key: cord-0822315-z9seyanz
authors: Chigwedere, Ottilia Cassandra; Sadath, Anvar; Kabir, Zubair; Arensman, Ella
title: The Impact of Epidemics and Pandemics on the Mental Health of Healthcare Workers: A Systematic Review
date: 2021-06-22
journal: Int J Environ Res Public Health
DOI: 10.3390/ijerph18136695
sha: b5f8b33a2fb341650df40e689df45d0ca842c30c
doc_id: 822315
cord_uid: z9seyanz

Background: There is increasing evidence that healthcare workers (HCWs) experience significant psychological distress during an epidemic or pandemic. Considering the increase in emerging infectious diseases and the ongoing COVID-19 pandemic, it is timely to review and synthesize the available evidence on the psychological impact of disease outbreaks on HCWs. Thus, we conducted a systematic review to examine the impact of epidemics and pandemics on the mental health of HCWs. Method: PubMed, PsycInfo, and PsycArticles databases were systematically searched from inception to June-end 2020 for studies reporting the impact of a pandemic/epidemic on the mental health of HCWs. Results: Seventy-six studies were included in this review. Of these, 34 (45%) focused on SARS, 28 (37%) on COVID-19, seven (9%) on MERS, four (5%) on Ebola, two (3%) on H1N1, and one (1%) on H7N9. Most studies were cross-sectional (93%) and were conducted in a hospital setting (95%). Common mental health symptoms identified by this review were acute stress disorder, depression, anxiety, insomnia, burnout, and post-traumatic stress disorder. The associated risk factors were working in high-risk environments (frontline), being female, being a nurse, lack of adequate personal protective equipment, longer shifts, lack of knowledge of the virus, inadequate training, less years of experience in healthcare, lack of social support, and a history of quarantine. Conclusion: HCWs working in the frontline during epidemics and pandemics experience a wide range of mental health symptoms. It is imperative that adequate psychological support be provided to HCWs during and after these extraordinary distressful events.

The frequency of disease outbreaks has increased over the past century due to population growth, the increased interconnectedness of the world, microbial adaptation and change, economic development, changes in land use, and climate change [1] . Emerging infectious diseases that have caused epidemics over the past two decades include the severe acute respiratory syndrome (SARS) Disease outbreaks cause an unexpected increase in morbidity and mortality, which in turn cause an increased demand on healthcare facilities [3] . The rapid increase in patient populations drastically reduces the healthcare worker (HCW) to patient ratio thus increasing workload. HCWs suffer from both physical and mental fatigue because their working hours are increased and they may be asked to work more night shifts; thus, they do not have enough time to sleep, rest, and recuperate. As they work in the frontline,

The three database searches yielded 5716 articles. After removal of 793 duplicates, the titles and abstracts of 4923 articles were screened. Two-hundred-and-thirty potential studies were identified, and the full texts were checked for eligibility. Sixty-eight articles met the inclusion criteria and eight more were identified through searching references of selected papers totaling 76 final studies. Details are provided in the PRISMA flowchart ( Figure 1 ). 

The characteristics of the selected studies are shown in Tables 1 and 2 . Overall, seventy-six papers met the inclusion criteria. Of these, 34 (44%) focused on SARS, 28 (37%) on COVID-19, seven (9%) on MERS, four (5%) on Ebola, 2 (3%) on H1N1, and one (1%) on H7N9. The studies were conducted in different countries: 26 (34%) China; nine (12%) Taiwan; seven (9%) Canada; eight (11%) Hong Kong; seven (9%) Singapore; four (5%) Saudi Arabia; four (5%) Korea; one (1%) each from Germany, Greece, Iran, Italy, Japan, Liberia, Sierra Leonne, Nigeria, Turkey, and USA; and one was conducted in two countries Singapore and India. Most studies were conducted in a hospital setting 71 (95%), three in a general practice setting, and one at a rehabilitation center. Sixty studies (80%) included more than one type of HCW, 12 had only nurses, and three had only doctors/physicians. A higher proportion of studies 71 (93%) studies were cross-sectional and only 5 (7%) were cohort studies.

