2022

“A Qualitative descriptive cross-

sectional study to assess the
development of stress among
Fujairah Primary health care
nurses, and ways of coping up
during Covid-19 pandemic
crisis.”

FUJAIRAH PHC NURSING DEPARTMENT RESEARCH- STUDY 1

REENA VARGHESE

EHS | reena.varghese@ehs.gov.ae
Date
20/04/2021

To
The MOHAP Research Ethics Committee
Dubai, UAE

To whom it may concern,

Greetings from Fujairah PHC Nursing department, PHC Fujairah………

According to the study of ‘The relative prevalence of health disorders in high-stress

occupations’ National Institutes of Health (NIH), “Nurses and physicians are affected by a
variety of stressors in their workplaces because of their responsibility to provide health and
treatment to patients”
We are presenting the proposal enclosure titled, “A Qualitative descriptive cross-sectional study
to assess the Development of stress among Fujairah Primary health care Nurses, and ways of
coping up during Covid-19 pandemic crisis.”

With this the Fujairah PHC nursing department, under Primary Health Care Fujairah would
like to express its keen interest to undertake this project which may be a hope to assess and
thereby improve the stressors among nurses towards existing Pandemic crisis.
Looking forward to hear positive response from your end.

Thanking you.
With regards,
REENA VARGHESE,
RESEARCH TEAM LEADER,
PHC FUJAIRAH

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2|Page
 “A Qualitative descriptive cross-sectional study to assess the
development of stress among Fujairah Primary health care nurses,
and ways of coping up during Covid-19 pandemic crisis.”

Reena Varghese, Amal AlHantoubi, Tiji Mathai, Jindiya Chris, Gils Jacob, Enrico, Alma.

Abstract

Aim: The aim of this study was to explore perceptions of the most salient sources of stress in the
early stages of the coronavirus pandemic in a sample of nurses who were working in Fujairah Primary
health care during the year 2020-21.

Background: During pandemic process, nurses reported to experience stress due to a very high risk
of being infected and workload. The coronavirus disease (COVID-19) pandemic has exposed nurses to
conditions that threaten their health, well-being, and ability to work. It is therefore critical to study
nurses’ experiences and well-being during the current crisis in order to identify risk groups for ill
health and potential sources of organizational intervention.

Method: A qualitative descriptive cross-sectional study with a sample consisting of 180 nurses
working in Fujairah Primary health care centers. To collect data, an online survey questionnaire was
formulated which was used together with the Perceived Stress Scale among a sample of 280 nurses
who were working in Fujairah Primary health care 2021. Content analysis was conducted on nurses’
responses (n = 180) for their perceptions.

Results: 180 nurses’ responses(N) were randomly chosen as samples in this current study of which
majority were female (n = 161, 89.4%) and only 10.6%(n=19) were males. Findings revealed the
distribution of respondents by stress level either low and moderate. 89.4% of respondents had
moderate stress level as compared to 10.6% with less stress. There is no presence of normal and high
stress. There was no significant association between the stress when compared to socio-economic
factors like age, gender, marital status, qualification, and job title (P > 0.05). But when it compared
to the relationship with working position and working area, it was showing a significant association
(P ≤0.05).

Conclusion: Nearly more than half of the nurses in Fujairah primary health care centers perceived
stress above average during COVID-19 pandemic, and their working conditions also affected this
situation.

Implications for Nursing Management: Healthcare institutions should provide opportunities for
nurses to discuss the stress they are experiencing, support one another, and make suggestions for
workplace adaptations during this pandemic. Meeting physiological needs, applying psychological
guidance and counselling interventions in the stress management of nurses may contribute to the
reduction of their stress levels. Effective infection control, reducing workload, increasing the number
of nurses and strengthening the coping mechanisms can minimize the perceived stress level of
nurses.

Keywords: nursing, COVID-19, qualitative, health workers, pandemic, stress, content analysis.

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1.Introduction
1.1 Background of the Study

The COVID‐19 pandemic has started to threaten the health care systems of countries and has
increased the burden on health care professionals (Chen & Huang, 2020;Açıksarı & Kınık, 2020).
Health care professionals are the most valuable resource in protecting, preventing and treating
public health for all countries (WHO, 2020b; Açıksarı & Kınık, 2020; Chen & Huang, 2020). The
services of primary health care, which are one of the units where these basic services are
provided, are the place that have important roles in the pandemic process as in other disasters
and make the first intervention to patients affected by the infectious agent (Açıksarı &
Kınık, 2020).

As on April 23rd, 2020, more than 2.6 million cases of COVID-19 have been detected globally
and the numbers were rising with each passing day. Understandably, parallel and equally
urgent need to strengthen primary healthcare was required. There are several reasons for this.
Primary Health Centers (PHCs) are likely to be the first point of contact for most COVID-19
patients. Experience from China and Italy suggests that of all patients with the disease, 5-10
percent become severely ill and require admission to a health facility. About 70 percent of these
patients can be managed with supportive care and oxygen, which PHCs can easily provide.
Additionally, on account of their proximity to the communities that they serve, primary health
facilities are best suited to educate and inform them about COVID-19. And finally, at a time
when there is such restricted access to healthcare due to the lockdown, PHCs ensure access to
healthcare for pregnant women, elderly, children and high-risk people with conditions such as
diabetes, hypertension etc.

