Nurse Caring and Mother Stress Level on Baby Hospitalization During the COVID-19 Pandemic

. Parents, mainly mothers, will be stressed when their children undergo hospitalization. Especially during the Covid-19 pandemic, the stress level goes higher. Nurse caring and nurse attitudes are treatments to lower mother stress levels. This research aims to see the correlation between nurse caring and mother stress levels on baby hospitalization during the Covid-19 pandemic. This research is observational and uses a cross-sectional design and accidental sampling technique. The samples are 95 mothers whose babies are being cared for in the neonatal intensive care unit at one of Yogyakarta's hospitals from December 2020 – January 2021. The instrument is the Caring Assessment Toll (CAT) questionnaire and the Parental Stress Scale (PSS). The Chi-square test was used as the statistical test. The result showed that 50 people (52.6%) said nurse caring was good. Then, 86 people (90.5%) have low to mid-stress levels. Thirty-eight people (40%) are the ones who categorized nurse caring as a good which affects their low-stress level. The p-value is 0.000 (p-value < 0.05). It can be concluded that there is a correlation between nurse caring and a mother's stress level during baby hospitalization in a perinatology room. Hopefully, the perinatology room nurses should improve their care, especially during the pandemic.


Introduction
Hospitalization constrains children to stay in a hospital to receive intensive care.It becomes a significant stressor for the children and the parents.Hospitalization affects children and parents in many ways.They are separation, lost control, and pain.Other effects on the children are losing hope, protesting, not cooperating, and depression (Sarjiyah et al., 2018).Meanwhile, the effect on the parents is anxiety because they are a significant factor in caring for the children during their stay in the hospital.Parents' responses towards their children's hospitalization commonly are disbelief, anger, guilt, fear, anxiety, stress, and frustration (Ulfa et al., 2018;Wong, 2009).Those effects were also stated in Fauziyah's research in a hospital in Bogor regency in 2014.Her result showed that 68% of parents had mild stress, and 2.7% had severe stress because of children's hospitalization (Fauziah & Agustin, 2014).Apart from the stress, many aspects will change parents' life by being in the hospital, including daily activities, social and economic issues, and anxiety.By being on their children's side during hospitalization to treat their children's sickness, most parents showed various reactions, including disbelief, anger, guilt, anxiety, frustration and even depression (Ulfa et al., 2018).
Let alone if the parents experience all this stress during the pandemic.The Covid-19 pandemic caused changes and modifications in providing health services, including nursing care.Fan et al.
(2020) stated that the Covid-19 pandemic pressures parents psychologically during neonatal care in the hospital.It is because there was a minimum chance to meet their baby and limitation to stay with their babies during the care.Another cause is pandemic uncertainty and raised financial expenses during the pandemic.Zhang et al. (2017) also stated the same problems saying that parents whose babies are being hospitalized tend to be anxious and depressed.It sparked a family conflict and a conflict between the family and health workers.Fan et al. (2020) also showed the same result that the respondents were anxious and depressed.
Because anxiety and psychological stress happen to the parents, it will negatively affect their family relationships and children's health service.Some research showed a conflict between the health workers and the parents.The conflict emerged due to psychological issues, which happened to most parents and families.The pressure, anxiety, and depression affect the family members and the medical worker.Parents also did not cooperate in caring (Diffin et al., 2016;Tandberg et al., 2019;Zhang et al., 2017).Parents become more stressed if their hospitalized children show deteriorating conditions.The parents become more anxious, afraid of their babies' worsening condition, and guilty about seeing their children suffering.They are easily irritated when they are asked trivial things.They are in a hurry when doing their work.For parents whose babies are in long hospitalization, it will disrupt their work because they must accompany their babies in the hospital.Those things stress the parents more (Ulfa et al., 2018).
There are some factors underlying parents' stress during children's hospitalization.They are the diagnosis of the disease, treatment or care, incapacity of treating children's disease, lack of support system, unable to use coping mechanisms, and lack of communication in the family (Wong, 2009).During the Covid-19 pandemic, the stress source has become more varied.The baby's condition, which is vulnerable to everything, having a disease or abnormality, unstabilizes the mother's psychological condition postpartum, triggering the parent's anxiety.
The research result shows that some respondents argued that their babies' condition worsened due to minimized care because of the Covid-19 pandemic (Fan et al., 2020).The covid-19 pandemic causes the parents to have less intensity in terms of communication and their chance to have a consultation about their baby's condition.Another rule of visit limitation and parents' interaction with their baby during care causes significant stress.In NICU, parents are prohibited from being too close to their baby.Their interactions are limited.The prohibition from entering the NICU room caused the parents to react negatively.They are angry, disappointed, afraid, anxious, depressed, and helpless (al Maghaireh et al., 2016).
Nurses and other health workers' workload are increasing during the pandemic.research showed that 19 nurses (61,3%) had a high workload.It happened because there was a spike in patients' number during the Covid-19 pandemic.The service and care mechanism policy were adjusted due to the increased risk of Covid-19 spread.Being infected by Covid-19 caused a stressor for health workers, specifically nurses.They were worried about interacting with the patients and their families.Padila & Andri's (2022) also showed that 16 nurses (51.6%) nurses had severe stress levels and 15 nurses (48.4%) had low-stress levels.Those things cause the nurse to provide minimum attention to the patient and the family.Thus, making the parents anxious and stressed.
On the other hand, the nurse should provide caring at the utmost level, providing their full attention or empathy to the patient and the family.That is the key to lower the parent's stress levels.Pardede et al. (2020) research showed a correlation between nurse care and parents' coping and anxiety.Inadequate caring caused parents' coping to be maladaptive, leading to anxiety.Until recently, no study has researched the correlation between nurse caring and parent stress levels on baby hospitalization during the Covid-19 pandemic.This research aims to know the correlation between them.

