Online Affirmation and Peer Support are Effective for Reducing Medical Personnel Stress in Dealing with COVID-19 Patients

The COVID-19 outbreak has psychological impacts on frontline medical personnel at risk of infection. Therefore, this study aimed to evaluate the effect of online affirmations and peer support on medical personnel stress level in dealing with COVID-19 patients, as well as social support and spiritual intelligence's influence. It was a quasi-experiment with pre-and post-test administered to 25 and 30 medical personnel as the intervention and control groups, respectively. The intervention was carried out on WhatsApp group for 4 weeks. The stress level pair T-test results showed p = 0.000 in the intervention group and p = 0.238 in the control, while the independent T-test results showed p = 0.009. Social support did not affect medical personnel’s stress (p=0.978), but the effect of spiritual intelligence was significant (p=0.000). According to the results of multiple regression test conducted using the Enter method, the coefficient value (R2) = 0.584. This intervention was effective in helping medical personnel to manage stress. Hence, hospital managers need to carry out stress management training to maintain medical personnel’s mental health.


INTRODUCTION
World Health Organization (WHO) has designated COVID-19 as a pandemic on March 11, 2020.COVID-19 had a broad impact in almost all aspects of human life, economy, politics, and have created unprecedented challenges to health care systems.Medical personnel are at the frontline of handling COVID-19.Since March, Bengkulu City has become the red zone for the COVID-19 outbreak.The increase in the number of sufferers is quite significant from day to day.On Saturday 24 October 2020, 548 people were confirmed positive, 35 people died (6.39%), 414 people recovered (75.55%).This high rate of morbidity and mortality has an impact on psychological stress for medical personnel who work to treat COVID-19 patients.
The common psychological stress responses to the COVID-19 Pandemic faced by medical personnel includes physical and cognitive/emo-tional exhaustion, fear, anxiety, anger related to the threat to safety in self, family, coworkers (transmitting COVID-19), worry about contracting the illness from patients, separation from family, especially care for children, inadequate personal protective equipment, stigma.This psychological stress will affect the professional appearance of medical personnel.The mental resilience of medical personnel is an important thing during this pandemic due to the unpredictability of when it will end (Blake et al., 2020;Chen et al., 2020;Lai et al., 2020).Maintaining staff mental health is essential because the psychological wellbeing of medical personnel will influence the duty performance (Langdon et al., 2016;Lohmann et al., 2019;Barzilay et al., 2020).It is important for hospital managers to seek strategies to maintain the mental resilience of medical personnel and preventing burnout and psychological trauma (Mo et al., 2020).These conditions affect psychological well-being.A healthy mental state is a basic need of every individual.psychological well-being of several factors such as demography, social support, evaluation of life experiences, locus of control, and religiosity.
COVID-19 had a broad psychological impact on individuals and had an impact on psychiatric morbidity.Especially for medical personnel who are facing excessive exposure to stressors due to this outbreak.The fact that there are medical personnel who have been evicted from their homes also shows the low social support.Positive social support was needed as a preventive measure from mental disorders and got psychological well-being (El-Zoghby et al., 2020;Nie et al., 2020;Wang et al., 2020).There was a significant relationship between spiritual intelligence and psychological well-being.Spiritual intelligence is important for individuals with stress adaptation to crises so that they can maintain their psychological well-being (Esfahani & Sadeghi, 2015;Ahoei et al., 2017) Psychological strengthening of medical personnel can be done starting from themselves or in groups.Positive affirmation or positive self-talk is one of the stress management interventions in the form of reinforcing positive motivational words to oneself that are repeated and every day (affirmation) which then attaches to the individual's subconscious mind.Several studies related to stress management show affirmations can reduce stress levels (Boutin-Foster et al., 2016;Kusumastuti et al., 2017;Mays & Zhao2, 2017).Besides strengthening the group of medical personnel is also an intervention that can be used as stress management.The health protocol during the COVID-19 pandemic required a saving of distances between individuals.However, the needs of humans as social creatures must still be fulfilled.The sense of togetherness in one fate requires medical personnel to be connected to remain mutually reinforcing (Albott et al., 2020).Affirmations and peer support Interventions by online so that medical personnel can encourage one another.Affirmation activities become more measurable so that bias in research can be avoided.
The aims of this study were to evaluate the effect of online affirmation interventions and peer support on the stress of medical personnel in dealing with COVID-19 patients.We also investigated the effects of social support and spiritual intelligence on medical personnel's stress (Liao et al., 2020;Pollock et al., 2020;Serrano-Ripoll et al., 2020).

