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. 2022 Oct 9:10.1002/pchj.599. Online ahead of print. doi: 10.1002/pchj.599

Posttraumatic growth levels of healthcare workers in two periods with different intensities of COVID‐19 pandemic

İmran Gökçen Yılmaz‐Karaman 1,✉, Cennet Yastıbaş‐Kaçar 2, Ferda Ece İnce 1
PMCID: PMC9874446  PMID: 36210343

Abstract

The COVID‐19 pandemic threatens health‐care workers' (HCW) mental health and well‐being. Although traumatic life events may result in psychiatric disorders, occasionally they give rise to positive changes, such as post‐traumatic growth. Accordingly, the present study evaluated the traumatic stress, anxiety, and depression levels of HCWs and their post‐traumatic growth levels during the pandemic. In addition, the study aimed to assess the changes in psychological outcomes during the pandemic. For this aim, the data were collected in two different periods. The first data‐collection period was between May and July 2020, and the second period started in November 2020 and ended in January 2021. The sociodemographic data form, Impact of Events Scale‐Revised (IES‐R), Generalized Anxiety Disorder‐7 (GAD‐7), Patient Health Questionnaire‐9 (PHQ‐9), and Post‐traumatic Growth Inventory (PTGI) were used to collect data. Sixty‐six HCWs participated in the study. No significant differences appeared between the baseline scores and 6‐month follow‐up in the depression, anxiety, and traumatic stress levels of HCWs. Furthermore, the PTGI scores decreased significantly over time. Although the change in the psychological distress scores was not statistically significant, the depression and post‐traumatic stress scores increased over time. Previous research specified an inverse‐parabolic relationship between traumatic stress and PTGI. Our results support previous research; as the exposure to the stressors continues, individual traumatic stress levels increase, psychiatric disorders become frequent, and affirmative changes (like post‐traumatic growth) decline.

Keywords: COVID‐19, depression, health‐care worker, post‐traumatic growth, post‐traumatic stress disorder

INTRODUCTION

General framework

A global public health crisis emerged due to the COVID‐19 pandemic. At the beginning of the second half of 2021, more than 6 million people had died due to COVID‐19 all over the world (World Health Organization, 2022). In addition to severe physical disease and death, the adverse mental health outcomes of COVID‐19 were revealed in the general population (Das et al., 2021; Islam, Daria, et al., 2021; Liao et al., 2021) and specific groups like university students (Daria & Islam, 2022; Hossain et al., 2022; Simegn et al., 2021). Health‐care workers' (HCWs’) mental health drew attention because of their critical role in the pandemic process. Besides the effects of the pandemic on daily life, HCWs were exposed to increased and continuous stress while treating patients. Also, they had job‐related risk factors for psychological distress, such as the deficiency of protective equipment (Yılmaz Karaman & Yastıbaş, 2021), as well as facing public stigma and discrimination due to their high risk of infection (Singh & Subedi, 2020).

Evidence demonstrated that HCWs had high levels of depression and anxiety during the COVID‐19 pandemic (L. Wang et al., 2020), regardless of their workplace's pandemic risk category (Fu et al., 2021). For example, in Bangladesh, 44% of HCWs were depressed, and 78% had anxiety scores above the cut‐off (Islam, Quaiyum, et al., 2021; Repon et al., 2021). In addition, Styra and colleagues showed that almost half of the HCWs experienced post‐traumatic stress (Styra et al., 2021), while Repon and colleagues found a prevalence of 87% regarding post‐traumatic stress (Repon et al., 2021).

