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Yong Loo Lin School of Medicine, National University of Singapore, SingaporeDivision of Neurology, Department of Medicine, National University Hospital, Singapore
A major surge in COVID-19 cases despite Singapore's high vaccination has strained the health care system in October 2021. Our aim was to assess and compare Healthcare Worker (HCW) mental well-being in 2021 against a previously published cohort in 2020.
Design
Cross-sectional survey study.
Setting and Participants
HCWs from 4 public hospitals and a primary health care system over a 4-week duration in 2021 coinciding with a major surge compared with a similar period in 2020.
Methods
A survey comprising of the Oldenburg Burnout Inventory (OLBI), Hospital Anxiety and Depression Scale (HADS), and Safety Attitudes Questionnaire (SAQ) was distributed via email. Primary endpoints were the proportion meeting OLBI thresholds for both disengagement and exhaustion and being at risk for both Anxiety and Depression using HADS. Multivariate analysis identified significant predictors among demographic, workplace, and SAQ data. Subgroup analysis of overseas HCWs was performed.
Results
We surveyed 1475 HCWs. Significantly more HCWs met primary outcomes using OLBI and HADS than in 2020 (84.1% and 39.6% vs 68.2% and 23.3%, respectively; P < .001). Burnout levels were uniformly high. A HADS score ≥8 in either subscale was significantly associated with meeting burnout thresholds (P < .001). Overseas HCWs (P = .002), South Asian ethnicity (P = .004), preuniversity educational qualifications (P = .026), and longer shift workhours of 8 to <12 (P = .015) and ≥12 (P = .001) were significantly associated with meeting HADS thresholds. Among overseas HCWs (n=407), seeing family more than a year ago was significantly associated with worse OLBI disengagement scores and a greater proportion meeting HADS thresholds vs seeing them within a year or being local HCWs (47.2% vs 37.2% and 35.6%, respectively; P = .001).
Conclusions and Implications
HCW mental health has objectively worsened between 2020 and 2021 in the pandemic’s second year. Avoiding prolonged shifts, adopting preventive mental health strategies, improving patient safety, and attention to HCWs of minority ethnicity, from overseas, and with preuniversity education may help.
Frontline nurses’ burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19 outbreak in Wuhan, China: a large-scale cross-sectional study.
among health care workers (HCWs) during the COVID-19 pandemic. In 2020, the pandemic was characterized by uncertainty about the disease, high patient loads,
and a lack of robust treatment or preventive options. Reduced physical interaction due to social distancing policies further compounded this by removing the supportive effects of peers and family.
This was especially difficult for overseas HCWs, who comprise a large proportion of several countries' health care workforces and are hindered by travel restrictions.
Indeed, mitigating factors, such as altruism, have emerged as themes during this pandemic, although opinions regarding the extent of their protective effects have been conflicting.
Frontline nurses’ burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19 outbreak in Wuhan, China: a large-scale cross-sectional study.
Grace under pressure: resilience, burnout, and wellbeing in frontline workers in the United Kingdom and Republic of Ireland during the SARS-CoV-2 pandemic.
which has increased uncertainty. Several countries, such as Singapore, are increasingly transiting from a zero-COVID policy to one that accepts COVID-19 endemicity. Despite our high vaccination rates (>85% of Singapore’s population
Outbreak of SARS-CoV-2 infections, including COVID-19 vaccine breakthrough infections, associated with large public gatherings—Barnstable County, Massachusetts, July 2021.
have contributed to a paradoxical surge in cases since the start of the pandemic from less than 0.7 daily cases per 100,000 population (April to August 2020) to a record high of 58.1 (October 2021) (Figure 1). Although about 98% are asymptomatic or mild,
serious cases have risen exponentially from less than 0.04 daily deaths per 1,000,000 population to 1.83 and a previous high of 31 critical care cases to a current peak of 67 over the same time frame.
At present, Singapore’s health care system is strained by a high volume of COVID-19 cases comprising individuals who are unvaccinated or have poor response despite home-based recovery being proposed as the standard of care.
The chronic, unrelenting volume of cases since the start of the pandemic combined with the continuation of restrictions have likely contributed to an exodus of health care workers from our workforce.
As more countries embark on this transition, it will be important to identify contributing factors to HCW mental health, well-being, and burnout in anticipation of possible strains on health care systems. In this follow-up study, we aim to compare the current prevalence of burnout and adverse mental health outcomes in HCWs with that derived from our previous study conducted in 2020 early in Singapore’s COVID-19 experience.
