Professional Quality of Life and Psychological Impact on Frontline Healthcare Worker during the Fourth Wave of COVID-19

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Introduction
Te novel coronavirus disease 2019 (COVID-19) pandemic rapidly spread over the world, causing a threat to public health [1].SARS-CoV-2 mostly afects and causes more damage to the respiratory system [2,3].On March 11, 2020, the World Health Organization (WHO) proclaimed COVID-19 to be a pandemic after the frst case was discovered in Wuhan, China, in December 2019 [4].Tis virus takes 2 to 14 days to incubate, and symptoms typically start to manifest during this time [5].On December 23, 2022, the disease infected 651.9 million confrmed cases of COVID-19, including 6.65 million deaths, across the world, as reported to the WHO [6].Te pandemic afected both developed and developing nations, with India, Brazil, and United States of America (USA) sufering greatly from its efects in terms of mortality and morbidity [7].In a little period of time, the total number of confrmed cases in emerging or lowresource nations signifcantly increased.Te world economy, particularly China and surrounding developing countries such as Pakistan, Iran, India, Bangladesh, and Afghanistan, is becoming more at risk from COVID-19 [8,9].Pakistan has a low-to medium-level economy and 197 million inhabitants, making it a country with a high population density.In Pakistan, from 3 January 2020 to 13 December 2022, there were 1.57 million confrmed cases of COVID-19 with 30,635 deaths, according to the WHO [10].COVID-19 is known to cause both physical and psychological problems in HCWs [11].HCWs, such as physicians, nurses, and paramedics, are fghting the pandemic on the frontlines.As is frequently the case, medical stafs coping with such widespread epidemics are susceptible to psychological stress and changes in mood, which impact their health [12].
Healthcare professionals are involved in a variety of tasks, including isolating patients and preventing and controlling infections [13,14].In addition, they were at a greater risk of infection during patient care [15].Although frontline HCWs primarily focus on preventing transmission and caring for COVID-19 patients, the pandemic's efects on mental health and their consequences cannot be underestimated [16].Healthcare professionals are more frequently experiencing mental health issues such as anxiety, insomnia [17][18][19][20][21], and burnout syndrome (BS) [22].Meanwhile, stress was a common problem for nurses fghting COVID-19 [23].During the COVID-19 epidemic, the mental workload of nurses rose [24].Te physical and mental health of nurses may sufer when they work under conditions that raise their risk of infection, pressure, and workload, when there are not enough resources available, and when they have to carry out more physical and psychological labor [25].Te debate over how the COVID-19 epidemic has afected mental health conditions has uncovered glaring gaps in the information that is currently available on the frequency of depression, anxiety, and sleep disturbance amongst HCWs.Terefore, it is essential to identify the mental health burden and deal with it appropriately [26].
Even before the pandemic, there were high levels of burnout and exhaustion among HCWs in Pakistan.According to a cross-sectional study on burnout among 179 HCWs in emergency rooms, 42.4% of them showed emotional fatigue [27].A study conducted in 2019 that evaluated 118 surgical residents in Karachi discovered that women had greater emotional exhaustion (49.2%) than men did (50.8%).In addition, married individuals showed higher degrees of personal fulflment and sleep deprivation than single individuals did [28].
A study conducted in six hospitals in Pakistan using the PHQ-9 and GAD-7 scales to evaluate 400 healthcare workers during the frst wave of COVID-19 revealed that 21.8% of them had moderate-to-severe anxiety or depression [29].Similar results were found in a study conducted on 398 healthcare workers from Punjab, where the prevalence of anxiety and depression was 21.4% and 21.9%, respectively [30].A study of 87 HCWs during the second COVID-19 wave found that 54% of participants experienced psychological fatigue, 77% experienced depersonalization, and 31% experienced low personal accomplishment.Tese symptoms were all linked to a history of COVID-19 infection or contact with patients who had such a history [31].As of January 27, 2021, a third-wave novel SARS-CoV-2 variant from the UK, also known as B.1.1.7,had been identifed in over 64 countries, including Pakistan.With an average of 100 individuals dying away in Pakistan every day, this B.1.1.7 variant is linked to a higher risk of death than other variants, implicating more burdens on healthcare professionals [32].In Pakistan, higher levels of burnout were observed in the COVID-19 fourth wave, likely as a result of the pandemic's cumulative physical and emotional repercussions; however, much is still not entirely clear at this time [33].It is important to comprehend the long-and short-term efects of CS, BO, and SCS in a lower-middle-income nation such as Pakistan.Tese efects include decreased healthcare quality, an increase in errors, and a decrease in ProQOL, low job satisfaction, and signifcant costs [33,34].However, during the fourth wave of the pandemic, Pakistan did not routinely report on the prevalence of CS, BO, and STS in HCWs.Terefore, in light of the fourth wave of the COVID-19 outbreak, the purpose of our study is to evaluate the levels of the contextual variables depressive concerns, BO, CS, and STS among HCWs in Pakistan.

