Abstract
Objectives: This study aimed to investigate the relationship between clinical decision for the novel coronavirus disease 2019 (COVID-19) patients and post-traumatic stress symptoms (PTSS) among healthcare professionals during the COVID-19 pandemic. Methods: Japanese healthcare professionals were recruited. The survey was conducted from May 21 to June 18, 2021. PTSS was assessed by the Impact of Event Scale-Revised. Items about the experience of clinical decision for COVID-19 patients and other independent variables were originally developed from previous studies. Univariate and multiple linear regression analyses were used to examine the association of independent variables and PTSS. Results: 515 (3.9%) healthcare professionals completed all questions. Among them, 172 (33.4%) had experienced clinical decision for COVID-19 patients. Multiple linear regression analysis showed that clinical decision for COVID-19 patients (B=3.32, 95% CI 1.41–5.24; p<0.01), as well as fear of getting a COVID-19 infection (B=2.15, 95% CI 0.32–3.98; p=0.02), were significantly associated with PTSS in the adjusted model. Conclusions: The study showed that clinical decision might be a very serious factor related to PTSS among healthcare professionals during the COVID-19. Clinical decision for patients with COVID-19 has a high experience rate and was considered to be a serious experience among healthcare professionals during the pandemic. As a countermeasure for the mental health of healthcare professionals during the COVID-19, it is important for healthcare professionals to take countermeasures for clinical decision for patients with COVID-19.
Introduction
It is well-known that mental health problems have occurred among healthcare professionals during the novel coronavirus disease 2019 (COVID-19) pandemic1,2,3). A systematic review reported an increased risk of mental health problems among healthcare professionals during the COVID-19 outbreak, with a prevalence of mental health problems being anxiety (23.2%), depression (22.8%), and insomnia (38.9%)4). The other systematic review showed that the prevalence rate of symptoms related to post-traumatic stress disorder (PTSD) was estimated to be 18% among healthcare professionals5). Mental health problems among healthcare professionals have been reported to be associated with turnover, absenteeism, and job performance6). Countermeasures for mental health problems among healthcare professionals are important to maintain the healthcare system during the COVID-19 pandemic.
During the COVID-19 pandemic, healthcare professionals have experienced the pain of having to make decisions for patients and witnessing patients in life-threatening situations but not being able to help them7). Clinical decision for patients in these situations was reported as a possible risk factor for mental health problems among healthcare professionals8). Clinical decision has been defined in many definitions, as an experience of clinical decision for patients with COVID-19 during the COVID-19 pandemic includes how to treat and care for patients with COVID-19, how to allocate scant resources to equally needy patients, how to align their desire and duty to patients with those of family and friends, and how to provide care for all severely unwell patients with constrained or inadequate resources9). Because of such difficult situations of healthcare professionals during the COVID-19 pandemic, it is important to study about the experience of clinical decision for patients with COVID-19. Clinical decision for patients during the COVID-19 pandemic is considered to be classified as a part of the potentially morally injurious event (PMIE)8). PMIE is defined as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations, which may leave long-lasting emotional, psychological, behavioural and spiritually harmful impacts10). A previous study, which investigated the prevalence of PMIE among physicians who worked in COVID-19 treatment medical units, showed that almost 50% of physicians experienced such exposure during the COVID-19 pandemic11). A systematic review and meta-analysis showed the association between work-related PMIEs and post-traumatic stress symptoms (PTSS)12).
However, a review reported that the previous studies had not assessed this association with respect to traumatic events of clinical decision for patients among healthcare professionals during the COVID-19 pandemic8). To the best of our knowledge, no study has investigated the relationship between clinical decision for patients and mental health disorders, such as PTSS, among healthcare professionals during the COVID-19 pandemic. Healthcare professionals have experienced the pain of having to make decisions for patients during the COVID-19 pandemic7), and these experiences can be traumatic events for them and lead to the development of PTSS. After the global pandemic of the COVID-19 started, many countries encountered a severe threat to their healthcare systems due to the exponential growth of positive cases and deaths. Due to the rapid increase in the number of patients and the need to make life-threatening decisions for patients with limited resources during the COVID-19 pandemic, clinical decision for COVID-19 patients may have a greater impact on the mental health of healthcare professionals than clinical decision unrelated to the COVID-19 pandemic.
