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 Table of Contents  
Year : 2023  |  Volume : 13  |  Issue : 2  |  Page : 55-61

Study of attitude and behaviour of healthcare professionals towards the patients in an Emergency Department during the COVID-19 pandemic

1 Department of Emergency Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
3 Department of Pharmacology, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
4 Department of Medicine and Endocrinology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission02-Sep-2022
Date of Decision24-Jan-2023
Date of Acceptance14-Feb-2023
Date of Web Publication28-Apr-2023

Correspondence Address:
Dr. Bharat Kumar
Department of Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmrp.cmrp_88_22

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Background: COVID-19 outbreak is known to have a psychological impact on patients.
Background and Objective: The main aim of the study was a to study the attitude and behavior of health care professionals (HCPs) in the emergency department towards chronic patients during COVID-19 pandemic and also the accessibility of healthcare system during COVID-19 period and to compare it with the pre-COVID period.
Materials and Methods: A random sampling technique was used, and a pre-designed questionnaire named the Brief Emergency Department Patients' Satisfaction Scale was adopted to record the patient's satisfaction with the healthcare services.
Results: The patients admitted to the emergency ward felt that the nursing and physicians' care in the emergency department was highly satisfactory in the pre-COVID period. In the COVID period, the same set of patients who got admitted felt that there was a deterioration in the behaviour and attitude of the HCPs towards them. In the COVID period, 30% of the patients felt that there was a marked deterioration in the general services in the emergency department. It was also observed in the study, that there was a marked change in the attitude and behaviour of the HCPs in the emergency department at the time of the COVID pandemic.
Conclusion: COVID-19 has significantly changed the attitude and behaviour of HCPs. The disease has critically transformed the working environment and the approach of HCPs to treat the patients. It is imperative to employ productive strategies to care for the health of our HCP.

Keywords: Attitude, behaviour, COVID-19, healthcare professionals, pre-COVID

How to cite this article:
Vaishnav N, Kumar B, Misra AK, Garg M K. Study of attitude and behaviour of healthcare professionals towards the patients in an Emergency Department during the COVID-19 pandemic. Curr Med Res Pract 2023;13:55-61

How to cite this URL:
Vaishnav N, Kumar B, Misra AK, Garg M K. Study of attitude and behaviour of healthcare professionals towards the patients in an Emergency Department during the COVID-19 pandemic. Curr Med Res Pract [serial online] 2023 [cited 2023 May 30];13:55-61. Available from: http://www.cmrpjournal.org/text.asp?2023/13/2/55/375237

  Introduction Top

COVID-19 is a pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which belongs to the Coronaviridae family, enveloped virus with single-stranded RNA. The first case of the disease was identified from Wuhan city of China at the end of the year, December 2019. In March 2020, the World Health Organization declared COVID-19 as a pandemic. SARS-CoV-2 virus replicates in the epithelial cells of the respiratory tract, and it causes upper respiratory tract infection, bronchiolitis, pneumonia and acute respiratory distress syndrome. The virus is known since 1960, and it has caused pandemics in 2003 and 2012 severe acute respiratory syndrome (SARS) and middle-east respiratory syndrome, respectively. To date, nearly 664 million cases have been diagnosed worldwide with a recorded 6.7 million mortalities with COVID-19.[1] The number of cases of the disease has grown up very rapidly globally. Much uncertainty revolved around the nature of the spread of COVID-19, its severity, associated mortality, morbidity and the availability of essential resources such as facial masks, hand sanitisers and digital thermometers.[2],[3]

Infectious disease outbreaks are known to have a psychological impact on the general population as well as on the healthcare professionals (HCPs). A notable example would be the psychological sequelae observed during the SARS outbreak in 2003. Studies on the SARS outbreak revealed that the healthcare workers experienced acute stress reactions.[4] In addition to the specific physical manifestations of various diseases, some symptoms may arise due to psychological factors as well. Such psychosomatic symptoms have been reported with increased prevalence during and after the outbreaks, such as the SARS and Ebola virus. The commonly reported symptoms range from specific symptoms such as fever, cough and shortness of breath to non-specific ones such as fatigue, weakness and lethargy.