Study Design and Participants.
To learn more about the experiences of frontline HCWs caring for patients with COVID-19, a cross-sectional study was carried out.Te study was conducted at two governmental health institutions, namely, Ayub Teaching Hospital and Combine Military Hospital Abbottabad, Pakistan.Te inclusion criteria for participation in this study were as follows: (1) voluntary participation in the study; (2) healthcare workers on the frontline against COVID-19; and (3) healthcare workers with direct bedside care experience involving COVID-19 patients.Exclusion criteria were as follows: nonfrontline HWCs involved in scientifc research, teaching, and hospital administration [13].Because there were nurses characterized by diferent levels of experience at least 5-10 times as many variables were represented in the sample size [13].Te current study included 20 variables.A total of 286 questionnaires were collected, 258 questionnaires were included for the fnal data analysis after those that did not match the requirements were removed.

Measures and Instruments.
Te relevant published articles and scientifc literature on COVID-19 were examined to create a structured questionnaire [13,26].Te questionnaire was administered in the English language, which is the ofcial language of Pakistan.Tree diferent sections were made in the questionnaire used: (1) sociodemographic information; (2) healthcare worker work conditions and COVID-19 pandemic-related aspects; and (3) mental health conditions [13].Te demographic features comprised of HCWs are their gender, marital status, age, work experience, educational attainment, the infection status (COVID-19) of friends or family members of the HCW, the number of night shifts worked per week, the number of working hours during the epidemic, job satisfaction, pay satisfaction, and work load [13].Te ProQOL Scale was used to measure ProQOL.Te ProQOL Version 5 was the instrument used; it consists of 30 items organized into three subscales: burnout (BO), compassion satisfaction (CS), and secondary traumatic stress (STS).Te following items were used to test CS : 3, 6, 12, 16, 18, 20, 22, 24, 27, and 30.Items associated with burnout (items 1,4,8,10,15,17,19,21,26, and 29 of the ProQOL tool) and STS (items 2, 5, 7, 9, 11, 13, 14, 23, 25, and 28) were included in order to quantify CF.A 5-point Likert scale was used to record responses to these questions, with 1 indicating never, 2 very rarely, 3 sometimes, 4 often, and 5 indicating very often [35].In published papers, the ProQOL shows high validity and reliability [36,37].According to Cronbach's alpha values of 0.89 for CS, 0.83 for BO, and 0.78 for STS in the primary research study, the ProQOL tool was considered reliable.Terefore, a Cronbach's alpha of 0.80 or higher is regarded as particularly desirable for all aspects [38].Te healthcare worker participants were contacted by WhatsApp, and they were informed about the study's purpose and the researchers' interest in the research topic.Te hospital administrators providing respondents who were battling COVID-19 were contacted to discuss the goal of our investigation.Tose who were not medical professionals and did not fnish the assessment were excluded from this survey.

Data Collection.
Data were collected between January 1 and March 31, 2022.Google Forms software was used to generate a survey, and the link to it was distributed via WhatsApp.Since every question was needed, only surveys that were completely flled out were collected, ensuring that there were no missing data.Te healthcare worker assisted in distributing the surveys individually and through WhatsApp groups.It took approximately 10-15 min to complete the questionnaire.
Te combined military hospital in Abbottabad's Ethical Research Committee gave its approval to the current study (CMH Atd-ETH-78-Paed-23).To participate in our online survey, respondents had to assent (accept or deny) to the informed consent declaration on the frst page.

