key: cord-0763309-chpde9ix
authors: Carriero, Maria Chiara; Conte, Luana; Calignano, Marica; Lupo, Roberto; Calabrò, Antonino; Santoro, Pietro; Artioli, Giovanna; Caldararo, Cosimo; Ercolani, Maurizio; Carvello, Maicol; Leo, Antonio
title: The psychological impact of the Coronavirus emergency on physicians and nurses: an Italian observational study
date: 2021-07-29
journal: Acta Biomed
DOI: 10.23750/abm.v92is2.11575
sha: 7db85fd99ba5a9f1b31464497d6837dc94b81f05
doc_id: 763309
cord_uid: chpde9ix

BACKGROUND AND AIM OF THE WORK: The Coronavirus has put a strain on the response capacity of health systems and there are various psychological effects on health workers. AIM OF THE STUDY: To investigate the psychological impact of the coronavirus emergency on physicians and nurses. METHODS: A study was conducted on a sample of nurses and physicians (n=770), who were asked to fill in a questionnaire investigating physical and psychological problems. It also included the IES (Impact Event Scale), STAI (State Trait Anxiety Inventory) scale and BDI (Beck Depression Inventory). RESULTS: 87.7% of the sample was represented by nurses (n=675), 12.3% (n=95) by physicians. 52.3% (n=403). Among the psychological symptoms, stress (76.2%; n=587), anxiety (59.4%; n=457) and depression (11.8%) prevailed and only 3.9% of the healthcare personnel sought help from a psychologist. The total score of the IES-R scale was 3.47. A significant association emerged between exposure and the risk of contagion (p-value = 0.003), stress was more present among nurses than among physicians (77.5% vs. 67.4%; p = 0.003). Among physical symptoms, headache (52.2%; n=402) and pressure injuries (24.8% n= 191) prevailed. CONCLUSIONS: The results of the study show that mental health monitoring of health workers, who are at risk of developing major psychological disorders, is a priority.

On 31 December 2019, Chinese health authorities notified an outbreak of pneumonia cases of unknown aetiology in Wuhan city (Hubei, China). On 9 January 2020, the China CDC (Centre for Disease Control and Prevention of China) identified a new Coronavirus (called 2019-nCoV) as the etiological cause of this disease. On 30 January 2020, the World Health Organization (WHO) designated the COVID-19 outbreak a "public health emergency of international concern" (1). From 23 March 2020, this new Coronavirus (Sars CoV-2) spread rapidly around the world, infecting more than 294,110 people in 187 countries and killing 12,944 people (2) . Pandemic conditions require an immediate response in terms of medical assistance, with health and social care workers having to be at the forefront of the epidemic in the various health service settings. It has affected and is drastically affecting all social and economic sectors of the world and, above all, has caused a number of adverse physical and psychological effects in the general population and among health workers (3) . Several studies show that concern about high mortality rates and restrictions on people's lives have contributed to higher levels of anxiety, depression and sleep disorders in the general population. (4) . Psychological disorders can also manifest themselves in non-functional attitudes, such as continuous medical consultations to obtain reassurance, distrust of public authorities, (5) or discrimination and stigma towards particular populations (6) . In addition, many events such as the ever-increasing number of deaths and confirmed and suspected cases, the workload and physical fatigue, the exhaustion of protective equipment, the widespread media coverage, the lack of specific drugs, the choice among patients whom to treat/select for essential therapy due to the lack of medical supplies, the risk of infection, the feeling of not being supported are all factors that can contribute to the formation of important psychological symptoms (7) . Health workers are therefore faced with critical situations that increase the risk of psychological distress. (8) and this could have serious repercussions not only on their quality of life but also on the quality of care provided to the patient. Studies conducted in Turkey, Iran and Spain confirm the prevalence of psychological symptoms among healthcare workers. A study conducted in China (9) showed that depression (50.4%), anxiety (44.6%), insomnia (34.0%) and stress (71.5%) were the most common psychological symptoms. Risk factors included being female, being a nurse, having a high risk of contracting COVID-19 or having at least one family member with COVID-19 (9) and social isolation are the most cited for the development of severe psychological symptoms (7) .

