|Year : 2020 | Volume
| Issue : 4 | Page : 299-307
Stress and psychological consequences of COVID-19 on health-care workers
Nevin F W. Zaki1, Mohammad Sidiq2, Mohammad Qasim2, Brenda Aranas3, Ali Hakamy4, Nabil Abdelaziz Ruwais5, Hussain Alanezi6, Dib Abdul-Aziz Al Saudi6, Raad Bin Saeed Alshahrani6, Abdullah Bin Ali Al-Thomali6, Md Dilshad Manzar7, Ahmed S BaHammam8, Abdelaziz F Al-Kaabba9, Seithikurippu R Pandi-Perumal10
1 Department of Psychiatry, Faculty of Medicine, Mansoura University, Mansoura, Egypt; Department of Psychiatry-NAAFH, Qasim Mental Health Hospital, Boraida, Saudi Arabia
2 Department of Physiotherapy and Rehabilitation Medicine, Qasim Mental Health Hospital, Boraida, Saudi Arabia
3 Medical Education and Research Unit -NAAFH, Qasim Mental Health Hospital, Boraida, Saudi Arabia
4 Department of Psychiatry-NAAFH, Qasim Mental Health Hospital, Boraida, Saudi Arabia
5 Departemnt of psychiatry, Head of Research Unit, Qasim Mental Health Hospital, Boraida, Saudi Arabia
6 Medical Administration, North Area Armed Forces Hospital, King Khalid Military City, Majmaah, Saudi Arabia
7 Department of Nursing, College of Applied Medical Sciences, Majmaah University, Majmaah, Saudi Arabia
8 Department of Medicine, The University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
9 Medical Education and Research Unit -NAAFH, Qasim Mental Health Hospital, Boraida; Department of Family Medicine, Medical Education and Medical Bioethics, Imam University, Riyadh, Saudi Arabia
10 Somnogen Canada Inc., Toronto, ON, Canada
|Date of Submission||07-Jul-2020|
|Date of Decision||18-Jul-2020|
|Date of Acceptance||06-Aug-2020|
|Date of Web Publication||02-Oct-2020|
Nevin F W. Zaki
Department of Psychiatry, Faculty of Medicine, Mansoura University, Mansoura, Egypt or King Khalid Military City, Hafr Elbaten
Source of Support: None, Conflict of Interest: None
Background: The wide scope and spread of Coronavirus Disease 2019 (COVID-19) could lead to a true mental health disaster, especially in countries with high caseloads. Very few studies have assessed the impact on hospital staff. This study aimed to assess mental health changes in health-care workers (Northern Area Armed Forces Hospital-Kingdom of Saudi Arabia). Materials and Methods: This is a cross-sectional study. A survey questionnaire was designed and distributed among the participants, and the survey contained demographic questions and questions related to anxiety, worries, and fears, in addition to depressive symptoms and basic sleep profile. In addition, the psychological impacts, feelings, fears of developing COVID-19, and symptoms of posttraumatic stress disorder were assessed using the Impact of Events Scale-Revised (IES-R). Results: The mean age of the staff was 38.2 years. The examined staffs showed high levels of anxiety and depressive features: 19.3% had crying and depressed mood and 2.4% had loss of motivation; they depended mainly on social media as a source of COVID-19 information. Moreover, these features correlated positively with their Post-Traumatic features measured by the IES-R. Nearly 27.3% of the participants had their duty impacted by COVID-19 and 40.6% were affected financially. Conclusion: Our study identified a vulnerable group susceptible to psychological distress. Psychological support could also be included as counseling services and development of support systems among colleagues.
