Before May 2020, the complete clinical picture regarding COVID-19 was not entirely clear. Reported clinical manifestations of COVID-19 have ranged from very mild (including some individuals with no reported symptoms) to severe symptoms, including illness that leading to hospitalization and death. While most of the clinical information so far suggests that the majority of COVID-19 illnesses were mild. Based on the American Centre for Disease Prevention and Control (CDC) Morbidity & Mortality Weekly Report, the results showed that about 80% of deaths among COVID-19 patients in the United States (U.S.) were among adults 65 years or older, and the severity of disease with the highest percentage of severe complications was among people 85 years or older [7].

Alongside the patients with COVID-19 disease symptoms, who comprised the main cause for transmission of COVID-19 disease, recent observations have also suggested that asymptomatic COVID-19 patients and those in the incubation period of the disease were also carriers of the disease. However, when COVID-19 was first discovered, it remained to be proven whether the infected patients with COVID-19 in the recovery phase were a potential source of transmission of the disease or not [16]. These epidemiological characteristics of COVID-19 made the control of COVID-19 extremely challenging. Moreover, the added difficulty of identifying and quarantining those at high risk of transmitting the virus early on contributed to the rapid acceleration of COVID-19 infection across communities.

At the time of conducting this study, there were no specific therapeutics or vaccines fully developed for COVID-19. The primary goal of public health measures was to inhibit the epidemic and decelerate the rate of infection. Several public health measures were implemented to prevent the person-to-person spread of the disease by means of isolation and quarantine. Isolation of patients was particularly effective in interrupting the transmission of viral diseases [17]. On January 30, 2020, the World Health Organization (WHO) announced that the COVID-19 outbreak had constituted a public health emergency and international concern [16].

The findings of previous clinical research showed that heavy nursing workloads adversely affected patient safety. Furthermore, they negatively affected nursing job satisfaction and consequently contributed to high turnover in the nursing profession. Moreover, excessive workload was a contributing factor to increased medical errors. Nurses experiencing stress and burnout may not be able to perform efficiently or effectively. The resulting suboptimal performance negatively affected patient care and decreased safety [18, 19].

The specific objectives of this study are to determine: 1) the perceptions taken by nurses working in Saudi Arabia, regarding the risks of exposure to COVID-19. 2) Participants’ measures and coping mechanisms to prevent the infection of COVID-19. 3) The impact of COVID-19 transmission on participants’ work and personal lives. 4) Participants’ opinion about receiving COVID-19 vaccine in the future (within 12 months). 5) Participants’ generalized anxiety disorder level, and 6) The significant associated factors for the participants’ generalized anxiety disorder.

A correlational cross-sectional study was conducted to determine the participants’ perceptions regarding their exposure to COVID-19 and the impact of the outbreak on their work and personal lives.

A convenience sampling method was used to recruit a total of 345 nurses to address the objectives of this study. The inclusion criteria for participation in this study were for bedside nurses to be registered in the two largest cities of Saudi Arabia’s Western Region (Medina and Jeddah), who were full time workers at hospital departments (including emergency department, medical-surgical department and critical care units) that provide diagnostic and therapeutic procedures to patients who were diagnosed with, or suspected to have COVID-19 disease, who were directly caring for patients with COVID-19 disease, and who were able to understand the English language. During COVID-19 pandemic, only the major government hospitals in the cities of Medina and Jeddah were assigned to provide care for patients with COVID-19. Therefore, the sample of this study was recruited from these major hospitals, which include: Ohud Hospital (Medina city) and King Fahad Hospital (Jeddah city). The study was conducted prior to the development of the COVID-19 vaccine, therefore, all participants were yet to be the recipients of the COVID-19 vaccine.

The software program G-POWER was used to identify the effective sample size. Power analysis for Spearman’s correlation test was conducted using a power of 95%, an alpha of 0.05, a medium effect size, 0.30, and two tailed tests. The power analysis for Spearman’s correlation test revealed the required sufficient sample size as being 320 participants [20].

Two authors of this study met the eligible nurses in person in their workplace settings. Each of the authors visited the selected departments/settings at different work-shifts (morning and night shifts) to meet a large number of the eligible participants. Thereafter, the researchers explained the purpose of the study to the eligible nurses and invited them to complete an online self-administered questionnaire, which was designed by the authors, and hosted digitally using Google Forms. The participants, who decided to partake in the study, were asked to their contact details (email or WhatsApp number) which were used to send them a hyper-link to the online survey. The authors also provided the eligible nurses who accepted to participate in the study with a flyer containing a QR code link which could easily be scanned by nurses’ smart phones to access and fill-in the survey. Further to this, the authors sent the link of the online survey by email and WhatsApp to nursing managers in the selected settings for them to distribute the link to nurses in their departments.

