Depression, anxiety, stress, and job performance among Turkish nurses in the early post‐earthquake period

Abstract

Background

Individual and social concerns can negatively affect nurses’ mental health during a large‐scale earthquake's early stages, making it challenging to perform their professional responsibilities.

Aim

This cross‐sectional correlational study aimed to examine the relationship between depression, anxiety, and stress levels Turkish nurses experienced during an earthquake's early period. The nurses participating in this study were not directly present in the earthquake‐affected area.

Methods

The study was conducted on 232 nurses between February 10 and 25, 2023. The data were collected using the Depression, Anxiety, Stress‐21 Scale and the Job Performance Evaluation Form developed by the researchers through a literature review. These were used to investigate nurses’ work motivation changes due to the earthquake. The study followed the STROBE checklist for cross‐sectional studies.

Results

The participants’ depression levels were severe, anxiety levels were extremely severe, and stress levels were moderate following the earthquake. Nurses who felt exhausted experienced reduced energy levels toward their work and reported a decrease in their desire, effort, and work motivation to perform well. In addition, they had higher depression, anxiety, and stress scores (p < 0.005).

Conclusion

Psychological difficulties, including depression, anxiety, and stress experienced by nurses not directly present in an earthquake‐affected area, reduced their professional efforts and motivation and negatively affected the patient care process. Further studies should focus on conducting comparative studies in different cultures affected by natural disasters on the longitudinal analysis of the impacts of nurses' psychological distress on their job performance.

Implications for nursing and health policy

Nursing policymakers should be aware of the negative psychological effects experienced by nurses during the early post‐earthquake period, even if they are not directly present in the earthquake‐affected area. The study recommended that nurses should be provided with psychological support to deal with the negative effects of natural disasters and maintain job performance, including the nursing care process.

INTRODUCTION

Natural disasters, such as earthquakes, floods, and landslides, occurring worldwide result in significant concerns at both national and international levels and exert dramatic effects on individuals, families, and societies (Fadilah et al., 2021; Shrestha et al., 2018; Tas et al., 2020). The term “disaster” is a severe threat or significant destruction to the community, leading to huge losses and limiting the community's functions and capabilities in several aspects (Ingham et al., 2022). Earthquakes disrupt people's daily lives and limit their demands for human and environmental resources such as services, materials, and information. Consequently, these effects exceed the ability of the affected community to cope with the situation (Ergün & Şenyüz, 2021; Uwishema, 2023). Several criteria such as the affected geographical area and population, casualties, structural damages, and social and economic losses are used to determine the scale of an earthquake (Uwishema, 2023). Particularly, severe earthquakes exert major traumatic effects, including destruction, death, and injuries, making it difficult for people to continue their daily lives (Bıçakçı & Ergüney Okumuş, 2023). The most recent examples in Turkey are the earthquakes of magnitudes 7.7 and 7.6 on February 6, 2023, centered in the Pazarcık and Elbistan districts of the Kahramanmaraş province, respectively. These earthquakes led to significant loss of life and property damage in 11 areas in Turkey. It accounted for the death of over 50,000 people. These earthquakes are documented in the literature with the highest number of fatalities and the most damage caused due to the proximity of the fault rupture to the surface, merging of fault lines, large affected area, and occurrence of two earthquakes with magnitudes of 7.0 or higher in close succession (Cumhurbaşkanlığı Strateji ve Bütçe Başkanlığı, 2023).

The earthquakes not only cause physical injuries and property damage but also exert a large psychological impact on the affected population (Uwishema, 2023). An individual affected by an earthquake may have experienced a quake herself/himself, witnessed traumatic events in the earthquake‐stricken area, or learned that such events occurred to someone very close despite them or their acquaintances not being in the earthquake‐stricken area. They may be affected remotely (Naushad et al., 2019). Severe natural disasters can result in both short‐ and long‐term psychological impacts (Liou et al., 2020) depending on the affected population and area size. Short‐term effects of disasters include an increased prevalence of psychiatric disorders, anxiety, depression, somatic complaints, and sleep disorders (Liou et al., 2020). Because of the disaster's sudden and traumatic nature, survivors and those who lost loved ones experience high stress, anxiety, and fear (Ergün & Şenyüz, 2021; Uwishema, 2023). Displacement, loss of homes and possessions, and uncertainty about the future contribute to the psychological distress of affected populations (Ergün & Şenyüz, 2021; Uwishema, 2023).

Among the healthcare provider workforce, nurses constitute the largest group and play a substantial role during the emergent phase of a disaster and throughout the stages of disaster preparedness and recovery (Raveis et al., 2017). Therefore, this group of healthcare workforce is most likely to be professionally and personally impacted to the highest degree. For instance, emergency or disaster responders frequently report high psychological and emotional stress (Liou et al., 2020). Nurses working during an emergency or disaster event are more likely to report symptoms of stress and anxiety triggering factors for negative moods following disaster relief (Naushad et al., 2019; Yamaoka & Yukawa, 2020). Several studies have been conducted on short‐ and long‐term psychological effects on nursing survivors from an earthquake and those working in earthquake areas (Liao et al., 2019; Sato et al., 2019). Despite the importance of psychologically supporting nurses in extraordinary circumstances, more information is required on how nurses who are not earthquake survivors or have not worked in earthquake areas cope with a catastrophic disaster process.

