Impacting Factors on Healthcare Workers´ Health and Safety in Times of COVID-19

(1)

Faculdade de Engenharia da Universidade do Porto

Rua Dr. Roberto Frias, s/n 4200-465 Porto PORTUGAL

VoIP/SIP: feup@fe.up.pt ISN: 3599*654 Telefone: +351 22 508 14 00 Fax: +351 22 508 14 40 URL: http://www.fe.up.pt Correio Electrónico: feup@fe.up.pt

MASTER IN OCCUPATIONAL

SAFETY AND HYGIENE

ENGINEERING

Dissertation presented to obtain the degree of Master in Occupational Safety and Hygiene Engineering Faculdade de Engenharia da Universidade do Porto

IMPACTING FACTORS ON HEALTHCARE

WORKERS´ HEALTH AND SAFETY IN TIMES OF

COVID-19

Bianca Louise Elliff

Supervisor: Professor Liliana Maria da Silva Cunha, phD (Assistant Professor, FPCEUP/FEUP) Guest Professor: Professor Joana Cristina Cardoso Guedes, phD (Assistant Professor, FEUP) President of the Juri: Professor Mário Augusto Pires Vaz, phD (Associate Professor, FEUP)

(2)

(3)

I

ACKNOWLEDGEMENTS

First and foremost, I would like to thank my family for all their support, especially my other half Raphael, who has kept me going and this work would not have been possible without his support. He is also responsible for giving me two of my greatest loves: Selina and Katherine.

I wish to express my sincere appreciation to my supervisor, Professor Liliana Cunha, who has guided me and ensured this thesis followed the right path towards success.

I would also like to thank all the healthcare workers whose assistance was a milestone in the completion of this project. I would like to thank these same workers for their service and endurance during these challenging times. They have become the heroes of this year and I am so very grateful for all they have done and continue to do to keep us all well and safe.

(4)

(5)

III

HIGHLIGHTS

1. The current study was performed to understand the impacting factor in the health and safety or healthcare workers.

2. The study had a large participation by nurses and female workers.

3. Healthcare workers felt apprehensive to work during the pandemic and had to work long shifts and additional rotations. Workers have also faced higher risk of infection due to shortage of personal protective equipment and difficulty in social distancing. Work violence has increased in the form of verbal aggression and spitting.

4. Inadequate government guidelines and lack of testing made available also had an impact on healthcare workers safety.

(6)

(7)

V

ABSTRACT

The COVID-19 pandemic has had a great impact on the world, especially amongst healthcare workers. The objective of this study was to understand the impacting factors on the health and safety of health sector workers. This was a cross-sectional study with anonymous participation to a self-answered survey focused on five topics: (a) Characteristics of the population of interest and their work, (b) The impact of COVID-19 on the lives of the population of interest, (c) The difference in life and work before and after the pandemic, (d) Health and safety of healthcare workers during the pandemic and (e) Anxiety and depression amongst the population of interest during the pandemic. A total of thirty-one surveys were completed with a significant response from nurses and female participants. From the results the present study verified that healthcare workers felt apprehensive to work during the pandemic and were faced with long shifts, shortage of staff, high risk of infection from difficulty in social distancing, shortage in personal protective equipment, workplace violence in different forms than before the pandemic began, inadequate government guidelines and lack of testing. These factors have had an impact in healthcare workers´ health and safety both physically and psychologically through increased stress, anxiety and even depression.

(8)

(9)

VII

INDEX OF FIGURES

Figure 1: Timeline for global pandemics and epidemics that had great impact on the world. ... 5

Figure 2: How COVID-19 compares to other viruses in terms of average basic reproduction number and fatality rate. ... 7

Figure 3: Business impact of COVID-19 on industries in the United Kingdom. ... 8

Figure 4: Characteristics of health care workers in highest exposure occupations. ... 10

Figure 5: Risk reduction framework for COVID-19 healthcare workers at risk of infection. ... 12

Figure 6: Healthcare workers´ apprehension towards working during the pandemic. ... 22

Figure 7: How physically clore to other people healthcare workers are when performing their current job – comparison between before and after the pandemic. ... 23

Figure 8: The importance of interactions in the work of healthcare workers – comparison between before and after the pandemic. ... 23

Figure 9: How often healthcare workers are exposed to diseases and infections in their current job – comparison between before and after the pandemic. ... 24

Figure 10: How often healthcare workers deal with unpleasant people – comparison between before and after the pandemic. ... 25

Figure 11: How often healthcare workers deal with aggressive or violent patients or patient families – comparison between before and after the pandemic.. ... 25

Figure 12: Symptoms from healthcare workers during the pandemic as indicators of stress and anxiety. ... 27

Figure 13: Results from the Hospital Anxiety and Depression Scale for Anxiety in healthcare workers. ... 28

Figure 14: Results from the Hospital Anxiety and Depression Scale for Depression in healthcare workers. ... 28

(12)

(13)

XI

INDEX OF TABLES

Table 1: Scores and interpretation of the Hospital Anxiety and Depression Scale... 16

Table 2: Characteristics of the sample of the study. ... 19

Table 3: Work location and work experience (in years) of the participants. ... 19

Table 4: Month of infection and number of participants infected. ... 20

Table 5: Statements from participants regarding contributing factors towards their COVID-19 infection and their protection from infection. ... 20

Table 6: Difference in working hours from before vs after the pandemic began. ... 22

Table 7: Personal protective equipment used by healthcare workers before the pandemic vs after the pandemic began. ... 24

Table 8: Statements from healthcare workers regarding aggression and violence from patients and their families. ... 26

(14)

(15)

XIII

GLOSSARY

BAME – Black and Minority Ethnicity EVD – Ebola Virus Disease

FFP3 – Filtering Face Piece Class 3 FRSM – Fluid Resistant Surgical Masks

HADS – Hospital Anxiety and Depression Scale HSE – Health and Safety Executive

MERS – Middle East Respiratory Syndrome NHS – National Health Service

NICE – National Institute for Healthcare Excellence PPE – Personal Protective Equipment

(16)

(17)

(18)

(19)

Elliff, Bianca Louise 3

1 INTRODUCTION

The subject addressed in this dissertation is a topic of great current impact. The COVID-19 pandemic, which started in 2019, is not the first viral outbreak with alarming proportions and mortality rates at a global level.

When a new zoonotic disease appears in a human population, a new pathological agent must be detected and identified quickly. Early identification, monitoring and surveying viruses circulating amongst humans is essential in preventing outbreaks and epidemics (Ellwanger, Kaminski, & Chies, 2017).

