EMOTIONS AND COPING STRATEGIES OF HEALTH CARE WORKERS WORKING IN DIFFERENT HOSPITALS OF CHITWAN DURING COVID-19 PANDEMIC

Background : Health Care Workers (HCWs) face huge emotional burden to balance the fundamental “duty to treat” with their parallel duties to family and loved ones. This study aimed to explore emo tions and coping strategies of HCWs working in hospitals during COVID-19 Pandemic. Methods: This cross-sectional survey consisted 482 randomly selected HCWs working in five govern - ment and private hospitals of Chitwan. Data were collected using self-administered structured ques tionnaire for emotions and Brief COPE questionnaire for coping strategies. Forms were distributed to the HCWs using Google Form. Collected data were analysed using descriptive and inferential statistics. Results: Majorities of the HCWs were moderate to very much worried to do their job (75.3%), infect - ing family members/others (74.9%), lack of government steps for infection control (74.1%), getting infections from patients (67.9%), lack of treatment protocol (67.6%), inadequate specialty hospitals (64.7%) , man powers (61.4%), increasing COVID-19 cases (60.4%) as well as they avoided social gath ering (72.8%). Nurses, female and HCWs with bachelors’ level experienced more emotional reactions (anxiety, sadness, shock, anger and enthusiasm) compared to doctors, male and HCWs with master and above education (p=<0.05). Adoption of coping strategies was higher among nurses compared to doctors (p=<0.05). Shock and sadness were the significant predictors of problem focused coping whereas anxiety and anger were the significant predictors of emotion-focused coping. Conclusions: Negative emotions and adoption of coping strategies are common among HCWs during this pandemic. Therefore, government and concern authorities need to organize screening program and psychological interventions for HCWs using identified predictors to enhance their mental wellbeing.


INTRODUCTION
Corona Virus Disease 2019 (COVID-19) has been declared as public health emergency worldwide on 30 th January 2020 and pandemic on 11 th March 2020. 1,2 Health Care Workers (HCWs) at the frontline are more likely to be in close contact with CO-VID-19 patients and are vulnerable to spread the infection to their closed ones. 3 In addition, inadequate accesses to personal protective equipment or weak infection prevention and control raise the risk among HCWs. 4 Currently, HCWs represents at least 10% of cases of COVID-19 infections globally 5 whereas 539 in Nepal till 27 th August 2020 and is increasing steadily. 6 HCWs are experiencing enormous mental burden due to the nature of their job, rapid spread, lethal in severe cases and no specific treatment for infection 3,7,8 However, persons' coping strategies keeps on changing based on the situation leading to emotional turmoil. 3,7 Hence, this study was aimed at assessing emotions and coping strategies among HCWs working in different hospitals during covid-19 pandemic.

METHODS
A cross-sectional survey consisted of health workers (doctors and nurses) working in five selected hospitals i.e. Chitwan Medical College and Teaching Hospitals, College of Medical Sciences Teaching Hospital, Bharatpur hospital, Mankamana hospital, and BP Koirala Memorial Cancer Hospital (BPKMCH) of Chitwan district. There were 1569 health workers (doctors-484 and nurses-1085) working in these hospitals.
Sample size was calculated using formula: n= z 2 pq/e 2 . Calculated sample size was 482 with 0.5 probabilities (p), 5% allowable error (e), 95% confidence level and 25% non-response error. All the doctors and nurses working in the selected hospitals were listed and were selected through simple random sampling technique with lottery methods. Structured self-administered questionnaire for emotions was developed based on the prior literature. [8][9][10][11] In total, there were 32 items grouped in 5 emotional domains (anxiety-11, shock-3, anger-5, enthusiasm-4, sadness-9). Each item was rated on 0-3 scale (0=not at all; 1=slightly; 2=moderately; 3=very much) where higher scores indicated higher emotional responses. Brief COPE Questionnaire 12 was used to measure the coping strategies. It consisted of 28 items under 14 theoretically identified coping responses. Each item was rated on 1 to 4 score where higher scores indicated higher levels of coping. All the responses were measured in the last 4 weeks. Pretesting of the instrument was done in Narayani Samudayak Hospital, Bharatpur among 40 HCWs and the reliability coefficient of emotional scale and Brief COPE Questionnaire were 0.87 and 0.85 respectively.
Ethical clearance was obtained from the Chitwan Medical College Institutional Review Committee (Ref: CMC-IRC/076/077-128) and administrative permission was taken from the concerned hospitals. Informed consent was obtained from the HCWs. Data were collected from 15 th June 2020AD to 15 th August 2020AD using Google Form.
Data were analysed in IBM SPSS version 20 for window using descriptive and inferential statistics. Data normality were tested and data were normally distributed so independent sample t test, and one way ANOVA were performed to measure the significance difference in emotions and coping strategies according to selected variables. Pearson correlation coefficient was calculated to determine the relationship among variables. Further linear regression models were constructed to find out the associated factors with emotions and coping responses using those variables which were significant at bivariate analysis. Statistical significant was set at <0.005.

