key: cord-0765663-j8n8auoi
authors: Hong, Su; Ai, Ming; Xu, Xiaoming; Wang, Wo; Chen, Jianmei; Zhang, Qi; Wang, Lixia; Kuang, Li
title: Immediate Psychological Impact on Nurses working at 42 Government-Designated Hospital During COVID-19 Outbreak in China: a cross-sectional study
date: 2020-07-19
journal: Nurs Outlook
DOI: 10.1016/j.outlook.2020.07.007
sha: 1101107a7898af5a5b3b984242f185e82bd4b04d
doc_id: 765663
cord_uid: j8n8auoi

BACKGROUND: During an epidemic of a novel infectious disease, frontline nurses suffer from unprecedented psychological stress. This study aimed to assess the immediate psychological impact on frontline nurses in China. METHODS: A multi-center, cross-sectional survey of frontline nurses was conducted via online questionnaires. Symptoms of depression, anxiety, somatic disorders and suicidal ideation were evaluated. Demographic, stress and support variables were entered into logistic regression analysis to identify the impact factors. RESULTS: Of the 4692 nurses who completed the survey, 9.4% (n=442) were considered to have depressive symptoms, 8.1% (n=379) represented anxiety, and 42.7% (n=2005) had somatic symptom. 6.5% (n=306) respondents had suicidal ideation. CONCLUSIONS: The study showed that the overall mental health of frontline nurses was generally poor during COVID-19 outbreak, and several impact factors associated with nurses’ psychological health were identified. Further research is needed to ascertain whether training and support strategies are indeed able to mitigate psychological morbidities.

friends, and neighbors of healthcare workers lead to disruption of interpersonal relationship, which could be another influence factor that induces psychological morbidity among healthcare workers. These mental health problems not only affect the healthcare workers" attention, understanding, and decision-making ability, which might hinder their work performance and long-term overall wellbeing. Protecting the psychological wellbeing of these healthcare workers is thus important for control of the epidemic and their own health.

The National Health Commission has issued guiding principles for emergency psychological crisis intervention for people affected by COVID-19, emphasizing the importance of strengthening medical staff"s psychological crisis intervention and counseling (National Health Commission of China). To provide better psychosocial support to healthcare workers and to strike a balance between the personal wellbeing and professional obligations, it is crucial to understand their psychological status during the outbreak.

In clinical settings, nurses have longer contact time and more frequent physical contacts with the patients, which means heavy workload and high possibility of cross-transmission. To date, studies about psychological status of nurses during COVID-19 outbreak are scant. In this study, staff nurses working in the 42 designated hospitals who were responsible for tackling the local outbreak were recruited for assessment. The purpose of this study was to determine the prevalence and type of psychological morbidity among the frontline nurses in relation to the COVID-19 outbreak and the influence factors.

This study was a multi-center, cross-sectional survey, using a convenience cluster sampling method. Chongqing is a municipality bordered by the province of Hubei to the east.

During the outbreak, 42 hospitals were designated to treat patients with the COVID-19 in Chongqing. Participants were recruited from these hospitals from February 8 to 14, 2020, two weeks after the authority in Wuhan suspended all public transport on January 23. The inclusion criterion was registered nurse working in frontline for the COVID-19, such as isolation wards, intensive care units, emergency departments, respiratory wards, infectioncontrol office, and fever clinics. Those working in departments providing indirect support were excluded. A total of 4738 nurses participated in this study.

The study was approved by the institutional ethics board of First Affiliated Hospital of Chongqing Medical University. After receiving permission from participated hospitals, data were collected by anonymous online questionnaires which were distributed to all nurses in participated hospitals via WeChat (the most widely used all-in-one messaging app in China).

Only one response per account to the questionnaire was permitted. The survey explicitly stated the purposes of the study and notified the participants that they provided informed consent when they accepted filling out the anonymous survey.

A structured self-administered questionnaire consisted of four parts was employed to conduct the survey.

Seven items were designed to collect participants" basic demographic information, including sex, age, marital status (single/married), educational level, years of working, department (isolation ward/non-isolation ward), exposure to COVID-19 patients (yes/no) was collected.

The participants were asked about their perceptions and attitudes towards COVID-19.

These included subjective health status assessments during the COVID-19 epidemic (poor/fair/good); the possibility of being infected (none/low/high); willingness to work in a COVID-19 designated ward (yes/no).

Two dichotomous questions (yes/no) were asked about participants" experiences during COVID-19 outbreak, including: whether a family member or neighbor of the participant had been infected; whether the participant had encountered COVID-19 discrimination.

A job-related stress severity scale developed for frontline healthcare workers in Severe Acute Respiratory Syndrome (SARS) outbreak (Tam, Pang, Lam, & Chiu, 2004 ) was employed. The scale consisted of 14 dichotomic (yes/no) items regarding subjective jobrelated stress during COVID-19 outbreak (e.g., risk to own health; interference with home life, etc.). In the current study, Cronbach"s alpha was 0.78. The total scores of 4 and 9 represent cutoff for low, medium, and high stress respectively.

