Highlights
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This study investigated the psychological effect of COVID-19 pandemic on nurses living in Islamic culture dominant region.
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Nurses who are of the Islamic culture were affected slightly by the COVID-19 outbreak in early February.
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The factors associated with psychological variables were social support, family role, fear of contagion, etc.
Background
The outbreak of Coronavirus Disease (COVID-19) in Wuhan (WHO, 2020a), which began at the end of 2019 (Mahase, 2020), has caused an unprecedented global health challenge (Choi, Heilemann, Fauer, & Mead, 2020). The COVID-19, also called Novel Coronavirus Pneumonia, is the human-to-human transmitted lower respiratory tract infection disease, while its pathogenicity and transmissibility remain unknown (WHO, 2020b). The current COVID-19 is of primary global concern and has been categorized by the World Health Organization (WHO) as a Public Health Emergency of International Concern (PHEIC) and assessed as very high risk at the global level.
A vast body of literature on disaster mental health had found that emotional distress is ubiquitous among populations during public health emergencies (Pfefferbaum & North, 2020). COVID-19 pandemic is a challenge to affect us not only physically, but also mentally (Ahmad, Mueller, & Tsamakis, 2020). Facing uncertain infectious threats, we should pay attention to the mental health of nurses based on our experience with other respiratory coronavirus diseases, such as the Severe Acute Respiratory Syndrome (SARS) (Xiang et al., 2020). In the struggle against COVID-19, nurses are the vulnerable population who constitute the largest workforce within medical systems internationally (Hall et al., 2003; Maunder et al., 2003).
According to Zangaro et al. research, racial and ethnic diversity has a sharp increase among the nursing workforce since the 21st century (Zangaro, Streeter, & Li, 2018). However, little is known about the responses of minority ethnicity to public emergency outbreak, especially the medical staff. China is a multi-ethnic society, and the ethnic regional autonomy system is one of China's basic political systems. Gansu province, situated in northwestern China, offers astonishing cultural and ethnic diversity. Linxia Hui Autonomous Prefecture, Gansu, is one of the two Chinese only Hui Autonomous Prefecture. Autonomous prefectures are equivalent to city-level administrative units. Linxia Hui Autonomous Prefecture is a multi-ethnic residential city and is influenced profoundly by Islamic culture. Nurses with different ethnicities have different responses to the same stressor (Jiang, 2009) since culture influences medical care providers' perceptions. As a multi-ethnic residential city, nurses working in Linxia Hui Autonomous Prefecture may have different perceptions of emerging infectious disease outbreak due to the influence of Islamic culture. However, it is unknown how much it affects frontline nurses' perceptions of the emerging infectious disease outbreak.
The purpose of this study was to investigate the psychological characteristics of nurses with minority ethnic backgrounds in response to the public health crisis and to explore its related factors. The findings may offer new insight into nurses' response to an infectious disease outbreak and build cultural awareness for nursing professionals.
Methods
Setting and procedures
We undertook a cross-sectional online survey in the Linxia Hui Autonomous Prefecture, through an online crowdsourcing platform in mainland China, which provided functions equivalent to Amazon Mechanical Turk. A total of 1648 participants were voluntarily recruited and enrolled in our survey, working in nine hospitals, six of which were COVID-19-designated hospitals. The questionnaire was administered between February 6th and February 10th, 2020. Questionnaires with answer time less than 5 min, the same rating responses were elicited for all questions, and had invalid responses for age or years of working were excluded. In the end, 1569 returned questionnaires were included and analyzed (valid response rate of 95.2%).
Ethical consideration
Ethical approval for this study has been granted by the ethics committee of Gansu Provincial People's Hospital (No. 2020-011). The participants were explained the research procedures, and it was emphasized that the results would remain anonymous, and agreed respondents were asked to sign a consent before completing the self-report questionnaire.
Instruments
The structured questionnaire consisted of four parts:
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1)
Demographic questionnaire
The demographic questions included gender, age, educational level, marital status, work position, years of working, department, need to take care of children or elders, voluntary to be the reserve personnel to provide medical assistance to Wuhan, and so forth.
