Abstract
Objective: Both Middle East Respiratory Syndrome (MERS) and Coronavirus Disease 2019 (COVID-19) have an emotional toll on healthcare workers (HCWs), but the difference of the impact between the two diseases remains unknown.
Design: A cross sectional descriptive survey.
Setting: A tertiary care hospital.
Participants: 125 HCWs who worked during the 2014 MERS as well as the 2020 COVID-19 outbreaks in high-risk areas of the hospital including critical care, emergency room and COVID-19 clinics.
Methods: The comprehensive survey comprised 5 sections and 68 questions and was administered to HCWs before availability of the COVID-19 vaccine. The survey evaluated hospital staff emotions, perceived stressors, external factors that reduced stress, personal coping strategies, and motivators for future outbreaks. The participants rated each question for MERS and COVID-19 simultaneously on a scale from 0–3. The responses were reported as mean and standard deviation, while Wilcoxon signed-rank test was used to calculate the difference in responses.
Results: There were 102 (82%) participants who returned the questionnaire. The ritual of obsessive hand washing, emotional and physical fatigue, ongoing changes in infection control guidelines, fear of community transmission, and limitations on socialization and travel were the major stressors that were significantly worse during COVID-19 compared to MERS (P<0.05) and led to HCWs adoption of additional ‘personal’ coping strategies during COVID-19. There was no difference between COVID-19 and MERS, however, among preferences for ‘external’ factors made available to HCWs that could reduce stress or in their preferences for motivators to work in future outbreaks (P>.05).
Conclusion: Both the MERS and COVID-19 outbreaks were emotionally draining for HCWs. However, COVID-19 was a relatively more stressful experience than MERS for HCWs and led to greater personal, behavioral, and protective adaptations by the hospital staff.
Keywords: MERS, COVID-19, Healthcare workers, Emotions, Motivators, Coping
Middle East respiratory syndrome (MERS) is a respiratory illness caused by a novel coronavirus called Middle East respiratory syndrome coronavirus (MERS-CoV), which emerged in 2012 in Saudi Arabia.1 The largest outbreak happened in March and April of 2014, with the majority of the described cases associated with healthcare settings.2 However, other occurrences of the infections have been reported, although only in small clusters. In either case, the documented case fatality rate for MERS has been high; 851 out of 2468 (34%) laboratory-confirmed MERS-CoV patients have died as per the World Health Organization.3
In contrast to the MERS epidemic, severe acute disease caused by the respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide since its emergence in December 2019. It has infected more than 190 million people and caused more than 4 million deaths as of July 2021.4 The spectrum of symptomatic infections of coronavirus disease 2019 (COVID-19) ranges from mild to serious, with critical disease reported in about 5% of the patients.5 The case fatality rate is dependent upon geographic location, age, and underlying comorbidities.6 The hospital mortality, which was very high ranging from 24% to 42% early in the pandemic, has improved with time but still is around 20% in critically ill patients.7,8
Whether it is an epidemic or a pandemic, there is a major psychological impact in addition to the physical devastation the disease may cause. This is especially true in HCWs who are working on the frontlines helping afflicted patients while battling for their own personal safety. During MERS outbreak, studies found that HCWs in contact with affected patients had greater levels of both acute or post-traumatic stress and psychological distress.9,10 Similarly, acute stress and emotional disturbance has been observed among medical staff during COVID-19.11,12
Even though extrapolations have been made about varying psychological experiences for different epidemics or pandemics, they have not been directly compared. Both MERS and COVID-19 have different infectivity and case fatality rates. Whether these dissimilarities would have varying impact on the emotional experience, perceived stressors, or coping strategies of HCWs is unknown. Our hospital is unique, as it was at the heart of the 2014 MERS outbreak and in 2020 shared the challenges facing the rest of the world in the form of COVID-19. A number of our HCWs had the distinct experience of facing both coronaviruses while working in the high-risk areas of the hospital. This gave us a chance to directly compare the emotional experience of these HCWs during MERS with that of COVID-19, which was the intended purpose of this study.
Methods
Study Location
King Faisal Specialist Hospital & Research Centre is a tertiary care hospital in Jeddah, Saudi Arabia. The hospital has over 500 beds, including 60 emergency room and 26 medical intensive care unit beds. The hospital was at the epicenter of both the MERS epidemic in 2014 and the COVID-19 pandemic and constituted as our study site. The hospital is accredited by Joint Commission International and has received Nurses Magnet Recognition by the American Nurses Credentialing Center. Ethical approval for the study was obtained from the Institutional Review Board of the hospital, and it was carried out with the ethical standards set forth in the Helsinki Declaration.