A total of 400 candidates were invited (by the authors or via head-nurses of selected departments) to participate in this study by using the above-mentioned methods. To prevent gaps in the collected data, all questions were set to require in the form (using the Google Forms settings), making submissions only possible once all questions had been answered. A total of 345 completed surveys were submitted to the authors of this study. In order to avoid unwanted or fraudulent data as well as duplicate submissions, all participants were required to submit their forms using their official Ministry of Health email address. This ensured that each submission contributing to the data of the study was from a unique email address of a verified professional.

In the first section of the online questionnaire contained an explanation cover page about the study, as well as a written consent form. Clarification of the nature, purpose, and specific objectives of the study and the inclusion criteria were documented for the eligible participants in this explanation cover page. Moreover, the participants were informed that their participation was entirely voluntary and that their personal information would be anonymous and confidential. All willing participants in the study were asked to confirm their agreement to participate and were informed that submission of the survey was considered written consent. The data collection window was between May 2020 and October 2020, prior to the distribution of the COVID-19 vaccinations in Saudi Arabia.

A structured questionnaire was used to assess the participants’ perceptions regarding their level of risk due to exposure to COVID-19. Participants were also asked about the measures and coping mechanisms they employed to prevent COVID-19 infection or transmission, as well as the impact of COVID-19 transmission on their personal and professional lives. This questionnaire was adapted from a previous study [21]. The original instrument was used to investigate healthcare workers’ perceptions of risk and preventive measures for SARS. ‏To use the original instrument (English version), a permission letter was obtained from the corresponding author of the previous study [21]. The validity and reliability of the original instrument are documented in the study held at the time [21]. Thereafter, the researchers of this study modified the original instrument to render it relevant to the COVID-19transmission and applicable to the context of Saudi Arabia.

Generalized anxiety disorder-2 items (GAD-2) scale was used to identify the anxiety among the participants [22]. GAD-2 is a very brief screening scale for assessing generalized anxiety disorder. The scale has also been used in several clinical research studies to screen three other common anxiety disorders, including panic disorder, social anxiety disorder, and posttraumatic stress disorder. The validity and reliability of the original English version of the GAD-2 scale were documented [22, 23]. The participants in this study were required to answer two items in this survey: “Over the last 2 weeks, how often have you been bothered by the following problems?”: 1) “Feeling nervous, anxious or on edge” and 2) “Not being able to stop or control worrying”. The two questions were answered via ‘multiple choice’ options which were as follows: (0=not at all), (1=several days), (2=more than half days), and (3=nearly every day). The total score of GAD-2 scale ranges from 0 (no anxiety) to 6 (severe anxiety). Using a cut-off of 3 (out of 6) for GAD-2 has been documented in previous studies to have very good sensitivity (86%) and specificity (83%) for diagnosing the GAD [22, 23].

Prior to conducting this study, official Institute of Review Board (IRB) permission was obtained from the ethical research committee at College of Nursing, Taibah University, Saudi Arabia, (approval number: Nursing-2020-014). Moreover, official permission was obtained from the Clinical Health Research Committee of the North Western region of Ministry of Health (via Medina city branch) in order to recruit and facilitate collecting data from the nurses at the selected departments in the governmental hospitals. The participants were informed that their participation in this study would be entirely voluntary, their personal information would be anonymous and confidential, and they could stop completing the survey at any time or not submit the online survey if they refused to participate in the study.

The authors of this study and two expert clinical health researchers checked the validity, clarity, and feasibility of the instruments that were used in this study. English language editors checked and verified the clarity, structure and grammar of the instrument. Moreover, a pilot study was conducted by recruiting 30 nurses from the selected hospitals to verify the reliability and clarity of the online survey used in this study. The findings of the pilot study showed very good internal consistency and reliability (Cronbach’s alpha=0.87). Moreover, the clarity of the questionnaire and ease of participation via the online Google Form were noted. Data collected from the pilot participants was excluded from the final statistical analysis of the current study.