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2)
“COVID-19” related questionnaire
For the present study, a 19-item questionnaire tailored to nursing workers was developed by the researchers, which was chosen based on the available literature on the perceptions and opinions of experts regarding infectious disease outbreaks (Goulia, Mantas, Dimitroula, Mantis, & Hyphantis, 2010). Items were grouped in four domains: (a) nurses' concerns and worries about the “COVID-19”, e.g. “Knowledge of the “COVID-19”, “concerned information”; (b) effects of “COVID-19” on nurses, e.g. “what pneumonia affects you most is”, “recent sleep situation compared to the past”, etc.; (c) expected behavior, e.g. “possible to avoid the occupational duty”, “avoidance to work”; and (d) social support, e.g. “outside views on medical staff”, “satisfaction with outside material assistance” (Table 2 shows the detailed questionnaire items).
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3)
Self-rating Anxiety Scale, SAS
Table 2.
“COVID-19” related questionnaire.
| Item | N (%) |
|---|---|
| Nurses' concerns and worries about the “COVID-19” | |
| Knowledge of the “COVID-19” | |
| Little understanding | 5(0.3) |
| Unconversant | 109(6.9) |
| Understand better | 1145(73.0) |
| Know a lot about | 310(19.8) |
| The desire to learn about “COVID-19” | |
| Without | 7(0.4) |
| Little | 26(1.7) |
| Relatively large | 508(32.4) |
| Very large | 1028(65.5) |
| The most need to update knowledge about the “COVID-19” | |
| Symptoms | 766(48.8) |
| Prognosis | 1215(77.4) |
| Transmission | 882(56.2) |
| Prevention | 1073(68.4) |
| Treatment | 1233(78.6) |
| Concerned information | |
| Outbreaks | 1213(77.3) |
| New preventive measures | 1421(90.6) |
| Progress in scientific research | 1306(83.2) |
| Social stability | 1186(75.6) |
| Information source about the “COVID-19” | |
| Media | 1559(99.4) |
| Family and friends | 510(32.5) |
| Hospital learning | 966(61.6) |
| People talk about | 215(13.7) |
| During the “COVID-19”, top three concerns | |
| Fear of family and friends will be infected | 1237(78.8) |
| Lack of protective gear | 944(60.2) |
| Fear of contagion | 720(45.9) |
| Possibility of infection by yourself or others around you | |
| No possibility | 137(8.7) |
| Little possibility | 579(36.9) |
| Some possibility | 507(32.3) |
| More likely | 346(22.1) |
| The effects of “COVID-19” on nurses | |
| What pneumonia affects you most is | |
| Work and study | 441(28.1) |
| Daily life | 685(43.7) |
| Mood status | 234(14.9) |
| Family reunion | 209(13.3) |
| Recent sleep situation compared to the past | |
| Sleepless night | 31(2.0) |
| Hard to fall asleep | 319(20.3) |
| Slightly difficult | 781(49.8) |
| Same as before | 438(27.9) |
| Are you easily upset recently | |
| No | 212(13.5) |
| Occasionally | 407(25.9) |
| Sometimes | 647(41.2) |
| Frequently | 303(19.3) |
| Whether need psychological assistance at present | |
| Never considered | 283(18.0) |
| Do not need | 1088(69.3) |
| Need | 151(9.6) |
| In great request | 47(3.0) |
| Expected behavior | |
| Avoidance to work | |
| Yes | 10(0.6) |
| No | 1559(99.4) |
| Possible to avoid the occupational duty | |
| Not at all possible | 976(62.2) |
| Not possible | 569(36.3) |
| Possible | 23(1.5) |
| In all probability | 1(0.1) |
| Restriction of social activities | |
| Yes | 1189(75.8) |
| No | 380(24.2) |
| Interpersonal isolation | |
| Yes | 1156(73.7) |
| No | 413(26.3) |
| Social support | |
| Outside views on medical staff | |
| Hostile | 35(2.2) |
| Not very friendly | 193(12.3) |
| Friendly | 895(57.0) |
| Very friendly | 446(28.4) |
| Satisfaction with outside material assistance | |
| Not very satisfied | 43(2.7) |
| Ordinary | 166(10.6) |
| Be fairly satisfied | 585(37.3) |
| Very satisfied | 775(49.4) |
| Acceptance of epidemics management | |
| Too strict | 3(0.2) |
| Strict | 127(8.1) |
| Should accept | 264(16.8) |
| Accept | 1175(74.9) |
| Outside views on medical staff | |
| Too strict | 3(0.2) |
| Strict | 127(8.1) |
| Should accept | 264(16.8) |
| Accept | 1175(74.9) |
The anxiety levels of nurses were measured using the 20-item Self-rating Anxiety Scale developed by Zung (1971). This 20-item scale has a wide range of applications, of which 15 are positive scores, and 5 are negative scores. A 4-point Likert scale is employed to evaluate each item (e.g. 1 = never or some of the time, 4 = most of the time), yielding a totally original score ranging from 20 to 80. The total standard score was recorded as the original score (the sum of 20 items) multiplied by 1.25, so the score range is 25 to 100. The higher the score, the higher the anxiety level. A total score of ≥50 points was considered as the cut off for experiencing anxiety symptoms in the Chinese population. A standard score of 50–59 points indicated mild anxiety, 60–69 points indicated moderate anxiety, and >70 points signified severe anxiety (Kong et al., 2013). In this study, the Cronbach's α coefficient of the scale was 0.865.
