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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 142-148

Stress among the nurses and their family involved in COVID-19 patient management


1 Nursing officer, CTC, Intensive care for CTVS, CNC, AIIMS, New Delhi, India
2 Additional Professor, Intensive care for CTVS, CNC, AIIMS, New Delhi, India

Date of Submission09-Apr-2021
Date of Decision27-Jun-2021
Date of Acceptance12-Jul-2021
Date of Web Publication31-Aug-2021

Correspondence Address:
Santoshi Kumari
Heart Failure Nurse, Department of Cardiology, 8th Floor CN Centre, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_19_21

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  Abstract 


Background: COVID-19 pandemic has caused havoc and many deaths around the world. Coronavirus is highly contagious and spreads like wildfire in the community. The nurses and other frontline health-care workers (HCWs) bore the brunt of this pandemic with maximum effect because they all worked with infected patients. Direct exposure has caused stress, anxiety, and physical cum mental discomfort among them. Objective: This study aimed to assess stress among nurses and family members related to COVID-19 outbreak. Methodology: In this study, mixed method of prospective approach was used. The study was conducted virtually using social media platforms by online questionnaire. It included 150 participants and information was collected on demographic data, change in relationship with family, spouse, children, self-concept, and perceived stress among themselves and their family members. Results: All the nurses were involved in the direct care of COVID-infected patients. Many participants (47%) became anxious and worried about themselves. More than half (56.7%) respondents had no change in relationship, while 40.7% experienced change in relationship with their family. Majority of the participants (88%) had long travel hours and accommodation issues. Although the nurses working for COVID patients were stressed, frightened, and anxious, most of them took pride in their work as a contribution toward the nation during this current pandemic. Conclusion: This study demonstrated that frontline HCWs were at increased risk of mental health consequences such as stress, anxiety, and frustration. Their children developed behavioral changes such as agitation and aggressiveness. Many nurses got more family support than before for their contribution during COVID-19 pandemic.

Keywords: COVID-19, mental health issues and nurses, SARS-COV-2


How to cite this article:
Rai P, Kumari S, Roy D, Sahu MK. Stress among the nurses and their family involved in COVID-19 patient management. J Pract Cardiovasc Sci 2021;7:142-8

How to cite this URL:
Rai P, Kumari S, Roy D, Sahu MK. Stress among the nurses and their family involved in COVID-19 patient management. J Pract Cardiovasc Sci [serial online] 2021 [cited 2021 Dec 7];7:142-8. Available from: https://www.j-pcs.org/text.asp?2021/7/2/142/325220




  Introduction Top


An outbreak in China, with a novel SARS-CoV-2, quickly spread around the world including India in early 2020.[1] SARS-CoV-2 infection affects multi-organ systems but mainly involves the respiratory system as the primary organ. It spreads through person-to-person contact and droplets and its severity ranges from mild to severe, even death can occur. Quarantine and isolation measures are taken in an attempt to limit the local, regional, and global spread of COVID-19 outbreak.[2],[3] With a death rate climbing rapidly, the disease was declared a pandemic by WHO in March 2020.

Due to its contagiousness, rapid spread, delay in treatment, lack of resources, and high death rate, the COVID-19 pandemic has created a stressful working environment for nurses and other health-care workers (HCWs). These changes have a strong impact on patients, their families as well as HCWs.[4]

Liu et al. found that HCWs were constantly afraid of being infected, getting unintentional occupational exposure, and of transmitting the SARS-COV2 to their loved ones, as a result, they constantly monitored their own health with great concern about not carrying the virus to their children, parents, and friends.[5]

According to Ginger, 88% of workers reported experiencing moderate-to-extreme stress due to COVID-19. Among those reporting stress, 62% noted productivity losing at least 1 h and 32% lost at least 2 h a day due to COVID-19-related stress.[6] The well-being and sound mental health of HCWs are key components of maintaining essential health-care services during the COVID-19 outbreak. Therefore, it will be crucial to anticipate the stresses associated with COVID-19 among health workers and provide support for them. Monitoring and assessment of mental health and well-being of health-care personnel is important.[7]

Studies showed that HCWs feared contagion and infection spreading to their family, friends, and colleagues. Feeling of uncertainty of life and stigmatization to COVID-19 was the cause for reluctance to work or contemplating resignation from job.[8] They also reported experiencing high levels of stress, anxiety, and depression, which could have long-term psychological implications.[9]

Frontline workers, especially nurses, are involved in direct care of the patients, so they are at greater risk of having adverse psychological outcomes than others. The reasons for such adverse psychological outcomes are due to excessive workload, change in duty hours, inadequate experience of COVID-19 management, working with personal protective equipment, without having food and water for a longer period of time, inability to meet elimination needs of the body, and menstrual hygiene. Staying away from family, leaving children with relatives, maintaining a distance from loved ones, and fear of infecting others have created more anxiety, depression, and stress among nurses.