Participants
The MERS epidemic in Jeddah (Saudi Arabia) occurred in April and May 2014, and our hospital was one of the main treating centers for MERS patients. As for COVID-19 cases, even though they were diagnosed earlier in other parts of the world, we started seeing these patients in our hospital beginning in March 2020. The high-risk areas in our study were defined as the medical-surgical intensive care unit, emergency department, and MERS/COVID ambulatory clinics. The staff in our hospital do not “float” to different clinical areas, so HCWs assigned to these clinical units truly represented the “high-risk” cohort. Only those HCWs who worked in these high-risk areas during both MERS and COVID-19 outbreaks were eligible to participate in the study. The survey was conducted in December 2020, before availability of a vaccine. Keeping employee turnover in mind, we anticipated that the number of employees who would qualify to participate in the study would be between 100-150.
Study Tool
The study tool was a comprehensive questionnaire adopted from the one published by our author group after the 2014 MERS epidemic.10 We termed it “MERS-COVID-19 HCWs Questionnaire.” The survey consisted of 5 sections with 72 question items in English language. Some of the questions were the same as those of the 2014 survey, but new questions were also added. The survey was administered to 10 hospital staff as a pilot. Based on their feedback, it was optimized and reduced to 68 items. The final version was converted to an online fillable form and the link was emailed to 125 HCWs who were identified through their respective ‘department heads’ as having worked in the high-risk areas of the hospital during both MERS and COVID-19. Participation was voluntary, and the survey was anonymous.
Questionnaire Sections
The initial part of the survey covered the demographics of the participants. Additionally, to estimate how well they remembered, participants were asked to rate the recollection of their 2014 MERS experience from 0-10: 0=Not at all to 10=Equivalent to COVID-19 experience. The first section of the questionnaire consisted of 15 questions that explored and compared staff emotions during MERS and COVID-19. Each question required a ‘Yes’ or ‘No’ answer. Those who answered ‘No’ received a score of 0 (zero) on a 4-point scale. Those who answered ‘Yes’ were prompted to rate the severity of the feelings further (1=slight; 2=moderate; 3=very much). Responses of all participants were included in the 4-point scale (Score Range 0-3). The internal consistency coefficients were 0.83 (Kuder-Richardson Formula 20) for the number of emotions and 0.88 (Cronbach’s α) for the severity of emotions.
The second section evaluated 20 different possible factors that could have caused stress among the staff. It also required a ‘Yes’ or ‘No’ response. Those who answered ‘No’ received a score of 0. Those who answered ‘Yes’ responded further regarding the severity of the stress factor (1=slight; 2=moderate; 3=very much). Responses of all participants were included in the 4-point scale (Score Range 0-3). The internal consistency coefficients were 0.93 (Kuder-Richardson Formula 20) for the number of stressors and 0.95 (Cronbach’s α) for the stress severity.
The third section, consisting of 13 questions, looked at different personal coping strategies that staff could have used themselves. It comprised firstly a response of ‘Yes’ or ‘No’ if they used the given coping strategy. Those who answered ‘No’ received a score of 0. Those who answered ‘Yes’ then rated the strategies further (1=sometimes; 2=often; 3=always). Responses of all participants were included in the final score (Score Range 0-3, on a 4-point scale). The internal consistency coefficients were 0.72 (Kuder-Richardson Formula 20) for the number of strategies and 0.82 (Cronbach’s α) for the rating of coping strategies.
Section four of the questionnaire had 10 queries looking at the various external factors that could have contributed, either directly or indirectly, in reducing the stress of HCWs. It comprised firstly a response of ‘Yes’ or ‘No’ if they used the given coping strategy. Those who answered ‘No’ received a score of 0. Those who answered ‘Yes’ then rated the strategies further (1=mildly effective; 2=moderately effective; 3=extremely effective). Responses of all participants were included in the final score (Score Range 0-3, on a 4-point scale). The internal consistency coefficient (Cronbach’s α) for the degree of effectiveness was 0.91.
