Coping strategies among nurses during the COVID -19 outbreak

PANDEMIC AS A CRISIS

In November 2019 an epidemic outbreak of COVID-19 was identified in Wuhan, the capital city of Hubei province in central China. On 11 March 2020 it was recognised as a coronavirus pandemic by the World Health Organisation (WHO) [1]. Until mid-January 2020 it was mostly Wuhan that was affected, but later the disease spread all over China. In the second half of February epidemics broke out in South Korea, Italy, and Iran. On 13 March 2020 the WHO announced that Europe had become the virus epicentre. Scientists started research into the virus, its characteristics, deadliness, and ori-gin [2], whereas the media and public health officials started a permanent and intensive campaign full of critical informa-tion [3]. In this way the pandemic became a common experience of intensive long-lasting distress.
Although this is not the first pandemic of the 21st century, it is worth considering its psychological consequences in li-ght of knowledge about environmental or catastrophic crises. Every crisis, as pointed out by Kubacka-Jasiecka [4], can be analysed from various perspectives: 1) loss or disturbance of emotional or psychological balance; 2) blocking or loss of an individual’s resources for habitual coping or defending strategies, which were available before; 3) a turning, critical, and world-shaking point that could be followed by the necessity of changing one’s life because of the sense of helplessness, powerlessness, or loss of control; 4) a threat to the system of beliefs related to oneself, or possibly, loss of one’s identity; or 5) a threat to the existing meaning of life and a system of values. Thus, a crisis is not analysed as a particular situation but rather as the human perception of this event and their reaction to the threatening situation. In this process people realise that their coping strategies might not be as effective as they were before [5].
Every crisis is responsible for some significant circumstances within this process. According to James and Gilliland [5], they are both threats and opportunities, which come with the crisis and include a growth potential, complex symptomato-logy, lack of quick solutions, necessity to make choices, universality of the crisis, and its uniqueness. Parry [6] pointed out a series of individual experiences of people involved in the crisis. She mentioned: a sense of acute/chronic psychological stress, perceiving the situation as an unexpected one, perceiving the situation in the category of a loss, threat, or challenge, experiencing negative emotions and events, a sense of uncertainty about the future and loss of control, a sudden change in the routine functioning, a state of emotional tension lasting usually from 2 to 6 weeks, and, finally, the necessity to verify and modify one’s way of functioning.
As was observed by Sęk [7], every critical event requires some significant changes in adaptive mechanisms within the functional system: human – surroundings – group – environment. A pandemic, as a situation that affects not only individuals but also all communities, possesses characteristics of so-called catastrophic (environmental) disaster. In the face of a pandemic people experience their own individual emotional crises with a population crisis in the background. In such cases people affected by the crisis, as well as typical features of emotional crisis, experience also the sense of disintegration of their beliefs about themselves and the world, a collapse of their system of basic values and the meaning of life, and finally a breaking of the continuity of social contacts [8].
Caplan [9] described four stages of a crisis reaction. At the first stage people suffer from anxiety, which is a part and parcel of any stressful event. If effective strategies of coping with stress are not activated at this stage, the anxiety and psy-chological stress will increase. During the second stage the anxiety and psychological stress are intensified. At the third phase the anxiety is still growing, and people often start looking for various sources of support. Lack of support or a continuous application of ineffective coping strategies make the chances of a crisis even greater. The last stage is the pro-cess of an active crisis, which is characterised by unproductive behaviours. At this stage people remain terrified, their ac-tions are disorganised and unproductive, and the main objective is to obtain a proper orientation towards problem solving and reaching stabilisation and balance. In order to achieve this goal, it is essential to turn to such coping strategies that would be the best in the given situation and time.

