key: cord-0773360-0nocn8l6
authors: Sharma, Monisha; Creutzfeldt, Claire J; Lewis, Ariane; Patel, Pratik V; Hartog, Christiane; Jannotta, Gemi E; Blissitt, Patricia; Kross, Erin K; Kassebaum, Nicholas; Greer, David M; Curtis, J Randall; Wahlster, Sarah
title: Healthcare professionals’ perceptions of critical care resource availability and factors associated with mental well-being during COVID-19: Results from a US survey
date: 2020-09-02
journal: Clin Infect Dis
DOI: 10.1093/cid/ciaa1311
sha: 3b44e6f1f055617a06765fff07ae69306ed459fa
doc_id: 773360
cord_uid: 0nocn8l6

BACKGROUND: Assessing the impact of COVID-19 on intensive care unit (ICU) providers’ perceptions of resource availability and evaluating factors associated with emotional distress/burnout can inform interventions to promote provider well-being. METHODS: Between April 23-May 7, 2020, we electronically administered a survey to physicians, nurses, respiratory therapist (RTs) and advanced practice providers (APPs) caring for COVID-19 patients in the US. We conducted multivariate regression to assess associations between concerns, reported lack of resources and three outcomes: emotional distress/burnout (primary outcome), and two secondary outcomes: 1) fear that hospital is unable to keep providers safe, and 2) concern about transmitting COVID-19 to family/community. RESULTS: We included 1,651 respondents from all 50 states; 47% nurses, 25% physicians, 17% RTs, 11% APPS. Shortages of intensivists and ICU nurses were reported by 12% and 28% of providers, respectively. The largest supply restrictions reported were for powered air purifying respirators (PAPRs); (56% reporting restricted availability). Provider concerns included worries about transmitting COVID-19 to family/community (66%), emotional distress/burnout (58%), and insufficient personal protective equipment (PPE) (40%). After adjustment, emotional distress/burnout was significantly associated with insufficient PPE access (aRR: 1.43, 95% CI: 1.32 - 1.55), stigma from community (aRR: 1.32, 95% CI: 1.24 - 1.41), and poor communication with supervisors (aRR:1.13, 95% CI: 1.06 - 1.21). Insufficient PPE access was the strongest predictor of feeling that the hospital is unable to keep providers safe and worries about transmitting infection to families/communities. CONCLUSION: Addressing insufficient PPE access, poor communication from supervisors, and community stigma may improve provider mental well-being during the COVID-19 pandemic.

The United States (US) has been disproportionately impacted by the COVID-19 pandemic; despite having less than 4% of the world's population, the US accounts for 28% of COVID-19 infections and 25% of COVID-19-related deaths worldwide. [1] The pandemic has overwhelmed healthcare systems which are struggling to care for massive surges in numbers of critically-ill patients. Maintaining a healthy workforce of healthcare professionals (HCPs) including physicians, nurses, respiratory therapists (RTs), and advanced practice providers (APP) is crucial to providing quality care for the growing volume of patients. [2] As US states start to relax social distancing guidelines, many regions are experiencing a resurgence of COVID-19 cases, placing renewed strain on HCPs and the healthcare system. [3] Recent studies have found high prevalence of stress and burnout among HCPs on the front lines of the COVID-19 response as they face a rapidly shifting work environment with increasing demands and heightened uncertainty. [4] [5] [6] Assessing HCPs' perceptions of resource availability, emotional stressors and job-related concerns during the pandemic can inform targeted interventions to support provider mental health and enable them to continue delivering high quality care to patients. [2] We aimed to characterize intensive care unit 

This study followed the STROBE guidelines for the reporting of cross-sectional studies. [7] A research team of physicians, nurses, RTs and APPs designed a 41-question online survey to elicit perspectives across domains including resource availability, personnel shortages and concerns during COVID-19. Prior to administration, the survey was pilot-tested to 30 HCPs and refined based on participant feedback. The overall aim of the survey was to assess the impact of COVID-19 on HCPs globally; however the present analysis is restricted to the US with the goal of assessing HCPs perceptions and concerns nationwide and by geographic region.

