Exploring healthcare workers’ perceptions and experiences regarding post-traumatic stress disorder after 2 years of the last global pandemic | BMC Health Services Research

Overview

This study aimed to investigate healthcare workers’ (HCWs) perceptions and experiences of post-traumatic stress disorder (PTSD) two years after the most recent global pandemic. To our knowledge, this is the first qualitative study conducted in Iran exploring HCWs’ perceptions and experiences of PTSD in this post-pandemic period. Most previous studies on this topic have been either cross-sectional, retrospective, or focused on PTSD during the COVID-19 pandemic itself. In contrast, the present study offers a qualitative exploration of PTSD perceptions and experiences among healthcare system employees after the pandemic.

The findings identified several core concepts and strategies, including helplessness, inadequate risk management, experiences related to life and death, seeking support, and self-care. To uncover HCWs’ perceptions and experiences of PTSD resulting from the COVID-19 pandemic—and to identify practical strategies to alleviate PTSD symptoms—the study explored theoretical frameworks and analyzed field data through thematic analysis, identifying themes, categories, sub-categories, and codes. These insights can inform policymakers in making strategic decisions and developing effective approaches for future epidemics.

Given the vital role HCWs play in caring for and treating patients during pandemics such as COVID-19, it is crucial to understand their perceptions and experiences of PTSD post-pandemic, as well as the long-term impacts on their mental health and potential strategies to support their well-being.

Theme 1: helplessness

We observed that helplessness is a key component of PTSD, encompassing six categories: physical consequences, psychological reactions, feelings of guilt, job-related implications, social consequences, and lack of support. The sense of hopelessness among healthcare workers (HCWs) can be further exacerbated by restrictive measures and policies implemented during the pandemic, which limited or entirely prevented engagement in socio-recreational activities known to benefit physical and mental health. Overall, the persistent hopelessness—driven by heavy workloads, social distancing restrictions, and heightened mortality rates—may significantly contribute to the severity of PTSD symptoms among HCWs.

The findings also highlighted that participants experienced varying degrees of psychological distress, including poor sleep quality, the heavy burden of hospitalized patients, close contact with COVID-19 cases, and the emotional toll of past traumatic events, all of which contributed to feelings of helplessness in coping with the crisis. This psychological distress is associated with adverse occupational outcomes, such as reduced quality of patient care, increased irritability towards colleagues, cognitive impairments affecting clinical performance, and intentions to leave the profession [25, 26].

Physical consequences

In line with this study, other research has shown that physical consequences such as low sleep quality and nightmares are one of the predictors of PTSD during the COVID-19 era [5, 12, 27]. In fact, sleep disorders are observed at a high rate in groups at risk of trauma, which can contribute to the occurrence and maintenance of PTSD [28], highlighting the need to address this issue in healthcare workers. In addition, the high load of hospitalized patients and close contact with patients were other issues identified by HCWs. HCWs are at increased risk of infection and contracting COVID-19 [29], which can lead to mental disorders such as PTSD in them. Another study demonstrated that healthcare workers (HCWs) who reported high levels of psychological distress during the COVID-19 outbreak also experienced various physical health issues, including sleep disturbances, headaches, and other somatic symptoms [34]. Participants commonly reported feelings of extreme fatigue, loss of appetite and energy, as well as lethargy and boredom. These findings highlight the critical need for both individual- and organizational-level interventions aimed at reducing fatigue, chronic stress, and burnout among HCWs responsible for patient care.

Psychological consequences

Almost all participants believed that psychological reactions were common consequences experienced by healthcare workers (HCWs) as a result of the COVID-19 pandemic. Many reported experiencing varying degrees of guilt and self-blame, persistent anxiety, fear of becoming ill, concerns about transmitting the virus to others—especially to spouses and children—obsessive-compulsive behaviors, lack of self-confidence, and even suicidal thoughts, all of which contributed to feelings of helplessness. Worrying about infection was identified as a key stressor for HCWs during the outbreak, given that the risk extended beyond their own health to the well-being of their families [30]. Feizipour et al. [31] found that employees with direct or indirect contact with COVID-19 patients experienced depression, aggression, anxiety, psychosomatic symptoms, poor sleep quality, obsessive behaviors, and suicidal ideation [31]. Similarly, a study by Bismark et al. [32] reported that one in ten Australian employees experienced suicidal thoughts or engaged in self-harm during the pandemic [32]. These outcomes were more prevalent among employees who had friends or family members infected with COVID-19 and among those living alone. Research on non-fatal suicidal behaviors during the pandemic has implicated psychiatric factors, emotional disturbances, depression, home and workplace stress, personality disorders, as well as various psychological, physical, and occupational stressors [33].

