**4. Results**

Demographic data were self-reported by the participants, as follows: gender (35.7% male and 64.3% female), marital status (42.8% single, 52.3% married, and 4.7% divorced), children (55.5% yes, 44.4% no), profession (74.6% physician, 25.3% nurse), sta ff category-doctors (45.2% trainee, 15% specialist, 16.6% primary, 23% other), and specialty (36.5% ICU and 63.4% EM) (Table 1), During the study period, the County Emergency Clinical Hospital Pius Brînzeu, Timisoara, was actively involved in the care of COVID-19 patients.

We split the sample of frontline healthcare workers into two groups based on the *criteria*: if they were or were not a ffected by fake news in their professional activity. We compared these groups concerning stress, depression, anxiety, and also insomnia (Table 2).

The frontline medical workers who were declared to be a ffected by false news (N1 = 43) were significantly more stressed (*t* = 3.04, *p* < 0.001) than healthcare workers who are not a ffected by misinformation related to pandemic time (N2 = 83), and this result o ffers support for Hypothesis 1. The healthcare workers who are a ffected by infodemia (N1 = 43) feel more anxiety (*t* = 1.91, *p* < 0.05) than healthcare workers who are not a ffected by false news (N2 = 83), supporting Hypothesis 2. Regarding Hypothesis 3, we found no di fference in the level of depression between the frontline clinicians who are declared to be a ffected by false news (N1 = 43) and their colleagues who claim not to be a ffected by infodemia related to pandemic times (*t* = 1.54, *p* < 0.12). Consistent with Hypothesis 4, the frontline workers who are a ffected by misinformation su ffer more from insomnia (*t* = 1.89, *p* < 0.05) than healthcare workers who are not a ffected by the infodemia related to pandemic time (N2 = 83).


**Table 1.** Demographic and professional characteristics of frontline healthcare workers.

**Table 2.** Statistical indicators of differences.


Regarding the specific questions related to the false news impact on the frontline medical staff, we obtained the following results: 34% of frontline healthcare workers answered yes to the question: "Are you affected by false news in the course of your professional activity?".

The most common answers to the question: "In what way fake news affects you?" were: "The doctor-patient relationship is affected. People distrust doctors and the medical system because they are misled by fake news." (23% of the respondents), "It affects me emotionally." (30% of the participants), and "It creates confusion." (19% of the respondents).

The top three words found in the answers of the frontline healthcare workers regarding the question: "What is the word that best describes the media position (print, audiovisual, online press) regarding medical staff during the outbreak of COVID-19?" are: "appreciation", (33% of the respondents), "distorted" (33% of the participants), and "objectivity" (15% of the respondents).

## **5. Discussion**

The purpose of this research was to study if doctors and nurses who declared to be a ffected by false news show di fferent types of psychological consequences than healthcare workers who do not consider themselves to be a ffected by fake news related to the COVID-19 pandemic.

The results were concordant with our predictions. Firstly, we found that almost half of the participants were a ffected by false news in their professional activity. The general population has been overwhelmed with information about COVID-19, including incorrect information and false information. Medical misinformation has centered around key themes: food and beverages as "cures," hygiene practices, and medicines. Healthcare workers must take action by refuting or rebutting misleading health information and providing appropriate information [16].

As false medical news about the novel coronavirus spread across the world, healthcare workers found themselves in another battle, the second pandemic, an infodemic. As one study shows, the job of healthcare workers has changed. Academics need to publicly denounce wrongdoers and hold them accountable with scientific evidence in the battle with fake news during the outbreak of COVID-19 [17].

The COVID-19 pandemic is putting health systems and healthcare workers around the world under immense pressure. Besides treating patients with COVID-19, medical specialists need to battle with another enemy, fake news. The frontline medical workers who declared to be a ffected by false news believe that misinformation a ffects them in many ways, such as: "I am emotionally a ffected by fake news.", "The doctor-patient relationship is a ffected by false medical news; patients distrust their doctors." "It consumes time and energy to battle misinformation. It creates confusion. "People are scared, and it takes more time and energy from our part to calm them and explain scientific information.", "Communication with patients influenced by fake news is di fficult.", "It a ffects our professional reputation and credibility.", "It a ffects the general population's trust in the medical system and doctors. People who su ffer from time-sensible health problems are afraid to go to hospitals to ge<sup>t</sup> treatment. That makes our job harder. It is sad and problematic for all of us, the healthcare workers."