The study was approved by the University of Washington Institutional Review Board. Before survey initiation, respondents were informed that their responses were anonymous, and summary results would be shared with the scientific community. Responses were stored without participant identifiers using REDCap electronic data capture software. [8] 

Our target population was physicians, physicians-in-training (residents and fellows), nurses, RTs, and APPs (nurse practitioners, physician assistants, and certified registered nurse anesthetists), self-reporting that they cared for COVID-19 patients in an ICU. The survey was administered between April 23 rd 2020-May 7 th 2020 to coincide with the initial pandemic peak in many US states.

We distributed the survey via scientific member societies, email to personal contacts, and social media groups restricted to HCPs caring for COVID-19 patients on platforms including Facebook and

A c c e p t e d M a n u s c r i p t 7 Variable categorization US states were grouped into five commonly used geographic regions: Northeast, Southwest, West, Southeast, and Midwest.

[9] A list of states in each region is provided in the Appendix. We categorized states by COVID-19 pandemic stage: 1) pre-peak, 2) during-peak, and 3) post-peak using a three-day rolling average of number of deaths per day [10, 11] . We classified states into COVID-19 pandemic severity category at the mid-point of data collection using a three-day rolling average of number of new cases/100,000 persons as: 1) <250 cases/day, 2) 250-750 cases/day, and 3) >750 cases/day (Supplemental Table 1 -3). [12] Statistical analysis Descriptive statistics were used to report participant characteristics and survey responses.

Our main outcome was HCP emotional distress/burnout in caring for COVID-19 patients, captured as a dichotomous variable. We assessed two secondary outcomes 1) HCPs concerns that their hospital was unable to keep them safe, and 2) concern about transmitting COVID-19 to their families/communities (See appendix for full survey). We conducted univariate and multivariate logbinomial regression with robust standard errors to assess factors associated with outcomes of interest. Exposures that were statistically significant in univariate regression were considered for inclusion in multivariate models. Those that did not improve the model fit using the likelihood ratio test were excluded. Analyses were conducted using R Software. [13] [14] [15] A c c e p t e d M a n u s c r i p t 8

Overall, 3,182 participants completed part of the survey and 2,706 met inclusion criteria for the global survey. Of these, 61% (N=1,651) reported practicing in the US and were included in the analysis ( Figure 1, Supplemental Figure 1 ). States with the highest number of respondents were Washington (N=268), California (N=176), Michigan (N=146), Massachusetts (N=120), and New York (N=105), which were some of the hardest hit states in the beginning of the pandemic (Table S1 and S3). Of total participants, 47% were nurses, 25% were physicians or physicians-in-training, 17% were RTs, and 11% were APPs (Table 1 ). Most HCPs practiced in large, urban teaching hospitals (69%) and 74% were female. Half of HCPs reported having cared for 10-50 COVID-19 patients; 12% reported having cared for >50 COVID-19 patients (highest in the Northeast 24%). Overall, 26 states were surveyed during COVID-19 pandemic peak, 13 were post-peak and 11 were pre-peak (Table S1 ).

Across geographic regions, 12% of HCPs reported a shortage of intensivists at their hospital, while a shortage of ICU nurses was more commonly reported (28%); 11% reported a shortage of ICU beds ( Table 2 ). All three shortages were reported most often in the Northeast, largely driven by high shortages in New York, New Jersey, and Connecticut (Supplemental Figure 2-4) . Availability of most personal protective equipment (PPE) was high across regions; most HCPs reported gloves, surgical masks, and gowns were always available (71-97%) ( Table 2 ). Approximately half of respondents reported that face shields and eye protection were always available; 40% stated that availability was restricted for select HCPs or based on patient characteristics. One third (33%) of HCPs reported N95 masks were always available, while 59% stated availability was restricted. The largest restrictions reported were for powered air purifying respirators (PAPRs); just 15% of HCPs reported that they M a n u s c r i p t 9 were always available, while 56% reported restricted availability. While supply shortages for most types of PPE were low (<10%), 29% of HCPs reported intermitted supply shortages of PAPRs. Overall, 27% of HCPs reported agreeing completely with their hospital's PPE policy, and 46% agreed somewhat. Overall, 10% of HCPs reported complete disagreement with PPE policy (highest in the Southwest 20%). Stratifying by occupation revealed that 50% of physicians agreed completely with hospital PPE policy compared with just 15% of nurses (Table S4 ). Across regions, 38% of nurses disagreed somewhat or completely with hospital PPE policy compared to just 7% of physicians.