Feelings of guilt

In the present study, we found that feelings of guilt contributed to increased helplessness, manifesting in various forms such as guilt over potentially infecting family members, insufficient knowledge, perceived time wasted, and the inability to save patients. Aligned with the present study, a study of Georgieva [34] revealed that one of the strongest predictors of the occurrence of PTSD in the time of COVID-19 was the fear of contracting COVID-19 [34]. A review study also showed that HCW’s fear of infection and transmission of the disease to family, friends and colleagues can lead to PTSD symptoms in them [10]. In a qualitative study, fear to infect family members, choosing work instead of family, inability to fulfill family roles were mentioned as challenges of HCW during COVID-19 era [35]. In line with this study, other studies mentioned the fear of contracting the disease, the fear of transmitting the disease to one’s spouse, children, and others as important predictors of PTSD [36,37,38,39]. The authors found that while healthcare workers (HCWs) fulfilled their professional responsibilities, the dual role of being both HCWs and family members created internal conflict. Participants were primarily concerned about infecting family and friends whom they perceived as vulnerable. Other studies on emergency situations reported that HCWs were worried about anticipated overtime if colleagues were quarantined, as well as the stigma associated with the disease and the health risks to themselves and their families [40], reflecting a broader emotional distress [41,42,43]. Several articles have examined HCWs’ knowledge, attitudes, and behaviors towards COVID-19 patients, highlighting that healthcare workers still harbor fear of the disease and sometimes discriminate against infected patients [44,45,46]. Contributing factors to these attitudes include fear of disease transmission, uncertainty about effective care, and a sense of futility in providing care to patients with potentially severe illness [47]. Therefore, it is essential to give greater attention to the detrimental impact of guilt and fear of contracting COVID-19 on the mental health of HCWs.

Job-related implications

In the present study, participants reported varying degrees of job-related consequences and challenges caused by COVID-19, which likely contributed to feelings of helplessness among healthcare workers (HCWs) and, consequently, to the development of post-traumatic stress disorder (PTSD) symptoms. Several participants expressed intentions to change jobs and reported experiencing burnout and job dissatisfaction. Moreover, our findings indicated that the high workload, particularly during the COVID-19 pandemic, led to a decline in work quality and service delivery, resulting in issues such as work-life imbalance and reduced capacity to perform work tasks effectively. Consistent with these findings, Alinejad et al. demonstrated a significant negative relationship between work-life balance and family functioning and burnout among nurses [48], suggesting that individuals who maintain an appropriate balance between professional and personal life are less prone to burnout. Similarly, Golparvar et al. reported that person-job fit is negatively associated with emotional and occupational exhaustion, and positively associated with job satisfaction and organizational commitment [49]. Thus, nurses who feel a strong connection and interest in their job or department are more likely to endure workplace hardships—such as high workload and stress—and are less susceptible to fatigue and burnout. It is crucial for individuals to consider their job fit and level of interest to mitigate burnout risks. Additionally, engaging in regular physical exercise and recreation emerged as effective strategies for coping with burnout related to COVID-19.

Social implications

Most participants noted that social implications—such as strained interpersonal relationships with patients, social stigma and rejection by patients’ families, taunting and humiliation directed at their families, and reduced social interactions with relatives, friends, and acquaintances—led to feelings of loneliness, isolation, and worthlessness. These experiences ultimately resulted in social rejection and contributed to PTSD symptoms among healthcare workers (HCWs) during the COVID-19 pandemic. These findings highlight the urgent need for HCWs to be more aware of factors that endanger their health. The social implications, particularly stigma and discrimination identified in this study, are generally linked to a lack of public understanding about the disease transmission cycle. Therefore, effective public communication and education are essential—not only to encourage adherence to preventive measures but also to foster genuine respect and cooperation toward frontline HCWs.

