IMPACT OF QUALITY OF WORK LIFE, PERCEIVED SOCIAL SUPPORT, AND APPLICATION OF 5S METHODOLOGY ON PSYCHOLOGICAL DISTRESS AMONG NURSES IN THE HEALTH CARE SECTOR DURING COVID-19

This research is about the Psychological Distress of nurses during the time of covid-19. The variables used to conduct this research were Perceived Social Support, 5 S Methodology, and Quality of Work Life on Psychological Distress of nurses in the nursing schools and hospitals of Karachi. The method used to collect data was survey questionnaires online and via hardcopy and the instruments used to test these variables were reliability, regression, and correlation through the SPSS software. The results indicated that the independent variables have no significant effect on the dependent variable and the model was weak. The results suggest that Psychological distress has a negative effect on independent variables during covid-19. The research literature suggested a positive effect of these variables on the Psychological distress of nurses but that was in a normalized situation. The limitations of this research suggest that a longer time frame should be used to conduct this research with a pre-notice to the institutions from where data has to be collected for a better way of collecting data.


Introduction
The health crisis caused by covid 19 is the biggest challenge faced by the world after the World War 2. The most vulnerable group that faces this contagious disease are the front-line health workers (doctors and nurses). These front-line health workers play a vital role in fighting against this disease and help the infected people with a set of pre-defined SOPs (Laura Lorente, 2020). These health care workers are a major resource for any country they provide continues care and assistance to all patients and control the spread of this disease. During the pandemic almost every health care worker majorly nurses have been facing extreme stress and depression. Nurses are facing psychological distress on daily basis which is leading to suffering physically and causing major psychological damage (Dehkordi, 2020).The working conditions for the front-line health workers have been harsh where the workers are working day and night, taking care of patients and also taking care of their own health for their family. This work load has put the workers under a huge amount of physical and psychological stress, for full filling their duties and putting their life at risk as well (Catton, 2020).
Quality work load was a theory developed in 1970. It mainly states the environment workers get within the organization so that the tasks are performed effectively and efficiently. The main objective is the employee betting a suitable better lifestyle within the work space so that they can be more productive and efficient. The workers are under fear of getting infected which in turn is a risk towards their families. Many Nurses were reluctant to perform their duties and were filing for resignations due to high level of work stress, anxiety and depression (Laura Lorente, 2020) (Ali Hasanpour Dehkordi, 2020). Studies show that the working environment and work load has had a major impact on personal health of the frontline workers which in turn increases the psychological distress among the working staff, leading to inefficiency to carry on their tasks (Mohammadi-Bolbanabad, 2016). Nurses during the early stages of covid 19 had faced a huge amount of psychological distress and anxiety not only because of high work load but also because of lack of proper medical equipment, and knowledge of the fast-spreading virus and direct contact with the patients (Zhang, 2020) (Catton, 2020). Due to work stress, there have been suicidal cases reported in NYC of frontline health workers (A. Shechter, 2020). This shows that these health care workers have less or no social support that they can trust. This further lead to lack of job satisfaction.
5S dates back to work war 2 after which japan was struck majorly into a financial crisis. The concept actually started in Toyota motors by their owner Toyoda who was looking over to get their company operating on lean operations with less time consumed. And providing the premium quality of products. The 5S consist of Seiri = Sort, Seiton = Straighten, Seiso = Shine, Seiketsu = Standardize, Shitsuke = Sustain. All were mainly to smooth down the workflow. These implementations were made successfully in the company making it a loading automotive company in the globe (Scheid, 2010) (Dehkordi, 2020). Today 5S is being implemented in the service sector as well, specifically the health care sector benefits from this technique extensively.
Psychological Distress is mainly a term derived from the work load and pressure a person feels being over burden with their duties. This causes in efficiency and lack of motivation is the workspace. And people are readily willing to leave the work. Or move away from it.
The uncertain environment among the effected cities having patients of Covid 19 increased the workload and stress amongst the nurses to fight back the Covid 19. (Zhang, 2020). Thus, the nurses were working day and night taking care of the patients while also taking care of themselves, as they had to return back to their families and were much worries about them as well.

