Sources of Distress and Coping Strategies Among Emergency Physicians During COVID-19

Erin Dehon, PhD; Kori S. Zachrison, MD, MSc; Jennifer Peltzer-Jones, PsyD, RN; Ramin R. Tabatabai, MD; Elizabeth Clair, DO; Michael A. Puskarich, MD; Amy Ondeyka, MD; Katherine Dixon-Gordon, PhD; Lauren A. Walter, MD; Elaine H. Situ-LaCasse, MD; Megan L. Fix, MD

Disclosures

Western J Emerg Med. 2021;22(6):1240-1252.

Abstract and Introduction

Abstract

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has been shown to increase levels of psychological distress among healthcare workers. Little is known, however, about specific positive and negative individual and organizational factors that affect the mental health of emergency physicians (EP) during COVID-19. Our objective was to assess these factors in a broad geographic sample of EPs in the United States.

Methods: We conducted an electronic, prospective, cross-sectional national survey of EPs from October 6–December 29, 2020. Measures assessed negative mental health outcomes (depression, anxiety, post-traumatic stress, and insomnia), positive work-related outcomes, and strategies used to cope with COVID-19. After preliminary analyses and internal reliability testing, we performed four separate three-stage hierarchical multiple regression analyses to examine individual and organizational predictive factors for psychological distress.

Results: Response rate was 50%, with 517 EPs completing the survey from 11 different sites. Overall, 85% of respondents reported negative psychological effects due to COVID-19. Participants reported feeling more stressed (31%), lonelier (26%), more anxious (25%), more irritable (24%) and sadder (17.5%). Prevalence of mental health conditions was 17% for depression, 13% for anxiety, 7.5% for post-traumatic stress disorder (PTSD), and 18% for insomnia. Regular exercise decreased from 69% to 56%, while daily alcohol use increased from 8% to 15%. Coping strategies of behavioral disengagement, self-blame, and venting were significant predictors of psychological distress, while humor and positive reframing were negatively associated with psychological distress.

Conclusion: Emergency physicians have experienced high levels of psychological distress during the COVID-19 pandemic. Those using avoidant coping strategies were most likely to experience depression, anxiety, insomnia, and PTSD, while humor and positive reframing were effective coping strategies.

Introduction

Prior to the coronavirus 2019 (COVID-19) pandemic, physicians struggled with heightened levels of burnout, job dissatisfaction, depression, post-traumatic stress symptoms (PTSS), and suicidal ideation.^[1,2] Over the past year, emergency physicians (EP) were positioned as frontline caregivers for COVID-19, which further escalated challenges and pressure on the healthcare system and its workers.

Studies have shown that pandemics such as severe acute respiratory syndrome (SARS) 2003 and COVID-19 are associated with increased levels of healthcare worker psychological distress, including burnout, anxiety, depression, insomnia, and post-traumatic stress.^[3–10] During the early stages of COVID-19, distress was particularly high in healthcare workers without consistent access to personal protective equipment (PPE)^[11] and those exposed to COVID-19 patients.^[12] A systematic review of 59 internationally diverse studies revealed that psychological distress associated with COVID-19 is a global problem.^[13] Studies of EPs, in particular, show increased levels of psychological distress in response to COVID-19.^[10,14,15] One survey of over 400 EPs revealed increases in work stress, home anxiety, emotional exhaustion, and burnout.^[14]

Given that physicians are experiencing negative effects from the COVID-19 pandemic, it is critical to identify factors influencing physician stress for appropriate interventions to be designed. To date, there is limited data on which interventions have yielded the most success. Of the few published qualitative studies that have investigated potential contributors to physician anxiety, organizational factors such as access to PPE, exposure to COVID-19 at work, uncertainty of organizational support and lack of access to testing, childcare access and up-to-date information and communication were noted as main drivers.^[16]

Current EP-specific literature is limited. Most studies were performed outside the US or in limited geographical areas such as New York City. Additionally, many do not include measures of psychological distress with strong validity evidence. Furthermore, there is not, to our knowledge, any current data focusing on possible positive psychological reactions to COVID-19 or effective coping strategies. Finally, although some studies have looked at factors contributing to clinician stress, none have performed a comprehensive stepwise approach using an assessment of multiple contributory factors. Our aim in this study was to extend prior research by identifying both individual and organizational factors that place EPs at risk for psychological distress during COVID-19. Additionally, we sought to identify any positive effects related to COVID-19 and examine coping strategies used by EPs.