COPING WITH CRISIS SITUATIONS

Lazarus and Folkman define coping as “constantly changing cognitive and behavioural efforts to manage specific external and internal demands that are appraised as taxing or exceeding the resources of the person” [10, p. 141]. Coping plays two basic roles: 1) a task-oriented one (problem-oriented, instrumental role) aimed at improving unfavourable rela-tions between the requirements resulting from a particular situation and an individual’s capacities; and 2) a self-regulation role aimed at relieving unpleasant tension and alleviating negative emotional problems. The same coping strategy may serve each of these two functions depending on the context. Emotions do not always hinder the coping process. They may also play an adaptive or informative role as well as energise the process and shape its course. Researchers claim that co-ping strategies based on emotions may increase agitation and, consequently, mobilisation for action [10]. Folkman and Moskowitz [11] emphasise an adaptive function of emotions as well as the role of social support in the process of coping.
Coping can be considered as a process, as a strategy, or as a style typical of a particular individual [12]. In the context of coping with a crisis situation that lasts over a period of time, as can be observed in the case of a pandemic, the first approach seems to be the most appropriate because it defines coping as a complex structure. It refers to the total human activity in a particular stress situation. Thus, it is the sum of various forms of human activity arising from a stressful situ-ation. The character and intensity of all preventive efforts depend on the assessment of individual resources and capacities and on the assessment of the current situation [13]. In this respect, coping can last a long time and be subject to dynamic changes. A decisive factor that is responsible for the course of these changes is the progress of a stressful situation. In the process of coping it is possible to isolate smaller entities, which are smaller activity units. They are called coping strategies or methods.
Coping strategies are defined as cognitive and behavioural efforts taken by an individual in a particular stressful situ-ation [14]. They are acquired following the rules of a learning process, and their efficiency results from their repetitive-ness and, consequently, consolidation [15]. They include specific attitudes and behaviours related to a particular situation in a specific time and, therefore, are dependent on the context and the conditions that provoke them [16]. Studies on co-ping strategies confirmed the idea of the existence of three basic types of strategies: a) problem-focused, b) emotion-focused, and c) avoidance, including loss of control and escape reactions. The first group is aimed at problem-solving. These strategies may include planning, instrumental coping, looking for support or information, as well as confrontation. Their effects may not be productive in the case of situations that cannot be changed or situations that cannot be controlled in any way. In turn, emotion-focused strategies include cognitive-behavioural avoidance, withdrawal, affective release, talking about one’s emotions, or ruminations (nagging thoughts) over the problem. Although they often do not relieve emotional discomfort and can even intensify it, they may have some potential for positive effects thanks to attempts to understand what has happened, positive revaluation, or seeking emotional social support.
Folkman and Lazarus [10] emphasise that activities taken by an individual who faces a stressful situation might be aimed at solving the problem or reducing emotions produced as a result of stress. Various coping techniques reflect these two cour-ses of action. Taking into consideration individuals’ attitude to stressful information, Heszen [17] distinguishes two groups of strategies: confrontation and avoidance. The former includes various activities aimed at changing a difficult situation, modifying its symptoms, or increasing one’s resources for fighting against stress. Avoidance techniques, in turn, are aimed at reducing negative emotions, which might be observed in the form of avoidance, contradiction, denial of information about a stressful situation, reinterpretation of this situation, an attempt to notice positive elements apart from negative ones, or diverting attention away from a stressor by changing one’s actions [18].
Folkman and Lazarus [10] propose a more specific classification in which they define remedial strategies: searching for information, direct action, refraining from action, and intrapsychic processes [19]. Searching for information consists of analysing a stressful situation with a view to finding information that would be essential to take some specific action or to re-evaluate the danger or harm. This strategy is connected mainly with an instrumental function, which is focused on pro-blem solving. A direct action is connected with an individual’s actions aimed at dealing with a stressful situation. These actions may refer to changes in the environment or in the individual. They may be determined by personal features or by the situation. Refraining from acting may sometimes be more beneficial than any action. Intrapsychic processes are cogni-tive processes whose aim is to regulate emotions; for example, defence mechanisms such as avoiding danger, denial, or projection [20].
Another typology of stress coping strategies was formulated by Ratajczak [19], who defined the following: 1) a preventive strategy, 2) a fight strategy, 3) a self-protective strategy, and 4) an escape strategy. The first strategy is activa-ted by an individual when the threat does not appear yet but is predicted. An individual takes actions that activate their personal resources so as to prepare for a confrontation with a danger. In the case of a real danger the second or the third strategy is activated depending on the assessment of one’s own resources. The fight strategy is applied if the assessment of one’s own resources is positive and an individual decides to face stress factors. Alternatively, if an individual decides to save strength and resources, isolates himself/herself, or believes that the danger will disappear on its own, a self-protective strategy is applied. An escape-strategy is the one that remains if none of the previous strategies can avert a danger.
Studies show that experienced emotions lead to a choice of particular strategies and chosen strategies provoke particu-lar emotions [21]. People who experience anger or anxiety are more likely to choose active coping strategies, whereas tho-se who experience sadness would rather opt for passive strategies such as avoidance of accepting problems [22]. Adequate-ly applied strategies help to cope with stress [23] and its consequences, including negative emotions [24]. Obviously, po-ssessing a variety of coping strategies makes it easier to apply the ones that are appropriate to a given situation; however, flexibility and efficiency of these strategies are also important.