As we have seen often, the healthcare system was poorly prepared to meet these challenges during a pandemic in developed and developing countries. Long waiting hours during registration, delay inpatient examination, receiving emergency treatment and getting beds in an emergency and ward admission are common problems faced by the patients. Overcrowding of the emergency department, increase the risk of acquiring the infection and not getting proper information about the patient's condition also increases the patient's worry.[5],[6]

The COVID-19 has significantly changed the attitude and behaviour of HCP.[7],[8] The disease has transformed the working environment and the approach of HCP to treat the patients. Providing care to COVID-19-infected patients is physically and emotionally difficult for HCPs. COVID-19 is associated with great social stigma and phobia amongst the patients and HCP as well. Social stigmatisation and uncertainty over acquiring the infection themselves and the risk of potentially exposing their families to infection are the prominent concerns of the HCPs during the crisis. These factors may lead to HCP to provide treatment that is suboptimal than they would provide under normal circumstances. The physical and psychological well-being of HCPs is very crucial, especially during infectious epidemics or pandemics, as patient numbers continue to increase and fellow co-workers getting infected with the same infection.[9],[10],[11]

Thus, it is imperative to employ productive strategies to care for the health of HCP. A study to identify the factors affecting the patients' dissatisfaction and provide a recommendation on an improved health service delivery that will be helpful to fill research knowledge gaps which ultimately contributes to enhance the quality of patient services in the hospital and improve the level of healthcare services.

Despite literature available on the attitude and behaviour of HCP in the COVID-19 pandemic, no report has comprehensively analysed the patient's satisfaction in the COVID-19 pandemic and compared it with the pre-COVID-19 period. This study focussed on assessing the level of patients' satisfaction with regard to behaviour and attitude of the doctors and nursing staff towards patients visiting the emergency department.

  Materials and Methods Top

Study design

A cross-sectional, observational, questionnaire-based study was conducted in the Department of Emergency Medicine at a Tertiary Care Teaching Hospital. The study setting was the ward of the Emergency Department with 36 beds and more than 1000 inpatient admissions per year. Adult patients (18–65 years of age) who visited the emergency department were enrolled in the study. The patients visiting the emergency ward were screened at the COVID-19 desk and then shifted to the emergency medicine department only when tested negative for COVID-19. In the emergency ward, the patient was examined, and history was taken from the patient or relatives if the patient was not able to give a history. Patients and relatives were asked to fill the questionnaire after taking informed written consent. The study was conducted using a predesigned questionnaire.[12] The tool used to record patient satisfaction was the Brief Emergency Department Patients' Satisfaction Scale (BEPSS). The questionnaire was divided into three sections to record the level of satisfaction of patients towards HCPs working in the emergency ward of the hospital. They were emergency department staff (EDS), physician care satisfaction (PCS) and general patient satisfaction (GPS). There were four items in each section for the pre-COVID and COVID periods. Each item was marked on a scale of 1–4. In the questionnaire, the following response scale was used: 1 = Completely disagree, 2 = Mildly disagree, 3 = Mildly agree and 4 = Completely agree (1%–25% =1, 25%–50% =2, 50%–75% =3 and 75%–100% =4). The duration of the study was 6 months and it is based on the following criteria.

All chronic patients visiting the emergency department at least once in the past and over the age of 18 had been included in the study. Since patients who were either confirmed or suspected cases of COVID-19 were kept in separate wards and not present in the main emergency ward, they were not included in the study.

Sampling size

There are no studies in the past which have recorded the patient's satisfaction in the COVID period and prevalence is not documented. Hence keeping in mind, the availability of patients and resources, it was decided to include around 500 patients (age between 18 and 60 years) attending the Emergency Medicine Department for the study duration of 6 months after written approval from the Ethics Committee of the institute (IEC Reference Number: AIIMS/IEC/2020–21/3092).

Sociodemographic clinical profile data

A structured pro forma was used to record certain demographic variables such as name, age, gender, locality and occupation and a clinical profile sheet was specially designed for the study to record various symptoms and diagnosis. A pre-formed questionnaire named BEPSS was given to the patients in the English and Hindi languages, and they were asked to fill out the form [Table 1].
Table 1: Brief Emergency Department Patient Satisfaction Scale

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Statistical analysis

Data were compiled using Microsoft Excel and analysed using SPSS software (IBM-SPSS statistics 20.0; SPSS Inc., Chicago, IL, USA). The mean and standard deviation were used to analyse quantitative variables of the sample. Baseline characteristics between groups were compared using an independent t-test for numerical variables. The data were used to analyse the difference in quantitative variables. Two-tailed P < 0.05 was considered statistically significant.

