Perspectives of Sierra Leoneans Healthcare Workers' Mental Health During the Ebola Outbreak

Perspectives of Sierra Leoneans Healthcare Workers'

Mental Health During the Ebola Outbreak

Chapter 1: Introduction to the Study

Introduction

Healthcare workers (HCWs) in an epidemic experience mental health

problems. HCWs with inadequate mental health care experienced mental

health difficulties during the 2014 and 2015 Ebola virus disease (EVD)

outbreak (Bell, 2016; World Health Organization [WHO], 2016). The mental

health delivery system in Westernized countries provides effective mental

health services to HCWs during an epidemic; however, this is not the case in

West African nations (Coltart, Johnson, &Whitty, 2015). West African

nations such as Sierra Leone continue to provide an inadequate mental health

delivery system for HCWs (Delamou, Beavogui, Konde, van Griensven, &

De Brouwere, 2015; Eckes, 2016). Cheung (2015) indicated that HCWs

during the EVD outbreak in West Africa experienced unexplained

psychological symptoms. Cheung called for effective mental health care in

West Africa. Qualitative studies have indicated that first responders such as

HCWs are prone to suffer posttraumatic stress disorder (PTSD) and

significant psychological trauma during an epidemic (Paladino et al., 2017).

While studies have assessed mental health symptoms via quantitative

instruments (Betancourt et al., 2016; Khalid, Khalid, &Qabajah, 2016; Li et

al., 2015), they have not been able toaddress the subjective experience of

mental health care or symptoms that HCWs experienced during the Ebola

virus outbreak, which would provide more meaningful, in-depth, and helpful

information on their mental health symptoms during the EVD epidemic.

Objective assessments have indicated that HCWs during the EVD

outbreak experienced mental health symptoms and stress. However,

objective assessments do not know what kind of symptoms they experienced

or if they personally felt that they were suffering because all of the

quantitative studies used objective assessments and not subjective ones.

Further, researchers know that the mental health care system in West Africa

was inadequate. Researchers do not know if HCWs sought help, or if that

help was available and effective.

This qualitative research study was conducted to explore HCWs’

perspectives on their mental health symptoms and lived experiences during

the Ebola outbreak and to help address problems of the current mental health

system in Sierra Leone. This study would also help to address public policies

related to HCWs’ perspectives on their mental health during an epidemic.

The rest of this chapter includes background information on HCWs’

mental health and the mental health care system in Freetown, Sierra Leone;

the statement of the problem; the nature of the study; the purpose of the

study; and the research question for this study. I also discuss the theoretical

framework and conceptual framework that were used in this study.

Furthermore, I explain the assumptions, scope of delimitations, and

limitations of the study. Finally, I conclude with the significance of the study

and a summary of this chapter.

Background

HCWs with inadequate mental health care are unable to cope with

stress that leads to mental health difficulties when working with highly

infectious patients. Although most of the literature in Chapter 2 addressed

the need for effective mental health treatment for HCWs, mental health

specialists in West Africa have been unsuccessful in their efforts to provide

quality mental healthcare for HCWs. In fact, Bell (2016), WHO

(2016), and Mugisha, De Hert, Stubbs, Basangwa, and Vancampfort (2017)

stressed the importance of quality mental healthcare for HCWs in West

Africa during an epidemic. It happens that the advocacy for effective mental

health treatment for HCWs in West Africa has not been effective. Betancourt

et al. (2016), Hughes (2015), and Li et al. (2015) postulated that the mental

health system in West Africa is either nonexistent or inadequate.

Several studies have called for effective mental health treatment for

HCWs in Africa (Centers for Disease Control and Prevention [CDC], 2014;

WHO, 2016); other studies have also noted that the lack of effective mental

health treatment in Africa for HCWs may affect the mental health of HCWs

(Gwaikolo, Kohrt, & Cooper, 2017; Mugisha et al., 2017). According to Li

et al. (2015), Scott et al. (2009), and Ansumana et al. (2017), HCWs in

Africa experience mixed mental health symptoms that need to be studied.

Mental health is still a serious problem in Africa that should be addressed by

qualified healthcare professionals (Hughes, 2015). It is made clear in the

literature review that there are limited intervention measures for mental

health in Africa. However, the limited intervention techniques used in Africa

appeared to be ineffective to address

HCWs’ mental health symptoms during the 2014 and 2015 EVD outbreak.

Lund, Myer,

Stein, Williams, and Flisher (2013); Greenberg, Wessely, and Wykes

(2015);and Brolin Ribacke et al. (2016) postulated that one of the major

reasons that mental health care is inaccessible to HCWs is lack of

government assistance.

Jalloh et al. (2018) and WHO (2015) postulated that HCWs exhibited

psychological symptoms after they experienced the death of 26,277 HCWs

during the Ebola outbreak. Additional studies have indicated that lack of

adequate resources induces stress among HCWs during an epidemic (Moll,

2014; Selamu, Thornicroft, Fekadu, &Hanlon, 2017). HCWs who did not

have effective coping skills during the epidemic experienced tremendous

stress (Khalid et al., 2016).

While the poor mental health of HCWs may affect their occupational

abilities, the long-term impact of mental health difficulties may lead them to

substance abuse problems (Mokaya et al., 2016). HCWs may experience

occupational stress and burnout due to lack of social support, which may

lead to mental illness (Glasberg, Eriksson, &Norberg, 2007). Musa, John,

Habib, and Kuznik (2016) and deMenil, Knapp, McDaid, and Njengo (2014)

argued that high economic cost and high unemployment are among the

reasons why mental health treatment in Africa is ineffective. There could be

a serious mental health crisis among HCWs if their mental health is not

addressed (CDC, 2014; Konis et al., 2015; WHO, 2016). These studies

together confirmed that HCWs with mental illness might have difficulties in

living a normal life. Currently, the body of literature addressing this problem

in West Africa is limited(Hughes, 2015; WHO, 2016).

Problem Statement

The mental health of HCWs who cared for patients with the Ebola

virus in 2014 in West Africa has received little or no attention from

healthcare professionals. Much of the scholarly research on HCWs during

the EVD outbreak has focused on the physiological health of HCWs (WHO,

2016) and not on their mental health (Greenberg et al., 2015). The WHO

(2016) continues to educate people about the need for mental healthcare for

HCWs in the West African region after the Ebola virus epidemic. HCWs

make good decisions and provide quality care for their patients when they

have good mental health (Rugema et al., 2015). HCWs have experienced the

death of over 26,277 confirmed cases of Ebola victims in Sierra Leone,

Guinea, and Liberia (WHO, 2016).

According to WHO (2016), some of these Ebola victims were related to the

HCWs.

Different stressors can affect HCWs’ mental health and their work

performance (WHO, 2016). HCWs in West Africa have a 5% higher chance

than others of becoming infected with EVD (Petti, Protano, Messano, &

Scully, 2016).

In a qualitative study not related to the EVD outbreak, Scott et al.

(2009) indicated that HCWs are second victims, especially when they watch

their clients die. Engel et al. (2017) conducted a qualitative study on a

diagnostic practice for HIV patients in South Africa. They found that

information provided by HCWs was relevant to implementing better

strategies to help HCWs and the general population.

In a qualitative study, Hughes (2015) indicated that there would be an

increase in psychiatric morbidity among HCWs treating EVD patients in

West Africa because of the lack of proper mental health care for them. The

WHO (2014) noted that the lack of qualified mental health professionals in

Sierra Leone had increased psychological distress among HCWs who treated

EVD patients. Greenberg et al. (2015) indicated that it is imperative that

scientists find an effective treatment for EVD and stressed that the

psychological needs of HCWs and patients should not be ignored.

Based on the existing data, quantitative studies conducted by

researchers have indicated that HCWs experience anxiety, depression, and

PTSD (Li et al., 2015; Scott et al., 2009). Some of the research has indicated

that HCWs suffer specific symptoms while some studies have not found that

HCWs are distressed (Khalid et al., 2016; Koh et al.,

2015). Therefore, the extent of mental health issues among HCWs treating

patients with EVD is unknown. To better understand HCWs’ lived

experiences in relation to their mental health while providing treatment to

patients with the Ebola virus in Sierra Leone, I conducted a qualitative study.

While numerous studies have examined the medical aspects of the Ebola

virus, no qualitative study has been done to examine the perspectives of

HCWs in Sierra Leone on experiencing mental health symptoms while

providing treatment to patients with EVD. While researchers know from a

quantitative study

(Cheung, 2015; Scott et al., 2009) that HCWs experienced anxiety,

depression, and PTSD, the qualitative perspective in the current study adds

to knowledge about mental health issues of HCWs who treat patients with

the Ebola virus. A qualitative inquiry into HCWs’ mental status and

perceived stressors while providing treatment to patients with the Ebola

virus provided relevant information that may lead to quality mental health

care interventions for the next EVD outbreak. This study addressed gaps in

the literature about how HCWs related to their mental health status while

providing treatment to patients with EVD during the EVD outbreak in

Freetown, Sierra Leone.

Purpose of the Study

The purpose of this study was to use a qualitative approach to explore

the lived experiences of HCWs in Freetown, Sierra Leone involving mental

health symptoms while providing treatment to patients with EVD. The

rationale for conducting this study was to provide more meaningful, in-

depth, and helpful information on mental health symptoms experienced by

HCWs during the EVD outbreak. This study may also foster positive social

change that enables HCWs and mental health professionals to work together

to address the mental health crisis in Freetown, Sierra Leone.

The interpretivist paradigm is often used in qualitative studies.

According to Cohen and Manion (1994), interpretive researchers seek to

understand the world of human experience. This finding gives credence to

Creswell’s (2009) contention that interpretivist researchers understand the

world through participants’ points of view, backgrounds, and experiences.

The interpretivist paradigm was used in this study because it enabled HCWs

in Freetown, Sierra Leone to describe their mental illness symptoms when

working with highly infectious patients.

Research Questions

This study was conducted to understand and explore the lived experiences

HCWs in Freetown, Sierra Leone. This inquiry facilitated a greater

understanding of HCWs’ mental health during the EVD outbreak. I

employed thoughtful consideration of the topic and a thorough review of

pieces of literature related to the topic, which enabled me to formulate the

following research questions:

RQ1. How do HCWs in Sierra Leone describe their lived experiences

regarding their own mental health when treating patients with

Ebola virus disease?

RQ2. How do HCWs feel about their abilities to cope with stress

while treating patients with the Ebola virus disease?

RQ3. How do HCWs describe their lived experiences of the mental

health care treatment they received while treating patients with

the Ebola virus disease?

Theoretical Framework

The stress process model was most appropriate for this study because

it is useful in explaining and identifying the stress factors that contribute to

mental health illness.

The stress process model is used to understand stress factors contributing to

well-being. Pearlin, Morton, Lieberman, Menaghan, and Mullan (1981) were

the first to use the stress process model to give some conceptual organization

to a diverse line of research. There are several factors intertwined with the

idea of well-being: “the social status of the individual,” “the context that

envelopes[individuals’]daily lives,” and individuals’ “exposures to stressors,

and resources that they can use to respond to the stressors, and the way stress

is manifested in their psychological and bodily functioning”(Pearlin, 1989,

p.396). Pearlin (1989) indicated that these stress factors are interconnected,

in that what affects one stress factor can affect the other stress factors.

According to Pearlin, social stress is found among ordinary people whoare

involved in everyday activities.

Aneshensel (1992) postulated that mental disorders could be caused

by different stressors. According to Pearlin (1989), psychologists and

psychiatrists are concerned with mental health outcomes when people are

under stress. I used the stress process model to explore the stressors of

HCWs while treating patients with EVD. According to Pearlin et al. (1981),

three factors contribute to the stress process model: stressors, moderation

and mediation, and stress outcomes. Pearlin argued that stressors coming

from external environmental factors can force a person to be exposed to

unwanted events. Moderation and mediation are social and personal factors

that modulate the effect of certain stressors. Stress outcomes include the

following: emotional distress, psychological distress, anxiety, and other

psychosocial distress (Pearlin, 1999).

The use of the stress process model was appropriate for this study

because it brought forth the views of HCWs in Freetown, Sierra Leone on

how they perceived the stress factors involved when taking care of patients

with EVD. Phenomenology was appropriate because this method enabled

participants to share their lived experiences of their own mental health when

treating patients with EVD. Further explanation regarding the stress process

model and phenomenology is shared in Chapter 2.This theory related to the

study approach and research questions because it helped to explain the

behavior and attitudes of HCWs during the EVD outbreak. This theory also

helped to explain how stress affects HCWs treating patients with the EVD.

Conceptual Framework

HCWs’ perceptions of their mental health constituted the phenomenon

that grounded this study. I used Heidegger’s (1889) conceptual framework of

hermeneutic phenomenology to understand the mental illness that HCWs

experienced while providing treatment to highly infectious patients.

Phenomenology methodology was originated by Husserl (1982). However,

Heidegger (1992) was a student of Husserl, and he formulated the concept of

a hermeneutic or interpretive approach to phenomenology (Converse, 2012;

Peredaryenko& Krauss, 2013). In this naturalistic qualitative

phenomenological study, I explored the lived experiences of HCWs

involving their mental health during the Ebola outbreak in Freetown, Sierra

Leone. The conceptual framework of hermeneutic phenomenology has been

used to understand the lived experiences of various phenomena (Tuohy,

Cooney, Dowling, Murphy, & Sixsmith, 2013; Valandra, 2012). Further

explanation regarding hermeneutic phenomenological studies of HCWs is

presented in Chapter 2.

Mental illness is a serious concern among HCWs working with highly

infectious patients (Li et al., 2015; Scott et al., 2009). Pescosolido(2013)

postulated that individuals with mental illness are labeled based on their

appearance and their socioeconomic status. Pescosolido recognized that a

mental illness diagnosis creates discrimination and prejudice. Researchers

have indicated that phenomenology involves how individuals experience

various phenomena, including ways of seeing, knowing about, and having

skills related to such phenomena(Patton, 2002). Heidegger (1992) indicated

that the aim of phenomenology is to qualitatively discover different ways

that individuals experience, conceptualize, realize, and understand aspects of

phenomena in an environment. Patton (2002) also stated that a researcher

can make a meaningful theoretical contribution by observing a phenomenon

that does not have a name and then giving it a name. Thus, I found that the

perspectives of HCWs in Freetown, Sierra Leone could help in formulating a

hypothesis regarding better mental health interventions for HCWs. Other

researchers such as Shane (2007) have described hermeneutic

phenomenology as studying the awareness and reflections of participants.

The conceptual framework of hermeneutic phenomenology related to

this study approach because it enabled me to employ an inductive approach

(Patton, 2002) and answer the key research question—How do HCWs in

Sierra Leone describe their lived experiences regarding their own mental

health? In addition, the conceptual framework of hermeneutic

phenomenology enabled me to start with the data to make sense of the lived

experiences of HCWs and their perspectives on their own mental health.

Hermeneutic phenomenology was used as a conceptual framework to

explore HCWs’ mental health while providing treatment to patients with the

EVD in Freetown, Sierra Leone. Because stress and mental health were used

interchangeably, Pearlin’s stress process model theory and hermeneutic

phenomenology provided the framework for this study.

Nature of the Study

I used a qualitative phenomenological approach to explore the

phenomenon of interest. I explored the lived experiences of HCWs from

Sierra Leone about their mental health as it related to stress during the EVD

outbreak, including their perceptions, beliefs, and attitudes while treating

patients with EVD. Qualitative interviewing enabled me to begin with the

assumption that HCWs’ experiences were meaningful and could be made

explicit (Patton, 2002). Creswell (2009) indicated that the phenomenological

design focuses on the essence of a lived experience. Morse (2006) noted that

individuals may have different opinions on similar experiences.

Husserl (1982) indicated that a sample size of 10 could be assessed in

a qualitative research. This sample size was estimated based on the approach

of the study, which was phenomenology. Morse (1994) postulated that

qualitative sample sizes should be large enough to obtain feedback for most

or all perceptions. In phenomenological studies, Creswell (2009) indicated

that five to 25 participants are enough, whereas Morse suggested at least six

participants.

The HCWs who participated in this study were registered nurses and a

psychiatrist between the ages of 36 and 60 years who were currently

working at Connaught Hospital in Freetown, Sierra Leone. The target

population in this study consisted of two women and eight men who were

originally from Sierra Leone and were working as HCWs. According to

estimate, all 150 of the HCWs (nurses and a psychiatrist) were employed

during the EVD outbreak (Hughes, 2015). I recruited 10 participants from

within this population.

I used purposeful sampling for this study. Purposeful sampling is used

in qualitative research to obtain information from a population (Patton,

2002). Purposeful sampling enabled me to select members of a group who

had knowledge of the phenomenon of interest. The participants’ ethnicities

were Creole, Mende, Temne, and Limba. All of the participants spoke

English, which is the official language in Sierra

Leone, as well as a common language called Krio.

I conducted a recorded interview of approximately 45 minutes with

each participant. I developed a set of open-ended questions related to the

research questions.

The data were analyzed by using the analysis of statements gathered during

the interview. Moustakas (1994) indicated that the gathering of information

in phenomenology is called an essence description. I used NVivo10 to

analyze the data. NVivo 10 software enables researchers to sort and arrange

their files. Coding was used as a method of developing themes that emerged

from the interview/transcript. Most of my data were managed using

software, index cards, and sticky notes. The data were collected in Freetown,

Sierra

Leone.

Definition of Terms

Epidemic: The spread of a disease in different areas or among a

specific group of people (WHO, 2013).

Healthcare worker (HCW): A person whose job description is to help

and protect the well-being of people and communities (WHO, 2015).

Anxiety disorders: A group of mental disorders that produce a feeling

of restlessness and fear (American Psychiatric Association [APA], 2013).

Mental health: A condition that describes a person’s psychological

and emotional well-being (APA, 2013).

Depression: A persistent feeling of sadness and worthlessness that

results in a lack of desire to engage in activities that were once pleasurable

(APA, 2013).

Middle East respiratory syndrome (MERS): A respiratory illness that

is recognized in a person (WHO, 2015).

Phobic anxiety: Fear of an object or a situation (APA, 2013).

Paranoid ideation: A grandiose belief that one is being persecuted,

harassed, or treated unfairly (APA, 2013).

Interpersonal sensitivity: The ability to judge someone correctly

(Brew& Kottler,

2008).

Posttraumatic stress disorder (PTSD): May affect anyone who has

been exposed to a traumatic or a stressful event (APA, 2013).

Paradigm: A set of beliefs or assumptions (Patton, 2002).

Assumptions

Creswell (2009) and Frankfort-Nachmias and Nachmias (2008) stated

that researchers must be aware of assumptions when conducting a study.

Creswell (2009) indicated that researchers bring their beliefs and their

philosophical assumptions to a study. In a quantitative study, there is a

hypothesis. However, in a qualitative study, there is no hypothesis. For this

qualitative study, I had five assumptions in my mind. These assumptions

wereas follows:

•I assumed that all of the participants in the study would remain

truthful.

•I assumed that HCWs understood the need for an effective mental

health care system in Freetown, Sierra Leone.

•I assumed that HCWs in Freetown, Sierra Leone wanted to know if

they had any mental illness.

•I assumed that the interview questions would enable me to collect

the correct information for the study.

•I assumed that the result of the study would effect positive social

change.

Scope and Delimitations

The mental health of HCWs in Freetown, Sierra Leone during the

EVD epidemic has been a serious concern for mental health care

professionals. The literature review indicated that mental healthcare

intervention for HCWs is inadequate (Betancourt et al., 2016; Greenberg et

al., 2015; Hughes, 2015). There has been a need to explore HCWs’

perspectives on their mental health during the Ebola virus outbreak in order

to provide effective measures for mental health treatment in Freetown, Sierra

Leone. The scope of the study was limited to HCWs and did not encompass

other individuals who might have been involved in caretaking. Enabling

HCWs in the West African region to voice their opinions empowered them

as they shared insights on the mental health symptoms they experienced.

During an epidemic, HCWs may experience the loss of patients,

friends, and family members. It was important to select HCWs as

participants in this study because they could provide vital information on the

topic of interest. They were able to relay information related to the direct and

indirect mental health symptoms they had experienced while providing care

for highly infectious patients. Further, in reviewing additional literature, it

became obvious that how HCWs coped with stress during the Ebola virus

epidemic had not been fully studied.

I selected Pearlin et al.’s (1981) stress process model as the best

theory for the study and Heidegger’s (1889) hermeneutic phenomenology as

a conceptual model. The stress process model was chosen over its

counterpart, the ecological model, because it explains and identifies the

stress factors that contribute to mental health issues. The stress process

model was able to bring forth the views of HCWs on how they perceived

intervention measures for stress and mental health intervention that were

used during the Ebola virus outbreak. As such, the stress process model was

optimal for the study.

