Psychological impact of COVID‐19 pandemic on healthcare workers in China Xi’an central hospital

Abstract Objective COVID‐19 significantly altered our routine, lifestyle, and stress level across the globe. This study investigated the psychological impact of COVID‐19 on healthcare workers in China Xi'an Center hospital. Methods A modified online questionnaire of Psychological Status and the General Health Questionnaire (GHQ‐12) was provided to 1,967 healthcare workers during the COVID‐19 pandemic. Participation was voluntary, and the responses were anonymous. The survey lasted for 2 weeks, and the GHQ‐12 was completed every other day. The data were collected automatically and electronically and then statistically analyzed. Results The 431 (21.9%) responders included 214 nurses (49.7%), 146 clinicians (33.9%), 29 pharmacists (6.7%), 15 medical technicians (3.5%), 17 administrative staff (3.9%), and 10 other departments (2.3%). Of these, 46.2% had 10 years of work experiences or more and 78.2% were married. Work experience increased emotional stress as 23% of participants with 10 years or more of experience exhibited higher stress compared to those with fewer than 3 years of work experience (7.5%). Moreover, 33.3% of participants who worked in or were exposed to the affected areas of the pandemic experienced psychological stress. Overall, this study identified four factors that were significantly associated with psychological stress: (a) work experience (OR 2.99; 95% CI: 1.06 to 8.41); (b) change in job position (OR 1.99; 95% CI: 1.10 to 3.59); (c) change in lifestyle (OR 4.06; 95% CI: 1.81 to 9.10); and (d) need for psychological counseling (OR 3.07; 95% CI: 1.62 to 5.82). Conclusions The COVID‐19 pandemic has increased psychological stress among healthcare workers with 10 years or more work experiences and who recently experienced a career position change.


| INTRODUC TI ON
Coronavirus 2019  is an infectious respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) . Since late in 2019, there have been more than 54 million cases reported from over 191 countries and territories and more than 1,317,812 deaths globally ( (Zhang, 2020). This work showed that among the 422 medical institutions providing diagnosis and treatment services for COVID-19 patients, 3,019 healthcare workers contracted the disease with 1,716 confirmed cases and 5 deaths (a crude mortality rate of 0.3%). On 22 January, our Xi'an Central Hospital was identified as one of the designated hospitals for  patients. Immediately after this designation, our hospital provided healthcare workers with centralized training, organized a specialized expert team to fight COVID-19, and mobilized healthcare workers to participate in a triage station, fever clinic, and quarantine ward. In our hospital, healthcare workers screen patients with a fever for the possibility of having contracted COVID-19 and admit the patients with the virus for hospitalization and treatment. To do this, many healthcare workers that are not work in the infectious department also participate in the screening and treatment of COVID-19 patients, but need to be trained for such a purpose.
The COVID-19 pandemic has not only significantly affected our community, society, country, and the whole world, but has also been responsible for adverse psychological impacts on our healthcare workers. Our healthcare workers have continued with their duty to care for patients, but are also at risk of becoming infected, due to the combination of the sudden outbreak and the little information known regarding COVID-19 characteristics, infection level, and severity. The several recent studies (Lai et al., 2020;Mohd Fauzi et al., 2020;Rossi et al., 2020) showed that healthcare workers in hospitals equipped with fever clinics or wards for COVID-19 patients had experienced psychological burden. Other healthcare workers with different positions and duties also face varying levels of psychological impact. A previous study showed that 50.7%, 44.7%, 36.1%, and 73.4% of epidemiologists and healthcare works experienced depression, anxiety, sleep disorder, and stress, respectively , while the first-line healthcare workers experienced even higher incidence rates and higher risk of psychological stress (Que et al., 2020;TsamakisK et al., 2020). The psychological stress negatively impacted their psyche, sleep quality, and work efficiency . Thus, a better understanding of the psychological impact on healthcare workers and their adjustment to treating COVID-19 patients could help provide them with appropriate psychological support and lead to better patient care. In this study, we assessed the psychological impact of COVID-19 on healthcare workers in the China Xi'an Central hospital. This work aims to provide useful information regarding the factors that induce stress on healthcare workers. The results of this study may help provide more appropriate and encompassing information for the psychological support of those healthcare workers experiencing stress and improve the quality of patient care.

