The Middle East Respiratory Syndrome (MERS) outbreak in South Korea in 2015 was unexpectedly large and fast-spreading, considering the epidemiological characteristics of the disease defined by previous incidents in the Arabian Peninsula. During the outbreak, 186 individuals were infected, 38 died, and 16,752 were quarantined, and exposed vulnerabilities of the public health system during an infectious disease epidemic.Reference Kim 1 Nearly every part of the health care system in South Korea underwent mass confusion due to the inexperience of how to respond to the outbreak, and, as a consequence, hospital workers on the front line attending to infected patients were exposed to a high infection risk. Indeed, among the infected cases, which had reached 181 by June 26, 2015, 19.9% were hospital workers who were infected while caring for MERS patients.Reference Kim 2 Furthermore, the workers also experienced a continuously high level of psychological stress during and after the outbreak. A survey conducted by the Korean Medical Association during 6 months after the outbreak revealed that about 28% of hospital workers who had treated MERS patients during the outbreak suffered from symptoms of depression. 3 Nonetheless, few attempts have been made to investigate hospital workers’ experiences during the outbreak to provide avenues to improve workplace protection measures and emotional preparedness of health care workers.
Hospital Workers and Crisis Management
Hospitals are key centers that deliver “lifeline” services in response to an infectious disease outbreak and, in turn, reduce the disease spread in the community.Reference Zhong, Clark and Hou 4 The importance of the hospital’s proper response to the outbreak is even increased when an outbreak is characterized as having spread through hospital-to-hospital transmission, as happened during the 2015 MERS outbreak in South Korea.Reference Ki 5 Meanwhile, hospitals are directly influenced by consequences of disease outbreaks, in that they are expected to expand their operations to meet the sudden and drastic increase in health care demands associated with the outbreak.Reference Sauer, McCarthy, Knebel and Brewster 6
Hospital workers play a primary role in a hospital’s capacity for rapid expansion to meet outbreak-induced demands (ie, surge capacity),Reference Kaji, Koenig and Bey 7 and their ability to perform at their highest professional capacity is related to a successful response to disease outbreaks.Reference Qureshi, Gershon and Sherman 8 To achieve optimal performance, proper knowledge and skills as a frontline caregiver are crucial, but hospital workers should also be emotionally capable because they will be facing highly stressful and traumatic situations during which strong negative emotions are often produced. If time and effort that should be dedicated to responding to patients’ needs are instead directed toward managing hospital workers’ distress, this comes at a cost to the hospital’s effective functioning.Reference Mitroff 9 Unfortunately, little attention has been given to the emotional responses of hospital workers during an outbreak. Moreover, recent studies that focus on this population are limited in several aspects. To be specific, previous studiesReference Maunder 10 – Reference Nickell, Crighton and Tracy 15 focused on a single case of the severe acute respiratory syndrome (SARS) outbreak in 2002, and a majority of these studies focused exclusively on stress. In addition, the emotions and related factors of concern were usually predefined as a structured questionnaire that was mostly used. The present study attempted to reflect actual experiences of hospital workers by using qualitative data collected in real time during the 2015 MERS outbreak in South Korea. From these data, we aimed to identify negative emotions and stress experienced by hospital workers, and also the events that triggered such experiences during the outbreak. Furthermore, we suggest managerial efforts that could be made by a hospital crisis management team prior to or during an infectious disease outbreak, to address the identified themes. Analyzing this disease outbreak and drawing implications that can be shared and used as learning tools are contributable to the development of more effective crisis management approaches.
METHODS
Data Collection
Qualitative data used in this study were collected from one hospital during June 2015. Located in Gyeonggi–do, where approximately 30% of MERS cases occurred, 16 this hospital treated 5 MERS patients in response to a government request while it continued to perform its functions as a local community hospital. During the outbreak, the center for empathy with patients affiliated to the hospital provided a special program for their employees to share what they were emotionally experiencing and issues that troubled them. At the end of the program’s session, the participants were encouraged to leave a short, anonymous note (1 note per participant) on the “Let It Out” panel prepared by the session moderator. In these notes, hospital workers wrote about their emotions, stress, and trigger events that were most representative of what they verbally communicated during the session.
