ABSTRACT

Objective:

This study investigated the effects of psychological distress on the work ability of intensive care nurses during the COVID-19 pandemic in Turkey.

Materials and Methods:

The sample size of this descriptive and cross-sectional study was determined to be at least 220 nurses, with a level of significance of 0.05, a confidence interval of 99%, and the ability to represent the population of 80%. The research was completed with 233 nurses. A Participant Information Form, the COVID-19-related Psychological Distress Scale, and the Work Ability Index were used to collect data online using Google Forms and email or social media accounts. In the analysis of data, Pearson and Spearman correlation analysis was used along with descriptive statistics.

Results:

A statistically significant positive correlation was found between the nurses’ length of time working in the profession and their WAI scores (r=0.132, p=0.043), and a negative correlation was found with their COVID-19 PDS scores (r=-0.162, p=0.013). A statistically significant difference was found about WAI total scores in the effect on work ability of the working conditions of the COVID- 19 pandemic (p<0.001). A statistically significant positive correlation was found between the WAI total score and the COVID-19 PDS sub-section of Doubt (r=0.128, p=0.049).

Conclusion:

It was found that the work abilities and COVID-19 psychological distress levels of intensive care nurses living in Turkey were medium. Correlations were found between nurses’ work competency and psychological distress. It is recommended that the many factors affecting work ability and psychological distress be taken under control.

Keywords:

Anxiety, COVID-19, work ability, pandemic, psychological distress, doubt, intensive care nurses

Introduction

All over the world, whenever there are outbreaks of disease, natural disasters or war, important responsibilities fall to nurses especially (1). One very special branch of nursing is intensive care nursing, and these nurses work in a physically and psychosocially high risk environment (2). At the same time, the intensive care nurse performs complex duties which include critical situations such as facing unforeseen events, rapid decision making under time stress, and dealing with aggressive relatives (3). In addition to these problems, the coronavirus pandemic appeared in China and rapidly spread over the whole world, infecting a very large number of people, resulting in a large number of people in need of intensive care, and intensive care nurses taking a major role in treatment and care. This increased their workload and caused intense stress, leaving them at risk of mental health problems such as exhaustion, depression and anxiety (4, 5). Studies have shown that the coronavirus disease-2019 (COVID-19) pandemic has increased the risk of mental disorders such as schizophrenia, anxiety, depression and acute stress disorder in both health workers and the general population, leading to an increase in fear of illness, anger, the misuse of alcohol and tobacco, divorce and suicide (6, 7). According to a report by the World Health Organization in 2020, there is not enough nursing workforce in the world to maintain universal health (8); the nursing workforce should remain healthy and not be worn out (9). Particularly during COVID-19, it is necessary to evaluate the difficulties experienced by intensive care nurses-working long hours without a break caring for and treating patients, both putting themselves at risk and living with the fear of infecting their families and friends-their workload, their psychological and mental health, and their work ability levels (2, 9).

The concept of work ability, which is frequently used in the field of work health, is an important element in work health services, where greater physical and psychosocial working capacity is needed, and the risk of disabling injury and illness is high (2), and is defined as how a person meets work-related difficulties, or in other words the ability of a worker to cope physically and mentally with difficulties at work (10). This concept is an indicator of how well a person’s physical, mental, social and interpersonal abilities match their personal capacities, but also of how well they match their work needs and improvement in their working environment and working conditions, job satisfaction, performance, health, knowledge, skill, attitude and motivation with the necessities of the work they do (10, 11). Studies have reported that an intensive care nurse’s work ability is affected by factors such as body mass index, age, personal characteristics, physical and mental fatigue, lack of sleep, disappointment, shift working and workload (2, 12, 13). Inadequate work ability in nurses causes poor quality of life (14), leaving the profession early (15), cardiovascular diseases in obese individuals, an increase in the risk of mental disorders or diseases such as those of the musculo-skeletal system and resulting disability (16). Taking all of these factors into consideration, it is necessary to improve the work ability levels of nurses, because a person whose work ability is high is predicted to be able to continue doing his or her job for longer (17). In a systematic review and meta-analysis study by Romero‐Sánchez et al. (9) evaluating the prevalence of the work inadequacy of nurses working in a hospital, it was concluded that in the world in general, approximately one nurse in four working in a hospital had work inadequacy and that there was an imbalance between individual resources and work, and for this reason nurses were at risk of various negative results throughout their working lives.

The literature shows that very little is known about work ability in a group of health care personnel who are very much needed throughout the world (2). At the same time, although there are studies on the work ability of intensive care nurses during the COVID-19 pandemic, no studies were found evaluating their work ability and psychological distress together. Thus, this study was aimed at investigating the effects on the work ability of intensive care nurses of psychological distress during the COVID-19 pandemic. It is thought that the conclusions of the research will make a contribution to the literature.

