Healthcare workers’ stress when caring for COVID-19 patients: An altruistic perspective

Abstract

Background:

When the contagious COVID-19 spread worldwide, the frontline staff faced unprecedented excessive work pressure and expectations of all of the society.

Objective:

The aim was to explore healthcare workers’ stress and influencing factors when caring for COVID-19 patients from an altruistic perspective.

Methods:

A cross-sectional, descriptive study was conducted in a tertiary hospital during the outbreak of COVID-19 between February and March 2020 in Wuhan, the capital city of Hubei province in China. Data were collected from 1208 healthcare workers. Descriptive statistics and multiple linear regression were used to analyze the data.

Ethical considerations:

Research ethics approval (with the code of TJ-IRB20200379) was obtained from Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology. Written informed consent was also received from participants.

Results:

Less than 60% of participants chose moderate or severe stress on all stressors, indicating a low stress level among healthcare workers. The main source of stress among frontline healthcare workers caring for COVID-19 patients came from the fear of being infected, the fear of family members being infected, and the discomfort caused by protective equipment. Frontline staff who were nurses, were married, and had worked more than 20 days suffered higher stress, whereas rescue staff showed lower stress.

Conclusion:

The healthcare workers caring for patients with COVID-19 had low stress level, although they still had the fear of being infected or uncomfortable feeling caused by personal protective equipment. A low stress level among healthcare workers indicated their professional devotion and altruism during COVID-19 epidemic. Medical institutions and the government should continue to strengthen infection prevention measures and provide more comprehensive care involving families of frontline healthcare workers, especially nurses and married staff. It will be a lesson to other countries that awaking healthcare workers’ inside motivation and providing necessary support from government and society were significant.

Keywords

Altruism COVID-19 healthcare workers nurses stress

Introduction

The Novel Coronavirus 2019 (COVID-19) is a new form of the coronavirus family and has spread throughout the world. For frontline healthcare workers caring for COVID-19 patients, their psychological condition was not optimistic and manifested as stronger somatization and terror; nearly one-third of the first-line healthcare workers showed high anxiety in Wuhan city.^1,2 To improve the psychological status of large-scale healthcare workers fighting in the front lines of caring for COVID-19 patients, it is necessary to identify their sources of stress. Therefore, this study used “The Stress Scale of Caring for Highly Infectious Disease Patients among Health Care Workers—Based on SARS” to investigate the sources of pressure among frontline healthcare workers caring for COVID-19 patients, which can provide directions for further psychological counseling and assistance policies.

Background

With a history of significant infectivity and morbidity as well as economic loss associated with previous epidemics of newly emerging infections such as the SARS or H1N1, the impending threat of COVID-19 has commanded substantial attention from the local government. As of 28 March 2020, a total of 82,230 cases had been confirmed in China, and 489,448 cases have been confirmed in other countries.³ The Chinese government has dispatched more than 42,000 medical personnel from all over the country to help others in Hubei Province, 70% of this medical personnel comprised nurses.⁴ The World Health Organization (WHO) announced that the COVID-19 outbreak can be characterized as a pandemic, as the virus has spread increasingly worldwide as of 11 March 2020.

The first-line healthcare providers are the most easily affected by the disease. In 2003, SARS developed only among healthcare workers initially but spread rapidly to the community; 19% (1002) of the cases of SARS were healthcare workers in mainland China.⁵ As of 11 February 2020, 1716 healthcare workers have been confirmed to have COVID-19 in China, accounting for 3.8% of the confirmed cases nationwide, 6 of whom have died.⁶ Healthcare workers’ motivation to provide professional services in a pandemic was largely altruistic and was in the context of high personal risk of becoming infected.⁷ They paid unselfish attention to the needs of patients, and put the altruism as the fundamental element of the decisions.⁸

After the outbreak of respiratory infectious diseases, such as SARS or influenza, several studies have been conducted to explore healthcare workers’ stress during the emerging situation. Almost 87% of healthcare workers were found to feel more stressed at work during avian influenza outbreaks.⁹ During the SARS epidemic, healthcare workers were also found to be more stressed when caring for infected patients. One study reported that 68% of healthcare workers reported a high level of stress.¹⁰ However, another study reported that 29%–35% of hospital workers experienced a high degree of distress.¹¹ Studies also found that healthcare workers in the initial stage of the SARS epidemic were significantly more likely to respond that their job put them at higher risk.¹²

