St. Paul University Philippines: Review of Related Literature

St.
Paul University Philippines

Tuguegarao City, Cagayan 3500
Review of Related Literature
As COVID-19 strikes the Philippine nation, people rise

together to counter it. At the forefront of the fight
against the virus are our healthcare workers and various
frontliners. However, as they battle against this invisible
enemy, they are as well, risking their lives just protect
us at all cost. This chapter presents a brief review of
literature and studies, both local and foreign that is
related to this study.
Healthcare Workers
Healthcare industry is one of the most hazardous

environments to work in. Employees in this industry are
constantly exposed to a complex variety of health and
safety hazards in the course of their work. Hazards range
from biological exposure to disease causing organisms such
as tuberculosis and human immunodeficiency virus (HIV) or
exposure to chemicals such as glutaraldehyde and ethylene
dioxide. Apart from physical hazards such as exposure to
radiation and noise, there are also ergonomic issues such
as heavy lifting and standing for long periods. Long
working hours and shift work add to the stress of work. A
healthcare worker is one who delivers care and services to
the sick and ailing either directly as doctors and nurses
or indirectly as aides, helpers, laboratory technicians, or
even medical waste handlers (Joseph, 2016).
School of Nursing and Health Sciences

St. Paul University Philippines
According to Bielicki (2020), health-care workers are

crucial to any health-care system. During the ongoing
COVID-19 pandemic, health-care workers are at a
substantially increased risk of becoming infected with
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-
2) and could come to considerable harm as a result. health
workers to be all people engaged in actions whose primary
intent is to enhance health. This meaning extends from
WHO’s definition of the health system as comprising
activities whose primary goal is to improve health.
Strictly speaking, this means that mothers looking after
their sick children and other unpaid carers are in the
health workforce. They make important contributions and are
critical to the functioning of most health systems (World
Health Report, 2017).
COVID- 19 Virus
Definition of COVID19 Virus
Coronavirus disease 2019 (COVID-19) is defined as illness

caused by a novel coronavirus called severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2; formerly
called 2019-nCoV), which was first identified amid an
outbreak of respiratory illness cases in Wuhan City, Hubei
Province, China. It was initially reported to the World
Health Organization (WHO) on December 31, 2019. On January
30, 2020, the WHO declared the COVID-19 outbreak a global
health emergency. On March 11, 2020, the WHO declared

COVID-19 a global pandemic, its first such designation

since declaring H1N1 influenza a pandemic in 2009. Illness
caused by SARS-CoV-2 was termed COVID-19 by the WHO, the
acronym derived from "coronavirus disease 2019." The name
was chosen to avoid stigmatizing the virus's origins in
terms of populations, geography, or animal associations. On
February 11, 2020, the Coronavirus Study Group of the
International Committee on Taxonomy of Viruses issued a
statement announcing an official designation for the novel
virus: severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) (Cennimo, 2021), Furthermore, corona viruses
are positive-stranded RNA viruses with a crown-like
appearance under an electron microscope (coronam is the
Latin term for crown) due to the presence of spike
glycoproteins on the envelope. The subfamily
Orthocoronavirinae of the Coronaviridae family (order
Nidovirales) classifies into four genera of CoVs: Alpha-
coronavirus (alphaCoV), Beta-coronavirus (betaCoV), Delta-
coronavirus (deltaCoV), and Gamma-coronavirus (gammaCoV).
Furthermore, the betaCoV genus divides into five sub-genera
or lineages. Genomic characterization has shown that
probably bats and rodents are the gene sources of alphaCoVs
and betaCoVs. On the contrary, avian species seem to
represent the gene sources of deltaCoVs and gammaCoVs.
Members of this large family of viruses can cause
respiratory, enteric, hepatic, and neurological diseases in
different animal species, including camels, cattle, cats,
and bats. Some of the human corona viruses were identified

in the mid-1960s, while others were only detected in the

new
millennium. (Cascella, et. al., 2021)
According to WHO (2021), coronavirus disease (COVID-19) is

a contagious infection caused by a newly discovered
coronavirus. The majority of people infected with the
COVID-19 virus will experience mild to moderate respiratory
illness and will recover without the need for special
treatment. People over the age of 65, as well as those with
underlying medical conditions such as cardiovascular
disease, diabetes, chronic respiratory disease, and cancer,
are at a higher risk of developing more serious illnesses.
The corona virus is a family of viruses that can cause
illnesses such as the common cold, severe acute respiratory
syndrome (SARS) and Middle East respiratory syndrome (MERS)
(Mayo clinic, 2021).
In line with Pathak (2021), he stated that coronavirus is a

kind of common virus that causes an infection in your nose,
sinuses, or upper throat. Most coronaviruses aren't
dangerous. In early 2020, after a December 2019 outbreak in
China, the World Health Organization identified SARS-CoV-2
as a new type of coronavirus. The outbreak quickly spread
around the world. COVID-19 is a disease caused by SARS-CoV-
2 that can trigger what doctors call a respiratory tract
infection. It can affect your upper respiratory tract
(sinuses, nose, and throat) or lower respiratory tract

(windpipe and lungs). It spreads similarly to other

coronaviruses, primarily through person-to-person contact.
Infections can range from mild to fatal. SARS-CoV-2 is one
of seven coronavirus types, including those that cause

severe diseases such as Middle East respiratory syndrome
(MERS) and sudden acute respiratory syndrome (SARS) (SARS).
The other coronaviruses cause the majority of the colds we
get throughout the year, but aren’t a serious threat for
otherwise healthy people.
Symptoms of COVID19 Virus
As stated by WHO (2020), COVID-19 affects different people

in different ways. Most infected people will develop mild
to moderate illness and recover without hospitalization.
Most common symptoms are fever, dry cough, tiredness. Less
common symptoms are aches and pains, sore throat, diarrhea,
conjunctivitis, headache, loss of taste or smell a rash on
skin, or discoloration of fingers or toes. Serious symptoms
include difficulty breathing or shortness of breath chest
pain or pressure, loss of speech or movement. Symptoms may
appear 2-14 days after exposure to the virus (Centers for
Disease Control and Prevention, 2021).
In line with Healthline (2021), doctors and scientists are

learning new things about this virus every day. So far, we
know that COVID-19 may not cause any symptoms for some
people. Some common symptoms that have been specifically

linked to COVID-19 include: shortness of breath, a cough

that gets more severe over time, fever chills, fatigue.
Less common symptoms include repeated shaking with chills,
sore throat, headache, muscle aches and pains, loss of
taste or smell, a stuffy or runny nose, gastrointestinal
symptoms such as diarrhea, nausea, and vomiting,
discoloration of fingers or toes, pink eye, rash. However,
individuals with COVID-19 may have some, all, or none of
the above symptoms. For instance, fever is often referred
to as the most common symptom of COVID-19. However, a July
2020 study of 213 people with mild disease found that only
11.6 percent of them had experienced fever.
Another definition stated by Medscape Drugs & Diseases

