Exploring anxiety levels in healthcare workers during COVID-19 pandemic: Turkey sample.

As in the whole world, the Novel Coronavirus (COVID-19) pandemic poses many threats to healthcare workers in our country too, which leads to anxiety in healthcare workers. This study was conducted to explore the anxiety levels of healthcare workers during the COVID-19 pandemic. The study is a cross-sectional study. The population consisted of health care workers employed in hospitals in seven regions in Turkey. All volunteer healthcare workers were included in the study, and 356 healthcare workers responded to the questionnaire. The data were collected using the State Anxiety Inventory and a questionnaire created by the researchers using an online questionnaire between 10 May 2020 and 15 May 2020. In the evaluation of the data, mean, standard deviation, percentages, t-test, one-way ANOVA, Pearson correlation, and multiple regression analysis were used. 33% of healthcare workers did not have anxiety, 50% had mild, and 17% had severe anxiety. The anxiety scores of those who were nurses (p < 0.001), who were working in the emergency room (p < 0.001), who were involved in treatment for COVID-19 patients (p = 0.040), who left their homes to prevent transmission to their families and relatives during the pandemic (p = 0.038), and whose working hours had changed (p = 0.036) were found to be significantly higher. It was observed that there was a positive and significant relationship between the fear of death and disease transmission, uncertainty, loneliness, anger, and hopelessness, and anxiety levels in healthcare workers. The main factors that significantly affected the anxiety levels of healthcare workers were male gender, weekly working hours, the presence of chronic diseases, and feelings of anger and uncertainty. In conclusion, during the COVID-19 pandemic, healthcare workers experienced some negative emotions, their anxiety levels increased, and they were psychologically affected. Planning psychosocial interventions for healthcare workers in the high-risk group will make significant contributions to the health system.

Introduction

The novel Coronavirus (COVID-19) was first identified on January 13, 2020, in the examinations of a group of patients who developed respiratory tract symptoms (fever, cough, shortness of breath) in Wuhan Province in late December. Then, the World Health Organization declared the novel disease a global pandemic on January 31, 2020 (Lamptey & Serwaa, 2020; Uzun et al., 2020). On December 26, 2020, the Turkish Health Minister announced that the number of healthcare workers infected with COVID-19 surpassed 130,000, and 326 health workers lost their lives in Turkey (Republic of Turkey Ministry of Health, 2020).

After COVID-19 infection gets inside the body, it activates the immune system and causes physical and psychological stress in the body. This stress is associated with factors such as viral, angiotensin, and cytokine load. These stressors are also related to the risk of being infected (Hanscom et al., 2020). Throughout the pandemic, the group at the highest risk of contracting the disease has been frontline healthcare workers struggling with the disease (Tuncay et al., 2020). The literature cites that healthcare workers are under intense pressure during the pandemic due to being in a high-risk group, fear of infecting their families and others, changes in the working hours and system, increased workload, rapidly changing up-to-date information, isolation, inability to see their family and children, social stigma, fear of death and having to provide care to patients with serious health problems. All these situations during the COVID-19 pandemic can lead to anxiety in healthcare workers (Xiang et al., 2020; Greenberg et al., 2020; Lai et al., 2020; Wong et al., 2005). Evidence shows that healthcare workers struggling with SARS experienced intense anxiety due to the fear and anxiety of transmitting viruses to their family members (Bai et al., 2004; Kisely et al., 2020; Wong et al., 2005). The most common emotions experienced by healthcare workers during epidemics are loneliness, fear, anger, stigma, uncertainty, and hopelessness, which increase their level of anxiety (Kackin et al., 2020; Lee et al., 2018; Maunder et al., 2003; Sun et al., 2020).

Outbreaks are known to have some psychological impacts on healthcare workers. Psychosocial interventions are needed for especially for frontline healthcare workers with high-risk. It is believed that the results of this study on the effect of the COVID-19 pandemic on the anxiety levels of healthcare workers will guide the planning of psychological interventions for healthcare workers. The study was conducted during the COVID-19 to explore the anxiety levels of the health workers in Turkey and associated factors.

Method

Participants and Procedure

This study is a descriptive and cross-sectional study. The data were collected between 10 May 2020 and 15 May 2020. The population of the study consisted of health care workers employed in hospitals in seven regions (Marmara, Aegean, Black Sea, Central Anatolia, Eastern Anatolia, Mediterranean, and Southeastern Anatolia) in Turkey. The sample included 385 healthcare workers determined with a 95% confidence interval and 0.05 margin of error. All volunteer healthcare workers were included in the study, and 356 nurses responded to the questionnaire (response rate of 72.46%). Ethical consent was granted by the Human Research Ethics Committee of the local university (2020/5). The participants were informed that they could withdraw from the survey at any moment without providing any justification, and electronic informed consent was obtained from each of them. The study was performed in accordance with the Declaration of Helsinki.

