key: cord-0860007-3dtzjgng
authors: Danet Danet, Alina
title: Psychological impact of COVID-19 pandemic in Western frontline healthcare professionals. A systematic review
date: 2021-03-19
journal: Med Clin (Engl Ed)
DOI: 10.1016/j.medcle.2020.11.003
sha: 9d42a5c2a4dc97f5d8974f4dd0229daa7233973c
doc_id: 860007
cord_uid: 3dtzjgng

The aim of this study was to assess the psychological impact among healthcare workers who stand in the frontline of the SARS-CoV-2 crisis and to compare it with the rest of healthcare professionals, by means of a systematic review of Western publications. The systematic review was carried out in PubMed, Scopus and Web of Science databases and 12 descriptive studies were reviewed. The European and American quantitative studies reported moderate and high levels of stress, anxiety, depression, sleep disturbance and burnout, with diverse coping strategies and more frequent and intense symptoms among women and nurses, without conclusive results by age. In the first line of assistance the psychological impact was greater than in the rest of the health professionals and in the Asian area. It is necessary to go deeper into the emotional experiences and professional needs for emotional support in order to design effective interventions for protection and help.

The declaration of the pandemic in March 2020 1 and the confinement measures imposed by the SARS-CoV-2 outbreak generated an unprecedented public health situation, with consequences for the mental health of the general population 2 and especially that of health personnel, according to studies carried out mainly in China and other Asian countries 3-12 . Although there are various systematic reviews that reflect the increase in the prevalence of stress, anxiety, depression, insomnia, or burnout among healthcare professionals during the current pandemic [13] [14] [15] [16] [17] , there are only a few studies that focus on professional well-being during the pandemic, with priority having been given to the epidemiological aspects of the disease 18 .

During the SARS-CoV-1 (2003) [19] [20] [21] [22] [23] , H1N1 (2009) 24, 25 , MERS-CoV (2012) 26, 27 and Ebola (2014) 28,29 outbreaks the impact on healthcare personnel's mental health was documented. Moderate and high levels of anxiety 24,27 , depression, post-traumatic stress 20 and absenteeism 27,29 were observed, with higher prevalence among nursing professionals, younger individuals 19, 22, 23 and those with direct contact with infected patients 22, 30, 31 .

In the current COVID-19 crisis, the frontline healthcare workers, especially those in the Emergency Services, Intensive Care Units (ICU) and the Pulmonology departments, were particularly susceptible to developing psychiatric disorders 4, 32 . Despite a social and professional identity based on experience and preparation to cope with intense emotional and cognitive demands 33 ─resilient personality or hardiness 34 ─, a lack of knowledge, preparedness 9 and stable protocols of action 32 can lead to demotivation and mental health problems 5 , such as a higher levels of stress 3,6 , anxiety or depression 35 . Other authors associated the greatest psychological impact among the "soldiers on the frontline" 14 to working conditions (use of personal protective equipment, reorganisation of the workspace, management of the lack of material resources and workload, extra shifts, and longer hours), social and family aspects (social distancing, fear of infecting loved ones) and factors related to patients (high mortality rate, contact with suffering, death and ethical dilemmas) 15 .

In Asia, studies carried out exclusively with frontline health personnel [36] [37] [38] [39] or compared with other health professionals 3,4 , indicated the need to promote the psychological well-being of the professionals. However, it is unknown whether support plans and measures implemented in other geographical and cultural settings would be applicable here. This means there is an urgent need to explore the psychological effects of COVID-19 in the Western world, and to understand the associated risks and possible protection factors. Then, optimal and efficient strategies to support and help mental health can be designed. Therefore, the objective of this study was to identify the psychological impact among frontline healthcare personnel when caring for SARS-CoV-2 patients and to compare it with the rest of healthcare professionals, through a systematic review of the scientific production in the Western world.

A systematic review of the bibliography available in the PubMed, Scopus and Web of Science databases was carried out. The search terms used were organised around four elements: 1. Context, epidemiological situation of the SARS CoV-19 pandemic (terms used: COVID, coronavirus, SARS CoV-19); 2. Agents, health personnel who treated patients with COVID (terms used: provider, personnel, professional, workers); 3. Results, impact and consequences 4/36 on mental and emotional health (terms used: mental, emotion, psychol*, stress, burnout); and 4. Scope, services and units that offered frontline healthcare (frontline, emergency, intensiv*, internal*). For each block, the indexed terms were located in Medical Subject Heading (MeSH) and Health Science Descriptors (DeCS), which were combined with free designation terms.