This study aimed to investigate the relationship between clinical decision for patients and PTSS among healthcare professionals during the COVID-19 pandemic.
Methods
Participants
Disaster Medical Assistance Team (DMAT) and Disaster Psychiatric Assistance Team (DPAT) are trained healthcare professionals who have the mobility to work in an acute phase of a disaster in Japan1). DMAT and DPAT are among the major disaster medical relief teams in Japan who respond at the onset of a disaster for a couple of days. DMAT and DPAT members (physicians, nurses, and other healthcare professionals such as pharmacists and occupational therapists) usually and mostly work at their own base hospital. At a time of need, the national or prefectural government requests a deployment to disaster base hospitals. The selected members provide rescue efforts to the affected areas or accident sites for several days and return to their normal working in their hospital after the rescue activity. The recruited participants in this study included DMAT and DPAT members who met the following inclusion criteria: 1) aged 18 years or older, 2) native Japanese speaker or nonnative speaker with Japanese reading and writing skills, 3) physically and psychologically capable of understanding and providing consent for study participation, 4) able to receive an e-mail with the written guide for this study from the DMAT office or the DPAT office.
Study design
Healthcare professionals belonging to DMAT or DPAT in Japan were recruited for this study. The survey was conducted from May 21 to June 18, 2021. For DMAT members, a written guide for this study was posted to the mailing list by the DMAT office, and for DPAT members by the DPAT office. The guide contained a written explanation of the study and the URL of a web page containing a questionnaire and a consent form for this study. Participants accessed the URL, read a detailed explanation of the study and responded online to the consent form and the questionnaire. For reference, the number of new confirmed cases of COVID-19 in Japan was 1,234 on February 21 2021, 5,711 on May 21, 1,550 on June 18, and the highest number of cases in 2021 was 25,877 on August 2113).
This study was conducted as part of the Japanese survey of the COVID-19 HEalth caRe wOrkErS (HEROES) study14). The HEROES study is a large, bottom-up initiative aimed to evaluate the impact of the COVID-19 pandemic on the mental health of healthcare professionals15). HEROES encompasses a wide variety of academic institutions in 19 low and low middle income countries (LMICs) and 8 high income countries (HICs,) in partnership with the Pan American Health Organization (PAHO) and with support from the World Health Organization (WHO). The participants in this study are only Japanese participants in the HEROES study and do not include participants from other countries.
This study was ethically approved by the research ethics committee of the National Hospital Organization Disaster Medical Center (No. 2019-19) and the research ethics committee of the Graduate School of Medicine and Faculty of Medicine at the University of Tokyo (No. 2019164NI-(1)(2)(3)). This study was also ethically approved to use the information of DMAT and DPAT by the Ministry of Health, Labor and Welfare of Japan. Informed consent was obtained by the participant reading an ethical document and completing a consent form on the web page of this study. This study was conducted in accordance with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement16).
Measurements
Outcome
The outcome of this study was evidence of PTSS, which was assessed by the Impact of Event Scale-Revised (IES-R). This is a self-reporting questionnaire consisting of 22 items (range: 0–88) on the three common symptoms in the diagnostic criteria for PTSS, namely, re-experiencing, avoidance, and hyperarousal; higher scores are representative of greater distress17). It is a widely used scale in disaster-area research. The reliability and validity of the Japanese version of the IES-R have been verified (Cronbach’s α=0.92–0.95)18).
Independent variables
Items about the experience of clinical decision for patients with COVID-19 and other independent variables were originally developed as questions in the HEROES study14). The question about the experience of clinical decision for patients with COVID-19 was asked “In the past 3 months, have you had to decide how to prioritize patients with COVID-19 for treatment?”, and was answered by a binary (yes/no). Clinical decision for COVID-19 patients during the COVID-19 pandemic in this study can be thought of as including decision makings about how to treat and care for COVID-19 patients, how to allocate scant resources to equally needy patients9).
