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Psychological Impact and Coping Strategies of Frontline Medical Staff in Hunan Between January and March 2020 During the Outbreak of Coronavirus Disease 2019 (COVID‑19) in Hubei, China

BEF 1 Haozheng Cai* EF 1,2,3 Baoren Tu* B 4 Jing Ma B 5 Limin Chen B 6 Lei Fu AG 4 Yongfang Jiang ACDG 1,2 Quan Zhuang

* Haozheng Cai and Baoren Tu contributed to this paper equally Corresponding Authors: Yongfang Jiang, e-mail: [email protected], Quan Zhuang, e-mail: [email protected] Source of support: Grants from the National Natural Science Foundation of China (No. 81700658 and 81974079), the National Science and

Technology Major Project (No. 2017ZX10202203), the Natural Science Foundation of Hunan Province (No. 2016JJ4105), and the New Xiangya Talent Project of the Third Xiangya Hospital of Central South University (No. JY201629)

Background: Throughout China, during the recent epidemic in Hubei province, frontline medical staff have been responsible for tracing contacts of patients infected with coronavirus disease 2019 (COVID-19). This study aimed to investigate the psychological impact and coping strategies of frontline medical staff in Hunan province, adjacent to Hubei province, during the COVID-19 outbreak between January and March 2020.

Material/Methods: A cross-sectional observational study included doctors, nurses, and other hospital staff throughout Hunan province between January and March 2020. The study questionnaire included five sections and 67 questions (scores, 0 – 3). The chi-squared χ² test was used to compare the responses between professional groups, age-groups, and gender.

Results: Study questionnaires were completed by 534 frontline medical staff. The responses showed that they believed they had a social and professional obligation to continue working long hours. Medical staff were anxious regarding their safety and the safety of their families and reported psychologi-cal effects from reports of mortality from COVID-19 infection. The availability of strict infection con-trol guidelines, specialized equipment, recognition of their efforts by hospital management and the government, and reduction in reported cases of COVID-19 provided psychological benefit.

Conclusions: The COVID-19 outbreak in Hubei resulted in increased stress for medical staff in adjacent Hunan prov-ince. Continued acknowledgment of the medical staff by hospital management and the government, provision of infection control guidelines, specialized equipment and facilities for the management of COVID-19 infection should be recognized as factors that may encourage medical staff to work dur-ing future epidemics.

MeSH Keywords: Coronavirus Infections • Emotions • Medical Staff • Stress, Psychological • COVID-19

Full‑text PDF: https://www.medscimonit.com/abstract/index/idArt/924171

1 Transplantation Center, The 3rd Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China

2 Engineering and Technology Research Center of National Health Ministry for Transplantation Medicine, Changsha, Hunan, P.R. China

3 The Center on Behavior Health, The Faculty of Social Science, The University of Hong Kong, Hong Kong, P.R. China

4 Department of Infectious Diseases, The 2nd Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China

5 Department of Infectious Diseases, The 3rd Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China

6 Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China

3178 6 1 24

e-ISSN 1643–3750©MedSciMonit,2020;26:e924171

DOI: 10.12659/MSM.924171

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924171Cai H. et al.:

Frontline medical staff in Hunan during COVID-19

CLR CLINICAL RESEARCHSRT SHORT COMMUNICATIONSDCS DRUG CONTROLLED STUDIESPHE PHARMACOECONOMICSDIA DIAGNOSTIC TECHNIQUESMET MEDICAL TECHNOLOGYPUB PUBLIC HEALTHSPR SPECIAL REPORTSEPI EPIDEMIOLOGYREV REVIEW ARTICLESLET LETTER TO THE EDITORHYP HYPOTHESISPIN PRODUCT INVESTIGATIONSPRE PRELIMINARY REPORTMHI MEDICAL HISTORYLBR LAB/IN VITRO RESEARCHANS ANIMAL STUDYHAN HUMAN ANATOMYMOL MOLECULAR BIOLOGYMTA META-ANALYSISBCH MEDICAL BIOCHEMISTRYEDT EDITORIALDBA DATABASE ANALYSIS

Authors’ Contribution:Study Design A

Data Collection B Statistical Analysis CData Interpretation D

Manuscript Preparation E Literature Search FFunds Collection G

Received: 2020.03.10Accepted: 2020.03.13

Available online: 2020.03.23Published: 2020.04.15

Background

Since the beginning of the coronavirus disease 2019 (COVID-19) outbreak began in Hubei province from November 2019, frontline medical staff throughout China have experi-enced an increase in workload, increased working hours, and increased psychological stress. According to previous stud-ies, during the outbreaks of severe acute respiratory syn-drome (SARS) and Middle East respiratory syndrome (MERS), frontline medical staff had reported high levels of stress that resulted in posttraumatic stress disorder (PTSD) [1,2]. The risk factors of psychological stress in medical staff had been previously investigated during the SARS and MERS ep-idemics. In 2008, Styra et al., in Toronto, identified four ma-jor risk factors for stress in medical staff during the SARS outbreak, including the perception of the medical of their risk of infection, the impact of SARS on their work, feelings of depression, and working in high-risk medical units [3]. The perception of infection risk by medical staff was previ-ously reported by Tam et al. in 2003 to be significantly asso-ciated with their risk of developing PTSD [1]. Other factors, including social stigmatization and contact with infected patients, has previously been shown to be associated with increased levels of stress and anxiety in medical staff [2].

Although recent reports have shown that 80% of patients with COVID-19 have mild symptoms and will recover and the mortality rate is low at up to 2%, because of the high trans-mission rate, total mortality from COVID-19 is greater than SARS and MRES combined [4]. Recently, Peeri et al. report-ed that the infection rate of medical staff during the SARS and MERS outbreaks reached 21% and 18.6%, respectively, which resulted in adverse psychological effects, including anxiety and depression [5]. Medical staff have been infect-ed and have died during the COVID-19 epidemic in China, there are no treatments for this infection, and no vaccines have been developed [6]. All these factors contribute to in-creased psychological stress of frontline medical staff in China, which may have immediate or long-psychological consequences that may have acute or chronic somatic ef-fects that result in conditions such as cardiac arrhythmia and myocardial infarction [7]. However, there have been few studies that have investigated the coping strategies that frontline medical staff can use during disease epidemics. Personality traits, such as optimism, resilience, and altru-ism, have previously been shown to have positive effects on reducing psychological stress [6,8]. Objective measures may reduce psychological stress, including effective infec-tion control, personal protective measures, clear institution-al policies and protocols, which may help to reduce stress in medical staff [9]. Recognition and appreciation of the work and efforts by the medical profession, hospital manage-ment, government, and society have a positive impact on

stress experienced by medical staff during epidemics [10]. Therefore, this study aimed to investigate the psychologi-cal impact and coping strategies of frontline medical staff in Hunan province, adjacent to Hubei province, during the COVID-19 outbreak between January and March 2020.

Material and Methods

Ethical approval

A cross-sectional observational study included doctors, nurses, and other hospital staff throughout Hunan province between January and March 2020. The Institutional Review Board of the 3rd Xiangya Hospital of Central South University provided ethical approval for this study.

