Prevalence and correlates of severe anxiety among front-line nurses during and after the COVID-19 pandemic: A large-scale multi-center study

doi:10.21203/rs.3.rs-4810727/v1

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Research Article

Prevalence and correlates of severe anxiety among front-line nurses during and after the COVID-19 pandemic: A large-scale multi-center study

https://doi.org/10.21203/rs.3.rs-4810727/v1

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Background

Nurses have been at the forefront of the battle against the COVID-19 pandemic, facing extended work hours and heightened stress, predisposing them to psychological distress. This study aims to investigate the prevalence and correlates of severe anxiety among frontline nurses in China during and after the COVID-19 pandemic.

Methods

A large-scale multi-center survey was conducted from November to December 2022 and from April to July 2023. Data were collected using online surveys, covering demographic characteristics, job-related factors, anxiety, depression, and sleep disorders. Statistical analyses, including chi-square tests, t-tests, and logistic regression, were performed to assess the incidence and factors influencing severe anxiety.

Results

The study included 816 nurses during the pandemic and 763 nurses after the pandemic. The prevalence of severe anxiety during the pandemic (52.3%) was significantly higher than after the pandemic (8.0%). Factors such as nursing title, night shift frequency, educational level, exercise frequency, COVID-19 infection status, economic pressure, and work pressure showed significant differences between the two periods. Binary logistic regression revealed associations between severe anxiety and factors such as night shift frequency, COVID-19 infection status, nursing title, depression, and sleep disorders. Receiver Operating Characteristic analysis demonstrated good predictive value for severe anxiety.

Conclusion

The study underscores the importance of understanding and addressing severe anxiety among frontline nurses during and after the COVID-19 pandemic. Future research should delve into long-term psychological effects and implement effective intervention measures to support nurses' mental health.

Severe anxiety

Front-line nurses

COVID-19 pandemic

Multi-center survey

Mental health

Nurses play a crucial role during the COVID-19 pandemic [1]. They are directly involved in combating the pandemic, often working extended hours and night shifts, which predisposes them to psychological distress [2]. Furthermore, the prevalence of mental health issues among nurses is higher than the general population [3]. Therefore, nurses' mental health problems during the COVID-19 pandemic are significant. For instance, approximately 24.5%-37% of clinical nurses reported anxiety during the peak of the pandemic [4, 5], a situation persisting into the later stages [6, 7].

Clinical nurses often experience anxiety [4, 7], notably surpassing other healthcare workers throughout the pandemic [8]. Exposure to COVID-19, female gender, fear of infection or infecting others, and social support with less were identified as the main sources of anxiety experienced by frontline nurses [9]. Severe anxiety can affect frontline nurses' work efficiency, decrease job satisfaction, and increase willingness to leave the profession [10, 11]. Hence, understanding the incidence of severe anxiety among nurses is crucial for enhancing their well-being and professional efficiency.

Mounting evidence suggests that the psychological impact of the COVID-19 pandemic is enduring [12, 13]. Thus, the concept of Long-COVID or post-COVID syndrome has been proposed [13, 14]. It defines the persistent effects people continue to experience after the COVID-19 pandemic, such as anxiety, depression, respiratory symptoms, fatigue, headaches, and insomnia [15, 16]. However, to our knowledge, no previous studies have specifically compared the incidence of severe anxiety among nurses in China during and after the pandemic. Therefore, we conducted a multicenter investigation in which frontline nurses were recruited during and after the COVID-19 pandemic, respectively. The main objectives of the current study were: 1. to compare the prevalence of severe anxiety among Chinese nurses during the COVID-19 pandemic and after the pandemic; and 2. to explore the risk factors affecting severe anxiety among frontline nurses.

2.1 Study Design

This study is a large-scale multicenter investigation aimed at examining the incidence of severe anxiety and related factors among frontline nurses in China during and after the COVID-19 pandemic. The study design followed the STROBE guidelines for observational studies.

We collected data on demographic characteristics, sleep disorders, depression, and anxiety using the "Wenjuanxing" online survey platform. Prior to the survey, informed consent was obtained from each participant. This study adhered to the ethical standards outlined in the 1964 Helsinki Declaration and its subsequent amendments. The study protocol was approved by the Institutional Review Board (IRB) of Tianjin Mental Health Center (Approval No: 2023-028).

2.2 Participants

The study was conducted in 27 provinces of China from November to December 2022 and from April to July 2023, recruiting frontline nurses. Unlike other countries, China was still in the midst of the COVID-19 pandemic from November to December 2022. April to July 2023 marked the period after the peak of the COVID-19 pandemic.