| Study participants
An anonymous cross-sectional study was performed using the social media platform-based (WeChat) survey program, "Questionnaire Star," between 1 and 14 February 2020. The data collection period was restricted to only these 2 weeks. We included questionnaires from all healthcare workers from Xi'an Central Hospital (Xi'an, China) who held a position involving clinical patient care, medical technologies, or administrative management. First, we sent the informed consent form electronically to all healthcare workers in our hospital, and those who agreed to participate in our study later received our study questionnaire. The exclusion criteria were as follows: (a) participant not a healthcare worker at Xi'an Central Hospital, (b) absentee due to disease or vacation, (c) participant not a user of WeChat, and (d) participant did not complete the assessment.

| Questionnaire and data collection
To collect data from the included healthcare workers, we utilized an online electronic questionnaire survey. Before initiating the formal study, we first interviewed 23 healthcare workers from the infectious disease department (including 9 doctors and 14 nurses) to test data acquisition, analyze the potential influencing factors, and finalize our questionnaire. We then revised and finalized the questionnaire by consulting with clinical psychiatrists (Peng Wang and his associates). The final questionnaire included three parts, that is, the first part involved general information of the respondents, such as gender, age, education level, work experience,  (Goldberg, 1972). GHQ-12 is also frequently used to assess psychological distress in a population (Cuéllar-Flores et al., 2014;Gómez-Salgado et al., 2020;Ogundipe et al., 2014), which includes 12 sections of questions each assessed with a four-point Likert scale, and is considered valid for use on adults and adolescents. According to the World Health Organization (WHO) guidelines, the GHQ-12 questionnaire is frequently used with the 0-0-1-1 scoring method where the first two and last two choices are scored as 0 and 1 point, respectively, leading to the total score ranging between 0 and 12 points. The General Health Questionnaire developed by Goldberg et al. have been used in various countries and was previously used in studies of other SARS-like epidemics (Tam et al., 2004). In this study, we used three points as the cut-off value where three points or more suggested a mental health problem (Bizu et al., 2015;Tomoyuki, 2015;Wang et al., 2012) (the higher the score, the more significant the mental problems are). We distributed these questionnaires electronically to all included healthcare workers (n = 1,967) in the hospital and collected 431 (21.9%) responses. This study was approved by the Ethics Committee of Xi'an Central Hospital (Xi'an, China), and all responders provided written informed consent form before participating in this study.
The electronic questionnaires were sent via either mobile phone or computer terminal but not both to prevent repeat filings. During the survey period, the responders provided data every 2 days for 2 weeks. The feedback questionnaires were also reviewed every 2 days and the incomplete questionnaires were eliminated electronically to insure only full datasets were acquired. The data were collected through an online survey platform and the responses to the questionnaires were automatically encoded and organized in the background to avoid errors caused by manual entry.

| Statistical analysis
The counting data are summarized as the composition ratio (the GHQ-12 data are "two class variance" and counted as numbers between 0 and 12), and the difference among groups was analyzed using a chi-square or Fisher's exact test. The variables exhibiting a significant difference were counted as independent variables, for example, the GHQ-12 threshold score was counted as a dependent variable and statistically analyzed using binary logistic regression. All statistical analyses were performed using the SPSS 23.0 for Windows software package and the statistical significance level was set at p ≤ .05.
Of the 431 responders who completed the GHQ-12 every other day for the full 2 weeks, 81 (18.8%) scored above the threshold of 3 (Figure 1), indicating the existence of different degrees of emotional distress. The numbers of responders with a score of 1 for each category are summarized in Figure 2. Of note, 135 responders (31.3%) scored 1 for Item 2 "insomnia due to worry," 78 (18.1%) for Item 5 "always tense," and 75 (17.4%) for Item 9 "feeling distressed and worried." These three items fall into the anxiety/depression dimension of the GHQ scale and indicate that anxiety and depression were prominent among healthcare workers for the duration of the 2-week survey. Moreover, 71 (16.5%) scored a 1 for Item 7 "can't enjoying daily activities" and 63 (14.6%) scored a 1 for Item 12 "feeling that everything isn't going well." These two items belong to the low

