Stress, Resilience, and Coping of Healthcare Workers during the COVID-19 Pandemic

Abstract

Objective
To estimate the health care workers (HCWs) self-reported stress, resilience, and coping during the COVID-19 pandemic, and to determine inter-professional differences.

Participants and Methods
An email survey was sent to 474 HCW at a Midwestern HealthCare facility between April 9, 2020 and April 30, 2020. A total of 311 (65.6%) responses were received by May 31, 2020. The survey utilized 3 validated instruments: Perceived Stress Scale (PSS), Brief Resilience Scale (BRS), Brief Resilience Coping Scale (BRCS).

Results
Of the 311 responses, 302 were evaluated: 97 from nonmedical staff with patient contact (NMPC); 86 from nonmedical staff with no patient contact (NMNPC); 62 from medical doctors (MD), physician assistants (PA) and nurse practitioners (NP); and 57 from nurses. Significant differences were noted across job categories for stress and resilience, with nurses reporting highest PSS scores (effect estimates: −2.72, P = .009 for NMNPC; −2.50, P = .015 for NMPC; −3.21, P = .006 for MD/NP/PA respectively), and MD/NP/PA group with highest BRS scores: nurses (−0.31, P = .02); NMPC (−0.3333, P = .01); and NMNPC (−0.2828, P = .02). Younger personnel had higher stress (−1.59 per decade of age, P < .01) and more resilience (0.11 per decade of age, P = .002).

Conclusion
These self-reported data indicate that MD/NP/PA had the highest resilience scores and the nurses had highest stress levels. Efforts are warranted to include all HCWs in systematic stress mitigating interventions with particular attention to understand specific factors contributing to stress for the nursing team.

Full text

https://doi.org/10.1177/21501327211008448
Journal of Primary Care & Community Health
Volume 12: 1–9
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Caring for the Caregivers during the COVID-19 Pandemic-Original Research
Introduction
On December 31, 2019, the Wuhan Municipal Health
Commission in China reported a cluster of cases of pneu-
monia.1 This was later identified as a SARS-CoV-2, coro-
navirus.1 On March 11, 2020, the virus, SARS-CoV-2, was
declared the COVID-19 pandemic by the WHO.2
During this evolving world-wide health care crisis and des-
perate time of need, the overwhelming burden of illness and
mortality has threatened operations of health care institutions
worldwide and the physical, emotional, and financial health
of their HCW. HCWs must grapple with fears of infection,
death, and the risk of COVID-19 transmission to their fami-
lies, as well as post-traumatic stress and other mental, physi-
cal, emotional, and spiritual concerns.3 To quote Greenberg
et al., “We have placed our healthcare professionals in an
impossible situation of having to make life and death deci-
sions while working under extreme pressure.”4
Resilience refers to one’s ability to bounce back from
adversity and view adversity as an opportunity for growth;
it is an increasingly recognized protective factor against
stress.5,6 Resilience among HCWs is influenced by multiple
factors at the individual, organizational, and societal
levels.7-10 It is imperative to address issues at the organiza-
tional level, including robust structural interventions within
1008448JPCXXX10.1177/21501327211008448Journal of Primary Care & Community HealthCroghan et al
research-article2021
1Mayo Clinic, Rochester, MN, USA
Corresponding Author:
Ivana T. Croghan, Mayo Clinic, 200 First Street SW, Rochester,
MN 55905, USA.
Email: croghan.ivana@mayo.edu
Stress, Resilience, and Coping of
Healthcare Workers during
the COVID-19 Pandemic
Ivana T. Croghan1, Sherry S. Chesak1, Jayanth Adusumalli1,
Karen M. Fischer1, Elizabeth W. Beck1, Shruti R. Patel1,
Karthik Ghosh1, Darrell R. Schroeder1, and Anjali Bhagra1
Abstract
Objective: To estimate the health care workers (HCWs) self-reported stress, resilience, and coping during the COVID-19
pandemic, and to determine inter-professional differences. Participants and Methods: An email survey was sent to 474
HCW at a Midwestern HealthCare facility between April 9, 2020 and April 30, 2020. A total of 311 (65.6%) responses
were received by May 31, 2020. The survey utilized 3 validated instruments: Perceived Stress Scale (PSS), Brief Resilience
Scale (BRS), Brief Resilience Coping Scale (BRCS). Results: Of the 311 responses, 302 were evaluated: 97 from nonmedical
staff with patient contact (NMPC); 86 from nonmedical staff with no patient contact (NMNPC); 62 from medical doctors
(MD), physician assistants (PA) and nurse practitioners (NP); and 57 from nurses. Significant differences were noted across
job categories for stress and resilience, with nurses reporting highest PSS scores (effect estimates: −2.72, P = .009 for
NMNPC; −2.50, P = .015 for NMPC; −3.21, P = .006 for MD/NP/PA respectively), and MD/NP/PA group with highest BRS
scores: nurses (−0.31, P = .02); NMPC (−0.3333, P = .01); and NMNPC (−0.2828, P = .02). Younger personnel had higher
stress (−1.59 per decade of age, P < .01) and more resilience (0.11 per decade of age, P = .002). Conclusion: These self-
reported data indicate that MD/NP/PA had the highest resilience scores and the nurses had highest stress levels. Efforts
are warranted to include all HCWs in systematic stress mitigating interventions with particular attention to understand
specific factors contributing to stress for the nursing team.
Keywords
pandemic, stress, resilience, healthcare, SARS, provider
Dates received 17 March 2021; revised 17 March 2021; accepted 18 March 2021.

