ABSTRACT
The spread of coronavirus disease-2019 (COVID-19) worldwide has caused sudden and dramatic changes in our daily routines and work lives. Healthcare workers tried to adapt to the pandemic process, protecting patients, themselves, and their families from COVID-19 infection. Our study explains the early psychological effects of the COVID-19 pandemic on healthcare professionals working in the front line in intensive care units and operating rooms.
This cross-sectional type of study was conducted face-to-face with 125 medical personnel working on the front line in the COVID-19 intensive care unit (ICU) during the pandemic. The beck depression inventory and perceived stress scale were used in our study to measure the depression and stress levels of worker healthcare care.
73.6% of the participants were female, 52.8% were nurses, and 28% were working in a pandemic ICU. The mean age was 34.17±7.72. Compared to the low-stress group, the high-stress group consisted of females with a statistically significantly higher frequency.
Unfortunately, history indicates that pandemics are inevitable and that we must help each other in these difficult times. Understanding early signs of the stress factors of healthcare workers can be helpful in protecting them from posttraumatic disorder. During this period, social distancing was the key to slowing down the transmission of the virus, but it led to increased health sector employees’ increased anxiety. Understanding the early signs of healthcare workers’ signs of anxiety and depression can protect them from serious health problems such as burnout syndrome and posttraumatic stress disorder.
Keywords: COVID-19, health workers, stress, anxiety
Introduction
The world faces an unprecedented health crisis caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Coronavirus disease-2019 (COVID-19) infection, also known as SARS-CoV-2, continues to cause concern worldwide, with a total number of 92,506,811 confirmed cases, including 2,001,773 deaths in more than 200 countries, as of January 16, 2021 (1). Among confirmed cases with COVID-19, the case mortality rate is estimated to be between 0.2% and 9.5% (2). In Turkey, the total number of patients as of January 16, 2021, is 2,380,665, while the number of patients who died is 23,882 (3). The COVID-19 disease is predominantly viral pneumonia and highly contagious (4) Approved viral infection routes mainly contact contaminated environmental surfaces and aerosolization (5). Procedures for COVID-19 patients in the intensive care unit (ICU) and operating room, especially air management, can produce aerosols that increase the risk of infection and are high-risk for medical personnel (6). Personnel involved in air management of COVID-19 patients and health employees treating the disease have a higher risk of infection by the disease (7). In a Washington Post article, anesthesiologist Cory Deburghgraeve described his work during the outbreak as “basically you are next to the nuclear reactor” (8). In addition to these causes, the world’s unpreparedness for the Coronavirus outbreak has created a sense of fear and anxiety. As the number of cases has increased rapidly, these feelings have increased. COVID-19 has brought severe burdens to the health system worldwide, and doctors’ and nurses’ efforts to recognize and prevent anxiety and stress levels, which are among the short-and long-term harmful effects, have been significant. Because the main goal in health policy is to prevent disease, fight against infection, ensure the development of treatment and vaccines, and focus on saving lives, doctors’ and nurses’ anxiety is at risk of being ignored. In this process, if health employees’ stress and anxiety are not treated sufficiently, we can observe adverse effects such as fatigue, depression, mood disorders, drug abuse, suicide, low quality of patient care, unexpected resignations, and early retirements (9). Our research aims to understand the mental health consequences of the COVID-19 pandemic on health employees working on the front line in our hospital’s intensive care units and operating rooms and reveal the consequences of its psycho-physical impact.
Materials and Methods
This cross-sectional type of study was conducted face-to-face with 125 medical personnel working on the front line in the COVID ICU during the pandemic, with written permission from the Ministry of Health and the Ethics Board Dokuz Eylül University Faculty of Medicine (acceptance no: 2021/02-38). COVID-19 first case in Turkey was announced by the health ministry on 11 March 2020. The first death due to the virus in the country occurred on March 15, 2020. Our study was completed in February 2021. An informed consent form was obtained from the participants. Beck depression inventory (BDI) and perceived stress scale (PSS) were used in our study to measure the depression and stress levels of workers health. BDI was developed by Beck et al. (10) in 1961 to measure behavioral signs of depression in adolescents and adults. In 1978, the full scale was revised, and duplications defining violence were extracted, and patients were asked to mark their status for the last week, including today. With respect to severity scoring is interpreted as follows; 0-9=minimal, 10-16=light, 17-29=moderate, 30-63=severe. The scale was converted into Turkish as BDI and beck depression scale in two separate forms, and a validity and reliability study was conducted (11). A high level of correlation has been found between the original and revised versions. Cross-cultural validity and reliability were also found to be high. The internal reliability of BDE has been tested at different times with an average value of 0.86 between 0.73-0.92 (12).