COPING WITH AN EPIDEMIC CRISIS

Clark [25], writing about a crisis, pointed out its three principal elements: time pressure, the possibility of real danger, an element of surprise, and the fact that it results from both a real danger and the situation in which it appears. These three fe-atures of a crisis situation are reflected in the situation of a crisis caused by an epidemic or pandemic. Because of a possible health hazard, the worldwide struggle with the spreading SARS-CoV-2 virus calls for immediate solutions. The scale of the phenomenon, during which the whole global society struggles with the virus, is undoubtedly an element of surprise. The ongoing pandemic crisis results not only from an epidemiologic hazard but also from other significant circumstances such as a long incubation time along with advanced globalisation, fast movement of people, and climatic changes that are conducive to the virus spread, etc. In the case of the ongoing pandemic it is possible to observe features that make it an extreme expe-rience. They include the spread and range of the pandemic involving diverse and remote social groups, a danger of contrac-ting SARS-CoV-2 virus related to both somatic and psychological spheres (e.g. influencing the form and character of social interactions), or a highly limited possibility of control. These three features of the ongoing world epidemiologic situation appear, in different proportions, in considerations about individuals’ reactions to the situation. For instance, Liu et al. [26], in their study on the factors affecting work adaptation of healthcare workers during COVID-19 pandemic, point out a series of factors that increase a potential individual’s burden resulting from this situation. These factors include the fact that COVID-19 is human-to-human transmissible, associated with high morbidity, and potentially fatal. Moreover, a predicted depletion of personal protection equipment was mentioned as well as an ever-increasing number of confirmed and suspected cases. Doherty [27], in turn, in his book mentions a slightly different and particularly burdening social experience resulting from the SARS epidemic outbreak of 2002-2003. First and foremost, a sudden outbreak of the disease confronted the suffering of numerous individuals with the state of ignorance about the causes of the disease and the ways in which it was transmitted. The second factor was a distinct ambiguity between the observed pathogenic mechanism and the mechanisms that had been observed before. Finally, both healthcare workers and patients were the ones most vulnerable to infection.
Working during a pandemic is a particular challenge for nurses because they put their life and health at risk while per-forming their daily professional duties, which is accompanied by intensified daily professional stress. Due to understaffing, the intensity of daily burdening stimuli is significantly higher for every person in the physical, cognitive, and environmental dimensions, which accounts for psychological overburden and the disorders that may be its direct results. The nurses who worked during the SARS epidemic feared contracting the disease, yet to the same or even greater extent they feared infec-ting their relatives, friends, or other people [28, 29]. Because of a long potential period of virus incubation, a lot of healthca-re workers who were afraid that they might infect their relatives or friends decided to move out and live away from their family, even at the cost of losing an important source of social support. A relatively high indicator (over 50%) of the perce-ived low control over the chance of being infected was observed among nurses [29]. It was pointed out in empirical analyses that the experienced acute psychological stress, work overload, and frequent changes within professional routine made it very difficult for numerous healthcare workers to follow all recommendations aimed at preventing the disease from spre-ading.
It was only one of the factors responsible for the perceived sense of helplessness, loss of control, uncertainty, reluctance towards professional duties that were performed previously, or experienced inner conflicts about willingness to continue to perform professional duties, which were pointed out in a number of analyses of a psychological situation of professionally active healthcare workers during the SARS epidemic [30-34]. The aforementioned experiences and inner conflicts are still relevant during the ongoing pandemic. A growing number of confirmed and suspected cases of SARS-CoV-2 disease causes healthcare workers to experience anxiety associated with potential contagion and its severe consequences both for them and for other people they interact with either deliberately or incidentally. As a consequence, they may experience the sense of loneliness, desperation or psychogenic insomnia [35]. Another emotional burden caused by the ongoing pandemic is anxiety caused by uncertainty about one’s health and the health of one’s family and friends, which is experienced by these members of medical staff who have to undergo obligatory isolation. Quarantined healthcare workers experience social rejection, a sense of financial loss and its consequences, as well as discrimination and stigmatisation targeted at medical staff because of their presumedly higher chance of transmitting the infection. These problems have already been reported in foreign rese-arch studies [36-38]. Such experiences account for the incidence of various aversive psychological reactions among heal-thcare workers. They may take the form of acute psychological stress, depression, or anxiety disorders. The significance of a correlation among the aforementioned individual experiences of healthcare workers and an assessment of various aspects of crisis situations is shown by the findings that emphasise that the proximity of the sphere of the greatest danger or the experience of obligatory quarantine are important predictors of the incidence of more severe disorders in psychological func-tioning of professionally active medical staff during the SARS epidemic or SARS-CoV-2 pandemic [26, 31].
