Discussion
The COVID-19 pandemic is globally the most serious and prolonged medical crisis, with Singapore bearing the early brunt of the pandemic. Our study indicated that study participants had a normal mean BRS score. This was similar to the resilience of primary healthcare professionals from a systematic review done in New York8. The median BRS score was 3.6 and 11.3% of respondents reported low resilience. Nurses had significantly lower BRS score compared to doctors in our study (3.8 vs 3.4, p=0.003). This may be in part related to their graduate educational background. A cross-sectional study conducted among nurses in Singapore in 2018 found that there was a positive correlation between highest educational qualification and resilience level; nurses with a bachelor’s or postgraduate degree were about three times more likely to be of moderate or high resilience compared to nurses with only a general nursing certificate9.
Male HCW had higher resilience scores than female HCW in this study. While this may be confounded by the lack of males amongst nurses in this study, previous studies analysing factors affecting resilience did not demonstrate association between gender and resilience scores8,10-12. There was no association between age of HCW and years of working experience with resilience score. This was unlike that suggested in Balmer et al 2014 that resilience among police officers was negatively affected by increased rank, age and length of service. However, the difference in the nature of the work may explain the difference in factors affecting resilience10.
In this study, respondents were generally more concerned regarding their family’s health and safety compared to their own. This was similar to studies done in Taiwan and China during the SARS outbreak on HCW caring for SARS patients. Their main worries included fears of contracting SARs and transmitting SARS to their families, being negligent and endangering co-workers and patients13,14. In addition to the heightened fear during work, the long working hours affected most HCW mentally. The social isolation from colleagues and self-imposed isolation from family members affected their social wellbeing and increased mental stress.
Three main factors were identified in this study that made our staff happy during their isolation duties: 1) Good teamwork with reliable and efficient colleagues; 2) Time away from routine clinical work and 3) Appreciation from the department, community and patients. These factors were similarly being identified in Saudi Arabia during the MERS-CoV outbreak15 and in Taiwan during the SARS outbreak13. At our hospital, we are fortunate to have sufficient provision of personal protective equipment (PPE) for all staff, right from the start of the outbreak, triaged according to task and exposure with clear clinical guidelines available on our hospital intranet and round-the-clock Infectious Disease (ID) specialists available over telephone, who were helpful and supportive. Concerns regarding sufficient PPE and equipment were unfortunately reported in other centres. This was found to be associated with higher HCW infections16. In our centre, we recognised that there would be concern regarding safety and hence staffs who are allocated isolation duties were prioritised for completion of PPE and PAPR training prior to commencing their isolation duties. This ethos continues till today where vaccination is offered to the HCWs over other population.
A study by Jens Klein et al conducted in Germany implied that interventions aimed at reducing psychosocial stress at work among clinicians could improve quality of healthcare17. Promotion of autonomy, provision of adequate support services, a cooperative work environment, and promotion of work-life balance, were possible interventions to reduce psychosocial stress at the organization level. At the same time, working overtime, inadequate rewards, high-perceived demands, and inefficiency at work should be reduced. At the individual level, the reduction of stressful workplace experience like over-commitment by stress prevention programs or other stress management interventions could be an option to increase personal well-being and stress coping methods. Studies suggested that social support at work, satisfying work relationships, and organizational trust were able to reduce symptoms of work stress and error frequency. Further possible interventions at the interpersonal level could address the improvement of leadership or provision of esteem reward and supervisory capacity. A reduction of formal hierarchies could promote social support as well. At the structural level, innovations in work organization, compensatory wage systems, or models of gain sharing could be implemented. Interventions on psychosocial work factors, addressing psychological demands, decision latitude, social support, and effort-reward-imbalance, for the different levels were effective in preventing mental health problems and improving working conditions in a hospital setting.