Rationale of the study
High stress levels: Nurses in the healthcare sector experience high levels of stress and burnout, especially during the COVID-19 pandemic, and studying the impact of QWL, perceived social support, and 5S methodology can help address this issue.
Improved well-being: Understanding the impact of these factors on psychological distress can inform interventions to improve the well-being of nurses and reduce stress levels. ISSN (Print): 2790-7848, ISSN (Online): 2790-7856 Volume 2, Issue 1, Page 41-56, June 30, 2022 Better care: When nurses are under high levels of stress, it can affect the quality of care they provide. Improving their well-being through QWL, perceived social support, and 5S methodology can lead to better patient outcomes.
Better workplace culture: Studying the impact of these factors can also help create a better workplace culture in the healthcare sector, where the well-being of nurses is prioritized.
Future pandemics: The findings from this study can inform how to better support and protect the well-being of nurses during future pandemics or crises.

Problem Statement
The research being conducted is on the impact of QWL, PSS and 5S Methodology on Psychological distress among nurses determining the importance of these variables. In literature it was discovered that nurses face psychological distress and although researchers have conducted studies on the factors that cause stress among nurses, this research determines the effects of QWL, PSS and 5S on the psychological distress among nurses within Pakistan, to find out the psychological distress among nurses in Pakistan.

Research Objectives
• To find out the impact of Quality of Work life on psychological distress among nurses.
• The impact of Perceived Social Support on Psychological distress among nurses.
• The effect of 5S Methodology on Psychological distress among nurses.

Research Questions
1. What is the impact of QWL on Psychological distress among nurses in the healthcare sector during covid-19?
2. What is the impact of PSS on Psychological distress among nurses in the healthcare sector during covid-19?
3. To what extent the application of 5S methodology effect upon Psychological distress among nurses in the healthcare sector during covid-19?

Significance of the study
The research is to be conducted on nurses who are currently being trained and also that are working in tertiary hospitals in Karachi. The variables involved are QWL, PSS, 5S and Psychological distress amongst the nurses, this will help understand if these three variables can be a reason to reduce Psychological distress among nurses. This will further assist the research on how these variables have affected the psychological distress amongst the nurses and how it can be further reduced down. The 44 Impact of Quality of Work Life, Perceived Social Support, and Application of 5s Methodology on Psychological Distress among Nurses in the Health Care Sector during  results of this research will assist the hospitals to implement effective measure to reduce down the psychological distress and increase job satisfaction while having healthy work environment.

Limitations of the study
The limitations of this study are mainly to the Covid-19 pandemic. First the nurses have high workload and lack time to fill the survey questionnaires (Laura Lorente, 2020). Second the responses were gained only from the hospitals and nursing schools specifically from Karachi so this causes a geographical constrain. The research is conducted within one city to make the research better hospitals and nursing schools in other cities should be surveyed. Lastly there should be open-ended questions asked or nurses should be interviewed to get a better view of the effect of Covid-19 on nurses (Zhang, 2020).

Psychological Distress
Psychological Distress is a state of emotional misery that is caused by demand and stressors that are difficult to cope up with daily. Fatigue, exhaustion, restlessness, irritability, weight and appetite changes are signs of Psychological distress. Psychological Distress was associated with having neurotic personality and difficulties to adjusting in different areas of work (L. Warbah, 2006). Studies show that students in general have reported that psychological distress influences the academic performance and adjustments (Papazisis G, 2008). A study by (Papazisis G, 2008) suggests that there is a strong and positive correlation between depression and Psychological Distress. It has been studied that nursing workers undergo more psychological distress then general population (Bruno Del Sarto Azevedo, 2017). Psychological Distress is strongly related to reduction of quality and duration of life, and increased use of health services. Psychological security is considered to be a mix of positive affective conditions and effective functioning (Beatrice I.J.M., 2017). It is studied that female nurses experience more psychological distress than male nurses (Beatrice I.J.M., 2017). Today health care workers are facing greater Psychological Distress due to the Covid-19 pandemic on a personal and professional level (A. Shechter, 2020). It was noted that psychological distress may disturb the body's stress response system, thereby making it a contribution to health risk (A. Shechter, 2020).