Research Questions

1. What are the levels of work ability in intensive care nurses?

2. What is the psychological distress on intensive care nurses in the COVID-19 pandemic?

3. Is there a correlation between the psychological distress on intensive care nurses in the COVID-19 pandemic and their work ability levels?

Materials and Methods

Type of Study

The study is descriptive and cross-sectional.

Study Design and Sample

The population of this study consisted all of nurses living in Turkey and working in an intensive care unit between March and September 2021, regardless of period of time, when the research was conducted. OpenEpi v.3, a statistics program available for general use, was used in calculating the size of the sample (http://www.openepi.com), and this was found to be at least 220 nurses, for a significance level of 0.05, a confidence interval of 99%, and an ability to represent the population of 80%. The research was completed with 233 nurses who were selected from the population by the non-probability random sampling method, and who participated willingly and voluntarily in the study. The inclusion criteria were working in an intensive care unit, voluntarily and willingly participating in the study, not having a problem with vision or hearing, having access to the internet and actively using social media (Facebook, Instagram or WhatsApp).

Data Collection

After obtaining the necessary permissions and before beginning the research, written and oral approvals were obtained from the nurses who met the inclusion criteria, and data was collected online between March and September 2021. The data collection forms created on Google Forms were sent to the nurses by email or to their social media accounts (Facebook, Instagram or WhatsApp), and they were asked to complete them.

Data Collection Tools

Data was collected using a Participant Information form created in line with the literature, the COVID-19 Related Psychological Distress scale (CPDS), and the Work Ability index (WAI).

Participant Information Form: This form, created by the researchers according to the literature 15 with the objective of determining the participants’ personal characteristics, contained questions on age, gender, education level, marital status, place of residence, years of work, length of time working in the intensive care unit, and the effects on physical and mental health of the COVID-19 pandemic.

CPDS: This scale was developed in 2020 by Feng et al. (18) and Turkish validity and reliability were performed by Ay et al. (19). It measures the level of psychological distress in uninfected people. The scale consists of a total of 14 items, and has two sub-sections, doubt, and anxiety or fear. The items on the scale are of five-way Likert type: 1-I definitely disagree, 5-I definitely agree. On the original scale, the Cronbach alpha consistency values were as follows: scale total 0.88, anxiety or fear sub-section 0.74, and doubt sub-section 0.87. In the present study, these values were 0.81, 0.62 and 0.78 respectively. Higher scores reflect a higher severity of psychological distress (19).

WAI: This scale began to be used in 1980 in Finland, and it was developed to prevent problems arising from work or the work environment in 1998 under the leadership of Prof. Juhani Ilmarinen at the Finnish Institute of Occupational Health (20). Turkish validity and reliability were performed by Das Gecim and Esin (21). The WAI is a Likert type scale with a total of seven items, intended to assess individuals’ work load and performance. Possible scores range between 7 and 49. According to the scale’s scoring system, a score of 7-27 represents low work ability, 28-36 medium work ability, 37-43 good work ability, and 44-49 excellent work ability. The Cronbach internal consistency value of the original scale is 0.72, and it is 0.67 in the present study. According to the score obtained on the scale, interventions are made to increase an individual’s physical or mental or both physical and mental capacities (20, 21).

Ethical Approval

During the research, the Helsinki Declaration on Human Rights was followed. Before commencing the research, approval was obtained from Amasya University Non-Interventional Ethics Committee dated 04 March 2021, decision no: 37, and written permission was obtained from the Turkish Health Ministry Pandemic Research Permission Portal.

Statistical Analysis

The program R version 2.15.3 was used for the statistical analyses (R Core Team, 2013). In reporting study data, minima, maxima, means, standard deviations, medians, first quartile, third quartile, frequencies and percentages were used. Conformity of quantitative data to normal distribution was assessed with the Shapiro-Wilk test and graphical inspections. In evaluating variables showing normal distribution between two groups, the independent groups t-test was used, in evaluating between more than two groups, One-Way variance analysis was used, and if significance was observed, the Bonferroni test was used to determine the source of the significance. In evaluating variables which did not show normal distribution between two groups, the Mann-Whitney U test was used; in evaluating between more than two groups, the Kruskal-Wallis test was used, and when significance was observed, the Dunn-Bonferroni was used to determine the source of the significance. In determining the level of correlation between quantitative variables, Pearson and Spearman analysis was used. In determining the levels of internal consistency of the scale, the Cronbach alpha coefficient was used. Statistical significance was taken as p<0.05.

