key: cord-0889430-vrcwg943
authors: Croghan, Ivana T.; Chesak, Sherry S.; Adusumalli, Jayanth; Fischer, Karen M.; Beck, Elizabeth W.; Patel, Shruti R.; Ghosh, Karthik; Schroeder, Darrell R.; Bhagra, Anjali
title: Stress, Resilience, and Coping of Healthcare Workers during the COVID-19 Pandemic
date: 2021-04-09
journal: J Prim Care Community Health
DOI: 10.1177/21501327211008448
sha: 293c26fa37a0bc776563ca4e0bc7cd8f44365880
doc_id: 889430
cord_uid: vrcwg943

OBJECTIVE: To estimate the health care workers (HCWs) self-reported stress, resilience, and coping during the COVID-19 pandemic, and to determine inter-professional differences. PARTICIPANTS AND METHODS: An email survey was sent to 474 HCW at a Midwestern HealthCare facility between April 9, 2020 and April 30, 2020. A total of 311 (65.6%) responses were received by May 31, 2020. The survey utilized 3 validated instruments: Perceived Stress Scale (PSS), Brief Resilience Scale (BRS), Brief Resilience Coping Scale (BRCS). RESULTS: Of the 311 responses, 302 were evaluated: 97 from nonmedical staff with patient contact (NMPC); 86 from nonmedical staff with no patient contact (NMNPC); 62 from medical doctors (MD), physician assistants (PA) and nurse practitioners (NP); and 57 from nurses. Significant differences were noted across job categories for stress and resilience, with nurses reporting highest PSS scores (effect estimates: −2.72, P = .009 for NMNPC; −2.50, P = .015 for NMPC; −3.21, P = .006 for MD/NP/PA respectively), and MD/NP/PA group with highest BRS scores: nurses (−0.31, P = .02); NMPC (−0.3333, P = .01); and NMNPC (−0.2828, P = .02). Younger personnel had higher stress (−1.59 per decade of age, P < .01) and more resilience (0.11 per decade of age, P = .002). CONCLUSION: These self-reported data indicate that MD/NP/PA had the highest resilience scores and the nurses had highest stress levels. Efforts are warranted to include all HCWs in systematic stress mitigating interventions with particular attention to understand specific factors contributing to stress for the nursing team.

On December 31, 2019, the Wuhan Municipal Health Commission in China reported a cluster of cases of pneumonia. 1 This was later identified as a SARS-CoV-2, coronavirus. 1 On March 11, 2020, the virus, SARS-CoV-2, was declared the COVID-19 pandemic by the WHO. 2 During this evolving world-wide health care crisis and desperate time of need, the overwhelming burden of illness and mortality has threatened operations of health care institutions worldwide and the physical, emotional, and financial health of their HCW. HCWs must grapple with fears of infection, death, and the risk of COVID-19 transmission to their families, as well as post-traumatic stress and other mental, physical, emotional, and spiritual concerns. 3 To quote Greenberg et al., " We have placed our healthcare professionals in an impossible situation of having to make life and death decisions while working under extreme pressure." 4 Resilience refers to one's ability to bounce back from adversity and view adversity as an opportunity for growth; it is an increasingly recognized protective factor against stress. 5, 6 Resilience among HCWs is influenced by multiple factors at the individual, organizational, and societal levels. [7] [8] [9] [10] It is imperative to address issues at the organizational level, including robust structural interventions within the work environment. 7 It is also essential to identify individual factors that contribute to resilience in order to inform best practices for empowering HCWs to cope and optimize their well-being, especially during adversity. Prior research has identified a direct relationship between non-productive coping and stress, burnout, and other well-being measures, among HCWs. 11 Recent studies during the COVID-19 pandemic have indicated direct relationships between pandemicrelated stress, anxiety and resilience among physicians in Israel. 12, 13 The purpose of our project was to assess the level of stress, resilience and ability to cope among HCWs at a tertiary care academic medical center during the initial stages of the pandemic, utilizing validated assessment scales, and to determine inter-professional differences.

This survey, intended for practice-improvement was completed by general internal medicine colleagues within 1 health care institution in the midwestern United States, during the COVID-19 pandemic. This study was reviewed and approved by the General Internal Medicine Leadership and the Institutional COVID-19 taskforce.

Participants included a convenience sample of staff within the General Internal Medicine division, including medical doctors (MD), nurses (RNs, LPNs), nurse practitioners (NP), physician's assistants (PA), administrative assistants (AA), as well as other division staff.

