Abstract
Objective:
to assess mental health issues in pediatric nurses during coronavirus pandemic in 2019.
Method:
cross-sectional study was conducted with pediatric nurses at the Instituto da Criança e do Adolescente based on online self-rated survey about clinical practice and mental health impact during COVID-19 pandemic. Validated self-reported scales for anxiety, depression and burnout were used for assessing these professionals.
Results:
107/298 (36%) nurses answered, 90% were female, median age was 41(23-64) years, 68% worked with adolescents, 66% in frontline. Burnout, anxiety and moderate/severe depression occurred in 65%, 72% and 74%, respectively. Lack of standardized treatment protocol for nurses (27%vs.10%, p=0.049), moderate/severe depression (74% vs. 16%, p=0.002) and burnout (82% vs. 58%, p=0.01) were significantly higher in pediatric nurses with anxiety compared to those without. Pediatric nurses that worked with adolescents compared to those that did not showed higher frequency of burnout in the former group (77% vs. 32%, p=0.0001). Multivariable analysis revealed that adequate quarantine adherence increased the presence of anxiety in 4.6 times [OR4.6(CI 1.1-20.2), p=0.04].
Conclusion:
most pediatric nurses who had worked in the frontline of COVID-19 were under precarious conditions, working with reduced team, and with an expressive changes in their monthly income. Current anxiety was a relevant issue, burnout was also an important mental condition for these professionals, reinforcing culture of good teamwork, collaboration practices and psychological/psychiatric approach.
Descriptors: COVID-19; Mental Health; Anxiety; Depression; Nurses, Pediatric; Burnout, Professional
Resumo
Objetivo:
avaliar problemas de saúde mental em enfermeiros pediátricos durante a pandemia causada pelo coronavírus 2019.
Método:
estudo transversal realizado com enfermeiros pediátricos do Instituto da Criança e do Adolescente, por meio de uma pesquisa online de autoavaliação sobre prática clínica e impacto na saúde mental, durante a pandemia de COVID-19. Foram avaliadas escalas de autoavaliação validadas para ansiedade, depressão e burnout.
Resultados:
107/298(36%) enfermeiros responderam, dos quais 90% eram do sexo feminino, a mediana de idade atual era 41(23-64) anos, 68% trabalhavam com adolescentes, 66% trabalhavam na linha de frente. Burnout, ansiedade e depressão moderada/grave ocorreram em 65%, 72% e 74% dos enfermeiros, respectivamente. Falta de protocolo de tratamento padronizado nas enfermarias (27% vs. 10%, p=0,049), depressão moderada/grave (74% vs. 16%, p=0,002) e burnout (82% vs. 58%, p=0,01) foram significativamente maiores em enfermeiros pediátricos com ansiedade, em comparação com enfermeiros sem essa condição. Os enfermeiros pediátricos que trabalhavam com adolescentes apresentaram maior frequência de burnout, quando comparados aos que não trabalhavam com esse grupo (77% vs. 32%, p=0,0001). A análise multivariada revelou que o cumprimento adequado da quarentena aumentou a presença de ansiedade em 4,6 vezes [OR 4.6(IC 1,1-20,2), p=0,04].
Conclusão:
a maioria dos enfermeiros pediátricos atuava na linha de frente da COVID-19, em condições precárias, trabalhando com equipe reduzida e enfrentando perdas expressivas de renda. A ansiedade atual foi um tema relevante e o burnout também foi uma condição mental importante para esses profissionais, reforçando a cultura do bom trabalho em equipe, das práticas de colaboração e do cuidado psicológico/psiquiátrico.
Descritores: COVID-19, Saúde Mental, Ansiedade, Depressão, Enfermeiras Pediátricas, Esgotamento Profissional
Resumen
Objetivo:
evaluar los problemas de salud mental en enfermeros pediátricos durante la pandemia del coronavirus 2019.
Método:
estudio transversal realizado con enfermeros pediátricos del Instituto da Criança e do Adolescente mediante una encuesta de autoevaluación en línea sobre la práctica clínica y el impacto en la salud mental durante la pandemia de COVID-19. Se evaluaron escalas de autoevaluación validadas para ansiedad, depresión y burnout.
Resultados:
respondieron 107/298 (36%) de los enfermeros, de los cuales 90% eran del sexo femenino, la mediana de edad actual fue de 41 (23-64) años, 68% trabajaban con adolescentes, 66% trabajaban en primera línea. Burnout, ansiedad y depresión moderada/grave ocurrieron en 65%, 72% y 74% de los enfermeros, respectivamente. Falta de protocolo de tratamiento estandarizado en las enfermerías (27% vs. 10%, p=0,049), depresión moderada/grave (74% vs. 16%, p=0,002) y burnout (82% vs. 58%, p=0,01) fueron significativamente mayores en enfermeros pediátricos con ansiedad en comparación con enfermeros sin esta condición. Los enfermeros pediátricos que trabajaban con adolescentes presentaron mayor frecuencia de burnout en comparación con los que no trabajaban con adolescentes (77% vs. 32%, p=0,0001). El análisis multivariado reveló que el adecuado cumplimiento de la cuarentena aumentó 4,6 veces la presencia de ansiedad [OR 4.6(IC 1,1-20,2), p=0,04].
Conclusión:
La mayoría de los enfermeros pediátricos trabajaban en la primera línea de la COVID-19, en condiciones precarias, trabajando con un equipo reducido y enfrentando importantes pérdidas de ingresos. La ansiedad actual fue un tema relevante y el burnout también fue una condición mental importante para estos profesionales, reforzando la cultura del buen trabajo en equipo, las prácticas colaborativas y la atención psicológica/psiquiátrica.
Descriptores: COVID-19, Salud Mental, Ansiedad, Depresión, Enfermeras Pediátricas, Agotamiento Profesional
Highlights
(1) Pandemic infectious diseases may promote psychological changes in health care workers.