Although coercive life events may cause psychiatric disorders, sometimes they may result in positive changes known as post‐traumatic growth (PTG). Tedeschi and Calhoun (2004) described PTG as positive psychological changes due to coping with traumatic life events. PTG will occur only if the person appeals to the events as stressful or traumatic ones (Tedeschi & Calhoun, 2004). Following the research, COVID‐19 can be accepted as a traumatic work‐related event experienced by HCWs (Finstad et al., 2021). In addition, a few researchers have focused on investigating the positive consequences of COVID‐19 on HCWs (Chen et al., 2021; Feingold et al., 2022). According to the related research findings, the HCWs who actively worked in COVID‐19‐related departments (e.g., intensive care units) can experience PTG (Chen et al., 2021; Feingold et al., 2022; Peng et al., 2021). There have been controversial findings on whether PTG is an independent construct from post‐traumatic stress (Shand et al., 2015) or is significantly positively or negatively related to post‐traumatic stress (İkizer et al., 2021). Some researchers suggested that these two constructs had reciprocal relations (Shigemoto, 2020). Thus, there are unstable findings on the relationship between PTG and post‐traumatic stress during an ongoing stressor.

More longitudinal studies that explore the influencing factors should be processed to enhance mental health outcomes and support the positive changes of HCWs. In their longitudinal research, Teo et al. (2021) stated that HCWs' stress and burnout levels got higher as the pandemic continued, while their anxiety levels fluctuated due to the pandemic response events (Teo et al., 2021). Furthermore, Gündoğmuş et al. (2021) compared the anxiety, depression, and stress levels of HCWs in the first and second COVID‐19 peaks: the second‐peak participants had worse mental health outcomes (Gündoğmuş et al., 2021).

In Turkey, the first COVID‐19 cases were reported on 11th March 2020 (Republic of Turkey Ministry of Health, 2022); the exact date the World Health Organization declared the novel coronavirus outbreak pandemic (World Health Organization, 2020). The disease spread rapidly among the public and HCWs. The first wave occurred until June 2020, and the second wave happened in the following fall and winter. We describe the situation of the COVID‐19 pandemic during the measurements in the Methods section.

Aims

To our knowledge, there is a lack of prospective research on the mental health of HCWs during the COVID‐19 pandemic. In addition, there is no research exploring PTG levels of HCWs longitudinally. Thus, the present study has the following questions:

  1. Between the first and second waves of the COVID‐19 pandemic in Turkey, are there differences in depression, anxiety, traumatic stress disorder prevalence, and symptom levels in HCWs?

  2. Between the first and second waves of the COVID‐19 pandemic in Turkey, do PTG prevalence and symptom levels change in HCWs?

  3. If there are differences in the variables mentioned above, what are the related factors?

METHOD

Participants

The HCWs who work in Eskişehir Osmangazi University Hospital were invited to participate in the present study, face‐to‐face or online. Researchers visited HCWs in their departments at the hospital, asking them to participate in the present study. Besides, HCWs were asked to spread the study link in the same hospital through their social media groups. Google Forms, a free online survey tool, was utilized to collect data. We recruited a sample of convenience, utilizing snowball sampling.

During the study period, the HCWs of Eskişehir Osmangazi University Hospital actively took part in caring for COVID‐19 patients. All HCWs cared for the patients with COVID‐19 by turns.

Sixty‐six HCWs participated in this study with a mean age of 34 years (SD = 8.34). Among them, 24 were male participants (36.4%), and the rest were female (63.6%). Most participants were frontline workers (63.6%), and the others worked in various hospital units, such as secretariat and technicians. In addition, 60.6% of the participants were married. Most HCWs (60.6%) had more than 5 years of working experience.

Procedure

While inviting the participants face‐to‐face, the researchers wore a mask and maintained social distance. Written informed consent or online informed consent was obtained from all participants. The study was approved by Eskişehir Osmangazi University Faculty of Medicine, Non‐Invasive Clinical Research Ethics Committee. The researchers worked following the principles in the Declaration of Helsinki.

Between 8 May 2020 and 6 July 2020, the first measurements were taken, and 131 HCWs participated in the first step. Then, the second evaluation was made between 13 October 2020 and 26 January 2021. However, 66 out of 131 HCWs participated in the second step. Thus, statistical analysis was made with the data of 66 participants.

