Hrev_master [Healthcare in Low-resource Settings 2023; 11:10642] [page 11] Fear of COVID-19 among critical care nurses of public hospitals in Lahore: empirical evidence during third wave Asma Nadeem,1 Rubina Jabeen,2 Shehla Nazir,3 Shahbaz Haider4 1Services Hospital Lahore; 2Superior College of Nursing, Lahore; 3Mayo Hospital, Lahore; 4Superior University, Lahore, Pakistan Abstract The world has seen a pandemic that dis- rupted life. Till now there are aftershocks of COVID-19 such as Omicron instilling fear among individuals. Healthcare staff is on alert specifically the nurses have suffered a lot mentally due to this issue by developing fatigue. The study was conducted during the deadly 3rd COVID-19 wave. The data were collected by developing the questionnaire of the previously validated measures related to the variables under study from nurses working in the intensive care unit, critical care unit, and floor wards of COVID-19 at Services Hospital, Lahore. A total of 140 questionnaires were used for data analysis. The study used Statistical Package for Social Sciences for frequency and descrip- tive statistics. Whereas the outcomes of fear of COVID-19 were assessed by using the latest Smart Partial Least Squares software which allows to assess the complex research frameworks. The results of the study revealed that the fear of COVID-19 results in poor quality of life among nurses and fatigue. Resilience among nurses can reduce the negative consequences but did not get statistical support. Introduction The world has been changed due to the pandemic situation of COVID-19 that affected countries globally, after the prima- ry epidemic in Wuhan, China1 due to which globally on May 20th, 2021, the affirmed instances of Coronavirus (COVID-19) recorded 84,780,171 with 1,853,525 deaths. In Pakistan, the confirmed cases were 893,461, with 20,089 deaths.2 The Government of Pakistan took a quick deci- sion in the form of a complete lockdown in the country, to stop the spread of the virus. All educational institutes, universities, and public and private schools are completely closed. The Government applied smart and micro-smart lockdowns to prevent the spreading of the virus. However, 3rd wave started in March 2021 day by day new affirmed cases and death cases rising rapid- ly. The third wave essentially influenced the areas of Punjab and Khyber Pakhtunkhwa. The deadly disease was not just caused by a high passing rate from the viral con- tamination yet additionally disturbed men- tal relaxation.3 Notably, the healthcare pro- fessionals remained on duty since they work under high tense climate resulting in emotional wellness issues.4 In Emergency and Outdoor departments the healthcare staff is at high risk instead of other depart- ments5 as they have to deal with the patients. More importantly, nurses are being the frontline employees of healthcare and are confronted with the massive difficulties caused by COVID-196 for instance, the death rate due to the COVID-19 may dis- turb them mentally7 because they are the ones who have to deal with the patient first. Notably, COVID-19 presence resulted in mental illness and fear of getting affected by the virus8-9 as they directly provide patient care to the patients affected by COVID-19 due to the shortage of PPE (Personal protective equipment). Additionally, higher fear of COVID-19 was found to reduce mental well-being and high- er emotional suffering.10 In other words, nurses are found at the edge of developing higher fatigue while treating patients affect- ed by COVID-19. It is supported by the pre- vious study which reported that COVID-19 resulted in mental health issues for instance, fatigue and reduced professional quality of life,6 nervousness, melancholy, and fanatical habitual indications among nurses.11 Fear of COVID-19 also results in decreased profes- sional quality of life among nurses. Notably, nurses may encounter an undeniable degree of fatigue12 due to the decreased profession- al quality of life as they are always triggered by the fear of getting affected by COVID-19 while serving such patients. In such circum- stances, resilience emerges to be the solution for increasing the quality of life along with decreasing fatigue among nurses. Resilience denotes the ability of an indi- vidual to manage adversity and positively respond to it without having long-lasting mental illness or stress.13 The fatigue could be reduced by developing resilience because it helps to fight tension14 and adver- sity.15 Besides nursing is a challenging pro- fession, it requires a great deal of dedica- tion, determination, and devotion for a bet- ter tomorrow. Accordingly, nurses’ ability to bounce back in difficult times is necessary to ensure their superior professional quality of life along with decreasing their fatigue. Along these lines, the capacity of nursing understudies to bounce back or individual versatility is fundamental to secure inner control, sympathy, helpful self-idea, associ- ation, and good faith in their regular diffi- culties. So it becomes necessary to address these issues so they can be prevented as the healthcare frontline staff cannot be sent home on