Psychological distress in health care workers during the beginning, the middle, and the last part of the COVID-19 pandemic

The results of this study, capitalizing on a longitudinal sample of HCWs in the Czech Republic, revealed a dynamic pattern in the relationship between stressors related to the COVID-19 pandemic and psychological distress among HCWs over time. Across the three waves of data collection, the distribution of stressors and distress followed a similar trajectory: both were lowest at baseline in 2020, after the initial wave of the pandemic subsided, highest at the second data collection point in 2021, then decreased at the third data collection in 2022 towards the end of the pandemic. This fluctuation suggests that participants experienced a surge in stressors and distress, which later returned to levels from the beggining of the pandemic. The path model further elucidates these relationships, indicating that distress in subsequent waves was strongly predicted by distress in the previous wave, demonstrating a carry-over effect of psychological distress over time. Examining intra-individual differences, we found that stressors in the first two waves significantly predicted concurrent distress. Further, the stressors towards the end of the pandemic did not seem to influence concurrent distress. The impact of stressors on psychological distress was similar for men and women. Gender emerged as a significant predictor of distress, with men experiencing lower levels of distress in the first two waves, but this pattern was not sustained towards the end of the pandemic, again reflecting intra-individual rather than inter-individual variations within the sample. Neither age nor occupation had a significant impact on distress, highlighting that other factors may be more critical in understanding the psychological experiences of HCWs in this context.

Secondary analyses revealed several stressors of particular importance. Most importantly, experiences of discrimination, stigma, or violence were associated with distress and were the only factor with carry-over effects from 2021 to 2022. Stigma, discrimination, and violence have been previously found to have significant negative consequences for mental health and psychological distress^13,14,15. A mediating element in the relationship between stigma and psychological distress may be social isolation and the use of maladaptive emotion regulation strategies such as rumination or suppression¹³. These elements were present during the pandemic, which was an unprecedented health threat not only for health professionals, with a lack of information, prevalent fear in society, and measures based on isolation and distance. Additionaly, prioritization of patients at the height of the pandemic in Czechia in 2021 predicted concurrent distress, and low trust in workplace predicted distress in 2021 and 2022. These findings align with international research from the HEROES study^16, where trust in workplace‘s and the goverment’s ability to manage the pandemic emerged as a predictor of mental healh across 22 studied countries. The timing of the role of these two predictors also aligns with the pandemic trajectory and lived experience of HCWs, as resource scarcity was highest in 2021. Low trust contributes to high-stress working environments and has a negative effect on the mental health and wellbeing of employees¹⁷. Factors of low trust in the workplace include non-benevolent behaviors, low competence of leaders, dishonesty of colleagues, unsafe environment, lack of openness and nepotism¹⁸.

Our study uncovered several novel aspects of the trajectory of psychological distress, which can be understood within the framework of the “recovery” response to stressors. This model describes a gradual return to baseline distress levels following an initial increase in distress during heightened adversity¹⁹. Our findings align with a longitudinal study of a representative sample of the U.S. general population, which reported an increase in psychological distress following a positive COVID-19 test, with distress returning to baseline levels after a month²⁰. That study also noted that psychological distress was more severe among individuals with more intense and prolonged COVID-19 related symptoms. The stressors among HCWs as well as in general population evolved over time in response to pandemic measures and the epidemiological situation, exerting temporary effects on psychological distress. This pattern is consistent with the “stress reaction model”²¹, which posits that work-related stressors impact psychological functioning only over the duration of exposure. Nevertheless, we observed a carry-over effect of psychological distress over time, perhaps due to the influence of pre-existing mental health conditions, which are among the most robust predictors of mental health problems during and after pandemics and disasters^7,22. It is also plausible that changes in other factors, such as increase in the out-of-workplace stressors (e.g., child caring, home schooling) may have contributed to the observed carry-over effect.

Our study uniquely found that COVID-19 related stressors during the last wave of data collection in 2022, towards the end of the pandemic, did not predict concurrent psychological distress. By including autoregressive paths in our analysis, we accounted for the impact of earlier observed factors on later outcomes. In contrast to the lacking direct effects, our additional analysis did reveal significant total effects in linear regression models. This suggests that, towards the end of the pandemic, it was primarily the same individuals whose distress increased due to the stressors, rather than the stressors causing new individuals to experience heightened distress. Therefore, these findings suggest that identifying individuals at hightened risk earlier on and working with them in interventions could have lasting impact on their mental health.