(2020), patients with a mild clinical presentation may not
initially require hospitalization, but clinical signs and
symptoms may worsen, with progression to lower respiratory
tract disease in the second week of illness. Risk factors
for progressing to severe illness may include, but are not
limited to, older age and underlying chronic medical
conditions (eg, lung disease, moderate to severe asthma,
cancer, heart failure, cerebrovascular disease, renal
disease, liver disease, diabetes, immunocompromising
conditions, and severe obesity). Emergency medical
attention should be sought if the patient develops trouble
breathing, persistent pain or chest pressure, new
confusion, inability to awaken or to stay awake, or bluish
lips or face. Most patients with confirmed COVID-19 have

developed fever and/or symptoms of acute respiratory

illness (eg, cough, difficulty breathing). The following
symptoms may indicate COVID-19 are Fever or chills, cough,
shortness of breath or difficulty breathing, fatigue,
muscle or body aches, headache, loss of taste or smell,
sore throat, congestion or runny nose, nausea or vomiting,
and diarrhea. Other reported symptoms have included the
following: sputum production, malaise, and respiratory
distress.
Based on the study of Harvard Health Publishing (2021),

some people infected with the virus have no symptoms. When
the virus does cause symptoms, common ones include fever,
body ache, dry cough, fatigue, chills, headache, sore
throat, loss of appetite, and loss of smell. In some
people, COVID-19 causes more severe symptoms like high
fever, severe cough, and shortness of breath, which often
indicates pneumonia. People with COVID-19 can also
experience neurological symptoms, gastrointestinal (GI)
symptoms, or both. These may occur with or without
respiratory symptoms. For example, COVID-19 affects brain
function in some people. Specific neurological symptoms
seen in people with COVID-19 include loss of smell,
inability to taste, muscle weakness, tingling or numbness
in the hands and feet, dizziness, confusion, delirium,
seizures, and stroke. In addition, some people have
gastrointestinal (GI) symptoms, such as loss of appetite,
nausea, vomiting, diarrhea, and abdominal pain or

discomfort associated with COVID-19. The virus that causes

COVID-19 has also been detected in stool, which reinforces
the importance of hand washing after every visit to the
bathroom and regularly disinfecting bathroom fixtures.
Risks of COVID19 Virus
The risk of getting COVID-19 is evolving daily and varies

between and within communities. Overall, the risk to
Canadians remains high. This doesn't mean that all
Canadians will get the disease. It means that there's
already a significant impact on our health care system. To
stay healthy and to protect ourselves and others, we must
be mindful of the ever-present risk of exposure to the
virus. Some settings and situations increase the risk, such
as being in closed spaces, crowded places, close-contact
settings where you can't keep 2 meters apart from each
other, close-range conversations, settings where there's
singing, shouting or heavy breathing (for example, during
exercise). It's particularly important to avoid settings
where these risks overlap, such as closed spaces and
crowded spaces where close-range conversations occur
(Government of Canada, 2021). COVID-19 is often more severe
in people who are older than 60 years or who have health
conditions like lung or heart disease, diabetes or
conditions that affect their immune system (WHO, 2020).

As explored by the Centers for Disease Control & Prevention

(2020), since COVID-19 is a new disease, more work is
needed to better understand the risk factors for severe
illness or complications. Potential risk factors that have
been identified to date include age, race/ethnicity,
gender, some medical conditions, use of certain
medications, poverty and
crowding, certain occupations, pregnancy.
In line with Mayo Clinic (2021), they have claimed that

some people have no symptoms at all, while others become so
sick that they eventually need mechanical assistance to
breathe. The risk of developing dangerous symptoms of
COVID-19 may be increased in people who are older and in
people of any age who have other serious health problems —
such as heart or lung conditions, weakened immune systems,
obesity, or diabetes. This is like what is seen with other
respiratory illnesses, such as influenza. While each of
these factors can increase the risk of severe COVID-19
symptoms, people who have several of these other health
problems are at even higher risk.
Complications of COVID19 Virus
According to the Centers for Disease Control & Prevention

(2020), age and sex have been shown to affect the severity
of complications of COVID-19. The rates of hospitalization
and death are less than 0.1% in children but increase to

10% or more in older patients. Men are more likely to

develop severe complications compared to women because of
SARS-CoV-2 infection. Patients with cancer and solid organ
transplant recipients are at increased risk of severe
COVID-19 complications because of their immunosuppressed
status. The main complications reported in patients with
SARS-CoV-2 may include: Coagulopathy, mainly disseminated
intravascular coagulation, venous thromboembolism, elevated
D-dimer and prolonged prothrombin time, Laryngeal oedema
and laryngitis in critically ill patients with COVID-19,
Necrotizing pneumonia due to superinfection caused by
Panton-Valentine leucocidin–secreting Staphylococcus aureus
infection. This superinfection is usually fatal,
Cardiovascular complications, including acute pericarditis,
left ventricular dysfunction, acute myocardial injury
(associated with increased serum troponin), new or
worsening arrhythmias and new or worsening heart failure,
Acute respiratory failure. Approximately 5% of COVID-19
patients require admittance to an intensive care unit
because they develop severe disease complicated by acute
respiratory distress syndrome, Sepsis, septic shock and
multiple organ failure, Higher risk of death, particularly
in male patients with severe disease, presence of heart
injury and cardiac complications, hyperglycemia and
patients receiving high doses of corticosteroids,
Ventilation-associated pneumonia in up to 30% of patients
requiring intensive mechanical ventilation, Massive

pulmonary embolism complicated by acute right-sided heart

failure
In addition, based on Medscape Drugs and Diseases (2020)

complications of patients with coronavirus disease 2019
(COVID-19) also include the following : Pneumonia,
Hypoxemic respiratory failure/acute respiratory distress
syndrome (ARDS), Diffuse alveolar damage, secondary
bacterial infections, sepsis and septic shock, cardiac
injury, cardiomyopathy, arrhythmia, sudden cardiac death,
acute kidney injury, liver dysfunction, multiorgan failure,
thromboembolism, gastrointestinal bleeding, and critical
illness polyneuropathy/myopathy.
Mode of Transmissions of COVID19 Virus
According to WHO (2020), respiratory infections can be

transmitted through droplets of different sizes: when the
droplet particles are >5-10 μm in diameter they are
referred to as respiratory droplets, and when then are <5μm
in diameter, they are referred to as droplet nuclei. Thus,
corresponding to current evidence, COVID-19 virus is
primarily transmitted between people through respiratory
droplets and contact routes. In an analysis of 75,465
COVID-19 cases in China, airborne transmission was not
reported. Droplet transmission occurs when a person is in
in close contact (within 1 m) with someone who has
respiratory symptoms (e.g., coughing or sneezing) and is
therefore at risk of having his/her mucosae (mouth and

nose) or conjunctiva (eyes) exposed to potentially

infective respiratory droplets. Transmission may also occur
through fomites in the immediate environment around the
infected person.8 Therefore, transmission of the COVID-19
virus can occur by direct contact with infected people and
indirect contact with surfaces in the immediate environment
or with objects used on the infected person (e.g.,
stethoscope or thermometer). Airborne transmission is
different from droplet transmission as it refers to the
presence of microbes within droplet nuclei, which are
generally considered to be particles <5μm in diameter, can
remain in the air for long periods of time and be
transmitted to others over distances greater than 1 m. In
the context of COVID-19, airborne transmission may be
possible in specific circumstances and settings in which
procedures or support treatments that generate aerosols are
performed; i.e., endotracheal intubation, bronchoscopy,
open suctioning, administration of nebulized treatment,
manual ventilation before intubation, turning the patient
to the prone position, disconnecting the patient from the
ventilator, non-invasive positive-pressure ventilation,
tracheostomy, and cardiopulmonary resuscitation. Also, in
line with Health & Senior Services (n.d.), they have
identified that human coronaviruses most commonly spread
from an infected person to others through: (1) the air by
coughing and sneezing, (2) close personal contact, such as
touching or shaking hand, (3) touching an object or surface
with the virus on it, then touching your mouth, nose, or

