Abstract
Background: Nurses are exposed to high levels of stress in the workplace. During the coronavirus disease 2019 (COVID-19) pandemic, levels of stress were exacerbated, impacting on nurses’ mental health.
Aim: The aim of the study was to investigate psychological distress and resilience, and how nurses with different levels of education responded to stress.
Setting: The study was conducted in three hospitals (a psychiatric hospital, a general district hospital and a dedicated COVID-19 hospital) in the Western Cape province, South Africa.
Methods: A survey was conducted with frontline nurses (N = 167 [71.8%]) in three hospitals in the Western Cape using six validated self-administered scales.
Results: Respondents reported high levels of moral distress related to time (3.42/6, ± 1.6) and protection during COVID-19 (1.3/3, ± 0.7). Mild-to-moderate levels of fear of COVID-19 (19.4/35, ± 8.2) and a moderate perception of vulnerability to disease (60.7/105, ± 19.9) contributed to nurses’ stress. High levels of psychological distress, especially during COVID-19 compared to current levels (27.2 vs 18.8; W = 8.9, p = < 0.001), with high levels of resilience (73.2/88, ± 17.9) were reported. Enrolled nurses reported significantly higher levels of stress during the pandemic.
Conclusion: Post COVID-19, there was reduction in the respondents who reported severe levels of psychological distress, highlighting the impact of the pandemic on nurses’ mental health and the need to build resilience.
Contribution: This study enhances understanding of the factors that result in psychological distress in nurses and how nurses with different levels of education respond to stress.
Keywords: categories of nurses; moral distress; sources of stress; fear of COVID-19; vulnerability to disease; psychological distress; resilience.
Introduction
The shortage of nurses in South Africa has resulted in increased stress on nurses who already must cope with high workloads. Nursing is a high-stress profession, with increased vulnerability to disease (Gökkaya et al. 2022; Osagiator Ariyo et al. 2022; Padmanabhanunni & Pretorius 2023; Pasay-An 2020). This was especially experienced during coronavirus disease 2019 (COVID-19), with exposure to a contagious disease that was life-threatening (Van der Groot et al. 2021). In addition, nurses have to deal with daily ethical and moral dilemmas (Arafat, Tahir & Harisa 2023; Chersich et al. 2020; Lam & Hung 2013; Shanafelt, Ripp & Trockel 2020), as well as other work-related pressures (Wang et al. 2022), which can impact negatively on their mental health and well-being (Chipps & Jarvis 2021; Manzanares et al. 2021; Naidoo & Sibiya 2019).
The COVID-19 pandemic resulted in heightened stress, anxiety, burnout and moral distress in nurses (Brysiewicz & Chipps 2022; Manzanares et al. 2021; Riedel et al. 2022; Sun et al. 2020; Udwadia & Raju 2020), resulting in low job satisfaction, burnout and high turnover (Norman et al. 2021). Frontline workers across the globe reported symptoms of depression, anxiety and stress (Van der Groot et al. 2021), with post-traumatic stress being the most commonly reported mental health condition, followed by psychological distress (Al Maqbali, Al Sinani & Al-Lenjawi 2021; Saragih et al. 2021). Many nurses also considered leaving the profession (Maben et al. 2022). An additional concern was the impact of varying levels of preparation for the pandemic, expressed in the educational preparation of nurses in terms of different categories of nurses. A previous study with psychiatric nurses in South Africa found that enrolled nurses and nurse assistants reported lower levels of burnout and secondary traumatic stress than the other professional groups (Maila, Martin & Chipps 2020).
Responding to stress may result in negative and positive coping strategies. A study by Munyanziza et al. (2021) found that three quarters of Intensive Care Unit (ICU) nurses in Rwanda used alcohol or drugs to cope with stress during the pandemic. However, positive responses to stress, such as resilient active coping strategies, and social support were found to be associated with lower levels of psychological distress in the general Chinese population (Yu et al. 2020).
Resilience, as a response to stress, is a process where both assets (personal characteristics, e.g. coping skills) and resources (external protective factors, e.g. social support systems) are used to obtain positive outcomes (Fergus & Zimmerman 2005).
Conceptual framework
The theory of a problem framework (Sidani & Branden 2021) is used to articulate the health problem that needs intervention. It describes the problem to identify factors that contribute to the problem – which can be predisposing, precipitating or perpetuating – and can specify possible consequences should the problem not be addressed. For this study, the identified problem was the high levels of stress that nurses are exposed to, for example COVID-19 and moral distress. Fear of COVID-19 was identified as a contributing precipitating factor, and perceived vulnerability of disease as the perpetuating factor. Psychological distress and resilience (measured as response to stress) were specified as possible outcomes of stress.
Aim of the study
The aim of the study was to investigate factors contributing to and the consequences of a major stressor, namely COVID-19, in terms of psychological distress and resilience among nurses with different levels of educational preparation.
