key: cord-0708752-bn98guai
authors: Roberts, N.J.; McAloney-Kocaman, K.; Lippiett, K.; Ray, E.; Welch, L.; Kelly, C.
title: Levels of resilience, anxiety and depression and in nurses working in respiratory clinical areas during the COVID pandemic
date: 2020-11-07
journal: Respir Med
DOI: 10.1016/j.rmed.2020.106219
sha: a884ba99d3f75d9c73bea69f23855c327677511d
doc_id: 708752
cord_uid: bn98guai

BACKGROUND: The delivery of healthcare during the COVID pandemic has had a significant impact on front line staff. Nurses who work with respiratory patients, have been at the forefront of the pandemic response. Lessons can be learnt from these nurses’ experiences in order to support these nurses during the existing pandemic and retain and mobilise this skilled workforce for future pandemics. METHODS: This study explores UK nurses’ experiences of working in a respiratory environment during the COVID-19 pandemic. An e-survey was distributed via professional respiratory societies the survey included a resilience scale, the GAD7 (anxiety) and the PHQ9 (depression) tools. Demographic data was collected on age, gender, ethnicity, nursing experience and background, clinical role in the pandemic, and home-life and work balance. RESULTS: Two hundred and fifty-five responses were received for the survey, predominately women (89%, 226/255), aged over 35 (79%, 202/255). Nearly 21% (40/191) experiencing moderate to severe or severe symptoms of anxiety. Similar levels are seen for depression (15.7%, 30/191). 18.9% (34/180) had a low or very low resilience score. Regression analysis showed that for both depression and anxiety variables, age and years of qualification provided the best model fit. Younger nurses with less experience have higher levels of anxiety and depression and had lower resilience. CONCLUSION: This cohort experienced significant levels of anxiety and depression, with moderate to high levels of resilience. Support mechanisms and interventions need to be put in place to support all nurses during pandemic outbreaks, particularly younger or less experienced staff.

The delivery of healthcare during the COVID pandemic has had a significant impact on front line staff. Nurses who work with respiratory patients, have been at the forefront of the pandemic response. Lessons can be learnt from these nurses' experiences in order to support these nurses during the existing pandemic and retain and mobilise this skilled workforce for future pandemics.

This study explores UK nurses' experiences of working in a respiratory environment during the COVID-19 pandemic. An e-survey was distributed via professional respiratory societies the survey included a resilience scale, the GAD7 (anxiety) and the PHQ9 (depression) tools. Demographic data was collected on age, gender, ethnicity, nursing experience and background, clinical role in the pandemic, and home-life and work balance.

Two hundred and fifty-five responses were received for the survey, predominately women (89%, 226/255), aged over 35 (79%, 202/255). Nearly 21% (40/191 ) experiencing moderate to severe or severe symptoms of anxiety. Similar levels are seen for depression (15.7%, 30/191) . 18 .9% (34/180) had a low or very low resilience score.

Regression analysis showed that for both depression and anxiety variables, age and years of qualification provided the best model fit.

Younger nurses with less experience have higher levels of anxiety and depression and had lower resilience.

Worldwide there is already more than 23 million cases of COVID-19 and more than half a million reported deaths from the virus, figures that are likely to rise as the pandemic continues [1] . The current coronavirus disease outbreak was declared a global pandemic by the World Health Organisation (WHO) on the 11th March 20201 [2] . The pandemic has since exerted a significant strain on the provision of healthcare, predominantly critical care and respiratory services. To provide additional support in the UK, the NHS has been asking retired staff and current nursing students to enter or return to clinical practice. Additionally, many staff have been retrained and redeployed to key clinical areas to support services during the pandemic [3] .

Nurses are the largest workforce within healthcare systems and are integral to management of a pandemic [4, 5] . this will be a significant worry for healthcare staff working in these areas.