Keywords: Anxieties, COVID-19, Impact of Events Scale-Revised, psychological impact, sleep
|How to cite this article:|
W. Zaki NF, Sidiq M, Qasim M, Aranas B, Hakamy A, Ruwais NA, Alanezi H, Al Saudi DA, Saeed Alshahrani RB, Ali Al-Thomali AB, Manzar MD, BaHammam AS, Al-Kaabba AF, Pandi-Perumal SR. Stress and psychological consequences of COVID-19 on health-care workers. J Nat Sci Med 2020;3:299-307
|How to cite this URL:|
W. Zaki NF, Sidiq M, Qasim M, Aranas B, Hakamy A, Ruwais NA, Alanezi H, Al Saudi DA, Saeed Alshahrani RB, Ali Al-Thomali AB, Manzar MD, BaHammam AS, Al-Kaabba AF, Pandi-Perumal SR. Stress and psychological consequences of COVID-19 on health-care workers. J Nat Sci Med [serial online] 2020 [cited 2020 Oct 24];3:299-307. Available from: https://www.jnsmonline.org/text.asp?2020/3/4/299/297124
| Introduction|| |
Infectious disease outbreaks such as Coronavirus Disease 2019 (COVID-19) can cause emotional distress and various psychological disturbances. Quarantine was introduced to control the transmission of COVID-19. On January 20, the World Health Organization (WHO) declared the novel COVID-19 an outbreak and advised all people to stay at home and practice social distancing., Quarantine is defined as the parting and limit of movement of people who have possibly been exposed to a transmissible disease to determine if they become unwell, so reducing the risk of them infecting others. On the other hand, isolation means separating people with a confirmed diagnosis of the infectious disease from those who are not sick;, however, the two terms are often used interchangeably.
Although quarantine has been planned to control potential health catastrophes, the impact of quarantine and compliance with restrictions is often an unpleasant experience for those who endure it. Separation from loved ones, loss of freedom, the feeling of helplessness, vagueness over the disease status, fear, boredom, and burnout can potentially cause dramatic effects on the affected individuals, especially on the mental health of the quarantined. Posttraumatic stress symptoms (PTSS) follows traumatic incidents outside the range of human control such as violent physical assaults, torture, accidents, rape, or natural disasters, and is characterized by a typical symptom pattern of intrusions, persistence of trauma, relevant stimuli avoidance, emotional numbing, and physiological hyperarousal. Several studies have explored the mental health impacts and the PTSS during previous SARS epidemics. For example, 3.7% of the public were found to have depression during that time, while 17.3% of the health-care workers had mental symptoms and 40% of SARS survivors had experienced PTSS at one time during the outbreak. In a wide-scale UK study, the prevalence of posttraumatic stress disorder (PTSD) in the UK during the initial COVID-19 pandemic was estimated to be 4.4%, and no gender differences were found. Furthermore, a recent study by Lui et al. found that the prevalence of PTSS a month after the COVID-19 epidemic for hardest-hit areas in China was 7%, with a higher prevalence in females. The same study also stated that individuals with bad sleep quality had higher PTSS.
Dong et al. expressed their worries that the wide scope and spread of COVID-19 could lead to a real mental health disaster, especially in countries with high caseloads. This will require both large-scale psychosocial management interventions and the integration of mental health-care services in disaster management plans in the future.
Galderisi et al., 2015, proposed the definition of mental health as follows: “Mental health is a dynamic state of internal equilibrium which enables individuals to use their abilities in harmony with universal values of the society. Basic cognitive and social skills; ability to recognize, express and modulate one's own emotions, as well as empathize with others; flexibility and ability to cope with adverse life events and function in social roles; and harmonious relationship between body and mind represent important components of mental health which contribute, to varying degrees, to the state of internal equilibrium.” On the other hand, the WHO identifies the following as necessary for proper mental health: well-being emotionally, psychologically, and socially. Happiness, interest in life, and satisfaction are the aspects of emotional well-being; liking most parts of one's own personality, being good at managing the responsibilities of daily life, having good relationships with others, and being satisfied with one's own life are the aspects of psychological well-being; positive functioning and having something to contribute to the society. These different identified mental health aspects are impacted negatively under stressful situations such as quarantine and the current COVID-19 crisis.
The experience of those placed under quarantine in terms of compliance with the quarantine conditions, difficulties, emotional reactions, and psychological impact remains under researched. Furthermore, most of the studies published are conducted on the general population, and very few have examined the psychological impact of quarantine on hospital staff.
Health-care workers and hospital staff in crises such as the COVID-19 pandemic are under more stress. They are exposed not only to infection with COVID-19 due to their frequent exposure to infected patients but also to psychological distress, long working hours, fatigue, occupational stigma, and physical violence. They might be exposed to a prolonged source of distress, which may exceed their coping skills. In a recent study by Abdel Wahed et al. in Egypt, it was found that more than three-quarters of health-care workers feel more susceptible to infection due to dealing with people who are careless about proper preventive measures. About two-thirds of the health-care workers in Wahed et al.'s study thought that COVID-19 is a newly emerging disease and several reasons made them more afraid of being infected such as unavailability of specific treatment or vaccine, associated fatalities, and the perceived unsatisfactory response of health authorities. Nevertheless, limited research has been reported on the psychological impacts of COVID-19 in hospital staffs from the Arab region and Saudi Arabia.
