Portuguese Nurses’ Stress, Anxiety, and Depression Reduction Strategies during the COVID-19 Outbreak
Abstract
:1. Introduction
- (1)
- The use of strategies to promote mental health by nurses, in the context of the COVID-19 pandemic, is significantly associated with symptoms of depression, anxiety, and stress.
- (2)
- Being a mental health nurse is significantly associated with fewer symptoms of depression, anxiety, and stress, compared to a non-mental health nurse.
- (3)
- Being a mental health nurse is significantly associated with the use of more mental health promotion strategies, compared to a non-mental health nurse.
2. Materials and Methods
2.1. Design
2.2. Data Collection
2.3. Strategies of Mental Health Promotion
2.4. Depression Anxiety Stress Scale—Short Version (DASS-21)
2.5. Statistical Analysis
3. Results
3.1. Sociodemographic and Clinic Characteristics
3.2. Findings Related to the Hypotheses
4. Discussion
- (1)
- The use of strategies to promote mental health by nurses, in the context of the COVID-19 pandemic, is significantly associated with symptoms of depression, anxiety, and stress.
- (2)
- Being a mental health nurse is significantly associated with fewer symptoms of depression, anxiety, and stress, compared to a non-mental health nurse.
- (3)
- Being a mental health nurse is significantly associated with the use of more mental health promotion strategies, compared to a non-mental health nurse.
Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Pappa, S.; Ntella, V.; Giannakas, T.; Giannakoulis, V.G.; Papoutsi, E.; Katsaounou, P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behav. Immun. 2020, 88, 901–907. [Google Scholar] [CrossRef]
- Labrague, L.J.; los Santos, J.A.A. COVID-19 anxiety among front-line nurses: Predictive role of organisational support, personal resilience and social support. J. Nurs. Manag. 2020, 28, 1653–1661. [Google Scholar] [CrossRef]
- Lai, J.; Ma, S.; Wang, Y.; Cai, Z.; Hu, J.; Wei, N.; Wu, J.; Du, H.; Chen, T.; Li, R.; et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw. Open 2020, 3, e203976. [Google Scholar] [CrossRef]
- Lee, A.M.; Wong, J.G.W.S.; McAlonan, G.M.; Cheung, V.; Cheung, C.; Sham, P.C.; Chu, C.-M.; Wong, P.-C.; Tsang, K.W.T.; Chua, S.E. Stress and Psychological Distress among SARS Survivors 1 Year after the Outbreak. Can. J. Psychiatry 2007, 52, 233–240. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Kang, L.; Li, Y.; Hu, S.; Chen, M.; Yang, C.; Yang, B.X.; Wang, Y.; Hu, J.; Lai, J.; Ma, X.; et al. The Mental Health of Medical Workers in Wuhan, China Dealing with the 2019 Novel Coronavirus. Lancet Psychiatry 2020, 7, e14. [Google Scholar] [CrossRef] [Green Version]
- Liu, Z.; Wu, J.; Shi, X.; Ma, Y.; Ma, X.; Teng, Z.; You, X.; Zhang, Y.; Zhang, W.; Feng, Z.; et al. Mental Health Status of Healthcare Workers in China for COVID-19 Epidemic. Ann. Glob. Health 2020, 86, 128. [Google Scholar] [CrossRef] [PubMed]
- Ning, X.; Yu, F.; Huang, Q.; Li, X.; Luo, Y.; Chen, C. The mental health of neurological doctors and nurses in Hunan Province, China during the initial stages of the COVID-19 outbreak. BMC Psychiatry 2020, 20, 436. [Google Scholar] [CrossRef]
- Huang, Y.; Zhao, N. Mental health burden for the public affected by the COVID-19 outbreak in China: Who will be the high-risk group? Psychol. Health Med. 2021, 26, 23–34. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Lu, W.; Wang, H.; Lin, Y.; Li, L. Psychological status of medical workforce during the COVID-19 pandemic: A cross-sectional study. Psychiatry Res. 2020, 288, 112936. [Google Scholar] [CrossRef]
