Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12850 Anxiety among nurses in caring for COVID-19 patients: a qualitative study Sri Eka Wahyuni,1 Budi Anna Keliat,2 Herni Susanti,2 Besral3 1Department of Psychiatric and Community Nursing, Faculty of Nursing, Universitas Sumatera Utara; 2Department of Mental Health Nursing, Faculty of Nursing, Universitas Indonesia, Depok; 3Department of Biostatistics and Population Studies, Faculty of Public Health, Universitas Indonesia, Depok, Indinesia Abstract This study aimed to explore anxiety among nurses in caring for Coronavirus Disease 2019 (COVID-19) patients. A qualitative descriptive design was used and the number of participants was 13 nurse managers selected using the purposive sampling method. Data collection was conducted using in-depth interviews coupled with a tape recorder and camera following the consent of partici- pants, while framework analysis was used to analyze data. The results showed that participants, comprising 12 females and one male, had work duration in the range of 1-10 years. The identified five major themes included: i) anxiety response, ii) risk factor, iii) protective factor, iv) interventions, and v) anticipated support from nurses. Nurses were found to experience anxiety when car- ing for COVID-19 patients, underscoring the need for mental health and psychosocial support to reduce risk factors, increase protective factors, and improve coping mechanisms, fostering resilience. The results provided data to help nurses overcome anx- iety when facing cases of infection such as the COVID-19 pan- demic. Furthermore, this study offered valuable insights for the government and hospitals in establishing policies regarding the importance of mental and psychological health support to main- tain the well-being of nurses. Introduction The Coronavirus Disease 2019 (COVID-19) pandemic is caused by a respiratory system infection attributed to the Coronavirus.1 This pandemic has rapidly spread globally with a prevalence of around 218 million cases and a national count of 4 million cases.2 The associated death toll worldwide is 4 million cases, while in Indonesia, the number of death cases is estimated at 134,930. The percentage of cases is 1.83% lower than the global cases, but the death rate is 3.3% higher. These data underscore the highly infectious nature of COVID-19 and its impact on the psy- chology of nurses. The onset of COVID-19 has led to the occurrence of anxiety among nurses working in hospitals, resulting in a feeling of worry and unease in response to stressful and threatening situations. Anxiety is associated with unpleasant feelings, restlessness, fear, and worry, representing a normal reaction to stress and threats.3 This condition arises due to changes in the work environment of nurses, such as an increase in infection cases, injuries, and the traumatic experiences of caring for patients, which can affect pro- ductivity.3-5 Based on the data, the increase in infection cases, such as the COVID-19 pandemic, leads to a two times risk of anxiety among nurses. Before the pandemic, the prevalence of anxiety among nurses was 12% in Europe, 5.6% in China, and 20% in intensive care units.3 Meanwhile, the prevalence during the pan- demic was 54.3% in Portugal,6 33.4% in China, and 46.5% in intensive care units.7.8 In Indonesia, the prevalence of anxiety before and during the COVID-19 pandemic was 18%,9 and 33% respectively.10 As the primary healthcare team that accompanies clients, there is a need to investigate anxiety among nurses in rela- tion to caring for COVID-19 patients. Nurses can adapt to stres- sors to effectively help clients but studies conducted in Indonesia or Medan regarding this topic are limited. Therefore, this study aimed to investigate anxiety among nurses in caring for COVID- 19 patients. Correspondence: Sri Eka Wahyuni, Department of Psychiatric and Community Nursing, Faculty of Nursing, Universitas Sumatera Utara, Indonesia. Email: eka_rizky06@yahoo.co.id Key words: anxiety; nurses; pandemic. Contributions: all authors discussed the results. All author responbility following: previous study and design and data collection. The others con- tributed the final manuscript. Ethica approval: in the preparation stage, permission was obtained from hospitals and the UI Faculty Nursing Ethics Commission with No. KET- 264/UN2.F12.D1.2.1/PPM.00.02/2022, while in the implementation stage, a quiet room was prepared to conduct in-depth interviews. Availability of data and material: the data of this study