Main findings
To our knowledge, this is the largest, national, cross-sectional study examining psychosocial distress during the COVID-19 pandemic in Australia that has included all frontline healthcare occupations and areas. Despite participants receiving high scores on the validated resilience instrument, the majority experienced anxiety or depressive symptoms, or EE (burnout). This indicates that the protective effects of resilience are not sufficient to prevent psychological harm during the pandemic. A significant proportion also experienced PTSD symptoms. Although less than half of the participants worked with patients with COVID-19 and very few had been infected with COVID-19 or quarantined, many experienced disruptions to family life, altered social relationships and financial worries. Our findings are consistent with those reported in international studies: high mental health burden on frontline workers during COVID-1910 11 15 and SARS pandemics.34 Fears of transmitting COVID-19 infection to family and of being blamed by colleagues for not taking adequate precautions if they did contract COVID-19 were extremely common. Personal, social and workplace predictors for mental illness symptoms have been identified.
Around the world, a growing number of largely country-specific, single timepoint, cross-sectional surveys have identified that mental health problems are common in HCWs during the COVID-19 pandemic. Prevalence estimates are as follows: 33% to 59% for anxiety, 30% to 62% for depression, 41% to 51% for burnout and approximately 57% for acute distress or PTSD.10 11 13–15 35 The upper limits of these prevalence estimates are strikingly similar to our own findings. However, moderate to severe burnout (EE) was much more prevalent in our study (70.9%), which may be explained by the later timing of our study, by which time Australian HCWs had endured many months of social and workplace disruptions, and lockdown restrictions.
By contrast, two separate, small (n=320 and n=668), single-site, single timepoint surveys of HCWs undertaken in Melbourne from April to May 2020 and from May to June 2020 both identified a lower prevalence of adverse mental health outcomes.36 37 Their findings may again be partly explained by the earlier timing of the studies in the first wave and the lack of power in those studies due to smaller size of the samples. Comparing our data to international data, the high prevalence of symptoms of poor mental health in our study is interesting given the comparatively low case load of COVID-19 in Australia. One explanation is that anticipation and fear of a catastrophic crisis leading to high death rates of patients and HCWs (as Australian HCWs saw occurring overseas) contributed to adverse psychological outcomes.14 This concept of psychological distress being related to anticipated, perceived risk is important and highlights the critical importance of crisis preparedness, good government and organisational leadership and consistent clear communication. In addition, the pervasive media coverage regarding COVID-19 along with the many restrictions enacted in local lockdowns may have contributed to poor mental health in Australian frontline workers.
Similar to our findings, studies from overseas have found that predictors of poor mental health in HCWs during the pandemic include female gender, less years of work experience (which in our study correlated with younger age), pre-existing psychological illnesses, working in a nursing role and working in certain frontline areas.10–13 15 16 35 38 39 Many of these groups are at heightened risk of psychosocial harm during non-pandemic times, and it is possible that crises such as COVID-19 exacerbate harm in pre-existing vulnerable groups.40 Importantly, unlike previous small local and international studies, the large sample size in our study enabled us to demonstrate that female gender and working in nursing or allied health roles are independent predictors of poor mental health. The relationship between nursing and poorer mental health may be explained by the heightened risk of COVID-19 exposure from prolonged and frequent contact with patients. Moreover, nursing and allied health professionals generally have less choice regarding their daily work environments.11–13 16 Reduced finances were not associated with a nursing role and therefore did not explain the association.
The relationship between gender and adverse mental illness outcomes is intriguing, given that this relationship was identified even during the SARS pandemic.34 One possible explanation is that men and women have different coping styles,41 with men having greater odds of reporting DP in this study. In addition, a British study identified that women have had to bear greater responsibilities (on average, an extra 11.2 hours of unpaid work per week) than men as primary carers for dependents during the pandemic.42 General population data from the Australian Bureau of Statistics report similar findings, with women three times more likely than men to perform the majority of caregiving tasks and twice as likely to undertake the majority of unpaid domestic work.43 In our study, having young or old dependents was not a predictor of poor mental health. However, we did not specifically enquire about the number of additional unpaid hours undertaken in the home for domestic or caregiving tasks during the pandemic. As there was no difference in resilience scores between men and women, this gender difference requires further exploration. The lack of a relationship between PPE training and poor mental health in our study may relate to the majority of frontline staff receiving training and the relatively low rates of COVID-19 infection in Australia compared with other countries.