Disasters can cause feelings of helplessness, stress, and anxiety, especially among nurses not working in an earthquake‐affected region who are not directly affected by the earthquake. In addition, they may worry about the sudden death of their loved ones. Similar to other people in society, nurses can experience negative emotions and thoughts, disrupting their cognitive resources due to the constant exposure to earthquake‐related news, images, and social media posts. Particularly, during the ongoing search and rescue operations in the early stages of the earthquake, individual and societal concerns can have adverse psychological effects on nurses, leading to severe emotional problems such as stress, anxiety, and depression (Helton & Head, 2012). On a positive note, life continues after a traumatic event such as an earthquake, and people must maintain their regular work routines. However, negative emotions and experiences can affect an individual's daily life and work (Shang et al., 2019). These emotional difficulties can reduce the work motivation among nurses and negatively impact their job performance.

Job performance is the level of completion of a task or an employee's behavior according to specified conditions (Durmuş et al., 2020; Hoşgör & Yaman, 2022). It significantly contributes to providing health services in an effective, efficient, and sustainable manner. It is highly essential to improve the job performance levels of healthcare professionals for both healthcare providers and healthcare clients (Hoşgör & Yaman, 2022). However, the expectations from nurses for high job performance and their ability to dedicate themselves to their work require a strong psychological background for working in extraordinary natural disaster crises such as large‐scale earthquakes.   Chen et al. (2022) reported that mental health problems can exert devastating effects on the process and performance of employees’ professional activities. Accordingly, they can affect caring behaviors by reducing the time dedicated to patient care and causing reluctance (Patil et al., 2021). Therefore, especially during the early period when society is still facing the acute effects of the earthquake, nurses' psychological ability and job performance become highly crucial to managing unpredictable events and maintaining routine patient care effectively.

To the best of our knowledge, the literature reports no studies on the relationship between anxiety, stress, depression, and job performance in nurses not directly present in the earthquake‐affected area during the early period after a large‐scale earthquake. Therefore, we evaluated the relationship between perceived depression, anxiety, stress, and job performance in nurses due to the large‐scale earthquake that occurred in Turkey on February 6, 2023. We believe the findings of this study will provide input to the policymakers and nursing administrators to effectively support the mental health of nurses and sustain their job performance at the international level during the early effects of large‐scale natural disasters. In addition, we have attempted to respond to the following research questions:

1. Are there any relationships between Turkish nurses’ sociodemographic and earthquake‐related characteristics and their depression, anxiety, and stress levels?

2. What are the levels of depression, anxiety, and stress among Turkish nurses participating in the study not directly present in an earthquake‐affected area?

3. Are depression, anxiety, and stress associated with Turkish nurses’ job performance not directly present in an earthquake‐affected area?

METHODS

Design and settings

This cross‐sectional study with a correlational design was conducted through a web‐based survey. The study population consisted of nurses not directly present in the earthquake‐affected area and working in a hospital in Turkey between February 10 and February 25, 2023. We used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist (Knottnerus & Tugwell, 2008) and the Checklist for Reporting Results of Internet E‐Surveys (CHERRIES) for reporting data. CHERRIES is a standard quality‐reporting tool for web‐based surveys. It includes essential items such as development, description, questionnaire testing, data protection, questionnaire administration, sample representativeness, response rates, informed consent, and statistical analysis. Applying CHERRIES before and during the survey administration ensures reliability (Eysenbachi, 2004).

Sample and recruitment

Because this study aimed to examine the psychological impact in the early period of the earthquake, an online survey method was used to make the data collection process faster and easier and increase the number of participants. The hospital where the study was conducted is a state hospital in Turkey. This hospital has many departments, including intensive care units, emergency services, outpatient clinics, and inpatient clinics. The nurses working in different departments in this hospital were invited to participate in this online survey. Because no target sample was set at the beginning of the study, we recruited as many nurses as possible using the convenience sampling method. Following the ethics approval, researchers provided the nurses with an electronic survey link online. The inclusion criteria were (a) working at the hospital where the study was conducted, (b) not directly present in the earthquake‐affected area, and (c) voluntarily participating by completing the online survey form. The exclusion criteria were (a) not actively working as a nurse and (b) incomplete or rejected survey responses.

Because we did not estimate the percentage of participation at the beginning of the study, we could not perform a priori sample size calculation. Therefore, after finalizing the data collection period, we conducted a post‐hoc power analysis to know whether we reached the minimum number of nurses. Accordingly, we used a two‐tailed α value of 5% and an estimated effect size of 0.30 and determined the post hoc power of the study as 99% for 232 participants. However, considering the number of survey participants, a low response rate was obtained in this study.

Data collection

After obtaining permission from the institution's management to conduct the study, an online invitation letter was sent to the participants to obtain informed consent (it included the purpose of the research, anonymity, expectations, and participant rights). Next, a Google Forms online survey link was created and sent to the nurses. Clicking on the URL link directed the participants to a cover letter explaining the study's purpose, the survey's length, how the data would be stored, details on ensuring confidentiality, and the researchers’ contact information. To obtain consent from the nurses, the following question was asked at the bottom of the first page, “Do you agree to participate in this survey?” Only those who answered “yes” were directed to the next page of the survey. Additional strategies, such as monetary incentives or rotating survey shares, were not used to encourage survey completion. Multiple survey entries were avoided using different individual web links. The survey data were stored in an encrypted file and kept in a secure database on a protected computer. Because the study was designed to assess nurses’ situation during the early period of the earthquake, the survey was open for 15 days from February 10 to February 25, 2023. Furthermore, participants were instructed to answer the questions considering the last week after the earthquake (mentioned on the cover letter of the online survey) because the study evaluated the early impact of the earthquake.

