Iran Occupational Health

INTRODUCTION: The Covid-19 pandemic put a lot of strain on staff and the health care system. Nurses who have a high-risk prolonged close contact with patients are at a great risk for infection. Recent research has shown that health care providers suffer from psychological distress due to the COVID-19 pandemic. They experience social isolation, role conflicts, fear, anxiety, and psychological distress when they work with these patients. Understanding the stressors in nurses during the caring for COVID-19 patients is essential for health care managers. Therefore, the present study aimed at identifying stressors in nurses involved in taking care of COVID-19 patients in hospitals affiliated to Babol University of Medical Sciences.

METHODOLOGY: The current research is a cross-sectional study. The statistical population of this study includes all nurses involved in Covid-19 patients in two hospitals: Rouhani (400 nurses) and Yahyanejad (250 nurses) for a total of 650 people. First, the sample size required for this study was calculated using the stratified sampling method, assuming an error of 0.053 with the help of Cochran's formula at a significant level of 0.05 to 224 people, but due to non-response of some samples and decrease in the number selected samples, 250 questionnaires were distributed. In proportion to the number of nurses in each hospital from the total study population, the required sample size of Rouhani Hospital was 160 and Yahyanejad Hospital was 90. The method of distributing the questionnaire among nurses was available based on the sample size. 

Inclusion criteria: having a bachelor's or master's degree in nursing, direct involvement in caring for COVID-19 patients, non-occurrence of any significant event in life (death, Illness or hospitalization of a person or death of first-degree relatives, divorce, severe financial problems) within six months In the past, not taking psychotropic drugs, consent to participate in the study.

The criterion for excluding the sample was the incompleteness of the questionnaire.

To conduct the research, questionnaires were provided to the nurses and after completion were collected by the researcher. It was explained to each research unit that participation in this research is optional and the information recorded in the questionnaires will remain anonymous and confidential. This study was registered in the University Ethics Committee with the code IR.MUBABOL.REC.1399.177.

The data collection tool was a researcher-made questionnaire. The questionnaire consists of two parts. The first part contained 11 questions about personal characteristics (age, gender, marital status, level of education, work experience, type of shift, interest in the nursing profession, average overtime, employment status, type of hospital, having children). The second part of the researcher-made questionnaire, includes questions related to stressors in nurses, which was prepared in 2020 with the aim of identifying stressors in nurses involved in the care of Coronavirus patients. The items of the questionnaire of stressors factors in nurses first through focused group discussions and based on the brainstorming as well as information and resources available in internal and foreign magazines in the relationship with the subject was adjusted.

A total of 54 items in five areas of interpersonal stressors, patient care, physical and environmental, individual and managerial (14 questions about interpersonal factors, 6 questions related to patient care, 12 questions related to physical and environmental factors, 12 questions related to individual stressors and 10 questions about managerial stressors). The responses for this part were scored using a 5-point Likert scale containing these options: none (0), low (1), medium (2), high (3) and very high (4). The validity of the questionnaire was confirmed by ten clinical nurses involved in caring for COVID-19 patients and faculty members of the School of Nursing and Midwifery, and after applying their opinions, some questions were removed and edited. 

Cronbach's alpha coefficient was used to determine the reliability of the questionnaire with an emphasis on internal correlations of questions and the following results were obtained: managerial stressors r = 0.85, patient care r = 0.84, individual factors r = 0.80, environmental r = 0.91, interpersonal r = 0.84 have been. An alpha coefficient of more than 0.7 means the questionnaire has acceptable reliability. 

To collect data, the researcher according to the work schedule of nurses in different shifts (morning, evening and night) in the two hospitals of Rouhani and Yahyanejad and in the wards where Coronavirus patients were hospitalized and according to the inclusion criteria Samples, while stating the purpose of the study, nurses were asked to select and answer one of the options by reading each of the questionnaire questions. Finally, 250 questionnaires were distributed among nurses in different Coronavirus wards in the above two hospitals. After collecting and reviewing them, 224 fully answered questionnaires were studied and the rest of the incomplete questionnaires were removed from the study.

SPSS software version 23 was used for data entry and statistical analysis. Moreover, one-way parametric analysis of variance (ANOVA) and independent t-test were used to investigate the relationship between each factor and individual characteristics with stressors in nurses. A p-value less than 0.05 were considered statistically significant.

