Perceived stress factors
and coping strategies of COVID ward
nurses:Psychological impact of COVID 19
Sophia Vijayananthan1, Bharathy R2, Mary Jancy Joy3, Ilavarasi Jesudoss4
1Professor cum Nurse Manager and
Additional Deputy Nursing Superintendent College of Nursing, Christian Medical College, Vellore,
Tamil Nadu.
2Reader cum Nurse Manager College
of Nursing, Christian
Medical College, Vellore,
Tamil Nadu.
3Reader cum Nurse Manager College
of Nursing, Christian Medical College,
Vellore, Tamil Nadu.
4Professor cum Nurse Manager
and Deputy Nursing
Superintendent, College of Nursing, Christian Medical College, Vellore,
Tamil Nadu.
ABSTRACT:
The Corona Virus Disease 2019 (COVID-19) outbreak, which began in Wuhan, China in 2019, has now spread
to every corner of the globe. Nurses dealing with COVID patients, in
particular, are overburdened around the world.
Nurses have been forced to make unavoidable lifestyle adjustments due to
disruptions in their everyday work
routines and active changes in procedures and policies. This study aimed at
determining psychological impact of
COVID 19 pandemic (perceived stressors, stress reducing factors, coping
strategies) among nursing personnel
involved in caring patients with COVID 19. Nursing staff who had taken care of
patients with COVID 19 for minimum
period of two weeks completed the self-administered instrument. The data was
analyzed using descriptive and
inferential statistics. Inconvenience due to constant use of Personnel
Protective Equipment (PPE) (94 %)
and lock down restrictions (93 %), vaccine unavailability (90%), and
uncertainty of treatment steps were the
main sources of stress for the nurses (89 %). The majority of the nursing staff
(72%) was stressed about the risk of developing an infection and 75 % of the staff was concerned about the risk of transmitting COVID to their family members and friends.
Trusting GOD for protection, adhering to strict infection control measures and lockdown restrictions were all coping
strategies that helped them deal with the pandemic. More than 90% of nurses accepted that their coping
mechanisms included engaging in relaxation/diversional activities, maintaining a well-balanced diet and
getting adequate rest.
KEYWORDS: COVID
19, Psychological impact, stress factors, stress reducing factors, coping
strategies, nursing personnel.
INTRODUCTION:
The first case
of Corona virus disease 2019 in India was reported in the state of Kerala on January
30, 2020. Nurses
as front line workers encountered greater challenges in
caring patients with COVID 19 and lock down
restrictions. Major stress sources
included working in an isolated
environment, changing one's way of life,
concerns about personal protective
equipment, having inadequate nurses
in the unit, fear of being infected, physical and emotional exhaustion1.
The fear of being infected, fear of infecting family members, and the
discomfort caused by protective equipment were the key sources of stress among frontline
healthcare workers caring for COVID-19 patients2.
Survey done in Wuhan reveals that, among 994 medical and nursing staff, 36.9% had sub-threshold mental health disturbances, 34.4% had mild disturbances, 22.4% had moderate
disturbances, and 6.2% had severe disturbance in the immediate aftermath of the viral
epidemic.3
As a member of the COVID team nurses,
the investigator noticed that
nursing staff were under a lot of stress due to their
work load, COVID procedures, and the
fear of being infected and spreading them to their family members. As a result,
this cross-sectional descriptive research was conducted with
the following objectives to assess the psychological impact of the COVID
19 pandemic among nursing personnel involved
in caring for COVID 19 patients.
OBJECTIVES:
1.
To determine the
psychological impact of COVID 19 pandemic
(perceived stressors, stress reducing
factors, coping strategies) among
nursing personnel involved in caring
patients with COVID 19.
2.
To find an association
between selected demographic variables
and psychological impact ( perceived stressors, stress reducing factors, coping strategies) of COIVID 19 pandemic among nursing personnel
involved in caring for patients
with COVID 19
MATERIAL AND METHODS:
Design and sampling:
A descriptive
cross sectional study design was used in this
study. Staff nurses caring for COVID 19 patients in the Medical Nursing
Department of a Tertiary care hospital in south India with experience of caring for patients with COVID 19 for at least one week were included in the study. There were 84 nurses in all, selected
by simple random sampling technique from all
three shifts. The participants gave their informed
consent. They were given a self-administered questionnaire to complete.
