Immediate impact of the COVID-19 pandemic on the work and personal lives of Australian hospital clinical staff

. Objective. This study investigated the short-term psychosocial effects of the COVID-19 pandemic on hospital clinical staff, specifically their self-reported concerns and perceived impact on their work and personal lives. Methods. Nurses, midwives, doctors and allied health staff at a large metropolitan tertiary health service in Melbourne, Australia, completed an anonymous online cross-sectional survey between 15 May and 10 June 2020. The survey assessed respondents’ COVID-19 contact status, concerns related to COVID-19 and other effects of COVID-19. Space was provided for free-text comments. Results. Respondents were mostly concerned about contracting COVID-19, infecting family members and caring for patients with COVID-19. Concerns about accessing and using personal protective equipment, redeployment and their ability to provide high-quality patient care during the pandemic were also reported. Pregnant staff expressed uncertainty about the possible impact of COVID-19on their pregnancy. Despite their concerns, few staff hadconsidered resigning,and positive aspects of the pandemic were also described. Conclusion. The COVID-19 has had a considerable impact and personal lives hospital clinical staff. Staff, would benefit from and support initiatives that address their


Introduction
The outbreak of COVID-19 is having, and will have, a considerable impact on health services in Australia and internationally. Health services in Australia implemented several measures in response to the outbreak aimed at protecting employees while providing best care for patients, including clinical testing and infection control measures such as the use of personal protective equipment (PPE), cancellation or postponement of patient clinics and elective surgeries, limited access for hospital visitors and suspension of volunteer programs (https://coronavirus.wh.org.au). The COVID-19 pandemic has also had an effect on many other aspects of society, including education, employment and the economy. Australia's federal, state and territory governments introduced lockdown restrictions in March 2020 in order to slow the spread of COVID-19, including the closure of schools and businesses (https://www.australia.gov.au).
To date there have been few studies about the psychosocial effects of this type of disease outbreak on health service staff. Previous research about the experiences of health service staff during the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003 suggests that staff were concerned about their risk of infection 1 and exposing their friends, family and colleagues to SARS. 1 Positive aspects of the SARS outbreak were also reported, including increased awareness of infection control and a sense of togetherness and cooperation. 2 Evidence is emerging about the psychological impact of COVID-19 on healthcare workers, [3][4][5][6][7][8][9] but little is known about their specific COVID-19-related concerns and the perceived impact of the pandemic on their work and personal lives, particularly for hospital clinical staff during the first wave of the pandemic in Australia (late January 2020-May 2020; https:// covid19.who.int/region/wpro/country/au). Identification and understanding of hospital clinical staff's COVID-19-related psychosocial concerns and the impact of the pandemic on their work and personal lives will help in the development and implementation of appropriate well-being and support initiatives. Without adequate support, staff may resign from their jobs, be absent from work, become unwell or be unable to provide high-quality care for their patients.
The aim of this study was to investigate the immediate psychosocial effects of the first wave of the COVID-19 pandemic on hospital clinical staff in Australia. The specific objectives of the study were to assess: (1) clinical staff's selfreported concerns about COVID-19; (2) the impact of the pandemic on their work and personal lives; and (3) differences in concerns and impacts between discipline groups (nursing and midwifery, allied health (AH) staff, doctors).

Design, setting and participants
A brief self-administered anonymous online cross-sectional survey was administered to clinical staff (nurses, midwives, AH staff, doctors) who were employed at the study health service during the recruitment period (15 May-10 June 2020). The health service is located in metropolitan Melbourne, Australia. It includes three acute hospitals, a day hospital, a transition care program and a drug and alcohol service, and provides acute tertiary services, subacute care, specialist ambulatory clinics and community health services.
The study was conducted during the first wave of the pandemic in Australia; at this time, the state of Victoria was in Stage 3 restrictions, 10 which included limits on indoor and outdoor gatherings (up to five visitors in the home, groups of up to 10 people outdoors), physical distancing, remote learning for schoolaged children and working from home for non-essential workers. Up until 15 May 2020, there had been 1543 cases of COVID-19 in Victoria (most in metropolitan Melbourne) and 18 deaths; nine people were in hospital, including seven patients in intensive care, 11 including some at the study health service. During data collection, the health service was affected by two COVID-19 clusters in the region, one from a fast food restaurant and one from a meat processing facility.

