Bangladesh Journal of Medical Science Vol. 22 No.

01 January’23

Original article
Agreement Between Nurses’ Anxiety And Depression Levels And Their Compliance With Isolation
Measures During The Covid 19 Pandemic: An Online Cross-Sectional Study
Melike DEMİR DOĞAN1, Aylin AYDIN SAYILAN2, Samet SAYILAN3
Abstract
Aims: The purpose of this study was to determine the relationship between nurses’ anxiety and
depression levels and their compliance with isolation measures during the COVID-19 pandemic.
Background: The global COVID-19 pandemic has had severe psychological impacts on nurses.
Methods: Following receipt of the requisite approvals, data were collected actively from 289
nurses consenting to participate in the study through an online questionnaire using theinternet/
social media. Results: Mean stress, anxiety, and depression scores were higher among carers for
COVID-19 patients than in non-Covidcarers. Analysis revealed significant positive correlation
between Isolation Precautions Compliance Scale scores and stress, anxiety, depression, and
burnout. Conclusion: Burnout increased while compliance with isolation precautions decreased
in this study as stress, anxiety, and depression increased.
Keywords: COVID-19, Nurse, Stress, Anxiety, Depression, Compliance with Isolation

Bangladesh Journal of Medical Science Vol. 22 No. 01 January’23 Page : 115-120

DOI: https://doi.org/10.3329/bjms.v22i1.61860

1introduction COVID-19 represents a hitherto unequaled burden

The global Corona virus 2019 disease (COVID-19) on health workers across the world.3,4,5 This has a
pandemic first appeared in the Chinese city of particular impact on nurses, especially in psychosocial
Wuhan, the capital of Hubei province, in December terms, due to their heavy and challenging working
2019, after which it was given the name SARS- conditions, working with protective equipment that
CoV-2.1,2 The prevalence of COVID-19 in the makes it difficult to function effectively, being away
general populations of many countries, its novel, from family and sources of social support, the risk
unpredictable and highly infectious nature, the need of disease transmission, witnessing the death of
for distancing and isolation, and its associated high caregivers / teammates, and being unable to perform
morbidity and mortality rates, rendered the familiar the usual funeral and mourning rituals in case of
coping mechanisms inadequate.3,4,5 death.6,9,10,11,12
Not only sick individuals and the general community, The global COVID-19 pandemic has had severe
but also healthcare professionals are physically and psychological impacts on nurses. A significant
psychosocially affected by the pandemic, both as proportion of nurses in the Chinese city of Wuhan
members of society and due to working under serious are reported to have experienced psychological
risk.6,7,8 problems associated with the pandemic.13 Studies

1. Melike DEMİR DOĞAN, RN, MSc, PhD, Associate Professor, Faculty School of Health Science, Gumushane
University, Gümüşhane, Turkiye. e-mail: melekdm@gmail.com, ORCID: 0000-0001-7051-2202
2. Aylin AYDIN SAYILAN, RN, MSc, PhD, Associate Professor, Kirklareli University School
of Health Science, Nursing Department, Kirklareli, Turkiye. e-mail: aylin.sayilan@klu.edu.tr,
ORCID: 0000-0003-0576-8732
3. Samet SAYILAN, MD, Assistant Professor, Kirklareli Medicine Faculty, Department of Internal
Medicine, Kirklareli, Turkiye. e-mail: sametsayilan@hotmail.com, ORCID: 0000-0002-8959-8381

Correspondence: Melike DEMİR DOĞAN, RN, MSc, PhD, Associate Professor, Faculty School
of Health Science, Gumushane University, Gümüşhane, Turkiye. e-mail: melekdm@gmail.com,
ORCID: 0000-0001-7051-2202

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have noted that nurses and physicians working total coefficients in clinical samples range between
inCOVID-19 clinics experience greater anxiety than 43 and 77. In a second study, DASS-21 exhibited
those in other clinics14 and that nurses are at greater good differentiation of patients (mean depression
risk of anxiety disorder and depression.15 Particularly score=10.83; mean anxiety score=10.39; mean
higher depressive symptoms have been reported in stress score=11.85) from normal individuals(mean
nurses and physicians working in intensive care.16 depression score=5.88; mean anxiety score=5.37;
In the light of the foregoing, the purpose of the present mean stress score=7.90) (U=5310.50; 4748.50;
study was to determine the relationship between 5562.50, p=0.00). With its psychometric
anxiety, stress, and depression levels in nurses and characteristics, DASS-21 is regarded as a valid and
their compliance with isolation procedures during reliable indicator of depression, anxiety, and stress
the Covid 19 pandemic. levels.18