Instruments

A nurse information form was created by researchers after considering the literature (Çelmeçe & Menekay, 2020; Huang et al., 2023; Sinsky et al., 2021). Sociodemographic characteristics such as age, gender, working year, education level, work unit, and information on the earthquake were included in this form. The earthquake‐related questions covered experiences of experiencing earthquakes in previous years, having a close relative affected by the current earthquake, how they were affected, the degree of closeness, and whether they had a close relative trapped under debris.

Scales in the literature that assess the psychological effects of the earthquake are used on earthquake survivors (Başoglu et al., 2001; Yöndem & Eren, 2008). On the other hand, our sample consisted of nurses who were not directly in the earthquake areas or were not earthquake victims. Regarding the aim and sample characteristic of the study, DASS‐21 was used for the population not directly affected by the earthquake to assess simultaneously depression, anxiety, and stress rather than addressing a single psychological and emotional state dimension. The Depression, Anxiety, Stress Scale‐21 (DASS‐21) is a short form containing 42 items. Depression, Anxiety, Stress Scale (DASS) was developed by Lovibond and Lovibond (Lovibond & Lovibond, 1995). It consists of three subscales: depression, anxiety, and stress, with seven items in each subscale and 21 items. A 4‐point Likert‐type rating system was used (0: never, 3: always). Scores for each subscale were calculated by summing the scores of the seven items separately, classified as normal, mild, moderate, severe, and extremely severe. Depression: normal (0−4), mild (5−6), moderate (7−10), severe (11−13), extremely severe (14+); anxiety: normal (0−3), mild (4−5), moderate (6−7), severe (8−9), extremely severe (10+); stress: normal (0−7), mild (8−9), moderate (10−12), severe (13−16), extremely severe (17+). The Turkish validity and reliability of the scale were studied by Sarıçam in 2018 (Sarıçam, 2018). Based on the scale's reliability, Cronbach's alpha internal consistency coefficient was found to be 0.85 for the depression subscale, 0.80 for the anxiety subscale, and 0.77 for the stress subscale (Sarıçam, 2018).

Previous scales evaluating professional performance mainly focus on nursing care or practices from dimensions such as knowledge skills, care coordination, ethics, and interpersonal communication (Greenslade & Jimmieson, 2007; Seren et al., 2018). For this reason, considering the psychological effects of natural disasters on nurses’ job performance, researchers developed the job performance evaluation form following a literature review to assess how the earthquake affected nurses’ work motivation (Deniz & Kumru, 2022; Guo et al., 2022; Hoşgör & Yaman, 2022; Xu & Wu, 2014). The form included questions related to nurses’ exhaustion due to the earthquake, the energy required for their work, difficulties they face in initiating and sustaining their work, the energy required to perform their job, their motivation, and processes affecting their ability to provide quality care to patients. An expert committee opinion was received for the content validity and comprehensibility of the form. The survey was iteratively revised and pilot‐tested before administration to the target sample with 15 participants to determine the clarity of questions. All participants in the pilot phase completed the online survey and provided written feedback using the job performance evaluation form. Finally, the form was revised based on the feedback, questions, and wordings received to finalize the online survey.

Ethical considerations

The study protocol, informed consent form, and all recruitment documents were thoroughly reviewed and approved by the Institutional Review Board of Sakarya University (decision number: E‐71522473‐050.01.04‐220143‐56). The study's aim, method, and expected benefits were explained to each nurse. During data collection, all participants were informed that they could withdraw from the study at any time without providing any reasons and that there was no cost to participate. Participants’ data were collected using a secure, password‐protected, web‐based application. The “anonymous responses” option was enabled in the Google Form security settings, ensuring that the respondents’ IP addresses, location data, and contact information were not recorded.

Statistical analysis

All data were analyzed using SPSS 26.0 (IBM Corp., Chicago, IL, USA). Frequency and percentage analyses were conducted to determine the descriptive characteristics of nurses participating in the study. Mean and standard deviation statistics were used to examine the scale data. Research variables demonstrated normal distribution when considering kurtosis and skewness values (+1.5 to −1.5) (Tabachnick & Fidell, 2013). Parametric methods were used in data analysis. The t‐test was used to compare the differences in the participants’ scale scores according to the descriptive characteristics between the two groups, and one‐way analysis of variance (ANOVA), and post hoc (Bonferroni) tests were used to compare more than two groups. The relationships between continuous variables and depression, anxiety, and stress scores were evaluated using Pearson's correlation analysis. A value of p < 0.05 was considered significant.

RESULTS

Descriptive characteristics of participants

The mean age of participating nurses was 29.20 ± 6.13 years, and the mean total years of work experience was 6.58 ± 6.41 years. Most nurses were female (69.82%) and had a bachelor's degree (75.86%). In addition, 42.67% of nurses worked in intensive care units, whereas 39.22% worked in general wards. Next, we found that 41.38% of participants had experienced earthquakes previously, 23.27% of participants had relatives affected by the current earthquake, and 64.81% of nurses’ relatives of earthquake victims survived. Only 4.75% of participants had a relative trapped under the debris (Table 1).

TABLE 1.

Nurses' descriptive characteristics and DASS‐21 correlations.