A study by Sun N et al., 2020, concluded that COVID-19 has a certain psychosocial impact on nurses engaged in direct care of patients. Effective measures should be taken and greater attention should be paid to nurses and nurses with family and children.[10] Hence, we conducted this study to evaluate the psychological issues among the nursing staff working in the COVID-19 care areas of different hospitals in India.

Objectives

  • To assess the stress of nurses related to COVID-19 outbreak
  • To explore their emotional status with their family members due to COVID-19.



  Methodology Top


Study design

A cross-sectional research study was used to assess the stress among nurses and their family due to COVID-19. Mixed-method research approach was used to collect data digitally from the respondents. The study was approved by the institute ethics committee. The survey began by obtaining informed consent from the participants. The participants were required to give their consent before filling the questionnaire. The study was conducted virtually on the Internet using commonly used social media platforms such as WhatsApp, text message, and E-mail.

Participants

Nurses who were directly in contact with infected COVID-19 patients were invited to participate in this online study by a convenience sampling method.

Inclusion criteria

  • Nurses working in the clinical area and engaged in care of COVID-19 patients
  • Nurses willing to participate in an online survey and able to read and write English
  • Participants with access to the Internet.


Exclusion

  • Nurses who are not involved in the care of COVID-19 patients.


Place of the study

This study involved nurses working in different hospitals catering to COVID-19-infected patients from different states of India.

Tool

A self-reported questionnaire was developed using available literature into an online form to observe the research variables. This study uses a mixed-method approach for the small sample size, which includes both quantitative and qualitative data. The tool was self-structured and validated by nursing experts. Convenience sampling techniques used and online E-mail and links were shared to potential responders. The tool had five sections; Section 1 was sociodemographic data which includes age, gender, working experience, marital status, and state in which nurses are working. Section 2 was about nurses and their relationship with family which includes dichotomous and multiple-choice questions; Section 3 was about nurses and their relationship with children. Section 4 depicted nurses and their relationship with partners. Section 3 and 4 contained dichotomous, multiple-choice, and open-ended questions. Section 5 was about self-concept and perceived stress and it contained 18 questions in which 10 questions were rated on a 3-point Likert scale ranging from not at all to some extent and to great extent, while 5 questions are multiple-choice questions, two questions were dichotomous, and last one is an open-ended question.

Variables

The study had both close-ended and open-ended questions. The close-ended questions were analyzed quantitatively. Open-ended questions in the questionnaire about experiences of emotional state related to children, spouses, or self were thematically coded and analyzed.

Data collection

The link of the questionnaire with a consent form appended to it was sent through E-mails, WhatsApp, and other social media to the contacts of the investigators. The participants were encouraged to roll out the survey to as many people as possible. Thus, the link was forwarded to people apart from the first point of contact and so on. On receiving and clicking on the given link, the participants got auto-directed to the information about the study and informed consent. After accepting the survey, they had to fill up the demographic details. Then, a set of several questions appeared sequentially, which the participants had answered.

Statistical analysis

Statistical data analysis of quantitative variables was done by frequency, percentage, mean, and standard deviations (SDs), whereas qualitative variables were thematically organized and coded.


  Results Top


Section 1: Sociodemographic data

We conducted an online study to find the stress among nurses involved in the direct care of COVID-19 patients and their relationships with family members. We sent a link of a questionnaire to 500 nurses working in different hospitals across India and received 150 responses. In section 1, 3 and 5 complete responses were received by respondents (n=150), whereas only 148 responded to Sections 2 and 4. Out of 150 responded, 145 participants answered about their self-esteem and 148 to stress related to COVID-19 pandemic.

The mean age of the participants was 32 ± 8.73 years and the mean of work experience was 6 years. [Figure 1] pie diagram represents gender-wise distribution of participants, among the participants, 90 (60%) were women and 60 (40%) were men.
Figure 1: Gender-wise distribution of the participants.

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[Figure 2] bar diagrams depict that the majority of the participants (70.27%) were married. [Table 1] shows state-wise distribution of nurse participants.
Figure 2: Marital status of the participants.

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Table 1: State wise distribution of participant

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Section 2: Nurses and their relationship with family

Among the 148 respondents, 67 (45%) people were living with their spouse but had no children, while 63 (43.0%) were living with their spouse and children and 18 (12%) respondents were living alone. Majority of the respondents (56.7%) had maintained an intact relationship with their family throughout the COVID pandemic, while for 43.3% of the participants, their family relationship was affected. Majority of the nurses said that their family members appreciated and liked them for their job.