The other independent variables (e.g., passed away of a patient who was treated or cared for, contact with patients who were suspected or confirmed cases of COVID-19, working in a COVID-19 unit, positive result of the test for COVID-19, fear of getting COVID-19 infection, and isolation for being a suspected or confirmed case of COVID-19) were factors associated with the mental health of healthcare professionals in previous studies during the COVID-19 pandemic1,2,3,4,19). The question about the experience of death of a patient who was treated or cared for, contact with patients who were suspected or confirmed cases of COVID-19, working in a COVID-19 unit, and positive result of the test for COVID-19 were, respectively, as follows: “In the past 3 months, have any of the patients with COVID-19 that you cared for passed away?”, “During the past week, have you been close to patients who were suspected or confirmed cases of COVID-19?”, “Are you working in a COVID-19 unit?”, and “In the past 3 months, have you tested positive for COVID-19?” These were answered by a binary (yes/no). The question about assessment of fear of getting COVID-19 infection was asked, “In the past 3 months, how worried have you been about getting COVID-19?”; it was answered by selecting one of the following four options: “Not at all”, “Slightly”, “Considerably”, and “Extremely”. The answer of “Not at all” was defined as “Not worried”, while answers of “Slightly”, “Considerably”, and “Extremely” were defined as “Worried”. The question about the experience of isolation for being a suspected or confirmed case of COVID-19 was asked, “In the past 3 months, how many days have you been in isolation for being a suspected or confirmed case of COVID-19?” and was answered by the number of days of isolation. An answer of no days of isolation experience was defined as “No experience in isolation”, and more than one day of isolation experience was defined as “Experience in isolation”.
Demographic variables of age, sex, occupation, and years of occupational experience were retrieved.
Statistical analysis
We analyzed the dataset of participants who completed all questions of the self-report questionnaire. Univariate linear regression analysis was used to examine the association of PTSS with the experience of clinical decision for patients with COVID-19 and other independent variables (passed away of a patient who was treated or cared for, contact with patients who had suspected or confirmed cases of COVID-19, working in a COVID-19 unit, positive result of the test for COVID-19, fear of getting COVID-19 infection, and isolation for having a suspected or confirmed case of COVID-19). Multiple linear regression analysis was used to examine the association of PTSS with the experience of clinical decision for patients with COVID-19 and other independent variables, adjusting for sex, age, and occupation (physicians: reference, nurses, and other healthcare professionals). Years of occupational experience were not included in the multiple regression analysis due to the high value of variance inflation factor (VIF) and multicollinearity with age. In addition, univariate and multiple regression analyses were conducted for differences in occupation (physicians, nurses, and other healthcare professionals) and experience of contact with patients who had suspected or confirmed cases of COVID-19. Any association between the independent variables and the dependent variables was shown as a regression coefficient (beta weight) and quantified by a 95% confidence interval (95% CI). All statistical analyses used 2-tailed tests. Statistical significance level was established at a p value of less than 0.05. All analyses were conducted using SPSS version 26.0 J for Windows (SPSS, Tokyo, Japan).
Results
Among 13,315 healthcare professionals, 777 (5.8%) agreed to participate in this study, and 515 (3.9%) completed all questions. The mean age was 44.0 (standard deviation [SD], 8.3), 131 participants (25.4%) were physicians, 205 participants (39.8%) were nurses, and 179 participants (34.8%) were other healthcare professionals (Table 1). Among them, 172 (33.4%) participants, 61 (46.6%) physicians, 79 (38.5%) nurses, and 32 (17.9%) other healthcare professionals had experienced clinical decision for patients with COVID-19. The mean score of PTSS assessed by IES-R was 5.2 (SD, 9.5).
Table 1. Participants’ characteristics (N=515)
| n | % | mean | SD |
|---|
| Sex | | | | |
| Male | 357 | 69.3 | | |
| Female | 158 | 30.7 | | |
| Age (years) | | | 44.0 | 8.3 |
| Occupational experience (years) | | | 19.5 | 8.1 |
| Occupation | | | | |
| Physicians | 131 | 25.4 | | |
| Nurses | 205 | 39.8 | | |
| Other healthcare professionals | 179 | 34.8 | | |
| Clinical decision for patients with COVID-19 (yes) | 172 | 33.4 | | |
| Passed away of a patient who was treated or cared for (yes) | 98 | 19.0 | | |
| Contact with patients who had suspected or confirmed cases of COVID-19 (yes) | 242 | 47.0 | | |
| Working in a COVID-19 unit (yes) | 242 | 47.0 | | |
| Positive result of test for COVID-19 (yes) | 11 | 2.1 | | |
| Fear of getting the COVID-19 infection (yes) | 134 | 26.0 | | |
| Isolation for having a suspected or confirmed case of COVID-19 (yes) | 28 | 5.4 | | |
| IES-R (range: 0–88) | | | 5.2 | 9.5 |
COVID-19, novel coronavirus disease 2019; IES-R, Impact of Event Scale revised; SD, standard deviation.
