Abstract
We aimed to examine the relation between the fear of COVID-19 and depression, anxiety and burnout of intensive carenurses. This cross-sectional and descriptive research was conducted with 116 intensive care nurses. The data were obtained with a web-based questionnaire created with the “Descriptive Information Form”, “COVID-19 Fear Scale”, “Depression, Anxiety and Stress Scale Short Form” and “Burnout Short Version”. A significant positive correlation was found between depression (r = 0.498, p < .001), anxiety (r = 0.633, p < .001), stress (r = 0.589, p < .001) and burnout (r = 0.299, p = .001) levels of intensive care nurses with a mean age of 30.18 ± 6.55 with the help of the “COVID-19 Fear Scale”. It was determined that the mental health of intensive care nurses was at risk and they reached the level of burnout. Intensive care nurses should be supported in understanding the symptoms of psychological problems and in stress management, personal and professional self-care. Receiving professional mental health support when necessary.
Introduction
COVID-19 is a virus that originates in Wuhan, China and spreads all over the world in a short time, causing severe acute respiratory syndrome and pneumonia (Huang et al., 2020a; She et al., 2020). COVID-19 was declared a pandemic by the World Health Organization (WHO), which emerged in late 2019, spread almost all over the world and was seen in thousands of people and caused thousands of people to die (World Health Organization, 2020).
The follow-up of patients with severe COVID-19 infection is carried out in intensive care units (Türkmen, 2016). All follow-up, treatment and care of highly dependent COVID-19 patients should be done by intensive care nurses (Liew et al., 2020). Intensive care nurses are regularly expose traumatic job stiations. Studies reported that intensive care nurses have higher depression, anxiety and burn-out levels (Huang et al., 2022; Li et al., 2021).
The emergence of new working orders due to the pandemic has made working environments extremely stressful. At the same time, the uncertainties in this new process caused nurses to fear. Nurses not only increase their workload, but also try to adapt to new protocols and a very “new normal”. Nurses are trying to adapt to such a situation where they have to take care of more patients than they are used to and they have to give more frequent end-of-life care because they witness the disease that can cause death more quickly (Maben & Bridges, 2020; Arpacioglu et al., 2021). Nurses are also people, they are someone’s spouse, child, mother, father, relative and friend. There is a possibility that their relatives as well as themselves can become infected or infect them (Smith et al., 2020). In nurses working in the COVID-19 pandemic, who are not being able to meet with family members to avoid physical contact due to the risk of infecting family members with the virus, an increasing number of relatives/colleagues getting sick/dying, reduced salaries and difficult working conditions, funerals being carried out in an unusual way due to isolation precautions causes to traumatic stress responses (Jun et al., 2020; Wu et al., 2020; Genzlinger, 2020).
One of the most important factors that enable people to enjoy their profession and to be professionally motivated is that feeling safe while performing their profession. However, in clinics or in all public units where people exist, occupational risks await nurses who provide care during the COVID-19 epidemic (Choi et al., 2020; Huang et al., 2020a; Yücel & Görmez, 2019). It has been proven by studies that the mental health of nurses, who are the closest witnesses of the process, was negatively affected in the pandemics we experienced in the past as we are experiencing now (Yan et al., 2015; Maridor et al., 2017). While emotional exhaustion was found to be higher in intensive care workers, job satisfaction was found to be low on the contrary (Arpacioglu et al., 2021).
In order to alleviate the psychological pressure on intensive care nurses caring for COVID-19 patients, their psychological problems should be addressed as soon as possible (Shen et al., 2020). In a study, it was reported that after the onset of the COVID-19 pandemic, 36.3% of nurses read books on mental health, 50.4% did activities to strengthen coping with social media, and 17.5% received professional psychological support (Kang et al., 2020). Therefore, it is important to support nurses to protect themselves in line with infection control protocols while caring for patients infected with COVID-19 (Choi et al., 2020; Huang et al., 2020b; Yücel & Görmez, 2019). In the literature, the necessity of psychological support of nurses during the pandemic period has been emphasized (Huang et al., 2020b; Li et al., 2020). In this period when everyone is afraid of approaching each other, nurses will be able to continue to do their job lovingly and to touch people and human life as long as they feel safe (Hachisu & Suzuki, 2018; Pedrazza et al., 2018). Research in this area will guide the intensive care nurses in order to prevent burnout and to provide them with psychological support.
