This cross-sectional survey enrolled 946 respondents and about half of the HCWs reported burnout, psychological distress or posttraumatic stress during the COVID-19 outbreak. Our results were similar to previously studies which revealed high rates of symptoms of burnout (19.3–53.5%), psychological distress (28.4–56.6%) and posttraumatic stress (13.2–58.6%) in the in HCWs during the pandemic (Salazar de Pablo et al. 2020).The evaluation of mediating factors suggested that systemic, individual and occupational factors were associated with the adverse psychological and occupational effects of the COVID-19 outbreak. These findings could be framed in terms of their potential value for the future, and we want to learn from the COVID-19 experience in China to try to buffer this negative impact.
Health authorities need to identify high-risk groups of HCWs based on sociodemographic information for early psychological interventions. Our sociodemographic data suggested that HCWs had one child were more likely to exhibit reduced psychological distress. Multivariable logistic regression analysis showed that HCWs who lived with elderly adults during the outbreak reported greater posttraumatic stress. We attribute this to the fact that the HCWs were worried about transmitting COVID-19 to the elderly, who were more likely to become infected by COVID-19 and had worse outcomes (Chen et al. 2020). The results of our study suggested that temporary separation between HCWs and the elderly adults during the outbreak of COVID-19 (but frequent communication online) may be helpful in reducing the adverse effects. Providing effective family support for healthcare workers may help to minimize the adverse mental health issues among HCWs during epidemic. We also found that HCWs with a poor health status were significantly associated with psychological distress, indicating the importance of maintaining one’s daily health status in the face of major infectious diseases. Hospital administrators should consider health status of HCWs when assigning work during the COVID-19 outbreak. In this study, HCWs with alcohol abuse were significantly associated with higher risk of psychological distress and posttraumatic stress. HCWs suffering from alcohol abuse may pose a risk for the health and safety of themselves. The occupational health specialist charged of medical surveillance of hospital workers need to recognize HCWs suffering from alcohol abuse and define effective strategies to deal with the problem such as transfer from frontline work.
Occupational factors often have an effect on psychological outcomes. Hospital level was the factor strongly associated with posttraumatic stress. HCWs worked at 3A hospital exhibited reduced posttraumatic stress. We attribute this to HCWs worked at 3A hospital were more likely to have experience to deal with disasters and public infectious events, and most of them had lower economic stress. Currently, with the increase in the number of cases of COVID-19 infection in China, frontline medical staff were required to wear protective masks and protective clothing. Many participants expressed discomfort in using PPE, especially wearing masks and isolation suits, as a highly intense shift in PPE may cause feelings of suffocation and dehydration, not to mention inconveniences with respect to urination and defecation, all of which may cause added stress. However, discomfort is incomparable to safety, and a shortage of PPE for frontline workers is realistic. In addition to isolation wards and fever clinics, personnel working in other departments may also contact COVID-19 patients, but special PPEs such as N95 mask were not provided to them by medical authorities. The protective effect of the PPEs were also doubted, as a portion of the PPE provided to hospital were not for medical use, some cautious HCWs chose to wear extra-work clothes, which would aggravate psychological distress according to our result. Cases of infection and death among HCWs were still reported in some hospitals, which may enhance the insecurity of HCWs, while providing enough and effective PPEs was an easy way to give HCWs security (Epidemiology Working Group for Ncip Epidemic Response and Prevention 2020). Great efforts should be made to access to abundant PPEs, including receiving donation from society, government’s coordination, and medical supplies manufacturing increase.
Perceptions of risk of infection are easily understood due to COVID-19’s preferential transmission to hospital workers and its substantial mortality. With the increasing reported cases of HCWs and acquaintances infection or deaths, HCWs experienced fear of getting infected, and these were significantly associated with psychological distress. HCWs feared of contagion were more likely to exhibit reduced work efficiencies and were significantly associated with burnout. Some of the HCWs predicted the epidemic would continue for quite a long time, which was the predictors of high psychological distress. Most HCWs believe they would survive if infected, which was strongly associated with lower posttraumatic stress. Professional psychotherapy teams should be established to support the mental health of medical staff and provide individually targeted interventions, especially for HCWs who experienced acquaintances infected or died from COVID-19. A more supportive social environment and more friendly mass media would be helpful to HCWs psychological health during an infectious disease outbreak. In China, there was a timely data in open to provide people with dynamic and important information so that they could fully understand the pandemic and policies; hospitals organized periodically training system to help HCWs updating knowledge of COVID-19. These would be helpful to reduce HCWs’ fear of the uncontrollable future and reduce adverse psychological and occupational effects of the COVID-19 outbreak.
