key: cord-0771406-z3tkb3mf authors: Tayyib, Nahla AbdulGadir; Alsolami, Fatmah Jabr title: Measuring the extent of stress and fear among Registered Nurses in KSA during the COVID-19 Outbreak date: 2020-09-02 journal: J Taibah Univ Med Sci DOI: 10.1016/j.jtumed.2020.07.012 sha: 1b5464e877317ecf1a4ccbf19d596a3e5131931a doc_id: 771406 cord_uid: z3tkb3mf OBJECTIVES: The novel Coronavirus Disease 2019 (COVID-19), also known as severe acute respiratory syndrome coronavirus, was officially recognised in the KSA in March 2020. Registered nurses (RNs) play a frontline role in the delivery of healthcare services to the COVID-19 patients. This role has potentially exposed RNs to infection with its associated consequences. We conducted this study to assess the psychological effects of fear and stress, and level of resilience to the COVID-19 outbreak by RNs in KSA. METHODS: In this cross-sectional study, we recruited all RNs working with patients with the COVID-19 in KSA during the outbreak. All participants completed an anonymous questionnaire, which included items about their sociodemographic details, job stress related to the COVID-19, and fear of infection. Data were analysed with descriptive correlation statistics and multiple regression tests. RESULTS: In total, 314 RNs responded to our survey. The results showed that the RNs had high levels of anxiety and stress during the COVID-19 outbreak. RNs were fearful about their safety and the well-being of their families. However, RNs felt more responsible for providing care to the COVID-19 patients. Moreover, our results signalled some predictive factors that increased RNs' level of fear, such as social media (β = 0.76, p = 0.03), exposure to trauma prior to the outbreak (β = −0.95, p = 0.003), and readiness to care for infected patients (β = −0.21, p = 0.001). CONCLUSION: This study reports high levels of perceived stress and fear among RNs in KSA while caring for patients with the COVID-19. Furthermore, certain factors have a significant impact on RNs' psychological status, which may affect the quality of patient care and safety. March 2020. Registered nurses (RNs) play a frontline role in the delivery of healthcare services to the COVID-19 patients. This role has potentially exposed RNs to infection with its associated consequences Q11 . We conducted this study to assess the psychological effects of fear and stress, and level of resilience to the COVID-19 outbreak by RNs in KSA . In this cross-sectional study, we recruited all RNs working with patients with the COVID-19 in KSA during the outbreak. All participants completed an anonymous questionnaire, which included items about their sociodemographic details, job stress related to the COVID-19, and fear of infection. Data were analysed with descriptive correlation statistics and multiple regression tests. Results: In total, 314 RNs responded to our survey. The results showed that the RNs had high levels of anxiety and stress during the COVID-19 outbreak. RNs were fearful about their safety and the well-being of their families. However, RNs felt more responsible for providing care to the COVID-19 patients. Moreover, our results signalled some predictive factors that increased RNs' level of fear, such as social media (b ¼ 0.76, p ¼ 0.03), exposure to trauma prior to the outbreak (b ¼ À0.95, p ¼ 0.003), and readiness to care for infected patients (b ¼ À0.21, p ¼ 0.001). Conclusion: This study reports high levels of perceived stress and fear among RNs in KSA while caring for 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 patients with the COVID-19. Furthermore, certain factors have a significant impact on RNs' psychological status, which may affect the quality of patient care and safety. The COVID-19 is highly contagious and infects the res Q14 piratory system, causing severe acute pneumonia, high fever, fatigue, and dyspnoea Q16 . The first COVID-19 case was discovered in Hubei Province in south China. 1 The disease is marked with rapid transmission. Recently, the number of infected cases totalled one million globally Q17 . The World Health Organisation declared it a pandemic because of its rapid transmission and projected its significant influence on global healthcare systems. In KSA Q18 , the first case of the COVID-19 was reported on 2 March 2020. Consequently, the country announced an emergency response plan to control the wide spread of the outbreak. However, despite the intensive measures taken in KSA, thousands of infected cases with 615 recoveries and 41 deaths were reported within 2 months. 2 The disease is not restricted to specific people. As such, the outbreak will drastically alter normal life and psychological resilience. Many healthcare workers including nurses are on the frontline of caring for infected cases during infectious outbreaks worldwide. They are the most vulnerable to and at high risk of infections. 1, 3 The rates of occupationally acquired Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS-CoV) infections during these outbreaks among healthcare workers was 21% and 18.6%, respectively. 