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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 6-11

Psychological effects of COVID-19 on hospital staff: A national cross-sectional survey in mainland China


1 Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
2 Center of Laboratory Medicine, Union Hospital of Fujian Medical University, Fuzhou, Fujian, China
3 Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
4 Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
5 Department of Surgery, Yale School of Medicine, New Haven, CT, USA

Date of Submission09-Nov-2020
Date of Decision20-Dec-2020
Date of Acceptance02-Jan-2021
Date of Web Publication17-Mar-2021

Correspondence Address:
Dr. Yongquan Gu
Department of Vascular Surgery, Xuanwu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT-2

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  Abstract 


OBJECTIVE: This study examined the psychological impact of the coronavirus disease 2019 (COVID-2019) outbreak on medical staff in China.
MATERIALS AND METHODS: In February 2020, an online survey was carried out by using an online survey tool (WeChat) to evaluate the effects of the outbreak on the mental health of medical staff in China.
RESULTS: A total of 11,118 medical staff responded to the survey. About 4.98% of the respondents reported middle and high levels of anxiety, while 13.47% of the respondents reported middle and high levels of depression since the COVID-19 outbreak. Nurses, frontline medical staff, and younger medical staff were more likely to have anxiety and depression than physicians, nonfrontline medical staff, and older medical staff.
CONCLUSIONS: Although the serious psychological impact of COVID-19 is not so common in medical staff in China, programs are needed to protect them against the negative impacts of COVID-19.

Keywords: Anxiety, China, coronavirus disease 2019, depression, infectious disease outbreak, medical staff


How to cite this article:
Guo J, Liao L, Wang B, Li X, Guo L, Tong Z, Guan Q, Zhou M, Wu Y, Zhang J, Dardik A, Gu Y. Psychological effects of COVID-19 on hospital staff: A national cross-sectional survey in mainland China. Vasc Invest Ther 2021;4:6-11

How to cite this URL:
Guo J, Liao L, Wang B, Li X, Guo L, Tong Z, Guan Q, Zhou M, Wu Y, Zhang J, Dardik A, Gu Y. Psychological effects of COVID-19 on hospital staff: A national cross-sectional survey in mainland China. Vasc Invest Ther [serial online] 2021 [cited 2021 Apr 11];4:6-11. Available from: https://www.vitonline.org/text.asp?2021/4/1/6/311339




  Introduction Top


During the past two decades, the world has experienced outbreaks of several highly infectious diseases. The psychosocial impacts of the highly infectious diseases on medical staff have been well documented.[1],[2],[3],[4] The coronavirus disease 2019 (COVID-19) epidemic, which rapidly spread from Wuhan City, Hubei province, to other places in China and then around the world, resulting in a Public Health Emergency of International Concern declaration, has caused considerable panic and anxiety around China and has posed a great threat to the health and even life of the people all over the world.

Despite due protection, health-care workers have been reported to have a higher rate of infection. Research published in the early February 2020 showed that of 138 patients treated at one hospital, 29% were health-care workers. In one case, a patient admitted to a hospital in Wuhan infected at least ten medical workers and four other patients.[5] According to Liang Wannian, an official from the China National Health Commission, >3000 frontline workers in China have tested positive for COVID-19 as of Monday (February 24, 2020).

From the beginning of the COVID-19 pandemic, easy access to the Internet with mobile phones in China has given rise to the so-called “infodemic” of fake news that spreads faster and more easily than the virus.[6] The level of perceived disaster-related risk is influenced by a person's level of awareness and knowledge related to the disaster. Due to the initial very high levels of unfamiliarity and uncontrollability, as well as the memories of SARS high level of contagiousness, relatively high mortality rate, and high (~20%) infection rate in medical workers, the mental health impact of the COVID-19 outbreak was expected to be relatively high. Shortage of supplies and medical staff as the tide of patients rose in Hubei province and the increased number of medical aid teams that were sent to the epicenter of the COVID-19 infection could be additional factors for medical workers' likelihood to develop psychological stress. Given the possibility of a long time of activity of the pandemic, more research is needed to understand the psychological impacts of the COVID-19 outbreak on the medical staff. To address this gap of knowledge and to strengthen preparations for potential medical aid team members, we explored levels of stress symptoms among medical workers in China by taking advantage of an online and rapid survey tool.


  Materials and Methods Top


Online survey design

This cross-sectional survey was open to all medical staff in China mainland area. Ethical approval was obtained from the institutional review board of the Xuanwu Hospital Capital Medical University. Participants were invited to complete an online psychological questionnaire through an online survey tool (WeChat) that can send online invitations through social media. The online tool contained a “Begin survey” link that, if clicked, would open the online questionnaire in the respondent's WeChat app. At the top of the questionnaire, there were words that clearly indicated that only physician, nurse, health-care administrators, health-care support staff, and medical students were invited for the survey. By clicking the “Begin survey” link, the respondent indicated his/her consent to participate in the study and the informed consent was electronically recorded. The participants' identities were kept confidential.

Demographic profile

Participants were required to complete the online questionnaire for assessing their demographic data including age, gender, place of residence, occupation, income, marital status, and educational background as well as current psychological status.

