Safety Responsiveness and Psychological Distress Among Health Care Workers During COVID-19 (2020–2022) in the Pacific Northwest

Abstract

Objectives. The COVID-19 pandemic imposed unprecedented safety challenges on health care facilities. This study examined whether health care workers who deemed a better safety response to the pandemic by their units or employers experienced lower psychological distress.

Methods. Patient care workers at a health care system in the Pacific Northwest were surveyed every 6 to 8 months from May 2020 to May 2022 (n = 3468). Psychological distress was measured with the Well-being Index (range: −2 to 7 points). Safety response was scored on the basis of participants’ ratings (on a 1–5 scale) of equipment sufficiency and responsiveness to safety concerns by their health care system and unit.

Results. Adjusted multilevel regressions showed an inverse association between safety responsiveness and psychological distress at the individual level (b = −0.54; 95% confidence interval [CI] = −0.67, −0.41) and the unit level (b = −0.73; 95% CI = −1.46, −0.01). The cross-level interaction was also statistically significant (b = −0.46; 95% CI = −0.87, −0.05).

Conclusions. Health care workers who deemed a better response to safety challenges reported lower psychological distress. This study highlights the need for continued efforts to ensure adequate safety resources. (Am J Public Health. 2024;114(S2):S204–S212. https://doi.org/10.2105/AJPH.2024.307582)

The COVID-19 pandemic imposed numerous and changing safety challenges for health care facilities across the globe, testing their ability and resilience to protect both patients and workers. Health care organizations were confronted with fast-changing infection control guidelines, protocols, and a need for innovative practices to minimize the risk of contagion while maintaining continuous yet modified operations.^1,2

Health care organizations were forced to constantly revise and implement protective measures, including engineering controls (e.g., ventilation), administrative changes (e.g., telework, isolation, and return to work protocols), provision of personal protective equipment, and updated information regarding the coronavirus.³ The initial stages of the pandemic were characterized by shortages of personal protective equipment (e.g., masks, gloves, and gowns), placing hospital workers at risk for exposure and infection. In subsequent pandemic stages, hospital workers and facilities were faced with the challenges of navigating rapidly changing guidelines and protocols for managing COVID-19 patients while integrating organizational, local, and national infection control directives.

The COVID-19 pandemic created a health care work environment clouded by immense stress, uncertainty, and constant change. A systematic review and meta-analysis of the psychological impact of the COVID-19 pandemic on health care workers reported a 37% pooled prevalence of anxiety, a 36% pooled prevalence of depression, and a 32% prevalence of insomnia.⁴ Ensuring the emotional well-being of health care professionals thus became a national priority in the United States as the risk of burnout, turnover, and diminished quality of care exploded.⁵

The pandemic also brought significant concerns to the psychosocial work environment of hospitals and other health care facilities. Hospital workers not only struggled with new demands, redeployment, and longer hours.⁶ Affective organizational commitment, defined as the emotional attachment and identification of employees with their organizations,⁷ has proven important in fostering a sense of belonging, motivation, and resilience among health care workers.^8,9 Also crucial for mental health promotion is the provision of social support from direct supervisors^10,11 and colleagues,¹² especially in light of the many work-life disruptions caused by the pandemic (e.g., school and day-care closures, staffing shortages) whose everyday resolution required constant interaction and input of supervisors as health care workers coped with the new pandemic reality.

Given that burnout among health care workers during COVID-19 often has antecedents from more than a single level,¹³ analyzing safety perceptions at individual and unit-aggregated levels can offer valuable insights for health care policymakers, practitioners, and researchers regarding modifiable drivers of worse outcomes as well as best protective practices.¹⁴ At the individual level, a deeper understanding of personal safety perceptions can help identify areas for improvement in employees’ awareness, behaviors, and involvement in safety-related issues. At the unit-aggregated level, patterns and trends are revealed within specific departments or care teams. Such insights can help identify shared beliefs, values, and practices and guide the implementation of targeted safety interventions. In addition, examining safety perceptions at both levels can shed light on interactions between individual and collective safety beliefs, which can be instrumental in optimizing patient care and outcomes.