Additionally, we aim to understand the effects on our HCWs from overseas.
Methods
We conducted a multicenter, cross-sectional study and disseminated a survey to all HCWs across 4 public hospitals and a network of primary health care centers (polyclinics) between September 19 and October 19, 2021 (Supplementary Table 1). This time frame coincided with the start of a surge in cases despite reaching milestone community vaccination levels. Health care workers surveyed comprised doctors, nurses, allied health care professionals (AHPs), administrative or managerial staff, and support staff. Support staff referred to nonclinical employees involved in hospital operations (eg, porters, housekeeping, and security staff). As cross-sectional studies are unable to assess temporal relationships between exposure and outcome, we sought to mitigate this by comparing results in an earlier study
collected over a similar duration from May 29 to June 24, 2020, which coincided with the tail end of the first major surge. The survey was distributed to HCWs in the same health care institutions and via the same methods as the earlier study, that is, through a link to a questionnaire platform (FormSG; GovTech, Singapore) which was disseminated via corporate email and snowball sampling by word of mouth. An email reminder was disseminated twice at the middle and toward the end of each study period. This questionnaire was worded in English, which is Singapore’s lingua franca. The first page declared the questionnaire’s aim, its voluntary and anonymous nature, and that implied consent was associated with proceeding with the survey.
We collected basic demographic and workplace environment information data and organized respondents by categories such as (1) HCW roles, (2) gender, (3) ethnicity, (4) redeployment outside primary roles, (5) being tested for COVID-19, (6) primary site of work, (7) if work-from-home or working in offsite facilities was part of their job scope, (8) highest educational qualification, (9) number of workdays and average duration of shifts, (10) vaccination status, and (11) if they were HCWs from overseas. For redeployed HCWs, we further categorized them into (1) redeployed onsite (low risk), that is, not in direct contact with known COVID-19 cases; (2) redeployed onsite (high risk), that is, highly likely to be in direct contact with known COVID-19 cases (eg, emergency department, critical care unit); and (3) redeployed offsite to high-risk areas (eg, foreign work dormitory, community care facility, swab isolation facility).
Responses to three validated questionnaires, that is, Oldenburg Burnout Inventory (OLBI), Safety Attitudes Questionnaire (SAQ), and Hospital Anxiety and Depression Scale (HADS) were collated. These tools have been described in our prior study.
comprises 16 positively and negatively framed questions rated on a 4-point Likert-type scale that are equally divided into 2 dimensions—exhaustion (which refers to feelings of emptiness, overwork, physical exhaustion, and a strong need for rest) and disengagement (which refers to distancing from the objects and content of one’s work) (Supplementary Table 2). An HCW was deemed to be burnt out if the mean score of both domains exceeded thresholds of ≥2.25 for exhaustion and ≥2.10 for disengagement, which have been correlated with physical symptoms.
self-reported questionnaire evaluating Depression and Anxiety with 7 items for each domain (Supplementary Table 3) rated on a 4-point Likert scale scored as 0, 1, 2, and 3. A score of ≤7 is normal, 8-10 is borderline abnormal, and ≥11 is abnormal. An HCW with a score ≥8 in both domains is deemed to be at risk of both depression and anxiety. The SAQ
(Supplementary Table 4) covers 6 patient safety domains (ie, teamwork climate, safety climate, perceptions of management, job satisfaction, working conditions, and stress recognition) rated on a 5-point Likert-type scale comprising 30 core questions common to all versions of the SAQ and some additional relevant questions from the full SAQ bank. Nonclinical HCWs had the option to omit domains that were not relevant. A Safety Culture Score
for each domain was calculated by the formula (Mean value of item scores within a domain – 1) × 25.
A score of 1 is transformed to 0, 2 to 25, 3 to 50, 4 to 75, and 5 to 100. A score of ≥75 is a percentage “agree” for that domain, and a percentage agree rate (PAR) is the proportion of respondents with a percentage agree.
Subgroup analysis was performed on HCWs from overseas as these comprised about 20% of the health care workforce in Singapore.
As overseas travel would mandate prolonged quarantining on return, this was disallowed unless special permission was given to preserve manpower for surge capacity, expansion of COVID treatment facilities, and higher operational tempo. We hypothesized that prolonged separation from family would have adverse mental health effects in this subgroup. We stratified HCWs from overseas based on whether they had seen their families within the last 1 year.
