Multidimensional assessment of the impact of COVID-19 pandemic on healthcare workers in governmental hospitals 2021

ABSTRACT

Background

Since the emergence of the pandemic, healthcare workers have been subjected to devastating psychological burden at all levels of healthcare. Depression, anxiety, and stress were greatly encountered in the era of the pandemic. Moreover, healthcare workers reported escalating levels of burnout syndrome compared to levels reported in the pre-pandemic era. They are exposed to multiple work-related stressors that have been exhausting to their mental and psychological well-being. The aim of the current study was to assess the impact of COVID-19 pandemic on the psychological well-being of healthcare workers.

Methods

A comparative cross-sectional study was conducted among 471 healthcare workers (245 front-line and 226 second-line healthcare workers) recruited from ten governmental hospitals. Data was collected using self-administered structured questionnaire, Depression, Anxiety and Stress Scale-21 Items (DASS-21) and Copenhagen Burnout Inventory (CBI).

Results

Symptoms suggestive of depression, anxiety, and stress were reported by 72.6%, 31.4%, and 18.6% of studied healthcare workers, respectively. Front-line healthcare workers had significantly higher mean anxiety and stress scores compared to second-line ones.

Burnout syndrome was reported by 86.4% of the study subjects, with statistically significant differences between front-line and second-line healthcare workers. The most commonly adopted organizational interventions against work-related stressors were increased workforce (41.6%), frequent staff meetings (32.3%), shifts rescheduling (31.4%), frequent breaks during the working day (29.1%), and staff training (16.8%). As for individually adopted interventions, following strict protective measures (63.5%), gaining more knowledge about COVID-19 (54.1%), avoiding media news (44.8%), and relaxation activities such as prayers, music, and meditation (37.2%) were the most commonly adopted interventions.

KEYWORDS:

• COVID-19; depression
• anxiety
• stress
• burnout
• health care workers

1. Introduction

Since the emergence of the pandemic, health care workers (HCWs) have been subjected to huge burden at all levels of healthcare. In addition to the physical sequel of COVID-19, there is a devastating psychological impact on HCWs at all levels of healthcare. Several factors have contributed to this psychological burden such as increased working hours, isolation in quarantine and living away from home as a response to the pandemic [1]. Also, fear of getting the infection as well as transmitting it to colleagues and family members have added a great pressure over HCWs during the pandemic [2]. Moreover, multiple management protocols which are frequently updated with progress of the pandemic have contributed to the burden experienced by HCWs [3]. Besides, shortage of personal protective equipment (PPE), especially during the first waves of the pandemic, has been an important stressor [4].

Several studies all over the world have discussed the psychological impact of COVID-19 pandemic on HCWs. A global study conducted in 2021 in UK, France, Italy, Belgium, China, Taiwan, and Egypt revealed that 16–49% of HCWs participating in the study have already been suffering from depression, while stress was encountered in 17–35% of them [5]. A systematic review conducted in UK in 2021 estimated the prevalence of depression, anxiety, and stress among HCWs to be around 13.5−44.7%, 12.3−35.6%, and 7.4−37.4%, respectively [6]. Similar results were obtained by a recent Spanish study conducted in 2021, which stated that Spanish frontline HCWs experience general worsening in their mental health assessment, especially regarding depression and stress [7].

In addition to the impact of the pandemic on the psychological profile of HCWs, one of the most prominent effects is the escalating increase in reported burn-out among them. Burn-out is defined as a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It has three characteristic dimensions: feelings of energy depletion or exhaustion, increased mental distance from one’s job, or feelings of negativism or cynicism (not trusting or respecting the goodness of other people and their actions) related to one’s job; and reduced professional efficacy [8].

This is due to the highly stressful situations they are exposed to as a result of the pandemic such as continuous threat of catching the infection and fear of transmitting the infection to family members, colleagues and other patients [9]. Moreover, work overload during the pandemic together with deficiency of resources have added additional psychological burden over HCWs [8]. A cross-sectional survey carried out in 2021, including HCWs from UK, Poland and Singapore, stated that nearly two thirds of the included participants had experienced symptoms of burn-out [10]. Almost similar results were obtained by another Italian systematic review in 2021 which declared that about 49.3−58% of the included HCWs were subjected to burn-out syndrome in the era of the pandemic [11].

