DOI: https://doi.org/10.21203/rs.3.rs-2680058/v1
Nurses are particularly at risk of suffering from post-traumatic stress disorder (PTSD) owing to their overwhelming workload, risk of infection, and lack of knowledge about the coronavirus disease 2019 (COVID-19). PTSD negatively affects an individual’s health, work performance, and patient safety. This study aims to assess factors related to PTSD among nurses after directly caring for patients with COVID-19.
This study is a secondary analysis aimed at identifying factors influencing PTSD among nurses who directly cared for COVID-19 patients. Data from 168 nurses, collected between October and November 2020, were analyzed. The independent variables were personal, interpersonal, and organizational and COVID-19-related factors (experience of quarantine and direct care of patients with COVID-19), and the dependent variables were PTSD symptoms evaluated based on the PTSD Checklist-5. The nurses’ experience of direct care for COVID-19 patients in the designated COVID-19 isolation wards during the first wave of the pandemic (February 2020 to May 2020) were included.
Among the nurses, 18.5% exhibited symptoms of PTSD. When directly caring for a patient in the designated COVID-19 isolation ward, nurses witnessing the death of a patient (p = .001), low level of nurse staffing (p = .008), and inconvenience of electronic health (p = .034) were associated with PTSD symptoms. The experience of quarantine owing to COVID-19 was also associated with PTSD symptoms (p = .034). Additionally, the higher the nurse managers’ ability, leadership, and support of nurses in the current ward, the higher the possibility of lowering nurses’ PTSD symptoms (p = .006).
Governments and hospitals should prepare and implement organizational intervention programs to improve nurse manager leadership, nurse staffing levels, and electronic health records programs. Additionally, because nurses who have witnessed the death of a COVID-19 patient or who are self-isolating are vulnerable to PTSD, psychological support should be provided.
Coronavirus disease 2019 (COVID-19) was first detected among patients with pneumonia in December 2019 in Wuhan, China [1]. COVID-19 has spread rapidly in many countries and regions [2]. South Korea’s first large outbreak in February 2020 occurred in a church in Daegu [3].To handle the surging demand for hospital care at the onset of the outbreak, the government recruited additional healthcare workers in Daegu [3]. Research shows that healthcare workers may experience psychological stress as a result of their overwhelming workload, insufficient psychological preparation, and lack of understanding of COVID-19 in the early stages [4].
Post-traumatic stress disorder (PTSD) is a psychiatric disorder that can affect people who have experienced or witnessed a traumatic event [5]. Healthcare workers are particularly at risk of suffering from PTSD owing to highly stressful work-related situations, such as witnessing death, trauma, working overtime, and overcrowded settings [6, 7]. Frontline healthcare workers may experience feelings of trauma owing to fear of infection, shortage of self-protection equipment, heavy work overload, and lack of knowledge about COVID-19 [8, 9]. PTSD rates of 36.5% have been reported for healthcare workers who directly care for COVID-19 patients, and 27.3% for those providing care indirectly [10]. Nurses are more closely connected to patients and face traumatic situations [11]. The prevalence of PTSD among nurses is higher than that among other healthcare workers [4, 10, 12]. PTSD may significantly affect mental, emotional, and physical health [13]. Additionally, PTSD is associated with increased turnover intention, diminished concentration, and cognitive ability, which results in medication errors and disrupts work performance, which can consequently affect patient safety and the healthcare organization [14–16]. There is a need to come up with a strategy to mitigate the harmful effect of PTSD and promote nurses’ well-being and quality of patient care [16].
Predictors of PTSD are important for identifying those who may be at risk of developing PTSD. Organizational, interpersonal, and intrapersonal factors influence PTSD among nurses [13]. A previous systematic review investigated the risk factors related to PTSD involved in coronavirus outbreaks of severe acute respiratory syndrome (SARS), middle east respiratory syndrome (MERS), and COVID-19 [6]. Some variables were risk and resilience factors, including age, gender, marital status, working role, years of work experience, exposure level, quarantine, social and work support, job organization, and coping styles [6]. A previous study shows that working in COVID-19 units, inadequate nurse staffing [17], and nurse manager leadership [18] were related to higher PTSD among hospital nurses during the COVID‑19 outbreak.
