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 Table of Contents  
Year : 2022  |  Volume : 24  |  Issue : 3  |  Page : 18-24

Psychological effects of COVID 19 pandemic on nurses deployed in high risk units: A multicentre observational study

1 Department of Psychiatry, Military Hospital Bareilly, Bareilly, Uttar Pradesh, India
2 Director, Institute of Naval Medicine and Professor in Psychiatry, INHS, Asvini, Mumbai, Maharashtra, India
3 Department of Medicine, Military Hospital Bareilly, Bareilly, Uttar Pradesh, India
4 Department of Anesthesia and Critical Care, East Kent Hospital University, Kent, UK

Date of Submission05-Jul-2021
Date of Decision28-Aug-2021
Date of Acceptance04-Oct-2021
Date of Web Publication21-Jan-2022

Correspondence Address:
Lt Col (Dr) Rashmi Chakraborty
Department of Psychiatry, Military Hospital Bareilly, Western Wing, Civil Lines, Bareilly - 243 001, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_101_21

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Introduction: Novel coronavirus disease-2019 pandemic continues to rage the world with enormous economic loss, sickness, and deaths. In management of infectious diseases, nurses play crucial roles in rendering care to patients by risking their own lives, going beyond their training and capacities. Frontline nurses are vulnerable for the development of diagnosable and subclinical psychological problems most often triggered with deaths of colleagues, exposure to the mass scale of deaths, perceived inability to save lives despite best efforts, lack of social supports, shift duties, and working in high-risk environment. Aim: The aim of the study is to assess the depression, anxiety, and stress among nurses working in COVID wards versus non-COVID wards. Materials and Methods: A multicenter observational study was done among 176 frontline nurses from seven different referral government hospitals. Psychological ailments were measured on validated instruments of Depression, Anxiety, and Stress Scale-42 items (DASS-42) and Perceived Stress Scale-10 (PSS-10). Results: Using SPSS version 23.0, data were analyzed using Pearson's Chi-square test, with P < 0.055 being considered statistically significant. On PSS, perceived stress was high in 75% of COVID ward nurses and 67% of non-COVID ward ones. On DASS-42 scale, depression, anxiety, and stress levels among nurses in the COVID-19 wards were 21.64% (n = 21), 32.98% (n = 32), and 20.61% (n = 20) compared to 17.72% (n = 14), 24.05% (n = 19), and 15.18%, (n = 12) in the non-COVID wards, respectively. Conclusions: The amount of reported stress, anxiety, and depression was higher in both groups of nurses, i.e., those working in COVID-19 wards and general wards as compared to general population.

Keywords: Anxiety, COVID-19, depression, nurses, psychological effects, stress

How to cite this article:
Ahmad A, Chakraborty R, Goyal S, Kapoor A, Sidhharth S, Ahmad P. Psychological effects of COVID 19 pandemic on nurses deployed in high risk units: A multicentre observational study. J Mar Med Soc 2022;24, Suppl S1:18-24

How to cite this URL:
Ahmad A, Chakraborty R, Goyal S, Kapoor A, Sidhharth S, Ahmad P. Psychological effects of COVID 19 pandemic on nurses deployed in high risk units: A multicentre observational study. J Mar Med Soc [serial online] 2022 [cited 2022 Dec 1];24, Suppl S1:18-24. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/3/18/336179

  Introduction Top

The clusters of novel coronavirus (2019-nCoV)-infected pneumonia cases were discovered in December 2019 at Hubei province of Wuhan, China.[1] The World Health Organization (WHO) Emergency Committee declared COVID-19 infection as a global health emergency on January 30, 2020. The WHO declared the outbreak as a pandemic on March 11, 2020, when cases were detected across the globe.[2] According to the WHO, approximately >166 million COVID cases and 3.45 million deaths have been reported worldwide.[3] The COVID-19 pandemic debacle has rewritten the world history of 1918 Spanish Flu, wherein the deadly influenza virus (H1N1) had claimed over 20 million lives which could strike back even today with increased virulence.[4] The etiologic agent responsible for the outbreak of coronavirus disease (COVID-19) is novel coronavirus closely related to the severe acute respiratory syndrome (SARS) virus which was named SARS-CoV-2. In India, first case of COVID-19 was reported in the state of Kerala in India on January 27, 2020. By April 2021, India witnessed the second wave of COVID-19 with a rapid upsurge of infectivity rate with cases surpassing two crore mark, resulting in more than 2.5 lacs death. The exponential rise in cases requiring hospitalization in intensive care units (ICUs) and high-dependency units (HDUs) associated with the possibility of a mutant variant has strained our existing healthcare system.