In the stressful and volatile COVID-19 context, conducting regular surveys to monitor mental health is paramount. In 2022, the National Academy of Medicine created the National Plan for Health Workforce Well-Being, which recommended routine measurement of psychological distress across the workforce as its first goal.¹⁵ Routine surveys to monitor psychological distress among health care workers throughout the pandemic became an important tool to identify individuals at significant risk and predictors of psychological distress. Repeated cross-sectional surveys can help leaders at health care organizations quantify their workers’ challenges and stressors and develop, enhance, or evaluate the effectiveness of support services, programs, and implemented interventions.

Findings of these surveys help communicate the importance of mental health to staff members, encourage open dialogue about their experiences and concerns, and allow for comparisons across various demographic, geographic, or socioeconomic groups within the organization.^16,17 This efficiency is beneficial when monitoring fast-changing situations, such as the pandemic, across a population rather than a cohort or individuals. Such flexibility enables stakeholders to stay current with the population’s evolving needs and maintain the relevance of their findings. By addressing the specific needs of their staff, organizations can create an environment that fosters teamwork, collaboration, and trust among health care workers.

The primary aim of this study was to test multilevel associations between appraisals of the safety response to pandemic concerns and the psychological distress of patient care workers. Analyses were based on 6 waves of a survey performed between May 2020 and May 2022 to assess psychological distress and selected organizational predictors. The study tested the hypothesis that workers who perceived a better safety response by their organizations and local units also experienced lower levels of psychological distress. A secondary objective was to examine correlations between psychological distress and features of the psychosocial work environment, such as affective organizational commitment and social support from coworkers and supervisors.

METHODS

We conducted a repeated cross-sectional study at an academic health center in the Pacific Northwest. Surveys were collected in May 2020 (wave 1; n = 731), September 2020 (wave 2; n = 181), February 2021 (wave 3; n = 464) May 2021 (wave 4; n = 516) November 2021 (wave 5; n = 898), and May 2022 (wave 6; n = 678). The response rate for each wave was difficult to calculate given fluctuations in the total number of health care employees during this period; according to public-facing institutional reports, however, response rate estimates ranged from 5% to 15%. Although each survey was open to all employees at the organization, including workers in the educational, research, and health care mission, the current analyses focus exclusively on those with patient care duties (e.g., physicians, advanced practice providers, nurses; n = 3468; Table 1). Participants worked at different hospital units and clinics (29 clusters in total).

TABLE 1—

Description of the Sample in Each Wave of the Survey at a Health Care System of the Pacific Northwest (2020–2022)