According to the literature during the SARS epidemic, it was found that the main sources of stress among healthcare workers were worrying about their own health or their family members’ health and being isolated.¹¹ One study reported that the proportion of people who worried about their own health and their families’ health has reached 2 out of 3.¹³ Moreover, during the COVID-19 outbreak, health workers needed to be isolated in hospitals or hotels outside of office hours over a 14-day observation period, as mandated by China’s health authorities.¹⁴

A growing body of literature has addressed the psychiatric impact of major disasters for relevant staff, which can be significant and long term. Some workers experience post-traumatic stress disorder, including anxiety, burnout, and depression.¹⁵ A study documented that approximately 10% of the staff had experienced high levels of post-traumatic stress symptoms since the SARS outbreak.¹⁶ Medical workers who had contacted with patients with SARS experienced a more intense acute traumatic response.¹¹ Hospital employees who had been quarantined, worked in SARS wards, or had friends or close relatives who contracted SARS were two to three times more likely to have high post-traumatic stress symptom levels, than those without these exposures.¹⁶ In Toronto, healthcare workers reported significantly higher levels of burnout, psychological distress, and post-traumatic stress 13–26 months after the SARS outbreak.¹⁷ They were more likely to reduce patient contact and work hours and to report behavioral consequences of stress.¹⁷ In addition, the perceived risk of fatality from SARS even was one of the main predictors of nurses’ consideration of leaving their jobs.¹⁸ Based on literature review,^17,19 we constructed a conceptual framework for healthcare workers’ stress when caring for COVID-19 patients, including four variables (the worry of social isolation, the discomfort caused by the protective equipment, the difficulties and anxiety of infection control, and the workload of caring for patients).

Aim

The aim of the study was to explore healthcare workers’ stress and influencing factors when caring for patients with COVID-19 in China from altruistic perspective.

Methods

Design

This was a cross-sectional, descriptive study concerning the stress of healthcare workers caring for COVID-19 patients and strictly followed the guidelines for reporting observational studies.²⁰

Setting

The study was conducted in a tertiary hospital in Wuhan, the capital city of Hubei Province, which has the highest number of confirmed COVID-19 cases in China. The hospital had 2025 beds in the epidemic period, and was designated for the care of critically ill patients with COVID-19. Thirty-five rescue teams from other provinces were dispatched to support this hospital. About 8,000 healthcare workers participated in fighting against COVID-19 in this hospital under the recall of the government.

Participants

Subjects were recruited by convenience sampling between February and March 2020 during the outbreak of COVID-19. Inclusion criteria were first-line healthcare workers who had the experience caring for patients suffering from COVID-19 and who were willing to participate in this study. Medical workers with confirmed COVID-19 were excluded.

Measurements

A self-designed questionnaire including items on gender, age, working years, marital status, number of children, education level, seniority, profession, place of work, work condition, rescue staff, previous work department, previous infectious disease experience, and number of days spent caring for COVID-19 patients was used to collect general information.

“The Stress Scale of Caring for Highly Infectious Disease Patients among Health Care Workers—Based on SARS” developed by Baoyu Zhuang in 2005 was used to investigate the stress of healthcare workers caring for COVID-19 patients.¹⁹ The scale has 32 items that are divided into four dimensions: worry about social isolation (10 items), discomfort caused by protection measures (8 items), difficulty and anxiety in infection control (7 items), and the burden of caring for patients (7 items). A 4-point Likert-type scale was adopted for each item, and the degree of feeling pressure was measured from 0 to 3 points, with possible scores ranging from 0 to 96. A high score signifies that the participants are under great pressure. The scale has good internal consistency and validity, the Cronbach’s α of each dimension ranged from 0.84 to 0.90, and the content validity index of the scale was 0.92.

After the original scale obtained the authorization of Professor Zhuang in Taiwan, China, the cross-cultural adaptation was carried out through four steps: the translation by three postgraduate nurses; synthesis; revision of sentence ambiguity, unclear semantics, and language mistakes by 13 postgraduate nurses; and pretesting. The reliability (Cronbach’s α) of the scale was 0.968 with 50 medical workers in pretesting survey. The main survey was conducted after the pilot study, and the reliability was 0.965.