Overburdening of our healthcare workers (HCWs) has adversely affected their psychological well-being. The various psychosocial factors responsible for distress among HCWs are increased risk of personal infection, burnout, sickness, having witnessed deaths of colleagues, exposure to the mass scale deaths, perceived inability to save lives despite best efforts, threats of violence from people, limited medical resources, separation from family, lack of social supports, and stress of inadvertently spreading the infection to others, including friends, family, and loved ones.[5] Increased incidence of psychological issues among HCWs was higher among frontline nurses than among other HCWs. The nurses deployed in COVID-19 units who felt scared and experienced bereavement on exposure to persistent traumatic events were likely to suffer mental ailments such as stress, insomnia, anxiety, depressive disorders, and posttraumatic stress disorder (PTSD), which could further jeopardize healthcare capacity.[6],[7]

  Background Top

Similar studies by Maunder et al., 2003; Ulrich, 2014; and Li et al., 2015 conducted in other countries during the outbreak of SARS, MERS, and Ebola revealed an increased burden of distress, anxiety, and depression among nurses who were assigned duties in high-risk zones.[8],[9],[10] Nursing care for COVID-19 patients is known to be a highly taxing job, with the possibility of judgment errors in the administration of treatment, resulting in serious consequences. Psychological problems result from acute shortage of workforce, mental illness, sick leave, or resignation. The poor psychological health of nurses was not only detrimental for individuals but was also jeopardizing their professional performance and eventually adversely hampering the healthcare delivery system of an organization.[11],[12] Thus, it is important for nurses working in COVID-19 ICU, HDU, and flu clinic to maintain good physical health and optimum psychological well-being. Earlier studies also reported that frontline nurses had received intense stigmatization from family, coworkers, and the community.[13] The coping style was also reported to be an important denominator of mental health among nurses.[14]

The impact of COVID-19 pandemic on the mental health of nurses has been studied in other countries; however, there is a gap in our knowledge of understanding the psychological impact on nurses working in COVID-19 government hospitals in India. Therefore, this study was undertaken to bridge the gap in our knowledge of prevalence of stress, anxiety, and depression among nurses deployed in COVID-19 units in North India.

[TAG:2]Materials and Methods[/TAG:2]

Study design

This multicenter, comparative, cross-sectional observational study was conducted in the psychiatric department of a zonal government hospital in Bareilly. After obtaining informed consent, 176 nurses from seven different government hospitals in Uttar Pradesh were recruited from July 1, 2020, to October 30, 2020.

Data collection

The scanned copies of all screening questionnaire of Depression, Anxiety, and Stress Scale-42 items (DASS-42) and Perceived Stress Scale-10 (PSS-10) were sent by registered post in a sealed envelope to principal supervisor of nurses of each hospital for further distribution to participants. This was done in collaboration with psychiatric matron and nursing supervisor of each hospital. Informed consent was taken from all participants. Anonymity of the volunteering participants and confidentiality of their responses were ensured. During the entire research and data collection, recommended COVID-19 appropriate behavior was adhered to.

Study population

All healthy nurses deployed in COVID-19 units (ICU, HDU, flu clinic, COVID screening, and acute COVID-19 wards) and nurses working in general wards were included. Nurses doing administrative duties and those with diagnosis of psychiatric disorder were excluded from the study.

Study sample

Prior data indicated that the probability of psychological morbidities in frontline HCWs was 20%.[15] Based on the known prevalence, the sample size was calculated using the formula N = Zα/2 × P × (1 − P)/d2. For an estimated prevalence (P) of anxiety as 20%, with 5% absolute precision (d), standard normal deviate Zα/2 value for 95% confidence interval taken as 1.96, and 20% nonresponse proportion, the sample size was estimated to be 151. By the convenient sampling method, initially, 205 participants from seven government hospitals were inducted into the study. Finally, 176 participants were recruited after 29 participants were excluded due to incomplete/erroneous responses at the data collection phase of the study.