Section 3: Nurses and their relationship with child

Respondents who were married among them only 25% had children younger than 5 years of age, 6% had children of 5–12 years of age, and 6% had children older than 12 years. Respondents who had children revealed that they had an intact relationship with their children, only 6% reported that COVID-19 had impacted their relationship, and they reported that they remained very much anxious and worried about the health of their children. The parents said that they tried to spend less time with the children to keep them safe, as a result of that, more agitation was seen among the children.

Psychological issues among the respondents were helplessness toward themselves and their family, living separately, and maintaining minimal contact with the other family members and friends. Most of the nurses had the same opinion and reported that they felt annoyed and anxious, maintained distance with their children because they felt concerned about their child's health. They had sent their children to their grandparent's house and this was a traumatic experience for some of them. Many parents where both parents were HCWs stated that “it was for the first time for them that their children were deprived of both parents suddenly, which had affected the psychology of both parent and children.” They also revealed that “this outbreak seemed to be never ending; every second was a threat which was killing them day by day.”

Section 4: Nurses and relationship with Spouse

More than half (58%) of the participants reported that there was no significant change in their relationships with their spouse. Many respondents (51.68%) realized worry, tension, and stress in their partner, as delineated in [Table 2], although many respondents did not feel any difference in the behavior of their spouse. Another most common response received was “Nurses felt isolated, emotionally disturbed and were getting irritated very quickly.”
Table 2: Change of relationship with Spouse (n=42)

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Section 5: Self-concept and perceived stress

Among the respondents (n = 150), two of them did not respond to self-concept and perceived stress. All the respondents were involved in direct care of COVID-infected patients. More than half (53%) of the HCWs thought at the time of data collection that the COVID-19 crisis was a temporary problem. Ninety-one percent of respondents felt proud about their work in the COVID crisis.

[Figure 3] bar diagram shows perceived difficulties among staff nurses. Majority of the nurses (47%) felt anxious and worried about themselves, whereas 26% of them felt guilty of exposing others.
Figure 3: Perceived difficulties due to working in COVID-19 areas.

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As shown in [Figure 4], around 145 participant, respondent regarding their self esteem. Participants (44%) felt highly energetic and motivated for their work. Respondents (29%) did not feel any change in their self-esteem and 10% felt demotivated, sad, and angry about the pandemic situation.
Figure 4: Impact of COVID-19 on the self-esteem of the nurses.

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[Figure 5] bar diagram shows that the majority of the respondents were tired of donning and doffing, felt irritated because of bathing many times daily, and many of them were uncomfortable with working in a new area. Participants (88%) had transportation and accommodation issues.
Figure 5: Multiple response chart of issues reported due to COVID-19.

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[Table 3] shows that the majority of participants had perceived irritability, stress, and isolation to some extent because of working for COVID-infected patients. Most of the respondents had a great fear of getting infected and difficulty in bowel and bladder regulation; but at the same time, they felt happy and took pride in their contribution toward national service during this pandemic.
Table 3: Nurses self - perception and COVID-19 Scale

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  Discussion Top


The pandemic is a health crisis that not only impacts physically but also affects mental health. The severity of the pandemic has a significantly higher impact on the mental status of the nurses, who were involved in direct care of infected patients and dealing with morbidity and mortality due to COVID-19. Nurses had extreme fear of exposing their family and friends to COVID-19, which gave rise to severe stress and anxiety among them.

In our study, the mean age of the participants was 32 ± 8.73 years and the mean year of work experience was 6 ± 6.22 years. Among the participants, more than half (60%) were female and majority of them (70.27%) were married. Among the participants, 37% had children. Similar findings were seen in a large-scale cross-sectional study conducted by Hu et al. in Wuhan, China. In their study, the mean age of the participant was 30.99 (SD = 6.17) years and the majority of them were female (87.1%). More than half were married (61.1%) and had had one or more children (54.6%).[10]

In this study, it was found that there were no significant changes in the family relationship of the nursing staff with their spouse, parents, and friends. However, nurses who had children were found to be more anxious about the safety of their children and old parents. To keep them safe, they spend less time and maintain minimal contact with family. Many of the mothers observed aggressive behavioral changes in their children and felt guilty about it. Niuniu Sun et al. in their study had similar findings that the nurses (n = 4) with the elderly and children were worried of their families. They also said that their families were also worried about their health. Some of them (n = 9), those who did not live with their parents, chose to hide the fact that they work in the isolation ward. Nurses felt helpless and guilty, as they lived away from the family during COVID-19.[11]

Among the married people, 51.68% nurses reported that they felt stressed, tensed, and worried about their spouse. Ermiati et al. in their study observed the same. Nurses were so stressed and worried to extant that they modified their behavior and environments. They limited direct interaction with families immediately after returning from work, modified the flow of entry to the house, slept in separate bedrooms, wore masks when interacting with their children, and practised bathing before seeing their families.[12]

This was because nurses had direct contact with the infected patients and their body fluids which was high risk of getting infection, as well as the concern about the possibility of spreading the virus to their families, friends, or colleagues. Similar concerns, anxiety, stress, and fear of getting infected by themselves and also spreading the infection to their family were described by the authors Ornell et al. in their study,[13] Fear and anxiety led nurses to isolate themselves from their family and child. It also made nurses to change their routine, narrow down their social support network and similar phenomenon happened with our study population too.