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Table 1. Characteristics of the emergency physicians who participated in COVID-19 survey.
Participant Characteristics	% (n)*
Gender
Male	63% (163)
Female	37% (96)
Age Range
30–40	52% (134)
41–50	30% (78)
51–60	12% (32)
>60	6% (15)
Time of Survey Completion
October 2020	44% (114)
November 2020	38% (99)
December 2020	18% (46)
Current Living Arrangements
Alone	11% (28)
With children	65% (169)
With elderly people	5% (13)
US Region
South	26% (65)
Northeast	15% (39)
Midwest	21% (53)
West	38% (96)
COVID-19's Impact on Mental Health
No negative impact	15% (39)
Small negative impact	41% (104)
Moderate negative impact	32% (81)
Large negative impact	12.5% (32)
Depression Severity; median (IQR)	8 (4–12)
Minimal	50.5% (129)
Mild	36.5% (93)
Moderate	7% (18)
Moderate to severe	5% (13)
Severe	1% (2)
Anxiety Severity; median (IQR)	4 (2–8)
Minimal	54.5% (139)
Mild	32.5% (83)
Moderate	9% (23)
Severe	4% (10)
Insomnia Severity; median (IQR)	4 (1–7)
None	49% (123)
Subthreshold insomnia	36.45% (92)
Clinical insomnia (moderate)	13.5% (34)
Clinical insomnia (severe)	1% (3)
PTSD (specific to COVID-19)
No PTSD	92.5% (236)
PTSD criteria met	7.5% (19)
Obsession with COVID-19
No problematic thinking related to COVID-19	87.5% (210)
Problematic thinking related to COVID-19	12.5% (30)

US, United States; COVID-19, coronavirus disease 2019; IQR, interquartile range.
PTSD, post-traumatic stress disorder.

Table 2. Mental and behavioral health before and during the pandemic.
Compared with how you were doing before COVID-19, how much have you been bothered by the following:	No change	A lot more than usual	A little more than usual	A little less than usual	A lot less than usual
Feeling stressed	15.2% (39)	31.1% (80)	49.8% (128)	3.1% (8)	.8% (2)
Feeling nervous or anxious	24.5% (63)	24.9% (64)	45.9% (118)	4.3% (11)	.4% (1)
Not being able to stop worrying	45% (116)	14.4% (37)	35.8% (92)	4.3% (11)	.4% (1)
Feeling sad	43.2% (111)	17.5% (45)	35.4% (91)	3.5% (9)	.4% (1)
Feeling annoyed or irritable	24.6% (63)	24.2% (62)	48% (123)	3.1% (8)	0
Experiencing lack of motivation	37% (95)	18.7% (48)	39.3% (101)	3.5% (9)	1.6% (4)
Feeling lonely	33.9% (87)	26.1% (67)	35% (90)	3.9% (10)	1.2% (3)
How often did you do the following in the 6 months before COVID-19…	Daily	3–4 days a week	1–2 days a week	1–3 days a month	Never
Exercise	28.1% (72)	41% (105)	20.3% (52)	8.2% (21)	2.3% (6)
Get together with friends	0.8% (2)	11.8% (30)	44.5% (113)	39.4% (100)	3.5% (9)
Get together with family	11.3% (29)	4.3% (11)	28.1% (72)	46.5% (119)	9.8% (25)
Drink alcohol	7.8% (20)	16.8% (39)	34% (86)	28% (70)	15% (37)
How often did you do the following in the past month…	Daily	3–4 days a week	1–2 days a week	1–3 days a month	Never
Exercise	24.5% (62)	31.6% (80)	26.9% (68)	11.5% (29)	5.5% (14)
Get together with friends in person	ND	1.6% (4)	18.1% (46)	54.3% (138)	26% (66)
Get together with friends virtually	4% (1)	1.6% (4)	15.3% (39)	45.5% (116)	37.3% (95)
Get together with family in person	9.8% (25)	4.7% (12)	8.6% (22)	52.9% (135)	23.9% (61)
Get together with family virtually	3.6% (9)	7.1% (18)	20.6% (52)	40.9% (103)	27.8% (70)
Drink alcohol	14.5% (37)	19.9% (51)	23% (59)	23% (59)	19.5% (50)
Burnout	I enjoyed my work. I had no symptoms of burnout.	Occasionally I felt under stress, and I didn't always have as much energy as I once did, but I didn't feel burned out.	I was definitely burning out and had one or more symptoms of burnout, such as physical and emotional exhaustion.	The symptoms of burnout wouldn't go away.	I felt completely burned out and often wondered if I could go on. I was at the point where I needed some changes or needed to seek some sort of help.
Burnout 6 months pre-COVID-19	16% (41)	67.7% (174)	14% (36)	1.9% (5)	0.4% (1)
Burnout past month	10.5% (27)	48.6% (125)	31.9% (82)	4.7% (12)	4.3% (11)

COVID-19, coronavirus disease 2019.

