The burden of anxiety, depression, and stress, along with the prevalence of symptoms of PTSD, and perceptions of the drivers of psychological harms, as perceived by doctors and nurses working in ICUs in Nepal during the COVID-19 pandemic; a mixed method evaluation
Authors: KC Shirish , Gooden Tiffany E. , Aryal Diptesh , Koirala Kanchan , Luitel Subekshya , Haniffa Rashan , Beane Abi ,   Collaboration for Research, Implementation, and Training in Critical Care in Asia and Africa (CCAA), Aryal Diptesh , KC Shirish , Koirala Kanchan , Luitel Subekshya , Nepal Rohini , Khanal Sushil , Paneru Hem R , Shreshta Subha K , Lakhey Sanjay , Amatya Samina , Thapa Kaveri , Maharjan Radhika , Kafle Roshani , Bashyal Anita , Shrestha Reema , Khadka Dipika , Dullewe Nilu 
Published: April 2024

Abstract
Background
The COVID-19 pandemic resulted in significant physical and psychological impacts for survivors, and for the healthcare professionals caring for patients. Nurses and doctors in critical care faced longer working hours, increased burden of patients, and limited resources, all in the context of personal social isolation and uncertainties regarding cross-infection. We evaluated the burden of anxiety, depression, stress, post-traumatic stress disorder (PTSD), and alcohol dependence among doctors and nurses working in intensive care units (ICUs) in Nepal and explored the individual and social drivers for these impacts.

Methods
We conducted a mixed-methods study in Nepal, using an online survey to assess psychological well-being and semi-structured interviews to explore perceptions as to the drivers of anxiety, stress, and depression. Participants were recruited from existing national critical care professional organisations in Nepal and using a snowball technique. The online survey comprised of validated assessment tools for anxiety, depression, stress, PTSD, and alcohol dependence; all tools were analysed using published guidelines. Interviews were analysed using rapid appraisal techniques, and themes regarding the drivers for psychological distress were explored.

Results
134 respondents (113 nurses, 21 doctors) completed the online survey. Twenty-eight (21%) participants experienced moderate to severe symptoms of depression; 67 (50%) experienced moderate or severe symptoms of anxiety; 114 (85%) had scores indicative of moderate to high levels of stress; 46 out of 100 reported symptoms of PTSD. Compared to doctors, nurses experienced more severe symptoms of depression, anxiety, and PTSD, whereas doctors experienced higher levels of stress than nurses. Most (95%) participants had scores indicative of low risk of alcohol dependence. Twenty participants were followed up in interviews. Social stigmatism, physical and emotional safety, enforced role change and the absence of organisational support were perceived drivers for poor psychological well-being.

Conclusion
Nurses and doctors working in ICU during the COVID-19 pandemic sustained psychological impacts, manifesting as stress, anxiety, and for some, symptoms of PTSD. Nurses were more vulnerable. Individual characteristics and professional inequalities in healthcare may be potential modifiable factors for policy makers seeking to mitigate risks for healthcare providers.