The fifth and final section consisted of 10 possible incentives that could promote willingness to participate in any future MERS or COVID-19 epidemic. These were rated on a 4-point scale in terms of importance of the factor (0=Not at all important to 4=most important). Cronbach’s α for rating of factor importance was 0.94.
Data Analyses
Descriptive statistics were used to organize the data collected from the questionnaire. Correlational analysis was performed to evaluate the internal consistency of the survey. The varying levels of stressors or effectiveness of measures were reported as mean and standard deviation, as appropriate. Wilcoxon signed-rank test was used for the between-group comparisons for the ordinal variables.
Results
Of the HCWs, 102 (82%) returned the questionnaire. The remainder did not participate in the survey and, therefore, were excluded. Demographics of the staff are outlined in Table 1. Respondents were mostly female, middle aged, and nurses by profession. They came from a diverse ethnic background, and a majority lived with families during the two outbreaks. Only half of the staff felt they were better able to handle the COVID-19 pandemic because of their prior experience with MERS. The workload during COVID-19 considerably increased for the majority of the staff when compared to their workload during MERS. The mean response to the question “How clearly do you remember MERS experience when compared to the current COVID-19 experience” was 8.5 out of 10, denoting their vivid recall of the MERS epidemic.
Table 1:
Demographics of Healthcare Workers (n=102)
| Characteristic | Value |
|---|---|
| Age, years, Mean (SD) | 44.5 (8.7) |
| Gender, n (%) | |
| Female | 79 (77) |
| Male | 23 (23) |
| Nationality, n (%) | |
| Philippines | 39 (38) |
| Saudi | 22 (22) |
| Asian | 13 (13) |
| North American | 6 (6) |
| Other | 22 (21) |
| Place of work, n (%) | |
| Critical Care | 59 (58) |
| Emergency Department | 19 (19) |
| MERS/COVID-19 Ambulatory Clinics | 24 (23) |
| Profession, n (%) | |
| Nurse | 72 (70) |
| Doctor | 18 (18) |
| Other | 12 (12) |
| Lived with Family, n (%) | |
| During MERS | 64 (63) |
| During COVID-19 | 38 (37) |
| How clearly you remember MERS experience compared to COVID-19 | 8.5 (2.4) |
| [0=Not at all, 10= Equivalent to COVID-19 experience], mean (SD) | |
| MERS enabled staff to handle COVID-19 better, n (%) | |
| Yes | 48 (47) |
| No | 54 (53) |
| Change in workload during the MERS outbreak, n | (%) |
| Increased | 52 (51) |
| Decreased | 8 (8) |
| Remained Unchanged | 42 (41) |
| Change in workload during COVID-19, n (%) | |
| Increased | 84 (82) |
| Decreased | 4 (4) |
| Remained Unchanged | 14 (14) |
N, number; SD, Standard Deviation; MERS, Middle East Respiratory Syndrome
The responses in the five core sections of the “MERS-COVID-19 HCWs questionnaire” were sorted in order of the number of respondents answering ‘yes’ to the questions during COVID-19 and MERS and then followed by the score out of 3 for the questions, respectively, in each section.
The first section of the questionnaire, which explored the emotions of the staff when comparing MERS to COVID-19, yielded some interesting insights (Table 2). Though a majority of the emotions were similar between the two outbreaks, a few questions scored higher for the emotions during COVID-19. The major emotions that were similar for both MERS and COVID-19 included the HCWs innate professional and ethical obligation, which kept them going through the arduous times, even though they felt nervous and scared while performing their duties. HCWs curtailed their visits to the patients’ rooms and had their morale boosted by appreciation of their courageous efforts from the hospital administration. During COVID-19, however, they endured more emotional and physical exhaustion, had higher expectations for financial compensation, and were more disturbed that other employees in non-coronavirus units escaped the risks they faced (P≤0.01).
