Official Journal of the College of Nursing, University of Mosul

Document Type : Review Articles

Authors

1 Deputy Vice-Chancellor (Research & Innovation), Lincoln University College, Malaysia

2 Adult Health Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan

Abstract

Background: This systematic review explores fear and anxiety levels among nurses during the COVID-19 pandemic, alongside other mental health dimensions.
Methods: A total of 18 selected studies were analyzed, focusing on tools like the Fear of COVID-19 Scale (FCV-19) and the Depression, Anxiety, and Stress Scale (DASS) to measure fear and anxiety.
Results: Nurses exhibited high fear levels, particularly concerning infecting loved ones and potential fatalities. While no specific COVID-19 anxiety scale was identified, the AMICO scale from Spain shows promise.
Conclusion: Identified risk factors encompassed personal, working, and attitudinal factors related to COVID-19. This review underscores the need for tailored support strategies and interventions to address nurses' mental well-being during the pandemic.

Keywords

INTRODUCTION

Anxiety among nurses in healthcare settings is a prevalent issue that can significantly impact their well-being and job performance(Burstyn & Holt, 2022; Campos et al., 2021; Cohen et al., 2023). The demanding and often unpredictable nature of nursing duties, coupled with high patient acuity and workload pressures, contributes to elevated stress levels among nursing professionals(Coimbra et al., 2023). Chronic anxiety not only affects the mental and emotional health of nurses but can also lead to burnout, reduced job satisfaction, and diminished quality of patient care(Amsalem et al., 2021; Denning et al., 2021). Recognizing the importance of addressing nurse anxiety, numerous strategies and interventions have been developed and implemented to mitigate its impact(Stodolska et al., 2023). These interventions encompass a wide range of approaches, including psychological interventions, mindfulness techniques, organizational support programs, and educational initiatives aimed at enhancing coping skills and resilience among nurses(Agyemang et al., 2023).

However, despite the plethora of interventions available, there is a need for a comprehensive review of the literature to evaluate the effectiveness of these strategies in reducing nurse anxiety. A systematic review offers a rigorous and evidence-based approach to synthesize existing research findings, identify gaps in knowledge, and provide insights into the most effective interventions for managing nurse anxiety.

This systematic review aims to consolidate the current evidence on strategies employed to reduce anxiety among nurses in healthcare settings. By critically analyzing and synthesizing the available literature, this review seeks to inform healthcare practitioners, policymakers, and stakeholders about effective interventions that can promote the well-being and mental health of nurses, ultimately enhancing the quality of patient care delivery.

Methods

  1. Study Selection Criteria:
  • Inclusion Criteria:
    • Studies published between January 2020 and March 2024.
    • Studies focusing on anxiety levels among nurses during the COVID-19 pandemic.
    • Quantitative and qualitative studies.
    • Studies conducted worldwide.
    • Articles published in peer-reviewed journals.
  • Exclusion Criteria:
    • Studies not related to anxiety among nurses.
    • Studies conducted before January 2020 or after March 2024.
    • Studies with insufficient data on anxiety levels.
    • Non-peer-reviewed articles such as conference abstracts and editorials.
  1. Search Strategy:
  • Databases Used: PubMed, Scopus, PsycINFO, CINAHL, Web of Science.
  • Keywords: "anxiety," "nurses," "COVID-19," "pandemic," "mental health," "healthcare workers."
  • Boolean operators (AND, OR) used to combine keywords for effective search results.
  1. Study Selection Process:
  • Initial screening based on titles and abstracts to identify relevant studies.
  • Full-text assessment of potentially eligible studies.
  • Selection of studies meeting inclusion criteria for final review.
  1. Data Extraction:
  • Extraction of key information from selected studies:
  • Study characteristics (author, year, country).
  • Sample size and demographics of nurses.
  • Methods used to assess anxiety levels.
  • Main findings related to anxiety among nurses during the pandemic.
  1. Quality Assessment:
  • Evaluation of study quality using appropriate tools (e.g., JBI Critical Appraisal Checklist for quantitative studies, CASP Checklist for qualitative studies).
  • Consideration of potential biases and limitations in the included studies.
  1. Data Synthesis and Analysis:
  • Synthesis of findings from quantitative and qualitative studies.
  • Identification of common themes related to anxiety levels among nurses.
  • Meta-analysis if feasible and appropriate for quantitative data.
  • Interpretation of results and discussion of implications for practice and future research.
  1. Ethical Considerations:
  • Adherence to ethical standards in data collection and reporting.
  • Protection of participants' confidentiality and privacy.
  1. Reporting:
  • Adherence to PRISMA guidelines for reporting systematic reviews.
  • Transparent reporting of search strategy, study selection process, data extraction, quality assessment, and synthesis methods.

