key: cord-0773448-d546f230 authors: Abu‐Snieneh, Hana M. title: Psychological factors associated with the spread of Coronavirus disease 2019 (COVID‐19) among nurses working in health sectors in Saudi Arabia date: 2021-01-29 journal: Perspect Psychiatr Care DOI: 10.1111/ppc.12705 sha: bd460af8d61ac700b18f16f7ddb6724284ea992b doc_id: 773448 cord_uid: d546f230 PURPOSE: To assess psychological symptoms in terms of depression, anxiety, and impact of an event associated with the spread of Coronavirus disease 2019 (COVID‐19) among nurses working in health sectors in Saudi Arabia and to investigate the relationship between the demographic variables of nurses and psychological symptoms. DESIGN AND METHODS: A cross‐sectional descriptive correlation design using an electronic questionnaire. FINDING: Of the 1,265 nurses who completed the study, nearly three‐quarters (74%) reported minimal or mild depression. The majority of participants reported minimal or mild symptoms of anxiety and impact of an event. PRACTICE IMPLICATIONS: Provides an introductory and evidence‐based study for governments, policymakers, other stakeholders, and nurse educators of the current situation, and suggests possible enhancements and strategies to improve psychological health. facilities with infection-preventing medical equipment. 6 Globally, the psychological health of healthcare providers in general, and of nurses in particular, has been challenged in the COVID-19 pandemic. Several earlier studies revealed that healthcare providers suffer from adverse psychological disorders, such as anxiety and fear. Depression is one of the dominant disorders and is often seen among healthcare workers. 7 Nurses must wear an N95 mask and heavy protective garments, making it much harder for them to carry out procedures than under regular circumstances. These factors, alongside the fear of being infectious, could increase the chances of nurses experiencing negative psychological symptoms. Psychological health is "The condition of the mind that shows whether someone is feeling happy, able to work, etc…" (Cambridge Dictionary). 8 Moreover, psychological health includes normal behavioral, emotional, and social development in an individual. It is usually acquired in society and through daily events and interactions. Worldwide, the healthcare systems in many countries acknowledge the significance and value of psychological health in the provision of care, because it supports positive coping mechanisms and reduces the symptoms of stress and depression. 4 Psychological problems, including anxiety, depression, and posttraumatic symptoms, have led to a decrease in overall wellbeing during the COVID-19 pandemic. Wang et al. 9 revealed that after pandemics many healthcare professionals (nurses, doctors, and paramedics) experience recurrent mental and psychological health distress rather than physical harm. Nurses are the healthcare professionals who spend the most time with patients. For this reason, nursing is the most appropriate profession to provide care. Lai et al. 10 carried out a cross-sectional study involving 1,257 participants: They reported an elevated incidence of mental health symptoms among healthcare providers who cared for patients with COVID-19 in China, namely, depression (50.4%), anxiety (44.6%), insomnia (34.0%), and distress (71.5%). They revealed that the causes of psychological problems might include feelings of susceptibility or failure of control, concerns regarding personal health, the spread of the virus and the health of family members and others, modification in work procedures, and continuous quarantine. In this serious situation, healthcare providers are in the front line and dealing directly with the diagnosis and care of patients with COVID-19, which puts them at risk of psychological health problems. The continuing escalation of confirmed and suspected cases of COVID-19, the overwhelming workload, the reduction of personal protection equipment, and the shortage of some drugs, may contribute to the negative psychological symptoms experienced by healthcare providers. Previous studies 10, 11 revealed that a notable proportion of healthcare providers suffer from an increase in psychological problems, including anxiety, depression, and stress. Furthermore, Liu et al., 12 in their study in China during the COVID-19 pandemic, reported that the prevalence of anxiety was 12.5%. They also reported that medical staff experienced symptoms of anxiety, particularly those who had direct contact with confirmed and suspected cases. Moreover, Sun et al. 13 measured the level of impact of an event for 442 participants in China. They found that the general impact of the pandemic on health-workers was at a mild level and that older and quarantined health-workers had an elevated negative impact of events. In addition, the majority of healthcare providers working in isolation departments in hospitals did not obtain any training for providing mental health care. 14 Unfortunately, to our knowledge, and after an extensive search in a number of databases, there are no studies related to this issue in Saudi Arabia. The current study is unique and provides a new body of knowledge and evidence about psychological factors in terms of depression, anxiety, and the impact of an event associated with the spread of COVID-19 among nurses working in health sectors in Saudi Arabia. Today, psychological factors are considered an essential part of the health and quality of life of an individual. WHO has stressed the importance of a person's physical, psychological, social, and spiritual well-being. Also, there is an