(2) Anxiety was a relevant issue reported by pediatric nurses during COVID-19 pandemic.
(3) Burnout was an important mental condition for professionals who had been working with adolescents.
(4) Hospitals must incorporate an appropriate health program for professionals.
Introduction
Coronavirus pandemic (COVID-19) in 2019, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, have changed healthcare workers lives.
Pandemic infectious diseases may promote psychological changes in health care workers, especially women and nurses. Indeed, preexisting health conditions, feelings of vulnerability, social distancing, concerns about family members may increase anxiety, depression and burnout for these health professionals 1 - 2 .
Children and adolescents have infrequent COVID-19, however, they may present moderate to severe conditions requiring hospitalization 3 - 5 . Pediatric nurses have been working tirelessly to care for COVID-19 patients, many of them need to stay away from their homes for prolonged periods, as they are afraid they may be putting their own families at risk of infection, impacting their mental and physical health 6 . In addition, number of deaths, changes in monthly income, sleep deprivation and sedentarism during this pandemic may influence self-reported anxiety and depression for nurses 7 and general practitioners, particularly for nurses who treats and care for adult patients around the word 7 - 13 .
However, to our knowledge, these issues were not systematically assessed in pediatric nurses during the COVID-19 pandemic, particularly in professionals of a tertiary hospital that follows-up children and adolescents with chronic and severe conditions.
Therefore, the aim of the present study was to assess demographic data, work-related conditions, and mental issues of pediatric nurses during pandemic COVID-19. We also compared demographic and issues related to COVID-19 data in pediatric nurses with and without anxiety, with and without depression, as well as pediatric nurses that worked with adolescents compared to those that did not work with teenagers, as there is a high percentage of patients in this age group being treated at the mentioned institution.
Method
From July to October 2020, a cross-sectional study was carried-out with pediatric nurses who were regularly working during the period studied, anchored by an online questionnaire about physical and mental health impacts during COVID-19 pandemic. All pediatric nurses who had been working at the Instituto da Criança e do Adolescente do Hospital das Clinicas da Faculdade de Medicina from the Universidade de São Paulo, a large university hospital in São Paulo metropolitan area, Brazil (n=298) were invited to participate. A total of 107 (36%) pediatric nurses answered our online survey, and therefore, they were selected as participants.
This anonymous survey was carried out using Research Electronic Data Capture (REDCap) tool to support data capture for research studies. Ethics Committee of our university hospital have approved our research (under the number 4.037.335), and the Informed Consent Form was signed by all participants in the beginning of survey. The online survey was sent to these professionals and at least six emails were sent to all of them to improve the response rate.
The survey included questions about clinical practice, as well as physical and physiological health problems during COVID-19 pandemic. Estimated time for responses of all survey was approximately 15 minutes. These questions were categorized in multiple choice-response, dichotomous (yes and no) or based on visual analogue scale (VAS) (ranged from 0-10) scores, and included:
Demographic data of pediatric nurses (current age and gender).
Pediatric nurse in remote attendance (telemedicine, cell phone orientations or both).
Whether they were working with adolescents (yes/no).
Whether they were working in the frontline of COVID-19 (yes/no).
Number of pediatric patients during COVID-19 (decreased, increased or remained the same).
Number of pediatric patients with suspected COVID-19.
Suspected or confirmed death in COVID-19 patients.
Changes in monthly income of pediatric nurses during COVID-19 (decreased, increased or remained the same).
Molecular and serological methods performed by nurses [real time - reverse transcription polymerase chain reaction (RT-PCR), serology for SARS-CoV-2) infection or both] (yes/no).
Seasonal influenza vaccination prescribed for pediatric patients during the pandemic (yes/no).
Seasonal influenza vaccination received by nurses during the pandemic (yes/no).
General supportive care availability for COVID-19: pediatric nurses, other pediatric health professionals, appropriate personal protective equipment, standardized treatment protocols for children and adolescents with COVID-19, pediatric COVID-19 ward and pediatric intensive care units availability.
Pediatric nurses reported feelings: feelings of apprehension, panic, tranquility, optimism, satisfaction and dissatisfaction.
The most important impact of pandemic in pediatric nurse: none, change in their monthly wages, psychological health issues, family concerns or preexisting health comorbidity in pediatric nurses (yes/no).
Preexisting health conditions of pediatric nurses: asthma, diabetes mellitus, cardiovascular condition, respiratory condition, arterial hypertension, renal insufficiency, obesity, tobacco use or others.
Changes in body weight reported by pediatric nurses during pandemic: increased, decreased, no change.
Adequate quarantine adherence (yes/no).
Physical activity according to VAS score, ranging from 0 (without any physical activity) to 10 (strong physical activity daily).
Night time sleep abnormalities according to VAS score, ranging from 0 (no abnormality) to 10 (severe insomnia).
Fear of COVID-19 according to VAS score, ranging from 0 (no fear) to 10 (with extreme fear).
Frequency of alcohol intake in the past 15 days (never, rarely: once a week, sometimes: around once a week, regularly: up to twice a week, frequently: 3 to 6 times a week or every day).
Total amount of alcohol intake [one shot (350ml of beer), or a glass of wine or 40 ml of vodka/whisky]: 1 to 2 shots, 3 to 4 shots, 5 to 6 shots or more than 6 shots.
Cigarettes number (no tobacco use, 1 to 5 cigarettes/day, 5-10 cigarettes/day, 10-20 cigarettes/day or more than 20 cigarettes/day).
Smoking history and return to smoking during the past 15 days (yes/no).
Frequency of smoking marijuana/cannabis in the past 15 days: never, rarely: once a week, sometimes: around once a week, regularly: up to twice a week, frequently: 3 to 6 times a week or every day.
Frequency of opioids use (morphine, codeine, tramadol) in past 15 days: never, rarely: once a week, sometimes: around once a week, regularly: up to twice a week, frequently: 3 to 6 times a week or every day.
