Introduction

The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) associated pneumonia that emerged in Wuhan, China in December 2019 and was later declared by the World Health Organization (WHO) to be a pandemic has been called coronavirus disease-2019 (COVID-19) (1). Respiratory droplets are the main ways in which COVID-19 spreads. This can make healthcare workers a high-risk population at the beginning of the pandemic. Healthcare personnel are forced to perform their jobs under challenging conditions. Moreover, COVID-19 spreads, they are under enormous psychological pressure. Not only do they generally experience traumatic events, they frequently witness patient deaths.

Previous studies have shown that post-traumatic stress disorder (PTSD) develops in healthcare personnel in such epidemics as SARS and middle east respiratory syndrome (MERS) (2). Reasons for such trauma are to living in isolation, work in high-risk environments and to being in contact for treatment of infected patients (3). Healthcare workers encountering traumatic events begin seeing their environment negatively and to lose a sense of security. Consequently, they may become increasingly isolated as they try avoiding situations that remind them of the traumatic events they have experienced (4). Given that the psychosocial effects of the pandemic on people are so immense, healthcare workers will come up against similar difficulties even more intensely. A study conducted in Italy in the COVID-19 situation there showed that physicians and nurses had greater levels of stress and anxiety than the non-health care worker population (5). Ourstudy aims to determine PTSD symptoms levels and psychiatric symptoms of healthcare workers working at pandemic hospital during the COVID-19 pandemic.

Method

This study was conducted between March 2020-June 2020 with 973 consenting participants working at the pandemic hospital. All participants studied in the pandemic services. For study we used an online questionnaire, which consisted of three parts: an online-informed consent, basic sociodemographic information and a set of online questions. This questionnaire was sent to all hospital workers (total number of 2703) with the permission of the head physician and the participants were doctors, nurses and the other healthcare workers. A total of 973 (36.0%) people completed all survey. These data were collected by the researchers. All procedures were approved by University of Health Sciences Turkey, İstanbul Training and Research Hospital’s Ethics Committee (approval number: 2276, date: 08.05.2020). Approval was also obtained from Scientific Committee.

The sociodemographic data form was created considering the participants’ position, sex, age, educational level, marital status, number of children, psychiatric illness status, use of psychiatric medications, alcohol-tobacco use, occupational status and working conditions at the hospital.

The second part of the questionnaire asked the participants to assess the COVID-19 risk in their workplace. It also asked if an elderly person lived in their home, as well as if they had received a diagnosis of COVID-19. The participants were asked to indicate the degree to which they had been psychologically affected by the pandemic and the extent to which they were afraid of transmitting COVID to other people and relatives. They were also asked how long they thought the current situation will last. Through these questions, healthcare workers’ behavior vis-à-vis the COVID-19 situation and the differences between them in terms of stress and anxiety was analyzed. To uncover the worries and fears of participants about COVID-19, the following statement was used: “I am very concerned about COVID-19” (COVID-19 anxiety). 

Traumatic Stress Symptom scale: This self-report scale was developed by Başoglu et al. (6) to determine the possibility of PTSD and depression accompanying PTSD over the course of the previous month. Ton this 23-point scale, there are 17 traumatic stress symptom-related statements and six depression symptom-related statements (6).

Statistical Analysis

Statistical analyses were performed using SPSS version 17.0. To determine the extent to which the variables were normally distributed, histogram graphs and the Kolmogorov-Smirnov test were used. Descriptive analyses were performed using means, median and standard deviations. Categorical variables were compared using Pearson chi-square test. When assessing non-parametric (non-normally distributed) variables, the Mann-Whitney U test was used for 2 categories and the Kruskal-Wallis test for more than 2 categories. When analyzing ordinal data, the Spearman correlation test was used. Results containing a value less than 0.05 were considered statistically meaningful.

Results

A total of 973 persons 352 men and 621 women participated in the study. The sociodemographic characteristics of the participants who completed the questionnaire are shown in Table 1.

Table 2 contains the responses of nurses, doctors and other personnel to items that make up the Traumatic Stress Symptom scale (TSSS). The TSSS scores of nurses were significantly higher than those of doctors and other participants. Based on these results, of the three groups, it can be said that nurses constitute the group most traumatized by the perception of severity of the COVID-19 situation. Infact, the fear of doctors about transmitting COVID-19 to people at home was less than this fear in the other two groups (p<0.001). Among the three groups, nurses also had the highest fear of dying during the COVID-19 pandemic (p<0.001); the highest feelings of hopelessness about the future during the COVID-19 pandemic (p<0.001); the highest increase in the level of anxiety (p<0.001), and the highest experience of recent sleep disturbances (p<0.001). Women had a statistically significantly higher mean TSSS score and  mean TSSS score of participants with doctors or medical specialization was lower than participants with other levels of education (p<0.001) (Table 3). Mean TSSS score of those working in high COVID-19 risk environments was higher than of those working in moderate COVID-19 risk environments (p<0.001).