The global spread of COVID-19 has therefore put the responsiveness of health systems to the test and numerous research studies are needed to assess the mental health of health workers, given their important role in responding to the situation. In addition, WHO also recommends that a large number of studies should be carried out in these circumstances (11) , to provide guidelines that can help strengthen the response capacity of health systems. In Italy, there are still few studies that have analyzed the psychological impact of the pandemic, looking at levels of anxiety and depression among medical and nursing staff. Our study aims to provide empirical data on the psychological outcomes of the pandemic in health workers.

To investigate the psychological impact of COVID-19 emergency on a population of physicians and nurses.

To survey the lifestyle, physical and psychological health status and difficulties experienced by health workers during the period of the Coronavirus emergency, from April 2020 to June 2020.

Observational, cross-sectional and multicentre study.

The study, conducted from April to June 2020, was carried out through the online dissemination of a questionnaire distributed by means of a link to all the presidents of the provincial orders of nursing and medical professions in the Country. All the Presidents of the Orders were sent an e-mail presenting the study and formally requesting their participation in the survey. Some of them did not reply to the e-mail. Others, however, did not wish to participate in the study. Only a few Presidents of the Orders agreed to participate in the survey, specifically eight provincial Orders of Nursing Professions (Lecco, Mantua, Genoa, Varese, Como, Lecce, Brindisi and Trapani) and one Order of Physicians and Dentists in the province of Lecce. After having obtained the access authorizations from the respective Presidents to the mailing list, each medical and nursing professional belonging to the Order was sent an e-mail containing a brief presentation of the survey and the link to access the online questionnaire. Medical and nursing professionals, including nursing coordinators and nursing managers, working in both the public and private sectors were included in the study. They aged between 20 and 70 years and agreed to participate in the study by signing the informed consent. All medical and nursing professionals waiting for their first job were excluded. N=770 health professionals agreed to participate in the study.

The survey instrument consists of 4 sections. The first section is aimed at collecting social-demographic data from participants, the second section was created by the study managers and explores the pandemicinduced lifestyle (12 items) and potential physical and psychological problems arising during the COVID-19 emergency (25 items). The third section includes the Impact Event Scale (IES) instrument (12) , validated in the Italian language (13), widely used test to assess through 21 items the psychological impact and stress reactions caused by traumatic events. It consists of two subscales measuring the experiences of intrusion (items 1, 4, 5, 6, 10, 11, 14) and avoidance (items 2, 3, 7, 8, 9, 12, 13, 15) . The items are rated on a 4-point Likert scale ranging from 0 ("not at all") to 4 ("extremely"). The fourth section includes the State Trait Anxiety Inventory scale consisting of 20 items (14) which assesses the level of Trait Anxiety, as a tendency to perceive stressful situations as dangerous and threatening. The items are rated on a 4-point scale (1 to 4) corresponding to "Not at all", "A little", "Somewhat" and "Very much". Higher scores are positively correlated with higher levels of anxiety. The fifth section is the Beck Depression Inventory (BDI) scale (15) (16) , consisting of 13 items that measure the presence and severity of depressive symptoms. The scale was constructed to measure the behavioral manifestations of depression, favoring the cognitive correlates, namely: sadness, pessimism, failure, dissatisfaction, guilt, self-esteem, suicide, loss of interest, indecision, appearance, work, fatigue, appetite. The test can be answered with a score from 0 to 3, while the total score ranges from 0 to 63. Scores from 0 to 13 indicate no depressive content; scores from 14 to 19 mild depression; scores from 20 to 28 moderate depression; scores from 29 to 63 severe depression.

All sections of the questionnaire were computerized using a pre-set form from the Google Drive platform.

Within the presentation of the questionnaire, the ethical characteristics of the study were stated. It was emphasized that participation was voluntary, and that the participant could refuse to take part in the protocol whenever he or she wished. Those interested in participating were given an informed consent form, which reminded them of the voluntary nature of participation, as well as the confidentiality and anonymous nature of the information. In addition, to ensure that the questionnaires were anonymous and to allow for identification of participants, a sequential identification (ID) number was given to each registered participant. Each questionnaire, therefore, had an ID number that corresponded to the database ID.