A previous study of experiences of nurses during the middle east respiratory syndrome outbreak highlights staff experiencing burnout due to high volume of work and safety concerns about being infected [9] . A study in Korea looked at the same pandemic and showed that burnout in emergency nurses was influenced by job stress, poor treatment resources and poor support from family and friends. [10] A US study showed that the majority of nurses reported that they would work during a pandemic, this decreased when the perceived risks were higher, illness, or family member needed care. [11] In China and the US an overall lack of preparedness for the pandemic was reported regarding the provision of protective equipment and available training to use it [12] . Moore et al has shown that 35% of UK frontline workers needed support but did not feel able to ask for it, and 64% reported feeling anxious during April 2020. [13] J o u r n a l P r e -p r o o f Some of the first studies that have been published on the psychological impact of COVID-19 on patients as reported in the Lancet by highlighting the need for appropriate planning, co-ordination between services, timely and appropriate interventions and the presence of appropriately qualified staff. Stress levels were found to be higher for non-front line nurses and the general public than those working directly (front line nurses) with COVID patients, labelled as 'vicarious traumatization', possibly related to knowledge and confidence and the voluntary nature of those in the front line [14] . Liu (2020) discusses the merits of on-line resources to support practice, in particular counselling and psychological support services not available in previous pandemics [15] .

In a further study by Liu et al the mental health status of doctors and nurses are assessed, factors influencing increased stress include: middle age, divorce, being widowed or living alone, and being a nurse (compared to doctor) [16] . Currently, very few UK studies are available; Maben and Bridges (2020) reflect on the challenges of nurses working with COVID-19 patients in the USA, Italy and UK.

They highlight the importance of peer support in addition to leadership and also warn of the longer term psychological effects when there is a return to normal [17] . A recent Nursing Times survey highlighted 33% (n=3500) described their overall mental health and wellbeing as bad or very bad during the pandemic [18] . The NHS ideally needs to maximise support for nurses who are experiencing high levels of anxiety and stress during the pandemic [18] , in order to promote wellbeing, loyalty and value them as skilled professionals. In order to do this there is a need to explore further the experiences of front line nurses working in respiratory areas to be able to learn from these experiences, identify support needs and strategies that retain and mobilise this skilled workforce for future pandemics.

This cross-sectional survey study explored UK nurses' experiences of working in a respiratory environment during the COVID-19 pandemic in order to understand and explain the levels of resilience, anxiety and depression in nurses working with respiratory patients during the COVID-19

pandemic.

J o u r n a l P r e -p r o o f Characteristics about homelife and work balance were also included. Survey tools were piloted with a small group of nurses from the teams' network (academic, or registered nurses); minor changes were made to questions to enhance ease of understanding. Variable categories were collapsed for the regression analysis. All four independent variables (Age, years qualified, providing support to the household, undertaking aerosol generating procedures)

were entered into an initial regression with each dependent variable, and two further alternative models estimated to account for multi-collinearity between two independent variables.

As this was a survey study, consent was inferred following the provision of participant information at the start of the survey. Signposting to mental health advice and charities were included at the completion of the survey. All data collected was anonymised and any identifiable information was removed prior to analysis. Three models (shown in Table 4 ) were designed to assess the variables which would predict depression score (>10 equating to moderate depression), one with all four predictors entered, and due to moderate multicollinearity between age and years of qualification (r =0 .70) two separate models were estimated with each independent variable entered separately. Examination of the Nagelkerke R square value indicates that model one, which included both age and years of qualification, was the best fitting, although age was not significantly associated with depression, it was shown that the ability to provide support to the household (financial, heat, food, emotional)

was important in all three models (p<0.01). Consistently supporting the household is a significant predictor of scoring above the threshold for depression. In model 1, individuals who reported difficulties in support in the household had over 5 times greater odds of meeting the criteria for depression, while those qualified for 20 years or more had significantly lower odds of meeting the criteria for depression.

For predictors of anxiety, three models (Table 5) were estimated, as age and years of qualification have some multicollinearity. Examination of Nagelkerke R squared indicated model 1 and 3 to be the best fitting models, which both included age. Across all three models there was a consistent association between scoring above the threshold (>10) for anxiety and support in the household, those indicating difficulties in household support had over 6 times greater odds of meeting the criteria for anxiety than those with no such difficulties. In the absence of age (model 2) as an J o u r n a l P r e -p r o o f 9 independent variable, those qualified over 20 years were significantly less likely to score about the threshold for anxiety; and when only age is considered (model 3) those in the age groups 35 -50 and older than 50 were less likely to meet the criteria for anxiety. However, in model 1 when both variables are included only age is significant, with individuals aged 35 -50 significantly less likely to score above the threshold for anxiety. Undertaking aerosol generating procedures had no significant association with anxiety and depression scores across any of the models.

