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Psychosomatic Medicine 66:938-942 (2004)
© 2004 American Psychosomatic Society

ORIGINAL ARTICLES

Factors Associated With the Psychological Impact of Severe Acute Respiratory Syndrome on Nurses and Other Hospital Workers in Toronto

Robert G. Maunder, MD, William J. Lancee, PhD, Sean Rourke, PhD, Jonathan J. Hunter, MD, David Goldbloom, MD, Ken Balderson, MD, Patricia Petryshen, PhD, Rosalie Steinberg, MSc, Donald Wasylenki, MD, David Koh, MD and Calvin S. L. Fones, MD

From the Department of Psychiatry, University of Toronto and Mount Sinai Hospital, Toronto, Ontario, Canada.

Address correspondence and reprint requests to Robert G. Maunder, MD, Department of Psychiatry, Ninth Floor, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario M5G 1X5, Canada. E-mail: rmaunder{at}mtsinai.on.ca


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 CONCLUSIONS
 REFERENCES
 
OBJECTIVES: A survey was conducted to measure psychological stress in hospital workers and measure factors that may have mediated acute traumatic responses.

METHODS: A self-report survey was completed by 1557 healthcare workers at three Toronto hospitals in May and June 2003. Psychological stress was measured with the Impact of Event Scale. Scales representing attitudes to the outbreak were derived by factor analysis of 76 items probing attitudes to severe acute respiratory syndrome. The association of Impact of Event Scale scores to job role and contact with severe acute respiratory syndrome patients was tested by analysis of variance. Between-group differences in attitudinal scales were tested by multivariate analysis of variance. Attitudinal scales were tested as factors mediating the association of severe acute respiratory syndrome patient contact and job role with total Impact of Event Scale by linear regression.

RESULTS: Higher Impact of Event Scale scores are found in nurses and healthcare workers having contact with patients with severe acute respiratory syndrome. The relationship of these groups to the Impact of Event Scale score is mediated by three factors: health fear, social isolation, and job stress.

CONCLUSIONS: Although distress in response to the severe acute respiratory syndrome outbreak is greater in nurses and those who care for patients with severe acute respiratory syndrome, these relationships are explained by mediating variables that may be available for interventions to reduce stress in future outbreaks. In particular, the data suggest that the targets of intervention should include job stress, social isolation, and health fear.

Key Words: infectious disease, • stress, • nursing, • risk factors, • social factors.

Abbreviations: SARS = severe acute respiratory syndrome;; IES = Impact of Event Scale;; HCW = healthcare worker;; MSH = Mount Sinai Hospital;; SMH = St. Michael’s Hospital;; CAMH = Centre for Addiction and Mental Health.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 CONCLUSIONS
 REFERENCES
 
In the spring of 2003, an outbreak of severe acute respiratory syndrome (SARS) originated in the Guangdong province of China and migrated to several cities including Hong Kong, Singapore, and Toronto, Canada (1,2). Severe acute respiratory syndrome had enormous immediate consequences for hospitals. In Toronto, these included closure of outpatient clinics; cancellation of surgery and family visiting privileges; students and nonessential staff being told to stay home; careful screening of staff entering hospitals; mandatory use of masks, gloves, and gowns by staff seeing patients or interacting with each other; quarantine for thousands of people; and recommendations that healthcare workers (HCWs) not have contact outside of work duties (3,4). Between February and June 2003, there were 375 cases of probable and suspected SARS in Ontario (primarily in Toronto) and 44 deaths (5). Healthcare workers accounted for over 40% of those infected with SARS in Toronto, and three infected healthcare workers died (4).

At the time of the outbreak, there were few published studies of the psychological impact of comparable outbreaks on hospital staff (6). Reports of the acute psychological impact of the SARS outbreak on hospital workers indicate that high levels of distress were common. In a survey of one Toronto hospital, 29% of respondents scored above the threshold for "emotional distress" (score ≥3) on the 12-item version of the General Health Questionnaire (7). In a general hospital in Singapore, 27% of respondents scored above the "case" cut-off (score ≥5) on the 28-item version of the General Health Questionnaire (1). Although the functional impact of acute distress has not yet been reported, it appears that a clear understanding of the factors that mediate stress in HCWs facing an emerging infectious disease is required to plan effectively for future outbreaks.

Nurses in SARS-affected hospitals experienced more distress than other hospital workers (1,7). Nurses form the single largest occupational group in most hospitals and are directly and intensively involved in patient care. Understanding the psychological impact of an infectious outbreak on nurses is, therefore, of particular importance to planning for future outbreaks of emerging infectious diseases.

