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Abstract
Objective To assess the perceived social support and professional quality of life (ProQOL) among healthcare professionals during COVID-19 pandemic in Nepal, encompassing both positive (compassion satisfaction) and negative (compassion fatigue) dimensions as well as the factors associated with them.
Design A cross-sectional web-based study.
Setting Nepal
Participants We carried out a convenience sampling technique to enrol 313 health professionals aged 18–60 years old.
Outcome measures We employed the ProQOL V.5 questionnaire (comparing 30 self-report items) and the Multidimensional Scale of Perceived Social Support with 12 items to assess the ProQOL and social support, respectively. A χ2 test was performed to determine associated factors of different dimensions of ProQOL.
Results The study included a total of 313 participants, mostly consisting of frontline health workers. More than one-third of the participants worked in places where precautionary measures were insufficient. However, the majority of them (73.8%) had high social support. Concerning the ProQOL, the percentage of health professionals that had moderate compassion satisfaction (CS), moderate Burnout (BO) and moderate secondary traumatic stress (STS) were 57.5%, 58.2% and 75.4%, respectively. Factors like sex, marital status, profession, work-shift, type of health institution and status of precautionary measures at the workplace were associated with the different dimensions of ProQOL at the significance level of 0.05.
Conclusion This study findings revealed a considerable proportion of BO and STS among health professionals during COVID-19 pandemic in Nepal. Implementation of appropriate interventions and support systems are needed to enhance CS, alleviate BO and mitigate STS among health professionals to combat future health emergencies.
- COVID-19
- quality of life
- percieved social support
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The use of well-established and validated instruments to measure both perceived social support (Multidimensional Scale of Perceived Social Support) and professional quality of life (ProQOL V.5 questionnaire) have enhanced the reliability and comparability of the study’s findings.
The involvement of mostly frontline health professionals in our study managing the COVID-19 pandemic has made the findings more relevant to those working in high-risk environments.
The use of convenient sampling method may have introduced selection bias, limiting the representativeness of health professionals in Nepal.
Due to self-reporting, social desirability bias in the completion of questionnaires is not excluded in this research.
The data have been obtained from a cross-sectional design study, which does not allow the examination of changes in our outcome variables over time.
Introduction
The global pandemic of COVID-19 emerged from Wuhan, China, in December 2019, then spread throughout the world and was declared a global pandemic on 11 March 2020. It attracted international concern about its psychological impacts on healthcare workers.1 2 Till 9 November 2020, globally there were 18 million total active cases and more than 5 million deaths had occurred. In Nepal, till 9 November 2020, there were more than 7000 total active cases and more than 11 thousand total deaths had occurred.3
During such health emergencies, the demand for healthcare services was expected to increase and burdened Nepal’s already poor healthcare system. Health professionals were involved in the diagnosis, treatment, prevention and care of patients with COVID-19 and it imposed a huge psychological impact on them because they were the first to deal with the care and management of COVID-19 patients.4 5 The fear of being infected, risk of spreading the disease to family members, stigmatisation, uncertainty in the duration of the pandemic, lack of effective treatment protocols and strategies and potential shortages of personal protective equipment (PPE) further amplified their psychological burden, and potentially affecting their professional quality of life (ProQOL).6 7
During infectious disease outbreaks, psychological impact faced by the health professionals could be immediate or sustained. It was found that health workers who were at high risk of contracting such infectious disease appear not only to have chronic stress but also to have higher levels of depression and anxiety.5 One study done among healthcare workers exposed to SARS-CoV-2 found that they were at risk of burnout (BO) and secondary traumatic stress (STS), which could lead to adverse mental health outcomes.6 However, another study conducted among nurses in Thailand in 2020 during first wave of COVID-19 pandemic found that the ProQOL of nurses was good. They had higher level of compassion satisfaction (CS) and a lower level of BO. According to this study, such finding might be due to the short duration of the first wave of the COVID-19 pandemic as well as due to the high spirit of care in Thai culture.8
For public health, ensuring a high standard of care during and after health emergencies like infectious disease epidemics and pandemics is a top priority. Health professionals have a huge role at all levels of the health system. A quick review incorporating studies from 2003 onwards focusing on the psychological effects of pandemics and epidemics on the mental well-being of healthcare professionals revealed that those engaged in patient care during such crises face heightened risks of mental health issues both in the immediate and prolonged periods. Specifically, these risks encompass psychological distress, sleep disturbances and substance misuse as well as symptoms indicative of post-traumatic stress disorder, depression, anxiety, BO and anger.9 10 This implies that healthcare professionals require psychological assistance to protect their mental health to sustain the delivery of quality patient care.
