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Mental health impacts in pediatric nurses: a cross-sectional study in tertiary pediatric hospital during the COVID-19 pandemic

Abstract

Objective:

to assess mental health issues in pediatric nurses during coronavirus pandemic in 2019.

Method:

cross-sectional study was conducted with pediatric nurses at the Instituto da Criança e do Adolescente based on online self-rated survey about clinical practice and mental health impact during COVID-19 pandemic. Validated self-reported scales for anxiety, depression and burnout were used for assessing these professionals.

Results:

107/298 (36%) nurses answered, 90% were female, median age was 41(23-64) years, 68% worked with adolescents, 66% in frontline. Burnout, anxiety and moderate/severe depression occurred in 65%, 72% and 74%, respectively. Lack of standardized treatment protocol for nurses (27%vs.10%, p=0.049), moderate/severe depression (74% vs. 16%, p=0.002) and burnout (82% vs. 58%, p=0.01) were significantly higher in pediatric nurses with anxiety compared to those without. Pediatric nurses that worked with adolescents compared to those that did not showed higher frequency of burnout in the former group (77% vs. 32%, p=0.0001). Multivariable analysis revealed that adequate quarantine adherence increased the presence of anxiety in 4.6 times [OR4.6(CI 1.1-20.2), p=0.04].

Conclusion:

most pediatric nurses who had worked in the frontline of COVID-19 were under precarious conditions, working with reduced team, and with an expressive changes in their monthly income. Current anxiety was a relevant issue, burnout was also an important mental condition for these professionals, reinforcing culture of good teamwork, collaboration practices and psychological/psychiatric approach.

Descriptors:
COVID-19; Mental Health; Anxiety; Depression; Nurses, Pediatric; Burnout, Professional

Resumo

Objetivo:

avaliar problemas de saúde mental em enfermeiros pediátricos durante a pandemia causada pelo coronavírus 2019.

Método:

estudo transversal realizado com enfermeiros pediátricos do Instituto da Criança e do Adolescente, por meio de uma pesquisa online de autoavaliação sobre prática clínica e impacto na saúde mental, durante a pandemia de COVID-19. Foram avaliadas escalas de autoavaliação validadas para ansiedade, depressão e burnout.

Resultados:

107/298(36%) enfermeiros responderam, dos quais 90% eram do sexo feminino, a mediana de idade atual era 41(23-64) anos, 68% trabalhavam com adolescentes, 66% trabalhavam na linha de frente. Burnout, ansiedade e depressão moderada/grave ocorreram em 65%, 72% e 74% dos enfermeiros, respectivamente. Falta de protocolo de tratamento padronizado nas enfermarias (27% vs. 10%, p=0,049), depressão moderada/grave (74% vs. 16%, p=0,002) e burnout (82% vs. 58%, p=0,01) foram significativamente maiores em enfermeiros pediátricos com ansiedade, em comparação com enfermeiros sem essa condição. Os enfermeiros pediátricos que trabalhavam com adolescentes apresentaram maior frequência de burnout, quando comparados aos que não trabalhavam com esse grupo (77% vs. 32%, p=0,0001). A análise multivariada revelou que o cumprimento adequado da quarentena aumentou a presença de ansiedade em 4,6 vezes [OR 4.6(IC 1,1-20,2), p=0,04].

Conclusão:

a maioria dos enfermeiros pediátricos atuava na linha de frente da COVID-19, em condições precárias, trabalhando com equipe reduzida e enfrentando perdas expressivas de renda. A ansiedade atual foi um tema relevante e o burnout também foi uma condição mental importante para esses profissionais, reforçando a cultura do bom trabalho em equipe, das práticas de colaboração e do cuidado psicológico/psiquiátrico.

Descritores:
COVID-19; Saúde Mental; Ansiedade; Depressão; Enfermeiras Pediátricas; Esgotamento Profissional

Resumen

Objetivo:

evaluar los problemas de salud mental en enfermeros pediátricos durante la pandemia del coronavirus 2019.

Método:

estudio transversal realizado con enfermeros pediátricos del Instituto da Criança e do Adolescente mediante una encuesta de autoevaluación en línea sobre la práctica clínica y el impacto en la salud mental durante la pandemia de COVID-19. Se evaluaron escalas de autoevaluación validadas para ansiedad, depresión y burnout.

Resultados:

respondieron 107/298 (36%) de los enfermeros, de los cuales 90% eran del sexo femenino, la mediana de edad actual fue de 41 (23-64) años, 68% trabajaban con adolescentes, 66% trabajaban en primera línea. Burnout, ansiedad y depresión moderada/grave ocurrieron en 65%, 72% y 74% de los enfermeros, respectivamente. Falta de protocolo de tratamiento estandarizado en las enfermerías (27% vs. 10%, p=0,049), depresión moderada/grave (74% vs. 16%, p=0,002) y burnout (82% vs. 58%, p=0,01) fueron significativamente mayores en enfermeros pediátricos con ansiedad en comparación con enfermeros sin esta condición. Los enfermeros pediátricos que trabajaban con adolescentes presentaron mayor frecuencia de burnout en comparación con los que no trabajaban con adolescentes (77% vs. 32%, p=0,0001). El análisis multivariado reveló que el adecuado cumplimiento de la cuarentena aumentó 4,6 veces la presencia de ansiedad [OR 4.6(IC 1,1-20,2), p=0,04].