leave. Therefore, the study consid- ered that fatigue occurs due to Fear of COVID-19 since it damages the profession- al quality of life which further can be reduced by developing resilience among Healthcare in Low-resource Settings 2023; volume 11:10642 Correspondence: Shahbaz Haider Superior College of Nursing, Lahore, Pak town Kamoke, Pakistan. Tel.: +92.3086149902. E-mail: Shahbazhaider199@gmail.com Key words: nursing practice environment, staffing adequacy, nurse leader, quality of care, patient care. Contribution: all the authors have equally con- tributed to this paper. Funding: this research study is not funded by any institute/agency. Conflict of interest: the Authors declare no conflict of interest. Ethics approval: the research study is approved by the research committee of Superior College of Nursing, Lahore (Ref. # SCN/RC/2021-RN07) Patient consent for publication: not applicable to the present study as data were not collected from the patients. Availability of data and materials: the underly- ing data are available from the corresponding author on request Acknowledgments: we acknowledge all the nurses who participated in the study voluntarily. Received for publication: 28 May 2022. Accepted for publication: 23 April 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:10642 doi:10.4081/hls.2023.10642 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guar- anteed or endorsed by the publisher. No n- co mm er cia l u se on ly nurses. Materials and Methods Population and sample size The target population was the nurses both males and females, working in Services Hospital, Lahore. Data were col- lected by using convenience sampling from the nurses working the COVID-19 Intensive care units (ICU), Critical care units (CCU), and ward floor of the Services Hospital, Lahore. As the population of the study is finite, the Yamane16 formula was used17 to determine the minimum sample size. According to the formula, the sample size for the present study should be 150 at ±5%. Below is the formula we used: In this formula n = Sample size; N = Total population; e = Precision level As per the calculations, the minimum sample for the study is 150 respondents. However, to address the non-response bias sample size was inflated by 20%. Previously it is recommended to inflate the sample size to attain the minimum required responses.18 Therefore, the sample size of the present study is 180 respondents. According to Hair et al.19 100 is the mini- mum sample size when there are five or fewer constructs in the model. Questionnaire and measurement Data were collected by using the ques- tionnaire. It contained questions related to the demography of the respondents and variables as well. All of the questions were adapted from the previous studies, the details of which are as follows; Fear of COVID-19 was assessed by using a 7-item measure. COVID-related quality of life was measured by a 12-item measure. It is the brief version adapted from the World Health Organization-Quality of Life brief scale.20 The scale used for quality of life was modi- fied by adding the following at the start of each item “COVID-19 pandemic”. For instance, the COVID-19 pandemic dis- turbed your quality of life. To measure the resilience among the nurses 6-item brief resilience questionnaire was adapted.14 The scale of resilience was adopted as its origi- nal version. Finally, fatigue among nurses was measured by 10 items.21 Point 5-Likert scale used for all the measures ranging from 1 = strongly disagree, 2 = disagree, 3 = neu- tral, 4 = agree, and 5 = strongly agree. The questionnaire was then sent to two nursing professionals and an academic expert to see Article Table 1. Descriptive statistics and correlation. Mean SD FC QL Ft RS Skewness Kurtosis FC 3.20 0.779 1 - - - -0.574 0.153 QL 3.72 0.607 0.410** 1 - - -1.320 2.666 Ft 3.43 0.663 0.455** 0.554** 1 - -0.924 0.655 RS 3.08 0.889 0.295** 0.277 0.202** 1 -0.469 -0.264 [page 12] [Healthcare in Low-resource Settings 2023; 11:10642] Table 2. Confirmatory factor analysis. Constructs Items Loadings Alpha rho_A CR AVE Fear of COVID-19 FC1 0.717 0.819 0.821 0.868 0.522 FC2 0.72 FC3 0.74 FC4 0.72 FC6 0.692 FC7 0.746 Fatigue Ft1 0.717 0.886 0.888 0.909 0.555 Ft2 0.759 Ft3 0.699 Ft5 0.785 Ft6 0.727 Ft7 0.784 Ft8 0.751 Ft9 0.735 Quality of life QL1 0.776 0.866 0.874 0.894 0.514 QL10 0.676 QL11 0.724 QL2 0.76 QL3 0.726 QL4 0.666 QL8 0.723 QL9 0.675 Resilience RS1 0.739 0.878 0.912 0.904 0.612 RS2 0.881 RS3 0.775 RS4 0.808 RS5 0.8 RS6 0.674 No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2023; 11:10642] [page 13] whether it matches the context of the study. Few changes were made and A total of 180 questionnaires were distributed among the nurses working the COVID-19-related wards floors, ICU, and CCU wards as well. A total of 140 questionnaires were collected from the respondents. Ethical considerations All of the participants were informed about their volunteer participation in the study without any reward or gift. They were not forced to participate in the study as well. Additionally, all of the questionnaires were designed in such a way that they do not reveal the participant’s identity to