- Zhang, Y.; Ma, Z.F. Impact of the COVID-19 Pandemic on Mental Health and Quality of Life among Local Residents in Liaoning Province, China: A Cross-Sectional Study. Int. J. Environ. Res. Public Health 2020, 17, 2381. [Google Scholar] [CrossRef] [Green Version]
- Luo, M.; Guo, L.; Yu, M.; Jiang, W.; Wang, H. The Psychological and Mental Impact of Coronavirus Disease 2019 (COVID-19) on Medical Staff and General Public—A Systematic Review and Meta-Analysis. Psychiatry Res. 2020, 291, 113190. [Google Scholar] [CrossRef]
- Ni, M.Y.; Yang, L.; Leung, C.M.C.; Li, N.; Yao, X.I.; Wang, Y.; Leung, G.M.; Cowling, B.J.; Liao, Q. Mental Health, Risk Factors, and Social Media Use During the COVID-19 Epidemic and Cordon Sanitaire Among the Community and Health Professionals in Wuhan, China: Cross-Sectional Survey. JMIR Ment. Health 2020, 7, e19009. [Google Scholar] [CrossRef]
- Benner, P.E.; Benner, P.; Hooper-Kyriakidis, P.L.; Kyriakidis, P.L.H.; Stannard, D. Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-in-Action Approach, 2nd ed.; Springer Publishing Company: New York, NY, USA, 2011. [Google Scholar]
- Said, N.B.; Chiang, V.C.L. The knowledge, skill competencies, and psychological preparedness of nurses for disasters: A systematic review. Int. Emerg. Nurs. 2020, 48, 100806. [Google Scholar] [CrossRef]
- Gázquez Linares, J.J.; Molero Jurado, M.d.M.; Martos Martínez, Á.; Jiménez-Rodríguez, D.; Del Carmen Pérez-Fuentes, M. The repercussions of perceived threat from COVID-19 on the mental health of actively employed nurses. Int. J. Ment. Health Nurs. 2021. [Google Scholar] [CrossRef]
- Alwani, S.S.; Majeed, M.M.; Hirwani, M.Z.; Rauf, S.; Saad, S.M.; Shah, H.; Hamirani, F. Evaluation of Knowledge, Practices, Attitude and Anxiety of Pakistan’s Nurses towards COVID-19 during the Current Outbreak in Pakistan. medRxiv 2020. [Google Scholar] [CrossRef]
- Sampaio, F.; Sequeira, C.; Teixeira, L. Nurses’ Mental Health during the Covid-19 Outbreak: A Cross-Sectional Study. J. Occup. Environ. Med. 2020, 62, 783–787. [Google Scholar] [CrossRef] [PubMed]
- Hu, D.; Kong, Y.; Li, W.; Han, Q.; Zhang, X.; Zhu, L.X.; Wan, S.W.; Liu, Z.; Shen, Q.; Yang, J.; et al. Frontline nurses’ burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19 outbreak in Wuhan, China: A large-scale cross-sectional study. Clin. Med. 2020, 24, 100424. [Google Scholar]
- World Health Organization. Mental Health and Psychosocial Considerations during the COVID-19 Outbreak. 2020. Available online: https://apps.who.int/iris/handle/10665/331490 (accessed on 12 March 2020).
- Hu, M.X.; Turner, D.; Generaal, E.; Bos, D.; Ikram, M.K.; Cuijpers, P.; Penninx, B.W.J.H. Exercise interventions for the prevention of depression: A systematic review of meta-analyses. BMC Public Health 2020, 20, 1255. [Google Scholar] [CrossRef]
- Goyal, M.; Singh, S.; Sibinga, E.M.S.; Gould, N.F.; Rowland-Seymour, A.; Sharma, R.; Berger, Z.; Sleicher, D.; Maron, D.D.; Shihab, H.M.; et al. Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis. JAMA Intern Med. 2014, 174, 357–368. [Google Scholar] [CrossRef] [Green Version]
- A Enfermagem e as Leis. Regulamento das Competências Específicas do Enfermeiro Especialista em Enfermagem de Saúde Mental e Psiquiátrica; Regulation No. 515/2018; Diário da República: Lisbon, Portugal, 2018. [Google Scholar]
- Instituto Nacional de Estatística. Estimativas Anuais da População Residente. 2020. Available online: https://www.pordata.pt/DB/Portugal/Ambiente+de+Consulta/TabelaAccessed (accessed on 2 January 2021).
