key: cord-256504-odbaubqm
authors: Kuo, Fang‐Li; Yang, Pei‐Hsuan; Hsu, Hsin‐Tien; Su, Che‐Yu; Chen, Chun‐Hsien; Yeh, I‐Jeng; Wu, Yen‐Hung; Chen, Li‐Chin
title: Survey on perceived work stress and its influencing factors among hospital staff during the COVID‐19 pandemic in Taiwan
date: 2020-08-19
journal: Kaohsiung J Med Sci
DOI: 10.1002/kjm2.12294
sha: 
doc_id: 256504
cord_uid: odbaubqm

This study aimed to investigate the perceived work stress and its influencing factors among hospital staff during the novel coronavirus (COVID‐19) pandemic in Taiwan. A web‐based survey was conducted at one medical center and two regional hospitals in southern Taiwan, targeting physicians, nurses, medical examiners, and administrators. The questionnaire included items on the demographic characteristics of hospital staff and a scale to assess stress among healthcare workers caring for patients with a highly infectious disease. A total of 752 valid questionnaires were collected. The hospital staff reported a moderate level of stress and nurses had a highest level of stress compared to staff in the other three occupational categories. The five highest stress scores were observed for the items “rough and cracked hands due to frequent hand washing and disinfectant use,” “inconvenience in using the toilet at work,” “restrictions on eating and drinking at work,” “fear of transmitting the disease to relatives and friends,” and “fear of being infected with COVID‐19.” Discomfort caused by protective equipment was the major stressor for the participants, followed by burden of caring for patients. Among participants who experienced severe stress (n = 129), work stress was higher among those with rather than without minor children. The present findings may serve as a reference for future monitoring of hospital staff's workload, and may aid the provision of support and interventions.

The novel coronavirus pneumonia Taiwan, to prevent disease spread, the government ordered the closure of a hospital due to severe cross infection. Healthcare workers rushed out of the blockade line due to insufficient protective equipment and fear of the disease, which resulted in fear of the pandemic among medical staff and the public. As the COVID-19 pandemic continues to grow, the collective memory of SARS has been revived, and people have vowed not to repeat the same mistake. As a result, hospitals in Taiwan have quickly implemented a containment campaign in response to the currently emerging pandemic by developing emergency response measures. Staffs are required to wear protective equipment, screen patients and visitors entering and leaving the hospital, and set up an outdoor fever screening area in the emergency clinic. Additionally, a scheduling roster has been set up, and all hospital staffs are deployed to fight against the pandemic by providing comprehensive care for patients in negative stress isolation wards or general inpatient wards, and by participating in rotational shifts to implement the quarantine measures at the hospital gate. The pandemic has disrupted the original schedule of hospital staff and has caused changes in their work or lives, resulting in substantial physical and mental stress.

Stress refers to individuals' reactions to different situations. It includes changes in their physiology or psychology in the face of events in the external environment that are evaluated as more than they can bear, such that they affect their physical and mental wellbeing. 3 Stress at work is regarded as the process of interaction between the individual and the work environment, which represents an accumulation of negative emotions generated by the work. 4, 5 These negative reactions lead to the experience of high stress for a long period, which in turn affects physical and mental health. Specifically, it causes multiple adverse symptoms, such as insomnia, headache, fatigue, anxiety, gastrointestinal discomfort, and immunity decline, as well as increased family conflicts, decreased work quality, interpersonal relationship disorders, and other negative effects. [5] [6] [7] [8] Hospital staffs are under high stress during the care process. They have to tackle the effects of misunderstanding by the general public, face worries from family members, experience fear of the unknown disease and of becoming a transmitter of the disease, and experience challenges related to their professional skills of personal infection control. These were major stressors for healthcare workers during SARS, 9 and as such, several of them experienced fear, exhaustion, and stress. 10 Extensive research has been conducted to examine the correlation between personal demographics and work stress. Studies have found that marital status, workplace, and educational level have significant effects on work stress. 12, 13 For example, Wang 14 explored the relationship between work stress and social support among nurses, and found that the older they were and the higher years of work experience they had, the higher was their work stress. This finding suggests that, with the increase of age and accumulation of work experience, nurses are likely to have better attitudes toward and abilities to respond to problems, and accordingly, they would be more likely to be assigned the responsibility to handle unexpected situations at work. 12, 15, 16 Unmarried, female, younger medical staff were found to be more prone to high work stress, 17 but work stress was also observed to decrease with the increase in age, years of work experience, and number of children. 16 Another study found that healthcare workers are busy at work, and work stress could result from the conflict of clinical work with family or personal affairs. 18 However, McGrath et al 18 found that marital status, work experience, but educational level had no significant impacts on work stress. 14 The contagion path of COVID-19 is still unknown. Therefore, since the outbreak of the pandemic, the Taiwanese government has formulated an emergency response plan, and hospitals have adopted several preventive measures. Moreover, hospital staffs have experienced the global impact of this highly communicable disease, whose sudden onset has caused a stress impact that is similar to that of SARS. This leads to the question, "are hospital staff suffering from the same magnitude of stress as before?" Accordingly, the objectives of the present study were 