The search was carried out on 5th and 6th August 2020 and included all the publications available since the start of the pandemic. Table 1 table 1 shows the strategies and terms used for each database, as well as the results obtained. Once the articles had been identified and duplicates eliminated, a process of (pre)selection, selection and analysis was carried out in four phases ( fig. 1 fig. 1 ), following the Prisma guidelines 40 . In the selection process, the inclusion and exclusion criteria described in table 2 table 2 were used.

The 12 selected articles were reviewed, and data was extracted regarding: setting/country, objectives, methodology (design, participants, and instruments) and main results. The evaluation of the methodological quality was based on the good practices standard criteria for questionnaire-based, cross-sectional, quantitative studies 41 . Table 3 table 3 includes the checklist of PRISMA 40 and AMSTAR-2 42 items for the critical appraisal of the systematic review.

The 12 articles reviewed 43 Non-probability convenience sampling was used in the participant selection process and samples varying from 115 professionals 50 to 1671 professionals 51 were generated, within which the percentage of participants who were frontline carers for SARS-CoV-2 patients ranged from 42% 50 to 82% 53 . In one of the studies, no information was provided regarding direct assistance to COVID-19 patients by the respondents 45. Five . The description of the samples was carried out jointly, with no discrimination regarding specific sociodemographic characteristics of the frontline personnel, except in one study 53 .

The main variables -stress, depression, anxiety, sleep disturbances and burnout-were measured with the following specific instruments: Depression, Anxiety and Stress Scale (DASS 21), Generalized Anxiety Disorder Scale (GAD), State-Trait Anxiety Inventory (STAI), Insomnia Severity Index (ISI), Pittsburg Sleep Quality Index (PSQI) and Maslach Burnout Inventory (MBI). Aspects related to health and perception of COVID-19 were measured with: Patient Health Questionnaire (PHQ), SF-36 Health Questionnaire and Illness Perception Questionnaire (IPQ). Data on coping strategies and support measures were also collected, through our own made-up instruments and the Cognitive Emotional Regulation Questionnaire (CERQ). Table 4 table 4 contains the information synthesised from the analysis of the selected sources.

Stress. In the global samples including frontline personnel -mainly from the Emergency Services, ICUs and Pulmonology departments-and those from other units, the percentage of healthcare personnel who suffered stress ranged from 37% 49 to 78% 45 , with a more frequent interval between 40% and 50% 47, 48, 52 and 54% among front-line personnel 53 .

Regarding direct care of COVID-19 patients, the studies reflected more stress among frontline personnel 43.45-48,51,52 , except for the Man et al. 50 study that did not find statistically significant differences. The departments with the highest levels of stress were the ICUs and Emergency departments, and the medical specialties most affected were Pulmonology and Geriatrics 51 .

Psychological stress varied in intensity, from mild and moderate to severe and extremely severe. On the DASS-21 scale, the mean global stress was 7.46░±░4.85 48 and 6.8░±░4.8 49 , with░>2 points difference between frontline professionals (6.07░±░4.10 vs 8.48░±░4.76) 47 . The comparison using the post-traumatic stress symptoms Severity Scale (DSM-5), with a range 0-80, indicated a mean of 29.2 for frontline workers, compared to 21.3 for the rest of the health personnel (p<░0.01) 46 . Finally, on the Secondary Traumatic Stress Scale (STSS), with interval 1-5, significant differences were observed between the mean in the frontline workers (2.66░±░0.93) compared to the other health professionals (2.46░±░0.83) and the general population (2.34░±░0.76) 43 .

By gender and professional category, the results (p<░0.05) unanimously indicated more stress among women 43, [45] [46] [47] [48] [49] 52 and the nursing personnel 50,53 . The analysis by age drew contradictory conclusions: different studies found the highest levels of stress among younger professionals 48, 51, 52 , older professionals 46,47 or reached no conclusive results 43 . Other factors aggravating stress were: suffering from chronic diseases or a history of mental health 43, 45 , less work experience, greater exposure to the mass media and being single 48 , have a worse perception 50 or living in areas with a higher incidence of the disease 51 .

On a general level, anxiety symptoms affected participating healthcare personnel in varying percentages: 20% in Italy 52 , 37% in the Basque-Navarre, Spain study 47 , 52% in Turkey 48 and up to 72% in the Italian area with the highest prevalence of COVID-19 49 .