Univariate linear regression analysis showed that clinical decision for patients with COVID-19 (B=4.36, 95% CI 2.66–6.07; p<0.01), passed away of a patient who was treated or cared for (B=2.27, 95% CI 0.19–4.36; p=0.03), contact with patients who had suspected or confirmed cases of COVID-19 (B=2.48, 95% CI 0.85–4.12; p<0.01), working in a COVID-19 unit (B=2.94, 95% CI 1.31–4.56; p<0.01), and fear of getting the COVID-19 infection (B=2.55, 95% CI 0.69–4.41; p<0.01) were factors associated with PTSS (Table 2). Multiple linear regression analysis showed that clinical decision for patients with COVID-19 (B=3.32, 95% CI 1.41–5.24; p<0.01), as well as fear of getting the COVID-19 infection (B=2.15, 95% CI 0.32–3.98; p=0.02), were significantly associated with PTSS in the adjusted model. R squared in the adjusted model (adjusted for sex, age, and occupation) was 0.09.
Table 2. Association between PTSS
† and the clinical decision for patients and the other independent variables among healthcare professionals during the COVID-19 outbreak (May 2021) in Japan: results of univariate and multiple linear regression analysis (N=515)
| Variables | univariate linear regression | multiple linear regression a |
|---|
| B | 95% CI | p | B | 95% CI | p |
|---|
| Clinical decision for patients with COVID-19 (yes) | 4.36 | 2.66, 6.07 | <0.01** | 3.32 | 1.41, 5.24 | <0.01** |
| Death of a patient who was treated or cared for (yes) | 2.27 | 0.19, 4.36 | 0.03* | −0.40 | −2.71, 1.92 | 0.74 |
| Contact with patients who had suspected or confirmed cases of COVID-19 (yes) | 2.48 | 0.85, 4.12 | <0.01** | 0.56 | −1.52, 2.63 | 0.60 |
| Working in a COVID-19 unit (yes) | 2.94 | 1.31, 4.56 | <0.01** | 1.19 | −0.96, 3.33 | 0.28 |
| Positive result of a test for COVID-19 (yes) | 2.77 | −2.91, 8.45 | 0.34 | 1.60 | −3.96, 7.15 | 0.57 |
| Fear of getting the COVID-19 infection (yes) | 2.55 | 0.69, 4.41 | <0.01** | 2.15 | 0.32, 3.98 | 0.02* |
| Isolation for having a suspected or confirmed case of COVID-19 (yes) | 1.60 | −2.02, 5.22 | 0.39 | 0.23 | −3.33, 3.80 | 0.90 |
Cl, confidence interval; COVID-19, novel coronavirus disease 2019; PTSS, post-traumatic stress symptoms.
†PTSS was assessed by the Japanese version of Impact of Event Scale-Revised.
a Adjusted for sex, age, and occupation (physicians: reference, nurses, and other healthcare professionals).
*p<0.05; **p<0.01.
Univariate linear regression analysis by occupation showed that working in a COVID-19 unit (B=4.05, 95% CI 0.45–7.65; p=0.03), and fear of getting the COVID-19 infection (B=6.51, 95% CI 2.62–10.40; p<0.01) among physician, clinical decision for patients with COVID-19 (B=5.69, 95% CI 2.72–8.66; p<0.01), contact with patients who had suspected or confirmed cases of COVID-19 (B=3.62, 95% CI 0.69–6.56; p=0.02), and working in a COVID-19 unit (B=3.54, 95% CI 0.60–6.47; p=0.02) among nurses were factors associated with PTSS, and no item was associated among other healthcare professionals (Table 3). Multiple linear regression analysis by occupation showed that contact with patients who had suspected or confirmed cases of COVID-19 (B=−6.79, 95% CI −11.59 – −2.00; p<0.01), working in a COVID-19 unit (B=7.26, 95% CI 2.48–12.04; p<0.01), and fear of getting the COVID-19 infection (B=6.63, 95% CI 2.78–10.47; p<0.01) among physicians, clinical decision for patients with COVID-19 (B=4.76, 95% CI 1.46–8.06; p<0.01) among nurses were factors associated with PTSS, and no item was associated among other healthcare professionals (Table 4). R squared in the adjusted model (adjusted for sex, age, and occupation) was 0.21 among physicians, 0.13 among nurses, and 0.04 among other healthcare professionals.