Descriptive analyses were conducted for all qualitative and quantitative variables using R-Studio software version 3.6.1. Continuous variables were summarized by means of mean and standard deviation (SD) and categorical variables by means of frequencies and percentages. After the descriptive analysis of all variables, the correlation between the S.T.A.I.-Y2 and B.D.I. scales and between these and the characteristics of the sample was analyzed. The ANOVA test was used to evaluate the difference between mean values on the IES; S.T.A.I.-Y2 and BDI scales. The association between occupational profile and levels of anxiety and stress, between work area and the impact scale, between exposure and the onset of symptoms was analyzed using the Anova tests. For all inferential analyses, statistically significant results below the 5% threshold are reported.

The sample that took part in the survey consisted of 770 health workers with a prevalence of the female gender (74.3%; n=572). Of the 770 participants in the study 675 were nurses (87.7%) and 95 were physicians (12.3%). 31% of the respondents had work experience of 1 to 5 years (n=239) and 49.2% had a Bachelor's degree as their highest level of education (n=379). 51.7% (n=391) live in the North, 16 .4% (n=124) in the Centre and 31.9% (n=241) in the South. 78.6% of the sample (n=594) were not located in an area other than their own residence. 77.2% (n=584) worked closely with COVID-19 patients (not necessarily in a COVID-19 department), 33.3% (n=252) had to change department/ work area due to the COVID-19 emergency. The area of work most represented in the study was the Critical Emergency Area (emergency department, 118, emergency medicine, intensive care, intensive short observation) with a percentage of 34.4% (n=265) (Tab. 1). 

The study found that 17.5 % (n=135) of healthcare workers developed symptoms indicative of Sars CoV-2. However, 13.9 % (n=107) did not stop working, 31.6 % (n=246) were not tested, 19.5 % (n=150) had difficulty undergoing the screening test, just over half of the sample 55.2 % (n=425) underestimated the public health effects of the pandemic during the initial days of the pandemic. 52.3% of the sample (n=403) did not feel that they had received good training from their health authority on the correct use of Personal Protective Equipment (PPE) against SARS CoV-2. 51.3% (n=395) stated that these devices were insufficient. 18.2% (n=140) stated that they had experienced at least one moment when they had to choose among patients whom to treat/select for essential treatment due to lack of medical supplies. 15.5% of the sample chose whom to treat by age (n=119). Among the main concerns experienced during the pandemic, fear of making loved ones ill prevailed in 64.9% (n=500) (Tab. 2).

In the second section the participant was asked to define their physical and psychological health status by means of a form with a detailed list (25 items) of potential physical and psychological problems that 

The total scores of the event impact scale, its subscales, trait anxiety and depression levels are shown in Table 4 . Mean and SD were calculated for the total score and the subscales of the IES questionnaires associated with the work areas. Considering a score ranging from 0 ("not at all") to 4 ("extremely"), it can be seen that the territorial work area already showed high scores in the early stages of the pandemic (IES_R 6.99) followed by the COVID-19 area (IES_R 3.86), indicating the presence of PTSD. The results are reported in Table 5 . Statistically significant results emerged between those who worked in close contact with COVID-19 patients and those who developed symptoms indicative of COVID-19 infection, where among other things the percentage of those who had COVID-19 symptoms doubled (19.5% compared to 9.9%) (Tab. 6). From the association between the professional profile and the levels of stress and levels of anxiety it emerges respectively that among nurse's stress is more present than among physicians (77.5% compared to 67.4%; p = 0.030) (Tab. 7); as well as for the various levels of anxiety, where however the chi-square test is not significant below the 5% threshold, but is significant at 10% (p = 0.083) (Tab. 8) 