	Wave 1 (May 2020; n = 731), Mean ±SD or %	Wave 2 (September 2020; n = 181), Mean ±SD or %	Wave 3 (February 2021; n = 464), Mean ±SD or %	Wave 4 (May 2021; n = 516), Mean ±SD or %	Wave 5 (November 2021; n = 898), Mean ±SD or %	Wave 6 (May 2022; n = 678), Mean ±SD or %
Psychological distress	2.5 ±2.3	3.5 ±2.3	3.2 ±2.3	3.1 ±2.2	4.2 ±2.5	3.5 ±2.3
Safety participation	4.5 ±0.9	…	…	…	…	…
Organization-wide safety response	…	4.0 ±0.8	4.1 ±0.8	4.1 ±0.8	3.3 ±0.9	3.4 ±1.2
Unit safety response	…	4.1 ±0.8	4.3 ±0.8	4.2 ±0.8	3.60 ±0.9	3.7 ±1.2
Safety equipment availability	…	3.9 ±1.0	4.1 ±0.8	4.2 ±0.9	3.8 ±0.9	3.9 ±1.0
Safety responsiveness	…	4.0 ±0.7	4.2 ±0.7	4.1 ±0.7	3.5 ±0.8	3.7 ±1.0
Affective organizational commitment	3.5 ±0.9	3.3 ±0.8	3.3 ±0.8	3.1 ±0.8	2.7 ±0.9	2.9 ±1.0
Supervisor support	4.0 ±1.0	…	4.0 ±0.9	3.9 ±0.9	3.6 ±1.1	3.8 ±1.1
Family supportive supervisor behaviors	…	3.6 ±1.1	3.7 ±0.9	3.6 ±1.0	3.3 ±1.1	3.5 ±1.1
Job demands	…	3.8 ±0.7	3.8 ±0.7	3.9 ±0.7	…	…
Decision authority	…	3.3 ±1.0	3.4 ±0.9	3.4 ±0.9	…	…
Coworker support	4.1 ±0.8	3.9 ±0.8	4.1 ±0.8	3.9 ±0.8	4.0 ±0.8	3.8 ±0.8
Union representation	57.1	52.0	53.3	56.5	77.9	72.1
Manager status	15.6	17.7	17.2	15.5	8.9	13.1
Hours per week
≤30	17.5	13.1	12.3	12.3	15.1	14.1
31–40	45.9	38.3	43.6	35.6	53.1	45.4
>40	36.7	48.6	44.1	52.1	31.9	40.6
Years of tenure
<1	11.1	5.1	6.6	7.8	7.7	12.0
1–5	80.4	89.7	88.3	84.7	85.8	80.3
>5	8.5	5.1	5.1	7.6	7.6	7.7
Age, y	42.1 ±10.5	41.9 ±9.5	40.8 ±9.8	42.4 ±9.9	40.9 ±10.3	40.9 ±9.8
Gender
Female	78.0	73.1	75.1	65.7	69.3	65.8
Male	18.2	14.9	11.2	14.3	11.3	16.0
Nonbinary	0.3	9.7	9.9	16.2	13.7	14.8
Prefer to self-describe/not answer	3.5	2.3	3.7	3.8	5.7	3.3
Race/ethnicity
White	85.1	76.0	75.3	71.1	83.0	84.8
Black or African American	0.6	1.7	1.3	0.9	0.9	1.2
Asian	4.4	6.9	6.6	4.3	2.6	6.2
Hispanic/Latino	1.1	3.4	2.6	3.4	1.7	3.9
American Indian or Alaska Native/Native Hawaiian or Pacific Islander	0.0	0.0	1.1	0.9	0.5	0.6
Prefer not to answer	5.7	9.1	9.9	16.6	9.8	0.8
Other	3.0	2.9	3.1	3.0	1.4	2.7
Have school-age dependents	45.9	51.3	45.3	44.1	44.3	39.3
Employment type
Advanced practice provider	8.5	7.2	10.3	8.3	4.1	5.5
Behavioral health/mental health	2.7	6.1	3.9	2.9	2.3	1.5
Case management	1.9	1.1	1.5	1.6	1.5	1.5
Dentist	0.0	0.0	0.0	1.2	0.3	0.4
Dental hygienist	0.0	0.0	0.0	0.0	0.0	0.2
Medical assistant	8.9	8.8	5.8	4.8	3.1	8.0
Nurse	36.5	37.6	40.5	31.8	62.9	45.0
Nurse assistant/nurse technologist	1.8	0.6	3.0	1.9	1.0	3.4
Other clinical support	3.2	2.8	2.6	4.1	3.9	6.9
Physician	23.8	23.8	20.3	26.9	10.4	15.2
Radiology technician	1.2	0.0	2.8	2.1	1.2	1.9
Rehabilitation services	4.7	6.1	3.5	2.7	3.9	3.1
Resident	8.5	2.2	2.6	8.7	0.9	3.7
Respiratory therapy	2.7	0.6	1.1	0.8	2.9	1.3
Social work	1.9	3.3	2.2	2.1	1.6	2.5

A link to a 15-minute electronic survey was sent in periodic and specific COVID-19 announcements and updates. As a means of protecting confidentiality, no administrative identifiers (e.g., employee IDs) were collected; thus, it was not possible to establish which workers participated in multiple surveys. No incentives were offered for completing the survey, but participants could enter a raffle for an electronic tablet in wave 6. The survey was translated into 6 to 10 languages to increase representation, and survey rollout was announced via organization-wide e-mail updates and newsletters as well as through several committees to improve response and representation.

