Psychological Medicine, 2004, 34, 1197–1204.

f 2004 Cambridge University Press

DOI : 10.1017/S0033291704002247 Printed in the United Kingdom

Severe acute respiratory syndrome (SARS) in

Hong Kong in 2003: stress and psychological impact
among frontline healthcare workers
C I N D Y W. C. T A M*, E D W I N P. F. P A N G, L I N D A C. W. L A M AND H E L E N F. K. C H I U
Department of Psychiatry, The Chinese University of Hong Kong; Dementia Research Unit, Jockey Club
Centre for Positive Ageing, Hong Kong

ABSTRACT
Background. The outbreak of severe acute respiratory syndrome (SARS) posed an unprecedented
threat and a great challenge to health professionals in Hong Kong. The study reported here aimed
at investigating the origin of stress and psychological morbidity among frontline healthcare workers
in response to this catastrophe.
Method. Self-administered questionnaires were sent to frontline healthcare workers in three
hospitals. The General Health Questionnaire was used to identify psychological distress. Socio-
demographic and stress variables were entered into a logistic regression analysis to find out the
variables associated with psychological morbidity.
Results. The response rate was 40 %. Sixty-eight per cent of participants reported a high level of
stress. About 57 % were found to have experienced psychological distress. The healthcare workers’
psychological morbidity was best understood by the perceptions of personal vulnerability, stress
and support in the workplace.
Conclusion. These findings shed light on the need for hospital administrators to be aware of the
extent and sources of stress and psychological distress among frontline healthcare workers during
disease outbreak.

INTRODUCTION nature of the virus, as well as the significant

morbidity and mortality of SARS. Within 4
A worldwide outbreak of severe acute respirat-
months, there were 1755 confirmed SARS in-
ory syndrome (SARS) began in March 2003.
Since it was first reported in the Chinese prov- fections and 299 deaths in Hong Kong. Over
30% of those infected were healthcare workers
ince of Guangdong in November 2002, this new
and medical students, and eight frontline health-
disease has killed more than 800 people and in-
care workers died. No new cases of SARS have
fected more than 8400 in about 30 countries.
been reported in our community since 22 June
In Hong Kong, a number of healthcare
2003.
workers and community members contracted
A growing epidemiological literature has ad-
the infection within a short period. This posed
dressed psychiatric morbidities associated with
an unprecedented threat to our community and
exposure to major disasters. Disasters that re-
presented a great challenge to the healthcare
sult in widespread injuries, loss of life, massive
professionals. Everyone was in a state of great
panic because of the high infectivity and unclear property damage and major financial problems
for the community appear to be associated with
an especially high rate of severe and persistent
* Address for correspondence : Dr Cindy W. C. Tam, Department psychological effects (Norris et al. 2002). There
of Psychiatry, The Chinese University of Hong Kong, G/F, Multi-
Centre, Tai Po Hospital, Tai Po, NT, Hong Kong SAR. is also a growing interest in research into occu-
(Email : tamwoonchi@hotmail.com) pational stress and psychological trauma in
1197
1198 C. W. C. Tam et al.
rescue workers. For example, about 24% of
rescue workers involved in an oil rig disaster
showed post-traumatic stress reactions 9 months
after the disaster, and 32 % of Australian
firefighters reported psychological disturbance
4 months after they combated disastrous bush
conflagrations (McFarlane, 1987; Ersland et al.
1989). Rescue workers, as well as firefighters,
policemen and medical personnel, are suscep-
tible to complex emotional responses and
psychological distress when they are personally
affected by a disaster, i.e. when they are victims
as well as helpers in a trauma.
It has been envisaged that frontline medical
staff who were in the vanguard of the battle to
combat SARS were at high risk of infection and
of spreading infection to others. They worked
under great psychological stress and faced many
threats and losses. As most of the energy and
resources tend to be directed towards alleviating
physical morbidity, the psychological well-being
of staff is often neglected. This study aimed
to investigate the sources of stress and the
psychological morbidity among the frontline
healthcare workers in relation to the SARS
outbreak. Staff working in the Prince of Wales
Hospital (PWH), Alice Ho Miu Ling Nethersole
Hospital (AHNH) and Tai Po Hospital (TPH)
who were responsible for tackling the first
major wave of the outbreak were recruited for
assessment.
RESEARCH DESIGN AND METHOD
Subjects
Frontline healthcare workers from medical
units and intensive care units were recruited
from PWH and AHNH, which were the major
sites of extensive outbreak of SARS in Hong
Kong. TPH was a convalescent hospital situated
near the above-mentioned two hospitals, and
members of its staff were also recruited. Doctors
from different disciplines, nurses, healthcare
assistants, physiotherapists and occupational
therapists were included. Ward managers and
department heads were contacted to obtain lists
of their staff members. A total of 1621 potential
subjects were identified.
Development of the questionnaire
A preliminary questionnaire was developed and
reviewed through qualitative work with a focus
group. Six people, including doctors, a nurse, a
physiotherapist and an occupational therapist,
participated in a focus group discussion in May
2003. Some rewording took place to improve
understanding. New items were added to cover
a wider range of questions.
The finalized self-administered questionnaire
consisted of six parts. Part 1 solicited basic
demographic data (age, sex, workplace, ex-
posure to SARS patients and subjective rating
of physical health). Part 2 consisted of 22
Likert-type questions regarding subjective job-
related stress levels before, during and after the
outbreak, and the severity of 19 sources of
stress. Responses were ranked according to the
severity of stressors on a fully anchored five-
point scale ranging from ‘ none ’ (0) to ‘severe ’
(4). Part 3 consisted of 13 coping behaviors.
Participants endorsed how often they used a
particular coping strategy on a four-point Likert
scale ranging from ‘never ’ (0) to ‘very often ’
(3). Part 4 was the Chinese version of the
12-item General Health Questionnaire (GHQ)
rating by the scoring method of 0-0-1-1 (Cheng
& Williams, 1986; Chong & Wilkison, 1989).
We used a cut-off score of three or more to
identify potential cases of psychiatric morbidity
(Harris et al. 1996). Part 5 consisted of 11
questions about the adequacy of various sup-
port items. Part 6 comprised 12 items about
the positive and negative perspectives of the
outbreak (see website for Appendix).
The questionnaires were mailed to the sub-
jects at their workplaces. Each questionnaire
contained an introductory letter, a guarantee of
anonymity and an addressed return envelope.
The study was approved by the Joint Clinical
Research Ethics Committee of the New Terri-
tories East Hospital and the Chinese University
of Hong Kong.
Statistical analysis
The data were analyzed using the Statistical
Package for the Social Sciences (SPSS). Mean
scores were obtained in questions based on
the Likert scale. Groups were compared using
the x2 test and Student’s t test according
to the characteristics of the variable being
examined. Principal component analysis with
varimax rotation was used for factor analy-
sis. Forward conditional logistic regression
analysis was used to identify the variables
 SARS in Hong Kong in 2003 1199