The “pandemic” label must have a sense of gravity to support the logic of having pandemic plans that are different from current public health programs. Insofar as these plans make it possible to respond effectively to the spread of serious infectious diseases, planning for hypothetical worst-case scenarios is valuable. However, these scenarios are rare and when they do occur, less people will need to convince themselves that urgent action is required (Doshi, 2011).

The ongoing pandemic has brought to light the importance of personal protective equipment (PPE) in the workplace and some of the key points towards the use of PPE are that coronavirus is a disease transmitted by contact or droplets from coughing and sneezing and PPEs are an important part of a system to protect staff and other patients from contamination (Cook, 2020).

Even though the importance of PPE has been a constant topic for discussion, the use of PPEs for long hours at work has caused discomfort, heat, makes verbal communication more difficult and reduces tactile sensitivity (Vidua, Chouksey, Bhargava, & Kumar, 2020).

There is a significant correlation between exposure to the disease and the physical proximity workers have across occupations (Office for National Statistics, 2020).

Health care workers have been constantly at risk during the COVID-19 pandemic facing exposure to pathogens, working long hours and shifts, phsychological distress, fatigue and burnout, and physical and psychological violence (World Health Organization, 2020).

A study also identified several risk factors and the main ones impacting in worker safety were long working hours, lack of PPE, having a diagnosed family member, insufficient or poor hand-washing, and improper infection control. It was also found that prolonged use of PPEs could lead to skin damage, especially on the nasal bridge (Shaukat, Ali, & Razzak, 2020).

The main objective of the present study is to understand the effect the pandemic has had on health workers in the United Kingdom and what measures have been implemented by employers to help mitigate risks and give support to workers.

The present dissertation is divided in two parts, the first part is set on reviewing the current literature on the novel coronavirus, although scarce, and government and health and safety guidelines, along with defining the objectives and methodology; the second part focuses on the analysis of results, discussion and final remarks.

(20)

Master´s in Occupational Safety and Hygiene Engineering

4 Introdução

This dissertation aims to provide further insight into the impacting factors in health worker safety in times of COVID-19 and contribute towards health and safety measures before the next pandemic.

(21)

2 LITERATURE REVIEW

2.1 Brief History of Pandemics

As demonstrated in Figure 1 the world has faced inumerous outbreaks and the World Health Organization (WHO) have said the challenges of improving international response and coordination are still far from ideal (World Health Organization, 2018).

Figure 1: Timeline for global pandemics and epidemics that had great impact on the world. Source: the Author.

In 1918 the world was devastated by an avian-borne flu that resulted in 50 million deaths. This pandemic was named the “Spanish Flu” after an outbreak in Madrid and swiftly spread across Europe and the rest of the world (History, 2020).

Another pandemic struck in 1957 starting in Hong Kong and spreading throughout China, then reaching the rest of the world. This was called the “Asian Flu” and after two waves of this pandemic it claimed the lives of around 1.1 million people worldwide. A vaccine was developed helping to contain the virus (History, 2020).

After initially developing in chimpanzees, HIV/AIDS spread to humans and was first identified in 1981. AIDS affects the immune system and death is usually caused by diseases that the body, without a healthy immune system, cannot fight off. A cure is yet to be found and latest studies show that the disease has claimed over 35 million lives worldwide since its discovery (History, 2020).

In the 21st_{century the world has seen many more virus outbreaks leading to epidemics or}

pandemics and in 2003 a virus named Severe Acute Respiratory Syndrome (SARS-CoV) was identified causing over eight thousand people to become ill worldwide. Although the WHO declared the outbreak over in 2003 there were several new reports in 2004 (Centers for Disease Control and Prevention, 2004).

Again, emerging in China there was an outbreak in 2004 of H5N1, an influenza virus with low transmission rates from human to human but with a high rate of mortality at 60%. There were no new cases reported to the WHO since 2011 but there are still no vaccines and there is huge concern of virus genetic changes that would cause the virus to be more transmitable (World Health Organization, 2011)

(22)

6 Literature review

In 2009 the world faced another viral outbreak named “Swine flu” or Influenza A (H1N1) that affected over 214 countries being declared a pandemic

Middle East Respiratory Syndrome (MERS) was identified in 2012, caused by a coronavirus, and does not have a vaccine available at present, although there are several vaccines for MERS in development (World Health Organization, 2019).

An Asian lineage of Influenza A (H7N9) virus was initially identified in 2013 with annual sporadic human infections and epidemics ever since. Around 39% of people confirmed to be infected have died (Centers for Disease Control and Prevention, 2018).

In 2014, the Ebola virus disease (EVD) outbreak caused great losses in West Africa with its fatality rate at 90% and still no vaccine or specific treatment available (World Health Organization, 2014). The latest viral outbreak has made the world revisit all responses and is a serious global health threat.

2.2 COVID-19

Coronaviruses are a type of virus and a newly identified strain of this virus called COVID-19 has caused a worldwide pandemic of respiratory illness (Johns Hopkins, 2020). Symptoms include a cough, fever or chills, shortness of breath or difficulty breathing, muscle or body aches, sore throat, new loss of taste or smell, diarrhea, headache, fatigue and nausea and vomiting. Sometimes the viral infection can be more severe causing even death.

The disease first emerged in the city of Wuhan, China, in December 2019, and although there are many investigations still ongoing early hypothesis suggests the outbreak is linked to a seafood market in Wuhan. The new coronavirus spreads through droplets released into the air and can travel not more than a few feet from an infected person when they cough or sneeze (Johns Hopkins, 2020).

COVID-19 is confirmed by a laboratory test scan and there is no specific treatment or vaccine for this virus. For severe cases patients are treated with supportive measures to releave symptoms (Johns Hopkins, 2020).

The average reproductive rate (R0) represents the number of secondary cases generated from one

infected individual and the WHO estimated around March 2020 that the reproductive number was around 2.5, indicating the contagiousness of the disease. The fatality rate for COVID-19 is between 3-4% (World Health Organization, 2020).

Although it does not seem as dangerous at first, COVID-19 is alarmingly close to the same data from the Spanish Flu of 1918, where R0 was 2.2 and the fatality rate was 2.5%, bringing global

leaders to place entire cities on lockdown and quickly act to respond to the threat. Figure 2 demonstrates a comparison between COVID-19 and other viruses in terms of their average basic reproduction number (contagiousness) and the fatality rate (deadliness) (McCandless, Kashan, Quick, Webster, & Starling, 2020).

(23)

Figure 2: How COVID-19 compares to other viruses in terms of average basic reproduction number and fatality rate. Source: The Author.

(24)

8 Literature review

As of September 2020, there were over twenty-five and a half million cases confirmed worldwide and over eight-hundred and fifty thousand casualties. The highest affected countries are the United States of America, Brazil, Mexico, India and the United Kingdom, respectively (Johns Hopkins, 2020).