Study participants

Questionnaires were sent to frontline medical staff who were working during the outbreak of coronavirus disease 2019 (COVID-19). The participants included doctors and nurs-es from departments of infectious diseases, emergency medicine, fever clinics, and intensive care units, and in-cluded technicians from radiology and laboratory medicine, and hospital staff from the section of infection prevention. A questionnaire was used that was previously designed by Lee et al. [11], which was used to evaluate medical staff dur-ing the 2003 severe acute respiratory syndrome (SARS) ep-idemic. The questionnaire was modified for this study and included five sections with 67 questions. All participants were required to understand the meaning of the question and to answer the questions on their own.

Study questionnaire

The first section of the questionnaire included 14 questions that examined the feelings of the medical staff during the COVID-19 outbreak. Each question had four choices on a four-point scale (0=not at all; 1=slightly; 2=moderately; 3=very much). The second section investigated 19 possible factors that could induce stress for the medical staff (0=not at all; 1=slightly; 2=moderately; 3=very much). The third section in-cluded 14 questions to identify factors that might reduce their stress (0=never; 1=sometimes; 2=often; 3=always). The fourth section included 11 questions, which aimed to identify per-sonal coping strategies in response to the stress of the out-break, with four choices with responses that ranged from not important to most important (scores, 0 – 3). The fifth section included questions on what would encourage medical staff to be more confident in future outbreaks and included nine questions, consisting of four choices with responses that ranged from not important to most important (scores, 0 – 3).

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Cai H. et al.:Frontline medical staff in Hunan during COVID-19

Statistical analysis

Statistical analysis of the data was performed with GraphPad Prism version 7.0 (GraphPad Software Inc., La Jolla, CA, USA). The chi-squared χ² test was used to compare the responses between professional groups, age-groups, and gender for the first four sections of the questionnaire. Descriptive statis-tics were used to present the data collected from the survey and included the mean, standard deviation (SD), and medi-an of the data collected for all the sections. A P-value<0.05 was considered to be statistically significant.

Results

Characteristics of the study participants

A total of 534 questionnaires were completed from 167 men and 367 women. The majority of participants were between the ages of 18 – 30 years (42.4%) and 31 – 40 years (60.7%). All the participants were working in hospitals in Hunan prov-ince. Doctors and nurses together accounted for 90% of the total participants. Most of the study participants were married (79%) and had children (76.6%). The average clini-cal experience was 14.5 years. Medical staff with a postgrad-uate degree represented the majority of the study partici-pants (64.4%). The demographic characteristics of the study

participants was shown in Table 1. All of the study partic-ipants were Chinese citizens and worked in different lev-els of hospital in Hunan, an adjacent province to Hubei. The questionnaires were evenly distributed to all adminis-trative districts in Hunan. The top three participating dis-tricts were Changsha, Hengyang, and Yueyang (Figure 1),

Table 1. Medical staff demographics (n=534).

Characteristic Value

Age (years), mean (SD) 36.4 (16.18)

Gender,N(%) Female Male

367 (68.7) 167 (31.3)

Professional,N(%) Nurse Doctor Medical Technician Hospital staff

248 (46.4) 233 (43.6) 48 (9.0) 5 (1.0)

Married,N(%) 422 (79.0)

Havingchildren,N(%) 409 (76.6)

Educationdegree,N(%) Undergraduate Master Doctor Others

344 (64.4) 96 (18.0) 56 (10.5) 38 (7.1)

Figure 1. The distribution of the study participants from Hunan province, China, during the epidemic of coronavirus disease 2019 (COVID-19) between January and March 2020. (1) Hunan province is located in the central southern area of China, adjacent to Hubei province. (2) There were 534 completed questionnaires that included medical staff from 13 administrative districts of Hunan province, including Changsha (317), Hengyang (79), Yueyang (27), Chenzhou (23), Shaoyang (23), Zhangjiajie (16), Huaihua (15), Xiangtan (13), Zhuzhou (5), Changde (5), Yongzhou (3), Loudi (2), and Jishou (2).

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which were adjacent to the Jing-Guang Line, the most im-portant railway and highway combining Hunan and Hubei.

The emotions of the medical staff in Hunan during the coronavirus disease 2019 (COVID‑19) outbreak in Hubei

The emotions of the medical staff from the different med-ical professionals are shown in Table 2. The chi-squared χ² test showed that differences in responses from eight of the 14 questions were statistically significant. The most im-portant element was their social and moral responsibility, which drove them to continue working during the outbreak (P=0.03), and doctors had the highest mean score (2.47 ± 0.66). Medical staff also expected to receive recognition from hos-pital authorities (P<0.001), and nurses had more concerns regarding extra financial compensation during or after the outbreak when compared with other healthcare workers (P=0.002). However, nursing staff also felt more nervous and anxious when on the ward when compared with other groups (P=0.02). Doctors were more unhappy about working overtime during the COVID-19 outbreak than other health-care workers (P=0.02). There was no significant difference between the medical professionals for regarding stopping work, and work overload.

Factors that caused stress, according to the age of the medical staff

The study population was divided into four age-groups (Table 3). The main factors associated with stress were con-cerns for personal safety (P<0.001), concerns for their fami-lies (P<0.001), and concerns for patient mortality (P=0.001). Medical staff in the 31 – 40 year age-group were more wor-ried about infecting their families compared with other groups (2.46 ± 0.72). Staff>50 years of age felt greater stress when seeing their patients die. Worry about their own safe-ty were also an important factor in anxiety in medical staff, particularly in the group aged 41 – 50 years. Lack of protec-tive clothing (P=0.0195) and exhaustion due to increased du-ration of working (P=0.03) were also significantly increased in older staff. Stress from other colleagues affected staff >50 years old when compared with other groups (P=0.0034). The safety of their colleagues and the lack of treatment for COVID-19 were considered to be important factors that in-ducd stress in all medical staff, with no significant differ-ences between the study groups.

Factors that helped to reduce stress of medical staff during the COVID-19 outbreak, according to gender

Section 3 of the study questionnaire aimed to identify could directly or indirectly help to reduce stress for a COVID-19 outbreak according to the previous severe acute respiratory

syndrome (SARS) and Middle East respiratory syndrome (MERS) outbreaks, and these were evaluated in Section 3 (Table 4). In this section, we would like to look for differ-ences from the sexual perspective. The safety of family was the biggest impact in reducing staff stress (P=0.37>0.05), though there are no significant difference in different gen-ders. However, factors like correct guidance and effective safeguards for prevention from disease transmission eased more female staff anxiety (P<0.001). The positive attitude from their colleagues was also important factor to reduce staff distress during the outbreak (P=0.04). In general, fac-tors of reducing stress had larger impact on female staff than male ones.

Personal coping strategies used by the medical staff to reduce stress among professionals

Section 4 of the study questionnaire was designed to pro-vide insights into the personal coping strategies used by the different professional groups of the medical staff (Table 5). Strategies, such as strict protective measures, knowledge of virus prevention and transmission, social isolation measures, and positive self-attitude resulted in the highest scores (mean scores <2.5), with nurses giving the highest scores in every question. Seeking help from family and friends was a significant supportive measure (P<0.001). Medical staff did not express a significant wish to reduce stress by consulting a psychologist to discuss their emotions, especially in the populations of doctors and medical technicians.

