Psychological status of health care workers during the outbreak of Coronavirus disease in China: a cross-sectional study

Background: Following the outbreak of Coronavirus disease (COVID-19) in Wuhan, China, thousands of health care workers (HCWs) joined in the battle to prevent epidemic. The purposes of this study were to assess the psychological status of health care workers fighting against COVID-19 and compared their status with non-health care workers. Methods: 1521 participants were invited to complete a cross-sectional survey which consisted of a demographic questionnaire, the symptom checklist-90 (SCL-90), the Connor-Davidson Resilience scale (CD-RISC) and Chinese-Version Social support revalued scale (SSRS). SCL-90 was used as a measure of psychological status, CD-RISC was used as a measure of resilience and SSRS was used as a measure of social support. All analyses were completed by SPSS21.0 and two-tailed with significance defined as p <0.05. Results: HCWs showed higher level of obsessive-compulsive symptoms ( p = 0.002), depression ( p =0.011), anxiety ( p = 0.037) and had lower level of subjective support ( p <0.001) as well as strength ( p =0.012). Compared with those who working in other hospital departments, H working in internal medicine department had high level of obsessive-compulsive, anxiety and interpersonal sensitivity, they also had low level of social support and resilience. Conclusions: HCWs were vulnerable to mental disorders, and health organizations and government should initiate psychological assistant program to keep them immune to mental disorders. HCWs who working in internal medicine department (IMD) were supposed to rebuild their resilience, social support systems, confidence and job satisfaction under the guidance of psychologists.

Frequency, percentage means and standard deviations were calculated for descriptive data.
Independent sample T-test was conducted to compare the outcomes between HCWs and non-HCWs.
One-way ANOVA, test of Homogeneity of variances and post hoc test were conducted to investigate the differences of HCWs working in different hospital departments. P 0.05 was considered statistically significant.

Descriptive data
A total of 1521 subjects completed this survey. The descriptive statistics of demographic data were shown in Table1. Samples consisted of 1198 HCWs and 323 non-HCWs who engaged in fighting this epidemic; There were 372 males and 1149 females took part in this study; 1123 participants were married, 380 participants were unmarried, 18 participants were at other situations; 132 participants worked in surgery department (SD),144 participants worked in internal medicine department (IMD), 67 participants worked in obstetrics and gynecology department (OGD), 41 participants worked in emergence room (ER), 32 participants worked in intensive care unit (ICU), 69 participants worked in outpatient department (OPD), 27 participants worked in pediatrics department (PD), 1participant worked in administration department, 7 participants worked in anesthesiology department (AD) and 975 participants didn't report.

Group differences between HCWs and non-HCWs
As shown in Table2, the outcomes of three scales between HCWS and non-HCWs were compared, there were significant differences on obsessive-compulsive (p = 0.002), depression (p=0.011), anxiety (p=0.037), subjective support (p<0.001), strength (p=0.012) and no significant difference on other subscales. It indicated HCWs suffered more anxiety, depression, obsessive-compulsive, lower subjective support and strength.

Group difference between different hospital department of HCWs
As shown in Table3, we compared the outcomes of HCWs working in different hospital departments on all subscales with one-way ANOVA. It indicated that there were significant differences in subscales of objective support (p = 0.039) and subjective support (p = 0.007) as well as total score of social support (p = 0.034) and no significant differences on other subscales.
We further conducted post hoc test to explorer the differences among HCWs working in different hospital departments and we found that there were significant differences among HCWs on some subscales. HCWs working in IDP had higher level of obsessive-compulsive symptoms than those working in ICU (p = 0.040) and OPD (p = 0.001); HCWs working in OGD had higher level obsessivecompulsive symptoms than those who working in OPD (p = 0.034); HCWs working in IMD had higher level than those working in OPD on the subscales of obsessive compulsive (p = 0.033) and anxiety (p = 0.037) as well as interpersonal sensitivity (p =0.033). There was no significant difference among HCWs on other subscales of SCL-90.
Post hoc test revealed that there were several significant differences in HCWs working in different hospital departments on the subscales of SSRS. HCWs working in AD had lower level of objective support than HCWs who working in SD (p =0.018); HCWs working in OPD had higher level of subjective support than HCWs who working in IMD (p < 0.001), OGD (p = 0.016), ER (p = 0.014) and ICU (p = 0.002); HCWs working in SD had higher total score of SSRS than HCWs who working in IMD (p = 0.001), OGD (p = 0.031) and ER (p = 0.035).
Beside differences on subscales of SCL-90 and SSRS, HCWs working in different hospital departments also had differences on subscales of CD-RISC. HCWs working in IMD had lower level of tenacity than those who working in SD (p = 0.007) and OPD (p =0.008), but there was no significant difference among HCWs working in other departments on this subscale. Moreover, HCWs working in IMD had lower level of strength than those working in SD (p = 0.012), ICU (p = 0.046), OPD (p = 0.023) and AD (0.028), but there was no significant difference among HCWs working in other departments on this subscale. HCWs working in IMD had lower level of optimism than those who working in ICU (p = 0.042) and OPD (p = 0.004), but there was no significant difference among HCWs working in other departments on this subscale. HCWs working in IMD had lower resilience than those who working in SD (p = 0.011), ICU (p = 0.046) and OPD (p = 0.007), but there was no significant difference among HCWs working in other departments on this subscale.

