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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 88-94

Mental health of the frontline nurses during the COVID-19 pandemic and its association with working conditions and personality traits


1 Department of Psychiatry, GSL Medical College, Rajahmundry, Andhra Pradesh, India
2 INTERN, GITAM Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India
3 Department of Psychiatry, Gayatri Vidya Parishad Institute of Health Care and Medical Technology, Visakhapatnam, Andhra Pradesh, India
4 Department of Psychiatry, GITAM Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India
5 Hinsdale Central High School, Hinsdale, Illinois, USA

Date of Submission30-Oct-2022
Date of Decision07-Nov-2022
Date of Acceptance07-Nov-2022
Date of Web Publication16-Dec-2022

Correspondence Address:
Dr. Archana Vinnakota
Department of Psychiatry, GSL Medical College, Rajahmundry - 533 296, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjp.tjp_41_22

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  Abstract 


Background: During the COVID-19 pandemic, hospital nurses are involved in the direct patient care despite high infection rate. During earlier pandemics, health-care personnel reported significant levels of stress, worry, and depression. The pandemic has adverse outcomes not only on the individual's well-being but also on the patient care and health-care system.
Aim: The aim of this study was to estimate the prevalence of stress, anxiety, and depression among nurses working in COVID-19 treating hospitals and its association with the hospital working conditions and the personality traits.
Methodology: A cross-sectional study was conducted among 218 nurses working in the COVID-19 hospitals. Data were collected using study tools which include the semi-structured sociodemographic questionnaire, hospital working conditions, Perceived Stress Scale, Generalized Anxiety Disorder-7 Scale, PHQ-9 Depression Scale, and Ten-item Personality Inventory (TIPI).
Results: In the current study, the prevalence of perceived stress, anxiety, and depression among nurses was found to be 88.1%, 50.9%, and 28.9%, respectively. Majority of the nurses with higher number of patients to be attended in the hospital were found to have statistically significant high-stress scores. The nurses with higher stress scores were found to have higher mean values of extraversion and openness to experiences traits on the TIPI Scale.
Conclusion: The nurses working in COVID-19 hospitals were found to have a high prevalence of stress, anxiety, and depression. The study showed that there is a significant influence of hospital working conditions along with the individual's personality traits on the mental health of nurses.

Keywords: Anxiety, COVID-19, depression, nurses, personality


How to cite this article:
Vinnakota A, Tummala N, Nemani A, Nukala S, Kasarla SR, Gandham SN. Mental health of the frontline nurses during the COVID-19 pandemic and its association with working conditions and personality traits. Telangana J Psychiatry 2022;8:88-94

How to cite this URL:
Vinnakota A, Tummala N, Nemani A, Nukala S, Kasarla SR, Gandham SN. Mental health of the frontline nurses during the COVID-19 pandemic and its association with working conditions and personality traits. Telangana J Psychiatry [serial online] 2022 [cited 2023 Feb 4];8:88-94. Available from: https://tjpipstsb.org/text.asp?2022/8/2/88/363976




  Introduction Top


Nurses have a critical role in the public health response in delivering direct patient care and take a major responsibility in a patient's safety, continuous monitoring, and treatment. The COVID-19 global health emergency has put intense pressure on nurses in the treatment and control of infectious disease in the country. The World Health Organization has declared 2020 the Year of the Nurse and the Midwife, as the nurses have played crucial frontline roles in pandemics throughout history. The experience of giving nursing care in this situation has the potential to have major short- and long-term effects on individuals, society, and the nursing profession.[1] Hospital nurses are involved in the direct patient care despite high infection rate. The high occupational demands among nurses during the COVID-19 pandemic resulted in stress due to low nurse-to-patient ratio, excessive workload, long working hours, constant shift duties, inadequate personal protective equipment (PPE), lack of adequate sleep, being away from family, and personal life. Their role is critical to the entire health-care operation and pandemic response-processing, assessing, and triaging patients quickly and efficiently. The daily increasing number of cases getting admitted into the hospital impedes the physical and psychological health of the medical staff working relentlessly.[2],[3]