HCWs are exposed to multiple work-related stressors that have been exhausting to their mental and psychological well-being. Thus, it is crucial to protect and support HCWs in workplace in order to maintain their performance against the pandemic to the required performance standards. Several organizational and individually adopted measures can be undertaken to support HCWs and manage work-related stressors in their workplace.

Although several studies have focused on HCWs combating the pandemic worldwide, in Egypt, the studies concerned with psychological well-being of HCWs are quite few. Therefore, the current study was carried out to highlight how COVID-19 pandemic have influenced psychological well-being of HCWs.

2. Aim of the work

2.1. General objective

To assess the multidimensional impact of COVID-19 pandemic on health care workers in Alexandria 2021.

2.2. Specific objectives

1. To reveal the psychological impact of COVID-19 pandemic namely; stress, anxiety, depression, COVID-19 related fear and level of burnout syndrome among the studied healthcare workers.

2. To identify the personal and organizational interventions to prevent and overcome work-related stressors during the pandemic.

3. Subjects

Sample size was calculated and the minimum estimated sample size was 220 subjects. A total number of 471 HCWs were enrolled in the study. Among them, 245 HCWs were front-line ones who were responsible for management of COVID-19 patients or follow-up of the isolated ones, for example, HCWs in emergency medicine, internal medicine (including chest departments), intensive care unit, laboratory and radiology departments. On the other hand, the remaining 226 HCWs were second-line ones who were not in charge for management of COVID-19 patients or follow-up of the isolated ones. All HCWs in the studied settings who agreed to join the study and fulfilled the inclusion criteria were included in the study during the study period.

Inclusion criteria for front-line HCWs were:

• Frontline HCWs (physicians, nurses, technicians and workers) who are responsible for management of COVID-19 patients or follow-up of the isolated ones e.g. HCWs in emergency medicine, internal medicine (including chest departments), intensive care unit, laboratory and radiology departments.

• Healthcare workers working in the selected departments for at least three months.

• Healthcare workers who agreed to participate in the study.

As for second-line HCWs, the inclusion criteria were:

• Healthcare workers who were not in charge for management of COVID-19 patients or follow-up of the isolated ones.

• Healthcare workers who agreed to participate in the study.

4. Methods

A comparative cross-sectional study was conducted among front-line and second-line HCWs during the duration from December 2021 to March 2022. Both groups were assessed regarding COVID-19 psychological impact and their adopted interventions for prevention and management of work-related stressors. The studied HCWs were enrolled from 10 governmental hospitals.

A self-administered structured questionnaire was designed to inquire about personal and occupational data. Moreover, it also inquired about coping measures adopted by HCWs as well as organizational measures adopted in workplace for prevention and management of work-related stressors.

Another data collection tool was Depression, Anxiety, and Stress Scale-21 Items (DASS-21) [12]. It was a set of three self-report scales designed to measure the emotional states of depression, anxiety and stress. Each of the three DASS-21 scales contained 7 items, with each item rated from 0 to 3. Scores for depression, anxiety and stress were calculated by summing the scores for the relevant items. The DASS-21 score ranges from 0 to 42. The cutoff point for depression score is 9, above which participants can be categorized into mild (10–13), moderate (14–20), severe (21–27), and extremely severe depression (28+). The cutoff point for anxiety score is 7, above which anxiety can be categorized into mild (8–9), moderate (10–14), severe (15–19) and extremely severe anxiety (20+). Regarding stress score, the cutoff point is 14, above which stress could be categorized into mild (15–18), moderate (19–25), severe (26–33), and extremely severe stress (34+).