Conclusión:

La mayoría de los enfermeros pediátricos trabajaban en la primera línea de la COVID-19, en condiciones precarias, trabajando con un equipo reducido y enfrentando importantes pérdidas de ingresos. La ansiedad actual fue un tema relevante y el burnout también fue una condición mental importante para estos profesionales, reforzando la cultura del buen trabajo en equipo, las prácticas colaborativas y la atención psicológica/psiquiátrica.

Descriptores:
COVID-19; Salud Mental; Ansiedad; Depresión; Enfermeras Pediátricas; Agotamiento Profesional

Highlights

(1) Pandemic infectious diseases may promote psychological changes in health care workers.

(2) Anxiety was a relevant issue reported by pediatric nurses during COVID-19 pandemic.

(3) Burnout was an important mental condition for professionals who had been working with adolescents.

(4) Hospitals must incorporate an appropriate health program for professionals.

Introduction

Coronavirus pandemic (COVID-19) in 2019, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, have changed healthcare workers lives.

Pandemic infectious diseases may promote psychological changes in health care workers, especially women and nurses. Indeed, preexisting health conditions, feelings of vulnerability, social distancing, concerns about family members may increase anxiety, depression and burnout for these health professionals11. Bai Y, Lin CC, Lin CY, Chen JY, Chue CM, Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv. 2004;55:1055-7. doi: https://doi.org/10.1176/appi.ps.55.9.1055
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-22. Sani G, Janiri D, Di Nicola M, Janiri L, Ferretti S, Chieffo D. Mental health during and after the COVID-19 emergency in Italy. Psychiatry Clin Neurosci. 2020;74:372. doi: https://doi.org/10.1111/pcn.13004
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.

Children and adolescents have infrequent COVID-19, however, they may present moderate to severe conditions requiring hospitalization33. Safadi MA, Silva CA. The challenging and unpredictable spectrum of covid-19 in children and adolescents. Rev Paul Pediatr. 2020;39:2020192. doi: https://doi.org/10.1590/1984-0462/2020/38/2020192
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4. Pereira MFB, Litvinov N, Farhat SCL, Eisencraft AP, Gibelli MABC, Carvalho WB, et al. Severe clinical spectrum with high mortality in pediatric patients with COVID-19 and multisystem inflammatory syndrome. Clinics (Sao Paulo). 2020;75:e2209. doi: https://doi.org/10.6061/clinics/2020/e2209
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-55. Sousa BLA, Sampaio-Carneiro M, Carvalho WB, Silva CA, Ferraro AA. Differences among Severe Cases of Sars-CoV-2, Influenza, and Other Respiratory Viral Infections in Pediatric Patients: Symptoms, Outcomes and Preexisting Comorbidities. Clinics (Sao Paulo). 2020;30:e2273. doi: https://doi.org/10.6061/clinics/2020/e2273
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. Pediatric nurses have been working tirelessly to care for COVID-19 patients, many of them need to stay away from their homes for prolonged periods, as they are afraid they may be putting their own families at risk of infection, impacting their mental and physical health66. Al-Mandhari A, Gedik FG, Mataria A, Oweis A, Hajjeh R. 2020 - the year of the nurse and midwife: a call for action to scale up and strengthen the nursing and midwifery workforce in the Eastern Mediterranean Region. East Mediterr Health J. 2020;26:370-1. doi: https://doi.org/10.26719/2020.26.4.370
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. In addition, number of deaths, changes in monthly income, sleep deprivation and sedentarism during this pandemic may influence self-reported anxiety and depression for nurses77. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated with Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3:e203976. doi: http://doi.org/10.1001/jamanetworkopen.2020.3976
https://doi.org/http://doi.org/10.1001/j...
and general practitioners, particularly for nurses who treats and care for adult patients around the word77. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated with Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3:e203976. doi: http://doi.org/10.1001/jamanetworkopen.2020.3976
https://doi.org/http://doi.org/10.1001/j...

8. Amerio A, Bianchi D, Santi F, Costantini L, Odone A, Signorelli C, et al. Covid-19 pandemic impact on mental health: a web-based cross-sectional survey on a sample of Italian general practitioners. Acta Biomed. 2020;91:83-8. doi: http://doi.org/10.23750/abm.v91i2.9619
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9. Lei L, Huang X, Zhang S, Yang J, Yang L, Xu M. Comparison of Prevalence and Associated Factors of Anxiety and Depression Among People Affected by versus People Unaffected by Quarantine During the COVID-19 Epidemic in Southwestern China. Med Sci Monit. 2020;26:e924609. doi: http://doi.org/10.12659/MSM.924609
https://doi.org/http://doi.org/10.12659/...

