Influence of new coronavirus pandemic on behavior and awareness of young nurses and nursing students in Japan

A novel pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was named coronavirus disease 2019 (COVID-19), emerged in the Chinese city of Wuhan at the end of December 2019, and spread not only domestically in China but also internationally [1]. The World Health Organization (WHO) designated the COVID-19 outbreak a public health emergency of international concern on January 30, 2020 [2] and declared a pandemic on March 11 because of its widespread and rapid rate of transmission [3]. To suppress spread of the virus during the expansion phase of the COVID-19 pandemic, several governments declared a state of emergency and implemented “lockdown” which imposed restrictions on movement, behavior, work and school attendance. Facing this critical situation, health care workers, especially nurses who are directly involved in the treatment of COVID-19 patients and are confronted with the crisis of medical collapse, are at risk of psychological distress, anxiety, fear, alienation, exhaustion and sometimes discrimination [4‐10].

In Japan, sporadic outbreaks of COVID-19 began in early March, and the number of infected people rose sharply in late March, mainly in urban areas such as Tokyo. The Japanese government focused on “3Cs” (Closed spaces, Crowded places, Close-contact settings) as infectious environments [11], and strongly encouraged avoidance of the 3Cs in addition to standard infection prevention measures such as wearing a mask, gargling and washing hands. Then, the Japanese government declared a state of emergency on April 16, continuing to May 25, which did not enforce restrictions but requested “voluntary restraint (self-quarantine)” to avoid the 3Cs, different from enforced lockdown in other countries. Despite voluntary restraint not being mandatory and the number of infected patients and deaths being relatively low in Japan as compared to other countries [12], young nurses facing their first experience of an unknown infectious disease must have been under stress, as in other countries. Also, the COVID-19 pandemic would be expected to influence their behavior and awareness such as nursing professionalism and views on life and death. However, little is known about the psychological impact of the pandemic on nurses and changes in their behavior and awareness after the rise of COVID-19 in Japan. Moreover, the influence of the COVID-19 pandemic on nursing students is still unclear.

Here, we investigated the influence of the COVID-19 pandemic on feelings of nurses and nursing students and changes in their behavior and awareness, evaluated the associated factors influencing these changes, and compared nurses with nursing students, employing an online questionnaire survey.

The COVID-19 pandemic has caused a serious public health threat worldwide. In addition to affecting physical health, psychological stress due to fear of the virus and lifestyle restrictions is also a critical issue [14]. In particular, health care workers, including nurses, who come in close contact with infected patients and experience traumatic events such as death, are particularly at risk of stress [15] and are considered a vulnerable group [16]. However, little is known about how much nurses have been psychologically affected by the COVID-19 pandemic in Japan, where there have been fewer infected patients and deaths than in other countries.

First, anxiety/fear about COVID-19 (section A in Table 1) during the state of emergency was significantly elevated among young nurses (Fig. 1), consistent with previous reports [4‐10]. Although a significant difference in the severity of psychological symptoms between frontline nurses and second-line nurses has been reported [4], in the present study, the work environment and experience caring for patients with COVID-19 did not affect anxiety/fear about COVID-19. This may be because the number of infected patients and the number of deaths were lower in Japan [12] than in other countries. However, a coping strategy for anxiety in nurses should be established to improve their mental health and prevent burnout or premature retirement. Of note, increased anxiety/fear about COVID-19 among nursing students not in direct contact with patients was the same as on-site nurses (Fig. 1). Similarly, it has been reported that anxiety under a forced lockdown is highly prevalent among nursing students because of economic uncertainty, fear of infection, and social distancing [17]. Our data and a previous report [17] suggest the importance of managing anxiety among nursing students as well as nurses.

Motivation for nursing work during the state of emergency was lower in nurses than in nursing students (Fig. 1), suggesting fatigue and exhaustion among nurses in clinical fields. However, significantly decreased motivation was observed even in nursing students (Fig. 1), suggesting that even Japanese-style voluntary measures, as well as forced restrictions under lockdown, had a psychological effect. However, it is interesting that nurses working in hospitals that accepted patients with COVID-19 had significantly higher motivation than nurses who worked in hospitals that did not (Table 3). It is unfortunate that nurses, especially those who cared for patients with COVID-19, experienced discrimination (Fig. 1b, Table 3). In Japan, discrimination, harassment, hostility, abusive language, and hate speech targeting infected individuals and health care workers were common, especially in the early stages of the pandemic. Although this was probably in the perceived interest of self-protection among the public, it likely accelerated the exhaustion of health care workers and, at times, may have exacerbated stress symptoms among nurses. This may be similar to the hostility towards and discrimination against Asians recorded in a minority of Western countries during the pandemic. Moreover, discrimination, harassment, and even violence against health care workers have been reported in other countries [18‐20], causing mental health problems such as stress, anxiety, depressive symptoms, and insomnia [19]. Social efforts to prevent unreasonable attacks on health care workers are urgently needed.

Although the COVID-19 pandemic must have influenced the quality of life of health care workers through its psychological impact, there have been no reports from Japan focusing on changes in behavior and outlook with regard to professionalism and views on life and death. This study evaluated these changes and investigated the associated factors influencing these changes. Concerning behavioral changes, the frequency of preventive measures against transmission was positively impacted (Fig. 2), and greater changes in these factors were observed in nurses and nursing students who were more anxious, fearful, and aware of maintaining voluntary restraint (Table 4). Of note, anxiety/fear about COVID-19 had a stronger impact on nursing students than on nurses (Table 4). These findings are not surprising and suggest that behavioral changes would be forced by stagnation due to anxiety/fear about COVID-19 in nurses, nursing students, and probably the public.