Statistical Analysis.
Data collected from respondents were directly deposited in Google Worksheets and later transfer into Microsoft Excel and SPSS 22.0.Te data analysis, which was based on the quantitative analysis, combined descriptive and inferential statistics.Descriptive statistics (univariate analysis) were performed for each main variable of the study, whether it was an independent or dependent variable, using frequency counts, percentages, and mean ± standard deviation (SD).Te socioeconomic characteristics of the individuals and variables associated with HCWs were examined using the chi-square test.Te ProQOL manual states that the responses to items 1, 14, 15, and 17 should be reversed to become (1 � 5) (2 � 4) (3 � 3) (4 � 2) (5 � 1).Te ProQOL was at a low level in the end, with sum answers of ≤22 and a moderate level with sum answers of 23-41; the ProQOL was at a high level, and the sum answers were ≥42 [35].Te signifcance level was <0.05.

Demographic Characteristics.
A total of 258 healthcare workers (204) (79.1%) were males, and 54 workers (20.9%) were females.Regarding marital status, 31.3% were single, and 68.7% were married.Regarding age, 50% were 18-30 years old, 43% were 31-40 years old, and 6.97% were >40 years old.On the basis of education, 32.6% had graduated, and 65.1% had postgraduate or above education.Moreover, 2.3% were senior medical students in the last stage of their undergraduate studies.In this study, 76.7% of the participants were physicians, 10.5% were nurses, 11.6% were technicians, and 1.2% were assistants.Furthermore, we found 5.8% of participants from the infectious disease department, 9.3% from the surgical department, 3.5% from the ICU, 15.1% from internal medicine, 16.3% from emergency, and 50% from other departments.Among all participants, 37.2% were satisfed with their monthly salary, 29% were not satisfed, 6.9% were very satisfed, and 26.7% were normal.Regarding work burden, 44.2% showed a heavy work burden.Te time interval of duty shown by the participant included 38.3% working for 8 h per day, 57% working for 9-12 h per day, and 4.6% working for 12 h per day as clinical frontline staf, as shown in Table 1.In addition, 34.9% of HCWs had 2 night shifts per week, 20.9% had 1 night shift per week, and 10.5% had 3 night shifts per week.Here, we found that 61.3% of HCW families were infected with COVID-19, and 68.6% of HCW lives were afected by COVID-19, as shown in Table 1.

Prevalence of ProQOL in Healthcare
Workers.Te healthcare workers' average scores for CS, BO, and STS were categorized into low, moderate, and high groups.Te mean scores ± standard deviation (SD) was as follows: CS was 35.29 ± 4.37, while BO and STS were 19.18 ± 2.92 and 24.03 ± 3.79, respectively.Tese results indicate that healthcare workers generally experience low levels of STS and moderate levels of CS and BO.Specifcally, the results reveal that healthcare workers reported moderate levels of compassion satisfaction (60.5%) to low levels (20.9%), low levels of STS (48.8%) to moderate levels (40.3%), and moderate levels of burnout (48%) to low levels (39.5%).Details are shown in Table 2.

Factors Related to HCWs' ProQOL.
In univariate analysis, general data were used as independent factors and anxiety, depression, BO, STS, and CS were used as dependent variables, and the fndings demonstrated that HCW age, marital status, number of working hours per day, workload, and job satisfaction were associated with STS; workload, job satisfaction, and salary satisfaction were associated with BO and CS (P < 0.05; Table 3).Chi-square analysis was performed, and it showed that males possessed lower anxiety, depression, STS, and compassion satisfaction than female HCWs (P < 0.001).Single HCWs had a lower burnout risk than married HCWs (P < 0.006).HCWs aged 18-30 had heavier STS than HCWs aged 31-40 and ≥41 (P < 0.001).Physicians had lower anxiety and depression, STS, and compassion satisfaction than nurses, technicians, and assistants (P < 0.05).Te HCWs who worked in the emergency department, ICU, and internal medicine department had higher levels of burnout, anxiety, and depression than those who worked in other departments or units (P < 0.05).Tose with 1-5 years of work experience had a larger percentage of moderate STS than those with more than 5 years of work experience (χ 2 �13.738,P � 0.008).Working hours per day (h) longer, the STS was heavier (χ 2 � 46.748, P < 0.001).When the job was more satisfed, the HCWs had lower anxiety and depression (χ 2 �15.020,P � 0.005) and secondary traumatic stress (χ 2 � 9.526, P � 0.009).In addition, the HCWs had more  Journal of Nursing Management satisfaction by monthly salary, and they had poor levels of burnout, anxiety, depression, STS, and CS (P < 0.001) (Table 3).

