Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers

Face to Face with Coronavirus Disease 19: Maintaining Motivation, Psychological Safety, and Wellness

Emerging infectious diseases have the potential to spread across borders extremely quickly. This was seen during the severe acute respiratory syndrome (SARS) outbreak and now, coronavirus disease (COVID 19) (novel coronavirus) pandemic. For outbreaks and pandemics, there will be behavioral, affective, and cognitive changes and adaptation seen. This may be prominent in frontline workers and healthcare workers (HCWs), who work in high-risk areas, as well as people in general. What represents the psychology and mindset of people during a pandemic? What is needed to allay anxieties and instill calm? What will be needed to keep the motivation levels of people and HCW high so that they continue to function optimally? Which motivation theory can be used to explain this and how do employers and management utilize this in their approach/strategies in planning for an outbreak? Finally, the impact of culture, in the various contexts, cannot be overlooked in crisis and pandemic management. The author is a senior emergency physician in Singapore, who has been through SARS and now the COVID pandemic. She has been instrumental in sharing some of the changes and practices implemented in Singapore, since SARS 17 years ago, until now. Besides being a full-time practicing emergency physician, the author is also an elected Member of the Singapore Parliament for the last 14 years. She shares her views on an aspect often overlooked during a pandemic: psychological wellness and motivations of people, including for HCW at the frontline.

Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China

Background: The 2019 coronavirus disease (COVID-19) epidemic is a public health emergency of international concern and poses a challenge to psychological resilience. Research data are needed to develop evidence-driven strategies to reduce adverse psychological impacts and psychiatric symptoms during the epidemic. The aim of this study was to survey the general public in China to better understand their levels of psychological impact, anxiety, depression, and stress during the initial stage of the COVID-19 outbreak. The data will be used for future reference. Methods: From 31 January to 2 February 2020, we conducted an online survey using snowball sampling techniques. The online survey collected information on demographic data, physical symptoms in the past 14 days, contact history with COVID-19, knowledge and concerns about COVID-19, precautionary measures against COVID-19, and additional information required with respect to COVID-19. Psychological impact was assessed by the Impact of Event Scale-Revised (IES-R), and mental health status was assessed by the Depression, Anxiety and Stress Scale (DASS-21). Results: This study included 1210 respondents from 194 cities in China. In total, 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe; 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels. Most respondents spent 20–24 h per day at home (84.7%); were worried about their family members contracting COVID-19 (75.2%); and were satisfied with the amount of health information available (75.1%). Female gender, student status, specific physical symptoms (e.g., myalgia, dizziness, coryza), and poor self-rated health status were significantly associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety, and depression (p < 0.05). Specific up-to-date and accurate health information (e.g., treatment, local outbreak situation) and particular precautionary measures (e.g., hand hygiene, wearing a mask) were associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression (p < 0.05). Conclusions: During the initial phase of the COVID-19 outbreak in China, more than half of the respondents rated the psychological impact as moderate-to-severe, and about one-third reported moderate-to-severe anxiety. Our findings identify factors associated with a lower level of psychological impact and better mental health status that can be used to formulate psychological interventions to improve the mental health of vulnerable groups during the COVID-19 epidemic.

Anxiety Status and Influencing Factors of Rural Residents in Hunan During the Coronavirus Disease 2019 Epidemic: A Web-Based Cross-Sectional Survey

Objective: To explore the status quo of anxiety and its influencing factors among rural residents in Hunan Province during the coronavirus disease 2019 epidemic, and to provide an effective basis for prevention of and intervention for anxiety symptoms among rural residents. Methods: Convenience sampling was used. An online questionnaire was distributed to Hunan rural residents through the questionnaire star platform from February 26-29, 2020. The general data and anxiety of Hunan rural residents were investigated, and the data were analyzed using SPSS 18.0. Results: The mean Self-Rating Anxiety Scale score of 179 rural residents in Hunan was 40.93 ± 9.36. Based on the cutoff criteria, 32 residents had anxiety, including 26 with mild anxiety, five with moderate anxiety, and one with severe anxiety. The detection rate of anxiety was 17.88%. Self-rated health status, level of concern about the epidemic, and self-rated impact of the epidemic on one's life were the factors influencing the anxiety score of rural residents in Hunan (P < 0.05). Conclusion: During the coronavirus disease 2019 epidemic, the detection rate of anxiety in rural residents in Hunan was higher than that of the general population in China. The relevant departments should pay attention to the mental health of rural residents and implement targeted mental health prevention and intervention measures during the epidemic situation.

Palestinian Health Care Workers' Stress and Stressors During COVID-19 Pandemic: A Cross-Sectional Study

BACKGROUND

COVID-19 is thought to be the most significant public health threat the modern world has encountered. Health care workers (HCWs) face enormous pressure due to work overload, negative emotions, exhaustion, lack of contact with their families, and risk of catching the infection and death.

AIM

This study aims to assess the level of stress perceived by HCWs and possible associated factors during the COVID-19 outbreak in Palestine.

METHODS

A cross-sectional sample of 430 frontlines HCWs was conducted using an online self-reported questionnaire. HCWs' stress from the COVID-19 outbreak, factors that increase stress, and the activities that reduced stress were assessed. Chi-square test was used to compare between a categorical variable and the study outcome; associations are presented as odds ratios (OR) and confidence intervals (95% CI) with 0.05 significance level. Al-Najah National University institutional review board granted ethics approval.