Though ecological theory is highly related to this area of study, its

main focus is on various systems of human development (Bronfenbrenner,

1994). Barrera (2011) conducted a study on how individuals view various

mental health systems in their environments (Barrera, 2011). Barrera used

the ecological system to understand why Latinos were not accessing the

mental health system available to them. Barrera found that microsystems

played a significant role in how individuals viewed the mental health system.

In another study, the ecological system was used by McCall (2009) for the

examination of school human development. McCall concluded that learning

and health are determined by the interaction of individuals in various

systems of the environment. I did not select this theory because this study

was built on HCWs’ perspectives on their mental health and how they coped

with stress. Ecological theory would have been optimal if this study had

been focused on the efforts of public health (as a macrosystem) to eliminate

EVD.

Pearlin (1999) asserted that there are several factors associated with

well-being. Applying Pearlin’s theory, I sought to guide HCWs to describe

their experiences with mental health professionals with an aim toward

developing adequate mental health care for HCWs in Freetown, Sierra

Leone. Furthermore, using an approach informed by Husserl’s

phenomenology, I prompted HCWs to elaborate on the mental illness they

had experienced during the EVD outbreak.

Because the study was qualitative, I considered boundaries when

interviewing participants. In a qualitative study, the physical proximity

between the interviewer and the participants must be taken seriously. The

scope and delimitations enabled me to reach authentic findings through the

study. This study was delimited to (a) HCWs in Freetown, Sierra Leone;(b)

HCWs who had worked directly or indirectly with EVD patients; and(c)

participants who understood and spoke fluent English.

Limitations

Qualitative methodology has its limitations, which should be

considered when conducting a study. Creswell (2009) asserted that

quantitative and qualitative research have different methodological

approaches. Creswell pointed out that qualitative research involves both

credibility and trustworthiness. According to Cope (2014), credibility in

qualitative research can be supported by researchers’ ability to engage in the

right methods when conducting the study. Polit and Beck (2006) emphasized

that credibility includes the truth of the data being studied and the

researchers’ truthfulness in the interpretation of the data. Sandelowski

(1986) pointed out that the credibility of a study is based on the recognition

of the phenomenon by other people who share the same experience being

studied. Polit and Beck (2006) asserted for a study to remain reliable, it must

have credibility and trustworthiness. Guba and Lincoln (1994) indicated that

reliability and validity are intertwined with trustworthiness in a qualitative

study. In addition, trustworthiness and quality can only be maintained when

a study is reliable, transferable, dependable, and credible (Cope, 2014).

Therefore, credibility and reliability are imperative in a qualitative study.

Creswell (2009) indicated that researchers are responsible for taking

the right steps to maintain accuracy and credibility in their findings. To

provide credibility and trustworthiness to this study. I employed the

strategies of both qualitative validity and reliability. These strategies were as

follows:

•As a single researcher, I employed an intercoder. According to

Creswell (2009), intercoder agreement occurs when two or more

coders agree on the codes used for a study.

•I carefully examined evidence from the sources gathered to justify

the themes.

•I conducted a follow-up interview with participants to get feedback

on the findings.

•I used peer debriefing to foster accuracy of the study.

As an active participant in the study, my participation could have led

to bias.

Therefore, I anticipated the following limitations:

•I was born in Freetown, Sierra Leone, which might have fostered

bias and prejudice due to my knowledge of the environment and

the participants.

•I only targeted a sample population of HCWs in Freetown, which

could be considered a limited sample.

•The result or outcomes of the study may be called into question

because all participants were HCWs in the Western area of

Freetown, Sierra Leone.

•The sample population might not generalize to other populations in

Freetown,

Sierra Leone.

Significance

This study was significant because HCWs in Freetown, Sierra Leone

may have experienced mental health problems during the 2014 and 2015

Ebola outbreak (Li et al., 2015; WHO, 2016). EVD continues to be a

healthcare concern in West Africa. Western countries have found an

effective strategy to provide mental health care during epidemics like the

EVD outbreak; this has not been the case for mental health care in West

African nations. The latest incident of the EVD happened in Sierra Leone in

2016, after Sierra Leone was discovered an Ebola-free country (WHO,

2016). Additional studies have indicated that health care workers and family

members of HCWs who had contact with infected people were at higher risk

for EVD than individuals who had no contact with infected patients (WHO,

2016). Further, pregnant women with EVD were at risk of passing EVD to

their unborn children. These factors may have increased stress for HCWs

(WHO, 2014). Aneshensel (1992) argued that mental disorders can be

caused by stress. Intervention methods to combat the Ebola virus involve

education, handwashing, avoiding patients infected with the virus, and

avoiding dead bodies with the virus (Eckes, 2016). Despite these

interventions, EVD continues to be a threat to HCWs, and HCWs continue

to experience mental health difficulties related to EVD.

This study provided opportunities for HCWs to understand their

mental health symptoms. It also provided opportunities for mental healthcare

professionals and the general Sierra Leone population to understand the

signs and symptoms of mental illness. Additionally, this study was

significant because Sierra Leoneans think that the EVD epidemic might

reoccur in West Africa. This study examined the beliefs of HCWs in Sierra

Leone to gain a more in-depth understanding of their mental health during

the

EVD outbreak.

It is important that HCWs tell their stories to inform policymakers and

practitioners, especially those in the mental healthcare delivery system, so

that they can implement better interventions in case there is another outbreak

of EVD. The views of HCWs may contribute to social change, which may

lead to the implementation of better mental health treatment interventions,

mental health clinics, and improved mental health education related to EVD

or any epidemic. Knowing the views of HCWs may encourage Sierra

Leoneans to become advocates for a high-quality psychological health care

system for workers dealing with EVD and other infectious diseases. The

information provided in this study may promote positive social change and

awareness of the mental health crisis, and it may help mental health care

workers to feel empowered.

Summary

The WHO (2016) and various researchers (Coltart et al., 2015; Jalloh

et al., 2018) have recognized that the mental health of HCWs in West Africa

during an epidemic should not be ignored. The 2014 and 2015 Ebola

outbreak in West Africa affected the mental health of HCWs. The WHO

(2016) indicated that early diagnosis of mental health issues in HCWs would

enable them to receive effective mental healthcare. HCWs mostly suffer

from mental health problems during an epidemic because of the enormous

stress of their roles as first responders (Gustafsson, Norberg, & Stranberg,

2008; Li et al., 2015). Mental health care professionals and researchers have

advocated tirelessly for an adequate mental health system in Africa (CDC,

2014; WHO, 2016).

The efforts of researchers and healthcare professionals to establish an

adequate mental health system in Africa have failed. Understanding the

views of HCWs in Freetown, Sierra Leone on the mental health symptoms

that they experienced could enable mental health officials to start a dialogue

that might promote an efficient mental health system in Freetown, Sierra

Leone.

This study is important because it provides relevant information on the

mental health symptoms of HCWs during the EVD epidemic. It may also

enable HCWs to voice their opinions on how increased stress during an

epidemic could cause mental illness and how it could also affect their work

performance.

Pearlin et al.’s (1981) stress process model coupled with Husserl’s (1982)

phenomenology were introduced as lenses of analysis in this study. Finally,

definitions of terms, assumptions, limitations, and the significance of the

study were addressed. Chapter

2 includes a view of the literature related to the theoretical and conceptual

framework., Chapter 2: Literature Review

Introduction

After the Ebola virus outbreak in West Africa in 2014, the mental

health of HCWs was the focus of increased interest in the healthcare field.

Within the last couple of years of the EVD epidemic, the HCWs of Sierra

Leone received humanitarian help from the CDC (Johnson, 2014). The CDC

(2014) and Li et al. (2015) found that HCWs in Sierra Leone were unable to

cope with stress while treating patients with EVD, resulting in anxiety,

depression, and PTSD. Ansumana et al. (2017) indicated that HCWs in

Sierra Leone experienced a feeling of loneliness and isolation during the

EVD outbreak. There has been a need to study HCWs’ mental health

symptoms in Freetown, Sierra Leone because of the evidence that they were

affected mentally during the EVD outbreak of 2014 to 2015.

The WHO (2016) postulated that little is known about the severity of

mental health issues in impoverished nations such as Sierra Leone. The CDC

(2014) has indicated that numerous attempts to provide adequate mental

health treatments in the African nation have effectively failed. To date,

numerous studies have investigated whether HCWs have received adequate

mental health treatment, especially during an outbreak of a disease such as

EVD (CDC, 2014; Hughes, 2015; WHO, 2016). Studies have found that

mental health treatment in this context has been nonexistent or ineffective

(Betancourt et al., 2016; WHO, 2015). Raab, Sogge, Parker, and Flament

(2015) and WHO (2016) addressed the need for good mental health among

HCWs while providing care for their clients to help address any mental

health difficulties they might be experiencing. The lack of adequate mental

health treatment for HCWs may result from the poor availability of mental

health care in Sierra Leone more generally. HCWs are not the only ones

affected by inadequate mental health treatment in West Africa; their

families, friends, and clients can also be affected by inadequate mental

health care (CDC, 2014; WHO, 2014). Research has also postulated that

limited psychotropic medications, lack of well-trained clinicians, and high

turnover contribute to inadequate mental health treatment in Sierra Leone

(Gwaikolo et al., 2017; WHO, 2016). The WHO (2016) has called for more

attention to be paid to the mental health system in West Africa. The WHO

(2016) indicated that mental illness is a serious problem among the general

population in West Africa.

Additional qualitative studies are needed to find effective mental

health care for HCWs. Numerous studies have provided information on the

medical aspect of the Ebola virus among HCWs. Based on existing data,

quantitative studies conducted by researchers have indicated that HCWs

have experienced anxiety, depression, and PTSD (Ansumana et al., 2017;

Cheung, 2015; Li et al., 2015; Scott et al., 2009). However, no qualitative

study has been conducted related to the mental health aspect of HCWs’

experiences in Sierra Leone while providing care for patients with EVD.

Some studies have indicated that HCWs had symptoms of mental illness

(Jalloh et al., 2018; Li et al., 2015; Scott et al., 2009), and some studies have

not found any mental health symptoms in this population (Khalid et al.,

2016; Moll, 2014). This study was conducted in an attempt to delve deeper

to address this contradiction. A qualitative inquiry involving in-depth

exploration of HCWs’ perceptions of their mental health while providing

care for patients with EVD was conducted to add to the body of knowledge.

The purpose of this study was to enable HCWs in Freetown, Sierra Leone to

voice their opinions of the mental health symptoms they experienced while

providing care for EVD clients.

Stress model theory guided this qualitative research study. While

many studies have been conducted on the physical health of HCWs related

to EVD (Coltart et al.,

2015), limited literature exists on the mental health of HCWs treating

patients with EVD. Research has provided insight on how many HCWs died

(WHO, 2016) and how many contracted the virus during the EVD epidemic

(CDC, 2015; WHO, 2016). Waldrop, Kramer, Skretny, Milch, and Finn

(2005) used the stress process model theory in a qualitative study to

interview 74 people who were providing hospice care for family members.

They found that some of the stressors involved with family members were

role conflict, work conflict, and financial strain.

In addition, Pack (2014) used the stress process model theory in a

qualitative phenomenological study to interview 13 social workers.

Participants in this study were asked how they would respond to a critical

outbreak. This study found that preparation, positive relationships among

peers, and support from management helped them during a catastrophic

outbreak. There has been no study specifically addressing HCWs’

perspectives on their mental health during the EVD outbreak. Thus, I sought

to explore how HCWs in Freetown, Sierra Leone described their mental

health symptoms, the stress they experienced, and the coping skills they used

when treating patients with EVD.

This chapter includes are view of the literature on the research topic

based on the research questions and the methodology. A literature review

involves research synthesis and critical evaluation of existing literature

related to the topic being studied (APA,

2000). The literature review identifies gaps in the literature. This literature

review focuses on HCWs’ perceptions of their mental health during the 2014

and 2015 Ebola outbreak because there had been limited research on the

mental health aspect of HCWs’ experiences during the EVD outbreak (CDC,

2015; WHO, 2016). This literature review covers key concepts related to

phenomenological studies, EVD, mental health issues in West Africa,

barriers to mental health care, stress factors related to mental health, coping

skills, and epidemics.

Literature Search Strategy

Walden University provided me with relevant literature for this study.

Search engines usedto gather literature included the Sacramento Public

Library, ProQuest Central, Academic Search, Google Academic, and the

CDC website. I searched for relevant literature by using terms closely related

to the current study. I chose the following as search terms: stress process

model, conceptual framework, phenomenology and healthcare workers,

EVD, the healthcare system in Africa, inadequate mental healthcare and

healthcare workers, HCWs and stress, HCWs and coping, barriers to mental

health, and epidemic and healthcare workers.

Theoretical Framework

Origin of the Stress Process Model

The stress process model was first introduced by Pearlin et al. in 1981

and was further developed by Pearlin in 1999. The stress process model,

which was used as a theory in this study, asserts that three factors describe

the stress process: stressors, moderators or mediators, and stressed outcomes

(Pearlin et al., 1981). Stressors involve both internal and external factors.

Internal factors involve individual biological and psychological factors that

enable a person to confront a situation, whereas external factors involve the

immediate individual environment or social context. Moderators or

mediators involve the strengthening or weakening of specific elements based

on the social or personal factors involved. According to Pearlin (1989,

1999), stress outcomes are the physiological and emotional effects on the

person or persons involved. Pearlin postulated that there are two main

categories of stressors: event stressors and chronic stressors. Event stressors

are stressors that happen when a person does not expect the stress to occur.

An example of an event stressor is an unexpected car crash on the way to

work. The 2014 outbreak of the Ebola virus in West Africa was also

categorized as an event stressor. Chronic stressors involve different kinds of

strains (Pearlin& Skaff, 1996). Status, role, contextual, and quotidian strains

are considered weak stressors. Unlike event stressors, chronic stressors

include those resulting from a biased system that promotes inequality and

injustice and exists for a period of time. These stressors persist despite being

verbalized by the person or persons they affect.

Pearlin (1999) postulated that status strain involves an individual’s

social and hierarchical structure. In the context of HCWs during the EVD

outbreak, an obvious example of this stressor is the lack of mental health

funding in West Africa, which affects mental health services. This issue

causes individuals in this population to be susceptible to an increased

amount of stress. Pearlin stated that limitations on their personal and social

resources cause HCWs to deal with stressors and increase their stress level.

According to Pearlin, this can lead to longer-lasting and more profound

stress.

Pearlin (1995) postulated that role strains are stressors comprising

family roles, occupational roles, and institutional roles. An example of this

type of stressor, as experienced by HCWs, is an increased demand of work

beyond the job description.

Pearlin indicated that when a job is challenging and intertwined with abstract

thinking skills, it creates stress for the employee, especially when it does not

coincide with rewarding incentives. Pearlin’s assessment of role strain

suggests that the strain factors are intertwined with other stress factors.

The kind of strain that is most relevant to this study is Pearlin’s (1999)

concept of role conflict. Role conflict is relevant because individuals are

exposed to stressors from variousareas of their perceived roles. According to

Pearlin, role conflict exposes an individual to stressors, which cause

increased stress. Pearlin (1995) described the impact of gradual changes to

family roles as an example of role conflict. For instance, most people depend

on their family for both social and psychological support. Teenagers may

feel role strain when their parents treat them like young children. As these

teenagers become adults and their parents become unable to function

independently, they develop the role strain of caring for their aging parents.

According to Pearlin, constant realignment and restructuring are needed to

cope with changing role settings. This role conflict also applies to HCWs

who strive to provide care for both patients and family members,

simultaneously fulfilling their responsibilities at work and home. The

HCWs’ roles as primary caregivers and support systems for their clients

promote role conflict and thus cause them to experience high levels of

psychological stress.

Contextual strains, according to Pearlin, involve strain between

individuals and their environment, which consists of the community and the

neighborhood. Pearlin (1995) provided an example by way of exploratory

qualitative interviews in which participants in the study indicated that they

experienced trepidation and uncertainty. This finding suggests that there

were threats to the safety and security of the participants’ wellbeing in their

neighborhood. During the EVD outbreak, HCWs experienced both

individual and environmental strains. Individual strains included the HCWs’

psychological symptoms during the EVD outbreak, whereas environmental

strains involved lack of resources and environmental support.

Finally, according to Pearlin, quotidian strains involve how

individuals deal with their everyday lives. According to Pearlin, this kind of

strain comes from normal activities both within and outside the home. For

instance, doing laundry on a regular basis cannot be avoided if one wants to

wear clean clothes. However, for some individuals, this task causes stress

and strain. Another example is going to bed on time to have a productive

next day. For some people, this quotidian activity causes strain. An example

of quotidian strain could be HCWs experiencing long hours of work and

being unable to get a restful night’s sleep. Given the compelling evidence

that many caregivers have experienced psychological stress(Jalloh et al.,

2018; Li et al., 2015; Scott et al., 2009), they should have access to quality

mental health care to help them cope with psychological stress. I designed

this study to explore the perceptions of HCWs concerning their mental

health while providing care for patients with EVD.

Rationale for the Theoretical Framework

Pearlin employed this theoretical framework to argue that individuals

are connected to social structures that influence their lives. The social

structures of HCWs who have cared for EVD patients relate to the roles of

their employers, the government, and other social factors that force them to

be exposed to certain events. In this study, I focused on HCWs’ connections

to the social structure of a hospital or clinic that provided care for Ebola

virus patients. Though HCWs’ hard work and extraordinary time spent with

clients during the epidemic saved many lives, international organizations

also played a considerable role in helping to provide support during the

Ebola outbreak (CDC, 2015; WHO, 2016). According to Pearlin (1999), the

stress process model can be usedin the medical field to examine the health

and well-being of those who care for persons with health problems and

disabilities. I decided that this model would be optimal for this study because

of the role that HCWs played in treating patients with EVD during the 2014

outbreak. The HCWs certainly influenced the patients, but the patients also

influenced the HCWs. The stress process model was selected over other

potential models because it facilitated this study’s analysis of relevant

information about HCWs’ perspectives on the stress they experienced while

providing care for patients with EVD in Freetown, Sierra Leone.

A theory is able to explain why behaviors occur (Creswell, 2009).

This theory was selected because it relates to the roles that HCWs play in

their everyday lives. The stress process model was applicable to the analysis

of what the HCWs said about the mental health symptoms that they

experienced while providing care for Ebola virus patients. The stress process

model was the most appropriate model for this study (Pearlin, 1989, 1991).

The research questions were derived from the premise of the stress process

model. This study was built on this existing theory as it helped to explain

and identify views of HCWs in Freetown, Sierra Leone on how they coped

with the stress factors and their own mental health when treating patients

with EVD. This theory brought light to the understanding of how different

stressors can cause mental illness.

Conceptual Framework

Phenomenology formed the conceptual framework for this study.

Heidegger (1889) used a conceptual framework of hermeneutic

phenomenology to understand lived experiences of different phenomena.

Like many conceptual frameworks, hermeneutic phenomenology can be

used to understand HCWs’ perspectives on their mental health during the

2014 and 2015 EVD outbreak. van Manen (2014) used hermeneutic

phenomenology to purport that individuals have different ways of

experiencing different phenomena. The social situation that HCWs

experienced could include the healthcare system, government regulations or

funding, and their patients. This study focused on HCWs whowere involved

with the social structure of clinics and hospitals during the 2014 to 2015

EVD outbreak in Freetown, Sierra Leone.

The hermeneutic phenomenological conceptual framework is widely

used by individuals to explain their ways of seeing things, knowing things,

and understanding how things relate to them (Valandra, 2012). More

specifically, it provides a framework for understanding the mental health

symptoms that HCWs experienced while providing care for patients during

the EVD outbreak of 2014 to 2015. Researchers applying Heidegger’s

concept of hermeneutic phenomenology employ intuition, reduction, and

intersubjectivity to understand the meaning of phenomena (Patton, 2002). In

using Heidegger’s conceptual framework of hermeneutic phenomenology in

this study, I sought to understand HCWs’ perspectives on their mental health

during the EVD outbreak in

Freetown, Sierra Leone.

Literature Review Related to Key Concepts

This literature review provides an overview of HCWs’ perceptions of

their mental health when working with highly infectious patients.

Qualitative, phenomenology, and quantitative studies were chosen

methodology and methods that set the foundation for this study. The studies

cited in the subsections that follow are related to the construct of interest and

the chosen methodology and are consistent with the scope of the study.

Phenomenology

According to Brinkmann (2014) and Converse (2012),

phenomenology is a philosophy and are search strategy that is used to

understand individuals’ perceptions of their lived experiences. An area of

phenomenology is hermeneutic phenomenology.