are available on request from corresponding author. Conflict of interests: the authors declare no conflicts of interest. Funding: none. Conference presentation: this work was presented at the 3rd International Nursing Scholar Congress 2023, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia. Acknowledgment: we would like to thank all the collaborators who are currently working on Received: 25 July 2024. Accepted: 25 July 2024. Early access: 25 July 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:12850 doi:10.4081/hls.2024.12850 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, 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 guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:12850] [page 645] Non -co mmerc ial us e o nly Materials and Methods This study used a descriptive qualitative design to explore anx- iety among nurses, and participants were 13 nurse managers sam- pled from several hospitals in Medan City. Participants were recruited using a purposive sampling method with the following inclusion criteria: nurse managers in the COVID-19 unit and able to provide informed consent. Data collection was carried out from November to December 2022, and this study comprised two stages, namely preparation and implementation. In the preparation stage, permission was obtained from hospitals and the UI Faculty Nursing Ethics Commission with No. KET- 264/UN2.F12.D1.2.1/PPM.00.02/2022, while in the implementa- tion stage, a quiet room was prepared to conduct in-depth inter- views. During the interviews, only the interviewer and participant were present, sitting face-to-face to ensure eye contact. Furthermore, interrogative questions were avoided to ensure par- ticipants could answer questions openly. Interviews were conduct- ed according to agreement with the participants and took 30 to 60 minutes. Study data including recordings stored and protection car- ried several years. A tape recorder and camera were used to assist the study process with the permission of the participants. Field notes were used to record nonverbal communication supporting or contradicting verbal communication and record environmental conditions. After the interview process, the results were presented in a transcript for validation and clarification to participants, while framework analysis was used to analyze the data. Framework analysis which consists of 5 steps: data familiarization, identification of thematic framework, indexing all studies related to the framework, conducting a data index summary using charts/charting and mapping/interpretation. Analysis was carried out using tools manually. The trustworthiness of the findings were indicated by data credibility, conformability, dependability, and transferability. Data credibility is carried out by prolonged engagement with data and findings, triangulating data sources, methods and investigators and carrying out member checking and identifying different findings.To ensure accurate descriptions and coding, researchers consulted with supervisors/experts. To confirm the results, researchers used more than two questions to explore the phenomenon. Coding is used during the analysis process to increase dependability. Confirmability is carried out through audits of the research process. To obtain rich data with information that can be confirmed, researchers recruited participants who have experience caring for COVID-19 clients. The researcher investigates and describes all the details of the research starting from selecting participants, collecting and analyzing data and comparing the data obtained.Transferability carried out in this research is by providing a research report as a thick description. The data were considered credible because they came directly from informants, who were the most trustworthy sources of infor- mation. The generated keywords, codes, and themes were re-read and re-checked by another researcher. Conformability of data was also supported by the fact. The triangulation of data collection by combining interviews with field observation to increased the trust- worthiness of the findings. The transferability of this study findings can be considered at other nurses in Indonesia or another country. Results The result showed that the majority (5) of nurse managers were in the age range of 40-44 years, with 11 being married, and only one had a master’s degree in nursing. Moreover, a significant proportion (12) were females, and six had worked for a duration of 1-10 years. The demographic characteristics are presented in Table 