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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Symptom Cluster of ICU nurses treating COVID-19 pneumonia patients in Wuhan, China</title><author><name sortKey="Yifan, Tang" sort="Yifan, Tang" uniqKey="Yifan T" first="Tang" last="Yifan">Tang Yifan</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Ying, Liu" sort="Ying, Liu" uniqKey="Ying L" first="Liu" last="Ying">Liu Ying</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Chunhong, Gao" sort="Chunhong, Gao" uniqKey="Chunhong G" first="Gao" last="Chunhong">Gao Chunhong</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Jing, Song" sort="Jing, Song" uniqKey="Jing S" first="Song" last="Jing">Song Jing</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Rong, Wang" sort="Rong, Wang" uniqKey="Rong W" first="Wang" last="Rong">Wang Rong</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Zhenyu, Li" sort="Zhenyu, Li" uniqKey="Zhenyu L" first="Li" last="Zhenyu">Li Zhenyu</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Zejuan, Gu" sort="Zejuan, Gu" uniqKey="Zejuan G" first="Gu" last="Zejuan">Gu Zejuan</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Peihung, Liao" sort="Peihung, Liao" uniqKey="Peihung L" first="Liao" last="Peihung">Liao Peihung</name><affiliation><nlm:aff id="aff2">Assistant professor, National Taipei University of Nursing and Health sciences. Taipei. Taiwan</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">32276095</idno><idno type="pmc">7141465</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141465</idno><idno type="RBID">PMC:7141465</idno><idno type="doi">10.1016/j.jpainsymman.2020.03.039</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000751</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000751</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Symptom Cluster of ICU nurses treating COVID-19 pneumonia patients in Wuhan, China</title><author><name sortKey="Yifan, Tang" sort="Yifan, Tang" uniqKey="Yifan T" first="Tang" last="Yifan">Tang Yifan</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Ying, Liu" sort="Ying, Liu" uniqKey="Ying L" first="Liu" last="Ying">Liu Ying</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Chunhong, Gao" sort="Chunhong, Gao" uniqKey="Chunhong G" first="Gao" last="Chunhong">Gao Chunhong</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Jing, Song" sort="Jing, Song" uniqKey="Jing S" first="Song" last="Jing">Song Jing</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Rong, Wang" sort="Rong, Wang" uniqKey="Rong W" first="Wang" last="Rong">Wang Rong</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Zhenyu, Li" sort="Zhenyu, Li" uniqKey="Zhenyu L" first="Li" last="Zhenyu">Li Zhenyu</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Zejuan, Gu" sort="Zejuan, Gu" uniqKey="Zejuan G" first="Gu" last="Zejuan">Gu Zejuan</name><affiliation><nlm:aff id="aff1">The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</nlm:aff></affiliation></author><author><name sortKey="Peihung, Liao" sort="Peihung, Liao" uniqKey="Peihung L" first="Liao" last="Peihung">Liao Peihung</name><affiliation><nlm:aff id="aff2">Assistant professor, National Taipei University of Nursing and Health sciences. Taipei. Taiwan</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Pain and Symptom Management</title><idno type="ISSN">0885-3924</idno><idno type="eISSN">1873-6513</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Objective</title><p>In treating highly infectious COVID-19 pneumonia, ICU nurses face a high risk of developing somatic symptom disorder (SSD). The present study aims to investigate the symptoms and causes of SSD of ICU nurses treating COVID-19 pneumonia. The research results are expected to provide evidence for the establishment of a better management strategy.</p></sec><sec><title>Methods</title><p>This study enrolled a total of 140 ICU nurses who were selected by Jiangsu Province Hospital to work in Wuhan (the epicenter of the COVID-19 epidemic in China) on 3<sup>rd</sup> February 2020. A questionnaire “Somatic Symptom Disorders for ICU Nurses in Wuhan No.1 Hospital” was designed based on the “International Classification of Functioning, Disability and Health” (ICF). Exploratory factor analysis was performed to cluster the symptoms, and logistic regression analysis to find the risk factors of the symptoms.