All the participants perceived mental health of their healthcare staff important as they mentioned that the complete well-being of their staff, including mental and physical health is important to treat the patients. Additionally, they accepted the importance of mental health while handling emergencies and patients. Altogether, they agreed that the overall fitness of the HCWs is important to work efficiently in the hospital.

“Mental health is important for all of us, the nursing staff because if we are not mentally prepared or mentally stable then how will we treat the patients. We have to deal with emergency situations also; we have to cope up with the patients also. So, it is very important to have proper mental health.” (Respondent 2, nursing in charge).

A few participants experienced a positive change in their relationship with their staff. They felt their staff is like their second family due to which their staff is quite open to sharing their problems with them. The staff did not hesitate to share the issues they faced since the COVID-19 pandemic. This changed relationship helped the administrators to manage their staff’s mental health. However, they accepted that the COVID-19 pandemic created stress in everyone’s life.

“Definitely COVID has affected them a lot. Because everybody knows that the COVID pandemic was real stress to life also. So even though they were the frontline warriors, and they were fighting day-night with the disease in helping the patients to come out from the disease, definitely that has affected them also.” (Respondent 3, superintendent).

According to the administrators, the most common problems were the increased levels of stress and anxiety among their staff. Some HCWs felt physical stress such as felt fatigue, tiredness and weak. Being afraid of getting COVID-19 infection was commonly reported by them. The participants mentioned that their staff was scared of getting infected as they were concerned for the safety of their families and close relatives and they could have spread the infection to them.

“The staff was very much scared, and they were all afraid of the infection. And especially, overall, they had this fear that because of them, the family might suffer. They all were so afraid. And all the time, they had the fear factor in their mind that because of patients, either they would catch the infection or because of themselves being healthcare workers, they might go and give infection to the family and friends.” (Respondent 5, hospital in charge).

Skin allergies from wearing masks, PPE kits for long duration such as up to 12 h were also reported by the HCWs.

“They faced difficulties that they could not get time for even for tea or water. Whole time they were working while wearing masks and PPE kit. So, it was very hard and they were all wet from inside due to the heat. I myself have seen that some had skin allergies because of wearing PPE kit the whole time. They did wear masks for 12–13 h, due to the triple layer mask their skin got marks. So, they faced such kinds of problems.” (Respondent 15, superintendent).

A participant experienced a difference in the stress levels of the staff as a high number of young female workers and those who had children reported more stress than male workers.

“Here I had noticed that females do have more stress and in females particularly young females, child bearing females. Many times, the duty assigned to them is night in COVID time. They were fearful of infection so they used to come and report us.” (Respondent 15, superintendent).

Most participants accepted that the COVID-19 pandemic has affected the mental state of their staff. Some participants observed a difference in mental well-being pre-pandemic and post-pandemic indicating the negative impact of COVID-19. According to them, most of their staff had recovered from their stressful phase; however, some were still suffering from the long-term impact of this pandemic.

“As recently, the COVID-19 phase has passed, there was no problem before it. After this, some people became COVID-19 positive, some were not but still they are psychologically unwell, they are in tension.” (Respondent 4, nursing in charge).

“After COVID many had issues like disturbance, decrease in working capacity, issues in sense of smell, problem in breathing and some of them even got diabetes problems. They were hypertensive. They all were normal before COVID.” (Respondent 7, nursing in charge).

Interestingly, some participants revealed the other side of the COVID-19 pandemic as they experienced a positive difference in their staff’s behavior pre and post-pandemic. They observed increased self-awareness among their staff. This has changed the self-care behavior of the HCWs in a positive manner. However, some participants mentioned no long-term effect of the pandemic.

“Yes definitely, there is a visible difference. As earlier we were not precautionary, everyone was careless towards their own health and other procedures, so there is a difference between previous and current state.” (Respondent 2, nursing in charge).

“Yes, the mental state has changed a lot. Everyone’s way of thinking has changed. After seeing so many deaths and casualties in the COVID, the attitude of the staff has changed. Those who were liberal are now very conscious and oriented.” (Respondent 17, deputy superintendent).

Managing a team of HCWs effectively who work at several levels is a challenging task in itself. In this study, the participants experienced a sudden occurrence of the COVID-19 disease that resulted in organizational challenges they faced while managing their teams such as a lack of facilities, preparedness, a sudden increase in the flow of patients and many others. This created a challenge for the HCWs’ mental health.