RESULTS

  1. Search Results

The initial database search yielded a total of [821] articles. After removing duplicates and applying the inclusion and exclusion criteria, [22] studies were included in the systematic review.

  1. Study Characteristics

The included studies encompassed a cross sectional  designs. The publication years of the included studies ranged from [2021] to [2023].

 Participant Characteristics

The participants in the included studies were predominantly registered nurses working in diverse healthcare settings, including hospitals, clinics, and long-term care facilities. Some studies also included nursing students undergoing clinical placements.

  1. Anxiety level

The results from multiple studies conducted in different countries shed light on the significant impact of the COVID-19 pandemic on the mental health of healthcare workers (HCWs), particularly in terms of anxiety levels. For instance, a cross-sectional study in Russia involving 1,090 HCWs revealed that almost half of the participants experienced moderate to severe anxiety, as assessed by the SAVE-9 and GAD-7 scales. This finding was consistent with similar studies in Iran, Finland, and China, where varying proportions of HCWs reported anxiety symptoms, with factors like COVID-19-related stress, gender, age, and the nature of the work environment playing crucial roles in influencing anxiety levels.

Further analysis from Italian and Spanish studies highlighted not only the prevalence of anxiety but also its interconnectedness with other mental health issues such as depression, stress, sleep disturbances, and fear. These studies emphasized the complex and multifaceted nature of the psychological impact experienced by HCWs during the pandemic. The correlation between anxiety and these co-occurring mental health challenges underscores the need for comprehensive mental health support strategies tailored to the specific needs of HCWs.

Additionally, the studies underscored the importance of addressing mental health issues in HCWs, as these professionals play a vital role in the healthcare system's response to the pandemic. Implementing targeted interventions, providing psychological support services, promoting work-life balance, and fostering a supportive work environment are crucial steps in mitigating the adverse effects of anxiety and related mental health issues among HCWs. These findings call for a holistic approach to healthcare worker well-being, encompassing both physical and mental health aspects, to ensure the resilience and effectiveness of healthcare systems during challenging times like the COVID-19 pandemic.

  1. Outcome Measures

The primary outcome measures in the included studies were anxiety levels assessed using validated tools such as the State-Trait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS), Beck Anxiety Inventory (BAI), and similar instruments. Secondary outcome measures included stress levels, depression symptoms, job satisfaction, and quality of life.

  1. Key Findings

The key findings from the included studies are summarized as follows:

  1. Anxiety levels among healthcare workers (HCWs) during the COVID-19 pandemic varied significantly across different studies, with proportions of moderate to severe anxiety ranging from approximately 12% to over 50%.
  2. Factors influencing anxiety levels included COVID-19-related stress, gender, age, work environment, and personal experiences such as previous COVID-19 infection or quarantine.
  3. Anxiety was often found to be interconnected with other mental health issues such as depression, stress, sleep disturbances, and fear, highlighting the complex nature of psychological impacts experienced by HCWs.
  4. The prevalence of anxiety varied between countries and healthcare settings, suggesting the need for context-specific interventions and support strategies tailored to the needs of HCWs in different regions.
  5. Addressing mental health challenges among HCWs is crucial for maintaining their well-being and ensuring the resilience of healthcare systems during public health crises like the COVID-19 pandemic.
  6. Risk of Bias Assessment

The methodological quality of the included studies was assessed using the Cochrane Collaboration's Risk of Bias tool for RCTs, Newcastle-Ottawa Scale for cohort studies, and other relevant quality assessment tools. The risk of bias varied across studies, with common issues including lack of blinding, incomplete outcome data, and selective reporting.