Rating instruments

Depression, Anxiety, and Stress Scale-42 items

This 42-item scale was developed by Lovibond and Lovibond in 1983 to assess the negative emotional states of depression, anxiety, and stress by 14-item questionnaire for each subconstruct.[16] It has well-established psychometric properties and its factor structure has been adequately substantiated by exploratory and confirmatory factor analysis. Internal consistencies (coefficient alpha) for each scale for the DASS normative sample were: depression - 0.91; anxiety - 0.84; and stress - 0.90.[17]

Perceived Stress Scale-10 items

The PSS (10-item) scale is a self-administered questionnaire to assess “the degree to which individuals appraise situations in their lives as stressful.” The original instrument is a 14-item scale (PSS-14) that was developed in English. Later, it was shortened to 10 items (PSS-10) using factor analysis. Internal consistency reliability, factorial validity, and hypothesis validity of the PSS are well reported. The psychometric properties of the 10-item PSS were found to be superior to those of the 14-item PSS.[18],[19]

Ethical consideration

After ethical approval of the hospital ethics committee, all participants have signed the informed consent form when they were explained the purpose of the study and assured the confidentiality of the information and participation.

Statistical analysis

The statistical analysis was performed using IBM SSPS Statistics version 23. The places of work variables were analyzed by Chi-square test for quantitative variables. 5% probability level was considered as statistically significant, i.e., P < 0.05.

  Results Top

The forms were sent to approximately 300 nurses of seven different hospitals. Only 205 nurses gave valid consent for participation in the study (response rate being 68.33%). Among a total of 205 volunteers, only 176 participants had correctly filled up the response sheets (validity rate 85.85%). About 14.15% of the participants (n = 29) had incomplete/erroneous responses and were excluded from the study. Statistical analysis was performed using SPSS version 23.0 (International Business Machines Corporation). The data were analyzed by Pearson's Chi-square test for qualitative variables. Descriptive statistics were depicted as frequency, mean, and standard deviation (SD) according to the type of data.

All participants (n = 176) were female, within the age group of 21–55 years, educated (Diploma Nursing, BSc Nursing, and MSc Nursing), and employed in government hospitals in Uttar Pradesh. Since our study was designed to keep all personal information of participants anonymous based on a small pilot prestudy survey to facilitate elicitation of unbiased and genuine responses, demographic data were not included in the study. Out of the 176 participants, 55% (n = 97) were actively involved in COVID-19 ICU, HDU, and ward whereas 45% (n = 79) were working in non-COVID wards [Figure 1].
Figure 1: Workwise distribution of sample in COVID and non-COVID wards

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In our study, out of 176, about 71.6% of participants (n = 126) reported moderate-to-severe perception of stress whereas 28.4% (n = 50) reported low stress levels on PSS. The prevalence of stress in nurses working in COVID-19 ICU, HDU, and fever clinics (COVID wards) (N = 97) measured on PSS revealed; low stress - 27.744% (n = 24); moderate stress - 71.13%(n = 69), and severe stress - 4.12% (n = 4) (mean - 16.948, SD - 6.1530) compared to those worked in non-COVID wards as low stress - 32.91% (n = 26), moderate stress - 65.82% (n = 52), and severe stress - 1.26% (n = 1) (mean - 16.013, SD - 6.1530). On comparing nurses perceiving moderate-to-severe stress (PSS score 14 or more) in both groups, 75.3% reported moderate/severe stress in COVID wards versus 42.1% in non-COVID wards. However, no significant difference among the two groups was present (P = 0.152) [Table 1], [Table 2] and [Figure 2].
Figure 2: Perceived Stress Scale: Work-wise distribution of perceived stress in study

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Table 1: Perceived Stress Scale-10: Working area wise distribution of perceived stress

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Table 2: Group statistics comparison of Perceived Stress Scale and Depression, Anxiety, and Stress Scale-42 items scores in nurses-workwise distribution

