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PoST-trAumaTic STRess DisordEr SymptomS

in hospital workers during COVID-19

A regional online survey evaluating the incidence of self-reported symptoms of post-

traumatic stress disorder (PTSD) and post-traumatic growth amongst hospital

workers in the West Midlands during the Covid-19 pandemic.

Twitter: @StatStress

Website: TBC

E-mail: statstress@gmail.com

The Protocol

Protocol version: 1.5

Protocol date: 28/05/2020

Short title: STAT-STRESS COVid19

IRAS ID: 285181

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Principal Investigator:

1. Dr Kasun Wanigasooriya, General Surgery Registrar, West Midlands Deanery,

E-mail: kasun.wanigasooriya@nhs.net

Co-investigators:

1. Dr Jodie Fellows – Consultant Clinical Psychologist, University Hospitals Birmingham

NHS Foundation Trust

1. Dr Priyanka Palimar, Consultant Child Psychiatrist, Forward Thinking Birmingham, UK

Senior leads and supervision:

2. Dr Jodie Fellows – Consultant Clinical Psychologist, University Hospitals Birmingham

NHS Foundation Trust

3. Mr Tariq Ismail – Consultant Surgeon, University Hospitals Birmingham NHS Foundation

Trust

4. Dr David Naumann, General Surgery Registrar, West Midlands Deanery, UK, E-mail:

david.naumann@nhs.net

5. Dr Priyanka Palimar, Consultant Child Psychiatrist, Forward Thinking Birmingham, UK

6. Mr Chris V Thompson – Consultant Surgeon, Sandwell West Birmingham NHS Trust

Collaborators:

Professor Khalida Ismail – Professor of Psychiatry and Medicine, Kings College London

Professor Andrew Beggs – Professor of Cancer and Genomics, University of Birmingham

The Steering committee: K Wanigasooriya, D Naumann, P Palimar

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A summary overview of this survey:

Title Post-Traumatic Stress Disorder Symptoms in hospital workers during

Covid-19

Short title STAT-STRESS COVid19

Aim To assess post-traumatic stress disorder (PTSD) symptoms amongst acute

hospital workers (clinical as well as non-clinical) in the West Midlands working

during the Covid-19 pandemic and to assess changes to the prevalence of

these symptoms over time amongst these workers.

Primary objective To establish the prevalence of PTSD symptoms amongst hospital workers in

the West Midlands

Secondary objectives Job specific variations in the Impact of Event Scale - Revised (IES-R)

PTSD symptom score

Job specific variations in Generalised Anxiety Disorder Score 2 (GAD-2)

and Public Health Questionnaire 2 (PHQ-2) scores

Changes to ISE-R, GAD-2, PHQ-2 scores over time in these hospital

workers

Changes to the Post-Traumatic Growth Inventory (PTGI) score over time

and amongst different hospital workers

To obtain a measure of access to mental health support and resources

Incidence of unplanned leave during this period due to mental health issues

Design A regional online survey which utilises the validated IES-R tool to self-report

PTSD symptoms, symptoms of anxiety, symptoms of depression amongst

hospital workers, as well as their post-traumatic growth following the Covid-19

pandemic. A subsequent follow up survey at 6 months and 12 months will also

assess changes to these symptoms.

Participants Inclusion Criteria:

All clinical and non-clinical (employees or volunteers), who worked on

site at a secondary or tertiary care hospital (including acute mental health

hospitals) in the West Midlands at any point on or after the 23/03/20 (the

start date of UK Coronavirus lockdown) to the 23/05/2020

Hospitals must be a NHS site and must have contained occupied

inpatient beds during the time period specified above

Locum and agency workers, volunteer and students exposed to the

clinical environment during this time may take part

Any hospital workers who meet all of the above criteria but have since

taken sick leave or maternity leave may also take part in this survey.

Exclusion criteria

Hospital workers who were on maternity, sick, compassionate or other

leave for the entirety of the lockdown period (23/03/20 – 23/05/20)

Hospital workers practicing or working outside of the West Midlands

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Introduction

Background

Covid-19 is caused by the novel coronavirus SARS-CoV-2 and has caused significant

changes in the social and working conditions of healthcare workers since the start of the

pandemic. The current pandemic may have detrimental effects on the mental health and

wellbeing of many people around the world (1). Studies have reported a higher prevalence of

mental health conditions including post-traumatic stress disorder (PTSD) amongst

healthcare workers compared to the general population (2, 3). Hospital workers around the

world continue to deal with increasingly stressful, often traumatic life and death situations in

a rapidly changing clinical environment, during this Covid-19 pandemic. They have been

tirelessly looking after patients, exposing themselves, their family and friends to the risk of

novel coronavirus infection. Many have also had to cope with critically unwell family and

friends. Many are also grieving the loss of loved ones and colleagues (4).

