Nurses´ mental health and professional quality of life during the COVID‑19 crisis: Effects of preventive quarantines

Salud mental y calidad de vida profesional de las enfermeras durante la crisis COVID‑19: Efectos de los confinamientos preventivos

The COVID-19 crisis has been the biggest global public health problem in decades and for many healthcare professionals it will represent the greatest professional challenge of their lives. For them, the crisis has resulted in high exposure to occupational stressors that can lead to psychopathological symptoms (Bettinsoli et al., 2020; Chen et al., 2020; Lai et al., 2020). In addition to the high care pressure caused by successive waves of the pandemic, there are also concerns such as the fear of becoming infected or infecting one's family (Wang et al., 2020). Among other factors, physical exhaustion, uncertainty, fear of not providing competent care, or lack of support have been linked to mental health problems (Pappa et al., 2020).

Numerous studies have found significant levels of anxiety, depression, and psychological distress in healthcare professionals since the beginning of the health crisis (Alonso et al., 2020; Lai et al., 2020; Pappa et al., 2020), as well as a negative impact on the quality of professional life in terms of burnout (BO) and compassion fatigue (CF; Dosil-Santamaría et al., 2021; Ruiz-Fernández et al., 2020). These effects are more intense in front-line professionals, women and young professionals (Lai et al., 2020; Pappa et al., 2020; Romero et al., 2020).

Physicians and nurses are the professionals most vulnerable to the crisis (García-Fernández et al., 2020; Rodríguez-Rey et al., 2020), and this vulnerability would be greater in nurses as they present higher levels of stress during the pandemic (Mo et al., 2020). In addition, greater stress is a risk factor for emotional disorders such as anxiety or depression, which are also more prevalent in women (Pérez-Martínez & Gabiña, 2019). These reasons, and especially the CF or personal cost of the helping relationship with the patient, lead us to consider nurses as a group particularly vulnerable to the psychological impact of the current crisis (García-Fernández et al., 2020; Rodríguez-Rey et al., 2020).

Despite the enormous amount of research that has been produced, to our knowledge there are no studies that evaluate the effect of close-contact preventive confinement or the experience of COVID-19 infection on both mental health and professional quality of life in Spanish healthcare professionals, and none that investigate the effect of these experiences on fear of infection.

The main objective of this study was to evaluate the impact of the COVID-19 crisis on a large sample of Spanish nurses in the public health system in terms of anxiety, depression, perceived stress, fear of COVID-19, CF, BO and demand for psychological help, as well as the possible effect of preventive confinements on these variables.

A total of 439 professionals with an age range of 22 to 64 years (M = 41.53; SD = 11.38) participated. All sociodemographic and occupational data of the sample can be seen in Table 1.

Table 1.

Descriptive data on socio-demographic and labor variables

Table 2 shows the percentages of professionals grouped into low, medium and high levels of perceived stress, anxiety, depression, BO and CF, as well as the cut-off points for each of the instruments used. These levels are presented according to sex and high or low exposure to COVID-19 patients.

Perceived stress levels were moderate in 65.4 % of the sample and high in 17.1 %. Cases of anxiety and depression were detected in 37.6 % and 17.1 % of participants, while 24.8 % and 28 % of the sample were identified as probable or at-risk cases of anxiety and depression, respectively. BO levels were medium in 11.4 % of the sample and high in 50.6 %, while CF levels were medium in 27.1 % and high in 59.7 %. Only 1.4 % and 13.2 % of the participants had low levels of BO or CF, respectively. Scores according to the percentages exposed tend to be higher for women and nurses with high exposure. Next, it will be tested whether these differences are statistically significant.

Table 2.

Frequencies and percentages of nurses at different levels of perceived stress, anxiety, depression, burnout, and compassion fatigue as a function of sex and high or low exposure to COVID-19 patients (N = 439)

Note: The cut-off points used to form the groups are indicated in parentheses.