</p></sec><sec><title>Results</title><p>Five major symptoms were chest-discomfort-and-palpitation (31.4%), dyspnea (30.7%), nausea (21.4%), headache (19.3%), and dizziness (17.9%). In exploratory factor analysis, the symptoms were classified into three clusters: Cluster A of breathing and sleep disturbances (dizziness, sleepiness, dyspnea); Cluster B of gastrointestinal complaints and pain (nausea, headache), and Cluster C of general symptoms (xerostomia, fatigue, chest-discomfort-and-palpitation). In Cluster A, urine/feces splash, sex, and sputum splash were independent predictive factors. In Cluster B, fall of protective glasses and urine/feces splash were independent predictive factors. In Cluster C, urine/feces splash and urine/feces clearance were independent predictive factors.</p></sec><sec><title>Conclusion</title><p>The ICU nurses in Wuhan showed varying and overlapping SSDs. These SSDs could be classified into three symptom clusters. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Pain Symptom Manage</journal-id><journal-id journal-id-type="iso-abbrev">J Pain Symptom Manage</journal-id><journal-title-group><journal-title>Journal of Pain and Symptom Management</journal-title></journal-title-group><issn pub-type="ppub">0885-3924</issn><issn pub-type="epub">1873-6513</issn><publisher><publisher-name>American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32276095</article-id><article-id pub-id-type="pmc">7141465</article-id><article-id pub-id-type="publisher-id">S0885-3924(20)30192-5</article-id><article-id pub-id-type="doi">10.1016/j.jpainsymman.2020.03.039</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Symptom Cluster of ICU nurses treating COVID-19 pneumonia patients in Wuhan, China</article-title></title-group><contrib-group><contrib contrib-type="author" id="au1"><name><surname>Yifan</surname><given-names>Tang</given-names></name><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author" id="au2"><name><surname>Ying</surname><given-names>Liu</given-names></name><xref rid="aff1" ref-type="aff">1</xref><xref rid="fn1" ref-type="fn">∗</xref></contrib><contrib contrib-type="author" id="au3"><name><surname>Chunhong</surname><given-names>Gao</given-names></name><email>2428813461@qq.com</email><xref rid="aff1" ref-type="aff">1</xref><xref rid="cor1" ref-type="corresp">#</xref></contrib><contrib contrib-type="author" id="au4"><name><surname>Jing</surname><given-names>Song</given-names></name><email>2428813461@qq.com</email><xref rid="aff1" ref-type="aff">1</xref><xref rid="cor1" ref-type="corresp">#</xref></contrib><contrib contrib-type="author" id="au5"><name><surname>Rong</surname><given-names>Wang</given-names></name><email>2428813461@qq.com</email><xref rid="aff1" ref-type="aff">1</xref><xref rid="cor1" ref-type="corresp">#</xref></contrib><contrib contrib-type="author" id="au6"><name><surname>Zhenyu</surname><given-names>Li</given-names></name><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author" id="au7"><name><surname>Zejuan</surname><given-names>Gu</given-names></name><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author" id="au8"><name><surname>Peihung</surname><given-names>Liao</given-names></name><xref rid="aff2" ref-type="aff">2</xref></contrib></contrib-group><aff id="aff1"><label>1</label>The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiang Province, 210029, P.R. China</aff><aff id="aff2"><label>2</label>Assistant professor, National Taipei University of Nursing and Health sciences. Taipei. Taiwan</aff><author-notes><corresp id="cor1"><label>#</label>Corresponding author: Mrs Wang Rong, Department of Nursing, The First Hospital Affiliated with Nanjing Medical University, Nanjing, Jiangsu, PR China, 210029. . Tel: 15251756536 <email>2428813461@qq.com</email><email>2428813461@qq.com</email><email>2428813461@qq.com</email></corresp><fn id="fn1"><label>∗</label><p id="ntpara0015">These authors contributed equally to this study.