A cross-sectional survey was conducted from the end of March to the beginning of April 2020, at the peak of the COVID-19 pandemic in Taiwan. Participants were selected from a 1700-bed medical center and two 800-bed regional hospitals in southern Taiwan. The survey was conducted using a web-based questionnaire and excluded new recruits, outsourced workers, research assistants, and other non-regular hospital employees. Details of the survey website were provided to the survey participants through the mailboxes of the three hospitals, and the researchers compiled the responses from each hospital for analysis. This study recruited participants from the four main categories of hospital staff, namely physicians, nurses, medical technicians, and administrators.

The questionnaire contained the following two sections 11 11 for SARS. The scale comprises 4 subscales, namely, "worry and social isolation" with 10 items, "discomfort caused by protective equipment" with 8 items, "difficulties and anxieties related to infection control" with 7 items, and "burden of caring for patients" with 7 items, totaling 32 items. Each item is rated on a 4-point Likert scale (0: not at all, 1: about the same as usual, 2: slightly more severe than usual, 3: more severe than usual) to assess the degree of stress caused by various stressors. The total score ranges from 0 to 96, with a higher total score indicating a greater degree of stress. A total score of 46 to 96 indicates "severe stress," that from 33 to 46 indicates "moderate stress," that from 0 to 32 indicates "low stress," and 0 indicates "no stress." The content validity index of the scale was 0.92 in the original study by Chuang and Lou (2005) , 11 who tested it on healthcare workers (n = 543) from medical centers in Taiwan. The Cronbach's α values for the four subscales were 0.84 to 0.90 in the original study. In the present study, the Cronbach's α value of the complete scale was 0.94, and that for the four subscales was 0.84 to 0.90.

Data were analyzed using JMP13.0 statistical package. Regarding descriptive statistics, continuous variables related to demographic characteristics and perceived work stress were presented as mean ± SD; categorical variables were presented as counts and percentages. For inferential statistics, the Pearson product moment correlation test was used to analyze the correlations between the study variables. Since severe stress has a significant impact on the physical and mental health of employees 20 and willingness to care for patients. 11 With a projected power of 80%, an alpha of .05, and an effect size of 0. 30 one-way analysis of variance (ANOVA) to identify if stress levels differed based on demographic characteristics, followed by a post hoc Tukey-Kramer comparison to identify groups with significant differences.

This study was reviewed and approved by the Institutional Review 

The sample comprised 752 hospital staff from one medical center and two regional hospitals in southern Taiwan. As shown in Table 1 Note: A score of 0 indicates "not at all," 1 "about the same as usual," 2 "slightly more severe than usual," and 3 "more severe than usual." Note: Rating scales: 4-point Likert scale (0: not at all, 1: about the same as usual, 2: slightly more severe than usual, 3: more severe than usual). Note: A score of 0 indicates "not at all," 1 "about the same as usual," 2 "slightly more severe than usual," and 3 "more severe than usual. stress could be attributed more to their fear of social isolation, discomfort due to protective equipment, and burden of patient care. In contrast, medical technicians had a higher degree of stress related to difficulties and anxieties related to infection control.

The mean score for each of the 32 items on work stress was 1.5 ± 0.5 (Table 3) , representing mild to moderate stress. The mean scores of each dimension and each item, and score rankings are presented in Table 4 . On 19 items, more than 50% of the participants experienced moderate to severe work stress (with mean scores of over 2 points). The five highest stress scores were observed for the items "rough and cracked hands due to frequent hand washing and disinfectant use," "inconvenience in using the toilet at work," "restrictions on eating and drinking at work," "fear of transmitting the disease to relatives and friends," and "fear of being infected with COVID-19".

"Hospital staff experienced discomfort caused by the use of protective equipment" and "the burden of caring patients" reported higher scores than other two dimensions of the scale.

Further, for hospital staff with severe stress (n = 129), we performed a t test or one-way ANOVA to explore whether their stress levels differed based on their demographic characteristics of gender, marital status, years of work experience, educational level, staff type, and experience with caring for patients with SARS. As shown in Table 5 

This study was the first one conducted in Taiwan to investigate the perceived stress of hospital staff and to identify relevant influencing factors during the COVID-19 pandemic, using a web-based structured questionnaire. The results showed that the total stress was moderate and discomfort caused by protective equipment emerged as the major stressor. Nurses generally perceived higher stress as compared to the other types of hospital staff. Difficulties and anxieties related to infection control were major stressors for medical technicians, while administrators were the least stressed among all types of staff. Further, those with minor children experienced a higher degree of work stress.