Overall, 37% of HCPs reported that COVID-19 testing was available for all patients (ranging from 19% in the Southwest to 44% in the Northeast), while 63% reported restricted availability based on patient characteristics. No HCPs reported a complete lack of patient testing. Compared to patient COVID-19 testing, reported restrictions were higher for HCP testing, with 13% reporting universal availability and 79% reporting testing restrictions based on HCPs' symptoms/exposures.

Overall, 7% of respondents stated testing was completely unavailable for HCPs (highest in the Southwest 18%). Self-reported testing availability differed substantially by provider type (Table S5) .

While 54% of physicians and 69% of physicians-in-training reported patient COVID-19 testing was available to all patients, just 26% of nurses and 21% of RTs reported universal availability. Similarly, 27% and 20% of physicians and physicians-in-training reported that COVID-19 testing was available for all HCPs, while 6% of nurses and 7% of RTs reported universal availability.

The most common HCP concerns were transmission of COVID-19 infection to one's family/community (66%), emotional distress/burnout (58%), and worries about one's own health (49%), which were high across all regions (Table 2 and Supplemental Figure 4 ). Overall, 40% of HCPs reported insufficient access to PPE, 26% felt that their hospital was unable to keep them safe and A c c e p t e d M a n u s c r i p t 10 22% reported poor communication with supervisors; all three concerns were highest in the Southwest. Social stigma from the community was reported by 26% of HCPs (highest in the Southwest 38%). Overall, 12% of HCPs reported worries about their financial situation. Concerns were generally more common in nurses, RTs, and APPs compared to physicians and physicians-intraining ( Figure 2 and Table S5 ). Emotional distress/burnout was highest among nurses (64%), APPs (56%) and RTs (55%), compared to physicians and physicians-in-training (49% and 48%, respectively).

Compared to physicians, nurses were more likely to report insufficient PPE (47% vs 31%), feeling the hospital is unable to keep them safe (32% vs 14%), poor communication with supervisors (27% vs 12%), and stigma from community (33% vs 11%).

In multivariate analysis, higher likelihood of emotional distress/burnout was most strongly associated with reporting insufficient PPE access (adjusted relative risk (aRR): 1.43, 95% CI: 1.32 -1.55) and social stigma from one's community (aRR: 1.32, 95% CI: 1.24 -1.41) ( Table 3) . Poor communication with supervisors was also associated with a higher risk of emotional distress/burnout (aRR:1.13, 95% CI: 1.06 -1.21) as were worries about one's financial situation (aRR:

1.09, 95% CI: 1.01 -1.18). Compared to HCPs who cared for <10 COVID-19 patients, those caring for ≥10 COVID-19 patients had a higher risk of emotional distress/burnout (aRR: 1.14, 95% CI: 1.05 -1.23). Perceived shortages of ICU nurses were associated with higher risk of burnout, (aRR: 1.10, 95% CI: 1.03 -1.18) while limited availability of PAPR was marginally associated (aRR: 1.12, 95% CI: 0.99 -1.28). Emotional distress/burnout was not significantly associated with geographic region, COVID-19 testing availability, COVID-19 severity, or timing from peak (Table 3a and Table S5 ).