</p></fn></author-notes><pub-date pub-type="pmc-release"><day>8</day><month>4</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>8</day><month>4</month><year>2020</year></pub-date><history><date date-type="received"><day>24</day><month>3</month><year>2020</year></date><date date-type="rev-recd"><day>29</day><month>3</month><year>2020</year></date><date date-type="accepted"><day>30</day><month>3</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder>American Academy of Hospice and Palliative Medicine</copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0010"><sec><title>Objective</title><p>In treating highly infectious COVID-19 pneumonia, ICU nurses face a high risk of developing somatic symptom disorder (SSD). The present study aims to investigate the symptoms and causes of SSD of ICU nurses treating COVID-19 pneumonia. The research results are expected to provide evidence for the establishment of a better management strategy.</p></sec><sec><title>Methods</title><p>This study enrolled a total of 140 ICU nurses who were selected by Jiangsu Province Hospital to work in Wuhan (the epicenter of the COVID-19 epidemic in China) on 3<sup>rd</sup> February 2020. A questionnaire “Somatic Symptom Disorders for ICU Nurses in Wuhan No.1 Hospital” was designed based on the “International Classification of Functioning, Disability and Health” (ICF). Exploratory factor analysis was performed to cluster the symptoms, and logistic regression analysis to find the risk factors of the symptoms.</p></sec><sec><title>Results</title><p>Five major symptoms were chest-discomfort-and-palpitation (31.4%), dyspnea (30.7%), nausea (21.4%), headache (19.3%), and dizziness (17.9%). In exploratory factor analysis, the symptoms were classified into three clusters: Cluster A of breathing and sleep disturbances (dizziness, sleepiness, dyspnea); Cluster B of gastrointestinal complaints and pain (nausea, headache), and Cluster C of general symptoms (xerostomia, fatigue, chest-discomfort-and-palpitation). In Cluster A, urine/feces splash, sex, and sputum splash were independent predictive factors. In Cluster B, fall of protective glasses and urine/feces splash were independent predictive factors. In Cluster C, urine/feces splash and urine/feces clearance were independent predictive factors.</p></sec><sec><title>Conclusion</title><p>The ICU nurses in Wuhan showed varying and overlapping SSDs. These SSDs could be classified into three symptom clusters. Based on the characteristics of their SSDs, specific interventions could be implemented to safeguard the health of ICU nurses.</p></sec></abstract><kwd-group id="kwrds0010"><title>Key words</title><kwd>COVID-19</kwd><kwd>Intensive Care Units</kwd><kwd>Symptom Cluster</kwd><kwd>Symptoms</kwd><kwd>Occupational exposure</kwd></kwd-group></article-meta></front><body><sec id="sec1"><title>Introduction</title><p id="p0010">COVID-19 pneumonia has been listed Category B infectious disease and is being treated in a category similar to that of Category A by the National Health Commission of China. A large proportion of COVID-19 patients will progress to a critical condition which needs intensive care. However, given the challenges in treating this disease, ICU nurses are highly prone to somatic symptom disorder (SSD) which is associated with the interaction of biology, cognition, emotion, behavior and environment<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref>. The ICU nurses must manage a heavy workload requiring frequent invasive procedures and high attention levels. Therefore, safeguarding the physical and psychological health of ICU nurses can provide a major contribution to the success of epidemic control <xref rid="bib2" ref-type="bibr"><sup>2</sup></xref><sup>,</sup><xref rid="bib3" ref-type="bibr"><sup>3</sup></xref>. A symptom cluster is a stable group of two or more co-existing symptoms. The symptom clusters in one population may show overlaps and interactions, a phenomenon that should be resolved to improve the efficiency of managing the disorder <xref rid="bib4" ref-type="bibr"><sup>4</sup></xref><sup>,</sup><xref rid="bib5" ref-type="bibr"><sup>5</sup></xref>. Currently, no study has investigated SSDs in ICU nurses fighting at the frontline against the COVID-19 epidemic. Previous studies have confirmed that an individual’s response to SSD is dependent on physical, emotional and social factors <xref rid="bib6" ref-type="bibr"><sup>6</sup></xref>. This study aims to analyze SSDs and associated risk factors in 140 ICU nurses who were sent by Jiangsu Province Hospital to No.1 Hospital of Wuhan, the epicenter of COVID-19 epidemic.