Infectious disease pandemics are expected to cause anticipated worry and PTSD after outbreaks [7, 19]. Considering potential post-COVID-19 issues, it is necessary to establish management strategies for PTSD among nurses after directly dealing with COVID-19 patients. The spread of COVID-19 was identified in Daegu in February 2020 and hospitals were designated as COVID-19 isolation wards for COVID-19 patients. As the caseload decreased in Daegu in May 2020, some hospitals ceased to operate as COVID-19 isolated wards and began accepting only non-COVID-19 patients. COVID-19 patients were transferred to another designated hospital [20]. Since nurses working in non-COVID-19 hospitals can be considered to be in a post-traumatic situation after directly caring for COVID-19 patients, they can be examined to identify PTSD-related factors in the post-COVID period.
This study aims to investigate factors related to PTSD among nurses who directly cared for patients with COVID-19. Based on an integrative review of PTSD among nurses, we included interpersonal, intrapersonal, and organizational [13], as well as COVID-19 related factors.
This study is a secondary analysis that aims to identify the factors affecting PTSD among nurses who directly cared for patients with COVID-19. Data from a previous study [18] was analyzed for this purpose.
The subjects of Bae et al.'s study [18] included 365 nurses who worked at three private tertiary hospitals that operated designated COVID-19 isolation wards from February to May 2020 during the COVID-19 epidemic in Daegu. The subjects of this study were 168 nurses who directly cared for patients, excluding 3 who performed administrative duties among the 171 who worked in the designated COVID-19 isolation ward.
In three private tertiary hospitals, designated COVID-19 isolation wards were operated from February to May 2020 and then terminated. The nurses in these hospitals, who are chosen as the subjects of the study, were caring for non-COVID-19 patients.
Intrapersonal and interpersonal characteristics included age, work experience, gender, marital status, cohabitation status, and educational level.
The nursing work environment, an organizational characteristic, referred to the ward where nurses worked from October to November 2020 when the survey was conducted and was not a characteristic of designated COVID-19 isolation wards whose operation ended in May 2020.
Organizational characteristics were evaluated using the Korean version of the Practice Environment Scale of Nursing Work Index (PES-NWI) [21], which is a translation of the Nursing Work Index [22]. PES-NWI measures a total of 29 items in 5 subscales: nurses’ participation in hospital work (9 items), nursing basis for quality of care (9 items), competence, leadership, and nurse support of nurse managers (4 items), adequacy of manpower and resources (4 items), and college nurse–physician relationship (3 items). Each item is rated on a 4-point Likert scale (1 = ‘not at all’ to 4 = ‘absolutely’); the higher the average score of the subscales, the better. At the time of the tool development, the Cronbach's alpha values of the subscales were 0.71–0.84 [22], and the Cronbach's alpha values of the Korean tools were 0.80–0.84 [21].
COVID-19-related experiences included quarantine and working in a designated COVID-19 isolation ward. Included in the latter were training and orientation of infection control, level of nurse staffing, availability of personal protective equipment (PPE), convenience of electronic health records (EHR), experience of witnessing COVID-19 patient death, and the length of working period in the COVID-19 isolation ward.
PTSD was evaluated using the PTSD Checklist-5 (PCL-5) [23], which Park [24] translated into Korean. The PCL-5 is a measurement tool developed to meet the PTSD diagnosis criteria of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). The PCL-5 comprises four subscales (a total of 20 items) namely aggression (5 items), avoidance (2 items), negative changes in perception and emotion (7 items), and irritability (6 items). Each item is rated on a 5-point Likert scale (0 points for 'not at all' to 4 points for 'very much so'), with a total score of 0 to 80 points. The cutoff point was 33 points; a higher score corresponds to the PTSD diagnostic criteria [25]. The Cronbach's alpha value of the original tool was .94 [26], and the Cronbach's alpha value of the Korean PCL-5 was .91–.93 [27].
This study was approved by the ethics committee of the university affiliated to the first author. All data were computerized to avoid subject identification
Nurses’ intrapersonal, interpersonal, organizational, and COVID-19-related characteristics were analyzed using descriptive statistics. The relationship between the subject's characteristics and PTSD was analyzed using the t-test and Pearson's test according to the variable characteristics. Regression analysis was performed to analyze the factors affecting PTSD. The analysis was performed using SAS 9.4 version (SAS Institute, Cary, NC, USA).