2 Materials and Methods 2.3 Ethical considerations

2.1Setting and participants The requisite permission for the study was granted
by the Turkish Ministry of Health. Ethics committee
This study was intended to determine nurses’ anxiety, approval was obtained from GümüşhaneUniversity
stress, and depression levels and their compliance Scientific Research and Publication Ethics Committee
with isolation procedures in the Covid 19 pandemic. (No.95674917-108.99-E.26753).
Following receipt of the requisite approvals, data were
collected from 289 nurses consenting to participate 2.4 Statistical analysis
in the study and actively using social media (e-mail, Descriptive statistics, mean, median, frequency, and
WhatsApp, Instagram, Facebook, etc.) by means percentage were used to describe the nurses’ socio-
of an online questionnaire between1.08.2020 and demographic characteristics. Comparisons were
5.10.2020. performed using the t test, theMann-Whitney Test,
2.2 Measures and instruments Pearson’s Correlation, and Spearman’s Correlation
for all statistical analyses, and a two-sided p value
The data collection form consisted of an information than 0.05 was considered statistically significant.
form, the Depression, Anxiety, and Stress Scale
(DASS), and the Isolation Precautions Compliance 3 RESULTS
Scale. Burnout levels were evaluated using a VAS Women represented 83.7% of the participants, 67.5%
scale between 0 and 10. of the nurses were married, 15.6% had a chronic
2.2.1The Isolation Precautions Compliance Scale: disease, and 95.8% reported complying with the
This five-point Likert-type scale was developed precautions recommended by the Turkish Ministry
in Turkey in 2010 and consists of 18 items and of Health. A family history of COVID-19 infection
four domains – ‘Hand Hygiene, Use of Gloves,’ was present in 26.6% of the participants in this study,
‘Environmental Infection Control,’ ‘Worker and and 80.6% of nurses reported caring for COVID-19
Patient Safety,’ and ‘Way of Contagion’. Negative patients. The mean time in the profession was
statements (items 5,7, 12, and 17) reverse scored 64.10±78.94months(Table1).
(from 5 to 1,), while positive statements are positively A significant gender difference was determined in
scores (from 1 to 5). The total scores (lowest 18, terms of compliance with isolation measures, being
highest 90) or mean score (lowest mean 1, highest greater among men than among women (p =0.002).A
mean 5) are used in scoring. Higher scores are significant association was observed between
regarded as indicating greater compliance.17 marital status and stress, with unmarried participants
2.2.2 The Depression, Anxiety, and Stress Scale registering higher mean stress scores than married
(DASS): This four-point Likert-type scale consists individuals (p =0,025). Weekly working hours were
of 21 items. The Cronbach alpha internal reliability also significantly associated with stress, individuals
coefficient in clinical samples is α=0.87, with values working more than 45 h a week having higher mean
of α=0.85 for the anxiety subscale and α=0.81 stress scores than those working less than 45 h (p
for the stress subscale. The test-retest correlation =0.027).
coefficients in a normal sample are r=0.68 for the Compliance with COVID-19 precautions was also
depression subscale, r=0.66 for the anxiety subscale, significantly correlated with stress, individuals
and r=0.61 for the stress subscale. Corrected item complying withCOVID-19 measures having higher

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mean stress scores than non-compliers (p =0.029). associated with caring for COVID-19 patients.
Caring for patients with COVID-19 was also Nurses on the frontline are one of the most severely
significantly related to stress, with individuals caring affected groups during the difficult period resulting
for a COVID-19 patients registering higher mean from the COVID-19 pandemic.20,21 Mental health
stress scores than non-COVID-19 carers (p =0.011). problems deriving from the uncertainty attendant
Mean anxiety scores were also higher among carers upon COVID-19 make compliance with isolation
for COVID-19 patients (p =0.012).Mean depression among nurses even more problematic. Studies
scores were similarly higher among individuals have emphasized that compliance is rendered more
caring for a COVID-19 patient (p =0.047). difficult by stress, anxiety, and depression, that
Anxiety levels were significantly associated with the burnout increases, and that professional help should
inability to devote sufficient time to participants’ own be sought on the subject.22,23,24,25 Our finding is
families, with individuals unable to devote sufficient compatible with the previous literature, suggesting
that stress, anxiety, and depression experienced by
time to their families registering significantly higher
nurses lay the foundation for burnout, while reducing
anxiety scores (p<0.001). Inability to devote sufficient
compliance.
time to one’s family was also significantly associated
with stress levels, with individuals unable to devote Mean stress scores in this study increased in line
sufficient time to their families registering higher with time worked. In a study intended to evaluate the
man stress scores (p<0.001). Participants who were effects of measures aimed at supporting the resilience
unable to devote sufficient time to their families also and mental health of health care professionals
had significantly higher depression scores (p<0.001). working in the front line,Pollock et al. (2020) reported
that stress increased in line with the length of time
Statistically significant association was also
worked, and that sleep and depression problems also
determined between fear of transmitting COVID-19
increased26. In their study titled ‘Are We Coping Well
and compliance with isolation procedures.
with COVID-19?’ Maduke et al. (2021) reported that
Individuals living with a fear of transmitting
stresses among health professionals increased in line
COVID-19 also exhibited greater compliance with
with the length of time worked, while their coping
isolation precautions (p=0.027). Depression was
abilities declined.27 This finding, may indicate that
significantly associated with the presence of an
length of working time is a risk factor for stress.
individual with COVID-19 infection in the family.
Higher mean depression scores were determined Participants with high mean stress scores and fearing
among participants with a family member who had transmitting the disease in this study exhibited greater
been infected with COVID-19 (p =0.045). compliance with COVID-19 precautions. Studies
have reported that health professionals experiencing
Mean DASS subdimension scores were 7±5.94 for
intense anxiety and stress due to COVID-19 also
stress, 7±4.84 for anxiety, and 8±5.51 for depression.
take many more isolation precautions in association
The mean Isolation Precautions Compliance Scale
with fear of death.27 Our finding is consistent with the
score was 82±8.84. Burnout increased in line
previous literature.
with stress, anxiety, and depression levels, while
compliance with isolation precautions decreased Participants caring for COVID-19 patients in this
(Table 2). study registered higher mean stress, anxiety, and
depression scores than those not caring for such
4 Discussion patients. Previous studies have also emphasized that
Analysis of the relationships between stress, nurses in many countries experience intense stress
anxiety, depression and burnout levels and Isolation and anxiety due to a lack of sufficient resources or
Precautions Compliance Scale scores in the present personal protective equipment, caring for numerous
studyrevealed that burnout levels increased in line patients with COVID-19, and insufficient personnel.28
with stress, anxiety and depression, while compliance At the same time, cracked hands associated with
with isolation precautions decreased. Studies have frequent hand washing and disinfectant use during
emphasized the importance of COVID-19 isolation the care of patients with COVID-19, and isolation-
precautions, particularly wearing facemasks, hand related problems such as difficulties going to the
washing, and social distancing.19 Health workers are bathroom have also been reported to exacerbate
both obliged to apply enforced isolation methods anxiety and stress in care provision.29,30 Our finding
and also experience intense stress and anxiety is also in agreement with the previous literature. We

