Existential Anxiety of Nurses in the Corona-Virus Units and Its Relation with Resilience and Posttraumatic Growth: A Survey in Southeast Iran

doi:10.21203/rs.3.rs-2330070/v1

Background

The study aimed to investigate the relationship between existential anxiety, post-traumatic growth, and resilience in nurses working in COVID-19 units of hospitals affiliated to Kerman University of Medical Sciences.

Methods

This was a Descriptive-analytical study. The researchers conducted this study on 224 nurses working in the COVID-19 units of four hospitals affiliated to Kerman University of Medical Sciences in Southeast Iran from 2020 to 2021. They collected data using demographic questionnaire, Masoudi Sani et al.'s existential anxiety questionnaire, Conner-Davidson resilience scale, post-traumatic growth inventory. They also used SPSS V 25 to analyze data.

Results

The results suggested that the mean score of existential anxiety was 80.92 ± 9.18, the mean resilience score was 63.51 ± 15.00, and the mean post-traumatic growth score was 87.69 ± 16.55. The results showed no statistically significant relationship between existential anxiety, resilience, and post-traumatic growth (P > 0.005) but a negative and significant relationship between post-traumatic growth and resilience (P < 0.001, r=-0.38). there were no statistical relationship between the mean existential anxiety score, age, sex, and education level, but the mean existential anxiety score in the emergency personnel was significantly higher than that in those of other departments.

Conclusion

The results demonstrated that the mean scores of existential anxiety and resilience were moderate, while post-traumatic growth score was high. The researchers suggest educational and interventional measures to improve resilience and reduce existential anxiety among nurses.

Existential anxiety

resilience

posttraumatic growth

nurse

COVID-19

COVID-19 has spread over the last few decades as one of the most serious threats to public health around the world (1) and put an unprecedented work pressure on healthcare workers (2) Nurses are the front line of caring for patients with COVID-19 (3). Stressors for healthcare workers include uncertainty about disease transmission and severe infection with the corona virus, which can lead to anxiety and post-traumatic stress disorder in nurses (4).

Remembering COVID-19-related death reveals existential anxiety. It is latent but becomes active when confronted with death (5). Existential anxiety emerges because of inevitable existential issues when humans face the phenomenon of death despite their desires for purpose and immortality (6). Tilich (1952) believes that there are three types of anxiety: of death and fate, meaninglessness and emptiness, and of guilt and condemnation (the quality of life that does not conform to universal standards) (5, 7).

Anxiety disorders are one the consequences of traumatic experiences. However, some stressful situations can pave the way for individuals’ progress; traumatized people return to their previous states and reach a higher level of mental performance (8). Healthcare workers can develop posttraumatic growth by saving lives and improving outcomes of patients (9). Post-traumatic growth refers to positive psychological changes occurred because of struggling with highly challenging and stressful life crises (10) during the process of coping with anxiety (11). Nurses suffer from distress, obsession, and mind rumination because of witnessing COVID-19-related deaths and concerning about their families’ infection. According to a recent study, post-traumatic growth has an effect on perceived distress (12).

Resilience is effective in controlling and reducing individuals’ anxiety in critical conditions, including the COVID-19 outbreak (13). It is the ability to adapt successfully, perform correctly, and avoid basic life stressors (14). Resilience prevents the occurrence of mental disorders in high-risk groups, helps them adapt to difficult and stressful life situations, and keeps them from pathological disorders (15). Nurses caring for patients must have a high level of resilience and manage their work stress and moral challenges during the COVID-19 outbreak (16).

Hernansaiz et al. (2017) revealed a negative correlation between anxiety, depression, and resilience score in newly diagnosed people living with HIV; anxiety and depression decreased as resilience increased. They demonstrated a direct and significant relationship between the anxiety score and the resilience score, and the higher the anxiety score, the higher the depression score, but they found no significant relationship between post-traumatic growth and stress (17). Barzillay et al. (2020) showed that the higher the resilience score and the lower the anxiety and depression among healthcare and non-healthcare workers during the COVID-19 pandemic, the higher the resilience score for COVID-19 (18). Weems et al. (2016) indicated the prevalence of existential anxiety in adolescents and a positive correlation between post-traumatic stress and depression (7). Tomaszek et al. (2020) studied “thinking about my existence during COVID-19, I feel anxiety and awe- the mediating role of existential anxiety and life satisfaction on the relationship between post-traumatic stress disorder and post-traumatic growth.” They demonstrated that post-traumatic stress affected post-traumatic growth through existential anxiety and life satisfaction level (5).

