Introduction to article publication
This article was published inInternational Journal of Nursing Studies(IF: 5.837, Chinese Academy of Sciences ranking: Nursing 1 /Medicine 1) in February 2021 by Dr. Zheng Rujun, Zhou Yuhong and Fu Yan (West China School of Nursing, Sichuan University/Department of Thoracic Oncology, West China Hospital, Sichuan University) as the first authors and Professor Jiang Yan(Department of Nursing/Evidence-based Nursing Center, West China Hospital, Sichuan University), Professor Yu Chunhua (West China School of Nursing, Sichuan University/ Department of Thoracic Oncology, West China Hospital, Sichuan University) and Professor Li Junying (West China School of Nursing, Sichuan University/ Department of Thoracic Oncology, West China Hospital, Sichuan University) as the corresponding authors, and it was included as an ESI Highly Cited paper in July 2021.
Part I Interpretation of article content
Background
The Municipal Health Commission of Wuhan, the capital ofHubei Province in China, notified an outbreak of atypical pneumonia caused by a novel coronavirus, designated severe acuterespiratory syndrome coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses. This entity was named coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO) on February 11, 2020, and the type of pneumonia was designated novel coronavirus pneumonia. COVID-19 spread to 215 countries or territories,and caused 8.8 million confirmed cases of pneumonia as of July26, 2020. SARS-CoV-2 is the third most pathogenichuman coronavirus that has emerged in the last two decades, after severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV).When COVID-19 emerged in Wuhan and rapidlyspread throughout China, the government has suspended all public transportation services in Wuhan on January 23, 2020, to prevent viral spread. As of February 14, 1716confirmed cases of infection of medical staff were reported, withsix deaths.COVID-19 has caused depression, anxiety, and fear across Chinaduring the outbreak of this public crisis.
There are an estimated 322 million people with depressivesymptoms and 264 million with anxiety worldwide.Moreover, nurses experienced higher rates of depression comparedto the general population, especially in the face of health emergencies. Specific stressors associated with emotional distress include thelack of effective treatment, high work demands, low job control,effort-reward imbalance, work-family conflict, and the life-threatening nature of the disease, especially direct exposure to SARS patients.Severe psychological problems may compromise physical, mental,and social health, increasing suicide risk.
Understanding the impact of COVID-19 infection control on personal and family health helps plan emergency responses to future infectious disease outbreaks. First, nursing workload and long working hours are significant predictors ofmental health (Helen et al., 2019). Nurses who are assigned unfamiliar tasks appear to suffer a higher risk of anxiety than othernurses doing familiar work. A study reported that health care workers at high risk of contracting SARSwere more likely to have a higher prevalence of depression andanxiety, and develop post-traumatic stress during the SARS epidemic. In addition, the relationship quality with family is important since it can improve psychologicaldistress. Some studies reported that work-family satisfaction wasnegatively correlated with psychological distress. Social support is knownto reduce depression and anxiety, and family support is associated with lower anxiety levels among nurses. Although the transmission of SARS-CoV-2 in the early phase ofthe outbreak remains largely unknown, there is evidence that therisk of SARS-CoV infection and the level of emotional exhaustion ishigher among nurses. Therefore, work stress,family dissatisfaction, and infectious disease exposure are morestrongly related to psychological distress. Managing psychologicaldistress can improve the physical, mental, and social health ofnurses.
The objective of this study is to assess the prevalence rates ofdepression and anxiety in nurses during the first COVID-19 epidemic through a questionnaire survey. The factors associated withthe mental health of nurses were determined to provide the basis for establishing psychological intervention programs for theseprofessionals.