We hypothesized that this lockdown and quarantine procedures caused a more negative psychological impact on staff working at the hospital and caused several mental health problems such as depressive and anxiety symptoms. In this study, the prevalence and identification of potential factors contributing to mental health problems of health-care workers at the Northern Area Armed Forces Hospital-Kingdom of Saudi Arabia (NAAFH-KSA) were investigated. We also aimed to describe the understanding of the rationale for quarantine, difficulties, compliance with its rationale conditions, and the mental health problems associated with the quarantine in health-care workers.
| Materials and Methods|| |
Study design and duration
This is a cross-sectional study that was conducted in the NAAFH-KSA from April 1, 2020, until the end of May 2020.
Ethical and formal approvals
The institutional review board approval was obtained and written informed consent was obtained from all participants. The participants were also informed that some topics may be sensitive and that whatever their answer is, it will not affect their job or judgment.
Staff members working at the NAAFH were called to participate. Confidentiality of the participants was ensured all through the study as per the standard protocol.
Participants and measures (diagram number 1 summarizes step-wise study methodology)
An official memo was issued from the hospital director's office and distributed to all hospital departments, encouraging staff members at each department to participate in the survey. Paper copies of the survey were distributed with the memo. All hospital staff (those working in the medical, paramedical, administrative, and assistant services) were invited to participate where departmental secretaries were asked to photocopy the survey and distribute it to department members. Staff participation was optional. Therefore, this study used a convenience sampling technique. The staff were ensured the privacy and anonymity of their data on answering. Some staff were non-Arabic and non-English speakers; they were excluded due to difficulty in translating the survey into different minor languages.
Due to the nature of the facility, a military hospital, some staff were worried that their answers might affect their contract or re-contracting; these worries were eliminated by the research team as an effort to remove psychological bias.
A convenience sampling technique was used to enroll staff according to their availability and accessibility. Nevertheless, the sample size was calculated using the website www. surveysystem.com based on the following assumptions: the proportion of hospital staff that show psychological symptoms was 50%, level of confidence was 95%, sample error was 10%, and the minimum number needed equaled 93 staff. We managed to collect responses from 249 participants.
We checked with the human resources department about the total number of hospital staff, and they declared that it was 1460. We excluded the ten test individuals and 400 non-Arabic and non-English speakers, which makes the response rate (n = 249/1050) at 23.7% of the hospital staff [Figure 1].
Screening survey questionnaire
A self-administrated survey questionnaire was designed by the research team and distributed to all participants. We had the questionnaire in Arabic and English, and the participants were left free to choose the language of their answers. The questionnaire was designed after reviewing several study standardized surveys with already-measured validity., The questionnaire was checked and validated for content and relevance by authors; one of the authors is a family medicine physician and another is a public health professor who helped with the revisions of the survey questions together with one external public health professor. The questions were tested on 10 staff members (5 Arabic-speaking and 5 English speakers); they were asked to give feedback, and the comprehensibility was fair. They were later excluded from the respondents' list.
- Sociodemographic characteristics in the questionnaire included items for sex, age, occupation, number of people sharing the house, how many hours they used to spend outside their homes before the quarantine, and whether they think the lockdown is a good idea
- Participants were asked whether they have any COVID-19-related anxieties. Respondents' degree of the psychological impact of the COVID-19 pandemic was assessed using a 5-point Likert scale, ranging from 0 – “not at all,” 1 – “a little bit,” 2 – “moderate,” 3 – “quite a bit,” and 4 – “extreme.” Fear of contracting the COVID-19, overuse of hand sanitizers, and sources of information about the pandemic were also assessed. The questions used to cover this item were: have you faced any psychiatric complaints during the lockdown?, I can't stop imagining catching infection, I feel helpless, I sympathize with COVID-19 patients, I believe all sources of information without evaluation, I collect data about COVID-19 all day and can't stop, I am skeptical about the good news of COVID-19, I avoid watching the news, and I share news about COVID-19 all the time
- The financial impact of the quarantine and whether it had affected their duty hours were also included in the survey questions. The questions included to fulfill this purpose were: Has COVID-19 impacted your employment? Did this job changes distress you, and has COVID-19 impacted you financially?
