key: cord-0962877-dwn7zz11 authors: Alwani, S. S.; Majeed, M. M.; Hirwani, M. Z.; Rauf, S.; Saad, S. M.; Shah, S. H.; Hamirani, F. M. title: Evaluation of Knowledge, Practices, Attitude and Anxiety of Pakistans Nurses towards COVID-19 during the Current Outbreak in Pakistan date: 2020-06-07 journal: nan DOI: 10.1101/2020.06.05.20123703 sha: 3d1fcd308de57db7036e2f3c9f48673208d3d4c8 doc_id: 962877 cord_uid: dwn7zz11 Since the emergence of novel corona virus the front line soldiers during this pandemic are the healthcare professionals because of their direct association with the patients. In the management of COVID-19 patient nurses play a significant role through proper care and preventive measures. Due to the contagious nature, fatality and no proper medicine, it is a risk to the health and life of nurses and has impact on their psychological health. In the current study we accessed the knowledge, attitude, practices and anxiety levels of the nurses who are directly involved in the management of COVID-19 patients. It was an online questionnaire based cross sectional survey targeted only those only nurses involved in the management of COVID-19 patients from different hospitals of Karachi, Pakistan. SPSS 21 was used for data analysis. Descriptive analysis, Chi Square and t-tests were applied. Value <0.05 was considered significant. Data of 78 nurses were analyzed .We observed that nurses possess good knowledge about COVID-19, its sources, symptoms, routes of transmission of virus and etc. The knowledge mean score was calculated 14.67 {+/-} 3.36. Health department /Hospital and social media are the main sources of information regarding COVID-19. We investigated that 92.3% of the nurses had mild to very severe anxiety and anxiety levels are significantly higher among the females (P<0.05). We conclude that the nurses performing their duties with COVID-19 positive patients have good knowledge and attitude. But their anxiety levels are high. Psychological interventions along with training should be given. The latest member of Corona Virus family is COVID-19 and before this two more members of the same family were the Severe acute respiratory syndrome coronavirus (SARSCoV) and Middle East respiratory syndrome coronavirus (MERSCoV) (1) . The novel Corona virus (COVID- 19) which was identified in December 2019 have been declared a pandemic on 11 th March 2020 as the virus reported to be highly contagious and deadly (2). By the time the total number of people infected and confirmed by the lab are more than 6 million and over 300000 have been died and the figure is raising exponentially (3) . In Pakistan the first case of the virus was reported on 26 th Feb 2020, a university student travelled from Iran, which was the epi center of this virus after China (4) . By the time (31 st May 2020) Pakistan has crossed the 70000 mark of reported cases and with more than 1400 deaths so far (5) . To control the spread CDS has recommended a guide line and protocol to follow. Mainly this virus spreads via aerosols, direct contact with the infected person or indirectly by touching surface that has virus on it. Fever, sore throat, dry cough and shortness of breath are the main symptoms (6). Up till now there is no specific treatment other than supportive treatment and its morbidity rates are less than 5%. The nature of virus is rapidly changing and new information regarding COVID-19 is pouring on daily basis. So updated knowledge and training is very necessary in order to fight with this deadly virus(6). Healthcare professionals are the front line soldiers in the outbreak of any disease and are more susceptible to be infected because of their direct and close interaction with the diseased individuals (7, 8) . The may not only infected but in severe cases it may lead to the death of the healthcare individuals or same scenario may happen with their family members or closed ones (9) . In the current pandemic thousands of healthcare professionals and healthcare workers infected in China . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 7, 2020. . https://doi.org/10.1101/2020.06.05.20123703 doi: medRxiv preprint , Spain, Italy , France, Turkey and other parts of the world (10) (11) (12) .International council of Nursing (ICN) stated that over 90000 healthcare workers have been infected with COVID-19 and only the death toll of nurses is estimated to be 360 (13, 14) .In Pakistan 100's health care professionals are reported COVID-19 positive along with many deaths (15, 16) . Moreover a suicide case of 27 years old doctor is also reported in the turmoil of COVID 19 due to anxiety (17) . The current situation is the challenge for health care professionals to cope up with anxiety, stress, and depression, not only for their health and life but for the safety of family members. In such conditions it is not un common for the front line workers that