Psychological Distress in Emergency Department Nurses at Women’s and Children’s Hospitals During the COVID-19 Epidemic: A Cross-Sectional Study

Abstract

Background

The COVID-19 epidemic has caused a huge amount of occupational stress among emergency department (ED) nurses. They are not only at high risk of infection, but they are also more likely to experience mental health problems. This study aimed to investigate the factors associated with psychological distress and resilience among ED nurses.

Material/Methods

This was a multi-center, cross-sectional study using cluster sampling. The survey utilizing a general information questionnaire, Kessler Psychological Distress Scale (K10), and 10-item Connor-Davidson Resilience Scale (CD-RISC-10) was conducted with 374 ED nurses working in 3 women’s and children’s hospitals in Chengdu, Sichuan, China between November 20 and November 27, 2021. Descriptive analysis, single-factor analysis, and correlation analysis were performed on data.

Results

The nurses’ mean score for the K10 was 20.65±5.99. Three hundred (80.2%) nurses had K10 scores of 16 or above. The nurses’ mean score for the CD-RISC-10 was 27.73±6.520. Work hours and work area were the factors associated with psychological distress (F=11.858, P<0.05; F=3.467, P<0.05). Age and work hours were the factors associated with resilience (F=3.231, P<0.05; t=11.937, P<0.05). The K10 score was negatively correlated with the CD-RISC-10 score (P<0.01, r=−0.453).

Conclusions

Of the 374 nurses, 80.2% had psychological distress. Nurse managers should consider the factors associated with psychological distress and resilience and take positive measures to relieve the nurses’ psychological distress.

Background

Since the COVID-19 epidemic broke out in Wuhan, Hubei, China in December 2019 [1,2], it has posed a serious threat and immense challenge for public health because of its long incubation period and high infection rate [3]. On 11 March 2020, the World Health Organization expressed deep concern about the scope and severity of the COVID-19 outbreak and indicated that the COVID-19 could be characterized as a pandemic [4]. At the beginning of the pandemic in 2020, many confirmed COVID-19 cases and deaths were reported worldwide, with COVID-19 cases reported in 176 countries and regions. The number of confirmed and suspected COVID-19 cases and deaths outside China increased sharply [5]. This has posed a huge public health challenge.

Clinical nurses performed their duties to the best of their ability in the battle against COVID-19, but at the same time they were in danger [6]. During the SARS epidemic in China in 2003, one-third of related deaths were among medical staff [7]. It was reported that the frontline nurses fighting against SARS had a high risk of psychological distress [8,9]. The increased workload and physical pressure caused by wearing physical protective equipment also threaten the health of nurses [10]. Sun et al [11] reported that 81.8–92.68% of frontline nurses have negative emotions due to high work intensity, little experience in dealing with public health emergencies, and lack of protective equipment. The results of An et al [12] show that nursing staff who cared for suspected or confirmed COVID-19 patients had significantly higher rates of anxiety and depressive symptoms. When nurses are exposed to a working environment with high work demands and low resources, the huge workload and psychological stress can easily lead to various degrees of psychological distress [13,14]. Psychological distress can lead to individual stress responses, affect the physical and mental health of medical staff, and reduce their quality of work and job satisfaction, thus affecting the prognosis of patients [15].

The ED is an important part of a hospital that copes with public health emergencies. ED staff are at the frontlines in the battle against COVID-19, and ED nurses play a significant role in infection prevention and control, patient isolation, and reduction in transmission of the SARS-CoV-2 virus, which causes COVID-19. The COVID-19 epidemic has caused very high levels of work stress among ED nurses [16]. They are not only at a high risk of infection, but they are also more likely to experience mental health problems [16]. The symptoms of COVID-19 and the common respiratory diseases in children are similar, and children and pregnant women are considered special populations, so it is difficult to distinguish between these diseases, bringing bigger infection prevention and control challenges to ED nurses working in the women’s and children’s hospitals compared with those working in the general hospitals, and increasing psychological distress among the nurses. Investigating the factors associated with psychological distress among ED nurses at women’s and children’s hospitals is critical to help them maintain mental health and is conducive to the prevention and control of COVID-19 [17]. We carried out a cross-sectional study on the factors associated with psychological distress and resilience among ED nurses working in the women’s and children’s hospitals to attract more attention to the ED nurses’ mental health and provide better care for patients.