ProQOL, particularly for healthcare providers during health emergencies, is crucial to be highlighted. ProQOL encompasses two main aspects: CS, which relates to the fulfilment derived from effective work as a helper, and compassion fatigue (CF), comprising BO and STS. BO reflects feelings of hopelessness and difficulties in managing work responsibilities, while STS involves experiencing trauma-related symptoms due to secondary exposure to others’ distressing events. These effects may include fear, sleep disturbances, intrusive thoughts or avoidance behaviours related to traumatic experiences.11
In addition, social support perceived by caregivers plays an important role in psychological well-being and quality of life. Social support is one of the predictors of their mental well-being and quality of life.12 Social support involves receiving resources through social interactions, assisting individuals in coping with uncertainty and enhancing their sense of personal control. For healthcare professionals, support from supervisors, family members and colleagues correlates strongly with reduced job strain and better health outcome. The role of social support and its protective relationship to mental health has been widely focused on the COVID-19 pandemic.13 14
In Nepal, few prepandemic studies evaluated the ProQOL. One of them studied among medical doctors revealed moderate levels of BO and STS among participants.15 Since then, as per our knowledge, there has been no further assessment of healthcare workers’ ProQOL. However, few segmented studies during the COVID-19 pandemic highlighted significant psychological impacts, particularly on frontline medical and nursing staff in emergency departments.16 17 Given this, there is a crucial need for a comprehensive exploration of healthcare professionals’ ProQOL, encompassing both positive (CS) and negative (compassion fatigue) aspects, along with perceived social support during the pandemic in Nepal. Therefore, the objective of this study was to assess the perceived social support and ProQOL among health professionals during the COVID-19 pandemic in Nepal. We believe that this study will fulfil this research gap and hence support the development of tailored strategies, and interventions aimed at enhancing the well-being of health professionals during health emergencies like COVID-19 pandemic.
Methods
Study design/setting
We conducted a descriptive cross-sectional web-based study among health professionals of age 18–60 years, working in public and private health facilities of all levels in Nepal between December 2021 and March 2022. Health professionals in our study included doctors, nurses, dentists, diagnostic personnel, public health practitioners, pharmacists, primary healthcare workers and other paramedics.
Sample size and participants recruitment technique
The sample size was calculated considering estimates from previous study and using the formula, n=(z2 pq)/d2.18 The value of z was 1.96 at 95% CI. We referred to the baseline prevalence of BO (p) of 0.72 among medical doctors from the previous study in Nepal.15 In our study, allowable error was 5% and the final adjusted sample size (n) was 357, assuming the 15% non-response rate.
We carried out a convenience sampling technique to collect the required number of samples. Following the approval of our research proposal by the ethics committee, we employed the data collection tools through online platforms such as email, Facebook Messenger, WhatsApp and Viber conveniently to those who were interested in participating in the survey. The data collection continued for more than 3 months, which was started from the last week of December 2021 ending at the end of March 2022. To limit the non-health workers’ responses to the survey, Google Forms was sent only after an invitation to potential participants. The total number of participants recruited for the study was 313 and the non-response rate in our study was 12.4%.
Data collection tools
The ProQOL was evaluated with the ProQOL Scale Version 5 (ProQOL 5) It consists of 30 items with a Likert-type score of 5 points (from 1=never to 5=very often). The questionnaire is composed of three subscales: CS (10 items), BO (10 items) and STS (10 items). The higher the score in each of the dimensions, the higher the level of CS, BO and STS respectively. The scores can be categorised in each of the subscales into STS (≤22 low; 23–41 moderate; ≥42 high); CS (≤22 low; 23–41 moderate; ≥42 high); and BO (≤22 low; 23–41 moderate; ≥42 high).19 (online supplemental annex 1).
