What Gave Us Strength: Perspectives From Aboriginal Community Controlled Health Services Staff on Working During the COVID-19 Pandemic

Abstract

Introduction:

There is limited evidence on the social and emotional wellbeing (SEWB) needs of staff working at Aboriginal Community Controlled Health Services (ACCHS) in Australia. The current study employed qualitative research methods to explore ACCHS staff’s experience during the COVID-19 pandemic and its impact on their SEWB, and to identify factors that provided strength.

Methods:

Yarning Circles and one-on-one Yarns were employed to explore clinical and non-clinical ACCHS staff’s experiences. Participants included staff who identified as Aboriginal and/or Torres Strait Islander, or were non-Indigenous. Thirty-one staff from 5 ACCHSs participated in 7 Yarning Circles and 3 one-on-one Yarns, between December 2021 and June 2022. Staff shared their perspectives on (i) ACCHSs’ responses, (ii) community and staff reaction, and (iii) impact of service-level changes on their SEWB. Data was analysed using thematic analysis.

Results:

The main themes identified as impacting ACCHS staff’s SEWB were: (1) constant change and prolonged stress, (2) community as a source of strength, (3) leadership safeguarding community and staff, (4) pride in their response, and (5) opportunities to lessen psychological toll. Staff were motivated by the seamlessness of their roles. They were motivated by positive work environment, reliable infection control measures, and resourceful leadership. Major concerns included fear of contracting and transmitting infection, and long-term consequences of disrupted patient care. There was a lack of awareness among staff about formal SEWB support, and if aware they were hesitant to use services due to cultural safety and privacy concerns. A major source of support for ACCHS staff was peer support.

Conclusion:

During the COVID-19 pandemic ACCHS staff experienced prolonged stress exacerbated by constant changes, inconsistent information, misinformation, and lack of resources. Staff found strength in community, cultural connections, and management’s response. Informal peer support was important in upholding ACCHS staff’s SEWB, suggesting that structured peer support can provide ongoing support.

Keywords

aboriginal community controlled health services primary care Aboriginal health healthcare staff social and emotional wellbeing COVID-19 pandemic

Introduction

Infectious disease outbreaks requiring drastic infection control measures can negatively impact the social and emotional wellbeing (SEWB) of healthcare workers (HCW).^1,2 The impacts are exacerbated by high-risk work environment, strict quarantine conditions, and work-related stress.¹ The 2019 coronavirus (COVID-19) pandemic caused a global public health crisis with rapid spread of infection, and high morbidity and mortality rates. Globally, stringent infection control measures were introduced rapidly with significant disruptions in usual healthcare services.^3-5

Experiences of Australian Healthcare Workers During COVID-19 Pandemic

During the COVID-19 pandemic HCWs had to rapidly implement infection control measures while managing high caseload. The subsequent increase in work pressure among HCWs was associated with mental health outcomes such as poor sleep, psychological distress, post-traumatic stress disorder (PTSD), anxiety, and depression.^6,7 Even though the morbidity and mortality rates from COVID-19 remained relatively low in Australia, the SEWB impact for HCWs working during the pandemic was similar to that in other countries. In April-May 2020, 21% of Australian HCWs reported moderate to severe levels of depression, 20% reported anxiety, and 29% met the criteria for PTSD.⁸ As the pandemic progressed, the burden shifted but remained significant; by March-April 2021, 15% of HCWs reported moderate to severe depression, 10% reported anxiety, and 13% were experiencing stress. The proportion increased again in September-October 2021, when 31% reported moderate to severe depression, 19% reported anxiety, and 25% were stressed.⁹

Experiences of Healthcare Staff in Aboriginal Community Controlled Health Services

A group of HCWs that is currently underrepresented in health research is HCWs working at Aboriginal Community Controlled Health Services (ACCHS). As staff within comprehensive primary healthcare organisations established by and for Aboriginal communities, ACCHS staff deliver culturally responsive, holistic care tailored to the needs of Aboriginal and Torres Strait Islander peoples.¹⁰ Their roles frequently extend beyond clinical care, as they support community members outside regular working hours and contribute to continuity of care, patient engagement, and culturally safe healthcare experiences.¹¹ Their work is often associated with improved health outcomes, increased patient attendance, and higher rates of treatment completion.¹²

ACCHS staff’s experiences, especially of those who identify as Aboriginal and Torres Strait Islander, are unique due to the seamlessness between their professional and personal self, with their roles often continuing beyond the ACCHS premises.^13,14 Even prior to the COVID-19 pandemic, ACCHS staff were working under challenging circumstances due to limited funding, resources, and workforce.¹³ The pandemic further increased pressure on ACCHS staff, however, there is limited evidence of its impact on their SEWB. In our cross-sectional study with 92 HCWs from 3 ACCHSs in New South Wales (NSW), Australia we found high levels of emotional exhaustion in 25% and psychological distress in 30% of HCWs.¹⁵ The current study employs qualitative research methods to develop a deep understanding of ACCHS staff’s experience during the COVID-19 pandemic and impact on their SEWB, and to identify factors that gave them strength.

Methods

Study Design

The study design was informed by the principles of research collaboration with Aboriginal and Torres Strait Islander communities.¹⁶ Aboriginal and Torres Strait Islander researchers led the study design, data collection, analysis, and interpretation of findings. Yarning methods, including Yarning Circles and one-on-one Yarns, were employed to explore HCWs’ experiences during the COVID-19 pandemic, providing a culturally safe and non-judgemental environment to share their experiences.¹⁷ To guide the Yarning Circles and one-on-one Yarns, Yarning Circle topic guide was co‑designed with ACCHSs (Supplemental Material S1). HCWs were asked to share their perspectives on (i) ACCHSs’ responses to the pandemic, (ii) community and HCW reaction to COVID-19, and (iii) impact of rapid service-level changes on staff’s SEWB.

