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Long-term Psychological and Occupational Effects of Providing Hospital Healthcare during SARS Outbreak
Open accessAbstract
Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known.From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes.Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p<0.001), and posttraumatic stress (p<0.001).Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress.Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive coping style and other individual factors.The results reinforce the value of effective staff support and training in preparation for future outbreaks.S evere 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, characteristics 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).
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“Following the outbreak of severe acute respiratory syndrome in 2003, health-care workers reported chronic stress effects for months to years.4”
From COVID-19: a heavy toll on health-care workers (2021) · cites this paper as [4]
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“Such an extraordinary event will have long-term effects on mental health according to previous studies of epidemics and quarantine (Maunder et al., 2006; Brooks S. K. et al., 2020; Kisely et al., 2020).”
From Traumatic Stress in Healthcare Workers during COVID-19 Pandemic: A Review of the Immediate Impact (2020) · cites this paper as Maunder et al., 2006
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“While some studies have found out that having children (38,39) and having an increased contact with affected patients (18-21,25,30-32,34-36,38-45,47,48) are predisposing factors, our study failed to find such a relationship.”
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“Nevertheless, as the evaluation of psychological distress in the current study has taken place during the spread of COVID-19 in Israel, we cannot rule out the possibility for higher psychological distress rates in the long term, as was found previously among healthcare workers after the 2003 outbreak of SARS in Canada…”
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“11 Therefore, it is necessary to explore how South Korean nurses perceive the experience of MERS-CoV patient care 12 months after caring for MERS-CoV patients.”
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“Depression, anxiety and posttraumatic stress disorder are the most common psychological disorders that were reported particularly in healthcare professionals during the 2003 SARS and 2014 Ebola virus pandemics (Dong & Bouey, 2020; Maunder et al., 2006; Tam et al., 2004).”
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“Unlike the results of this study, Maunder et al. (2006) has determined that healthcare workers mostly used negative coping strategies, such as hostile confrontation and self-blame, during the SARS outbreak (Maunder et al., 2006).”
MethodResultFinstad, G. L., Giorgi, G., Lulli, L. G., Pandolfi, C., Foti, G., León-Perez, J. M., Cantero-Sánchez, F. J., & Mucci, N. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18189453 · Cited by 273
“Data from previous experiences, as in the case of Severe Acute Respiratory Syndrome (SARS) of 2003, Middle East Respiratory Syndrome (MERS) of 2013–2016 and Ebola of 2014–2016, display an alarming picture with symptoms such as anxiety, depression, burnout and post-traumatic stress disorder (PTSD) that persist even aft…”
MethodSaddik, B., Hussein, A., Sharif-Askari, F., Kheder, W., Temsah, M., Koutaich, R., Haddad, E., Al-Roub, N., Marhoon, F. A., Hamid, Q., et al. (2020) · medRxiv · doi:10.2147/rmhp.s273333 · Cited by 214
Islam, M. S., Ferdous, M. Z., & Potenza, M. N. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.06.049 · Cited by 266
COVID-19: Peer Support and Crisis Communication Strategies to Promote Institutional Resilience
Wu, A., Connors, C. A., & Everly, G. (2020) · Annals of Internal Medicine · doi:10.7326/m20-1236 · Cited by 204
“In the case of SARS, up to 50% of HCWs had acute psychological distress, burnout, and posttraumatic stress while caring for these patients (1, 5).”
BackgroundInfluentialMedical students and COVID-19: the need for pandemic preparedness
O’Byrne, L., Gavin, B. E., & McNicholas, F. (2020) · Journal of Medical Ethics · doi:10.1136/medethics-2020-106353 · Cited by 251
Traumatic Stress in Healthcare Workers during COVID-19 Pandemic: A Review of the Immediate Impact
Benfante, A., Di Tella, M., Romeo, A., & Castelli, L. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.569935 · Cited by 237
Xiao, X., Zhu, X., Fu, S., Hu, Y., Li, X., & Xiao, J. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.05.081 · Cited by 303
Depression and Anxiety among Iranian Medical Students during COVID-19 Pandemic
Nakhostin-Ansari, A., Sherafati, A., Aghajani, F., Khonji, M. S., Aghajani, R., & Shahmansouri, N. (2020) · Iranian Journal of Psychiatry · doi:10.18502/ijps.v15i3.3815 · Cited by 231
“care workers who had close contacts with patients affected by SARS disease (5).”