Research methods and design
A quantitative descriptive cross-sectional study was conducted. A survey was used to collect the data from nurses in three hospitals in the Western Cape between October and December 2022, after the COVID-19 pandemic.
Setting
The study was conducted in three hospitals (a psychiatric hospital, a general district hospital and a dedicated COVID-19 hospital) in the Western Cape province, South Africa. These hospitals were purposively selected to represent diverse hospital settings that dealt with a wide range of patients during COVID-19.
Study population and sample
The study population were all categories of nurses working at the three hospitals. Using a pooled anxiety prevalence of 23.2% (Pappa et al. 2020) and a precision of 5%, a sample size of 271 was calculated. Inclusion criteria were nurses, registered and enrolled, with the South African Nursing Council (SANC), and involved in direct patient care. Purposive sampling was used to recruit the sample from the three hospitals described earlier.
Instruments
A self-reported questionnaire was used to collect the data. The questionnaire included questions on gender, age, level of educational preparation (reflecting the different categories of nurses), years of experience as a nurse and area of current work. In addition, for the COVID-19 period, questions were asked about whether nurses worked with patients diagnosed with COVID-19 during the pandemic, whether they were tested and/or diagnosed with COVID-19 and their area of contact with COVID-19. Based on the theory of a problem framework (Sidani & Braden 2021), six validated self-administered scales were used to measure the variables of interest (Table 1). Respondents completed the Kessler Psychological Distress Scale (Kessler-10, Kessler et al. 2002) twice: firstly, on their experiences during COVID-19 and secondly, on their experiences based on the 30 days preceding the completion of the questionnaire.
Data collection
The nurse managers of each of the selected hospitals were contacted via email, and arrangements were made to facilitate access to potential respondents. Four trained clinical facilitators collected the data between October 2022 and December 2022, with ongoing cases of COVID-19 in healthcare facilities in South Africa. The respondents were informed of the purpose of the study and that participation was voluntary. Written informed consent was obtained from those who agreed to participate. Questionnaires were paper-based and took approximately 15 min to complete.
Data analysis
Statistical analysis was performed using the IBM SPSS v 28.0 (IBM Corp. Released 2021. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp). Frequencies and descriptive statistics were used to describe the demographic data, and differences between nurse categories and demographic data were determined using Chi-square tests. The results were analysed according to nurses’ level of educational preparation (category of nurse). Non-parametric tests were used to compare the contributing factors to psychological distress among the different categories of nurses. Logistic regression was performed to assess the impact of several factors on psychological distress during COVID-19 and the last 30 days, prior to completing the questionnaire. The scales were analysed according to the instructions for each scale:
- Moral distress: Scale statements were averaged for each of the three domains, namely Relationships, Resources and Time, and summed to derive a total score. If the score reached or exceeded 50% of the maximum possible score, it was regarded as perpetuating psychological distress (Eizenberg et al. 2009). Moral distress was recoded into a binary variable reflecting not having moral distress (low levels of moral distress: scores between 15 and 30) and having moral distress (including moderate and high levels of distress with scores between 31 and 60 [moderate] and 61 and 90 [severe]).
- Source of stress: Individual mean scores of the scale statements and the domains of the scale (Shanafelt et al. 2020) were calculated and ranked from highest source of anxiety to the lowest (Chipps et al. 2022).
- Fear of COVID-19: Ratings on the Fear of COVID Scale (FCV-19 scale) statements were summed to derive a total score (Ahorsu et al. 2020). Scores of 7 and above indicated the presence of fear of COVID-19, with categories of severity indicated as mild (scores between 7 and 19), moderate (scores between 20 and 26) and severe (scores of 27 and above) (Faro et al. 2022).
- Vulnerability to disease: The scale statements were summed to derive a score for the two subscales, perceived infectability and germ aversion. If the score reached or exceeded 50% of the maximum possible score for each subscale, it was regarded as perpetuating psychological distress (Duncan et al. 2009).
- Kessler-10: Ratings on the Kessler-10 were summed to derive a total score. Respondents were classified as ‘likely to be well’ (scores below 20) or likely to have mild (scores between 20 and 24), moderate (scores between 25 and 29) or severe (scores of 30 and above) psychological distress (Kessler et al. 2002). Psychological distress scores during COVID-19 and the last 30 days, prior to completing the questionnaire, were compared using Wilcoxon Signed Rank Test. Psychological distress was recoded into binary variable, reflecting no distress (scores below 20) and having distress (including mild [scores between 20 and 24], moderate [scores between 25 and 29], or high [scores of 30 or above] levels of distress).
- Response to stressful events: Ratings on the Response to Stressful Event Scale were summed to derive a total score. Respondents were regarded as having low (scores below 49), moderate (scores between 50 and 70) and high (scores between 71 and 88) resilience based on their total score (Johnson et al. 2011). Means were calculated for the subscales.
