Mental health and well‐being of anaesthetists during the COVID‐19 pandemic: a scoping review

Summary

The COVID‐19 pandemic has imposed substantial burdens on clinicians and there is a need to better understand the impact on mental health and well‐being. This scoping review investigates the prevalence of mental health concerns in anaesthetists, risk and protective factors for mental well‐being, and anaesthetists' pandemic‐related concerns and support. We searched online databases for articles published between January 2020 and May 2022, using search terms related to: anaesthesia; burnout, well‐being, mental health or stress; and COVID‐19. We identified 20 articles comprising 19 different populations of anaesthetists (n = 8680) from 14 countries. Studies identified the prevalence of the following condition in anaesthetists: burnout (14–59%); stress (50–71%); anxiety (11–74%); depression (12–67%); post‐traumatic stress (17–25%); psychological distress (52%); and insomnia (17–61%). Significant risk factors for poorer mental health included: direct COVID‐19‐related issues (fear of self and family exposure to infection; requirement for quarantine); practitioner health factors (insomnia; comorbidities); psychosocial factors (loneliness; isolation; perceived lack of support at home and work); demographic factors (female gender; non‐white ethnicity; LGBTQIA+); and workplace factors (redeployment outside area of clinical practice; increased work effort; personal protective equipment shortages). Protective factors identified included: job satisfaction; perceived organisational justice; older age; and male sex. Anaesthetists' self‐reported concerns related to: personal protective equipment; resource allocation; fear of infection; fear of financial loss; increased workload; and effective communication of protocols for patient treatment. Support from family, colleagues and hospital management was identified as an important coping mechanism. Findings from this review may support the design of interventions to enhance anaesthetists' psychological health during pandemic conditions and beyond. Future research should include consistent psychological outcome measures and rigorous experimental design beyond cross‐sectional studies.

Introduction

The role of the anaesthetist is often stressful. Everyday practice involves working in an unpredictable and dynamic environment where errors can lead to patient harm. The onset of the COVID‐19 pandemic in early 2020 led to increased concern about the additional physical and psychological demands on this important subset of healthcare workers [1, 2, 3]. With their expertise in airway management, many anaesthetists were re‐assigned from operating theatres to ICUs [4]. As a consequence, they have been at potentially increased risk of contracting COVID‐19 infection due to exposure to respiratory droplets or aerosols during airway procedures [5, 6]. Compounding these concerns, pandemic‐related pressures included: workplace changes; surgical backlogs; staff and equipment shortages; carrying out tasks wearing personal protective equipment (PPE); witnessing patients and colleagues dying; and interactions with distressed families of patients [4, 7, 8].

Additional workplace pressures of this nature can lead to increased psychological distress and burnout, which is characterised by emotional exhaustion, depersonalisation and reduced personal accomplishment [9]. Burnout and poor well‐being are associated with: lower work performance; impaired decision‐making; risk of medical errors and reduced patient safety [10, 11, 12]; depression and suicidal ideation [13]; sleep disorders [14]; alcohol and drug use [15]; and clinician attrition [16]. This compounds the existing concern that anaesthetists are already at increased risk of suicide compared with the general population [17, 18].

Although disruptions to essential healthcare services still persist well into the third year of the COVID‐19 pandemic, responses have evolved with the introduction of vaccines, treatment protocols and improved PPE and equipment supply chains. The focus of practice has shifted toward the resumption of business as usual, including the restoration of primary care, management of elective backlogs and the consequences of medical staff turnover and loss [8]. Importantly, clinicians who worked during previous epidemics were found to be at high risk of developing long‐term mental health issues [19], demonstrating the need for ongoing psychological support once a pandemic has ended.

The purpose of this scoping review was to investigate the known prevalence of psychological distress and burnout in anaesthetists during the COVID‐19 pandemic; identify the risk and protective factors associated with mental health and well‐being; and report concerns and support mechanisms related to working under pandemic conditions. Findings from this review can inform monitoring and intervention strategies that support psychological health during periods of increased demand under pandemic conditions, which may be useful beyond the pandemic.