Discussion
Te current fndings demonstrated that during the COVID-19 pandemic, HCWs had a high frequency of selfreported sociodemographic and psychological issues.Te prevalence of anxiety, depression, burnout, and general psychological issues varied signifcantly among diferent types of healthcare employees.Tis research revealed several sociodemographic factors associated to HCWs to help offcials and policymakers establish policies and improve HCW facilities.Due to their frequent use of empathy, extended exposure to secondary trauma, and work environment, healthcare practitioners are likely to feel depression, anxiety, burnout, and secondary traumatic stress [39].In addition, the constrained resources and numerous healthcare needs during this time may raise the possibility of compassion fatigue.Tis evidence has increased the risk of psychological distress due to the pandemic.According to our research, HCWs had to moderate degrees of anxiety and depression, whereas high levels of depression signs and symptoms were found in Indian healthcare professionals who were classifed as having moderate-to-severe depression symptoms (22% of them) [40].During the COVID-19 pandemic, HCWs who scored higher on fatigue, melancholy, anxiety, and stress also had a greater fear of contracting coronavirus [41].In China, healthcare professionals and nurses experienced symptoms of despair, anxiety, insomnia, and discomfort two months after the frst identifed COVID-19 case [42].Managing COVID-19 patients led to increased anxiety and reduced health-related quality of life [43].Frontline healthcare workers with moderate-to-severe depression and anxiety symptoms saw a decline in their overall quality of life [40].
According to our research, medical stafs that have been exposed to the COVID-19 pandemic might experience both positive and negative psychological consequences.According to the results, STS and burnout were frequent, although levels of CF varied from moderate to high.While greater levels of CS and less CF were detected in HCWs who reported feeling highly content with their salaries, less BO was seen in HCWs who reported feeling highly satisfed with their earnings (P < 0.05).Similarly, during the pandemic, 72.5% of nurses were satisfed with their current job, while 73.6% of nurses were satisfed with their pay [44].Less BO was experienced by nurses who were satisfed with their pay, while higher CS and less CF were seen in nurses who were highly satisfed with their jobs [13].During the COVID-19 epidemic, similar fndings were reported in Ecuador, where medical staf experienced mild to moderate burnout and CF [45].Similar fndings were made by Jordan et al. in their study, which revealed that high-income nurses had a low incidence of CF [46].According to Tian et al., nurses who were dissatisfed with their salaries had higher BO [47].In addition, in the study reported by Niu et al., nurses who reported having low job satisfaction were more likely to sufer from CF, which is consistent with our fndings regarding job satisfaction [13].
Te results of this study showed that STS scores were greater than the crucial value, as well as higher than those of Turkish nurses prior to the pandemic and Italian nurses during the pandemic [48].Te signs and symptoms of STS can include anxiety, sleeplessness, and intrusive thoughts [49].Patients with COVID-19 are more likely to experience mood swings, irritability, and grief [13].HCWs who interact with these patients could feel a great deal of psychological pressure.It has been discovered that nurses fghting the pandemic are more likely to have symptoms of somatization [50].As a result, it is essential to care about HCWs and STS, ofer social and psychological support, promote a healthy team culture, and engage in proper exercise to lessen the pandemic's negative efects on HCWs.
In this study, HCWs with excessive workloads exhibited higher levels of BO and STS (P < 0.001), as well as substantially lower CS levels.According to certain research and our study, nurses who work a lot are more likely to experience STS, which lowers job satisfaction and BO [51].In a 2020 study with 506 Spanish healthcare professionals, 94% showed moderate-to-severe compassion fatigue, 84% showed moderate-to-severe burnout, and 84.4% of the entire sample showed moderate-to-severe compassion satisfaction [52].Burnout and secondary traumatic stress were more severe in physicians than in nurses.In addition, nurses had higher levels of compassion satisfaction.Another Spanish study of 973 healthcare professionals revealed that 90.6% had high levels of compassion satisfaction, noting that this trait is more common in people between the ages of 35 and 55 and that nurses outnumbered physicians even though nurses were more prevalent [53].
Te study's fndings showed that the COVID-19 pandemic signifcantly increased the burden of psychological issues among various healthcare professionals.Te results imply that exposure to negative information about the pandemic may be linked to a higher risk of psychological issues.Participating in frontline work appears to be a signifcant risk factor for anxiety, sleeplessness, and psychological issues in general [54][55][56].Tese results suggest the implementation of measures that go beyond saving patient lives with COVID-19 psychosocial interventions and support for healthcare workers, which will help us better understand the impact of pandemics on psychological health among HCWs.Early in the pandemic, support for transient psychological issues, including anxiety and depression, is required, along with evidence-based psychosocial therapies.Furthermore, stress should be placed on self-relaxation training, regular exercise, and a healthy lifestyle.

