Authors: Ann Pearman; MacKenzie L. Hughes; Emily L. Smith; Shevaun D. Neupert

[This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). Front. Psychol., 13 August 2020 | https://doi.org/10.3389/fpsyg.2020.02065]

Summary

To understand the psychological impact of COVID on healthcare professionals in the United States, these early U.S. researchers looked at an array of potential symptoms related to stress in COVID healthcare workers.  These included anxiety and stress, depressive symptoms, general anxiety, tiredness, control beliefs, and proactive coping. Results showed higher levels of anxiety and depressive symptoms, more tiredness and concern for their health, and more severe stress appraisals, along with lower levels of perceived control and coping compared to age-matched controls. In conclusion, the authors warned of potential ongoing mental health impairment in this cohort.

Abstract

We conducted this study to better understand the psychological impact of COVID-19 on healthcare professionals in the United States We used an online survey tool to collect demographic data and measures of well-being in adults 18 and older who were living in the United States between March 20, 2020 and May 14, 2020.

Measures included:

• Anxiety and stress related to COVID-19
• Depressive symptoms
• Current general anxiety
• Health questions
• Tiredness
• Control beliefs
• Proactive coping
• Past and future appraisals of COVID-related stress

Healthcare professionals reported higher levels of depressive symptoms, past and future appraisal of COVID-related stress, concern about their health, tiredness, current general anxiety, and constraint, in addition to lower levels of proactive coping compared to those who were not healthcare workers. Within the context of this pandemic, these groups were at increased risk for a number of negative well-being outcomes. We discuss potential targets for intervention, such as adaptive coping.

Introduction 

On May 14, 2020, the United States had 1,340,098 confirmed COVID-19 cases with 80,695 deaths and was considered the epicenter of the pandemic (WHO, 2020). Although social distancing and quarantine guidelines have slowed the pandemic’s spread, recent relaxing of guidelines suggests continued challenges to the healthcare systems and healthcare professionals. Indeed, there are calls for COVID-19 to be considered as a new occupational hazard for healthcare workers around the globe (Godderis et al., 2020).

Not only are many healthcare workers more likely to contract COVID-19 themselves, but providing care during a pandemic can place tremendous pressure on those caring for very sick and dying patients, helping the families of the sick, and dealing with the frustrations of U.S. healthcare systems, all while trying to take care of their own families and loved ones (Maunder et al., 2003; Bai et al., 2004).

Studies out of China have examined the experiences of healthcare professionals during the height of their COVID-19 outbreak. In a sample of 1,563 Chinese staff working during the pandemic, 73.4% reported stress-related symptoms, 50.7% reported symptoms of depression, 44.7% reported anxiety, and 36.1% reported experiencing insomnia (Liu et al., 2020).

Lai and colleagues (2020) found evidence for higher rates of anxiety, depression, and distress among healthcare professionals in Wuhan compared to those in other regions in China. Other studies examined the need for, and impact of services offered to healthcare workers, such as adjusting shifts to allow time for rest (Chen et al., 2020; Kang et al., 2020).

While there have been several commentaries regarding the well-being of healthcare workers in the United States during this pandemic (Godderis et al., 2020; Gold, 2020; Greenberg et al., 2020), we are aware of only one descriptive study New York City (Shechter et al., 2020) that did not include a control group. There have been several meta-analyses and reviews of the impact of this pandemic on healthcare professionals internationally (Chew et al., 2020; Pappa et al., 2020; Rajkumar, 2020), but no studies from the United States were available to be included here.

Pre-COVID studies have shown that the mental health challenges to healthcare workers during pandemics often impact their ability to continue as part of the frontlines working to help treat and care for patients and their own families (Maunder et al., 2006; Shechter et al., 2020). Further, enduring psychological effects could negatively impact their ability to provide patient care in the future as well as impacting their own quality of life (Goulia et al., 2010).

A crucial mission for researchers during this time is enhancing our understanding of the experiences of healthcare professionals in order to plan for interventions and care, both in the short-term (now) and in the long-term (over the next couple of years).

The current study is designed to examine several critical outcomes, such as depressive symptoms, anxiety (current general anxiety as well as anxiety about developing COVID-19), COVID-related stress, and health of themselves during the early months of the pandemic across the United States. In addition, we also examine potentially beneficial indicators of resilience such as control beliefs and proactive coping.

