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Derya Çınar, Nazan Kılıç Akça, Pınar Zorba
Bahçeli, Yaşar Bağ. “Perceived stress and
affecting factors related to covid‐19
pandemic of emergency nurses in Turkey”,
Journal of Nursing Management, 2021
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April 14, 2022


Approved by the Committee on Oral Examination with a grade of __________ on _______________________.



____________________ ____________________

Panel Member Panel Member


This is to certify further that AWAD EID NADAA AL-SHAMMARI, have satisfactorily completed all academic requirements in the MASTER’S DEGREE IN NURSING.


Dean, Graduate Studies

Hail University

Date Signed: __________


This study is primarily dedicated to Allah. Peace be unto Him!

To my parents, siblings, and relatives.

To my colleagues in the profession.

To my Hail University family.


Title Page……………………………………………………………………………………………………………. 1 Approval Sheet …………………………………………………………………………………………………… 2

Dedication ………………………………………………………………………………. 3

Table of Contents…………………………………………………………………………………………………. 4

List of Tables and Figures ………………………………………………………………. 7

List of Appendices ……………………………………………………………………… 8

Abstract …………………………………………………………………………………. 9

Chapter 1 – Introduction

Introduction to the Research Project ……………………………………………. 10

Statement of the Research Problem …………………………………………….. 11

Background of the Problem …………………………………………………….. 11

Purpose of the Project …………………………………………………………… 14

Definition of Terms …………………………………………………………….. 14

Significance to Nursing ………………………………………………………… 15

Summary ……………………………………………………………………….. 15

Chapter 2 – Review of Evidence

Introduction ……………………………………………………………………. 16

Conceptual Model/ Theoretical Framework …………………………………… 16

Evaluation of Evidences ………………………………………………………. 18

Summary ……………………………………………………………………… 28

Chapter 3 – Project Methodology

Introduction …………………………………………………………………… 30

Research Design ………………………………………………………………. 30

Target Population, Subjects, Sample, and Setting ……………………………. 30

Instrument …………………………………………………………………….. 31

Plan and Implementation Process …………………………………………….. 32

Data Analysis …………………………………………………………………. 33

Ethical Consideration …………………………………………………………. 35

Summary ……………………………………………………………………… 36

Chapter 4 – Project Outcome

Introduction …………………………………………………………………… 37

Findings ………………………………………………………………………. 37

Chapter 5 – Discussion

Introduction ……………………………………………………………………. 41

Discussion ……………………………………………………………………… 41

Conclusions ……………………………………………………………………. 43

Implications to Nursing …………………………………………………… 43

Recommendations for further research …………………………………… 43

References …………………………………………………………………………. 45

Lists of Tables and Figures

Table 1 Statistical Limits and Descriptive Equivalence ……………………………… 34

Table 2 Profile of Respondents ………………………………………………………. 38

Table 3 Extent of Mental Wellbeing of Emergency Room Nurses ……………………39

Table 3 Correlation Analysis …………………………………………………………. 40

List of Appendices

Appendix A Sample Informed Consent ……………………………………………… 51

Appendix B sample Questionnaire …………………………………………………… 53


Background Health care professionals including nurses experienced increase in their workload, psychological suffering, shortage of protective equipment and gears, social discrimination like stigmatization, absence of incentives or proper compensation, and management system approach during the course of their duty in times of pandemic. Therefore, it is significant to protect the wellbeing of nurses during Covid-19 pandemic in order to continuously provide good, effective, quality services to patients and maintain a mental health status needed during crises.

Results The response rate as of percentage is 95% which composed of 114 respondents out of 120 nurses. Majority of the respondents are female, Non-Saudi Employees, and having 3-5 years of experience in the Emergency room. The extent of mental well-being of emergency room nurses in different government hospitals of Hail Region, Kingdom of Saudi Arabia is generally often. the correlation analysis of the moderating variables in the study. The extent of mental well-being of emergency nurses has significant relationship with nationality (Correlation = 0.808, p-value= 0.000), and, year of ER experience (Correlation=0.872, p-value=0.087). However, extent of mental well-being of ER nurses has no significant relationship to gender (Correlation = 0.151, p = 0.095).

Conclusion Therefore, it is concluded based on the findings and results that Emergency Room nurses are greatly affected with the occurrence of Covid-19 crisis in fulfilling their duties and responsibilities. The impact of the health crisis influenced their mental wellbeing which affects their physical, psychological, emotional, and social aspects. Mental wellbeing of emergency room nurses is not related to gender however the nationality and years of experiences of nurses have an influence.

Keywords Mental Wellbeing, Emergency Room Nurses, Covid-19 crisis



This chapter discusses the background of the study that explains the importance of the formulating the study. It also involves the statement of the problem, purpose of the study and its main objective, definition of the important concepts used in the study, and elaboration of the significance of the study to the nursing profession.


The world was shaken with an unprecedent advent of one of the deadliest viruses in the history of mankind happened towards the end days of 2019. Corona virus was named SARS Cov-2 after an outbreak happened in Wuhan China. The spread was too rapid which was seen to be contagiously outrageous in its effect to the people ( This infectious and transmissible disease was branded as one of the most concentrated health diseases happened in the history mankind (Dos Santos, 2020). It was declared a pandemic in March 2020 by the World Health Organization which was due to its rapid and speedy scale of transmission.