Yarning is an established and culturally appropriate process among Aboriginal and Torres Strait Islander people that centres on sharing knowledge, deep listening, and collective interpretation.¹⁷ It supports in-depth, relational conversations in a relaxed culturally grounded manner, offsetting Western research processes offering limited flexibility and cultural sensitivity.^17,18 In research, Yarning operates as a relational and reflexive practice in which trust, accountability, reciprocity, and 2‑way learning are actively cultivated, requiring researchers to be transparent about their positionality and responsibilities within the relationship.¹⁹ It privileges Indigenous knowledge systems and ensures that meaning‑making occurs through culturally grounded, ethically accountable dialogue.^17-19

Study Setting and Participants

The study was conducted between December 2021 and June 2022 in 5 ACCHSs in urban; (1), regional (2) and remote (2) NSW. All staff at the partner ACCHS were invited to participate, via emails sent by ACCHS CEOs or Research Officers employed through this study. Staff were eligible to participate if they were: ≥18 years old, employed at one of the partner ACCHSs and provided written consent to participate. Any staff could participate in the study, regardless of cultural identity, their role, duration at ACCHS, or employment status (eg, permanent or temporary, part-time, or full-time). Participants were required to provide written consent; they were informed that participation was voluntary and that they could withdraw from the study at any stage. There was a requirement that staff were employed at the partner ACCHS during the COVID-19 pandemic.

Positionality

The research team comprised of 1 Aboriginal and Torres Strait Islander (CA.C), 8 Aboriginal (SB, DW, CH.C, JN, KW, LW, NS, and MD), and 2 non-Indigenous (SN and PL) researchers, working in ACCHSs and academic settings. Six Aboriginal researchers (DW, CH.C, JN, KW, LW, and NS) and 1 non-Indigenous researcher (PL) worked in ACCHSs. Three of the Aboriginal and Torres Strait Islander researchers (CA.C, SB, and MD) and 1 non-Indigenous researcher (SN) worked in academic settings. The non-Indigenous researchers in the team have experience working with Aboriginal and Torres Strait Islander peoples in health and research settings, with training in cultural safety and culturally sensitive research methodologies.

Research Process

Yarning sessions were conducted with 31 ACCHS staff based in urban, regional, and remote NSW. Sample size was determined by data saturation, stopping recruitment once additional Yarning sessions no longer produced new insights. Pragmatic considerations including minimising burden on ACCHS staff during the COVID‑19 response and maintaining culturally safe, participant‑led Yarning environments further shaped the sample size. Participants were predominantly Aboriginal and Torres Strait Islander, and included a mix of clinical and non-clinical staff. Most of the non-Indigenous participants lived and worked in the local communities, and had established relationships with community members. Seven Yarning Circles and 3 one-on-one Yarns were conducted. The Yarning Circles were conducted face-to-face at the ACCHS premises, and 2 one-on-one Yarns took place via video conferencing. The face-to-face sessions were audio-recorded and transcribed verbatim while the video conferencing sessions were recorded using field notes.

All sessions were facilitated by an Aboriginal and Torres Strait Islander researcher (CA.C) in partnership with a non-Indigenous researcher (SN), combining cultural expertise and collaborative research practice. Deep listening and participant‑led pacing were used to minimise researcher influence, while CA.C and SN maintained transparency about their positionalities and responsibilities to reduce bias and support ethical, relational engagement. To support reflexivity, peer debriefing and reflexive note‑taking were integrated throughout the Yarning Circles. After each session, CA.C and SN met for peer debriefs to reflect on facilitation, emerging interpretations, and how their roles and positionalities as public health researchers may have shaped the Yarning process. Reflexive notes documented observations, methodological decisions and reflections on power, relationships, and context.

Data Analysis

Data was coded and analysed in NVivo using Braun and Clarke’s 6 stage method for thematic analysis.²⁰ CA.C reviewed all the transcripts for accuracy and familiarisation before undertaking inductive coding to identify patterns across the dataset. Coding decisions were refined through analytic notes and comparison within and across transcripts. Preliminary themes were developed by CA.C by grouping related codes and reviewing them against the full dataset. CA.C and SN then collaboratively refined and named the final themes, ensuring that interpretations were grounded in participants’ accounts and informed by attention to cultural context, relational accountability, and the researchers’ positionalities. Once the analysis was complete, the findings were reported back to partner ACCHSs.

Ethics Approval

Ethics approval for the study was obtained from the University of New South Wales ethics committee (HC210540) and the Aboriginal Health and Medical Research Council of NSW (1834/21).

Results

The findings reflect: challenges ACCHS staff faced during the pandemic and associated emotional toll; sources of strength and how these inspired HCWs; and reported opportunities for improvement (Figure 1). Table 1 shows that the main themes identified as impacting ACCHS staff’s SEWB during the COVID-19 pandemic were: (1) constant change and prolonged stress, (2) community as a source of strength and motivation for HCWs, (3) ACCHS leadership safeguarded community and HCWs, (4) the pride HCWs felt from their response to the pandemic, and (5) opportunities reported by HCWs to lessen the psychological toll of the pandemic.

Figure 1.

Staff experiences during COVID-19 pandemic.

Table 1.

Experiences of ACCHS Staff During the COVID-19 Pandemic.

