Psychosocial Responses and Preparedness During Initial Phase of COVID-19 Pandemic Among Nurses Working Different Hospitals of Eastern Nepal: A Pre-Experimental Mixed Method Approach

Background: Most documented studies have focused on mental health status of Health care workers during the pandemic but there are very few studies, focusing on mitigation of mental health problems among nurses. There is an increasingly urgent need to understand mental health impact of COVID-19 and address these impacts through research. Objective: To study psychosocial responses and preparedness for covid-19 and to assess effectiveness of intervention among nurses working in COVID-19 hospitals of eastern Nepal. Methods: Prospective explanatory mixed-method study was conducted among 278 nurses by purposive sampling. Self administered questionnaire method was used for data collection. Psychosocial strengthening program was delivered and effectiveness was assessed after 4-5 weeks of intervention among 192 nurses. DASS-21, Composite measure of personal �nancial burden scales and in-depth interview guide were used to collect data. Chi-square and paired t test, and Pearson's correlation test were used at 95% con�dence interval. Results: Mild depression was found among 13.7%, moderate and severe depression were found among 9.4% and 1.1% respectively. Similarly, mild, moderate, severe and extremely severe anxiety were found among 21.2%, 8.6%, 3.2%, 2.2% respectively. Stress was mild among 9%, moderate 1.4% and severe in 0.7% of the participants. Lack of PPE and fear of transmitting infection to family were found as frequent causes of problems during in-depth interview. Mean Scores of Depression, Anxiety and Stress were signi�cantly decreased after receiving psychosocial strengthening program (p=<0.001 for each). Majority of the participants (92.8%) had made infection prevention preparation and 11.2% of the participants had high �nancial worry. Conclusion: Anxiety and depression were common problems though having adequate preparedness to deal with COVID-19. Psychosocial strengthening program was effective in reducing the problems.


Background
The novel corona virus disease 2019 (COVID- 19) is a peril to the international health in an inimitable loom.Nepal, is also affected by the outbreak with the distressing effects on every aspect including its economy and health care.The Government of Nepal imposed Lockdown from March 24, which persisted for about 10 weeks [1].Lockdown has been recognized as a successful method in breaking the chain of corona virus infection across the world [2,3].Psychological health has an important impact on persons' performance.
The impact of COVID-19 on mental health among health workers has been recognized in previous studies [1,4].However, evidence regarding the impact of the COVID-19 pandemic on nurses and ways for mitigating it is not available in Nepal.Nurses spend the most of their time working at patients' bedsides.There are very few studies included nurses to know psychological status [1,4] but no study reported the intervention and effectiveness of intervention among nurses.During the initial response to COVID-19, media reports were spotlighted on Testing, treating and PPE [5,6].Mental health effects and ways of promoting mental health at the workplace is crucial during health emergencies [7].Khanal et al. in a web-based study reported high level of depression and anxiety among nurses during the initial phase of pandemic in Nepal [1].A timely assessment of mental health status and mental health needs of Nurses during a pandemic would be helpful to reduce psychological distress, and also to motivate them for providing effective care to the clients in need.Therefore, this study was conducted with the aims of assessing the psychosocial response of nurses, providing psychosocial strengthening intervention and evaluating the effectiveness of intervention.

Methods
Design: Prospective explanatory mixed-method Study was adopted for the study Study setting: This study was conducted in two hospitals of Eastern Nepal.One is Level three COVID-19 treatment center speci ed by Nepal Government.It is a tertiary care center and semi-government, university hospital consisted 750 beds.This is a referral center of eastern Nepal, where about 450 nurses work.This center provides treatment to the SARS-CoV-2 positive clients thorough separate 100 bedded hospital with labour room, operation theatre, lab and radiology and other multispecialty services, which is about 100 meters far from the main hospital.Level two COVID-19 treatment center speci ed by Nepal Government, it is a provincial level hospital under Nepal government.This center started COVID-19 isolation center for the rst time in the province.One hundred nurses working in this hospital.