BackgroundResultLasalvia, A., Bonetto, C., Porru, S., Carta, A., Tardivo, S., Bovo, C., Ruggeri, M., & Amaddeo, F. (2020) · Epidemiology and Psychiatric Sciences · doi:10.1017/s2045796020001158 · Cited by 241
A Second Pandemic: Mental Health Spillover From the Novel Coronavirus (COVID-19)
Choi, K. R., Heilemann, M. V., Fauer, A. J., & Mead, M. (2020) · Journal of the American Psychiatric Nurses Association · doi:10.1177/1078390320919803 · Cited by 221
Psychological impact on SARS survivors: Critical review of the English language literature.
Gardner, P. J., & Moallef, P. (2014) · Canadian Psychology/Psychologie canadienne · doi:10.1037/a0037973 · Cited by 220
Xin, M., Luo, S., She, R., Yu, Y., Li, L., Wang, S., Ma, L., Tao, F., Zhang, J., Zhao, J., et al. (2020) · American Psychologist · doi:10.1037/amp0000692 · Cited by 215
Impact of COVID-19 outbreak on nurses’ mental health: A prospective cohort study
Sampaio, F., Sequeira, C., & Teixeira, L. (2020) · Environmental Research · doi:10.1016/j.envres.2020.110620 · Cited by 220
Vagni, M., Maiorano, T., Giostra, V., & Pajardi, D. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.566912 · Cited by 223
Danet, A. (2021) · Medicina Clínica (English Edition) · doi:10.1016/j.medcle.2020.11.003 · Cited by 225
“…en lo que se refiere a la tasa de participación y al control de posibles sesgos de selección y representatividad muestral, justifica-das investigación 55 sistemático de búsqueda y selección, existió un sesgo idiomático y se pudieron omitir algunos artículos, especialmente por incluir en la…”
Stress and burnout in health care workers during COVID-19 pandemic: validation of a questionnaire
Talaee, N., Varahram, M., Jamaati, H., Salimi, A., Attarchi, M., Dizaji, M. K., Sadr, M., Hassani, S., Farzanegan, B., Monjazebi, F., et al. (2020) · Journal of Public Health · doi:10.1007/s10389-020-01313-z · Cited by 208
Wang, Y., Xu, B., Zhao, G., Cao, R., He, X., & Fu, S. (2010) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2010.11.001 · Cited by 206
“[10], but consistent with reports on the long-term effects of SARS [15].”
ResultSirois, F. M., & Owens, J. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.589545 · Cited by 201
“of burnout, psychological distress, and post-traumatic stress when surveyed 13–26 months after the outbreak (14).”
BackgroundResultInfluentialMental Health During the Covid-19 Outbreak in China: a Meta-Analysis
Ren, X., Huang, W., Pan, H., Huang, T., Wang, X., & Ma, Y. (2020) · Psychiatric Quarterly · doi:10.1007/s11126-020-09796-5 · Cited by 199
Brier, N. D., Stroobants, S., Vandekerckhove, P. G., & Buck, E. D. J. D. (2020) · PLoS ONE · doi:10.1371/journal.pone.0244052 · Cited by 211
Kok, N., van Gurp, J. L. P., Teerenstra, S., van der Hoeven, H., Fuchs, M., Hoedemaekers, C., & Zegers, M. (2021) · Critical Care Medicine · doi:10.1097/ccm.0000000000004865 · Cited by 189
Chigwedere, O. C., Sadath, A., Kabir, Z., & Arensman, E. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18136695 · Cited by 181
“Maunder et al. (2006) [73] Canada SARS Epidemic SARS Epidemic N = 769 73.5% nurses, 8.3% clerical, 2.9% physicians, 2.3% respiratory therapists, 12.9% others HCWs (hospital) Stress (IES) Distress (K10) Burnout (MBI) Increase in smoking, drinking alcohol, Stigma, job stress, (WCQ), Toronto HCWs vs.…”
BackgroundResultInfluentialMoral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study
Donkers, M. A., Gilissen, V. J. H. S., Candel, M. J. J. M., van Dijk, N. M., Kling, H., Heijnen‐Panis, R., Pragt, E., van der Horst, I. C. C., Pronk, S. A., & van Mook, W. (2021) · BMC Medical Ethics · doi:10.1186/s12910-021-00641-3 · Cited by 192
Kuper, H., Banks, L. M., Bright, T. M., Davey, C., & Shakespeare, T. (2020) · Wellcome Open Research · doi:10.12688/wellcomeopenres.15833.1 · Cited by 178
Magnavita, N., Chirico, F., Garbarino, S., Bragazzi, N. L., Santacroce, E., & Zaffina, S. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18084361 · Cited by 188
“HCWs exposed to infected patients reported significantly higher levels of burnout than their non-exposed colleagues [35].”
