Factors associated with post-traumatic stress disorder in nurses after directly caring for COVID-19 patients: a cross-sectional study

Coronavirus disease 2019 (COVID-19) was first detected among patients with pneumonia in December 2019 in Wuhan, China [1]. Since then, COVID-19 has spread rapidly to 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 [3]. Research shows that healthcare workers may experience psychological stress because 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 especially vulnerable to PTSD owing to highly stressful work-related situations, such as witnessing death, trauma, and working overtime and in overcrowded settings [6, 7]. Frontline healthcare workers may experience feelings of trauma resulting from 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]. PTSD is more prevalent in nurses than in other healthcare workers [4, 10, 12]. PTSD may significantly affect mental, emotional, and physical health [13]. Additionally, PTSD is associated with increased turnover intention and diminished concentration and cognitive ability, resulting in medication errors, and disrupts work performance, affecting patient safety and the healthcare organization [14‐16]. There is a need to develop a strategy to mitigate the harmful effect of PTSD and promote nurses’ well-being and quality of patient care [16].

Predictors of PTSD is 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]. Previous studies show 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 having directly dealt 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 in Daegu decreased in May 2020, some hospitals ceased to operate as COVID-19 isolation 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 also be in a post-traumatic situation after providing direct care to COVID-19 patients, they can be examined to identify PTSD-related factors in the post-COVID period.

There is a critical need to develop strategies that address PTSD and promote the well-being of nurses, ensuring the delivery of high-quality patient care. Understanding the predictors of PTSD is essential for identifying at-risk individuals. Given the potential effects of the pandemic, it is crucial to establish management strategies for PTSD among nurses who have provided direct care to COVID-19 patients. Examining the factors related to PTSD in nurses working in non-COVID-19 hospitals after their direct involvement with COVID-19 patients can provide valuable insights into the post-COVID period. This study aims to investigate factors related to PTSD among nurses who provided direct care to COVID-19 patients. 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 novel in that it investigates the factors influencing PTSD among nurses after they provide direct care to COVID-19 patients. The participants of this study did not provide direct care to COVID-19 patients for more than five months after providing direct care to them. Our results show that nurse managers’ ability, leadership, and support of nurses, experience of witnessing COVID-19 patients’ deaths, experience of quarantine, level of nurse staffing, and convenience of EHR were all significantly associated with PTSD among nurses after providing direct care to COVID-19 patients.

After providing direct care to a COVID-19 patient, 18% of nurses experienced PTSD for more than five months. 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 disparity in the PTSD prevalence is attributable to variability in measurement tools [31] and points, depending on whether it is evaluated several months after the traumatic event [13, 32]. A longitudinal study found that the proportion of nurses with PTSD was lower during the stable periods than during the outbreak periods [32]. 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, the prevalence of PTSD among health workers who experienced natural disasters showed a decreasing trend as the follow-up duration increased [34]. 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 [32]. Nevertheless, some nurses still suffer from PTSD; therefore, these nurses and their mental health condition must be carefully considered.

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. It had a buffering effect on PTSD. Social support from supervisors proved helpful in reducing PTSD among nurses [35, 36]. The workload of nurse managers to manage the supply of appropriate personnel and supplies is overwhelmingly heavy in emergency situations such as the COVID-19 pandemic. Hence, it is recommended that hospitals allocate additional personnel to psychologically support nurses who provide direct care to COVID-19 patients [37]. Additionally, although it is difficult in an emergency, this study found that proper support and leadership for nurses after a traumatic event can lower PTSD. Hence, it is necessary to develop 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 who cared for COVID-19 patients who died had a higher risk of developing PTSD [17]. Particularly, the death of COVID-19 patients differs from that of the general population. As COVID-19 patients are isolated from their families and pass away alone, nurses experience overwhelming loss, grief, shame, helplessness, and powerlessness following the patients’ lonely death [38, 39]. However, the length of the time spent working 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 [37], in which quarantined nurses recognized their feelings of vulnerability and were found to be at higher risk for PTSD [6]. When the nurses were quarantined, they suspected that they may have contracted COVID-19. Therefore, interventions to prevent PTSD are needed for nurses who have cared for deceased patients or have been quarantined.

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, nurses 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 COVID-19 patients. It is related to PTSD symptoms because it causes psychological distress when work efficiency is low owing to low EHR reliability and low support for cooperation [40]. 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 a serious issue in Korea. Following the MERS outbreak, the Korean government prepared a prevention system for infectious diseases after learning [41]. 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 difficulty accessing PPE [40]. This could be due to the importance of PPE accessibility. 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 [42]. We noted that participants working in the COVID-19 ward with poorer staffing and an inaccurate EHR were at higher risk of developing PTSD, highlighting 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 recall bias may exist. Additionally, although the survey was conducted among nurses several months after providing direct care to 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 only caring for non-COVID-19 patients in hospitals where COVID-19 patients were not hospitalized. Furthermore, unlike other Korean cities, Daegu did not experience a second wave of COVID-19 after the first wave, when the number of confirmed cases increased rapidly [43].

We analyzed factors influencing PTSD among nurses who provided direct care to COVID-19 patients after the COVID-19 pandemic. Consequently, we found that nurse managers’ ability, leadership, and support of nurses in the ward after the COVID-19 pandemic significantly influenced PTSD symptoms among nurses. When providing direct care to 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, if the COVID-19 patient whom the nurse was taking 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. Further research is needed, in particular, 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.