Skip to main content

Post-traumatic stress disorder symptoms among nursing staff who provided direct care to COVID-19 patients: a cross-sectional study

Abstract

Background

The coronavirus disease 2019 (COVID-19) pandemic has led to a major physical and psychological burden on nursing staff who provide patient care in difficult circumstances with persistent exposure to infected patients. This study aimed to assess the prevalence of post-traumatic stress disorder (PTSD) symptoms among nursing staff working during the COVID-19 pandemic and its relationship with different work-related variables. It was designed as a cross-sectional comparative study in which 102 nurses on duty during the past 6 months were enrolled and divided into two groups. The first group included fifty-one COVID-dealing nurses who provided direct patient care to COVID-19 patients (emergency department, isolation zone, and intensive care unit (ICU)), while the second group included fifty-one non-COVID-dealing nurses on duty during the same period but in other hospital units and not providing direct care to COVID-19 patients (inpatient and outpatient wards).

Sociodemographic data, work-related variables, PTSD symptom severity, and diagnosis were all assessed.

Results

The COVID-dealing nurses had significantly less frequent short breaks (P = 0.007), inadequate organizational support and compensation (P = 0.024), and inadequate time off work (P = 0.004) compared to non-COVID-dealing nursing staff. They were also significantly suffering from PTSD compared to second-line staff (P = 0.025).

Conclusions

COVID-dealing nurses providing direct care to COVID-19 patients suffered significantly from PTSD with a variety of contributing work-related variables.

Background

According to the World Health Organization (WHO), continually emerging novel viruses always represent a threat to public health. In 2019, a new coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was found in Wuhan, China, which is the largest city in the province of Hubei [1].

Prior to the coronavirus disease 2019 (COVID-19) pandemic, nursing staff always reported high levels of fatigue, little recovery time, and problems with sleep, leading to burnout and decreased psychological well-being [2].

Given the unknown and highly infectious nature of this new virus, the COVID-19 pandemic caused greater physical and psychological difficulties for nursing staff compared to past public health events in the form of increased workload, need for personal protection, and fears of potentially infecting themselves and their families [3].

Seeing patients die, patients’ aggression, dealing with end-of-life care, verbal abuse from family members, feeling overloaded due to inadequate nurse-to-patient ratio, and not being able to save a patient’s life all constitute trauma dimensions that nurses have to continuously face during the pandemic. The symptoms of post-traumatic stress disorder (PTSD) include sleep problems, continuous intrusive thoughts about patients, and irritability. The least common symptoms of secondary traumatic stress are avoidance of people, places, and disturbing dreams about patients [2].

As a result, this study was designed to assess the prevalence of PTSD symptoms among nursing staff working during the COVID-19 pandemic and its relationship with different work-related characteristics to unveil how the nursing population has been affected by the COVID-19 pandemic and formulate efficient evidence-based interventions to support them psychologically.

Methods

Participants and procedures

A cross-sectional comparative study which started from April 2021 till October 2021 was done in which 102 nurses on duty during the previous 6 months at Suez Canal University Teaching Hospital were enrolled and divided into two groups:

  • Group 1 included 51 COVID-dealing nurses who provided direct patient care to COVID-19 patients; they were working in the following hospital departments:

    1. 1.

      Emergency department where 60 beds were available for assessing suspected COVID-19 cases on a daily basis

    2. 2.

      Isolation zone, a building merely assigned to admit confirmed COVID-19 patients with a capacity of 77 beds

    3. 3.

      Intensive care unit (ICU) where 15 beds were allocated for deteriorating confirmed COVID-19 patients

  • Group 2 included 51 non-COVID-dealing nurses on duty during the same period but in other hospital units not directly caring for patients with COVID-19 including 16 inpatient wards and 20 outpatient clinics.

The sample size was calculated according to the proportion of PTSD symptoms among healthcare personnel dealing with COVID-19 patients being 5.7%, absolute error or precision usually equals 10%, and the confidence interval as 1.96. The calculated sample size was 91 participants, but after adding the expected (drop-out) rate (10%), the final sample size was 102 participants [4].

We conducted interviews for all nursing staff who accepted our participation request after excluding those who were on vacation and maternity leaves, nursing administration and leadership, those with a history of pre-existing psychiatric or medical illness, and those with confirmed COVID-19 infection during the past 6 months.