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4)
Self-rating Depression Scale, SDS
The 20-item Self-rating Depression Scale developed by Zung (1965) was used to assess depression symptoms. This scale is commonly used to measure depression symptoms in the population over the past week, including subjective feelings of emotional, psychological, and physical aspects (Gong et al., 2014). Each item is rated on a 4-point Likert scale and ranges from 1 (never or some of the time) to 4 (most of the time). The total possible standard score, ranging from 25 to 100, was obtained by multiplying the total original score by 1.25. According to the results of Chinese norms, the boundary value of SDS was 53 points, a standard score of 53–62 points indicated mild depression, 63–72 points indicated moderate depression, and >72 points signified severe depression (Liu et al., 2013). The Cronbach's α coefficient of this scale was 0.892.
Statistical analysis
The Statistical Package for the Social Sciences 22.0 (SPSS) for Windows was used for analysis. Descriptive analysis of socio-demographic data, work-related characteristic variables, and self-perceived physical health status were performed. The enumeration data was expressed as frequencies and percentages. Measurement data was expressed as mean ± standard deviation(M ± SD). The independent sample two-tailed t-test was used to evaluate differences in the mean in dichotomous variables, and One-way ANOVA was used to evaluate differences in the mean value of categorical variables. Stepwise multiple regression analysis was used to identify the influencing factors of anxiety and depression. The independent variables were the factors with statistically significant differences in univariate analysis such as gender, COVID-19-designated hospital (yes, no), age (<30 years old, 30–40, ≥40 years old). P < 0.05 was considered statistically significant.
Results
Demographic and psychological characteristics (Table 1)
Table 1.
Demographic and psychological characteristics of nurses (N = 1569).
| Item | N (%) |
|---|---|
| Gender | |
| Male | 19(1.2) |
| Female | 1550(98.8) |
| Age, y (M ± SD: 30.93 ± 6.484) | |
| <30 | 740(47.2) |
| 30–40 | 677(43.1) |
| ≥40 | 152(9.7) |
| Education level | |
| Secondary school and below | 156(9.9) |
| Junior college | 934(59.5) |
| College or above | 479(30.5) |
| Marital status | |
| Single | 399(25.4) |
| Married | 1170(74.6) |
| Need to care for children | |
| Yes | 1002(63.9) |
| No | 567(36.1) |
| Need to care for elders | |
| Yes | 1328(84.6) |
| No | 241(15.4) |
| Department | |
| High exposure department | 393(25.0) |
| Non-high exposure department | 1176(75.0) |
| Years of working, y (M ± SD: 31.02 ± 6.324) | |
| <10 | 971(61.9) |
| ≥10 | 598(38.1) |
| Work position | |
| Frontline nursing worker | 1520(96.9) |
| Nursing administrators | 49(3.1) |
| Experience of caring for a confirmed or suspected case with “COVID-19” | |
| Yes | 59(3.8) |
| No | 1510(96.2) |
| Reserve personnel to assist Wuhan | |
| Yes | 414(26.4) |
| No | 1155(73.6) |
| Anxiety level (M ± SD: 42.56 ± 8.957) | |
| Normal | 1250(79.7) |
| Mild | 251(16.0) |
| Moderate | 58(3.7) |
| Severe | 10(0.6) |
| Depression level (M ± SD: 46.52 ± 11.883) | |
| Normal | 1055(67.2) |
| Mild | 387(24.7) |
| Moderate | 104(6.6) |
| Severe | 23(1.5) |
The majority of the nurses were women (98.8%), the mean age of the participants was 30.93 ± SD 6.484, and the mean working years was 31.02 ± SD 6.324, holders of a junior college degree (59.5%), married (74.6%), needed to care for children (63.9%) or elders (84.6%), non-reserve personnel to assist Wuhan (73.6%) and worked at non-high exposure departments (75%) in secondary hospital (66.9%) or COVID-19-designated hospital (85.4%). As for the psychological variables, 16% of nurses had mild anxiety, 3.7% had moderate anxiety, and 0.6% had severe anxiety. With respect to depression, 24.7% of nurses had mild depression, 6.6% had moderate depression, and 5.5% had severe depression. Detailed data about recruited participants are presented in Table 1.
