Effects of Coping Strategies on Anxiety Levels of Nurses during COVID-19 Pandemic

An Investigation of the Effects of Coping Strategies on Anxiety Levels
of Nurses during COVID-19 Pandemic
Abstract
This research aimed to investigate the effects of coping strategies on nurses' anxiety levels
during the COVID-19 pandemic. Anxiety is defined as "a disordered condition" of the body's
emotional sensitivity. During the Coronavirus Disease 2019 (COVID-19) pandemic, nurses in
COVID-19 wards, emergency departments, and fever clinics have served as healthcare system
gatekeepers while risking their own and families’ health and lives. Uncertain situations, working
for long hours, and fear of contracting the disease have increased the nurses' anxiety level. The
nurses serving in the COVID and emergency wards use several coping strategies to overcome
their anxiety. It is vital to understand the correlation between the coping strategies used by the
nurses and their anxiety levels during the COVID-19 pandemic. For this purpose, this study
employed a cross-sectional design and used Brief-COPE and Self-rating Anxiety Scale (SAS) for
data collection. The study sample consisted of 404 nurses working in the COVID-19 wards in 10
UK hospitals. The data was collected online and analysed with the help of SPSS (v. 25) by
running descriptive statistics, Pearson correlation analysis, and Regression analysis for
determining the relationship among the study variables. The study findings revealed that the
nurses' most commonly used coping strategy is problem-focused coping to overcome and bring
down their anxiety levels. Further results showed a positive relationship between the three
sub-scales of managing (problem-focused coping, emotion-focused coping and avoidant coping)
and the nurses’ anxiety levels during the COVID-19 pandemic.
1

Contents
Abstract.......................................................................................................................................................1
Chapter One: Introduction...........................................................................................................................4
1.1Introduction and Background ............................................................................................................4
1.2 Rationale of the Research .................................................................................................................8
1.3 Research Aim, Objectives & Question................................................................................................8
1.4 Theoretical Framework......................................................................................................................9
1.5 Study Hypotheses..............................................................................................................................9
1.6 Outline of the Dissertation...............................................................................................................10
Chapter Two: Literature Review................................................................................................................10
2.1 Introduction.....................................................................................................................................11
2.2 Anxiety.............................................................................................................................................11
2.3 Anxiety amongst Healthcare Professionals during COVID-19..........................................................13
2.4 Anxiety Levels of Nurses during COVID-19.......................................................................................16
2.5 Coping Strategies.............................................................................................................................18
2.5.1 Usage of COVID-19 protective measures .................................................................................18
2.5.2 Avoidance coping......................................................................................................................19
2.5.3 Role of social support................................................................................................................20
2.5.4 Faith-based practices................................................................................................................20
2.5.5 Psychological support...............................................................................................................21
2.5.6 Managerial support...................................................................................................................22
2.6 Research Gap...................................................................................................................................22
Chapter Three: Methods...........................................................................................................................23
3.1 Introduction.....................................................................................................................................23
3.2 Study Design....................................................................................................................................24
3.3 Study Participants ...........................................................................................................................24
3.4 Research Tools.................................................................................................................................24
3.4.1Demographic questionnaire......................................................................................................24
3.4.3Coping Orientation to Problems Experienced Inventory (Brief-Cope) (Dias et al., 2012)...........25
3.5 Procedure........................................................................................................................................26
3.6 Data Analysis....................................................................................................................................27
3.7 Ethical Considerations......................................................................................................................27
Chapter Four: Results................................................................................................................................28
4.1 Introduction.....................................................................................................................................28
2

