2.2. Procedure

On a voluntary basis, the SARS team members were invited to participate in two debriefing groups provided by the psychiatric team during the period of their mission. Ten nurses participated in the first group, which lasted 50 min, during the early phase of their mission and 22 participated in the second, lasting 90 min, during the middle phase.

Topics related to their SARS experiences were discussed in these two groups, such as the psychological conflicts and stresses experienced in this mission, coping strategies and possible preventive or intervening measures for staff. Permissions from all the group respondents were granted to the researchers to use the group notes in formulating several significant issues (i.e., immediate reactions, major stressors, effective measures, coping strategies, motivators to join future missions).

At the closing phase of the mission, 21 (81%) nurses were interviewed in small groups of 4 to 6. The interviews followed a semistructured schedule derived from previously identified issues. Based on the analysis of the interview protocols, the SARS Team Questionnaire was developed. Twenty-six (87%) female nurses who gave informed consent to participate in the survey then completed this questionnaire.

2.3. Measure

Due to the difficulty of conducting research during a crisis in which clinical responsibilities precluded careful research planning and systematic data collection, the psychiatric team used whatever materials were available at hand to design the SARS Team Questionnaire in an effort to understand the experiences of the SARS team members. Preliminary analysis showed that some scales in this questionnaire have satisfactory internal consistency while further examination of reliability and validity is not available.

The SARS Team Questionnaire consists of 72 items that assess six areas: (a) immediate reactions to the mission; (b) major stressors inherent in caring for SARS patients; (c) effective measures to reduce stress; (d) coping strategies; (e) motivators to join future missions; and (f) evaluation of psychiatric services. The “immediate reactions to the mission” subscale consists of 18 items that measure the cognitive and emotional reactions of the respondents immediately after learning about their mission of taking care of SARS patients — for example, “I felt it was unfair,” “I felt nervous and worried” and “I took it as a call of duty.” All respondents were asked to rate the degree to which they had various psychological reactions toward their duty of caring for SARS patients on a four-point scale (0=not at all; 1=slightly; 2=moderately; 3=very much). The internal consistency coefficient was .86 (Cronbach's α) for the immediate reaction subscale.

The “major stressors inherent in caring for SARS patients” subscale consists of 23 items that assess stresses related to the nurses' mission. All respondents were asked first to indicate if they had experienced each of the stressors (yes/no) and then to rate the severity of their experienced stress on a four-point scale (0=not at all; 1=slightly; 2=moderately; 3=very much). Sample items are listed in Table 2 . The internal consistency coefficients were .86 (Kuder-Richardson Formula 20) for the number of stressors and .86 (Cronbach's α) for the stress severity.

The “effective measures to reduce stress” subscale consists of 15 items enumerating actions/resources that were taken or provided to meet the respondents' needs during the SARS crisis and their perception of the effectiveness of these measures. All the respondents were asked first to indicate if they had used each of the measures (yes/no) and then to rate the effectiveness of the measures on a four-point scale (0=not effective; 1=mildly effective; 2=moderately effective; 3=very effective). Sample items are listed in Table 3 . The internal consistency coefficients were .47 (Kuder-Richardson Formula 20) for the number of measures and .85 (Cronbach's α) for the degree of effectiveness.

The “coping strategies” subscale includes 12 behaviors that the respondents might have employed in coping with the stresses related to their mission. All respondents were asked to rate the frequency of various coping strategies used on a four-point scale (0=almost never; 1=sometimes; 2=often; 3=almost always). Sample items are listed in Table 4 . The internal consistency was .27 (Cronbach's α) for the rating of coping strategies.

The “motivators to join future missions” subscale consists of five possible considerations that may enhance respondents' willingness to join the SARS team in the future. These items are family support, adequate and sufficient protective equipment, clear information about the disease, bonus pay for dangerous work and reasonable staffing/shift. Respondents were asked to rank their preference for these considerations.

Finally, the “evaluation of psychiatric services” subscale was conducted by asking the respondents to rate their experience of the debriefing groups on a five-point scale (0=not helpful; 1=slightly helpful; 2=fairly helpful; 3=moderately helpful; 4=very helpful). They were also invited to write down their suggestions for future services to be provided by the psychiatric team.

