Healthcare Workers are in Trouble

Healthcare Workers are in Trouble:

Impact of Fear of COVID-19 Pandemic on the Mental Health of Nurses in Pakistan: A Moderation Approach

 Abstract

Aim: The current research aimed to examine the impact of fear of COVID-19 pandemic on the mental health of Frontline nurses.

Background: The current pandemic significantly impacted the mental, emotional and psychological health of Frontline nurses. To date and up to the researcher’s best knowledge, in Pakistan, no study was found to examine the impact of fear of COVID-19 on nurses mental and psychological well-being and job outcomes. Additionally, past researches did not explore the possible moderating variable that may compensate for the negative impact of fear of COVID-19 on the mental health of nurses.

Methods: Through a cross-sectional research design, we contacted 380 Frontline nurses to participate in the study. We received their responses through standardized scales.

Results: It is found that an increase in fear of COVID-19 may also increase psychological distress, secondary trauma and turnover among Pakistani nurses. Further, we found that leader support moderates the significant relationship of fear of COVID-19 with nurses’ psychological distress, secondary trauma and turnover intention such that the effect of fear of COVID-19 on psychological distress, secondary trauma and turnover intention is low when leader support is high and vice versa.

Conclusions: Based on the findings, it is concluded that hospital administrations should support, encourage and motivate Frontline nurses to reduce negative emotional and mental health issues. Corrective actions are needed to reduce fear among nurses as it adversely affects their mental health, well-being and job outcomes.

Implications for Nursing Management: Hospital administrations are advised to provide a safe and efficient work environment, ensured availability of personal protection equipment, provide adequate moral and financial support, encourage and motivate, offered training on how to effectively manage COVID-19 patients and share recent and correct information with Frontline nurses. These factors may reduce nurses fear of COVID-19, and they become able to perform their work roles effectively.

Key Words: COVID-19, Secondary Trauma, Psychological Distress, Turnover Intention, Leader Support, Frontline Nurses, Pakistan

Introduction

COVID-19 pandemic is a new disease and poses a great challenge to the global health system (Ornell et al., 2020). Like other viruses, this virus has a range of symptoms including sore throat, mild flu, dry cough and fever, to a more hazardous one such as breathing difficulties, pneumonia and in some cases even death (Cirrincione et al., 2020). The working environment for the healthcare workers is significantly affected, and delivering healthcare services has been emotionally difficult for them due to uncertainty, stress and stigmatization (Ramaci et al., 2020). These workers offer their services in extreme situations because of the hasty blowout of COVID-19, lack of specific medication, mortality cases, high levels of infection, no formal operative protocols, lack of personal protection equipment and lockdown. These workers are usually exposed to traumatic events and even witness the death of patients. Still, during the current COVID-19 pandemic, healthcare workers experience intense and enduring exposure to these factors leading to develop the risk of post-traumatic stress disorder (PTSD) or secondary trauma. Past researches highlight that healthcare workers can develop secondary trauma or PTSD following events like MERS outbreaks and SARS epidemics after the end of the emergency (Lillie et al., 2020; Kim 2017; Lee et al., 2018).

Healthcare Workers serving in emergency departments experience a higher risk as compared to those working in other departments of developing one or more symptoms of secondary traumatic stress or vicarious trauma, a common phenomenon during such calamities (Morrison and Joy, 2016; Ratrout and Mansour, 2017; Ornell et al., 2020). Secondary trauma is the indirect exposure to trauma, through the firsthand narrative of a traumatic event, resultantly a set of reactions and symptoms like those found in the people with posttraumatic stress disorder (e.g. hyperarousal, avoidance and re-experiencing). Updated research conducted on COVID-19, particularly in China showed that the psychological health of doctors and nurses is strongly affected by such epidemic. Some studies explored the stress of healthcare workers operating in COVID-19 and concluded that such workers face anxiety, great depression, distress and insomnia related to stressful experiences (Lai et al., 2019; Zhu et al., 2020). Furthermore, the sternness of the symptoms was influenced by age, role, kind of activity performed, gender, specialization and direct exposure to COVID-19 patients.  Labrague and Santos, (2020) studied the impact of fear of COVID-19 on nurses’ job satisfaction, psychological distress and professional and organizational turnover intention and concluded that increase in fear of COVID-19 would increase psychological distress, professional turnover and organizational turnover and decrease job satisfaction.