4.2 Reliability and Validity of the Data...................................................................................................28
4.3 Demographic Results.......................................................................................................................29
4.4 Descriptive Statistics........................................................................................................................30
4.5 Inferential Analysis...........................................................................................................................35
4.5.1 Analysis of correlation between Brief-COPE (Coping Strategies) and SAS (Anxiety levels).......35
Chapter Five: Discussion............................................................................................................................38
5.1 Introduction.....................................................................................................................................38
4.2 Discussion of Findings......................................................................................................................38
Chapter Six: Implications...........................................................................................................................46
6.1 Introduction.....................................................................................................................................46
6.2 Implications.....................................................................................................................................46
6.2.1 Implications for theory..............................................................................................................46
6.2.1 Implications for nursing management......................................................................................47
6.3 Recommendations...........................................................................................................................48
Chapter Seven: Conclusion........................................................................................................................50
7.1 Introduction ....................................................................................................................................50
7.2 Summary of Research......................................................................................................................50
7.3 Limitations and Future Research Suggestions .................................................................................52
References ................................................................................................................................................53
Appendices................................................................................................................................................62
Appendix A............................................................................................................................................62
Demographic questionnaire..................................................................................................................62
Appendix B.................................................................................................................................................65
Zung Self-Rating Anxiety Scale (SAS)..........................................................................................................65
Appendix C.................................................................................................................................................66
Coping Orientation to Problems Experienced Inventory (Brief-Cope).......................................................66
Chapter One: Introduction
3

Introduction and Background
The outbreak of COVID-19 in December 2019 has been associated with innumerable challenges,
especially to the healthcare workers, as they occupy the frontline in dealing with COVID-19 pandemics
and are at increased risk of burdens led by COVID-19. Cases of mental health issues among these groups
of individuals are associated with the excessive workload and risk of transmitting the disease during
healthcare pandemics (World Health Organization [WHO] 2020a.) Unpreparedness to handle the surging
cases of the pandemic and emotional distress associated with the fear of infection concerns include the
fact that the disease is highly contagious with a low level of knowledge on the factors surrounding the
infection. The lack of established vaccines or treatments to handle the outbreak has also been another
concern (Pappa et al. 2020) for an extended period before the introduction of vaccines.
The World Health Organisation (WHO, 2020B) reports that nurses are the most prominent health
professionals in the health sector. They play a crucial role in public health emergencies in improving
public health even though COVID-19 has put more burden on health systems, and its impact is beyond
description. Nurses’ contributions and vigilance in health promotion during epidemic outbreaks like
influenza, Ebola, and Zika were seen in the past years. Currently, nurses are at the forefront of caring for
COVID-19 patients in acute care settings (WHO, 2020b.) In addition, they have been engaged together
with the interprofessional sectors, teams, and communities in this global pandemic preparedness and
response (American Academy of Nursing, 2018).
Nurses have proved to be the more excellent asset. In the past decades, nurses have been on the
frontline during major hits of infectious disease outbreaks, including “H1N1, Swine Flu, Severe Acute
Respiratory Syndrome SARS, Middle East Respiratory Syndrome (MERS) and Ebola” (Ruiz-Fernandez et
al., 2020, p. 4321). Similarly, the study done by Jung and Jun (2020) has found that nurses have always
been the front liners and role models in infection control and prevention practices and public health
promotion. It has become apparent that nurses work all around the clock to provide hospital care to the
affected ones. Public health nurses are shifted to acute care settings. They lead a response team,
demonstrating skills and expertise in emergency preparedness, predictive modelling, hospital, and field
operations to deal with the pandemic. However, they are not exempted from experiencing accidental
outcomes such as exposure to outbreaks, occupational stress, lethargy, psychological fatigue, and
trauma (Jung & Jun 2020).
4