For assessment of burnout among HCWs, Copenhagen Burnout Inventory (CBI) was used [13]. It was a nineteen-item five-point likert scale where each item was given a weighted score (0, 25, 50, 75, or 100). It categorized burnout syndrome according to average scores into very mild/absent (score = 0), mild (score <50), moderate (score = 50–74), severe (score = 75–99), and very severe (score = 100).

The collected data were revised, coded, and transferred to master table. Then, data were fed to the computer using Statistical Package for Social Science (SPSS/PCT) program (version 22.0). Appropriate descriptive and inferential statistical analyses were done for quantitative data. Chi-square test, Student t test, Analysis of variance test (ANOVA), and Pearson's correlations were used in the analysis. A 5% level of significance was selected for this study.

Objectives of the study, the expected benefits, and types of information to be obtained were explained to the health care staff to get their informed consent. The proposal was submitted to the Research Ethics Committee and it gained approval. Verbal Informed consents were obtained from the included participants and privacy and confidentiality of data were ensured.

5. Results

5.1. Sociodemographic and professional profile of the study HCWs

The current study included 471 participants, 245 of them were considered front-line HCWs, while the remaining 226 were considered second-line HCWs. The mean age of the included HCWs was 42.4 ± 4.97 years, ranging from 32 years to 56 years, with nearly 56.7% of them were in the age group from 40 to 50 years. Slightly less than two-thirds (60.5%) of the study subjects were females, while the remaining 39.5% were males. The majority of the studied HCWs were nurses (47.6%), followed by physicians (41.4%), technicians (7.2%), pharmacists (2.5%), and workers (1.3%). The included front-line HCWs belonged to emergency department (30.6%), internal medicine department (28.2%), intensive care unit (27.3%), clinical pathology department (7.8%), and radiology department (6.1%). However, the second-line HCWs belonged to pediatrics, ophthalmology, gastroenterology and general surgery departments (30.5%, 25.2%, 17.3%, and 27.0%, respectively).

5.2. Depression, anxiety and stress assessment

As demonstrated by Table 1, the mean depression score was comparable among front-line and second-line HCWs (11.01 ± 4.24 and 11.03 ± 3.97, respectively). Symptoms suggestive of depression was reported by 72.6% of studied HCWs. Mild depression was reported by 41.2% of study HCWs while 31.4% of them reported symptoms of moderate depression. The difference between front-line and second-line HCWs as regard depression was statistically insignificant.

Table 1. Distribution of the study HCWs as regard findings of their psychological assessment.

Psychological assessment	Front-line HCWs (n = 245)		Second-line HCWs (n = 226)		Total (n = 471)		Test of significance
	N	%	N	%	N	%
Depression
Min-Max Mean score ± SD	2–20 11.01 ± 4.24		2–20 11.03 ± 3.97		2–20 11.02 ± 4.11		t = 0.016 P = 0.98 CI= −0.75–0.74
Normal	70	28.6	59	26.1	129	27.4	χ2 = 0.61 P = 0.74 DF = 2
Mild	97	39.6	97	42.9	194	41.2
Moderate	78	31.8	70	31.0	148	31.4
Anxiety
Min-Max Mean score ± SD	0–14 6.37 ± 3.24		0–14 4.71 ± 3.06		0–14 5.57 ± 3.26		t = 5.7 P = 0.001* CI = 1.08–2.2
Normal	170	69.4	153	67.7	323	68.6	χ2 = 34.51 P = 0.001* DF = 2
Mild	34	13.9	66	29.2	100	21.2
Moderate	41	16.7	7	3.1	48	10.2
Stress
Min-Max Mean score ± SD	4–30 13.59 ± 5.5		2–30 9.13 ± 4.75		2–30 11.45 ± 5.61		t = 9.4 P = 0.001* CI = 3.5–5.4
Normal	172	70.2	211	93.5	383	81.4	χ2 = 41.87 P = 0.001* DF = 3
Mild	22	9.0	6	2.7	28	5.9
Moderate	42	17.1	7	3.1	49	10.4
Severe	9	3.7	2	0.9	11	2.3

t: Independent sample t test; CI: 95% Confidence interval of the mean difference; χ2: Chi square test; *: statistically significant; DF: degree of freedom.

