During COVID-19 epidemic, in addition to the psychological effects of the national state of emergency, HWs experienced specific critical issues and they were exposed to uncomfortable situations with limited possibilities of resolution.21–23 The psychological stress on frontline workers was incredible, compromising their sleep quality and mental health; more than 70% of HWs in China has reported psychological distress including insomnia, anxiety and depression.24
To the best of our knowledge, this is the first study assessing sleep quality, stress and anxiety in Italian pediatric HWs and their relationship with self-efficacy and perceived social support.
We observed that during COVID-19 outbreak, in our population mean PSQI score resulted 7.85 ± 3.52 and 67.43% of pediatric HWs were suffering sleep disturbance (PSQI > 5). PSQI resulted slightly higher compared to HWs of a children’s healthcare center in Wuhan (7.22 ± 2.62)25 and lower than 180 Chinese frontline HWs (8.58 ± 4.56)5 and 801 frontline medical workers in Hubei Province (9.3 ± 3.8).26
Sleep quality is a key indicator of health; good sleep quality helps clinical staff to work better.27 We found a positive correlation between sleep disturbances and stress and between sleep disturbances and anxiety. Stress and anxiety were considered major causes of insomnia28 and their negative influence on sleep quality was previously demonstrated.29,30
SASR score in our population resulted 63.11 ± 30.11, lower compared to frontline Chinese HWs (77.58 ± 29.52).6 According to the definition of DSM-IV, 53% of our population was at risk of developing an acute stress disorder. Mean SAS values in our population were 39.27 ± 12.48 and 19.42% of subjects reported a SAS ≥ 50. A similar SAS value was found in the Chinese study conducted on HWs at a children’s healthcare center in Wuhan (34.44 ± 7.21),25 while higher values were found in frontline Chinese HWs (55.25 ± 14.18). 6 These data may indicate a particular situation in Pediatric Departments, where stress and anxiety have not reached frontline departments levels, and they depend on different factors.
In the early days of COVID-19 outbreak, pediatric patients were relatively rare, and they were thought to be not susceptible to the infection. However, as the number of infected people increases, the disease has gradually been documented in children.31,32 In Italy, the pediatric confirmed cases are 1.8% of the total,33 similar to China (2%).34 Anyway, children are less commonly affected by SARS-CoV-2 and most of them presented with mild disease.35
In Italy, on May 14, only 3.3% of pediatric COVID-19 cases needed hospitalization.33 Furthermore, closing schools and adopting the Italian government extraordinary measures led to a significant reduction of other respiratory infections in children36 and the fear to refer to the hospital (where probability of infection is high) have led to a substantial decrease (ranging from 73–88%) in Pediatric Emergency Department visits compared with the same time period in 2019 and 2018.37 These factors created a unique condition in the Pediatric Departments, opposed to Adult Departments, where bed capacity was early saturated. This particular situation was confirmed in our population by the low exposure and infection rate detected by the swab and the serological test (Table 1). These data are reassuring compared to the infection rate found in Italian HWs in general (25.704 of HWs infected, equal to 11.6% of total infection).33
Despite less exposure and infection probability, most of our population resulted affected by sleep disturbance, stress and anxiety. While in the COVID-19 Units frontline workers (in particular in Intensive Care Units) stress could be related to the palpable infection exposure, the fear of infecting family members,4 prolonged shift times and prolonged use of protective equipment,38 in Pediatric Units stress and anxiety could be related to other factors.
First, as a child is usually susceptible to respiratory infections, to distinguish it from other common respiratory infections was particularly difficult.32
Secondly, it has been suggested that asymptomatic or mildly symptomatic children might spread the infection.39 This probably represented an important cause of stress and anxiety in pediatric HWs, due to the fear of spreading the infection from asymptomatic subjects to HWs and other patients.40 To detect asymptomatic carriers, in a lot of Pediatric Departments, the swab for SARS-CoV-2 was also performed to hospitalized patients with non-suggestive COVID-19 symptoms40 and to the caregiver, whose presence is inevitable in Pediatric Departments.
About personal protective equipment, especially at the beginning of the pandemic, personal protective equipment was not always available in Pediatric Units; in fact, it was more readily available in high-risk specialty sectors.41
Lastly, workplace reorganization was particularly difficult in Pediatric Department. The rapid evolution of the pandemic and the progressive updating of national and local indications led to a continuous reorganization of activities, procedures, but also to a workplace remodeling.42,43 For adult patients, entire departments were intended for COVID-19 and it was therefore easier to divide COVID-19 patients from non-COVID-19 patients. For Pediatric Departments, especially in medium-small hospitals, it was not so easy to find a solution to safely divide COVID-19 patients from non-COVID-19 patients in a unique department.
After the early confusion, when the lower children involvement was actually documented, someone experimented feelings of uselessness:42 together with the substantial decrease in Pediatric Emergency Department visits, it was necessary to stop all routine and non-urgent outpatient activity.43 Concern for difficulties in accessing treatment of non-COVID patients were experimented too, because it was very difficult to protect other patients and healthcare staff.44 Lastly, the fear of being co-opted from other Operating Units, working in clinical areas requiring tasks beyond their own skills, was reported.41,42
All these sudden changes caused an emotional overload with a significant increase in stress levels among pediatric HWs with negative effects on their well-being.42
We found that self-efficacy was negatively associated to stress (Fig. 1); higher self-efficacy could maintain relatively stable emotions even under pressure. Self-efficacy results in increased confidence to do the job well, and higher values help to suffer less from loneliness and pessimism, improving coping mechanisms when under stress.6,45
We also found that mean PSS value was indicative of high social support and that social support was negatively associated to stress (Fig. 1), helping medical staff to reduce stress by decreasing the perception of the threat of stressful events and the inappropriate behavior that can result from stress.6,46
About differences between hospital HWs (group A) and family pediatricians (group B), we did not find statistically significant difference in having contact with suspected or confirmed COVID-19 patients, but group B mostly had telephonic contacts rather than actual medical examinations. Probably for this reason, the provision of personal protective equipment and the performance of rhino-pharyngeal swabs and serology were significantly lower in group B.
Group A resulted more affected by anxiety than group B (Fig. 2). This was probably caused by the greater exposure to COVID-19 patients compared to family pediatricians. The higher prevalence of women in group A, more predisposed to anxiety,47 must be considered.
Social support was considerably higher in group A (Fig. 2), probably because institutions support was higher in the hospitals, but also because of the particular working setting of the family pediatrician, who works alone in his own clinic without any cooperation with other professional figures.