Table 3. Perceived stigma, organizational support, and job stress.
	Disagree	Neither	Agree
Training protection and support
I believe I have had adequate training to deal confidently with the situations that I face in the ED.	15.6%	12.4%	72.1%
I am provided with the PPE that I need.	15.2%	8.0%	76.8%
I believe there was adequate training provided to me in terms of infection control procedures.	25.1%	13.1%	61.8%
I believe that changes in protocols and procedures are communicated clearly to me.	27.1%	10.0%	63%
My work provides emotional support to those who need help.	12%	23.5%	64.5%
I feel appreciated by my employer.	37.4%	14.7%	47.8%
My hospital is supportive.	29.6%	17.1%	53.4%
Job stress
I have had an increase in workload.	25.5%	11.6%	62.9%
I feel more stressed at work.	20.4%	13.9%	65.8%
There is more conflict among colleagues at work.	53.4%	20.7%	25.9%
Perceived stigma
People avoid me because of my profession.	30.4%	13.5%	56.2%
People avoid my family members because of my work.	50.2%	18.3%	31.5%

Note: For the purpose of this table, we combined responses of "strongly disagree" "disagree," and "somewhat disagree" into one "Disagree" category. Responses of "strongly agree" "agree," and "somewhat agree" were combined into one "Agree" category. The full scale was used to calculate total subscale scores.
ED, emergency department; PPE, personal protective equipment.

Table 4. Relationship between pandemic-related factors and psychological distress.
Participant Characteristics	% (n)	Depression			Anxiety			PTSS			Insomnia
Participant Characteristics	% (n)	Median (IQR)	P	Adj. alpha	Median (IQR)	P	Adj. alpha	Median (IQR)	P	Adj. alpha	Median (IQR)	P	Adj. alpha
Surge during time of survey
Yes	27.7% (70)	5 (2–9)			4.5 (1–9.5)			8 (1.5–15)			10 (3.5–13.5)
No	72.3% (183)	4 (2–8)	.19	.017	4 (1–6)	0.08	.017	5 (1–12)	.09	.017	7 (4–11)	.12	.007
Infected with COVID-19 (any time)
Yes	4% (10)	7 (2–12)			5 (2–11)			9 (0–29)			10.5 (5–16)
No	96% (241)	4 (2–8)	.37	.025	4 (1–6)	0.39	.025	6 (1–13)	.46	.025	8 (4–12)	.36	.013
Isolated self from family at any point
Yes	24.5% (63)	6 (3–9.5)			6 (1–7)			10 (2.5–21.5)			7 (4–11)
No	75.5% (194)	4 (1–7)	<.001	.006	4 (1–6)	.003	.006	5 (1–11)	.004	.007	10 (6–14)	.002	.006
Adequate PPE at work (throughout COVID-19)
Yes	41.7% (108)	5 (3–9)			5 (2–7.5)			8 (2–15)			8 (4.5–12)
No	54.8% (142)	4 (1–7)	.03	.007	3 (1–6)	.006	.008	4 (.5–10)	.01	.008	8 (4–12)	.63	.025
Staffing shortages due to COVID-19
Yes	73.2% (183)	5 (2–8)			5 (2–7)			7 (2–15)			7 (4–11)
No	26.8% (67)	3 (1–6.5)	.06	.01	2 (0–5)	.003	.007	3 (1–8.5)	.02	.01	8 (4.5–12)	.41	.017
Ventilator Shortage (throughout COVID-19)
Yes	12% (30)	6 (4–9)			5 (4–8)			10 (5–18)			9 (6–12)
No	88% (219)	4 (2–8)	.05	.008	4 (1–6)	.013	.01	5 (1–12)	.001	.006	8 (4–12)	.28	.01
Access to COVID-19 testing (throughout)
Yes	32.4% (81)	4 (1–7)			3 (1–6)			3 (1–11)			8 (3–11)
No	67.6% (169)	4 (2–8)	.16	.0125	4 (2–7)	.02	.0125	6 (2–14)	.04	.0125	8 (4–12)	.13	.008
Replacement of N95 masks
At least after 1 day	57.6% (144)	5 (1.5–8)			4 (1–7)			5 (1–14)			8 (4–12)
> 1 day or never	42.4% (106)	4 (2–8)	.62	.05	4 (1–6)	.79	.05	6.5 (1–12)	.65	.05	7.5 (4–12)	.87	.05

Note: P values derived from Mann-Whitney U tests. Bolded P values denote statistical significance.
PTSS, post-traumatic stress symptoms; IQR, interquartile range; Adj, adjusted; COVID-19, coronavirus disease 2019; PPE, personal protective equipment.