Stigma remains an urgent problem for national health systems and has been recognized as a health crisis that HCWs must actively combat [50]. HCW stigmatization is closely associated with both physical and psychological health outcomes; those who anticipated higher levels of stigma reported greater psychological distress and more pronounced somatic symptoms [51]. Several key domains assess social stigma in healthcare, including discrimination and the distress associated with fears of infection and its consequences [52,53,54]. When HCWs are unaware of stigmatizing attitudes and behaviors, the impact of stigma can be particularly severe. Identifying and addressing stigmatizing views and practices is critical, as stigma adversely affects individuals’ self-concept [55, 56], professional quality of life, stress levels, engagement, burnout [57, 58], and life satisfaction [57, 58].

Lack of support

Another important component contributing to symptoms of helplessness associated with PTSD is the lack of adequate support, which includes deficiencies in professional resources, insufficient or unavailable personal protective equipment (PPE), limited financial resources, shortages of human resources, and inadequate preparedness to manage future epidemics. These factors were observed to play a significant role in the emergence of helplessness symptoms among healthcare workers (HCWs). Practical support—encompassing instrumental support, informational support, appraisal support, and social support—represents a crucial resource in efforts to assist the most vulnerable personnel during the COVID-19 pandemic. Although the pandemic altered the modalities of support delivery, collaboration with relevant managers and decision-makers was essential to secure professional support, funding, human resources, equipment, facilities, and other necessary forms of assistance. It has been demonstrated that working in a hospital with low human resources can negatively affect the physical and mental health of HCWs [59]. In fact, exposure to high working hours can lead to the occurrence of PTS in HCWs [60]. In a qualitative study conducted by Romate et al. [35], lack of resources was one of the work-related challenges mentioned by HCWs. Lack of human resources can be caused due to servant being infected with COVID-19, unwillingness to work during the epidemic and abdication [35]. At the same time, it is important to mention that maintaining an adequate healthcare workforce in the COVID-19 crisis requires not only a sufficient number of doctors, nurses, specialists, pharmacists, respiratory therapists and other HCWs, but also requires the ability of each person to take care of a high volume of patients [61]. In another qualitative study, it was found that increased workload, lack of protective equipment, or lack of standard operating procedures were linked to mental health problems and were identified as needs of frontline healthcare workers during the COVID-19 pandemic [62]. As a result of the reduction of work shifts and the subsequent elimination of physical and mental fatigue of nurses, the recruitment of new auxiliary staff in the health medical system can lead to the reduction of PTSD in health system employees [8]. All these issues were mentioned by the participants of this study. These findings emphasize the important role of support and related factors in reducing the risk of helplessness, as well as physical and mental distress, among healthcare workers.

Theme 2: poor risk management

According to the findings, deficiencies in vocational skills training, inadequate anger management, a low sense of security, and the hazardous nature of the workplace contributed to the development of PTSD symptoms among healthcare workers in Iran during the COVID-19 crisis, largely due to poor risk management.

Weakness in vocational skills training

The findings in this category revealed that healthcare workers exhibited significant weaknesses in vocational skills training related to managing the COVID-19 crisis at various levels. These included insufficient training on the coronavirus itself, lack of clear procedures for caring for COVID-19 patients, limited knowledge about the virus, inadequate communication skills with patients, and a general absence of practical and scientific training. The lack of education and information about the virus was identified as a major weakness among medical HCWs in controlling the disease, which contributed to increased workload and the emergence of PTSD symptoms. During the early stages of the COVID-19 outbreak, little was known about the precise mechanisms through which the virus affected both physical and mental functioning. The sudden onset of a life-threatening illness placed extraordinary pressure on healthcare workers [4]. Several studies have shown that concerns regarding staff education about emerging disease trends are significant sources of stress among HCWs. One of the greatest challenges facing healthcare systems worldwide during epidemics is the lack of knowledge about the causes and progression of the disease [21, 47, 63, 64]. Therefore, careful planning to enhance HCWs’ empowerment—through both material and moral support—alongside comprehensive training and provision of necessary information about the disease, increasing the availability of psychologists in hospitals, and equipping HCWs with appropriate crisis management skills can be highly effective in addressing these challenges.

