STRESS AND COPING MECHANISM AMONG NURSES WORKING AT NOBEL MEDICAL COLLEGE TEACHING HOSPITAL NEPAL DURING COVID 19 PANDEMIC

ABSTRACT


INTRODUCTION
Stress is defined as an individual's reac on to any change that requires an adjustment or response which can be physical, mental or emo onal. Responses directed at stabling internal biological processes and preserving self-1 esteem can be viewed as healthy adapta ons to stress. Nurses are the primary group who come in first contact with pa ents, an important source of exposure to infected cases in hospital. The Corona Virus Disease 2019(COVID- 19) pandemic caused dras c changes in healthcare and severe social restric ons. Healthcare workers like nurses are on the front line against infec on and have been highly exposed to 2 pandemic related stressors. COVID-19 is a highly contagious respiratory infec on caused by a severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2). It was first reported in December 2019 from 4 Wuhan, Hubei province in China. The world was alarmed when the WHO declared a public health emergency of interna onal a en on on January 30, 2020, about the outbreak of Nobel Coronavirus Disease 7 2019 (COVID- 19) . Covid -19 pandemic has spread around over 222 countries with more than 511 million confirmed cases and over 6 million deaths worldwide, whereas in Nepal the number is growing gradually and reached 978,778 confirmed cases as 8 of 27 April 2022 with 11951 death and 966575 recovered. The pandemic spread across the world and had a great impact on the healthcare system. In already fragile healthcare system in developing country like Nepal, high stress roles with unique demands, the fear of contagion, s gma za on, social isola on and compulsion of performing duty have definitely brought extreme stress and 9,10 anxiety in healthcare workers. From a nursing stand, nurses as front liners experienced dilemmas because they thought of safety not only for 11 themselves but also their families. As they are exposed to Covid 19 pa ents, fear, escalates, emo on intensifies, and 12 anxiety increases, thereby coping is more u lized . A study conducted in High Income countries indicate that more than half of all respondents' concerned stress related .13 to problems in workplace response to the pandemic A study conducted in Saudi Arabia found that outpa ent department and COVID-19 isola on ward had more nega ve feelings and encountered several factors causing 14 stress but were coping in a be er way than others. Another study conducted in India found that 25.5 % nurses 15 had stress. Similarly, another study conducted in Nepal showed that more than half of the respondents (54.7%) had moderate stress, 37.6% had high level of stress. Whereas . 16 7.7% respondents had low level of stress Stress and coping abili es influence the health status and 17 work performance of nurses. Stress also occurs during the Covid-19 pandemic, Health Care Workers (HCW), who felt s gma zed, perceived s gma concerning nega ve public a tude and disclosing about one's work, experienced higher level of depression, anxiety and psychological distress.
In nursing, during COVID outbreak perceived social s gma was associated with higher stress and poorer mental health. Media reports from many of the world's COVID hotpots, including Italy and the United States document extreme exhaus on, physical discomfort from long working hours with face masks and other Personal Protec ve Equipment 18,19 (PPE) fear of contagion, and emo onal distress in nurses. Present study is performed, ge ng to iden fy the stress and the coping strategies by nurses working at Nobel Medical College Teaching Hospital, Biratnagar. This research can lay the inspira on of effec ve interven on programs to minimize the stress within the pandemic situa on, of nurses. Stress is recognized as an inherent feature of the work life me of nurses. Interna onally, many studies were conducted to iden fy the sunshine on stressors among nurses; however, rela vely few studies were conducted within the Nepalese context. This study has iden fied the stress and use coping strategies in pandemic situa on stress among nurses working at Nobel Medical College Teaching Hospital Biratnagar and therefore the main factors that contribute it. The aim of this study was to assess stress level and different coping strategies among nurses working at Nobel Medical College Teaching Hospital Biratnagar, Nepal during COVID-19 pandemic.

METHODOLOGY
A cross-sec onal study was conducted from August 2021 to February 2022. A total of 300 nurses were selected from study se ng by using a non-probability consecu ve sampling technique. Sample was calculated using the formulae for cross-sec onal study design Data was collected by using self-administered ques onnaire. The reliable and interna onally free access valid tool was used to rate the stress and coping strategy. Permission/Ethical approval was obtained from The Ins tu onal Review Commi ee of Nobel Medical College and Teaching Hospital Biratnagar and wri en informed consent was also obtained from each par cipant before data collec on. The collected data were then entered in MS Excel and transferred to SPSS version 23 for further analysis. Frequency tables, crosstables, mean and standard devia ons and other descrip ve analysis were done. A er descrip ve analysis chi-square test was also applied to find the associa on between variables. P value was considered as significant at 95% confidence interval (P<0.05).