The situation on COVID‐19 pandemic during measurements

The first COVID‐19 case was identified on 11 March 2020 in Turkey (Republic of Turkey Ministry of Health, 2022). During the first period of the present study, 10 HCWs died in 60 days, and in the second period of the study, 224 HCWs lost their lives in 106 days due to COVID‐19 across the country (Turkish Medical Association, 2022). During these two study periods, in Turkey, 1600 and 16,449 citizens lost their lives, respectively (Republic of Turkey Ministry of Health, 2022). See Figure 1 for a nationwide overview.

FIGURE 1.

FIGURE 1

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Description of the study periods

At the end of the second period of the study, after 13 January 2021, the HCWs in Eskişehir Osmangazi University Hospital were able to get vaccinated against COVID‐19 with their counterparts in Turkey (Republic of Turkey Ministry of Health, 2021).

Measures

Sociodemographic data form

The sociodemographic form was created by the researchers and aimed to evaluate the following descriptive demographic information of the participants: age; gender; marital status; length of work experience; how they took part in the health service during the pandemic; whether they, their relatives, or colleagues had been diagnosed with COVID‐19; and whether they had chronic diseases. In addition, several items were created to evaluate personal protective equipment given to the participants by the institution during the pandemic, the amount of knowledge about COVID‐19 provided by the institution, the participant's perceived level of knowledge about protection from the infection, and the work compliance of the participants with their colleagues and team leaders.

Impact of Event Scale‐Revised

The Impact of Event Scale‐Revised (IES‐R) consists of 22 items and three sub‐dimensions that evaluate traumatic stress symptoms' presence and severity (Weiss & Marmar, 1997). Çorapçıoğlu et al.'s (2006) study shows that the Turkish version of IES‐R is valid and reliable, and the internal consistency coefficient was calculated as .94 for the total score. In the present study, “the traumatic life event” specified in the scale was defined as “working as an HCW in the novel coronavirus disease (COVID‐19) epidemic.” The highest value obtained from the scale is 88. Individuals with a score of 24 or more are defined as having possible experience of mild or more severe post‐traumatic stress disorder (PTSD; Creamer et al., 2003). In the current study, the cut‐off score for IES‐R was evaluated as 24 points, as Roberts et al. (2021) named “a clinically significant traumatic stress response.” In the current study, the Cronbach's alpha scores for IES‐R were.94 at T1 and .94 at T2.

Patient Health Questionnaire‐ 9

The Patient Health Questionnaire‐ 9 (PHQ‐9) is a 9‐item scale created according to DSM‐IV depression criteria (Kroenke et al., 2001). Our study preferred the scale because it is shorter than other depression scales, is valid and reliable, and has been used in international publications for the depression screening of HCWs (Kroenke et al., 2001; Lai et al., 2020). PHQ‐9 evaluates the severity of depressive symptoms between 0 and 27 points. In the Turkish adaptation study, the internal consistency coefficient of the scale was found to be .84, and researchers stated that it is a valid and reliable measurement tool (Sari et al., 2016). Besides, Sari et al. (2016) indicated that the participants who scored 1–4 on the scale experienced minimal depression, those with 5–9 mild, 10–14 moderate levels, 15–19 moderate/severe depression, and 20–27 points severe depression. The cut‐off point for depression risk was 15 in the studies with HCWs during the pandemic. Similarly, we determined 15 points as our cut‐off score in the present study (Rossi et al., 2020). PHQ‐9 indicated good internal consistency in the current study (Cronbach's alpha score was .88 at T1 and .87 at T2).

Generalized Anxiety Disorder‐ 7

The Generalized Anxiety Disorder‐7 (GAD‐7) is structured according to DSM‐IV‐TR generalized anxiety disorder criteria (Spitzer et al., 2006). The scale's total score, which consists of seven questions, ranges from 0 to 21 points. The Turkish validity and reliability study calculated the internal consistency coefficient as .85, and the cut‐off score was eight points (Konkan et al., 2013). GAD‐7 showed good internal consistency in the current study (Cronbach's alpha score was .94 at T1 and .94 at T2).

