Severe acute respiratory syndrome (SARS) emerged from Guangdong Province, People's
Republic of China, in November 2002 and spread rapidly; transmission occurred primarily
in hospitals, often to healthcare workers (HCWs). Although initially virtually no
literature was available to guide expectations of how an emerging infection would
affect the psychological well-being of hospital staff (
1
), by the summer of 2003 the acute psychological impact of SARS had been widely studied.
Significant emotional distress was present in 18%–57% of HCWs (
2
–
6
) and was associated with quarantine (
7
), fear of contagion (
6
,
8
,
9
), concern for family (
5
,
9
,
10
), job stress (
6
,
9
), interpersonal isolation (
6
,
9
), perceived stigma (
6
,
7
,
11
), conscription of nonspecialists into infectious disease work (
12
), and attachment insecurity (
10
).
Working in SARS-affected hospitals could have been traumatic for some HCWs (i.e.,
an event that "threatens an individual's life or physical integrity and involves a
subjective response of fear, helplessness, or horror" [13]). Before the SARS coronavirus
was identified (
14
–
17
), SARS was an infection of unknown cause, unknown mode of transmission, global spread,
and high mortality, c haracteristics that generally increase perceived risk (
18
). However, although the SARS outbreak was acutely stressful, the longer term impact
of SARS on HCWs is unknown.
Understanding the enduring occupational and psychological effects of working during
this SARS outbreak is important because it involves the well-being of large numbers
of HCWs. Additionally, this information has wider relevance to health systems in planning
for emerging infections, including pandemic influenza (http://www.who.int/csr/disease/influenza/inforesources/en)
and the potential for bioterrorism (
19
). Although healthcare work during the SARS outbreak and during an influenza pandemic
will differ in key respects, SARS experience provides the most extensive information
available about the effects on HCWs of a large-scale infectious outbreak. The objective
of the Impact of SARS Study was to assess the long-term psychological and occupational
impact of SARS outbreak on HCWs and to identify personal and systemic factors that
increase vulnerability.
Methods
Design, Setting, and Participants
The study took place in hospitals in Toronto and Hamilton in Ontario, Canada. Most
of Canada's 438 suspected and probable SARS cases were identified in Toronto. Hamilton
HCWs were selected as a comparison group because Hamilton is 57 km from Toronto and
experienced all of the healthcare processes and precautions associated with Ontario's
response to SARS (e.g., restrictions on access to care, protocols for staff screening,
isolation procedures) but did not have SARS patients. Hamilton and Toronto hospitals
are otherwise similar in terms of size, workload, and organizational characteristics.
Thirteen participating sites (9 Toronto, 4 Hamilton) included academic and community
hospitals. All Toronto sites treated SARS patients. Eligible HCWs included nurses
in medical and surgical inpatient units and all staff of intensive care units, emergency
departments, and SARS isolation units. Fifty-five clinical units participated (Toronto
40, Hamilton 15) from October 23, 2004, to September 30, 2005. This study was approved
by the Research Ethics Board of each hospital.
Survey A measured adverse outcomes. All participants completed survey A anonymously
and received Can $10. Those who were willing to provide more information participated
in survey B, which measured potential mediators of adverse outcomes, and in 2 structured
interviews (results to be reported elsewhere). Participants in survey B also received
$50.
A separate "representativeness survey" was conducted from September through November
2005 to compare eligible Toronto HCWs who had participated in the Impact of SARS Study
with those who had not. HCWs were approached at staff meetings in 14 participating
clinical units and asked to complete an anonymous, 6-question questionnaire that surveyed
whether or not they had participated in the Impact of SARS Study, exposure to SARS
patients, age range, job type, years of healthcare experience, and overall subjective
impact of SARS on their lives.
Measures
In the study instruments, "during the SARS outbreak" was defined for Toronto HCWs
as the period from February 2003 to the day the last SARS patient was discharged from
a participant's hospital or died. For Hamilton HCWs, the comparable period was defined
as February through September 2003. SARS patients included probable and suspected
SARS patients and persons isolated while their cases were under investigation for
SARS according to the participants' report, rather than by using case definitions
(http://www.phac-aspc.gc.ca/sars-sras/sarscasedef_e.html).