RESULTS

Most respondents (74.0%) reported high-stress levels during the outbreak. Fear of transmitting the virus to family was the most stressful factor (91.6%). HCWs who did not have training on the outbreak response were more likely to have high-stress levels (OR = 2.7 [95% CI = 1.7-4.4], P < .001). Those with high stress reported being disappointed (OR = 2.4 [95% CI = 1.5-3.6], P < .001), and strongly considered taking sick leave (OR = 3.9 [95% CI = 1.9-7.9], P < .001).

CONCLUSION

HCWs are under tremendous stress, given the ongoing COVID-19 pandemic. Understanding the psychological impact of the outbreak on HCWs and the activities that mitigate the stress is crucial to guide policies and interventions that can maintain psychological well-being.

Internet Addiction and Related Psychological Factors Among Children and Adolescents in China During the Coronavirus Disease 2019 (COVID-19) Epidemic

BACKGROUND

The Coronavirus disease 2019 (COVID-19) is an infectious disease presenting a major threat to public health. This study aims to assess Internet use characteristics and objectively examine the potential psychological factors associated with Internet addiction (IA) during the COVID-19 epidemic.

METHODS

A cross-sectional, anonymized, self-reported survey was conducted among Chinese children and adolescents aged 6 to 18 years old. Participants completed questionnaires containing Young's Internet Addiction Test (IAT) and the Depression, Anxiety, and Stress Scale (DASS-21), and questions regarding demographic information and Internet use characteristics.

RESULTS

A total of 2050 participants (mean age:12.34 ± 4.67 years old, female: 48.44%) were enrolled. Fifty-five (2.68%) participants met the criterion for addictive Internet use (IAT≥70), while 684 (33.37%) participants were classified as problematic Internet users (69≥IAT≥40). Internet usage had grown during the COVID-19 epidemic, including the frequency and duration of recreational Internet use, and the frequency of stay-up Internet use. A linear regression analysis showed female gender (β=-0.091, p<0.001), age (β=0.066, p=0.001), depression (β=0.257, p<0.001), and stress (β=0.323, p<0.001) were significantly correlated with the IAT total scores (R=0.539, R^{2 =} 0.291, p<0.001).

CONCLUSIONS

We observed excessive Internet use among Chinese children and adolescents during the outbreak of COVID-19. Age, gender, depression, and stress were the potential key factors affecting IA. Extended family and professional support should be considered for vulnerable individuals during these unprecedented times.

The Psychological Impact of Epidemic and Pandemic Outbreaks on Healthcare Workers: Rapid Review of the Evidence

PURPOSE OF REVIEW

We aim to provide quantitative evidence on the psychological impact of epidemic/pandemic outbreaks (i.e., SARS, MERS, COVID-19, ebola, and influenza A) on healthcare workers (HCWs).

RECENT FINDINGS

Forty-four studies are included in this review. Between 11 and 73.4% of HCWs, mainly including physicians, nurses, and auxiliary staff, reported post-traumatic stress symptoms during outbreaks, with symptoms lasting after 1-3 years in 10-40%. Depressive symptoms are reported in 27.5-50.7%, insomnia symptoms in 34-36.1%, and severe anxiety symptoms in 45%. General psychiatric symptoms during outbreaks have a range comprised between 17.3 and 75.3%; high levels of stress related to working are reported in 18.1 to 80.1%. Several individual and work-related features can be considered risk or protective factors, such as personality characteristics, the level of exposure to affected patients, and organizational support. Empirical evidence underlines the need to address the detrimental effects of epidemic/pandemic outbreaks on HCWs' mental health. Recommendations should include the assessment and promotion of coping strategies and resilience, special attention to frontline HCWs, provision of adequate protective supplies, and organization of online support services.

Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic

OBJECTIVE

The mental health toll of COVID-19 on healthcare workers (HCW) is not yet fully described. We characterized distress, coping, and preferences for support among NYC HCWs during the COVID-19 pandemic.

METHODS

This was a cross-sectional web survey of physicians, advanced practice providers, residents/fellows, and nurses, conducted during a peak of inpatient admissions for COVID-19 in NYC (April 9th-April 24th 2020) at a large medical center in NYC (n = 657).

RESULTS

Positive screens for psychological symptoms were common; 57% for acute stress, 48% for depressive, and 33% for anxiety symptoms. For each, a higher percent of nurses/advanced practice providers screened positive vs. attending physicians, though housestaff's rates for acute stress and depression did not differ from either. Sixty-one percent of participants reported increased sense of meaning/purpose since the COVID-19 outbreak. Physical activity/exercise was the most common coping behavior (59%), and access to an individual therapist with online self-guided counseling (33%) garnered the most interest.

CONCLUSIONS

NYC HCWs, especially nurses and advanced practice providers, are experiencing COVID-19-related psychological distress. Participants reported using empirically-supported coping behaviors, and endorsed indicators of resilience, but they also reported interest in additional wellness resources. Programs developed to mitigate stress among HCWs during the COVID-19 pandemic should integrate HCW preferences.

Sleep Disturbance and Psychological Profiles of Medical Staff and Non-Medical Staff During the Early Outbreak of COVID-19 in Hubei Province, China

OBJECTIVE

The outbreak of coronavirus disease 2019 (COVID-19) has considerably burdened the healthcare system in the Hubei Province, the most severely affected region in China. The aim of our study was to assess the psychological effects of COVID-19 epidemic on the healthcare workers in Hubei.

METHODS

A total of 2737 healthcare workers were sampled using a two-dimensional code shared online between Mar 4 and Mar 9, 2020. The questionnaires consisted of three elements: baseline characteristics, Pittsburgh Sleep Quality Index (PSQI), and Hospital Anxiety and Depression Scale (HADS). The primary outcome variables were PQSI, anxiety and depression scores of non-medical staff, non-frontline medical staff and frontline medical staff. Binary logistical regression analyses were used to compare between respondents with and without sleep disturbance.

