key: cord-341256-2j0tqmd4 authors: An, Ying; Yang, Yuan; Wang, Aiping; Li, Yue; Zhang, Qinge; Cheung, Teris; Ungvari, Gabor S.; Qin, Ming-Zhao; An, Feng-Rong; Xiang, Yu-Tao title: Prevalence of depression and its impact on quality of life among frontline nurses in emergency departments during the COVID-19 outbreak date: 2020-07-15 journal: J Affect Disord DOI: 10.1016/j.jad.2020.06.047 sha: doc_id: 341256 cord_uid: 2j0tqmd4 BACKGROUND: Frontline medical staff exposed to the novel coronavirus disease (COVID-19) could be psychologically and mentally exhausted. This study examined the prevalence of depressive symptoms (depression hereafter) and its correlates and the association between depression and quality of life (QOL) in Emergency Department (ED) nurses during the COVID-19 pandemic in China. METHODS: This national, cross-sectional online survey was conducted between March 15 to March 20, 2020 in China. Depression and QOL were measured using the 9-item Patient Health Questionnaire, and the World Health Organization Quality of Life Questionnaire-Brief Version, respectively. RESULTS: The overall prevalence of depression in 1,103 ED nurses was 43.61% (95% CI=40.68%-46.54%). Multiple logistic regression analysis revealed that working in tertiary hospitals (OR=1.647, P=0.009), direct patient care of COVID-19 patients (OR=1.421, P=0.018), and currently smoking (OR=3.843, P<0.001) were significantly associated with depression. After controlling for covariates, nurses with depression had an overall lower quality of life compared to those without (F((1,1103))=423.83, P<0.001). CONCLUSION: Depression is common among ED nurses during the COVID-19 pandemic. Considering the negative impact of depression on quality of patient care and nurses’ quality of life, a heightened awareness and early treatment of depression for frontline ED nurses should be provided. Frontline Emergency Department (ED) nurses exposed to the novel coronavirus disease could be psychologically and mentally drained, but the prevalence of depression in this population is still unknown. The overall prevalence of depression among 1,103 ED nurses was 43.61% (95% CI=40.68%-46.54%).  A heightened awareness and timely treatment of depression for frontline ED nurses should be provided in a timely fashion. In late 2019, the novel coronavirus disease was first found in China. On the 30 th January, 2020, the World Health Organization (WHO) declared COVID-19 a public health emergency of international concern (World Health Organization, 2020). In order to reduce the rapid transmission of the COVID-19 and to take care of confirmed and suspected patients, additional services, such as fever clinics and isolation infectious units, have been set up in emergency departments (ED) in many hospitals (National Health Commission, 2020) . ED nurses often face enormous psychological pressure due to overwhelming workload, long hours, shirt duties and working in a fast-paced and high-risk environment (Healy and Tyrrell, 2011; Hooper et al., 2010) . Nurses working in a such physically and emotionally challenging situation frequently experience fatigue, burnout, mental exhaustion, and emotional detachment (Boyle, 2011) . During the COVID-19 pandemic, frontline clinicians including nurses, especially those who have close contacts with infected patients, regularly experienced anxiety and depressive symptoms (depression hereafter), emotional breakdown and sleep disturbances due to the limited clinical knowledge of the new virus and the insufficient provision of protective gears and other medical supplies , which may lead to poor morale at work, absenteeism, apathy, and poor work performance leading to patient dissatisfaction (Portnoy, 2011; Vahey et al., 2004) . Since the outbreak of the COVID-19, some studies have examined the epidemiology of psychiatric problems in frontline clinicians. For instance, a recent cross-sectional study reported that the prevalence of depressive, anxiety, insomnia and non-specific distress symptoms was 50.4%, 44.6%, 34.0%, and 71.5%, respectively in frontline clinicians including nurses (Lai et al., 2020 (Li, 2016; Xi, 2017) . WeChat is a communication program employed by the Chinese Nursing Association for continuing education for all its members. In order to reduce disease transmission during the COVID-19 outbreak, face-to-face interview could not be adopted. To be eligible, participants should be: 1) adults aged 18 years or above; 2) frontline nurses working in ED during the COVID-19 outbreak; 3) able to understand Chinese and provide written informed consent. The study protocol was approved by the Ethics Committee of the University of Macau, China. Basic demographic information including gender, age, marital status, educational background, work experience, shift duty, living circumstances, rank (junior/senior), type of hospital (primary/tertiary), work place (inpatient/outpatient), current smoking status, and work experience during the 2003 SARS outbreak. Nurses were also asked three additional standardized questions whether 1) they were directly engaged in clinical services for patients with COVID-19; 2) their family, friends or colleagues were infected with the COVID-19; and 3) there were 500 or more confirmed COVID-19 cases in the province where they lived/worked. a 9-item self-report instrument, which is widely used in clinical settings. Each item is scored from 0 to 3, with the total score of 5 or more indicating "depression" (Kroenke et al., 2010) . A total score of 5-9 indicates "mild depression"; 10-14 "moderate depression", 15-19 "moderate-to-severe depression", and ≥20 "severe depression" (Kroenke et al., 2010) . The Chinese version of PHQ-9 demonstrated satisfactory psychometric properties (Cronbach"s alpha=0.89) (Chen, 2015; Leung et al., 2020) . Nurses" QOL was assessed with the sum of the first two items on overall quality of life derived from the World Health Organization Quality of Life Questionnaire-Brief Version (WHOQOL-BREF) (Harper et al., 1998) . Higher total scores indicate higher QOL (Skevington and Tucker, 1999) . The Chinese version of this scale has satisfactory psychometric properties (Fang, 1999 ). All the analyses were performed with the SPSS, Version 21.0. The normal distribution of continuous variables was examined by the Kolmogorov-Smirnov test. Demographic variables between the "Depression" and No-depression" groups were compared using the Chi-square tests, two samples independent sample t-tests, or Mann-Whitney U tests, as appropriate. To examine the independent demographic