ANXIETY AND ITS ASSOCIATED FACTORS AMONG FRONTLINE NURSES DURING COVID-19 PANDEMIC IN SELECTED HOSPITALS OF KATHMANDU, NEPAL

Introduction: Frontline warier especially, nursing workforce were at potential risk of anxiety during COVID-19 Pandemic that could affect their well-being and work performance. Thus, this study aimed to assess the level of anxiety and its associated factors among frontline nurses working in selected hospital of Kathmandu, Nepal. Methods: A descriptive cross-sectional study was conducted during period of January 2022 to February 2022 in Shree Birendra Hospital and Nepal Police Hospital of Kathmandu, Nepal. Non-probability purposive sampling technique was used to select 101 nurses involving in the direct management of COVID-19 patients. Self-administered method using pretested tool was used to collect the data. Descriptive statistics such as frequency, percentage, mean and standard deviation were used to describe selected variables. Fisher exact test was used to find out the association between anxiety and selected variables. Results: More than half of the nurses (66.3%) had mild to moderate level of anxiety whereas, only 8.9% of nurses had severe anxiety. Age (p=0.005), high risk group in family (0.048), fear of being infected with COVID 19 (p=0.021), and working department (p=<0.001) were found to be statistically significant with anxiety among frontline nurses. Conclusion: Frontline nurses are facing high burden of anxiety during COVID 19 Pandemic. It suggests the need of planning of appropriate coping strategies and interventions to safeguard nurses from the physiological distress and consequences of anxiety, ultimately enabling them to provide quality health services.


INTRODUCTION
A novel corona virus disease (COVID) 2019, firstly emerged in Wuhan city of Hubei Province, China in late December 2019, crosses the countries territory and declared public health emergency as well as a pandemic by WHO on 11th March 2020 (Huang et al., 2020;Jin et al., 2020).This serious acute respiratory disease transmitted from the droplet method is responsible for massive morbidity and mortality around the global nations (Jin et al., 2020).Globally, as of 4 August 2021, the total number of confirmed COVID-19 cases reached 199,446,221 including 4244541 deaths, reported to WHO (World Health Organization, 2021).Especially the countries of SEAR (South East Asia Region) with low resources are struggling to manage the overwhelming challenges imposed by this highly infectious disease.The first case of COVID-19 in South East Asia Region was seen in Nepal on 23 January 2020 in a man who had returned from Wuhan, China (Dhakal & Karki, 2020).As the data of 5th August 2021, 7,08,079 COVID-19 cases including 9,994 deaths were reported in Nepal (Ministry of Health and Population, 2021).Due to the fragile health system as well as the open border with India and China, Nepal is facing an escalating burden of COVID-19 affecting people's lives, livelihoods, trade and economy.Health workers especially nurses are the frontline warriors fighting the COVID-19 pandemic by providing direct care, treatment, and life support to COVID-19 patients has a higher rate of exposure than the general population (Maben & Bridges, 2020;Nguyen et al., 2020;Salman et al., 2020).Nurses directly or indirectly involved in the COVID-19 case management were susceptible to anxiety and depression (Lai et al., 2020).The fear of being contaminated, sleep deprivation, stigmatization of COVID-19, social isolation, and the compulsion to perform duty despite the adverse environment to treat patients have 2 lodged health workers at risk of anxiety and other mental health disorders (McGinty, Presskreischer, Han, & Barry, 2020).
This unfolding pandemic placed additional loads on health care workers (HCWs).Nurses possess the largest cohort among frontline health workers directly involved and providing 24/7 services to patients suffering from COVID-19 or susceptible to the COVID-19 infection (Usher et al., 2009;Varghese et al., 2021).Regardless of fearful circumstances, nurses are always on the frontline, exhibiting commitment, compassion, and spend most of their time working at patient bedsides, devoted their personal lives owing to a great sense of duty toward their patients (Fernandez et al., 2020;Kang, Son, Chae, & Corte, 2018;Liu et al., 2020;Pokharel, Shah, Lama, Karki, & Shrestha, 2022).
Nurses spend more time with patients and face greater risks as compared to other health care providers (Luo, Guo, Yu, & Wang, 2020;Pappa et al., 2020;Shechter et al., 2020).Another study also revealed that health care workers especially nurses are at high risk of infection during the COVID-19 pandemic (Sabetian et al., 2021).Nurses involved directly in providing care for patients with COVID-19 have reported significant work-related stress and anxiety (Barello, Palamenghi, & Graffigna, 2020).Previous studies conducted in Saudi Arabia, Bangladesh, Sri Lanka, India, and China reported anxiety among nurses as 51.4%, 51.8%, 53.6%, 9.2%, 18.1% respectively (Alsharif, 2021;Chowdhury et al., 2021;Dharra & Kumar, 2021).Past study in Wuhan observed that factors such as being the only child in their family; long working hours per week; excessive physical energy consumption; and wearing uncomfortable protective equipment that limited their ability to rest, consume food, and use the toilet, influenced nurses' anxiety and stress (Mo et al., 2020).Moreover, other previous studies identified that poor self-confidence, heavy workload, family members in the medical profession, lack of PPE, years of work experience, age, female nurse, contact with COVID-19 cases, and level of education were found to be significant factors associated with anxiety among Nurses during COVID-19 pandemic (Alsharif, 2021;Chowdhury et al., 2021;Dharra & Kumar, 2021;Zheng et al., 2021).
Some studies have been documented anxiety among frontline health workers during COVID-19 pandemic in Nepal.However, limited studies show the figures of anxiety among nurses during the COVID-19 pandemic in the hospitals of Nepal.Similarly, the study setting of most of those studies was outside of the Kathmandu valley.In Nepal, Kathmandu is an epicenter for the COVID-19 cases and most of the referral hospitals are situated in the Kathmandu, capital city of Nepal.Thus, Nurses working in the hospitals of Kathmandu are experiencing surplus burden and workload related to the management of COVID-19 cases as compared to other places of Nepal.It suggests the timely assessment of anxiety among Nurses working in hospitals of Kathmandu, Nepal.Therefore, this study aimed to assess the anxiety and its associated factors among frontline nurses of selected hospitals during COVID-19 pandemic in Kathmandu, Nepal.

