Nurses' Anxiety amid of COVID-19 Pandemic Corresponding author: Dewi Setyawati dewisetyawati@unimus.ac.id South East Asia Nursing Research, Vol 3 No 2, June 2021 ISSN:2685-032X DOI: https://doi.org/10.26714/seanr.3.2.2021.59-65 Original Research Nurses' Anxiety amid of COVID-19 Pandemic Dewi Setyawati1, Rasti Sastro2, Siti Aisah1 1 Universitas Muhammadiyah Semarang, Indonesia 2 Undergraduate Student of Nursing Program, Faculty of Nursing and Health Sciences, Universitas Muhammadiyah Semarang Article Info Abstract Article History: Submit April 2nd, 2021 Accepted May 23rd, 2021 Published June 23rd 2021 Keywords: Anxiety; Covid 19; Pandemic The psychological response toward pandemics experienced by medical workers is increased due to the anxiety about their health condition and the risk to infect the family member. This research was aimed to describe the nurses’ anxiety amid the COVID 19 pandemic at Piru Hospital. This research was descriptive quantitative research with the cross-sectional approach. The research was conducted from December 29, 2020, to March 4, 2021. The population was 125 medical workers at RSUD Piru, with 95 respondents taken as a sample by using the random cluster sampling technique. The instrument used was Hamilton Rating Scale for Anxiety (HRS-A). The data was then analyzed by using frequency distribution data classified in a table. The result of univariate data analysis showed that 91 respondents (95.8%) didn’t experience anxiety, and 2 respondents (2.1%) experienced anxiety. In case of anxiety, 95.8% of nurses at Piru Hospital in West Seram Regency, Maluku didn’t experience anxiety. The research finding shows the importance of prevention and early detection of anxiety disorder to minimize further impact. Individual identification on the early stage of psychological disorder could be an effective intervention strategy. INTRODUCTION The disease caused by the novel coronavirus SARS-CoV-2 has become a global public health emergency and has been designated by the World Health Organization (WHO) as a pandemic in March 2020.1 Coronavirus infection 2019 or often referred to as COVID-19 is a disease that associated with respiratory symptoms with death due to acute respiratory distress syndrome.2 It was recorded that until July 2020 globally there were 216 regions affected by COVID- 19 cases with more than 12,000,000 positive confirmed cases and more than 500,000 confirmed deaths.3 The number of cases indicates that the global health system could be overwhelmed by the COVID-19 disease. Health workers are on the front line who must be protected as the most valuable resource of every country.4 According to data from the Task Force for the Acceleration of Handling Covid 19, 45 medical personnel were infected with Covid 19 while on duty to treat patients at health centers and several hospitals in Maluku and the first death case of health workers in https://doi.org/10.26714/seanr.3.2.2021.59-65 https://jurnal.unimus.ac.id/index.php/SEANR/index https://jurnal.unimus.ac.id/index.php/SEANR/index https://jurnal.unimus.ac.id/index.php/SEANR/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.3.2.2021.59-65&domain=pdf&date_stamp=2021-06-23 South East Asia Nursing Research, Vol 3 No 2, June 2021/ page 59-65 60 Dewi Setyawati / Nurses' Anxiety amid of COVID-19 Pandemic Maluku died from Covid on July 2, 2020. According to data from the Head of the Task Force Acceleration of Handling Covid 19 on May 11, 2020, in Maluku Kasrul Selang said 32 medical personnel were infected with covid 19 and the Haulussy Hospital, which is the Covid Referral Hospital in Maluku, was temporarily closed for the next 14 days for sterilization of all rooms in the hospital, The closure was carried out after 14 medical personnel, including the director of the hospital, tested positive for COVID-19 on Friday, June 12, 2020. The psychological response experienced by health workers to infectious disease pandemics is increasing because it is caused by feelings of anxiety about one's health and the spread of the family.5 Various psychological disorders have been reported and publicized during the COVID- 19 outbreak in China, both at an individual, national and international community levels. At an individual level, people are more likely to experience fear of contracting and experiencing severe or dying symptoms, feel helpless, and stereotype others. The pandemic even causes a psychological crisis.6 Identification of individuals in the early stages of psychological disorders makes intervention strategies more effective. The health crisis of the COVID-19 pandemic causes psychological changes such as fear, anxiety, depression, or discomfort. This disorder is not only felt by health workers or all people who work in the medical field but also by all citizens7. Previous research has shown that mental disorders from a major disaster have a broader and longer- lasting impact than physical injuries, while attention to mental health is much less, both in terms of providing personnel for planning and resources.8 Health workers who treat