A more detailed assessment is available in Tables 3 and 4 . All eligible studies were included in the review, regardless of their quality assessment results. Of the 71 cross-sectional studies, 42 papers (59%) were of very good quality, five papers (7%) were of good quality, 15 papers (21%) were of average quality, and nine papers (13%) were of poor quality. Of the five cohort studies, one paper was of very good quality, two papers were of good quality, one paper had average quality, and one was of poor quality. 

The characteristics of the selected studies are shown in Tables 1 and 2 . Overall, seventysix papers met the inclusion criteria. Of these, 34 (44%) focused on SARS, 28 (37%) on COVID-19, seven (9%) on MERS, four (5%) on Ebola, 2 (3%) on H1N1, and one (1%) on H7N9. The studies were conducted in different countries: 26 (34%) China; nine (12%) Taiwan; seven (9%) Canada; eight (11%) Hong Kong; seven (9%) Singapore; four (5%) Saudi Arabia; four (5%) Korea; one (1%) each from Germany, Greece, Iran, Italy, Japan, Liberia, Sierra Leonne, Nigeria, Turkey, and USA; and one was conducted in two countries Singapore and India. Most studies were conducted in a hospital setting 71 (95%), three in a general practice setting, and one at a rehabilitation center. Sixty studies (80%) included more than one type of HCW, 12 had only nurses, and three had only doctors/physicians. A higher proportion of studies 71 (93%) studies were cross-sectional and only 5 (7%) were cohort studies.

A more detailed assessment is available in Tables 3 and 4 . All eligible studies were included in the review, regardless of their quality assessment results. Of the 71 crosssectional studies, 42 papers (59%) were of very good quality, five papers (7%) were of good quality, 15 papers (21%) were of average quality, and nine papers (13%) were of poor quality. Of the five cohort studies, one paper was of very good quality, two papers were of good quality, one paper had average quality, and one was of poor quality. The hopelessness and state anxiety levels of HCWs were higher than non-HCWs. Nurses' anxiety and hopelessness levels were higher than doctors and other HCWs. Anxiety and hopelessness levels were higher in females, those living with a high-risk individual at home, those with difficulty in caring for their children, those with increased working hours and those whose income decreased Vicarious traumatization (Self-developed questionnaire) Vicarious traumatization scores for non-front-line nurses were significantly higher than those of front-line nurses. Vicarious traumatization scores of the general public were significantly higher than those of the front-line nurses. No significant difference was noted in vicarious traumatization scores between the general public and non-front-line nurse The group exposed to MERS confirmed or suspected cases experienced more stress as compared to those who had not exposed to it. Prior outbreak nursing experience had a protective effect Tang Burnout was higher in those who had nursed MERS-CoV infected or suspected patients than those who did not. Job stress was the biggest influencing factor of burnout. Poor hospital resources for treatment of MERS-CoV and poor support from family and friends increased burnout Non HCWs had higher levels of distress compared to HCWs. Losing a relation to the EVD outbreak was associated with high levels of distress. 

More GPs were directly involved in the care of patients with SARS. 14.1% GPs, 6% TCMs had psychological distress (GHQ-28 > 7)

More GPs had psychological distress compared to TCM practitioners. The mean score of the GHQ somatic, anxiety, and social dysfunction subscales were higher in GPs as compared to practitioners. GPs experienced more stigma.

Kong SARS Epidemic N = 137 GPs (General Practice) Anxiety (Self-designed questionnaire)

Significant anxiety was found in family doctors. 75% requested more investigations. 25% over-prescribed antibiotics Young doctors found their quality of life more affected than their older colleagues Abbreviations: Appendix B. 

Sin.S.S. and Huak C. 

The Impact of Events Scale (IES) and the Perceived Stress Scale (PSS) were the most common instruments used to measure stress. The Generalized Anxiety Disorder (GAD) and the Zung Self-Rating Anxiety Scale (SAS) were frequently used instruments to measure anxiety. Commonly used instruments to measure depression were the Patient Health Questionnaire (PHQ) and the Zung Self-Rating Depression Scale. Insomnia was often measured using the Insomnia Severity Index (ISI) and the Pittsburgh Sleep Quality Index (PSQI). Most studies which measured burnout used the Maslach's Burnout Inventory.