Study design and participants
A total of 5300 nurses in Sichuan Province and Wuhan Citywere selected in this cross-sectional study by convenience sampling. All participants were invited to complete the questionnairesfrom January 27, 2020, to February 3, 2020.Theyinvited 35 volunteers (29 coordinators of regional hospital network establishedby West China Hospital, and 6 members of the Nursing AcademySpecialty Committee) from 35 hospitals to investigate their hospital nurses. A professional questionnaire survey platform called“Wenjuan Xing” was used to investigate psychological health ofparticipants through 46 WeChat groups (number of participantsrange from 83 to 395).Pneumology, infection, feverclinics, isolation wards, or ICUsweredefinedas high-risk Covid-19 wards, andgeneral outpatient or emergency wardsweredefinedas middle-risk Covid-19wards, other wardsweredefinedas low-risk Covid-19 wards. In thisstudy, a self-made questionnaire combining the Self-rating Depression Scale (SDS) and Self-rating Anxiety Scale (SAS) was used to conduct an anonymous survey with the permission of the researchethics committees of the participating hospitals. A total of 3228 nurses answered the questionnaire, corresponding to a response rate of 60.91%.
Questionnaires
Including demographic characteristicsquestionnaire, a self-reported questionnaire base on psychosocial factors during the SARS and Covid-19 pandemic,self-rating depression scale (SDS) and self-rating anxiety scale (SAS).
Data analysis
Data were analyzed using SPSS software version 25.0. Descriptive statistics were used to determine the distribution of demographic characteristics. Continuous variableswere reported as means and standard deviations. Categorical variables were expressed as absolute values and percentages. Bivariateand multivariate logistic regression was used to measure the riskfactors of anxiety, depression and perceived health, respectively.The bivariate logistic regression analyses were used to estimate theodds ratio for each independent variable, to assess which of thefactors associated with depression and anxiety. Multivariate logistic regression analysis was used with potential associated characteristics (demographic characteristics, COVID-19-related stress, andrelationship quality with family) as independent variables and perceived health status as dependent variable. A two-sided p-value ofless than 0.05 was considered statistically significant.
Ethical approval
The participating hospitals’ research ethics committees approved this study. The first section of the questionnaire mainly included informed consent, participants will read the informed consent at first, if they agree to participate in the study，they will click “I agree” to complete the following survey. The questionnaire survey was anonymous, and personal information was not disclosed,except for demographic data.
Results
The total prevalence of depression and anxiety among nurses were 34.3% and 18.1%, respectively. The rates of depression and anxiety in nurses who cared for the COVID-19 patients was 47.1% and 28.4%, respectively.
The factors associated with depressive symptomswere nursing workload (OR, 1.319; 95% CI, 1.167~1.492), unknown origin(OR, 1.190; 95% CI, 1.045~1.355), the fear of infection (OR, 1.146;95% CI, 1.103~1.191), bad couple relationship (OR, 1.358; 95% CI,1.213~1.520), and poor family members relationship (OR, 1.455;95% CI, 1.294~1.635).
The factors associated with anxiety symptomswere nursing workload (OR, 1.432; 95% CI, 1.218~1.683), unknown origin (OR, 1.260; 95% CI, 1.063~1.495), the fear of infection (OR, 1.132; 95% CI, 1.080~1.879), badparent-child relationship(OR,1.146; 95% CI,1.034~1.270), and poor family membersrelationship(OR,1.464; 95% CI,1.290~1.660)
The factors associated with perceived health status were unknown origin (OR, 1.52; 95% CI, 1.204~1.940), fear of infection (OR, 1.100,95% CI, 1.042~1.162), lack of effective treatment (OR, 1.605,95% CI, 1.261~2.043), poor patient compliance (OR, 1.235; 95% CI, 1.039~1.469), poor social support (OR, 1.28; 95% CI, 1.083~1.512), parent-child relationship (OR, 1.422; 95% CI, 1.248~1.619), family members relationship (OR, 4.985; 95% CI, 4.098~6.064), age (OR, 0.676; 95% CI, 0.545~0.840), and female gender (OR, 0.432; 95% CI, 0.217~0.861).
Conclusions
Their findings demonstrate that the COVID-19 pandemic had significant psychosocial effects on nurses. COVID-19-related stress, relationship quality with family, and demographic characteristics were associated with depression, anxiety, and perceived health status. Therefore, hospitals should implement effective mental health promotion programs focused on occupational safety and family support to improve the well-being of nurses.
