3.1. Participants
A total of 142 PCPs participated in the survey. Sample characteristics are summarized in Table 1. Most are female (n = 118, 83 %) with a mean age of 44 (SD: 10.06; Range: 23–69). Around two-third of the participants were married (N = 91, 64%), and only 38% have a religion (n = 54).
Nurses constitute the largest proportion in the samples (n = 56, 39%), followed by physicians (n = 24, 17%) and social workers (n = 24, 17%). On average, the participants have been working in the PC setting for nine years (SD = 8.17). Only 9% (n = 12) reported that they had worked in the high-risk areas which served COVID-19 patients during the pandemic. Although our sample size was small, the socio-demographic background, such as age, gender, and type of profession, was broadly representative of the workforce of PCP in Hong Kong’s public hospitals (15)(HKSAR, 2019).
Table 1
Demographics and Characteristics of the Respondents (n = 142)
|
|
Mean
|
SD
|
Age
|
43.64
|
10.06
|
Years in the profession
|
17.34
|
9.85
|
Years of PC service
|
8.97
|
8.17
|
|
|
n
|
(%)
|
Gender
|
|
|
|
|
Male
|
24
|
(16.9)
|
|
Female
|
118
|
(83.1)
|
Education Level
|
|
|
|
Non-degree holder
|
7
|
(4.9)
|
|
Degree holder
|
55
|
(38.7)
|
|
Master’s degree or higher
|
82
|
(57.7)
|
Profession
|
|
|
|
Physician
|
24
|
(16.9)
|
|
Nurse
|
56
|
(39.4)
|
|
Medical social worker
|
24
|
(16.9)
|
|
Physiotherapist/Speech therapist/Occupational therapist/Dietitian
|
16
|
(11.3)
|
|
Spiritual care provider
|
14
|
(9.9)
|
|
Clinical psychologist
|
8
|
(5.6)
|
Religion
|
|
|
|
Have a religion
|
54
|
(38)
|
|
No religion
|
88
|
(62)
|
Marital Status
|
|
|
|
Single
|
46
|
(32.4)
|
|
Married
|
91
|
(64.1)
|
|
Divorced or other
|
5
|
(3.5)
|
Children
|
|
|
|
No
|
87
|
(61.3)
|
|
Yes
|
55
|
(38.7)
|
Professional Status in SARS
|
|
|
|
Worked in non-medical field
|
13
|
(9.2)
|
|
Worked in health care profession
|
78
|
(54.9)
|
|
Student in health care field
|
16
|
(11.3)
|
|
Primary or secondary school student
|
35
|
(24.6)
|
Worked in high-risk area
|
|
|
|
Yes
|
12
|
(8.5)
|
|
No
|
130
|
(91.5)
|
3.2. Mental Health Outcomes And Associated Socio-demographic Factors
Our results suggest that 86% of the participants (N = 110) felt moderately and highly stressed during the pandemic (Table 2). A considerable proportion of participants reported at least mild depression (43%), mild anxiety symptoms, (42%) and mild post-traumatic stress symptoms (60%). Despite this, 99% of participants had average and above average levels of compassion satisfaction from their work, and none showed high levels of burnout or secondary traumatic stress.
Table 2. Mental Health of Palliative Care Professionals
|
|
N
|
(%)
|
Depression; PHQ-9 (n = 134)
|
|
|
Normal
|
76
|
(56.70)
|
Mild
|
44
|
(32.80)
|
Moderate
|
11
|
(8.20)
|
Severe
|
3
|
(2.20)
|
Anxiety; GAD-7 (n = 134)
|
|
|
Normal
|
78
|
(58.20)
|
Mild
|
48
|
(35.80)
|
Moderate
|
4
|
(3.00)
|
Severe
|
4
|
(3.00)
|
Perceived distress; PSS (n = 129)
|
|
|
Low
|
18
|
(14.00)
|
Moderate
|
98
|
(76.00)
|
High
|
13
|
(10.10)
|
Post-traumatic stress; IES-Revised (n = 125)
|
|
|
Normal
|
50
|
(40.00)
|
Mild PTSD
|
40
|
(32.00)
|
Moderate PTSD
|
15
|
(12.00)
|
Severe PTSD
|
20
|
(16.00)
|
Professional quality of life; PROQoL (n = 118)
|
|
|
Compassion Satisfaction subscale (CS)
|
|
|
Low
|
1
|
(0.80)
|
Average
|
93
|
(78.80)
|
High
|
24
|
(20.30)
|
Secondary Traumatic Stress subscale (STS)
|
|
|
Low
|
45
|
(38.10)
|
Average
|
73
|
(61.90)
|
High
|
0
|
(0.00)
|
Burnout Subscale (BO)
|
|
|
Low
|
45
|
(38.10)
|
Average
|
73
|
(61.90)
|
High
|
0
|
(0.00)
|
PHQ-9: Patient Health Questionnaire-9; The severity categorization was based on cut-off points suggested by(8). The mean of PHQ-9 is 4.42 (SD: 4.14).
