Discussion

The nurse’s role has long been regarded as stress-filled and emotionally exhausting based upon the physical labor, human suffering, work hours, staffing, and interpersonal relationships that are central to the work nurses do. In Mexican nurses, in recent years, the prevalence of traumatic distress responses was 10% approximately, ^{Reference Enriquez-Estrada, Corlay-Noriega and Garcia32} a psychological distress of 26.4%, ^{Reference Vargas-Terrez, Villamil-Salcedo and Rodríguez-Estrada31} and the high emotional exhaustion was around 18.9% to 29.6%. ^{Reference Colmenares De La Torre, Acosta Martínez and Ayón33,Reference Montoya, Peña and Villa34} Additionally, nurses, as the largest group of health professionals, are at the frontline of health-care system responses to pandemics such as COVID-19, making them more susceptible to complex emotional reactions and psychological distress. Therefore, the present study examined the psychological effects in Mexican nurses and identified factors associated with worse outcome during the COVID-19 outbreak. In general, the results showed that a large portion of Mexican nurses is suffering moderate-severe traumatic distress as well as moderate-severe psychological distress and a high level of emotional exhaustion. The data supporting these findings are discussed below.

First, in the present study, 46.72% of nurses rated their traumatic distress response to the outbreak as moderate to severe. Our findings are consistent with previous results in Italian nurses (43-49.3%) during COVID-19^35,36 and similar to the relatively high rates of posttraumatic stress disorder (7-53.8%) reported in the general population during the COVID-19 pandemic in China, Spain, Italy, Iran, the United States, Turkey, Nepal, and Denmark. ^{Reference Xiong, Lipsitz and Nasri37} In addition, this study found that an increase in working hours per week due to COVID-19 and contact with a suspected and confirmed case of COVID-19 in their workplace are factors associated with higher traumatic distress response to the outbreak. Other studies report similar findings. During the H1N1 pandemic, hospital workers in high-risk work environments who felt significantly more “workload,” had significant traumatic distress responses, ^{Reference Matsuishi, Kawazoe and Imai38} and frontline health-care workers who engaged in direct diagnosis, treatment, and care of patients with COVID-19 in China had higher traumatic distress response. ^{Reference Lai, Ma and Wang39} Additionally, our results may have been due to a discouraging perspective presented by Mexican health institutions ^{Reference Cattan40} in a moment when the country and the world are being besieged by the COVID-19 pandemic.

Frontline nurses are working longer hours than usual due staff shortages; therefore, they are exposed to the highest risk of infection because of their close, frequent contact with patients. And if this was not enough, nurses are working with deficient protective supplies. ^{Reference Smith, Ng and Ho Cheung Li7,Reference Catton9} In fact, personal protective equipment provides protection of mental health. ^{Reference Tan, Hao and McIntyre10,Reference Wang, Pan and Wan11} Of note, in Mexico, nurses have been stigmatized as vectors of contagion and have been assaulted, abused, and marginalized. ^{Reference Poy Solano19} This situation requires special attention because emotional breakdowns following these disgraceful episodes could trigger common psychiatric illnesses in the short- and long-terms. ^{Reference Bao, Sun and Meng41} Accordingly, our result is not surprising, given the traumatic nature of the situations, including deficient protective supplies, long work hours, heavy work loads, exposure to the virus, contact with people infected with COVID-19, and social stigmatization, to which nurses are exposed in their daily work during this COVID-19 outbreak.

Second, our results show that 42.40% of nurses had a high level of emotional exhaustion. In the literature, it is stated that nurses and physicians are the most at-risk group among health-care workers in terms of burnout. ^{Reference Qiao, Chen and Chen42} In Mexico, the vast majority of documented deaths have occurred within hospitals, and research has shown that frontline health-care workers may experience emotional exhaustion when they communicate death notifications. ^{Reference Shoenberger, Yeghiazarian and Rios43,Reference Wakam, Montgomery and Biesterveld44} Also, our finding corresponds to previous studies that found that the levels of emotional exhaustion appeared higher than normative values in health-care workers during the SARS ^{Reference Maunder, Lancee and Balderson45} and COVID-19 outbreaks in Italy. ^{Reference Barello, Palamenghi and Graffigna46} Furthermore, our results reported that an increase in working hours per week due to COVID-19 was associated with a higher emotional exhaustion score. It has been identified that, especially in health-care workers, the intense workload and the necessity of continuing work life during the pandemic increases the emotional exhaustion related to the risks taken during the care and treatment processes of COVID-19 patients, ^{Reference Sahin, Aslaner and Eker47} similar to our findings. This could be because demand work stressors, such as increasing workloads and greater levels of work pressure, are positively related to rates of emotional exhaustion. ^{Reference Lee and Ashforth48} This result requires special attention, because it has been shown that emotional distress is frequently associated with suboptimal patient care and professional inefficiencies along with long-lasting effects on health professionals’ health status. ^{Reference Panagioti, Geraghty and Johnson49}

Finally, in our study, 41.78% of nurses showed moderate to severe psychological distress, similar to that reported in nurses from Singapore (37.4%). ^{Reference Lee, Thampi and Chan50} Research has addressed that fear of an unknown can contribute to the high level of psychological distress among people during an outbreak, ^{Reference Blendon, DesRoches and Cetron51} including health-care staff. ⁵² In the present study, the psychological distress during COVID-19 in nurses who have 2 or more children, those who reported an increase in working hours per week due to COVID-19, and contact with a suspected and confirmed case of COVID-19 in their workplace, were associated with elevated psychological distress.

Similarly, it has been identified that health workers who have 2 or more children are susceptible to depression and anxiety, likely due to being placed in a considerable dilemma, that is, caring for patients and family members and needing to avoid contact with family members. ^{Reference Li, Miao and Wang53} Furthermore, previous studies, which were conducted when SARS emerged, revealed that the fear of contracting disease from a patient, due to direct exposure during patient care, has been associated positively with elevated psychological distress in health-care workers ^{Reference Su, Lien and Yang54} ; similar to recent findings during the COVID-19 outbreak in Israel ^{Reference Shacham, Hamama-Raz and Kolerman55} and China. ^{Reference Lu, Wang and Lin56} Additionally, as we know, after confirming the outbreak of COVID-19 in Mexico and during its current increase in number of cases and deaths, the nurse workforce is taking pains to struggle with the disease in the front line and protect the health of the public. ⁵⁷ These specific situations pose considerable stress on them, stress being an important risk factor for diseases. ^{Reference Brosschot, Verkuil and Thayer58} Additionally, this stress might lead to high levels of psychological distress. ^{Reference Wang, Pan and Wan23} Of note, it has been suggested that people who report high emotional exhaustion experience and more anxiety symptoms are more likely to develop greater psychological distress. ^{Reference Zou, Shen and Tian59-Reference Ahola and Hakanen61}