Nurses suffer from post-traumatic stress disorder, existential anxiety, and distress because of witnessing mortality and the consequences of the epidemic; post-traumatic growth improves these symptoms (19). Low level of resilience associates with feelings of mental pressure, anxiety, and depression (20). Improving resilience in nurses reduces their mental and emotional problems and increases their mental health. Nurses have an important role in maintaining and promoting health, so their anxiety disorders have negative effects on their psychological health and they must improve their resilience and post-traumatic growth. We decided to determine the relationship between anxiety, post-traumatic resilience, and growth in nurses working in the COVID-19 units of teaching hospitals affiliated to Kerman University of Medical Sciences in 2021.

1.1. Study design and setting

This descriptive-correlational cross-sectional study was conducted on nurses working in COVID-19 units of teaching hospitals affiliated to Kerman University of Medical Sciences in 2021. Kerman, a city in southeast Iran, includes four teaching hospitals affiliated to Kerman University of Medical Sciences. The researchers used COVID-19 units in Afzalipur, Shahid Bahonar, Shafa, and Shahid Beheshti hospitals. Afzalipur is the corona center of Kerman, with the highest number of infectious departments.

1.2. Sampling and sample size

The researchers used the census method in this study. During the research, the following nurses were working in different departments of Afzalipour hospital: 40 nurses in the emergency department, 18 nurses in the Corona ICU, 35 nurses in the infectious wards, 20 in the suspected ward, 20 in the General ICU, 20 in the Corona Wards, 15 in the pulmonary ward, and 16 in the gastrointestinal department. Sixty, thirty, and fourteen nurses were working in emergency departments of Shafa, Bahonar, and Shahid Beheshti hospitals, respectively (N = 288). The inclusion criteria were nurses’ willingness to participate in the research, with a work experience in COVID-19 wards for at least three months, without severe depression and anxiety disorders, no addiction to narcotics and psychotropic drugs. The exclusion criteria were employee turnover and incomplete questionnaires. We excluded the participants who did not complete more than a third of the questionnaires.

1.4. Questionnaires

1.4.1. Demographic information questionnaire

This questionnaire included information about participants’ age, sex, marital status, work experience in nursing, education level, name of the department, frequency of COVID-19 infection, sources used to obtain information about the disease, enough information about the diagnosis, prognosis, and treatment of COVID-19, death of close relatives with COVID-19, caring for family members with COVID-19.

Existential Anxiety Questionnaire

The researchers used existential anxiety questionnaire developed by Masoudi Sani et al. (2015). The 29-item questionnaire contains four subscales: death anxiety (4, 8, 11, 16, 20, 24, 28), responsibility anxiety (1, 5, 9, 13, 17, 21, 26, 27), loneliness anxiety (2, 6, 10, 14, 18, 22), and meaning anxiety (3, 7, 12, 15, 19, 23, 25). The items are graded on a 4-point scale ranging from one (not at all) to four (very much). The scores vary between 29 and 116, with a low score indicating ignoring existential anxiety and a high score indicating experiencing high existential anxiety. Masoudi Sani et al. used the ICC method to report the content validity (0.95) as well as concurrent and convergent validity of the questionnaire (0.82 and 0.55, respectively). They reported the questionnaire reliability to be 0.82 and 0.86 using Cronbach's alpha and retest method, respectively (6).

Conner-Davidson Resilience Scale (CD-RIS)

This 25-item scale was used to measure nurses’ resilience based on a Likert scale ranging from zero (not true at all) to four (true nearly all of the time). These ratings result in a number between 0-100, and higher scores indicate higher resilience. Conner-Davidson reported the resilience scale to be 0.89 using the Cronbach's alpha coefficient (21). In Iran, Mohammadi et al. (2006) standardized the resilience scale; they confirmed its validity and calculated its reliability (0.89) using Cronbach's alpha coefficient (22).

Posttraumatic growth inventory (PTGI)

Tedeschi and Calhoun (1996) developed this 21-item inventory on a six-point Likert scale ranging from zero (I did not experience this change as a result of my crisis) to five (I experienced this change to a very great degree as a result of my crisis). The scores range from 0 to 105, with the higher score indicating the greater post-traumatic growth. Tedeschi and Calhoun reported the internal consistency of this inventory to be 0.90 (23). In Iran, Heidarzadeh et al. used Cronbach's alpha coefficient to report reliability for the whole inventory (0.87). The reliability of subscales was between 0.55 and 0.75 (24).