This study set out to understand and explain the levels of resilience, anxiety and depression in nurses working with respiratory patients during the COVID-19 pandemic. Resilience can be described as an individual's ability to 'bounce back' in difficult circumstances [24] . It has been shown to be important in the ability to cope in crisis situations, such as the COVID-19 pandemic. promote and support resilience in the nursing workforce, will be a key attribute to any future pandemic planning. However, resilience is not solely a personal experience, or influenced only by employment. Resilience has been shown to be influenced by some personal characteristics (home ownership, siblings, commute, working relationships) as well as environmental factors (social support, role model) [27] .

Sul et al [28] has shown that resilience increases with age, and job banding, the average resilience scores were moderate, suggesting that individuals at this level may possess some of the characteristics of resilience but these need strengthening (Wagnild RS14 [31] .

Just over half of respondents in this study experienced minimal symptoms of anxiety or depression.

Approximately 20% experienced moderate-to-severe anxiety symptoms and 17% experienced moderate-to-severe depression symptoms higher than normative anxiety levels in the general public and general medical practice [20] , and higher than levels reported in the general population [32] .

However a large proportion of the nursing population has already been shown to have mental health issues [33] . Participant age, years of experience and providing support to their household were all identified as key variables in the regression analysis for predicting depression and anxiety. There is still a significant proportion of the participants who experienced moderate to severe symptoms of anxiety or depression and 12.4% of participants who could not support their household in terms of heat, food and emotional support. The regression analysis identified age and years of experience were important predictors of anxiety and depression identified. The ability to provide support to the household was important in of the models (p<0.01).

The findings suggest that age and experience are significant indicators in predicting anxiety and depression symptoms. Those people who responded between the age of 35-50 were less likely to score above the threshold (>10) for anxiety and depression. This is reflected in the experience of the respondents. As individuals younger than 35 would not be able to accrue more than 20 years post qualification, and individuals aged over 50 more likely to have more time to accrue specialist respiratory skills and knowledge.

Supporting employees in the workplace, listening and acting on genuine family concerns, particularly during pandemic and crisis situations, can enhance front line experiences and enable confidence in employers. Therefore , healthcare leaders need to consider how to support healthcare workers during the pandemic, to reduce emotional distress and risks staff have taken [34] . The COVID-19

pandemic has enabled many people to work remotely to prevent unnecessary cross-infection, however the lack of visibility of management has been highlighted by some [35] . Healthcare managers and leaders do have a responsibility to support work life balance initiatives, to enhance clinical resilience in the workplace and need to signpost staff to existing and new interventions and support mechanisms.

This study represents a good representation of nurses working in respiratory clinical contexts.

However, it is limited by the lack of breadth of ethnicities and age-groups working in these areas.

The demographics are similar to that of the study carried out on the workforce by the British J o u r n a l P r e -p r o o f thoracic society [36] . This analysis is part of a programme of work looking at other components of the survey, a mixed methods paper is underway examining some of the other components of the survey, such as the provision of PPE and the mental health provisions and support provided during the first few months of the pandemic. This is just one snapshot of the pandemic and it is planned to survey this population of nurses working in respiratory clinical areas again if there is a significant wave of infections and hospitalisations in the future. Unfortunately, we do not plan to match the population as we felt it was unethical to repeatedly sample the same group working under significant pressures at the peak of the pandemic.

The nurses who responded however were overall fairly resilient, as many of this particular group were older and with significant nursing experience. However, a proportion experienced significant symptoms of anxiety or depression and some experienced difficulties providing support to their households. This study explored short-term resilience, but did not examine burnout which looks at the impacts of prolonged stress and physical exhaustion.

It is important that we continue to support our healthcare professionals to improve and maintain levels of resilience and reduce anxiety and depression. In part this can be done by informing appropriate organisations, NHS management and professional bodies to implement interventions and programmes to support employees. There is an urgent need to develop evidence based selfhelp interventions to improve and support those working on the front line during the COVID pandemic [37] .