RESULTS

About 61.6% of the respondents reported sleep problems, 22.6% experienced anxiety, and 35% exhibited depressive symptoms. The prevalence of sleep disorders was higher among the frontline healthcare workers compared to the non-frontline and non-medical staff, while anxiety and depression were prevalent in the entire cohort. Logistic regression analysis identified medical occupation, family burden, bereavement, anxiety, and depression as significantly predictive of poor sleep quality.

CONCLUSIONS

Frontline medical staff are more vulnerable to sleep disturbances. Psychosocial interventions are needed to help allied healthcare personnel to better respond to COVID-19 and future outbreaks.

A Systematic Review of the Impact of Viral Respiratory Epidemics on Mental Health: An Implication on the Coronavirus Disease 2019 Pandemic

Background: The twenty-first century viral respiratory epidemics have taught us valuable lessons. Our systematic review examined the impact of these epidemics, including coronavirus disease 2019 (COVID-19), on mental health among different population groups, drawing on their insights for recommendations for the current COVID-19 pandemic. Methods: Searches were performed on PubMed, Embase, PsycINFO, Web of Science, Scopus, CINAHL, and Cochrane on April 4, 2020. Studies that had undefined mental health outcomes or did not use a validated scale for measure were excluded. Quality assessment was carried out via the Newcastle-Ottawa Scale. Results: We included 95 studies, most of which were conducted in Hong Kong (31.6%) and China (21.4%). A total of 30 (30.9%) studies are on the general public, 41 (42.2%) on healthcare workers, and 26 (26.6%) on patients and quarantined individuals. Furthermore, 36 (37.1%) of the studies are of high quality, 48 (49.5%) are of moderate quality, and 13 (13.4%) are of low quality. The most significant mental health outcomes reported include anxiety, depression, and post-traumatic stress disorder symptoms. The subgroups identified to have a higher risk of psychiatric symptoms among the general public include females, the elderly, individuals with chronic illness, migrant workers, and students. Long-term mental health impact was reported in some healthcare workers and epidemic patients, even up to 3 years in the former. Interestingly, when compared to non-quarantined groups, quarantine was not significantly associated with worse mental health outcomes. Conclusion: Important implications for the COVID-19 pandemic were highlighted. Respiratory epidemics pose a significant psychological morbidity onto many population groups. Psychological support for vulnerable groups, including healthcare workers and patients, should be implemented to prevent them from spiraling into clinical psychiatric conditions.

The Effect of Cognitive Behavioral Therapy on Depression, Anxiety, and Stress in Patients With COVID-19: A Randomized Controlled Trial

Background: As a public health emergency of international concern, the COVID-19 outbreak has had a tremendous impact on patients' psychological health. However, studies on psychological interventions in patients with COVID-19 are relatively rare. Objectives: This study examined the effectiveness of Cognitive Behavioral Therapy (CBT) in relieving patients' psychological distress during the COVID-19 epidemic. Methods: Ninety-three eligible participants selected by cluster sampling were randomized to an intervention group (N = 47) and a control group (N = 46). Participants in the control group received routine treatment according to the Chinese Management Guidelines for COVID-19, while participants in the intervention group received routine treatment with additional CBT. The Chinese Version of Depression Anxiety and Stress Scale-21 (DASS-21) was used to evaluate depression, anxiety, and stress for all participants at baseline and post-intervention. Two-sided t-test, and proportion tests were used to examine the differences between the intervention and control group for each DASS-21 indicator. Univariate linear regression was used to examine the association between chronic disease status and change in each DASS-21 indicator after intervention. Two-way scatter plots were generated to show the association of the length of hospital stay and the changes of each DASS-21 indicator by intervention and control groups. Results: Significant decreases in means were found for scales of depression, anxiety, stress and total DASS-21 in both intervention (p < 0.001) and control group (p = 0.001), with participants in the intervention group having a bigger reduction in means. After the intervention, more participants in the intervention group had no depression or anxiety symptoms than in the control group, but no statistical differences were found (p > 0.05). Compared with participants with chronic disease, participants with no chronic disease had a significantly larger reduction of total DASS-21 scale (coefficient = -4.74, 95% CI: -9.31; -0.17).The length of hospital stay was significantly associated with a greater increase in anxiety scale in the intervention group (p = 0.005), whilst no significant association was found in the control group (p = 0.29). Conclusions: The patients with COVID-19 experienced high levels of anxiety, depression and stress. Our study result highlights the effectiveness of CBT in improving the psychological health among patients with COVID-19, also suggests that CBT should be focused on patients with chronic disease and those who have longer hospital stays. These results have important implications in clinical practice in improving psychological health in the context of COVID-19 pandemic. Trial Registration: ISRCTN68675756. Available at: http://www.isrctn.com/ISRCTN68675756.

A Systematic Review of the Impact of Disaster on the Mental Health of Medical Responders

INTRODUCTION

Medical responders are at-risk of experiencing a wide range of negative psychological health conditions following a disaster.

AIM

Published literature was reviewed on the adverse psychological health outcomes in medical responders to various disasters and mass casualties in order to: (1) assess the psychological impact of disasters on medical responders; and (2) identify the possible risk factors associated with psychological impacts on medical responders.

METHODS

A literature search of PubMed, Discovery Service, Science Direct, Google Scholar, and Cochrane databases for studies on the prevalence/risk factors of posttraumatic stress disorder (PTSD) and other mental disorders in medical responders of disasters and mass casualties was carried out using pre-determined keywords. Two reviewers screened the 3,545 abstracts and 28 full-length articles which were included for final review.