Methods

This review investigated existing literature regarding the mental well‐being of anaesthetists in the context of the COVID‐19 pandemic. We used a scoping review method because this provides a means of rapidly mapping key concepts within a nascent research area [20]. Scoping reviews are useful for exploring fields where evidence is emerging and a lack of randomised controlled trials prevents completion of more rigidly structured systematic reviews and meta‐analyses. Scoping review methodology provides freedom to go beyond questions of intervention effectiveness [21], for instance where there are no published interventions or where interventions have not been empirically evaluated.

With a librarian, we identified relevant articles by searching Web of Science, PubMed, Embase, Scopus and Google Scholar with search terms (and their permutations) including: anaesthesia; burnout, well‐being, mental health or stress; and COVID‐19. We also searched reference lists of identified articles and hand searched relevant journals for articles published between 1 January 2020 and 18 May 2022. The principal search was conducted on 10 September 2021 (see online Supporting Information, Table S1), with article alerts monitored up to 18 May 2022. Search results were exported to Covidence systematic review software (Covidence, Melbourne, Australia) and duplicates removed. Two authors (EP, LF) screened titles and abstracts then assessed full texts that met inclusion criteria. A third author (NP) screened any articles that were queried.

Inclusion criteria were: published between January 2020 and May 2022; English language; use any research of quantitative or qualitative design; published in a peer‐reviewed journal, conference proceedings or abstracts; included anaesthetists as participants either as the total sample or as a subset of the total sample; and described assessment of burnout, mental health and/or well‐being of anaesthetist participants irrespective of any comparison with other healthcare workers or the general population. Review articles were excluded.

Data were extracted onto a Microsoft Excel spreadsheet (Microsoft Corp, Redmond, WA, USA), including: sample size; study location; study design; outcome measures; prevalence; risk and protective factors; effect size and 95%CIs (see online Supporting Information, Tables S2 and S3) [22]. Two authors charted the data (EP, LF) and cross‐checked for accuracy.

Results

Of 1254 articles initially returned, we included 20 articles that studied 8680 anaesthetists (Fig. 1) [23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42]. Studies sampled anaesthetists from 14 countries: Canada (n = 55) [26]; Egypt (n = 330) [32, 41]; France (n = 46) [36]; India (n = 512) [24]; Italy (n = 195) [28, 34]; Malaysia (n = 85) [23]; Pakistan (n = 8) [31]; Saudi Arabia (n = 241) [30]; Singapore (n = 115) [42]; Spain (n = 776) [39]; South Africa (n = 391) [33]; Turkey (n = 34) [40]; UK and Ireland (n = 1143) [27, 37, 38]; and the USA (n = 4759) [25, 29, 35].

Figure 1.

Flow chart illustrating the scoping review process.

Sixteen of the 20 studies used a cross‐sectional survey design. Three were longitudinal – one study reported follow‐up data [34] from a previously reported study [28], while two studies reported data from the same prospective longitudinal cohort study [37, 38]. One study was solely qualitative and used semi‐structured telephone interviews [31]. All 19 quantitative studies used self‐report surveys to assess mental health and well‐being of anaesthetists. Four of the cross‐sectional studies incorporated a mixed‐methods qualitative component (i.e. focus group [28] or open‐text survey items [26, 27, 35]).

Eighteen of the 20 studies used validated outcome measures to assess mental health and well‐being constructs (see online Supporting Information, Table S2), including: burnout [23, 25, 26, 29, 32, 34]; stress [25, 28, 32, 34, 39, 41]; anxiety [23, 24, 25, 28, 30, 34, 35, 40, 42]; depression [23, 24, 25, 28, 30, 34, 35, 40, 42]; post‐traumatic stress [30, 33, 37, 38]; psychological distress [37, 38]; insomnia and sleep concerns [24, 26, 28, 34, 40, 42]; resilience [36]; happiness [34] and well‐being [25, 27]. Two studies did not specify validated outcome measures: one was a conference proceeding that only noted that a survey was used [27], and the other used qualitative interview techniques [31].