- World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard. 2021. Available online: https://covid19.who.int/ (accessed on 15 February 2021).
- Decree No. 2-A/2020. Application of the State of Emergency Decreed by the President of the Republic. 2020. Available online: https://www.portugal.gov.pt/download-ficheiros/ficheiro.aspx?v=3f8e87a6-3cf1-4d0c-b5ee-72225a73cd4f (accessed on 1 March 2021). (In Portuguese)
- Pais-Ribeiro, J.L.; Honrado, A.; Leal, I. Contributes for the Portuguese adaptation of the Lovibond and Lovibond depression, anxiety and stress scales (DASS)—Short version. Psicol. Saúde e Doenças. 2004, 5, 229–239. (In Portuguese) [Google Scholar]
- Lovibond, P.F.; Lovibond, S.H. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav. Res. Ther. 1995, 33, 335–343. [Google Scholar] [CrossRef]
- Wang, C.; Pan, R.; Wan, X.; Tan, Y.; Xu, L.; Ho, C.S.; Ho, R.C. Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int. J. Environ. Res. Public Health 2020, 17, 1729. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Qiu, J.; Shen, B.; Zhao, M.; Wang, Z.; Xie, B.; Xu, Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen. Psychiatry 2020, 33, e100213. [Google Scholar] [CrossRef] [Green Version]
- Moreira, P.S.; Ferreira, S.; Couto, B.; Machado-Sousa, M.; Fernández, M.; Raposo-Lima, C.; Sousa, N.; Pérez, M.P.; Morgado, M.P. Protective elements of mental health status during the COVID-19 outbreak in the Portuguese population. medRxiv 2020. [Google Scholar] [CrossRef]
- Lim, G.Y.; Tam, W.W.; Lu, Y.; Ho, C.S.; Zhang, M.W.; Ho, R.C. Prevalence of Depression in the Community from 30 Countries between 1994 and 2014. Sci. Rep. 2018, 8, 2861. [Google Scholar] [CrossRef] [PubMed]
- Jalnapurkar, I.; Allen, M.; Pigott, T. Sex Differences in Anxiety Disorders: A Review. J. Psychiatry Depress Anxiety 2018, 4, 102. [Google Scholar] [CrossRef]
- Harris, E.; Kirk, J.; Rowsell, R.; Vitetta, L.; Sali, A.; Scholey, A.B.; Pipingas, A. The effect of multivitamin supplementation on mood and stress in healthy older men. Hum. Psychopharmacol. Clin. Exp. 2011, 26, 560–567. [Google Scholar] [CrossRef]
- Blampied, M.; Bell, C.; Gilbert, C.; Rucklidge, J.J. Broad spectrum micronutrient formulas for the treatment of symptoms of depression, stress, and/or anxiety: A systematic review. Expert Rev. Neurother. 2020, 20, 351–371. [Google Scholar] [CrossRef] [PubMed]
- Taylor, A.M.; Holscher, H.D. A review of dietary and microbial connections to depression, anxiety, and stress. Nutr. Neurosci. 2020, 23, 237–250. [Google Scholar] [CrossRef]
- Cheung, T.; Yip, P.S.F. Depression, Anxiety and Symptoms of Stress among Hong Kong Nurses: A Cross-sectional Study. Int. J. Environ. Res. Public Health 2015, 12, 11072–11100. [Google Scholar] [CrossRef] [Green Version]