Motivational factors to encourage continuation of work in future outbreaks of infection

Section 5 of the study questionnaire included questions for the medical staff about motivators to continue working during any future COVID-19 or other epidemic outbreaks (Table 6). Adequate protective equipment provided by the hospitals was considered to be the most important moti-vational factor to encourage continuation of work in future outbreaks. The availability of strict infection control guide-lines, specialized equipment, recognition of their efforts by hospital management and the government, and reduction in reported cases of COVID-19 provided psychological benefit.

Discussion

Frontline medical staff during epidemics of infectious dis-ease include doctors and nurses from departments of in-fectious disease, emergency medicine, fever clinics, and in-tensive care units, and technicians mainly from radiology and laboratory medicine, and hospital staff from infec-tion control [11]. Previous studies during the severe acute

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Table 2. Staff feeling during COVID-19 outbreak among different position.

Question Condition

Groups

χ² PNursesN=248

DoctorsN=233

Medical Technician

N=48

Hospital staffN=5

TotalN=534

1.Youthinkthatyourcurrentfront-line job comes from your social and moral responsibility

Not at all 13(5.2) 3(1.3) 2(4.2) 0(0) 18(3.4)

13.59 0.03*

Slight 11(4.4) 13(5.6) 5(10.4) 0(0) 29(5.4)

Moderate 114(50.0) 89(38.2) 16(33.3) 0(0) 219(41.0)

Very Much 110(44.4) 128(54.9) 25(52.1) 5(100) 268(50.2)

Mean±SD 2.29±0.78 2.47±0.66 2.33±0.83 3.00±0.00 2.38±0.74

2.Youhavefeltnervousorfrightenin the ward

Not at all 40(16.2) 46(19.7) 10(20.8) 2(40) 98(18.4)

15.02 0.02*

Slight 88(35.5) 108(46.4) 22(45.8) 1(20) 219(41.0)

Moderate 96(38.7) 71(30.5) 13(27.1) 1(20) 181(33.9)

Very Much 24(10.0) 8(3.4) 3(6.3) 1(20) 36(6.7)

Mean±SD 1.42±0.87 1.18±0.78 1.19±0.84 1.20±1.30 1.29±0.84

3.Youwereunhappyaboutworkingovertimeduringtheoutbreak.

Not at all 133(53.6) 96(41.2) 31(64.6) 2(40) 262(49.1)

15.08 0.02*

Slight 66(26.6) 85(36.5) 12(25) 1(20) 164(30.7)

Moderate 43(17.4) 42(18.0) 5(10.4) 1(20) 91(17.0)

Very Much 6(2.4) 10(4.3) 0(0) 1(20) 17(3.2)

Mean±SD 0.69±0.84 0.85±0.86 0.46±0.68 1.20±1.30 0.74±0.85

4.Youexpectrecognitionofyourworkfromthehospitalauthorities

Not at all 12(4.8) 2(0.9) 8(16.7) 0(0) 22(4.1)

98.12 <0.001***

Slight 21(8.5) 33(14.1) 24(50) 1(20) 79(14.8)

Moderate 103(41.5) 105(45.1) 16(33.3) 2(40) 226(42.3)

Very Much 112(45.2) 93(39.9) 0(0) 2(40) 207(38.8)

Mean±SD 2.27±0.81 2.24±0.72 2.17±0.69 2.20±0.84 2.25±0.76

5.Youexpecttoreceivebonuscompensation during or after the outbreak

Not at all 22(8.9) 18(7.7) 8(16.7) 2(40) 50(9.4)

20.67 0.002**

Slight 38(15.3) 66(28.3) 15(31.3) 0(0) 119(22.3)

Moderate 94(37.9) 84(36.1) 15(31.3) 0(0) 193(36.1)

Very Much 94(37.9) 65(27.9) 10(20.7) 3(60) 172(32.2)

Mean±SD 2.05±0.94 1.84±0.92 1.56±1.01 1.80±1.64 1.91±0.96

6.YoutrytoreduceexposuretopatientsdiagnosedwithCOVID-19

Not at all 66(26.5) 54(23.2) 9(18.8) 2(40) 131(24.5)

11.74 0.07

Slight 78(31.5) 77(33.0) 19(39.6) 0(0) 174(32.6)

Moderate 82(33.1) 72(30.9) 9(18.8) 2(40) 165(30.9)

Very Much 22(8.9) 30(12.9) 11(22.8) 1(20) 64(20.0)

Mean±SD 1.24±0.95 1.33±0.97 1.46±1.05 1.40±1.34 1.30±0.97

7.Youwanttostopyourpresentjob

Not at all 156(62.9) 142(60.9) 45(93.8) 4(80) 347(65.0)

20.83 0.02**

Slight 53(21.4) 57(24.5) 2(4.2) 1(20) 113(21.2)

Moderate 23(9.3) 23(9.9) 1(2.0) 0(0) 47(8.8)

Very Much 16(6.4) 11(4.7) 0(0) 0(0) 27(5.0)

Mean±SD 0.59±0.90 0.58±0.85 0.08±0.35 0.20±0.45 0.54±0.85

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Question Condition

Groups

χ² PNursesN=248

DoctorsN=233

Medical Technician

N=48

Hospital staffN=5

TotalN=534

8.YouthinkHCWswhohavenotbeenexposedtoCOVID-19shouldreduce their contact with you

Not at all 53(21.4) 40(17.2) 14(29.2) 2(40) 109(20.4)

90.4 <0.001***

Slight 41(16.5) 45(19.3) 14(29.2) 0(0) 100(18.7)

Moderate 70(28.2) 89(38.2) 12(25.0) 2(40) 173(32.4)

Very Much 84(33.9) 59(25.3) 8(16.6) 1(20) 152(28.5)

Mean±SD 1.75±1.14 1.72±1.03 1.29±1.07 1.40±1.34 1.69±1.09

9.Youwanttobeabletoworkinaunit where you don't have to deal withpatientswithCOVID-19

Not at all 96(38.7) 79(33.9) 23(47.9) 1(20) 199(37.2)

10.79 0.09

Slight 60(24.2) 69(29.6) 15(31.3) 2(40) 146(27.3)

Moderate 59(23.8) 47(20.2) 9(18.7) 0(0) 115(21.5)

Very Much 33(13.3) 38(16.3) 1(2.1) 2(40) 74(14.0)

Mean±SD 1.12±1.07 1.19±1.08 0.75±0.84 1.60±1.34 1.12±1.06

10.YounoticethatotherHCWsoutside your department are avoiding contact with infected patients

Not at all 47(19.0) 27(11.6) 12(25.0) 3(60) 89(16.7)

22.17 0.01**

Slight 47(19.0) 47(20.2) 17(35.4) 1(20) 112(21.0)

Moderate 78(31.5) 83(35.6) 16(33.3) 0(0) 177(33.1)

Very Much 76(30.5) 76(32.6) 3(6.3) 1(20) 156(29.2)

Mean±SD 1.74±1.09 1.89±0.99 1.21±0.90 0.80±1.30 1.75±1.05

11.Iftheepidemicsuddenlygetsworse, you will have to stop your job

Not at all 166(66.9) 142(610) 41(85.4) 3(60) 352(65.9)

11.22 0.08

Slight 49(20.0) 56(24.0) 3(6.3) 2(40) 110(20.6)

Moderate 25(10.1) 27(11.6) 3(6.3) 0(0) 55(10.3)

