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. 2023 Jan 30;45(6):554–561. doi: 10.1177/01939459231152121

Factors Influencing Frontline Screening Nurses’ Depression as a Long-Term Impact of COVID-19

Min-Sun Song 1, Sung Suk Park 2, Soohyun Park 3,✉
PMCID: PMC9892809  PMID: 36715305

Abstract

Frontline screening nurses experienced exhaustion and depressive symptoms as a long-term impact of COVID-19. This study aimed to explore fatigue, depression, and empowerment among frontline screening nurses and examine the factors influencing depression. This was a descriptive cross-sectional study. The study included 140 frontline screening nurses in South Korea recruited from February to March 2021. The measures included a fatigue scale, the Text of Items Measuring Empowerment (TIME), and the Center for Epidemiological Studies Depression Scale (CES-D). The STROBE checklist was used for reporting aspects of the cross-sectional design. Frontline screening nurses showed high fatigue scores (M = 3.47, SD = 0.55), and 55.7% (n = 78) of them were depressed and had low empowerment scores (M = 3.53, SD = 0.69). Empowerment and fatigue were predictors of depression. Increased empowerment and decreased fatigue were important in decreasing depression. Therefore, efforts to provide sufficient staffing, screening for depression, and listening to nurses’ voices are necessary.

Keywords: COVID-19, fatigue, depression, empowerment, nursing

Since the World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) a pandemic in March 2020, more than 260 million people have tested positive for COVID-19, and more than 5,180,000 people have died (Coronavirus Resource Center, 2021). As of November 5, 2022, in the Republic of Korea, 25,801,564 people were diagnosed with COVID-19, including 29,354 deaths (Statistics Korea, 2022). The COVID-19 pandemic resulted in a high rate of hospitalizations and necessitated a high demand for health care providers, particularly nurses (Alharbi et al., 2020). Further, the COVID-19 pandemic led to a dramatic increase in health care providers’ workloads, and the resulting fatigue and burdens from their increased workload can lead to inefficiency and reduce the quality of nursing (Gu, 2017; Kho et al., 2004). As the COVID-19 pandemic has continued, health care workers, particularly frontline screening nurses, have experienced burnout, and many nurses in public health clinics have quit or temporarily left their jobs due to the cumulative fatigue and mental stress from the prolonged pandemic (Chae, 2021).

During the COVID-19 pandemic, 32.3% of nurses working at one general hospital showed high stress related to the increased workload from the spread of the virus (Yun, 2020). Nurses reported increasing fatigue because of the additional infection control measures required when caring for patients suspected of being infected or infected with COVID-19 (Jun et al., 2021; Zhan et al., 2020). Nurses’ fatigue increased when patients’ conditions deteriorated, and nurses lacked knowledge about COVID-19 resulting in fear from the uncertainty of the pandemic trajectory and the demands related to new roles related to infection control (Jun et al., 2021; McAlonan et al., 2007).

In the early days of the COVID-19 pandemic, 34.3% of nurses reported depression (Zheng et al., 2021), although the scores were lower than the rate of depression reported during the severe acute respiratory syndrome (SARS) outbreak. However, as the COVID-19 pandemic has continued for more than 2 years, exhaustion and depression among nurses might have worsened. Various traumatic situations have resulted from the COVID-19 pandemic, but nurses’ emotional well-being has not been considered in this pandemic situation (Alharbi et al., 2020). Nurses have described their exhaustion from the intensity of their nursing workload, and this high level of cumulative stress has been reported in the popular media with titles such as “Health workers urged to scrap planned strike amid prolonged pandemic” (August 31, 2021) and “COVID-19 nurse found dead in Busan in apparent suicide” (May 26, 2021). A systematic review of health care workers during the COVID-19 pandemic indicated that female nurses showed higher rates of depression than other subgroups of health care workers (Pappa et al., 2020). A total of 43.61% of nurses experienced depression during the COVID-19 pandemic in the Republic of Korea (An et al., 2020). Therefore, research on nurses’ depression levels and the factors influencing the long-term impact of COVID-19 is necessary.