Acute stress and post-traumatic stress disorder

Traumatic experiences (which can include witnessing, hearing about or other indirect

exposure to actual or threatened death) may lead to symptoms of acute stress disorder such

as difficulty concentrating, sleeping and mood disturbance. For the majority of people these

symptoms will resolve within 4 weeks and will therefore not develop into PTSD and may

indeed become more resilient as a result of having survived. PTSD symptoms occur when

details of a traumatic or stressful experience are not processed from implicit memory to

explicit memory. They are therefore stored inappropriately resulting in the event(s) still

feeling “current” for months to years after. This manifests as involuntary retrieval of trauma

memories via nightmares, intrusive memories, negative impacts on thoughts and mood, and

All community based health and social care workers, workers from non-

acute hospital healthcare provider sites; unless they were working or

volunteering at a secondary or tertiary care hospital site for majority of

the working week.

Students, volunteers or apprentices who were not exposed to the clinical

environment

Staff working from home from the 23rd of March 2020

Other members of the general public

If you are under 18 years of age

Sample size 2000

Duration Data collection will continue for a 6 week period

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results in impairments in social or occupational functioning. These symptoms need to be

present for a minimum of 6 months to result in a full diagnosis of PTSD, however identifying

those experiencing for over one month may identify those potentially at risk of developing

PTSD. It may help those with impaired functioning to recognise need and will help those

planning services to meet this need to determine the likely level of service required.

Healthcare workers

The prevalence of PTSD amongst healthcare workers has been extensively researched

across different specialities (2). Previous studies have shown a significant increase in PTSD

amongst healthcare workers following the 2003 SARS outbreak in Asia (5). Two early

studies conducted during the current Covid-19 pandemic observed an increased reporting of

PTSD symptoms amongst healthcare workers from China, India and Singapore (6, 7). Early

identification of PTSD symptoms can be an indicator of other underlying associated mental

health conditions such as anxiety and depression (8). The true extent of the mental health

impact of the Covid-19 pandemic on hospital workers in the UK is yet to be confirmed.

The West Midlands, which saw the highest incidence and mortality of Covd-19 cases after

London, is also home to several acute hospital trusts where tens of thousands of staff are

based. These employees were directly exposed to and continue to experience the stressors

of Covid-19. West Midlands also has a very diverse ethnic minority population. Therefore,

the local healthcare worker population serves as representative and generalizable sample

for any healthcare study. It is also essential to address the mental health needs of hospital

employees initially at a local level to ensure the retention of an efficient workforce at this

critical time. An early assessment of the level of PTSD symptoms could serve a valuable

resource to local and national level policy makers to ensure adequate resources and support

is available for their staff, in order to effectively address the mental health needs relating to

PTSD and other mental health problems amongst hospital workers following the aftermath of

this pandemic.

Aims and objectives:

Using a voluntary online survey that utilises validated self-report mental health symptom

questionnaires, we aim to record and quantify the prevalence and severity of self-reported

PTSD, depression and anxiety symptoms amongst hospital workers on duty during the peak

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of the Covid-19 pandemic (23/03/20 – 23/05/20) in the West Midlands. The survey will

assess variations in observed PTSD symptoms across different employee groups and

specialities as well as assess the impact Covid-19 has had on their personal and

professional lives. The survey will also explore post traumatic growth amongst hospital

workers over time following the Covid-19 pandemic. The follow up survey conducted at 6

and 12 month intervals will provide insight into the changes to the mental health of these

hospital workers over time.

The primary objective of this survey is to ascertain the immediate prevalence of PTSD

symptoms amongst hospital workers in the West Midlands during the Covid-19 pandemic.