Very Much 8(3.0) 8(3.4) 1(2.0) 0(0) 17(3.2)

Mean±SD 0.50±0.80 0.58±0.83 0.25±0.67 0.40±0.55 0.51±0.81

12.Youfeelangrybecauseyourworkloadisgreaterandmoredangerous than other doctors whohavenotbeenexposedtoCOVID-19

Not at all 134(54.0) 124(53.0) 29(60.4) 3(60) 290(54.3)

8.303 0.22

Slight 53(21.4) 61(26.0) 15(31.3) 2(40) 131(24.5)

Moderate 44(17.7) 34(15.0) 4(8.3) 0(0) 82(15.4)

Very Much 17(6.9) 14(6.0) 0(0) 0(0) 31(5.8)

Mean±SD 0.77±0.97 0.73±0.92 0.48±0.65 0.40±0.55 0.73±0.93

13.Youwanttocallinsick

Not at all 207(82.5) 195(83.7) 46(95.8) 5(100) 453(84.8)

9.17 0.16

Slight 22(8.9) 28(12.0) 2(40) 0(0) 52(9.7)

Moderate 16(6.5) 8(3.4) 0(0) 0(0) 24(4.5)

Very Much 3(12.1) 2(0.9) 0(0) 0(0) 5(0.9)

Mean±SD 0.25±0.63 0.21±0.54 0.04±0.20 0.00±0.00 0.22±0.56

14.You'vebeenoffworkatleastonce

Not at all 228(92.0) 219(94.0) 48(100) 5(100) 500(93.6)

8.555 0.2

Slight 10(4.0) 10(4.3) 0(0) 0(0) 20(3.7)

Moderate 10(4.0) 3(1.3) 0(0) 0(0) 13(2.4)

Very Much 0(0) 1(0.4) 0(0) 0(0) 1(0.3)

Mean±SD 0.12±0.43 0.08±0.36 0.00±0.00 0.00±0.00 0.09±0.38

*<0.05;**<0.01;***<0.001.χ²testwasonlyperformedamongthegroupsofnurse,doctorandmedicaltechnicianbecauseofprettysmallsamplesizeinthegroupofhospitalstaff.

Table 2 continued. Staff feeling during COVID-19 outbreak among different position.

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Question ConditionGroups (years old)

TotalN=534

χ² P18–30N=150

31–40N=215

41–50N=117

50+N=52

1.Seeyourcolleagueswereinfected

Not at all 23(15.3) 24(11.2) 16(13.7) 9(17.3) 72(13.5)

8.109 0.52

Slight 26(17.3) 33(15.3) 20(17.1) 9(17.3) 88(16.5)

Moderate 45(30.0) 75(34.9) 31(26.5) 21(40.4) 172(32.2)

Very Much 56(37.4) 83(38.6) 50(42.7) 13(25.0) 202(37.8)

Mean±SD 1.89±1.08 2.01±1.00 1.98±1.07 1.73±1.03 1.94±1.04

2.You'reworriedaboutinfectingyour family

Not at all 8(5.33) 3(1.4) 2(1.7) 3(5.8) 16(3.0)

137 <0.001***

Slight 19(12.7) 20(9.3) 24(20.5) 5(9.6) 68(12.7)

Moderate 47(31.3) 68(31.6) 28(24.0) 20(38.5) 163(30.6)

Very Much 76(50.7) 124(57.7) 64(53.8) 24(46.1) 287(53.7)

Mean±SD 2.27±0.88 2.46±0.72 2.30±0.85 2.25±0.86 2.35±0.81

3.Smallmistakesorinattentionscanmakeyouorothersinfected

Not at all 6(4.0) 8(3.7) 0(0.0) 7(13.5) 21(3.9)

37.69 <0.001***

Slight 37(25.0) 41(19.1) 25(21.4) 3(5.8) 106(19.9)

Moderate 56(37.0) 93(43.3) 34(29.1) 25(48.0) 208(39.0)

Very Much 41(34.0) 73(34.0) 58(49.5) 17(32.7) 199(37.2)

Mean±SD 2.01±0.87 2.07±0.82 2.28±0.80 2.00±0.97 2.10±0.85

4.Takecareofyourinfectedcolleagues

Not at all 35(23.3) 44(20.5) 17(14.5) 9(17.3) 105(19.7)

12.88 0.17

Slight 37(24.7) 42(19.5) 33(28.2) 11(21.1) 123(23.0)

Moderate 50(33.3) 83(38.6) 32(27.4) 21(40.4) 186(34.8)

Very Much 28(18.7) 46(21.4) 35(29.9) 11(21.2) 120(22.5)

Mean±SD 1.47±1.05 1.61±1.04 1.73±1.05 1.65±1.01 1.60±1.04

5.Seeyourinfectedpatientdieinfront of you

Not at all 16(10.7) 25(11.6) 9(7.7) 2(3.9) 52(9.7)

27.06 0.001**

Slight 19(12.7) 30(14.0) 35(29.9) 6(11.5) 70(13.1)

Moderate 57(38.0) 64(29.8) 40(34.1) 18(34.6) 168(31.5)

Very Much 58(38.6) 96(44.7) 33(28.3) 26(50.0) 244(45.7)

Mean±SD 2.05±0.97 2.07±1.02 2.26±0.96 2.31±0.83 2.13±0.98

6.Youdon'tknowwhentheoutbreakwillbecontained

Not at all 7(4.6) 6(2.8) 9(7.7) 2(3.9) 24(4.5)

11.41 0.25

Slight 39(26.0) 69(32.1) 35(29.9) 18(34.6) 161(30.1)

Moderate 73(48.7) 94(43.7) 40(34.2) 19(36.5) 226(42.3)

Very Much 31(20.7) 46(21.4) 33(28.2) 13(25.0) 123(23.1)

Mean±SD 1.85±0.80 1.84±0.79 1.83±0.93 1.83±0.86 1.84±0.83

7.Newinfectionsorsuspectedcasesaskforyourhelp.

Not at all 12(8.0) 17(7.9) 15(12.8) 4(7.7) 48(9.0)

8.36 0.5

Slight 45(30.0) 73(34.0) 40(34.2) 20(38.5) 178(33.3)

Moderate 61(40.7) 89(41.4) 35(29.9) 19(36.5) 204(38.2)

Very Much 32(21.3) 36(16.7) 27(23.1) 9(17.3) 104(19.5)

Mean±SD 1.75±0.88 1.67±0.85 1.63±0.98 1.63±0.86 1.68±0.89

Table 3. Factors that caused stress among staff with different ages.