Results

Participants’ General Characteristics

The ages of the nurses in the study ranged from 21 to 49 years (Table 1).

The findings of the research can be grouped under three headings:

Intensive Care Nurses’ Work Ability and COVID-19 Psychological Distress Levels

The nurses scored the following: WAI total score mean 31.41±6.97 [minimum (min): 11-maximum (max): 47]; COVID-19 PDS anxiety and fear sub-section score mean 10.06±3.78 (min: 5-max: 25); COVID-19 PDS doubt sub-section score mean 20.13±5.86 (min: 7-max: 35), and COVID-19 PDS total scale mean 30.18±8.42 (min: 12-max: 60) (Table 2).

Correlation Between Intensive Care Nurses’ Work Ability and COVID-19 Psychological Distress Levels

A statistically significant positive correlation was found between the nurses’ WAI total score mean and their COVID-19 PDS doubt sub-section score mean (r=0.128, p=0.049). A statistically significant positive correlation was found between the COVID-19 PDS total score mean and the anxiety and fear and the doubt sub-sections (r=0.799, p<0.001; r=0.922, p<0.001), and a statistically positive correlation was found between the COVID-19 PDS anxiety and fear sub-section and the doubt sub-section (r=0.503, p<0.001) (Table 3).

Factors Affecting the Intensive Care Nurses’ Work Ability and their COVID-19 Psychological Distress Levels During the Pandemic

A statistically significant positive correlation was found between the nurses’ length of time in the profession and WAI total score (r=0.132, p=0.043), and a statistically significant negative correlation was found with the COVID-19 PDS total score (r=-0.162, p=0.013). In other words, it was seen that the level of COVID-19 PDS decreased as the time spent in the profession increased. A statistically significant difference was found with regard to the nurses’ COVID-19 PDS total scores according to their gender (p<0.001). It was found that the COVID-19 PDS scores of the males were higher than those of the females (Table 4).

A statistically significant difference was found regarding WAI and COVID-19 PDS total scores according to whether the participants has had a coronavirus infection (p=0.022 and p=0.012 respectively). The scores of those who had had a coronavirus infection were lower (Table 4). A statistically significant difference was found regarding WAI and COVID-19 PDS total scores according to the test results of participants who had had a COVID-19 test (p=0.010 and p=0.044 respectively). The scores of those whose test results were positive were lower. A statistically significant difference was found regarding WAI and COVID-19 PDS total scores according to whether they were afraid of being infected by coronavirus (p=0.026 and p<0.001 respectively). Those who were afraid of coronavirus infection had lower scores (Table 4).

Discussion

In this research, an investigation was made of the effect of psychological distress on intensive care nurses’ work abilities during the COVID-19 pandemic.

Work Ability

It was found in the study that the work ability of nurses living in Turkey and working in intensive care units was at a medium level. There are also other studies in the literature which similarly state that nurses’ work abilities are at a medium level (22, 23). In contrast to the results of our research, Vasconcelos et al. (24) found that nurses’ work abilities were low, and in studies with nurses by Milosevic et al. (14) and Rotenberg et al. (12) it was found that nurses’ work abilities were at a good level. In international studies, inadequate or low work ability has been correlated with advanced age, female gender, difficulties with place of work, having another job, doing repetitive or monotonous work, inadequate personnel, and various morbidities (23, 25). Evaluating work ability is frequently used in work health services, and both helps to improve workers’ health, to ensure the continuation of people’s ability to work, and for correct measures to be taken, and also allows the determination of which worker needs which work health service, and of whether there is a decline in people’s working conditions (26). At the same time, it allows negative situations for work and workers to be noticed earlier and the necessary measures to be taken, so that its assessment is important (19). According to the literature, studies on work ability among intensive care nurses are insufficient (2). Work ability can be disrupted by such work-related factors as excessive use of muscle strength, lifting and carrying loads, repeated movements, inadequate or wrong standing positions, exposure to accidents related to work or the work environment and the risks which these create, conflicting roles and the lack of opportunity development and recognition in the workplace (24). It was found in this study that intensive care nurses’ work abilities were affected by income status, general health level, regularly used medication or chronic illness, willingness to work in intensive care, whether they thought that the work strength or the capacity of the unit where they worked was suitable, their satisfaction with their work or working conditions, the effect of the COVID-19 pandemic on their work satisfaction, experiencing health problems arising from their work or working environment, the state of participants’ satisfaction with their work or working conditions, the effect of the COVID-19 pandemic on physical and mental health, and the fear of infection or of infecting others with the coronavirus. It was found in a study by Tuomi et al. (27) that an excessive work load together with symptoms of a high level of stress cause low work ability, and a study by Rostamabadi et al. (2) found that factors such as individual characteristics, illness, tiredness and an excessive work load affected the work ability of intensive care nurses. It has also been found that age is one of the factors reducing work ability both in nurses (15) and in other professions (13). In order to improve the negative factors affecting the skill; It can be recommended to improve the clinical physical environment, to develop and maintain in-service training programs, to make learner-centered education programs, to adopt lifelong learning approaches, and to develop and implement a peer-mentoring system for nurses.