Table 2:
Staff “Emotions” during MERS and COVID-19 (n=102, Maximum Score 3)
| During MERS | During COVID-19 | |||||
|---|---|---|---|---|---|---|
| Number | Questions about the staff “Emotions” | Answered Yes (%) | Mean Score (SD) | Answered Yes (%) | Mean Score (SD) | P Value |
| 1 | You felt that you had to do your job as it was your professional and ethical duty | 92 | 2.45 (0.94) | 94 | 2.49 (0.85) | 0.33 |
| 2 | You felt nervous and scared | 92 | 2.14 (0.96) | 92 | 2.27 (0.91) | 0.06 |
| 3 | You felt exhausted from the extra workload | 82 | 1.51 (1) | 90 | 2.06 (1) | <0.001* |
| 4 | You were disturbed that employees in non-Coronavirus units avoided you | 76 | 1.43 (1.06) | 92 | 1.80 (0.95) | <0.001* |
| 5 | Appreciation of your high-risk work by the Hospital administration uplifted your morale | 86 | 1.96 (1.13) | 88 | 2.22 (1.10) | 0.07 |
| 6 | You expected/expect financial compensation after the outbreak | 75 | 1.88 (1.28) | 88 | 2.21 (1.09) | 0.001* |
| 7 | You would have liked financial compensation during the outbreak | 69 | 1.78 (1.34) | 86 | 2.24 (1.14) | 0.001* |
| 8 | You felt it was unfair that some staff were exposed to coronavirus patients while others were not involved at all | 73 | 1.55 (1.6) | 84 | 1.9 (1.06) | <0.001* |
| 9 | You tried curtailing your contact with the coronavirus infected patients (eg, shorten your trips to patient rooms) | 76 | 1.67 (1.14) | 82 | 1.75 (1.07) | 0.40 |
| 10 | You felt irritated that your workload increased substantially in comparison to employees in non-coronavirus units | 59 | 0.92 (1.01) | 71 | 1.2 (1.03) | 0.01* |
| 11 | You were unhappy to do overtime | 61 | 2.06 (0.94) | 65 | 2.02 (0.92) | 0.18 |
| 12 | You thought of quitting your job | 47 | 1.04 (1.23) | 49 | 1.08 (1.24) | 0.33 |
| 13 | If optional, you would have worked in a Non-MERS/Non-COVID unit | 45 | 0.82 (1.1) | 45 | 0.84 (1.08) | 0.41 |
| 14 | You thought of calling in sick | 39 | 0.63 (0.91) | 41 | 0.75 (1.05) | 0.18 |
| 15 | You felt it was better to get infected by coronavirus and attain natural immunity | 18 | 0.24 (0.55) | 31 | 0.51 (0.88) | <0.001* |
Response Score Key; 0=No; 1=Slightly; 2=Moderately; 3-Very Much.
*Favors COVID-19
Section 2 of the questionnaire explored the different stressors that affected the HCWs (Table 3). Of the 20 different possible factors that could have caused stress during the epidemic or pandemic, COVID-19 was hands down the worse experience. The mean score was higher than MERS in 18 out of 20 stressors. With no light at the end of the long COVID-19 tunnel, the ritual of obsessive hand washing and disinfecting objects, ongoing changes in infection control guidelines, fear of getting COVID-19 from the community, limitations on socialization and travel, and anxiety of acquiring infection from work and transmitting it to family were the main factors that HCWs scored significantly higher for COVID-19 as compared to MERS (P≤0.01).
Table 3:
Questions regarding Factors that caused stress during MERS and COVID-19 (n=102, Maximum Score 3)
| During MERS | During COVID-19 | |||||
|---|---|---|---|---|---|---|
| Number | Factors causing stress | Answered Yes (%) | Mean Score (SD) | Answered Yes (%) | Mean Score (SD) | P Value |
| 1 | Not knowing when the coronavirus outbreak will be under control | 84 | 1.96 (1.13) | 98 | 2.45 (0.69) | <0.001* |
| 2 | To continuously wash/sanitize hands | 76 | 1.69 (1.12) | 98 | 2.35 (0.71) | <0.001* |
| 3 | Changing Infection Control guidelines | 62 | 1.81 (1.09) | 91 | 2.58 (0.81) | <0.001* |
| 4 | Limitations placed on travel and socialization outside hospital | 45 | 1.27 (1.2) | 96 | 2.37 (0.82) | <0.001* |
| 5 | Seeing patients with coronavirus dying in front of you | 90 | 2.06 (0.98) | 94 | 2.33 (0.84) | 0.01* |
| 6 | Wearing full protective gear daily causing discomfort | 90 | 1.65 (1.17) | 92 | 2.06 (0.98) | <0.001* |
| 7 | Taking shower and disinfecting clothes/belongings after returning home from work | 84 | 2.06 (1.08) | 90 | 2.35 (0.9) | 0.006* |
| 8 | Worry that you could transmit coronavirus to your family or friends | 82 | 2.02 (1.10) | 90 | 2.31 (0.98) | 0.002* |
| 9 | Fear that you could get Coronavirus infection from someone in the community | 41 | 1.50 (1.16) | 88 | 2.09 (1.02) | <0.001* |
| 10 | News of cases reported in TV/newspapers | 75 | 1.31 (1.04) | 86 | 1.75 (1.03) | <0.001* |