GAD-7: Generalized anxiety disorder-7. The severity categorization was based on cut-off points suggested by(16). The mean of GAD-7 is 4.08 (SD: 3.86).
PSS: Perceived stress scale. The mean score of perceived stress is 19.63 (SD: 5.28).
IES-Revised: The impact of event scale. The severity categorization was based on cut-off points of (4). The mean total score of IES-R of our sample is 25.74 (SD: 11.35), and the subscale scores of intrusion, avoidance, and hyperarousal are 1.34 (SD: 0.58), 1.03 (SD: 0.61) and 1.11 (SD: 0.51) respectively. The cut-off point for all the subscale scores is 2.
ProQOL: Professional Quality of life. The severity categorization was based on (12) The mean scores of CS, ST and BO in our sample are 36.84 (SD: 4.98), 23.64 (SD: 4.36) and 23.58 (SD: 4.57) respectively.
|
Multivariate regression (Table 3) showed that a younger age was associated with more symptoms of depression during the COVID-19 pandemic (Beta: -0.33, p < .001) Participants who are younger (Beta: -0.25, p = 0.05) and do not have a religion (Beta = 0.14, p = 0.97) were also associated with more anxiety symptoms. There was no statistically significant association between any of the demographic variables with perceived stress and post-traumatic stress symptoms (p > .05).
Regarding professional quality of life, being younger (Beta: -0.30, p < .001), female (Beta: 0.20, p = 0.03), and without a religion (Beta: 0.18, p = 0.04) were associated with a higher level of secondary traumatic stress. We also found that being younger was associated with a higher level of burnout (Beta: -0.35, p < .001). There was no statistically significant association between any of the demographic variables with compassion satisfaction (p > .05).
3.3. Impact Of Pandemic On Pc Services
3.3.1. Survey findings
The majority of participants (90%; 113 out of the 125 who answered this question) agreed that PC services had been affected by the COVD-19 pandemic. Table 4 shows the details. Regarding questions on ‘interruption to PC services’, 82% (n = 102 reported feeling stressed when communicating with patients and family about the visitor policy, 78% (n = 98) agreed that the negative social atmosphere had influenced PC service quality, and 50% (n = 63) agreed their workload had increased. Around 33–43% reported that wearing a face mask and limiting physical contact during the pandemic had affected the service quality of PC.
Regarding questions on ‘fear of infection and infection control support’, around 64% (n = 80) reported they feared being infected during work, but only 20% (n = 25) reported fear of death. About 34% (n = 42) worried that that compassionate visiting (hospital visits of patients’ relatives are not allowed during the pandemic except on compassion grounds) in the PC ward may put them at greater risk of infection. Only 47% (n = 59) felt at ease when serving febrile PC patients during the pandemic. For perceived support on infection control measures, 73% (n = 90) believed they received sufficient and appropriate infection control training for COVID-19. A similar proportion of participants reported feeling safe (n = 92, 74%) when they wore personal protective equipment (PPE) while serving PC patients.
For questions on overall support from government and hospital, 62% (n = 77) and 76% (n = 95) expressed lack of confidence in the anti-epidemic policy of the Hong Kong government and the Hospital Authority respectively. Despite this, 80% (n = 100) felt they were well supported in general by their own PC team during the pandemic.