Poor anger management

Most participants noted that poor anger management—including difficulty controlling situations, managing patients’ panic, and reacting impulsively—contributed to their inability to effectively manage the risks posed by the disease during the pandemic. These challenges led to heightened stress levels and increased symptoms of PTSD. Additionally, patients’ violent reactions and confrontations, as well as aggressive and impulsive behavior from both patients and their companions, created significant psychological strain on medical staff. These findings align with previous studies [63, 65,66,67]. Consequently, it is crucial to plan and implement in-service training courses for healthcare workers aimed at enhancing resilience, anger management, and stress coping skills to better prepare them for future epidemics.

Low sense of security

The findings of a recent study revealed that the majority of participants experienced a strong sense of insecurity. They reported intense fear related to close contact with infected or suspected patients, which sometimes escalated into aggressive behavior by patients and their companions. These conditions heightened their concerns about potentially infecting family members, often resulting in forced social isolation and a reduction in social interactions, consistent with findings from other studies [68, 69]. Healthcare workers play a critical and demanding role as frontline responders in any epidemic. They protect lives while confronting numerous threats, including psychological and physical violence, long working hours, stigma, insomnia, concerns about their own health and that of their families, low energy, job-related burnout, lack of protective equipment, and PTSD [69]. Therefore, it is essential to ensure the security of healthcare workers not only to safeguard patients but also to guarantee the safety and well-being of the workers themselves [69, 70]. The increasing emphasis on occupational safety within healthcare systems has led to ongoing monitoring and improvements in safety practices for healthcare workers. Providing accessible, practical guidance on coping strategies and stress management within healthcare systems remains a critical and challenging task, yet it is vital for enhancing quality of life and work, and for preventing PTSD among healthcare workers.

The harmful nature of the workplace

Participants reported exposure to physical attacks and violence, rude behavior from patients, and occasionally even insulting conduct from superiors or colleagues, which caused them to gradually withdraw socially—a known precursor to the development of PTSD. Consistent with our findings, other studies have documented that healthcare workers (HCWs) are often subjected to violence from patients and their companions, resulting in elevated levels of PTSD symptoms [71, 72]. Furthermore, research indicates that senior HCWs tend to exhibit fewer symptoms of PTSD and burnout compared to their junior counterparts [73]. This may be explained by the possibility that nurses experiencing persistent post-traumatic stress reactions tend to leave the profession earlier, while more resilient individuals remain. Multiple studies have highlighted that the ongoing demands of the COVID-19 pandemic continue to exert significant negative effects on the mental health of HCWs [63, 65, 67, 74, 75].

Given that workplace violence is a known predictor of PTSD symptoms, training HCWs in violence management has been shown to be effective. Specifically, there is evidence that training HCWs to anticipate, recognize, and respond appropriately to violent behavior—as well as establishing protocols for interacting with aggressive patients that eliminate unsupervised interventions—can prevent or mitigate PTSD symptoms of traumatic events [76]. Lee et al. found that nurses who participated in violence management courses experienced a reduced risk of developing PTSD symptoms after workplace violence incidents. They suggested that gradual, systematic training over several years offers HCWs repeated opportunities to refine violence management skills, thereby enhancing self-esteem and reducing the psychological impact [64]. Additionally, a cross-sectional study by Hamama-Raz et al. investigating the relationship between PTSD symptoms, age, and length of service found that stressful experiences such as workplace violence tend to recur in hospital environments [77]. Shi et al. further reported that among HCWs subjected to physical violence in hospital settings, PTSD symptom severity was inversely correlated with levels of objective social support and the effective utilization of support resources [78].

This suggests that cumulative exposure to violence may increase PTSD vulnerability over time, which could explain why older, more experienced HCWs often report higher PTSD symptoms than younger, less experienced colleagues.

Our findings align with growing evidence regarding the profound adverse mental health consequences of the COVID-19 pandemic on HCWs. We emphasize the severe distress experienced by many HCWs, manifesting as PTSD symptoms, depression, anxiety, and stress. Moreover, participants described the traumatic nature of their workplace environments, which contributed to feelings of disappointment, failure, and intentions to leave the profession and patient care roles.