Ethical considerations
The study was approved by the Institutional Review Board at a large public university in the Western Cape (reference number: BM20/6/2) and the South African National Health Research Database (WC_202012_021). Permission to conduct the study was obtained from the Chief Executive Officers of the selected hospitals. Information about the study was distributed to all respondents. Written informed consent was obtained from those who agreed to participate. Participation was voluntary and questionnaires were completed anonymously, and confidentiality was maintained.
Results
Demographics and sample realisation
A total of 231 questionnaires were distributed to nurses across the three hospitals and 167 questionnaires were completed (71.8% response rate). The average age of the respondents was 39.8 (± 10.4) years. Most of the respondents were female (146, 88%). On average, respondents had 11.9 (± 10.8) years of work experience (median = 8, range: 1–40 years). More than half of the respondents were professional registered nurses (n = 87, 52.1%), followed by enrolled nursing auxiliaries (n = 59, 35.2%) and enrolled nurses (n = 19, 11.4%). There were significant differences between the categories of nurses in terms of gender (no male enrolled nurses) (χ2 = 17.4, p < 0.001; Table 2). Almost half of the respondents worked in psychiatric units (n = 81, 49.7%), followed by general areas (medical, surgical or orthopaedic) (n = 32, 19.6%), and eight (4.9%) respondents worked in emergency departments. There were significant differences in work area by category of nurse, with general areas being the most frequent work area for enrolled nurses and enrolled nursing auxiliaries (χ2 = 32.6, p = <0.001; Table 2).
| TABLE 2: Demographic variables and COVID-19 exposure of nurses by total sample and category of nursing. |
Exposure to COVID-19
Nearly all the respondents worked with COVID-19 patients during the pandemic (n = 160/167 [97.6%]). Almost half of the respondents (n = 82, 49.1%) were tested for COVID-19, and over a third (n = 57, 34.1%) were diagnosed with COVID-19. More professional nurses were tested for COVID-19 than enrolled nurses and enrolled nursing auxiliaries (58.6% vs. 57.9% and 32.2%, respectively, χ2 = 10.5, p = 0.006). Most contact with COVID-19 patients were in general units (n = 140, 83.8%), followed by the screening of patients (n = 38, 22.8%). Only 12 (7.4%) respondents reported having contact with COVID-19 in paediatric units or other places (n = 12, 7.4%; Table 2).
Moral distress and sources of stress during COVID-19
Moral distress: A total of 149 respondents completed the scale. The average score for moral distress among respondents was 24/90 (± 18.78). The average score for the total sample and across the different categories of nurses was less than 50% of the total maximum score and therefore did not contribute to psychological distress. There were no statistically significant differences in the moral distress score among the different categories of nurses (K = 0.036, p = 0.982). The lack of time (2.27/6 ± 1.6) was rated significantly higher than the lack of resources (1.57/6 ± 1.4) or relationship challenges (1.55/6 ± 1.5) with no significant differences between the categories of nurses (Table 3).
Sources of stress: Sources of stress were classified into five domains in terms of stress related to protection, preparation, consideration, support and care. Stress related to protection (1.3, ± 0.7) had the highest mean score, followed by care (1.3, ± 0.9), preparation (1.2, ± 0.9), consideration (1.0, ± 1.0) and support (1.0, ± 0.9) (Table 3). Professional nurses had higher stress scores for protection (1.6 vs. 1.4 vs. 1.2, K = 7.2, p = 0.027) and consideration (1.5 vs. 1.2 vs. 0.9, K = 7.1, p = 0.029) compared to enrolled nurses and enrolled nurse assistants (Table 3). Specific stress related to exposure at work (1.6/3, ± 0.9) and stress about infecting family at home (1.5/3, ± 0.9) were rated the highest. The lack of access to up-to-date information (1.8 vs. 0.9 vs. 1.1, K = 6.3, p = 0.043) and the lack of access to up-to-date communication were scored higher among enrolled nurses compared to professional nurses and enrolled nursing auxiliaries (1.7 vs. 0.9 vs. 1.2, K = 7.3, p = 0.026; Table 3).
Fear of COVID-19
Respondents reported mild-to-moderate fear of COVID-19 (19.4/35, ± 8.4). Fewer professional nurses were classified as having severe fear of COVID-19 (15, 18.3%) compared to enrolled nurses (8, 42.1%) and enrolled nursing auxiliaries (20, 37%) (χ2 = 10.2, p = 0.037; Table 3).
Vulnerability to disease
Respondents reported a mean score of 60.7/105 (± 19.9) for the total scale, with higher scores indicating greater perceived vulnerability. Enrolled nurses reported the highest level of perceived vulnerability (67.2, ± 24.3) and professional nurses the lowest level (58.1, ± 18.9; K = 1.98, p = 0.372). For perceived infectability, respondents reported a mean score of 27/49 (± 10.5) and for germ aversion, a mean score of 32.1/56 (± 11.2), with higher scores reflecting higher discomfort with potential disease transmission (Padmanabhanunni & Pretorius 2023; Pretorius et al. 2022). Total and subscale scores exceeded the maximum possible score for nurses of all levels of educational preparation and therefore contribute to psychological distress. There were no significant differences between the different categories of nurses (Table 3).
