How did the psychological impact of COVID-19 change healthcare workers in times of fighting the pandemic?

1Introduction

While the coronavirus disease 2019 outbreak (COVID-19) continues as a serious public health problem worldwide, according to the World Health Organization (WHO) data, 2.581.976 people died at the time of writing this article [1]. The number of cases is increasing rapidly in many countries. Millions of people around the world have been and continue to be psychologically affected. Within this population, healthcare workers (HCWs) who worked in COVID-19 units, were quarantined, or had friends infected with coronavirus experienced significantly more anxiety, depression, frustration, fear, and post-traumatic stress than those without such experience [2]. Initial studies came from China, where the disease was first seen, and it was reported that depression (50.4%), anxiety (44.6%), insomnia (34.0%), and a sense of distress (71.5%) were observed in a significant portion of the HCWs [3]. In subsequent studies and meta-analyses, results supporting these data were obtained [4–6].

In the last 20 years, new infectious disease outbreaks such as SARS (2002) and H1N1 (2009) influenza pandemics have been observed worldwide, and during these processes, anxiety, depression, and distress have been detected at high rates in HCWs [7]. Therewithal, anxiety, and degree of anxiety have been significantly associated with intentional absenteeism, restriction of social contacts, and psychological distress [7]. The COVID-19 pandemic has been on the agenda for approximately 14 months, and it is understood that it has already lasted longer than the SARS and H1N1 pandemics. There is no study on what the psychological effects of the prolongation of the process will be or whether there will be a change in reactions.

With the detection of the first case of COVID-19 in China, many healthcare professionals and people were exposed to a psychological effect even without encountering the cases, with the effect of the widely used information sources of the age (social media; Twitter, Youtube, Instagram). In the first leg of this study, our working group investigated and reported stress, anxiety, depression, sleep quality, and influencing factors in volunteer HCWs from different groups who do not have secondary trauma to COVID-19 in the period between the first cases in Turkey until the first case in the hospital. It was shown that 29.6% of the participants had psychological effects even before the epidemic was seen in the hospital.

In this study, approximately 3 months after the arrival of the first case in the hospital, we reached the HCWs in the first leg sample and we aimed to investigate whether the psychological effects such as stress, anxiety, and depression and sleep quality changed after exposure to the work (physical) burden and secondary traumas of the epidemic.

2Materials and methods

3Results

A total of 110 hospital workers, 65 men, and 45 women, were included in our study. The average age of the participants was 33.90±6.62 years. Sociodemographic data such as marital status, position, and smoking status are given in Table-1. DASS-21, IES-R and PSQI tests and the scores of the first and second legs of the study are given in Table-2.

There was no statistically significant difference between DASS-21, IES-R, and PSQI total scores as a result of the comparison of DASS-21, IES-R and PSQI tests and their sub-dimensions between the legs of the study (p = 0.679, p = 0.390 and p = 0.717, respectively). When the subdimension scores were compared, there was no statistically significant difference except for PSQI subdimension 4 (sleep efficiency) and 6 (hypnotic drugs) (p = 0.033 and p < 0.001, respectively).

The scores of the participants in the first and second leg of the study were compared; There was a statistically significant decrease in DASS-21 total, DASS-21 anxiety, and IES-R total scores in the academic member group only (p = 0.020, p = 0.028 and p = 0.043, respectively). The levels of the assessment scored have been reported in the first leg of the study [18]. We had found that 15.4% of HCWs were affected mildly, 4.7% moderately and 9.5% of them severely and 42.6% of HWs had a poor sleep quality.

4Discussion

Psychological problems that develop in healthcare workers due to the rapid spread of COVID-19 disease, uncertainty, unpredictability, workplace safety and lack of adequate support mechanisms were demonstrated in our first cross-sectional study [18]. Here, we compared the psychological symptoms of HCWs such as stress, anxiety, depression, and sleep quality before and after the arrival of the first case in the hospital.

Our results showed that the total scores of the scales (DASS-21, IES-R, and PSQI) which evaluate depression, anxiety, stress, the impact of events and sleep quality applied after the COVID-19 cases were seen in the hospital partially increase compared to the first applied scores. However, there was no statistically significant difference. It was determined that only PSQI subdimension 4 (sleep efficiency) and 6 (hypnotic drugs) of the subscales increased statistically significantly after the case was seen in the hospital. This means that sleep efficiency increased but the need for the hypnotic drugs increased together.