Theme 3: life and death experiences

We observed that life and death experiences are a vital component of PTSD in HCWs. In addition, disappointment with life and the future and unexpected death witness contributed to increasing PTSD in HCWs.

Disappointment with life and the future

Under the category disappointment with life and the future, subcategories include a vague or highly negative perception of the future, lack of life planning post-pandemic, diminished motivation to continue living, loss of interest in life, and recurrent rumination on traumatic events. The critical nature of the COVID-19 pandemic—marked by threats to personal and colleagues’ safety, a continuous rise in infections, increasing mortality, and the absence of effective treatments or vaccines—contributed significantly to the onset of mental health disorders such as PTSD among healthcare workers (HCWs [8]. A qualitative study by Khezri et al. identified several PTSD-related experiences among nurses, including persistent recollection of traumatic events, denial of colleagues’ deaths, absence of life plans, intrusive distressing thoughts, irritability, unresolved grief, frequent mental flashbacks of traumatic scenes, fear of receiving bad news, sudden loss of loved ones, and avoidance of intensive care units [79]. The present study similarly found that past traumatic experiences and pre-existing psychological disorders contributed to ongoing mental distress. This aligns with previous research indicating that prior psychiatric conditions are significant risk factors for PTSD during public health crises such as COVID-19, SARS, and MERS [54, 72]. Furthermore, social distancing measures exacerbated feelings of loneliness and disrupted grieving processes, particularly for HCWs who experienced the unexpected loss of family members or close colleagues due to COVID-19. Such experiences can fundamentally alter one’s perception of the world as a safe and predictable place, and diminish trust in supervisors as sources of protection. HCWs may find themselves overwhelmed by grief and unable to adequately support the emotional needs of their own families. In these critical circumstances, the emotional distress of bereaved individuals may be easily overlooked. Organizational support—particularly from managers and supervisors—can play a vital role in helping HCWs navigate grief by fostering creative ways to honor the deceased, providing education on the grieving process, and cultivating a compassionate environment in which staff feel supported and encouraged to share their experience [80]. Given that psychological distress is defined as a state of emotional suffering caused by exposure to stressful events that threaten one’s physical or mental health [67], it is essential that health systems prioritize the psychological wellbeing of HCWs.

Witnessing unexpected deaths

The findings of the present study indicate that participants reported experiences of witnessing the unexpected deaths of colleagues, patients, and even loved ones—events perceived as extremely stressful and strongly associated with the emergence of PTSD symptoms. According to both the results of this study and the participants’ narratives, individuals exposed to direct risk during the pandemic experienced more acute distress at the time of the event, sustained emotional arousal, heightened frustration, and increased signs of PTSD, alongside growing disillusionment with their work environment. Prior research similarly underscores that witnessing the sudden death of loved ones or colleagues constitutes a significant psychological burden for healthcare workers (HCWs), frequently serving as a precipitating factor in the development of PTSD [66,67,68, 75]. While HCWs recognize their duty to support the bereaved families of deceased patients, they also carry the weight of their own professional and personal grief—grief that has been intensified by the unprecedented nature of the COVID-19 pandemic. Amid the overwhelming demands and rapid spread of the virus, concerns for personal safety, the well-being of colleagues, and the health of loved ones often came into tension with HCWs’ professional obligations. In light of the mental health risks associated with bereavement in the context of COVID-19, it is essential that HCWs be adequately prepared for the reality of patient and colleague death, and that they are equipped with the resources and support necessary for a healthy grieving process. Equally important is the responsibility of healthcare systems and institutional leadership to anticipate and address the psychological toll of bereavement. Organizational support mechanisms should be implemented to prepare HCWs—especially those newly entering the profession—who may lack experience with managing personal or professional grief and who are beginning their careers in a clinical landscape marked by high levels of disruption and emotional strain. Systematic preparation and ongoing psychological support are crucial to ensuring that HCWs are not only able to fulfill their roles effectively, but also to preserve their own mental health in the aftermath of loss.

Theme 4: seeking support

This theme includes four categories: social support, psychological support, and organizational support.