Inclusion criteria: (1) Nurses working on the frontline during and after the COVID-19 pandemic; (2) Voluntary participation in the study. Exclusion criteria: (1) Lack of nursing qualifications; (2) Absence due to pregnancy or various reasons; (3) Refusal to participate in the study. During the COVID-19 pandemic, we recruited 1,153 nurses. Follow-up assessments were conducted with these nurses after the pandemic. The study flowchart is shown in Fig. 1.

2.3 Assessment Measures

We utilized a self-designed general demographic questionnaire, covering nurses' demographic characteristics, job characteristics, and perceptions of the impact of the COVID-19 pandemic on their lives and work. For example, the definition of weekly exercise frequency was: exercising for more than 30 minutes per session was considered as one instance of exercise; 0 indicated never exercising, 1–2 times per week, and 3 times or more per week. High economic pressure and high work pressure were primarily based on nurses' self-reports. Additionally, we investigated whether nurses felt that COVID-19 disrupted their lives and whether they were worried that clinical work could lead to COVID-19 infection.

PSQI was used to assess sleep disorders [17]. PSQI comprises 19 questions divided into seven components: sleep duration, sleep disturbances, sleep onset latency, subjective sleep quality, sleep efficiency, daytime dysfunction, and use of sleep medications. Each component has a score ranging from 0 to 3, with the total PSQI score ranging from 0 to 21. A total PSQI score ≥ 8 indicates sleep disorders [18]. Anxiety was measured using the Zung Self-Rating Anxiety Scale (SAS) [19], and depression was measured using the Self-Rating Depression Scale (SDS) [20]. The cutoff values for SAS and SDS were 50 [21] and 40 [22], respectively. Severe anxiety was defined as a standard SAS score ≥ 70 [21].

2.4 Statistical Analysis

Statistical analysis was performed using SPSS 23.0. Categorical variables were presented as frequencies and percentages, while continuous variables were presented as means (M) and standard deviations (SD). Comparisons between categorical variables during and after the COVID-19 pandemic were conducted using the chi-square test, and comparisons between continuous variables were conducted using the t-test. Significance was set at P < 0.05, with Bonferroni correction applied. Binary logistic regression analysis was used to assess the influence of different factors on severe anxiety, with the presence of severe anxiety as the dependent variable and factors showing significant differences in the chi-square test or t-test as independent variables. Results were expressed as odds ratios (OR) and 95% confidence intervals (95% CI). Receiver Operating Characteristic (ROC) analysis was performed using GraphPad Prism 9.0 to evaluate the predictive value of relevant variables for severe anxiety.

3.1 Comparison of Severe Anxiety among Nurses during and after the COVID-19 Pandemic

A total of 816 nurses working during the COVID-19 pandemic and 763 nurses recruited after the pandemic were included. The results revealed that the incidence of severe anxiety among nurses during the COVID-19 pandemic was significantly higher than that after the pandemic (52.3% vs. 8.0%, P < 0.001). As shown in Table 1, significant differences were observed between nurses during and after the COVID-19 pandemic in terms of nursing title, monthly night shift frequency, educational level, weekly exercise frequency, COVID-19 infection status, severe economic pressure, severe work pressure, and life disruption (P < 0.01). For example, after the COVID-19 pandemic, there was a significant decrease in the frequency of night shifts, exercise frequency, and COVID-19 infection rate among nurses (P < 0.01). However, the proportion of nurses who believed that COVID-19 disrupted their lives significantly increased (52.0% vs. 78.6%, P < 0.001).

