Work environment factors correlated to physical and psychological health risk of nurses following the first two surges of COVID-19

The COVID-19 pandemic imposed tremendous strain on the U.S. healthcare system and consensus exists that nurses have experienced alarming rates of burnout, depression and anxiety [1]. Stress, a precursor to burnout, may be exacerbated by specific work environment or home characteristics [2], and pre-existing chronic health conditions. However, it remains unclear which personal or work environment factors are significantly associated with increased risk for burnout and poor psychological health in nurses. Further, there is limited evidence about the impact of COVID-19 on a nurse's personal health risk, including attention to pre-existing chronic condition and the ability to self-manage personal physical health needs.

We obtained ethical approval from the institutional review boards at the researcher's primary organization and all study sites. We distributed an electronic cross-sectional survey to registered nurses (RNs) working across three hospitals in the New York City area from September–December 2020. The survey consisted of validated items and instruments to measure personal demographics (e.g., age, race, gender); work environment characteristics (e.g., years in primary position; years' experience); work stress (Work Stress Questionnaire [3]); somatic physical health symptoms [Patient Health Questionnaire (PHQ-15) [4]]; burnout [5]; job satisfaction; depression (Patient Health Questionnaire-2 [6]); anxiety (Generalized Anxiety Disorder-2 [7]); and resilience (Brief Resilience Scale [8]).

The final sample included 553 nurses (35% response rate). On average, the sample was over 40 years old with majority self-identifing as female (88.6%), White (56.3%), and having a bachelor's degree (72.1%). More than half (54%) reported burnout symptoms and 32% had intentions to leave their job within 1 year. (See Table 1 ). The mean scores for PHQ-2 were 3.7 and GAD-2 was 4.35, indicating positive screening for depression and anxiety. RNs who reported no workplace conflicts reported lower depression (PHQ2) scores (β =  − 0.56, p = 0.0426).Personal involvement in conflicts was a predictor for anxiety. RNs whose supervisors did not address conflicts had lower resilience scores (β =  − 0.17, p = 0.0058). There was a significant association between clear workplace goals and job satisfaction. Older RNs reported lower odds of burnout (OR:0.97, p = .0222), depression scores (β =  − 0.03, p < 0.0048), and anxiety scores (β =  − 0.04, p < 0.0049). In contrast, years of experience was only significantly associated with resilience scores. RNs who reported having over a decade of experience had higher resilience scores compared to those who had three years or fewer (β = 0.22, p < 0.0051). Of the RNs reporting a pre-existing chronic condition, 23% endorsed missing their own medications while working during the pandemic. Respondents who had little workplace stressors reported significantly fewer symptoms of poor somatic physical health symptoms. Those who reported no “trouble sleeping due to thinking about work” reported significantly fewer symptoms of poor somatic physical health symptoms (β =  − 4.64, p < 0.001). Finally, it appears that nurses working in intensive care units, compared to other clinical settings, had significantly higher scores for resilience (p = .011) and depression (p < .001), but not anxiety (p = .60) and burnout (p = .19).

Table 1.

Factors correlated to psychological health outcomes in nurses working during the COVID-19 pandemic.

	Depression	Anxiety	Burnout	Job dissatisfaction	Plan to leave job
Increased Workload	0.783	0.477	<0.001**	<0.001**	0.05*
Unclear workplace goals	<0.001**	<0.001**	<0.001**	<0.001**	0.003*
Unclear work assignments	<0.001**	<0.001**	0.08	<0.001**	0.002*
Conflicts at Works	0.043*	<0.001**	<0.001**	<0.001**	0.025*
Lack of Leadership Support	0.09	0.01*	<0.001**	<0.001**	0.19
Difficulty setting limits to work assignments	<0.001**	<0.001**	<0.0001**	0.095	0.037*
Working after-hours to finish assignments	0.13	0.12	0.72	0.47	0.11
Difficulty Sleeping	<0.001**	<0.001**	<0.001**	<0.001**	<0.001**
	Non-ICU Nurses	ICU Nurses	p
Resilience (BRS mean)	2.95	3.11	0.011*
PHQ-15	8.22	10.35	0.019*
Depression (PHQ-2 mean)	1.55	2.33	0.005*
Anxiety (GAD-2 mean)	2.34	2.50	0.608
	N(%)	N(%)
Burnout	174 (63.74%)	41 (74.55%)	0.191
Job Satisfaction	115 (42.12%)	25 (45.45%)	0.696
Intention to Leave Job	89 (32.60%)	21 (38.18%)	0.479

Note: *p < .05; **p < .001; interpretation of mean scores: BRS <3 (low resilience); PHQ-15 > 10 (moderate to high somatization); PHQ-2 > 2 (positive depression screen); GAD-2 (positive anxiety screen).

In summary, we found several modifiable workplace factors or stressors that were correlated with poor mental health outcomes (depression, anxiety and burnout), lower job satisfaction, and the intent to leave one's job. It appears that an increase in perceived workload does not pose risk for poor psychological health but rather higher workforce turnover risk. More research that isolates specific and modifiable burnout-inducing work environment factors is recommended in addition to clinical trials that test interventions to help mitigate burnout and improve job satisfaction. Work environment factors such as leadership support, conflict resolution, and transparent workplace goals may play a significant role in mitigating adverse nurse workforce outcomes, including burnout or intention to leave one's job.

One of the most salient findings was workplace conflict. Nurses who reported conflict exposure endorsed higher risk for depression, anxiety, and burnout, decreased job satisfaction, and higher intention to leave their job compared to those who did not. Workplace conflict, which may include bullying or violence, has been found in to yield counterproductive behaviors. In nursing workforce specifically, a generous amount of literature has focused on nurse-to-nurse incivility and hostility or poor patient/client-nurse interactions [9]. Despite the exponential increase in evidence identifying adverse outcomes related to workplace conflict, more attention to intervention-based organizational and state-based policies to help mitigate such conflict is greatly needed.

We also explored how RNs perceived their own physical health while working during the pandemic. Several nurses reported having pre-existing chronic conditions that were not appropriately managed over the pandemic. Our respondents reported missing their own medications and an inability to seek medical care to manage their physical health. Organizations may consider incorporating on-site clinics for employees to help manage their own personal health needs and alleviate their efforts seeking care, especially during public health crises or emergency-related events. Further, respondents reported difficulty sleeping. Researchers have found that poor sleep may increase one's risk for depression, anxiety, work stress and lower self-care [10]. Further research using longitudinal design and the addition of physiologic measures of stress and sleep are needed to determine which protective factors maty help mitigate poor physical and psychological health risk.

Funding

A.S.'s effort was supported by a National Institutes of Health, National Institute for Nursing Research T32 training grant (T32 NR014205, Poghosyan, Stone, Co-PIs) Comparative and Cost-Effectiveness Research Training for Nurse Scientists at Columbia University.

Disclaimer

The views expressed in this paper are those of the authors and do not reflect official policy of the Department of Veterans Affairs, the National Institutes of Health, or any Federal agency.

Declaration of Competing Interest

None declared.

Data availability

Data will be made available on request.