RESULT: A total of 224 employed nurses were included in the study, of which 80 (35.7%) were male and 144 (64.3%) were female. the mean age of both sexes was 33.43±5.69 years, the minimum age was 23 and the maximum was 50 years. The majority of nurses (91.5%) had bachelor's degree, 80.4% of them were married and 84.8% worked rotating shifts. In determining the severity of stressors in nurses, the highest and the lowest intensities belonged respectively to the physical and environmental stressors and patient care stressors with a mean score of 29±10.12 and 13.38±5.02. The mean scores of interpersonal stressors, managerial stressors and individual stressors were 25.62±8.34, 25.57±7.60 and 25.41±7.61, respectively (Figure1).

Figure 1- Comparison of stressors in nurses involved in caring for coronavirus patients in Babol University of Medical Sciences

The most important stressors in nurses are insufficient support provided by the medical system for nurses involved in caring for COVID-19 patients (68.2%), high workload (63.9%), tight monthly nursing work schedule (63.5%), heaviness and inconvenience of protective clothing and boots (63.3%), inappropriate nurse-to-patient ratio (61.5%), lack of adequate space to change protective clothing (60.2%), lack of personal protective equipment (60.1%), lack of adequate opportunity for staff to rest (58.3%), nurses’ thirst caused by excessive sweating due to wearing protective clothing (56.1%), absence of doctors in emergency situations (54.3%), contact with equipment and infected objects (53.7%), nurses’ fear of getting infected by Corona virus (52.1%), caring for a dying patient (51.1%), patient density in Covid-19 wards (50%) and the noise made by the clients (50%). There were significant relationships between stressors in nurses involved in caring for COVID-19 patients and gender (female), work experience of 1-10 years and type of hospital (Yahyanejad). On the other hand, the physical and environmental stressors were only associated with shift work, interpersonal stressors were associated with education and patient care stressors were associated with overtime. It is worth mentioning that there were no significant relationship between the different stressors and variables including age (p=.629), marital status (p=.525), having children (p=.495), employment status (p=.241), overtime (p=.118) and interest in nursing profession (p=.421)(Table 1) .

Table 1: Relationship between stressors and some demographic variables of nurses involved in caring for coronavirus patients in hospitals of Babol University of Medical Sciences 

Managerial stressors:

Mean (SD)

Individual stressors:

Mean (SD)

Physical and environmental stressors:

Mean (SD)

Stress factors of patient care:

Mean (SD)

Interpersonal stressors:

Mean (SD)

                              Stressors

  variable

25.96(7.57)

25.93(6.88)

Median=27

28.7(9.19)

13.06(4.68)

24.2(7.91)

Median=24

30=>

age

25.29(7.60)

25.09(7.97)

Median=26

29.15(10.64)

13.5(5.18)

26.3(8.5)

Median=26

<30

p-value =.536

p-value =.491

p-value =.750

p-value =.539

p-value =.115

test

22.56(7.01)

22.71(6.79)

25.16(8.58)

11.58(4.77)

23.58(8.25)

male

sex

27.25(7.42)

26.93(7.64)

31.14(10.31)

14.38(4.89)

26.75(8.20)

female

t (221) =-4.62

p-value =.000*

t (221)=-4.1

p-value =.000*

t (222)=-4.4

p-value =.000*

t (222 )=-4.13

p-value =.000*

t (222)=-2.67

p-value =.006*

test

27.25(7.54)

Median=29

26.45(7.56)

Median=27

31.24(10.56)

Median=31

14.19(5.07)

Median=15

26.06(8.65)

Median=27

1-10

Work experience

23.25(7.27)

Median=23

24.16(7.67)

Median=23

26.36(8.83)

Median=25

12.26(4.75)

Median=12

24.92(7.99)

Median=24

11-20

25.50(4.88)

Median=24.5

22.66(3.88)

Median=22

22.50(7.52)

Median=22

13.66(5.60)

Median=15

28(7.09)

Medin=29.5

21-30

Χ2=16.10

p-value=.000*

Χ2=5.53

p-value=.063*

Χ2=15.43

p-value=.000*

Χ2=9.89

p-value=.007*

 χ2=2.66

p-value=.263

test

21.11(8.02)

Median=20

20.33(7.31) 

Median=19

20.33(7.84) 

Median=22

11.44(5.19)

Median=12

25.55(10.08) 

Median=27

Morning

Work shift

24.24(8.78) 

Median=25

24.44(6.80)

