1. Introduction
Corona Virus Disease 2019 (COVID-19) is a highly infectious disease with a long incubation period caused by Severe Acute Respiratory Coronavirus 2 (SARS-COV-2) [
1]. On 31 December 2019, the China Office of the World Health Organization (WHO) was notified of new pneumonia cases of unknown etiology occurring in Wuhan (Hubei Province) [
2]. The outbreak was first identified at a seafood market in Wuhan, where wild animals, including bats, were sold illegally [
3]. Since then, the virus has spread rapidly inside and outside China, becoming a global health emergency [
4]. Due to the rapid spread of COVID-19 worldwide it was declared a pandemic on 11 March 2020 by the WHO. The first case of COVID-19 infection in Poland was recorded on 4 March 2020 (in western Poland) [
5]. Since then, the number of infected people has increased steadily, resulting in the announcement of an epidemic by the Minister of Health on 20 March 2020. In response to the COVID-19 epidemic, state authorities have adopted several drastic civil protection measures, including closing the state’s borders. Those measures include: obligatory 14-day quarantine for people returning from abroad, working remotely, suspension of face-to-face teaching at schools and universities, limiting the number of people simultaneously present in shops, limiting the number of attendees in churches, the obligation to cover the nose and mouth and closure of some service providers (i.e., hairdressers, beauticians, etc.) and cultural venues (i.e., cinemas, theaters, exhibitions, etc.). As of 2 July 2020, there have been 35,146 confirmed cases and 1,492 deaths due to coronavirus in Poland. From the beginning of the epidemic in Poland until 3 June 2020, 2404 healthcare workers (HCW) became infected with COVID-19 [
5,
6]. According to the Ministry of Health, among those infected, there were 1659 nurses, 660 doctors, and 85 midwives. On 3 June, HCW-infected constituted 9.79% of all infected in Poland, i.e., almost one in ten suffering from COVID-19 worked in a hospital, clinic, or some other healthcare facility [
7].
In the face of such a tremendous global challenge as the COVID-19 pandemic, HCWs are an indispensable resource for every country. Their health and safety are of key importance, not only to ensure the continuity and safety of care for infected people but also to control the number of infections [
8]. Nurses constitute the most numerous professional group among medical personnel in Poland and worldwide. They play an essential role in preventing the spread of infections, controlling infections, and supporting patients in isolation [
9]. As a result, they are exposed to the negative psychological consequences of a pandemic. Also, they are the first in the line of duty to come into contact with COVID-19 infected patients. Older adults and people with chronic comorbidities are at greater risk of complications and they have higher rates of mortality from COVID-19. Nursing teams are essential for managing this patient population. Nurses also play a vital role in providing public education concerning preventing and reducing the spread of the disease. Due to nurses’ unique nature, they require the necessary support [
10].
The COVID-19 pandemic not only affects physical health but can also lead to mental health problems such as sleep problems, depression, and traumatic stress [
11,
12]. The United Nations have highlighted in their recommendations that HCWs are particularly vulnerable to the psychological effects of the COVID-19 pandemic [
13]. Published evidence enumerates significant changes in the work environment and the requirements for HCWs, i.e., working under more significant pressure or an unfavorable work environment as causes of this vulnerability [
14]. HCWs, besides the distress concerning the exposure to COVID-19, are concerned about the lack of personal protective equipment (PPE) or other necessary equipment, and the challenges of maintaining a family and providing care for children with an increase tendency to irregular working hours, increased workloads and anxiety when entering new clinical roles [
15]. They often experience emotional tension and physical exhaustion from having to provide care to an increasing number of patients whose condition can deteriorate rapidly. Moreover, the HCW worker is also at risk of infection, death of co-workers or stigmatization and social exclusion due to work with infected patients [
16,
17]. There are also moral dilemmas related to making decisions regarding the provision of care with limited health care resources [
18].