</p></sec><sec id="sec2"><title>Methods</title><sec id="sec2.1"><title>Sample</title><p id="p0015">A total of 140 nurses at COVID-19 pneumonia ICUs were selected through convenience sampling. Inclusion criteria: (1) Employed as a full-time nurse at Jiangsu Province Hospital; (2) Aged 20-50 years; (3) Has worked at an ICU for serious/critical COVID-19 pneumonia patients in Wuhan; (4) Presented informed consent. Exclusion criteria: (1) No experience in an ICU in Wuhan; (2) Lactation.</p></sec><sec id="sec2.2"><title>The Symptom Scale</title><p id="p0020">A questionnaire “Somatic Symptom Disorders for ICU Nurses in Wuhan No.1 Hospital” was designed based on “International Classification of Functioning, Disability and Health” (ICF) <xref rid="bib7" ref-type="bibr"><sup>7</sup></xref>. The questions were set out during an expert meeting attended by team leaders, rehabilitation therapists, psychologists, and ICU nurses. Twelve second-level ICF categories were selected from the component of “Body Function” in ICF (<xref rid="tbl1" ref-type="table">Table 1</xref>). At this step, standardized ICF-linking rules were used <xref rid="bib8" ref-type="bibr"><sup>8</sup></xref>. Finally, a list of ICF categories was compiled that was intended to cover 16 symptoms that ICU nurses could reasonably have experienced when treating COVID-19 pneumonia patients in Wuhan, China (<xref rid="tbl1" ref-type="table">Table 1</xref>). The frequency and severity of each symptom were scaled (0, no; 1, mild; 2, moderate; 3, severe).<table-wrap position="float" id="tbl1"><label>Table 1</label><caption><p>ICF Categories and symptoms</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Symptom</th><th>ICF categories</th></tr></thead><tbody><tr><td>sleepiness</td><td>b134-Sleep functions</td></tr><tr><td>dry eyes</td><td>b220-Sensations associated with seeing and adjacent structure function</td></tr><tr><td>dizziness</td><td>b240-Sensation associated with hearing and vestibular functions</td></tr><tr><td>stomachache</td><td rowspan="4">b280-Sensation of pain</td></tr><tr><td>headache</td></tr><tr><td>waist pain</td></tr><tr><td>neck pain</td></tr><tr><td>dyspnea</td><td>b440-Respiration functions</td></tr><tr><td>cough</td><td>b450-Additional respiratory functions</td></tr><tr><td>fatigue</td><td>b455-Exercise tolerance functions</td></tr><tr><td>chest-discomfort-and-palpitation</td><td>b460-Sensations associated with cardiovascular and respiratory functions</td></tr><tr><td>emesis</td><td>b510-Ingestion functions</td></tr><tr><td>diarrhea</td><td>b525-Defecation functions</td></tr><tr><td>nausea</td><td>b535-Sensations associated with the digestive system</td></tr><tr><td>xerostomia</td><td rowspan="2">b545-Water, mineral and electrolyte balance functions</td></tr><tr><td>sweating</td></tr></tbody></table></table-wrap></p><p id="p0025">Another questionnaire was designed to evaluate the possible risk factors. Included in this questionnaire were three datasets: demographic data (sex, age, educational background, marriage, etc.), career data (working years, working years in a particular department, previous in-hospital rotation, title, position, technical level, etc.), and data about ICU work in Wuhan (frequency and time in ICU, extra work, exposure to contaminants and treatment, invasive procedures, etc.).</p></sec><sec id="sec2.3"><title>Procedures</title><p id="p0030">The questionnaires were handed out through WeChat, an online APP. Participants who met the study criteria logged onto a website (<ext-link ext-link-type="uri" xlink:href="http://www.wjx.cn" id="intref0010">http://www.wjx.cn</ext-link>) to complete the survey. The investigators informed the nurses of the details of the research. All the questionnaires were completed and returned (an efficiency of 100%) 5-7 days after the first group of ICU nurses started work in Wuhan The study was approved by the ethics committee of Jiangsu Province Hospital (2020-SR-101).