INTRODUCTION

Coronavirus disease (COVID-19) is an acute respiratory syndrome caused by a new coronavirus, SARS-CoV-2. The first cases were identified in China at the end of 2019 and, in just a few months, they spread throughout the world¹, its accelerated expansion exceeding any planning, prognosis, and response capacity, causing the highest rates of morbidity and mortality known until now in the XXI century². In this dramatic context, it was considered a pandemic on March 11, 2020 ³.

Data obtained from John Hopkins University & Medical⁴ on November 22, 2021, indicates 258,079,329 confirmed cases and 5,157,195 deaths from COVID-19. In Peru, the Ministry of Health⁵ reported 2,234,075 confirmed cases on November 27; 201,108 deaths and 91,762 discharged, a situation that is increasing every day.

This health crisis has highlighted the precariousness and fragility of the world's health systems, subjected to increasing healthcare pressure. Likewise, the pandemic has exposed the shortage of health professionals, especially nurses, to manage care from the front line⁶. In this scenario, the nursing personnel has played a leading role, and with it, the social status of the profession and its work in times of pandemic has been reconFigured, revealing their capacities and potential in the face of an international health emergency⁷.

Care is an inner good that pursues and defines nursing professionals. However, in this pandemic, the principles of comprehensive patient care and personal care came into conflict due to increased work pressure, risk of infection, physical stress and emotional stress, changes in daily work life, and the insufficient availability of adequate personal protective equipment (PPE)⁸.

Therefore, psychologically supporting nurses is essential to preserve short- and long-term health, especially when the occupational stress levels are very high. Institutions must guarantee the psychological well-being of these professionals with the use of different strategies that must focus on prevention, support, and treatment⁹.

Considering the crisis caused by the new coronavirus, occupational conditions and illnesses, and the possible emotional impact on nursing professionals, the following research question arises: What are the working conditions and factors associated with COVID-19 in the nursing personnel who care for suspected and confirmed patients? To provide an answer, the study's objective was to determine the prevalence of COVID-19 in nursing personnel, working conditions, and its associated factors.

MATERIALS AND METHODS

A quantitative, descriptive cross-sectional study of the web survey was carried out between November 2020 and February 2021 with nursing personnel from three public hospitals in Peru: The Guillermo Almenara Irigoyen National Hospital, II Vitarte Hospital, and San Isidro Labrador Hospital, located in Lima. These hospitals, during the pandemic, implemented exclusive services for the care of patients with suspected and diagnosed COVID-19.

The study sample was for convenience through a non-probabilistic sampling process; for the calculation, the formula for estimating proportions for a known population was used (N=1,180), with a confidence level of 95% and a margin of error of 3%, finally obtaining a sample of 513 participants.

The inclusion criteria considered in the study were nurses and nursing technicians/assistants working in the care of patients with COVID-19, work experience in the Inpatient Unit or the ICU with a time equal to or greater than six months. The exclusion criteria were professionals on vacation or sick leave during the data collection period and non-acceptance of informed consent.

For data collection, the participants had access to the link to the web-based survey form, which was sent via social networks. The form contained the informed consent and the instrument that consisted of two sections: The first collected sociodemographic information such as sex, age, level of education, housing conditions, with whom they live, use of transportation to go to work, family income, and risk factors presented by the personnel.

The second section included questions such as whether you had a positive diagnosis of COVID-19, how to get to your workplace, information on working conditions, work in more than one place, the availability of Personal Protective Equipment (PPE), and whether you had previous training to care for patients with COVID-19.

Data processing was performed with the Statistical Package for the Social Sciences (SPSS) v. 26. Data cleaning was carried out considering as elimination criteria those cases that had at least one missing piece of data; Of the 567 who answered the form, 72 participants were eliminated, leaving 495 valid data as the final sample.

Bivariate analysis was performed through the Chi-square test for categorical variables; in the numerical variables, the fit of the data distribution to a theoretical distribution was verified. Since the assumptions of normality were not verified, the analysis was carried out through the Mann Witney U. Odds Ratio (OR) were also calculated to analyze the occurrence of COVID-19. The analysis was performed considering a significance of 0.05.

The authorization to carry out the study was approved on October 30, 2020, by resolution No. 42-IETSI-ESSALUD-2020, within the framework of the COVID-19 pandemic.

RESULTS

Of the 495 professionals from the three health institutions, 63% (312) were from the Guillermo Almenara Irigoyen National Hospital, 20% (99) from the San Isidro Labrador Hospital, and 17% (84) from the Vitarte Hospital.

The prevalence of nursing personnel infected by COVID-19 was 47.3%. The variables sex (OR=0.912, p =0.727), marital status (OR=1.225, p =0.270), age (OR=0.986, p =0.135) and number of people at home (OR=1.053, p =0.189) showed no association with the disease. The education variable was the only one that showed a significant association (OR=1.500, p =0.044), evidencing a probability of having COVID-19 that was 1.5 times greater in those with higher education compared to those with postgraduate studies (OR=1.50), p =0.04).

