Since the first case of the coronavirus disease 2019 (COVID-19) was identified over 2 years ago, the world has witnessed the rapid spread of SARS-CoV-2. As of April 30, 2022, 510,824,055 cases of COVID-19 were confirmed and 6,235,957 COVID-19 deaths were reported worldwide (1). South Korea, a country known for epidemic preparedness, reported 17,237,878 confirmed cases of COVID-19 and 22,794 deaths on that same day (2). Although the main focus is on the physical health consequences of an infectious disease outbreak, rates of mental illnesses, such as depression, anxiety, and post-traumatic stress disorder also rise during of global health emergencies (3). According to a systematic review, the prevalence of stress, anxiety, and depression in the population during the COVID-19 pandemic is alarming, with rates as high as 29.6%, 31.9%, and 33.7%, respectively (4). With complete eradication of SARS-CoV-2 appearing unrealistic, the Korean government implemented the policy of coexistence with COVID-19 in November, 2021, which loosened restrictions. Shortly after the implementation of this policy, as somewhat expected, the number of confirmed COVID-19 cases increased rapidly, reaching 621,328 daily cases in only 4 months (2).

One of the groups most severely impacted by the COVID-19 pandemic are healthcare workers. They work long hours in the frontline of the pandemic, diagnosing and treating patients while being continuously exposed to their patients’ pain and suffering. This unprecedented situation has not only entailed high levels of physical exhaustion for healthcare workers but has also caused severe psychological conditions, such as depression, anxiety, and insomnia (5). A systematic review of 38 studies on the mental health problems of healthcare workers (e.g., doctors, nurses, and allied health workers) during the COVID-19 pandemic revealed that the estimated prevalence of depression, anxiety, and post-traumatic stress disorder is higher than thatof the general population, with estimates of 37% (95% confidential interval [CI]: 29%–45%), 40% (95% CI: 29%–52%), and 49% (95% CI: 25%–50%) (6), respectively. Unsurprisingly, many of these healthcare workers reported fear of contracting and transmitting the virus (6) while maintaining an unusually high and stressful workload (7).

Nurses play a unique and important role in a healthcare system by helping patients and their families cope with death and grief (8). Moreover, nurses commonly witness multiple patient deaths within a brief period. Although their invaluable services entail numerous benefits, their exposure to such traumatic experiences adversely affects their psychological and personal well-being over time (9). Repeated exposure to death and grief can result in occupational stress and burnout in addition to the emotional distress nurses encounter (10). During the COVID-19 pandemic, social distancing policies restricted in-person contact between patients and their loved ones. End-of-life COVID-19 patients who were quarantined were not allowed to visit their immediate family members (8). In this context, nurses also played the intimate role of caregiver and emotional support provider for COVID-19 patients, some of which died in isolation without loved ones and family around (8). Some nurses described this situation as a “tsunami of death,” reporting uncharacteristically high levels of psychological distress caused by witnessing patient deaths due to COVID-19 (11). Given the pandemic situation and the important role nurses play in the healthcare system, grief support must be provided for the nurses who have experienced patient loss due to COVID-19.

During the pandemic, the Pandemic Grief Scale (PGS) (12) was developed to help clinicians and researchers effectively identify individuals suffering from dysfunctional levels of grief due to COVID-19 deaths. Since its publication, the PGS has been validated in different countries and effectively used in various settings (12–14). However, the validation of a healthcare version of this instrument has yet to be published. Therefore, we aimed to explore the reliability and validity of the PGS for healthcare workers using frontline nursing professionals who worked with COVID-19 inpatients and witnessed the death of their patients.

A total of 229 respondents (94.3% women, 5.7% men) participated in the study (Table 1). The mean age was 30.1 (±6.3) years, with the majority (175, 76.4%) being single. The average years of employment were 6.9 (±6.0) years, and 218 (95.2%) worked on a shift basis. All respondents were caring for COVID-19 infected patients at the time of the survey and had witnessed patient deaths. All were fully vaccinated, with 95 (41.5%) and 85 (37.1%) having been quarantined and infected, respectively, due to COVID-19. Regarding psychiatric problems, 37 (16.2%) reported a history of depression, anxiety, or insomnia, and 33 (14.4%) complained of present depression or anxiety.

