Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak.Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome Severe Acute Respiratory Syndrome (SARS) Definition
Severe acute respiratory syndrome (SARS) is the first emergent and highly transmissible viral disease to appear during the twenty-first century. (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout Burnout
Depletion of a tax shelter's benefits. In the context of mortgage backed securities it refers to the percentage of the pool that has prepaid their mortgage. (p = 0.019), psychological distress psychological distress The end result of factors–eg, psychogenic pain, internal conflicts, and external stress that prevent a person from self-actualization and connecting with 'significant others'. See Humanistic psychology. (p<0.001), and posttraumatic posttraumatic /posttrau·mat·ic/ (post?traw-mat´ik) occurring as a result of or after injury.
Following or resulting from injury or trauma. stress (p<0.001). Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress. Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive Maladaptive
Unsuitable or counterproductive; for example, maladaptive behavior is behavior that is inappropriate to a given situation.
Mentioned in: Cognitive-Behavioral Therapy coping style and other individual factors. The results reinforce the value of effective staff support and training in preparation for future outbreaks.
Severe acute respiratory syndrome (SARS) emerged from Guangdong Province Noun 1. Guangdong province - a province in southern China
Guangdong, Kwangtung , People's Republic People's Republic
A political organization founded and controlled by a national Communist party. of China, in November 2002 and spread rapidly; transmission occurred primarily in hospitals, often to healthcare workers (HCWs). Although initially virtually no literature was available to guide expectations of how an emerging infection would affect the psychological well-being psychological well-being Research A nebulous legislative term intended to ensure that certain categories of lab animals, especially primates, don't 'go nuts' as a result of experimental design or conditions of hospital staff (1), by the summer of 2003 the acute psychological impact of SARS had been widely studied. Significant emotional distress emotional distress n. an increasingly popular basis for a claim of damages in lawsuits for injury due to the negligence or intentional acts of another. Originally damages for emotional distress were only awardable in conjunction with damages for actual physical harm. was present in 18%-57% of HCWs (2-6) and was associated with quarantine quarantine (kwŏr`əntēn), isolation of persons, animals, places, and effects that carry or are suspected of harboring communicable disease. (7), fear of contagion Contagion
The likelihood of significant economic changes in one country spreading to other countries. This can refer to either economic booms or economic crises.
An infamous example is the "Asian Contagion" that occurred in 1997 and started in Thailand. (6,8,9), concern for family (5,9,10), job stress (6,9), interpersonal in·ter·per·son·al
1. Of or relating to the interactions between individuals: interpersonal skills.
2. isolation (6,9), perceived stigma stigma: see pistil.
mark of Cain
God’s mark on Cain, a sign of his shame for fratricide. [O. T.: Genesis 4:15]
scarlet letter (6,7,11), conscription conscription, compulsory enrollment of personnel for service in the armed forces. Obligatory service in the armed forces has existed since ancient times in many cultures, including the samurai in Japan, warriors in the Aztec Empire, citizen militiamen in ancient of nonspecialists into infectious disease Infectious disease
A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. work (12), and attachment insecurity Insecurity
Inseparability (See FRIENDSHIP.)
Insolence (See ARROGANCE.)
introspective, vacillating Prince of Denmark. [Br. Lit.: Hamlet]
cartoon character who is lost without his security blanket. (10).
Working in SARS-affected hospitals could have been traumatic for some HCWs (i.e., an event that "threatens an individual's life or physical integrity and involves a subjective response of fear, helplessness, or horror" ). Before the SARS coronavirus The SARS coronavirus is the virus that causes severe acute respiratory syndrome (SARS). On April 16 2003, following the outbreak of SARS in Asia and secondary cases elsewhere in the world, the World Health Organization (WHO) issued a press release stating that the was identified (14-17), SARS was an infection of unknown cause, unknown mode of transmission, global spread, and high mortality, characteristics that generally increase perceived risk (18). However, although the SARS outbreak was acutely stressful, the longer term impact of SARS on HCWs is unknown.
Understanding the enduring occupational and psychological effects of working during this SARS outbreak is important because it involves the well-being of large numbers of HCWs. Additionally, this information has wider relevance to health systems in planning for emerging infections, including pandemic pandemic /pan·dem·ic/ (pan-dem´ik)
1. a widespread epidemic of a disease.
2. widely epidemic.
Epidemic over a wide geographic area.
n. influenza influenza or flu, acute, highly contagious disease caused by a virus; formerly known as the grippe. There are three types of the virus, designated A, B, and C, but only types A and B cause more serious contagious infections. (http://www. who.int/csr/disease/influenza/inforesources/en) and the potential for bioterrorism bi·o·ter·ror·ism
The use of biological agents, such as pathogenic organisms or agricultural pests, for terrorist purposes.