Table 4
Respondents’ Response about the Impact of the Pandemic on Palliative Care
|
|
Agree or Strongly Agree
|
Disagree or Strongly Disagree
|
|
|
n
|
(%)
|
n
|
(%)
|
1.
|
Under the no-visiting policy, I feel stressed when communicating with patients and family members. (INTERR)
|
102
|
(81.6)
|
23
|
(18.4)
|
2.
|
With the personal protection equipment provided, I feel safe when serving patients in palliative care. (IC)
|
92
|
(73.6)
|
33
|
(26.4)
|
3.
|
I worry I would be infected if I allow family members to visit dying patients under compassionate visiting. (IC)
|
42
|
(33.6)
|
83
|
(66.4)
|
4.
|
I feel at ease when serving febrile palliative care patients. (IC)
|
59
|
(47.2)
|
66
|
(52.8)
|
5.
|
The negative social atmosphere would influence the palliative care service quality. (INTERR)
|
98
|
(78.4)
|
27
|
(21.6)
|
6.
|
I am confident about the anti-epidemic policy and instructions of the Hospital Authority. (SUP)
|
48
|
(38.4)
|
77
|
(61.6)
|
7.
|
During the COVID-19 epidemic, I feel the support of the palliative care team. (SUP)
|
100
|
(80.0)
|
25
|
(20.0)
|
8.
|
During the COVID-19 epidemic, my workload has increased. (INTERR)
|
63
|
(50.4)
|
62
|
(49.6)
|
9.
|
I think I have received enough and appropriate infection control. (IC)
|
90
|
(72.0)
|
35
|
(28.0)
|
10.
|
I am confident about the anti-epidemic policy of the government. (SUP)
|
30
|
(24.0)
|
95
|
(76.0)
|
11.
|
I am afraid I would be infected by COVID-19 at work. (IC)
|
80
|
(64.0)
|
45
|
(36.0)
|
12.
|
I am afraid I would die of COVID-19. (IC)
|
25
|
(20.0)
|
100
|
(80.0)
|
13.
|
The patient and I need to wear masks during the epidemic, and it affects my communication with patients. (INTERR)
|
41
|
(32.8)
|
84
|
(67.2)
|
14.
|
During the epidemic, my patient and I are afraid of physical contact, and it affects the service I provided. (INTERR)
|
54
|
(43.2)
|
71
|
(56.8)
|
(INTERR) represent questions about ‘interruption to everyday PC services’ (5 questions).
(IC) represent questions about ‘fear of infection & infection control support’ (6 questions).
(SUP)represent questions about ‘overall support from government and hospital’ (3 questions).
|
3.3.2. Qualitative Findings
The majority of participants (83%) provided a response to the open-ended question relating to the perceived impacts of COVID-19 on PC services. Three major themes were identified: 1. Tightening the restrictions on visitors, 2. Limiting the provision of PC services and 3. Staff deployment.
3.3.2.1. Tightening The Restrictions On Visitors
Our findings showed that participants expressed the most concern about the tightening the restrictions on visitors. About 72% of responses (75 out of 104) were related to this theme. During COVID-19, visiting hours and number of visitors were restricted in the inpatient PC service. Visits were only granted for the family on compassionate grounds, when patients deteriorated to the final stage of life: “In my acute care setting, although the family visit is allowed for end-of-life cases on compassionate grounds…still subject to individual ward policy, some wards only allow short visits like 15 minutes, twice per week” (Participant 12, physician). The tightening of restrictions on visitors affected the following people.
A) Patients
Participants reported that tightening the restrictions on visitors has limited patients’ chances to interact with their loved ones, leading to distress and loneliness. Although video calls were arranged, participants found they did not really replace family visits. One participant said: “Our patients are profoundly affected, as ward visits are banned now. Their mood is influenced by the physical disconnection from families” (participant 45, physician).
B) Family Caregivers
Participants reported family caregivers were particularly concerned and anxious about their patient’s health condition because of the visiting policy. They were upset because they could not convey their support directly to the patients “Diet is traditionally the main concern of many families. Caregivers can no longer take homemade meals to patients every day. And many of them were upset to see patients feeling lonely in their hospital bed” (Participant 45, physician). It also potentially led to complicated bereavement. Participants reported that most family caregivers expressed guilty feelings for not being able to uphold their caregiving responsibility during the pandemic.
C) Pcp
Participants reported that tension and conflicts had increased between them and patients and patients’ family caregivers because of tightening of restrictions on visitors. One participant reported, “The majority of PC patients have a poor prognosis… it is difficult to give discretion to relatives to visit patients just because of their terminal condition. If we allow all families to visit, the ward will be too crowded, and this will increase the risk of infection” (Participant 36, physician).
