key: cord-1005972-q6eugxnu authors: Blanco-Daza, Mónica; de la Vieja-Soriano, María; Macip-Belmonte, Susana; Tercero-Cano, María del Carmen title: Posstraumatic stress disorder in nursing staff during the COVID-19 pandemic() date: 2022-02-21 journal: Enferm Clin (Engl Ed) DOI: 10.1016/j.enfcle.2021.10.006 sha: f9a1210672d9f0eac0a613d4c40858f90388e569 doc_id: 1005972 cord_uid: q6eugxnu AIM: To analyse the prevalence of post-traumatic stress disorder (PTSD) in nursing staff and the variables that may contribute to its development. METHOD: Cross-sectional study using a self-administered questionnaire given to nurses, nursing assistants and nursing supervisors in June 2020. It included sociodemographic, mental health, occupational, COVID-19 related variables, Modified Risk Perception Scale (modified RPS) score, Brief Resilience Scale (BRS) and Davidson Trauma Scale (DTS) score for the assessment of PTSD. Descriptive, bivariate, and multivariate analyses were performed. RESULTS: Of the 344 participants, 88.7% were women and 93.6% cared for infected patients; 45.9% had PTSD (DTS≥40). The variables associated with PTSD were previous PTSD symptoms (OR=6.1, 95% CI [2.68-14.03]), death of a family member or friend due to COVID-19 (OR=2.3, 95% CI [1.22-4.39]), and higher scores on the modified RPS (OR= 1.1, 95% CI [1.07-1.31]). Higher BRS scores were associated with a lower risk of PTSD (OR=0.4, 95% CI [0.31-0.68]). CONCLUSIONS: The prevalence of PTSD in nursing staff is high, mainly in professionals with previous PTSD symptoms, family members or friends deceased from COVID-19, high risk perception and/or low resilience. The first case in Spain of the new SARS-CoV-2 coronavirus (COVID-19) was diagnosed on 31 January, and the number of infections has increased exponentially and continuously. In June 2020, Spain was one of the most affected countries in Europe with more than 240,000 cases. 1 This scenario caused the healthcare system to be overwhelmed, and contingency plans had to be implemented. In particular, the psychological wellbeing of nurses and nursing care technicians (NCT), as they are on the front line, has been affected even though they are used to dealing with critical situations. 2 Caregiving during stressful events such as epidemics poses a significant risk for the development of post-traumatic stress disorder (PTSD). 3, 4 DSM-5 defines PTSD as the characteristic clinical picture of victims who have been exposed to traumatic events and whose symptoms are of intrusion, avoidance, negative cognitive and emotional alterations, and disturbances in arousal and reactivity. The duration of symptoms must be longer than one month. 5 PTSD poses a risk to personal and occupational health, and interpersonal relationships. Moreover, up to 75% of people diagnosed with PTSD will have another associated psychiatric disorder, including anxiety and depression. 6 Studies undertaken in epidemics like the current situation have described high prevalence rates of PTSD in healthcare workers. In Taiwan, 33% of nurses in severe acute respiratory syndrome (SARS) units had PTSD, compared to 19% in non-SARS units. 3 In Korea, during the Middle East Respiratory Syndrome (MERS) outbreak, PTSD was reported in 51.5% of healthcare workers. 4 In the current COVID-19 outbreak, the prevalence of PTSD in healthcare workers varies from 9.1% 7 reported in China to 52.8% in Italy. 8 In Spain, Luceño-Moreno et al. 2 found that 56.6% of healthcare workers had PTSD. The main risk factors associated with PTSD in healthcare workers were female sex, being a nurse, having a lower level of education, and concern about infecting people living with them. 2,9---11 On the other hand, resilience was a protective factor. Healthcare workers with greater resilience had a lower prevalence of anxiety, depression, and burnout. 2, 9 Despite the recommendations made during the pandemic aimed at protecting mental health, due to its magnitude, it is likely that there are psychological consequences for nurses. The main objective of the study was to analyse the prevalence of PTSD in nursing staff one month after contingency measures ended in a tertiary level hospital, and the secondary objective was to analyse the variables that could contribute to the development of PTSD in nursing staff. We designed a descriptive cross-sectional study in which 377 nursing professionals (nurses, NCT and nursing supervisors) from the Hospital 12 de Octubre in Madrid were included from 15 June to 15 July 2020 by convenience sampling. This referral hospital for the southern area of Madrid has 1,368 beds and is defined as a highly complex hospital (level III). Adult and paediatric departments of the entire hospital were included in the study: inpatient units, surgical services, intensive care units, emergency, dialysis, and endoscopy. The inclusion criteria were to have consented to participate in the study and having worked in the hospital between 1 March and 15 May 2020 (ending of contingency measures). Exclusion criteria were not having fully completed the Davidson Trauma Scale (DTS) or having been on sick leave for 60 days or more, as this was considered insufficient exposure to the stressors specific to nursing work during the pandemic. The sample size was calculated based on the percentage of PTSD in nurses (28.4%) as described by Su et al. during the SARS outbreak in Taiwan. 