10. Zhu Z, Xu S, Wang H, Liu Z, Wu J, Li G, et al. COVID-19 in Wuhan: Sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on healthcare workers. EClinicalMedicine. 2020;24:100443. doi: http://doi.org/10.1016/j.eclinm.2020.100443
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11. Sarboozi Hoseinabadi T, Kakhki S, Teimori G, Nayyeri S. Burnout and its influencing factors between frontline nurses and nurses from other wards during the outbreak of Coronavirus Disease - COVID-19 in Iran. Invest Educ Enferm. 2020;38:e3. doi: http://doi.org/10.17533/udea.iee.v38n2e03
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12. Tiete J, Guatteri M, Lachaux A, Matossian A, Hougardy JM et al. Mental Health Outcomes in Healthcare Workers in COVID-19 and Non-COVID-19 Care Units: A Cross-Sectional Survey in Belgium. Front Psychol. 2021;11:612241. doi: http://doi.org/10.3389/fpsyg.2020.612241
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-1313. Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry. 2020;7:e15-e16. doi: http://doi.org/10.1016/S2215-0366(20)30078-X
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.

However, to our knowledge, these issues were not systematically assessed in pediatric nurses during the COVID-19 pandemic, particularly in professionals of a tertiary hospital that follows-up children and adolescents with chronic and severe conditions.

Therefore, the aim of the present study was to assess demographic data, work-related conditions, and mental issues of pediatric nurses during pandemic COVID-19. We also compared demographic and issues related to COVID-19 data in pediatric nurses with and without anxiety, with and without depression, as well as pediatric nurses that worked with adolescents compared to those that did not work with teenagers, as there is a high percentage of patients in this age group being treated at the mentioned institution.

Method

From July to October 2020, a cross-sectional study was carried-out with pediatric nurses who were regularly working during the period studied, anchored by an online questionnaire about physical and mental health impacts during COVID-19 pandemic. All pediatric nurses who had been working at the Instituto da Criança e do Adolescente do Hospital das Clinicas da Faculdade de Medicina from the Universidade de São Paulo, a large university hospital in São Paulo metropolitan area, Brazil (n=298) were invited to participate. A total of 107 (36%) pediatric nurses answered our online survey, and therefore, they were selected as participants.

This anonymous survey was carried out using Research Electronic Data Capture (REDCap) tool to support data capture for research studies. Ethics Committee of our university hospital have approved our research (under the number 4.037.335), and the Informed Consent Form was signed by all participants in the beginning of survey. The online survey was sent to these professionals and at least six emails were sent to all of them to improve the response rate.

The survey included questions about clinical practice, as well as physical and physiological health problems during COVID-19 pandemic. Estimated time for responses of all survey was approximately 15 minutes. These questions were categorized in multiple choice-response, dichotomous (yes and no) or based on visual analogue scale (VAS) (ranged from 0-10) scores, and included:

  • Demographic data of pediatric nurses (current age and gender).

  • Pediatric nurse in remote attendance (telemedicine, cell phone orientations or both).

  • Whether they were working with adolescents (yes/no).

  • Whether they were working in the frontline of COVID-19 (yes/no).

  • Number of pediatric patients during COVID-19 (decreased, increased or remained the same).

  • Number of pediatric patients with suspected COVID-19.

  • Suspected or confirmed death in COVID-19 patients.

  • Changes in monthly income of pediatric nurses during COVID-19 (decreased, increased or remained the same).

  • Molecular and serological methods performed by nurses [real time - reverse transcription polymerase chain reaction (RT-PCR), serology for SARS-CoV-2) infection or both] (yes/no).

  • Seasonal influenza vaccination prescribed for pediatric patients during the pandemic (yes/no).

  • Seasonal influenza vaccination received by nurses during the pandemic (yes/no).

  • General supportive care availability for COVID-19: pediatric nurses, other pediatric health professionals, appropriate personal protective equipment, standardized treatment protocols for children and adolescents with COVID-19, pediatric COVID-19 ward and pediatric intensive care units availability.

  • Pediatric nurses reported feelings: feelings of apprehension, panic, tranquility, optimism, satisfaction and dissatisfaction.

  • The most important impact of pandemic in pediatric nurse: none, change in their monthly wages, psychological health issues, family concerns or preexisting health comorbidity in pediatric nurses (yes/no).

  • Preexisting health conditions of pediatric nurses: asthma, diabetes mellitus, cardiovascular condition, respiratory condition, arterial hypertension, renal insufficiency, obesity, tobacco use or others.

  • Changes in body weight reported by pediatric nurses during pandemic: increased, decreased, no change.

  • Adequate quarantine adherence (yes/no).

  • Physical activity according to VAS score, ranging from 0 (without any physical activity) to 10 (strong physical activity daily).

  • Night time sleep abnormalities according to VAS score, ranging from 0 (no abnormality) to 10 (severe insomnia).

  • Fear of COVID-19 according to VAS score, ranging from 0 (no fear) to 10 (with extreme fear).

  • Frequency of alcohol intake in the past 15 days (never, rarely: once a week, sometimes: around once a week, regularly: up to twice a week, frequently: 3 to 6 times a week or every day).

