On 11 March 2020, the World Health Organization declared the coronavirus disease 2019 (COVID-19) outbreak a global pandemic.¹ As per the World Health Organization Africa region report, close to nine million cases had been reported in the African region, with South Africa accounting for four million cases in this region as of 08 August 2022.² At that stage, healthcare worker (HCW) infections continued to rise, and South Africa remained one of the five countries accounting for approximately 70% of all infections reported in African HCWs.²

In addition to the evidenced increased risk of infection experienced during disease outbreaks, HCWs are exposed to several physical and psychological stressors, which may result in severe mental health outcomes.³

Following the severe acute respiratory syndrome (SARS) outbreak, HCWs reported elevated stress levels, as well as significant emotional distress and psychiatric morbidity.^4,5,6,7,8 Long-term psychological morbidity in the form of elevated stress levels, anxiety, depression and post-traumatic stress disorder (PTSD)-like symptoms has been documented up to 2 years after the SARS outbreak.^4,7,8

Similarly, following the Middle East respiratory syndrome outbreak, HCWs expressed moderate anxiety towards Middle East respiratory syndrome-coronavirus infection related to the novelty of the virus, its ability to cause severe disease or death and the lack of availability of specific treatments or vaccines.⁹ Additionally, higher levels of concern were associated with younger HCWs, being non-physician, direct patient contact and working within the central region of the outbreak.¹⁰

Recent literature produced during the COVID-19 outbreak has displayed significant negative psychological effects among HCWs.^11,12,13,14 These effects occur in the face of an increasing workload, limited personal protective equipment, widespread media coverage and lack of specific treatment regimens.¹³ A meta-analysis of 12 studies, primarily performed in China, found the prevalence of anxiety, depression and insomnia among HCWs during this outbreak to be 23.3%, 22.8% and 38.9%, respectively.¹⁵ In a study completed among HCWs in Oman, the overall psychological well-being of these workers was poor. This was more evident among females, young HCWs and those who cared directly for COVID-19-positive patients.¹⁶

Trauma is defined as a ‘stressful occurrence that is outside the range of the usual human experience and that would be markedly distressing to almost anyone’. It involves a ‘perceived intense threat to life, physical integrity, intense fear, helplessness, or horror.¹⁷ Post-traumatic stress symptoms (PTSS) follow an acute traumatic occurrence and are characterised by a typical symptom pattern of intrusive thoughts, persistence of trauma, relevant stimuli avoidance, emotional numbing and physiological hyperarousal.¹⁸

Persistently experiencing PTSS may lead to the development of PTSD. Research has identified that PTSS that developed within days of trauma was a robust predictor for the development of PTSD.¹⁹ By means of its threat to human life and the associated emotions induced, the presence of a global pandemic in the form of COVID-19 meets the definition of a traumatic event.¹⁸

The PTSD checklist for DSM-5 (PCL-5) utilised in this study is one of the most widely used self-report measures of PTSD, demonstrating excellent reliability and validity. The tool quantifies and monitors symptoms over time, screening for PTSD and assisting in making a provisional diagnosis of PTSD. Although there is only one version of the PCL-5, there are three formats that differ in how Criterion A is assessed. The first version, used in this study, does not assess Criterion A, the second version defines Criterion A and provides examples of qualifying events, and the third version includes the Life Events Checklist for DSM-5 and a more detailed assessment of Criterion A. The PCL-5 is meant to assess patient symptoms in the past month. Versions that assess symptoms over a different time frame (the past day, past week, or past 3 months) have not been validated.^20,21

Literature related to the SARS outbreak investigating PTSS in three subgroups, namely patients, HCWs and the general public, found the incidence of PTSS among HCWs to be 25.8%.²² In a prospective and follow-up study completed in Taiwan among 102 nurses working in both SARS and non-SARS units, no significant difference was found in the PTSD prevalence rate.²³ This is in keeping with the findings of a Toronto-based study, which looked at the long-term psychological and occupational effects of providing healthcare during the SARS outbreak.⁶ This is suggestive that epidemic experiences could be considered traumatic for HCWs across departments. These emotions may result from uncertainty regarding redeployment to understaffed high-risk areas, an imbalance between skill set and work demand and limited psychological preparation.^17,24

In a rapid review assessing the psychological impact of epidemic and pandemic outbreaks on HCWs, PTSS were examined in 23 studies. During outbreaks, the prevalence of PTSD-like symptoms ranged between 11% and 73.4%, with the prevalence range gradually decreasing from 10% to 40% 1–3 years after the outbreaks.³

Regarding risk and protective factors, various organisational, social, personal and psychological predictors have been associated with a higher prevalence of PTSS in HCWs.²⁵ In terms of organisational predictors, occupational role, working in high-risk environments and being quarantined are associated with a higher prevalence of PTSS.^25,26,27