The aim of this study was toreveal the physical, psychological and social problems of nurses caring for COVID-19 patients in intensive care units. In particular, the relation between the fear of COVID-19 and depression, anxiety and burnout levels of intensive care nurses, who are the group that makes the most effort during the pandemic process, will be examined.
Material and Methods
Research Design and Participants
Differences in the mean scores of the nurses from the COVID-19 Fear Scale according to their characteristics (n = 116).
Data Collection Tools
The data were obtained through a web-based survey, created with the “A Descriptive Information Form”, “COVID-19 Fear Scale”, “Depression, Anxiety and Stress Scale Short Form (DASS-21)” and “Burnout Measure Short Version (BMS)”.
A Descriptive Information Form
A questionnaire prepared by the researchers in which sociodemographic characteristics are questioned, such as the intensive care nurses' age, gender, education level, family structure, presence of individuals over 65 years of age or with a chronic disease in their family, smoking or alcohol use and its increase, presence of chronic disease, presence of constantly used drugs, the total time worked in an intensive care unit, the type of working order, the total weekly working hours and the knowledge of contracting COVID-19 disease.
COVID-19 Fear Scale
The Fear of COVID-19 Scale, developed by (Ahorsu et al., 2022) to measure the fear levels of individuals due to Covid-19, was adapted to Turkish, validity and reliability were done by Satici et al. (2020). The items of the scale were created based on a comprehensive review of existing scales on fear, expert assessments, and participant interviews. The applicable age scale of the scale is wide and can be used on university students and adults. All items of the scale consisting of seven questions are scored positively. The questions were scored from one to 5 (1- Strongly disagree…5- Strongly agree) using a 5-point Likert-type scaling. Scoring on the scale is between 7 and 35. In the Turkish validity and reliability study of the scale, the Cronbach Alpha value was found to be (α = 0.82). The high score obtained from the scale indicates that the fear of Covid-19 is high (Satici, et al., 2020). In this study, the Cronbach Alpha value of the scale was found to be 0.88.
Depression, Anxiety and Stress Scale Short Form
The Depression, Anxiety and Stress Scale was created by (Lovibond & Lovibond, 1995) with a 42-item form. Afterwards, a 21-item short form of the scale was created. The scale was developed to measure the symptoms of depression, anxiety and stress appropriate to both clinical samples and normal samples.There are seven items in total for each factor. The scale has a 5-point Likert-type answer format and the lowest score that can be obtained from each dimension is seven and the highest score is 35. Increasing scores on the scale indicate an increase in symptoms. In the original study, the internal consistency coefficients for the sub-factors of the scale were found as follows: Depression, 0.94; Anxiety, 0.87 and Stress, 0.91. The Turkish adaptation of the scale was made by (Sarıçam, 2018). According to this adaptation study, the scale was found to be a valid and reliable measurement tool for the Turkish sample (Sarıçam, 2018). In this study, the internal consistency coefficients for the sub-factors of the scale were found as follows: Depression, 0.87; Anxiety, 0.90 ve Stress, 0.88.
