|Year : 2023 | Volume
| Issue : 1 | Page : 10-16
Severe acute respiratory syndrome coronavirus 2 Omicron variant and psychological distress among frontline nurses in a major COVID-19 center: Implications for supporting psychological well-being
Hanita Dahiya, Harshita Goswami, Chanchal Bhati, Ekta Yadav, Bhanupriya, Divya Tripathi, Deepa Rani, Deepika, Gayatri Pal, Geeta Saini, Lalita Yadav, Rajesh Kumar
Department of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||21-Jul-2022|
|Date of Decision||11-Oct-2022|
|Date of Acceptance||23-Oct-2022|
|Date of Web Publication||16-Dec-2022|
Dr. Rajesh Kumar
Department of Nursing, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
Background: Coronavirus outbreak severely affected the psychological health of frontline health-care workers, including nurses. Nurses relatively face many more psychological problems compared to other health-care workers. This study aimed to assess nurses' fear, stress, and anxiety status during the Omicron, a new variant of the severe acute respiratory syndrome coronavirus 2, outbreak in India. Materials and Methods: This questionnaire survey included 350 frontline nurses working at a tertiary care teaching hospital in North India. The information was collected using the Coronavirus Anxiety Scale, Impact of Event Scale-Revised, and Fear of COVID-19 Scale. Nurses working in the hospital since COVID-19 outbreak were included in the study. Appropriate descriptive and inferential statistics were applied to compute the results. Results: Nurses hospitalized after contracting an infection (odds ratio [OR] – 3.492, 95% confidence interval – 1.644–9.442, P < 0.002) and attended training on COVID-19 (OR – 2.644, 95% CI – 1.191–5.870, P < 0.017) reported high distress than their counterparts. Likewise, nurses hospitalized after contracting an infection (β = 3.862, P < 0.001 vs. β = 2.179, P < 0.001) and have no training exposure on COVID-19 management and care (β = 2.536, P = 0.001 vs. β = 0.670, P = 0.039) reported higher fear and anxiety, respectively. Likewise, married participants (β = 1.438, P < 0.036) who lost their friends and colleagues in the pandemic (β = 0.986, P = 0.020) reported being more frightened and anxious. Conclusions: Participants reported experiencing psychological burdens, especially nurses hospitalized after contracting an infection and who lost their friends and colleagues to COVID-19. High psychological distress may be a potential indicator of future psychiatric morbidity. Authors recommend a variant-specific training to improve nurses' mental health to combat the pandemic.
Keywords: Anxiety, COVID-19, distress, fear, mental health, nurses
|How to cite this article:|
Dahiya H, Goswami H, Bhati C, Yadav E, Bhanupriya, Tripathi D, Rani D, Deepika, Pal G, Saini G, Yadav L, Kumar R. Severe acute respiratory syndrome coronavirus 2 Omicron variant and psychological distress among frontline nurses in a major COVID-19 center: Implications for supporting psychological well-being. J Prim Care Spec 2023;4:10-6
|How to cite this URL:|
Dahiya H, Goswami H, Bhati C, Yadav E, Bhanupriya, Tripathi D, Rani D, Deepika, Pal G, Saini G, Yadav L, Kumar R. Severe acute respiratory syndrome coronavirus 2 Omicron variant and psychological distress among frontline nurses in a major COVID-19 center: Implications for supporting psychological well-being. J Prim Care Spec [serial online] 2023 [cited 2023 Jun 6];4:10-6. Available from: https://www.jpcsonline.org/text.asp?2023/4/1/10/364032
| Introduction|| |
Since the last week of December 2019, the world has been in the firm grip of a novel coronavirus. The virus outbreaks in Wuhan city, in Hubei province in China, and reported to be caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Soon, the attack was declared a pandemic in March 2020 by the World Health Organization (WHO). Since the outbreak, multiple variants of the virus have been reported around the globe. A SARS-CoV-2 variant that meets the definition of a variant of concern has been reported to have a higher transmissibility, virulence, and a decrease in the effectiveness of public health safety measures, including drugs, vaccines, and social distancing measures. Variants of the virus occur when there is a change or mutation to the virus's genes. Each new variant raises many questions including severity, safety measures, and vaccine potency, and spread more panic and havoc in the common public. As of now, Omicron, alpha, beta gamma, and delta variants are reported as variants of concern by the WHO. The Omicron variant has more than 30 mutations on its spike protein suggesting high a risk of reinfection and contagiousness., This variant has been reported in multiple countries around the globe. A study on health-care workers following the spread of the SARS-CoV-2 Omicron variant revealed a high level of worry. Therefore, considering the crunch of studies on the Omicron variant and its impact on mental health, it is crucial to study nurses' mental health and factors associated with mental health for developing preventive and efficient interventions during the uncertainties of the pandemic.