increasing acknowledgment within the healthcare system of the value and importance of psychological health in the provision of care and a demonstrated positive association between psychological health, individual healthcare outcomes, and quality of life. Psychological health problems are currently occurring among healthcare providers who come into direct contact with patients with confirmed or suspected COVID-19. However, in Saudi Arabia, there has to date been no study to assess the psychological factors associated with the spread of COVID-19 among nurses. This study will provide significant evidence to promote the psychological well-being of nurses. We provide an introductory and evidence-based study for governments, policymakers, other stakeholders, and nurse educators about the current situation, detail any potential enhancements, and suggest strategies to improve psychological health. This study could also be used as a baseline for additional assessment of psychological factors among nurses during pandemics. Training programs to increase positive psychological health are very important, and integrating them into the curriculum is a vital process. Furthermore, the outcomes of this study could provide a platform for future policies and guidelines on how to help nurses cope with and adjust to critical conditions. Specific aims include decreasing the risk of nurses developing negative psychological symptoms, improving well-being, and encouraging preventive activities both in Saudi Arabia and more extensively in other developing countries in the region. • What are the psychological symptoms in terms of depression, anxiety, and the impact of an event associated with the spread of COVID-19 among nurses working in health sectors in Saudi Arabia? • Is there a relationship between the demographic variables of nurses and their psychological symptoms in terms of depression, anxiety, and impact of an event associated with the spread of COVID-19 among nurses working in health sectors in Saudi Arabia? • What factors have psychological effects associated with the spread of COVID-19 among nurses working in health sectors in Saudi Arabia? The purposes of this study were to assess psychological effects in terms of depression, anxiety, and the impact of an event associated with the spread of COVID-19 among nurses working in health sectors in Saudi Arabia and to investigate the relationship between the demographic variables of nurses and their psychological effects. A cross-sectional descriptive correlation design using an electronic questionnaire. The target population was all nurses from various governmental and private hospitals in various cities in Saudi Arabia. This study adopted a nonprobability convenience sampling technique to engage participants who met the inclusion criteria. Nurses from hospitals were invited to voluntarily participate in the study by filling in an electronic questionnaire. The researcher sent the link to the questionnaire to nurses at hospitals during the data collection period and asked them to participate in the study and to send the link to their colleagues. The accessible population met the following inclusion criteria: Nurses who worked in healthcare sectors in Saudi Arabian hospitals and who had agreed to participate were eligible to take part in the study. There were no specific criteria for excluding participants regarding their characteristics (i.e., age, gender, etc.). The sample size is a necessary part of the research design and has a considerable effect on the validity and significance of the results. 15 In this study, to calculate the required sample size and avoid the risk of having a type II error, the sample size was considered using the G*Power software program. 16 After inserting the significance level (α = 0.050), the power (1 − β) = 0.80, and the medium effect size (Cohen's d) = 0.40. The first section of the questionnaire was concerned with demographic characteristics: Gender (male or female), age (years), nationality, marital status, having children, live with old age (more than 60 years), educational level, years of experience, geographic location (place of residence), and hospital type (public, private). Participants were asked whether they were directly providing nursing care to patients who had confirmed or suspected COVID-19 and dealing with family members of patients who had confirmed COVID-19. The second section assessed psychological factors in terms of depression, anxiety, and the impact of an event for all participants using the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder (GAD-7), and the 22-item Impact of Event Scale-Revised (IES-R). These instruments were applied in the original version (English version) as the majority of nurses in Saudi Arabia are expatriates and English is their native language. The questionnaire was sent to three nurses to ensure that there were no ambiguities. The nurses reported that all items appeared clear and easy to understand. The time needed to complete the questionnaires was according to the convenience of participants. A self-administered instrument for diagnosing common mental disorders is PHQ. It provides a total score in the range of 0-27, scoring each of the 9-item criteria between "0" (not at all) and "3" screening instrument and has good internal consistency (Cronbach's ɑ = 0.851). 