During the implementation, 59 department heads of the hospital initially participated in the program’s session and learned from the center’s instructors. They subsequently implemented the program to their respective departments as they played the role of the moderator. After the implementation of the program sessions was ended, the “Let It Out” panels were gathered at the center, where the short notes were then removed from the panels and collected. Overall, 156 short notes were collected and electronically transcribed for analysis. As the data were prospectively produced and independently collected by the hospital in support of its workers to relieve their emotional load, the data had a low risk of recall bias or of manipulation by the researchers.
Data Analysis
Qualitative methodology was adopted to investigate the negative emotion and stress of hospital workers during an outbreak, and the triggers behind those emotions and stress. Specifically, 2 different analysis approaches under qualitative methodology were adopted to meet the purposes of the study – qualitative content analysis and thematic analysis. We believed that emotion and stress is a type or kind; therefore, we used the qualitative content analysis method.Reference Elo and Kyngäs 17 Meanwhile, analysis of triggers behind the emotions and stress is best accomplished through thematic analysisReference Braun and Clarke 18 given the importance of identifying core issues of complex event experiences. The results of both analyses were later matched to identify what emotions and stress were specifically triggered by each event experience: emotion A and theme B were related to the same feature of data, then, theme B was considered to trigger emotion A.
To analyze negative emotions and stress, features of a meaning unit consisting of emotions and stress expressed implicitly (latent data), as well as explicitly (manifest data), were coded. The emotion category used for coding was derived from theories and previous studies, whereby basic human emotionsReference Chaiken and Trope 19 and predominant negative emotions during crisisReference Lazarus 20 were combined and adjusted into a single category. The finalized emotion category was “anger,” “anxiety,” “fear,” “sadness,” “disgust,” “shame/guilt,” where “stress” and “other” were added.
When coding the expressions of emotions and stress into the category, 2 dictionaries of emotion-related Korean wordsReference Park and Min 21 , Reference Sohn and Park 22 derived from psychological research were referred. Coding that could not be identified by the dictionaries – coding of an expression that was not present in either of the dictionaries and coding an expression into an emotion category that was not used in either of the dictionaries – referred a consultation from a psychologist who had expertise in emotions and was also the first author of one of the referred dictionaries.Reference Park and Min 21 All coding processes were independently conducted by the 2 researchers, and any discrepancy in categorizing emotion and stress expressions was resolved through discussion (inter-coder reliability: α = 0.89). The result of emotion and stress categorization is shown in Appendix 1.
To analyze the events that triggered negative emotions and stress, a thematic analysis process was followed. After coders familiarized themselves with the data, features of triggering events that carried the expression of negative emotions and stress were coded into 2 kinds of condensed information of the features – the coder’s description (or summary) of the features and the interpretation of underlying meanings. To search for a theme, a 2-step collation was performed. The codes were first collated into the potential subthemes, and, then, the subthemes were collated into the themes. The themes were subsequently reviewed relative to not only the coded features under each theme, but also the entire data set. If the theme did not properly represent the coded features and the data set, it returned to the step of collating codes. The themes were refined and finalized through this iterative process. In reporting, the most representative and vivid data of each subtheme and theme, with regard to the research question of this study, were presented.
RESULTS
First, diverse negative emotions (ie, anger, anxiety, fear, sadness, disgust, and shame/guilt) and stress were found in the hospital workers’ short notes. Also, 4 event themes that triggered those emotions and stress in hospital workers during the MERS outbreak were identified (Table 1).
TABLE 1 Themes and Subthemes
Theme 1: My Workplace Becoming an Unsafe Area
Subtheme 1a: Risk of Getting Infected and Infecting Close Others
The hospital workers had anxiety (eg, “nervous,” “worry”), fear (eg, “afraid”), and sadness (eg, “sorry”) when they thought that they could become infected with MERS and even be a virus carrier who passes on the infection to their significant others (eg, family and/or patients).