  • Total amount of alcohol intake [one shot (350ml of beer), or a glass of wine or 40 ml of vodka/whisky]: 1 to 2 shots, 3 to 4 shots, 5 to 6 shots or more than 6 shots.

  • Cigarettes number (no tobacco use, 1 to 5 cigarettes/day, 5-10 cigarettes/day, 10-20 cigarettes/day or more than 20 cigarettes/day).

  • Smoking history and return to smoking during the past 15 days (yes/no).

  • Frequency of smoking marijuana/cannabis in the past 15 days: never, rarely: once a week, sometimes: around once a week, regularly: up to twice a week, frequently: 3 to 6 times a week or every day.

  • Frequency of opioids use (morphine, codeine, tramadol) in past 15 days: never, rarely: once a week, sometimes: around once a week, regularly: up to twice a week, frequently: 3 to 6 times a week or every day.

  • Frequency of sleeping pills usage in the past 15 days: never, rarely: once a week, sometimes: around once a week, regularly: up to twice a week, frequently: 3 to 6 times a week or every day.

Burnout symptoms were measured by a single-item burnout measurement based on the Maslach Burnout Inventory Emotional Exhaustion (MBI:EE)1414. Dolan ED, Mohr D, Lempa M, Joos S, Fihn SD, Nelson KM, et al. Using a single item to measure burnout in primary care staff: a psychometric evaluation. J Gen Intern Med. 2015;30:582-7. doi: http://doi.org/10.1007/s11606-014-3112-6
https://doi.org/http://doi.org/10.1007/s...
. Participants answered the following question: “In general, based on your definition of exhaustion, how would you rate your level of exhaustion?” the chosen answer scored on an ordinal scale of five categories: 1=“I enjoy my work. I have no symptoms of burnout”; 2 =“Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out”; 3 =“I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion”; 4 = “The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot”; and 5 =“I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help”. Score ≤2 was considered as no symptoms of burnout and ≥3 was considered as presence of 1 or more burnout symptoms1414. Dolan ED, Mohr D, Lempa M, Joos S, Fihn SD, Nelson KM, et al. Using a single item to measure burnout in primary care staff: a psychometric evaluation. J Gen Intern Med. 2015;30:582-7. doi: http://doi.org/10.1007/s11606-014-3112-6
https://doi.org/http://doi.org/10.1007/s...
-1515. West C, Dyrbye L, Sloan J, Shanafelt T. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24:1318-21. doi: http://doi.org/10.1007/s11606-009-1129-z
https://doi.org/http://doi.org/10.1007/s...
.

Anxiety and depression were considered as dependent variables. The validated self-reported scores for depression and anxiety in Portuguese language were also evaluated for pediatric nurses based on responses based on their previous 15 days. Patient Health Questionnaire (PHQ-9) scale comprised nine questions using four-point Likert-scale ranging from 0 (not at all) to 3 (almost every day) for each question, and score ranged from 0 to 27. Total score of pediatric nurses was characterized as absent (scores 0-4), mild (scores 5-9), moderate (scores 10-14), moderate to severe depression (scores 15-19) and severe depression (scores 20-27)1616. Lamela D, Soreira C, Matos P, Morais A. Systematic review of the factor structure and measurement invariance of the patient health questionnaire-9 (PHQ-9) and validation of the Portuguese version in community settings. J Affect Disord. 2020;276:220-33. doi: https://doi.org/10.1016/j.jad.2020.06.066
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. Generalized Anxiety Disorder (GAD-7) scale comprised seven questions using four-point Likert-scale, ranged from 0 (not at all) to 3 (almost every day) for each question. The total score of pediatric nurses was considered and divided in two groups: without anxiety (scores ≤ 4) and with anxiety (scores ≥ 5)1717. Sousa TV, Viveiros V, Chai MV, Vicente FL, Jesus G, Carnot MJ, et al. Reliability and validity of the Portuguese version of the Generalized Anxiety Disorder (GAD-7) scale. Health Qual Life Outcomes. 2015;13:50. doi: https://doi.org/10.1186/s12955-015-0244-2
https://doi.org/https://doi.org/10.1186/...
.

Statistical analysis

Data were presented as median (minimum to maximum values) or mean ± standard deviation for continuous variables according to the Shapiro-Wilk test. Data were showed in number (percentage) for categorical variables. Mann-Whitney test or Student’s t-test were used to compare continuous variables, and Fisher exact test or Pearson chi square test were used for categorical variables, as indicated and p value <0.05 was considered as significant. Logistic regression models were used to identify possible factors that would increase the chance of anxiety. Variables with a level of significance less than or equal to 20% in the univariable model were included in the multivariable model as independent variables. The results of the final model are presented as odds ratios (ORs) and 95% confidence intervals (CIs). For all statistical tests, the significance level was set at 5% (p < 0.05). SPSS software, version 22 (IBM Corporation, Armonk, NY, USA) was used for analysis.