Data collection

All the healthcare workers were recalled to participate in the survey by their nurse leaders who were trained to understand the purpose, instructions, inclusion criteria, and precautions of the survey in the direction of nursing department. Nurse leaders would explain the purpose of the study to the healthcare workers; if they agreed to participate, an informed consent form must be signed and the web-based questionnaires were distributed. The web questionnaire was conducted after the written consent was signed.

Ethical considerations

The study was based on anonymous online survey. A written permission (with the code of TJ-IRB20200379) was acquired from the Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, and written informed consents were also received from the participants. No participants’ names were attached to the questionnaires. The researchers would encode the questionnaires uniformly when collating the data. Furthermore, the participants could withdraw at any time without prejudice.

Data analysis

Data were processed using SPSS 21.0 for Windows statistical software program. The participants’ general characteristics and stress status were analyzed using descriptive analysis. Continuous variables were represented by means and standard deviations, while classification or rank variables were represented by frequencies and percentages. Stepwise multiple linear regression analysis was carried out with participants’ demographics as independent variables and the total pressure score as the dependent variable to identify the factors of influencing health workers’ stress when caring for COVID-19 patients. Statistical significance was set at p < 0.05.

Results

Participants’ demographics

A total of 1234 healthcare workers filled out the questionnaire with a response rate of 14.8%. Twenty-six incomplete or invalid questionnaires were excluded. Ultimately, 1208 complete questionnaires were obtained, with an efficiency rate of 97.9%.

Detailed demographics of participants are summarized in Table 1. A total of 118 were men and 1090 women, average age and working years were 30.7 and 7.8 years, respectively. The majority of participants had bachelor’s degree (79.3%) and junior title (68.7%). And 86.1% of participants were nursing staff. Others were doctors, pharmacists, clinical laboratory technicians, and radiologists. About 60% of participants were married, and 50.2% of participants had one or more children. Participants whose workplace was in isolation ward accounted for 76.0%. Most of participants (84.7%) were still working in front line when the survey was conducted. Almost 85% of participants worked for 11–30 days in the front line. It is worth noting that 13.2% of participants were rescue staff who came from other provinces to help in Hubei Province. The majority of participants had no experience of caring for patients with high infectious diseases (92.4%), and 81.4% of participants’ previous departments were not related to the infectious diseases.

Table 1.

Participants’ characteristics (N = 1208).

Variables	M ± SD (range)
Age (years)	30.7 ± 5.4 (21, 5)
Working years (years)	7.8 ± 5.7 (0, 35)
	n (%)
Gender
Male	118 (9.8)
Female	1090 (90.2)
Marital status
Single	480 (39.7)
Married	717 (59.4)
Divorced	11 (0.9)
Number of children
None	602 (49.8)
One	496 (41.1)
≥2	110 (9.1)
Educational level
Associate’s degree	84 (7.0)
Bachelor’s degree	958 (79.3)
Master’s degree	57 (4.7)
Doctoral degree	109 (9.0)
Seniority
Junior	830 (68.7)
Intermediate	329 (27.2)
Senior	49 (4.1)
Profession
Doctor	132 (10.9)
Nurse	1040 (86.1)
Other	36 (3.0)
Place of work
Isolation ward	918 (76.0)
Fever clinic	123 (10.2)
Mobile cabin hospital	26 (2.2)
Other location	141 (11.7)
Working condition
Front line	1023 (84.7)
Observation period	149 (12.3)
End of the observation period	36 (3.0)
Rescue staff
Yes	159 (13.2)
No	1049 (86.8)
Previous work department
Respiratory department	47 (3.9)
Emergency department	65 (5.4)
Infectious disease department	16 (1.3)
ICU	97 (8.0)
Other departments	983 (81.4)
Previous infectious disease experience
Yes	92 (7.6)
No	1116 (92.4)
Number of work days spent caring for COVID-19 patients
≤10	105 (8.7)
11–20	536 (44.4)
21–30	490 (40.6)
≥31	10 (0.8)

M: mean; SD: standard deviation; COVID-19: Novel Coronavirus disease 2019.

