ANALYSIS OF FACTORS AFFECTING NURSE ANXIETY DURING PANDEMIC COVID-19

Method: The research design used was descriptive analytic with a cross-sectional approach. The sample size was 55 respondents, taken according to the inclusion criteria and sampling using the proportional stratified random sampling technique. The inclusion criteria in this study were nurses who worked in room units that did not treat Covid-19 patients and were cooperative at RSUD Kayen Pati. The independent variables in this study were perceptions of risk, workload as well as information and training. The dependent variable in this study was the level of anxiety of nurses. The instrument used for the perception of risk as well as information and training was a questionnaire from Gershon et al (1995), for the workload instrument using a questionnaire from Nursalam (2016) while for anxiety instruments using a Depression Anxiety Stress Scale (DASS) 42 questionnaire. Analysis using a test Logistics Regression statistic with significance level p<0.05.


INTRODUCTION
The development of cases of Corona Virus Disease 2019  in Pati Regency is increasing day by day and currently has a red zone status or a high risk of Covid-19 (Nugroho, 2020). Health workers who treat Covid-19 patients are a group with a very high risk of exposure to Covid-19 disease. Many nurses who work in hospitals have psychological problems, due to high workloads and prolonged fatigue but are also at high risk of infection (Tan et al., 2020b). Psychological problems of nurses in dealing with Covid-19 patients, such as the stress of nurses working in the ward during the Covid-19 pandemic, encountered various signs and symptoms, one of which was anxiety (Astuti & Suyanto, 2020). The biggest contribution that causes disruption of psychological conditions and mental health is psychological factors which include levels of anxiety, stress, coping mechanisms and problems encountered; These four factors can trigger the Covid-19 pandemic, so psychological treatment is needed as a form of preparedness (Priyantini et al., 2021).
Based on data from the World Health Organization (WHO) on November 6, 2020, the number of confirmed cases of Covid-19 in the world was 48.3 million people, patients died from this virus infection reached 1.23 million people and as many as 32 million people were declared cured. from . The case of the spread of Covid-19 in Pati Regency until November 2020 was in the 22nd place in Central Java. The number of confirmed patients being treated was 52 people, the number of suspects being treated was 53 people, the number still confirmed was 50 people, 84 people died positive and 106 people died. There were 4 confirmed COVID-19 patients being treated at the RSUD Kayen Pati. The prevalence of anxiety from 164 health workers who treat patients infected with Covid-19, 53 health workers suffer from mild anxiety, 7 health workers suffer from moderate anxiety and 4 health workers suffer from severe anxiety . At the RSUD Kayen , there were 11 employees most of whom were medical personnel who were declared reactive or positive for Corona after undergoing a rapid Covid-19 test.
During the Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), frontline health workers reported experiencing high levels of stress resulting in Post Traumatic Stress Disorder (PTSD) . The four main risk factors that influence stress on health care workers during the SARS outbreak include medical perceptions of their risk of infection, the impact of SARS on their work, feelings of depression and working in high-risk space units .
Factors that affect nurses' anxiety during the Covid-19 pandemic based on Roy's Adaptation Theory model include a focal stimulus (ie negative stigma from the community or the surrounding environment), contextual stimulus (ie age, gender, marital status, length of work, level of education, workspace unit, availability of PPE and workload) and residual stimulus (ie perception of risk as well as information and training). The factor that will be examined in this study is the contextual stimulus factor because this stimulus experienced by a person both internally and externally that can affect the workload and residual stimulus is the perception of risk as well as information and training. The purpose of this study was to analyze the factors that influence the anxiety level of nurses during the Covid-19 pandemic at RSUD Kayen Pati.

METHODS
The design of this research was descriptive analytic with a cross-sectional approach. The sample size was 55 respondents, taken according to the inclusion criteria and sampling using the proportional stratified random sampling technique where the sample was determined according to the proportion of each inpatient room and the selection is done randomly using lottery numbers. The respondent recruitment process was carried out by asking for data on the names of nurses who worked at Kayen Hospital in the nursing committee section. Then a room that does not treat Covid-19 patients is selected. After knowing the data of the nurse who will be the respondent, the researcher then contacted the head of each room. The way to maintain the privacy of respondents is to use the initials in the questionnaire sheet, filling out the questionnaire can be done at each respondent's home. Distribute questionnaires to respondents to fill out, then check the filling of the questionnaires to ensure that the questionnaires have been filled out completely by the respondents. The inclusion criteria in this study were nurses who worked in room units that did not handle Covid-19 patients and were cooperative. The exclusion criteria in this study were nurses who were sick so that it could affect the research process and nurses were on leave.
The instrument of perception about risk as well as information and training uses a questionnaire from Gershon et al (1995), the workload instrument uses a questionnaire from Nursalam (2016) while for anxiety instruments uses the Depression Anxiety Stress Scale 42 (DASS) questionnaire. The results of the validity test of the Depression Anxiety Scale 42 (DASS 42) questionnaire on anxiety items that opened 14 questions, a perception questionnaire about risk that would open 3 questions, an information and training questionnaire that operated 4 questions and a workload questionnaire that opened 13 questions, all questions were found on valid questionnaire. The results of the reliability test on the Depression Anxiety Scale 42 (DASS 42) questionnaire on anxiety items that appeared 14 questions, a perception questionnaire about risk that opened 3 questions, an information and training questionnaire that operated 4 questions and a workload questionnaire that appeared 13 questions, the results of all questions were reliable. This research meets the ethical requirements issued by the Health Research Ethics Commission, Faculty of Nursing, Airlangga University, as evidenced by a certificate of passing the ethical review number 2154-KEPK dated February 1, 2021.
The inclusion criteria in this study were nurses who worked in room units that did not treat Covid-19 patients and were cooperative. The exclusion criteria in this study were nurses who were sick so that it could affect the research process and nurses were on leave. The data analysis used by the researcher is by using the help of SPSS. The analysis used logistic regression statistical test with a significance level of p<0.05. The independent variables in this study are perceptions of risk, workload as well as information and training. The dependent variable in this study is the level of anxiety of nurses.

