Emotional Response and Coping Strategies of Nurses Working in COVID Referral Hospitals of Morang District

coping was slightly higher among nurses over thirty-one years old and those with two or more children. Positive and negative emotional responses were associated with problem-focused coping, indicating its influence on both types of responses. Moreover, emotion-focused coping was linked to negative responses


INTRODUCTION
Nepal experienced its first wave in 2020, marked by a four-month cross-country lockdown.A more lethal second wave emerged in April 2021, driven by the delta variation of COVID-19, significantly impacting the country's fragile healthcare system and resulting in widespread damage. 1,2 he symptoms of the virus vary from none to severe, with the severity particularly affecting individuals with comorbidities. 3 The World Health Organization (WHO) has documented more than 772 million verified cases and close to seven million deaths worldwide due to COVID-19, as of December 17, 2023.4,5 Subsequently, in Nepal with over 9 million cases and approximately 12,000 reported deaths as of March 1, 2023.6 The concepts of the illness and preventive measures, such as social distancing, affect both physical and mental health in the general population.The outbreak led to diverse mental reactions, including acute stress, unease, post-traumatic stress disorder, anxiety, and depression. 3As COVID-19 cases rise in Nepal, the country has implemented various forms of lockdown to control the pandemic.While encouraging social distancing to reduce interpersonal interactions and the risk of new infections, these measures have had effects on the overall well-being of the population.7 The increasing number of cases, together with a shortage of personal protective equipment and unclear treatment protocols, adds psychological pressure on healthcare workers.8 Healthcare workers, particularly nurses, are on the frontline, facing occupational risks and emotional burdens.Stressors among healthcare teams arise from separation, changes in home life, and the unique challenges of patient care.Nurses, in particular, spend significant time with confirmed or suspected patients, leading to heightened stress. Likewise, other study done in India found that a considerable percentage of nurses overall suffered depression (41.3%), anxiety (49.1%), and stress (29.5%).15 In a similar vein, according to a study conducted in Nepal, 91.7% of nurses experienced moderate stress, and 5.3% expressed high stress.16 The coping strategies employed by individuals during the pandemic play a crucial role in managing emotional reactions.Effective use of coping mechanisms, whether problem-focused or emotion-focused, can help people navigate stress and mitigate negative emotions.17 While emotion-focused coping is typically defined as striving to regulate uncomfortable emotion, problem-focused coping entails attempts to change the disturbed person's surroundings.18,19 A study found that 92% of nurses utilized moderate coping techniques, while only 3.3% employed high coping methods to lessen their perceived stress. Amidst the challenges faced by healthcare workers, including social stigma and increased caseloads, understanding the emotional responses and coping strategies of nurses becomes paramount.Therefore, the researcher is interested in this study to find out emotional response and coping strategies of nurses working in hospital during COVID-19 pandemic.
Descriptive analysis included obtaining frequency, mean, and standard deviation.The final emotional response score was derived by summing 10 positive and 10 negative items, each on a scale of 10 to 50.Higher positive scores indicated more positive effects, while lower negative scores suggested less negative effects.Mean scores and standard deviations were calculated for coping strategies.Normality tests (Shapiro-Wilk) were conducted for problem-focused coping, emotionfocused coping, positive response, and negative response.As the data were not normally distributed (p-values < 0.05), Mann-Whitney U and Kruskal-Wallis tests were employed to examine differences in emotional response and coping mechanisms.Spearman correlation assessed the relationship between emotional response and coping strategies.Multiple linear regression determined associations between emotional response and coping strategies.Statistical significance was set at p < 0.05.

RESULTS
The study showed that the majority (84.6%) of the respondents were between the ages of 21 and 30 years.Regarding sex of the respondent, most (97.1%) of the respondents was female.Likewise, half (54%) of the respondents were Brahmin/Chettri, 17.7 %and 16 % participants were Terai/Madhesi and Janajati respectively.Half (54%) of the respondents had completed PCL in nursing, 30% completed B. Sc. nursing and least (2%) of the respondents had completed Masters in nursing.Concerning the marital status, two third of the respondents were unmarried.Among the married population, 72% respondent had no children, 16% had one child, 11% had two children and only 0.9% respondent had three children.With regards to type of family, two third of the respondent were from nuclear family.Relating to the family support, almost 94% of the respondent had family support.In employment status, three fourth (73.1%) of the respondents were working in contract basis.Almost Fiftynine percent respondent had 1-5 years of work experience and more than half (56.7%) of respondent had received training related to COVID-19.Table 4 represents the association of coping strategies with demographic variables where there was no significant difference in the use of problem-focused coping in an age whereas emotional-focused coping (p=0.019) was slightly higher in the age group more than 31.Nurses with children two or more used more emotion-focused coping (p=0.004)than the nurse with no children and one, whereas there was no difference in the use of problem-focused coping.Likewise, there was no difference in their use of problem-focused coping and emotion-focused coping in ethnicity, education, employment status and work experience.** Statistically significant (p<0.001),Spearman correlation analysis Table 5 depicts that there was correlation between coping strategies and emotional response as, emotional responses both positive and negative were correlated with problemfocused coping, (r=0.24,p-values=0.000 and r=0.15, p=0.003).
Whereas, no correlation between emotional response (positive and negative) with emotion-focused coping (r=0.05 and 0.08).