1. The result showed that five major themes included: i) anxiety response, ii) risk factor, iii) protective factor, iv) interventions, and v) anticipated support from nurses. The themes and categories are presented in Table 2 below. Anxiety response This theme showed the various dimensions of anxiety respons- es among nurses including cognitive, physiological, behavioral, social, and affective. Several informants explained that the cognitive response they experienced was fear of being infected and infecting other people. The physiological response experienced by Article Table 1. Nurse manager demographic characteristics. Variable Frequency (f) Age 30–34 1 35–39 2 40–44 5 45–49 3 50–54 2 Marital status Married 11 Separated 2 Educational level Ners 12 Master of Nursing 1 Sex Female 12 Male 1 Work Duration (years) 1-10 6 11-20 5 21-30 2 Table 2. Themes and categories that emerged. Themes Categories Anxiety response Cognitive response Physiological response Behavior response Social response Affective response Risk Factor Biological factor Psycholigical factor Socialcultural factor Protective Factor Biological factor Psychological factor Socialcultural factor Interventions conducted to address anxiety Cognitive coping Spiritual Coping Ego-focused coping Problem-focused coping Expected Support Family Peer Institusional [page 646] [Healthcare in Low-resource Settings 2024;12:12850] Non -co mmerc ial us e o nly several informants was fatigue. The social response experienced by several informants was feeling isolated from family and other people. The behavioral response experienced by several informants was to carry out preventive activities repeatedly to prevent infection. Meanwhile, the affective response experienced was that several informants felt sad and cried seeing the condition of the COVID-19 pandemic which did not know when it would end. The various responses of nurse managers include: “… afraid of getting infected and transmitting it to others …”. “Tired, surely there is fatigue …”, “At that time, when we returned home, I took a shower first. At my house, it feels unfamiliar, there is a different bed for the children and my husband …”, “So, we are on our own, isolating ourselves…”, “Sometimes I cry alone, wondering when this will pass, like, it’s okay, just cry …”. Risk factor This theme showed evidence that the risk factors of nurses were biological, psychological, and social-cultural. The biological risk factor experienced was the informant’s exposure to cases of infection. The risk factor experienced by several informants was a lack of knowledge regarding COVID-19. The sociocultural risk factors experienced by several informants were feeling shunned by other people. The responses from nurse managers were as follows: “… fear of transmitting it…”, “Lack of knowledge about the dis- ease …”, “Avoid people …”. Protective factor This theme showed evidence that the protective factors of nurses included biological, psychological, and social-cultural. The biological protective factor possessed by several informants is young age. The psychological factor is the experience of the informant and the socio-cultural factor is the informant’s single status (not yet married). The various responses from nurse man- agers include: “… The age of 21-30 is still considered young …”, “Having experience in the field for at least 1 year …”, “Everyone is still young women, single…”. Overcoming anxiety This theme showed strategies used to overcome anxiety among nurses including cognitive, spiritual, ego-focused, and problem- focused coping. Several informants explained that cognitive coping was done by thinking positively about the current situation and conditions they were experiencing. Several informants explained that spiritual coping was also done by getting closer to God and carrying out religious activities such as praying. Some informants used ego-focused coping by trying to enjoy and think about happiness. Some informants also carried out problem- focused coping by breathing relaxation. The responses from nurse managers were as follows: “… positive thinking …”, “closer to God, prayer …”, “…relaxation…”, “…Just bring happiness, enjoy…”. Expected support This theme showed the expected support of nurses from fami- ly, peer, and institutional. Several informants hoped for support from the family in the form of motivation and encouragement. Several informants hoped for support from friends such as helping at work, reminding each other, collaborating with each other and coordinating in caring for