Perceived stress was higher in professionals with high exposure (M = 29.17) with respect to the rest (M = 26.91, p = .019) with a small effect size (d = .23). The same was observed for the anxiety variable, with higher levels in first-line nurses (M = 9.63) than in the rest of the professionals (M = 8.65, p = .023) with an effect size also small (d = .23). However, no differences were found between professionals with high and low exposure to infected patients in fear of COVID-19 and in depression. On the other hand, differences in BO were found between professionals with high exposure to COVID-19 patients (n = 161) and low exposure (n = 278), with BO being higher in the nurses with high exposure (M = 27.36) with respect to the nurses with low exposure (M = 25.06, p = .001) with an intermediate effect size (d = .32). Similarly, significant differences in CF were observed between professionals with high exposure (M = 22.54) versus low exposure (M = 19.73, p = .004) with a small effect size (d = .29).

Finally, statistically significant differences were found between men and women in all psychological variables, as shown in Table 3.

Table 3

T-test for the difference in means between women and men

Note: T: value of the t-statistic; p: p-value of the t-test for the mean difference; d: effect size according to Cohen's d.

Regarding the demand for psychological help, 38.5 % of the sample considered this help necessary, while 7.7 % were already receiving it. Eighty-six percent of the participants considered that it would have been useful to receive this type of intervention in the workplace. Between those who considered psychological help necessary or were already receiving it (n = 169) and those who did not consider it necessary (n = 270), statistically significant differences were found in all the psychological impact variables analyzed. Thus, nurses who considered it necessary to receive psychological help obtained higher scores on all these variables with a large effect size, as shown in Table 4.

Table 4.

T-test for the difference in means between nurses who considered psychological help necessary or not on different variables (N = 439)

Note: T: value of the t-statistic; p: p-value of the t-test for the mean difference; d: effect size according to Cohen's d

No statistically significant differences were found between those who had received a diagnosis of COVID-19 or positive test (n = 40) and the rest of the professionals (n = 399) in perceived stress (p = .939), anxiety (p = .580), depression (p = .891), BO (p = .354), CF (p = .766) or fear of COVID-19 (p = .337). However, significant differences were observed between those who had performed preventive quarantines (n = 104) and those who had not (n = 335), with levels of anxiety, depression, CF and fear of COVID-19 being higher in the former, as shown in Table 5.

Table 5.

T-test for the difference in means between nurses with and without preventive quarantines

Note: T: value of the t-statistic; p: p-value of the t-test for the mean difference; d: effect size according to Cohen's d

The results of the present study reveal a significant impact on the mental health of nurses during the COVID-19 crisis, with percentages of "cases" and "probable cases" of anxiety and depression high for a sample of active workers. The study shows a high number of cases of depression, anxiety, perceived stress and burnout among nursing staff. Also, being a woman, working with COVID-19 patients, and previous quarantines were associated with higher psychological distress. On the other hand, the COVID-19 infection among nurses does not have a significant impact in terms of their psychological distress or professional quality of life. However, it is important to note that the HADS is only a screening tool used to assess the intensity of anxiety and depression symptoms. Thus, although this scale allows participants to be grouped in terms of "cases", "probable cases" or at-risk cases and "non-cases", it should be emphasized that no score obtained implies a clinical diagnosis of anxiety or depression, and that no score on this scale is a necessary or sufficient condition for diagnosis. The results of our study are similar to others carried out both in Spain (Alonso et al., 2020; Dosil-Santamaría et al., 2021; Erquicia et al., 2020; Lobos-Peña et al., 2021;Londoño-Ramírez et al., 2021; Luceño-Moreno et al., 2020) and in other countries (AlAteeq et al., 2020; Xiong & Peng, 2020). Thus, with respect to depression, the sum of "cases" and "at-risk cases" detected by Luceño-Moreno et al. (2020) yields 51.3 %, slightly higher than our 45.1 %. In their study, the percentage of professionals above the cut-off point for the identification of anxiety risk cases is 79.3 %, also higher than our 62.4 %. Erquicia et al. (2020) found 71.6 % of healthcare professionals with symptoms of anxiety, while Alonso et al. (2020) concluded that 45.7 % of Spanish healthcare professionals present some emotional disorder, a percentage that rises to 50.4 % among nurses. In other countries, Xiong and Peng (2020) found symptoms of anxiety in 40.8 % of nurses, as well as depression in 26.4 %, while Azoulay et al. (2020) identified a prevalence of these symptoms of 50.4 % and 30.4 %, respectively. For their part, Simonetti et al. (2021) observed moderate anxiety levels in 33.23 % of the nurses. In summary, being a nurse during the present crisis is associated with psychopathological symptoms of anxiety and depression (Luceño-Moreno et al., 2020).