We lead an investigation concerning the level of posttraumatic stress, perceived social support, opinions on the positive and negative consequences of the epidemic, the sense of security, and the sense of meaning in life among nurses in a face of new and not fully understood epidemiological phenomena of a global nature. A literature search revealed that published evidence [
2,
8,
10,
11,
12,
14,
16,
18] has focused on determining the level of stress in HCWs in the context of the COVID-19 pandemic. However, there has been little research on perceived support, opinions on the positive and negative consequences of the epidemic, sense of security, and sense of meaning in life in the context of the pandemic COVID-19. Therefore, we were the first to take on the challenge of assessing those factors among nurses. The study aims to present the research protocol and preliminary results in assessing each of these focus areas among nurses in Poland during the COVID-19 pandemic.
4. Discussion
The outbreak of an epidemic poses an enormous challenge to the national health care system and the country’s economy, while the virus itself poses a threat to physical and mental health. For these reasons, the COVID-19 pandemic will have long-term consequences that will affect international and national public health policies [
30]. In the circumstances of the COVID-19 pandemic, nurses are at the forefront of the fight against the virus worldwide. Nurses are actively involved in the fight against COVID-19, in a way that few professionals are, being required to demonstrate professionalism and to remain calm. However, many nurses experience fear of the unknown, stress, and concern for patients, themselves, colleagues, relatives, and friends [
31]. The ubiquitous risk of COVID-19 infection may be the cause of psychosocial stress [
32]. Therefore, the study aimed to present the preliminary results in terms of assessing the level of traumatic stress, received social support, the sense of positive and negative consequences of the epidemic, experiencing safety and sense of life in the group of nurses in Poland in the context of the COVID-19 pandemic. This study is part of more extensive research aimed at identifying the characteristics and psychological consequences of the COVID-19 pandemic among Poland’s professionally active nurses and factors potentially protecting against excessive stress. Summing up, the preliminary results indicate an intensification of traumatic stress symptoms with particularly pronounced symptoms of avoidance exhibiting in the studied group of nurses. Respondents characterized the experience of a pandemic by a reduced sense of security with an intense reflection on issues related to their personal safety, that of others, and the world. The nurses in the study received support mostly from significant others (i.e., other than family and friends). The respondents are characterized by a sense of the meaning in life; the tendency to seek it is less pronounced. They also notice positive changes in the existing situation, which may be an expression of adaptation in the form of posttraumatic growth.
Symptoms of posttraumatic stress appear after traumatic events beyond the scope of regular human experiences, such as a violent physical attack, torture, accidents, rape, or natural disasters [
33]. Several studies have assessed the psychological effect during an epidemic, e.g., Severe Acute Respiratory Syndrome (SARS) and H
1N
1. Lu et al. [
34] found that 17.3% of healthcare workers experienced significant psychological symptoms during the SARS epidemic when faced with the threat. On the other hand, Mak et al. [
35] and Lam et al. [
36] showed that more than 40% of people who survived the SARS epidemic experienced PTSD. Wu et al. [
37] revealed that people who were isolated when working on wards treating patients with SARS or had relatives or loved ones who had contact with SARS exhibited a two to three times higher risk of developing PTSS symptoms, compared to those who were not exposed to the virus, whether professionally or among loved ones. The lower intensity of traumatic stress symptoms in the general population during the COVID-19 pandemic is confirmed by Forte et al. [
38] by research conducted among Italian respondents. Participants exhibited a mean score of 22.38 on IES-R, with 1.01 on the Intrusion subscale, 1.06 on the Avoidance subscale, and 0.98 on the Hyperarousal subscale. Similar research lead amongst Egypt’s general population achieved the following mean results: overall score 34.25, Intrusion—13.68, Avoidance—12.83, and Hyperarousal—7.73 [
39]. A similar average results indicating a mild stressful impact of the pandemic was obtained in the Chinese population in the research by Zhang and Ma [
40] and Wang et al. [
41]. Interesting research was conducted by Tan et al. [
42] evaluating, among others, traumatic stress among medical workers (doctors and nurses) and non-medical workers (caregivers, pharmacists, technicians. administration, office workers and cleaners) in Singapore. The authors observed a lower mean IES-R score among healthcare workers during the COVID-19 epidemic than during the SARS epidemic, during which the severity of PTSD symptoms was three times higher than in the cited study. The authors suggested that respondents were more prepared for the COVID-19 epidemic, and they had in place infection control procedures following experiences from the previous SARS epidemic. The obtained results of our research indicated a high intensity of PTSD among the surveyed nurses, which may be due to the lack of experience in infection management because the last epidemic of an infectious disease in Poland before the COVID-19 occurred in 1963 and it was a smallpox epidemic covering the city of Wroclaw.
