key: cord-1033860-h9if17ba
authors: Aksoy, Yasemin Erkal; Koçak, Vesile
title: Psychological effects of nurses and midwives due to COVID-19 outbreak: The case of Turkey
date: 2020-07-08
journal: Arch Psychiatr Nurs
DOI: 10.1016/j.apnu.2020.07.011
sha: 3276983bd9d48d30b9bf71b75db4dfcc5ca189d3
doc_id: 1033860
cord_uid: h9if17ba

PURPOSE: The study was carried out to determine the psychological impact levels of nurses and midwives due to the COVID-19 outbreak. METHODS: The research is planned in a descriptive type. Nurses and midwives working in any health institution in Turkey constituted the population of the research. The questionnaire form of the study was shared on social media tools between 01 and 14 April 2020 and a total of 758 nurses and midwives were included in the study sample. Personal Information Form, State-Trait Anxiety Inventory and Intolerance of Uncertainty Scale were used as data collection tools. RESULTS: Participants who attended the study were 56.9% of nurses and 43.1% of midwives. Approximately half of the nurses and midwives (48.8%) participating in our study contacted the patient with suspected COVID-19, and 29.8% provided care to the patient diagnosed with COVID-19. Nurses and midwives were scored 52.75 ± 9.80 for State Anxiety, 44.87 ± 7.92 for Trait Anxiety Inventory and 35.16 ± 9.42 for Intolerance of Uncertainty Scale. It has been determined that 54.5% of nurses and midwives have been making their lives worse since the outbreak started, 62.4% had difficulties in dealing with the uncertain situation in the outbreak, 42.6% wanted psychological support and 11.8% had alienated from their profession. It was determined that there was a difference between scale scores and difficulties in work, family and private life due to COVID-19. CONCLUSION: As a result, it is seen that the midwives and nurses in our country have high psychological effects due to the COVID-19 outbreak.

J o u r n a l P r e -p r o o f Introduction COVID-19 is an infectious Corona virus disease caused by a newly discovered virus.

COVID-19 was first reported on December 12, 2019 in Wuhan (Wang, Tang, & Wei, 2020; Zhou et al., 2020a) . has been shown to be a clone of beta-corona viruses associated with human Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) (F. Wu et al., 2020; N. Zhu et al., 2020) . Most people infected with the COVID-19 virus experience mild or moderate respiratory disease and recover without special treatment. The disease is severe in individuals with elderly and chronic diseases (cardiovascular diseases, diabetes, chronic respiratory disease, cancer) (Perlman, 2020; WHO, 2020) . Since COVID-19 has fast spreading feature, it causes difficulties in the health systems of societies. (NMBA, 2020) . More than 150 countries are now infected due to the virus outbreak, and the outbreak of this virus has become a global emergency (Al-Mohaissen, 2017; Jiang et al., 2020) . Like SARS and Ebola, COVID-19 has a serious impact on mental health as well as causing physical damage (Lehmann et al., 2015; Lin et al., 2007; Wang et al., 2020; Zhou et al., 2020b) . COVID-19 is a worldwide lifethreatening concern.

Nurses and midwives who care for individuals in the health system continue to work at the forefront to ensure public safety. Nurses and midwives are in close contact with individuals during the care process (WHO, 2019) . Despite the use of protective equipment and precautions, COVID-19 may be contaminated (OSHA, 2020) . In our country, the case of COVID-19 first appeared on March 10, 2020 (Republic of Turkey Ministry of Health, 2020).