Health workers’ stress when caring for COVID-19 patients

It was detected that the median stress score of healthcare workers was 34, the median stress score in sub-scales were displayed in Table 2. For each stressor of the scale, less than 60% of the participants chose moderate or severe stress. The results showed that the healthcare workers considered the following five items as higher source of stress in Table 3 and five items to be lower sources of stress in Table 4.

Table 2.

Median of health workers’ stress scores in sub-scale.

Sub-scales	Median (25–75, percentiles)
The worry of social isolation	9 (5, 14)
The discomfort caused by the protective equipment	10 (7, 15)
The difficulties and anxiety of infection control	7 (3, 10)
The workload of caring for patients	7 (4, 10)

Table 3.

The higher five items that were moderate or severe stress.

Items	Moderate or severe stress (%)
Worrying about transmitting COVID-19 to my relatives and friends	58.6
Fear of being infected	52.5
Poor vision while wearing protective masks or goggles	50.7
Fear of deterioration or death of the patient	47.0
Living apart from and limited visits with my family for fear of infection	46.9

COVID-19: Novel Coronavirus disease 2019.

Table 4.

The lower five items that were moderate or severe stress.

Items	Moderate or severe stress (%)
Immature protective measures	16.6
Taking care of patients is health workers’ professional responsibility and cannot be refused	16.7
No suitable place to live after work	11.7
Not daring to talk about work in public places	10.6
Not supported by relatives and friends, such as being asked to refuse to care for COVID-19 patients or resign	6.6

COVID-19: Novel Coronavirus disease 2019.

Factors influencing health workers’ stress when caring for COVID-19 patients

The results showed that participants’ stress was affected by profession, marital status, number of days spent caring for COVID-19 patients at work and being a rescue staff member (Table 5). These variables explained 4.40% of the variance in health workers’ stress when caring for COVID-19 patients. Compared with doctors, nurses experienced higher pressure (β = 0.117, p < 0.001); compared with unmarried staff, married staff experienced higher pressure (β = 0.137, p < 0.001); compared with frontline staff working 10 days or less, frontline staff working between 21 and 30 days had higher pressure (β = 0.080, p < 0.01); and compared with provincial healthcare workers, the pressure of rescue staff from other provinces displayed lower stress levels (β = –0.077, p < 0.01).

Table 5.

The results of multiple linear regression analysis predicting health workers’ stress when caring for COVID-19 patients.

Variables	B	SE	β	t	F	Adjusted R2
Constant	57.94	1.745		33.211***	11.496***	4.40
Nurses	6.485	1.650	0.117	3.930***
Married	5.312	1.140	0.137	4.658***
Spending 21–30 days caring for COVID-19 patients	3.072	1.142	0.080	2.690**
Rescue staff	−4.343	1.644	−0.077	−2.641**

SE: standard error; COVID-19: Novel Coronavirus disease 2019.

**p < 0.01. ***p < 0.001.

Discussion

The results of the present research revealed that healthcare workers had a lower level of stress. The fear of family members and themselves being infected, and the discomfort caused by protective equipment were leading factors of psychological stress. “Fear of deterioration or death of the patient” also caused healthcare workers’ stress, which reflected their greater altruism.

In this study, less than 60% of participants chose moderate or severe stress for all the stress items. While, in Singapore, 66% healthcare workers of a tertiary hospital would feel more stress at work when an avian influence outbreak.²¹ And 47.8% staff considered SARS a “mild” stress, 41.3% considered it a “serious” stress, and 4.3% members considered it a “very serious” stress during the SARS outbreak in Taiwan, China.²² In this study, the level of stress among frontline healthcare workers was below the medium level, which may be related to the powerful interventions taken by the government in a timely manner and the middle or later stage of the epidemic at the time of the investigation. The government directed substantial attention during the initial stage toward listing COVID-19 as a class B infectious disease and requiring class A protection measures. The public could learn the number of infected people or the death rates in real time online, and people volunteered to help healthcare workers. Effective diagnostic tests and treatments were developed within days. Major coping strategies to relieve psychological stress were promoted by psychology professors.²³ In addition, hotels around the hospitals were expropriated temporarily to provide a comfortable living environment for healthcare workers. Free buses were used to address their commuting issues. Besides, healthcare workers could communicate with the outside world, and their older relatives were also supported by the government. Moreover, compensation was increased for frontline staff. For medical workers who became infected with or who died from COVID-19, their rights were protected by the law.²⁴