COVID-19 clients. Several informants also hoped for support from the hospital in the form of increasing knowledge and information through training. The responses received from nurse managers were as follows: “… give encour- agement and motivation…”, “…Mutual reminders, cooperation, and coordination, mutually reinforcing…”, “…given training, sharing information…” Discussion Theme 1. Anxiety response The results showed that the theme on signs and symptoms of anxiety experienced by nurses regarding COVID-19 consisted of five sub-themes, namely physiological, behavioral, cognitive, affective, and social. Signs and symptoms of anxiety are associated with the response of the body to stressors that can be observed directly or indirectly through physiological, behavioral, cognitive, affective, and social changes.11 The physiological responses shown in this study were fatigue, difficulty sleeping, breathing, and urinating, as well as headaches. The results were consistent with physiological responses such as respiratory changes, neuromuscular changes, and urinary tract changes.11 The behavioral response is crucial to avoid transmission from the source, as nurses fear both contracting and transmitting the infection to others. Extra preventive measures include double- masking, spraying money with disinfectant, repeatedly washing hands with hand sanitizer, and repeated bathing, with some partic- ipants reporting migraines due to frequent bathing. The cognitive response experienced by nurses included nega- tive thoughts such as feeling that the virus was still present in the hair or on fruit even after bathing and washing, fear of death, fear of being blamed, feelings of fear/worry/anxiety of contracting or transmitting the infection to others, and confusion about what to do when caring for COVID-19 patients. A similar study reported that cognitive responses to anxiety included concentration/evaluation/attention, fear and decreased productivi- ty, attention disturbances, poor concentration, forgetfulness, judg- ment errors, preoccupation, thought blocking, decreased percep- tion field, confusion, and embarrassment.11 Affective responses experienced by nurses included sadness, crying, and mood changes such as feeling irritated and emotionally affected when caring for COVID-19 patients. This aspect reported- ly consisted of impatience, nervousness, tension, unease, dread, frustration, helplessness, worry, terror, anxiety, restlessness, numb- ness, guilt, and shame.11 Sadness, frequent crying, and mood changes are caused by pity when nurses witness the condition of patients, imagining the consequences for themselves or close fam- ily members, as well as feeling helpless in the COVID-19 pandem- ic situation. The social response was demonstrated by individuals limiting social interactions with others. This was consistent with the results of previous studies stating that the social response expe- rienced by COVID-19 nurses included self-limitation of social interaction and avoidance of the surrounding environment.11 Nurses isolate themselves or limit interaction due to the fear of transmitting the infection to others and avoid contact with hospi- tals or sources of infection. Theme 2. Risk factor The theme of anxiety risk factors consists of biological, phys- iological, and social-cultural aspects, with stressors arising from internal and external components.12,13 Biological factors contribut- ing to anxiety in nurses stem from direct contact with a source of infection. This is consistent with the theory that the biological cause of anxiety in nurses is the exposure to toxins/viruses/bacteria due to an increase in infection cases.11 The surge in infection cases, Article [Healthcare in Low-resource Settings 2024;12:12850] [page 647] Non -co mmerc ial us e o nly coupled with injuries, and traumatic experiences becomes a signif- icant source of.3-5 Nurses are a vulnerable group and COVID-19 is a highly infectious stressor.1,14-16 Approximately 3.8% of healthcare workers worldwide were confirmed with COVID-19 worldwide while data from the International Council of Nurses reported an average of 6-10%, with the infection rate reaching up to 30% of all cases. Nurses worry about contracting COVID-19 and becoming carriers who could spread the disease to family.17-19 Psychological factors causing nurse anxiety include lack of knowledge, traumatic experiences, and lack of experience, as COVID-19 is a newly occurring disease.17,20 According to a previ- ous study, factors causing nurse stress during the pandemic