of Dickoff et al. (1968) as theoretical underpinnings for the study. The Donabedian framework (Figure 2) was found to be the most appropriate for this purpose because it encompasses all relevant aspects of the structure, process, and outcome of an organisation as well as the interrelationships between these elements (Donabedian 1988). The model is premised on the philosophical assumptions of Donabedian’s theory, and describes structure, process, and outcome measures as being interrelated and interdependent, with each being important to the overall environment in which care is provided (Donabedian 1980a, 1980b). In this instance, the focus was on delivery of health services during COVID-19 and the impact of this on the psychosocial well-being of nurses working at the frontline. Donabedian describes the structural measures of the model as referring to the environment and the resources necessary to enhance service provision, with these encompassing facilities, equipment, staff and financial resources. The process encompasses the techniques and practices utilised. Outcomes refer to the end results that have an effect on the recipients (nurses) in providing care. Process measures include delivery of care to patients and workflows. According to Donabedian, an effective structure is critical for the facilitation of an effective process, and ultimately, effective processes are in turn a prerequisite for high-quality outcomes (Botma & Labuschagne 2019; Donabedian 1985).

The findings of the phenomenological study were also conceptualised on the basis of Dickoff et al. (1968) practice theory elements: agents, recipients, context, process, dynamics, and outcome the theory poses six questions, which elucidate concepts and analyze the prescribed activities (study’s findings) as shown in Table 1.

To develop this model the following were used: Walker and Avant’s (2018) processes for theory development and Chinn and Kramer’s (2018) steps for model development.

The expert reviewers that contributed to the evaluation of the model are based in Zimbabwe and South Africa. The model was sent to five academics from South Africa and Zimbabwe for them to critically reflect on the model elements as outlined by Chinn and Kramer (2018). These were selected for the diversity of their skills and expertise in model development. They were asked to evaluate the model using Chin and Kramer’s (2018) evaluation guide, which included clarity, simplicity, generality, accessibility and importance of the model. As part of the evaluation process, two rounds of questionnaires were sent to the group of experts, as per the recommendations by Fletcher and Marchildon (2014). The two rounds enabled the expert reviewers to respond to and to revise their responses in view of the group members’ previous ones, until a consensus was reached (Wilkes 2015).

Feedback from experts was given to another group of healthcare workers who had experiences from the COVID-19 pandemic. The group that participated in the reflection of the model comprised healthcare workers from Bulawayo hospitals who were either sufferers or survivors from COVID-19 or carers of COVID-19 patients. They used their experience of COVID-19 in the evaluation of the model.

Following further adjustments, the model was presented and discussed in a meeting for nurses. The participants in this meeting confirmed that the model was clear, accessible, user friendly and could be utilised in other clinical settings particularly during pandemics.

According to Pfadenhauer et al. (2017), context is an overarching concept, comprising not only a physical location but also role interactions and relationships at multiple levels. Strauss and Corbin (1990) state that a context is characterised by a ‘specific set of properties pertaining to a phenomenon and a particular set of circumstances’ within which an action takes place. In the context of the study reported on in the present article, the context was the healthcare environment within which COVID-19 response activities took place. The context has an influence on both healthcare service delivery and the psychosocial well-being of players (nurse practitioners) involved (Montori et al. 2019). Figure 3 illustrates the context in which the model was developed. Below is a description of the context within which COVID-19 activities took place. The context is discussed at three levels: global, national and institutional.

The global context (macro factors) is represented by the outer rectangle in Figure 3 and comprises the World Health Organization Guidelines on the Management of COVID-19 (WHO 2021).

The national context is regulated by the following legislative frameworks: the Zimbabwe Ministry of Health and Child Care COVID-19 Guidelines of 2020 and 2022, and the Guidelines for the Prevention, Surveillance and Management of COVID-19 infection among healthcare workers. The healthcare system in Zimbabwe is fragile, under-funded and under-resourced (Makoni 2020). While the financing model is both public- and donor-funded, the national budget still falls far below the 15% recommended by the Abuja Declaration (United Nations International Children’s Emergency Fund [UNICEF] 2021; Zimbabwe Ministry of Health and Child Care 2016).

As a context, the environment comprises central hospitals and city health facilities, with various healthcare providers (mostly nurses) involved in COVID-19 activities. These activities include caring for suspected or confirmed COVID-19 patients as well as conducting COVID-19 contact tracing. This context is regulated by the same legislative frameworks highlighted with regard to the national context, as well as institutional policies and protocols.

Empirical findings from phase 1 of the study showed healthcare institutions as experiencing shortages of material resources such as PPE and other medical equipment. A shortage of human resources was a further obstacle. Evidence has demonstrated that the shortage of PPE and other medical equipment during a pandemic reduces the work efficiency of employees in that they experience high levels of anxiety, frustration, and insecurity (Cai et al. 2020; Watterson 2020). The inadequacies and gaps identified in the study affected the healthcare environment negatively, causing providers of care stress and anxiety. For COVID-19 response activities to be carried out efficiently and productively, it is recommended that the government and Ministry of Health and Child Care should undertake resource mobilisation so as to ensure a sustainable and adequate supply of medical equipment and resources to enhance productivity during public health emergencies of this nature.