Table 5. Positive outcomes as a result of COVID-19.
Rate how much you feel you have experienced change in the area described as a result of COVID-19	A great deal	A lot	Moderate amount	A little	None at all
Feel more appreciated by my patients	4.3% (11)	7.4% (19)	22.9% (59)	38.4% (99)	27.1% (70)
Feel more appreciated by society	5% (13)	20.9% (54)	25.2% (65)	38.8% (100)	10.1% (26)
Have a greater sense of job satisfaction	1.6% (4)	8.9% (23)	20.5% (53)	33.7% (87)	35.3% (91)
Have become more enthusiastic about my job	1.6% (4)	5.4% (14)	12% (31)	24.8% (64)	56.2% (145)
Have a greater appreciation for the value of my job	6.2% (16)	16.7% (43)	22.5% (58)	28.7% (74)	26% (67)
Feel an increased sense of togetherness and cooperation among my colleagues	8.9% (23)	19% (49)	28.7% (74)	30.6% (79)	12.8% (33)

COVID-19, coronavirus disease 2019.

Table 6. Three-step hierarchical multiple regression analyses for mental health outcomes.
Outcome	PTSS			Anxiety			Depression			Insomnia
Step	1	2	3	1	2	3	1	2	3	1	2	3
Male	.07	.01	.05	.14*	.06	.10*	.07	.02	.07	.10	.05	.09
Over 40	.01	.07	.06	−.02	.06	.05	−.01	.06	.05	.12	.18**	.17**
Living alone	−.01	.03	.02	.02	.05	.04	.12	.15*	.13*	.07	.09	.07
Living with children	.05	.05	.10	.15*	.15	.19**	.11	.11	.14*	.09	.08	.10
Living with elderly	.03	.00	.03	.05	.01	.03	.06	.02	.04	.05**	.03	.03
Isolated from family	.20**	.12*	.14*	.22**	.12*	.13*	.21**	.13*	.14*	.23*	.17*	.17*
Time of survey	.14*	.09	.06	.18**	.12*	.10*	.15*	.12*	.08	.12	.10	.08
Protection and support		−.04	−.03		−.02	−.01		−.08	−.05		−.04	−.01
Job stress		.23**	.14*		.29**	.21**		.23**	.15**		.14*	.11
Stigma		−.04	−.06		−.02	−.04		−.02	−.04		.07	.06
Obsession with COVID-19		.29**	.04		.28**	.06		.24**	.00		.17*	.06
Fear of COVID-19		.08	.04		.14*	.11		.08	.06		.04	.04
Approach coping			−.05			−.07			−.13			−.14
Avoidant coping			.58**			.52**			.56**			.30**
R squared	.06	.26	.47	.11	.37	.54	.09	.27	.46	.09	.18	.24
R square change	.07*	.19**	.21**	.11**	.26**	.17**	.09**	.18**	.19**	.09*	.09**	.06**

Note: Standardized beta coefficients are reported for comparability. Male is coded as 1, other genders = 2. Over 40 is coded as 2 and less than 40 is 1. Living with and isolation variables are coded as 1 = yes or 2 = no, *P < .05, **P <.01.
PTSS, post-traumatic stress symptoms; COVID-19, coronavirus disease 2019.

Table 7. Multiple regression analyses for coping variables predicting mental health outcomes.
	Mean	SD	Depression	Anxiety	PTSS	Insomnia
	Mean	SD	β	β	β	β
Avoidant coping
Denial	2.17	0.66	−0.08	−0.02	0.03	−0.09
Substance use	2.83	1.34	.04	0.10	0.05	0.01
Venting	3.49	1.30	0.14*	0.23**	0.20**	0.03
Behavioral disengagement	2.55	1.08	0.32**	0.27**	0.27**	0.34**
Self-distraction	4.09	1.32	0.05	0.03	−0.03	0.12
Self-blame	2.91	1.29	0.39**	0.28**	0.42**	0.12
Approach coping
Active coping	4.28	1.90	0.11	0.15**	0.06	0.09
Positive reframing	3.85	1.46	−0.14*	−0.17**	−0.04	−0.09
Planning	4.12	1.65	0.15*	0.17*	0.09	0.12
Acceptance	5.42	1.64	−0.09	−0.06	−0.06	−0.11
Use of emotional support	4.17	1.64	−0.12	−0.02	−0.002	−0.22*
Use of instrumental support	3.58	1.49	0.02	−0.01	−0.01	0.18*
Other
Humor	3.89	1.64	−0.12*	−0.16**	−0.16**	−0.12
Religion	3.47	1.79	0.05	−0.06	0.05	−0.09

Note: Standardized beta coefficients are reported for comparability. *P < .05. **P < .01.
SD, standard deviation; PTSS, post-traumatic stress symptoms.

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Sources of Distress and Coping Strategies Among Emergency Physicians During COVID-19

Abstract and Introduction

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