| 11 | Avoiding touching surfaces outside hospital due to fear of transmission | 63 | 1.33 (1.21) | 86 | 1.94 (1.02) | 0.002* |
| 12 | People displaying respiratory symptoms near you | 75 | 1.60 (1.13) | 80 | 1.94 (1.12) | 0.006* |
| 13 | Getting screened for coronavirus infection after possible exposure | 71 | 1.43 (1.16) | 84 | 1.86 (1.05) | <0.001* |
| 14 | Avoiding touching surfaces inside the hospital due to fear of transmission | 69 | 1.41 (1.16) | 84 | 1.90 (1.07) | <0.001* |
| 15 | Getting Coronavirus infection from a patient in the hospital | 78 | 1.63 (1.14) | 82 | 1.78 (1.11) | 0.11 |
| 16 | Lack of treatment/vaccine for virus | 75 | 1.63 (1.16) | 82 | 1.98 (1.09) | 0.009* |
| 17 | People not using masks in the community | 21 | 0.35 (0.74) | 85 | 2.1 (0.62) | <0.001* |
| 18 | Conflict between your duty and own safety | 63 | 1.29 (1.22) | 76 | 1.65 (1.16) | 0.002* |
| 19 | Fear that you may die from Coronavirus if you got infected | 65 | 1.41 (1.25) | 75 | 1.69 (1.19) | 0.08 |
| 20 | You developed respiratory symptoms and feared that you had coronavirus | 49 | 0.94 (1.13) | 65 | 1.31 (1.2) | 0.01* |
Scoring for Level of Stress; 0=No; 1=Slightly Stressed; 2=Moderately Stressed; 3=Very Much Stressed
*Favors COVID-19
As anticipated in any stressful situation, all staff used some sort of personal coping strategies. Section 3 was designed to probe into these strategies (Table 4). Staff were much more involved in personal coping strategies during COVID-19 and scored higher in 10 out of 13 possible strategies presented to them. Reading about the disease itself, following strict infection control practices even in non-coronavirus patients, using separate clothes for work, minimizing outside exposure, and confiding in family for support were the major strategies used by staff, more so during COVID-19 (P≤0.002).
Table 4:
“Personal” coping strategies used by staff to alleviate stress (n=102, Maximum Score 3)
| During MERS | During COVID-19 | |||||
|---|---|---|---|---|---|---|
| Number | Personal Strategies used by the staff | Answered Yes (%) | Mean Score (SD) | Answered Yes (%) | Mean Score (SD) | P Value |
| 1 | Read about coronavirus, its prevention and mechanism of transmission | 100 | 2.27 (0.82) | 100 | 2.57 (0.64) | <0.001* |
| 2 | Followed strict personal protective measures (eg, mask, gown, hand washing etc) | 98 | 2.75 (0.62) | 100 | 2.98 (0.14) | <0.001* |
| 3 | Considered every patient admitted to the hospital as having coronavirus infection | 90 | 2.19 (1.02) | 100 | 2.71 (0.57) | <0.001* |
| 4 | Avoided going out in public places to minimize exposure from coronavirus | 90 | 2.02 (1.04) | 100 | 2.53 (0.7) | <0.001* |
| 5 | Kept separate clothes for work/used disposable scrubs to minimize transmission | 92 | 2.49 (0.88) | 98 | 2.8 (0.53) | <0.001* |
| 6 | Chatted with family and friends to relieve stress and obtain support | 92 | 1.71 (0.88) | 98 | 1.65 (0.62) | 0.33 |
| 7 | Did relaxation activities, e.g., involved in prayers, watch TV, exercise etc. | 89 | 2.12 (0.87) | 91 | 2.44 (0.65) | <0.002* |
| 8 | Avoided media news about coronavirus related fatalities | 76 | 1.31 (0.96) | 84 | 1.39 (0.89) | 0.37 |
| 9 | Involved in activities that would keep mind away from Coronavirus | 54 | 1.12 (1.2) | 83 | 2.51 (0.72) | <0.001* |
| 10 | Lived away from the family and friends to protect them | 65 | 1.51 (1.31) | 80 | 2 (1.18) | <0.001* |
| 11 | Resorted to online shopping wherever possible | 42 | 1.3 (1.1) | 73 | 2.3 (0.6) | <0.001* |
| 12 | Tried to avoid overtime | 82 | 2.01 (1.12) | 78 | 1.56 (0.57) | <0.001† |
| 13 | Got help from family physicians or other doctors to reduce your stress and get reassurance | 42 | 1.09 (1.05) | 49 | 1.13 (0.65) | 0.61 |
Scoring key for using strategies: 0=No; 1=Sometimes Used; 2=Often Used; 3=Always Used
*Favors COVID-19
†Favors MERS
In section 4, staff were presented with different options provided to them directly or indirectly that could have helped reduce their stress (Table 5). Interestingly, all factors were scored high for both MERS and COVID-19, with no statistical difference between the two outbreaks. Supportive colleagues in the workplace, infected colleagues getting better, availability of potential treatment, ample provision of personal protective supplies, and majority of the patients recovering from the disease eased the anxiety of the staff (P≥0.06).