	Themes	Subthemes	Illustrative examples
Challenges	1. Constant change and prolonged stress Staff managed constant service-level changes that led to uncertainty, exhaustion, and difficulty disconnecting from work.	1.1. Information overload 1.2. New rules of engagement 1.3. Impact of isolation 1.4. Vaccination rollout and vaccine concerns	“The rules kept changing every fortnight . . . there was a lot of confusion.” (Remote) “We were all stretched . . . stepping out of our usual job roles to assist.” (Regional) “I think there was a bit of [vaccination] hysteria right at the beginning and that was probably because there was not as much information available.” (Remote)
Sources of strength	2. Community as a source of strength and motivation for staff Staff saw their role as community members as a constant source of strength, comfort, and purpose during difficult times.	2.1. Duty: responsibility to community 2.2. Belonging: being part of the community	“We did home visits to check on them . . . it gave them a bit of one-on-one to ask questions when we’d go and drop off things.” (Remote) “Seeing the Elders . . . fills my cup.” (Urban) “Staff and community to me are almost like one . . . to me [they] are like, linked.” (Urban)
	3. ACCHS leadership safeguarded community and staff Staff had confidence in leadership and their response to the pandemic.	3.1. Leadership reputation 3.2. Response to the pandemic response 3.3. Information management 3.4. Leadership accessibility	“There was enough protocols in place to feel safe.” (Remote) “Whatever information they had, they relayed to us.” (Regional) “Senior management was good. Whatever we wanted, our manager was there.” (Remote)
	4. Staff were proud of their response to the pandemic Staff viewed having endured the COVID‑19 pandemic as a source of strength and validation, highlighting shared burden, staff resilience, camaraderie, and strong work ethic.	4.1. Work ethic: stepping up 4.2. Resilience: Staying strong 4.3. Camaraderie: Supporting one another	“Even though we were short staffed every single staff member put their hands up . . . we were working here, there, and everywhere.” (Remote) “I always reminded myself that I’m not going through it, everybody is going through it and I’m not alone.” (Remote) “We all pulled together working as a team . . . it gave me a chance to forge relationships with staff from other teams.” (Regional)
Opportunities reported by staff for improvement	5. Opportunities reported by staff to lessen the psychological toll of the pandemic Staff identified need for better support systems, noting burnout, persistent stress, limited opportunities to decompress, and a desire for improved work‑life balance and job satisfaction.	5.1. More staff to spread the load 5.2. Fostering a self-care mindset 5.3. Accessible and culturally safe SEWB support 5.4. Opportunities to decompress	“More staff is what we need . . . those phones ring all day every day.” (Regional) “It’s great that clients are our priority, but I had to keep reminding people (staff) that they were at risk of collapsing.” (Urban) “A problem was the lack of support to offer our staff . . . the resources just weren’t there for the organisation to be able to offer.” (Urban).
	Themes	Subthemes	Illustrative Examples
Challenges	2. Constant change and prolonged stress Staff managed constant service-level changes that led to uncertainty, exhaustion, and difficulty disconnecting from work.	5.1. Information overload5.2. New rules of engagement5.3. Impact of isolation5.4. Vaccination rollout and vaccine concerns	“The rules kept changing every fortnight . . . there was a lot of confusion.” (Remote)“We were all stretched . . . stepping out of our usual job roles to assist.” (Regional)“I think there was a bit of [vaccination] hysteria right at the beginning and that was probably because there was not as much information available.” (Remote)
Sources of strength	6. Community as a source of strength and motivation for staff Staff saw their role as community members as a constant source of strength, comfort, and purpose during difficult times.	2.1. Duty: responsibility to community2.2. Belonging: being part of the community	“We did home visits to check on them . . . it gave them a bit of one-on-one to ask questions when we’d go and drop off things.” (Remote)“Seeing the Elders . . . fills my cup.” (Urban)“Staff and community to me are almost like one . . . to me [they] are like, linked.” (Urban)
	7. ACCHS leadership safeguarded community and staff Staff had confidence in leadership and their response to the pandemic.	3.1. Leadership reputation3.2. Response to the pandemic response3.3. Information management3.4. Leadership accessibility	“There was enough protocols in place to feel safe.” (Remote)“Whatever information they had, they relayed to us.” (Regional)“Senior management was good. Whatever we wanted, our manager was there.” (Remote)
	8. Staff were proud of their response to the pandemic Staff viewed having endured the COVID‑19 pandemic as a source of strength and validation, highlighting shared burden, staff resilience, camaraderie, and strong work ethic.	4.1. Work ethic: stepping up4.2. Resilience: Staying strong4.3. Camaraderie: Supporting one another	“Even though we were short staffed every single staff member put their hands up . . . we were working here, there, and everywhere.” (Remote)“I always reminded myself that I’m not going through it, everybody is going through it and I’m not alone.” (Remote)“We all pulled together working as a team . . . it gave me a chance to forge relationships with staff from other teams.” (Regional)
Opportunities reported by staff for improvement	9. Opportunities reported by staff to lessen the psychological toll of the pandemic Staff identified need for better support systems, noting burnout, persistent stress, limited opportunities to decompress, and a desire for improved work‑life balance and job satisfaction.	5.1. More staff to spread the load5.2. Fostering a self-care mindset5.3. Accessible and culturally safe SEWB support5.4. Opportunities to decompress	“More staff is what we need . . . those phones ring all day every day.” (Regional)“It’s great that clients are our priority, but I had to keep reminding people (staff) that they were at risk of collapsing.” (Urban)“A problem was the lack of support to offer our staff . . . the resources just weren’t there for the organisation to be able to offer.” (Urban).

