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Brief Report   |    
Survey of Stress Reactions Among Health Care Workers Involved With the SARS Outbreak
YaMei Bai, M.D.; Chao-Cheng Lin, M.D.; Chih-Yuan Lin, M.D.; Jen-Yeu Chen, M.D.; Ching-Mo Chue, M.D.; Pesus Chou, Ph.D.
Psychiatric Services 2004; doi: 10.1176/appi.ps.55.9.1055
Abstract

The outbreak of severe acute respiratory syndrome (SARS) was unique because it was highly concentrated in health care settings and a large number of health care workers were infected. This study investigated stress reactions among 338 staff members in a hospital in East Taiwan that discontinued emergency and outpatient services to prevent possible nosocomial outbreak. Seventeen staff members (5 percent) suffered from an acute stress disorder; stepwise multiple logistic regression analysis determined that quarantine was the most related factor. Sixty-six staff members (20 percent) felt stigmatized and rejected in their neighborhood because of their hospital work, and 20 of 218 health care workers (9 percent) reported reluctance to work or had considered resignation.

Abstract Teaser
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The outbreak of severe acute respiratory syndrome (SARS) in multiple countries—especially in Asian countries and Canada—is believed to have been caused by a newly discovered SARS-associated coronavirus (1). The first case of SARS that was identified in Taiwan was on March 14, 2003, in a traveler from Guangdong Province, China. SARS then spread to multiple regions of Taiwan, with 664 cases ultimately identified; by the end of June 2003, 184 patients had died. SARS was unique in its speed of transmission, its high concentration in health care settings, and the large number of health care workers who were infected (2,3,4). In fact, more than 70 percent of patients who tested positive for SARS by the use of a polymerase chain reaction assay had the origin of their disease traced back to a hospital (5).

In Taiwan a total of 105 health care workers became infected with SARS, and 12 of these workers ultimately died (5). Four hospitals had to discontinue emergency and outpatient services to prevent possible nosocomial infection. The outbreak of SARS caused not only extraordinary public health concerns but also tremendous psychological distress, particularly among health care workers. The known lethality of the syndrome as well as the intense media coverage of the outbreak exacerbated perceptions of personal danger. Staff members were discouraged from interacting with colleagues, thereby increasing feelings of isolation (6). Infection control procedures were frequently modified because of the evolving understanding of SARS. Health care workers spent hours each day putting on and removing airtight protective equipment, which only added to the exhaustion that the workers were experiencing from the increased workload that was caused from the SARS outbreak. Health care facilities became highly stressful environments (7).

We report here the stress reactions of staff members in a 2,500-bed psychiatric teaching hospital. The hospital, which is located in Hua-Lien, East Taiwan, also provides medical and surgical services to local residents. The hospital has 120 medical and surgical beds and averages 100,000 outpatient visits and 2,000 operations a year. Between May 10 and May 18, 2003, eight soldiers from the same squad successively presented to the emergency department, complaining of a fever and cough. On May 18 one nurse who had worked in the emergency department developed a fever. On May 19 the local anti-SARS team leader instructed the hospital to cease all outpatient and emergency services to prevent possible nosocomial transmission. Fifty-seven staff members who may have come in contact with suspected SARS cases were quarantined. Fortunately, all staff members were cleared of having SARS after nine days of quarantine, but all had endured tremendous stress during the quarantine period. This study surveyed SARS-related stress reactions among all hospital staff members during the SARS outbreak.

The authors designed an anonymous SARS-related stress reactions questionnaire, composed of acute stress disorder criteria according to DSM-IV criteria and related emotional and behavioral changes. It was hoped that the anonymity would allow colleagues to feel less embarrassed about expressing their psychological stress. On May 29, after all quarantined members had returned to work, the personnel department sent the questionnaires to 557 staff members in all departments (402 health care workers and 155 administrative personnel), with instructions to complete the questionnaire within one week. The filled-out questionnaire was then to be put in a departmental collection box, for collection and return to the personnel department on June 5.

The statistical significance level was set at 5 percent for two-sided tests. The software package SPSS 10.0 for Windows was used for statistical analysis.

Three hundred and thirty-eight staff members completed the questionnaires, giving a total response rate of 61 percent. Health care workers were defined as the doctors, physician assistants, and nursing staff members who had direct contact with patients every day, whereas all other staff members—including accountants and sanitary teams—were defined as administrative personnel. A total of 41 questionnaires did not identify the respondents' duties; therefore, responses were obtained from 218 health care workers and 79 administrative personnel, for response rates of 54 and 51 percent, respectively. Seventeen staff members (5 percent) met the criteria for an acute stress disorder, stepwise multiple logistic regression analysis determined that quarantine was the most related factor (β=1.405, standard error=.647, odds ratio=4.077, 95 percent confidence interval=1.148 to 14.48). SARS-related stress reactions in the total sample, comparisons between health care workers and administrative personnel, and comparisons between quarantined and nonquarantined staff members are shown in t1.

Sixty-six staff members (20 percent) reported feeling stigmatized and rejected in their neighborhood because of their hospital work, and 52 staff members (15 percent) did not to go home after work during the outbreak for fear of infecting their family.

