Psychological Impact on the Nursing Professionals of the Rioja Health Service (Spain) Due to the SARS-CoV-2 Virus

Background: The COVID-19 pandemic is a public health emergency that has affected health professionals around the world, causing physical and mental exhaustion with a greater probability of developing mental disorders in professionals who provide healthcare. Objective: The objective of this study was to know the psychological impact of the SARS-CoV-2 virus on the nursing professionals working for the Rioja Health Service. Methods: We conducted an observational and descriptive cross-sectional study. The nursing staff at the Rioja Health Service were invited to respond to a self-administered questionnaire between June and August 2020. Results: A total of 605 health professionals participated in the questionnaire; 91.9% were women, 63.14% were registered nurses, and 36.28% were auxiliary nurses. Risk factors for mental health professionals were identified in more than 90% of nurses (p = 0.009), affecting their psychological state with feelings of exhaustion, emotional overload (p = 0.002), and less use of coping strategies among women. Younger professionals with less experience had higher levels of stress compared to those with more than five years of experience, who showed a progressive reduction in the impact of stressors (p < 0.001). Professionals with dependent family members presented higher levels of emotional overload and coping problems (p = 0.009). Conclusion: The COVID-19 pandemic has had a significant psychological impact on health professionals in terms of stress, emotional well-being, and the use of coping strategies. Female health professionals with dependents, a temporary contract, and less work experience have been more psychologically affected.


Introduction
In December 2019, the first outbreak of the SARS-CoV-2 virus, known as COVID-19, was reported in Wuhan, China, with rapid expansion throughout the world [1]. Soon, it was declared an international public health emergency and recognized by the World Health Organization (WHO) as a global pandemic on 11 March, 2020. Across the world, the virus has had an intense negative impact, the rapid increase in demand for health facilities and professionals has caused many healthcare systems to not function effectively [2]. Since the start of the pandemic to 18 November 2020, 1,291,808 cases of COVID- 19 have been reported in Spain [3]. Healthcare workers have suffered enormous pressure with long work shifts, [4] inadequate conditions, high risk of infection, ethical dilemmas when allocating scarce resources to equally needy patients [5], lack of specific skills, frustration [6], social stigmatization, isolation, concern about spreading the virus to their families [4,7], lack of contact, and lack of social support [8]. These factors have forced many health professionals to make sensible changes in their daily lives that compromise their health and psychological well-being, as a consequence of physical and mental exhaustion [2,[9][10][11].
These factors can give rise to different levels of psychological pressure that can trigger health problems such as feelings of loneliness, helplessness, stress [12], anguish [9], anxiety [6,13], depressive symptoms [4], insomnia, denial, anger, fear, irritability, sleep disorders [2], burnout syndrome [5], and even risk of suicide [10]. This pressure exceeds the psychological and emotional limits of health professionals, increasing the risk of psychological suffering with a higher probability of developing the abovementioned mental disorders [6,11,12], in addition to vicarious traumatization related to compassion towards the patients cared for [14]. Further, post-traumatic stress [5,15,16] can be a long-term consequence of this pressure [7].
According to studies in the first months of the pandemic, between 71% and 89% of health workers that were in high-risk situations, had suffered psychological symptoms [2,5,6]. About half reported depressive symptoms (50.4%) and anxiety (44.6%), respectively, whereas 34% reported insomnia [5,[8][9][10]. In total, 34.4% of nurses and physicians claimed to have mild disorders, 22.4% had moderate disorders, and 6.2% had severe disorders [5]. This especially affected young women, which is consistent with previous pandemics [4,17,18]. Direct and continuous contact with infected patients influences anxiety; these professionals experienced higher anxiety scores than those who had not met directly with positive patients [19]. Higher incidence values were found in female nurses compared with male physicians because they tend to have longer and closer contact with patients [12]. To find a solution, 36.3% of professionals searched for and accessed psychological materials, such as books on mental health, whereas 50.4% sought psychological resources available through the media, such as online information on mental health and coping methods. Furthermore, 17.5% of the sampled healthcare workers participated in professional counseling or psychotherapy [5]. About 20% of health professionals suffered stigmatization or discrimination from some people with whom they interacted at work, and up to 49% perceived similar feelings when interacting with the population in their daily life outside of work [4,5].
It should be noted that managers of health systems need to maintain the physical, mental, and professional integrity of their workers, especially nurses, who have witnessed a high number of deaths, illnesses, and disabilities caused by COVID-19 [2]. This should involve global strategies to protect the health of these workers by maintaining mental health and especially controlling depressive symptoms, anxiety, and suicidal ideations, as well as early identification of secondary psychosocial factors that can generate stress [12]. Most studies have indicated that the psychological safety of health personnel is an essential condition to providing quality care to patients [7], and it should be a chief concern to develop strategies to prepare, educate, and strengthen the mental health of the affected population [2,5].
To protect professionals, it is necessary to obtain information about the reality of the psychological impact caused by this pandemic, and to relate this new knowledge with that generated in other previous similar pandemics (such as the SARS-CoV-1 and MERS pandemics). In this way, optimal intervention strategies can be designed to moderate or reduce the risks and consequences of mental health deterioration in nurses. There is a need for more resilient professionals who take advantage of their personal resources to face health crises with greater personal strength. For this reason, the objective of this study was to uncover the psychological impact of the SARS-CoV-2 virus on nursing professionals at the Rioja Health Service (SERIS).