Job satisfaction is considered to be strongly associated with job stress [21, 22], and previous studies have reported decreased job satisfaction among frontline medical staff fighting COVID-19 [23, 24]. In the present study, we focused on job satisfaction and the views of health care workers regarding nursing as a profession. Metrics associated with professionalism, including job satisfaction, were evaluated in four items, as shown in Table 1. Similar to previous reports [23, 24], in the present study, professionalism was significantly negatively impacted in nurses by the rise of COVID-19 (Fig. 2), along with a greater decline in motivation among nurses than nursing students (Fig. 1). Unexpectedly, anxiety/fear about COVID-19, hospital type, and experience caring for patients with COVID-19 did not affect professionalism (Table 4), contrary to a previous report demonstrating an increased level of fear of COVID-19 was associated with job dissatisfaction [24]. Decreased motivation during the state of emergency was strongly associated with the damaged professionalism of nurses in this study (Table 4). Contrary to expectations, our findings showed no difference in the damage to professionalism between nurses working in hospitals that accepted infected patients and those working in hospitals that did not. This suggests a widespread impact on Japanese society caused by this heretofore unknown virus. As damaged professionalism is considered to be associated with premature retirement, burnout, deterioration in the work environment, and patient safety, it is important to build an approach that improves job satisfaction and enhances professionalism in medical fields.

The present study also demonstrated that the COVID-19 pandemic influenced the views on life and death of both nurses and nursing students. As expected, anxiety/fear about COVID-19 among nurses and nursing students and experience caring for patients with COVID-19 were strongly associated with changes in views on life and death. Our data and previous reports [25‐27] show the necessity of providing spiritual support for bereaved families as well as health care workers. Of interest, views on life and death varied greatly among nursing students rather than nurses despite the fact that nursing students did not experience traumatic events such as patients’ deaths. This suggests the importance of appropriate education on life and death for young students.

In the present study, there was no major difference in the type of hospital or experience caring for patients with COVID-19 (Tables 3 and 4). In addition, nurses and nursing students showed similar trends, although some differences were observed (Figs. 1 and 2). These results may be unique to Japan, where the number of infected people is low and the medical care system has not yet collapsed. Also, sex differences were found in some categories. Female nurses were less motivated than male nurses during the state of emergency (Table 3), and female nursing students were more likely to maintain voluntary restraint than male nursing students (Table 3). Also, increased anxiety about nursing was higher among female nursing students than among male students. This is consistent with previous reports that showed that women were more likely to have severe symptoms of anxiety and depression [4, 7, 28], experience burnout [10], and practice preventive measures and social distancing [29]. Further study is needed to evaluate sex differences because of the small number of male nurses and male nursing students in this study.

Several limitations of this study should be considered. First, the severity of anxiety and the degree of change in professionalism are not necessarily an accurate assessment because established scales, such as the Generalized Anxiety Disorder scale (GAD-7) [30], the Minnesota Satisfaction Questionnaire (MSQ), Stember’s Web-based 80-question job satisfaction survey [23, 31], were not employed in this study. In addition, this study focused on anxiety specific to COVID-19. As previous reports have evaluated generalized anxiety, it is difficult to compare the reported findings exactly with those of the current study from the perspective of anxiety. Second, the participants were limited to nurses and nursing students in the Osaka area of Japan, where the prevalence of infected patients is higher than in the suburbs and lower than in the Tokyo area. As such, the results of this study cannot necessarily be generalized to all nurses and nursing students in Japan. Third, the questionnaire consisted of questions that did not focus on the current situation, but asked about the subjects’ recollections of past feelings, behavior, and awareness. Bias due to failed recollection cannot be excluded. Fourth, this study did not have a large number of participants. In particular, the percentages of male nurses and nurses who had experience caring for patients with COVID-19 were relatively small. The numbers may not have been sufficient for statistical analysis to evaluate differences in sex and variance among frontline and second-line staff. Finally, the questionnaire used in this study has not yet been validated, and the results of this study may be limited due to a problem with the analysis method based on the assumption that items of the questionnaire can be scored on an interval scale. Further study is required in the future to assess the validity of this questionnaire.

The COVID-19 pandemic has had a psychological impact, followed by changes in behavior, lifestyle and awareness of nurses and nursing students after the rise of COVID-19, even in Japan where the number of infected patients and deaths, mortality, and severity of COVID-19 are lower than those in other countries and no mandatory lockdown but voluntary restraint was implemented. Especially noteworthy are that the COVID-19 pandemic has influenced the professionalism of nurses and views on life and death of not only nurses but also nursing students. Anxiety/fear about COVID-19, voluntary restraint and decreased motivation at the peak of the pandemic were major associated factors affecting these changes. Our findings will help to understand changes in awareness of nurses and nursing students facing a critical situation, and demonstrate the importance of coping strategies for anxiety and damaged professionalism for nurses and education on life and death for nursing students. These efforts will help improve the clinical environment in the next emerging infectious disease in the future.