Several factors were identified that may have contributed to the distress experienced by HCWs during SARS: an uncertain pathogen, significant mortality, rapidly changing medical information and procedures, extraordinary infection control precautions, media scrutiny, reduced contact and interaction between colleagues, stigmatization, and frequent transmission of the infection to HCWs (3,7–11).

Based on observations of the early psychological impact of the Toronto SARS outbreak assessed with an unstructured methodology (3), we hypothesized that the following factors contributed to HCWs experiencing SARS as a psychological trauma: job stress, feeling stigmatized, and having reduced contact with colleagues. We also hypothesized that trust in protective equipment and hospital procedures reduced stress. The purpose of this study was to test these hypotheses regarding the factors mediating the psychological impact of SARS on two groups of particular importance: nurses and HCWs who have contact with patients with SARS.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 CONCLUSIONS
 REFERENCES
 
The study was a cross-sectional, anonymous, self-report survey of hospital personnel at three Toronto hospitals. Mount Sinai Hospital (MSH) and St. Michael’s Hospital (SMH) are large, general teaching hospitals that treated SARS patients. The Centre for Addiction and Mental Health (CAMH) is a health sciences center for psychiatric illness and substance abuse. The CAMH was SARS-free but was obliged to follow infection control guidelines and screening procedures.

In the spring of 2003, the number of full-time and part-time staff was 4526 at MSH and 2813 at CAMH. At these institutions, ethical concern about the burdens being faced by hospital workers resulted in limits on the aggressiveness with which the survey could be distributed and collected. At MSH, surveys were available in a lobby display and on the intranet (May 12 to June 8). Completed surveys were returned by 455 staff members (298 paper, 157 electronic, total is 10.1% of all staff). At CAMH, surveys were available at a lobby display (May 22 to June 20). Completed surveys were returned by 257 staff members (9.1% of all staff). At SMH, physicians received the survey by e-mail and managers distributed the survey directly to hospital employees (May 13 to May 28). The survey was distributed directly to 3625 HCWs, and 845 complete surveys were returned (23.3%).

Complete surveys were collected from 1557 HCWs. The sample was 74.6% female. There were 430 nurses (27.6%). The distribution of occupations is provided in Table 1. The mean age was 40.2 years (SD 11.0) and the mean hospital experience was 14.3 years (SD 10.6).


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  		TABLE 1. Distribution of 1557 Healthcare Workers by Job Category
 
The survey included the Impact of Event Scale (IES) (12) and 76 items probing attitudes toward SARS. Because the information required was specific to the SARS outbreak and because the outbreak was unprecedented, the survey was not validated against other measures of coping and perceived risk. The attitude survey, therefore, has only face validity. The IES is a measure of traumatic stress probing responses over the previous week related to the SARS outbreak. Seven items probe intrusion and 8 items probe avoidance of thoughts, feelings, and reminders (12,13). Internal reliability (Cronbach {alpha}) is 0.79 to 0.92 for intrusion and 0.73 to 0.91 for avoidance (14). Surveys were not included if more than 15 attitude items were missing or if any IES item was missing.

Mean IES for HCWs who cared for persons under investigation for SARS, those who cared for probable or suspected SARS cases, and those who cared for both did not differ, but each had higher IES scores than HCWs who cared for none of these patients, so the three SARS contact groups were collapsed into one dichotomous variable. For each of the two groups, SARS contact (yes/no) and job type (nurse/other) between-group differences in total IES score were tested by analysis of variance (ANOVA).

Attitude scales were identified by factor analysis on logical clusters of survey items (maximum likelihood extraction method using Varimax rotation with Kaiser normalization). Scales were calculated for each factor as the mean score of all items with factor loading >0.40. Logically similar scales were combined if the internal reliability of the resulting combined scale was adequate (Cronbach {alpha} > 0.75). Scales with inadequate internal reliability ({alpha} < 0.75) were eliminated. Properties of attitude scales are provided in Table 2.


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  		TABLE 2. Scales Derived from Attitude Items of Severe Acute Respiratory Syndrome Survey and Example Items
 
Four patient groups (2 x 2) were defined by membership in each of the two dichotomous grouping variables (SARS contact or not, nurse or not). Between-group differences in attitude scales for these four groups were tested by multivariate analysis of variance (MANOVA). Finally, attitude scales were tested as mediators of the association of group factors to total IES score by regression analysis with all variables (job stress, social isolation and avoidance, health fear, doubt about protection, dissatisfaction system and processes, job type, contact with patients with SARS) entered simultaneously.