Socially, organisational support and support from family or friends have proved to protect HCWs’ mental health outcomes.^23,24,27 Personal characteristics that increase the risk of PTSS in HCWs include being single, female, a young healthcare professional with less work experience and earning a lower household income.^8,13,27,28 Psychological predictors, such as maladaptive coping styles and having a negative emotional experience of the outbreak, are associated with an increased likelihood of PTSS among HCWs.^24,26,27

Mental healthcare workers (MHCWs) play an important role amid a pandemic by providing psychological support and guidance. They are often considered role players in developing strategic protocols to alleviate distress and improve coping skills among their colleagues and the public.²⁹

Although there is significant literature exploring the impact of epidemics on HCWs’ mental health, many of these are focused on direct frontline workers with minimal evidence surrounding the mental health of MHCWs.

This study aimed to explore PTSS and associated factors among MHCWs in the Gauteng province within the context of the COVID-19 pandemic.

The study objectives were:

The prevalence of PTSS in this study was 11.7%. This is in keeping with a South African-based survey, including public psychiatric HCWs, in which the estimated prevalence rate of PTSD was 13%, and a cross-sectional survey conducted in China in which the estimated prevalence of PTSD was 13.7%.^31,32 However, in relation to international research, this is lower than a comparison study carried out during the SARS outbreak and more recent studies performed in East Africa, Europe and East Asia in the context of COVID-19 in which the estimated prevalence of PTSD ranged from 25.7% to 80.5%.^22,33 This discrepancy may result from the findings being influenced by different healthcare settings and various chronological periods during the COVID-19 pandemic in which these studies were conducted.³⁴

In this study, the profession of the MHCW, particularly being a nurse, was a significant predictor of PTSS. This is consistent with a cross-sectional survey among nurses in the Free State province, South Africa, in which 44% of nurses were screened positive for PTSD.³⁵ It is also in keeping with the findings of two cross-sectional studies based in China, which focused on the acute psychological effects of the COVID-19 outbreak on doctors and nurses working in affected hospitals.^36,37 This finding is also in keeping with an international review of mental health disorders in nurses during the COVID-19 pandemic, which reported that nurses were at the highest risk of developing PTSD-like symptoms, highlighting the need for appropriate psychological support for this high-risk group.³⁸ As was the case among participants in this study, the population found to be most at risk of developing PTSS included female nurses who worked in COVID-19-designated departments.^38,39

Poor levels of perceived social support of MHCWs in this study were associated with a higher rate of PTSS than in those with good levels of perceived social support; however, the sample size was too small to make meaningful conclusions. Participants with greater BRCS scores reported less PTSS. This was in keeping with a cross-sectional survey of 863 medical workers in China, in which perceived social support and active coping strategies were negatively correlated to depression, anxiety and stress.⁴⁰ In contrast, a South African-based survey revealed that moderate to high levels of coping behaviour and social support of hospital staff did not protect against psychiatric outcomes.³¹ However, these findings may have resulted from a smaller sample size in that particular study.

Global research found that being female, a younger HCW, earning a lower household income, working in a high-risk environment and undergoing quarantine were associated with a higher risk of PTSS.^{8,13,25,26,27,28} In addition, a study performed in Italy of 1379 HCWs found that having a colleague who died during the pandemic was associated with PTSS.⁴¹ However, none of the socio-demographic and COVID-19-related factors explored in this study were significant predictors of PTSS, which was out of keeping with findings in the literature.

There were limitations to this study. As a result of the cross-sectional nature, small sample size and specialised medical population, the findings may not be generalisable to other settings. It was also not possible to determine a causal relationship between pandemic-related exposure and associated outcomes. Data for this study were collected at a later stage of the pandemic, which may have impacted the degree of psychological distress experienced at that time. Participants were offered acute psychological containment but not referred for formal assessment in cases of probable PTSD. A strength of this study was that it addressed a significant research gap related specifically to the well-being of MHCWs.

In this cross-sectional study, the prevalence of PTSS among MHCWs, as well as the risk and protective factors associated with this outcome, were studied. An elevated prevalence of PTSS was found and was significantly associated with the profession of the MHCW.

Based on these findings, it is recommended that existing employee wellness programmes be strengthened to promote mental well-being and improve resilience among MHCWs. It is recommended that regular screening programmes be implemented to identify staff members’ psychological distress and enable appropriate referrals. It is also recommended to provide additional resources to high-risk professionals, such as nursing staff, to regulate psychological well-being better. This could include departmental debriefing following a traumatic event, mental health education-based workshops targeting nursing staff and implementing resilience training programmes, as well as mindfulness exercises and relaxation techniques.