Study Design
We performed an observational and descriptive cross-sectional study carried out between June and November 2020.

Population and Scope of the Study
The study was carried out in the autonomous community of La Rioja (Spain). According to data from the government of La Rioja, for a sample with a 95% confidence interval and an alpha error of 5%, the minimum sample calculated was 310 subjects. The questionnaire was sent to all SERIS workers (highlighting registered nurses and nurse auxiliary) using an internal mailing service. We analyzed the results received during the time the questionnaire was available between 19 June and 6 August 2020, as long as the minimum sample size was exceeded.

Study Variables
The main variables in the study population were stressors, perceived emotions, and coping strategies. The secondary variables included the demographic data of the professionals (age by intervals, sex, marital status, number of children, dependents) as well as data related to the job, among others (professional category, type of contractual relationship with the company (e.g., permanent, temporary) and years of professional experience, see Table 1.)

Data Collection Instrument and Procedure
For data collection, a self-administered questionnaire was prepared that collected information on the response of the health system and its professionals in the COVID-19 crisis.
The objective of the study was defined and characterized by a bibliographic review to know what had been published so far, as a starting point to carry out the process of questionnaire construction. With the information obtained, two of the researchers analyzed and defined three dimensions of study that contributed to a better selection and operationalization of the variables.
Once the first version of the questionnaire was made, it was sent to two independent experts for questionnaire validation. The reviewers evaluated the following aspects: structure of the general design of the questionnaire; the number of questions; structure and content of each question, and their interpretation; problems with the application of the questionnaire; understanding the questions and operations of the instrument that concerned the language or writing of the items; and the ease of interpretation for each item. With their contributions, the final questionnaire of 47 items was prepared. The questionnaire was prepared in a digital version using the Microsoft Forms ® tool for digital dissemination. To increase methodological control and avoid duplication, all similar questionnaires carried out on the same date and within one minute were filtered and eliminated. IP filtering was not used, as it prevented access to independent responses if users were connected to the Internet from the services of major institutions.
In the survey form, a combination of forced-choice (i.e., Never, Sometimes, Almost Always, Always) and comments were used. The forced-choice questions were mandatory.
The validation of the internal consistency of the questionnaire was determined through the calculation of Cronbach's alpha coefficient, which allowed us to check the internal context of each item. The test was considered acceptable when the alpha value was equal to or greater than 0.7.
The questionnaire itself had 3 important parts: the stressors dimension (which collected items from 14 to 34), the perceived emotional dimension (which collected items 35 to 38), and the coping dimension (which collected items 39 to 42). The reliability of this structure was acceptable where Cronbach's alpha is shown for each of the original dimensions, see Table 2.
To observe the differences in different stressors, it was decided to quantify the instrument. To do this, a total score was created for each dimension that took values from 0 to 3 or 0 to 5, depending on the item to be assessed (on the Likert scale). First, 0 was the most positive answer and 3 or 5 was the most negative. Two questions were categorized in another way: the first was related to whether one had been infected by the SARS-CoV-2 virus. If a participant answered with 0, then they indicated that they had not been infected whereas 1 denoted that they had been infected. The second question corresponded to item 43. If a participant answered with 0, then they had not requested psychological help on the indicated telephones; if they answered 1 then it indicated that they had not, but would like to, and; 2 indicated that they had requested help.  Thus, the first dimension (stressors) adopted values between 0 and 81 (questions 20, 28, 29, and 30 were not included in the total score since only a small group of the initial sample answered).
The second dimension (perceived emotions) adopted values between 0 and 20, since the Likert scale in the four questions made up this dimension of values from 0 to 4.
The third dimension (coping strategies) adopted values between 0 and 16, since the Likert scale in the four questions made up this dimension of values from 0 to 3.
The questionnaire was available throughout the validity period of the survey (between 19 June and 6 August 2020). This period coincided with the mitigation phase of the crisis, a time that seemed ideal not to overload professionals even more in the acute phase of the pandemic, but having very recent experience, and therefore it was more faithfully remembered.