Burnout Scale Short Version
Instead of (Pines & Aronson, 1988) Burnout Scale (BL) consisting of 21 items, (Pines & Keinan, 2005) adapted the Short Version of the Burnout Scale in order to create an easy-to-use measurement tool with fewer items to meet the needs of researchers and practitioners. Its adaptation to Turkish, validity and reliability was done by Tümkaya et al. (2009). The Burnout Scale Short Version consists of 10 items with response options ranging from 1 (Never) to 7 (Always). It has been observed that those who score higher on the scale report has more complaints such as chronic fatigue, headaches and backaches than those with lower scores, and they have low job satisfaction and low performance expectations. Original Burnout Scale Short Version scores are negatively correlated with life satisfaction, general optimism, and job satisfaction. On the other hand, it showed positive relations with the somatic disorder, general job stress, and various specific job stressors. The internal consistency coefficients calculated by (Pines & Keinan, 2005) with the data obtained from different ethnic origins, occupations and student groups ranged from 0.85 to 0.92. In the adaptation study of the scale, the internal consistency reliability coefficient obtained from the pre-service teachers was calculated as 0.91. In addition, the test-retest coefficient of the original BMS was found to be 0.74 in the student group with an interval of 3 months. In the adaptation study, the correlation coefficient obtained from the pre-service teachers with an interval of 4 weeks was calculated as 0.70 (Tümkaya et al., 2009). In this study, the Cronbach Alpha value of the scale was found to be 0.95.
Ethical Aspects of the Research
Approval was obtained from ethics committee for the research to be carried out. Written institutional permission was obtained from Health Ministry and the hospital where the study was conducted. The nurses were informed about the purpose of the study and they agreed to participate in the research in the digital forum before starting the research.
Data Analysis
SPSS 22.0 package program was used in the analysis of the obtained data. Descriptive data were presented as numbers, percentages, mean and standard deviation. Whether the datashowed normal distribution was checked with skewness and kurtosis analysis. Parametric tests were used because the data showed normal distribution. Student’s t test was used to compare quantitative data. One-way analysis of variance (ANOVA) was used for comparison in more than two groups. Pearson correlation analysis was used to evaluate the relation between fear of COVID-19 and depression, anxiety and burnout of intensive care nurses. Analysis results were evaluated at p < .05 significance level.
Results
The mean age of the intensive care nurses participating in the study was 30.18±6.55 and the average working year in the intensive care unit was 5.35 ± 4.69. The differences in the mean scores of the nurses from the COVID-19 Fear Scale according to their characteristics are shown in Table 1.
Women’s total mean score on the COVID-19 Fear Scale was higher than men’s (22.33 ± 5.62, 19.20 ± 7.01; t = 2.213, p = .032). The total mean score of the COVID-19 Fear Scale of smokers or alcohol users was higher than those who did not use (23.03 ± 6.25, 20.16 ± 5.75; t = 2.565, p = .012). The total mean score of the COVID-19 Fear Scale of those whose smoking and alcohol consumption increased during the COVID-19 process was higher than those who did not (24.37 ± 5.63, 19.84 ± 5.83; t = 4.121, p < .001). The total mean score of the COVID-19 Fear Scale of those who did not use regular medication was higher than those who used regular medication (22.22 ± 5.97, 19.22 ± 6.22; t = -2.265, p = .032). There was no difference in the mean scores of the nurses from the COVID-19 Fear Scale according to their educational status, family structure, the presence of individuals over 65 years of age or with a chronic disease in the family, the presence of a diagnosed chronic disease, and the status of contracting COVID-19 disease (p > .05).
Differences in the mean scores of the nurses from the COVID-19 Fear Scale according to their socio characteristics (n = 116).
aPearson correlation test.
Total score averages of the nurses “COVID-19 Fear Scale”, “Depression, Anxiety and Stress Scale Short Form” and “Short Version of Burnout Scale” (n = 116).