There are a large number of health professionals in the World and Turkey who were infected with the virus and thus, died (Choi, Skrine Jeffers, & Cynthia Logsdon, 2020; Republic of Turkey Ministry of Health, 2020) . Healthcare workers may face social isolation and social discrimination. Therefore, healthcare professionals appear as a sensitive group against complex emotional reactions and psychological distress (Kang et al., 2020) . In a study J o u r n a l P r e -p r o o f objective reason (Alavi & Omrani, 2019) . Uncertainty may arise due to a new, complex or contradictory, unsolvable situation (Alavi & Omrani, 2019; Tovilovic, Novovic, Mihic, & Jovanovic, 2009 ). Uncertainties about the vaccine, treatment and transmission rate of COVID-19 virus can affect the level of anxiety of nurses and midwives (Geçgin & Sahranç, 2017) . In addition, it is possible for nurses and midwives working in the epidemic to experience problems in their family and social life due to the fear of infecting. Uncertainty about when the outbreak will end raises negative emotions. An individual's level of intolerance to uncertainty and anxiety and concern levels were found to be related (Anderson et al., 2012; Dugas, Schwartz, & Francis, 2004) . It is thought that the increase in the level of anxiety and intolerance of uncertainty during the epidemic may lead to many psychological problems in nurses and midwives. The aim of this study is to determine the psychological impact levels of nurses and midwives due to the COVID-19 outbreak.

The research is planned in a descriptive type. Research question: What are the psychological effect levels of nurses and midwives due to the COVID-19 outbreak?

It has created the population of the research who nurses and midwives working in any health care provider in Turkey. The sample calculation was made with known average scores of State and Trait Anxiety Inventory and Intolerance of Uncertainty Scale. After calculations, the known average score of the scale which is calculated the highest number of samples was taken as a reference. The sample size of the study was determined as 726 nurses and midwives with 90% power within one point deviation with the known score (41.9±8.3) using J o u r n a l P r e -p r o o f study between 01 and 14 April 2020 by using convenience sampling method. Personal Information Form, State and Trait Anxiety Inventory and Intolerance of Uncertainty Scale were used as data collection tools. An online questionnaire link was shared through social media tools (such as Whatsapp, Instagram, Facebook), information was provided about the research, and nurses and midwives were invited to fill in the questionnaire. The questionnaire link was sent to online profession groups to which nurses and midwives are joined. The data of the research were collected based on self-report. While creating the online form, standardizations have been made for the nurses and midwives to respond once; only one response for each participant. Only one response was provided to the surveyed nurses and midwives. The collected questionnaires were checked daily and quality control was made.

Social media research can present various challenges or opportunities in terms of research validity and reliability. While social media researches have difficulties for users not to have organic (real) accounts, it is easy to access major data when it is difficult to collect face-toface data such as COVID-19 outbreak. Social media users do not represent the entire population. However, it can turn into an opportunity when it is made with a special group such as nurses and midwives (Ruths & Pfeffer, 2014; Social Media Research Group, 2016) .

Personal Information Form; it consists of 22 question statements that question personal such as age, gender, marital status, profession, educational background, etc of nurses and midwives and COVID-19 related features (Huang & Zhao, 2020; Nemati, Ebrahimi, & Nemati, 2020; Wang et al., 2020; N. Zhu et al., 2020; Z. Zhu et al., 2020) . Intolerance of Uncertainty Scale (IUS-12); it was developed by Carleton et al. (Carleton, Norton, & Asmundson, 2007) and Turkish validity reliability was performed by Saricam et al. (Sariçam, Erguvan, Akin, & Akça, 2014) . Each item was rated on a Likert scale from 1 (not at all characteristic of me) to 5 (entirely characteristic of me).The scale consists of 12 items and two subscales. Rising scores indicate high levels of intolerance of uncertainty. The prospective anxiety subscale of the scale consists of 1-7. items, and inhibitory anxiety subscale consists of 8-12 items. While the minimum score to be obtained from the scale is 12, the maximum score is 60. Scoring of the scale is performed by adding the number values corresponding to the marking made. Cronbach alpha coefficient is found to be 0.88 for the whole scale; 0.84 for prospective anxiety subscale and 0.77 for inhibitory anxiety subscale (Sariçam et al., 2014) . In this study, Cronbach alpha coefficient is determined to be 0.92 for scale whole; 0.86 for prospective anxiety subscale and 0.90 for inhibitory anxiety subscale.

Nurses and midwives who voluntarily agreed to participate in the study were accepted.

Before starting the questionnaire form, it was made mandatory to read and approve the informed consent form explaining the purpose of the study. The questionnaire does not include questions containing the contact information or any special information of the participants. Ethical permission was not obtained from any institution because the research was not interventional as the data was collected using social media tools.