Supplemental material
Perceived social support was evaluated by the Multidimensional Scale of Perceived Social Support (MSPSS).20 It consists of 12 items with a score of 7 points (from 1=very strongly disagree to 7=very strongly agree). The mean scale score ranging from 1 to 2.9 could be considered as low social support, a score ranging from 3 to 5 could be considered as moderate social support, and a score ranging from 5.1 to 7 could be considered as high social support. These tools were made freely available for use by the owners (online supplemental annex 1).
Eligibility criteria
The inclusion criteria of our study were health workers aged 18 and above and living in Nepal. Participants who did not have internet access were excluded from the study. Also, the health professionals who were not engaged in the management (identification, prevention, control and treatment) of COVID-19 pandemic were excluded from the study to increase the relevance of the study findings to those working in high-risk environments.
Study variables
Independent variables of our study include sociodemographic characteristics (age, sex, ethnicity, marital status, family type, etc) and work-related variables (level of health institution, type of health facility, work experience, work role, profession, working time, work shift, work contract, etc), whereas dependent variables include different dimensions of ProQOL (CS, BO, STS).
Statistical methods
After extracting data from Google spreadsheet, cleaning and storing were performed using Excel 2013 and statistical analysis was performed using SPSS software, V.25.0 (SPSS, Chicago, Illinois). Descriptive analysis was done by calculating the frequency and percentage of the categorical variables and the mean and SD of continuous variables. A χ2 test was performed to find the association between categorical dependent variables and categorical independent variables. A p value ≤0.05 was considered statistically significant.
Ethical consideration
The participation was voluntary and we maintained the confidentiality and anonymity of the respondents at all stages of data management by using unique code numbers and by storing data in password-locked laptops with access to the research team only.
Patient and public involvement
Participants were not involved in the design, implementation, reporting or dissemination plans of our research.
Results
Descriptive statistics
Sociodemographic characteristics of the respondents
The study included a total sample of 313 health professionals, 143 (45.7%) men and 170 (54.3%) women with a mean age of 26.87±4.68 years. The minimum age of the respondents was 20 years and the maximum age was 48 years. The largest ethnic group represented in the sample was Brahmin (34.2%), followed by Chhettri (23%), Janajati (23%), Madhesi (15.3%) and Dalit (4.5%). Most of the respondents were unmarried (68.7 %). While categorising the family type, the majority of respondents (69.3%) had a nuclear family (table 1).
Sociodemographic and work-related characteristics of the participants (n=313)
Work-related characteristics
Our study encompassed 71 (22.7%) doctors, 106 (33.9%) nurses and 136 (43.5%) paramedics. Among the health professionals surveyed, 202 (64.5%) reported having less than 5 years of work experience, while the remainder possessed 5 years or more. A majority of participants, totalling 181 (57.8%), were employed in governmental health institutions. Likewise, nearly half of the participants (47.3%) were working in tertiary-level health institutions, and the majority (81.5%) served as frontline workers. Additionally, 228 (78.8%) participants had temporary job contracts, and 44.2% were working during the day shift only, while 55.9% of the participants were working during both day and night shifts. On average, participants worked 8.15 hours per day.
Furthermore, approximately 44.1% of the participants received COVID-19 incentives (which were received as a hazard allowance in addition to basic pay), and 55.3% reported having been infected with COVID-19 at some point. Notably, 95.5% of participants received timely COVID-19 vaccinations. However, 35.1% of participants perceived inadequate precautionary measures in their workplaces (table 1).
Perceived social support
The average score for perceived social support was 5.37±0.949, with scores ranging from 1 to 6.8. Perceived social support scores were then classified into three categories based on the MSPSS. A majority of respondents (73.8%) reported high social support, while 23% indicated moderate social support, and 3.2% reported low social support.
Professional quality of life
Regarding the ProQOL-5 subscale scores, the mean score for CS was 39.71±6.24 (ranging from 20 to 50), BO had a mean score of 23.72±5.39 (ranging from 11 to 36), and STS had a mean score of 26.3±5.10 (ranging from 14 to 40). Subsequently, these subscale scores were classified into three categories as outlined by the ProQOL-5.