There are differences in the results of the studies cited, and these may be due to different reasons such as the use of different samples and assessment instruments. In addition, it is important to consider that environmental conditions have changed over time, so that some shortcomings of the first months of the pandemic, such as the lack of personal protective equipment or less scientific evidence to guide the clinical approach to patients, have improved substantially.

In our study, those professionals who had performed preventive quarantines by close-contact to COVID-19 cases show a greater negative impact on their mental health in terms of anxiety and depression, in coherence with previous studies (Alonso et al., 2020). Our work also reveals that quarantines increase CF and fear of COVID-19, and to the best of our knowledge, this is an unexplored effect in the literature. However, the COVID-19 infection of the own professionals would be a less important variable to consider, or even irrelevant, as it has not been shown to increase the impact on the mental health of nurses or their professional quality of life in terms of BO and CF.

The BO levels is a issue of great concern. A study conducted during the first months of the pandemic in Spain (Ruiz-Fernández et al., 2020) found medium/high levels of both CF and BO in healthcare professionals, as well as perceived stress, especially in front-line workers. However, while the percentage of workers with high levels of CF in that study and ours is practically the same (60.5 % and 59.7 %, respectively), this research found a substantial increase in the percentage of professionals with high levels of BO, which rises from 36 % to 50.6 %. This finding implies that while CF and perceived stress have remained stable, BO could have increased in nurses during the pandemic. Given this scenario and considering the high proportion of nurses at risk of presenting emotional disorders, the need to implement preventive programs aimed at strengthening resilience is justified.

The responsibility of the institutions is fundamental because we will continue to need nurses to face the crisis we are experiencing. Unfortunately, protocolized psychological interventions in healthcare professionals have been scarce during the crisis, with great variations in format and objectives (Priede et al., 2021), despite the reduction in psychological distress and the positive impact on patient care and on the healthcare system itself that they produce (Forner-Puntonet et al., 2021). In this regard, it is important to consider that 86% of the participants in our study considered it useful or very useful to receive psychological interventions in the workplace. This is important because physicians and nurses are generally reluctant to participate in psychological interventions, and that they prefer a face-to-face format as opposed to online (Shechter et al., 2020).

In the interpretation of our results, one aspect to take into account is the context of the lack of nurses in the Spanish healthcare system. This situation has led many professionals with little experience and without advanced training to perform their functions in special services such as the ICU or the emergency room. This situation may have led to greater psychological distress. Especially in young professionals, the absence of consolidated technical skills leads more frequently to experiences of overwhelm and greater perceived stress.

Some limitations of our work should be noted. First, the non-probability sampling used should be considered, which does not fully guarantee that the participants represent the population studied. Secondly, the voluntary nature of the study and the context of the health crisis may have introduced a response bias. In addition, the online evaluation may have discouraged participants from the older age group, as they are less familiar with new technologies. Finally, another limitation is the cross-sectional design used, since the effects of the pandemic are dynamic and their variations cannot be captured in this type of design, requiring longitudinal studies. All these reasons lead us to interpret the results with caution, especially with regard to their generalizability. In conclusion, this study finds a high number of cases of depression, anxiety, perceived stress and burnout among nursing staff. These levels of anxiety, depression, and perceived stress are higher in women and in front-line professionals. Having received a diagnosis of COVID-19 or a positive test is not associated with a greater psychological impact, but having performed preventive quarantines implies higher levels of anxiety, depression, CF and fear.

Healthcare institutions should implement psychological interventions aimed at reducing symptoms of anxiety and depression in healthcare professionals, as well as reducing BO and promoting psychological well-being and resilience. Future research should be directed at assessing the long-term psychological effects of the pandemic on health care workers, especially BO, the current levels of which are of great concern. It would also be timely to evaluate the effectiveness of protocolized interventions to prevent deterioration of mental health and professional quality of life. Deliberate evidence-based interventions are needed to protect the mental health and well-being of healthcare professionals. Implementing prevention and mental health promotion is important for these professionals to enable them to continue caring for patients with the quality of care they deserve.

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