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Based on DASS-42, depression in nurses working in COVID wards was mild in 6.18% (n = 6), moderate in 5.15% (n = 5), severe in 8.24% (n = 8), and extremely severe depression in 2.06% (n = 2) versus in nurses working in non-COVID ward was mild in 5.15% (n = 5), moderate in 6.18% (n = 6), severe in 1.26% (n = 1), and extremely severe in 2.06% (n = 2) (P = 0.320, not significant). Mean scores of depression were 5.74 in nurses who worked in COVID ward versus 4.76 in nurses who worked in non-COVID ward (P = 0.206, not significant). Anxiety in COVID ward nurses was mild in 9.27% (n = 9), moderate in 10.38% (n = 10), severe in 7.21% (n = 7), and extremely severe in 6.18% (n = 6) versus anxiety in non-COVID ward was mild in 3.79% (n = 3), moderate in 10.12% (n = 8), severe in 3.79% (n = 3), and extremely severe in 6.32% (n = 5) (P = 0.508, not significant). Mean scores of anxiety were 6.062 in COVID ward nurses versus. 5.068 in nurses who worked in non-COVID ward (P = 0.337, not significant). Stress was mild in 8.24% (n = 8), moderate in 4.2% (n = 4), severe in 8.2% (n = 8), and none in extremely severe category in COVID ward nurses versus mild in 3.79% (n = 3), moderate in 5.06% (n = 4), severe in 2.53% (n = 2), and extremely severe stress in 3.79% (n = 3) (P = 0.098, not significant). Mean scores of stress in COVID ward nurses was 8.103 versus in nurses who worked in non-Covid ward was 7.051 (P = 0.209, not significant) [Table 2], [Table 3] and [Figure 3].
Table 3: Depression, Anxiety, and Stress Scale -42 items: Work- Wise distribution of Depression, Anxiety and Stress in Nurses

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Figure 3: Linear by linear association of variables measured on Depression, Anxiety, and Stress Scale-42 in both groups of nurses

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  Discussion Top

Research studies on the psychological impact of SARS and COVID-19 pandemic on HCWs have been done globally. After extensive search on PubMed and Google Scholar for research in HCWs in the Indian setup, we found few published studies on HCWs, however not a single exclusive study on psychological health of nurses in COVID-19 pandemic. This study is novel in terms of focus of research on psychological problems in frontline nurses in seven different government hospitals in North India amid the COVID-19 pandemic health crisis.

Stress levels measured on PSS revealed low levels of stress in 24.7% and moderate-to-severe stress in 75.3% of the participants who were working in COVID wards with mean PSS score of 16.94 (6.09) as compared to 32.9% and 67.1%, respectively, with those in non-COVID wards and mean PSS score of 16 (6.15); (P = 0.152). On DASS-42 scale, approximately 21.64% of nurses working in COVID ward reported depression versus 17.72% (P = 0.572) of those working in non-COVID wards. Similarly, 32.98% and 20.61% of nurses detailed in COVID wards reported anxiety and stress symptoms versus 24.05% and 15.18% (P = 0.243, P = 0.433), respectively, in non-COVID wards. The findings of the study are consistent with the study by Wang et al. on acute psychological effects on HCWs in Wuhan, China, during the pandemic which revealed the prevalence of depression, anxiety, and PTSD to be 15.0%, 27.1%, and 9.8%, respectively.[20] A study on Indian healthcare professionals reported that anxiety and depression were present in 23% and 16.8% of participants, respectively; however, the intensity of psychological symptoms was mild. 40.9% of the participants reported sleep disturbances, 33.5% abused substance abuse, and 1.1% reported thoughts of self-harm.[21] Another study by Lua et al. in anesthesiologist and nurses in Singapore found stress in 37.4%, moderate anxiety in 30.7%, and depression in 30.0%. The depression was proportionately higher in nurses (13.7%) compared with anesthesiologists (6.7%), although it was not statistically significant (P = 0.097).[22]

An Ethiopian study about psychological distress during COVID-19 pandemic on nurses revealed higher prevalence of anxiety, depression, and stress being 69.6%, 55.3%, and 20.5%, respectively.[23] Another multicenter study done in India reported that anxiety and depression were higher in COVID-19–exposed participants. 60% of HCWs showed that moderate depression was deployed in secondary and tertiary care centers and 55% of HCWs had mild depression deployed in tertiary care centers. Stress factor did not show any significant difference between the different groups and there was no significant difference of psychological distress measured on DASS concerning working environment.[24]

The systematic review of psychological impact on HCWs during the current COVID-19 pandemic revealed the percentage of HCWs with anxiety ranged from 9% to 90%, with a median of 24%; for depression ranged from 5% to 51%, with a median of 21%; and for stress ranged from 7% to 97%, with a median of 37%.[25] Another similar systematic review by Cabarkapa et al. unraveled various protective factors such as positive personal coping strategies, psychosocial intervention targeting fear and worries, workplace measures such as clear communication, social support, protective equipment, and infection control policies and planning.[26] The plausible explanation of wide gaps in the incidence of psychological ailments in HCWs across different studies might have been due to difference in study designs, research methodology, coping mechanism, and availability of protective gears, work environment, training, and progressive advancement in scientific research about SARS-CoV-2 infection. In our study, the lesser percentage of prevalence of psychological morbidities might have been due to the study population being from armed forces, were more resilient, disciplined, followed infection control protocols, and had congenial working condition. These protective factors might have been reasons for better outcome when compared with psychological impact on frontline workers in other countries like Spain.[27]