The average age of the nurses was 31.47 ± 9.25 years and the median age was 28 years. Their mean work experience was 8.91 ± 9.53 years and median were 4 years. Most participants were women (96.4%), unmarried (70.2%), living with family (85.7%), and had a bachelor’s degree in nursing or higher (85.1%) (Table 1).
| n (%) or Mean ± SD | |
|---|---|
| Intrapersonal and Interpersonal characteristics | |
| Age (years) | 31.47 ± 9.25 |
| Below the median (< 28) | 80 (47.6) |
| Above the median (≥ 28) | 88 (52.4) |
| Work experience (years) | 8.91 ± 9.53 |
| Below the median (< 4) | 83 (49.4) |
| Above the median (≥ 4) | 85 (50.6) |
| Gender | |
| Male | 6 (3.6) |
| Female | 162 (96.4) |
| Marital status | |
| Unmarried | 118 (70.2) |
| Married | 50 (29.8) |
| Cohabitation status | |
| Living alone | 24 (14.3) |
| Living with family | 144 (85.7) |
| Education level | |
| Associate’s degree or lower | 25 (14.9) |
| Bachelor’s degree or higher | 143 (85.1) |
| Organizational characteristic | |
| Nursing work environments | 2.47 ± 0.40 |
| Nurse participation in hospital affairs | 2.33 ± 0.47 |
| Nursing foundations for quality of care | 2.68 ± 0.41 |
| Nurse managers’ ability, leadership, and support of nurses | 2.69 ± 0.54 |
| Staffing and resource adequacy | 2.24 ± 0.62 |
| Collegial nurse-physician relations | 2.27 ± 0.61 |
| COVID-19-related characteristic | |
| Experience of quarantine | |
| No | 123 (73.2) |
| Yes | 45 (26.8) |
| Training/orientation of infection control | |
| No | 82 (48.8) |
| Yes | 86 (51.2) |
| Level of nurse staffing | |
| Appropriate | 98 (58.3) |
| Inappropriate | 70 (41.7) |
| Availability of PPE | |
| Appropriate | 90 (53.6) |
| Inappropriate | 78 (46.4) |
| Convenience of EHR | |
| Convenience | 58 (34.5) |
| Inconvenience | 110 (65.5) |
| Experience of witnessing COVID-19 patient death | |
| No | 124 (73.8) |
| Yes | 44 (26.2) |
| Length of working period in the COVID-19 isolation ward | 26.61 ± 18.31 |
| PTSD | 15.77 ± 16.57 |
| ≤ 33 | 137 (81.5) |
| > 33 | 31 (18.5) |
| Note: COVID-19 = Coronavirus disease 2019; EHR = Electronic health records; PPE = Personal protective equipment; PTSD = Post-traumatic stress disorder; SD = Standard deviation | |
Insert Table 1 here
The overall average PES-NWI was 2.47 ± 0.40. Regarding the average of the five subcategories, nurse managers' ability, leadership, and support of nurses scored the highest with 2.69 ± 0.54, followed by nursing foundations for quality of care at 2.68 ± 0.41 and nurse participation in hospital affairs at 2.33 ± 0.47; collegial nurse-physician relations scored 2.27 ± 0.61, and staffing and resource adequacy scored the lowest with 2.24 ± 0.62.
A proportion of 26.8% of the nurses underwent quarantine owing to COVID-19. The experiences of nurses in the designated COVID-19 isolation ward operating from February to May 2020 were as follows: more than half of all nurses underwent training or orientation of infection control (51.2%), and recognized that the level of nurse staffing was appropriate (58.3%), and the availability of PPE was appropriate (53.6%). One-third of all the nurses (65.5%) stated that EHR was inconvenient, and 26.2% stated that the COVID-19 patient they cared for died. The average length of days nurses they worked in the designated COVID-19 isolation ward was 26.61 ± 18.31.