During earlier pandemics, health-care personnel faced significant levels of stress, worry, and depression. Emotions experienced by health-care personnel during the SARS outbreak were linked to resignations and poor work performance.[4] A study conducted on nurses by Garg et al., during COVID-19 pandemic in India, found that 35.4% of nurses experienced stress and 31.1% experienced anxiety symptoms.[5] Another study during COVID-19 by Gupta et al. in India among health-care workers showed that 37.2% had anxiety symptoms and 31.4% had depressive symptoms.[6] In China, a study done by Lai et al., among 1257 health-care workers from 34 hospitals, showed that nurses who were caring directly for patients with COVID-19 experienced higher levels of stress, anxiety, and insomnia than other health-care workers. This study also reported a 50.4% prevalence of depression, 44.6% of participants with anxiety symptoms and 71.5% of them with distress.[7] Mo et al.'s study showed that stress among Chinese nurses is positively correlated with severe anxiety during COVID-19 pandemic.[8] The extreme pressures experienced by nurses during a pandemic have adverse outcomes not only on the individual's well-being but also on the patient care and health-care system. There are worldwide media reports of suicide among hospital nurses during COVID-19 due to extreme levels of stress at workplace with severe anxiety and depressive symptoms.[9]

Various studies have shown that the individual differences in the personality traits explain why few people are more prone to psychological disorders such as depression and anxiety.[10] According to Five-Factor Model, the five personality dimensions are neuroticism, extraversion, openness, agreeableness, and conscientiousness for an individual. A study by Wang and Zhang among nurses showed that extraversion was negatively correlated with and predicted work-related depression and anxiety while neuroticism was positively correlated with and predicted work-related depression and anxiety.[11]

There is a dearth of studies in literature on mental health of nurses during the COVID-19 pandemic in India. There is a need to study the extent and severity of stress, anxiety, and depression among nurses working in COVID-19 treating hospitals and its association with the hospital working conditions and the personality traits of nurses to design the psychological interventions and modify the conditions at workplace by the health-care system. These necessary steps will help in preventing the adverse physical and mental health consequences among the health-care workers.

The objectives of the present study include estimating the prevalence of stress, anxiety, and depression among nurses working in COVID-19 hospitals and determining the association between stress among nurses and personality traits, anxiety, and depression, as well as hospital working conditions.


  Methodology Top


A cross-sectional study was conducted among nurses working in COVID-19 hospitals after obtaining permission from the institutional ethics committee. Convenience sample technique was used in the present study. In a pilot study that was conducted among 20 nurses, the prevalence of stress was found to be 35%. Using the formula for sample size calculation with 95% confidence interval and 0.05 expected margin of error, the required study sample came to be 178. Our final study sample was 218 nurses working in COVID-19 hospitals in a city in South India.

The study tools include study details, consent for participation, sociodemographic data, and study questionnaires. The study material was circulated among nurses working in COVID-19 hospitals through Google Forms links via cross-platform messengers such as WhatsApp and Facebook. The study was conducted for a duration of 3 months from April–June 2021. The nurses who have given consent for their participation were taken into the study. Nurses who were having history of chronic medical illness or psychiatric illness were excluded from the study. The study data were collected from 218 nurses working in COVID-19 treating hospitals in a city in South India.

Study tools

  1. Semi-structured sociodemographic questionnaire and working conditions: For collection of data regarding age, gender, marital status and working conditions in the hospitals, etc.
  2. Perceived Stress Scale (PSS): It is the most extensively used psychological test for assessing the perception of stress. It is a measure of how stressful things in one's life are perceived to be. The test items were designed to capture how unpredictable, uncontrollable, and overloaded respondents find their lives the scale also contains numerous direct questions regarding present stress levels. The PSS questions enquire about the respondent's feelings and thoughts during the last month. In each scenario, respondents are asked how frequently they felt a certain way. PSS scores are calculated by reversing responses (e.g., 0 = 4, 1 = 3, 2 = 2, 3 = 1, and 4 = 0) to the four positively stated items (items 4, 5, 7, and 8) and then summing across all scale items (0 = never, 1 = almost never, 2 = sometimes, 3 = fairly often, and 4 = very often). The individual scores on the PSS can range from 0 to 40 with higher scores indicating greater perceived stress. Scores ranging from 0 to 13 indicate no or low stress. For moderate stress, the scores range from 14 to 26. Scores ranging from 27 to 40 would indicate high perceived stress. This scale has a high level of internal consistency with alphas ranging from 0.829 to 0.903[12]
  3. Generalized Anxiety Disorder-7 (GAD-7) Scale: In anxiety disorder research and general practice, GAD-7 is employed as a measure of anxiety.[13],[14] The GAD-7 total score ranges from 0 to 21 for the seven items. Cutoff thresholds for mild, moderate, and severe anxiety are 5, 10, and 15, respectively. Using a threshold of 10, the GAD-7 has an 89% sensitivity and an 82% specificity for generalized anxiety disorder[15]
  4. PHQ-9 Depression Scale: The PHQ-9 is the Patient Health Questionnaire's nine-item depression measure. It is one of the most validated tests in mental health and may be a strong tool to assist physicians with diagnosing depression and monitoring the response of the treatment.[16] The nine items of the PHQ-9 are directly based on the DSM-IV diagnostic criteria of major depressive disorder. The response categories “not at all,” “several days,” “more than half the days,” and “nearly every day,” are given scores of 0, 1, 2, and 3, respectively and then the total score is calculated. The PHQ-9 total score ranges from 0 to 27 for the nine items. Cutoff points for mild, moderate, moderately severe, and severe depression are 5, 10, 15, and 20, respectively. Cronbach's alphas range from 0.83 to 0.89 and inter-rater reliability ranges between 0.83 and 0.92[17]
  5. Ten-Item Personality Inventory (TIPI): This inventory was drawn up by two American psychologists at the University of Texas and consists of a list of 10 items of personality traits that may describe the subject. From the questionnaire, we get what are the 5 factors in the Big Five: extroversion, agreeableness, conscientiousness, emotional stability, and openness to experiences.[18] It was asked to the participants to indicate the degree of agreement for each of the features presented by a 7-point Likert scale (1 = strongly disagree, 2 = moderately disagree, 3 = poorly disagree, 4 = neither agree or disagree, 5 = quite agree, 6 = moderately agree, and 7 = strongly agree). TIPI Scale scoring (“R” denotes items that have been reverse-scored): Extraversion items are 1, 6R; Agreeableness items are 2R, 7; Conscientiousness items are 3, 8R; Emotional Stability items are 4R, 9; and Openness to Experiences items are 5, 10R.



