Healthcare Workers after Two Years of COVID-19: The Consequences of the Pandemic on Psychological Health and Sleep among Nurses and Physicians

The COVID-19 pandemic has been the largest global health crisis of recent times, with healthcare workers (HCWs) required to intensify their professional activity during acute phases. Prior research documented detrimental effects on physical and mental health among HCWs. In Italy, >260,000 COVID-19 cases were recorded among HCWs. Heightened vulnerability among HCWs has been attributed to increased infection risk and occupational exposure. This study aimed to retrospectively explore how psychological health and sleep changed from the pre-pandemic period to the current phase (February–June 2022) among Italian nurses and physicians, and to compare the impact between these professional groups. The study also examined whether frontline work and personal COVID-19 experiences predicted current psychological and sleep outcomes.

Design: Cross-sectional web-based survey with retrospective assessment of pre-pandemic status (T0) and current status (T1, February–June 2022). Reporting followed CHERRIES guidelines. Ethics approval: Comitato Etico "LAZIO 2" (prot. N. 0223816/2021, 11/17/2021). Informed consent obtained; participation anonymous, voluntary, no compensation. Setting and recruitment: All HCWs employed by the Local Health Authority "Azienda ASL Roma 6" (Lazio Region, Central Italy; ~3312 employees across 4 hospitals, 8 medium-intensity private structures, ≥36 territorial facilities) were invited via email. The online survey took ~20 minutes and was open February–June 2022. Participants: 287 HCWs completed the survey (212 nurses, 75 physicians). Collected socio-demographic data (age, gender, marital status, education), occupational data (profession, department, length of service, frontline status), and COVID-19 experiences (positivity, quarantine, relatives/friends infected or deceased, satisfaction with governmental measures). Measures: - Impact of Event Scale (IES; Italian version): 15 items assessing PTSD symptoms related to prior traumatic events. - Pittsburgh Sleep Quality Index (PSQI; Italian version): 19 items, 7 subscales and global score; global >5 indicates poor sleep quality. - PSQI-Addendum (PSQI-A): assesses seven disruptive nocturnal behaviors common in PTSD; score >4 predictive of PTSD. - Depression Anxiety Stress Scale-21 (DASS-21; Italian version): assesses depression, anxiety, and stress over the previous week; severe cutoffs after doubling raw subscale scores: Depression ≥21, Anxiety ≥15, Stress ≥26. Procedure: Participants provided ratings for both pre-pandemic (T0) and current (T1) periods for sleep and psychological measures. Statistical analyses: Descriptive statistics characterized the sample overall and by profession. A two-way ANCOVA tested IES differences with Profession and Gender as between-subjects factors and Years on the job as covariate. A two-way mixed MANCOVA tested effects on PSQI, PSQI-A, DASS-Depression, DASS-Anxiety, and DASS-Stress with Time (T0 vs T1; within-subjects) and Profession (between-subjects), controlling for Years on the job. Two separate mixed MANCOVAs assessed the interaction of Time and frontline status (Yes/No) within nurses and within physicians, controlling for Years on the job. Multiple linear regressions in the whole sample identified COVID-19-related predictors (COVID-19 positivity, quarantine, infected relatives/friends, relatives/friends deceased, satisfaction with governmental measures) of current (T1) PSQI, PSQI-A, DASS-Depression, DASS-Anxiety, and DASS-Stress. Normality was checked; significance threshold p≤0.05. Software: SPSS v25.0 and Matlab R2016.