Stress was the most commonly measured mental health symptom. Any one of acute stress, distress, or post-traumatic stress symptoms was examined in forty-two studies [4, [24] [25] [26] 29, 30, 35, 38, 40, 44, 45, 49, [52] [53] [54] [56] [57] [58] 60, [62] [63] [64] [73] [74] [75] [76] 78, [80] [81] [82] [83] [84] 86, 87, [89] [90] [91] [92] [95] [96] [97] . The prevalence of stress varied, and it ranged from 5% to 80%. Ten studies identified that nurses experienced more distress compared to doctors [30, 38, 54, 63, 64, [80] [81] [82] 87, 91] . HCWs providing direct care to confirmed cases of SARS and COVID 19 were more likely to be distressed compared to those who did not provide direct care [30, 45, 53, 58, 63, 76, 78, 91, 92] . Moving from a low risk ward to work in a high risk ward [75] , more working time per week [35] , frequent changes in infection control measures and protocols [79] , seeing a colleague getting sick, being intubated or dying increased stress [57] while those who received adequate social support were least likely to have PTSD [90] . Having been in quarantine during the outbreak was associated with high levels of PTSD [4, 62, 83] . Availability of adequate PPE significantly reduced stress [38, 49, 90] .

Anxiety and fear symptoms were examined in 29 studies [23, [25] [26] [27] [28] [29] [30] [32] [33] [34] [35] [36] [37] [40] [41] [42] [44] [45] [46] 48, 50, 51, 59, 64, 68, 88, 93, 96, 97] . The prevalence of anxiety varied and ranged from 7% to 78% across all virus exposures. Nine studies found that HCWs who had contact with confirmed cases had more anxiety compared to HCWs who had had no contact with confirmed cases [27, 30, 33, 34, 37, 44, 88, 97] . A common cause of anxiety was worrying about transmitting infection to family members [41, 51, 88] . Nurses had higher anxiety scores compared to doctors [27, 30, 35, 37, 38, 50, 88] . Female healthcare workers were more likely to have anxiety compared to males [26, 27, 30, 45, 46, 48, 56, 88] . Three studies from China compared anxiety levels of HCWs in Wuhan to those of HCWs in the outreach or other regions and found that HCWs in Wuhan, which was the epicenter of COVID-19 at that time, had significantly higher anxiety compared to HCWs in other regions of China [26, 30, 33] . Similar results were found in Canada were HCWs in Toronto who had more contact with SARS patients had higher levels of burnout and distress compared to HCWs in Hamilton where they had fewer confirmed cases [73] . Fear and anxiety were significantly increased when a colleague became infected or died. Anxiety and fear of infection were inversely related to availability of hospital resources, HCWs' resilience and support from family and friends [26, 28] . The increase in working hours during a disease outbreak was directly related to anxiety levels [27, 35] . Lack of knowledge of the virus was also associated with an increase in anxiety [59] .

Symptoms of depression were examined in 25 studies [23, 25, 26, [28] [29] [30] 32, 34, [36] [37] [38] 40, 42, [44] [45] [46] [48] [49] [50] 59, 62, 67, 71, 96, 97] . The prevalence of depression ranged from 8.9% and 74.2%. Five studies showed that depression was higher in females compared to males [30, 45, 46, 49, 50] . The frontline medical staff working in the respiratory, emergency, ICU, and infectious disease departments were twice more likely to suffer from depression than the non-clinical staff [30, 34, 44] . Nurses working in SARS units were more depressed than nurses in non-SARS units [97] . The HCWs in Wuhan, which was the epicenter of the COVID-19 pandemic, had higher levels of depression compared to HCWs outside Hubei province [26, 30] . Increased working hours were associated with elevated depression and hopelessness [27, 35] . Having a past exposure to traumatic events or pre-existing psychiatric disorder before the epidemic was associated with high levels of depressive symptoms [62, 95] . Those HCWs with a marital status of being single were more likely than married HCWs to have high levels of depressive symptoms [46, 62] . A history of being quarantined was associated with higher levels of depression [62] . Support from family and friends [26, 28, 34] , psychological preparedness, altruistic acceptance, and perceived efficacy of dealing with the pandemic was associated with lower levels of depression [46, 62] .

