|Year : 2020 | Volume
| Issue : 2 | Page : 208-214
Concerns and stress-related problems among medical personnel during COVID-19 lockdown phase in a general hospital in Mumbai
Neena Sawant, Aditya Shah, Shaunak Mangeshkar, Aishwarya Thakurdesai, Amey Angane, Sachin Mahajan
Department of Psychiatry, Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India
|Date of Submission||14-Sep-2020|
|Date of Decision||10-Oct-2020|
|Date of Acceptance||19-Oct-2020|
|Date of Web Publication||25-Nov-2020|
Dr. Neena Sawant
Department of Psychiatry, Seth GSMC and KEM Hospital, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: COVID-19 pandemic has resulted in heightened stress, anxiety, and depression in doctors. This research was undertaken during the lockdown period in Mumbai to study the differences in perceptions of the various concerns related to the pandemic, viz., concerns related to area of residence, workplace, personal, and educational and stress faced by the 3 groups of health-care workers, medical interns, resident doctors, and medical teachers, during the pandemic. Materials and Methods: 1011 residents participated in this online cross-sectional survey after informed consent and ethics approval and 494 completed the survey via a Google Form sent on the WhatsApp groups. Results: Significant differences were noted with interns and residents staying in COVID hotspots, sealed homes, being ostracized, and having difficulty in procuring food as compared to the teachers. Workplace concerns significantly revealed that 90% interns and residents had training before duty, wore personal protective equipment, had difficulty in donning, doffing, were uncomfortable, anxious about being dehydrated, and used frequent sanitizer as compared to teachers. Interns and residents were also significantly anxious about not following social distancing, being preoccupied about the same, and having sleep problems as compared to teachers. They also were concerned about financial issues, travel plans, exams, and missing skill training as compared to teachers. Conclusion: It highlights the difficulties faced by the participants during the lockdown and its impact on their emotional well-being.
Keywords: Concerns, COVID-19, medical personnel, pandemic, stress
|How to cite this article:|
Sawant N, Shah A, Mangeshkar S, Thakurdesai A, Angane A, Mahajan S. Concerns and stress-related problems among medical personnel during COVID-19 lockdown phase in a general hospital in Mumbai. Ann Indian Psychiatry 2020;4:208-14
|How to cite this URL:|
Sawant N, Shah A, Mangeshkar S, Thakurdesai A, Angane A, Mahajan S. Concerns and stress-related problems among medical personnel during COVID-19 lockdown phase in a general hospital in Mumbai. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Apr 20];4:208-14. Available from: https://www.anip.co.in/text.asp?2020/4/2/208/301424
| Introduction|| |
The rapid spread of COVID-19 across the world resulted in it being listed as a pandemic by the World Health Organization on March 11, 2020. Considering delayed imposition of travel restrictions, the virus spread to a multitude of countries. India reported its first case of COVID-19 on January 30, 2020, in Kerala, and thereafter cases have continued to rise.
In the COVID-19 emergency, medical workers in Wuhan had dealt with a high risk of infection with inadequate protection against contamination, overwork, frustration, discrimination, isolation, a lack of contact with their families, and exhaustion.,
These mental health problems not only affect attention, understanding, and decision-making capacity of medical workers but also have a lasting effect on their overall well-being., This could be attributed to the anxiety and fear of becoming infected, which is high because of greater risk of exposure. The delicate balance between duty, altruism, and fear for oneself and others often causes conflict and feelings of helplessness and dissonance in many health-care workers (HCWs). Similarly, there have been reports of psychological distress among frontline HCWs due to working under extreme pressures and having to make very difficult decisions for the patients in the setting of unprecedented resource constraint. Moreover, the increasing number of suspected and confirmed cases, widespread media coverage, depleted personal protective equipment (PPE), ambiguity of specific treatment, overwhelming workload, and lack of support led the way for a myriad of mental health problems which affected them. In addition, health professionals experience stigmatization due to working in close proximity of patients with COVID-19 with a high prevalence of anxiety, depression, stigmatization, posttraumatic stress disorder, insomnia, and distress in health-care workers ranging from 23% to 71%.,,,
This research was undertaken during the lockdown period in Mumbai to study the differences in perceptions of the various concerns related to the pandemic, viz., concerns related to self like infecting self/others, sleep problems, concerns at workplace, and educational concerns and also the stress faced by the 3 groups of HCW, medical interns, resident doctors, and medical teachers, during the pandemic.
