Two studies today in JAMA Network Open describe the emotional toll of the COVID-19 pandemic on healthcare workers (HCWs), one showing that US HCWs experienced a range of negative emotions as the pandemic progressed, and the other concluding that mental distress eased 14 months into the pandemic in Italian clinicians.

Pandemic ‘has shaken my faith in medicine’

In the US study, a team led by Duke University researchers surveyed 1,344 HCWs in 2020 about their emotional state before the availability of COVID-19 vaccines. They recruited HCWs via email and social media from Apr 24 to May 30 (phase 1) and Oct 24 to Nov 30 (phase 2).

In phase 1 involved 335 survey respondents of whom 32.6% were 35 to 44 years old, 86% were women, and 87.8% were White. Phase 2 included 1,009 participants, of whom 38.1% were aged 35 to 44, 90.5% were women, and 93.7% were White. Respondents included nurses, physicians, advanced practice practitioners, and chaplains.

The HCWs reported emotions related to changes in family, social life, and occupational function. They expressed fear of contracting COVID-19 and spreading the infection to family and friends, stigmatization, short-staffing, and inadequate personal protective equipment (PPE).

HCWs also said they experienced fear in phase 1, progressing to fatigue in phase 2, as well as isolation, alienation, and betrayal by coworkers, management, the healthcare system, and the community. Said one respondent, “My levels of fear have decreased, just because they weren’t sustainable.”

In open-ended responses, participants said that witnessing patients die alone owing to isolation measures was “heartbreaking” and also “has also shaken my faith in medicine, it makes me feel vulnerable and scared … there isn’t much modern medicine can do to help.”

HCWs also indicating a growing distrust and fear of patients and coworkers “who have lied and hid in [sic] symptoms ultimately exposing me, my patients, and clinic staff.” One participant said that criticism on social media was “the most painful moral injury…fighting hard at front lines and coming home from gnarly ER [emergency room] shifts only to have to battle on social media.”

The researchers called these types of emotional distress “moral injury…resulting from events or transgressive acts that create dissonance within one’s very being due to a disruption or violation of their existential orientation and values system.” They added that moral injury can come from an internal conflict between, for example, prioritizing patients versus productivity.

Moral injury, the authors noted, is tied to medical errors, HCW burnout, and suicidal ideation, and will likely leave mental illnesses and burnout in its wake.

“Moral injury was not only experienced after a single moral dilemma but also from working in morally injurious environments,” the researchers wrote.

“These experiences can serve as potential starting points for organizations to engender and enhance organizational and individual recovery, team building, and trust. System-level solutions that address shortages in staffing and personal protective equipment are needed to promote HP [health professional] well-being.”

Symptoms waned over time

The observational Italian study, led by researchers from the University of Rome Tor Vergata, involved an online mental health survey of 2,856 HCWs across Italy from Mar 1 to Apr 30, 2020—when parts of the country were deluged with COVID-19 patients—and from the same period in 2021.

Of the 2,856 HCWs, 34.9% responded to the follow-up questionnaire. Participants were, on average, 43 years old, and 82.0% were women.

Respondents’ symptoms of depression (b, −2.88), anxiety ( , −2.01), and post-traumatic stress disorder (PTSD) (b, −0.77) lessened over time, but insomnia symptoms rose (b, 3.05). Working on the front lines of care in 2020 was tied to fewer depression symptoms (b, −1.04), while COVID-19 hospitalization was linked to more depression symptoms (b, 5.96). Younger age (b, −0.36) and working on the frontlines in 2020 (b, −1.04) were associated with less anxiety.

Male sex was tied to increased insomnia (b, 1.46). Working on the front lines in 2020 (b, −0.42) and working as a physician (b = −0.52) were associated with fewer PTSD symptoms, whereas younger age (b, 0.35) and male sex (b, 0.12) were tied to more PTSD symptoms.

Female sex was tied to persistent depression (odds ratio [OR], 3.69), anxiety (OR, 6.50), and remittent (OR, 2.99) and incident (OR, 2.60) PTSD. Younger age was associated with remittent depression (OR, 1.22) and incident (OR, 1.46) and persistent (OR, 1.27) PTSD.

Among the 2,856 HCWs, 629 (65.5%) were resilient to depression, 181 (18.8%) had recurring depression, 58 had incident cases (6.0%), and 92 (9.6%) reported persistent depression.

Anxiety cases included 701 (73.3%) resilient, 149 (15.6%) remittent, 45 (4.7%) incident, and 61 (6.4%) persistent. Among anxiety trajectories, 858 (88.9%) were resilient, 77 (8.0%) were remittent, 20 (2.1%) were incident, and 10 (1.0%) were persistent. PTSD cases were characterized as resilient (363 [38.5%]), remittent (267 [28.3%]), incident (86 [9.1%]), or persistent (226 [24.0%]).

“The results of this study highlight a decreasing trend of mental health symptoms in the Italian HCWs,” the authors concluded. “Age, sex, and frontline working position were relevant risk factors for the persistence of conditions over time. These results could inform working policies that should avoid overexposure of HCWs to frontline working positions in the future.”



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