Discussion
In this study, we tested the psychological status and resilience as well as social support of volunteers who engaged in fighting this epidemic during the peak period, we compared the outcomes of HCWs and non-HCWs and then, we tested the differences among HCWs working in different hospital departments on all the subscales of SCL-90, SSRS and CD-RISC. Result showed that psychological status of HCWs were worse than non-HCWs on subscales of obsessive-compulsive, depression and anxiety. It indicated that HCWs suffered more stress, negative emotions and burnout than non-HCWs.
The comparisons among HCWs working in different hospital departments showed that HCWs working in IMD had higher level of obsessive-compulsive, interpersonal sensitivity and anxiety on SCL-90 and lower level of subjective support, objective support on SSRS as well as lower level of tenacity, optimism and resilience on CD-RISC.
Different studies have documented that HCWs suffer more stress during the outbreak of SARS[20-23].
HCWs were backbone in the battle toward this epidemic, however, HCWs were at high risk of being affected. Studies showed that 20 percentage of patients affected SARS were HCWs during the outbreak of SARS in Hongkong [24], and there were more than 3000 HCWs affected and 5 died by the date of February 10, 2020. Unfortunately, Wenliang Li, one of the first doctors who realized the outbreak of epidemic, died in February 10, 2020. HCWs treated different patients coming from everywhere without full information about whether they were affected during the peak of epidemic and crowd patients easily lead to cross affection. HCWs who engaged in face to face diagnose and treatments needed wear protective clothing, surgical masks, medical eye proctors and other necessary protective equipments those were uncomfortable for their performance. worsely, working long hours and tremendous work stress rendered physicians and psychologists tired out [25,26]. As we discussed above, worrying about being affected and enduring harsh working environments as well as enormous workload were the significant stressors for HCWs and account for the low level of mental health.
Patients affected mainly presented cough, fever and symptoms of pneumonia, which were classical characteristics of respiratory symptoms, internal medicine physicians and nurses could be the first and main HCWs connected with these patients with respiratory symptoms, so HCWs working in IMD suffered more stress than those working in other departments for they were at higher risk of being affected, which explained why they presented more symptoms of obsessive-compulsive, interpersonal sensitivity and anxiety in this investigate. However, the reasons result in their low levels of social support and resilience need further explore and we observed that diagnosis for patients coming to IMD were frequently ambiguous and internal medicine physicians must try to judge them by experience and knowledge at the first stage, they should have to keep conventional treatments until clear clinic diagnoses were developed, they may have to overturn their diagnosis during this procedure and their self-confidence would be impacted during long-term medical work. Moreover, working in IMD was relatively monotonous and lack of challenges, sense of achievements and job satisfactions were deficient. The impacts of work environment, work characteristic and job satisfactions to social support and resilience of HCWs working in IMD were study emphases in our further research. Previous studies showed that social support and resilience were protective factors of mental health [27][28][29][30], but this study showed that HCWs working in IMD presented low levels of social support and resilience which could partly explain their more symptoms of obsessive-compulsive, interpersonal sensitivity and anxiety [31,32].
This study investigated the psychological status of volunteers battling in this epidemic at the peak period, we found that HCWs had worse mental health status than non-HCWs, especially HCWs working in IMD who suffered more than those in other hospital departments, reported less social support and lower resilience. However, we didn't collect data of volunteers before the outbreak, so there was a lack of controls for other potential variables impacting the psychological effect of this epidemic.

Conclusion
HCWs need particularly psychological assistance program to help them keeping mental health during the outbreak of major health events, especially internal medicine physicians, they need Comprehensive psychological help program to rebuild their resilience, social support systems, confidence and job satisfaction.