eyes before washing your hands, and rarely, (4) fecal

contamination.
Currently available evidence indicates that COVID-19 may be

transmitted from person to person through several different
routes. In the scoping review published by La Rosa et. al
(n.d.), the human coronaviruses primary transmission mode
is person-to-person contact through respiratory droplets
generated by breathing, sneezing, coughing, etc., as well
as contact (direct contact with an infected subject or
indirect contact, through hand-mediated transfer of the
virus from contaminated fomites to the mouth, nose, or
eyes). Infection is understood to be mainly transmitted via
large respiratory droplets containing the SARS-CoV-2 virus.
Transmission through aerosols has also been implicated but
the relative role of large droplets and aerosols is still
unclear Indirect transmission through fomites that have
been contaminated by respiratory secretions is considered
possible, although, so far, transmission through fomites
has not been documented (European Centre for Disease
Prevention and Control (2020),
Effects of Covid- 19 to Healthcare Workers
The COVID-19 pandemic has resulted in significant burdens

globally. Detrimental effects include high rates of
infection and death, financial hardships faced by
individuals, stress related to known and particularly
unknown information, and fear of the uncertainty regarding

continued impact. Healthcare workers, at the heart of the

unparalleled crisis of COVID-19, face challenges treating
patients with COVID-19: reducing the spread of infection;
developing suitable short-term strategies; and formulating
long-term plans. Healthcare workers must also continue to
successfully treat non-COVID patients and maintain personal
responsibilities, including taking care of their families
and themselves. The psychological burden and overall
wellness of healthcare workers has received heightened
awareness, with research continuing to show high rates of
burnout, psychological stress, and suicide (Santarone,
McKenney and Elkbuli, 2020).
Healthcare workers experience emotional exhaustion, which

may lead to medical errors, lack of empathy in treating
patients, lower productivity, and higher turnover rates
(Penwell- Waimes, Ward and Smith, 2018). The ability of
HCWs to adequately cope with stressors is important for
their patients, their families, and themselves. Providers
vary in levels of psychological resilience, the ability to
positively adapt to adversity to protect themselves from
stress (Lydon and Connoly. 2018). Prior to COVID-19, wide-
ranging research had established the multifactorial nature
of stressors in healthcare: electronic health record
duties; insurance and billing issues; any patient
dissatisfaction; and balancing busy work-life schedules
(Nanda, Wasan and Sussman, 2017). Healthcare workers must

continue to balance these existing obstacles to wellness

while facing the unique challenges of a pandemic.
The director of the National Hospital Infection Management

and Quality Control Centre summarized some reasons for such
a high number of infected healthcare workers during the
beginning of the emergency outbreak (Wang, 2020). First,
inadequate personal protection of healthcare workers at the
beginning of the epidemic was a central issue. In fact,
they did not understand the pathogen well; and their
awareness of personal protection was not strong enough.
Therefore, the front-line healthcare workers did not
implement the effective personal protection before
conducting the treatment. Second, long-time exposure to
large numbers of infected patients directly increased the
risk of infection for healthcare workers. Also, pressure of
treatment, work intensity, and lack of rest indirectly
increased the probability of infection for healthcare
workers. Third, shortage of personal protective equipment
(PPE) was also a serious problem. First-level emergency
responses have been initiated in various parts of the
country, which has led to a rapid increase in the demand
for PPE. This circumstance increased the risk of infection
for healthcare workers due to lack of sufficient PPE.
Fourth, the front-line healthcare workers (except
infectious disease physicians) received inadequate training
for IPC, leaving them with a lack of knowledge of IPC for
respiratory-borne infectious diseases. After initiation of

emergency responses, healthcare workers have not had enough

time for systematic training and practice. Professional
supervision and guidance, as well as monitoring mechanisms,
were lacking. This situation further amplified the risk of
infection for healthcare workers (Wang, Zhou and Liu,
2020).
Healthcare professionals are faced with high stressors

while working with patients during the pandemic. The first
intercontinental survey was conducted in order to examine
the perceptions of HCP across the world regarding the
COVID-19 outbreak. Participants from 60 countries responded
to a survey that focused on measuring exposure, perception,
and workload. Within the survey 51.4% of participants
reported emotional exhaustion among 33 countries as a
result of their burnout while working during the pandemic
(Azoulay, 2020). Across all the countries, the reported
burnout was associated with various factors. Among one of
the sections from the survey, participants answered “No”
regarding what they were not being provided from the
hospital. This includes how they felt about being provided
adequate PPE (45.2%), available mental health support
(52.2%), and being provided COVID-19 specific training
(53.1%) (Azoulay, 2020). All these factors impacted work
productivity and safety because none of these options were
made accessible to healthcare workers. It placed many
workers at risk for contracting the virus, as well as
contributing to their anxiety and fear. These components

may be taken into consideration in order to decrease the

likelihood of healthcare workers burnout. The factors
contributing to the increased likelihood of experiencing
burnout affects the mental health outcomes in healthcare
workers. A meta-analysis was done in order to measure the
most frequently reported psychological symptoms. Fear
(43.7%) was one of the most common mental health concerns
amongst this population. This feeling of fear was
associated with a frequency of psychological distress
(37.8%) as well (Salazar de Pablo, 2020). This may be due
numerous contributing factors of the pandemic such as the
increase in demand of longer shifts and hours. The report
also stated a higher frequency of anxiety (29%) and
depressive (26.3%) features within healthcare workers
(Salazar de Pablo, 2020). This was compared to the previous
population who experienced the SARS/MERs infection. Anxiety
and depressive features had an increase of about 10% from
COVID-19 pandemic compared to the previous epidemics.
healthcare workers also reported having stigmatization
feelings (39.5%) compared to the general population
(Salazar de Pablo, 2020). Due to the fact that these
healthcare workers are in contact with COVID-19 patients,
some expressed that their family members and friends have
avoided them in fear of contracting the virus. This may
contribute to healthcare workers feeling isolated from
their support system which ultimately takes a toll on their
mental health. Despite the enormous amounts of challenges
these healthcare workers are facing every day, one

systematic review found that there was a great sense of

duty and dedication for patient care. From this study,
nurses still felt a great sense of professional duty to
work during this pandemic, regardless of how dangerous the
situation is (Fernandez, 2020). Many of these nurses took
pride in their professionalism and felt like they still had
a role to perform regardless of the infection risk,
ultimately showing a great commitment to patient care. This
commitment creates an ethical and moral dilemma, since many
have to choose between exposing themselves to patients or
their families. This sacrifice continues to affect the
psychological health of healthcare professionals.
Currently, there are 1.2 million physician Healthcare

Workers (HCWs) in the United States (US), 20% over the age
of 55 (Hopkins, 2020). Similarly, in the hospital setting,
there are 2 million registered nurses, with 22% are over
the age of 55 and of the 1.2 million registered nurses
employed outside of the hospital, 29% are over the age of
55 (Buerhaus, Auerbach and Staiger, 2020). According to the
CDC, older adults are at higher risk of infection and
complications related to COVID-19, particularly those over
the age of 65, the age group that currently comprises 8 out
of 10 US deaths from COVID 19 (Hopkins, 2020). All ages are
susceptible to COVID-19, with close contact with an
infected individual (Lung Cancer Foundation, n.d.). Given
this assessment, physicians, nurses and other staff risk
their personal health each time they tend to COVID-19

patients and this is made worse by the shortage of PPE

(Personal Protective Equipment). Lack of PPE and inadequate
social distancing are the two modifiable risk factors that
if addressed through the implementation of enforced
physical distancing, increasing the availability of PPEs,
and proper guidelines would significantly reduce
transmission rates and help save lives (Benjamin, Muntner
and Alonso, 2020; Sen- Crowe and McKenny, 2020). In March
2020, Italy reported over 2600 HCWs were infected,
devastating their already worn-down workforce (Centers for
disease Control and Prevention, 2020). Observing the
wreckage ensuing across the globe, it is imperative to
better prepare and care for our healthcare workers.
Many hospitals and states have not yet released their

