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Year : 2020  |  Volume : 13  |  Issue : 4  |  Page : 196-202

Mental health outcome and professional quality of life among healthcare workers during COVID-19 pandemic: A frontline-COVID survey

1 Department of Gastroenterology, Hepatology and Transplant, NIMS University, Rajasthan, Jaipur, India
2 Department of Pharmacy Practice, NIMS University, Rajasthan, Jaipur, India

Date of Submission20-Jun-2020
Date of Decision27-Aug-2020
Date of Acceptance06-Aug-2020
Date of Web Publication17-Dec-2020

Correspondence Address:
Supriya Suman
Department of Pharmacy Practice, NIMS University, Rajasthan, Jaipur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/HMJ.HMJ_53_20

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Background: Healthcare workers are under substantial level of negative health outcomes due to risk of exposure, workload and moral dilemmas when India is on upsurge of coronavirus disease 19 (COVID-19) cases. Since there is a scare of research on this issue from India, we decided to conduct online survey to evaluate psychological impact and quality of life. Methods: From 25 May to 10 June 2020, a web-based Frontline-COVID survey was conducted. Feeling-related questions, Impact of Event Scale-Revised, Connor-Davidson Resilience Scale (CD-RISC) and Professional Quality of life were administered among healthcare workers from different departments. Results: Among the respondents, 218 (52.1%) belong from low-risk unit and 200 (47.9%) from the 'high-risk unit' including higher proportion of nurses 191 (45.7%), female 282 (67.5%), aged 31–40 years (48.3%) and married 220 (52.6%). Overall female nurses, doctors and working in emergency unit had a greater proportion of psychological distress. Middle aged (31–40 years) had a higher level of resilience contrast to this; working in COVID-19 unit was associated with a lower scale of resilience. Resilience and QoL were an important predictor for psychological distress. Conclusion: Results implicate interventions for stress management and social support among medical staff working in the pandemic. Need for systematic and longitudinal assessment for holistic strategies by policy makers targeting resilience and training for public health emergency.

Keywords: Coronavirus disease 19, frontline worker, mental health, quality of life, resilience

How to cite this article:
Tomar BS, Suman S, Singh P, Raj P, Nathiya D. Mental health outcome and professional quality of life among healthcare workers during COVID-19 pandemic: A frontline-COVID survey. Hamdan Med J 2020;13:196-202

How to cite this URL:
Tomar BS, Suman S, Singh P, Raj P, Nathiya D. Mental health outcome and professional quality of life among healthcare workers during COVID-19 pandemic: A frontline-COVID survey. Hamdan Med J [serial online] 2020 [cited 2023 Mar 29];13:196-202. Available from: http://www.hamdanjournal.org/text.asp?2020/13/4/196/303734

  Introduction Top

The coronavirus disease 19 (COVID-19) has attracted international concern in which skilled healthcare workers are a decisive factor to overcome the viral epidemic.[1] India is witnessing a growing surge in COVID-19 cases with 3.5 lakhs confirmed cases and 12,000 fatalities ranking 4th globally regardless of safety instructions and prevention policies imposed by government of India.[2] At present, burden is on two forms: first to manage the physical outcomes on healthcare work including the risk of infection and second the impaired quality of life and psychological impact due to COVID-19.[3] Mental health problems are multifaceted phenomena consisting of distressing emotions, physiological awakening and associated with bodily sensation, notion and images of elucidation and endangerment. Previous studies, during severe acute respiratory syndrome (2003) on healthcare workers, reported a higher level of psychological symptoms in 10% of hospital staff.[4] Another study, during the H1N1 pandemic, indicated high-risk healthcare workers with raised apprehensive anxiety and burnout.[5] At present, a study from Wuhan, China, revealed 50.4% depression, 44.6% anxiety and 71.5% distress among healthcare workers.[6] Concern about these data is the vulnerability of health workers with a pre-existing mental health condition, mainly physicians with high rates of suicide commitment.[7],[8]

Pandemic had significantly transformed working place as a negative influencer due to high-pressure work with lack of proper guidelines, adverse environment, emotionally demanding interaction jeopardising the quality of life, effecting mental health and challenging resilience.[9] Resilience is viewed as a positive adaptation that empowers an individual's capacity to face adversity and quickly recover. Research has shown that positive resilience in healthcare workers is associated with positive psychological impact. Thus, the assessment of resilience might help in the prediction of the mental health of healthcare workers.[10]

Therefore, this aimed to investigate the psychological impact of COVID-19 among frontline workers battling against COVID-19 and to explore the association of quality of life, resilience and mental health outcomes.

  Methods Top

Study design and participants

As the survey was descriptive quantitative cross-sectional, a web-based study was conducted between 25 May to 10 June 2020 using a snowball sampling technique. The URL link was circulated through social media platforms immediately after COVID-19 contagion was at a peak. Hospitals having COVID-19 wards were enrolled in the study to compare the interdepartmental difference of mental outcomes (i.e. COVID-19 ward, intensive care unit [ICU], emergency and other departments). Efforts were made to reach out to healthcare workers from all over the nation to have a competent representation of the sample. To assess the clarity, acceptability and time duration, the study was forwarded to 10 participants. All the workforce aged above 20 years with understandability of English were recruited.

