The Influence of the Factors of the Period and Place of Quarantine and Stigmatization on the Resilience of COVID-19 Survivors of Nurses

. As health workers, nurses at the forefront of the COVID-19 pandemic tend to be very prone to suffer both physical and mental health problems due to workloads and other factors during the Covid-19 pandemic.This study aimed to analyze the impact of factors such as length and place of quarantine and stigma on the resilience among COVID-19 survivors nurses. This research uses a quantitative descriptive technique and a cross-sectional approach. The google form questionnaire method is used as an instrument in data collection and processed utilizing multi regression analysis. The research output showed that 58.7% of nurses who survived COVID-19 had moderate resilience, 25.4% had high resilience, and 15.9% had low resilience. The long quarantine period results lead to an average of 85.7%, 11.1% for the long quarantine period, and 3.2% for the short quarantine period, with an influence value of 7.1%. The result of stigmatization leads to moderate 71.4%, high 15.9%, and 12.7% low with an influence value of 94.7%. By getting in multiple regression analysis p-values of 0.003 < 0.05, the F test value (5,120) > F tab (3.09) and it is summarized that place, the length of quarantine and stigmatization simultaneously influence the resilience of COVID-19 survivor nurses. It influences the value of the determinant coefficient (R2) of 20.7%, and the rest is influenced by factors outside the study, such as gender, age and academic degree. These findings suggest that stigma and place of quarantine factors are important predictors that affect mental toughness and quality of life to increase immunity for nurses themselves.


Introduction
COVID-19 has become a pandemic disaster with an alarming level of spread and severity. This has been determined by WHO since March 11, 2020, as a global pandemic. The facts emerged from the second wave of the spread of this pandemic with the very rapid spread of new confirmed cases outside China, namely in several countries in Europe such as North America, Asia, and the Middle East [1]. The case of COVID- 19 in Indonesia has been going on for several months since it was first announced on March 2, 2020. Until now, the spread of the virus, first described as spreading in Wuhan, China, has not shown any signs of stopping. Even in the last few days, the cases have soared. Until January 17, 2021, all provinces have reported cases. With the highest cases, DKI Jakarta, West Java, Central Java, East Java, South Sulawesi, East Kalimantan, Riau, West Sumatra, Banten, and Bali [2].
High transmission of biological hazards indicates the importance of an infection control effort by applying standard precautions. A high BOR value will increase the intensity of the nursing staff in providing nursing care. This has the potential to transmit biological hazards [3], especially among nurses. What Indonesia is currently facing is not only the trend of increasing the number of * Corresponding author: twinugroho@gmail.com cases both morbidity and mortality. There is still a stigma that arises from the community, both among patients and health workers, as well as psychological factors among health workers.
On January 4, 2021, the Indonesian Doctors Association announced that 504 health workers died amid the pandemic in Indonesia, consisting of 237 doctors (general and specialist) and 15 dentists, 171 nurses, 64 midwives, 7 pharmacists, 10 laboratory technical personnel [4]. Protection of health workers are urgently needed because the number of health workers exposed and dying increases [5]. Steps that can be applied are zoning health facilities, shift systems, and supply of personal protective equipment (PPE), supplements and vitamins. If there is no upstream intervention, it will continue to pose risks to health workers and affect the health services provided to patients.
Non-natural disasters caused by the spread of COVID-19 have an impact on increasing the number of victims, property losses, expanding the coverage area affected by the disaster, and having implications for broad socioeconomic aspects in Indonesia. Indonesia declared the COVID-19 case a non-natural national disaster on April 13, 2020. Through the COVID-19 Task Force, the Ministry of Health reported an increasing trend in the number of cases per day until this research was conducted [2]. The determination of the status of a national disaster certainly brings consequences on the responsibilities of the Central Government and Regional Governments. The center is responsible for, among other things, reducing disaster risk, protecting the community from the impact of disasters.
The existence of a group of individuals/community groups who provide stigmatization to health workers and COVID-19 patients creates a trend of increasing mortality and morbidity in COVID-19 cases. This is why patients and nurses as health workers at the forefront of the COVID-19 pandemic tend to be very prone to suffering from health problems both physically and mentally due to the stigma they receive. The emergence of social stigma will actually encourage someone to cover up the disease to avoid different treatment, prevent immediately seeking help, and prevent doing and adopting a healthy lifestyle. This condition will affect the handling of the prevention of the spread of the disease during the COVID-19 pandemic.