Constant Change and Prolonged Stress

Staff navigated rapidly changing information, safety protocols, the emotional toll of isolation, and community concerns about vaccines. The constant demands created sustained uncertainty, exhaustion, and an inability to fully disconnect from work.

Information Overload

Staff noted that regular, complex, and inconsistent information from mainstream and social media created confusion and mistrust among community members. Media amplified community concern, especially early in the pandemic.

If you did get COVID, you were going to die, as the media portrayed it . . . They showed pictures, going to end up in the ICU with a tube down your throat. (Remote) (Verbatims from regional staff, remote staff and urban staff are referred to as regional, remote and urban in this section of the paper).

As a trusted community healthcare service, staff described ACCHSs as taking on responsibility for explaining events as they unfolded and what it meant for community. As the conduit between the ACCHS and community, staff had limited opportunities to “switch off” after work.

New Rules of Engagement

Having to adapt to new COVID-19 safety protocols, within and outside the ACCHSs, was disorienting and frustrating for community and staff.

It was frustrating for the community as well that they couldn’t understand why us, as a health service, couldn’t see them face-to-face, and we were getting a lot of anger from community regarding that . . . it’s taken a toll. (Regional)

The rules kept changing every fortnight. Then the [NSW Health] hotline was even worse . . . there was a lot of confusion about the rules. (Remote)

While they understood the importance of safety protocols, adhering to them was described as tedious. For a few staff, being pulled away from their usual roles left them feeling like their skills were underutilised. Seconding of staff to undertake COVID-19 specialised tasks (eg, Polymerase Chain Reaction (PCR) tests, vaccination) added further physical burden.

We were all stretched, like we were all stepping out of our usual job roles to assist. (Regional)

As community members themselves, staff constantly feared spreading the virus and worked hard to protect the community.

Any impact it [COVID-19] has on staff has an impact on community and vice versa. (Urban)

Some staff were concerned about the impact of reduced healthcare access, and harboured guilt about perceived compromised care due to the limited access community had to the ACCHS and suspension of services.

It was hard for us in our role because we do so much community engagement . . . that just stopped . . . that made us feel, well, like we were sort of letting them down because we couldn’t give them what they need. (Urban)

Limited face-to-face appointments were considered not to meet cultural needs of Aboriginal and Torres Strait Islander clients; some staff feared that clients were postponing treatments due to the suspension of face-to-face care.

I think a lot of us felt hopeless because [ACCHS] is a safe place for a lot of our clients, and they weren’t able to come in. (Regional)

. . . they’d want face-to-face and you went ‘at the moment we can’t do face-to-face’. They’d go ‘well, I’ll just wait’. Some of these health conditions can’t wait! (Remote)

Some staff expected the limited face-to-face contact to result in increased workload post-pandemic, fearing that they would have to rebuild relationships and reassess management plans.

When we go into lockdown, we see less face-to-face patients. It’s all done via telehealth, so their health is not managed at 100% as it should be. Then when things do go back to normal, the clinical team are playing catch-up. (Regional)

Impact of Isolation

The community and ACCHS staff were heavily impacted by COVID-19 pandemic related restrictions. Staff felt disconnected from their social circles and community, and felt “trapped” and lonely at home.

It was hard being in lockdown . . . to relax and unwind. It was just you’re stuck at home, stuck in the same four walls. (Regional)

I didn’t want to visit nobody. I just isolated myself. I didn’t see anyone, visit anyone. It just got to me. (Remote)

The SEWB impact of prolonged social isolation on community was noted to be an issue of concern for community and staff. Staff observed significant rise in SEWB support needs and a growing waitlist to access SEWB services.

A lot of the social and emotional stuff is face-to-face and getting out, engaging community, getting community to be active, empowering community. Once you’re in lockdown you can’t do that - community’s got to stay home. (Regional)

The amount of mental health that come out of it [the pandemic] was unbelievable. And I don’t think that will ever sort of, you know, go back to getting it under control. (Urban)

While restrictions were in place, not being able to attend to Sorry Business (The period of mourning for deceased Aboriginal or Torres Strait Islander people is commonly known as Sorry Business. [Guidelines for Aboriginal and Torres Strait Islander Terminology, Australian Indigenous HealthInfoNet, 2022]) was especially traumatising for staff and community.

Sitting at home, not able to go anywhere, that was really, really hard . . . especially when you had Sorry Business. (Remote)

Staff also noted the fear of being disconnected from family, and the concern (especially for older community members) of dying alone.

People were really scared . . . they didn’t want to die on their own. (Urban)

Vaccination Rollout and Vaccine Concerns

Staff and community were fearful when COVID-19 cases were rising and vaccines were not yet available. Once vaccines became available, community members were anxious about vaccine efficacy and side-effects as they thought the vaccine was under-researched. The responsibility to respond to vaccine-related questions fell on the ACCHS staff.

I think there was a bit of [vaccination] hysteria right at the beginning and that was probably because there was not as much information available. (Remote)

When we had the vaccine that brought on its own sort of stress because people were vaccination hesitant. (Regional)

Interruptions to vaccine supply created additional work for staff who had to cancel and reschedule vaccination appointments.

The people who did want to get it were getting frustrated with the process . . . we didn’t know when the vaccines were coming, when we got the date, it didn’t come that day. (Regional)

Community as a Source of Strength and Motivation for Staff

Staff described commitment towards being a community member as a source of strength and comfort, providing them with a sense of purpose during challenging times. Their sense of responsibility towards community was always present.