includes medical doctors, dentist , nurses and other health care profession to develop psychological symptoms , mental and other health related problems (18) . Health care workers involved with the testing and treatment of individuals with COVID-19 are more vulnerable to get infection than the general public as well as more prone to spread infection to their loved ones and this may also results in psychological distress (19, 20) . Furthermore during the episodes of SARS and MERS multiple cases of panic attacks, anxiety, stress even suicides have been reported (3, (21) (22) (23) . The transmission of the disease among the HCP is linked with the improper knowledge, training, protection, not following the recommended protocols or guideline, absence of isolation rooms and also the lack of knowledge and awareness regarding the course and spread of the disease (24) . It is well documented that proper knowledge of the disease may have the positive impact on the attitude and practices thus less chances of infection (25) . Nursing is the largest healthcare profession in the world, with approximately 20 million nurses worldwide (26) .Along with the other healthcare professional nurses plays a pivotal role in healthcare setup in prevention, infection control, isolation, containment monitoring of the patients and because of their unique patient-facing nature, there are occupational risks to providing care . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 7, 2020. . https://doi.org/10.1101/2020.06.05.20123703 doi: medRxiv preprint during the COVID-19 outbreak (27) and it is also reported that chances of occupational exposure is relatively higher in nurses (28) .Moreover previous studies have shown also higher level of anxiety and depression among the nurses due to their long interaction with the patients and nature of their job (29) (30) (31) . Deprived mental health among nurses may not only be damaging to them but may also impede effect their professional routine and in turn, the quality of patient care provided (32) as it is evident that wellbeing of the mental state is crucial to in order to manage infectious diseases (18, 33) . The current study aimed to assess the knowledge, attitude and anxiety levels toward COVID-19 among Nurses of Karachi, Pakistan who are directly involved with COVID-19 patients. The findings will help us to evaluate the knowledge and anxiety levels among the nurses associated with patients suffering from Corona Virus in different hospitals of Karachi, Pakistan and the results of this study will also help the authorities to organize the necessary educational programs in order to provide up-to-date information and deliver the best practice to control the COVID-19 disease and to arrange counseling sessions or physiatrist/psychological intervention to control the psychological and mental problems. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 7, 2020. According to Raosoft the minimum required sample size was 67 considering a response rate of 50%, 90% confidence interval (CI) and 10% margin of error. Ethical approval was obtained from the ethics and review committee of Altamash Institute of Dental Medicine, Karachi, Pakistan (AIDM/EC/04/2020/03). The participation was voluntary, informed consent along with the approval to publish the outcomes of the study was obtained. SPSS 21 used for data analysis. Chi Square and t-tests were applied to compare different factors. Value <0.05 was considered significant. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 7, 2020. . https://doi.org/10.1101/2020.06.05.20123703 doi: medRxiv preprint Total 85 forms were submitted and due to incomplete submissions and errors we excluded 7 forms so the data of 78 nurses have been analyzed. Among the participants, 38 (48.71) were females and 40 (51.28%) were males. The difference among the gender is not significant (P=0.821) (Table1) In the current study 37 (47.43%) of the participants were below 30 years of age, 34 (43.6%) were in the age group of 31 to 40 years and 5 (6.4%) were between 41-50years old and 2 (2.6%) participants were above 50 years of age. We found that 8(10.3%) were having Master's degree in nursing, 33 (42.3%) of the participant were holding a Bachelor's degree and 31 (39.7%) nurses were equipped with diploma in nursing and 6 (7.7%) were having education till high school or less. . We found that 30 (38.5 %) of the nurses were having experience of less than 5 years. The maximum number of nurses were having experience of 5-15 years i.e. 34 (43.6%) and 14 (17.9%) were having experience of 16 years or more. There is a statistically significant difference of age, education and working experience among the participants. (Table1) In the current study we found that 12 (15.38%) of nurses reported that they were infected with COVID-19 (P>0.05) and 56(71.79%) of the participants claimed that their colleagues