Disease outbreaks such as COVID 19 pandemic are stress-provoking situations. Stress is

common among healthcare workers especially nurses who are directly involved in managing
affected patients during pandemic. The main source of stress in nurses during COVID-19
pandemic are fear of becoming infected or unknowingly infecting others. (m o et.al:2020).
Shanfelt, Ripp and Trockel (2020) identified other sources of stress in nurses, including lack of
personal protective equipment, fear of access to COVID-19 testing, fear of transmitting the virus
at work, doubt that their institution would support them if they become infected and fear of
being deployed in an unfamiliar ward or unit and lack of accurate information on the disease.

Stress is a universal human experience and is an integral part of the biological structure of any
living organism. Stress has both positive and negative effects on people. While a low level of
stress is motivating for the person, above‐average stress can cause people to be unable to work
or cause serious physiological problems (Görüş, 2016).

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The psychological and physical health of nurse was influenced by many factors. Previous studies
reported that personal factors such as gender, age, educational level, marital status, having
children or not, and personality might be correlated with the mental health among nurses
(Cañadas-De la Fuente et al., 2018; Sadati, Hemmati, Rahnavard, Lankarani, & Heydari, 2016)

Previous studies (Li et al., 2015; Maunder et al., 2003; Ulrich, 2014) carried out during the
outbreak of SARS described increased mental burden on nursing staff. These frontline nurses
were reported to have a high risk of psychological distress, such as increased stress level, sleep
disturbance, loss of self-confidence and inability to make decisions, as well as physical health
problem (Nickell et al., 2004; Thamet al., 2004).

2. Materials and Methods

2.1. Aim

The aim of this study was to explore perceptions of the most salient sources of stress in the
early stages of the coronavirus pandemic in a sample of nurses who were working in Fujairah
Primary health care during the year 2020-21.

2.2. Design

A descriptive cross-sectional study was done based on an online survey for nurses in Fujairah
primary health care centers in December 2021. The 29-item questionnaire was developed by
the research team for the purpose of the study. It included measures regarding demographic
and work-related factors, as well as COVID-19 experiences concerning patient contact,
emergency preparedness, personal protective equipment, fear, and mental health and well-
being [13]. In addition to the 29 forced-choice items, there was a Google form of 10
questionnaire as another part of our research study to assess the stressful situations dealt with
during the COVID-19 pandemic based on a classic stress assessment tool, the Perceived Stress
Scale (PSS). In this study, qualitative content analysis was used to examine nurses’ responses to
this question.

2.3. Study Population

280 nurses working in Fujairah PHC during Covid-19 pandemic crisis.

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2.4. Sample

Inclusion criteria: Nurses working full time in Fujairah PHC.

Exclusion Criteria: Nursing staff who resigned, terminated, students, newly hired temporary
staff and nurses who were not working full time basis.

2.5 Sample size calculation

The questionnaire was distributed to all the nurses working in primary health care centers of
Fujairah region.

2.6 Sampling Technique

Random Sampling out of the respondents of questionnaires distributed via online survey and
forms were done among the total nurses working in the Fujairah PHC.

2.7 Study Settings

The 13 different primary health care clinics located in Fujairah area of Merashid, Madina, Faseel,
Qurayah, Murbah, Qidfa, Bidiyah, Siji, Hala, Wadisader, Tawain, Dadana and preventive medicine.

2.8 Duration of study

The estimated duration was from June 2021 to June 2022

2.9 Study instruments

Online questionnaire with selected questions to be distributed evenly among all the staff nurses
working in Primary health care centers of Fujairah district.

2.10 Plan for pilot study

No plan for pilot study.

2.11. Participants

Participants included all the nurses working in Fujairah PHC Nursing department, were eligible
to participate (approximately 280 nurses). During the survey period, 278 responses were
collected. Of these, 180 nurses’ responses(N) were randomly chosen as samples that are
examined in the current study. The majority of this sample was female (n = 161, 89.4%)
whereas only 10.6%(n=19) were males. Approximately 70% (n = 126) of respondents were

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between 31- 40 years of age, 23.9% (n = 43) were above 40, and 6.1% (n = 11) between 26-30.
Only 6%(n=12) were unmarried whereas 93.3% (n=168) were married. Of which majority 87.8
%(n=158) had children while only 12.2 % (n=22) didn’t have children. Just over 3.3% (n = 6)
have master’s in nursing whereas 54.4%(n=98) are bachelor’s and 41.1 %(n=74) of them with
diploma in nursing. The majority of respondents were registered nurses (RNs)
(84.5%=70%(nurse)+12.8% (qualified technicians) +1.7% (unit managers)),
(n=126+23+3=152), followed by dental assistants (15.6%, n = 28). Most worked in a general
outpatient setting (68.3%, n = 123) with 31.7 % where posted in an isolation setting (n = 57).
90% (n = 162) of participants reported being in contact with COVID-positive patients very
often/daily working as front liners while only 10 % of them worked as second liners. Nurses
whose responses to the survey’s question were taken did not differ significantly from non-
respondents with regard to age, gender, position, or current stress level (p > 0.05 for all
variables). However, a significantly larger proportion of question respondents worked as front
liners (n=162,90%) compared to second line respondents (n = 18, 10%).