Material and Methods

Ethics Statement

All research methods were carried out in accordance with the relevant guidelines and regulations. This study was carried out in accordance with the Declaration of Helsinki and was approved by the Medical Ethics Committee of West China Second University Hospital, Sichuan University [No. YXKY2022LSP(023)]. Verbal informed consent for participation was obtained from all nurses participating in this study. The Medical Ethics Committee of West China Second University Hospital, Sichuan University approved the procedure of obtaining verbal informed consent from the participants.

Participants

Inclusion criteria were: frontline nurses working in the ED in any of the 3 women’s and children’s hospitals in Chengdu, China during the COVID-19 epidemic and who voluntarily participated in this study. The hospitals were at different levels: national, provincial, and municipal.

Each of the EDs in our study consisted of 6 areas: pre-hospital emergency care, triage, resuscitation room, consultation room, observation ward, and transfusion center. On average, a total of 22 ED nurses worked per shift. The ratio of nurses to physicians to paramedics on the observation ward was 1: 2: 1.

To become an ED nurse in China, one must obtain a Chinese nurse qualification certificate and possess more than 3 years of clinical work experience. During the COVID-19 pandemic, the ED nurses on duty wore disposable isolation gowns, disposable caps, and disposable protective masks (N95). Three 8-h shifts every 24 h were used in the EDs.

Study Tools

The survey used a self-designed general information questionnaire, the Kessler Psychological Distress Scale (K10), and the10-item Connor-Davidson Resilience Scale (CD-RISC-10) administered to 374 ED nurses working in 3 women’s and children’s hospitals in Chengdu, China between November 20 and November 27, 2021.

The general information questionnaire was used to collect the respondent’s information about gender, age, marital status, working years, education background, department, nursing hierarchy, professional title, work hours per day, night shifts per month, type of hiring, position (triage level: 1, 2 or 3), work area (fever outpatient area, waiting area/isolation rooms for suspected COVID-19 patients, isolation wards, and other), whether the respondent cared for a patient with suspected or confirmed COVID-19, whether the respondent had rotated to another department since the outbreak of the COVID-19 epidemic, whether the respondent voluntarily applied to join the emergency medical team to support Wuhan in the fight against COVID-19, and whether the respondent participated in the fight against COVID-19 in Wuhan.

The Kessler Psychological Distress Scale (K10), developed by Kessler [18], has been fully validated and applied in China [19,20]. Cronbach’s alpha for K10 was 0.92. The K10 was used to evaluate the respondent’s nonspecific psychological distress such as anxiety and depression that the respondent had experienced in the most recent 4-week period. The K10 consisted of 10 items and was unidimensional. The higher the K10 score, the worse the psychological distress. The K10 score, which was the sum of the scores of all items, was 10–50. It was interpreted as: K10 score of 1–15, No psychological distress; K10 of 16–21, Mild psychological distress; K10 score of 22–29, Moderate psychological distress; K10 score of 30–50, Severe psychological distress. Respondent who received the K10 score of 16 or above were considered to experience psychological distress [21].

The 10-item Connor-Davidson Resilience Scale (CD-RISC-10), co-developed by Connor and Davidson [22], contained 10 items. Cronbach’s alpha for CD-RISC-10 was 0.85, indicating good reliability and construct validity. The Chinese version of CD-RISC-10, translated and revised by Chinese scholars, was used in this study. Cronbach’s alpha for the Chinese version was 0.92, indicating good psychometric properties, internal consistency, consequential validity, and criterion-related validity [23,24]. It was also applied to nursing students in China [25]. Each of the 10 items was scored on a 5-point Likert scale. The scores ranging from 0 to 4 were assigned to the following responses: ‘never’, ‘seldom’, ‘sometimes’, ‘frequently’, and ‘always’. The CD-RISC-10 score was the sum of the scores of all items. The higher the CD-RISC-10 score, the greater the resilience.