2.3 COVID-19 in the United Kingdom

With the spread of the virus in the United Kingdom, many professions were impacted differently. Some workers were placed on the government furlough scheme for business continuity, where they would still receive their normal wages but not work, others started working from home and those who could not work from home began using PPEs to contain and prevent spreading the virus. There is a significant correlation between exposure to coronavirus and the physical proximity to others at work with all professions. Those found to be more exposed are healthcare workers, however many industries have also been affected with many completely closing or pausing trade, placing staff on furlough, as demonstrated in Figure 3 (Office for National Statistics, 2020).

(25)

The sector most impacted during the coronavirus pandemic in terms of safety and wellbeing has been the healthcare sector, therefore the present study focuses on healthcare workers, who have not stopped working and are actively at the frontline fighting agains the novel coronavirus.

2.4 Working Conditions Before the Pandemic

To better understand the effects of the COVID-19 pandemic it is important to evaluate the working conditions of healthcare workers before the pandemic began.

Healthcare professionals are faced with psychosocial challenges on a daily basis due to working conditions characterised by the shortage of skilled workers, increased workload and the complexity of tasks (Wagner, et al., 2019).

Even without the threat of COVID-19 healthcare workers have been exposed to work conditions where the transmission of other infectious diseases is also possible. A study by Tran et. al (2012) suggested that certain procedures where there is aerosol generation are associated to the increased risk of SARS transmission to health care workers. Tracheal intubation was identified as higher risk as it requires staff to be near patients for a prolongued period.

The NHS staff have always been potentially at risk of infections from a large number of different biological agents, where the source could be the laboratory or directly from patients themselves (NHS Employers, 2015).

The main principles for infection control in 2015 were to maintain hand hygiene, use PPEs, dispose of sharp objects after use and educate patients, carers and staff (NHS Employers, 2015).

2.5 Working Conditions During the Pandemic

Amidst the COVID-19 pandemic the world had to take urgent measures to strengthen capacities to protect the occupational health and safety of health workers and first responders. Health workers are at the front line in the coronavirus response and are exposed to a series of work hazards, including pathogen exposure, long working hours, phsychological distress, fatigue, occupational burnout, stigma and physical and psychological violence (World Health Organization, 2020). Prevention of infections requires appropriate measures by all health workers with special attention to hand hygiene, use of PPE and environmental and administrative controls when caring for patients with COVID-19 (World Health Organization, 2020).

The long hours of work have been found to cause headaches due to the compression from tight bands or straps around the head (Jonathan, et al., 2020).

From the above-mentioned hazards, physical and psychological violence and stigma are a high risk for health workers all over the world. According to the WHO between 8% and 38% of health workers have suffered physical violence at some point of their career and even more are exposed to verbal aggression and social stigma due to their work. During the pandemic the world was faced with a sudden shortage of staff and resources, causing an increase in social tensions and violence

(26)

10 Literature review

against front-line workers and other workers in health care facilities (World Health Organization, 2020).

Moral injury is a risk that health workers face due to their exposure to situations they do not feel prepared for. During the pandemic, healthcare workers require support to help mitigate the negative moral effects from the current situation and dilemmas they face (Greenberg, Docherty, Gnanapragasam, & Wessely, 2020).

Three out of four (75%) employees working in highly exposed occupations are women. One in five (20%) people working in these occupations are over 55 years of age. One in five (20%) workers are of black and minority ethnic (BAME) groups (Office for National Statistics, 2020). (Figure 4)

Figure 4: Characteristics of health care workers in highest exposure occupations. Source: Office for National Statistics (2020).

The WHO found that long and irregular working hours and high workload from the increased demand for health services and the psychological hazards from emergencies, where demands

(27)

increase and there is a high risk of infection and exposure to patients suffering and occasional deaths, have caused fatigue, occupational burnout, increased psychological distress and declining mental health (World Health Organization, 2020).

2.6 Risk Assesment

The National Health Service (NHS) is a complex health system structure operating in the United Kingdom and guidance provided to NHS organisations by the Health and Safety Executive help identify who is at risk of harm and a full risk assessment for staff (NHS Employers, 2020). Government guidelines state that only essential employees and people who cannot work from home should be on any given work site (GOV.UK, 2020).

The government also suggests that workplaces should involve employees and consider the protected characteristics of their employees, visitors and customers when conducting a risk assessment. The results of the risk assessment should be shared with the organisation´s workforce by displaying it prominently in the workplace, as well as on the website (GOV.UK, 2020). According to the Health and Safety Executive (HSE), employers should identify work activities and situations that might cause transmission of the virus, consider who could be at risk and how likely someone might be exposed and act towards removing the activity or situation whenever possible and control the risk in situations where removing the activity or situation is not possible (Health and Safety Executive, 2020).

It has been found that there is a disproportionate impact of coronavirus on NHS workers from BAME backgrounds. The risk assessment for these workers requires more sensitive engagement due to systemic issues in every NHS organisation identified by the Workforce Race Equality Standard (WRES), which added to discrimination make it more difficult for BAME workers to raise concerns and be heard within their organisations (NHS Employers, 2020).

According to the risk assessment guidance from NHS Employers and HSE there should be more attention to vulnerable workers. The NHS employ around 1.2 to 1.5 million people, from which 21% are from BAME populations (Khunti, et al., 2020).

Khunti et al. (2020) created a COVID-19 Risk Reduction Framework to be implemented in the NHS employer´s guidance to help employers with risk assessment of their staff. The Risk Reduction Framework (Figure 5) analyses the following criteria in order:

• A general workplace assessment of potential exposure to the virus and subsequent application of appropriate control measures, including increased hygiene and correct use of PPE.

• A workforce assessment to identify specific individuals with higher vulnerability to the virus and/or its adverse outcomes.

(28)

Figure 5: Risk reduction framework for COVID-19 healthcare workers at risk of infection. Source: Faculty of Occupational Medicine

The study performed by Khunti (2020) indicated that main categories of vulnerability and main factors that must be considered for the individual assessment are:

• Age: those over 70 years of age have been identified as vulnerable. • Sex: males have been identified as most vulnerable.

• Clinically vulnerable people, including those with underlying health conditions (hypertension, cardiovascular disease, diabetes, chronic kidney disease or chronic obstructive pulmonary disease) or co-morbidities.

(29)

• Pregnancy, especially over 28 weeks and/or with underlying health conditions. • Disabilities identified that might be subject of reasonable adjustments.

Pregnant healthcare workers are required to begin maternity leave from 28 weeks pregnant due to the high risk of infection.