The negative psychological effects of the COVID-19 pandemic on HCWs have been shown in studies conducted in many countries around the world [2–5, 19]. In a study conducted in China, among 1563 healthcare professionals, the rates of stress-related symptoms were 73.4%, depression 50.7%, anxiety 44.7%, and insomnia rates 36.1% [20]. In a study conducted with 442 healthcare professionals in our country, it was reported that 286 (64.7%) of the participants had depression, 224 (51.6%) had anxiety and 182 (41.2%) had stress symptoms [4]. When a previous epidemic was reviewed, it was found that those who were quarantined among HCWs, who worked in SARS units or had family or friends infected with SARS, experienced much more anxiety, depression, frustration, fear and post-traumatic stress than those who did not [21]. The data in the first leg of our study are already compatible with the literature and it has been shown that % 15.4 HWs were psychologically affected mildly, % 4.7 moderately, % 9.5 severely. According to PSQI scale % 42.6 (72) of HWs had poor sleep quality in those results. This information shows that mental health is affected globally.

The amount of information about the novel coronavirus is increasing day by day, and more data is collected worldwide on its route of transmission, reservoirs, incubation time, symptoms, and clinical outcomes [22]. However, the change in mental influence during this process is neglected. After the first cases seen in Turkey and after our study we apply to cases seen in our hospital health workers DASS-21, IES-R and has tried to show psychological changes that are effective with PSQI scales. There was no significant change in DASS-21, IES-R and PSQI scores before and after the first case

seen in the hospital. We think these results may be related to more than one factor. The first of these is the importance of information about the new coronavirus and video-based news in international, national and local media sources with the first case seen in Wuhan and the height of the traumatic impact caused by this news. Secondly, it is the sharing of individual bad experiences of patients and healthcare professionals who are infected with the virus from social media sources and their rapid spread. For eg, we had shown that 74.6 of the HCWs provided information about coronavirus via social media during the pandemic [18]. Third, the majority of HCWs were worried that COVID-19 would spread to their family members through them [11]. Forth, stress might continue similarly because of increased workload [23]. Although there were no cases in the hospital yet, sharing about the new coronavirus disease in social media, especially WhatsApp groups of health personnel that includes from Turkey’s metropolitan areas may have led to the anxious expectation. Another one is especially important for healthcare professionals; Intensive care occupancy observed in some of the European countries, having to choose patients for a ventilator and decompensation of the health system. Taking steps that verify the seriousness of the situation in our country has initiated a rapid transformation and adaptation process in the health system. To increase the hospital capacity of COVID-19 patients, many inpatient units have been transformed into COVID-19 related services in our hospital as in all Country [24]. All of them can cause people in the healthcare system to be more traumatized than the normal population, even without facing COVID-19. Because increased workload found to affect health complaints and depressive states of workers [23]. The similarity of the level of psychological influence before and after COVID-19 cases in the hospital suggests that expectancy anxiety can affect HCWs similarly to situational anxiety.

PSQI sleep efficiency and hypnotic drugs, which are sub-dimension scales, differed significantly after the occurrence of a case in our hospital compared to before. It can be said that with the process, sleep quality decreases and the need for hypnotic drugs increases and sleep efficiency may be increased by the intake of sleeping pills. In a study conducted in Wuhan, where the new coronavirus disease first appeared, it was found that personnel with heavy loads received direct help from psychiatrists and psychologists [25]. In our study, the increased need for hypnotic drugs shows that healthcare professionals need and receive medical help.

It was observed that there was a statistically significant decrease in DASS-21 total, DASS-21 anxiety, and IES-R total scores only in the academic member, this group had higher education levels and read more scientific publications, so they might be less exposed to disinformation. It has been shown by studies that the number of research conducted in such conditions increases and that more scientific evidence is needed [26].

As a result; the psychological outcomes of the COVID-19 pandemic on health care workers emerged after the outbreak reached in Turkey, seems to continue in a similar way, Although the increase in COVID-19 positive patients in the hospital where they work and the follow-up of these patients. The anxiety of what may arise after the epidemic has largely affected HCWs, and there is no significant increase in this psychological response during the fight against the pandemic. Measures to protect the mental health of healthcare professionals should start with the epidemic at the same time with fighting the epidemic. Online therapies, e-psychological support programs may be effective to reduce the stress levels of HCWs during a pandemic. Keeping the shifts short, increasing the number of HCWs during pandemics, and balancing the workload between workers can also reduce the stress level. In taking these measures, attention should be paid to the power of news and social media and necessary regulations should be made.