Statistical Procedures and Analysis
The description of the quantitative values was made using descriptive statistics (mean and standard deviation). Since the data distributions were not Gaussian, other robust statistics such as the median and interquartile range, as well as the maximum and minimum values, were also indicated. The distributions of categorical variables were described using absolute and relative frequencies of the distribution.
For the inferential analysis of the data, the items of the questionnaires between the groups formed by demographic variables were described by means and standard deviation. The t-Student or Mann-Whitney U test was used to estimate the relationships between variables (in the case of comparing two groups depending on whether the variable has a normal distribution or not), or utilizing the one-way ANOVA test or Kruskal-Wallis H test (in the case of comparing more than two groups).
To assess the validity and structure of the three dimensions once its Cronbach has been analyzed and indicated good internal consistency, an exploratory factor analysis (EFA) was performed (Table 3)

Ethical Considerations
The survey was anonymous and did not collect personal data or devices that could identify the informant. There was no trace (Internet protocol (IP) or any other) of the respondents. The information was treated confidentially and anonymously since they had dissociated data, following the Data Protection Regulation (EU) 2016/679 of the European Parliament and the Spanish Organic Law 3/2018. [20]. The researchers did not declare any type of ethical, moral, or legal conflict, nor did they claim to have received financial compensation of any kind. The participants did not receive any type of compensation for answering the questionnaire, as it was voluntary.

Descriptive Results
In total, 605 participants answered the questionnaire (response rate = 37.88%). Interestingly, 91.9% of the study participants were women. The mean age was mostly between 36 and 55 years (56.5%). Most of the participants were married (56.2%). Some participants (18.68%) had dependents in their charge. Further, 63.80% were RN, whereas 36.2% were AN. Concerning the type of service provision, 52.23% were civil servants. Almost 60% had more than 15 years of professional experience (Table 1).

Descriptive Data
We can see the obtained scores from the questionnaire in Table 5 and Figures 1-3.

Comparative Analysis of the Variables
The analysis of the sex variable in relation to the study dimensions (i.e., stressors, perceived emotions, and coping strategies) shows a mean of the stressors in women of 25.96 ± 6.75 and 23.31±7.47 in men. A value of p = 0.009 was estimated, and these differences were statistically significant. We observed significance (p = 0.002) with respect to the mean of emotions perceived in women (10.34 ± 3.68) and men (8.67 ± 4.08). Regarding the analysis of the dimensions and the variable "dependents", an average of perceived emotions with dependents (11.03 ± 3.68) and without dependents (10.02 ± 3.72) was observed, with a p-value = 0.009. These differences were statistically significant. The analysis of the employment relationship with the company and assessing the relationship of being or not being a permanent staff member with the dimensions under study showed an average amount of stress factors in permanent staff (24.54 ± 6.53) compared to an average amount

Comparative Analysis of the Variables
The analysis of the sex variable in relation to the study dimensions (i.e., stressors, perceived emotions, and coping strategies) shows a mean of the stressors in women of 25.96 ± 6.75 and 23.31±7.47 in men. A value of p = 0.009 was estimated, and these differences were statistically significant. We observed significance (p = 0.002) with respect to the mean of emotions perceived in women (10.34 ± 3.68) and men (8.67 ± 4.08). Regarding the analysis of the dimensions and the variable "dependents", an average of perceived emotions with dependents (11.03 ± 3.68) and without dependents (10.02 ± 3.72) was observed, with a p-value = 0.009. These differences were statistically significant. The analysis of the employment relationship with the company and assessing the relationship of being or not being a permanent staff member with the dimensions under study showed an average amount of stress factors in permanent staff (24.54 ± 6.53) compared to an average amount