Study questionnaire

The survey consisted of generalised narration of study in the beginning after providing consent for the study; the questionnaire subdivides into five parts: demographic variables, mental health assessment, evaluation of resilience, impact on the quality of life and effect on feeling due to the COVID-19 outbreak.

Sociodemographic information included gender (male or female), age (20–30, 31–40 or >40 years), marital status (single or married), working position (nurse, doctor, paramedics or non-clinicians) and working department divided into the high-risk unit (COVID-19 ward, ICU or emergency) and other departments as comparison unit.

The Impact of Event Scale-Revised (IES-R) developed by Weiss and Marmar[11] comprises 22-item self-reported questions was used to assess subjective distress caused by a traumatic stressor (COVID-19).[12] Tool scores ranged from '0' to '4' with cut-off ≥33 scores classified under moderate (32–36) and above 36 as severe distress. The IES-R comprises 22 items in three subscales (eight intrusion items, eight avoidance items, and six hyperarousal items). Respondents are asked to rate each item on a scale of 0–4 (0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit, and 4 = extremely) with total score on IES-R ranges between 0 and 88.. The Cronbach's alpha for the present study was 0.913.

The Connor-Davidson Resilience Scale (CD-RISC) was used for the evaluation of resilience.[13] The 25-item Guttman scale rated on a five-point Likert scale ranging from '0' – notable to '4' – extremely time. Items scores are summed together to obtain the total score between 0 and 100, with a higher score denoting higher resilience. Scales were divided into four dimensions: (a) adaptability and acceptance, (b) tolerance to tenacity and strength, (c) optimism and (d) trust in insights that presented with good psychometric properties.[14] The Cronbach's alpha for the present study was 0.926.

The Professional Quality of Life (ProQOL) was developed by Stamm BH for assessing individual's ProQOL on scale of compassion satisfaction (CS: 8 items), compassion burnout (BO: 7 items) and compassion fatigue (CF: 7 items) which measure the experience of satisfaction, symptoms of burnout and risk of traumatic stress with higher scores. Participants rated each item on a five-point scale ranging from 0 – never, 1 – rarely, 3 – sometimes, 4 – often and 5 – very often.[15] In this research, the Cronbach's alpha was 0.789.

Assessment of feeling was done by adaption of survey instruments from a Chinese study conducted in healthcare workers during the COVID-19 outbreak. The questionnaire included ten questions that were validated to examine responsiveness with each domain consisting of four options (0 – not at all, 1 – slightly, 2 – moderately and 3 – very much).[16]

Statistical analysis

Descriptive statistics were used to assess for sociodemographic variables and questions of feeling.

The scores of scales (IES-R, CD-RISC and ProQOL) were expressed in mean and standard deviation, and differences between means of different units were analysed by t-test. Demographics and association with feelings were established using Chi-square test. We used multinomial logistic regression analysis to calculate the association between sociodemographic characteristics, psychological impact, resilience and quality of life, and further, Pearson correlation analysis was carried out. All the tests were two-tailed, with a significance of P < 0.05. Data analysis was performed using SPSS statistic 22.0 (IBM corp. Chicago IL, USA).

  Results Top

In this study, we retrieved 893 questionnaires. Of this, 418 respondents completed all the required fields of the survey with a response rate of 46.8%.

In [Table 1], among the respondents, 218 (52.1%) belonged from the 'low-risk unit' and 200 (47.9%) from the 'high-risk unit'. Maximum respondents were nurses 191 (45.7%), followed by doctors 135 (32.3%). The respondents were mainly female 282 (67.5%), aged 31–40 years (48.3%) and married 220 (52.6%). The comparison and high-risk unit are similar with respect to demographic details (age, marital status and working position) except gender (P = 0.10). Out of all participants, 5.3% of respondents had endorsed moderate-to-severe symptoms of Post-traumatic Stress symptoms (PTSS).
Table 1: Sample characteristics (n=418)

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As shown in [Table 2], working in the COVID-19 outbreak was directly associated with the social and moral responsibility of healthcare workers (P = 0.001), and doctors had the highest mean score (2.68 ± 0.62). Healthcare workers, especially nursing staff, want recognition (P = 0.016) and bonus compensation (P = 0.001) from hospital authorities. Non-clinicians have reduced exposure to patients diagnosed with COVID-19 patients (P = 0.003). Medical health workers were not frightened of working in the hospital scenario (P = 0.002). No significant difference exists between health professionals regarding taking a day off from work.
Table 2: Healthcare worker feeling during coronavirus disease -2019