Empowerment is a process involving the strengthening and development of skills in individuals that promote positive changes and is related to the employee’s experience of intrinsic motivation (Goedhart et al., 2017; Moura et al., 2020). During the COVID-19 pandemic, nurses required a sense of empowerment and the ability to appropriately play their roles by offering opportunities to problem-solve and develop skills to promote positive changes (Goedhart et al., 2017; Koo, 2000). However, research on nurses’ empowerment during the COVID-19 pandemic was not found during an extensive literature search. In previous studies, empowerment has been shown to strengthen nurses’ work capabilities and internal motivation. In addition, it has been found to help maximize the potential or creativity of nurses (Nursalam et al., 2018). Increased empowerment is associated with increased nurse job satisfaction and reduced burnout (Wagner et al., 2010). Nurses who perceive themselves to be empowered are more likely to use effective work practices resulting in positive patient outcomes (Donahue et al., 2008) than those with lower empowerment. Nurses who are empowered feel committed to their job, resulting in increased performance (Leggat et al., 2010). When nurses have high empowerment, their stress is lowered, and job satisfaction increases, improving the quality of their nursing (Choi et al., 2014; Park & Choi, 2004). Therefore, exploring how empowerment can influence nursing performance during the COVID-19 pandemic is necessary.

In South Korea, each hospital has assigned frontline screening nurses who triage patients with COVID-19 based on the results of polymerase chain reaction (PCR) tests. These nurses had a higher workload than nurses who were not providing direct care to patients with COVID-19 (Sagherian et al., 2020). During the pandemic, these nurses provided care to infectious patients and wore level D protective equipment, which is considered the minimum level of protection from hazardous environments and includes gloves, coveralls, safety glasses, face shields, and chemical-resistant steel-toed shoes, providing cover to the entire body all day in both hot and cold weather. They are the nurses working on the frontline of the COVID-19 pandemic. This study assessed fatigue, depression, and empowerment among frontline screening nurses during the prolonged course of the COVID-19 pandemic and identified factors associated with depression.

Methods

Study Design

This cross-sectional descriptive study was conducted at two university hospitals in Daejeon, South Korea, from February to March 2021.

Participants

Participants were frontline screening nurses. They worked as staff nurses and cared for patients with COVID-19 only. Their main duties included assisting with PCR test sampling for physicians to screen for COVID-19 and providing simple direct nursing care and procedures only to patients with COVID-19 in the emergency room. They isolated patients with COVID-19 until the PCR test results were obtained. Nurses who had experience working in pulmonology or infection units before the COVID-19 pandemic were eligible to work as frontline screening nurses. Recruitment of participants was conducted by one of the researchers. They visited the units where the frontline screening nurses worked. A survey was conducted on the nurses who voluntarily participated in the study.

The necessary sample size for this study was calculated using G*power version 3.1.9.7. Considering a moderate effect size of 0.15, an alpha of 0.05, and a power of 0.80 for regression analysis with 11 variables, a minimum sample of 123 participants was required. Thus, we recruited 145 participants, anticipating a possible 15% dropout rate. Five nurses were excluded because they did not answer the questionnaire completely. Data were analyzed from 140 completed questionnaires. Participants were eligible if they worked as frontline screening nurses in university hospitals in Daejeon, South Korea, could understand the questionnaires, and consented to participate in this study.

Data Collection

Permission from the nursing departments of two university hospitals was received before recruiting participants for data collection. The researcher visited the nursing units in charge of screening for COVID-19 in two university hospitals. A survey was distributed to nurses who voluntarily agreed to participate in this study from February to March 2021. Before the survey, the researcher explained to participants the study’s purpose and methods and that there were no disadvantages in stopping their study participation. They completed the self-report questionnaire, and the estimated completion time was approximately 20 minutes.