7 Cronbach's ɑ of this tool in the present study was 0.86. To diagnose anxiety, we asked participants to rate the frequency of anxiety symptoms in the previous 2 weeks using the 7-item GAD-7 questionnaire. It uses a Likert scale ranging from "0" (not at all) to "3" (nearly every day). The final score ranges from 0 to 21 and is interpreted as follows: Normal (0-4), mild anxiety (5-9), moderate anxiety (10) (11) (12) (13) (14) , and severe anxiety (15) (16) (17) (18) (19) (20) (21) . The GAD-7 demonstrates excellent predictive validity and reliability (Cronbach's ɑ = 0.911). 17 The internal consistency of the tool in the present study was 0.90. The 22-item IES-R is very useful in evaluating the effect of everyday life stress and traumas. It ranges from 0 to 88 and is interpreted as follows: normal (0-8), mild distress (9-25), moderate distress (26-43), and severe distress (44-88). Test-retest reliability ranges from 0.89 to 0.94. 18 The internal consistency of the tool in the present study was 0.97. To distinguish symptoms of major depression, anxiety, and the impact of an event, the cutoff scores were 10, 10, and 26, respectively. Participants who had scores higher than the cutoff scores were described as having severe symptoms of these disorders. This study complied with the principles of the Declaration of Helsinki. Permission to conduct the study was obtained from a specifically constituted research ethics committee, the Local Committee of Bioethics at Jouf University (Dated April 20, 2020/No 05-0841). A self-reported Google form of an electronic questionnaire was disseminated. The questionnaire detailed the purpose and significance of the study, and a letter assured the participants of confidentiality. No personal identification data were collected, so the participants' anonymity is assured. The cover letter noted that participation was voluntary, without any indirect or direct effects, and that the data collected would be utilized only in the current study. Moreover, it included contact data for the researcher to allow participants to ask questions regarding the study. The link was disseminated as a message via mobile phone and social media groups. Finished and put forward an electronic questionnaire, proposed participants' consent to participants. 15 Furthermore, participants were asked to pass on the link to their colleagues for maximal participation. Data collection was performed from the end of April 2020 until the middle of June 2020. The data were coded and analyzed using IMS SPSS Statistics version 23 (IBM). Data analysis includes descriptive statistics to describe nurses' demographics and levels of depression, anxiety, and impact of an event (means ± standard deviation) for continuous variables, and numbers and percentages for categorical variables). Spearman's correlation coefficient was used to explore the significant relationships between participants' demographic characteristics and psychological symptoms. Moreover, to determine the potential risk factors that affect psychological symptoms among nurses, a binary logistic regression analysis was performed. A result was considered to be statistically significant when two-tailed p < 0.05. The demographic characteristics of the 1,265 nurses who finished the study are shown in Table 1 In addition to demographic data, information was gathered about whether the participants had provided care for patients who had confirmed or suspected COVID-19 and dealt with a family member for a patient who had confirmed COVID-19. Seven hundred nurses (55.3%) did not provide care for patients who had confirmed COVID-19. However, 749 nurses (59.2%) provided care for patients who had suspected COVID-19. About 20.6% of the participants dealt with a family member for a patient who had confirmed COVID-19. The levels of depression, anxiety, and impact of an event among nurses are shown in Table 2 . Of the 1,265 nurses who completed the study, about 74% (n = 936) reported minimal or mild depression, whereas 25.9% (n = 329) reported moderate or severe depression. The mean total depression score was 6.89 (SD = 5.88). Regarding anxiety level, the majority of participants (81.5%) reported minimal or mild symptoms, whereas 18.5% (n = 234) reported moderate or severe anxiety. The mean total anxiety score was 5.92 (SD = 5.21). Furthermore, regarding the impact of an event level, the majority of participants, 82.1% (n = 1,039), reported minimal or mild psychological impact, whereas 17.9% (n = 226) reported moderate or severe psychological impact. The mean was 19.28 (SD = 18.10). Spearman's correlation coefficient was utilized to explore the significant relationships between participants' demographic characteristics and psychological symptoms, as presented in Table 3 . Gender, type of hospital, and providing care for patients with confirmed COVID-19 were not statistically significant with levels of depression, anxiety, and impact of an event during the COVID-19 pandemic. However, Saudi nationality, younger age, single and married status, live with a person of older age (older than 60 years), fewer years of experience, providing care for patients with suspected COVID-19, and dealing with a family member for a patient with confirmed COVID-19 had statistically significant relationships with levels of depression, anxiety, and impact of an event. In addition, having children was statistically significant for levels of depression and anxiety: r = 0.158, p < 0.001 and r = 0.085, p < 0.002, respectively. Moreover, a higher level of education was significant for levels of depression (r = 0.143, p < 0.001). To distinguish the symptoms of major depression, anxiety, and impact of an event, the cutoff scores were 10, 10, and 26, respectively. Participants who had scores higher than the cutoff score were characterized as having severe symptoms. The dependent variables were categorical with two categories based on cutoff