The aim of this study is to explore the usefulness of the Stress and Anxiety to Viral Epidemic-3 items (SAVE-3) scale as a tool for assessing work-related stress in healthcare workers.
There were 389 participants and all remained anonymous. The SAVE-9, the Patient Health Questionnaire-4, the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSS-MP), the perceived stress scale (PSS), and single item insomnia measure were used. After checking whether the SAVE-3 scale is clustered into a sole factor from SAVE-9 scale based on principal component analysis with promax rotation, confirmatory factor analysis (CFA) was done on the 3 items of the SAVE-3 to examine the factorial validity for a unidimensional structure.
The SAVE-3 was clustered with factor loadings from 0.664–0.752, and a CFA revealed that 3 items of the SAVE-3 cohered together into a unidimensional construct with fit for all of indices (comparative fit index = 1.00; Tucker Lewis index = 1.031; standardized root-mean-square residual = 0.001; root-mean-square-error of approximation = 0.00). The SAVE-3 scale showed acceptable reliability (Cronbach’s α = 0.56 and McDonald’s ω = 0.57) in this sample. A high SAVE-3 score correlated significantly with younger age (r = -0.12, p = 0.02), a high PSS score (r = 0.24, p < 0.001), a high total score for the MBI-HSS-MP (r = 0.35, p < 0.001) and all of its subscales (emotional exhaustion, r = 0.40, p < 0.001; personal accomplishment, r = -0.14, p < 0.005; depersonalization, r = 0.39, p < 0.001), and poor sleep quality (r = 0.15, p < 0.001).
Taken together, the data suggest that SAVE-3 is a reliable, valid, and usable scale for measuring work-related stress in healthcare workers during the COVID-19 epidemic.
During 2020, the coronavirus disease 2019 (COVID-19) outbreak spread rapidly to countries worldwide. During the outbreak, healthcare workers have suffered high levels of psychological distress as they care for patients, placing themselves at high risk of exposure to this potentially fatal infectious disease [
Previous studies [
The COVID-19 pandemic has lasted for more than 1 year, during which many studies reported the psychological consequences experienced by healthcare workers in different countries. Lu et al. [
Recently, we developed the Stress and Anxiety to Viral Epidemic-9 items (SAVE-9) scale, which is designed to assess workrelated stress and anxiety in healthcare workers specifically in response to the COVID-19 pandemic [
The study was conducted via an anonymous online survey at the Asan Medical Center, Seoul, Korea. Participants were recruited from the hospital via an advertisement posted on the intranet. The advertisement explained the study’s objective, enrolment procedure and the reward for participants. From the 28th of January, 2021, to the 29th of January, 2021, 389 workers were enrolled and responded voluntarily to the survey. In return they received a coupon valued at about $3. The study protocol was approved and obtaining the written informed consent was waived by the Institutional Review Board (2021-0124) of the Asan Medical Center.
The SAVE-3 scale is a subcategory of the original SAVE-9 scale developed by Chung et al. [
The Patient Health Questionnaire-4 (PHQ-4) was developed to assess two of the most prevalent psychiatric symptoms among the general population [
The MBI is used widely to assess burnout. It has three dimensions: emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA) [
The PSS is a self-reporting scale designed to measure the perceived severity of stress [
We included a single item assessment of insomnia intended to measure the quality of sleep. We asked healthcare workers as “How is your sleep quality?” (0, very good, to 10, very poor) to measure sleep quality briefly. Higher score reflects poor sleep quality.
First, we tested the normality assumption of the SAVE-9 scale using skewness and kurtosis for an acceptable limit of range ± 2 [
The 389 healthcare workers included 55 medical doctors, 247 nursing professionals and 87 “other” healthcare workers (
In this study we explored the factor structure of the SAVE-9 scale to confirm whether it can be clustered into two factors in this sample. We checked the normality of the items of SAVE-9 scale, and we observed that the skewness of the items were -0.999–0.407, and the kurtosis of items were -0.719–1.483 (
The normality of items in the SAVE-3 scale was checked and the distribution of each 3 items were within the normal limit based on skewness and kurtosis ranged within ± 2 (
The SAVE-3 scale showed acceptable reliability (Cronbach’s α = 0.56 and McDonald’s ω = 0.57) in this sample. A high SAVE-3 score correlated significantly with younger age (r = -0.12, p = 0.02), a high PSS score (r = 0.24, p < 0.001), a high total score for the MBI-HSS-MP (r = 0.35, p < 0.001) and all of its subscales (EE, r = 0.40, p < 0.001; PA, r = -0.14, p < 0.005; DP, r = 0.39, p < 0.001), and poor sleep quality (r = 0.15, p < 0.001). The SAVE-3 scores were also significantly higher in workers rated as having anxiety (anxiety scale score PHQ-4 ≥ 3, [t(387) = 6.58, p < 0.001]) or depression (depression scales score PHQ-4 ≥ 3, [t(387) = 6.45, p < .001]), and in those who reported that they needed immediate psychological help with their psychiatric symptoms [t(387) = 2.86, p < 0.001]. However, there was no significant difference in the SAVE-3 scores with respect to experience of caring for infected patients [t(387) = 1.33, p = 0.19], being quarantined [t(387) = 1.38, p = 0.17], past psychiatric history [t(384) = 0.87, p = 0.53], sex [t(387) = 0.35, p = 0.73], and nursing professionals versus other [t(384) = 1.43, p = 0.16].