number of healthcare workers testing positive for COVID 19.
Those who have released their numbers include hospitals
from Washington State, Massachusetts and Alabama. The
number of US healthcare workers confirmed infected with
COVID 19 is over 800 (Soucheray, 2020; Inslee, 2020). As
more states release their numbers, the amount is expected
to rise, possibly dramatically, as more states are issuing
tests to their healthcare workers in high- risk exposure
situations (Newsom, 2020). Additionally, there is an ever-
growing list of healthcare workers from across the globe
who have lost their lives due to COVID-19 (Florida Health,
2020). As the number of healthcare workers infected and
dying continue to rise, so our providers continue to

diminish. The physical and psychological well-being of our

healthcare workers are being tested as patient loads
continue to increase and fellow co-workers become infected
with COVID-19, contributing significantly to burnout among
healthcare workers (Patti and Schlottman, 2018). The
effects of this increase in workload in the dangerous
atmosphere of this pandemic are the decline in the mental
health of our healthcare worker (Ayanian, 2020; Lai, Wang
and Cai, 2020). Throughout this pandemic HCWs have had to
self-isolate from their own families for fear of
transmitting the virus to their loved ones (Lai, Ma and
Wang, 2018). There will be guilt when a family member
becomes infected. Our healthcare workers are bravely living
in a constant state of psychological stress founded in
fear; fear of transmitting the virus and stress of the
unknown aspects of this virus. The long- term effects of
stress can result in post-traumatic stress disorder,
anxiety and depression (Cuomo, 2021). Thus, it is
imperative to employ productive strategies to care for the
mental health of our healthcare worker.
The mental health needs of our providers must be addressed
with the same priority of their physical health. Keeping
our healthcare workers updated on the latest information
diminishes the fear of uncertainty and negative emotions
associated with the virus (Li, Wang and Zhao, 2020). This
entails frequent information sessions on the specific
details of the virus, practicing ethical decision making,
and how to effectively use hospital resources (Cuomo,

2021). By ensuring that the entire team maintains the same

understanding of information and protocols, a certain
amount of order can be maintained to curtail the negative
impacts of this crisis. Additionally, establishing break
time will allow for healthcare workers a time to take care
of themselves. Another recommendation centers on creating
healthcare staff reserves to relieve those on duty before
exhaustion and strain sets in resulting in anxiety and
depression, affecting the quality of healthcare delivery.
This can be done in several ways, including incorporating
outside registered nurses into the hospital system, re-
employing healthcare workers who recently retired, and
adding in the newly matched fourth year medical students.
As this crisis progresses it is imperative to continue to
evaluate the well-being of our healthcare workers and
implement effect measures to care for their mental health.
This global crisis has fostered fear among healthcare

workers. Healthcare workers are scared for their co-
workers, their families, their friends, our communities and
our country. Despite this fear, they continue to fight on
the frontlines to execute their job while in a persistent
state of survival mode in order to protect everyone around
them. In order to win this war against COVID 19, we must
come together on a united front to support those on the
frontlines. While our healthcare workers continue to fight,
we must help them fight off any potential short or long-
term effects during and after the COVID19 pandemic. This

requires the implementation of accessible counseling

services and effective measures to care for their mental
well-being in order to preserve their health.
Based on the study made by Fernandez (2021). the COVID-19

pandemic has created a variety of challenges throughout the
nation and has impacted the health of many healthcare
workers. The uncertainty of the pandemic has brought up
feelings of anxiety and fear as many adapt to the
adjustment of being at home. The dangers of being in
contact with COVID-19 patients places healthcare workers in
a difficult position when treating patients. This comes
with the risk of bringing the virus home and potentially
exposing it their own families. Many have expressed their
concerns and fears about being an infection risk when they
go home, and this ultimately affects how they feel
emotionally. It is clear through numerous studies that the
level of burnout has increased due to the new challenges
COVID-19 has imposed on healthcare workers and their work
environment. There have been a handful number of
interventions that have been implemented in order to help
with the increased levels of burnout. The need for these
interventions has positively affected the lives of those
who have been feeling the effects of high stress levels.
Since the pandemic is still extremely prevalent in many
countries, especially the United States, it is still
important to measure how effect these interventions will be
for the present and the future. The current research has

presented that many physicians and nurses have been working

extremely long shifts which leaves many of them
experiencing physical and mental exhaustion. With the
stress and anxiety that is created within the hospital work
environment, it is crucial to implement stress-reducing
techniques to healthcare workers to promote their health.
healthcare workers would not be capable to provide adequate
patient care if they are struggling to take care of their
own health. As physicians and nurses continue to provide
care to COVID-19 patients, it is important to provide
available resources and emotional outlets to alleviate
their stressors and to gain support during this
unprecedented time. If burnout levels may be managed, this
may lead to the promotion of the physical and mental well-
being of many physicians and nurses. The success of these
resources will be able to promote a high functioning work
environment, which may be able to lighten the heavy patient
workload. The staff should be able to access these
resources at any time in order to mitigate their stress and
be able to work without fear or anxiety. Since the pandemic
has been on-going for several months now, there must be
research following healthcare workers in order to evaluate
the digital care package. It is also crucial to be able to
compare this data from the United States with other
countries where the pandemic is not as rampant. This will
be able to allow researchers to investigate what works in
aiding the physical and mental health of these workers.
There has been a large amount of positive feedback

regarding the digital care package, and this may prove to

have potential in helping future healthcare workers who may
need it if another pandemic were to occur. If the digital
care package proves it has massive impact on decreasing
burnout levels and promoting physical and mental health
over a longer period of time, this will aid many physicians
and nurses who are struggling with maintaining self-care
during highly intense periods in healthcare.
The COVID-19 pandemic crisis resulted in an abrupt paradigm

shift of nurses’ life in healthcare systems, leading to
stressful and overwhelming challenges in their daily battle
against this illness. This descriptive phenomenological
inquiry explored the meaning of Filipino nurses’ work on
the frontlines of community quarantine facilities amidst
this pandemic health crisis. Using purposive and snowball
sampling, and in-depth interviewing a total of 12 nurses
were participants in this study that sought to deeply
understand and explain their lived experience while working
in their respective facilities. (Sadang, 2020). Three major
themes emerged from the data analysis of the transcribed
verbatim responses using Colaizzi’s approach: Work as self-
sacrifice with 3 sub-themes, Work as self-fulfillment with
2 sub-themes, and Work as a psychological struggle with 2
sub-themes. The nurses demonstrated outstanding
professional efforts and sacrifices in battling this crisis
to overcome difficulties amidst insufficient or unavailable
needed resources. Hence, comprehensive support must be

provided to safeguard their well-being so they can continue

their noble service in combating and eliminating this
illness in our respective communities.
Aside from which, a study conducted by Pasay-an (2020)