score (i.e., having severe symptoms or not having severe symptoms). In the bivariate analysis, no statistically significant differences existed in the percentage of nurses who had severe symptoms of were 0.57 times than those who did not. On the contrary, nurses who lived with an older person (older than 60 years) were significantly associated with severe symptoms of anxiety (OR 1.64, p = 0.025) was about 1.64 times than those who did not. Dealing with a family member of a patient with confirmed COVID-19 was significantly associated with severe symptoms of anxiety (OR 1.86, p = 0.025) and about 1.86 times higher than for those who did not. This study found that about three-quarters of the nurses had minimal or mild depression, whereas about one-quarter had moderate or severe depression. These results are higher than in Lai et al. 10 This might be explained by the fact that nurses in hospitals in Saudi Arabia experience heavy workloads due to the escalating number of confirmed and suspected cases, which leads to an increased psychological health burden. Regarding anxiety levels, the study revealed that four-fifths of participants experienced minimal or mild symptoms of anxiety, whereas close to one-fifth experienced moderate or severe symptoms. These results are higher than in Lai et al. 10 and Liu et al. 12 This could be explained by the different assessment tools and differing times since the advent of COVID-19. By the time this study was performed, nearly one and a half months after the first COVID-19 patient was declared in Saudi Arabia, healthcare workers, especially nurses, had had adequate time to regulate caring for confirmed and suspected cases and to gain confidence in their responsibilities. Furthermore, the Saudi MOH was providing stricter and safer protective procedures to support healthcare providers, particularly nurses, to reduce anxiety. Regarding the impact of an event, our study found that the majority of participants reported minimal or mild psychological impact, and 17.9% reported moderate or severe impact, which is congruent with the literature, demonstrating that 71.5% of participants reported symptoms of distress. 10 In addition, Sun et al. 13 found the impact of an event to be at a mild level among healthcare providers. The current study revealed that younger age groups were significantly associated with a greater likelihood of having severe symptoms of depression, anxiety, and the impact of an event. These results are in agreement with Mukhtar. 19 In contrast, Sun et al. 13 found that the older the health workers, the higher the impact of In addition, the analysis revealed that providing care for patients with confirmed COVID-19 was significantly associated with a higher probability of having severe symptoms of depression, anxiety, and the impact of an event. Moreover, providing care for patients who had suspected COVID-19 was significantly associated with severe symptoms of the impact of an event, about one and half times than those who did not. Dealing with a family member of a patient with confirmed COVID-19 was significantly associated with severe symptoms of anxiety, about near one and half times than those who did not. This is consistent with earlier research 10 This study has attempted to investigate the effect of the spread of COVID-19 on psychological factors in terms of depression, anxiety, and the impact of an event. Moreover, it provides an introductory and evidence-based study for governments, policymakers, other stakeholders, and nurse educators about the current situation, any possible enhancements, and suggests strategies to improve psychological health. This study can be used as a baseline for the additional assessment of psychological factors among nurses during the pandemic. Furthermore, administrators in hospitals should implement policies to improve psychological health, such as decreasing work hours, increasing the number of staff in specific departments, decreasing workload and work pressure, providing personal protective equipment, encouraging nurses to obey infection-control guidelines, offering social support, and providing psychological counseling. In addition, the findings from this study emphasize the factors that have major impacts on psychological health and that need to be ABU-SNIENEH | 9 taken into consideration when looking after nurses during a pandemic. Healthcare authorities and governments should proactively implement appropriate psychological intervention programs to prevent, alleviate, or treat psychological burdens. Furthermore, healthcare leaders can provide direct psychological health support to the affected nurses and strongly advocate for them in communities and organizations. These steps are essential to alleviate the burden on nurses and to enhance their inspiration and enthusiasm. Educators may also teach and coach future nurses to deal with the psychological health consequences of a pandemic, including depression, anxiety, and the effect of an event. For valuable assistance in data collection, I would like to thank the Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia ement-on-the-second-meeting-of-the-international-health-regula tions-(2005)-emergency-committee-regarding-the-outbreak-of-n ovel-coronavirus-(2019-ncov) Statistical data COVID-19 cases World Health Organization. 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Twitter. 2020 Psychological factors associated with the spread of Coronavirus disease 2019 (COVID-19) among nurses working in health sectors in Saudi Arabia The author declares that there is no conflict of interest. http://orcid.org/0000-0003-0682-2964