Most researchers concur concerning the salutary effect of social ties on an individual’s mental health and well-being [
43]. Social support refers to the care and support people feel they receive from others [
44]. In an epidemic situation, social support, apart from psychological support, reduces the adverse psychological effects of the epidemic [
45]. Liu et al. [
46] amongst a group of young adults in the US have proven a pivotal role of family support resulting in low levels of depression and lower PTSD symptoms during the COVID-19 pandemic. Xiao et al. [
47] confirmed that in a group of doctors and nurses caring for COVID-19 patients in China, the level of anxiety, stress, and self-efficacy depended on social support.
Unfortunately, HCWs often neglect social relationships with friends or family due to heavy workloads or concerns about the risk of exposing others to disease as they come into contact with people with COVID-19. On the other hand, maintaining social contacts becomes a challenge due to the need to maintain social distance [
18]. According to the results of studies from China, in the face of both the SARS epidemic in 2003 and the current COVID-19, residents of Hong Kong (2003) and Liaoning Province (2020) reported increased social and family support during the epidemic compared to the pre-epidemic period. Increased social support may result from the fact that many preventive measures have been introduced to avert the spread of the epidemic (i.e., closing workplaces, theaters, shopping centers, etc.) [
40,
48]. The cited body of literature included respondents from a general sample population, while in the presented research, they were explicitly nurses with the highest level of support obtained from the significant other. This may be since, despite the government’s restrictions in the form of closed workplaces, the introduction of online work, movement restrictions, etc., nurses were not subjected to those restrictions and continued their work. Due to the problematic situation they found themselves in; it can be assumed that they received the highest support from people in a similar position to them, i.e., colleagues from work who could relate to their concerns about the COVID-19 epidemic.
Experiencing a traumatic event has consequences for the psyche of an individual. One of the more severe effects of traumatic experiences is acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). Despite the existence of negative consequences for an individual’s psyche, people experiencing a stress reaction may also declare some psychosocial benefits. This phenomenon is called posttraumatic growth (PTG), and it concerns life transformations as a result of attempts to deal with traumatic events. PTG is not regarded as an adaptation mechanism; however, as the result of adaptation. PTG is related to the use of remedial strategies. Development understood in this way may refer to changes in the philosophy of life, interpersonal contacts, or the deepening of self-understanding. It is estimated that 40–70% of people experience PTG due to experiencing a traumatic event [
49]. The original research found a higher average in terms of positive psychological changes after the COVID-19 pandemic amongst participating nurses. The authors of the research, despite a thorough literature review, did not uncover any manuscripts examining the positive impact of the COVID-19 pandemic on psychological functioning. Therefore, we believe that these are the first results that describe this aspect.
Safety is one of the most critical categories allowing to describe the context of life and the way people function [
50,
51]. Safety is defined as an actual state of non-threat that is subjectively felt by individuals or groups [
52]. In the light of the above definition, security should be understood in two perspectives: (1) objective, i.e., related to external, objective factors that are important for a proper life, and (2) subjective, i.e., individual, objective assessment of the state of possession or availability of essential goods relating to the individual experience. The feeling of security is significant; therefore, it constitutes a motivating factor either as a need [
53] or as a value [
54]. With the prospect of the COVID-19 pandemic, the sense of security for healthcare professionals may be low. The following factors may contribute to the low sense of security: close contact with patients infected or suspected of being infected, lack of personal protective equipment or insufficient number, lack of training on the subject of coronavirus, lack of procedures for caring for a patient with COVID-19, and finally little information about the virus itself. The sense of security may also be influenced by events that are not directly related to patient care but are consequences of the place where the individual works, e.g., fear of stigmatization, fear of infecting loved ones, or uncertainty about the direction of the epidemic and the consequences of forced social isolation. The results of the described original research demonstrated lower results in the Sense of security scale and higher in the Reflection on safety subscale. Therefore, in the studied group, reflection on the individual safety, loved ones, the nation, and the world has been intensified and accompanied by a reduced sense of security (understood as the belief that basic needs are met, that they have satisfactory working conditions and the ability to act). A sense of security during a pandemic is also enhanced by a well-prepared workplace, especially healthcare workers. According to the studies by Delegrado et al. [
55] conducted among medical staff in Latin America, HCWs had limited access to personal protective equipment, and health authorities support during the COVID-19 pandemic, which may have affected their sense of security. Unfortunately, the authors of the study did not find studies evaluating the sense of security of medical personnel during the COVID-19 pandemic in the literature, so this is the first study to evaluate this issue.
