Mental health impacts in pediatric nurses: a cross-sectional study in tertiary pediatric hospital during the COVID-19 pandemic

Abstract Objective: to assess mental health issues in pediatric nurses during coronavirus pandemic in 2019. Method: cross-sectional study was conducted with pediatric nurses at the Instituto da Criança e do Adolescente based on online self-rated survey about clinical practice and mental health impact during COVID-19 pandemic. Validated self-reported scales for anxiety, depression and burnout were used for assessing these professionals. Results: 107/298 (36%) nurses answered, 90% were female, median age was 41(23-64) years, 68% worked with adolescents, 66% in frontline. Burnout, anxiety and moderate/severe depression occurred in 65%, 72% and 74%, respectively. Lack of standardized treatment protocol for nurses (27%vs.10%, p=0.049), moderate/severe depression (74% vs. 16%, p=0.002) and burnout (82% vs. 58%, p=0.01) were significantly higher in pediatric nurses with anxiety compared to those without. Pediatric nurses that worked with adolescents compared to those that did not showed higher frequency of burnout in the former group (77% vs. 32%, p=0.0001). Multivariable analysis revealed that adequate quarantine adherence increased the presence of anxiety in 4.6 times [OR4.6(CI 1.1-20.2), p=0.04]. Conclusion: most pediatric nurses who had worked in the frontline of COVID-19 were under precarious conditions, working with reduced team, and with an expressive changes in their monthly income. Current anxiety was a relevant issue, burnout was also an important mental condition for these professionals, reinforcing culture of good teamwork, collaboration practices and psychological/psychiatric approach.


Introduction
Coronavirus pandemic   Pandemic infectious diseases may promote psychological changes in health care workers, especially women and nurses. Indeed, preexisting health conditions, feelings of vulnerability, social distancing, concerns about family members may increase anxiety, depression and burnout for these health professionals (1)(2) .
Children and adolescents have infrequent COVID-19, however, they may present moderate to severe conditions requiring hospitalization (3)(4)(5) . Pediatric nurses have been working tirelessly to care for COVID-19 patients, many of them need to stay away from their homes for prolonged periods, as they are afraid they may be putting their own families at risk of infection, impacting their mental and physical health (6) . In addition, number of deaths, changes in monthly income, sleep deprivation and sedentarism during this pandemic may influence self-reported anxiety and depression for nurses (7) and general practitioners, particularly for nurses who treats and care for adult patients around the word (7)(8)(9)(10)(11)(12)(13) .
However, to our knowledge, these issues were not systematically assessed in pediatric nurses during the COVID-19 pandemic, particularly in professionals of a tertiary hospital that follows-up children and adolescents with chronic and severe conditions. Therefore, the aim of the present study was to assess demographic data, work-related conditions, and mental issues of pediatric nurses during pandemic COVID-19. We also compared demographic and issues related to COVID-19 data in pediatric nurses with and without anxiety, with and without depression, as well as pediatric nurses that worked with adolescents compared to those that did not work with teenagers, as there is a high percentage of patients in this age group being treated at the mentioned institution.

Method
From July to October 2020, a cross-sectional study was carried-out with pediatric nurses who were regularly working during the period studied, anchored by an online questionnaire about physical and mental health impacts during COVID- 19 (14) . Participants Score ≤2 was considered as no symptoms of burnout and ≥3 was considered as presence of 1 or more burnout symptoms (14)(15) .
Anxiety and depression were considered as severe depression (scores 20-27) (16) . Generalized Anxiety Disorder (GAD-7) scale comprised seven questions using four-point Likert-scale, ranged from 0 (not at all) to 3 (almost every day) for each question. The total score of pediatric nurses was considered and divided in two groups: without anxiety (scores ≤ 4) and with anxiety (scores ≥ 5) (17) .

Statistical analysis
Data were presented as median (

Discussion
To our knowledge, this study was relevant in order to investigate physical and mental health issues in Brazilian pediatric nurses during the COVID-19 pandemic in a tertiary hospital. Our study showed relevant impact on the work routine of pediatric nurses, including expressive rates of anxiety, burnout, and depression.
These findings were similar to other studies that evaluated health professionals during COVID-19 pandemic (9,(18)(19)(20) , especially female nurses (7,21) . In 2004, a study about the SARS outbreak had already revealed increased levels of anxiety and depression. Nowadays, in order to attenuate possible complications, it is necessary to learn from this experience and provide medium or long-term psychological and psychiatric support for these professionals (22)(23)(24) .
Pediatric nurses reported herein a high rate of burnout, which could have a relationship with increased workload, stress, being single, social distancing and familyassociated stress. In fact, the new protocols and routine, impacted their physical and mental health during pandemic COVID-19 (25) . In the present study, burnout rate was significantly higher in pediatric nurses, particularly in those who worked with adolescents. This finding may be related to relevant physical and mental impact in adolescent populations during COVID-19 pandemic, particularly in patients hospitalized due to chronic severe disease, requiring multiple immunosuppression therapies (26) .
Indeed, a Chinese study showed a higher burnout rate in professionals that worked in usual wards compared to professionals that had worked in the frontline (27) .
We showed high prevalence of burnout in pediatric nurses with anxiety and moderate/severity depression. The reports are linked to emotional exhaustion, anxiety and depression (28)(29)(30) . Furthermore, stress may be considered as a preceding factor for these mental health issues (29,31) .
Association between anxiety and depression were also observed in the present study, as also described by other authors (32)(33) . Depression was significantly mentioned by pediatric nurses with anxiety. These findings were also reported in other studies, possibly related to inadequate available resources, exhaustive workloads, working in tertiary hospitals and in the frontline of COVID-19 pandemic (7,25) .
Furthermore, the lack of other pediatric nurses and other health professionals, as well as lack of standardized treatment protocols, especially in the beginning of pandemic, and quarantine adherence, could also contribute to higher rates of anxiety, burnout and the fear of COVID-19 (9,25,27) . Quarantine adherence involved social distancing, which has been associated with mental health disorders (34)(35) . Indeed, some studies have found that loneliness was associated with symptoms of depression and anxiety (36)(37) , and another research has observed that lockdown measures adopted in Germany were associated with higher psychosocial distress and more loneliness, however, they were not related to anxiety and depressive symptoms (38) .
Our study has strengths and limitations. The evaluation of two validated self-reported scales for anxiety and depression, associated to a single item burnout measurement, were extremely relevant to assess the overall mental health impact during this catastrophic period. We also assessed pediatric nurses of a large and referral university hospital. However, limitations included the small sample of pediatric nurses in only one center, lack of information about previous mental health disorders, and the cross-sectional design of the study, allowed us to interpret the results only as current symptoms. The moderate response rate was observed in the present study, possible related to the lack of payment incentive. Furthermore, the absence of a control group with another health professional was another weakness of the present study. In addition, these validated mental health tools were not evaluated in pediatric nurses in other circumstances, such as out of COVID-19 pandemic period.
The COVID-19 pandemic is undoubtedly a stressful experience for different health care providers (39)(40)(41) . Thus, since the beginning of the COVID-19 pandemic, and in order to care for nurses and other health professionals, our institution has developed a program to offer mental health and psychological/psychiatric support and treatment (42) .

Conclusion
This study revealed that the mental health of pediatric