RESULTS
Out of 482 HCWS, 65.7% were nurses. Mean age was 30.2 (± 8.1) years. Majorities of the HCWS (63.5%) belonged to nuclear family, living with their family members (71.4%) and married (56.0%). Only 4.3% of HCWs had history of chronic illness (Table 1).   Majorities of HCWs were moderate to very much worried to do job as it is professional and ethical duty (75.3%), infecting family members/others (74.9%), lack of governments strict steps for infection prevention and control (74.1%), getting infections from patients (67.9%), and lack of treatment protocol (67.6%).Less than half of HCWs felt mood change (38.8%), repeated negative thoughts about transmission (38.5%), felt being unable to protect others (38.2%), and agitated to wear protective gears daily (33.2%). Besides, more than half of the HCWs showed moderate to very much enthusiasm to work by hearing recovered cases in the news (74.5%), felt energetic (58.7% ) and expected financial compensation (50.6%) during this outbreak ( Table 2 and Table 3).
The independent sample t-test found that anxiety (p=0.009), sadness (p=<0.001), shock (p=<0.001) and enthusiasm (p=0.009) were significantly higher among female HCWS compared to male. Likewise, nurses had significantly higher anxiety (p=0.004), enthusiasm(p=0.001), sadness (p=0.016) and shock (p=<0.001) compared to doctors. Similarly, One Way ANOVA found that there was significant difference on emotions according to level of education, and professional qualification. Further, multiple comparisons revealed that HCWS who completed Bachelor level education had significantly higher emotional reactions like anxiety, and anger compared to masters' level education. Likewise, enthusiasm, sadness and shock were higher among them compared to HCWs with PCL and master level education (Table 4). Table 5 shows that females unmarried HCWs and nurses made significantly higher use of problem-focused and emotion focused coping to deal with COVID -19 compared to male married HCWs and doctors. Further, significant differences was observed in use of both coping strategies according to level of education where use of both coping strategies were significantly higher among HCWS with PCL education compared to bachelor and master level education.
A stepwise multiple regression analysis models (1 and 2) were constructed to measure the predictors of coping strategies where coping strategies was used as dependent variables and emotions as independent variables. In model 1, only two emotions (such as shock and sadness) were found to be the significant predictors of problem focused coping and explains 10.8% variation in the model. In model 2, anxiety and anger were found to be the significant predictors of emotion-focused coping and these two factors explain 30.2% variation in the model (Table 6).
A stepwise multiple regression analysis was performed and four model were constructed to find out the contribution of coping strategies on emotional responses. Emotional scores were used as the dependent variable, and two dimensions of coping strategies were used as independent variables (Table 7).   In model 1, problem focus coping and emotion focused coping are the significant predictors of anxiety which explain 5.9% variation in the model. Similarly, in model 2, emotion-focused coping was found to be significant predictors of sadness which explains 29.9% variation in the model. Likewise, emotion focused coping explains 9.7% of the variation in the anger model 3 (R 2 = 0.097, F=26.824, p=<0.001). In model 4, problem-focused coping and emotion-focused coping were included in the regression equation of shock and found to be significant predictors of shock which explain 11.6% variation in the model (Table 7).