  Results Top

A total of 504 participants were enrolled who completed the questionnaire in the study. Their demographics are shown in [Table 2]. Most of the participants were between 18 and 65 years of age (87.7%) with a predominance of the male population (64.28%). The participants were mostly from urban areas (51.79%). Farming/business (37.3%) was the most common occupation amongst the participants followed by homemakers (16.46%) and students (15.47%).
Table 2: Sociodemographic characteristics of study respondents

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As shown in [Table 3], the descriptive analysis of the patient's response by the BEPSS was recorded. It was found in the first section of the scale, i.e. the EDS, which usually deals with nursing care, the patients' response was mostly agreeable (mildly and completely) with preponderance towards 'completely agree' (84.6%–86.9%) to all the items of the EDS part of the questionnaire in the pre-COVID period. This means that the patients were highly satisfied with the nursing care at the emergency ward of the hospital. As the same, patients were admitted to the emergency department in the COVID period, it was seen that the patient's response to the nursing care parameters changes dramatically. The patients' satisfaction responses were recorded to decline towards 'mildly disagree' and 'mildly agree.' In this scenario, it can be assumed that the patients were not satisfied with the overall management by the nursing staff (i.e. care, treatment, communication and behaviour) in the emergency department of the tertiary care teaching hospital. The satisfaction level of the patients falls drastically for all the parameters (EDS1, EDS2, EDS3 and EDS4) from 'completely agree' (i.e. highly satisfied) which was about 84.6%–86.9% approximately in the pre-COVID period to the moderate satisfaction level of 50.4%–37.5% in the COVID period.
Table 3: Mean patient's satisfaction response as a function of the subject responder

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The next section was PCS, which primarily deals with the physicians' care for the patients in the emergency department. In the pre-COVID period, it was documented that the patients were highly satisfied with the management of the physicians working in the emergency department. It was found that patients' satisfaction level was approximately 88%–92.8% for the response (PCS1, PCS2, PCS3 and PCS4) of 'completely agree.' During the COVID period, the same sample of patients developed a negative response about physician care in the emergency ward. The patients in the COVID period were mostly moderately satisfied with the physicians' care as they had downgraded their response of 'completely agree' to 63.1%–71.1%. The remaining patients in the COVID period were of the opinion that the physician care is 'mildly disagree' (0.4%–3%) and 'mildly agree' (23.6%–28.9%).

The GPS section of the scale deals with the overall satisfaction level of the patients in the emergency ward [Table 1]. In this section, the patients admitted in the pre-COVID period were highly satisfied as the response (GPS1, GPS2, GPS3 and GPS4) were 82.5%–62.7% of 'completely agree'. The results in the GPS section can be extracted to assume that the patients were content with the services provided in the emergency ward. In the COVID period, the satisfaction level of the services was downgraded by the same set of patients whose responses were mostly towards 'mildly disagree' (20.5%–39.4%) and 'mildly agree' (28.5%–43.3%).

As shown in [Table 4], a comparison of items in the section of the BEPSS (pre-COVID vs. COVID) showed that patients care was highly impacted by the COVID pandemic. There was a drastic fall in the satisfaction level of the patient in the emergency ward with respect to the nursing care, physician care and overall quality services. In the table, comparing the items of the scale in the pre-COVID and COVID period, the data are highly significant which invalidates our null hypothesis that there will be no differences in the patients' satisfaction in the different timelines.
Table 4: Comparison of patients' satisfaction response (pre-COVID vs. COVID period) by Brief Emergency Department Patient Satisfaction Scale

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  Discussion Top

India has a population of 1.35 billion and by following the epidemic model around 1 million people would have serious manifestations of COVID-19 and may have required ventilatory support and constant vigilance of healthcare workers (HCPs).[12] In this highly populous country. where the doctor population ratio is only 0.76/1000 and availability of beds for admission is only 0.7/1000, this will add up the heavy burden on HCPs while dealing with the pandemic. To cope with this pandemic, it is of utmost importance to protect the HCPs from COVID-19 infection as they are the key players in the fight against COVID-19.[13],[14] Nevertheless, the HCPs are subjected to a high risk of contracting COVID-19. Erdem and Lucey. documented 110 HCPs' deaths in India by August 2020 and 1313 were infected with COVID-19.[15] It may contribute only 0.01 mortality of HCPs per 100,000 population, but it may substantially impact the burden on the HCPs working in the COVID-19 hospitals.