Survey A
This survey measured demographic and job data as well as traumatic stress response
(15-item Impact of Events Scale [IES] [20,21]), nonspecific psychological distress
(Kessler Psychological Distress Scale [K10] [22]), and professional burnout (emotional
exhaustion scale of the Maslach Burnout Inventory [MBI-EE] [23–25]). To measure the
practical and functional impact of SARS experience, participants were surveyed about
changes since the SARS outbreak in healthcare work hours and the amount of face-to-face
contact with patients in their work. Survey A also asked if survey participants had
experienced an increase since the SARS outbreak in smoking, drinking alcohol, or "other
activities that could interfere with your work or relationships" and how many work
shifts had been missed in the 4 months preceding the survey because of stress, illness,
or fatigue.
Survey B
Survey B, by using a previously described instrument, measured SARS-related perception
of stigma and interpersonal avoidance; adequacy of training, protection, and support;
and job stress (
6
,
10
,
26
). Scales calculated as the mean of all items related to these constructs showed adequate
internal reliability (Table 1). Adaptive coping (problem-solving, seeking support,
positive reappraisal) and maladaptive coping (escape-avoidance, self-blame, confrontative
coping) regarding SARS were measured with the relevant subscales of the Ways of Coping
Questionnaire (
27
), for which the stressful event was defined as the SARS outbreak. Attachment insecurity
was measured with the anxiety and attachment avoidance scales of the Experiences in
Close Relationships-Revised questionnaire (
28
).
Table 1
Scales to measure perceptions about severe acute respiratory syndrome (SARS) experience
Scale
Perception
Training, protection and support*
Cronbach α = 0.89
I had adequate training to deal confidently with the situations that I faced.
Infection control procedures were adequately explained.
I received adequate training in infection control procedures.
I was provided with the protective equipment and procedures that I needed.
I had someone to ask when I had problems using equipment.
The hospital where I worked took my well-being into account when decisions were made
that affected me.
Emotional support (e.g., counseling) was available to those who needed help.
I felt appreciated by the hospital/clinic/my employer.
My hospital/workplace was supportive.
Job stress†
Cronbach α = 0.76
There was more conflict among colleagues at work.
I felt more stressed at work.
I had to do work that normally I don't do.
I had an increase workload.
I had to work overtime.
Perceived stigma and interpersonal avoidance†
Cronbach α = 0.77
I thought that people avoided me because of my profession.
I thought that people avoided my family members because of my profession.
I coped with the SARS situation by avoiding crowded places.
I coped with the SARS situation by avoiding colleagues who might be exposed.
*Items scored on a 5-point scale from 1 (very confident that this is false) to 5 (very
confident that this is true).
†Items scored on a 6-point scale from 1 (strongly disagree)
to 6 (strongly agree).
Statistical Analysis
Central tendencies of parametric variables are described by mean and standard deviation;
nonparametric variables are described by median and interquartile range. Between-group
differences in parametric variables were determined by Student t test and in nonparametric
variables by Mann-Whitney U test. To make the identified between-city differences
more clinically meaningful, the prevalence of high scores was determined with standard
cutoff values: IES >26 (http://www.mardihorowitz.com), MBI-EE >27 (
25
), K10 >16 (http://www.crufad.unsw.edu.au). Between-group differences in categorical
variables were tested by χ2.
To identify factors that might explain variance in adverse outcome, between-group
differences in traumatic stress symptoms, psychological distress, and burnout were
tested for the following categories: gender; duration of healthcare experience; job
type; regular work during the SARS outbreak in emergency department, intensive care
unit, or SARS isolation unit; indicators of the frequency and intensity of contact
with SARS patients; and exposure to quarantine. A 10-day cutoff for quarantine was
used, which corresponds to the standard period of quarantine for SARS (i.e., quarantine
>10 days indicates extended quarantine or >1 period of quarantine). This analysis
was performed in the full sample.
