**3. Nursing in the COVID-19 pandemic**

Nurses are anonymous heroes, playing critical roles in disease prevention and diagnosis, and providing primary health care services including prevention, treatment, and rehabilitation [28]. They have been and continue to be at the forefront of combating infectious diseases such as COVID-19, leading the way in developing best practices in disease management and clinical security [13, 29, 30]. However, despite this obvious situation, for centuries nurses have found themselves trying to explain the importance of their profession, the reason for its existence, and its indispensability.

The World Health Assembly has announced the year 2020 as the "International Year of Nurses and Midwives" [31]. Because of the COVID-19 pandemic, the nursing profession is on the world agenda, just as it suits the name of the year, and nurses have started to show that they are "A Pioneering Voice in World Health" [32]. This year, which created a global awareness for nurses, once again emphasized the importance of necessary health security measures in harmony with the changing roles of nurses.

### **3.1 Changing roles of nurses in the pandemic**

The high prevalence, highly contagious nature, and associated morbidity and mortality rates of COVID-19 in the general population of many countries create an unprecedented demand for health and social care services worldwide [13, 14]. This demand has transformed the role of nurses beyond patient care, which is regarded as a security boat that integrates different professions and communities to reduce the risk of the COVID-19 pandemic and ensure effective communication [13]. The addition of new ways of nursing, which is already demanding in terms of attention and care, has made working in the COVID-19 environment extremely stressful. Nurses try to adapt to new protocols to the "new normal", beyond just experiencing an increase in the intensity of their work in this process. Concomitantly, due to the increasing number of patients, the need for more nurses in clinics, emergency rooms and intensive care units where care is provided for COVID-19, and the interruption of work due to the infection of health personnel in this process, has constituted an extra workload for all healthcare professionals [14].

Nurses who work at maximum capacity also experience various problems such as deciding which critically ill patients may be allocated to the intensive care unit and which patients can be provided with a respiratory device; they accompany the end-of-life journey of both the patient and the family in the face of deterioration faster than they are accustomed to [33–35]. At the same time, because of isolation precautions and rules, patient relatives are not able to be with the patients, which results in nurses' providing the necessary support and establishing remote communication between the patient and relatives, giving nurses additional responsibilities [36]. Protective measures such as masks, visors, and social distancing applied in this process make interaction difficult and patients, and nurses suffer from communication problems such as not being able to see each other's faces or hear what they are saying [5, 14].

In addition, factors such as limited resources of hospitals, lack of protective equipment, longer shifts, increased workload, new tasks and procedures, exposure to COVID-19 and risk of transmitting the infection, inadequate access to COVID-19 testing if symptoms develop, uncertainty as to whether their organization will support their needs if infection develops, support for additional needs (such as food, accommodation, transportation) as working hours increase, obligation to work in new units (such as those who are not intensive care nurses to serve in the intensive care unit), dilemmas with teammates, prioritizing care for specific patients, watching patients die alone, different pathologies seen in addition to COVID-19, neglect of personal and family needs, social distancing from loved ones, inadequate communication, and exposure to insufficient information make nurses' compliance even more difficult [8, 11, 37]. Nurses experience many complications at the same time in this process, such as inadequacy, uncertainty, fear, and change, and not only need physical but also mental support.

#### **3.2 International health security of nurses in the pandemic**

When determining innovative ways to provide an adequate workforce during the pandemic period, it is important that everything applied is safe for staff and patients [30]. The WHO called on governments and healthcare leaders to address persistent threats to the health and security of healthcare workers and patients in the COVID-19 pandemic and emphasized that no country, hospital, or clinic can keep their patients safe unless they first keep healthcare workers safe [38]. In this regard, the importance of mental security as well as physical security has been emphasized. The psychological effects of the infection itself should not be neglected for healthcare professionals.

While the COVID-19 crisis continues, situations such as the dismissal of nurses in some areas, reducing workforce and granting leaves, calling back retired nurses for help due to the growing demand for nursing services to combat the COVID-19 outbreak, or suspension of leave has made health care even more difficult [13, 35, 39]. Most of the nurses were not allowed to go home due to lack of staff: to meet their staffing needs many organizations have asked healthcare professionals treating COVID-19 patients to continue working until they show symptoms of the disease [13].

Although these different regulations made by governments are important for the protection of groups and society at risk of COVID-19 infection, it supports the stigmatization and exclusion of nurses [24, 40, 41]. Being able to report difficulties without worrying about being stigmatized or blamed is very important for both nurses and others to dare seek help [5, 14, 42]. Nurses' mental problems should be detected early, and their access to mental health services should be provided for the security of the entire society, not just nurses or healthcare professionals [35].

#### **4. Mental problems of COVID-19 nurses**

Nurses are not only exposed to physical risks, but have also faced concerns over the impact of COVID-19 on their own lives and families, as well as long working hours and work environment security [13, 19]. The susceptibility to psychiatric disorders has increased, especially in nurses who directly care for infectious patients in critical and intensive care units [7, 30]. Studies conducted in centers and units providing COVID-19 care in different parts of the world have reported that the mental health of nurses has been significantly affected and that nurses experience psychological problems [6, 15, 43–45].

#### *COVID-19 Pandemic and Mental Health of Nurses: Impact on International Health Security DOI: http://dx.doi.org/10.5772/intechopen.96084*

It has been determined that the most common psychological effects in nurses were fear, despair, anxiety, depression, and post-traumatic stress symptoms [19–21, 37, 46, 47]. Worldwide studies on mental problems that occur as a cause or consequence of these psychiatric disorders showed that nurses are facing primary and secondary traumatic stress, job burnout, compassion fatigue and moral injury [4, 17–26]. To better understand the mental problems seen in nurses in the pandemic it is necessary to define these concepts and carry out studies within the scope of combating these problems.