- In addition, three questions related to the sleep characteristics were included. These included “the nature of shift work, whether they use their mobile phones before sleep, and whether the pandemic disrupted their sleep/wake rhythm before this quarantine was introduced”
- Furthermore, questions about their mood and possible depressive features were also incorporated within the survey (these items included whether they have guilt feelings, whether they feel pessimistic and have lost interest in life, and their sadness and bouts of crying).
Impact of Events Scale-Revised
We further assessed the psychological impacts, feelings, fears of developing COVID-19, and symptoms of PTSD using the Impact of Events Scale-Revised (IES-R). We used the original English version with English-speaking staff, and the translated Arabic version validated by Agostini et al. 2018 was used with the Arabic-speaking staff. Seven additional item questions were added to the IES-R. They contained questions related to the hyperarousal symptoms of PTSD that were not included in the original scale. These items paralleled directly the 14 of the 17 DSM-IV symptoms of PTSD. The respondents were asked to identify a specific stressful life event (in this study, it was quarantine and lockdown) and then indicated how much they were distressed or bothered during the past 7 days by each “difficulty” listed. The items were rated on a 5-point scale ranging from 0 (“not at all”) to 4 (“extremely”). The total score of the IES-R (ranges from 0 to 88) and intrusion, avoidance, and hyperarousal subscale scores can also be calculated. The mean of the three subscale domains (avoidance, intrusion, and hyperarousal) indicates the level of distress experienced. “The intrusion subscale is calculated by finding the mean item response of items 1, 2, 3, 6, 9, 14, 16, and 20. The avoidance subscale is calculated by the mean item response of items 5, 7, 8, 11, 12, 13, 17, and 22. At the same time, the hyperarousal subscale is the calculated mean item response of items 4, 10, 15, 18, 19, and 21.” Thus, scores for each of these three subscales, i.e., intrusion, avoidance, and hyperarousal, can range from 0 through 4. The scale showed high internal consistency (alpha = 0.96) in a study by Creamer et al. In a study by Beck et al., the IES-R three-factor subscales (intrusion, avoidance, and hyperarousal) showed adequate internal consistency for each subscale. Concurrent and discriminative validity were supported. Some differences were noted between the IES-R avoidance subscale and the DSM criteria of this cluster of symptoms, but these differences did not result in significant measurement problems. It was concluded that the IES-R is a solid measure of posttrauma phenomena.
A score of 24 or more indicates that PTSD is a clinical concern. Those with high scores who did not have full PTSD would have partial PTSD or at least some of the symptoms later and were targets of clinical attention. A score of 33 and above represented the best cutoff for a probable diagnosis of PTSD, whereas a score of 37 or more is high enough to suppress the immune system's functioning (even 10 years after an impact event). IES when compared to the diagnostic criteria using DSM-IV, the original IES (without the hyperarousal scale), was found to have a sensitivity of 0.89–1.00 and a specificity of 0.78–0.94 for PTSD depending on the cutoff points used.
Data entry was done by transferring paper forms into an excel sheet, and SPSS Statistics for windows version 25 (IBM Corp., Armonk, N.Y., USA) was used for descriptive statistics and correlative calculations.
| Results|| |
The mean age of the staff was 38.2 years, the average number of hours spent outside the house before the quarantine was 6.5 h, and the average number of people sharing the same house was 3.1. The male-to-female ratio was nearly one to one 1:1, and most of the participants were married (66.3%). Most of the staff thought that the lockdown was a good idea (92%). Nearly half of the sample were shift workers. Most of the staff got their COVID-19 information from social media (42.6%), whereas only 30.1% listened to the Ministry of Health's daily press release [Table 1]. The participation of each occupation in the survey questions is depicted in [Figure 2], which represents the percentages of participants according to their job. The highest numbers of participants constituted nurses and allied health professionals (42.51%), followed by doctors (23%), and the least participating were pharmacists (0.4%).
|Figure 2: Percentage of individuals in each occupation of the recruited staffs|
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In [Table 2], a descriptive summary of different types of the psychological and financial impact of the COVID-19 is presented. It shows that most (81.9%) of the staff believed all information mentioned by different media resources about the pandemic without assessment or verification. Around 62% of the staff were skeptical about the good news mentioned of the pandemic (e.g., finding a vaccine, finding a cure, and defeating the spread of infection), and 25% of the staff avoided watching the news about COVID-19. It can also be seen that 40.6% of the staff were affected financially with the quarantine and 19.3% had depressive feelings and loss of motivation, while 41% had disrupted sleep/wake cycle after the quarantine.