This study aims to investigate the psycho-physical impact of the COVID-19 emergency on the quality of life, work-related stress and psycho-physical wellbeing of health workers. The sample that took part in the study by filling in the questionnaire consisted of 770 participants including nurses and physicians, 74.3% of whom were female, with work experience of 1 to 5 years and a three-year degree. The data from this study is in line with the study by Kang et al., (17) , which shows both that the majority of professionals (24) and Seale et al. (25) : Both agree that nurses are at the forefront of the health system's response to both epidemics and pandemics. In addition, nurses provide care directly to patients in close physical proximity, are often directly exposed to these viruses and are at high risk of developing disease. 59.7% of the sample were rescuers or health workers who come into contact with positive people or people who know someone who has tested positive. 40.1% believed they had been exposed to 11-100 people, 64.0% were tested for COVID-19, 48.1% were tested for COVID-19 1-2 times, 82% had no flu-like symptoms or symptoms indicative of COVID-19 infection and 13.9% did not stop working after developing these symptoms. After developing symptoms indicative of COVID-19 5.1% continued to work, 0.6% started medical treatment, 3.8% physically moved away from family/loved ones, 1.6% went to the emergency room, 1.4% went to the general practitioner, 6.9% voluntarily quarantined themselves, consistent with the study by Lam and Hung, 2013 (18) . The results of our study show a significant association between work area and risk of Post-Traumatic Stress Disorder (PTSD), in particular the territorial areas (community medicine) and COVID-19 area are those with higher scores (IES_R 6.99 & IES_R 3.86). The greatest concern that health workers feel in this period is that of making loved ones ill. This result is consistent with the findings of some studies (18, (26) (27) (28) , which found that the risk of being infected, transmission to family members, stigma about vulnerabilities in their work and restrictions on personal freedom were reported as key concerns (29) In addition, 34.2% presented mild anxiety, 17.0% presented moderate anxiety and 5.5% presented severe anxiety; this is in full agreement with several studies (15, 28) which highlight the fact that nurses experienced greater anxiety about their health while caring for infected patients during a pandemic. (29) . This does not deviate from what was previously stated by Pappa et al. (32) which showed that most experienced mild symptoms for both depression and anxiety, while moderate and severe symptoms were less common among participants. The results of our study show that nurse practitioners experienced higher levels of stress in the early months of the pandemic than physicians (see Table VII ). This underlines the need for early diagnosis and the importance of effectively collecting and treating psychological symptoms before they develop into more complex and lasting clinical pictures as shown by the results of a study conducted in Italy (33) . Mental health monitoring and adequate psychological care and intervention must therefore be considered fundamental for the support of the whole community and, in particular, of the most fragile or exposed persons, such as health workers.

The results of our study must be considered taking into account some limitations concerning the sample size, which consisted in the majority of nurses compared to physicians; the lack of follow-up of the psychological consequences and the lack of investigation of the long-term effects of the participants in the study and, finally, the choice of electronic dissemination of the questionnaire that may have excluded professionals Physicians and nurses with a low computer background. However, this could be considered as a preliminary study that could contribute to the understanding of psychological consequences among healthcare professionals involved in the SARS-CoV-2 epidemic.

This study aims to investigate the psychological impact of the Coronavirus emergency on healthcare professionals, physicians and nurses. Furthermore, it aims to return a greater awareness not only of the emotional and psychological consequences but also of the difficulties experienced by healthcare professionals during this period, particularly from April 2020 to June 2020. Looking to the future, further studies could investigate the psychological impact not only on healthcare professionals but also on social and health workers (OSS), who were also on the frontline during the Pandemic. In addition, it would be useful to analyses the long-term effects of this emergency in order to suggest appropriate interventions at both local and national levels. It might also be useful to investigate the effectiveness of psychological support in such delicate situations.

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We would like to thank the medical and nursing professionals who contributed to this study. We would like to thank in particular Dr. Filippini Aurelio (President of order of nursing professions, province of Varese) and Dr. Marchisio Daniele (President of the scientific society "G.F.T -Triage Training Group) for having contributed to the realization of this contribution.

Each author declares that they have no commercial associations (e.g. consultancies, shares, patent/licence agreements, etc.) that could lead to a conflict of interest in relation to the submitted article.