Comparative Analysis of the Variables
The analysis of the sex variable in relation to the study dimensions (i.e., stressors, perceived emotions, and coping strategies) shows a mean of the stressors in women of 25.96 ± 6.75 and 23.31±7.47 in men. A value of p = 0.009 was estimated, and these differences were statistically significant. We observed significance (p = 0.002) with respect to the mean of emotions perceived in women (10.34 ± 3.68) and men (8.67 ± 4.08). Regarding the analysis of the dimensions and the variable "dependents", an average of perceived emotions with dependents (11.03 ± 3.68) and without dependents (10.02 ± 3.72) was observed, with a p-value = 0.009. These differences were statistically significant. The analysis of the employment relationship with the company and assessing the relationship of being or not being a permanent staff member with the dimensions under study showed an average amount of stress factors in permanent staff (24.54 ± 6.53) compared to an average amount (27.14 ± 6.87) in temporary personnel. As such, p < 0.001 was estimated, and these differences were considered statistically significant. Significance was also observed in the perceived emotional dimension. It was 14.02 ± 3.77 in fixed staff versus 15.10 ± 3.39 in temporary staff. For the coping dimension, a mean of 2.51 ± 1. 53 was observed in permanent staff and 3.27 ± 2.20 in temporary staff, with an estimated significance of p = 0.035 for the emotional dimension and p = 0.005 for coping strategies. Regarding the work experience variable, the mean of the stressors in professionals with an experience of 1 to 5 years was 28.46 ± 7.06. From 6 to 10 years, the mean was 27.57 ± 6.17, from 11 to 15 years the mean was 26.15 ± 6.62, and over 15 years the mean was 24.98 ± 6.75. A p-value of 0.001 was estimated, and these differences were considered statistically significant. The analysis of the age of the sample reflected statistical significance for the impact of stress factors. A p-value of 0.001 was estimated, with a mean for the stress factors in people under 25 years to be 27 ± 5.77 For those aged 26 to 35 years, it was 28.24 ± 6.45, and for those aged 36 to 45 years it was 26.95 ± 6.67. Further, for those aged 46 to 55 years, it was 24.71 ± 6.97 and 23.27 ± 6.45 for those aged over 55 years. Table 6 shows the results of the comparative analysis between the independent variables (sex, dependents in charge, type of employment relationship, time of experience, and age) and the dependent variables (stressors, perceived emotions, and coping). The sex variable showed statistically significant differences concerning stressors and perceived emotions. The variable that corresponded to people with dependents was statistically significant for perceived emotions. The type of employment relationship presented statistically significant differences between the three dimensions. The time of experience showed statistically significant differences in all age groups to stressors. Age presented statistically significant differences in the dimension of stressors.