Settings such as primary or community care, hospital settings or environments where aerosol generating procedures are performed must be taken into consideration (Khunti, et al., 2020). Staff from higher risk groups should have ongoing support including communication and dialogue with union and health and safety representatives, engage with relevant staff networks, speak up to raise any concerns and there is great importance in reviewing data from local COVID-19 incidence (NHS Employers, 2020).

2.7 Safety Measures at Work

Some measures are suggested to improve safety at work during the COVID-19 pandemic and it is very important to talk to workers and explain the changes planned and listen to their ideas too. Hand hygiene has become a serious topic for discussion and handwashing facilities should be provided and government guidelines suggest washing hands more frequently for at least 20 seconds (Health and Safety Executive, 2020).

Hand hygiene is extremely important for the health sector and is one of the best preventive measures to contain the spread of infections.

Social distancing is a new term which has been present since the start of the pandemic. Is consists of keeping people apart from each other either by confining them in their homes or establishing a minimum distance between them (Greenstone & Nigam, 2020). To help manage social distancing facilities, whenever possible, should have different entrance and exit points or arrival and departure times should be coordinated.

Although maintaining social distancing for healthcare workers is a challenge due to close contact with patients it is a necessary action for both healthcare workers and patients.

Two meters is the recommended distance between people and the number of individuals per work area should be low. Floor tape or paint can be used to mark social distancing and appropriate signage must be available. In many locations, screens can be found to create a physical barrier between people (Health and Safety Executive, 2020).

2.8 Personal Protective Equipment for Health Workers

Healthcare workers should be trained to know what PPE to wear for each setting and context and the Government of the United Kingdom set out a few guidelines towards each context for healthcare workers (GOV.UK, 2020).

(30)

Once the pandemic began, PPE shortages have been described in the most affected facilities around the world. Some medical professionals have been attending to patients who may be infected without appropriate PPE as these are sometimes unavailable (Lancet, 2020).

The PPEs most used are, according to the UK government: • Filtering face piece class 3 (FFP3) respirators • Fluid resistant (Type IIR) surgical masks (FRSM) • full-face shield or visor

• polycarbonate safety spectacles • Disposable plastic aprons

• Fluid repellent overalls or long-sleeved gowns • Disposable gloves

The correct use of PPE can protect workers against an infection, however extended or incorrect use and PPEs that do not fit appropriately offer more harm that safety to users. Research performed by Vidua et al. (2020) found that some of the adverse effects of wearing PPE for too long are facial bruisings, fatigue, dehydration, headaches, dizziness and even fainting.

2.9 Objectives

The greatest challenge currently in the world is the fight against COVID-19 and the pandemic caused by this virus while protecting the workforce and maintaining productivity. Each sector of economic activity has created measures to ensure the safety of staff and the present dissertation aimed to understand the impacting factors on the safety of workers amidst the pandemic, focusing on healthcare workers in the United Kingdom and their perception of how the new coronavirus has impacted their occupational health and safety.

(31)

3 PARTICIPANTS AND METHODS

The present study is designed as a cross-sectional study with anonymous participation to a self-answered survey. A survey research is a quantitative method, highly useful to describe situations and features of a group of people. The present survey was composed by a set of predetermined questions with open and closed end answers aiming to measure 5 study topics:

(a) Characteristics of the population of interest and their work: To understand the demographic characteristics of each participant in the study regarding gender, age group, ethnic background, profession, experience time in the healthcare sector and work location.

(b) The impact of COVID-19 on the lives of the population of interest: The objective was to capture aspects of each healthcare worker´s own experience with COVID-19, asking if they have ever had the disease or believe they have been infected. Other important aspects are when this infection might have taken place and if the participant has underlying health conditions that could worsen the symptoms of the novel coronavirus. It was also asked about each worker´s perception on what contributed either to their infection or their safety.

(c) The difference in life and work before and after the pandemic: An important aspect to understand is where the greatest impacts lie in the safety of healthcare workers. This sector explores the difference before and after the start of the pandemic in working hours, proximity to co-workers, exposure and preparedeness to diseases and hazardous conditions, dealing with unpleasant and violent people and PPE availability.

(d) Health and safety of healthcare workers during the pandemic: This sector covers aspects of each participant´s perception of the importance of their health and safety and that of their co-workers, besides aspects of communication and support from their organisation. Another aspect explored are the effects each participant has felt towards their own health and stress levels. (e) Anxiety and depression amongst the population of interest during the pandemic: This sector approaches the anxiety and depression of healthcare workers, which commonly coexist. Identifying workers with elevated anxiety can help with preventing depression, as anxiety usually precedes depression. The Hospital Anxiety and Depression Scale (HADS) verifies non-physical symptoms and is validated in many languages and countries as well as being one of the National Institute for Healthcare Excellence (NICE) recommended tools for diagnosis of depression and anxiety (Stern, 2014).

The inclusion criteria for the study were (1) be an active healthcare worker; (2) currently residing in the United Kingdom; (3) have online access to answer the survey; and (4) be able to read and comprehend the questions of the survey.

After informed consent of participants, the survey was conducted via Google Forms and all participants were maintained anonymous. The reach of participants was done via NHS staff

Facebook groups. NHS hospitals were also contacted but there was no success in communication.

Participants were required to answer all questions. The fields for each question on Google Forms were made mandatory. The complete survey can be viewed on Annex I.

(32)

16 Participants and methods

After data collection a descriptive analysis was performed to summarise and organise the data for easy understanding.

The HADS questions were alternated between anxiety and depression and to obtain the result one must add the scores for each of the items. Each item in from the HADS is scored from 0-3 and the total score for anxiety and depression, separately, can vary from 0 to 21 (Stern, 2014). Table 1 demonstrates the scores and interpretation.

Table 1: Scores and interpretation of the Hospital Anxiety and Depression Scale. (Stern, 2014)

Score Interpretation

0 – 7 Normal 8 – 10 Mild 11 – 14 Moderate 15 - 21 Severe

(33)

(34)

(35)

4 RESULTS AND DISCUSSION

A total of thirty-one surveys were completed. The main limitations to obtain a higher number of participants was the difficulty to engage with NHS management and obtain approval to send the survey to healthcare workers and the time constraint to complete the study, resulting in a lower participation rate.

The sample consisted of NHS staff, from different age groups, job titles and working in different facilities. The demographic characteristics of the sample is summarised in Table 2.

Table 2: Characteristics of the sample of the study. Source: The Auhor.