Quality of Work Life
Quality of work life describes a person's experience related to their employment, it is how favorable or unfavorable the environment is for the workers. It is suggested that companies that have better quality of work life environment hire and retain valuable employees (Tung-Chun Huang, 2007). The Quality of Work Life helps employees to work efficiently and actively. The goal for QWL is to achieve organization effectiveness and to improve quality of life at work for employees (Mohammed J Almalk, 2012). QWL covers all aspects of work including rewards, benefits, security, work conditions, organizational and social relationships and its essential meaning in a person's life (P). (Mohammed J Almalk, 2012) identifies that a major dissatisfaction in QWL regarding work life balance, majority identified work overload, lack of family time and lack of energy after work, this study concluded that nurses were not satisfied with QWL and planned modifications were needed to be made and that nurses should assist the development of new QWL strategies. It is suggested that health care managers should consider improving QWL to retain workforce for long term (Mohammed J Almalk, 2012). QWL not only effects staff performance but also predicts quality of organization service (Mohammed J Almalk, 2012). It was noted that QWL of physicians is higher than that of non-physicians (nurses and other front line health workers) (Mohammadi-Bolbanabad, 2016). QWL not only focuses on the work life but non-work life as well (Bruno Del Sarto Azevedo, 2017). Literature identified that in the situation of Covid-19 the physical and psychological damage of health care workers increased, this led to a decrease in QWL of workers, it is important for health care institutions to improving the QWL of nurses and physicians to maintain a stable health care system (Ali Hasanpour Dehkordi, 2020).

Perceived Social Support
Perceived Social Support is an acceptable support from individual or group that helps reduce stress level (Flora R, 2017). (Flora R, 2017) Also states that theorists of social support believe that relationships that are suitable and meet needs of the person are considered a support, this research also showed a positive relationship between PSS and quality of life. From the same research we identified that Perceived Social Support related to quality of life and stress tolerance. Studies show that nursing students' social support systems and personal relationships are important for their academic success and constructive mental health (Adeviye AYDIN, 2017). Nursing students are a part of university students and it has been found that students with high level of PSS have higher life satisfaction and lower misery and isolation (Adeviye AYDIN, 2017). (Adeviye AYDIN, 2017) concludes that PSS and psychological wellbeing for senior year students were better and as PSS level in nursing students increases their psychological well-being increases, with this we can hypothesize that as PSS increases PD decreases. Perceived Social Support is a perception of gaining emotional support from family, friends and peers. This PSS helps protect a person from threats against their mental and physical health, which further helps reduce the negative effects of stressful events in life (Emine Öksüz, 2018). Also advocating social support within the institutions is required to strengthen the ability for coping with sources of stress (Liat Hamama, 2019).

5S Technique
The 5 S is a total quality management tool to reduce unnecessary waste and organize things logically. In Japanese the 5 S terms are seiri, seiton, seisō, seiketsu, and shitsuke, in English they are translated to sort, set, shine, standardize and sustain. Originally this technique was formed in 1980's by Takashi Osada to maintain quality in the organization. With the implementation of 5 S the working environment becomes safe, sustained and cost and defects are reduced (Young, 2014). 5 S technique being applied in health care can be beneficial to help increase productivity and cut down cost by making the work place organized and efficient, this will also lead to safety and sustainability and reduce supply chain cost (Young, 2014). 5 S in the health care can 46 Impact of Quality of Work Life, Perceived Social Support, and Application of 5s Methodology on Psychological Distress among Nurses in the Health Care Sector during  also lead to quality assurance standards such as IOS and ensure a safe working environment (Hisahiro Ishijima, 2015). 5S can be applied in any health care organization irrespective of where it is located, it would not only help health care workers but also the policymakers improve safety, efficiency and readiness for patient care (Shogo K, 2016). Not too long back healthcare professionals saw the 5S technique as a way to improve the quality of service of poor government health care institutions of low-and middle-income countries (Shogo K, 2016). Health care facilities reported a better drug dispersing cycle time, improvement in process flow, increased capacity and shortened patient stay (Shogo K, 2016).