Characteristics			Depression	Anxiety	Stress
	M ± SD		r/p	r/p	r/p
Age, years	29.20 ± 6.13		−0.163/0.013 *	−0.118/0.073	−0.158/0.016 *
Working duration, years	6.58 ± 6.41		−0.164/0.012 *	−0.137/0.037 *	−0.172/0.009 *
	n	%	M ± SD	M ± SD	M ± SD
Gender
Female	162	69.82	11.70 ± 5.27	10.74 ± 5.71	11.28 ± 5.61
Male	70	30.18	12.68 ± 5.26	11.97 ± 6.15	12.58 ± 5.92
t/p			−1.295/0.197	−1.463/0.145	−1.590/0.113
Education level
High school	38	16.38	12.13 ± 5.76	10.81 ± 6.02	11.52 ± 5.91
Bachelor	176	75.86	11.91 ± 5.21	11.18 ± 5.81	11.68 ± 5.65
Master+	18	7.76	12.61 ± 6.07	11.11 ± 6.33	12.55V6.20
F/p			0.154/0.857	0.060/0.941	0.231/0.794
Working unit
Intensive care	99	42.67	13.67 ± 4.99	13.32 ± 5.27	13.92 ± 5.06
Emergency	42	18.11	8.56 ± 4.99	6.36 ± 5.12	6.58 ± 4.92
Clinic	91	39.22	11.76 ± 4.91	10.92 ± 5.50	11.58 ± 5.30
F/p			15.527/0.000 * 1 > 3 > 2	24.727/0.000 * 1 > 3 > 2	29.668/0.000 * 1 > 3 > 2
Experiencing the earthquake in previous years
Yes	96	41.38	10.68 ± 5.65	8.95 ± 6.21	9.53 ± 6.15
No	136	58.22	12.92 ± 4.81	12.61 ± 5.12	13.18 ± 4.93
t/p			−3.236/0.001 *	−4.892/0.000 *	−5.000/0.000 *
Having any relatives who were affected by the earthquake
Yes	54	23.27	10.74 ± 5.29	8.80 ± 5.74	9.26 ± 5.60
No	182	76.73	12.35 ± 5.23	11.75 ± 5.75	12.34 ± 5.61
t/p			−1.924/0.056	−3.215/0.001 *	−3.438/0.001 *
The closeness of your relative
First‐degree (mother, father, sibling, husband/wife, child)	6	11.11	10.50 ± 3.50	9.00 ± 3.74	9.00 ± 4.19
Second‐degree (aunt, uncle, cousin, nephew, grandmother, grandfather)	15	2.78	11.72 ± 5.93	10.36 ± 6.56	10.72 ± 6.48
Third‐degree relatives, friends, neighbors	33	61.11	10.37 ± 5.83	8.43 ± 6.10	8.86 ± 5.94
F/p			1.710/0.166	2.824/0.111	2.674/0.093
How was your relative affected by the earthquake?
Survived	35	64.81	10.02 ± 5.82	7.74 ± 5.83	7.97 ± 5.78
Injured	13	24.08	12.46 ± 5.68	12.00 ± 5.73	12.30 ± 5.85
Died	6	11.11	10.50 ± 3.39	8.83 ± 5.49	10.16 ± 3.92
t/p			2.216/0.136	2.432/0.087	2.195/0.102
Have you had any relatives stay under the debris?
Yes	11	95.25	12.81 ± 6.91	12.63 ± 7.14	12.45 ± 7.32
No	221	4.75	11.96 ± 5.19	11.04 ± 5.80	11.63 ± 5.66
t/p			0.523/0.601	0.880/0.380	0.460/0.646

Abbreviations: F, one‐way ANOVA; M, mean; r, Pearson correlation test; SD, standard deviation; t, Independent sample t‐test.

1, Intensive care; 2, emergency; 3, clinic.

^*p < 0.005.

Depression, anxiety, and stress levels

When the DASS‐21 mean scores of participants not directly present in the earthquake‐affected area were examined during the early stages of the earthquake, the mean scores were 12.00 ± 5.27 (severe) for depression, 11.11 ± 5.86 (extremely severe) for anxiety, and 11.67 ± 5.67 (moderate) for stress (Table 2). A statistically significant and weak negative correlation was recorded between age and years of work experience with DASS‐21 scores. With an increase in the age of participants, depression and stress scores reported due to the effect of a large‐scale earthquake decreased (p < 0.005). Similarly, as the years of work experience increased, depression, anxiety, and stress scores decreased (p < 0.005). Regarding working settings, nurses working in intensive care units had statistically higher depression, anxiety, and stress scores than those working in emergency departments and clinics (p < 0.005). In addition, nurses who had not experienced earthquakes previously had higher depression, anxiety, and stress scores (p < 0.005). A significant difference was observed in anxiety and stress scores among nurses whose relatives were affected by the earthquake (p < 0.005). Those unaffected by their relatives’ earthquake had higher anxiety and stress scores (p < 0.005; Table 1).

TABLE 2.

DASS‐21 scale scores of nurses in the early period of the earthquake.

Subscales	N	M ± SD	Scale Scoring Range
DASS‐Depression	232	12.00 ± 5.27	11–13	Severe
DASS‐Anxiety	232	11.11 ± 5.86	10+	Extremely severe
DASS‐Stress	232	11.67 ± 5.67	10–12	Moderate

Abbreviations: M, mean; SD, standard deviation.

Job performance

Among the nurses who were not directly present in the earthquake‐affected area, 53.9% felt tired, 54.3% experienced a decrease in the energy level required for work, and 46.6% experienced a reduction in effort and willingness to perform well. Furthermore, 43.1% of nurses reported decreased work motivation due to the earthquake, and 34.1% reported a reduced desire to spend extra time to care for patient needs (Table 3).