The relationship between adverse outcomes and potential mediating factors was identified
by using Spearman rank-order correlations between adverse outcomes and measures of
perceived systemic characteristics (stigma and interpersonal avoidance, adequacy of
training, protection and support, and job stress) and psychological variables (coping
style and attachment insecurity). This analysis was performed for survey A and B participants.
A stepwise regression analysis was performed for each adverse outcome. All potential
mediating factors (those identified in the preceding univariate analyses with a significance
of p<0.05) were entered. This analysis was performed for survey A and B participants.
Finally, to determine if factors that increase personal perceptions of risk had a
practical functional impact on HCWs in the full sample, we identified an item in survey
A that could serve as a proxy for the survey B factors that mediate vulnerability.
This item is the duration (in months) of continuing perceived increased risk after
the last SARS patient was discharged from a study participant's hospital or died.
Duration of perceived risk was significantly correlated with the 2 SARS-specific mediating
factors identified in the regression analysis: 1) maladaptive coping and perceived
adequacy of training and 2) protection and support. For this analysis, the functional
impact of SARS experience was operationalized as the number of adverse outcomes experienced
by a person (from 0 to 7) of the following 7 outcomes: posttraumatic stress (IES >26);
psychological distress (K10 >16); burnout (MBI-EE >27); decrease in face-to-face patient
contact since SARS; decrease in work hours since SARS; increase in smoking, alcohol,
or other problematic behavior since SARS; and >4 shifts missed because of stress or
illness in the 4 months before the survey.
Results
In total, 1,984 HCWs received detailed information about the Impact of SARS Study
and 769 (39%) completed survey A. The interval between the last SARS patient discharged
or deceased and study participation was 13–25 (median 19) months.
To determine how representative participants were of all eligible hospital staff,
after the Impact of SARS Study a representativeness study was presented to 258 Toronto
HCWs who had been eligible; it was completed by 255 (99%) of these HCWs. Exposure
to SARS patients was more common in HCWs who participated in the Impact of SARS Study
than those who did not. However, study participants and nonparticipants did not differ
in age range, job type, years of healthcare experience, or overall subjective impact
of SARS on their lives (Table 2).
Table 2
Comparison of eligible Toronto healthcare workers who chose to participate or not
to participate in the Impact of SARS Study*
Characteristics
Participation in Impact of SARS Study
p value
Did not participate, % (n = 144)
Participated, % (n = 111)
Age group, y
<40
53
44
>40
47
56
0.17
Job type
Nurse
73
71
Other
27
29
0.76
Experience, y
<10
51
41
>10
49
59
0.12
Treated SARS patient
Yes
31
59
No or don't know
69
41
<0.001
Overall impact
Bad
40
50
Neutral or good
60
50
0.11
*SARS, severe acute respiratory syndrome.
Of the 769 participants, 73.5% were nurses (69.4% staff nurse, 3.1% manager or educator,
1.0% infection control practitioner). The next most prevalent job types were clerical
staff (8.3%), physicians (2.9%), and respiratory therapists (2.3%). The remaining
99 participants (12.9%) were distributed among 14 different job types. Other characteristics
of study participants, by city of employment, are presented in Table 3. Most Toronto
participants (71.6%) reported contact with SARS patients, and Toronto participants
were much more likely than Hamilton participants to have experienced quarantine (47.9%
vs. 1.6%, p<0.001), which confirms the anticipated difference in SARS-related experience
between comparison groups. A higher proportion of Hamilton participants were nurses
(Hamilton 84.1% nurses vs. Toronto 71.2%, p = 0.001).