Participants
Self-administered questionnaires were distributed to the nurses working in level two and level three COVID-19 treatment centers of Province one as speci ed by Nepal Government by purposive sampling technique.All willing to participate nurses were included.Data were collected from 17 th May to 20 th August 2020.A total of 320 sets of questionnaires were distributed in-person and 278 of them were returned.
A Composite measure of personal nancial burden scale was used to measure nancial burden and nancial distress [9].The scale consists of six items having "yes=1" or" no=0" options to measure nancial burden.Score ranges from 0-6, more score indicates high burden.One item in the scale is for measuring nancial worry.For that item score range from 1 to5, 0-3 is considered as "low worry" and 3-5 is considered "high worry".English version of tool was translated and back translate to and from Nepali language by bilingual persons.
Interview guide was used to collect qualitative data.After collecting baseline data, in-depth interview was done among ten consenting nurses, who had moderate to severe level of anxiety, depression and/or stress.The audio was recorded during the interview, then it was transcribed and translated by two persons (RP & ES).Questions of interview guide were considered as broad theme and analysis was done accordingly.

Intervention
After baseline quantitative data collection and in-depth interview, intervention was done.For intervention, a package was developed with the contents; introduction to COVID-19, infection prevention measures, dealing with uncertainty and stress management techniques with short practical sessions.Intervention session was about two hours.Participants who reported moderate to severe level of stress and anxiety were provided separate counselling sessions along with combined session.Post intervention Depression, Anxiety and stress were measured in after 4 to 5 weeks of intervention.

Analysis and statistics
Data were analysed using SPSS for Windows, version 16.0 (SPSSInc.,Chicago, IL, USA).Chi-square test, Pearson's correlation and paired t-test were applied at 95% CI.Qualitative (audio record) data were analyzed manually.

Ethical consideration
All methods were carried out in accordance with national ethical guidelines for health research and local regulations.Study was approved by institutional review committee of the University.Informed written consent was obtained from each participant.Participants having symptoms of anxiety and depression even after receiving intervention, were advised to visit Psychiatrist.The intervention was provided during initial months of pandemic.Therefore, all interested nurses who were working in those hospitals were included in group intervention session.Total 460 nurses received the psychosocial intervention package.All the woks were done with standard precautions, none of the participant and researcher was infected during and till two weeks after the study period.

Results
Total 278 nurses were enrolled from two hospitals, 228 from Level three and 50 from Level two COVID-19 treating hospitals speci ed by Government of Nepal.Questionnaire response rate was 86.87%.In-depth interview was done among 10 nurses Among them 240 received intervention session.192 were participated till the end of the study, retention rate was 80%.Cronbach's alpha score of Composite measure of personal nancial burden scale was 0.67 in this study.
All (100%) of the respondents were female in this study.Table 1 shows the socio-demographic, preparedness and other variables of the nurses.Majority were Hindu (83.9%), educated up to Diploma level (62.2%), working as staff nurse (87.1%) (Table 2 shows the Psychosocial status among nurses.Table 3 depicts the association of psychosocial status with selected variables of participants.Contact history was signi cantly associated with stress and existence of chronic health problems was signi cantly associated with anxiety among the nurses.Table 4 illustrates the correlation of DASS scores with selected variables.There was signi cant positive correlation of Depression with age, nancial worry and nancial burden of nurses.Financial burden had signi cant correlation with anxiety and stress.Table 5 shows post intervention psychological status of the nurses and table 6 illustrates the pre and post intervention comparison of mean DASS scores. Qualitative data from in-depth interview were analysed on following themes Theme 1 Most important factors those are increasing your stress "We do not have appropriate PPE" (P1,2,3,4,5,7,8,10) and" I have fear of transmitting infection to my family members from hospital.Not worried for myself if I get infected, but the greatest fear is I may transmit to my family members if I become an asymptomatic carrier of virus" (P1,2,3,4,6,7,8,10). "Situation is uncertain, how should we work in coming days we do not know."(P1,2,3) "My neighbours do not say directly, but indirectly they tell me to stay in hospital quarter, do not come into the community, they stare at me, it gives emotional pain because I cannot leave my small child and old parents alone without me."(P3,9)"Very painful experience to stay far from family, I have grandparents of old age, I miss them very much, but I cannot visit them because of fear of losing them if infection is transmitted to them" (P4)."I have a toddler, he wants to be close to me immediately after entering into home after my 12 hour shift, but I should avoid him, it's very painful and I myself am a client of diabetes, receiving insulin, I also have a fear of death."(P5)."Working with new disease in a newly constructed set up is quiet stressful, I am fearful thinking that if I will not be able to handle then what will be the situation."(P3) "Initially situation was very fearful but now fear has been decreased after seeing persons with SARS-CoV-2 infection.Feeling that it will not be transmitted if we take adequate precautions."(P9) Theme 2 Effects of lockdown "Life is locked inside home, everything is locked, it added more responsibility towards children because schools are locked.Very di cult to manage home and work simultaneously."(P3).
However, some positive effects can be seen in eating habits, hygiene and control the transmission of virus to some extent (P1,2,3) Theme 3 Role in prevention and control of COVID 19 as a healthcare provider Spread awareness for family and locality.Preparation of diet and preventive measures of self and family.(P1-10)

