Occupational Stress and Quality of Life among Health Professionals during the COVID-19 Pandemic

Since December 2019, the global community has been facing a new infectious disease, COVID-19 [1]. In Greece, the first case was reported on 26^th February, 2020. On April 4^th of the same year, the “restructuring” of the health care services so as to manage the pandemic was announced [2]. However, healthcare professionals provided care to patients at increased risk of contracting the disease [1] using inadequate protocols and sometimes inappropriate personal protective equipment [3].

Such working conditions may adversely affect healthcare workers, particularly their mental health [4,5], due to the work overload, constant exposure to COVID-19 patients and the uncharted waters of this new situation [5,6]. Although the resulting psychological effects may subside within a few weeks, they can be of great significance since they involve a combination of emotional, cognitive, physical and social reactions [7]. The resulting stress, as a reaction to pressure, can in turn lead to mental disorders, such as anxiety and depression [8].

The factors which contribute to the development of physical and psychological fatigue during this pandemic include the few protective measures, occupational hazards and work-life balance. Moreover, healthcare professionals are often reluctant to return home due to fear of exposing their family members to the virus [9] and the feeling of being stigmatized and rejected, which results in emotional and physical exhaustion [1]. This burnout syndrome, by definition, refers to experiencing fatigue over extended time periods along with reduced motivation and interest in work, leading to a reduction in productivity. It derives from excessive effort in the workplace with limited opportunities for recovery. Intensive patient care, high mortality and inappropriate working conditions combined with a lack of time to adequately address patients’ needs are among the factors which contribute to high risks of exhaustion [10]. However, amidst this sudden global crisis, it is important for healthcare professionals to maintain their physical and psychological health [11].

The present large-scale cross-sectional descriptive correlational study aimed to assess healthcare workers’ stress and depression levels as well as their quality of life (QoL) and compare them to those before this crisis.

The present study was carried out in the Intensive Care Unit (ICU) of a COVID-19 clinic, the clinic itself and an Emergency Department (ER) of “Attikon” General University Hospital and the 2^nd Health Centre of Peristeri (HC) of the 2^nd Health Region in Greece (HRG), where COVID-19 cases were received. The study protocol was approved by the ethics committees of both bodies (no. 206/27-4-2020 & no.24607/28.04.2020 respectively). The nursing directors and supervisors were then informed of the purposes of the study.

To determine the adequate number of participants for this study the G* Power Version 3.1.9.6 was used the results of which showed that 84 participants is considered sufficient based on the following:

Test family= t-test, statistical test = means: Difference between two independent means (two groups), type of power analysis= A priori: Compute required sample size-given α, power, and effect size. Input parameters: tails (two), effect size d (0.8), α err prob(0.05), power 1-β err prob (0.95), allocation ratio N2/N1(1) = total sample size 84. The participants in the study were 147 healthcare professional, exceeding the required number of 84.

Assessing the impact of the COVID-19 pandemic on the psychological status and QoL of healthcare professionals in Athens, Greece, it was observed that although the majority of the participants experienced normal stress and depression levels, moderate to severe levels for both disorders were found at a significant percentage. These findings are in agreement with other studies assessing the psychological status of healthcare workers during the COVID-19 pandemic. Temsah et al [17] also found normal anxiety levels (68.2%), followed by mild anxiety (20.8%) and severe for the 2.9%. Results from another study showed that 51.6% of healthcare workers had anxiety symptoms and 64.7% depressive ones [1]. Hu et al [18] reported mild anxiety for 27.15%, moderate for 11.05% and severe for 3.3%.

In the present study, female healthcare workers experienced higher levels of both anxiety and depression. Moreover, women were at greater risk of developing these two mental disorders compared to men. These findings are in agreement with other studies reporting that women tend to experience more anxiety and depression. In particular, Elbay et al [1] found that women were significantly more stressed than men and Ning et al [19] also reported higher anxiety levels in women healthcare workers. Xiao et al [8] reported that working women are 1.6 times more likely to experience anxiety than men in agreement with other studies [20,21], findings which support that the male gender is a protective factor against stress and depression [20].