Data Collection

The electronic questionnaire was produced via Wenjuanxing during November 15 to November 18, 2021 and distributed among the ED nurses working in the 3 women’s and children’s hospitals during November 20 to November 27, 2021. Cluster sampling was used to collect data from 380 ED nurses. The nurses scanned the quick response code of the questionnaire and complete it on a voluntary basis. To ensure data validity and avoid multiple submission by the same respondent, all questions were made compulsory and the WeChat accounts were allowed to submit the questionnaire only once. The questionnaire was completed anonymously to ensure confidentiality. Both researchers were responsible for data collection and double-checked to ensure data validity. A total of 380 questionnaires were collected. Of them, 6 were invalid and 374 were valid. The valid recovery rate was 98.42%.

Statistical Analysis

Data were analyzed using SPSS 22.0. Descriptive analysis was conducted on the socio-demographic data. Categorical variables were described as frequency and percentage. Continuous variables were described as mean (±) and standard deviation (SD). The independent samples t test was performed on the binary categorical variables that were normally distributed. The chi-square test was performed on polytomous variables. Nonparametric test was performed on data that were not normally distributed. Pearson correlation analysis was used to evaluate the relationship between psychological distress and resilience. A statistically significant difference was identified by α=0.05 and P<0.05.

Results

The general information collected from the ED nurses who participated in this study and the results of the single-factor analysis for their psychological distress and resilience are shown in Table 1.

Table 1.

Single-factor analysis of psychological distress and resilience in emergency nurses.

Item	n	Psychological distress	F/t	P	Resilience	F/t	P
Gender			t=−0.037	0.847		t=0.281	0.779
Male	8	18.00±6.23			28.38±6.545
Female	366	20.71±5.98			27.72±6.528
Age			F=2.053	0.106		F=3.231	0.022
20–30 years old	230	20.56±6.187			27.14±6.437
31–40 years old	105	21.22±5.550			28.00±6.460
41–50 years old	26	21.00±6.164			30.08±7.031
51–55 years old	13	16.92±4.786			31.38±5.679
Marital status			F=0.952	0.387		F=0.555	0.574
Married	244	20.92±5.863			27.85±6.631
Never married	122	20.23±6.286			27.38±6.400
Divorced	8	18.75±5.471			29.63±4.897
Working years			F=1.332	0.257		F=2.081	0.083
<1 year	26	18.77±5.982			27.54±4.675
1–5 years	142	20.22±6.131			27.40±6.865
5–10 years	83	21.43±6.061			26.53±6.367
10–15 years	40	20.73±5.277			29.63±5.705
>15 years	83	21.16±5.977			28.65±6.738
Education background			F=0.935	0.424		F=0.075	0.974
Secondary specialized school	10	18.20±6.374			27.70±6.129
Two or 3 years’ higher education diploma	148	20.88±5.813			27.86±6.753
Undergraduate	204	20.70±6.048			27.68±6.520
Masters and above	12	19.00±7.097			27.00±4.023
Nursing hierarchy			F=1.331	0.258		F=0.836	0.503
N0	50	20.30±6.089			27.36±6.620
N1	132	19.88±6.047			27.45±6.599
N2	107	21.64±5.845			27.42±6.393
N3	65	20.82±5.887			28.49±6.527
N4	20	20.80±6.396			29.70±6.506
Professional title			F=1.192	0.314		F=1.145	0.335
Nurse	122	20.24±6.321			27.56±7.069
Nurse practitioner	160	20.75±5.894			27.28±6.159
Supervising nurse	75	21.39±5.831			28.47±6.312
Associate senior/senior nurse	17	19.41±5.304			30.06±6.427
Work hours per day			F=11.858	0.008		t=11.937	0.008
<8 hours	27	20.87±5.409			28.44±6.222
8 hours	210	19.77±5.435			28.56±5.862
8–9 hours	91	21.46±7.046			26.96±7.895
9 hours	46	23.00±5.835			25.09±5.823
Night shifts per month			F=0.325	0.723		F=0.275	0.759
≤4 nights	189	20.40±6.307			27.88±6.727
5–9 nights	132	20.89±5.272			27.76±5.883
≥10 nights	53	20.92±6.610			27.13±7.328
Type of hiring			t=1.605	0.658		t=5.849	0.119
Employment contract	67	20.19±5.203			29.30±6.394
Through a staffing agency	14	18.50±4.183			28.43±4.071
Service contract	287	20.81±6.090			27.44±6.520
Other	6	23.1±11.548			22.67±9.331
Position			F=0.128	0.944		F=0.115	0.951
Level 1 triage	38	20.42±6.529			28.13±6.811
Level 2 triage	55	21.09±5.681			27.51±6.638
Level 3 triage	30	20.50±6.196			27.30±6.385
Other	251	20.61±5.989			27.77±6.500
Work area			F=3.467	0.016		F=1.495	0.216
Other	284	20.10±5.733			27.96±6.469
Fever outpatient area	73	22.36±6.310			26.47±6.644
Waiting area/isolation rooms for suspected COVID-19 patients	13	22.15±8.030			29.85±6.950
Isolation wards	4	23.75±5.909			28.00±4.690
Had the respondent ever cared for the patient with suspected or confirmed COVID-19?			F=1.748	0.187		F=0.583	0.446
Yes	29	20.55±7.074			28.62±6.946
No	345	20.66±5.909			27.66±6.488
Had the respondent ever rotated to another department since the outbreak of COVID-19 epidemic?			F=2.230	0.136		F=0.038	0.845
Yes	28	20.46±7.021			27.96±6.274
No	346	20.66±5.918			27.71±6.548
Did the respondent voluntarily apply for joining the emergency medical team to support Wuhan in the fight against COVID-19?			F=0.004	0.953		F=1.005	0.317
Yes	271	20.76±6.017			27.94±6.651
No	103	20.37±5.964			27.18±6.161
Did the respondent participate in the fight against COVID-19 in Wuhan?			F=0.03	0.862		F=0.000	0.991
Yes	14	18.14±6.225			27.71±7.898
No	360	20.75±5.975			27.73±6.474