Around 56% (n = 100) of participants with moderate-to-severe stress levels had flagged two important factors as causes of their apprehension in their additional inputs' columns: (1) mind schema that if they contract infection, they will die or pass on infection to their loved ones and (2) role conflict (cognitive dissonance) whether to adopt the ethical path of care for patients or adopt own life safety and resultant moral injury, guilt. The predisposing factors incriminated for psychological problems in HCWs were biological factors (history of mood disorders, young age), psychological factors (cluster C traits, childhood trauma, individuals with emotional-focused coping, denial defenses),[28],[29] and socioenvironmental factors (lack of proper communications, misinformation).[23],[24] Others include risk of exposure to infection (associated fear and negative thoughts of being contagion for his/her own loved one back at home), social distancing/quarantine (loneliness, boredom, loss of support system), job-related stress, personal protective equipment-related issues, and role conflict.[30],[31],[32],[33],[34]

Further, National Mental Health Survey 2015–16 had reported lifetime mental morbidity in Uttar Pradesh as 8.7%.[35] A matter of concern is that the incidence of psychological ailments is much higher in nurses deployed in COVID hospitals as compared to general population, which needs to be addressed at institutional and community level to prevent psychiatric morbidity among HCWs, especially nurses.

Our study found greater number of nurses working in COVID wards reporting depression, anxiety, and stress as compared to non-COVID wards, though the difference was not statistically significant. This echoed the findings of the study done by McAlonan et al. during peak of the 2003 SARS outbreak among high-risk HCWs (who practiced respiratory medicine) and compared them with low-risk HCWs (nonrespiratory medicine workers). The high-risk HCWs had elevated stress levels (PSS-10 score = 17.0) that were not significantly different from levels in low-risk HCWs control subjects (PSS-10 score = 15.9).[36] The reason could be that those detailed in non-COVID ward were also facing challenges in the form of risk of infection from undiagnosed COVID-19 patients, social stigma by virtue of being HCW, work overload, shift duties, and possibility of conscripted duties in COVID ward in the future.

The meta-analysis by Sheraton et al. on the psychological impact of COVID-19 pandemic in HCW (n = 6035) versus non-HCWs (NHCWs, n = 5417) did not find statistically significant difference between combined effect of anxiety, depression, PTSD, and occupational stress of HCW when compared with NHCWs during the current pandemic. Only the insomnia parameter was noted to be significantly higher in the HCW group compared to the NHCW group.[37]

The study has some limitations. It was done in government hospital nurses in Uttar Pradesh and more research in different settings needs to be done for generalization of findings amongst nurses in the community. Next, this was a cross-sectional study. Hence, the number of nurses developing syndromal psychiatric disorder longitudinally would vary as there was no long-term follow-up.

  Conclusions Top

Our study has revealed higher levels of stress, anxiety, and depression among nurses deployed in both COVID and non-COVID wards in COVID-19 hospitals during COVID-19 pandemic outbreak. Prevalence of psychological symptoms was higher in nurses working in the COVID ward compared to those working in non-COVID wards, although the difference was not statistically significant. The higher levels of psychological symptoms in nurses deployed in general wards of a COVID-19 hospital possibly could be attributed to large number of silent infectious cases, atypical clinical presentation of COVID-19, and to some extent a relatively lesser degree of infection control measures being adopted in general wards versus COVID-19 wards. We conclude that the prevention of psychiatric morbidity among HCWs, especially nurses, would reduce further collapse of the overburdened healthcare system. Therefore, various psychological interventions with focus on enhancing coping skills, resilience building, psychological debriefing sessions, relaxation training, problem-solving skills, sleep hygiene, and ensuring provision of adequate personal protective gears to HCWs in the high-risk zone are some of the steps to safeguard the psychological well-being of the COVID-19 warriors.


We would like to acknowledge Mr. Amit Mahajan, Biostatistician, Maharaja Agrasen Hospital, New Delhi, and Col Omana Kuriakose, Principal Matron at INHS Asvini (erstwhile Principal Matron at MH Bareilly).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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[PUBMED]  [Full text]  
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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