Nurses constitute a significant proportion of the trained workforce in the health-care system and are expected to carry multiple tasks related to medical care. A severe shortage of qualified nurses has been reflected in earlier work from India, further intensified by a higher quarantine status after infection and a few deaths., Further, COVID-19-related uncertainties were not limited to the probability of infection, but extended to the possible future consequences, vaccine efficacy on new strains, new safety guidelines, and cumulative panic spread by media.
Uncertainties have challenged health-care workers, including frontline nurses, since the beginning of the COVID-19 pandemic. Higher uncertainties have been reported to lead to higher anxiety and stress in various countries during the pandemic. Most relevantly, frontline nurses with higher uncertainties were found to have a higher risk of stress and burnout during the pandemic. Furthermore, health-care workers, especially nurses, work round the clock to meet different kinds of patients' needs and are often found struggling with personal protective devices, high risk of contracting and transmitting the infection to their loved ones, working burnout, fear, anxiety, and other poor psychological outcomes., Nurses are known to be vulnerable to significant levels of stress and burnout. There is ample evidence on the impact of coronavirus disease on nurses' mental health and its associated factors from developed and developing countries, including India. However, the regional data on mental health issues of nurses are limited. To address this issue, a better understanding of the mental status of nurses is necessary. This study aimed to assess the impact of the Omicron variant outbreak on mental health and factors that predicted the mental health outcomes among frontline nurses working in a tertiary care teaching hospital in North India.
| Materials and Methods|| |
Design, sample, and setting
This cross-sectional questionnaire-based survey was conducted in April–May 2022 at a tertiary care teaching hospital in North India. Nurses involved in direct patient care since the COVID-19 outbreak was enrolled in the study. The survey questionnaire was shared with 500 frontline nurses, and 400 (80%) participants responded. Finally, after carefully scrutinizing the filled questionnaire, 350 questionnaires were deemed suitable to include in the analysis.
The survey used three self-reported questionnaires, including the Coronavirus Anxiety Scale (CAS), Impact of Event Scale-Revised (IES-R), and Fear of COVID-19 Scale, and a structured sociodemographic data sheet to collect personal and professional information of the frontline nurses.
Sociodemographic profile sheet
It consists of information on personal and professional characteristics of nurses, including age (years), gender, professional education, habitat, working area, involvement in the care of patients with ventilators, history of infection with coronavirus, hospitalization due to coronavirus, and loss of family and colleagues due to COVID-19. The sociodemographic sheet sought validation from psychology, psychiatric nursing, and public health experts.
The Coronavirus Anxiety Scale
The CAS measures the anxiety nurses experienced during the Omicron variant outbreak., It is a 5-item Likert rating scale rate anxiety using a 5-point scale: 0 (not at all); rare, less than a day or two (1); several days (2); more than 7 days (3); and to nearly every day over the last 2 weeks (4), based on experiences over the past 2 weeks. The scaling format is consistent with the DSM-5's cross-cutting symptom measure. The instrument is a valid and reliable (Cronbach's alpha = 0.93) tool (sensitivity index = 90%, specificity = 85%, and area under the curve = 0.94, P < 0.001) to distinguish an individual with coronavirus-related anxiety and those without anxiety., A score ≥9 indicates probable signs of dysfunctional coronavirus-related anxiety.
Impact of Event Scale-Revised
The IES-R Revised English version questionnaire, a widely available scale used to measure psychological distress due to coronavirus disease. Nurse participants were requested to rate 22 items on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely). The IES-R total score ranges from 0 to 88, with a score ≥26 indicating probable stress symptoms in the last week., The scale Cronbach's alpha for the study sample was 0.87 for the total scale.
Fear of COVID-19 scale
The fear of COVID-19 scale, a 7-item scale, was used to measure fear of COVID-19 among the nurses. Nurse participants were requested to indicate their level of fear for each statement using a 5-point Likert scale: "strongly disagree (1)," "disagree (2)," "neutral (3)," "agree (4)," and "strongly agree (5)." The scale has a total score range from 7 to 35, with a higher score reflecting higher fear and vice versa for COVID-19. The scale is widely used in earlier studies and validated for similar populations., The English scale version shows acceptable psychometric properties (Cronbach's alpha = 0.88) in the present study.
