Worry and fear as predictors of fatalism by COVID-19 in the daily work of nurses

Abstract Objective: to analyze the relationship between the concern and fear of COVID-19 with fatalism in the daily work of nurses. Method: analytical cross-sectional study carried out with a total of 449 nurses. Data collection was performed using instruments validated in Peru. In the analysis, the Shapiro-Wilk test and the Spearman correlation coefficient were used, and two multiple regression models were estimated, with variable selection in stages. Results: nurses had a moderate level of fatalism and a low level of fear and concern about COVID-19. The first statistical model, which included sociodemographic variables, explains only 3% of the fatalism variance. However, a second model that includes fear and perception explains 33% of it. Conclusion: Worry, fear and having been diagnosed with COVID-19 were predictors of fatalism. It is suggested the implementation of psycho-emotional interventions in daily work - aimed at Nursing professionals who present high levels of fear or concern - to reduce fatalism and prevent fatal consequences of the pandemic and promote health.


Introduction
The COVID-19 pandemic showed that, in addition to a simple health crisis, there were signs of a real civilizational or "social" crisis in everyday life (1) , which not only affected the physical and mental health of the population, but also disrupted essential mental health services in 93% of the countries in the world (2) . In this context, compared to other health workers, nurses are at greater risk of developing trauma or psychiatric disorders (3) .
The impact of COVID-19 on nurses' mental health is related to the daily conditions of their work and the fear of contracting the disease and infecting their family members (4) ; this consequence could trigger a state of psychological and physical tension capable of activating pathological behaviors (5) , which would increase the risk of committing suicide (6) . In fact, recent evidence from a retrospective study suggests that psychological distress and extreme fear of COVID-19 were stressors in cases of suicide during quarantine (7) .
One of the psychological constructs little investigated during the pandemic is fatalism by COVID-19, conceptualized as the perception or belief that a person has about possible situations after being infected by this virus (8) . Thus, a study in Peru indicated that this perception is associated with sex, age, religion and risk of infection (9) .
In addition, among people living in the United States, it was reported that fatalistic messages increased the fatalism score, while optimistic messages reduced it (10) .
Fear of COVID-19 is defined as an unpleasant emotional state, triggered by the perception of threatening stimuli (11) . Recent studies have shown differences in the type of association that exists between this emotional state and fatalism. Fear of COVID-19 was inversely associated with fatalism (destiny would be determined externally) (12) and with the fight against coronavirus (10) . However, a study that evaluated its relationship with three fatalism subscales reported that two of them -predetermination and luck -affect negatively, in contrast to pessimism, which impacts positively (13) . On the other hand, no studies were found that evaluated the association between fatalism and concern about COVID-19, conceptualized as an emotional response to this disease and which constitutes an important aspect for its management (14) .
Research on fatalism in nurses' daily work is relevant, as this perception not only increases psycho-emotional stress, but also represents a barrier to the adoption of preventive and health-promoting measures. Thus, a study indicates that fatalism predicts the refusal to adopt preventive behaviors in the face of COVID-19 (15) . Likewise, predetermination -one of the dimensions of fatalism -is associated with participation in activities with a risk of contracting this disease (13) .
It is known that the fatal consequences of COVID-19 in nurses can be prevented through interventions focused on their risk factors (16) . However, there are few studies that analyze the factors associated with fatalism. The following research question was raised: what is the relationship between the concern and fear of COVID-19 with fatalism, considering the possibility of being infected with this virus, in the daily work of nurses? Thus, this study aims to analyze the relationship between the concern and fear of COVID-19 with fatalism in the daily work of nurses.

Study design
Analytical cross-sectional quantitative study, guided by the Standards for Quality Improvement Reporting Excellence (SQUIRE) tool.

Setting
The study was carried out in the city of Lima, Peru.
Nurses who work in public (hospitals, health centers) and private (clinics, outpatient clinics) health facilities were invited to participate.

Population and sample
The sample consisted of 449 nurses who reported performing some care work activity at the time of the research. They were selected through intentional sampling. Nurses who did not live in Peru and those who did not have access to electronic devices connected to the Internet were excluded.