METHODS
This study is a quasi-experiment with pre and post-test with a control group.The study was conducted on medical personnel at two government hospitals that handled COVID-19 patients, namely the Regional General Hospital (RSUD) dr.M. Yunus (Intervention group) and Bengkulu City Regional Hospital (Bengkulu City Hospital) as the Control group.The control group was used to find the difference in effectiveness between online and offline affirmation interventions, reducing research bias.Determination of the hospital for the intervention and control groups was carried out by simple random sampling, but the research sample was taken by purposive sampling.The criteria for medical personnel who participated in this study were those with a maximum age of 45 years, no comorbidities, not pregnant or breastfeeding, were medical personnel who were included in the special COVID-19 team.Fiftyfive medical personnel participated in this study and were divided into two groups, were in the intervention group of 25 people and the control group of 30 people.
The interventions carried out in the medical personnel group at RSMY were online affirmation and peer support.Researchers formed a WhatsApp group called "We Can Fight CO-VID-19" for an intervention group.Each health worker in the intervention is required to write positive affirmation sentences twice a day with a minimum period of 6 hours.WhatsApp groups respect each other and provide mutual support.The intervention was carried out for 30 days, starting from 19 September to 19 October 2020.In the control group, researchers explained orally and in writing about positive affirmations as one of the interventions that can be used in stress management.Researchers provide articles on the importance of affirmations for managing stress in maintaining psychological well-being and advise each medical staff in the control group to do affirmations.
We assessed the stress levels of medical personnel before and after the intervention (30 days later) using the Perceived Stress Scale (PSS) questionnaire (Chan & la Greca, 2013).Before analyzing the PSS data, we first conducted a data normality and homogeneity test.Data were homogenous and normally distributed, so we used the analysis of the PSS results in each group using the paired t-test, while to compare the PSS results in the two groups we used the Independent t-test.
To assess the effect of social support (ISEL questionary) and spiritual intelligence (SISRI) on nurses' stress, we performed multiple linear regression tests.The results of the validity and reliability test of the social support and spiritual intelligence instrument show that all items of questions have r > 0.36 which means that all questions on both meet the validity requirements.In the reliability test results, the value of alpha Cronbach's ISEL was 0.84 and SISRI 0.92 was obtained.The data obtained were then analyzed using descriptive statistical analysis for univariable analysis.Bivariable analysis using the paired t test and independent t Test.Multivariable analysis using the logistic regression test of the Enter LR method with a significance level of 95% using data processing software.
This research has passed an ethical review with a letter number 226/UN30.14.9/LT/2020 issued by the Health Research Ethics Committee of the Faculty of Health and Medicine, University of Bengkulu.

RESULTS AND DISCUSSION
Respondents in this study were medical personnel who treated patients with positive CO-VID-19.RSUD dr.M. Yunus and RSUD Bengkulu City are two government hospitals in Bengkulu City that provide a special room for COVID-19 treatment.The intervention group consisted of 25 medical personnel while the control group consisted of 30 people.The descriptions of the medical personnel that participated in this study are as follows.
The results of data processing social support (p = 0.160) and spiritual intelligence (p = 0.173) in both groups are normally distributed and homogeneous.The mean value of social support is 41.9 below the median value of 47. Spiritual intelligence had a mean of 37.49 with a median value of 41.The possible range of social support is 22-88, the acquisition of the respondents' score is 22-65.While the acquisition of spiritual intelligence scores from 17 -60 with a possible range of 17-68.
Measurement of the level of stress before the intervention in the control group was mostly at low stress levels, namely 18 people (60%), while in the intervention group at severe levels there were 14 people (56%).Furthermore, after 4 weeks of the implementation of the intervention, post intervention measurements were carried out, the results showed that the number of medical personnel experiencing low stress in the control group was increased to 20 people (66.7%).In the intervention group, there were no medical personnel who experienced severe stress.To perform a bivariate analysis, we first tested the homogeneity and normality of the data.The two groups were homogeneous (p = 0.092).Testing data normality using the one-sample Kolmogorov-Smirnov obtained p value = 0.176 in the control group and p = 671 in the intervention group.This shows that the data is normally distributed so that the pair t test and independent t test are used to see differences in stress levels before and after inter and inter-group interventions.
The results of the pair t test in the control group obtained p = 0.238 and in the intervention group p = 0.000.Based on these results, it can be said that there was a significant change in stress levels in the medical personnel group at RSUD Dr. M. Yunus (intervention group) before and after the intervention with a mean rank of 8.200 (95% CI: 7.217 to 9.183).This shows that the intervention group tends to decrease stress with an average of 8.200.Furthermore, the results of the independent t test obtained p value = 0.009, this indicates that there is a difference in stress levels between the two groups before and after the implementation of the intervention.
The results of multiple linear regression showed the effect of social support on stress with p value 0.978, spiritual intelligence 0.000.the two variables simultaneously contribute to the stress of medical personnel with the opposite effect of 58.4%.Other factors outside the focus of the study affected 41.6%.The higher the social support and intelligence of medical personnel, the lower the stress faced by medical personnel.