According to the International Council of Nurses (ICN, 2021), 90 million people have been infected with
the disease globally, resulting in 1.9 million deaths worldwide. In Mexico, 21% of nurses have been
infected with COVID-19, whereas 45% were infected with COVID-19 in Iran. Both countries were hardly
hit by COVID-19, shown by the report of ICN (2021). Research has shown that at least 1 in 5 healthcare
workers are showing signs of depression and anxiety, whereas 4 in 10 workers are experiencing
insomnia and a higher rate of anxiety and depression among the female nursing staff and health workers
(Pappa et al., 2020).
According to a systematic literature review conducted by Pappa et al. (2020), “the uneven and increased
distribution of workload, physical exhaustion, lack of personal protective equipment, nosocomial
transmission” as well as “the need to make ethically difficult decisions on the rationing of care” have
posed a tremendous impact on “the physical and mental well-being of nurses” (p. 902). Isolation and
loss of social support, risks of infecting loved ones and relatives as well as rapid changes in the working
environment can further compromise the resilience of nurses leading them to be at a higher risk of
experiencing a variety of psychological effects, including “acute stress disorder, depression, post-
traumatic stress disorder, insomnia, irritability, anger, and emotional exhaustion following disease
outbreak” (Pappa et al., 2020, p. 902).
Ruiz-Fernandez et al. (2020) discovered that “the prevalence of depression (nurses: 30.30 percent vs.
physicians: 25.37 percent) and anxiety (nurses: 25.80 percent vs. doctors: 21.73 percent)” was
substantially greater among nurses in comparison to doctors during the COVID-19 pandemic (p. 4321).
Previous research has indicated that continuous usage of protective equipment, such as “surgical masks,
gloves, goggles, face shields, gowns, and N95 masks”, might result in physical issues like “skin lesions
and de novo PPE-associated headache” (Ruiz-Fernandez et al., 2020, p. 4321). Furthermore, reported
stress symptoms include decreased appetite or dyspepsia, exhaustion, sleeplessness, anxiety, frequent
sobbing, and even suicidal thoughts. It is hardly unexpected that junior and inexperienced nurses suffer
higher stress levels. The psychological crises can and will negatively influence nurses' safety and quality
of life in the long run (Ruiz-Fernandez et al., 2020).
It is essential to understand what the theories and literature say about nurses' experiences during the
crisis. Crisis refers to a decisive stage that bears critical consequences in the future of an individual or a
system. It also refers to an event or a situation perceived as an intolerable difficulty that exceeds
individuals' or people's available resources and coping mechanisms (Yeager & Roberts, 2015). Theories
have been used to explain nurses' and other healthcare professionals’ handling and managing the
5

COVID-19 pandemic. An association between individual psychology and outward expression of behavior
was studied by various psychologists who came up with psychodynamic theories. They believed that
depression and other mental health issues resulted from inwardly directed anger, severe superego
demands, and the loss of self-esteem, among others. The psychodynamic theories handle a variety of
human behaviors and reactions to various issues affecting their day-to-day lives (Marčinko et al., 2020).
The psychodynamic processes are critical in gaining an in-depth understanding necessary for managing
individual and group mental health issues in times of crisis. Psychodynamic theories are being applied to
explain the general population's reaction to the current coronavirus pandemic situation. These include a
clearer understanding of behaviors such as spreading panic, stigmatization, defensive responses, and
socially disruptive behavior in times of such pandemics (Uji, 2020).
Csikszentmihalyi and Seligman (2000) defined positive psychology as a positive subjective experience
that builds positive individual qualities. The four personality traits that contribute to “positive
psychology are subjective well-being, optimism, happiness, and self-determination” (p. 6). These
subjective experiences refer to “what people think and how they feel about their lives to the cognitive
and affective conclusions they reach when they evaluate their existence” (Csikszentmihalyi & Seligman,
2000, p. 6). Positive psychology is different from humanistic psychology in that positive psychology
observes both strength and weakness as authentic and responsive to scientific understanding as
described by (Peterson & Seligman, 2004).
The “need for competence, belongingness, and autonomy” are central to the self-determination theory
and are investigated within the approach. Researchers claim that personal well-being and social
development are greatly optimized (Csikszentmihalyi & Seligman, 2000, p. 6). Optimism is more involved
in cognitive, emotional, and motivational components, according to the article published by Peterson
(2000).
When viewed from the perspective of positive psychology, an optimistic employee has more likelihood
of practicing good habits and work ethics that promote their self-development than a pessimistic one.
Positive psychology is used in preventative and therapeutic strategies that promote positive traits,
creating positive subjective experiences. These experiences can be achieved through resilience. Fear of
uncertainty can lead to anxiety or depression among workers. Positivity builds strength and creates
solutions to the problems by opening the awareness level. Positive psychology helps the healthcare
worker become more resilient and persistent (Csikszentmihalyi & Seligman, 2000).
6