COVID-19 patients are a group with a very high risk of exposure. Research has shown that the probability of medical personnel being infected with COVID-19 is 3.8%, mainly due to unprotected initial contact with infected patients.9 COVID-19 infection has a higher transmission and mortality rate than those caused by Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS).10 Health workers must wear protective clothing and N95 masks to avoid exposure to infection, this makes the service much more difficult and tiring than under normal conditions, in addition, the fear of contracting and being infected has been reported to be a trigger for adverse psychological problems such as anxiety, stigmatization, and depression. This can have an adverse effect on the quality of care.11 Mental health problems are also reported to affect the attention, understanding, decision-making, and abilities of health workers.12 Many nursing staff has mental health problems, because they not only carry a work overload, are at high risk of infection and prolonged fatigue. So that it leads to an increased risk of infection, therefore it is very necessary for health workers and makes policies to pay attention to protection factors and a successful adaptation process in the COVID- 19 pandemic conditions for health workers.13 The lack of focus on the mental health of health workers has the potential to disrupt and even turn off health services and will affect the handling of the COVID-19 pandemic. Anxiety is a symptom of early psychological disorders and is still very likely to be overcome. This is what underlies the author to research on the Description of Nurse Anxiety amid of the COVID-19 Pandemic at the PIRU Hospital. METHODS This research uses descriptive quantitative with a cross-sectional approach, namely the type of research that is carried out only once or at the same time by looking for variable South East Asia Nursing Research, Vol 3 No 2, June 2021/ page 59-65 61 Dewi Setyawati / Nurses' Anxiety amid of COVID-19 Pandemic relationships, where data is collected momentarily, or data is obtained right now. The variable in this study is a univariate variable, namely the anxiety of nurses amid the COVID-19 pandemic. The population in this study were 125 people. The sample in this study amounted to 95 people. The cluster random sampling technique was used in determining the number of respondents who would become the research sample, namely nurses who currently work in the Piru Hospital treatment room, who were willing to become respondents by signing an informed consent which was an inclusion criterion. This research was conducted at the Piru Hospital in December-March 2021. This research has been approved by the Ethics Committee of the University of Muhammadiyah Semarang with No. 098/UNIMUS.G2/EP.PM.LJ/2021 and considers the principles of research. The data collection procedure used a questionnaire. The questionnaire for the anxiety variable uses the Hamilton Rating Scale for anxiety (HRS-A) which is the standard in measuring anxiety, especially in trial clinic research. The HRS-A scale has been proven to have high enough validity and reliability to measure anxiety levels in trial clinic research, namely 0.93 and 0.97. The research has received permission from the research agency by paying attention to ethics in research such as beneficence, respecting human opinions and getting justice. Before the respondent filled out the questionnaire, informed consent was first explained. So the respondent has the right to choose whether he is willing to be a respondent or not. After the questionnaires were collected, data processing was carried out. The steps in the data processing process include editing, coding, tabulating, and data entry. Data analysis in this study used univariate analysis with SPSS. Using Chi Square statistical test. RESULT The results of this study are presented in the form of a table consisting of the characteristics of the respondents and the level of anxiety of the univariate test results. Based on table 1, the characteristics of respondents 76 (80%) are female, 72 (75,8%) are in the 26–35-year age group. 56 (58,9%) respondents are unmarried. In the workplace, most respondents are Meranti as many as 16 people (16,8%) and for the number of children, most of them do not have children 63 (66,3%). Tabel 1 The Frequency Distribution of Respondent Characteristics at Piru Hospital, March 2021 (n=95) Indicators f % Gender Male Female 19 76 20,0 80,0 Age 26-35 36-45 46-55 72 23 75,8 24,2 Work place Emergency Room Comprehensive Emergency Neonatal Obstetric Service Meranti Agatis Gupasa Makila Kid’s Room Makila Class Lenggua Zikki Covid Isolation 11 7 16 10 7 7 8 9 9 11 11,6 7,4 16,8 10,5 7,4 7,4 8,4 9,5 9,5 11,6 Marital Status Married Single 39 56 41,1 58,9 Number of Children No children Less than 2 children or equal More than 2 children or equal 63 24 8 66,3 25,3 8,4 Based on table 2, it is found that the characteristics of respondents at most do not experience anxiety by 95,8%, and moderate anxiety by 2 people (2,1%). South East Asia Nursing Research, Vol 3 No 2, June 2021/ page 59-65 62 Dewi Setyawati / Nurses' Anxiety amid of COVID-19 Pandemic Table 2 The Frequency Distribution of Respondents' Anxiety Levels Based on the HRS-A Questionnaire, March 2021 at Piru Hospital (n= 95) Indicators f % No Anxiety 91 95,8 Mild Anxiety 1 1,1 Moderate Anxiety 2 2,1 Severe Anxiety 1 1,1 DISCUSSION Another research that supports is Yulia Dewi (2018) states that as they age, there is a tendency for their anxiety to decrease at work, those who have a lot of work experience are better able to control their emotions and control the situation when interacting directly with patients. So that older people will be able to manage stress management well. The analysis of this study shows that the majority do not experience anxiety because respondents can manage stress management well and the more mature a person is, the more mature they are in thinking rationally and more adaptable to the environment, but there are still respondents who experience moderate anxiety, 2 respondents are supported by Kozier (2011). Mild anxiety creates a state of mild arousal that enhances perceptual, learning, and productive abilities. Most individuals who experience mild anxiety may be healthy as a mild feeling of anxiety that prompts a person to seek information and ask questions. From the results of the univariate analysis, it was found that the characteristics of respondents based on gender were more female than male. This research analysis is because the total sample is dominated by women. This is in line with the research sample conducted by14 involving 170 hospital workers in Spain showed that the number of female genders (58,%) was more than male (41,2%). Fortinesh said that women are twice as likely to experience anxiety. A study conducted by Maryam and Kurniawan which stated that the gender factor could significantly affect the patient's level of anxiety, in the study it was also stated that the female gender was more at risk of experiencing anxiety compared to the male gender15. This research16 stated that significantly higher scores in anxiety were found in women. This research is supported by research conducted by the University of Calgary in Alberta (2011) which states that women are more susceptible to stress due to work than men. According to Ramli (2017) said that women have high levels of anxiety due to excessive autonomic nervous reactions. In addition, in women there is a change in hormone secretion, especially estrogen which affects anxiety. The imbalance of estrogen hormone levels in women causes the emergence of effects on women which include cognitive and emotional 17. Analysis of this study women is more susceptible to stress due to hormonal changes. Supported by Videbeck (2018) suggests that women and men have different levels of anxiety where women are more easily offended, very sensitive, and highlight their feelings, while men have masculine characteristics that tend to be dominant, active, more rational, and don't accentuate their feelings. Based on the results of the study, it was found that 39 (41,1%) marriages were married. Based on Purqoti's research (2017), married individuals will have a more adaptive adaptation response to stressors than unmarried individuals. According to Heriyanto (2011), people who are married have a life partner whose mental condition is relatively stable when compared to those who are not married. Analysis of this research respondent who is not married and married have an adaptive response. Based on the results of this study, it was found that 63 respondents (66,3%) had less than two children, 24 (25,3%), and had more than two children, 8 respondents (8,4%). Likewise, the study of Chang et al, 2020 stated that 12 (18,5%) symptoms of South East Asia Nursing Research, Vol 3 No 2, June 2021/ page 59-65 63 Dewi Setyawati / Nurses' Anxiety amid of COVID-19 Pandemic anxiety and depression during this pandemic were due to having babies. In contrast to this study, most of them did not experience anxiety. In the analysis of this study respondents did not experience anxiety because they had good knowledge about covid transmission and prevention. Because parental anxiety during the pandemic could be due to parental ignorance about covid 19. Based on the results of this study, it was found that nurses working in the treatment room were not evenly distributed. In the Emergency Room, there are 11 nurses (11,6%), in the Comprehensive Emergency Neonatal Obstetric Service there are 7 nurses (7,4%) Meranti there are 16 nurses (16,8%), Agatis there are 10 nurses (10,5%), Gupasa there are 7 nurses (7,4%), Makila Kid’s Room there are 7 nurses (7.4%), Makila Class there are 8 nurses (8,9%), Lenggua there are 9 nurses (9,5%), Zikki there are 9 nurses (9,5%), and the isolation of covid there are 11 nurses (11,6%). The selection of nurses who work in each room is usually based on hospital policy. Room rotation is almost 5 months or once a year rotation. The analysis of this study reduces work anxiety and stress due