The intensity of symptoms, measured in Italy using the STAI tool (range 20-80) placed the total mean between 47.3░±░11.9 49 Overall, the comparative results indicated greater anxiety among frontline professionals 47, 48, 52, 54 , although not always with statistical significance 46 , with the most affected being the nursing personnel, with 40% compared to 15% of other categories 53 . According to sex, women suffered a higher level of anxiety 47, 48, 52 : 21% with severe or very severe anxiety, compared to 4% of men in the north of Spain 47 . In some studies, older in years was a protective factor for anxiety 48, 52 , while in others it entailed more symptoms 47 .

Depression. Between 25% 52 and 31% 49 of all healthcare professionals showed symptoms of depression in Italy, while in a Turkish study the percentage reached 65%, of which 20% were severe or extremely severe 48 . In the United Kingdom, 64% of the total sample responded affirmatively to the phrase "I feel low, sad or depressed" 45 .

The quantification of the symptoms of depression showed variable results in the different studies, with a greater impact on the frontline personnel and, within this group 53% were nurses, compared to 38% of other professional categories 53 . In BDI-II (range 0-63), the general mean score was 13.7 (compared to 9.8 for the rest of the professionals, p<░0.05) 46 . The global mean scores in the measurement with the DASS-21 subscale ranged from 2.68░±░3.14 in Spain (3.78░±░3.85 in the frontline workers, p<░0.05) 47 , 4.0░±░2.3 in Italy 49 and up to 6.92░±░4.70 in Turkey 48 . In Serbia, after applying the Zung Self-Rating Depression Scale (SDS), with an interval 25-100, the results indicated a mean of 46.39░±░10.61, vs 53.14░±░11.41 in frontline professionals (p░>0.05) 54 .

Symptoms of depression affected women to a greater extent 46,48,52 , single people 46,48 and younger age groups 52 or those with less work experience 48 .

Sleep disturbance. Sleep disorders were observed in 8% 52 and 55% 44 of the total samples in Italy, 29% in Spain 47 and up to 72% in the UK 45 . Frontline personnel showed greater sleep disturbance, with a mean of 9.42░±░3.47 vs 8.77░±░3.27 on the Athens Insomnia Scale with range 0-24 47 and 8.3 versus 4.5 mean in the Pittsburg Sleep Quality Index, with a range of 0-21 54 . Among the frontline personnel, nursing had least rest: 5.6 h/day compared to 6.2 h/day among the other professionals 53 . Women had severe and very severe insomnia problems in 25%, compared to 4% of men 47 .

Burnout. In Italy, all health personnel reported high (32%) and medium (36%) levels of emotional exhaustion and depersonalisation (12% high and 14% moderate), with higher burnout among frontline personnel who had a greater workload and were younger (p<░0.05) 49 . In the frontline population, the percentages of high and medium emotional exhaustion reached 37% and 23% and in depersonalisation they reached 25% and 22.9% respectively 44 , being more intense among women and nursing personnel, and related to a worse self-perceived state of health.

Coping strategies and measures. Most of the health personnel showed interest and positively valued individual and group psychological support measures 45,53 and practiced physical, religious, and spiritual activities to reduce stress, anxiety and depression 53 . The most used coping strategies were refocusing and positive reappraisal 50 .

In the critical evaluation of the methodology (table 5 table 5 ), it was observed that, in general, the studies met most of the standard criteria of good practices for cross-sectional quantitative studies. The aspects with the poorest quality were sample representativeness, the selection biases and validation of the data collection instrument.

The review of studies carried out in the Western world reflected variable levels of stress, anxiety, depression, sleep disturbance and burnout in the population of health professionals from different countries in Europe and the USA. The presence of more frequent and intense symptoms was seen among frontline personnel, as well as among females and individuals in the nursing category. In addition to the relative scarcity of published studies, a joint but not always comparative approach of data analysis was observed, with no discrimination between frontline professionals and the rest of the health personnel. In this respect, this review J o u r n a l P r e -p r o o f 7/36 evidenced the need for rigorous knowledge of the socio-demographic and professional profile of the personnel directly involved in the health care of COVID-19 patients.

The methodological quality of the studies was optimal, except regarding the participation rate and the control of possible selection biases and sample representativeness which were justified in the epidemiological context, and the generalised difficulties imposed by the SARS outbreak, both in the healthcare and research teams 55 .