2.12. Data Collection

Fujairah PHC Nursing department IT distributed surveys directly to the nurse members. Each of
the staff was sent an email with link to the online survey created by DSD with 29 Questions
developed by the research team members and a google form to assess the stress level during the
COVID-19 pandemic with 10 questions based on a classic stress assessment tool, The Perceived
Stress Scale (PSS).
Data collection technique & Validity: The questionnaire in English and Arabic was prepared
by the authors and submitted to ethical department for validation and thereby distributed. It
had two parts:
Part I: Covering their sociodemographic variables and variables on their working environment,
including attitude of the different category of working staff, job title, and so on.
Part II: To assess the stress level with 10 questions as part of our research study to assess the
stressful situations dealt with during the COVID-19 pandemic based on a classic stress
assessment tool, The Perceived Stress Scale (PSS). A total score 60, was classified into
0–13: Stress is not a problem in life; 16–30: Moderate stress, which can reasonably be reduced
27–40: Stress is a major problem and something must be done.

Stress Score Interpretation1: Items and way of scoring the PSS-10-C.

Almost Fairly Very

During the last 7 days Never Sometimes
Never Often Often

Q1. Last year during Covid -19 pandemic, how often have
you been upset because of something that happened 0 1 2 3 4
unexpectedly?

Q2. Last year during Covid -19, pandemic how often have 0 1 2 3 4

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 Almost Fairly Very
During the last 7 days Never Sometimes
Never Often Often
you felt that you were unable to control the important
things in your life?

Q3. Last year during Covid -19, pandemic how often have
0 1 2 3 4
you felt nervous and stressed?

Q4. In the last year during Covid -19 pandemic, how often
have you felt confident about your ability to handle your 4 3 2 1 0
personal problems?

Q5. Last year during Covid -19 pandemic, how often have
4 3 2 1 0
you felt that things were going your way?

Q6. Last year during Covid -19 pandemic, how often have
you found that you could not cope with all the things that 0 1 2 3 4
you had to do?

Q7. Last year during Covid - 19 pandemic, how often

4 3 2 1 0
have you been able to control irritations in your life?

Q8. Last year during Covid -19 pandemic, how often have
4 3 2 1 0
you felt that you were on top of things?

Q9. Last year during Covid -19 pandemic, how often have
you been angered because of things happened that were 0 1 2 3 4
outside of your control?

Q10. Last year during Covid -19 pandemic, how often

have you felt difficulties were piling up so high that you 0 1 2 3 4
could not overcome them?

Stress score interpretation

Total questions=10

Questions 4,5 ,7 & 8 are in reverse orders.

0 – Never;1- Almost Never; 2 – Sometimes; 3-Fairly Often; 4- Very Often

S.no Grade Score

01 More stress 27-40
02 Moderate stress 14-26 Scores: 27-40 will be considered
03 Low stress 0-13 having more stress, from 14-26 as
moderate, and 0-13 having less stress.

2.13. Ethical Considerations

Each nurse who participated to the survey questions were by his/her consent and not driven by
any external or internal sources. The survey was confidential and anonymous, and the
participants could terminate their participation at any time. The study questionnaires were
approved by EHS, Data and Statistical Department.

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2.14. Data Analysis

The data obtained were analysed in terms of the objectives of the study using Descriptive and
Inferential statistics. A master data sheet was prepared with responses given by the participants
with Frequencies and percentage for the analysis of demographic data, the mean and standard
deviation of answered questions. The Chi Square test was used to determine association
between stress level and selected demographic variables presented in tables and graphs.

The consolidated criteria for reporting qualitative research, were followed in the planning and
execution of this study to ensure methodological integrity. Qualitative content analysis of the
responses was conducted using a data-driven approach.

The Perceived Stress Scale (PSS), a classic stress assessment instrument was used to
framework for structuring qualitative data for analysing the stress level that are relevant to the
research question. Structuring the data in this way helps to create meaning out of complex raw
data.

3. Results
3.1 Baseline characteristics of respondents:

A total of 280 nurses participated in the online survey, in which 180 responses which were
completely answered in different section were randomly chosen. The results after analysis of
data using SPSS statistical software are contained in this chapter.

The analysis of survey questionnaires revealed as described below in Table 1 Demographic and
Socio-economic characteristics of nurses working in Fujairah Primary Health care centers.

