1.1. Literature Background
The pandemic of the severe acute respiratory coronavirus 2 (SARS-COV-2) and its associated disease, named coronavirus disease 19 (COVID-19), emerged in Wuhan, China, at the end of December 2019, then spread to the entire country, and attracted enormous concern from around the world [1
]. Up to 1 July 2020, more than 10 million confirmed cases of COVID-19 have been diagnosed worldwide, with 506,064 deaths (WHO: Coronavirus disease (COVID-19) Situation Report 163 1 July 2020) [2
According to literature from SARS or Ebola epidemics, the onset of a sudden and immediately life-threatening illness could lead to exceptional levels of pressure on healthcare workers (HCWs). Increased workload, physical pressure, isolation and loss of social support, inadequate protective measures, professional viral transmission, and unprecedented ethical concerns on the rationing of care may have important consequences on their personal physical and mental well-being [4
The actual outbreak has markedly changed the working scenario and job demands. Current literature reports a proportion of infected hospital staff of 3.8%, mainly due to early non-protected contact with infected patients. HCWs need to wear heavy personal protective equipment (PPE), making it difficult to carry out medical procedures. These factors, together with the fear of being contagious and infecting others, could increase the risk of psychological consequences. Taking care of patients, for the first time, mixed with HCWs concern for their one’s health, uncertainty, emotional difficulties, and stigmatization. HCWs reported conflicting thoughts and difficulties about balancing their professional roles and their familiar duties. They referred to the struggles of weighing responsibility and a sense of guilt [7
Current literature describes that HCWs on the front line have proven to be more at risk of developing psychological symptoms and mental health disorders [10
]. Frontline workers are, in fact, directly responsible in the caring process of patients with COVID-19 and have to face peculiar psychosocial risk factors such as the depletion of PPE, lack of specific guidelines of treatment, and feelings of being inadequately supported, which may all contribute to their mental burden [10
Some studies reported that those HCWs who feared infection of their close one’s, reported experiencing high levels of stress, anxiety, and depression symptoms, which could have long-term psychological implications [8
]. A multicenter cross-sectional study on more than 1000 Chinese HCWs evidenced percentages of distress, depression, anxiety, and insomnia of 71.5%, 50.4%, 44.6%, and 34.0%, respectively [11
]. The best evidence based on a systematic review and meta-analyses of 13 studies and a total of 33,062 subjects confirmed that a high number of HCWs are experiencing significant levels of anxiety, depression, and insomnia during the COVID-19 outbreak. The prevalence rates of anxiety and depression were 23.2% and 22.8%, respectively. It appeared that a high proportion of HCWs reported mild symptoms both for depression and anxiety, while on the contrary, moderate and severe symptoms were less common. [3
Nevertheless, in battling SARS, psychological distress among HCWs appeared gradually. In particular, fear and anxiety appeared immediately and decreased in the early stages of the outbreak, but depression, psychophysiological symptoms, and post-traumatic stress symptoms appeared in a second moment and lasted for a long time, leading to a deep impact [13
At the same time, beyond the new burden of psychosocial risk factors, COVID-19 brought also positive elements that should be analyzed. The public response toward HCWs has been globally heart-warming as never before. Numerous testimonies report worldwide expressions of gratitude and closeness to HCWs. The pandemic has put HCWs in the spotlight, and for some, it has been an important positive reinforcement. Others have hypothesized that these peculiar elements related to COVID-19 have somehow buffered the burnout effects, at least in the first phase, giving a profound sense of self-efficacy [15
As previously described, the pandemic has exposed HCWs to several elements derived from completely new work-related circumstances that contribute to a new complex work environment [1
]. In the current healthcare context, signs of occupational stress are an important public health concern [4
]. Repeated exposure to unpredictable challenges in practice may cause, on one hand, symptoms of anxiety, exhaustion, and stress described in working context as compassion fatigue (CF, burnout, and ST) but on the other hand public opinion on HCWs improved and everyone gathered around them in a way without historical precedents [1
]. This second element can be named CS, which is described as the satisfaction experienced by HCWs when performing their work properly, which also includes satisfaction with their relationship with colleagues and the sense that the work they perform is of social value. Unsurprisingly, the balance between CS and CF determines the level of professional quality of life [17
Certain work and personal-related factors may influence quality of life among HCWs. Specifically, CF and CS have already been reported to be related to the healthcare setting and the work environment. Nevertheless, previous studies analyzing these factors do not determine exactly what socio-demographic and work-related variables may influence professional quality of life and HCWs global health [17
What is quite evident is that COVID-19 demonstrates a dramatic gap in the current scientific literature regarding these dimensions and the related mental health of HCWs [24
]. Surprisingly, while Italy has been deeply struck by the pandemic, only two studies provide evidences about the COVID-19 subjective mental experience; Ramaci et al. (2020) report some findings about the effect of social stigma on workers’ psychological well-being to be further ascertained [9
], and Magnavita et al. [27
] show that frequency of anxiety and depression disorders in the population examined were not higher than that commonly recorded during the scheduled checks previous to the epidemic.
Accordingly, it is important for occupational teams to study HCWs health dimensions with both a more detailed characterization of clinical endpoints about baseline workers’ condition before to COVID-19 outbreak and cross-sectional and longitudinal designs.
The scientific community has called for high-quality evidence on the mental health effects of the COVID-19 pandemic across the whole population and vulnerable groups such as HCWs, which has since confirmed that data on this challenging issue are still limited [28
]. In this context, it is therefore an essential contribution to literature in order to better understand the effects of COVID-19 pandemic on HCWs’ outcomes.
In light of what has emerged so far, we believe that the pandemic has brought changes in the HCWs working framework, which seems to be acting both positively and negatively on the psychological equilibrium of HCWs. These theories arise from the literature and from our own clinical experience, since we are a multidisciplinary team responsible for the well-being of hospital HCWs and therefore are in close contact with their psychic feedback, especially in the context of the first Italian emergency phase of the pandemic (Azienza OspedalieroUniversitaria Pisana psicocovid19 protocol
In particular, it is fundamental to analyze whether and how the new COVID-19-related working burden is potentially capable of producing changes to the quality of professional life of HCWs.