Post‐traumatic Growth Inventory

The Post‐traumatic Growth Inventory (PTGI) developed by Tedeschi and Calhoun (1996) consists of 21 items and five sub‐dimensions. The internal consistency coefficient for the total score was calculated as .90. The Turkish translation and psychometric properties of the scale were examined by Dirik and Karanci (2008). They stated that internal consistency coefficients were found to vary between .86 and .88. For assessing the PTG level, previous studies were followed. We defined moderate and above levels of PTG as a mean item score of PTG > 3 and a total score > 60 (Cui et al., 2021; C. S. Tang, 2006; Y. Wang et al., 2018). The Cronbach's alpha scores of the PTGI were .97 at T1 and .97 at T2 in our study.

Data analysis

Statistical analyses were performed using SPSS Version 23 (IBM, New York). Descriptive statistics were used to explore the demographic characteristics of the sample. First, the sum scores of IES‐R, PHQ‐9, GAD‐7, and PTGI were calculated, and then the measures of skewness and kurtosis were used to assess the normality of the data. Since the data showed a normal distribution, we used paired sample T‐test to compare the baseline and 6‐month follow‐up of the measurement tools. Multivariate multiple regression for continuous variables and independent sample t‐test for categorical variables were performed to investigate the predictors for the significant differences between the baseline and 6‐month follow‐up dependent measurements (pre‐ and post‐test differences were entered as a dependent variable). Some sociodemographic factors, such as gender, marital status, frontline HCWs, and COVID‐19‐related information (like subjective level of knowledge on COVID‐19), were tested if they served as predictors or protectors of the study outcomes. In all analyses, p values < .05 were considered statistically significant.

RESULTS

See Table 1 for an overview of participants' sociodemographic characteristics.

TABLE 1.

Sample demographics

Variables N(%)
Gender, female (n, %) 42 (63.6%)
Occupation, front line (n, %) 42 (63.6%)
Age (years, range) 66 (21–58)
Marital status, married (n, %) 40 (60.6%)
Working years (years, range) 66 (1–35)
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Prevalence of depression, anxiety, post‐traumatic stress, and post‐traumatic growth (baseline and 6‐month follow‐up measurement)

Sixteen (24.2%) HCWs reported major depressive symptoms during the first period of the study; this prevalence increased to 22 (33.3%) in the second period. Fifteen (22.8%) HCWs reported generalized anxiety symptoms in the first and the second measurement. Regarding post‐traumatic stress symptoms, 19 (28.8%) HCWs were above the cut‐off score in the first measurement; and 20 (30.3%) in the second. Twenty‐two (33.3%) HCWs reported moderate and high levels of PTG in the first period; this number increased to 18 (27.3%) in the second period (see Figure 2).

FIGURE 2.

FIGURE 2

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Depression, anxiety, post‐traumatic stress, and PTG prevalence of the participants in two study periods

Differences in depression, anxiety, post‐traumatic stress, and post‐traumatic growth scores (baseline and 6‐month follow‐up measurement)

In order to analyze, the changes in the mean scores of the dependent variables over time were tested with paired‐samples t‐tests. There were no significant differences in terms of depression scores (p = .198), anxiety scores (p = .661), or post‐traumatic stress scores (p = .642).On the other hand, the PTG scores of the participants significantly decreased over time (p = .023, d = .07). For an overview, see Table 2.

TABLE 2.

Comparison of baseline and follow‐up measurements of depression, anxiety, distress, and post‐traumatic growth

Baseline measurement Follow‐up measurement t f p
Variable Mean, SD Mean, SD
PHQ‐9 7.80, 5.42 8.63, 5.34 −1.30 65 .198
GAD‐7 5.71, 5.72 5.44, 5.48 .44 65 .661
IES‐R 17.77, 15.25 18.62, 15.07 −.47 65 .642
PTGI 45.04, 26.39 37.89, 26.28 2.33 65 .023*
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Note: N = 66.

Abbreviations: GAD‐7, Generalized Anxiety Disorder‐7; IES‐R, Impact of Event Scale‐Revised; PHQ‐9, Patient Health Questionnaire‐ 9; PTGI, The Post‐traumatic Growth Inventory.