Table 3
Demographic and job characteristics of participants, Impact of SARS Study*
Characteristics
Toronto % (n = 587)
Hamilton % (n = 182)
p value
Female
86.0
89.6
0.22
Single
23.7
20.3
Married or common-law
65.2
68.1
Separated or widowed
11.1
11.5
0.41
Living with child <16 y of age
36.3
36.8
0.90
Living with adult >65 y of age
9.2
5.5
0.11
Worked in healthcare >10 y
65.1
68.7
0.37
Worked any shifts during SARS in
Surgical inpatient unit
13.8
18.7
0.11
Medical inpatient unit
26.4
21.4
0.18
Isolation unit with SARS patients
22.5
†
Intensive care unit
32.9
34.1
0.66
Emergency department
32.2
24.7
0.06
*SARS, severe acute respiratory syndrome.
†Hamilton had no patients with SARS.
Survey B was completed by 187 HCWs (survey A and B participants). Survey A and B participants
did not differ significantly from participants who only completed survey A by sex,
job type (nurse or other), or city of employment. Survey A and B participants were
older (mean 45 ± standard deviation 9 years vs. 41 ± 10 years, p<0.001) and more experienced
in healthcare work (21 ± 10 years versus 16 ± 10 years, p<0.001). Survey A-only participants
and Survey A and B participants did not differ with respect to exposure to SARS patients,
working >5 shifts in intensive care unit, emergency department or SARS isolation unit
during the outbreak or with respect to traumatic stress symptoms, psychological distress,
or burnout.
During the study period (13–25 months after the SARS outbreak), Toronto HCWs reported
significantly higher levels of burnout (Toronto median score 19, interquartile range
10–29; Hamilton 16, 9– 23, p = 0.019), psychological distress (Toronto 15, 12–19;
Hamilton 13, 11–17, p<0.001), and posttraumatic stress (Toronto 11, 4–21; Hamilton
7, 0–19, p<0.001). To make these differences more clinically meaningful, the prevalence
of high scores was calculated (Table 4). The prevalence of the following functional
indicators of distress since the SARS outbreak was higher in Toronto HCWs: decrease
in patient contact and work hours, increase in substance use and other traits that
interfere with function, and more days off work (Table 4). Of the 7 adverse outcomes
reported in Table 4, Toronto HCWs were more likely to be experiencing >1 problem (Toronto
68.1% vs. Hamilton 50.1%, p<0.001)) and were almost twice as likely to be experiencing
multiple (>2) problems (Toronto 44.0% vs. Hamilton 22.5%, p<0.001).
Table 4
Prevalence of adverse outcomes in Hamilton and Toronto healthcare workers*
Adverse outcomes
Toronto, n = 587, %
Hamilton, n = 182, %
p value
High burnout (MBI-EE score >27)
30.4
19.2
0.003
High psychological distress (K10 score >16)
44.9
30.2
<0.001
High posttraumatic stress (IES score >26)
13.8
8.4
0.06
Since SARS have
Decreased face-to-face patient contact
16.5
8.3
0.007
Decreased work hours
8.6
2.2
0.003
Increased smoking, drinking alcohol, or other behavior that could interfere with work
or relationships
21.0
8.1
0.001
Missed >4 work shifts because of stress or illness
21.6%
12.6%
0.007
*MBI-EE, Maslach Burnout Inventory; K10, Kessler Psychological Distress Scale; IES,
Impact of Events Scale; SARS, severe acute respiratory syndrome.
Personal and occupational characteristics of participants and the relationship of
these variables to adverse outcomes are shown in Table 5 and Table 6. Univariate relationships
significant at the level of p<0.05 were retained for stepwise regression analysis
to determine which of these variables accounted for significant variance in each adverse
outcome (Table 7). Maladaptive coping and perceived adequacy of training together
with protection and support explained 18% of the variance in burnout. The same 2 variables
explained 21% of the variance in posttraumatic stress. Maladaptive coping and attachment
anxiety, together with a protective effect of experience in healthcare, explained
31% of the variance in psychological distress.
