key: cord-0755721-dr68vwjw authors: Choi, Hye-Ji; Yang, Chan-Mo; Lee, Sang-Yeol; Lee, Hye-Jin; Jang, Seung-Ho title: Mental Health and Quality of Life for Healthcare Workers in a University Hospital Under COVID-19 date: 2021-12-20 journal: Psychiatry Investig DOI: 10.30773/pi.2021.0307 sha: 6b307b2dd5d0bb1b3b7ad7fdfb23a443b2bf8f49 doc_id: 755721 cord_uid: dr68vwjw OBJECTIVE: The aim of this study was to assess the psychosocial characteristics of the employees working at a university hospital and investigated the factors affecting their quality of life (QOL) under COVID-19. METHODS: This study enrolled 1,191 healthcare workers from a university hospital, including doctors, nurses, administrative officer and technicians. Besides demographic information, depression, anxiety, somatization, insomnia, resilience, and QOL were assessed. RESULTS: The nurses presented significantly higher scores for anxiety, depression and showed significantly higher insomnia scores and significantly lower resilience scores. The occupations showed significant differences in the QOL and sub-groups, including the overall quality of life and general health (F=4.774, p<0.001), psychological domain (F=6.230, p<0.001), and environment domain (F=5.254, p<0.001). There was a positive correlation between the QOL and resilience (r=0.608, p<0.01). However, depression (r=-0.502, p<0.01), anxiety (r=-0.425, p<0.01), somatization (r=-0.364, p<0.01), and insomnia (r=-0.385, p<0.01) showed negative correlations with the QOL. Resilience was the most important factor influencing the QOL. CONCLUSION: The results of this study showed that low resilience adversely affected the QOL and the mental health of the healthcare workers, which consequently had a direct effect on the quality of medical care given to patients. due to an increasing number of confirmed and suspected cases, excessive workload, lack of personal protective equipment, exaggerated media coverage, insufficient number of supportive staff, etc. 14 As reported in the studies conducted during the 2003 SARS outbreak, healthcare workers experience significant levels of stress, anxiety, and depression, as well as possible long-term psychological effects. 15, 16 In South Korea, the National Center for Disaster Trauma conducted a thorough mental health survey for 1,375 personnel working at public health centers at each municipality, the National Center for Mental Health, the Metropolitan Mental Health Welfare Centers, and the Basic Mental Health Promotion Centers. The research examined the presence of depression, anxiety, somatization, post-traumatic stress symptoms, suicidal risk, and resilience in the healthcare workers. According to the Report on the Mental Health Status of Disaster Psychosocial Support Personnel in 2020, among the psychological symptoms, a clinically significant level of depression was reported in 7.5% of the responders, anxiety in 4.6%, somatization in 18.1%, post-traumatic stress symptoms in 8.6%, and suicidal risk in 0.5%. 17 However, reports on abnormal mental health cases related to COVID-19 are limited, especially those on frontline healthcare workers working to overcome the disaster. Therefore, this study assessed the psychosocial characteristics of the employees working at a single university hospital and investigated the factors affecting their quality of life. This study enrolled 1,191 healthcare workers from a single university hospital, including doctors, nurses, administrative officer and technicians, who understood the purpose of this study and provided written informed consent. The research was conducted from November 2020 to January 2021 and was approved by the Institutional Review Board (IRB) of the Wonkwang University Hospital (IRB approval number: WKUH 2020-02-052). The protocol for the research project is conformed to the provisions of the Declaration of Helsinki. The Hospital Anxiety and Depression Scale (HADS) developed by Zigmond and Snaith 18 was used to assess the level of anxiety and depression in the participants. HADS consists of 14 items, of which the 7 odd-numbered questions represent the anxiety subscale (HAMD-A) and 7 even-numbered questions represent the depression subscale (HAMD-D). Each item is rated on a 4-point scale (range: 0-3), and the optimal cutoff score is 8 for both HAMD-A and HAMD-D. In Korea, Oh et al. 19 translated the scale to Korean and standardized it. The Patient Health Questionnaire-15 (PHQ-15), a self-administered test developed by Kroenke et al. 20 to diagnose psychiatric illnesses in a primary care setting, was used to assess the somatic symptoms. The PHQ-15 comprises 15 items, and each item is rated on a 3-point scale (range: 0-2). The total score reflects the severity of the somatic symptoms, where scores ≤5 are defined as "low, " 6-10 as "medium, " and ≥11 as "high. " In South Korea, Han et al. 21 translated it to Korean and tested its reliability and validity. The Insomnia Severity Index (ISI) developed by Bastien et al. 22 was used to assess insomnia. It consists of total 7 items, wherein each item is rated on a scale of 0-4, and the total score ranges between 0 and 28. The ISI assesses the insomnia severity in the past 2 weeks, degree of satisfaction with the present sleep cycle, functional impairment during the day, concerns about sleep, and diminished quality of life. In the Korean version of ISI, a total score ≥15 is classified as high risk for insomnia. In South Korea, Cho et al. 23 validated the Korean version of the index. To assess the resilience, we used the Connor-Davidson Resilience Scale (CD-RISC) developed by Conner and Davidson. 