2 Journal of Primary Care & Community Health
the work environment.7 It is also essential to identify indi-
vidual factors that contribute to resilience in order to inform
best practices for empowering HCWs to cope and optimize
their well-being, especially during adversity. Prior research
has identified a direct relationship between non-productive
coping and stress, burnout, and other well-being measures,
among HCWs.11 Recent studies during the COVID-19 pan-
demic have indicated direct relationships between pandemic-
related stress, anxiety and resilience among physicians in
Israel.12,13 The purpose of our project was to assess the level
of stress, resilience and ability to cope among HCWs at a
tertiary care academic medical center during the initial stages
of the pandemic, utilizing validated assessment scales, and to
determine inter-professional differences.
Methods
This survey, intended for practice-improvement was com-
pleted by general internal medicine colleagues within 1
health care institution in the midwestern United States, dur-
ing the COVID-19 pandemic. This study was reviewed and
approved by the General Internal Medicine Leadership and
the Institutional COVID-19 taskforce.
Study Population and Survey Methods
Participants included a convenience sample of staff within
the General Internal Medicine division, including medical
doctors (MD), nurses (RNs, LPNs), nurse practitioners
(NP), physician’s assistants (PA), administrative assistants
(AA), as well as other division staff.
Participants received information regarding the general
purpose of the project and contact information for ques-
tions/complaints. This voluntary and anonymous survey
was sent as a link through an email. The initial email went
out on April 9, 2020; non-responders received reminder
emails on April 16, 2020, April 23, 2020, and April 30,
2020. Study collection was closed on May 31, 2020. A
detailed summary of the above is found in the consort dia-
gram presented in Figure 1, which adheres to Consolidated
Standards of Reporting Trials (CONSORT) guidelines.14
All surveys were delivered as a link via email through the
use of REDCap.15 There was no compensation offered for
participation.
Survey Instruments
This survey was developed utilizing Research Electronic
Data Capture (REDCap)15 and consisted of validated scales
measuring resilience (Brief Resilience Scale (BRS)),16 cop-
ing (Brief Resilience Coping Scale (BRCS)),17 and stress
(Perceived Stress Scale (PSS)),18 Other measures which
were included in the survey, will be reported elsewhere.
Many questions had Likert scale responses such as “strongly
agree,” “agree,” “neutral,” “disagree,” and “strongly dis-
agree.” The total number of questions ranged from 44 to
54 depending on how respondents answered individual
questions with branching logic. The 5 overarching compo-
nents of the survey were: (1) Current task burden (direct
patient contact or no patient contact); (2) stress (PSS); (3)
resilience (BRS); (4) coping (BRCS); (5) socio-demo-
graphic characteristics.
Pilot testing of the survey was conducted with 4 rounds
amongst 7 clinicians, nurses, and nonmedical staff to assess
the acceptability, readability, and understandability of the
survey. The resulting survey took 5 to 7 min to complete.
Data Analysis
For the purposes of this analysis, respondents were divided
into 4 groups according to their current job description: (1)
MD/PA/NP; (2) nurses; (3) non-medical health staff with
patient contact (NMPC) and (4) non-medical staff with no
patient contact (NMNPC).
Descriptive characteristics for the respondents were
reported using frequencies and percentages for each
group. For each of the 3 surveys (PSS, BRS, BRCS) a
multiple linear regression model was used to compare the
groups. Age and sex were adjusted for each model. Age
was collected in the survey as a range of values, but for
the purposes of the model was coded as a 10-year con-
tinuous variable. P-values of <.05 were considered sta-
tistically significant and 95% confidence intervals were
reported with all point estimates. SAS statistical software
(SAS version 9.4, SAS Institute Inc.)19 was used for all
analysis.
Results
Of the 474 surveys sent, a total of 311 (65.6%) responses
were received. Among the 311 survey responses, 302 were
evaluated. The 8 excluded from analysis did not self-iden-
tify their job role/title. Among the 302 responses included
in the analysis, 86 were from NMNPC, 97 from NMPC, 62
from MD/PA/NP, and 57 from nurses.
Descriptive characteristics are reported in Table 1. A
majority of those who responded were white (90%) and
female (85%). A large portion of respondents (32%) had
worked in the health care field for over 25 years. Overall,
only 15% of the respondents were male, and for the nursing
group only 4% were male. The MD/PA/NP group had the
highest percentage of participants over the age of 60 (24%).
A total of 129 (43%) respondents identified as caregivers
outside of their job.
A higher score on the PSS survey indicates a higher
level of perceived stress. Compared to the nursing group,
all of the groups had significantly lesser perceived stress
(Table 2, Figure 2a) with the MD/NP/PA group having the