*

p < .05.

Predictors of the changes in post‐traumatic growth scores

PTG was significantly lower in the second period compared to the first period. Thus, researchers analyzed the factors related to PTG change in HCWs between two periods. We entered differences between pre‐ and post‐test of PTG as a dependent variable. We conducted three independent‐sample t‐tests for categorical variables, and gender (p = .742), frontline versus non‐frontline HCWs (p = .756), and marital status (p = .631) were found to be statistically non‐significant predictors. For continuous variables, we performed multivariate multiple regression. Working years, age, the subjective evaluation of the relationship with colleagues, and the subjective level of knowledge were entered as independent variables for predicting a decrease in PTG. As Table 3 shows, the subjective level of knowledge about COVID‐19 (t = −2.47, p = .016) and the subjective evaluation of the relationship with colleagues (t = −2.69, p = .009) were found as significant predictors. Sixteen percent of the variance was explained and effect size was calculated as .19.

TABLE 3.

Testing for significant differences in PTGI score using multiple regression

B SE B 95% CI β
Age 0.28 0.72 −1.21, 1.66 .08
Working years −0.44 0.73 −1.89, 1.01 −.15
Subjective level of knowledge −6.83 2.77 −12.38, −1.29 −.29*
Subjective assessment of relationship −11.66 4.33 −20.31, −3.01 −.32*
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Note: Significance differences in PTGI at both measurements (pre‐ and post‐test) = dependent variable. R 2 = 16.2, F(4) = 2.96.

*

p < .05.

DISCUSSION

The present follow‐up study evaluates the depression, anxiety, post‐traumatic stress, and PTG levels of HCWs in two periods. In the first period of the study, the deaths due to COVID‐19 disease or COVID‐19‐related conditions were lower; thus, we may comment that the second period was more stressful for HCWs. The depression and post‐traumatic stress levels of HCWs became higher, while their PTG levels decreased in the second period. In the second period of the present study, 33.3% HCWs had depressive symptoms, 22.8% had anxiety symptoms, and 30.3% had traumatic stress symptoms; on the other hand, 27.3% of HCWs indicated moderate and high levels of PTG.

In the second measurement, 33.3% HCWs had depressive symptoms above the cut‐off. The pooled prevalence of depression in Batra et al.'s (2020) meta‐analysis was 31.8% among HCWs. At the same time, Sahebi et al. (2021) stated that the prevalence of depression among HCWs was 24.8% during the COVID‐19 pandemic. Depression prevalence in the general population was 32.4%–35.3% in Europe and Asia during the COVID‐19 pandemic (Salari et al., 2020). We may say our sample was in line with previous studies regarding depression rates. Before the pandemic, an epidemiological study from Turkey remarked that subthreshold and clinical depression prevalence was 1.7% among the population aged between 35 and 45 years (Topuzoğlu et al., 2015). Additionally, the same study stated a prevalence of subthreshold and clinical depression as 1.4% or those aged between 25 and 35 years (Topuzoğlu et al., 2015). The researchers observed the negative effect of the COVID‐19 pandemic among HCWs regarding depressive symptomatology.

In the last measurement of the present study, 22.8% of HCWs had notable anxiety symptoms. According to the meta‐analysis of Batra et al. (2020), anxiety prevalence among HCWs during the COVID‐19 pandemic was 34.4%. An umbrella review stated that 24.9% of HCWs suffered from anxiety during the pandemic (Sahebi et al., 2021). Anxiety prevalence was 23.8%–32.9% in the general population in Europe and Asia during the pandemic (Salari et al., 2020). The psychosocial impact of COVID‐19 negatively affects the mental health of HCWs and the public. On the other hand, the prevalence increases to 89.26% in frontline nurses at Wuhan (Li, Su, et al., 2021). With this, we can deduce that the place and the conditions are essential for developing anxiety symptoms because the level of danger changes. This may explain our relatively low anxiety prevalence.

Female participants versus male participants, nurses versus doctors, frontline HCWs versus second‐line HCWs had higher levels of anxiety and depression (Batra et al., 2020). However, our study may not detect any of these related factors because of the smaller sample size and convenience sampling method.