Hypotheses Development
Ho1: There is no impact of QWL on Psychological distress among nurses in the healthcare sector during covid-19.
H1: There is impact of QWL on Psychological distress among nurses in the healthcare sector during covid-19.
Ho2: There is no impact of PSS on Psychological distress among nurses in the healthcare sector during covid-19.
H2: There is impact of PSS on Psychological distress among nurses in the healthcare sector during covid-19.
Ho3: There is no effect of 5S methodology on Psychological Distress among nurses in the healthcare sector during covid-19.

Design of the study
This research aims at how the quality of work life, perceived social support, and the use of the 5S technique relate to psychological distress among nurses working in the healthcare sector in CVID-19. The research focuses on numbers. The primary data sources for this study were questionnaires and a literature review. The study's focus was on Pakistan's nursing students and front-line medical staff. Due to geographic limitations, we could only target businesses located in Karachi. A google form was made to easily disseminate to respondents and get responses. Three Likert scales-a 4-point, a 5-point, and a 7-point scale-were utilised to compile responses to the 28 items given. There was a total of 28 questions, including 8 for the PD, 6 for the QWL, 5 for the 5S approach, and 9 for the PSS. The application used to test the hypothesis was SPSS. To get a conclusion, the validity of the data was examined using descriptive analysis, reliability, correlation, and regression tests.

Research Design
The nature of this study is quantitative and descriptive. Finding out how the independent and dependent variables interact is the study's goal. This study attempts to find out the effect of Quality of Work Life (QWL), Perceived Social Support (PSS), And Application Of 5s Methodology (5S) on Psychological Distress (PD) of frontline health workers during Covid-19. The study's target audience consists of Karachi's nurses and nursing students. Non-probable purposive sampling will be used in this study since we will choose the survey respondents from the study's intended audience. A quantitative investigation was conducted. In order to examine the effects of Quality of Work Life, Perceived Social Support, and the use of the 5S Methodology on Psychological Distress among nurses working in the healthcare sector, quantitative data was collected during COVID-19. This study's questionnaire, which was adapted from earlier studies, was used to obtain data on psychological distress, work-life balance, social support perception, and 5S implementation. Data were gathered and reviewed in order to determine whether the hypothesis was valid. Because the data was only gathered once, the study was cross-sectional. The four months that the study was conducted. Data from a survey was acquired in less than two weeks using both online and paper questionnaires. The sample, comprised of 164 survey forms, was compiled.

Instrument / measure design
The scales used in this study's independent and dependent variables were derived from earlier work. The questionnaires included a 4-point Likert scale for PD, a 5-point Likert scale for QWL, a 7-point Likert scale for PSS (Zimet, 1988), and a 5point Likert scale for 5S (Hisahiro Ishijima, 2015). (Lovibond). Participants completed the survey using Google forms. The covid-19 epidemic was the driving force behind the online data collecting. 48 Impact of Quality of Work Life, Perceived Social Support, and Application of 5s Methodology on Psychological Distress among Nurses in the Health Care Sector during Covid-19