Table 5
Relationship of healthcare worker, job, and SARS exposure characteristics to adverse
outcomes in Toronto healthcare workers*
Characteristics
Burnout
Psychological distress
Posttraumatic stress
n
Median
Interquartile range
p value
Median
Interquartile range
p value
Median
Interquartile range
p value
Sex
Male
82
18
9–29
14
12–19
10
2–19
Female
505
19
10–29
0.30
15
12–19
0.91
12
4–21
0.02
Job type
Nurse
418
21
11–29
14
11–18
12
5–22
Other
169
14
8–27
0.002
15
12–20
0.16
10
2–19
0.1
Healthcare experience
<10 y
205
21
12–30
16
12–21
11
11–21
>10 y
382
18
10–28
0.82
14
11–18
0.03
11
5–22
0.06
Worked on SARS unit
<5 shifts
498
19
10–30
15
12–19
12
4–22
>5 shifts
89
17
11–26
0.75
15
11–20
0.54
10
3–17
0.63
Worked in ICU
<5 shifts
427
20
10–30
15
12–19
11
4–21
>5 shifts
160
17
9–17
0.02
14
11–20
0.29
11
3–22
0.46
Worked in Emergency
<5 shifts
434
18
10–28
15
12–20
12
5–21
>5 shifts
153
21
10–32
0.12
13
11–17
0.005
9
2–21
0.24
Ever in SARS patient room
No
167
19
9–30
15
12–19
11
4–22
Yes
420
19
10–28
0.33
15
11–19
0.09
12
4–21
0.16
Touched SARS patient
No
265
19
9–30
15
11–19
12
4–22
Yes
322
19
11–28
0.42
15
12–19
0.32
11
4–22
0.41
Protected contact with saliva or phlegm of SARS patient
No
438
19
9–29
15
12–19
11
4–21
Yes
149
19
11–29
0.43
15
12–18
0.78
10
4–22
0.44
Unprotected exposure to SARS patient
No
502
18
9–28
15
11–19
11
4–21
Yes
85
24
13–32
0.012
16
13–22
0.08
13
6–22
0.38
In SARS patients' rooms >5 min, >5 times
No
316
18
9–28
15
11–18
11
3–21
Yes
271
20
11–31
0.08
15
12–21
0.02
11
5–22
0.24
Quarantined
Never
252
19
9–28
15
11–19
11
4–22
<10 d
235
17
10–28
15
11–19
11
3–21
>10 d
100
21
11–34
0.36
16
12–22
0.09
13
5–22
0.42
*SARS, severe acute respiratory syndrome.
Table 6
Correlation between adverse outcomes after SARS and perceived characteristics of workplace
and environment, coping style, and attachment insecurity in Toronto healthcare workers*
Characteristics of healthcare workers
Burnout
Psychological distress
Posttraumatic stress
Spearman ρ
p value
Spearman ρ
p value
Spearman ρ
p value
Training, protection and support
–0.297
<0.001
–0.162
0.06
–0.269
0.001
Stigma and avoidance
0.153
0.07
0.080
0.36
0.302
<0.001
Job stress
0.312
<0.001
0.224
0.008
0.164
0.052
Adaptive coping
0.066
0.44
0.147
0.08
0.182
0.03
Maladaptive coping
0.261
0.002
0.312
<0.001
0.364
<0.001
Attachment anxiety
0.179
0.049
0.355
<0.001
0.295
0.001
Attachment avoidance
0.078
0.40
0.204
0.03
0.139
0.13
*SARS, severe acute respiratory syndrome.
Table 7
Variables that explain variance in adverse outcomes to severe acute respiratory syndrome
(SARS) in Toronto healthcare workers
Variables
β
t
p value
Dependent variable: burnout*
Maladaptive coping
0.29
3.34
0.001
Perceived adequacy of training, protection and support
–0.27
–3.10
0.002
Model R2 = 0.18, p<0.001
Dependent variable: psychological distress†
Maladaptive coping
0.31
3.78
<0.001
Years of healthcare experience
–0.26
–3.28
0.001
Attachment anxiety
0.24
2.87
0.005
Model R2 = 0.31, p<0.001
Dependent variable: posttraumatic stress‡
Maladaptive coping
0.37
4.39
<0.001
Perceived adequacy of training, protection and support
–0.22
–2.63
0.01
Model R2 = 0.21, p<0.001
*Excluded variables: job stress, attachment anxiety, job type, worked in intensive
care unit, unprotected contact with SARS patient(s).
