Original Article

The Effect of Occupational Stress and Concerns about the COVID-19 Pandemic on Secondary Traumatic Stress Syndrome among Iranian Frontline Nurses: A Mediating Model


Objective: With the increasing effects of stress caused by the COVID-19 pandemic and occupational stress on the mental health of frontline nurses, it is imperative to further investigate how these stresses affect nurses’ mental health and secondary traumatic stress syndrome. This research aimed to investigate the relationship of nurses' occupational stress and concerns about COVID-19 with secondary traumatic stress syndrome, and also to investigate the mediating effect that concerns about the COVID-19 pandemic have on the relationship between nurses' occupational stress and secondary traumatic stress syndrome.

Method: A cross-sectional design was adopted. The population of the study was defined as all front-line nurses in Shiraz hospitals, from which 225 nurses of two corona care hospitals were selected using convenience sampling. The degree of secondary traumatic stress, concerns about the COVID-19, and nurses' occupational stress were assessed using Bride’s Secondary Traumatic Stress Scale (STSS), an adopted version of Level of Concerns about the COVID-19 questionnaire, and the Nurses’ Occupational Stressor Scale (NOSS) among Hospital-based Healthcare Workers. Structural equation modeling (SEM) was used to examine the relationships among variables.

Results: Results showed that nurses’ occupational stresses presented a direct effect on nurses’ level of concern about the COVID-19 pandemic (β = 0.85, P < 0.001), and concern about the COVID-19 pandemic was directly related to front-line nurse's secondary traumatic stress syndrome (β = 0.83, P < 0.001). In addition, nurses’ level of concern about the COVID-19 pandemic fully mediated the effects of nurses’ occupational stresses on their secondary traumatic stress (β = 0.70, P < 0.001). This indirect effect has explained 68% of the variance in nurses’ secondary traumatic stress.

Conclusion: These results emphasized the indirect effect of nurses’ occupational stresses on secondary traumatic stress syndrome via mediating the level of concern about COVID-19. Therefore, to reduce the secondary traumatic stress of nurses who have dealt directly with COVID-19 patients, it seems necessary to pay serious attention to the sources of their occupational stress, which probably existed even before this pandemic and increased their concerns in pandemic conditions.