Characteristic of the study Number of

participants Percentage (%) Profession Nurse 25 80.65% Others 6 19.35% Gender Male 2 6.5% Female 29 93.5% Age group 18-24 1 3.2% 25-34 6 19.4% 35-44 5 16.1% 45-54 10 32.3% 55-64 8 25.8% 65 and over 1 3.2%

There was a significant difference in responses from different professions and the responses from nurses was the most present in the survey. The same occurred for the gender and background, where most participants were female. Only one participant was of BAME backgrounds.

The work location varied and there was a predominance of hospital workers in the present sample. There was also a predominance of people who have worked in the healthcare sector for over 21 years. These results can be observed in Table 3.

Table 3: Work location and work experience (in years) of the participants. Source: The Author.

Characteristic of the study Number of

participants Percentage (%) Work location Hospital 24 77.4% GP Surgery 2 6.5% Maternity Services 1 3.2% Community 6 9.7%

Strategic planning of children services 1 3.2% Work experience in the healthcare sector

(36)

20 Results and Discussion

6-10 years 5 16.1%

11-20 years 6 19.4%

Over 21 years 17 54.8%

From the participants in the survey, six healthcare workers (19.4%) claimed to have had COVID-19, nine healthcare workers (29%) believed they might have been infected but were never tested to confirm and sixteen healthcare workers (51.6%) affirm they have never had COVID-19. Ten healthcare workers believe they were infected with the novel coronavirus at work. Table 4 demonstrates the dates when workers believe they were affected.

Table 4: Month of infection and number of participants infected. Source: The Author.

Month of infection Number of

participants Percentage (%) January 1 3.2% February 0 0% March 4 12.9% April 5 16.1% May 1 3.2%

Unknown or not applicable 20 64.5%

From the thirty-one participants only eleven had underlying health conditions, which are an impacting factor to worsen symptoms of the virus. People who have underlying health conditions not only are at a higher risk of developing the disease but they are also more likely to die (Haybar, Kazemnia, & Rahim, 2020).

The reality for most healthcare workers is that even if they suffer from underlying health conditions, they might not have the option to take time off work. Six participants with underlying health conditions (19.4%) confirmed that taking time off was never an option for them and four participants with underlying health conditions (12.9%) had the chance to and took time off work or their current job. Only one participant with underlying health conditions (3.2%) opted not to take time off work. The remaining 64.5% participants did not have any underlying health conditions.

Table 5 presents statements from participants towards contributing factors to their COVID-19 infection or contributing factors towards their protection from infection.

Table 5: Statements from participants regarding contributing factors towards their COVID-19 infection and their protection from infection. Source: The Author.

What do you believe contributed towards your infection?

“Family member, working as care worker may have picked up from care home, due to lack of PPE and delay in government lockdown”

“Close proximity to patients and poor PPE” “Lack of PPE”

(37)

“Not being allowed to wear a mask around the hospital only until the government changed their minds”

“Constantly changing inadequate PPE guidelines and trust complacency” “Lack of awareness”

“I possibly had it before people were taking social distancing seriously” “I walked onto a ward without PPE, but this was my fault”

“Lack of PPE and staffing. Complacencies by ward manager and matron. Belittling staff worries and concerns. Lack of compassion and care from management”

“Close proximity to patients and lack of testing” “Lack of appropriate PPE. Lack of testing”

If you have never had COVID-19, what do you believe contributed for your safety?

“Sufficient PPE”

“Good PPE at work and well prepared”

“Unsure, PPE took a while to come into our work reality, women and partners were not being very compliant to start with, witholding information about symptoms or contact with others. My personal awareness of safety, keeping distance where possible, hand hygiene reinforcement, etc might have helped. It is difficult to state one helping factors as measures put in by hospital and government guidance were slow, scanty to start with, and working in Community still doing house visits I was more vulnerable. However somehow appears I kept safe!”

“Adequate PPE in department”

“Being as safe as possible with PPE and universal precautions”

“Work in very rural area very low numbers of covid patients on case load” “Working from home”

“Safe social distance and hand higiene and PPE”

“Adequate PPE, following government guidance during lockdown”

“Luck. Maybe a good immune system. Very good hands washing and cleaning” “PPE and extra prepared screening of patients”

Some repeated arguments suggest the main factors that contributed towards healthcare workers´ infection were the lack of PPE, inadequate government guidelines and lack of testing. On the other hand, participants who were not infected argued that the main factors that contributed towards their protection against a COVID-19 infection were adequate or sufficient PPE and a well-prepared work environment. This also indicates that although hospitals and clinics are part of the NHS system certain locations had more access to PPE.

Due to the high risk of infections that healthcare workers face they also fear contagion and spreading the virus to their families, which lead many professionals to self-isolate from their own household (Souadka, Essangri, Benkabbou, Amrani, & Majbar, 2020). Nine participants (29%) have self-isolated from their families during the pandemic because of their line of work, meaning they have been socially isolated from loved ones and susceptible to feeling lonely and upset at times.

(38)

When asked about feeling apprehensive to work considering the current conditions with the pandemic, 35.5% participants said they feel apprehensive at all times, 38.7% participants said they felt apprehensive only at the start of the pandemic but now feel more at ease and 25.8% participants said they did not feel apprehensive to work during the pandemic at any time (Figure 6).

Figure 6: Healthcare workers´ apprehension towards working during the pandemic. Source: The Author.

To better understand the impact on work conditions for healthcare workers it is important to evaluate the situation both before and after the pandemic began. Table 6 demonstrates the difference in working hours before and after COVID-19 where we can verify the impact the pandemic has had on working hours. The number of healthcare workers from the sample who work over 40 hours per week doubled since the beginning of the pandemic, indicating heavy workloads have been implemented to deal with the current situation and demand for health services.

Table 6: Difference in working hours from before vs after the pandemic began. Source: The Author.

Working hours per week

Before the pandemic After the pandemic began Number of participants Percentage Number of participants Percentage < 40 hours 20 64.5% 13 41.9% 40 hours 4 12.9% 4 12.9% > 40 hours 7 22.6% 14 45.2%

Another main factor for the safety against the transmission of COVID-19 is social distancing, where people maintain a safe distance from each other. This is not always possible when working in the health sector with most healthcare workers working physically close to other people at a very close distance, almost touching the other person. This situation has maintained the same for most workers before and after the pandemic began, indicating that even with prevention measures their work requires close proximity to others (Figure 7).

(39)

Figure 7: How physically clore to other people healthcare workers are when performing their current job – comparison between before and after the pandemic. Source: The Author.

The proximity of healthcare workers is not always only with patients, but with each other as a group or team. When questioned about the importance of interactions in their line of work, 58% participants said it was extremely important to perform their job, as demonstrated in Figure 8. There was no significant difference between before and after the pandemic began.