Table 5:
“External factors” that helped reduced stress during MERS and COVID-19 (n=102, Maximum Score 3)
| During MERS | During COVID-19 | |||||
|---|---|---|---|---|---|---|
| Number | External factors that helped reduce stress | Answered Yes (%) | Mean Score (SD) | Answered Yes (%) | Mean Score (SD) | P Value |
| 1 | Support from colleagues in workplace | 98 | 2.45 (0.75) | 100 | 2.49 (0.72) | 0.62 |
| 2 | Your colleagues infected with Coronavirus got better | 96 | 2.43 (0.80) | 98 | 2.51 (0.75) | 0.18 |
| 3 | Availability of potential treatment for the coronavirus | 94 | 2.35 (0.78) | 97 | 2.41 (0.9) | 0.54 |
| 4 | Protective equipment provided to you by the Hospital | 96 | 2.37 (0.82) | 94 | 2.19 (0.93) | 0.06 |
| 5 | Majority patient recovering from infection | 96 | 2.29 (0.85) | 94 | 2.16 (0.92) | 0.07 |
| 6 | Possibility of extra compensation | 92 | 2.22 (0.96) | 92 | 2.16 (0.96) | 0.49 |
| 7 | Confidence in the hospital staff in case you got sick from coronavirus | 90 | 1.98 (1.00) | 90 | 1.96 (1.01) | 0.57 |
| 8 | Clear and consistent guidelines from Hospital for infection prevention | 88 | 2.01 (1.04) | 88 | 2.06 (1.04) | 0.68 |
| 9 | Sharing jokes or humor among colleagues | 88 | 1.73 (0.99) | 88 | 1.84 (0.98) | 0.09 |
| 10 | None of the staff getting the infection while using strict protective measures | 80 | 1.75 (1.12) | 86 | 1.86 (1.03) | 0.38 |
0=No; 1=Mildly Effective; 2=Moderately Effective; 3=Extremely Effective in Reducing Stress
In the final section of the questionnaire, when asked about motivators to continue working during any future MERS or COVID-19 outbreaks, the responses were almost unanimous for both (Table 6). The HCWs wanted ample provision of personal protective equipment, family support, availability of a possible cure or vaccine for the disease, recognition of their efforts, psychiatric counseling, financial compensation, and provision of disability benefits to pull them through in any future pandemic or epidemic.