TABLE 3.

Distribution of nurses' job performance survey responses.

Questions	Variables	n	%
Due to the earthquake:
1.I feel exhausted.	No	26	11.2
	Sometimes	81	34.9
	Yes	125	53.9
2.I feel the energy needed for my job is decreasing.	No	27	11.6
	Sometimes	79	34.1
	Yes	126	54.3
3.I have difficulty starting and maintaining work.	No	38	16.4
	Sometimes	100	43.1
	Yes	94	40.5
4.I think my desire and effort to do my job well have decreased.	No	42	18.1
	Sometimes	82	35.3
	Yes	108	46.6
5.I think my work motivation has decreased.	No	33	14.2
	Sometimes	99	42.7
	Yes	100	43.1
6.I have difficulty making decisions while caring for the patient.	No	79	34.1
	Sometimes	77	33.2
	Yes	76	32.8
7.I cannot concentrate while caring for the patient.	No	72	31.0
	Sometimes	91	39.2
	Yes	69	29.7
8.I do not think that I am providing enough quality care to patients during this period.	No	77	33.2
	Sometimes	89	38.4
	Yes	66	28.4
9.I do not want to spend extra time meeting patients' needs.	No	75	32.3
	Sometimes	78	33.6
	Yes	79	34.1
10.I strive to raise the morale of other nurses.	No	51	22.0
	Sometimes	111	47.8
	Yes	70	30.2

Comparing job performance based on depression, anxiety, and stress levels

The relationship between depression, anxiety, and stress experienced by nurses due to the earthquake and their job performance is depicted in Table 4. Although nurses were not directly present in the earthquake‐affected area, those feeling exhausted and experiencing decreased energy levels required for work due to the earthquake had higher depression, anxiety, and stress scores (p < 0.005). Similarly, those who reported decreased desire, effort, and work motivation to perform well due to the earthquake had higher depression, anxiety, and stress scores (p < 0.005). Moreover, participants facing difficulty making decisions and focusing while providing care reported higher depression, anxiety, and stress scores (p < 0.005). Those who did not believe they offered adequate quality care to patients during the early stage of the earthquake had higher depression, anxiety, and stress scores than those who thought they provided good quality care (p < 0.005). Participants who did not wish to spend extra time or sometimes did not want to meet patient needs had higher depression, anxiety, and stress scores than those who provided extra time to care for patient needs (p < 0.005).

TABLE 4.

Comparing job performance according to depression, anxiety, and stress among nurses.

Questions	Variables	Depression	Anxiety	Stress
Due to the earthquake:		M ± SD	M ± SD	M ± SD
1.I feel exhausted.	No	7.96 ± 5.53	6.53 ± 6.12	7.34 ± 6.13
	Sometimes	10.86 ± 5.18	10.03 ± 5.82	10.64 ± 5.57
	Yes	13.58 ± 4.64	12.76 ± 5.17	13.21 ± 5.17
	F/p	17.2477/0.000 * 3 > 2 > 1	16.099/0.000 * 3 > 2 > 1	14.624/0.000 * 3 > 2 > 1
2.I feel the energy needed for my job is decreasing.	No	7.33 ± 5.05	5.37 ± 5.54	6.44 ± 5.40
	Sometimes	11.48 ± 4.94	11.02 ± 5.49	11.24 ± 5.45
	Yes	13.33 ± 4.92	12.40 ± 5.43	13.07 ± 5.41
	F/p	17.038/0.000 * 3 > 2 > 1	18.406/0.000 * 3 > 2 > 1	17.296/0.000 * 3 > 2 > 1
3.I have difficulty starting and maintaining work.	No	7.00 ± 4.90	5.00 ± 5.25	5.68 ± 5.25
	Sometimes	12.22 ± 4.82	11.62 ± 5.25	12.10 ± 5.21
	Yes	13.79 ± 4.61	13.05 ± 5.07	13.64 ± 4.81
	F/p	27.853/0.000 * 3 > 2 > 1	33.492/0.000 * 3 > 2 > 1	34.119/0.000 * 3 > 2 > 1
4.I think my desire and effort to do my job well have decreased.	No	6.95 ± 4.66	5.14 ± 4.96	5.83 ± 4.81
	Sometimes	12.29 ± 5.10	12.04 ± 5.56	12.42 ± 5.54
	Yes	13.75 ± 4.34	12.73 ± 4.90	13.37 ± 4.73
		32.079/0.000 * 3 > 1, 2 > 1	34.756/0.000 * 3 > 1, 2 > 1	34.888/0.000 * 3 > 1, 2 > 1
5.I think my work motivation has decreased.	No	7.87 ± 4.77	6.33 ± 5.56	7.00 ± 5.00
	Sometimes	11.28 ± 5.17	10.75 ± 5.64	11.04 ± 5.71
	Yes	14.08 ± 4.53	13.05 ± 5.18	13.85 ± 4.89
	F/p	22.183/0.000 * 3 > 2 > 1	19.193/0.000 * 3 > 2 > 1	22.147/0.000 * 3 > 2 > 1
6.I have difficulty making decisions while caring for the patient.	No	9.05 ± 5.42	7.16 ± 5.84	7.94 ± 5.60
	Sometimes	12.28 ± 4.15	11.40 ± 4.24	12.05 ± 4.63
	Yes	14.78 ± 4.53	14.93 ± 4.57	15.17 ± 4.47
	F/p	28.576/0.000 * 3 > 2 > 1	47.970/0.000 * 3 > 2 > 1	41.798/0.000 * 3 > 2 > 1
7.I cannot concentrate while caring for the patient.	No	9.37 ± 5.46	7.36 ± 6.00	8.16 ± 5.35
	Sometimes	12.35 ± 4.27	11.85 ± 4.55	12.37 ± 4.81
	Yes	14.28 ± 5.11	14.05 ± 5.22	14.42 ± 5.13
	F/p	17.837/0.000 * 3 > 2 > 1	30.263/0.000 * 3 > 2 > 1	26.946/0.000 * 3 > 2 > 1
8.I do not think that I am providing enough quality care to patients during this period.	No	9.40 ± 5.41	7.76 ± 5.85	8.53 ± 5.23
	Sometimes	12.64 ± 4.34	11.83 ± 4.83	12.44 ± 4.87
	Yes	14.18 ± 5.06	14.06 ± 5.26	14.30 ± 5.19
	F/p	17.911/0.000 * 3 > 1, 2 > 1	26.224/0.000 * 3 > 2 > 1	22.911/0.000 * 3 > 1, 2 > 1
9.I do not want to spend extra time meeting patients' needs.	No	9.22 ± 5.17	7.56 ± 5.65	8.40 ± 5.44
	Sometimes	13.01 ± 4.61	12.23 ± 5.05	12.82 ± 5.04
	Yes	13.64 ± 4.96	13.39 ± 5.27	13.65 ± 5.36
	F/p	17.925/0.000 * 3 > 1, 2 > 1	25.636/0.000 * 3 > 1, 2 > 1	21.791/0.000 * 3 > 1, 2 > 1
10.I strive to raise the morale of other nurses.	No	10.84 ± 4.77	10.21 ± 5.60	10.58 ± 5.10
	Sometimes	12.26 ± 5.13	11.05 ± 5.61	11.82 ± 5.64
	Yes	12.44 ± 5.77	11.876.40	12.22 ± 6.28
	F/p	1.616/0.201	1.189/0.306	1.282/0.279

