Table 1 presents sample characteristics, including demographics, CROS scores, psychiatric symptoms, and outcome assessments, for the entire sample and stratified by subgroups. In addition to comparing HCW and FR, sufficient respondents from the subgroup physicians, nurses, LEO plus fire, and EMS were present to analyze these groups independently. In general, responses were similar for HCW and FR, including similar scores on CROS measures. However, nurses scored significantly higher than physicians on both total exposure (CROS total, p < 0.01) and most psychiatric symptoms domains (PTSD, depression and insomnia p < 0.01, thoughts of suicide or self-harm p = 0.04). Similarly, CROS total was significantly higher for EMS versus LEO/fire (p < 0.01), as were symptoms of depression (p < 0.01). Fewer FR (40.6%) than HCW (55%) reported experiences working during the pandemic had decreased their likelihood of remaining in their current field (p = 0.004).
Bivariate Relationship of CROS Total Score to Psychiatric Symptoms and Occupational Outcomes
Figure 2 presents bivariate associations between demographic variables, exposure scores, and psychiatric symptom scores. Of the psychiatric symptom domains, the CROS total was most strongly correlated with the PCL5 (R = 0.52) but was also significantly associated with the PHQ9 (R = 0.44), ISI (R = 0.41), and GAD7 (R = 0.43, all p < 1e-15). CROS total also was significantly correlated with thoughts of suicide or self-harm (R = 0.25, p < 1e-5), problems completing work tasks (R = 0.28, p < 1e-8), and likelihood of leaving field (R = 0.18, p < 0.001). For the subgroup that reported at least moderate insomnia symptoms and was asked about the impact of sleep problems on functioning at work (N = 367), CROS total was significantly related to reported impact of sleep problems on work performance (R = 0.37, p < 1e-11).
Multivariable Relationships of the 3 CROS Factors to Psychiatric Symptoms and Occupational Outcomes
We conducted a series of multivariable linear regression models. The relationships of CROS factors to psychiatric symptoms across all respondents are presented in Fig. 3A, and by subgroup in Supplemental Fig. 3. These models found that all 3 CROS factors were significantly and positively related to all 4 psychiatric symptom domains. Across all participants and for both HCW and FR, the demoralization factor was the strongest correlate of PTSD (HCW β = 0.37, FR β = 0.59), depression (HCW β = 0.30, FR β = 0.5) and anxiety symptoms (HCW β = 0.29, β = 0.42, all p < 0.0001). The relationships were similar across the four small subgroups (physicians, nurses, LEO + fire, and EMS) with the exception that for LEO + fire, the volume factor was as or more strongly associated with these outcomes than demoralization (β = 0.58 GAD7, β = 0.47 PTSD, β = 0.44, all p < 0.01). For insomnia symptoms, the demoralization factor was strongly associated with symptom intensity for physicians (β = 0.41, p < 0.05) and EMS (β = 0.35, p < 0.01), while the risk factor was associated with symptom intensity for nurses (β = 0.36, p < 0.01).
Across all respondents, thoughts of suicide or self-harm were significantly and positively related to both the volume factor and the demoralization factor, as well as to prior trauma history (Fig. 3B and Supplemental 3B). On subgroup analysis, this pattern was maintained for nurses and EMS, but not for physicians (no significant predictors) or LEO + fire (volume factor β = 0.95, p < 0.001).
In examining the relationship of CROS factors to occupational outcome measures across all respondents, only the demoralization factor was significantly related to the likelihood of leaving one’s current field or problems completing work-related tasks. This pattern was preserved across subgroups, with the exception that for LEO + fire demoralization was significantly related to the likelihood of leaving one’s field (β = 0.52, p < 0.01) but not to occupational functioning, while for EMS demoralization was significantly related to occupational functioning (β = 0.55, p < 0.0001) but not the likelihood of leaving one’s field.
Relationship of Psychiatric Symptom Domains to Functional Outcome Measures and Suicidality
The relationship of psychiatric symptom domains (PTSD, anxiety, depression, and insomnia) to functional outcome measures and thoughts of suicide or self-harm were similarly characterized (Fig. 3C and Supplemental 3C). Across all participants, PTSD symptom severity was significantly related to the likelihood of leaving one’s current field, trouble completing work tasks, and thoughts of self-harm or suicide. In addition, older age had a significant positive relationship to the likelihood of leaving one’s current field, and depression symptoms were significantly and positively related to thoughts of self-harm or suicide. However, based on subgroup analyses, the relationship of PTSD symptoms to the increased likelihood of leaving one’s current field was driven most strongly by nurses (β = 0.41, p < 0.01) and LEO + fire (β = 0.74, p < 0.05), while the relationship of PTSD to occupational functioning was driven most strongly by physicians (β = 0.67, p < 0.05) and EMS (β = 0.43, p < 0.01). Interestingly, for LEO + fire, anxiety symptoms were strongly and positively associated with thoughts of suicide or self-harm (β = 1.2, p < 0.001) but strongly and negatively associated with thoughts of leaving one’s field (β = 0.91, p < 0.01).
Qualitative Analysis of Free-Text Responses
Over one-third of participants (36% of total, 37.5% of HCW and 32.4% of FR) responded to the optional, open-ended question about sources of occupational stress during the COVID-19 pandemic, with an average response length of 31 words (range: 1–169). Responses vividly conveyed the challenges faced by HCW and FR and the magnitude of associated distress. A rapid template analytic approach identified 12 overarching codes within respondent data, which are described, along with illustrative quotes in Table 2.
Overall, responses were highly consistent with the quantitative analyses above. Among the 12 identified codes, “Lack of Protection and Support,” “Increased Demands,” and “Emotional Toll” were the most common. Respondents described their work during COVID-19 as involving “some of the saddest death stories” they had experienced and feeling “spread thin and exhausted.” Notable for a relative lack of representation were comments addressing respondents’ personal risk of COVID-19 infection, with most references to this type of risk taking the form of concern for the impact of this risk on others.
HCWs were overrepresented (> 5% deviation) in categories “staffing shortages,” “increased demands,” and “patient care.” FRs were overrepresented in “fear of or enacted reprisal from leaders,” “concern for the well-being of others,” and “betrayal by colleagues.” HCW and FR were represented in all categories.