Results

The overall response rate was 107/298 (36%) and 90% were female. Table 1 shows demographic and COVID-19 data reported by pediatric nurses during pandemic. Working in the frontline of COVID-19 was reported by 66% of them, the median age was 41 years (23-64), 68% worked with adolescents and 66% worked in the COVID-19 frontline. Deaths in patients with confirmed or suspected COVID-19 were reported by 47%. Changes in monthly wages during the pandemic COVID-19 and feelings of apprehension were informed by 84% and 82% of pediatric nurses, respectively. Anxiety, burnout and moderate/severe depressive symptoms were reported by 65%, 74% and 72%, respectively and emotional impact of pandemic was related by 58% of pediatric nurses (Table 1).

Variables reported by pediatric nurses Pediatric nurses (n=107) Demographic data Female gender 96 (90) Current age, years 41 (23-64) Local of practice 60 (56) Emergency and intensive care units 23 (21) Inpatients Unit 24 (22) Ambulatory and administrative 13 (12) Working in the frontline of COVID-19 71 (66) Working in two or more hospitals 6 (6) Remote care provided n=98 None 91 (85) Cell phone orientation 4 (4) Telemedicine 3 (3) Decreased number of patients during pandemic 54 (50) Deaths in patients with confirmed or suspected COVID-19 51 (47) Changes in monthly income during pandemic COVID-19 by pediatric nurses 90 (84) Seasonal influenza vaccination 104 (97) Molecular and serological methods performed by nurses Real-time RT-CPR* positive 4 (4) Real-time RT-CPR* negative 44 (41) Quick test negative 24 (22) No test 35 (33) Confirmed COVID-19 in pediatric nurses 4 (4) General supportive care availability for COVID-19 Lack of pediatric nurses 49 (46) Lack of other pediatric healthcare workers 62 (58) Lack of appropriate personal protective equipment 22 (20) Lack of standardized pediatric treatment protocol 23 (21) Lack of pediatric Intensive care unit 16 (15) Reported feelings Feelings of apprehension 88 (82) Feelings of dissatisfaction 24 (23) Feelings of optimism 20 (19) Feelings of panic 11 (10) Most important impact of pandemic Changes in monthly income 7 (6) Emotional 62 (58) Family concerns 34 (32) Preexisting health condition None 61 (57) Arterial hypertension 22 (21) Obesity 17 (16) Diabetes 7 (6) Smoking 5 (5) Adequate quarantine adherence 67 (63) Fear of COVID-19 (VAS† scale 0-10) 7 (0-10) Physical activity (VAS† scale 0-10) 0 (0-10) Sleep deprivation (VAS† scale 0-10) 5 (0-10) Anxiety 69 (65) Mild 42 (39) Moderate to severe 27 (25) Depression 77 (72) PHQ-9‡ score 5-9 - mild 25 (23) PHQ-9‡ score 10-14 - moderate 29 (27) PHQ-9‡ score 15-19 - moderate to severe 14 (13) PHQ-9‡ score >20 - severe 9 (8) Burnout 79 (74) Alcohol consumption 53 (49) Tobacco use 9 (8) Return to smoking during COVID-19 pandemic 7 (6) Cannabis use 1 (0,9) Sleeping pills consumption 17 (16) Working with adolescents as patients 73 (68) Nursing practice with adolescents, years 10 (0.8-36) Results are presented in n (%) and median (minimum to maximum values); *RT-PCR = Reverse Transcription Polymerase Chain Reaction; †VAS = Visual Analogue Scale; ‡PHQ-9 = Patient Health Questionnaire

Table 2, below, presents demographic and COVID-19 data reported by pediatric nurses during pandemic according to GAD-7 scale for anxiety. Moderate/severe depression (PHQ-9 score ≥10) (74% vs. 16%, p=0.002) and burnout (82% vs. 58%), p=0.01 were significantly higher in pediatric nurses with anxiety compared to those without this condition, while mild depression (PHQ-9 score ≥5 and ≤9) (26% vs. 60%, p=0.016) and no depression (PHQ-9 score was≤ 4) (10% vs. 61%, p< 0.001) were more prevalent in nurses without anxiety.

Table 2
Demographic and coronavirus infectious disease in 2019 (COVID-19) data reported by 107 Pediatric Nurses during pandemic according to professionals with anxiety (GAD-7* score ≥ 5) and without anxiety (GAD-7* score ≤ 4). São Paulo, SP, Brazil, 2020

Table 3 shows demographic and COVID-19 data reported by pediatric nurses during pandemic according to PHQ-9 scale for depression. Lack of pediatric nurses (60% vs. 33%, p=0.006), burnout (86% vs. 62%, p=0.004), GAD-7 score ≥ 5 (88% vs. 42%, p=0.0001) and consumption of sleeping pills (33% vs. 4%, p=0.0001) were significantly higher in pediatric nurses with depression compared to those without this condition. Regarding nurses who worked with adolescents, the prevalence of PHQ-9 ≥ 10 (49% vs. 47%, p=0.83), GAD-7 ≥ 5 (63% vs. 68%, p=0.67) was similar to nurses who did not work with adolescent. Burnout was significant more prevalent in former group (77% vs. 32% (p<0.001).