| Comparison of the different GHQ-12 scores among responders
There was a statistically significant difference (χ 2 = 8.113, p = .017) in work experience for those participants who exhibited a score greater than 3. In this sense, only 7.5% of participants with less than 3 years of work experience scored above the threshold of greater than 3 whereas 23.1% of participants with 10 years or more work experiences scored above than 3. Moreover, 33.3% of those who worked in or were exposed to the affected areas of the epidemic scored 3 or more, whereas only 17.7% of participants with no such an exposure scored a 3 or more (χ 2 = 4.467; p = .035).
Moreover, the method of acquiring epidemic information also affected the GHQ-12 scores. The proportion of healthcare workers with GHQ-12 ≤ 3 who obtained COVID-19 epidemic-related information through text message, community information, and hospital department training was higher than those who did not receive such information. Furthermore, change in job position also significantly affected the GHQ-12 scores (χ 2 = 7.285; p = .007) as 27.5% of participants reported a score of 3 or more after a job change, whereas only 15.8% reported a score of 3 or more without job changes. Job position also affected the GHQ-12 scores. Only 14.3% of responders who worked at the triage station reported a score of 3 or more, whereas 47.4% of responders who worked at the fever clinic reported the same (Fisher = 10.75; p = .041).
In addition, emotional distress was also higher among those who believed "the epidemic has changed personal or family lifestyle" (χ 2 = 9.378; p = .002). However, responders who denied "the epidemic to play a positive role in improving the doctor-patient relationship" seemed to be more inclined to experience emotional distress (χ 2 = 4.462; p = .035). The corresponding data are shown in Table 2.

| D ISCUSS I ON
Our current study revealed an increased risk of developing psychological stress among healthcare workers with 10 years or more work experience. Nevertheless, there was no statistically significant difference among age groups at this experience level. Moreover, our analysis identified four factors that were significantly associ-  et al., 2018). Our current study showed that the stress level was specifically higher in healthcare workers who had 10 years or longer work experience. The reason for this may be because this group of healthcare workers was required to make more decisions regarding diagnosis and treatment of COVID-19 patients and therefore possessed more responsibilities and pressure. Such a difference may The Fisher exact test was used because the chi-square test is invalid when the theoretical frequency of the cell is less than 5.

F I G U R E 3
Multi-factor binary logistic regression analysis. To assess the factors that affected the GHQ-12 scores, we performed a binary logistic regression analysis to identify four factors that were significantly associated with the presence of emotional distress also be due to the setting of the healthcare work in China, for example, younger healthcare workers have fewer decisions to make during routine patient care than those in positions that are more senior. Moreover, our current study also revealed that job changes led to higher GHQ scores (≥ 3), which may be due to the fact that the sudden COVID-19 outbreak and pandemic altered job position distribution. Nevertheless, the increase in distress level may not only have been directly involved with positions with potential highrisk exposures, such as the diagnosis, treatment, and prevention of COVID-19, but may have also involved job content after switching to new job functions. This conclusion is similar to the conclusions of Maunder et al. (2004) that found that some hospital workers who were assigned unfamiliar tasks appeared to be under a greater stress level than others who performed work with higher objective risk (i.e. nurses working in a severe acute respiratory syndrome isolation ward) even when the work was within their usual areas of competence and expertise. collect data instead of a face-to-face questionnaire, resulting in some uncontrolled situations for the respondents to fill out the questionnaire in a self-administered way, which may create a certain degree of subjectivity.

| CON CLUS ION
The results from the current study demonstrated that the COVID-19 pandemic significantly impacted the psychological stress of healthcare workers. For example, those healthcare workers with more work experience (>10 years) experienced more risk in developing psychological stress than those with less work experience. Thus, speedy and continuous mental health interventions are needed to alleviate such stress and pressure to improve their mental health and patient care.

ACK N OWLED G M ENTS
We would like to thank Dr. Peng Wang of The Departments of Psychiatry for his advice and support of this study. We would also like to thank the members of the COVID-19 team for sharing their experiences and made this work possible.

CO N FLI C T S O F I NTE R E S T
All authors declare that they have no conflicts of interests.

PEER R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1002/brb3.2028.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.