Median=25

28.08(11.21) 

Median=28

12.8(6.34)

Median=11

24.88(11.24) 

Median=22

Evening

25.95(7.39) 

Median=27

25.76(7.67)

Median=27

29.55(9.94) 

Median=29

13.57(4.82)

Median=14

25.75(7.86) 

Median=26

circulation

χ2=4.27

p-value=.118

χ2=3.83

p-value=.147

χ2=7.69

p-value=.021*

χ2=2.34

p-value=.309

χ2=1.19

p-value=.55

test

25.76(7.39) 

Median=26

25.64(7.57) 

Median=26.5

29.04(9.9) 

Median=28

13.36(4.84)

Median=13

25.97(7.97) 

Median=26

bachelor

education

23.52(9.57) 

Median=26

23(7.82) 

Median=23

28.63(12.61) 

Median=29

13.63(6.79)

Median=12

21.89(11.19) 

Median=20

master

t (221)= 1.22

p-value =.221

Z=-1.387 

p-value =.166

Z=-.165 

p-value =.869

t (222)=-.224

p-value =.823

t (222)= 2.05

p-value =.041*

test

25.58(7.80)

24.25(8.09)

26.56(9.90)

11.91(4.74)

23.37(7.81)

Rouhani

hospital

59.67(5.20)

27.80(5.87)

34.05(8.66)

16.42(4.15

30.28(7.46)

Yahyanejad

t (221 )=-6.04

p-value =.000*

t (221)=-3.34

p-value =.000*

t (222 )=-5.51

p-value =.000*

t (222 )=-6.93

p-value =.000*

t (222)=-6.29

p-value =.000*

test

DISCUSSION: The aim of this study was to identify stressors in nurses involved in caring for coronavirus patients in hospitals of Babol University of Medical Sciences. In determining the areas of stressors in nurses, the mean scores of physical and environmental stressors with 29±10.12 and patient care stressors 13.38±5.02 were the highest and lowest, respectively. The mean scores of interpersonal, managerial and individual stressors were 25.62±8.34, 25.57±7.60 and 25.41±7.61, respectively. That is, the average score of physical and environmental stress areas was higher than other stress areas in nurses.
The average score of physical and environmental stress was higher than other areas. The most important stressors in nurses are: inadequate support provided by the medical system for nurses involved in caring for COVID-19 patients, high workload, tight nursing schedule, heaviness and inconvenience of protective clothing and boots, inappropriate nurse-to-patient ration, Lack of adequate space to change protective clothing, lack of protective equipment, lack of adequate resting opportunities for staff, nurses’ thirst resulted from excessive sweating due to wearing protective clothing, unavailability of doctors in emergency situations, contact with contaminated equipment and objects, nurse's fear of getting infected by Corona virus, caring for a sick and dying patient and the density of patients referred to the Covid-19 ward.

A study conducted by Ong et al showed that one of the main concerns and tensions of nurses when caring for patients with contagious infectious diseases such as COVID-19 is how to take care of themselves against the disease and prevent it. A study in China also showed that nurses were worried about the risk of transmitting the disease to their families.
 The study of Kuo et al. (2020) in Taiwan showed that the discomfort caused by wearing protective equipment and responsibility of patient care were the first and the second major causes of stress in nurses. In other studies, "dry, cracked hands caused by frequent hand washing and use of disinfectants", "inconvenience to go to the toilet at work", "restrictions on eating and drinking at work", "fear of getting infected by Coronavirus" and "fear of transmitting the virus to relatives and friends" were reported as the most important stressors in nurses. In terms of physical and environmental stressors (discomfort due to the use of protective equipment such as "heavy clothing and protective boots", "nurse feeling thirsty due to excessive sweating due to wearing protective clothing", "fear of nurse and family becoming infected with COVID- 19 "are consistent with our study. Liu et al. (2020) also reported that in addition to caring for patients, wearing protective equipment for a long time led to physical discomfort for nurses, especially the ones who had to stay in isolated wards for all shifts. In terms of stressors, "heavy clothing and protective boots", "high workload" and "tightness of nurses' work schedule" are consistent with our study. The above mentioned studies indicated that nurses are required to wear protective equipment (goggles, protective clothing, masks and gloves) for a long time to effectively prevent the source of infection from entering into the hospital, which makes eating, drinking and using the toilet unpleasant for them. 
Based on the results of the present study, interpersonal factors were assigned as the second stressors factor among nurses involved in the care of coronavirus patients. When the interpersonal relationships in nurses are weak, it ultimately leads to low trust, lack of interest, and the feeling of insecurity and dissatisfaction of patients, as well as increasing the level of occupational stress in nurses. 
The results of the present study showed that the third of stressors factor among nurses involved in the care of coronavirus patients was management factors. In the study of Faremi et al. (2019) in southwestern Nigeria, the most stressful aspects of nurses' work were: insufficient staff cover workload, lack of medication and equipment needed for nursing care, and seeing patients die. In our study, the factors of "lack of nurses compared to patients", "lack of protective equipment", "care of the sick and dying patient" are among the most important stressors in nurses involved in the care of coronavirus patients, so this study is consistent with our study. The results of the present study showed that personal factors and care of COVID-19 patients constitute the fourth and fifth stressors, respectively, among nurses involved in the care of COVID-19 patients. Among the most important individual factors in the COVID-19 ward that can lead to an increase in the stress level of nurses is the critical condition of patients and the need to make momentary decisions regarding care. Frontline medical workers in the COVID-19 pandemic due to unpredictable conditions and high work pressure, excessive fatigue and exposure to sick patients and high patient mortality, lack of protective equipment against the transmission of the virus, concern about the transmission of the virus to family members, In addition to being at risk of viral infection, they also suffer from many psychological problems. In terms of stress factors, "caring for a sick and dying patient" is one of the most important stress factors in nurses involved in caring for coronavirus patients, so it is consistent with our study.