“COVID-19” related questionnaire (Table 2)
Concerns and worries about the “COVID-19”
19.8% of the participants said they knew a lot about the “COVID-2019”, and the primary sources of information were from the media (99.4%) and hospital learning (61.6%). There were 65.5% of nurses who were very eager to acquire the knowledge of “COVID-19”. The knowledge that needed to be supplemented were, in descending order, treatment (78.6%), prognosis (77.4%), prevention (68.4%), transmission (56.2%), and symptoms (48.8%). The two most concerning pieces of information about the “COVID-19” were new preventive measures (90.6%) and the progress in scientific research (83.2%). There were 22.1% of nurses thinking they or those around them were more likely to be infected with “COVID-19”. During the “COVID-19”, the top three concerns were the fear that family and friends would be infected (78.8%), lack of protective gear (60.2%), and fear of contagion (45.9%).
Effects of “COVID-19” on nurses and expected behavior
The most significant influences of “COVID-19” on nurses were, in descending order, daily life (43.7%), work and study (28.1%), mood status (14.9%), and family reunion (13.3%). There were 72.1% of nurses with different degrees of sleep disorders, and 86.5% of them were easily upset. Besides, 12.6% of nurses thought they needed psychological assistance at present. There were 75.8% who would take the initiative to limit their social activities because their work environment was considered “dangerous”, and 73.7% thought they would avoid contact with family and friends (interpersonal isolation) because they worked in a “high-risk” environment. Only 0.6% of nurses would take leave to avoid going to work, and 1.6% would avoid their occupational duties in an emergency due to the “COVID-19”. More details are presented in Table 2.
Influencing factors of nurses' anxiety and depression (Table 3)
Table 3.
Association of demographic characteristics, COVID-19 related concern, impact of the COVID-19 on nurses with anxiety and depression (N = 1569).
| Independent variables | N(%) | Anxiety |
Depression |
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|---|---|---|---|---|---|---|---|
| Mean ± SD | F/t | P | Mean ± SD | F/t | P | ||
| Demographics | |||||||
| Gender | |||||||
| Male | 19(1.2) | 39.47 ± 9.801 | 1.510 | 0.131 | 41.38 ± 11.718 | 1.899 | 0.058 |
| Female | 1550(98.8) | 42.60 ± 8.943 | 46.59 ± 11.875 | ||||
| Age, y | |||||||
| <30 | 740(47.2) | 41.99 ± 8.727 | 3.514 | 0.030 | 45.61 ± 11.786 | 7.036 | 0.001 |
| 30–40 | 677(43.1) | 43.24 ± 9.024 | 47.80 ± 11.915 | ||||
| ≥40 | 152(9.7) | 42.30 ± 9.599 | 45.27 ± 11.738 | ||||
| Education level | |||||||
| Secondary school and below | 156(9.9) | 42.64 ± 7.223 | 0.164 | 0.848 | 47.08 ± 11.167 | 0.217 | 0.805 |
| Junior college | 934(59.5) | 42.64 ± 9.222 | 46.41 ± 11.975 | ||||
| College or above | 479(30.5) | 42.36 ± 8.957 | 46.56 ± 11.947 | ||||
| Marital status | |||||||
| Single | 399(25.4) | 41.89 ± 8.630 | 1.735 | 0.083 | 46.07 ± 11.588 | 0.890 | 0.374 |
| Married | 1170(74.6) | 42.79 ± 9.058 | 46.68 ± 11.982 | ||||
| Need to care for children | |||||||