The burdens of the COVID-19 pandemic are likely to have both short- and long-term impacts on
healthcare workers. For safe and continuous patient care, nurses ́ health and safety play a crucial role in
controlling any disease outbreak. However, healthcare workers are under tremendous stress and
anxiety during the current pandemic (Cabarkapa et al., 2020). Hence, comprehensive support is needed
for health care workers and nurses during the pandemic crisis.
1.2 Rationale of the Research
Coronavirus disease 2019 (COVID-19) is an ailment caused by coronavirus that causes “severe acute
respiratory syndrome.” COVID-19 is so infectious that by January 2022, it has infected over 298 million
individuals and killed over 5.47 million people worldwide. A significant frequency of a contagious viral
illness will strain any healthcare system and its employees. Healthcare personnel are in danger of
jeopardizing their health, catching the disease, and possibly becoming a source of disease in their
community while performing their professional tasks. The physical hazards are exacerbated by the
concurrent risk of mental health disorders. It is a terrible reality that more than 180,000 healthcare
professionals have died due to the coronavirus globally. Nurses on the front lines of giving life-saving
treatment to COVID-19 patients are at a significantly increased risk of mass traumatization. Their
psychological stress and anxiety are increasingly acknowledged as significant issues. Nurses face
enormous physical and mental stress and anxiety as a result of physical tiredness from “increased
workload,” the danger of transmitting the virus, particularly with an insufficient supply of “personal
protective equipment (PPE),” and the ethical quandary of “triaging patient care.” In response to the
COVID-19, millions of nurses work as COVID-19 front liners. A considerable proportion of nurses are in
psychological turmoil during outbreaks; hence there is an urgent need to establish support mechanisms
and enhance the possible interventions for the holistic well-being of nurses during the pandemic
situation. Therefore, understanding the burdens of COVID-19 and nurses' experiences during the
outbreak is crucial in policy formulation and interventions for maintaining their health and well-being.
1.3 Research Aim, Objectives & Question
The current research aimed to investigate the effects of coping strategies on nurses' anxiety levels
during the COVID-19 pandemic. The aim was met by addressing the following research objectives:
7

1. To explore the levels of pandemic induced anxiety amongst the nurses
2. To study the strategies adopted by the nurses to cope with the pandemic induced anxiety
3. To determine the correlation between the anxiety levels and coping strategies adopted by the
nurses during the COVID-19 pandemic
This study attempted to answer the following research question “What are the effects of coping
strategies adopted by the nurses on their anxiety levels during the COVID-19 pandemic?”
1.4 Theoretical Framework
The following figure presents the theoretical framework of this study. The correlation between overall
coping strategies (and the three sub-scales of coping strategies) and nurses’ anxiety levels was tested to
determine the effects of the coping strategies used by the nurses on their anxiety levels during the
COVID-19 pandemic. Coping strategies (“problem-focused coping, emotion-focused coping, and
avoidant coping”) were the independent variable, and anxiety levels were the study's dependent
variable.
Figure 1.1 Theoretical framework
1.5 Study Hypotheses
The study attempted to test the following null hypothesis:
H0 = There is no effect of coping strategies on anxiety levels of nurses during the COVID-19 pandemic
The study also tested the following alternate hypotheses
H1= The use of problem-focused coping has a positive correlation with the anxiety levels of nurses during
the COVID-19 pandemic
H2= The use of emotion-focused coping has a positive correlation with the anxiety levels of nurses during
the COVID-19 pandemic
8