Frequency of sleeping pills usage in the past 15 days: never, rarely: once a week, sometimes: around once a week, regularly: up to twice a week, frequently: 3 to 6 times a week or every day.
Burnout symptoms were measured by a single-item burnout measurement based on the Maslach Burnout Inventory Emotional Exhaustion (MBI:EE) 14 . Participants answered the following question: “In general, based on your definition of exhaustion, how would you rate your level of exhaustion?” the chosen answer scored on an ordinal scale of five categories: 1=“I enjoy my work. I have no symptoms of burnout”; 2 =“Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out”; 3 =“I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion”; 4 = “The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot”; and 5 =“I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help”. Score ≤2 was considered as no symptoms of burnout and ≥3 was considered as presence of 1 or more burnout symptoms 14 - 15 .
Anxiety and depression were considered as dependent variables. The validated self-reported scores for depression and anxiety in Portuguese language were also evaluated for pediatric nurses based on responses based on their previous 15 days. Patient Health Questionnaire (PHQ-9) scale comprised nine questions using four-point Likert-scale ranging from 0 (not at all) to 3 (almost every day) for each question, and score ranged from 0 to 27. Total score of pediatric nurses was characterized as absent (scores 0-4), mild (scores 5-9), moderate (scores 10-14), moderate to severe depression (scores 15-19) and severe depression (scores 20-27) 16 . Generalized Anxiety Disorder (GAD-7) scale comprised seven questions using four-point Likert-scale, ranged from 0 (not at all) to 3 (almost every day) for each question. The total score of pediatric nurses was considered and divided in two groups: without anxiety (scores ≤ 4) and with anxiety (scores ≥ 5) 17 .
Statistical analysis
Data were presented as median (minimum to maximum values) or mean ± standard deviation for continuous variables according to the Shapiro-Wilk test. Data were showed in number (percentage) for categorical variables. Mann-Whitney test or Student’s t-test were used to compare continuous variables, and Fisher exact test or Pearson chi square test were used for categorical variables, as indicated and p value <0.05 was considered as significant. Logistic regression models were used to identify possible factors that would increase the chance of anxiety. Variables with a level of significance less than or equal to 20% in the univariable model were included in the multivariable model as independent variables. The results of the final model are presented as odds ratios (ORs) and 95% confidence intervals (CIs). For all statistical tests, the significance level was set at 5% (p < 0.05). SPSS software, version 22 (IBM Corporation, Armonk, NY, USA) was used for analysis.
Results
The overall response rate was 107/298 (36%) and 90% were female. Table 1 shows demographic and COVID-19 data reported by pediatric nurses during pandemic. Working in the frontline of COVID-19 was reported by 66% of them, the median age was 41 years (23-64), 68% worked with adolescents and 66% worked in the COVID-19 frontline. Deaths in patients with confirmed or suspected COVID-19 were reported by 47%. Changes in monthly wages during the pandemic COVID-19 and feelings of apprehension were informed by 84% and 82% of pediatric nurses, respectively. Anxiety, burnout and moderate/severe depressive symptoms were reported by 65%, 74% and 72%, respectively and emotional impact of pandemic was related by 58% of pediatric nurses (Table 1).
| Variables reported by pediatric nurses | Pediatric nurses (n=107) |
|---|---|
| Demographic data | |
| Female gender | 96 (90) |
| Current age, years | 41 (23-64) |
| Local of practice | 60 (56) |
| Emergency and intensive care units | 23 (21) |
| Inpatients Unit | 24 (22) |
| Ambulatory and administrative | 13 (12) |
| Working in the frontline of COVID-19 | 71 (66) |
| Working in two or more hospitals | 6 (6) |
| Remote care provided n=98 | |
| None | 91 (85) |
| Cell phone orientation | 4 (4) |
| Telemedicine | 3 (3) |
| Decreased number of patients during pandemic | 54 (50) |
| Deaths in patients with confirmed or suspected COVID-19 | 51 (47) |
| Changes in monthly income during pandemic COVID-19 by pediatric nurses | 90 (84) |
| Seasonal influenza vaccination | 104 (97) |
| Molecular and serological methods performed by nurses | |
| Real-time RT-CPR* positive | 4 (4) |
| Real-time RT-CPR* negative | 44 (41) |
| Quick test negative | 24 (22) |
| No test | 35 (33) |
| Confirmed COVID-19 in pediatric nurses | 4 (4) |
| General supportive care availability for COVID-19 | |
| Lack of pediatric nurses | 49 (46) |
| Lack of other pediatric healthcare workers | 62 (58) |
| Lack of appropriate personal protective equipment | 22 (20) |
| Lack of standardized pediatric treatment protocol | 23 (21) |
| Lack of pediatric Intensive care unit | 16 (15) |
| Reported feelings | |
| Feelings of apprehension | 88 (82) |
| Feelings of dissatisfaction | 24 (23) |
| Feelings of optimism | 20 (19) |
| Feelings of panic | 11 (10) |
| Most important impact of pandemic | |
| Changes in monthly income | 7 (6) |
| Emotional | 62 (58) |
| Family concerns | 34 (32) |
| Preexisting health condition | |
| None | 61 (57) |
| Arterial hypertension | 22 (21) |
| Obesity | 17 (16) |
| Diabetes | 7 (6) |
| Smoking | 5 (5) |
| Adequate quarantine adherence | 67 (63) |
| Fear of COVID-19 (VAS† scale 0-10) | 7 (0-10) |
| Physical activity (VAS† scale 0-10) | 0 (0-10) |
| Sleep deprivation (VAS† scale 0-10) | 5 (0-10) |
| Anxiety | 69 (65) |
| Mild | 42 (39) |
| Moderate to severe | 27 (25) |
| Depression | 77 (72) |
| PHQ-9‡ score 5-9 - mild | 25 (23) |
| PHQ-9‡ score 10-14 - moderate | 29 (27) |
| PHQ-9‡ score 15-19 - moderate to severe | 14 (13) |
| PHQ-9‡ score >20 - severe | 9 (8) |
| Burnout | 79 (74) |
| Alcohol consumption | 53 (49) |
| Tobacco use | 9 (8) |
| Return to smoking during COVID-19 pandemic | 7 (6) |
| Cannabis use | 1 (0,9) |
| Sleeping pills consumption | 17 (16) |
| Working with adolescents as patients | 73 (68) |
| Nursing practice with adolescents, years | 10 (0.8-36) |
Results are presented in n (%) and median (minimum to maximum values); *RT-PCR = Reverse Transcription Polymerase Chain Reaction; †VAS = Visual Analogue Scale; ‡PHQ-9 = Patient Health Questionnaire
Table 2, below, presents demographic and COVID-19 data reported by pediatric nurses during pandemic according to GAD-7 scale for anxiety. Moderate/severe depression (PHQ-9 score ≥10) (74% vs. 16%, p=0.002) and burnout (82% vs. 58%), p=0.01 were significantly higher in pediatric nurses with anxiety compared to those without this condition, while mild depression (PHQ-9 score ≥5 and ≤9) (26% vs. 60%, p=0.016) and no depression (PHQ-9 score was≤ 4) (10% vs. 61%, p< 0.001) were more prevalent in nurses without anxiety.