Moreover, 57.5% of participants had a moderate level of CS, while 58.2% experienced moderate BO and 75.4% reported moderate levels of STS (table 2).
Professional quality of life of health professionals (n=313)
Inferential statistics
Association of CS, BO and STS with sociodemographic characteristics
The relationship between sociodemographic variables and subscales of ProQOL was assessed by χ2 test. Results indicated that sex, ethnicity and marital status of the participants were statistically significant to CS. Additionally, sex, ethnicity and family types of the participants were found to be statistically significant to BO.
Furthermore, ethnicity and family types showed significant associations with STS. However, it is noteworthy that while sex exhibited significant associations with other subscales, it did not demonstrate a significant association with STS (online supplemental table 1).
Supplemental material
Association of CS, BO and STS with work-related characteristics
Among work-related variables, type of profession, job contract and work role were statistically significant to CS. Similarly, the type of profession, work shift and precautionary measures at workplace were also statistically significant to BO. Whereas, type of profession, type of health institution, work shift and job contract were significantly associated with the STS (online supplemental table 2).
Discussion
This study aimed to assess ProQOL among health professionals and social support perceived by them during the third phase of COVID-19 (Omicron variant) in Nepal. It was the time when there was a surge in daily new COVID-19 cases that peaked on 20 January 2022, reaching a record of more than 10 000 cases per day in Nepal due to super contagious Omicron variant.21 During such time, the demand for healthcare services is expected to increase and become challenging to the service givers, as they are involved in prevention, diagnosis, treatment and management of patients with COVID-19. This study’s finding revealed a considerate proportion of BO and STS among health professionals during the COVID-19 pandemic in Nepal.
The findings of our study revealed that an overwhelming majority of participants (99.4%) reported a moderate to high level of CS, while 58.5% experienced moderate BO, and 75.4% reported moderate STS. These results underscore the necessity for interventions or support systems to enhance CS while addressing and alleviating BO and STS in health professionals.
Interestingly, our study contrasts with few researches conducted in Spain during the initial phase of COVID-19 pandemic, where over one-third of the participants reported high levels of BO, a phenomenon absent in our study. Moreover, the percentage of healthcare professionals reporting low CS was notably lower in our study (0.6%) compared with the Spanish studies; 17.2%22 and 45.1%.23 This comparison suggests a gradual decrease in the prevalence of BO and an increase in CS from the first wave to the third wave of the COVID-19 pandemic.
However, a study conducted among nurses in Portugal during the third wave of the COVID-19 pandemic yielded findings similar to ours. This study revealed that nearly all participants (98%) reported moderate to high levels of CS, with the majority (72%) also reporting moderate levels of STS, mirroring our results.24 However, in the same study, a majority of participants experienced moderate levels of BO (72%), slightly higher than the findings in our study. Research conducted in Ecuador suggested that the high level of CS among healthcare professionals may be attributed to a stabilised health system and increased recognition of the healthcare task force during the later phase of the COVID-19 pandemic.25 In Nepal, one study among medical doctors assessed similar variables before COVID-19 pandemic. This study indicated that the majority of doctors experienced moderate levels of CS, BO and STS, aligning with our findings.15
The results we obtained may be attributed to the fact that, by the third wave of the COVID-19 pandemic, healthcare professionals may have developed supportive and motivating factors. These could include access to vaccinations, adherence to safety protocols such as face masks and sanitizers, availability of PPE and incentives related to COVID-19 (hazard allowance). During this time the government of Nepal had published ‘Hazard Allowance Management Order for Human Resources Involved in the Treatment of COVID-19 Infection’, which aimed to provide hazard allowance to the human resources involved in the identification, prevention, control and treatment of COVID-19. As per this directive, personnel directly engaged in patient care will receive an extra 100% of their standard government-prescribed salary, while those indirectly involved in COVID-19 treatment will receive an additional 75% of their basic pay.26 Our study revealed that nearly half of the participants received COVID-19 incentives, 95.5% of participants received timely vaccinations and 65% worked in healthcare settings where precautionary measures and equipment were deemed sufficient. These factors likely contributed to the positive ProQOL, especially the higher level of CS observed in our study.