Croghan et al 3
Figure 1. Consort diagram.

4 Journal of Primary Care & Community Health
largest difference from the nursing group. Age was also
significantly (P < .001) related to PSS, with an average
decrease of 1.59 points for every decade increase in age.
Just as PSS, a higher BRS score indicates a higher level
of resilience. With the nurse group as the reference group,
only the MD/NP/PA group was noted to have significantly
higher resilience scores. When the MD/NP/PA group is
used as the reference, the MD/NP/PA group was found to
have higher BRS scores than nurses (−0.31, P = .02); non-
medical staff with patient contact (−0.3333, P = .01); and
Table 1. Participant Characteristics.
Allied health: no patient
contact (N = 86)
Allied health: patient
contact (N = 97)
MD/NP/PA
(N = 62)
Nurse
(N = 57)
Total
(N = 302)
Age range, n (%)
30 years or lower 14 (16.3) 17 (17.7) 2 (3.2) 3 (5.3) 36 (12.0)
31-40 years 22 (25.6) 26 (27.1) 20 (32.3) 11 (19.3) 79 (26.2)
41-50 years 26 (30.2) 20 (20.8) 10 (16.1) 16 (28.1) 72 (23.9)
51-60 years 17 (19.8) 25 (26.0) 14 (22.6) 20 (35.1) 76 (25.2)
60 years or higher 6 (7.0) 8 (8.3) 15 (24.2) 7 (12.3) 36 (12.0)
I do not wish to answer 1 (1.2) 0 (0.0) 1 (1.6) 0 (0.0) 2 (0.7)
Missing 0 1 0 0 1
Gender, n (%)
Female 76 (89.4) 83 (87.4) 39 (63.9) 54 (96.4) 252 (84.8)
Male 9 (10.6) 12 (12.6) 21 (34.4) 2 (3.6) 44 (14.8)
I do not wish to answer 0 (0.0) 0 (0.0) 1 (1.6) 0 (0.0) 1 (0.3)
Missing 1 2 1 1 5
Race, n (%)
White 82 (95.3) 90 (92.8) 45 (72.6) 55 (96.5) 272 (90.1)
Hispanic, Latino or Spanish origin 1 (1.2) 4 (4.1) 0 (0.0) 0 (0.0) 5 (1.7)
Black or African American 0 (0.0) 0 (0.0) 4 (6.5) 2 (3.5) 6 (2.0)
Asian 2 (2.3) 3 (3.1) 9 (14.5) 1 (1.8) 15 (5.0)
American Indian or Alaskan Native 1 (1.2) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.3)
Native Hawaiian or Other Pacific Islander 0 (0.0) 0 (0.0) 1 (1.6) 0 (0.0) 1 (0.3)
Other 0 (0.0) 0 (0.0) 2 (3.2) 0 (0.0) 2 (0.7)
Do not wish to answer 0 (0.0) 1 (1.0) 3 (4.8) 0 (0.0) 4 (1.3)
How many years have you worked in health
care (in any capacity and also including
employment outside of Mayo)? n (%)
5 years or less 25 (29.4) 24 (24.7) 6 (9.7) 1 (1.8) 56 (18.6)
5-9 years 12 (14.1) 16 (16.5) 7 (11.3) 5 (8.8) 40 (13.3)
10-14 years 8 (9.4) 12 (12.4) 12 (19.4) 4 (7.0) 36 (12.0)
15-19 years 7 (8.2) 12 (12.4) 5 (8.1) 8 (14.0) 32 (10.6)
20-24 years 13 (15.3) 10 (10.3) 6 (9.7) 12 (21.1) 41 (13.6)
25 years or more 20 (23.5) 23 (23.7) 26 (41.9) 27 (47.4) 96 (31.9)
Missing 1 0 0 0 1
Has your sleep been adversely affected
during this pandemic? n (%)
No 50 (58.1) 41 (42.7) 42 (67.7) 23 (40.4) 156 (51.8)
Yes 36 (41.9) 55 (57.3) 20 (32.3) 34 (59.6) 145 (48.2)
Missing 0 1 0 0 1
Did you participate in any stress
management activity or skill on a regular
basis prior to the pandemic? n (%)
No 46 (54.8) 46 (47.9) 22 (35.5) 24 (42.1) 138 (46.2)
Yes 38 (45.2) 50 (52.1) 40 (64.5) 33 (57.9) 161 (53.8)
Missing 2 1 0 0 3

