International Journal of Collaborative Research on Internal Medicine & Public Health

Scale of Stress Manifestation, Anxiety, Depression and Professional Burning in Relation to Resilience of Kosovo Healthcare Workers During the Period of Covid - 19 Pandemic

Behare Bojaxhiu Huçaj^1* and Sami Rexhepi^{2 *}Correspondence: Behare Bojaxhiu Huçaj, Clinical Psychologist, Mental Health Centre, Kosovo, Email:

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Introduction

Corona virus (Covid 19) and its appearance

In December 2019, the city of Wuhan in English, and reported unusual cases of patients with pneumonia from the novel Coronavirus virus (COVID-19) and its spread rapidly became a widespread global virus [1].

In January 2020, the World Health Organization (WHO) declared the outbreak of the Coronavirus disease a Public Health Emergency of International Concern. The WHO declared that there is a high risk of the spread of the new coronavirus disease (COVID-19) in other countries of the world and therefore declared a pandemic. WHO and public health authorities around the world, including Kosovo, have taken action to control the outbreak of COVID-19). There have been several viral diseases in the past 20 years including Severe Acute Respiratory Syndrome (SARS) in 2003, H1N1 influenza virus in 2009, Middle East Respiratory Syndrome (MERS) in 2012 and Ebola virus in 2014 [2-4].

Although COVID-19 is a new virus, it is so far known to cause diseases ranging from the common cold to more severe diseases such as SARS and MERS [4]. Symptoms of a Coronavirus infection include fever, chills, cough, sore throat, nausea and vomiting, and diarrhea. Individuals with a history of other diseases are more likely to be infected with the virus and may experience worse outcomes [5]. Severe cases of the disease can lead to respiratory failure, heart failure, acute respiratory syndrome or even death [6].

Corona virus (Covid 19) in Kosovo

In Kosovo, from the first confirmed case of the Covid 19 virus in March 2020 to June 2021, we have 107,655 positive cases, 105,241 recoveries and 2,252 deaths. After a period of almost 3 months in quarantine, and the rest with concrete bans, the state has continued to face difficulties in managing the virus. Many institutions have been active in their work during the pandemic period, especially during the quarantine. The medical services considered essential remain the key profession that connects the wide range of services and the first response in a situation created like this pandemic where the population feels unsafe and is vulnerable in physical and psychological aspects.

The psychological state of the population

In addition to physical impacts, COVID-19 can have serious effects on people's mental health A wide range of psychological outcomes have been observed during the virus outbreak, at individual, community, national and international levels. At the individual level, people are more likely to experience fear of getting sick or dying, feeling powerless and being stereotyped by others [7, 8]. The pandemic has had a detrimental effect on public mental health, which may even lead to psychological crises [9]. Early identification of individuals in the early stages of a psychological disorder makes intervention strategies more effective. A health crisis, such as the COVID-19 pandemic, leads to psychological changes, not only in health workers, but in other individuals who contribute in other fields, and such psychological changes are driven by fear, anxiety, depression or insecurity [10].

Nervousness and anxiety in a society affect everyone to a great extent. Recent evidence suggests that people kept in isolation and quarantine experience significant levels of anxiety, anger, confusion and stress [11]. In general, all studies that have examined psychological disorders during the COVID-19 pandemic have reported that affected individuals to exhibit some symptoms of mental trauma, such as emotional distress, depression, stress, mood swings, irritability, insomnia, attention deficit hyperactivity disorder, post-traumatic stress and anger [12, 13].