ED Nurses’ K10 and CD-RISC-10 Scores

The ED nurses’ mean score for the K10 was 20.65±5.99 and 80.2% of them had K10 scores of 16 or above, indicating psychological distress. Their mean score for the CD-RISC-10 was 27.73±6.520, as show in Table 2.

Table 2.

Emergency nurses’ K10 and CD-RISC-10 scores.

Item	n	Percentage (%)	Mean±standard deviation
Did not have psychological distress	74	19.8
Had mild psychological distress	151	40.4
Had moderate psychological distress	109	29.1
Had severe psychological distress	40	10.7
K10	374		20.65±5.99
CD-RISC-10	374		27.73±6.520

Single-Factor Analysis of Factors Associated with Psychological Distress and Resilience

The results of this study showed that work hours and work area (fever outpatient area, waiting area/isolation rooms for suspected COVID-19 patients, isolation wards) were the factors associated with psychological distress (F=11.858, P<0.05; F=3.467, P<0.05), showing statistically significant differences; age and work hours were the factors associated with resilience (F=3.231, P<0.05; t=11.937, P<0.05), showing statistically significant differences (Table 1).

Pearson Correlation Analysis Between Psychological Distress and Resilience

Pearson correlation analysis showed that the ED nurses’ psychological distress was negatively correlated with their resilience (r=−0.45, P<0.01) (Table 3).

Table 3.

Pearson correlation analysis between psychological distress and resilience (r value).

Item	Psychological distress	Resilience
Mental health	1	−0.453*

^*P<0.01.