Tools

The following data were gathered from both study groups:

  • Sociodemographic data, including age, sex, marital status, dependent children, and dependent parents

  • Work-related data included the unit of practice, years of work experience, employment status, shift length, hours worked per week, frequent short breaks, provision of appropriate work wear, adequate training, organization support and compensation, and time off work

  • PTSD symptom prevalence and severity assessments were done using the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT). It consists of eight items that address four core symptoms of PTSD: somatic malaise, stress vulnerability, and impairment in the role and social functioning. A total score of ≥ 14 is considered high on symptom severity, a positive indication for further clinical evaluation for PTSD with Mini-International Neuropsychiatric Interview ( M.I.N.I)

The previous data were collected during the first appointment, and 2 weeks later, the participants who had scores more than 14 on SPRINT were invited to a second appointment for an evaluation with M.I.N.I., a brief structured diagnostic interview for the major psychiatric disorders in DSM-III-R, DSM-IV, and DSM-5, and ICD-10.

Statistical analysis

The data were coded and imported into the Statistical Package for the Social Sciences (SPSS version 25) software. Data normality of distribution was tested before data analysis. All studied variables were expressed as means, standard deviations, and percentages. The chi-square test, independent samples t-test, and logistic regression explained the study results. The results were considered significant if the P-value was ≤ 0.05.

Results

One-third of the COVID-dealing nurses were females; their mean age was 27.00 ± 4.26. Additionally, about one-third of the COVID-dealing nurses had at least one child, and about half of them were dependent parents. There was no statistically significant difference between both study groups regarding sociodemographic data (Table 1).

Table 1 Sociodemographic characteristics of the studied population

One-third of the COVID-dealing nurses was working in the ICU and two-thirds of them were working in the isolation zone. About 60% of the COVID-dealing nurses had working experience of between 3 and 8 years, and 57% had significantly more working hours per week compared to non-COVID-dealing nursing staff (Table 2).

Table 2 Work-related characteristics of the studied population

COVID-dealing nurses had significantly higher SPRINT score for the prevalence of PTSD symptoms compared to non-COVID-dealing nurses not providing direct care to COVID-19 patients (18.57 ± 7.69 vs. 14.49 ± 7.01) (P = 0.035); 64.7% were having severe symptoms and 51% were diagnosed with PTSD according to M.I.N.I. (Table 3).

Table 3 PTSD symptoms, severity, and diagnosis among nursing staff

Nursing staff diagnosed with post-traumatic stress disorder had significantly less frequent short breaks (P = 0.007), inadequate organizational support and compensation (P = 0.024), and inadequate time off work (P = 0.004) (Table 4).

Table 4 Relationship between work-related characteristics and PTSD among nursing staff

Regression analysis used to assess predictors of PTSD among nursing staff showed a three-time increase in the odds of having PTSD for nursing staff who provide direct patient care to COVID-19 patients compared to non-COVID-dealing nursing staff (P = 0.019). Moreover, there was a 2.643-time increase in the odds of having PTSD for nursing staff who did not have frequent short breaks (P = 0.036) (Table 5).

Table 5 Logistic regression analysis of determinants of PTSD among nursing staff

Discussion

This study aimed to assess the PTSD symptoms among nursing staff working during the COVID-19 pandemic and its relationship with different work-related characteristics. Our findings showed that COVID-dealing nurses providing direct care to patients with COVID-19 were three times more likely to have PTSD than non-COVID-dealing nurses not providing direct care to COVID-19 patients.

We found that 64.7% of the COVID-dealing nurses had severe PTSD symptoms, and 51% were diagnosed with PTSD. Less frequent short breaks, inadequate organizational support and compensation, and inadequate time off work were the most work-related characteristics significantly associated with PTSD among COVID-dealing nurses.

Providing care to COVID-19 patients coupled with more time spent in the hospital leads to repeated exposure to trauma, which may have significantly increased the risk of PTSD [5].

Additionally, fear of transmitting the disease to family members, paucity of resources, heavy workloads, caring for potentially rapidly deteriorating patients, seeing colleagues continuously fall sick, and lack of psychological and social support also increase the risk of PTSD [6].

Similarly, a study that assessed the mental health of healthcare workers during the COVID-19 pandemic in Italy revealed that healthcare professionals working in COVID-19 wards reported higher levels of depressive symptoms and post-traumatic stress symptoms compared to those who work in other healthcare units. Also, the authors noted that being an older female is related to higher levels of post-traumatic stress symptoms [7].

Moreover, in China, a mental health survey of medical staff in a tertiary infectious disease hospital for COVID-19 showed that the incidence of anxiety and PTSD is high among medical staff, especially female nurses [8].

Another Chinese online survey carried out on medical health workers during the COVID-19 outbreak reported that medical health workers had a higher prevalence of insomnia, anxiety, depression, somatization, and obsessive–compulsive symptoms compared with non-medical health workers [9].