A nurse's endurance in facing the demands of her job and her responsibilities in caring for patients in the hospital is very necessary so that a nurse can balance the performance, daily problems, and workloads faced almost every day in her life. Endurance is meant by resilience. Resilience does not stand alone, its high and low is influenced by many factors. Therefore, the ability of resilience as a bulwark of self-defense to survive in the midst of the current global pandemic conditions needs to be improved.
Research on resilience in infectious patients was carried out. Nurses may face several other obstacles at work, especially those who handle infectious diseases. As happened at the Sulianti Saroso hospital, including Tuberculosis (TB) and Human Immunodeficiency Virus (HIV), nurses must deal with patients who do not want to receive a positive test result and keep their confidentiality/status even though they know the patient [6].
It is an irony that should receive special appreciation from the government. Because health workers such as doctors, midwives, nurses, and other hospital technical personnel have been willing to dedicate themselves to providing health services in the community and even sacrifice their life and body and put their relatives aside to help deal with the spread of COVID-19. Health personnel is a great job, and this work increasingly shows its actualization in the current COVID-19 pandemic disaster [5].
Nurses are health workers who play an important role when a disaster occurs because nurses work 24 hours to monitor developments and provide health care for COVID-19 patients. The community, government, and non-governmental organizations have realized the importance of preparedness of health workers, especially hospital nurses in dealing with disasters, maintaining patient health and safety, and providing comprehensive health services in carrying out their duties.
Resilience depends on adaptation efforts and is influenced by various factors, such as marital status, length of work, and others. Individuals with good resilience are more likely to adopt proactive ways of dealing with problems when faced with adversity. Therefore, resilience is an important skill that can help medical professionals adjust to and recover effectively from physical and psychological damage and quickly adapt to work. pressure-related [7].
In this case, the nurse may be exposed to psychosocial problems arising from the ambiguity of the current and future workplace conditions or the transitional process and work rules. Even more worrying, health workers still experience many triggers during this pandemic that can cause stress. Such as a fear of themselves or their families and work partners who may be infected with COVID-19, minimal personal protective equipment, lack of social support, the emergence of debate about the rules enforced and expectations of caring for or accommodating individuals, the inability in daily activities such as exercise, eating regularly and getting enough rest [8].
Health practitioners and patients who have recovered from COVID-19 will feel stigmatized and generally discriminated against [9]. According to Bagcchi [10], the stigma associated with COVID-19 poses direct risks to the lives of health care practitioners, patients, and those who have recovered from the virus. In May 2020, many health institutions advocated protecting patients infected with COVID-19 and healthcare practitioners with adequate facilities during the COVID-19 virus crisis.
Nurses in carrying out their responsibilities and duties require physical and psychological preparation. An unpleasant workplace coupled with patient behaviour will make nurses lose concentration. Something likely to cause stress and conflict in the nurse is a pressure that must be overcome immediately [10]. Unsupportive feelings, bad personal health conditions, worry about being a source of infection and spreading it to relatives or other people, feeling isolated, uncomfortable response, social labeling, overloaded work obligations, and feeling insecure and comfortable when providing care and health services to individuals exposed to COVID-19 are other risk factors identifiable [11].
A study explains that self-isolation and quarantine experienced by an individual will substantially change levels of anxiety, emotions, nervousness, and mental stress. On the other hand, people outside where individuals carry out quarantine/isolation will certainly experience fear and anxiety of being infected due to a lack of limited or inaccurate knowledge about COVID-19 [12]. Based on previous research, the pandemic condition caused by a viral infection with symptoms such as SARS is similar to the COVID-19 pandemic that is currently happening and has a serious psychological and mental impact on health workers and the general public, including anxiety, depression, and psychotic symptoms [13]. In order for this not to happen to nurses, the mental burden, psychological burden, and workload must be faced to work in totality and have good performance. For that, a nurse needs a strength that comes from within, called resilience [14].
