Resilience and emotions of frontline obstetrics and gynaecology healthcare workers during the COVID-19 pandemic
2023; Medknow; Linguagem: Inglês
10.4103/singaporemedj.smj-2022-027
ISSN2737-5935
AutoresHester Chang Qi Lau, Ni Ni Soe, Shi Qi Monica Chua, Jill Cheng Sim Lee, Suzanna Sulaiman,
Tópico(s)Optimism, Hope, and Well-being
ResumoINTRODUCTION Singapore was one of the earliest countries affected by the novel coronavirus disease-2019 (COVID-19) outbreak. In times of infectious disease outbreak, Singapore utilises the 'Disease Outbreak Response System Condition' (DORSCON), a colour-coded framework to show the current disease condition. On 7th February 2020, Singapore Ministry of Health stepped up its alert level from yellow to orange, signifying that the disease is severe and spreads easily from person to person, although the disease is being contained.[1] Following this escalation, the Department of Obstetrics and Gynaecology at KK Women's and Children's Hospital, which delivers more than 11,000 babies annually, established isolation teams to care for patients with suspected or confirmed COVID-19 infection. Each team comprised two doctors (one registrar and one medical officer) and one or two nurses, depending on the patient volume per shift. Two teams were on-site at all times, caring for two main clinical areas — the labour ward and the urgent obstetrics and gynaecology centre, which provides emergency gynaecology and early pregnancy care. These teams rotated on 12-hour shifts over seven consecutive days and segregated themselves from other colleagues and clinical areas. Healthcare workers (HCWs) face intense demands daily, from arduous shifts to constant pressure to perform, and increasing levels of responsibility. It is unsurprising that HCWs experience a higher prevalence of burnout than the general population. This psychological pressure and emotional stress among HCWs appeared to heighten during a pandemic, as seen from studies conducted following severe acute respiratory syndrome (SARS) outbreak in 2003.[2] Burnout is a syndrome characterised by emotional exhaustion, depersonalisation and a diminished sense of personal achievement. Resilience, defined as "the ability to adapt successfully in the face of trauma, adversity, tragedy or significant threat", is critical in helping to combat burnout.[3] Resilience building becomes critical during a pandemic. Understanding the emotional and psychological effects of COVID-19 outbreak can improve the well-being of HCWs. Additionally, this information has wider relevance to healthcare systems in planning for emerging infections and potential bioterrorism.[2] This study aims to explore the impact of COVID-19 pandemic on the resilience and emotions of frontline HCWs in obstetrics and gynaecology. METHODS This was a cross-sectional retrospective descriptive study involving doctors and nurses who were on isolation duty from 7 February 2020 to 30 April 2020. The brief resilience scale (BRS) was used to evaluate resilience [see Appendix 1https://links.lww.com/SGMJ/A14]. The BRS is a concise, six-item, self-rating questionnaire that was developed by Smith et al.[4] in 2008 to measure individuals' ability to recover from stress. It has been validated in many countries to be an accurate and reliable measure of resilience.[5-7] The BRS consists of six statements. Statements 1, 3 and 5 are positively worded, while statements 2, 4 and 6 are negatively worded. The BRS is scored by reverse coding statements 2, 4 and 6, and finding the mean of the six statements. Study participants reported how strongly they agreed or disagreed with the statements. The BRS score is classified into three resilience categories: low (1.00–2.99), normal (3.00–4.30) and high (4.31–5.00). Additional survey questions were added to (a) explore the emotions of HCWs during the isolation shifts, (b) identify factors that reduced stress and (c) determine how the health of HCWs was affected when working in isolation teams [see Appendix 2https://links.lww.com/SGMJ/A15]. Participants could choose more than one option for selected questions. The questions and content in the survey were developed following discussion between study investigators and key departmental leaders. The survey was piloted on junior doctors to ensure ease of use and understanding before distribution. All HCWs who completed isolation duties were invited to participate. Survey responses were anonymous to ensure confidentiality. Completed surveys were consolidated. Incomplete responses were excluded. The responses were transcribed and transferred into Microsoft Excel. The mean BRS score was analysed with paired t-test and one-way analysis of variance using IBM SPSS Statistics version 22 (IBM Corp, Armonk, NY, USA). A P value < 0.05 was considered statistically significant. The qualitative data was summarised into themes and categories. This study was approved by the SingHealth Centralised Institutional Review Board (CIRB), reference number 2020/2471. RESULTS A total of 50 doctors and 51 nurses worked in the isolation team during the study period. Of the 101 HCWs who received the survey, three did not return the survey and one had incomplete BRS, and hence, they were excluded. The response rate was 96.0% (97 out of 101 HCWs). The respondents' age ranged from 21 to 60 (mean 34 ± 7.970) years. Their professional work experience ranged from 1 to 40 (mean 9.3 ± 7.818) years. As seen in Table 1, the mean BRS score of the respondents was 3.6 ± 0.664. The majority of respondents had normal resilience (76.3%), 11.3% had low resilience and 12.4% had high resilience. There was no statistically significant difference in the mean resilience scores when analysed by age (P = 0.700) and years of experience (P = 0.918). Doctors had significantly higher BRS than nurses (mean 3.8 vs. 3.4, P = 0.003). Male HCWs had significantly higher BRS scores than female HCWs (mean 4.0 vs. 3.5, P = 0.043). Among the 49 doctors, there was no observed difference in BRS scores between male and female doctors (P = 0.318). There were no male nurses