explored the perceived vulnerability to COVID-19 and the
perceived stress of frontline nurses. It examined the
demographic variables affecting perceived vulnerability and
perceived stress and the relationship between perceived
vulnerability and perceived stress. Frontline nurses’
highly perceived infectability and germ aversion put them
in a moderately stressful situation. This suggests their
need for precautionary measures, positive health behavior,
and positive reinforcement to avoid stress. Precautionary
techniques also need to be in place to safeguard these
nurses and other healthcare workers to protect them from
illness because of the exposure at work. Certainty in
infection-control procedures may alleviate an adaptive
stress response. Support from colleagues and supervisors
and clear communication of directives and precautionary
measures are recommended to help reduce stress and/or other
psychiatric symptoms. Consequently, it is imperative to
protect the self-esteem and mental health of the nurses
because it might affect the quality of delivering
healthcare services. This finding contributes toward
maintaining wellness on the frontline wherein a supportive
work culture is vital to preserving the resilience of
nurses during the COVID-19 pandemic. It is crucial to
recognize the frontlines that have perceived vulnerability
to disease and psychological distress to enable timely

intervention.
The age and sex of frontline nurses were not determinants

of perceived infectability, germ aversion or stress. While
the females in this study had slightly higher scores in
perceived infectability and germ aversion than the males,
there were no statistically significant differences (Diaz
and Zueco, 2020). A study on perceived vulnerability to
disease provided support to the notion that the women had a
higher score than the men. Moreover, previous reports have
shown that sex-based differences exist concerning the
ability to cope with stress. Verma (2011), for example,
posit that males and females have been shown to have
variable patterns for particular incidence rates of
different disorders (e.g., psychological and physical) and
that they respond to stress differently. Similarly, civil
status, nationality, number of children, and years of
experience (but not in germ aversion) are not attributes of
perceived infectability, aversion, or stress. This
indicates that, regardless of these variables, the
frontline nurses recognized the possible sources of
contracting the disease, fostered avoidance behavior, and
reduced the possibility of contracting infection, thus
perceiving less stress. However, an earlier study predicted
that people with increased levels of viral avoidance were
associated with less stress (Gassen, Makhanova and White,
2018). These findings contribute to eliminating the factors
that could influence helping frontline nurses with their
vulnerability to COVID-19 disease and stress.

Considerations of these factors could help identify other
variables that may need attention to improve the preventive
practices and behaviors of nurses during the pandemic. A
greater number of years of nursing experience resulted in
higher germ aversion compared to fewer years of experience.
This indicates that more experienced frontline nurses felt
discomfort and were more susceptible to infection. One
possible reason for this is that their known competencies
owing to their work experience deemed them to be exposed in
the area during the pandemic. Hospital authorities viewed
these experienced nurses to have better control in the
workplace and a stronger control of the situation.
According to Shanafelt (2015), those with more years of
experience may have felt closer to key decision makers and
have access to well-timed and specific data. This indicates
that psychological support for those on the frontlines and
affected by COVID-19 should be prioritized and made more
promptly accessible. The results of this study contribute
toward the awareness of policy makers regarding the
possibility of potentially injurious exposure events of
these experienced nurses. Hospital authorities may help to
advance physical, emotional, and psychological
preparedness, allowing the staff to comprehend some
unavoidable symptoms because of the high probability of
pathogen transmission. Hence, there was no significant
correlation between the perceived vulnerability to disease
and the perceived stress by frontline nurses. This suggests

that perceived vulnerability does not translate into

stress. However, previous findings suggest that individuals
with higher perceived vulnerability scores are also
vulnerable to stress (Diaz and Pelena, 2017). One valid
explanation based on the current study is be that the
frontline nurses manage to stay away from contracting those
pathogens because of their long-term experience in dealing
with the situation. Moreover, policies and protocols for
these nurses have been in place for protecting themselves
from susceptibility to disease and stress. This current
finding could contribute toward good practices of frontline
nurses during pandemics. Despite their vulnerability to the
disease, their composure on the frontline could lead them
to less stress, thereby carrying out their roles with
confidence.
Pandemic preparedness is key to the control and management

of infections in workplaces and at homes (Chunsuttiwat,
2016). Based on the study of Nyanshanu, Pfende, and
Ekpenyong (2020), the research participants reported lack
of preparedness within the health and social care sector
owing to nonexistence of pandemic control and management
policy and protocols. This caused panic and fear among
healthcare workers as they could not envisage the extent
COVID-19 pandemic was going to cause. It also brought a
feeling of uncertainty among them leading to low morale and
coordination in the workplace (Aronson & Smith, 2017). In
light of the above assertions, it is important that health
and social care workplaces have viable pandemic control and
management policies to protect both workers and individuals

they look after (Roberts et al., 2018). Such policies can
provide direction to healthcare workers when they are
confronted with a pandemic like COVID-19 as opposed to the
feeling of panic and fear when a pandemic strike.
Personal protective equipment is one of the most important

requirements when fighting an infectious pandemic like
COVID-19 (Cook, 2020). Nearly all the research participants
in this study reported a severe shortage of personal
protective equipment in their workplaces. This exposed the
health care Filipino workers in many health and social care
settings to possible infection of COVID-19. The shortage of
PPE undoubtedly brought fear and anxiety among healthcare
workers. This is also compounded by the fact that COVID-19
is untreatable (Santic, 2020). Furthermore, the shortage of
PPE posed a threat of COVID-19 infection to individuals in
receipt of care and visitors. In light of this, there is
need for all health and social care organizations to have a
clear policy on procurement of PPE. This will ensure
adequate stock of PPE and safety for all concerned. More
importantly broader policies on procurement of PPE for
health and social care organizations need to be reflected
as a national policy by central government (Grasselli et
al., 2020). This will ensure coordinated supply of PPE in
times of pandemic of this nature.
When people are confronted with a pandemic which is new and

untreatable, they are often gripped with fear and anxiety

(DeJean, 2016). This phenomenon is not new as evidenced in

the early days of the HIV pandemic and COVID-19,
respectively (El Alama et al., 2020). Almost all research
participants reported that the emergence of COVID-19 made
them feel anxious and fearful, citing that it was
untreatable and many health care Filipino workers had lost
their lives. Such anxiety and fear can severely impact on
the discharging of duties by health care Filipino workers.
It is important that health and social care workplaces have
established on-site supporting systems to counter fear and
anxiety in times of pandemics like COVID-19 amongst
healthcare Filipino workers (Knapp et al., 2017). Such
support can take the form of mental health and wellbeing
support services for affected health care Filipino workers.
More importantly the initiative needs to be part of
national policies to enhance effective support and
enforcement from central government, such as through Public
Health England (PHE) and the National Institute of Clinical
Excellence (NICE) in the UK.
Nearly all the research participants from the study

reported feelings of fear and anxiety among the individuals
they cared for. Among other reasons the fear was being
driven by the absence of treatment and no clear strategies
to protect them from COVID-19 (Ho, Chee and Ho. 2020).
Moving forward, it is therefore important that health and
social care organizations equip their healthcare workers
with skills to support individuals they look after during
pandemic periods.
In times of any infectious pandemic, social distancing is

important in preventing infection among the population
(Fong et al., 2020). Social distancing is especially
important in preventing infections in enclosed spaces like
buildings and workplaces. Almost all the research
participants reported challenges with enforcing social
distancing among the individuals they care for. Such
challenges were common among individuals with severe
debilitating conditions including those living with
dementia (Krumer-Nevo & Benjamin, 2016). There is greater
need to prepare for such challenges when working with
people affected by different conditions. It is also
important to increase the ratio of staff to individuals
during a pandemic to make sure that individuals are helped
to maintain social distancing and prevent cross-infections.
Furthermore, individual care organizations should have
strategies for implementing social distancing in times of
an infectious pandemic.
Social shielding in health and social care involves an

obligation to protect individuals living in care (Lustig,
2016). More importantly the principle goes beyond mere
protection of individuals to include empathy and commitment
on the part of healthcare workers. In this study, the
research participants reported challenges with social
shielding during the COVID-19 pandemic. During this period,
healthcare workers had to contend with staying at
workplaces for weeks to protect the individuals they were
looking after from being infected with COVID-19 (Yu et al.,
2018). It is also important to acknowledge that the HSCFWs