include the novelty of COVID-19 and insufficient information.21 Causes of socio-cultural stress include lack of family support, isolation/stigma/discrimination. The COVID-19 pandemic limits the social interactions of nurses with families and the community. Nurses also become victims of discrimination from society (public stigma) and experience self-stigma. Public stigma includes actions in which nurses and the families are labeled as dangerous and potential transmitters of COVID-19.22,23 A previous study reported that nurses in Japan experienced discrimination.18 The feeling of not being able to work, isolation from society, unable to join places of worship, inability to participate in activities with friends and family, as well as discrimination from society are socio-cultural stressors for nurses.24 Sociocultural stressors also occur due to a lack of social support.17,25,26 Themes 3. Protective factor Protective factors play a crucial role in helping nurses over- come anxiety, consisting of three sub-themes, namely biological, physiological, and social-cultural. These factors are determinants of resilience development that come from oneself, family, and the environment. According to theory, protective factors include a healthy diet and physical exercise/activities, support, emotional regulation, coping and problem-solving abilities, optimistic feel- ings, positive self-esteem, social competence, building relation- ships with others, participating in communities and society, finan- cial support, access to support services.27 The results showed that young age was a protective factor associated with good health con- ditions and the absence of comorbidities. As stated by a previous study, the age group of 14–24 years is a protective factor.23 Another study mentioned that older individuals tend to have financial sta- bility in psychological and emotional aspects. According to a sur- vey conducted in the UK, early adulthood, low income, and living alone pose a higher risk of mental health disorders during the COVID-19 pandemic. Younger people have more access to infor- mation about COVID-19 through social media, leading to increased stress. Anxiety occurs at a young age (20-35 years), specifically in nurses who work on the front line. These individuals are more susceptible to contacting sources of infection and have less experience in caring for clients.28 Psychological protective factors include work experience, knowledge, positive feelings, and positive experiences in nursing due to the recovery of many clients, motivation, and positive thoughts.28 Motivation is a coping source for nurses in facing stres- sors.11 The experience of providing services for more than 20 years, becomes a protective factor along with the knowledge gained through training related to COVID-19 information and self- protection.28,29 Nurses who have the knowledge and skills to care for COVID-19 are protected from anxiety. Socio-cultural protective factors are nurses who are not yet married and live alone. Previous studies stated that being married posed a risk of causing psychological problems in nurses. Living with a partner, marital status, and living with children are risk fac- tors for anxiety.17 Themes 4. Overcoming anxiety Coping strategies are protective factors in preventing anxiety, specifically problem-focused coping, while negative strategies cause anxiety.25 Positive coping mechanisms, including story- telling with friends, distracting behaviors, and positive thinking, are recognized as protective factors.25 Coping strategies are cogni- tive and behavioral efforts that individuals must make to manage internal and external stressors. These strategies are shaped by per- sonal attributes, situational factors, and available resources, aiming to restore balance to face reactions triggered by stressors. Commonly used adaptive coping includes relaxation exercises, meditation, physical activity, or modifying cognitive processes. The results showed that nurses dealt with stressors by spending significant time outdoors and engaging in deeper spiritual activi- ties toward God, themselves, and others. Praying and reading holy books are effective strategies for reducing stress and anxiety dur- ing the COVID-19 pandemic.30 Prayer provides inner strength and enables individuals to manage stress more effectively, practically, and safely. Spiritual beliefs are useful as a source of hope and can support coping efforts in unexpected situations.11 The ability of nurses to overcome stressors, as well as resilience, and