The relationship between nurses' scores on the “COVID-19 Fear Scale”, “Depression, Anxiety and Stress Scale Short Form” and “Short Version of Burnout Scale” (n = 116)
**p < .001
Discussion
In our study, the relation between the fear of COVID-19 and depression, anxiety and burnout of intensive care nurses during the COVID-19 pandemic was investigated. Women’s total mean score on the COVID-19 Fear Scale was higher than men’s (22.33 ± 5.62, 19.20 ± 7.01; t = 2.213, p = .032). The total mean score of the COVID-19 Fear Scale of smokers or alcohol users was higher than those who did not use (23.03 ± 6.25, 20.16 ± 5.75; t = 2.565, p = .012). The total mean score of the COVID-19 Fear Scale of those whose smoking and alcohol consumption increased during the COVID-19 process was higher than those who did not (24.37 ± 5.63, 19.84 ± 5.83; t = 4.121, p < .001). The total mean score of the COVID-19 Fear Scale of those who did not use regular medication was higher than those who used regular medication (22.22 ± 5.97, 19.22 ± 6.22; t = -2.265, p = 0.032).
Between nurses' “COVID-19 Fear Scale” and “Depression, Anxiety and Stress Scale Short Form” sub-dimensions “Depression” (r = 0.498, p < .001), “Anxiety” (r = 0.633, p < .001) and “Stress” (r = 0.589, p < .001) were significant positive correlations. There was a significant positive correlation between nurses' “COVID-19 Fear Scale” and “Short Version of Burnout Scale” (r = 0.299, p = .001)
A negative correlation was found between the variables total time worked in intensive care (years) and weekly working time (hours) and the COVID-19 Fear Scale.
It has been determined that there is a significant relation between the fear of COVID-19 and the levels of stress, depression, anxiety and burnout of intensive care nurses. Being at the forefront of the diagnosis, treatment and care of COVID-19 patients as a nurse during the pandemic has been shown to affect all measures of mental health symptoms to a greater degree than that of other healthcare professionals (Lai et al., 2020; Li et al., 2020). Working with an infectious disease in an unknown process, having fear of getting infected and spreading around, having a heavy workload and feeling tired for a long time, encountering unsuccessful treatments, caring for too many critical patients and depression are the problems faced by intensive care nurses. Especially the inexperience of young nurses in critical patient care leads to greater psychological crises for young intensive care nurses (Shen et al., 2020). According to the related analysis made according to the working years of intensive care nurses, a positive and significant relationship was found between negative emotions and working years. As the number of years worked by intensive care nurses increases, their negative emotion scores will also increase (Akalın & Modanlıoğlu, 2021). In one study, nurses who worked directly with COVID-19 patients had higher scores on the Covid Fear scale than doctors. In the HSA-4 “Anxiety” and “Depression” subscales, it was observed that the mean scores of the nurses were higher than the doctor and dentist/pharmacist/psychologist/social worker group averages. In the same study, in the Covid Fear Scale, the group average of those who say they live with their family was found to be higher than the group average of those who say they live alone. Whereas, in terms of Emotional Exhaustion, HSA total, Anxiety and depression sub-scores, the group average of those who say they live with their parents is different and larger than those who say they live alone (Arpacioglu et al., 2021). Lai and Li studies have shown that young nurses have higher negative emotions, and married or divorced people are more likely to experience trauma (Lai et al., 2020; Li et al., 2020). Similarly, in this study, a positive and significant relationship was found between intensive care nurses' depression, anxiety, stress and burnout levels with the help of the “COVID-19 Fear Scale” (p = .001).
Limitations
This study is limited to intensive care nurses in one hospital. Its results are limited only to the region where the study was conducted.
Conclusions
In line with the findings obtained from this study, which examined the relationship between the fear of COVID-19 and depression, anxiety and burnout levels of intensive care nurses during the COVID-19 pandemic process; • It has been observed that intensive care nurses are at risk, and the most common psychosocial problems in intensive care nurses are anxiety, depression, stress and burnout. The COVID 19 pandemic effected the ICU nurses negatively. • The fear of COVID 19 increased the level of depression, anxiety, burnout, and a signification positive correlation was found. • It was concluded that in order to alleviate the psychological pressure on intensive care nurses, their psychological problems should be addressed as soon as possible.
Footnotes
Acknowledgments
The authors would like to thank all the intensive care nurses who participated in this study.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