Although nurses and females had a higher risk of emotional distress/burnout in univariate analysis, this association was no longer statistically significant after adjusting for other factors in multivariate A c c e p t e d M a n u s c r i p t 11 analysis. Similarly, intensivist shortages and lack of ICU beds were not associated with emotional distress/burnout in multivariate regression (aRR close to 1.0, data not shown).

After adjustment for covariates, HCPs who reported insufficient access to PPE were 5.82 times more likely to feel that their hospital is unable to keep them safe (95% CI: 4.36 -7.82) (Table   3b ). Limited availability of PAPR (aRR: 1.62, 95% CI: 1.14 -2.30), lack of ICU nurses (aRR: 1.46, 95% CI: 1.27 -1.67), poor communication with supervisors (aRR: 1.76 95% CI: 1.52 -2.04) and social stigma from the community (aRR: 1.23, 95% CI: 1.07 -1.40) were also associated with HCPs feeling that their hospital is unable to keep them safe. Although females, nurses, APPs, and RTs had a higher risk of reporting that hospitals are unable to keep them safe in univariate analysis, these associations were no longer statistically significant after adjustment in multivariate analysis. Similarly, shortages of intensivists, lack of ICU beds, and testing availability were not associated with the outcome in multivariate regression (aRR close to 1.0, data not shown); COVID-19 testing availability, COVID-19 severity, or timing from peak were not associated with the outcome (Table S6) transmitting infection to one's family/community. Physicians were at slightly higher risk of concern about transmission compared to nurses, APPs and RTs, while region and gender did not show significant associations.

A c c e p t e d M a n u s c r i p t 12

In this nationwide survey of HCPs caring for COVID-19 patients, we find substantial reported shortages of personnel and PPE, as well as high rates of emotional distress/burnout across geographic regions. Shortages of ICU nurses were more commonly reported than shortages of intensivists or ICU beds, and all three were highest in the Northeast. This is likely related to the higher reported volume of COVID-19 patients in the Northeast during the survey period. Significant numbers of respondents reported restricted availability of N95 masks, face shields, and eye protection, with the largest supply shortages and restrictions reported for PAPRs.

Perceptions about availability of PPE and COVID-19 testing differed by HCP type. Nurses were more likely to report restrictions on N95 masks availability than physicians and physicians-intraining and more likely to report concerns about insufficient PPE and disagreement with hospital PPE policy. While most physicians reported COVID-19 testing was available for all patients, less than a quarter of nurses and RTs reported universal availability. Our results are consistent with another US survey of ICU providers during COVID-19 conducted by the Society for Critical Care Medicine, which found nurses were less likely to report their hospital was prepared to care for COVID-19 patients and more likely to express concerns about PPE shortages compared to physicians. [16] This finding may indicate discrepancies in communication of hospital policies by HCP type. Additionally, nurses often spend more time at the bedside of sick patients and may feel shortages more acutely; they may also have higher levels of supervision compared to physicians. However, the findings may also represent differences in hospital settings. Future research to investigate these discrepancies is needed as they may have important implications for provider well-being and nurse/physician collaboration.

The most commonly reported HCP concerns include worries about transmitting infection to family/community and worries about their own health, consistent with a previous survey of ICU providers in the US[6]. Concerns were generally more common in nurses, APPs, and RTs compared A c c e p t e d M a n u s c r i p t 13 to physicians or physicians-in-training. The prevalence of emotional distress/burnout in our study was similar to that of another HCP survey conducted during COVID-19 that reported 62% burnout in the US (compared to 58% found in our study), which is higher than pre-pandemic levels of emotional distress/burnout in critical care HCPs (50%). [5, 17, 18] Provider concerns are likely exacerbated by reported lack of PPE, which was the strongest predictor of all three outcomes assessed: emotional distress/burnout, feeling that the hospital was unable to keep HCPs safe, and worries about COVID-19 transmission to family/community. HCPs who reported insufficient PPE were nearly 6-times more likely to feel that hospitals could not keep them safe, which is a substantially large association; specifically restricted availability of PAPR was a salient predictor. As the pandemic steadily continues in the US, sustained and coordinated efforts to prioritize PPE for HCPs are critical to protecting the mental health and morale of frontline healthcare workers. Additionally, more research is needed to understand the types of PAPR restrictions most associated with stressors among HCPs, as reporting restricted availability could either indicate that HCPs can obtain a PAPR after completing a request process or that their request is denied because it falls outside hospital guidelines for intended use. Future research is also needed to assess types of hospital PPE policies most likely to elicit provider disagreement, including whether policies following CDC guidelines are less likely to elicit disagreement.