Procedure
All nurses, midwives, doctors and AH staff were invited by email sent via distribution lists for each clinical discipline to complete an online anonymous survey available on Qualtrics (Qualtrics, Provo, UT, USA), an online survey platform. A reminder email was sent 2-3 weeks later.
The self-report survey was informed by published studies on the effect of similar infectious diseases (e.g. SARS, Middle East Respiratory Syndrome Coronavirus (MERS-CoV)) on the psychosocial well-being of health service staff 1,2,12-15 and the clinical experience of the research team.
The survey included mostly fixed-response questions assessing: (1) sociodemographic and employment characteristics (see Table 1); (2) symptoms of depression, anxiety and stress in the past week (these findings have been reported previously 4 ); (3) one fixed-response question about exposure to or contact with COVID-19; (4) six items about concerns related to the effects of COVID-19 on personal and family health, rated using a fivepoint Likert scale ranging from 'not concerned' to 'extremely concerned'; (5) nine items assessing the impact of COVID-19 precautionary measures, rated using a three-point Likert scale ranging from 'does not affect my ability to do my job' to 'affects my ability to do my job a lot'; and (6) 15 items on work impacts and 11 items on personal impacts of COVID-19, each rated on a five-point Likert scale ranging from 'strongly disagree' to 'strongly agree'.
For analysis and in order to avoid low cell counts for smaller cohorts, responses to Likert-scale items were recoded to binary variables for concerns related to the effects of COVID-19 on personal and family health ('not concerned' or 'extremely/very concerned'), the impact of COVID-19 precautionary measures ('does not affect my ability to do my job' or 'affects my ability to do my a job a lot/a little') and the work and personal impacts of COVID-19 (disagree' or 'strongly agree/agree'). Space was also provided at the end of the survey for respondents to make free-text comments.

Data management and analysis
Data were analysed using IBM SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarise the data.
Chi-squared tests were used to test for differences between discipline groups (nursing and midwifery, AH staff, doctors), comparing column proportions. Bonferroni corrections were applied to adjust for multiple tests. 16 Free-text comments were analysed using content (conceptual) analysis in order to identify the presence and meaning of certain themes or concepts. 17 The findings have been used to complement the quantitative data and illustrative quotes have been provided for each theme identified and to highlight the findings.

Ethical considerations
The email invitation to complete the survey included a participant information sheet. Completion of the survey was taken as implied consent. The study was approved by the Western Health Low Risk Ethics Panel (HREC Reference no. HREC/20/WH/ 62913, 5 May 2020).

Sample and response
Approximately 4530 clinical staff are employed by the health service. Of the 668 (15%) respondents, 618 completed all sections of the survey and were included in analyses.
More than half the respondents (n ¼ 358; 57.9%) were nurses or midwives; the remainder were AH staff (n ¼ 135; 21.8%) and doctors (n ¼ 125; 20.2%). Most respondents were female, born in Australia and employed on a part-time basis; approximately one-third lived with school-aged children (Table 1).
In all, 335 free-text comments were provided by respondents: 261 (77.9%) from nurses and midwives, 38 (11.3%) from AH staff and 36 (10.7%) from medical staff. Respondents' free-text comments included elaboration on the fixed-response questions and identification of other concerns and impacts of COVID-19 that were not specifically asked about in the survey ( Table 2).

COVID-19 contact status
Three respondents had been diagnosed with COVID-19, and 108 (17.5%) had been in direct contact with people (in the community and/or at work) with a COVID-19 diagnosis and had experienced associated self-isolation and testing (with negative results).

Self-reported concerns about COVID-19
More than half the respondents were (extremely or very) concerned about passing COVID-19 on to family members and their family's health, and more than one-third were extremely or very concerned about caring for a patient who had or had suspected COVID-19. Significantly more nurses and midwives were extremely or very concerned than other clinicians for each of the six concerns items (Table 3).
Free-text comments outlined participants' concerns about exposing their family members to COVID-19 and having contact with patients who were asymptomatic ( Table 2).

Use and effects of COVID-19 precautionary measures
Respondents reported that certain COVID-19 precautionary measures, such as PPE, interfered with their ability to do their job. Over two-thirds of respondents reported face shields, social distancing from colleagues and not being able to have face-toface meetings or gatherings affected their duties. AH staff and doctors were significantly more likely than nurses and midwives to indicate that social distancing from colleagues, restricted face-to-face meetings and wearing gloves affected their work a lot or a little. Doctors were more likely than other clinicians to report that the use of face shields, masks and goggles and having to self-isolate after an overseas trip affected their ability to do their job. AH staff were more likely than the other two groups to report that staying away from work if they had any signs of illness and restricted access to some or all hospital sites affected their ability to do their job (Table 4).
Free-text comments also highlighted the effects that these precautionary measures had on participants personally, and on their ability to provide high-quality patient care and communicate with patients (Table 2).