Psychiatric morbidity in the forms of depression and/or anxiety not only is troubling in its own right, but also highly correlates with burnout, higher rates of chronic diseases, reduced quality of life, and suicide (Kumar, 2016). During the SARS pandemic in Greece, researchers found that the pressure of the work environment combined with fears about the disease itself created negative outcomes in the form of anxiety and depression that had profound impacts on the well-being of healthcare workers during that time (Goulia et al., 2010).

Followup studies revealed that the emotional distress from the pandemic was often long-lasting (Maunder et al., 2006). For instance, 1 to 2 years after the SARS outbreak, Maunder and colleagues (2006) found that SARS healthcare workers reported higher levels of burnout and distress, had increased smoking and alcohol consumption, were more likely to have reduced patient contact, and worked fewer hours compared to healthcare workers who did not treat SARS.

The SARS outbreak was much more contained than the current worldwide pandemic, which has even greater potential to have both ongoing and lasting consequences on society as a whole, and healthcare professionals in particular.

Identifying opportunities for resilience will be especially critical to combat negative consequences. Control beliefs represent the subjective perceptions that we can influence what happens in our life and include beliefs or expectations about the extent to which our actions can bring about desired outcomes (Agrigoroaei & Lachman, 2010). Lachman and Firth (2004) distinguished two main sources of control: (1) one’s own efficacy (internal control, competence, or personal mastery); and (2) the responsiveness of the environment or other people (external control, contingency, or perceived constraints) (Bandura, 1977).

The two control beliefs included in the present study are mastery and constraint. Mastery is often described in terms of our judgments about our ability to achieve a goal, while perceived constraints refers to the extent to which we believe factors exist that interfere with goal attainment (Lachman & Weaver, 1998b).

Pearlin and Schooler (1978) suggested that personal mastery is an important psychological resource that mitigates the effects of stress and strain, and it is also associated with reduced reactivity to work-related stressors (Neupert et al., 2007). When faced with stressful situations, a strong sense of control has also been linked to low levels of self-reported stress (Cameron et al., 1991) and lower risk of depression (Yates et al., 1999).

Aspinwall and Taylor (1997) characterized proactive coping as a series of steps we take to preemptively modify or avoid stressful events. In their cohort, those who had higher levels of proactive coping showed more meaning in life (Miao et al., 2017), fewer symptoms of PTSD (Vernon et al., 2009), and higher levels of quality of life (Cruz et al., 2018).

Proactive coping is also associated with lower levels of depression, fewer declines in functional disability in aging, and larger systems of social support (Greenglass et al., 2006; Bokszczanin, 2012). When stressors do occur, those with higher levels of proactive coping are better able to maintain their emotional functioning (Polk et al., 2020).

Within the context of the COVID-19 pandemic, individuals who are at high risk of exposure to the virus could particularly benefit from engaging in proactive coping strategies to prevent exposure to future stressors. Indeed, we know from past work that older adults, who are vulnerable to the effects of the virus, had lower levels of stress when they were high in proactive coping (Pearman et al., 2020).

This study is designed to examine the experiences of U.S. healthcare professionals during this pandemic. Data collection took place between March 20 and May 14, 2020, a timeframe when the United States was experiencing a spike in new coronavirus cases, which limited the availability of important medical resources (including appropriate PPE) and put tremendous strain on the nation’s frontline professionals. The sample is derived from a larger online study focused on individuals’ psychological and behavioral responses to COVID-19 (Pearman et al., 2020).

In the current study we specifically examine the following variables in a sample of healthcare professionals and age-matched controls:

• Stress related to COVID-19
• Anxiety about developing COVID-19, depressive symptoms, current general anxiety
• Past and future appraisals of stress related to COVID-19
• Perceived health and health-related concern
• Tiredness
• Control beliefs (mastery and constraint)
• Proactive coping

We hypothesized that healthcare professionals would show significantly more challenges on our measures of stress, mental and physical health issues, control, and coping.

Methods and Materials

Participants

Potential participants responded to this description: “The purpose of this study is to examine how people living across the United States are reacting to the current COVID-19 pandemic.” Participant requirements for the current study were as follows: 18 years of age or older, living in the United States, native English-speakers, and free from a dementia diagnosis.

Once recruited and consented, the participants completed the survey through the Qualtrics platform, which is an online survey tool. The sample for the larger study consisted of 1,000 participants. Participants answered yes or no to the question, “Are you a healthcare professional?” Participants for the current study included all participants who answered yes to this question as well as age-matched controls drawn from the same dataset.