The Covid-19 pandemic manifested many changes and vulnerabilities in the different sectors in the society around the globe. This includes economic sector, educational sectors, government sectors, and most especially the health sectors ( As it rapidly affecting the lives of many people around the world, it is bringing along considerable fear, anxiety, stress, and worries which affects individual in all walks of life. According to World health Organization-Europe (2020) this phenomenon is felt tremendously by specific group of people which includes elderlies, immune-compromised individuals and most especially health care providers. This gave rise to the public issue of psychological to health care providers affecting their performances and productivity in the field of health care. Furthermore, research has shown an increase in the number of health care professionals showing high levels of anxiety and depression having a percentage rate of 13% and 12.2% respectively (

Statements of the Problem

Generally, the study identified mental well-being status of emergency room nurses during COVID 19 pandemic. Specifically, it sought the answers of the following queries:

1. In what extent do emergency room nurses’ mental well-being status during COVID 19 pandemic?

2. What is the relationship on the extent of mental well-being status of emergency room nurses when the following variables are considered?

a. Nationality

b. Years of Service

c. Gender

Background of the Study

Nurses as members of the healthcare team have been showing up to their work shifts and working hard to provide the best care to patients with various acuity levels during the COVID-19 pandemic (Fernandez, et al., 2020). Generally, nurses respond in different time situation may either be in a daily routine of their regular work and even during disasters like pandemic. In fact, nurses constitute the majority number of the entire health care team in different set up and they are required to function critically in order to respond to the different cases confronting the (Powers, 2020, Al Thobaity, Alamri, Plummer, and Williams, 2019).

Emergency room nurses are mostly involved in assigning and sorting cases of patients according to the degree of urgency of care and also involved in detecting cases with infections with extra precautionary measures. They are also responsible in the process of refinement and synchronization with other health care providers. Moreover, as part of their duties to provide holistic management of care to numerous types of infection concurrently dealing not only to the patients directly but even to their families as well (Xie, Tong, Guan, Qiu, and Slutsky 2020).

During crises, they are tasked to assist patients and their respective families in a high degree of satisfaction as being demanded at all times. Therefore, emergency room nurses are required to be fully equipped with indispensable knowledge, skills, and right attitude in managing catastrophes or emergencies which involves clinical treatment, isolation, communication, sorting or triaging, psychological support, and palliative care if it is needed and necessary (Bosario, Gamondi, Obrist, & Jox 2020, Corless, Nardi, Milstead, Nokes, Orsega et al 2018, Al Thobaity, Williams, & Plummer 2016, Al Thobaity, Plummer, Innes, & Copnell 2015).

A qualitative report in a study on the challenges faced by health care professionals in Bangladesh revealed that health care professionals including nurses experienced increase in their workload, psychological suffering, shortage of protective equipment and gears, social discrimination like stigmatization, absence of incentives or proper compensation, and management system approach during the course of their duty in times of pandemic (Razu et al, 2021).

Numerous health care professionals also suffered other types of encounters which includes insomnia, sadness, sleep disturbances and difficulties, and to the extent of having mental depression which was observed to be related to their increased workload and other related stress (Su, Lien, Yang, Su, Wang, Tsai et al, 2007). Moreover, these professionals including nurses have been observed to experience attacks of anxiety and frustrations as well which is related to their ignorance, changes happening in their environment, and feeling of dread of acquiring the disease extending to their family members (Sun, Wei, Shi, Jiao, Song, Ma, et al, 2020). In addition to their emotional burden is the practice of being socially distant to their families when they got home after work as a precautionary measure to mitigate possibilities of infection which aggravates their psychological distress (WHO, 2020).

One of the key challenges that nurses face during Covid-19 pandemic is the provision of psychological and even social support (Chen et al, 2020). Based on the claims of Abadi et al, low level of job satisfaction of nurses was significantly observed as caused by having a higher psychological and physical demands from their jobs. Therefore, the quality of performances of nurses during pandemic is influenced by the degree and level of their job satisfaction.

Reconnoitering the matters that nurses face when caring for patients with COVID-19 will help upsurge nurse and hospital flexibility in reply to the crisis, as well as improve readiness and regaining from the crisis. Additionally, understanding these issues will help sustain nurses by enlightening leaders and decision-makers about these problems and providing commendations and insinuations. Hence, with provision of information of the presented literatures, it is then therefore significant to protect the well being of nurses during Covid-19 pandemic in order to continuously provide good, effective, quality services to patients and maintain a mental health status needed during crises. Therefore, this study will be highlighting the determination of the mental well-being of emergency nurses in the field while unanimously fighting the dreadful effect of the COVID-19 virus not only to healthcare professionals but to the entire humanity as a whole.

Purpose of the Study

The proposed study would be able to provide useful information to encourage Emergency Room nurses to be aware of their mental well-being amidst their experiences during COVID-19 pandemic. It will also bridge the knowledge gap on nurses’ mental well-being and identify strategies and interventions that have been proven to address these potential concerns especially among the members of the nursing community. It might be a stepping stone in developing or improving active and responsive interventions or programs that can help support their professional morale and raise awareness on measures to decrease mental challenges while promoting workplace diversity and safety.

Definition of Terms

The following terms were operationally defined based on their use in the study.

Mental Health. It is a state of nurses’ health when he/she comprehends his/her abilities, able to manage normal life stresses and events, can display potential at work, and able to provide contributions to his/her community.

Mental Well-being. The status of emergency room nurses to respond ups and down or challenges while performing their professional jobs. It is an integral part of the over all health of emergency room nurses.

Emergency Room Nurses. Licensed registered nurses working in the emergency room of the hospital.

COVID 19 Pandemic. The occurrence of health crisis brought by COVID 19 virus affecting worldwide population.

Significance to Nursing

This study will serve as an eye opener to nursing authorities to consider possible solutions that prompts the nursing profession in terms of mental health promotion and other related issues specifically those that affects the delivery of quality care to patients. Furthermore, the development of different programs by authorities will help our emergency room nurses in the field to remain steadfast and resilient at all times. Programs that could provide professional assistance and growth holistically to promote high level of mental well-being and support systems.


Health related crisis brought about by COVID 19 virus affected our lives multidimensionally. Health care providers who play vital role in caring people afflicted with disease due to their vulnerability are the most concerned individuals in these times. However, so much so with studies that focused on the promotion of health, prevention of the disease, rehabilitation of the cured patients, and prolonging lives of individuals, emergency room nurses were not given that much attention in terms of their mental well-being while caring during uncertainties. The level of anxiety and stress brought by the current situation is affecting their job performances which will eventually affects their job satisfaction in the end. Hence, the mental health status of these emergency room nurses affects the quality of nursing care given to their patients.