| Materials and Methods|| |
The study was a cross-sectional online survey conducted from June 12 to June 30, 2020, during the lockdown phase in the city of Mumbai after the permission of the Institutional Ethics Committee and informed consent of the participants which included medical interns, resident doctors, and medical teachers of this General Municipal Medical college and hospital of Mumbai via a Google Form sent on respective WhatsApp groups comprising of total 1011 participants.
A semistructured pro forma was designed to gather information about the demographics and various concerns related to self, workplace, educational goals, and psychological stress, which comprised closed-ended yes/no type questions and multiple-choice questions along with some open-ended questions for recording participants' opinions. The questionnaire was validated by 4 experts from the disciplines of medicine, psychiatry, and community medicine.
Four hundred and ninety-four of the total 1011 WhatsApp members participated, amounting to nearly 49% response rate. There were 131 (26.5%) interns, 200 (40.5%) residents, and 163 (33%) medical teachers. These 3 groups were analyzed for differences in the various concerns and stresses experienced. Descriptive statistics were applied and the collected data were analyzed using Statistical Package for the Social sciences version 20 (IBM Corp. Armonk, NY, USA). Chi-square statistics was used to study the differences in the 3 groups.
| Results|| |
[Table 1] gives the demographic variables of the study participants. The mean age of interns, residents, and teachers was 22.5 ± 0.8, 27.8 ± 2.7, and 42.3 ± 10.4 years, respectively, with an almost equal distribution of both genders across the 3 groups. Majority of the interns and residents were staying at hostel as compared to only 10% teachers staying in the staff quarters.
[Table 2] gives significant differences in the 3 groups related to demographics and concerns about COVID-19 like staying in a COVID-19 hotspot locality or sealed residential premises. Majority of the health-care personnel did not experience being ostracized by people in their residential premises due to their working in a COVID hospital which was statistically significant. More than 2/3rds participants of the total sample had known someone who had either been infected or had passed away due to COVID-19 and nearly 90% of them knew someone who was quarantined. 43% of interns, 55% of residents, and 31% of teachers expressed difficulty in procuring essential items such as milk and groceries in their area of residence or locality during the lockdown, which was statistically significant. About 70% of all participants walked or used their vehicle to travel to work. Only 10%–15% of all the participants in the 3 groups used the bus for commuting and expressed concerns about social distancing not being maintained due to limited availability of bus services.
[Table 3] depicts the various workplace concerns expressed by the 3 groups.
More than 90% of interns and resident doctors were posted for COVID duties as compared to only 48% teachers. 85% of interns and 70% of residents received COVID-related training from the institute as compared to only 41% of teachers. 35% of interns and 22% of residents did not find training useful as compared to only 9% of teachers; also 30% of interns, 38% of residents, and 25% of teachers did not feel that the training helped in reducing their fear or anxieties. 96% of interns and 98% of residents wore PPE, masks, face guards, caps, etc., while seeing patients as compared to 80% teachers. When the healthcare personnel were asked about difficulties faced while using PPE, then nearly 57% of interns and residents respectively and 43% of teachers expressed difficulties in donning and doffing, while 53% of teachers said that they did not feel comfortable wearing the mask as compared to about 20% of residents and interns. 91% of interns, 83% of residents, and 60% of teachers felt worried about getting dehydrated or unable to eat/use the restroom while wearing PPE. Close to 61% of interns, 68% of residents and 47% of teachers felt anxious about not getting required PPE, masks, caps, sanitizer, etc., at work. 40%–45% of all the participants reported repeated hand sanitizer use even without touching anywhere. Around 85%–90% of all the participants had come in contact with a colleague who was COVID positive on duty but did not feel worried about the same, though nearly 60% of residents and teachers expressed fear of getting infected when walking in hospital corridors and/or interacting with colleagues. Around 50%–60% of them expressed that their workload had increased. Among the COVID duty postings, 53% of interns, 49% of residents, and 32% of teachers were most anxious working in emergency as compared to working in COVID isolation wards while they felt least anxious working in fever or routine outpatient departments (OPDs).