RESULTS

Depression and PTSD were the most studied outcomes in medical responders. Nurses reported higher levels of adverse outcomes than physicians. Lack of social support and communication, maladaptive coping, and lack of training were important risk factors for developing negative psychological outcomes across all types of disasters.

CONCLUSIONS

Disasters have significant adverse effects on the mental well-being of medical responders. The prevalence rates and presumptive risk factors varied among three different types of disasters. There are certain high-risk, vulnerable groups among medical responders, as well as certain risk factors for adverse psychological outcomes. Adapting preventive measures and mitigation strategies aimed at high-risk groups would be beneficial in decreasing negative outcomes.

A Systematic, Thematic Review of Social and Occupational Factors Associated With Psychological Outcomes in Healthcare Employees During an Infectious Disease Outbreak

OBJECTIVE

To conduct a systematic literature review to identify social and occupational factors affecting the psychological wellbeing of healthcare workers involved in the severe acute respiratory syndrome (SARS) crisis.

METHODS

Four literature databases were searched and data extracted from relevant papers.

RESULTS

Eighteen thousand five papers were found and 22 included in the review. The psychological impact of SARS on employees appeared to be associated with occupational role; training/preparedness; high-risk work environments; quarantine; role-related stressors; perceived risk; social support; social rejection/isolation; and impact of SARS on personal or professional life.

CONCLUSIONS

To minimize the psychological impact of future outbreaks of infectious diseases, healthcare workers should be prepared for the potential psychological impact; employers should encourage a supportive environment in the workplace and ensure that support is in place for those most at risk, for example, those with the most patient contact.

Mental Health Care for Survivors and Healthcare Workers in the Aftermath of an Outbreak

When pandemics sweep across communities, they leave behind tremendous suffering in their wake. It is not only the illness that becomes a pandemic, but the same can be inferred about fear, mourning, and despair. The reverberations of loss are felt in a multitude of ways by those left behind. Often times, the mental health issues of affected persons and entire communities do not receive the attention they deserve in the light of other competing, immediate needs imparted by the devastation of the pandemic. This chapter aims to develop strategies for providing psychiatric care to survivors and their families, in the aftermath of a pandemic outbreak. Lastly, special considerations in the application of psychopharmacological interventions are reviewed.

Critically ill healthcare workers with the middle east respiratory syndrome (MERS): A multicenter study

Background

Middle East Respiratory Syndrome Coronavirus (MERS-CoV) leads to healthcare-associated transmission to patients and healthcare workers with potentially fatal outcomes.

Aim

We aimed to describe the clinical course and functional outcomes of critically ill healthcare workers (HCWs) with MERS.

Methods

Data on HCWs was extracted from a multi-center retrospective cohort study on 330 critically ill patients with MERS admitted between (9/2012–9/2015). Baseline demographics, interventions and outcomes were recorded and compared between survivors and non-survivors. Survivors were approached with questionnaires to elucidate their functional outcomes using Karnofsky Performance Status Scale.

Findings

Thirty-Two HCWs met the inclusion criteria. Comorbidities were recorded in 34% (11/32) HCW. Death resulted in 8/32 (25%) HCWs including all 5 HCWs with chronic renal impairment at baseline. Non-surviving HCW had lower PaO2/FiO2 ratios 63.5 (57, 116.2) vs 148 (84, 194.3), p = 0.043, and received more ECMO therapy compared to survivors, 9/32 (28%) vs 4/24 (16.7%) respectively (p = 0.02).Thirteen of the surviving (13/24) HCWs responded to the questionnaire. Two HCWs confirmed functional limitations. Median number of days from hospital discharge until the questionnaires were filled was 580 (95% CI 568, 723.5) days.

Conclusion

Approximately 10% of critically ill patients with MERS were HCWs. Hospital mortality rate was substantial (25%). Patients with chronic renal impairment represented a particularly high-risk group that should receive extra caution during suspected or confirmed MERS cases clinical care assignment and during outbreaks. Long-term repercussions of critical illness due to MERS on HCWs in particular, and patients in general, remain unknown and should be investigated in larger studies.

Examination of Hospital Workers' Emotional Responses to an Infectious Disease Outbreak: Lessons From the 2015 MERS Co-V Outbreak in South Korea

ABSTRACTHospital workers are critical for a successful response to an infectious disease outbreak and for preventing disease transmission to the community. Therefore, hospital crisis management should implement efforts to improve hospital workers' preparedness in responding to public health emergencies caused by infectious diseases. Traditionally, preparedness and skill of hospital workers have been emphasized, but awareness of the importance of the emotional mindset of hospital workers in dealing with disease outbreaks has only recently increased; therefore, empirical approaches to examining emotional responses of hospital workers has been limited. This study analyzed qualitative data of the 2015 Middle East Respiratory Syndrome outbreak in South Korea. In particular, negative emotions and stress experienced by hospital workers who treated patients were characterized, as were the events that triggered such experiences. These events were categorized into four themes (eg, Mistake, Missing, Delay Due to Communication Failure). Identifying events that trigger negative emotions in hospital workers has important implications for hospitals' management guidance in relation to an infectious disease outbreak. (Disaster Med Public Health Preparedness. 2019;13:504-510).

The role of autonomy and social support in the relation between psychosocial safety climate and stress in health care workers

Background

Health care workers are exposed to psychosocial work factors. Autonomy and social support are psychosocial work factors that are related to stress, and are argued to largely result from the psychosocial safety climate within organisations. This study aimed to assess to what extent the relation between psychosocial safety climate and stress in health care workers can be explained by autonomy and social support.