|Table 2: Distribution and prevalence of various psychological symptoms extracted from the survey questions|
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In [Table 3], the means and standard deviations of the IES and its subscales are shown, while [Table 4] summarizes the survey situations, which affected most of the IES-R scores. We extracted only those screening questions which showed a statistically significant difference in IES-R groups. It can be noticed that occupation and some of the questions screening for fears, anxieties, and depressive features had higher scores on the impact of the event scale, indicating that these subjects are affected more traumatically by the quarantine experience.
|Table 3: Means and standard deviations of the Impact of Events Scale-Revised subscales|
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|Table 4: Impact of Events Scale.Revised severity among the different survey categories|
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| Discussion|| |
This study aimed to highlight the psychological impact of quarantine due to the paucity of data about this topic in the literature in general and in Saudi Arabia in particular. Our findings suggest that clinical depression was, to some extent, prevalent among our study sample, despite that 97.6% of them reported no past history of psychiatric disorders prior to the quarantine. Regarding features of anxiety and fears, 39% of the respondents in the current study reported that they could not stop imagining catching infection and 23.7% reported feeling helpless. Among the study group, 32.5% of the study participants had an urge to collect data about the COVID-19 pandemic and could not stop collecting these information, and also 25.7% avoided watching the news about the virus. Our findings of disrupted sleep are in contrary to those of Bihlmaier et al., who suggested that people who were trained to deal with stress such as health-care workers and law enforcement officers can maintain a relatively stable emotional state even under stress, and they may experience fewer episodes of night waking, sleep anxiety, and sleep delay. The sleep profile of our participants was disrupted in around 41%, with 82.7% reporting using their smartphones at bedtime. Researches on previous pandemics documented that psychological impact can continue even after the quarantine is over. The psychological impact of these highly contagious viruses is even thought to have been greater than the physical health danger imposed by the illnesses, and in the case of COVID-19, multiple studies referred to this particular outbreak in terms of a “mental health catastrophe.” Gardner and Moallef showed that studies consistently reported high rates of emotional distress among survivors, persisting for years post infection. Hospital staff and health-care workers are at a higher risk of adverse mental health outcomes during the COVID-19 outbreak. According to Kang et al., reasons for this include long working hours, high risk of catching the infection, lack of protective equipment, aloneness, physical fatigue, and separation from families.
Our findings are comparable to the study of Wang et al., where 16.5% of their study sample reported moderate-to-severe depressive symptoms and 28.8% reported moderate-to-severe anxiety symptoms. Wang et al. also found that updated and truthful health information and particular preventive measures (e.g., hand hygiene, wearing a mask) were associated with a lower psychological impact and lower levels of stress, depression, and anxiety (P < 0.05). This has also been observed by previous researchers revealing a wide range of psychosocial impact on people at the individual, community, and international levels during the outbreaks of infection. Hall et al. reported fear of falling sick or dying among their study group, and feelings of helplessness and stigma were also detected. During one influenza outbreak, around 10%–30% of the general population were worried about the possibility of catching the viral infection.
Anxiety was associated with impaired sleep in studies examining this link. In addition, Rajkumar suggested that symptoms of anxiety and depression (16%–28%) and self-reported stress (8%) are common psychological reactions to the COVID-19 pandemic and may be associated with disturbed sleep. These sleep profile disruptions were previously stated in a study by Jahrami et al. in Bahraini health-care workers where they found that frontliners had a mean global Pittsburgh Sleep Quality Index score of 7.1, indicating poor sleep quality, and the mean Perceived Stress Scale score was 20.3, which reflects moderate stress. The current results are also similar to that of the study conducted in Egypt by Wahed et al., who found that about 83.1% of health-care workers reported that they were afraid of being infected with COVID-19, and 89.2% stated that they were more susceptible to the COVID-19 infection as compared to others. Unavailability of personal protective equipment, fear of transmitting the disease to their families, and social stigma were the most frequently reported reasons for increased risk perception. Similarly, in a review by Spoorthy, it was found that females, older age, nursing profession, and single doctor category were associated with an increased level of stress, anxieties, depressive complaints, and insomnia in health-care workers.