Duty: Responsibility to Community

Sense of duty towards community was a driving force in staff rallying together on initiatives such as delivery of essential items and mental health care packages, and wellness checks where staff visited Elders (especially those living alone).

At the start I was worried about how fearful staff would be, would they just leave and say look I’m just going to stay home . . . Then you think about the community, how will we look after community? (Regional)

We did home visits to check on them . . . it gave them a bit of one-on-one to ask questions when we’d go and drop off things. (Remote)

Although time-consuming and tiring, staff regarded these actions as rewarding due to the support provided to community. For most staff, the stress from the additional roles was offset by the sense of purpose and wellbeing in caring for community.

Don’t get me wrong, it was hard work. You think ‘are we ever going to come out of this?’ . . . you see the Elders and seeing them fills my cup. (Urban)

Staff were proud of their efforts in providing care and believed that the majority of the community appreciated their efforts during the pandemic. They described feeling appreciated, validated, and connected to community. Staff also spoke of drawing strength from acts of kindness from community members, particularly during busy periods (eg, long-hours at PCR testing and vaccination clinics).

I think they [community] were grateful with the service that we provided during lockdown. (Urban)

Belonging: Being Part of the Community

While ACCHS staff spoke of duty and responsibility towards community, they also acknowledged how being part of community gave them strength during the pandemic.

Feeling connected to community was a powerful motivator, however, being isolated from their wider social support circles adversely impacted staff’s SEWB. Going home to family at the end of the day provided staff the opportunity to reconnect and find some modicum of normalcy.

Staff and community to me are almost like one . . . to me [they] are like, linked. (Urban)

ACCHS Leadership Safeguarded Community and Staff

Staff described having confidence in leadership and the way they responded to the COVID-19 pandemic.

Leadership Reputation

Staff trusted ACCHS leadership to advocate for much needed resources, especially when they had a proven track record (pre-COVID-19) of advocating for and mobilising resources. Staff described the importance of strong, pre-existing relationships between the ACCHS and health services such as the Local Health District, was important for swiftly accessing COVID-19 resources and information.

[Leadership] kept in touch with Kerry Chant (Dr Kerry Chant is an Australian public health physician and she has been the Chief Health Officer of New South Wales, Australia since 2008. She gained prominence during COVID-19 pandemic as she provided regular public health advice.), you know, and made sure that we had the latest updates. (Urban)

Response to the Pandemic

ACCHS staff reported that management teams were swift and proactive in their response to the pandemic, introducing appropriate practice-level changes to safeguard community and staff.

As a clinic we adapted really quickly . . . it was harder for the community to adapt to it especially because we didn’t have a case here. (Regional)

ACCHSs’ COVID-19 initiatives included early implementation of patient triage, closure of drop-in clinics to reduce operational strain, and suspension of certain services to minimise risk of transmission.

There was enough protocols in place to feel safe. (Remote)

Staff also noted that management adapted their responses as the pandemic progressed. This was exhibited across all sites through initiatives such as the drive-through PCR test clinics, on-site vaccination hubs, and telehealth services. Leadership was credited with being cognisant of and responding to technological challenges that community members faced, by providing appropriate alternatives. For example, staff used iPads when triaging clients who either did not have a mobile phone or struggled with using QR codes.

We had an iPad out the front and that’s how we checked them in if they didn’t have a phone . . . we had a lot of people that didn’t have phones at all. (Remote)

Information Management

Staff appreciated leadership’s capacity to provide timely, relevant, and inclusive information.

Whatever information they (management) had, they relayed to us (Regional)

Regular staff meetings were found to be inclusive, timely, transparent, and they facilitated consistent information.

Our morning meetings gave everyone the opportunity to ask questions . . . everyone was put on the same page. Everyone was together in the room. You were all told the same information. (Regional)

By providing timely and consistent information, management ensured that staff had information relevant to their roles (eg, responding to community queries). When a dedicated position to manage community questions was created at 2 sites, staff felt relieved as it freed reception and other staff to focus on patient care.

We had a person allocated specifically to answer any kind of questions from patients . . . there were so many people in the medical reception area, they were overwhelmed with the phone calls, overwhelmed booking people in for the COVID clinics . . . there was a lot of things going on. (Urban)

Leadership Accessibility

Staff at all ACCHSs spoke of managers being accessible, and the positive impact this had on their overall SEWB. Initiatives that engaged staff (eg, daily briefings) were credited not just with providing COVID-19 updates but also creating a sense of shared burden and whole-of-team effort. Managers visibly being part of the ACCHS response, reinforced leadership’s commitment to staff and how leadership demonstrated respect for their work.

Senior management was good. Whatever we wanted, our manager was there. (Remote)

At some sites, however, staff resisted reaching out to leadership with any concerns or issues they had because they did not want to add to perceived leadership burden.

We all feel that we can go to management and debrief or whatever, but we just felt more like it wasn’t really an option because management was so busy attending all these meetings around COVID and trying to bring in new processes and everything. (Regional)

Staff Were Proud of Their Response to the Pandemic

Having stepped up and “survived” the COVID-19 pandemic was a source of strength and validation for staff. Sharing the burden with colleagues was rewarding for staff and they described it as evidence of staff resilience, camaraderie, and work ethic.

Work Ethic: Stepping Up

Staff spoke of responding to the COVID-19 pandemic as a cohesive unit. They were proud of their efforts and willingness to “step up” and provide support, as required by the community and ACCHS. Staff worked with a mindset to get in and do what needed to be done.

