On February 6, 2023, at 04:17 and 13:24 (Turkey time), 2 powerful earthquakes measuring 7.7 and 7.6 in magnitude struck with epicenters in Pazarcık and Elbistan, located in Kahramanmaraş.
As aftershock activity persisted, an additional “triggered” earthquake, registering a magnitude of Mw: 6.4, occurred in Yayladağı (Hatay) on February 20, 2023. These seismic events resulted in extensive loss of life and significant damage in Kahramanmaraş, Hatay, Adıyaman, Gaziantep, Malatya, Kilis, Diyarbakır, Adana, Osmaniye, Şanlıurfa, and Elazığ provinces. 1 As a consequence of the earthquakes, the toll was devastating, with over 48 thousand lives lost and more than half a million buildings sustaining damage. The impact extended beyond the loss of human lives, affecting communication and energy infrastructure and leading to substantial financial losses.
The population in the 11 provinces affected by the earthquake exceeded 14 million in 2022, constituting 16.4% of the country’s overall population. 2
Adıyaman stands as one of the provinces highly susceptible to seismic activity. Situated 122 km away from Pazarcık, where a 7.7 magnitude earthquake occurred, and 98 km from Elbistan, experiencing a 7.6 magnitude quake, Adıyaman bears a significant proximity to seismic epicenters (Figure 1).Reference Mertol, Tunç and Akış 3 While individuals were grappling with meeting their fundamental needs in the aftermath of the earthquake, health care professionals were compelled to address these basic requirements and ensure the continued provision of health services. Given the potentially catastrophic consequences of a disruption in health care services, the earthquake’s impact on health care workers, particularly nurses, is notably significant.Reference Tyer-Viola 4
Proximity of Adıyaman to the epicenters of the Mw 7.7 and Mw 7.6 Kahramanmaraş Earthquakes.
Earthquakes can trigger new mental health conditions or worsen existing ones, such as Post-Traumatic Stress Disorder (PTSD). PTSD, a mental health condition that develops following personal trauma or significant events like earthquakes, is particularly prevalent in women and tends to become more widespread after earthquake-like events.Reference Öz, Küçükkelepçe and Kurt 5 Job stress arises when a mismatch between workplace demands and employees’ capabilities or resources exists. It is not a random occurrence but is often triggered by factors like excessive workload or poor management practices.Reference Üngüren, Onur and Demirel 6 Nurses confront demanding conditions after major events, including heightened patient loads, critical situations, and the need to operate with limited resources. These challenges elevate job-related stress and may contribute to the development of long-term Post-Traumatic Stress Disorder (PTSD). The traumatic experiences endured by nurses can detrimentally affect their emotional and mental health, intensifying the complexities of their profession. Consequently, it becomes imperative for nurses to cultivate psychosocial support networks and employ effective post-traumatic stress coping strategies in the aftermath of earthquakes.Reference Tahernejad, Ghaffari and Ariza-Montes 7 , Reference Mattei, Fiasca and Mazzei 8
This study aims to investigate the prevalence of PTSD and the relationship between post-traumatic stress disorder (PTSD) and job-related stress among nurses working in both the central and district areas of Adıyaman following the earthquake. Additionally, we assess potential risk factors influencing both PTSD and job-related stress. This research is one of the first to explore these dynamics in an earthquake-affected region and various work environments (not just hospitals), providing valuable insights into the bidirectional impact between PTSD and job-related stress.
Methods
Study Design and Sampling
This cross-sectional study examines nurses working in both central and district areas of Adıyaman. According to data from the local health directorate, Adıyaman employs 2567 nurses. Based on a power analysis, a minimum sample size of 335 nurses was required, assuming a 50% prevalence of post-traumatic stress disorder (PTSD) with a 95% confidence interval.Reference Öz, Küçükkelepçe and Kurt 5 A haphazard sampling method was used, and participants were recruited through an online survey distributed via work-related WhatsApp groups, with approval from their supervisors. Nurses who agreed to participate were provided with a survey link.
Nurses currently on antidepressant or anti-anxiety medications were excluded from the study. However, those who were diagnosed with PTSD after the earthquake were included. Additionally, nurses who were not actively working during the 6 months following the earthquake were also excluded to focus specifically on those who experienced the event while on duty. The survey was administered between August and September 2023.
Questionnaire Design, Validity, and Reliability
An online survey, consisting of 3 parts, was administered to study participants. In the first part, questions examining sociodemographic characteristics and earthquake-related questions were administered; in the second part, the Post-Traumatic Stress Disorder (PTSD) scale was administered; and in the third part, the Job Stress Scale-20 scale was administered.