Most HCWs disinfected themselves as soon as they arrived home and some of them avoided contacting with children not to passing the virus on to their family members, which were significantly associated with burnout and posttraumatic stress. During January to March, when the outbreak was hardly under control, instead of returning home, most frontline workers were accommodated in designated hotels or dormitory, which may alleviate their concern. Most of the HCWs reported that there were adequate staff at their workplace to handle the different demands, which were independently associated with decreased burnout and psychological distress. Social isolation in infectious diseases was related to the threat of infection and reduced contact and may be a stress-provoking feature (Hall et al. 2003). Our study suggested that interpersonal isolation provoked psychological distress. Efforts to reduce the negative impact of interpersonal isolation could include creative efforts to increase effective interpersonal communication, such as web-based support or discussion groups.
Job-related stressors during the COVID-19 crisis included increased workload and a lack of control over work, including involuntary conscription. The study showed that working overtime was a significant predictor of burnout. Therefore, it is important to attend to organizational characteristics that are known to buffer burnout during the prepandemic period, which include reducing patient-to-HCW ratios, arranging HCWs’ work and rest schedules reasonably and increasing perceived empowerment (Laschinger et al. 2001). An inability to take care of their family was the independent predictive factor of posttraumatic stress and psychological distress. Personal economic losses were significantly associated with psychological distress. In China, most frontline workers were transferred from other department after detailed pre-training, whose work time was no more than a month. Substantial subsidy was leaned to HCWs especially the frontline workers in China during the pandemic. Preference to the frontline workers was rewarded in professional title promotion. These supportive interventions such as increased incomes and reasonable work and rest schedules for two-worker households may be useful for HCWs.
Maladaptive coping was a strong independent risk factor for worse mental health and occupational outcomes in all dimensions of interest. Adaptive coping could significantly reduce psychological distress and burnout. According to previous studies, social support contributes to improving self-efficacy, leading to a sense of professional achievement, which improves coping mechanisms under stress (Glozah 2015; Meixia et al. 2016). For example, hostile confrontation and self-blame may be reduced in a work environment that fosters positive working relationships through effective leadership (Yank et al. 1992). It is important to encourage staff to plan for future outbreaks, reducing the tendency to cope by means of avoidant strategies and enhancing coping through problem solving and peer support. Programs directed towards healthy lifestyles, diet, exercise, and smoking cessation may also be important in providing support to staff.
After the outbreak, China tried to adopt a thorough prevention measures in an attempt to bring the virus under control. Individuals could apply or download a health QR codes in three colors—green, yellow and red—indicating different risks to serve as permits for hospital safety. Designated hospitals were organized for treatment of confirmed patients and HCWs were recruited from different departments, which would be helpful to prevent collapse of the health systems. When the lessons of COVID-19 in China applied to other affected countries, effective protection, training and support may be a primary target to bolster the resilience of HCWs who will face future outbreaks. The State Council also issued a notice to strengthen psychological crisis interventions and psychological counseling for healthcare workers. Mental health psychological centers set up psychological consultation platforms, developed psychological intervention plans, and offered remote psychological interventions to provide psychological assistance for healthcare workers.
Positive aspects of the COVID-19 outbreak were also reported. Most of the staff noted an increased awareness and experience of infection control. The majority of HCWs reported treasuring life and work more. It may be useful for preparatory training packages and interventions to encourage healthcare workers focusing on the potential positive impact of their work or considering coping strategies that may help them to see the positive effects of working in a crisis.
This study has several limitations. The most significant methodological limitation of this study was that we use subjective self-reported questionnaires online to obtain the data, which was not based on a random selection of the sample, and the study population might not reflect the actual patterns of the general population. Nonetheless, our results must be interpreted conservatively. Among the study's limitations were its small sample size, and cohort studies with larger samples are needed to investigate the psychological and occupational impact of COVID-19 outbreaks on HCWs. A further limitation is that self-reports of COVID-19 experiences do not provide an objective evaluation of actual differences in the training, protection, or support that HCWs received. Regardless of the limitations, the Impact of the COVID-19 Study provides a window to the long-term effects of working during times of extraordinary infectious risk.
Our findings demonstrate a significant adverse psychosocial and occupational impact of the COVID-19 outbreak in China on HCWs. The findings from this study may provide support for the implementation of measures to improve the social support of medical staff during increased demands associated with COVID-19 outbreak at this time. Future follow-up investigations using both qualitative and quantitative approaches will be necessary to understand the psychosocial effects of COVID-19 on HCWs over time.