[Table 4] depicts personal concerns of the 3 groups with respect to the pandemic.
When the 3 groups were assessed for feeling anxious about not maintaining social distancing at their place of residence, 64% of interns and residents and 51% of teachers responded in the affirmative. 62% of interns and 81% of residents expressed being more preoccupied about the same as compared to only 18% of teachers. Less than 20% of participants expressed concern about suffering from any symptoms while nearly 16.8% of interns, 7.5% of residents, and 4.2% of teachers got themselves checked frequently from the hospital physician regarding fever and other symptoms, which was statistically significant.
More than 75% of the participants in the 3 groups expressed that they were concerned about their family members getting affected due to them and nearly 80% also felt that their belongings could spread infection at their homes or workplaces. Reading daily information about updates on the virus, research studies, or statistics on COVID-19 also caused concern in about 60% of participants. A significant change in sleeping habits was noticed by 47.3% of interns, 53.5% of residents, and 38.6% of teachers. Among these, difficulty in falling asleep was expressed by 87.1% of interns, 79.4% of residents, and 80.9% of teachers, whereas 69% of teachers suffered from awakening in the middle of the night and being unable to fall back to sleep as compared to others.
[Table 5] gives the various stress related symptoms experienced by the 3 groups. Less than 20%of the participants experienced symptoms of palpitations, restlessness, tremors, apprehension, etc., after having thoughts about Coronavirus. 27% of interns, 13% of residents, and 11% of teachers expressed a prior history of panic such as symptoms, fear of crowded places, and fear of closed spaces. More than half of the residents and interns also expressed that the situation was bad and they were worried about their life ahead due to the impact of COVID-19. Surprisingly, 75% of residents were upset due to cancellation of family functions, business plans, or vacations as compared to about 47% interns and teachers. Only 30%–40% of the participants in the 3 groups anticipated a financial crisis for themselves and/or their family due to the lockdown. 49.6% of teachers reported a history of consuming substances such as tobacco and alcohol during the lockdown as compared to 3.8% of interns and 8% of residents.
Eighty percent of interns, 50% of residents, and 43% of teachers reported being significantly anxious about the uncertainty of exam schedules such as NEET PG/MUHS PG/NEET SS/USMLE/MUHS University. 75% of interns and 69% of residents also reported significant concerns about the disruption of their normal teaching schedules, completion of their university syllabi, or thesis data collection whereas 72% teachers were unconcerned.
| Discussion|| |
Mumbai has been a hotspot of COVID-19 cases since the beginning due to it being the capital and financial center of Maharashtra and being highly populated. The hospital was located in a hotspot zone. Hence, there were several occasions during the lockdown period when the various hostels for undergraduates, interns, postgraduates and staff quarters got sealed with relocation of the residents and staff to hotels or other hostels. This significantly affected the residents and interns more than the teachers as they also had difficulties in procuring daily essentials due to the fact that canteens and restaurants were all closed during the lockdown. Though the government had allowed all essential food grain shops to remain open for a few hours daily, the area was a containment zone and so, most of the places were shut. This caused inconvenience to most interns and residents staying in hostels. About 11%–26% of all our participants felt ostracized by neighbors/friends as they were working in a COVID hospital which is higher than the study by Grover et al. who reported the same in 10% in their national survey. Public transport facilities in Mumbai during the rigorous lockdown included the limited bus services for the essential services sector. 45%–60% of interns and residents walked to the hospital from their residence while 55% of the teachers used their own vehicles. About 10%–15% used the bus services and expressed concern as they had to queue up for a long time due to the limited buses and as there was no social distancing maintained which worried them.