PSS was developed by Ali et al. (13). PSS, consisting of 14 articles, is designed to measure how several situations in a person’s life are perceived as stressful. PSS-14’s scores range from 0 to 56, while PSS-10’s scores range from 0 to 40, and PSS’s scores range from 0 to 16. A high score indicates an excess of a person’s perception of stress.
Statistical Analysis
All analyses were performed on SPSS v21 (SPSS Inc., Chicago, IL, USA). Data are given as mean ± standard deviation or median (minimum - maximum) for continuous variables according to normality of distribution and frequency (percentage) for categorical variables. Normally distributed variables (height, weight and blood glucose) were analyzed with independent samples t-test and ANOVA test. Non-normally distributed variables were analyzed with the Mann-Whitney U test. Categorical variables evaluated using the chi-square tests or Fisher’s Exact tests. P<0.05 values accepted as statistically significant results.
Results
73.6% of the participants were female, 52.8% were nurses, and 28% were working in pandemic ICU. The mean age was 34.17±7.72. 67.8% of those with low stress levels and 88.6% of those with high stress levels were female. Compared to the low-stress group, the high-stress group consisted of females with a statistically significantly higher frequency (p=0.018) (Figure 1). 25.6% of the group with low-stress level and 48.6% of the group with high-stress level stated that they did sports. Compared with the group with high stress level, the group with low stress level was doing sports with a statistically significantly higher frequency (p=0.013). Summary of individuals characteristics with regard to stress level were shown in Table 1.
Among the groups determined according to the anxiety level, the frequency of insomnia and concentration disorder, forgetfulness and mental complaints was determined at a statistically significant level (p=0.026, 0.017, 0.015, respectively). 94.1% of the minimal anxiety group and 12.5% of the severe anxiety group stated that they felt stressed. The frequency of feeling stress was statistically significantly different among the groups determined according to the anxiety level (p<0.001). Summary of individuals characteristics with regard to anxiety level were shown in Table 2.
Discussion
Our research revealed the psychological effects of the COVID-19 pandemic on medical staff working on the front line in intensive care units and the operating rooms. 73.6% of participants were women, and 52.8% were nurses. Compared to the low-stress group, the high-stress group consisted statistically significantly of female health employees. The prevalence of insomnia and concentration disorder, forgetfulness, and mental reactions (easy irritability, depressive emotion, inability to enjoy life, feeling helpless, pessimism) were high among the groups determined by the anxiety level of health professionals who were directly involved in the care of patients infected by COVID-19. During the COVID-19 pandemic, anxiety was detected by 23.2% in a meta-analysis that included 13 studies with 33,062 participants to understand and analyze factors that had the potential to affect medical personnel’s mental health in critical areas (14). In this meta-analysis, nurses and doctors were compared for anxiety, and mental symptoms were shown in nurses with a higher prevalence, unlike in our study. When gender and occupation analysis was performed, it was noted that female health employees and nurses showed higher levels of emotional symptoms than male health personnel. Our study also found that the vast majority of staff with high-stress levels were female health employees. Again, a study investigating the anxiety and stress levels of 1,830 health employees in Wuhan found that emotional burden was more significant in female employees and nurses (15). In another analysis made for health professionals, it was found that depression and anxiety symptoms for women employees were higher for those less prepared psychologically, self-competence, and those who lacked family support and who have a low quality of sleep (16). A web-based survey of 7,236 people in China, which was participated voluntarily, found that anxiety symptoms were significantly higher in health employees, for women and youth (age<35) (17). The high proportion of nurses participating in our survey and the fact that nurses were engaged in closer and longer working hours with COVID-19 patients may have increased the level of anxiety and stress (18). It was found that high anxiety levels of healthy employees can cause harmful cognitive interference in making task-related goals, negatively affecting their decision-making ability and performance (14). Higher anxiety may also increase burnout; it can invite depression and similar diseases (17). Since previous studies have shown that emotional distress is often associated with inadequate patient care and professional inefficiencies, and a long-term low effect on healthcare professionals’ health status, these results require special attention (19). The COVID-19 pandemic is complicated due to infection caused by those infected but asymptomatic. It causes additional risk for people they live with and increases the emotional burden of medical personnel (20). A survey found that 48% of