Secondary objectives of this survey include:

o Investigate job specific variations in symptoms of mental health conditions (using

the Impact of Events Scale-Revised (IES-R) - PTSD, Generalised Anxiety

Disorder Score 2 (GAD-2) - Anxiety and Public Health Questionnaire 2 (PHQ-2) –

Depression, immediately following the pandemic and over time

o Changes to the Post-Traumatic Growth Inventory (PTGI) score over time and

amongst different hospital workers

o Obtain a measure of availability of support and access to mental health support

and resources for hospital workers in the region

o Assess the impact of Covid-19 on the mental health of hospital workers over time

across different employee groups

o Investigate the use of unplanned leave during the peak pandemic period and in

the 12 months after, due to mental health issues

Hypotheses

1. Significant difference in self-reported IES-R scores between clinical versus non

clinical hospital workers.

2. Significant difference in self-reported IES-R score between different ethnic groups

3. Significant differences in PHQ-2 and GAD-2 scores between clinical versus non

clinical workers and different ethnic groups.

4. Significant self-reported impact on personal and professional life during the Covid-19

pandemic

5. Allowing for comorbidities no significant difference in ISE-R, PHQ-2, GAD-2 scores

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6. Significant rise in IES-R, PHQ-2, GAD-2 scores over time amongst different groups

of hospital workers who were working during the Covid-19 pandemic.

7. Significant differences in PTG-I scores measured over time and amongst different

groups of hospital workers

Ethical approval

As per the UK health research authority (HRA) this observational survey which involves

hospital workers recruited on the basis of their professional role does not require research

ethics committee review but may require HRA approval. We are currently in the process of

seeking sponsorship to apply for fast-track HRA approval.

Funding

No external funding has been received for this project at present

Methods

Survey design and distribution

The survey will comprise of an index primary survey conducted immediately after exposure

period (after the 23/05/20), a follow up survey at 6 months and a further survey at 12 months

after the exposure for consenting participants.

All three surveys will be conducted online using SurveyMonkey™ (San Mateo, California,

USA) commercial survey design tools. The initial survey will be promoted via social media

platforms such as Twitter (San Francisco, California, USA) and Facebook (Menlo Park,

California, United States) and promoted using geographically targeted paid social media

advertising campaigns on the above platforms.

The initial survey which takes approximately 20-30mins to complete will include the following

sections:

Confirm inclusion criteria and participant eligibility, access to resources and information

Demographics – Age, gender, ethnicity, marital status

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Self-reported baseline risk factors - History of mental health issues, comorbidities and

lifestyle factors (smoking, alcohol), family composition (dependents)

Employment details (non-identifiable) – location of employer, no of inpatient beds

Exposure confirmation – Employment (PPE availability, primary sub-location of work

within hospital, measure patient contact, working hours, emphasis on mental health

wellbeing and support by employer), Other (affected family or friends, bereavements,

loss of usual support)

Impact on personal and professional life including absences due to mental health and

accessing help, resources

Self-report PTSD symptoms using the Impact of Events Scale-Revised (IES-

R) questionnaire

Self-reported GAD-2 and PHQ-2

Post-traumatic growth measure using PTGI

Conclusion address and linked email address to send a follow up survey

The follow up surveys at 6 and 12 months will comprise similar questions to the index

survey including the IES-R, GAD-2, PHQ-2 symptoms self-reporting tools and the PTGI. The

several additional questions in the two follow up surveys will explore sick leave taken since

the exposure, subsequent diagnosis of mental health conditions during the follow up period

and further impact on professional or personal life (e.g. unemployment, loss/ decline in

income, changes to relationship status).

Please see Appendix A for a full list of questions included in this survey.

Inclusion Criteria:

All clinical and non-clinical (employees or volunteers), who worked on-site at a

secondary or tertiary care hospital (including acute mental health hospitals) in the West

Midlands at any point from the 23/03/20 (the start date of UK Coronavirus lockdown) to

the 23/05/2020

Hospitals must be NHS sites and must have contained occupied inpatient beds during

that time

Locum and agency workers, volunteer and students exposed to the clinical environment

during this time may take part

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Any hospital workers who meet all of the above criteria but have since taken sick leave

or maternity leave may also take part in this survey.

Exclusion criteria

Hospital workers who were on maternity, sick, compassionate or other leave for the

entirety of the lockdown period (23/03/20 – 23/05/20)

Hospital workers practicing or working outside of the West Midlands

All community based health and social care workers, workers from non-acute hospital

healthcare provider sites; unless they were working or volunteering at a secondary or

tertiary care hospital site for majority of the working week.

Students, volunteers or apprentices who were not exposed to the clinical environment

Staff working from home from the 23rd of March 2020

Other members of the general public

Participants under the age of 18

Target population

We estimate a sample size of approximately 2000 participants will take part in this survey.