Table 3. Association between PTSS
† and the clinical decision for patients and the other independent variables among healthcare professionals during the COVID-19 outbreak (May 2021) in Japan: results of univariate linear regression analysis by occupation (N=515)
| Variables | Physicians (n=131) | Nurses (n=205) | Other healthcare professionals (n=179) |
|---|
| B | 95% CI | p | B | 95% CI | p | B | 95% CI | p |
|---|
| Clinical decision for patients with COVID-19 (yes) | 3.50 | −0.13, 7.13 | 0.06 | 5.69 | 2.72, 8.66 | <0.01** | 1.31 | −1.11, 3.73 | 0.29 |
| Death of a patient who was treated or cared for (yes) | 0.94 | −3.30, 5.19 | 0.66 | 3.04 | −0.44, 6.52 | 0.09 | −0.08 | −3.17, 3.01 | 0.96 |
| Contact with patients who had suspected or confirmed cases of COVID-19 (yes) | −0.25 | −4.02, 3.52 | 0.89 | 3.62 | 0.69, 6.56 | 0.02* | 1.36 | −0.70, 3.42 | 0.20 |
| Working in a COVID-19 unit (yes) | 4.05 | 0.45, 7.65 | 0.03* | 3.54 | 0.60, 6.47 | 0.02* | −0.11 | −2.08, 1.86 | 0.91 |
| Positive result of a test for COVID-19 (yes) | 3.52 | −5.98, 13.02 | 0.47 | 4.05 | −6.67, 14.78 | 0.46 | −3.28 | −12.11, 5.56 | 0.47 |
| Fear of getting the COVID-19 infection (yes) | 6.51 | 2.62, 10.40 | <0.01** | 1.28 | −2.02, 4.57 | 0.45 | 0.15 | −2.10, 2.40 | 0.89 |
| Isolation for having a suspected or confirmed case of COVID-19 (yes) | 6.84 | −0.28, 13.95 | 0.06 | −1.65 | −7.74, 4.44 | 0.59 | −0.94 | −6.10, 4.23 | 0.72 |
Cl, confidence interval; COVID-19, novel coronavirus disease 2019; PTSS, post-traumatic stress symptoms.
†PTSS was assessed by the Japanese version of Impact of Event Scale-Revised.
*p<0.05; **p<0.01.
Table 4. Association between PTSS
† and the clinical decision for patients and the other independent variables among healthcare professionals during the COVID-19 outbreak (May 2021) in Japan: results of multiple linear regression analysis
a by occupation (N=515)
| Variables | Physicians (n=131) | Nurses (n=205) | Other healthcare professionals (n=179) |
|---|
| B | 95% CI | p | B | 95% CI | p | B | 95% CI | p |
|---|
| Clinical decision for patients with COVID-19 (yes) | 3.12 | −0.96, 7.20 | 0.13 | 4.76 | 1.46, 8.06 | <0.01** | 1.46 | −1.07, 4.00 | 0.26 |
| Death of a patient who was treated or cared for (yes) | −2.16 | −6.76, 2.44 | 0.36 | 0.18 | −3.67, 4.02 | 0.93 | −0.18 | −3.63, 3.28 | 0.92 |
| Contact with patients who had suspected or confirmed cases of COVID-19 (yes) | −6.79 | −11.59, −2.00 | <0.01** | 1.94 | −1.59, 5.47 | 0.28 | 2.06 | −0.50, 4.63 | 0.11 |
| Working in a COVID-19 unit (yes) | 7.26 | 2.48, 12.04 | <0.01** | 0.31 | −3.43, 4.05 | 0.87 | −1.09 | −3.69, 1.51 | 0.41 |
| Positive result of a test for COVID-19 (yes) | 3.28 | −5.68, 12.13 | 0.48 | 3.09 | −7.51, 13.68 | 0.57 | −2.30 | −11.43, 6.84 | 0.62 |
| Fear of getting the COVID-19 infection (yes) | 6.63 | 2.78, 10.47 | <0.01** | 0.65 | −2.56, 3.85 | 0.69 | 0.59 | −1.76, 2.95 | 0.62 |
| Isolation for having a suspected or confirmed case of COVID-19 (yes) | 3.32 | −3.57, 10.22 | 0.34 | −2.72 | −8.64, 3.20 | 0.37 | −2.13 | −5.26, 1.00 | 0.18 |
Cl, confidence interval; COVID-19, novel coronavirus disease 2019; PTSS, post-traumatic stress symptoms.