Table 2. Demographic and coronavirus infectious disease in 2019 (COVID-19) data reported by 107 Pediatric Nurses during pandemic according to professionals with anxiety (GAD-7* score ≥ 5) and without anxiety (GAD-7* score ≤ 4). São Paulo, SP, Brazil, 2020.
| Variables of pediatric nurses | With anxiety (n=69) | Without anxiety (n=38) | P |
|---|---|---|---|
| Demographic data | |||
| Current age, years | 41 (23-64) | 41 (28-60) | 0.147 |
| Female gender | 64 (93) | 32 (84) | 0.192 |
| Working in the frontline with suspected COVID-19 | 49 (71) | 22 (20) | 0.202 |
| Changes in monthly income | 0.789† | ||
| None | 56 (81) | 34 (89) | 0.408 |
| Decrease of up to 20% | 7 (10) | 3 (8) | 1.0 |
| Decrease between 21 to 50% | 3 (4) | 1 (3) | 1.0 |
| Decrease of more than 50% | 3 (4) | 0 (0) | - |
| Molecular and serological methods performed by nurses | |||
| None | 20 (29) | 15 (39) | 0.288 |
| Real time RT-CPR‡ | 33 (48) | 15 (39) | 0.425 |
| Serology for SARS-CoV2§ infection | 16 (23) | 8 (22) | 1.000 |
| Confirmed COVID-19 in pediatric nurses | 3 (4) | 1 (2) | 1.000 |
| General supportive care availability for COVID-19 | |||
| Lack of pediatric nurses | 33 (48) | 16 (42) | 0.685 |
| Lack of other pediatric healthcare workers | 43 (62) | 19 (50) | 0.227 |
| Lack of appropriate personal protective equipment | 17 (25) | 5 (13) | 0.213 |
| Lack of standardized treatment protocol in pediatric ward | 19 (27) | 4 (10) | 0.049 |
| Lack of pediatric Intensive care unit | 12 (17) | 4 (10) | 0.407 |
| Reported Feelings | |||
| Feelings of apprehension | 60 (87) | 28 (74) | 0.113 |
| Feelings of panic | 8 (11) | 3 (8) | 0.743 |
| Feelings of dissatisfaction | 19 (27) | 5 (13) | 0.097 |
| Feelings of optimism | 14 (20) | 6 (16) | 0.615 |
| Adequate quarantine compliance | 47 (68) | 20 (52) | 0.144 |
| Fear of COVID-19 (VAS|| scale 0-10) | 7 (0-10) | 7 (1-10) | 0.975 |
| Physical activity (VAS|| scale 0-10) | 0 (1-10) | 0 (1-10) | 0.955 |
| Sleep deprivation (VAS||scale 0-10) | 5 (0-10) | 5 (0-10) | 0.928 |
| Pre-existing health condition | |||
| Obesity | 11 (16) | 6 (16) | 1.000 |
| Arterial hypertension | 15 (22) | 4 (10) | 0.190 |
| Diabetes mellitus | 4 (6) | 3 (8) | 0.697 |
| Smoking | 3 (4) | 2 (5) | 1.000 |
| Impact of pandemic | 0.389† | ||
| Decrease of income | 5 (7) | 2 (5) | 1.0 |
| Mental health | 43 (62) | 19 (50) | 0.228 |
| Family concerns | 19 (27) | 15 (39) | 0.278 |
| PHQ-9¶ score | 9 (0-24) | 9 (0-17) | 0.183 |
| PHQ-9¶ score ≥10 | 46/62 (74) | 6/15 (16) | 0.002 |
| PHQ-9¶ score 5-9 | 16/62 (26) | 9/15 (60) | 0.016 |
| PHQ-9¶ score ≤4 | 7(10) | 23 (61) | <0.001 |
| Burnout | 57 (82) | 22 (58) | 0.01 |
| Tobacco use | 7 (10) | 2 (5) | 0.486 |
| Return to smoking | 5 (7) | 2 (5) | 1.000 |
| Cannabis use | 1 (1) | 0 (0) | 1.000 |
| Sleeping pills consumption | 16 (23) | 3 (8) | 0.064 |
| Working with adolescents as patients | 46 (67) | 27 (71) | 0.671 |
Results are presented in n (%) and median (minimum to maximum values); *GAD-7 = Generalized Anxiety Disorder; †Pearson Chi Square; ‡RT-PCR = Reverse Transcription Polymerase Chain Reaction; §SARS-CoV2 = Severe Acute Respiratory Syndrome Coronavirus 2; ||VAS = Visual Analogue Scale; ¶PHQ-9 = Patient Health Questionnaire
Table 3 shows demographic and COVID-19 data reported by pediatric nurses during pandemic according to PHQ-9 scale for depression. Lack of pediatric nurses (60% vs. 33%, p=0.006), burnout (86% vs. 62%, p=0.004), GAD-7 score ≥ 5 (88% vs. 42%, p=0.0001) and consumption of sleeping pills (33% vs. 4%, p=0.0001) were significantly higher in pediatric nurses with depression compared to those without this condition. Regarding nurses who worked with adolescents, the prevalence of PHQ-9 ≥ 10 (49% vs. 47%, p=0.83), GAD-7 ≥ 5 (63% vs. 68%, p=0.67) was similar to nurses who did not work with adolescent. Burnout was significant more prevalent in former group (77% vs. 32% (p<0.001).