social support are related to psychology.30 A previ- ous study stated that nurses with spirituality, hope, and optimism experienced lower anxiety. There is a positive relationship between religious coping mechanisms and reduced symptoms of anxiety, aggressive behavior, psychological distress, and depression. Spirituality, peace, and faith are protective factors that prevent anx- iety. Other studies showed that healthcare workers used problem- focused and emotion-focused coping to manage stress during the COVID-19 pandemic.30 Themes 5. Expected support Psychological resilience, similar to social support, is a protec- tive factor in dealing with stressors and traumatic events.30 Resilient healthcare workers can recover and endure psychological burdens. Psychological resilience plays a significant role in pro- tecting individuals from mental health consequences in emergen- cies or disasters.30 The support expected by nurses includes sched- uling arrangements and human resources in nursing services. The results showed that well-rested nurses had lower levels of anxiety and stress. Overwork can cause a sense of control loss, feelings of helplessness, as well as insomnia, headaches, loss of appetite, and other physical disorders. Hospitals must ensure adequate nursing staffing, organize rotations and ensure adequate rest for nurses.17 Furthermore, adequate resources, increased welfare, incentives, counseling, support from the environment, and management dur- ing the COVID-19 pandemic are expected support of nurses.19 Labrague et al. also states that social support is needed by nurses,30 specifically from the family, nurse managers, and people in the environment. Social support, daily and structured life rou- tines, as well as well-established family relationships can enhance psychological well-being. The different forms of support include emotional, social, and relational.25 Recognition and acknowledg- ment of efforts, infection control guidelines, and the provision of facility amenities during the pandemic are forms of support needed by nurses from hospitals. The limitation of study is that researchers could not directly observe the anxiety experienced by nurses because the research was conducted after the COVID-19 pandemic. In conclusion, this study examined responses, risk factors, pro- Article [page 648] [Healthcare in Low-resource Settings 2024;12:12850] Non -co mmerc ial us e o nly tective factors, interventions, and the support expected by nurses in managing anxiety. Research shows that nurses need intervention in dealing with signs and symptoms of anxiety, reducing existing risk factors and increasing protective factors within themselves in order to produce adaptive coping and resilience in facing every challenge that exists in the work environment. The research results show that nurses are subjects who are vulnerable to anxiety. The use of adaptive coping can be one of the factors that can reduce negative responses to biological, psychological, socio-cultural and environmental stressors faced by nurses in health care settings. The use of adaptive coping can be developed and applied in hospitals and nurses need social support to strengthen it and achieve resilience in facing stressors that will continue to exist in the nurse’s work environment. The results underscored the presence of signs and symptoms, as well as risk and protective factors that could prevent anxiety. This study showed that nurses needed interventions to address the signs and symptoms of anxiety, reduce existing risk factors, and enhance pro- tective factors in themselves to develop adaptive coping and resilience in facing challenges in the work environment. References 1. The Ministry of Health of Republic of Indonesia. the Ministrial Decree of the Ministry of Health of Republic of Indonesia No. Hk.01.07/Menkes/278/2020 on Providing incentives and death compensation for health workers who suffer from corona virus disease 2019 (COVID-19). 2020. 2. World Health Organization. Mental health and psychosocial support aspects of the COVID-19 response [Internet]. Geneva: World Health Organization Western Pacific Region; 2021. 3. Gao YQ, Pan BC, Sun W, et al. Anxiety symptoms among Chinese nurses and the associated factors: a cross sectional study. BMC Psychiatry 2012;12:141. 4. Hogg B, Medina JC, Gardoki-Souto I, et al. Workplace inter- ventions to reduce depression and anxiety in small and medi- um-sized enterprises: a systematic review. J Affective Disord 2021;290:378–86. 