and clinical correlates of depression, multiple logistic regression analyses with the "Enter" method (i.e., entering all independent variables in the model simultaneously) was conducted. Depression was entered as the dependent variable, while all variables with a P value of <0.1 in the univariate analyses were the independent variables. Analysis of covariance (ANCOVA) was performed to compare the QOL between the two groups after controlling for variables with significant group difference in univariate analyses. Level of significance was set as P<0.05 for all tests (2-sided). A total of 1,103 frontline ED nurses met the study criteria and completed the survey. The demographic characteristics of the sample are shown in To the best of our knowledge, this was the first study that comprehensively examined the epidemiology and correlates of depression among ED nurses during the COVID-19 pandemic. Close to half (43.6%; 95% CI: 40.68%-46.54%) of the ED nurses suffered from depression, which is similar to the findings reported by Lai et al. (Lai et al., 2020) in Chinese frontline clinicians (50.4%). Another Chinese study using the same assessment tool found that 31.37% of frontline clinicians reported depression during the outbreak of COVID-19 (Zheng, 2020) . Using the PHQ (cut-off of 10), Cui (2019) found that the prevalence of depression in Chinese ED nurses was 29.1%. ED is an ever-changing, highly regulated workplace, dealing with patients in critical conditions (Lu et al., 2015) . ED nurses are responsible for a wide spectrum of clinical tasks, some of which may be life-threatening clinical situations and require immediate attention (Lu et al., 2015) . The high work pressure, low level of control and autonomy and perceived powerlessness as revealed in a free-flowing interview of ED nurses could account for the higher risk of depression and related health problems (Severinsson, 2003) . Besides, heavy workload, shift work, resuscitation and death were proven risk factors of psychological distress, particularly depression among ED nurses (Lim et al., 2010; Morrison and Joy, 2016; Winwood et al., 2006) . During the COVID-19 outbreak, ED nurses were more likely to experience excessive workload, fatigue, helplessness, and feared high risk of infection. These factors could also be associated with the reported high prevalence of depression in ED nurses. Nurses working in tertiary hospitals and those who looked after COVID-19 patients were more likely to suffer from depression. During the COVID-19 outbreak in China, 30 provinces, municipalities, and autonomous regions covering over a population of 1.3 billion initiated first-level responses to such a major public health emergency . Most tertiary hospitals in each province were designated as first-line emergency isolation hospitals/units to provide clinical services for suspected and confirmed cases of COVID-19 (National Health Commission, 2020). Compared to those in primary/community clinical settings, ED nurses in tertiary hospitals required to have more frequent close contacts with infected patients as they were responsible for triage and initial care. The nature of work assigned to ED nurses led to higher level of stress and fear, which subsequently resulted in higher rate of depression. Working in frontline clinical settings is an independent risk factor for poor mental health (Lai et al., 2020) . During the 2003 SARS outbreak in China, almost 90% of the frontline clinicians in high-risk clinical settings reported psychological symptoms (Chua et al., 2004) . Consistent with previous findings (Lai et al., 2020) , frontline nurses who engaged in clinical care of COVID-19 patients were at higher risk of depression in the current study. ED nurses were required to work longer hours than ever due to the huge number of patients during the COVID-19 outbreak. After long working hours, all ED nurses had 14 days of mandatory quarantine, which could further exacerbate their anxiety and guilt because of the social stigma conferred on to their families. Furthermore, ED nurses also experienced fear of getting infected and spreading the virus to their families and friends. All these factors could substantially increase the risk of depression. Similar to previous findings (Li et al., 2017; , current smoking was significantly associated with higher risk depression in this study. ED nurses had high-pressure jobs in clinical settings, and some of them may find smoking immediately relaxing despite of its long-term harmful effects. According to the distress/protection model of QOL (Voruganti et al., 1998) , QOL is determined by the interaction between protective (e.g., good social support and high socioeconomic status) and distressing factors (e.g., physical diseases and mental disorders). Considering the negative impact of depression on the quality of clinical practice and its symptom profile including hopelessness, helplessness, insomnia, cognitive impairment, and somatic complaints (Ivbijaro et al., 2019; Singleton, 2001) , it is reasonable to assume that depressed nurses are far more likely to have lower QOL than nurses without depression. In this study depressed nurses reported lower QOL than those without, which echoed previous findings (Malhi and Mann, 2018; Sjoberg et al., 2020) . The strengths of this study included the large sample size and the use of standardized instruments on depression and quality of life. However, there were several limitations. First, due to logistical reasons, some variables associated with depression, such as social support, collegial relationship, health status and pre-existing psychiatric disorders, were not examined. Second, because of the cross-sectional study design, the causal relationship between depression and other variables could not be examined. Third, more than 90% of the participants were female nurses, which may have biased the findings to an uncertain extent. In conclusion, depression is common among ED nurses during the COVID-19 outbreak. Considering the detrimental impact of depression on quality of life and quality of care (Ng et al., 2013) , health authorities should organize regular screening targeting depression, and develop preventive measures to alleviate the risk of depression by providing a timely provision of financial support, online psychological counselling service, and on-site psychological guidance as well as offering psychiatric treatment for vulnerable nurses directly engaged in the treatment and care of COVID-19 patients. 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