Bioterrorism (19). Although healthcare work during the SARS outbreak and during an influenza pandemic
Design, Setting, and Participants
The study took place in hospitals in Toronto The following is a list of hospitals in Toronto:
n. units and all staff of intensive care units, emergency departments, and SARS isolation units. Fifty-five clinical units participated (Toronto 40, Hamilton 15) from October 23, 2004, to September 30, 2005. This study was approved by the Research Ethics Research ethics involves the application of fundamental ethical principles to a variety of topics involving scientific research. These include the design and implementation of research involving human participants (human experimentation); animal experimentation; various aspects of Board of each hospital.
Survey A measured adverse outcomes. All participants completed survey A anonymously and received Can $10. Those who were willing to provide more information participated in survey B, which measured potential mediators of adverse outcomes, and in 2 structured interviews (results to be reported to be spoken of; to be mentioned, whether favorably or unfavorably.
See also: Report elsewhere). Participants in survey B also received $50.
A separate "representativeness survey" was conducted from September through November 2005 to compare eligible Toronto HCWs who had participated in the Impact of SARS Study with those who had not. HCWs were approached at staff meetings in 14 participating clinical units and asked to complete an anonymous, 6-question questionnaire that surveyed whether or not they had participated in the Impact of SARS Study, exposure to SARS patients, age range, job type, years of healthcare experience, and overall subjective impact of SARS on their lives.
In the study instruments, "during the SARS outbreak" was defined for Toronto HCWs as the period from February 2003 to the day the last SARS patient was discharged from a participant's hospital or died. For Hamilton HCWs, the comparable period was defined as February through September 2003. SARS patients included probable and suspected SARS patients and persons isolated while their cases were under investigation for SARS according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. the participants' report, rather than by using case definitions (http://www.phac-aspc.gc.ca/sarssras/sarscasedef_e.html).
This survey measured demographic and job data as well as traumatic stress Traumatic stress is recognized by the Diagnostic and Statistical Manual of Mental Disorders  as an acute emotional condition associated with reactive anxiety. response (15-item Impact of Events Scale [IES] [20,21]), nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik)
1. not due to any single known cause.
2. not directed against a particular agent, but rather having a general effect.
1. psychological distress (Kessler Psychological Distress Scale [K10] ), and professional burnout (emotional exhaustion Emotional exhaustion is a chronic state of physical and emotional depletion that results from excessive job demands and continuous hassles. it describes feeling of being emotionally overextended and exhausted by one's work. scale of the Maslach Burnout Inventory [MBI-EE] [23-25]). To measure the practical and functional impact of SARS experience, participants were surveyed about changes since the SARS outbreak in healthcare work hours and the amount of face-to-face contact with patients in their work. Survey A also asked if survey participants had experienced an increase since the SARS outbreak in smoking, drinking alcohol, or "other activities that could interfere with your work or relationships" and how many work shifts had been missed in the 4 months preceding the survey because of stress, illness, or fatigue.
Survey B, by using a previously described instrument, measured SARS-related perception of stigma and interpersonal avoidance; adequacy of training, protection, and support; and job stress (6,10,26). Scales calculated as the mean of all items related to these constructs showed adequate internal reliability (Table 1). Adaptive coping (problem-solving, seeking support, positive reappraisal) and maladaptive coping (escape-avoidance, self-blame, confrontative coping) regarding SARS were measured with the relevant subscales of the Ways of Coping Questionnaire (27), for which the stressful event was defined as the SARS outbreak. Attachment insecurity was measured with the anxiety and attachment avoidance scales of the Experiences in Close Relationships-Revised questionnaire (28).
Central tendencies of parametric variables are described by mean and standard deviation In statistics, the average amount a number varies from the average number in a series of numbers.
(statistics) standard deviation - (SD) A measure of the range of values in a set of numbers. ; nonparametric variables are described by median and interquartile range In descriptive statistics, the interquartile range (IQR), also called the midspread, middle fifty and middle of the #s, is a measure of statistical dispersion, being equal to the difference between the third and first quartiles. . Between-group differences in parametric variables were determined by Student t test and in nonparametric variables by Mann-Whitney U test Mann-Whitney U test,
n.pr See test, Mann-Whitney U. . To make the identified between-city differences more clinically meaningful, the prevalence of high scores was determined with standard cutoff values: IES [greater than or equal to] 26 (http://www.mardihorowitz.com), MBI-EE [greater than or equal to] 27 (25), K10 [greater than or equal to] 16 (http://www.crufad.unsw. edu.au). Between-group differences in categorical That which is unqualified or unconditional.
A categorical imperative is a rule, command, or moral obligation that is absolutely and universally binding.
Categorical is also used to describe programs limited to or designed for certain classes of people. variables were tested by [chi square chi square (kī),
n a nonparametric statistic used with discrete data in the form of frequency count (nominal data) or percentages or proportions that can be reduced to frequencies. ].
To identify factors that might explain variance in adverse outcome, between-group differences in traumatic stress symptoms, psychological distress, and burnout were tested for the following categories: gender; duration of healthcare experience; job type; regular work during the SARS outbreak in emergency department, intensive care unit, or SARS isolation unit; indicators of the frequency and intensity of contact with SARS patients; and exposure to quarantine. A 10-day cutoff for quarantine was used, which corresponds to the standard period of quarantine for SARS (i.e., quarantine >10 days indicates extended quarantine or >1 period of quarantine). This analysis was performed in the full sample.