In contrast to administrative personnel, health care workers reported experiencing significantly more insomnia, exhaustion, and uncertainty about the frequent modifications to infection control procedures. Twenty health care workers (9 percent) reported that they were reluctant to work during the outbreak or had considered resignation.

This report is very preliminary. Generalization of the results is limited by the type of institution and by the time that had elapsed from the most stressful period of the nine-day quarantine to when all staff members had been excluded as probable SARS cases. Psychological stress may have been greater and more sustained among workers in SARS treatment centers. Other limitations were the moderate response rate; the voluntary nature of the survey, which may have created a selection bias; and a lack of validity in the absence of face-to-face interviews. Anonymity may have allowed staff members to feel comfortable in reporting their stress, but it prevented the tracing and investigation of nonresponders and follow-up of staff members who needed help. Nevertheless, this preliminary report should contribute to the understanding of stress reactions among health care workers who were involved in the SARS outbreak.

These findings suggest that there is a role for providing accurate and timely SARS information to health care workers and the public to reduce uncertainty and minimize stigmatization of health care workers. Providing suitable accommodation to health care workers would benefit those who are concerned about the risk of infecting loved ones.

The results highlight the value of shortened work hours as a means by which the tremendous stress caused by a SARS outbreak can be reduced and the value of unambiguous information in reducing uncertainty.

Quarantined staff members were at a high risk of developing an acute stress disorder. In addition, almost a quarter of the respondents who were quarantined were reluctant to work or had considered resignation. Although the hospital's psychiatric team tried to support staff members with informal support groups and education about relaxation techniques, there was clearly a need for more psychosocial support and follow-up programs.

The past quarter century has seen the emergence of several new diseases, but the SARS outbreak was unique because of the speed at which SARS was transmitted, the high concentration of cases in health care settings, and the large number of health care workers who were infected (5). Organizations will need to develop an integrated administrative and psychosocial response to the occupational and psychological challenges that are caused by future outbreaks of this nature.

Dr. Bai, Dr. Chao-Cheng Lin, Dr. Chih-Yuan Lin, Dr. Chen, and Dr. Chue are affiliated with the Yu-Li Veterans Hospital, 91, Hsin Hsing Street, Yu-Li, Hua-Lien, 981, Taiwan (e-mail, ymbi@mail2000.com.tw). Dr. Bai is also with the Institute of Public Health at National Yang-Ming University. Dr. Chou is with the Institute of Public Health at National Yang-Ming University in Taipei, Taiwan.

 
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Table 1.

Demographic characteristics and stress reactions among 338 staff members who were working in a hospital in East Taiwan that discontinued emergency and outpatient services to prevent a possible nosocomial outbreak of severe acute respiratory syndrome (SARS)a

a Data were not available for all questions.

Kuiken T, Fouchier RA, Schutten M, et al: Newly discovered coronavirus as the primary cause of severe acute respiratory syndrome. Lancet 26:263—270,  2003
 
Koh D, Lim MK, Chia SE: SARS: health care work can be hazardous to health. Occupational Medicine 53:241—243,  2003
[PubMed]
[CrossRef]
 
Cluster of severe acute respiratory syndrome cases among protected health-care workers—Toronto, Canada, April 2003. Morbidity and Mortality Weekly Report 52:433—436,  2003
[PubMed]
 
Fletcher M: SARS: nurses among first quarantined. Canadian Nurse 99:12,  2003
[PubMed]
 
SARS Online Information Center. Center for Disease Control, Department of Health, Taiwan, ROC. Available at www.cdc.gov.tw/sarsen
 
Maunder R, Hunter J, Vincent L, et al:: The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. Canadian Medical Association Journal 168:1245—1251,  2003
[PubMed]
 
Severe acute respiratory syndrome—Taiwan, 2003. Morbidity and Mortality Weekly Report 52:461—466,  2003
[PubMed]
 
Anchor for JumpAnchor for JumpAnchor for Jump
Table 1.

Demographic characteristics and stress reactions among 338 staff members who were working in a hospital in East Taiwan that discontinued emergency and outpatient services to prevent a possible nosocomial outbreak of severe acute respiratory syndrome (SARS)a

a Data were not available for all questions.

+

References

Kuiken T, Fouchier RA, Schutten M, et al: Newly discovered coronavirus as the primary cause of severe acute respiratory syndrome. Lancet 26:263—270,  2003
 
Koh D, Lim MK, Chia SE: SARS: health care work can be hazardous to health. Occupational Medicine 53:241—243,  2003
[PubMed]
[CrossRef]
 
Cluster of severe acute respiratory syndrome cases among protected health-care workers—Toronto, Canada, April 2003. Morbidity and Mortality Weekly Report 52:433—436,  2003
[PubMed]
 
Fletcher M: SARS: nurses among first quarantined. Canadian Nurse 99:12,  2003
[PubMed]
 
SARS Online Information Center. Center for Disease Control, Department of Health, Taiwan, ROC. Available at www.cdc.gov.tw/sarsen
 
Maunder R, Hunter J, Vincent L, et al:: The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. Canadian Medical Association Journal 168:1245—1251,  2003
[PubMed]
 
Severe acute respiratory syndrome—Taiwan, 2003. Morbidity and Mortality Weekly Report 52:461—466,  2003
[PubMed]
 
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