The Effect of Online Affirmation and Peer Support Techniques on The Stress of Medical Personnel
The COVID-19 pandemic is a major challenge for health workers in facing the crisis.The stress they face not only poses a risk to them physically but also mentally (Lai et al., 2020;Mo et al., 2020).Affirmation as a stress management strategy is self-strengthening by instilling positive sentences that are repeated into the subconscious mind so that a negative perception of events occurs in the environment.Affirmative intervention is a cognitive therapy strategy that reflects positive values and beliefs that can become a buffer against stress.A study in China shows good results about the effect of self-affirmation on the decline of society in the face of the COVID-19 pandemic (during 7 days of intervention).This therapy is free of charge, requires no special place or equipment, and does not require professional guidance.Thus this therapy is easy and comfortable to do (Zainiyah et al., 2018;Li et al., 2020;Liu et al., 2021) COVID-19 requires physical social distance, this has triggered the use of online media in all aspects including the health sector.Previous study shows that smartphones are effective as a  (Economides et al., 2018).COVID-19 has had a changing impact on the well-being of medical personnel.The risk of infection and death, especially in the presence of real data, makes this task a stressor.This condition makes medical personnel continue to experience crisis and stress syndrome.With this in mind, strategies for maintaining mental health at both the individual and group level are important.The results showed that there was a significant effect between online affirmation intervention and peer support on reducing stress levels of medical personnel.The mental strengthening of medical personnel is carried out starting at the level of the medical personnel themselves to the group.Each individual will perceive all the things that happen in the environment and everything that they experience.Negative perceptions can cause anxiety and excessive stress.Positive affirmation or self-talk is a cognitive psychology technique used to stop negative cognition that can cause anxiety, depression, and pessimism that interfere with one's work performance.This intervention has been shown to be effective in several studies in the athlete group, cancer treatment, renal failure treatment, preeclampsia treatment, adherence to rehabilitation programs (Hamilton et al., 2011;Boutin-Foster et al., 2016;Cholifah et al., 2017;Kusumastuti et al., 2017;Muniroh & Wardani, 2018;Wijaya & Rahayu, 2019).In this study, besides doing positive affirmations, medical personnel also reinforced each other.Several studies have shown that support groups can be a part of stress management, in groups of people with diabetes mellitus, groups of people with infertility and interventions for medical personnel to deal with emotional changes in the workplace (Heisler et al., 2008;Grunberg et al., 2018;Taylor et al., 2018).A sense of togetherness that this pandemic disaster is a joint disaster.Reinforcement from groups who have similar obligations and face the same risks will have a positive effect on the psychological health of medical personnel.