Data analysis was carried out using Statistical Package for the Social Science (SPSS) 20.0 package program (SPSS Inc., Chicago, IL, USA). The Kolmogorov Smirnow test was used to determine whether the data were normally distributed. In data analysis, number and percentage mean and standard deviation analysis were used, and t test, ANOVA analysis was used in independent groups. Statistical significance of the data was evaluated at p <0.05 level.

Participants who attended the study was 56.9% of nurses and 43.1% of midwives. The average age of the nurses and midwives participating in the study was determined as 30.51±7.24 (Min=20.00, Max=56.00) and the year of work in the profession was 8.69±7.82 (Min=1.00, Max=35.00). In Turkey there are seven geographic regions. Forty-seven point two percent of the participants in the study live in Central Anatolia, 19.5% in Marmara, 9.9% in Eastern Anatolia, 7.7% in Aegean, 6.2% in Mediterranean, 5.9% in Black Sea and 3.6% in Southeast Anatolia. In our study, it was determined that 92.7% of the nurses and midwives were women, 55.1% were married and 74.1% were of Bachelor's Degree. It was determined that 80.6% of nurses and midwives worked in secondary and tertiary health institutions and 23.1% had chronic disease (Thyroid, Respiratory Diseases, Diabetes, etc.) (Table 1) . (Table 2) .

Variables n %

Yes 370 

When the answers given by the nurses and midwives to some statements made about the COVID-19 outbreak, it has been determined that 54.5% of their lives have become worse since the outbreak started, 62.4% had difficulties in dealing with the uncertain situation in the outbreak, 42.6% wanted psychological support, and 11.8% alienated from their profession. In the epidemic period, 59.4% of nurses and midwives stated that they felt valuable while caring for the patients, realized the purpose of their profession and 76% of them stated that they were proud to be health workers (Table 3) . J o u r n a l P r e -p r o o f

It was determined that there was a statistically significant difference between the State Anxiety Inventory scores of the nurses and midwives participating in our study with the state of chronic disease, the most intense emotion felt due to COVID-19, experiencing remorse due to their occupation, and difficulties in social, profession, family and private life due to COVID-19. It was determined that there was a statistically significant difference between the Trait Anxiety Inventory scores with the most intense emotion felt due to COVID-19, experiencing remorse due to their profession, and difficulties in profession, family and private life due to COVID-19.

It was found that there was a difference between the total score of the Intolerance of Uncertainty Scale with remorse due to their occupation and difficulties in profession, family and private life due to COVID-19. It was determined that there was a statistically significant difference between prospective anxiety subscale score of Intolerance of the Uncertainty Scale with gender variable and chronic disease status. It was determined that there was a difference between the inhibitory anxiety subscale score of the Intolerance of Uncertainty Scale with having remorse due to their profession and having difficulties in profession, family and private life due to COVID-19 (Table 4) . (Lai et al., 2020) . The same situation was observed in the SARS outbreak, and the source of stress in nurses was determined to be the loss of control/vulnerability, fear of selfhealth, and fear of spreading the virus (Wong et al., 2005) . Possible cause of psychological problems may be anxiety about infection and fear of controlling the outbreak (Furer, Walker, Chartier, & Stein, 1997; Huang & Zhao, 2020) . In addition, the shortage of medical facilities across the country can be effective (Nemati et al., 2020) .

In our study, it was found out that most of the participants had difficulty in dealing with the uncertainty in the outbreak and that there was a statistically significant difference between intolerance of uncertainty prospective anxiety subscale score and gender and chronic disease status. Similarly, in the study of Huang and Zhao, it is seen that the psychological impact seen in one out of every five participants is caused by the uncertainty in the progress of the epidemic and this situation will cause more psychological impact (Huang & Zhao, 2020) . The concept of uncertainty brings with it the concept of concern, anxiety and fear in general (Sari & Dağ, 200 ) . Individuals who are intolerant of high levels of uncertainty find uncertain and challenging situations in daily life events worrying and challenging and have an intense threat perception and this may be related to depression symptoms (Carleton, 2012) .People who are

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