Measures

For psychological distress evaluation, the internationally recognized Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) were used.[7],[8] The SAS scale consists of twenty questions that assess how respondents feel during the previous week. Each question has a score of 1–4. Higher scores indicate higher levels of anxiety. SAS scores of 50–59 points, 60–69 points, and 70 or more indicate mild anxiety, moderate anxiety, and severe anxiety, respectively.

The SDS scale is a 20-item self-reported questionnaire that covers affective, psychological, and somatic symptoms associated with depression. Each item has a score from 1 to 4. The total score ranges from 20 to 80. Higher scores indicate higher levels of depression: 50–59 for mild depression, 60–69 for moderate depression, and 70 or more for severe depression.

Data collection and statistical methods

Responses were downloaded from the online survey tool as a spreadsheet and anonymized. Given the exploratory nature of the study, the statistical analyses were descriptive. Data were processed by SPSS (20.0) software package (SPSS Inc., Chicago, IL, USA). SAS and SDS scores were expressed as mean and standard deviation. Mann–Whitney U-test was used to compare the difference in SDS and SDS scores between the groups. Comparison of continuous variables was performed using t-test for independent samples. For the data that did not conform to the normal distribution, rank sum test was performed. P < 0.05 was considered statistically significant.


  Results Top


Demographic profile

The survey started at February 18, 2020, 19:26, and ended by February 20, 2020, 19:26. The respondents' demographic profile is presented in [Table 1]. A total of 11,118 health-care workers completed the survey. Among them, 2802 (25.2%) were male and 3245 (29.19%) were aged 40 years or older. There were 7940 (71.42%) participants who were married. Almost all of them (96.37%) had a bachelor's degree or above. There were respondents from all provinces and major cities of China mainland [Table 2], and the top five regions were Jiangsu (3874, 34.84%), Hebei (945, 8.50%), Henan (853, 6.95%), Beijing (730, 6.57%), and Heilongjiang (647, 5.82%).
Table 1: Demographic profile of the survey responders

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Table 2: Distribution of locations of the survey responders

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Among the survey responders, 3351 (30.14%) were physicians, 5900 (53.07%) were nurses, 757 (6.81%) were medical students, 464 (4.17%) were clinical medical assistants, and 450 (4.05%) were clinical administration staff. There were 3351 (30.14%) first-line medical workers who were directly involved in the care for patients infected with COVID-19 [Table 1].

Presentation of psychological stress

Among all the participants, 6348 (57.10%) reported that they often felt anxious or panic, and only 1541 (13.86%) reported that they had never experienced anxiety. Approximately three-quarters of the survey responders (6932, 65.48%) thought that they had no suitable methods to solve their psychological stress and had to endure or address the distress by themselves. Most of the participants (9274, 83.41%) thought that psychological interventions were necessary. Over one-half of the participants (6711, 60.36%) believed that psychological interventions should be available to medical staff as soon as possible after the outbreak to alleviate psychological stress [Table 3].
Table 3: Survey results

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Approximately 4.98% of the medical staff reported at least moderate levels of anxiety (SAS score ≥60) and 13.47% reported at least moderate levels of depression (SDS score ≥60) following the outbreak of COVID-19 [Table 4]. We compared stress between frontline medical staff and nonfrontline medical staff [Table 5]. The median SDS score for the frontline medical staff was 44, whereas that for the nonfrontline medical staff was 41; the SDS scores of the frontline medical staff were statistically significantly higher than those of the nonfrontline medical staff (U = 1.200E7, Z = −6.539, P < 0.0005). The median SAS score of the frontline medical staff was 41, and that of the nonfrontline medical staff was 39; the SAS scores of the frontline medical staff were statistically significantly higher than those of the nonfrontline medical staff (U = 1.131E7, Z = −10.988, P < 0.0005).
Table 4: Self-Rating Depression Scale and Self-Rating Anxiety Scale scores

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Table 5: Frontline medical personnel versus nonfrontline medical personnel

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We then compared the SDS scores between physicians and nurses [Table 6]. The median SDS score of the physicians was 41, and that of the nurses was 43; nurses had statistically significantly higher SDS scores than the physicians (U = 9111898.5, Z = −6.631, P < 0.0005). The median SAS score of the physicians was 39, and that of the nurses was 40; similarly, the nurses had statistically significantly higher SAS scores than the physicians (U = 9165186, Z = −6.204, P < 0.0005).
Table 6: Physicians and nurses

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Finally, we compared SDS score and SAS score between participants aged 40 years and below and that of those over 40 years of age [Table 7]. The median SDS score in the staff aged 40 years and below was 43, and that of the staff aged above 40 years was 40. Younger responders had significant higher SDS scores than the older responders (U = 1.184E7, Z = −6.050, P < 0.0005). A similar trend was observed for the SAS scale.
Table 7: Participants under 40 and over 40

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  Discussion Top


Here, we present our recent online survey on the psychological impact of the COVID-19 outbreak on hospital staff in China around the peak of the epidemic. Among all the participants, the majority (57%) reported that they often felt anxious or panicked, and a significant minority (14%) reported that they never experienced anxiety. About 5% of the respondents reported moderate or high levels of anxiety, while 13% reported moderate or high levels of depression. These data are critical to help understand the medical staff's stress and the factors associated with those stress. The level of perceived disaster-related risk will be influenced by a person's level of awareness and knowledge related to the disaster. Programs aimed at raising such knowledge and awareness influence peoples' perceptions, and may help a society to become better prepared and potentially be able to obtain more control of a disaster situation; however, such programs are currently unavailable at the outbreak of COVID-19. More efforts are needed to quickly establish such programs.