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On ProQOL Scale, being married (odds ratio [OR]: 1.95; 95% confidence interval [CI]: 0.40–2.33; P ≤ 0.01) and >40 years (OR: 1.31; 95% CI: 0.48–2.13; P = 0.04) were associated with higher satisfaction level, whereas women (OR: 1.67; 95% CI: 1.05–2.31; P = 0.007) and working in the emergency department (OR: 1.45; 95% CI: 0.65–2.60; P = 0.01) were associated with the increased extent of burnout. Women (OR: 1.15; 95% CI: 0.61–1.98; P = 0.03) and nurses (OR: 1.45; 95% CI: 0.71–2.17; P = 0.01) were associated with increased stress level [Figure 1]a.
Figure 1: Association of Quality of life-Satisfaction, Burnout, Stress (a), Resilience (b) and mental health (c) with socio-demographic variables

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Middle aged (31–40 years) had a higher level of resilience (OR: 1.61; 95% CI: 0.97–2.54; P = 0.02), whereas working in COVID-19 (OR: 0.85; 95% CI: 0.42–1.43; P = 0.009) was associated with a lower scale of resilience [Figure 1]b.

Women (OR: 1.98; 95% CI: 1.66–2.90; P ≥ 0.001), doctors (OR: 1.47; 95% CI: 1.45–2.95; P = 0.02) and working in emergency unit (OR: 1.99; 95% CI: 1.36–2.22; P ≤ 0.001) had greater psychological impact on IES-R Scale [Figure 1]c.

[Table 3] presents the correlation results; low resilience predicts negative psychological impact and burnout, whereas low satisfaction predicts hyperarousal in healthcare workers. More precisely, burnout was also associated with negative mental health outcomes.
Table 3: Descriptive statistics and zero-order correlations among variables of the study

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  Discussion Top

Frontline workers during epidemic not only suffer from psychological impact, but they also have impaired quality of life till long after the initial outbreak.[17] Epidemic impact varies with geographic location, pathogen characteristics, route of dissemination, reproducibility and mortality, and attainment of treatment had a consequential impact on healthcare workers.[18]

To our knowledge, there are scarce data that quantify intradepartmental differences and professionals in mental health outcomes due to the COVID-19 epidemic. From the preliminary data analysis, social and moral responsibilities were a major empowering force to healthcare workers during COVID-19 upsurge. The expectation of recognition and compensation of hospital employees from hospital authorities was supported by previous studies performed in Hunan, China.[16] Stigma towards healthcare workers due to fear of the contracting virus and its outcomes had been a topic of focus in the literature.[19] The following could be the reason regarding the limit of exposure from patients diagnosed with COVID-19.

Interestingly, females, especially nurses, had a greater risk of burnout and stress. This could be due to a high level of emotional exhaustion, depersonalisation and lack of personal accomplishment which leads to secondary to maladaptive detachment.[20] Marital status is associated as a major predictor for satisfaction; subsequently, older couples over time develop psychological resilience.[21] Being seniors influence greater job satisfaction because they experience foster adjustment and responsibility towards patient care. Khamlub et al. suggested that a high position in healthcare services tends to have greater responsibility ultimately associated with an elevated level of satisfaction.[22] Medical workers in an emergency were at risk of burnout due to a dangerous atmosphere with a consistent increase in COVID-19 cases. Emergency care professionals deal with unavoidable life conditions with high volumes of interaction in the earlier scenario of insufficient access to PPE and lack of guidelines.[23] Baruah et al. indicate that emergency departments suffer from the major discrepancy in relation to infrastructure and work environment setup which could be the probable reason for burnout.[24] Another intriguing finding from our study significantly predicts resilience in middle-aged staff. This result might be interpreted by Erikson's theory of life cycle development which postulates middle-aged adults' attributes to greater courage and generativity.[25] Certainly, the resilience of healthcare workers in the COVID-19 unit should be buffered up by good social support and proper stress management.[26]

IES-R among healthcare workers was lower than those published in previous literature with almost three times higher fold of PTSS.[12],[27] This could be due to quintessential infection control measures and the multifaceted approach through Indian government collaboration with esteemed institutions.[28] Adoption of telemental health services can be a comprehensive approach to address mental health needs irrespective of any circumstances.[29],[30]

Quality of life is a broad range affected by individual's health, psychological state, social relations and salient feature of environment. Previous studies suggested perceived QoL as a positive predictor or psychological disorders.[31] This study demonstrates the correlation of decreased resilience play mediating role on quality of life and mental health of healthcare workers and vice versa.

The first important limitation of the study was its self-reported format which has lesser disparity than face-to-face interviews. Secondly, the study design was cross-sectional due to which continuous effect cannot be studied. In addition to that, there is a need to manifest association of social support to mental health in future studies

  Conclusion Top

On the basis of our findings, female nurses, doctors and working in emergency unit had a greater proportion of psychological distress. Working as frontline was moral and social responsibility. Elderly and married had a higher level of satisfaction. In the end, resilience and QoL were important predictors for negative mental health outcome. There is a need of effective strategies by policymakers considering mental health issues targeting resilience and training for public health emergency.

Ethical Appeoval

The purpose of the survey was explained to potential participant, who were requested to provide consent of voluntary willingness prior to their participation. All procedures performed in the this study involving human participant were in adherence to the ethics of 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was conducted and reported according to the Checklist for Reporting Result of Internet E-Surveys (CHERRIES) guidelines.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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