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Question ConditionGroups (years old)

TotalN=534

χ² P18–30N=150

31–40N=215

41–50N=117

50+N=52

8.LackofspecifictreatmentforCOVID-19

Not at all 11(7.3) 11(5.1) 8(6.8) 3(5.8) 33(6.2)

6.732 0.67

Slight 46(30.7) 56(26.0) 29(24.8) 14(26.9) 145(27.2)

Moderate 61(40.7) 94(43.7) 42(35.9) 20(38.5) 217(40.6)

Very Much 32(21.3) 54(25.1) 38(32.5) 15(28.8) 139(26.0)

Mean±SD 1.76±0.87 1.89±0.84 1.94±0.92 1.90±0.89 1.87±0.87

9.News,Weibo,WeChat,etc.reportthe number of new cases every day

Not at all 9(6.1) 10(4.7) 7(6.0) 6(11.5) 32(6.0)

9.149 0.42

Slight 59(39.3) 80(37.2) 45(38.5) 15(28.9) 199(37.3)

Moderate 53(35.3) 96(44.7) 43(36.8) 22(42.3) 214(40.0)

Very Much 29(19.3) 29(13.5) 22(18.7) 9(17.3) 89(16.7)

Mean±SD 1.68±0.85 1.67±0.77 1.68±0.85 1.65±0.90 1.67±0.82

10.Youfeelexhausted

Not at all 43(28.7) 44(20.5) 26(22.2) 12(23.1) 125(23.4)

18.43 0.03*

Slight 65(43.3) 97(45.1) 43(36.8) 31(59.6) 236(44.2)

Moderate 35(23.3) 57(26.5) 35(29.9) 4(7.7) 131(24.5)

Very Much 7(4.7) 17(7.9) 13(11.1) 5(9.6) 42(7.9)

Mean±SD 1.04±0.85 1.22±0.86 1.30±0.94 1.04±0.84 1.17±0.88

11.Whenyouseeyourcolleaguesshowing symptoms of infection

Not at all 17(11.3) 16(7.4) 8(6.8) 6(11.5) 47(8.8)

13.51 0.14

Slight 30(20.0) 46(21.4) 26(22.2) 3(5.8) 105(19.7)

Moderate 61(40.7) 77(35.8) 37(31.6) 23(44.2) 198(37.0)

Very Much 42(28.0) 76(35.3) 46(39.4) 20(38.5) 184(34.5)

Mean±SD 1.85±0.96 1.99±0.93 2.03±0.95 2.10±0.96 1.97±0.95

12.Whenyouhavesomerespiratory symptoms, worry about whether you will be infected

Not at all 7(4.7) 7(3.3) 7(6.0) 6(11.5) 27(5.1)

13.27 0.15

Slight 45(30.0) 50(23.3) 33(28.2) 13(25.0) 141(26.4)

Moderate 61(40.7) 107(49.8) 43(36.8) 24(46.2) 235(44.0)

Very Much 37(24.6) 51(23.7) 34(29.0) 9(17.3) 131(24.5)

Mean±SD 1.85±0.85 1.94±0.77 1.89±0.90 1.69±0.90 1.88±0.84

13.Youwereinfectedbyaninfectedpatientwhileworkingatthehospital

Not at all 24(16.0) 31(14.4) 18(15.4) 6(11.5) 79(14.8)

7.044 0.63

Slight 27(18.0) 34(15.8) 29(24.8) 11(21.2) 101(18.9)

Moderate 48(32.0) 74(34.4) 30(25.6) 20(38.5) 172(32.2)

Very Much 51(34.0) 76(35.3) 40(34.2) 15(28.8) 182(34.1)

Mean±SD 1.84±1.07 1.91±1.04 1.79±1.08 1.85±0.98 1.86±1.05

14.Youoftenfeelweakandcontradictory, between your own responsibility and life safety

Not at all 33(22.0) 30(14.0) 24(20.6) 10(19.2) 97(18.2)

13.84 0.128

Slight 58(38.7) 86(40.0) 35(29.9) 12(23.1) 191(35.8)

Moderate 43(28.6) 75(34.9) 39(33.3) 20(38.5) 177(33.1)

Very Much 16(10.7) 24(11.2) 19(16.2) 10(19.2) 69(12.9)

Mean±SD 1.28±0.93 1.43±0.87 1.45±1.00 1.58±1.02 1.41±0.93

Table 3 continued. Factors that caused stress among staff with different ages.

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Question ConditionGroups (years old)

TotalN=534

χ² P18–30N=150

31–40N=215

41–50N=117

50+N=52

15.Seeingstressorfearfromyourcolleagues

Not at all 41(27.3) 30(14.0) 10(8.5) 7(13.5) 88(16.5)

24.62 0.0034**

Slight 54(36.0) 80(37.2) 55(47.1) 18(34.6) 207(38.8)

Moderate 45(30.0) 84(39.1) 39(33.3) 19(36.5) 187(35.0)

Very Much 10(6.7) 21(9.8) 13(11.1) 8(15.4) 52(9.7)

Mean±SD 1.16±0.91 1.45±0.85 1.47±0.80 1.54±0.92 1.38±0.87

16.Constantlyscreenyourselfforinfection

Not at all 41(27.3) 67(31.2) 43(36.8) 17(32.7) 167(31.3)

6.957 0.6416

Slight 61(40.7) 78(36.3) 34(29.1) 22(42.3) 195(36.5)

Moderate 35(23.3) 53(24.7) 33(28.2) 9(17.3) 130(24.3)

Very Much 13(8.7) 17(7.9) 8(6.9) 4(7.7) 42(7.9)

Mean±SD 1.13±0.92 1.09±0.93 1.06±0.96 1.00±0.91 1.09±0.93

17.Everydayforalongtimestayinprotective clothing

Not at all 25(16.7) 23(10.7) 23(19.7) 10(19.2) 81(15.2)

19.76 0.0195*

Slight 46(30.7) 77(35.8) 29(24.8) 14(26.9) 166(31.1)

Moderate 61(40.6) 85(39.5) 35(29.9) 20(38.5) 201(37.6)

Very Much 18(12.0) 30(14.0) 30(25.6) 8(15.4) 86(16.1)

Mean±SD 1.48±0.91 1.57±0.86 1.62±1.07 1.50±0.98 1.55±0.94

18.Youthinkthecurrentprotectionmeasuresarestilllacking

Not at all 24(16.0) 31(14.4) 28(23.9) 10(19.2) 96(18.0)

7.941 0.9401

Slight 64(42.7) 91(42.3) 41(35.0) 19(36.5) 215(40.2)

Moderate 46(30.7) 65(30.2) 36(30.8) 20(38.5) 167(31.3)

Very Much 16(10.6) 25(11.6) 12(10.3) 3(5.8) 56(10.5)

Mean±SD 1.36±0.88 1.38±0.89 1.27±0.94 1.31±0.85 1.34±0.89

19.Oftenfacedwithalackofmore medical staff, medical equipment, medical resources

Not at all 21(14.0) 20(9.3) 15(12.8) 5(9.6) 61(11.4)

3.773 0.9257

Slight 52(34.7) 75(34.9) 38(32.5) 17(32.7) 182(34.1)

Moderate 53(35.3) 76(35.3) 39(33.3) 20(38.5) 188(35.2)

Very Much 24(16.0) 44(20.5) 25(21.4) 10(19.2) 103(19.3)

Mean±SD 1.53±0.92 1.67±0.91 1.63±0.96 1.67±0.90 1.62±0.92

*<0.05;**<0.01;***<0.001.

Table 3 continued. Factors that caused stress among staff with different ages.

respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) outbreaks have shown that medical staff are not only under stress during epidemics, but they may also suffer psychologically long after the initial outbreak is over [10,12]. Although each epidemic has significant differ-ences due to geographic location, pathogen characteristics, route of transmission, infectivity, mortality rate, and avail-ability of treatments, based on previous studies, epidem-ics have a significant impact on the psychological wellbe-ing of medical staff [13]. The present study was the first to investigate the psychological effects of the recent outbreak of coronavirus disease 2019 (COVID-19) in Hubei, China, on

the medical staff of Hunan province, from the aspects of emotions, perceived stressors, and coping strategies. This study also investigated motivational factors that might en-courage the continuation of work in future similar outbreaks.