Data collection instrument:
The study tool
was adapted from a tool created by Lee et al4
for hospital workers during the 2003 SARS epidemic, which was later updated and used by Imran Khalid et al (2012)5 under the name "MERS-CoV staff questionnaire."
With the authors' permission, the current study's
investigator modified this tool further to make it applicable to the current study's setting and population. The questionnaire was pilot tested on ten
nursing staff members, and no changes
were required. There were two sections to the instrument. Part A dealt
with the study
subjects'
demographic variables, while Part B included a
self-administered questionnaire with three sections
to assess the psychological
impact of COVID 19 on nursing staff caring
for COVID 19 patients.
The first
section evaluates 10 different possible factors that could have caused stress among the staff. The participants
have responded to the statements as per the severity of the stress factor (0=No stress; 1= Mild; 2=Moderate; 3=Severe). The content
validity index score of this section was 0.98.
The second
section of the tool has 12 factors that were
made available to the nursing staff, either directly
or indirectly, and would have helped reduce their stress. Each item was rated on a 4-point
scale (0=not at all effective; 1=mildly effective; 2=moderately effective; 3=Very
effective). The content validity index score of this section was 0.98.
Section third, consisting of 10 items is looking
at different personal coping
strategies that the staff could have used. Where the participants
rated the strategies from 0–4
(0=Never used 1=sometimes; 2=often; 3=Very often).
The content validity index score of this section was 0.96.
Data analysis:
The data was analyzed
using SPSS 23.0 statistics. Descriptive statistics were used to analyze
the demographic distribution, emotions, and motivating factors using frequency, proportions (percent), mean, and
standard deviations. To see whether there was an association between psychological impact and demographic variables, the Chi square
test was used.
RESULTS AND DISCUSSION:
Part A: Demographic
Characteristics of the nursing personnel
Table 1: Distribution of subjects based on demographic variables
|
Demographic characteristics
|
Variable
|
Percentage n=84
|
|
Age in years
|
21-40 years
|
96.4
|
|
>40 years
|
3.6
|
|
Gender
|
Male
|
19.7
|
|
Female
|
89.3
|
|
Marital status
|
Married
|
47.6
|
|
Single
|
52.4
|
|
Children at home
|
Yes
|
47.6
|
|
No
|
52.4
|
|
Elder at home
|
Yes
|
69
|
|
No
|
31
|
|
Number of family
members
|
Upto 4 persons
|
61.9
|
|
5-6 persons
|
26.2
|
|
>6 persons
|
11.9
|
|
Place of stay
|
Hostel
|
22.6
|
|
Home
|
77.4
|
|
Place of work
|
General ward
|
27.4
|
|
|
ICU
|
72.6
|
|
|
Work experience
|
Upto 5 years
|
53.57
|
|
|
>5 yeras
|
46.43
|
|
|
Duration of working with COVID
patients
|
2 to 8 weeks
|
21.5
|
|
|
> 8weeks
|
78.5
|
|
|
|
|
|
|
|
|
Demographic characteristics
indicated that most of the nurses
were females (89.3%). Majority of the
nurses (96.4%) are between 21 to 40
years of age. About half of the
nurses (46.53%) have work experience of more
than 5 years. More than half
(52.4%) of the nurses are married,
and 47.6% of the nurses had their children at
home with them. Greater part
of the nurses (69%) had elderly relatives to look after at home. Since
we had prepared more Intensive Care
Units (ICU) for managing patients with COVID 19, more than three-quarters (77.4%) of them work in ICU. The majority
of the nurses (78.5) had spent more than 8 weeks in the
COVID area.
The major
stress factors of the staff were Inconvenience
due to continuous use of PPE (94%) and lockdown
(93%), unavailability of vaccine (90%)
and uncertainty of treatment measures
(89%) most of the staff
(72 %) had expressed that they were stressed about the risk of contracting infection to self and 75% of
the staff were stressed about the risk of spreading
COVID to their family members
and friends.
A qualitative
study done by Galehdar Nasrin etal (2020)6 also supports this finding that nursing staff expressed significant inconvenience in using the
full attire of PPE recommended to
protect them from COVID 19 and fear and
anxiety of transmitting infection from the work area to their family environment always burdened them. They expressed concern about having to wear
the full gown with other protective gears for
the whole shift which placed difficulties in meeting their
basic needs such as eating, drinking and even going to rest
rooms.