1.5. Data collection

The researchers started sampling after obtaining permission from hospitals affiliated to Kerman University of Medical Sciences. They selected nurses working in COVID-19 wards by census. They had to do online sampling due to the spread of COVID-19 and nurses’ insufficient time. First, They prepared an electronic questionnaire, then explained the research objectives to supervisors of each department and invited them to participate in the study. The researchers could access and contact eligible nurses, explained them the research objectives, the research method, and how to fill in the electronic questionnaire. The researchers referred the participants to the questionnaire link to read and sign the consent form; they received the link of the questionnaire on WhatsApp and had enough time to complete it.

2.5. Data analysis

the researchers used SPSS25 trial version to analyze the data. Descriptive statistics (frequency, percentage, mean and standard deviation) were used to describe the background characteristics of nurses, existential anxiety, resilience, and posttraumatic growth. Pearson correlation coefficient was used to determine the relationship between existential anxiety, resilience, and post-traumatic growth. As data were normally distributed with equal variances, independent t and ANOVA tests were employed to compare scores of existential anxiety, resilience, post-traumatic growth, and demographic variables. A significance level of 0.05 was considered.

Socio-demographic characteristics

The researchers invited 288 nurses to participate in the study, but 235 completed the questionnaire (response rate = 81%). 11 incomplete questionnaires were excluded, so 224 nurses participated in this research, with the mean age of 30.88 ± 6.53. Seventy-six point three percent of them were female and 57.6 percent were married. Table 1 illustrates nurses’ demographic information.

Table 1

The distribution of the participants in terms of the demographic characteristics
Variable	N (%)
Gender
Female	171(76.3)
Male	53(23.7)
Marital status
Single	88 (39.3)
Married	129 (57.6)
Divorced	7 (3.1)
Education
Diploma	11 (4.9)
Bachelor	201 (89.7)
Master	12 (5.4)
Name of wards
Emergency ward	115 (51.3)
Infectious	32 (14.3)
Suspected ward	19 (8.5)
General ICU	11 (4.9)
Corona ICU	18 (8.1)
Pulmonary	12 (5.4)
Gastrointestinal	10 (4.5)
Psychiatric	6 (2.7)
Infection with COVID-19
0	73 (32.6)
1	103 (46.0)
2	43 (19.2)
3	5 (2.2)
Having information about corona
No	10 (4.5)
Yes	212 (95.5)
Source of information Iran health ministry	92 (41.1)
WHO	32 (14.4)
Social media	117 (52.5)
Partners	99 (44.4)
In-service training	26 (11.7)
Other ways	21 (9.4)
Family members with corona infection
No	61 (27.4)
Yes	162 (72.6)
Caring for family members
No	29 (13.1)
Yes	193 (86.9)
Death of a family member with COVID-19
No	185 (82.6)
Yes	39 (17.4)

Table 2 indicates the mean scores of existential anxiety and its dimensions, resilience, and post-traumatic growth of nurses working in corona wards. The mean score of existential anxiety was 80.92 ± 9.18, the mean resilience score was 63.51 ± 15.00, and the mean post-traumatic growth score was 87.69 ± 16.55.

Table 2

The descriptive statistics for existential anxiety and its dimensions, resilience, and posttraumatic growth
Variable	Mean ± SD
Existential Anxiety
Death anxiety	20.40 ± 3.14
Responsibility anxiety	22.96 ± 3.81
Loneliness anxiety	15.79 ± 2.50
Meaning anxiety	18.64 ± 2.89
Total	80.92 ± 9.18
Total Resilience	63.51 ± 15.00
Total Posttraumatic Growth	87.69 ± 16.55

Table 3 illustrates the relationship between existential anxiety, resilience, and posttraumatic growth. There were a negative and significant correlation between posttraumatic growth and resilience (P < 0.001, r=-0.38) but no statistically significant relationship between existential anxiety, resilience, and post-traumatic growth (P > 0.005) (Table 3).

