Our study reported psychological distress of HCWs including nurses, physicians, and public health officers. We found that emotional exhaustion of HCWs is highly serious, as evidenced by an average score (30.8) that was higher than the prevalence cut-off point (27). The prevalence of emotional exhaustion of this study was 63%, which was worse than that for studies concerning SARS or MERS [5, 25]. In particular, the prevalence of burnout among nurses was the highest of the different work types examined. This result is similar to that reported in other related COVID-19 studies. The higher prevalence of emotional exhaustion could be attributed to long-term COVID-19 work participation, having to work in a risky workplace, and continuous presence of COVID-19 related tasks[5, 7]. The traumatic distress of staff working in public health centers was worse than that for any other type of HCW. These results (Table 4) indicated that more attention to mental health wellbeing of nurses caring for COVID-19 patients is needed. There was no significant difference in the prevalence of PDI among work characteristics, but the mean PDI score for public health officers was statistically higher than that for respondents engaged in other types of work. Furthermore, although the mean score for emotional exhaustion for NC was the highest of the work types examined, the scores for PNC were as high as the exhaustion scores for nurses. This result implies that first-line medical workers do not always have higher psychological distress than other workers, and highlights that supports such as provision of rest time, safety training and education, and psychological support are needed for all types of HCWs, regardless of their job type and obligations. Based on previous reports concerning the relationship between exhaustion and psychological distress[27, 28], future research should consider the importance of psychological wellbeing of HCWs.
The results of multiple regression analyses showed that full-time employment and the perception that COVID-19 work participation was compulsive were negatively associated with psychological distress. This result could reflect the conflicting obligations of duty to care for COVID-19 patients on the one hand and the drive for self-preservation on the other. Full-time HCWs are exposed to higher risks from COVID-19 compared to part-time workers simply based on the number of hours worked. Due to their full-time status, such HCWs are more likely to be placed on response teams, which can enhance feelings of stress and perception that participation in the work is mandatory. As an infectious disease outbreak can result in decreased willingness to work[29–33], compulsory work may exacerbate negative impacts on psychological well-being in that conflicts between work obligations and worry about infection can affect mental wellbeing.
Difficulties in the workplace including insufficient break time, concern for safety, and long-term workload can also contribute to psychological distress of HCWs in the COVID-19 pandemic. Previous research found that there is indeed an association between physical health problems and workplace environmental stressors[13, 21]. Contact with confirmed COVID-19 patients or those suspected of having COVID-19, the possibility of being infected, and stigma could worsen the psychological wellbeing of HCWs.
The results of the present study were consistent with previous studies and showed that stigma influenced psychological health or mental illness[20, 34]. Stigmatization of HCWs affects their psychological and physical health[8, 20, 34, 35]. Particularly during outbreaks of infectious diseases, HCWs who had contact with confirmed patients felt more stigma compared to other workers. Thus, preventing stigma of HCWs is an important issue that should be addressed during catastrophic situations including pandemics[36–38]. Hospital administrators and policymakers should take appropriate actions to ensure that HCWs do not suffer from pandemic-related stigma and minimize negative effects from stigma that may occur.
Psychological distress of HCWs could persist for years after the outbreak, and this sustained psychological distress would be expected to have adverse effects on the physical health of these workers[5, 6, 40]. Thus, development of evidence-based interventions is needed to prevent adverse mental health problems among HCWs. The current study found that psychological supports could mitigate emotional exhaustion of HCWs who are treating patients with COVIC-19, which is a similar to that reported in an earlier study . Breaktime, safety training and education, and psychological support all improve mental health of HCWs[11, 41]. In this context, individual and organizational interventions need to be initiated for HCWs. Strategies such as mindfulness practices and leveraging of positive psychology resources that are readily available to individual HCWs could help them manage their mental well-being[42–44]. Another important factor that might minimize HCW burnout and traumatic stress are altruistic behaviors, which are negatively related to traumatic stress. Organizations including hospitals, clinics, and public health institutions need to provide sufficient training and exercises to provide psychological support for employees that would mitigate the negative impact of infectious disease outbreaks on mental health, and guarantee sufficient rest time or flexible working hours. Routine support from colleagues and supervisors enhance the perception by HCWs that they are being protected[23, 48]. Mobile health tools, telephone helplines, or digital learning packages are other approaches to reduce and manage their mental illnesses associated with working during an infectious disease outbreak.
The strength of this study is that we surveyed both medical staff and public health officers who, unlike nurses or physicians, are typically not considered in studies of the psychological impacts of disease outbreaks. In South Korea, there is a tendency to recognizes HCWs as only including nurses and physicians. Our examination of the mental health status of public health workers in the present study could be helpful for the lay public to recognize the extent of the effects on these workers by disease outbreaks. In this study we estimated the traumatic distress of HCWs using PDI. Although most of the relevant studies use PTSD scales to estimate traumatic distress, consideration of peritraumatic distress could reveal traumatic distress during or right after the disease outbreak.
This study does have several limitations. First, there was a bias in the type of survey respondent. More than half of the participants were nurses and few physicians responded to the survey. Furthermore, only those HCWs living in Gyeonggi-do were included in the survey. Second, the variables for an objective index of work, for instance, number of hours spent working with patients with COVID-19, was not determined. We were only able to identify associations between adverse outcomes and perception and respondents’ perceptions. Finally, since this was a cross-sectional study, the significant association between psychological distress and organizational support (i.e., training, education, break time, psychological support) may not imply a causal relationship. Due to the characteristics of the PDI, we could only examine the short-term effect of COVID-19 situation on mental wellbeing of HCWs. As such, follow-up research is needed to identify long-term negative impacts of disease outbreaks on mental health aspects of HCWs such as PTSD.