underwent this sacrifice of social shielding not only for
the individuals they cared for but also for their families
as travelling to and from work could increase their chances
of acquiring infection from COVID-19. It would seem
important for health and social care organizations to have
clear strategies to manage the principle of social
shielding without causing strain on the healthcare workers.
Jernigan (2019) suggests that testing where there is

pandemic potential is critical for prevention and public
health interventions. The research participants reported
that staff were unable to access diagnostic testing for
COVID-19 at the point of need. The rapidly evolving
pandemic presented several barriers to rapid testing of
healthcare workers. Burke (2020), cited accuracy and
reliability of tests, getting the right supply of equipment
and logistics as challenges associated with delay in
testing. Whilst it is possible that some HSCFWs would have
tested negative for the coronavirus the uncertainty
regarding cause of disease or symptoms had an impact on
management decisions (Binnicker, 2020). McMichael (2020)
reported that a care home in Washington, USA had 81
residents, 34 staff and 23 deaths following the outbreak of
COVID-19. Based on the views of participants in the current
study, there looks to be a need for a robust COVID-19
testing policy which prioritizes frontline workers to make
sure that new cases can be controlled (Department of Health
and Social Care, 2020). However, the health and social care
sector arguably remained a blind spot in prioritization as

seen by the manifestation of COVID-19 in the UK. McMichael
(2020) suggests the rapid contact tracing and testing of
care home communities to mitigate devastating outcomes can
be key in alleviating surging cases of COVID-19.
Improvement in availability of testing at the point of care
is essential (Jernigan et al., 2019). There is a need to
improve understanding of the way in which COVID-19 spreads
in care homes, as evidence from influenza suggests that
vulnerability of residents provides a conducive environment
for rapid infection (Lansbury et al., 2017).
Recent literature has established the ill effects of stress

on the nurses' psychological well-being and work outcomes
(Falguera et al., 2020; Faremi et al., 2019; Vivian et al.,
2019). Stress is generally sourced from situations that a
person has no control over, such as a pandemic. Currently,
there is a surge of studies on how the COVID-19 pandemic
has caused much stress to the various healthcare systems
across the globe. It has compromised the workforce,
particularly nurses. In fact, among the healthcare workers,
nurses are found to be the most anxious and stressed in
caring for and treating patients infected with the COVID-19
virus (Mo et al., 2020). For instance, it is reported that
nurses are stressed about a myriad of situations, including
worrying about getting infected or inadvertently infecting
others and caring for an infectious yet dying patient
(Alharbi et al., 2020; Pappa et al., 2020). Moreover, work
situations such as erratic and exhaustive work schedules,
the lack of personnel protective equipment, and forced

deployment to unfamiliar stations are additional burdens.
Similarly, they are wary about the social stigma and the
uncertainty of whether their employers are genuinely
concerned about their welfare (Maben & Bridges, 2020; El-
Hage et al., 2020; Zhu et al., 2020).
COVID-19 challenged and brought turmoil to the nurses'

psychological well- being. To mitigate possible physical
and psychological damage to the nurses, health facilities
advocated the use of mental health services such as
psychological first aid, crisis interventions, morale
boosters provided by their colleagues, and access to social
media and self-help reading materials (Blake et al., 2020;
Kang et al., 2020). Interestingly, one study distinctly
compared nurses' feelings and found that those who are less
exposed to fever stations appeared to experience more
burnout than those on the actual front line. This implies
that attention should be provided on an organizational
scale, particularly to health and mental wellness
interventions (Wu et al., 2020). On the other hand,
mounting studies found that nurses who provided direct
patient care appeared to be more stressed, overworked, and
psychologically disturbed and less fulfilled in their job
compared to nurses in other areas of assignment (Zerbini et
al., 2020). Hospital nurses, particularly women performing
diagnosis, care, treatment, and management of patients with
COVID-19, have displayed psychological disturbances such as

anxiety, lack of sleep, and depression (Lai et al., 2020).

Thus, researchers have thoroughly discussed the impact of
the pandemic on the hospital nurses' health risks and
psychological well-being. However, based on the available
literature, there is an evident lack of investigation on
the effect of COVID- 19 on the nurses' work outcomes and
turnover intention, especially among those deployed in the
community.
As explored in the research of Xu, Geng, and Li (2020), it

was found that in the face of the catastrophic health
emergency caused by COVID-19, medical staff have been
affected by different kinds of subjective and objective
factors. Their mental health problems are a form of human
stress response, an explanatory, emotional, and defensive
response within the human body, and a physiological
response of the human body to the invasion of needs or
injuries. In this special environment, their work, life,
and emotions tend to be regularly abnormal. Due to the
requirements for isolation and disinfection, medical
personnel need to wear several layers of protection
clothing. This increases the intensity of their work and
requires great physical energy, causing severe hypoxia and
physical symptoms such as headache and muscle soreness.
Other symptoms such as obsessive-compulsive symptoms,
interpersonal sensitivity, depression, anxiety, phobic
anxiety, hostility, and paranoid ideation are all normal
psychological reactions in the handling of emergencies and

environmental stimuli. In face of a disaster, persons with

good mental health will tend to actively take measures such
as catharsis, transference, compensation, relaxation,
humor, self-consolation, and rational response. The results
of this study show that the overall mental health of
medical staff is generally poor when dealing with COVID-19.
Psychological tests show that people have a process of
adaptation to catastrophic emergencies, from initial
rejection, shock, and fear, to habituation, acceptance, and
calm, to co-existence and living together, which is a
regular process. In the face of such a sudden disaster as
COVID-19, these psychological symptoms have manifested in
both doctors and patients. For medical personnel, it is
particularly important to pay attention to mental health
conditions while fulfilling their responsibilities. In
future research, it is worth exploring how to strengthen
the monitoring of mental health conditions of medical
personnel and establish an active, systematic, and
scientific psychological defense system under such special
circumstances.
As provided by Graham (2020), Covid-19 is a newly

identified disease, and evidence is still emerging on its
pathophysiological impact and epidemiology, and the
demographical implications of the pandemic. The Chinese
government has studied the mental health and wellbeing of
the frontline healthcare workforce in Wuhan, identifying
factors leading to long-term suboptimal mental health

status, including stress, anxiety, depressive symptoms,

insomnia, denial, anger and fear. These factors are
associated with, and correspond to, the high risk of
potential infection with the virus and inadequate
protection against contamination, overwork, physical and
mental exhaustion, discrimination, isolation, complex
patient care, and a lack of contact with families. The
impact of these mental health issues will not only affect
healthcare workers in the present fight against Covid-19
but may also affect their long-term health status (Kang et
al, 2020). Strategies to ameliorate the effects on staff
include redeploying staff from other regions and
establishing shift systems that allow workers time to rest
and to take turns in high-pressure roles. The nursing
profession has embedded within it an ethos of compassionate
care, with the workforce engaged on an everyday basis in
intense and sustained emotional and psychological
interactions with patients and their families and
caretakers, often under exceptionally challenging
conditions (Kinman and Leggetter, 2016). For many nurses,
underlying politics and the history of traditional
organizational hierarchies still have the potential to
negatively affect elements of their work today (Feeley et
al, 2019) – for example, perceptions and views of the
status of nurses among other health professionals and
profession-based silos, which can lead to exclusion and
lack of opportunity for interprofessional collaboration
(Braithwaite et al, 2016).