Table 3. Demographic and coronavirus infectious disease in 2019 (COVID-19) data reported by Pediatric Nurses during pandemic according to professionals with moderate/severe depression (PHQ-9* score ≥ 10) and without/mild depression (PHQ-9* score < 10). São Paulo, SP, Brazil, 2020.
| Variables of pediatric nurses | Moderate/severe depression (n=52) | Without/mild depression (n=55) | P |
|---|---|---|---|
| Demographic data | |||
| Current age, years | 41 (23-64) | 41 (24-63) | 0.703 |
| Female gender | 49 (94) | 47 (85) | 0.203 |
| Working in the frontline with suspected COVID-19 | 35 (67) | 36 (65) | 1.000 |
| Changes in monthly income | 0.287† | ||
| None | 42 (81) | 48 (87) | - |
| Decrease of up to 20% | 5 (10) | 5 (9) | - |
| Decrease between 21 to 50% | 2 (4) | 2 (4) | - |
| Decrease of more than 50% | 3 (6) | 0 (0) | - |
| Molecular and serological methods performed by nurses | |||
| None | 16 (31) | 19 (34) | 0.686 |
| Real time RT-CPR‡ | 24 (46) | 24 (44) | 0.847 |
| Serology SARS-CoV2§ infection | 12 (23) | 12 (22) | 1.000 |
| Confirmed COVID-19 in pediatric nurses | 2 (4) | 2 (4) | 1.000 |
| General supportive care availability for COVID-19 | |||
| Lack of pediatric nurses | 31 (60) | 18 (33) | 0.006 |
| Lack of other pediatric healthcare workers | 35 (67) | 27 (49) | 0.077 |
| Lack of appropriate personal protective equipment | 14 (27) | 8 (14) | 0.151 |
| Lack of standardized treatment protocol ward | 14(27) | 9 (16) | 0.240 |
| Lack of pediatric Intensive care unit | 7 (13) | 5 (9) | 0.549 |
| Reported Feelings | |||
| Feelings of apprehension | 45 (86) | 43 (78) | 0.316 |
| Feelings of panic | 8 (15) | 3 (4) | 0.116 |
| Feelings of dissatisfaction | 13 (25) | 11 (20) | 0.644 |
| Feelings of optimism | 8 (15) | 12 (22) | 0.461 |
| Adequate quarantine compliance | 31 (60) | 35 (64) | 0.695 |
| Fear of COVID-19 (VAS|| scale 0-10) | 7 (0-10) | 7 (0-10) | 0.964 |
| Physical activity (VAS|| scale 0-10) | 0 (0-10) | 0 (0-10) | 0.847 |
| Sleep deprivation (VAS|| scale 0-10) | 0 (0-10) | 5 (0-10) | 0.987 |
| Pre-existing health condition | |||
| Obesity | 10 (02) | 7 (13) | 0.432 |
| Arterial hypertension | 13 (25) | 9 (16) | 0.340 |
| Diabetes mellitus | 4 (8) | 3 (5) | 0.710 |
| Smoking | 1 (2) | 4 (7) | 0.364 |
| Impact of pandemic | 0.882† | ||
| Changes in monthly income | 4 (08) | 3 (5) | - |
| Mental health | 31 (60) | 31 (56) | - |
| Family concerns | 16 (31) | 18 (33) | - |
| GAD¶ score | 6 (0-18) | 6 (5-13) | 0.360 |
| GAD¶ score ≥5 | 46 (88) | 23 (42) | 0.0001 |
| Burnout | 45 (86) | 34 (62) | 0.004 |
| Alcohol consumption | 30 (06) | 23 (42) | 0.123 |
| Tobacco use | 5 (10) | 4 (7) | 0.737 |
| Return to smoking during COVID-19 pandemic | 4 (08) | 3 (5) | 0.710 |
| Cannabis use | 1 (02) | 0 (0) | 0.486 |
| Sleeping pills consumption | 17 (33) | 2 (4) | 0.0001 |
| Working with adolescents as patients | 36 (69) | 37 (67) | 0.838 |
Results are presented in n (%) and median (minimum to maximum values); *PHQ-9 = Patient Health Questionnaire; †Pearson Chi Square; ‡RT-PCR = Reverse Transcription Polymerase Chain Reaction; §SARS-CoV2 = Severe Acute Respiratory Syndrome Coronavirus 2; ||VAS = Visual Analogue Scale; ¶GAD-7 = Generalized Anxiety Disorder
Table 4 demonstrated the univariable and multivariable analysis in the logistic regression model of data reported by 107 pediatric nurses during pandemic related to presence of anxiety. There was only one factor which had significantly increased the chances of anxiety in 4.6 times, adequate quarantine adherence. The univariable and multivariable analysis in the logistic regression model related to presence of depression and burnout showed no statistically significant difference.
