Burnout and psychological distress amongst Australian healthcare workers during the COVID-19 pandemic

Objective: To examine psychological distress in healthcare workers (HCWs) during the COVID-19 pandemic in April–May 2020. Methods: A cross-sectional survey examining demographic, employment and mental health characteristics of HCWs in a large metropolitan hospital in Australia. Results: HCWs showed significant symptoms of moderate-severe level depression (21%), anxiety (20%) and posttraumatic stress disorder (PTSD; 29%), associated with burnout, prior psychiatric history, profession and resilience. Conclusion: Despite low levels of COVID contact, moderate to high levels of psychological distress were reported. Continued monitoring and support for HCWs’ mental well-being is warranted as the COVID-19 pandemic develops.

exposure, profession, past psychiatric history and measures of burnout.

Methods
A cross-sectional survey was conducted between 16 April and 13 May 2020 amongst staff at a major tertiary hospital in Melbourne, Australia. In anticipation of the COVID-19 pandemic, major hospital preparations including ward repurposing and staff redeployment occurred alongside mandated restriction of social contact outside hospital. The survey closed at a time that initial social distancing practices were being relaxed in Australia.
The Hospital Ethics Committee approved the study (project ID 204/20). Participants were recruited via wellbeing workshops in front-line departments, followed by targeted emails, posters and word of mouth. Written information was provided to participants and electronic consent obtained. The survey was anonymous; however, participants had the opportunity to engage with a psychiatric clinician following the survey.
Demographic data were reported, including occupation (senior medial staff, junior medical staff, nursing, allied health, other), gender (male, female, non-binary), age, past psychiatric history and years of experience. Participants who reported direct contact with COVID-19 patients were defined as 'front-line'. 'High-exposure environments' were classified as the emergency department (ED), intensive care unit (ICU), respiratory medicine and infectious diseases departments.
The primary outcome was self-reported levels of psychological distress (symptoms of depression, anxiety and PTSD) experienced during the 2 weeks prior to the survey. The nine-item Patient Health Questionnaire (PHQ-9; range 0-27), 10 seven-item Generalised Anxiety Disorder scale (GAD-7; range 0-21), 11 22-item Impact of Event Scale-Revised (IES-R; range 0-88), 12 10-item Connor-Davidson Resilience Scale (CD-RISC10, range 0-40), 13 and Stanford Professional Fulfilment Index (PFI; burnout range 0-40) 14 were used to assess the severity of symptoms of depression, anxiety, PTSD, resilience and burnout, respectively. The total scores of these instruments were interpreted as per previously validated cut-offs. [10][11][12][13][14] We calculated descriptive statistics, including means and percentages. Contingency table analyses, using χ 2 tests of independence, were used to investigate the relationship between nominal variables, and t-tests were used for continuous variables. General linear models (GLMs) were used to investigate the predictors of psychological outcome variables. Continuous variables were centred prior to analysis and categorical variables were dummycoded after choosing a sensible reference class. Omnibus F tests were used for null hypothesis significance testing of overall model effects, with effect sizes reported as partial eta squared (η p 2 ). Unstandardised model coefficients with 95% confidence intervals were computed for key models. Care was taken to assess for statistical assumptions, including the distribution of model residuals where necessary. All statistical analyses were performed using Jamovi (version 1.2) 15 and R (version 3.6.3). 16
Two hundred and forty-one participants (75%) had at least 5 years of clinical experience and 121 participants (39%) were front-line workers. Medical and nursing staff were more likely to be in direct contact with COVID-19 patients than other professions (χ 2 (4) = 81.7, p < 0.001, Table 1).
Eighty-three participants (29.5%) screened positively for symptoms of burnout. Rates of burnout, depression, anxiety and PTSD differed across the professions sampled; senior medical staff reported the lowest levels of psychological distress.
Front-line workers reported high levels of resilience when compared with other HCWs and no greater severity of psychological distress (Table 3) Table 4).  Note. GAD-7 = seven-item Generalised Anxiety Disorder; IES-R = Impact of Event Scale-Revised; PHQ-9 = nine-item Patient Health Questionnaire.

Discussion
We report the first study, to our knowledge, of mental health outcomes amongst Australian HCWs during the COVID-19 pandemic. A substantial proportion of HCWs self-reported moderate-to-severe symptoms of depression, anxiety and PTSD (21%, 20% and 29%, respectively). This was comparable to published rates reported by countries severely affected by the COVID-19 pandemic, 8,9 and to those reported in the Australian public around the same time. 17 Similar to these reports, this study doesn't allow comparison to pre-pandemic baseline data. However, previous research suggests HCWs experience higher rates of anxiety and depression when compared with the general population. 2,3 Psychological distress in HCW may develop in response to a range of stressors: risk of personal infection, fear of spreading the illness to family and friends, inadequate access to personal protective equipment and moral distress. 18 Our survey found working in front-line settings was not associated with increased risk of psychological distress. This could be because distress related to COVID-19 extended beyond one's occupational exposure risk, which at the time of the survey was low, to a general preoccupation with the pandemic, its uncertain future course, socio-economic and lifestyle impacts, exposure to media and the limitation of social supports. 5 This highlights the importance of making supports flexible and available to all HCWs, not just front-line workers.
Data from previous epidemics and abroad during COVID-19 have identified disparate mental health  impacts amongst different professionals. 5,9 In our study, senior medical staff reported lower rates of psychological distress than other staff. This is consistent with beyondblue survey data, showing senior doctors report less psychological distress than their less senior colleagues. 2 There is limited research examining the relationship between mental health outcomes and a pre-existing mental illness during the COVID-19 pandemic. Cardozo et al. 19 reported that a history of mental illness increased the risk of psychological distress following deployment in humanitarian workers. Our study supported this finding, identifying past psychiatric history as predictive for reporting symptoms of anxiety, depression, PTSD and burnout.
This study also investigated the relationship between resilience, burnout and symptoms of psychological distress. The relationship between burnout and mental illness remains unclear; 4 however, recent research suggests burnout increases the risk of developing depression and PTSD. 6 In our study, 29.5% of participants screened positively for burnout, and symptoms of burnout were predictive of psychological distress.
Psychological resilience mediates the stress response to trauma. High levels of psychological resilience are protective against the development of mental illness, 20 and this was reflected in this study. Recent research has considered introducing resilience training as a preventative treatment for reducing mental health outcomes amongst first responders. 20 Similar strategies could be developed for HCWs in anticipation of future public health emergencies.
Our study had some limitations. Cross-sectional studies don't allow tracking of changes in psychological distress following the onset and escalation of the pandemic. Our dissemination strategy precluded a formal response rate calculation. A large number of responses were excluded due to incomplete data. Selection bias and response bias may have resulted in an overestimation or underestimation of psychological distress and rates of pre-existing psychiatric history.