Attitude items that included avoidance (of crowds or colleagues) to cope with SARS may have confounded the analysis because avoidance (of thoughts and feelings associated with SARS) was one aspect of the outcome variable. Confounding effects were tested in two ways. First, the analysis was repeated excluding the attitude factor that contains avoidance items (social isolation and avoidance). Second, the analysis was repeated using IES intrusion as the dependent variable (ie, excluding avoidance from the outcome). Results were similar for these two analyses.

Statistical tests were performed using SPSS 12.0 (SPSS, Chicago, IL). The IES data are presented as mean (95% confidence interval). This study was approved by the Research Ethics Board at each hospital.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
CONCLUSIONS
 REFERENCES
 
In four groups defined by both contact with patients with SARS (yes/no) and job type (nurse/other), there were significant between-group differences in total IES score (F(3, 1553) = 21.06, p < .001). Higher total IES score was associated with SARS patient contact (F(1, 1553) = 24.93, p < .001) and being a nurse (F(1, 1553) = 14.66, p < .001), but there was no interaction effect (F(1, 1553) = 0.047, p not significant). Table 3 shows between-group differences in each of five attitude scales (health fear, job stress, social isolation and avoidance, dissatisfaction with system and processes, doubt about protection) for the same four groups.


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  		TABLE 3. Differences in Attitude Scales in Groups Defined by Job Type and Contact With Patients With Severe Acute Respiratory Syndrome
 
Each of the five attitude scales was significantly correlated with total IES score (p < .001 for each). Table 4 shows the results of the regression analysis in which the grouping factors (job type, contact with patients with SARS) and the five attitude scales are entered simultaneously with total IES score as dependent variable. This analysis demonstrates three attitudinal factors that fully mediate the association of contact with patients with SARS and being a nurse with psychological stress: health fear, social isolation, and job stress. That is to say that after accounting for the contribution of these three factors to total IES score, there is no further significant contribution by contact with patients with SARS or being a nurse. These factors, in combination, explain 29% of the variance in total IES score. Factors probing doubts about protection and dissatisfaction with hospital systems and procedures did not contribute to total IES.


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  		TABLE 4. Multiple Linear Regression Model of the Variance in Total Impact of Event Score Explained by Job Type, Contact With Patients With Severe Acute Respiratory Syndrome Patients and Five Attitude Scales
 

   CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 CONCLUSIONS
REFERENCES
 
We measured the intensity of the acute traumatic impact of the SARS outbreak on hospital workers, as characterized by intrusive thoughts, feelings, and memories and avoidance of such thoughts, feelings, and reminders. This study demonstrates that, compared to other hospital workers, nurses and HCWs who have contact with patients with SARS experienced a more intense acute traumatic response. Differences in the intensity of distress in these groups of HCWs were fully mediated by attitudinal responses to the outbreak and its circumstances. In particular, the mediating factors were: i) fear for one’s health and the health of others; ii) social isolation and avoidance; and iii) experiencing increased job stress.

Health fear is easily understood as a direct result of the circumstances for nurses and HCWs caring for patients with SARS. In particular, although a clear understanding of SARS was not available early in the outbreak, its preferential transmission to hospital workers and its substantial mortality was evident.

Job stress also mediated the relationship between SARS contact and acute traumatic stress and the relationship between being a nurse and acute traumatic stress. The job stress scale includes items probing conflict among colleagues, increased workload, and being assigned to unusual duties. The contribution of the latter item confirms in part the anecdotal observation that some hospital workers who were assigned unfamiliar tasks appeared to be under greater stress than others doing work of higher objective risk (eg, nurses working in a SARS isolation ward) when the work was within their usual area of competence and expertise (10).

Early unstructured observation suggested that perceived stigma and disrupted contact with colleagues provoked stress (3). This observation is supported by the mediating role of the social isolation and avoidance scale, which contains items probing stigma and coping by avoidance of crowds and colleagues. It bears emphasis that avoidance of contact with colleagues was recommended to reduce infectious spread. Social support is known to be an effective buffer of stress (15,16). Thus, coping by adherence to this particular recommendation appears to have increased the acute traumatic impact of the SARS experience. Stigma, in the form of being avoided by family and community contacts, was observed to be a prominent aspect of the experience of many HCWs during SARS (3,10,17). Because the reasons for social isolation in SARS were peculiar to the nature of the infectious threat (stigma) and measures required to contain it (reduced contact), social isolation may be a stress-provoking feature of emerging infectious diseases that differs from other large-scale stressors.