BackgroundHong, S., Ai, M., Xu, X., Wang, W., Chen, J., Zhang, Q., Wang, L., & Kuang, L. (2020) · Nursing Outlook · doi:10.1016/j.outlook.2020.07.007 · Cited by 185
Alsubaie, S., Hani Temsah, M., Al-Eyadhy, A. A., Gossady, I., Hasan, G. M., Al-rabiaah, A., Jamal, A. A., Alhaboob, A. A., Alsohime, F., & Somily, A. M. (2019) · The Journal of Infection in Developing Countries · doi:10.3855/jidc.11753 · Cited by 169
Healthcare workers’ stress when caring for COVID-19 patients: An altruistic perspective
Wang, H., Liu, Y., Hu, K., Zhang, M., Du, M., Huang, H., & Yue, X. (2020) · Nursing Ethics · doi:10.1177/0969733020934146 · Cited by 175
“In Toronto, healthcare workers reported significantly higher levels of burnout, psychological distress, and post-traumatic stress 13–26 months after the SARS outbreak.(17) They were more likely to reduce patient contact and work hours and to report behavioral consequences of stress.”
BackgroundDas, R. K., Hasan, M. R., Daria, S., & Islam, M. R. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-045727 · Cited by 173
McGuire, A., Aulisio, M., Davis, F., Erwin, C. J., Harter, T. D., Jagsi, R., Klitzman, R., Macauley, R. C., Racine, E., Wolf, S., et al. (2020) · American Journal of Bioethics · doi:10.1080/15265161.2020.1764138 · Cited by 134
“Possible repercussions of pandemic care on healthcare providers include depression, sleep disruption, anxiety, and post-traumatic stress disorder (Khalid et al. 2016; Lee et al. 2005; Maunder et al. 2006).”
Background'Resilience training for hospital workers in anticipation of an influenza pandemic'
Aiello, A., Khayeri, M. Y.-E., Raja, S., Peladeau, N., Romano, D., Leszcz, M., Maunder, R. G., Rose, M., Adam, M. A., Pain, C., et al. (2011) · Journal of Continuing Education in the Health Professions · doi:10.1002/chp.20096 · Cited by 159
Self-citationWas SARS a mental health catastrophe?
Maunder, R. (2009) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2009.04.004 · Cited by 162
“7%) is also consistent with one previous report [2] and with the finding that healthcare workers who cared for SARS patients but were not infected continued to experience substantial psychological distress [5], if not mental illness [6], 1–2 years after the outbreak.”
Self-citationChew, N. W. S., Ngiam, J. N., Tan, B. Y.-Q., Tham, S.-M., Tan, C. Y.-S., Jing, M., Sagayanathan, R., Chen, J. T., Wong, L. Y. H., Ahmad, A., et al. (2020) · BJPsych Open · doi:10.1192/bjo.2020.98 · Cited by 159
COVID-19 and employees’ mental health: stressors, moderators and agenda for organizational actions
Hamouche, S. (2020) · Emerald Open Research · doi:10.1108/eor-02-2023-0004 · Cited by 170
Experiences of front‐line nurses combating coronavirus disease‐2019 in China: A qualitative analysis
Liu, Y., Zhai, Z., Han, Y., Liu, Y., Liu, F., & Hu, D. (2020) · Public Health Nursing · doi:10.1111/phn.12768 · Cited by 156
“The physical and emotional effects on nurses who cared for SARS, H1N1, and MERS patients were, however, very similar to those on other health care workers during these epidemics (Honey & Wang, 2013; Kim, 2018; Maunder et al., 2006).”