RESULTS
Based on table 1, it can be concluded that the characteristics of respondents based on age are known to be mostly in the age range of 36-45. Based on gender, it is known that most of the respondents are female. Based on the length of work, it is known that most of the respondents have worked longer than 3 years. Based on the level of education, it is known that most of the respondents are D III nursing graduates. Based on marital status, it is known that most of the respondents are married. Based on the room where they work, it is known that most of the respondents work in the cendana room, emergency room and seruni. Based on the history of comorbid diseases, it is known that most of the respondents do not have a history of comorbid diseases. Based on living at home with family, it is known that most of the respondents live at home with family.
There was a significant relationship between perceptions of the risk of anxiety during the Covid-19 pandemic at RSUD Kayen Pati with a p value of 0.001. Most respondents have a good perception of the possibility of being exposed to infection in the workplace (58,2%).
There was a significant relationship between workload and the level of anxiety of nurses during the Covid-19 pandemic at RSUD Kayen Pati with a p value of 0.000. Most of the respondents experienced a moderate workload (41,8%).
There was a significant relationship between information and training with nurses' anxiety levels during the Covid-19 pandemic at RSUD Kayen Pati with a p value of 0.000. Most of the respondents have less information and training about the transmission of the Covid-19 disease (56,4%).  3 shows that the factors related to the anxiety level of nurses during the Covid-19 pandemic which showed significance with a value of <0.05, which can be seen from the workload factor (p = 0.001) as well as information and training (p = 0.002) while the perception about risk (p = 0.995) did not have a significant relationship with the level of anxiety of nurses during the Covid-19 pandemic because it had a value> 0.05.
Determination of the most dominant variable that is most related to nurses' anxiety levels during the Covid-19 pandemic can be seen by looking at the value of Exp (B) from the value of the variable that has a significant relationship <0.05. The most dominant factor affecting nurses' anxiety levels during the Covid-19 pandemic was information and training with an Exp (B) value = 863.566 and the second was workload with an Exp (B) value = 83.072. Respondents who had information and training on the use of PPE during the Covid-19 pandemic had the opportunity to experience anxiety problems by 863.566 times than those who did not. In addition, respondents who have a high workload are 83,072 times more likely to experience anxiety problems than those who do not.

The effect of perceptions of risk on nurses' anxiety levels during the Covid-19 pandemic
The results of the research that have been carried out showed that the perception of risk affects the anxiety level of nurses during the Covid-19 pandemic at RSUD Kayen Pati. The fear of contracting Covid-19 increases the severity of anxiety symptoms. Nurses who have a good perception of the risk of Covid-19 transmission will decrease their level of anxiety.
These results are in line with research which states that one of the factors that is significantly related to psychological problems in the form of anxiety, depression, and insomnia is the perception of the risk of exposure (Hanggoro et al., 2020). Health workers have a good perception of the risk of being infected with Covid-19, most of the respondents are aware that they are more at risk of contracting Covid-19 compared to their families because they spend more time in the hospital (Gorini et al., 2020). In the early stages of the Covid-19 epidemic, health workers were more concerned about the risk of transmitting it to co-workers and family members than themselves. The fear of health workers, especially nurses, transmitting the virus to their families is the main source of this burden of anxiety. They are afraid of being a carrier of the virus that causes transmission to their families and among other health workers (Dai et al., 2020).
The results of the research findings, the perception of risk affects the anxiety level of nurses during the Covid-19 pandemic. Perceptions about the threat of contracting the disease influence the behavior of nurses in preventing this virus. Nurses will increase their vigilance and self-protection in dealing with Covid-19 patients so that the level of anxiety will be reduced. Information: *) p < 0,05 Information: *) p < 0,05