It is very important that nurses’ mental well-being must be given attention by assessing their current situations. This will provide information on how they are providing the quality services while being confronted with different anxieties and stresses brought about the pandemic




This chapter introduces the different literatures that explores knowledge of the world in terms of professional quality of life of emergency room nurses. It also presents the theoretical framework that is believed to support the future findings of the study.

Theoretical Framework

As it was observed by many authorities that health care workers including nurses are always confronted with the different demands and levels of toxicity in their field of work. Most of them were trained to put patients on the priority list before themselves and this is one of the most important and essential quality of being a nurse – selflessness. Others before self.

However, it has been seen that this practice if abused and neglected could lead to physical and psychological breakdown which yields to a more disruptive effect to their health and performances of their jobs. Therefore, it is being suggested that practicing self-care would solve issues that confronts nurses stress and improve their coping abilities to their workloads, duty demands, and other obligations they have.

This study is rooting in the theory of Self-care by Dorothea Orem. Self-care theory is a nursing theory that was developed between 1959 and 2001 (American Sintenel, 2011). This theory focuses on the concept that every individual has the capacity to practice and perform activities that an individual will perform on their behalf. In addition, this theory explains that a certain individual is able to initiate a behavior that will maintain his life, health, and well-being.

One of the major assumptions of this theory is that an individual must be independent and responsible for their own care and also including the care for other involving their families. This independence entails the ability of an individual to initiate actions that will promote and maintain well-being in all situations. These initiatives shall include different activities and programs that will promote and enhance health status.

Moreover, this theory also assumes that if a certain individual has the knowledge of potential health problems that may occur based on situations upholding a certain person, this would help him promote self-care behaviors. Nurses are well knowledgeable on this matter in regards to health problems, so therefore they are capable also of designing their potentials in order to build defenses for them to fight stress and emotional disturbances that tries to affect them internally and externally.

Research had shown that activities that are needed in order to promote self-care includes self-awareness, self-compassion, the practice of unselfishness and the employment of different variations of approaches that will affect physical, social, and inner self or mental aspects. In this manner, nurses will be able to obtain balanced work life which will improve their health and mental well-being.

Practicing self-care among nurses is significant especially in times of crises and uncertain times. This could be accomplished by always assessing mental well-being status in order to become aware to one’s emotional level and stress level as needed. Upon examining these factors, nurses would the be given numerous strategies and measures in order to mitigate or lessen the effect of stress and emotional disturbances that affects their mental health status as they perform their duties and responsibilities as nurses.

This theory is significantly providing a framework that nurses as individuals also needs proper practice of self-care. This practice will be a beneficial too in order to improve their physical, emotional, and mental well-being which will give their way in providing quality and sustaining care to their patients. Moreover, practicing self-care will try to lead them to become more resilient in times of uncertainties thus enabling to endure and give them the power to handle harder situations.

Evaluation of Evidences

Emergency nurses are health care professionals who are the first to face close contact with patients and their families while caring for infected patients and provide first care to patients.

The pressures of working in an emergency department are real. There are high expectations of staff – from their managers, their colleagues and themselves. They need to perform to a high standard. Staff are constantly in high adrenaline, ‘reaction’ mode Staff across a range of roles described the ED environment as unpredictable and intense. It was hard for them to predict what their working day would be like or to plan their schedules. They needed to be alert and on guard throughout their shift, to react and adapt to the circumstances and perform at the best of their abilities. While many staff complained about the pressures of working in the emergency department, most were conscious that the adrenalin-fueled atmosphere, the unpredictability, the variety of challenges and the opportunities to contribute to saving lives were a huge part of the appeal and kept them working there. Both clinical and non-clinical staff loved the intensity and thrived on the pressure, even if it at times it could feel overwhelming (Shepard, 2021).

As the world becomes increasingly interconnected, so do the risks it faces. The COVID-19 has affected day to day life and is slowing down the global economy. Its impact is extensive and have far reaching consequences. Not only has it cost a million lives but it has also burdened the existing medical system, disrupted the supply chain of products and services, shattered livelihoods, travel became a luxury, and almost all social events were disrupted (Haleem & Javaid, 2020). The COVID-19 pandemic has had an unprecedented impact on health systems in most countries, and in particular, on the mental health and well-being of health workers on the frontlines of pandemic response efforts. Though they described themselves as resilient, many Emergency Department staff describe experiencing poor mental health.

Further, the COVID-19 pandemic has taken a toll on the mental health of emergency department staff, both clinical and non-clinical. Front line health care workers in hospital emergency departments are at increased risk for anxiety, burnout, depression and post-traumatic stress disorder while coping with the COVID-19 pandemic, according to research published in Annals of Emergency Medicine in February. The study, done in 20 emergency departments at hospitals in the United States, found that symptoms of anxiety and burnout were prevalent across the full spectrum of emergency department staff during the pandemic, and as many as one-fifth of health care employees were at risk for PTSD. (Shepard, 2021). There are considerable opportunities to provide support and significant benefits to doing so. But initiatives and interventions need to take account of the culture within the Emergency Department, the performance mentality of most of its staff and the prevailing narratives around putting the patient first. Mind developed the ‘Taking care of you’ toolkit and champions program as a pilot intervention to help ED staff prioritize self-care and develop coping strategies to manage the challenges of their workplace.

The struggle to balance literal survival with all the things that make surviving worthwhile has never been so clear, with the COVID-19 pandemic forcing many to sacrifice social connections, and therefore quality of life, for life itself. Being socially connected in meaningful ways is actually key to human health and survival. The COVID-19 pandemic and the need to slow the virus’ spread have highlighted the pervasiveness of social contact within, and social relevance of, nearly every sector of our lives, including employment, education, entertainment, travel, transportation, recreation and health. (Holt-Lunstad, 2020). As such, COVID-19 has underscored the necessity of strengthening organizational systems to rebuild and sustain not only the physical but also the psychological, social and emotional needs of the population – a task that will be critical to a nation’s public health recovery from the pandemic. With the exception of “essential workers,” the pandemic has meant limiting physical proximity to those with whom one lives.