Regarding anxiety, the mean anxiety score was significantly higher among front-line HCWs compared to second-line ones (6.37 ± 3.24 compared to 4.71 ± 3.06, respectively), where t = 5.7, P = 0.001. Symptoms suggestive of anxiety were reported by 31.4% of studied HCWs. Mild anxiety was more reported among second-line HCWs compared to frontline HCWs (29.2% and 13.9%, respectively) while moderate anxiety was more reported among frontline compared to second-line participants (16.7% and 3.1%, respectively). The difference between front-line HCWs and second-line ones was statistically significant (χ2 = 34.51, P = 0.001).

As for stress, the mean stress score was significantly higher among front-line HCWs compared to second-line ones (13.59 ± 5.5 compared to 9.13 ± 4.75, respectively), where t = 9.4, P = 0.001. Only 18.6% of the included HCWs showed symptoms of different grades of stress which was more reported among front-line HCWs than second-line participants (29.8% and 6.7%, respectively). Moderate stress was the most commonly reported degree of stress (10.4%) followed by mild and severe stress (5.9% and 2.3%, respectively). Mild, moderate, and severe degrees of stress were more significantly reported among front-line HCWs compared to second-line ones (9.0%, 17.1%, and 3.7% compared to 2.7%, 3.1%, and 0.9%, respectively), where χ2 = 41.87, P = 0.001.

As demonstrated by Table 2, analysis of the current results showed that mean depression score of the studied HCWs was significantly higher among those with history of chronic illness, non adherence to strict hand washing, non adherence to mask wearing and adherence to social distancing (t = 3.348 P = 0.001, t = 2.586 P = 0.01, t = 2.71 P = 0.007, and t= −2.1 p = 0.036, respectively).

Table 2. Factors associated with depression, anxiety and stress scores among the study HCWs.

Factors associated with depression, anxiety, and stress scores	Depression score		Anxiety score		Stress score
	Mean±SD	Test of significance	Mean±SD	Test of significance	Mean±SD	Test of significance
Age (n = 471)	11.13 ± 4.11	r = 0.014 P = 0.77	5.57 ± 3.26	r = −0.052 P = 0.257	11.4 ± 5.6	r = 0.048 P = 0.302
History of chronic illness: Yes (n = 167) No (n = 304)	11.97 ± 3.49 10.66 ± 4.35	t = 3.348 P = 0.001*	5.9 ± 3.2 5.4 ± 3.2	t = 1.466 P = 0.143	11.9 ± 5.9 10.6 ± 4.8	t = 2.389 P = 0.017*
History of past COVID-19 infection: Yes (n = 394) No (n = 77)	11.04 ± 4.17 11.56 ± 3.76	t = −1.001 P = 0.317	5.5 ± 3.3 5.9 ± 3.2	t = −0.955 P = 0.34	11.7 ± 5.4 10.1 ± 6.4	t = 2.248 P = 0.025*
Severity of past COVID-19 infection: Mild (n = 192) Moderate (n = 113) Severe (n = 89)	11.23 ± 4.88 10.48 ± 3.57 11.07 ± 3.1	F = 2.348 P = 0.072	5.5 ± 3.6 5.9 ± 2.9 6.2 ± 2.9	F = 3.797 P = 0.01*	10.7 ± 4.8 11.3 ± 4.8 13.5 ± 6.9	F = 3.797 P = 0.01*
Number of COVID-19 cases dealt with daily (n = 471)	11.13 ± 4.11	r= −0.051 P = 0.269	5.57 ± 3.26	r = 0.088 P = 0.058	11.4 ± 5.6	r = 0.423 P = 0.001*
Number of cases among colleagues (n = 471)	11.13 ± 4.11	r= −0.009 P = 0.851	5.57 ± 3.26	r= −0.011 P = 0.81	11.4 ± 5.6	r= −0.055 P = 0.237
Availability of clear COVID-19 protocols: Yes (n = 335) No (n = 52) Do not know (n = 84)	11.17 ± 4.4 11.04 ± 3.8 11.02 ± 2.77	F = 0.075 P = 0.928	5.7 ± 3.5 3.9 ± 2.1 5.6 ± 2.4	F = 7.308 P = 0.001*	11.4 ± 5.6 13.2 ± 7.5 10.5 ± 3.5	F = 7.308 P = 0.001*
Adherence to strict hand washing: Adherent (n = 277) Not adherent (n = 194)	10.7 ± 4.2 11.7 ± 3.9	t = 2.586 P = 0.01*	4.9 ± 2.4 6.5 ± 3.9	t = 5.161 P = 0.001*	12.7 ± 5.7 9.7 ± 4.9	t = 5.883 P = 0.001*
Adherence to mask wearing: Adherent (n = 322) Not adherent (n = 149)	10.8 ± 4.04 11.9 ± 4.16	t = 2.71 P = 0.007*	5.2 ± 2.8 6.3 ± 4.0	t = 3.436 P = 0.001*	11.7 ± 5.9 10.8 ± 4.8	t = −1.634 P = 0.108
Adherence to social distancing: Adherent (n = 112) Not adherent (n = 359)	11.8 ± 4.1 10.9 ± 4.1	t= −2.1 P = 0.036*	4.9 ± 2.8 5.8 ± 3.4	t = 2.399 P = 0.017*	11.2 ± 5.8 11.5 ± 5.5	t = 0.417 P = 0.677