Figure 8: The importance of interactions in the work of healthcare workers – comparison between before and after the pandemic. Source: The Author.

The exposure to diseases or infection has also maintained almost the same frequency with most healthcare workers in this exposure situation daily both before and after the pandemic began (Figure 9). The occupational risk of acquiring diseases and infections is unavoidable in daily patient care (Kent & Sepkowitz, 1996).

(40)

Figure 9: How often healthcare workers are exposed to diseases and infections in their current job – comparison between before and after the pandemic. Source: The Author.

Nineteen participants (61.3%) feel they are exposed to hazardous conditions and twenty-four participants (77.4%) feel prepared to deal with hazardous conditions if they are faced with them. The use of PPE is the most important strategy to protect healthcare workers from potential pathogens (Honda & Iwata, 2016). The use of PPEs increased significantly after the start of the pandemic as demonstrated in Table 7.

Table 7: Personal protective equipment used by healthcare workers before the pandemic vs after the pandemic began. Source: The Author.

Personal Protective Equipment

Number of participants Before the

pandemic

After the pandemic began

Filtering face piece class 3 (FFP3) repirator 0 8

Fluid resistant (Type IIR) surgical mask 5 27

Full-faced shield or visor 1 15

Polycarbonate safety spectacles 3 5

Disposable plastic aprons 27 28

Fluid repellent overalls 0 5

Long-sleeved gowns 1 7

Disposable gloves 27 25

The increase in PPE usage also brought an increase in their shortage. Before the pandemic only 19.4% participants reported having faced shortage of PPE and after the pandemic began this number increased to 51.6% participants reporting shortage of PPE. The lack of PPEs was stated by one participant as a reason he now dislikes his job:

“I now hate my job. I hate the politics and being told by my matron not to use PPE sent by the Covid room because the trust says it’s scarce.” [Nurse, Female, 35-44 years of age]

Twenty-three participants (74.2%) indicated receiving additional training to cope with the pandemic, including how to use PPE correctly.

Another risk healthcare workers face is experiencing workplace violence, which is defined by the International Labour Organization as “Any action, incident or behavior that departs from

(41)

reasonable conduct in which a person is assaulted, threatened, harmed, injured in the course of, or as a direct result of, his or her work” (International Labour Organization, 2003). The consequences of workplace violence can be physical, psychological, emotional, related to work functioning and the relationship with patients, interfering with quality of care (Lanctôt & Guay, 2014). Healthcare workers who participated in the study indicated dealing with unpleasant people the most at least once a week, but not daily. There was a slight decrease in weekly cases and a slight increase in daily cases, but in general dealing with unpleasant people showed no significant difference in frequency before and after the pandemic began (Figure 10).

Figure 10: How often healthcare workers deal with unpleasant people – comparison between before and after the pandemic. Source: The Author.

When questioned about dealing with aggressive or violent patients or family members the participants indicated an increase in daily ocurrences after the pandemic began in comparison to before the pandemic. (Figure 11).

Figure 11: How often healthcare workers deal with aggressive or violent patients or patient families – comparison between before and after the pandemic. Source: The Author.

(42)

The present study also aimed to comprehend better the type of violence healthcare workers face and asked each participant to provide details of their assaults, threats, or injuries. Before the pandemic began most agressions were physical, such as kicking, punching and bitting, whereas after the pandemic began most aggressions were verbal or even relating to spitting on healthcare workers, which can be explained by the social distancing guidelines and new forms of aggression. The statements provided can be found in Table 8.

Table 8: Statements from healthcare workers regarding aggression and violence from patients and their families. Source: The Author.

When aggression or

violence happened Statement

Before the pandemic

“I have been punched and kicked whist working as a nurse before. Verbally abusive and swearing at times as well as threatened attitude.

Not as much now as Midwife but at times some attitudes can be counted as as almost threat.”

Before the pandemic “Mainly threats of violence, colleagues have been hurt before.” Before the pandemic

“Kicked by a patient post anaesthetic, rugby tackled to the floor and sat on by a mental health patient, punched in the mouth by a dementia

patient.”

Before the pandemic “I have been kicked, punched, slapped, bitten and scratched.” After the pandemic “I was kicked in the back several times last week helping a patient who

fallen, this week I was spat at in the face!”

After the pandemic “Pushed, kicked and spat at.”

After the pandemic “Punched in the face by a patient with dementia.”

After the pandemic “Just verbal.”

Violence at the workplace can lead to various negative impacts in the physical and psychological health of healthcare workers, leading to an increase in stress and anxiety levels and feeling of anger, insecurity and burnout (Mento, et al., 2020).

The act of spitting on another person has shown to be more present after the pandemic began, which indicates a far more aggressive form of violence that includes the threat of viral transmission and humiliation of the victim leading to elevated anxiety and stress and possible infection by COVID-19, which in certain cases can be fatal.

When asking the participants about what stress and anxiety related symptoms they have been feeling since the beginning of the pandemic and lockdown the five most reported symptoms were feeling overwhelmed, sleeping too much or too little, eating too much or too little, feeling constantly worried and headaches or dizziness. The full list of symptoms can be found in Figure 12.

(43)

Figure 12: Symptoms from healthcare workers during the pandemic as indicators of stress and anxiety. Source: The Author.

Social support given to healthcare workers can cause a reduction in anxiety and stress leves and can cause an increase in self-efficacy (Spoorthy, Pratapa, & Mahant, 2020). Fourteen participants (45.2%) believe there is poor communication with their employer regarding the current situation and when asked about the main changes between before and after the pandemic some healthcare workers expressed their concerns with the workplace environment and handling of the pandemic.

“What changed the most is the increased levels of anxiety regarding wellbeing of the team and the total disrespect, lack of confidence and disappointment towards higher level nurse management, in their attitude and lack of compassion towards ward staff. Makes me wonder why I have been in this profession for so long.” [Nurse, Female, 45-54 years of age]

Even with the dissatisfaction of some healthcare workers towards management, twenty-three participants (74.2%) affirmed that their employers offered help to cope with mental stress.

To fully evaluate the anxiety and depression levels of healthcare workers the survey also included the HADS, which evaluates the level of anxiety and depression as independent measures. When the anxiety level is high or rising it is important to identify the employee before this transitions to depression to implement intervention methods (Stern, 2014).

Based on the HADS, 17% participants face a severe case of anxiety, 30% participants face a moderate case of anxiety, 7% participants face a mild case of anxiety and 46% participants are within normality and not suffering from anxiety. In terms of depression, 54% participants are within normality and not suffering from depression, whereas 13% participants face a severe case

(44)

of depression, 13% participants face a moderate case of depression and 20% participants face a mild case of depression (Figure 13 and 14).