a. Design
This research is nonexperimental research or observational research.A cross-sectional design was used in this research.

b. Population and Sample
The population of this research is mothers whose babies undergo hospitalization in a perinatology room.This research used accidental sampling and acquired the data for two months, from December 2020 -January 2021.The total sample is 95 mothers whose babies undergo caring in a neonatal care room in one of Yogyakarta's hospitals.The inclusion criteria are parents whose babies were being cared for in a perinatology room for ≥ two days and were agreed to be respondents.

c. Research Instrument
This research used two questionnaires, Caring Assessment Toll (CAT) and the Parental Stress Scale, as the research instruments.Duffy (1990) developed the Caring assesment toll (CAT) and had been translated and tested its validity-reliability by Kusumarini (2016).The questionnaire consists of 41 questions covering favourable and unfavourable statements For favourable questions, if the respondent answered "strongly agree", they receive 3 points, 2 points for answering "agree", 1 point for answering "not agree", and 0 points for answering "strongly disagree".If the respondent answered "strongly agree" for unfavourable questions, they received 0 points.One point for answering "agree", 2 points for answering "not agree", and 3 points for answering "strongly disagree".Then, nurse caring is categorized into three categories based on the total points.They are good (81-123), fair (32-80), and poor (<32).Miles (1987) developed the Parental stress scale (PSS) NICU in English.Then, it was translated tested its validity-reliability by Jayanti (2013).This instrument has 34 questions and uses a Likert scale.They are 0 (not applicable), 1 (not stressful), 2 (a bit stressful), 3 (mildly stressful), 4 (very stressful), and 5 (severely stressful).To evaluate the questionnaire by summing up the score of each item.Then, separate it into three categories.Low (<56), Mid (56-114), and High (>114).

d. Data acquiring procedure
The data was acquired directly (primary data) by asking the respondents using the questionnaire.
The researchers conducted the process with the help of an enumerator.

e. Research ethics
The researchers applied ethical principles during the research.The researchers abide by ethical principles: autonomy, confidentiality, beneficence, nonmaleficence, and justice.All respondents were given the informed consent form before agreeing to be respondents.This research has passed an ethical review conducted at KEPKN STIKes Surya Global with issuance No. 216/KEPK-SSG/09/2020.

f. Data Analysis
The chi-square correlation test is used as the statistical test.