The response rates were 10.6% male & 89.4% female in which 93.3% were married and only
6.7% were unmarried. Among the sample, only 6.1% were between 26- 30 years of age while
23.9 % were above 40 years and majority i.e. 70% of them were between 31-40 years of age. In
educational back ground, professional qualification revealed that 54.4 % were bachelor’s in
nursing with almost 41.1% of them diploma and only 3.3% had a master’s in nursing with 1.1%
of them holding other qualifications. The sample size mainly were staff nurses with registered
licenses (70% +12.8%+1.7%=83.5%) working as Qualified technicians or unit managers with
only few 15.6 % of them working as dental assistants. The study further revealed that 90% of
them were working as front liners while only 10% were on second line service during the
Covid-19 pandemic time. 68.3% of them were working in general units while 31.7 % of
respondents were working in isolation areas.

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 GENDER AGE (in years)

19, 11% 6%
24%
26-30
MALE
31-40
FEMALE
>40
161, 89% 70%

Socio- demographic datas

100.00% 93.30%
87.80%
80.00%
60.00%
40.00%
20.00% 12.20%
6.70%
0.00%
Marital status Having children
yes 93.30% 87.80%
no 6.70% 12.20%

yes no

Working status
100% 90%

80% 68.30%
60%
40% 31.70%

20% 10%

0%
Working position with Covid positive
Working area
patients
Front Line 90% 31.70%
Second Line 10% 68.30%

Graphical representation of few socio-demographic data

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Table -1. Frequency Table of Distribution of Socio-demographic properties

Socio-demographic properties

Frequency Percent
Gender Male 19 10.6
Female 161 89.4
Total 180 100.0
Age 26-30 11 6.1
31-40 126 70.0
>40 43 23.9
Total 180 100.0
Marital status Married 168 93.3
Unmarried 12 6.7
Total 180 100.0
Having children Yes 158 87.8
No 22 12.2
Total 180 100.0
Educational level Diploma 74 41.1
Bachelor in Nursing 98 54.4
Master’s in Nursing 6 3.3
Other’s 2 1.1
Total 180 100.0
Job title Nurse 126 70.0
Dental Assistant 28 15.6
Qualified technician 23 12.8
Acting Unit Manager 3 1.7
Total 180 100.0
Working position Front Line 162 90.0
with Covid positive
patients Second Line 18 10.0
Total 180 100.0
Working area Isolation 57 31.7
General 123 68.3
Total 180 100.0

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3.2 Assessment of stress among staff nurses in Fujairah PHC

Overall, our respondents had moderate to low stress with majority of them 89.4% facing
moderate stress towards the effect of COVID-19 pandemic and only 10.6% facing a low stress
with respondents showing no presence of more stress.

The below table shows the level of perceived stress scale score and association towards the
effect of COVID-19 pandemic among the nurses working in Fujairah PHC.

S.no Grade No. Percentage

01 More stress 00 0.0%

02 Moderate stress 161 89.4%

03 Low stress 19 10.6%

Low stress More stress

11% 0%

PERCENTAGE OF STRESS Moderate stress

89%

Findings revealed the distribution of respondents by stress level either low and moderate.
89.4% of respondents had moderate stress level as compared to 10.6% with less stress.
There is no presence of more stress.

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Table-2. Nurses’ Perceived stress score during the coronavirus (COVID-19) pandemic and
the level of significance for association between stress on nurses during covid-19 pandemic

The table given below shows the level of significance for association between stress on nurses
during covid-19 pandemic with selected demographic variables of staff nurses working in the
Fujairah PHC. Finding related to association between the occupational stress with their selected
socio demographic variables among staff nurses reveal that there is no significant relationship
found between occupational stress of staff nurses and sociodemographic variables such as age,
gender, marital status, qualification, and job title.

Table 2 Frequency of low and moderate perceived stress by variables and associations by
Pearson’s chi-square tests

Low stress Moderate stress n/ Pearson Chi-

Variable n/Frequency (%) Frequency (%) Square values

Gender
Male 3 (1.6%) 16(8.9%) .616

Female 16 (8.9 %) 145(80.6%)

Age
26-30 0 11(6.1%) -

31-40 12 (6.7%) 114(63.3%)

>40 7 (3.9%) 36(20%)

Marital status
Married 17(9.4%) 151(83.9%) .509

Unmarried 2(1.1%) 10(5.6%)

Having children
Yes 15 (8.3%) 143(79.4%) 1.544

No 4 (2.2%) 18(10%)
Educational level

Diploma 8 (4.4%) 66(36.7%) -

Bachelor in Nursing 10 (5.6%) 88(48.9%)

Master’s in Nursing 0 6(3.3%)

Other’s 1 (0.6%) 1 (0.6%)

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 Job title
Nurse (RN) 18 (10%) 108(60%) -

Dental Assistant 0 28(15.6%)

Qualified technician 1 (0.6%) 22(12.2%)

Acting Unit Manager 0 3 (1.6%)

Working position with Covid positive patients

Front Line 17(9.4%) 145(80.6%) .007

Second Line 2(1.1%) 16(8.9%)

Working area
Isolation 6(3.3%) 51(28.3%) .000

General 13 (7.2%) 110(61.1%)

(P ≤0.05)-significant, (P > 0.05, not significant)

Pearson Chi square test was applied to find out the association between the stress on staff
nurses working in the Fujairah PHC during the coronavirus (COVID-19) pandemic with their
socio-demographic variable. In some crosstabs, the Pearson Chi square test were violated
accordingly the alternative association called Fisher's Exact Test was applied. There was no
significant association between the stress towards when compared to socio-economic factors
like age, gender, marital status, qualification, and job title (P > 0.05). But when it was related
with working position and working area as it was showing a significant association (P ≤0.05).

