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To the Editor:
The United Kingdom's National Health Service (NHS), along with other health services around the world, faces unprecedented pressures dealing with the COVID-19 pandemic.1 The stress on the NHS is not limited to resource and financial constraints or the loss of lives but also the significant impact on the NHS workforce in terms of physical and psychological wellbeing. A large cross-sectional survey amongst health care workers (HCW) from Wuhan, China shows that HCW exposed to the COVID-19 pandemic showed signs of increased psychological burden.2 This is not dissimilar to experiences in the past with HCW exposed to the SARS outbreak in 2003.3–5 Data on the psychological burden of the COVID-19 outbreak on the NHS workforce is scarce.
In this letter, we would like to highlight the important issue of psychological wellbeing of healthcare workers during the COVID-19 outbreak. We designed and conducted a voluntary, anonymized staff survey at our tertiary cardiac center in the North West of England to assess the psychological burden of COVID-19 on the workforce. We administered two questionnaires, in the first week of April 2020, consisting of self-designed questions as well as questions from well validated psychology tools. During the time, the center was anticipating the arrival of large numbers of COVID-19 patients and the hospital had started receiving some early cases. The primary questionnaire (part 1) used the Patient Health Questionnaire (PHQ-9) depression assessment scale and the Perceived Stress Scale-4 (PSS-4) to assess stress levels. Burnout and preparedness were assessed in the initial questionnaire using self-designed questions (appendix 1, http://links.lww.com/JOM/A757). A second questionnaire was administered a couple of days later to assess anxiety (part 2), using the Generalised Anxiety Disorder-7 (GAD-7) scale. The PHQ-9, PSS-4, and GAD-7 are established and validated scales used to assess for depression, stress, and anxiety respectively.6–8 The cut-off values for the severity of depression using the PHQ-9 are as follows: 0 to 4 = none-minimal; 5 to 9 = mild; 10 to 14 = moderate; 15 to 19 = moderately severe; 20 to 27 = severe. The cut-off values for anxiety using the GAD-7 are as follows: 0 to 4 = minimal anxiety; 5 to 9 = mild anxiety; 10 to 14 = moderate anxiety; more than or equal to 15 = severe anxiety. For the PSS-4, a higher score indicates a higher level of stress. The British population had a mean PSS-4 score of 6.1 in a previous study.9
PSYCHOLOGICAL DISTRESS IN HEALTHCARE WORKERS
A total of 106 responses were obtained: 65 responses to the survey containing PHQ-9, PSS-4 and questions on preparedness and burnout, and 41 responses to the survey containing GAD-7. The characteristics of each respondent group according to occupation are shown in Table 1 and Supplementary Table S1, http://links.lww.com/JOM/A756, respectively. The median age of respondents was 41 years old, 67% were women. Median (IQR) time of NHS experience amounted to 14 [5 to 20] years. Three-quarters had direct contact with patients. Pre-existing diagnosis of depression was disclosed by 16% of survey participants. The baseline characteristics of GAD-7 respondents were broadly similar except for higher proportion of patients with pre-existing depression (32%).
On the depression test questionnaire (PHQ-9), the median score of the total cohort was 5 [2.5 to 8] indicating mild depression of the surveyed NHS employees. Mild (PHQ-9: 5 to 9), moderate (PHQ-9: 10 to 14), moderately severe (PHQ-9: 15 to 19), and severe depression (PHQ-9 more than or equal to 20) was noted in 38%, 6%, 3%, and 6%, respectively. Median PHQ-9 score was similar in people with pre-existing depression/anxiety compared with those without (5.5 [3 to 19] vs 5 [2.5 to 7.5], P = 0.327). There was no significant difference in depression severity when comparing different professions (clinicians vs nurses/allied healthcare professionals [AHP] vs administrative staff), sex, different age groups, length of experience in NHS, or direct patient contact status (Table 2).
The median stress (PSS-4) score of the overall cohort was 7 [5 to 8] and it was significantly higher in respondents with pre-existing depression and anxiety compared with those without (8 [6 to 10] vs 7 [5 to 8], P = 0.042). Importantly, there was no significant difference in perceived stress level in the respective prespecified groups stated above.