The extreme stress, uncertainty, and often difficult medical nature of global infectious disease outbreaks, such as Coronavirus (COVID-19), require special attention to the needs of healthcare personnel. Taking care of yourself and encouraging others to practice self-care sustains the ability to care for those in need. Sustaining the Mental-Well-Being of Healthcare Personnel during Coronavirus and other Infectious Disease Outbreaks. Numerous factors contribute to elevated stress among healthcare workers, including heavy workloads, long shifts, a high pace, lack of physical or psychological safety, chronicity of care, moral conflicts, perceived job security, and workplace related bullying or lack of social support. The resulting psychological distress can lead to burnout, depression, anxiety disorders, sleeping disorders, and other illnesses. Work related stress can have a negative impact on health care providers’ professionalism, quality of care delivery, efficiency, and overall quality of life (Pedrosa, 2020). Therefore, it is critical to identify and mitigate these work-related risk factors to protect the mental health and well-being of healthcare workers.

According to a study published by Brown University, 32.8% of people who were directly exposed to Covid-19 stressors experienced elevated depressive symptoms compared to only 8.5% before the pandemic. The findings underscore the inextricable link between the pandemic and its short- and long-term impacts on mental health. Typically, a few months after a traumatic event, depression peaks and lowers over time. But for this pandemic, 18 months after its onset, levels of depression still remained high and the burden to the overall mental well-being is still prevalent. Columbia University analyzed data from different sources like PubMed, Medlin, Web of Science about depression and anxiety prevalence.

The global rate is between 21 to 24%, Asia has an overall rate of 18 percent with China registering the lowest at 16% while the rest of the world had 29% depression and anxiety rate. Closure of public transportation, job loss, closure of schools, closure of work and restriction or cancellation of public events are the main sources of the anxiety aside from the virus. Rates of anxiety in Asia prior to the pandemic was only about 2.1 to 4.1% (Henderson, 2020). These results have important implications to policy makers to delve into the urgency of support for the prevention and early intervention of depression and anxiety.

According to Munter (2021), the challenges for health systems, further complicated by the emergence of new more infectious variants of the virus, are likely to persist—even though infection rates have decreased in many parts of the world and the vaccine roll out progresses at a rapid pace at the time of writing this article—because we are now facing a second and equally serious pandemic of mental health challenges. The threats to mental health run deep within communities and are far reaching, affecting the millions of individuals who have been traumatized during national or regional lockdowns, left vulnerable to substance use or loneliness, those who have lost loved ones to the virus or face heightened anxieties of getting sick, or among those facing the dire economic consequences of the pandemic. In this challenging recovery phase of the pandemic, the mental health needs of healthcare workers and those on the frontlines such of the pandemic response cannot be overlooked.

Working in a stressful or challenging environment for long periods with little recovery time is a risk factor for burnout. Burnout is defined as an occupational phenomenon in ICD-11: Maslach et. al. describe burnout as that point at which important, meaningful, and challenging work becomes unpleasant, unfulfilling, and meaningless. Energy turns into exhaustion, involvement (also referred to as engagement) becomes cynicism and efficacy is replaced by ineffectiveness. Grobler.

In a recent research study by Naslund (2021) healthcare systems in many countries have been overwhelmed by the coronavirus disease (COVID-19) pandemic, with increasing demands to contain and respond to the virus. The result has been increased pressure on frontline health workers. As the pandemic unfolds, the impact on health systems in low-income and middle-income countries (LMICs) is becoming apparent. In lower resource settings, the detrimental effects on frontline health workers will likely be significant due to fragmented infrastructure, low compensation, and significant shortages of necessary resources such as personal protective equipment. These high stress conditions, coupled with risk of infection and fears and anxieties among patients, can result in grave psychosocial consequences for frontline health workers, who play a vital role in delivering the bulk of primary care services in LMICs. In this narrative review, we consider the psychological impact of the COVID-19 pandemic on frontline health workers in LMICs.

The important role of frontline health workers, summarize existing literature on burnout and risks to mental health in this essential workforce, and consider how public health emergencies exacerbate these concerns to showcase their vulnerability to mental health impacts of COVID-19. The study explores emerging research on the detrimental effects of the COVID-19 pandemic on health workers and consider possible approaches to mitigate these consequences. This review draws from existing studies and emerging evidence to highlight the critical need to consider the wellbeing of frontline health workers, and to address these challenges as health systems respond to the pandemic (Naslund, 2021).

Researchers are increasingly examining the experiences of healthcare workers (HCWs), yet there is a dearth of research considering how gender shapes frontlines Health care workers (HCWs) personal experiences. As the majority of HCWs in the UK and worldwide are women, research that investigates gender and focuses on women’s experiences is urgently needed. We conducted an analysis of 41 qualitative interviews with HCWs in the British NHS during the first peak of the COVID-19 pandemic in the Spring of 2020. Our findings demonstrate that gender is significant when understanding the experiences of HCWs during COVID-19 as it illuminates ingrained inequalities and asymmetrical power relations, gendered organizational structures and norms, and individual gendered bodies that interact to shape experiences of healthcare workers. These findings point to important steps to improve gender equality, the wellbeing of healthcare workers, and the overall strength of the NHS (Fernandez et. al., 2021).

In a recent study by Gold JA. (2020) indicates that COVID-19 has a considerable impact on the psychological wellbeing of front-line hospital staff. Results suggest that nurses may be at higher risk of adverse mental health outcomes during this pandemic, but no studies compare this group with the primary care workforce. Furthermore, no studies investigated the psychological impact of the COVID-19 pandemic on social care staff. Other risk factors identified were underlying organic illness, gender (female), concern about family, fear of infection, lack of personal protective equipment (PPE) and close contact with COVID-19. Systemic support, adequate knowledge and resilience were identified as factors protecting against adverse mental health outcomes. Health and social care workers (HSCWs) have carried a heavy burden during the COVID-19 crisis and, in the challenge to control the virus, have directly faced its consequences. Supporting their psychological wellbeing continues, therefore, to be a priority. This rapid review was carried out to establish whether there are any identifiable risk factors for adverse mental health outcomes amongst HSCWs during the COVID-19 crisis.