“I felt so nervous that I might catch MERS.” (Note #95)
“I was afraid that I might get infected and without my knowledge, infect my elderly parents.” (Note #81)
“I felt so sorry for my family. What if they got infected with MERS because of me? (crying text emoticon).” (Note #140)
Subtheme 1b: Large Decrease in Patient Volume and the Impact on Financial Status and Job Security as a Consequence
Because the hospital was known to treat MERS patients, there was a drastic decrease in the number of outpatients. This news, in itself, brought fear to the hospital workers. Moreover, the employees were very anxious (eg, “worry”) about the future impact of the crisis on their job security and whether the hospital would try to compensate for the financial damages caused by the decrease in patient volume.
“As MERS spread, the number of outpatients in our hospital suddenly and drastically decreased. I felt fearful because of the situation.” (Note #27)
“I think our hospital’s financial management would be difficult because of the decrease in the number of patients, and I am worried about whether I would be able to receive my salary.” (Note #26)
“Please do not give us a hard time! I already cried because of MERS, and I don’t want to cry again because of the salary cut.” (Note #97)
Theme 2: Stigmatization on Myself and My Family
Subtheme 2a: Being Avoided in Public Places as a Possible Disease Carrier
The hospital workers were stigmatized as high-risk spreaders and were avoided and rejected in various places such as public transportation hubs. This avoidance induced sadness and anger.
“When they recognized where I worked, they shunned me. I was really upset.” (Note #58)
“People who didn’t know much about MERS said bad things about the hospital on the Internet and shunned its employees. It was heartbreaking and resentful as the hospital workers worked really hard during the outbreak. I was also refused from a taxi.” (Note #111)
Subtheme 2b: Forced Alienation From a Close Social Group
The hospital workers (and their family members) were picked on by their close social groups, at work, in school, or in their community, which made them sad.
“During the initial stage of the MERS outbreak, people started to be concerned about which hospitals were treating MERS patients. My little brother innocently said at his workplace, ‘My sister works at the hospital.’ After that, he was sent home without letting him know why. Seeing him at home at such an early hour broke my heart as he was also the object of prejudice just because he has a sister working in a hospital as a nurse.” (Note #110)
“In an online chat room where members were parents of the class to which my kids belonged, a mother said that she felt afraid because a physician from our hospital lived in the same apartment complex as her family. Another mother asked if someone’s mother in the class worked at our hospital. I couldn’t say anything (crying text emoticon).” (Note #3)
Theme 3: Mistake, Missing, Delay Due to Communication Failure
Subtheme 3a: Lack of Information Sharing Inside of the Hospital
During the initial stage of the MERS outbreak, employees were not told that MERS patients were being treated in the hospital. This left employees uninformed about what was happening in their own workplace, which caused feelings of anxiety (eg, “nervous”) and sadness (eg, “feeling helpless”). Moreover, they felt anger (eg, “stifled”) and disgust (eg, “hate”) toward the decision.
“I was nervous and stifled as I know nothing about what was going on in my workplace.” (Note #99)
“As a health-care worker, I felt helpless as I can’t disclose any information to my family and friends when they asked me about my workplace simply because I don’t have anything to tell them.” (Note #11)
“The hospital did not notify us that patients with MERS were being treated in the hospital. After Chosun newspaper’s report, they sent us a text message that they would be transparent and would disclose information. I hated that.” (Note #86)
Subtheme 3b: Hospital’s Improper Instruction in Communicating With the Community
The initial strategy of the hospital management for communicating with the community was to conceal the presence of MERS patients in the hospital, but then news outlets revealed what was happening in their reports. Furthermore, instructions on how to respond effectively to highly concerned community members were lacking. This failure induced anger (eg, “baffling”), stress (eg, “hard”), and shame/guilt to the hospital workers.