As the COVID pandemic was the first of its kind with the world struggling to understand its symptoms and management, our institute decided on a basic training module for all the healthcare workers before they were recruited in the various wards or OPDs for managing the patients. This training gave basic information about the virus, symptoms, management, how to keep oneself safe, the mental health effects and dealing with stress as well as a demonstration on donning and doffing of PPE. This was necessary as nearly 90% of the residents and interns were posted in COVID duties and so were trained as compared to 45% of the teachers with those above 55 years of age being advised not to come for work due to the risk factors. Though the teachers' trained felt training was adequate, the residents and interns did not feel so. Researchers have given the importance of training in healthcare workers engaging in public.,
Due to COVID-19 being highly contagious, it was mandatory to wear PPE including masks, gloves, face shields when dealing with patients and all the participants felt uncomfortable and dehydrated in their 6 h-long duties. This is known to cause mental and physical fatigue. Donning and doffing was also time consuming. Fear of not getting adequate PPE was also seen in our participants as there was a shortage due to the global pandemic. Other researchers have also stated difficulties in communication arising due to masks and protective suits., Working in a highly contagious environment, coming in contact with asymptomatic carriers was a fear that was seen among most of our participants in keeping with findings of researchers.,
Most of the participants showed concern regarding inability to maintain social distancing at hostels and being preoccupied with getting infected. Hence, having to balance their own safety with the needs of patients, family, and employers in the face of limited resources can lead to distressing ethical dilemmas for doctors and potentially, to moral injury. The ever-increasing number of confirmed and suspected cases and deaths, overwhelming workload, depletion of PPE, widespread media coverage, lack of specific drugs, infection risk to families, and feelings of being inadequately supported may all contribute to the mental burden of these HCWs.,, Hence, the interns and residents in our sample often sought physician opinion for symptoms of fever/cough. This pandemic has also been described as an information epidemic, as due to the lockdown most people had constant access to news about the negative consequences which increased the concerns of the general public and the frontline workers. Several researchers have found a prevalence of 30%–34% of insomnia in medical workers,, whereas 50% of our residents and interns had the same. Zhang et al. found a significant difference in all parameters of sleep, viz., falling asleep, staying asleep, early awakening, and unsatisfied sleep in medical healthcare workers as compared to nonmedical healthcare workers which is in keeping with our findings. Gupta et al. in a national survey found that nearly a quarter of participants reported worsening of sleep quality after lockdown and compared to the pre lockdown period, and there was a shift to a later bedtime and waking time, with a reduction in night-time sleep and an increase in day-time napping.
Although we did not evaluate for anxiety or depression in our sample using standardized scales, we had questions related to the same in our questionnaire to assess for the concerns, worries, and preoccupations related to the pandemic. Though only 15%–20% participants had symptoms of anxiety, most reported worrying thoughts about the future, financial burdens, time for the pandemic to abate, etc., Residents and interns were the most upset with cancellation of their traveling plans and vacations as they could not go back to their families in the lockdown phase. A surprising finding was increased consumption of addictive substances by the teachers' group in the lockdown phase.
As the study was conducted in a medical college, the intern and resident groups were upset about the uncertainty of exam schedules and delay in getting the degree or applying for further studies in centers outside the state or country. Residents also reported difficulty in doing their thesis, research projects, or acquiring the skills in their related disciplines. However, teachers remained unaffected with the disruption of teaching or exam schedules.