Insomnia and sleep quality was assessed in 11 studies [23, 29, 30, [36] [37] [38] 42, 44, 48, 71, 97] . All 11 studies reported substantial sleep problems, ranging from 26% to 45%. Insomnia was independently associated with depression and anxiety [23, 42] . In three studies, insomnia symptoms were higher in frontline HCWs compared to second line workers [30, 36, 37, 42] . Nurses reported more sleep problems compared to other HCWs [30, 37, 38] , and nurses working in SARS units were more likely to have insomnia compared to nurses working in non-SARS units [97] . HCWs in Wuhan reported more insomnia symptoms compared to healthcare workers in other areas out of Hubei province [30] .

Burnout (emotional exhaustion) was assessed in eight studies, and they all confirmed high levels of burnout in HCWs [28, 43, 58, 70, 72, 73, 88, 96] . HCWs who worked in the frontline or had contact with confirmed cases were more likely to be emotionally exhausted compared to HCWs who were not in the frontline and who had no direct contact with confirmed cases [70, 72, 73, 88] , while one study reported different results in that front-line HCWs had lower levels of burnout compared to other HCWs. The possible explanation given by the researchers for this unexpected trend was front-line HCWs had received timely and accurate information hence they had a higher sense of control of their situation [43] . Two studies showed that HCWs who had spent more time in quarantine had higher levels of burnout [70] . Lower levels of organizational support, job stress and poor hospital resources, were directly related to emotional exhaustion [58, 70, 72] . Burnout was negatively correlated to self-efficacy, resilience and family support [28] . High anxiety scores predicted high levels of burnout [88] .

Five studies examined stigma and in all studies, HCWs had been stigmatized either by their family or by the community or both [52, 76, 78, 83, 92] . The prevalence of stigma in HCWs ranged from 20% to 49%. HCWs who were working in direct contact with confirmed cases and those who had been quarantined experienced higher levels of stigma [76, 92] . One study which compared psychological morbidity of stigma between general practitioners and Chinese traditional practitioners found that general practitioners had more exposure to SARS patients and suffered more stigma than the Chinese traditional practitioners [92] 

This review showed that epidemics and pandemics have a negative impact on the psychological wellbeing of HCWs by the wide range of mental health symptoms, in particular stress, depression, anxiety, insomnia, fear, stigma, and emotional exhaustion.

This review identified common factors that increased the risk of mental health symptoms. Frontline HCWs working in high risk environments where they had direct contact with suspected and confirmed cases of SARS and COVID 19 reported more psychological symptoms compared to non-frontline HCWs working in low risk environ-ments [30, 31, 34, 36, 37, [43] [44] [45] 48, 53, 58, 63, 65, 66, 69, 73, 75, 76, 85, 91, 92, 96] . Working in direct contact with infectious patients was associated with higher levels of symptoms of anxiety, stress, insomnia, and depression due to the increased fear of contracting infection, greater concern of infecting family members, stigmatization, and isolation [34, 54, 72, 88] . This might explain why nurses were found to be more stressed, anxious, depressed, and had poorer sleep quality compared to doctors. Most studies explained this to be due to the higher workload that nurses have and the more time they spend in direct contact with patients whilst nursing them [27, 30, 37, 38, 41, 50, 54, 63, 72, 76, [80] [81] [82] 87, 88, 91] . HCWs in the epicenter of a pandemic experienced more psychological distress compared to HCWs in other regions due to the higher exposure to infectious patients [26, 30, 33, 73] . Another occupational risk factor identified was the extent of healthcare experience that a HCW had. HCWs with less work experience were more likely to be stressed compared to HCWs with more years of work experience. Less experienced HCWs have less knowledge, skills, and are less able to self-regulate, thus they get stressed more easily compared to more experienced HCWs who have more knowledge and skills, and are thus more able to adapt [53, 54, 96] .