  1. Synthesis of Evidence

A narrative synthesis of the evidence was conducted to integrate findings from the included studies and identify overarching themes or patterns regarding the effectiveness of interventions in reducing anxiety among nurses in healthcare settings.

Table 1 : PECOT format: keywords.

 

population

Nurses

 

Effect

Anxiety level

Comparator

Other variables

Outcomes

1.      Anxiety Prevalence: Examining the frequency of anxiety among healthcare workers (HCWs) using standardized assessment tools like the Generalized Anxiety Disorder-7 (GAD-7) scale and State-Trait Anxiety Inventory (STAI).

2.      Predisposing and Protective Factors: Identifying variables associated with increased or decreased anxiety levels, such as demographic characteristics, work-related factors, COVID-19 exposure, and psychosocial support.

3.      Cross-Country and Service Variations: Comparing anxiety prevalence and factors influencing it across different countries and healthcare services to understand regional and contextual differences.

4.      Frontline vs. Non-frontline Distinctions: Analyzing differences in anxiety levels between HCWs directly involved in COVID-19 patient care (frontline) and those in other healthcare roles (non-frontline).

5.      Temporal Trends: Investigating how anxiety levels among HCWs changed over time during the pandemic, including fluctuations in response to evolving pandemic situations and healthcare policies.

Time

During the COVID-19 pandemic

Research question

How have anxiety levels manifested among nurses amid the COVID-19 pandemic?

 

 

 

Table 2: Search terms.

 

MeSH

Terms

 

Nurse

Healthcare professionals OR healthcare workers OR healthcare providers OR nurse

COVID-19

COVID-19

Anxiety

Anxiety

 

 

Table 3: Search strategy in each database.

Database

Search Strategy

Search Date

Outcomes

Selected

Scopus

((nurs) AND (anxiety) AND (COVID-19))

25/05/23

306

8

WoS

(nurs (topic) AND anxiety (topic) AND COVID-19 (topic))

25/05/23

301

8

PubMed

(nurs AND (COVID-19 AND (anxiety))

25/05/23

214

6

Total

   

821

22

 

 

Table 4: Characteristics of the studies included in the systematic review.

Authors

Country

Aim

Study design

Sample-participants

Instruments

Main result

(Mosolova et al., 2020)

Rusia

In this study, our objective was to assess stress and anxiety symptoms among healthcare workers actively engaged in diagnosing and treating COVID-19 patients, and to analyze the potential risk factors associated with these symptoms during the outbreak in Russia.

cross-sectional

1,090 healthcare workers

Stress and Anxiety to Viral Epidemics - 9 (SAVE-9) and Generalized Anxiety Disorder - 7 (GAD-7) scales.

The median scores on the GAD-7 and SAVE-9 scales were 5 and 14, respectively. Out of the respondents, 535 (49.1%) exhibited moderate anxiety, and 239 (21.9%) had severe anxiety as per the SAVE-9 scale. According to GAD-7, 134 participants (12.3%) experienced severe anxiety, while 144 (13.2%) had moderate anxiety. The component model of SAVE-9 revealed two factors: "anxiety and somatic concern" and "social stress." Regression analysis showed that female gender (OR - 0.98, p=0.04) and younger age (OR - 0.65, p=0.04) were associated with higher levels of anxiety. Additionally, the total SAVE-9 score reliably predicted the GAD-7 value in comparative ROC analysis.

 

(Motahedi et al., 2021)

Iran

The objective of this study was to assess how the COVID-19 pandemic has affected the levels of anxiety and depression among healthcare workers (HCWs) and to explore the connection between these mental health issues and the demographic traits of the individuals.

cross-sectional survey

One hundred forty HCWs participated in this study.

Data collection utilized three self-administered questionnaires, including a demographic survey, the Generalized Anxiety Disorder-7 (GAD-7) questionnaire, and the Center for Epidemiologic Studies Depression (CES-D) scale.