The present study is the first to explore the reliability and validity of the PGS for healthcare workers, which measures healthcare workers’ dysfunctional grief over the death of patients caused by COVID-19. The results of this study provide ample evidence for the psychometric integrity of this PGS for healthcare workers.

Specifically, we observed that the PGS for healthcare workers showed good internal consistency and reliability and yielded acceptable corrected item-total correlation, as well as good composite reliability or standard error of measurement. This model also demonstrated good convergent validity with rating scales for measuring viral anxiety, depression, or generalized anxiety. Regarding factor analysis results, this version of the PGS indicated good model fit for a single factor model, with item factor loadings ranging between 0.718 and 0.802. As this is the first validation study of the PGS for healthcare workers, no comparable studies exist. From the multi-group CFA, we observed that the PGS for healthcare workers can measure dysfunctional grief responses similarly across nurses with viral anxiety, depression, or general anxiety. Regarding slope parameters, all items of the PGS have a very high slope coefficient, ranging from 2.416 to 5.948 (mean = 3.565) (Supplementary Table 4). In terms of threshold parameters, an above average level of latent trait is required to endorse all the Likert-type response options in all items. Scale information curve (Supplementary Figure 1) demonstrates that this version of the PGS provides more information about people between 0.3 and 3.3 θ level. Collectively, these results suggest that all the items of this scale are highly efficient and provide useful information about the latent trait.

The need to develop and validate the PGS for healthcare workers is based on two important factors: First, although the number of infected people worldwide has been decreasing recently (1), the disappearance of the virus seems unlikely as new variants continue to be detected. Second, grief caused by COVID-19-related losses has been found in some studies to be more intense than deaths from other causes (23). Thus, the need for a short screening instrument that can identify individuals experiencing dysfunctional grief due to COVID-19 deaths appears vital during this pandemic. Third, nurses play a vital role in any healthcare system, particularly during a pandemic. However, the emotional toll of working with patients who die of an infectious disease, such as COVID-19, is particularly high for healthcare professionals (5). Nurses experience a range of emotional responses, such as sadness, helplessness, loss, and guilt, when a patient they work with dies (24). They not only grieve over the loss of patients but also feel guilty about their patients’ deaths given that they consider these losses as failures of their medical treatment (25). Moreover, nurses may develop compassion fatigue, emotional exhaustion, and insomnia when they witness numerous patient deaths (26) that are coupled with the common excessive workload during this COVID-19 pandemic. Given these psychological issues, we believe a healthcare-focused version of the PGS is warranted.

This study holds several limitations. First, it was aimed at those who witnessed patient death among frontline nurses in a COVID-19 inpatient ward. However, healthcare workers who have experienced patient losses due to COVID-19 are not limited to healthcare workers in dedicated wards. Although it depends on the characteristics of the hospital, for patients who died in the general ward, the exact cause of death may not be known and determining whether they died from COVID-19 may be difficult. Therefore, the reliability and validity of the PGS scale must be expanded to encompass not just healthcare workers in COVID-19 dedicated wards but also other healthcare workers who witnessed patient deaths during the pandemic. This aspect must be addressed in future studies. Second, only nurses participated in our study. Despite the fact that nurses’ depression, general anxiety, and virus-related anxiety symptoms are among the highest across healthcare professions during the COVID-19 pandemic (27), future research would benefit from including other healthcare professionals. Finally, the adaptation of healthcare workers to the COVID-19 situation during the second year of the pandemic may have affected the results of the study. Future research should determine if the PGS is sensitive to temporal changes. This study has a strength despite its limitations; it is the first to present a Korean-language instrument for identifying nurses experiencing dysfunctional levels of grief during the pandemic.

In conclusion, we found the PGS for healthcare workers to be a psychometrically sound tool. The rating scale was valid and reliable for measuring dysfunctional grief reactions among nursing professionals facing viral epidemics. Thus, this PGS version will be beneficial to healthcare workers for a system that provides psychological support.

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 Institutional Review Board of the Asan Medical Center, Institutional Review Board of Ulsan University Hospital, and Institutional Review Board of GangNeung Asan Hospital. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

CP, SC, JP, and SL contributed to conception and design of the study. OA and SC performed the statistical analysis. JK and SC wrote the first draft of the manuscript. JK, CP, YH, and JP wrote sections of the manuscript. All authors contributed to the manuscript revision, 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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