Table 4. Univariable and multivariable analysis in the logistic regression model of data reported by 107 Pediatric Nurses during pandemic related to presence of anxiety. São Paulo, SP, Brazil, 2020.
| Independent variables | univariable | multivariable | ||||
|---|---|---|---|---|---|---|
| OR* | CI† (95%) | p | OR* | CI† (95%) | p | |
| Female gender | 0,42 | 0.12-1.47 | 0.17 | 3.9 | 0.55-27.9 | 0.17 |
| Lack of standardized treatment protocol in pediatric ward | 3.2 | 1.0-10.3 | 0.05 | 3.0 | 0,85-10.7 | 0.09 |
| Feelings of apprehension | 2.4 | 0.9-6.5 | 0.09 | 3.0 | 0.5-17,9 | 0.23 |
| Feelings of dissatisfaction | 2.5 | 0.9-7.4 | 0.10 | 0.51 | 0.08-3.3 | 0.48 |
| Adequate quarantine adherence | 1.9 | 0.8-4.3 | 0.12 | 4.6 | 1.1-20.2 | 0.04 |
| Arterial hypertension | 1.2 | 0.5-3.3 | 0.69 | - | - | - |
| PHQ-9‡ score ≥10 | 4.3 | 1.3-14.0 | 0.02 | 2,4 | 0.5-11.3 | 0.26 |
| Burnout | 1.0 | 0.19-5.4 | 0.90 | |||
| Sleeping pills consumption | 3.5 | 1.0-12.9 | 0.06 | 2.3 | 0.32-16.4 | 0.41 |
*OR = Odds Ratio; †CI = Confidence Interval; ‡PHQ-9 = Patient Health Questionnaire
Discussion
To our knowledge, this study was relevant in order to investigate physical and mental health issues in Brazilian pediatric nurses during the COVID-19 pandemic in a tertiary hospital. Our study showed relevant impact on the work routine of pediatric nurses, including expressive rates of anxiety, burnout, and depression.
These findings were similar to other studies that evaluated health professionals during COVID-19 pandemic 9 , 18 - 20 , especially female nurses 7 , 21 . In 2004, a study about the SARS outbreak had already revealed increased levels of anxiety and depression. Nowadays, in order to attenuate possible complications, it is necessary to learn from this experience and provide medium or long-term psychological and psychiatric support for these professionals 22 - 24 .
Pediatric nurses reported herein a high rate of burnout, which could have a relationship with increased workload, stress, being single, social distancing and family-associated stress. In fact, the new protocols and routine, impacted their physical and mental health during pandemic COVID-19 25 . In the present study, burnout rate was significantly higher in pediatric nurses, particularly in those who worked with adolescents. This finding may be related to relevant physical and mental impact in adolescent populations during COVID-19 pandemic, particularly in patients hospitalized due to chronic severe disease, requiring multiple immunosuppression therapies 26 . Indeed, a Chinese study showed a higher burnout rate in professionals that worked in usual wards compared to professionals that had worked in the frontline 27 .
We showed high prevalence of burnout in pediatric nurses with anxiety and moderate/severity depression. The reports are linked to emotional exhaustion, anxiety and depression 28 - 30 . Furthermore, stress may be considered as a preceding factor for these mental health issues 29 , 31 . Association between anxiety and depression were also observed in the present study, as also described by other authors 32 - 33 . Depression was significantly mentioned by pediatric nurses with anxiety. These findings were also reported in other studies, possibly related to inadequate available resources, exhaustive workloads, working in tertiary hospitals and in the frontline of COVID-19 pandemic 7 , 25 .
Furthermore, the lack of other pediatric nurses and other health professionals, as well as lack of standardized treatment protocols, especially in the beginning of pandemic, and quarantine adherence, could also contribute to higher rates of anxiety, burnout and the fear of COVID-19 9 , 25 , 27 . Quarantine adherence involved social distancing, which has been associated with mental health disorders 34 - 35 . Indeed, some studies have found that loneliness was associated with symptoms of depression and anxiety 36 - 37 , and another research has observed that lockdown measures adopted in Germany were associated with higher psychosocial distress and more loneliness, however, they were not related to anxiety and depressive symptoms 38 .
Our study has strengths and limitations. The evaluation of two validated self-reported scales for anxiety and depression, associated to a single item burnout measurement, were extremely relevant to assess the overall mental health impact during this catastrophic period. We also assessed pediatric nurses of a large and referral university hospital. However, limitations included the small sample of pediatric nurses in only one center, lack of information about previous mental health disorders, and the cross-sectional design of the study, allowed us to interpret the results only as current symptoms. The moderate response rate was observed in the present study, possible related to the lack of payment incentive. Furthermore, the absence of a control group with another health professional was another weakness of the present study. In addition, these validated mental health tools were not evaluated in pediatric nurses in other circumstances, such as out of COVID-19 pandemic period.
The COVID-19 pandemic is undoubtedly a stressful experience for different health care providers 39 - 41 . Thus, since the beginning of the COVID-19 pandemic, and in order to care for nurses and other health professionals, our institution has developed a program to offer mental health and psychological/psychiatric support and treatment 42 .
Conclusion
This study revealed that the mental health of pediatric nurses was undoubtedly impacted during COVID-19 pandemic, corroborating the importance of continuous monitoring of the mental health of professionals. Most of them worked in the frontline of COVID-19, under precarious conditions, working with reduced team and with expressive decrease in their income. Current anxiety was a relevant issue associated with quarantine adherence, which included social distancing by pediatric nurses in the frontline during COVID-19 pandemic. Burnout was also an important mental condition for these professionals that worked with adolescents, reinforcing culture of good teamwork, collaboration practices and psychological/psychiatric approaches. Recognizing mental health status of pediatric nurses is essential to plan future and also for preventive strategies.