The finding of low COVID positivity (8.4%) among the healthcare workers participating in our study may be attributable to the quarantine measures that were in place at the time. However, 785 (80.7%) of them had had a relative or colleague test positive for COVID-19. Fear of transmitting COVID-19 to people at home, fear of dying, feelings of hopelessness about the future, increasing anxiety levels, and experiencing recent sleep disturbances were all higher in women than in men (p<0.001). More men predicted that the COVID-19 pandemic would last 6 months, whereas more women said that it would last one or more years (Table 4). The participants who were working in a department at high risk of COVID-19 was 54.3%. More persons working in such departments reported feelings of hopelessness about the future and increased anxiety during the pandemic than those working in departments at moderate risk of COVID-19 (p<0.001). Likewise, more reported having recently experienced sleep disturbances than those working in environments at low and moderate risk of COVID-19 (p<0.001). Previous psychiatric treatment history was reported less among persons working in departments at moderate risk of COVID-19 (p<0.001). The number of people working in environments at high risk of COVID-19 stating that it would last more than one year was higher than people working in other risk environments (p<0.001).

Discussion

Our aim in this study was to analyze the post-traumatic stress symptoms of healthcare workers. It is crucial that healthcare institutions provide psychosocial support and intervention to their healthcare employees. Concern about infection, fatigue, burnout at the workplace and PTSD may be seen in healthcare workers (7). A study reported that PTSD was seen in 25% of healthcare workers during the SARS and Ebola epidemics (8). Our study found that the mean PTSD score in women was significantly higher than in men. Similarly, the mean TSSS score of nurses was higher than that of doctors and other healthcare workers. The reason for this may be that nurses constitute a group of healthcare workers having the greatest contact with patients. Nurses report a higher degree of physical reactions such as heart palpitations, trembling and sweating-when confronting environments reminding them of previous events than doctors and other healthcare workers do (p<0.001) (29.9%). Additionally, nurses report a higher degree (68.6%) of avoidance behavior than do doctors and other healthcare workers.

The loss of a sense of security is closely related to PTSD. An earlier study reported that one of the greatest fears healthcare workers had during the SARS and MERS epidemics was that they would transmit infection to family and friends (4). The rapidity and ease at which COVID-19 spreads have also been a major stressor negatively affecting the mental health of healthcare workers. This stressful situation has been reported to be a critical risk factor for PTSD in healthcare workers (9). In our study, the fear of transmitting COVID-19 to others at home was less in doctors (83.7%) than in nurses (89.1%) and the other groups (91.4%). However, the difference between the groups was not statistically significant (p=0.008). The fear of transmitting the disease was quite high in all three groups. The fear of death, hopelessness about the future, an increase in anxiety levels, and recently having experienced sleep disturbances during the COVID-19 pandemic was higher in nurses than in doctors and the other groups. The virus is a cause of illness and death and involves uncertainty, which may produce unrealistic fear and panic (10). The greatest psychological impact of the COVID-19 pandemic on the mental health of society can be seen in the rise of extreme stress or anxiety in individuals (WHO, 2020). Sleep disturbances may explain the high rate of PTSD in nurses. In addition to having severe negative impacts on physical health, COVID-19 may cause mental health problems such as stress, insomnia, high anxiety and chronic depression (11).

While there is no monitoring system systematically tracking COVID-19-related deaths of healthcare workers in the world, according to statistics compiled by Amnesty International, more than 3,000 healthcare workers in 79 countries have died from COVID-19 (12). This situation increases the fear of death among healthcare workers. In our study, the fear of death was greater than the fear of transmitting COVID-19 to others at home. It was also greater in people who had children.

Although the rate of PTSD was significantly higher in nurses in our study, PTSD was also seen in the other two groups. Indeed, it was much higher in people working in environments at high risk for COVID-19 than in the other groups. A systematic study of the mental health of the general population showed that individuals experience the following mental health issues at the rates indicated: anxiety (6.3-50.9%), depression (14.6-48.3%), PTSD (7-53.4%), and stress (8.1%-81.9%) (12). In our study, the rate of anxiety among healthcare workers, which has increased, was 71.2%. They experienced feelings of hopelessness at a rate of 62.8% and PTSD at a rate of 75%. The difficulties that health care workers have in feeling safe at work may be due to the psychological distress that health care workers experience. The virus not being fully understood, the lack of information on how to prevent and control it, long heavy workloads, the high risk of being exposed to COVID-19 patients, shortages of protective medical equipment, insufficient rest, and being exposed to critical life event like death may contribute to this feeling of being unsafe at work. 

Study Limitations

Our study is not sustainable. We cannot predict what will happen one year later because most of the workers who participated in our research left our hospital. Also our study was conducted only one pandemic hospital. Future studies will be conducted different hospitals.

Conclusion

PTSD has occurred in all healthcare workers during the COVID-19 pandemic, which claimed many lives of healthcare workers in Turkey since February 2021. It occurs more in nurses than in doctors and other healthcare workers. PTSD is also higher in women, who work in a risky setting or who have elderly people or children living at home. Anxiety levels in healthcare workers are high. This can be attributed to the length of work hours and insufficient rest, so it is recommended that healthcare workers should work on well-designed shifts and psychological support should be provided whenever it is necessary.

Ethics Committee Approval: All procedures were approved by University of Health Sciences Turkey, İstanbul Training and Research Hospital’s Ethics Committee (approval number: 2276, date: 08.05.2020).

Informed Consent: It was obtained.

Peer-review: Externally and internally peer-reviewed.

Authorship Contributions: Concept: İ.G.K., S.B.; Design: İ.G.K., Ö.C., S.B.; Data Collection or Processing: İ.G.K., S.B.; Analysis or Interpretation: İ.G.K., Ö.C., S.B.; Literature Search: İ.G.K., Ö.C., S.B.; Writing: İ.G.K., Ö.C., S.B.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.