Table 1. Risk factors for high stress and General Health Questionnaire (GHQ) case status
Odds ratio (95 % confidence interval)

High-stress group GHQ case

Age f33 v. >33 1.46 (1.01–2.10)* 1.33 (0.94–1.87)

Female v. male 1.06 (0.70–1.59) 1.58 (1.07–2.33)*
Professional group
Nurse v. healthcare assistant 2.47 (1.67–3.65)* 2.20 (1.49–3.26)*
Nurse v. medical professional 1.31 (0.49–3.57) 1.33 (0.54–3.29)
Medical v. healthcare assistant 0.74 (0.63–4.81) 1.50 (0.57–3.92)
Nursing v. others 2.33 (1.66–3.27)* 1.82 (1.31–2.54)*
Direct contact with SARS patients
Yes v. No 1.92 (1.36–2.71)* 1.00 (0.73–1.38)
Self-rating of health condition
Poor v. Fair 1.63 (0.73–3.61) 3.11 (1.35–7.17)*
Fair v. Good 2.40 (1.68–3.43)* 2.93 (2.04–4.19)*
Poor v. Good 4.01 (1.79–9.01)* 9.35 (3.97–22.62)*
Willingness to work in SARS unit
Not willing v. Willing 1.84 (0.86–3.94) 5.53 (2.40–12.78)*
Not willing v. No objection 0.91 (0.43–1.93) 2.79 (1.23–6.32)*
Job-related stress during outbreak
High stress v. Low stress N.A. 5.24 (3.61–7.61)*
Support items (inadequate v. adequate)
Counseling and psychological support from employer N.A. 2.80 (1.96–4.00)*
Insurance and compensation 2.78 (1.88–4.12)*
Frontline staff feedback reaching administrators 2.66 (1.83–3.86)*
Clear infection control guideline 2.49 (1.76–3.51)*
Gratitude from patients and relatives 2.43 (1.64–3.61)*
Expressing opinions through staff unions or mass media 2.22 (1.56–3.16)
Protective facilities and temporary residential arrangements 1.98 (1.39–2.82)*
Sense of coherence and team spirit 1.95 (1.27–2.99)*
Appreciation from the community 1.92 (0.94–3.95)
Support from relatives 1.91 (1.06–3.45)*
Religious support 1.81 (1.11–2.93)*