in the study.Table 1: Mean brief resilience scale based on the occupation, gender, years of experience and age among the study respondents.Out of 97 respondents, 26 (26.8%) reported positive attitudes when informed of their assigned isolation duties: 18 (18.6%) HCWs were excited, seven (7.2%) HCWs were happy, one (1.0%) HCW volunteered and one HCW felt ready (1.0%). Conversely, 65% of HCWs reported negative emotions: 52.6% of HCWs were worried, 2.1% of HCWs were anxious, 4.1% of HCWs were angry and 1.0% of HCWs were upset.Twenty-five (25.8%) HCWs were indifferent. Respondents were more often concerned for their families (88.8%) than for themselves (62.9%) [Table 2].Table 2: Degree of concern for family and one's health during isolation duties.During isolation duties, the majority of HCWs (79/97) expressed negative emotions, such as low mood (23.7%), anxiety (39.2%), irritability (23.7%), anger (2.1%) and fear (3.1%). Nineteen (19.6%) HCWs felt neutral and only 6.2% of HCWs had positive emotions such as cheerfulness, happiness and motivation. Three respondents refrained from responding to questions on mental health issues. Half of the respondents (47/94, 50.0%) felt that their mental health was the most affected during isolation duties, followed by social well-being (28/94, 29.8%) and physical health (19/94, 20.2%). HCWs on isolation duties were advised not to meet other colleagues and to minimise contact with family members. They reported less family time due to the 12-hour shift work for seven consecutive days. This impacted their social well-being and resulted in self-reported low mood. A total of 80 respondents answered the question, "What makes you happy during isolation duties?" [Table 3]. The most common responses (32.5%) showed that supportive team members with good teamwork made the isolation duties of HCWs more enjoyable: "Going through it with friends/colleagues", "Company of colleagues", "Teamwork and positivity is important" and "Good team with nurses and doctors". Many of them (23.8%) appreciated the time away from routine clinical work: "No ward rounds, no clinic, no ward duties" and "Able to have staff empowerment to do things that we don't usually/routinely do". Also, 22.5% of the respondents enjoyed the small acts or gifts of appreciation from the department, hospital and community: "Thanks from patient", "Being appreciated" and "Care and concern from colleagues outside (of) iso(lation duties)". Some of the respondents also commented that the well-equipped negative pressure rooms gave them confidence in managing COVID-19 patients.Table 3: Factors that contribute to feelings of happiness during isolation duties (N=80).Respondents were concerned that junior doctors were placed at a higher risk of infection as they were at the frontline of patient interaction and many were assigned to the isolation team multiple times during the study period. There were also concerns regarding financial remuneration for the additional shifts, and that all leave was cancelled at very short notice. DISCUSSION Globally, the COVID-19 pandemic is the most prolonged medical crisis, with Singapore bearing the early brunt of it. Our study indicated that respondents had normal mean BRS score, similar to the resilience of primary HCWs from a systematic review done in New York.[8] In our study, the median BRS score was 3.6, and 11.3% of respondents reported low resilience. Nurses had significantly lower BRS score compared to doctors (3.8 vs. 3.4, P = 0.003). This may be partly related to their educational background. A cross-sectional study conducted among nurses in Singapore in 2018 found a positive correlation between highest educational qualification and resilience level; nurses with a bachelor's or postgraduate degree were three times more likely to be of moderate or high resilience compared to nurses with a general nursing certificate.[9] It was observed that male HCWs had higher resilience scores than female HCWs. This may be confounded by the absence of male nurses in this study, as previous studies did not demonstrate any association between gender and resilience.[8,10-12] There was also no association between age or years of working experience with resilience score. Balmer et al.[10] suggested otherwise, that resilience among police officers was negatively affected by increased rank, age and length of service. This may be explained by the difference in the nature of the work. In this study, there were only seven participants who had more than 20 years of experience, while 90 participants had less than 20 years of experience. Hence, the former may be under-represented. Furthermore, resilience building requires transformational growth, which involves struggling, changing mindset and adaptation. The duration for this process varies among individuals, and the struggles one experienced may not always correlate with years of working experience. There is also a risk of burnout due to being in the system for a longer period of time. Moreover, most HCWs would not have experienced a pandemic despite longer years of service. Thus, they may not be more prepared or equipped with the skills to adapt to the adversity that a pandemic brings. In this study, respondents were generally more concerned about their family's health and safety compared to their own. This is similar to the results of studies done in Taiwan and China during the SARS outbreak. Their main worries included fears of contracting and transmitting SARS to their families, being negligent and endangering co-workers and patients.[13,14] The long working hours affected most HCWs mentally. The social isolation from colleagues and self-imposed isolation from family members affected their social well-being and increased mental stress. Three main factors were identified in this study that made the respondents happy during their isolation duties: (a) good teamwork with reliable and efficient colleagues, (b) time away from routine clinical work and (c) appreciation from the department, community and patients. These factors were similarly being identified in Saudi Arabia during the Middle East respiratory syndrome-related coronavirus outbreak and in Taiwan during the SARS outbreak.