†Excluded variables: job stress,
attachment avoidance, worked in emergency department, in SARS patients room >5 min
or >5 times.
‡Excluded variables: perceived stigma and avoidance, adaptive coping,
attachment anxiety, job type, sex.
Finally, the functional impact of vulnerability factors on the full survey A sample
was tested by using duration of perceived risk after SARS as a proxy for the SARS-related
vulnerability factors identified in the regression analysis. Duration of post-SARS
perceived risk was correlated with maladaptive coping (Spearman ρ = 0.28, p = 0.001)
and perceived adequacy of training, protection, and support (Spearman ρ = -0.27, p
= 0.001). The Figure shows a linear increase in the prevalence of multiple adverse
outcomes in HCWs with longer duration of perceived risk. Duration of perceived risk
and the overall number of adverse outcomes were significantly correlated. (Spearman
ρ = 0.23, p = 0.005).
Figure
Relationship between prolonged perception of personal risk and reporting multiple
adverse consequences of severe acute respiratory syndrome (SARS) in Toronto healthcare
workers. Adverse outcomes are burnout; psychological distress; posttraumatic stress;
decrease in face-to-face patient time since SARS; decrease in work hours since SARS;
increase in smoking, drinking alcohol or other behavior that might interfere with
work or relationships since SARS; and >4 work shifts missed because of stress or illness
in the past 4 months.
Discussion
This study highlights the resiliency of HCWs and, despite this trait, the potential
that working during the SARS outbreak had a substantial negative impact on a statistically
significant number of people. The evaluation of mediating factors suggests both systemic
and individual targets for interventions to buffer the adverse effects of an extraordinary
outbreak of infectious disease. Systemically, enhanced support and training may reduce
burnout and posttraumatic stress. Individually, interventions that reduce maladaptive
coping may decrease prolonged suffering.
The differences in adverse outcomes between Toronto and Hamilton HCWs were significant
but small. However, further analysis suggests that the long-term impact of SARS has
not been trivial. In particular, a categorical analysis (Table 4) shows that long-term
adverse outcomes in Toronto HCWs occurred at a prevalence ≈50%–100% higher than in
Hamilton HCWs. Furthermore, these outcomes may have a systemic impact, since SARS-affected
HCWs reported reducing patient contact and hours of healthcare work as well as more
frequent sick absences and an increase in behavior that could affect function.
These findings can be framed in terms of their potential value for the future. If
the emergence of a new infectious disease is likely to increase the prevalence of
significant distress in HCWs by 50%, to double the number of HCWs who are reducing
their clinical practice or calling in sick, and if these difficulties will persist
for >1–2 years after the outbreak's resolution, we want to learn from the SARS experience
to try to buffer this negative impact. This discussion, therefore, addresses the identified
mediators of SARS-related distress in HCWs and how these can guide preparation for
pandemic influenza and other infectious disease outbreaks.
Exposure to high-intensity and high-risk work settings (such as intensive care units
and emergency department work) and direct exposure to infected patients were not the
primary determinants of adverse psychological outcomes. In fact, trends toward lower
burnout in intensive care unit workers and less general psychological distress in
emergency department workers were noted. These trends may be explained by the resilience
of HCWs who choose this type of work and are consistent with the findings that longer
healthcare experience was protective. We also found that the extent of various forms
of distress was increased in Toronto HCWs, irrespective of their degree of contact
with SARS patients, which implies that factors that are associated with the hospital
environment as a whole and healthcare work in general during the outbreak were provocative.