Table 3
Demographic and coronavirus infectious disease in 2019 (COVID-19) data reported by Pediatric Nurses during pandemic according to professionals with moderate/severe depression (PHQ-9* score ≥ 10) and without/mild depression (PHQ-9* score < 10). São Paulo, SP, Brazil, 2020

Table 4 demonstrated the univariable and multivariable analysis in the logistic regression model of data reported by 107 pediatric nurses during pandemic related to presence of anxiety. There was only one factor which had significantly increased the chances of anxiety in 4.6 times, adequate quarantine adherence. The univariable and multivariable analysis in the logistic regression model related to presence of depression and burnout showed no statistically significant difference.

Table 4
Univariable and multivariable analysis in the logistic regression model of data reported by 107 Pediatric Nurses during pandemic related to presence of anxiety. São Paulo, SP, Brazil, 2020

Discussion

To our knowledge, this study was relevant in order to investigate physical and mental health issues in Brazilian pediatric nurses during the COVID-19 pandemic in a tertiary hospital. Our study showed relevant impact on the work routine of pediatric nurses, including expressive rates of anxiety, burnout, and depression.

These findings were similar to other studies that evaluated health professionals during COVID-19 pandemic99. Lei L, Huang X, Zhang S, Yang J, Yang L, Xu M. Comparison of Prevalence and Associated Factors of Anxiety and Depression Among People Affected by versus People Unaffected by Quarantine During the COVID-19 Epidemic in Southwestern China. Med Sci Monit. 2020;26:e924609. doi: http://doi.org/10.12659/MSM.924609
https://doi.org/http://doi.org/10.12659/...
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, especially female nurses77. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated with Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3:e203976. doi: http://doi.org/10.1001/jamanetworkopen.2020.3976
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,2121. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behav Immun. 2020;88:901-7. doi: http://doi.org/10.1016/j.bbi.2020.05.026
https://doi.org/http://doi.org/10.1016/j...
. In 2004, a study about the SARS outbreak had already revealed increased levels of anxiety and depression. Nowadays, in order to attenuate possible complications, it is necessary to learn from this experience and provide medium or long-term psychological and psychiatric support for these professionals2222. Thompson DR, Lopez V, Lee D, Twinn S. SARS - a perspective from a school of nursing in Hong Kong. J Clin Nurs. 2004;13:131-5. doi: http://doi.org/10.1046/j.1365-2702.2003.00884.x
https://doi.org/http://doi.org/10.1046/j...

23. Smith GD, Ng F, Li WHC. COVID-19: Emerging compassion, courage and resilience in the face of misinformation and adversity. J Clin Nurs. 2020;29:1425-8. doi: http://doi.org/10.1111/jocn.15231
https://doi.org/http://doi.org/10.1111/j...
-2424. Kang L, Ma S, Chen M, Yang J, Wang Y, Li R, et al. Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study. Brain Behav Immun. 2020;87:11-7. doi: http://doi.org/10.1016/j.bbi.2020.03.028
https://doi.org/http://doi.org/10.1016/j...
.

Pediatric nurses reported herein a high rate of burnout, which could have a relationship with increased workload, stress, being single, social distancing and family-associated stress. In fact, the new protocols and routine, impacted their physical and mental health during pandemic COVID-192525. Maben J, Bridges J. Covid-19: Supporting nurses' psychological and mental health. J Clin Nurs. 2020;29:2742-50. doi: http://doi.org/10.1111/jocn.15307
https://doi.org/http://doi.org/10.1111/j...
. In the present study, burnout rate was significantly higher in pediatric nurses, particularly in those who worked with adolescents. This finding may be related to relevant physical and mental impact in adolescent populations during COVID-19 pandemic, particularly in patients hospitalized due to chronic severe disease, requiring multiple immunosuppression therapies2626. Pereira MFB, Litvinov N, Farhat SCL, Eisencraft AP, Gibelli MABC, Carvalho WB, et al. Severe clinical spectrum with high mortality in pediatric patients with COVID-19 and multisystem inflammatory syndrome. Clinics (Sao Paulo). 2020;75:e2209. doi: http://doi.org/10.6061/clinics/2020/e2209
https://doi.org/http://doi.org/10.6061/c...
. Indeed, a Chinese study showed a higher burnout rate in professionals that worked in usual wards compared to professionals that had worked in the frontline2727. Wu Y, Wang J, Luo C, Hu S, Lin X, Anderson AE, et al. A Comparison of Burnout Frequency Among Oncology Physicians and Nurses Working on the Frontline and Usual Wards During the COVID-19 Epidemic in Wuhan, China. J Pain Symptom Manage. 2020;60:e60-e65. doi: http://doi.org/10.1016/j.jpainsymman.2020.04.008
https://doi.org/http://doi.org/10.1016/j...
.

We showed high prevalence of burnout in pediatric nurses with anxiety and moderate/severity depression. The reports are linked to emotional exhaustion, anxiety and depression2828. Golonka K, Mojsa-Kaja J, Blukacz M, Gawlowska M, Marek T. Occupational burnout and its overlapping effect with depression and anxiety. Int J Occup Med Environ Health. 2019;32:229-44. doi: http://doi.org/10.13075/ijomeh.1896.01323
https://doi.org/http://doi.org/10.13075/...