The relatively high level of flexibility or acceptance of the situation in the resilience of Indonesians is related to aspects of religious and cultural identity. For this reason, it is necessary to look at resilience with a broader picture than the internal aspects of the individual, such as looking at the family and community aspects which will later be very closely related to the formation of individual resilience. Research that discusses patient characteristics associated with length of stay shows that patients with dengue fever have an average stay of three to fourteen days. Age specifications being young age where there is a relationship between age and length of stay in dengue fever patients. Thus there is a correlation between length of stay and the characteristics of people with dengue fever [15].
Based on the preliminary study of nurses who survived COVID-19, they preferred to be treated or quarantined other thin in the hospital. If they are treated in a hospital, it will give them feelings of anxiety, discomfort, and fear of aggravating their condition, which impacts their stress and will reduce their immunity while being treated/quarantined, which is feared to prolong the time of treatment. According to [10], anxiety is one of the factors that prolong the length of stay in the hospital. On the other hand, to prevent the transmission of COVID-19 from getting higher, especially with moderate to severe symptoms, the government appeals to COVID-19 patients to be treated at referral hospitals that the government has appointed. On the based one, this research aims to analyze the effect of place and duration of quarantine/isolation and stigmatization of covid-19 survivors on the resilience of nurses at the Military Hospital of Central Java Province, Indonesia, during the period December 2020 to March 10, 2021.

Samples
The research approach used is an associative quantitative approach. This study uses a proportional cluster random sampling technique to obtain research respondents based on the area of the Military Hospital of Magelang. This research has been approved by the head of Kesdam IV/Diponegoro with the number B/1930/IX/2021. For the population in this study, the inclusion criteria with a minimum working period of two years are inpatient nurses who treat COVID-19 patients at the Army Hospital Dr. Soedjono Magelang in Central Java Province. The exclusion criteria for this study were volunteers, a working period of fewer than two years, and outpatient nurses.
Based on data obtained from the hospital, it is knownthat the total population of COVID-19 inpatient nurses is 86. With a significant degree of 95% (or 5% error), then the sample size of the entire population is calculated using the Slovin formula [16], and the number of samples is 69 samples. The researcher used a google form questionnaire or a questionnaire instrument in this study. From the 69 questionnaires that were enlarged, 63 were returned.
The validity test in this study was conducted at an Army Wijaya Kusuma Hospital, Purwokerto, Central Java Province. The Cronbach alpha formula was used to test the reliability of this instrument in the form of a questionnaire. The questionnaire used a Likert scale for questions. The variables will be measured on the Likert scale then they will be translated into sub-variables and measurable indicators. The scale is based on positive and negative statements on the questionnaire, with options Strongly Disagree (1), Disagree (2), Disagree (3), Agree (4), and Strongly Agree (5) [16].
Based on the validity test, it can be seen as follows: 14 items of stigma variable statements are tested for validity, there are 3 items that are not valid, 14 items of statements on the quarantine place variable are nine that are declared invalid, 10 items of statements on the variable length of quarantine time there is 1 which is invalid and there are 25 items of resilience statement that are good which are invalid so that they are refused to be used in the questionnaire distributed to respondents.
Based on the value of Cronbach's alpha on the variables of stigma, quarantine place, length of time quarantine, and resilience are 0.765, 0.638, 0.710, and 0.618, where all of these numbers exceed 0.6. It means that the statement items on the instrument all variables are said to be reliable and reliable.

Statistical analysis
The analysis used in this study uses multiple regression analysis to analyze the variables, whereas the data analysis used SPSS assistance. This analysis was conducted to analyze the effect of 3 variables: the dependent variable (nurse survivor COVID-19 resilience) and the independent variable of social stigmatization and nurses' coping with stress. Descriptive analysis was an implementation for all variables. The Student's T-test performed comparisons for all items. For all tests, statistical significance was defined by a p ≤ 0.05. All data were analyzed using SPSS VERSION 20. Mean presented the values for measurements.

Results and Discussion
Data in Table 1 shows that the respondents' age distribution above is quite even. Aged 41-45 years are the respondents who have the most frequency, namely 20 In Table 2, paying attention to the score categorization table, the result of the analysis shows that the category of the subject score for stigmatization leads to the mediumhigh category. It can be seen that 10% of the subject's scores are in the low stigma category, 71.4% in the medium category and 12.7% are in the high category. Meanwhile, the resilience categorization results show the medium-high category. It can be seen that 58.7% of nurses who survived COVID-19 had moderate resilience, 25.4% had high resilience and 15.9% had low resilience.These results show that the stigmatization received on the leadership resilience of COVID-19 survivor nurses has moderate variations. Table 3, the analysis shows that the quarantine period's length leads to a moderate 85.7% and 11.1% of the long quarantine period and 3.2% of the short quarantine period.