Croghan et al 5
nonmedical staff with no patient contact (−0.2828, P = .02).
Age also significantly correlated to the overall BRS score,
with older age associated with higher resilience (0.11 per
decade of age; P = .002) (Table 2, Figure 2b).
For the BRCS survey, a higher score indicates that the
respondent is more likely to cope effectively. For this out-
come, no significant differences were detected before and
after adjusting for sex and age (Table 2, Figure 2c).
Table 2. Multiple Linear Regression Models.
PSS model (N = 281) BRS model (N = 290) BRCS model (N = 292)
Point estimate
(95% CI)
P-
value
Point estimate
(95% CI)
P-
value
Point estimate
(95% CI)
P-
value
Intercept 23.21 3.37 15.28
Allied health: no patient contact −2.72 (−4.77, −0.67) .009 0.02 (−0.21, 0.25) .86 −0.50 (−1.34, 0.33) .23
Allied health: patient contact −2.50 (−4.50, −0.50) .01 −0.02 (−0.25, 0.21) .85 0.15 (−0.66, 0.96) .72
MD/NP/PA −3.21 (−5.50, −0.92) .006 0.31 (0.05, 0.57) .02 0.30 (−0.62, 1.22) .52
Nurse Ref Ref Ref
Female 1.04 (−0.98, 3.07) .31 −0.17 (−0.40, 0.06) .15 −0.41 (−1.23, 0.41) .32
Male Ref Ref Ref
Age (Unit = 10 years) −1.59 (−2.17, −1.01) <.001 0.11 (0.04, 0.17) .002 0.02 (−0.22, 0.25) .90
Figure 2. (a) Boxplot of PSS scores by job category, (b) Boxplot of BRS scores by job category, and (c) Boxplot of BRCS scores by
job category.