We identified gender differences in the descriptive part of our study, but the lack of effect modification suggests that gender did not significantly alter the association between pandemic-related stressors and psychological distress. Previous research, including a systematic review, has shown that female HCWs are more likely to experience psychological distress during infectious disease outbreaks, including COVID-19⁸. Our findings from the first two waves, showing lower psychological distress among men, align with this. There are several possible reasons for the higher rates of distress among women during the pandemic. Women are generally more likely to report mental health issues, a trend that may have been amplified by the pandemic. A systematic review and meta-analysis of 134 studies found that mental health declines during the pandemic were more pronounced among women²³. Additionally, women faced increased domestic responsibilities, such as childcare, especially during school closures^24,25. In the Czech Republic, where schools were closed for an extended period, these added burdens may have contributed to higher distress among female HCWs. Interestingly, in our study, women did not report a higher distribution of COVID-19 related occupational stressors, contrasting with other studies that found that female HCWs experienced some work-related stressors to a higher degree than men. For example, the global HEROES study showed that women were less likely to receive support from colleagues and more likely to perceive personal protective equipment as insufficient – both factors linked to higher distress²⁶. By the time of our final data collection in 2022, many of the pandemic’s pressures had eased: schools were open, vaccinations were widespread, and COVID-19 patient management was more established. These changes may have reduced gender-specific stressors. The absence of significant gender differences in distress during the later stages of the pandemic in the path model likely reflects intra-individual rather than inter-individual variations in these associations. This means that the lack of direct effects in the path model, in contrast to the total effects from linear regression, suggests that the same women who experienced higher distress compared to men in earlier waves continued to do so, rather than new women experiencing increased distress relative to men. Additionally, participants´ characteristics, such as temperament, resilience, personality or attachment style^27,28,29, may have played a role beyond gender and gender-associated factors. For instance, individuals with higher resilience may adapt more effectively to prolonged stressors, potentially buffering against distress. Similarly, traits like emotional stability or flexibility could play a critical role in modulating stress responses over time. Future research should consider integrating these and other psychological factors to better understand the interplay between gender and intraindividual variations during prolonged crises.

Our study found no evidence that age or profession affect the psychological distress of HCWs. The literature on this topic presents mixed results. A systematic review of 139 studies⁸ found that 72 of them examined age as a predictor of psychological distress. In 39 studies, younger age was identified as a significant risk factor, while eight studies found that older HCWs were at greater risk, and the remaining studies reported no significant association between age and distress. Regarding the type of profession, in the systematic review by Sirois et al.⁸, 34 studies examined occupational roles, with 18 studies reporting that nurses experienced higher stress levels, while 16 found no difference, and five indicated that physicians were at greater risk.

The study has several strengths, including the examination of multiple COVID-19 related stressors, the inclusion of diverse healthcare professions in the sample, and the representation of all regions of the Czech Republic through the original HEROES study. Additionally, the longitudinal design, with data collected across three waves from 2020 to 2022, allows for the tracking of psychological distress over time, providing valuable insights into the evolving impact of the pandemic. However, there are limitations, notably a large dropout rate, which reduced the sample size and limited the ability to examine individual factors in detail. A significant limitation of this study lies in the attrition rate, with less than 20% of the original sample providing complete data across all three waves. We found that the participants who remained in the study had a slightly larger representation of physicians and slightly lower levels of distress when compared to those who dropped out. It is also possible that these two groups systematically differed in other unmeasured characteristicsl. Consequently, the generalizability of our findings to the full study cohort may be limited.

Another limitation of our study is the relatively small number of participants within certain subgroups, such as specific professional roles, gender categories, and socioeconomic levels. This constraint limits the statistical power and precision of our estimates for these subgroups, potentially masking meaningful differences or interactions. As a result, the generalizability of findings to these subgroups is restricted, and interpretations should be made with caution. Future research should aim to recruit larger, more diverse samples that allow for robust subgroup analyses and ensure adequate representation across professional, gender, and socioeconomic categories. Furthermore, the study did not account for stressors outside of work or personal factors that could contribute to heightened risk for psychological distress, potentially overlooking key influences on the mental health of HCWs.

The implications of our findings are important for the development of mental health support strategies for HCWs during pandemics and other crises. The dynamic nature of psychological distress observed in our study suggests that interventions should be adaptable, with heightened support during peak stress periods and ongoing resources as distress levels taper off. The early gender differences in distress indicate that successful programs should consider gender-specific challenges that go beyond occupational stressors. Additionally, the lack of significant effects of age and occupation on distress suggests that mental health interventions should be broad-based, addressing a wide range of HCWs rather than focusing solely on specific groups. Moreover, the carry-over effect of distress over time underscores the importance of long-term mental health monitoring and support, even after the immediate crisis has subsided and providing support to those in whom distress levels rise. These insights can inform more effective mental health policies and practices, ultimately improving the well-being and resilience of HCWs in future public health emergencies.

While our study identified key predictors of distress among HCWs, future research could benefit from longitudinal monitoring of specific factors to better understand stress dynamics over time. Factors such as resilience, coping strategies, emotional regulation, and work-life balance could provide deeper insights into stress adaptation processes. Additionally, organizational-level variables, including staffing adequacy, workplace support, and access to mental health resources, merit continuous evaluation to assess their impact on stress levels. By examining these elements in tandem, future studies could develop more targeted interventions to mitigate stress and promote well-being among HCWs, particularly during prolonged or recurring crises.