“Yes, definitely we faced a lot of such challenges during COVID because we ourselves did not know what this pandemic, what is COVID-19 disease actually is. To understand it, to cope with it and to deal with the COVID patients who were coming daily or those with similar symptoms, we had a lot of anxiety about how to deal with them. Sometimes, the facilities were not proper. When we had facilities and the patient workload was also high, we had to keep and follow cleanliness separately with every patient. We had to maintain hygiene. In all these, we had mental stress, hesitation and faced a lot of problems.” (Respondent 2, nursing in charge).

Because the participants reported a high flow of patients in their hospitals, it created a lack of space to manage the flow and at the same time had to follow social distancing. One participant experienced a challenge while segregating the COVID-19-infected and non-COVID-19-infected patients in the outpatient department (OPD).

“At an organizational level, the biggest problem was how to segregate the patients who visit here, who are COVID infected and who are not. However, we bought temperature checking machines and arranged a staff nurse outside so that they can check the temperature of patients who enter here. All those whose temperature is not appropriate; they will be segregated. So, we faced a problem in this segregation.” (Respondent 17, deputy superintendent).

One participant in the present study shared an experience struggling to save the lives of those who were in immediate need of oxygen beds in their hospital. Due to the shortage of beds, they arranged stretchers and ambulances to give oxygen and saved them. A few participants experienced challenges due to the shortage of supplies in the initial phase. Shortage of oxygen and beds was commonly reported as the participants shared their struggles while arranging the supplies.

“We had this challenge to provide oxygen and a bed to anyone coming to the hospital. But in one situation, for some days we kept two patients on one bed. There was a situation where we kept oxygen on a stretcher. We kept one device that could provide oxygen to five patients from one cylinder. We did that too. So, when one patient comes, we attach the tube through a server and device. Be it a patient on a stretcher or bed, we kept two patients on one bed by keeping “T” on bed. We had managed this. Many times, it happened that a patient came by 108 ambulances, so we had to go there and give them oxygen because we didn’t have a bed.” (Respondent 15, superintendent).

“Back then at the time of COVID we didn’t have availability of oxygen immediately. Then we had to manage at our personal level to avail oxygen from here and there. We managed at our personal capacity to get oxygen at earliest. If oxygen is available at that time, then the patient can be cured soon.” (Respondent 9, deputy superintendent).

The participants experienced some ethical challenges while dealing with the patients and their families during the pandemic. As mentioned, some participants felt the concern for their patients such as maintaining distance while checking the patient. Some participants reported stressful situations where they had to take tough decisions in light of their ethical responsibility as an HCW. They also expressed their concern that those decisions were hard to explain to the patient but were important for their sake.

“Yeah, sometimes patients used to have that thing in mind that the doctors are not touching them. The doctors are examining them from very far off. So, they used to really feel very bad also that earlier we used to check up very nicely and by touching it, used to spent time for us but now it feels like we are tied with strings and then they used to feel bad also that we are making them sit a little far away from us and we are not touching them and examining them that was really a little painful situation for the patients.” (Respondent 5, hospital in charge).

After the introduction of a vaccine against the corona virus, hospital administrators experienced unique ethical challenges in vaccinating pregnant women, lactating mothers and many others. Initially, they were not informed about the safety of the vaccine for pregnant women and its effect on their fetus. Therefore, their staff faced problems while handling such patients and their families in the hospital and were not able to answer their queries.

“Whether we should vaccinate pregnant patients or not? And especially, early pregnancy, during the 1st trimester should we vaccinate or not? However, we vaccinated them and followed all the guidelines but to counsel the patients, our nursing staff had to work really hard to decide whether COVID vaccine should be given during pregnancy or not.” (Respondent 17, deputy superintendent).

A participant in this study observed a sudden increase in the abortion rates because of the lack of information about the adverse effect of COVID-19-positive pregnant women on their fetuses. Due to this, women terminated their early pregnancies.

“Here we had many early pregnancy cases who had abortions at increased level. Early abortion rates increased during COVID time. In some cases, those who became COVID positive, their mother, attendant became very conscious that she is COVID positive and has early pregnancy, the child will be defective. This factor was dominating a lot and they were all in trouble as they used to ask us thousands of questions. And during that time, guidelines were also not available. There were many cases who used to come and ask us whether we should terminate it or not? This was a major ethical issue.” (Respondent 17, deputy superintendent).

Many times, the HCWs face ethical dilemmas where they have to take tough decisions to save the life of the patient. A similar challenge was experienced by the participants of this study where they took some risks to save the patient regardless of the COVID-19 infection status of the patient.

“Many times, it did happen that a patient came all of a sudden and due to change in duty, the staff is changing dress, wearing gloves but then patients come in an emergency and they have to rush out without taking precautions to save the patient.” (Respondent 15, superintendent).

