Impact of burnout, secondary traumatic stress and compassion satisfaction on hand hygiene of healthcare workers during the COVID‐19 pandemic

Abstract Aim To assess the prevalence of burnout, secondary traumatic stress, and compassion satisfaction and explore their impacts on self‐reported hand hygiene among medical aid teams in the COVID‐19 period in Wuhan, China. Design Cross‐sectional study. Method A total of 1,734 healthcare workers from 17 medical aid teams were surveyed. The survey included burnout, secondary traumatic stress and compassion satisfaction measured by the professional quality of life scale and self‐reported hand hygiene. Data were collected between 5–7 March 2020. Multiple regression analyses were performed. Results Burnout and secondary trauma stress were at low and average levels, and compassion satisfaction was at average and high levels. Burnout was negatively associated with hand hygiene, while compassion satisfaction was positively associated. Hospital administrators should pay attention to burnout and compassion satisfaction to improve infection control behaviours. Management of healthcare workers in our study may be constructive in emerging infectious diseases.

exposed to potentially traumatizing events, as a result of paid or volunteer work, like medical aid teams (Stamm, 2010). As the positive aspect of ProQOL, compassion satisfaction refers to positive feelings or a sense of self-efficacy derived from helping others (Christian-Brandt et al., 2020). As the negative aspects of ProQOL, burnout is related to frustration with work situations and colleagues, whereas secondary traumatic stress is unique to the healthcare profession and patient care (Polat et al., 2020). Researchers found that negative aspects of ProQoL in HCWs are associated with poor quality of care, including poor quality and safety measures and unprofessional behaviour, etc. (Harolds, 2019;Tawfik et al., 2019). The positive aspect, compassion satisfaction, means that individuals feel happy with the work and want to continue, and worse compassion satisfaction was reported to reduce the standards of care (Dasan et al., 2015;Stamm, 2010).
Based on the existing studies, we found that psychological statuses were crucial influencing factors of HCWs' behaviours. Studies on the association between psychological status and hand hygiene behaviours can provide the premise for the intervention aiming to improve the compliance of hand hygiene. However, current evidence in the prevalence of HCWs' ProQoL and its impact on hand hygiene behaviours or even infection prevention and control (IPC) measures were limited. The gap remains in the impacts of psychological status on the hand hygiene behaviours, especially in the emerging infectious disease period. Thus, this study aimed to assess the prevalence of burnout, secondary traumatic stress and compassion satisfaction among HCWs in medical aid teams and explore their impacts on hand hygiene in the context of the COVID-19 pandemic. The following research questions were addressed: what level are burnout, secondary traumatic stress, and compassion satisfaction, and to what extent they influenced hand hygiene in HCWs in medical aid teams.
We hypothesized that.
1. HCWs in medical aid teams experience a high level of burnout and secondary traumatic stress and a low level of compassion satisfaction.
2. Burnout and secondary traumatic stress are negatively associated with hand hygiene.
3. Compassion satisfaction is positively associated with hand hygiene.

| Data collection
A structured self-administered questionnaire was used to collect data from 5-7 March 2020. HCWs in medical aid teams who were willing to take part in the study submitted the finished online questionnaires, which included self-reported hand hygiene behaviours, the ProQOL scale covering burnout, secondary traumatic stress and compassion satisfaction, and socio-demographic characteristics. A total of 1,734 HCWs were surveyed.

Self-reported hand hygiene behaviours
Outcome indicators were self-reported hand hygiene behaviours because the compliance of the other important measures was nearly 100% or hard to measure. For example, the compliance of the use of personal protective equipment (PPE) was approximately 100% due to the strict management of medical aid teams. Hand hygiene behaviours were measured by 18 moments of hand hygiene based on the IPC guideline issued by the National Health Commission of the People's Republic of China (2020), along a five-point Likert scale that ranges from 1 (never)-5 scores (very often), reflecting the frequency of hand hygiene. 18 moments consisted of moments before touching a patient, before the aseptic procedure, after body fluid exposure risk, after touching a patient, after touching patient surroundings, during work on a soiled body site to a clean body site on the same patient, before putting on PPE, before after and during removing all the PPE, before wearing a glove, after removing the glove, arriving at and leaving the ward, before drinking, before and after using the toilet, before returning to the place of residence (Zhou et al., 2020).

Measures Details
Work scheduling 1. Nurses worked 4 hours every day; doctors worked 6 hours every day. 2. Days off were set based on the number of patients. 3. One nurse cared for no more than two patients, based on the severity of patients.
Protective equipment A protective suit, a gown, a goggle or a face shield, three layers of gloves, a pair of ordinary shoe cover and a pair of waterproof long shoe cover were provided every shift. Adult diapers were used in work time.
Education and meeting 1. Educations including diagnosis, treatment and infection control measures were developed by leader groups, and delivered to doctors and nurses by department managers via video or text. 2. Meetings were held among the managers every week, discussing the flow, position arrangement, obligation and measure improvement, and delivered to doctors and nurses by department managers via text. 3. HCWs must wear masks and keep one-metre distance with each other in the meetings.
Health measures Daily surveillance of the health status and the risk exposure of HCWs were conducted. Nasopharyngeal swabs and blood samples were collected every month. The flow of treatment for HCWs was formulated, if HCWs were suspected or diagnosed, etc.
Psychological support Psychological supports were provided by psychological professors via telephone. The telephone numbers were given to HCWs; they can contact if necessary.
Financial support Salaries of HCWs in medical aid teams included one part from the original hospital and the other from local subsidies of Wuhan from district service centre, aid hospital and the Red Cross.