r: Pearson correlation coefficient; t: Independent sample t test; F: Analysis of Variance (ANOVA) test; *: statistically significant.

Moreover, the current study highlighted the following factors that significantly affected the mean anxiety score among the study HCWs; severe forms of past COVID-19 infection, availability of clear COVID-19 protocols in workplace, non-adherence to strict hand washing, mask wearing and social distancing (F = 3.797, P = 0.01, F = 7.308, P = 0.001, t = 5.161, P = 0.001, t = 3.436, P = 0.001, and t = 2.399, P = 0.017, respectively).

The current study revealed significant positive correlation between stress score among the studied HCWs and number of COVID-19 cases dealt with daily r = 0.423, P = 0.001. Furthermore, the mean stress score among the studied HCWs was significantly higher among those with positive history of chronic illness, past history of COVID-19 infection, severity of past COVID-19 infection, non-availability of clear COVID-19 protocols in workplace and adherence to strict hand washing (t = 2.389, P = 0.017, t = 2.248, P = 0.025, F = 3.797, P = 0.01, F = 7.308, P = 0.001, and t = 5.883, P = 0.001, respectively) (Table 2).

5.3. Burnout syndrome and coping strategies in workplace

Table 3 showed that burnout syndrome was reported by 86.4% of the study HCWs in the studied settings. Regarding burnout levels, moderate and severe levels of burnout syndrome were highly reported among front-line HCWs compared to second-line participants (61.2% compared to 8%, 13.5% compared to 10.6%, respectively). On the other hand, mild level of burnout syndrome was more encountered among second-line HCWs (65.9%) compared to front-line ones (13.5%). These differences were statistically significant where χ2 = 179.16, P = 0.001.

Table 3. Distribution of the studied HCWs as regard levels of burnout syndrome.

Burnout syndrome	Front-line HCWs (n = 245)		Second-line HCWs (n = 226)		Total (n = 471)		Test of significance
	N	%	N	%	N	%
Burnout levels among HCWs
Absent	29	11.8	35	15.5	64	13.6	χ2 = 179.16 P = 0.001* DF = 3
Mild	33	13.5	149	65.9	182	38.6
Moderate	150	61.2	18	8.0	168	35.7
Severe	33	13.5	24	10.6	57	12.1

χ2: Chi square test; *: statistically significant; DF: degree of freedom.