The relationship between adverse outcomes and potential mediating factors was identified by using Spearman spear·man
A man, especially a soldier, armed with a spear. rank-order correlations Noun 1. rank-order correlation - the most commonly used method of computing a correlation coefficient between the ranks of scores on two variables
rank-difference correlation, rank-difference correlation coefficient, rank-order correlation coefficient between adverse outcomes and measures of perceived systemic characteristics (stigma and interpersonal avoidance, adequacy of training, protection and support, and job stress) and psychological variables (coping style and attachment insecurity). This analysis was performed for survey A and B participants.
A stepwise regression In statistics, stepwise regression includes regression models in which the choice of predictive variables is carried out by an automatic procedure. analysis was performed for each adverse outcome. All potential mediating factors (those identified in the preceding univariate analyses with a significance of p<0.05) were entered. This analysis was performed for survey A and B participants.
Finally, to determine if factors that increase personal perceptions of risk had a practical functional impact on HCWs in the full sample, we identified an item in survey A that could serve as a proxy for the survey B factors that mediate MEDIATE, POWERS. Those incident to primary powers, given by a principal to his agent. For example, the general authority given to collect, receive and pay debts due by or to the principal is a primary power. vulnerability. This item is the duration (in months) of continuing perceived increased risk after the last SARS patient was discharged from a study participant's hospital or died. Duration of perceived risk was significantly correlated cor·re·late
v. cor·re·lat·ed, cor·re·lat·ing, cor·re·lates
1. To put or bring into causal, complementary, parallel, or reciprocal relation.
2. with the 2 SARS-specific mediating factors identified in the regression analysis In statistics, a mathematical method of modeling the relationships among three or more variables. It is used to predict the value of one variable given the values of the others. For example, a model might estimate sales based on age and gender. : 1) maladaptive coping and perceived adequacy of training and 2) protection and support. For this analysis, the functional impact of SARS experience was operationalized as the number of adverse outcomes experienced by a person (from 0 to 7) of the following 7 outcomes: posttraumatic stress (IES [greater than or equal to] 26); psychological distress (K10 [greater than or equal to] 16); burnout (MBI-EE [greater than or equal to] 27); decrease in face-to-face patient contact since SARS; decrease in work hours since SARS; increase in smoking, alcohol, or other problematic behavior since SARS; and [greater than or equal to] 4 shifts missed because of stress or illness in the 4 months before the survey.
In total, 1,984 HCWs received detailed information about the Impact of SARS Study and 769 (39%) completed survey A. The interval between the last SARS patient discharged or deceased and study participation was 13-25 (median 19) months.
To determine how representative participants were of all eligible hospital staff, after the Impact of SARS Study a representativeness study was presented to 258 Toronto HCWs who had been eligible; it was completed by 255 (99%) of these HCWs. Exposure to SARS patients was more common in HCWs who participated in the Impact of SARS Study than those who did not. However, study participants and nonparticipants did not differ in age range, job type, years of healthcare experience, or overall subjective impact of SARS on their lives (Table 2).
Of the 769 participants, 73.5% were nurses (69.4% staff nurse, 3.1% manager or educator, 1.0% infection control practitioner). The next most prevalent job types were clerical staff (8.3%), physicians (2.9%), and respiratory therapists (2.3%). The remaining 99 participants (12.9%) were distributed among 14 different job types. Other characteristics of study participants, by city of employment, are presented in Table 3. Most Toronto participants (71.6%) reported contact with SARS patients, and Toronto participants were much more likely than Hamilton participants to have experienced quarantine (47.9% vs. 1.6%, p<0.001), which confirms the anticipated difference in SARS-related experience between comparison groups. A higher proportion of Hamilton participants were nurses (Hamilton 84.1% nurses vs. Toronto 71.2%, p = 0.001).
Survey B was completed by 187 HCWs (survey A and B participants). Survey A and B participants did not differ significantly from participants who only completed survey A by sex, job type (nurse or other), or city of employment. Survey A and B participants were older (mean 45 [+ or -] standard deviation 9 years vs. 41 [+ or -] 10 years, p<0.001) and more experienced in healthcare work (21 [+ or -] 10 years versus 16 [+ or -] 10 years, p<0.001). Survey A-only participants and Survey A and B participants did not differ with respect to exposure to SARS patients, working [greater than or equal to] 5 shifts in intensive care unit, emergency department or SARS isolation unit during the outbreak or with respect to traumatic stress symptoms, psychological distress, or burnout.
