Since the beginning of the COVID-19 pandemic, healthcare workers (HCWs) were in the front line, assisting patients with COVID-19; they faced an unexpected and sudden increase in healthcare demands and were exposed to a high risk of contracting the disease (1). Furthermore, because of the fear of contagion and the social-distance measures put in place to contain the pandemic, HCWs often could not or chose not to see their families and friends for long periods, so they found themselves alone and with no emotional support. Such conditions are known to have negative effects on the psychological health of HCWs (2, 3).

Psychological sequelae secondary to the outbreak of an epidemic have already been reported for Middle East respiratory syndrome (MERS) in 2012 and severe acute respiratory syndrome (SARS) in 2003, in which symptoms of post-traumatic stress disorder (PTSD), sleep disorders, social isolation, work-related stress, burnout, and generalized anxiety disorder (GAD) were reported in HCWs (4–7). In the case of the COVID-19 pandemic, the scientific literature shows that HCWs, especially nurses and women who worked in the front line and in emergency areas, experienced more severe mental health symptoms than others (3). According to a meta-review of systematic reviews, GAD and PTSD were the most prevalent COVID-19 pandemic-related mental health conditions affecting HCWs, especially nurses (8). Several more detailed studies, conducted after the first wave of the pandemic in China, reported that HCWs suffered from anxiety and stress-related symptoms, with prevalence ranging from 28.5 to 36.1% and 24 to 73.4%, respectively (9–11). In addition, some studies have reported high levels of anxiety and acute stress disorders in nurses more than a year after the start of the pandemic (12, 13).

Focusing attention on the psychological impact of COVID-19 on HCWs, particularly on the Italian nurses who were among the first in Europe to deal with the pandemic and to assist COVID-19 patients (14), is crucial to investigate if such HCWs are to be offered the right tools to face this extraordinary scenario and to preserve their mental health, both as individuals and as actors in the National Health Service. In the Italian context, relatively few studies have investigated the prevalence of GAD and PTSD in HCWs, and most of these were conducted exclusively during the first wave of COVID-19 (15, 16), focusing on local contexts (12, 17, 18). Given this, we conducted a study on a national sample of nurses employed during the second wave of the COVID-19 pandemic to investigate the long-term impact on nurses’ mental health, with the specific aims of (i) determining the prevalence of symptoms of potential GAD and PTSD; (ii) identifying possible predictors of PTSD.

This study aimed to assess the prevalence of symptoms of GAD and PTSD among nurses employed during the second wave of COVID-19 in Italy and to evaluate the factors influencing PTSD in this sample.

Overall, the results of the present study confirm that the COVID-19 pandemic has had a profoundly negative effect on the mental health of Italian nurses.

Generalized anxiety disorder symptoms were reported by half the nursing population sample employed during the second wave of the pandemic. The prevalence of symptoms of anxiety appears in line with the international context. In fact, during the global pandemic, anxiety was the most prevalent mental disorder in HCWs and prevalence was significantly higher than in the general population, with a similar distribution in the pooled prevalence across all geographic areas: global 42%, (25) Africa 49% (26), South America 35% (27), Eastern Europe 30% (28), and Southeast Asia 23% (9). These results are also consistent with other studies conducted in Italy and other European countries (25, 29–31). Significant differences were observed in the occurrence and severity of the condition according to gender, with female nurses reporting a higher median GAD-7 score. However, even before the pandemic, anxiety overload in the nursing profession, together with its symptomatic manifestations and their potential effect on patient safety, appeared to be a well-established phenomenon: pre-pandemic studies reported a prevalence of GAD greater than 35% in the nursing population, with a particular impact on female nurses (32–36). Therefore, to rebuild a healthcare system challenged by COVID-19, it will be necessary to increase efforts to screen and diagnose anxiety disorders in healthcare providers.

In the case of PTSD, the recorded IES-R scores suggest the presence of PTSD symptoms in almost 60% of the sample. This is markedly higher than the prevalence shown in pre-pandemic studies, which reported PTSD in 7–21% of nurses (37, 38). However, our findings are still consistent with studies carried out during other emergencies/crisis periods when HCWs, particularly nurses and frontline workers, experienced higher levels of psychological distress, anxiety, and PTSD (39). In addition, recent systematic reviews have reported a prevalence of PTSD among HCWs ranging from 21.5% to 73.5% (25, 40); in studies conducted specifically in Italy, during the current pandemic, the reported levels of PTSD symptoms ranged from 37.2% to 52.6% (16, 31). Another finding that emerged from our study was the gender difference in the distribution of mental-health conditions, with a higher prevalence of psychological symptoms of PTSD in females, which is also in line with a recent systematic review of the literature (41). Women are more likely than men to suffer from psychological disorders due to a combination of multiple biological, social, and gender-role factors. Gender differences are extensively described in the literature and in psychopathology texts: the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the U.S. National Center for PTSD define being female as a risk factor for the development of PTSD (42–44). This difference is evident both in the median IES-R score of the sample (female nurses 38.0 vs. male nurses 30.0) and in terms of symptomatology, with a significant difference in the presence of symptoms related to intrusion and hyperarousal. With reference to intrusion symptoms, higher scores were recorded in the female sample, especially for the intrusive emotional experience (reliving negative feelings). Although this characteristic is typical of the period immediately following a traumatic event, its persistence over months seems to be a good predictor of long-term PTSD (45). This suggests that PTSD-related disorders resulting from COVID-19 could be a serious problem that needs addressing during the transition to post-pandemic conditions: interventions will be needed to support nurses to ensure a healthy workforce.