* Significant at p=0.05.

independently associated with GHQ case and
non-case status.
RESULTS
Sample description
A total of 1621 questionnaires were sent out in
June 2003 to the frontline healthcare workers.
Six hundred and fifty-two questionnaires were
returned before August 2003, with a response
rate of 40.2%. The sample was approximately
79 % female. The mean age was 34.1 years
(S.D.=8.3) and the median was 33. Of the
respondents, 62 % were nurses, 24% were
healthcare assistants and 3 % were medical pro-
fessionals. Thirty-two per cent of respondents
rated their physical health condition as ‘good ’,
60 % as ‘fair, ’ and 7 % as ‘poor ’. Two hundred
and eighty-eight respondents (44.2 %) had
worked in the intensive care unit or in medical
units taking care of SARS patients during the
outbreak, with a mean duration of 8.74 weeks
(S.D.=5.33 weeks). Four hundred and forty-
four participants (68 %) reported ‘significant’
or ‘severe ’ levels of job-related stress during
the outbreak and 205 (32 %) reported stress
levels as ‘mild’ or ‘ moderate ’. They were cat-
egorized into high-stress and low-stress groups
respectively in the following analyses. Among
the high-stress group, the majority (79 %) re-
ported low levels of job-related stress before the
outbreak.
Risk factors associated with high stress levels
during the SARS outbreak (Table 1)
Demographic risk factors associated with high
job-related stress are depicted in Table 1. Vari-
ables that were significantly associated with high
job-related stress were younger age (f median
age), being a nursing professional, experience of
1200 C. W. C. Tam et al.
Table 2. Logistic regression with variables
predicting General Health Questionnaire (GHQ)
case
Odds 95 % confidence
ratio interval
Sex (male) 0.55 0.21–0.98
Insurance and compensation 0.52 0.29–0.93
(adequate)
Counseling and psychological 0.53 0.31–0.89
support from employer (adequate)
Self-rated health condition (poor) 5.73 1.70–19.25
Self-rated health condition (fair) 2.43 1.39–4.23
Job-related stress (high) 4.06 2.28–7.23
direct care of SARS patients and poorer self-
rated physical health condition.
Risk factors associated with psychological
morbidity (Table 1)
A total of 56.7% of the participants scored
above the threshold on GHQ (3 or more). Cases
were more likely to have higher levels of job-
related stress and poor self-rated physical
health, and be less willing to work in SARS
units. Female workers and nursing professionals
were more likely to be cases. Perceived inad-
equacy of all support items except ‘appreciation
from the community ’ were significantly associ-
ated with psychological morbidity. Next, all the
study variables in Table 1 were entered into
a logistic regression model predicting psycho-
logical morbidity (Table 2). ‘GHQ case ’ was
entered as the dependent variable. Variables
that were significant predictors of psychological
morbidity included female gender, poor self-
rated physical health, high level of job-related
stress and inadequate support in two aspects :
counseling and psychological support from the
employer, and insurance and compensation.
The odds ratios of these predictors are shown in
Table 2. None of the other variables predicted a
significant percentage of the variance.
Origin of stress (Table 3)
Nineteen sources of stress were included. Factor
analysis yielded three factors : ‘ work factor ’
(Factor 1), ‘personal factor’ (Factor 2), and
‘ role factor’ (Factor 3). The mean scores of
work factor, role factor and personal factor
were all significantly higher in the high-stress
group compared with the low-stress group
(Table 4). The mean difference was greatest in
the personal factor.
Attitude change after SARS outbreak
Changes in attitude and personal values after
the SARS outbreak are depicted in Table 5.
Over 90% of participants agreed that they now
had an increased awareness of personal and en-
vironmental hygiene and they valued gatherings
with family members more. They also felt that
they would be more devoted to helping others,
as they had survived the disaster. There was no
statistically significant difference in the preva-
lence of participants who agreed or disagreed
with the items of personal reflection between
the high-stress and low-stress groups, with the
exception of one. Participants who agreed that
‘death and disease could be unexpected and
near ’ had a significantly higher relative risk of
being in the high-stress group compared with
those who disagreed [relative risk : 1.25 ; 95 %
confidence interval (CI) 1.09–1.44].
DISCUSSION
Our study found that nurses experienced higher
levels of stress and more psychological mor-
bidity during the outbreak compared with other
professionals. This was understandable because
the nurses had longer contact time and more
frequent physical contacts with the patients.
Younger workers appeared to have higher job-
related stress. This could be because they might
be less experienced in handling disaster and
less familiar with infection control measures.
Surprisingly, experience of working in a SARS
unit was associated with increased job-related
stress but not with psychological morbidity
in our study. One explanation was that staff in
the general wards did not think that they were
exempt from the hazard, as there might be
‘invisible ’ SARS cases, such as elderly patients
with atypical presentations in the other wards.
Moreover, staff worried that protective mea-
sures and vigilance were inadequate in their
units, as most resources would be directed to the
SARS units first. It was the staff’s perception
of risk, rather than direct exposure to SARS
patients, that contributed to psychological
morbidity.
 SARS in Hong Kong in 2003 1201