These issues may, unsurprisingly, make nurses vulnerable to

stress and can lead to feelings of compassion fatigue with
the duties they perform (Mason et al, 2017). Compassion
fatigue is best defined, in these circumstances, as a state
of physical and mental exhaustion caused by a depleted
ability to cope with one’s everyday environment (Cocker and
Joss, 2016), which may lead to reduced levels of resilience
and burnout, resulting in an overall poor quality of life,
both personally and professionally.
Compassion fatigue, burnout and compassion satisfaction

were identified as key factors influencing nurses’ health-
related quality of life in a research study of 1,521
Spanish nurses. The study’s authors recommended that
healthcare organizations should actively implement programs
to support nurses’ emotional wellbeing and offer protection
against negative variables, such as fatigue and burnout
(Ruiz-Fernández et al, 2020). In a study of emergency care
nurses, support of nurses by management staff was found to
be conducive to high levels of compassion satisfaction,
while lower levels of support resulted in burnout and
compassion fatigue (Hunsaker et al, 2015)
The covid-19 pandemic is likely to put healthcare

professionals across the world in an unprecedented
situation, having to make impossible decisions and work
under extreme pressures. These decisions may include how to

allocate scant resources to equally needy patients, how to

balance their own physical and mental healthcare needs with
those of patients, how to align their desire and duty to
patients with those to family and friends, and how to
provide care for all severely unwell patients with
constrained or inadequate resources. This may cause some to
experience moral injury or mental health problems.
(Greenberg, 2020)
COVID- 19, a biomedical disease has serious physical and

tremendous mental health implications as the rapidly
spreading pandemic. One of the most vulnerable, but
neglected, an occupational community of internal migrant
workers is prone for development of psychological ill-
effects due to double whammy impact of COVID-19 crisis and
concomitant adverse occupational scenario.
Permutations and combinations of the factors viz

susceptibility for new viral infections, potential to act
as vectors of transmission of infection, high prevalence of
pre-existing physical health morbidities such as
occupational pneumoconiosis, tuberculosis, HIV infections,
pre-existing psychological morbidities, adverse
psychosocial factors like absence of family support and
caretaker during the crisis, their limitations to follow
the rules and regulations of personal safety during the
COVID 19 crisis, social exclusion, and inability to timely
access the psychiatric services; all give rise to the peri-
traumatic psychological distress to internal migrant

workers. Superadded, is the blow of financial constraints

due to loss of work, absence or suspension of occupational
safety and health-related basic laws with associated
occupational hazards, which make this occupational group
highly vulnerable for the development of psychological
illnesses. (Choudhari, 2020).
As explored in the study of Khanal, Devkota, Dahal, Paudel

and Joshi (2020), the new coronavirus disease 2019 (COVID-
19) is currently a threat to the global health in an
unprecedented manner. Nepal, a South Asian country, is no
exception and is affected by the outbreak with overwhelming
effects on its economy and health system. The Government of
Nepal initiated its response against COVID-19 immediately
after its first reported case in the last week of January
in a Nepalese traveler from China (Bastola and Rodriguez-
Morales, 2020). As of June 29, 13,248 cases and 29 deaths
had been reported in the country despite nationwide
lockdown imposed from March 24, which continued for nearly
10 weeks. (Alrawashdeh, 2019).
The mental health impact of a disease outbreak is usually

neglected during pandemic management although the
consequences are costly. (Alwafi and Bokhary, 2019). Early
evidence has shown that health workers directly involved in
the diagnosis, treatment, and care of patients with COVID-
19 are at risk of developing mental health symptoms (Kang,
Chen and Yang, 2020).. Similar adverse psychological
reactions were reported among health care workers in
previous studies during the 2003 Severe Acute Respiratory

Syndrome (SARS) outbreak (Nicke, 2017). The increasing
number of confirmed cases and deaths, work burden,
inadequate personal protective equipment (PPE), media
coverage, lack of specific treatment, vulnerability to
infection and having to stay in quarantine, as well as
feelings of being inadequately supported in the workplace,
can contribute to the mental burden of health workers
(Almeida, 2019).
Psychological wellbeing has an important impact on

individuals’ performance. The impact of COVID-19 on mental
health is well documented in various countries among
different populations including health professionals.
However, evidence regarding the impact of the COVID-19
pandemic on health professionals is not available in Nepal.
During the initial response to COVID-19, there were media
reports regarding inadequate testing kits, and lack of PPEs
(Narayan, 2020). At the work place, health workers require
a support system to promote their mental wellbeing and
their activity need to be continually monitored - this is
crucial during health emergencies. A timely assessment of
mental health status and mental health needs of health
workers during emergencies will help the management to
respond and reduce psychological distress, and also align
health workers to the patient needs. In this context, this
study aimed to evaluate mental health outcomes among health
care workers involved in the COVID-19 response by

quantifying the magnitude of symptoms of depression,

anxiety and insomnia and by analyzing potential risk
factors associated with these symptoms (Zigmond, 2017).
The need to respond to the COVID-19 pandemic has created

challenges for services delivered by frontline workers
(FLW). This paper analyzes how the Brazilian government
regulated the reorganization of Primary Health Care (PHC)
and how FLW responded to these initiatives, comparing the
roles played by nurses and community health workers. Given
the multilevel health system, it was expected that the high
level of ambiguity would stimulate innovations. However,
data show that the ambiguity created different situations
for each profession. While nurses were able to adapt their
work and act with more autonomy, CHW lost their role in the
policy. (Lotta, 2020)
Healthcare workers are toiling countless number of hours

since the global outbreak of COVID-19 (caused by the SARS
CoV-2 and also known as the novel coronavirus) which has
been recently declared as a pandemic by the World Health
Organization (WHO 2020). Healthcare systems across
developed and developing nations are being put to the
ultimate test and are under tremendous pressure to limit
the spread of the novel coronavirus and majority of this
responsibility is being shouldered by frontline health care
workers effortlessly putting their lives on the line in
order to do so. Through this article, we attempt to
highlight some of the dire challenges currently being faced
by frontline health workers and propose certain

recommendations to reduce the encumbrance being imposed on
them in order to ensure the provision of rapid, well-
equipped, efficient health care services.
Unconditional and unprejudiced servitude is one of the

principles health workers around the world adhere to,
especially in time of peril as the present day. The last
two weeks have been unusual and have set the norm for a
new-normal- it is an understatement to state that the
COVID-19, apart from causing widespread morbidity,
mortality and fear, has specifically thrown the health care
workforce on emergency mode. Reports from affected
countries have revealed in the past that 22% of health care
workers were affected in hospitals across Hong Kong, with
the initial wave managing to infect 80% of the staff
working in the medical wards of Prince Wales Hospital. This
is just one example of the magnitude with which this virus
has taken a toll on the health workforce (Lee and Chan,
2016)
The exposure to the virus causes debility, morbidity and

mortality - but to a significant extent, also leads to
immense physical and psychological exhaustion. This
breakdown has led to health departments and ministries
reaching out to retired medical staff and those who spend
more time in research etc., to return to clinical work, to
tide over the mounting pressures on the health system. As
is evident in the last week, from all over the world,

hospitals and other health facilities are reporting

deficient supplies of personal protective equipment and
other vital necessities. Those working in the emergency and
the intensive care units are particularly and
disproportionately affected, when they are the ones who
need it the most. In addition to battling endless hours,
draining shifts, staff shortages and deficient supplies,
most are isolated from their families, affecting them
emotionally and physically. Anxiety, depression, denial,
insomnia and anger in the face of this pandemic will take a
toll on the health service delivery adding to the
increasing morbidity and ill health. These mental health
problems are not only affecting health workers’ clinical
decision-making ability, judgement, attention and
understanding of the disease but might also have a lasting
impact on their overall well-being (Kang, Li and Chen,
2020).
Perhaps the largest misery remains the shortages in

personal protective equipment for frontline health care
workers, who are now resorting to reuse single use gear or
develop local, generic quick fixes, both of which do not
offer the same protection as professional quality gear. In
Wuhan, the epicenter of the outbreak, medical professionals
have reported using tape to patch up torn masks, reused
one-time use eye goggles, and wrap their toes in domestic
use plastic bags, for lack of availability of shoe covers.
It has been worse for female frontline health care workers
who have reportedly had to shave their heads to prevent
spread of the virus, and are not being provided necessary

sanitary hygiene services to take care of their menstrual
needs. (Buckley, 2020)
According to Centers for Disease Control and Prevention