†PTSS was assessed by the Japanese version of Impact of Event Scale-Revised.
a Adjusted for sex, age.
*p<0.05; **p<0.01.
Univariate linear regression analysis showed that clinical decision for patients with COVID-19 (B=3.48, 95% CI 0.95–6.00; p<0.01) and fear of getting the COVID-19 infection (B=3.12, 95% CI 0.23–6.01; p=0.03) among participants who had experience of contact with patients who had suspected or confirmed cases of COVID-19, clinical decision for patients with COVID-19 (B=4.49, 95% CI 1.83–7.15; p<0.01) among participants who did not have experience were factors associated with PTSS (Table 5). Multiple linear regression analysis showed that clinical decision for patients with COVID-19 (B=3.04, 95% CI 0.24–5.83; p=0.03) among participants who had experience of contact with patients who had suspected or confirmed cases of COVID-19, clinical decision for patients with COVID-19 (B=4.04, 95% CI 1.29 – 6.79; p<0.01) among participants who did not have experience were factors associated with PTSS. R squared in the adjusted model (adjusted for sex, age, and occupation) was 0.09 among participants who had experience of contact with patients who had suspected or confirmed cases of COVID-19 and 0.08 among participants who did not have experience.
Table 5. Association between PTSS
† and the clinical decision for patients and the other independent variables among healthcare professionals during the COVID-19 outbreak (May 2021) in Japan: results of univariate and multiple linear regression analysis
a by experience of contact with patients who had suspected or confirmed cases of COVID-19 (N=515)
| Variables | Experience of contact with patients who had suspected or confirmed cases of COVID-19 (n= 242) | Without experience of contact with patients who had suspected or confirmed cases of COVID-19 (n= 273) |
|---|
| univariate linear regression | multiple linear regression a | univariate linear regression | multiple linear regression a |
|---|
| B | 95% CI | p | B | 95% CI | p | B | 95% CI | p | B | 95% CI | p |
|---|
| Clinical decision for patients with COVID-19 (yes) | 3.48 | 0.95, 6.00 | <0.01** | 3.04 | 0.24, 5.83 | 0.03* | 4.49 | 1.83, 7.15 | <0.01** | 4.04 | 1.29, 6.79 | <0.01** |
| Death of a patient who was treated or cared for (yes) | 1.58 | −1.12, 4.28 | 0.25 | −0.05 | −2.96, 2.87 | 0.94 | 0.68 | −3.56, 4.92 | 0.75 | −1.32 | −5.74, 3.11 | 0.56 |
| Working in a COVID-19 unit (yes) | 1.95 | −1.17, 5.06 | 0.22 | 0.68 | −2.63, 4.00 | 0.69 | 2.56 | −0.12, 5.25 | 0.06 | 2.18 | −0.66, 5.03 | 0.13 |
| Positive result of a test for COVID-19 (yes) | 4.25 | −2.86, 11.36 | 0.24 | 3.69 | −3.36, 10.73 | 0.30 | −3.40 | −13.49, 6.68 | 0.51 | −3.57 | −13.62, 6.49 | 0.49 |
| Fear of getting the COVID-19 infection (yes) | 3.12 | 0.23, 6.01 | 0.03 * | 2.38 | −0.56, 5.31 | 0.11 | 2.11 | −0.27, 4.48 | 0.08 | 2.22 | −0.13, 4.56 | 0.06 |
| Isolation for having a suspected or confirmed case of COVID-19 (yes) | −0.07 | −4.70, 4.56 | 0.98 | −1.13 | −5.73, 3.46 | 0.63 | 3.44 | −2.78, 9.67 | 0.28 | 3.47 | −2.68, 9.61 | 0.27 |
Cl, confidence interval; COVID-19, novel coronavirus disease 2019; PTSS, post-traumatic stress symptoms.
†PTSS was assessed by the Japanese version of Impact of Event Scale-Revised.
a Adjusted for sex, age, and occupation (physicians: reference, nurses, and other healthcare professionals).