DISCUSSION
Present study revealed that infecting family members and others, getting infections from patients, lack of treatment protocol, specialty hospitals and man powers, social distancing and isolation were the major emotional concern to HCWs during this pandemic and these findings are consistent with the various literatures where HCWs showed greatest concerns regarding viral transmission to their family/others. 13,14,15 These reactions might be because of novelty of virus, lack of treatment and specific protocols prevailing in the current pandemic. Therefore, health care institutions and Government of Nepal need to consider the strict measures and protocols to control the chain of infection. Other studies also revealed that lack of treatment for covid-19 caused increase in emotional responses among HCWs to work during the pandemic. 14,15,16 However, inconsistent finding reported by study in China where medical staffs were less concern regarding lack of treatment for COV-ID-19. 13 The possible reason in the variation of the views might be because of the time and severity of cases in the concerned country. Half of HCWs of this study were shocked being avoided by others for the fear of transmitting infections and similar results were observed in other studies. 17,18 Thus, there is a need for public education campaigns concerning COVID-19 and its preventive measures.
In this study, female HCWs had significantly higher anxiety (p= 0.009), sadness (p < 0.001), shock (p<0.001) and enthusiasm (p= 0.009) compared to male HCWs and this is in line with other studies where women showed severe anxiety, depression, distress and fear. 3,[19][20][21] Similarly, studies pointed out that women had significantly higher anxiety, hopelessness 22 , sadness 23,24 and enthusiasm 15 compared to male HCWs. This might be due to the facts that women are considered to be fragile, emotionally attached, sensitive and they perceive events more negatively and uncontrollable compared to the men.
This study found that nurses felt more emotions such as anxiety (p=0.004), sadness (p=0.016) and shock (p<0.001) than the doctors which is consistent with other studies in which nurses felt significantly higher anxiety, nervousness and fear compared to doctors. 3,7,13,21,25 The might be attributed to the fact that they spend more time with patients, see them with pain and dying during COVID-19 outbreak and fear in nurses intensifying the perception of danger on COVID-19. 7 Our finding presents the existence of enthusiasm (p=0.01) which appeared more among nurses compared to doctors. Research evidence confirmed that nurses showed positive attitude, encouragement, and collective power, calm and rational behaviour despite of challenges in the fight against the disease. 9,18 Further, Kakunje concluded that positive emotions play an important role in the recovery and adjustment of psychological trauma. 26 In this study, positive reframing, planning, emotional support, self-distraction, and religion were frequently used by health workers and use of these measures were significantly higher among nurses compared to doctors and these findings is supported by studies from other part of the world in which nurses commonly used religion, [27][28] planning, 29 social support 30 as coping measure. The variation in use of coping strategies across the countries might be due to the inconsistent severity and HCWs perceptions towards COVID-19 outbreak.
Similar with other study done in China, this study found the positive relationship between problem-focused coping and emotion-focused coping (p<0.001) of HCWs. 3 Further, it was found that female made more use of problem-focused coping and emotion focused coping than the male to deal with COVID -19 and this is supported by studies done in China 3 and Romania. 7 It might be attributed to the fact that modern woman unlike her counterpart is challenged by the career and familial goals leading to excessive use of coping for stability in face of the enormous difficulties.
In our study, shock and sadness were found to be significant predictors of problem focused coping whereas, anxiety and anger were the significant predictors of emotion-focused coping.
Various studies reported that the high-users of emotion-focused coping have higher levels of depression and anxiety. 31,32 Likewise, the findings during the SARS outbreak concluded that problem-solving coping strategies reduced sadness. 33 However, other study reported that it contributed to increase anxiety levels. 34 The conflicting results might be because of one's appraisal of the situation especially during the time of pandemic.
We found that the coping strategies of HCWs had significant predictive effects on emotional responses in which problem focused and emotion focused coping are the significant predictors of anxiety and shock whereas emotion focused coping has significant predictive effects on sadness and anger. In harmony with these findings, other studies showed significant predictive effect of problem focused coping on anxiety and sadness. 3,7 Similarly  reported that the greater use of emotion-focused coping reduced anger and sadness for all age groups and greater use of problem-focused coping reduced sadness for older adults. 12 In addition, a study from Nepal revealed that the nursing students who used emotion-focused coping have higher levels of depression and anxiety. 35 Enthusiasm of most HCWs after starting the anti-epidemic tasks is rarely mentioned in other studies and we have included thinking it might have been related to health professionals' gradual adaptation, acceptance, positive response, and personal growth. In addition, it highlights the need of mental health services, especially to those with pre-existing mental illness and who may be affected by the COVID-19 pandemic. Besides, this study has some limitations. First, it is a cross-sectional survey which could not explore the causal conclusions. Second, most participants were from Chitwan district, limiting the generalization of findings to less affected regions. Third, psychological assessment was done based on self-report tools. Despite of this, study findings highlights the need of safe working conditions, screening program and psychological interventions for HCWs while offering financial subsidies and rewards by health care authorities and institutions.

CONCLUSION
HCWs working in different government and private hospitals experience positive and negative emotions during COVID-19 pandemic and these emotions are higher among nurses compared to the doctors. Besides, nurses are more frequently using the coping measures to adjust with their working situations. Hence, health institutions and local government need to organize mental health programs for the health workers during this pandemic considering the identified factors to enhance positive attitude and mental wellbeing.