Instrument
The survey questions from earlier studies that focused on each variable separately were used to gather data for the independent and dependent variables. The questionnaire featured a 4-point Likert scale with the options "Did not apply to me at all" to "Applied to me very much, or most of the time," a 5-point Likert scale with the options "Always to Never/Almost," a 7-point Likert scale, and expressions like "Strongly Disagree" and "Strongly Agree" (labeled as Very Strongly Disagree to Very Strongly Agree). The tool used to analyse the data was SPSS, and the tests run on the data included descriptive statistics, reliability, correlation, and regression.
The Likert scale is a measurement tool used to quantify attitudes, opinions, and perceptions. It was developed by psychologist Rensis Likert in 1932. The scale is named after him.
There are several types of Likert scales, including: 1. A 5-point Likert scale, which has five response options, such as "strongly agree," "agree," "neutral," "disagree," and "strongly disagree." 2. A 7-point Likert scale, which has seven response options, such as "strongly agree," "moderately agree," "slightly agree," "neutral," "slightly disagree," "moderately disagree," and "strongly disagree." 3. A 4-point Likert scale, which has four response options, such as "strongly agree," "agree," "disagree," and "strongly disagree." 4. A semantic differential scale, which uses bipolar adjectives to measure attitudes and perceptions, such as "good-bad" or "pleasant-unpleasant." Regardless of the number of response options, the Likert scale is used to measure the strength and direction of an individual's agreement or disagreement with a particular statement or question. The results of a Likert scale survey can provide valuable insights into people's attitudes and perceptions, and they are commonly used in social science research, market research, and customer satisfaction surveys (Fowler, 2013).

Organization/situation/respondent profile
The organizations targeted in this research were the hospitals and nursing schools of Karachi. These hospitals and schools were chosen to easily gain data from the potential sample for this research. The population aimed to attain data were the nurses that worked and studied in these institutions. Majority of the respondents were working students' others were either students or full-time nurses. The results of the research show that there were more female nurses that filled the survey questionnaires than the males and majority of the respondents belonged to a nuclear family system and the statistics show that there were more middle children becoming nurses than first born, last born or single child. ISSN  The Table 1 shows that the sample include 41.5% males and 58.5% females, with a total of 100% of the individuals accounted for. The Table 2 shows that sample includes 53.0% of individuals who live in nuclear families and 47.0% of individuals who live in joint families, with a total of 100.0% of the individuals accounted for. The Table 3 shows that the sample includes 26.2% of individuals who are first born, 45.7% of individuals who are middle born, 15.9% of individuals who are last born, and 12.2% of individuals who are only children, with a total of 100.0% of the individuals accounted for. The correlation between dependent variable Psychological Distress and independent variable Quality of Work Life is weak and negative as Pearson Correlation is -0.166 this shows an inverse effect and there is a significant relationship between the two variables as the level of significance is below 0.05 hence we will reject the null hypothesis and state that there is a weak but significant correlation.

Reliability Analysis
Looking at the significance value between Psychological Distress and Perceived Social Support we will accept the null hypothesis as the value of significance is greater than 0.05 and the Pearson Correlation determines that there is a weak relationship between the variables.
The correlation of Psychological Distress and 5 S Methodology is less than 0.05 hence we reject the null hypothesis and looking at the Pearson Correlation it can be stated that the relationship between the two variables is significant but weak. The R Square represents the change that occurs in the dependent variable due to the independent variables and the strength of the independent variables on the dependent variable. The R Square is 0.196 this means the model is very weak. ISSN (Print): 2790-7848, ISSN (Online): 2790-7856 Volume 2, Issue 1, Page 41-56, June 30, 2022 Analysis of Variance Analysis (ANOVA) The value of significance is 0.000 less than 0.05 this shows that the level of significance is high, and we will reject H0 and accept HA. This means the model is fit and the independent variables influence dependent variables. Since the beta of PSS and SM are positive we conclude that they have a positive effect on PD whereas QWL has a negative effect on PD. PD = 0.543(SM) + 1.442

Data analysis
From the results it is gathered that the variables are highly reliable and the variables are strong. As the results move ahead it is analyzed that there is a high significance between Psychological Distress, Quality of Work Life and 5 S Methodology but there is no significance with Perceived Social Support and the Pearson Correlation for all variables shows a weak relationship. The correlation results for Quality of Work Life indicate a negative correlation between the two variables concluding that if QWL increases the PD will decrease.
The results from the regression tables show that the model is weak and independent variables have less effect on dependent variables. The level of significance is high hence the alte rnative hypothesis will be accepted, by analyzing the regression equation it is concluded that QWL has a better effect of decreasing Psychological distress than the other two variables. 52 Impact of Quality of Work Life, Perceived Social Support, and Application of 5s Methodology on Psychological Distress among Nurses in the Health Care Sector during Covid-19