The median anxiety (GAD-7) score of the overall cohort was 5 [4 to 12]. Mild anxiety (GAD-7 = 5 to 9) was present in 27%, moderate (GAD-7 = 10 to 14) in 12%, and severe (GAD-7 more than orequal to15) in 22% of survey participants. The GAD-7 score was significantly higher in women compared with men (6.5 [4 to 17] vs 4 [1 to 7], P = 0.006). There was no significant difference in anxiety score based on occupation, direct exposure to patients, age, or length of NHS experience. Furthermore, there was no significant difference in GAD-7 score in respondents with and without pre-existing depression/anxiety (12 [2 to 18] vs 5 [4 to 9], P = 0.407).
PREPAREDNESS, BURNOUT, AND FEAR
Only 40% of respondents felt fairly well or very well prepared mentally to work during the pandemic. Majority (81%) of employees were scared of contracting COVID-19. Logistic regression did not identify independent risk factors for being worried of contacting coronavirus among baseline variables such as age, sex, pre-existing depression/anxiety, occupation of physician/nurse/AHP versus administrative role, length of NHS experience, direct patient contact versus no direct contact with patients, living with partner versus alone, and dependants versus no dependants. At present the staff are not displaying symptoms of burnout, however, only 19% are confident they would not experience burnout if the pandemic was prolonged until the second half of this year. This is certainly worrying. The staff attitude to the current pandemic is shown in Fig. 1.
The results of the survey show a prevalence, at this current point in time, of mild depression, increased levels of stress and mild anxiety amongst healthcare workers working during the current COVID-19 pandemic. It raises concerns of a perceived lack of preparedness of the NHS in dealing with the pandemic and a risk of staff burnout if the current situation continues beyond the middle of the year.
A number of studies have looked at psychological stress in healthcare staff during and after the Severe Acute Respiratory Syndrome (SARS) coronavirus outbreak in 2003.5,10–12 Reported incidence of psychological distress amongst staff has varied, with one study reporting more than half of workers affected.11 Furthermore, studies have shown a persistently high level of psychological distress in the longer term, including chronic stress, increased incidence of depression and anxiety, increased drinking and problem behavior and staff absenteeism.13 The results of the current survey are concerning and raises the need for early intervention to mitigate the immediate and longer-term consequences of the psychological stress amongst our NHS workers. Greenberg et al14 described the increased risk of morale injury and the heightened risk of mental health problems in healthcare workers. A similar concern has also been raised in national media.15 The findings of the current study support these concerns. Various factors that contribute to such heightened psychological stress have been described including interpersonal isolation, fear of contagion (81% in our survey), quarantine, stigma, concern for family, and non-infectious specialty workers being drafted on to infectious wards.10 Particularly, in an infectious outbreak setting, the presence of social isolation (whether outside work or at work in terms of personal protective equipment [PPE] and distancing) and fear and concern for healthcare workers with children appear to be unique driving factors. Furthermore, as shown in previous studies and our survey, staff with pre-existing depression or anxiety, are more vulnerable to psychological distress.3
To get through these difficult times will require early and persistent psychological support from colleagues and the organization, addressing the above factors and with extra attention to the vulnerable, high-risk groups. Individual and organizational resilience are the key.13 Additionally important is the need to provide adequate after care, including into the longer term. Otherwise, as evidenced from our survey, the risk of burnout amongst staff is high should the current crisis persist for another few months. Furthermore, the support at a more national scale is also very relevant in terms of staff confidence in dealing with the outbreak. As evidenced from the survey, more than half of the staff felt the NHS was not well prepared to deal with the pandemic. Multiple factors are likely to have influenced this outcome including the issues regarding the adequacy of PPE supplies nationally and the fast evolving nature of the situation that make it difficult for organizations to adopt. Early recognition of psychological distress and institution of support are key.
The current survey is a snapshot in time only of healthcare workers in a defined specialty and not throughout the hospital. We recognize this is a limitation. However, due to the acuity of the current crisis and the importance of communicating the findings as a messenger to highlight the very important topic of mental health of the healthcare workers during the COVID-19 outbreak to the larger healthcare community, a larger and serial survey could not be carried out.
Our NHS healthcare workers are leading the fight against the COVID-19 pandemic which has claimed more than 20000 lives in the UK and the numbers are continuing to increase. We need to ensure our workforce are looked after well. The current survey highlights the presence of psychological distress amongst healthcare workers and the risk of burnout. Early recognition of signs of psychological distress, setting up adequate support services, and long-term aftercare for our healthcare workers are of paramount importance.
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15. Hill A. NHS staff to be offered mental health support for covid-19 ‘shell shock’; The Guardian 2020, Available at: https://www.theguardian.com/society/2020/apr/08/nhs-staff-mental-health-shell-shock-tackling-covid-19-coronavirus
. Accessed April 10, 2020.