1. World Health Organization (WHO, 2020). Archived from the original on 31 January 2020. Available from: https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov) [Accessed 30 January 2020].
2. Guterres, A. UN leads call to protect most vulnerable from mental health crisis during and after COVID-19. UN News. 2020, Available from: https://news.un.org/feed/view/en/story/2020/05/1063882
3. Peeri NC, Shrestha N, Rahman MS, Zaki R, Tan Z, Bibi S, et al. The SARS, MERS and novel coronavirus (COVID-19) epidemics, the newest and biggest global health threats: what lessons have we learned? Int J Epidemiol. 2020;49(3):717-26.
4. Bambi S, Iozzo P, Lucchini A. New Issues in Nursing Management During the COVID-19 Pandemic in Italy. Am J Crit Care. 2020;29(4):e92-e3.
5. Cai Z, Cui Q, Liu Z, Li J, Gong X, Liu J, et al. Nurses endured high risks of psychological problems under the epidemic of COVID-19 in a longitudinal study in Wuhan China. J Psychiatr Res. 2020;131:132-7.
6. Cabarkapa S, Nadjidai SE, Murgier J, Ng CH. The psychological impact of COVID-19 and other viral epidemics on frontline healthcare workers and ways to address it: A rapid systematic review. Brain Behav Immun Health. 2020;8:100144.
7. Lee AM, Wong JG, McAlonan GM, Cheung V, Cheung C, Sham PC, et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. Can J Psychiatry. 2007;52(4):233-40.
8. McAlonan GM, Lee AM, Cheung V, Cheung C, Tsang KW, Sham PC, et al. Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers. Can J Psychiatry. 2007;52(4):241-7.
9. Batra K, Singh TP, Sharma M, Batra R, Schvaneveldt N. Investigating the Psychological Impact of COVID-19 among Healthcare Workers: A Meta-Analysis. Int J Environ Res Public Health. 2020;17(23):9096.
10. Figley CR. Traumatization and comfort: Close relationships may be hazardous to your health. In Keynote address for Families and Close Relationships: Individuals in Social Interaction, Conference at Texas Tech University, Lubbock, TX 1982 Feb.
11. Figley CR. Compassion fatigue: Toward a new understanding of the cost of caring. In: Stamm BH (Ed.). Secondary Traumatic Stress Self-Care Issue for Clinicians, Researchers, & Educators (2nd Ed.). 1995a. p. 3–28. Baltimore, MD, USA: Sidran Press;
12. Figley CR. Compassion fatigue: psychotherapists' chronic lack of self-care. J Clin Psychol. 2002;58(11):1433-41.
13. Ludick M, Figley CR. Toward a mechanism for secondary trauma induction and reduction: Reimagining a theory of secondary traumatic stress. Traumatology. 2017;23(1):112-3.
14. Coetzee SK, Klopper HC. Compassion fatigue within nursing practice: a concept analysis. Nurs Health Sci. 2010;12(2):235-43.
15. Geoffrion S, Morselli C, Guay S. Rethinking Compassion Fatigue Through the Lens of Professional Identity: The Case of Child-Protection Workers. Trauma Violence Abuse. 2016;17(3):270-83.
16. Brady JL, Guy JD, Poelstra PL, Brokaw BF. Vicarious traumatization, spirituality, and the treatment of sexual abuse survivors: A national survey of women psychotherapy STSS. P Psychol: Res Prac. 1999; 30:386–93.
17. Meyers TW, Comille TA. The trauma of working with traumatized children. In treating compassion fatigue. 2013. p. 39-55. Routledge.
18. Pfefferbaum B, North CS, Bunch K, Wilson TG, Tucker P, Schorr JK. The impact of the 1995 Oklahoma City bombing on the partners of firefighters. J Urban Health. 2002;79(3):364-72.
19. Gale K, Flannelly KJ, Greene PB, Kudler T. Burnout, secondary traumatic stress, and social support. Past Psychol. 2011;60(5):633-649.
20. Greinacher A, Derezza-Greeven C, Herzog W, Nikendei C. Secondary traumatization in first responders: a systematic review. Eur J Psychotraumatol. 2019;10(1):1562840.
21. Orrù G, Marzetti F, Conversano C, Vagheggini G, Miccoli M, Ciacchini R, et al. Secondary Traumatic Stress and Burnout in Healthcare Workers during COVID-19 Outbreak. Int J Environ Res Public Health. 2021;18(1):337.
22. World Health Organization, Last update: 14 February 2021. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
23. Albott CS, Wozniak JR, McGlinch BP, Wall MH, Gold BS, Vinogradov S. Battle Buddies: Rapid Deployment of a Psychological Resilience Intervention for Health Care Workers During the COVID-19 Pandemic. Anesth Analg. 2020;131(1):43-54.
24. Shanafelt T, Ripp J, Trockel M. Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic. Jama. 2020;323(21):2133-4.
25. Ayanian JZ. Mental Health Needs of Health Care Workers Providing Frontline COVID-19 Care. JAMA Heal Forum. 2020; 1(4): e200397.
26. Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: address mental health care to empower society. Lancet. 2020;395(10224):e37-e8.
27. Temsah MH, Al-Sohime F, Alamro N, Al-Eyadhy A, Al-Hasan K, Jamal A, et al. The psychological impact of COVID-19 pandemic on health care workers in a MERS-CoV endemic country. J Infect Public Health. 2020;13(6):877-82.
28. Tsamakis K, Rizos E, Manolis AJ, Chaidou S, Kympouropoulos S, Spartalis E, et al. COVID-19 pandemic and its impact on mental health of healthcare professionals. Exp Ther Med. 2020;19(6):3451-3.
29. Mohindra R, R R, Suri V, Bhalla A, Singh SM. Issues relevant to mental health promotion in frontline health care providers managing quarantined/isolated COVID19 patients. Asian J Psychiatr. 2020;51:102084.
30. Ramaci T, Barattucci M, Ledda C, Rapisarda V. Social stigma during COVID-19 and its impact on HCWs outcomes. Susta. 2020 May 8;12(9):3834.