Both systemic and personal variables were associated with persisting distress. In
contrast to studies of distress during and shortly after the SARS outbreak (
6
,
9
,
12
), job stress related to conflict, workload, and conscription to new duties did not
mediate long-term outcome. However, perceived adequacy of training, moral support,
and protection were associated with better outcome. When the lessons of SARS are applied
to pandemic planning, effective staff support may be a primary target to bolster the
resilience of HCWs who will face future outbreaks. This observation is consistent
with ones made during the SARS outbreak regarding the benefits of responsive communication
(
29
), opportunities for facilitated reflection on normal emotional responses to extraordinary
stress, and opportunities for HCWs to contribute to decision-making in the workplace
(
10
,
30
).
Effective support benefits from careful planning and preparation before an outbreak,
which the SARS situation did not allow. For example, effective moral or psychological
support typically occurs in the context of trusted professional and institutional
relationships, which should ideally be established before the outbreak situation.
In particular, burnout has been identified as 1 of the most substantial health-related
problems facing nurses (
31
). Because future outbreaks are likely to increase job strain and burnout, the prepandemic
period is a critical time to attend to organizational characteristics that are known
to buffer burnout, which include reducing patient-to-nurse ratios (
32
) and increasing organizational characteristics that increase nurses' autonomy, flexibility,
control over practice (
33
), and perceived empowerment (
34
). The results of our study suggest that supportive interventions may be especially
important for HCWs with fewer years of experience, who were more likely to experience
prolonged psychological distress. Opportunities for mentorship or "buddying" with
more experienced colleagues may be useful (
35
).
The personal variables that contributed to adverse outcomes were maladaptive coping
through avoidance, hostile confrontation, and self-blame, and in the instance of general
psychological distress, attachment anxiety. Although a review of interventions to
modify coping style is beyond the scope of this paper, we note that organizational
approaches to support staff and the individual experience of workers coping with extraordinary
events are related. Hospital-based interventions to support staff may also promote
adaptive coping. For example, engaging staff in collaborative planning for future
outbreaks may reduce the tendency to cope by means of avoidant strategies and may
enhance coping through problem-solving and peer-support. Anger and blame directed
toward others (hostile confrontation) or oneself (self-blame) may be reduced in a
working environment that fosters positive working relationships through effective
leadership (
36
). Attachment anxiety is a common, relatively enduring, and stable interpersonal style
within close relationships (
37
), which is known to be associated with sensitivity to stress under many conditions
(
38
,
39
). Attachment anxiety is probably not a sensible target for hospital-based interventions
to buffer the impact of systemic stresses, but it is a marker of those at greater
risk for general psychological distress.
The results of this study also have implications for mitigating the effects of an
infectious outbreak in the postoutbreak period. Because the duration of perceived
risk in HCWs after the resolution of SARS is correlated with the severity of outcome,
identifying and supporting HCWs who are at the highest risk for multiple and persistent
psychological and occupational consequences of an outbreak may be possible by identifying
HCWs whose perceived risk has not returned to normal within a few months after the
event. Support programs, it would appear, need to be longer term to deal with ongoing
residual effects after an outbreak. Programs directed toward healthy lifestyles, diet,
exercise, and smoking cessation may also be important after the occurrence of an outbreak
such as SARS to provide support to staff. Furthermore, for pandemic planning, the
likelihood of prolonged subjective distress in a substantial percentage of HCWs should
be factored into surge capacity modeling during and after the pandemic, particularly
because distress is associated with reduced healthcare work.
Our conclusions are limited by the study method. With respect to generalizability,
despite a response rate of 39%, the representativeness survey suggests that HCWs who
participated were similar to nonparticipants. HCWs who had contact with SARS patients
are overrepresented in the study sample, which may be because the study had greater
salience for those persons, but study participants and nonparticipants did not differ
in the subjective impact attributed to the SARS experience. A further limitation is
that self-reports of SARS experiences do not provide an objective evaluation of actual
differences in the training, protection, or support that HCWs received. Regardless
of the limitations, the Impact of SARS Study provides a window on the long-term effects
of working during times of extraordinary infectious risk.