Table 3

Correlation between existential anxiety, resilience, and posttraumatic growth
Variable	Existential Anxiety	Resilience	Posttraumatic Growth
Variable	Pearson coloration
Existential Anxiety	1	0.08	-0.09
P Value		0.28	0.20
Resilience	-0.09	1	-0.38
P Value	0.20		< 0.001
Posttraumatic Growth	0.08	-0.38	1
P Value	0.30	< 0.001

Comparison of the scores of existential anxiety, resilience and posttraumatic growth in terms of the demographic characteristics

The researchers noticed a statistically significant correlation between the department and the mean scores of existential anxiety and resilience, so that the mean score of existential anxiety in emergency personnel was higher than that in personnel of corona units, but resilience was higher in those working in other departments than those in emergency department. The result was shown a significant relationship between the death of relatives and existential anxiety, so that the total mean score of anxiety was 84.17 ± 9.09 for those whose one of their relatives died of COVID-19, while it was 80.24 ± 9.09 for those whose one of their relatives did not die of COVID-19 (p < 0.02). There were no statistically significant relationship between other demographic variables and the mean scores of existential anxiety, resilience, and post-traumatic growth (P > 0.05).

The study aimed to investigate the relationship between existential anxiety, resilience, and post-traumatic growth in nurses working in corona wards of the hospitals affiliated to Kerman University of Medical Sciences. The results indicated that the mean score of existential anxiety in nurses was moderate. The results were consistent with the results of Huang et al. (2020) who stated that nurses experienced anxiety, fear, and sadness during the COVID-19 outbreak. The disease was a source of anxiety for different social groups, particularly those who exposed to the disease (25). Silwal et al. (2020) demonstrated high levels of anxiety in nurses (26). Korkmaz et al. (2020) concluded that healthcare workers developed psychological disorders, such as anxiety during the COVID-19 pandemic (27). Sarboozi Hosein Abadi et al. (2020) revealed moderate levels of depression, anxiety, and stress in nurses working in COVID-19 wards in Nohom Day hospital in Torbat Heydarieh (28). Their results and ours suggested moderate prevalence or high level of psychological disorders, particularly anxiety in nurses during the COVID-19 outbreak. Anxiety is the most basic characteristic of crises that disturbs the social and individual life structures (29). Nurses in COVID-19 wards are at risk of developing psychological disorders due to the nature of their work, heavy protective clothing, N-95 masks, and the risk of becoming infected and contaminating others (30). Xuehua et al. considered the following factors that contributed to anxiety in nurses: infection, death of a critically ill patient, prolonged stay away from family, and observation of a stressed patient (31). The results suggested a moderate resilience level among nurses. Some other studies showed a moderate level of resilience among nurses during the COVID-19 pandemic (32–34). Roberts et al. (2021) in the United Kingdom, Luceño-Moreno et al. (2020) in Spain, and Yusefi et al. (2021) found moderate levels of resilience among nurses during the COVID-19 pandemic (35–37). However, Afshari et al. (2021) reported a low resilience score in nurses during the outbreak of COVID-19 (38). The COVID-19 spread had a negative impact on the resilience of people; the sample size, the research population, and the hospital management atmosphere were among the causes of this difference. The researchers recognized that optimal resilience assisted healthcare workers in exhibiting more adaptive behaviors in stressful situations, such as the spread of COVID-19 and the high volume of admitted patients (39), so nurses and doctors could accept the existing conditions and perform at their best (40). Resilience refers to positive patterns of adaptation to adversity and problems that arise over time; nurses with favorable resilience will demonstrate greater flexibility and mental health over time (41). The studies believed that resilient healthcare workers cope with psychological pressures and problems, respond to stressors, deal with daily problems, and show better adaptability in stressful situations, such as the COVID-19 pandemic (42).

The results suggested that nurses experienced high post-traumatic growth during the COVID-19 pandemic. CUI et al. (2020) and PENG et al. (2021) reported a moderate level of posttraumatic growth in nurses (43, 44). Afzali et al. (2020) indicated a moderate level of post-traumatic growth in nurses during the COVID-19 pandemic (45). Their results contradicted our results because the studies were at different times with different research sections. Individuals’ occupations require them to endure their jobs (46–48); nurses always work in difficult conditions and have high burnout (49). Nurses from various departments were among the first to fight against the corona virus. Nurses and doctors were under a lot of pressure because they were unable to treat COVID-19. They witnessed the deaths of many patients and the distress of their families, which led to post-traumatic stress and psychological problems in healthcare workers (50–53). Nurses and other healthcare workers used various methods to deal with these problems and improve the quality of their care during the COVID-19 pandemic; they improved their posttraumatic growth through their communication with others and resilience in the face of illness and death.