</p></sec><sec id="sec2.4"><title>Data Analysis</title><p id="p0035">The data were analyzed with SPSS 25.0. Descriptive analysis was performed for the data on general characteristics and SSDs. Enumeration data were presented as frequencies and percentages, measurement data in normal distributions as mean±SD, and measurement data in skewed distributions as medians and interquartile ranges. Exploratory factor analysis was performed to assess the presence of correlations between particular types of symptoms which might reflect symptom complexes. To express the symptoms accurately, this study included the variables ranking in the top 10 in both frequency and severity. Factor loading was calculated through principal component analysis and rotation through varimax. The factors were selected according to the following criteria: (1) eigenvalue>1 (Kaiser criterion); (2) suitable for Cattell’s 16 Personality Factors Test; (3) containing at least two within factor variance; (4) having psychological implications; (5) loadings of 0.5 or higher. Logistic regression analysis was used to explain the interrelationships of symptom clusters and variables in three datasets (demographic data, career data, and data about ICU work), α=0.05.</p></sec></sec><sec id="sec3"><title>Results</title><sec id="sec3.1"><title>Sample Characteristics</title><p id="p0040">During one week (15-22 February 2020) after the nurses started the work in ICUs in Wuhan No.1 Hospital, 63 person-times of COVID-19 pneumonia cases were admitted, including 35 serious/critical cases (55.56%) and 3 deaths (4.76%). A total of 140 nurses were surveyed, including 118 females (84.3%), and 63 married nurses (45%). The mean age was 29.35±4.92 years (range 22-43 years). The nurses had worked for a mean of 7.03±5.44 years (range 1-23 years), and a mean of 3.66±3.70 years (range 1-18 years) in a particular department (such as ICU, emergency, respiratory department, infectious disease department). Other general data are shown in <xref rid="tbl2" ref-type="table">Table 2</xref>.<table-wrap position="float" id="tbl2"><label>Table 2</label><caption><p>General data of the nurses</p></caption><table frame="hsides" rules="groups"><thead><tr><th colspan="2"></th><th>Number</th><th>（%）</th></tr></thead><tbody><tr><td rowspan="3">Educational background</td><td>Junior college degree</td><td>30</td><td>21.4</td></tr><tr><td>Bachelor’s degree</td><td>109</td><td>77.9</td></tr><tr><td>Master’s degree</td><td>1</td><td>0.7</td></tr><tr><td rowspan="4">Title</td><td>Nurse</td><td>23</td><td>16.4</td></tr><tr><td>Senior nurse</td><td>81</td><td>57.9</td></tr><tr><td>Supervisor nurse</td><td>32</td><td>22.9</td></tr><tr><td>Co-chief superintendent nurse</td><td>4</td><td>2.9</td></tr><tr><td rowspan="2">Position</td><td>Nurse</td><td>136</td><td>97.1</td></tr><tr><td>Head nurse</td><td>4</td><td>2.9</td></tr><tr><td rowspan="4">Technical level</td><td>N0-N1</td><td>74</td><td>52.9</td></tr><tr><td>N2</td><td>36</td><td>25.7</td></tr><tr><td>N3</td><td>28</td><td>20</td></tr><tr><td>N4</td><td>2</td><td>1.4</td></tr><tr><td colspan="2">In-hospital rotation（x±s）</td><td colspan="2">2.14±1.38</td></tr></tbody></table></table-wrap></p></sec><sec id="sec3.2"><title>Scores of SSD symptoms</title><p id="p0045">Each nurse showed a median of 1.5 (mean 2.04±2.11) SSD symptoms and a median of 2 (3.88±6.13) symptom onsets. The 10 most frequent symptoms were chest-discomfort-and-palpitation (31.4%), dyspnea (30.7%), nausea (21.4%), headache (19.3%), dizziness (17.9%), xerostomia (15.7%), fatigue (15.0%), sleepiness (9.3%), sweating (8.6%), and waist pain (7.1%). The 10 most severe symptoms were dyspnea (0.74±1.17), chest-discomfort-and-palpitation (0.62±1.02), headache (0.40±0.90), fatigue (0.30±0.77), xerostomia (0.30±0.75), dizziness (0.29±0.71), nausea (0.29±0.61), sleepiness (0.19±0.66), dry eyes (0.14±0.56), and diarrhea (0.13±0.61).