This part consisted of 6 dichotomous questions (enough/not enough) about perceived adequacy of social support, including support from family, colleagues, hospital authority, patients, insurance and compensation, mass media.

Three instruments were employed to evaluated participant"s psychological status.

Patient Health Questionnaire-9 (PHQ-9) was used to assess the depression symptoms (Kroenke, Spitzer, & Williams, 2001) . Based on a five-point Likert-type scale from "not at all" (0) to "extremely" (4), participants were asked to indicate how often they had been bothered by the symptoms over the past 2 weeks. The Cronbach"s alpha of the PHQ-9 is 0.86 (W. . The total score of the PHQ-9 ranged from 0 to 27. A cutoff total score of 10 has been recommended for diagnosis of major depression, which provides adequate sensitivity (74%) and specificity (91%) (Arroll et al., 2010) . The ninth item of PHQ-9 was used as a measure of suicidal ideation (thoughts that you would be better off dead, or thoughts of hurting yourself in some way).

Generalized Anxiety Disorder 7-item Scale (GAD-7) was used to evaluate anxiety disorders (Spitzer, Kroenke, Williams, & Löwe, 2006) . The GAD-7 assess the frequency of anxiety symptoms over the past two weeks on a 4-point Liker-scale ranging from 0 (never) to 3 (nearly every day). The Cronbach"s of the GAD-7 is 0.82 (L. Wang, Lu, Ding, Hu, & Li, 2014) . The total score of GAD-7 ranged from 0 to 21, with increasing scores indicated a more severe functional impairments as a result of anxiety. In this study, a cutoff total score of 10 was defined as the presence of anxiety symptoms (Kroenke, Spitzer, Williams, Monahan, & Löwe, 2007) .

The Patient Health Questionnaire Somatic Symptom Severity Scale-15 (PHQ-15) was applied to assess somatic symptoms (Kroenke, Spitzer, & Williams, 2002) . The Scale consists of 15 items that asks whether somatic symptoms, such as stomach pain or dizziness, were present in the last 4 weeks and the severity (response categories of "not bothered at all," "bothered a little," and "bothered a lot"). The Cronbach"s alpha coefficient of PHQ-15 is 0.83 (Zhang et al., 2016) . With a cutoff total score of 6 or more, the sensitivity of the PHQ-15 was 78% and specificity was 71% (Van Ravesteijn et al., 2009) .

The participants were also asked whether they currently needed the help of a mental health professional; whether they felt it necessary to participate regularly in individual or group counseling during the outbreak.

Data were analyzed using SPSS 26.0 for Mac (SPSS, Chicago, IL). Descriptive statistics was applied to the general characteristics and study variables. Groups were compared using the Chi-square analysis, t-test and one-way ANOVA according to the characteristics of the variable being examined. Variables with P value < 0.05 in univariate analyses were subjected to multivariable logistic regression analysis with a stepwise forwards elimination procedure.

Four thousand eight hundred and thirty-eight nurses completed the online questionnaire;

146 questionnaires with a logic mistake (e.g., age>80 yrs) or non-response items ≥10% were excluded, and 4692 nurses" questionnaires were included in the final analysis. Details of the respondents" demographic information are shown in Table 1 .

The overall prevalence of depression, anxiety, and somatic symptoms were 9.4% (n=442), 8.1% (n=379) and 42.7% (n=2005), respectively. The three most common symptoms were "feeling tired or having low energy" (n=2978), "pain in arms, legs or joints" (n=2213), "shortness of breath" (n=1981). 6.5% (n=306) of respondents reported suicidal ideation. 3556 (75.8%) respondents believed it was necessary to participate regularly in individual or group counseling during the outbreak, 363 (7.7%) respondents reported they currently needed the help of a mental health professional. Characteristics associated with psychological morbidities were depicted in Table 2 .

Logistic regression showed that being married (OR=0.74) was a protective factor for depression. Education below baccalaureate degree (OR=1.26) and family member not infected (OR=0.31) were shown to be a risk factor and a protective factor of anxiety, respectively. Female gender (OR=1.79) and education below baccalaureate degree (OR=1.14)

were risk factors of somatic symptoms. In the analysis of suicidal ideation, poorer subjective health (poor: OR=7.56; fair: OR=3.38), not enough support from family (OR=2.05) or hospital authority (OR=1.54), and less opportunities for reflecting opinions through mass media (OR=1.47) were shown to be risk factors. Family member not infected (OR=0.15) and lower job-related stress (low: OR=0.40; medium: OR=0.61) had protective effects on suicidal ideation (Table 3) .