Even though we were short staffed every single staff member put their hands up . . . we were working here, there, and everywhere. (Remote)

We all stepped up. We all dropped what we were doing and we went and did what need to be done. (Regional)

As the pandemic progressed staff felt better prepared since processes became familiar and were embedded within daily functioning. At the same time, community were perceived to better accept and adopt safety protocols.

I think the second wave we did a lot better because we sort of knew what to expect . . . what was happening in the community. (Regional)

Resilience: Staying Strong

Reflecting on their SEWB, staff reported feeling overwhelmed and anxious during the pandemic. They considered pre-COVID levels of stress were higher for ACCHS staff than mainstream healthcare workers. Staff attributed being a part of their community with creating a sense of “always being on” and contributing to difficulty with disconnecting from work at the end of the day.

Working in this space I think, working with Indigenous people, it is a bit stressful. So, we were already at a level of stress before it started. (Regional)

Staff were philosophical about pushing on and getting things done.

Just done what had to be done . . . just got on with it. (Urban)

While staff noted that their own networks shrank from an inclusive community to only colleagues and family, the shared burden of this gave them strength to keep working during the crisis.

I always reminded myself that I’m not going through it, everybody is going through it and I’m not alone. (Remote)

Camaraderie: Supporting One Another

Staff supporting each other was critical to getting through the pandemic; staff camaraderie was widely spoken of as being a “lifeline.” Staff spoke of reaching out to colleagues and if they needed SEWB support, they believed their colleagues could empathise and understand their challenges due to shared experience and common goals. Incidental conversations to “check-in” on colleagues was the norm throughout the pandemic.

We’d all come together like, you know, or walk past each other or something like that, and we’ll have that bit of a debrief or, you know, just even that bit of a yarn or a laugh or something, you know. (Urban)

I think we all just know who we can trust and de-stress in the workplace. Half the time you just sit there and say ‘I know what you’re going through’ or ‘I’ve been there’. (Remote)

With service delivery changes introduced, staff’s roles changed rapidly with some taking on additional tasks outside the scope of their usual roles. This helped staff develop new appreciation for colleagues, as they got an insight into other’s roles. In the 5 participating ACCHS staff reported that they had either developed or strengthened relationships with colleagues across the organisation. Some staff added that relationships developed during COVID-19 have been maintained post-COVID.

I feel that a lot of our staff may have actually come a little bit closer since COVID-19 . . . there’s more, like, tightness. (Urban)

We all pulled together working as a team . . . it gave me a chance to forge relationships with staff from other teams. (Regional)

Opportunities Reported by Staff to Lessen the Psychological Toll of the Pandemic

Whilst proud of their efforts, when staff reflected on their experience of COVID-19, staff were describing the experience of burnout. As the pandemic continued, staff described feeling drained, being distracted, or having reduced tolerance, both at home and in the workplace.

I actually started going through . . . started getting depressed. Burnout, I was at burnout. (Remote)

Staff found COVID-19 related stress at work all-encompassing, and it was often unavoidable to take home work-related stress.

We never really got to turn off . . . the last two years you haven’t had a proper break. (Urban)

Staff described their experiences, especially during lockdowns, as akin to being on a treadmill; they felt like they were moving through a cycle of work to home and back again without opportunities to decompress. Some staff reported re-evaluating work-life balance and job satisfaction and questioning whether they needed a change from their roles.

Outside of work we’ve still got families at home that we’ve still got to look after and we’re so tired . . . we’ve got to autopilot and keep going you know, cook tea and do all the family stuff that you have to do after work. It takes its toll. (Regional)

More Staff to Spread the Load

Despite being burnt-out and needing a break, staff reportedly avoided taking leave as they did not want to burden their colleagues. Staff felt guilty about not working, even when they had to isolate due to illness or exposure to the virus. They anticipated that if low staff numbers continued being an issue post-COVID then that would have long-term consequences on their SEWB. Increasing staff numbers was posited as a means of reducing workplace stress, taking pressure off staff who are often stretched.

More staff is what we need . . . those phones ring all day every day . . . If we had another person, it would take the load off us . . . we’re always chasing our tails. (Regional)

Fostering a Self-Care Mindset

Many staff spoke of de-prioritising their physical and emotional needs to provide care to the community at a time when SEWB should have been a priority. They acknowledged the importance of a self-care mindset and of putting their needs first. Environments that foster a self-care mindset were important for staff to prioritise their wellbeing during such a crisis.

I was going to have a RDO (Rostered Day Off (RDO) is accrued when employees work hours beyond their standard roster, often through longer shifts or additional time worked across a set period such as a fortnight or month. It forms part of flexible work arrangements that allow staff to take a scheduled day off in recognition of the extra hours worked.) on that day, then you’re like ‘oh, I’ll just push it back’. So, you’re not really putting yourself first, you’re putting more the clients’ needs first. (Regional)

It’s great that clients are our priority, but I had to keep reminding people (staff) that they were at risk of collapsing. (Urban)

Accessible and Culturally Safe SEWB Support

Making staff aware of the SEWB supports available, streamlining services, and dismantling access barriers were considered as initial steps to encourage ACCHS staff to utilise SEWB support. Even where support services were available (eg, Employee Assistance Programme [EAP]), not all staff were aware of them. Support services such as the EAP were not uniformly available across the 5 ACCHS sites in the study.

I think they need to tell staff or email staff to let them know that that’s available because I didn’t know that was a thing. (Regional)

A problem was the lack of support to offer our staff . . . the resources just weren’t there for the organisation to be able to offer. (Urban)

While ACCHS staff had the option to approach their managers to seek SEWB support, they were aware of their managers’ high workload and therefore did not want to add burden by discussing their challenges.