Hence, it can be interpreted that the level of PSS score related to the demographic variables were
only by chance and not true and the null hypothesis is accepted (Table No.2.b).

Implications for Nursing Management:

Healthcare institutions should provide opportunities for nurses to discuss the stress they are
experiencing, support one another, and make suggestions for workplace adaptations during this
pandemic. Meeting physiological needs, applying psychological guidance and counselling
interventions in the stress management of nurses may contribute to the reduction of their stress
levels. Effective infection control, reducing workload, increasing the number of nurses and
strengthening the coping mechanisms can minimize the perceived stress level of nurses.

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Limitations

While this qualitative analysis sheds light on sources of nurses’ experiences of stress early in the
pandemic, the study has some limitations. First, participants were limited to nurse members of
only one nursing organizations that is primary health care centers in a single emirates (Fujairah),
and results may not be generalizable to nurses in other PHC’s, hospitals or emirates. Significantly,
there are good number of nurses (N = 180) who completely respond to the survey questions
working in Fujairah primary health care, compared to nurses who did not respond to the
question. It is possible that non-respondents may have experienced different work-related
factors that may have influenced their perceptions of stress. Nevertheless, the majority of
respondents (over 95%) answered, which limits non-response bias. Our study sample was also
substantially larger than those of two previous qualitative studies that explored the perceptions
of 20 nurses [21] and 13 nurses and physicians [22] in China. As in all qualitative studies,
researcher bias may influence findings. However, analysis in the current study were validated
through another researcher who was not involved in the original coding.

4. Conclusions
The results of this study clearly demonstrate that the prevalence of stress, within front-line
healthcare workers caring for COVID-19 patients are moderate. Therefore, the healthcare
authorities, and decision-makers, nationally and internationally, should take measures to reduce
this stress in staff treating the COVID-19 patients. This increases the productivity of the staff,
speeds up the measures to control the pandemic, and provides more effective treatment
procedures for the COVID-19 patients. Exploration of nurses’ perceptions of stress during the
pandemic’s early phase provides important insight into the nature of nurses’ experiences and
potential measures that healthcare institutions can take to mitigate nurses’ stress. Providing
nurses with adequate personal protective equipment is one concrete measure that can help to
keep nurses safe and to alleviate their fear of becoming infected. Healthcare units should provide
opportunities for nurses to discuss the stress they are experiencing, support one another, and
make suggestions for workplace adaptations during this pandemic. Healthcare institutions and
nurse managers need to recognize these sources of stress in order to identify potential
organizational interventions to maintain nurses’ health, safety, and well-being.

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Coping with Stress

The COVID-19 pandemic has had a major effect on our lives. Many of us are facing challenges
that can be stressful and overwhelming. Learning to cope with stress in a healthy way will
help you, the people you care about, and those around you become more resilient.

Stress can cause the following:

• Feelings of fear, anger, sadness, worry, numbness, or frustration

• Changes in appetite, energy, desires, and interests
• Difficulty concentrating and making decisions
• Nightmares or problems sleeping
• Physical reactions, such as headaches, body pains, stomach problems, or skin rashes
• Worsening of chronic health problems and mental health conditions
• Increased use of alcohol, illegal drugs (like heroin, cocaine, methamphetamine), and
misuse of prescription drugs (like opioids)

Healthy Ways to Cope with Stress

It’s natural to feel stress, anxiety, grief, and worry during the COVID-19 pandemic. Below are
ways that you can help yourself, others, and your community manage stress.

• Take breaks from news stories, including those on social media: It’s good to be
informed, but constant information about the pandemic can be upsetting. Consider
limiting news to just a couple times a day and disconnecting from phone, TV, and
computer screens for a while.
• Take care of your body:
✓ Get vaccinated and stay up to date on your COVID-19 vaccines.
✓ Eat plenty of fruits and vegetables, lean protein, whole grains, and fat–free or
low–fat milk and milk products. Eating well also means limiting saturated fats,
cholesterol, salt, and added sugars.
✓ Going to bed at the same time each night and getting up at the same time each
morning, including on the weekends, can help you sleep better (seven or more
hours per night for adults).
✓ Move more and sit less-every little bit of physical activity helps. You can start
small and build up to 150 minutes a week that can be broken down to smaller
amounts such as 20 to 30 minutes a day.
✓ Take deep breaths, stretch, or meditate external icon.
✓ Limit alcohol intake. Choose not to drink, or drink in moderation by limiting
consumption to one drink a day for women—two for men—on days that alcohol
is consumed.
✓ Avoid using prescription drugs in ways other than prescribed, someone else’s
prescription, or illegal drugs. Treatment external icon is available and recovery
starts with asking for help external icon.
✓ Avoid smoking and the use of other tobacco products. People can and do quit
smoking for good.
✓ Continue with regular health appointments, testing, and screening.
• Make time to unwind: Try to do some other activities you enjoy.
• Connect with others: Talk with people you trust about your concerns and how you are
feeling.
• Connect with your community- or faith-based organizations: While social distancing
measures are in place, try connecting online, through social media, or by phone or mail.