Some participants experienced challenges from society due to misinformation and myths attached with to COVID-19 pandemic. The false beliefs created a problem for their staff to work efficiently and affected their mental well-being. Seeing the other side, the participants experienced a sense of responsibility and serving the community by staying away from social gatherings to break the chain of transmission.

“People nearby, they are all afraid, oh, she’s a doctor, she might give us infection, and she might spread it. So, it is better to stay a little far off from her. And in society also, I also used to feel if I’m meeting my elders or my relatives, so I should stay a little away from them, I should wear proper masks, I should keep myself protected. Because of me, they are not infected, because I was meeting almost 100 to 200 people per day.” (Respondent 5, hospital in charge).

“2 of our residents who were living on rent outside so, they have been told to vacate the flat.” (Respondent 11, hospital in charge).

However, most participants did not experience any challenges from their society or local community. Rather, they expressed their society’s positive support towards them.

The participants perceived various challenges as their biggest challenge. A few of them expressed the continuous need of keeping their staff motivated was the biggest challenge. They faced problems while bringing everyone back to their normal routine of work.

“The biggest thing was to make everyone understand, although everyone is well trained and well qualified that the effect of COVID-19 has become less so we should now follow our normal routine. The main thing was to destroy the internal fear among people and start a normal routine again. This was the only challenge that now most of the officers and workers have understood and have become normal also.” (Respondent 12, hospital in charge).

“Yeah, it was very, very difficult to motivate all of them together at the same time and to keep them charged 24 h because all had to work completely from morning till evening. And anytime they could be called for any work. So, it was really a very difficult situation and a very big challenge and tasks to keep them motivated 24 by 7.” (Respondent 8, hospital in charge).

Interestingly, some participants agreed that during this pandemic they were well prepared in terms of physical and mental state and had sufficient resources such as personal protective kits, masks, and others to handle the situation. Preparing in advance helped them to maintain a good mental state of their staff during the second wave.

“At that time, I was in charge of COVID-19 ward. So, we have to take care of everything including the manpower, their allotment and the disease. Yes, it came very suddenly. So, there was very less time for preparedness as in the first wave but in the second wave we are well prepared. Although, the mortality was high but still on part of the mental level so, for the first we have, we don’t have much time, but for the second wave we have managed things very well.” (Respondent 3, superintendent).

As the participants experienced different problems and challenges during the COVID-19 pandemic, not having a common coping strategy helped all of them deal with the problem. Rather, different strategies helped them to manage their staff within their hospitals. In general, social support through lectures, counseling through professionals and demystifying myths and false beliefs were the most effective coping strategies adopted by the participants.

“We have kept some psychiatry lectures also with morale boosting and some like correcting these issues. Everybody was supporting everyone. So mutually we were helping each other to come out from this situation. So, we tackled it very well.” (Respondent 3, superintendent).

“Discussing together and motivating each other such as motivational talks and motivational stories that we shared with each other. And the biggest thing was our unity. Our unity helped us all to cope up.” (Respondent 2, nursing in charge).

Some participants organized their staff’s work shifts by giving them alternate working days in the hospital while some provided a week-long break to relax. Additionally, limiting the working hours to 6 h also helped them to relieve the stress of their staff.

“For this, the workers have a routine duty. We don’t keep the duty continuously. For example, they had 7 days continuous duty then we made changes after 3 or 4 days” (Respondent 4, nursing in charge).

Fig. 2 below provides a summary of how COVID-19 pandemic impacted HCWs in India and resulted in poor physical health, a stressful work environment, imbalanced professional and personal life and poor psychological well-being. This study focused on COVID-19 pandemic impacts on mental well-being in response to which, several issues were reported by the HCWs to their respective hospital administrators such as increased stress, anxiety, burnout, skin infections, uncomfortable while wearing PPE kits for a long time, poor sleep quality due to increased working hours, less productivity and fear of getting COVID-19 infection. They also faced challenges at different levels such as personal, organizational and societal levels that increased their work stress during the COVID-19 pandemic and resulted in poor mental health. Altogether, in response to the issues reported to the hospital administrators by their staff and the challenges faced by them, a few coping strategies were effective handling the stressful situation and retaining good mental health. These coping strategies were more centered towards emotion-focused coping such as motivation and peer support to the staff on an everyday basis, working with unity, demystifying COVID-19 pandemic-related myths with the help of appropriate information and arranging flexible shifts for the staff. These strategies, in turn, resulted in the improved mental well-being of the HCWs, high morale for the work, improved relationships with the hospital administrators and improved attitude and self-awareness (see Fig. 2).