3 Based on the population of 3,149 nurses in the hospital, a minimum sample size of 335 subjects was estimated with a 95% CI and a margin of error of 5%, assuming a loss rate of 15%. For the data collection, an ad hoc anonymous paper form was drafted and piloted by 10 professionals representative of the sample, which collected the following data: • 14 The scale assesses the ability to recover from adversity, with a Cronbach's alpha of .83 in its Spanish version. It is a self-administered scale with 6 items formulated positively (items 1, 3, 5) and negatively (items 2, 4, 6). Likert-type responses range from 1 (strongly disagree) to 5 (strongly agree). The sum of the items ranges from 6 to 30 points. For interpretation, the scores of negative items should be reversed (1 would be 5, 2 would be 4, etc.). The scores are then added and divided by 6 to find the mean. The higher the score, the higher the resilience. 12, 14 • Data relating to the DTS: devised in 1997 by Davidson et al. to assess PTSD symptoms, 15 and translated and adapted to Spanish, showing adequate reliability and validity. 16 This is a self-administered scale consisting of 17 items that quantify the frequency and severity of a series of symptoms grouped into categories according to the criteria established in DSM-4 for PTSD. The time reference is the previous week. Each item is rated from 0 to 4 on a frequency scale and on a severity scale (0 = never or no severity, 4 = daily or extreme severity) generating two scores. The sum of the two is the total score, which ranges from 0 to 136. A score of 40 is the cut-off used to diagnose PTSD. 16 The study began following approval by the Research Commission of the Hospital Universitario 12 de Octubre (TP20/0144). The research team contacted each of the nursing supervisors of the units involved in the study and explained in detail both the objective of the study and the methodology for data collection. One month after contingency measures ended, each supervisor was given alphanumerically coded forms to guarantee the confidentiality of the participants. They distributed these forms to staff in their units who had given their consent to participate in the study. They then kept them until the research team collected them to be tran- The results were processed statistically using the IBM ® SPSS v25 software package. Qualitative variables were described by frequencies and percentages and quantitative variables by median and interquartile range, because after performing the normality test using the Kolmogorov-Smirnov test we observed that the sample did not follow a normal distribution. Differences were compared with non-parametric statistical tests: 2, Mann-Whitney U test and Spearman correlation. To analyse the impact of the different variables on onset of PTSD, initially we performed a bivariate binary logistic regression, followed by a multivariate regression using the backward stepwise method (Wald). For this purpose, the variables that obtained a p-value of less than .25 were included, in addition to the variables sex and age. The statistical and inferential analysis was performed establishing a 95% CI and a statistical significance level of p < .05. We received 377 of the 470 questionnaires submitted, with a response rate of 80.2%. Thirty-three were rejected as they met the exclusion criteria (29 due to incomplete completion of the DTS scale and 4 due to sick leave of 60 days or more). Eventually, 344 questionnaires were included in the analysis. Of the 344 participants, 305 (88.7%) were women, with a median age of 41 years [34-50]. The sociodemographic and mental health characteristics of the sample are presented in Table 2 . In this study, 322 professionals (93.6%) cared for infected patients, and their distribution by unit is shown in Fig. 1 . Work and COVID-19 characteristics are presented in Table 3 . The items of the RPS are presented by percentages in (Tables 2 and 3 ), this therefore suggests that they might have PTSD. The analysis to find associations between onset of PTSD (DTS ≥ 40) and the other variables showed statistically significant differences as presented in Tables 2 and 3 . No statistically significant difference was found between onset of PTSD and the work unit (Fig. 1) . A statistically significant, moderate, and inversely proportional linear relationship was found between the BRS score and the DTS score (r = -.410, p < .001). A statistically significant, moderate, and directly proportional linear relationship was also found between the DTS score and the modified PRS score (r = .423, p < .001). After including the variables in the binary logistic regression model (Table 5 ), the following variables showed an impact on the development of PTSD using the multivariate model: having PTSD symptoms in the month prior to answering the questionnaire (OR = 6. (Fig. 2 ). The results show that nurses had a high prevalence of PTSD (45.9%) one month after contingency measures had ended. Similar figures have been reported in healthcare professionals in areas where the pandemic has been particularly severe, such as northern Italy (52.8%) 8 or Madrid (56.6%), 2 with nurses showing the highest prevalence, 2, 17, 18 and this professional category is described as a risk factor for development of PTSD. 17 We should exercise caution when comparing the different studies due to the variability of the instruments used. In terms of socio-demographic characteristics, the professionals educated to intermediate vocational training level and the NCTs had higher levels of PTSD. Previous studies during the pandemic associated the presence of PTSD with educational level, with lower levels of PTSD in health professionals with higher academic training, such as bachelor's, master's, or doctorate degrees. 