to frequent room rotation and environmental changes that reduce boredom. Other research explained that 69 nurses from 80 nurses in the RSPG inpatient room experienced a moderate level of work stress with a working period of 6 months to 3 years as much as 50%. Mahastuti et al (2017) in the difference in work stress in the emergency room with nurses at the "S" hospital inpatient in Denpasar City in 2017 explained that 39 nurses (67,2%) who worked in the Emergency Room and 29 nurses who worked in the emergency department. hospitalization (50%) experienced moderate stress. Other research shows that health workers who are on the front line experience moderate to severe stress 10,7% and 12, 4%, respectively.18 Furthermore, based on research by Liu and Liu (2020) it is known that the anxiety level of nurses in the emergency unit is higher than in the isolation room or polyclinic. According to other research that from 180 respondents, the results of respondents who were not anxious were 13 (7.2%), respondents who were at a mild level of anxiety, namely 37 (20.6%), respondents who were at a level of anxiety. moderate, namely 59 (32.8 %), and respondents who are at the level of severe anxiety are 71 (39.4%). Based on this research, most nurses experience moderate and severe anxiety, this is due to the Covid-19 disease for which there is no cure, causing excessive fear, in addition to the nurses who treat Covid-19 patients feel that even though personal protective equipment has been facilitated does not guarantee that they will be free from Covid-19 transmission. Nurses who do not treat Covid-19 patients always feel excessive anxiety and worry because in providing services to patients because nurses have not been provided with the same personal protective equipment facilities as nurses who treat Covid-19 patients, and some of these nurses have illnesses. morbid or comorbidities so that from the results of a positive swab examination, nurses experience a dilemma in caring for patients, because apart from the patient and the patient's family, they have not fully implemented the health protocol even though it is repeatedly delivered by the RSUD or by nurses, this is what always makes people worry and worried about the spread of Covid-19. The anxiety felt by nurses cannot be separated from initial contact with patients.19 This is inversely proportional to the results of research obtained by researchers. It was found that most did not experience anxiety. This difference can occur due to several factors such as internal and external factors. South East Asia Nursing Research, Vol 3 No 2, June 2021/ page 59-65 64 Dewi Setyawati / Nurses' Anxiety amid of COVID-19 Pandemic Internal factors can be in the form of age, gender, marital status, latest education, and coping mechanisms owned by nurses. Meanwhile, external factors can be in the form of excessive work environment demands such as an increase in the number of patients seeking treatment and a shortage of PPE by officers. Following other study that two factors influence psychological distress, namely interpersonal factors (personality) and situational factors in the form of physiological, cognitive and social influences.20 Hospital management carries out room rotation activities very often to minimize psychological distress. The level of anxiety in this study was categorized into four categories, namely, no anxiety, mild anxiety level, moderate anxiety level, and severe anxiety level. In contrast to the results of the other research regarding health workers who are at risk of experiencing psychological disorders in treating COVID-19 patients, the results show that there are 50,4% of respondents have symptoms of depression and 44,6% have symptoms of anxiety due to feeling depressed. A similar study also showed from 13 participants experienced anxiety because protective supplies had not been met when taking action on patients.21,22 In overcoming mental health problems for health workers, it is necessary to intervene by forming a medical team in psychological treatment and applying a health belief model for health workers.22 This research stated that respondents experienced an increase in fear of 79%, anxiety 83%, and depression 38%.23 Many health workers must isolate themselves from their family and closest people even though they do not have COVID-19, this is a difficult decision and can cause a significant psychological burden on them.12 Working in the middle of the media and public that intense duration of a long, massive and perhaps unprecedented in some health workers have additional implications in the trigger psychological effects of negative including emotional disorders, depression, stress, mood low, irritability, panic attacks, phobias, insomnia symptoms, anger, and emotional exhaustion.24 The severity of the COVID-19 outbreak influences negative emotions, which can cause sleep disturbances7. And the COVID- 19 pandemic situation causes feelings of anxiety and uncertainty.25 The results of the analysis of this study that nurses in hospitals do not experience