During the study period (13-25 months after the SARS outbreak), Toronto HCWs reported significantly higher levels of burnout (Toronto median score 19, interquartile range 10-29; Hamilton 16, 9-23, p = 0.019), psychological distress (Toronto 15, 12-19; Hamilton 13, 11-17, p<0.001), and posttraumatic stress (Toronto 11, 4-21; Hamilton 7, 0-19, p<0.001). To make these differences more clinically meaningful, the prevalence of high scores was calculated (Table 4). The prevalence of the following functional indicators of distress since the SARS outbreak was higher in Toronto HCWs: decrease in patient contact and work hours, increase in substance use and other traits that interfere with function, and more days off work (Table 4). Of the 7 adverse outcomes reported in Table 4, Toronto HCWs were more likely to be experiencing [greater than or equal to] 1 problem (Toronto 68.1% vs. Hamilton 50.1%, p<0.001)) and were almost twice as likely to be experiencing multiple ([greater than or equal to] 2) problems (Toronto 44.0% vs. Hamilton 22.5%, p<0.001).
Personal and occupational characteristics of participants and the relationship of these variables to adverse outcomes are shown in Tables 5 and 6. Univariate relationships significant at the level of p<0.05 were retained for stepwise regression analysis to determine which of these variables accounted for significant variance in each adverse outcome (Table 7). Maladaptive coping and perceived adequacy of training together with protection and support explained 18% of the variance in burnout. The same 2 variables explained 21% of the variance in posttraumatic stress. Maladaptive coping and attachment anxiety, together with a protective effect of experience in healthcare, explained 31% of the variance in psychological distress.
Finally, the functional impact of vulnerability factors on the full survey A sample was tested by using duration of perceived risk after SARS as a proxy for the SARS-related vulnerability factors identified in the regression analysis. Duration of post-SARS perceived risk was correlated with maladaptive coping (Spearman [rho] = 0.28, p = 0.001) and perceived adequacy of training, protection, and support (Spearman [rho] = -0.27, p = 0.001). The Figure shows a linear increase in the prevalence of multiple adverse outcomes in HCWs with longer duration of perceived risk. Duration of perceived risk and the overall number of adverse outcomes were significantly correlated. (Spearman [rho] = 0.23, p = 0.005).
This study highlights the resiliency The ability to recover from a failure. The term may be applied to hardware, software or data. of HCWs and, despite this trait trait (trat)
1. any genetically determined characteristic; also, the condition prevailing in the heterozygous state of a recessive disorder, as the sickle cell trait.
2. a distinctive behavior pattern. , the potential that working during the SARS outbreak had a substantial negative impact on a statistically significant number of people. The evaluation of mediating factors suggests both systemic and individual targets for interventions to buffer the adverse effects of an extraordinary outbreak of infectious disease. Systemically, enhanced support and training may reduce burnout and posttraumatic stress. Individually, interventions that reduce maladaptive coping may decrease prolonged pro·long
tr.v. pro·longed, pro·long·ing, pro·longs
1. To lengthen in duration; protract.
2. To lengthen in extent. suffering.
The differences in adverse outcomes between Toronto and Hamilton HCWs were significant but small. However, further analysis suggests that the long-term impact of SARS has not been trivial. In particular, a categorical analysis (Table 4) shows that long-term adverse outcomes in Toronto HCWs occurred at a prevalence [approximately equal to] 50%-100% higher than in Hamilton HCWs. Furthermore, these outcomes may have a systemic impact, since SARS-affected HCWs reported reducing patient contact and hours of healthcare work as well as more frequent sick absences and an increase in behavior that could affect function.
These findings can be framed in terms of their potential value for the future. If the emergence of a new infectious disease is likely to increase the prevalence of significant distress in HCWs by 50%, to double the number of HCWs who are reducing their clinical practice or calling in sick, and if these difficulties will persist for [greater than or equal to] 1-2 years after the outbreak's resolution, we want to learn from the SARS experience to try to buffer this negative impact. This discussion, therefore, addresses the identified mediators of SARS-related distress in HCWs and how these can guide preparation for pandemic influenza and other infectious disease outbreaks.
Exposure to high-intensity and high-risk work settings (such as intensive care units and emergency department work) and direct exposure to infected in·fect
tr.v. in·fect·ed, in·fect·ing, in·fects
1. To contaminate with a pathogenic microorganism or agent.
2. To communicate a pathogen or disease to.
3. To invade and produce infection in. patients were not the primary determinants of adverse psychological outcomes. In fact, trends toward lower burnout in intensive care unit workers and less general psychological distress in emergency department workers were noted. These trends may be explained by the resilience resilience (r·zilˑ·yens),
n of HCWs who choose this type of work and are consistent with the findings that longer healthcare experience was protective. We also found that the extent of various forms of distress was increased in Toronto HCWs, irrespective of irrespective of
Without consideration of; regardless of.
preposition despite their degree of contact with SARS patients, which implies that factors that are associated with the hospital environment as a whole and healthcare work in general during the outbreak were provocative.