Research Results
The research provides univariate and bivariate analysis.The univariate analysis covers the frequency and characteristic percentage of the respondents.It also covers the variable assessment result, namely caring and mother stress level on hospitalization.Bivariate analysis is the correlation test between nurse caring application and the mother's stress level during baby hospitalization.In this research, the mother's characteristics include age, occupation, hospitalization, number of children, family support, social-economic status, and education.
There are ninety-five mothers served as respondents.) have an income the same or above the regional minimum wage (UMR -Upah Minimum Regional).
Nurse caring is stated in a score based on respondent answers in the questionnaire.The total score was categorized into three categories (bad, decent, and good).The above showed that 50 respondents (52.6%) evaluate that the nurse caring in the Perinatology Room is in a good category.
Mother stress level is stated in a score based on respondent answers in the questionnaire.Then, the total score was categorized into three categories (low, mild, and severe).Table 3 below shows the mother's stress level.The table above shows that 44 respondents (46.3%) have low-stress levels during their baby's hospitalization.
Cross-tabulation was used to know the correlation between nurse caring and mother stress level on baby hospitalization in the Perinatology Room in one of Yogyakarta's hospitals.Table 4 shows the result of the cross-tabulation.Parents' occupations also may take part as stressor cause to the mothers.Fauziah & Agustin (2014) stated that working respondents have higher stress levels.It is because parents have double roles as the breadwinners and caring for their sick children.It causes a conflict between the role leading to a higher stress level.Tehrani et al. (2012) also stated that working parents have a higher stress level because they cannot accompany their children for 24 hours.Take into account the far distance between the working place and the hospital.
Economic status (family income) also may take part as a stressor caused to the mothers.Fauziah & Agustin (2014) found that parents with income higher than minimum wage will have lower stress levels than those with lower than minimum wage.That statement aligns with Supartini's (2014) research.She stated that the parents are anxious and afraid of the expenses for the children's treatment.Being ever or never hospitalized also may cause stress to the mothers.
According to Priyoto (2014), one who ever faced a stressful situation will be more capable of overcoming the same situation in the future.Parents who ever being hospitalized or their children whoever being hospitalized will have a better experience in treating sick children.
Thus, it is easier for them to overcome the problem.
Support also may take part as a stressor caused to the mothers.Yeni et al. (2015) pointed out that respondents who receive family support will have lower stress levels than those who do not.
Priyoto (2014) stated that supports and others' empathy significantly help lower stress levels.
One of the nurses' efforts to minimize hospitalization's effect is providing a caring service.The nurse will involve the parents in the treatment process to avoid raising stress levels, improve self-control, and minimize children's separation.In this research, the nurses are friendly and provide a clear explanation regarding a nursing procedure which makes the parents understand the treatment given to their children.In Alligood (2010)

Conclusions and Recommendations
Based on the research result, data analysis, and the discussion, we conclude that there is a correlation between nurse caring and mother stress levels in baby hospitalization during the Covid-19 pandemic-the better the nurse's caring, the lower the mother's stress level.
Nurses assigned explicitly to the perinatology room should improve their caring treatment of the parents, mainly the baby's mother.Nurses should improve their future care treatment, including giving the parents a chance to disclose their feelings, concerns, or worries.Also, nurses should routinely provide information on the baby's condition and development.Lastly, nurses should always provide emotional support.
, one of Watson's carative factors stated that nurses can improve interpersonal learning systems.Nurses should conduct an exciting and outright learning process which includes providing information and the definition of health and sharing experiences with the patients and their family.Providing nursing services based on caring will improve the quality of health services.Applying caring integrated with biophysical and human traits knowledge will improve one's health and facilitate patient health services.Watson (1979)  inAlligood (2010) added that practical caring stimulates health and growth.Furthermore,Gaghiwu et al. (2013) found a significant correlation between nurses caring for children's stress on being hospitalized.The better the nurse caring, the lower the children's stress on being hospitalized.One of the factors affecting parents' stress is their inability to communicate, accept, and understand complex information.They also made a difficult decision during the initial stage of hospitalization(Needle et al., 2009).Therapeutic communication in nurse caring will reduce parents' stress.This statement is supported byHeidari et al., (2015)In his research, he stated that the appropriate response and answer from the nurses to parents' questions on their children's condition reduce parent stress significantly.This statement aligns with Currie et al. (2018) research.In the research, she stated that providing understandable information showed sensitivity and recognition to the parents.It reduces parents' confusion about their children's condition.Solheim & Garratt (2013) also stated the same thing.They stated that caring and therapeutic communication display nurse warmness and care towards the children and the family.Those will surely improve the satisfaction of the clients and their families.Nurses can use the advancement of information technology to provide care during the pandemic.They also can provide any form of support, including psychological support, to give any information without having physical contact.Monaghan et al. (2020) conducted research that showed the same result.Family satisfaction is improving due to the use of multimedia technology to communicate between doctors and patients.It can also be optimized for providing health education-many applications in the gadget support the interaction between patients, parents, and health workers.Animations can also show or demonstrate any health education.Those are significantly beneficial for the effective communication between doctors and patients during the Covid-19 pandemic (Yin et al., 2019).Stress affects parents' actions in treating their children.Thus, it is vital for nurses to provide nursing services and as a holistic provider of client health needs.Nurse caring fills that role.This statement aligns with Gaghiwu et al. (2013) research.In his research, he stated that a caring nurse could reduce parent stress levels when hospitalized.It also aligns with Ludyanti et al. (2015) research.She stated that caring, which fulfills basic human needs physically and psychologically, provides comfort to the patient.Fan et al. (2020) suggested giving the family more emotional support than usual during this pandemic.That support can be conducted by giving the parents a chance to disclose their feelings and worries.Nurses must communicate with the parents daily by phone call to provide an update on the baby's condition and development.The updates include the volume of eating, drinking, urine, feces, temperature, and movements.