Social support

In the category of social support, participants identified several key sources: improved interpersonal communication, family support, support from colleagues and supervisors, media support, and broader community support. These findings reflect the recognition that recovery from loss is significantly facilitated by social support and the maintenance of cultural, familial, communal, spiritual, and religious customs surrounding death and mourning. Prior research has demonstrated the protective effect of social support in mitigating psychological harm among healthcare workers (HCWs) during the COVID-19 pandemic [81, 82]. Consistent with these findings, a qualitative study by Romate et al. [35] highlighted the importance of social support as a central theme in understanding the experiences, perceptions, and needs of frontline HCWs in public hospitals in India. Participants in that study expressed a strong need for support from their social networks—including family, friends, supervisors, and colleagues [35]. Additional studies have identified high levels of social support as a key independent protective factor against the development of PTSD symptoms among HCWs [83]. For instance, Zhang et al. [83] found that HCWs who received family support during the pandemic were significantly less likely to experience PTSD symptoms. Similarly, Pan et al. [84] reported a strong inverse relationship between family support and PTSD prevalence among HCWs, which aligns with the findings of the present study [84]. A study conducted in Singapore further corroborates these conclusions, identifying multiple factors that help reduce PTSD symptoms: (a) clear and consistent communication regarding safety protocols; (b) opportunities for emotional expression and consultation; (c) familial support; (d) support from supervisors and colleagues; (e) reciprocal feedback between HCWs and their institutions; and (f) engagement in religious practices [85]. Taken together, these findings underscore the importance of providing comprehensive and multidimensional support systems—including familial, professional, community, and organizational support—to safeguard the mental health of HCWs.

Psychological support

Psychological support emerged as another essential strategy for enhancing support to healthcare workers (HCWs) facing post-traumatic stress disorder (PTSD) during the COVID-19 crisis. Key elements include reducing the stigma associated with COVID-19, facilitating rehabilitation after crisis situations, and strengthening coping skills during periods of difficulty and distress. Throughout the pandemic, HCWs often faced social rejection and avoidance by others who feared contagion—an experience that was frequently perceived as stigmatizing and isolating [43]. This social isolation is a recognized risk factor for the onset of PTSD [88]. Feelings of uncertainty, rejection, and stigma in HCWs’ residential environments, stemming from their association with hospitals, further compounded their vulnerability to PTSD symptoms [10].

In a qualitative study by Poh et al., HCWs explicitly expressed the desire for greater attention to their mental health needs, emphasizing the importance of access to psychological interventions. These included counseling services, telephone helplines, and self-help resources, all of which were seen as vital tools for psychological resilience and recovery [90]. The importance of coping skills for managing distress and adversity was also highlighted in the present study and is consistent with findings from earlier research [24, 79].

Extensive evidence suggests that psychological support is a critical predictor of work-related stress among emergency care workers [91, 92]. It is typically defined as the perception that one both needs and receives help from others, and that one belongs to a broader network of support [91]. A Dutch study [93] previously found a strong association between psychological support in the workplace and reduced incidence of PTSD among emergency care workers. Similarly, other studies [93, 94] have demonstrated that emotional support—particularly from managers and colleagues—is the most common form of assistance inversely associated with PTSD symptoms. In essence, the more emotional and psychological support HCWs receive (e.g., having confidants, being listened to, and experiencing empathy following a traumatic event), the lower their risk of developing or exacerbating PTSD symptoms [95, 96].

Organizational support

Organizational support was another key strategy proposed by healthcare workers (HCWs) to mitigate PTSD during the COVID-19 crisis. Participants emphasized the importance of ongoing monitoring and screening of HCWs, systematic workplace risk assessments, the implementation of regular training programs, the provision of short work breaks, formal recognition of HCWs’ contributions, access to psychotherapy, training in psychosomatic techniques, and opportunities for group discussions on stressful experiences and events.

Consistent with the findings of this study, Sirois et al. [89] found that organizational support—along with positive work attitudes, timely and accurate information about disease outbreaks, access to adequate protective equipment, and systematic workplace risk assessments and training—was associated with lower levels of psychological distress in HCWs during infectious disease crises [34]. Similarly, routine health check-ups, as part of a proactive monitoring strategy, can help identify signs of psychological distress and assess whether appropriate coping strategies are being employed [97].

