Prolonged COVID 19 Outbreak and Psychological Response of Nurses in Italian Healthcare System: Cross-Sectional Study

For nursing students

Study summary

This Italian study looked at how nurses' mental health changed over the first six months of the COVID-19 pandemic. Researchers at the University of L'Aquila assessed 69 female nurses aged 22 to 64 (average age 37.3) at two points in time: March 2020, right as the outbreak began, and September 2020, after months of sustained exposure. Just over half of the nurses (55%) worked directly with confirmed COVID-19 patients ("frontline"), while the rest worked with other infectious patients but not confirmed COVID-19 cases ("secondline"). Instead of an online survey, nurses came in for in-person clinical psychology sessions using four standard tools: the DASS-21 for anxiety, the IES-R for post-traumatic stress symptoms, the PDEQ for peritraumatic dissociation (feeling detached or unreal during a threatening event), and the BFI-10, a short personality inventory covering traits like openness, extraversion, and agreeableness.

The results show a mental health picture that got worse, not better, as the pandemic dragged on. In March 2020, about 77% of nurses already reported anxiety symptoms, just over half (52.6%) scored in the probable-PTSD range on the IES-R, and 55% showed significant peritraumatic dissociation. By September 2020, after roughly six months of ongoing pandemic work, nearly all nurses reported anxiety (87% at the extremely severe level), 61.2% scored in the probable-PTSD range, and 61% showed significant dissociation. In other words, distress did not fade with time or adaptation; it stayed high and, on several measures, increased.

The researchers also looked at who was most affected and why. In the early phase, younger nurses and those who were single reported significantly higher anxiety and PTSD scores than older or married colleagues. By the later phase, nurses working in northern Italy, which was hit earlier and harder by the pandemic, showed notably worse outcomes than nurses in southern regions. Anxiety scores were also correlated with dissociation and PTSD scores, meaning nurses who felt more anxious were also more likely to report feeling dissociated during stressful events and to show post-traumatic stress symptoms. The authors also reported a positive association between anxiety and the agreeableness personality trait, though this relationship was described as modest.

One of the more interesting findings involves personality. In March 2020, personality traits did not appear to protect nurses from distress; the acute shock of the outbreak overwhelmed any buffering effect individual traits might normally provide. But by September 2020, personality traits started to function as protective, or mediating, factors. Specifically, nurses who scored higher on openness reported fewer intrusive thoughts (unwanted memories or images related to the trauma), and nurses who scored higher on extraversion reported less avoidance behaviour and less hyperarousal (feeling constantly on edge). This suggests that over a longer, sustained crisis, personal characteristics can become a resource that helps some nurses cope better than others, even though the overall level of distress in the group remained high.

For nursing students and future clinicians, this study is a reminder that psychological strain during a prolonged public health emergency is not something nurses simply "get used to." The data suggest the opposite: distress can build over months rather than resolve. It also highlights that individual differences, such as personality traits, single status, age, and regional exposure to the outbreak, all shape how much a nurse suffers psychologically, which means support programs probably should not be one-size-fits-all. Because this was a small, single-country, all-female sample assessed at only two time points without a pre-pandemic baseline, the findings should be read as a signal for further research and workplace mental health planning rather than as a definitive, generalizable rule about all nurses everywhere. Still, the pattern of rising distress over six months, combined with emerging personality-based coping differences, gives Canadian nursing educators and administrators a concrete, source-grounded reason to build early and ongoing mental health check-ins into pandemic and disaster response planning for staff, rather than assuming resilience will develop naturally with time.

For educators

Teaching and appraisal notes

This cross-sectional study by Ranieri and colleagues (Frontiers in Psychology, 2021) examined posttraumatic stress risk and the role of personality traits among 69 female nurses at the University of L'Aquila healthcare system, assessed at two time points: March 2020 (acute outbreak onset) and September 2020 (approximately six months into the pandemic). Fifty-five percent of the sample worked directly with confirmed COVID-19 patients (frontline), while 45% worked with other infectious patients without confirmed COVID-19 status (secondline). Assessment used a validated battery administered in a traditional clinical psychology laboratory setting rather than online screening: the DASS-21 (anxiety), IES-R (post-traumatic stress symptoms), PDEQ (peritraumatic dissociation), and BFI-10 (Big Five personality traits).

The core finding useful for classroom discussion is the trajectory of distress over time. Anxiety symptoms rose from 77.3% of the sample in March 2020 to near-universal prevalence by September 2020 (87% extremely severe), probable PTSD rose from 52.6% to 61.2%, and significant peritraumatic dissociation rose from 55% to 61%. This runs counter to a simple habituation or adaptation hypothesis; distress did not resolve with prolonged exposure, it intensified. ANOVA analyses in the early phase identified younger age and single marital status as associated with higher anxiety and PTSD scores. In the later phase, geographic exposure mattered: nurses in northern Italy (which experienced the earlier, more severe wave) showed significantly worse outcomes than those in southern regions (large effect sizes, Cohen's d approximately 1.38–1.42). Spearman correlations confirmed a robust relationship between anxiety and both dissociation and PTSD symptoms, and a positive but more modest association between anxiety and agreeableness.

The personality findings are the study's most pedagogically interesting contribution. In the acute phase, personality traits did not buffer distress; the shock of outbreak onset appeared to overwhelm individual coping resources uniformly. By the prolonged phase, however, openness was negatively associated with intrusive thoughts and extraversion was negatively associated with avoidance and hyperarousal, suggesting personality-based coping resources emerge or become detectable only once an acute crisis stabilizes into a chronic stressor. This is a useful discussion point for students studying stress-vulnerability and resilience models: protective factors are not static, and their measurable effect may depend on the phase of a crisis.

For appraisal purposes, instructors should highlight several methodological constraints the authors themselves acknowledge or that are evident from the design: a small sample (n=69) drawn from a single Italian university health system limits generalizability; the sample was exclusively female, so findings cannot be assumed to apply to male nurses; only two time points were assessed with no pre-pandemic baseline, limiting causal claims about trajectory; the battery, while validated, was described by the authors as brief; and the cross-sectional, correlational design cannot establish that personality traits caused the observed differences in symptom trajectory. Discussion should also address the ANOVA and correlation strength (some p-values, such as the anxiety-agreeableness association, are only modestly significant), reinforcing the importance of distinguishing between statistical significance and clinically large effects in student journal-club exercises. This study is well suited to seminars on occupational mental health, disaster nursing, personality and stress-vulnerability frameworks, and critical appraisal of small cross-sectional designs conducted under crisis conditions where recruitment and follow-up options are constrained.