Work impacts of COVID-19
Most respondents were concerned about the risk of getting COVID-19 as a result of their job; almost two-thirds felt more stress at work than they normally did, and more than half reported having to do work tasks that they would not normally do. However, respondents reported that the COVID-19 pandemic had also had some positive work impacts. Many respondents indicated that COVID-19 had been a learning experience, they had increased their awareness and knowledge of disease control and that there was an increased sense of togetherness and cooperation among staff. Only a small proportion of respondents indicated that they had considered resigning as a result of COVID-19 (Table 5).
Doctors were significantly more likely than AH staff to agree that their job puts them at risk of COVID-19. AH staff were significantly more likely than the other groups to strongly agree or agree that they have had to do work tasks that they would not usually do and had to retrain or complete training courses for these roles or jobs. AH staff and doctors were significantly more likely than nurses and midwives to strongly agree or agree that they had to cancel or postpone their annual leave because of the COVID-19 outbreak and felt disappointed as a result, and that they had been less busy than usual. AH staff and nurses and midwives were significantly more likely than doctors to strongly agree or agree that they did not feel very prepared to care for patients with COVID-19 (Table 5).
Several respondents provided comments about the effect that redeployment had on their work lives during the pandemic, as  well as the effect of COVID-19 on their ability to provide highquality patient care. Positive aspects of the pandemic were also outlined in respondents' free-text comments ( Table 2).

Personal impacts of COVID-19
Most respondents (.80%) agreed that they had avoided public or crowded spaces and interacting with friends and extended family, and that COVID-19 had affected their personal and family's lifestyle. Three-quarters indicated that people close to them were concerned about their health. Nurses and midwives were significantly more likely than other groups to agree that that they avoided telling people that they worked at a hospital, and that they had a greater appreciation of life and work ( Table 6). Respondents also provided comments about the impact of COVID-19 on their personal lives, including effects on their physical and mental health. Many female respondents articulated their uncertainty and concerns about being pregnant during the pandemic. Respondents also wrote comments about the impact COVID-19 was having on other aspects of their personal lives, such as their financial situation and the difficulties managing work and remote learning for school-aged children ( Table 2).

Discussion
The first wave of the COVID-19 pandemic has had a considerable effect on the personal and work lives of Australian hospital clinical staff. The respondents in this study identified challenges in their work lives, such as a risk and fear of being exposed to COVID-19, problems associated with accessing and using PPE, redeployment and barriers to providing high-quality care for COVID-19-infected and non-infected patients. They also identified that the pandemic had a major effect on their personal lives, including potentially infecting family members with COVID-19, financial concerns, remote learning for schoolaged children and uncertainty about the possible impact of COVID-19 on pregnancy.
Differences between the discipline groups were identified. Nurses and midwives expressed more concern than clinicians from the other groups about caring for patients with COVID-19 and the risk to themselves and their families; AH staff reported more concerns about redeployment, having to retrain and do tasks they normally would not perform, as well as limiting work across hospital sites; and, although doctors were less concerned than nurses and midwives about falling ill with COVID-19, they were more likely to feel that their job put them at risk and that PPE affected their ability to do their job.

Exposure to COVID-19
Similar to the findings of other studies conducted during the COVID-19 pandemic 9,18-20 and outbreaks of other infectious diseases, such as SARS, 1,2,21,22 MERS 15 and the H1N1 strain of influenza, 23,24 two of the most frequently reported concerns among respondents in this study were the impact of COVID-19 on their own health and the risk of infecting friends, family and colleagues due to their clinical role. These concerns are justified because healthcare workers are at increased risk of COVID-19 infection through their occupational exposure, 25,26 and are likely to be aware of the risks of COVID-19 to their own health given the effects of other infectious disease outbreaks, such as SARS, on healthcare workers' health. A substantial proportion of COVID-19 cases in Victoria and overseas has been among healthcare workers; 25,27,28 as of 18 November 2020, 17.6% (3574) of the total number of COVID-19 cases in Victoria (20 345) were healthcare workers 27,29 (earlier data relevant to the study period are not available). Almost three-quarters of the Victorian healthcare worker cases were acquired in a healthcare setting. 27 Exposure to, and deaths from, COVID-19 among healthcare workers have also been widely reported in the media. 30,31 Redeployment Health services have had to make many changes to the working arrangements of their staff during the COVID-19 pandemic in order to ensure adequate staffing and the provision of care for infected patients, including the redeployment of clinical staff to other areas and the implementation of infection prevention and control strategies, such as PPE. 26 Over half the respondents in this study reported changes to their regular work tasks during the first wave of the COVID-19 pandemic, which is consistent with the findings of other studies of the effects of infectious disease outbreaks on healthcare workers. 2,9,18 Redeployment has implications for staff, including loss of connection with work colleagues, potential stress of performing new tasks and being assigned to work areas that may not align with a person's choice of occupation.

