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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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“As suggested by previous studies [4,5], healthcare workers (HCWs), who are at the forefront of the fight against COVID-19, are always at a risk of mental health crises during an infectious disease outbreak.”
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“The current findings were consistent with previous studies where the exposed HCWs reported increased levels of anxiety, depression and hostility (Chou et al., 2020; Liu, Yang, et al., 2020; Maunder et al., 2006; Park & Park, 2020).”
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Nursing leadership in disaster preparedness and response lessons learned and future directions
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“However, regardless of the amount of change experienced, poorly managed redeployment has been associated with adverse outcomes (Maunder et al., 2006, Nickell et al., 2004).”
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CHALLENGES FACED BY CORONA WARRIORS DURING COVID-19 PANDEMIC: A REVIEW
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Bronheim, R. S., Kebaish, K. M., Jain, A., Neuman, B. J., & Skolasky, R. L. (2022) · North American Spine Society Journal (NASSJ) · doi:10.1016/j.xnsj.2022.100103 · Cited by 4
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Li, H., Cui, Y., Efstathiou, N., Li, B., & Guo, P. (2022) · PLoS ONE · doi:10.1371/journal.pone.0273429 · Cited by 5
“In a cohort of healthcare workers caring for severe acute respiratory syndrome (SARS) patients, significantly higher levels of burnout, psychological distress and posttraumatic stress were reported after the outbreak ended [28].”
BackgroundGabra, M. A., Moez, K. A. E., Hegazy, M. N., & Hendi, A. E. (2022) · Middle East Current Psychiatry · doi:10.1186/s43045-022-00233-w · Cited by 5
“pre-existing psychological or physical illness [17], and fear of infecting or having an infected family member [18].”
BackgroundCOVID-19 Pandemic-Specific PTSD: Risk and Protective Factors Among University Students
Feiler, T., Vanacore, S. M., & Dolbier, C. (2022) · Journal of loss & trauma · doi:10.1080/15325024.2022.2132670 · Cited by 3
“We modified five items to assess COVID fear (Chong et al., 2004) and three items to assess COVID-19 stigma (Maunder et al., 2006; 1¼ strongly disagree to 5¼ strongly agree).”
MethodKim, K. D., & Yi, Y. H. (2022) · Journal of Korean Critical Care Nursing · doi:10.34250/jkccn.2022.15.3.101 · Cited by 5
Psychological Distress among Pharmacists during Second Wave of Pandemic: A Cross-Sectional Study
Dhakal, K., Nepal, S., & Sapkota, P. (2022) · Advances in Pharmacological and Pharmaceutical Sciences · doi:10.1155/2022/3606351 · Cited by 4
Azizi, T. H., Nayeri, N. D., Jackson, A. C., & Bahramnezhad, F. (2023) · Nursing Open · doi:10.1002/nop2.1627 · Cited by 3
“Since the adverse effects of the pandemic on HCWs (e.g., burnout) are long term, organizations must implement programs to reduce burnout and promote resilience during and after the pandemic subsides when the health system is relatively stable (Maunder et al., 2006).”
BackgroundFeizipour, H., Goli, R., Gharebaghi, N., & Kiani, A. (2023) · Nursing and Midwifery Journal · doi:10.52547/unmf.20.10.830 · Cited by 4
The Art of Health Promotion: linking research to practice
Johnson, S. S. (2018) · American Journal of Health Promotion · doi:10.1177/0890117118776735 · Cited by 5
Preparedness of ICU networks for pandemics
Florio, G., Zanella, A., & Pesenti, A. M. (2020) · Current Opinion in Critical Care · doi:10.1097/mcc.0000000000000792 · Cited by 4
COVID-19 pandemic and the healthcare workers- The call of duty
Muhammad, S., KUMAR, G., Kumar, N., & Tabassum, R. (2021) · Journal of Research in Pharmacy · doi:10.29228/jrp.90 · Cited by 4
“World Health Organization (WHO) in its guideline has recommended that the HCWs should take proper rest and and diet and in this study it was observed that about two-third of the respondents were properly following the recommended WHO guidelines [9, 10] and this will improve physical and mental state of HCWs.”
Hoque, A. M., Hoque, A. M., Buckus, S., Hoque, M., Alam, A. B. M. M. U., Hoque, M., & Singh, N. (2021) · Psychological Disorders and Research · doi:10.31487/j.pdr.2021.01.01 · Cited by 3
“These factors are likely to increase the incidence of psychological problems of HCWs especially at the lowest level of health facility in SA, such as fear, anxiety, depression, stress and insomnia, which are known to affect negatively on individual’s work efficiency and long-term well-being [8, 9].”