Measures

Psychological distress (waves 1–6)

The Well-being Index, a widely used tool in health care that predicts mental health issues among physicians,¹⁸ nurses, and physician assistants, was our outcome measure.¹⁹ The index has 9 items (e.g., “During the past month, have you often been bothered by feeling down, depressed, or hopeless?”) that yield a continuous score in which higher values indicate more psychological distress (range: −2 to 7). Validation studies^19,20 have established that scores above 4 points predict suicidal ideation, burnout, and turnover.

Safety compliance (wave 1)

This measure assesses employees’ active involvement in promoting workplace safety.²¹ Employees rated their agreement on each of the scale’s 3 items (e.g., “When I'm on-site, I use all the necessary safety equipment to do my job”) on a scale ranging from 1 (strongly disagree) to 5 (strongly agree; Cronbach α = 0.96). Although safety compliance predicts workplace injuries, its focus is on individual behaviors; it does not serve as a measure of an organization’s response to emerging safety challenges.

Safety responsiveness (waves 2–6)

New items were developed regarding workers’ appraisal of the general safety response of their unit and organization as opposed to individual-level assessments of their behaviors. The items were as follows: (1) My health care system has been responsive to safety concerns since the COVID-19 pandemic; (2) My unit has been responsive to safety concerns since the COVID-19 pandemic; and (3) I feel I have access to the necessary safety equipment (e.g., personal protective equipment) to do my job. The items were scored on a 1 (strongly disagree) to 5 (strongly agree) scale (Cronbach α = 0.81). Individual- and unit-aggregated variables for each of the 29 clusters were computed for all 3 items as well as their arithmetic mean.

Affective organizational commitment (waves 1–6)

Affective organizational commitment measures the emotional attachment employees have to their organization.²² The scale consisted of 6 items (e.g., “I feel emotionally attached to my employer”), and employees rated their agreement with each item on a scale ranging from 1 (strongly disagree) to 5 (strongly agree; Cronbach α = 0.90).

Social support at work

The survey included measures²³ regarding support from coworkers (waves 1–6; 3 items; e.g., “Your co-workers go out of their way to do things to make your work life easier for you”; Cronbach α = 0.82) and supervisors (wave 1, waves 3–6; 3 items; e.g., “Your supervisor can be relied upon when things get tough on the job”; Cronbach α = 0.85). Each subscale was scored from 1 (strongly disagree) to 4 (strongly agree). Considering pandemic impacts on the work–family interface, surveys also included the Family Supportive Supervisor Behaviors (FSSB) scale,²⁴ which focuses on 4 key dimensions: emotional support, instrumental support, role modeling behaviors, and creative work–family management. The FSSB consists of 4 items (e.g., “Your supervisor makes you feel comfortable talking to them about your conflicts between work and non-work”) ranging from 1 (strongly disagree) to 5 (strongly agree; Cronbach α = 0.93). The FSSB was included from wave 2 onward.

Job demands and decision authority (waves 2–4)

The survey included 3 items from the Job Content Questionnaire²⁵ regarding job demands (e.g., “My job requires working very hard”; Cronbach α = 0.67) and 3 items for decision authority (e.g., “My job allows me to make a lot of decisions on my own; Cronbach alpha = .86). Both subscales were scored from 1 (strongly disagree) to 5 (strongly agree). The subscales were dropped from the survey once their stability was revealed over time (Table 1).