*p<0.05; **p<0.01.
Discussion
This cross-sectional study aimed to investigate the relationship between clinical decision for patients and PTSS among healthcare professionals during the COVID-19 pandemic. The study found that about one in three participants (33.4%) had experienced clinical decision for patients with COVID-19. The results of multiple linear regression analyses showed that an experience of clinical decision for patients with COVID-19 and fear of getting COVID-19 infection are risk factors for PTSS.
An experience of clinical decision for patients with COVID-19 was significantly associated with PTSS in univariate and multiple linear regression analyses in this study. To the best of our knowledge, this study is the first study to show an association between clinical decision for patients and PTSS among healthcare professionals during the COVID-19 pandemic. An experience of clinical decision for patients with COVID-19 during the COVID-19 pandemic often ranges across issues, such as the allocation of scarce resources, caring for severely ill patients, and aligning patient needs with the family’s wishes8). Since clinical decision for patients with COVID-19 is a decision that healthcare professionals may fear during the COVID-19 pandemic, it is a possible reaction for healthcare professionals who have experienced such clinical decision may develop PTSS12). In addition, multiple linear regression analysis showed that only clinical decision for patients with COVID-19 and fear of getting the COVID-19 infection were significantly associated with PTSS in the adjusted model, while the other independent variables that were associated with mental health in previous studies were not significantly associated. An experience of clinical decision was shown to be a more important factor related to PTSS than the items reported in previous studies as factors related to mental health of healthcare professionals during the COVID-19 pandemic. To protect the mental health of healthcare professionals during the COVID-19 pandemic, it is important to take countermeasures for clinical decision for patients with COVID-19, as well as for the fear of getting COVID-19 infection, as shown in previous studies3,20).
Univariate and multiple regression analysis by occupation showed a significant association between clinical decision for patients with COVID-19 and PTSS among nurses but not among physicians and other healthcare professionals. It was interesting that there was no association among physicians, who make many clinical decisions in their daily clinical practice and during the COVID-19 outbreak, whereas there was a significant association between clinical decision and PTSS among nurses. This result may be because nurses had to make clinical decision for patients with COVID-19 during the COVID-19 outbreak that they would not usually make, and this experience was associated with PTSS. In addition, because nurses have more contact with patients and their families than other professions, it is possible that the experience of clinical decision for patients with COVID-19 might be more likely to be a traumatic event during the COVID-19 outbreak. It may be important for nurses who experienced clinical decision during the COVID-19 outbreak to take care of their mental health. In addition, univariate and multiple regression analysis by occupation showed a significant association between clinical decision for patients with COVID-19 and PTSS among both participants who had experience of contact with patients who had suspected or confirmed cases of COVID-19 and who did not have. Based on these results, mental health care may be necessary not only for healthcare professionals who have had contact with patients with suspected or confirmed COVID-19, but also for healthcare professionals who have not had contact with patients with suspected or confirmed COVID-19 who have experienced clinical decision for patients with COVID-19 during COVID-19 outbreak.
The current study revealed that about one in three participants (33.4%) experienced clinical decision for patients with COVID-19 in the prior 3 months. The experience rate of the contact with the patients who had suspected or confirmed cases of COVID-19 among participants in this study was 47.0%, while the experience rate of clinical decision for patients with COVID-19 was high at 33.4%. Compared to the experience rates of the other independent variables in this study, the experience rate of clinical decision for patients with COVID-19 was high, and clinical decision for patients with COVID-19 was a highly experienced event among healthcare professionals during the pandemic. In addition, this study was conducted during the declaration of the third state of emergency in Japan. The period of the declaration of the third state of emergency was from April 25 to June 20, 2021, and this study was considered to represent the results of the middle to end period of the declaration of the third state of emergency. Therefore, the results of this survey can be considered as the results of a survey conducted at a time when medical resources were tight. However, the maximum number of new confirmed cases of COVID-19 in Japan during the survey period was 5,711, while the maximum number in 2021 was 25,877 on August 2113). Therefore, it was assumed that there were periods when medical resources were tighter than during the period of this study. In situations with a large number of infected patients and hospital admissions, a larger proportion of healthcare professionals may have experienced clinical decision than in this study. Clinical decision for patients with COVID-19 has a high experience rate among healthcare professionals during the pandemic, and countermeasures are needed for those who experience it.