The outbreak of COVID-19 in Wuhan provoked an overwhelming public health response and concerns with infection control during the beginning of 2020. Nurses working in the hospitals officially designated for the patients diagnosed or suspected with COVID-19 have been and are under extreme physical and psychological stress. This multi-center survey showed that the rate of depression, anxiety, somatic symptom was 9.4%, 8.1%, 42.7% respectively, and 6.5% (n=306) respondents had suicidal ideation. Many studies comparing psychological wellbeing across different occupational roles showed that nurses were more likely to have poorer outcomes in handling infectious disease outbreaks than other healthcare workers (Koh et al., 2005; Maunder et al., 2004; Nickell et al., 2004; Tam et al., 2004; T. W. Wong et al., 2005) . However, the rate of depression and anxiety in this study was lower compared with that found in medical staff (including nurses) working in Wuhan during the same period (Chen et al., 2020; Zhu et al., 2020) . Despite of the different measurements used in these studies, the differences may mainly due to the situations that participants were facing.

As the epicenter of COVID-19, healthcare workers in Wuhan were experiencing more panic, distress and heavier workload.

It should be noticed that there was an extremely high prevalence of somatic alteration among frontline nurses during the outbreak compared to Chinese nurses in non-COVID times . The decreased psychosomatic health of nurses will also generate a negative influence on healthcare performance (Gu et al., 2019; Johnson et al., 2018) . In this study, female gender was one of the risk factors of somatic symptoms, which is consistent with previous studies (Barsky, Peekna, & Borus, 2001; Halbreich & Kahn, 2007) . Therefore, there is an urgent need of strengthen labor protection for women in special periods.

Among the sociodemographic characteristics, the common risk factor for acute anxiety and somatization was lower educational level. The importance of preparedness, in terms of either specialized training or previous experience working during a crisis was highlighted in previous studies. It has been proved that nurses who were confident in their infection control knowledge and skills had lower stress levels than those who felt less prepared. Moreover, nurses perceived inadequate training were more likely to experience burnout, posttraumatic stress symptoms, and longer continuing perceived risk even after the crisis (Maunder et al., 2006) . The knowledge about handling infectious disease outbreaks and accurate updates about the COVID-19 outbreak should be provided to nurses in order to address their sense of uncertainty and fear (Wong, Wong, Lee, & Goggins, 2007) .

These results showed vulnerable perceived health status was a predictor of poor psychological wellbeing. It should be noted that poor mental health may bias the estimates, and the correlation between perceived risk and mental health symptoms may be bidirectional. Therefore, treatment of the distress symptoms, or cognitive behavioral approaches designed to alter the negative thinking patterns, may be helpful in improving mental health symptoms and potentially lessening risk estimates. Specialized training may be helpful to decrease nurses" negative perception and thus lead to more positive outcomes (Styra et al., 2008; Wu et al., 2009) .

In this study, occupational stressors during the outbreak were shown to be associated with even poorer mental health outcomessuicidal ideation. Similar findings have been reported in studies on the H1N1 and SARS pandemics, which showed that staffs in infected wards and fever clinics experienced more serious anxiety, fatigue, and higher posttraumatic stress symptoms than those in low-risk work environments (Brandt, F Rabenau, Bornmann, Gottschalk, & Wicker, 2011; Matsuishi et al., 2012; Maunder et al., 2004; McAlonan et al., 2007) . Other job-related stressors included high workload, being quarantined, impaired work ability was also shown to be significantly associated with poor mental health. On the other hand, there has been researches suggesting that healthcare workers experience positive effects such as personal growth, sense of achievement, and a better appreciation for life (Rubin et al., 2016; West et al., 2008) . It may be useful for preparatory training and interventions to encourage nurses to focus on the potential positive impact and take positive coping strategies during the humanitarian work.

Besides occupational factors, social factors are significantly related to nurses" psychological wellbeing. Poor perceived support from both family and hospital authority were shown to be important risk factors against poor mental health. Married nurses could receive more support from family, which decreased the risk of depression. Being discriminated against was also associated with psychological morbidities in nurses. During the epidemic, healthcare workers were labelled as the source of infection. Discrimination and stigmatization increased the isolation of the nurses, and even had potentially long-term effects on individuals" psychological well-being (Liu et al., 2012; Robertson, Hershenfield, Grace, & Stewart, 2004) . Although few studies discussed the effect of supportive mass media, we found that less opportunities for reflecting opinions through mass media were associated with nurses" distress. Frontline healthcare workers need more encourages and constructive feedback from the public.

In this study, nurses who had family members infected presented a significantly increased risk of anxiety and suicidal ideation. Administrators should provide better psychosocial support to nurses and to strike a balance between professional obligations and family responsibilities of nurses. Interestingly, except for "family members not infected", all of the influencing factors of suicidal ideation were subjective perception towards stress and support.

Subjective perceptions regarding the risk can differ widely among individuals with objectively similar levels of danger exposure. These subjective perceptions may be more strongly associated with an individual"s subsequent psychological morbidity (Gallacher, Bronstering, Palmer, Fone, & Lyons, 2007; Marshall et al., 2007) . 

This study showed that the overall mental health of frontline nurses was generally poor during COVID-19 outbreak, and several impact factors associated with nurses" psychological health were identified. In the face of such a sudden disaster as COVID-19, it is important to pay attention to nurses" mental health conditions while fulfilling their responsibilities. Further research is needed to ascertain whether training and support strategies are indeed able to mitigate psychological morbidities. 

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