Figure 13: Results from the Hospital Anxiety and Depression Scale for Anxiety in healthcare workers. Source: The Author.

Figure 14: Results from the Hospital Anxiety and Depression Scale for Depression in healthcare workers. Source: The Author.

From the results of the HADS we can conclude that 54% of the healthcare workers who participated in the present study are currently suffering with some level of anxiety and for some that has already translated into depression and require immediate attention from their employers so the conditions do not develop further.

Many changes were made in the health sector since the start of the pandemic and from statements of each participant these could be divided into six categories: (a) PPE, (b) Social distancing, (c) Personal life, (d) Fears, (e) Compliance to regulations and (f) Shortness of staff. Table 9 presents the main statements from each participant regarding the main categories.

(45)

Table 9: Main categories and statements regarding changes since the pandemic began. Source: The Author.

Category Statement

PPE

“The greatest change has been wearing full PPE for hours on end.” “Use of PPE, proper infection control policies in place.”

“Wearing masks and visors for all interactions. Not being allowed to wear long sleeve gowns for rehab sessions when very close to patients who are incontinent and needing to be on the bed behind them when helping them sit

up. Having to wear PPE for all interactions even to stand near someone having a discussion.”

“PPEs improved.”

Social distancing

“The difficulty in having to remain distant when wanting to be closer contact as my work requires as a Midwife. The flexibility and mental gymnastics to

assess and reassess each individual needs at start of shift and as day went along, having to fundament all actions taken with or against new guidance,

constantly to repeat myself and explain several times the changes in care pathways.”

“Self isolation at home.” “Shielding isolation.”

Personal life

“Putting my personal life in second plan, to ensure it would not interfere with safety of the ones I care for at work, as well as being afraid to resume life in

society as errant and inconsequent behaviours notes in the community surrounding me.”

“Not being able to visit my family.”

“Juggling childcare as a single parent plus the increased expectation of work.”

“I feel I have put my family safety at risk.”

“The inconvenience of not being able to live a normal life by quarantining the healthy and destroying the economy.”

Fears

“The unknown - not knowing if it would get worse or how it would affect you as an individual”

“Having to work in unfamiliar environments with new routine and feel weary that might be missing out on an important care need for lack of familiarity

with the woman’s or baby’s clinical needs and family routines and characteristics.”

“The unknown, and watching staff go downhill very quickly as they got symptoms.”

“More irritable, fear of uncertainty, worrying for my loved ones.”

Compliance to regulations

“I saw a big change in patient compliance with wearing masks.” “Seeing how people still acted and still act like there’s not a pandemic and

are living life as normal.”

“Measures to avoid bringing contamination home.” “Staff compliance for hand hygiene.”

Shortness of staff

“Shortness of staff and several rotations during the day to cover such shortness.”

“Not enough people to do the job.”

From the statements above, the main changes in PPEs since the start of the pandemic are related to the time workers spend using them and the availability of additional PPE.

(46)

Regarding social distancing, the health sector requires close contact of healthcare workers and patients and the implementation of social distancing has brought challenges to how people perform their daily tasks. Another important factor for social distancing is the self isolation needed from healthcare workers with coworkers and patients, which is not easy given the proximity required to perform tasks.

Patient care has become distant and impersonal, with healthcare workers wearing PPEs from head to toe and for certain professionals this has become a challenge to perform their day to day activities, especially those where professionals wish to show compassion towards patients and family members.

The personal life of healthcare workers was severily impacted as they could possibly endager family members or patients from close contact with others, as they are not able to live normally and must sometimes completely isolate from family members for months.

The “unknown” was mentioned a couple of times as one of the main fears amongst healthcare workers due to unfamiliar circumstances, environments, routines, and concerns for safety for themselves and family members.

Regarding compliance to regulations, healthcare workers have been more compliant towards safety measures, but one participant highlighted that many people do not understand or act as if they were in a pandemic situation, completely ignoring safety protocol and government guidelines. Another healthcare worker mentioned noticing higher compliance from patients at the hospital to safety guidelines, which was not seen prior to the pandemic.

The long shifts and working hours are most likely related to the shortness of staff. There is insufficient staff qualified to perform certain tasks and this leads to a need for longer and multiple rotations.

The uncertainty of immigrant healthcare workers status due to Brexit has impacted in the number of international recruitments (Buchan, Charlesworth, Gershlick, & Seccombe, 2019) and added to the closure of borders driven by the pandemic there is a shortage of qualified professionals. According to Baker (2020) of every 1,000 NHS staff in England, 862 are British and 55 are from the EU and the most common nationalities of NHS staff are British, Indian, Filipino, Irish, Polish, Nigerian and Portuguese.

The shortage of staff in the NHS is partly related to international qualified workers who left the UK since the threat of Brexit and their residency in the country and also partly related to the demand for health workers worldwide during the pandemic, which added to the closure of borders meant that no workers were able to come to the UK and work in hospitals here treating coronavirus patients.

Healthcare workers have been faced with a number of challenges during the pandemic and require that the government and health institutions be more prepared to handle crisis situations such as COVID-19.

(47)

5 CONCLUSIONS

The impact of COVID-19 worldwide has proven to be a challenge for many sectors. The health sector has seen the impact of the novel coronavirus as the frontline to treat patients with symptoms and being a sector that has not only continued to work throughout the pandemic and lockdown, but has faced its own challenges to cope with the demand and increase in workload.

Most healthcare workers felt apprehensive to work during the pandemic at one point and the shortage in staff resulted in long shifts of over 40 hours after the pandemic began, which were factors contributing towards an increase in stress and anxiety. The NHS relies strongly on immigrants to complete the workforce and a combination of fears from Brexit and closure of borders due to the pandemic have prevented the international recruitment of healthcare workers, ultimately causing shortage in staff, who have been overloaded with the number of patients with COVID-19.

There has been a high risk of infection amongst healthcare workers due to the difficulty to social distance and treat patients at a certain distance. The usual distance for most patient care is at a very close proximity, almost touching the patient and for these cases the use of PPE is extremely important. Social distancing and the use of PPE also impacted negatively patient care as many healthcare workers cannot verbally communicate as before with patients and treatment has become impersonal and this affects the relationship between patient and caregiver.

There was a significant increase in PPE use and guidelines indicating that employers were aware of its importance and also provided additional training for healthcare workers, however this also increased the national shortage in PPEs, due to the unexpected demand for supply chains, resulting in an insecure workplace and even higher risk of infection and spreading of the virus.

The increase in PPE use for long hours has also caused harm to healthcare workers in some cases, such as discomfort, heat, and facial bruising, indicating that the workplace did not take certain aspects of purchasing PPE into consideration to increase comfort.

