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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: [email protected]
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: [email protected]
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:
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