Among the nurses, 18.5% exhibited PTSD symptoms, with a PCL-5 score of 34 points or more (Table 1). The t-test showed that nurses' PTSD- and COVID-19-related characteristics were statistically significant (Table 2). Nurses who perceived an inappropriate level of nurse staffing in the designated COVID-19 isolation ward (p = .006) or the EHR as inconvenient (p = .021), or witnessed COVID-19 patient death (p = .003) exhibited statistically significantly higher PTSD than nurses who did not. Nurse managers' ability, leadership, and support of nurses, which are subscales of the nursing work environment, and PTSD, were statistically significantly correlated (p = .023) (Table 3).
| Mean ± SD | t | p | |
|---|---|---|---|
| Intrapersonal and Interpersonal characteristics | |||
| Age (years) | |||
| Below the median (< 28) | 13.65 ± 16.40 | -1.59 | .114 |
| Above the median (≥ 28) | 17.69 ± 16.58 | ||
| Work experience (years) | |||
| Below the median (< 4) | 14.98 ± 17.42 | -0.61 | .542 |
| Above the median (≥ 4) | 16.54 ± 15.75 | ||
| Gender | |||
| Male | 4.33 ± 7.76 | -1.73 | .085 |
| Female | 16.19 ± 16.67 | ||
| Marital status | |||
| Unmarried | 14.39 ± 15.91 | -1.66 | .098 |
| Married | 19.02 ± 17.76 | ||
| Cohabitation status | |||
| Living alone | 15.54 ± 17.51 | -0.07 | .943 |
| Living with family | 15.81 ± 16.47 | ||
| Education level | |||
| Associate’s degree or lower | 11.92 ± 15.54 | -1.26 | .209 |
| Bachelor’s degree or higher | 16.44 ± 16.70 | ||
| COVID-19-related characteristic | |||
| Experience of quarantine | |||
| No | 14.37 ± 15.83 | -1.83 | .070 |
| Yes | 19.60 ± 18.07 | ||
| Training/orientation of infection control | |||
| No | 14.93 ± 16.08 | -0.64 | .522 |
| Yes | 16.57 ± 17.08 | ||
| Level of nurse staffing | |||
| Appropriate | 18.71 ± 17.59 | 2.78 | .006 |
| Inappropriate | 11.64 ± 14.14 | ||
| Availability of PPE | |||
| Appropriate | 17.40 ± 16.45 | 1.38 | .171 |
| Inappropriate | 13.88 ± 16.61 | ||
| Convenience of EHR | |||
| Convenience | 19.83 ± 18.33 | 2.34 | .021 |
| Inconvenience | 13.63 ± 15.21 | ||
| Experience of witnessing COVID-19 patient death | |||
| No | 13.22 ± 14.94 | -3.10 | .003 |
| Yes | 22.95 ± 18.87 | ||
| Length of working period in the COVID-19 isolation ward | |||
| Below the median | 16.50 ± 17.90 | 0.54 | .587 |
| Above the median | 15.10 ± 15.33 | ||
| Note: COVID-19 = Coronavirus disease 2019; EHR = Electronic health records; PPE = Personal protective equipment; PTSD = Post-traumatic stress disorder; SD = Standard deviation | |||
| PTSD | |
|---|---|
| Nursing work environments | -0.131 |
| .092 | |
| Nurse participation in hospital affairs | -0.075 |
| .332 | |
| Nursing foundations for quality of care | -0.110 |
| .156 | |
| Nurse managers’ ability, leadership, and support of nurses | -0.176 |
| .023 | |
| Staffing and resource adequacy | -0.120 |
| .120 | |
| Collegial nurse-physician relations | -0.066 |
| .397 | |
| Note: PTSD = Post-traumatic stress disorder | |
Insert Table 2 here
Insert Table 3 here
The basic hypotheses of multicollinearity and autocorrelation were tested before performing the regression analysis. Multicollinearity was found, with variance inflation factors ranging from 1.11 3.46. Therefore, we concluded that multicollinearity was not a problem in the data [28]. The Durbin–Watson value was 1.94, indicating no autocorrelation.
Nurses who perceived that the nursing manager's ability in the current ward was leadership and support had a statistically significantly lower PTSD score and were found to be the most influential (β = -0.275, p = .006).