Table 3. Factor analysis of sources of stress

Factor 1 Factor 2 Factor 3
First-order factors (Work factor) (Personal factor) (Role factor)

Heavy workload 0.49* 0.41 0.12

Hazardous working environment 0.58* 0.52 x0.10
Deployment 0.55* x0.02 0.27
Unclear job instructions 0.78* 0.18 0.20
Ambiguous infection control policies 0.74* 0.27 0.21
Lack of feedback to senior 0.76* 0.30 0.10
Being blamed for mistakes 0.63* 0.21 0.34
Lack of appreciation at work 0.67* 0.20 0.28
Risk to own health 0.17 0.70* 0.24
Interference with home life 0.30 0.64* 0.26
Risk of infecting relatives/friends 0.00 0.79* 0.22
Disrupting personal plans 0.40 0.49* 0.23
Isolation by friends/relatives 0.31 0.46* 0.41
Healthcare workers getting infected 0.29 0.54* 0.42
Fear of infecting colleagues 0.46 0.56* 0.16
Hospital service restructuring, 0.23 0.08 0.65*
uncertain job prospects
Handling colleagues’ negative emotions 0.27 0.32 0.65*
Being discriminated as high-risk spreader 0.18 0.36 0.67*
Public’s high expectations 0.16 0.27 0.72*

The second-order factor scores were calculated by summing the scores of the first-order factors and dividing by number of first-order
factors.
* Loading value >0.4.

Table 4. Comparison of mean score of level and psychological morbidity. Workers

second-order factors of sources of stress with poor physical health might have perceived
that they were more vulnerable to contracting
n Mean score# t
SARS ; hence, it was deemed stressful and
Work factor psychologically distressing to work with infec-
High stress 425 2.36 12.39 tious patients. Moreover, the authors postulated
Low stress 194 1.55
that the stressed workers might have had more
Personal factor
High stress 437 2.64 15.26 physical complaints. Some non-specific somatic
Low stress 196 1.78 discomfort might reflect underlying psychologi-
Role factor cal morbidity.
High stress 433 2.47 0.44 More than half of the respondents were found
Low stress 198 1.80
to have psychological distress. A causal link
All the differences between the high-stress and low-stress groups between the SARS outbreak and psychological
were significant at p<0.001. morbidity was not established in this study.
# ‘ 1 ’ represented ‘ mild ’, ‘2 ’ represented ‘moderate ’ and ‘ 3 ’
represented ‘significant’ degree of severity on the Likert scale. However, when job-related stress was high and
support was inadequate, the risk of psychologi-
cal morbidity increased considerably. Adequate
practical support, especially in terms of in-
Our results suggested that workers’ unwill- surance and compensation issues and psycho-
ingness to work in SARS units was associated logical support from employers, appeared to
with psychological morbidity. The willingness have a protective effect against stress in the
of those who volunteered to work in SARS units workplace during the outbreak.
might reflect the fact that they were psycho- Our study found that the most prevalent
logically prepared or had better ‘ reserves ’ to stressors came from the fact that the health
cope with the challenge, and therefore suffered and welfare of the healthcare workers were
less psychological distress. One interesting find- jeopardized. Over 70% of respondents ex-
ing in this study was that perceived poor physi- pressed the view that the most distressing aspect
cal health was associated with higher stress was healthcare workers becoming infected. This
1202 C. W. C. Tam et al.