Research has also shown that frequent media exposure can cause anxiety [14]. However, in the current situation, it is challenging to accurately predict the psychological and emotional consequences of COVID-19. Studies conducted in China, the first country to be affected by this spread of the virus, show that people's fear of the unknown nature of the virus can lead to mental disorders [15, 16]. Numerous studies show that psychological responses to previous pandemics such as the SARS flu in 2003 have included several psychiatric comorbidities and maladaptive behaviors such as anxiety, depression, panic attacks, and emotional disturbances [17]. People who are prone to psychological problems are especially vulnerable at such times [18]. Surely Covid-19 will be no different from other viruses. It has caused substantial disruption to people's lives, rapid spread and high mortality rates that are already having a major impact on society, the economy and the provision of health and social care. Preliminary evidence suggests that symptoms of stress, anxiety and depression and later post-traumatic stress disorder are possible reactions [18]. At the individual level the fear of personal infection, or the infection of friends and family members, stands alongside the fear of the possibility of isolation and restricted movement which affect mental health, well-being, social functioning and work.

All of these concerns can be influenced by constant information, and misinformation from the news, the Internet, and social media, coverage of which can blur the lines between home and work. A Chinese study from January and February 2020 found that 54% of respondents rated the psychological impact of Covid-19 as moderate or severe; 29% reported moderate to severe symptoms of anxiety; and 17% reported moderate to severe depressive symptoms [18].

Data from Public Health England show that 4 in 5 adults are worried about the effect it is having on their lives, with more than half saying it has affected their well-being and nearly half reporting high levels of anxiety during this period. More than 45% of Scots feel that the ban/lockout measures have had a negative impact on their mental health [19].

Health care and mental health of health workers

Topics such as the psychological difficulties that follow an unknown and relatively dangerous situation are being researched globally and in Kosovo. To see how the mental health of health workers has been affected, the resilience they will build after facing a dangerous situation will give us a more detailed insight into the research topic.

Three groups are at particular risk of psychological symptoms:

• Health workers responding to the pandemic and their patients/clients.

• Individuals diagnosed with Covid-19, losing their family and loved ones to the disease, or affected by prolonged social distancing.

• Individuals with existing mental health conditions exacerbated by current circumstances

Health care workers can often fall into all three of these categories. Health care is already a stressful profession and undoubtedly according to data from Great Britain this category of professionals was facing a health care crisis even before Covid-19.

The Public Policy Research Institute's report, Care Fit for Carers, found that the pandemic is having a severe impact on the mental health of healthcare workers who experience stress, anxiety, adversity, or trauma. In YouGov surveys, half of the staff cited how mental health has been affected by Covid-19, ahead of concerns about family safety and their ability to look after patient or service user safety due to a lack of testing and equipment personal protective equipment.

A survey led by the trade union GMB Scotland investigated the mental health of people working in the healthcare sector. Four in five workers said their mental health had already been damaged by their work. The same number said they had not been offered professional mental health support by their employer (ITV News).

Studies from previous pandemics and from countries recently affected by Covid-19 show similar results - higher prevalence of sleep disorders, anxiety, depression, obsessive-compulsive disorder and post-traumatic stress disorder with emotional distress experienced at the beginning, during and after the outbreak of infection [20].

Theoretical perspective stress, anxiety, depression, burnout and resilience

Stress is associated with both short-term and long-term health problems. It is therefore important to track the health risks of social work, a profession that coexists with stress, depression and professional burnout. (Community Care).

Anxiety is often a general emotional reaction to stress, it is a fear caused by the demands placed before the person when he does not know what these demands actually are. Depression is a mental health disorder. It is more than a temporary bad feeling for some particular reason; it is a medical disorder that needs professional help and can be treated. Symptoms of depression should not be confused with normal distress or suffering, depression is an illness that involves signs and symptoms that last for weeks, months or years, without recognition or treatment.

In the context of exposure to a significant disaster, resilience is the ability of individuals to find their way to the psychological, social, cultural, and physical resources that support their well-being, as well as their individual and collective ability to negotiate for these resources. be provided in cultural and meaningful ways" [21]. Burnout is characterized by emotional exhaustion, cynicism and ineffectiveness in the workplace and by chronic negative responses to stressful workplace conditions.