Inadequate hospital equipment and the limited supply of personal protective equipment (PPE) were also associated with higher levels of psychological symptoms [23, 34, 38, 58] . Being of female gender was also identified as a risk factor [27, 29, 30, 38, 39, 45, [48] [49] [50] 54, 56, 62, 81, 85, 91] . A history of exposure to other traumatic events before an t outbreak increased the risk of re-occurrence of a psychiatric disorder [62, 95] . Having a high perceived risk of infection and low self-efficacy were also identified as risk factors associated with mental health symptoms [49, 56, 62, 74, 87] . HCWs who were unconfident about beating the outbreak [49, 56, 62, 74, 87] were more depressed and had a poor mental state compared to HCWs who were more confident and resilient [28, 77] . Lack of knowledge of the virus and lack of outbreak management training was associated with low perceived self-efficacy. Constantly changing infection control measures and documentation processes also reduced self-efficacy and caused an increase in stress levels [45] . Having been quarantined was identified as a risk factor of depressive and post-traumatic stress symptoms. This was attributed to the increased fear of dying from the disease. Quarantining was associated with increased levels of fear and stress in HCWs due to the emotional isolation and loneliness experienced during quarantine [39, 62, 65, 67, 70, 77, 83] .

Despite the limited number of cohort studies compared to cross sectional studies, the cohort studies conducted during the SARS epidemic confirmed the persistence of mental health symptoms up to a year after the pandemic has ended.

Protective factors identified in this systematic review include adequate information, clear guidelines, training and organizational support [24, 43, [70] [71] [72] 78, 79, 95] , altruistic acceptance of risk, [62, 65] , availability of specialized equipment for treating patients, adequate personal protective equipment [49, 57, 74, 78, 90] , having more years of healthcare experience [95] , adequate time off work [68] , and support from family and friends [71, 90] .

The strengths of this review are, first, that it identified a large number of studies conducted during and after the epidemics and pandemics that have occurred in the past twenty years, including the current COVID-19 pandemic. Second, results are generalizable as the included studies were from Asia, Europe, Africa, Middle East, and America. Third, most papers included in this review used standardized and previously validated instruments for measuring mental health symptoms. However, a potential limitation is that we only included published articles and excluded gray literature, which might have caused some publication bias. Another limitation is that there were only five cohort studies, 94% of the studies included were cross-sectional which implies that no causal inferences can be drawn. Furthermore, meta-analyses were not undertaken because of the methodological heterogeneity of the studies.

It is important to conduct more cohort studies to obtain a detailed picture of mental health symptoms at the different points of a disease outbreak, and to understand the long-term mental health impact of a pandemic or epidemic among HCWs.

The possible role of occupation and exposure on mental health needs to be examined further in future studies. While many studies have reported higher levels of mental health problems among female HCWs, it is still unclear whether gender is a sole influencing factor, or if gender is being confounded by other factors. For instance, most of the female HCWs were nurses, and nurses experience higher mental health problems due to their increased exposure and nature of work. Besides, previous studies have shown that nurses and doctors working in the emergency department and intensive care units are at a higher risk of burnout, depression, and job stress compared to their colleagues working in other hospital departments [98] [99] [100] . Therefore, future studies need to rule out these aspects, while determining the effects of a pandemic or epidemic on mental health.

Increasing age, and prior chronic medical conditions make a person more susceptible to the effects of a pandemic. Therefore, in future studies, it is important to address the association between these factors and mental health outcome.

Many studies used online platforms for data collection, and this method is known to increase the risk of sampling and response bias [101] . However, we consider this method as appropriate for the current studies as face-to-face data collection was not possible due to social distancing guidelines.

As this review identified many protective factors including adequate information about the pandemic, clear guidelines and training, social support, availability of specialized equipment for treating patients, adequate personal protective equipment, adequate time off work, may be provided to the HCWs for reducing adverse mental health outcome.

This systematic review provides a comprehensive narrative synthesis of the underlying negative impacts of epidemics and pandemics on the mental health of HCWs which include acute stress, post-traumatic stress disorders, severe depression, anxiety, burnout, insomnia, and stigmatization. It is apparent from this review that the current healthcare systems and many governments across the globe need to prioritize mobilizing resources to provide sufficient and necessary psychological support to HCWs during and after epidemics and pandemics. 