The results was shown a negative and significant relationship between post-traumatic growth and resilience- with higher resilience resulting in lower post-traumatic growth- but no statistically significant relationship between existential anxiety, resilience, and post-traumatic growth. Nasirzadeh et al. (2020) reported that although the mean scores of depression, anxiety, and stress decreased with the increase of resilience during the COVID-19 pandemic, they noticed no significant relationship between them (54). Most of the studies did not support our study. Peng et al. (2021) indicated a negative correlation between post-traumatic growth and trait anxiety but a positive correlation between post-traumatic growth and resilience in medical students. Resilience could mediate the relationship between trait anxiety and posttraumatic growth (55). Hernansaiz et al. (2017) reported a negative relationship between anxiety, depression, and resilience; increasing resilience resulted in less anxiety and depression. They found a direct and significant relationship between the scores of anxiety and resilience, as well as a positive and significant correlation between the scores of anxiety, depression, resilience, and stress before diagnosis but no significant correlation between post-traumatic growth and stress scores (56). Barzillay et al. (2020) recognized that an increase in the resilience score resulted a decrease in anxiety and depression among healthcare and non-healthcare workers, and a higher resilience score had an association with less concern about COVID-19. Resilience has a negative effect on post-traumatic growth during the COVID-19 pandemic, because resilient individuals are flexible, adapt to the environmental changes occurred by corona, and quickly recover after the crisis. Therefore, a significant relationship between post-traumatic growth and resilience is expectable.

Limitations

One of the limitations of the present study was the collection of information through social media; therefore, people who did not have access to these resources were unable to respond. Another limitation of the study was the study of a small sample of the country and the nurses of Kerman hospitals, so we should generalize the data with caution.

The results found a negative and significant relationship between post-traumatic growth and resilience-an increase in resilience resulted in a decrease in post-traumatic growth- but no statistically significant relationship between existential anxiety, resilience, and post-traumatic growth. Nurses had moderate existential anxiety and resilience but high post-traumatic growth. The researchers suggest training courses and workshops with the focus on controlling and reducing existential anxiety and promoting resilience during the COVID-19 pandemic to reduce the negative effects of existential anxiety in healthcare workers.

Since the earliest days of the spread of COVID-19, nurses have dealt with this virus; they were away from their families, lacked proper protective equipment, and witnessed the deaths of a large number of patients, resulting in psychological problems that hindered their productivity. In addition to physical and social care, it is necessary to focus on the prolonged psychological dimensions of COVID-19 in nurses in order to promote post-traumatic growth and resilience and reduce existential anxiety among healthcare workers. Limited studies addressed the relationship between resilience, existential anxiety, and post-traumatic growth in nurses during the outbreak of COVID-19, so we were unable to confirm or reject our results. It is necessary to conduct more studies because demographic and cultural factors and governance systems of hospitals can affect the results of studies.

i. Ethical approval and consent to participate

All methods were carried out in accordance with relevant guidelines and regulations of Kerman University of Medical Sciences. .Kerman University of Medical Sciences Ethics committee approved this project (IR.KMU.REC.1400.022). After approval, permission was issued to the management of the hospitals. We provided some oral information, including the goals and objectives of the study, the confidentiality and anonymity of the data, and that the participants were free to withdraw from the study at any time. Then written informed consent was taken individually from all subjects.

ii. Consent to publication

Not applicable

iii.Data Availability statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

iv. Conflict of interests

The authors declare that they have no competing interests

v. Funding

There was no funding for this study.

vi. Acknowledgements

The researchers would like to thank all the nurses for their cooperation.

vii. Authors’ contributions

FR, AGH designed the study. FR, AGH, RM wrote the manuscript. FR, AGH, RM and FM contributed to the study design, they provided critical feedback on the study and statistical analysis, and inputted to the draft of this manuscript. FR, AGH, FM collected data. All authors have read and approved the final manuscript.

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No competing interests reported.

Existential Anxiety of Nurses in the Corona-Virus Units and Its Relation with Resilience and Posttraumatic Growth: A Survey in Southeast Iran

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Introduction

Method

1.1. Study design and setting

1.2. Sampling and sample size

1.4. Questionnaires

1.4.1. Demographic information questionnaire

1.5. Data collection

2.5. Data analysis

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1