| Yes | 1002(63.9) | 42.98 ± 9.217 | 2.537 | 0.011 | 46.88 ± 11.944 | 1.596 | 0.111 |
| No | 567(36.1) | 41.81 ± 8.436 | 45.89 ± 11.758 | ||||
| Need to care for elders | |||||||
| Yes | 1328(84.6) | 42.90 ± 9.052 | 3.620 | <0.001 | 46.82 ± 11.962 | 2.335 | 0.020 |
| No | 241(15.4) | 40.64 ± 8.171 | 44.88 ± 11.322 | ||||
| Years of working, y | |||||||
| <10 | 971(61.9) | 42.06 ± 8.696 | 2.803 | 0.005 | 45.99 ± 11.777 | 2.281 | 0.023 |
| ≥10 | 598(38.1) | 43.36 ± 9.317 | 47.39 ± 12.011 | ||||
| Work position | |||||||
| Frontline nursing worker | 1520(96.9) | 42.59 ± 8.987 | 0.694 | 0.488 | 46.60 ± 11.885 | 1.446 | 0.148 |
| Nursing administrators | 49(3.1) | 41.68 ± 8.006 | 44.11 ± 11.684 | ||||
| Hospital level | |||||||
| Secondary | 1049(66.9) | 42.42 ± 8.813 | 0.869 | 0.385 | 46.33 ± 11.802 | 0.918 | 0.359 |
| Tertiary | 520(33.1) | 42.84 ± 9.243 | 46.91 ± 12.047 | ||||
| Stressor | |||||||
| COVID-19-designated hospital | |||||||
| Yes | 1340(85.4) | 42.79 ± 9.033 | 2.504 | 0.012 | 46.75 ± 12.036 | 1.973 | 0.049 |
| No | 229(14.6) | 41.19 ± 8.389 | 45.19 ± 10.874 | ||||
| Working department | |||||||
| High exposure department | 393(25.0) | 43.25 ± 9.369 | 1.773 | 0.076 | 47.70 ± 12.366 | 2.279 | 0.023 |
| Non-high exposure department | 1176(75.0) | 42.33 ± 8.807 | 46.13 ± 11.696 | ||||
| Experience of caring for a confirmed or suspected case with “COVID-19” | |||||||
| Yes | 59(3.8) | 44.07 ± 10.712 | 1.321 | 0.187 | 49.66 ± 11.769 | 2.070 | 0.039 |
| No | 1510(96.2) | 42.50 ± 8.881 | 46.40 ± 11.874 | ||||
| Reserve personnel to assist Wuhan | |||||||
| Yes | 414(26.4) | 41.86 ± 8.920 | 1.840 | 0.066 | 45.33 ± 11.971 | 2.379 | 0.017 |
| No | 1155(73.6) | 42.81 ± 8.962 | 46.95 ± 11.827 | ||||
| Possibility of infection by yourself or others around you | |||||||
| No possibility | 976(62.2) | 40.86 ± 8.457 | 22.079 | <0.001 | 45.20 ± 11.979 | 4.518 | 0.004 |
| Little possibility | 569(36.3) | 40.81 ± 8.573 | 45.47 ± 12.062 | ||||
| Some possibility | 23(1.5) | 43.06 ± 8.586 | 46.97 ± 11.304 | ||||
| More likely | 1(0.1) | 45.41 ± 9.508 | 48.15 ± 12.187 | ||||
| Knowledge level related to “COVID-19” | |||||||
| Little understanding | 5(0.3) | 48.50 ± 7.148 | 2.806 | 0.038 | 60.25 ± 2.404 | 6.651 | <0.001 |
| Unconversant | 109(6.9) | 44.24 ± 10.107 | 49.64 ± 12.822 | ||||
| Understand better | 1145(73.0) | 42.58 ± 8.785 | 46.59 ± 11.664 | ||||
| Know a lot about | 310(19.8) | 41.78 ± 9.105 | 44.94 ± 12.094 | ||||
| Desire to learn about “COVID-19” | |||||||
| Without | 7(0.4) | 43.39 ± 9.006 | 4.857 | 0.002 | 48.93 ± 12.362 | 12.695 | <0.001 |
| Little | 26(1.7) | 44.28 ± 11.652 | 49.71 ± 12.541 | ||||
| Relatively large | 508(32.4) | 43.72 ± 8.660 | 49.01 ± 11.462 | ||||
| Very large | 1028(65.5) | 41.94 ± 8.976 | 45.20 ± 11.869 | ||||
| Coping strategies | |||||||
| Avoidance to work | |||||||
| Yes | 10(0.6) | 47.38 ± 8.609 | 1.707 | 0.088 | 46.88 ± 11.921 | 0.940 | 0.925 |
| No | 1559(99.4) | 42.53 ± 8.954 | 46.52 ± 11.886 | ||||
| Avoid the occupational duty | |||||||
| Not at all possible | 976(62.2) | 41.69 ± 8.938 | 13.624 | <0.001 | 45.19 ± 11.740 | 13.133 | <0.001 |
| Not possible | 569(36.3) | 43.68 ± 8.418 | 48.47 ± 11.619 | ||||