This study found that discomfort caused by protective equipment was the major stressor for the participants, followed by burden of caring for patients. The overall stress was slight to moderate. This result was consistent with the findings of Yu et al, 21 but it was different from other similar studies conducted during the SARS pandemic. Specifically, those studies found that the main stressor among hospital staff was difficulties and anxieties related to infection control. 11, 22, 23 Participants in the present study were more stressed by the discomfort caused by wearing protective equipment for a long period, probably because, to effectively prevent the source of infection from entering the hospital and causing cross infection, the hospital staff were required to wear masks throughout their stay in the hospital.

Additionally, they had to set up simple triage stations at the emergency and outpatient departments' entrances, while different types of staff took turns to participate in monitoring individuals entering the hospital. The staff on duty was required to wear basic protective gear, including goggles, protective clothing, surgical masks or N95 masks, and gloves, which made it inconvenient for them to eat and drink at work, as well as to use the toilet. They were required to wash their hands and use disinfectants frequently, and the fear that hands would become rough and cracked made them stressed. The COVID-19 pandemic has changed the work style and environment of the healthcare system, leading to physical and mental imbalance, and thereby, an increased level of stress among hospital staff. 24 When the SARS pandemic hit Taiwan Stressful events or stressors in the workplace can cause stress reactions, and an employee's personal characteristics and behaviors interact with the practice environment. 26 Strong physical and mental demands lead to an increase in stress levels of hospital staff, which may in turn influence patient care. 27 A survey of 532 regional hospital staff examined the correlation between perceived overwork and musculoskeletal symptoms. Findings revealed that nurses ranked the highest among hospital staff in terms of overwork, followed by administrative staff, medical technicians, and physicians, in order of decreasing overwork. 28 By nature, nursing is a highly stressful occupation. Nurses reported highest stress level in this study. This could be attributed to physical discomfort caused by protective equipment, also, nurses often Previous studies have shown that work stress is related to one's demographic characteristics, 13, 17 and that child care at home is a common problem for hospital staff, 28, 29 which is an important factor leading to work-family conflicts. 30 The present results showed that hospital staff with minor children was more stressed, confirming the viewpoint presented in prior research. However, these findings were different from those reported by Wang et al 14 and Lambert et al, 16 who found that employees with children were less stressed than those without. Perhaps this is due to the parenting style difference between the East and the West world. 31 In the face of the COVID-19 pandemic, since the end of January 2020, hospitals started hospital-wide staff mobilization to contain the pandemic, such as setting up triage stations at the entrances and exits, and medical tents and special wards at the emergency department.

These measures changed the existing work pattern of staff and caused unprecedented stress on all types of healthcare workers. As the temperature rises in southern Taiwan, wearing of protective equipment for prolonged periods causes discomfort in staff. Such discomfort can be alleviated by shortening shift durations and installing more mobile air conditioners in emergency and outpatient departments. Since healthcare workers are in a high-stress occupation, it is recommended that they should be assessed and monitored regularly, and appropriate interventions need to be implemented. It is necessary to provide psychological counselling and stress relief measures for this population.

During the pandemic containment, some staff was concerned that they could be carries of the infection after caring for patients with COVID-19, and that they would bring the source of infection home to their family and relatives. This led to higher work stress on hospital staff with minor children. To cope with this situation, it is recommended to assess the needs of hospital staff with minor children and provide appropriate arrangements for the transportation of employees' children to and from school or offer after-school programs.

This would reduce the burden on frontline healthcare staff who are responsible for pandemic containment. In addition, hospitals may consider recruiting medical technicians as members in the Emerging Infectious Diseases Response Drills in future, as this would familiarize them with various disposal processes. This would enable hospitals to commission these staff, as soon as necessary, for pandemic containment.

Such measures would in turn promote the response ability of medical technicians and reduce their stressors.

Due to workforce, financial, and time limitations, this study collected data only from one medical center and two regional hospitals in Together, such findings could be used to provide appropriate support and response measures for hospital staff during a pandemic.

The authors gratefully acknowledge the supports from Kaohsiung Medical University Hospital, Taiwan, Grant number KMUH-C18.

Taiwan Centers for Disease Control: Coronavirus disease 2019 (COVID-19)

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The authors declare no potential conflict of interest.

https://orcid.org/0000-0003-2699-6283Hsin-Tien Hsu https://orcid.org/0000-0001-9638-1589Che-Yu Su https://orcid.org/0000-0002-2946-3207