Participants also stated that the no-visiting policy created an additional workload for them. Front-line PC nurses needed to make an extra effort in arranging video conferences and implementing additional infection control measures (e.g., temperature checking and filling in visit records). They also needed to rearrange appointments, as patients declined admission during COVID-19. Additional emotional support had to be provided to family caregivers, as they showed more concern about the patients’ situation during the pandemic. Moreover, one nurse reported that it is difficult to assess the needs of family caregivers and provide them with timely support during the outbreak, as they now had limited chances to interact with family caregivers during the pandemic.
3.3.2.2. Limiting The Provision Of Pc Services
About half of the responses (54%; 56 out of 104) described how the provision of PC services had been affected during COVID. Different PC service components were affected.
A) Homecare Support Service
Some nurses stated that the number of home visits had been greatly reduced due to the outbreak. Homecare support service is often considered non-essential by the authorities. Therefore, participants claimed that they were unable to provide timely intervention to patients and families. They also shared their worries in providing homecare support services, due to the scarcity of PPE. One participant mentioned, “PPE was limited, which creates great anxiety for the homecare nurses… The department has to buy raincoats for us to replace the formal PPE, which harms our professional image” (Participant 40, nurse).
B) Spiritual Support Service
Spiritual support service for PC patients was limited during COVID-19. This service changed to provision-on-request from patients and required approval from the hospital chief executive. The spiritual needs of patients were ignored, which may lead to further emotional distress to patients. One participant reported, “The referral procedure of spiritual support service in my hospital is complicated, and the time for approval may need a whole day… In some cases, the patients died while waiting” (Participant 59, spiritual care worker).
C) Service Routine
PC routine service was delayed or suspended. Participants mentioned that patients were required to undergo a complicated admission procedure to PC wards during the pandemic and that affected the patient’s well-being: “The new admission procedure is so complicated that the patients suffered a lot from it…They have to waste a lot of time being admitted to the PC ward, and some patients need to stay at home without any assistance while waiting...This arrangement totally contradicts the value of PC” (Participant 30, nurse). Some PC services (e.g., pain management consultation) and interventions (e.g., palliative radiotherapy/surgery) were suspended, as they were regarded as non-essential. Multidisciplinary team meetings also became less frequent. In one hospital, the entire PC ward was closed, and all cubicles were converted to managing suspected/confirmed COVID-19 cases. Support received from non-governmental organizations was reduced because their staff was not allowed to enter the clinical areas of the hospital. Furthermore, participants said that many patients were afraid of entering the hospital and therefore declined their outpatient follow-up appointments.
D) Post-death Service
Participants mentioned that post-death support had been reduced. This created hassles to the family and affected the quality of service. For example, due to infection control measures, funeral service providers and family members could not go to the hospitals to do the make-up or change clothes for the deceased. Also, the hospital stopped providing the venue (e.g., a farewell hall) for family members to hold simple memorial rituals before transferring the bodies to the crematorium. This created additional financial burden to the families, as they had to use the services of private funeral parlors. Some social workers mentioned the difficulty of providing bereavement support to family. They found the comprehensiveness of bereavement risk assessment conducted solely by phone was inevitably compromised.
3.3.2.3. Staff Deployment
Nine out of 104 responses were related to staff deployment during COVID-19. Participants reported that some PC staff had been deployed to other wards or a ‘dirty team’ (team that provides care to suspected and confirmed COVID-19 patients), as PC services were regarded as non-essential. Such deployment caused distress and confusion and increased the workload of the PC team.
One physician mentioned that “In my hospital, two-thirds of PC physicians are deployed to either dirty teams or acute medical duties. Two-thirds of PC homecare nurses are deployed to either the dirty team or acute medical duties” (Participant 28, physician). One nurse also stated: “The situation was the same during SARS, that PC service in acute hospitals was once again regarded as a non-essential service. The PC ward was even temporarily closed, and only ambulatory service remained” (Participant 19, nurse). Some participants also mentioned that the reduction of staff caused an increased workload in PC services. One physician even said that his role in PC service was diminished and became ambiguous, as all the attention had been shifted to infection control.