BackgroundKong, C., Tan, L., Gao, X., Fan, H., Zhang, J., Wang, Z., & Wang, J. (2021) · Journal of Psychosocial Nursing and Mental Health Services · doi:10.3928/02793695-20210527-03 · Cited by 4
Yang, B., Yen, C., Lin, S., Huang, C., Wu, J.-L., Cheng, Y., Hsieh, C., & Hsiao, F. (2021) · Journal of Nursing Management · doi:10.1111/jonm.13527 · Cited by 4
Aljohani, K. A., Aljohani, M. S., Natividad, M. J. B., Gracia, P. R. B., & Qazanli, I. I. (2021) · Sudan Journal of Medical Sciences · doi:10.18502/sjms.v16i4.9952 · Cited by 4
“In detail, nurses who care for patients with EIDs as part of their duties suffer from several negative psychological consequences including depression, anxiety, and post-traumatic stress response [5, 8].”
BackgroundCOVID-19 et trouble de stress post-traumatique (TSPT) chez les professionnels de santé
Underner, M., Perriot, J., Peiffer, G., & Jaafari, N. (2021) · Revue des Maladies Respiratoires · doi:10.1016/j.rmr.2020.11.014 · Cited by 4
“[3], un seul préentait un minime épanchement pleural bilatéral visible niquement à la TDM de haute résolution.”
Li, J., Xu, J., Zhou, H., You, H., Wang, X., Li, Y., Liang, Y., Li, S., Ma, L., Zeng, J., et al. (2020) · doi:10.2471/blt.20.255471 · Cited by 4
“Increased workload, fear of infection due to patient care, inadequate training and equipment, and lack of support were risk factors for poor mental and physical health [18-22].”
BackgroundAragonès, E., Rodoreda, S., Guitart, M., Garcia, E., Berenguera, A., Martín, F., Rambla, C., Aragonès, G., Calvo, A., Mas, A., et al. (2023) · BMC Primary Care · doi:10.1186/s12875-023-02187-2
“The psychological vulnerability of healthcare workers has also been underscored, and moreover, exhaustion and the psychological consequences of this experience may appear at any time and be long-lasting [14].”
Unmasking Distress: An Analysis of COVID-19’s Mental Health Impact on Nurses in South Africa
Haine, P., Kagee, A., Coetzee, B., Vuuren, M. J. V., & Shongwe, L. (2025) · Western Journal of Nursing Research · doi:10.1177/01939459251316049 · Cited by 3
“27 For example, research by Lee et al. found that HCWs continued to experience significantly elevated levels of stress, depression, anxiety, and posttraumatic symptoms even 1 year after the SARS outbreak, in comparison to non-healthcare professionals.”
Liu, Y., Xie, Z., Li, H., Song, Y., Chen, C., Li, Y., Li, S., Leng, Z., & Chen, H. (2025) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2025.09.053 · Cited by 3
Hostiuc, S., & Gherghiceanu, F. (2026) · Medicina · doi:10.3390/medicina62020305 · Cited by 6
“Previous coronavirus outbreaks provided important precedents: healthcare workers involved in the 2003 SARS outbreak demonstrated acute PTSD rates of 10–20%, with long-term follow-up studies revealing persistent symptoms in 5–18% of affected staff up to four years post-outbreak [146,147].”
Lynch, A., Britt, T. W., Shuffler, M. L., McCallus, R. L., & Hirsh, E. (2026) · Stress and Health · doi:10.1002/smi.70160 · Cited by 4
“In developing a checklist of work demands for the present study, our research team conducted discussions with EMCs and also consulted prior research on the topic (Brooks et al. 2018; Maunder et al. 2006; Tam et al. 2004).”
Predictive Modeling of Healthcare Professional’s Stress Based on XGBoost Model
Gupta, P., Maji, S., & Mehra, R. (2021) · IEEE India Conference · doi:10.1109/indicon52576.2021.9691725 · Cited by 3
Mental Health Impacts on Other Essential Workers
Horney, J. A. (2023) · Emerald Group Publishing Limited eBooks · doi:10.1108/978-1-80262-115-020231013 · Cited by 3
Pahrol, M. A., Ismail, R., Mohamad, N., Lim, Y. C., Robat, R. M., Rajendiran, S., Thahir, S. S. A., Shakor, A. S. A., Ramly, N., & Shaharudin, R. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1028443 · Cited by 4
Guo, Z., Wu, K., Shan, H., Kim, Y., & He, Q. (2023) · BMC Nursing · doi:10.1186/s12912-023-01270-4 · Cited by 4
“A study on the long-term effects of SARS patients’ care reported that healthcare providers felt high levels of Post-traumatic stress disorder, even 13–26 months later [38].”