Methods

In a cross-sectional study, psychosocial safety climate, stress, autonomy, co-worker support, and supervisor support were assessed using questionnaires, in a sample of health care workers (N = 277). Linear mixed models analyses were performed to assess to what extent social support and autonomy explained the relation between psychosocial safety climate and stress.

Results

A lower psychosocial safety climate score was associated with significantly higher stress (B = −0.21, 95% CI = −0.27 – -0.14). Neither co-worker support, supervisor support, nor autonomy explained the relation between psychosocial safety climate and stress. Taken together, autonomy and both social support measures diminished the relation between psychosocial safety climate and stress by 12% (full model: B = −0.18, 95% CI = −0.25 – -0.11).

Conclusions

Autonomy and social support together seemed to bring about a small decrease in the relation between psychosocial safety climate and stress in health care workers. Future research should discern whether other psychosocial work factors explain a larger portion of this relation.

Trial registration

This study was registered in the Netherlands National Trial Register, trial code: NTR5527.

Effect of a Faith-Based Education Program on Self-Assessed Physical, Mental and Spiritual (Religious) Health Parameters

The aim of the study was to determine the effect of attending a faith-based education program (FBEP) on self-assessed physical, mental and spiritual health parameters. The study was designed as a prospective, observational, cohort study of individuals attending a 5-day FBEP. Out of 2650 sequential online registrants, those previously unexposed to the FBEP received automated invitations to complete 5 sequential Self-Assessment Questionnaire's (SAQ's) containing: (1) Duke University Religion Index (DUREL); (2) Negative Religious Coping (N-RCOPE); (3) Perceived Stress Scale (PSS); (4) Center for Epidemiology and Statistics-Depression Scale (CES-D); (5) Brief Illness Perception Questionnaire (BIPQ); and the (6) State Trait Anxiety Inventory (STAI). Pre-attendance SAQ (S1) was repeated immediately post-FBEP (S2), at 30 days (S3), 90 days (S4) and after 1 year (S5). Of 655 invited, 274 (42 %) succeeded, 242 (37 %) failed and 139 (21 %) declined to complete S1. Of the 274, 37 (14 %) were excluded at on-site interview; 26 (9 %) never attended the FBEP (i.e., controls: 5♂; 21♀; 27-76 years); and 211 (77 %) participated (i.e., cases: 105♂; 106♀; 18-84 years) and were analyzed over time: 211 (S1); 192 (S2); 99 (S3); 52 (S4); 51 (S5). IRB approval was via the Human Research Ethics Committee of Stellenbosch University. DUREL showed significant, sustained changes in Intrinsic Religiosity. N-RCOPE showed significant, lasting improvement. In others, median values dropped significantly immediately after the FBEP (S1:S2) for STAI-State p < 0.0001; PSS p < 0.0001; BIPQ p < 0.0001; and CES-D p < 0.0001; and at 1 month (S1:S3) for STAI-Trait p < 0.001; all changes were sustained (S3 through S5). This FBEP produced statistically and clinically significant changes; these lasted in those followed up >1 year.

Psychometric properties of the Perceived Stress Scale (PSS): measurement invariance between athletes and non-athletes and construct validity

Background

Although Perceived Stress Scale (PSS, Cohen, Kamarack & Mermelstein, 1983) has been validated and widely used in many domains, there is still no validation in sports by comparing athletes and non-athletes and examining related psychometric indices.

Purpose

The purpose of this study was to examine the measurement invariance of PSS between athletes and non-athletes, and examine construct validity and reliability in the sports contexts.

Methods

Study 1 sampled 359 college student-athletes (males = 233; females = 126) and 242 non-athletes (males = 124; females = 118) and examined factorial structure, measurement invariance and internal consistency. Study 2 sampled 196 student-athletes (males = 139, females = 57, M_age = 19.88 yrs, SD = 1.35) and examined discriminant validity and convergent validity of PSS. Study 3 sampled 37 student-athletes to assess test-retest reliability of PSS.

Results

Results found that 2-factor PSS-10 fitted the model the best and had appropriate reliability. Also, there was a measurement invariance between athletes and non-athletes; and PSS positively correlated with athletic burnout and life stress but negatively correlated with coping efficacy provided evidence of discriminant validity and convergent validity. Further, the test-retest reliability for PSS subscales was significant (r = .66 and r = .50).

Discussion

It is suggested that 2-factor PSS-10 can be a useful tool in assessing perceived stress either in sports or non-sports settings. We suggest future study may use 2-factor PSS-10 in examining the effects of stress on the athletic injury, burnout, and psychiatry disorders.

Preventing healthcare-associated transmission of the Middle East Respiratory Syndrome (MERS): Our Achilles heel

Middle East Respiratory Syndrome (MERS) coronavirus is the most recent among the Coronaviridae family to jump species and infect humans. Major healthcare associated MERS outbreaks have occurred in the Middle East and Korea that affected both patients and healthcare workers. These outbreaks were characterized by intra and inter-hospital spread and were exacerbated specifically by overcrowding, delayed diagnosis and appropriate use of personal protective equipment. Recent experience with this virus emphasizes the importance of compliance with infection control practices and with other interventions addressing patient triage, placement and flow within and between healthcare facilities. Our Achilles heel remains compliance with the best infection prevention practices and their harmonization with patient flow. Both infection prevention compliance and maintenance of patient flow are critical in preventing healthcare-associated transmission of many of these emerging infectious diseases, including MERS.