- Wendsche, J.; Ghadiri, A.; Bengsch, A.; Wegge, J. Antecedents and outcomes of nurses’ rest break organization: A scoping review. Int. J. Nurs. Stud. 2017, 75, 65–80. [Google Scholar] [CrossRef]
- Cruwys, T.; Dingle, G.A.; Haslam, C.; Haslam, S.A.; Jetten, J.; Morton, T.A. Social group memberships protect against future depression, alleviate depression symptoms and prevent depression relapse. Soc. Sci. Med. 2013, 98, 179–186. [Google Scholar] [CrossRef]
- Thomassin, K.; Morelen, D.; Suveg, C. Emotion Reporting Using Electronic Diaries Reduces Anxiety Symptoms in Girls with Emotion Dysregulation. J. Contemp. Psychother. 2012, 42, 207–213. [Google Scholar] [CrossRef]
- Gao, J.; Zheng, P.; Jia, Y.; Chen, H.; Mao, Y.; Chen, S.; Wang, Y.; Fu, H.; Dai, J. Mental health problems and social media exposure during COVID-19 outbreak. PLoS ONE 2020, 15, e0231924. [Google Scholar]
- Goh, Y.; Yong, Q.Y.J.O.; Chen, T.H.; Ho, S.H.C.; Chee, Y.I.C.; Chee, T.T. The Impact of COVID-19 on nurses working in a University Health System in Singapore: A qualitative descriptive study. Int. J. Ment. Health Nurs. 2020, 5. [Google Scholar] [CrossRef]
- Wu, L.-M.; Sheen, J.-M.; Shu, H.-L.; Chang, S.-C.; Hsiao, C.-C. Predictors of anxiety and resilience in adolescents undergoing cancer treatment. J. Adv. Nurs. 2013, 69, 158–166. [Google Scholar] [CrossRef] [PubMed]
- Yılmaz, E.B. Resilience as a strategy for struggling against challenges related to the nursing profession. Chin. Nurs. Res. 2017, 4, 9–13. [Google Scholar] [CrossRef]
- Brown, R.; Abuatiq, A. Resilience as a strategy to survive organizational change. Nurs. Manag. 2020, 51, 16–21. [Google Scholar] [CrossRef] [PubMed] [Green Version]
Mean (sd) | Range | %Normal | %Mild | %Moderate | %Severe | %Extremely Severe | |
---|---|---|---|---|---|---|---|
DASS-21 Depression | 4.00 (3.86) | 0–21 | 64.9 | 14.9 | 12.8 | 4.5 | 2.9 |
DASS-21 Anxiety | 4.18 (4.06) | 0–21 | 54.3 | 9.6 | 17.5 | 7.7 | 10.8 |
DASS-21 Stress | 7.32 (4.54) | 0–21 | 36.4 | 36.9 | 15.7 | 8.0 | 2.9 |
Adjusted Models | |||||||||
---|---|---|---|---|---|---|---|---|---|
DASS-21 Depression | DASS-21 Anxiety | DASS-21 Stress | |||||||
B (se) | 95% CI | p | B (se) | 95% CI | p | B (se) | 95% CI | p | |
Sex: fem. [ref: male] | 0.73 (0.32) | 0.09–−1.37 | 0.025 | 1.35 (0.34) | 0.68–2.03 | <0.001 | 1.50 (0.38) | 0.76–2.24 | <0.001 |
Age | −0.04 (0.01) | −0.06–−0.01 | 0.005 | −0.06 (0.01) | −0.09–−0.03 | <0.001 | −0.10 (0.02) | −0.13–−0.07 | <0.001 |
Mental health specialty: yes [ref: no] | −0.76 (0.33) | −1.40–−0.12 | 0.020 | −0.78 (0.34) | −1.45–−0.10 | 0.024 | −0.74 (0.38) | −1.48–−0.01 | 0.048 |
Time searching for information | 0.16 (0.06) | 0.05–0.27 | 0.005 | 0.17 (0.06) | 0.05–0.28 | 0.006 | 0.34 (0.07) | 0.22–0.47 | <0.001 |
Rest between work shifts [ref: often or always] | |||||||||
Never or rarely | 0.54 (0.42) | −0.30–1.37 | 0.206 | 1.34 (0.45) | 0.46–2.23 | 0.003 | 0.98 (0.49) | 0.02–1.94 | 0.047 |