| Possible | 23(1.5) | 50.71 ± 14.241 | 54.46 ± 14.933 | ||||
| In all probability | 1(0.1) | 57.50 ± 0.000 | 56.25 ± 0.000 | ||||
| Restriction of Social activities | |||||||
| Yes | 1189 (75.8) | 42.83 ± 9.125 | 2.169 | 0.030 | 46.69 ± 11.928 | 0.960 | 0.337 |
| No | 380(24.2) | 41.69 ± 8.362 | 46.01 ± 11.741 | ||||
| Interpersonal isolation | |||||||
| Yes | 1156(73.7) | 42.91 ± 9.090 | 2.588 | 0.010 | 46.70 ± 11.900 | 0.971 | 0.332 |
| No | 413(26.3) | 41.58 ± 8.511 | 46.04 ± 11.837 | ||||
| Social support | |||||||
| Outside views on medical staff | |||||||
| Hostile | 35(2.2) | 47.96 ± 9.815 | 14.414 | <0.001 | 54.79 ± 11.794 | 12.348 | <0.001 |
| Not very friendly | 193(12.3) | 44.86 ± 10.164 | 48.74 ± 12.585 | ||||
| Friendly | 895(57.0) | 42.71 ± 8.878 | 46.71 ± 11.641 | ||||
| Very friendly | 446(28.4) | 40.84 ± 8.052 | 44.54 ± 11.610 | ||||
| Satisfaction with outside material assistance | |||||||
| Not very satisfied | 43(2.7) | 49.10 ± 10.576 | 17.824 | <0.001 | 53.26 ± 12.489 | 13.356 | <0.001 |
| Ordinary | 166(10.6) | 44.48 ± 9.225 | 48.43 ± 12.192 | ||||
| Be fairly satisfied | 585(37.3) | 43.30 ± 8.888 | 47.70 ± 11.608 | ||||
| Very satisfied | 775(49.4) | 41.22 ± 8.564 | 44.85 ± 11.708 | ||||
| Acceptance of epidemics management | |||||||
| Too strict | 3(0.2) | 51.67 ± 6.415 | 14.321 | <0.001 | 67.08 ± 4.390 | 22.893 | <0.001 |
| Strict | 127(8.1) | 45.76 ± 8.535 | 50.71 ± 11.738 | ||||
| Should accept | 264(16.8) | 44.54 ± 9.103 | 50.26 ± 11.823 | ||||
| Accept | 1175(74.9) | 41.74 ± 8.823 | 45.18 ± 11.599 | ||||
The mean anxiety of the participants was 42.56 ± SD 8.957, and the mean depression was 46.52 ± SD 11.883. Age, need to take care of elders, years of working, working in a designated hospital, knowledge of the “COVID-19”, the possibility of infection, possible to avoid the occupational duty, outside views on the medical staff, satisfaction with outside material assistance, acceptance of epidemics management were found to be significantly associated both with anxiety (P < 0.05) and depression (P < 0.05).
Stepwise multiple regression analysis for anxiety (Table 4)
Table 4.
Result of Stepwise multiple regression analysis for anxiety.
| Model | Unstandardized coefficients |
Standardized coefficients |
t | P | |
|---|---|---|---|---|---|
| B | SE | β | |||
| (Constant) | 51.727 | 2.408 | 21.478 | 0.000 | |
| Possibility of infection by yourself or others around you | 1.616 | 0.239 | 0.165 | 6.757 | 0.000 |
| Acceptance of epidemics management⁎ | −1.731 | 0.346 | −0.122 | −5.006 | 0.000 |
| Outside views on medical staff⁎ | −1.250 | 0.325 | −0.097 | −3.848 | 0.000 |
| Avoid the occupational duty | 1.760 | 0.422 | 0.102 | 4.171 | 0.000 |
| Satisfaction with outside material assistance⁎ | −1.084 | 0.295 | −0.094 | −3.678 | 0.000 |
| Years of working | 1.135 | 0.444 | 0.062 | 2.559 | 0.011 |
| Need to care for elders⁎ | −1.307 | 0.601 | −0.053 | −2.176 | 0.030 |
| Desire to learn about “COVID-19”⁎ | −0.884 | 0.408 | −0.053 | −2.167 | 0.030 |
| Interpersonal isolation⁎ | −0.986 | 0.494 | −0.049 | −1.995 | 0.046 |
Remarks: R2 = 0.110, F = 22.615, P < 0.05.