Accommodation and transportation measures
HCWs of medical aid teams resided in hotel, which also provided meals. HCWs transported between the hotel and the hospital via special shuttle bus.

| Relationship between hand hygiene and burnout, secondary traumatic stress and compassion satisfaction
According to univariate analyses, the lower burnout and higher compassion satisfaction in HCWs were associated with higher selfreported hand hygiene behaviours in hand hygiene (p < .001). HCWs with different secondary traumatic stress and compassion satisfaction reported different levels of hand hygiene. (Table 3).

TA B L E 2 ProQOL means, prevalence and SD
Self-reported hand hygiene behaviours in our study were consistent with previous studies during the MERS-CoV outbreak (Alshammari et al., 2018). HCWs reported higher compliance of hand hygiene concerning those behaviours that perceived as self-protective and having a high risk of cross-contamination or cross-infection, such as after body fluid exposure risk, after removing a glove and PPE (Lambe et al., 2019;WHO & WHO Patient Safety, 2009). Interestingly, we can find that the level of burnout and secondary traumatic stress is lower and compassion satisfaction is higher than previous studies conducted in China and other countries, not in the period of emerging infectious diseases (Dasan et al., 2015;Shen et al., 2015;Wang, Chudzicka-Czupała, et al., 2020;Wang, Okoli, et al., 2020;Woo et al., 2020). In general, HCWs reported more psychological burden, when they were exposed to the centre of the outbreak, had experience in caring for the infected or suspected patient and in the frontline (Kim & Choi, 2016;Lai et al., 2020). The lower level of the negative and higher level of positive ProQOL we obtained may be associated with the effect of activities acting on HCWs to confront the pandemic. The activities included careful management from the hospital, the positive report, and higher social status from the public during the pandemic. The zero infection of HCWs in medical aid teams also proves the effective management in medical aid teams It is also observed that the environment of management and public may be highly associated with the burnout and compassion satisfaction of HCWs (Chung et al., 2020;Saeidi et al., 2020).
As for the impact to hand hygiene behaviours, we find that burnout, compassion satisfaction and age are influencing factors of hand hygiene behaviours. More precisely, lower burnout, higher compassion satisfaction and younger age promote hand hygiene behaviours, which is consistent with previous studies. High burnout in HCWs is associated with poor-quality care, including poor adherence to management guidelines, medical error, healthcare-associated infections and hand hygiene (Manomenidis et al., 2019;Tawfik et al., 2019). And Dasan et al. (2015) found that consultants with lower compassion satisfaction reduce their standards of care because they are more irritable with patients or colleagues. The reasons why burnout is associated with infection control mainly include three assumptions.
First, HCWs with higher burnout may be less likely to follow the standard behaviour or notice errors and omissions, which contribute to the reduction of compliance with infection control (Cimiotti et al., 2012). Second, the emotional and cognitive detachment and the development of cynicism associated with burnout may cause inadequate infection control behaviours and personal inefficiency (Galletta et al., 2016). Third, bad infection control behaviours can increase burnout in HCWs in turn, by increasing the nosocomial infection incidence, the length of stay and higher workload in HCWs (Tawfik et al., 2017).
Similar to previous studies, younger age can be associated with a higher score on hand hygiene (Erasmus et al., 2010). Oh also found that the infection control experience is an influencing factor of hand hygiene behaviours (Oh, 2018). It is worth mentioning that recent studies have also found that low IPC behaviour (wearing masks) could be the contributing cause of negative psychological factors (Wang, Chudzicka-Czupała, et al., 2020;Wang, Okoli, et al., 2020). Based on this, future studies can further investigate the causal relationship between psychological factors and IPC behaviours, including hand hygiene, wearing masks and use of protective equipment.
Relevant intervention is the approach to reduce burnout and increase compassion satisfaction. The individual-based interventions include mindfulness-based technique, educational, emotional empowerment (Janssen et al., 2018;West et al., 2018). The organization-directed interventions include increased support for clinical work, structural changes, routine staff meetings and improving the work environment (Bresesti et al., 2020). To improve hand hygiene behaviours and compassion satisfaction, and relieve burnout in a pandemic, the managers should take more into consideration and intervention targeting should be performed. As we found that relatively lower burnout and compassion satisfaction in medical aid teams, the management of HCWs adopted in our study (Table 1)