The first section includes age, gender, marital status, presence of children, place of residence, being in Adıyaman at the time of the earthquake, family loss due to the earthquake, and place of work.
Post-Traumatic Stress Disorder Scale was developed by Weathers, Litz, Huska, and Keane in 1993.Reference Weathers, Litz and Herman 9 The Turkish validity and reliability of this have been conducted by Kocabasoglu et al.Reference Kocabaşoğlu, Çorapçıoğlu Özdemir and Yargıç 10 The PTSD Checklist-Civilian Turkish version is a comprehensive scale assessing all DSM-IV PTSD symptoms, demonstrating a high internal consistency with a Cronbach’s alpha value of 0.922. Comprising 17 items, respondents answer on a 5-point scale ranging from “none” to “extremely.” As scores escalate, stress levels increase, with a designated cut-off score set at 37. Although various studies propose different cut-off ranges between 37-44, our study adopts the widely accepted 37 score, known for its higher sensitivity in the literature (Sensitivity = 79%; specificity = 91%).Reference Karstoft, Andersen and Bertelsen 11 In our study, the Cronbach alpha value of the PTSD scale was calculated as 0.942.
The Job Stress Scale-20, developed by Tatar in 2020, assessed job stress. This scale exhibits strong internal consistency, as indicated by a Cronbach’s alpha value of 0.91. Comprising 20 items, the scale is evaluated using a 1-dimensional approach, providing a total score. Each item is measured on a 5-point Likert-type scale, ranging from “Not at all Appropriate” (1) to “Completely Appropriate” (5), without any reverse items. Although the scale lacks a specific cut-off point, its scoring ranges from a minimum of 20 to a maximum of 100.Reference Tatar 12 In our study, the Cronbach alpha value of the job stress scale was calculated as 0.904.
Ethical Approval
Ethics committee approval was obtained from Non-Interventional Research Ethics Committee of Fırat University, with a decision dated 27.09.2023 and numbered 2023/13-39. Written consent was obtained from all participants, and the study followed the principles outlined in the Declaration of Helsinki.
Statistical Analysis
Data analyses were conducted using SPSS 22 (Statistical Package for Social Sciences; SPSS Inc., Chicago, IL). Descriptive statistics were presented as n and % for categorical variables and as mean ± standard deviation (Mean ± SD) for continuous variables. Group comparisons for categorical variables were performed using Chi-square analysis (Pearson Chi-square). The normal distribution of continuous variables was assessed using the Kolmogorov-Smirnov test. Paired group comparisons were carried out using the Student t test, and One-Way ANOVA analysis was employed for comparisons involving more than 2 variables. To explore relationships between continuous variables, the Pearson correlation test was utilized for those with normal distribution, while the Spearman correlation test was applied for those with non-normal distribution. Linear Regression analysis was employed to identify predictors of PTSD and work stress scale, using the Enter method to construct the model, including variables with a significant relationship from the correlation test. Additionally, logistic regression analysis was executed to determine the risk of PTSD. Throughout the analyses, statistical significance was established at P < 0.05.
Results
A total of 332 participants, comprising 245 women (73.8%) and 87 men (26.2%), were enrolled in the study. The average age of the participants was 34.7 ± 7.6 years, ranging from 23-51. Among the participants, 72.3% were married, and 55.7% had children. Regarding workplace distribution, 57.8% of the nurses worked in hospitals, 17.8% in Family Health Centers (FHC), and 24.4% in other institutions affiliated with the directorate. The average duration of their professional experience was 10.9 ± 8.1 years. Additionally, 18.1% of the nurses resided in containers, while 81.9% stayed home.
During the earthquake, 94% of the participants were in Adıyaman, and 23.2% lost a family member due to the earthquake. When asked about job satisfaction, 4.5% were not satisfied at all, 13.6% were dissatisfied, 20.2% were undecided, 48.2% were satisfied, and 13.6% were very satisfied.
Furthermore, 69% of the nurses showed symptoms of post-traumatic stress disorder. The mean PTSD score was 48.6 ± 17.0, and the mean job stress scale score was 46.1 ± 17.0 (Table 1).
All characteristics of the nurses participating in the study
Significant associations were observed between higher PTSD scores and several demographic factors: being female (P < 0.001), married (P < 0.001), having children (P < 0.001), residing in a container (P = 0.008), being in Adıyaman during the earthquake (P < 0.001), and experiencing family loss due to the earthquake (P < 0.001).