Originating in Husserl’s work, hermeneutic phenomenology was founded by

Heidegger (1889), a student of Husserl (Converse, 2012). As Pietkiewicz

and Smith (2014) stated, phenomenology is the study of human lived

experiences, and the key elements of phenomenology are description,

reduction, essence, and intentionality. In the reduction process, Patton (2002)

indicated that the researcher’s goal is to describe the individual’s personal

experience of the phenomenon of interest without influencing the outcome

of the result. When the individual expresses his or her feelings about his or

her lived experiences, this process is called an essence. Intentionality,

according to Converse (2012) and Peredaryenko and Krauss (2013), involves

the ability of individuals to describe what things mean to them. According to

Tuohy et al. (2013) and Valandra (2012), hermeneutic phenomenology is

one of the components of phenomenology. I selected hermeneutic

phenomenology because of its descriptive and interpretive components. The

application of hermeneutic phenomenology in this study included the use of

semi structured interviews to communicate with participants.

Phenomenological Studies of Healthcare Workers

Jonsson and Halabi (2006) conducted a phenomenological study on the

consequences of work-related stress among HCWs in the Middle East. Their

study aimed to understand the relationship between stress exposure and

posttraumatic stress disorder. They interviewed 25 nurses. They found that

stress-related symptoms are related to poor social support. They also found

that HCWs in the Middle East were at serious risk for a high level of stress

symptoms. They concluded that their study would enable HCWs to deal

with stress in an early efficient manner.

Corley, Hammond, and Fraser (2010) conducted a phenomenological

study on the lived experiences of HCWs working in the intensive care unit

during the H1N1 influenza pandemic in Australia. They found that eight

common themes emerge from the study. Some of the themes are (a) the

wearing of protective equipment, (a) infection control procedure, and (c)

morale level. They concluded this study indicated that the planning for an

epidemic is stressful because of its unpredictable nature.

Troy, Wyness, and McAuliffe (2007) conducted a qualitative study on

HCWs using a phenomenological approach. They interviewed 12 HCWs in

South Africa and the Philippines. They found that there was a high turnover

among HCWs and it was challenging to recruit HCWs because of language

and cultural differences.

Matiti (2005) used a phenomenology approach to study the cultural

experiences of internationally recruited nurses. Matiti interviewed 12

nurses–seven females and five males. Matiti found that cultural perception of

nurses influences their adaptation at their workplace.

In another study, Gustafsson, Norberg, and Strandberg (2008)

interviewed 20 female healthcare professionals. They used a

phenomenological approach to ask healthcare workers about burnout at

work. They found that healthcare workers who are autonomous in their jobs

can avoid burnout. However, healthcare workers that were dissatisfied at

their jobs were prone to burnout.

Ebola Virus Disease

According to Beeching, Fenech, and Houlihan (2014), there are three

phases of symptoms associated with the Ebola virus disease. The first phase

of symptoms includes fever, headache, and myalgia. The second phase of

symptoms is gastrointestinal, such as diarrhea and vomiting. The third phase

of symptoms includes loss of consciousness and bleeding. According to the

WHO (2014) the most common symptoms reported during the 2014 Sierra

Leone EVD outbreak were: “Fever (87.1%), fatigue (76.4%), loss of appetite

(64.5%), vomiting (67.6%), diarrhea (65.6%), headache (53.4%), abdominal

pain (44.3%), and unexplained bleeding (18%)” (p. 3). Researchers indicated

that children and adults exhibit similar symptoms. However, younger

children exhibit more respiratory difficulties as compared to adults (CDC,

2014). Patient’s temperature, blood pressure, pulse rate, and respiration

should be monitored after an EVD diagnosis (Beeching et al., 2014). Other

possible symptoms related to the EVD are maculopapular rash, bleeding,

hepatomegaly, lymphadenopathy, and geological signs (CDC, 2014).

However, early recognition of the first two phases of symptoms and

diagnosis of the EVD can help save the lives of patients and healthcare

workers.

Symptoms and Diagnosis of EVD

The EVD is diagnosed by the collection of specimens, a process that is

under strict precaution guidelines (Beeching et al., 2014). A patient is

diagnosed after a test shows positive Ebola RT-PCR (CDC, 2014). When a

patient or HCW is isolated because of a suspected case of the EVD, this test

is ordered. A positive test indicates that the patient or HCW is infected with

the EVD. Usually, a negative test is repeated within 48 hours after the first

test to confirm the result (Beeching et al., 2014). The EVD is best managed

by early diagnosis and supportive treatment (CDC, 2014). Beeching et al.

(2014) have suggested that high fatality rates in emerging countries occur

because of a lack of proper funding for basic health care. Beeching et al. and

the CDC also indicated that the EVD could be easily misdiagnosed as

malaria because of the increased temperature of the patient. However, if the

patient continues to exhibit symptoms of uncontrolled diarrhea and

vomiting, they are at risk of the EVD. Because of the lack of funding,

patients with malaria are often misdiagnosed with the EVD. This creates a

stressful situation for HCWs because it causes confusion regarding diagnosis

and treatment.

Management, Treatment, and Prognosis

There have been over 26,277 confirmed cases of Ebola in Sierra

Leone, Guinea, and Liberia (Beavogui et al., 2016). There were 10,884 EVD

related deaths between December of 2013 and April of 2015 (WHO, 2015).

The CDC has suggested that a patient who is suspected to have the EVD

must be isolated from the public and should be monitored for the duration of

the incubation. HCWs suspected to have the EVD should be treated the same

way as other suspected patients. The CDC indicated that HCWs who are

exposed to body fluid from a patient should wash affected areas with soap

and copious amount of water. There is no known cure for the EVD; the

treatments currently available are fluid for hydration and anti-nausea

medication (Saxena& Gomes, 2016). The fluid provides electrolyte

replacement, which decreases the mortality rates in some patients with the

EVD (WHO, 2014). Beeching et al. (2014) addressed the steps of

symptomatic management for the EVD that are recommended by healthcare

providers. Fever and pain are to be treated with paracetamol and morphine

for severe pain. Nonsteroid medications are to be avoided because of

excessive bleeding. Nausea and vomiting are to be treated with intravenous

anti-emetics, and omeprazole is recommended for heartburn.

Benzodiazepines are recommended when the patient is experiencing

seizures. Though seizures are uncommon, HCWs should be prepared to treat

them. Phenobarbital is given if the patient is exhibiting repeated seizures.

Haldol or benzodiazepine are used if the patient is agitated. HCWs should be

prepared to avoid body contact to minimize risk of needlestick injuries. The

best-known treatment for the

EVD is the ZMapp. Research has suggested that the ZMapp is a combination

of three EV “glycoprotein epitopes and it’s engineered for expression in

tobacco plants” (Beeching et al., 2014, p. 7). ZMapp had been proven to be

effective when given to nonhuman primates; however, it has not yet been

successfully tested in humans. Beeching et al. also indicated that the drug

Favipiravir was proven to be effective in treating the influenza virus, West

Nile virus, and yellow fever. It has proven to be effective in treating the

EVD in mice. However, it has not yet been proven to be effective in human

subjects. These studies indicate that the EVD is deadly and there is no

available cure, which causes stress among healthcare workers. However,

following safety measures and using effective coping skills can help HCWs

deal with this deadly virus (Khalid et al., 2016).

There is a higher mortality rate for the EVD among children under the

age of five and adults over the age of 40 (CDC, 2014). The CDC reported

that pregnant women have a higher chance of miscarriage after being

diagnosed with the Ebola virus disease.

However, early diagnosis helps promote the survival of the virus.

The management, treatment, and prognosis of the EVD are relevant to

this study. However, how HCWs describe their mental health symptoms

while working with infectious patients in a poor-quality healthcare system

applies to this study. Reviewing additional literature that provides

information on the healthcare system in West Africa is addressed in the next

paragraph.

History of Healthcare for Mental Illness in West Africa

In the 1800s, African men from the Yoruba tribe from Sierra Leone,

West Africa left their native land to study medicine in the United Kingdom

(Oyebode, 2006). Oyebode stated that during the colonial times, most the

men who went to study medicine in the United Kingdom returned as medical

doctors. In the 1800s, the African government began formulating plans to

help the mentally ill in colonial Africa (Oyebode, 2006). However,

psychiatry, related to mental health in Africa did not start until the 1900s.

Oyebode postulated in the 1900s, African medical doctors were encouraged

by the government to practice psychiatry in West Africa. Forster (2012)

cited that before 1951 there was no African psychiatrist in colonial Africa.

Forster indicated after 1951 there were just four psychiatrists in the entire

continent of Africa.

The first mental health hospitals in West Africa were in Nigeria,

Ghana, and Sierra Leone (Manuwa, 1971). During the 1900s African

patients were treated separately from European patients in these mental

health hospitals and African doctors were paid less than European doctors

(Oyebode, 2006). Similarly, Schram (1971) has suggested that racial origin

played a significant role in psychiatry in West Africa. Oyebode postulated

that the government was looking for a way to build a hospital that would

treat patients with the principles of fairness, respect, and compassion. In

1957 the Kissy Lunatic Asylum in Freetown, Sierra Leone started treating

patients with mental illness. Many of the asylums were considered prison

cells for convicted felons, such as the Kissy Lunatic Asylum that was built in

1847(Sadowsky, 1999). Sadowsky reported that the asylums were not

properly kept, lacked basic supplies, were dark and congested, and patients

were shackled. McCulloch (1995) noted that most of the mentally ill people

in West Africa were treated like convicted felons as compared to mentally ill

patients in the developed world. For instance, patients were kept in small

cells in their own feces and urine.

The African population was reluctant to accept psychiatry during the

colonial days. Csordas and Lewton (1998) indicated that Africans during

colonialism believed that psychiatry was witchcraft, juju, taboos, and a

religious cult. Sadowsky also emphasized the fact that some of the people

who were diagnosed as mentally ill were people who stood up against

colonialization. Forster (2012) noted that the cultural conditioning of

Africans toward psychiatry prevents many Africans to go into the field of

psychiatry. Forster added that some Sierra Leoneans believed that

psychiatric patients were religiously possessed as they were punished for

their sins. In 1900, Forster stated that it was a challenging time for

psychiatry in Africa as compared to the current psychiatry.

McCulloch (1995) postulated that colonialization influenced modern

psychiatry in West Africa. In other words, all the psychological concepts

used in African psychiatry came from white society. For instance, African

society was described as sexually promiscuous, violent, lazy, and savagery.

According to McCulloch, “ethnopsychiatry was the settlers’ most eloquent

response to the challenge of African nationalism” (p. 334).

Forster (2012) pointed out that more African doctors from Africa are

studying psychiatry in the United Kingdom, Canada, and other parts of the

world today as compared to the colonial days. Forster added that the attitude

of the population toward psychiatry has changed as many Africans have

embraced psychiatry to understand the meaning of mental illness. Forster

included that there are many Africans seeking psychiatric help as compared

to none in the colonial days. Forster added that despite the beliefs of

psychiatry in Africa by some Africans, some Africans still hold on to their

cultural beliefs after they are discharged from the hospital. Forster indicated

that one of the current problems facing psychiatry in West Africa is the

overcrowding of patients in clinics. The overcrowding is caused by limited

mental institutions. The current psychiatric treatment in Africa is

pharmacotherapy and psychotherapy (Forster, 2012).

Forster indicated that patients are admitted voluntarily, and the extent of

mental illness in West Africa is unknown as many patients are

misdiagnosed. Forster indicated that there are no special laws for defective

individuals with mental problems. The sample of the study was collected in

Ghana, West Africa. According to Forster, many of the patients in Ghana

have schizophrenia. Forster cited that the need for psychiatrists is in great

demand in the continent of Africa.

Sukeri, Betancourt, and Emsley (2014) postulated that mental health

service in Africa is mixed with colonial history and apartheid.Sukeri,

Betancourt, and Emsley indicated that, before the development of formalized

mental health services, mental health care was provided through a network

of public assistance and missionary hospitals. Sukeri, Betancourt, and

Emsleynoted that the historical context of mental health in Africa affects the

current status of psychiatry in Africa. The WHO (2014) indicated that

funding for mental health clinics in the West African region remains low,

while funding for mental illness in developed nations remains high.

Therefore, because of the historical context, lack of funding for mental

health clinics, lack of knowledge, and stigmatization, Africans are often

afraid to be labeled mentally ill.

Healthcare System in West Africa

In addition, poor quality healthcare system can affect the role of

healthcare workers. Brolin Ribacke et al. (2016) reported that during the

Ebola crisis of 2014 in West Africa, Sierra Leone, the healthcare system was

deplorable. They indicated because of the inadequate health care system in

Sierra Leone, HCWs were afraid to go to work. Brolin Ribacke et al.

postulated that one of the problems associated with the healthcare system in

Sierra Leone is the lack of incentives for healthcare workers. Many HCWs in

Sierra Leone prefer to work for an NGO organization for better salary than

for the government of Sierra Leone. They found that the main hospital in

Freetown, Sierra Leone called Connaught lacks the necessary medical

supplies such as sterilized needles, proper clothing for an epidemic, and

catheters for patients that need them (Greenberg et al., 2015). Brolin Ribacke

et al. stated that healthcare assistance is inadequate because the government

failed to provide basic resources to healthcare workers. For instance, poor

transportation and the lack of infrastructure make it difficult for many

HCWs, especially those that are poor. Healthcare workers are underpaid and

showed no motivation to perform their duties.

Parpia, Ndeffo-Mbah, Wenzel, and Galvani (2016) examined the

effect of the response of the 2014 to 2015 EVD outbreak in West Africa.

They conducted a threecomputational simulation on the healthcare system in

Sierra Leone, Liberia, and Guinea. A quantitative study was performed using

a survey to gather the data from participants. They indicated that the Ebola

outbreak of 2014 and 2015 affected the healthcare system, the diagnosis of

malaria, HIV/AIDS, and tuberculosis. They argued that the deaths of several

HCWs and the limited number of HCWs affected the healthcare system.

According to their findings, they indicated that fear of transmission of the

EVD was another factor that affected the healthcare system and healthcare

workers. Also, mandatory emergency curfew, border closures, and

transportation difficulties all affected the healthcare system and healthcare

workers.

Ansumana et al. (2017) cited that the Mano River Union (MRU) was

found to help the healthcare system in West Africa so that HCWs can

provide effective care for their patients. According to Ansumana et al., the

healthcare assistance in the MRU countries includes a prevention program

for tuberculosis. Ansumana et al. indicated that during the outbreak of the

EVD, most of the HCWs contracted the virus and eventually died.

According to Ansumana et al., there were 810 confirmed deaths among

HCWs in Sierra Leone, Liberia, and Guinea.

Fasina et al. (2015) cited that the healthcare system during the EVD

outbreak in

2014 was deplorable. They conducted a qualitative study in West Africa

during the EVD outbreak of 2014. They found that the reason for the

increase in death was based on the poor healthcare system. Their findings

suggest the need for a quality healthcare system in

West Africa in case there is another outbreak of the EVD

The healthcare system has been a challenge for HCWs since and after

the EVD outbreak of 2014 in Sierra Leone (Alonso et al., 2014). Some of the

challenges of the healthcare system are (a) lack of proper health

infrastructure, (b) the lack of appropriate treatment method to control the

spread of the Ebola virus disease, and (c) the lack of trust of healthcare

workers by the population. Healthcare workers in Sierra Leone ranked the

EVD as a serious problem in West Africa (Wenshu et al., 2014). They

indicated that understanding the factors contributing to the problems of the

healthcare system would help promote adequate health care system in Sierra

Leone.

Healthcare Workers and Mental Health

Psychological problems for healthcare workers are a growing concern,

especially in the West African region. Mugisha et al. (2017) indicated that

there would be an increase in mental health problems among HCWs in West

Africa if better strategies for adequate mental healthcare are not

implemented. Abendroth and Flannery (2006) indicated because HCWs

provide a high degree of quality care for their patients, they suffer from

compassion fatigue (CF). According to Abendroth and Flannery, CF can

cause physical and psychological problems for healthcare workers. It is

reasonable to argue that good mental health enables HCWs to provide

effective care to their clients. Betancourt et al. (2016) and CDC (2015) have

confirmed that if adequate resources are not provided to HCWs in West

Africa, it will be difficult for them to provide adequate treatment to their

patients.

Khalid et al. (2016) found that HCWs in Saudi Arabia contracted the

Middle East respiratory syndrome coronavirus (MERS-COV) while

providing care for their patients. They exhibited the symptoms of diarrhea,

difficulty breathing, nausea, and vomiting. The fatality rate among HCWs

during the MERS-COV outbreak was between 30% and 70%.

The overall fatality rate was 35%, and the mortality rate among ventilated

patients was 60% to 70%. HCWs who experienced MERS-Cov experienced

significant stress and emotional problems. HCWs remained emotionally

committed to their jobs during the MERS-COV outbreak despite the deaths

of some of their co-workers. Moll (2014) postulated that HCWs are

committed to their work despite their high rates of stress. Moll found that

HCWs with mental health issues are ostracized by society and suggested

that, if adequate care is not provided, their symptoms might get worse. He

indicated that poor mental health among HCWs affects not only their

families but also their patients and society. Therefore, because HCWs are

emotionally committed to their work, they need effective strategies to cope

with the stress factors they experience.

Mental health problems can affect the quality of services provided by

healthcare workers. Koinis et al. (2015) postulated that workplace stress

influences the physical and emotional well-being of healthcare workers. In

their quantitative study, Koinis et al. (2015) sampled 200 HCWs to identify

their coping strategies at work. The results indicated that most HCWs do not

have stress management techniques. They recommended stress management

technique for healthcare workers. If the psychological problems among

HCWs are not taken seriously in the West African nations, HCWs will have

difficulties providing quality care to their clients. Some of the emotional

problems HCWs experience include anxiety, depression, and PTSD (Li et

al., 2015; Shoji et al., 2014). These emotional difficulties can cause HCWs

to abuse drugs and alcohol to cope with their psychological problems

(Charlson, Diminic, Lund, Degenhardt, &Whiteford, 2014). Mateen and

Dorji (2009) found that HCWs who exhibit mental difficulties are at a

greater risk for suicide. There is no clinic in Sierra Leone that provides

adequate mental health treatment for healthcare workers (Alonso et al.,

2014). HCWs with undiagnosed mental health issues are likely to have

difficulties adjusting to their everyday lives

(WHO, 2016). The WHO (2016) has indicated that mental health disorders

among HCWs, especially HCWs combating outbreaks and epidemics, are

likely to impact their lives both psychologically and physiologically.

Therefore, numerous studies have contended that HCWs experience high

levels of stress and that a lack of stress management techniques may affect

the quality of their work performance.

Shoji et al. (2014) studied the increase in PTSD among healthcare

workers. In their quantitative study, they found that direct exposure to a

traumatic event is related to posttraumatic stress disorder (PTSD). They

conducted two studies of a total of 408 participants working in behavioral

healthcare in the U.S. They found that some of the symptoms of PTSD

include re-experiencing, avoidance, and hyperarousal. Bride, Robinson,

Yegidis, and Figley (2004) postulated that secondary traumatic stress (STS)

is an indirect exposure to a traumatic situation. STS is commonly seen

among HCWs who are providing care for traumatized patients. These studies

indicate that PTSD and STS occur among HCWs who are exposed to

outbreaks or an epidemic. Higher levels of distress and negative cognition

are experienced by HCWs who are exposed to these negative situations

(Shoji et al., 2014).

Ansumana et al. (2017) stated that HCWs in Sierra Leone during the

EVD outbreak experienced low self-esteem, lack of trust toward the

healthcare system, and a feeling of loneliness. They found that HCWs were

restricted to attend the burial of their loved ones and to touch their families

or colleagues. These restrictions left them feeling lonely and isolated.

However, this study did not cover the mental health of HCWs while

providing care for the EVD patients, an area that was explored in this study.

Analysis of Healthcare Workers and Mental Health

The studies addressed above indicated that the mental healthcare of

HCWs cannot be ignored, especially in an epidemic. Mugisha et al. (2017),

Abendroth and Flannery (2006), Khalid et al. (2016), and Moll (2014) all

suggested that poor mental health is a significant risk among healthcare

workers. Mugisha et al. found increased mental illness among HCWs, while

Abendroth and Flannery identified compassion fatigue among HCWs as a

mental health concern. Koinis et al. (2015) found that most HCWs did not

have stress management techniques.

Mateen and Dorji (2009) found that HCWs have a high risk of suicide.

Shoji et al. (2014) found that posttraumatic stress disorder and secondary

traumatic stress are found among HCWs who are exposed to an epidemic.