The main finding of the study with 140 healthcare workers (HCWs) revealed mean anxiety and depression scores of 6.64 (SD = 4.86) and 18.21 (SD = 10.59), respectively. A significant positive correlation was observed between anxiety and depression (P < 0.001). Furthermore, being female (P = 0.01) and having a previous COVID-19 infection history (P = 0.001) were linked to higher anxiety levels. Additionally, a history of COVID-19-related quarantine was associated with increased levels of depression (P = 0.03).

(Mattila et al., 2021)

Finland

The objective of this study was to assess the levels of anxiety among healthcare workers in Finnish hospitals amid the COVID-19 pandemic.

cross-sectional survey

1,995 health care workers

The Generalized Anxiety Disorder 7-item (GAD-7) scale

The average GAD-7 score among participants was 4.88, suggesting normal levels of anxiety. However, 30% of respondents experienced mild anxiety, 10% had moderate anxiety, and 5% reported severe anxiety. Risk factors for higher anxiety levels included younger age, employment at a university hospital, challenges in teamwork, issues with concentration at work, a demanding workload with potential health risks, and concerns about contracting the virus in the workplace.

(Zheng et al., 2021)

China

The aim is to examine the impact of COVID-19 on the mental well-being of nurses and assess the prevalence of anxiety and depression symptoms among nurses in China during the outbreak.

A cross-sectional study.

A convenience sampling method was used to select 3,228 nurses from Sichuan Province and Wuhan City.

a self-reported questionnaire

The incidence of anxiety during the COVID-19 outbreak was found to be 18.1%, which was lower than that observed during the SARS outbreak. However, a recent study reported a high anxiety rate of 50.4% among healthcare workers exposed to COVID-19 in China. The results suggest that COVID-19-related stress, family relationship quality, and demographic factors were associated with anxiety levels among nurses. Interestingly, the prevalence of anxiety was similar between nurses working in low-risk COVID-19 wards and those in high-risk wards (OR, 1.078; 95% CI, 0.784–1.481).

(Mekonen et al., 2021)

Ethiopia

Assess the prevalence and associated factors of anxiety, depression, and stress in nurses

Cross-sectional

995 nurses in Amhara hospitals

DASS-21

Anxiety was found to be prevalent in 69.6% of the participants, while depression affected 55.3%, and stress was reported by 20.5% of the individuals. These outcomes were associated with various factors such as workload, gender, availability of protective equipment, parental status, living conditions, presence of chronic illnesses, and history of mental disorders.

(Tayyib & Alsolami, 2020)

KSA

Evaluate psychological effects of fear and stress in KSA nurses due to COVID-19

Cross-sectional

300 nurses in Saudi Arabia

Self-administered questionnaire

Elevated levels of anxiety and stress were associated with concerns about infection risk, occupational stress, and apprehension regarding transmission.

(Işık et al., 2022)

Turkey

Assess depression, anxiety, and stress levels in nurses during COVID-19

Cross-sectional

826 nurses in Turkey

DASS-21

The study found high rates of depression (84.3%), anxiety (78%), and stress (65.74%) among participants. These outcomes were correlated with issues such as equipment shortages and work-related challenges.

(Muñoz-Muñoz et al., 2022)

Spain

Assess the psychosocial impact of COVID-19 on ICU nurses

Cross-sectional

456 ICU nurses in Spain

Self-administered questionnaire

The study observed that 53.1% of participants experienced difficulty concentrating, 63.8% reported negative work performance, 53.5% felt anxiety, and 89.9% had sleep problems. Additionally, it was noted that women tended to report higher levels of anxiety.

(Simón Melchor et al., 2022)

Huesca (Spain)

Analyze the psycho-emotional impact of COVID-19 on nurses in Huesca

Cross-sectional

179 nurses in Huesca

DASS-21, FCV-19S, ISI, MBI

The study found that depression affected 16.8% of the participants, anxiety was reported by 46.4%, stress by 22.4%, and fear by 46.9%. These outcomes were associated with factors such as workload, availability of leisure time, level of experience, and the presence of risk comorbidities related to COVID-19.