Duration

We anticipate the survey to be open for a minimum 2 month period to obtain the desired

sample size.

Key design considerations

Participation in this survey is completely voluntary. Employer identifiable information will not

be collected. All data will be collected and stored securely on SurveyMonkey™ webservers,

accessible only to pre-authorised members of the steering committee. The scores from the

ISE-R, GAD-2, PHQ-2, PTGI will not be provided to the participants. This survey will only be

used for data collection for research and not as a diagnostic tool. This will be made clear to

the participants. A voluntary opt-in option for email address submission will be provided to

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participants at the end of the survey to disseminate anonymised final results as well as a

follow up survey in 6 months and 12 months (voluntary participation only). The email

addresses will be stored and processed on the SurveyMonkeyTM and Mailchimp™ (Atlanta,

Georgia, USA) servers by pre-authorised members of the steering committee in compliance

with the European Union, General Data Protection Regulations (GDPR).

Results and dissemination

The data will be analysed by the steering committee and results will be disseminated in the

form of publication (s) in peer reviewed journals, presentations at local, national and

international meetings. Where applicable the results may be disseminated via social media

platforms and popular media.

Perceived benefits from the outcomes of this survey

This survey will provide valuable insight into the presence of (or lack thereof) early self-

reported PTSD symptoms, anxiety or depression amongst hospital workers in the UK during

the Covid-19 pandemic. A follow up survey at 6 and12 months after the initial STAT-

STRESS COVID19 survey could also provide valuable insight into the role of this scale as a

screening tool for symptoms of mental health conditions over time, changes to hospital

worker symptoms of mental health conditions over time, following exposure to the stressors

of Covid-19 amongst hospital workers in the West Midlands. This project will also pave the

way for additional research on other at risk employee groups and the population at large.

The outcomes will increase the public and key decision maker awareness of mental health

wellbeing amongst hospital workers during this stressful and traumatic time. The survey will

help highlight the services which may be required to cater to the mental health well-being of

hospital workers following the Covid-19 pandemic.

References

1. World Health Organisation. Mental health and psychosocial considerations during the

COVID-19 outbreak [internet].2020 [cited 2020 May 20]. Available from:

https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf.

2. Thompson CV, Naumann DN, Fellows JL, Bowley DM, Suggett N. Post-traumatic

stress disorder amongst surgical trainees: an unrecognised risk? The Surgeon.

2017;15(3):123-30.

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3. Tan BY, Chew NW, Lee GK, Jing M, Goh Y, Yeo LL, et al. Psychological impact of

the COVID-19 pandemic on health care workers in Singapore. Annals of Internal Medicine.

2020.

4. BBC News. Coronavirus: Remembering 100 NHS and healthcare workers who have

died [internet].2020 [cited 2020 May 21]. Available from:

https://www.bbc.co.uk/news/health-52242856.

5. Chan AO, Huak CY. Psychological impact of the 2003 severe acute respiratory

syndrome outbreak on health care workers in a medium size regional general hospital in

Singapore. Occupational Medicine. 2004;54(3):190-6.

6. Chew NW, Lee GK, Tan BY, Jing M, Goh Y, Ngiam NJ, et al. A multinational,

multicentre study on the psychological outcomes and associated physical symptoms amongst

healthcare workers during COVID-19 outbreak. Brain, behavior, and immunity. 2020.

7. Wang H, Chen Z, Chen B, Li Q, Zhang H, Zhu J, et al. The psychological impact of

COVID-19 outbreak on medical staff and the general public. 2020.

8. Kar N, Bastia BK. Post-traumatic stress disorder, depression and generalised anxiety

disorder in adolescents after a natural disaster: a study of comorbidity. Clinical Practice and

Epidemiology in Mental Health. 2006;2(1):17.

9. Weiss D, Marmar C, Wilson J, Keane T. Assessing psychological trauma and PTSD.

The Impact of Events Scale—Revised. 1997;19:399-411.

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Appendix A: Survey Data Fields

(Please refer to the Questionnaire.docx file for the latest version)

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Appendix B: Definitions

Hospital Worker - All employees, volunteers, students based at a secondary or tertriary care hospital with occupied inpatient beds between the 23/03/2020 to 23/05/2020

Covid-19 - Illness caused by novel coronavirus SARS-CoV-2 charachterised by high temperature, cough, shortness of breath and can lead to pneumonia, adult respiratory distress syndrome or death