Table 6:
Motivational factors to encourage continuation of work in future outbreaks (n=102, Maximum Score 3)
| During MERS | During COVID-19 | |||||
|---|---|---|---|---|---|---|
| Number | Motivational factors for future outbreaks | Answered Yes (%) | Mean Score (SD) | Answered Yes (%) | Mean Score (SD) | P Value |
| 1 | Adequate personal protective equipment supplies by the Hospital | 98 | 2.65 (0.63) | 96 | 2.59 (0.69) | 0.44 |
| 2 | Family support | 98 | 2.65 (0.59) | 96 | 2.63 (0.68) | 0.67 |
| 3 | Available cure or vaccine for the disease | 90 | 2.54 (0.35) | 96 | 2.59 (0.39) | 0.17 |
| 4 | Recognition from management and supervisors for the extra efforts | 96 | 2.41 (0.80) | 92 | 2.31 (0.90) | 0.13 |
| 5 | Psychiatric help and therapy made available in workplace to help reduce stress and anxiety | 90 | 2.10 (0.98) | 92 | 2.16 (0.96) | 0.50 |
| 6 | Disability benefits if incapacitated from the disease | 90 | 2.35 (0.95) | 90 | 2.41 (0.95) | 0.47 |
| 7 | Compensation to family if disease related death at work | 90 | 2.35 (0.95) | 90 | 2.39 (0.97) | 0.63 |
| 8 | Financial recognition of efforts | 88 | 2.29 (0.98) | 84 | 2.27 (1.09) | 0.72 |
| 9 | Reduced working hours during outbreaks | 82 | 1.84 (1.07) | 84 | 2.0 (1.07) | 0.08 |
| 10 | Not forced to do overtime | 78 | 1.75 (1.1) | 82 | 1.8 (1.05) | 0.39 |
0=Not important at all; 3=Most important
To assess recall bias for the MERS experience of HCWs, we identified the questions in the study questionnaire that were used in our previously published 2014 MERS survey.10 When we compared the cumulative means of the responses of those questions between the two surveys, there was no statistical difference in the score of the responses. The similar intensity of the responses corroborates that the HCWs current recall of their MERS experience was optimal (Table 7).
Table 7:
Comparison of the responses to the similar questions regarding MERS between the 2014 and current survey
| Section | Number of Similar Questions regarding MERS | MERS Responses in 2014 Survey | MERS Responses in Current Survey | |||
|---|---|---|---|---|---|---|
| Cumulative Mean | Cumulative SD | Cumulative Mean | Cumulative SD | P Value | ||
| 1 | 11 | 1.78 | 1.04 | 1.62 | 1.08 | 0.26 |
| 2 | 10 | 2.43 | 0.82 | 2.14 | 1.13 | 0.057 |
| 3 | 9 | 1.77 | 0.88 | 1.82 | 0.95 | 0.68 |
| 4 | 9 | 2.04 | 0.94 | 2.14 | 0.93 | 0.43 |
| 5 | 10 | 2.47 | 0.77 | 2.29 | 0.84 | 0.11 |
Discussion
Any epidemic or pandemic can cause anxiety and adversely affect the general population.13 The emotional toll on HCWs, however, can be even more intense and may result in long term consequences.9-12 This is especially true for the frontline HCWs in high-risk areas who risk their lives in the line of duty.14 Differences in geographic location, infectivity, and fatality rates result in varying psychological and emotional impacts of the epidemics, and any comparison among them is usually a subject of extrapolation and assumption.15 We, however, were in a unique situation where many of our HCWs faced both the MERS epidemic and the COVID-19 pandemic. This enabled us to directly compare their emotions, perceived stressors, and coping strategies during the two coronavirus outbreaks. We used our own questionnaire instead of tools like Beck’s Depression Inventory-II or State-Trait Anxiety Inventory for Adults, as we wanted to do a more in-depth and multifaceted analysis.
We included HCWs who worked in high-risk inpatient and outpatient areas, as they constituted the biggest cohort of employees with direct exposure to both MERS and COVID-19 patients. The staff were from a diverse ethnic background, which follows the general trend in Saudi Arabia, where expatriates still comprise a majority of the healthcare work force.16 The completion response rate of 82% for a very comprehensive survey is better than what might be expected in similar studies.17
The HCWs’ mean MERS recall score of 8.5 out of 10 denotes their vivid remembrance of the MERS epidemic. This gives credence to our results when comparing MERS and COVID-19 experiences a few years apart. The strong recollection is not surprising, as stressful and distressing experiences have been associated with long term remembrance and recall even years later.18,19 Furthermore, the similar intensity of the responses for MERS questions in the current survey compared to our 2014 study gives further credibility to our results.10
COVID-19 had a stronger impact on many of the emotions of the HCWs when compared to MERS. The staff felt more exhausted, had feelings of disgruntlement because of the disproportionate increase in their workload, and had higher expectations of financial compensation in return of their arduous efforts. COVID-19 has lasted much longer than MERS and could explain these sentiments, as duration of the impact may increase intensity of one’s emotions.20
Almost all the factors causing stress in the HCWs were significantly worse during COVID-19 as compared to MERS. There could be various reasons to explain this. Even though fatality rates for both MERS and COVID-19 were high in critically ill patients, the overwhelming infectivity, higher transmissibility to self and family, and that COVID-19 was rampant both in the hospital and community, could have been influencing factors for the stronger responses.21,22
When it came to strategy adoption and measures undertaken by the staff at a personal level, the trends followed their emotions and perceived stressors. The coping strategies reflected the instinctive human nature of evading illness and bolstering defense through precautionary measures.23 Some researchers have touched partly on this aspect, although not in detail.24 The HCWs in our study exercised cautious behavior when they handled any patient, used strict protective measures, minimized outdoor activities, and resorted to meditation and relaxation activities. Some of these strategies were reported during MERS;10 however, our results show that HCWs embraced these measures more during COVID-19, which reflects the overwhelmingly negative impact of COVID-19 on the HCWs as compared to MERS.