For data analysis, the Statistical Package for the Social Sciences (SPSS) software program was used. Frequency and descriptive statistics were used to describe the participants’ socio-demographic data and work characteristics. Spearman’s correlation analysis was used to determine the association between the participants’ GAD and the following factors: demographical and work characteristics, participants’ exposure to patients with COVID-19 diagnosis, participants’ perception regarding their exposure to COVID-19 and risk to contract COVID-19, impact of the COVID-19 transmission on personal life and work, and participants’ measures and coping mechanisms to prevent transmission of COVID-19. Participants’ perceptions of variables (regarding the risks of COVID-19 disease), which may increase GAD rating, were gauged via multiple choice responses: “1=strongly disagree”, “2=disagree”, “3=not sure disagree/ agree”, “4= agree”, and “5=strongly agree”. While, participants’ perceptions of variables regarding the risks of COVID-19 disease and their measures and coping mechanisms to prevent the transmission of COVID-19 variables that may reduce the participants’ GAD level (for example “I am confident my employer will look after my medical needs if I were to fall ill with COVID-19”) were reversed coded to “5=strongly disagree”, “4=disagree”, “3=not sure disagree/ agree”, “2= agree”, and “1=strongly agree”. These variables (with reversed coded responses) were identified by adding a star (*) at end of the sentences in tables of results. Also, Spearman’s correlation analysis was used to identify any relationship between the preventive measures taken by participants and coping mechanisms to reduce the risk ofCOVID-19 infection to themselves, their friends and families. A p value of < 0.05 will be used to be a statistical significant test. After running these correlation tests, only the significant associated factors were reported in correlation table.

The response rate for participating in this study was high (86.3%) with 345 candidates participating in the questionnaire out of a total of 400 invitations. The majority of the participants were females (67.0%), married (65.2%), Saudis (45.2%), over 30 years old (62.6%), living with their families in a house/apartment (65.2%), and had more than 10 years experiences as a staff nurse. Most participants (30.4%) worked in Intensive Care Units (ICUs) (Table 1).

The majority of the participants (61.8%) were directly exposed to or gave care to between one to five patients with COVID-19. Moreover, most participants (66.9%) were exposed daily to COVID-19 patients (Table 2).

The majority of the participants perceived that they were most likely at risk of contracting COVID-19 from close contact with infected patients (75.7%) or through close contact with colleagues exposed to COVID-19 patients (65.2%). Regarding the risk of contracting COVID-19, most of the participants believed that their jobs put them at great risk of exposure to COVID-19 (73.0%). Over half said they were afraid of falling ill with COVID-19 (56.5%) and that their families believed that they were at high risk of getting COVID-19 (66.1%). Moreover, about two-thirds of the participants believed that the people closest to them (e.g. spouses/partners, family members, and friends) were: at high risk of getting COVID-19 because of their job (60.9%), worried for their health (66.1%), and worried they themselves might get infected through interaction with the participants (60.0%). Most participants were concerned about passing COVID-19 to their family members (65.2%), close friends (55.7%), and work colleagues (55.7%). When the participants were asked about the impact of COVID-19 transmission on their personal and professional lives, most participants said they were afraid of telling their families about the risk that they were exposed to in the workplace (54.8%).

Roughly half of all participants felt appreciated by their hospital/clinic/employer (51.3%), the society at large (55.7%). Over half of the participants felt that there was adequate staff at their workplace to handle the different demands (56.5%), however, they felt more stressed at work (51.3%) (Table 3).

Regarding the measures and coping mechanisms that had been used by the participants to prevent the spread of COVID-19 to themselves and others, most of the participants said that they were: getting information as much as possible about COVID-19 (81.7%), taking nutritional supplements, and vitamins (73.0%), adhering to protocols and recommended measures (77.4%), trying not to think too much about the risks (65.2%), keeping their mind positive and convincing themselves that they won’t contract COVID-19 (73.9%), avoiding crowded places (84.3%), avoiding colleagues who may be exposed to COVID-19 (68.7%), or practicing exercises regularly (73.0%). Most participants were changing out of work clothes before going home (73.0%), showering before going home (54.8%), or temporarily staying away from home altogether, in alternative housing (53.9%) to prevent passing COVID-19 to their families or others (Table 4).

The majority of the participants (67.0%) strongly agreed or agreed that a COVID-19 vaccine would protect them from COVID-19 infection in the future. However, most participants (44.9%) also strongly agreed or agreed that receiving a vaccine in the future would put them at high risk for contracting other secondary diseases (such as CVD, stroke, respiratory problems), as a resultant complication of a COVID-19 vaccine. Accordingly, most of the participants (42.3%) strongly disagreed or disagreed that they would be willing to receive a COVID-19 vaccine in the future (in the case that it would be offered voluntarily) (Table 4).

Over one-third of the participants said that they were bothered by “feeling nervous, anxious or on edge” with experiencing these feelings for several days (38.8%), and for more than half the days (31.5%), over the last 2 weeks. Moreover, about 11% were bothered by “feeling nervous, anxious or on edge” nearly every day over the last 2 weeks. Moreover, the participants said that they were bothered by “not being able to stop or control worrying” for more than half the days (31.5%), several days (26.2%), nearly every day (18.6%) over the last two weeks. Using a cut-off point of (3 out of 6) for GAD-2 scale, more than half of the participants (56.5%) were classified to have generalized anxiety disorder. During stressful life events, most of the participants (53.9%) were taking the following actions nearly every day: avoid letting themselves get upset when they think about it or reminded of it (53.9%), and tried to remove it from their memory (42.6%) to avoid getting stressed (Table 5).