Table 1
The Characteristics of Respondents whose Baby being Cared in Perinatology Room in One of Yogyakarta's hospitals (n=95)

Table 2
below shows the data analysis of nurses caring in the Perinatology Room in one of Yogyakarta's Hospital.

Table 2
Nurse Caring in the Perinatology Room in One of Yogyakarta's Hospitals (n=95)

Table 3
Mother Stress Level during Baby Hospitalization in Perinatology Room in One of

Table 4
(Aryanti et al., 2019)4) Caring and Mother Stress Level on Baby Hospitalization in During the Covid-19 pandemic, all aspects and organizations are modified and adjusted.So does nursing care in hospitals.The rules and policies related to health services and caring change due to the increasing transmission risk of Covid-19.According to the parents, thoseThis negatively affects the children and the parent.Apriany (2013)pointed out that parents are afraid during hospitalization for unclear reasons.They occasionally had bad dreams, easily annoyed and panicking.That statements correlate with Wong's.He stated that parent's responses during children's hospitalization include disbelief, guilt, anger, afraid, anxiety, and stress(Wong, 2009).Some factors may relate to the respondent's stressor in this research.Some are age, education level, occupation, social-economy status, ever or not being hospitalized, and family support.Yeni et al. (2015)research showed that as one age, they easily overcome stress.According to her, parent age affects their thoughts and acts to be mature enough to accept children's treatment in the hospital.Fauziah & Agustin (2014)conducted the same research showing that as one gets older, one becomes more experienced and has a broad knowledge.Both traits showed their preparedness to face a problem.Experienced parents in caring for their children will be calmer in facing problems relating to children's health conditions(Aryanti et al., 2019).
Oktavianto et al. (2018)han other nurse caring categories (poor and decent).The correlation test between nurse caring and mother stress level on baby hospitalization resulted in a p-value < 0.05.There is a correlation between the issues.The higher category of nurse caring, the lower the mother's stress level on baby hospitalization.4.Research DiscussionHuman Caring, emphasized that caring is a type of relation and transaction needed between the giver and the receiver of nurse caring to improve and protect the patient as it affects the patient's ability to recover.In common terms, caring is the ability to dedicate oneself to others, attentive supervision, showing attention, empathy, and love others; that is the will of nursing (Potter & Perry, 2010).Various nursing theories place caring as the core of nursing.It formed the nursing practice in which the nurse helps the client recover from his/her disease, explains his/her disease, and manages or rebuilds the relationship.Potter and Pery said that caring is an important core of nursing practice.It emphasizes the recognition of one's dignity.In nursing practice, nurses always appreciate the client by accepting the client's strengths and weaknesses (Potter & Perry, 2010).Caring is closely related to human relationships and the ability to dedicate oneself to others.hospitalization in a perinatology room.Forty percent of mothers who regard good nurse caring have lower stress levels than mothers who regard poor and decent nurse caring.The Chi-square test result shows p-value = 0.000 (p-value <0.05).It can be concluded that there is a correlation between nurse caring and mother stress levels in baby hospitalization.Being hospitalized means the children and the mothers must adapt to the new surroundings during the children's treatment.Education level and knowledge also may take part as stressor cause to the mothers.Fauziah & Agustin (2014) said that respondents with higher education levels are more capable of overcoming stress by using effective coping systems than respondents with lower education levels.Oktavianto et al. (2018)stated that knowledge causes one's level of stress and anxiety.A better-knowledge nurse is more confident in facing any problems.