</p></sec><sec id="sec3.3"><title>Symptom clusters</title><p id="p0050">Exploratory factor analysis was performed based on eight SSDs, the frequency and severity of which both ranked in the top 10, including nausea, chest-discomfort-and-palpitation, dyspnea, sleepiness, dizziness, fatigue, xerostomia, and headache. KMO value of 0.694 and P<0.001 (Bartlett’s sphericity test) indicated these factors were suitable for factor analysis. The results showed three common factors (eigenvalue>1) explaining 55.75% of common variance. After rotation with varimax, the factor loadings were calculated, as shown by the matrix in <xref rid="tbl3" ref-type="table">Table 3</xref>. Finally, three symptom clusters were defined: Cluster A of breathing and sleep disturbances (dizziness, sleepiness, dyspnea); Cluster B of gastrointestinal complaints and pain (nausea, headache); and Cluster C of general symptoms (xerostomia, fatigue, chest-discomfort-and-palpitation). The score of each cluster was the total of each symptom score (<xref rid="tbl3" ref-type="table">Table 3</xref>).<table-wrap position="float" id="tbl3"><label>Table 3</label><caption><p>Symptom clusters of ICU nurses</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th>NO.1</th><th>NO.2</th><th>NO.3</th><th>Cluster score<break></break>（x±s）</th></tr></thead><tbody><tr><td>Dizziness</td><td>0.71</td><td>-</td><td>-</td><td rowspan="3">1.22±1.88</td></tr><tr><td>Sleepiness</td><td>0.68</td><td>-</td><td>-</td></tr><tr><td>Dyspnea</td><td>0.621</td><td>-</td><td>-</td></tr><tr><td>Nausea</td><td>-</td><td>0.819</td><td>-</td><td rowspan="2">0.69±1.17</td></tr><tr><td>Headache</td><td>-</td><td>0.596</td><td>-</td></tr><tr><td>Xerostomia</td><td>-</td><td>-</td><td>0.815</td><td rowspan="3">1.22±1.89</td></tr><tr><td>Fatigue</td><td>-</td><td>-</td><td>0.637</td></tr><tr><td>Chest-discomfort-and-palpitation</td><td>-</td><td>-</td><td>0.51</td></tr><tr><td>Explained variance (%)</td><td>21.75</td><td>17.1</td><td>16.91</td><td>-</td></tr></tbody></table></table-wrap></p></sec><sec id="sec3.4"><title>Risk factors of symptom clusters</title><p id="p0055"><xref rid="tbl4" ref-type="table">Table 4</xref>shows the 15 types of nursing operations and 11 types of exposure. A total of 599 person-times of invasive operations (4.28±7.49 times per person) and 46 person-times of body fluid/blood exposure (0.33±0.58 times per person) were reported. On average, one nurse accomplished 2.57±0.95 shifts of ICU work. A total of 16 nurses (11.4%) had taken on extra work.<table-wrap position="float" id="tbl4"><label>Table 4</label><caption><p>Nursing operations and types of exposure</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Operation</th><th>Person-times</th><th>Proportion</th><th>Exposure</th><th>Person-times</th><th>Proportion</th></tr></thead><tbody><tr><td>Endotracheal intubation</td><td>6</td><td>1.00</td><td>Fall of protective glasses</td><td>12</td><td>26.09</td></tr><tr><td>Deep vein catheterization</td><td>3</td><td>0.50</td><td>Fall of mask</td><td>4</td><td>8.70</td></tr><tr><td>Venous indwelling needle</td><td>26</td><td>4.34</td><td>Fall of shield</td><td>1</td><td>2.17</td></tr><tr><td>Artery indwelling needle</td><td>0</td><td>0.00</td><td>Glove fall</td><td>8</td><td>17.39</td></tr><tr><td>Open suction</td><td>21</td><td>3.51</td><td>Glove broken</td><td>8</td><td>17.39</td></tr><tr><td>Close suction</td><td>137</td><td>22.87</td><td>Protective garment broken</td><td>0</td><td>0.00</td></tr><tr><td>Clearing oral and nasal secretions</td><td>84</td><td>14.02</td><td>Protective garment contaminated</td><td>3</td><td>6.52</td></tr><tr><td>Replacing the instruments fixing the endotracheal tube</td><td>3</td><td>0.50</td><td>Blood splash</td><td>1</td><td>2.17</td></tr><tr><td>Sputum sample collection</td><td>16</td><td>2.67</td><td>Sputum splash</td><td>3</td><td>6.52</td></tr><tr><td>Blood sample collection</td><td>35</td><td>5.84</td><td>Urine/feces splash</td><td>1</td><td>2.17</td></tr><tr><td>Venous transfusion</td><td>91</td><td>15.19</td><td>Others</td><td>5</td><td>10.87</td></tr><tr><td>Venous injection</td><td>35</td><td>5.84</td><td></td><td></td><td></td></tr><tr><td>Urine/feces clearance</td><td>116</td><td>19.37</td><td></td><td></td><td></td></tr><tr><td>Corpse treatment</td><td>5</td><td>0.83</td><td></td><td></td><td></td></tr><tr><td>Others</td><td>19</td><td>3.17</td><td></td><td></td><td></td></tr></tbody></table></table-wrap></p><p id="p0060">Taking the occurrence of symptom clusters as a dependent variable