Psychological distress
Psychological distress was significantly higher during COVID-19 (27.2, ± 11.6) compared to the last 30 days prior to completing the questionnaire (18.8, ± 8.6; W = 8.9, p = <0.001; Table 3). This was true for nurses with all levels of educational preparation. However, in the last 30 days prior to completing the questionnaire, enrolled nurses reported the highest levels of psychological distress (during the pandemic: 31.2, ± 11.3 and last 30 days: 22.8, ± 9.9, respectively) compared to professional nurses who reported the lowest level of psychological distress during the pandemic (24.2, ± 9.6) and in last 30 days (17.6, ± 7.6; K = 10.9, p = 0.004) (Table 3, Figure 1). Psychological distress was moderately correlated with fear of COVID-19 (r = 0.478, p < 0.001) and weakly with moral distress (r = 0.28, p = 0.003) and perceived vulnerability to disease (r = 0.201, p = 0.04) during the last 30 days prior to completing the questionnaire; and during the pandemic highly with fear of COVID-19 (r = 0.502, p < 0.001) and moderately with moral distress (r = 0.350, p < 0.001).
 |
FIGURE 1: Psychological distress during COVID-19 and last 30 days. |
|
Direct logistic regression was performed to assess the impact of several factors on the likelihood that respondents meet criteria for psychological distress (moderate or severe stress) in the last 30 days prior to completing the questionnaire and during COVID-19.
The model of last 30 days prior to completing the questionnaire contained three independent variables (level of educational training, perceived vulnerability to disease, moral distress). The full model containing all predictors was statistically significant, X2 (3, N = 167) = 16.7, p < 0.002, indicating that the model was able to distinguish between respondents who were distressed and not distressed. The model explained between 19.7% (Cox and Snell R square) and 26.3% (Nagelkerke R squared) of the variance and correctly classified 69.7% of cases. One independent variable made a unique statistically significant contribution to the model, with moral distress making the biggest contribution, recording an odds ratio of 2.4–21.4 (p < 0.001). Nearing significance (as a result of small sample size) was being an enrolled nurse (OR: 0.93–22.1, p = 0.062).
The distress during COVID-19 model contained four independent variables (level of educational training, perceived vulnerability to disease, moral distress and COVID-19 fear). The full model containing all predictors was statistically significant, X2 (4, N = 167) = 15.8 p < 0.001, indicating that the model was able to distinguish between respondents who were distressed and not distressed. The model explained between 18.1% (Cox and Snell R square) and 26.5% (Nagelkerke R squared) of the variance and correctly classified 77.9% of cases. One independent variable made a unique statistically significant contribution to the model, namely, moral distress – lack of time (OR: 1.6–25.9, p = 0.008). Having severe fear of COVID-19 (OR: 0.78–29.7, p = 0.091) approached significance.
Response to stress (resilience)
Overall, the respondents reported high levels of resilience (73.2/88, ± 17.9), with 98 (58.7%) classified as having high levels of resilience, 34 (20.4%) as moderate level of resilience and 12 (7.2%) as low level of resilience. Professional nurses (74.9, ± 13.2) and enrolled nursing auxiliaries (72.7, ± 20.2) reported high levels of resilience, and enrolled nurses reported moderate levels of resilience (68.0, ± 72.7, K = 0.45, p = 0.800; Table 3). The highest rated coping strategy was spirituality (3.44, ± 0.97), followed by active coping (3.31, ± 0.79), meaning-making (3.29, ± 0.99), self-efficacy (3.24, ± 0.99) and cognitive flexibility (3.15, ± 1.0), with no significant difference.
Discussion
The aim of the study was to investigate factors contributing to and the consequences of a major stressor, such as COVID-19, in terms of psychological distress and resilience among nurses with different levels of educational preparation. Overall, the study found low levels of distress in the nurse respondents (18.8/50) in the last 30 days prior to completing the questionnaire, with the score falling in the likely to be well category (Spies et al. 2009). However, an extreme stressor, such as COVID-19, had a significant impact on stress levels, with all respondents reporting significantly higher levels of psychological distress during the pandemic (27.2/50). The number of nurses who were likely to be well more than doubled after the pandemic from 45 (26.9%) in the pandemic to 89 (53.3%) post-pandemic (McNemar–Bowker test = 66.5, p ≤ 0.001), with a notable reduction in the number of respondents who were likely to suffer from a severe mental disorder. This result is expected, as the normal stressors that nurses encounter daily were exacerbated during the COVID-19 pandemic, when work and other demands were higher than usual, with nurses having to work extra shifts, function in new roles, and adapt to new situations and protocols (Van der Groot et al. 2021). The result is in line with previous research where frontline workers across the globe reported symptoms of depression, anxiety and stress during the pandemic (Van der Groot et al. 2021).