These studies recommended that additional measures should be taken to help

HCWs cope with mental illness. However, asking HCWs how they cope

with their mental health when working with infectious patients during the

EVD is relevant to the study. This was the area that was explored in this

study.

Further, Li et al. (2015) found that anxiety and depression are the two

most common mental health problems among healthcare workers. However,

these researchers did not explicitly elaborate on the extent of these mental

health symptoms of healthcare workers. The WHO (2016) has called for

immediate attention regarding the mental health crisis in Africa. Numerous

studies have therefore recommended that additional measures be taken to

help address the mental health crisis among HCWs in Africa. These studies

together confirmed that HCWs might experience mental health issues,

especially in a traumatic situation.

Based on the quantitative pieces of literature, HCWs have been found

to exhibit mental health symptoms such as anxiety, PTSD, and depression

(Gwaikolo et al., 2017; Li et al., 2015; Shoji et al., 2014). While the

qualitative studies show that HCWs experience CF, lack of adequate

resources, low self-esteem, and high stress (Abendroth&

Flannery, 2006; Ansumana et al., 2017; CDC, 2015; Khalid et al., 2016;

Moll, 2014).

Therefore, the extent of mental health issues among HCWs treating patients

with the EVD is unknown, and the findings are mixed. Thus, the advantage

of doing a qualitative study over quantitative study was that a qualitative

study enabled me to get an in-depth understanding of the perspectives of

HCWs regarding any mental health issues they experienced and the care they

received. This study explored HCWs perspectives on how they cope with

stress while providing care for patients with the Ebola virus disease. This

study would encourage mental healthcare providers, as well as policymakers

to incorporate effective measures to address the mental health crisis in

Africa.

Mental Health Treatment and Cost

Padayacheya, Ramlalla, and Chipps (2017) employed a quantitative

research method to study depression in older adults by assessing the cost

associated with their mental health treatment in South Africa. They found

that the cost of mental health treatment, especially for depression, is lower

when it is diagnosed early. To determine the prevalence of depression

among South Africans, they used a 15-item genetic depression scale. They

also used a sociodemographic questionnaire on 255 geriatric patients. The

data were compared to other mental health care systems in Africa. They

concluded that early diagnosis of mental illness cost less as compared to late

diagnosis when dealing with mental illness in South Africa.

Musa et al. (2016) used a quantitative research method to evaluate

cost optimization in the treatment of multi-drug-resistant tuberculosis (MDR

TB) in Nigeria, West Africa and determined the cost differences between

home-based treatment and hospital treatment. They found that patients who

were treated for MDR TB at home saved 35% as compared to patients who

were treated in a hospital setting. The study found that the associated costs

for a hospital stay were very expensive. The treatment costs for patients with

family support were lower. However, one major limitation associated with

the study was that the researchers did not provide any information on

psychotropic medications related to mental illness. The researchers

recommended further studies on public costs related to health care in Africa.

Lund et al. (2013) studied mental illness and lost income among 4,351

adults in South Africa and found that anxiety and depression can prevent

South Africans from obtaining affordable living and mental health care. The

study found that mental illness is a major economic disadvantage for the

low-income population in Africa. Individuals in lower income groups were

unable to obtain adequate mental health services. Lund et al. (2013) also

found that the mental health cost for adults in South Africa is estimated at

$59 million annually. They also evaluated both the direct and indirect costs

of mental health care in Africa and found that the indirect cost outweighs the

direct cost. They suggested that indirect cost means the cost of lost income

based on unexpected unemployment and recommended government

assistance to help cover indirect costs for low-income individuals.

In a similar quantitative study, Lund, Boyce, Flisher, Kafaar, and

Dawes (2009) studied human resource requirements and cost for mental

health care among children and adolescents in South Africa. They found that

children and adolescents pay a total of $5.99 to $21.50 per hospital visit.

They indicated that this cost model could be used in other parts of Africa for

mental health services and made recommendations for better calculation of

low-cost mental health care in low and middle-income countries. Flisher et

al. (1997) found that both direct and indirect costs for mental health services

in South Africa were affected by apartheid. They stated that the public policy

of apartheid did not provide adequate mental healthcare for ethnic Africans.

However, after the apartheid government, mental health care did include

ethnic Africans with mental illness.

deMenil et al. (2014) indicated that there is a wide margin between the

need and treatment for mental disorders in Africa. The researchers used a

quantitative method to study a 30-bed psychiatric hospital in Nairobi Kenya,

in Africa. They indicated that mental health cost is mostly funded by a

private insurance company (PHI). They evaluated the effect of PHI in the

largest private psychiatric hospital in East Africa. The study utilized a

Multilinear and binary logistic regression to examine the impact of PHI

related to the admission, readmission, and the length of stay of patients in the

hospital. They indicated that 66.4% of patients were male and they were

voluntarily admitted to the hospital. However, 70% of the patients were

involuntarily admitted to the hospital.

According to this study, 31.6% of the patients were diagnosed with

substance abuse and that 1.6% were diagnosed with serious mental health

problems. They indicated that twothirds of the patients received individual

counseling and group therapy. And most of the patients were prescribed

psychotropic medications. The study found that patients with PHI received

better treatment than patients who paid out of their pockets. Also, patients

that paid out of their pocket had 2.5% odds of relapsing within 12 months

after being discharged. The study also found that PHI was billed at a 7.1%

more than patients who paid out of their pockets. They concluded that the

cost for mental health is Kenya benefits only individuals with private health

insurance.

Evans-Lacko and Knapp (2016) utilized a quantitative method on the

cost of depression across eight diverse countries. The researchers reviewed

data collected in the Global Impact of Depression in the Workplace in

Europe Audit. The data was collected from employees that were absent from

work due to depression. The researchers reviewed focused on the cost of

depression from South Africa, Brazil, China, Canada, Korea, Japan, and

Mexico. They indicated that the economic cost of depression is affecting

employers’ work productivity. The study found that there is a high financial

cost for employers in South Africa than the other countries studied.

The above-reviewed literature addressed the costs related to mental illness

Africa. Lund et al. (2013) indicated that mental health cost in Africa is

difficult among South Africans that are unemployed. Lund et al. (2009)

found that children and adolescents paid the same for mental health cost in

South Africa. deMenil et al. (2014) provided relevant information related to

PHI in East Africa. Evans-Lacko and Knapp

(2016) provided relevant information on the cost employers pay for mental

healthcare for their employees in South Africa. Musa et al. (2016) provided

information about the cost of a hospital stay and homestay in West Africa.

These studies confirmed that effective cost strategies for mental health are

needed to promote efficient mental health service in Africa. These studies

also confirmed that the cost of mental healthcare in Africa was inadequate, as

this could promote stress for HCWs. Therefore, the question is- How do

HCWs cope with inadequate mental healthcare while providing treatments to

the Ebola virus patients in Freetown, Sierra Leoneans? Reviewing additional

pieces of literature that provide information on the inadequate mental

healthcare and HCWs are addressed in the next paragraph.

Inadequate Mental Healthcare and Healthcare Workers

Inadequate mental healthcare programs affect the psychological well-being

of healthcare workers. Khalid et al. (2016) have argued that every disease

outbreak is unique in its totality, geographical location, pathogenesis,

transmissibility, and effectivity. HCWs in the Western region of Africa

experienced psychological stress because of inadequate mental healthcare

and poor living conditions (CDC, 2015; WHO, 2016). While developed

nations receive adequate mental healthcare treatment for psychological

problems, West African nation’s mental healthcare treatment is inadequate

to help HCWs with psychological problems, especially during an epidemic

(Betancourt et al., 2016; WHO, 2016). The government is the primary

influence on HCWs’ psychological well-being in Sierra Leone, and several

studies have called for adequate mental health care for HCWs in the West

African region (Betancourt et al., 2016; WHO,

2016). The above studies showed inadequate or nonexistence mental

healthcare for

HCWs promotes psychological stress (Betancourt et al., 2016; CDC, 2015;

WHO, 2016).

HCWs take risks to help their patients without access to quality

psychological care for themselves. Khalid et al. (2016) noted that HCWs

often have emotional problems and require mental health care. In Sierra

Leone, mental illness among HCWs is not diagnosed as quickly as that of

HCWs in developed nations because of the lack of adequate resources

(CDC, 2015; Greenberg et al., 2015). These findings give credence to

Greenberg et al.’s claim that inadequate resources for mental health care in

Africa are preventing early diagnosis. The number of HCWs with mental

illness in Sierra Leone should be investigated to prove the need for mental

health services that would help them cope with stress during the next

outbreak or epidemic.

Clinics and hospitals can enhance the work of HCWs by providing

them with quality psychological and physiological care. Even though clinics

and hospitals are designed to provide adequate care for patients, poor mental

health among HCWs affects the quality of their work (Greenberg et al.,

2015). Most of the clinics and hospitals in Sierra Leone are poorly funded by

the government and rely primarily on international sponsors (Greenberg et

al., 2015). Khalid et al. (2016) found that positive attitude and humor among

colleagues in the workplace environment reduce stress. Also, HCWs who

were provided adequate mental healthcare at their worksites reported a

reduction in their psychological symptoms (deMenil et al., 2014; Li et al.,

2015). HCWs are forced to work overtime during an outbreak or epidemic

(Khalid et al., 2016). Khalid et al. also indicated, despite the emotional

difficulties HCWs experienced, they were obligated to their ethical and

professional duties in their work settings. Therefore, hospitals should focus

on providing quality psychological help for healthcare workers. It is evident

that providing adequate mental healthcare and emotional support will

improve the psychological well-being of healthcare workers. These studies

recommended that additional measures be taken to provide adequate mental

healthcare for HCWs in Africa. Therefore, asking HCWs how they cope

with their mental health when working with infectious patients during the

EVD in an inadequate mental health setting was relevant to this study. This

was the area that was explored in this study. Reviewing additional literature

that provides information on HCWs and stress was significant for this study.

As a result, literature addressing HCWs and stress is addressed in the next

paragraph.

Healthcare Workers and Stress

Raab et al. (2015) conducted a study in Canada to determine the

effectiveness of mindfulness-based stress reduction (MBSR) for treating

healthcare workers. Glasberg et al. (2007) postulated that stress affects

healthcare workers’ work performance. This study was conducted at a large

Canadian mental health center in an urban setting. Twenty-two female

HCWs between the ages of 24 and 69 years were included in the study. Pre-

and post-assessment measures consisted of the SCS, MBI, and QLI. They

found that HCWs are vulnerable to stress overload and burnout (Harris,

2001; Moore & Cooper, 1996). They also found that HCWs experienced

increased anxiety, depression, and mental fatigue (Myers, 1994; Radeke&

Mahoney, 2000). However, they concluded that MBSR is an effective

intervention to help HCWs cope with stress.

Shoji et al. (2014) conducted a quantitative study in the United States

to determine traumatic growth among healthcare workers. Shoji et al.

postulated that negative exposure to traumatic events causes psychological

disorders such as posttraumatic stress disorder (PTSD). The study indicated

that symptoms of PTSD include re-experiencing, avoidance, and

hyperarousal (Brewin, Andrews, & Valentine, 2000). They indicated that

secondary traumatic stress (STS) is indirect exposure to stress.

The study found that individuals with STS exhibit the same symptoms as

PTSD. Pearlman and Mac Ian (1995) also noted that negative consequences

and work distress affect HCWs’ performance. They conducted two studies at

a behavioral center in the United States. The first study involved 408 HCWs

in the U.S. and the second study involved 487 HCWs from different

backgrounds. HCWs in the first study were given questionnaires to rate their

STS, perceived social support, and workplace burnout. HCWs in the second

study were given the same questionnaire, with the inclusion of the SPS scale,

STSE scale, MSPSS scale, and Posttraumatic Growth Inventory-Short Form.

In both studies, the researchers found that the relationship between STS and

STG was mediated by STSE and social support. The study concluded that

education and social development programs would enable HCWs to boost

their self-efficacy and perceived social support.

Ding, Qu, Yu, and Wang (2014) conducted a study in China to explore

the relationship between occupational stress and anxiety symptoms among

healthcare workers. They indicated that there are several occupational

stressors that affect the quality of work HCWs provide to their clients. Ding

et al. stated that one of the symptoms associated with HCWs’ stress is

anxiety. They conducted a cross-sectional survey of 1,752 HCWs, using

questionnaires—the Zung Self Rating Anxiety Scale, the Chinese Fashion of

the Effort-Reward Imbalance Scale, and the Maslach Burnout Inventory-

General Survey—to rate anxiety symptoms. Additionally, they performed a

hierarchical linear regression to assess the burnout effect of healthcare

workers. The study found that the prevalence of anxiety symptoms among

community HCWs was 38%. Thus, there is a relationship between burnout,

occupational stress, and anxiety symptoms. They concluded that burnout

mediates the effect of occupational stress and anxiety symptoms. Ding et al.

recommended burnout management classes for HCWs to reduce the impact

of occupational stress and anxiety symptoms.

In a qualitative study not related to the EVD, Scott et al. (2009)

indicated that HCWs are second victims, especially when they watch their

clients die. The researchers used a semistructured interview to ask HCWs if

they experienced stressrelated to work problems that led to anxiety and

depression. The key finding from this study was that HCWs "suffer alone"

and they recommended that effective strategies should be implemented to

help HCWs cope with stress related to their jobs (pg. 331).

Selamu et al. (2017) conducted a study in Ethiopia, Africa to explore

the lived experiences of HCWs well-being, stress, and burnout when treating

their patients. They postulated that HCWs’ well-being is important so that

they can provide quality care for their patients. This study was conducted in

a primary healthcare setting in rural Ethiopia through in-depth interviews

with 52 primary HCWs: 35 facility-based healthcare professionals and 17

community-based healthcare workers. The study found that facilitybased

HCWs think of well-being as the absence of stress. Participants indicated

that the cause of their main stressors was inadequate medical supplies and

the limited supplies might cause infection. They also indicated that

performance evaluation in their work setting also provoked stress. In the

community-based setting, HCWs reported role ambiguity to be their main

stressor. Additionally, the study found that both groups suffered from heavy

workloads and economic self-sufficiency. HCWs reported symptoms of

burnout and emotional difficulties. Selamu et al. (2017) concluded that

HCWs in Ethiopia are experiencing job-related stress that promotes burnout.

They further indicated that job-related stress and burnout among HCWs

created a high turnover of staff. They recommended a better understanding

of job-related stress and burnout among HCWs to benefit healthcare

professionals. However, this study did not address HCWs perspectives of

their mental health during an epidemic, an area that was explored in this

study.

Darboe, I-Feng, Hsien-Wen, Lin, and Kuo (2016) conducted a

quantitative study in Gambia, West Africa to investigate perceived stress

among healthcare workers. They postulated that the work of HCWs is

critical to the community and suggested that HCWs should be free from

inborn worries and anxieties. The study was conducted at the secondary

public health facility in the Gambia and analyzed results from a cross-

sectional random sample of 287 HCWs using a 22-item ERI. They used a

single measure to assess perceived stress and subjective health among

healthcare workers. They found that there was a relationship between

perceived work stress and subjective health. They also found that high

effort-reward imbalance is related to poor subjective health among HCWs in

the Gambia. Psychosocial stress increases overall stress among healthcare

workers (Darboe et al., 2016). They concluded that high perceived effort-

reward imbalance among HCWs, better incentives, and reasonable allocation

of resources for healthcare workers would help prevent stress at work.

Potter, Gonzalez, and Xu (2015) conducted a quantitative study in

Sierra Leone, West Africa to determine heat stress among HCWs treating

patients with the Ebola virus disease. Potter et al. indicated that HCWs in

Sierra Leone, West Africa were required to wear personal protective clothing

(PPC); however, because of the heat, HCWs still complained of heat stress.

According to the study, heat stress can affect HCWs’ performance at work

and can also be deadly. The study was conducted in West Africa during the

EVD outbreak with the aim of producing a stress-free environment for

healthcare workers combating the Ebola virus disease. The researchers used

a sweating thermal manikin to measure operating resistance among

healthcare workers. The researchers indicated that there was a rise in body

temperature among healthcare workers.

They found that heat exhaustion occurs between 37°C and 40°C and

heatstroke prevents HCWs from providing quality care for their clients. They

concluded that HCWs caring for patients with the EVD need personal

cooling systems to create a safe and stress-free work environment.

The studies addressed in the section above clearly indicate that stress

among HCWs cannot be ignored. Raab et al. (2015) concluded that stress

affects how HCWs perform their jobs. Shoji et al. (2014) suggested the need

for effective mental health programs to help HCWs with self-efficacy and

perceived social support. Ding et al.

(2014) concluded that burnout causes both occupational stress and anxiety

symptoms. Selamu et al. (2017) recommended a better understanding of job-

related stress and burnout among healthcare workers. Darboe et al. (2016)

recommended better incentives for HCWs while Potter et al. (2015) called

for better cooling systems for healthcare workers.

However, these existing literatures do not provide information on

HCWs mental health while providing care for patients with the Ebola virus

disease. Most of the studies found that stress can affect the performance of

HCWs, and Ding et al. (2014) further addressed some of the specific

symptoms, such as anxiety and depression, exhibited by healthcare workers

when they are under stress. Most of the studies cited the importance of

dealing with stress so that HCWs can provide quality care for their clients.

Some of the studies recommended that additional effective measures are

needed to help HCWs with stress at work. Finally, these studies confirmed

that the impact of stress among HCWs should not be ignored and effective

stress management measures are needed to help

HCWs provide adequate care for their patients. However, there has been no

study on how

HCWs cope with stress while providing treatments to the Ebola virus

patients in Freetown, Sierra Leoneans. Therefore, how do HCWs of

Freetown, Sierra Leone cope with stress during the EVD while working with

highly infectious patients is relevant to this study? This was an area that was

explored in this study. Reviewing additional literature that provides

information on HCWs and coping was significant for this study.

As a result, I addressed Literature to HCWs and coping in the next

paragraph.

Healthcare Workers and Coping

The lack of effective coping skills can affect the performance of

HCWs, especially when working with highly contagious patients. Jordan,

Khubchandani, and Wiblishauser (2016) examined the impact of perceived

stress and coping adequacy among healthcare workers. They conducted a

cross-sectional study in the Midwestern United States and gathered data

from 174 participants using a quantitative survey method. The study found

that HCWs used effective and positive methods to cope with stress. Some of

the methods were talking to friends, meditating, listening to music, and

watching television. They reported that there was no statistical significance

across selected demographic variables on self-reported coping ability.

However, the study found that 42% of healthcare workers cope poorly with

stress. The study concluded that both stress and the lack of coping abilities

affect the quality of services provided by healthcare workers.

Fernandes and Nirmala (2017) conducted a qualitative study in India

on workplace stress and coping strategies among healthcare workers. They

indicated that increased levels of stress and burnout among HCWs

contributed to high turnover among healthcare workers. The study indicated

that there would be shortages of HCWs by the year 2020 if better coping

strategies are not implemented for healthcare workers. They investigated

work stress and coping strategies among 51 HCWs working at the Goa

hospital in India. Occupational stress is an emotional state of mind (Lee &

Wang, 2002).

Lee and Wang indicated that occupational stress causes HCWs to feel

as if they are not meeting their employers’ demands. They also found that

major stress resulted in high turnover among healthcare workers. That is,

some HCWs were leaving their jobs because of high stress. They found that

the coping strategies used include avoidance of the problem, mental

disengagement, problem- solving/planning, speech coping and social

support.

Saini, Kaur, and Das (2016) conducted a study among 285 HCWs in

both a general unit and an intensive care unit (ICU) in India. The data were

collected using the modified work stress symptom scale (WSS) and coping

checklist (CCL). They found that HCWs experienced different kinds of

stresses. HCWs working in the ICU experienced a moderate level of stress.

They found that the primary coping strategies used by HCWs were problem-

solving and religion. The study noted that there had been only four other

studies conducted on coping skills in India, which suggests that it may not be

relevant to

HCWs in other parts of the world.

Koh et al. (2015) conducted a cross-sectional study in Singapore to

determine the use of coping mechanisms among HCWs in connection with

burnout and psychological morbidity. The participants in this study were

doctors, nurses, and social workers. A total of 493 participants were included

in the study. Cases of prevailing burnout were reported by 3.3%; 91 of the

292 participants complained of burnout. The study found that HCWs who

had coping mechanisms complained less of psychological morbidity and

burnout. The study also found that HCWs used the following coping

mechanisms to prevent workplace burnout: physical well-being, clinical

variety, hobbies, and meditation. HCWs in Singapore used spirituality and

family relationships as coping strategies. Koh et al. concluded that there is a

high prevalence of burnout among HCWSs in Singapore as compared to

HCWs in other parts of the world. However, HCWs in Singapore with

effective coping strategies adjusted well to workplace burnout.