Insulin resistance, selfish brain, and selfish immune system: an evolutionarily positively selected program used in chronic inflammatory diseases

Insulin resistance (IR) is a general phenomenon of many physiological states, disease states, and diseases. IR has been described in diabetes mellitus, obesity, infection, sepsis, trauma, painful states such as postoperative pain and migraine, schizophrenia, major depression, chronic mental stress, and others. In arthritis, abnormalities of glucose homeostasis were described in 1920; and in 1950 combined glucose and insulin tests unmistakably demonstrated IR. The phenomenon is now described in rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, polymyalgia rheumatica, and others. In chronic inflammatory diseases, cytokine-neutralizing strategies normalize insulin sensitivity. This paper delineates that IR is either based on inflammatory factors (activation of the immune/ repair system) or on the brain (mental activation via stress axes). Due to the selfishness of the immune system and the selfishness of the brain, both can induce IR independent of each other. Consequently, the immune system can block the brain (for example, by sickness behavior) and the brain can block the immune system (for example, stress-induced immune system alterations). Based on considerations of evolutionary medicine, it is discussed that obesity per se is not a disease. Obesity-related IR depends on provoking factors from either the immune system or the brain. Chronic inflammation and/or stress axis activation are thus needed for obesity-related IR. Due to redundant pathways in stimulating IR, a simple one factor-neutralizing strategy might help in chronic inflammatory diseases (inflammation is the key), but not in obesity-related IR. The new considerations towards IR are interrelated to the published theories of IR (thrifty genotype, thrifty phenotype, and others).

Demographic and occupational predictors of stress and fatigue in French intensive-care registered nurses and nurses' aides: a cross-sectional study

BACKGROUND

Healthcare workers (HCWs) working in intensive-care units (ICUs) are exposed to high physical and mental demands potentially affecting their health or having repercussions on patient care. Although several studies have explored the links between some aspects of working conditions in hospitals and HCW health, the complex dynamics at play are not fully understood.

OBJECTIVES

This study aimed to explore the impact of a wide array of demographic, employment and organizational factors related to fatigue and stress of French ICU HCWs.

DESIGN AND SETTING

A cross-sectional study was conducted in ICUs of Paris-area hospitals between January 18, 2013 and April 2, 2013. All types of adult ICUs were included (medical, surgical and polyvalent).

PARTICIPANTS

Included in the study were HCWs with patient contact (doctors, residents, registered nurses, nurse's aides and physical therapists). Participation was proposed to all eligible HCWs present during on-site visits. Temporary staff not typically assigned to the given ICU was excluded.

METHODS

Data were collected using an individual questionnaire administered in interviews during day and night shifts (N=682). Stress and fatigue outcomes included the 10-item Perceived Stress Scale (PSS10), the Nottingham Health Profile sleep and energy level rubrics and the current fatigue state at the interview. Multivariate analysis was restricted to nurse and nurse's aide data (n=536).

RESULTS

Doctors and residents reported fewer sleep difficulties but were more likely to report a tired current state. Female gender was associated with higher stress levels and greater fatigue for all outcomes, while greater social support of supervisor or colleagues decreased stress and fatigue. At the organizational level, longer shifts (12 h vs. 8 h) were associated with tired current state and greater sleep difficulties. Personnel on rotating shifts had lower stress and a better current state, while those on night shifts had greater sleep and energy level difficulties.

CONCLUSIONS

Even when controlling for demographic factors, employment and organizational elements remained significantly associated with stress and fatigue outcomes. To improve HCW health it is important to consider simultaneously factors at the individual and organizational level.

Encouraging an environment to nurture lifelong learning: an Asian experience

INTRODUCTION

Within an Asian context, this study examines the effect of changing from traditional course grades to a distinction/pass/fail (D/P/F) grading system on medical student self-perceived stress levels and on student exam performance.

METHODS

At the end of the 2010-2011 academic year, the Perceived Stress Scale-10 (PSS-10) was administered to the cohort of students finishing their first year of medical studies. For the academic year 2011-2012, the grading system was changed to D/P/F for the first year of medical school. The PSS-10 was also administered to the subsequent cohort of first-year medical students at the same point in the academic year as previous. Qualitative comments were collected for both cohorts.

RESULTS

Stress as measured by the PSS-10 was significantly lower in the cohort that went through the year with the D/P/F grading system in place. Thematic analysis of qualitative responses showed a shift in sources of student stress away from peer-competition. There were no significant differences in overall exam performance.

DISCUSSION

Within an Asian context, switching to a D/P/F grading system can alleviate stress and peer competition without compromising knowledge. This may help foster a "learning orientation" rather than an "exam orientation," and contribute to inculcating lifelong learning skills.

Feasibility and effectiveness of a Chen-style Tai Chi programme for stress reduction in junior secondary school students

Stress is common in junior secondary school students (JSSS). This study aimed to determine the feasibility and effectiveness of a Chen-style Tai Chi programme for stress reduction in JSSS. A non-equivalent pre-test/post-test control group design was adopted, and a convenience sample of 69 JSSS was recruited. The experimental group (n = 32) joined a Chen-style Tai Chi programme, which included 10 sessions of 80-minute Tai Chi training (one session per week). The control group (n = 37) proceeded with self-study. Participants' stress levels were assessed using the Perceived Stress Scale. Feasibility was determined as the percentage of participants completing and attending the programme. Effectiveness was measured as the significant difference in changes in stress levels before and after the intervention between the two groups. Results preliminarily supported that the programme was feasible for JSSS. Completion rate was 100%, and attendance rate was 90%. However, no significant difference was noted in changes in stress levels before and after the intervention between the two groups. The potential health benefits of Tai Chi could not be detected owing to the restrictions imposed by the research setting and study limitations. The present study represents initial efforts in this direction and serves as reference for future study.