Discussion

Analysis of Psychological Distress and Resilience of ED Nurses

A meta-analysis performed by Pappa et al [26] showed that most nurses experienced severe psychological distress during the COVID-19 pandemic. There is a rapidly changing environment within the ED, where patients constantly change and conditions are unpredictable [27]. Rybojad et al [28] found that 7–10% of ED medical staff experienced distress and post-traumatic stress disorder. ED nurses had to deal with an unpredictable number of patients with possible or suspected SARS-CoV-2 infection during the COVID-19 pandemic, so ED nurses were more likely to experience psychological distress in such a high-risk setting. Our study showed that 300 (80.2%) ED nurses working in the women’s and children’s hospitals experienced psychological distress (K10 score ≥16) during the COVID-19 pandemic. They had higher levels of psychological distress than nurses working in the United Arab Emirates [29,30] and the frontline nurses included in the research of Nie et al [10]. Nickell et al [8] reported that 29% of hospital staff in Canada experienced psychological distress associated with SARS and the percentage in nurses was as high as 45%. It is obvious that public health crises, such as the SARS and COVID-19 pandemics, can have a huge psychological impact on hospital staff, especially nurses. The possible reasons were: (1) the nurses worried about their health because coronavirus was extremely contagious and caused high morbidity and fatalities. To avoid potential infection risks among family members, frontline nurses were quarantined or not allowed to go home after work during the pandemic; (2) the common symptoms in children who came to the EDs of the women’s and children’s hospitals were fever and/or cough, requiring COVID-19 nucleic acid tests or computed tomography lung screening to distinguish these cases from COVID-19. However, the children’s parents usually assumed that it was a common cold and their dissatisfaction with the medical procedures increased. Moreover, the children were not self-disciplined enough to abide by the COVID-19 prevention and control measures [31], making the nurses feel more stressful; (3) China carried out strict COVID-19 prevention and control measures; “Do not leave home unless for necessity” was advocated when the COVID-19 situation became severe, making the nurses stressed.

Nurses are usually the main medical staff responding to public health emergencies, and their good mental health is conducive to coping with the pandemic. COVID-19 spread quickly around the world, and all hospital staff fought against the pandemic. Due to the characteristics of women’s and children’s hospitals, the incidence of psychological distress in ED nurses during the COVID-19 pandemic was high. Nursing managers should pay more attention to it.

In this study, 49.6% of the nurses had severe psychological distress, lower than the findings of Lai et al [32]: 71% of the nurses working in Wuhan had moderate or severe psychological distress. The nurses working in Wuhan, which was the center of coronavirus outbreak, faced more challenges and had heavier workload and higher risk of occupational exposure to coronavirus compared to those working in other places. There were very few cases of COVID-19 in Chengdu and fewer cases were reported in children and pregnant women, so the nurses working in Chengdu might have regarded themselves as being at low risk of infection [33]. In addition, COVID-19 patients were transferred to designated hospital for treatment, so the nurses working in the women’s and children’s hospitals had low probability of contact with COVID-19 patients. Compared with the nurses working in Wuhan, ED nurses working in the women’s and children’s hospitals in Chengdu had lower rates of psychological distress.

The results of this study showed that the mean CD-RISC-10 score of the ED nurses working in Chengdu, Sichuan Province, China was 27.73±6.520, consistent with the result of research on frontline medical staff in Hubei Province [34]. It was possibly because the nurses working in Sichuan had work experience in dealing with public health emergencies, such as SARS [35] or that Sichuan Province is a place that natural disasters frequently occur. Previous studies have shown that nurses working in Sichuan had a lower incidence of psychological problems but had a higher level of resilience 6 years after the 2008 Sichuan earthquake [36], so they might be able to better respond to public health emergencies. The mean CD-RISC-10 score of the ED nurses in this study was also higher than that of nurses who cared for COVID-19 patients [37], possibly because there were very few cases of COVID-19 infection in pregnant women and children in China and fewer cases were report in Chengdu, Sichuan. A previous study has shown that offering situational stimulation training for nurses before they are assigned to care for COVID-19 patients can improve their first aid skills, relieve their psychological problems, and enhance their psychological adjustment [38].