Outcomes
Our primary outcome measures were the proportions of HCWs meeting thresholds for both OLBI exhaustion and disengagement as well as HADS Anxiety and Depression. This recognizes that HCWs meeting thresholds for both domains in each scale likely demonstrated the highest burnout and adverse mental health risks. Secondary outcomes measured included mean HADS and OLBI scores for each domain as well as SAQ PARs overall and for each domain.
Statistics
All analyses were performed using Stata, version 17.0 (StataCorp LLC) with statistical significance set as 2-sided P <.05. Cronbach alphas and confirmatory factor analysis (utilizing root mean square error of approximation, comparative fit indices, and standardized root mean square residual
) demonstrated very good reliability and good model fit for most subscales (Supplementary Table 5).
Multivariate logistic regressions and generalized linear models were used to evaluate for differences in binary and numerical outcomes, respectively, between the 2021 and 2020 cohorts.
Predictors (demographic, workplace characteristics, and SAQ domain scores) for meeting thresholds for both OLBI exhaustion and disengagement domains as well as both HADS anxiety and depression were investigated using generalized linear mixed model with institution as a random effect and presented as adjusted odds ratios (ORs) with 95% CIs. As respondents comprised random samples from each institution, “Institution” was considered as a random factor (clustering effect) to account for the interinstitutional variance contribution and its impact on the P values. Forest plots are shown for the multivariate analyses (Figure 1). A subgroup analysis on HCWs from overseas has been performed (Table 1).
Table 1Comparison of OLBI, HADS, and SAQ Among Overseas HCWs
Local HCWs (n = 1068)
Overseas HCWs
Last Seen Family Within Last Year (n = 45; 11.1%)
Last Seen Family Beyond a Year Ago (n = 362; 88.9%)
Ethics approval with waiver of individual participant consent was obtained from the National Healthcare Group’s Domain Specific Review Board (reference number 2020/00598).
Results
Survey Responses
We had 1475 respondents (response rate 14.5%) (Table 2), with an average age of 36.4 years. Among these, 74.6% were female (1.91% were pregnant) and 67.9% were of Chinese ethnicity (the remainder were of Malay, South Asian, and Other ethnicities in roughly equal proportions). Doctors, nurses, AHPs, support staff, and administrative staff comprised 21.6%, 41.6%, 18.2%, 9.4%, and 9.1% of respondents, respectively. Further, 89.4% worked in a hospital, with the remainder working in a primary care setting. Redeployed HCWs accounted for 14.8% of respondents whereas HCWs from overseas comprised 27.6% of respondents. For highest educational qualification, degree holders and above, preuniversity (ie, associate degrees, diploma, A levels, technical college), and high school and below comprised 80.7%, 15.3%, and 4.0%, respectively. We received valid OLBI and HADS scores for all 1475 respondents, whereas 979 (66.3%) HCWs completed all 6 domains of the SAQ.
Table 2Respondent Demographic, Work Environment Characteristics, and Baseline Measures of Emotional Well-Being
2021, n (%)
2020, n (%)
P
Total
1475
3075
Age, y, mean (SD)
36.37 (10.04)
36.94 (9.95)
.29
Gender
.004
Male
321 (21.8)
794 (25.8)
Female
1100 (74.6)
2199 (71.5)
Not stated
54 (3.7)
82 (2.7)
Ethnicity
<.001
Chinese
1001 (67.9)
1608 (52.3)
Malay
120 (8.1)
401 (13.0)
South Asian
128 (8.7)
410 (13.3)
Others, eg, Filipino, Burmese or from Myanmar, Eurasian, Caucasian, Vietnamese
158 (10.7)
506 (16.5)
Not stated
68 (4.6)
159 (4.9)
Current primary place of work
Hospital
1318 (89.4)
2841 (92.4)
<.001
Polyclinic or general practice
157 (10.6)
228 (7.41)
Not stated
0 (0)
6 (0.20)
Role
<.001
Doctor
318 (21.6)
458 (14.9)
Nurse
614 (41.6)
1394 (45.3)
Allied health professional
269 (18.2)
483 (15.7)
Support staff, ie, cleaners, porters, technicians, security
138 (9.4)
491 (16.0)
Administrative and managerial
134 (9.1)
247 (8.0)
Not stated
2 (0.1)
2 (0.1)
Highest education qualification
<.001
Degree and above
1190 (80.7)
2132 (69.3)
Preuniversity (ie, associate degrees, diploma, A levels, technical college)
226 (15.3)
699 (22.7)
High school or below
59 (4.0)
244 (8.0)
Redeployment to other areas
<.001
Not redeployed
1257 (85.2)
2534 (82.4)
Redeployed
218 (14.8)
541 (17.6)
Within hospital, low risk
81 (37.2)
140 (25.9)
Within hospital, high risk
78 (35.8)
245 (45.3)
Outside of hospital
43 (19.7)
156 (28.8)
Not specified
2 (0.92)
0 (0)
Have you ever been infected with COVID-19?