Hypotheses Assessment Summary
Ho1: There is no impact of QWL on Psychological distress among nurses in the healthcare sector during covid-19.
Looking at the results of the regression the significance value is greater than 0.05 showing that there is insignificant relationship between QWL and psychological distress, therefore we accept the null hypothesis and reject alternative hypothesis showing that there is no impact of QWL on Psychological distress among nurses in the healthcare sector during Covid-19.
Ho2: There is no impact of PSS on Psychological distress among nurses in the healthcare sector during Covid-19.
The result of coefficient analysis shows that the relationship between PSS and Psychological distress is insignificant as the significance value is greater than 0.05. Therefore, we accept the null hypothesis and reject alternative hypothesis, showing that there is no impact of PSS on Psychological distress among nurses in the healthcare sector during covid-19.
Ho3: There is no effect of 5S methodology on Psychological Distress among nurses in the healthcare sector during covid-19.
As per the result of coefficient analysis, we will reject the null hypothesis as the significance value is less than 0.05 and accept the alternative hypothesis which shows that there is an impact of 5S methodology on Psychological Distress among nurses in the healthcare sector during Covid-19.

Discussions
This research was conducted to find out the Psychological Distress of nurses during covid-19. Through this research the effects of Quality of Work Life, Perceived Social Support and 5 S Methodology were tested on the Psychological Distress of nurses to determine how these factors affect nurses and if there is a positive effect of the independent variables on the dependent variable and how these variables have an effect. The results show that the independent variables have no significant effect on Psychological Distress except for 5 S Methodology, through this it was discovered that bringing in new techniques can cause there to be distress among nurses. The reliability of all the variables was strong that showed that the results were accurate and can be used for further continuing this research. The correlation indicates weak but significant correlation between variables whereas regression shows a weak model and high significance of variable 5 S Methodology. The 5 S Methodology is a set of quality techniques to make the work environment better and efficient. During the pandemic the quality of work environment had to be compromised to help the patients so the result driven from regression is accurate that if new methods are applied during this time there is bound to be Psychological Distress. It was observed in the institutions that there were numerous patients coming in and going out and there was no time for nurses to take rest causing load and stress so in this condition bringing in new methods would cause more stress in this panic situation. ISSN (Print): 2790-7848, ISSN (Online): 2790-7856 Volume 2, Issue 1, Page 41-56, June 30, 2022

Conclusions
The conclusion of this research is that due to the pandemic there is less or no motivation among nurses. The results of our research indicate that there is no significant effect of PSS, 5 S or QWL on the PD of nurses the significance level is high, because of this pandemic nurses have no time to adopt to new work techniques or spend time with family this shows that the nurses have no effect of these factors and other variables should be used to determine the effect on PD on nurses during this pandemic. there is a negative effect of 5 S on PD of nurses indicating that as the 5 S techniques increases the PD of nurses also increases. The reason behind this result is that during this time with workload and stress on nurses is very high and bringing in new methods and techniques can cause their stress level to increase, there will also be a resistance in adopting the methods that the management brings in due to the level of difficulty of the work environment. Other than that to be quick in working in decision making during this pandemic it is difficult to follow regular SOP's and wait for the process to occur and to save lives every process has to become quick hence bringing in new methods by 5 S Methodology to make the environment better will have a negative effect on the Psychological Distress of nurses.

Recommendations
It is recommended that future researchers use different variables to test for Psychological Distress on nurses. The geographical region can be expanded by surveying more nursing schools within Pakistan. Other than that, there can be more time associated with future research with descriptive questions. The number of questions in the questionnaire can decrease and the survey can be made interactive through conducting interviews and studying the environment nurses study and work in. Other than that, institutes can be contacted before the survey is conducted to help coordination between researcher and institutions to achieve maximum responses.