6 Journal of Primary Care & Community Health
Discussion
This survey in the initial stages of the pandemic was focused
on self-perceptions of stress, resilience, and coping. The
results indicate that while stress was rife across differing
HCW, there were inter-professional differences and, in our
case, nurses reported higher stress and lower resilience
compared to the other job categories.
Pandemics highlight the emotional and occupational
vulnerabilities of health care professionals.20 A recent
review of 14 COVID-19 related studies (N = 37-1257)21
confirmed an extensive strain on HCWs due to stress,
depression and anxiety. The severity of these mental issues
was influenced by age, gender, occupation, specialization,
type of activities performed and proximity to the COVID-
19 patient.21 This corroborates with our survey results and
demonstrates a heightened need for organizational and indi-
vidual strategies for stress management, enhancing resil-
ience, peer support for coping and self-care among HCWs.
The COVID-19 pandemic has placed HCW in unten-
able stress while balancing the risk to themselves and oth-
ers.4 Stress, which may be caused by physical, mental or
emotional factors22 has both physical and psychological
consequences, including increased allostatic load, fatigue,
inattentiveness, mood disorders, addiction issues, job-
related injuries, and absenteeism.9,23,24 Add to this the idea
of moral injury, which is defined as “the psychological
distress that results from actions or lack of them, which
violate someone’s moral or ethical code.”25 Individuals
who experience moral injury may develop depression,
post-traumatic stress and suicidal ideation.26 Not only are
HCWs placed in a situation of personal moral injury by
being in the frontline during this COVID-19 pandemic27
but the societal burden of constant updates on death and
infection, the misinformation, the added issues of protests,
the divide over taking protective steps by the people at
large, the shortage of medical and testing supplies, and the
call to make decisions on life and death due to these short-
ages, has increased personal stress.
Overall, HCWs reported moderate-high self-reported
stress scores in our survey (average PSS = 17.1), normal
range for resilience (average BRS = 3.6) and normal range
for resilience coping (average BRSC = 14.9). Further, the
stress among nurses was significantly higher than that of
MD/PA/NP group. Nurses also reported lower levels of
resilience than the MD/PA/NP group, as well as inadequate
stress management skills (prior to COVID19 pandemic)
(64.25% vs 57.9%, physicians vs nurses respectively, Table
1). As in prior studies, our findings highlight the effects of
how the psychosocial impact on HCW can differ by the
occupation and perception of risk.28 Similar findings were
identified in previous studies in China. In one such study
both the incidence and levels of anxiety were significantly
higher amongst nurses in comparison to doctors,29 and in
another study, while HCWs reported low levels of stress
overall; nurses reported higher levels of stress than doc-
tors.30 There is limited research regarding nurses’ levels of
resilience during the pandemic; however, 1 study demon-
strated that nurses’ low personal resilience predicted
COVID-19 anxiety.31
A 2003 study within the Toronto health care system,
which examined the emotional distress impact of the SARS
outbreak on the HCWs, confirmed that 29% of all respond-
ers showed emotional distress. Similar to our observed
inter-professional differences, in this survey, 4 factors asso-
ciated with emotional distress included: (1) being a nurse;
(2) part-time employment status; (3) lifestyle being affected;
(4) ability to do one’s job affected by the precautionary
measures.28 Finally, a 1-time cross-sectional survey during
the COVID-19 pandemic conducted in China during peak
months (January-Feb 2020) showed that among responders
(1257/1830; 69%) 50% expressed depression, 44.6%
expressed anxiety; 34% insomnia; and 71.5% distress.32
These scores were modified by job type (nurses > physi-
cians); sex (females > males); patient care (frontline > no
direct patient care); location (Wuhan (pandemic hot
spot) > outside of Wuhan); and finally years of experience
(junior nurses > more experienced nurses).32
Nurses have been described as the backbone of the health
system and outbreak responses.33 Although the stressors are
higher among physicians and nurses who are frontline
(direct patient care) compared to others, it is understandable
that nurses experience greater stress due to the nature of
their work responsibilities which involve spending more
time delivering direct patient care, and providing direct
social and emotional support to patients whose families are
barred from visiting.34 Further understanding of specific
factors contributing to the stress for nurses is important so
that stress reduction approaches can be appropriately imple-
mented for this population.
With regard to age differences and resilience, our find-
ings indicated that older age was associated with higher
resilience. Previous research has indicated that there is
some evidence to support the premise that resilience
increases with age.35 Rational for this has not been well-
studied; however, there is speculation that the improved
resilience among older individuals could be contributed to
the exposure to more adversity throughout their lifetime
(and thus the development of strategies to overcome
adversity),35 and the tendency of older individuals to
invest more time and energy in their health and family.36
There is a lack of evidence regarding differences in resil-
ience levels among HCWs according to age, thus this
would warrant further research.
As with most studies, our study had limitations which
included this being a 1-time cross-sectional survey of all
individuals within 1 division (General Internal Medicine) at
1 institution. An additional limitation was the lack of