Table 5. Changes in attitude after the outbreak of severe acute respiratory syndrome (SARS)
n Agree (%) Disagree (%) No comment (%)

Greater awareness of personal and environmental hygiene 639 96.7 1.3 2.0
Valued gatherings with family members more 640 95.2 0.3 4.5
Willing to devote more time to helping others, having escaped infection personally 633 91.3 1.2 7.5
Fulfilled the ambitions of joining a healthcare profession and understood the 638 85.8 2.8 11.14
meaning of professional sacrifice
Became more empathetic towards patients 638 77.6 3.8 18.6
Felt a lack of control 634 74.5 16.1 9.4
Relationship with colleagues became closer and more supportive 636 69.7 11.2 18.9
Felt that death could be near and unexpected, fear of disease and death 641 58.9 25.1 16.0
Felt that job and life were unpredictable, that the present should be enjoyed 640 53.8 30.7 15.5
and that long-term planning was less important than previously
Changed values and priority of goals in life 639 49.7 11.6 38.7
Felt guilty for surviving when colleagues were sick or deceased 639 32.9 36.3 30.7
Protective measures and fear of infection created greater interpersonal distance 597 21.5 65.5 13.3

evoked fear about their own personal vulner-
ability, as the working staff shared similar per-
sonal characteristics and identified emotionally
with their sick colleagues. The rapid deterio-
ration and potentially fatal outcomes of the
syndrome elicited feelings of frustration, self-
doubt and guilt in medical professionals taking
care of their colleagues. Most respondents
worried more about the health of their relatives
than their own. They avoided close social con-
tact deliberately, to reduce the risk of transmit-
ting infection to their loved ones. Their home
life and social relationships were significantly
disrupted. Our findings of stressors relating
to personal factors corresponded to those found
in an earlier study, which reported the psycho-
logical effects of the SARS outbreak in health-
care workers in Canada (Maunder et al. 2003).
The role factor illustrated the conflict between
the professional responsibility of the healthcare
workers and their sense of incompetence. The
public had high expectations of the medical
professionals and expressed a high regard for
their professionalism. These professionals were
expected to be altruistic and brave during the
battle. However, many staff experienced doubts
about their self-efficacy and uncertainties re-
garding their medical knowledge. An inability to
handle colleagues’ worries and distress increased
the sense of powerlessness and fear at work.
For the work-related factor, most of the
respondents complained about ambiguity of
policies, ineffective dissemination of inform-
ation and lack of a feedback mechanism, rather
than insufficient protective wear or hazards in
the workplace. SARS was a catastrophe for the
public hospital system in Hong Kong. In ad-
dition to the mysterious routes of transmission
of the virus, the frequent changes to infection
control policies and restructuring of services
exacerbated the sense of uncertainty.
Although the battle with SARS was tragic
and arduous, our study found that many re-
spondents were able to perceive positive aspects
to the disaster. Almost all respondents agreed
that the epidemic had increased their awareness
of personal and environmental hygiene. The
majority also agreed that they gained a new
appreciation of life and the relationships they
had formerly taken for granted. They reported
a deepening of their relationships with family
members and colleagues, with the realization
of how quickly they could lose them. About
half of the respondents reported making posi-
tive changes to the priorities in their lives,
such as relaxing more and deriving more en-
joyment from life. Recognition of similar posi-
tive impacts of trauma has previously been
reported in the literature (Tedeschi & Calhoun,
1995).
SARS stimulated healthcare workers to de-
velop complex feelings towards their careers
and perceptions of control. About 50–75% of
respondents admitted that they had a decreased
sense of taking control of their lives after con-
fronting repeated unexpected disastrous events.
There has been a vast volume of literature in
psychology linking perceptions of control over
events to a sense of psychological well-being
(Bandura, 1995; Lea et al. 1998). One-third of
respondents in the present study admitted to
having survival guilt. This crisis reminded them
 SARS in Hong Kong in 2003
of their limitations and vulnerability. At the
same time, 90 % of respondents believed them-
selves to be more altruistic, having survived
the outbreak. This might have been because
the act of diverting attention and energy to
helping others helped them to conquer their
own feelings of powerlessness and regain a sense
of control over other aspects of life, besides
the SARS catastrophe. Having worked in
healthcare for some considerable time, many
workers reported emotional exhaustion. Treat-
ing patients had become mechanical and they
were accustomed to dealing with death. After
the outbreak, 86 % of respondents reported a
renewed appreciation for the meaning and
importance of their profession. Seventy-eight