Measures

Demographic characteristics

Demographic characteristics that were collected included age, gender, marital status, education, years working as a nurse, job title, work setting before their COVID-19 screening duty, experience working with a new infectious disease, the average length of shift (hours), average overtime per day (minutes), and perception toward COVID-19 quarantine policy (positive or negative).

Fatigue

For fatigue, an instrument developed by Gu (2017) was used. This instrument was developed to measure fatigue in nurses caring for patients with a new infectious disease (i.e., Middle East respiratory syndrome [MERS]) and consisted of 39 questions about the complexity of nursing duty and shortage of employees (12 questions), the conflict caused by uncertain situations and the lack of support (11 questions), deteriorating patient conditions and lack of knowledge (7 questions), difficulties due to new roles and demands (5 questions), and concerns about infections and the burden caused by an excessive amount of attention (4 questions) that were rated on a 5-point scale ranging from 1 (not feeling at all) to 5 (feeling very badly). Higher scores indicated higher fatigue. Cronbach’s α in the original study was .95 (Gu, 2017) and was .96 in this study.

Depression

Depression was measured using an integrated Korean version of the Center for Epidemiological Studies Depression Scale (CES-D), which was translated and developed by Chon et al. (2001) based on the original CES-D scale created by Radloff (1977). The scale included 20 questions, scored on a scale from 0 to 3, with total scores ranging from 0 to 60. A total score of ≤15 was considered no depressive symptoms, scores 16–24 were classified as mild depressive symptoms, and scores ≥25 were classified as significant depressive symptoms. A score of 16 points or more is considered depressed. Cronbach’s α in the original study was 0.91 (Chon et al., 2001) and was 0.94 in this study.

Empowerment

In this study, empowerment was assessed using the Text of Items Measuring Empowerment (TIME), developed by Spreitzer (1995), and translated into Korean by Jung (1998). It consists of a total of 12 items with the following 4 subcomponents: Meaning (3 items), Competence (3 items), Self-Determination (3 items), and Impact (3 items). Each question was rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating higher empowerment. At the time of the development of this instrument, Cronbach’s α was 0.86 (Jung, 1998), and in this study, it was 0.93.

Ethical Considerations

This study was approved by the institutional review board of Konyang University Hospital (IRB no: KYUH 2020-12-001-003). The purpose and method of the study were explained to those volunteering to participate in the study. After researchers explained that participation was voluntary, could be refused or discontinued at any time if desired, and that there was no disadvantage for declining to participate, participants signed the informed consent. The participants were assigned a unique code to preserve their anonymity. The data will be stored for 3 years after the completion of the study. After 3 years, related documents will be destroyed and discarded.

Data Analysis

Data analyses were conducted using SPSS WIN 26.0 (Armonk, NY; IBM Corp.). Frequency, percentage, mean, and standard deviation were calculated for the participants’ demographic characteristics and for the measures of empowerment, depression, and fatigue. Differences in empowerment, depression, and fatigue according to participants’ demographic characteristics were analyzed using t-tests, ANOVAs, and post-hoc Scheffé tests. Participants’ fatigue, depression, and empowerment were normally distributed, and Pearson’s bivariate correction coefficients were calculated to determine the correlations between these variables. In addition, a stepwise multiple regression analysis was performed to identify the factors affecting nurses’ depression. Before conducting the regression analysis, whether the data satisfied the assumption of the analysis was examined. According to the results of ANOVA in general characteristics and Pearson correlations, the variables with p-values < .05 were selected for the multiple regression analysis. Non-ordinal categorical variables and ordinal categorical variables were analyzed after they were dummy-coded.