The final sample included 90 healthcare professionals and 90 age-matched controls from 35 states across the United States.

Demographics

Participants indicated their year of birth, gender, their education from a checklist (e.g., GED, Associates), and their race. Healthcare providers were also asked to report the specific profession within the healthcare field from a checklist.

COVID-19 Anxiety

Participants indicated their level of anxiety related to contracting coronavirus by answering the question, “How anxious are you about developing COVID-19?” on a scale of 1 (not at all anxious) to 5 (very anxious).

COVID-19 Stress

On a 1 (not at all) to 5 (extremely) scale, participants indicated their level of stress by answering the question, “How stressed are you about the COVID-19 outbreak?”

Depressive Symptoms

Participants completed the 15-item Geriatric Depression Scale Short Form (GDS) (Yesavage, 1988). The GDS is a self-report screening tool that examines depressive symptoms. Reflecting over the past week, participants respond yes or no to each item. An example item: “Do you feel that your situation is helpless?” The scale has been shown to have good diagnostic sensitivity and specificity for adults across the adult lifespan (Guerin et al., 2018). The scale was not used for diagnostic purposes in this study, but higher scores indicate greater depressive symptoms.

Current Anxiety

Ten state anxiety items from the State-Trait Anxiety Inventory (Spielberger et al., 1983) were rated on a four-point scale ranging from 1 (not at all) to 4 (very much so). Participants indicated how they were feeling in the moment. Example items include “I am tense” and “I feel frightened.” Five items were reverse coded.* A mean was calculated across the 10 items with higher scores indicating more anxiety.

*Reverse coding. An example of reverse coding would be “I really hate parties” and “I like being alone.” Both are used to measure the same underlying construct or hidden cause. Health.

Health

Participants self-rated their health on a five-point scale ranging from 1 (poor) to 5 (excellent) by answering the question, “How would you rate your overall health?” In addition, participants rated their health concern on a 1 (no concern) to 5 (very serious concern) scale, responding to the question, “How much concern/distress do you feel about your health at this time?” Both items were included in analyses because one focuses on current health status while the other focuses more specifically on how concerned individuals are generally about their health.

Tiredness

On a five-point scale ranging from 1 (not at all tired) to 5 (very tired), participants were asked “In general, how tired are you right now?”

Control Beliefs

Control beliefs were measured using the mastery and constraint scales from the Sense of Control Scales from the Midlife Development Inventory (Lachman and Weaver, 1998a). On a 1 (strongly disagree) to 7 (strongly agree) scale, participants rated their agreement with statements such as “What happens in my life is often beyond my control” (constraint) and “I can do just about anything I really set my mind to” (mastery).

Proactive Coping

The Proactive Coping Scale (Aspinwall et al., 2005) includes six items rated on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). An example item includes, “I prepare for adverse events.” One item was reverse coded.* Higher scores indicate more proactive coping.

Stress Appraisals

On a 4-point scale ranging from 1 (not at all) to 4 (a lot), participants rated the extent to which COVID-19 affected different areas of their lives in the past 24 hours, as well as the extent to which they expected COVID-19 to affect their lives in the next 24 hours. Example items include “Your physical health or safety” and “Your plans for the future” (Lazarus, 2006). Items were scored so that higher scores indicate COVID-19 having a greater impact on one’s life.

Results

A statistical analysis was performed with the following results. There were no significant differences on gender between healthcare professionals and the control group. As expected, there were significant differences on education in that healthcare professionals had more education than non-healthcare professionals. Results controlling for education show that healthcare professionals reported significantly higher levels of depressive symptoms, current anxiety, concern about their health, tiredness, constraint, and past and future appraisal of COVID-related stress; however, they showed lower levels of proactive coping compared to non-healthcare professionals. Of note, there were no significant group differences on COVID-related stress or on the specific anxiety of developing COVID-19.

Discussion

This study is a timely look into the experiences of healthcare professionals across the United States during the COVID-19 pandemic. Comparing an age-matched group, the healthcare professionals were significantly more depressed and generally anxious than the non-healthcare professionals during the first months of the pandemic. In line with Shechter and colleagues (2020), who documented high rates of lack of control and sleep disturbances within healthcare professionals in New York City, our results show that healthcare professionals across the United States had significantly higher rates of lack of control and tiredness compared to controls.