The rate of the HCWs having moderate or severe traumatic stress symptoms was 30.3% in our study. Several studies assessed post‐traumatic stress disorder in HCWs during the COVID‐19 pandemic. The prevalence of traumatic stress symptoms above the threshold was 11.4%, according to Batra et al. (2020). Chew et al. (2020) indicated that 7.4% of HCWs had significant post‐traumatic stress responses. A longitudinal study evaluating frontline doctors during the COVID‐19 pandemic found a prevalence of traumatic stress at 23.7% in the peak period and 17.7% in the deceleration period in the United Kingdom and Ireland (Roberts et al., 2021). On the other hand, J. Li et al.'s study showed that 81.2% of frontline nurses in Wuhan and 36.7% of non‐frontline nurses out of Wuhan had moderate or severe post‐traumatic stress symptoms (J. Li, Zhao, et al., 2021). Our results indicate a high prevalence of traumatic stress symptoms among HCWs in Eskişehir Osmangazi University Hospital. The preliminary results of the present study showed that lower occupational experience, having a relative or friend diagnosed with COVID‐19, having subjectively enough knowledge about COVID‐19, having adequate personal protective equipment, having a good relationship with coworkers, and previously having a mental health disorder were related to traumatic stress symptoms (Yılmaz Karaman & Yastıbaş, 2021).

In the second period of the present study, 27.3% of HCWs developed moderate and high levels of PTG. HCWs face challenging circumstances, such as witnessing death, negative workplace experiences, stressful doctor–patient relationships, exposure to violence against HCWs, night shifts, and work overload. Besides, the COVID‐19 pandemic intensifies current difficulties. These experiences may result in post‐traumatic growth. The mean value of the PTG scores among the nurses in Chen and colleagues' (2021) study was 28.0, and Cui et al. (2021) stated the mean score of PTG was 70.53 in nurses, while in our study, it was 37.86. Uziel et al. (2021) evaluated dental practitioners during the pandemic and found a mean PTG score of 17.83, 20.50, and 21.43, respectively, for Israel, France, and Canada. Various factors are related to PTG. Cui et al.'s (2021) cross‐sectional study showed that older age, more working years, previous experience in public health emergencies, and self‐confidence about frontline work were associated with higher PTG in nurses. In addition, PTG levels are associated with post‐traumatic stress, like worries about physical health and caring for patients with COVID‐19 (Chen et al., 2021; Uziel et al., 2021). However, it is vital to emphasize that traumatic stress and PTG have a curvilinear relationship (Dar & Iqbal, 2020).

Between the first and the second wave, HCWs showed stable levels of anxiety symptoms, and slightly higher levels of depression and traumatic stress symptoms (each p > .05). As the researched stated that the second wave had more COVID‐19 cases and deaths related to the COVID‐19 disease, one may evaluate the second period as more stressful. The anxiety levels remained the same between the two periods. Johansson and colleagues' cohort study with Swedish university students demonstrated similar results: Students had stable levels of depression, anxiety, and stress during baseline and the waves (i.e., September 2020, December 2020–January 2021, and March–April 2021; Johansson et al., 2021). In this study, students' depression scores got slightly higher during the follow‐up; it was not a significant change (Johansson et al., 2021). On the other hand, Y. Li and colleagues stated that Chinese college students experienced lower levels of post‐traumatic stress and higher levels of depression and anxiety at the end of follow‐up (Y. Li, Su, et al., 2021). Y. Li and colleagues had the measurements in February 2020 and March–April 2020; they stated that the second period was less stressful. “Delayed dysfunction” was related to low social support and low levels of family functioning (Y. Li, Zhao, et al., 2021). A population cohort from China had measurements in February–March 2020 and July–August 2020: Shi and colleagues observed that while depression frequency increased, anxiety symptoms decreased (Shi et al., 2021). Shi and colleagues defined improvements in the control of the pandemic during the second period of the study, in other words, less stressful regarding COVID‐19 pandemic (Shi et al., 2021). The study of Steenkiste and colleagues focused on the nurses working on the frontline during the pandemic in Belgium (Van Steenkiste et al., 2022). Between April and June 2020, frontline nurses had declining levels of depression and anxiety. Van Steenkiste and colleagues underlined the existence of a multidisciplinary corona support team, which provides psychosocial support to HCWs and patients (Van Steenkiste et al. 2022). Besides, the decrease may result from lower COVID‐19 cases and higher experience with patients with COVID‐19 (Van Steenkiste et al., 2022).