Additionally, a significant difference in PTSD scores was identified across various workplaces, with notably lower scores for those working in Family Health Centers (FHC) compared to those in institutions affiliated with the directorate (P = 0.018).
Similarly, elevated job stress scale scores were significantly associated with being female (P = 0.028), married (P = 0.005), having children (P < 0.001), being in Adıyaman during the earthquake (P < 0.001), and experiencing family loss due to the earthquake (P < 0.001). Job stress scale scores also exhibited a substantial difference across workplaces, with lower scores observed for those in FHCs compared to counterparts in other institutions (P < 0.001) (Table 2).
Comparison of scale scores according to all parameters
* Student’s t test.
** One-Way ANOVA analyses were applied.
a,b The group from which the difference originates.
A positive correlation was found between the PTSD score and the job stress scale score, as well as age and time in the profession. Additionally, a noteworthy negative correlation was identified between the PTSD score and job satisfaction. Similarly, there is a positive relationship between the job stress scale score and age, along with time in the profession. Furthermore, a significant negative correlation emerged between the job stress scale score and job satisfaction, as summarized in Table 3.
Correlation of scale scores
Results from the multiple linear regression analysis revealed that the PTSD scale score is predicted by the job stress scale score (β = 0.571, P < 0.001). Conversely, the job stress scale score is predicted by both the PTSD score (β = 0.507, P < 0.001) and job satisfaction (β = −4.918, P < 0.001), as detailed in Table 4.
Linear regression analysis of PTSD and job stress scale
Discussion
Conducted 6 months after the Kahramanmaraş earthquakes in the heavily affected Adıyaman province, this study investigated the levels of PTSD and job stress among nurses.
The study explored the correlation between these 2 factors and identified key contributors to PTSD onset. The present study revealed that 2/3 of participating nurses experienced PTSD, consistent with previous research indicating a prevalence of post-disaster mental health issues among health care professionals.Reference Cansel and Ucuz 13 –Reference Sakuma, Takahashi and Ueda 16 Moreover, our assessment of job stress underscored its significance for nurses, aligning with prior studies highlighting the pervasive nature of this challenge in the nursing profession.Reference Isfahani, Shamsaie and Peirovy 17
This study found variations in PTSD scores and incidence among nurses associated with various sociodemographic and earthquake-related characteristics.
Notably, women exhibited higher PTSD scores and incidence rates compared to men, although gender was not identified as an independent risk factor for PTSD development. Existing research has consistently highlighted a higher prevalence of psychological issues in women following disasters.Reference Cansel and Ucuz 13 , Reference Shrestha 15 , Reference Hyland, Redican and Shevlin 18
Being married emerged as a risk factor for PTSD in our sample, although the literature presents conflicting results on the impact of marital status.Reference Karstoft, Andersen and Bertelsen 11 , Reference Ali, Farooq and Bhatti 19 While nurses with children demonstrated higher PTSD scores and frequency, having children did not prove to be a direct risk factor for PTSD.
Our study revealed that the working environment significantly influences nurses’ mental health, with a lower incidence of PTSD among nurses working in Family Health Centers (FHCs) compared to those in other settings.Reference Isfahani, Shamsaie and Peirovy 17 This discrepancy is attributed to FHCs’ relatively less chaotic nature, which provides a stabilizing influence, especially compared to other work areas.
Living in a container was identified as a risk factor for PTSD, aligning with expectations, as individuals residing in temporary settlements—particularly those whose homes were destroyed or significantly damaged—are presumed to have experienced the earthquake more intensely. Individuals who suffered a family loss exhibited higher PTSD prevalence and scores, consistent with literature suggesting that the loss of a loved one increases vulnerability to PTSD.Reference Laposa, Alden and Fullerton 20 , Reference Cénat and Derivois 21
Variations in job stress were evident based on place of residence and across various sociodemographic and earthquake-related factors. Aligning with the majority of literature, women exhibited higher job stress levels, although conflicting studies exist, reporting higher stress in men with no clear gender-stress relationship.Reference Vahedian-Azimi, Hajiesmaeili and Kangasniemi 22 -Reference Jaradat, Nielsen and Kristensen 24
Contrary to prevailing notions, our findings show that marriage was linked to increased job stress.Reference Osei-Mireku, Wang and Lartey 25 , Reference Durmuş and Sarıkoç 26 Additionally, higher job stress was observed among individuals with children, while those working in Family Health Centers (FHCs) experienced lower stress levels. Job stress exhibited a positive correlation with work intensity and extended working hours.Reference Karstoft, Andersen and Bertelsen 11 , Reference Kokoroko and Sanda 27
Nurses employed in Family Health Centers (FHCs) demonstrated lower job stress than their counterparts in hospitals and other institutions, which can be attributed to more favorable working conditions in FHCs. Notably, heightened job stress was associated with earthquake exposure and family loss, reflecting an extended stress response to the severe traumatic event and its aftermath.
