Frontline healthcare workers’ mental distress, top concerns, and assessment on hierarchy of controls in response to COVID-19: a cross-sectional survey study

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by a newly discovered coronavirus, identified as severe acute respiratory syndrome coronavirus 2 (SAR-CoV-2), which is highly transmissible and threatens human health and public safety [1, 2]. The outbreak of COVID-19 has affected almost every country around the world [3]. On the front lines of this pandemic are healthcare workers (HCWs) who continue to show up to work and come into close contact with patients with COVID-19 [4] despite shortages of personal protective equipment (PPE) [5], exhaustion and uncertainty [6]. In Italy, up to 9% of HCWs were estimated to have contracted the virus [7]. In the United States (U.S.), among states with more complete reporting data, the number of COVID-19 infections among HCWs was up to 11%, and is expected to continue rising [8]. As of early April 2021, more than 3600 HCWs had died of COVID-19 in the U.S. [9].

In comparison to past pandemics, SAR-CoV-2 has tricky and complex mechanisms that have facilitated its rapid and catastrophic spread worldwide [10]. Although the COVID-19 pandemic is commonly compared to the influenza pandemic of 1918 [11], more recent viral outbreaks, such as severe acute respiratory syndrome (SARS) in 2003, H1N1 influenza pandemic in 2009, and Ebola in 2014, have offered insights into the unusual stressors experienced by HCWs during these crises. Commonly cited stressors are the interference with family relationships [12‐14], shortage of supplies [13, 15], heavy workloads [13, 15, 16], caring for an infected patient [17], and perceived threat [18], which have been linked to absenteeism [19], insomnia [17], and mental distress [12, 14] among HCWs.

A systematic review reported the significant mental impact of infectious disease outbreaks on HCWs, with the top three diagnoses being anxiety, depression, and acute stress disorder [20]. Others found post-traumatic stress symptoms among HCWs have persisted years after an outbreak [21]. These serious and persistent effects of viral outbreaks reported among HCWs require further exploration into the stress they experience. This study explored whether health professionals working on the front lines during COVID-19 showed symptoms of depression and how their concerns could be better addressed through the lens of their assessment on the responses to COVID-19 at workplace, state government, and federal government. It aimed to provide insights on how to strengthen public health responses to protect healthcare workers both physically and mentally, and effectively control the disease in light of hierarchy of controls.

There were 271 participants that completed the survey with 98.52% valid responses. The majority of the respondents were nursing professionals, among which, 38.58% of them were Certified Nursing Assistants (CNAs) and 46.82% of them were nurses with a variety of specialties. Compared to nurses, CNAs typically have limited nursing education primarily related to personal care of sick or disabled people. Other participants (14.61%) were physicians, phlebotomists, emergency medical technicians, lab technicians, transport aides, pharmacists, etc. About 90% of the respondents were currently seeing patients, 75.28% of them worked in a hospital setting, and 78.49% of them were practicing in MA. As the survey was mainly distributed to nursing students, the participants tended to be young and had less work years. Over 93% of them had someone live in the same household which elevated the risk of infection. Table 1 reports the characteristics of participants.

MA has been one of the hardest hit states in the U.S., according to the State government. The survey was conducted during the surge of the COVID-19 in MA where the confirmed cases increased from 20,974 on April 10th to 70,271 on May 5th [27]. On April 18th, the positive cases reported in MA were just behind New York and New Jersey and became the top 3 states with the most confirmed cases of coronavirus per 100K population in the country with the prediction of a peak in hospitalizations at the end of the month [28]. The non-essential business closures in MA started on March 23rd and were extended at the end of April. Against this backdrop, there were about one-third of the surveyed participants showed the symptom of depression which deserves an immediate attention. As reported, HCWs infected by SARS were at 40.7% increased risk of post-traumatic stress disorder (PTSD) [29], while those cared for SARS patients but were not infected continued to experience substantial long-term psychological distress [30, 31]. At the institution level, it is important to recognize the workplace stressors and address them, such as reducing burnout [32] and strengthening emergency preparedness for disease outbreak [33, 34]. To individual HCWs, besides support lines and a meditation remedy [35], more tailored programs should be in place to proactively help them undergo psychological adaptation [18] and cope with stress, such as the Stress Management and Resiliency Training (SMART) Program [36]. For instance, 38.6% respondents were CNAs from the undergraduate nursing program who are at the early stage of their career. This pandemic may affect their career choice in either direction, in terms of affirmation or quit. A previous study showed that students’ level of commitment to nursing programs could be harmed by high levels of experienced stress [37]. External support and putting HCWs first in fighting with infectious disease could attribute to their decisions in continuing nursing career. Further, improving job satisfaction of nurses can positively influence their professional commitment, in terms of willingness to make an effort, appraisal in continuing nursing career, and belief in goals and values [38].

Respondents who were less likely to have a symptom of depression were those being a nurse, considering workplace responses effective, having enough PPE, and perceived no shortage of HCWs. In contrast, CNA respondents, considering workplace responses somewhat effective, having just ok PPE, perceived shortage of HCWs at their workplace were more likely to have a symptom of depression.

The full hierarchy of comprehensive infection control measures has been recommended to protect HCWs [39]. The survey results showed that engineering and administrative controls, as well as PPE were widely used in response to COVID-19. The assessment on the state and workplace responses was better than the federal government responses. The workplace responses were considered most effective. Adaptation to change with the implementation of telemedicine during the pandemic was a good example. Future disease prevention and control with early responses and consistent standards of implementation from policies could utilize elimination and substitution measures to benefit from more effective control methods.

Those who perceived the absence of stress management for patients and the shortage of medical supplies and HCWs were likely to consider workplace responses “effective”, which seemed counter-intuitive. A possible explanation was the fact that the demand for patient-level intervention and more HCWs existed even without the pandemic [40, 41]. As the respondents may have adapted to the reality, they were less likely to count those existing factors toward the responses to the new disease outbreak. The other explanation was with respect to the absence and shortages, the respondents thought their workplace still managed COVID-19 effectively. In addition, those working 1–5 years and never being married were more likely to consider the workplace responses effective.

Both the descriptive statistics and comments by the respondents provided the insightful information about the actions taken in responses to COVID-19. The limitations included: (1) the cross-sectional survey provides frontline health professionals’ opinions and what was happening at work only during the survey period; and (2) the outcomes of PHQ-2 and effectiveness of workplace responses have not been examined holding confounding factors constant. Therefore, the conclusion needs to be drawn with caution. More in-depth statistical analysis will be followed.

In addition, the survey did not capture job titles and duties which may influence perceived control of HCWs, especially nursing staff. The existing studies show that HCWs with more control tend to have less burnout and be more resilient facing the pandemic [42, 43]. Further research can be conducted to examine the impact of this factor.

This study suggested that timely response at the policy level will be more effective in controlling the epidemic. For instance, consistent guidelines not only for hospitals, but also for the public on curbing the disease will help save more lives; the emergency preparedness protocols with standard procedures to follow will direct the fight against the pandemic in a more organized manner; and rigorous implementation of the hierarchy of control measures can improve HCWs’ protection from infection. PPE as an important physical protection should be coupled with actions addressing mental distress of HCWs. Universities with a nursing program should consider providing a situation-specific career coaching or counseling for students. Furthermore, a longitudinal study at a larger scale is warranted to capture the variation with the time change and across geographic regions. Persistent health education before, during, or after the pandemic is expected to bring enduring benefit to families, communities, and the country at large.