Healthcare workers identified the lower stress from the relatives and the public’s attitude, and less worried about the suitable place to live after work (less than 17%, in Table 4). In line with another study in Taiwan, when fighting against infectious diseases, many nursing staff were dedicated to their work under professional responsibility, took care of SARS patients, and even volunteered to be involved in the front line.²⁵ However, research in South Korea showed that the friends and families of clinical nurses did not support them in providing care for SARS patients. Moreover, nurses thought caring for SARS patients threatened their own safety.²⁶ A study in Toronto showed that, some healthcare workers felt stigmatized in the community and avoided being identified as hospital workers.²⁷ During the SARS epidemic in Singapore, many healthcare workers also experienced social stigmatization (49%) and ostracism by family members (31%), but most (77%) felt appreciated by society. They believed that healthcare institutions have a duty to protect healthcare workers and help them cope with their personal fears and their very stressful work situation.²⁸ In Hong Kong, many hospital workers volunteered to stay in hospital facilities instead of going home for fear of transmitting the SARS virus to family members, and they were discouraged from interacting with the outside world.²⁹

Although the national government and hospitals have taken a series of measures to greatly alleviate the psychological pressure of healthcare workers on the front line, there were still several sources of pressure that were likely to lead to moderate and severe pressure among healthcare workers, which needed to be taken further measures. This study showed that the worry about being infected and transmitting COVID-19 to relatives and friends made healthcare workers suffer from a heavy amount of pressure (over 50%, Table 3). Literature reviews also found similar results that the proportion of healthcare workers worrying about being infected had reached 66%.^11,13 Almost 70% of healthcare workers perceived themselves to be at personal risk when performing their duties during a pandemic.³⁰ Nearly 90% of healthcare workers were worried about the harm of occupational and infectious diseases to their health.⁹ The researchers learned that these measures have been implemented in China, such as ensuring a sufficient supply of personal protective equipment (PPE) supplement sufficiently, arranging shift schedules reasonably, rotating days off once a month as a requirement, and monitoring the staff’s health daily. The term of altruism describes unselfish attention to the needs of others.⁸ In treating patients with COVID-19, Chinese healthcare providers showed a great deal of professional dedication and acceptance of the need to place themselves at risk.³¹ Altruism might be the reason why healthcare workers were actively involved in the treatment of patients with COVID-19 and the overall pressure was low. However, healthcare workers afraid of being infected and infecting others were the main sources of pressure, showed that they still struggled between egoism and altruism. Therefore, further accurate measures should be taken to protect them and their families from being infected, so as to relieve healthcare workers’ stress and tension.

This result found that discomfort caused by PPE, such as poor vision, made most medical personnel feel moderate to severe stress (Table 3). In a previous report, it was also found that PPE was one of the stressors among healthcare workers.³² Due to the discomfort and technical difficulties caused by wearing the PPE, insisting on the proper use of PPE is a challenge. In fact, the perceived effectiveness of PPE among healthcare workers outweighed the barriers of shortages, costs, and discomfort of PPE.³³ Future researches should be devoted to improving this situation, including redesigning PPE and shortening working hours, which is beneficial to protect the safety of medical personnel and reduce their psychological pressure.^34,35

In this study, the stress among nurses or married staff members was higher than that of others caring for COVID-19 patients. Similarly, a study conducted during the SARS epidemic also found that nurses were more stressed than doctors, and married employees with children were also more stressed.²⁸ A study in Singapore found that doctors and single healthcare workers were at higher risk of stress disorders than were nurses and those who were married during the SARS outbreak.³⁶ Likewise, a study of more than 500 participants in China found that occupation and marital status were not related to stress.¹⁶ The results of this research may be related to closer contact between nurses and patients. Married healthcare workers were more stressed than unmarried staff were, possibly because they have a family to worry about.