There are several notable findings in the present survey. First, we found that more than one-half of the participants (57%) reported that they often felt anxious or panicked even they were not currently dealing with COVID-19 patients. The National Health Commission of China released notification of basic principles for emergency psychological crisis interventions for 2019-nCoV pneumonia on January 26, 2020;[9] however, this notification only emphasizes that mental health care should be provided for frontline medical workers directly caring for infected patients and does not mention any suggestions for the mental health problems of nonfrontline medical workers who report high-level stress in this study. Early experience of a university teaching hospital in responding to the psychological and occupational impact of the SARS outbreak on hospital workers reported fear of contagion and of infecting family, friends, and colleagues immediately after the outbreak.[10] This survey suggests that the psychological impact may appear in the medical staff before they even contact or care for infected patients.

Second, we found that nurses have higher levels of stress compared to physicians. Confounding factors may be relatively young and mostly female group of responders. One study of a hospital outbreak of vancomycin-resistant enterococci reported a severe burden on nursing staff.[11] In addition, nurses are responsible for the collection of sputum for virus detection, which may be significantly a dangerous work. Similarly, younger staff reported higher levels of stress compared to older staff. The most recent outbreak of highly infectious disease in China was SARS that occurred in mid-November 2002 in Guangdong Province and killed 349 patients in mainland China. Since 18 years have passed since the outbreak of SARS, medical staff older than 40 years have likely experienced and remember the SARS epidemic and are thus more mentally prepared for COVID-19 compared with their younger colleagues. We speculate that the younger staff's level of fear and worry related to an infectious disease outbreak may be greater if they live with children or have significant family responsibilities.

Although one of the strengths of this study is the examination of levels of stress symptoms in a relatively large sample of people comprised of various types of hospital staff, this study is limited by its relatively few participants from Hubei province, which has the most extensive and serious situation and has most of the frontline medical staff. Because COVID-19 is highly contagious, the frontline medical workers are exposed to more viral particles than nonfrontline medical workers. In addition, long work hours required to provide care could suppress their immune systems and increase stress. However, the findings do provide valuable information for policymakers and mental health professionals worldwide regarding the psychological impact of an infectious disease outbreak, which may assist them in making preparations for possible outbreaks in areas outside China.

When we were preparing this manuscript, two comments were published regarding potential COVID-19-related mental health of the hospital workers in China. Kang et al. pointed out that presently mental health care for the patients and health professionals directly affected by the 2019-nCoV epidemic has been underaddressed, although psychological intervention teams have been set up in a few hospitals; several psychological assistance hotline teams providing telephone guidance to help deal with mental health problems are also available.[12] Hundreds of medical workers are receiving these interventions with good response.[13] However, we found that 65% of medical staff reported inability to find a suitable solution to their psychological distress. Therefore, additional resources for psychological intervention appear to be necessary. Indeed, 60% of medical staff believed that psychological intervention should be implemented at the very beginning of an epidemic outbreak to help deal with psychological distress.


  Conclusions Top


During the COVID-19 pandemic, Chinese medical staff have been placed under great psychological pressure and are dealing with high risk of psychological distress. In addition to quickly establishing programs that provide knowledge on the virus, timely psychological support and intervention should be provided to the medical staff to alleviate their anxiety and improve their general mental health.

Financial support and sponsorship

This work is supported by The National Key R&D Program of China (2017YFC1104100, 2018YFC2000704), Beijing Municipal Administration of Hospitals Climbing Talent Training Program (DFL20150801), Beijing Municipal Administration of Hospitals Incubating Program (PX2018035), and Beijing Municipal Administration of Hospitals' Youth Program (QML20180804).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 5
    
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Zung WW. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63-70.  Back to cited text no. 8
    
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National Health Commission of China Principles for Emergency Psychological Crisis Intervention for the New Coronavirus Pneumonia (in Chinese). Available from: http://www.nhc.gov.cn/jkj/s3577/202001/6adc08b966594253b2b791be5c3b9467.shtml. [Last accessed on 2020 Dec 24].  Back to cited text no. 9
    
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Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003;168:1245-51.  Back to cited text no. 10
    
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Mitchell A, Cummins T, Spearing N, Adams J, Gilroy L. Nurses' experience with vancomycin-resistant enterococci (VRE). J Clin Nurs 2002;11:126-33.  Back to cited text no. 11
    
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Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX, et al. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry 2020;7:e14.  Back to cited text no. 12
    
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Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry 2020;7:e15-e16.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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