Research Methodology

In the following part, the methodological aspects of the research on the relationship between stress, anxiety and depression with professional burnout and resilience in health workers will be examined. During the first phase, we paid special attention to defining the main issues on which we carried out the work for the future. At this point, we will describe the research methods, the purpose, the measuring instruments used for the realization of this research, the variables, the hypotheses and the subjects that were presented for this research [22, 23].

Referring to the work difficulties faced by health workers during the pandemic, the idea of studying psychological problems that may have appeared during these difficulties arises, and within this phenomenon, this study focused on the degree of manifestation of stress, anxiety and depression and their appearance in health workers, during the provision of services.

To discover new facts, these phenomena were given scientific importance to achieve the essential objectives and purpose.

• The primary goal of this study is to detect the degree of manifestation of stress, anxiety, depression and resilience in people who provide health services in specialized clinics.

• The second goal of this study is to identify the degree of professional burnout of health workers during the pandemic period.

• The third purpose of this study is to prove the relationship that can be between stress, anxiety, depression and resilience with professional exhaustion or burnout.

Hypothesis

• It is hypothesized that workers who have developed resilience will more easily cope with stressful situations, anxiety and depression, while workers who for certain reasons and factors have not managed to develop resilience in this situation will be more vulnerable to stress and anxiety and depression.

• Workers who have provided direct services to patients with Covid-19 tend to develop more anxiety and depression compared to workers who have provided services from the office.

• The primary hypothesis of this study presents: "The relationship between the degree of manifestation of stress, anxiety and depression with resilience and professional burnout in health workers.

• H1. Health workers have high levels of stress, anxiety and depression.

• H2. Health workers who have a high degree of manifestation of anxiety, stress and depression do not have developed resilience at a high level.

• H3.There are gender differences in the degree of resilience development among health workers.

• H4 Health workers have suffered a high degree of professional burnout during the pandemic.

• H5. There is a strong relationship between burnout and resilience with stress, anxiety and depression in healthcare workers.

Presentation and interpretation of results

In this research, the focus has been on finding the arithmetic mean for the degree of manifestation of anxiety, stress and depression during the pandemic period among health workers. On the other hand, the degree of professional burnout and resilience was also requested, which shows the ability to recover from a life-threatening stressor, in our case Covid-19.

Stress is considered the source of many mental health concerns and is also considered a key factor in the manifestation of depression and anxiety, while it has been highlighted in health workers during the pandemic according to the statistical analysis of the findings we have these data the arithmetic mean M=13.16, standard deviation б=11.67 and measurement error б=0.52

As for the degree of manifestation of anxiety among health workers during the pandemic period, the data have resulted in a moderate average degree, where the arithmetic mean is M=11.72, the standard deviation б=10.88 and the measurement error б=0.48.

As for the degree of manifestation of depression among health workers, the arithmetic mean has resulted in M=10.72, which means a low degree of manifestation of depression with a standard deviation of б=11.16 and the measurement error б=0.49.

Resilience, which is considered the coping ability to recover oneself after a difficulty, has been at a fairly high level among health workers, and this has been proven by the findings of statistical analysis, where the average degree of resilience has resulted in a height of M=48.15, with a standard deviation of б=6.10 and standard error б=0.27 (Table 1). From the results found, we realized that over time the burning rate decreases and we have r=- 0.52; p<0.01, means a negative correlation between burnout rate and work experience at the 95% confidence level (Figure 1).

Figure 1: Distributions of averages for occupational burnout.

Table 1. Presents the correlation between professional burnout and years of experience.

The truth of the hypothesis

The validity of the hypotheses was tested through correlative and differential statistical methods, where the Pearson correlation was tested for the correlation between the variables, while the T-test method was tested for the differences between the mean distributions. Mean values and corresponding 95% confidence intervals were calculated for all indicators. In all cases, a value of p ≤ 0.05 was considered statistically significant. All statistical analysis was performed in SPSS v.22 (Table 2, 3)

Table 2. Values of distributions of averages for stress, anxiety, depression, burnout and resilience.