Howlett et al. (2015) conducted a quantitative, cross-sectional study in

Canada on how HCWs in the emergency department cope with burnout.

They used Linear regression with the Coping Inventory for Stressful

Situation (CISS) and the Maslach Burnout

Inventory (MBI) to evaluate the coping styles of 616 emergency staff. The

study used CISS to measure coping styles in three categories: task-oriented,

emotion-oriented, and avoidance-oriented coping. The study found that task-

oriented coping is related to decreases risk of burnout, whereas, emotion-

oriented coping is related to increased risk of burnout. They concluded that

coping style intervention might reduce burnout, which would foster staff

well-being. Howlett et al. (2015) commented that future studies should

“focus on building and sustaining task-oriented coping, along with an

alternative to emotion-oriented coping” (p. 5).

Petrites, Mullan, Spangenberg, and Gold (2016) examined how

healthcare workers in Ghana, West Africa cope with high rates of perinatal

death. They indicated that perinatal mortality affects the well-being of

healthcare workers as well as the patient care they provide. The authors

conducted semi-structured interviews among healthcare workers at a hospital

in Kumasi, Ghana and included 36 participants—comprised of midwives,

pediatricians, and physicians—in the study. The researchers used content

analysis to identify nine themes that emerged from the study. Participants

reported that they learned to cope by understanding the meaning of their

clients’ deaths. Participants also recognized their ability to be an agent of

change and demonstrated emotional engagement in response to perinatal

death. Participants noted that they developed multiple coping skills related to

their clients’ deaths. The study found that 42% of HCWs noted that a lack of

resources contributed to their clients’ deaths. They also claimed that the lack

of medical equipment contributed to their lack of coping skills. Of the

HCWs studied, 22% reported believing that God was responsible for the

deaths of their clients and 52% indicated that they try not to think about the

deaths of their clients. However, 72% of HCWs reported symptoms of

emotional impact and 72% of HCWs developed coping mechanisms to deal

with the loss of their clients. The study concluded that HCWs in low-

resource countries, especially Saharan Africa, demonstrated high resiliency

in coping with perinatal death. Petrites et al. (2016) recommended that

additional research should be conducted concerning coping strategies for

HCWs to strengthen their selfefficacy and engagement. These studies

together confirmed that effective coping skills are needed for healthcare

workers even when they are not working with highly contagious patients.

Additionally, Qiao et al. (2016) conducted a study on occupational

burnout and coping among HCWs who care for patients with HIV/AIDS in

China. The cross-sectional study included 264 HCWs caring for patients

with HIV/AIDS and an additional 228 physicians and nurses caring for

patients with other infectious diseases. The researchers conducted a

quantitative study using a self-administered questionnaire, Maslach Burnout

Inventory-General Survey (MBI -GS), the Symptom Checklist 90 (SCL-90),

the Eysenck Personality Questionnaire (EPQ), and Trait Coping Style

Questionnaire (TCSQ). They found that HCWs with HIV/AIDS scored

higher on markers of emotional exhaustion and depersonalization than other

healthcare workers. They also found that HCWs with HIV/AIDS used

negative coping skills, which affected their work performance. They

concluded that 76.9% of HCWs met the criteria for burnout.

Because of their role, HCWs experience tremendous stress, which can

lead to long-term psychological difficulties (Khalid et al., 2016). Khalid et

al. postulated that it was evident that HCWs were under extreme stress

during the MERS-COV outbreaks. They found that, during the MERS-COV

epidemic, HCWs experienced emotional difficulties including anxiety and

nervousness. They indicated that some of the stressors

HCWs experienced during the MERS-COV outbreak were related to safety

concerns. HCWs observed patients and coworkers die in their presence and

were therefore concerned about transmitting the disease to their friends and

family. They also found that two of the factors that helped HCWs cope with

the MERS -COV outbreak were positive attitudes and following strict

precautions of safety standards.

Bangura, Lynch, and Binns (2013) evaluated the impact of coping

strategies in the rural area of Kono in the Kambia district of Sierra Leone.

The study found that all 250 of the participants were resilient to climatic

conditions, despite the lack of adequate support from the government. The

study concluded that external support is needed in Sierra Leone, especially

during an epidemic or crisis. This study did not report findings related to

healthcare workers’ coping strategies. However, it provided relevant

information on coping strategies of Sierra Leoneans in West Africa.

These studies together confirmed that effective coping methods are

needed when working with highly contagious patients. Further, the studies

reviewed indicated that factors such as inadequate resources in poor nations

affect effective coping strategies for healthcare workers. These studies have

encouraged policymakers to incorporate strategies that will help HCWs to

develop effective coping skills. Therefore, how HCWs cope with stress

while working with infectious patients in a poor-quality healthcare system

applies to this study. Asking participants about their stress and coping in

addition to the mental health issues and treatment they experienced was

relevant to this study. This is an area I intend to explore.

Because stress is bad and leads to mental health issues and numerous

coping strategies are helpful, reviewing additional literature that provides

information on barriers to mental health was significant for this study. Thus,

literature addressing barriers to mental healthcare is discussed in the next

paragraph.

Barriers to Mental Health Care

Good mental health enables individuals to be productive in society

and poor mental health is a significant problem in today’s society. One of the

barriers to good mental health for HCWs in the West African nation is the

lack of optimal mental health care (Gwaikolo et al., 2017). Another barrier

associated with mental illness in Africa is stigmatization (Taghva et al.,

2017).

Oexle et al. (2015) examined perceived need as a barrier to mental

health among members in the community healthcare in Africa. They cited

that the refusal of mental healthcare is a burden for individuals with mental

illness. They conducted a quantitative study using the Brief Illness

Perception Questionnaire to assess participants’ symptoms related to mental

illness and the Self Appraisal of Illness Questionnaire to measure

participants’ perceived need for mental health care. They surveyed 202

participants between the ages of 20 -41 with distress symptoms. They found

that perceived need for mental health care was moderate. However,

participants reported perceived barriers, such as stigma, as being low. Oexle

et al. (2015) found that perceived need for mental illness treatment was

related to increased stigma. They also found that increased stigma was a

barrier for most of the participants. They concluded that an intervention of

increased mental health services would help change the attitude of

individuals experiencing mental health crises. They argued that

stigmatization is one of the main barriers to mental illness. Even though the

study did not include healthcare workers as participants, the findings are

relevant to our purposes regarding the barriers associated with mental health

care in Africa.

Weiss and Amie (2017) conducted a quantitative research study using

an online survey to examine barriers to global health development. They

invited 432 healthcare workers to participate in the study, with a

participation rate of 62% (268 participants). They conducted descriptive and

inferential statistics and found that 34/66 barriers were global challenges for

mental health care. They found perceived social and culture as barriers to

mental health services. The study concluded that mental health barriers have

a tremendous effect on both individual and system levels. The researchers

hoped that the 22 barriers found in this study could create a solution that will

address the global mental health crisis.

Rugema, Krantz, Mogren, Ntaganira, and Persson (2015) conducted a

qualitative study addressing mental health barriers at a mental health hospital

in southern Rwanda, South Africa and at a psychosocial center within the

capital city of Kigali. They used a qualitative approach with six focus group

discussions (FGD) to evaluate 43 HCWs, both men and women. They found

that there was a constant struggle among Rwandans who received mental

health care and cited some of the related barriers: “Poverty and lack of

family support, fear of stigmatization, poor community awareness of mental

disorder, societal believe in traditional healers and prayers, scarce resources

in mental health care, and Gender imbalance” (Rugema et al., 2015, p. 5).

However, individuals in Rwanda who are privileged enough to have good

insurance were able to get successful mental health treatment.

Umubyeyi, Mogren, Ntaganira, and Krantz (2016) conducted a study

to investigate the barriers to care and self-efficacy among young adults with

depression and suicidality in low-income areas of Rwanda, South Africa.

The cross-sectional study used two samples: 247 participants suffering from

depression and 502 participants suffering from other mental illness. They

measured self-seeking behavior as a barrier to care and self-efficacy for

mental health care. They used logistic regression to identify risk factors

associated with barriers. They found that 30% of participants with

depression and suicidality asked for mental health care and 64% asked for

help from people they trusted.

However, the study found that only six people reached out for mental health

care from experienced professionals. The key barriers identified were limited

accessibility and acceptability of mental healthcare services. The population

experiencing depression and suicidality also expressed low confidence to

seek mental health care. However, individuals had high levels of confidence

to talk about their mental health problems. Umubyeyi et al. (2016) concluded

that the study’s population experienced limited access to mental health care

and encouraged mental health literacy for the population.

Gwaikolo et al. (2017) conducted another study in Liberia, West

Africa. They employed a mixed methods approach, which involves both

quantitative and qualitative methods. They collected data from 22 HCWs at

19 rural healthcare facilities over the course of six focus groups and semi-

structured assessment of 19 primary healthcare facilities. They found several

potential barriers affecting mental health treatment in Liberia, West Africa,

which included:

Lack of mental health knowledge among plan by healthcare staff, the

high workload for plan healthcare workers, additional mental health

responsibilities, lack of mental health drugs, the poor physical

infrastructure of health facilities...poor communication support

including the lack of electricity and mobile phone, negative attitude

and stigma towards people with severe mental disorders…and stigma

against mental healthcare workers. (p. 5)

They concluded that Liberia should improve the barriers to mental

health care in West Africa and must improve their infrastructure and the

attitude of the population toward mental illness.

Hann, Pearson, Campbell, Sesay, and Eaton (2015) examined barriers

to mental health in Freetown, Makeni, Sierra Leone, West Africa. They

conducted a quantitative study among low-income individuals. The study

used grounded theory to guide the study of 24 participants. They found that

the barriers to mental health care were the lack of mental health networking

and lack of political will. They suggested creating a policy to advocate for

quality mental health care in Sierra Leone and help provide quality mental

health care. The study also identified a need to increase awareness of mental

health. Hann, Pearson, Campbell, Sesay, and Eaton concluded the study by

indicating that networking and the lack of political help from the government

are the major barriers to mental healthcare in Sierra Leone, West Africa.

The above studies clearly identify that there are several barriers to

mental health care. Rugema et al. (2015) provided information about the

struggle of Africans to accept mental health diagnoses because of

stigmatization. They found that poverty and stigma are barriers to mental

health care in Africa. Umubyeyi et al. (2016) indicated that there are limited

accessibility and acceptability of mental health care in Africa. Gwaikolo et

al. (2017) found that the lack of psychotropic medication and poor

infrastructure are barriers to mental healthcare in Africa. Hann et al. (2015)

found the lack of political will in Sierra Leone as a barrier to mental health.

These studies indicated that stigmatization, poverty, acceptability,

accessibility, the lack of psychotropic medication, and the lack of political

influence are the significant barriers to the mental healthcare system.

On the contrary, Oexle et al. (2015) used specific measures to address

the barriers to mental health care. They found that one of the barriers to

mental health care is stigmatization. The study provided general information

related to mental illness. Weiss and Amie (2017) provided specific

information on barriers to global health development and addressed 22

barriers related to mental health. These studies addressed specific barriers to

mental health care, findings which will encourage policymakers to address

the barriers related to mental health care. However, the existing literature did

not address HCWs’ perspectives on mental health symptoms they

experienced while caring for patients with the Ebola virus. The study also

found that inadequate resources for HCWs, especially during an epidemic

like the Ebola virus disease as a barrier to mental healthcare. Therefore, the

next paragraph addressed epidemic and healthcare workers.

Epidemic and Healthcare Workers

The EVD outbreak of 2014 to 2015 was an epidemic that resulted in

the deaths of many healthcare workers. The CDC (2014) cited that the

epidemics of the EVDinvolved human contact between body fluid of

infected animals. According to the CDC, when an individual is infected or

dies, the virus continues to spread to other individuals who encounter the

infected individual's body fluid or blood. The CDC postulated that HCWs

accidentally die when working with the EVD patients.

HCWs are at an increased risk to be infected with the influenza virus.

The CDC (2014) and the WHO (2016) cited that the epidemic of the

influenza virus occurs yearly, and it is a respiratory illness that is caused by

Influenza A or B virus. According to the CDC (2014), the influenza virus is

seasonal, that is, the virus spreads during the winter seasons. The spread of

the influenza virus depends on the population that is susceptible to the virus.

The CDC (2016) postulated that HCWs are a high-risk population for the

influenza virus.

HCWs are at an increased risk to be infected with the human

immunodeficiency virus (HIV). Engel et al. (2017) did a qualitative study on

a diagnostic practice on HIV patients in South Africa. They found that

information provided by healthcare workers is relevant to implement better

strategies to combat infectious diseases. They stated that HCWs indicated

that the strategies used to combat HIV were ineffective. The knowledge of

HCWs is relevant to make clinical decisions (Eckes, 2016). A qualitative

study is one- way knowledge can be interpreted and translated to make a

clinical decision because it involves individuals lived experiences (Biswas et

al., 2008). Joyce, Kuhar, and Brooks (2015) cited that the epidemic of the

HIV is transmitted through occupational exposure to blood, body fluids, and

viral cultures. According to the WHO (2015), HCWs should use preventive

measures because they work with a vulnerable population that can spread the

immunodeficiency virus.

Ansumana et al. (2017) postulated that 28% of the 9.6 million new

cases of tuberculosis are found in the African region. They stated that the

spread of the EVD of

2014 and 2015 affected the tuberculosis healthcare system and HCWs in

Sierra Leone, Liberia, and Guinea. They found that the spread of the EVD

Killed doctors, nurses, ambulance drivers, porters, and community

organizers. The WHO (2016) reported that the spread of the EVD killed 328

HCWs in Sierra Leone, 288 HCWs in Liberia, and 199 HCWs in Guinea.

Ansumana et al. postulated that the spread of the EVD weakened the

healthcare system in West Africa.

These studies together confirmed that HCWs are the most vulnerable

population to an epidemic because they work with highly contagious

patients. Further, the literature reviewed recommended protective measures

and vaccinations for HCWs during an epidemic. These studies have

encouraged policymakers to incorporate strategies that would help HCWs to

receive yearly vaccinations and employ effective measures during an

epidemic. An epidemic is bad and could lead to stress, and the deaths of

healthcare workers and proper preventive measures are needed. Therefore,

how do HCWs cope with the EVD while providing treatments to the Ebola

virus patients in Freetown, Sierra

Leoneans was the area that was explored in this study.

Summary and Conclusion

Creswell (2009) and Patton (2002) recommended the need for

selecting the right literature and theoretical work for a study. The literature

review for this study showed that HCWs in Africa during the EVD

experienced mixed mental health symptoms that need to be investigated.

Some of the quantitative studies in the literature provide vital information

related to the mental health of healthcare workers during an epidemic. After

a comprehensive review of the literature, it was evident that the mental

health of HCWs needs to be studied to help provide adequate mental health

care for them during an outbreak or an epidemic. Based on the existing data,

the literature review utilized quantitative research (Li et al., 2015; Scott et

al., 2009); whereas, qualitative research has not been used to study the

mental health of HCWs during the EVD outbreak of 2014 to 2015. Creswell

(2009) cited that qualitative study provides an in-depth understanding of a

phenomenon. Fasina et al. (2015) utilized the qualitative research method

during the EVD to examine the health care system in West Africa.

A similar study conducted by Brolin Ribacke et al. (2016) used a

qualitative methodology to examine the health care system in Sierra Leone,

West Africa. Another qualitative study by Khalid et al. (2016) examined

how HCWs cope with the cases of the MERS –COV outbreak in Saudi

Arabia. Hughes (2015) also utilized a qualitative study to explore the mental

health system in Sierra Leone, West Africa. These studies utilized a

qualitative method to get an in-depth understanding of how HCWs cope with

the mental health system.

I reviewed and divided the literature into different topics. The findings

of this literature were helpful to understand the health care system and

HCWs in Africa.

However, the studies failed to provide information about how HCWs in

Freetown, Sierra Leone describe their mental health symptoms they

experienced and how they used coping skills when treating patients with the

Ebola virus. The next chapter of the study elaborates on the methodology

that was used. Because HCWs are the first responders to an epidemic, it was

essential to understand the experiences and perceptions of their mental

health during an epidemic. Chapter 3 expands on the qualitative design of

the study to describe HCWs perspectives on their mental health when

treating EVD patients. Chapter 3 includes the introduction, the research

design, and rationale for the design, the role of the researcher, methodology,

participants’ selection, instrumentation for recruitment, participation, data

collection, and analysis plan. Issues of trustworthiness and ethical

procedures were also discussed. Chapter 3 ends with a summary and a

highlight of

Chapter 4.

Chapter 3: Research Method

Introduction

The purpose of this study was to explore HCWs’ perspectives on their

mental health symptoms during the 2014 and 2015 EVD outbreak in

Freetown, Sierra Leone. Chapter 1 provided an overview of this research,

and Chapter 2 addressed the theoretical framework that was used in this

study. In addition, Chapter 2 focused on a literature review that identified the

gap in the study. Chapter 3 of the study addresses the research design, the

role played by the researcher, the methodology used in this study, issues of

trustworthiness, and ethical implications related to this study.

Research Design and Rationale

Research Questions

RQ1. How do HCWs in Freetown, Sierra Leone describe their lived

experiences regarding their own mental health when treating

patients with Ebola virus disease?

RQ2. How do HCWs feel with their abilities to cope with stress while

treating patients with the Ebola virus disease?

RQ3. How do HCWs describe their lived experiences of the mental

health care treatment they received while treating patients with

the Ebola virus disease?

Phenomenon

Creswell (2009) asserted that research designs enable researchers to

select the right method for a study. The phenomenon that was explored in

this study was HCWs’ perspectives on their mental health symptoms during

the EVD outbreak of 2014 and 2015. Creswell (2009) asserted that it is

imperative that a researcher select a research design that addresses the goal

of his or her study. Phenomenological research design was selected for this

study. Phenomenological research design fosters an inductive approach,

which allows the researcher to begin with the data and explore what is going

on in a particular place (Patton, 2002). This design enabled me to address the

phenomenon being studied and answer the research questions.

Role of the Researcher

According to Creswell (2009) and Patton (2002), qualitative

researchers are required to select the right instrument that is valid and

reliable when collecting data. Denzin and Lincoln (2003) and Greenbank

(2003) postulated that interview questions are the instruments in qualitative

research data collection. The interview questions served as the primary

instrument in conducting face-to-face interviews with the participants in a

natural setting, and I served as the researcher. Researchers play several roles

in qualitative research (Creswell, 2009; Patton, 2002). These roles are

observing participants, acting as a participant observer, and conducting in-

depth interviews or remaining neutral. My role as a researcher was to recruit

and select the right participants for this study. Additionally, my role included

interviewing participants, gathering data, and completing and interpreting

the data analysis. I did not have any personal or professional relationships

with the participants. In this study, I used in-depth interviewing to gather

information on the phenomenon of interest. Time was properly used to make

sure the data were collected and reviewed effectively.

Because I am from Freetown, Sierra Leone, it was imperative that I

avoid all biases associated with the study. I was aware that cultural

perspectives play a significant role in the diagnosis of mental illness in

Africa. I was also aware that any form of bias or prejudice would easily

compromise my study. Therefore, I was openminded concerning any issues

related to prejudice or bias during the study. Additionally, I sought to

measure any biases or power relationships that I had as the researcher by

employing bracketing. Husserl (1967) postulated that bracketing is the act of

suspending all judgement and focusing on participants lived experience. I

used bracketing as a phenomenological analysis in the following ways: I

approached the study without bias or judgment (Husserl, 1967). I suspended

the truth in the objective world (Jarvis, 2013). I was able to set aside any

assumptions, revisit the data, and gain a full understanding of the study.

Bracketing was crucial for me because I was born in Freetown, Sierra Leone,

and my background experience could have affected my judgment.

Methodology

Participant Selection

The present study was focused on the perceptions of HCWs who

provided care to patients during the 2014 and 2015 EVD outbreak. The

sample was drawn from HCWs in the western area in Freetown, Sierra

Leone who cared for Ebola victims. HCWs were given invitational

letters(see Appendix A)asking them to participate in the study.

Sampling

Purposeful sampling was used to select participants for this study.

According to Patton (2002) and Verial (2013), purposeful sampling gives

researchers the opportunity to select a specific group or a particular

population for a study. This method is used to gather in-depth information

from a particular group. As such, HCWs in Freetown, Sierra

Leone who worked with EVD patients were selected for this study. The

participants were directly selected from the western area of Freetown, Sierra

Leone. The selected area includes the main hospital called Connaught, which

is located at 6 Lamina Sankoh Street in Freetown. Participants were recruited

by invitational letters (see Appendix A). Most of the HCWs had been

employed at this hospital during the EVD outbreak. The capital city was

chosen because of the different social and economic background in terms of

its diversity of the people. In addition, Freetown, Sierra Leone has more

qualified HCWs than the provinces of the country. Individuals leave the

provinces to seek a better life in the capital city of Freetown. The selected

participants were all Africans who shared the same cultural values.

