This was a cross-sectional study that collected data from respondents at one point in time to assess COVID 19 related anxiety among nurses in Malawi.
The study setting was Malawi as a country including all members of National Organisation of Nurses in Malawi (NONM) working in Christian Health Association of Malawi (CHAM) and government health facilities.
The target population were all Enrolled Nurses, Nurse Midwife Technicians and Registered Nurses in Malawi. Enrolled Nurse and Nurse Midwife Technicians are the lowest cadre of nurses with a college Certificate or Diploma in Nursing and Midwifery while Registered Nurses either have Bachelor of Science in Nursing and Midwifery or Bachelor of Science in Nursing plus a University Certificate in Midwifery or University Diploma in Nursing and Midwifery or University Diploma in Nursing plus a University Certificate in Midwifery (Nurses and Midwives Council of Malawi, 2009).
The sample size was calculated using the methodology detailed by Jones, Carley, and Harrison (2003). This was used to ensure there were enough cases and non-cases of anxiety for validating Coronavirus Anxiety Scale. Using estimated Sensitivity=.90, estimated Specificity=.85 (Lee, 2020), estimated population prevalence of COVID 19 related Anxiety of .23 (Pappa et al., 2020), and width of Confidence Interval 0.05 the following two sample sizes N1 (601) and N2 (255) were calculated. The larger sample size (601) was chosen for this study. However, 320 individuals viewed the survey questionnaire online and a total of 106 respondents completed the questionnaire of which 4 respondent who were not residing in Malawi were excluded resulting in 102 respondents who participated in this study. This was a convenient sample.
The data collection instrument for this study included background information, the Coronavirus Anxiety Scale (CAS) and the Work and Social Adjustment Scale (WSAS). The instrument was self-administered in English because nurses are expected to understand English by virtue of their training.
Respondents were asked questions related to the background information including: age, gender, level of their education, employment status, marital status, coronavirus diagnosis, history of anxiety, if they are working with a COVID-19 positive patients, if they have a relative or acquaintance with COVID-19 diagnosis (Evren et al., 2020), nursing cadre and workplace.
Coronavirus Anxiety Scale (CAS)
This study used the Coronavirus Anxiety Scale (CAS) which was specifically designed to assess Anxiety that is triggered by COVID 19 (Lee, 2020). The tool is a 5-item likert scale with each item having 5 possible responses ranging from 0 (not at all) to 4 (nearly every day over the last 2 weeks). The CAS has maximum score of 20 and minimum score of 0 with an optimum cutoff score of ≥9 (Lee, 2020; Lee, Mathis, Jobe, & Pappalardo, 2020). It is a reliable (Cronbach’s Alpha=.93) and valid tool for measuring COVID 19 related Anxiety (Sensitivity = 90%, Specificity=85%, AUC = 0.94, p < .001) (Lee, 2020). The instrument was used to distinguish individuals with dysfunctional anxiety and those without anxiety.
Work and Social Adjustment Scale (WSAS)
This study also used an adapted Work and Social Adjustment Scale (WSAS) to measure functional impairment experienced by respondents (Mundt, Marks, Shear, & Greist, 2002). The WSAS is 5-items Likert scale with each item having 9 possible responses ranging from 0 (not at all impaired) to 8 (very severely impaired). The tool has maximum score of 40 and minimum is score of 0 with an optimum cutoff score of ≥ 21 for moderately severe or worse psychopathology (Lee et al., 2020; Mundt et al., 2002). Scores of 10 to 20 suggests significant functional impairment but less severe clinical symptomatology while scores < 10 are associated with subclinical populations. It is a reliable instrument (Cronbach’s Alpha≥.88) (Lee et al., 2020; Mundt et al., 2002). The WSAS was used as a gold standard against which the CAS was validated.
Data collection procedure
Data collection was conducted from August to September 2020 using a self-administered questionnaire powered by Surveys for Pages and google pages. Online links for the study questionnaire was sent to potential respondents through whatsapp, facebook page, messenger and email. The questionnaire included information about study and a question which asked consent from potential respondents before deciding to participate in the study.
The study received ethics approval and institutional clearance from relevant authorities. The online questionnaire was preceded by an information sheet that explained the nature and benefits of the study to nurses before they were asked to give consent to participate in the study. Respondents’ names did not form part of background information that was collected, thus respecting their privacy and maintaining confidentiality. Respondents were informed that only aggregated data will be analysed and disseminated. Respondents were informed that their participation in the study was voluntary and they were free to withdraw at any time if they felt uncomfortable about any aspect during the course of the study. They were also informed that refusing to join the study would not have any effect on their job.
Data was analysed using Statistical Package for Social Sciences (SPSS) 25. Descriptive statistics including means, standard deviations, percentages, frequencies were used to summarise data for background information, the CAS scores and the WSAS scores. Analysis of variance (ANOVA) and independent samples Students t-tests was used to test for mean differences of respondents scores. A Receiver Operating Characteristic (ROC) analysis was used to generate values for sensitivity, specificity, area under the curve (AUC), positive predictive values (PPV), negative predictive values (NPV) and Youden index for the CAS to identify functionally impaired nurses and test whether or not its original cut-off score of ≥ 9 (Lee, 2020) remained an optimal score for psychiatric screening in the local setting. Finally, Cronbach’s alpha for the CAS and the WSAS were computed to assess their internal consistency locally.