and the factors in the three datasets as independent variables, the univariate Cox regression analysis showed that sex, sputum splash, urine/feces splash, and urine/feces clearance were risk factors for the occurrence of symptom clusters (P<0.05). Using these risk factors as independent variables and the occurrence of symptom clusters as a dependent variable, the multiple linear regression analysis showed that urine/feces splash, female, and sputum splash were independent predictive factors for Cluster A; fall of protective glasses and urine/feces splash were independent predictive factors of Cluster B; and urine/feces splash and urine/feces clearance were independent predictive factors for Cluster C (<xref rid="tbl5" ref-type="table">Table 5</xref>).<table-wrap position="float" id="tbl5"><label>Table 5</label><caption><p>Logistic regression analysis on the risk factors of three symptom clusters</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th>Variables</th><th>Regression coefficient</th><th>SE</th><th>Standardized regression coefficient</th><th>t</th><th>p</th></tr></thead><tbody><tr><td>Cluster A</td><td>（Constant）</td><td>1.924</td><td>0.755</td><td></td><td>2.55</td><td>0.012</td></tr><tr><td></td><td>Urine/feces splash</td><td>1.252</td><td>0.195</td><td>0.457</td><td>6.417</td><td>0.000</td></tr><tr><td></td><td>Sex</td><td>-0.82</td><td>0.397</td><td>-0.133</td><td>-2.063</td><td>0.041</td></tr><tr><td></td><td>Sputum splash</td><td>1.46</td><td>0.237</td><td>0.4</td><td>6.16</td><td>0.000</td></tr><tr><td></td><td colspan="6">R=0.669，F=27.306，P=0.000</td></tr><tr><td>Cluster B</td><td>（Constant）</td><td>0.41</td><td>0.092</td><td></td><td>4.475</td><td>0.000</td></tr><tr><td></td><td>Fall of protective glasses</td><td>0.55</td><td>0.266</td><td>0.153</td><td>2.066</td><td>0.041</td></tr><tr><td></td><td>Urine/feces splash</td><td>0.69</td><td>0.106</td><td>0.48</td><td>6.483</td><td>0.000</td></tr><tr><td></td><td colspan="6">R=0.789，F=27.547，P=0.000</td></tr><tr><td>Cluster C</td><td>Urine/feces splash</td><td>1.982</td><td>0.17</td><td>0.693</td><td>11.651</td><td>0.000</td></tr><tr><td></td><td>Urine/feces clearance</td><td>0.32</td><td>0.105</td><td>0.186</td><td>3.06</td><td>0.003</td></tr><tr><td></td><td colspan="6">R=0.789，F=31.097，P=0.000</td></tr></tbody></table></table-wrap></p></sec></sec><sec id="sec4"><title>Discussion</title><p id="p0065">On 30 January 2020, the World Health Organization (WHO) declared COVID-19 a “public health emergency of international concern”. The infection, with a route of human-to-human transmission, caused clusters of severe respiratory illness that was associated with ICU admission and high mortality <xref rid="bib9" ref-type="bibr"><sup>9</sup></xref>. China has quickly pooled medical personnel into Wuhan, the origin of the epidemic in China. A major workforce are ICU nurses, who are exposed to a broad range of mental and physical health disorders. Particular efforts to mitigate these challenges must be directed to the ICU nurses under the greatest workload <xref rid="bib9" ref-type="bibr"><sup>9</sup></xref>. By investigating the symptom clusters experienced by nurses and associated risk factors, a better management model may be developed to relieve the SSDs in ICU nurses <xref rid="bib10" ref-type="bibr"><sup>10</sup></xref>.</p><p id="p0070">We found that the ICU nurses reported symptoms which could be grouped into three symptom clusters and that the median number of symptoms in each nurse was 1.5. A night shift could be expected to lead to sleepiness and fatigue <xref rid="bib11" ref-type="bibr"><sup>11</sup></xref>. Previous studies have studied symptom clusters in patients with cancer or chronic disease <xref rid="bib10" ref-type="bibr"><sup>10</sup></xref><sup>,</sup><xref rid="bib12" ref-type="bibr"><sup>12</sup></xref>. The present study is the first to investigate symptom clusters in ICU nurses in an epidemic.