Introduction

COVID-19 disease caused by the new SARS-CoV-2 Coronavirus was considered a pandemic by the World Health Organization (WHO) on March 11, 2020 ¹. Nurses are on the first line of care for patients diagnosed with COVID-19, providing quality care that ensures patient safety ². To achieve this, health systems require the availability of sufficient nursing personnel, and during this pandemic, the lack of human resources in nursing in the world was demonstrated. Figures report the existence of 27.9 million nurses, with a ratio of 4.6 nurses per physician in European countries³, while in Mexico there is an estimated rate of 2.5 nurses per 100,000 inhabitants, while in the State of Michoacán de Ocampo in Mexico, the rate of 1.7 nurses per 100,000 inhabitants is the lowest in the country ⁴. These data are of great importance, given that the shortage of human resources in nursing contributes to increase the negative impact on the health of nurses with psychosocial factors such as stress, difficulty to sleep or waking up during the night ⁵, grief or dissatisfaction due to the loss of a patient⁶; in addition to occupational factors such as exposure to pathogens, stigma, and physical and psychological violence⁷, which increased during the COVID-19 pandemic.

Although it is recognized that psychological stress and negative emotions experienced during an epidemic are expected; there are numerous general and specific stressors that nurses face in health crises that cause them uncertainty. Specific stressors are considered to be the risk of infecting oneself, family or others, or the misinterpretation of flu symptoms with COVID-19 ^8-9; as well as the fear of dying or social isolation due to the association with the disease ¹⁰.

There are also institutional stressors such as the stigmatization of working with patients with COVID-19, discomfort with the use of Personal Protective Equipment (PPE), insufficient PPE training or shortage of PPE, inexperience or few nurses, and the perception of limited support from health authorities during the pandemic ^8-14. In addition, nurses may experience frustration at the often inevitable death of patients or even be at risk of burnout and compassion fatigue from the patients they care for in Intensive Care Units (ICUs) ^9-10,15-17.

Therefore, there are multiple elements during the pandemic that cause nurses psychological stress, decreased appetite, fatigue, difficulty sleeping, nervousness, frequent crying^8-9 and even suicidal thoughts in addition to uncertainty when they are directly caring COVID-19 patients because they feel isolated and vulnerable to infection ^18-23.

Uncertainty, according to Merle Mishel's theory, is defined as the inability to determine the meaning of the facts related to the disease, and during the COVID-19 pandemic, nurses face unknown work, family and personal situations resulting from the pandemic that prevent them from determining the outcome for their lives²⁴. Therefore, it is important to investigate the uncertainty variable from Michel's theoretical underpinning to create empirical evidence that strengthens the nursing discipline. Unfortunately, no studies on this subject were found, so the objective was to evaluate the level of uncertainty in the COVID-19 disease among nursing personnel in second-level care hospitals in Morelia, Michoacán, Mexico.

Methodology

Descriptive and cross-sectional study ²⁵ performed in a non-probabilistic sample of 160 nurses selected at convenience, who were asked to participate in the Facebook groups of the researchers of the study. Nurses working in public or private second-level care hospitals in Morelia, Michoacán, Mexico, male and female, aged 18 to 50 years, in direct care of patients with COVID-19, or any disease, were included; nurses on sick leave or performing administrative activities were excluded.

A two-part data collection questionnaire was applied. The first section presented questions to describe the population with sociodemographic variables such as age, sex, schooling, institution, shift, training received (hand washing, general information on COVID-19 and use of PPE) and available protective material and equipment (paper towels, masks, hand sanitizer, face shield and PPE). The second section included variables such as COVID-19 disease online course, contact with COVID-19 patients and reconversion to COVID-19 hospital.

The Uncertainty of Illness Scale in Community Version (MUIS-C) ²⁶, consisting of 23 items, uses a Likert type scale ranging from 1 to 5, where 5 = completely agree, and 1 = do not agree at all. All items are added and the score obtained is classified as low uncertainty (18 to 42 points), moderate uncertainty (43 to 66 points), and high uncertainty (67 to 90 points). The scale was modified to target nurses with emphasis on COVID-19 disease, and a content validation was performed by ten instrument experts. The final modified version consists of 18 items and was applied to nurses from a different private hospital, obtaining an internal consistency with Cronbach's alpha test of 0.863.

Study approved by the Research and Bioethics Committee of the Nursing School (CIB/FacEnf/017/2020). Data collection was performed on a Google form published on the researchers' Facebook social network during the month of June 2020, indicating the selection criteria necessary to participate, emphasizing that the research was risk-free and free of charge, data handling was confidential, withdrawal is possible since no question was mandatory, and express consent was requested ⁽²⁷. The statistical analysis was performed with descriptive statistics using frequencies, proportions, measures of central tendency and dispersion. The inferential analysis was through Pearson's Chi-square test defining a significance level of p=<0.05.

Results

The participants had a mean age of 36.7 years (SD=8.5) and were mostly women (87.5%); had a nursing degree (63.1%); belonged to the Ministry of Health: and worked the morning shift (37.5%) (Table 1).