anesthesiologists said they were most likely to get COVID-19 at work but thought they would heal after the disease with mild symptoms (21). Among the causes of anxiety and stress of medical staff; in addition to the fear of being infected with COVID-19, the uncertainty of personal protective equipment or other essential equipment, difficulties with child care, witnessing critical illness or death of co-employees, irregular work hours, and high workload can be specified (22). Maintaining health employees’ mental well-being is imperative for the health workforce’s long-term capacity for caring for COVID-19 patients (21). On the other hand, health employees’ satisfaction with their work and personal satisfaction can be considered a protective factor against anxiety (21,22). It is possible to define personal satisfaction as a sense of professional recognition and self-sufficiency (21). In particular, providing psychological support to front-line employees seems to retain its importance over the coming weeks and months (19). Besides, in our study, insomnia and concentration disorders were detected by 75% in the severe anxiety group. In a study conducted during the pandemic, health employees’ anxiety was reported between 13% and 46.4%, and insomnia was reported between 20% and 89.7% (23). Another study conducted on health employees in Wuhan found a high prevalence of anxiety (44.6%) (along with high depression, insomnia, and general distress) (24). In another study, the prevalence of insomnia was 32-34% (25). Surveys conducted during the COVID-19 outbreak found a significant relationship between anxiety and depression and sleep quality (26). In the study, which investigated the findings of Novitiate syndrome for health professionals in Italy, 45% of participants reported experiencing at least one physical symptom, including increased irritability, changes in eating habits, difficulty falling asleep, and muscle tension (19). In our study, somatic symptoms such as chest constriction sensation, palpitations, novelties, and gastrointestinal tenderness were observed in 81% of the severe anxiety group employees. Besides, all participants answered the open-ended questions of our survey in writing. It suggested that this reflected the desire of medical staff to express and share their feelings and concerns. Our study found that compared to the group with high-stress levels, the group with low-stress levels regularly exercised at a statistically significantly higher rate. It has been known for many years that regular physical activity benefits individuals with depressive and anxiety symptoms (27). Studies have shown that individuals without psychiatric symptoms who exercise regularly experience better moods than those who do not (28). Also, it is believed that regular exercise can protect against the development of depression due to its healing effects, such as self-esteem, fitness, general well-being, and satisfaction with physical appearance (27). During the COVID-19 pandemic, it is suggested to spend as much time as possible with the family, regular exercise and good nutrition, methods such as therapy and meditation in order to help reduce the stress of health employees and reducing the use of social media can be considered to avoid stimuli that arouse anxiety (23). In order to avoid the undesirable social, psychological, and economic burden like working factors (excessive workloads, irregular working hours, the uncertainty of personal protection equipment), personal characteristics (work-life imbalance, insufficient social support, sleep deprivation), and organizational factors (workload, expectations, rewards, and peer communication are insufficient, managers negative feedback) it is essential to determine the cause of the outbreak (19). Our work has some limitations. First, the data from self-reported surveys were not compared with clinical data on healthcare professionals’ health. Second, health workers were not asked if any of their relatives had COVID-19.
Conclusion
Because intensive care and operating room employees are healthy employees on the front lines responding to the COVID-19 outbreak, health care professionals’ investment should be made to avoid short-and long-term distress caused by anxiety and stress. Essential measures should be taken to identify and manage employee anxiety and its consequences, especially in the early stages of COVID-19. Instead of reacting later when stress deepens, it is more beneficial to start moving in advance in terms of employee health. Even though our study revealed the state of anxiety and stress, especially for staff working in the operating room and intensive care units, we think it might reflect front-line workers in hospitals.
Ethics
Ethics Committee Approval: The study was approved by the Ministry of Health and the Ethics Board on 18 January 2021 (decision no: 2021/02-38) from the Dokuz Eylül University.
Informed Consent: An informed consent form was obtained from the participants.
Peer-review: Externally peer-reviewed.
Authorship Contributions
Concept: Ö.Ö., S.B., N.G., Design: Ö.Ö., S.B., N.G., Data Collection and Process: Ö.Ö., S.B., N.G., Analysis or Interpretation: Ö.Ö., S.B., N.G., Literature Search: Ö.Ö., S.B., N.G., Writing: Ö.Ö., S.B., N.G.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.