Abbreviations: 1, no; 2, sometimes; 3, yes; F, one‐way ANOVA; M, mean; SD, standard deviation.

^*p < 0.005.

DISCUSSION

The large‐scale earthquake exerted a destructive impact on and hampered Turkish society. It created a chaotic atmosphere where thousands of lives and property were lost, leaving the survivors worrying about returning to normal life (Lee & Lee, 2019; Uwishema, 2023). Nurses not in the earthquake‐affected area could experience psychological distress and lack of job performance that may negatively affect patient care processes, mainly due to the acute effects of the earthquake. Therefore, we determined the levels of stress, anxiety, and depression experienced by nurses not present in the earthquake‐affected area during the early period of the earthquake and examined their relationship with job performance. Our study is unique because of the limited number of studies investigating the aforementioned variables after a large‐scale earthquake. Thus, it is the first study to address these variables among Turkish nurses who were not directly present in the earthquake‐affected areas.

Exposure to disasters is an essential factor to consider when examining the psychological resilience of healthcare workers (Guo et al., 2022). Considering the international prevalence of natural disasters and their inevitability, it is crucial to understand how nurses are psychologically affected during such traumatic events. We found that the nurses reported severe depression, extremely severe anxiety, and moderate stress levels during the early phase of the earthquake. However, a comparative study could not be conducted due to the lack of studies involving the nurse population not directly present in the earthquake‐affected area. Therefore, we compared the results to those of studies on nurses and other healthcare workers who were either earthquake victims or directly worked in the rescue team. A relatively high prevalence of possible post‐traumatic stress disorder has been reported among healthcare workers involved in disaster rescue operations (Guo et al., 2022; Tyer‐Viola, 2019). For example, a study on the 2011 Japan earthquake stated that 14% of healthcare workers experienced depression, and 15% experienced psychological distress (Sakuma et al., 2015). Similarly, Huang et al. (2023) reported that rescue nurses in emergency medical teams reported moderate psychological flexibility and high levels of anxiety and depression during the disaster preparedness phase (Huang et al., 2023).

Healthcare workers living in disaster‐prone and affected communities can also be negatively affected by their disaster experiences (not as members of rescue teams) regarding their psychological and mental health (Naushad, et al., 2019). For instance, Guo et al. (2022) reported no significant difference in psychological resilience between healthcare workers exposed to and not exposed to the Wenchuan earthquake. The same study suggested that daily life and work‐related stressors, rather than exposure to the Wenchuan earthquake, were important factors affecting healthcare workers’ mental health and resilience (Guo et al., 2022). Nursing involves handling an individual's physiological, psychological, and spiritual requirements and therefore expects skills including strong sensitivity, insight, and empathetic attitude (Yin et al., 2022). Developing a sense of empathy and sensitivity for earthquake victims or those in physical or psychological distress results in developing the same emotive experiences in nurses, and therefore, they can be indirectly affected by the earthquake consequences. Accordingly, depression, anxiety, and stress levels related to the earthquake are expected to be high in nurses working under challenging conditions and those responsible for critical clinical decision‐making and care continuity. In our study, factors such as nurses being constantly exposed to negative news on television and social media during the acute phase of the earthquake, having affected relatives in the earthquake zone, thinking that there could be an earthquake in their place of residence, and fear of death and loss could have led to higher levels of depression, anxiety, and stress.

