Worsening psychological wellbeing of Australian hospital clinical staff during three waves of the coronavirus (COVID-19) pandemic

Objective This study aimed to assess and compare the psychological wellbeing of Australian hospital clinical staff at three timepoints during the coronavirus disease 2019 (COVID-19) pandemic. Methods An anonymous, online, cross-sectional survey was conducted at three timepoints during the COVID-19 pandemic (T1: May-June 2020; T2: October-December 2020; T3: November 2021-January 2022). The surveys were completed by nurses, midwives, doctors and allied health staff employed at a large metropolitan tertiary health service located in Melbourne, Australia. The Depression, Anxiety and Stress Scale (DASS-21) assessed respondents' psychological wellbeing in the past week. General linear models were used to measure the effects of survey timepoint on DASS-21 subscale scores, adjusting for selected sociodemographic and health characteristics. Results A total of 1470 hospital clinical staff completed at least one survey (T1: 668 (14.7%), T2: 358 (7.9%) and T3: 444 (9.8%)). Respondents' sociodemographic characteristics were similar across the three timepoints and within professional discipline groups. Respondents' psychological wellbeing was worse at T3 compared to the earlier survey timepoints. Adjusting for respondent characteristics, depression, anxiety and stress scores were significantly higher for respondents of the third survey compared to the first (P  < 0.001). Conclusions There was a significant and persistent negative impact on the psychological wellbeing of hospital clinical staff in Australia across waves of the COVID-19 pandemic. Hospital clinical staff would benefit from ongoing and continued wellbeing support during and after pandemic waves.

OUP accepted manuscript

Background

Hospital clinicians report poor psychosocial well-being during the COVID-19 pandemic. Few studies have reported data at more than one time point.

Aims

To compare psychosocial well-being among hospital clinicians at two different time points during the COVID-19 pandemic in 2020.

Methods

Participants included doctors, nurses, midwives and allied health clinicians at a multi-site, public health service in Melbourne, Australia. Data were collected via two cross-sectional, online surveys: May to June (wave 1; n = 638) and October to December 2020 (wave 2; n = 358). The Depression, Anxiety and Stress Scale (DASS-21) assessed psychological well-being in the past week. Investigator-devised questions assessed COVID-19 concerns and perceived work impacts. General linear models were used to assess impact of wave on psychological distress.

Results

There were no significant demographic differences between the two groups. Both positive (e.g. learning experience) and negative (e.g. risk of getting COVID-19) impacts were reported. In both waves, staff were most concerned about health risks to family members. Wave 2 respondents were significantly more likely than wave 1 respondents to indicate concerns about colleagues having COVID-19, increased workloads, leave cancellation and increased conflict at work (all P < 0.001). Adjusting for sex, age, self-rated health and discipline group, depression, anxiety and stress scores were significantly higher for respondents in the second than the first wave (all P < 0.001).

Conclusions

Psychological well-being of hospital clinicians was significantly worse during the second wave of the COVID-19 pandemic than the first. Sustained occupational and psychosocial support is recommended even when immediate COVID-19 concerns and impacts resolve.

Palliative care and COVID-19 in the Australian context: a review of patients with COVID-19 referred to palliative care

ObjectivePalliative care has played a key role in the response to the coronavirus disease 2019 (COVID-19) pandemic in Australia. This review of consecutive patients with COVID-19 referred to the palliative care consultancy service of a tertiary health service in Melbourne describes the palliative care experience with COVID-19 in Australia.MethodsThe experiences of 55 patients (median age 86 years; interquartile range (IQR) 81-90 years; 55% male; median Charlson comorbidity score 6 (IQR 5-8); 85% with Australia-modified Karnofsky Performance Status ≤50; 67% from residential aged care facilities) were reviewed to collect relevant data points.ResultsMost patients were referred for end-of-life care with symptoms including dyspnoea (80%) and agitation/delirium (60%). Continuous subcutaneous infusions were commenced in 71% of patients, with the most frequent medications being opioids and benzodiazepines in relatively small doses; 81% required ≤20mg subcutaneous morphine equivalent and 64% required ≤10mg subcutaneous midazolam over 24h. Fifty patients (91%) died in hospital and the median time from palliative care referral to death was 3 days (IQR 1-5 days). Five patients were discharged back to residential aged care facilities. Overall, 80% of referrals were from the aged care team.ConclusionOur patients had similar demographics, symptoms, medication needs and outcomes to patients in similar settings overseas. We found the symptom management of patients with COVID-19 to be generally straightforward. However, the psychosocial needs of patients were predominant and contributed to complexity. This study highlights the need for well-integrated relationships between the palliative care consultancy service and the diverse range of key treating teams involved in the delivery of pandemic health care.What is known about the topic?Palliative care has played a key role in the response to the COVID-19 pandemic in Australia. There is limited research describing the Australian palliative care experience with the COVID-19 pandemic.What does this paper add?Patients with COVID-19 referred to a hospital-based palliative care consultancy service in Australia had similar demographic characteristics, symptoms, medication needs and outcomes to patients with COVID-19 referred to other palliative care services in the UK and the US. There were significant psychosocial issues affecting patients, families and staff in the context of the pandemic.What are the implications for practitioners?This study highlights the need for well-functioning working relationships between the palliative care consultancy service and other hospital teams that can be leveraged at a time of crisis, such as a pandemic, to provide optimal palliative care to patients.