Several factors were found to contribute to nurses’ levels of distress. In the last 30 days prior to completing the questionnaire, moral distress, primarily because of a lack of time, perceived vulnerability to disease and different levels of educational preparation (specifically being an enrolled nurse with 2 years of training) all contributed to moderate or severe distress levels. During COVID-19, moral distress and fear of COVID-19 significantly contributed to moderate or severe distress levels. Moral distress, the psychological experience in response to moral stressors, such as a lack of time because of staff shortages, is common in the nursing profession (Eşer et al. 2021; Riedel et al. 2022). Studies have shown that moral distress increased during the pandemic, with increased reports of post-traumatic stress, burnout and high turnover of staff (Arafat et al. 2023; Norman et al. 2021; Silverman et al. 2021).
This is compounded with beliefs of perceived vulnerability, with our study finding moderate scores (60.7/105, ± 19.9). Coronavirus disease 2019 is a life-threatening disease, and although nurses in this sample reported mild-to-moderate (19.4/35, ± 8.2) levels of fear of contracting COVID-19, they may have felt a heightened sense of vulnerability to contract the disease considering that the disease is highly contagious. Several studies found that the COVID-19 pandemic impacted on nurses’ perceived vulnerability to the disease (Gökkaya et al. 2022; Osagiator Ariyo et al. 2022; Padmanabhanunni & Pretorius 2023; Pasay-An 2020) and could result in heightened stress, anxiety, burnout and moral distress (Brysiewicz & Chipps 2022; Manzanares et al. 2021; Riedel et al. 2022; Sun et al. 2020; Udwadia & Raju 2020). Nurses’ sense of vulnerability may further have been exacerbated by realities of workload and time constraints, limited access to personal protective equipment (PPE), access to timely information, and fears of infecting others or family members at home. In the current sample, nurses reported higher levels of stress related to stressors of protection (1.3, ± 0.7) and care (1.3, ± 0.9), with professional nurses having higher stress scores for protection (1.6 vs. 1.4 vs. 1.2, K = 7.2, p = 0.027) and consideration (1.5 vs. 1.2 vs. 0.9, K = 7.1, p = 0.029) compared to enrolled nurses and enrolled nursing auxiliaries.
The finding also confirmed that the educational preparation of nurses in terms of different categories of nurses could negatively impact their sense of self-efficacy in dealing with stress, with enrolled nurses reporting significantly higher stress and vulnerability. Possibly because of increased stress during the pandemic, these findings are in contrast to a previous study in South Africa in a psychiatric setting, which found enrolled nurses and nursing auxiliaries with lower levels of burnout and secondary traumatic stress than the other professional groups (Maila et al. 2020).
The nursing profession is exposed to several stressors related to the profession, and an event like COVID-19 can significantly impact on nurses’ mental health, although the respondents reported moderate levels of resilience. This was similar to another South African study of nursing students during COVID-19 (Steenkamp & Chipps 2024) and as reported globally (Brysiewicz & Chipps 2022). Respondents in this study used a variety of (positive) coping strategies, including active coping, meaning-making, self-efficacy and cognitive flexibility and relying on spirituality. This was again similar to the South African nursing student study, which found spirituality rated the highest (3.36/4, ± 0.88), followed by self-efficacy (3.34/4, ± 0.64), meaning-making (3.26/4, ± 0.56), active coping (3.24/4, ± 0.66) and cognitive flexibility (3.05/4, ± 0.92), with no significant differences between these strategies (Steenkamp & Chipps 2024). Active coping strategies and increased social support are associated with lower levels of psychological distress and psychological capital (self-efficacy, hope, resilience, optimism) during COVID-19 (Sun et al. 2020). Nurses affected by stress require education, support and coping tools to alleviate the adverse effects on their well-being (Hossain & Clatty 2021). In addition, considering the role of social support in resilience and coping, the principles of Ubuntu that emphasise support, shared humanity and interconnectedness (Nicolaides 2023) can be useful to promote the social, physical, spiritual and psychological well-being of healthcare workers (Mulaudzi, Mogale & Masoga 2018; Nicolaides 2023; Rasweswe et al. 2024).
Limitations of the study
The sample was drawn from three public hospitals in the Western Cape province and may not reflect the entire nurse population. Results may have varied for nurses working in private hospitals. In addition, data were collected post COVID-19, because of inability to access nurses during COVID-19, and recall bias may affect the findings. Lastly, it would have been beneficial to also measure the levels of moral distress during and after the pandemic.
Recommendations
The nursing profession is, by nature, a high-stress environment, which can impact negatively on nurses’ mental health. Exposing nurses to resilience training programmes and teaching effective coping strategies may be useful in helping nurses cope with the burden of care. In addition, resilience training should include building self-efficacy, that is, adequately preparing nurses to deal with stressors in the workplace.