Nearly half of the emergency nurses perceived stress above average during pandemic, and their working conditions affected this situation. The factors that significantly affect the perceived stress score of emergency nurses during the COVID-19 pandemic included applying respiratory isolation, changing the way of life, not being able to access protective equipment, insufficient nurses in the unit and thinking that COVID-19 will be transmitted to oneself. Hence, an implication that meeting physiological needs and applying psychological guidance and counselling interventions in the stress management of emergency nurses may contribute to the reduction of their stress levels. Effective infection control, reducing workload, increasing the number of nurses and strengthening the coping mechanisms can minimize the perceived stress level of emergency nurses. Some studies reported that in previous epidemics, psychological problems such as stress, anxiety and depression were observed in emergency nurses (Muktar, 2020).

During the pandemic process, health professionals have been reported to experience physical and mental fatigue, affective disorders and sleep problems due to the stress experienced (Ohayon et. al, 2021). If emergency nurses are not provided with timely, effective support and training during the COVID-19 pandemic process, stress-related health problems may develop (Mukhtar, 2020). WHO had identified these risks for health care professionals and had reported a greater need to prevent depression and exhaustion, and manage stress and anxiety (Bethesda, 2020).

The COVID-19 pandemic has increased stress factors in health care professionals. Emergency nurses are the first group to encounter infected patients. For nursing managers to find solutions to the individual and workplace stressors of emergency nurses working at the front line of the pandemic process, it became necessary to determine the stress factors and basic needs. Our research is the first and original study conducted with emergency nurses in Turkey at the first stage of the pandemic process in terms of providing a basis for future studies (Anglim, J. & Horwood, S. (2021)).

This study aimed to examine the stress levels and factors affecting the stress level of nurses working in the emergency department related to the COVID-19 pandemic. The population of the study was formed by all nurses working in the emergency services of hospitals during the COVID-19 pandemic process in Turkey and actively registered with the Emergency Nurses Association. It had been determined that there were 250 nurses actively registered with the Emergency Nurses Association in Turkey.

Emergency Nurses Association data are collected through the sole association where the emergency nurses are actively registered in Turkey. In the sample of the study, no sample selection was made, and an online questionnaire form was sent to 250 nurses actively registered with the Emergency Nurses Association between April and August 2020. The sample of the study consisted of 169 (67.6%) emergency service nurses who completed the questionnaire completely and returned. The professional characteristics of emergency nurses are given in Table 1. According to this, it was determined that of the emergency nurses, 74.4% were female, 42.9% were between the ages of 25 and 34, 56.5% were single, 68.5% had no children, 94.6% lived with elementary families, and 10.7% had a chronic disease. When the professional characteristics of emergency nurses were evaluated, it was found that 92.9% of them were clinical nurses, 46.4% of them worked in emergency care and follow-up, 75.0% of them had vocational training at the undergraduate level, and 42.5% had 10 years or more professional experience (Çınar et. al, 2021).

It was determined that the perceived stress score of the emergency nurses was 29.57 ± 7.65 (13–51) and they experienced moderate stress. However, it was determined that 44.6% of the emergency nurses experienced stress above average (30 points and above). It was found that the stress levels of female emergency nurses were significantly higher than male nurses (p < .05) and that the stress levels of emergency nurses under the age of 25 who have just started their profession were significantly higher than those of other age group nurses (p < .05) (Table 1). When we look at the requirements most needed by emergency nurses during the COVID-19 pandemic, they were observed to be psychological support (67.9%), quality sleep (67.3%), hygiene (66.7%), reduced working hours (65.5%) and healthy nutrition (60.1%), respectively.

The factors that significantly affect the perceived stress score of emergency nurses during the COVID-19 pandemic with the regression analysis performed included applying respiratory isolation, changing the way of life, not being able to access protective equipment, insufficient nurses in the unit and thinking that COVID-19 will be transmitted to oneself. These variables explain 26% of the perceived stress level of emergency nurses during the COVID-19 pandemic (Çınar et. al, 2021).

Emergency nurse managers’ planning regarding pandemic management is important in terms of reducing the perceived stress in employees. Study findings showed that the COVID-19 pandemic affected the stress levels of emergency nurses. In our study, it was determined that emergency nurses experienced moderate perceived stress during the pandemic process, and nearly half (44.6%) of them had a perceived stress level above the average. There is no study encountered showing the stress levels of emergency nurses in the literature. However, according to the United Nations COVID-19 and mental health action report published by WHO, it has been stated that approximately half of the health care professionals (47%) in Canada need psychological support. In a study conducted with health professionals in Pakistan, it has been reported that approximately half of the participants (42%) experienced moderate psychological distress (United Nations, 2020). In other studies, with health care professionals, it has been stated that more than half of the participants experienced intense stress or stress-related symptoms (Shuai et al., 2020; Lai et al., 2020). Studies conducted during pandemics such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) have shown that emergency room workers have a higher development of post-pandemic stress disorder (Min et al., 2018).

In this study, perceived stress levels of female nurses were found to be higher than male nurses (p < .05). In a study conducted in Turkey, it has been reported that female health professionals have higher anxiety and stress levels than males (Polat, 2020). A study conducted in Wuhan has shown that females, nurses and front-line health care professionals experienced more severe psychological symptoms than others (Lai et al., 2020). Finding was similar to other studies, suggesting that female nurses’ concern for the risk of infecting their families and staying away from their families to protect them from infection negatively affect their stress levels. Among the participants in the study, it was found that the stress levels of the emergency nurses who were 25 years old and younger were higher than the nurses of other age groups (p < .05).

According to a review conducted during the pandemic process, it has been stated that there was a relationship between the age of health professionals and their stress levels. It has been reported that health care professionals aged 30 and younger had higher depression scores (Spoorthy et al., 2020). The fact that young emergency nurses started their profession recently and had less professional experience compared with other nurses was also predicted to have an effect on stress levels. In the light of these findings, the nursing management should plan the emergency care services in order to prevent the interruption of emergency care services, while personnel planning should be made by considering the socio-demographic characteristics such as gender and age in the nurses who will work in the emergency.