COVID-19 Psychological Distress

The outbreak of COVID-19 has significantly affected the psychological, social and mental health of health workers on the front line, including nurses caring for and treating patients. It is reported in the literature that nurses, who are exposed to infection or the risk of infection and to intense stress, experience stress, anxiety, insomnia and psychosocial problems (28, 29). In a study by Da Rosa et al. (4) it was found that the prevalence of emotional distress in nurses was high. For this reason, it is of great importance to understand the effects of the COVID-19 pandemic on psychological health (30). It was found in our research that the psychological distress levels of intensive care nurses relating to the COVID-19 outbreak were at a medium level. Similarly, Kackin et al. (28) found in a study conducted with nurses in Turkey that nurses caring for patients with a diagnosis of COVID-19 were negatively affected both psychologically and socially by the pandemic, and that nurses used short-term coping strategies and needed psychosocial support and resource management. It was found in a study by Zonp et al. (31) that nurses were at a high risk of developing mental health problems during the COVID-19 pandemic. It was found in our study that the intensive care nurses’ total COVID-19 PDS scores were affected by factors such as length of time working in the profession, gender, income, health problems arising from work or the work environment, the effect of the COVID-19 pandemic on physical health, and fear of infection or of infecting others with coronavirus. It was also found that the psychological stress levels of male intensive care nurses were higher than those of female nurses. In contrast to these research results, it was found in studies conducted with various different sample groups evaluating psychological distress during the COVID-19 pandemic that the psychological distress of females was higher (32, 33).

Correlation Between Work Ability and COVID-19 Psychological Distress

It was found in the study that the mean scores on the COVID-19 PDS sub-sections of anxiety and fear and doubt were at a medium level, and that there was a positive correlation between the WAI total score and these sub-sections. In other words, nurses with high work ability are more fear of COVID-19 and experience more anxiety than other nurses. It has been found in the literature that during the COVID-19 pandemic, there was a feeling of not being prepared for the pandemic, emotional distress, anxiety, concern, depression, stress and worry caused by a deterioration in mental health conditions, dissatisfaction with work, and a fear of the workplace being infected because of the number of COVID-19 cases (28, 29). It was concluded in a study by Da Rosa et al. (4) that health professionals worried about being infected or infecting their families or others. Sampaio et al. (34) found a positive correlation between the fear of being infected and depression, anxiety and stress, and Said and El-Shafei (35), in a study conducted in Egypt during the pandemic, found that a very stressful work environment resulted in dissatisfaction with work and a tendency to leave work. Considering all of this, it is an expected result that doubts or worries connected to psychological distress experienced by intensive care nurses in the COVID-19 pandemic should be parallel to their work ability. The COVID-19 pandemic has affected health workers’ mental health with increased stress, worry, depressive symptoms and insomnia (29). Also, the COVID-19 pandemic has led to a high incidence of COVID-19 infections in health workers who are on the front line, and a high prevalence of post-infection symptoms (36). The fact that all of these conditions have a negative effect on work ability suggests that low work ability will increase in the pandemic, and that the situation will remain for some time afterwards (9). Also, it is necessary to increase awareness of how important work in the intensive care unit is, and for nurses working in these units who have a heavy work load and are at risk to have work ability and working capacity in accordance with their work demands (2).

Limitations of the research are that the research results can only be generalized to the sample group, and because it was a cross-sectional study, cause and effect relationships cannot be established. Also, the difficulty of contacting the intensive care nurses and the collection of data online during the COVID-19 pandemic are a further limitation of the study.

Conclusion

In the research, it was determined that the work abilities and the COVID-19 psychological distress levels of intensive care nurses living in Turkey were at a medium level. In order to reduce or eliminate factors such as having had coronavirus, length of time working, or general health condition, it is recommended that suitable work health services be implemented. Also, in order to eliminate all physical and mental factors which cause a decline in work strength and performance by reducing work ability in intensive care nurses, the implementation of programs to improve work health is of importance.

Acknowledgements: We wish to thank all the participating intensive care unit nurses.

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The Effect on the Work Ability of Intensive Care Nurses of Psychological Distress During the COVID-19 Pandemic: Descriptive and Cross-sectional Study