There is no association between the demographic variables and the psychological impact of the nursing staff in regard to their stress factors,
stress reducing factors
and coping strategies.
Part B: Psychological impact:
stress factors, stress reducing factors
and coping strategies of nursing personnel
Stress factors:
Table 2: Factors that caused stress among staff during
COVD 19 outbreak
|
Stress factors
|
Percentage of staff answered
“ Yes”
|
Mean score + SD on the
scale of 1 to 3
|
|
Risk of contracting infection
|
85.71
|
1.6+ 0.74
|
|
COVID 19 news and updates in media
|
76.19
|
1.73+ 0.62
|
|
Colleagues infected with COVID
|
84.52
|
1.75+ 0.71
|
|
Risk of spreading COVID
19 to family
members/ friends
|
89.29
|
1.89+ 0,80
|
|
Uncertainty of treatment measures
|
89.24
|
1.68+ 0.74
|
|
Unavailability of vaccine
|
90.48
|
2.13+ 0.82
|
|
Social stigma
|
83.33
|
1.76+ 0.77
|
|
Physical stress/fatigue
|
82.14
|
1.81+ 0.73
|
|
Inconveniences due to continuous use of PPE
|
94.05
|
2.05+0.81
|
|
Inconveniences due to lockdown
|
92.86
|
2.13+0.81
|
Unavailability
of the vaccine then was adding stress to them and this would have been greatly reduced
at present with most of them
are being vaccinated. Some of the
nurses expressed that it was difficult task for them to keep away from their loved ones especially children who could
not understand social distancing and quarantine and always wanted to be physically closer to them.
Mekonen etal (2021)
also discussed in their study
done in North West Ethiopia
that the prevalence of anxiety, depression,
and stress among nurses involved in
caring patients with COVID 19 was
69.6%, 55.3%, and 20.5%, respectively7. Fear of infecting
family members were their
main stressors which also expressed
by the nurses in our hospital in South India. Staff were also
under considerable stress as a result of the lockdown
restrictions, especially the lack of sufficient transportation, which hampered their
ability to report to duty and return home on time. The organization recognized this early on, and special transportation arrangements were made for the
on-duty personnel.
It is also
interesting to note the findings of study by Wu et al. (2020) that frontline medical staff working in the COVID-19 wards experienced lower levels of
burnout than healthcare workers
working in other non COVID wards. It
might be due to the feeling of situation under
control, in a well equipped work environment with strict adherence
of infection control guidelines.8
Stress reducing
factors:
Table 3: Factors that helped to reduce the stress of nursing
staff in the COVID area (n=84)
|
Item
|
Percentage of staff answered “ Yes”
|
Mean score + SD on the scale of 1 to 3
|
|
Positive attitude from colleagues in my department towards patient care
|
98.81
|
2.11+0.78
|
|
Availability of protective measures including PPE
|
100
|
2.36+0.71
|
|
Improvement in condition of COVID positive patients/colleagues without complications
|
95.24
|
1.86+0.72
|
|
Clear guidelines and protocol provided by the
hospital
|
95.24
|
2.33+0.76
|
|
All healthcare professionals working together as a team on front line
|
100
|
2.29+0.77
|
|
Availability of medical benefits for staff and staff dependants
|
94.05
|
2.06+0.70
|
|
Sharing jokes
or humour among
colleagues
|
82.14
|
1.65+0.70
|
|
Availability of refreshment at ward
|
94.05
|
1.73+0.71
|
|
Arrangement of 2 days
off per week
|
97.62
|
2.5+0.67
|
|
Transport arrangement made by the institution
|
91.67
|
2.45+0.75
|
|
Two weeks of paid
extraordinary leave provided for all staff
|
94.05
|
2.42+0.73
|
|
Training on COVID 19
|
97.62
|
2.44+0.67
|
All the staff
had agreed on the availability of adequate Personnel
Protective Equipment(PPE) and the team work
as their major stress reducing factors. They appreciated the team work where all the health care
workers worked together on frontline supporting each other. They had felt reduced stress looking at the
positive attitude from their
colleagues towards patient care which shows the commitment and compassion of the staff towards patient care. Staff also had
expressed comfort about changes
made by the nursing administrators in duty hours schedule
(98%) to avail 2 days off in a week. Staff had
found the arrangement of transport, availability of medical benefits
for staff, clear guideline and protocols from
the administrators to be stress
relieving factors.