Overall, in this study, social media (42.6%) was the primary source of information to hospital staff about the virus, followed by the Internet (39%) and the Ministry of Health (30%). Most of the hospital staff (81.9%) believed the news announced about the virus without revision or verification. Furthermore, 62.2% were skeptical about any good news of the virus. The IES-R prevalence of moderate or severe psychological impact was higher in those respondents who showed depressive anxiety features. In addition, the occupation of the respondents affected their score and the risk of development of PTSD symptoms, and this is very similar to the findings of Chatterjee et al., who found that doctors (physicians) working during the COVID-19 pandemic had higher percentages of psychiatric morbidity. In a study by Tan et al., it was found that the IES-R scores among health-care workers were lower than those in the published literature from previous disease outbreaks; this is contradictory to Bohilken et al., who reported that severe degrees of PTSSs were found in 2.2%–14.5% of all participants. The severity of mental symptoms was influenced by age, gender, occupation, specialization, type of activities performed, and proximity to the COVID-19 patients. Previously, in a study by Wu et al., it was found that after the end of the quarantine, having been quarantined was the most predictive factor of symptoms of acute stress disorder. In the same study, the quarantined staff was significantly more likely to report exhaustion, detachment from others, and anxiety when dealing with febrile patients, irritability, insomnia, poor concentration and indecisiveness, and deterioration of work performance and reluctance to work or consideration of resignation. Such studies have shown that health-care workers experienced greater psychological distress, including symptoms of PTSD. In addition, physicians providing acute treatment of infections during quarantine can have a significant impact on individuals' mental health. Furthermore, in a recent meta-analysis, it was found that risk factors for psychological distress in health-care workers included being younger, being more junior, being the parents of dependent children, or having an infected family member. Longer quarantine, lack of practical support, and stigma also contributed. Clear communication, access to adequate personal protection, adequate rest, and both practical and psychological support were associated with better outcomes.
Some of the survey questions studied the economic impact of the COVID-19 and its effects on duty. Approximately, 41% of the staff stated that COVID-19 had affected them financially, and 27.3% were affected and stressed in their employment schedules because of the pandemic and consequent preventive measures. These results of the economic impact in the current study are similar to those reported in the Japanese population.
Our study identified hospital staff as a vulnerable group susceptible to psychological distress. In a recent review, it was concluded that most of the health-care workers developed mild depression and anxiety symptoms, while severer symptoms were infrequent, indicating that early screening and detection can be very beneficial for such groups. The incorporation of educational interventions should target health-care workers and hospital staff to guarantee the understanding and use of infection control procedures. Psychological support could also be included as counseling services and development of support systems among colleagues.
Strength and limitations
This is the first study that provides valuable information on the psychological responses of hospital staffs after the outbreak of COVID-19 from respondents in Saudi Arabia. Most importantly, our findings raise a red flag to health-care authorities to develop a strategy of psychological management of hospital employees and health-care workers to minimize various psychological impacts during the COVID-19 pandemic and provide a foundation for guideline development for the assessment, prevention, control, and treatment of the current outbreaks and similar future ones.
However, the current study has several limitations. The current study is a cross-sectional study, which did not allow us to follow the course of stress and psychological problems among hospital employees over time. This was out of our control due to ethical requirements on confidentiality and the military nature of the included hospital. The small sample size is another limitation. A third limitation is that self-reported levels of psychological impact, anxiety, depression, and stress are subjective complaints and were not confirmed by the objective psychiatric interviews. Thus, generalization of the current findings should be considered with caution, and follow-up of the recruited sample can be done in future research studies. Similarly, the respondents might have provided socially desirable responses. We tried as much as we can to avoid psychological and selection bias.
| Conclusions|| |
Hospital staff and health-care workers are at increased risk of developing psychological and mental health issues during the COVID-19 crisis. Special supportive measures should be implemented during and after the pandemic is over. Further research on the risk and preventive factors should be taken into account in future. Designing proper mental health management guidelines during pandemics could be designed and executed.
The research team is grateful to all the participating hospital staff for their time and effort. We would also like to thank the medical secretaries and all the contributing departments for the help with submitting the survey forms to the research office, and we would also like to thank the head and all members of the department of medical education for encouraging this research and facilitating logistics.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]