According to our research findings, the most needed requirements of emergency nurses during the COVID-19 pandemic were psychological support (67.9%), quality sleep (67.3%) and hygiene (66.7%). It was seen that the needs of the emergency nurses involved in the study during the pandemic process were mostly psychological and physiological needs. Various practices have been reported in many countries to meet the needs of health care professionals during the pandemic process. In Wuhan, China, in order to relieve the health professionals working in the front line, the number of personnel was increased, the shift system was arranged, the information to reduce the risk of transmission was provided on online platforms, and psychological counselling and guidance support services by phone were provided (Zang et al., 2020; Shuai et al., 2020).


It is in this light that the researcher sought to understand the extent of effect of mental well-being of Emergency Room Nurses in Hail, Kingdom of Saudi Arabia with the intent to prevent mental health problems and come up with a mental health program to address the results of this research. There is no perfect policy response to a pandemic, but acknowledging tradeoffs, examining consequences over time, and advocating for a more voluntary, decentralized approach can minimize human costs and maximize overall health and well-being of these academic stakeholders. The COVID-19 pandemic has had an unprecedented impact on health systems in most countries, and in particular, on the mental health and well-being of health workers on the frontlines of pandemic response efforts. Hence, Prioritizing the Mental Health and Well-Being of Frontlines Healthcare Workers is an urgent global public health priority.




This chapter will delineate the research design and methods to be used to conduct the study. The researcher shall explain how the necessary data will address the research objectives. Responses from questionnaires shall be collected, tabulated, treated, and analyzed. This will also include the justifications as to how data shall be gathered, the process of selecting the respondents, and the features of the instruments to be used.

Research Design

A cross-sectional correlational design was utilized in this study. Correlational studies do not necessarily imply cause and effect bonds but could provide a sound basis to incur relationships while descriptive design provides an overview of collated data and simple representation of differences among variables or categories (Polit & Beck, 2017). Having a cross-sectional design is a representation of the duration of the measurement phase (Lavrakas, 2008). For this study, the data will be collected while the COVID-19 pandemic is still ongoing. The variables that will be correlated are extent of mental well-being as well as their correlation when grouped according to profile variables- gender, nationality, and years of experiences.

Target Groups

The study involved Emergency room nurses from the different government hospitals situated in Hail Region Kingdom of Saudi Arabia. Based from the statistical profile of the different hospitals, there are around 120 ER nurses currently employed in the area working in the government hospitals.

Respondents were recruited through total purposive sampling. They were selected based on the inclusion and exclusion criteria set by the researcher. This study involved the following inclusion criteria – currently working as ER nurse in a government hospital, with Saudi Council License or registered nurse, in any position in the emergency department, and belonging to any nationality. However, this study did not include the nurse assistants and other paramedical profession working in the Emergency room. It will be exclusively to emergency room nurses working in a government hospital in Hail region, Kingdom of Saudi Arabia.


This study adapted the Warwick-Edinburgh Mental Well-Being Scale which was developed by expert panels which was led by Professor Sarah Stewart-Brown together with his colleagues in 2005. This instrument aimed to capture a wide conception of well-being to general population and it is intended to come up with mental health promotion activities and programs. It is consisting of 14 items worded all in positive statement and it is answered in 5 response categories.

The instrument was previously tested based on the report of Tennant et al (2007) for its internal consistency yielding a standard Cronbach’s alpha to 0.91 score for the general population sample. Furthermore, the confirmatory factor analysis of the instrument was administered to 17489 respondent population sample which showed good content validity. And lastly, test-retest was also administered to the said population and yielded to a high score (0.83).

However, this instrument shall be tested in its reliability to the population that is intended in this research study. It will be administered to 30 respondents whereas the data that will be gathered will be computed still with Cronbach’s alpha statistical formula.

Plan and Implementation Process

The researcher observed the research process in a strict manner. The initiation of data gathering started after the pronouncement of the approval of the proposed study unanimously decided by the designated panel members.

After which, the researcher obtained approval from the different ethical board/committees involved in the process. An ethical approval shall be obtained from the Ethical Board of the University of Hail noted by the Dean of the Graduate Schools. A letter of request and permission was forwarded to the different hospital’s ethical board which included King Salman Specialist Hospital, King Khalid Hospital, Hail General Hospital, and Erada Complex and Mental Health Hospital. The researcher will be attending personal meetings to the different ethical Boards in order to explain the full nature of the research study and importantly the significance and purpose of the study.

Data were gathered through an electronic questionnaire which will be designed in Google Form. The respondents’ answers were stored and collectively tallied and analyzed through SPSS statistical treatment. The respondents’ voluntary participation is implied once they accomplished the questionnaire.

Results were inferentially analyzed and processed in order to formulate significant findings and conclusions. The researcher carefully examined the findings which is in linked with the raw results from the statistical treatment. The recommendations were based on the conclusion exclusively. A concrete output shall be drafted once the conclusions and recommendation are finally developed and a checked by the panel members.

Data Analysis

The obtained data after data gathering was treated by SPSS version 23 and specifically applied the descriptive and inferential formula.

For specific problem number 1, it was treated by frequency, percentage and ranking. Frequency is defined as the absolute occurrence of all events and or the number of times a data appeared as it occurred. Percentage is the proportion times 100.

For specific number 2, it was treated with person product moment correlation formula. Pearson product moment correlation is a measure of the strength and direction of association that exists between two variables measure on an interval scale.


The gender variable and its correlation to the extent of professional quality life were treated with Chi-square tests-of-independence. Chi-square used to assess relationships between two independent nominal variables.


χ2 = ∑(Oi – Ei)2/Ei


· Oi = observed value (actual value)

· Ei = expected value.