Limitations
The large sample size in our study enabled detailed examination of independent predictors of poor mental health. Most participants in our study were women, which is consistent with data from both the Australian Institute of Health and Welfare and the Australian Health Practitioner Regulation Agency demonstrating that 75% of the Australian health workforce is female.44–46 Because of the very broad survey dissemination strategy, calculation of a response rate was not possible. Selection bias and response bias may have led to overestimation or underestimation of psychological distress and rates of pre-existing mental health illness. Similarly, in line with other international surveys exploring the psychosocial effects of the COVID-19 pandemic on healthcare workers, we were not able to confirm clinical diagnoses of mental illness with the symptoms measured by the validated psychological scales. Nevertheless, these scales are validated and the only feasible option for measuring mental health symptoms in a large-scale survey such as this.
Because of the spontaneous and unexpected nature of the COVID-19 pandemic, no baseline data regarding mental health symptoms in non-pandemic times had previously been collected from a large cohort of Australian HCWs. Therefore, it is not possible to demonstrate a change in the prevalence estimates of mental health symptoms in this study. Nevertheless, the prevalence estimates in this study are much higher than those reported in earlier studies in non-pandemic times.2 47–49 Notably, the case load of COVID-19 in Australia at the time of survey closure was low relative to international settings, with 27 484 cases recorded.50 The prevalence of mental health impacts arising in the Australian context is indicative of harm related to the prolonged stress of a pandemic, even with relatively few cases. Participant responses were measured at a single timepoint, not longitudinally, to avoid excessively burdening the frontline healthcare workers during the pandemic. However, given the ongoing nature of the pandemic, we believe that longitudinal research is urgently required to better understand any persisting psychosocial effects of the pandemic on HCWs and any ramifications for patient safety and workforce retention. Similar prospective studies sampling Italian HCWs during the first and second waves of COVID-19 have reported growing prevalence of mental health issues as the pandemic continues, and it is likely that similar trends exist in Australia.51 Furthermore, research is required to examine the acceptability, uptake and effectiveness of any new interventions introduced to support the well-being of HCWs.
Implications
Although many factors, including lockdown restrictions, social disconnection and media coverage, likely have contributed to the high prevalence of mental health symptoms in frontline healthcare workers in this study, occupational factors cannot be ignored. Indeed, occupational factors (related to workloads, training, PPE, organisational leadership, communication and policies) must be actively considered because they represent important opportunities to intervene and prevent mental health issues. Both better crisis preparedness and new psychological support services for HCWs are needed. Importantly, such services should not just be short-term ‘fixes’ to address the current pandemic-related issues, but instead should provide long-term support given the high prevalence of pre-existing mental health diagnoses. These supports must be accessible and acceptable to HCWs. Although resilience was identified as a protective factor in this study, the overall resilience level of HCWs was already high, and as such, approaches that aim to build resilience are likely to have limited efficacy in this cohort. Furthermore, it is vital that health leaders in the government, secondary care and the community recognise that certain groups of HCWs are more vulnerable to mental health problems and therefore require additional targeted support interventions. Crucially important are organisational policies and practices that address burnout (and contributing factors such as information overload), given its extremely high prevalence and the risk it poses to workforce retention.7
The health workforce is an indispensable asset. Yet crises such as the COVID-19 pandemic are associated with significant mental health symptoms in frontline HCWs, with potentially wide repercussions for individuals, patients and the workforce. Crisis preparedness, along with long-term, evidence-based policies and practices that focus on preventing and actively addressing psychological well-being, is needed to protect, maintain and ‘future-proof’ the health workforce.