Dongting Lake separates the adjacent provinces of Hunan and Hubei, which have similar cultures and are linked by transportation, and there is frequent migration between these two provinces. Therefore, the development of an epi-demic in Hubei province is likely to affect Hunan, and the de-gree of clinical work and psychological stress of medical staff in Hunan is second only to that of Hubei. An understanding

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Question ConditionGroups

Total N=534

χ² PMale N=167

Female N=367

1.Positiveattitudefromyourcolleagues

Never 7(4.2) 9(2.5) 16(3.0)

8.586 0.04*

Sometimes 54(32.3) 83(22.6) 137(25.7)

Often 77(46.1) 184(50.1) 261(48.8)

Always 29(17.4) 91(24.8) 120(22.5)

Mean±SD 1.77±0.78 1.97±0.76 1.91±0.77

2.Aftereffectiveprotectionmeasureshavebeentaken,noneofyourcolleagues have been infected with the virus

Never 21(12.6) 26(7.1) 47(8.8)

20 <0.001***

Sometimes 31(18.6) 37(10.1) 68(12.7)

Often 63(37.7) 122(33.2) 185(34.7)

Always 52(31.1) 182(49.6) 234(43.8)

Mean±SD 1.87±1.00 2.25±0.90 2.13±0.95

3.Yourpatientisgettingbetter

Never 7(4.2) 9(2.5) 16(3.0)

9.167 0.03*

Sometimes 27(16.2) 37(10.0) 64(12.0)

Often 80(47.9) 161(43.9) 241(45.1)

Always 53(31.7) 160(43.6) 213(39.9)

Mean±SD 2.07±0.80 2.29±0.74 2.22±0.77

4.Yourinfectedcolleagueisgettingbetter

Never 23(13.8) 29(7.9) 52(9.7)

17.56 <0.001***

Sometimes 26(15.6) 32(8.7) 58(10.9)

Often 72(43.1) 144(39.2) 216(40.4)

Always 46(27.5) 162(44.2) 208(39.0)

Mean±SD 1.84±0.98 2.20±0.90 2.09±0.94

5.Yourhospitalprovidesyouwitheffective safeguards

Never 4(2.4) 3(0.8) 7(1.3)

5.117 0.16

Sometimes 26(25.6) 45(12.3) 71(13.3)

Often 74(44.3) 151(41.1) 225(42.1)

Always 63(37.7) 168(45.8) 231(43.3)

Mean±SD 2.17±0.78 2.32±0.72 2.27±0.74

6.Hospital'scorrectguidanceforinfection prevention

Never 4(2.4) 5(1.4) 9(1.7)

2.932 0.4

Sometimes 17(10.2) 33(9.0) 50(9.4)

Often 75(44.9) 146(39.7) 221(41.3)

Always 71(42.5) 183(49.9) 254(47.6)

Mean±SD 2.28±0.74 2.38±0.71 2.35±0.72

7.Noneofyourfamilymembersareinfected and are in a relatively safe state

Never 8(4.8) 13(3.5) 21(3.9)

3.158 0.37

Sometimes 10(6.0) 16(4.4) 26(4.9)

Often 48(28.7) 91(24.8) 139(26.0)

Always 101(60.5) 247(67.3) 348(65.2)

Mean±SD 2.45±0.81 2.56±0.74 2.52±0.76

Table 4. Factors that helped in reducing stress during COVID-19 outbreak between genders.

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Question ConditionGroups

Total N=534

χ² PMale N=167

Female N=367

8.Decreaseinreportedcases

Never 6(3.6) 7(1.9) 13(2.4)

6.195 0.1

Sometimes 25(15.0) 39(10.6) 64(12.0)

Often 71(42.5) 141(38.4) 212(39.7)

Always 65(38.9) 180(49.1) 245(45.9)

Mean±SD 2.17±0.81 2.35±0.74 2.29±0.77

9.Yougetextrafinancialcompensationwhenyouworkinthefield.

Never 24(14.4) 43(11.7) 67(12.5)

1.568 0.67

Sometimes 76(45.5) 158(43.1) 234(43.8)

Often 39(23.4) 100(27.2) 139(26.0)

Always 28(16.8) 66(18.0) 94(17.7)

Mean±SD 1.43±0.93 1.51±0.92 1.49±0.92

10.Yourfamiliarfriends,colleagues,leadersworkwithyouinthefield

Never 6(3.6) 10(2.7) 16(3.0)

11.18 0.01*

Sometimes 42(25.1) 59(16.1) 101(18.9)

Often 75(44.9) 153(41.7) 228(42.7)

Always 44(26.3) 145(39.5) 189(35.4)

Mean±SD 1.94±0.81 2.18±0.80 2.10±0.81

11.Onceyougetinfected,yourtrustin the hospital will give you peace of mind

Never 14(8.4) 17(4.6) 31(5.8)

5.751 0.12

Sometimes 35(21.0) 93(25.4) 128(24.0)

Often 74(44.3) 141(38.4) 215(40.2)

Always 44(26.3) 116(31.6) 160(30.0)

Mean±SD 1.89±0.89 1.98±0.87 1.95±0.88

12.Jokingandchattingwithyourcolleagues

Never 6(3.6) 9(2.5) 15(2.8)

2.689 0.44

Sometimes 39(23.4) 75(20.3) 114(21.3)

Often 79(47.3) 165(45.0) 244(45.8)

Always 43(25.7) 118(32.2) 161(30.1)

Mean±SD 1.95±0.80 2.07±0.79 2.03±0.79

13.Noovertime

Never 23(13.8) 28(7.7) 51(9.5)

8.537 0.04*

Sometimes 72(43.1) 138(37.6) 210(39.3)

Often 45(26.9) 122(33.2) 167(31.3)

Always 27(16.2) 79(21.5) 106(19.9)

Mean±SD 1.46±0.92 1.69±0.89 1.61±0.91

14.Receivedfreelunch,milkteaprepared by the hospital for frontline staff

Never 10(6.0) 18(4.9) 28(5.2)

8.726 0.03*

Sometimes 51(30.5) 76(20.7) 127(23.8)

Often 61(36.5) 135(36.8) 196(36.7)

Always 45(26.9) 138(37.6) 183(34.3)

Mean±SD 1.84±0.89 2.07±0.88 2.00±0.89

*<0.05;**<0.01;***<0.001.

Table 4 continued. Factors that helped in reducing stress during COVID-19 outbreak between genders.

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Question Condition

Groups

TotalN=534

χ² PNursesN=248

DoctorsN=233

Medical Technician

N=48

Hospital staffN=5

1.Followstrictprotectivemeasures, such as handwashing,masks,facemasks,protectiveclothing,etc.