The health sector has always dealt with several unpleasant and aggressive patients and family members and the amount of workplace violence increased during the pandemic, escalating to spitting and verbal abuse of workers. One of the interesting results of the present study was that the act of spitting increased since the start of the pandemic and can be seen as the most aggressive form of violence due to the threat of infection and humiliation the action portrays.

The main factors that contributed towards healthcare workers´ infection were the shortage of PPE, inadequate government guidelines and lack of testing. Some locations had an adequate or sufficient PPE supply and the work environment was more well-prepared to deal with the pandemic and surge of patients, which resulted in increased safety for healthcare workers.

These factors have had an impact in healthcare workers´ health and safety both physically and psychologically through increased stress, anxiety and even depression.

The present study suggests that health institutions should recruit and train more healthcare workers to prevent understaffing, increase security against aggressive patients and family members, consult

(48)

32 Conclusões e perspetivas futuras

with staff about discomforts in current PPE and increase communication on government guidelines and safety procedures. These suggestions are intended to increase staff safety and wellbeing and decrease levels of stress and anxiety, however for those members of staff who already suffer from both conditions health institutions should ultimately implement support measures to deal with the increased levels of stress and anxiety amongst workers and implement steps to fight back anxiety and depression.

Even though healthcare workers are focused on maintaining the general public safe and healthy they also require attention and care from their employers to be able to perform their jobs in a healthy and safe manner.

(49)

6 BIBLIOGRAPHY

Baker, C. (04 de June de 2020). NHS staff from overseas: statistics. House of Commons Library: https://commonslibrary.parliament.uk/research-briefings/cbp-7783/

Buchan, J., Charlesworth, A., Gershlick, B., & Seccombe, I. (February de 2019). A critical moment: NHS staffing trends, retention and attrition. The Health Foundation.

Centers for Disease Control and Prevention. (2004). Frequently Asked Questions About SARS. Retrieved from https://www.cdc.gov/sars/about/faq.html

Centers for Disease Control and Prevention. (2018). Asian Lineage Avian Influenza A(H7N9)

Virus. Retrieved from https://www.cdc.gov/flu/avianflu/h7n9-virus.htm

Cook, T. M. (2020). Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic – a narrative review. Anaesthesia, 920-927.

Doshi, P. (2011). The elusive definition of pandemic influenza. Bulletin of the World Health

Organization, 532–538.

Ellwanger, J. H., Kaminski, V. d., & Chies, J. A. (2017). How to detect new viral outbreaks or epidemics? We need to survey the circulation of viruses in humans and other animals using fast, sensible, cheap, and broad-spectrum methodologies. Brazilian Journal of Infectious

Diseases, 21, 211-212.

GOV.UK. (18 de June de 2020). COVID-19 personal protective equipment (PPE). GOV.UK:

https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe

GOV.UK. (2020). Reopen your business safely during coronavirus (COVID-19). GOV.UK: https://www.gov.uk/coronavirus-business-reopening/y/none/over_4/yes/yes/no/yes Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental health

challenges faced by healthcare workers during covid-19 pandemic. BMJ.

Greenstone, M., & Nigam, V. (March de 2020). Does Social Distancing Matter? University of Chicago, Becker Friedman Institute for Economics Working Paper No. 2020-26.

Haybar, H., Kazemnia, K., & Rahim, F. (2020). Underlying Chronic Disease and COVID-19 Infection: A State-of-the-Art Review. Jundishapur Journal of Chronic Disease Care. Health and Safety Executive. (2020). Working safely during the coronavirus (COVID-19)

outbreak. Health and Safety Executive:

https://www.hse.gov.uk/coronavirus/working-safely

History. (2020). Pandemics That Changed History. Retrieved from https://www.history.com/topics/middle-ages/pandemics-timeline

Honda, H., & Iwata, K. (2016). Personal protective equipment and improving compliance among healthcare workers in high-risk settings. Current Opinion in Infectious Diseases, 400-406.

(50)

34 Bibliography

International Labour Organization. (October de 2003). Code of practice on workplace violence in

services sectors and measures to combat this phenomenon. Geneva: International Labour

Office. INTERNATIONAL LABOUR ORGANIZATION.

Johns Hopkins. (2020, June 28). Coronavirus Resource Center. Retrieved from https://coronavirus.jhu.edu/

Jonathan, J. Y., Bharatendu, C., Goh, Y., Tang, J. Z., Sooi, K. W., Tan, Y. L., . . . Sharma, V. K. (2020). Headaches Associated With Personal Protective Equipment – A Cross‐Sectional Study Among Frontline Healthcare Workers During COVID‐19. Headache, 864-877. Kent, A., & Sepkowitz, M. (1996). Occupationally Acquired Infections in Health Care Workers.

Annals of Internal Medicine.

Khunti, K., de Bono, A., Browne, I., Greenhalgh, T., Hanif, W., Majeed, A., . . . Smeeth, L. (2020).

Risk Reduction Framework for NHS Staff at risk of COVID-19 infection. Faculty of

Occupational Medicine.

Lancet. (2020). COVID-19: protecting health-care workers. Elsevier Public Health Emergency

Collection.

Lanctôt, N., & Guay, S. (2014). The aftermath of workplace violence among healthcare workers: A systematic literature review of the consequences. Elsevier, 492-501.

McCandless, D., Kashan, O., Quick, M., Webster, K., & Starling, S. (2020). Centers for Disease

Control, World Health Org, CIDRAP. The MicrobeScope:

https://www.informationisbeautiful.net/visualizations/the-microbescope-infectious-diseases-in-context/

Mento, C., Silvestri, M. C., Bruno, A., Muscatello, M. R., Cedro, C., Pandolfo, G., & Zoccali, R. (2020). Workplace violence against healthcare professionals: A systematic review.

Elsevier.

NHS Employers. (25 de March de 2015). Protecting staff from infection. NHS Employers: https://www.nhsemployers.org/~/media/Employers/Publications/Protecting%20staff%20f rom%20infection.pdf

NHS Employers. (02 de July de 2020). Risk assessments for staff. NHS Employers: https://www.nhsemployers.org/covid19/health-safety-and-wellbeing/risk-assessments-for-staff

Office for National Statistics. (11 de May de 2020). Which occupations have the highest potential

exposure to the coronavirus (COVID-19)? Office for National Statistics:

https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemp loyeetypes/articles/whichoccupationshavethehighestpotentialexposuretothecoronavirusco vid19/2020-05-11

Shaukat, N., Ali, D. M., & Razzak, J. (2020). Physical and mental health impacts of COVID-19 on healthcare workers: a scoping review. Int J Emerg Med.