Experience of 2003 SARS has a negative psychological impact on healthcare workers in the COVID-19 pandemic: a cross-sectional study

ABSTRACT BACKGROUND: The COVID-19 pandemic has instilled fear and stress among healthcare workers. OBJECTIVES: The aim of this study was to assess work stress and associated factors among healthcare workers during the COVID-19 outbreak and to evaluate whether prior experience of treating severe acute respiratory syndrome (SARS) had a positive or negative influence on healthcare workers’ stress levels during the COVID-19 pandemic. DESIGN AND SETTING: Cross-sectional survey in a tertiary hospital in Kaohsiung City, in southern Taiwan. METHODS: The survey was conducted using an online self-administered questionnaire to measure the stress levels among healthcare workers from March 20 to April 20, 2020. The stress scales were divided into four subscales: worry of social isolation; discomfort caused by the protective equipment; difficulties and anxiety regarding infection control; and workload of caring for patients. RESULTS: The total stress scores were significantly higher among healthcare workers who were aged 41 or above, female, married, parents and nurses. Those with experience of treating SARS reported having significantly higher stress scores on the subscale measuring the discomfort caused by protective equipment and the workload of caring for patients. During the COVID-19 outbreak, frontline healthcare workers with experience of treating SARS indicated having higher stress levels regarding the workload of caring for patients than did non-frontline healthcare workers with no experience of treating SARS. CONCLUSIONS: Work experience from dealing with the 2003 SARS virus may have had a negative psychological impact on healthcare workers amidst the COVID-19 outbreak.


INTRODUCTION
Infectious disease outbreaks are always important issues that need to be to learned from, tackled and prevented. The coronavirus disease 2019 (COVID-19), a novel virus causing pneumonia that was first reported in Wuhan, China, is spreading locally and internationally. According to a report from the World Health Organization (WHO), 1 over three million people around the world were confirmed to have COVID-19 between December 2019 and April 30, 2020, and approximately 217,000 of them died, which resulted in a mortality rate of approximately 7%.
Symptoms of COVID-19 appear within about 2 to 14 days after infection with the virus, and the disease progresses rapidly from an asymptomatic state or mild symptoms to severe symptoms. COVID-19 is highly transmissible between humans, is associated with high morbidity rates, and may potentially lead to fatality. This instills fear not only among the public but also among healthcare workers. Moreover, healthcare workers involved in diagnosis, treatment and care of patients with COVID-19 are at greater risk of contracting the disease. Therefore, they may have a higher possibility of developing psychological distress and other mental health symptoms. concerns but also led to tremendous psychological distress, particularly among healthcare workers.
These workers suffered from acute stress disorders; 4 feared contagion and infection of their families, friends and colleagues with the SARS virus; and felt stigmatized and rejected in their neighborhoods because of their hospital work. 4 Furthermore, these healthcare workers reported feeling reluctance to work or had considered resigning. 4,5 In addition, healthcare workers who cared for SARS patients but did not become infected continued to experience substantial psychological distress, even one to two years after the outbreak. 6 The stress scales were divided into four subscales, which measured the worry of social isolation (10 items), discomfort caused by the protective equipment (8 items), difficulties and anxiety regarding infection control (7 items) and the workload of caring for patients (7 items). Each of these 32 items was rated on a four-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 factors. The total score could range from 0 to 96. A higher total score would indicate a greater degree of stress, such that a total score from 47 to 96 would denote severe stress, while a score from 0 to 46 would indicate mild to moderate stress. A score of 0 would indicate absence of stress.

Statistical analysis
The software package JMP 13.0 for Windows (SAS Institute Inc, Cary, North Carolina, United States) was used for statistical analysis. Continuous variables relating to demographic characteristics and perceived work stress were presented as the mean ± standard deviation (SD); categorical variables were presented as counts and percentages. Correlations between variables were analyzed using Pearson's product-moment correlation coefficient and were compared using the chi-square and Levene tests.
Logistic regression on different variables was also used to evaluate the effect of the variables on the total stress scale.

Ethics
This study was reviewed and approved (IRB Number: KMUHIRB-E(I)-2020008; approval date: April 7, 2020) by the institutional review board of the participating hospital. Data were collected anonymously, and background data were deidentified. Information about the respondents that was obtained in this study was handle in accordance with the principles of confidentiality and privacy.

Characteristics of participants
Out of the 492 healthcare workers who completed this questionnaire, 51 were male (10.4%) and 441 were female (89.6%). The demographic characteristics of these healthcare workers are displayed in Table 1.
Their mean age was 38 years (ranging from 23 to 65 years) and their average length of work experience was 12.4 years.
Approximately half of the respondents were married (50.6%) and were parents (43.7%). Most of the respondents were nurses (82.8%), followed by medical technicians (9.8%) and doctors (8.1%). A total of 427 respondents (86.8%) had graduated from college or university at not more than bachelor level, while the remaining respondents (13.2%) had also reached higher degree levels (master's or doctoral degree). Ninety-three respondents (18.9%) had prior work experience at the time of the SARS outbreak and 57 (11.6%) were frontline healthcare workers who were directly involved in the diagnosis, treatment and care of patients with COVID-19.

The stress levels of healthcare workers amidst the COVID-19 pandemic
The total stress score was collated and analyzed in relation to different variables (see Table 2). The respondents aged 41 years or above

Influence of SARS work experience on healthcare workers
The healthcare workers were divided into two groups according to whether they had experience of treating SARS. The total stress score and the scores from the four subscales were analyzed in each group (see Table 4).