In the study, the patient's response as per the BEPSS showed a statistically significant result when the responses were compared from the pre-COVID period to the COVID-19 period. In the COVID period, the patients responded that the care, treatment, communication and behaviours of the HCPs were not comparable to the pre-COVID period. The patients responded that the quality of care by HCPs was impacted by the COVID pandemic. There could be many reasons for the underlying disparity in the quality care by the HCPs in the emergency department of the hospital. The extensive work hours of the HCPs in the emergency ward while managing the pandemic with inadequate time to rest and improper timings of consuming food makes the HCPs fatigued and escalate the danger of burnout amongst HCPs.[16] To handle these issues, some prominent institutes in the world have adopted a model where the working schedule of the HCPs has been arranged in a fixed duration of days followed by rest for the same period so that the HCPs can protect themselves from acquiring infections by getting relieved from the contaminated ward of COVID and gets enough rest to rejuvenate for the next round of duty. The most common strategy followed is 14 working days for health workers dealing with COVID-19 patients followed by 14 days (also the incubation period for COVID-19) of rest period. It will reduce the burnout amongst the HCPs. Outpatient departments (OPD), triage OPD, and emergency departments are on the frontline for dealing with the patients of COVID-19 and crowding is a big concern in such OPDs. Hence, the patients may not be attended to as swiftly as possible during the COVID period. The HCPs in emergency care are more at risk to contact COVID-19, which may also lead to the reluctance to attend the patients who are coming without masks and are not following COVID norms in the hospital.[16] Mahajan et al. suggested 11% prevalence of SARS-CoV-2 infection amongst HCPs, 4% co-infection and 1% mortality.[17]

In recent studies, it has been established that training and knowledge about the management of COVID-19 patients play an important role amongst the HCPs in the emergency ward. Necessary training and protocol need to be established and hands-on practice is essential.[18] The HCPs are under a lot of stress and anxiety when they make the challenging COVID patient triage decisions. The agony of losing patients, the concern that other people will contract the illness, and the trouble of being away from family members for an extended period of time may lead to mental health issues. The parent institute should arrange a trained psychologist who should give regular psychological and bolstering sessions to the HCPs in the emergency ward.[19] Besides the concerns of personal safety, HCPs with infection could cause secondary transmission amongst patients, family members and the community. The HCPs may be worried to transmit the infection, especially to the elderly in the family and the majority of whom are already having comorbidities (e.g. diabetes and cardiovascular diseases). This may be one of the important factors that reduce the efficacy of the HCPs, the fear of losing the near and dear ones. Addressing this concern, providing the family members priority access to testing, prophylaxis and treatment facility may ameliorate stress-level amongst the HCPs.[20]

The present study gives an insight into the satisfaction level of the patients in the emergency ward of the hospital. It helps to determine the perception of the HCPs about their regular duty during the COVID period. The data recorded in the study will help in planning future strategies amongst HCPs to handle the patients of COVID-19 in the emergency ward. This will give the confidence amongst the HCPs to acquire the necessary skills in dealing with COVID patients as well as building defence in limiting exposure to infection and fatigue. This study might be the first of its kind which will highlight the perceptions of the patients in the emergency ward in the COVID period.

There are some limitations to the study. The study was conducted in a single centre as well as the sample size was small and may not reflect the response of all the patients of a larger population. Based on our study, it may be possible to make a policy about treating patients in the emergency ward. It may be recommended that the practice of hand hygiene, physical distancing and wearing emergency ward should be made mandatory to reduce the chances of transmission of COVID amongst the HCPs in the emergency ward. The observations made in the study need to be confirmed in different parts of the country so that a common consensus or policy can be made to tackle COVID patients in the emergency ward and improve the patients' care.

  Conclusion Top

The results of the study will be useful for determining the impact of COVID-19 and adverse outcomes on the satisfaction level of the patients' care. The protocols and training about COVID management should be followed strictly to handle the epidemic of COVID-19 amongst HCPs. This research article depicts that the HCPs in India are under tremendous stress while dealing with the COVID-19 situation. To maintain their zeal at work and constantly motivate them, their challenges need to handle with priority. Proper maintenance of personal protective equipment, taking care of the HCW's physical and mental health, curtailing all kinds of harassment against HCPs and provision of proper training to the HCPs are the need of the hour. Political will and strengthening of healthcare facilities in India are an important step to control this pandemic situation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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