Sometimes | 0.79 (0.30) | 0.20–1.38 | 0.009 | 0.69 (0.32) | 0.07–1.32 | 0.030 | 0.68 (0.35) | −0.004–1.36 | 0.051 |
Eating healthy [ref: often or always] | |||||||||
Never or rarely | 1.71 (0.46) | 0.80–2.62 | <0.001 | 1.23 (0.49) | 0.26–2.19 | 0.013 | 1.42 (0.53) | 0.37–2.46 | 0.008 |
Sometimes | 1.03 (0.32) | 0.42–1.65 | 0.001 | 0.66 (0.33) | 0.002–1.31 | 0.049 | 1.16 (0.36) | 0.45–1.88 | 0.001 |
Adequate water intake [ref: often or always] | |||||||||
Never or rarely | −0.08 (0.40) | −0.85–0.68 | 0.830 | −0.02 (0.41) | −0.83–0.79 | 0.967 | 0.30 (0.45) | −0.58–1.18 | 0.503 |
Sometimes | 0.19 (0.30) | −0.40–0.78 | 0.518 | −0.22 (0.32) | −0.84–0.40 | 0.488 | 0.02 (0.35) | −0.66–0.69 | 0.964 |
Physical activity [ref: often or always] | |||||||||
Never or rarely | 0.68 (0.41) | −0.11–1.48 | 0.093 | 1.15 (0.43) | 0.31–1.99 | 0.007 | 0.78 (0.47) | −0.14–1.70 | 0.097 |
Sometimes | 0.21 (0.42) | −0.61–1.03 | 0.613 | 0.55 (0.44) | −0.32–1.41 | 0.215 | 0.33 (0.48) | −0.62–1.27 | 0.497 |
Relaxing activities [ref: often or always] | |||||||||
Never or rarely | 0.48 (0.45) | −0.40–1.36 | 0.281 | 0.32 (0.47) | −0.61–1.25 | 0.501 | 0.82 (0.52) | −0.19–1.83 | 0.113 |
Sometimes | 0.08 (0.44) | −0.78–0.93 | 0.856 | 0.31 (0.46) | −0.59–1.22 | 0.500 | 0.72 (0.50) | −0.26–1.71 | 0.151 |
Recreational activities [ref: often or always] | |||||||||
Never or rarely | 0.55 (0.40) | −0.22–1.33 | 0.164 | 0.63 (0.42) | −0.19–1.46 | 0.133 | 0.79 (0.46) | −0.11–1.68 | 0.086 |
Sometimes | −0.19 (0.32) | −0.82–0.44 | 0.560 | −0.20 (0.34) | −0.87–0.47 | 0.551 | 0.02 (0.37) | −0.71–0.75 | 0.966 |
Maintenance of social connections [ref: often or always] | |||||||||
Never or rarely | 1.23 (0.44) | 0.37–2.08 | 0.005 | 0.81 (0.46) | −0.09–1.71 | 0.079 | 0.73 (0.50) | −0.25–1.72 | 0.144 |
Sometimes | 0.14 (0.31) | −0.47–0.76 | 0.651 | 0.43 (0.33) | −0.22–1.08 | 0.199 | 0.28 (0.36) | −0.42–1.00 | 0.431 |
Verbalization of feelings/emotions [ref: often or always] | |||||||||
Never or rarely | 0.40 (0.35) | −0.30–1.09 | 0.263 | −0.04 (0.37) | −0.77–0.70 | 0.918 | 0.09 (0.41) | −0.71–0.89 | 0.817 |
Sometimes | 0.69 (0.33) | 0.04–1.34 | 0.038 | 0.47 (0.35) | −0.22–1.15 | 0.183 | 0.52 (0.38) | −0.23–1.27 | 0.175 |
Avoidance of access to information from unreliable sources [ref: often or always] | |||||||||
Never or rarely | 0.16 (0.34) | −0.49–0.82 | 0.623 | 0.16 (0.36) | −0.54–0.86 | 0.659 | −0.39 (0.39) | −1.15–0.37 | 0.313 |
Sometimes | 0.33 (0.33) | −0.31–0.97 | 0.312 | 0.45 (0.34) | −0.22–1.13 | 0.190 | −0.06 (0.38) | −0.79–0.68 | 0.880 |
R2 = 19.4%; F = 8.643; p < 0.001 | R2 = 18.5%; F = 8.143; p < 0.001 | R2 = 23.2%; F = 10.852; p < 0.001 |
Never | Rarely | Sometimes | Often | Always | p Value * | |
---|---|---|---|---|---|---|
n (%) | ||||||
Rest between work shifts | ||||||
Mental health nurses | 3 (2.0) | 13 (8.6) | 36 (23.7) | 64 (42.1) | 36 (23.7) | p = 0.196 |