RESULTS
Among the 300 nurses par cipated in this study, 71.7 % were below 25 years of age, and the mean age was 24.76 years with SD 3.64. Most of the par cipants were belong to Hindu religion (92.7%) and having nuclear family structure (76.0%). Majority of the par cipants were unmarried (70.3%) and most of them (84.3%) had monthly income less than 20,000. Similarly, highest percentage of par cipants (70.3%) had their educa on of PCL in nursing and working as staff nurse (82.3%). Most of the par cipants had working experience of less than 5 years (Table1).       Table 3 presents the result of cross tabula on between sociodemographic variables and perceived stress. Among the nine variables tested, only three variables as marital condi on, duty schedule and monthly income of the respondents significant associated with perceived stress.   Table 4 shows that most of the respondents 92.0% u lized moderate level coping strategies and only 3.3% nurses u lized high level of coping strategies during COVID-19.

Variables Coping strategies (%)P Value
Low N(%) Moderate N(%) High N(%) Table 5 presents the result of cross tabula on between sociodemographic variables and coping strategies adopted. Among the seven variables tested, only the living condi on of the respondents found associated with coping strategies.

DISCUSSION
The world was alarmed when the WHO declared a public health emergency of interna onal a en on about the outbreak of Nobel Coronavirus Disease 2019 on January 30, 7 2020 (COVID-19) . The pandemic spread across the world and had a great impact on the healthcare system. Having fragile healthcare system in developing country like Nepal, high stress roles with unique demands, the fear of contagion, s gma za on, social isola on and compulsion of performing duty have definitely brought extreme stress and anxiety in healthcare workers. Hence this study was conducted with the aim to iden fy level of stress and coping strategies adopted by nurses during the Covid-19 pandemic. The present study revealed that the majority (71.7%) of nurses were from 25 years or below age, with mean age 24.76±3.64 years. Most of the par cipants (92.7%) were following Hindu religion and more than three forth (76.1%) were from nuclear family. Majori es (70.3%) were unmarried and most of them (84.3%) had monthly income below twenty thousand. They found the par cipants who had female gender, fear of infec on among family members, regre ng being a nurse, less rest me, more night shi s, having children, lack of confidence in figh ng transmission, not having emergency protec on training, and nega ve professional a tude had more severe mental health problems in comparison to their opponents. This study also supports the present study in many ma ers however, present study is slightly differs to get significant varia ons in many socio-demographic variables.
In conclusion, the health professionals, especially the nurses had been facing high level of stress during COVID-19 pandemic and also they were trying to adopt some coping strategies as far as possible. However, they need more inspira on and training on coping strategies.

CONCLUSION
The research finding showed all working nurses having some level of stress during the COVID-19 pandemic. Moreover, about 96% nurses having moderate or high level of stress

REFERENCES
Chapagain S et al and in contrast they were also following moderate level of coping strategies. However, they need high level of coping strategies to overcome the persis ng stress level.

RECOMMENDATIONS
Mental health status should be screened in nurses with care of COVID-19 pa ents. Further studies with large popula on to dis nguish prevalence of stress and coping among nurses who provide care of COVID-19 pa ents.

LIMITATION OF THE STUDY
This study has limited coverage since it is based on only one health ins tu on with only 300 samples. Large studies may provide more valid result to generalize. The associa on of stress with other variables also needs to be explored. Despite the fact our study also has few limita ons; there is a lack of control group for comparison. Findings of the study may not be generalized to other se ng as it was done at a single site in Nepal.

ACKNOWLEDGMENT
We would like to acknowledge the department of Nursing service unit, Nobel Medical College Teaching Hospital for providing us permits to conduct the study. We would also like to thank Mr. Sheldon Cohen for developing PPS and Mr. Carver for developing Brief-COPE inventory which were given free access to the user and appreciate respondents for their valuable me and kind coopera on.

CONFLICT OF INTEREST
There are no conflicts associated with this research study.

FINANCIAL DISCLOSURE
No funding has received.