Resignation
In order for health services to respond to a pandemic or an infectious diseases outbreak, they need to maintain an adequate workforce, including ensuring sufficient staff while employees are isolating and awaiting test results. Very few (11.6%) of the respondents in this study had considered resigning because of COVID-19. This is a similar proportion to that reported among healthcare workers in Singapore during the bird flu pandemic (15%). 24 Consistent with these findings, less than 10% of hospital physicians in a Canadian study stated that the SARS outbreak had caused them to re-evaluate their career choice, 21 and only a small proportion (4.3%) of Greek healthcare workers during the A/H1N1 influenza pandemic reported that they would take leave from work to avoid infection. 23 Several studies have found that healthcare workers believe it is their professional duty and ethical obligation to continue to provide care for patients during pandemics, despite the potential risks to themselves or their families. 15,21,23,24,[32][33][34] The COVID-19 pandemic has also had an impact on the Australian economy and it is estimated that over 300 000 jobs may be lost in the state of Victoria due to the pandemic. 35 Healthcare workers may be more likely to remain in their current positions if they perceive that there are few other available jobs. It should be noted that data for this study were collected during the first wave of the pandemic in Australia.
Respondents' intentions may change during later waves of the pandemic as a result of caring for more infected patients and being infected themselves.

Risk for clinicians' families
Family responsibilities and other life stressors continue, and may be exacerbated, for healthcare workers during infectious disease outbreaks. 36 The respondents in this study identified difficulties managing their paid work and family responsibilities during the pandemic, including supervising school-aged children who were at home undertaking remote learning. Pregnant women are often particularly vulnerable during outbreaks of infectious diseases. 37 Little is currently known about the impact of COVID-19 on pregnant women and their babies. 38 Similar to the findings of a recent rapid review about the psychological impact of infectious disease outbreaks on women who were pregnant at the time of the outbreak, 37 pregnant staff in this study reported occupational and health concerns, including uncertainty about the risk of COVID-19 to their health and that of their baby and a lack of information and advice about working while pregnant during the pandemic.

Strengths and limitations
A large and diverse sample of hospital clinical staff, including nurses, midwives, AH staff and doctors, was surveyed for this study. The proportion of respondents from each clinical discipline group is broadly representative of the proportion in the health service: approximately two-thirds (66%) of the clinical staff at the health service are nurses and midwives and one-quarter (26%) are doctors. AH staff were overrepresented in the study sample; the proportion in the health service is approximately 7%. Although the response rate was relatively low, it is similar to that of other survey-based studies conducted during an infectious disease outbreak. 13 Staff were only able to be invited to participate in the study via email, and the survey had to be completed online due to infection control protocols at the health service.
The study was conducted at one large metropolitan health service in Australia and therefore the results may not be generalisable to other health services or settings.
The study design was cross-sectional. Therefore, causal relationships cannot be determined.
Data collection was only conducted at one time point in order to minimise participant burden and the impact on essential clinical care. Given that the perceptions and experiences of health service staff are likely to vary at different stages of the pandemic, follow-up surveys will be conducted in order to understand the long-term effects of the pandemic on Australian hospital clinical staff.

Implications for health policy and practice
In order to manage and mitigate the psychosocial effects of the COVID-19 pandemic and help health services assist and retain their staff, hospital clinical staff need appropriate interventions and support. 39,40 The health service in this study and the Victorian State Government implemented several well-being initiatives to support health service staff during the pandemic (https://coronavirus.wh.org.au/wellbeing-support). 41 This study found that although similar concerns were identified by respondents from all clinical discipline groups, there were also differences between groups. Accordingly, the findings of this study indicate that many staff would benefit from further targeted (e.g. by discipline group) initiatives that address (or help them manage) their work and personal concerns, particularly their fears about their own health and the risks to their families. Staff who are pregnant would especially benefit from evidencebased information and support addressing their specific needs and concerns.

Future research
The findings of this study indicate that the COVID-19 pandemic has had a considerable impact on the work and personal lives of hospital clinical staff. However, little is known about the psychosocial effects of this outbreak on other types of healthcare workers, 39 such as those in primary care practices or community health services who undertake various roles, including education, advocacy and clinical services, and work with a range of communities, including those that experience disadvantage and are culturally and linguistically diverse, many of whom have been disproportionally affected by COVID-19. Many community and primary care health services have also provided COVID-19 services, such as respiratory clinics, testing sites, care for positive patients in a community setting and working with vulnerable people in high-risk accommodation settings. Future research is needed to gain a greater understanding of the impact of the pandemic on healthcare workers in different services and settings so that appropriate and targeted support initiatives can be implemented.

Conclusion
The COVID-19 pandemic has had a considerable impact on the work and personal lives of hospital clinical staff. Pregnant staff reported particular concerns about the uncertainty of being pregnant during the pandemic. Despite their concerns, few staff reported considering resigning from the health service, and positive aspects of the pandemic were also described. The findings of this study indicate that staff would benefit from targeted psychoeducational, social and occupational initiatives and support that address their psychosocial concerns.