Prevalence rates of mental health and well‐being varied widely (Fig. 2 and online Supporting Information, Table S2). Included studies reported the rates of burnout (14–59%); stress (50–71%); anxiety (11–74%); depression (12–67%); post‐traumatic stress (18–25%); psychological distress (52%); and insomnia (17–61%).

Figure 2.

Prevalence of mental health and well‐being outcomes with location. Studies which did not report prevalence for anaesthetists are omitted. Dots are prevalence in each study.

In a Canadian study, 42/69 (61%) anaesthetists felt more stressed than they did before the onset of the pandemic and 4/69 (6%) reported making a major medical error in the previous 6 months [26]. In the same study, a qualitative matrix revealed impacts on sleep were heterogeneous, such that some respondents slept more than before the onset of the pandemic whereas some had worse sleep [26].

Four studies reported outcome measures related to positive psychological health [25, 27, 34, 36]. One study from France found that anaesthesia as a specialty was associated with higher resilience scores relative to other specialties, including emergency medicine, intensive care medicine and infectious disease [36]. A study from Italy measured happiness in life using a single‐item measure [34] and found mean (SD) happiness scores were 6.5 (2.0) on a 10‐point scale. Two studies measured well‐being [25, 27]. From a sample from the UK, 20/29 (69%) anaesthetists reported that they believed that working during the height of the COVID‐19 pandemic had been detrimental to their mental well‐being [27]. A study from the USA assessed anaesthetists' ratings of positive emotion; engagement; relationships; meaning; accomplishment; and health [25]. While well‐being prevalence was not reported, the study showed that 141/561 (25%) respondents felt isolated.

There was a range of statistically significant risk and protective factors reported for mental well‐being (Fig. 3, online Supporting information, Table S3). Risk factors included: direct COVID‐19 related issues (fear of exposure to infection; requirement for quarantine) [24, 42]; practitioner health factors; (insomnia; having comorbidities) [24, 33, 42]; psychosocial factors (loneliness; isolation; perceived lack of support at home and work) [29, 33, 34]; demographic factors (female sex; non‐white ethnicity, LGBTQIA+) [25, 29, 35, 42]; and workplace factors (high work effort; perceived staff shortages; redeployment outside area of clinical practice; PPE shortages) [29, 32, 33, 34, 42]. High effort was also associated with lower happiness [34].

Figure 3.

Magnitude of risk (black dots) and protective (grey dots) factors for mental health and well‐being. Point estimates are standardised regression coefficient or transformed odds ratio [43, 44]. Error bars are 95%CIs, where reported. EE, emotional exhaustion.

Protective factors included: job satisfaction; perceived procedural and organisational justice; older age; and male sex [24, 28, 32, 34]. Procedural and organisational justice refers to processes and procedures employed to resolve conflicts or allocate resources in the workplace.

A range of concerns and supports were identified (see online Supporting Information, Table S4). A consistent concern was risk of infection to self and family members [24, 26, 27, 41, 42]. There were also concerns relating to PPE, including its unavailability [24, 25, 41, 42]; training on its use [41]; and difficulty of working while wearing it [27]. In addition, respondents were worried about treatment protocols; procedures employed to resolve conflicts or allocate resources reliably; and ineffective communication about the pandemic [26, 27, 28, 41].

Working conditions were identified as a salient factor when treating patients during the pandemic. Perception of workload varied across study locations: in Egypt, anaesthetists felt overwhelmed by their increased workload [41] whereas in Singapore the majority of respondents perceived their workload to be similar to pre‐pandemic levels [42]. Other work‐related concerns included: fear of financial loss as a result of the pandemic [24]; pandemic‐related increases in parenting responsibilities; and reductions in academic time and productivity [25]. In the USA, some respondents intended to alter their future occupational plans as result of the COVID‐19 pandemic, including: changing clinical responsibilities (122/561, 21.7%); reducing working time (60/561, 10.6%); or leaving the profession (7/561, 1.2%) [25].