In our study, we explored various work-related factors, including profession type, work experience, institution type, job role, shift schedules, job contracts, COVID-19-related experiences and perceived precautionary measures. These factors revealed significant associations with different facets of ProQOL. Notably, profession type and job role exhibited strong associations with CS, BO and STS, indicating unique challenges encountered by doctors, nurses and paramedics.
Similar to our findings, a study conducted among physicians and nurses in a Portuguese hospital during the third wave of the COVID-19 pandemic revealed associations between CF, BO and profession type among healthcare professionals.24 Another study conducted during the pandemic in Iran reported similar findings to ours, with 98.3% of participants experiencing moderate to high levels of CS. Additionally, this study identified associations between marital status and CS as well as between sex and BO, mirroring our findings. Also, this study highlighted the association between healthcare workers’ work experience and BO, a relationship not observed in our study.27 Conversely, a study in Egypt reported high levels of BO among physicians, which contrasts with our findings. Nevertheless, associations between sex, marital status, BO and CS resembled our study’s findings.28
The noteworthy connections between BO and factors such as profession type, work shifts and level of perceived precautionary measures highlight the pivotal role of work-related variables in shaping the mental and emotional well-being of health professionals. The prevalence of temporary job contracts among a sizeable proportion of respondents, coupled with notable levels of perceived inadequacy in precautionary measures, may contribute to heightened BO and STS.
Additionally, our study aimed to assess the level of social support among healthcare professionals. Our findings revealed that 73.8% of healthcare professionals reported high levels of social support, contrasting with a study conducted in Germany among healthcare professionals during the first wave of the COVID-19 pandemic.14 Similarly, a study conducted in Nepal during the first wave of COVID-19 pandemic indicated that nearly half (44.2%) of the healthcare workers perceived poor social support, given that the 35% of the healthcare workers felt stigmatised.29 Furthermore, it is noteworthy that stigmatisation might have steadily decreased by later phase of the pandemic, potentially contributing to the heightened social support observed in our study.
Strengths/limitations
Our study has several limitations to be considered. First, the cross-sectional design of this study limited our ability to examine changes in our outcome variables over time. Therefore, a longitudinal study is necessary to better understand our outcome variables over a period of time. Second, the use of a convenient sampling method may have introduced selection bias, thus limiting the representativeness of health professionals in Nepal. Third, due to the self-reporting of the questionnaire by the participants, the social desirability bias is not excluded in this study. Despite these limitations, our study has some strengths as well. The use of well-established and validated instruments to measure both perceived social support (MSPSS) and ProQOL version five questionnaire has enhanced the reliability and comparability of the study’s findings. Also, the inclusion of mostly frontline health professionals directly managing and responding to the COVID-19 pandemic has increased the relevance of the findings to those working in high-risk environments. In addition, this research fulfils the research gap in the context of Nepal because it provides meaningful insights regarding ProQOL and perceived social support by health professionals during health emergencies like COVID-19 pandemic in Nepal.
Conclusion
This research provides information on the ProQOL among healthcare professionals in Nepal during the third wave of the COVID-19 pandemic, focusing on CS, BO, STS and perceived social support. The findings reveal a significant proportion of healthcare professionals experiencing moderate levels of BO and STS, despite a high level of CS. Notably, social support among healthcare professionals was found to be high. This study emphasises the importance of addressing healthcare professionals’ psychological well-being during health emergencies like the COVID-19 pandemic. Implementation of appropriate interventions and support systems is needed to enhance CS, alleviate BO and mitigate STS among health professionals to combat future health emergencies.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Institutional Review Board, Institute of Medicine, Kathmandu Reference ID: 218(6-11)E2. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We would like to appreciate and acknowledge all the study participants for their valuable time in completing the questionnaire despite their busy schedule during COVID-19 pandemic.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
X @Bikramsingh_11
Contributors BKS conceptualised and designed this study, performed the statistical analysis and wrote the manuscript. PRB and SP carried out data collection, assisted with statistical analysis and helped in drafting and revising the manuscript. UH and DPP reviewed and edited the manuscript. All authors have read and approved the final manuscript. BKS is the guarantor for this manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer-reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.