This review had a number of limitations. Despite the systematic search and selection method, there was an idiomatic bias, and some articles may have been omitted, especially because of including the specification of frontline health personnel in the search strategy. Furthermore, in the context of maximum prioritisation of the topic and rapid management of the publications, a comparative study that was sensitive to the differences between the characteristics and the impact of acute and chronic psychological stress was not possible. The socio-demographic heterogeneity of the participating samples, as well as the instruments and questionnaires used, made it difficult to compare and extrapolate results and to analyse biases. However, to date, there are no known systematic reviews focused on frontline professionals in the Western world, which may represent the main strength of this study.

The heterogeneity of samples, instruments, and results already observed in previous reviews on the psychological impact of the pandemic in China and other Asian countries [13] [14] [15] [16] [17] , made it difficult to compare the psychological impact of the SARS-CoV-2 outbreak on health personnel in different geographical settings. However, this review showed a higher prevalence of anxiety in Western studies compared to those carried out in China, where anxiety was below the European percentages (between 23 and 44%) 4,7,11 and only 6.2% of professionals exceeded the threshold of 15 points (severe anxiety) on the GAD-7 scale, compared to 20% in Italy 52 , with means in Asia of 1.30 11 or 8.2 points 7 , compared to 8.25 (13.26 in frontline personnel) in Serbia 54 . This review also recorded a higher level of stress compared to the range of 4% to 68% found in professionals in China 13 .

Regarding the symptoms of depression and sleep disturbance, the results were similar to those observed in Asia, with the condition varying from one quarter 13, 15 to over half 4,5,11 of professionals affected by mild or moderate depression and approximately one third by insomnia 4, 13, 15, 16 . This indicated more moderate symptoms than during the SARS or MERS health crises 15 . However, these data should be interpreted with caution, as symptoms such as depression, shown in 23% of professionals 31 or burnout, post-traumatic stress and addictive behaviors can continue medium-to long-term, with some being recorded two years after exposure to the SARS-CoV-1 outbreak 55 .

In relation to the differences between frontline personnel and the rest of the professionals, the Western studies showed that the greatest psychological impact occurred in cases of direct contact with infected patients. This confirmed the data observed in China regarding the level of stress (OR 1.60; CI 1.25-2.04), depression (OR 1.52; CI 1.11-2.09), anxiety (OR 1.57; CI 1.22-2.02) and insomnia (OR 2.97; CI 1.92-4.60) 4 . Other authors also highlighted that the long working hours, the concentration, and permanent vigilance required when working in the Emergency Services, ICUs and Pulmonology departments in situations of pandemic respiratory diseases, as well as the contact with suffering and death 10 While the effect of age was not conclusive, the main explanatory variables for a higher prevalence of psychological symptoms were gender and professional category. The results were similar to those in Asia 4,15,16 , where females and nursing personnel suffered more anxiety (25.7% females versus 11.6% males and 26.9% nurses versus doctors 14.3%) 11 Given the increased risk and exposure to mental health problems among women, both in pandemic situations and on a general level 29 , and taking into account the high feminisation of the health sector in the western world 57 , the planning and design of support measures and interventions to reduce the psychological impact, widely documented in recent months 58 , would have to include the gender perspective 59 . Furthermore, in light of the evidence that the majority of professionals accept and seek these interventions, an individualised approach would be necessary to optimise the results. This approach should take into account sociodemographic variables, the professional role, direct contact with patients or a history of mental health 60 , while bearing in mind that protective measures and psychological support are necessary despite the mildness of the symptoms 7 .

Finally, this review highlights the need to use qualitative methodologies to delve deeper into the experiences and specific needs of healthcare personnel, especially the frontline workers, as well as to explore the medium-and long-term implications on their physical and mental health and emotional.

The author declares that she has no conflict of interest. 

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* Tema y objetivo: consecuencias no psicológicas ni emocionales, tele-asistencia, salud física, riesgos epidemiológicos, gestión y liderazgo, programa e impacto de intervenciones y apoyo, otros.* Topic and objective: non-psychological nor emotional consequences, tele-assistance, physical health, epidemiological risks, management and leadership, programme and impact of interventions and support, others. * Perfil de participante: personal no sanitario, pacientes, personal en formación, familias * Participant profile: non-health personnel, patients, personnel in training, family members * Ámbito: países asiáticos y latinoamericanos * Region: Asia and Latin America * Tipo de publicación: editorial, opinión, carta, revisión * Type of publication: editorial, opinion, letter, review Causas de exclusión (n = 137)Reasons for exclusion (n = 137) * Unidades y servicios asistenciales * Healthcare departments and services * Perfiles de participantes * Participant profiles * Tipo de estudio/publicación * Study/participation type * Requisitos éticos * Ethical requirements