Control variables

Along with reporting job units and job titles, the survey gathered age and other sociodemographic information. Gender was self-identified under the following options: man, woman, binary/third gender, prefer to self-describe, or prefer not to say. Race/ethnicity was self-reported under the following multiple-choice options: White, Black or African American, Asian, Hispanic/Latin, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, prefer to self-describe, or prefer not to say. Managerial status, union representation, and presence of school-age children at home were coded with respective dichotomous variables. Work hours per week were categorized as less than or equal to 30, 31 to 40, or greater than 40. Tenure at the organization was coded as less than 1 year, 1 to 5 years, or greater than 5 years.

Statistical Analysis

After assessing the variables in each wave (Table 1), we applied random intercept multilevel models to examine the association between these variables, accounting for the clustering of workers within 29 units and the autocorrelation across waves. The multilevel model featured the individual-level safety responsiveness scores, the unit-aggregated scores, and a cross-level interaction between individual- and unit-aggregated scores. The model included other psychosocial work environment and control variables and survey wave as a categorical variable (Table 2). Continuous variables were centered at their mean values. All models were 2-tailed with a .05 level of significance, analyses were performed with the SAS version 9.4 (SAS Institute, Cary, NC) proc mixed command and a compound symmetry variance structure.

TABLE 2—

Adjusted Models for the Association Between Safety Responsiveness and Psychological Distress Among Health Care Workers at a health care system of the Pacific Northwest (2020–2022)

	ba (95% CI)
Fixed effects
Intercept	3.72 (3.28, 4.17)
Survey wave (ref: wave 2)
Wave 3	−0.16 (−0.56, 0.23)
Wave 4	−0.24 (−0.64, 0.15)
Wave 5	0.24 (−0.13, 0.62)
Wave 6	−0.29 (−0.60, 0.18)
Safety responsiveness
Individual level	−0.54 (−0.67, −0.41)
Unit level	−0.73 (−1.46, −0.01)
Cross-level interaction	−0.46 (−0.87, −0.05)
Age	−0.04 (−0.05, −0.04)
Race/ethnicity (ref: White)
Black	0.00 (−0.90, 0.89)
Asian	−0.02 (−0.47, 0.44)
Hispanic/Latino	−0.39 (−0.94, 0.15)
Alaska Native/Native Hawaiian	0.28 (−0.77, 1.34)
Prefer not to answer	−0.30 (−0.93, 0.33)
Other	0.05 (−0.58, 0.67)
Gender (ref: female)
Male	−0.09 (−0.36 0.18)
Nonbinary	1.17 (0.19 2.16)
Prefer to self-describe	−0.30 (−1.03 0.42)
School-age dependents (ref: no)	0.05 (−0.14 0.25)
Manager (ref: no)	0.35 (0.05 0.66)
Union member (ref: no)	−0.03 (−0.28 0.22)
Affective organizational commitment	−0.28 (−0.40 −0.18)
Coworker support	−0.24 (−0.33 −0.09)
Family supportive supervisor behaviors	−0.26 (−0.40 −0.15)
Random effects
Between-unit variance	0.10 (0.04, 0.64)
Within-unit variance	0.04 (0.03, 0.04)
Intraclass correlation	0.02
Model log-likelihood	9353.3

Note. CI = confidence interval. The sample size was 2151).

^a Unstandardized regression coefficient showing the average difference in psychological distress (range = −2 to 7).

RESULTS

A total of 3468 health care workers completed at least 1 of the 6 surveys, with a range of 181 (wave 2) to 898 (wave 5). Table 1 shows sample descriptive statistics in each wave. Overall, the participants were 41.4 years of age on average, and the majority self-identified as female (79.1%) and non-Hispanic White (80.5%). Nurses (44.9%), physicians (18.6%), advanced practice providers (6.9%), and medical assistants (6.2%) accounted for the majority of the sample. Slightly less than half of the sample respondents (44.2%) indicated having one or more school-age children in their households; 13.5% were managers, and 65.3% were union members. More than a third of the sample (39.9%) reported working more than 40 hours per week, and the vast majority (84%) had worked for the organization between 1 and 5 years.