Not at all important 1(0.4) 2(0.86) 0(0.0) 0(0.0) 3(0.6)

9.025 0.17

Slightly important 3(1.2) 6(2.58) 2(4.2) 0(0.0) 11(2.1)

Important 30(12.1) 45(19.31) 10(20.8) 0(0.0) 85(15.9)

Very Important 214(86.3) 180(77.25) 36(75.0) 5(1.0) 435(81.4)

Mean±SD 2.84±0.43 2.73±0.55 2.71±0.54 3.00±0.00 2.78±0.50

2.Everyfeverpatientmay be infected with COVID-19,evenifthenucleic acid test is negative

Not at all important 4(1.6) 3(1.29) 0(0.0) 0(0.0) 7(1.3)

19.16 0.004**

Slightly important 11(4.4) 30(12.88) 4(8.3) 0(0.0) 45(8.4)

Important 74(29.8) 89(38.20) 17(35.4) 2(0.4) 182(34.1)

Very Important 159(64.1) 111(47.64) 27(56.3) 3(0.6) 300(56.2)

Mean±SD 2.56±0.66 2.32±0.75 2.48±0.65 2.60±0.55 2.45±0.70

3.LearnaboutCOVID-19,its prevention and mechanism of transmission

Not at all important 1(0.4) 0(0.00) 0(0.0) 0(0.0) 1(0.2)

9.207 0.16

Slightly important 6(2.4) 5(2.15) 2(4.2) 0(0.0) 13(2.4)

Important 46(18.5) 68(29.18) 12(25.0) 0(0.0) 126(23.6)

Very Important 195(78.6) 160(68.67) 34(70.8) 5(1.0) 394(73.8)

Mean±SD 2.75±0.51 2.67±0.52 2.67±0.56 3.00±0.00 2.71±0.52

4.Chooseamoresinglemode of travel, such as self-driving,andavoidtransportation such as subways

Not at all important 2(0.8) 2(0.86) 1(2.1) 0(0.0) 5(0.9)

54.37 <0.001***

Slightly important 4(1.6) 16(6.87) 1(2.1) 0(0.0) 21(3.9)

Important 56(22.6) 65(27.90) 12(25.0) 0(0.0) 133(24.9)

Very Important 186(75.0) 150(64.38) 34(70.8) 5(1.0) 375(70.3)

Mean±SD 2.72±0.53 2.56±0.66 2.65±0.64 3.00±0.00 2.64±0.60

5.Dosomeleisureactivities in your free time, such as watching movies,reading,etc.

Not at all important 2(0.8) 1(0.43) 0(0.0) 0(0.0) 3(0.6)

13.68 0.03*

Slightly important 18(7.3) 26(11.16) 5(10.4) 0(0.0) 49(9.1)

Important 78(31.5) 96(41.20) 24(50.0) 1(0.2) 199(37.3)

Very Important 150(60.5) 110(47.21) 19(39.6) 4(0.8) 283(53.0)

Mean±SD 2.52±0.67 2.35±0.69 2.29±0.65 2.80±0.45 2.43±0.68

6.Chattedwithfamilyandfriends to relieve stress and obtain support

Not at all important 2(0.8) 8(3.43) 3(6.3) 0(0.0) 13(2.4)

29.42 <0.001***

Slightly important 27(10.9) 54(23.18) 12(25.0) 0(0.0) 93(17.4)

Important 90(36.3) 93(39.91) 15(31.3) 1(0.2) 199(37.3)

Very Important 129(52.0) 78(33.48) 18(37.5) 4(0.8) 229(42.9)

Mean±SD 2.40±0.71 2.03±0.84 2.00±0.95 2.8±0.45 2.21±0.81

7.Talkingtoyourselfandmotivating to face the COVID-19outbreakwithpositive attitude

Not at all important 1(0.4) 2(0.86) 0(0.0) 0(0.0) 3(0.6)

10.23 0.12

Slightly important 15(6.0) 14(6.01) 6(12.5) 0(0.0) 35(6.6)

Important 74(29.8) 94(40.34) 14(29.2) 0(0.0) 182(34.0)

Very Important 158(63.7) 123(52.79) 28(58.3) 5(1.0) 314(58.8)

Mean±SD 2.57±0.63 2.45±0.65 2.46±0.71 3.00±0.00 2.51±0.64

Table 5. Personal coping strategies used by the staff to alleviate stress among professionals.

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Cai H. et al.:Frontline medical staff in Hunan during COVID-19

Question Condition

Groups

TotalN=534

χ² PNursesN=248

DoctorsN=233

Medical Technician

N=48

Hospital staffN=5

8.Seekhelpfromapsychologist

Not at all important 26(10.5) 75(32.19) 17(35.4) 1(0.2) 119(22.3)

69.11 <0.001***

Slightly important 64(25.8) 80(34.33) 19(39.6) 2(0.4) 165(30.9)

Important 78(31.5) 53(22.75) 6(12.5) 1(0.2) 138(25.8)

Very Important 80(32.3) 25(10.73) 6(12.5) 1(0.2) 112(21.0)

Mean±SD 1.85±0.99 1.12±0.98 1.02±1.00 1.40±1.14 1.46±1.06

9.AvoideddoingovertimetoreduceexposuretoCOVID-19patientsinhospital

Not at all important 33(13.3) 45(19.31) 12(25.0) 0(0.0) 90(16.9)

26.88 <0.001***

Slightly important 65(26.2) 73(31.33) 21(43.8) 2(0.4) 161(30.1)

Important 79(31.9) 81(34.76) 12(25.0) 1(0.2) 173(32.4)

Very Important 71(28.6) 34(14.59) 3(6.3) 2(0.4) 110(20.6)

Mean±SD 1.76±1.01 1.45±0.96 1.13±0.87 2.00±1.00 1.57±1.00

10.AvoidedmedianewsaboutCOVID-19andrelated fatalities

Not at all important 80(32.3) 108(46.35) 26(54.2) 2(0.4) 216(40.4)

27.12 <0.001***

Slightly important 61(24.6) 66(28.33) 15(31.3) 0(0.0) 142(26.6)

Important 68(27.4) 36(15.45) 6(12.5) 2(0.4) 112(21.0)

Very Important 39(15.7) 23(9.87) 1(2.1) 1(0.2) 64(12.0)

Mean±SD 1.27±1.08 0.89±1.00 0.63±0.79 1.40±1.34 1.04±1.05

11.Ventedemotionsbycrying,screamingetc.

Not at all important 83(33.5) 135(57.94) 35(72.9) 2(0.4) 255(47.8)

45.82 <0.001***

Slightly important 87(35.1) 56(24.03) 11(22.9) 1(0.2) 155(29.0)

Important 50(20.2) 29(12.45) 2(4.2) 0(0.0) 81(15.2)

Very Important 28(11.3) 13(5.58) 0(0.0) 2(0.4) 43(8.1)

Mean±SD 1.09±0.99 0.66±0.90 0.31±0.55 1.40±1.52 0.84±0.96

*<0.05;**<0.01;***<0.001.χ²testwasonlyperformedamongthegroupsofnurse,physicianandmedicaltechnicianbecauseofprettysmallsamplesizeinthegroupofothers.

Table 5 continued. Personal coping strategies used by the staff to alleviate stress among professionals.