have been is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 7, 2020. (Table 2) The main sources of COVID-19 information are hospital or health ministry and social media 67(85.89%) and 47 (60.25%) respectively, followed by Colleagues OR Friends, Research Articles, Television and Radio, etc. Some of the participants were actively involved in taking webinars and reading research material on internet (Fig 1) . Significant number of nurses have anxiety (p=0.00). The number of nurses having no or mild anxiety are 6 (7.7%) and 6 (7.7%) respectively and those having moderate, high and very high levels of anxiety are 19 (24.4%), 24 (30.8%) and 23 (29.5%) respectively (FIG 2) . Significant Difference in the levels of anxiety has been observed among the genders (p=0.016) Female are more anxious as compared to males (FIG 2) .The mean self-anxiety score to be infected for participant was found to be 3.60 ± 1.25 and for their family the mean anxiety level was recorded 3.85 ± 1.31. Anxiety about performing measures like aerosol producing procedures, taking nasopharyngeal swab, nebulizing, suctioning etc. was calculated 3.30 ±1.33 (Fig 3) .We found that the anxiety levels are significantly higher among those individuals who have been previously infected with COVID-19 (P=O.013). As per our results around 80% of the nurses put face masks, protective clothing's, place suspected patients in ventilated single room, routinely clean and disinfect environmental surface, frequent hand cleaning and follow respiratory hygiene and cough etiquette and practice social distancing. ( Table 3) . Current study findings demonstrates a positive attitude of the nurses towards COVID-19. 75(96%) nurses who have dedicated themselves for COVID-19 patients willing to continue their work. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 7, 2020. (Table 3) . . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 7, 2020. . https://doi.org/10.1101/2020.06.05.20123703 doi: medRxiv preprint To best of our knowledge, this is the first study that has targeted only the Nurses in order to assess their knowledge and practices towards COVID 19 and their level of anxiety in Pakistan. This study was being conducted when Pakistan crossed the mark of 40000 reported cases of COVID 19. In the current study the participants were the nurses who were directly involves with COVID-19 patients. And we assessed their knowledge, attitude and practice in order to shield them and prevent the further spread of the infection. It is reported that nurses are more prone to infection due to the close contact with the patients (35) . Moreover we analyzed the anxiety levels among the nurses as studies suggests that in case of big disasters mental health issues may arise (36) . In this study the data of 78 participants was analyzed. All the participants were the nurses that have been involved in the management of patients' diagnosed with COVID-19. Total number of males were 40 and females were 38. There is no significant difference among the gender. Usually in other studiers higher female to male ratio has been observed(28) but contrary to other studies in our study we found higher number of males. This is because of the reason that here males are usually the bread earners and they have no other option on the other hand many female nurses have quit their jobs and resigned due to the family burden (37) . In this this study we analyze a significant differences in age, educational level and experience. We further investigate that 90% of the nurses are below 40 years of age and majority have bachelor's degrees or associated diplomas in nursing. Similar finding witnessed in other studies (34, 38) . The finding of the current study showed that nurses in Karachi have sufficient knowledge regarding different aspects of COVID-19. In a recent study conducted on health care professionals in Pakistan reveled that HCP have good knowledge towards COVID-19 (39, 40) . Moreover different studies performed in different parts of the world showed the strikingly similar results (34, . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 7, 2020. . https://doi.org/10.1101/2020.06.05.20123703 doi: medRxiv preprint 41, 42) . Contradictory to the findings of our study, a research conducted in Pakistan few weeks before reported low level of knowledge among the nurses (43) .Previous studies in different parts of the world during epidemic revealed that the rate of influx of information is much high during the current pandemic (44, 45) . We appraised that Health department or hospital and social media and are the two major source of information regarding COVID 19. Our results are further endorsed by different studies stated that the previously mentioned sources are the primary sources of information regarding (38, 46, 47) . In the current study we have observed that nurses' follows correct protocols in order to prevent themselves and patients. Such practices are very important in order to control the cross infection. Practices are associated with knowledge, work experience, and other factors. Furthermore data from other countries are in accordance with our findings (50) In Italy 12 % of . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 7, 2020. . https://doi.org/10.1101/2020.06.05.20123703 doi: medRxiv preprint the nurses got COVID-19. In Brazil it is also reported that 1000s of nurses have been infected and 100s dead (51). Same are the conditions in other countries as per reports (52-54) Moreover we believe that higher rate of infection and mortality among the healthcare professional and their family members could be one of the cause of anxiety. But on the contrary a study in Iran showed totally different results with zero infected case (34) . Likewise in different researches, in our study significant majority of the participants believes that there is dire need of more trained workers in order to accommodate the need that is aroused because of the current pandemic (55, 56) . Anxiety is an undesirable emotional condition perceived individually and it is reported that anxiety is one the commonest psychological hurdle of nurses (28) . In our study 72 (91.3%) nurses have the overall anxiety ranges from mild to very severe. In a similar study on health care workers conducted in China expressed the similar results (57) and in another study that was purely conducted over nurses showed the higher level of anxiety among the nurses which further validates our findings, furthermore in accordance with the results of our study it also showed the anxiety for the family member (33, 34, 58) . Moreover previous studies have also shown higher level of anxiety and depression among the nurses due to their long interaction with the patients and nature of their job (29) .Similar findings were reported by other studies during SARS and MERS (3, 59, 60) . According to the findings of this study females exhibited more anxiety as compare to males which is in agreement to the outcome of other studies (61, 62) . In our opinion the high rate of anxiety is because of unavailability of personal protective equipment (PPE), lack of counselling sessions, deficiency of proper health care facilities etc. Moreover job stress , demands , exertions may not only have negative impact on the psychology and mental health but also on the general wellbeing (63, 64) . Moreover due to the social media and easy access to the current news and . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 7, 2020. . https://doi.org/10.1101/2020.06.05.20123703 doi: medRxiv preprint information the anxiety and obsession has been increased (65, 66) . Anxiety of nurses towards their family member to be infected with COVID-19 is significantly on the very severe side. Studies have shown that due to the highly contagious nature of this virus healthcare professionals are in stress and depression as they might transfer the infection to their family members (41) . In order to reduce the anxiety counseling sessions should be organized. Same recommendations were given in parallel studies as the wellbeing of the mental state is crucial to in order to manage infectious diseases (18, 33) . This study concludes that the Nurses working with COVID-19 patients have good knowledge regarding symptoms, route of infection, treatment options etc. Majority of the Nurses in Karachi, Pakistan showed typical signs of anxiety. Therefore it is recommended that proper counseling sessions may help them cope with the pandemic. Proper training and mentorship along with fortnightly or monthly refresher course may aid into tackling such situations. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 7, 2020. . https://doi.org/10.1101/2020.06.05.20123703 doi: medRxiv preprint The authors declare that they do not have any interests that could constitute a real, potential or apparent conflict of interest with respect to their involvement in the publication . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 7, 2020. . https://doi.org/10.1101/2020.06.05.20123703 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 7, 2020. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 7, 2020. 3 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 7, 2020. . Source of Information . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 7, 2020. . https://doi.org/10.1101/2020.06.05.20123703 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 7, 2020. . https://doi.org/10.1101/2020.06.05.20123703 doi: medRxiv preprint 270-3. 