Conclusion
Exposure to extreme stressors, such as the COVID-19 pandemic, and the concomitant impact on moral distress, especially related to time, can place additional stress on nurses and can impact on nurses’ mental health. However, despite this, nurses reported high levels of resilience, using a variety of coping strategies. Recognising this, there is a need to build on nurses’ natural resilience and positive responses to stress, with a specific focus on the educational preparation of the nurses in relation to the changed roles during crises.
Acknowledgements
The authors express their gratitude to all participating nurses for their contribution to this study and thank Ms. Delia Meyer, Goba Mbalenhle and Zenobia Heradien for the collection of the data.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
J.C. and P.B. conceptualised the study, A.P. participated in the revision of the study, and I.S. managed the data collection. J.C., I.S. and A.C. wrote the article and A.P. and P.B. commented on the article.
Funding information
Research reported in this publication received funding from Cape Higher Education Consortium (CHEC) (2022) - City of Cape Town (CCT)- Resilience for Inclusive Development and the South African Medical Research Council with funds received from the Department of Science and Innovation (2023).
Data availability
The authors confirm that the data supporting the findings of this study are available within the article.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
References
Ahorsu, D.K., Lin, C.-Y., Imani, V., Saffari, M., Griffiths, M.D. & Pakpour, A.H., 2020, ‘The fear of COVID-19 scale: Development and initial validation’, International Journal of Mental Health and Addiction 20(3), 1537–1545. https://doi.org/10.1007/s11469-020-00270-8
Al Maqbali, M., Al Sinani, M. & Al-Lenjawi, B., 2021, ‘Prevalence of stress, depression, anxiety and sleep disturbance among nurses during the COVID-19 pandemic: A systematic review and meta-analysis’, Journal of Psychosomatic Research 141, 110343. https://doi.org/10.1016/j.jpsychores.2020.110343
Arafat, R., Tahir, T. & Harisa, A., 2023, ‘Moral distress among nurses in caring COVID-19 patients’, Clinical Ethics 18(1), 62–66. https://doi.org/10.1177/14777509211057251
Brysiewicz, P. & Chipps, J., 2022, ‘Out of chaos leaders emerged’, Nursing Clinics 58(1), 87–96. https://doi.org/10.1016/j.cnur.2022.10.006
Chersich, M.F., Gray, G., Fairlie, L., Eichbaum, Q., Mayhew, S., Allwood, B. et al., 2020, ‘COVID-19 in Africa: Care and protection for frontline healthcare workers’, Globalization and Health 16, 46. https://doi.org/10.1186/s12992-020-00574-3
Chipps, J. & Jarvis, M.A., 2021, ‘Weathering the COVID-19 storm: The impact on health professionals’, Health SA Gesondheid 26, 1690. https://doi.org/10.4102/hsag.v26i0.1690
Chipps, J., Penelope, M., Jeffrey, H., Margaret, W., Olivia, B., Fiona, W. et al., 2022, ‘Evaluation of a digital programme for final year nursing students during COVID-19’, International Journal of Africa Nursing Sciences 17, 100455. https://doi.org/10.1016/j.ijans.2022.100455
Duncan, L.A., Schaller, M. & Park, J.H., 2009, ‘Perceived vulnerability to disease: Development and validation of a 15-item self-report instrument’, Personality and Individual Differences 47, 541–546. https://doi.org/10.1016/j.paid.2009.05.001
Eizenberg, M.M., Desivilya, H.S. & Hirschfeld, M.J., 2009, ‘Moral distress questionnaire for clinical nurses: Instrument development’, Journal of Advanced Nursing 65(4), 885–892. https://doi.org/10.1111/j.1365-2648.2008.04945.x
Eşer, İ., Şahbaz, M., Ergin, E., Taşkiran, N., Yilmaz, S. & Şahin, M., 2021, ‘Moral distress experience in nursing: Perceptions of nurses: Descriptive study’, Turkiye Klinikleri Journal of Medical Ethics-Law and History 29(3), 357–363. https://doi.org/10.5336/mdethic.2021-81865
Faro, A., Silva, L.D.S., Santos, D.N.D. & Feitosa, A.L.B., 2022, ‘The fear of COVID-19 scale adaptation and validation’, Estudos de Psicologia (Campinas) 39(53), e200121. https://doi.org/10.1590/1982-0275202239e200121
Fergus, S. & Zimmerman, M.A., 2005, ‘Adolescent resilience: A framework for understanding healthy development in the face of risk’, Annual Review of Public Health 26, 399–419. https://doi.org/10.1146/annurev.publhealth.26.021304.144357