Table 6. Motivational factors to encourage continuation of work in future outbreaks (N=534, Maximum score=3)

Motivational factors for future outbreaks Mean (SD) Median SD

1.SimilaradequatepersonalprotectiveequipmentsupplybytheHospital 2.71 3 0.56

2.Treatmentseffectivefordiseasesorapplicationofvaccines 2.66 3 0.59

3.Familysupport 2.61 3 0.61

4.Social,mediaidentity 2.59 3 0.64

5.Compensationtofamilyifdiseaserelatedinfectionordeathatwork 2.36 3 0.83

6.Reduceworkinghoursandmoreflexibleschedulingduringepidemics 2.29 2 0.81

7.Thehospital'sfinancialsupportforyou 2.28 2 0.83

8.Hospitalcanprovidepsychologistsupport 2.11 2 0.96

9.Reduceovertime 2.05 2 0.93

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of psychological effects, perceived stressors, and coping strategies from the Hunan medical staff is important and may have implications for medical staff in other Chinese provinces, and other countries.

The findings from the present study showed that front-line medical staff experienced emotional stress during the COVID-19 outbreak, which has been supported by previ-ous studies on other epidemics, although their extent dif-fers [9,10]. However, in the present study, expectations of financial compensation during or after the outbreak were not established, which differed from other studies [10,14]. However, medical staff in Hunan expected recognition from the health authorities, as reported during previous epidem-ics [9,10]. Also, the most important factors that motivated them to continue working were their social and moral re-sponsibilities and professional obligations.

For medical staff in Hunan, safety from infection was the main concern as they worried most that they might in-fect their families with COVID-19. Medical staff between 31 – 40 years of age had the greatest concern regarding viral transmission to their families, possibly because most of them had young children and living parents in their families. These findings were also reported among medical staff during the SARS epidemic but were less significant [15]. Another cause of stress for the medical staff in this study was an awareness of the mortality rate from COVID-19 infection. All age groups in this study expressed psychological stress when they saw their colleagues under stress. Therefore, hospital manag-ers and governments should improve interventions for pre-venting the spread of epidemics, promote disease treatment methods, and also offer psychological support for medical staff. In the present study, the study participants showed less concern regarding the new cases and lack of treatment for COVID-19, which was not consistent with previous stud-ies during other infectious disease epidemics [10]. Medical staff were satisfied with current protection measures, the numbers of medical staff, medical equipment, and medical resources, although these were identified as problems by the general public and the media [8]. This finding might be explained because, at the time of this study, the COVID-19 epidemic in Hunan was not as severe as that in Wuhan and Hubei, and disease prevention measures in Hunan were be-ing instigated, and medical workers and the general pop-ulation were better informed about these measures [16].

Previous studies have shown that gender differences ex-ist regarding the ability to cope with stress [17,18]. Women in society and at work are more likely than men to develop social and personal mechanisms to cope with stress [17,18]. The responses to the questionnaires in the present study showed that the most important factor that helped ease

the stress of the medical staff was when their family was well, not infected with COVID-19, and were not believed to be at risk of infection. A positive working environment with the re-assurance of personal safety while at work dur-ing the COVID-19 epidemic were the two main factors that might be key to encourage medical staff to continue work-ing during the epidemic. Also, awareness of the effects of disease prevention measures with reduced numbers of re-ported cases reduced staff stress. Financial or other forms of remuneration were not significant concerns by medical staff in this study. The personal coping strategies that were used by medical staff to reduce stress during the COVID-19 epidemic is an important topic to investigate that requires further long-term studies as in China and throughout the world. During this study, medical staff in Hunan who were under stress from the COVID-19 epidemic were reassured by the implementation of clear disease prevention guide-lines, including handwashing, the use of face masks, and protective clothing [19].

Recently, Cheng et al. commented that with the develop-ment of the COVID-19 epidemic, infection control was im-portant as there is still no vaccine or antiviral therapy, but that testing based on the identification of viral RNA using polymerase chain reaction (PCR)-based tests may show false-negatives [20]. Li et al. have recently reported that both anti-virus IgM and IgG could be used for confirmed di-agnosis when molecular testing is negative [21]. Screening of all individuals with a fever is recommended, and aware-ness of aerosol and droplet spread of COVID-19 has sup-ported avoiding social gatherings and public transport. During infectious disease epidemics, support from family and friends, as well as a positive attitude, have previously been shown to reduce stress [22]. However, in China, med-ical staff are less likely to seek help from a psychologist or to express their emotions, when compared with medical staff in western countries.

There have been recent epidemics with novel forms of coro-navirus that have included the SARS outbreak in 2003, and the Middle East respiratory syndrome (MERS) outbreak in 2014, which are now followed by the COVID-19 outbreak from 2019. In 2005, Wang et al. reported the findings from a study on the psychological impact of the SARS outbreak on emergency healthcare workers [23]. The findings showed that psychological stress was greatest for emergency nurses, followed by emergency doctors, and then for healthcare assistants [23]. This previous study showed that the most important variables associated with stress included loss of control and vulnerability to infection, the fear for personal health, and the spread of the novel virus [23]. The most common coping strategies by emergency medical staff were previously reported to include acceptance of the medical

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situation, the active use of coping strategies, and positive framing or outlook while working [23].

This study had several limitations. The study was designed as a cross-sectional observational study that included doctors, nurses, and other hospital staff throughout Hunan province and was of short duration, conducted between January and March 2020. However, psychological stress can accumulate over time and have an impact later in the outbreak, includ-ing posttraumatic stress disorder (PTSD), which should be investigated in future studies. Also, although the staff in-cluded in this study were all from frontline medical depart-ments that included departments of infectious diseases, emergency medicine, fever clinics, intensive care units, radi-ology, and laboratory medicine, this study did not analyze the differences between workers in different departments. Following the findings from this preliminary observational study, the risk factors associated with the psychological im-pact of the COVID-19 infection should be investigated in fu-ture long-term studies. Because this was a cross-sectional study, the effects of continuous changes on the psycho-logical status of medical workers were not studied. Finally, the data from this study was based on subjective responses using questionnaires, and in future studies, these findings should be supported by objective measurements of stress.

Conclusions

This study aimed to investigate the psychological impact and coping strategies of frontline medical staff in Hunan province, adjacent to Hubei province, during the COVID-19 outbreak between January and March 2020. The findings showed that the COVID-19 epidemic in Hubei resulted in in-creased workload and stress for medical staff in the adja-cent province of Hunan. The main factors associated with stress included the perceived risk of infection to them-selves and their families, patient mortality, the availabili-ty of clear infection control guidance, the availability of ef-fective protective equipment, recognition of their work by hospital authorities, and a decrease in reported cases of COVID-19. Staff support and the provision of facilities and equipment by hospital managers and the government are required to retain and encourage medical staff involvement in future epidemics.

Conflict of interest

None.

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22. Lai THT, Tang EWH, Chau SKY et al: Stepping up infection control mea-sures in ophthalmology during the novel coronavirus outbreak: An ex-perience from Hong Kong. Graefes Arch Clin Exp Ophthalmol. 2020 [Epub ahead of print]

23. Wong TW, Yau JKY, Chan CLW et al: The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergen-cy departments and how they cope. Eur J Emerg Med, 2005; 12(1): 13 – 18

24. 16 Cases a Day! China’s Epidemic Prevention and Control Faces New Challenges as Overseas Imports Increase. Available at [URL]: http://news.sina.com.cn/o/2020 – 03 – 06/doc-iimxxstf6983661.shtml

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Cai H. et al.:Frontline medical staff in Hunan during COVID-19

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