2. WHO. WHO Director-General's opening remarks at the media briefing on COVID-19 -11 Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers COVID-19 Cases in Pakistan Assessment of anxiety level of emergency health-care workers by generalized anxiety disorder-7 tool What paramedics think about when they think about fatigue: Contributing factors Diminishing returns? Risk and the duty to care in the SARS epidemic Factors associated with mental health outcomes among health care workers exposed to coronavirus disease Nurses TICo. Immediate and serious threat: ICN calls on WHO member states to collect and share data on health worker COVID-19 infection rates and deaths 2020 Over 90,000 health workers infected with COVID-19 worldwide: nurses group. Reuters COVID-19 outbreak: 440 doctors, 111 nurses and 215 paramedics infected so far 2020 PAKISTAN CASES DETAILS 2020 Coronavirus: Young doctor commits suicide in Pakistan due to lack of protective measures 2020 Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed When health professionals look death in the eye: the mental health of professionals who deal daily with the 2019 coronavirus outbreak Compare the severity of psychological distress among four groups of Iranian society in COVID-19 pandemic Mental health status of people isolated due to Middle East Respiratory Syndrome Conwell YJIJoGPAjotpoll, sciences a. Elderly suicide and the 2003 SARS epidemic in Hong Kong Survey of stress reactions among health care workers involved with the SARS outbreak 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 Metaanalysis of the reasoned action approach (RAA) to understanding health behaviors 2020: unleashing the full potential of nursing COVID-19: Emerging compassion, courage and resilience in the face of misinformation and adversity Work stress among Chinese nurses to support Wuhan for fighting against the COVID-19 epidemic The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope Stress, depression, and intention to leave among nurses in different medical units: Implications for healthcare management/nursing practice Prevalence and risk factors of depression, anxiety, and stress in a cohort of Australian nurses Reed DBJWh, safety. Depression in registered nurses: a state of the science The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus Assessment of Iranian nurses' knowledge and anxiety toward COVID-19 during the current outbreak in Iran Nurses' contacts and potential for infectious disease transmission The mental health of school children after the Great Hanshin-Awaji Earthquake: II. Longitudinal analysis Why Pakistan's health workers are against easing the COVID-19 lockdown Knowledge and attitude toward COVID-19 among healthcare workers at District 2 Hospital Knowledge, attitude, practice and perceived barriers among healthcare professionals regarding COVID-19: A Cross-sectional survey from Pakistan Awareness and Practice of Health care Professionals amid SARS-CoV-2, Corona Virus Disease Outbreak Knowledge and attitude toward COVID-19 among healthcare workers at District 2 Hospital Knowledge of COVID-19 among nursing and Allied health care professionals working in tertiary care hospital Is Pakistan prepared for the COVID-19 epidemic? A questionnaire-based survey The covid-19 social media infodemic Social media for rapid knowledge dissemination: early experience from the COVID-19 pandemic Knowledge, attitude, practice and perceived barriers among healthcare professionals regarding COVID-19: A Cross-sectional survey from Pakistan Media's effect on shaping knowledge, awareness risk perceptions and communication practices of pandemic COVID-19 among pharmacists Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey ICN calls for data on healthcare worker infection rates and deaths 2020 Asymptomatic and presymptomatic SARS-CoV-2 infections in residents of a long-term care skilled nursing facility-King County High COVID-19 infection rates among doctors and nurses in Germany COVID-19 cases among health care workers top 62,000, CDC reports. NBC NEWS Mental Wellbeing of Nursing Staff during the COVID-19 Outbreak: A Cultural Perspective 2020-The Year that Needed the Nurse: Considerations for Critical Care Nursing Research and Practice Emerging in the Midst of COVID-19 Knowledge, attitude and practice regarding COVID-19 among health care workers in Henan Anxiety and Depression in Health Workers and General Population During COVID-19 Epidemic in IRAN: A Web-Based Cross-Sectional Study The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak perceptions of risk and stress evaluation in nurses COVID-19 and mental health: A review of the existing literature Comparison of characteristics of anxiety sensitivity across career stages and its relationship with nursing stress among female nurses in Hunan Job stress and burnout in hospital employees: comparisons of different medical professions in a regional hospital in Taiwan Work related stress, burnout, job satisfaction and general health of nurses The effects of social support on sleep quality of medical staff treating patients with coronavirus disease Aggregated COVID-19 suicide incidences in India: Fear