Maintaining their psychological and mental health is essential for nurses to play an effective role during this pandemic. Although recent literature highlighted that COVID-19 pandemic significantly impacted nurses psychological and mental well-being (Catton, 2020; Xing et al., 2020). Furthermore, recent research also postulated a significant relation between COVID-19 pandemic and adverse mental health issues like anxiety, depression, burnout and stress (Mo et al., 2020; Xing et al., 2020; Nemati et al., 2020; Wu et al., 2020). Ahorsu et al., (2020) argued that vulnerability to disease could create fear and anxiety among nurses that possibly affect their work effectiveness, well-being and psychological health during this pandemic. Furthermore, the mental health of Frontline nurses who directly worked in coronavirus department is highly affected as they are eyewitness of COVID patients suffering and dying (Alharbi et al., 2020) leading to post-traumatic stress (Kameg, 2020). Thus, supporting the nursing workforce in this COVID-19 pandemic is of paramount importance and essential for a healthy work environment.

Brief History of COVID-19 in Pakistan

In Pakistan, the first two cases of COVID-19 were reported on 26 February 2020 in two big cities, i.e. Karachi and Islamabad. Due to fast transmission and lack of proactive steps, the virus spread in the whole country, and at least one confirmed case was reported in each district. Presently Pakistan has the third-largest number of confirmed cases in Asia and the second largest number of confirmed cases in South Asia and the 12^th highest number of confirmed cases in the world. Despite this, the death ratio is comparatively low, i.e. 2.14% compared to the global average of 3.9%. To date, there are 264082 confirmed COVID cases in Pakistan. Among them, 5000 were healthcare professionals, including doctors, nurses and paramedic staff. According to the National Institute of Health, 65 medics lost their lives while fighting against COVID-19. In Pakistan, the number of confirmed cases in healthcare professionals is increasing day by day due to non-availability of Corona Kits, PPE, lack of information and non-serious attitudes of healthcare professionals.

The Role of Supportive Leadership

Mitigating the negative effect of COVID-19 pandemic on Frontline healthcare workers needs potential mechanisms. One possible way to reduce the associated risk of mental health problems is to properly prepare the workforce for the job and the associated challenges (Iversen et al., 2008). The leaders must fully and frankly assess what the workers will face, delivered without euphemisms and false reassurance (Halcomb et al., 2020). The leaders should help and support the healthcare staff to make a morally challenging decision in the current pandemic. This could be achieved through discussion based on Schwarz rounds (Maffoni et al., 2020; Katz et al., 2020), which allows healthcare workers to openly discuss the social and emotional challenges they are facing during patient care. Leaders are human, too, supportive leaders make it possible to protect their follower’s mental health (Jones et al., 2012). Thus, to provide a good working environment, leaders need to study the mind of their staff and act accordingly (Wu et al., 2020).

A mounting body of recent research on COVID-19 pandemic mostly focused on medical investigation, i.e. How to control, prevention strategy, diagnosis and treatment. Also, researchers studied how this pandemic impact healthcare professionals’ lives and mental health and they concluded that it affects healthcare workers’ mental health. However, the question of how this impact is minimized need further investigation. Thus, the current research as an effort to answer the question of how to reduce psychological distress, turnover intention, and secondary trauma caused by COVID-19 among Pakistani nurses.

Objectives of the Current Research

1) To investigate the impact of COVID-19 fear on Nurses psychological distress, secondary trauma and turnover intention

2) To examine significant differences concerning psychological distress, secondary trauma and turnover intention between Nurses who worked with COVID-19 patients and those who did not

3) To investigate the moderating role of leadership support on the relationship of COVID-19 fear and Nurses psychological distress, secondary trauma and turnover intention

Figure 1: Conceptual Framework of the Current Research

Materials and Methods

Participants

A sample for this study was selected from 10 large hospitals of the Khyber Pakhtunkhwa province of Pakistan. A total of 700 sample size was selected from these hospitals by using a cross-sectional research design. We contacted nurses who directly involved to deal COVID-19 patients and those who did not directly involve in dealing COVID-19 patients with this notion that the mental health of those nurses that directly involved with COVID-19 patients is more affected in comparison with others. We received 380 usable responses from the respondents having a response rate of 54.28%. The majority of the respondents were female staff (320) with 84.21%. Their average age was 31.5 years. Majority of the respondents have a BS nursing degree (81%).

Instruments

A scale developed by Ahoru et al. (2020) with seven items for measuring fear of COVID-19 threat was used. A sample item is “how much does your illness affect you emotionally”. To measure turnover intention, a scale used by Labrague et al. (2020) having two items was used. A sample item of turnover intention is “Given the current situation, I am thinking about leaving nursing as a profession”. To measure psychological distress, a short version scale with five items developed by Cavanagh et al. (2006) was used. An example item is “Please tell me how often you have felt very tired for COVID 19 reason in the past three months”. Secondary trauma was assessed with five items of short version scale developed by Bride et al. (2004) was used. An example item is “My heart started pounding when I thought about my work with CVOID 19 patients”. To measure leadership support, a scale developed by Saks (2006) with four items was used. An example item is “My leader cares about my well-being during this pandemic”.