Differences in the prevalence of symptoms of PTSD could be explained by multiple factors, such as the specific temporal and epidemiological context in which the study was conducted, the characteristics of the organization (e.g., the presence of professional support for HCWs), and the context in which nurses are employed (e.g., type of COVID-19 work area) (16). In our study, nurses employed in the critical care area had a higher likelihood of a diagnosis of PTSD. This result is in line with data from the literature and previous pandemics (46–54). Nurses employed in critical care directly cared for COVID-19 patients and thus experienced patient deaths more frequently and had to make difficult decisions about the allocation of resources and equipment for the people in their care (41, 55–57). They were also exposed to greater health risks as a result of working with infected patients who required constant nursing care (58). In addition, female nurses, and nurses of both sexes with moderate-to-severe symptoms of GAD, reported more severe clinical predictors of PTSD. The literature supports these findings: in particular, a systematic review with a meta-analysis found a positive correlation between being female, anxiety, and PTSD during the pandemic (40), especially in nurses employed on the front line of care for COVID-19 patients (59). On the other hand, our model did not report associations for some predictors of PTSD described in the pandemic literature. Thus, marital status, being of young age, having worked continuously in COVID-19 units (first and second waves), and having been infected with COVID-19 were not found to be predictors of PTSD for the nurses examined, although they emerged as variables of interest in other studies (39, 60).

Some limitations of this study must be addressed. First, the selection of the sample was carried out by a snowball sampling procedure via social media using an online survey link. This has some limitations, as the method does not guarantee that the sample is representative of the larger population, especially due to the possibility that nurses with risk factors were more likely to participate and complete the survey. On the other hand, the selection method is easy to perform and allows the recruitment of a larger number of relevant individuals, and we therefore feel it is suitable for an exploratory analysis. Second, the survey used a self-reported questionnaire, which does not investigate the psychological status of nurses, especially for sensitive topics. However, to avoid bias, we adopted two validated questionnaires with reliable cut-offs that have been widely used in the study population. The above limitations have also been described in some of the pandemic literature and appear to be acceptable and understandable given the particularity of the pandemic context. In addition, the authors are aware that multiple other factors, such as a concurrent traumatic event experienced by HCWs, or pre-existing COVID-19 disorders, may have influenced our results. However, this summary allows us to obtain a current view of the emotional and psychological state of the nurses analyzed. Finally, the cross-sectional design of the study is a limitation, especially since it is a single measurement in a changing context (i.e., the pandemic); however, pending longitudinal analyses, these data can provide a useful overview of the health problem in question.

In conclusion, levels of PTSD symptoms and anxiety among nurses were high during the pandemic (27, 28) especially in the female sample (10, 61). These findings suggest that, as a primary prevention measure, screening for psychological problems among HCWs should be carefully conducted by healthcare organizations to protect the most vulnerable. Screening for anxiety disorders should be a priority; assessment can be conducted using commonly used validated instruments, such as the GAD-7 questionnaire. Indeed, assessment of anxiety disorders appears to be a reliable predictor for second-level screening of, for example, PTSD in employees with higher-than-average anxiety scores. This would enable organizations to identify the extent of the disorder early and to direct the at-risk population to targeted psychological support interventions. Routine assessment of nurses’ mental well-being is critical considering the results on reported PTDS symptoms, which seem to predict, especially for females, possible long-term sequelae (strong presence of intrusion symptoms). Finally, it seems necessary to implement gender policies in the post-pandemic period to address and modify support services specifically for female nurses, who have emerged as a vulnerable target population. The implementation of an early screening service for GAD and PTSD and the establishment of psychological programs for nurses (especially for those employed in critical care settings) seem to be mandatory actions that are required to promote organizational well-being and improve the quality of care. In addition, the scientific literature highlights that acute COVID-19 stress-related disorders and personal growth are linked and influenced by multiple factors. For this reason, it is necessary to develop support strategies that consider the resilience and emotions regulation skills of HCWs as an instrument for growth and psychological well-being. This strategy must be implemented at the organizational level with the purpose of promoting social support (62).

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Institutional Ethics Board of the Policlinico Umberto I Teaching Hospital/Sapienza University of Rome (protocol number 0489/2021). The patients/participants provided their written informed consent to participate in this study.

ER, PV, and AM contributed to the conception and design of the study. ER, DM, and GG performed data collection. ER, DM, and GG conducted the analyses and contributed to data curation. ER wrote the first draft of the manuscript. VI and AM wrote sections of the manuscript. VB, GM, CD, CM, PV, and AM critically revised the manuscript. All authors contributed to manuscript revision and read and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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