Table 1. Descriptive Equivalence and Statistical Limits

1.00 – 1.80

None of the Time

1.81 – 2.60


2.61 – 3.40

Some of the Time

3.41 – 4.20


4.21 – 5.00

All of the Time

Ethical Consideration

For the ethical consideration, this study sought ethical approval from the Ethical Board of the University of Hail and to the different hospitals involved in the study. If other institutional research ethics committee is also present from other target facilities, approvals were sought. The online questionnaire will provide the necessary information to inform the eligible participants particularly with the aim, benefits, and possible risks associated with the study. To enhance veracity and focus in answering the questionnaire, the participants were flagged online through a reminder in the online form to answer it during their rest period and not during their work. Furthermore, alphanumeric coding was used to preserve anonymity among the respondents while serving as a tracker for the researcher. Participation in this study is voluntary. Respondents may choose not to participate and may withdraw their consent to participate at any time. Participation in this research study is completely voluntary and refusal to participate will involve no penalty or loss of benefits to which the subject is otherwise entitled. All responses remain ed anonymous and confidential.


This study is limited in its scope as to the population characteristics. The population of the study includes emergency room nurses all with Saudi Council registration, belong to any position or rank in the emergency department, any nationality, currently working and employed to any government hospitals in Hail region, Kingdom of Saudi Arabia.

Moreover, variables of interest which includes gender, nationality, and years of experience in the emergency were the focus of the study and its correlation the extent of mental well-being status of the emergency room nurses. Further and additional variables and other analysis shall be suggested for the improvement of the study.


The research methodology of the study enlightened the analysis process of the study. It also explains the data gathering process and the use of the appropriate instrument for the sake of getting the relevant information which will eventually affect the conclusions of the study. Ethical approvals are important to obtain prior to the administration of the data gathering tool. Statistical formula that is indicative per sub problem will give better ways of solution that will yield to clearer findings and better conclusions.


Project Outcomes


This chapter exhibits the analyzed results from the data gathered. Data were computed using both descriptive and inferential statistical treatment based on the problem presented. The treatment used in the computation include frequency, percentage, chi-square, and person-product moment correlation. The variables that were used to analyzed includes extent of mental well-being, gender, nationality, and years of experience in emergency room.


Data gathered were collated and tallied by the researcher in order to figure out the results. Data were analyzed using the SPSS version 27 applying inferential statistics and descriptive statistics accordingly.

Table 2 shows the distribution of respondents according age, nationality, and years of experience in the emergency room. The response rate as of percentage is 95% which composed of 114 respondents out of 120 nurses. Majority of the respondents are female, Non-Saudi Employees, and having 3-5 years of experience in the Emergency room. Specifically, as to gender of the respondents, there are 27% are males and 73% are females. Moreover, as to the nationality of the respondents, 37% were Saudi nationals and 63% are non-Saudi nurses. Finally, as to the number of years of experience incurred by the respondents, 14% belongs to ER nurse with 0-2 years of experience, 46% have 3-5 years of experience, and 40% have the longest experience of staying in the Emergency room with 6 years and above.

Table 2. Profile of Respondents


Hospital Affiliation

No. of Respondents



Years of Experience

King Salman Specialist Hospital



Male= 12

Female= 22

Saudi = 14

Non-Saudi = 20

0-2 = 4

3-5 = 18

6-above = 12

King Khalid Hospital,



Male = 8

Female =24

Saudi = 10

Non-Saudi = 22

0-2 = 3

3-5 = 15

6-above = 14

Hail General Hospital



Male = 10

Female = 16

Saudi = 8

Non-Saudi =18

0-2 = 5

3-5 = 11

6-above =10

Erada Complex and Mental Health Hospital



Male = 9

Female = 13

Saudi = 10

Non-Saudi = 12

0-2 = 3

3-5 = 8

6-above = 11

Table 3 shows the extent of mental well-being of emergency room nurses in different government hospitals of Hail Region, Kingdom of Saudi Arabia. It is well gleaned from the table that generally have “Often” extent of mental well being of Emergency room nurses working from different government hospitals in Hail region.

Among all the mental wellness items, item number 13 which states that “I’ve been interested in new things” got the highest mean of 4.89 interpreted as all the time. On the other hand, the lowest mean reflected is item number 9 which states “I’ve been feeling close to everyone” having a weighted mean of 2.00 interpreted as rarely.

Table 3. Extent of Mental Well-being






I’ve been feeling optimistic about the future


All the Time


I’ve been feeling useful


All the Time


I’ve been feeling relaxed


Some of the time


I’ve been feeling interested in other people


Some of the time


I’ve had energy to spare


Some of the time


I’ve been dealing with problems well


Some of the time


I’ve been thinking clearly


Some of the time


I’ve been feeling good about myself




I’ve been feeling close to other people




I’ve been feeling confident


Some of the time


I’ve been able to make up my own mind about things


Some of the time


I’ve been feeling loved


Some of the time


I’ve been interested in new things


All the Time


I’ve been feeling cheerful





Some of the Time

Table 3 shows the correlation analysis of the moderating variables in the study. The extent of mental well-being of emergency nurses has significant relationship with nationality (Correlation = 0.808, p-value= 0.000), and, year of ER experience (Correlation=0.872, p-value=0.087).

However, extent of mental well-being of ER nurses has no significant relationship to gender (Correlation = 0.151, p = 0.095)

Table 4: Correlation Analysis

Mental Health and















Year of ER experience







This chapter explores thoroughly the results based on the analysis of the data gathered. The implications of each result will bring evidence to the different insights that was driven out of the data. The corroboration to the implication suggests a significant proof to the consumers of the study that this study is supremely needed to be undertaken.

This chapter will present the discussion of each of the results, conclusions derived from the analysis of the data, its implications to the nursing profession, and the recommendations for future researches.


The results on the extent of mental well-being of Emergency Room Nurses appeared to be generally some of the time. It only means that mental well being of the respondents are deeply affected during Covid-19 crisis. A some of the time results would imply that occasionally they are in good condition of their mind. In the study of Ghaleb et al in 2021, most of the health care workers experiencing depression, stress, and anxiety during Covid-19 pandemic. Frontline workers reported having mild to moderate signs and symptoms of depression, distress, and burn out (Ali, Sha, and Thalib 2021). Furthermore, in the study of De Kock et al in 2021, the emergence of Covid-19 produces a substantial impact in the psychological well-being of many health care workers especially the front-liners. Thus, this appears to be evident that the result of this study is congruently the same with other researchers had found out.