Acknowledgments
We thank Professor Guilherme V. Polanczyk, Department of Psychiatry, Faculdade de Medicina and Simone Pavani, Nursing Division, Instituto da Criança da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
Referências
- 1.Bai Y, Lin CC, Lin CY, Chen JY, Chue CM, Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv. 2004;55:1055–1057. doi: 10.1176/appi.ps.55.9.1055. [DOI] [PubMed] [Google Scholar]
- 2.Sani G, Janiri D, Di Nicola M, Janiri L, Ferretti S, Chieffo D. Mental health during and after the COVID-19 emergency in Italy. Psychiatry Clin Neurosci. 2020;74:372–372. doi: 10.1111/pcn.13004. [DOI] [PubMed] [Google Scholar]
- 3.Safadi MA, Silva CA. The challenging and unpredictable spectrum of covid-19 in children and adolescents. Rev Paul Pediatr. 2020;39:2020192–2020192. doi: 10.1590/1984-0462/2020/38/2020192. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Pereira MFB, Litvinov N, Farhat SCL, Eisencraft AP, Gibelli MABC, Carvalho WB, et al. Severe clinical spectrum with high mortality in pediatric patients with COVID-19 and multisystem inflammatory syndrome. Clinics (Sao Paulo) 2020;75:e2209. doi: 10.6061/clinics/2020/e2209. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Sousa BLA, Sampaio-Carneiro M, Carvalho WB, Silva CA, Ferraro AA. Differences among Severe Cases of Sars-CoV-2, Influenza, and Other Respiratory Viral Infections in Pediatric Patients: Symptoms, Outcomes and Preexisting Comorbidities. Clinics (Sao Paulo) 2020;30:e2273. doi: 10.6061/clinics/2020/e2273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Al-Mandhari A, Gedik FG, Mataria A, Oweis A, Hajjeh R. 2020 - the year of the nurse and midwife a call for action to scale up and strengthen the nursing and midwifery workforce in the Eastern Mediterranean Region. East Mediterr Health J. 2020;26:370–371. doi: 10.26719/2020.26.4.370. [DOI] [PubMed] [Google Scholar]
- 7.Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated with Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3:e203976. doi: 10.1001/jamanetworkopen.2020.3976. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Amerio A, Bianchi D, Santi F, Costantini L, Odone A, Signorelli C, et al. Covid-19 pandemic impact on mental health: a web-based cross-sectional survey on a sample of Italian general practitioners. Acta Biomed. 2020;91:83–88. doi: 10.23750/abm.v91i2.9619. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Lei L, Huang X, Zhang S, Yang J, Yang L, Xu M. Comparison of Prevalence and Associated Factors of Anxiety and Depression Among People Affected by versus People Unaffected by Quarantine During the COVID-19 Epidemic in Southwestern China. Med Sci Monit. 2020;26:e924609. doi: 10.12659/MSM.924609. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Zhu Z, Xu S, Wang H, Liu Z, Wu J, Li G, et al. COVID-19 in Wuhan: Sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on healthcare workers. EClinicalMedicine. 2020;24:100443–100443. doi: 10.1016/j.eclinm.2020.100443. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Sarboozi Hoseinabadi T, Kakhki S, Teimori G, Nayyeri S. Burnout and its influencing factors between frontline nurses and nurses from other wards during the outbreak of Coronavirus Disease - COVID-19 in Iran. Invest Educ Enferm. 2020;38:e3. doi: 10.17533/udea.iee.v38n2e03. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Tiete J, Guatteri M, Lachaux A, Matossian A, Hougardy JM, et al. Mental Health Outcomes in Healthcare Workers in COVID-19 and Non-COVID-19 Care Units: A Cross-Sectional Survey in Belgium. Front Psychol. 2021;11:612241–612241. doi: 10.3389/fpsyg.2020.612241. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry. 2020;7:e15–e16. doi: 10.1016/S2215-0366(20)30078-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Dolan ED, Mohr D, Lempa M, Joos S, Fihn SD, Nelson KM, et al. Using a single item to measure burnout in primary care staff a psychometric evaluation. J Gen Intern Med. 2015;30:582–587. doi: 10.1007/s11606-014-3112-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.West C, Dyrbye L, Sloan J, Shanafelt T. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24:1318–1321. doi: 10.1007/s11606-009-1129-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Lamela D, Soreira C, Matos P, Morais A. Systematic review of the factor structure and measurement invariance of the patient health questionnaire-9 (PHQ-9) and validation of the Portuguese version in community settings. J Affect Disord. 2020;276:220–233. doi: 10.1016/j.jad.2020.06.066. [DOI] [PubMed] [Google Scholar]
- 17.Sousa TV, Viveiros V, Chai MV, Vicente FL, Jesus G, Carnot MJ, et al. Reliability and validity of the Portuguese version of the Generalized Anxiety Disorder (GAD-7) scale. Health Qual Life Outcomes. 2015;13:50–50. doi: 10.1186/s12955-015-0244-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Lee AM, Wong JGWS, McAlonan GM, Cheung V, Cheung C, Sham PC, et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. Can J Psychiatry. 2007;52:233–240. doi: 10.1177/070674370705200405. [DOI] [PubMed] [Google Scholar]
- 19.Chua SE, Cheung V, Cheung C, McAlonan GM, Wong JWS, Cheung EPT, et al. Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers. Can J Psychiatry. 2004;49:391–393. doi: 10.1177/070674370404900609. [DOI] [PubMed] [Google Scholar]
- 20.Wong TW, Yau JK, Chan CLW, Kwong RSY, Ho SMY, Lau CC, et al. The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope. Eur J Emerg Med. 2005;12:13–18. doi: 10.1097/00063110-200502000-00005. [DOI] [PubMed] [Google Scholar]