Spearman’s correlation analyses showed a very weak significant correlation between participants’ anxiety level (GAD) and the male gender (r=0.1, p=0.04). Also, there was data to suggest moderate significant correlation between participants’ anxiety level (GAD) and nursing experience (r=0.41, p=0.02), and number of children that the participants have (r=0.35, p=0.03). Also, moderate significant correlation was found between participants’ anxiety level and participants’ perception regarding the risks of COVID-19 variables including participants’ worries about the risk of transmit the COVID-19 to those people closest them (r=0. 53, p=0.02), participants’ concern about passing COVID-19 to those people closest to them (r=0. 51, p=0.02), and the impact of COVID-19 transmission on the participants’ personal life and work (r=0. 68, p=0.01). Moreover, moderate significant correlation between participants’ anxiety level and participants’ measures and coping mechanisms to prevent the transmission of COVID-19 variables including participants’ coping mechanisms with the risk of getting COVID-19(r=0. 47, p=0.02), and participants’ measures for preventing me from passing COVID-19 to others(r=0. 38, p=0.04). Moreover, the correlation test showed strong significant correlation between participants’ anxiety level (generalized anxiety disorder) and participants’ exposure to patients with COVID-19 diagnosis variables (Table 6).

Implementing the basic standard precautions (e.g., hand hygiene and wearing N95 mask and face shields or eye goggles), as well as implementing of additional measures for those healthcare workers in isolation hospitals/departments are considered the most important measures, which are needed to protect them and their families from COVID-19 infection. Recommended standard precautions, and policies must be followed by the healthcare providers. Personal protective equipment (PPEs) must be available when caring for patients in health facilities to reduce transmission of infection, and these precautions should be part of practice for all patients at all levels, regardless of whether they have infectious diseases (including COVID-19) or not. Available literature shows that these preventive measures are essential and have significant contributions to protecting the nursing and healthcare staff from the transmission of COVID-19 infection, which also positively leads to reducing their distress and anxiety [6, 38, 39]. The World Health Organization advised healthcare workers to get enough rest between shifts and after working hours, eat healthy nutrition, stop smoking, and practice exercises in order to take care of their health, enhance their immunity and prevent COVID-19 infection. During the pandemic, due to their working conditions and high risk of having COVID-19 infection, healthcare workers are advised to communicate with their families and friends, using indirect contact methods such as the phone and social media [6, 38]. Furthermore, conducting continuing health educational programs and workshops for nursing and healthcare staff about the characteristics, preventive measurement, and treatment of COVID-19 are essential to enhance health professionals’ knowledge, self-confidence, and practices for preventing the transmission of COVID-19 among healthcare workers and their families and friends. These educational programs should include the correct skills for hand hygiene and donning and removing of all PPEs, as well as provide information about the benefits of taking a COVID-19 vaccine. Implementation of such educational programs and preventive measures consequently will reduce their worries, distress, and anxiety [6, 38, 39]. Literature showed that a high frequency of nurses had moderate to severe anxiety levels during the COVID-19 pandemic, which negatively affected the nurses quality of life and nurses care on the job while increasing their level of burnout. Therefore, nursing managers must pay attention to their nursing staff’s psychosocial condition and identify the related factors that may increase the anxiety level and intervene to stabilize the nursing staff. Also, the nursing managers and head-nurses should encourage the nursing staff to discuss their feelings of anxiety with their colleagues. Moreover, interventional strategies, including providing health educational programs, additional training and psychosocial counseling, conducting small groups team meetings, hiring highly qualified nurses, should be encouraged to reduce the nursing staff’s anxiety and improve the team work environment [14, 32].

To the authors’ knowledge, this study is the first study in Saudi Arabia that was conducted to investigate the impact of COVID-19 transmission on nurses’ work and psychosocial health, the associated factors for nurses’ anxiety and their coping mechanisms to prevent COVID-19. Therefore, this study will provide a baseline of information and useful data for developing clinical guidelines for nurses in Saudi Arabia and other Arab countries, for preventing respiratory infectious diseases such as COVID-19, and how to cope with similar infectious diseases in the future.

Despite several strengths of this study, using cross-sectional design limits the studies ability to determine the effectiveness and causality of the relationship between the variables in this study. Moreover, the results of this study cannot be fully representative of all nurses in Saudi Arabia due to the natural limitations of the convenience sampling method. Further experimental and longitudinal research and recruiting nurses and other healthcare providers are suggested.