Support mechanisms for managing distress were also identified. Canadian respondents agreed that support from family (57/62, 91%), colleagues (52/61, 85%), management/head of department (41/56, 71%) and hospital administration (26/52, 50%); someone to discuss concerns with (45/62, 73%); and religious beliefs (18/42, 43%), helped them cope during the pandemic [26]. In a UK study, 4/29 (14%) respondents sought help from a departmental wellness lead or psychologist [27].

Only one study canvassed anaesthetists directly about their opinions on recommendations to improve well‐being. In a qualitative study, Haq et al. interviewed eight anaesthetists from Pakistan [31]. Suggestions included: healthcare workers strictly following standard operating procedures; governing bodies spreading awareness of the infection to decrease stigmatisation; provision of dedicated rest spaces for physicians; establishment of a multidisciplinary team to treat COVID‐19 patients; and better management of healthcare workers and patients with COVID‐19.

In other studies, authors made suggestions and recommendations to support and improve the mental health and well‐being of anaesthetists working in COVID‐19‐affected workplaces. These included: screening for psychological risk factors [23, 42]; access to appropriate psychological or well‐being interventions such as online/telehealth consultations [24, 25, 27, 34, 38, 39]; psychological first aid [26]; family and peer support [23, 26, 29, 36]; promotion of physical activity; relaxation and sleep hygiene [27, 28, 29, 34, 36, 39]; psychoeducation [23, 24, 26, 27]; appointment of a wellness committee or officer [23, 26]; and individual and team debriefs [36].

From an organisational perspective, recommendations included: regulation of work hours to alleviate fatigue [24, 28, 32]; provision of a safe and well‐designed workplace [24, 28, 31, 32]; education and training [28, 30, 41]; provision of adequate PPE [26]; clear communication about treatment protocols [26, 30]; financial support [23, 24]; and accommodation for those on COVID‐19 duties [23, 24]. In particular, two studies highlighted the importance of organisations taking steps to identify and monitor psychological distress on an ongoing basis [23, 37].

Discussion

This scoping review highlights the effect of the COVID‐19 pandemic on the workplace for anaesthetists. We found that specific impacts on mental health and well‐being are heterogeneous across countries and practice contexts. Our findings are generally consistent with evidence of mental health outcomes for other healthcare providers working during the pandemic. For example, clinicians working in ICU were found to be at risk of developing post‐traumatic stress disorder, burnout, anxiety and depression, and felt more stressed at work, with some considering leaving their job [45, 46, 47]. More generally, exposure to COVID‐19 was found to be positively correlated with mental health issues experienced by healthcare workers, with rates of depression, anxiety, stress and post‐traumatic stress disorder being higher in those working in high‐risk locations than those working in low‐risk areas [48, 49].

Research that investigated concerns of healthcare workers during the current pandemic, as well as the SARS 2003 outbreak, supports the findings of this review. Risk of infection of self and family; availability of PPE and inadequate training in its use; increased workload; ineffective communication about treatment protocols; and financial worries were all concerns of those working under pandemic conditions [19, 24, 25, 27, 31, 33, 35, 37, 41, 46, 50]. The evidence suggests these factors are important, not only in securing immediate infection control and safety, but also in having a perceived downstream impact on mental health and well‐being.

We identified several limitations in the current evidence base. Most studies used cross‐sectional designs, none went beyond qualitative or quantitative observational designs and none directly evaluated an intervention or programme to support anaesthetists' mental well‐being. Cross‐sectional study designs make it difficult to explain the wide range of prevalence rates for mental well‐being measures, or to attribute directionality and causality of risk and protective factors. Differences in epidemiological burden, management of working conditions, national preparedness and cultural beliefs may contribute [51]. Measurement heterogeneity and variability in organisational norms on reporting mental health concerns are also relevant. Well‐designed comparative research using nationally representative samples is required to confirm whether these differences are due to geographical or other latent factors.