Based on
The description of Table 4 can be explained as follows: a. The constant value of 14,997 means that if there are no variables for the length of quarantine time, stigma, and place of quarantine or the three independent variables are worth 0, then the variable value of the resilience of the COVID-19 nurse survivors at RS dr. Soedjono in Central Java will remain constant at the position of the value of 14,997.
b. The regression coefficient for the length of quarantine time is -0.78, indicating that every decrease in the variable length of quarantine time (X1) in one unit will also increase the variable value of COVID-19 survivor nurses' resilience at the dr. Soedjono (Y). It can be seen that the coefficient obtained is negative, so if there is a decrease in the length of quarantine time, the resilience of survivor nurses will decrease by 7.8% and vice versa.
c. The social stigma regression coefficient is -0.947. This regression coefficient indicates that if there is an increase of 1 point in the social stigma variable and other variables are considered constant, there will be a decrease in the resilience variable of health workers at TNI Hospital Central Java (Y) by -0.947. It can be seen that the coefficient obtained is negative, so if there is a decrease in social stigma -0.947, the resilience of COVID-19 survivor nurses will increase by 94.7% and vice versa.
d. The regression coefficient for quarantine is 0.557, indicating that every increase in the quarantine variable (X3) in one unit, will also increase the resilience of health workers at the TNI Hospital in Central Java (Y) by 0.547 or 54.7%. It can be seen that the coefficient obtained is positive, so if there is an increase in social support, the resilience of health workers will increase and vice versa.
Data in Table 4 shows the significance value obtained is 0.021 < 0.05, with the hypothesis (H0), is rejected and hypothesis alternative (Ha) is accepted. This shows that stigmatization affects resilience and the emergence of positive stigmatization will increase the resilience of COVID-19 survivor nurses. Likewise, based on the significant value at the quarantine place where the value obtained is 0.006 < a0.05, it shows that the quarantine place positively affects resilience. The quarantine place will provide comfort for COVID-19 survivor nurses to reduce stressors due to exposure to COVID-19 and increase immunity.
According to the F test was carried out simultaneously (Table 5), the results obtained were that there was a significant influence simultaneously between the quarantine place and the length of the quarantine. Length of quarantine period, stigmatization, place quarantine of   COVID-19 nurses survivors. This is indicated by obtaining a significance value (0.003) smaller than a (0.05) and the F test value (5,120) > F tab (3.09), Based on Table 6 above, the R Square value of 0.207 means that the variables of quarantine length period, stigmatization, and place quarantine simultaneously influence 20.7% of the resilience of survivor nurses COVID-19. Other factors influence the remaining 79.32%. These factors include age, gender, and level of education. By the researcher these factors are not the focus of this study.
The results of this study illustrate that there is no effect on the length of time of quarantine/isolation among COVID-19 survivors in Central Java with resilience. The absence of the influence of the length of the quarantine period with resilience may be because nurses sometimes work more than 12 hours and have to provide good service to patients and their families. This condition causes nurses to be accustomed to adapting to the demands of a lot of work and with a high enough level of stressors. Therefore, resilience is defined as the ability of individuals to choose to recover from sad and challenging life events by increasing their knowledge to be adaptive and cope with situations also similar disadvantages in the future [17].
Another study shows that the quarantine site has a positive contribution to the length of the quarantine period. This could be due to compliance with the Ministry of Health regulations that individuals exposed to COVID-19 with no signs or with signs of a mild illness can selfisolate without being treated with strict health protocols. Individuals will feel comfortable if they are in a comfortable and supportive environment for the healing process [18]. However, statements based on this research cannot be used as a foothold related to the length of treatment in the COVID-19 case [19].