#### **4.1 Primary traumatic stress**

Primary (direct) traumatic stress, stress that is directly perceived by the individual, is a threat to health security, along with time constraints, patient expectations, lack of social support, and inadequate coping [25]. Among the factors that directly lead to stress for nurses in the COVID-19 pandemic are staff shortages, lack of personal protective equipment, being in an unfamiliar environment or care system, and concerns about lack of organizational support. In addition, the psychological conflict between health care workers' responsibility to care for patients and their behavior to protect themselves from a potentially deadly virus can also lead to stress [14].

Nurses who are at bedside 24 hours a day, seven days a week, have the highest occupational stress compared to other groups [14]. Studies on COVID-19 show that work-related stress is especially prominent in nurses [4, 20, 21, 24]. Work-related stress in nurses leads to decreased physical function, emotional exhaustion, desensitization, decreased personal success, low job satisfaction, and personnel transfer [25]. Although nurses seem to function in this process, they also experience accompanying physical and psychological symptoms due to background long-term stress exposure.

#### **4.2 Secondary traumatic stress**

Secondary (indirect) traumatic stress, defined as the stress of helping people who are in pain or who were traumatized and recovered, develops without direct sensory traces because of long-term exposure of the helping individual to the traumatic event and the continuous repetition of an event with unpleasant details [25, 48]. The more traumatic the event and the greater the contact with the patient, the greater the risk of secondary traumatic stress formation [24]. It emerges due to risk factors such as the unpredictability and increased infection rate during the COVID-19 emergency, repeated exposure to trauma, and witnessing patients suffering. In addition, a more intense empathic approach to patients that causes greater vulnerability of healthcare workers also leads to secondary traumatic stress [10, 24, 40].

Secondary traumatic stress, which is considered an occupational hazard, is very common in nurses, especially those working in emergency, oncology, psychiatry, and pediatrics departments [25]. Healthcare workers who directly encountered COVID-19 patients intensive care units and in critical centers reserved for COVID-19, experienced higher secondary traumatic stress than others. [17, 18, 25]. Secondary trauma has been studied more than primary trauma. Its prevalence brings with it other serious problems such as anorexia, insomnia, fatigue, anger, apathy, unwillingness, hopelessness and depression.

#### **4.3 Job burnout**

Burnout is a psychological syndrome characterized by emotional exhaustion associated with prolonged exposure to occupational stress (depletion of emotional resources), desensitization (developing cynical attitudes about patients), and decreased professional success (a sense of negative self-evaluation) [18, 49, 50]. The deadly and uncontrollable nature of COVID-19 with currently no known effective cure and the relatively high infection and mortality rate among healthcare workers trigger feelings of anxiety and stress. Problems such as social stigma, lack of personal protective equipment, and heavy workload pave the way for burnout in healthcare workers [49].

Recent studies report that nurses caring for COVID-19 patients experience more burnout than others [18, 19, 23, 25]. Burnout can have serious consequences for patients, healthcare professionals, and institutions. This not only results in poor physical and mental health consequences, lack of motivation, absenteeism, and low morale, but also in deterioration of the quality of care provided by the staff affected, decrease in patients' satisfaction levels, an increase in health-related infections, and high mortality among patients [18, 49].

#### **4.4 Compassion fatigue**

Compassion fatigue is seen as contextually interchangeable with secondary traumatic stress; it is generally known as a combination of secondary traumatic stress and burnout symptoms [8]. Compassion fatigue is a job-related stress response that is considered a "maintenance cost" in healthcare workers. It is closely related to professional satisfaction, personnel transfer rate, and nursing quality [7, 25]. During pandemics such as COVID-19, intensive care nurses witness patient suffering and death more frequently than before, and in addition are responsible for decisions regarding allocation and use of resources, which is why they carry a high risk of compassion fatigue [7].

Studies report that among all healthcare professionals, nurses who provide uninterrupted care to patients and who show an approach with empathy are at risk for compassion fatigue and that their health status, job performance, and professional satisfaction levels are affected [8, 25]. It was seen that nurses, who have been in contact and interacting with COVID-19 patients for a long time, also experience compassion fatigue [19, 23, 25]. Nurses experiencing compassion fatigue may use harmful coping methods such as absenteeism, leaving work, despondency, social isolation, alcohol-substance use, and overeating [7].

#### **4.5 Moral injury**

Moral injury is a concept used to describe psychological distress caused by acts that violate a person's ethical or moral rules or acts that lack said rules [8, 51]. The pandemic is a difficult time during which healthcare professionals experience dilemmas in the triage of COVID-19 patients, for instance where they must decide which of two patients will get the emergency room's only remaining ventilator. As a result of this decision the nurse may experience feelings such as guilt, shame, or remorse, which will negatively affect all aspects of life. Although the health worker tells himself/herself that he/she is following the protocol and doing his/her best, he/ she will think that he/she has violated moral values [14, 52].

All healthcare workers and all frontline workers such as emergency first responders are subject to moral injury during this time [51, 52]. However, the measurement tools and studies to diagnose the painful and powerful internal struggles experienced by healthcare workers during the COVID-19 pandemic and the resulting moral injury are insufficient [52, 53], although some scales have been developed to describe this process [22, 26]. Moral injury negatively affects ability to function and performance; it can also lead to depression and post-traumatic stress disorder [5, 52]. In addition, nurses are prone to quit their jobs if they feel that they are not sufficiently supported by organizations and the government [14].