Stress scores of healthcare workers according to two factors
The respondents were categorized into four groups according to two factors, namely, SARS work experience and caring for suspected or confirmed COVID-19 cases (refer to

DISCUSSION
The cross-sectional survey used in this study was completed by 492 respondents and the mean total stress score was 48.4 ± 16.3 points.
Most participants were female, were nurses, had been educated to college or university level and had no prior experience of treating SARS.
In this survey, the total stress score was significantly higher among healthcare workers aged 41 or above who were female, married, parents and nurses. The total stress score did not show any significant differences with regard to education level, having SARS work experience or having cared for suspected or confirmed cases of COVID-19. Furthermore, respondents who were older or were nurses had higher odds of being in the group with severe stress during the COVID-19 outbreak.
Nurses not only had higher total stress scores than physicians or medical technicians, but also had significantly higher odds of being in the group with severe stress in facing the COVID-19 pandemic.
This was consistent with previous findings that demonstrated that SARS had caused a significant level of distress among emergency department staff, with the highest levels of distress among nurses, followed by doctors and healthcare assistants. 8 The higher stress among nurses was attributable to the following reasons: nursing is a highly stressful occupation; nurses are exposed to patients with suspected or confirmed COVID-19 for long periods; and the inconvenience caused by stringent infection control measures is a source of stress.
Being a parent also gave rise to a higher total stress score in this study. This may be attributed to the fear among these healthcare workers that if they contracted COVID-19, they could spread the disease to their children, be separated from and not able to see their children, or would face inconvenience in taking care of their children. Furthermore, a recent study conducted in tertiary-level hospitals found that nurses, women, frontline workers and workers at the epicenter of COVID-19 reported experiencing greater severity of symptoms of depression, anxiety, insomnia and distress. 9 One intriguing finding from the present study was that healthcare workers with SARS work experience presented significantly higher stress scores on the subscales relating to discomfort caused by the protective equipment and the workload of caring for patients. However, no significant differences in the total stress score were found.
Prior experience of treating SARS had either positive, negative or neutral psychological impacts on the healthcare workers when they were faced with another pandemic; in this case, COVID-19. A survey completed by healthcare workers who practiced respiratory medicine during the SARS outbreak in Hong Kong showed that these workers remained highly stressed one year after the outbreak. The perceived stress levels were higher and were associated with higher levels of depression and anxiety, and higher posttraumatic stress scores. 10 A study on healthcare workers in Taiwan who had taken care of suspected SARS patients, both at the first stage and a year later, indicated that the stress was initially in response to the life-threatening nature of the SARS epidemic. The stress experienced thereafter was from their jobs, families and stressful events within daily life, rather than from a continuation of previous symptoms caused by vulnerability to or complications from stress created by the SARS attack. 11 In another study, SARS work experience resulted in increased mental preparedness and implementation of stringent infection control measures that led to lower impact of events on stress scores among physicians and nurses, as well as lower prevalence rates for posttraumatic stress disorder in response to the COVID-19 pandemic. 12 A complete set of personal protective equipment (PEE) is imperative and paramount for curbing the spread of COVID-19 when dealing with suspected or confirmed cases. However, healthcare workers who wear a complete set of personal protective equipment have experienced states of tension and fatigue, thereby increasing the difficulty of their work and becoming more prone to burnout. 13 In the present study, the healthcare workers with SARS work experience had higher stress scores due to the discomfort experienced through using personal protective equipment. The three most troublesome effects were the following: skin damage to their hands from frequent hand washing and use of disinfectants; the inconvenience of going to the bathroom wearing PPE; and restriction of the intake of water and food because of wearing a complete set of PPE.
Because hand hygiene compliance is essential amidst the COVID-19 pandemic, prevention of skin dermatitis caused by constant hand washing and sanitizing among healthcare workers has been found to be important for increasing hand hygiene compliance. 14 For lipophilic enveloped viruses, such as SARS-CoV-2, Table 5. Psychometric evaluation on the healthcare workers, in four subgroups according to their experience of severe acute respiratory syndrome (SARS) and whether they were caring for suspected or confirmed COVID-19 cases  to work stress among healthcare workers. Fourth, the non-inclusion of a scale for evaluating depression was also a limitation of this study.

CONCLUSIONS
In summary, healthcare workers who are older than 40, female, married, parents or nurses are prone to have higher total stress scores amidst the COVID-19 pandemic. The odds of being in the group with severe stress were significantly higher when the respondents were older or nurses. Furthermore, healthcare workers with SARS work experience reported having higher total stress scores and had higher odds of being in the group with severe stress, although this was not statistically significant compared with healthcare workers without SARS work experience. Specifically, healthcare workers with experience of treating SARS showed greater distress on the subscales relating to the discomfort caused by the protective equipment and the workload of caring for patients in the COVID-19 pandemic. In addition, frontline healthcare workers with SARS work experience also had higher stress scores on the subscale of the workload of caring for patients.
Due to limitations of workforce, finance and time, data for this study were collected only from one medical center in southern Taiwan.
It is recommended that future studies should include larger sample sizes and should make comparisons between groups with the same numbers of study subjects in other tertiary-level hospitals in Taiwan.
Moreover, a longitudinal study design should be adopted in order to follow up the long-term effect of COVID-19 on healthcare workers.
It was clear from this study that experience of treating the 2003 SARS outbreak had a partly negative psychological impact on these healthcare workers facing the COVID-19 outbreak. Thus, hospital administrators should provide psychological measures or interventions in order to reduce the burden on healthcare workers amidst the COVID-19 pandemic.