According to another cross-sectional online survey conducted in Turkey to assess psychological responses of healthcare workers and related factors during the COVID-19 outbreak, being female, being young, being single, having less work experience, and working in frontline jobs were associated with higher scores of stress [10].

Also, several previous studies described acute and post-traumatic stress among healthcare staff working with patients during viral outbreaks, which was related to a variety of sociodemographic and work-related characteristics [11].

Predisposing factors were being women [12, 13], younger [14], parents of dependent children [15], exposed to prolonged quarantine [16], having pre-existing psychological or physical illness [17], and fear of infecting or having an infected family member [18].

Significantly work-related risk factors among nurses were being less experienced, part-time employment, and frustration about the effect of precautionary measures on their ability to do their jobs [19].

Other factors included inadequate staff training, organizational support, compensation, and societal stigma against healthcare workers [20].

Protective factors found by previous studies were being older, having greater clinical experience, frequent short breaks from clinical duties, adequate time off work, family support, adequate training, a supportive work environment, clear communication, and faith in precautionary measures. [21].

Having access to psychologically supportive interventions was also noted to be protective [22]. Although nurses are more vulnerable to psychological distress than other healthcare workers, they are more likely to adhere to infection control procedures [23]. Lastly, seeing infected colleagues getting better, as well as a general drop in disease transmission, improved psychological outcomes [24].

This study highlights the importance of healthcare workers’ mental health caring for patients during a viral outbreak. The COVID-19 pandemic has burdened our nursing population and exacerbated previously existing problems such as post-traumatic stress, so effective interventions including communication, access to adequate personal protective equipment (PPE), more frequent short breaks, adequate rest, and psychological support should be immediately implemented.

Conclusions

COVID-dealing nurses providing direct care to patients with COVID-19 who are having less frequent short breaks, inadequate organizational support and compensation, and inadequate time off work are more likely to have PTSD compared to non-COVID-dealing nurses not providing direct care to COVID-19 patients.

Availability of data and materials

All data generated or analyzed during this study are available on request.

Abbreviations

COVID-19:

Coronavirus disease 2019

PTSD:

Post-traumatic stress disorder

WHO:

World Health Organization

SARS-CoV-2:

Severe acute respiratory syndrome coronavirus 2

M.I.N.I:

Mini-International Neuropsychiatric Interview

PPE:

Personal protective equipment

References

  1. Lake MA (2020) What we know so far: COVID-19 current clinical knowledge and research. Clin Med 20(2):124

    Article  Google Scholar 

  2. Han K, Trinkoff AM, Geiger-Brown J (2014) Factors associated with work-related fatigue and recovery in hospital nurses working 12-hour shifts. Workplace Health Safety 62(10):409–414

    Article  Google Scholar 

  3. Nishiura H, Jung S-m, Linton NM, Kinoshita R, Yang Y, Hayashi K, et al. (2020) The extent of transmission of novel coronavirus in Wuhan, China. MDPI; p. 330.

  4. Charan J, Biswas T (2013) How to calculate sample size for different study designs in medical research? Indian J Psychol Med 35(2):121–126

    Article  Google Scholar 

  5. Sagherian K, Steege LM, Cobb SJ, Cho H (2020) Insomnia, fatigue and psychosocial well‐being during COVID‐19 pandemic: a cross‐sectional survey of hospital nursing staff in the United States. J Clin Nurs 10–1111.

  6. Walton M, Murray E, Christian MD (2020) Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic. Eur Heart J Acute Cardiovasc Care 9(3):241–247

    Article  Google Scholar 

  7. Di Tella M, Romeo A, Benfante A, Castelli L (2020) Mental health of healthcare workers during the COVID-19 pandemic in Italy. J Eval Clin Pract 26(6):1583–1587

    Article  Google Scholar 

  8. Huang JZ, Han MF, Luo TD, Ren AK, Zhou XP (2020) Mental health survey of medical staff in a tertiary infectious disease hospital for COVID-19. Zhonghua lao dong wei sheng zhi ye bing za zhi. 38(3):192–5

    CAS  PubMed  Google Scholar 

  9. Zhang WR, Wang K, Yin L, Zhao WF, Xue Q, Peng M, Min BQ, Tian Q, Leng HX, Du JL, Chang H (2020) Mental health and psychosocial problems of medical health workers during the COVID-19 epidemic in China. Psychother Psychosom 89(4):242–250