Our research also found that compared with staff working on the front line for no more than 10 days, those working on the front line for 21–30 days had a tendency toward increasing stress levels, which indicated that frontline staff should be arranged to take shifts reasonably and shortened working time. In fact, the participants spent no longer than 30 days working on the front line, which was set by Chinese government.²⁴ Although a majority of rescue staff did not work on the outbreak of SARS in 2003, many medical personnel from other provinces participated in the rescue voluntarily. It was surprising to find that there were lower stress levels among rescue staff than among local staff in Hubei Province. The reasons may be related to their party membership role and voluntary application, and they had sworn to fight the epidemic before departure and got themselves psyched up for the anti-epidemic. In addition, the attention of the state and the media has increased the pride of healthcare workers. Rescue workers who traveled the furthest to care for COVID-19 patients in Hubei Province were more altruistic and probably more dedicated.

Limitations

There were several limitations that need to be acknowledged. First, the study was conducted during the middle and later stages of the outbreak of COVID-19 in China, when all healthcare institutions were on maximum alert and the recommended institutional preventive measures were already in place. Second, we only conducted the investigation in one hospital whose patients with COVID-19 were in critical condition. Third, convenience sampling was used, so selection bias may occur. Finally, based on the results of the literature review, the study analyzed only four variables that might influence healthcare workers’ stress, but there may be additional influential variables. Accordingly, further research is required to analyze influencing factors other than the general characteristics and variables used in this study.

Conclusion

The healthcare workers caring for patients with COVID-19 had low stress level, although they still had the fear of being infected or uncomfortable feeling caused by PPE. A low stress level among the healthcare workers indicated their professional devotion and altruism in COVID-19 epidemic. Frontline staff who were nurses, were married, and had worked more than 20 days had greater pressure. Therefore, the follow-up research should be devoted to improving the comfort and safety of protective equipment. Medical institutions and the government should continue to strengthen infection prevention measures and provide more comprehensive care involving the families of frontline healthcare workers, especially nurses and married staff. It will be a lesson to other countries that awaking healthcare workers’ inside motivation and providing necessary support from government and society were important.

Footnotes

Acknowledgements

The authors would like to thank the healthcare workers who participated in this study, and they appreciate their efforts against COVID-19.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Hui Wang

Kaili Hu

References

Wang

Chen

Zhou

, et al. Psychological status of Wuhan medical staff in fighting against COVID-19. Wuhan Univ J (Med Ed.) 2020; 4(41): 547–550, https://doi.org/10.14188/j.1671-8852.2020.0098

Zhang

Peng

, et al. A survey on mental health of medical staff fighting 2019 Novel Coronavirus Diseases in Wuhan. J Trop Med (Chinese) 2020, https://kns-cnki-net.web.bisu.edu.cn/kcms/detail/44.1503.R.20200311.0813.002.html

World Health Organization. Coronavirus disease (COVID-2019) situation reports, 2020, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/

People’s Daily Online. 42000 medical personnel rushed to the rescue for Wuhan, Nurses account for nearly 70%, 2020, http://bj.people.com.cn/n2/2020/0301/c14540-33840656.html

World Health Organization. Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 2003, 2020, https://www.who.int/csr/sars/country/table2004_04_21/en/

Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 Novel Coronavirus Diseases (COVID-19) in China. Chin J Epidemiol 2020; 41(2): 145–151.

Shaw

Chilcott

Hansen

, et al. The GP’s response to pandemic influenza: a qualitative study. Fam Pract 2006; 23(3): 267–272.

Haigh

. Reconstructing nursing altruism using a biological evolutionary framework. J Adv Nurs 2010; 66(6): 1401–1408.

Wong

Koh

Cheong

, et al. A cross-sectional study of primary-care physicians in Singapore on their concerns and preparedness for an avian influenza outbreak. Ann Acad Med Singapore 2008; 37(6): 458–464.

10.

Tam

Pang

Lam

, et al. Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: stress and psychological impact among frontline healthcare workers. Psychol Med 2004; 34(7): 1197–1204.

11.

Maunder

Lancee

Rourke

, et al. Factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in Toronto. Psychosom Med 2004; 66(6): 938–942.

12.

Chong

Wang

Hsieh

, et al. Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital. Br J Psychiatry 2004; 185: 127–133.

13.