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essentially attribute this to inadequacy of resources Table 1: The study participants’ sociodemographic
and other occupational difficulties. characteristics
Participants unable to devote sufficient time to their
families registered higher mean anxiety, stress, and n %
depression scores than those able to devote time to
their families.Mo et al. (2020) reported that nurses Gender
experience intense anxiety, stress, and depression due Female 242 83.7
to COVID-19 and are unable to devote adequate time Male 47 16.3
to their families out of fear of transmitting the disease Marital status
and because of intensive working hours.31At the
Married 94 32.5
same time, multiple regression analysis revealed that
Unmarried 195 67.5
individuals with children experience greater anxiety,
stress, and depression. Similarly, other studieshave Presence of chronic disease

also reported that nurses work intensive hours due to Yes 45 15.6
caring for intensive patients and are unable to devote No 244 84.4
sufficient time to their families, resulting in stress Have you taken protective
and anxiety.28,30 Our finding is again compatible with measures against the risk of
COVID-19 transmission?
the previous literature.
Yes 277 95.8
Individuals in this study with family members who had
No 12 4.2
contracted COVID-19 had higher mean depression scores
Has a family member been
than those with no such relatives. COVID-19 can exhibit diagnosed with COVID-19?
mild to very severe symptoms, and is a life-threatening (Mother-Father-Spouse- Child-
disease.32Studies have reported that although nurses need Brother-Sister)

the support of their families at this time, their fear of Yes 77 26.6
spreading COVID-19 and thus of losing a relative, and None 212 73.4
the fear of being isolated from relatives, are also triggers Where do you work?
of depression. Nurses with relatives who have contracted Pandemic ward 68 23.5
COVID-19 experience greater anxiety, and this is known Emergency department 24 8.3
to be capable of triggering depression.33,34 Participants in
Intensive care 50 17.3
this study with relatives who had contracted COVID-19
Pandemic intensive care 24 8.3
may therefore have experiences greater depression due to
the serious symptoms involved and to the fear of losing Surgical ward 18 6.2

a family member. Internal diseases 33 11.4

Pediatric ward 17 5.9
4.1 Limitations of the study
Infectious diseases ward 1 .3
The main limitation of this study is that the data were
Mixed ward 1 .3
collected online and from nurses only.
Administration-Laboratory-etc. 43 14.9
5 Conclusion
Operating theater 10 3.5
Burnout increased in line with stress, anxiety, and Nature of work
depression in this study, while compliance with Day and night 226 78.2
isolation precautions decreased. We suggest that
Daytime only 60 20.8
future studies should investigate measures aimed at
Nights only 3 1.0
preventing or reducing anxiety, stress and depression
experienced by nurses, at increasing compliance Weekly hours worked

with isolation, and at proposing solutions to protect Less than 45 86 29.8

mental health. More than 45 203 70.2

Data Availability Have you cared for a

COVID-19 patient?
The datasets generated during and/or analysed during
Yes 233 80.6
the current study are available from the corresponding
No 56 19.4
author on reasonable request.

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Table 2: Correlations between stress, anxiety, depression, and burnout levels and mean Isolation
Precautions Compliance Scale scores
Compliance with isolation
Stress Anxiety Depression
precautions
r p r p r p r P
Stress 1 - 0.662 <0.001 0.774 <0.001 -0.085 0.150
Anxiety 0.662 <0.001 1 - 0.656 <0.001 -0.035 0.551
Depression 0.774 <0.001 0.656 <0.001 1 - -0.063 0.285
Burnout level 0.370 <0.001 0.257 <0.001 0.303 <0.001 0.009 0.872

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