Longitudinal studies of psychological disorders during the COVID‐19 pandemic showed heterogenic results. This may originate from the methodologic design of the studies, study samples, the timing of the study versus the intensity of the pandemic in the country/city. Both the peak periods and remission periods have their mental health risks. Intense pandemic periods may result in psychological distress; on the other hand, remission periods may uncover financial difficulties and lead to work overload due to lockdown. Shevlin and colleagues argued that psychological responses to the pandemic are mostly stable over time (Shevlin et al., 2021). In our study, anxiety levels remained stable, while depression and traumatic stress levels increased slightly. Since we had measurements in stressful and more stressful periods regarding the pandemic, we had expected to encounter increasing psychopathology. There are possible explanations: (1) Our participants may have experienced delayed dysfunction, like Y. Li and colleagues mentioned (Y. Li, Zhao, et al., 2021). Thus, at the time of measurements, some participants may not have experienced the psychological symptoms yet. (2) Our sample may be too small to detect differences. (3) Psychological responses to pandemics may predominantly be associated with personal factors. That may be the reason for their stability over time, as Shevlin and colleagues put forward (Shevlin et al., 2021).

In the second wave of the COVID‐19 pandemic, HCWs had lower PTG scores than in the first wave (p < .05). The second period of the present study had worse indicators of pandemic intensity, higher numbers of cases, and higher numbers of deaths. Adversity and PTG have a curvilinear relationship. It means that increasing stress levels can increase or decrease PTG. We observed a decreasing trend in PTG levels of HCWs during the follow‐up. Park and colleagues found a stable trend of PTG among US general population in five measurements during the COVID‐19 pandemic (Park et al., 2022). They argued whether PTG is stable or a trait‐like dimension (Park et al., 2022). Besides, Park and colleagues underlined that they found no evidence to support that PTG is related to better mental health (Park et al., 2022). The trend of PTG levels may differ related to sample characteristics. PTG occurs after a traumatic event; during the pandemic, HCWs faced traumatic situations more than ever. We hypothesize PTG trends would be different between HCWs and the general population. Lyu et al. (2021) claimed that PTG scores of frontline HCW decreased over time, especially when they realized the pandemic was not under control, which is consistent with our study. Furthermore, Kapur et al. (2022) also found a decline in PTG scores in radiation medicine staff over time. W. Tang and colleagues surveyed adolescents to assess PTG levels in February 2020 and July 2020 (W. Tang et al., 2022). PTG levels of adolescents (39.46 vs. 42.38) were lower during the lockdown compared to a relatively relaxed period after 5 months (W. Tang et al., 2022). Adolescents' vulnerability to traumatic stress may result in similar results to the present study: Lockdown stress may have lowered their PTG.

Decreasing PTG scores were related to a lower personal level of knowledge about COVID‐19 and a lower subjective evaluation of the relationships with coworkers. A low level of knowledge may cause uncertainty and more stress and thus harm one's resilience. Besides, it may negatively affect workplace stress. Additionally, it may refer to the avoidance symptoms of psychological trauma, like preferring not to know as it may cause too much anxiety. On the other hand, perceived social support is positively correlated to PTG (Yastıbaş et al., 2021). Therefore, low‐quality relationships with colleagues can mean lower social support from the working environment. Lyu et al. (2021) underlined that burnout negatively relates to PTG in HCWs. Even though our study did not evaluate burnout levels, the decrease in PTG levels may be related to the increasing burnout levels of HCWs during the COVID‐19 pandemic.