Croghan et al 7
diversity, with the majority of participants being white
females. The survey was delivered during the initial stage of
the pandemic, wherein the staff was experiencing signifi-
cant change: social distancing, mask wearing, cancellation
of routing patient practices, conversion to virtual care, can-
cellation of time away and work related/ other travel, reduc-
tion of salaries and furloughs; creating economic uncertainty,
all while the media was ripe with misinformation. It would
have been ideal to deliver this survey and track outcomes at
serial time points during the pandemic. This, however, was
not feasible due to the decision to minimize survey burden
and keep it anonymous and de-identified.
Informed by the staff and this survey, the General Internal
Medicine divisional leadership took numerous proactive
steps to support colleagues and mitigate the evolving impact
of pandemic-induced stress across all HCWs. The leadership
stepped up the communication across multidisciplinary
teams with daily and weekly web-based meetings that
focused on disseminating accurate and updated information
related to the COVID-19 pandemic. There was timely dis-
semination of institutional initiatives and solutions to address
emerging work-related issues, establishment of work teams
addressing safety, creation of financial aid fund through the
divisional social committee for staff members in need,
updating of wellness websites, creation of videos and other
resources for coping and resilience in addition to augmenta-
tion of opportunities for active peer support and stress man-
agement through uptake of existing programs (HELP:
healing emotional lives of peers and SMART: stress man-
agement and resilience training) as well as virtual town halls
to increase connection. There were more frequent check-ins
across institutional and departmental administration.
Conclusion
These self-reported data indicate that while HCWs reported
moderate-high stress scores, and normal levels of resilience
and coping, the MD/NP/PA group had the highest resilience,
while nurses had the lowest. In addition to lower resilience,
nurses also had higher stress levels compared to the MD/PA/
NP group. It is imperative to have robust strategies and tac-
tics in place for early identification and mitigation of distress
across job categories within health care and help enhance
resilience and coping among all HCWs, with particular
attention to nurses and nonmedical staff. In addition, inter-
ventions should be implemented at the individual, organiza-
tional, and societal level in order to order to address the
multifactorial factors of HCW stress, resilience and coping.
Abbreviations
AA—Administrative Assistants
BRCS—brief resilience coping scale
BRS—brief resilience scale
CONSORT—Consolidated Standards of Reporting Trials
HCW—healthcare worker
MD—medical doctor
NP—nurse practitioner
REDCap—Research Electronic Data Capture
RN—Registered Nurse
LPN—Licensed Practical Nurse
PA—physician assistant
PSS—perceived stress scale
Acknowledgments
A special thanks to all the survey participants. Without their par-
ticipation, this practice improvement project would not have
been possible.
Author Contributions
All the authors participated in the study concept and design,
analysis and interpretation of data, drafting and revising the
paper, and have seen and approved the final version of the
manuscript.
• ITC and AB conceived of the study concept and design and
provided administrative, technical, and material support; had
full oversight of the study conduct during data collection.
They take responsibility for the integrity of the data and the
accuracy of the data analysis; and together they drafted the
manuscript and participated in critical revision of the manu-
script for important intellectual content.
• ITC, SSC, EWB, SRP, KG, JA, KMF, DRS, and AB
participated in the study design, review and editing of the
protocol and data collection and participated in the review
and interpretation of study results, and critical revision of the
manuscript for important intellectual content.
• KF & DRS participated in the study design and were
responsible for data quality checks and data analysis; they
also had full access to all the data in the study and take full
responsibility for the integrity of the data and the accuracy
of the data analysis as well as participating in the manu-
script reviews and edits.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: This practice improvement project was supported in
part by Mayo Clinic General Internal Medicine. The data entry
system used was RedCap, supported in part by the Center for
Clinical and Translational Science award (UL1 TR000135)
from the National Center for Advancing Translational Sciences
(NCATS).
Ethics and Consent to Participate
This was a practice improvement project. As such, it did not qual-
ify for Institutional Review Board approval. It was reviewed and

8 Journal of Primary Care & Community Health
approved by the Mayo Clinic General Internal Medicine
Leadership and Practice Committee, as well as the Mayo Clinic
COVID-19 Taskforce.
Ethical Standards
This was a practice improvement project, which was reviewed and
approved by the Mayo Clinic General Internal Medicine
Leadership and Practice Committee, as well as the Mayo Clinic
COVID19 Taskforce. All authors assert that all procedures con-
tributing to this work comply with the ethical standards of the
Mayo Clinic.
ORCID iD
Ivana T. Croghan https://orcid.org/0000-0003-3464-3525
Availability of Data and Materials
All data supporting the study findings are contained within this
manuscript
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