Both systemic and personal variables were associated with persisting distress. In contrast to studies of distress during and shortly after the SARS outbreak (6,9,12), job stress related to conflict, workload, and conscription to new duties did not mediate long-term outcome. However, perceived adequacy of training, moral support, and protection were associated with better outcome. When the lessons of SARS are applied to pandemic planning, effective staff support may be a primary target to bolster the resilience of HCWs who will face future outbreaks. This observation is consistent with ones made during the SARS outbreak regarding the benefits of responsive communication (29), opportunities for facilitated reflection on normal emotional responses to extraordinary stress, and opportunities for HCWs to contribute to decision-making in the workplace (10,30).
Effective support benefits from careful planning and preparation before an outbreak, which the SARS situation did not allow. For example, effective moral or psychological support typically occurs in the context of trusted professional and institutional relationships, which should ideally be established before the outbreak situation. In particular, burnout has been identified as 1 of the most substantial health-related problems facing nurses (31). Because future outbreaks are likely to increase job strain and burnout, the prepandemic period is a critical time to attend to organizational characteristics that are known to buffer burnout, which include reducing patient-to-nurse ratios (32) and increasing organizational characteristics that increase nurses' autonomy, flexibility, control over practice (33), and perceived empowerment (34). The results of our study suggest that supportive interventions may be especially important for HCWs with fewer years of experience, who were more likely to experience prolonged psychological distress. Opportunities for mentorship or "buddying" with more experienced colleagues may be useful (35).
The personal variables that contributed to adverse outcomes were maladaptive coping through avoidance, hostile confrontation, and self-blame, and in the instance of general psychological distress, attachment anxiety. Although a review of interventions to modify coping style is beyond the scope of this paper, we note that organizational approaches to support staff and the individual experience of workers coping with extraordinary events are related. Hospital-based interventions to support staff may also promote adaptive coping. For example, engaging staff in collaborative planning for future outbreaks may reduce the tendency to cope by means of avoidant strategies and may enhance coping through problem-solving and peer-support. Anger and blame directed toward others (hostile confrontation) or oneself (self-blame) may be reduced in a working environment that fosters positive working relationships through effective leadership (36). Attachment anxiety is a common, relatively enduring, and stable interpersonal style within close relationships (37), which is known to be associated with sensitivity to stress under many conditions (38,39). Attachment anxiety is probably not a sensible target for hospital-based interventions to buffer the impact of systemic stresses, but it is a marker of those at greater risk for general psychological distress.
The results of this study also have implications for mitigating the effects of an infectious outbreak in the post-outbreak period. Because the duration of perceived risk in HCWs after the resolution of SARS is correlated with the severity of outcome, identifying and supporting HCWs who are at the highest risk for multiple and persistent psychological and occupational consequences of an outbreak may be possible by identifying HCWs whose perceived risk has not returned to normal within a few months after the event. Support programs, it would appear, need to be longer term to deal with ongoing residual effects after an outbreak. Programs directed toward healthy lifestyles, diet, exercise, and smoking cessation smoking cessation Public health Temporary or permanent halting of habitual cigarette smoking; withdrawal therapies–eg, hypnosis, psychotherapy, group counseling, exposing smokers to Pts with terminal lung CA and nicotine chewing gum are often ineffective. may also be important after the occurrence of an outbreak such as SARS to provide support to staff. Furthermore, for pandemic planning, the likelihood of prolonged subjective distress in a substantial percentage of HCWs should be factored into surge capacity modeling during and after the pandemic, particularly because distress is associated with reduced healthcare work.
Our conclusions are limited by the study method. With respect to generalizability, despite a response rate of 39%, the representativeness survey suggests that HCWs who participated were similar to nonparticipants. HCWs who had contact with SARS patients are overrepresented o·ver·rep·re·sent·ed
Represented in excessive or disproportionately large numbers: "Some groups, and most notably some races, may be overrepresented and others may be underrepresented" in the study sample, which may be because the study had greater salience sa·li·ence also sa·li·en·cy
n. pl. sa·li·en·ces also sa·li·en·cies
1. The quality or condition of being salient.
2. A pronounced feature or part; a highlight.
Noun 1. for those persons, but study participants and nonparticipants did not differ in the subjective impact attributed to the SARS experience. A further limitation is that self-reports of SARS experiences do not provide an objective evaluation of actual differences in the training, protection, or support that HCWs received. Regardless of the limitations, the Impact of SARS Study provides a window on the long-term effects of working during times of extraordinary infectious risk.
This study was funded with a research operating grant from the Canadian Institutes of Health Research Canadian Institutes of Health Research (CIHR) is the major federal agency responsible for funding health research in Canada. It is the successor to the Medical Research Council of Canada. .
Dr Maunder is a consultation-liaison psychiatrist psychiatrist /psy·chi·a·trist/ (si-ki´ah-trist) a physician who specializes in psychiatry.
A physician who specializes in psychiatry. whose research interest is in the interface between physical disease and psychological health. He was an author of the first published report of the psychological impact of SARS during the outbreak.
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1. a diseased condition or state.
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n. Abbr. GP
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See Table at currency.
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Palo Alto (păl`ō ăl`tō), city (1990 pop. 55,900), Santa Clara co., W Calif.; inc. 1894. Although primarily residential, Palo Alto has aerospace, electronics, and advanced research industries. (CA): Consulting Psychologists Press; 1986.