Psychological support needs to be available in a variety of formats which is tailored to the individual's needs. The support can be via phone, internet or forms as well as support groups and information leaflets and other reading materials but it needs to be flexible to allow tailoring for the individual [38] [16] [39] . In addition to psychological support, and in order to be pandemic prepared, resilience training could be offered. Resilience training has been researched before the pandemic with positive effects after the SARS epidemic. The training showed that participants felt better able to cope after the session [40] .

Some of these types of interventions have been put in place as part of the response to COVID, however as expected public NHS mental health services are really overstretched at the moment because of increased need.

J o u r n a l P r e -p r o o f 25 ^ = threshold for depression a score above 10 OR, odds ratio; CI, confidence interval; *P < 0.05 **P<0.001 a Adjusted ORs: model includes all significant predictors identified in univariate analysis; Wald reported to three significant places Anxiety ^ J o u r n a l P r e -p r o o f Table 5 Influence of key variables on anxiety ^ ^ = threshold for anxiety a score above 10 OR, odds ratio; CI, confidence interval; *P < 0.05 **P<0.001 a Adjusted ORs: model includes all significant predictors identified in univariate analysis; Wald reported to three significant places 

Coronavirus Disease (COVID-19) Situation Reports

WHO declares COVID-19 a pandemic

Challenges for NHS hospitals during covid-19 epidemic

Nurses' experiences of ethical preparedness for public health emergencies and healthcare disasters: A systematic review of qualitative evidence

Life in the pandemic: Some reflections on nursing in the context of COVID-19

Hopelessness, helplessness and resilience: The importance of safeguarding our trainees' mental wellbeing during the COVID-19 pandemic

At least 100 UK healthcare workers have died from coronavirus, figures show | World news | The Guardian

SARS-CoV-2 and viral sepsis: observations and hypotheses

Working experiences of nurses during the Middle East respiratory syndrome outbreak

Factors Influencing Emergency Nurses' Burnout During an Outbreak of Middle East Respiratory Syndrome Coronavirus in Korea

Nurses' ability and willingness to work during pandemic flu

Protecting Health Care Workers Against COVID-19-and Being Prepared for Future Pandemics

Acute Depression, Extreme Anxiety, and Prolonged Stress among COVID-19 Frontline Healthcare Workers

Vicarious traumatization in the general public, members, and nonmembers of medical teams aiding in COVID-19 control

Online mental health services in China during the COVID-19 outbreak

Associated With Mental Health Outcomes Among Health Care Workers JAMA Network Open

Covid-19: Supporting nurses' psychological and mental health

Exclusive: Nursing Times survey reveals negative impact of Covid-19 on nurse mental health | Nursing Times

A brief measure for assessing generalized anxiety disorder: The GAD-7

Validation and utility of a self-report version of PRIME-MD: The PHQ Primary Care Study

Aerosol generating procedures

A simulation study of the number of events per variable in logistic regression analysis

Resilient Individuals Use Positive Emotions to Bounce Back From Negative Emotional Experiences

Reliability and validity of the Italian version of the 14-item resilience scale

The resilience scale user's guide: For the US English version of the Resilience Scale and the 14-item Resilience Scale (RS-14)

Personal characteristics and behavioral factors that promote resilience among nurses: a cross-sectional study

Resilience of health-care workers in the UK; A cross-sectional survey

Association between demographics and resilience -a cross-sectional study among nurses in Singapore

Burnout and Resilience Among Neurosciences Critical Care Unit Staff

Resilience in nurses: An integrative review

Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population

The mental health of nurses in the UK

Preserving Organizational Resilience, Patient Safety, and Staff Retention during COVID-19 Requires a Holistic Consideration of the Psychological Safety of Healthcare Workers

As a nurse, my hospital's leaders frighten me more than Covid-19 -STAT

Correction: Evaluation of the current landscape of respiratory nurse specialists in the UK: Planning for the future needs of patients

Urgent need to develop evidence-based self-help interventions for mental health of healthcare workers in COVID-19 pandemic

Care for the psychological status of frontline medical staff fighting against COVID-19 | Clinical Infectious Diseases | Oxford Academic

COVID-19: Emerging compassion, courage and resilience in the face of misinformation and adversity

Resilience training for hospital workers in anticipation of an influenza pandemic