DISCUSSION
Covid-19 had created mental distress and anxiety in individual and community people.Emotional response varies from individual to individual whereas for the frontline workers.It was hardest thing to deal with.They faced different problem while balancing the personal and professional life.When facing pandemic, the frontline workers experience variety of anxiety, fear, sadness, anger and frustration.The changing demand of the health care system, working with limited human resources and fear of getting infected while caring the patient causes extreme psychological distress to nurses working in Covid-19 referral centers.Frontline workers' emotional and mental health can be negatively impacted by long-term exposure to high stress in a variety of ways. 23is study found no significant association between perceived stress and any of the socio-demographic variables, including age, sex, ethnicity, education, marital status, family structure, number of children, and residence for family support.This finding is supported by a study that found no association between perceived stress and any of the socio-demographic variables. 3Whereas it contradicts to the findings of the study showed compared to participants from urban areas, participants from rural areas reported higher levels of sadness (p 0.0001, Cohen's d = 0.285), while those from urban expressed greater levels of anxiety (p =0.009), and anger p=0.002,Cohen's d = 0.226). 24Another study conducted in Nepal showed that there was association of stress in nurses with marital status, duty schedule and monthly income. 16Likewise, another study showed age (less than 30 years) and sex (females) were linked to greater levels of perceived stress. 25e findings of the study showed that there was no significant difference in the use of problem-focused coping strategy by age.Although, emotional-focused coping (p=0.019) was somewhat more prevalent in the age group over 31.This finding is coherence with the study conducted among nurses working at Covid and Non-covid hospital.During pandemic, older nurses used more coping strategy than younger nurses. 20The present study showed that nurses with two or more children used more emotion-focused coping (p=0.004)than the nurses with no children and one child.Whereas there was no difference in the use of problem-focused coping, which is supported by the study done on nurses with no children, they used avoidance strategies more frequently than emotional or problem focused coping. 20This study showed that there is no difference in how people use problem-focused coping versus emotion-focused coping based on their ethnicity, level of education, work experience, and place of residence, which is supported by the findings indicating that there was no significant difference in the use of emotion-focused coping and problem-focused coping.However, there is a difference in anxiety level based on the spatial distance of COVID-19 cases. 24Problem-focused coping and emotion-focused coping have no significant difference in employment status.Regardless of employment status, nurses use both problem-focused coping and emotion-focused coping.
The ineffective use of coping mechanisms among nurses can result in burnout, emotional disturbances, and psychological disorders.The health system should consider these factors and pay attention to the nurses working in COVID hospitals during the pandemic.
This study showed that emotional response both positive and negative was correlated with problem-focused coping (p-value < 0.001 and 0.017) which was consistent with the findings of the study. 26Likewise, the findings were supported by the study, which showed that, in addition to sadness, emotional response and coping strategies were correlated with each other (p < 0.001).The findings also cohere with a study that showed a significant correlation between coping strategies and emotional intelligence, whereas there was no correlation between emotional responses (positive and negative) and emotion-focused coping.Similarly, there was a correlation between problem-focused coping and emotion-focused coping (p-value<0.001). 27e relationship between emotional response and coping strategies was determined using multiple linear correlations, which suggests that there was a relationship between coping and emotional response.Problem-focused coping was influential to positive response (p-value <0.001, CI 17.044-27.254)as well as a negative response (p-value-0.000,CI16.467-26.104).Similarly, emotion-focused coping was an influencing factor for negative response (p-value 0.001, 0.062-0.246).According to a study, nurses display more intense emotional reactions and are more willing to employ problem-focused coping strategies than nursing students.Among nurses, there may be a loop of "more coping-more panic."In order to maintain a safe environment while combating COVID-19, hospitals should focus on taking the following steps: providing nurses with more psychological support, enhancing coping mechanisms, setting up adequate healthcare protective equipment, and developing a wide range of interventions to stop the spread of infectious diseases. 24

CONCLUSION
This study concludes that emotional coping is slightly higher in age groups more than thirty-one years and nurses with two or more children.The nurse's emotional responses both positive and negative are correlated with problem-focused coping.This reflects that Problem-focused coping was influential in positive responses as well as negative responses.Similarly, emotionfocused coping was an influencing factor for the negative response

RECOMMENDATION
It is recommended that counseling services with grievances handling should be provided to nurses during the time of pandemic.Furthermore, information regarding coping strategies should be disseminated through training and education to overcome the emotional stress at the time of pandemic/difficult.

LIMITATIONS OF THE STUDY:
Only nurses involved directly in the care of COVID infected patients were not the representative of all the nurses working with different patients in non-COVID wards.Stress and coping strategy were equally applicable for them as new cases identified daily among the non-COVID cases.
The online questionnaire for data collection may include selection bias of study participants.The pre-validated complex scale may not be understandable to all level of participants.
More research with large-scale cases is needed involving nurses working in COVID and non-COVID units to compare the result.

Table 1 : Frequency and mean distribution of emotional response of participants Statements Very slightly or not at all A little Moderately Quite a bit Extremely mean±SD Positive response
Table 1 denotes the emotional response of the respondents where in positive response, active had greater mean score (3.48±1.35)and alert had lower mean score (1.70±1.05)than others.Likewise, in negative response jittery had higher mean score (3.82±1.24)and guilty had lower mean score (1.70±1.11)than others

Table 3 : Association between Emotional Responses with Demographic Variables
Table no 3 reflects that there was no significant difference in relation to emotional response and demographic variables such as age, sex, ethnicity, education, marital status, type of family, no of children, family support residence, and employment status.