The data presented in this study are available at (online version link).

The authors declare no conflict of interest.

The search was performed from May 2020 to end-June 2020. An English language limit was applied. No restrictions were placed on the publication date and location of study. The search terms were grouped into three categories: Category 1: Population ("healthcare professional", "healthcare workers", physician, doctor, nurse) Category 2: Exposure (epidemic, pandemic) Category 3: Outcomes ("mental health", "mental disorder", psychological, depression, anxiety, stress, burden, insomnia, "sleep disturbance", burnout, fear, stigma, discrimination).

Mesh terms and synonyms of the keywords were identified and used in the search. 

("health personnel" OR " healthcare provider*" OR "healthcare worker*" OR "healthcare personnel" OR " healthcare professional*" OR "healthcare staff" OR doctor OR physician OR "physician assistant*" OR nurse OR "healthcare assistant*" OR "allied health*" OR clinician OR "hospital worker*" OR "hospital staff" OR "hospital employee*") 1,923,975 #2 (epidemic* OR pandemic* OR SARS OR "severe acute respiratory syndrome" OR coronavirus OR MERS OR "middle east respiratory syndrome" OR MERS-CoV OR Ebola OR EVD OR H1N1 OR "influenza type A virus" OR H7N9 OR covid-19 OR 2019-nCoV OR SARS-COV-2 OR "2019 novel coronavirus") 220,091 #3 mental* OR psychiatric* OR psychological* OR resilience OR depression OR emotio* OR anxiety* OR nervous* OR stress* OR PTSD OR "post-traumatic stress disorder" OR insomnia OR "sleep disorder" OR DIMS OR " disorder of initiating and maintaining sleep" OR burnout OR exhaustion OR fear OR panic OR stigma* OR discrimination OR "mental health"

3,376,683 #4 #1 AND #2 AND #3 3311 Table A2 . PsycArticles Search.

("health personnel" OR " healthcare provider*" OR "healthcare worker*" OR "healthcare personnel" OR " healthcare professional*" OR "healthcare staff" OR doctor OR physician OR "physician assistant*" OR nurse OR "healthcare assistant*" OR "allied health*" OR clinician OR "hospital worker*" OR "hospital staff" OR "hospital employee*") 17,759 #2 (epidemic* OR pandemic* OR SARS OR "severe acute respiratory syndrome" OR coronavirus OR MERS OR "middle east respiratory syndrome" OR MERS-CoV OR Ebola OR EVD OR H1N1 OR "influenza type A virus" OR H7N9 OR covid-19 OR 2019-nCoV OR SARS-COV-2 OR "2019 novel coronavirus") 932 #3 mental* OR psychiatric* OR psychological* OR resilience OR depression OR emotio* OR anxiety* OR nervous* OR stress* OR PTSD OR "post-traumatic stress disorder" OR insomnia OR "sleep disorder" OR DIMS OR " disorder of initiating and maintaining sleep" OR burnout OR exhaustion OR fear OR panic OR stigma* OR discrimination OR "mental health"

158,189 #4 #1 AND #2 AND #3 117 Table A3 . PsycInfo Search.

("health personnel" OR " healthcare provider*" OR "healthcare worker*" OR "healthcare personnel" OR " healthcare professional*" OR "healthcare staff" OR doctor OR physician OR "physician assistant*" OR nurse OR "healthcare assistant*" OR "allied health*" OR clinician OR "hospital worker*" OR "hospital staff" OR "hospital employee*") 344,711 #2 epidemic* OR pandemic* OR SARS OR "severe acute respiratory syndrome" OR coronavirus OR MERS OR "middle east respiratory syndrome" OR MERS-CoV OR Ebola OR EVD OR H1N1 OR "influenza type A virus" OR H7N9 OR covid-19 OR 2019-nCoV OR SARS-COV-2 OR "2019 novel coronavirus" 41,531 #3 mental* OR psychiatric* OR psychological* OR resilience OR depression OR emotio* OR anxiety* OR nervous* OR stress* OR PTSD OR "post-traumatic stress disorder" OR insomnia OR "sleep disorder" OR DIMS OR " disorder of initiating and maintaining sleep" OR burnout OR exhaustion OR fear OR panic OR stigma* OR discrimination OR "mental health" 2,335,979 #4 #1 AND #2 AND #3 2288