Immediate impact of the COVID-19 pandemic on the work and personal lives of Australian hospital clinical staff

ObjectiveThis study investigated the short-term psychosocial effects of the COVID-19 pandemic on hospital clinical staff, specifically their self-reported concerns and perceived impact on their work and personal lives.MethodsNurses, midwives, doctors and allied health staff at a large metropolitan tertiary health service in Melbourne, Australia, completed an anonymous online cross-sectional survey between 15 May and 10 June 2020. The survey assessed respondents' COVID-19 contact status, concerns related to COVID-19 and other effects of COVID-19. Space was provided for free-text comments.ResultsRespondents were mostly concerned about contracting COVID-19, infecting family members and caring for patients with COVID-19. Concerns about accessing and using personal protective equipment, redeployment and their ability to provide high-quality patient care during the pandemic were also reported. Pregnant staff expressed uncertainty about the possible impact of COVID-19 on their pregnancy. Despite their concerns, few staff had considered resigning, and positive aspects of the pandemic were also described.ConclusionThe COVID-19 pandemic has had a considerable impact on the work and personal lives of hospital clinical staff. Staff, particularly those who are pregnant, would benefit from targeted well-being and support initiatives that address their concerns and help them manage their work and personal lives.What is known about the topic?The COVID-19 pandemic is having an impact on healthcare workers' psychological well-being. Little is known about their COVID-19-related concerns and the perceived impact of the pandemic on their work and personal lives, particularly hospital clinical staff during the 'first wave' of the pandemic in Australia.What does this paper add?This paper contributes to a small but emerging evidence base about the impact of the COVID-19 pandemic on the work and personal lives of hospital clinical staff. Most staff were concerned about their own health and the risk to their families, friends and colleagues. Despite their concerns, few had considered resigning. Uncertainty about the possible impact of COVID-19 on pregnancy was also reported.What are the implications for practitioners?During the current and future pandemics, staff, especially those who are pregnant, would benefit from targeted well-being and support initiatives that address their concerns and help them manage the impact on their health, work and personal lives.

Psychological well-being of Australian hospital clinical staff during the COVID-19 pandemic

Objective This study assessed the psychological well-being of Australian hospital clinical staff during the COVID-19 pandemic. Methods An anonymous online cross-sectional survey was conducted in a large metropolitan tertiary health service located in Melbourne, Australia. The survey was completed by nurses, midwives, doctors and allied health (AH) staff between 15 May and 10 June 2020. The Depression, Anxiety and Stress Scale - 21 items (DASS-21) assessed the psychological well-being of respondents in the previous week. Results In all, 668 people responded to the survey (nurses/midwives, n=391; doctors, n=138; AH staff, n=139). Of these, 108 (16.2%) had direct contact with people with a COVID-19 diagnosis. Approximately one-quarter of respondents reported symptoms of psychological distress. Between 11% (AH staff) and 29% (nurses/midwives) had anxiety scores in the mild to extremely severe ranges. Nurses and midwives had significantly higher anxiety scores than doctors (P<0.001) and AH staff (P<0.001). Direct contact with people with a COVID-19 diagnosis (P<0.001) and being a nurse or midwife (P<0.001) were associated with higher anxiety scores. Higher ratings of the health service's pandemic response and staff support strategies were protective against depression (P<0.001), anxiety (P<0.05) and stress (P<0.001). Conclusions The COVID-19 pandemic had a significant effect on the psychological well-being of hospital clinical staff, particularly nurses and midwives. Staff would benefit from (additional) targeted supportive interventions during the current and future outbreaks of infectious diseases. What is known about the topic? The outbreak of COVID-19 is having, and will have, a considerable effect on health services. No Australian data about the effect of COVID-19 on the psychological well-being of hospital clinical staff are available. What does this paper add? Australia healthcare providers have experienced considerable emotional distress during the COVID-19 pandemic, particularly nurses and midwives and clinical staff who have had direct contact with people with a COVID-19 diagnosis. In this study, nurses and midwives had significantly higher levels of anxiety, depression and stress during the pandemic than general Australian adult population norms, and significantly more severe anxiety symptoms than medical and AH staff. Despite a lower number of COVID-19 cases and a lower death rate than in other countries, the proportion of Australian hospital clinical staff experiencing distress is similar to that found in other countries. What are the implications for practitioners? Targeted well-being interventions are required to support hospital clinical staff during the current and future outbreaks of infectious diseases and other 'crises' or adverse events.