The Institutional Ethics Committee (IEC) approved the project (AIIMS/IEC/22/151). A consent form was provided with the questionnaire as a mandatory requirement to participate in the survey. However, no personal information of the participants is collected during the study.
Data are transferred to a Microsoft Excel sheet and analyzed using SPSS version 23.0. Descriptive statistics used frequency, percentage, means, and standard deviation. Binary logistic and multilinear regression is used to explore the predictors of psychological health among nurses. All test statistics are measured at P < 0.05 level (two-tailed).
| Results|| |
This questionnaire survey included 350 frontline nurses working in a tertiary care teaching hospital. The mean age of the participants was 28.04 (±3.11) years, with a slightly more number (59.1%) of male nurses. Around three-fourth of the participants (84.9%) completed a bachelor's degree as their professional qualification and were on a regular job (74.3%). More than half (52.0%) of the participants belonged to rural backgrounds and lived alone (48.9%). Regarding COVID-19-related information, 43.1% of the participants worked in specialty areas in the hospital were involved in COVID-19 patients' care (96.9%), and provided care to mechanically ventilated patients (91.4%). Other COVID-19-related information is summarized in [Table 1].
In addition, the Mann–Whitney U test was applied considering the nonnormal distribution of data to compare the fear among nurses hospitalized after contracting infection to a nonhospitalized group. The mean score and difference in findings are shown in [Table 2].
Bivariate logistic regression analysis was applied to explore participants' psychological distress predictors. The findings revealed a significant association between psychological distress with hospitalization and the training status of the participants on COVID-19 management.
It can be interpreted that participants hospitalized after contracting COVID-19 disease reported four times higher distress (odds ratio [OR] – 3.492, 95% confidence interval [CI] – 1.644–9.442, P < 0.002) than their counterparts. Likewise, the participants who attended training on COVID-19 and its management reported higher distress (OR – 2.644, 95% CI – 1.191–5.870, P < 0.017) compared to those who did not participate in the training [Table 3].
|Table 3: Predictors of psychosocial distress: Bivariate regression analysis|
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A multilinear regression analysis was applied to explore the predictors of fear and anxiety. The model explained 9.1% of the variance of the fear during the pandemic, which was statistically significant (F = 11.607, P < 0.001) and meets the model fitting requirement for further analysis. Out of entered variables into the model, hospitalization for COVID-19 advanced care, marital status, and training on management and care of COVID-19 patients show significant association with fear. This can be interpreted that married nurses (β = 1.438, P < 0.008), hospitalized after contracting an infection (β = 3.862, P < 0.001), and attended training on COVID-19 management and care (β = 2.536, P = 0.001) reported more frightened than their counterparts. Likewise, multilinear regression analysis explained an 11.9% variance of the anxiety in nurses during the pandemic, which was statistically significant (F = 11.607, P < 0.001) for model fitting. Further, nurses who lost friends and colleagues (β = 0.986, P = 0.014) did not have exposure to training on COVID-19 management (β = 0.670, P = 0.049) and were hospitalized after contracting an infection (β = 2.179, P < 0.001), reported independent predictors for anxiety among nurses [Table 4].
|Table 4: Multilinear regression analysis: Predictors of fear and anxiety|
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| Discussion|| |
Working in a pandemic can significantly affect the mental health of all health-care workers. In particular, nurses at the frontline level involved in the care of COVID-19 patients experienced more severe psychological distress, fear, and anxiety.
In this study, 3.1% and 9.4% of frontline nurses experienced anxiety and psychological distress, respectively. However, the prevalence of psychological distress is somewhat low considering the decline of COVID-19 cases in India and uplifting COVID-19 restrictions. The distress was significantly higher among nurses who worked without extra days off and leave. Nurses hospitalized after contracting an infection and losing their friends or colleagues in the pandemic and who attended training on different issues of COVID-19 patients' management reported significantly higher distress than their counterparts. The prevalence of psychological distress and anxiety is reported lower in our work than in previously published work that reported a higher prevalence in nurses involved in care of COVID-19 patients and availed a few vacations. These findings look normal considering the present pandemic situation in India, where the COVID-19 cases were declined to the lowest level ever, and people have started resuming normal daily activities. However, the findings on COVID-19-induced psychological distress in nurses vary across the studies since the pandemic's beginning and need careful interpretations while generalizing and extrapolating.