Instruments

The data of the study were collected using the State Anxiety Inventory and the questionnaire form developed by the researchers. After obtaining the necessary permissions for the study, an online questionnaire form was prepared with the Google Forms web application and sent to the smartphones of healthcare professionals via WhatsApp, mail, social media (Instagram, Facebook, etc.). The questionnaire form consists of 3 parts and 16 questions. In the first part, there are 9 questions to identify the socio-demographic characteristics of health care workers, the second part includes 6 questions regarding health care workers’ experiences in the COVID-19, and the third part includes 1 question related to the emotions experienced most during the COVID- 19 outbreak (loneliness, boredom, anger, fear of death, fear of disease transmission, uncertainty, hopelessness, etc.). Access to the survey form is available at [URL] https://docs.google.com/forms/d/1RhzGt7_RpnoJR94dlOPwWpR_uTZzY5th9ExCFBf4bzI/edit

State Anxiety Inventory (SAI)

The State Anxiety Inventory is a self-assessment survey including short statements to identify state and trait anxiety levels. It was developed by Spielberger and his colleagues in 1970 and adapted for Turkey with the validity and reliability analysis by Öner and Le Compte in 1977 (Öner et al., 1983; Spielberger et al., 1970). The 20-item State Anxiety Inventory and the 20-item Trait Anxiety Inventory are independent of each other. Only the State Anxiety Inventory was utilized in this study. In the State Anxiety Inventory, each item is rated in four Likert type responses as follows: none: 1, a little: 2, a lot: 3, and completely: 4; in the Trait Anxiety Inventory, each item is rated in four Likert type responses: rarely: 1, sometimes: 2, most of the time: 3, and almost always: 4. High scores indicate a high level of anxiety. Cronbach’s alpha value was found to be 0.929 in this study.

Data Analysis

SPSS 20,0 statistical package program was used for statistical analysis. In the evaluation of the data, descriptive statistical methods such as frequency, percentage, mean, standard deviation, as well as the Kolmogorov-Smirnov distribution test were performed to examine the normal distribution. Kurtosis-Skewness values were evaluated between +2 and − 2. The comparison of variables showing normal distribution between groups was evaluated using a t-test and one-way ANOVA, the relationship between numerical variables was evaluated using Pearson correlation and multiple regression analysis. Cronbach alpha was used to evaluate the internal consistency of the scales. A p value of <0.05 was considered statistically significant.

Results

The results revealed that the mean age of healthcare workers was 32.56 ± 7.30 years (min: 20; max: 54), 74.6% were females, 61.8% were married, and 42.7% had a bachelor’s degree. 85.1% of them did not have a chronic disease, 60.7% were living in a metropolitan city. 59.1% were nurses,14.5% were physicians, 10.8% were emergency medical technicians, 5.1% were anesthesia technicians, and 4% were cleaning personnel. The remaining 27 participants (10.5%) had 5 different types of professions. 61.8% of healthcare workers had an average of 48.09 ± 5.7 weekly working hours in clinics. 1.1% were diagnosed with COVID-19, 30.1% had someone diagnosed with COVID-9 in their immediate environment, 39.3% were involved in the care of COVID-19 patients, and 26.7% of healthcare workers lived apart from their families due to the risk of transmission during the pandemic. The diet patterns, sleep patterns, and working hours of 56.3%, 63.4%, and 64.8% of them changed, respectively.

The average scores of healthcare workers were compared by gender, and the anxiety levels of males healthcare workers were found to be significantly higher than those of females (p = 0.013). The anxiety scores of nurses (p = 0.000) and healthcare workers working in the emergency room (p = 0.000) were determined to be significantly higher. A significant positive relationship was seen between age (p = 0.000), weekly working hours (p = 0.000), and anxiety level, and as the age and the weekly working hours increased, anxiety scores increased. No significant relationship was observed between anxiety level, marital status, educational status, chronic illness, and the region of residence (p > 0.05) (Table 1).

