This study is novel in that it investigates the factors influencing PTSD among nurses after directly caring for patients with COVID-19. The participants of this study did not directly care for patients with COVID-19 for more than five months after directly caring for them. Our results show that nurse managers’ ability, leadership, and support of nurses, experience of witnessing COVID-19 patients' death, experience of quarantine, level of nurse staffing, and convenience of EHR were significantly associated with PTSD among nurses after providing direct care for patients with COVID-19.
Eighteen percent of nurses still suffered from PTSD for more than five months after directly caring for a COVID-19 patient. A previous study reported that the prevalence of PTSD during COVID-19 accounted for 55% among nurses and 4–72% among healthcare workers [29, 30]. This difference in the prevalence of PTSD is attributable to variability in measurement tools and points depending on whether it is evaluated several months after the traumatic event [31, 32]. In a longitudinal study, the proportion of nurses with PTSD was lower during the stable than during the outbreak periods [31]. A systematic review reported that post-traumatic stress symptoms accounted for 23.4% of healthcare workers in the acute phase but decreased to 11.9% one year after the psychological distress-causing event [33]. Additionally, in the early stages of the COVID-19 pandemic, nurses experienced uncertainty and limited knowledge about newly emerging infectious diseases. However, over time, the prevalence of PTSD may have declined because nurses' perceived that the degree of threat of the disease reduced following the provision of appropriate protective equipment and adequate protection training [31]. Nevertheless, there are nurses who still suffer from PTSD; therefore, these nurses and their mental health condition need to be considered closely.
The results of this study show that nurse managers' ability, leadership, and support of nurses in the current ward were most related to PTSD among nurses who had cared for COVID-19 patients. Nurse managers' ability, leadership, and support of nurses had a buffering effect on PTSD. Social support from supervisors proved helpful in reducing PTSD among nurses [34, 35]. In urgent situations such as the COVID-19 pandemic, the workload of nurse managers to manage the supply of appropriate personnel and supplies is overwhelmingly heavy. Hence, it is recommended that hospitals allocate additional personnel to psychologically support nurses who directly care for COVID-19 patients [36]. Additionally, although it is difficult in an emergency situation, according to this study, proper support and leadership for nurses after a traumatic event can lower PTSD. Hence, it is necessary to prepare strategies at the organizational level so that nurse managers can improve the ability, leadership, and support of nurses.
Among the nurses in this study, those who witnessed the death of their patients had higher PTSD scores than those who did not. A previous study reported that nurses caring for COVID-19 patients who died were associated with a higher risk of suffering from PTSD [17]. Particularly, the death of patients with COVID-19 differs from that of the general population. As patients with COVID-19 are isolated from their families and pass away alone, nurses experience overwhelming loss, grief, shame, helplessness, and powerlessness following the patients’ lonely death [37, 38]. However, the length of the working period in the COVID-19 ward did not appear to influence PTSD symptoms. In other words, the severity of exposure is considered more important than the period of exposure. Most COVID-19 patients complain of cold-like symptoms or require simple oxygen therapy; therefore, the situation of nursing these patients may not have been recognized as a traumatic event. However, while caring for a dying high-risk patient, they experienced the relevance of perceived threats to their health and life [6]. This study identifies quarantine as an independent factor related to PTSD. This is consistent with a previous study [36], in which nurses who had been quarantined recognized their feelings of vulnerability and were shown to be at higher risk for PTSD [6]. When the nurse was quarantined, they suspected that they may have contracted COVID-19 infection. Therefore, interventions to prevent PTSD are needed for nurses who have cared for deceased patients or experienced quarantine.
Consistent with a previous study [17], this study demonstrates that PTSD was significantly higher for nurses who responded that nurse staffing was poor than for those who responded that nurse staffing was good. When nurse staffing is inadequate, they must care for numerous patients and have a high workload. The higher the number of patients, the more the stress the nurse experiences; exposure to this stress is associated with PTSD [17]. Furthermore, nurses who perceived EHR as inconvenient to use exhibited higher PTSD symptoms. As special medical records for patients with newly emerged infectious diseases were not implemented in the originally used EHR, it was not user-friendly or suitable for nurses caring for patients with COVID-19. It is considered to be related to PTSD symptoms because it causes psychological distress when the efficiency of work is low owing to low EHR reliability and low support for cooperation [39]. The availability of appropriate PPE did not appear to be related to PTSD in this study, which is attributable to the fact that the lack of PPE is not serious in Korea. The Korean government prepared a prevention system for infectious diseases after learning from the MERS outbreak [40]. In this study, 46% of the participants stated that they felt there was a lack of PPE. However, in a previous study, nearly all nurses (92.4%) reported having difficulty accessing PPE [39]. This may be because the accessibility of PPE is important. However, the effectiveness of PPE is considered more important in preventing transmission. Previous research shows that the perception of low security while using PPE is associated with higher PTSD, but not with a lack of PPE access [41]. We noted that participants working in the COVID-19 ward with poorer staffing and an unstable EHR were at higher risk of developing PTSD, which highlights the importance of organizational support for a proper working environment.
Our study has several limitations. As this is a cross-sectional study using subjective questionnaires in some hospitals in Korea, generalization is limited, causality cannot be identified, and there may be recall bias. Additionally, although the survey was conducted among nurses several months after directly caring for COVID-19 patients, there are limitations in assuming that it is a fully post-COVID-19 situation because the pandemic is ongoing. However, at the time of the survey, the participants were caring only for non-COVID-19 patients in hospitals where COVID-19 patients were not hospitalized. Furthermore, after the first wave, when the number of confirmed cases of COVID-19 increased rapidly, Daegu did not experience a second wave of COVID-19, unlike other Korean cities [42].