As such, individuals who were selected for the study had direct

experience in working with highly infectious patients. These individuals

were able to voice their opinions about their mental health symptoms while

providing care for patients with EVD.

Participation in this study occurred on a voluntary basis.

Sample Size

The sample size was determined by the type of study being conducted.

According to Creswell (2009), a sample of five to 20 participants can be

studied usinga phenomenological design. Morse (1994) indicated that a

sample of six participants is appropriate for a phenomenological design.

Because of the above recommendation, 10 participants were selected for this

study. I used an additional 10 participants in case participants dropped out of

the study. I also focused on saturation during the interview process.

Saturation occurs when adequate data have been collected for analysis

(Creswell, 2009).

The following criteria were used to select participants for this study.

•Participants were both male and female adult HCWs who had

treated EVD patients during the 2014 and 2015 EVD outbreak in

Freetown, Sierra Leone.

•All participants had resided in Freetown, Sierra Leone for at least

5years.

•All participants spoke English (English is one of the languages

spoken in the area where participants were recruited).

•All participants were willing to participate in a study on issues

related to their mental health symptoms during the EVD outbreak

of 2014 and 2015.

Instrumentation

Interviews are based on the development of relationships between

participants and the researcher (Brew &Kottler, 2008). To interview

participants, I used semi structured interview questions. I conducted

interviews in a calm and a non-distracting environment (Ivey, 2000). I

strived to be genuine and to serve as an empathetic listener during the

interview process. Patton (2002) contended that building rapport is important

in ensuring an effective interview. To build rapport with the participants, I

was not emotional, and I sought to provide a calm atmosphere during the

interviews. This study was conducted at a café outside of Connaught

Hospital at6 Lamina Sankoh Street in the western area of Freetown, Sierra

Leone. I conducted interviews at a location near where participants had

experienced the problems of interest to the study. This location was chosen

because it was less restrictive and separate from participants’ actual place of

employment. To capture participants’ experiences and to get in-depth

information on their mental health during the EVD outbreak, Connaught

Hospital was used as the main site.

I explained the purpose of the interview to all participants. I explained

the rules of confidentiality and the length of the interview to all the

participants. Participants were encouraged to leave their contact information

after this study in case further information was needed.

I recorded one interview per respondent for at least 45 minutes. I used

interview questions in this study. Additionally, I used the following

guidelines recommended by

Creswell (2009) fora phenomenological interview:

•Researchers are to understand the philosophical understanding of

the participants;

•Researchers are to collect data only from participants who have

experienced the phenomenon;

•Researchers are to employ a phenomenological approach to

analyze the data during the interviews, and

•Researchers are to employ a reduction method in data analysis.

I conducted in-depth interviews with open-ended questions. I

described the concept or phenomenon of individual lived experiences

directly to the participants (Moustakas, 1994). I applied the

recommendations of Moustakas(1994) forin-depth interviews in

phenomenological inquiries by doing the following:

•I focused on the lived experience of the individual or the

phenomenon of interest,

•I focused on present experiences, and

•I combined the first and second experiences of HCWs to

understand the phenomenon of interest.

Field Notes

To gather data in an efficient manner, I used field notes (Patton,

2002), which then provided additional layers of data that I could properly

analyze (Creswell, 2009).I avoided gathering data that were not relevant to

the study (Patton, 2002). To document participants’ responses to the

interview questions at the research site, field notes were incorporated as a

tool. Using the field notes, I was able to categorize common themes related

to the research problem underpinning the study. Creswell (2009)

recommended that field notes consist of both reflective and descriptive

information. Therefore, I documented factual data during the interviews in

addition to recording my thoughts, ideas, and concerns.

Researcher-Developed Instruments

I developed open-ended, semi structured, in-depth questions to gather

a full understanding of HCWs’ perceptions of their mental health while

providing treatment for EVD patients. The questions were developed based

on the literature review regarding HCWs’ perceptions when working with

highly infectious patients. Appendix B provides the interview questions for

this study. All interviews were tape recorded and transcribed for data

analysis.

Content validity was established by communicating with the

participants to capture and understand their perspectives related to the

research questions and the research topic (Creswell, 2009). According to

Patton (1990), a qualitative content analysis provides patterns, themes, and

categories for a study, where coding becomes the fundamental analytic

process in a qualitative content analysis. However, van Manen

(2017) recognized that phenomenology is not about instrumentalities and

technicalities but involves a search for deep understanding of the lived

experiences of individuals. van Manen contended that phenomenology is the

practice of both scholar-practitioners and quotidian practitioners. For

instance, a thoughtful understanding of the everyday lives of people is of

great value to scholar-practitioners. He also pointed out that phenomenology

is an approach that differs from other types of inquiry.

Procedures for Recruitment, Participation, and Data Collection

Procedures for recruitment and data collection started after I received

Institutional Review Board (IRB) approval from Walden and signed consent

forms from the selected participants. A purposeful sample of 10 participants

was selected through the use of invitation letters (see Appendix A). I

obtained contact information from all individuals who wanted to take part in

the study.

I collected data through interviews and field notes. All data were

collected at 6

Lamina Sankoh Street in Freetown, Sierra Leone. According to Turner

(2010) and Creswell (2009), there are different types of interview

techniques. I collected data using semi structured interview questions (see

Appendix B). I used this approach to ask openended questions. Participants

were given the opportunity to unfold their views and understanding of the

phenomenon during the interviews (Creswell, 2009). Data collection and

analysis were conducted at the same time (Merriam, 1998). Data collection

occurred at a location close to where participants had experienced the

problem of interest. All of the data were collected and organized into

categories of themes.

Semi structured interviews enable researchers to interact with

participants (Creswell, 2009). The incorporation of semi structured

interviews in research, according to Creswell (2009), enables researchers to

be attentive and to provide in-depth information on the phenomenon being

studied. This method enabled me to pause, give participants the opportunity

to express themselves freely, and control the questions being asked. Semi

structured interviews in this study enabled me to follow a set of instructions

that produced reliable, comparable qualitative data. However, face-to-face

semi structured data collection has some limitations. Specifically, indirect

information can be filtered by the interviewees’ perspectives, and the

information is provided ina designated setting (Creswell, 2009). To explore

any issue that might have been difficult for participants to explain, I asked

additional questions (Creswell, 2009). Creswell contended that not all

participants are able to properly elaborate on their perceptions of their own

lived experiences.

Interview Guide Protocol

An interview guide enabled me to use the same basic line of inquiry

with each participant who was interviewed (Patton, 2002). I used the

interview guide (see Appendix B)to explore, probe, and ask questions that

enabled participants to explore their lived experiences (Patton, 2002). As an

interviewer, I sought to manage my time efficiently when using the

interview guide questions (Patton, 2002). I kept my interactions with the

interviewees focused until their perspectives and experiences emerged.

Patton (2002) postulated that interviews begin with the notion that

individuals have valuable lived experiences that they might want to share.

Creswell (2009) and Moustakas (1994) stated that phenomenological study

is the process of collecting data through interviewing. Individuals may

process and experience things differently. The interview questions were

generated from the following research questions:

RQ1. How do HCWs in Freetown, Sierra Leone describe their lived

experiences regarding their own mental health when treating

patients with Ebola virus disease?

RQ2. How do HCWs feel with their abilities to cope with stress while

treating patients with the Ebola virus disease?

RQ3. How do HCWs describe their lived experiences of the mental

health care treatment they received while treating patients with

the Ebola virus disease?

The first semi structured interview question that addressed RQ1 was

“Describe for me your mental health when treating patients with the Ebola

virus disease.” I asked this question to engage participants by prompting

them to provide a full narrative of their mental health (Creswell, 2009;

Patton, 2002) when treating patients with EVD. The second interview

question, whichaddressedRQ2, was “Talk to me about how you responded or

coped with the death of your patients, friends, or family members.” The third

interview question, whichaddressedRQ3, was “What specific support do you

think will be helpful in relieving stress when working with highly infectious

patients, such as Ebola virus disease patients? ”I also used a follow-up

interview question to address RQ3:“How will effective mental healthcare

improve your work performance, especially during an epidemic like the

EVD outbreak?” These questions enabled participants to reflect on the need

for adequate mental health care during an epidemic and to start a dialogue

for quality mental health care in Freetown, Sierra Leone. The last question

was “What does it feel like to be a participant in this study?” This question

was presented in recognition of the importance of a debriefing period.

Further, this question gave participants the opportunity to share any

experiences they might have forgotten to include, as well as to ask questions

related to the study.

In a phenomenological study, researchers sometimes need more

information than they get from the participants. Therefore, it’s essential that

researchers employ strategies when interviewing participants (Patton, 2002).

Rubin and Rubin (1995) contended that the modification of questions and

researchers’ calmness and flexibility would enable researchers to be

receptive to what the participant is saying. Probing allowed participants to

provide in-depth information about their feelings, personal opinions, and

there use of critical thinking (Rubin &Rubin, 1995). Probing in interview

provides the following three purposes. These purposes are (a) it improves the

depth of the interview, (b) it enables the interviewee to provide more details,

and (c) it gives reassurance to the interviewer that the interviewee is

listening (Rubin & Rubin, 1995). Therefore, probing was necessary on this

study, as it gave participants the opportunity to provide in-depth information

during the interviews, I also used probes to prompt participants to provide

full narratives of their lived experiences when providing care for Ebola virus

patients.

I interviewed each participant on different days. All data was recorded

by audio tape. I checked the audio tape to ensure that the interview process

was being recorded efficiently and effectively. In qualitative data recording

procedure, I examined the recording information to make sure that I was

recording the correct information for the study (Creswell, 2009; Patton,

2002). The advantage of audio recording data collection enables researchers

to collect data from participants without being obstructed (Creswell, 2009).

The recruitment resulted in 10 participants; therefore, I did not develop a

compensation strategy that adequately reimburses participants to participate

in the study. Also, I networked with healthcare staff who were not affiliated

with the research to help cultivate sources of referral to recruit participants.

Debriefing Procedures

Before participants exit the study, they were assured that all

information disclosed in the study would remain confidential. But also,

participants were informed that results from the data collected in this study

would be shared with mental health providers to help them understand the

need for quality mental health care during an epidemic, such as the EVD

outbreak. In addition, participants were encouraged to provide contact

information in case I have follow-up questions. Participants were also

informed that the result of this study would be provided to them through

their emails.

Data Analysis Plan

Polit and Beck (2006) stated that the main aspect of data analysis is to

provide a detailed description of the experiences and perceptions of

individuals. For this study, I analyzed how HCWs in Freetown, Sierra Leone

described their lived experiences regarding their own mental health when

treating patients with EVD? Specific interview questions for each RQ are

shown in Appendix B. I was able to ask specific open-ended questions that

narrowed the scope of the study. I also used inductive data analysis to build

patterns, categories, and themes from the bottom up (Patton, 2002). In an

inductive approach, as I read through all the data, encoding the data, themes

emerged from this study. I worked back and forth between the themes and

the database until I established a comprehensive set of themes.

Open coding was used to look for distinct concepts and the data to

develop first level categories, as well as second (third, fourth, etc.) level

codes that are associated and coded to the primary codes. At the first level of

coding, I looked for distinct concepts in the data to form the basic categories

or units of analysis. Three rounds of coding were done.

I uploaded my transcribed interviews into NVivo 10 to create themes

from the participants. I used NVivo 10 to code all transcripts and to open all

the themes by double clicking on the themes. To display participants coded

quotes, I used NVivo 10 and the most common themes were transcribed

from NVivo into words. I then copied each of the quotes that applied to the

individual theme from NVivo and transcribed it into Word. According to

Hsiung (2008), reflexivity challenges researchers to explain how their

emotions, personal beliefs, assumptions, and subject location affect the

research process. To present my findings in Chapter 4, I included the

applicable participant quotes from each theme. The manner of treatment of

discrepant cases was addressed by using a colorcoded system to highlight

specific themes before data analysis. Erickson (2012) postulated that color

coding is an effective manner to treat discrepancies during research.

Erickson also posited that triangulation is an effective strategy for data

collection. This researcher used triangulation as a manner of treatment of

discrepant cases.

Issues of Trustworthiness

According to Shenton (2004), trustworthiness in a study includes

credibility, transferability, dependability, and confirmability. In this study,

credibility was achieved by ensuring validity. That was, I measured what I

set out to measure. I understood participant’s views on their mental health

symptoms they experienced during the EVD outbreak. To maintain internal

validity, I used the following strategies: (a) member checking–I asked

participants to review my interpretation to foster truth and validity of the

data (Creswell, 2009). Through member checks, I gave participants the

opportunity to remove any information not suitable for future publication.

Participants were required to sign a consent form for the release of

information. I verified the clarification of researchers' bias, which was found

in the proposal under researcher’s role that described the relevant aspect of

the research (Denzin & Lincoln, 2008). Finally, (c) I collected data through

interviews and field notes (Creswell, 2009).

Denzin and Lincoln (2003) postulated that transferability is

demonstrated when the study applies to other populations. I provided full

description of the population that the reader would use as a guide to

understand that the finding could be used to other population or situation

(Denzin& Lincoln, 1994). Also, I made sure that other researchers

researching HCWs mental health during the EVD outbreak are able to

understand the findings of this study.

Dependability would enable other researchers to use my research

study for research purposes, as noted in my data analysis plan. I

demonstrated that if the study was repeated over time, employing similar

methods, context as well as participants, the similar results would be

obtained (Denzin & Lincoln, 2003). Also, I worked with my chair and

committee member to ensure that the result of this study is from HCWs

perspectives and not from my own opinion.

Confirmability involves researchers’ concerns for objectivity

(Shenton, 2004). I maintained a nonbiased position and allowed participants

to retell their lived experiences. Further, I established reliability by

employing three techniques. First, I provided information on the focus of the

study; my role and position as a researcher, and how the data are be gathered

(Creswell, 2009; Patton, 1990). Second, I ensured that the data analysis and

the data collection provide a clear picture of the study being conducted. I

also expect the study to be scrutinized by experienced qualitative

researchers. Also, reliability involves the repetition of the phenomenon being

studied (Morse, 1994; Patton, 2002). Therefore, I conducted a final audit at

the end of my study to make sure that the study was efficiently and

effectively done.

Ethical Procedures

Walden University Institutional Review Board (2008) indicated that

researchers are to maintain the highest standards when conducting research

involving human subjects. Walden University Review Board indicated that

researchers are always to be ethical during the research. Also, Walden

University IRB strongly discourages the collection of any data before the

approval from the International Review Board. This would enable Walden

University IRB to approve all current and future use of ethical issues before

collecting data. Application for IRB approval was obtained before data

collection. The application for permission from the IRB was included after I

received approval from the IRB on September 11, 2018. Walden University

Institutional Review Board approval number is 09-11-18-0319268, which is

included in the informed consent form.

To address the treatment of human participation, I employed the

National Institutes of Health (NIH; see Appendix C) privacy rule to let

participants know that this rule upholds the rules of confidentiality. Ethical

concerns related to recruitment materials and processes and a plan were

addressed by upholding IRB recommendation and APA ethical standards.

The IRB recommended that all data collected are to be stored in a safe place

to promote confidentiality. Creswell (2009) indicated that researchers inform

participants that their participation is strictly voluntary, and they have the

rights to withdraw at any time. I addressed the risk factors associated with

the study in the consent form. I also followed all ethical guidelines before

the data collection process and after IRB approval of the consent form. An

informed consent form was obtained before the beginning of the interview,

and participants were given enough time to read and sign the consent form.

To maintain ethical concerns, a consent form, which included

disclosure of risk and benefits associated with the study, and pseudonyms

wereused to maintain participants’ confidentiality. Given the nature of the

study, participants were informed that the information would remain

confidential. All participants where be informed that the study is voluntary

and there would be no coercion to participate in the study. The participants

were given the opportunity to relax during the interviews, and with an

understanding that they can discontinue the interview at any time. In

addition, because this study was conducted outside the United States, the

IRB guidelines were upheld. The IRB guidelines indicated that researchers

consult with the international compilation of regulations provided by the

USA Federal Office of Human Research Protections (OHRR). Therefore, the

permission to conduct this study was obtained from the Office of the Sierra

Leone Ethics and Scientific Review Committee Ministry of Health and

Sanitation in Freetown, Sierra Leone located at Youiyi Building, Fifth Floor,

East Wing. Walden University IRB indicated that applications for ethical

behavior related to data collection in the US also applies to international

countries. However, if the ethical standard of the international countries is

stricter than those from the United States, then researchers can use the US

ethical guidelines. In Sierra Leone, English is the official language, and all

the participants in the study speak fluent English. Therefore, there was no

language barrier associated with the study.

The treatment of all data was confidential. The data was collected

upon the approval from IRB. This study took me two months to collect data,

and 45 minutes of recorded interview with each participant. In addition, I

took fieldnotes as I interviewed, and recorded the impression of participants’

experiences, thoughts, and feelings. I scheduled a follow-up interview in

case participants had additional questions. Participants that wanted to

withdraw from the study were given the opportunity to leave without any

repercussion.

The protection of data is an important aspect in research. Morse

(2006) postulated that developing a plan to store and file data is an important

aspect of data analysis. This study used hardcopies of interviews, as well as

electronic copies of the interviews to store data. Electronic copies were

stored on computer hard drive and flash drive. The participants’ information

was kept confidential at all times. Creswell (2009) recommended the use of

hard copy files as a backup for all electronics files. I intended to destroy all

data in 5years. Other confidential information such as field notes, informed

consent, etc. were securely kept in a safe at my house. I was the only one

with access to the data. According to Morse, mishandling of any data can

compromise the outcome of the study. Other ethical issues such as conflict

of interest or power differential and incentives were addressed before the

beginning of the study. Therefore, there was no conflict of interest in doing

this study. All participants were informed that there would be no

compensation for participating in this study.

Summary

Chapter 3 provided information of the research methodology that was

used in the study and the other aspects of the methodology. Chapter 3 also

includes a rationale for choosing a qualitative phenomenological research

design; plans for sampling data collection, and analysis for participants’

protections, and issues related to trustworthiness. The procedures used in

selecting participants, sampling strategies, instrument and how the data was

analyzed were outlined in this section. Chapter 4 presents the results of the

analysis of the interview data collection, data coding, and a description of

the findings.

Chapter 4: Result

Introduction

The purpose of this study was to explore HCWs’ perspectives about

their mental health while providing care to Ebola patients. Participants were

asked interview questions designed to address the following research

questions:

RQ1. How do HCWs in Freetown, Sierra Leone describe their lived

experiences regarding their own mental health when treating

patients with Ebola virus disease?

RQ2. How do HCWs feel about their abilities to cope with stress

while treating patients with the Ebola virus disease?

RQ3. How do HCWs describe their lived experiences of the mental

health care treatment they received while treating patients with

the Ebola virus disease?

Chapter 4 includes the interview analysis for the study. This chapter

also addresses the setting of the study, demographics, data collection, data

analysis, and evidence of trustworthiness, concluding with a summary. This

study enabled HCWs to voice their opinions on their own mental health

while providing care to highly infectious patients.

Setting of the Study

I conducted all interviews in a café outside of Connaught Hospital at 6

Lamina Sankoh Street in Freetown, Sierra Leone. Ten participants were

interviewed onsite. The weather was sunny during all of the interviews.

There was no personal or organizational condition that influenced

participants or the result of the study. The interviews were conducted on

participants’ own time (nonworking hours) and on different dates.

Demographics

Table 1 provides information about the participants’ demographics.

Participants’ ages ranged from 36 to 60 years. All participants were in the

healthcare field (nine nurses and one medical doctor); see Figure 1.

Participants’ educational backgrounds ranged from high school education to

university level. Participants were from six different tribes (Mende, Temne,

Limba, Kono, Mandingo, and Fuller); see Figure 2. All of the participants

spoke English fluently. In addition, eight participants were married, and two

were unmarried.

Table 1

Demographics of the Participants

Gender Age Education Marital status

P1 (male) 36 University Married

P2 (female) 47 College Married

P3 (female) 44 College Married

P4 (male) 39 Graduate Married

P5 (male) 48 High school Married

P6 (male) 58 High school Married

P7 (male) 56 College Married

P8 (male) 60 High school Married

P9 (male) 57 College Unmarried

P10 (male) 43 College Unmarried

Note. P=Participant.

Data Collection

Data were collected from 10 participants in a café outside of

Connaught Hospital at 6 Lamina Sankoh Street in Freetown, Sierra Leone.

Participants were recruited by posting flyers. To answer the research

questions, each participant was asked a series of semi structured questions.