Instrument
The research technique was used through a virtual questionnaire. In the first section of the instrument, the informed consent form was requested, which included a question to consult the desire to participate in the study.
In the second section, questions were asked about the sociodemographic characteristics considered as possible predictive factors: age, sex, vaccination status, length of professional experience, workplace, remote work and whether the patient was diagnosed with COVID-19.
To measure fatalism, the scale of fatalism at the possibility of being infected with coronavirus (F-COVID-19 Scale) was used (8) . This scale measures the perception/ belief of possible situations after the contagion of this disease. The scale was validated to be applied to a Peruvian population in 2020 and showed adequate reliability (Cronbach's alpha of 0.70). Their answer alternatives ranged from 1 = strongly disagree to 5 = strongly agree, so that the higher the score on the www.eerp.usp.br/rlae 3 Zeladita-Huaman JA, Zegarra-Chapoñan R, Castro-Murillo R, Surca-Rojas TC.
scale, the greater the fatalistic perception. This scale is composed of two subscales: extreme fatal consequences as a result of infection (4 questions) and concern about the consequences of coronavirus infection (3 questions). The scale allows obtaining a total score and a score for each factor of the subscale (8) . Furthermore, in this investigation, adequate reliability was found (McDonald's Omega coefficient of 0.77). This coefficient was preferred over Cronbach's Alpha, because McDonald's Omega coefficient is a more robust measure against violation of assumptions in instrument measurement (17) .
Fear of COVID-19 was assessed using the Fear of COVID-19 Scale (FCV-19S/FCV-19S Scale) (11) . This scale, built on an extensive literature review, was validated in a Peruvian population in 2020 and showed an optimal level of internal consistency (Comparative Fit Index of 0.988).
It has a total of 7 questions and its alternatives range from 1 = strongly disagree to 5 = strongly agree. Therefore, the higher the score on the scale, the higher the fear score. This scale is composed of two subscales: emotional reactions of fear (7 questions) and somatic expressions of fear (3 questions). In addition, it allows obtaining a total score and a score for each subscale (11) . Thus, in this study, it was found to have adequate reliability (McDonald's Omega coefficient of 0.87).
Concern about the contagion of the COVID-19 was assessed using a Likert PRE-COVID-19 Scale (14) , which was adapted from a cancer concern scale and validated in a Peruvian population in 2020; consists of six questions whose answer alternatives range from 1 = never or rarely to 4 = almost always, so that the higher the scale score, the greater the concern (14) . As with the other scales, in this study it was found to have adequate reliability (McDonald's Omega coefficient of 0.85). It is important to emphasize that, to be used in this study, it had the approval of its authors. However, as the scales were used in nurses, they were previously submitted to the approval of specialist professionals who worked in Nursing specializing in mental health and health in general. These were members of rapid response teams to COVID-19 in different areas of Peru.

Data collection procedures
Data collection was carried out using a form created on Google Forms, which was disseminated on the social networks of health institutions, in scientific nursing societies and in universities that offer postgraduate degrees in Nursing programs, between April and June 2021.

Data statistical analysis
At first, to meet the objectives of this study, the descriptive statistical results of the variables studied were analyzed. In this analysis, the assumption of normality of continuous variables was revised using the Shapiro-Wilk test, identifying that none of the variables followed a normal distribution. Subsequently, to estimate the bivariate correlations, the Spearman correlation coefficient was used.
The interpretation of the effect was made considering that: correlations close to 0.10 are small, those close to 0.30 are moderate and those close to 0.50 are strong (18) .
Finally, two regression models were estimated, with selection of variables in stages (19) , to identify the model with the best capacity to predict the fatalism score. The first stage included control variables such as age, sex, vaccination status, whether they work remotely and whether they were diagnosed with COVID-19. The second stage included, in addition to the control variables, concern and fear. Both models were compared in terms of R 2 (Coefficient of Determination) and the model was interpreted with a significantly higher level of explained variance. For both models, the assumptions of normality of the residuals were revised using the comparative graphical method with a halfnormal distribution (20) . This method allows to graphically diagnose the adjustment of the residuals of the models against a theoretical normal distribution. Furthermore, the assumption of homogeneity of the variances of both models was verified with the Breusch-Pagan test, which when presenting statistically significant statistics, indicated the presence of heteroscedastic residues (21) . Likewise, the multicollinearity of both models was revised using the Variation Inflation Factor (VIF). According to this indicator, variables that obtain scores greater than 10 are considered problematic (22) . The existence of outliers was explored by calculating Cook's D indicator; when this indicator has scores higher than 1, it is considered a case with high influence and high residuals, for which it is considered a probable outlier. The software R v 4.1.0 (23) was used in all analyses.

