Surviving SARS and living through COVID-19: Healthcare worker mental health outcomes and insights for coping

Fear, anxiety, and distress are natural human reactions to emerging infectious diseases [1–3]. Healthcare workers (HCWs) must deal with potential risks of infection to themselves and their families, possible work interruption or redeployment, and the threat of shortages of personal protective equipment. A survey of physicians and nurses in China and Italy during the current coronavirus-19 disease (COVID-19) pandemic [4, 5] reported significant levels of depression, anxiety, insomnia, and post-traumatic distress similar to the responses seen during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreaks [6–8]. The Greater Toronto Area (GTA) was at the center of the 2003 Canadian SARS outbreak [9, 10]. Healthcare experience during a prior infectious diseases outbreak might heighten or attenuate the emotional response to an emerging infectious disease. For HCWs who worked during the SARS outbreak, a recurrence or intensification of psychological distress may occur in response to exposure to a similar trauma, such as the COVID-19 pandemic.

We conducted this study in the GTA to explore the psychological effects of the COVID-19 pandemic on clinical and non-clinical HCWs, to identify factors that may put HCWs at higher risk of poor mental health outcomes and to assess the impact of work during a previous novel pathogen outbreak, namely the 2003 SARS outbreak in Toronto, on mental health outcomes. As the COVID-19 pandemic continues into its next waves, the results of this study are crucial to assist in the development of strategies to address the mental health needs of HCWs to support their wellbeing, promote their retention and to preserve a high-functioning workforce during this pandemic, and those that will arise in the future.

Participants in our survey reported a high prevalence of moderate or severe symptoms of post-traumatic stress, anxiety, and depression in all HCWs in the current pandemic similar to other studies examining psychological distress [4, 5, 17]. To our knowledge our study is the first to examine the effects of previous work experience during an outbreak of a novel pathogen. The results are both surprising and encouraging: previous work experience during the SARS outbreak did not result in increased psychological distress in HCWs during the COVID-19 pandemic compared to those without prior outbreak experience. These results are important as they can provide insights into how familiarity with outbreak management may temper negative mental health effects and potentially promote staff retention.

Similar to our previous research in SARS [11], caring for fewer patients resulted in greater symptoms of post-traumatic stress. We hypothesize that HCWs caring for a greater number of patients, especially in dedicated COVID-19 or ICU units, may gain a sense of normalization in their work environments. They may receive more extensive education and training, develop standard operating procedures, and build team resilience related to the bonds formed between team members who are jointly working during the pandemic [18]. Our results suggest a greater burden of symptoms of PTSD are experienced by HCWs who cared for only a few patients which may relate to having less confidence and experience with the pandemic and its control measures, and seems to suggest that increased experience may result in a sense of self-efficacy that comes with having experienced a previous outbreak, adding to the resilience of the individual [19, 20]. The finding that those who have experienced a previous outbreak or pandemic had lower levels of distress suggests that the experience of surviving an outbreak physically unscathed may add to the HCWs confidence in precautionary measures and their training. As the COVID-19 pandemic continues, these results may indicate that HCWs growing experience in caring for patients will provide some protection against adverse mental health outcomes. Yet as the pandemic continues, or with future pandemics of emerging infectious diseases, ways to mitigate distress could be accomplished by creating a buddy system with a more experienced or resilient colleague, using simulation-based training prior to clinical duties, and the creation of a team of experienced HCWs to onboard redeployed staff to bolster their internal locus of control.

HCWs who during the COVID-19 pandemic were in isolation were at increased risk of PTSD symptoms, whereas those who were quarantined were at increased risk of symptoms of anxiety. Both of these findings suggest that a personal health experience with COVID-19 is a psychologically traumatic event. In our study, there was a small number of participants who were either isolated or quarantined during SARS, and this group endorsed more symptoms of PTSD, anxiety, and depression than others who had also worked during the SARS outbreak. This is consistent with the significant impact of isolation and quarantine on mental health seen in previous research [1, 21, 22]. Individuals experiencing isolation or quarantine are at increased risk of poorer mental health outcomes, and these effects may be longer lasting or may place the individual at risk of exacerbation when faced with the potential of repeated quarantine or isolation during a future outbreak or pandemic [23]. Since resources for support are often limited, priority for HCWs who were isolated or quarantined should be considered. These individuals may be more vulnerable to distress or feel a greater lack of control and should be flagged for “check-ins” with occupational health or be offered psychological support resources through individual telehealth or online groups both during and after isolation and quarantine.

Research during the COVID-19 pandemic has focused on the experience of nurses and physicians. Allied HCWs and non-clinical staff who form an integral and important part of the healthcare system have not consistently been included. Our study identified that non-clinical HCWs were found to have the greatest burden of symptoms of anxiety and depression in comparison to other HCWs. Reports during the COVID-19 pandemic from Singapore have also demonstrated a higher prevalence of anxiety amongst non-clinical HCWs in comparison to clinical HCWs [24]. Studies of HCWs in the United States found that non-clinical HCWs had a higher risk of depression, anxiety, PTSD, and alcohol use [25], and higher levels of stress [26]. Non-clinical staff may experience less control over their work situations and lower self-efficacy as it relates to core medical knowledge and receive less dedicated education relating to the pandemic compared to clinical HCWs which may account for this observed difference. It is imperative for healthcare institutions to not overlook the need for strong communication, educational interventions, and psychological support for all categories of HCWs, both clinical and non-clinical [27, 28].

A proportion of HCWs endorsed a deterioration in their sleep and reported new or increased use of alcohol and sedatives. Sleep disturbances are common diagnostic symptoms of PTSD as well as depression and may signal that emotional functioning and wellbeing are impacted [29]. An additional concern is the substantial proportion of participants who identified neglecting their own physical health. Sleep hygiene, optimizing sleep habits, relaxation techniques and respect for off-hours time should be promoted by healthcare organizations [30]. Initiating or increasing alcohol consumption has long been recognized as a sign of distress. Educational programs promoting self-awareness and a focus on self-care are essential. Neglect of one’s physical health may result in both poor mental and physical health outcomes that can result in absenteeism and retention issues in the workforce. Institutions may look to address these concerns with more easily accessible on-site healthcare, resources to encourage healthy eating and activity, and dedicated respite centers for HCWs.

This study has several limitations. First, in an effort to broaden the scope of participants, our non-targeted email link did not permit us to estimate the response rate since we are unaware of the number of HCWs who saw the notice and then opted not to participate. Second, due to logistical issues, participation in one center was delayed, which may have resulted in a differential exposure to the pandemic by HCWs. Sensitivity analyses did not suggest this to be the case. The sample selection and size of this cohort may have been affected by the possibility that some of the staff working during SARS have since left the workforce over the past 17 years. This may have been due to retirement or possibly worse mental or physical health outcomes as a result of their experience during SARS. Finally, while community and tertiary care hospitals were included, the survey did not include an environmental scan of mitigating or exacerbating factors at individual organizations, including dedicated resources and leadership interventions, to determine possible differences between the two settings.

The results of this study demonstrate that HCWs with previous work experience during the SARS outbreak did not have worse mental health outcomes compared to those without any previous experience. These findings have significant implications for staff wellness, the prevention of burnout and promotion and maintenance of staff retention—all of which are ongoing challenges in this current and in future pandemics. Our findings provide guidance for healthcare systems seeking to provide appropriate, targeted, and timely support to HCWs especially those at greater risk, in order to promote individual wellness and a healthy workforce.