A small cohort of nurses is still anxious about the new coronavirus Omicron variant. However, these findings are relatively reported by a small group of participants, which may not be comparable to other studies considering the different time intervals and duration of Omicron variants outbreak across the globe. Earlier published studies reported anxiety among a large cohort of nurses when the Omicron wave peaked in India., There was a hue and cry everywhere, including medical health setup. Furthermore, fear was significantly higher among the married cohort hospitalized for COVID-19 treatment after contracting an infection. These findings align with the study that reported a significant association of fear with COVID-19 work settings and went for quarantine after contracting an infection., In addition, nurses who did not have training exposure on COVID-19 management reported higher anxiety than their counterparts. However, the author speculates that higher anxiety might be due to a lack of training on specific Omicron variants and associated risks while working with the other variant of coronavirus patients in the hospital. Since the training was not designed explicitly for the Omicron variant of coronavirus, it could not have helped the nurses gain confidence to treat patients, making them more nervous and anxious during this variant outbreak. The higher anxiety among nurses who attended training on various aspects of COVID-19 handling might have sensitized them to the risk of exposing and working with coronavirus patients and could be postulated as a reason for these findings.
In line with that, findings reported that nurses who attended training on COVID-19 prevention and management had lower anxiety than their counterparts. Authors postulated that following training might be made the nurses more confident about caring for patients with COVID-19 and reduce burnout and anxiety, which is in line with the study conducted in India and China at different time intervals of the pandemic. Henceforth, nurses who attended training on COVID-19 management felt confident in patient handling and reported lower anxiety and fear. In a shred of evidence, we recommend appropriate variant-specific training to prepare the nurses to take different upcoming variants of the coronavirus disease. In contrast, earlier published studies reported lower anxiety among health-care workers, including nurses who attended training on COVID-19 management., Although this training is provided in the beginning to prepare the nurses to fight with pandemic, where variants concern was not declared, and therefore could be a possible reason to lower anxiety and make the nurses more confident to combat the pandemic.
Nurses hospitalized after contracting an infection reported higher anxiety than other cohorts. Nurses reported feeling uncomfortable and afraid of losing life after watching news and stories on social media. Furthermore, nurses reported physical signs of anxiety, including disturbance in sleep, racing heart or palpitation, and numbness. By professional virtue, frontline nurses are at high risk of developing psychological issues. During the SARS outbreak, the health-care workers who worked in high-risk situations developed psychological symptoms, which concurs with our study findings where nurses reported insomnia, fatigue, emotional exhaustion, and palpitations, which were shared among nurses caring for the COVID-19 patients.,
Likewise, our study findings reported that more nurses who contracted infection worried about losing life, which concurs with another published work. According to another survey conducted in China and Italy in early outbreaks, frontline health-care workers and nurses reported more severe mental health symptoms., During the SARS outbreak, it was reported that nurses experienced more distress and behavioral disengagement than other health-care workers, considering frequent contact with patients and exposure.
Limitations and recommendations
The study has certain limitations that future researchers should consider while interpreting and extrapolating the findings in their settings. First, the study was done when the COVID-19 cases were at a lower level after the Omicron variant was almost over, so it may not represent the information furnished in work. Second, although a large and calculated sample size has been taken to explore the attributes in the study, a multicenter approach may be more suitable for the appropriate generalization of the findings. Third, the survey of the impact of Omicron on nurses' mental health is scarce, and further investigation is recommended to devise evidence-based interventions to protect mental health. Fourth, all the questionnaires used in the study are self-reported and may lead to reporting bias. Finally, there were no data on the effect of Omicron variant-focused training on psychological health among health-care workers, including nurses. The authors recommended organizing variant-specific training for nurses in the future to prepare and make them more confident to fight with an upcoming variant if any. Authors recommend interventions that bolster psychological well-being may be of benefit to protect against adverse mental health outcomes among nurses. A supportive work environment and strengthening psychological resilience on a personal basis may be effective in protecting mental health outcomes.
| Conclusions|| |
We investigated the psychological burden that frontline nurses experienced during the region's Omicron outbreak. The study reported that participants experienced higher psychological burdens after getting hospitalized and losing their friends and colleagues during the spell. Participants who did not attend training on COVID-19 management reported more significant psychological problems. The present study findings can be helpful for the future research during any variant outbreak. Similarly, our result may help nurse administrators devise variant-specific training for frontline nurses to deal with variant-specific challenges in the near future.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]