Retrospective evaluation of control measures for contacts of patient with Marburg hemorrhagic fever

Measures had substantial effects on contacts and household members.

After an imported case of Marburg hemorrhagic fever was reported in 2008 in the Netherlands, control measures to prevent transmission were implemented. To evaluate consequences of these measures, we administered a structured questionnaire to 130 contacts classified as either having high-risk or low-risk exposure to body fluids of the case-patient; 77 (59.2%) of 130 contacts responded. A total of 67 (87.0%) of 77 respondents agreed that temperature monitoring and reporting was necessary, significantly more often among high-risk than low-risk contacts (p<0.001). Strict compliance with daily temperature monitoring decreased from 80.5% (62/77) during week 1 to 66.2% (51/77) during week 3. Contacts expressed concern about development of Marburg hemorrhagic fever (58.4%, 45/77) and infecting a family member (40.2%, 31/77). High-risk contacts had significantly higher scores on psychological impact scales (p<0.001) during and after the monitoring period. Public health authorities should specifically address consequences of control measures on the daily life of contacts.

Depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic

AIM

The aim of the study was to examine, among hospital employees exposed to an outbreak of severe acute respiratory syndrome (SARS), post-outbreak levels of depressive symptoms and the relationship between those depressive symptom levels and the types of outbreak event exposures experienced.

METHODS

In 2006, randomly selected employees (N = 549) of a hospital in Beijing were surveyed concerning their exposures to the city's 2003 SARS outbreak and the ways in which the outbreak had affected their mental health. Subjects were assessed on sociodemographic factors, on types of exposure to the outbreak, and on symptoms of posttraumatic stress disorder and depression.

RESULTS

The results of multinomial regression analyses showed that, with other relevant factors controlled for, being single, having been quarantined during the outbreak, having been exposed to other traumatic events before SARS, and perceived SARS-related risk level during the outbreak were found to increase the odds of having a high level of depressive symptoms 3 years later. Altruistic acceptance of risk during the outbreak was found to decrease the odds of high post-outbreak depressive symptom levels.

CONCLUSIONS

Policy makers and mental health professionals working to prepare for potential disease outbreaks should be aware that the experience of being quarantined can, in some cases, lead to long-term adverse mental health consequences.

Work-related critical incidents in hospital-based health care providers and the risk of post-traumatic stress symptoms, anxiety, and depression: a meta-analysis

This meta-analysis reviewed existing data on the impact of work-related critical incidents in hospital-based health care professionals. Work-related critical incidents may induce post-traumatic stress symptoms or even post-traumatic stress disorder (PTSD), anxiety, and depression and may negatively affect health care practitioners' behaviors toward patients. Nurses and doctors often cope by working part time or switching jobs. Hospital administrators and health care practitioners themselves may underestimate the effects of work-related critical incidents. Relevant online databases were searched for original research published from inception to 2009 and manual searches of the Journal of Traumatic Stress, reference lists, and the European Traumatic Stress Research Database were conducted. Two researchers independently decided on inclusion and study quality. Effect sizes were estimated using standardized mean differences with 95% confidence intervals. Consistency was evaluated, using the I(2)-statistic. Meta-analysis was performed using the random effects model. Eleven studies, which included 3866 participants, evaluated the relationship between work-related critical incidents and post-traumatic stress symptoms. Six of these studies, which included 1695 participants, also reported on the relationship between work-related critical incidents and symptoms of anxiety and depression. Heterogeneity among studies was high and could not be accounted for by study quality, character of the incident, or timing of data collection. Pooled effect sizes for the impact of work-related critical incidents on post-traumatic stress symptoms, anxiety, and depression were small to medium. Remarkably, the effect was more pronounced in the longer than in the shorter term. In conclusion, this meta-analysis supports the hypothesis that work-related critical incidents are positively related to post-traumatic stress symptoms, anxiety, and depression in hospital-based health care professionals. Health care workers and their supervisors should be aware of the harmful effects of critical incidents and take preventive measures.

Nurses' ability and willingness to work during pandemic flu

AIM

The present study reports factors affecting nurses' ability and willingness to work during pandemic flu (PF).

BACKGROUND

Previous studies suggest some nurses may be unable or unwilling to work during PF.

METHOD

A questionnaire was mailed to nurses during October to December 2009, the second wave of the 2009 A/H1N1 flu pandemic.

RESULTS

Most (90.1%) reported they would work. Willingness decreased primarily as personal protective equipment (PPE) dwindled, family or nurse were perceived to be at risk and when vaccine or antiviral medication was not provided to both nurse and family although many other factors also affected willingness to work. Ability decreased primarily when the nurse was sick, a loved one needed care at home or transportation problems existed although many other factors also affected ability to work.

CONCLUSION

Certain factors can decrease willingness and ability of nurses to work during a flu pandemic.

IMPLICATIONS FOR NURSING MANAGEMENT

Managers can anticipate factors that may decrease nurse's ability and willingness to work during pandemic flu. Preparing for staffing during emergencies can retain the health care workforce when it is needed most.

Psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease

OBJECTIVE

The psychological and coping responses of the noninfected community towards infectious disease outbreaks are relatively understudied. This cross-sectional study sought to determine the prevalence of severe acute respiratory syndrome (SARS)-related psychiatric and posttraumatic morbidities and associated coping styles within the general population visiting community health care services.

METHODS

It was conducted on individuals attending community polyclinics in Singapore within the first week of July 2003, 16 weeks after the first national outbreak of SARS. The General Health Questionnaire-28, Impact of Event Scale-Revised, and Brief COPE were used to determine the prevalence rates of psychiatric and posttraumatic morbidities and employed coping strategies respectively.