Results

Participants’ Demographic Characteristics

The demographic characteristics of the study participants are summarized in Table 1. Participants had a mean age of 31 years (SD = 6.14; range: 23–46 years), and 72 nurses (51.4%) were under age 30. More than 93% (n = 131) of the nurses were women, and 66% (n = 93) were single. A total of 105 nurses had a bachelor’s degree (75.0%), with a mean work experience of 88.31 months (7.36 years); half of the participants had been working for more than 5 years. Most participants (n = 122, 87.1%) were staff nurses, and 61% (n = 85) worked in specialized units before working as frontline screening nurses. Before the COVID-19 pandemic, 30.0% (n = 43) of the participants had experience caring for patients with new infectious diseases. The average length of their daily shift screening patients with COVID-19 was 7.20 hours (SD = 2.17), with average overtime of 24.34 minutes (SD = 26.20). Of the nurses, 65.0% (n = 91) had a positive perception of COVID-19 quarantine policies.

Table 1.

Characteristics of the Participants (N = 140).

Characteristics Categories n (%) Mean ± SD
Age (years) <30 72 (51.4) 31.39 ± 6.14
Range: 23–46
≥30 68 (48.6)
Gender Men 9 (6.4)
Women 131 (93.6)
Marital status Single 93 (66.4)
Married 47 (33.6)
Education 3-year college 24 (17.1)
Bachelor’s degree 105 (75.0)
>Master’s degree 11 (7.9)
Work experience (years) <5 20 (14.3) 88.31 months ± 70.48
Range: 9–288
5–10 46 (32.8)
>10 74 (52.9)
Job title Staff nurses 122 (87.1)
Charge nurse or Nurse manager 18 (12.9)
Work setting before COVID-19 screening duty Floor 21 (15.0)
Specialized unit (e.g., ICU, ER) 85 (60.7)
Outpatient department 34 (24.3)
Experience working with new infectious disease Yes 42 (30.0)
No 98 (70.0)
Average length of a work day (hour) 7.20 ± 2.17
Range: 0–10
Average amount of overtime per day (minute) 24.34 ± 26.20
Range: 0–120
Perception toward COVID-19 quarantine policy Positive 91 (65.0)
Negative 49 (35.0)
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Note: SD = standard deviation; COVID-19 = coronavirus disease 2019; ICU = intensive care unit; ER = emergency room

Fatigue, Depression, and Empowerment

The study participants’ fatigue, depression, and empowerment scores are summarized in Table 2. Their mean fatigue score was 3.47 (SD = 0.55), and of the five subcategories, fatigue due to complex performance procedures and labor shortage factors showed the highest score (M = 3.53, SD = 0.64). The depression score was 18.06 (SD = 10.30, range = 0–45); 38 nurses (27.1%) were mildly depressed, and 40 were severely depressed (28.6%). Their mean empowerment score was 3.53 (SD = 0.69), and among the four subcomponents, meaning (M = 3.80, SD = 0.83) was the highest score subcomponent.

Table 2.

Fatigue, Depression, and Empowerment (N = 140).

Variables Mean ± SD / n (%)
Fatigue, mean ± SD 3.47 ± 0.55
 1) Complexity of nursing duty and shortage of employees 3.53 ± 0.64
 2) Conflict caused by uncertain situations and lack of support 3.48 ± 0.60
 3) Deteriorating patient conditions and lack of knowledge 3.41 ± 0.65
 4) Difficulties due to new roles and demands 3.48 ± 0.66
 5) Concerns about infections and burden caused by the excessive amount of attention 3.31 ± 0.74
Depression 18.06 ± 10.30
 1) Normal 62 (44.3)
 2) Mild 38 (27.1)
 3) Significant 40 (28.6)
Empowerment 3.53 ± 0.69
 1) Meaning 3.80 ± 0.83
 2) Competence 3.65 ± 0.76
 3) Self-determination 3.51 ± 0.84
 4) Impact 3.15 ± 0.93
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Note: SD = standard deviation.

Depression Based on Demographic Characteristics

There were no significant differences in nurses’ depression by age (t = 0.28, p = .782), gender (t = −0.99, p = .325), marital status (t = 0.99, p = .325), education level (F = 0.62, p = .538), work experience (F = 0.49, p = .613), job title (t = 0.76, p = .449), work setting before COVID-19 screening duty (F = 1.82, p = .166), or experience working with a new infectious disease (t = 0.30, p = .767).