Table 1: Confirmatory Factor Analysis

The above table shows the confirmatory factor analysis of each study variable. The results revealed that fear of COVID-19 has good model fit as all of model fit value is matching with minimum and a maximum threshold. Leadership support is moderating variable in this study; it shows a good model fit. Secondary trauma, psychological distress and turnover intention are dependent variables in this study. The results of the one-factor analysis show that all dependent variables have a good model fit. It shows that the data have fit the model.

Figure 2: CFA of Fear of COVID-19

Figure 3: CFA of Leadership Support

Figure 4: CFA of Psychological Distress

Figure 5: CFA of Secondary Trauma

Figure 6: CFA of Turnover Intention

Table 2: Paired Comparison CFA

To avoid common method bias, we apply Harman’s single factor test. The results of Harman’s test show that confirmatory factor analysis was done for fear of COVID-19 which is an independent variable, moderating variable (leadership support) and dependent variables (secondary trauma, psychological distress and turnover intention). All variables are loaded on a single factor and then compare it with two factors, three factors and five factors. The results of two factors, three factors and five factors have good model fit as compared to their one-factor model. The bold values show a good model fit.

Results

To know whether fear of COVID-19 impact on nurses’ secondary trauma, psychological distress and turnover intention, we apply regression analysis. The results reported in Table 3 shows that fear of COIVD-19 has significant effect on nurse’s secondary trauma (β = .848, p = .000), psychological distress ((β = .840, p = .000) and turnover intention (β = .798, p = .000). This indicates that an increase in fear for COVID-19 may also increase secondary trauma, psychological distress and turnover intention among Pakistani nurses. A one unit increase in fear of COVID-19 composite score will increase 0.848 units secondary trauma, 0.840 units psychological distress and 0.798 units turnover intention among nurses who fight for COVID-19.

Table 3: Coefficients

Model                            UnStd. Beta         S.E.          Std. Beta             t                     p                    

FC         TI                   .798                      .031          .857                25.453             0.000

FC        PD                  .840                      .033          .856                25.405             0.000

FC       ST                   .848                       .030          .879                25.247             0.000

R² = 74%, 73%, 77% respectively

Moderation of Leadership Support

The moderating role of leadership support on fear of COVID-19 on the mental health of nurses is reported here. As seen in the table, the interaction effect of all three models are significant, and LLCI and ULCI do not contain any zero, confirming that leadership support moderates the relationship of fear of COVID-19 with secondary trauma, psychological distress and turnover intention such that the level of psychological distress, secondary trauma and turnover intention is low when leadership support is high. Thus, we concluded that hospital management should facilitate and support their nursing staff in this current pandemic to reduce their level of stress, trauma and distress. The interaction plots of all three relationships were also produced.

Table 4: Moderating Effect of Leadership Support

Models                                Coefficient           se              t                 p           LLCI       ULCI

FC*LS and TI Int_1              .084                    .033         2.54            .012        .119            .149

FC*LS and PD Int_1             .172                    .037        4.65             .000        .193            .245

FC*LS and ST Int_1              .116                    .038        3.07              .002        .142            .191

Figure 7: Interaction plot

Group Comparison

The table reported below highlights the independent sample t-test for group comparison. We generate two groups, i.e. One including nurses that directly involved to deal COVID-19 patients, and the second group include those nurses that have no direct interaction with COVID-19 patients and work in other departments. As the mean scores of nurses dealing with COVID-19 and those working in the other department have almost the same indicating that fear for COVID-19 for nurses fighting directly with COVID-19 and working in the other department is same. So, no significant difference was observed.

Table 5: Group Comparison

Designation                                         N            Mean       Std. Deviation       Std. Error Mean

Dealing with COVID-19 patients     175             3.14            1.062                      .080

Worked in other Department              62             3.24             1.054                     .134

Discussion

The current research was an attempt to empirically examine the impact of fear of COVID-19 on nurses’ psychological health, i.e. Secondary trauma, psychological distress and turnover intention. Furthermore, up to the authors’ knowledge, the current research firstly introduces a mechanism that how the impact of COVID-19 fear is reduced among nurses by introducing leadership support as a possible moderator that may play a remedial role. As we found that fear of COVID-19 has a significant impact on nurse’s secondary trauma, psychological distress and turnover intention and leadership support moderates this relationship indicating that the relationship is weak when there is higher support from leaders. Thus, the current research contributes a key finding to nursing management and leadership. We also compare the level of fear among nurses who directly involved in dealing with COVID-19 patients and those working in other departments. No significant difference was found in the level of fear between the two groups. Generally, the fear of COVID-19 among nurses is high in comparison with the general public leading to their feelings of fear to be infected or unknowingly infected others, including their beloved ones. Furthermore, factors like easy transmission, an increase in the number of cases per day and workload, death ratios, quarantine, social distancing, work-related COVID precautions and non-availability of personal protection equipment’s deepen the fear among nurses and strongly affect their emotional and psychological health and job performance. The dominant factor that increases nurses fear is the risk of being infected as well as unknowingly infected their family members.