Non-mental health nurses | 27 (4.0) | 52 (7.8) | 190 (28.4) | 260 (38.9) | 140 (20.9) | |
Eating healthy | ||||||
Mental health nurses | 1 (0.7) | 11 (7.2) | 36 (23.7) | 71 (46.7) | 33 (21.7) | p = 0.006 |
Non-mental health nurses | 4 (0.6) | 77 (11.5) | 203 (30.3) | 283 (42.3) | 102 (15.2) | |
Adequate water intake | ||||||
Mental health nurses | 2 (1.3) | 20 (13.2) | 51 (33.6) | 55 (36.2) | 24 (15.8) | p = 0.013 |
Non-mental health nurses | 12 (1.8) | 137 (20.5) | 232 (34.7) | 214 (32.0) | 74 (11.1) | |
Physical activity | ||||||
Mental health nurses | 29 (19.1) | 58 (38.2) | 36 (23.7) | 20 (13.2) | 9 (5.9) | p = 0.253 |
Non-mental health nurses | 167 (25) | 223 (33.3) | 176 (26.3) | 75 (11.2) | 28 (4.2) | |
Relaxing activities | ||||||
Mental health nurses | 13 (8.6) | 52 (34.2) | 54 (35.5) | 26 (17.1) | 7 (4.6) | p < 0.001 |
Non-mental health nurses | 162 (24.2) | 245 (36.6) | 179 (26.8) | 71 (10.6) | 12 (1.8) | |
Recreational activities | ||||||
Mental health nurses | 4 (2.6) | 20 (13.2) | 51 (33.6) | 56 (36.8) | 21 (13.8) | p < 0.001 |
Non-mental health nurses | 44 (6.6) | 135 (20.2) | 230 (34.4) | 216 (32.3) | 44 (6.6) | |
Maintenance of social connections (while social distancing) | ||||||
Mental health nurses | 1 (0.7) | 14 (9.2) | 49 (32.2) | 62 (40.8) | 26 (17.1) | p < 0.001 |
Non-mental health nurses | 13 (1.9) | 94 (14.1) | 275 (41.1) | 222 (33.2) | 65 (9.7) | |
Verbalization of feelings/emotions | ||||||
Mental health nurses | 5 (3.3) | 29 (19.1) | 55 (36.2) | 47 (30.9) | 16 (10.5) | p = 0.003 |
Non-mental health nurses | 43 (6.4) | 184 (27.5) | 222 (33.2) | 180 (26.9) | 40 (6.0) | |
Avoidance of access to information from unreliable sources about COVID-19 | ||||||
Mental health nurses | 12 (7.9) | 17 (11.2) | 33 (21.7) | 53 (34.9) | 37 (24.3) | p = 0.661 |
Non-mental health nurses | 47 (7.0) | 86 (12.9) | 138 (20.6) | 211 (31.1) | 187 (28) |
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
de Pinho, L.G.; Sampaio, F.; Sequeira, C.; Teixeira, L.; Fonseca, C.; Lopes, M.J. Portuguese Nurses’ Stress, Anxiety, and Depression Reduction Strategies during the COVID-19 Outbreak. Int. J. Environ. Res. Public Health 2021, 18, 3490. https://doi.org/10.3390/ijerph18073490
de Pinho LG, Sampaio F, Sequeira C, Teixeira L, Fonseca C, Lopes MJ. Portuguese Nurses’ Stress, Anxiety, and Depression Reduction Strategies during the COVID-19 Outbreak. International Journal of Environmental Research and Public Health. 2021; 18(7):3490. https://doi.org/10.3390/ijerph18073490
Chicago/Turabian Stylede Pinho, Lara Guedes, Francisco Sampaio, Carlos Sequeira, Laetitia Teixeira, César Fonseca, and Manuel José Lopes. 2021. "Portuguese Nurses’ Stress, Anxiety, and Depression Reduction Strategies during the COVID-19 Outbreak" International Journal of Environmental Research and Public Health 18, no. 7: 3490. https://doi.org/10.3390/ijerph18073490