Table 4 showed that the most common organizational interventions adopted by the studied settings against work-related stressors, as reported by the study HCWs, were increased workforce (41.6%), frequent staff meetings (32.3%), shifts rescheduling (31.4%), frequent breaks during the working day (29.1%), and staff training (16.8%). Frequent staff meetings, as an organizational intervention against work-related stressors, were more significantly reported by front-line HCWs (36.3%) compared to second-line HCWs (27.9%), where χ2 = 3.84, P = 0.05. On the contrary, frequent breaks during the working day, as an adopted organizational intervention, was more significantly reported among second-line participants (χ2 = 28.45, P = 0.001).

Table 4. Distribution of the study HCWs as regard coping strategies and adopted interventions against stressors in their workplace.

Coping strategies and adopted interventions	Front-line HCWs (n = 245)		Second-line HCWs (n = 226)		Total (n = 471)		Test of significance
	N	%	N	%	N	%
Organizational interventions in workplace to prevent or manage work-related stressors**
Increase workforce	95	38.8	101	44.7	196	41.6	χ2 = 1.69 P = 0.19
Frequent meetings with staff	89	36.3	63	27.9	152	32.3	χ2 = 3.84 P = 0.05*
Shifts rescheduling	27	29.4	76	33.6	148	31.4	χ2 = 0.98 P = 0.32
Frequent breaks during working day	45	18.4	92	40.7	137	29.1	χ2 = 28.45 P = 0.001*
Staff training	36	14.7	43	19.0	79	16.8	χ2 = 1.58 P = 0.21
Individual interventions adopted by HCWs to prevent or manage work-related stressors**
Following strict protective measures	138	56.3	161	71.2	299	63.5	χ2 = 11.28 P = 0.001*
Gaining knowledge	173	55.9	118	52.2	255	54.1	χ2 = 0.65 P = 0.42
Avoid media news	134	54.7	77	34.1	211	44.8	χ2 = 20.22 P = 0.001*
Relaxation activities	108	44.1	67	29.6	175	37.2	χ2 = 10.49 P = 0.001*
Support from family and friends	71	29.0	72	31.9	143	30.4	χ2 = 0.46 P = 0.49
Physical activity	74	30.2	62	27.4	136	28.9	χ2 = 0.44 P = 0.06
Days-off	79	32.2	53	23.5	132	28.0	χ2 = 4.51 P = 0.03*
Cognitive behavioral therapy (CBT)	56	22.9	52	23.0	108	22.9	χ2 = 0.002 P = 0.97

χ2: Chi square test: *: statistically significant; **: Categories are not mutually exclusive.

In addition to organizational interventions against work-related stressors, several interventions were individually adopted by HCWs to manage stressors in workplace. The most commonly reported individual interventions were following strict protective measures (63.5%), gaining more knowledge about COVID-19 (54.1%), avoiding media news (44.8%), and relaxation activities such as prayers, music, and meditation (37.2%). On the other hand, the least commonly adopted individual interventions were cognitive behavioral therapy (CBT), days-off and physical activity (22.9%, 28%, and 28.9%, respectively). Following strict protective measures was significantly more reported among second-line HCWs compared to front-line participants (71.2% and 56.3%, respectively), where χ2 = 11.28, P = 0.001. On the other hand, avoiding media news were significantly more reported among front-line HCWs (54.7%) compared to second-line participants (34.1%), where χ2 = 20.22, P = 0.001. Besides, relaxation activities were also significantly more reported among front-line HCWs compared to second-line participants (44.1% and 29.6%, respectively), where χ2 = 10.49, P = 0.001. Moreover, days-off, as an individually adopted intervention against work-related stressors, was significantly more reported among front-line HCWs (32.2%) compared to second-line personnel (23.5%), where χ2 = 4.51, P = 0.03.

6. Discussion

The current study revealed that HCWs complained of varying degrees of depression, anxiety and stress. Symptoms suggestive of depression were identified among 72.6% of participants, while anxiety and stress were less commonly identified (31.4%, 18.6%, respectively). These results were somehow different from the results of another study conducted in Kosovo in 2022. According to this study, 13.9% of HCWs showed symptoms suggestive of depression, while anxiety and stress were identified in 13% and 21.9% of HCWs, respectively [14]. Moreover, another study was conducted in 2023 and it enrolled HCWs working in the middle east. This study revealed that 70.9% of enrolled HCWs showed symptoms of depression. The prevalence of anxiety and stress among them was estimated to be 68.1% and 61.5%, respectively [15].