In our current sample, a moderate positive correlation was identified between PTSD levels and job stress. This aligns with findings from a study among mental health nurses in China, highlighting a significant relationship between job stress and PTSD.Reference Liu, Sun and Yin 28 While existing literature predominantly explores the link between job stress and PTSD in high-risk occupational groups such as firefighters, police officers, and emergency service workers, our study contributes to understanding this relationship in the context of nursing.Reference Klimley, Van Hasselt and Stripling 29
In a study focused on firefighters, a positive association between PTSD and job stress was observed.Reference Mitani, Fujita and Nakata 30 Our findings suggest a weak inverse relationship between job satisfaction and both PTSD and job stress levels. This echoes similar results in the literature, reinforcing the direct connection between job satisfaction and mental health.Reference Otaghi, Azadi and Sayehmiri 31
Exploring the relationship between age and PTSD revealed a weak positive association, with conflicting results in the literature. While many studies indicate higher PTSD symptoms in older age, some report the opposite.Reference Dell’Osso, Carmassi and Massimetti 32 Our study found a weak positive relationship between age and job stress, deviating from conventional expectations.Reference Hsu 33 The prevailing notion, often supported by literature, is that increased professional experience would correlate with reduced job stress and psychological issues. However, our study challenges this assumption, revealing an association between longer professional tenure, heightened job stress, and increased PTSD symptoms.
In our further analysis, we observed that the level of job stress independently influenced the level of PTSD, irrespective of age, professional tenure, and job satisfaction. This finding aligns with existing literature indicating that elevated job stress can detrimentally impact mental health, contributing to the development of PTSD.Reference Laposa, Alden and Fullerton 20 , Reference Liu, Sun and Yin 34 The reciprocal relationship was also evident, where the levels of PTSD and job satisfaction independently affected job stress, irrespective of age and professional tenure.
This bidirectional association is crucial to the study’s conclusion, as increasing job stress can heighten depressive symptoms among nurses, which in turn exacerbates job stress, creating a vicious cycle.
To break this cycle, the health system should implement routine psychological evaluations and closely monitor nurses with mental health issues. Additionally, alongside mental health support, efforts should be made to reduce job-related stress. This includes addressing factors like workload and administrative errors, which should be comprehensively evaluated during evaluations of the health facilities. Further research is needed to explore this association more deeply, ensuring a clearer understanding of the causal relationship between PTSD and job stress.
This study stands out as one of the first articles to examine the levels of post-earthquake PTSD and job stress among nurses across various tiers of health services based on insights garnered from the literature review.
Limitations
This study’s limitations include the lack of random participant selection and reliance on self-administered, remote questionnaires. Additionally, the cross-sectional design may restrict the generalizability of the findings.
Conclusion
In the aftermath of disasters, health care workers in affected regions play a pivotal role in providing essential care to victims. It is crucial, however, to recognize that these health care workers are also victims of the disaster, susceptible to mental health challenges and the strains of a stressful work environment. The study’s findings underscore a significant association between earthquake-related PTSD and job stress among nurses. The mental health issues triggered by earthquakes can amplify work stress among nurses, and conversely, the work stress they endure can adversely impact their mental well-being. Consequently, health care managers must be attentive to the prevalence of PTSD symptoms and job stress levels among staff post-earthquake. To address this, interventions like optimizing working conditions and providing psychological support should be implemented to improve both staff welfare and efficiency.
Author contribution
Osman Kurt: Conception, design, supervision, data collection, analysis, literature review, writing – original draft, writing – review & editing, visualization, supervision, project administration, resources, validation. Fatma Sena Konyalıoğlu: Conception, writing – original draft, writing – review & editing, visualization. Osman Küçükkelepçe: Conception, design, supervision, data collection, analysis, supervision. A. Ferdane Oğuzöncül: Conception, design, project administration, resources, validation.
Acknowledgments
None.
Funding statement
None.
Competing interests
None.