Psychological distress was high from the first wave (May 2020; 2.56) to the sixth wave (May 2022; 3.61), with an increasing temporal trend (b = 0.24; 95% confidence interval [CI] = 0.20, 0.29). The mean score (on a 1–5 scale) for safety compliance, measured only in wave 1, was 4.45. Results from random intercept models showed that safety responsiveness decreased over time (b = −0.14; 95% CI = −0.17, −0.12), from a starting average of 3.94 in wave 2 to 3.67 in wave 6 (1–5 scale rating). Similar trends were found for each of the 3 items.

Psychosocial variables declined over time, with the most noticeable drop for affective organizational commitment (b = −0.14; 95% CI = −0.16, −0.13), followed by supervisor support (b = −0.07; 95% CI = −0.09, −0.05), family supportive supervisor behaviors (b = −0.06; 95% CI = −0.10, −0.03), and coworker support (b = −0.03; 95% CI = −0.05, −0.02). Job demands and decision authority, which both were measured in waves 2, 3, and 4, did not change in this sample and hence were removed from subsequent waves to reduce the length of the survey.

Table 2 shows results for the association between safety responsiveness and psychological distress after adjustment for control variables, psychosocial work environment features, and survey wave. Perceptions of a positive safety response to pandemic concerns were associated with lower psychological distress at both the individual (b = −0.54; 95% CI = −0.67, −0.41) and unit (b = −0.73; 95% CI = −1.46, −0.01) levels. The adjusted cross-level interaction showed that health care workers at units with more positive appraisals of the safety response had lower psychological distress (b = −0.46; 95% CI = −0.87, −0.05).

Table 2 also shows associations of features of the psychosocial work environment. There were inverse correlations with affective organizational commitment (P < .001), family supportive supervisor behaviors (P < .001), and coworker support (P < .05). The magnitudes of the associations ranged from roughly one third (affective organizational commitment) to one fifth (coworker support) per 1-unit increment of each variable. Finally, age was associated with higher psychological distress (P < .001), and workers who self-identified their gender as nonbinary reported higher psychological distress (P < .05). Other control variables were not associated with psychological distress.

DISCUSSION

This study assessed associations between psychological distress and safety responsiveness to pandemic concerns in a sample of patient care workers in a health care system in the Pacific Northwest. Data came from 6 repeated cross-sectional surveys conducted during the most intense phases of the COVID-19 pandemic (May 2020 to May 2022). Safety responsiveness was defined as the extent to which health care workers perceived that their units or employers addressed safety concerns brought about by the pandemic. Secondarily, our study examined whether psychological distress was correlated with affective organizational commitment and social support from coworkers and supervisors.

Results showed high and sustained levels of psychological distress during the first 2 years of the pandemic. Although there was a declining trend of safety responsiveness, workers who deemed a better response to safety challenges reported lower psychological distress.

The stress and trauma of caring for patients with COVID-19 took a toll on hospital workers’ mental health, and many health care workers struggled with burnout, anxiety, and depression. Health care institutions had to address safety and mental health challenges by modifying the work environment, providing support services, and promoting teamwork among staff members. The results of this study are consistent with those of other studies documenting high levels of distress in the health care workforce. Pappa et al. conducted a systematic review and found a 23.2% pooled prevalence of anxiety and a 22.8% pooled prevalence of depression among health care workers during the first year of the pandemic.²⁶ Lai et al. reported that health care workers experienced increased symptoms of depression (50.4%), anxiety (44.6%), insomnia (34.0%), and distress (71.5%) in the pandemic’s early stages.²⁷ Other studies reported similar trends in the latter stages of the pandemic,²⁸ underscoring the prolonged and alarmingly high levels of distress among health care workers.