Poor communication from supervisors was another modifiable risk factor of emotional distress/burnout and other concerns among HCPs. With unprecedented changes in workload, shifting responsibilities, and rapidly evolving hospital policies during COVID-19, supervisors may feel unsure about how to communicate difficult decisions with transparency. However, leadership serves a crucial role in creating an environment that supports the mental health of HCPs, through tangible support such as availability of PPE and mental health services, as well as expressions of gratitude and appreciation. [19] Targeted training to improve supervisory support systems and promote clear communication may improve HCPs well-being during the pandemic. Stigma from one's community A c c e p t e d M a n u s c r i p t 14 was associated with higher risk of HCP emotional distress/burnout and concerns and was more commonly reported among nurses (33%) compared to physicians (11%). Although HCPs may be perceived as "healthcare heroes," they can simultaneously experience distancing from their community due to fears that they are at high risk of having COVID-19. [20] We find a lack of studies in the literature regarding HCPs perceptions of stigma and interventions to reduce stigma, suggesting more research is needed in this important area. Additionally, shortage of ICU nurses was a stronger predictor of HCP concerns and burnout than shortage of intensivists. Since nurses may be more likely to experience burnout, our findings highlight the importance of maintaining an emotionally healthy workforce of nurses to support high-quality care to patients during the pandemic.

Our findings that nurses and females have a higher likelihood of experiencing emotional distress and burnout is consistent with other studies conducted during COVID-19 [4, 5] . However, after adjustment in multivariate regression, burnout was no longer associated with gender or occupation. This suggests that the higher likelihood of emotional distress/burnout among nurses and females may be largely mediated by concerns about insufficient access to PPE, poor communication with supervisors, and social stigma. Interventions targeted towards alleviating these concerns may reduce the higher burnout rates observed in these groups. Further, only 105 respondents in our sample were physicians-in-training. More studies are needed to assess differences in perspectives across specialties and training level. Additionally, due to the crosssectional nature of our study, we cannot determine the directionality of the relationships assessed or evaluate long-term trends or longitudinal predictors of concerns. Further, due to our sampling approach, we are unable to assess participation rates among persons who saw the survey, which may limit generalizability. Finally, the two-week sampling period provides a snapshot of HCPs' experiences which are likely dynamically changing as the pandemic evolves. For example, we found that <15% of HCPs were worried about their financial situation; however, this proportion may increase over time as hospitals institute layoffs or furloughs.

Experts recommend understanding the specific sources of HCPs' concerns to effectively target interventions, rather than teaching general approaches to stress reduction. [2] We assessed a broad range of HCP perceptions regarding shortages of PPE, personnel, ICU beds, and COVID-19 testing and rigorously evaluated predictors of emotional distress/burnout and other concerns. Our analysis suggests insufficient access to PPE is the strongest predictor of provider concerns and burnout. In addition, addressing poor communication from supervisors, nursing shortages, and social stigma may help mitigate concerns an improve HCP mental well-being during COVID-19 and future pandemics.

A c c e p t e d M a n u s c r i p t 16

The study was approved by the University of Washington Institutional Review Board (STUDY00010095).

The authors of this paper received no direct funding for this publication. MS received support from NIMH K01MH115789. CH reports current funding by the Federal Joint Committee Innovation Funds FKZ 01VSF17010. CC is supported by NINDS NS099421. A c c e p t e d M a n u s c r i p t 20 M a n u s c r i p t 22 M a n u s c r i p t 25 

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