Our results demonstrated that with an increase in the age and experience of nurses, their scores for earthquake‐related depression, anxiety, and stress decreased. Taşkıran and Baykal (2017) conducted a study on nurses’ views and preparedness regarding disasters and reported that newly graduated nurses were more stressed and tense. In their review of disasters and nursing, Harthi et al. (2020) emphasized that young nurses involved in disaster management had higher stress and anxiety levels than experienced nurses (Harthi et al., 2020). A study that measured the knowledge levels of nurses regarding disaster preparedness reported that younger nurses had lower knowledge levels and were more affected psychologically and emotionally than older nurses in managing the chaotic environment (Kimin et al., 2021). In line with the literature, younger nurses and those who had newly graduated from the profession are believed to encounter higher levels of anxiety, stress, and depression in disaster situations, irrespective of whether they served in the earthquake‐affected areas or not due to their lower knowledge levels, lack of experience, and deficiencies in managing the chaotic and stressful environment.

Another significant finding is that intensive care nurses reported higher levels of stress, anxiety, and depression during the early stages after an earthquake compared with those working in the clinic and emergency department. Ergün et al. (2016) reported that 47.8% of intensive care nurses reported anxiety symptoms, and 31.0% showed signs of depression (Ergün et al., 2016). Similarly, Karanikola et al. (2015) reported that nurses in the intensive care unit encountered more psychological burden than those in other departments and the general population (Karanikola et al., 2015). In addition, studies in different settings have reported high stress levels among intensive care nurses during the COVID‐19 pandemic and emphasized the need for psychological support for intensive care nurses in disaster situations (Lin & Zheng, 2021; Yin et al., 2022). Factors such as the need for intensive care of patients injured in earthquakes, challenging working conditions, and the psychological effects of earthquakes have been reported to significantly impact intensive care nurses more than other nursing specialties (Donelan et al., 2020). Furthermore, the additional burden exerted by natural calamities such as earthquakes amplifies psychological stress in intensive care nurses, leading to increased stress and anxiety. The emergency department nurses are the least psychologically affected group by this large‐scale earthquake due to their experience in coping with stress and working under traumatic situations, frequent exposure to emergencies, and their ability to respond rapidly (Bahadırlı & Sağaltıcı, 2021).

In the present study, the anxiety, depression, and stress levels of nurses who had not experienced an earthquake were higher than those who had previously experienced earthquakes. This could be attributed to their direct lack of experience with a severe earthquake, preventing them from completely understanding the destructive effects of a disaster and the uncertainties associated with the future. In addition, their lack of necessary training and experience in dealing with emergencies negatively impacts them. Factors such as not knowing how to act before, during, and after an earthquake; what precautions to take; and how to intervene, can negatively affect their emotional responses and adaptive abilities (Abu Hasheesh, 2023; Songwathana & Timalsina, 2021; Xie et al., 2023). Furthermore, low motivation to prepare themselves for earthquake risks contributes to the overall negative effect. Nurses not working in earthquake‐prone areas may not feel the requirement to know and learn about earthquake‐related preparations, thus increasing their vulnerability to uncertainties and difficulties arising after an earthquake. The inexperience, lack of training, and unpreparedness of nurses who have not experienced earthquakes can significantly impact them (Bektaş Akpınar & Ceran, 2020). Therefore, they should be educated on handling disasters, be prepared, and enhance their emotional resilience to function more effectively in emergencies such as earthquakes and deliver better healthcare services.

During the early period of the large‐scale earthquake, although most nurses participating were not directly present in the earthquake‐affected areas, we found a decrease in their sense of fatigue and levels of energy, effort, motivation, and willingness to spend extra time to care for patient needs. The majority of previous studies have focused on the impact of individual and organizational factors on nurses’ job performance (Baljoon et al., 2018). No study has examined the effect of natural disasters such as earthquakes on nurses’ job performance. Ingham et al. (2022) used a job performance form (similar to that used in our study) and reported that cumulative, prolonged, and severe exposure to disasters could result in societal disaster fatigue (Ingham et al., 2022). Kitamura et al. (2013) reported that two‐thirds of local government employees involved in disaster response experienced psychological distress and fatigue (Kitamura et al., 2013). Furthermore, Sato et al. (2019) examined the psychosocial consequences among nurses in affected areas of the Great East Japan Earthquake of 2011 and the Fukushima complex disaster. Initial acute stress, acute stress turning chronic, and chronic physical, and mental fatigue emerged as the main themes from their qualitative study (Sao et al., 2019). Motivation for their job is essential to nurses’ energy response to increasing challenges and demands (Baljoon et al., 2018). The destructive effects of severe natural disasters can create additional psychosocial pressure on nurses’ sense of social responsibility (Tyer‐Viola, 2019), resulting in reduced mental fatigue and motivation and a reluctance to provide patient care. Uncertainty during a global crisis such as the COVID‐19 pandemic has been reported to trigger anxiety, lower motivation, and negatively impact nurses’ performance (Resnick, 2020; Sperling, 2021). In contrast, Tyer‐Viola (2019) reported that nurses with high crisis‐coping abilities and motivation could continue providing care to patients despite facing stress and multiple barriers (Tyer‐Viola, 2019). Thus, it is vital to enhance nurses’ ability not to be actively involved in earthquake‐affected areas to cope with the effects of disasters, maintain their energy and motivation levels, and indirectly reduce the negative impact on their job performance.