A meta-analysis of the problem of stress and coping created by Kwak, Zaczyk, and Wilczek-Różycka [39] allowed the observation of some differences in the efficiency of coping strategies mentioned by Polish nurses, depending on the applied research tool. The studies in which the Ways of Coping Questionnaire (WCQ) was used showed that when confronted with stress, healthcare workers usually resort to strategies such as concentrating on the problem, seeking support, or escapism and avoidance – according to some analyses, whereas according to others the respondents opt for wishful thinking, self-blaming, and fighting. On the other hand, studies that used the Coping Orientation to Problems Experienced (COPE) inventory sho-wed a significant prevalence of active coping strategies and seeking support over all other applied strategies. The dominating character of task-focused strategies was also observed in the findings of analyses conducted with the application of the Co-ping Inventory for Stressful Situations (CISS). However, it is worth pointing out that the application of the questionnaire that indicated the incidence of emotion- or avoidance-focused strategies along with problem-focused strategies is seen in older studies (conducted before 2010), and they were partially carried out in groups of nursing students. The most up-to-date stu-dies conducted in a group of Polish nurses show that the most frequent strategies of coping with various stressors include active coping, planning, getting involved in other activities, seeking emotional support, as well as a positive revaluation or development. The least popular strategies were denial, sense of humour, refraining from action, taking psychoactive substan-ces, or seeking specialist help [40-42].
Although the studies do not refer to the process of coping with the pandemic crisis, they are significant because they define some repertoire of coping strategies available to Polish nurses. As was indicated before, every crisis inevitably veri-fies the affected individual’s set of coping strategies. Because of the character of a particular stressful situation, the strate-gies that have been applied before may turn out to be insufficient; nevertheless, an analysis of the previously applied stra-tegies and their efficiency will be important from the perspective of individual choices and introducing coping strategies in a given crisis situation. The studies carried out in healthcare workers during the SARS epidemic show that the aforemen-tioned coping strategies typical for Polish nurses, for example planning or positive revaluation, remain in the group of the most commonly applied strategies among people working during the time of an epidemic [33, 34]. These findings are even more optimistic taking into account the fact that further research proved the importance of positive cognition on relieving a negative, psychological effects of epidemic crisis experience in healthcare workers group [32, 43]. They are strategies that allow the definition of any positive effects of a crisis experience such as increased awareness of the necessity to take care of one’s health, strengthening the relations with family and friends, or a sense of community, which were the aspects mentioned by medical staff working during the SARS epidemic.
The first studies of nurses working during the COVID-19 epidemic were carried out in China, and they indicated that in comparison to nursing students, people who have already been working as nurses not only show more intense reactions to the experienced crisis but also remain more pro-active and apply more problem-focused strategies than emotion-focused ones [44, 45]. The studies also showed a more frequent application of problem-focused strategies in a female group and an opposite trend for emotion-focused strategies in the same group. What is important, if healthcare workers were from socie-ties in which some cases of COVID-19 were diagnosed, an increase in emotion-focused coping strategies could be observed. In the aforementioned studies some interesting correlations were observed between emotional experience reported by nurses and their choice of stress coping strategies. The more anger the respondents experienced, the more likely they were to cho-ose emotion-focused coping strategies. On the other hand, the more anxiety they felt, the more likely they were to resort to problem-focused coping. An analysis of reversed relations led to conclusions that problem-focused coping was likely to ac-company emotions such as anxiety, sadness, or anger. It might have been expected that in the case of medical staff involved in providing nursing care during an epidemic or pandemic, which are characterised by a certain phase pattern, the coping process is dynamic as well. It seems to have been confirmed by the outcomes of studies conducted in a group of Taiwanese nurse managers who were professionally active during the SARS pandemic [46]. The studies showed that within the analy-sed 12 weeks of working during an epidemic, nurse managers’ involvement in their duties had a gradual character. First, the respondents experienced shock and chaos, after which they started looking for reliable sources of information in order to dispel myths about the epidemic. Afterwards, they started to develop and adjust the process of nursing care, and then provide support to other nurses and patients and finally – reward the nurses. These studies showed that even coping with a situational crisis by means of emotional self-regulation may gradually develop into problem-focused coping. They also proved that nurse managers possess appropriate skills necessary to activate coping mechanisms in the face of a new unknown crisis situ-ation. This force may in turn trigger adaptive coping mechanisms among other team members.

SUMMARY

The ongoing epidemic situation gives rise to questions about the chances to activate the best possible adaptive strategies of coping with the crisis in Polish nurses. The first empiric reports coming from foreign research centres, mainly Asian ones, are reassuring. According to them, despite the crisis situation, nurses possess sufficient resources to activate constructive strategies of coping with this situation. A conclusion drawn from Polish studies that were conducted before the outbreak of the pandemic is comforting as well, as it proves that Polish nurses within the last decade have managed to develop the skills and capacities necessary to cope with the effects of the psychological stress that they experience. Individual and collective capacities to apply them in the present circumstances still need to be examined. The potential efficiency of the actions that are taken in these days in order to cope with the effects of the experienced crisis will certainly need long-term observation.

Disclosure

The authors declare no conflict of interest.

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