Participants received information regarding the general purpose of the project and contact information for questions/complaints. This voluntary and anonymous survey was sent as a link through an email. The initial email went out on April 9, 2020; non-responders received reminder emails on April 16, 2020, April 23, 2020, and April 30, 2020. Study collection was closed on May 31, 2020. A detailed summary of the above is found in the consort diagram presented in Figure 1 , which adheres to Consolidated Standards of Reporting Trials (CONSORT) guidelines. 14 All surveys were delivered as a link via email through the use of REDCap. 15 There was no compensation offered for participation.

This survey was developed utilizing Research Electronic Data Capture (REDCap) 15 and consisted of validated scales measuring resilience (Brief Resilience Scale (BRS)), 16 coping (Brief Resilience Coping Scale (BRCS)), 17 and stress (Perceived Stress Scale (PSS)), 18 Other measures which were included in the survey, will be reported elsewhere. Many questions had Likert scale responses such as "strongly agree," "agree," "neutral," "disagree," and "strongly disagree." The total number of questions ranged from 44 to 54 depending on how respondents answered individual questions with branching logic. The 5 overarching components of the survey were: (1) Current task burden (direct patient contact or no patient contact); (2) stress (PSS); (3) resilience (BRS); (4) coping (BRCS); (5) socio-demographic characteristics.

Pilot testing of the survey was conducted with 4 rounds amongst 7 clinicians, nurses, and nonmedical staff to assess the acceptability, readability, and understandability of the survey. The resulting survey took 5 to 7 min to complete.

For the purposes of this analysis, respondents were divided into 4 groups according to their current job description: (1) MD/PA/NP; (2) nurses; (3) non-medical health staff with patient contact (NMPC) and (4) non-medical staff with no patient contact (NMNPC).

Descriptive characteristics for the respondents were reported using frequencies and percentages for each group. For each of the 3 surveys (PSS, BRS, BRCS) a multiple linear regression model was used to compare the groups. Age and sex were adjusted for each model. Age was collected in the survey as a range of values, but for the purposes of the model was coded as a 10-year continuous variable. P-values of <.05 were considered statistically significant and 95% confidence intervals were reported with all point estimates. SAS statistical software (SAS version 9.4, SAS Institute Inc.) 19 was used for all analysis.

Of the 474 surveys sent, a total of 311 (65.6%) responses were received. Among the 311 survey responses, 302 were evaluated. The 8 excluded from analysis did not self-identify their job role/title. Among the 302 responses included in the analysis, 86 were from NMNPC, 97 from NMPC, 62 from MD/PA/NP, and 57 from nurses.

Descriptive characteristics are reported in Table 1 . A majority of those who responded were white (90%) and female (85%). A large portion of respondents (32%) had worked in the health care field for over 25 years. Overall, only 15% of the respondents were male, and for the nursing group only 4% were male. The MD/PA/NP group had the highest percentage of participants over the age of 60 (24%). A total of 129 (43%) respondents identified as caregivers outside of their job.

A higher score on the PSS survey indicates a higher level of perceived stress. Compared to the nursing group, all of the groups had significantly lesser perceived stress (Table 2, Figure 2a ) with the MD/NP/PA group having the largest difference from the nursing group. Age was also significantly (P < .001) related to PSS, with an average decrease of 1.59 points for every decade increase in age.

Just as PSS, a higher BRS score indicates a higher level of resilience. With the nurse group as the reference group, only the MD/NP/PA group was noted to have significantly higher resilience scores. When the MD/NP/PA group is used as the reference, the MD/NP/PA group was found to have higher BRS scores than nurses (−0.31, P = .02); nonmedical staff with patient contact (−0.3333, P = .01); and nonmedical staff with no patient contact (−0.2828, P = .02).

Age also significantly correlated to the overall BRS score, with older age associated with higher resilience (0.11 per decade of age; P = .002) (Table 2, Figure 2b ).

For the BRCS survey, a higher score indicates that the respondent is more likely to cope effectively. For this outcome, no significant differences were detected before and after adjusting for sex and age (Table 2, Figure 2c ). 

This survey in the initial stages of the pandemic was focused on self-perceptions of stress, resilience, and coping. The results indicate that while stress was rife across differing HCW, there were inter-professional differences and, in our case, nurses reported higher stress and lower resilience compared to the other job categories. Pandemics highlight the emotional and occupational vulnerabilities of health care professionals. 20 A recent review of 14 COVID-19 related studies (N = 37-1257) 21 confirmed an extensive strain on HCWs due to stress, depression and anxiety. The severity of these mental issues was influenced by age, gender, occupation, specialization, type of activities performed and proximity to the COVID-19 patient. 21 This corroborates with our survey results and demonstrates a heightened need for organizational and individual strategies for stress management, enhancing resilience, peer support for coping and self-care among HCWs.