The high prevalence of psychological burden in general, and depression in particular in the current study compared to other studies could be justified through the fact that HCWs were already exposed to several psychological, social and occupational factors. In other words, HCWs in Egypt were already working in stressful and unfavorable working conditions which rendered them much vulnerable to depression and other features of psychological burden. Therefore, the current pandemic status had exaggerated the preexisting psychological burden among HCWs. Moreover, psychological profile of HCWs greatly varied with passage of time since emergence of the pandemic. More understanding of the nature of COVID-19 virus, variations in clinical profile with different COVID-19 waves, and the introduction of COVID-19 vaccines were important contributing factors to variations in HCWs’ psychological response toward the pandemic.

The current study revealed that depression among enrolled HCWs was influenced by several risk factors. Presence of history of chronic illness, non-adherence to proper hand hygiene and mask wearing, and adherence to social distancing were associated with increase in the mean depression score among the enrolled HCWs. Depression among HCWs during the pandemic was investigated by several studies. For example, a Mexican study conducted in 2023 identified history of chronic illness as a risk factor for depressive symptoms among HCWs [16]. Moreover, another study was conducted in 2021, which enrolled HCWs from Pakistan, India, and Sri Lanka. This study stated that lack of satisfaction with preventive measures and presence of COVID-19-positive cases among family members was contributing to occurrence of depressive symptoms among HCWs [17]. In general, adherence to COVID-19 preventive behaviors had a varying impact on depression risk among HCWs. Some HCWs might be relieved by being adherent to preventive behaviors, thus decreasing the risk of depression among them. On the other hand, being adherent to these precautions while living under the stressful conditions of the pandemic might contribute to occurrence of depressive symptoms among a considerable part of HCWs. In other words, adherence to preventive precautions could decrease mean depression score among some HCWs while increasing the mean score among others. On the other hand, depression status itself could render HCWs reluctant which could influence their adherence to COVID-19 preventive precautions.

Regarding anxiety among the enrolled HCWs, multiple risk factors were investigated in the current study. Higher anxiety score was associated with increasing severity of past COVID-19 infection, lack of COVID-19 clear protocols in workplace and non-adherence to strict hand hygiene, mask wearing and social distancing. Other risk factors were discussed through other studies. In 2020, a wide scale study included HCWs from 48 states in USA revealed that anxiety was more reported among HCWs who isolated themselves during the pandemic, moved to another residence and those who continued to live with family members [18]. Opposite to the results of the current study, adherence to preventive precautions was an associated factor with anxiety among HCWs.

As for risk factors of stress among enrolled HCWs in the current study, increase in mean stress score was associated with presence of history of chronic illness, history of past COVID-19 infection, increasing severity of past infection, increasing number of COVID-19 patients dealt with daily in workplace, absence of COVID-19 protocols and adherence to strict hand washing. Other studies had reported several risk factors for stress among HCWs during the pandemic. In 2020, a wide scale study enrolled 1833 HCWs all over Turkey revealing that stress symptoms were more reported among HCWs who were isolated, had history of COVID-19 past infection and feared spreading infection to family members [19]. Moreover, another study conducted in USA in 2022 identified other risk factors for stress such as lack of support and increased work duties and occupational demands [20].

One of the most significant findings revealed by the current study was that enrolled HCWs were greatly exposed to burnout syndrome. According to the systematic review conducted in Italy in 2021, the prevalence of burnout was estimated to be ranging from 49.3% to 58% [11]. Nearly similar results were obtained by a Japanese study conducted in 2021, which stated that 50% of HCWs showed symptoms of burnout syndrome [21]. Lower prevalence was estimated by a Spanish Meta-analysis conducted in 2022, which stated that 37% of HCWs were suffering from symptoms suggestive of burnout syndrome [22]. However, the current study revealed that 86.4% of HCWs suffered varying degrees of burnout syndrome. Mild, moderate, and severe levels of burnout were identified among enrolled participants (38.6%, 35.7%, and 12.1%, respectively).