Reverse item: the lower variable's score, the higher anxiety.
Nurses who were older and needed to care for children, worked in COVID-19-designated hospital, desired knowledge related to COVID-19, and restricted social activities had high anxiety scores. It was found that the years of working, the possibility of infection, and sense of duty were positive correlations with anxiety (P < 0.05). The need to care for elders, desire to learn about COVID-19, interpersonal isolation, and social support were negatively correlated with anxiety (P < 0.001).
Stepwise multiple regression analysis for depression (Table 5)
Table 5.
Result of stepwise multiple regression analysis for depression.
| Model | Unstandardized coefficients |
Standardized coefficients |
t | P | |
|---|---|---|---|---|---|
| B | SE | β | |||
| (Constant) | 72.764 | 3.760 | 19.351 | 0.000 | |
| Acceptance of epidemics management⁎ | −2.824 | 0.462 | −0.150 | −6.111 | 0.000 |
| Avoid the occupational duty | 2.329 | 0.563 | 0.102 | 4.138 | 0.000 |
| Outside views on medical staff⁎ | −1.453 | 0.434 | −0.085 | −3.350 | 0.001 |
| Desire to learn about “COVID-19”⁎ | −1.867 | 0.554 | −0.085 | −3.372 | 0.001 |
| Possibility of infection by yourself or others around you | 1.028 | 0.316 | 0.079 | 3.257 | 0.001 |
| Satisfaction with outside material assistance⁎ | −1.190 | 0.395 | −0.078 | −3.015 | 0.003 |
| Experience of caring for a confirmed or suspected case⁎ | −3.727 | 1.513 | −0.060 | −2.463 | 0.014 |
| Years of working | 1.576 | 0.597 | 0.064 | 2.640 | 0.008 |
| Knowledge level related to “COVID-19”⁎ | −1.309 | 0.583 | −0.057 | −2.245 | 0.025 |
| Working department⁎ | −1.494 | 0.666 | −0.055 | −2.243 | 0.025 |
Remarks: R2 = 0.098, F = 18.043, P < 0.05.
Reverse item: the lower variable's score, the higher depression.
Depression scores were higher for older nurses who were reserved personnel to assist Wuhan, needed to take care of elders, and worked in COVID-19-designated hospitals. The working department, the experience of caring for a confirmed or suspected case, knowledge level related to COVID-19, and social support were negatively correlated with depression (P < 0.001). The years of working, fear of contagion and sense of duty had positive correlations with depression (P < 0.001).
Discussion
To our best knowledge, this is the first study that investigates the psychological effect of COVID-19 pandemic on nurses living in Islamic culture dominant region. Compared with the findings among 2014 nurses using the same Zung's scale in February (Hu et al., 2020), the psychological impact of COVID-19 outbreak on nurses in the Linxia Hui Autonomous Prefecture were slightly affected. The anxiety and depression level of our results (M ± SD: 42.56 ± 8.957; 46.52 ± 11.883, respectively) is much lower than Hu et al. results (M ± SD: 47.8 ± 11.2; 50.5 ± 11.31, respectively).