BackgroundResultRieckert, A., Schuit, E., Bleijenberg, N., ten Cate, D., de Lange, W., Ginkel, J. M. D. M., Mathijssen, E. G. E., Smit, L. C., Stalpers, D., Schoonhoven, L., et al. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-043718 · Cited by 169
Anxiety and Resilience of Healthcare Workers During COVID-19 Pandemic in Indonesia
Setiawati, Y., Wahyuhadi, J., Joestandari, F., Maramis, M. M., & Atika, A. (2021) · Journal of Multidisciplinary Healthcare · doi:10.2147/jmdh.s276655 · Cited by 174
Zaka, A., Shamloo, S. E., Fiorente, P., & Tafuri, A. (2020) · Journal of Health Psychology · doi:10.1177/1359105320925148 · Cited by 153
“…after the severe acute respiratory syndrome (SARS) in 2003, health care workers from Canada and China reported higher levels of burnout, psychological distress, post-traumatic stress disorder and fear of a possible future outbreak of infectious diseases (Liu et al., 2012; Maunder et al., 2006).”
BackgroundThe Impact of COVID-19 on Cancer Screening: Challenges and Opportunities
Cancino, R. S., Su, Z., Mesa, R. A., Tomlinson, G. E., & Wang, J. (2020) · JMIR Cancer · doi:10.2196/21697 · Cited by 163
“During the SARS (severe acute respiratory syndrome) outbreak, health care workers and hospital systems experienced measurable negative psychological impacts [45-48].”
BackgroundDanet, A. (2021) · Medicina Clínica · doi:10.1016/j.medcli.2020.11.009 · Cited by 194
Mental Health in Elderly Spanish People in Times of COVID-19 Outbreak
Fernandez, L. G., Romero‐Ferreiro, V., López‐Roldán, P. D., Padilla, S., & Rodríguez–Jiménez, R. (2020) · American Journal of Geriatric Psychiatry · doi:10.1016/j.jagp.2020.06.027 · Cited by 157
McFadden, P., Ross, J., Moriarty, J., Mallett, J., Schroder, H. S., Ravalier, J. M., Manthorpe, J., Currie, D., Harron, J., & Gillen, P. A. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18020815 · Cited by 156
Metadata
- Authors
- Maunder, R., Lancee, W., Balderson, K., Bennett, J., Borgundvaag, B., Evans, S., Fernandes, C., Goldbloom, D., Gupta, M., Hunter, J., McGillis Hall, L., Nagle, L., Pain, C., Peczeniuk, S., Raymond, G., Read, N., Rourke, S., Steinberg, R., Stewart, T., VanDeVelde-Coke, S., Veldhorst, G., & Wasylenki, D.
- Affiliations
- Mount Sinai Hospital (CA)
- Scarborough Health Network (CA)
- Sunnybrook Health Science Centre (CA)
- University of Toronto (CA)
- St. Michael's Hospital (CA)
- Corresponding author
- Maunder, Robert
- Lancee, William
- Bennett, Jocelyn
- Borgundvaag, Bjug
- Goldbloom, David
- Hunter, Jonathan
- Pain, Clare
- Steinberg, Rosalie
- Stewart, Thomas
- ORCID
- Venue
- Emerging Infectious Diseases
- Published
- 2006
- Volume
- 12
- Issue
- 12
- Pages
- 1924-1932
- ISSN
- 1080-6040 (ISSN-L)
- PMC
- PMC3291360
- OpenAlex
- W1985834457
- Cited by
- 1,109
- References
- 44
- Citations by year
- 2026: 16 · 2025: 33 · 2024: 47 · 2023: 121 · 2022: 223 · 2021: 335 · 2020: 259 · 2019: 12 · 2018: 8 · 2017: 5 · 2016: 6 · 2015: 4 · 2014: 1 · 2013: 5
- FWCI
- 6.15
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Licence
- cc-by
- Locations
- Emerging infectious diseases (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Funders
- Canadian Institutes of Health Research (67807)
- Topics
- Social Sciences › Psychology › Clinical Psychology › COVID-19 and Mental Health
- Health Sciences › Health Professions › General Health Professions › Healthcare professionals’ stress and burnout
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Occupational Health and Burnout
- Keywords
- SARS, healthcare workers, burnout, psychological distress, post-traumatic stress, occupational stress, coping styles, staff training and support, hospital staff well-being, stigma, working time reduction, insecure attachment, risk perception, 2003 SARS outbreak
- MeSH terms
- Adult, Data Collection, Disease Outbreaks, Female, Humans, Male, Ontario, Personnel, Hospital, Regression Analysis, Severe Acute Respiratory Syndrome, Severe acute respiratory syndrome-related coronavirus
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