31. Bai Y, Lin CC, Lin CY, Chen JY, Chue CM, Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv. 2004;55(9):1055-7.
32. Spoorthy MS, Pratapa SK, Mahant S. Mental health problems faced by healthcare workers due to the COVID-19 pandemic-A review. Asian J Psychiatr. 2020;51:102119.
33. Wong TY, Koh G, Cheong SK, Lee HY, Fong YT, Sundram M, et al. Concerns, perceived impact and preparedness in an avian influenza pandemic--a comparative study between healthcare workers in primary and tertiary care. Ann Acad Med Singap. 2008;37(2):96-102.
34. Koh D, Lim MK, Chia SE, Ko SM, Qian F, Ng V, et al. Risk perception and impact of Severe Acute Respiratory Syndrome (SARS) on work and personal lives of healthcare workers in Singapore: what can we learn? Med Care. 2005;43(7):676-82.
35. Abolfotouh MA, AlQarni AA, Al-Ghamdi SM, Salam M, Al-Assiri MH, Balkhy HH. An assessment of the level of concern among hospital-based health-care workers regarding MERS outbreaks in Saudi Arabia. BMC Infect Dis. 2017;17(1):4.
36. Gupta S, Sahoo S. Pandemic and mental health of the front-line healthcare workers: a review and implications in the Indian context amidst COVID-19. Gen Psychiatr. 2020;33(5):e100284.
37. Dagget T, Molla A, Belachew T. Job related stress among nurses working in Jimma Zone public hospitals, South West Ethiopia: a cross sectional study. BMC Nurs. 2016;15:39.
38. Poursadeghiyan M, Moghimian M, Amjad R, Baneshi M, Yari A, Noroozi M, Hami M, Khammar A, Farrokhi M. Effects on job stress on Iranian clinical nurses. Anna Trop Med. 2017 Jul 1;10(4).
39. Lee E, Jang I. Nurses' Fatigue, Job Stress, Organizational Culture, and Turnover Intention: A Culture-Work-Health Model. West J Nurs Res. 2020;42(2):108-16.
40. Van Bogaert P, Peremans L, Van Heusden D, Verspuy M, Kureckova V, Van de Cruys Z, et al. Predictors of burnout, work engagement and nurse reported job outcomes and quality of care: a mixed method study. BMC Nurs. 2017;16:5.
41. Bagheri Hosseinabadi M, Etemadinezhad S, Khanjani N, Ahmadi O, Gholinia H, Galeshi M, et al. Evaluating the relationship between job stress and job satisfaction among female hospital nurses in Babol: An application of structural equation modeling. Health Promot Perspect. 2018;8(2):102-8.
42. Chin WS, Chen YC, Ho JJ, Cheng NY, Wu HC, Shiao JSC. Psychological Work Environment and Suicidal Ideation Among Nurses in Taiwan. J Nurs Scholarsh. 2019;51(1):106-13.
43. Mamashli L, Mohammadpour Y, Moghadam A, Esmaeilzadeh S. Examination of the Occupational Stressors among the Nurses Working in Educational Centers in Urmia. Spec J Med Res Health Sci. 2019;4(1):6-13.
44. Chatzigianni D, Tsounis A, Markopoulos N, Sarafis P. Occupational Stress Experienced by Nurses Working in a Greek Regional Hospital: A Cross-sectional Study. Iran J Nurs Midwifery Res. 2018;23(6):450-7.
45. Arnetz JE, Goetz CM, Sudan S, Arble E, Janisse J, Arnetz BB. Personal Protective Equipment and Mental Health Symptoms Among Nurses During the COVID-19 Pandemic. J Occup Environ Med. 2020;62(11):892-7.
46. Oh N, Hong N, Ryu DH, Bae SG, Kam S, Kim KY. Exploring Nursing Intention, Stress, and Professionalism in Response to Infectious Disease Emergencies: The Experience of Local Public Hospital Nurses During the 2015 MERS Outbreak in South Korea. Asian Nurs Res (Korean Soc Nurs Sci). 2017;11(3):230-6.
47. Kline RB. Principles and practice of structural equation modeling. Guilford publications; 2015 Nov 3.
48. Bride BE, Robinson MM, Yegidis B, Figley CR. Development and validation of the secondary traumatic stress scale. Res soc prac. 2004 Jan;14(1):27-35.
49. Ahmadi K, Rezapour Y, Davoudi F, Saberi M. Investigate of validity and reliability of secondary trauma stress scale for evaluation of PTSD symptoms in samples of warfare victims’ wives. Iri J War Pub. 2013 Jun 10;5(3):47-57.
50. Chen YC, Guo YL, Lin LC, Lee YJ, Hu PY, Ho JJ, et al. Development of the Nurses' Occupational Stressor Scale. Int J Environ Res Public Health. 2020;17(2):649.
51. Safari Shirazi M, Sadeghzadeh M, Abbasi M. Psychometric Properties of Persian Version of Condensed Nurses' Occupational Stress Scale in Covid-19 Pandemic Period. Avicenna J Nurs Midwifery Care. 2021; 29 (3):245-55.
52. Kline RB. Principles and practice of structural equation modeling (4th Ed.). New York, NY: The Guilford Press; 2016.
53. Bentler PM. EQS structural equations program manual. Encino, CA: Multivariate software; 1995.
54. Hooper CJ, Mullen M. Structural equation modelling: guidelines for determining model fit. Elec J Bus Res Meth. 2008; 6(1):53-60.
55. Kirkpatrick DD, Fassihi F, Mashal M. The New York Times. Times. Retrieved Mar 24, 2020. Available from: https://www.nytimes.com/2020/02/24/world/middleeast/coronavirus-Iran.html
56. World Health Organization (WHO, 1 February to 30 June 2020). COVID-19 Preparedness and Response Progress Report. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019 [accessed 6 Nov 2020].
IssueVol 17 No 4 (2022) QRcode
SectionOriginal Article(s)
DOI https://doi.org/10.18502/ijps.v17i4.10685
COVID-19 Nurses Occupational Stress Secondary Traumatic Stress

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How to Cite
Safari Shirazi M, Sadeghzadeh M, Abbasi M, Yousefi M, Hedayati A. The Effect of Occupational Stress and Concerns about the COVID-19 Pandemic on Secondary Traumatic Stress Syndrome among Iranian Frontline Nurses: A Mediating Model. Iran J Psychiatry. 2022;17(4):369-378.