Design
A quantitative descriptive cross-sectional study design was applied in this study to assess the anxiety and its associated factors among frontline nurses during COVID-19 pandemic in selected hospitals of Kathmandu, Nepal.The study was conducted during January 2022 to February 2022 which was the period after second wave and starting of third wave of COVID-19 pandemic associated morbidity and mortality.

Population and Sampling
Study population was the nurses of Shree Birendra Hospital and Nepal Police Hospital of Kathmandu who were directly involved in care and treatment of COVID-19 patients during pandemic.Total study population was 250 nurses i.e. 145 nurses in Shree Birendra Hospital and 105 in Nepal Police Hospital.The total number of sample was 101 frontline nurses.Proportion of sample size was calculated as 40.4%.Then, the sample of 59 nurses from Shree Birendra Hospital and 42 nurses from Nepal Police Hospital were selected using non probability purposive sampling technique in this study.Nurses who gave consent and available for data collection were included in the study.

Variables
Dependent variable assessed in this study was anxiety whereas, independent variables were sociodemographic characteristics (age, educational level, marital status, type of family, monthly family income, presence of high risk group in the family) and work related characteristics (job title, employment status, working department, work experience, working hours per week, training on COVID-19 management, availability of PPE, witnessed a death of a COVID-19 patient, fear of being infected, allowance for COVID-19 management).