Nurses play a critical role in the response to public health emergencies. It emerged from the study that nurses engaged in COVID-19 response activities were overwhelmed as a result of the increased workload, particularly during the first and second waves of COVID-19. For example, there were cases of nurses working for 12 h or more. A solution would be to recruit more staff to allow for flexibility in working shifts and prevent burnout.

Empirical findings showed that the nurses engaged in COVID-19 activities felt that they were not appreciated by hospital management despite the daunting tasks they were required to carry out. Because of the movement restrictions introduced in response to the COVID-19 pandemic, nurses experienced difficulties with transport either to work or back to their homes. Meals were initially provided for the team involved in COVID-19 contact tracing activities, but these were later discontinued, a situation that had a negative impact on the nutritional status of the staff carrying out this work. Nurses who contracted COVID-19 struggled to pay medical bills, as they had to pay for laboratory investigations (COVID-19 polymerase chain reaction [PCR] testing) and X-rays at private facilities. The Ministry of Health and Child Care needs to develop innovative strategies for caring for the careers. In the given context, government support is required to provide a basic budget to cater for the welfare (transport, meals, medical bills) of healthcare workers at the frontline during a public health emergency.

Arising from the pandemic were multiple stressors: fear of contracting the disease and transmitting it to family members, fear of loss of life, safety fears, supply shortages, increased workload, a sense of being overwhelmed and the long hours they were required to work. All these took a psychological toll on the nurses who participated in this study. Despite being drained both physically and emotionally, the providers of care nevertheless demonstrated resilience and commitment, and continued to execute their duties in a professional manner, even in the absence of a supportive structure. No supportive conversation such as counselling was provided. Ardebili et al. (2021) emphasised the pivotal role played by mental health support strategies such as counselling or other forms of supportive conversation during public health emergencies. To rectify this omission, institutions need to develop a structured supportive intervention strategy with dedicated staff for the provision of person-centered psychosocial support for healthcare providers either as providers of care or after contracting COVID-19. Most of the nurses who contracted COVID-19 received no follow-up during the time they were in isolation, the only contact being a call a day prior to the end of the isolation period to remind them about returning to work.

A support system structure, comprising a team whose mandate it is to provide psychosocial support to healthcare workers, conduct active (virtual) follow-up and offer counselling to staff and their significant others in isolation, is vital. Also critical to this is support to family members of a staff member who have contracted COVID-19 through the provision of information and counselling and feedback about their result as contacts. Such strategies were successfully implemented in the United Kingdom and United States (Greenberg et al. 2020; Jaklevic 2021), where time was allocated to providing counselling for distressed healthcare workers during COVID-19 by means of telehealth strategies. Based on lessons learnt from China, a structured psychological intervention programme is recommended. This will include creating awareness among healthcare workers of the need for psychosocial support during such emergencies, followed by the actual implementation of these services through telehealth (He et al. 2020). This will mean that from the outset designated crisis intervention groups need to be established to conduct virtual follow-up and offer supportive counselling for other members of staff who might have contracted COVID-19 or are providers of care at the frontline. The Ministry of Health and Child Care should set aside a budget to cater for the welfare of its healthcare workers during a crisis. Nurses who have contracted COVID-19, struggled to cover medical expenses and incurred out of pocket expenses should receive assistance from this budget.

Communication between nurses working at the frontline and nurse managers was found to be ineffective. This was because the nurses did not have access to their managers for debriefing purposes or to speak about their experiences or problems they encountered during their participation in the COVID-19 response. Tomlin et al. (2020) emphasised the crucial role of communication during public health emergencies. Therefore, the authors call for an effective and sustained two-way communication structure between the nurses and management to keep staff informed or provide them with up-to-date information. If utilised, this proposed structure will ensure that healthcare workers are given an opportunity to express their fears and concerns via virtual platforms. An anonymous online platform needs to be created to allow healthcare workers working at the frontline to share insights into their experiences as they provide care in the context of COVID-19. According to Shanafelt et al. (2020), healthcare professionals ask five things of their organisation: hear me, protect me, prepare me, support me, and care for me. In addition, healthcare professionals would want the assurance that their opinions and expertise have been incorporated into the organisation’s emergency preparedness plans so as to improve the response to the pandemic.

The model is intended as a contribution to the body of knowledge relating to public health emergencies and presents unique insights into the problems encountered in healthcare environments. In addition, the model proposes public health interventions to enhance support for healthcare workers involved in combating COVID-19 in a low-resource setting. The model can be utilised during pandemics and in any public healthcare crisis in other sub-Saharan countries or in other environment dealing with COVID-19. The implementation of this model will contribute towards establishing an enabling and supportive environment that facilitates efficiency. The current healthcare environment in Zimbabwe is fragile and under-resourced (Chingono 2019; Makoni 2020), a situation making it difficult to respond efficiently and effectively to the COVID-19 pandemic, and ultimately exerting a negative effect on the psychosocial well-being of nurses working at the frontline. The model also calls upon policymakers to ensure a strong supply chain system; this will require the government to mobilise adequate resources and to source funding for public health emergency response activities.

Although the model was evaluated after its development, further piloting and monitoring of its implementation would be critical. The authors recommend its adoption, adaptation, and utilisation of this model in other low-resource settings particularly during epidemics and or pandemics.

The limitation of this study is that the model was not piloted as this was out of the scope of this study. The empirical data from healthcare providers was restricted to one province in the country; hence, findings report only the experiences in this province. However, the model would be useful in different healthcare settings in the sub-Saharan Africa.