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Acknowledgments

The authors would like to thank our Data & Statistics department -Research section (DSD) for

their assistance in administering the online survey, Fujairah PHC nursing Department for their

coordination for distribution of the survey links to the concerned nurses and also our CRN,

Mohammad Hourani who was our facilitator from beginning till the end. In addition, sincere

thanks to all the nurses who responded to the survey on time.

Author Contributions

All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

This research has no conflicts of interest. The author(s) declared no potential conflicts of
interest with respect to the research, authorship and/or publication of this article.

5. References
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……………………………………. Thank you………………………………………..

21 | P a g e
 Appendix

List of Appendices

Appendix Appendix Page No.

No.
I Ethics Committee Approval Letter. 23-25

II Administrative Approval Letter 26

III Informed Consent form English 27-29

IV Informed Consent Form Arabic 30-32

V Research Questionnaire English 33-36

VI PSS Stress scale 37-38

VII Good Clinical Practice Certificate for all team members 39-45

22 | P a g e
I. Ministry of Health and
Prevention Ethical Committee
approval letter.

23 | P a g e
24 | P a g e
25 | P a g e
II. Administrative Approval letter.

26 | P a g e
III. Informed Consent Form-English Version.
INFORMED CONSENT FORM
Informed Consent form for nurses, both males and females who served in Primary health
centers in Ministry of health and prevention, Fujairah zone, and who we are inviting to participate in
research on, “A qualitative descriptive study to assess the development of stress among the
Fujairah PHC Nurses as the impact of COVID-19 outbreak and the ways of coping up among these
nurses”.

Name of Principal Investigator: Reena Varghese

Name of Organization : Primary health centers, Fujairah

Name of Sponsor : Ministry of Health

Name of Proposal : A qualitative descriptive cross-sectional study to assess the

development of stress among the Fujairah PHC Nurses as the impact of COVID-19 outbreak and
the ways of coping up among these nurses.

PART I: Information Sheet

Introduction

I am Reena Varghese, working for Ministry of Health and prevention, Fujairah zone. Investigators are
doing research on Development of stress among Fujairah Primary health care Nurses, and ways of
coping up during Covid -19 pandemic crisis.

Purpose of the research

Psychological stress is one of the most common problems among healthcare providers during COVID-
19 pandemic. The purpose of this study is to provide a deeper understanding of the impact of stress
among you and ways of coping stress during this pandemic. This would in turn enable leaders and
decision makers to promote a healthier work environment for their nurses. The investigators are
doing this research through a questionnaire.

Type of Research

This is a qualitative descriptive cross-sectional study; in which it will involve answering a

questionnaire once.

Participant selection: - Investigators are inviting all nurses, both males and females’ working at
primary health centers under ministry of health and prevention, Fujairah. Participation in this study
is voluntary and participants have the right to withdraw from the study at any time, without giving
an explanation.

The participants responsibilities are answering the questionnaire in a proper way within the allotted
time period and should be: - clear -accurate - complete.

If you agree: -

- All information obtained will be completely anonymous.

- The information will be used for research purposes only.
- There are questionnaires in the survey.

27 | P a g e
 Risk /benefits/ expenses: All nurses working in Fujairah PHC will be included in the study
without any cost/ payment/ additional benefits. There is no maleficence/ intended clinical
benefits, but just assessment of nurses in current situation. There is no anticipated expense,
assessment by general online questionnaire, which is not intended to do any harm to the
subjects of this study.

The subject’s participation is voluntary and may refuse to participate or withdraw at any time,
without penalty or loss of benefits.

The inconveniences to participate in this survey, we are expecting is the lack of interest to share,
work load and tiredness. To overcome, we are giving the questionnaire through e-mail and time
period to finish even at home.

Confidentiality: The ethical committee and concerned authority will be granted direct access to the
original records for verification of data, without violating the confidentiality of the subject, to the
extent permitted by the applicable laws and regulations and that, by signing a written consent form.

Safety: The records, identifying the subject will be kept confidential and to the extent permitted by
the applicable law and / or regulations, will not be made publicly available. The data will not be
shared or use for any other study or purposes. If the results of the study are published, the subject’s
identity will remain confidential.

For further information/ if you have any questions you may ask to research team members/ Nursing
administration in Murshid, now or later, even after the study has started.

The foreseeable circumstances and / or reasons under which the participation may be terminated
are:

- Incomplete data
- Unclear data
- Postdated data
- Inaccurate data

The expected duration of the subject’s participation is 2-3 weeks.

Estimated participants are 150-180 out of which 100-120 exact data will be considered into account.