Sample characteristics (N=287): Mean age 46.12 (SE±0.66); mean years on the job 18.45 (SE±0.72); 76.4% female; 37.6% frontline; 42.9% had COVID-19; 51.6% quarantined; 72.5% had infected relatives/friends; 14.3% had relatives/friends who died; 71.1% satisfied with governmental measures. Traumatic impact (IES): Nurses showed higher IES scores than physicians (F1,282=7.425, p=0.007). Years on the job was protective (F1,282=10.590, p=0.001). Sleep and psychological outcomes (mixed MANCOVA with Time x Profession): Significant main effects of Profession (Pillai's Trace=0.109, F5,280=6.824, p<0.001) and Time (Pillai's Trace=0.317, F5,280=25.993, p<0.001), and a significant Time x Profession interaction (Pillai's Trace=0.042, F5,280=2.448, p=0.034), controlling for Years on the job (Pillai's Trace=0.050, F5,280=2.926, p=0.014). - Across both time points, nurses had worse PSQI, PSQI-A, DASS-Depression, DASS-Anxiety than physicians (not for DASS-Stress). - From T0 to T1, both groups worsened on all sleep and psychological scales. - Nurses exhibited greater pandemic-related worsening than physicians on PSQI, PSQI-A, DASS-Anxiety, and DASS-Stress. Frontline effects (mixed MANCOVAs by profession, Time x Frontline): Main effect of Time significant in both groups (nurses: Pillai's Trace=0.382, F5,205=25.368, p<0.001; physicians: Pillai's Trace=0.280, F5,68=5.280, p<0.001). Main effect of Frontline not significant. Time x Frontline interaction significant only in nurses (Pillai's Trace=0.063, F5,205=2.764, p=0.019), not in physicians (Pillai's Trace=0.035, F5,68=0.487, p=0.785). In nurses, frontline work was associated with a more marked worsening in DASS-Depression (F1,209=11.282, p=0.001), DASS-Anxiety (F1,209=4.333, p=0.039), and DASS-Stress (F1,209=7.311, p=0.007); PSQI and PSQI-A Time x Frontline interactions were not significant. Predictors of current (T1) outcomes (multiple regressions, whole sample): Significant models for PSQI (R=0.249, adj R2=0.045, F=3.707, p=0.003), PSQI-A (R=0.307, adj R2=0.078, F=5.849, p<0.001), DASS-Depression (R=0.319, adj R2=0.086, F=6.355, p<0.001), DASS-Anxiety (R=0.360, adj R2=0.114, F=8.342, p<0.001), DASS-Stress (significant per text). Across outcomes, having relatives/friends who died from COVID-19 positively predicted worse scores (e.g., PSQI β=0.175, t=2.938, p=0.004; PSQI-A β=0.229, t=3.928, p<0.001; DASS-Depression β=0.163, t=2.794, p=0.006; DASS-Anxiety β=0.226, t=3.937, p<0.001). Greater satisfaction with governmental measures negatively predicted symptom severity (e.g., PSQI β=−0.173, t=−2.974, p=0.003; PSQI-A β=−0.209, t=−3.651, p<0.001; DASS-Depression β=−0.275, t=−4.821, p<0.001; DASS-Anxiety β=−0.283, t=−5.047, p<0.001). COVID-19 positivity, quarantine, and having infected relatives/friends were not consistent significant predictors.

The study demonstrates that two years into the pandemic, both nurses and physicians experienced significant worsening in sleep quality and psychological symptoms compared with the pre-pandemic period, addressing the central question about the pandemic’s prolonged impact. Nurses were more adversely affected than physicians at baseline and showed greater deterioration over time in anxiety, stress, sleep quality, and sleep-related traumatic symptoms, highlighting professional role as a key risk factor. Frontline engagement further amplified psychological worsening among nurses but not physicians, suggesting role-specific vulnerability likely tied to more prolonged, direct patient care, resource reallocation, and differing crisis management experience. Length of service emerged as protective, consistent with the buffering effect of professional experience and adaptability to emergencies. Elevated sleep-related traumatic symptoms support the conceptualization of the pandemic as a traumatic stressor influencing nocturnal PTSD-like phenomena, which can impair daytime functioning and patient safety. Personal proximity to tragedy (death of relatives/friends) and lower trust in governmental measures were robust predictors of worse current sleep and mental health, underscoring that individual and institutional factors shape outcomes. Collectively, findings emphasize the need for tailored prevention and intervention strategies, with particular focus on nurses and frontline staff, to mitigate chronic stress consequences and sleep problems.

This study provides evidence of persistent adverse effects of COVID-19 on HCWs’ mental health and sleep, with nurses disproportionately impacted and frontline nursing representing an additional risk factor. Professional experience appears protective. The results support implementing targeted, profession-sensitive preventive and treatment programs to enhance resilience and coping under high workload conditions, including psychoeducation and sleep hygiene interventions, alongside institutional measures to build trust and support. Future research should: (1) use longitudinal and objective measures (e.g., actigraphy/polysomnography) to validate retrospective findings; (2) examine the role of work schedules/shifts; (3) disentangle socio-demographic confounds; and (4) evaluate the effectiveness of tailored interventions for high-risk subgroups, especially nurses.

The retrospective assessment of pre-pandemic status introduces recall bias that may inflate perceived pandemic effects. Reliance on self-report without prospective or objective measures (e.g., sleep diaries, actigraphy, polysomnography) limits precision and generalizability. The sample was confined to a single regional health authority (Lazio), restricting national generalizability. Potential confounding by socio-demographic differences between nurses and physicians (e.g., age, gender distribution) and unequal group sizes may influence comparisons. Information on specific work shift patterns was unavailable, precluding analysis of their impact.