The COVID-19 pandemic has placed HCW in untenable stress while balancing the risk to themselves and others. 4 Stress, which may be caused by physical, mental or emotional factors 22 has both physical and psychological consequences, including increased allostatic load, fatigue, inattentiveness, mood disorders, addiction issues, jobrelated injuries, and absenteeism. 9, 23, 24 Add to this the idea of moral injury, which is defined as "the psychological distress that results from actions or lack of them, which violate someone's moral or ethical code." 25 Individuals who experience moral injury may develop depression, post-traumatic stress and suicidal ideation. 26 Not only are HCWs placed in a situation of personal moral injury by being in the frontline during this COVID-19 pandemic 27 but the societal burden of constant updates on death and infection, the misinformation, the added issues of protests, the divide over taking protective steps by the people at large, the shortage of medical and testing supplies, and the call to make decisions on life and death due to these shortages, has increased personal stress.

Overall, HCWs reported moderate-high self-reported stress scores in our survey (average PSS = 17.1), normal range for resilience (average BRS = 3.6) and normal range for resilience coping (average BRSC = 14.9). Further, the stress among nurses was significantly higher than that of MD/PA/NP group. Nurses also reported lower levels of resilience than the MD/PA/NP group, as well as inadequate stress management skills (prior to COVID19 pandemic) (64.25% vs 57.9%, physicians vs nurses respectively, Table  1 ). As in prior studies, our findings highlight the effects of how the psychosocial impact on HCW can differ by the occupation and perception of risk. 28 Similar findings were identified in previous studies in China. In one such study both the incidence and levels of anxiety were significantly higher amongst nurses in comparison to doctors, 29 and in another study, while HCWs reported low levels of stress overall; nurses reported higher levels of stress than doctors. 30 There is limited research regarding nurses' levels of resilience during the pandemic; however, 1 study demonstrated that nurses' low personal resilience predicted COVID-19 anxiety. 31 A 2003 study within the Toronto health care system, which examined the emotional distress impact of the SARS outbreak on the HCWs, confirmed that 29% of all responders showed emotional distress. Similar to our observed inter-professional differences, in this survey, 4 factors associated with emotional distress included: (1) being a nurse;

(2) part-time employment status; (3) lifestyle being affected; (4) ability to do one's job affected by the precautionary measures. 28 Finally, a 1-time cross-sectional survey during the COVID-19 pandemic conducted in China during peak months (January-Feb 2020) showed that among responders (1257/1830; 69%) 50% expressed depression, 44.6% expressed anxiety; 34% insomnia; and 71.5% distress. 32 These scores were modified by job type (nurses > physicians); sex (females > males); patient care (frontline > no direct patient care); location (Wuhan (pandemic hot spot) > outside of Wuhan); and finally years of experience (junior nurses > more experienced nurses). 32 Nurses have been described as the backbone of the health system and outbreak responses. 33 Although the stressors are higher among physicians and nurses who are frontline (direct patient care) compared to others, it is understandable that nurses experience greater stress due to the nature of their work responsibilities which involve spending more time delivering direct patient care, and providing direct social and emotional support to patients whose families are barred from visiting. 34 Further understanding of specific factors contributing to the stress for nurses is important so that stress reduction approaches can be appropriately implemented for this population.

With regard to age differences and resilience, our findings indicated that older age was associated with higher resilience. Previous research has indicated that there is some evidence to support the premise that resilience increases with age. 35 Rational for this has not been wellstudied; however, there is speculation that the improved resilience among older individuals could be contributed to the exposure to more adversity throughout their lifetime (and thus the development of strategies to overcome adversity), 35 and the tendency of older individuals to invest more time and energy in their health and family. 36 There is a lack of evidence regarding differences in resilience levels among HCWs according to age, thus this would warrant further research.

As with most studies, our study had limitations which included this being a 1-time cross-sectional survey of all individuals within 1 division (General Internal Medicine) at 1 institution. An additional limitation was the lack of diversity, with the majority of participants being white females. The survey was delivered during the initial stage of the pandemic, wherein the staff was experiencing significant change: social distancing, mask wearing, cancellation of routing patient practices, conversion to virtual care, cancellation of time away and work related/ other travel, reduction of salaries and furloughs; creating economic uncertainty, all while the media was ripe with misinformation. It would have been ideal to deliver this survey and track outcomes at serial time points during the pandemic. This, however, was not feasible due to the decision to minimize survey burden and keep it anonymous and de-identified.

Informed by the staff and this survey, the General Internal Medicine divisional leadership took numerous proactive steps to support colleagues and mitigate the evolving impact of pandemic-induced stress across all HCWs. The leadership stepped up the communication across multidisciplinary teams with daily and weekly web-based meetings that focused on disseminating accurate and updated information related to the COVID-19 pandemic. There was timely dissemination of institutional initiatives and solutions to address emerging work-related issues, establishment of work teams addressing safety, creation of financial aid fund through the divisional social committee for staff members in need, updating of wellness websites, creation of videos and other resources for coping and resilience in addition to augmentation of opportunities for active peer support and stress management through uptake of existing programs (HELP: healing emotional lives of peers and SMART: stress management and resilience training) as well as virtual town halls to increase connection. There were more frequent check-ins across institutional and departmental administration.