Single-Factor Analysis of Psychological Distress in ED Nurses

The survey results showed that the longer hours the nurses worked, the more psychological distress they had, consistent with the results of Azoulay et al [39] and Wozniak et al [40]. The nurses who worked in the fever outpatient areas, waiting area/isolation rooms for suspected COVID-19 patients, and isolation wards must abide by the safety guideline for working in these areas. Working long hours might result in increased sweating, blurry vision, chest tightness/shortness of breath, difficult communication, and medical-device-related pressure injuries, which might affect the nurses’ health [41]. The Chinese government proposed that the nursing shift should be cut to 4 or 6 h and 4 or 6 shifts per day should be used to reduce nurses’ work intensity. Therefore, nurse managers should set an appropriate work schedule and take intervention measures based on the factors associated with the nurses’ psychological distress, thereby reducing their psychological distress. It is advisable to provide sufficient medical protective equipment and facilities for nurses, such as shower facilities, to reduce the risk of infections.

The survey results also showed that the ED nurses who worked in the fever outpatient area, waiting area/isolation rooms for suspected COVID-19 patients, and isolation wards had more psychological distress. Their psychological distress score was 23.75±5.909, higher than the mean psychological distress score of 20.65±5.99. This is consistent with the results of Lai et al [32], possibly because these nurses had close contact with patients and had higher risk of infection. The results of Hewlett et al [42] showed that many people were afraid of seeing a doctor because they thought doctors carry the virus. Most nurses were shunned by family members, friends, and colleagues to avoid potential infections. The ED nurses dealt not only with the COVID-19 epidemic, but also with their family concerns and perceptions of the public, resulting in an increase in psychological distress during the pandemic.

Single-Factor Analysis of Resilience in ED Nurses

The survey results showed that the nurses who were younger had lower CD-RISC-10 scores, consistent with the results of other scholars [43], possibly because (1) the younger nurses lacked experience in dealing with emergencies; and (2) the COVID-19 pandemic lasted a long time. Information about COVID-19 and knowledge of prevention and control measures was updated quickly, and there were many surprise inspections of COVID-19 infection prevention and control measures. More attention should be paid to psychological states of younger nurses, and regular psychological counseling and psychological skill training should be offered to them to improve their psychological adjustment.

As shown in this study, working long hours per day was associated with an obvious decline in the nurses’ resilience, consistent with the results of other scholars [44,45]. Resilience is associated with internal and external factors. Working long hours can cause the nurses to feel unfit, with increased sweating, blurry vision, chest tightness, and difficult communication [41], and wearing protective gowns can result in fatigue. Nurse managers should improve the management of human resources, especially during epidemics, and create a reasonable work schedule for nurses, thereby reducing the nurses’ workload intensity and relieving their stress at work.

Analysis of Correlation Between Psychological Distress and Resilience in ED Nurses

This study has shown that the ED nurses’ K10 scores were negatively correlated with their CD-RISC-10 scores (r=−0.453, P<0.01), consistent with the results of Liang et al [34] and Li et al [43]. The greater the resilience, the better the psychological adjustment. Resilience can be considered as a stress absorber and a line of defense of the human body. Nurses with a higher level of resilience are more proactive in dealing with emergencies. Offering resilience training for nurses can stimulate their positive energy and improve their mental health, thereby helping fight COVID-19.

Limitations

This was a cross-sectional study. All participants were living in the same city, so the survey results were not representative of the psychological distress and resilience of the ED nurses who were living in other places. We carried out stratified sampling among the ED nurses who were working in the hospitals at 3 different levels: national, provincial, and municipal, but we lacked data from ED nurses who were working in the primary-level women’s and children’s hospitals. A further study with a larger sample size is required. The impact of the COVID-19 pandemic on mental health of ED nurses may be continuous, changing, and long-lasting. The explanation for causality between risk factors and psychological distress in the cross-sectional study might be insufficient. A longitudinal study is required to investigate the predictions.

Conclusions

This study has shown that 80.2% of the emergency department nurses working in 3 hospitals in Chengdu, China experienced psychological distress even though there were standard prevention and control precautions for COVID-19, and 49.6% of these nurses experienced severe psychological distress. The number of hours they worked per day and the work area they worked in were the factors associated with their psychological distress, but age and the number of hours worked per day were factors associated with their resilience. Nurse managers should prepare an appropriate shift work schedule for nurses and develop mental health training courses, thereby alleviating psychological distress in the nurses and enhancing their abilities to cope with psychological distress. Consequently, emergency department nurses could provide better nursing care for patients.