3 This phenomenon has led to increased work-related stress, which is usually high among nurses because of their frequent exposure to unfamiliar contagious diseases. These aspects greatly influence nurses' psychological health. Investigating the psychological consequences of the outbreaks of acute respiratory infectious diseases on nurses, numerous studies demonstrated the significant associations of outbreaks with mental health problems 4 ; increased stress 5 ; refusal to care for patients 6 ; desire to leave the job 7 ; and psychological problems such as anxiety, depression, and hostility. 8 Furthermore, 27% of healthcare workers experienced psychiatric symptoms, 9 and fear Q19 and nervousness, 7,10 stigma, 11 and posttraumatic stress 9 were also observed. The psychological effects of these outbreaks on healthcare workers should be urgently assessed, understood, and monitored. Understanding and assessing these effects are essential to the promotion and protection of healthcare workers' well-being and emotional resilience, which directly affect the quality of healthcare services amid an outbreak such as the COVID-19. In KSA, few studies have focused on assessing the psychological effect of respiratory disease outbreaks on nurses. 12e14 The current study was conducted on a nationwide level to assess the psychological effect of the recent COVID-19 outbreak in KSA on nurses and provide accurate figures of the extent of this phenomenon. One aim of this study was to assess the psychological effects, represented by fear and stress level, of the COVID-19 outbreak on nurses in KSA. The other aim was to identify significant factors correlated with RNs' perceived level of fear and stress. A descriptive, cross-sectional design was used to guide Q3 the process of data collection and analysis. Data were collected through convenience sampling from 25 March to 6 April 2020 at the height of the COVID-19 outbreak in KSA. All nurses working in tertiary hospitals during the outbreak were invited to answer the survey questions. The inclusion criteria included all registered nurses (RNs Q21 ) working in hospital settings, nurses who understand the English language, and those willing to participate in the study. The sample size was calculated based on the 1:10 rule, which is essential to ensure the statistical power of the analysis. Therefore, 260 participants were needed based on the 28 variables included in this study. 15 However, a study stated that a large sample size of 300 or more participants is crucial in a clinical survey conducted in a non-experimental study. 16 Thus, the minimum sample size required to ensure the strong statistical power of the analysis was 300. Ethical approval was obtained from the willing to share the survey with different hospitals and medical centres in their region. A description of the study background, importance, objectives, and aim was included at the beginning of the online survey. Participants were informed on the first page of the survey that participating in this study is voluntary and that proceeding with the online survey indicates their agreement to join the study. The online survey collected no personal information from the participants to ensure the confidentiality and anonymity of the data collected. Participants were deemed to consent to Q39 participate by submitting the survey. This study involved an online survey platform (Microsoft form) on which participants completed a questionnaire comprising 36 items. The survey was divided into five sections: demographic information, exposure to the COVID-19 outbreak, job stress related to the COVID-19, fear of infection, and factors that might contribute to stress. Demographic information included age, nationality, gender, marital status, education level, employment status, type of healthcare facility, work experience in a hospital in KSA, and status of working with the COVID-19 patients. The second section included six items to assess exposure to the COVID-19 outbreak either directly such as working with cases confirmed as positive or indirectly through different types of media. The third section included ten items adopted and modified with permission from the (SARS-related stress Q23 ). 18 A validation of the original instrument showed Q24 internal consistency with a Cronbach's alpha of 0.71. 5 However, the instrument was modified for the purposes of this study so that it could be used for the COVID-19 outbreak. Each of the ten items is rated on a Likert scale ranging from 0 to 10. Nine items addressed the perception of stress related to the COVID-19 during the pandemic, and the last item measured the altruistic acceptance of risk. The fourth section included six items that aimed to assess RNs' level of fear using a five-point Likert scale ranging from 1 (not at all) to 5 (very). Five additional items were constructed based on the current literature and local context. 