Limitations of the Work.
Tis study has certain limitations, even if it adds empirically to the conversation about the ProQOL of HCWs.First, because the study was performed online, self-selection bias could have been a factor.Considering that a convenience sample was used, it is not possible to extrapolate the fndings to other situations because they may not accurately represent the population.Tis 6 Journal of Nursing Management study was cross-sectional in design and evaluated ProQOL at a single moment in time within the particular era and COVID-19 pandemic scenario, care must be taken when interpreting the data.As the number of COVID-19 cases continued to rise in Pakistan during the fourth wave, hospitals faced increasing strain from the infux of patients.Government policies proved inefective due to public indiference.Notably, the private sector hospitals in Pakistan outnumber government-run facilities, and they have a larger contingent of healthcare professionals, particularly physicians and doctors, compared to nurses and other healthcare providers.Consequently, during the fght against COVID-19, physicians had to take on the frontline roles compared to nurses and other professionals following suit [57].In addition, there is a signifcant gender disparity in the healthcare workforce, with a higher proportion of men compared to women, largely attributed to the country's ongoing struggle for women's empowerment and education.Tis gender imbalance is especially prominent in roles such as nursing and nursing assistants, where men dominate the positions [58].Another limitation of the study is its crosssectional design, as the pandemic has since subsided and the study cannot capture the long-term impact on the mental health of these frontline healthcare workers.To address this, it would be advisable to conduct a longitudinal study to track the evolution of the mental health symptoms assessed in this research over time.

Implications for Nursing Management
Prior to fghting the epidemic, it is essential to teach HCWs about patient knowledge, epidemic control and preventive techniques and to build personal resiliency.Programs for stress management and peer social support are also essential to lower BO and STS levels, and they should ofer efcient interventions to increase HCWs' satisfaction levels.Te foundation of the healthcare system's physical and mental health must be protected; thus, governments must take the necessary action.Financial subsidies and rewards from the government are advised to increase work satisfaction for HCWs.According to our research, structural empowerment techniques can be developed by hospital administration and HCWs to improve HCWs' psychological empowerment.We also advocate for the development of counseling services, assistance, and programs to support HCWs' psychological well-being.Tese measures will help preserve a strong team culture.

Conclusion
Te HCWs have moderate levels of compassion satisfaction, secondary traumatic stress, and low levels of burnout.High levels of perceived susceptibility and severity, as well as elevated psychological distress, are present in HCWs battling COVID-19.Healthcare professionals' levels of anxiety and CF may be impacted by professional contextual factors (poor income and lengthy hours).HCWs with a heavy workload and little pay had more severe depression and STS.Te administration of the hospital must to keep a low degree of burnout, increase CS levels, manage STS levels, and provide HCWs with a good work environment.Further research studies with diferent research approaches and diferent lowresource sceneries are suggested to address the professional quality of life level.

Table 3 :
Factors related to HCWs' professional quality of life.