Table 1

Distribution of mean anxiety scores according to some descriptive characteristics of healthcare workers (n = 356)

Characteristics	N (%)	State anxiety inventoryMean ± SD	p value
Gender
Female	266 (74.6)	38.29 ± 4.32	p = 0.013a
Male	90 (25.4)	39.71 ± 5.53
Marital status
Married	220 (61.8)	38.96 ± 4.94	p = 0.329a
Single	136 (38.2)	38.46 ± 4.51
Education level
Vocational School of Health	66 (18.5)	39.0 ± 4.47	p = 0.498b
Associate Degree	78 (21.9)	38.28 ± 5.59
Undergraduate Degree	152 (42.7)	38.42 ± 4.09
Postgraduate Degree	60 (16.9)	39.31 ± 5.01
Having a chronic disease1
Yes	53 (14.9)	38.21 ± 3.99	p = 0.471a
No	303 (85.1)	38.72 ± 4.79
The region healthcare workers live
Metropolis	215 (60.4)	38.54 ± 4.86	p = 0.808b
City Center	117 (32.9)	38.76 ± 4.57
Rural area	24 (6.7)	39.12 ± 3.63
Occupation
Nursea	210 (59.1)	41.70 ± 4.91	p < 0.001b a > b = c
Physician b	51 (14.5)	38.40 ± 4.58
Other healthcare staff c	115 (26.4)	40.06 ± 4.85
The units of healthcare workers
Intensive carea	83 (23.3)	41.09 ± 4.20	p < 0.001b b > a = c
Emergency serviceb	53 (14.9)	45.58 ± 4.12
Other clinicsc	223 (61.8)	37.92 ± 3.66
Age	32.56 ± 7.30		r = 0.333 p < 0.001c
Weekly working hours	48.09 ± 5.7		r = 0.212 p < 0.001c

at-test; b one-way ANOVA; c Pearson correlation analysis; 1 Chronic disease: Diabetes, Hypertension, Cardiac Diseases, Respiratory System Diseases

Bold emphasis is p < 0.005

p < 0.001

p < 0.001

Anxiety scores of the healthcare workers providing care for COVID-19 patients were found to be significantly higher than the others (p = 0.040). Anxiety scores of healthcare workers who left their homes to avoid infecting their families and relatives during the pandemic (p = 0.038) and whose working hours changed (p = 0.036) were found to be significantly higher. No significant relationship was detected between anxiety level and having someone diagnosed with COVID-19 in the immediate environment, and changes in diet and sleep patterns (p > 0.05) (Table 2).

Table 2

Distribution of mean anxiety scores according to the healthcare workers’ experience regarding the epidemic process (n = 356)

Characteristics	n(%)	State anxiety inventory Mean ± SD	p value
Having someone diagnosed with COVID-19 in the immediate environment
Yes	110 (30.9)	38.46 ± 5.13	p = 0.613a
No	246 (69.1)	38.73 ± 4.48
Providing care for a patient diagnosed with COVID-19
Yes	140 (39.3)	39.21 ± 4.90	p = 0.040 a
No	216 (60.7)	38.28 ± 28
Living with family during the COVID-19 epidemic process
Living apart from family	95 (26.7)	39.49 ± 4.54	p = 0.038 a
Living with family	261 (73.3)	38.09 ± 5.09
Eating pattern during COVID-19 process
Changed	198 (56.3)	38.95 ± 5.04	p = 0.165 a
Not changed	158 (43.7)	38.25 ± 4.16
Sleep pattern during COVID-19 process
Changed	227 (63.4)	38.66 ± 4.55	p = 0.968 a
Not changed	129 (36.6)	38.64 ± 4.91
Working hours change during the outbreak
Yes	228 (64.8)	39.03 ± 4.76	p = 0.036 a
No	128 (35.2)	37.94 ± 4.46

at- test; b Mann Whitney u testi

Bold emphasis is p < 0.005

Table 3 shows how anxiety levels of healthcare workers were affected by the COVID-19 pandemic. While 33% of healthcare workers in the study did not have anxiety, 50% had mild, and 17% had severe anxiety. The mean anxiety score of the healthcare workers was 38.65 ± 4.68 (min: 26; max: 56) (Table 3). Emotions that healthcare professionals intensely experienced during the COVID-19 pandemic were loneliness, anger, fear of death, disease transmission, uncertainty, and despair. It was observed that there was a positive and significant relationship between these emotions and anxiety level (Table 4). According to the model created according to the multiple regression analysis, the factors that significantly affected the anxiety levels of healthcare workers were male gender, weekly working hours, chronic diseases, and feelings of anger and uncertainty. On the other hand, age, fear of death, and hopelessness had no significant effects on the anxiety scores (Table 5).