5, 7, 9 The validity and reliability of the study survey were evaluated. The content validity index was 0.95 and Cronbach's alpha coefficient was 0.9. Descriptive statistical methods were performed using SPSS (version 25; Chicago, IL). The level of statistical significance was set at a p-value of 0.05 (29). All demographic characteristics were analysed using descriptive statistics (frequencies and percentage) and a mean test was employed for RNs' perceptions of stress related to the COVID-19. Bivariate analyses were performed to identify the variables associated with RNs' level of fear and to Q25 explore the direction of the relationship between the correlated variables and their level of fear. Finally, a linear regression adjusted for covariates (age, working experiences, type of healthcare facility, prior exposure to trauma, impact of social media) was used to explore the variables that influence RNs' level of fear during the outbreak. The response rate was 87% (N ¼ 314 out of a total of 360 questionnaires). The majority of respondents were female (80.4%) and married (70%), and 34.7% held a bachelor's degree in nursing. Approximately one-third of the The results indicated that the RNs generally had high levels of anxiety and stress during the COVID-19 outbreak (7.76 out of 10). Table 2 presents an overview of RNs' perceptions of the COVID-19-related stress they experienced during the outbreak. The participants reported that their job placed them at a high risk of being infected (mean ¼ 7.61, SD AE 2.72) and caused them much stress at work (mean ¼ 6.92, SD AE 2.91) and about falling ill (mean ¼ 6.72, SD AE 2.98). Furthermore, they had a high level of fear of passing the COVID-19 to their families, friends, and colleagues (mean ¼ 7.61, SD AE 2.72). Nevertheless, despite their perceived increased stress during the outbreak, they still tended to altruistically accept the risks (mean ¼ 6.92, SD AE 2.89). Furthermore, all participants reported having attended yearly infection control training and received adequate personal protective equipment (PPE). Approximately 48% of the RNs believed their hospitals had a clear plan for handling the COVID-19 outbreak. However, 60% felt they were not personally well prepared for the outbreak. p¼<0.001, R 2 ¼ 0.209). Statistically significant factors that increased RNs' level of fear were social media (b ¼ 0.76, p ¼ 0.03), exposure to trauma prior to the outbreak (b ¼ À0.95, p ¼ 0.003), and readiness to care for infected patients (b ¼ À0.21, p ¼ 0.001, Table 4 ). However, the RNs felt confident that the hospital would take care of them if they contracted the COVID-19 (r ¼ 0.31, p < 0.001). The present study was the first in KSA to assess the psychological influence of the COVID-19 outbreak on nurses from the aspects of their fear and stress, and level of responses, and Q28 to identify related variables. The findings of this study showed that RNs working during the outbreak in KSA perceived a high risk of the COVID-19. The fear of infection among RNs has been extensively reported in studies that focused on acute respiratory infection outbreaks. A study found that frontline healthcare workers who worked directly on cases of MERS-CoV perceived a high level of risk and stress related to the outbreak. 7, 12 This result is aligned with that in a previous study conducted during the SARS outbreak in Singapore, which showed that health workers perceived the risk of infection. 19 The current study showed that despite their willingness, 60% of the RNs were not personally prepared to take care of patients infected with the COVID-19. RNs perceive fear regarding contracting occupationally acquired infections while treating patients infected during an outbreak when they lack institutional support for health workers with clear policies and procedures. 11 Another reason is the lack of managerial support that includes providing information and monitoring nurse training, which improves the confidence of nurses involved in healthcare during outbreaks. 20 Social and family support during stressful events such as pandemics help reduce the level of stress and threat perception. Unfortunately, this study showed that the RNs lacked this aspect, given that they demonstrated fear of transmitting the infection to their families, friends, or colleagues. This finding is aligned with that of other studies reporting health workers' fear of passing the infection to their family and children. 1 The unfamiliarity of the virus and limited information available about its treatment increase RNs' fear regarding their families. Furthermore, their experiences in providing direct care to patients with the COVID-19 also influence this fear. Providing information and frequent monitoring of nurses' performance and availability of PPE increase Q29 nurses' confidence during their work and reduce their risk of stress. 21 In addition, providing extended healthcare support to the family of RNs can alleviate this fear and stress. Interesting results were found regarding the predictors of perceived fear and stress related to the COVID-19 outbreak in KSA. RNs' fear of being infected was significantly associated with the presence of infected relatives or friends, exposure to social media, and exposure to psychological trauma prior to the outbreak. RNs' fear of an occupationally acquired infection was linked to their previous working experience with similar situations. Previous studies conducted to explore nurses' perceived fear of being infected with HIV showed that the risk was high among those who experienced needle prick injuries. 20 In the absence of previous exposure, RNs perceive fear and stress from senior nurses with previous negative experiences of occupationally acquired infections who pass it to or witness the experience of an ill relative or friend. 