Implications for the future

Maercker and Zoellner (2004) suggested that PTG has two different components: positive illusory and constructive side, which is self‐transforming as the theory of Tedeschi and Calhoun (1996, 2004). Although there are many contradictory findings on the relationship between PTG and psychological adjustment, it is stated that the constructive side of PTG may be accompanied by psychological adjustment. Hence, PTG may be an essential concept for psychosocial intervention. Our finding highlighted the importance of clear information about the pandemic and the relationship quality between colleagues for PTG. It could be essential to provide transparent information about COVID‐19 and to carry out activities or interventions to strengthen the relationship between HCWs.

The authors suggest that the following interventions may reduce harm during stressful working conditions: providing adequate information about the current crisis, enhancing good relationships between coworkers, and screening for psychological distress. We believe team leaders should know the importance of mental health and common mental disorders, especially in crises. The authors may advise team leaders to conduct regular meetings, enhancing information on the current duty and conditions of the stressful event, as well as social meetings to ensure group cohesion. Team leaders and stakeholders may invite mental health professionals to screen their employees. That can be done online if there is a danger of spreading a disease, like COVID‐19. Mental health professionals may use validated short scales to identify risk.

Psychological distress and PTG have a complex relationship. To result in PTG, an event must be stressful. On the other hand, it looks like after some degree of stress, it causes more harm than growth (Yastıbaş et al., 2021). The present study did not define a critical threshold for reduced PTG. However, screening employees for common mental disorders may be helpful during stressful conditions. Employees with psychological distress may benefit from interventions to augment PTG. The findings may apply to the workers in critical conditions other than HCWs, like firefighters, search and rescue teams, or military personnel.

Limitations and strengths

The study suffered from significant attrition. Almost half of the sample was lost; this may have reduced the signal and the significance in some outcomes. Likely, the study was not powered enough to detect the differences in depression, anxiety, and post‐traumatic stress. Because of the many ongoing studies with HCWs, we suspect there was reporter fatigue, leading to a significant lack of engagement.

Our results may have a response bias. For example, we may not have reached the HCWs with work overload because they did not have time to participate, or HCWs with severe traumatic stress symptoms may have avoided answering questions about a stressful event. Recruiting a sample of convenience is also a limitation for us. Last but not least, the present study did not cover the psychological variables related to PTG as the challenge to core beliefs or ruminative thoughts.

As a strength, the present study evaluates HCWs in two periods with different pandemic intensities. That provides an opportunity to assess study outcomes under the same stressor with different levels. Moreover, recruiting in the same city and hospital homogenizes the stressor.

Previous studies on HCWs' mental health during the COVID‐19 pandemic usually focused on cross‐sectional psychopathology. To our knowledge, the present study is the first to assess HCWs' PTG levels in two waves. It is novel as it assesses post‐traumatic growth, a dimension showing positive changes after traumatic events.

CONCLUSION

The depression and post‐traumatic stress levels of health‐care workers become high, and their post‐traumatic growth levels tend to decrease in chronic stressful conditions in the COVID‐19 pandemic without a vaccine. Future research may focus on interventions to empower post‐traumatic growth in health‐care workers and promote resilience across the stress.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

FUNDING STATEMENT

The authors received no funding for the present study.

ETHICS STATEMENT

The study was approved by Eskişehir Osmangazi University Faculty of Medicine, Non‐Invasive Clinical Research Ethics Committee by the date 10 April 2020 and the number 01.

PATIENT CONSENT FOR PUBLICATION STATEMENT

All participants gave written informed consent to join the study.

Supporting information

Appendix S1

Click here for additional data file. (56.8KB, pdf)

ACKNOWLEDGMENTS

The authors appreciate all participants for joining the study.

Yılmaz‐Karaman, İ. G. , Yastıbaş‐Kaçar, C. , & Ece İnce, F. (2022). Posttraumatic growth levels of healthcare workers in two periods with different intensities of COVID‐19 pandemic. PsyCh Journal, 1–10. 10.1002/pchj.599

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