It’s just that they (management) were just so stretched themselves and maybe they didn’t really need that as well. (Regional)

Other barriers to staff seeking SEWB support were stigma and fear of judgement; staff felt uncomfortable about exposing any vulnerabilities and accessing support. Most staff reported that they would prefer to access external services to avoid any involvement from management.

. . . by-pass going to the manager, then that makes less stuff for the manager to do as well. It takes away that fear around the staff member having to go to the manager as well. (Regional)

While ACCHSs offered staff SEWB support through programmes such as the EAP, awareness of and willingness to use them were limited, and/or staff were not confident of receiving culturally sensitive support. Staff also questioned the extent to which structured, mainstream support services could address their challenges. Therefore, instead of utilising professional SEWB support services, most staff preferred to seek support from colleagues. They were able to provide each other with personal and cultural check-ins.

We just offloaded to each other . . . where else was there to go? (Remote)

. . . someone who knows who you are [as an Aboriginal person]. They understand the culture. They understand the way black folks work. They understand how things is and how things were and how you could avoid it. (Urban)

Opportunities to Decompress

At the time of the study, as restrictions eased and the majority of the population received the vaccination, ACCHS staff anticipated return of some semblance of normality to communities and the workplace. They looked forward to reconnecting with their social networks and accessing regular activities, the seemingly ordinary encounters that would reportedly reduce stress levels.

Those little things, like being able to get your hair done and that. (Regional)

Staff felt team building activities needed to be reintroduced given most of the community were vaccinated and effective COVID-19 safety measures were still in practice. These activities allowed staff to decompress and strengthen bonds with colleagues across the organisation. Staff also thought that by organising such activities ACCHSs demonstrated that they valued staff’s contribution.

I’m really looking at something that we can do as a team to kind of boost that energy back because it’s been pretty draining. (Urban)

Staff need to feel valued . . . I think the get-togethers and those sorts of things are important. (Remote)

Discussion

The current study highlights the impact of the COVID-19 pandemic on the SEWB of ACCHS staff. To our knowledge this is the first comprehensive exploration of the SEWB impact of the pandemic on ACCHS staff who are instrumental in providing culturally safe care to Aboriginal and Torres Strait Islander communities. Themes identified in the study represented staff’s strengths during a time of crisis, challenges they encountered, and opportunities to improve responses to staff’s SEWB needs. ACCHS staff’s work and SEWB were impacted by the constant change and prolonged stress, their sense of responsibility towards community, support they received from management, sense of pride due to their response, and the psychological toll from working during the pandemic.

The findings from the study supplement results from the research team’s previous study wherein 25% of ACCHS staff had high emotional exhaustion and 30% had high-very high psychological distress during the COVID-19 pandemic.¹⁵ The current study demonstrates that experiences of ACCHS staff were similar to those of HCWs in other healthcare settings across Australia and globally, with high levels of psychological distress, burnout, anxiety, and depression.^21-23 Due to high work pressure, low staff numbers and high tension in the communities, HCWs were generally under increased pressure with limited opportunities to relax and decompress even at home where they may have had caretaking and/or home-schooling responsibilities.²⁴

During the COVID-19 pandemic ACCHS staff remained resilient and motivated. This may be explained by their work being informed by ACCHS principles of self‑determination, cultural safety, and holistic support.¹² The support of colleagues and management, visible ACCHS leadership, reliable infection control protocols, and regular information kept staff motivated; this was similar to experiences of HCWs working in mainstream services who.²⁵ Like ACCHS staff, most HCWs were confident in their leadership, especially when leaders used their networks and experience to ensure access to safety gear (eg, PPE) as well as accurate and timely information about the COVID-19 virus and pandemic.^25,26 For ACCHS staff and HCWs in mainstream services, major concerns included the fear of contracting the COVID-19 virus, transmitting infection to family and community, and the long-term consequences of disrupted patient care.^22,27

ACCHS staff discussed the seamless ways of working they have developed due to living and working in the same community. This “seamlessness” across home and work life is widely acknowledged in the literature among HCWs who identify as Aboriginal and/or Torres Strait Islander.¹⁴ Seamlessness can include frequently being visible and available as HCWs; this was the experience of ACCHS staff in the current study. While there are potential negative impacts from seamlessness, ACCHS staff in the current study found being able to serve community during as motivating.

ACCHS staff’s experiences during the pandemic were shaped by broader structural and relational pressures. Funding constraints limited staffing and intensified workload during COVID‑19, as staff took on additional roles, delayed leave, and worked to sustain service delivery.¹³ These pressures intersected with the central role of trust: rapidly shifting government advice and widespread misinformation created confusion in communities, increasing reliance on ACCHSs to interpret advice and counter misinformation. While staff valued visible and responsive leadership, some were hesitant to raise concerns because leaders were themselves overstretched. Strengthening leadership structures may help maintain the support that staff identified as crucial to their SEWB.

SEWB Support

There was a lack of awareness among ACCHS staff about SEWB support services available. Even when staff were aware of support, they were hesitant to utilise them due to lack of cultural safety and concerns about privacy. There is an urgent need for targeted SEWB support for ACCHS staff, including destigmatising help seeking and making concessions for those needing support. A major source of strength for ACCHS staff during the pandemic was being able to rely on their colleagues for support, however, this was informal and unstructured. Considering the effectiveness and acceptability of workplace-based peer support,²⁸ there is an opportunity to develop structured, peer support programmes that can provide ongoing support to staff. This can be supplemented supports such as counselling services with culturally safe providers, cultural supervision, opportunities to debrief with managers and senior leadership, and regular cultural immersion opportunities for non-Indigenous HCWs.