Table 1:  Association between the demographic characteristics of nursing personnel and COVID-19 in health institutions. Peru, 2021 

The variables related to work as a professional category (OR=1.275, p =0.181), being a boss or coordinator (OR=1.277, p =0.485), having received training (OR=1.154, p =0.455), working in an exclusive area COVID (OR=1.275, p =0.201), traveling by public transport (OR=1.254, p =0.308), traveling by private car (OR=1.033, p =0.897), using transportation by application (OR=0.854, p = 0.607), on foot (OR=0.892, p =0.803), using another type of transport (OR=2.530, p =0.116), lack of PPE (OR=1.137, p =0.480), and working time (OR= 1,000, p =0.878) did not present a significant association with COVID-19. Regarding salary, no category showed association (p >0.05).

Table 2:  Association between the working conditions of nursing personnel and COVID-19 in health institutions. Peru, 2021 

Note: * Mann-Whitney U test ** In Peru, the minimum wage corresponds to S/. 930.00 soles or its equivalent to USD 226.83.

Regarding the variables related to the availability of personal protective equipment, such as the lack of PPE in the institution (OR=1.137, p =0.480), N95 respirator (OR=0.913, p =0.64), elastomeric respirator (OR=1.709 , p =0.244), surgical mask (OR=1.860, p =0.170), protective goggles (OR=1.367, p =0.386), disposable apron (OR=1.179, p =0.442), face shield (OR=0.844, p =0.656), disposable gloves (OR=1.732, p =0.455), disposable shoe/boot protectors (OR=0.672, p =0.274), disposable cap (OR=0.941, p =0.885), disposable jacket (OR=1.425 , p =0.163), disposable pants (OR=1.239, p =0.352) and the lack of disposable romper (OR=0.916, p =0.697) did not show sufficient evidence to affirm an association with the presence of COVID-19.

Table 3:  Association between the availability of Personal Protective Equipment and COVID-19 in health institutions. Peru, 2021 

Regarding the variables related to health, such as belonging to the risk group (OR=0.802, p =0.317), cardiovascular disease (OR=0.661, p =0.426), respiratory disease (OR=0.730, p =0.410), diabetes (OR=0.805, p =0.645), neoplasia (OR=0.472, p =0.290), immunosuppressed person by medications (OR=0.730, p =0.63), autoimmune disease (OR=0.411, p =0.318), pregnancy (OR=1.117, p =0.893), being over than 60 years (OR=0.792, p =0.694), being a smoker (OR=0.526, p =0.343), obesity (OR=1.120, p =0.813), and other risks (OR=1.388, p =0.310), all of them did not show sufficient evidence to affirm an association with the presence of COVID-19.

Table 4:  Association between the risk factors of nursing personnel and COVID-19 in health institutions. Peru, 2021 

DISCUSSION

The study identified that the prevalence of COVID-19 infection in nursing personnel was close to half of the study sample. Health professionals have been one of the most susceptible groups to contagion by the coronavirus. With the onset of the disease in Wuhan, the prevalence of infected professionals was from 3.5% to 29%¹⁰. On the other hand, in Italy, the number of infected during the start of the pandemic was 10.7%¹¹, in Spain 14%¹² and the United States 19%¹³.

Of the nursing personnel who participated in the study, about a third did not receive training to care for patients with COVID-19. Although this characteristic did not show a significant association with the disease, many consider the education and training of health personnel essential to contribute to the prevention, control, case management, and self-protection¹⁴. Therefore, training should not be neglected because it is a fundamental mechanism for improving skills¹⁵. Moreover, it is the responsibility of managers to guarantee it.

The study shows that most nursing personnel travel from home to their workplace by public transportation, with a minority traveling by private car, transportation by application, on foot, or other means. Public transport is the most used means by essential workers, which has been intensified by the crisis and was initially also affected by the established restrictions¹⁶.

Based on the transmission characteristics of SARS-CoV-2 and the nature of public transportation sites, the risk of human infection could be extremely high due to the length of the exposure time window, the routes of transmission, and the structural features during travel or work. Therefore, since the beginning of the pandemic, according to the provisions of the governments of each country, most public transport operators have implemented specific measures so that transit systems offer security against COVID-19 to personnel and passengers¹⁷. A study showed that public transport operators adopted social distancing policies, mandatory use of masks, temperature screening, contact tracing, sanitation of exposed surfaces, and improvements in ventilation to inhibit transmission of the virus¹⁸. The strategies implemented sought to mitigate the risk of contagion in closed, crowded spaces and situations of close contact.

Another measure was the establishment of limits on transport capacity; such is the case of the United Kingdom, Colombia¹⁷, and Peru,¹⁹ which reduced to 10%, 35%, and 50%, respectively, of their total capacity.