To effectively manage such pandemic, well-planned work-related procedures and protocols should be in place, including sets of actions related to the disease outbreak such as guidelines about how to care affected patients, relevant training, safety practices, response plans and mutual collaboration with other units. As nurses are directly involved in dealing with COVID patients, they need to be aware of safety and workplace protocols and practice it in their work environment to perform better their services (Labrague and Santos, 2020; Hirshouer et al., 2020; Labrague et al., 2018). The government of Pakistan initiates a huge media campaign about awareness regarding workplace protocol to prepare the hospital administration as well as the general public for the COVID-19 pandemic. This makes hospitals administration, including doctors, nurses, paramedic and emergency staff to manage the situation effectively.

Limitations and Future Directions

Although, regarding the novel contributions of the current research, there are several important limitations as well that must be addressed. First, the results are based on data collected from hospitals operated in one city, i.e. Peshawar and exclude nurses working in other hospitals in the country. This may affect the generalizability of the findings. To avoid this limitation, future research is needed to include nursing staff from diverse areas. Second, using a cross-sectional research design limits us to examine the causal relationship and lead to common method bias. Thus, for better results and to avoid common method bias, future researchers should use longitudinal or time lag research design. Third, we only study few variables and their link with COVID-19 fear and fail to study other personal and organizational variables like work environment, hospital resources, personal nurse competency, staff adequacy, patient’s volume and acuity that may also affect nurse’s perception of fear. Lastly, we only select nurses’ staff and ignore other emergency workers who are also directly involved in dealing with COVID-19 patients. Future researchers may conduct a similar nature of research by selecting a diverse sample that includes nurses, paramedic staff and emergency workers.

Implications for Nursing Management

The results of our study highlight that in the current phase, nurses are facing huge pressure that affects their mental, psychological and emotional health. In such a scenario, the mental health of nurses requires a preservative approach. It is suggested that a safe and efficient work environment is provided as it may increase a personal sense of control and maximize nurse’s resilience during the pandemic.  The hospital’s administration must provide psychological support, financial support, on the job training and supportive supervision of nurses and other emergency workers who directly fight against COVID-19 patients. Additionally, it is also appropriate for healthcare management to share accurate and valid information about managing stress, reducing burnout and increasing the resilience of nursing staff during a crisis of this magnitude. Ensuring that nurses are updated about the recent and correct information related to COVID-19 may reduce their fear and negative emotions related to this disease. Information that should be shared with nurses includes the proper utilization of available resources, the nature of the virus, precautionary measure to avoid transmission, number of new cases reported per day, number of recovered cases, hospital protocols and the new trend of managing COVID patients.  Moreover, through mental health training, resilience can be attained, and through this personal sense of self-efficacy and self-confidence can be improved (Yoon et al., 2013). Buselli et al. (2020) also argued that encouraging healthcare workers in such a pandemic may empower their emotional and cognitive skills.

As the findings of the current research as well as recent past studies show that excessive fear may badly affect mental health, leading to provoke anxiety and then finally affect their job outcomes (e.g. Turnover intention, job performance, job satisfaction). Thus, hospital administrators must give due attention to the nurses, mental, emotional and psychological health. Thus, proactively taking these measures may improve job performance, job satisfaction, enhance perceived health, reduce professional and organizational turnover and psychological distress among nurses. During pandemic situations, mental health professionals are instrumental in supporting and caring about the mental health of Frontline nurses.

Several important factors may help to reduce nurses fear. These factors are support from supervisors, colleagues, family and friends, adequate break time, sharing work experiences and on the job training. These factors may create a sense of safety, boost their morale and motivate them to perform their assign duties and responsibilities better. As we empirically tested that supervisor support may reduce nurses’ psychological distress, secondary trauma and turnover; thus, support from peers make them able to take proactive decisions confidently. Supervisors may help nurses by providing them training opportunities related to the current pandemic, provide personal protection equipment, share accurate information, give appreciation and motive them through certain financial and career advancement rewards.

Conclusion

The current research sheds light on how fear of COVID-19 impact mental, emotional and psychological health of Pakistani nurses. Further, we also explore and empirically examined how the fear of COVID-19 among nurses should be reduced. Our findings suggest that leader support may use as a remedy for a low level of fear among nurses. Understanding the factors that contribute towards nurses’ fear of COVID-19 and its impact on their mental and psychological health and job outcomes is important when designing strategies related to effective nursing management.

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