CHQ-12 Chinese Health Questionnaire-12, COPE Coping Orientation to Problems Experienced, DASS-21 Depression, Anxiety and Stress Scale-21, DRS-15 Dispositional Resilience Scale-15, DTS-C Davidson Trauma Scale-Chinese version, ECR-R Experiences in Close Relationships-Revised, EPQ Eysenck Personality Questionnaire, FS-HPs Fear Scale for Healthcare Professionals, GAD-7 Generalized Anxiety Disorder-7, GHQ-28 General health Questionnaire -28, HAM-A Hamilton Anxiety Score, HAMD Hamilton Depression Scale, HADS Hospital Anxiety and Depression Scale, IES-R Impact Events Scale Revised, ISI -7 Insomnia severity index-7, K-10 Kessler Psychological Distress Scale-10, K-6 Kessler Psychological Distress Scale-6

The 90-item symptom checklist, SCSQ Simplified coping style questionnaire, SDS Self-Rating Depression Scale, SES Self-Efficacy Scale, SF-12 Short Form Health Survey-12, SF-36 Short Form Health Survey-36, SFS SARS Fear Scale, SRSR SARS-Related Stress Reactions questionnaire, SSI Suicidal and self-harm ideation, SOS Stress Overload Scale, SPOS Survey of Perceived Organizational Support, SRQ-20 WHO Self-Reporting Questionnaire, STAI The State-Trait Anxiety Inventory, STAXI State-Trait Anger Expression Inventory, TCSQ Trait Coping Style Questionnaire, VAS Visual Analogue Scale, WCQ Ways of Coping Questionnaire, HCW Health Care Worker

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Emotional exhaustion and state anger in nurses who worked during the SARS outbreak: The role of perceived threat and organizational support

Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak

The Impact of Work-Related Risk on Nurses during the SARS Outbreak in Hong Kong

Psychological distress of nurses in Taiwan who worked during the outbreak of SARS

The occupational and psychosocial impact of SARS on academic physicians in three affected hospitals

Fear of severe acute respiratory syndrome (SARS) among health care workers

Risk perception and impact of severe acute respiratory syndrome (SARS) on work and personal lives of healthcare workers in Singapore: What can we learn?

Facing SARS: Psychological impacts on SARS team nurses and psychiatric services in a Taiwan general hospital

Coping responses of emergency physicians and nurses to the 2003 severe acute respiratory syndrome outbreak

Psychological morbidity among emergency department doctors and nurses after the SARS outbreak

The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope

Survey of stress reactions among health care workers involved with the SARS outbreak

Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore

psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital

Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers

Psychosocial effects of SARS on hospital staff: Survey of a large tertiary care institution

Impact of severe acute respiratory syndrome on anxiety levels of frontline health care workers

Severe acute respiratory syndrome-related psychiatric and posttraumatic morbidities and coping responses in medical staff within a primary health care setting in Singapore

Psychological impact of the SARS outbreak on a Singaporean rehabilitation department including commentary by Leong, I., Thompson DR

Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: Stress and psychological impact among frontline healthcare workers

Post-SARS psychological morbidity and stigma among general practitioners and traditional Chinese medicine practitioners in Singapore

How did general practitioners protect themselves, their family, and staff during the SARS epidemic in Hong Kong?

Mental symptoms in different health professionals during the SARS attack: A follow-up study

Prevalence of psychiatric disorders among Toronto hospital workers one to two years after the SARS outbreak

Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers

Prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured SARS caring unit during outbreak: A prospective and periodic assessment study in Taiwan

A Cross sectional study evaluating psychosocial job stress and health risk in emergency department nurses

Burnout and related factors of nurses caring for DNR patients in intensive care units, South Korea

Acute stress and anxiety in medical residents on the emergency department duty

Researching internet-based populations: Advantages and disadvantages of online survey research, online questionnaire authoring software packages, and web survey services