This prospective longitudinal survey of EM physicians and APPs at academic and community emergency departments was conducted during the acceleration phase of the COVID-19 pandemic in Indiana when cumulative positive COVID-19 cases increased statewide by over 4,400%.39 The study had several interesting findings. First, the majority of frontline EM providers experienced high baseline levels of stress, anxiety, fear, concerns for safety, and relationship strain due to COVID-19. Of note, despite coinciding with the acceleration phase of the pandemic, EM providers reported an improvement in each of these domains, although concerns persisted. Second, despite being a resilient group, many providers were at risk for burnout. Third, feelings of isolation endured during the study and were higher for women. Fourth, several subgroups, including women, part-time, mid-career, and academic providers had greater odds of COVID-19 impacting their wellness domains. And lastly, our study was able to identify specific needs of our EM providers (e.g., PPE, scrubs, showers, childcare options, mental health resources) that guided the advocacy work and targeted interventions by our department and institution. [Figure 2 and Supplement Table 1].
The high level of concern about personal safety and the safety of family and dependents found in our study is consistent with the findings from prior pandemics and at other geographical locations affected by COVID-19.41–45 Our study adds the early longitudinal perspective that safety concerns among our EM providers steadily improved. This reassuring finding and may be due, in part, to the fact that specific wellness needs were addressed early and resources made available quickly via departmental, institutional, and community initiatives. Examples of interventions include the increased availability of PPE, hospital-supplied scrubs and onsite showers, access to sleep space either on site or at local hotels, and community-based laundry services. As Chen et al. reported, of these interventions, adequate PPE and rest were more important to frontline healthcare providers early in the pandemic to reduce stress than access to a psychologist.46
Consistent with other studies, a majority of EM providers in our study reported feelings of psychological distress including anxiety, stress, and fear due to COVID-19.3–4,43−46 In addition, about one third to one half reported increased strain on their relationships (with partner, children, and co-workers). Factors at the individual and systems levels may contribute to these findings. Each EM provider is beholden to the pressures of their collective communities during a pandemic such as fluctuations in childcare and school situations, financial stress, and social isolation. Confounding this, EM providers may experience internal role conflict with regard to their work duties as frontline health care providers and their personal responsibilities to care for family or depedents.2,46 Along with these pressures, EM providers often worry about the lack of treatment options or ventilator capacity for patients, bear the fear of infecting family or friends, and face thoughts of their own mortality or that of their colleagues and loved ones.25,41,46
The persistent feelings of isolation experienced in our study is consistent with reports from the 2003 SARS outbreak. During SARS, frontline healthcare workers were at greater risk of feeling isolated than the general public, as well as the associated negative mental health consequences.4 During COVID-19, the degree of social distancing and isolation is unprecedented on this generation, and the toll it will take on mental health is not fully evident.
Our study found that the well-being of certain subgroups of providers (i.e., women, part-time, mid-career, and academic providers) may be at greater risk during a pandemic. For example, in our study, women were twice as likely to affirm feelings of isolation. Other studies have shown that female gender is associated with more severe symptoms of depression, anxiety, or distress due to the COVID-19 pandemic.3,43,49−52 It is imperative to consider the unique professional and personal situations of these subgroups in order to target support and resources. Additional investigation into how gender, employment status, or stage of career affects or is affected by the complex circumstances facing frontline providers is warranted.
Burnout is a syndrome resulting from chronic workplace stress and is characterized by emotional exhaustion, cynicism or depersonalization from one’s job, and reduced efficacy, which suggests little malleability for positive change under conditions of heightened stress, such as a pandemic.53 Our study confirmed this, as burnout, using the PWLS item, remained steady at about one quarter of EM providers. Interestingly, this burnout rate did not worsen and is less than the national average for the specialty of EM. This could be in part due to the normal to high baseline resilience scores or from other individual or system factors noted below.
It is curious that during our study the burnout rates remained steady using the PWLS, while provider well-being improved using the WBI, which also contains a burnout item. A likely explanation lies in the difference between the PWLS and WBI scales. The PWLS evaluates the self-determined presence of burnout via a single question. The WBI calculates burnout risk more broadly as one of many domains of wellness. Burnout amongst providers assessed by the WBI may not have changed over time, while other domains of wellness showed improvement, resulting in a lower “at risk” frequency.
Our study suggests that using brief validated scales, such as the PWLS and/or WBI, can provide valuable guidance to institutions before and during pandemics. Of particular note, the EM providers who endorsed burnout on the PWLS single item and screened “at-risk” on the WBI carried greater risks of endorsing concerns about personal safety, impact on dependent care, relationship strain, additional work responsibilities, and feelings of isolation due to COVID. Additionally, EM providers who screened at-risk on the WBI had a twenty times higher odds of reporting stress, anxiety, and fear due to COVID-19. These significant correlations support the utility of these tools in identifying early distress among frontline EM providers and guiding system-based interventions and resource allocation.
The significant improvement in provider well-being on the WBI may be related to both individual and system factors. The timely response and culture of the department and institution may account for mitigating factors, such as the presence of social support, leadership support, safety needs being met (e.g. PPE, scrubs, showers), financial security, childcare options, and access to mental health support. Of particular note, 81–93% of providers reported having a friend, mentor, colleague, or family member to help them decompress, which offers the consistent presence of social support that is found to shield against negative life stress.47,48 Additionally, the vast majority of respondents reported feeling supported by leadership (89–99%), which was sustained during the study period. The formation of a departmental wellness taskforce prior to the acceleration phase of the pandemic, whose objective was to evaluate wellness and elicit actionable items during the early stages of the pandemic, may have contributed, in part, to the decreased distress, and may be a key strategy to improve provider well-being.
The literature indicates that system, leadership, and community responses in conjunction with effective communication are crucial prior to and during a pandemic, as this can mitigate negative psychological responses.2 In our provider group, no frontline health care providers experienced salary cuts or furloughs, despite decreased ED volumes, unlike numerous other hospital systems across the country. The tremendous outpouring of appreciation and support for frontline healthcare providers from the community may also have contributed to the improved wellness factors. Gratitude from patients, families and the community may have offset feelings of burnout and increased job satisfaction.42 Emergency department volumes significantly decreased during the study period, which may have improved wellness factors. It is also possible, though not measured in this study, that providers’ sense of control and perceived knowledge of the virus improved with time, which has been shown to mitigate negative effects of a pandemic on emotional wellness.54
Limitations
This study had several limitations. The study design used an online survey instrument, which is susceptible to response biases including self-selection (voluntary response bias), the sample size (nonresponse bias), as well as the survey length and competing surveys (fatigue bias). Although our response rate is similar to other online survey response rates, it remains a potential limitation.55 Due to anonymous data collection we could not assess individual-level change over time. Another limitation is the lack of race/ethnicity demographic data, which is needed to further analyze the association of race/ethnicity on provider wellness. Due to the time-sensitive need for the survey, the COVID-specific questions were not validated against other measures, and therefore only have face validity. The WBI asks questions regarding symptoms “over the last month,” however, the instrument was used on a weekly basis and therefore may not be sensitive to that degree of change.56