PART 2: CONSENT CERTIFICATE

TOPIC: A qualitative descriptive study to assess the development of stress among the Fujairah PHC
Nurses as the impact of COVID-19 outbreak and the ways of coping up among these nurses.

Principal investigator: Reena Varghese

Other members: Eric, Gils Jacob, Amal, Alma, Jindya Cris, Tiji Mathai

Participant name:

28 | P a g e
 We invite you to take part in a research study at Fujairah zone. Taking part in this study is
entirely voluntary. We urge you to discuss any questions about this study with our staff members.
Talk to your family and friends about it and take your own time to make your decision. If you decide
to participate, you must sign this form to show that you want to take part. If you have questions/
complaints/concerns, contact principal investigator at (055-6193357)/ contact any research team
members.

I have read the information. I have had the opportunity to ask questions about it and any questions I
have been asked have been answered to my satisfaction. I consent voluntarily to be a participant in
this study.

Name of participant: Signature:

Date:

I confirmed that the individual has not been coerced into giving consent and the consent has been
given freely and voluntarily.

Name of the research member/ person taking the consent:

Signature:

Date:

29 | P a g e
‫‪III. Informed Consent Form-Arabic Version.‬‬
‫إستمارة الموافقة المسبقة‬
‫استمارة الموافقة للممرضات والممرضين الذين خدموا في مراكز الصحة األولية بوزارة الصحة ووقاية‬
‫المجتمع بالفجيرة‪ ،‬حيث ندعوهم للمشاركة في بحث حول "دراسة وصفية نوعية لتقييم تطور اإلجهاد بين‬
‫ممرضات وممرضي الرعاية الصحية االولية‪ ،‬وطرق التعامل مع أزمة جائحة كوفيد ‪.19-‬‬

‫اسم الباحث الرئيسي‪ :‬رينا فارغيز‬

‫اسم الجهة‪ :‬المراكز الصحية األولية‪ ،‬الفجيرة‬
‫اسم الكفيل‪ :‬وزارة الصحة‬
‫اسم االقتراح‪ :‬تطور التوتر بين ممرضات الرعاية الصحية األولية في الفجيرة‪ ،‬وطرق التعامل مع أزمة‬
‫جائحة كوفيد ‪.19-‬‬

‫الجزء األول‪ :‬المعلومات‬

‫مقدمة‬
‫أنا رينا فارغيز‪ ،‬أعمل في وزارة الصحة والوقاية‪ ،‬منطقة الفجيرة‪ .‬يقوم الباحثون بإجراء بحث حول‬
‫دراسة وصفية نوعية لتقييم تطور اإلجهاد بين ممرضات وممرضين الرعاية الصحية األولية في الفجيرة‪،‬‬
‫وطرق التعامل مع أزمة جائحة كوفيد ‪.19-‬‬
‫الغرض من البحث‪:‬‬
‫عا بين مقدمي الرعاية الصحية خالل جائحة كوفيد ‪19-‬‬
‫يُعد اإلجهاد النفسي أحد أكثر المشاكل شيو ً‬
‫الغرض من هذه الدراسة هو توفير فهم أعمق لتأثير التوتر واالجهاد النفسي وطرق التعامل بها خالل‬
‫هذه الجائحة ‪,‬وهذا بدوره سيمكن القادة وصناع القرار من تعزيز بيئة عمل صحية لممرضاتهم‪.‬‬
‫يقوم الباحثون باستخدام طريقة االستبيان في التقصي عن المعلومات المرادة تجميعها‬

‫نوع البحث‬
‫هذه دراسة وصفية كمية‪ ,‬والتي ستشمل اإلجابة على استبيان لمرة واحدة‪.‬‬

‫‪30 | P a g e‬‬
 ‫اختيار المشاركين‪- :‬‬
‫يقوم المحققون بدعوة جميع الممرضات والممرضين العاملين في المراكز الصحية األولية التابعة لوزارة‬
‫الصحة ووقاية المجتمع بالفجيرة‪.‬‬
‫المشاركة في هذه الدراسة تطوعية ويحق للمشاركين االنسحاب من الدراسة في أي وقت دون إبداء‬
‫أسباب‪.‬‬

‫في حال الموافقة‪- :‬‬

‫‪ -‬ستكون جميع المعلومات التي تم الحصول عليها مجهولة المصدر تما ًما‪.‬‬
‫‪ -‬سيتم استخدام المعلومات ألغراض البحث فقط‪.‬‬
‫‪ -‬توجد استبيانات في المسح‪.‬‬
‫‪ -‬لن يكون هناك مخاطر ومزايا مباشرة ‪ /‬غير مباشرة‬

‫ملحوظة‪ - :‬إذا كان لديك أي أسئلة يمكنك طرحها على أعضاء فريق البحث ‪ /‬إدارة التمريض في مريشد‪،‬‬
‫اآلن أو الحقًا‪ ،‬حتى بعد بدء الدراسة‪.‬‬