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goes to Wizard of Oz to get brains. [Am. Lit.: The Wonderful Wizard of Oz]
See : Ignorance
can’t live up to his name. [Am. Lit.: The Wonderful Wizard of Oz; Am. Press; 1997. p. 191-218.
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New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of : American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 148,000 members are mainly American but some are international. Annual Meeting, May 6, 2004.
(31.) Kerr MS, Laschinger HKS HKS Harvard Kennedy School (John F. Kennedy School of Government at Harvard University; Cambridge, MA)
HKS Hrvatski Košarkaški Savez (Croatian Basketball Federation)
HKS Silver Hake
HKS Hong Kong Standard , Severin CN, Almost JM, Shamian J. New strategies for monitoring the health of Canadian nurses: results of collaborations with key stakeholders Stakeholders
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1. Functionally independent; not under voluntary control. function during standardized standardized
pertaining to data that have been submitted to standardization procedures.
standardized morbidity rate
see morbidity rate.
standardized mortality rate
see mortality rate. acute stress in healthy adults. J Psychosom Res. 2006;60:283-90.
Robert G. Maunder, *([dagger]) William J. Lancee, *([dagger]) Kenneth E. Balderson, * ([double dagger double dagger
A reference mark () used in printing and writing. Also called diesis.
Noun 1. ]) Jocelyn P. Bennett, * Bjug Borgundvaag, * ([dagger]) Susan Evans, ([section]) Christopher M.B. Fernandes, ([paragraph]) # David S. Goldbloom, ([dagger]) ** Mona Gupta, ([dagger]) ([dagger])([dagger]) Jonathan J. Hunter, * ([dagger]) Linda McGillis Hall, ([dagger]) Lynn M. Nagle, ([dagger]) Clare Pain, * ([dagger]) Sonia S. Peczeniuk, ([double dagger])([double dagger]) Glenna Raymond, ([subsection subsection
any of the smaller parts into which a section may be divided
Noun 1. subsection - a section of a section; a part of a part; i.e. ]) Nancy Read, ([double dagger]) Sean B. Rourke, ([dagger])([double dagger]) Rosalie J. Steinberg, * (dagger]) Thomas E. Stewart Thomas Elliott Stewart (September 22, 1824 - January 9, 1904) was a U.S. Representative from New York.
Born in New York City, Stewart completed preparatory studies. He studied law. He was admitted to the bar in 1847 and commenced practice in New York City. , * ([dagger]) Susan VanDeVelde-Coke, ([dagger])([dagger]) Georgina G. Veldhorst, ([paragraphs]) and Donald A. Wasylenki ([dagger])([double dagger])
* Mount Sinai Hospital Mount Sinai Hospital can refer to:
The Scarborough Hospital was created in September 1998, through the amalgamation of The Salvation Army Scarborough Grace Hospital and Scarborough General Hospital. , Toronto, Ontario, Canada; ([paragraph]) Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; # McMaster University McMaster University, at Hamilton, Ont., Canada; nondenominational; founded 1887. It has faculties of humanities, science, social sciences, business, engineering, and health sciences, as well as a school of graduate studies and a divinity college. , Hamilton, Ontario, Canada; ** Centre for Addiction and Mental Health The Centre for Addiction and Mental Health (CAMH) is a consortium of mental health clinics at several sites in Toronto, Ontario, Canada. Its name in French is Centre de Toxicomanie et de Santé Mentale. (The acronym CAMH is most commonly pronounced "Cam-H". , Toronto, Ontario, Canada; ([dagger])([dagger]) Sunnybrook and Women's Health Women's Health Definition
Women's health is the effect of gender on disease and health that encompasses a broad range of biological and psychosocial issues. Sciences Centre, Toronto, Ontario, Canada; ([double dagger])([double dagger]) Rouge Valley Health System, Toronto, Ontario, Canada; ([subsection] Whitby Mental Health Centre The Whitby Mental Health Centre is a mental health facility located in Whitby, Ontario, Canada.