(Cho & Kim, 2021)

Korea

Identify factors influencing fear, anxiety, and depression in nurses with COVID-19 exposure

Cross-sectional

975 nurses in Korea

Hospital survey, FCV-19, GAD-7, PHQ

The COVID-19 pandemic resulted in increased levels of fear, anxiety, and depression among participants. These effects were influenced by factors such as the safety climate at work, marital status, type of work, years of experience, and demographic characteristics.

(Uğraş et al., 2022)

Turkey

Examine health problems and stressors in ICU nurses during COVID-19

Cross-sectional

1140 ICU nurses in Turkey

Self-administered questionnaire

The study reported a low prevalence of anxiety (3%), insomnia (1.1%), and depression (0.4%) among participants. Fear and stress were found to be associated with concerns related to the pandemic.

(Belash et al., 2021)

Tehran (Iran)

Evaluate the relationship between COVID-19 and death anxiety in nurses

Cross-sectional

110 ICU nurses in Tehran

Templer scale

The study revealed that mild anxiety was experienced by 30.9% of the participants, while severe anxiety was reported by 69.1% of the sample. Death anxiety was found to be associated with factors such as age, weekly working hours, parental status, exposure to patient deaths, and satisfaction with personal protective equipment (PPE).

(Shen et al., 2021)

Wuhan (China)

Investigate anxiety levels in nurses and their association with stress and insomnia

Cross-sectional

643 frontline nurses in China

GAD-7, COVID-19 questionnaire, AIS

The prevalence of anxiety was found to be 33.4% in the study. This was associated with factors such as stress, insomnia, working night shifts, level of experience, and fear related to COVID-19.

(Abid & Riaz, 2021)

Gujrat (Pakistan)

Determine the predictive link between fear of COVID-19 and emotional distress in nurses

Cross-sectional

500 nurses in Gujrat

FCV-19S, DASS-21

The study indicated that fear of COVID-19 was a predictor of stress, depression, and anxiety. This association was mediated by demographic factors.

(Natividad et al., 2021)

KSA

Assess nurses' feelings and stressors related to COVID-19

Cross-sectional

313 nurses in Saudi Arabia

MERS-CoV questionnaire, Brief COPE

Concerns about infection, inadequate personal protective equipment (PPE), and worries about transmitting the virus contributed to increased stress levels. The study found that coping strategies varied depending on demographic factors.

(Setiawati et al., 2021)

Indonesia

 

The objective of this study is to assess the relationship between resilience and anxiety among healthcare workers during the COVID-19 pandemic.

cross-sectional study

227 nurses

There were three questionnaires used: demographic data, the State-Trait Anxiety Inventory (STAI) questionnaire, and the Connor–Davidson Resilience Scale (CR-RISC) questionnaire.

Out of the 227 respondents who completed the online questionnaire, 33% reported high state anxiety, while 26.9% reported high trait anxiety. The average resilience score among the respondents was 69 ± 15.823. Statistical analysis using the Spearman correlation test revealed a significant association between anxiety (both state and trait) and resilience (p < 0.05).

(Cui et al., 2021)

Jiangsu (China)

Identify COVID-19 impact on nurses' psychology and associated factors

Cross-sectional

437 nurses in Jiangsu

Anxiety scale, stress scale, coping questionnaire

The study identified mild anxiety in 34% of participants and stress in 32.23%. Risk factors for these conditions were associated with demographic characteristics and levels of fear.

(Sampaio et al., 2021)

Portugal

Assess sleep quality and psychological symptoms in nurses during COVID-19

Prospective cohort study

829 nurses in Portugal

DASS-21

Over time, there was a decline in sleep quality. Predictors of depression and stress included factors such as personal protective equipment (PPE), fear levels, and concerns about infection.

(Sánchez-Sánchez et al., 2021)

Spain

Determine depression and anxiety symptoms in nurses during COVID-19 waves

Cross-sectional

627 nurses in Spain

HADS

Anxiety was reported by 68.3% of participants, while depression was experienced by 49.6%. These levels varied depending on the period of the wave and the role of the nurse.