BackgroundAlrjoub, W., Alarjeh, G., Ammar, K., Shamieh, A., Harding, R., Booth, C. M., Sullivan, R. J., Al-Ruzzieh, M. A., Mansour, A. H., & Shamieh, O. M. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1288483 · Cited by 3
Post-traumatic stress disorder in hospital doctors after the COVID-19 pandemic
Rollin, L., Guérin, O., Petit, A., Bourdon, L., Guillemette, S., Gislard, A., Clin, B., Bachelet, L., Rouget-Mejjad, I., Rouger, F., et al. (2024) · Occupational Medicine · doi:10.1093/occmed/kqad125 · Cited by 3
Pandemic scars: long-term impact of COVID-19 on work stress among healthcare workers in China
Qian, H., Lin, S., Zhang, L., Song, S., & Liu, N. (2024) · Journal of Health Organization and Management · doi:10.1108/jhom-11-2023-0346 · Cited by 3
Balancing Duty and Risk: A Critical Analysis of Frontline Medical Workers During Health Emergencies
Ahmari, A. S. M. A., Alqahtani, A. S., Asiri, F. H., Samiti, F. A. S., & Alqahtani, K. A. (2024) · Journal of Ecohumanism · doi:10.62754/joe.v3i8.5520 · Cited by 3
Nguyen, H. T., Duong, B. T., Vu, T. T., Lin, S., Susilawati, T. N., Nguyễn, B. T., & Duong, M. C. (2025) · BMC Health Services Research · doi:10.1186/s12913-025-12702-z · Cited by 3
“Lessons learnt from the SARS outbreak in Canada highlight that HCWs continued to endure high levels of burnout, psychological distress, and post-traumatic stress for an extended period of 13 to 26 months after the end of the outbreak [20].”
Faria, S., Fonseca, S. M., Marques, A. J., & Queirós, C. M. L. (2025) · Healthcare · doi:10.3390/healthcare13121434 · Cited by 8
“These studies also considered how frontline workers were exposed to greater risks and developed more severe symptoms, which is in line with what had already happened during the SARS outbreak [39].”
Work circumstances, job loss, and wellbeing during New Zealand’s Covid-19 Alert Level 4 lockdown
Habibi, H., Prickett, K. C., Fletcher, M., & Chapple, S. (2021) · New Zealand Economic Papers · doi:10.1080/00779954.2020.1871064 · Cited by 3
“The literature also suggests that those whose work circumstances change experience distress and poorer well-being (De Boer et al., 2011; Maunder et al., 2006; Wu et al., 2009).”
BackgroundReimagining Relationship-Based Health Care in a Post-COVID World
Hutchison, K., Sweeney, J., Bechtel, C., & Park, B. (2021) · Journal of Patient Experience · doi:10.1177/2374373521998622 · Cited by 3
“Prior outbreaks have resulted in spikes in provider burnout and stress (13,14), and the current financial picture suggests health systems will be asked to do more with less.”
BackgroundFazaeli, S., Yousefi, M., Jamali, J., Ebrahimi, Z., & esmaeili, M. H. (2021) · Iranian Red Crescent Medical Journal · doi:10.32592/ircmj.2021.23.5.366 · Cited by 3
“Moreover, support and education play significant roles in reducing the negative effects on the mental health of the employees (2).”
BackgroundPsychological Resilience towards COVID-19 amongst Emergency Medical Professionals in Pune (India)
Rishipathak, P., Vijayraghavan, S., & Hinduja, A. (2021) · Journal of Pharmaceutical Research International · doi:10.9734/jpri/2021/v33i42a32379 · Cited by 3
“To deal with the difficult situation effectively, Emergency Medical Professionals would require a high degree of psychological resilience [1,14].”
COVID-19 psychological impact during the Italian lockdown: A study on healthcare professional
Destro, C. L., & Gasparini, C. (2021) · Journal of Workplace Behavioral Health · doi:10.1080/15555240.2021.1930022 · Cited by 3
“However, as previously demonstrated (e.g., Maunder et al., 2006), healthcare employees exposed to the virus were still experiencing higher stress and burnout levels two years after the SARS pandemic.”
MethodInfluential
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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