The origins of the facility date back to the creation of an Ontario Hospital for the Criminally Insane and the Whitby Psychiatric Hospital in 1912. , Whitby, Canada; and ([paragraphs]) North York General Hospital North York General Hospital (NYGH) is one of Toronto's many hospitals and serves the area of north central Toronto (formerly North York). The current Chief of Medicine is Dr. David Baron. It is also a teaching hospital for the University of Toronto. , Toronto, Ontario, Canada
Address for correspondence: Robert G. Maunder, Department of Psychiatry, Mount Sinai Hospital, 600 University Ave, Toronto, Ontario M5G 1X5; email: firstname.lastname@example.org
Table 1. Scales to measure perceptions about severe acute respiratory syndrome (SARS) experience Scale Perception Training, protection and I had adequate training to deal confidently support * with the situations that I faced. Cronbach [alpha] = 0.89 Infection control procedures were adequately explained. I received adequate training in infection control procedures. I was provided with the protective equipment and procedures that I needed. I had someone to ask when I had problems using equipment. The hospital where I worked took my well-being into account when decisions were made that affected me. Emotional support (e.g., counseling) was available to those who needed help. I felt appreciated by the hospital/clinic/my employer. My hospital/workplace was supportive. Job stress ([dagger]) There was more conflict among colleagues Cronbach [alpha] = 0.76 at work. I felt more stressed at work. I had to do work that normally I don't do. I had an increase workload. I had to work overtime. Perceived stigma and I thought that people avoided me because interpersonal avoidance of my profession. ([dagger]) I thought that people avoided my family Cronbach [alpha] = 0.77 members because of my profession. I coped with the SARS situation by avoiding crowded places. I coped with the SARS situation by avoiding colleagues who might be exposed. * Items scored on a 5-point scale from 1 (very confident that this is false) to 5 (very confident that this is true). ([dagger]) Items scored on a 6-point scale from 1 (strongly disagree) to 6 (strongly agree). Table 2 Comparison of eligible Toronto healthcare workers who chose to participate or not to participate in the Impact of SARS Study Participation in Impact of SARS Study Characteristics Did not participate, Participated, % (n = 144) % (n = 111) p value Age group, y < 40 53 44 [greater than 47 56 0.17 or equal to] 40 Job type Nurse 73 71 Other 27 29 0.76 Experience, y < 10 51 41 [greater than 49 59 0.12 or equal to] 10 Treated SARS patient Yes 31 59 No or don't know 69 41 <0.001 Overall impact Bad 40 50 Neutral or good 60 50 0.11 * SARS, severe acute respiratory syndrome. Table 3. Demographic and job characteristics of participants, Impact of SARS Study * Toronto % Hamilton % Characteristics (n = 587) (n = 182) p value Female 86.0 89.6 0.22 Single 23.7 20.3 Married or common-law 65.2 68.1 Separated or widowed 11.1 11.5 0.41 Living with child 36.3 36.8 0.90 [less than or equal to] 16 y of age Living with adult 9.2 5.5 0.11 [greater than or equal to] 65 y of age Worked in healthcare 65.1 68.7 0.37 [greater than or equal to] 10 y Worked any shifts during SARS in Surgical inpatient unit 13.8 18.7 0.11 Medical inpatient unit 26.4 21.4 0.18 Isolation unit with SARS patients 22.5 ([dagger]) Intensive care unit 32.9 34.1 0.66 Emergency department 32.2 24.7 0.06 * SARS, severe acute respiratory syndrome. ([dagger]) Hamilton had no patients with SARS. Table 4. Prevalence of adverse outcomes in Hamilton and Toronto healthcare workers * Toronto, Hamilton, Adverse outcomes n = 587, % n = 182, % p value High burnout (MBI-EE score 30.4 19.2 0.003 [greater than or equal to] 27) High psychological distress 44.9 30.2 <0.001 (K10 score [greater than or equal to] 16) High posttraumatic stress 13.8 8.4 0.06 (IES score [greater than or equal to] 26) Since SARS have Decreased face-to-face patient 16.5 8.3 0.007 contact Decreased work hours 8.6 2.2 0.003 Increased smoking, drinking 21.0 8.1 0.001 alcohol, or other behavior that could interfere with work or relationships Missed [greater than or 21.6% 12.6% 0.007 equal to] 4 work shifts because of stress or illness * MBI-EE, Maslach Burnout Inventory; K10, Kessler Psychological Distress Scale, IES, Impact of Events Scale; SARS, severe acute respiratory syndrome. Table 5. Relationship of healthcare worker, job, and SARS exposure characteristics to adverse outcomes in Toronto healthcare workers * Burnout Interquartile p Characteristics n Median range value Sex Male 82 18 9-29 Female 505 19 10-29 0.30 Job type Nurse 418 21 11-29 Other 169 14 8-27 0.002 Healthcare experience <10 y 205 21 12-30 [greater than or 382 18 10-28 0.82 equal to] 10 y Worked on SARS unit <5 