anxiety due Piru is not a Referral Hospital Covid 19 in Maluku also because there are patients with severe complaints, so nurses do not feel anxious. This shows an adaptive response from nurses to pandemic outbreaks in hospitals. In addition, because nurses already have good knowledge about information about preventing covid, how to transmit and how to prevent it. CONCLUSION After conducting the research, it can be concluded that the anxiety of nurses at the Piru Hospital, West Seram District, Maluku Province 95,8% did not experience anxiety. ACKNOWLEDGEMENT Thank you to those who supported this research, including Education and Training Agency of Piru Hospital, National and Political Unity Agency which has given permission to conduct research. In addition, the authors would also like to thank the nurses for their participation in this study. CONFLICTS OF INTEREST Neither of the authors has any conflicts of interest that would bias the findings presented here. REFERENCES 1. Jawad MJ, Abbas MM, Jawad MJ, Hassan SM, South East Asia Nursing Research, Vol 3 No 2, June 2021/ page 59-65 65 Dewi Setyawati / Nurses' Anxiety amid of COVID-19 Pandemic Hadi NR. Mental Health and Psychosocial Considerations Post Covid-19 Outbreak. Wiad Lek. 2021;74:3156–9. 2. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506. 3. Culp WC. Coronavirus Disease 2019: In-Home Isolation Room Construction. A&A Pract. 2020;14:e01218. 4. Armitage R, Nellums LB. Protecting health workers’ mental health during COVID-19. Public Health. 2020;185:18. 5. Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al. Mental health care for medical staff in China during the COVID-19 outbreak. The Lancet Psychiatry. 2020;7:e15–6. 6. Xiang Y-T, Zhao Y-J, Liu Z-H, Li X-H, Zhao N, Cheung T, et al. The COVID-19 outbreak and psychiatric hospitals in China: managing challenges through mental health service reform. Int J Biol Sci. 2020;16:1741. 7. Zhang J, Lu H, Zeng H, Zhang S, Du Q, Jiang T, et al. The differential psychological distress of population affected by the COVID-19 pandemic. 2020;49–50. 8. Allsopp K, Brewin CR, Barrett A, Williams R, Hind D, Chitsabesan P, et al. Responding to mental health needs after terror attacks. Bmj. 2019;366. 9. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. Jama. 2020;323:1239–42. 10. Mahase E. Coronavirus: covid-19 has killed more people than SARS and MERS combined, despite lower case fatality rate. British Medical Journal Publishing Group; 2020. 11. Du J, Dong L, Wang T, Yuan C, Fu R, Zhang L, et al. Psychological symptoms among frontline healthcare workers during COVID-19 outbreak in Wuhan. Gen Hosp Psychiatry. 2020; 12. Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX, et al. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. The Lancet Psychiatry. 2020; 13. Hassannia L, Taghizadeh F, Moosazadeh M, Zarghami M, Taghizadeh H, Dooki AF, et al. Anxiety and Depression in Health Workers and General Population During COVID-19 in IRAN: A Cross-Sectional Study. Neuropsychopharmacol Reports. 2021;41:40–9. 14. Herrero A, Martin S, Parra J, Diaz T. Sleep characteristics in health workers exposed to the COVID-19 pandemic. Sleep Med. 2020;75:388– 94. 15. Vellyana D, Lestari A, Rahmawati A. Faktor- Faktor yang Berhubungan dengan Tingkat Kecemasan pada Pasien Preoperative di RS Mitra Husada Pringsewu. J Kesehat. 2017;8:108–13. 16. Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al. Depression, anxiety and stress during COVID-19: associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. Int J Environ Res Public Health. 2020;17:4065. 17. Danu VK, Ningsih OS, Suryati Y. Faktor-Faktor yang Mempengaruhi Kecemasan Perawat selama Pandemi COVID-19 di Kabupaten Manggarai. J Wawasan Kesehat. 2021;6:21–31. 18. Liu K, Chen Y, Wu D, Lin R, Wang Z, Pan L. Effects of progressive muscle relaxation on anxiety and sleep quality in patients with COVID-19. Complement Ther Clin Pract. 2020;39:101132. 19. Banna T, Gurning M, Sahetapy V. T ingkat Kecemasan Perawat dalam Pelayanan Kesehatan di Masa Pandemi Covid-19. An Idea Heal J. 2022;2:15–9. 20. Azzahra F. Pengaruh resiliensi terhadap distres psikologis pada mahasiswa. J Ilm Psikol Terap. 2017;05:80–96. 21. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw open. 2020;3:e203976–e203976. 22. Chen B, Wang Y, Yang T, Li C, Xu C, Shen Y, et al. Mental health among COVID-19 survivors and healthcare workers exposed to COVID-19 in Wuhan, China: a cross-sectional study. Authorea Prepr. 2020; 23. Croll L, Kurzweil A, Hasanaj L, Serrano L, Balcer LJ, Galetta SL. The psychosocial implications of COVID-19 for a neurology program in a pandemic epicenter. J Neurol Sci. 2020;416:117034. 24. Brooks S, Amlôt R, Rubin GJ, Greenberg N. Psychological resilience and post-traumatic growth in disaster-exposed organisations: overview of the literature. BMJ Mil Heal. 2020;166:52–6. 25. Tysiąc-Miśta M, Dziedzic A. The attitudes and professional approaches of dental practitioners during the COVID-19 outbreak in Poland: a cross-sectional survey. Int J Environ Res Public Health. 2020;17:4703.