December 2022

Lessons from the COVID-19 Pandemic: How Deficits in Safety Culture Failed Healthcare Workers (pdf)

Contributed by Sundus Siddique, MBBS, MPH, Zuckerburg College of Health Sciences, University of Massachusetts Lowell. 

In the spring of 2020, the COVID-19 pandemic swept the world and left in its wake a global healthcare emergency. By the fall of 2022, the U.S. had the highest cumulative COVID-19 deaths per capita among its peer nations.1 An unprecedented burden was placed on the physical and mental well-being of healthcare workers, who were working in novel, challenging, and potentially unsafe conditions. These included but were not limited to increased staffing shortages, workload, infection control protocols, and unprecedented safety policy uncertainties.2 Two years into the pandemic, we think it is of utmost importance to examine the impact of organizational actions during the pandemic to ensure employee safety. We explored how these actions might have affected healthcare worker well-being and what could be learned for the future.

We have studied the impact of institutional-level safety policies on immediate working conditions during the pandemic healthcare workers.3 Our study, which included surveys and interviews, was conducted in a mixed population of licensed and unlicensed personnel in five U.S. public sector healthcare facilities. We learned that worker perceptions of general organizational support for safety, and safety hazards before the pandemic, had a meaningful effect on the subsequent work experiences of staff in 2020-2021. To our knowledge, this is the first study to report these types of findings.

The most problematic work experiences healthcare workers reported during the pandemic were decreased staffing, increased workload, and inability to take time off due to COVID-19 vaccine side effects. When examining predictors of pandemic work experience, we found that workers who reported higher organizational support for safety and lower safety hazards pre-pandemic were more likely to report a better work experience during the pandemic. Examples of better pandemic experiences included: increased odds of better staffing; access to COVID-19 testing at work; paid sick time for COVID-vaccine-related illness; being able to stay home from work with COVID-19 symptoms; receiving mental health supports at work; experiencing a generally supportive workplace during the pandemic; and not intending to leave the job within the next two years.

In-depth interviews with 17 healthcare workers from the same facilities revealed four major problem areas: immediate working conditions during the pandemic, organizational policy and communication, pandemic impact on the organization, and impact on employees. Reports of major problems with working conditions included a lack of adequate personal protective equipment (PPE), fit testing for PPE, training for correct PPE use, infection control, and COVID- 19 testing access in the initial months of the pandemic. Inadequate staffing in the facilities before the pandemic onset was exacerbated during the pandemic, causing longer shifts and mandatory overtime. Staffing and workload concerns began to be alleviated through supplemental staffing in some facilities by either the National Guard or by hiring temporary workers several months into the pandemic. In facilities hiring temporary help, participants reported that temporary workers lacked experience and commitment to the workplace and patients, which generated feelings of hostility on the part of permanent workers. Social support and coworker support were essential for participants to carry on their work during the pandemic; few reported coworker incivility. Most interviewees said their organizations struggled to communicate policies effectively before the pandemic and these communication problems intensified during the pandemic. Frequently changing CDC guidelines for healthcare institutions created uncertainty in a wide array of safety policies regarding testing, isolation, quarantine, and PPE usage. Concerning the impact on the organization, employee and patient morale was low wherever poor organizational response was reported. In terms of individual impact, healthcare workers faced several challenges in terms of their mental health and relationships with family members and the community at large.

This study highlighted the importance of organizational commitment to and institutional policies supporting healthcare worker safety as a standard of healthcare management practice. Current safety culture and practices set the stage for future worker well-being and performance in times of crisis. Our prospective findings highlighted specific work environment problems that predated the pandemic; some of these problems, such as poor organizational communication, had been documented separately by our research team.4 The pandemic both exposed and intensified these weaknesses. Our results suggest that clear and concise safety policies to ensure adequate staffing to manage workload, provision of fit tested safety gear, including PPE, and provision of training and education regarding new policy implementation are essential for protecting and promoting healthcare worker well-being during public health emergencies. Policies should address positive and timely responses to employees who call attention to potentially harmful work situations. Fostering an environment of coworker and supervisor support in the workplace is important for improving professional performance and mental health. Future pandemic preparedness would benefit from having a crisis management plan in advance, and efficiently executing it while remaining flexible enough to make changes as the situation evolves. We hope that our findings inform healthcare policymakers and occupational health specialists to identify potential ways to strengthen a safety program in preparation for future public health crises.


  1. Mueller B. & Lutz E. (2022, February 1). U.S. Has Far Higher Covid Death Rate Than Other Wealthy Countries.The New York Times. Accessed: August 24, 2022
  2. Aymerich, C., Pedruzo, B., Pérez, J. L., et al. (2022). COVID-19 pandemic effects on health worker's mental health: Systematic review and meta-analysis. European psychiatry: the journal of the Association of European Psychiatrists, 65(1), e10.
  3. Siddique, S., Rice, S., Bhardwaj, M., et al. (2022). Healthcare organization policies for employee safety and COVID-19 pandemic response: A mixed-methods study. Journal of occupational and environmental medicine, 10.1097/JOM.0000000000002741. Advance online publication.
  4. Nobrega, S., Morocho, C., Robertson, M., et al. (2021). A mixed-method approach to tailor the implementation of a participatory Total Worker Health® program. International Journal of Workplace Health Management. 

Sundus Siddique is a physician, epidemiologist, and an occupational health researcher and ScD candidate in Public Health at UMass Lowell. Her work addresses psychosocial work environment exposures, healthcare policies, and mental health outcomes in healthcare workers.
CPH-NEW is a NIOSH Center of Excellence for Total Worker Health®. CPH-News & Views is a quarterly blog written by center researchers and guest authors on emerging topics related to healthy workplaces. We welcome your responses and discussions. Please send all comments to
Total Worker Health® is a registered trademark of the U.S. Department of Health and Human Services (HHS). Participation by CPH-NEW does not imply endorsement by HHS, the Centers for Disease Control and Prevention, or the National Institute for Occupational Safety and Health (NIOSH). This publication was supported by NIOSH Grant Number 1 U19 OH012299. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NIOSH or CPH-NEW.