Ethical aspects
The study was approved by the Research Ethics

Results
In total, 456 nursing professionals responded, seven participants were excluded because they were from other countries. The remaining 449 were eligible, with a mean age of 37.9 years old (SD = 11.1). According to the State/ Region in which they lived, 75.5% (339) lived in Lima, 8.0% (36) in Ayacucho, 2.9% (13) in Callao, 2.9% (13) in Junín and 10     It is observed that, in both models, all cases of adjusted residuals fall within the simulation bands of a half-normal distribution. This indicates that, for both models, the residuals fit a normal univariate distribution.  Model 2 was equal to 9.65, with 8 degrees of freedom and a p-value of 0.29, which is also not statistically significant.
Thus, in this model it is also concluded that the variance is homogeneous along the regression line. positively affects fear (13) . However, this is in disagreement with the studies carried out in the first months of the pandemic, as they report an inverse relationship between the fear of COVID-19 with fatalism in the fight against COVID-19 (10) and non-critical pessimistic fatalism (12) . It is pertinent to note that one of these studies used a scale not contextualized in COVID-19. This difference can be explained by the fear that motivates people to respond effectively to a threat or a certain stimulus, that is, a limit, a determination or a commitment. It represents a survival mechanism in everyday situations, that is, what protects us from certain facts characteristic of the human condition, which can become a potential danger (24) .
However, extreme or persistent fear can cause negative psychological reactions, such as psychological stress (25) , anxiety and depression (26) .
On the other hand, when considering that the average score of fear of COVID-19 obtained is higher than that reported in a study that used the same scale, in a Peruvian population (11) , but lower than that obtained among nurses who worked on the front line (25) , could be indicating that nursing professionals who work in direct Another predictor of fatalism reported in this study was concern about COVID-19. As no previous studies were found that evaluated this relationship specifically in this pandemic, this finding coincides with a survey carried out with Peruvian nurses that suggests that worry is a predictor of other psychological aspects such as anxiety (27) . In addition, another study was found that reported the correlation between worry and anxiety (14) .
Likewise, it would be in agreement with a research carried out with people with cancer, in which it was found that the environmental concern of individuals reflects cognitive rationality and reasonableness in opposition to the negative association between fatalism and concern (28) .
The average score for concern about COVID-19 obtained in this research is similar to the score reported by a study carried out in a Peruvian population carried out in March 2020 (14) , but slightly lower than that reported by another carried out with nurses, between April and July of the same year (27) . This shows that the result is consistent and confirms the findings of previous studies that used the same scale.
Finally, among the various variables analyzed in this investigation, the fact of having been diagnosed with COVID-19 was a predictor of fatalism in the two proposed models. Therefore, nurses who suffered from this disease had a higher fatalism score. As no studies were found that analyzed this association, it was not possible to compare this finding. However, when the results of the research were compared with studies carried out in the general population, having a history of cancer is a predictor of fatalism (29) .
The study reports that nurses have a moderate level of fatalism, a result that coincides with previous researches carried out in the general population (13) . This finding suggests the need for urgent implementation of measures to prevent and mitigate the psycho-emotional repercussions caused by the COVID-19 pandemic. Thus, everyday activities, contrary to a life project anchored in progress, appear tragic: they live between joy and pain, remembering that life is also a work of art, with all its ambiguity (24) . Thus, when everyday life hurts or is felt as anger, "only art has the power to transform what is horrible and absurd in existence and make life pleasant and possible" (30) .
The findings of this study highlight the need for authorities, health and nursing establishments to consider fear, worry and fatalism as occupational diseases, in order to implement strategies to promote mental health and prevent psycho-emotional problems.
We suggest the implementation of educational and psycho-emotional interventions to reduce fatalism -aimed at nursing professionals diagnosed with COVID-19 who present high levels of fear or concern about this disease -through communication strategies that promote followup, due to the fact that of "being-together", although it does not overcome death, at least it allows to relativize it and witness that life lasts (1) . Likewise, it is recommended to carry out research that assess the association of fatalism with other possible associated factors, such as spirituality, resilience and optimism, or its influence on the adoption of preventive and health promotion measures.
The preparation of health teams in the development of emotional coping skills both in the face of acute and chronic stress is very important, avoiding an undesirable impact on the mental health of the professionals.
Thus, reassessing art allows rescuing the artist that exists in every human being, in the nurse, because nursing is a profession, science and art, "the most beautiful of the arts" (31) , in its confrontation in the face of the tragic and fruitful of so many life lessons, considering that the end of a world is not the end of the world, because we can build other possible worlds in the daily work through and after the pandemic, towards a dignified and healthy life.
The study had some limitations. As nurses from different regions of Peru were included, data collection was performed using a virtual form. Therefore, the information should be considered as self-reported. No previous researches were found that evaluated the factors associated with fatalism in nurses in the local and international context. Thus, the results were compared with studies performed in the general population. Finally, the results can be affected by selection bias due to the type of sample chosen, which must be considered when interpreting the findings.

Conclusion
In conclusion, the study presents evidence that concern, fear and the fact of having been diagnosed with COVID-19 can predict fatalism in nursing professionals through a model that explains a third of the total variability.
Likewise, nurses had a moderate level of fatalism and a low level of fear and concern about COVID-19.
To reduce the fatalistic thinking of nursing professionals in the context of pandemics, it is suggested the implementation of interventions in the management of fear and concern that also strengthen individual and collective coping strategies. Thus, the fatal consequences of COVID-19 can be prevented and mental health promoted.