The effect of workload on nurses' anxiety levels during the Covid-19 pandemic
The results of the research that have been carried out show that the workload affects the anxiety level of nurses during the Covid-19 pandemic at RSUD Kayen Pati. Nurses who have a high workload, the level of anxiety will increase. As the number of patients with Covid-19 increases, more health resources are needed, including staff, beds and facilities. Limited resources have an impact on the emergence of pressure and anxiety on health workers, especially nurses. Physical work activities that exceed the capacity of a nurse can reduce productivity at work, so that actions are taken that are not in accordance with applicable procedures. These results are in line with research which states that health workers in the areas most severely affected by Covid-19 have higher anxiety scores than health workers from other areas . These health workers are suffering from a heavy workload due to the increasing number of cases infected with Covid-19. Excessive or high workload results in fatigue of health workers (Laksono, 2021). One of the workloads of nurses during the current Covid-19 pandemic is the intensity of care for patients who require intensive care, in addition to the large number of patients with a minimal number of nurses causing an excessive workload for nurses themselves. Most of the Covid-19 patients who progress to critical condition will require intensive care. Given the challenges of treating this disease, nurses must manage a heavy workload that often requires invasive procedures and a high level of attention. Therefore, maintaining the physical and psychological health of nurses can make a major contribution to the success of controlling this pandemic (Yifan et al., 2020).
The results of the research findings, the workload affects the anxiety level of nurses during the Covid-19 pandemic because most nurses experience a high workload. Based on this, nurses are very at risk of making mistakes in nursing actions so that they are less than optimal to maintain patient safety. The number of nurses must always be pursued in accordance with the workload to produce effective and efficient services.

The effect of information and training on nurses' anxiety levels during the Covid-19 pandemic
The results of the research that have been carried out show that information and training affect the anxiety level of nurses during the Covid-19 pandemic at RSUD Kayen Pati. Nurses who have information and training regarding the use of personal protective equipment (PPE) are not good, then the level of anxiety will increase. This is in line with research which explains that health workers experience moderate depression due to lack of accessibility of formal psychological support, lack of medical information about the outbreak, and less intensive training on personal protective equipment and infection control measures (Tan et al., 2020a). As for the relationship between personal protective equipment and nurses' anxiety, even though nurses have used personal protective equipment, it is possible that they can still be dangerous for patients to infect, especially when they regulate the patient's condition, wipe their sweat, or when taking off the patient's clothes. Transmission of the virus can occur by droplets, or aerosols from Covid19 through the gaps that are formed without being carried out by health workers (Astin & Paembonan, 2021).
The results of the research findings, information and training have a significant and most influential relationship on the anxiety level of nurses during the Covid-19 pandemic. Information on the risk of transmission and how to protect against Covid-19 makes nurses able to increase awareness of the disease and how to overcome this anxiety. Meanwhile, the training consisted of the use of Personal Protective Equipment (PPE) related to the welfare/protection of a team of health professionals and maintaining practice standards during the pandemic. This is for the safety of patients and health workers from the transmission of the Covid-19 disease. Adequate pre-employment training for health workers who will work on the front lines regarding accurate information about disease, risk of transmission and means of protection, establishing systematic diagnostic and treatment protocols with clear guidelines can help reduce depression and increase job confidence.

CONCLUSSION
Perception factors about risk affect nurses' anxiety levels during the Covid-19 pandemic at RSUD Kayen Pati. Nurses who have a good perception of the risk of Covid-19 transmission will decrease their level of anxiety. The workload factor affects the anxiety level of nurses during the Covid-19 pandemic at RSUD Kayen Pati.Nurses who have a high workload, the level of anxiety will increase. Information and training factors affect the anxiety level of nurses during the Covid-19 pandemic at Kayen Pati Hospital. Nurses who have information and training regarding the use of personal protective equipment (PPE) are not good, then the level of anxiety will increase. The most dominant factors affecting the anxiety level of nurses during the Covid-19 pandemic at Kayen Pati Hospital are information and training.
Suggestions for nurses need to improve the prevention and control of Covid-19 disease in treating patients, get support for efforts to resolve anxiety experienced and provide counseling services and receive ongoing education and training regarding the use of Personal Protective Equipment (PPE) before treating Covid-19 patients. Health institutions need to pay more attention and immediately implement policies that support efforts to maintain and restore mental health for health workers, especially nurses.
Steps that can be considered include: the formation of groups that can support efforts to resolve anxiety and the provision of counseling services. It is necessary to increase information and training for nurses regarding the use of Personal Protective Equipment (PPE) before treating Covid-19 patients. Suggestions for further researchers considering that there are still some limitations in this study, it is recommended for further researchers to: a questionnaire about the main causes of anxiety based on open-ended questions can add information that can be answered with more than one reason. The questionnaire used to measure the workload should use subjective and objective measurement instruments.