</p><p id="p0075">Our study showed that dizziness, sleepiness and dyspnea co-occurred in Cluster A; headache and nausea in Cluster B; xerostomia, fatigue and chest-discomfort-and-palpitation in Cluster C. We confirmed that the occurrence of symptom clusters was caused by the environmental and personal stress disorder. For infection control, personal protective equipment (PPE), such as a fluid-resistant gown, gloves, eye protection, full face shield and fit-tested N95 respirators, should be worn <xref rid="bib13" ref-type="bibr"><sup>13</sup></xref>. However, accidental events when using this equipment, such as fall of protective glasses, may harm both the physical and mental health of nurses. In this study, we showed an association between PPE failure and symptom cluster B. It was previously reported that sleepiness coexisted with other symptoms in a single cluster <xref rid="bib14" ref-type="bibr"><sup>14</sup></xref>. Interventions, including physical exercise or cognitive behavioral therapy, could relieve the symptoms in the sleepiness-related cluster <xref rid="bib15" ref-type="bibr">15</xref>, <xref rid="bib16" ref-type="bibr">16</xref>, <xref rid="bib17" ref-type="bibr">17</xref>.</p><p id="p0080">In Wuhan, most ICU patients required high-flow nasal cannula or higher-level oxygen support to correct hypoxemia <xref rid="bib18" ref-type="bibr"><sup>18</sup></xref>. Nursing of critical patients included condition monitoring, sequential oxygen care, sequential treatment nursing, infection prevention, nutrition support, and psychological nursing <xref rid="bib19" ref-type="bibr"><sup>19</sup></xref>. In our study, 55.56% of patients were in critical condition. Our results showed that supervisor nurses had more exposures to infectious material and a heavier workload (4.28±7.49 invasive operations and 0.33±0.58 exposures per person).</p><p id="p0085">We identified urine/feces splash as an independent risk factor associated with the occurrence of all symptom clusters, which can be explained by three reasons. Firstly, patients’ excreta may create aerosols that can allow airborne transmission to those closely involved in the procedure <xref rid="bib12" ref-type="bibr"><sup>12</sup></xref>. Secondly, the fecal-oral route of transmission is possible <xref rid="bib20" ref-type="bibr"><sup>20</sup></xref>. Thirdly, the proportion of patients needing urine/feces clearance (116, 19.37%) was high, second only to that of closed sputum aspiration (137, 22.87%). Our finding suggested that it is important to develop standard procedures to prevent ICU nurses from urine/feces splash.</p><p id="p0090">We found that female was a significant factor associated with occurrence of the symptom cluster of breathing and sleep disturbances. Several previous studies showed that female nurses have a higher risk of daytime sleepiness than male nurses <xref rid="bib21" ref-type="bibr"><sup>21</sup></xref><sup>,</sup><xref rid="bib22" ref-type="bibr"><sup>22</sup></xref>. To mitigate this risk, care should be given to female ICU nurses if they suffer from daytime sleepiness.</p><p id="p0095">Finally, our results showed that fall of protective glasses was an independent risk factor for the occurrence of the pain symptom cluster. Blocking transmission is a leading strategy against COVID-19 <xref rid="bib23" ref-type="bibr"><sup>23</sup></xref>. This finding shows the importance of PPE. A nurse may develop adverse reactions caused by heavy PPE, including nausea and vomiting <xref rid="bib24" ref-type="bibr"><sup>24</sup></xref>. We suggest identifying infection control nurses as observers to monitor staff compliance with infection control guidance, give clarification and advice where appropriate and record significant issues relating to infection control procedures <xref rid="bib25" ref-type="bibr"><sup>25</sup></xref>.</p><sec id="sec4.1"><title>Limitations</title><p id="p0100">Our study has several limitations. First, only 140 nurses were included; the findings should be validated with studies covering more professionals. Second, other centers should be included to get a more comprehensive understanding.</p></sec></sec><sec id="sec5"><title>Conclusions</title><p id="p0105">The ICU nurses in Wuhan showed varying and overlapping SSDs. These SSDs could be classified into three symptom clusters. Based on the characteristics of their SSDs, specific interventions could be implemented to guarantee the health of ICU nurses. 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