We found that the earthquake‐related stress, anxiety, and depression scores of nurses increased during the early stages of an earthquake, and their job performance decreased. Chen et al. (2022) reported that psychological status negatively and significantly affects employees' job performance. Similarly, meta‐analyses have confirmed a negative association between job performance and adverse mental health outcomes (Ford et al., 2011). This could be explained by mental disorders manifesting as depression and other emotional disorders causing reduced productivity and job performance due to a severe reduction in workability (Chen et al., 2022). Moreover, poor job performance could have a greater negative impact on patient care. Although studies have been conducted on the psychiatric symptoms and disorders experienced by local emergency response teams after significant disasters resulting in loss of life and property (Cankardaş & Sofuoğlu, 2019), no studies have examined the effects of early psychological distress experienced by nonlocal nurses on job performance. Therefore, considering the findings from studies examining the impact of nurses’ psychological well‐being on their professional lives during several crises and disasters, our research results were discussed. A study reported that nurses working under uncontrolled and potentially dangerous conditions during Superstorm Sandy in New York–New Jersey in October 2012 were concerned about the welfare of their families/loved ones and experienced increased psychosocial burdens (Raveis et al., 2017). Nurses experiencing increased psychosocial burdens are expected to have decreased willingness and efforts to fulfill their professional roles, such as patient care, as the devastating effects of disasters continue to affect the community. Hoşgör and Yaman (2022) reported a significant positive relationship between psychological resilience and job performance among nurses working on the front lines during the COVID‐19 pandemic (Hoşgör & Yaman, 2022). Çelmeçe and Menekay (2020) emphasized that the anxiety experienced by healthcare professionals during crisis intervention impaired cognitive processes, disrupted attention and coordination, and reduced problem‐solving abilities. All these studies are compatible with our study results.

It is crucial to consider the nature of the nursing profession. Nurses are easily prone to developing mental health problems, such as fatigue, low energy, lack of motivation, being easily annoyed, and trouble remembering things due to working in shifts and having heavy workloads (Liou et al., 2020). Moreover, these circumstances can increase workplace stress and reduce nurses’ job performance. Consequently, they can lead to quality issues in patient care, increased errors, and decreased efficiency. We could not distinguish whether the earthquake caused these psychological symptoms, the nature of nursing work, or both. Therefore, this question warrants further studies. In all, it is vital to recognize the factors affecting nurses’ mental health to intervene and improve their results, especially when the intensity of tension and stress is considerably higher than usual. Strategies to reduce depression, anxiety, and stress among nurses working in disasters such as earthquakes would significantly contribute to optimizing their job performance and achieving high‐quality patient care outcomes.

Limitations of the study

This study had several limitations. First, because it was conducted on Turkish nurses, the results may not be generalizable. Second, although the sample size of this study is in line with the power analysis results, a low response rate was noted. The response rate and reason for not participating were not disclosed as this was an online survey. Third, information about depression, anxiety, stress, and job performance was based on individuals’ subjective reports. Lastly, the participating nurses were not followed up longitudinally. Therefore, larger sample sizes and longer‐term and more in‐depth research comparing the levels of depression, anxiety, and stress with job performance among nurses actively involved in disaster response and those not present in the disaster area are warranted to expand the scope of this study's findings.

CONCLUSION

Nurses not directly present in the earthquake‐affected area experienced severe depression, extremely severe anxiety, and moderate stress levels. In addition, the levels of depression, stress, and anxiety among nurses during the early post‐earthquake period were associated with age, experience, the unit of work, and past earthquake experience. Depression, stress, and anxiety experienced by nurses negatively affected their job performance and the quality of patient care. Future research should focus on conducting comparative studies in different cultures affected by a major disaster on the longitudinal analysis of nurses' psychological distress and job performance.

IMPLICATIONS FOR NURSING PRACTICE AND NURSING POLICY

To the best of our knowledge, this is the first study at both national and international levels investigating the level of depression, anxiety, and stress due to the large‐scale earthquake among nurses who were not directly present in the earthquake‐affected areas and determining the correlation between job performance. This study emphasizes the urgent need to develop crisis management and preparedness policies to decrease nurses’ psychological symptoms and improve their psychological status following a large‐scale earthquake to maintain nursing professional responsibilities. Accordingly, this study provides insights for nurse managers in clinical settings to be aware of the psychological effects experienced by nurses during the early post‐natural disaster period and its negative implications on patient care, even if they are not directly exposed to the disaster. Nurse policymakers should pay more attention to improving the psychological health of nurses directly or indirectly exposed to major disasters by developing coping strategies for dealing with stress, enhancing their psychological resilience, and supporting job performance.

AUTHOR CONTRIBUTIONS

Study design: HS, MGE, FK, YY; data collection: MGE, FK; data analysis: HS, MGE; study supervision: HS, YY; manuscript writing: HS, MGE, FK, YY; critical revisions for important intellectual content: HS, YY. All authors read and approved the final manuscript.

CONFLICTS OF INTEREST STATEMENT

No conflict of interest has been declared by the authors.

FUNDING INFORMATION

This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.

Sert, H. , Gulbahar Eren, M. , Koc, F. & Yurumez, Y. (2025) Depression, anxiety, stress, and job performance among Turkish nurses in the early post‐earthquake period. International Nursing Review, 72, 1–13. 10.1111/inr.12920

DATA AVAILABILITY STATEMENT

Data are available on request due to privacy/ethical restrictions.