Correlations between Fatigue, Depression, and Empowerment Scores

Depression scores were positively associated with fatigue scores (r = .28, p < .001) and empowerment scores (r = –.46, p < .001) as shown in Table 3. Empowerment scores were not statistically correlated with fatigue (r = –.07, p < .388).

Table 3.

Correlation among Study Variables (N = 140).

Variables Empowerment Fatigue
r (p) r (p)
Empowerment –
Fatigue −.07 (.388) –
Depression −.46 (<.001) .28 (<.001)
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Predictors of Depression

Stepwise multiple regression analysis was conducted to identify the factors influencing depression. Table 4 shows the predictors of depression among frontline screening nurses in the COVID-19 pandemic crisis using stepwise linear regression analysis. The regression results indicated that the predictors explained 26.1% of the variance overall. Significant predictors of depression were empowerment (β = −0.44, p < .001) and fatigue (β = 0.25, p = .001).

Table 4.

Factors Influencing Depression (N = 140).

Variables B SE (B) β t p
(Intercept) 25.13 6.40 3.93 <.001
Empowerment −0.55 0.09 −0.44 −5.98 <.001
Fatigue 0.12 0.04 0.25 3.39 .001
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R2 = 0.272, Adjusted R2 = 0.261, F = 25.07, p < .001.

Note: B = unstandardized regression coefficient; SE= standard error; β = standardized regression coefficient.

As a result of the test of multicollinearity, the condition index was 1.00–1.06 (<15), and the variance inflation factor (VIF) was 1.00 (<10). Therefore, none of the variables had any multicollinearity problems. All other assumptions of multiple regression analysis were also satisfied.

Discussion

This study was conducted to identify fatigue, depression, and empowerment among frontline COVID-19 screening nurses working in university hospitals and the factors associated with depression. Its primary focus was examining nurses’ depression after experiencing the COVID-19 pandemic for more than a year. In this study, the nurses rated their fatigue level at 3.47 out of 5, similar to the fatigue scores (M = 3.49) reported by nurses caring for MERS patients in 2017 (Gu, 2017). During the COVID-19 pandemic, the fatigue scores (3.43) reported for all nurses regardless of caring for patients with COVID-19 and 3.57 for frontline nurses in Wuhan, China were similar to the fatigue scores in this study (Jun et al., 2021; Zhan et al., 2020). In this study, the highest score related to fatigue was the complex performance procedures and labor shortage factors (3.53), similar to a study of nurses participating in MERS patient care (Gu, 2017). High fatigue levels can threaten both nurses’ health and patient safety, leading to decreased performance during work hours (Bai et al., 2004; Sagherian et al., 2020). Although nurses who take rest breaks more frequently have less fatigue (Sagherian et al., 2020), these breaks may have been insufficient because of their worry about critical patients, nursing shortages, and inadequate staffing during the COVID-19 pandemic. Therefore, governmental agencies or the disease control and prevention department should pay attention to the high rate of frontline screening nurses’ fatigue over the prolonged COVID-19 pandemic. In addition, leaders should try to decrease nurses’ overtime and improve nursing shortages that contribute to frontline nurses leaving their jobs.

Many nurses experienced high levels of depression during the COVID-19 pandemic as it continued for over 1 year. More than 27% of nurses experienced mild depression, and 28.6% experienced severe depression in this study. Overall, 55.6% of frontline screening nurses experienced depression, which was higher than the rates of depression reported by nurses working at five regional general hospitals in a previous study (37.6%; Yoon & Kim, 2013). A previous systematic review on the prevalence of depression among health care workers during the COVID-19 pandemic reported a prevalence rate of 22.8%, with 30.3% of female nurses reporting depression (Pappa et al., 2020). Another study on the prevalence of depression among nurses in emergency departments during the COVID-19 pandemic reported a prevalence rate of 43.61%. Thus, the prevalence of depression in this study was higher than previously reported estimates. This difference might be due to the timing of the study, which was conducted when the COVID-19 pandemic had lasted more than a year, while other studies were conducted in early 2020. Although nurses may have begun to care for patients with a strong sense of vocation at the beginning of COVID-19, they experienced depression and exhaustion in their bodies and minds due to having an unmanageable workload for an extended time, along with fear of not knowing when the COVID-19 pandemic would end. Therefore, researchers should focus on frontline nurses’ depression and consider interventions to improve their depression.