Gökkaya, B., Yazici, T.N. & Kargul, B., 2022, ‘Perceived stress and perceived vulnerability at healthcare workers during covid-19 pandemic’, Clinical and Experimental Health Sciences 12(2), 431–438. https://doi.org/10.33808/clinexphealthsci.971161
Hossain, F. & Clatty, A., 2021, ‘Self-care strategies in response to nurses’ moral injury during COVID-19 pandemic’, Nursing Ethics 28(1), 23–32. https://doi.org/10.1177/0969733020961825
Johnson, D.C., Polusny, M.A., Erbes, C.R., King, D., King, L., Litz, B.T. et al., 2011, ‘Development and initial validation of the response to stressful experiences scale’, Military Medicine 176(2), 161–169. https://doi.org/10.7205/MILMED-D-10-00258
Kessler, R.C., Andrews, G., Colpe, L.J., Hiripi, E., Mroczek, D.K., Normand, S.L.T. et al., 2002, ‘Short screening scales to monitor population prevalences and trends in non-specific psychological distress’, Psychological Medicine 32(6), 959–976. https://doi.org/10.1017/S0033291702006074
Lam, K.K. & Hung, S.Y.M., 2013, ‘Perceptions of emergency nurses during the human swine influenza outbreak: A qualitative study’, International Emergency Nursing 21(4), 240–246. https://doi.org/10.1016/j.ienj.2012.08.008
Maben, J., Conolly, A., Abrams, R., Rowland, E., Harris, R., Kelly, D. et al., 2022, ‘“You can’t walk through water without getting wet” UK nurses’ distress and psychological health needs during the covid-19 pandemic: A longitudinal interview study’, International Journal of Nursing Studies 131(12), 104242. https://doi.org/10.1016/j.ijnurstu.2022.104242
Maila, S., Martin, P.D. & Chipps, J., 2020, ‘Professional quality of life amongst nurses in psychiatric observation units’, South African Journal of Psychiatry 26, 1553. https://doi.org/10.4102/sajpsychiatry.v26i0.1553
Manzanares, I., Sevilla Guerra, S., Lombraña Mencía, M., Acar-Denizli, N., Miranda Salmerón, J. & Martinez Estalella, G., 2021, ‘Impact of the COVID-19 pandemic on stress, resilience and depression in health professionals: A cross-sectional study’, International Nursing Review 68(4), 461–470. https://doi.org/10.1111/inr.12693
Mulaudzi, F., Mogale, R. & Masoga, M., 2018., ‘Revisiting current nursing ethics: Can Ubuntu foster an environment for ethics of care’, Ubuntu and Personhood 239–252.
Munyanziza, T., Bhengu, B., Cishahayo, E.U. & Uwase, A., 2021, Workplace stressors and coping strategies of intensive care unit nurses at university teaching hospitals, in Rwanda. Rwanda Journal of Medicine and Health Sciences 4(1), 53–71. https://doi.org/10.4314/rjmhs.v4i1.5
Naidoo, V. & Sibiya, M.N., 2019, ‘Critical care nurses’ experiences with death and dying: A South African perspective’, Global Journal of Health Science 11(9), 69. https://doi.org/10.5539/gjhs.v11n9p69
Nicolaides, A., 2023, ‘Considering the philosophy of Ubuntu in South African healthcare ethical practices’, The Journal of Medical Laboratory Science and Technology of South Africa 5(1), 71–76. https://doi.org/10.36303/JMLSTSA.133
Norman, S.B., Feingold, J.H., Kaye-Kauderer, H., Kaplan, C.A., Hurtado, A., Kachadourian, L. et al., 2021, ‘Moral distress in frontline healthcare workers in the initial epicenter of the COVID-19 pandemic in the United States: Relationship to PTSD symptoms, burnout, and psychosocial functioning’, Depression and Anxiety 38(10), 1007–1017. https://doi.org/10.1002/da.23205
Osagiator Ariyo, J., Olutope Akinnawo, E., Chinonye Akpunne, B., Oluwasanmi Kumuyi, D. & Foluke Onisile, D., 2022, ‘An investigation of associations and incidence of anxiety, depression, perceived vulnerability to diseases, and fear of COVID-19 among Nigerian health care workers’, Archives of Pediatric Infectious Diseases 10(1), e114746. https://doi.org/10.5812/pedinfect.114746
Padmanabhanunni, A. & Pretorius, T.B., 2023, ‘Teacher burnout in the time of COVID-19: Antecedents and psychological consequences’, International Journal of Environmental Research and Public Health 20(5), 4204. https://doi.org/10.3390/ijerph20054204
Padmanabhanunni, A., Pretorius, T.B., Stiegler, N. & Bouchard, J.-P., 2021, ‘A serial model of the interrelationship between perceived vulnerability to disease, fear of COVID-19, and psychological distress among teachers in South Africa’, Annales Médico-Psychologiques, Revue Psychiatrique 180(1), 23–28. https://doi.org/10.1016/j.amp.2021.11.007