N/A
Yes
17 (1.2)
Not Surveyed
No
1458 (98.8)
COVID-19 status in the last 1 wk
<.001
Negative
1400 (94.9)
506 (16.5)
Positive
9 (0.6)
21 (0.7)
Do not know or not tested
66 (4.5)
254 (82.9)
Vaccination status
Not Applicable
N/A
Completed 2 doses at least
1456 (98.7)
Completed only 1 dose
9 (0.61)
Not vaccinated
10 (0.68)
Have you treated a COVID-19–positive patient in the past week?
<.001
Yes
332 (22.5)
462 (15.0)
No
1059 (71.8)
2449 (79.6)
Don’t know
84 (5.7)
164 (5.3)
Average duration of your shift or daily work hours?
Compared to the previous study in 2020 (3075 respondents, response rate 27.2%) (Table 2), there was no significant difference in age (mean age 36.37 vs 36.94, P = .29). However, the 2021 cohort had a slightly higher proportion of females (74.6% vs 71.5%, P = .004). Additionally, there were significant differences observed in ethnic composition, primary place of work, HCW role, highest education qualification, redeployment status, latest COVID-19 testing status, recently treating a COVID-19 patient and shift duration (all P <.001).
In the current 2021 study, the average OLBI disengagement and exhaustion scores were 2.65 and 2.78, respectively, with 90.2% and 88.9% reaching threshold in each domain and 84.1% reaching thresholds in both domains. This was significantly higher than in the 2020 cohort, where 68.2% met burnout threshold in both domains (P <.001). The HADS scores also showed a significantly higher proportion of respondents at risk of mental health issues in 2021, with 39.6% meeting thresholds for risks of both anxiety and depression vs 23.3% in 2020 (P <.001). Finally, SAQ scores also showed a significantly poorer PAR in each domain in 2021, with only 16.9% reaching PAR for the total score compared with 25.9% in 2020 (P <.001).
Multivariate Analysis
In the multivariate analysis (Figure 1), we identified having a HADS score of 8 or more for either the anxiety (OR 4.85, 95% CI 2.72-8.65; P = .001) or depression domains (OR 4.85, 95% CI 2.35-10.0; P <.001) to be independently associated with meeting the thresholds for both OLBI disengagement and exhaustion. Furthermore, reaching a percentage agree in the SAQ domains for job satisfaction (OR 0.13, 95% CI 0.07-0.25; P < .001) and stress recognition (OR 0.25, 95% CI 0.09-0.75; P = .014) was negatively associated with meeting burnout thresholds.
For being at risk of both anxiety and depression, independent predictors included being HCWs of South Asian ethnicity (OR 2.13, 95% CI 1.28-3.55; P = .004), having a preuniversity educational certificate as the highest qualification (eg, diploma, A levels, technical college) (OR 3.53, 95% CI 1.16-10.7; P = .026), being an HCW from overseas (OR 1.74, 95% CI 1.23-2.45; P = .002), and working longer workhours per shift (8 to <12 hours: OR 3.21, 95% CI 1.26-8.18; P = .015; and ≥12 hours: OR 7.40, 95% CI 2.65-20.63; P = .001). In the SAQ, having a percentage agree for safety climate (OR 0.68, 95% CI 0.47-0.98; P = .041), job satisfaction (OR 0.41, 95% CI 0.28-0.59; P <.001), stress recognition (OR 0.17, 95% CI 0.04-0.79; P = .024), and working conditions (OR 0.55, 95% CI 0.36-0.84; P = .006) were negatively associated.