Regarding training, 73.1% of the participants attended sessions regarding hand washing, 75% attended sessions regarding general information about COVID-19, and 50.6% did not receive training in the use of PPE. The nurses had materials such as paper towels (72.5%), masks (84.4%), hand sanitizer (68.8%), field shields (60%) and 71.9% did not have access to PPE for the direct care of people with COVID-19. It is noteworthy that 62.5% of the participants did not receive online courses about how to handle COVID-19, only 36.9% of the nurses had contact with COVID-19 patients and 33.8% of the hospitals were reconverted to COVID-19 hospital (Table 2).

In this sample, 64.4% of the participants showed moderate to high uncertainty and only 35.6% showed low uncertainty (Table 3).

When the relationship of uncertainty with sociodemographic and work variables was analyzed, a statistically significant relationship (p=≤0.005) was found between uncertainty and sociodemographic variables (sex and schooling), in training (COVID-19 disease generalities and use of PPE), in availability of material (masks and PPE) and in COVID-19 variables (COVID-19 online course) (Table 4).

Discussion

Regarding sociodemographic variables, the participants in this study have similar characteristics to other studies performed in China that addressed factors associated with the mental health of personnel exposed to COVID-19 and stress in nursing personnel, which include being mostly women and with a bachelor's degree in nursing ^18-19. The nurses in direct patient care in this study reported having access to paper towels for hand washing and hand sanitizer, but not to PPE. This situation has been frequently highlighted by nursing organizations and recent research, where it is mentioned that nursing personnel have limited access to PPE even in developed countries^12-13, which increases the risk of exposure to the virus and the possibility of being infected with the disease, which can lead to an increase in the level of uncertainty that nurses may experience during their work^13,21-23.

Nurses received training in the institution where they worked in topics such as hand washing and general statements regarding COVID-19, but not in the use of PPE; in this respect, training is essential for nurses when they are faced with emerging diseases such as that caused by the SARS-CoV-2 Coronavirus, where information is generated on a daily basis. This is especially important because PPE training is essential to ensure nurses’ safety; when this does not occur, nurses feel threatened by the possibility of becoming infected when the PPE is removed and this can be a factor for the presence of uncertainty ^{10,13,20-21,24,28-29}.

Nurses mostly did not take courses on COVID-19 available in platforms of the Mexican Health System. Although there are successful experiences in nurses focused on training with zero infection rates²⁰, this is not common. So, health institutions should ensure necessary, recent and evidence-based training. Mishel points out in his theory that training and credibility in the health system authorities (sources of structure) reduce uncertainty ²⁴, suggesting also the need to strengthen the mindset of the nursing personnel, that is, the subjective interpretation they make regarding the disease in order to strengthen the stimuli framework ^26,28.

Regarding the level of uncertainty, more than half of the nurses showed moderate to high uncertainty, which confirms what has been pointed out in several studies with Mishel's theoretical reference, where the stimuli framework perceived by the nursing personnel through personal, work or institutional stressors ^8-13 which have a negative effect producing uncertainty in the person ^24,29.

It was also seen that lower uncertainty was related in this study to having a higher academic degree, receiving training on the disease, the use of PPE and personal training with online courses regarding COVID-19, since practical theoretical knowledge allows nurses to recognize their areas of improvement and identify processes that increase the risk of infection such as the placement and removal of PPE^8-9.

This confirms that sources of structure such as education or training will support the reduction of uncertainty in the nursing personnel ^24,26. As can be seen, there are several factors that cause uncertainty in nurses who are in direct care of people with COVID-19 and require that managers and organizations of health systems take measures to mitigate mental health side effects in nurses, one of them is to provide psychological care to personnel who are on the first line of Covid-19 treatment.

Conclusions

Given that the objective of the study was to evaluate the level of uncertainty about COVID-19 in second level nursing personnel in Morelia, Michoacán, Mexico, a moderate to high level of uncertainty was identified, it was higher in women and in nurses with undergraduate and graduate schooling; Uncertainty was also higher when nurses received training regarding COVID-19 information and the use of PPE, with availability of face shields and PPE, and, finally, when nurses participated in COVID-19 online courses.

A limitation of this study was that only slightly more than one third of the nurses were in contact with patients with COVID-19, so no statistically significant relationship was found between uncertainty and maintaining contact with COVID-19 and conversion to COVID-19 hospital. Other limitations to note are the use of a non-probabilistic sample and a cross-sectional design that does not consider the changes that nurses may experience throughout the pandemic. This study allowed an approach to the reality experienced by nurses in Mexico while caring for the population during the COVID-19 pandemic, so it is expected that the results will allow nursing managers in Mexico to propose personalized interventions to improve the mental health of their personnel, especially in situations of uncertainty that they are experiencing on a daily basis.

Conflict of interests

The authors stated they have no conflicts of interests.

Funding

This research did not receive any funding.