shifts 498 19 10-30 [greater than or 89 17 11-26 0.75 equal to] 5 shifts Worked in ICU <5 shifts 427 20 10-30 [greater than or 160 17 9-17 0.02 equal to] 5 shifts Worked in Emergency <5 shifts 434 18 10-28 [greater than or 153 21 10-32 0.12 equal to] 5 shifts Ever in SARS patient room No 167 19 9-30 Yes 420 19 10-28 0.33 Touched SARS patient No 265 19 9-30 Yes 322 19 11-28 0.42 Protected contact with saliva or phlegm of SARS patient No 438 19 9-29 Yes 149 19 11-29 0.43 Unprotected exposure to SARS patient No 502 18 9-28 Yes 85 24 13-32 0.012 In SARS patients' rooms >5 min, >5 times No 316 18 9-28 Yes 271 20 11-31 0.08 Quarantined Never 252 19 9-28 [less than or 235 17 10-28 equal to] 10 d >10 d 100 21 11-34 0.36 Psychological distress Interquartile p Characteristics Median range value Sex Male 14 12-19 Female 15 12-19 0.91 Job type Nurse 14 11-18 Other 15 12-20 0.16 Healthcare experience <10 y 16 12-21 [greater than or 14 11-18 0.03 equal to] 10 y Worked on SARS unit <5 shifts 15 12-19 [greater than or 15 11-20 0.54 equal to] 5 shifts Worked in ICU <5 shifts 15 12-19 [greater than or 14 11-20 0.29 equal to] 5 shifts Worked in Emergency <5 shifts 15 12-20 [greater than or 13 11-17 0.005 equal to] 5 shifts Ever in SARS patient room No 15 12-19 Yes 15 11-19 0.09 Touched SARS patient No 15 11-19 Yes 15 12-19 0.32 Protected contact with saliva or phlegm of SARS patient No 15 12-19 Yes 15 12-18 0.78 Unprotected exposure to SARS patient No 15 11-19 Yes 16 13-22 0.08 In SARS patients' rooms >5 min, >5 times No 15 11-18 Yes 15 12-21 0.02 Quarantined Never 15 11-19 [less than or 15 11-19 equal to] 10 d >10 d 16 12-22 0.09 Posttraumatic stress Interquartile p Characteristics Median range value Sex Male 10 2-19 Female 12 4-21 0.02 Job type Nurse 12 5-22 Other 10 2-19 0.10 Healthcare experience <10 y 11 11-21 [greater than or 11 5-22 0.06 equal to] 10 y Worked on SARS unit <5 shifts 12 4-22 [greater than or 10 3-17 0.63 equal to] 5 shifts Worked in ICU <5 shifts 11 4-21 [greater than or 11 3-22 0.46 equal to] 5 shifts Worked in Emergency <5 shifts 12 5-21 [greater than or 9 2-21 0.24 equal to] 5 shifts Ever in SARS patient room No 11 4-22 Yes 12 4-21 0.16 Touched SARS patient No 12 4-22 Yes 11 4-22 0.41 Protected contact with saliva or phlegm of SARS patient No 11 4-21 Yes 10 4-22 0.44 Unprotected exposure to SARS patient No 11 4-21 Yes 13 6-22 0.38 In SARS patients' rooms >5 min, >5 times No 11 3-21 Yes 11 5-22 0.24 Quarantined Never 11 4-22 [less than or 11 3-21 equal to] 10 d >10 d 13 5-22 0.42 * SARS, severe acute respiratory syndrome. Table 6. Correlation between adverse outcomes after SARS and perceived characteristics of workplace and environment, coping style, and attachment insecurity in Toronto healthcare workers * Burnout Characteristics of healthcare workers Spearman [rho] p value Training, protection -0.297 -0.001 and support Stigma and avoidance 0.153 0.07 Job stress 0.312 -0.001 Adaptive coping 0.066 0.44 Maladaptive coping 0.261 0.002 Attachment anxiety 0.179 0.049 Attachment avoidance 0.078 0.40 Psychological distress Characteristics of healthcare workers Spearman [rho] p value Training, protection -0.162 0.06 and support Stigma and avoidance 0.080 0.36 Job stress 0.224 0.008 Adaptive coping 0.147 0.08 Maladaptive coping 0.312 -0.001 Attachment anxiety 0.355 -0.001 Attachment avoidance 0.204 0.03 Posttraumatic stress Characteristics of healthcare workers Spearman [rho] p value Training, protection -0.269 0.001 and support Stigma and avoidance 0.302 -0.001 Job stress 0.164 0.052 Adaptive coping 0.182 0.03 Maladaptive coping 0.364 -0.001 Attachment anxiety 0.295 0.001 Attachment avoidance 0.139 0.13 * SARS, severe acute respiratory syndrome. Table 7. Variables that explain variance in adverse outcomes to severe acute respiratory syndrome (SARS) in Toronto healthcare workers Variables [beta] t p value Dependent variable: burnout * Maladaptive coping 0.29 3.34 0.001 Perceived adequacy of training, -0.27 -3.1 0.002 protection and support Model [R.sup.2] = 0.18, p value <0.001 Dependent variable: psychological distress ([dagger]) Maladaptive coping 0.31 3.78 <0.001 Years of healthcare experience -0.26 -3.28 0.001 Attachment anxiety 0.24 2.87 0.005 Model [R.sup.2]= 0.31, p value <0.001 Dependent variable: posttraumatic stress ([double dagger]) Maladaptive coping 0.37 4.39 <0.001 Perceived adequacy of training, -0.22 -2.63 0.01 protection and support Model [R.sup.2] = 0.21, p value <0.001 * Excluded variables: job stress, attachment anxiety, job type, worked in intensive care unit, unprotected contact with SARS patient(s). ([dagger]) Excluded variables: job stress, attachment avoidance, worked in emergency department, in SARS patients room >5 min or >5 times. ([double dagger]) Excluded variables: perceived stigma and avoidance, adaptive coping, attachment anxiety, job type, sex.