Table 3

Distribution of health workers’ state anxiety scale mean scores (n = 356)

Inventory	n (%)	Mean ± SD	Median (min.-max)
State anxiety inventory		38.65 ± 4.68	38.00(26–56)
Normal	116 (33.0)	33.93 ± 1.88	34.00(26–36)
Mild	176 (50.0)	39.11 ± 1.73	39.00(37–42)
High	64 (17.0)	46.43 ± 2.95	46.00(43–56)

SD, Standard Deviation

Table 4

Relationship between the healthcare workers’ feelings and their anxiety scores during epidemic process (n = 356)

Feelings	Anxiety level
	r*	p**
Loneliness	0.111	0.037
Boredom	0.036	0.503
Anger	0.516	<0.001
Fear of death	0.180	0.001
Fear of disease transmission	0.152	0.004
Uncertainty	0.246	<0.001
Hopelessness	0.216	<0.001

r*: correlation coefficient (Cohen 1992) **Pearson correlation coefficient analysis

Table 5

Multiple regression analysis results between the State Anxiety Inventory and independent variables

Dependent variable: state anxiety inventory
Independent variables	B	SE	β	t	p
Constant	141.38	23.65		6.94	<0.001
Gender (0.Female, 1. Male)	4.14	0.66	0.20	6.22	<0.001
Age (numerical/year)	−0.13	0.11	−0.42	−1.24	0.21
Weekly working hours (numerical/h)	1.99	0.52	0.12	3.77	<0.001
Presence of chronic diseases (0.No 1.Yes)	3.55	1.13	0.10	3.13	<0.001
Anger (0.Yok, 1.Var)	0.972	0.100	0.29	9.74	<0.001
Uncertainty (0.No, 1.Yes)	1.92	0.66	0.08	2.91	<0.001
Fear of death (0.No, 1.Yes)	0.74	1.49	0.03	0.50	0.61
Hopelessness (0.No, 1.Yes)	−1.36	1.27	−0.05	−1.07	0.28

Model R = 0.39; R2 = 0.15; Adjusted R2 = 0.14; F = 4.82; p˂ 0.01

Discussion

This study was conducted to explore the anxiety level of healthcare workers during the COVID-19 pandemic. This section includes a discussion of our research findings with the literature.

The descriptive characteristics of the healthcare workers involved in the study showed that most of the participants were females, married, nurses, and had a bachelor’s degree. Various studies on the anxiety and depression states of healthcare workers struggling with COVID-19 report that most healthcare professionals were females, single, nurses, and had a bachelor’s degree (Labrague & De Los Santos, 2020; Sakaoğlu et al., 2020; Zhu et al., 2020). Therefore, it can be said that the descriptive characteristics of healthcare workers in the relevant studies are similar to each other.

In this study, the female gender was found to be a protective factor for anxiety in the COVID-19 pandemic. However, there are studies in the literature suggesting that gender is not an associated factor for anxiety during the pandemic (Labbrague & De Los Santos, 2020) and that females experience more stress, anxiety, and depression during epidemics (Hacımusalar et al., 2020; Lai et al., 2020; Sakaoğlu et al., 2020; Wang et al., 2020; Zhu et al., 2020). It is argued that the rates of depression in females are universally higher depending on factors such as biological markers and gender role changes (Parker & Brotchie, 2010). This current study was carried out when the pandemic first emerged in Turkey when there was a belief that the incidence of COVID-19 was higher in males. Therefore, the anxiety levels of males healthcare workers in our study may have increased.

In this study, the anxiety scores of nurses were found to be significantly higher than the other healthcare professionals. Various studies conducted during the COVID-19 outbreak also revealed that nurses had the highest level of anxiety among healthcare workers (Hacımusalar et al., 2020; Lai et al., 2020). This result may stem from the fact that the working conditions of nurses have been negatively affected during the pandemic, and as nurses are the frontline workers in the patient care and treatment, and they have more physical contact with them.

The anxiety levels of healthcare professionals working in the emergency department were found to be significantly higher than those working in other units in our study. Literature reports that healthcare workers working in emergency departments, a high-risk area for transmission, have higher anxiety levels than those working in other units (Ageron et al., 2020; Wong et al., 2005). This is an expected result as emergency services are regarded as the high-risk health care services where patients are first admitted.