When it came to external factors provided to hospital staff, either directly or indirectly, there were no differences in responses between MERS and COVID-19. The HCWs found equal comfort amidst both the coronaviruses from any positive external influences. This is not that surprising, as it is human nature to accept and find solace in any available physical, social, or behavioral support during adversarial circumstances.25 This same sentiment was reflected in the responses in the last section of the questionnaire, where HCWs did not differentiate in the motivators for future outbreaks. When asked about the factors that would incentivize them to continue working during any future epidemic or pandemic, factors related to safety, family support, availability of vaccine or cure for the disease, psychiatric help, and special compensation and recognition stood out. Some of these factors reflect what also has been reported in other epidemics.12,14
Our study is unique in many ways. Most studies regarding COVID-19 in HCWs have focused on single or few aspects of emotions or psychological health.11-15,23,26 We describe a comprehensive insight on multiple aspects related to emotions and coping strategies. Comparison of the anxiety levels between MERS and COVID-19 has also been touched upon, but current literature misses out on the elaborate insight that our study provides.26 Most of the studies have described experiences of specific ethnic cohorts, whereas our study participants represent a diverse ethnic group.
Our study does have a few limitations. As mentioned earlier, the two outbreaks were separated by a few years. Even though the participants subjectively assessed their recall of MERS experience as exceptional, it could not be objectively assessed. The survey was administered almost 9 months into the COVID-19 pandemic. This could have impacted on the responses favoring COVID-19. The study participants were predominantly nurses. A survey solely in physicians or other professions could have differing results. Participants were from a diverse ethnic background and do not reflect sentiments of the indigenous population. Our staff did not face any shortage of personal protective supplies; in other hospitals with less-than-ideal working environments, this could have a major impact on emotions. The survey also could have missed those employees who either quit after MERS or during the COVID-19 pandemic.
Future studies could elaborate on the emotional and psychological impact in other cohorts of HCWs, like respiratory therapists or housekeeping. They can use our results and see if addressing a particular stressor will help mitigate anxiety of the hospital staff, or whether a particular coping strategy can influence their stress or emotional experience. We did not explore any maladaptive coping strategies (eg, substance abuse), which could be addressed in future studies. Half of our participants did not feel their MERS experience enabled them to handle COVID-19 any better. This needs to be further explored. Although our sample size was fair, larger groups of HCWs need to be engaged to delineate any changes in future hospital policies. Impact of vaccines on the HCWs emotional experience also needs evaluation in future studies. Addressing the issues highlighted in our study may help hospitals improve their staff experience and increase satisfaction during future pandemics or epidemics.
Conclusion
Both the MERS and COVID-19 outbreaks were emotionally draining for HCWs. However, COVID-19 was much more stressful in many aspects and led to greater behavioral and protective adaptations by hospital staff. The HCWs appreciated and utilized the resources made available to them and expected physical, psychological, and financial support to help them cope in future outbreaks. Further studies could focus on strategies to improve HCWs emotional wellbeing, based on our results.
Acknowledgments
We would like to thank following individuals for their help in the study. Dr Musaab A Mujalli, Dr Mansor Binhashr, Dr Mubaraka Amanullah, Dr Muhammad Saqib Iqbal, Dr Hanan Alghamdi, Dr Moayad S Qashqari, Dr Yassir Siddiq, Dr Raghad A Aldehasi, Dr Hattan W Alturki, Dr Muhannad S Alzahrani and Dr Khalid Y Abumelha.
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