22 The high media awareness of the number of cases and mortality related to the COVID-19 also plays a role in increasing perceived fear and stress, which was significant in this study. In KSA, the previous MERS-CoV pandemic in 2014 was not far from home Q30 . 7,12 RNs experienced psychological stress and fear during that time, which may explain the significant association of their prior exposure to a previous psychological trauma and perceived fear in this study. Assessing the level of fear and stress of nurses who work during outbreaks/pandemics is a priority that should be considered by nursing leaders. Furthermore, assessing the contributing factors to fear and stress related to caring for infectious cases or being exposed to information related to outbreaks is important in understanding related causes and tailoring interventions to tackle these contributing factors (e.g. coping measures, interventions to enhance emotional resilience). We acknowledge limitations in the external validity of the results owing to design elements. Furthermore, the reliance on self-reports is a limitation, as these may lead to bias in reporting and overestimation of the results. Another limitation is that items in the instrument were adapted without implementing the whole process of instrument adaption and modification, for example, instrument translation. Therefore, a longitudinal study using structured clinical interviews is essential to determine the magnitude of the COVID-19 outbreak on RNs' psychological state. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 The findings of this study provide support to previous studies conducted in KSA during outbreaks of acute respiratory infectious diseases. RNs' high levels of stress and perceived fear of occupationally acquiring the infection while caring for patients with the COVID-19 place a risk on the quality of the care provided and safety of practice. The most important aspects that should be considered regarding RNs' perceived high levels of fear and stress are the coping measures that should be taken during and after this time to alleviate post-traumatic stress and increase their emotional resilience. Working during an infectious disease outbreak increases the stress of healthcare providers, especially RNs on the frontline taking care of infected patients. Stress and workload during an outbreak lead to the unwanted consequences of burnout. RNs working during an outbreak require close attention and an assessment of their level of fear, stress, and anxiety. Coping measures and supportive interventions are also warranted for this group of RNs. Further longitudinal prospective studies using a large population and different time series are recommended to validate the results of this study and to provide a more thorough understanding of this issue. Moreover, it is recommended that interviews be conducted with nurses on the factors that impact their level of stress and fear during such times. These studies will facilitate the development of supportive intervention measures to improve the psychological impact on RNs during an outbreak, which will increase patient safety and ensure the high quality of care. This research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors. Psychological impacts and coping strategies of front-line medical staff during COVID-19 outbreak in Hunan, China No Title Ministry of Health-Kingdom of Saudi Arabia. MOH issues COVID-19 awareness guidelines in many languages The SARS, MERS and novel coronavirus (COVID-19) epidemics, the newest and biggest global health threats: what lessons have we learned? The psychological impact of SARS on health care providers Factors influencing emergency nurses' burnout during an outbreak of Middle East respiratory syndrome coronavirus in Korea Knowledge, attitudes and behaviours of healthcare workers in the kingdom of Saudi Arabia to MERS coronavirus and other emerging infectious diseases Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak Psychosocial consequences of infectious diseases Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk Risk perception and impact of severe acute respiratory syndrome ( SARS ) on work and personal lives of Middle east respiratory syndrome coronavirus (MERS-CoV) outbreak perceptions of risk and stress evaluation in nurses Middle East Respiratory Syndrome Coronavirus epidemic impact on healthcare workers' risk perceptions, work and personal lives An assessment of the level of concern among hospital-based health-care workers regarding MERS outbreaks in Saudi Arabia Multivariate data analysis: a global perspective Determination of minimum sample size requirement for multiple linear regression and analysis of covariance based on experimental and nonexperimental studies World medical association declaration of Helsinki Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital Preparing to respond: Irish nurses' perceptions of preparedness for an influenza pandemic Emergency nurses' perceptions regarding the risks appraisal of the threat of the emerging infectious disease situation in emergency departments Comprehensive systematic review of healthcare workers' perceptions of risk and use of coping strategies towards emerging respiratory infectious diseases Available from:. How to cite this article: Tayyib NahlaA, Alsolami FJ. Measuring the extent of stress and fear among Registered Nurses in KSA during the COVID-19 Outbreak