These self-reported data indicate that while HCWs reported moderate-high stress scores, and normal levels of resilience and coping, the MD/NP/PA group had the highest resilience, while nurses had the lowest. In addition to lower resilience, nurses also had higher stress levels compared to the MD/PA/ NP group. It is imperative to have robust strategies and tactics in place for early identification and mitigation of distress across job categories within health care and help enhance resilience and coping among all HCWs, with particular attention to nurses and nonmedical staff. In addition, interventions should be implemented at the individual, organizational, and societal level in order to order to address the multifactorial factors of HCW stress, resilience and coping. 

A special thanks to all the survey participants. Without their participation, this practice improvement project would not have been possible.

All the authors participated in the study concept and design, analysis and interpretation of data, drafting and revising the paper, and have seen and approved the final version of the manuscript.

• ITC and AB conceived of the study concept and design and provided administrative, technical, and material support; had full oversight of the study conduct during data collection. They take responsibility for the integrity of the data and the accuracy of the data analysis; and together they drafted the manuscript and participated in critical revision of the manuscript for important intellectual content. • ITC, SSC, EWB, SRP, KG, JA, KMF, DRS, and AB participated in the study design, review and editing of the protocol and data collection and participated in the review and interpretation of study results, and critical revision of the manuscript for important intellectual content. • KF & DRS participated in the study design and were responsible for data quality checks and data analysis; they also had full access to all the data in the study and take full responsibility for the integrity of the data and the accuracy of the data analysis as well as participating in the manuscript reviews and edits.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This practice improvement project was supported in part by Mayo Clinic General Internal Medicine. The data entry system used was RedCap, supported in part by the Center for Clinical and Translational Science award (UL1 TR000135) from the National Center for Advancing Translational Sciences (NCATS).

This was a practice improvement project. As such, it did not qualify for Institutional Review Board approval. It was reviewed and approved by the Mayo Clinic General Internal Medicine Leadership and Practice Committee, as well as the Mayo Clinic COVID-19 Taskforce.

This was a practice improvement project, which was reviewed and approved by the Mayo Clinic General Internal Medicine Leadership and Practice Committee, as well as the Mayo Clinic COVID19 Taskforce. All authors assert that all procedures contributing to this work comply with the ethical standards of the Mayo Clinic.

Ivana T. Croghan https://orcid.org/0000-0003-3464-3525

All data supporting the study findings are contained within this manuscript

Archived: WHO Timeline -COVID-19

Center for Disease Control and Prevention. New ICD-10-CM code for the 2019 Novel Coronavirus (COVID-19)

Strategies for resiliency of medical staff during COVID-19

Managing mental health challenges faced by healthcare workers during covid-19 pandemic

Building your resilience

Resilience definitions, theory, and challenges: interdisciplinary perspectives

Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis

Burnout among women physicians: a call to action

Stress management interventions for nurses: critical literature review

Resilience in the Health professions: a review of recent literature

Paediatric healthcare professionals: relationships between psychological distress, resilience and coping skills

Anxiety, pandemic-related stress and resilience among physicians during the COVID-19 pandemic

Authentic connections groups: a pilot test of an intervention aimed at enhancing resilience among nurse leader mothers

Consort: Transparent Reporting of Trials

Research electronic data capture (REDCap)-a metadatadriven methodology and workflow process for providing translational research informatics support

The brief resilience scale: assessing the ability to bounce back

The development and psychometric evaluation of the brief resilient coping scale

A global measure of perceived stress

SAS/ STAT Users Guides Web site

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

COVID-19 pandemic: stress experience of healthcare workers -a short current review

Medical Definitions of Stress

Factors related to physician burnout and its consequences: a review

Medical Student Well-Being: An Essential Guide

Moral injury and moral repair in war veterans: a preliminary model and intervention strategy

Occupational moral injury and mental health: systematic review and metaanalysis

Gaining resilience and reducing stress in the age of COVID-19

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

Mental health survey of medical staff in a tertiary infectious disease hospital for COVID-19. Chinese journal of industrial hygiene and occupational diseases

Healthcare workers' stress when caring for COVID-19 patients: an altruistic perspective

COVID-19 anxiety among front-line nurses: predictive role of organisational support, personal resilience and social support

Factors associated with mental health outcomes among health care workers exposed to Coronavirus disease 2019

Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic

Resilience in context: the special case of advanced age

Self, Personality, and Life Regulation: Facets of Psychological Resilience in Old Age