24 The CD-RISC comprises 25 items, including 5 factors on hardiness, persistence, optimism, support, and spirituality in nature. Since each item is rated on a 5-point Likert scale from 0 ("not true at all") to 4 ("true nearly all of the time"), the total score ranges from 0 to 100, with higher scores indicating greater resilience. In South Korea, Baek et al. 25 translated it to Korean and tested the validity. To measure the quality of life, we used the WHO Quality of Life Instruments (WHOQOL-BREF) developed by the WHO-QOL Group. 26 This instrument consists of 26 items across 5 fields (2 questions on the Overall Quality of Life and General Health, 7 in the physical health domain, 6 in the psychological domain, 3 in the social relationships domain, and 8 in the environment domain). Each item is rated on a 5-point Likert scale from 0 ("not true at all") to 4 ("true nearly all of the time"), where a higher score reflects a better quality of life, and the optimal cut-off score is 60. 27 In South Korea, Min et al. 28 translated it to Korean and tested its validity and reliability. The demographic and psychosocial characteristics were compared among the different groups. The continuous variables are presented as means and standard deviations and categorical variables as frequencies and ratios. A one-way ANO-VA was used to compare the parametric quantitative variables, followed by a Bonferroni test for post hoc analysis to further examine the differences among the groups. Pearson's correlation test was performed to assess the association between the quality of life and psychosocial factors of the participants from different occupations. To determine the factors affecting the quality of life, we performed stepwise regression analysis. All the collected data were analyzed using the Statistical Package for the Social Sciences (SPSS, version 21; IBM Corp., Armonk, NY, USA) and p values <0.05 were considered statistically significant. The demographic characteristics of the study participants showed that females (n=969, 81.4%), unmarried individuals (n=673, 56.4%), and university graduates or above (n=761, 63.9%) were predominant. With respect to the various occupations, the proportion of nurses (n=664, 55.9%) was the largest, followed by administrative officer (n=344, 29.0%), technicians (n=129, 10.9%), and doctors (n=51, 4.3%) ( Table 1) . The psychosocial characteristics were compared among the different occupations. The nurses presented significantly higher scores for anxiety (6.25±3.50) as compared to the technicians (4.59±3.28) and administrative officer (5.03±3.27) (F= 11.794, p<0.001). Similarly, the nurses showed significantly higher scores for depression (7.97±3.69) as compared to the technicians (6.50±3.87) and administrative officer (6.82±3.63) (F= 8.616, p<0.001). The nurses (8.47±4.70) and administrative officer (6.67±4.79) presented higher scores for somatization than that of the doctors (3.78±3.57) (F=22.855, p<0.001). The nurses showed significantly higher insomnia scores (10.10±5.60) as compared to the doctors (6.22±4.54), technicians (7.72±5.28), and administrative officer (7.55±5.27) (F=18.320, p<0.001). Furthermore, the nurses (57.10±14.32) showed significantly lower resilience scores than that of the technicians (65.82±14.09) and administrative officer (60.29±14.71) (F=11.254, p<0.001) ( Table 2 ). The occupations showed significant differences in the quality of life and all its sub-groups, including the (Table 3) . There was a positive correlation between the quality of life and resilience (r=0.608, p<0.01). However, depression (r= -0.502, p<0.01), anxiety (r=-0.425, p<0.01), somatization (r= -0.364, p<0.01), and insomnia (r=-0.385, p<0.01) showed negative correlations with the quality of life (Table 4 ). A stepwise regression analysis was performed to determine the factors predicting the quality of life. Resilience (β=0.463, p<0.01), depression (β=-0.175, p<0.01), insomnia (β=-0.141 p<0.01), and anxiety (β=-0.089, p<0.01) showed statistical significance, of which resilience was the most important factor influencing the quality of life. These factors accounted for 46.0% of the explanatory variance of the total quality of life (Table 5 ). As COVID-19 spread around the world, the governments implemented quarantines and travel bans on an unprecedented scale. Although