We aimed to examine the factorial validity of the SAVE-3 scale and the utility to assess work-related stress of healthcare workers specifically in response to the viral epidemic in this pandemic era. The results support use of the single-factor SAVE-3 model for this purpose as the scale demonstrated an excellent fit for all indices, and measurement invariance with respect to sex, job, experience of taking care of infected patients, depression, or anxiety. In addition, the SAVE-3 scale demonstrated satisfactory reliability for this cohort. The SAVE-3 showed the good convergent validity with the validated burnout rating scale (MBI-HSS-MP) and rating scales about the perceived stress, depression, anxiety, and insomnia. Our results support the use of SAVE-3 as a tool for assessing work-related stress in healthcare workers in COVID-19 pandemic.
Originally, we developed the SAVE-9 scale to assess stress and anxiety in healthcare workers during the COVID-19 pandemic [
The CFA of the SAVE-3 in this study showed good fit for unidimensional model, but the internal consistency was relatively low (McDonald’s ω = 0.57, Cronbach’s α = 0.56). Generally, Cronbach’s α = 0.6–0.7 is considered to be an acceptable level of reliability. We accepted this value and did not try to increase it by excluding items since the main objective of the study is to explore the applicability and validity of the SAVE-3 scale when used alone. The factor loadings of 3 items were 0.475, 0.599, and 0.712, though usually over 0.6 of factor loading value was considered to be acceptable [
To examine convergent validity, we applied the MBI-HSS-MP and PSS alongside the SAVE-3 scale. The SAVE-3 scale score correlated significantly with the total scores for the MBI-HSSMP (r = 0.35, p < 0.001) and all its subscales (EE, r = 0.40, p < 0.001; PA, r = -0.14, p < 0.005; DP, r = 0.39, p < 0.001). The MBI-HSS-MP scale is a widely used rating scale for measuring burnout of healthcare workers [
This study has several limitations. First, it was conducted via an anonymous online survey. The pandemic makes it difficult to conduct face-to-face interviews to collect information. Second, most participants were nursing professionals (63.5%); therefore, the results may not adequately reflect stress experienced by other healthcare workers. Third, the results do not accurately reflect stress experienced by infected healthcare workers since only one participant was infected. Fourth, the single item question for sleep quality was not validated formally. More reliable scale needs to be applied. In further study, it needs to be considered. Fifth, we did not perform a test-retest correlation.
In conclusion, we found that the SAVE-3 scale is a brief, reliable and valid scale that can be used to measure work-related stress in healthcare workers during the viral pandemic. There are numerous dimensions to work-related stress, but these need to be fine-tuned and applied to a “viral epidemic-specific” rating scale that can measure work-related stress accurately. We hope that the SAVE-3 will be a simple and useful tool for assessing the status of frontline healthcare workers.
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
Conceptualization: Chung S, Suh S. Data curation: Chung S, Son HS, Kim K, Cho IK, Lee J. Formal analysis: Son HS, Chung S, Ahn MH. Funding acquisition: Suh S. Investigation: Suh S. Methodology: Chung S, Ahn MH, Suh S. Writing—original draft: Chung S, Son HS. Writing—review & editing: Ahn MH, Kim K, Cho IK, Lee J, Suh S.
The authors have no potential conflicts of interest to disclose.
None.
A unidimensional construct of the SAVE-3 scale. SAVE-3, Stress and Anxiety to Viral Epidemic-3 items.
Demographic characteristics of the study participants (n = 389)
Characteristics | Value | ||
---|---|---|---|
Healthcare workers | |||
Medical doctors | 55 (14.1) | ||
Nursing professionals | 247 (63.5) | ||
Other healthcare workers | 87 (22.4) | ||
Sex (female) | 335 (86.1) | ||
Age | 35.3 ± 8.0 | ||
Years of employment | 10.6 ± 8.3 | ||
Marital status | |||
Single | 181 (46.5) | ||
Married, with children | 41 (10.5) | ||
Married, without children | 167 (42.9) | ||
Are you a shift-worker? (Yes) | 112 (28.9) | ||
COVID-19 questions | |||
Did you take care of confirmed COVID-19 patients? (Yes) | 74 (19.0) | ||
Were you quarantined due to infection with COVID-19? (Yes) | 36 (9.3) | ||
Were you infected with COVID-19? (Yes) | 1 (0.3) | ||
How many times have you been swab-tested? | 3.2 ± 2.7 | ||
Psychiatric history | |||
Did you have experience or treated depression, anxiety, or insomnia? (Yes) | 50 (13.0) | ||
Now, do you think you are depressed or anxious, or do you need help for your mood state? (Yes) | 49 (12.6) | ||
Rating scales | |||
SAVE-9 | 23.0 ± 5.5 | ||
PSS | 18.4 ± 3.3 | ||
MBI-HSS-MP scale | 75.2 ± 15.5 | ||
Emotional exhaustion | 31.0 ± 9.9 | ||
Personal accomplishment | 30.7 ± 7.5 | ||
Depersonalization | 13.6 ± 6.6 |
Data are presented as n (%) or mean ± standard deviation.