- 21.Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behav Immun. 2020;88:901–907. doi: 10.1016/j.bbi.2020.05.026. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Thompson DR, Lopez V, Lee D, Twinn S. SARS - a perspective from a school of nursing in Hong Kong. J Clin Nurs. 2004;13:131–135. doi: 10.1046/j.1365-2702.2003.00884.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Smith GD, Ng F, Li WHC. COVID-19: Emerging compassion, courage and resilience in the face of misinformation and adversity. J Clin Nurs. 2020;29:1425–1428. doi: 10.1111/jocn.15231. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Kang L, Ma S, Chen M, Yang J, Wang Y, Li R, et al. Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study. Brain Behav Immun. 2020;87:11–17. doi: 10.1016/j.bbi.2020.03.028. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Maben J, Bridges J. Covid-19: Supporting nurses' psychological and mental health. J Clin Nurs. 2020;29:2742–2750. doi: 10.1111/jocn.15307. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Pereira MFB, Litvinov N, Farhat SCL, Eisencraft AP, Gibelli MABC, Carvalho WB, et al. Severe clinical spectrum with high mortality in pediatric patients with COVID-19 and multisystem inflammatory syndrome. Clinics (Sao Paulo) 2020;75:e2209. doi: 10.6061/clinics/2020/e2209. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Wu Y, Wang J, Luo C, Hu S, Lin X, Anderson AE, et al. A Comparison of Burnout Frequency Among Oncology Physicians and Nurses Working on the Frontline and Usual Wards During the COVID-19 Epidemic in Wuhan, China. J Pain Symptom Manage. 2020;60:e60–e65. doi: 10.1016/j.jpainsymman.2020.04.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Golonka K, Mojsa-Kaja J, Blukacz M, Gawlowska M, Marek T. Occupational burnout and its overlapping effect with depression and anxiety. Int J Occup Med Environ Health. 2019;32:229–244. doi: 10.13075/ijomeh.1896.01323. [DOI] [PubMed] [Google Scholar]
- 29.van Dam A. Subgroup Analysis in Burnout: Relations Between Fatigue, Anxiety, and Depression. Front Psychol. 2016;7:90–90. doi: 10.3389/fpsyg.2016.00090. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Bianchi R, Schonfeld IS, Laurent E. Burnout-depression overlap: a review. Clin Psychol Rev. 2015;36:28–41. doi: 10.1016/j.cpr.2015.01.004. [DOI] [PubMed] [Google Scholar]
- 31.Plieger T, Melchers M, Montag C, Meermann R, Reuter M. Life stress as potential risk factor for depression and burnout. Burnout Res. 2015;2:19–24. doi: 10.1016/j.burn.2015.03.001. [DOI] [Google Scholar]
- 32.Löwe B, Spitzer RL, Williams JBW, Mussell M, Schellberg D, Kroenke K. Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment. Gen Hosp Psychiatry. 2008;30:191–199. doi: 10.1016/j.genhosppsych.2008.01.001. [DOI] [PubMed] [Google Scholar]
- 33.Lamers F, van Oppen P, Comijs HC, Smit JH, Spinhoven P, van Balkom AJLM, et al. Comorbidity patterns of anxiety and depressive disorders in a large cohort study: the Netherlands Study of Depression and Anxiety (NESDA) J Clin Psychiatry. 2011;72:341–348. doi: 10.4088/JCP.10m06176blu. [DOI] [PubMed] [Google Scholar]
- 34.Wang Y, Xu B, Zhao G, Cao R, He X, Fu S. Is quarantine related to immediate negative psychological consequences during the 2009 H1N1 epidemic? Gen Hosp Psychiatr. 2011;33:75–77. doi: 10.1016/j.genhosppsych.2010.11.001. [DOI] [PubMed] [Google Scholar]
- 35.Wu P, Fang Y, Guan Z. The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry. 2009;54:302–311. doi: 10.1177/070674370905400504. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Palgi Y, Shrira A, Ring L, Bodner E, Avidor S, Bergman Y, et al. The loneliness pandemic: Loneliness and other concomitants of depression, anxiety and their comorbidity during the COVID-19 outbreak. J Affect Disord. 2020;275:109–111. doi: 10.1016/j.jad.2020.06.036. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.González-Sanguino C, Ausín B, Castellanos MA, Saiz J, López-Gómez A, Ugidos C, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. Brain Behav Immun. 2020;87:72–76. doi: 10.1016/j.bbi.2020.05.040. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Benke C, Autenrieth LK, Asselmann E, Pané-Farré CA. Lockdown, quarantine measures, and social distancing: Associations with depression, anxiety and distress at the beginning of the COVID-19 pandemic among adults from Germany. Psychiatry Res. 2020;293:113462–113462. doi: 10.1016/j.psychres.2020.113462. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Cotrin P, Moura W, Gambardela-Tkacz CM, Pelloso FC, Santos K, Carvalho MDB, et al. Healthcare Workers in Brazil during the COVID-19 Pandemic: A Cross-Sectional Online Survey. Inquiry. 2020;57:46958020963711–46958020963711. doi: 10.1177/0046958020963711. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.El-Hage W, Hingray C, Lemogne C, Yrondi A, Brunault P, Bienvenu T, et al. Health professionals facing the coronavirus disease 2019 (COVID-19) pandemic: What are the mental health risks? Encephale. 2020;46:S73–S80. doi: 10.1016/j.encep.2020.04.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Kozu KT, Casella CB, Strabelli CAA, Aikawa NE, Campos LMA, Elias AM, et al. Mental Health Impact in Latin American Pediatric Rheumatologists During the COVID-19 Pandemic. J Clin Rheumatol. 2021 doi: 10.1097/RHU.0000000000001782. [DOI] [PubMed] [Google Scholar]
- 42.Fukuti P, Uchôa CLM, Mazzoco MF, Corchs F, Kamitsuji CS, Rossi L, et al. How Institutions Can Protect the Mental Health and Psychosocial Well-Being of Their Healthcare Workers in the Current COVID-19 Pandemic. Clinics (Sao Paulo) 2020;75:e1963. doi: 10.6061/clinics/2020/e1963. [DOI] [PMC free article] [PubMed] [Google Scholar]