Relationship Between Social Support and Stress of Medical Personnel
The community as consumers of health services has a very distribution of stress on medical personnel.Kackin et al in 2020 wrote that nurses caring for patients with COVID-19 were experience negative psychosocial impacts.This is due to tiring changes in work patterns but also facing a community situation due to stigma.Witnessing the high number of morbidity and mortality rates and even co-workers themselves creates great psychological stress.Social support from all circles is important to maintain the psychological well-being of health workers.Psychological resilience is needed by health workers in order to provide excellent service.Good social support from various sources will increase the psychological resilience of medical personnel and health workers (Kackin et al., 2020;Kılınç and Sis Çelik, 2020).
Stigma is one of the major obstacles to improving mental health.Stigma in the community can be formed from hoaxes circulating amidst the swiftness of information via social media.The news can cause psychosomatic symptoms that trigger public anxiety.Furthermore, it affects people's behavior towards health workers, such as the incidence of evictions from rented houses, refusal in public transportation and rejection of the bodies of patients and nurses who are confirmed by COVID-19.However, like two blades, social media can also be used as an effective educational media in promoting the prevention of CO-VID-19.This is due to the high number of users that can reach many people at the same time.Given this, the role of government regulations to ward off hoax news circulating in the community needs to be further improved (Ridlo, 2020;Santoso & Santosa, 2020).
Other support that is no less important can even be a factor that has an impact on community social support that comes from these social institutions.Heat etc. 2020 wrote that management must be able to find good strategies to maintain professional retention.The COVID-19 outbreak has made rapid changes, so we all have to be quick and responsive in adapting.All of these changes create stress that lasts a long time with COVID-19 not yet ending.Repetitive chronic stress, if not resolved properly, will cause traumatic disorders (Heath, Sommerfield and von Ungern-Sternberg, 2020).The results of online positive affirmation interventions in the WhatsApp group for 4 weeks.In this group medical personnel communicate with each other and provide support between them.
The results showed that social support simultaneously with spiritual intelligence is a factor that affects the stress of medical personnel.The COVID-19 pandemic is a prolonged stressful and it cannot be ascertained that in the end, WHO has set a new normal era.The length of the pandemic period requires health workers to be able to maintain mental status.Stress conditions that are not managed properly for a long time will cause health problems, diseases, somatic disorders and functional disorders.Handling stress as early as possible is needed so that individuals do not fall into Post Trauma Distress syndrome.Group support and a sense of community can reduce stress due to a lack of social support outside the hospital (Wong et al., 2020).
The length of this pandemic period has made public obedience to loosen up.These conditions can affect social support for health workers.Amid the diversity of views that exist in the community, health workers must still be at the forefront of carrying out their duties.All of this is a form of fulfilling the professional oath.Public education needs to be improved with an approach that fits the target.The use of foreign languages in terms related to COVID-19 makes not all people understand well.For this reason, it is necessary to replace the foreign language with Indonesian that can be understood by all people.Besides that, there is another problem that is no less important, namely the problem of "hoaxes" or fake news.Hoaxes can lead to public opinion and form a stigma that affects their attitude in implementing the recommended Health protocol.The rapid use of online media and social media has become the most widely used medium for broadcasting fake news.The detrimental effects of misinformation on social media are faster in spreading the corona virus itself.It provides a wide range of critique and consequences for Health.Thus the public is advised to be careful and able to filter information from social media (Barua et al., 2020).Freedom of media must remain wise by considering the benefits of society.Next, the role of religious figures as people heard in issuing fatwas must be more proactive down to the lowest level of the structure in society.In several incidents, the fatwas of the Indonesian Ulema Council and religious organizations such as Nahdatul Ulama and Muhammadiyah have not been well socialized in the community.This can lead to conflicts such as events in Gorontalo, Bandung, South Sulawesi, East Jakarta and Banyu Mas, Central Java (Santoso & Santosa, 2020).
COVID-19 is a crisis faced globally.No matter how bad the conditions are to maintain mental well-being, we must be able to see the positive aspects of every incident.Learn from the experience of the SARS outbreak that occurred in 2013 that the crisis has increased solidarity among staff due to friendship and common problems.Social support and high hospital institutional support contribute to reducing anxiety and stress faced by health workers.Institutions must provide adequate support, Infection control training, support existing materials that offer risks as a platform for health care to remain in the profession.Psychological and mental support services as well as stress management training to increase the psychological resilience of health workers (Chou et al., 2020;Kim et al., 2020; Labrague & de los Santos, 2020; Labrague & de los Santos, 2020)