Each participant was encouraged to read the invitation letter and consent

form before signing them, as proposed in Chapter 3. In addition, participants

were informed that the interview would be audiotaped and that I would be

taking field notes during the interviews. I also informed all participants that

they could withdraw from the study at any time. All participants signed the

consent form before the start of the interview.

I interviewed participants separately, and the interview process went

on without any problem, as participants appeared calm and comfortable.

Each interview lasted for no more than 45 minutes. I used an interview guide

protocol (see Appendix B) to enable participants to elaborate on their lived

experiences. The interview guide protocol reminded me of the questions to

ask. As such, it enabled me to stay focused on the topic. My time was

managed efficiently by using the interview guide questions. Probing

questions during the interviews gave participants the opportunity to provide

in-depth information. I also used probes to prompt participants to provide

full narratives of their lived experiences when providing care for Ebola virus

patients. On the first day, two participants were interviewed at different

times; on the second day, two participants were interviewed at different

times; on the third day, two participants were interviewed at different times;

on the fourth day, three participants were interviewed at different times; and

on the fifth day, one participant was interviewed at 5:30 p.m. I used my

computer and flash drive to file audiotapes and field notes for the interviews.

All data collected were stored in a safe location under lock and key at my

house. This approach protected the participants in this study. There was no

variation from the data collection plan presented in Chapter 3. There was no

unusual circumstance encountered.

Data Analysis

NVivo 10 enabled me to manage the data and generate findings from

the data. Data coding and analysis were completed to answer the research

questions. Coding is an iterative, analytical process in which data are

organized, sorted, and categorized for analysis. Codes capture the essence of

a research story, and when clustered together as patterns, they actively

facilitate the development of categories and their connections (Saldaña,

2015). They are tags and labels for assigning units of meaning to the

descriptive or inferential information compiled during a study (Erickson,

2012).

Open coding was used to look for distinct concepts and the data to

develop firstlevel categories, as well as second- (third-, fourth-, etc.) level

codes that were associated and coded to the primary codes. At the first level

of coding, I looked for distinct concepts in the data to form the basic

categories or units of analysis. Three rounds of coding were done.

In Round 1coding, three transcripts were imported into NVivo for

coding, which represented the first-level codes named RQ1, RQ2, and RQ3.

The second-level codes were generated based on the research questions and

coding of the transcripts. The names of the codes were assigned directly for

the words that comprised each interview question, and answers in the

transcripts were directly aligned to the appropriate first-level codes to ensure

consistency. For example, participants were asked about their mental health

while

providing care to Ebola patients. Participants discussed various mental

illness symptoms that they experienced. The code for these coded passages

of the text was mental illness symptoms (see Tables2-4).

In the second round of coding, each transcript was reopened, and

open coding was conducted again. The coding labels were assigned using

NVivo codes or words that participants stated in the interviews. The codes

or labels were developed directly from a word, words, or phrases from the

coded passages of text. The data were coded and grouped according to

similarities. For example, one answer that participants gave to the question

about coping with stress was that they believed in their faith. The NVivo

code assigned to these passages of the text was spirituality (see Tables2-4).

In the third round of coding, a thorough review of the coding was

carried out to ensure that NVivo codes had been assigned properly and to

collapse any closely similar codes together.

The codes were as follows:

•Depression

•Anxiety

•Sleepless nights

•Shaking

•Chills

•Sickness Fast heartbeat

•Joint pain

•Sweating

•Flashbacks

•Choking

•Headaches

•Panic attack

•Weight loss

•Lack of gov support

•Lack of medication_ psychotropic drugs

•Lack of psychological help

•Poor quality

•Psychologists not good

•More focus on medical

•Professional counseling not adequate

•Lack of planning

•Death

•No one cares

•Racing thoughts

•Fear of unknown

•Embarrassment

•Fear of being called crazy

•A nightmare

Panic

Over vigilance

Intrusive

Love being HCW

Suicidal

Mental illness not taken seriously

•Spirituality

•Prayer

•Counseling by pastor

•Read Bible

•Deep breathing

•Drinking

•Meditation

•Family issues

•Problems at work

•HCWs did not discuss problem

•Reliving experience

•Cannot escape thoughts

•Life is different

•Not taking care of self

•Mental breakdown

•Faced discrimination

•Psychological help

Awareness

Medication

Gov standards to fight depression Funding for mental health

God

Spiritual guidance

•Faith

•Controlling my thoughts

•Being strong for patients

•Psychotherapy

•Lack of coping mechanisms

•Lack of funding

•Emotional issues

•Crying

•Hopelessness

•Frustration

•Unable to cope with stress

•Could not perform work effectively

•Came close to death

•Life is a mess

•Treatment ineffective

•Costly

•Unaffordable treatment

•Lack of qualified mental health

•Medications ineffective

•Undiagnosed mental illness

•Gov support inadequate

•Mental health system

•inadequate

•Clinics lacking resources

•Mental health educ

•Effective mental health treatment

•Affordable mental health treatment

•Use of native herbs

•Medicines

•Qualified mental health professionals

Themes Development

Nine emergent patterns were identified from the data based on the

analysis: four from research question 1, three from research question 2, and

two from research question

3. The themes are listed below.

Research Question 1:

•Mental Illness Symptoms

•Personal Thoughts and Feelings

•Strategies for Coping

•Detrimental Impacts Research Question 2:

•Coping with Stress

•Personal Consequences of Inadequate Mental Health Treatment

•Shortfalls in the Mental Health System

Research Question 3:

Problems with Mental Health Care

Recommendations to Improve Mental Health Treatment

Discrepant Cases

There was no discrepant case to report because my findings are not

incompatible with the literature review on Chapter 2.

Evidence of Trustworthiness

Credibility

Credibility in this study was accomplished by allowing participants to

listen to their own interview questions. The strategy used to maintain

credibility was member checking. Participants had the opportunity to clarify

responses. This study captured a clear picture of HCWs’ perspective on

their mental health while providing care to Ebola patients in Freetown,

Sierra Leone. As a qualitative researcher, I upheld a nonbiased approach to

ensure that my experience did not interfere with the interview process. This

approach was accomplished by being objective through the interview

process. The researcher proceeded with data collection until saturation was

accomplished (Creswell,

2009).

Transferability

To ensure transferability, a full description of the main participants

was used as a guide to ensure that the findings could be applied to other

population (Denzin &Lincoln, 1994). In addition, the result from the study

would remain available to other researchers studying the same or similar

population.

Dependability

Dependability was accomplished as the result would enable other

researchers to use my study for research purposes, as indicated in my data

analysis plan. The result of the interview questions was recorded and

reported in detail. The transcripts, codes, and themes were kept in a safe

location to enable other researchers to use for future research purposes. All

data will be destroyed in five years after the completion of this study.

Confirmability

The research findings brought a unique perspective that was

supported by my data collection during the interview process. To enforce

conformability, I employed a nonbiased approach during the research

process. A nonbiased approach was important because I was born in

Freetown, Sierra Leone, as I could have easily brought my personal bias to

this study. It is important the result of the study be accepted and utilized by

other researchers. I provided a full detailed explanation of all the necessary

steps taken in the study and how I reached the final decision. To maintain

confirmability, my role and position as a researcher, and how the data would

be gathered were provided to participants. At the end of the study, I

conducted a final review to ensure that the study was properly done, as

indicated in Chapter 3.

Results

I was able to understand and transcribed participants’ spoken words

verbatim. Findings from data analysis indicated that HCWs who treated

Ebola patients experienced mental health symptoms during 2014and2015

Ebola outbreak in Freetown, Sierra Leone. Participants also elaborated on

the need for effective mental health treatment and other strategies for coping

with mental illness. The majority of the participants stated that they were

unable to cope with the stress factors associated with the Ebola outbreak.

Discrepant Cases

There was no discrepant case that contributes to an emerging pattern

of the finding. It is imperative to recognize discrepant cases because they

represent cases that do not belong to the emerging patterns of evidence.

According to Patton (2002), discrepant cases create barriers around

emerging patterns that can change the primary pattern of findings.

Research Question 1

How do HCWs in Freetown, Sierra Leone describe their lived experiences

regarding their own mental health when treating Ebola patients? The answer

provided by participants during the interviews showed that participants

experienced mental illness symptoms. During the data collection, I was able

to ask additional questions to enable participants to elaborate on their

perceptions of their lived experiences. The first semistructured interview

question that was used to address RQ1 was–Describe for me your mental

health when treating patients with the Ebola virus disease? This question

was asked to get participants to provide a full narrative of their mental

health (Creswell, 2009; Patton, 2002) when treating patients with Ebola

virus disease. Themes emerged from this question were mental illness

symptoms, personal thoughts, and feelings, strategies for coping,

detrimental impacts (See Table 2), The majority of the participants

experience anxiety and depression. For example, Participant 1 stated, “I

went into severe anxiety.” Participant 2 stated, “I became depressed because

of the isolation. Other participants complained of other symptoms such as

shaky feelings, intrusive thoughts, and over vigilance. For instance,

Participant 5 stated, “I was shaking like a leaf and I was having bad

thoughts in my head.”

Table 2

Themes and Codes Related to HCWs’ Mental Health

Research Themes Codes Aggregate

questions references

RQ1: How do

HCWs

in Sierra Leone

describe their

lived

experiences

regarding their

own mental

health when

treating patients

with the

Ebolavirus?

Mental

illness

symptoms

Personal

thoughts

and

feelings

Depression, anxiety, sleepless

nights, shaking, chills,

sickness, fast heartbeat, joint

pain, sweating, flashbacks,

choking, headaches, panic

attack, weight loss, racing

thoughts

Death, no one cares, fear of

unknown, embarrassment, fear

of being called crazy, denial, a

nightmare, panic, over

vigilance, _intrusive, love being

HCW, suicidal, mental illness

not taken seriously

Strategies

for coping

Spirituality, prayer, counseling

by pastors, read Bible, deep

breathing, drinking, meditation

Detrimental

impacts

Family issues, problems at

work, HCWs did not discuss

problems, reliving experience,

cannot escape thoughts, life is

different, not taking care of self,

drinking, mental breakdown,

faced discrimination

Research Question 2

How do HCWs feel about their abilities to cope with stress while

treating patients with the Ebola virus disease? The answers provided by

participants during the interview showed that the majority of HCWs were

unable to cope with stress while treating patients with the Ebola virus

disease. For instance, Participant 3 stated, “I did not know how to cope with

stress!” Participant 8 stated, “I used my Bible to cope with stress!”

In addition, I used a second interview question to addressed RQ2.

Participants were asked – Talk to me about how you responded or coped

with the death of your patients, friends, or family member? This question

enabled participants to reflect on their coping skills while providing care to

Ebola patients. Themes emerged from this question were (a) coping with

stress, (b) shortfalls in the mental health system, and (c) personal

consequences of inadequate mental health treatment (See Table 3). While

participants 2, 8, 9, and 10 indicated they used spirituality to cope with

stress, the majority of the participants indicated that they were unable to

cope with stress during the Ebola outbreak. For instance, Participant 3

indicated, “I felt a sense of hopelessness and I was unable to cope.”

Participant 4 stated, “there were no coping measures.” And, Participant 5

stated, “I did not know how to cope.” Other participants, such as participant

9 and 10 blamed the government for not providing an effective measure to

cope with the Ebola outbreak. Participants 1 and 5 stated that they could

have coped if they were exposed to adequate mental health treatments.

Table 3

Themes and Codes Related to HCWs’ Coping

Research

questions

Themes Codes Aggregate

references

RQ2. How do

HCWs feel

about their

abilities to cope

with stress

while treating

patients with

the

Ebola virus

disease?

Coping with

stress

Shortfalls in

the mental

health system

Spirituality, prayer, God,

spiritual guidance, faith,

controlling my thoughts,

being strong for patients,

psychotherapy

Lack of government support,

lack of coping mechanisms,

lack of funding, lack of

medicine

Personal

consequences

of inadequate

mental health

treatment

Emotional issues, depressed,

far, crying, hopelessness,

frustration, unable to cope

with stress, could not perform

work

effectively, came close to

death, life is a mess

Research Question 3

How do HCWs describe their lived experiences of the mental health

care they received while treating patients with Ebola virus disease? The

answer provided by the majority of the participants during the interview

indicated that they did not receive adequate mental health treatment.

Themes emerged from this question were problems with mental health care

and resources and recommendation to improve mental health treatment (See

Table 4). Participant 2 stated, “I received psychotropic medications for

mental illness symptoms, but they were ineffective.” Participant 8stated,

“The psychotropic medications given to HCWs were ineffective or

placebo.” Participant 9 stated, “The mental health treatment was bad, not

good.” Participant 10 stated, “The medication given to me did not help me.”

All participants recommended that the government promote effective mental

health treatment for healthcare workers.

Participants also recommended education on the signs and symptoms of

mental illness. Further, Participant 3 stated, “The government should start

using natural herbs to treat mental illness symptoms.”

Table 4

Themes and Codes Related to HCWs’ Treatment

Research

questions

Themes Codes Aggregate

references

RQ3. How do

HCWs

describe their

lived

experiences of

the mental

health care

they received

while treating

patients

withEbola

virus disease?

Problems with

mental health

care

Treatment ineffective,

costly, unaffordable

treatment, lack of

qualified mental health,

medications ineffective,

undiagnosed mental

illness, gov support

inadequate, mental

health system

inadequate, clinics

lacking resources,lack of

gov support, lack of

medication_

psychotropic drugs, lack

of psychological help,

poor quality,

psychologists not good,

more focus on medical,

professional counseling

not adequate, lack of

planning.

Needed resources

and

recommendations

Psychological help,

awareness, medication,

gov standards to fight

depression, funding for

mental health, mental

health educ, effective

mental health treatment,

affordable mental health

treatment, use of native

herbs

Summary

The purpose of this chapter was to write out the analysis of the

research questions and provide detailed information about participants’

experiences with their mental health while taking care of Ebola patients.

There were 10 participants selected for the study. Participants were selected

at Connaught hospital in Freetown, Sierra Leone. HCWs who provided care

to Ebola patients were directly included in the study. In other to gain a

deeper and in-depth understanding of the experiences of HCWs in

Freetown, Sierra Leone about their mental health while providing care to

Ebola patient; three research questions were designed.

The first research question was designed to capture the overall

perspective of healthcare workers lived experiences of their own mental

health while treating Ebola patients. It was evident from their explanations

that they suffered mental illness symptoms. Major themes that emerged

from this research question were mental illness symptoms, personal

thoughts and feelings, strategies for coping, and detrimental impacts.

Participant responses from this research question verified that HCWs

experienced anxiety, depression, nightmares, suicidal thoughts, panic

attacks, insomnia, and sleepless nights etc.

The second research question was designed to capture how do HCWs

feel about their abilities to cope with stress while providing care to Ebola

patients. The major themes that emerged from this research question were

coping with stress, shortfalls in the mental health system, and personal

consequences of inadequate mental health treatment. In response to this

research question, the majority of the participants indicated that they were

unable to cope with stress while taking care of Ebola patients. These

feelings were shared by six of the participants. The majority of the HCWs

perceptions toward coping with stress, especially during the Ebola outbreak,

was that they were unable to cope, especially when they watched their

patients die.

The third research question was designed to explore the lived

experiences of mental health care treatment HCWs received while providing

treatment to Ebola patients. Themes derived from this question were

problems with mental health care and recommendations to improve mental

health treatment. All the participants gave similar responses that the mental

health treatment provided to them was inadequate and ineffective.

Participants were concerned that the lack of effective treatment enabled

them to have difficulties to cope with stress during the Ebola outbreak.

Also, participants felt that the government needs to be more involved

with helping all Sierra Leoneans with mental illness. Participants felt that

most of the people in Sierra Leone are ashamed of being labeled mentally

ill. Therefore, education was referenced by most of the participant as an

effective way to promote mental health awareness. Participants were

concerned that many people with mental illness cannot afford effective

mental health treatment. As a result, participants are encouraging the

government to advocate for affordable mental health treatment for all Sierra

Leoneans. Majority of the participants urged the government to develop

effective coping measures for healthcare workers during an epidemic.

While Chapter 4 provided the analysis of the research questions and

provided detailed information about participants’ experiences of their own

mental health, Chapter 5 provided an overview of why the study was

conducted. Chapter 5 also highlights the interpretation, finding, and

limitation of the study. Recommendation and positive social change were

also addressed.

Chapter 5: Discussion, Recommendations, and Conclusions

Introduction

The purpose of this phenomenological study was to explore HCWs’

perspectives on their mental health while working with Ebola patients.

HCWs were asked to describe their lived experiences while treating patients

with EVD. Ten participants were selected from one geographical location in

Freetown, Sierra Leone. Participants were interviewed outside Connaught

Hospital.

I only selected HCWs who had worked directly with Ebola patients.

Participants were asked to provide their perceptions pertaining tothree

research questions. The first research question was as follows: How do

HCWs in Freetown, Sierra Leone describe their lived experiences regarding

their own mental health when treating patients with Ebola virus disease?

The second research question was the following: How do HCWs feel about

their abilities to cope with stress while treating patients with the Ebola virus

disease? The third research question was as follows: How do HCWs

describe their lived experiences of the mental health care treatment they

received while treating patients with the Ebola virus disease?

The findings of this study were compared to the literature reviewed In

Chapter 2.I expect that the study will benefit healthcare professionals and

ordinary Sierra Leoneans with mental illness. The findings were also

interpreted in the context of the stress process model and hermeneutic

phenomenology.

Pearlin et al.’s (1981) stress process model was selected as a lens to

analyze the findings of this study. The stress process model is helpful in

understanding the stress factors associated with HCWs during an epidemic.

Hermeneutic phenomenology was used as a lens to analyze the findings of

this study. Hermeneutic phenomenology enables researchersto understand

the lived experiences of a person or a group. As I proceeded with this study,

several major themes were identified from three research questions. Major

themes were selected based on the similarity of meaning of words and

phrases. In addition, limitations of the study, recommendations, implications

of the study and the conclusion of the study are discussed in this chapter.

Key Findings

This section summarizes the key findings from the themes for each

research question. Mental illness symptoms, personal thoughts and feelings,

strategies for coping, and detrimental impact were the major themes that

emerged from Research Question 1. All of the participants complained of

either depression, anxiety, or PTSD, and they were afraid of being called

crazy. Although a few participants used the Bible to cope with their mental

illness symptoms, the majority of participants believed that they were

unable to cope and that they faced discrimination after the Ebola outbreak.

Three emergent patterns—coping with stress, shortfalls in the mental health

system, and personal consequences of inadequate mental health treatment—

were identified in relation to Research Question 2. The majority of the

participants felt that they were unable to cope with stress while providing

treatment to Ebola patients and blamed the government for not providing

adequate measures to cope. Moreover, two emergent patterns—problems

with mental health care and the need for resources and recommendations—

were identified in relation to Research Question 3. Though participants

stated that they received psychotropic medications while providing

treatment to Ebola patients, they also noted that the psychotropic

medications were not helpful. The nine major themes developed from data

analysis were as follows:

•Mental illness symptoms: Participants complained of anxiety,

depression,

PTSD, and other psychological difficulties.

•Personal thoughts and feelings: Participants gave their opinions

on the mental illness symptoms they experienced, the mental

health system, and what could be done.

•Strategies of coping: Participants claimed that they used

spirituality to cope; however, the majority of the participants

stated that they were unable to cope.

•Detrimental impacts: Participants claimed that they were still

suffering from the symptoms of mental illness and discrimination.

•Coping with stress: The majority of the participants claimed that

they were unable to cope with stress.

•Shortfalls in the mental health system: Most of the participants

claimed that the clinicians were not qualified and that mental

health clinics lacked resources.

•Personal consequences of inadequate mental health treatment:

Participants claimed that they would have coped if adequate

treatments had beenprovided.

•Problems with mental health care: Participants claimed that there

were problems with mental health care.

•Recommendations to improve mental health treatments:

Participants gave recommendations on how to improve the mental

health care system.

Interpretation of Findings

Extended Knowledge

The stress process model and hermeneutic phenomenology have

never been used to explore the mental health of HCWs who provided

treatments to Ebola patients. The result of the study adds to the body of

knowledge on HCWs experiencing high stress that leads to mental illness

symptoms. HCWs’ sincere ignorance of mental illness symptoms because of

lack of proper education, lack of effective mental health treatment, and

inadequate resources contributes to increased mental health symptoms in

this population.

Literature and Research Question 1 Findings

RQ1. How do HCWs in Freetown, Sierra Leone describe their lived

experiences regarding their own mental health when treating

patients with Ebola virus disease?

Ebola is a deadly disease that can affect the mental health of HCWs.

