The Prevalence of Post-Traumatic Stress Disorder (PTSD) among Emergency Front-Line Nurse during the COVID-19 Outbreak: A Cross Sectional Study in Wuhan, China

The outbreak of a novel corona virus (COVID-19) in Wuhan is bring in rapidly evolving situation at the end of 2019 ,which was parallels with the 2003 outbreak of severe acute respiratory syndrome (SARS) caused by another corona virus with confirmed infection in China[1] . By Apr 5, 2020, there were 82966 confirmed cases of the COVID-19 in China [2]. Wuhan, with population of over ten million in the affected area, had 50008 people got infected and 2570 people lost their life in this epidemic till Apr 5, 2020. Many healthcare workers also lost their life in this disaster. Local residents have been comparing the situation to “the end of the world”, hospitals are overwhelmed and there were concerns about medical supplies shortages [3]. “Panic in Wuhan” is a common refrain[4]  .Individuals severely exposed to disasters, both residents and nurses and they experienced both physical sufferings and great psychological distress with the increasing number of infected cases and deaths at the first breaking stage. As we know, accidents, particularly artificial disasters, may develop PTSD or other mental disorders[5-6] . Fear and anxiety usually appear immediately after the disaster and disappear within a short period of time, but the depression and psychophysical symptoms persist for a longer period of time [7] . When healthcare workers were taking care of COVID-19 patients, they not only had intense pressure from their workload, but also experienced stigma, fear, and frustration. Front-line nurses in emergency are vulnerable to the emotional impact of corona virus in this framework [8]. 

PTSD is an anxiety disorder which occurs in response to experiencing accidents and events accompanied by fear, frustration, and terror [9-12]. Some studies indicated that PTSD can develop in those who witness disastrous events in the workplace not only this affected person [13-18]. Considering the special situation and complexity of COVID-19, which are associated with unpredictable infections and taking care of critically patients and witnessing the death of patients, who were infected, create highly stressful conditions for front-line nurses who are directly in contact with patients. This can cause development of job-related psychological problems such as PTSD symptoms [19-21]. The impact of this epidemic on front-line nurses’ mental health has few been studied. There is also an urgent need to understand the possible psychological impacts of the COVID-19.Thus the aim  of this study is to investigate the prevalence of PTSD among healthcare workers going through the infectious disease.

a. Participant and questionnaire

All front-line nurses in this cross-sectional study are provided by the Emergency Department of Zhongnan Hospital of Wuhan University, and 150 questionnaire were distribute totally to those nurses who went through the COVID-19.Finally,142 questionnaires(94.67%)met the criteria. Every participant completed questionnaires online by their own phone and data were collected after questionnaires completed. Besides, researchers interviewed each participant and explained the purpose, significance, and relevant instructions before administering the questionnaire. Every participant in this project signed a detailed informed consent form. Further, in order to help participants confide in the study, they were requested not to write their personal information and name on the questionnaires. The questionnaire includes two parts. The first part is consisted of demographic characteristics such as age, educational level, job title, working hours per day, marital status, and work experience? experience of disasters. The second part is PCL-C which was utilized in this study to investigate the prevalence of PTSD. 

b.Instrument

PTSD was evaluated in our population using a Chinese-language version of the PTSD Checklist – Civilian Version (PCL-C).The PCL-C includes 17 items that reflect Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria [22]. Participants were asked about how bothered they were by each item over the COVID-19 break time on a 5-point Like scale with regard to their most significant life event stressor. Total scores on the PCL-C range from 17 to 85. We used a PCL-C score of 38 or higher to indicate presence of PTSD in our population. The coefficient of concordance of PCL-C in our population is 0.88-0.94 [23-24] .

We first examined characteristics using number (n) and percentages (%) for categorical variables and mean and standard deviation (SD) for continuous variables. For categorical values, p-values were calculated using the Chi-square test. For continuous variables, p-values were calculated using analysis of variance (ANOVAs). The P values less than 0.05 was considered statistically significant. SPSS Statistics 22.0 was used to performed all statistics analyses.

A total of 142 front-line nurse going through the COVID-19 in Zhongnan Hospital of Wuhan University were included in this study. The demographic characteristics and total scores for PTSD of this study are presented in (Table 1).The majority of front-line nurses in this study (81.69%,n=116) acquired bachelor’s degree. Female nurse consist heavily part of the population (90.14%) and the mean age of women was 32.77 years (SD=7.19).And only 38 participants (26.76%) mentioned experience of disasters in their past work experiences. In this study, the mean (SD) total score of PTSD was 35.81(14.42)in front-line nurse. The prevalence of PTSD was 35.21%.The score was 35.89(14.22) and 35.14(16.74) in female and male, which does not show significantly difference. The mean score in aged over 40 years old was 40.37, which higher than others (p-value=0.012).In the classification of job title, intermediate nurse got the highest score(41.00) than other titles(p-value=0.033). 

Table 1: Demographic characteristics of front-line nurses and total scores for PTSD,n=142

Few studies on the prevalence of PTSD among front-line nurses during the COVID-19 break have been reported to date. Therefore, we conducted an online study to examine the prevalence of PTSD among emergence department in the Zhongnan Hospital of Wuhan University nurses contacted the COVID-19 patients directly, in order know about their stress and to help the better fight the epidemic disaster. In this cross sectional study, 35.21% of emergency front-line nurses experienced PTSD, which is lower than the results of the studies by band Iranmanesh in Iran [25] .This discrepancy can be due to the different target group in the present study, which investigated front-line nurses currently going through the COVID-19. Actually, over 40000 medical staffs have been sent from other provinces to Wuhan to care for patients who are infected and those with suspected infection, 16 Fangcang Hospital were built in only 15 days, Leishen Shan and Huoshen Shan Hospital also finished in a shocking speed, all those steps can strengthen logistics support, and help reduce the pressure on health-care personnel [26]  .Besides, a range of guidelines and expert consensus have been developed by health authorities and academic association in China [27] to help front-line nurses conduct right and precise clinical decision.Actually,hospitals in Hubei lacked of medical supplies in early stage, which may affect nurses’ mental state and this situation went better after other provinces send medical teams and medical supplies to Hubei provinces. All steps above help nurses to adjust their mental stress and avoid some negative mood like depress and anxiety. 

Although the mental health service system in China has been greatly improved after several major disasters, especially the Wenchuan earthquake and the National Health Commission of China released the notification of basic principles for emergency psychological crisis interventions for the COVID-19 on Jan 26, 2020 [28]. Mental health care for the front-line nurses going through the COVID-19 epidemic still has been under-addressed. The Chinese authorities should announced relevant policies and actuating principles aimed at isolated patients or citizens. Unfortunately, few psychological polices are published to mention about nurses or other health workers. As the fight to COVID-19 continues, we hope this study will help researchers from various fields to have a better understanding about the prevalence of front-line nurses towards the COVID-19 and then help the local authority to provide multifaceted guidance aiming at promote health workers mental state effectively.

We declare no competing interests.

None.

The authors' thank Research Group: Department of Emergency in Zhongnan Hospital Wuhan University.

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