Apparently, past experience of working in a dedicated COVID-19 ward significantly influenced PTSD among nurses (Table 4). The nurse whose patient in charge had died was most affected (β = 0.246, p = .001), followed by those who recognized the inappropriateness of the nurse staffing level (β = 0.205, p = .008), and the nurses who perceived discomfort with the computer program (β = 0.162, p = .034). Additionally, nurses who had undergone quarantine were also found to be significant (β = 0.167, p = .034).
| B | SE | β | t | p | |
|---|---|---|---|---|---|
| Intrapersonal and Interpersonal characteristics | |||||
| Years of experience | 0.262 | 0.227 | 0.151 | 1.153 | .251 |
| Female | 9.163 | 6.567 | 0.103 | 1.395 | .165 |
| Married | 1.568 | 4.628 | 0.043 | 0.339 | .735 |
| Living with family | -0.373 | 3.505 | -0.008 | -0.106 | .915 |
| Bachelor’s degree or higher | 2.657 | 3.463 | 0.057 | 0.767 | .444 |
| Organizational characteristic | |||||
| Nurse participation in hospital affairs | 3.990 | 4.215 | 0.113 | 0.947 | .345 |
| Nursing foundations for quality of care | 2.378 | 4.700 | 0.059 | 0.506 | .614 |
| Nurse managers’ ability, leadership, and support of nurses | -8.420 | 2.990 | -0.275 | -2.816 | .006 |
| Staffing and resource adequacy | -1.648 | 2.399 | -0.062 | -0.687 | .493 |
| Collegial nurse-physician relations | -0.555 | 2.721 | -0.020 | -0.204 | .839 |
| COVID-19-related characteristic | |||||
| Experience of quarantine | 6.236 | 2.906 | 0.167 | 2.146 | .034 |
| Training/orientation of infection control | 0.679 | 2.513 | 0.021 | 0.270 | .787 |
| Inappropriate of level of nurse staffing | 6.881 | 2.565 | 0.205 | 2.682 | .008 |
| Inappropriate of availability of PPE | 2.407 | 2.579 | 0.073 | 0.933 | .352 |
| Inconvenience of EHR | 5.638 | 2.638 | 0.162 | 2.137 | .034 |
| Experience of witnessing COVID-19 patient death | 9.232 | 2.800 | 0.246 | 3.297 | .001 |
| Length of working period in the COVID-19 isolation ward | 0.042 | 0.071 | 0.047 | 0.589 | .557 |
| R2 | 0.262 | ||||
| Adj R2 | 0.179 | ||||
| F | 3.14 | ||||
| P | < .001 | ||||
| Durbin-Watson | 1.943 | ||||
| Note: COVID-19 = Coronavirus disease 2019; EHR = Electronic health records; PPE = Personal protective equipment; PTSD = Post-traumatic stress disorder | |||||
Insert Table 4 here
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].
We analyze factors influencing PTSD among nurses who directly cared for COVID-19 patients after the COVID-19 pandemic. Consequently, nurse managers’ ability, leadership, and support of nurses in the ward after the COVID-19 pandemic significantly influenced PTSD symptoms among nurses. When directly caring for COVID-19 patients, nurses were more likely to develop PTSD symptoms if the level of nurse staffing was low or if the EHR was inconvenient. Accordingly, hospitals should prepare and implement organizational intervention programs for the leadership of nurse managers, level of nurse staffing, and EHR program. Additionally, because the COVID-19 patient whom the nurse took care of died, or the nurse who was quarantined was vulnerable to PTSD symptoms, the corresponding nurse should be provided with psychological and psychiatric support. Especially, further research is needed to develop interventions to cultivate nurse managers' ability, leadership, and support of nurses, as well as interventions to support nurses, and to confirm the effectiveness of such interventions.
COVID-19: Coronavirus disease 2019; DSM-5: Diagnostic and statistical manual of mental disorders, fifth edition; EHR: Electronic health records; MERS: Middle east respiratory syndrome; PCL-5: Post-traumatic stress disorder checklist-5; PPE: Personal protective equipment; PTSD: Post-traumatic stress disorder; SARS: Severe acute respiratory syndrome
Ethics approval and consent to participate:
The study was approved by the institutional review board of Jeonbuk National University (NO. JBNU 2023-01-009). Written informed consent was obtained from all participants. The procedures were conducted per the ethical standards of the 1964 Declaration of Helsinki.
Consent for publication: Not applicable
Availability of data and materials:
The datasets analyzed during the current study are available from the corresponding author on reasonable request.
Competing interests:
The authors declare that they have no competing interests
Funding: Not applicable
Authors’ contribution:
The authors confirm contribution to the paper as follow: study conception and design: HY, SB, JB; data collection: HY, SB; analysis and interpretation of results: HY, JB; Draft manuscript preparation and edit: HY, SB, JB. All authors reviewed the results and approved the final version of the manuscript.
Acknowledgement: Not applicable