Moreover, the extent of mental well-being of Emergency nurses is significantly related with nationality. This only implies that respondents’ cultural background affects the way they exercise their mental capacities during Covid-19 crisis. The mental health status of every individual is unique. Mental health or well-being is displayed differently by people around the world. According to Mental Health Foundation in UK (2021), there are some nationalities that high level of mental wellbeing like people of India, Pakistan, and African-Caribbean compared to other nationalities ( In addition, according to the result of the study of Oliveira, Pankalla, and Cabechinas (2012) found out that there is an association positive attitude and sense of ethnic belonging which was seen among European students. Hence, nationality is considered as one predictor of mental well-being based on studies presented.

Furthermore, relationship also exist between extent of mental well-being and years of experience of the respondents. A good mental wellbeing exists when an individual learns to thrive in his job thus giving the manifestation of job satisfaction. Job satisfaction is the sense of contentment of workers or an individual brought by his skills of adapting properly himself to his job. This is manifested when a certain worker has a good state of mental wellbeing. Nadinloyi, Sadeghi, and Hajloo in 2013 found out that the longer the history of an individual to his job, the higher job satisfaction rate he got. Hence, applying this finding to the study, Emergency Room nurses with more years of experiences precisely displays job satisfaction which is one of the manifestations of possessing good level of mental wellbeing.

Lastly, gender has no significant relationship as correlated to the extent of mental wellbeing of emergency room nurses. This only implies that whatever gender a person has, his state of mental wellbeing is remained the same.


Therefore, it is concluded based on the findings and results that Emergency Room nurses are greatly affected with the occurrence of Covid-19 crisis in fulfilling their duties and responsibilities. The impact of the health crisis influenced their mental wellbeing which affects their physical, psychological, emotional, and social aspects. Mental wellbeing of emergency room nurses is not related to gender however the nationality and years of experiences of nurses have an influence.

Implication to Nursing

The findings of the study suggest on the importance of providing mental wellbeing programs that are timely needed for our Emergency Room nurses especially during disruptive times. Emergency room nurses must be given attention in their physical, psychological, and emotional welfare in order to be assisted in their mental health needs during health crisis. It is then time for nurse administrators to start formulating these programs in order to promote better mental wellbeing of emergency room nurses thus promoting better and satisfactory nursing services to patients.

Recommendations for Future Research

The researcher humble recommends researches that will explore further other related variables that affects the mental wellbeing of nurses. This could also be done by including other group of nurses who are greatly affected with the health crisis that everybody is facing now. Furthermore, a qualitative inquiry is suggested in order to explore further experiences of Emergency room nurses in terms of their mental wellbeing during health crisis.


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Appendix A

Sample Informed Consent

Dear Respondent,

I, Awad Eid Nadaa Alshammari, a graduate student of Master of Arts in Nursing of the University of Hail is currently conducting a study on Mental Well-being Status of Emergency Room Nurses of Hospitals in Hail Region Kingdom of Saudi Arabia During COVID-19 Pandemic. In cases of ambiguity, you may address questions or concerns to the principal investigator through the following contact details: +966561999155

Awad Eid Nadaa Alshammari

Graduate Student – Master of Science in Nursing

University of Hail


PURPOSE OF THE RESEARCH: This study aims to understand the extent of mental well-being of emergency room nurses in the different government hospitals in Hail region Kingdom of Saudi Arabia with its primary goal of identifying which aspects and profile of these nurses are significant factors

PROCEDURES: You will be asked to accomplish an online form after this information sheet where you will tick the appropriate answers to the items asked or fill-up short responses.

DURATION: This online-based questionnaire can only take up approximately 3-5 minutes to accomplish.

RISKS: This study involves no risks and/or discomfort on the part of the respondents.

BENEFITS: Potential benefits might recommendations to improve the mental well-being of emergency room nurses despite pandemic.

CONFIDENTIALITY: No names will be mentioned during and after the course of the study including any publication that might result from this study. Furthermore, alphanumeric coding will be used to preserve anonymity among the respondents while serving as a tracker for the researchers.

SHARING THE RESULTS: The general findings of this study will be communicated to the nursing leaders and professional organizations. The study may also be presented to local or international publications, posters, or oral presentations but there’ll be no way that any personal information of the participants will be exposed.

RIGHT TO REFUSE OR WITHDRAW: Your participation is voluntary and includes your right to withdraw. You also have the opportunity to review your responses and make necessary corrections as necessary.

Note: Since this is an online form, your completion of this online survey indicates your affirmation that you have read and understood the information regarding the study and indicates your full consent for participation. A copy of your response will be sent through e-mail.

Appendix B

Sample Questionnaire

PART 1 – Respondent’s Characteristics

or fill in the necessary spaces. Please do not leave any blank entries.

Name (optional): _____________________________ Date: ______________

Gender: ( ) Male ( ) Female

Nationality: ( ) Saudi ( ) Non saudi

Years of Service in ER: ( ) 0-2 years ( ) 3-5 years ( ) 6 years and more

PART 2 – The Extent of Mental Well-being

Below are some statements about feelings and thoughts. Please tick the box that best describes your experience of each over the last 2 weeks.

1 – None of the Time 2- Rarely 3- Some of the Time 4- Often 5- All the Time







I’ve been feeling optimistic about the future

I’ve been feeling useful

I’ve been feeling relaxed

I’ve been feeling interested in other people

I’ve had energy to spare

I’ve been dealing with problems well

I’ve been thinking clearly

I’ve been feeling good about myself

I’ve been feeling close to other people

I’ve been feeling confident

I’ve been able to make up my own mind about things

I’ve been feeling loved

I’ve been interested in new things

I’ve been feeling cheerful

Adapted from Warwick–Edinburgh Mental Well-being Scale (WEMWBS) © NHS Health Scotland, University of Warwick and University of Edinburgh, 2006, all rights reserved. Accessed @

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