On average, the healthcare group fell into the clinically depressed range (Guerin et al., 2018). While some of the other findings (e.g., fatigue) may represent differences sometimes seen between healthcare professionals and other professions in non-pandemic times (Dyrbye et al., 2014), meeting the criteria for depressive disorder should not. We believe that the heightened level of depressive symptoms in healthcare professionals may be due not only to occupational differences but also to occupational differences during a pandemic.

Clearly, this is of concern not just for understanding and (perhaps) helping the current situation but also to look ahead to the potential lasting influence of this experience (see Maunder et al., 2006; Lee et al., 2007). It is well understood that the long-term consequences of depression and anxiety can create enduring negative impacts (Sareen et al., 2005; Musliner et al., 2016).

Finding ways to intervene and support healthcare professionals, such as cognitive behavioral therapy or support groups, will be an important goal to healthcare systems and workplaces now and in the future.

In addition to increased general anxiety and depressive symptoms, healthcare professionals were more tired and more concerned about their health than the age-matched controls. There are many possible reasons for their health concerns during this pandemic (CDC, 2020). To start, healthcare professionals are more likely to be exposed to COVID-19, which increases their health risk. Other health risks include long work hours and mental and physical exhaustion (Shanafelt et al., 2020; The Lancet, 2020). It is not surprising, therefore, that the healthcare professionals also have higher perceived constraints and are more tired.

The real experiences in healthcare settings during the pandemic may present workers with what seem like insurmountable pressures when it comes to maintaining their own health and well-being. Helping healthcare professionals find ways to differentiate between immovable constraints, such as lack of PPE, and possible malleable constraints, such as feeling there is no opportunity to engage in self-care, may be a possible avenue for buoying the well-being of healthcare workers (De Raedt & Hooley, 2016).

Along these same lines, the healthcare professionals showed lower proactive coping and fewer resources to dedicate to adaptive coping behaviors. We know from past work that proactive coping (Polk et al., 2020) and control beliefs (Neupert et al., 2007) are key ingredients for resilient stress responses, and represent potential targets for intervention. For instance, Stauder and colleagues (2017, 2018) found that coping skills training with employees from work environments that were stressful but unchanging helped reduce stress and improve well-being.

Although statistically equivalent on COVID-19–related stress and anxiety, the healthcare professionals in the current study scored significantly higher on both current and future stress appraisal when compared to controls. In their real-time study of work stress in nurses, Johnston and colleagues (2016) showed that appraisals of stress were more predictive of psychological and physiologic reactivity than the actual tasks being performed.

In addition, the perceived reward for the work actually helped reduce stress. Given the high levels of stress appraisal both current and future in our sample, it may be beneficial during this time of crisis to help healthcare workers recognize and focus on the rewards of their work as a means of managing negative stress appraisals.

We acknowledge several limitations in this study. Our observational design limits our ability to find causes. Future studies should examine the long-term impact of this pandemic on the mental health of healthcare professionals.

We also do not know the extent to which the healthcare professionals in the sample are serving on the frontlines of the pandemic; however, given that they showed significant differences on most of our measures, it is likely that our effects actually underestimate the experiences of frontline workers.

We encourage future work that seeks to explore potential differences between professions, but note that our results suggest that all healthcare professionals are at risk for decreased well-being, perceived control, and coping resources during the COVID-19 pandemic.

Finally, our sample was restricted to those living in the United States—the current epicenter of the pandemic. Healthcare professionals’ experiences during the COVID-19 pandemic could differ for those living and working in countries outside of the United States.

Conclusion

In conclusion, our results suggest that COVID-19 may function as an occupational hazard for healthcare professionals (Godderis et al., 2020) because we found evidence of higher levels of anxiety and depressive symptoms, more tiredness and concern for their health, and more severe stress appraisals of COVID-19, along with lower levels of perceived control and coping compared to age-matched controls.

Across a wide array of indicators, healthcare professionals appear to be at increased risk for mental health challenges. In addition, given that previous studies during other pandemics have shown lasting impacts of service during this time, including reduced workforce participation and increased traumatic symptomatology, this is a critical issue. We encourage efforts to intervene that can provide relief now and in the future.

References

For these references, please go to https://www.frontiersin.org/articles/10.3389/fpsyg.2020.02065/full.