Negative and significant social stigmatization means that nurses with high negative social stigmatization will have low resilience in handling COVID-19. Conversely, if the nurse has a low negative social stigmatization, it will increase the resilience of the nurse itself. This finding strengthens the research [20], which found that the emergence of an understanding of social stigma with a feeling of well-being psychologically has a negative and significant impact, but social support has a positive effect on psychological well-being. The acceptance of social stigma and social support simultaneously affects the feeling of well-being psychologically by 42.5%, and other aspects influence the rest. This shows that the increase in negative social stigmatization will significantly reduce the level of nurse resilience, and vice versa, the decrease in negative social stigmatization will significantly increase the resilience of nurses.
This individual's ability to cope with stigma is shown by the ability to control emotions. Be calm and apathetic to negative comments, try to stay good with bad people, admonish and greet, develop self-confidence and think optimistically and positively. Become positive role models for families and the environment, believe in their abilities, take an active role in social activities, and seek to act as addiction counselors, social activists, or entrepreneurs. The research results are in line with Fatin [15], that an addict who recovered from drug dependence has a good resilience capacity, which reflected in seven aspects, namely emotional regulation, optimism, attitudes, ability to control impulses, ability to learn the main problem, empathize, have self-efficacy and selfempowerment efforts.
Apart from the toughness above, another resilience was also found in honesty, gratitude, and the ability to effectively use sources of assistance. This is in line with a study that explains that self-isolation and quarantine experienced by an individual will result in substantial changes in the level of anxiety, emotions, nervousness, and mental stress [12]. Resilience cannot walk alone. This must be balanced with the existence of self-efficacy, selfesteem, religious factors, and self-confidence to grow the individual's resilience.
Although infectious diseases profoundly impact people's mental health and emotional responses, not everyone will experience the same degree of impact. Based on a recent systematic review of the impact of disasters on the mental health of health workers, common risk factors identified for developing psychological disorders include a lack of social and communication support, maladaptive coping, and a lack of training. In addition to the impact of COVID-19 on people's emotions and coping strategies, society will also change [21].
The strength of this study is that it may be the first time this research has been conducted in a field dealing with the duration and location of the pandemic and the stigma associated with COVID-19. So that this research can be used as a basis for conducting other research on the same topic, but with different methods and different variables. This research is also carried out to see the performance of nurses in terms of their resilience to face health disasters in the future. In addition, because the respondents of this study were nurses, we hoped that the results of this study could be used as a basis for research by other health workers. The weaknesses of this study were that the researcher did not include confounding factors such as age, gender, or educational background, so it was not clear which resilience was higher in survivor nurses. There are still some nurses who do not provide feedback on the questionnaires that have been distributed. The data were taken in this study only came from survivor nurses, so researchers could not measure the resilience of health workers.

Conclusion
Based on the results and discussion of this study, it can be concluded that the length of quarantine time with a sig value of 0.071 does not affect the resilience of survivor nurses at dr. Soedjono Magelang. However, with a sig value of 0.021, the decrease in the stigma on nurses significantly affects their resilience by 94.7%. The increased resilience of COVID-19 survivor nurses is also supported by the quarantine they feel apart from in the hospital to give them a sense of comfort, security, and closeness to their families, followed by the implementation of a fairly strict policy health protocols. This quarantine place contributed 55.7% to the increase in the resilience of the survivor nurses.
Nursing is a profession that treats potentially highly contagious patients, causing considerable stigmatization, especially in Indonesia. It is important to study the factors associated with resilience and stigma to provide preventive measures for health workers during a pandemic. Nurses are at the forefront of health care. They serve patients 24 hours a day, so they are prone to burnout, resulting in decreased resilience during the pandemic.
This study is very important because it is one of the few studies investigating the length and place of quarantine and the effect of stigmatization on resilience in health workers who survived COVID-19 during the COVID-19 pandemic. Although, in theory, a quarantine duration longer than 10 days is associated with increased mental disorders, especially Post-Traumatic Stress Disorder (PTSD) symptoms, avoidance behavior, and anger, in this study, no effect of quarantine duration was found on the resilience of nurses who survived COVID- 19.
Researchers assume that the factors of working experience in hospitals and coping with stress are god for them., They assume that staying in the hospital is something normal even though they are in a state of exposure to COVID-19. This finding shows that stigma and quarantine factors are important predictors that affect mental toughness and quality of life to increase immunity for nurses themselves.
Thank you to the Head of the Hospital who has been allowed to carry out research and fellow nurses who are willing to spend time during their busy lives in the room.