  Results Top


In the present study, the statistical analysis was performed by using IBM SPSS statistics (Version 16), Chicago, United states and MS Excel 2007. Descriptive statistics were used. Qualitative variables were expressed as frequencies and percentages. Chi-square test was used to find the association between variables. For all statistical analyses, P < 0.05 was considered statistically significant.

In the present study, the final sample population was 218 nurses working in COVID-19 hospitals. Among the total sample, majority of the nurses were female (83%) and most of them belonged to 20–30 years' age group (48.6%). Majority (72.5%) of the nurses in COVID-19 hospitals were found to be living with family members and 31.7% were living with elderly members in their family. 39.4% of nurses were having children of age <10 years [Table 1].
Table 1: Sample characteristics (total sample=218)

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In the current study, the hospital working conditions of the nurses during the COVID-19 pandemic showed that 25.2% of the nurses were found to be working for >5 months in the COVID-19 hospitals at the time of the study. 65.1% of nurses were found to be attending 50–100 COVID-19-positive patients during the past 1 month, 65.13% of nurses were found to be taking quarantine after COVID duties, and 92.2% of nurses had PPE kits available during their working period. Most of the nurses (47.2%) were having more than 1 year of previous experience of working in hospitals [Table 2].
Table 2: Hospital working conditions during COVID-19 pandemic

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In this study, 88.1% (n = 192) of nurses were found to have a PSS score >13. On the GAD-7 Scale, 111nurses (50.9%) were found to have anxiety. On the PHQ-9 Scale, 63 (28.9%) nurses were found to have depression [Table 3].
Table 3: Prevalence of stress, anxiety, and depression

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The association between stress (PSS >13) and working conditions in the COVID hospitals was calculated. In this study, a statistically significant association was found between stress and number of COVID patients attended by the nurses in the hospitals (P < 0.05). The other working conditions such as total duration of work in COVID hospitals and availability of PPE did not show a statistically significant association with number of individuals having stress, but significant differences in the percentages were found in the study [Table 4].
Table 4: Association between stress and working conditions in COVID-19 hospitals

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Mean values of all the five personality traits on the TIPI Scale showed a statistically significant association with stress [Table 5].
Table 5: Association between stress and personality traits

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Out of 192 nurses with high-stress score (PSS >13), 99 (51.6%) showed high anxiety scores on the GAD-7 Scale. Fifty-seven (29.7%) nurses of 192 with PSS >13 showed high depression scores on the PHQ-9 Scale [Table 6].
Table 6: Association of stress with anxiety and depression

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  Discussion Top


The widespread outbreak of COVID-19 pandemic has been the cause of many psychological problems such as stress, anxiety, depression, and posttraumatic disorders across worldwide due to its high disease prevalence, novelty, and high infectious nature.[19],[20] The COVID-19 mental health impact is not only seen among general population but also among the health-care workers.[21],[22] Studies have shown that among health-care workers, the frontlines nurses are more vulnerable to psychological distress as they are in continuous and direct patient care during the pandemic. The underdiagnoses of the mental health impact of COVD-19 among nurses may lead to low quality of life, low occupational performance, and suicide.[23],[24] In this sense, the current study was designed to better understand the influence of the pandemic on the metal health of nurses.