5. Arensman E, O'Connor C, Leduc C, et al. Mental health promo- tion and intervention in the workplace: protocol for the MEN- TUPP intervention feasibility study. Int J Environ Res Public Health 2022;19:947. 6. de Pinho LG, Sampaio F, Sequeira C, et al. Portuguese nurses’ stress, anxiety, and depression reduction strategies during the COVID-19 outbreak. Int J Environ Res Public Health 2021;18:3490. 7. Shen X, Zou X, Zhong X, et al. Psychological stress of ICU nurses in the time of COVID-19. Crit Care 2020;24:200. 8. Li W, Yang Y, Liu ZH, et al. Progression of mental health serv- ices during the COVID-19 outbreak in China. Int J Biol Sci 2020;16:1732–8. 9. Ariasti D, Handayani AT. Hubungan tingkat kecemasan dengan motivasi kerja perawat di RSUD dr. Soeratno Gemolong. KOS- ALA : Jurnal Ilmu Kesehatan 2019;7:19–28. 10. Setiawati Y, Wahyuhadi J, Maramis MM, Atika A. Anxiety and resilience of healthcare workers during COVID-19 pandemic in Indonesia. J Multidisclip Healthc 2021;14:1-8. 11. Stuart GW. Principles and practice of psychiatric nursing.9th ed. Philadelphia: Elsevier Mosby; 2008. 12. Aligood M. Nursing theorists and their work. 8th Ed. Missouri: Elsevier; 2014. 13. Jennings KM. The roy adaptation model: a theoritical frame- work for nurses providing care to individuals with anorexia ner- vosa. ANS Adv Nurs Sci 2017;40:370-83. 14. Arnetz JE, Goetz CM, Arnetz BB, Arble E. Nurse reports of stressful situations during the COVID-19 pandemic: qualitative analysis of survey responses. Int J Environ Res Public Health 2020;17:8126. 15. Oh H, Lee NK. A phenomenological study of the lived experi- ence of nurses caring for patients with COVID-19 in Korea. J Korean Acad Nurs 2021;51:561–72. 16. Peng X, Yang Y, Gao P, et al. Negative and positive psycholog- ical experience of frontline nurses in combatting COVID-19: a qualitative study. J Nurs Manag 2022;30:2185-93. 17. Cui S, Jiang Y, Shi Q, et al. Impact of COVID-19 on anxiety, stress, and coping styles in nurses in emergency departments and fever clinics: a cross-sectional survey. Risk Manag Healthc Policy 2021;14:585-94. 18. International Council of Nurses. COVID-19 update [Internet]. International Council of Nurses; 2021. 19. Rathnayake D, Clarke M, Jayasinghe VI. Health system per- formance and health system preparedness for the post-pandem- ic impact of COVID-19: a review. Int J Healthc Manag 2021;14:497-513. 20. Hoseinabadi TS, Kakhki S, Teimori G, Nayyeri S. Burnout and its influencing factors between frontline nurses and nurses from other wards during the outbreak of Coronavirus Disease COVID-19 in Iran. Investigacion y Educacion En Enfermeria 2020;38:e03. 21. Ghorbani A, Shali M, Matourypour P, et al. Explaining nurses’ experience of stresses and coping mechanisms in coronavirus pandemic. Nurs Forum 2022;57:18–25. 22. Keliat BA, Marliana T, Windarwati DH, et al. Dukungan kese- hatan jiwa dan psikososial COVID-19: keperawatan jiwa. 2nd ed. Jakarta: FIK Universitas Indonesia; 2020. 23. Sun L. Intervention effect of time management training on nurses’ mental health during the COVID-19 epidemic. Psychiatr Danub 2021;33:626–33. 24. Aulia AP. Gambaran kesehatan mental perawat selama masa pandemi COVID-19 di RSUD Saweriganding Kota Palopo tahun 2021. [Bachelor’s thesis]. Makassar: Universitas Hasanuddin; 2022. 25. Hugh W, Schweizer R, Marks E, et al. The effectiveness of sup- port groups: a literature review. Mental Health and Social Inclusion 2018;22:85–93. 26. Lixia W, Xiaoming X, Lei S, et al. A cross-sectional study of the psychological status of 33,706 hospital workers at the late stage of the COVID-19 outbreak. J Affect Disord 2022;297:156-68. 27. American Psychiatric Association. Mental health: a guide for faith leaders [Internet]. Washington DC: American Psychiatric Association Foundation and the Mental Health and Faith Community Partnership Steering Committee; 2018. 28. Gupta S, Prasad AS, Dixit PK, et al. Survey of prevalence of anxiety and depressive symptoms among 1124 healthcare workers during the coronavirus disease 2019 pandemic across India. Med J Armed Forces India 2021;77:S404–S12. 29. Zheng R, Zhou Y, Qiu M, et al. Prevalence and associated fac- tors of depression, anxiety, and stress among Hubei pediatric nurses during COVID-19 pandemic. Compr Psychiatry 2021;104:152217. 30. Labrague LJ, De los Santos JAA. COVID-19 anxiety among front-line nurses: Predictive role of organisational support, per- sonal resilience and social support. J Nurs Manag 2020;28:1653–61. Article [Healthcare in Low-resource Settings 2024;12:12850] [page 649] Non -co mmerc ial us e o nly