This study found that the frontline screening nurses’ mean empowerment score was 3.53. This is lower than the mean score of 3.75 reported by home-visiting nurses in South Korea (Suk et al., 2018) and 3.95 reported by newly graduated nurses (Kuokkanen et al., 2016). In this study, the main factor that influenced depression was empowerment. Previous research has reported that college students who participated in a program to increase their empowerment showed improvement in depressive symptoms (Hart Abney et al., 2019), and this program was reportedly helpful in coping with life’s challenges and illuminating how the individual looks and reacts to challenges (Hart Abney et al., 2019). In another study, an empowerment intervention helped caregivers manage their psychological problems, such as depression and anxiety (Etemadifar et al., 2018). For new graduate nurses, high empowerment contributed to decreased mental health symptoms, such as depressive and anxious symptoms (Wing et al., 2015).

During the COVID-19 pandemic, many nurses experienced powerlessness and were depressed in their job because health care resources, including medical supplies and human resources, were limited. Empowerment helps nurses decrease depression and increases their job satisfaction. When nurses feel empowered, they are happier and less likely to leave their jobs. Therefore, nurse leaders should listen to frontline nurses during weekly meetings where nurses have opportunities to share their concerns, experiences, and challenges.

Another factor that influenced depression among frontline screening nurses was fatigue. Higher depression was associated with higher fatigue, consistent with another study conducted in China in March 2020 during the early stages of the COVID-19 pandemic. Participants at risk for depression reported higher physical and mental fatigue (Zhan et al., 2020). Frontline screening nurses experienced various emotional difficulties, including pressure to provide good care for patients with COVID-19 despite their fear of possible infection. In addition, they also faced an ethical dilemma in forcing patients to die alone because family or friends were not allowed to visit them to prevent the spread of COVID-19 (Lee, 2021). As a result, nurses are prone to psychological crises, such as depression, insecurity, and fear, exacerbating their fatigue (Zhan et al., 2020). Therefore, appropriate policies should be suggested to protect health care workers physically and emotionally. Nurses need to be vocal about their rights to work in conditions that adequately protect their physical and psychological health. Further, supportive services, such as employee assistance programs, chaplaincy services, and mental health hotlines, could address psychological problems for nurses (Morley et al., 2020).

This study has some limitations. This was a cross-sectional study, and data collection was conducted in only two South Korean university hospitals. Therefore, our results may not generalize to the entire population of South Korean nurses. Since this study was conducted before vaccines and other treatments became widely available, our results should be interpreted with caution, and follow-up research is needed.

Conclusion

As the COVID-19 pandemic has continued, depression among health care workers has worsened. Increased depression could lead to other problems, such as health care workers striking and leaving their jobs. This study aimed to identify factors influencing depression in frontline screening nurses during the COVID-19 pandemic; empowerment and fatigue were significant factors. Our findings suggest that nurses need to be aware of their depression, and their empowerment should be enhanced. Further research, such as intervention studies, is suggested—for example, a study of an empowerment-based education program (Anderson & Funnell, 2010) to increase empowerment and a study of aroma therapy or fatigue management education (Finlayson et al., 2011) to decrease fatigue.

Even when the COVID-19 pandemic was stabilized, other pandemics and public health crises could occur at any time. Therefore, governments and hospitals need to provide appropriate work environments to protect nurses from infectious diseases and burnout through sufficient staff support, listening to nurses’ concerns to promote their empowerment, depression screening, and offering psychiatric treatment.

Footnotes

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

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