Various studies in the literature show that epidemics cause many different psychological effects in individuals of all age groups (Bao et al., 2020; Okunlola et al., 2020; Shigemura et al., 2020). A significant relationship was observed between the age of healthcare workers and their level of anxiety, and the level of anxiety increases with age. These results are thought to be related to the fact that advanced age poses a risk for COVID-19 disease, that the symptoms of the disease are more severe, and the mortality rate is higher in this group.

In our study that the anxiety levels of healthcare workers whose weekly working hours increased also increased. During epidemics, the change in working conditions of healthcare workers and increase in their workload cause them to experience anxiety (Khangura et al., 2012; Lai et al., 2020; Wong et al., 2005). The increase in working hours of healthcare professionals who work in units of COVID-19 patients is reported to be significantly higher than those who do not. This increase in working hours constitutes a risk factor for anxiety, unhappiness, and burnout in healthcare workers (Hacımusalar et al., 2020). It is thought that the levels of anxiety of healthcare workers increase because the excessive working hours and the increase in the workload make it difficult for healthcare workers to rest, to allocate enough time for themselves and their families, and to reduce contact time with infected patients.

In this study, the anxiety scores of healthcare professionals providing care for patients with COVID-19 were significantly higher than those of other healthcare staff. In a metanalysis, healthcare workers who were in contact with COVID-19 patients had higher stress levels both in the acute and long term (Kisely et al., 2020). Our study results are consistent with the literature. The risk of transmission increases due to the close contact of healthcare professionals involved in the care of patients with COVID-19. It is possible to explain this situation by the fact that there is a positive relationship between the risk of transmission and anxiety level.

It is known that healthcare professionals experience anxiety during the pandemic due to the risk of becoming infected and infecting their families and others (Kisely et al., 2020; Wong et al., 2005). This study revealed that the anxiety levels of healthcare workers who had to live separately from their families not to infect their families and relatives were higher than the healthcare professionals living with their families. In this challenging period, it is believed that their anxiety levels are higher due to the decrease in emotional support from the family and isolation because of the separation from family members, etc.

The prevalence of anxiety in healthcare workers during the COVID-19 outbreak is higher than the rest of the population (Chen et al., 2020; Dai et al., 2019; Du et al., 2020; Hacımusalar et al., 2020; Lai et al., 2020). Most of the healthcare workers had anxiety in our study. It is not surprising that the anxiety levels of healthcare professionals increase during the pandemic, but the rapid spread of the COVID-19 pandemic, not knowing when it will end and what the consequences will be are associated factors that increase anxiety.

During the pandemics, healthcare workers feel insufficient support, anger, fear, disappointment, guilt, helplessness, insecurity, and anxiety more, and experience more trauma symptoms in the long term and are frequently stigmatized by society (El-Hage et al., 2020; Lai et al., 2020; Reynolds et al., 2008; Wong et al., 2005). Our study also revealed a significant relationship between the emotions and anxiety levels in healthcare workers, and they experienced loneliness, anger, fear of death, fear of infection, uncertainty, and hopelessness during the pandemic. Healthcare workers are the most vulnerable group at the center of the risk of infection. They are exposed to various negative factors and physical, mental, and environmental stimuli against this pandemic, which are thought to cause negative psychological effects on healthcare workers.

Conclusion and Recommendations

Our study showed that 50% of health workers have a mild level of anxiety, and 17% have a severe level of anxiety in Turkey due to the pandemic. Male gender, advanced age, being a nurse, working in the emergency department, changed working hours, and increased weekly working hours are associated with the anxiety levels of healthcare workers. The most intense emotions the health workers experience during COVID-19 in Turkey have been loneliness, anger, fear of death, fear of disease transmission uncertainty, and despair. It has been observed that these emotions have increased their anxiety levels. We think that determining the anxiety levels of healthcare workers and the associated factors during the COVID-19 pandemic in our study will guide the planning of psychological interventions for healthcare workers.

Strengths and Limitations

This research presents several overarching strengths. In the literature, the number of studies examining the anxiety levels and emotions of healthcare workers during the COVID-19 outbreak is limited. No study to our knowledge had been carried out to explore the level of anxiety in healthcare workers in Turkey when our study was conducted. Moreover, our study may reflect the general nature of healthcare workers’ anxiety in Turkey because it is a multicenter study involving seven regions. However, the study also had several limitations. It was aimed to include all healthcare professionals across the country in the study, but there was limited participation. Besides, only the short-term effects of anxiety on health workers could be determined since the study was conducted in the period in which the pandemic first appeared in Turkey. The long-term effects of anxiety on healthcare workers are not yet known. Therefore, the long-term experiences of the research subjects would be a valuable avenue to explore in the future.