Our findings highlight the importance of perceived organizational support. Psychological distress was also lower among workers who were more committed to their organization, although commitment waned over time. Workers who perceived higher support from their colleagues and deemed that their supervisors demonstrated more family supportive behaviors had lower psychological distress as well. However, these psychosocial factors also decreased in the observed period (2020–2022). Family supportive supervisor behaviors were deemed an important and more stable psychosocial factor in reducing emotional exhaustion, even amid the volatile and turbulent times of the pandemic.²⁹ Likewise, our results complement those of other studies showing that long working hours, insufficient protective equipment, fear of infection, witnessing of death and suffering, ethical dilemmas,^30,31 and reduced support networks³² are key contributors to psychological distress among health care workers.

Our results point to the utility of periodic mental health surveys. Repeated cross-sectional surveys offer numerous benefits for researchers and policymakers, including monitoring of trends and changes, broad representation, reduced respondent burden, efficient data collection, flexibility in questionnaire design, cost-effectiveness, and benchmarking opportunities. These advantages make repeated cross-sectional surveys a powerful tool for understanding complex and dynamic populations and informing evidence-based decision making. The present study contributes to the knowledge base regarding health care health and safety by tracking psychological distress and several of its psychosocial predictors and by focusing on safety issues, chiefly the extent to which health care systems in general and, more specifically, local units responded to the safety demands of the pandemic.

The findings of this study highlight the importance of health care systems effectively addressing pandemic-related safety challenges to protect the mental well-being of patient care workers. Hospital administrators and other health care leaders must prioritize the implementation of robust safety protocols and continuously review and update these measures as needed. In addition to ensuring occupational health and safety, health care organizations must establish and maintain open lines of communication with employees. This includes providing regular updates on organizational policies and pandemic-related news and offering opportunities for workers to voice their concerns and suggestions. Furthermore, hospital administrators should consider implementing programs to support the mental health of their staff, including mental health and counseling services but also training of unit leaders about ways to listen and change modifiable work stressors.^29,33

Study Limitations

Although repeated cross-sectional surveys can be a valuable tool for tracking changes in attitudes and behaviors over time, there are several limitations to using this design. Repeated cross-sectional surveys provide information on different individuals at each time point. Therefore, changes in attitudes or behaviors at the individual level over time were not tracked, limiting the ability to draw causal conclusions or assess attrition rates, which can affect the validity of the results.

Because each survey is based on a new sample of participants, there is a risk of sampling bias if the samples are not representative of the studied population. It was difficult to estimate the response rate for each wave because the population denominator changed over time. On the basis of prepandemic internal organizational surveys, the response rate was calculated at about 5% to 15%, which, albeit in line with other prepandemic estimates, limits the external validity of our study.³⁴ However, the recruitment methods used were relatively passive, with minimal reminders sent in mass e-mails and with an emphasis on not adding factors to reduce survey fatigue, an issue documented in several studies during COVID-19.

Despite these challenges, the demographic characteristics of our respondents were similar to those in other employer surveys (e.g., engagement and satisfaction) as well as in workforce administrative data. In this sense, these surveys may be representative of the mental health concerns of this particular workforce during the most intense phases of the COVID-19 pandemic. Repeated cross-sectional surveys are usually conducted at fixed intervals, which may not capture rapid changes in attitudes or behaviors between surveys, although more frequent intervals may lead to survey fatigue. Finally, common method variance bias is possible given that all of our data were based on surveys,³⁵ but this issue is minimized because associations were examined not at a single time point but across 6 occasions.

Conclusions

Patient care workers who perceived that their unit and organization responded better to the safety challenges of the COVID-19 pandemic reported lower psychological distress than those who perceived a worse safety response. Patient care workers who remained more committed to their organization and reported more social support from colleagues and supervisors, especially regarding the work–family interface, also reported lower psychological distress. This study emphasizes the need for health care systems to address pandemic-related safety challenges to support the mental well-being of patient care workers. By focusing on safety measures, supportive training to enhance supervisory support, and mental health support programs, hospital administrators can contribute to a healthier and more resilient workforce, ultimately leading to improved patient outcomes.