per cent admitted that they would be more
empathetic towards patients, with greater sensi-
tivity to their psychological distress, in the
future.
These results illustrated that frontline health-
care workers suffered from significant stress
from various sources during the SARS out-
break. Cognitive factors such as appraisal of
situations, risk perception and sense of control
played an important role in mediating factors
of stress. Our findings underscore the need for
hospital administrators to be aware of the extent
and sources of psychosocial stress among
frontline healthcare workers. Adequate protec-
tive facilities, effective communication, clear
guidelines and appropriate feedback mechan-
isms for administrators were found to be para-
mount in alleviating the practical problems in a
crisis such as that described here. Strengthening
social support in the workplace was also found
to be necessary in stress management. Staff fo-
rums or group meetings provided an opportunity
for cathartic ventilation and gaining a better
perspective on the situation and on sources of
emotional stress. Staff members were en-
couraged to share their experiences and obtain
constructive feedback from other colleagues.
Early identification of at-risk individuals, coun-
seling and stress management were found to be
necessary for workers with severe emotional
distress. The underlying premise of early inter-
vention was to limit the establishment of mala-
daptive and disruptive cognitive or behavioral
patterns in response to the crisis. Our study
showed that frontline healthcare workers sel-
dom considered professional counseling, despite
1203
the fact that the Hospital Authority of Hong
Kong had set up a hotline and a counseling
service for distressed members of staff. Con-
venient and confidential referral systems for
professional counseling should therefore be
promoted. The underlying reason for the low
take-up rate for this type of service needs further
investigation. It might be related to our culture
of low emotional expressiveness or to a lack of
publicity of the counseling service.
The present study adopted a cross-sectional
survey design with self-administered ques-
tionnaires. Reliance on self-report data has its
limitations. However, as stress is an experience
based on the perception of a mismatch between
demands and resources to meet those demands,
subjective reporting has to be paramount. The
questionnaires were administered near the end
of the epidemic, in June 2003 ; the participants
might have experienced recall bias about the
events from a few months previously. However,
recall of a disastrous event like the SARS out-
break was likely to be more consistent than
recall of other life-events, as the outbreak had a
marked impact on the whole community. Most
of the content of the scales in our questionnaire
was not based on locally validated instruments,
except GHQ-12. As the SARS outbreak was
unprecedented, there were no validated scales
that were specific to measuring the stressors and
support related to this epidemic in Hong Kong.
Therefore, a focus group was set up in an
attempt to overcome the problem of the validity
in the design of our questionnaire. The response
rate in our study was fair for a cross-sectional
survey. The responses of the returned ques-
tionnaires covered a wide range of areas and the
respondents covered a range of ages. However,
the number of ancillary staff included was small
and the response rate of doctors was low. The
demographic data of the non-respondents were
not available to us for comparison. We did not
send out questionnaires to the non-respondents
in the second phase because the staff underwent
frequent changes of working location towards
the end of the outbreak, and it was difficult
to locate the non-respondents. The study sample
might not have been representative of our study
population. The authors believed that the re-
sponse rate was low because the healthcare
workers were busy, and some of them had
already expressed their opinions through other
1204 C. W. C. Tam et al.
channels such as media programs or staff
forums.
In conclusion, our results show that frontline
healthcare workers suffered from significant
stress from various sources during the SARS
outbreak. The most prevalent of these were
hazards to personal health, role conflicts and
frequent changes to infection control policies.
The healthcare workers’ psychological mor-
bidity was best understood by their perceptions
of personal vulnerability, stress and support
in the workplace. Although the outbreak was
tragic and frightening, many healthcare workers
perceived some benefits and personal growth in
the struggle with the disaster. It is hoped that
this study may help to guide interventions to
support hospital staff in future disease out-
breaks.
ACKNOWLEDGMENTS
We thank Ms S. Chia, Ms Q. L. Chen and Ms
J. Lee for their assistance in data entry, the ward
managers for their assistance in distributing the
questionnaires, and all of the participants for
their contributions.
NOTE
Supplementary information accompanies this
paper on the Journal’s website (http://journals.
cambridge.org).
DECLARATION OF INTEREST
None.
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