Table 1

Comparison of nurses' severe anxiety during and after the COVID-19 epidemic
Variables		During the COVID-19 epidemic	After the COVID-19 epidemic	x²	P
Nurse title	Assistant nurse	266 (32.6%)	190 (24.9%)	13.296	0.001
	Nurse practitioner	280 (34.3%)	268 (35.1%)
	Nurse-in-charge and above	270 (33.1%)	305 (40.0%)
Gender	Male	410 (50.2%)	381 (49.9%)	0.015	0.902
Gender	Female	406 (49.8%)	382 (50.1%)	0.015	0.902
Frequency of night shifts per month	< 5	279 (34.2%)	287 (37.6%)	37.037	< 0.001
	5–10	274 (33.6%)	330 (43.3%)
	> 10	263 (32.2%)	146 (19.1%)
Academic qualifications	Associate college and below	271 (33.2%)	191 (25.0%)	136.611	< 0.001
	Bachelor's degree	302 (37.0%)	490 (64.2%)
	Postgraduate and above	243 (29.8%)	82 (10.7%)
Frequency of exercise per week	0	278 (34.1%)	316 (41.4%)	39.861	< 0.001
	1–2	265 (32.5%)	299 (39.2%)
	≥ 3	273 (33.5%)	148 (19.4%)
Personality trait	Extraversion	426 (52.2%)	428 (56.1%)	2.401	0.121
Personality trait	Introversion	390 (47.8%)	335 (43.9%)	2.401	0.121
COVID-19 virus infection status	No	218 (20.0%)	139 (28.5%)	110.992	< 0.001
COVID-19 virus infection status	Under infection	873 (80.0%)	349 (71.5%)	110.992	< 0.001
High economic pressure	No	407 (49.9%)	194 (25.4%)	99.999	< 0.001
High economic pressure	Yes	409 (50.1%)	569 (74.6%)	99.999	< 0.001
High work pressure	No	426 (52.2%)	220 (28.8%)	89.102	< 0.001
High work pressure	Yes	390 (47.8%)	543 (71.2%)	89.102	< 0.001
Disruption of life	No	392 (48.0%)	163 (21.4%)	123.098	< 0.001
Disruption of life	Yes	424 (52.0%)	600 (78.6%)	123.098	< 0.001
Worried about potential infection	No	414 (50.7%)	403 (52.8%)	0.685	0.408
Worried about potential infection	Yes	402 (49.3%)	360 (47.2%)	0.685	0.408
Severe anxiety	No	389 (47.7%)	702 (92.0%)	362.927	< 0.001
Severe anxiety	Yes	427 (52.3%)	61 (8.0%)	362.927	< 0.001
Note: The question of “Disruption of life”: Has your life been disrupted by COVID-19? Bolding indicates P < 0.05.

3.2 Comparison of SAS, SDS, and PSQI Scores among Nurses during and after the COVID-19 Pandemic

The comparison of SAS, SDS, and PSQI scores among nurses during and after the COVID-19 pandemic is presented in Table 2. The SAS and SDS scores of nurses after the COVID-19 pandemic were significantly lower than those during the pandemic (P < 0.001). Furthermore, the total PSQI score, subjective sleep quality, sleep duration, severe anxiety, and sleep medication scores of nurses after the COVID-19 pandemic were significantly lower than those during the pandemic (P < 0.01). After Bonferroni correction, significant differences still existed in SAS scores, SDS scores, total PSQI scores, sleep duration, severe anxiety, and sleep medication scores (P Bonferroni < 0.05/10 = 0.005).

Table 2

Comparison of SAS, SDS, and PSQI scores of nurses during and after the COVID-19 epidemic (Mean ± SD)
Variables	During the COVID-19 epidemic	After the COVID-19 epidemic	t	P
SAS scores	69.60 ± 5.02	51.37 ± 12.21	39.252	< 0.001
SDS scores	62.46 ± 4.69	55.43 ± 12.76	14.716	< 0.001
Subjective sleep quality	1.35 ± 1.00	1.49 ± 1.08	-2.709	0.007
Sleep latency	1.64 ± 0.76	1.68 ± 0.93	-0.916	0.360
Sleep duration	1.55 ± 1.02	1.28 ± 0.85	5.801	< 0.001
Habitual sleep efficiency	1.20 ± 0.75	1.17 ± 0.76	0.874	0.382
Sleep disorder	1.89 ± 0.38	1.52 ± 0.76	12.156	< 0.001
Sleep medications	1.44 ± 1.00	0.59 ± 0.89	17.957	< 0.001
Daytime dysfunction	1.59 ± 0.73	1.59 ± 1.05	-0.036	0.971
PSQI total scores	10.66 ± 2.53	9.32 ± 4.69	7.155	< 0.001
Note: SAS, Self-rating Anxiety Scale; SDS, Self-rating Depression Scale; PSQI, Pittsburgh Sleep Quality Index. Bolding indicates P < 0.05.

3.3 Factors Influencing Severe Anxiety

To further assess the relationship between severe anxiety (SAS ≥ 70) and factors with significant statistical differences, binary logistic regression analysis was conducted. As shown in Table 3, binary logistic regression analysis was performed on the covariates of severe anxiety. The results showed that during the COVID-19 pandemic, nurses with more than 10-night shifts per month had a 1.520 times higher risk of severe anxiety compared to those with less than 5-night shifts per month (OR = 1.520, 95% CI 1.074–2.152). Interestingly, nurses infected with COVID-19 had a 0.711 times lower risk of severe anxiety compared to those not infected (OR = 0.711, 95% CI 0.528–0.958).