Organizations may employ validated screening tools—such as the PTSD Checklist for assessing post-traumatic stress symptoms, the Prolonged Grief Disorder Scale for persistent grief reactions, and the Patient Health Questionnaire (PHQ) for detecting symptoms of depression—to identify HCWs at heightened risk of mental health challenges [98]. Healy et al. [99] further confirmed the efficacy of supportive management practices in mitigating the psychological impact of workplace trauma. Their findings highlighted that empathetic, communicative, and anticipatory leadership fosters a supportive organizational culture—one that values teamwork, interdisciplinary collaboration, and the recognition of HCWs’ psychosocial needs following traumatic experiences.

Such a supportive environment, characterized by a strong social network of management and personnel, may serve as a psychological buffer against the detrimental effects of sustained occupational stress. Creating a safe narrative space—where HCWs can openly express their emotions and share their experiences of traumatic events—has also been identified as an effective strategy for reducing PTSD symptomatology [71].

. In light of the ongoing threat of future pandemic waves, it is imperative to sustain and strengthen mental health support for HCWs. Healthcare leaders should adopt evidence-based, anticipatory strategies to prepare workers for high-stress scenarios. These include training HCWs in effective coping mechanisms, minimizing the development of PTSD and broader psychological distress, and promoting a culture of support among health professionals.

Theme 5: Self-care

Self-care emerged as a practical and essential strategy for mitigating symptoms of PTSD among healthcare workers during the COVID-19 crisis. This approach encompassed taking personal health responsibility, adopting a healthy lifestyle, and actively building resilience to buffer against PTSD.

Health responsibility

Health responsibility among healthcare workers (HCWs) encompassed various dimensions, including enhancing health literacy, engaging in self-care to prevent illness, caring for family members during periods of wellness, and actively participating in health-related decision-making. Consistent with the findings of the present study, prior research has underscored the critical role of health literacy and the dissemination of accurate, timely information in managing public health crises. Effective communication of health risks is a pivotal element in epidemic control, as it not only improves public awareness and reduces hazardous behaviors but also helps maintain trust in health systems. Conversely, misinformation and negative media portrayals during the COVID-19 pandemic heightened fear among HCWs and their families, ultimately undermining healthcare delivery [35]. The early proliferation of false information via mass media posed significant challenges to individual and systemic health outcomes [86]. Therefore, efforts to improve health literacy represent a vital self-care strategy. Although promoting COVID-19-related knowledge across diverse populations presents challenges, such initiatives are instrumental in enhancing adherence to precautionary measures [87]. Moreover, low perceived control is recognized as a trans-diagnostic vulnerability factor contributing to negative emotional states such as anxiety and stress [88]. he literature suggests that fostering a sense of control—achievable at the organizational level through the provision of adequate resources enabling HCWs to manage infection risks—is essential for mitigating health-related distress [89]. These findings are consistent with the findings of the present study.

Healthy lifestyle

As the COVID-19 pandemic spread and persisted in Iran, it became increasingly evident that healthcare workers (HCWs) were unable to fully manage the escalating work pressure alongside symptoms of anxiety and PTSD. Consequently, many HCWs experienced a range of physical and psychological health problems. Adopting a healthy lifestyle has emerged as a direct and effective approach to promoting self-care and mitigating PTSD symptoms. The pandemic itself acted as a catalyst for change, encouraging the implementation of innovative self-care strategies focused primarily on avoiding high-risk behaviors, maintaining physical strength, undergoing regular testing, and dedicating time to sports and recreational activities. Participants in the present study emphasized that prioritizing a healthy lifestyle plays a crucial role in reducing PTSD symptoms and enhancing self-care among HCWs. Although significant advancements have been made in disease treatment, prevention through a healthy lifestyle remains one of the most effective defenses against COVID-19. Public health measures such as hygiene adherence and social distancing are essential to limiting viral transmission, while expanded testing capacity facilitates early case identification and containment [90]. Moreover, engaging in physical activity and recreation has been identified as a valuable coping mechanism for PTSD. Weight et al. [91] found that sports have beneficial effects on general health and provide the opportunity for positive interaction with others [91]. Furthermore, Soltaniyan and Aminbeidokhti [92] reported that HCWs who participate in sports exhibit lower levels of emotional fatigue compared to their non-athletic peers, regardless of gender [92]. Similarly, a study by Lange and Nakamura [93] show that while no univalent food, nutrient, or dietary supplement can prevent COVID-19, a moderate diet containing adequate amounts of a variety of macronutrients and micronutrients s essential for an optimally functioning immune system Alcohol and tobacco consumption have harmful effects on the immune system. Therefore, controlling body weight, reducing smoking and limiting alcohol consumption are important preventive measures. In addition, adequate restorative sleep is required for proper immune system function. As a result, appropriate lifestyle changes related to nutrition, exercise, sleep, smoking, and alcohol consumption may help to change the distribution of the risk of infection in the population and ultimately help to prevent the severe disease of COVID-19 [93]. Since preventive behaviors have been crucial during the pandemic to reduce disease, maintaining a healthy lifestyle continues to be identified as essential preventive behavior.