Limitations
This study has some limitations. First, the cross-sectional design does not allow establishing a definitive causal link between COVID-19-related stress, relationship quality with family, and distress symptoms. Second, the participants completed the questionnaires using the WeChat application and mobile devices, which might lead to self-selection bias. Third, the self-designed questionnaire was not validated due to time constraints. Fourth, the sample size of Wuhan was small, the findings need to be tested in other high risk areas for COVID-19.
Part II Guiding significance of research results for practice
As an international public health emergency, COVID-19 pandemic had a greater impact on public mental health. This study clarified the impact of COVID-19-related stressors and family relationships on depression and anxiety among nurses. In order to promote physical and mental health of the public, mental health professionals should focus on the stressors of emergencies and family support in carrying out psychological counseling in public health emergencies.
PartⅢPeer expert reviews
Professor Jiang Yu:At the end of 2019, COVID-19 pandemic broke out. It first attacked China and then the rest of the world, becoming a public health emergency of international concern. Its strong infectivity and high mortality not only threatened human health, but also brought great psychological challenges to the public. It was important to pay attention to the psychological conditions of medical staff, because they have borne the responsibility and pressure of medical treatment and the risk of infection, and were prone to psychological crises during the pandemic. The study found that in the early stage of COVID-19 pandemic, the incidence of depression and anxiety among nurses was 34.3% and 18.1%, respectively. The main risk factors for depression, anxiety and health perception of nurses were age, gender, nursing workload, COVID-19-related stresses, and relationship quality with family. This study was one of the first large sample studies focusing on the mental health of nurses during COVID-19 pandemic, indicating that the pandemic had a significant impact on the mental health of nurses, and also provides an objective basis and intervention direction for hospitals to carry out targeted psychological intervention and mental health promotion in the future.
Jiang Yu:Chief Physician, doctoral supervisor, Deputy Director ofDepartment of Head & Neck Oncology, West China Hospital, Sichuan University. He is a standing member of the Tumor Psychology Committee of Chinese Anti-Cancer Association, deputy leader of the Cancer Psychology Collaboration Group of Cancer Foundation of China, a standing member of Malignant Melanoma Committee of Chinese Society Clinical Oncology, a member of Sarcoma Committee of Chinses Anti-Cancer Association, chair of Skin and Soft Tissue Tumor Committee of Sichuan Cancer Society, chair-designate of the Cancer Pain Committee of Sichuan Anti-Cancer Association, deputy chair of the Cancer Psychology and Health Management Committee of Sichuan Cancer Society, deputy chair of the Cancer Rehabilitation Committee of Sichuan Geriatrics Society, vice chair of Oncology MDT Committee of Sichuan International Medical Exchange & Promotion Association, a standing member of the Psychiatry Committee of Sichuan Medical Association, and an editorial board member ofPsycho-Oncology.
Part IV Introduction to corresponding authors, first authors
Corresponding authors:
Jiang Yan,Ph.D, FAAN, Chief Nurse, doctoral supervisor, Director of Department of Nursing/Evidence-based Nursing Center, West China Hospital, Deputy Dean of West China School of Nursing, Sichuan University. She is a visiting scholar of the School of Nursing, University of Minnesota, an “Outstanding Nursing Worker" of the Chinese Nursing Association, a skilled teacher of Sichuan Province, a member of the 10th National Committee of the Chinese Association for Science and Technology, amemberof the Nursing Professional Committee of the National Health Standards Committee, a member of the Standards Committee of Chinese Nursing Association, vice chair of theNursing Association of Sichuan Province, chair of the Evidence-based Nursing Committee of the Nursing Association of Sichuan Province, a member of the Council of the Asia Quality Function Deployment Association, amember of the International Society for Quality in Health. As the person in charge, she has won a gold prize of Asian Hospital Management, second and third prizes of Science and Technology Progress of Sichuan Province, and a third prize of Chinese Nursing Association for Science and technology.