Instruments
A semi-structured self-administered questionnaire was developed by reviewing the related literature and seeking the opinion from subject experts.Questionnaire was constructed using simple and understandable words in English version.GAD-7(General Anxiety Disorder-7) scale was used for assessing the level of anxiety.GAD-7 scale includes 7 statements related to problems that individual had experienced during COVID-19 patient care.The score of each statement was ranged from 0-3.Total score from the 7 statements were obtained and sum score is used to categorize level of anxiety as minimal anxiety (0-4), mild anxiety (5-9), moderate anxiety (10-14), and severe anxiety (15-21) (Spitzer, Kroenke, Williams, & Löwe, 2006).Questionnaire was divided into three parts: Part I: Questions related to socio-demographic characteristics Part II: Questions related to work related characteristics Part III: Questions to assess the level of anxiety.It was assessed by using GAD -7(General Anxiety Disorder-7) scale (Spitzer et al., 2006).The content validity of the instrument was established by seeking opinion from subject experts, peer groups and related consultant.Similarly, pretesting of the instrument was done among 10% (12 nurses) of the study population in Armed Force Hospital having similar characteristics with the study population to check its clarity, sequence and feasibility with the purpose of maintaining the reliability of the instrument.

Data Collection Procedure
Data was collected after getting ethical approval from the research committee of NAIHS-CON.Written permission for data collection was taken from Shree Birendra Hospital and Nepal Police Hospital.Proportion of sample size of the study was calculated for study settings (two hospitals).Then appropriate sample from both hospitals were selected using purposive sampling technique.Objectives of the research study was clearly explained and informed written consent was obtained from each participant.Anonymity was maintained by asking participants not to write their names.Participants were provided instructions to fill the questionnaire in the presence of researcher to prevent data contamination.It took about 10-15 minutes to fill the questionnaire and collected their responses immediately after filling the questionnaire by respondents.At the end of the data collection, the questionnaires were collected and checked for completeness and consistency.All the procedures of data collection were performed following strict COVID-19 preventive measures.

Data Analysis
Data were checked, coded, classified and entered into statistical package for the social sciences (SPSS) version 16.Data analysis was done through descriptive and inferential statistics.Descriptive statistics i.e. frequency, percentage, mean, standard deviation was used to describe socio demographic characteristics and work-related characteristics.Inferential statistics i.e. chi square test was used to analyze the associations of selected demographic variables with anxiety among frontline nurses.

Ethical Clearance
Ethical clearance to conduct this study was sought from the research committee of NAIHS-CON with reference number of १५४४५/ए/१९/०७८/७९/८३. Informed written consent was obtained prior to the data collection from the participants.Anonymity and confidentiality of participant's information was maintained.

RESULTS
A total of 101 frontline nurses were participated in the study.Table 1 shows that highest proportions (62.4%) of respondents were of age 25-34 years with mean age of 27.80 and standard deviation ± 5.69.Concerning the professional qualification, more than half (52.5%) of respondents had education level of PCL Nursing.Majority of respondents (52.5%) were unmarried.Highest proportion of respondents (64.4%) had nuclear family.Regarding monthly family income highest proportion (42.5%) of the respondents had income of NRS 50,000-1,00,000.Majority of the respondent (52.5%) had no high risk group in their family.
Table 2 shows that the majority of respondents (89.1%) were staff nurse.In terms of employment status, majority of respondents (78.2%) were permanent.28.7% of the respondents were working at general ward.More than half (58.4%) of the respondents had work experience of 1-5 years.Regarding working hours of respondents, it was found that majority of the respondents (93.1%) were working ≤48 hours per week.
Table 3 shows that highest proportion (71.3%) of the respondents were trained on COVID-19 management.Similarly, almost all (91.4%) of the respondents had reported the availability of complete set of PPE.Almost half of the respondents (44.6%) were involved in the care of COVID-19 patient since 4-6 months.Furthermore, 2/3rd of the respondents (74.3%) were witnessed of death of the COVID-19 patient.
Table 4 shows that majority of the respondents (39.6%) had mild level of anxiety whereas least respondents (8.9%) had severe level of anxiety.Table 5 shows that almost half (46.5%) of the respondents feel anxious and almost 1/4th (24.8%) of the respondents were not able to stop or control worrying several days.Similarly, 29.7% of the respondents had mentioned that they worried too much about different things in several days.Furthermore, 29.7% of the respondents were feeling afraid in several days, as if something awful might happen.
Table 6 shows that age (p=0.005) and high risk group in family (p=0.048)were found to be statistically significant with level of anxiety.However,  *p≤0.05 is statistically significant educational level, marital status, type of family, monthly family income, and high risk group in family were not found to be associated with level of anxiety among nurses.
Table 7 shows that only working department (p=<0.001)was found to be statistically significant with level of anxiety.However, job title, employment status, working department, work experience, and working hours per week were not found to be associated with level of anxiety among nurses.Table 8 shows that fear of being infected with COVID-19 (p=0.021) was found to be statistically significant with level of anxiety.However, training on COVID-19 management, availability of PPE, witness of death of COVID-19 patient, and allowances for COVID-19 management were not found to be associated with level of anxiety among nurses.