Health Care Workers From Overseas
Among 407 HCWs from overseas (Table 1), 362 (88.9%) had last seen their families more than a year ago. OLBI disengagement scores for this group were significantly higher (2.70) compared with local HCWs and HCWs from overseas who had seen their families within a year ago (2.64 and 2.50, respectively) (P = .023), whereas the percentage meeting thresholds for being at risk of depression and anxiety was higher at 47.2% vs 37.2% and 35.6%, respectively (P = .0013). There was no significant difference, however, in SAQ PARs, mean HADS scores, or the proportion meeting OLBI thresholds for both domains.
Discussion
Our study uniquely addresses the longitudinal impacts of a prolonged pandemic posture on HCW mental well-being by comparing outcomes in 2020 and 2021, in the face of a spike of new cases despite high population vaccination rates. We demonstrated that OLBI and HADS mean scores and proportion of HCWs meeting thresholds for burnout and being at risk of both anxiety and depression has increased significantly between 2020 and 2021. The absolute percentage of HCWs meeting these thresholds in 2021 is at a worrying level of 84.1% and 39.6% respectively as opposed to 68.2% and 23.3% in 2020. Additionally, attitudes toward patient safety have also deteriorated, with a significantly lower PAR for the total score (16.9% vs 25.9% in 2020). This is despite increased awareness and the institution of several protective policies
The rapid implementation of a psychological support model for frontline healthcare workers during the COVID-19 pandemic: a case study and process evaluation.
When comparing independent predictors for burnout between our 2020 and 2021 cohort, only reaching threshold HADS scores for being at risk of depression and/or anxiety was common. Other predictors identified in 2020, such as being redeployed, and longer working hours per shift were no longer seen as independent predictors in our present cohort although this is likely due to uniformly high levels of burnout among different subgroups of our study population, limiting the power to detect significant differences.
Regarding adverse mental health outcomes, South Asian ethnicity (a minority ethnic group in Singapore), longer workhours per shift, holding a preuniversity certificate as the highest education qualification, and being an HCW from overseas were independently associated with risk of anxiety and depression. Although some studies have identified people of minority ethnicity as being at risk for mental health issues,
owing to poorly understood religio-cultural aspects, the role of community support, varied minority experiences in different countries, and significant intraethnic heterogeneity. Indeed, in Singapore’s multiethnic context, minorities in non-HCW populations have frequently demonstrated better self-reported mental health.
and contrasts against collectivist cultures with Confucian roots among those of Chinese ethnicity that prioritize social and familial harmony over open displays of emotions.
This reversal of trends may be due to negative impacts of the pandemic on important supportive community, religious, familial, and social networks. This is an area that warrants further study.
Achieving a percentage agree in several SAQ domains had a statistically significant negative association with the primary outcomes. Although the causal relationship between perceptions of patient safety and burnout, depression, or anxiety is unclear, institutional focus on improving patient safety in deficient domains of the SAQ may be protective.
Like our previous study, shifts lasting less than 8 hours may be protective against burnout, highlighting the importance of proper work-rest cycles and prevention of prolonged shift lengths as a potential way to prevent burnout.
Subgroup analysis of HCWs from overseas demonstrated a significant association between prolonged separation from families for longer than a year and higher HADS anxiety and depression mean scores. This supplements the scarce data pertaining to this important and vulnerable group that comprises a significant component of several countries’ HCW workforces.
Finding ways to allow HCWs from overseas to travel by facilitating and prioritizing leave to return home, enabling more efficient quarantining processes (if required), ensuring completion of vaccination, and expanding psychological support may be beneficial.
A very large proportion of our sample was fully vaccinated (98.7%) or undergoing regular SARS-CoV-2 testing (95.5%). This may be attributed to both of these being mandatory workplace requirements in the absence of valid contraindications,
Factors influencing seasonal influenza vaccination uptake among health care workers in an adult tertiary care hospital in Singapore: a cross-sectional survey.
among HCWs. Nevertheless, this reduced the power of our study to determine the effects of these variables on our primary outcomes. The effects of these potentially protective factors should be further evaluated in settings with less HCW vaccination coverage or testing uptake either due to a lack of availability or personal preferences.
Despite an abundance of recommendations on how to combat burnout and adverse mental health outcomes among HCWs, there is limited evidence on their efficacy in this pandemic.