Li Junying,Chief Nurse, master supervisor, Head Nurse of the Department of Cancer Center, West China Hospital, Sichuan University. She is anAcademic and Technical Leader of Sichuan Province, a member of Cancer Nursing Committee of Chinese Nursing Association, a standing member of Cancer Nursing Committee of Chinese Anti-Cancer Association, astanding member of Tumor Psychology Committee of Chinese Anti-Cancer Association,chair of Cancer Nursing Committee of Sichuan Anti-Cancer Association, chair-designate of Cancer Nursing Committee of Nursing Association of Sichuan Province, vice chair of Psychosomatic Rehabilitation Committee of Sichuan Western Psychiatric Association, a member of Cancer Rehabilitation and Palliative Treatment Committee of Sichuan Anti-Cancer Association, chair of Cancer Nursing Committee of Chengdu Nursing Association, an adviser of Intravenous Professional Committee of Chengdu Nursing Association. Her main research interests are oncology nursing, intravenous infusion therapy and standardized management of pain. She has published more than 40 papers, edited 8 monographs, and been in charge of 5 provincial and ministerial scientific research projects. In addition, she was awarded the third prize of Science and Technology Progress of Sichuan Province twice and the second prize of Sichuan Medical Association once.
Yu Chunhua,Chief Nurse, Head Nurse of the Department of Thoracic Oncology, West China Hospital, Sichuan University. She is a member of the expert pool of the Cancer Committee of the Chinese Nursing Association, a member of the Cancer Nursing Committee of the Rehabilitation Association of Chinese Anti-Cancer Association,vice chairof the Cancer Patient Survival Care Committee of the Western Nursing Center, a member of the Cancer Committee ofNursing Association of Sichuan Province, vice chair of Hospice Care Committee of Chengdu NursingAssociation.She has been engaged in cancer clinical nursing and nursing management for more than 20 years. She is good at symptom management, pain management, psychological counseling, hospice care, vascular pathway management and complications management for cancer patients with radiotherapy and chemotherapy. She has published more than 20 papers (including5 SCI papers),been in charge of1 project of Science & Technology Department of Sichuan Province, and participated in 10 research projects.In addition, she has won four provincial and municipal Awards for Progress in Science and Technology .
First authors:
Zheng Rujun,Ph.D., Senior Nurse, Deputy Head Nurse of Department of Thoracic Oncology,West China Hospital, Sichuan University.He isvice chair of the Hospice Care Committee ofSichuan Province, a member of Lung Cancer Specialty Committee ofSichuan Cancer Society, amemberof Psychological and Health Management Special Committee of Sichuan Cancer Society, a youth member of Oncology Professional Committee of Chinese Nursing Association, amemberof the Pulmonary Rehabilitation Committee of Sichuan Association of Rehabilitation Medicine.His main research interests are psychological distress management, pain management, hospice care and symptom management of cancer. He has published more than 30 papers, coedited 4 monographs, participated in the compilation ofChina Cancer Symptom Management Practice Guideline, as well as been in charge of 2 provincial and ministerial scientific research projects. In addition, he has won the third prize of Awards for Progress in Science and Technology of Sichuan Province twice.
Zhou Yuhong,agraduate student in nursing, mainly focusing on oncology nursing. She has published 1 SCI paper as the first author and participated in 3 research projects. At present, she is carrying out basic research work of animal experiments on "The Role and Mechanism of Intestinal Microflora in Tumor Chronic Stress" at West China Nursing Innovation Research Center. She was awarded "Excellent Postgraduate" of West China School of Medicine.
Fu Yan,Associate Chief Nurse, Deputy Head Nurse of Department of Thoracic Oncology, West China Hospital, Sichuan University. She is a standing member of Cancer Nursing Committee of Chengdu Nursing Association, a member of Cancer Nursing Committee of Sichuan Anti-Cancer Association, a standing member of Cancer Nursing Committee of Sichuan Cancer Society, a standing member of Cancer Nutrition and Prevention Committee of Sichuan Preventive Medical Association. She is good at clinical oncology nursing. She has published 3 SCI papers, coedited 4 monographs, been in charge of 3 scientific research projects, andwon a third prize of Awards for Progress in Science and Technology of Sichuan Province.