Participants felt that they experienced symptoms of mental illness when

treating patients with the Ebola virus. Participants complained of

restlessness, fear, and difficulties sleeping at night. One of the symptoms

elaborated by most participants was excessive worry that they were going to

die. According to the DSM-V (APA, 2013), one of the common signs of

anxiety is excessive worry. The DSM-V also indicates that sleep disturbance

is often reported by people experiencing anxiety disorders. I noted that all

participants complained about symptoms of mental illness during the Ebola

outbreak. They also indicated that they were still experiencing these

symptoms daily at the time of the study and that they were having

difficulties in providing effective treatment to their patients.

They stated that one of the causes of the symptoms they experienced was

the stress they experienced during the Ebola outbreak. The DSM-V

indicates that people with anxiety disorders exhibit difficulties in responding

to stress. Similarly, Li et al. (2015) and Shoji et al. (2014) found that some

of the emotional difficulties experienced by HCWs are anxiety and PTSD.

Furthermore, the perceptions of all the participants indicated that they

were depressed. Participants believed that they experienced sadness,

feelings of hopelessness, loss of interest, insomnia, suicidal ideation, and

tiredness. I noted that the sudden outbreak of the Ebola virus produced

stress for HCWs while working with Ebola patients. Pearlin (1989)

postulated that stressors may be both internal and external, with external

factors involving the individual’s immediate environment. All participants

stated that the sudden change of environment with the Ebola outbreak

increased their stress level, which caused them to be depressed. All

participants believed that the focus was on finding a way to eradicate the

Ebola virus and not on their own mental health.

Existing literature indicates that during epidemics, HCWs (nurses,

doctors, and emergency room technicians) experience anxiety, depression,

and PTSD (Li et al., 2015; Shoji et al., 2014). My study found that some

HCWs (nurses and doctors) who cared for Ebola patients used spirituality to

cope with their mental illness symptoms. This finding adds to the body of

knowledge.

Participants in my study mentioned that they did not get adequate

mental health treatment during the Ebola virus outbreak. They reported that

even though they received some teaching on coping skills from healthcare

professionals, it was not enough for them. They believed that the

government should work with qualified mental health professionals to

provide adequate mental health treatment for all Sierra Leoneans. HCWs

complained that psychotropic drugs were ineffective and clinicians were not

good. All participants blamed the government for not doing enough to

support their mental health while they provided treatment to Ebola patients.

Besides their own mental health, participants believed that the government

should focus on effective mental health treatment for all Sierra Leoneans for

future epidemics.

HCWs are vulnerable to stress, which can lead to mental illness. In

their study, Myers (1994) and Radeke and Mahoney (2000) indicated that

HCWs (nurses) experienced increased anxiety, depression, and mental

fatigue. Myers and Radeke and Mahoney found in their research that HCWs

(nurses) who were vulnerable to stress were given the opportunity to use

mindfulness-based stress reduction (MBSR) to cope with their stress. In

contrast, participants in my study were not given the opportunity to use

MBSR to cope with their stress while providing care to Ebola patients.

Participants in my study perceivedthe mental healthcare system of Sierra

Leone as ineffective. According to Jalloh et al. (2018) and Scott et al.

(2009), there is compelling evidence that HCWs (nurses and medical

doctors) experience psychological stress and should be given highquality

mental health treatment. Similarly, in my study, HCWs who cared for Ebola

patients complained of psychological stress and were seeking high-quality

mental health care. The findings from the studies of Jalloh et al. and Scott et

al. give credence to my findings. Lack of adequate mental health treatment

for HCWs in Sierra Leone can affect the quality of work they provide to

their patients and their activities of daily living.

Participants complained that the mental health symptoms they

experienced prevented them from providing adequate treatment to their

patients. Koinis et al. (2015) argued that symptoms of mental illness can

affect the quality of services provided by HCWs (nurses). They also stated

that if the psychological problems of HCWs are not taken seriously in West

Africa, HCWs will have difficulties in providing quality care to their

patients. Additionally, WHO (2016) called for adequate mental health

treatment for

HCWs (nurses and medical doctors) in the West African region after

uncovering that HCWs were experiencing mental health difficulties.

The overall findings support the literature review’s indication that

HCWs should receive mental health treatment, especially when they are

under stress. The findings also give credence to the notion that HCWs are

vulnerable to high levels of stress at their workplace. These studies found

that HCWs’ mental health cannot be ignored. The overall perceptions of

participants were that HCWs experienced mental health symptoms while

providing care to Ebola patients.

Literature and Research Question 2 Findings

RQ2. How do HCWs feel about their abilities to cope with stress

while treating patients with the Ebola virus disease?

The themes derived from this research question were coping with

stress, shortfalls in the mental health system, and personal consequences of

inadequate mental health treatment.

Four out of 10participants believed that they coped well with the

Ebola outbreak while treating patients with Ebola virus. These participants

felt that their religious beliefs and controlling their thoughts helped them to

cope while treating patients with Ebola virus. Participant 8 contended that

he was able to cope because of his love for his work. Though these

participants were able to cope, they also recommended that the government

provide effective psychotherapy for HCWs. In their study, Koh et al. (2015)

found that HCWs who had coping skills complained less of psychological

morbidity and burnout. Petrites et al. (2016) reported in their study that 72%

of HCWs in West Africa used religion to cope with the loss of their clients.

The findings of this study may encourage HCWs and mental health care

professionals to change their attitudes toward the mental health system in

Sierra Leone. Khalid et al. (2016) found in their study that the two factors

that helped HCWs cope during an epidemic were positive attitudes and strict

precautions derived from safety standards. These findings are in alignment

with my study, as this study encourages a positive attitude in coping with an

epidemic.

Furthermore, six out of 10 participants felt that they were unable to

cope with the Ebola outbreak while providing care to Ebola patients. In their

study, Jordan et al. (2016) reported that the majority of HCWs have

difficulties in coping with stress. Participants claimed that their stress levels

were too high, which affected their coping abilities. Fernandes and Nirmala

(2017) reported that high stress levels among HCWs contributed to

emotional burnout. The majority of the participants in my study stated that

when they saw their patients die, they were unable to cope. WHO (2015)

has encouraged public officials to provide adequate coping-related mental

health services for Sierra Leoneans. Some participants from my study

responded that if some Sierra Leoneans had been educated on mental

illness, they would have been able to cope with the symptoms of mental

illness.

The WHO (2016) and CDC (2015) reported that HCWs in the West

African region experienced high stress because of inadequate resources and

poor living conditions. In my study, participants responded that adequate

resources would enable them to cope better with high stress levels. A similar

finding was shared by participants in a study, as they indicated that they

were able to cope with an epidemic while taking care of their patients

(Khalid et al., 2016). This finding gives credence to Betancourt et al.’s

(2016) finding. Betancourt et al. indicated that the government is the

primary influence on HCWs’ psychological well-being. Betancourt et al.’s

finding was confirmed by Greenberg et al. (2015), who encouraged the

development of adequate mental health care services for HCWs in Sierra

Leone. A similar recommendation was given by deMenil et al. (2014), who

stated that HCWs who were provided adequate mental health care at their

workplace reported a reduction of their psychological symptoms. This

finding was confirmed by Li et al. (2015), who indicated that adequate

mental health care for HCWs in the Western Africa region would enable

them to cope with stress. My study adds to the body of knowledge

indicating that the personal consequences of inadequate mental health

treatment for HCWs during an epidemic lead to mental health difficulties

for them.

Literature and Research Question 3 Findings

RQ3. How do HCWs describe their lived experiences of the mental

health care treatment they received while treating patients with

the Ebola virus disease?

The themes derived from this research question were problems with

mental health care and needed resources and recommendations. While few

participants mentioned that they received some treatment, all participants

felt that their treatments were inadequate and ineffective. This report is

supported by other findings in the literature review (Betancourt et al. 2016;

CDC, 2015; Greenberg et al., 2015; WHO, 2016). Betancourt et al.;

Greenberg; and WHO stressed the importance of adequate mental health

care, adequate resources, and early diagnosis of mental illness for HCWs.

Greenberg concluded that these aspects are relevant to providing adequate

mental health care for Sierra Leoneans.

Participants felt that government officials had failed to implement a

proper protocol that would help to combat mental illness. Some participants

stated that the medications provided to them were expired. They responded

that the doctors were unsure how to treat their psychological problems.

Participants also mentioned that the clinicians were unqualified to help them

with their psychological problems.

Another theme that emerged from Research Question 3 was the

recommendation to improve mental health treatment. Some participants

believed that it is important to educate the public on mental illness.

Participants stated that doctors could not just give medications to their

patients, arguing that doctors must also educate their clients about mental

illness. According to participants, most Sierra Leoneans do not want to seek

mental health treatment because of stigmatization. Participants felt that most

Sierra Leoneans do not know that they have mental illness and are

diagnosed when it is too late. A study conducted by Padayacheya et al.

(2017) reported that early mental health diagnosis is better than late

diagnosis. Participants felt that lack of affordability is one of the reasons

that mental illness is not diagnosed early. Lund et al. (2013) found in their

study that mental illness is a major economic disadvantage for low-income

populations in Africa. They recommended government assistance for low-

income individuals in West Africa. deMenilal (2014) found that mental

health costs in Africa arefunded by private health insurance companies that

only benefit the privileged.

This finding gives credence to a study conducted by Brolin Ribacke et

al. (2016) that the mental health care system in Sierra Leone, West Africa

was deplorable during the Ebola outbreak. This perspective was elaborated

by all participants in my study. Above all, the participants indicated that

adequate mental health care is expensive. WHO (2016) has stated that

funding of adequate mental health care in the West African region remains

extremely poor.

Some participants blamed the ignorance of the ordinary Sierra

Leoneans for inadequate mental health treatment. They felt that if the

majority of the people were educated, they would have advocated for

adequate mental health care in Sierra Leone. Jalloh et al. (2018) found that

sincere ignorance is one of the barriers to adequate mental health treatment

in the West African region. Participants also maintained that free mental

health care should be made available to all healthcare workers. The findings

confirmed that there were problems with the mental health care HCWs

received while providing treatments to Ebola patients. Therefore, HCWs

gave recommendations on how to improve the mental healthcare system in

Sierra Leone.

Theoretical Framework

The stress process model asserts that three factors describe the

stressors individuals experience. These factors are stressors, motivation or

mediations, and stress outcomes (Pearlin et al., 1981). Pearlin et al.’s stress

process model was used as a lens of analysis to help understand HCWs’

perspectives on their own mental health while providing care to Ebola

patients. This theory was also chosen as a theoretical framework. All

participants in the study responded that they experienced mental illness

symptoms while providing treatment to Ebola patients.

Pearlin et al.’s (1981) stress process model enabled me to understand

the stressors HCWs experienced while providing care to EVD patients. This

theory facilitates the understanding of how different stressors foster mental

illness. HCWs who participated in this study during the Ebola epidemic did

not expect the sudden outbreak of the Ebola virus. Pearlin postulated that

there are two categories of stressors: event stressors and chronic stressors.

According to Pearlin, event stressors happen unexpectedly. Therefore, the

2014 Ebola outbreak can be categorized as event stressor. On the other

hand, chronic stressors involved different kinds of strains. An example of

chronic stressor experienced by HCWs during the Ebola outbreak was a

status strain. Pearlin (1999) postulated that status strain involves an

individual’s social and hierarchical structure. In the context of HCWs during

the EVD outbreak, an obvious example of this stressor was the lack of

mental health funding in West Africa, which affected mental health

services. This issue caused individuals in this population to be susceptible to

an increased amount of stress.

HCWs during the EVD outbreak were exposed to stressors from

different areas of their perceived roles, which created role conflict.

According to Pearlin, role conflict increases a person’s stress level. HCWs

during the Ebola outbreak simultaneously fulfilled their responsibilities at

home and at work.

HCWs experienced psychological symptoms caused by the lack of

resources to help them cope with their stress. According to the stress process

model, the different psychological symptoms experienced by HCWs is

called individual strain. On the other hand, the lack of resources and support

is called environmental strains. Therefore, HCWs who provided treatment to

Ebola patients experienced both kinds of strain.

All HCWs during the Ebola outbreak worked long hours to help their

clients and did not get restful sleep. HCWs complained of psychological

discomfort while providing care to Ebola patients. According to the stress

process model, this kind of stressor is called quotidian strain. Therefore,

HCWs who provided treatment to Ebola patients experienced quotidian

strain.

Conceptual Framework

Hermeneutic phenomenology enabled me to understand the lived

experiences of HCWs who cared for Ebola patients. HCWs were able to

relay their lived experiences on their psychological discomfort, poor mental

health treatment, and inadequate resources in Sierra Leone. Hermeneutic

phenomenological conceptual framework asserts that individuals can

explain their ways of seeing things, knowing things, and the way things are

related to them (Valandra, 2012). This framework facilitates the

understanding of the symptoms of mental illness HCWs in Freetown, Sierra

Leone experienced while providing treatment to Ebola patients.

The finding from this study shows that HCWs experienced both

internal and external stressors. The Hermeneutic phenomenology gave me

the opportunity to understand the lived experienced HCWs who provided

treatments to Ebola patients. However, the stress process model provided

insight into how HCWs handled stress while providing care to Ebola

patients. From the internal and external stressors, the majority of the HCWs

were unable to cope with the stressors while providing treatment to Ebola

patients. HCWs were unable to cope with stress due to inadequate resources

and the lack of effective coping measures.

From a general point of view, the stress process model was not only

used as a lens of analysis, but it was selected to uncover other factors

associated with the study. For example, other factors such as sincere

ignorance and poor living conditions increased HCWs stress. These factors,

intertwined with the stress process model, emphasized the importance of

educating HCWs on effective coping measures to combat stress, especially

during an epidemic.

Limitation of the Study

During the study, I was able to self-check on several issues. I was

born in Freetown, Sierra Leone and participant responses made me

uncomfortable. As a qualitative researcher, I had to remove myself from

their experiences and remained more objective as participants told their

lived experiences. Further, the study only included HCWs in the Westin

area of Freetown, Sierra Leone and excluded HCWs in the provinces.

Therefore, the study may not generalize to other areas of Sierra Leone, other

countries, or HCWs treating other epidemics.

I was the sole data collector and there was no peer review during the

interview session. The research findings may not be transferable to other

populations. This study was limited to only 10 participants who worked

directly with Ebola patients. Additional studies on this phenomenon could

include HCWs lived experiences of their own mental health while providing

care to Ebola patients from different geographical areas in the

Western region of Africa.

Recommendations

This study only focused on HCWs’ perspectives on their own mental

health while providing treatment to Ebola patients in Freetown, Sierra

Leone. The experiences of ordinary Sierra Leoneans on this phenomenon

should be included in future studies in order to provide optimal measures to

cope with mental illness in Freetown, Sierra Leone. This study only

included HCWs that were fluent in English. The common language in Sierra

Leone is Creole. Future study should include participants that are fluent in

Creole to get a deeper understanding of this phenomenon. It is also my

recommendation that mental health care professionals conduct yearly

workshops to improve adequate mental healthcare in Sierra Leone. Mugisha

et al. (2017) stated that there would be an increase in mental health

problems among HCWs in West Africa if better strategies for adequate

mental health care are not implemented. According to my findings,

healthcare practitioners need to provide empirically based education on the

effect of an epidemic on the mental health of the health practitioners. Such

education should be a mandatory workshop for all healthcare workers.

Education on mental illness as well as on the cure for Ebola virus, especially

during an epidemic would enable HCWs to cope during an epidemic. I am

recommending that the government implemented effective strategies, such

as yearly workshops on mental illness to combat mental health crisis during

an epidemic.

Implications

Positive Social Change

HCWs in Freetown, Sierra Leone were given the opportunity to voice

their lived experiences on their own mental health while providing care for

Ebola patients. HCWs with undiagnosed mental illness have difficulties

adjusting to their everyday lives (WHO, 2016). In fact, several studies have

been conducted to help address the mental health problem in the West

African region (Greenberg et al., 2015). However, as of yet, the mental

health system in Freetown, Sierra Leone remains inadequate. On the level of

individuals, the responses about mental health symptoms, coping and lack

of treatment provided by HCWs in this study will affect positive social

change. These findings would enable Sierra Leoneans, especially HCWs to

understand the signs and symptoms of mental illness they may experience.

I will make the finding of the study available to the Ministry of Health

and

Sanitation in Sierra Leone so that they will have knowledge of the mental

health concerns HCWs experienced during the Ebola outbreak. In addition, I

will make myself reachable to healthcare professionals and government

officials to discuss any relevant issues about the major findings of the study.

Because it is my goal to affect positive social change, I will start a mental

health clinic in Freetown, Sierra Leone after the completion of my degree.

The purpose of this clinic will be to provide and promote effective mental

health treatment to low income Sierra Leoneans. It is my hope that this

study and the opening of my mental health clinic in Freetown, Sierra Leone

would empower all Sierra Leoneans and bring positive social change.

Based on my findings, hopefully, government officials in Freetown,

Sierra Leone would start the dialogue on effective mental health care for all

Sierra Leoneans. Government officials and mental healthcare officials can

access the findings by contacting me directly as I will make myself

available via telephone, email, and website to discuss any relevant issues

about the major findings of the study. This study found that the mental

health treatment provided to HCWs in Freetown, Sierra Leone was

inadequate and ineffective. Adequate mental health treatment for HCWs

would enable them to provide adequate care to their patients (deMenil et

al.,2014). In addition, I will encourage government officials to provide

adequate education on mental health.

The result of the study will foster collaboration between mental health

professionals and government officials to engage in effective

communication about mental healthcare in Sierra Leone. Effective

education takes place in collaboration (Vygotsky, 1978). This study shows

that HCWs during the Ebola outbreak have serious concerns about their

mental health. Further, the study provides relevant information that mental

health care professionals would use to address the mental health problems in

Sierra Leone. Participants were concerned that their mental health might

decline if there is another Ebola outbreak. The result of the study is also

important as it would enable government officials to understand the signs

and symptoms of mental illness. It is imperative that government officials

know that HCWs who provided treatment to Ebola patients experience

mental health difficulties. The study also found that the lack of affordable

cost for mental health is making it difficult for many Sierra Leoneans to

seek adequate mental health care. Studies conducted by Lund et al. (2013)

suggested that the government help cover the cost of mental health for low-

income individuals in Africa.

HCWs involvement was an important factor in this study, as they are

the most vulnerable to stress during an epidemic. HCWs are vulnerable to

anxiety, depression, and PTSD (Li et al., 2015; Shoji et al., 2014). HCWs

reported that they played multiple roles and were mostly affected by the

Ebola epidemic. The result of the study might empower ordinary Sierra

Leoneans to advocate for better mental healthcare.

Methodological and Theoretical Implications

The use of phenomenological approach coupled with Pearlin et al.

(1981) stress process model and Heidegger (1889) hermeneutic

phenomenology was appropriate for this study because this study was a

qualitative study, an in-depth perspective was provided by participants. In

addition, it can be appropriate for future researchers studying healthcare

workers’ perspectives on an epidemic, especially HCWs mental health

during an Ebola virus outbreak. Pearlin’s et al. stress process model and

Heidegger’s (1889) hermeneutic phenomenology are well designed to

capture the needed data from participants about their mental illness during

the Ebola outbreak.

Conclusion

As I conducted the study, I was aware that participants experienced

mental illness but did not get adequate mental health care. The lack of

adequate mental health care prompted participants to be frustrated and

blame the government. This study was unique because it gave HCWs during

the Ebola outbreak in Freetown, Sierra Leone the opportunity to talk about

their lived experiences with mental illness. The finding of the study showed

that the mental health care system in Sierra Leone is inadequate. And, as of

yet, after the Ebola outbreak, the mental health of HCWs continues to be

ignored. The study found that many in Freetown view mental illness as a

stigma and even though they experienced signs and symptoms of mental

illness they refused to seek help. This should not be the case for HCWs,

because good mental health would enable HCWs to provide adequate care

for their patients. Many Sierra Leoneans cannot afford adequate mental

health care and therefore turn to their religion.

Finally, mental illness continues to affect the lives of many Sierra

Leoneans. Mental health care professionals and the government are

encouraged to advocate for adequate mental health care for all Sierra

Leoneans. Mental illness is seen as a serious psychological problem and

factors such as stress, poverty, inadequate resources, poor education, and

lack of advocacy can promote the continuation of mental illness. Mental

health officials have not done enough to combat mental illness in Sierra

Leone. However, if mental health officials start the dialogue, government

officials mightjoin them to implement effective strategies to combat mental

illness in Sierra Leone, especially during an epidemic.

Perspectives of Sierra Leoneans Healthcare Workers' Mental Health During the Ebola Outbreak

Students also viewed