DISCUSSION
The results of the present study shows that, majority (39.6%) of the nurses experienced minimal level of anxiety followed by moderate level of anxiety (26.7%) and high level of anxiety (8.9%).This findings is nearly consistent with the findings of the study conducted among 83 nurses in India which showed 33.33% and 4.8% nurses who worked as frontline workers had experienced moderate level of anxiety and severe anxiety respectively (Cornelio, Suseel, & Thomas, 2021).This finding is contrast with the finding of study carried out among 152 nurses in kaski district, Nepal where 7.9%, 20.4% and 9.9% of the nurses had experienced mild, moderate, and severe level of anxiety respectively (Silwal et al., 2020).
Similarly, another study conducted in Chitwan Medical College and Teaching Hospital among 181 nurses revealed that current study findings regarding anxiety was higher as compared to their study findings (Neupane, Angadi, Joshi, & Neupane, 2020).It demonstrated that 1.1 % and 10.5% of the nurses had experienced intense to severe and mild to moderate level of anxiety during COVID-19 pandemic respectively.The probable reason for the difference in this finding could be due to the study settings.Furthermore, another reason might be due to time period of the study where this study was conducted after second wave of COVID-19 pandemic in Nepal i.e., possess high morbidity and mortality due to COVID-19 while other studies were conducted during first wave of COVID-19 pandemic in Nepal i.e., less morbidity and mortality due to COVID-19 in comparison to second wave.
Present study shows that age (p=0.030) was significantly associated with anxiety among nurses.This result is consistent with studies conducted among nurses in China with p<0.01 (Lai et al., 2020) and Finland with p<0.01 (Mattila et al., 2021) .However, studies of Pakistan (Khan et al., 2021) and Philippines (Labrague & De los Santos, 2020) shown the contradict result that age was not associated with anxiety.This difference in result could be due to sample size, study setting, and wave of COVID-19.
Similarly, working department (p<0.01) was found to be associated with anxiety among nurses in this study.It was supported by study conducted in China where working department was statistically significant with anxiety among nurses (Zheng et al., 2021).
Fear of being infected with COVID-19 (p=<0.01)also observed to be associated with anxiety among nurses working in hospital during COVID-19 pandemic.The studies among nurses in China (Zheng et al., 2021)and among health workers in Nepal (Barello et al., 2020)during COVID-19 pandemic found the similar findings of this study i.e., association of fear of being infected with COVID-19 and anxiety.
This study was conducted in only two central hospitals of Kathmandu which limits the generalization of the study.The findings of the study might be helpful for hospital administration to provide psychological preparedness training before posting nurses on duty and conduct psychological interventions and support like stress relieving programs, motivational program to enhance better working environment, sound mental health among nurses for standardization in patient care.The finding of this study might be useful as a source of reference for the further research in this area.

CONCLUSSION
Based on the findings of the study, the study concludes that there is high burden of anxiety among frontline nurses during COVID-19 Pandemic.Age, high-risk group in family, working department, and fear of being infected with COVID-19 were statistically significant predictors of increased level of anxiety among frontline nurses.Therefore, significant interventions addressing these factors should be planned and endorsed to overcome the burden of anxiety among frontline nurses which will ultimately aids to maintain the mental health of the nurses and beneficial for patient management during this COVID-19 pandemic.

Table 2 .
Work related characteristics of the participants (n=101)

Table 6 .
Association of level of anxiety with socio-demographic variables (n=101)

Table 7 .
Association of level of anxiety with work related variables (n=101)

Table 8 .
Association of level of anxiety with COVID-19 related variables (n=101)