Another critical issue in the pandemic context is the level of sense of meaning and meaning in life that health care workers experience in this challenging period. Different meanings (meaning) are assigned to events, places, persons, objects, and theories by every person [
56]. Frankl believes that the meaning of life is a fundamental factor of human existence, and it primarily relates to the enormous existential power of a man to face adversities and everyday challenges [
57,
58]. Steger et al. [
59] draw attention to the necessity to understand the time perspective in the studied dimensions of the presence of meaning in life and its search. According to the authors, the critical issue is to be aware of a goal in the present time and the need to pursue it and always acquire it. He defines this second dimension of meaning in life, i.e., seeking it as an activity related to constant effort, marked by persistence and intensity in establishing or expanding knowledge about the meaning of one’s own life. According to numerous studies, a high level of meaning in life increases resistance to stress and generally possesses a positive effect on physical health [
60,
61]. More studies confirmed the existence of a positive relationship between the meaning of life and the quality of life and well-being [
62,
63]. Also, associations between the meaning in life, high self-esteem and sense of control have been noticed [
64]. The lack of meaning in life, on the other hand, leads to an internal emptiness and existential neurosis, presenting itself in the lack of willingness to live and act [
57,
65]. Likewise, there has been described a relationship between the lack of meaning in life and pathologies and disorders, abuse of addictive substances, and suicidal thoughts [
66,
67]. Trzebiński et al. [
68] in their research concerning meaning in life and life satisfaction during COVID-19 outlined the following dependence of a mediated nature: basic hope supports meaning in life, and life satisfaction, and the increase in the latter two factors results in lower anxiety and COVID-19 stress. Original research described a slightly higher result in the Presence subscale as compared to the Search subscale. Those outcomes may result from the age of the respondents because, as shown by the research of Stager et al. [
69], age is an important factor differentiating people in terms of the presence of meaning in life. Older people have a higher level of meaning in life than younger people, who, on the other hand, seek it more.
4.1. The Strengths and Limitations
The strengths of this research demand further consideration. Firstly, to the best of our knowledge, this is the first study assessing the psychological effects of the COVID-19 epidemic in a group of Polish nurses in such a multi-faceted manner. Secondly, our study implemented standardized questionnaires not yet used to assess psychosocial functioning in the context of the COVID-19 pandemic. Thirdly, our sample consists of nurses working in Poland who have never encountered an epidemic on the scale of COVID-19.
Nevertheless, our study also possesses some limitations. Firstly, our study is a cross-sectional study and does not show cause-effect or time-effect relationships. However, our results were descriptive rather than hypothesis-testing. Secondly, we adopted the strategy of distributing the questionnaire online due to the limitations of social contacts. Therefore it was not possible to collect data on people who refused to participate in the survey and no refusal rate was recorded. Moreover, when recruiting study participants, we relied on access to social networking sites, therefore, the surveyed population does not include participants who do not have access to social networking sites and nurses who do not use such sites. The above arguments make the generalization of our research results limited.
4.2. Implications and Future Directions
Our research’s preliminary results may provide a direction for the development of active protection programs for nurses against the adverse effects of the COVID-19 pandemic by strengthening protective factors for the pejorative phenomena related to it. A literature review revealed many gaps in research on certain psychological factors and their impact on healthcare professionals’ traumatic stress. Most of the published studies focus on traumatic stress or the impact of a pandemic on mental and physical health. Some elements such as social support, the sense of meaning and meaning in life, the positive and negative effects of a pandemic have not been thoroughly researched. Therefore, subsequent studies should be cross-sectional and broadly assessing the psychological context influencing the perception of traumatic stress among nurses and HCWs.