the researcher or others (complete secrecy of the data collected). It was ensured that the data collected would be used for research purposes only. All of the necessary permis- sions were obtained from the Superior College of Nursing as well. Results Demographic profile of the respon- dents The study sample comprised 140 respondents working in the critical care units and ward floors with COVID-19. Males constituted 15% and females consti- tuted 85% of the sample size. The majority of the sample of the study belonged to the age group of 21-30 years (54.3%). Whereas, 32.1%, 12.1%, and only 1.4% of the respon- dents belonged to the 31-40 years, 41- 50years and 51-60 years of age groups respectively. Moreover, 62.1% and 37.9% of the respondents belonged to Islam and Christianity. The majority of the respon- dents were having BPS 16 (87.9%) and BPS 17 (21.1%). Regarding duties 41.1%, 33.6%, and 25% of the respondents were assigned to provide services at COVID- ICU, COVID-ISOLATION, and COVID- WARDFLOOR respectively. Most of the respondents had experience working as a nurse from 4 years to 6 years (27.9%). Whereas only 17.1% of nurses were having more than 12 years of experience. Descriptive statistics and correlation The following Table 1 shows the descriptive statistics and correlation. As per the findings reported in Table 1 mean values for the variables namely; fear of COVID- 19, quality of life, fatigue and nurse resilience were 3.20, 3.72, 3.43, and 3.08 respectively. Additionally, the table also shows the values of skewness and kurtosis. Notably, all of the values for skewness and kurtosis ranged from +2 to -2 which estab- lishes the data normality. All of the vari- ables were found to be significantly corre- lated with the highest correlation between fatigue and quality of life valued at 0.557. Confirmatory factor analysis Tables 2, and 3 shows the results for the confirmatory factor analysis. First of all, Cronbach’s Alpha values for all the vari- ables are greater than 0.7 indicating reliabil- ity. Secondly, the values of the factor load- ings are greater than 0.5 along with Average Variance Extracted (AVE) greater than 0.50 indicating the convergent validity of the constructs. Finally, the results also show the value of the Composite Reliability (CR) for the variables which is greater than 0.8 indi- cating the reliability. Discriminant validity Conducting cross-sectional research where the relationship between the vari- ables it becomes necessary to assess the dis- criminant validity to assure that variables are different from each other. Accordingly, the present study has used the Heterotrait- Monotrait Correlation Ratio (HTMT) to assess the discriminant validity. The values of HTMT for all the variables less than 0.85 indicates that all of the constructs are differ- ent.22 As per the findings reported in Table 3 all of the values are less than 0.85 estab- lished the discriminant validity. Path coefficients The following Table 4 shows the values for the path coefficients, explained vari- ance, and collinearity statistics. As per the results of the study R2 for fear of COVID- 19 regarding fatigue is valued at 0.346, indicating that fear of COVID-19 has cap- tured the 34.6% variance in fatigue while it captured the 22.2% variance in quality of life of nurses. Additionally, the VIF value for variables ranged between 1.088 and 1.195 indicating no multi-collinearity issue in the data. Moreover, the table also shows the path coefficients for the relationship between the variables. As per the results reported in Table 4, fear of COVID-19 was found to positively influence both fatigues among nurses (β=0.251, t=2.377, p=0.017) and quality of life (β= 0.332, t=3.969, p=0.000) indicating that one unit increase in fear of COVID-19 will increase in poor quality of life and fatigue among nurses working at COVID-19 ICU, ward floors and isolations. Additionally, the poor quality of life among nurses was found to be a signification medi- ator between the fear of COVID-19 and fatigue among nurses (β= 0.146, t=2.512, p=0.012). Whereas resilience was found too weak in the relationship between the fear of COVID-19 and quality of life among nurses but did not find statistical support (β= - Article Table 3. HTMT. FOC Ft QOL RS FOC - Ft 0.493 - QOL 0.446 0.589 - RS 0.356 0.238 0.348 - Table 4. Path coefficients Standardized estimates Significance Decision Explained variance Collinearity Hypotheses β SD t value p value S/US R2 VIF FOC -> Ft 0.251 0.106 2.377 0.017 S 0.346 1.195 FOC -> QOL 0.332 0.084 3.969 0 S 0.222 1.088 QOL -> Ft 0.44 0.097 4.552 0 S - 1.195 FOC -> QOL -> Ft 0.146 0.058 2.512 0.012 S - - FOC*RS -> QOL -0.019 0.117 0.163 0.87 US - - S, Supported; US, Unsupported; FOC, Fear of COVID-19; QOL, Quality of life; Ft, Fatigue; RS, Resilience. No n- co mm er cia l u se on ly [page 14] [Healthcare in Low-resource Settings 2023; 11:10642] 0.019, t=0.163, p=0.87). Discussion Nurses play a significant role by provid- ing humanitarian services to our healthcare centers.23 They face different adversities at the workplace such as emotional labor, deaths, violence, harassment, etc. The rise of some critical