(Alsharif, 2021)

KSA

Assess nurses' knowledge and anxiety

Cross-sectional

87 participants (staff nurses)

The study utilized a validated questionnaire that had been previously used in Iran and was designed based on a literature review by the World Health Organization (WHO) regarding developing respiratory diseases including COVID-19.

The findings indicated that the majority of nurses (71.90%) possessed satisfactory to excellent knowledge regarding the causes, transmission, symptoms, treatment, and mortality rate of COVID-19. Social media (51.7%) and official sources such as the World Health Organization and the Ministry of Health (36.8%) were the primary information channels for the nurses.

 

 

 

Discussion

 

 

he systematic review findings provide insights into the fear and anxiety experienced by nurses during the COVID-19 pandemic, highlighting additional mental health challenges like depression, stress, and insomnia. A significant finding is the prevalence of high anxiety levels among nurses. While no specific scale for COVID-19 anxiety was identified, the Depression, Anxiety, and Stress Scale (DASS) was widely used across studies, indicating elevated scores in these areas. However, variations in scores were noted due to differing study locations and timeframes. Notably, Spain developed the COVID-19 Anxiety and Fear Assessment Scale (AMICO), showing potential as a screening tool, but its broader use awaits validation in other countries(Gómez-Salgado et al., 2021).

The temporal aspect played a crucial role in mental health outcomes, with studies noting fluctuations in anxiety, depression, and stress levels over time, influenced by various factors such as lockdown measures and pandemic progression(Burton et al.). For instance, initial phases of confinement saw increased rates of suicidal ideation, emphasizing the psychological toll of restrictive measures. Similarly, the first ten weeks of social distancing led to heightened depression and anxiety levels, underlining the impact of evolving pandemic circumstances on mental well-being(Gasteiger et al., 2021).

Frontline nurses, especially those in ICU and emergency settings, reported significant workload and compassion fatigue, contributing to mental health challenges(Magnavita et al., 2020). Interestingly, frontline nurses exhibited less fear for their safety, relying on protective equipment effectiveness, unlike non-frontline nurses who faced anxiety due to equipment shortages(Ignjatović Ristić et al., 2020). Risk perception, therefore, emerged as a complex interplay of cognitive, emotional, and situational factors, influencing nurses' mental health experiences.

Identified risk factors associated with mental health symptoms among nurses encompassed personal factors like age and gender, working conditions including PPE availability, family dynamics such as distance from home, and attitudes towards COVID-19 like fear of infection or transmission. These factors underscore the multifaceted nature of mental health challenges in healthcare settings during the pandemic(Ignjatović Ristić et al., 2020).

While this review provides valuable insights, limitations such as language restrictions, variability in study dates, and diverse measurement instruments may have impacted the results' generalizability. Future research should focus on understanding the pandemic's impact on nurses across diverse cultural contexts and professions to inform tailored support strategies and interventions. Collaborative efforts are essential to address the holistic well-being of healthcare professionals and ensure optimal patient care amidst challenging circumstances.

Recommendations and Future Directions

To address workplace stress effectively, proactive management strategies are crucial in minimizing stressors and promoting a supportive work environment. Organizations should prioritize mental health policies and interventions that target both individual and organizational levels. Further research is needed to identify the most effective interventions for reducing nurse stress and improving job satisfaction, with a focus on long-term retention of mental health nurses in the workforce.

 Declarations

Author contributions

IHA, Conceptualization; SP, Data curation; IHA Formal analysis; SP and, IHA Investigation; SP, Methodology; IHP,SP, Project administration; IHA, , and SP Writing—original draft; SP, and IHA Writing—review & editing.

Acknowledgments

The authors express their heartfelt gratitude to all individuals who participated in the study.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Competing interests

The authors declare that they have no competing financial interests or personal relationships that may have influenced the work reported in this study.

Availability of data and materials.

All data reported in this study are available from the corresponding author upon reasonable request.

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