Discussion
The present study was aimed to assess the psychosocial status of nurses working in front line to take care of patients with covid-19.
For this purpose, 278 nurses from two COVID-19 treatment centers speci ed by Nepal government were enrolled in the study.
Majority of the nurses (87.1%) were working as a staff nurse.In nationwide hospitals, staff nurses comprised the highest proportion of the workforce.Although, Nepal had not entered into community transmission stage, 55% of the participants had contact history with suspected cases of COVID-19 before baseline data collection.After initiation of nationwide lockdown in Nepal, all international ights were restricted.Therefore, many people locked abroad, which added stress and nancial burden to themselves and family members.As one of the reputed news channels also reported hundreds of Nepalese, who wanted to return to Nepal got stuck on Indian border points [10] In this study also, 14% of the nurses had their family members locked abroad due to travel restriction.The high nancial worry was found among 12.2% of the participants.
PPE drew the attention of all people during initial days of the pandemic and became one of the scarcest resources during the initial days.The World Health Organization (WHO) encouraged people to wash hands with soap and water or use an alcohol-based hand sanitizer, and proper usage of face masks for protecting them from infection, it put a match to panic-buying and hoarding of those goods, leading to shortages in most of the cities of Nepal including health sectors [11] [12].This study found, only 14% had perceived of having adequate PPE.Healthcare became challenging, lots of ethical challenges were present in front of health workers and problems were also faced by health care institutions regarding nance and sustainability of organizations.Probably because of the same reason, 11.2% of participants felt the threat of losing their job due to COVID 19.Nearly one fth (19.1% )of the participants had chronic health problems like diabetes hypertension etc. Regarding preparation from a personal level, 92.8% were prepared for infection prevention measures to protect self and family from getting infected, followed by extra stock of food by 79.5% and 22.66% had made other preparations like saving of money, some medicines etc.
One web-based survey among health care workers of Nepal found Overall, 13.5% had symptoms of depression in abnormal level as measured by hospital anxiety and depression scale [1].The present study also found 13.7 % had mild depression Finding of this study was similar to a study conducted among public people of china, which also found mild depression among 13.8% of the participants [13].Moderate and severe depression were relatively high among Chinese population as compared to this study [13].This study revealed 9.4% moderate and 1.1% had severe depression.Age of the participants had a signi cant positive correlation with depression in this study.Similar ndings were reported by Khanal et al that, the younger health workers had reported the lesser depressive symptoms in their study [1].Financial worry and nancial burden also had a signi cant positive correlation with depression score.During the data collection period, none of the institution had initiated corona insurance for their employees.Scarcity of appropriate PPE was also high and employees were managing PPEs of their own.This can also be explained by the evidence of a statistical signi cant association of availability of PPE with nancial worry in this study.Therefore, nancial issues might have put extra pressure on them.
