The COVID-19 outbreak in China overwhelmed healthcare facilities in the epicenter, Wuhan, causing the drafting of healthcare workers from the countryside to Wuhan. Our study evaluated the effect of burnout, depression, anxiety, and stress on general self-efficacy of drafted nurses returning from Wuhan.
A total of 408 (Mean age: 36.67 ± 11.21) nurses had returned to our hospital from Wuhan. All drafted nurses (100%) participated in our study. All 408(100%) were females, of whom 279 (68.4%) were single. The majority 192 (47.1%) of our participants had a technical secondary school diploma. From our results, the majority of nurses demonstrated high levels of burnout with depersonalization (73.1%), emotional exhaustion (57.8%), and reduced levels of personal achievements (59.1%). These results coincide with those by (22), who not only demonstrated higher burnout levels among healthcare workers in Wuhan as compared to other areas, but also the burden of burnout decreasing with increasing distance from Wuhan. Our findings, however, contradict with Wu et al. (2020)(23) who reported lower levels of burnout with less than 13% of front line healthcare workers in Wuhan having higher levels of emotional exhaustion or depersonalization; and 39% have reduced levels of personal achievement. In contrast to our study whereby participants came from an area with a lower burden of infection, Wu et al. (2020) utilized participants permanently employed to Wuhan health facilities. The differences in the psychological adjustments to the Wuhan setting among participants could explain the differences in burnout levels between the two studies.
The majority of participants had extremely high levels of depression (88.48%), anxiety (100%), and stress (99.76%). From a previous study by Lee et al. (2018)(24), levels of depression and anxiety were reported to be 11% and 15.1%, respectively, among nurses during the MERS outbreak about a decade ago. In another study, Chen et al. (2006)(25) assessed nurses caring for SARS patients during the 2002 outbreak and found a 31.9% level of stress among them. Ko et al. (2006)(26) reported 3.7% depression level among healthcare workers during the SARS outbreak in Taiwan, while Wu et al. (2008)(27) reported 77.2% in Beijing with associated alcohol abuse and dependence. The reason for the differences could be due to higher infection rates demonstrated by COVID-19 but also the role of widespread internet usage of social media, which at times spread rumors inducing anxiety and panic to the public.
Regarding self-efficacy, our study reported that all participants (100%) had levels that were below average (i.e., 14.28 ± 2.12). This is in contrast to the result by Ratnayake et al. (2016)(28) during the Ebola virus disease (EVD) outbreak where general self-efficacy among nurses caring for the sick was above average defined by median of 4 (i.e., strongly agree) in the general self-efficacy Likert scale. In another study by Ko et al. (2004)(29), the mean general self-efficacy among nurses caring for SARS patients in Taiwan was 11.38 ± 12.98, which is lower than the one reported from our results. The study by Ratnayake et al. was conducted 2 years after the official announcement of the EVD outbreak in Sierra-Leone. After the epidemic had passed its peak, healthcare workers had already developed psychological acceptance, and they had already received thorough safety training courses, adequate medical supplies, and personal protective equipment (PPE) from WHO and partners. This is in contrast to our study, which was conducted about 2 months after the official announcement of the outbreak when the knowledge and experience of the disease were limited, the public was in a panic, the outbreak had not yet reached its peak, and PPE was inadequate. Time differences in conducting the studies could explain the differences in the self-efficacy results reported. We call upon for studies comparing trends of self-efficacies during different time points in the infection curve.
From our study, emotional exhaustion (Beta=-0.016, p-Value = 0.034) and stress (Beta=-0.138, p-Value = 0.004) were found to negatively affect general self-efficacy significantly. Anxiety, personal achievement, depersonalization, and depression did not show a statistically significant relationship with general self-efficacy. The results for anxiety contradict those reported by Ho et al. (2005)(30). They reported that increased anxiety significantly lowered self-efficacy among nurses during the SARS outbreak in 2002. In another study by Ng et al. (2006)(31) demonstrated that lower levels of depression among nurses caring for SARS patients were significantly associated with increased general-self efficacy. SARS had about 4 times higher fatality rate as compared to COVID-19 (32). This could mean that SARS created higher anxiety and depression levels in healthcare works as compared to COVID-19. We unexpectedly found a small positive correlation between depersonalization and general self-efficacy. Authors believe this was due to the encountered biases in our study. We call upon for lesser biased studies such as systematic reviews and meta-analyses on the topic.
In an attempt to stall the spread of COVID-19 amid the world’s effort to develop new treatments and manufacture dire needed medical equipment, WHO officials during the World Economic Forum’s briefing, recommended countries to practice “Isolate, Test, Treat and Trace.” We support the slogan. However, we believe that the slogan is disproportionately favoring patients than healthcare workers. We, therefore, recommend to healthcare systems and partners to provide psychological support, protective training, and adequate PPE to healthcare workers. We also promote paying tributes to healthcare workers and other public service front liners across the world through cheering and encouragement posts in social media.
Limitations and strengths of the study
Despite promising results, authors urge readers to interpret these results with caution due to several encountered biases. To mitigate non-response biases, adequate time (i.e., 1 week) to respond was given, confidentiality was guaranteed, and electronically accessed questionnaires were previously tested for compatibility to different electronic devices. Correspondence with participants was made possible through a joint WeChat group; therefore, mitigating attrition biases. The STROBE tool was utilized in the write-up to alleviate reporting and publication biases.
On the other hand, the extensive popular and nearly a “must-have” mobile application in China, WeChat, made it possible to reach all participants effectively. This reliable platform for correspondence may explain our study’s strength achieving a 100% participants’ response rate. Moreover, the participants had received a “hero-welcoming” upon their return from Wuhan. From an otherwise a weaker basis, such welcoming might also have motivated the participants to take part in the interviews.