The cost of care: Cognitive and psychological toll on healthcare professionals

SUMMARY

The authors conducted an analytical cross-sectional study between April and August 2023 among staff working in a hospital in Iran. They compared the cognitive function and work resilience of 235 healthcare professionals (HCPs) with 107 randomly selected administrative staff. The administrative staff worked in human resources, information technology, customer service, procurement, management, and medical records departments. The authors collected data on the nature, shift, schedule, and duration of work hours. They assessed cognitive function using the Mini-Mental Status Examination scale (MMSE) across five domains: orientation, registration, attention and calculation, recall, and language. The researchers captured work resilience through the self-administered Arabic version of the Brief Resilience Scale (BRS), which has been reported to have excellent internal consistency (Cronbach’s alpha coefficient 0.98) and good convergent and construct validity. They measured psychological distress using the depression, anxiety and stress scale-21 (DASS-21). The authors used the Mann– Whitney U, Chi-square, or Fisher’s exact test, and simple and multiple binary logistic regression models for inferential analysis.

Compared to the administrative staff, HCPs were younger (mean age 32.2 v. 34.4 years) and more frequently unmarried (29.8%), physically active (21.7%), and living in urban areas (65.5%). They also reported significantly longer working hours (mean 5.93 hours per shift) and a higher prevalence of shift duties (48.9% v. 20.6%). Cognitive performance, measured by the MMSE, was notably lower in HCPs (mean score 26.8) than in administrative staff (29.9), and 14% of HCPs were classified as cognitively impaired compared to 4.7% of administrative staff. Psychological distress was also more common in the HCP group, with depression affecting 37%, anxiety 44.7%, and stress 37.9%, all markedly higher than among administrative staff. Regarding resilience, HCPs had a lower mean BRS score (2.92 v. 3.14), and 54% fell into the low resilience category, compared to 30% of administrative staff. The odds of cognitive impairment in HCPs were 3.33 times higher in crude analysis (p=0.015) and increased to 4.45 after adjusting for confounders (p=0.02). Similarly, the crude odds of low resilience were 2.64, rising to 5.81 after adjustment (p<0.001). Interestingly, no significant association was found between low resilience and cognitive impairment after adjustment (OR 0.55, p=0.185).

COMMENTS

HCPs are considered vulnerable to stress and face many work-related health problems, especially in low and middle-income countries, where demand-supply mismatch is prevalent. The stressors, such as longer work hours, night shifts, low pay scale, etc., have compounded after the Covid-19 pandemic. Successful coping with stressors is reflected in resilience. Continued stress affects HCPs and may lead to poorer mental health. This study has provided the magnitude of poor resilience and cognitive impairment due to work-related stress among HCPs. The presence of a high burden of depression among HCPs in this study is a cause of extreme concern.

We graded this article as seven out of nine stars using the Newcastle Ottawa scale for cross-sectional studies. The study fails to score in mentioning limitations, conflict of interest, funding source, generalizability, consistency with other literature, and bias assessment. The authors reported having used a ‘comparative’ cross-sectional study design. Standard textbooks of epidemiology mention an ‘analytical’ cross-sectional design. Even an analytical cross-sectional design has limitations in establishing a causal relationship due to a lack of temporality and cessation criteria between exposure and outcome. This study demonstrates a stronger association between working as an HCP with poor resilience and impaired cognitive function. It replicates the findings of previous studies and is consistent with the current literature. There are few studies on cognitive impairment among HCPs based on working hours, but there is vast literature showing low resilience and increased psychological problems (stress, anxiety, and depression). Additionally, psychological issues can lead to cognitive impairment in the long run.^1-4 The exposure and outcome relationship is biologically plausible.⁵ The authors did not mention inclusion and exclusion criteria. Potential biases such as prevalence-incidence bias, selection bias, recall bias, etc, were not discussed. The authors had set the cut-off value of MMSE as <27/30 for cognitive impairment, but the standard cut-off to estimate cognitive impairment through MMSE is <23/30.⁶ Variables with a p value <0.05 in bivariate logistic regression were selected for the multivariate model, which is unusual (usual cut-off p value is <0.25).

Relevance to India

In India, the health and psychological well-being of HCPs remain underexplored, particularly the impact of occupational stress. Before the Covid-19 pandemic, only a handful of studies focused on the toll that long duty hours, night shifts, and high patient loads took on the mental health of HCPs. Even though this study reports an average of around 6 working hours per day, the intensity of work, compounded by frequent shift duties and staff shortages, can still lead to significant psychological strain. These persistent stressors may gradually erode resilience and impair cognitive performance over time.² Evidence from a tertiary hospital in Mumbai paints an even grimmer picture. There, HCPs reportedly worked up to 88 hours per week, with over half showing signs of burnout.^7–9 Despite these alarming numbers, India still has no legal standards to regulate duty hours for medical staff, especially resident doctors. Laws like the Clinical Establishments Act (2010) and the National Medical Commission Act (2019) do not address this issue explicitly.^10,11 In contrast, other labour sectors are protected by the Factories Act (1948), which sets working-hour limits, but HCPs are not covered under its provisions.¹² International bodies such as the WHO and International Labour Organization (ILO) have recognized overwork as a health hazard, but specific guidelines for HCPs, especially in the Indian setting, are still lacking.⁸

The situation is often worse in rural and underserved regions, where HCPs face limited resources, increased workload, and professional isolation. Many institutions still lack basic mental health support systems, such as counselling services or wellness programmes, leaving staff to manage stress on their own. Young trainees, particularly interns and residents, are also at risk. They often enter the workforce with limited coping skills and are subjected to unpredictable shifts, high workloads, and minimal psychological support. Gender-related challenges are also worth noting. Women in healthcare—especially nurses and junior doctors—frequently juggle demanding professional responsibilities and household roles, adding another layer of stress. Moreover, incidents of workplace violence against HCPs have been reported for decades and continue to contribute to emotional fatigue and job dissatisfaction.^13,14

The consequences of psychological distress, poor resilience, and cognitive fatigue can be severe. There is an increased risk of clinical errors, but iatrogenic mistakes remain an overlooked issue in India. Likewise, burnout is still not formally acknowledged in health policy discussions. There is a need to better document work-related health concerns among HCPs in India, not just for the sake of the workforce but for the overall safety and quality of patient care. Introducing regular mental health screening, enforcing shift regulations, and building supportive infrastructure should become an essential part of health system reform.