Pappa, S., Ntella, V., Giannakas, T., Giannakoulis, V.G., Papoutsi, E. & Katsaounou, P., 2020, ‘Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis’, Brain Behavior and Immunity, 901–907. https://10.1016/j.bbi.2020.05.026
Pasay-An, E., 2020, ‘Exploring the vulnerability of frontline nurses to COVID-19 and its impact on perceived stress’, Journal of Taibah University Medical Sciences 15(5), 404–409. https://doi.org/10.1016/j.jtumed.2020.07.003
Pretorius, T.B., Padmanabhanunni, A., Isaacs, S.A. & Jackson, K., 2022, ‘Perceived vulnerability to disease and the relationship with teacher satisfaction in South Africa during COVID-19: The serial role of burnout, role conflict, and ambiguity’, Behavioral Sciences 12(6), 160. https://doi.org/10.3390/bs12060160
Rasweswe, M.M., Kgatla, N.M., Ramavhoya, I.T. & Mulaudzi, F.M., 2024, ‘Ubuntu Is a Critical Component in the Fight against Human Immunodeficiency Virus and Tuberculosis Stigma: Nursing Students’ Perceptions’, International Journal of Environmental Research and Public Health 21(2), 229. https://doi.org/10.3390/ijerph21020229
Riedel, P.-L., Kreh, A., Kulcar, V., Lieber, A. & Juen, B., 2022, ‘A scoping review of moral stressors, moral distress and moral injury in healthcare workers during COVID-19’, International Journal of Environmental Research and Public Health 19(3), 1666. https://doi.org/10.3390/ijerph19031666
Saragih, I.D., Tonapa, S.I., Saragih, I.S., Advani, S., Batubara, S.O., Suarilah, I. et al., 2021, ‘Global prevalence of mental health problems among healthcare workers during the Covid-19 pandemic: A systematic review and meta-analysis’, International Journal of Nursing Studies 121, 104002. https://doi.org/10.1016/j.ijnurstu.2021.104002
Shanafelt, T., Ripp, J. & Trockel, M., 2020, ‘Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic’, JAMA 323(21), 2133–2134. https://doi.org/10.1001/jama.2020.5893
Sidani, S. & Braden, C..J., 2021, Nursing and health interventions: Design, evaluation, and implication, 2nd edn., John Wiley & Sons, Hoboken, NJ.
Silverman, H.J., Kheirbek, R.E., Moscou-Jackson, G. & Day, J., 2021, ‘Moral distress in nurses caring for patients with Covid-19’, Nursing Ethics 28(7–8), 1137–1164. https://doi.org/10.1177/09697330211003217
Slade, T., Grove, R. & Burgess, P., 2011, ‘Kessler psychological distress scale: Normative data from the 2007 Australian National Survey of Mental Health and Wellbeing’, Australian & New Zealand Journal of Psychiatry 45(4), 308–316. https://doi.org/10.3109/00048674.2010.543653
Spies, G., Stein, D., Roos, A., Faure, S., Mostert, J., Seedat, S. et al., 2009, ‘Validity of the Kessler 10 (K-10) in detecting DSM-IV defined mood and anxiety disorders among pregnant women’, Archives of Women’s Mental Health 12(2), 69–74. https://doi.org/10.1007/s00737-009-0050-0
Steenkamp, I. & Chipps, J., 2024, ‘South African nursing students’ stress and resilience during the global COVID-19 health crisis’, Journal of Psychology in Africa 34(2), 169–175. https://doi.org/10.1080/14330237.2024.2335867
Sun, N., Shi, S., Jiao, D., Song, R., Ma, L., Wang, H. et al., 2020, ‘A qualitative study on the psychological experience of caregivers of COVID-19 patients’, American Journal of Infection Control 48(6), 592–598. https://doi.org/10.1016/j.ajic.2020.03.018
Udwadia, Z.F. & Raju, R.S., 2020, ‘How to protect the protectors: 10 Lessons to learn for doctors fighting the COVID-19 coronavirus’, Medical Journal, Armed Forces India 76(2), 128–131. https://doi.org/10.1016/j.mjafi.2020.03.009
Van der Groot, W.E., Duvivier, R.J., Van Yperen, N.W., De Carvalho-Filho, M.A., Noot, K.E., Ikink, R. et al., 2021, ‘Psychological distress among frontline workers during the COVID-19 pandemic: A mixed-methods study’, PLoS One 16(8), e0255510. https://doi.org/10.1371/journal.pone.0255510
Wang, J., Zheng, Z., Tang, Y., Zhang, R., Lu, Q., Wang, B. et al., 2022, ‘Psychological distress and its influencing factors among psychiatric nurses in China: A cross-sectional study’, Frontiers in Psychiatry 13, 948786. https://doi.org/10.3389/fpsyt.2022.948786
Yu, H., Li., M., Li., Z., Xiang, W., Yuan, Y., Liu, Y. et al., 2020, ‘Coping style, social support and psychological distress in the general Chinese population in the early stages of the COVID-19 epidemic’, BMC Psychiatry 20(1), 426. https://doi.org/10.1186/s12888-020-02826-3
|
Hide
Show all
Email this article (Login required)