“I had to lie when receiving phone calls asking if there were MERS patients in the hospital.” (Note #93)
“The parents from my daughter’s school asked me if our hospital was treating MERS patients; I said ‘no,’ which made me feel ashamed of myself.” (Note #98)
“I just followed the instruction and said that there were no MERS patients. The news outlets then widely reported that MERS patients were being treated in and discharged from our hospital. What happened baffled me a lot because, after all, the frontline hospital workers lied.” (Note #4)
“We suffered from a zillion inquiries as a result of the news reports, but the hospital did not tell us what to say and what not to say, or how to respond to them. It was just so hard.” (Note #75)
Theme 4: Mistrust and Blame From the Community for Loss of Responsiveness
Subtheme 4a: Community Members’ Aversion to a Hospital Visit
Outpatients who were mostly from the community distrusted the hospital’s safety and refused to visit. When they needed medical service, they made requests that were against current medical practices, such as requesting that medical consultations and prescriptions be made via telephone and fax, so that they could avoid visiting the hospital. This avoidance induced stress in the hospital workers.
“I understand that they were worried, but there were just too many phone calls asking if it was absolutely safe to visit the hospital. It was really stressful to take care of multiple cancellations and rearrangements of visits.” (Note #25)
“Every day, what I did first in the morning was to receive phone calls from outpatients. They said that they would not come to our hospital because of MERS and would want to receive medical consultation from physicians via telephone. It was straining to respond to them.” (Note #91)
“What was hard is that… (omitted)… I was asked too many times to send medical prescriptions via fax.” (Note #71)
Subtheme 4b: Community Members’ Blame for Dishonesty
After the news outlets had reported about MERS patients being discharged from the hospital, the community began to lose its trust in the hospital and its employees. As a result, hospital workers were blamed by community members that they were dishonest and irresponsible, which induced stress and sadness.
“Things that were hard for me… (omitted)… it was hard when they yelled at me that the patients knew everything and that what I was saying was a flat-out lie” (Note #62)
“What hurts me is that… (omitted)… he was so sure that there were MERS patients in our hospital and asked me why I was lying to him.” (Note #19)
“He did not believe my words that there were no MERS patients in our hospital so I referred him to the Centers for Disease Control and Prevention in Korea. At that point, he yelled at me that I should take responsibility if he visited our hospital and became infected. I was so upset.” (Note #79)
The themes and the emotions they triggered are summarized in Table 2.
TABLE 2 Triggered Emotions by Theme
DISCUSSION
Using a qualitative approach, we found various negative emotions and stress experienced by the hospital workers, and 4 themes that triggered those emotions and stress during the MERS outbreak. Noticeably, the themes occurred at multiple levels. Two themes at an individual level – “my workplace becoming an unsafe area” (Theme 1) and “stigmatization of myself and my family” (Theme 2) – were seemingly familiar from previous studies.Reference Maunder 10 , Reference Maunder, Lancee and Rourke 12 , Reference McAlonan, Lee and Cheung 14 In contrast, themes with wider contexts – “mistake, missing, delay due to communication failure” (Theme 3) (organizational level) and “mistrust and blame from the community for loss of responsiveness” (Theme 4) (community level) – have not been highlighted before. Each of these themes either stood alone or were accompanied by others related to the specific managerial issues of the hospital in crisis (Figure 1). Based on those relationships, we propose suggestions for hospital crisis management approaches that could moderate the impact of the outbreak on the emotional capacity of hospital workers during an outbreak.
Figure 1 Events That Trigger Negative Emotions and Stress, and Implications to a Hospital’s Crisis Management.
First, Themes 1 and 2 were related to the issues of the improvement of workplace safety. Therefore, we reemphasize the necessity that the hospital management reduce workplace risk to acceptable levels by providing appropriate protection measures for hospital workers and their families (eg, information, safeguards, vaccines, and medicines).Reference O’Boyle, Robertson and Secor-Turner 23 – Reference Nekoie-Moghadam, Kurland and Moosazadeh 26 Such lowered levels of workplace risk do not only assure the safety of hospital workers, but also could possibly relieve the anxiety and fear of the community toward hospitals and hospital workers, thus alleviating the issue of unwarranted avoidance – that is, stigmatization – of hospital workers and their family.