The hypothesized benefits of trust in protective equipment and infection control measures were not confirmed. This may be because of a lack of variability in the distribution of scores on these scales. There were 1241 participants (79.7%) who scored three or less out of a possible six on the dissatisfaction with systems and processes scale and 1252 participants (80.4%) who scored three or less out of a possible six on the doubt about protection scale. Thus, the large majority of participants had a positive view protective equipment and hospital procedures and resources.

The most significant methodological limitation of this study is the response rate. The method of distribution at two hospitals, employed for compassionate and ethical rather than scientific reasons, does not allow an accurate assessment of the denominator of the response rate (ie, the number of HCWs who were aware of the study and made a decision about participation). The most conservative estimates have been provided using the total number of staff as a denominator, which essentially calculates the lower limit of the response rate. However, two comparisons suggest that the study sample is representative of HCWs in Toronto during SARS. First, the characteristics of the study sample are similar to the total population of the institutions surveyed. For example, nurses comprise 26.8% of the staff of the participating hospitals and 27.6% of study sample. Hospital-wide figures on the prevalence of contact with patients with SARS are not available. Second, a survey of another Toronto hospital during the SARS outbreak, which achieved a 47% response rate, reported similar results. Specific similarities are that in that study there was increased distress in nurses; distress was associated with being treated as different and fearing death; and reports of job stress were prominent (7). Nonetheless, our results must be interpreted conservatively. The cross-sectional design does not allow causal interpretations to be made of the association of IES score to constructs that were treated statistically as mediators. Further methodological limitations are differences in sampling methods between the three hospitals and gathering SARS patient exposure information by self-report. The survey probed acute responses to a stressor, which does not provide information about long-term, persistent consequences of the outbreak.

We have discussed the implications of the SARS experience for future hospital preparedness elsewhere (10). Briefly, the data suggest that three attitudinal responses to the outbreak of an emerging infectious disease should be mitigated as effectively as possible. High perceived risk (reflected in health fear) may be accurate or exaggerated. Accurate estimates of risk may not be available early in an outbreak. Correcting miscalculations in perceived risk is a complex task that requires much greater sophistication than simply providing accurate information (18). Efforts to reduce the negative impact of social isolation could include creative efforts to increase effective interpersonal communication (11), careful evaluation, site by site, of the necessity of specific contact restrictions for infection control and efforts to provide accurate information to the media to reduce stigmatizing reports (10). The survey data also support efforts to reduce the job stress that results from increased workload and assignment to unfamiliar tasks. Efforts to reduce conflict and distress may include interventions with staff that increase the opportunity for reflection, provide a framework by which stress responses are understood as normal responses to an extraordinary situation, and increase collaboration and control over procedures in some cases (9).

In summary, this survey suggests that although distress in response to the SARS outbreak is greater in nurses and those who care for patients with SARS these relationships are explained by mediating variables that may be available for interventions to reduce stress in future outbreaks. In particular, the data suggest that the targets of intervention should include job stress, social isolation, and health fear.

Received for publication February 23, 2004.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 CONCLUSIONS
 REFERENCES
 

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  3. Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, Sadavoy J, Verhaeghe LM, Steinberg R, Mazzulli T. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003; 168: 1245–51.[Abstract/Free Full Text]
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  8. Avendano M, Derkach P, Swan S. Clinical course and management of SARS in health care workers in Toronto: a case series. CMAJ 2003; 168: 1649–60.[Abstract/Free Full Text]
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  14. Horowitz MJ, Wilner N, Alvarez W. Impact of event scale (IES). Handbook of Psychiatric Measures. Washington DC: American Psychiatric Publishing Group, 2000.
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  16. Uchino BN, Cacioppo JT, Kielcolt-Glaser JK. The relationship between social support and physiological processes: a review with emphasis on underlying mechanisms and implications for health. Psychological Bulletin 1996; 119: 488–531.[CrossRef][Medline]
  17. McGillis Hall L, Angus J, Peter E, O’Brien-Pallas L, Wynn F, Donner G. Media portrayal of nurses’ perspectives and concerns in the SARS crisis in Toronto. J Nurs Scholarship 2003; 35: 211–6.
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