29. van Dam A. Subgroup Analysis in Burnout: Relations Between Fatigue, Anxiety, and Depression. Front Psychol. 2016;7:90. doi: http://doi.org/10.3389/fpsyg.2016.00090
https://doi.org/http://doi.org/10.3389/f...
-3030. Bianchi R, Schonfeld IS, Laurent E. Burnout-depression overlap: a review. Clin Psychol Rev. 2015;36:28-41. doi: http://doi.org/10.1016/j.cpr.2015.01.004
https://doi.org/http://doi.org/10.1016/j...
. Furthermore, stress may be considered as a preceding factor for these mental health issues2929. van Dam A. Subgroup Analysis in Burnout: Relations Between Fatigue, Anxiety, and Depression. Front Psychol. 2016;7:90. doi: http://doi.org/10.3389/fpsyg.2016.00090
https://doi.org/http://doi.org/10.3389/f...
,3131. Plieger T, Melchers M, Montag C, Meermann R, Reuter M. Life stress as potential risk factor for depression and burnout. Burnout Res. 2015;2:19-24. doi: http://doi.org/10.1016/j.burn.2015.03.001
https://doi.org/http://doi.org/10.1016/j...
. Association between anxiety and depression were also observed in the present study, as also described by other authors3232. Löwe B, Spitzer RL, Williams JBW, Mussell M, Schellberg D, Kroenke K. Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment. Gen Hosp Psychiatry. 2008;30:191-9. doi: http://doi.org/10.1016/j.genhosppsych.2008.01.001
https://doi.org/http://doi.org/10.1016/j...
-3333. Lamers F, van Oppen P, Comijs HC, Smit JH, Spinhoven P, van Balkom AJLM, et al. Comorbidity patterns of anxiety and depressive disorders in a large cohort study: the Netherlands Study of Depression and Anxiety (NESDA). J Clin Psychiatry. 2011;72:341-8. doi: http://doi.org/10.4088/JCP.10m06176blu
https://doi.org/http://doi.org/10.4088/J...
. Depression was significantly mentioned by pediatric nurses with anxiety. These findings were also reported in other studies, possibly related to inadequate available resources, exhaustive workloads, working in tertiary hospitals and in the frontline of COVID-19 pandemic77. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated with Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3:e203976. doi: http://doi.org/10.1001/jamanetworkopen.2020.3976
https://doi.org/http://doi.org/10.1001/j...
,2525. Maben J, Bridges J. Covid-19: Supporting nurses' psychological and mental health. J Clin Nurs. 2020;29:2742-50. doi: http://doi.org/10.1111/jocn.15307
https://doi.org/http://doi.org/10.1111/j...
.

Furthermore, the lack of other pediatric nurses and other health professionals, as well as lack of standardized treatment protocols, especially in the beginning of pandemic, and quarantine adherence, could also contribute to higher rates of anxiety, burnout and the fear of COVID-1999. Lei L, Huang X, Zhang S, Yang J, Yang L, Xu M. Comparison of Prevalence and Associated Factors of Anxiety and Depression Among People Affected by versus People Unaffected by Quarantine During the COVID-19 Epidemic in Southwestern China. Med Sci Monit. 2020;26:e924609. doi: http://doi.org/10.12659/MSM.924609
https://doi.org/http://doi.org/10.12659/...
,2525. Maben J, Bridges J. Covid-19: Supporting nurses' psychological and mental health. J Clin Nurs. 2020;29:2742-50. doi: http://doi.org/10.1111/jocn.15307
https://doi.org/http://doi.org/10.1111/j...
,2727. Wu Y, Wang J, Luo C, Hu S, Lin X, Anderson AE, et al. A Comparison of Burnout Frequency Among Oncology Physicians and Nurses Working on the Frontline and Usual Wards During the COVID-19 Epidemic in Wuhan, China. J Pain Symptom Manage. 2020;60:e60-e65. doi: http://doi.org/10.1016/j.jpainsymman.2020.04.008
https://doi.org/http://doi.org/10.1016/j...
. Quarantine adherence involved social distancing, which has been associated with mental health disorders3434. Wang Y, Xu B, Zhao G, Cao R, He X, Fu S. Is quarantine related to immediate negative psychological consequences during the 2009 H1N1 epidemic? Gen Hosp Psychiatr. 2011;33:75-7. doi: https://doi.org/10.1016/j.genhosppsych.2010.11.001
https://doi.org/https://doi.org/10.1016/...
-3535. Wu P, Fang Y, Guan Z. The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry. 2009;54:302-11. doi: https://doi.org/10.1177/070674370905400504
https://doi.org/https://doi.org/10.1177/...
. Indeed, some studies have found that loneliness was associated with symptoms of depression and anxiety3636. Palgi Y, Shrira A, Ring L, Bodner E, Avidor S, Bergman Y, et al. The loneliness pandemic: Loneliness and other concomitants of depression, anxiety and their comorbidity during the COVID-19 outbreak. J Affect Disord. 2020;275:109-11. doi: https://doi.org/10.1016/j.jad.2020.06.036
https://doi.org/https://doi.org/10.1016/...
-3737. González-Sanguino C, Ausín B, Castellanos MA, Saiz J, López-Gómez A, Ugidos C, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. Brain Behav Immun. 2020;87:72-6. doi: https://doi.org/10.1016/j.bbi.2020.05.040
https://doi.org/https://doi.org/10.1016/...
, and another research has observed that lockdown measures adopted in Germany were associated with higher psychosocial distress and more loneliness, however, they were not related to anxiety and depressive symptoms3838. Benke C, Autenrieth LK, Asselmann E, Pané-Farré CA. Lockdown, quarantine measures, and social distancing: Associations with depression, anxiety and distress at the beginning of the COVID-19 pandemic among adults from Germany. Psychiatry Res. 2020;293:113462. doi: http://doi.org/10.1016/j.psychres.2020.113462
https://doi.org/http://doi.org/10.1016/j...
.