the selected strategies of quarantine and isolation are adopted to protect the physical health of the individuals from infectious diseases, these measures affect their psychological as well as emotional well-being. Particularly, As compared to the other occupation groups, the nurses demonstrated higher levels of depression, anxiety, and somatization, but lower resilience. According to previous studies, Yoon and Cho 29 reported that working in shifts could disturb the circadian rhythm, sleep, and daily life. The nurses on three rotating shifts had higher stress levels than those on fixed shifts. Moreover, lack of occupational autonomy, increased workload, and inadequate recognition and compensation affected the mental health of the nurses. 30, 31 In the process of familiarizing themselves with new tasks, nurses may face physical and psychological stress from their interaction with the patients and their colleagues. Additionally, continuous rise in the number of patients is associated with increased job stress. 32 According to a study conducted for the medical staff working in the emergency room during the SARS outbreak, 33 the nurses complained of more psychological distress including depression and anxiety as compared to the doctors. Similar results were observed during the COVID-19 pandemic, which could be attributed to the longer contact time and closer proximity of the nurses with the patients than that of the doctors. [34] [35] [36] Additionally, due to unfamiliar work environment, new colleagues, complex work procedures, risk of infection, and prolonged time to wear the protective equipment, the nurses may experience increased psychological burden of anxiety, depression, and fear. 37 The WHO defined the quality of life as "an individual's perception of their position in life in the context of culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. " 38 The COVID-19 pandemic resulted in the deaths of 2 million people worldwide, and the workload of healthcare workers increased dramatically. According to previous studies, due to COVID-19, the medical staff encountered high levels of anxiety and depression, and their quality of life reduced. In this study, the quality of life showed a negative correlation with depression, anxiety, soma-tization, and sleep disturbance, but a positive correlation with resilience. 39, 40 Resilience, which is a part of the physical and psychological characteristics of an individual, refers to the ability to adapt to changes and cope with stressful situations. 41 The results of this study showed that low resilience adversely affected the quality of life and the mental health of the healthcare workers, which consequently had a direct effect on the quality of medical care given to patients. 42, 43 Since resilience can be acquired and strengthened through learning, 44 we believe that it is necessary to adopt educational programs and psychiatric therapy to promote the resilience of the disaster workers in South Korea. There are several ways to increase resilience, including self-management strategies such as regular exercise, 45 sleep hygiene education, 46 mindfulness, and meditation. 47 In terms of organizational justice, reasonable distribution of work, 45, 48 compliance with working hours, and effective communication are recommended. 45, 49 By utilizing e-learning and video platforms, medical institutions can also engage in interventions to improve communication skills, case management, and troubleshooting strategies to solve any possible psychological problems that might arise when treating COVID-19 patients. 50 There are some limitations in this study. First, there is a limit to the generalization of its results since the study participants were from a single university hospital. Second, the proportion of doctors among the study participants was small. Third, as a cross-sectional study, the confounding factors including exposure level of the patients infected with COVID-19, baseline anxiety and depressive symptoms of healthcare worker, and other are not adjusted in their mental health and quality of life in COVID-19 pandemic. There are limitations in inferring the causal relationships. Nevertheless, this study is the first report on the mental health of disaster workers and the inadequacy in the current policy or system to prevent stress in disaster workers. Thus, through a mental health survey, this study sought to provide the necessary evidence for promoting the mental health of these workers, which would in turn improve the quality of medical care given to the patients. The confounding factors including exposure level of the patients infected with COVID-19, baseline anxiety and depression symptoms of healthcare worker, and other should be The datasets generated or analyzed during the study are available from the corresponding author on reasonable request. 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This study was supported by Wonkwang University in 2021.