The study analyzed the perceived difficulties among nurses due to working in COVID areas and showed that 47% of nurses felt anxious, 26% felt guilty of exposing others, and some of them had feelings of loneliness and isolation. Fear of getting and spreading infection triggers feelings of loneliness and helplessness, or a series of dysphoric emotional states, such as stress, irritability, physical and mental fatigue, and despair. Xiang et al. in their study described that the work overload and the symptoms related to stress made nurses especially vulnerable to psychological suffering.[14] We, in our study, also found similar experience expressed by the participants due to work overburden. The findings of the study were similar to a study conducted by authors Chua et al., during the acute SARS outbreak in which 89% of HCWs who were in high-risk situations reported psychological symptoms.[15]

Our study demonstrated that 60%–75% of our study population were affected from psychological stress due to different reasons such as long duty hours (88%), difficulty to maintain personal/menstrual hygiene, long travel, and distant accommodation. The fact that SARS-CoV2 is human-to-human transmissible, associated with high morbidity, and potentially fatal may intensify the perception of personal danger as discussed by the authors Wang et al.[16]

Cho and Kim in their study found that nurses said that nursing care is difficult and exhausting, with protective clothing and equipment. It made them feel uncomfortable and irritated more easily. Nurses felt COVID-19 seemed like an endless fight that had made our body and mind more tired.[17]

Our study too had similar findings, battling COVID-19 made nurses vulnerable to psychological distress and found that 66% of nurses had perceived irritability due to overburden of work. Seventy-five percent of nurses perceived stress which was related to unusual and long duty hours. More than half (67%) had reported isolation due to limitations and to a great extent (75%) had fear of getting infection and 47.97% had difficulty in bowel and bladder regulation. This can be explained by the fact that nurses have longer work shifts and closer contact with patients, which can easily lead to fatigue, irritability, and tension. This study is consistent with the various studies showing psychological impact of COVID-19 on HCWs.[16],[17],[18] A study conducted in Saudi Arabia assessed mental health of HCWs during COVID-19 and revealed that nurses had more anxiety who were directly engaged in the diagnosis, treatments, or care for suspected or confirmed COVID-19 patients.[19] In line with the findings of the study, a systematic review and meta-analysis has shown a high prevalence of mental disturbances such as anxiety and depression among HCWs during the COVID-19 pandemic.[20],[21],[22],[23] Same as the above mentioned, we also found that the participating nurses who worked directly for the COVID-infected patients developed more anxiety, fear, and stress.

The findings of the study can be used to identify problem areas of nurses working in the pandemic and understanding their physical and psychological difficulties. The findings of the study can be utilized in understanding the concerns and strengths of nurses as professionals working in the frontline. Interventional studies can be planned on the basis of the findings of this study. Similar studies can be replicated in non-COVID areas and can be compared with those working in COVID-19 and other high-risk areas. Development and standardization of tools for nurses and HCWs can be done based on our study. Nurse's experiences based on this study can be taken into concern for the purpose of developing remedies, for reducing their physical and psychological discomfort while taking care of COVID-19 patients.

Limitations

This study being a descriptive study used analysis that is limited to frequency, percentage, mean, and SD The quantitative data have a small sample size, as the methodology is a mixed method, the sample size was not calculated previously. This study also has limitations related to survey methodology and self-reporting, thus complete data were not available from all the sections and all the respondents. As the topic of the study is novel, thus no standardized tool was available.


  Conclusion Top


The result of the study revealed that nurses even under stressful situation had an intact relationship with their family and spouse. Few of them had fear of infecting their loved ones. Nurses' family members appreciated them for their job and profession of serving during the national crisis. Parents who had children were more anxious about the health of their children. Majority of nurses felt tired, uncomfortable, irritated, and anxious because of donning and doffing every day, changing shift duties, bathing multiple times, and fear of getting infected. Majority of the nurses had perceived irritability, stress, and felt isolated and 75% had fear of getting COVID-19 infection. The study showed that nurses thought that COVID-19 was a temporary problem, and they were happy to work for their country and humanity.

Ethics clearance

This prospective study was approved by Institute Ethics Committee(IEC),AIIMS,New Delhi. (IEC-821/07.08.2020).

Acknowledgment

We would like to acknowledge the contribution of the nurses working in the COVID-19 pandemic and participating in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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