Only three studies incorporated a longitudinal design [34, 37, 38]. However, these datasets were not subjected to longitudinal statistical analyses, such as cross‐lagged panel modelling or other mixed‐effects modelling, which hinders knowledge about which predictors and processes are important and determining those that interventions might target.

All studies we included lacked pre‐pandemic baseline measures and many did not report key statistics, error margins or effect sizes in their results or supplementary data, which impedes meta‐analysis. There was also minimal overlap in identified risk factors across studies, primarily because studies measured different predictors and psychological outcomes. Finally, no studies in the review measured other important mental health outcomes such as suicidal ideation, self‐harm or suicide attempts, despite prior evidence that anaesthetists have increased suicide risk and access to means [17, 18, 52].

Converging research points to the importance of support from colleagues, management and hospital administration for promoting healthcare workers' mental well‐being, including under pandemic conditions [26, 53, 54]. There is also a range of psychological interventions that were developed for these workers before and during the pandemic [55, 56, 57, 58, 59]. Currently, anaesthetists have access to workplace psychological interventions [60, 61] and resources found on websites of professional bodies (see online Supporting Information, Table S5). Access to interventions such as counselling, psychoeducation and self‐care including exercise and relaxation techniques may be helpful [23, 24, 26, 27, 28, 52, 57, 62, 63]. In addition, evidence from this review highlights that interventions to support the mental well‐being of anaesthetists during pandemics should consider participant diversity because female, LGBTQIA+ and non‐white anaesthetists may be more at risk of mental health impacts [24, 25, 29, 41]. A systematic review conducted before the onset of the COVID‐19 pandemic suggested that organisation‐directed interventions have larger treatment effects for burnout than physician‐directed interventions [64]. There is broad recognition that it is not enough to leave mental well‐being as an individual responsibility but rather, a systems‐level approach that targets organisational and cultural change is required [23, 37, 56, 65, 66]. Using a collaborative model may enhance organisational justice within the work environment and foster resilience in anaesthetists [54, 67].

Our findings reinforce the need for high‐quality research into anaesthetists' mental health and well‐being that includes baseline or pre‐ and post‐intervention assessment using consistent, standardised measures [57, 61, 68, 69]. Programmes should be designed or adapted where possible in light of deficiencies identified in this review, and incorporate multi‐site trials where feasible. A user‐centred approach using in‐depth interview techniques may be helpful in identifying barriers and facilitators to uptake of initiatives [57, 68, 69], anaesthetists' specific concerns about working under pandemic conditions, and what kind of organisational and psychological interventions might be helpful.

This review has several limitations. The quality of data included was modest, thereby precluding firm conclusions being drawn. The design was a scoping review; thus no quantitative synthesis or meta‐analysis was performed. Included studies were conducted during periods of increased work pressures imposed by the pandemic, but this varied throughout the period of evaluation. In addition, potential respondents most impacted may not have had the time or inclination to participate, which may have contributed to bias within the findings. Furthermore, most of the studies investigated well‐being during initial phases of the pandemic and, although highly instructive, they do not reflect experiences as conditions changed due to factors such as vaccine uptake, improved treatment protocols and resource management.

It is becoming increasingly important to support the mental well‐being of anaesthetists as they face the persistent stressors of their high‐risk workplace, which may lead to psychological distress and burnout, medical error and staff attrition. Effective interventions to improve psychological health are needed more than ever with the additional burden imposed during the ongoing COVID‐19 pandemic. We identified the prevalence of psychological distress, factors associated with mental health and concerns of anaesthetists working under pandemic conditions. Findings may be helpful in the design, implementation and evaluation of work strategies, protocols and interventions to support mental well‐being.

Supporting information

Table S1. Search strategy.

Table S2. Prevalence of psychological outcomes for anaesthetists during the COVID‐19 pandemic.

Table S3. Risk and protective factors for psychological outcomes in anaesthetists during the COVID‐19 pandemic.

Table S4. Summary of studies included in the review on mental well‐being of anaesthetists during the COVID‐19 pandemic.

Table S5. Resources for anaesthetists' mental health and well‐being.