(2021), “Adults of any age with certain underlying medical
conditions are at increased risk for severe illness from
the virus that causes COVID-19. Severe illness from COVID-
19 is defined as hospitalization, admission to the ICU,
intubation or mechanical ventilation, or death. Adults of
any age with the following conditions are at increased
risk of severe illness from the virus that causes COVID-19:
Cancer, Chronic kidney disease, COPD (chronic obstructive
pulmonary disease), Down Syndrome, Heart conditions, such
as heart failure, coronary artery disease, or
cardiomyopathies, Immunocompromised state (weakened immune
system) from solid organ transplant, Obesity (body mass
index [BMI] of 30 kg/m2 or higher but < 40 kg/m2), Severe
Obesity (BMI ≥ 40 kg/m2), Pregnancy, Sickle cell disease,
Smoking, and Type 2 diabetes mellitus.
COVID-19 is a new disease. Currently there are limited data

and information about the impact of many underlying medical
conditions on the risk for severe illness from COVID-19.
Based on what we know at this time, adults of any age with
the following conditions might be at an increased risk for
severe illness from the virus that causes COVID-19: Asthma
(moderate-to-severe), Cerebrovascular disease (affects
blood vessels and blood supply to the brain), Cystic

fibrosis, Hypertension or high blood pressure,

Immunocompromised state (weakened immune system) from blood
or bone marrow transplant, immune deficiencies, HIV, use of
corticosteroids, or use of other immune weakening
medicines, Neurologic conditions, such as dementia, Liver
disease, Overweight (BMI > 25 kg/m2, but < 30 kg/m2),
Pulmonary fibrosis (having damaged or scarred lung
tissues), Thalassemia (a type of blood disorder), and Type
1 diabetes mellitus.
According to US Pharmacist (2020), the PLOS One online

journal advises that cardiovascular disease, hypertension,
diabetes, congestive heart failure, chronic kidney disease,
stroke and cancer all can increase mortality rates. In an
effort to improve patient care and help develop
interventions to protect high-risk populations, Penn State
College of Medicine researchers determined which conditions
were the most dangerous. They report that common
cardiovascular diseases appear to double a patient’s risk
of dying from COVID-19, while the other pre-existing
conditions might increase COVID-19 mortality rates one-and-
a-half to three times.
Based from Ssentongo, 2020. the study suggests that these

chronic conditions are not just common in patients with
COVID-19, but their presence is a warning sign to a higher
risk of death. Moreover, there is a high prevalence of
cardiovascular disease and hypertension around the world
and in particular, the U.S. With the persistence of COVID-

19 in the U.S., this connection becomes crucially

important. For the review, a study was made to, looking for
the risks of COVID-19 mortality in patients with and
without pre-existing comorbidities. Ultimately, 11 pre-
existing comorbidities—cardiovascular diseases,
hypertension, diabetes, congestive heart failure,
cerebrovascular disease, chronic kidney disease, chronic
liver disease, cancer, chronic obstructive pulmonary
disease, asthma, and HIV/AIDS—were included in the meta-
analysis. The 65,484 patients in those studies had COVID-19
and a mean age of 61 years.
Researchers determined that conditions associated with

significantly greater risk of mortality from the novel
coronavirus were:
 Cardiovascular disease (risk ratio (RR) 2.25 [95% CI =

1.60-3.17], number of studies (n) = 14)
 Hypertension (1.82 [1.43-2.32], n = 13)
 Diabetes (1.48 [1.02-2.15], n = 16)
 Congestive heart failure (2.03 [1.28-3.21], n = 3),
 Chronic kidney disease (3.25 [1.13-9.28)], n = 9)
 Cancer (1.47 [1.01-2.14), n = 10)
Tailored infection prevention and treatment strategies

targeting this high-risk population might improve survival
(Ssentongo, 2020). Although the health care community has
circulated anecdotal information about the impact of these
risk factors in COVID-19 mortality, our systematic review

and meta-analysis is the most comprehensive to date that

attempts to quantify the risk. As the COVID-19 pandemic
continues through 2020 and likely into 2021, we expect that
other researchers will build on our work (Chinchilli,
2020).

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St.

Paul University Philippines

Review of Related Literature

As COVID-19 strikes the Philippine nation, people rise

Healthcare industry is one of the most hazardous

School of Nursing and Health Sciences

According to Bielicki (2020), health-care workers are

Definition of COVID19 Virus

Coronavirus disease 2019 (COVID-19) is defined as illness

School of Nursing and Health Sciences

COVID-19 a global pandemic, its first such designation

School of Nursing and Health Sciences

in the mid-1960s, while others were only detected in the

millennium. (Cascella, et. al., 2021)

According to WHO (2021), coronavirus disease (COVID-19) is

In line with Pathak (2021), he stated that coronavirus is a

School of Nursing and Health Sciences

(windpipe and lungs). It spreads similarly to other

of seven coronavirus types, including those that cause

Symptoms of COVID19 Virus

As stated by WHO (2020), COVID-19 affects different people

In line with Healthline (2021), doctors and scientists are

School of Nursing and Health Sciences

linked to COVID-19 include: shortness of breath, a cough

Another definition stated by Medscape Drugs & Diseases

School of Nursing and Health Sciences

developed fever and/or symptoms of acute respiratory

Based on the study of Harvard Health Publishing (2021),

School of Nursing and Health Sciences

discomfort associated with COVID-19. The virus that causes

Risks of COVID19 Virus

The risk of getting COVID-19 is evolving daily and varies

School of Nursing and Health Sciences

As explored by the Centers for Disease Control & Prevention

crowding, certain occupations, pregnancy.

In line with Mayo Clinic (2021), they have claimed that

Complications of COVID19 Virus

According to the Centers for Disease Control & Prevention

School of Nursing and Health Sciences

10% or more in older patients. Men are more likely to

School of Nursing and Health Sciences

pulmonary embolism complicated by acute right-sided heart

In addition, based on Medscape Drugs and Diseases (2020)

Mode of Transmissions of COVID19 Virus

According to WHO (2020), respiratory infections can be

School of Nursing and Health Sciences

nose) or conjunctiva (eyes) exposed to potentially

School of Nursing and Health Sciences

eyes before washing your hands, and rarely, (4) fecal

Currently available evidence indicates that COVID-19 may be

Effects of Covid- 19 to Healthcare Workers

The COVID-19 pandemic has resulted in significant burdens

School of Nursing and Health Sciences

continued impact. Healthcare workers, at the heart of the

Healthcare workers experience emotional exhaustion, which

School of Nursing and Health Sciences

continue to balance these existing obstacles to wellness

The director of the National Hospital Infection Management

School of Nursing and Health Sciences

emergency responses, healthcare workers have not had enough

Healthcare professionals are faced with high stressors

School of Nursing and Health Sciences