Table 3

Logistic regression analysis of the influencing factors of nurses' severe anxiety
Influence factors	During the COVID-19 epidemic			After the COVID-19 epidemic
Influence factors	B	P	OR (95%CI)	B	P	OR (95%CI)
Constant	-0.748	0.471	0.473	-10.088	< 0.001	< 0.001
Nurse title (Assistant nurse)			Ref.			Ref.
Nurse practitioner	0.068	0.700	1.070 (0.758–1.511)	-0.264	0.502	0.768 (0.355–1.660)
Nurse-in-charge (and above)	0.065	0.710	1.067 (0.758–1.501)	-0.821	0.028	0.440 (0.211–0.916)
Frequency of night shifts per month (< 5)			Ref.
5–10	-0.050	0.776	0.951 (0.674–1.342)	-0.327	0.437	0.721 (0.316–1.645)
> 10	0.419	0.018	1.520 (1.074–2.152)	-0.196	0.606	0.822 (0.391–1.730)
Academic qualifications (Associate college and below)			Ref.
Bachelor's degree	0.210	0.244	1.234 (0.866–1.758)	-0.272	0.564	0.762 (0.303–1.917)
Postgraduate and above	0.029	0.867	1.030 (0.730–1.453)	-0.713	0.138	0.490 (0.191–1.258)
Frequency of exercise per week (0)			Ref.
1–2	-0.274	0.117	0.760 (0.539–1.071)	0.016	0.971	1.016 (0.437–2.359)
≥ 3	-0.190	0.284	0.827 (0.584–1.171)	-0.034	0.939	0.967 (0.403–2.317)
COVID-19 virus infection status (No infection)	-0.340	0.025	0.711 (0.528–0.958)	0.279	0.510	1.322 (0.576–3.035)
High economic pressure (No)	0.107	0.456	1.113 (0.840–1.474)	-0.424	0.298	0.655 (0.295–1.455)
High work pressure (No)	0.097	0.497	1.102 (0.832–1.460)	0.419	0.278	1.521 (0.713–3.244)
Disruption of life (No)	0.018	0.902	1.018 (0.769–1.347)	0.422	0.180	1.525 (0.822–2.827)
SDS total scores	0.009	0.570	1.009 (0.979–1.039)	0.103	< 0.001	1.108 (1.067–1.152)
PSQI total scores	0.020	0.490	1.020 (0.965–1.078)	0.176	< 0.001	1.193 (1.101–1.292)
Note: Ref., Reference; SDS, Self-rating Depression Scale; PSQI, Pittsburgh Sleep Quality Index. Bolding indicates P < 0.05. The question of “Disruption of life”: Has your life been disrupted by COVID-19?

After the COVID-19 pandemic, the risk of severe anxiety among nurses in supervisory positions and above was 0.440 times lower than that of nurses below supervisory positions (OR = 0.440, 95% CI 0.211–0.916). Additionally, depression (OR = 1.108, 95% CI 1.067–1.152) and sleep disorders (OR = 1.193, 95% CI 1.101–1.292) were independent risk factors for severe anxiety among nurses. ROC analysis showed that SAS scores and PSQI scores had good predictive value for severe anxiety among nurses after the pandemic (area under the ROC curve for SDS score was 0.798, and for PSQI score was 0.799, respectively) (Fig. 2).

This study aimed to compare the incidence of severe anxiety and related factors among frontline nurses in China during and after the COVID-19 pandemic. The results showed that during the COVID-19 pandemic, the incidence of severe anxiety among frontline nurses was significantly higher than that after the pandemic. This finding is consistent with previous studies [23], indicating that nurses face more psychological stress and anxiety during the pandemic, and this effect persists after the pandemic, manifested as Long-COVID or post-COVID syndrome [24, 25].

During the COVID-19 pandemic, we found a certain relationship between nurses' night shifts and severe anxiety. Nurses with higher night shift frequencies had a higher risk of severe anxiety. A cohort study found that shift work was significantly associated with a high risk of depression and anxiety [26]. In addition, anxiety and insomnia are very serious problems for nurses working night shifts[27]. For instance, one study found that 62.08% of shift nurses experienced anxiety symptoms [28]. Frontline nurses faced tremendous work pressure and heavy tasks during the COVID-19 pandemic [29–31]. This suggests that work environment factors are crucial for nurses' mental health, and reducing work pressure, especially night shift frequencies, may help lower nurses' anxiety levels [28].