Relationship Between Spiritual Intelligence and Nurse Stress
Spiritual intelligence in this study has a significant effect on the stress level of health workers.This is in accordance with the results of research at a hospital in East Kalimantan.High spiritual intelligence has a high positive effect on organizational commitment, which will then affect the performance of health workers (Kaur et al., 2013;Haryono et al., 2018).Health Workers in carrying out their duties, providing Health services often face unforeseen and emergency conditions.This condition was inevitable even before the COVID-19 pandemic occurred.Because of the nature of the profession it is this that places them at high risk of exposure to and at risk for psychosocial disorders.A study conducted in 2015 to 2016 has shown the importance of training to increase spiritual intelligence for health workers, especially nurses.These results show that in the pre-COVID-19 period spiritual intelligence was important to reduce stress for health workers, especially nurses (Tulenko, 2021).
Nurses are health workers who have the most and longest interactions with patients.
When the patient is cared for, the nurse is the first to stand by the patient and assess the response when an emergency occurs.The nurse provides assistance with basic needs when the patient is away from family and loved ones.In the era of the COVID-19 pandemic, aerosol assistance is an action that has a high risk of transmission and transmitting disease to families.The use of Personal Protective Equipment (PPE) for a long time disturbs the integrity of the skin.Witnessing and caring for many sick people and co-workers themselves being exposed to even death is a stressor that can affect the psychosocial resilience of nurses (Heinzerling et al., 2020;Hu et al., 2020;Jeon et al., 2020;Park, 2020).A qualitative study that describes the experience of health workers in dealing with the COVID-19 outbreak states, the awareness that they still have to provide the best service and take full responsibility for the welfare of patients amid physical and emotional exhaustion as a form of professional dedication, this pandemic is a unique experience that provides challenges and motivation to survive (Liu et al., 2020).
Loyalty of health workers to the professional oath is the main asset for them to manage stress that occurs.it is very much influenced by spiritual intelligence.Spiritual intelligence can strengthen the belief and personality of health workers in improving services to clients.Health workers, especially nurses, provide holistic care, namely bio, psycho, social and spiritual.So before they give good spiritual care to patients, they must first have good spiritual intelligence as well.Research shows spiritual care training for nurses can improve the quality of nursing care.Spiritual services to patients can reduce anxiety, increase satisfaction, and even reduce hospitalization days and the quality of life for patients in general (Riahi et al., 2018;Beni et al., 2019;Pfefferbaum & North, 2020) It is not only health workers who must have high spiritual intelligence.The impact of COVID-19 is a common problem that requires government and community cooperation from various groups.High spiritual intelligence will provide a high ability to survive the psychological disorders caused by COVID-19.One of the spiritual domains is the relationship with God Almighty or in this case the religious aspect (Pirutinsky et al., 2020).Realizing the increasing need for health personnel services in this pandemic era, the community, health institutions and the government need to cooperate to reduce the work pressure they face.Compliance with the Health protocol is one of the keys to breaking the chain of transmission of COVID-19.

CONCLUSION
Online affirmation techniques and group support are effective at reducing the level of stress faced by health workers caring for patients with COVID-19.Social support from various sources is very necessary for the mental resilience of health workers.Social support and spiritual intelligence have a significant effect on stress for health workers.
Maintaining the mental health of health workers is essential to public health.Stigma and misinformation have detrimental consequences for both individuals and healthcare providers.The government should be able to stop the stigma by regulating the social information system in an effort to maintain the mental resilience of nurses.Health service provider institutions should be able to make continuous efforts to improve the welfare of health workers both materially and psychosocially.Online affirmation techniques and group support by providing networks to improve communication between health workers can be used as strategies to reduce stress for health workers.

ACKNOWLEDGEMENT
This research was funded by PNBP FMI-PA Bengkulu University with contract No. 2048 / UN30.12 / HK / 2020 and presented in the 1 st International Nursing and Health Science Symposium (INHSS) "Adapting to New Habits: Strengthening Interprofessional Collaboration and Embracing Innovative Measures to Improve Quality of Healthcare Service" on 13-15 November 2020 organized by School of Nursing and Nutrition Department, Faculty of Medicine, Universitas Brawijaya, Malang Indonesia.

Table 1
Results of Analysis of Sociodemographic Characteristics of Medical Personnel

Table 2
Changes in stress levels before and after the online affirmation and support group intervention in the control group (n=30) and intervention group n = 25