The high prevalence of burnout could be explained. HCWs in the current study were already suffering from varying levels of burnout syndrome due to multiple personal, emotional and social factors as well as stressful standard working and living conditions. Severe work overload, continuous fear of catching and transmitting the infection and shortage of resources have greatly increased the preexisting levels of burnout among HCWs. Also, care for severely ill patients, making difficult decisions and dealing with patients and relatives in unfavorable circumstances have exaggerated burnout among HCWs. In other words, COVID-19 pandemic had exaggerated the already existing burnout suffered by HCWs.

Compared to other studies, the high prevalence of burnout in the current study reflected the burnout status among HCWs, generally in Egypt, where HCWs were already experiencing unsuitable and unfavorable working condition with lack of support, appreciation, and protection. In other words, the pandemic had increase burnout levels among HCWs who were already suffering from high levels of burnout.

Burnout and work-related stressors in workplace were managed by HCWs through multiple organizational and individual coping procedures. According to the current study, the most common organizational interventions adopted in workplace to prevent or manage work-related stressors were increasing workforce (41.6%), frequent staff meetings (32.3%), shifts rescheduling (31.4%), frequent breaks during working day (29.1%), and staff training (16.8%). As for the individual interventions adopted by HCWs, following strict protective measures, gaining more knowledge, avoiding media news, relaxations activities, and support from family and friends were most commonly reported (63.5%, 54.1%, 44.8%, 37.2%, and 30.4%, respectively).

Same coping interventions were investigated by other studies. According to a Canadian study conducted in 2021, the most commonly adopted organizational interventions were psychological counseling, continuous support and clear communication with administration and coping training. As for individual interventions, most HCWs reported receiving support from friends and family members and doing relaxation activities such as sitting in nature, eating favorite food and practicing desired hobbies. These organizational and individual adopted interventions were perceived useful in coping with work-related stressors [23]. Moreover, organizational measures such as infection control and workplace safety as well as individual interventions such as positive thinking were also adopted by HCWs against work-related stressors, as reported by a study conducted in Singapore in 2020 [24].

7. Conclusion

Healthcare workers were exposed to considerable levels of depression, anxiety, and stress, with anxiety and stress being more significantly encountered among front-line compared to second-line HCWs. Moreover, burnout syndrome was highly encountered by HCWs with moderate and severe burnout more significantly reported by front-line HCWs compared to second-line HCWs. Increasing workforce, frequent staff meetings, and shifts rescheduling were the most commonly adopted organizational measures against work-related stressors. On the other hand, following strict protective measures, gaining knowledge, and avoiding media news were the most commonly adopted individual measures against stressors in workplace.

8. Recommendations

Extra care should be provided to HCWs specially in the era of the pandemic. Periodic assessment of psychological profile of HCWs is highly needed in order to monitor their psychological well-being as well as their possible exposure to burnout syndrome. It is essential to provide continuous support and training for HCWs to handle work-related stressors and preserve their psychological integrity. Coping measures should be adopted by health authorities in workplace on a wider scale. Moreover, clear policies and regulations should be established by policy makers regarding preserving psychological well-being of HCWs and managing work-related stressors in workplace.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Nadia Abd EL-Monem El-Zeiny

Prof. Nadia Abd El-Monem El-Zeiny, Department of Community Medicine.

Eman Ahmed Fawzy Darwesh

Prof. Eman Ahmed Fawzy Darwesh, Department of Community Medicine.

Heba Mahmoud Taha Elweshahi

Prof. Heba Mahmoud Taha Elweshahi, Department of Community Medicine.

Andrew Malak Tawfik Michael

Dr. Andrew Malak Tawfik Michael, assistant lecturer, Department of Community Medicine, faculty of medicine, Alexandria university.