The present study revealed, 21.2% of the participants had mild anxiety.This nding is quite higher than the nding of previous study in Nepal 18.3% [1] and Singapore 14.5% [14].Those studies were done among all health care workers and reported higher proportion of nurses had anxiety as compared to the other health workers.This may be the reason of a bit higher proportion of mild anxiety in this study.A systematic review from few Asian countries also reported similar levels of anxiety among health workers [15].Another study of China among public found 7.5% had mild anxiety, which is quiet lower as compared to present study [13].The present study found 8.6% moderate, 3.2% had severe and 2.2% extremely severe anxiety.Moderate and severe anxiety were found to be lower than the study done in China [13].Similar to the nding of previous studies done in Nepal and China, the anxiety level was signi cantly associated with having chronic health problems [1,13].Financial burden had a signi cant positive correlation with anxiety.Similar nding was reported by Gautam et al. in their social media based survey [16].
Regarding stress, 9% had mild and 1.4% had moderate level of stress while, 0,7% had severe stress.Shrestha et al.Also reported 11% were mild to moderate distressed and 0.5% were severely distressed due to COVID-19 pandemic [4].The stress score had a signi cant positive correlation with nancial worry and burden.Similar nding was reported in other studies done in Nepal, where low monthly family income had associated with high distress [16,4].
While conducting the in-depth interview, the reasons of their problems and effects of the pandemic were also supported by quantitative ndings.Lack of PPE, fear transmitting the infection to family members, feeling of stigmatization, feeling of pain to isolate the self from family, feeling of incompetency in a new situation, stress due to uncertainty and problems in work life balance were reported by the participants.These feelings are also supported by others' feelings in the studies done across different countries [17][18][19][20].This shows that the healthcare workers sharing similar feelings, condition and problems, regardless of socio-economic status of the country.Pre-intervention mean scores of depression, anxiety and stress scores were comparable to the mean scores in a study done among health workers in Singapore [14].
After baseline data collection, we provided psychosocial support to the individuals where necessary and one intervention session for all in groups.After 4 to 5 weeks of intervention, mild depression was found among 5.2% and moderate depression was found among 2.1%.Similarly, mild anxiety was reduced to 12% and moderate to severe anxiety was 1%.Stress was also reduced.The reduction in mean scores of depression, anxiety and stress was statistical signi cant (p = < 0.001 for each).This shows the importance of stress management program for the nurses working in the front line; in their daily practice.
The post intervention reduction in mean scores may be because of low threat perception after managing the cases.Though this study did not quantify the psychological status of nurses before and after managing the patients with COVID 19, one of the participants during an in-depth interview mentioned about reduction of fear after seeing the recovered patients and managing the cases.

Limitations Of The Study
The study adopted self-administered questionnaire method for data collection.Therefore, understanding level of participants may have affected the scores.Though it is the rst documented study of its kind from Nepal, this study could not address the confounding variables for signi cant reduction of stress, anxiety and depression during post intervention test.

Conclusion
Psychosocial problems were common among nurses.Infection prevention measures, food and other preparations were done by the majority of the nurses.Intervention was found to be effective in reducing the psychological problems of the nurses.

Recommendation
A stress management program on a regular basis would be effective for managing professional stress.

Table 2 :
Psychosocial Status of Participants before intervention (n=278)

Table 3 :
Association of Psychosocial status with selected variables n=278

Table 4 :
Correlation of DASS score with selected variables

Table 5 :
Psychological Status of Participants after intervention (n=192)

Table 6 :
Mean DASS Scores Comparison pre and post intervention (n=192)