Table 3. Presents the correlation between resilience and depression.

From the obtained statistical values, we have understood that resilience has a negative relationship with anxiety, which means that the higher the resilience, the lower the anxiety state (Table 4).

Table 4. Presents the correlation between anxiety and resilience.

Statistical differences based on occupation

The results have confirmed that for occupational burnout there are no significant statistical differences based on profession and we have t=-1.42; p>0.05 and the significance result Sig= 0.15 which is higher than 0.05 within the 95% confidence interval, which has exceeded the limits of statistical significance which means the absence of differences based on the doctor and nurse professions, while the result among the support staff and nurses we have t=1.83; p ≤ 0.05 with the significance value Sig=0.052 which is equal to 0.05 within the 95% confidence interval, which means the presence of differences for professional burnout based on the profession of nurse and support staff (Table 5-7).

Table 5. Presents the correlation between anxiety and resilience.

Table 6. Presents the correlation between anxiety and resilience.

Table 7. Levene's Test for Equality of Variances.

Statistical differences for occupational burnout on an institutional basis

Regarding the institutional level, the highest levels were in the anesthesiology clinic, followed by the Institute of Public Health and Pulmonology compared to Regional Hospitals and Family Medicine Centers. Statistical data are presented in (Table 8).

Table 8. Presents the average values of the burnout rate based on the institutions.

The level of resilience was quite high for all ages, genders and professions, where there were no significant differences. What made them functional and did not stop their work was the high resistance to risk factors, from the results found we have a high level of resilience in all ages and genders. M=48.14 (Figure 2).

Figure 2: It presents the mean values of the Resilience distributions.

Referring to health workers who have been infected and those who have not been infected by Covid 19, we have used the method of difference between the averages and have the following data (Table 9):

Table 9. Shows the difference between the average levels of anxiety of health workers who have been infected and those who have not been infected.

Referring to the vaccination, we found no differences in the level of stress, anxiety and depression, and the results are as follows (Table 10):

Table 10. Presents the mean values for stress, anxiety and depression based on vaccination.

Discussion and Conclusion

From all this, we can emphasize that the Covid-19 Pandemic has easily affected the psychological well-being of health care workers, manifesting the risk of burnout. So from all this, we conclude that all our research work has been mostly focused on professional burnout, considering it as an important factor in the functioning of health workers during the Covid 19 period. Emotional exhaustion, which was highlighted in health workers, is usually related to a relationship with work that is perceived as difficult, tiring, and stressful. This is seen differently from depression as it is likely that burnout symptoms will be reduced during rest.

Depersonalization or loss of sensitivity is characterized by a loss of respect for others (clients, colleagues, etc.) and by maintaining a greater emotional distance, which is expressed through cynical, derogatory, and even callous comments. Appreciation of personal achievements is a feeling that acts as a safety valve and contributes to achieving a balance if burnout and depersonalization occur at work. It provides fulfillment in the workplace and a positive outlook on professional achievements.

Relying on the results obtained, from the literature of the relevant theories and from the results obtained from the research, regarding the degree of manifestation of stress, anxiety and depression, we can say that the genuine treatment and understanding of the nature of the problems affecting mental health leads to the maximization of positive benefits and the minimization of the deterioration of psychological well-being, which can result in high rates and more severe anxiety states leading to emotional exhaustion and professional burnout. The results we discussed find support in the theoretical framework and relevant research carried out by Carlo Giaomo, Saaverio Sabina, etc. From the Clinical Institute of Physiology, the National Council of Scientific Research in Lecce of Italy, October 2021 and the Turkish University Clinic-Turkish Psychiatry Dergisi 2021 by Ozen Onen Sertos, Ozlem Kuman Tuncel, etc. Where they had similar results on psychological phenomena in health care professionals.

These results from relevant research support our hypotheses, among other things this research will be at the service of any researcher who wants to study these phenomena in the future. Based on these results, we can declare recommendations and conclusions drawn from the research, which will be profitable and favorable for the population that has been the focus of this study, such recommendations and conclusions will be presented below.