Secondly, the frontline doctors and nurses who were declared to be a ffected by false news were significantly more stressed than healthcare workers who are not a ffected by medical misinformation related to the pandemic. Previous studies concerning the psychological sequelae observed during the SARS COV-1 in the 2003 outbreak revealed that healthcare workers experienced acute stress reactions [18]. In 2020, as one study shows, since the declaration of the coronavirus outbreak as a pandemic, some healthcare workers from di fferent hospitals screened positive for moderate to extremely severe stress [19].

Work-associated stress affects healthcare workers, including doctors, nurses, auxiliary personnel, administrative staff, and other medical technicians. The three main work-related stress factors identified were: heavy workloads, the time-related pressure on the job, and extended working hours [20]. During a pandemic, frontline workers who are called upon to assist or treat those with COVID-19 may experience stress related to a physical strain of protective equipment, physical isolation, constant awareness, and vigilance regarding infection control procedures, pressures regarding procedures that must be followed [21]. Furthermore, as our study shows, frontline healthcare workers in Romania are influenced by false news and feel stress, among other psychological outcomes, in dealing with this particular factor concerning the public misinformation about the COVID-19 medical crisis.

Thirdly, the frontline medical workers who were declared to be a ffected by the infodemia felt more anxiety than healthcare workers who are not a ffected by false news related to pandemic time. The most frequently reported symptom during pandemic time is anxiety, both in the general population and medical sta ff. Many studies already demonstrated that frontline healthcare workers screened positive for moderate to severe anxiety during the outbreak of COVID-19. Before COVID-19, internet addiction was already recognized as a growing problem contributing to social anxiety, attention-deficit/hyperactivity disorder, and other wellness aspects, which may only intensify during a pandemic time [22].

Since the COVID-19 pandemic outbreak, the constant stream of information and fake medical news can be overwhelming for anyone, let alone clinicians already facing stressful challenges in their professional and personal lives [23]. False medical messages trigger feelings of fear and panic in public. When the message has an emotional impact, people are more inclined to share that information with family and friends. Despite our Government's efforts to communicate efficiently and disseminate medical information to the public, false news continued to spread much faster than the virus itself, leaving the medical community on the frontline of another battle, with misinformation and disinformation regarding the coronavirus crisis.

Finally, the frontline healthcare workers who are declared to be affected by misinformation suffer more from insomnia than healthcare workers who are not affected by false news related to pandemic time. Previous studies on emergency medicine specialists in Romania demonstrated that work-related stress symptoms, such as sleep disorders, play an essential role in the medical staff's mental health [24].

During a pandemic time, medical staff is placed under tremendous pressure, leading to many psychological reactions, including sleep disorders and low sleep quality, being present almost all the time [25,26]. A cross-sectional survey among healthcare workers treating patients with COVID-19 in China revealed that a significant proportion of participants experienced insomnia symptoms [27]. Having to face permanent dissemination of misinformation about the coronavirus, its treatments, evolution, impact, and even existence of the virus, the frontline medical workers felt the influence of this significant stress factor also, infodemia.

This research could be considered an initial attempt to integrate the false medical information stress-factor, among the other occupational stress causes during a pandemic time, which, to our understanding, is new and unique in Romanian frontline healthcare workers during the SARS COV-2 pandemic.

The results of this study should be evaluated, considering several limitations. One of the limits is the cross-sectional design. Our research cannot assess if there will be a change in variables over time. The relations found do not involve causal inferences between the studied variables. We attempted to compare the study groups concerning stress, depression, anxiety, and insomnia; further longitudinal research may contribute to a better understanding of ways in which the causality relationship regarding the false news effect on medical frontline healthcare workers and other psychological implications may occur. Another limit is the self-reported impact of the false news in the medical activity; the subjectivity of the cohort classification can be overcome in future research aiming at objective measurements of the false news factor. Despite the Romanian Strategic Communication Group's effort to present and explain in real-time, when possible, the false medical information that appeared in the Romanian media, separating false information from actual news can seem daunting and may influence our study variables.

Moreover, the sample size was too small. Further research with a larger sample, such as a nation-wide study, should be performed to gain a complete image of the fake news influence on doctors and nurses during the pandemic time. Longitudinal studies could further strengthen our conclusions and evidence of the relationships between fake news and different psychological outcomes Further research is needed to test a regression model of the study variables and factors that may be associated with the exposure to fake news in the medical and general population. Future research also may improve our knowledge of the impacts of false medical news, from efficient tools to discern between true and false content to better develop our cognitive reflection and overcome other psychological implications due to the exposure to false news in the COVID-19 pandemic.