social, psychological, and economic impacts globally due to the COVID-19 pandemic.24 It has been proven by recent studies that the symp- toms of anxiety and depression are get- ting more common in people25 as well as in nurses. Considering the importance of the issue the aim of the study was to examine the outcomes of fear of COVID- 19 among nurses who are providing healthcare services to the COVID-19 affected patients during the 3rd wave in services hospitals of Pakistan. It was hypothesized that the fear of COVID-19 among nurses will result in a poor quality of life. In support of our hypothesis, the study results revealed a pos- itive influence of COVID-19 on the poor quality of life among nurses. It may be the scenario that a nurse who is doing duty in the COVID-19 ward ICU or isolation or ward floor may get worried about getting affected by COVID-19 or maybe worried to communicate the infection to his/her family members at home after duty is over. Healthcare workers were found to have depression, anxiety, and low well-being during COVID-19, especially, the workers working in ICUs26 because the pandemic changed the structure of ICUs as compared to other departments. And, approximately 10% of front-line professionals were found to have stress.27 On the other hand, COVID- 19 has resulted in different changes in the daily life of individuals due to lockdowns and strict compliance with the Standard Operating Procedures (SOPs).28 Accordingly, the study has provided evi- dence of the influence of the fear of COVID-19 and fatigue among nurses. Additionally, the study results also sup- ported the relationship between poor quality of life and fatigue among nurses. Poor qual- ity of life tends positively drive fatigue among nurses.29-30 Previously available empirical evidence also supports this asser- tion that COVID-19 results in poor quality of life,31-33 for instance,34 contended that COVID-19 has affected the quality of life among nurse students resulting in poor well-being and mental health as well. The results not only supported the hypothesis but also enriched the empirical evidence from the nurse practitioners’ perspective serving the COVID-19 affected patients. Results of the study revealed that the poor quality of life among nurses positively mediates the relationship between the fear of COVID-19 and fatigue among nurses. These results are consistent with the previ- ous studies, for instance, previous evidence has put forward that the quality of life of nurse students has been adversely impacted by COVID-19 resulting in negative conse- quences such as stress.35 The study results also revealed that the poor quality of life among the nurses results in fatigue among them due to COVID-19. Finally, the study also revealed that resilience among nurses tends to weaken the relationship between the fear of COVID-19 and poor quality of life. But it did not obtain statistical support and the reason may be attributed to the fact that all of them are not fully aware of resilience or data were collected from only a single hospital. Limitations and future directions The study has accomplished its objec- tives, but still, some limitations need to be addressed and serve as a future research area. For instance, the study has examined the influence of the fear of COVID-19 on mental health by considering fatigue but due to its cross-sectional nature, it did not result in the causality. So future studies are suggested to consider the longitudinal research design. The sample of the study was dominated by female participants, thus, future studies while considering more inclu- sion of male nurses will enrich the insights into the fear of COVID-19. Notably, we are still living in COVID-19 affected communi- ty and since the Omicron is there, future studies may explore the role of media in creating fear among the healthcare staff. Conclusions Based on the results of the study it is stated that the nurses reported fear of COVID-19 while caring for the patients infected with COVID-19. They feared get- ting infected and carrying that infection to their family members as well. Additionally, results also revealed that it triggers fatigue. Considering the limitations of the study, the findings demonstrate that the pandemic has exerted a negative influence on nurses in the form of fear of either getting infected or carrying the infection to their family mem- bers, ultimately, having a poor quality of life. Therefore, the frontline nurses dealing with the infected patients should be provid- ed with the appropriate safety equipment by the hospitals so they may feel safe and develop less fatigue. The findings also demonstrate that the negative outcomes can be tacked or reduced by developing positive personality attributes such as resilience. So hospitals should provide training to develop adaptability among nurses to enrich fearless and safe patient care. The study is not estab- lishing any cause-and-effect relationship since it is not an experimental research study, so the conclusions must be made by considering this fact. References 1. Jones DS. History in a crisis – lessons for Covid-19. 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