The female gender and work experience of 1-10 years are significantly associated with stressors in nurses involved in caring for coronavirus patients. Findings from Maphangela (2015) in line with our study showed that women experienced more stress than their male counterparts. Nurses with less work experience were more stressed, however, in the study of Faremi et al. (2019) there was no significant difference between the stress experienced by young and senior nurses. This research is not in line with our study. In the interpretation of the contradiction of this finding with the current research, it can be pointed out that most nurses with experience expect less presence in the care department of COVID-19 patients from hospital officials. The nurses at Yahyanejad Hospital experienced more stressors than the ones at Rouhani Hospital. This may be due to the fact that this hospital is the primary treatment and care center for COVID-19 patients in the city of Babol, and its nurses have been involved in caring for COVID-19 patients for a longer period than the nurses at Rouhani Hospital. There was no significant relationship between different stressors and the variables including age, marital status, having children, employment status, overtime and interest in the nursing profession. Likewise, in the study of Hebrani et al., there was no significant relationship between nurses' job stressors and any of the variables including age, sex, marital status, year of work, shift work and finally employment in different hospital wards. However, in the study of Eriksen et al., it showed a significant inverse relationship between work experience and the level of occupational stress in nurses. The discrepancy between the findings of the present research and the mentioned studies can be due to the difference in the research environment and critical conditions during the corona pandemic, as well as the pervasive anxiety of this disease on all nurses. Regarding the relationship between employment status and stressors, our study, like Shojaei et al.'s study, showed that employment status has no significant relationship with stressors.
CONCLUSIONS: The most stressful area in nurses employed in hospitals is related to physical and environmental stress. The most important stressors in nurses include: inadequate support provided by the medical system for nurses involved in caring for COVID-19 patients, high workload, tight nursing schedule, heaviness and inconvenience of protective clothing and boots, inappropriate nurse-to-patient ratio, lack of suitable space for changing protective clothing and lack of protective equipment. Undoubtedly, the authorities can be of a great help in reducing stress in nurses involved in caring for coronavirus patients. Therefore, it is recommended that they eliminate or modify the factors that cause or increase stress in nurses, which can improve their health status and ultimately lead to faster recovery of patients.
Among the limitations of this study, nurses with master's and bachelor's degrees were selected. Therefore, the results can not be generalized to other categories of nursing, such as post-diploma, nurse, assistant nurse and managers and head nurses of departments.
On the other hand, the mental state and fatigue of nurses working in corona wards could also affect the way the questionnaire was answered, so we tried to provide full questionnaires to nurses at the appropriate time, but complete control was beyond the researcher.
ACKNOWLEDGMENT: We would like to thank the vice chancellor for research and technology of Babol University of Medical Sciences for supporting the implementation of the project and also all the nurses who have participated in this study.
CONFLICT OF INTEREST: "The authors declare that there are no conflicts of interest regarding the publication of this manuscript".