2, 9, 17 These results could be explained by better development of coping strategies during academic training. In terms of professional category, most of the PTSD sufferers have a lower academic level, and deliver care that involves more contact with infected patients, such as hygiene and nutrition, and therefore greater exposure. We found no relationship between PTSD and female sex, unlike previous studies 19---22 but, from the results, it is evident that a larger sample is needed to reach statistical significance. In terms of mental health characteristics, the need for psychopharmacological and/or psychotherapeutic treatment during the pandemic and the onset of PTSD-related symptoms during the month prior to completing the questionnaire increased the incidence of PTSD, and the presence of symptoms was considered a risk factor, with a 6-fold greater likelihood of suffering from PTSD. This is not surprising, since a confirmed diagnosis of PTSD requires these symptoms to be maintained for more than one month. 5 Although the study did not distinguish between treatments received before the pandemic and those started after it, there was no association between a history of mood disorder and the onset of PTSD, and therefore it seems that these treatments were used acutely over that period as insomnia, stress and anxiety increased. 8 In relation to work characteristics, about 30% of the professionals worked in a different unit to their usual unit, but this did not seem to influence the development of PTSD. Nor was there any particular unit with a higher concentration of PTSD. Almost half the staff in each unit had PTSD, following a similar distribution to that presented in the overall sample. Care of COVID patients did not play a role, unlike that described in different studies, 9, 11, 23 possibly due to the few professionals who did not care for these patients. In addition, all the nurses were affected in some way by the contingency plans. They were obliged to move to different departments and the vast majority were in contact with COVID patients, which increased the likelihood of contagion and working in isolation conditions using personal protective equipment that made it difficult to perform procedures, creating visual and auditory barriers. Many of the professionals who remained in their unit cared for patients with different diseases to those they were accustomed to, and others had to work in improvised spaces. 24 Professional experience was not shown to be a determining factor in the development of PTSD. In the evidence, there are discrepancies with the relationship between both variables. 2, 9, 17, 18, 23 It is possible that nurses with less experience adapt better to forced change, as they have unstable contracts that entail greater mobility, and nurses with more experience may compensate for more difficult adaptation with more knowledge. We could not establish a relationship between PTSD and self-infection with COVID (as in the study by Luceño-Moreno et al. 2 ), nor with infection by cohabitants, friends, or relatives. However, the death of friends or relatives doubled the likelihood of developing PTSD. This factor has previously been described as a predisposing factor for the development of mental illness. 12, 25 It should be noted that the development of PTSD depends not only on the type of exposure event, but also on the frequency and intensity of anxiety. 26 Nursing professionals who experienced the death of a loved one, were not able to carry out their farewell rituals due to the restrictions, thus prolonging their grief and, in these circumstances, continued to face the illness in their jobs and therefore repeatedly relive this event. With respect to the variables making up the RPS, it is evident how the nursing team assumes the role of caregiver in the work environment, as well as in the family and in the community, as they are willing to assume the risk of contracting the disease to deliver the care required by patients. This extends to their private lives, with 20% fear- ing infection of their loved ones more than being infected themselves. Moreover, although it is reported that the work entailed significant risk, professionals were willing to take this risk because they wanted to help. Studies describe how nurses feared passing on the disease to their family, but also felt professionally valued and proud. 27 They were also willing to work on the front line, making it a protective factor for mental health. 28 The RPS score is high in the present study, as in other similar studies. 28, 29 In addition, a high RPS score was found to increase the likelihood of developing PTSD by 17%, as it did during the 2003 SARS epidemic. 12, 18 Therefore, it is not the exposure to a risky environment per se that can trigger PTSD, as described in several studies, 18 but the extent to which the risk of exposure is perceived due to fear of infection. The median resilience score was 3.3, similar to the study by Luceño-Moreno et al. 2 If we consider that the highest score on this scale is 5, the score obtained can be improved. Furthermore, in different studies resilience appears as a protective factor against the development of PTSD, 2, 9, 28 as in the present study, in which a high resilience score prevented the likelihood of developing this illness by 54%. Given the relationship between resilience and PTSD, it would be useful to work on increasing this skill. A way of increasing it would be through the implementation of educational interventions such as group training sessions on stress coping models or training in emotional education and skills such as relaxation, assertiveness, and self-control. 