Prospective analysis of 30-day mortality following palliative chemotherapy at a tertiary cancer centre

BACKGROUND

Thirty-day mortality after chemotherapy has been suggested as a marker of quality in oncology care. Retrospective audits worldwide have put this figure at between 8.1% and 43%, with previous retrospective Australian audits putting this figure at between 3.4% and 18%. To date, there has not been a prospective cohort study of patients receiving palliative intent chemotherapy at an Australian chemotherapy day unit.

AIM

The aim of the study is to benchmark 30-day mortality for patients receiving palliative intent chemotherapy and identify associated factors at an Australian tertiary cancer centre.

METHODS AND RESULTS

A prospective cohort study of all patients with a diagnosis of malignancy referred for palliative intent intravenous chemotherapy to the Sunshine Hospital Chemotherapy Day Unit over a 12-month period. The primary outcome was death within 30 days of receiving palliative intent chemotherapy. Other outcome measures included place of death and whether the patient received an outpatient palliative care referral. A total of 314 patients were enrolled in the study, and 98 patients died within the audit period. Of these, 21 (6.6%) died within 30 days of commencing palliative intent chemotherapy, and 60 (18.8%) died more than 30 days after receiving chemotherapy. Of the 34 patients that were referred, but did not start chemotherapy, 18 (52%) died. Multivariable logistic regression found that patients who received an outpatient palliative care referral and received chemotherapy were more likely to die within 30 days, although these did not reach statistical significance.

CONCLUSION(S)

This prospective cohort study demonstrated that 6.6% of patients died within 30 days of the administration of palliative intent chemotherapy; however, none of the prespecified factors were found to be statistically significantly associated with 30-day mortality.

Does Care for Australians With Pancreatic Cancer Compare Favourably to a Consensus-Based Standard of Optimal Care?

Background: Pancreatic cancer has one of the lowest survival rates of all cancer types, with an incidence to mortality ratio approaching one. People with pancreatic cancer experience a rapid decline in health characterized by pain, nausea, fatigue and weight loss. For most people, the disease is detected at an advanced stage and the focus of treatment is palliative. In Victoria, Australia, knowledge regarding patterns of care for people with pancreatic cancer is out-of-date, but central to quality improvement initiatives targeting unwarranted variations in care and improvement in supports that are consistent with patient preferences. Aim: Our aim was to compare care received by patients with pancreatic cancer with a consensus-based standard representing optimal care to identify deviations from best practice and highlight processes that may improve the quality and safety of care provided. Methods: Eligible patients included those with pancreatic cancer, first treated in 2015, at one of three tertiary hospitals in Victoria, Australia. Once identified, dates and details of events indicated by the optimal care pathway were extracted from the medical record of each patient. Data were summarized using descriptive statistics and process maps: a visualization method that illuminates gaps, duplication, deviations from best practice and processes that may be amenable to improvement. Results: Thirty-two of 165 care pathways have been mapped to date. The nature and timing of care received appears highly variable. Only nine of 32 patients (28%) received all of their cancer care at a single institution; the remainder (n=23, 72%) received care in multiple tertiary and community facilities. Apart from four (13%) emergency presentations, referrals for specialist care came from general/primary practitioners (n=26, 81%). The timeframe for general/primary practitioner investigations ranged from one to 57 days. Once referred to a tertiary setting, most patients (n=23, 72%) were discussed at a multidisciplinary team meeting and received standard therapies. Only four had resectable disease. Nineteen patients (60%) had documented referrals to hospital- or community-based palliative care services. Where observed, deviations from the consensus-based standard tended to be related to the difficult nature of diagnosing pancreatic cancer, and determining appropriate care for patients with an advanced cancer with nonspecific symptoms. Conclusion: Process mapping provided a useful and efficient means of comparing care received with a consensus-based standard; however, the assessment of adherence to optimal timeframes and specific care events was complicated by missing data. Implications for quality improvement activities will be considered in the context of study limitations. We will also emphasize the importance of engaging patients and carers in setting improvement priorities.