The reason why the psychological outcomes of nurses in Islam culture dominant region were better than that of other Chinese nurses during the COVID-19 outbreak can be summarized as follow. Firstly, the Linxia Hui Autonomous Prefecture contains Dongxiang Autonomous County and Jishishan Baoan Dongxiang Salar Autonomous County. The Hui nationality, the Dongxiang nationality, the Baoan nationality, and the Salar nationality are ethnic minorities consisting of the Muslim population, which are part of fifty-six Chinese ethnic groups. Moreover, the Hui nationality ranks second in the number of population of the Chinese ethnic minority. Islam is the dominant religion and has a considerable impact on the Linxia Hui Autonomous Prefecture citizens' daily life. Muslims tend to be conservative and believe the view that Allah controls everything according to his will. Muslims do not eat pork or drink alcohol, however, Cheung's research found that nurse stress is associated with drinking alcohol (Cheung & Yip, 2015) that were related to substance abuse. Religious belief, which forbids nurses to relieve their stress by depending on alcohol, has remarkable social and psychological influences that help them to sustain a similar pattern in their daily lives during the COVID-19 outbreak. Secondly, Gansu province is seated in northwestern China, while Hubei province is located in central China. The geographic distance between two provincial capital is more than 1000 km. Up to February 3, the number of confirmed cases in Gansu province is 53, meanwhile, that of Hubei province is nearly thirteen thousand (Fan, Liu, Pan, Douglas, & Bao, 2020). Thirdly, the SARS outbreak is an unprecedented public health crisis for China in the 21st century, but the experience we learned from SARS can help us to face the COVID-19 challenge. For example, the nursing procedures of caring for SARS patients have been compiled into professional textbooks. Besides, the case-fatality rate of COVID-19 (1.4%) is lower than SARS (9–10%) (Guan et al., 2020). Fourthly, in the past few decades, rapid progress and innovation have been achieved in medical technology. For instance, the extracorporeal membrane oxygenation (ECMO) can provide life support for acute respiratory failure patients (Zanella, Carlesso, & Pesenti, 2019).
Besides, the factors associated with the psychological health status are consistent with the result of Brooks, Dunn, Amlot, Rubin, and Greenberg's (2018) review, including training or preparedness, role-related stressor, social support, interpersonal isolation, perceived risk. The valuable findings of this study add new information to our understanding of the nurses with minority ethnic backgrounds in the face of the public health crisis.
According to our result about the COVID-19 effects on nurses and their concerns, several improvement measures are required. First of all, it is of high urgency to conduct COVID-19 related training programs for nurses. The global tendency of emerging infectious diseases is of growing significance over time (Jones et al., 2008). Our results showed that 97.9% of nurses have the desire to learn knowledge about COVID-19, and it points to where we need to improve. Facing the unknown nature of COVID-19, illness uncertainty easily causes fear, anxiety and depression, which has been reflected by a number of researchers (Marjanovic et al., 2007). Second, the media, as the nurses' dominant information source (99.4%), should take the responsibility of building a positive image of the nurse. The public's view on the medical staff is actually one of the nurses' social support. Media coverage can influence the social conception of nurses' roles (Hall et al., 2003). Social support negatively correlated with anxiety and depression levels (Su et al., 2007). The positive media portrayal of nurses can increase morale (Maunder, 2004). Third, it is vital to guarantee occupational safety. Nurses have direct contact with patients and have potential exposure to coronavirus contagion (Tzeng & Yin, 2006). The hospital should spend more effort to assure the supplies of personal protective equipment, such as gloves, face masks, gowns, which help nurses cope effectively and mitigate their fear of contagion (Maunder et al., 2003). Fourth, government and institutions should provide credible support to nurses' families. The need to care for children or elders is a nurse role-related stressor. Consistent with Nickell's research (Nickell et al., 2004), more than two-thirds of nurses were concerned that their family members would be infected. Lastly, it is necessary to increase payment and provide benefits for nurses appropriately, owing to higher salary and better benefits are the strongest predictors of nurse retention (Buffington, Zwink, Fink, Devine, & Sanders, 2012; Hagan & Curtis, 2018). In order to relieve Wuhan's medical burden, the hospitals outside Hubei would send competent nurses to assist Wuhan, resulting in the local shortage of nursing workforce. To avoid the nurse's intention to leave, the matched bonus should be distributed to motivate nurses in their jobs.
Several limitations need to be mentioned. First, our analysis based on the cross-sectional survey only reflects the condition at the time that the data was gathered and did not track the dynamic change. Besides, we only collected data from one Islam culture dominant region and it is unable to represent the all Islam situation.
In light of our results, it is suggested that future research should expand the investigation to the other minority ethnic and monitor the dynamic trajectory with different stages of the public health emergency. Further exploration of the potential mechanism about how religious belief would affect how nurses encounter public health emergency is needed.
Conclusion
In conclusion, our result reveals how nurses from ethnic minorities cope with emerging infectious diseases. Nurses who are of the Islamic culture are affected slightly by the COVID-19 outbreak, but their concern and factors associated with psychological variables are in keeping with the common nursing groups.
Fundings
National Nature Science Foundation of China (grant 71663002), the Fundamental Research Funds for the Central Universities (lzujbky-2018-ct05), and Lanzhou Chengguan District Science and Technology Project (2020-1-2-3).
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