SAVE-9, Stress and Anxiety to Viral Epidemic-9 items; PSS, perceived stress scale; MBI-HSS-MP, Maslach Burnout Inventory-Medical Personnel.
Frequency of participant answers to each item of the SAVE-9 scale (n = 389)
Item | Never | Rarely | Sometimes | Often | Always | Descriptive | Skewness | Kurtosis | Factor I | Factor II |
---|---|---|---|---|---|---|---|---|---|---|
1. Are you afraid the virus outbreak will continue indefinitely? | 0 (0.0) | 10 (2.6) | 31 (8.0) | 196 (50.6) | 150 (38.8) | 3.26 ± 0.71 | -0.980 | 1.483 | 0.564 | 0.179 |
2. Are you afraid your health will worsen because of the virus? | 13 (3.4) | 45 (11.6) | 74 (19.1) | 180 (46.5) | 75 (19.4) | 2.67 ± 1.02 | -0.726 | 0.006 | 0.766 | 0.267 |
3. Are you worried that you might get infected? | 13 (3.4) | 47 (12.1) | 79 (20.4) | 193 (49.9) | 55 (14.2) | 2.59 ± 0.99 | -0.736 | 0.092 | 0.780 | 0.599 |
4. Are you more sensitive toward minor physical symptoms than usual? | 13 (3.4) | 46 (11.9) | 75 (19.4) | 174 (45.0) | 79 (20.4) | 2.67 ± 1.04 | -0.698 | -0.079 | 0.714 | 0.356 |
5. Are you worried that others might avoid you even after the infection risk has been minimized? | 60 (15.5) | 149 (38.5) | 82 (21.2) | 73 (18.9) | 23 (5.9) | 1.61 ± 1.13 | 0.407 | -0.719 | 0.634 | 0.367 |
6. Do you feel skeptical about your job after going through this experience? | 43 (11.1) | 140 (36.0) | 96 (24.7) | 88 (22.6) | 22 (5.7) | 1.75 ± 1.10 | 0.239 | -0.794 | 0.200 | 0.752 |
7. After this experience, do you think you will avoid treating patients with viral illnesses? | 13 (3.3) | 71 (18.3) | 96 (24.7) | 166 (42.7) | 43 (11.1) | 2.40 ± 1.01 | -0.422 | -0.515 | 0.401 | 0.736 |
8. Do you worry your family or friends may become infected because of you? | 2 (0.5) | 18 (4.7) | 44 (11.4) | 199 (51.4) | 124 (32.0) | 3.10 ± 0.81 | -0.999 | 1.271 | 0.708 | 0.473 |
9. Do you think that your colleagues would have more work to do due to your absence from a possible quarantine and might blame you? | 5 (1.3) | 34 (8.7) | 47 (12.1) | 196 (50.4) | 107 (27.5) | 2.94 ± 0.93 | -0.908 | 0.540 | 0.456 | 0.664 |
Data are presented as n (%) or mean ± standard deviation.
SAVE-9, Stress and Anxiety to Viral Epidemic-9 items.
Frequency of participant answers to each item of the SAVE-3 scale (n = 389)
Item | Never | Rarely | Sometimes | Often | Always | Descriptive | Skewness | Kurtosis | Factor loading |
---|---|---|---|---|---|---|---|---|---|
1. Do you feel skeptical about your job after going through this experience? | 43 (11.1) | 140 (36.0) | 96 (24.7) | 88 (22.6) | 22 (5.7) | 1.75 ± 1.10 | 0.239 | -0.794 | 0.475 |
2. After this experience, do you think you will avoid treating patients with viral illnesses? | 13 (3.3) | 71 (18.3) | 96 (24.7) | 166 (42.7) | 43 (11.1) | 2.40 ± 1.01 | -0.422 | -0.515 | 0.712 |
3. Do you think that your colleagues would have more work to do due to your absence from a possible quarantine and might blame you? | 5 (1.3) | 34 (8.7) | 47 (12.1) | 196 (50.4) | 107 (27.5) | 2.94 ± 0.93 | -0.908 | 0.540 | 0.599 |
Data are presented as n (%) or mean ± standard deviation.
SAVE-3, Stress and Anxiety to Viral Epidemic-3 items.