The present study highlights elevated stress levels in a cohort of Italian-speaking hospital workers during the early phases of the outbreak of Sars-Cov2 infection due to the novel CoVid-19. To best of our knowledge, our study was the earliest to explore the psychological impact of this novel pandemic on healthcare workers among Italian speaking countries (Italy and Italian-speaking regions of Swizerland).
Hospital workers have engaged with catastrophic events caused by the massive CoVid-19 outbreak [11]. Beyond demanding clinical and logistic issues, hospital employees have to deal with their own physical and mental health [11–15]. Work-related stress has shown to impact physician's mental health, patients’ care quality and the efficiency of the healthcare system [16]. Consequences in terms of mental health in the context of maxi-emergency situations may be even more pronounced than normal. Feelings of inadequacy, insufficiency, lostness or confusion are common and hospital workers may even experience negative behavioral reactions, depression and illness, possibly leading to lack of effectiveness and efficiency at work [4–6].
The large number of responses and the small percentage of uncompleted surveys (2,7%) in less than 40 hours advocates for a high interest in the subject among healthcare personnel. This may also express the need among healthcare workers to communicate, to be heard and understood that encompasses professional attitude and rules of conduct and touches the psyche and emotions.
More than 50% of survey participants were physicians, probably because the survey promoters were physicians both in southern Switzerland and northern Italy and invitations to participate were sent through personal contacts and social media. However, the high turnout rate of several other hospital categories could mirror the concept that the present is a common burden among all health workers.
Demographics, social and working distribution
The population aged 26–45 represents the majority of the sample, probably because it is are more likely to be reached by social media. The small number of people aged between 18–25 is likely to reflect the relatively low number of very young people working in hospitals as confirmed by the fact that medical trainees under 26-years of age are not yet medical doctors in Italy and Switzerland. The distribution of worked years in hospital roughly reflects the age distribution.
In our sample, two thirds of survey participants were female. This could be interpreted according to the fact that a growing percentage of medical professionals is represented, nowadays, by women. It could be also speculated that gender differences may play a role in stress perception and management. Hormonal differences in hypothalamic-pituitary-adrenal axis and autonomic nervous system response are well-known. It has been hypothesized that females tend to experience more frequently anxious and depressive states (also with physical symptoms), being more aware of potential stressors rather than men [17] In our sample, percentages of married, single, divorced etc. and other demographic characteristics were grossly comparable to the Swiss and Italian population [18, 19].
Nearly one third of hospital workers in our study had to increase their working activity. It represents the first, well-recognized stress factor, proportional to the increase of worked hours [20]. As expected, health care professionals having to increase their working hours, are those employed either in critical care settings or general practitioners, the first categories having to be confronted with the CoVid-19 emergency. On the other hand, in several hospitals in northern Italy and southern Switzerland a dramatic reduction of surgical elective cases and outpatient clinic activity has been deemed necessary to contain virus spread and, as a consequence, surgeons as a category experienced a reduction in working hours. Notwithstanding, a reduction of working hours should not be considered less insidious, as it could nonetheless jeopardize the mental status and could lead to depressive symptoms, hopelessness and uselessness [21].
Stress symptoms
Sleep disturbances can be caused by stress and be related to post-traumatic stress disorder and the first response is generally considered a period of arousal and wakefulness [22, 23]. A great proportion of hospital workers in our study declared to sleep less than normal and to feel less restored by sleep in general, presumably as a reaction to the stressful circumstances and it is likely to reflect the high prevalence of sleep arousal and anxiety symptoms in healthcare professionals.
The correlation analysis showed a relatively higher prevalence of stress symptoms among young professionals with at least one child to care of, as response of having to face the CoVid-19 outburst emergency.
Similarly, an increase or a decrease in in food intake may mirror a reaction to a stressful situation and, actually, in our sample, only 40% of the interviewed reported no change [24]. Moreover, among smokers, there was a high proportion of participants that declared to have increased the number of cigarettes per day in the first three weeks since the outbreak onset. A smaller, but significant proportion of people reported an increase in alcohol consumption. All these behavioral changes can be considered stress symptoms [25, 26]. In our study, a strong correlation was found between the above-mentioned symptoms and the need for psychological support. In fact, people reporting such symptoms were more prone to report the need for psychological support. As far as we know, this is the first time that such a need is quantified within the emergency of CoVid-19.
Need for psychological support
Interestingly, people with children reported the most stressful answers and felt the need for professional psychological support more often than their not-parenting peers. Despite some might consider this obvious, such data are nonetheless of outstanding importance, as hospital employees are often in the fertile age range. In the setting of a massive viral outbreak, hospital caregivers experience important issues in caring for their children because of the closure of schools and of other facilities. Parents probably do not experience only the stress related to future uncertainty but also the fear of getting infected and possibly transmit such an infectious disease to their offspring. Specifically, CoVid-19 has shown to be particularly infective also for hospital workers and casualties have been reported among hospital staff [12]. Coherently, many hospital workers with children (nearly 95%) declared to have reduced their physical contacts with other family components.
Almost all subcategories of hospital workers perceive the stress related to the outbreak equally. Only long-career workers and ambulance service personnel reported to need psychological support less as compared to other categories. This may be explained by the high level of experience and long-standing training in stress management in long-career employees. On the other hand, emergency services personnel may be used to address stressful situations, as they are part of a coordinated and ordered emergency response and have to constantly handle very high levels of stress [27, 28].
The actual outbreak could be a repeated trauma for many healthcare categories, putting them at risk of psychiatric sequelae such as PTSD [8, 29]. The present outbreak could be a repeated trauma for many health professionals and could put them at risk of developing psychiatric sequelae such as post-traumatic stress disorder. It is of outstanding importance in such a critical situation to promptly implement measures to mitigate the impact of the emotional burden of the present COVID-19 pandemic while at the same time dealing with its clinical challenges [2, 4].
In particular, positive behaviors such as healthy eating, sport practicing and sleeping an adequate number of hours have shown to impact and reduce the impact of stress [30]. Many other strategies have also shown to be effective, such as the implementation of debriefing sessions and group therapies to share experiences and relieve the sorrow related to challenging and stressful situations. Programs of de-escalation of tension through mindfulness techniques could be also cost-effective and easily implemented in routine practice to prevent future development of acute and chronic PTSD, major depression or suicidal behaviors [31, 32].
Our study has some limitations. Firstly, our data were collected in a completely anonymized and we have not certainty on their truthfulness. Nonetheless, our data denote a certain internal coherence, that can be interpreted as trustworthiness. Secondly, it can be considered an initial evaluation and further studies in different time points of the outbreak are needed to understand the impact of CoVid-19 emergency on healthcare workers’ psychology and mental health. Thirdly, our sample is mainly (but not exclusively) composed of physicians and that could lead to a selection bias among the different hospital working categories and may not entirely reflect the actual global status.