    Article  Google Scholar 

  10. Elbay RY, Kurtulmuş A, Arpacıoğlu S, Karadere E (2020) Depression, anxiety, stress levels of physicians and associated factors in Covid-19 pandemics. Psychiatry Res 290:113130

    CAS  Article  Google Scholar 

  11. Kisely S, Warren N, McMahon L, Dalais C, Henry I, Siskind D (2020) Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. Bmj 369:m1642

  12. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, Wu J, Du H, Chen T, Li R, Tan H (2020) Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA network open. 2;3(3):e203976

    Article  Google Scholar 

  13. Bukhari EE, Temsah MH, Aleyadhy AA, Alrabiaa AA, Alhboob AA, Jamal AA, Binsaeed AA (2016) Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak perceptions of risk and stress evaluation in nurses. The Journal of Infection in Developing Countries 10(08):845–850

    Article  Google Scholar 

  14. Nickell LA, Crighton EJ, Tracy CS, Al-Enazy H, Bolaji Y, Hanjrah S, Hussain A, Makhlouf S, Upshur RE (2004) Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution. CMAJ 170(5):793–798

    Article  Google Scholar 

  15. Koh D, Lim MK, Chia SE, Ko SM, Qian F, Ng V, Tan BH, Wong KS, Chew WM, Tang HK, Ng W (2005) Risk perception and impact of severe acute respiratory syndrome (SARS) on work and personal lives of healthcare Workers in Singapore What can we Learn? Med Care. 43(7):676–82

    Article  Google Scholar 

  16. Lee SM, Kang WS, Cho AR, Kim T, Park JK (2018) Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry 87:123–127

    Article  Google Scholar 

  17. Dai Y, Hu G, Xiong H, Qiu H, Yuan X (2020) Psychological impact of the coronavirus disease 2019 (COVID-19) outbreak on healthcare workers in China. medrxiv.

  18. Maunder RG, Lancee WJ, Balderson KE, Bennett JP, Borgundvaag B, Evans S, Fernandes CM, Goldbloom DS, Gupta M, Hunter JJ, Hall LM (2006) Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis 12:1924

    Article  Google Scholar 

  19. Serrano-Ripoll MJ, Meneses-Echavez JF, Ricci-Cabello I, Fraile-Navarro D, Fiol-deRoque MA, Pastor-Moreno G, Castro A, Ruiz-Pérez I, Campos RZ, Gonçalves-Bradley DC (2020) Impact of viral epidemic outbreaks on mental health of healthcare workers: a rapid systematic review and meta-analysis. J Affect Disord 277:347–357

    CAS  Article  Google Scholar 

  20. Brooks SK, Dunn R, Amlôt R, Rubin GJ, Greenberg N (2018) A systematic, thematic review of social and occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak. J Occup Environ Med 60(3):248–257

    Article  Google Scholar 

  21. Khalid I, Khalid TJ, Qabajah MR, Barnard AG, Qushmaq IA (2016) Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak. Clin Med Res 14(1):7–14

    Article  Google Scholar 

  22. Chan AO, Huak CY (2004) Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore. Occup Med 54(3):190–196

    Article  Google Scholar 

  23. Cheong D, Lee C (2004) Impact of severe acute respiratory syndrome on anxiety levels of front-line health care workers. Hong Kong Med J 10(5):325

    PubMed  Google Scholar 

  24. Chen CS, Wu HY, Yang P, Yen CF (2005) Psychological distress of nurses in Taiwan who worked during the outbreak of SARS. Psychiatr Serv 56(1):76–79

    Article  Google Scholar 

Download references

Acknowledgements

None

Funding

None.

Author information

Authors and Affiliations

Authors

Contributions

MG and MH recruited the participants, analyzed and interpreted the data, and were the contributors in writing the manuscript. KA and AH revised the data interpretation and read and approved the final manuscript. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Ahmed Elarabi Hendi.

Ethics declarations

Ethics approval and consent to participate

The study protocol was approved by the Ethical Committee Board of the Faculty of Medicine, Suez Canal University. The reference number is 4548/5–4-2021. Methods were performed following the principles of the Declaration of Helsinki (2000 revision). Written informed consent was obtained from all participants after explaining the purpose of the study.

Consent for publication

The participants consented to publishing their data result.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Gabra, M.A., Mohammed, K.A.E., Hegazy, M.N. et al. Post-traumatic stress disorder symptoms among nursing staff who provided direct care to COVID-19 patients: a cross-sectional study. Middle East Curr Psychiatry 29, 67 (2022). https://doi.org/10.1186/s43045-022-00233-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s43045-022-00233-w

Keywords

  • COVID-19
  • Nursing staff
  • PTSD