Discussion
The study of psychological impacts experienced by nursing professionals during a pandemic has a limited history, especially in Spain, and scientific publications at the national and international level are still scarce. Faced with this reality, the present study aimed to analyze the impact of the pandemic on nursing professionals (RN and AN), assessing the significance of variables typically studied, i.e., age, sex, family situation, type of employment contract, experience professional, analyzing professional exposure to stressors, emotional response, and coping capacity.
The designed questionnaire obtained a reliability coefficient according to Cronbach's alpha that varied from 0.79 to 0.88 depending on the dimension under study. The internal consistency within each of the dimensions was classified as "very good", which allowed us to trust the results of the study and we highlighted their robustness [21][22][23].
The results reflect that psychological risk factors were present in a high percentage of professionals under study. Factors were related to the fear of becoming infected or infecting loved ones. Moreover, the fear of making mistakes, as well as not giving adequate physical and/or psycho-emotional care to a patient's needs, were factors present in practically the entire sample. More than 90% of the nursing professionals reported that the development of their work activity during the pandemic impacted their psychological state, with feelings of physical exhaustion and emotional overload. Previous studies at an international level correlated to this type of pandemic with high levels of psychological symptoms [24], among which the suffering of anxiety, stress, depression, and sleep disorders stands out [25,26].
In relation to emotional overload, the sample scores showed feelings of sadness, rumination, negativism, and emotional destabilization. These feelings were consistent with those described by other authors in different samples of professionals during the COVID19 pandemic [2,4]. At the level of coping strategies, less than 5% of professionals requested psychological support, but the sample scores were high in coping with problems and self-critical analysis. Professionals aware of the psychological impact, sought help in prepared materials, bibliographies, and psychological resources available online. In a very small percentage, they requested specialized external help [5].
Regarding the analysis of the organizational components at the level of human, material, and coordination resources, the perception of the sample in a high percentage, according to the regional study service (SERIS), refers to the development during the pandemic of coordinated work, with the availability of appropriate material resources and staff according to needs. These elements can be understood as protective factors against the psychological risks of professionals. The concern of health system managers to maintain the psychophysical integrity of health professionals during the pandemic is reflected as a result of different studies [2]. The psychological safety of health personnel is perceived as an essential condition to provide quality patient care [5,7,12]. In the analysis of the psychological impact, the study reflects differences by sex, a greater presence of stressors, greater emotional burden, and less use of coping strategies among the women in the sample, results that are in line with other previous studies at an international level [13,25]. The role of the caregiver within the family home, which has been developed by women in our society throughout history, can be related to these results. The emotional burden and the perceived risk factors can be associated with the perception of COVID-19 fear and its impact on the family. Fear is an adaptive and natural human response to threatening situations, and SARS-CoV-2 is currently experienced as a threat, generating this feeling, in many cases, due to misinformation and a lack of knowledge based on evidence. It associates fear with feelings of vulnerability, loss of control, and concern for one's own health, as well as the health of the family environment [27,28]. In this sense, the professionals in the sample with dependents reveal, along the same lines, higher levels of emotional charge, stressors, and coping problems. A study carried out in our country showed that living with people with chronic diseases increased the psychological impact on healthcare professionals due to the fear of contagion [27].
Regarding the repercussion of the impact and the age of the sample, older nursing professionals showed less affectation for the first stressors under study. As the age of the sample increased, the impact of these stressors decreased. This difference was usually statistically significant (p < 0.001). Other studies support these results [17], relating them to less work experience, greater vulnerability, and less adaptation to an overloaded and fickle healthcare environment. The analysis of the experience and labor relationship (permanent/temporary) reveals an experience of more than five years on the job showed a progressive reduction of stress. These differences consider work experience to be statistically significant (p < 0.001). Likewise, a contract with greater consolidation in the administration significantly reflects less stressors (p < 0.001), less emotional overload (p = 0.035), and a greater coping capacity (p = 0.005). Different studies have linked older age, experience, and consolidation in employment with the development of coping strategies that reduce stress, emotional overload, and the ensuing impacts of such stressors [2,7,17].
Similar epidemics, such as SARS-CoV-1 and MERS-CoV permitted us to understand similarities in pandemic-related psychological damage. In the SARS-CoV-1 epidemic, health professionals were affected by the fear of contagions and experienced high levels of depression, anxiety, fear, distress, and post-traumatic stress [29]. On the other hand, health professionals who were on the front lines of the MERS epidemic experienced greater symptoms of post-traumatic stress disorder [30].
It is surprising to note how similar experiences and complications during other pandemics did not prevent psychological consequences in this pandemic for healthcare professionals. As such, it is possible to determine the main strengths of this study, i.e., its timeliness, its results pertaining to the psychological impact of COVID-19, practical implications, potential application of intervention protocols that could reduce the psychological impact on nursing teams (especially for women, younger professionals, and less work experience). In line with the conclusions of other studies, we found it necessary to inter-vene in order to improve information and training regarding COVID-19, enhance security measures, guarantee professionals' functional health stability with regard to sleep/rest, nutrition/metabolism, stress tolerance, role/relationships, protecting the family, and offering professional psychological support from occupational risk prevention services. Intervening early in the prevention of psychological risks that affect these professionals is essential to provide quality care to patients, maintain the system's sustainability, and generate greater resilience for professionals in the face of stressful situations that may affect patients in the future [2,5,7,27].

Conclusions
Our study has shown that the COVID-19 pandemic has had a significant psychological impact on health professionals, both in terms of stress, emotional well-being, and the use of coping strategies. In our context, female health professionals with dependents, a temporary contract, and less work experience were more psychologically affected than others. Future research can be based on these results to design strategies to prevent the psychological impact of pandemics, or high-stress situations in healthcare systems.

Limitations
Since this is a descriptive study, we did not use a statistical projection to infer associations. Regarding sex, the idiosyncrasies of nursing professionals in our country should lead us to estimate the results of differences by sex with some reserve, due to the distribution of the sample with 91.9% of women versus 8.1% of men. Although an attempt has been made to avoid duplication through the specified methodology, it has not been possible to establish IP filtering due to the loss of subjects carrying out the questionnaires through the same network in the health institutions. Parallel control procedures through cookies could be implemented in future studies Funding: We declare that we did not receive any funding in support of this research or to cover publication costs.

Institutional Review Board Statement:
The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of La Rioja Biomedical Research Center (CIBIR) Reference CEImLar P.I. 416.

Informed Consent Statement:
The consent was voluntary, free and no personal data was collected.