Stress among Resident Doctors Working in Different Hospitals of Nepal in the Face of COVID-19 Pandemic: A Descriptive Cross-sectional Study

ABSTRACT Introduction: The emergence and propagation of COVID-19 pandemic has subjected resident doctors to greater workload and consequent psychological implications. Many studies have illustrated various degrees of mental health issues among health care workers in general; however very limited ones have focused primarily on the resident doctors. Therefore, this study aimed to find out the prevalence of stress among the resident doctors of Nepal. Methods: A descriptive cross-sectional study was carried out in all the teaching hospitals of Nepal with ethical clearance from the Institutional Review Committee (Reference number-245). An online self-designed structured questionnaire developed using Google forms along with questions from stress subscale of Depression, Anxiety and Stress Scale - 21 was disseminated to the residents via social media platforms using Convenience sampling technique. Responses generated were analyzed with Statistical Package for the Social Sciences. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Results: The prevalence of stress among resident doctors was found to be 16 (8.2%) (4.3-12.1 at 95% Confidence Interval). Greater prevalence of stress was seen among residents working outside Kathmandu valley, those in the frontline and those who were unmarried. Loss of collaborative study/ professional and academic growth experiences was responsible for causing extremely severe stress among 60 (30.9%) residents, followed by stress due to uncertainty regarding COVID-19 58 (29.9%) and unavailability/lack of quality control of personal protective equipment 58 (29.9%). Conclusions: This study has shed light upon the prevalence of stress and its precipitating factors in Nepalese resident doctors due to COVID-19 pandemic. Our findings could help address these issues for their mitigation promptly.


INTRODUCTION
The COVID-19 pandemic, since its emergence in December, 2019, 1 has inundated hospitals around the world with sick patients, putting relentless work pressure and mental health tolls on the Health Care Workers (HCW). [2][3][4][5][6][7] At least 3000 HCWs around the world have died because of COVID-19 and this figure is deemed to be highly underreported. 8 The scenario is akin in Nepal, where HCWs are working with limited resources and still giving their best to care for the ailing patients.
Amongst them, resident doctors pursuing their postgraduate studies in different teaching hospitals in Nepal are more prone to developing health conditions like anxiety, depression and burnout syndromes 9,10 as they are working in clinical settings for longer durations and taking responsibility for multiple units of a hospital.
This study has attempted to find out the prevalence of stress and the major factors responsible for causing stress among the residents.

METHODS
A descriptive cross-sectional study was conducted among residents of all the specialties including basic sciences and clinical sciences of 14  Prefer not to say 12 (6.2) It was observed that among the 68 residents working outside the Kathmandu valley, 8 (11.8%) of them were stressed compared to only 8 (6.5%) among the 118 working within the valley. Furthermore, more number of participants working in the frontline reported being stressed 14 (9%) than those not working in the frontline 2 (5.3%). The prevalence of stress was more in participants aged less than 30 years 10 (9.1%) compared to those of ages 30 and above 6 (7.1%). There were no differences in stress levels experienced according to gender and variability in working hours. Respondents who were unmarried had greater prevalence of stress 8 (10.3%) than those who were married 8 (6.9%) ( Table 2).  Stress prevalence was not seen to differ among demographic variables like age, gender and marital status of the participants. 14 (87.5%) of resident doctors who experienced stress were front liners. It was possibly because of increased burden of patient care and risk of exposure to infection. Likewise, a greater number of participants working in hospitals outside the Kathmandu valley (11.8% compared to 6.5% working inside the valley) reported being stressed probably due to the lack of attention towards health care demands in the sub-urban and remote areas, inadequate manpower and insufficient protection to the HCWs from violence 16 to name few. Contrary to what would generally be expected, working hours (<72 or >72) didn't make much difference between the stress outcomes in participants, with nearly equal prevalence of stress in these groups.
Our study shows that out of the 13 stress factors that were included in the questionnaire, loss of collaborative study, professional and academic growth experiences caused the most profound level of stress among residents (extremely severe in 30.9%). Residency is a formative time in training based upon the principles of graduated responsibility and autonomy. 17 The future excellence of residents depends largely on collaborative study experiences like research, conferences and group interactions, 18 and this aspect of their training has been severely hampered due to the nation-wide lockdown of four months. 19 Both unavailability/ lack of quality control in PPE and uncertainty regarding COVID-19 have caused extremely severe stress to 29.9% of the residents. Since PPE has not been adequately supplied 20,21 and quality check has not been done effectively, 22 the fear of contracting infection has constantly distressed the residents. Even in studies performed in the USA, the availability of PPE for HCWs is a tremendously debated issue and in many countries, the lack of PPE has been defined as a source of anxiety among HCWs. 22,23 Furthermore, the disease pattern of SARS-COV-2 is yet to be established, leading to the inevitable anxiety among HCWs around the world. In comparison to the foreign countries, sadly Nepal has not been able to provide adequate PCR testing even for the HCWs themselves, 24 leading to severe stress as observed in our study in 34% participants. This imposes a higher risk of transmission of infection to large number of patients being treated by these residents who might have asymptomatically been harboring the infection.
Contrary to the huge existence of social stigma associated with COVID-19 being reported by newspapers frequently, 25 our study has shown the least amount of stress (no stress mentioned by 15.5% respondents) in this regard, which is possibly because they have experienced these kinds of mistreatments on a daily basis. In a study performed in Nepal, more than half of HCWs (53.7%) mentioned facing stigma due to COVID-19, one-fourth of them (26.7%) being stigmatized because of their profession, 21.5% accused of being a carrier, 3.2% threatened and 2.3% being asked to leave a rented place. 10 Moreover, in a country like ours where insufficient economic aid is given to health sector, lack of incentives and unexpected pay cuts 26 in this health crisis has been demotivating the HCWs and making it difficult to make their ends meet, demonstrated by the prevalence of at least some level of stress among 91.8% of the participants.
Surprisingly, it was observed that nearly twice as more residents were stressed regarding transmission of COVID to their family members than contracting the infection themselves, probably owing to the kind, giving nature of the profession they have delved into and always putting others in priority. In a similar study conducted on surgery residents, they overwhelmingly reported "risk to loved ones" (84% of respondents) as the most anxiety-provoking aspect of their potential contraction of COVID-19, compared to "Risk to self" (47% of respondents). 27 Our study has some limitations. Firstly, it was an online survey, limiting face-to-face interaction with the participants, creating cognitive bias. Only resident doctors were taken as study units, therefore limiting study sample and not including control groups. The use of self-designed questionnaire was not able to include all the possible variables, decreasing accuracy of the study. Since the study was not funded by any external sources, it couldn't be conducted extensively. The travel limitations during nation-wide lockdown limited effective collaboration with respective teaching hospitals and thus limiting the number of participants.

CONCLUSIONS
To conclude, this is one of the few studies of its kind in Nepal where the prevalence of stress and stress factors experienced by resident doctors have been pointed out. The prevalence of stress was found to be much higher in frontline residents, especially in those who were working outside Kathmandu valley. Furthermore, loss of collaborative studies and professional/ academic growth experiences was found to be causing the most severe form of stress in the maximum number of residents followed by unavailability/ lack of quality control in PPE and the uncertainty regarding the nature of COVID-19. Since the residents are working in all the provinces of Nepal and dedicating most of their time in patient care, they can be taken as the representative units of health Free Full Text Articles are Available at www.jnma.com.np manpower. Hence, measures inculcated to alleviate their stress and address their problems could benefit all the other HCWs. This would consequently lead to better health care delivery to patients and overall mitigation of the health crisis in the face of this deadly pandemic.