‫الجزء الثاني‪ :‬شهادة الموافقة‬

‫الموضوع‪ :‬دراسة وصفية نوعية لتقييم تطور اإلجهاد بين ممرضات وممرضين الرعاية الصحية األولية‬
‫في الفجيرة‪ ،‬وطرق التعامل مع أزمة جائحة كوفيد ‪.19-‬‬
‫الباحث الرئيسي‪ :‬رينا فارغيز‬
‫األعضاء اآلخرون‪ :‬إريك توريس‪ ،‬جيلز جاكوب‪ ،‬أمل علي‪ ،‬ألما دي جوزمان‪ ،‬جينديا كريس‪ ،‬تيجي‬
‫ماثاي‬

‫‪31 | P a g e‬‬
 ‫اسم المشارك‪......................................................................................... :‬‬

‫ندعوكم للمشاركة في دراسة بحثية في منطقة الفجيرة ‪,‬المشاركة في هذه الدراسة تطوعية بالكامل ‪ ,‬نحثك‬
‫على مناقشة أي أسئلة حول هذه الدراسة مع موظفينا‪ ,‬تحدث إلى عائلتك وأصدقائك حول هذا الموضوع‬
‫وخذ وقتك الخاص التخاذ قرارك‪ ,‬إذا قررت المشاركة‪ ،‬يجب عليك التوقيع على هذا النموذج إلظهار‬
‫رغبتك في المشاركة‪ ,‬إذا كانت لديك أسئلة ‪ /‬شكاوى ‪ /‬مخاوف‪ ،‬فاتصل بالباحث الرئيسي على الرقم‬
‫(‪ / )6193357-055‬اتصل بأي من أعضاء فريق البحث‪.‬‬

‫لقد قرأت جميع المعلومات ‪,‬ولقد أتيحت لي الفرصة لطرح األسئلة حول هذا الموضوع وتم الرد عليها‪.‬‬
‫أوافق طواعية على أن أكون مشار ًكا في هذه الدراسة‪.‬‬
‫التوقيع‪:‬‬ ‫اسم المشارك‪:‬‬
‫تاريخ‪:‬‬
‫أؤكد إن المشارك لم يُجبر على إعطاء الموافقة وأن الموافقة تم منحها بحرية وطوعية‪.‬‬
‫الشخص الذي أخذ الموافقة‪:‬‬ ‫اسم عضو البحث‪:‬‬
‫التوقيع‪:‬‬
‫تاريخ‪:‬‬

‫‪32 | P a g e‬‬
IV. Questionnaire Used for Survey
Questionnaire to assess nurse’s demographic and professional information in relation to the
development of stress on Fujairah PHC nurses working during Covid-19 pandemic.

PART A : Demographic Data

1) Sex:
 M
 F
2) Age:
 18-25
 26 -30
 31- 40
 >40

3) Marital status:
 Married
 Unmarried

4) Having children:
 Yes
 No

5) Educational level:
 Diploma
 Bachelor in nursing
 Master’s in nursing
 Other’s( Specify)………….

PART B : Socio-economic, physical and psychosocial Data

6) Job title:
 ………………………..

7) Working position with Covid patients

 Front line
 Second line

8) Working area
 Isolation
 General

9) Clinical experience
 1-5
 6-10

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  11-15
 > 15

10) Average working hours

 7 to 8
 10 to 12

11) Have you received infection control training?

 Yes
 No

12) Do you have any prior experience of caring patients with infectious diseases?
 Yes
 No

13) Are you confident in caring Covid-19 patient?

 Lack of confident
 General confident
 Quite confident

14) Do you feel safe while caring Covid-19 patient?

 Safe
 Unsafe

15) Are afraid of being infected by Covid-19?

 Yes
 No

16) Please select what do you feel about your control over the work that is assigned to you.
 Well controlled
 Partially controlled
 Slightly controlled
 Uncontrolled

17) Do you feel you have work -life balance?

 Yes
 No

18) Do you have fear of infecting your family members?

 Yes
 No

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19) Do you have strong familial support?
 Yes
 No

20) Are you afraid of being isolated in the society?

 Yes
 No

21) Do you receive strong organizational support to combat Covid-19 pandemic?

 Yes
 No

22) Are you informed about the recent updated of Covid-19 pandemic?
 Yes
 No

23) Do you get affected with any of the following psychological problems?
 Yes
 No

24) If Yes, select any of the listed below: -

 Anxiety
 Sleep disturbances
 Loss of appetite
 Over stress
 Fear

25) Are you satisfied as a nurse during Covid-19 pandemic?

 Yes
 No

26) What is your professional attitude towards Covid-19 pandemic?

 Negative
 General
 Positive
 Strongly positive

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27) Do you have any support either emotionally/psychologically in case you got infected
by Covid19?
 Yes
 No

28) Are you either anxious/excited regarding your job or situation being affected by
Covid19 pandemic due to global crisis?

 Yes
 No

29) Are you holding up knowing that you have limited/restricted time to be with your
family at home or in your own country?

 Yes
 No

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V. Perceived stress scale (PSS) used for stress association

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VI. Good Clinical Practice(GCP) certification for all team members

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……………………………. THANK YOU……………………….…….

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