The study also analyzed the protection of health professionals who work on the front line and was considered essential due to the contagiousness and virulence of the disease²⁰, identifying that half of the PPE was unavailable among the nursing personnel who fell ill with COVID-19. Although no statistical significance was found, it is essential to highlight the high risk of contagion that these professionals had to COVID-19. These results coincide with the study on working conditions and PPE against COVID-19 in health workers in Peru, in which only 53.9% received PPE each working day; 40.6% never received it; those who work without an employment relationship, sometimes and those under 56 years of age received incomplete equipment. 62.7% reported never receiving an N95 mask, and only 0.5% received an N95 mask per shift. Gloves, aprons, and caps were the most delivered materials ²¹.

In China, a study showed that the infection of health workers was directly related to the availability of adequate PPE¹⁰. Another study in the United States and the United Kingdom showed that the lack of availability, inappropriate use, and reuse of PPE increases the risk of contracting COVID-19 in front-line health workers²². These facts show the high vulnerability of health personnel to get sick and die from COVID-19. In this sense, the WHO urges governments and authorities to guarantee the health and life of front-line health workers, thus preserving that of patients²³.

Regarding risk factors, the study identified that, among the nursing personnel, 234 presented some risk factors; of them, 43% fell ill with COVID-19. Although no statistical significance was found, these professionals' risk was noTable. These findings reinforce the need for health institutions to invest in workers' health.

The literature shows that different risk factors increase the possibility of presenting serious complications and causing death. Among the risk factors for developing the disease is advanced age (being an older adult), being male, having a smoking habit, suffering from chronic diseases such as high blood pressure, diabetes mellitus, tuberculosis, Chronic Obstructive Pulmonary Disease (COPD), cardiovascular diseases, cerebral vascular accident, and alteration in blood markers²⁴, obesity, which can predispose people to present more severe symptoms explained by inflammation, altered physiology, and immune dysfunction²⁵. Diabetes mellitus causes a low-grade chronic inflammatory state in the body, increasing the risk of becoming ill²⁶.

At the level of blood markers, poor T cell function and increased interleukin 6 are factors that increase the risk and severity of SARS-CoV-2 infection²⁷. Finally, the interaction of SARS-CoV-2 and the renin-angiotensin-aldosterone system could contribute to the overrepresentation of hypertension among patients with severe COVID-19²⁸.

Finally, the statistical significance between the level of education and COVID-19 in the nursing personnel shows a 1.5 times greater risk of getting sick in the group of people with higher education than those with postgraduate studies. This result is consistent with what was reported in the National Health and Nutrition Survey on COVID-19 developed in Mexico, where the highest prevalences were found in people with secondary and upper secondary education, lower in people with higher education²⁹. Additional support that would reinforce those mentioned above is observed in comparing the percentage amounts in the group that received training where there is a difference of 8% between the group of people who contracted and those who did not contract the disease.

Among the study's limitations is that the data collection was carried out in the middle of the pandemic, when the personnel was overloaded and tired, which could have limited the number of participants. Likewise, the information collection took place from November 2020 to February 2021, at the end of the year and holidays.

The study contributes to the field of practice, research, and teaching. The field of practice presents the working and health conditions of the workers of three public hospitals in Lima-Peru, which were declared benchmarks in the care of COVID-19; highlights the need to invest in the health of workers, in personal protective equipment, and continuing education.

The research opens the possibility of more profound studies on the potential causes of contracting COVID-19 among higher-level professionals and on the experiences of these professionals in such a unique and challenging period in the history of professional practice in health care of people with COVID-19, in addition to the meanings of having the disease and dealing with loss and pain. To conclude, in the teaching field, it encourages the need to rethink the study plans of higher educational institutions to prepare young people who will enter the labor world to lead the new challenges that will arise. The pandemic is an indication that the world is undergoing changes and that it is necessary to take care of the planet.

CONCLUSION

Of the 567 professionals who responded to the web survey, the prevalence of COVID-19 in nursing professionals was 47.3%. The education variable was the only one that showed a significant association with the mentioned disease, presenting a probability of having COVID-19, 1.5 times greater than those with higher education compared to those with postgraduate studies.

No significant association to COVID-19 was identified between demographic characteristics such as gender, marital status, age, and the number of people living at home. There was also no evidence of association with variables related to work as a professional category; salary; have received training; work in exclusive COVID-19 area; lack of PPE; working time; travel by public transport, by private car, by application transport, walking or using another type of transport.

Regarding the variables related to health, they did not show sufficient evidence to affirm an association with the presence of COVID-19 belonging to the risk group; have cardiovascular, respiratory, and autoimmune disease, diabetes, neoplasia; immunocompromised person due to medications; pregnancy; being over 60 years; being a smoker, obesity, and other risks.

This research makes significant contributions to nursing practice, research, and teaching.