18 More general measures aimed at improving the feeling of control and reducing the perception of risk are also necessary. 23 The most important of these are to provide the worker with information in advance and institutional support to ensure provision of protective equipment and access to psychological interventions. Other interventions that facilitate the well-being of the professional are appropriate rest with regular work shifts, voluntary relocation of care services, and the possibility of alternative accommodation that reduces the risk of infecting family members or cohabitants. 23 Although in a significant percentage of PTSD sufferers symptoms remit over time without requiring intervention, 30 those involved in delivering care are most at risk for the long-term consequences of PTSD. Specifically in epidemic contexts, the prevalence of PTSD remained in 10% of healthcare workers 3 years after the onset of PTSD. 12, 30 The data obtained and the evidence suggest the need for future longitudinal studies to assess the prevalence, incidence, and evolution of PTSD and its long-term consequences, as well as the interventions implemented in the socio-occupational-health context. This study had some limitations. Firstly, convenience sampling was used, which may have resulted in selection bias and overestimated the results. Secondly, the collection of data through self-administered questionnaires may have implied a response bias. Finally, the RPS scale has good internal consistency but has not been validated by psychometric studies and the DTS scale has not been used in other current studies, which makes it difficult to compare results. In conclusion, we observed a high prevalence of PTSD in nursing staff in the present study. Factors such as the onset of PTSD symptoms during the previous month, the death of family members or friends due to COVID-19, and a high perception of risk influenced onset of the condition. Resilience was shown to be a protective factor. Communicable disease threats report European Centre for Disease Prevention and Control Symptoms of Posttraumatic Stress, Anxiety, Depression, Levels of Resilience and Burnout in Spanish Health Personnel during the COVID-19 Pandemic Prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured SARS caring unit during outbreak: a prospective and periodic assessment study in Taiwan Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients Trastorno de estrés postraumático. DSM-5 Manual Diagnóstico y Estadístico de los Trastornos Mentales Med -Programa Form Médica Contin Acreditado Mental health status of medical staff in emergency departments during the Coronavirus disease 2019 epidemic in China Mental Health Outcomes Among Frontline and Second-Line Health Care Workers During the Coronavirus Disease 2019 (COVID-19) Pandemic in Italy Factors associated with the psychological well-being among front-line nurses exposed to COVID-2019 in China: A predictive study Psychological impact of COVID-19 outbreak on frontline nurses: A crosssectional survey study Personal Protective Equipment and Mental Health Symptoms Among Nurses During the COVID-19 Pandemic The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk The Foundations of Resilience: What Are the Critical Resources for Bouncing Back from Stress? Reliability and validity of the Brief Resilience Scale (BRS) Spanish Version Assessment of a new self-rating scale for posttraumatic stress disorder Evaluation of the psychometric properties of the Spanish version of 5 questionnaires for the evaluation of post-traumatic stress syndrome Acute psychological effects of Coronavirus Disease 2019 outbreak among healthcare workers in China: a cross-sectional study Impact of viral epidemic outbreaks on mental health of healthcare workers: a rapid systematic review and meta-analysis Posttraumatic stress disorder symptoms in healthcare workers after the peak of the COVID-19 outbreak: A survey of a large tertiary care hospital in Wuhan Mental health of healthcare workers during the COVID-19 pandemic in Italy Prevalence of posttraumatic stress symptoms in health care workers after exposure to patients with COVID-19 Posttraumatic stress symptoms of health care workers during the corona virus disease 2019 Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis Nurses' perceptions and demands regarding COVID-19 care delivery in critical care units and hospital emergency services Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions Trauma exposure and post-traumatic stress disorder in the general population Psychological effects of nurses and midwives due to COVID-19 outbreak: The case of Turkey Frontline nurses' burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19 outbreak in Wuhan, China: A large-scale +Model Enfermería Clínica xxx (xxxx) xxx---xxx cross-sectional study The Severity of Traumatic Stress Associated with COVID-19 Pandemic, Perception of Support, Sense of Security, and Sense of Meaning in Life among Nurses: Research Protocol and Preliminary Results from Poland Remission from post-traumatic stress disorder in adults: a systematic review and meta-analysis of long term outcome studies We would like to thank our colleagues at the Hospital Universitario Doce de Octubre for participating in the study and for their commendable work over the past year. The authors have no conflict of interests to declare.