Previous reviews showed that the most common support for the mental health of healthcare professionals during the COVID-19 pandemic included one or more of the following initiatives: expanded basic resources/services, additional workplace training programs that bolstered professional preparedness while also indirectly boosting healthcare professionals’ emotional health, and/or expanded psychological support programs, such as peer support programs, psychoeducational or counselling services21,22). In order to prevent developing PTSS under stressful environments in the COVID-19 pandemic, it is important to have a work environment where healthcare professionals can take training programs about the mental health and receive mental health care after experiencing clinical decision for patients with COVID-19 and other traumatic events21,23). Healthcare professionals may experience several traumatic events, such as clinical decisions for patients with COVID-19, during the COVID-19 outbreak. It has been reported that exposure to a traumatic event during recovery from trauma was a risk factor for mental health problems after experiencing trauma in healthcare professionals during the COVID-19 outbreak24). Therefore, it seems important that health care professionals experienced in clinical decisions for COVID-19 patients be considered for their mental health and work in an environment where they can receive support from their colleagues in their hospitals. Furthermore, the results of this study suggest that nurses in particular need mental health measures after experiencing clinical decision for patients with COVID-19 among healthcare professionals. In addition, as a countermeasure for fear of getting COVID-19 infection of healthcare professionals, hospital managers should provide a safe working environment that can lower the infection risk of healthcare professionals25).
This study has several limitations. First, the item about the experience of clinical decision for patients with COVID-19 was only one item and was originally developed as a question in the HEROES study13). To the best of our knowledge, a scale to measure clinical decision for patients with COVID-19 has not been developed, so we could not use a scale with confirmed reliability and validity in this study. Therefore, the item about the experience of clinical decision for patients with COVID-19 was not fully evidence-based nor comprehensive. The item about the experience of clinical decision for patients with COVID-19 may not have sufficiently asked the intended intent and content of the question and may not have measured the aspects of how to align their desire and duty to patients with those of family and friends and how to provide care for all severely unwell patients with constrained or inadequate resources included in clinical decision for patients with COVID-19. In addition, there was a possibility that the clinical decisions for patients with COVID-19 recalled from the question in this study differed depending on the characteristics of the participants, such as occupation. Future studies are needed to clarify the definition of clinical decision for patients with COVID-19 and to measure it with a scale with confirmed reliability and validity. Second, this study was conducted from May 21 to June 18 2021. The results may be different in a situation where the number of patients is much higher, and medical resources are tighter than in this study. Third, the response rate was low, which may limit the external validity of this study. Non-responders could be too stressed to respond or not at all stressed and therefore not interested in this survey. In the future, a survey with a larger sample and a higher response rate would be necessary. Fourth, motivated healthcare professionals tended to register as DMAT and DPAT members in general. Thus, DMAT and DPAT members are not representative of healthcare professionals in Japan. Fifth, R squared of multiple linear regression analysis in the adjusted model among all participants was low in this study. Finally, this study was a cross-sectional study, and the causality cannot be clarified. It is necessary to conduct a longitudinal survey with a larger sample, including healthcare professionals with characteristics other than those of the participants in this study, in the future.
The study found that about one in three participants (33.4%) experienced clinical decision for patients with COVID-19. Clinical decision for patients with COVID-19 has a high experience rate and was considered to be a serious experience among healthcare professionals during the pandemic. The results of multiple linear regression analyses showed that an experience of clinical decision for patients with COVID-19 and fear of getting the COVID-19 infection are risk factors for PTSS. The study showed that clinical decision might be a much more serious factor related to PTSS than the items reported in previous studies as factors related to mental health of healthcare professionals during the COVID-19 pandemic. As a countermeasure for the mental health of healthcare professionals during the COVID-19, it is important to take countermeasures for clinical decision for patients with COVID-19 as well as for fear of getting the COVID-19 infection.
Acknowledgments
The authors thank all participants in this study.
Conflicts of Interest
All authors declare no relevant conflicts of interest in relation to the subject of the manuscript. DN reports personal fees from Startia, Inc., en-power, Inc., MD.net, AIG General Insurance Company, Ltd, outside the submitted work.
Funding
This work was supported by Health and Labor Sciences Research Grants (19IA2014 to DN). The funder had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
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