Within few weeks of outbreak, the management had addressed significant stress factors of the nurses and these factors were addressed
systematically to reduce the work related
stress of the nursing staff. Counseling services
were made available
to staff. Update
on infection control
guidelines and protocols were clearly communicated to the
staff.
Strengthening
training and special preparation is the key to
reduce the psychological pressure of the health care workers.9 Training on nursing care of patients
with COVID 19 was initiated
and implemented by the nursing management
giving special attention to the skill training
on donning and doffing PPE. Management made provision
of water and snacks in the clinical area. Shift timings and adjustments in the duty schedule were made considering the difficulties of the
staff.
Personal coping strategies:
All the staff had expressed that the most important personal coping strategies in battling
with the COVID 19 pandemic were trusting GOD for His protection, following
strict infection control
measures, following lockdown
restrictions. The findings
of this study are similar to the finding of the study by
Franco JA and Levi PLA (2020).10
More than 90 %
of the staff had agreed that involving themselves in relaxation/ diversional activities, eating well balanced diet and adequate rest
were helping them to cope with their stress. More than 80
% of the staff found it useful
ventilating their feelings, spending time with their loved ones and receiving
help from their supervisors.
Table 4: Personal coping
strategies used by staff to cope
with stress. (n=84)
|
Personal coping
Strategies
|
Percentage of Staff
answered “yes”
|
Mean score o + SD On
the scale of 1 to 3
|
|
Following strict
personal protective and infection control measures
|
100
|
2.75+0.51
|
|
Updating knowledge on COVID 19
|
100
|
2.27+0.61
|
|
Following lockdown restrictions
|
100
|
2.5+0.67
|
|
Involving in relaxation/ diversional activities
|
96.48
|
1.90+0.77
|
|
Spending time
with family and friends to relieve stress
and obtain support
|
88.10
|
1.85+0.81
|
|
Praying and trusting God
|
100
|
2.70+0.60
|
|
Getting help from supervisors or others
to reduce my stress
|
85.71
|
1.75+0.78
|
|
Ventilating emotions
|
84.52
|
1.83+0.76
|
|
Eating well-balanced meal
|
92.86
|
2.05+0.77
|
|
Adequate rest
|
96.43
|
1.94+0.78
|
Getting help from others,
ventilating emotions and spending
time with family and friends are scored lower
than the other coping strategies by the staff. Social support
is an important protective factor for psychological resilience that alleviates stress and strengthens the mental health.11 Social gathering was not encouraged due to restrictions as infection control
measures. Innovative methods
such as social media groups were tried to keep the nurses working in the COVID area in touch which strengthened
social support among nurses by
sharing their feelings and experiences with their colleagues to vent negative
emotions. Garcia‐Rojas and Schmidt also supports that
mobilization of the social support
system is essential
mitigating measure of stress. 12-13
LIMITATIONS:
In our study,
there are few limitations. Sample size was not
large enough to focus on nurses response, depending on the levels of COVID treatment setting.
This is a unique experience at a multispecialty tertiary care hospital accredited by NABH. Results may vary in smaller
hospitals.
CONCLUSION:
Nurses are on the front lines in every emergency situation. In the process of delivering
holistic nursing care, they work
closely with patients. We began the year 2020
with the aim of commemorating the “International Year of Nurse and Midwife,”
declared by the World Health
Organization to commemorate Florence Nightingale,
the pioneer of modern nursing, on her 200th
birthday. However, nurses all over the world had endured
a grueling year on a physical, psychological, and social basis. Nurses have been forced to make unavoidable
lifestyle adjustments due to disruptions in their everyday
work routines and active changes
in procedures and instructions. Nurses
bravely stepped up to fulfill
the demands of both the patients and the institution, despite the danger of
catching the infection from the
patients. As the COVID 19 pandemic enters its
second wave, we must continue to fight with compassion and care.
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Received on 21.04.2021 Modified on
01.05.2021
Accepted on 29.05.2021 © AandV Publications all right reserved
Int. J. Nur. Edu. and Research. 2021; 9(4):407-411.
DOI: 10.52711/2454-2660.2021.00094