Our study has strengths and limitations. The evaluation of two validated self-reported scales for anxiety and depression, associated to a single item burnout measurement, were extremely relevant to assess the overall mental health impact during this catastrophic period. We also assessed pediatric nurses of a large and referral university hospital. However, limitations included the small sample of pediatric nurses in only one center, lack of information about previous mental health disorders, and the cross-sectional design of the study, allowed us to interpret the results only as current symptoms. The moderate response rate was observed in the present study, possible related to the lack of payment incentive. Furthermore, the absence of a control group with another health professional was another weakness of the present study. In addition, these validated mental health tools were not evaluated in pediatric nurses in other circumstances, such as out of COVID-19 pandemic period.

The COVID-19 pandemic is undoubtedly a stressful experience for different health care providers3939. Cotrin P, Moura W, Gambardela-Tkacz CM, Pelloso FC, Santos K, Carvalho MDB, et al. Healthcare Workers in Brazil during the COVID-19 Pandemic: A Cross-Sectional Online Survey. Inquiry. 2020;57:46958020963711. doi: https://doi.org/10.1177/0046958020963711
https://doi.org/https://doi.org/10.1177/...

40. El-Hage W, Hingray C, Lemogne C, Yrondi A, Brunault P, Bienvenu T, et al. Health professionals facing the coronavirus disease 2019 (COVID-19) pandemic: What are the mental health risks? Encephale. 2020;46:S73-S80. doi: https://doi.org/10.1016/j.encep.2020.04.008
https://doi.org/https://doi.org/10.1016/...
-4141. Kozu KT, Casella CB, Strabelli CAA, Aikawa NE, Campos LMA, Elias AM, et al. Mental Health Impact in Latin American Pediatric Rheumatologists During the COVID-19 Pandemic. J Clin Rheumatol. 2021 Aug 5. doi: http://doi.org/10.1097/RHU.0000000000001782
https://doi.org/http://doi.org/10.1097/R...
. Thus, since the beginning of the COVID-19 pandemic, and in order to care for nurses and other health professionals, our institution has developed a program to offer mental health and psychological/psychiatric support and treatment4242. Fukuti P, Uchôa CLM, Mazzoco MF, Corchs F, Kamitsuji CS, Rossi L, et al. How Institutions Can Protect the Mental Health and Psychosocial Well-Being of Their Healthcare Workers in the Current COVID-19 Pandemic. Clinics (Sao Paulo). 2020;75,e1963. doi: https://doi.org/10.6061/clinics/2020/e1963
https://doi.org/https://doi.org/10.6061/...
.

Conclusion

This study revealed that the mental health of pediatric nurses was undoubtedly impacted during COVID-19 pandemic, corroborating the importance of continuous monitoring of the mental health of professionals. Most of them worked in the frontline of COVID-19, under precarious conditions, working with reduced team and with expressive decrease in their income. Current anxiety was a relevant issue associated with quarantine adherence, which included social distancing by pediatric nurses in the frontline during COVID-19 pandemic. Burnout was also an important mental condition for these professionals that worked with adolescents, reinforcing culture of good teamwork, collaboration practices and psychological/psychiatric approaches. Recognizing mental health status of pediatric nurses is essential to plan future and also for preventive strategies.

Acknowledgments

We thank Professor Guilherme V. Polanczyk, Department of Psychiatry, Faculdade de Medicina and Simone Pavani, Nursing Division, Instituto da Criança da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.

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    » https://doi.org/https://doi.org/10.1177/070674370905400504
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    González-Sanguino C, Ausín B, Castellanos MA, Saiz J, López-Gómez A, Ugidos C, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. Brain Behav Immun. 2020;87:72-6. doi: https://doi.org/10.1016/j.bbi.2020.05.040
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Edited by

Associate Editor

Sueli Aparecida Frari Galera

Publication Dates

  • Publication in this collection
    05 May 2022
  • Date of issue
    2022

History

  • Received
    01 Oct 2021
  • Accepted
    26 Jan 2022
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