The present study was conducted among 218 nurses who were working in COVID-19 hospitals. Majority of the nurses in the current study sample were female, were married, and belonged to 20–30 years' age group. This is in accordance with the general male–female distribution of health workforce statistics in India where majority were female nurses in the hospitals.[25]

In the current study, the prevalence of perceived stress, anxiety, and depression among nurses working in COVID-19 hospitals was found to be 88.1%, 50.9%, and 28.9%, respectively. Other studies in India showed different rates of prevalence of stress, anxiety, and depression among nurses and other health-care workers. Garg et al. conducted an online cross-sectional survey among 209 nurses in a COVID-19-designated tertiary care hospital in India and found 35.40% of nurses with moderate-to-high level of stress and 31.1% with anxiety symptoms.[5] Another study by Gupta et al., among 1124 health-care workers in India, showed that 37.2% had anxiety symptoms and 31.4% had depressive symptoms during the COVID-19 pandemic.[6] Cornelio et al.'s study on 83 nurses working in COVID-19 intensive care unit and wards in a hospital of Mumbai city in India showed that 48% had moderate stress, 11% had severe stress, and 1% with extremely severe level of stress. In the same study, 17%, 4%, and 4% were found to have had mild, moderate, and severe depression, respectively. It also showed that 38% of nurses had moderate levels of anxiety.[26]

The high prevalence rates of stress, anxiety, and depression in the present study might be because of the surge in the COVID-19 cases in the study region during the data collection period, the geographical variations, and the differences in hospital working conditions. The study also showed that a significant number of nurses were found to be living with family members while working in COVID-19 hospitals, especially elders and children in their family. This may also contribute to the increased frequency of stress, worry, and depression among nurses during pandemics due to the fear of illness transfer to family members. Studies found that the major obstacle faced by the nurses working in the COVID-19 unit as the fear of the risk in transmission of infection to the vulnerable population in the family such as elders, pregnant women, and children.[27]

In this study, the working conditions in the COVID-19 hospitals were found to have impact on stress among nurses. Majority of the nurses with higher number of patients to be attended in the hospital were found to have statistically significant high-stress scores (P < 0.05). The other working conditions such as duration of work and availability of PPE kit also showed differences in number of nurses with high-stress scores but not statistically significant. In literature, the other studies also showed that high workload contributed to the psychological stress among nurses, especially high patient–nurse ratio.[28]

In the current study, a statistically significant association was found between personality traits and stress among nurses working in the COVID-19 hospitals. The nurses with low stress were found to have higher mean values of personality traits such as agreeableness (3.788), conscientiousness (4.365), and emotional stability (4.058) on the TIPI Scale. The nurses with higher stress scores were found to have higher mean values of extraversion (4.388) and openness to experience (5.063) traits on the TIPI Scale. This is in accordance with other studies that showed the influence of personality traits on occupational stress among nurses. Certain personality traits are found to be strong predictors for stress and psychological well-being.[29],[30]

The present study findings also showed that majority of the nurses with high-stress scores also had high anxiety (GAD-7) and depression (PHQ-9) scores but statistically not significant. Other studies among nurses in general hospitals showed a statistically significant association between stress, anxiety, and depression. Poursadeghiyan et al.'s study among nurses in Iran showed that work-related stress was negatively associated with depression and anxiety.[31]


  Conclusion Top


This study highlights the extent of psychological impact on nurses in COVID-19 treating hospitals along with the influence of hospital working conditions and individual's personality traits on the mental health of nurses. The study showed a high prevalence of stress (88.1%), anxiety (50.9%), and depression (28.9%) among nurses during pandemic. Among the working conditions of the COVID-19 treating hospitals, the number of patients to be attended by the nurses was found to be associated with high stress. Nurses with personality traits such as extraversion and openness to experiences were found to have high-stress levels.

Limitations

The study has certain limitations such as small sample size and the data restricted to one geographical area. Hence, the study findings may not be generalizable. The methodology of the study is another limitation as only those nurses with availability of cellphones and cross-platform messengers were able to participate in the survey, but considering the pandemic situation, this method is much helpful in understanding the mental health of nurses. Certain other factors like coping strategies among nurses that might be helpful in dealing with stress need to be studied in detail. The role of any intervention that was not included in the present study is another drawback.

Future directions

There is a need for multicentric studies among the nurses from various hospitals in the country to explore the extent and severity of psychological impact of COVID-19 pandemic. There is a need for studying the effectiveness of standardized regular mental health screening procedures to prevent the damaging effect on the physical and psychological well-being of nurses. There is a need to study and implement the timely psychological interventions and modifications in the hospital working conditions for the nurses.

Acknowledgment

We would like to thank all the nurses who participated in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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