The objective worsening of these outcomes highlights the need for renewed efforts to combat this. This may be through the formal creation of well-resourced internal mental well-being departments dedicated to HCWs at an institutional level with appointed welfare champions spread across departments and health care roles. Our study identified HCWs from overseas and of minority ethnicity as groups vulnerable to adverse mental health outcomes, which we postulate may be due to effects of the pandemic on community support structures. As poorer HADS scores was significantly associated with higher risks of burnout, ensuring good HCW mental health may be protective
and this can be done by increasing access to trained counseling services, encouraging regular mental well-being breaks, disseminating reminders about self-care with emphasis on adequate rest, sleep, recreation, and maintaining connections with loved ones amid hectic schedules.
Psychological and coping responses of health care workers toward emerging infectious disease outbreaks: a rapid review and practical implications for the COVID-19 pandemic.
Policies should be enacted or reinforced at the institutional, state, and national level to guarantee the protection of rest cycles, leave taking, child and family care aspects, and manpower allocations. Factors contributory or indicative of work stress such as shift durations, patient numbers, leave taken, days off, and sick leaves should be tabulated with regular mental health surveys. Redline thresholds for escalation to senior management should be assigned. Finally, targeting deficient patient safety domains as guided by SAQ may complement the above recommendations.
Limitations and Strengths
Although the 2021 study adopted the same methodology and recruitment strategy as the 2020 study over a similar study duration, we unexpectedly had fewer respondents (1475 vs 3075). This may have led to a sampling bias with some differences in baseline characteristics of the respondents. Nonetheless, the distribution of respondents’ age was similar, and these differences were adjusted for when performing multivariate analysis to study the primary outcomes. Furthermore, we sampled the same population that would have faced similar changes in workplace conditions and policies between the 2 study periods. Thus, although a similar response rate with equivalent demographic factors would have been ideal, we feel that our findings remain valid. Various factors may have contributed to our reduced response rate. We postulate that HCWs had reduced ability to respond to survey invitation as workloads in 2021 were significantly higher because of a large surge in COVID-19 cases coupled with a return to prepandemic levels of non-COVID cases.
Significantly more HCWs treated COVID-19–positive patients in our present study (22.5% vs 15.0%). Additionally, because of difficulties with predicting case trajectories, the 2020 study coincided with the tail end of the initial surge whereas the 2021 one coincided with the peak of a much larger one (Figure 2).
Fig. 2Daily new cases and percentage of population fully vaccinated in Singapore.
The majority of studies in the current literature that evaluate mental health outcomes in HCWs during the COVID-19 pandemic are cross-sectional in nature, hence limiting their interpretation of causality. We believe a significant strength in our study is that we attempted to mitigate this by comparing the outcomes with our 2020 cohort. Nevertheless, longitudinal follow-up with individual subjects as part of a prospective cohort study design would have improved our understanding of how this relationship has changed with time. Additionally, mixed methods analysis can be employed to qualitatively understand other relevant factors contributing to these worrying trends.
Conclusions and Implications
Singapore’s paradoxical peak in COVID-19 cases despite high population vaccination rates is a cautionary message to all countries aiming to open their economies and accept COVID-19 endemicity. Furthermore, until global vaccine equality is achieved,
Although HCW burnout and mental health issues have been a perennial problem, it has worsened over this pandemic despite increased awareness and support. Thus, as we transit to a state of COVID endemicity, we may face a second mental health epidemic among HCWs. We urge health care systems to comprehensively audit the state of mental health among their HCWs and to continually evaluate for contributory factors to guide formal steps toward protecting them and keeping health care delivery sustainable.
Acknowledgments
The authors would like to acknowledge and thank Ms Dawn Sim for her assistance in the dissemination of the survey.
Frontline nurses’ burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19 outbreak in Wuhan, China: a large-scale cross-sectional study.
Grace under pressure: resilience, burnout, and wellbeing in frontline workers in the United Kingdom and Republic of Ireland during the SARS-CoV-2 pandemic.
Outbreak of SARS-CoV-2 infections, including COVID-19 vaccine breakthrough infections, associated with large public gatherings—Barnstable County, Massachusetts, July 2021.
The rapid implementation of a psychological support model for frontline healthcare workers during the COVID-19 pandemic: a case study and process evaluation.
Factors influencing seasonal influenza vaccination uptake among health care workers in an adult tertiary care hospital in Singapore: a cross-sectional survey.
Psychological and coping responses of health care workers toward emerging infectious disease outbreaks: a rapid review and practical implications for the COVID-19 pandemic.
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