Resilience against PTSD

According to reports from healthcare workers (HCWs), resilience serves as a practical approach to mitigating symptoms of PTSD by enabling adaptation to stressors, adjusting motivations, regulating emotions, exercising self-control, fostering spiritual attachment, and promoting post-traumatic growth. Resilience is understood as a capacity that HCWs can develop and cultivate to survive and thrive amid the complexities encountered in hospital and clinical settings [94, 95]. The scientific literature on COVID-19’s impact on mental health in Iran reflects a lack of comprehensive understanding of the major risks posed by the pandemic, compounded by the presence of unreliable information. Given that social support is crucial for coping with occupational stress, fostering a healthy lifestyle alongside enhancing HCWs’ resilience emerges as a key strategy for improving their mental health outcomes. Similarly, Abdelsadig Mohammed et al. [96] identified personal characteristics such as resilience and optimism, as well as the implementation of effective coping strategies, as significant factors in reducing stress levels [96]. Indeed, when individuals adopt a positive attitude toward their work and environment, their physical and psychological well-being, as well as overall quality of life, tend to improve. Consequently, HCWs who demonstrate greater interest in their job or workplace are more likely to endure difficult conditions and experience less fatigue. Research by Moradi et al. [97] highlights the importance of screening for personality traits such as high neuroticism and low agreeableness among HCWs in clinical roles, suggesting that targeted interventions to modify these traits could be effective in preventing post-traumatic stress [97]. Furthermore, Musavi Asl and Parooie [98] showed that screening combined with positive psychology interventions enhances nurses’ sense of coherence, resilience, and psychological well-being [98]. Omidi et al. (2022) also found that support from family, colleagues, and managers, as well as the subjective sense of being supported, improves quality of life and bolsters coping capacity in stressful situations [99]. Social support from family and close individuals is particularly vital during crises like pandemics, where empathy, companionship, active listening, and assistance in reducing individual responsibilities provide a strong buffer that enhances resilience and helps HCWs manage the heightened pressures they face.

Limitations of the study

The findings of the present study cannot be generalized to the broader population due to the inherent limitations of qualitative research. Nonetheless, the results provide valuable insights into the perceptions and experiences of healthcare workers (HCWs) within the Iranian context, which may share similarities with HCWs in other countries. Owing to a limited pool of eligible participants, the researchers were unable to conduct focus group discussions, and data collection was therefore restricted to individual semi-structured interviews. Additionally, the inclusion criteria may have introduced selection bias, as it is possible that participants were more inclined to participate due to their direct experiences with mental health challenges and PTSD symptoms, as well as their desire to share their perspectives. This is reflected in the notably rich and detailed responses to open-ended questions, indicating the depth of participants’ emotions and the importance they attached to the opportunity to convey their views. Such extensive, nuanced feedback likely reflects both the frustration and concerns of Iranian HCWs regarding their mental health and workplace challenges. To enhance the generalizability of these findings, it is recommended that this qualitative work informs the development of a structured survey that could be distributed to a greater sample of study participants, the results could then perhaps be generalized to other study backgrounds.