Second, Themes 2, 3, and 4 were related to the issues of the establishment of crisis communication principle and strategy. The importance of communication during crises has been emphasized strongly and repeatedly.Reference Zucker, Whalen and Raske 27 – Reference Gesser-Edelsburg, Stolero and Mordini 29 Clear, accurate, and timely communication is known to enable informed decision-making and cooperation within the hospital as well as to promote public relations. 24 – Reference Nekoie-Moghadam, Kurland and Moosazadeh 26 , Reference Djalali, Castren and Khankeh 30 In particular, the data for this study revealed the importance of internal communication of the hospital, which was surprisingly neglected during the 2015 MERS outbreak. As Heide and SimonssonReference Heide and Simonsson 31 have pointed out, fulfilling the need that hospital workers have for information is crucial for them to function effectively as “communicators” responding to the outside (eg, patients, journalists, and government officials) as well as health care professionals. In this way, effective crisis communication during an outbreak reduces negative responses from the outside community – mistrust, blame, and stigmatization – and also the internal problems of mistake, missing, and delay.
Finally, Themes 2 and 4 were related to the building of a cooperative relationship between the hospital and the community, which we strongly suggest. As inferred from the data, the hospital and the outside community considered each other as adversaries. Inarguably, the hospital takes the utmost role in responding to infectious diseases; however, disjointed crisis preparedness can often lead to failure.Reference Maldin, Lam and Franco 32 In the United States, hospitals were recognized as an integral component of the community’s response to the crisis after the 9/11 attack, a recognition that eventually contributed to an increase in hospital preparedness.Reference Barbera, Yeatts and Macintyre 33 We believe that establishing a relationship with important community leaders prior to disease outbreaks would reduce the emotional loss due to negative responses from the outside community, because such a relationship facilitates mutual understanding of disease outbreak situations and a collective response.
There are a few limitations of this study. First, it is possible that the experiences of hospital workers who left a short note and those who did not leave a note are not entirely consistent. For example, the latter might have had a greater workload and felt more emotionally distressed and therefore unable or unwilling to participate in the program. Second, in regards to those who participated, the data include a wide range of hospital workers with diverse levels of participation in MERS treatment. On the one hand, hospital workers with a relatively low risk of infection, who also psychologically suffered during an outbreakReference Maunder, Hunter and Vincent 34 but might have different kinds of event experiences,Reference Lin, Peng and Wu 11 presumably contributed to the multilevel triggering events identified in this study. On the other hand, experiences could not be distinguished by subgroups with various risk levels or by subgroups having different biological or other occupational factors because the notes were completely anonymous. Third, these results were collected at a single hospital, and thus the findings may not be applicable to other hospital settings. Despite these limitations, this research sheds light on how hospitals prepare for and manage the emotional capacity of frontline hospital workers in an infectious disease outbreak, which have not been fully discussed in previous studies. Results from this study could draw more attention to the emotional capacity and resiliency of hospital workers. Because we provide evidence from one recent case of outbreak, more case analyses are needed in the future. We believe that the accumulation of evidences from past failures and successes can eventually contribute to adaptable and realistic hospital crisis management policies in the face of an infectious disease outbreak. In addition, the analyses that consider organizational factors such as type (primary, secondary, or tertiary), ownership (private or public), and culture (eg, hierarchy, flexibility) further add to the development of appropriate management strategies.
CONCLUSIONS
Hospital workers are primary responders during an infectious disease outbreak. Hence, for effective disease responses, it is highly important that they are not only intellectually competent but also emotionally prepared. In this regard, this study focused on the emotional responses of hospital workers when facing infectious disease outbreaks. From the data concerning the 2015 MERS outbreak in South Korea, the hospital workers’ experiences (specifically of negative emotions and stress, and also the events that triggered such affective experiences during the outbreak) were explored to provide information that could help with the development of future crisis management plans for hospitals.
Acknowledgments
The data for this research were collected and provided by Myongji Hospital. This work was supported by the Institute of Health and Environment and the National Research Foundation of Korea Grant funded by the Korean Government (No.21B20151213037).