What do the experts recommend?

Recommended interventions to reduce professional burnout, burnout, loss of compassion, real or perceived stress and ineffective therapeutic techniques include:

• Prioritize individual self-care practices

• Breathing exercises, "mindfulness" and use of telehealth services (therapy)

• Using social media applications and virtual platforms (eg Twitter and Zoom) to create social activities that promote health and wellness, book clubs, support groups, meditation, yoga, etc., that will encourage the creation of support networks social.

• Participation in social marketing campaigns regarding social distancing, self-care, etc.

• Volunteering in the community (distributing food, helping people in need, contributing to the community and monitoring for needed services).

• Engagement in the social work community to stay connected with other professionals and raise awareness of additional opportunities and individual contributions.

• Review of local, national and global emergency preparedness policies.

Recommendations are drawn from this study

• Professional burnout occurs when stress and workload become overwhelming, negatively affecting the life and health of the individual.

• Relying on the results obtained, from the literature of the relevant theories and from the results obtained from the research, regarding the degree of manifestation of stress, anxiety and depression, we can say that the genuine treatment and understanding of the nature of the problems that affect health mental health leads to the maximization of positive benefits and the minimization of the deterioration of psychological well-being, which can result in high rates and more severe anxiety states leading to emotional exhaustion and professional burnout.

• To understand the nature of their psychological problem and not judge them without knowing exactly the nature of the problem. In such cases, a possible inappropriate behavior of any health professional that may be a consequence of professional burnout should be understood.

• Burnout is not something that goes away on its own. On the contrary, it can get worse if the underlying issues causing it are not addressed.

• Ignoring the signs of burnout can cause further damage to physical and mental health in the future, as well as loss of ability and energy to effectively meet the demands of the job, which can have negative effects on the other aspects of life.

• Social support can be expected to protect against burnout. Therefore, the urgent implementation of effective psychosocial and organizational interventions to protect the mental health of healthcare workers and prevent burnout is of particular importance.

• Repeating the research after 6 months or eventually after the end of the pandemic and comparing the findings from the different phases of testing among health workers.

• Supervision and team support protect them from professional burnout and are protective factors in maintaining mental health.

• Strengthening support systems and identifying protective factors (internal factors of resilience - being proactive, feeling self-controlled and making decisions about what to do and external ones - children, families, society-cultivating caring relationships, expectations positive and opportunities for meaningful participation in solving a difficulty)

• By strengthening and developing these factors, the effects of the risk will be reduced and adaptive skills will increase.

• It is important to be aware of the warning signs of occupational burnout so you can recognize when you have them.

• There are several ways to take care, stay healthy and prevent burnout.

• Offer them support - Talking about what they are going through, and getting support from family and friends or a support group helps you process their feelings and emotions. Keeping everything inside can make them depressed and contribute to feeling overwhelmed.

• Offer them professional counseling - if necessary.

• Vacations - help relieve some of the stress and restore energy. Relaxing activities improve mood, and even 10-minute breaks can help

• Talk to work colleagues - This helps you get support and allows you to give support and encouragement to others going through something similar.

• Pay attention to their feelings and needs-While providing services, they can easily forget to take care of their own needs, so it is good to provide them with help so that they can find time for themselves.

Limitations of the study

In stressful and life-threatening periods, the individual focus can be oriented towards survival/relatively towards finding and developing resilient factors and ignore potential risk factors which tend to appear after the end of the dangerous situation (Covid 19).

Long experience in health care work and dealing with other stressful situations may have influenced health workers have developed a high level of resilience. The nature of working in dangerous situations has made them gain professional immunity and not develop a high degree of stress, anxiety and depression. These values cannot be taken as a basis for the care workers of other KKUK clinics, but only for anesthesiology and pulmonology, because the other clinics were not subjected to the survey.

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