Several researchers in the previous severe acute respiratory syndrome epidemic found that the unremitting stress faced by the medical health-care workers could trigger psychological issues of anxiety, fear, panic attacks, posttraumatic stress symptoms, psychological distress, stigma and avoidance of contact, depressive tendencies, sleep disturbances, helplessness, etc.,,,, Staff are often required to work longer hours and live away from home, thus disrupting relationships and the opportunity for rest breaks and days off. Hence, it is important that organizational support is available while making duty rotations to prevent burnout and provide psychological support, food, and housing and transport facilities to reduce the burden on healthcare workers during this pandemic.
| Conclusion|| |
Our study is the first of its kind to evaluate the various concerns related to the pandemic faced by the interns, residents, and teachers working in a tertiary care center and medical college. It highlights the difficulties faced by the participants during the lockdown and its impact on their emotional well-being. The study emphasizes the need to provide psychosocial support to all the healthcare workers in order to reduce stress and uncertainty. Our study has a few limitations. It was done at a tertiary care center in only medical doctors and the other health-care workers were not evaluated. It was an online survey and long-term prospective studies would help in evaluating the impact of the lockdown.
This study was approved by the Institutional Ethics Committee with reference number EC/OA-100/2020 obtained on June 12, 2020.
Declaration of patient consent
Patient consent statement was taken from each patient as per the institutional ethics committee approval along with consent taken for participation in the study and publication of the scientific results/clinical information/image without revealing their identity, name or initials. The patient is aware that though confidentiality would be maintained anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jin Y, Yang H, Ji W, Wu W, Chen S, Zhang W, et al
. Virology, epidemiology, pathogenesis, and control of COVID-19. Viruses 2020;12:E372.
Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX, et al
. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry 2020;7:e14.
Torales J, O'Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health. Int J Soc Psychiatry 2020;66:317-20.
Ho CS, Chee CY, Ho RC. Mental health strategies to combat the psychological impact of COVID-19 beyond paranoia and panic. Ann Acad Med Singap 2020;49:155-60.
Lima CK, Carvalho PM, Lima IA, Nunes JV, Saraiva JS, de Souza RI, et al
. The emotional impact of Coronavirus 2019-nCoV (new Coronavirus disease). Psychiatry Res 2020;287:112915.
Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ 2020;368:m1211.
Petzold MB, Plag J, Ströhle A. Umgang mit psychischer Belastung bei Gesundheitsfachkräften im Rahmen der COVID-19-Pandemie [Dealing with psychological distress by healthcare professionals during the COVID-19 pandemia]. Nervenarzt 2020;91:417-21.
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al
. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
Zhang WR, Wang K, Yin L, Zhao WF, Xue Q, Peng M, et al
. Mental health and psychosocial problems of medical health workers during the COVID-19 epidemic in China. Psychother Psychosom 2020;89:242-50.
Huang JZ, Han MF, Luo TD, Ren AK, Zhou XP. Mental health survey of 230 medical staff in a tertiary infectious disease hospital for COVID-19. Chin Ind Hyg Occup Dis 2020;38:192-5.
Galbraith N, Boyda D, McFeeters D, Hassan T. The mental health of doctors during the COVID-19 pandemic [published online ahead of print, 2020 Apr 28]. BJPsych Bull. 2020;1-4. doi:10.1192/bjb.2020.44.
Grover S, Sahoo S, Mehra A, Avasthi A, Tripathi A, Subramanyan A, et al
. Sychological impact of COVID-19 lockdown: An online survey from India. Indian J Psychiatry 2020;62:354-62. [Full text]
Cai W, Lian B, Song X, Hou T, Deng G, Li H. A cross-sectional study on mental health among health care workers during the outbreak of Corona Virus Disease 2019. Asian J Psychiatr 2020;51:102111.
Rana W, Mukhtar S, Mukhtar S. Mental health of medical workers in Pakistan during the pandemic COVID-19 outbreak. Asian J Psychiatr 2020;51: 102080.
Tsamakis K, Rizos E, Manolis AJ, Chaidou S, Kympouropoulos S, Spartalis E, et al
. COVID-19 pandemic and its impact on mental health of healthcare professionals. Exp Ther Med 2020;19:3451-3.
Walton M, Murray E, Christian MD. Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic. Eur Heart J Acute Cardiovasc Care 2020;9:241-7.
Gupta R, Grover S, Basu A, Krishnan V, Tripathi A, Subramanyam A, et al
. Changes in sleep pattern and sleep quality during COVID-19 lockdown. Indian J Psychiatry 2020;62:370-8. [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]