Nickell

Crighton

Tracy

, et al. Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution. CMAJ 2004; 170(5): 793–798.

14.

National Health Commission and National Administration of Traditional Chinese Medicine. Diagnosis and treatment protocol for COVID-19 (Trial Version 7), 2020, http://www.nhc.gov.cn/yzygj/s7653p/202003/46c9294a7dfe4cef80dc7f5912eb1989.shtml

15.

Brooks

Rubin

Greenberg

. Traumatic stress within disaster-exposed occupations: overview of the literature and suggestions for the management of traumatic stress in the workplace. Br Med Bull 2019; 129(1): 25–34.

16.

Fang

Guan

, et al. The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry 2009; 54(5): 302–311.

17.

Maunder

Lancee

Balderson

, et al. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis 2006; 12(12): 1924–1932.

18.

Shiao

Koh

, et al. Factors predicting nurses’ consideration of leaving their job during the SARS outbreak. Nurs Ethics 2007; 14(1): 5–17.

19.

Chuang

Lou

. Psychometric evaluation of the stress scale of caring for highly infectious disease patients among health care workers: based on SARS. Taiwan J Public Health 2005; 24(5): 420–430.

20.

von Elm

Altman

Egger

, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg 2014; 12(12): 1495–1499.

21.

Wong

Koh Cheong

Lee

, et al. Concerns, perceived impact and preparedness in an avian influenza pandemic—a comparative study between healthcare workers in primary and tertiary care. Ann Acad Med Singapore 2008; 37(2): 96–102.

22.

Lin

Peng

, et al. The psychological effect of severe acute respiratory syndrome on emergency department staff. Emerg Med J 2007; 24(1): 12–17.

23.

Wong

Lee

, et al. Healthcare workers’ duty concerns of working in the isolation ward during the novel H1N1 pandemic. J Clin Nurs 2012; 21(9–10): 1466–1475.

24.

National Health Commission of the People’s Republic of China. NHC: All hands-on deck in virus fight, 2020, http://www.nhc.gov.cn/xcs/xxgzbd/gzbd_index.shtml

25.

Feng

Chiu

, et al. Applying theory of planned behavior to predict nurses’ intention and volunteering to care for SARS patients in southern Taiwan. Kaohsiung J Med Sci 2004; 20(8): 389–398.

26.

Kim

Yoo

, et al. Attitude, beliefs, and intentions to care for SARS patients among Korean clinical nurses: an application of theory of planned behavior. Taehan Kanho Hakhoe Chi 2006; 36(4): 596–603.

27.

Maunder

Hunter

Vincent

, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003; 168(10): 1245–1251.

28.

Koh

Lim

Chia

, et al.

Risk perception and impact of Severe Acute Respiratory Syndrome (SARS) on work and personal lives of healthcare workers in Singapore: what can we learn?

Med Care 2005; 43(7): 676–682.

29.

Chan-Yeung

. Severe Acute Respiratory Syndrome (SARS) and healthcare workers. Int J Occup Environ Health 2004; 10(4): 421–427.

30.

Balicer

Omer

Barnett

, et al. Local public health workers’ perceptions toward responding to an influenza pandemic. BMC Public Health 2006; 6(1): 99–100.

31.

Liu

Luo

Haase

, et al. The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. Lancet Glob Health 2020; 8: E790–E798, https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30204-7/fulltext

32.

Pan

Qiu

. A preliminary study on the stress of nurses who care for SARS patients and their corresponding behaviors. J Taiwan Soc Nephrol 2003; 2(2): 120–128.

33.

Tan

Goh

Lee

. Family physicians’ experiences, behaviour, and use of personal protection equipment during the SARS outbreak in Singapore: do they fit the Becker Health Belief Model. Asia Pac J Public Health 2006; 18(3): 49–56.

34.

Tompkins

Kerchberger

. Special article: personal protective equipment for care of pandemic influenza patients: a training workshop for the powered air purifying respirator. Anesth Analg 2010; 111(4): 933–945.

35.

Honda

Iwata

. Personal protective equipment and improving compliance among healthcare workers in high-risk settings. Curr Opin Infect Dis 2016; 29(4): 400–406.

36.

Chan

Huak

. Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore. Occup Med (Lond) 2004; 54(3): 190–196.