Strengths and Limitation of the Study

The needs of HCWs can get overlooked due to the focus on patient care and related processes, during public health emergencies. The strength of the current study lies in privileging the voices of ACCHS staff. To our knowledge this is the first comprehensive exploration of the SEWB impact of the COVID-19 pandemic on ACCHS staff who are instrumental in providing culturally safe care to Aboriginal and Torres Strait Islander communities. While the study provides insights into the experiences of a small sample of ACCHS staff, the Yarning methodology can be scaled up to include a larger sample of staff across Australia.

Lessons Learnt: Implications for Practice

Based on ACCHS staff’s experiences, the current study has identified transferrable “lessons learnt” from the COVID-19 pandemic that can be implemented by ACCHSs to respond to future public health crises, to protect staff’s SEWB (Table 2).

Table 2.

Implications for Practice.

Lessons learnt	During the COVID-19 pandemic	Implications for practice
Timely response	When ACCHS leaders have established relationships at the state and local government levels, support can be mobilised swiftly. Flexible response protocols can facilitate timely response.	Strong, established relationships with government and flexible response protocols can support timely response to pandemics, positively impacting staff’s SEWB.
Ongoing support for community	ACCHS staff have a strong sense of duty towards community, and efforts to provide tangible and intangible support is of utmost importance to them.	ACCHSs can ensure staff wellbeing by establishing structures to provide ongoing support to community.
Timely and transparent information	ACCHS staff were required to continually adapt their practices in response to evolving government messaging and widespread media misinformation.	ACCHSs can develop systems to disseminate accurate information and counter misinformation, alongside structured, solutions‑focused internal communication processes that clarify staff roles and ensure consistent organisation‑wide information sharing.
Visible leadership	Staff stated that visible leaders instilled a sense of trust, showcasing their commitment to effective and timely actions. Accessible and proactive leaders instilled confidence in staff that issues could be managed in a timely manner.	Visible, proactive and transparent leadership can support staff’s SEWB at work.
Prioritise staff self-care	During the pandemic ACCHS staff de-prioritised self-care as community needs were high and/or ACCHSs were understaffed.	Creating environments of self-care for staff with opportunities to decompress, and encouraging staff to take time off work can support SEWB.
Mental health vigilance	Stigma and concerns about cultural safety discouraged ACCHS staff from using formal SEWB supports, as concerns about judgment, privacy, and culturally unsafe services led many to avoid external programmes and rely instead on trusted peer‑based support.	ACCHSs can create an environment of mental health vigilance among staff by training them to recognise and respond to emerging SEWB concerns among colleagues. They can ensure that staff are informed about, and have clear pathways to, culturally safe and trusted SEWB supports.
Acknowledge staff contributions	ACCHS staff carried significant emotional and physical burdens throughout the COVID‑19 pandemic, often working beyond their usual roles. In such situations, lack of acknowledgment can contribute to reduced morale, diminished motivation, and ongoing psychological strain.	ACCHSs can formally and informally acknowledge staff’s commitment and work ethic, contributing to a motivated and resilient workforce.

Recommendations

The findings can be translated to the following policy recommendations (Table 3), They can contribute to a more resilient, sustainable, and culturally grounded ACCHS workforce.

Table 3.

Policy Recommendations.

Policy recommendations
1. Sustainable funding: Long‑term, secure funding is needed to support adequate staffing that can reduce workload burden, and strengthen workforce retention.
2. Investment in leadership: Leadership development and protected leadership time is essential to maintain the visibility and responsiveness central to staff’s SEWB.
3. Culturally safe SEWB support: Implementing structured peer support, culturally safe counselling services, and clear pathways to trusted SEWB programmes can address barriers related to stigma, privacy, and cultural safety.
4. Crisis‑ready communication: Formalising internal and community‑facing communication processes can help counter misinformation and deliver consistent, culturally grounded guidance during any public health crises.

Conclusion

The COVID-19 pandemic was a challenging time for ACCHS staff. They experienced prolonged periods of stress that were exacerbated by constant changes, inconsistent information, misinformation, lack of resources, and adverse SEWB impacts. ACCHS staff found strength in their community, cultural connections, and their management’s response to the pandemic. Informal peer support was instrumental in upholding ACCHS staff’s SEWB, suggesting that structured peer support programme can be instrumental in providing ongoing support to staff.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319261433349 – Supplemental material for What Gave Us Strength: Perspectives From Aboriginal Community Controlled Health Services Staff on Working During the COVID-19 Pandemic

Supplemental material, sj-docx-1-jpc-10.1177_21501319261433349 for What Gave Us Strength: Perspectives From Aboriginal Community Controlled Health Services Staff on Working During the COVID-19 Pandemic by Carmel Crook, Smriti Nepal, Sandra Bailey, Darryl Wright, Christine Corby, Jamie Newman, Katrina Ward, Peta Larsen, Lachlan Wright, Natalie Smith and Michelle Dickson in Journal of Primary Care & Community Health

Footnotes

ORCID iDs

Smriti Nepal

Michelle Dickson

Ethical Considerations

Ethics approval for the study was obtained from the University of New South Wales ethics committee (HC210540) and the Aboriginal Health and Medical Research Council of NSW (1834/21).

Consent to Participate

Prior to data collection, all participants provided informed consent.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by NSW Health (reference number H20/139482).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data are not publicly available due to Australian personal data legislation but are available from the lead authors upon reasonable request. Any sharing of data will be regulated through a data transfer and user agreement with the recipient.

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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