Additionally, during the COVID-19 pandemic, we found a relationship between nurses infected with COVID-19 and severe anxiety. Interestingly, nurses infected with COVID-19 had a lower risk of severe anxiety. No previous study explored the relationship between nurses' infection with COVID-19 and anxiety. We hypothesis that nurses have a long-term fear of COVID-19, and COVID-19 infection is a form of exposure. Cognitive psychology suggests that exposure can reduce anxiety levels [32, 33]. Moreover, in China, nurses infected with COVID-19 were required to rest or undergo home isolation [34]. Rest may also lead to a decrease in anxiety levels, especially with reduced work pressure such as night shifts.

After the COVID-19 pandemic, the current study found that the higher the nursing title level, the lower the level of severe anxiety. Higher nursing title levels mean more years of work, older age, and higher positions, which may reduce the risk of anxiety levels [35, 36]. Higher nursing title levels imply more social support received, which is important for nurses' psychological resilience [37]. Therefore, after the COVID-19 pandemic, we need to pay attention to the mental health and career development of nurses with lower nursing titles.

Furthermore, our study found that depression and sleep quality were associated with severe anxiety among nurses after the COVID-19 pandemic. The relationship between depression and sleep disorders and severe anxiety is closely related [3, 5, 38]. A meta-analysis found 29.9% of hospital workers reported anxiety and 28.4% had depression symptomatology, while about 40% suffered from sleeping disorders [38]. Our research results show that depression and sleep disorder can cause anxiety, which indicates that nurses' mental health problems are often interrelated [39] and may require comprehensive psychological intervention.

For the development of intervention strategies for nurses' mental health, we suggest focusing on the following aspects: firstly, enhancing mental health education to improve nurses' awareness and coping abilities regarding mental health issues [40]; secondly, improving the work environment to reduce nurses' work pressure and economic pressure [41]; thirdly, promoting healthy lifestyles and encouraging nurses to actively participate in exercise and other health activities [42]; finally, establishing a comprehensive mental health support system to provide timely psychological health services and support for nurses [43, 44].

Although this study provided a preliminary exploration of severe anxiety among nurses in China during and after the COVID-19 pandemic, there are still some limitations. Firstly, this study adopted a cross-sectional design, which cannot establish causal relationships. Secondly, survey data were based on self-reports, which may introduce potential information bias. Additionally, this study only included samples of nurses in China, and the results may not be generalizable to other countries or regions. Finally, this study was conducted online, which may lead to information bias.

In conclusion, we found a high incidence of severe anxiety among nurses in China during and after the COVID-19 pandemic. The incidence of severe anxiety among nurses in China decreased after the COVID-19 pandemic. Lower nursing titles, depression, and sleep disorders were risk factors for severe anxiety among nurses after the COVID-19 pandemic. Therefore, addressing nurses' mental health issues requires attention and support from the entire society. Future research could further explore the mechanisms of long-term psychological health effects and implement effective intervention measures to support nurses' mental health.

Disclosures of interest: The authors declare no conflicts of interest.

Author Contributors: GSL and YY were responsible for the study design and manuscript preparation. GSL, YY, STY, and HYS were involved in evolving the ideas and editing the manuscript. QLH, JLand CL were responsible for recruiting the patients, performing the clinical rating, and statistical analysis. JL, STY, YSF, CY, and CL collected the data, provided language help and writing assistance. All authors have contributed to and approved the final manuscript.

Acknowledgements: The authors would like to show their great gratitude to all the individuals who participated in this study for their participation.

Conflict of Interest Statement: The authors declare no conflicts of interest.

Funding: None.

Ethics approval and consent to participate: The protocol for the research project had been approved by the Institutional Review Board (IRB) of the Tianjin Anding Hospital (approving number: 2023-028), and had therefore been performed following the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Patients' informed consent forms were obtained, and their anonymity was protected.

Data availability statement: The data supporting this study's findings are available on request from the corresponding author.

Consent for publication

Not applicable.

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Prevalence and correlates of severe anxiety among front-line nurses during and after the COVID-19 pandemic: A large-scale multi-center study

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Abstract

Background

Methods

Results

Conclusion

Figures

1. Introduction

2. Methods

2.1 Study Design

2.2 Participants

2.3 Assessment Measures

2.4 Statistical Analysis

3. Results

3.1 Comparison of Severe Anxiety among Nurses during and after the COVID-19 Pandemic

3.2 Comparison of SAS, SDS, and PSQI Scores among Nurses during and after the COVID-19 Pandemic

3.3 Factors Influencing Severe Anxiety

4. Discussion

Declarations

References

Additional Declarations

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