Tailored chemotherapy information faxed to general practitioners improves confidence in managing adverse effects and satisfaction with shared care: results from a randomized controlled trial

PURPOSE

General practitioners (GPs) play a critical role in the treatment of patients with cancer; yet often lack information for optimal care. We developed standardized information for GPs about chemotherapy (CT). In a randomized controlled trial we assessed the impact of sending, by fax, information tailored to the particular patient's CT regimen. Primary end points were: confidence treating patients who were receiving CT (confidence), knowledge of adverse effects and reasons to refer the patient to the treatment center (knowledge), and satisfaction with information and shared care of patients (satisfaction).

METHODS

Focus group work informed the development of the CT information which focused on potential adverse effects and recommended management strategies. GPs of patients due to commence CT were randomly assigned to receive usual correspondence with or without the faxed patient/regimen-specific information. Telephone questionnaire at baseline and 1 week postintervention assessed knowledge, confidence, and satisfaction.

RESULTS

Ninety-seven GPs managed 97 patients receiving 23 types of CT. Eighty-one (83.5%) completed the follow-up questionnaire. GPs in the intervention group demonstrated a significantly greater increase in confidence (mean difference, 0.28; 95% CI, 0.10 to 0.47) and satisfaction (mean difference, 0.57; 95% CI, 0.27 to 0.88) compared with usual care, reflecting a 7.1% and 10.5% difference in score, respectively. No differences were detected for knowledge. GPs receiving the CT sheet found correspondence significantly more useful (P < .001) and instructive (P < .001) than GPs who received standard correspondence alone.

CONCLUSION

Information about CT faxed to GPs is a simple, inexpensive intervention that increases confidence managing CT adverse effects and satisfaction with shared care. This intervention could have widespread application.

A panacea of general practice

As a general practitioner with an interest in palliative medicine, occasionally patients with end-stage malignancies are referred to me. For these people the search for a panacea is well and truly over. Rather than searching for a cure for cancer they are now mostly searching for control of their “pain,” with all that that implies. One of my roles is to protect my patients from those peddling a panacea who in the process may impose burdensome costs, be they physical, psychological, or financial. The motives of those selling a “cure” may be altruism or greed, or indeed both.

Tailored chemotherapy (CT) information (info) faxed to general practitioners (GP) improves knowledge and confidence in managing side effects (SFX): Results from a randomized controlled trial (RCT)

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Background: The literature indicates discontinuity in patient (pt) care and poor communication between hospitals and community practice. GPs would like more info about CT, SFX and how to manage these. We aimed to develop standardized info for GPs about CT and to assess the impact of this in an RCT. Primary endpoints were: confidence managing pts having CT, knowledge of CT SFX, and satisfaction with both info and shared care of pts. Secondary endpoints included how useful and instructive GPs found the info. Methods: Peter Mac IRB approved the study. Initial focus group work with GPs informed the development of info about 23 CT regimens. GPs of pts due to commence a CT regimen for the first time were randomized to receive usual correspondence (UC) or UC plus info. Prior to randomization GPs were telephoned and verbal consent obtained. Telephone questionnaire (qstnre) assessed GPs confidence in managing pts and knowledge of CT SFX, as well as satisfaction with info and shared care of pts. GPs in the intervention group were then faxed the relevant info. One week later all GPs were phoned and completed a similar standardized qstnre. Measures used a 5 point scale/range. Results: 97 GPs managed 97 pts receiving 21 types of CT. GPs on average had 27.1 yrs clinical experience (SD=9.8) and were managing 5.5 pts receiving CT (SD=6.8). Of 97 GPs randomized, 81 (83.5%) completed the follow up qstnre. GPs confidence in managing CT SFX was fair at baseline (M=3.34, SD=0.69). GPs in the intervention group demonstrated a significantly greater increase in confidence (difference 0.36; p<0.01) and knowledge of CT SFX - eg febrile neutropenia (diff 0.55; p<0.01) - and close to significant effect for satisfaction with info / shared care (diff 0.35; p=0.051) compared with UC. GPs receiving info + UC also considered it significantly more useful (diff 1.48; p<0.001) and instructive (diff 1.88; p<0.001) than GPs who only received UC. Conclusions: Info about CT faxed to GPs is a simple, inexpensive intervention that increases GPs knowledge of CT SFX and confidence in managing pts. Further, GPs find this info more useful and instructive than UC alone. This intervention could have widespread application.

No significant financial relationships to disclose.