The participants in this study were found to experience higher anxiety and depression levels during the COVID-19 pandemic compared to the pre-COVID-19 era, especially among women. These findings are consistent with other research reporting significant differences of stress and depression levels before and during the pandemic [22]. The fact that women tend to be more vulnerable to these two disorders during the current pandemic is due to several factors, such as a higher risk of infection, increased family pressure as well as the effects of female hormones. As for women nurses, their crucial role in the management of COVID-19 can justify the increased levels of anxiety and depression they experience. In addition, due to the nature of their job and their close contact with patients on a day-today basis, nurses are at higher risk of infection [19]. Yin et al [23], assessing the stress symptoms between clinical roles, demonstrated that women were more vulnerable than men in exhibiting post-traumatic stress. These findings are supported by another study which also found increased risk of depression and anxiety among women [24].

Another reason leading to increased anxiety among healthcare workers, who utilize emotion suppression strategies, is the contact with COVID-19 patients. It has been supported that due to that, men have less cognitive re-esteem and emotion suppression than women [6]. Moreover, another pattern observed in women can be linked to a societal issue. Women face more difficult conditions due to their social roles, which lead to differentiating professional and family care, avoiding contact with family members [25].

Comparing anxiety and depression levels between nurses and other specialties in the present study, it was observed that doctors experience less anxiety and depression than nurses and other healthcare workers. Similar results were reported by Shechter et al [26], who demonstrated significant differences in acute stress between nurses and doctors (64% vs. 40%, p=<0.001) and in depression (53% vs. 38%, p=0.004). Similarly, Pandey et al [21], comparing doctors and nurses, found that the latter were twice as likely to experience anxiety. Healthcare professionals with inadequate or no personal protective equipment were nearly three times more likely to be stressed and twice more at risk of depression than those working in high-risk areas. Li et al [27], investigating the levels of anxiety among healthcare workers, found that nurses are 1.41 times more likely to experience anxiety than other specialties. Tan et al [28] investigated the stress of healthcare workers (doctors and nurses) and “non-medical” staff (related health professionals, pharmacists, technicians, administrators, employees and maintenance workers) during the COVIC-19 pandemic. They found that the prevalence of anxiety was higher among non-medical healthcare workers. Another study highlighted the statistically significant difference between clinical roles for post-traumatic stress, reporting significant differences between nurses and, qualified doctors and auxiliary staff (p=0.011) [29]. These findings can be explained by the fact that nurses make up the bulk of healthcare staff during an epidemic and undertake most of the tasks related to infectious diseases [18].

The present study did not demonstrate significant differences in stress and depression levels among healthcare professionals in COVID-19-related departments, as demonstrated by Liang et al [11]. However, it was observed that the healthcare professionals do experience more anxiety and depression during the pandemic compared to the pre-COVID-19 era.

Based on the correlations of the sub-scales of SF-36, this study demonstrated a negative correlation between QoL and both anxiety and depression. More specifically, as anxiety and depression increase, physical functionality, physical pain, general health, vitality, mental health and emotional role tend to decrease. It was also found that men have better physical health than women. Tountas et al [16] have also highlighted gender differences and women in particular were reported to have a lower health status than men in all eight sub-scales of SF-36. Huang et al [30], assessing QoL of healthcare professionals, found that women experienced decreased QoL compared to men regarding emotional and cognitive functioning.

During this COVID-19 period, increased workload, redistribution of tasks and uncharted guidelines for managing the disease result in increased risk of occupational stress and depression negatively affect healthcare professionals’ QoL. The factors which lead to increased levels of stress and depression among healthcare professionals should be recognized, so as to implement strategies and measures to reduce the psychological burden caused by the pandemic and increase the workers wellbeing and productivity.

The findings of this study should be interpreted within its limitations, the main of which is the limited representation of more specialties mainly due to the measures for the protection of public health.