RESULTS

The overall response rate was 78.0%. Of the 415 community health care setting respondents, we found significant rates of SARS-related psychiatric (22.9%) and posttraumatic morbidities (25.8%). The presence of psychiatric morbidity was associated with the presence of high level of posttraumatic symptoms [adjusted odds ratio (OR) 2.26, 95% confidence interval (CI) 1.24-4.13, P=.008]. Psychiatric morbidity was further associated with being seen at fever stations (adjusted OR 1.90, 95% CI 1.08-3.34, P=.026), younger age (adjusted OR 0.97, 95% CI 0.94-0.98, P=.021), increased self blame (adjusted OR 1.67, 95% CI 1.22-2.28, P=.001), less substance use (adjusted OR 0.74, 95% CI 0.56-0.98, P=.034) and posttraumatic morbidity was associated with increased use of denial (adjusted OR 1.31, 95% CI 1.04-1.67, P=.024), and planning (adjusted OR 1.51, 95% CI 1.16-1.95, P=.002) as coping measures.

CONCLUSION

These findings could potentially inform the development of practical community mental health programs for future infectious disease outbreaks.

The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk

OBJECTIVE

We examined the psychological impact of the 2003 outbreak of severe acute respiratory syndrome (SARS) on hospital employees in Beijing, China.

METHODS

In 2006, randomly selected employees (n = 549) of a hospital in Beijing were surveyed concerning their exposure to the 2003 SARS outbreak, and the ways in which the outbreak had affected their mental health.

RESULTS

About 10% of the respondents had experienced high levels of posttraumatic stress (PTS) symptoms since the SARS outbreak. Respondents who had been quarantined, or worked in high-risk locations such as SARS wards, or had friends or close relatives who contracted SARS, were 2 to 3 times more likely to have high PTS symptom levels, than those without these exposures. Respondents' perceptions of SARS-related risks were significantly positively associated with PTS symptom levels and partially mediated the effects of exposure. Altruistic acceptance of work-related risks was negatively related to PTS levels.

CONCLUSIONS

The psychological impact of stressful events related to an infectious disease outbreak may be mediated by peoples' perceptions of those events; altruism may help to protect some health care workers against these negative impacts.

The prevalence and impact of post traumatic stress disorder and burnout syndrome in nurses

OBJECTIVE

To determine whether post traumatic stress disorder (PTSD) and burnout syndrome (BOS) are common in nurses, and whether the co-existence of PTSD and BOS is associated with altered perceptions of work and nonwork-related activities.

METHODS

University hospital nurses were administered four validated psychological questionnaires.

RESULTS

The response rate was 41% (332/810). Twenty two percent (73/332) had symptoms of PTSD, 18% (61/332) met diagnostic criteria for PTSD, and 86% (277/323) met criteria for BOS. Ninety eight percent (59/60) of those fulfilling diagnostic criteria for PTSD were positive for BOS. When grouped into three categories: positive for PTSD and BOS (n=59), positive for BOS and negative for PTSD (n=217), and negative for both BOS and PTSD (n=46), there were significant differences in the years of employment as a nurse (P<.0001), perceptions of collaborative nursing care (P=.006), confidence in physicians (P=.01), and perception that their work impacted patient outcomes (P=.01). Nurses with BOS and PTSD were significantly more likely to have difficulty in their life outside of the work environment when compared to those with BOS alone.

CONCLUSIONS

We identified that PTSD and BOS are common in nurses and those with PTSD will almost uniformly have symptoms of BOS. Co-existence of PTSD and BOS has a dramatic effect on work and nonwork related activities and perceptions.

Stress and psychological distress among SARS survivors 1 year after the outbreak

OBJECTIVE

Our study examined the stress level and psychological distress of severe acute respiratory syndrome (SARS) survivors 1 year after the outbreak.

METHOD

During the SARS outbreak in 2003, we used the 10-item Perceived Stress Scale (PSS-10) to assess SARS survivors treated in 2 major hospitals (non-health care workers, n = 49; health care workers, n = 30). We invited SARS survivors from the same hospitals (non-health care workers, n = 63; health care workers, n = 33) to complete the PSS-10 again in 2004. At that time, they were also asked to complete the General Health Questionnaire (GHQ-12) and measures of depression, anxiety, and posttraumatic symptoms. PSS-10 scores were also obtained from matched community control subjects during the outbreak (n = 145) and again in 2004 (n = 112).

RESULTS

SARS survivors had higher stress levels during the outbreak, compared with control subjects (PSS-10 scores = 19.8 and 17.9, respectively; P < 0.01), and this persisted 1 year later (PSS-10 scores = 19.9 and 17.3, respectively; P < 0.01) without signs of decrease. In 2004, SARS survivors also showed worrying levels of depression, anxiety, and posttraumatic symptoms. An alarming proportion (64%) scored above the GHQ-12 cut-off that suggests psychiatric morbidity. During the outbreak, health care worker SARS survivors had stress levels similar to those of non-health care workers, but health care workers showed significantly higher stress levels in 2004 (PSS-10 score = 22.8, compared with PSS-10 score = 18.4; P < 0.05) and had higher depression, anxiety, posttraumatic symptoms, and GHQ-12 scores.

CONCLUSIONS

One year after the outbreak, SARS survivors still had elevated stress levels and worrying levels of psychological distress. The situation of health care worker SARS survivors is particularly worrying. The long-term psychological implications of infectious diseases should not be ignored. Mental health services could play an important role in rehabilitation.