3.2. Major stressors inherent in caring for SARS patients

As the epidemic waxed and waned, some situations were additionally stressful. Table 2 shows that a majority of respondents suffered from stresses related to worries about colleagues (n=24, 92%), patients (n=23, 89%) and family members (n=23, 89%). The frequent changes in infection control measures (n=24, 92%) and documentation process (n=21, 81%) as well as the increase in casualties had caused further stresses of uncertainty (n=24, 92%). They were also concerned about their lack of knowledge of the virus (n=21, 81%), which was becoming increasingly rampant. Not armored with adequate protective equipment (n=21, 81%), they felt that their well-being was threatened. On the other hand, wearing protective equipment hindered their work, causing discomfort (n=23, 89%) and impairing the quality of care (n=19, 73%).

Furthermore, the potential threat of the nosocomial spread of SARS (n=21, 81%) added an extra burden to the SARS team members. Twenty respondents (77%) reported the tragic death of the head nurse as a major stressor for them. The conflict between their duty and their own safety in the workplace (n=17, 65%) made them reconsider the expectations of their profession (i.e., putting their patients' well-being first). One of the SARS team members, who had cared for the deceased nurse, reported that caring for a colleague as a patient was emotionally difficult. However, none of the SARS team members had actually left the profession of nursing due to the stress of the SARS epidemic.

Eighteen (69%) respondents reported conflicts with doctors over “who should be accountable for explaining patients' physical condition to the concerned parties” or “who should handle the hassles with the patients and their families regarding the limited availability of negative-pressure rooms and isolation beds,” among others. Some respondents complained that some doctors interacted with SARS patients and their families in a negative manner that caused tension between the patients and the medical staff, adding an extra burden to the team members, hurting the cooperative relationship between doctors and nurses and leading the latter to sometimes feel powerless and helpless.

3.3. Effective measures to reduce stress

During the outbreak, our hospital responded rapidly to help the team in many ways. Table 3 lists all the effective actions/resources mentioned by the respondents. Although psychiatric services were not included in the very early stage of the hospital's action, the nurses all agreed that the psychiatric services (n=26, 100%) were significantly effective in helping them manage their stress. Encouragement among peers (n=26, 100%), enough rest and time off (n=25, 96%) and appropriate work shifts (n=25, 96%) were all helpful in reducing their stress and restoring their energy.

Enforcement of stringent infection control procedures (n=25, 96%), supplies of adequate protective equipment (n=24, 92%) and the regular education program (n=22, 85%) were taken as strong, committed support from the hospital administration and therefore beneficial to morale, as was the senior nurses' mentoring of the junior nurses (n=24, 92%).

3.4. Coping strategies

The SARS team members also reported strategies for relieving tension during the epidemic (see Table 4). For examples, they adopted more active personal protective measures (n=26, 100%; e.g., taking their own temperature, wearing masks, washing their hands), learned more about the disease (n=25, 96%; e.g., symptoms, mode of transmission) and engaged in health-promoting behaviors (e.g., more rest, exercise, balanced diet).

Instead of feeling frustrated, some changed their attitudes and started facing their work more positively (n=22, 85%). Team members frequently met after work for a debriefing session, keeping themselves posted on problems that they were faced with at the time and exchanging information with the head nurse. These informal small group gatherings made them feel confident rather than confused.

Some (n=22, 85%) engaged in recreational activities such as telling jokes, shopping, going to movies, internet surfing and participating in outdoors activities to reduce stress. Twenty-one (81%) nurses reported feeling comforted in chatting with their families and friends over the phone. In particular, photos showing nurses in protective gear sent by video cell phones to family members were a great source of reassurance.

Sixteen (62%) respondents avoided watching much news about SARS on TV, which had been disturbing and unfair, imposing unnecessary pressure on them. In general, they seemed to cope well with this extremely stressful situation.

3.5. Motivators to join future missions

Among motivating factors that could make the nurses more willing to join the team in the future, the most crucial was having adequate and sufficient protective equipment, followed by clear information about the disease, bonus pay for dangerous work, reasonable staffing/shift and family support.

3.6. Evaluation of psychiatric services

Respondents' feedback about the psychiatric services provided was solicited to help improve the delivery of psychiatric services in the future. This is especially helpful and important since interdisciplinary cooperation is required in such a situation. Twenty-three (89%) respondents agreed that the psychiatric services were a great form of support, with the debriefing group being the most commended.

We dedicate this article to the late head nurse, Ms. Chin-Chiu Chen, who was an inspiration to all who knew her. We are grateful to the staff of the departments of psychiatry and emergency for their support and contribution to this study. We would also like to thank Mr. Frank Sharp and Dr. Paul Kretchmer for their assistance in editing this manuscript. Deepest gratitude goes to all the members of the SARS team who have shared their experiences with us and made this work possible.