[13,15] Concerns regarding sufficient infection control and personal protective equipment (PPE) were reported in other centres, and deficiency in these measures was found to be associated with higher HCW infections.[16] At our hospital, we are fortunate to have sufficient supply of PPE for all staff, clear clinical guidelines available on the hospital intranet and round-the-clock support from infectious disease specialists. We recognised that there would be concern regarding safety, and hence staffs allocated isolation duties were prioritised for completion of PPE and powered air-purifying respirators training before isolation duties. This ethos continues till today where vaccination is offered as a priority to the HCWs over other populations. A study by Klein et al.[17] conducted in Germany implied that interventions aimed at reducing clinicians' psychosocial stress at work could improve the quality of health care provided. They highlighted the importance of targeting intervention at multiple levels, and this theme is similarly identified in our study. Potential interventions at the organisational level include promotion of autonomy, adequate support systems, collegial work environment and work–life balance. On the other hand, overtime work, inadequate remuneration, high perceived demands and workplace inefficiency should be reduced. At the individual level, engaging in stress prevention programmes helps reduce overcommitment issues among HCWs. This can, in turn, help to increase personal well-being, aid in stress management, and reduce the symptoms of work stress and error frequency. Reducing formal hierarchies could promote social support as well. At the structural level, innovations in work organisation, compensatory wage systems or models of gain sharing could be implemented. These may prevent mental health issues and plan provision of care for future mental health issues for HCWs, especially in the face of a pandemic. An evident example is ensuring adequate supply of PPE and that HCWs undergo proper training to allay concerns regarding safety. Practical gestures of gratitude, such as provision of meals, public acknowledgement or monetary remunerations, help HCWs feel appreciated. Despite the increased stress experienced during a pandemic, additional effort needs to be taken to promote good working relationships and maintain open communication. This applies not only to the healthcare teams, but also to interdisciplinary teams such as the administrators and leadership. This can be achieved through implementation of communication channels that are easily accessible (e.g. multidisciplinary chat groups). This study has some limitations. First, it utilised a self-designed, 11-domain survey designed to assess emotional and psychological stress. As the survey is not standardised or validated, its reliability and ease of comparison with other published literature may be limited. Second, our department sees COVID-19 patients with only gynaecological or obstetrical issues, and so, the overall psychological distress reflected may be underestimated when compared to other departments (e.g. emergency department).[18] Also, the department has more female than male staff; therefore, comparison between the genders may increase type 1 error rates. Furthermore, our study did not adjust for possible comorbidities among participants, which may affect their ability to handle additional stress and workload during a pandemic. Mealer et al.[19] reported a significant negative relationship between resilience and coexisting mental disorders when comparing HCWs from intensive care unit; it was found that those with high levels of resilience had less coexisting posttraumatic stress disorder, anxiety symptoms and depression. Resilience can also be affected by personal and environmental factors, such as personality, working and family relationships, education level, social support and role modelling, which were not completely explored in this study. As one in nine of our respondents had low resilience scores, the department should develop ways to follow-up on potential issues that may affect HCWs after the pandemic. Finally, this was a cross-sectional study that analysed the acute reaction of HCWs in the first few months of the pandemic. It did not analyse the longitudinal adaptation and building of resilience as the pandemic progressed to an endemic situation. Thus, additional follow-up studies would be beneficial to monitor the progress of the interventions proposed. In conclusion, the COVID-19 pandemic has, beyond its impact on physical health, caused emotional distress among frontline HCWs. The resilience score, emotions, perceived stressors and coping strategies of HCWs in our study were similar to those in other studies. However, analysis from qualitative data helped identify key areas that healthcare institutions can engage in to improve HCWs' well-being. It is evident that resilience is influenced by many factors other than the individual alone. Even though the overall resilience scores were in the normal range, 11.3% of the HCWs had low levels of resilience. Thus, it is important to put in place interventions to support the mental well-being of our HCWs to prevent burnout. Acknowledging and recognising the workplace burdens is vital to establishing supportive workforce resources during a pandemic. This study concludes that the main stressor stems from concerns over personal and family safety, while positive attitudes at work, and healthy and supportive work environments are key factors keeping the HCWs happy and productive. Understanding these helps us implement measures to reduce stress and promote positivity and good working relationships among HCWs. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Supplemental Digital Content APPENDIX 1 APPENDIX 2 https://links.lww.com/SGMJ/A14 https://links.lww.com/SGMJ/A15
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