Factors associated with changes in nurses' emotional distress during the COVID-19 pandemic

Abstract

Purpose

The purpose of this study was twofold: to assess if nurses experienced changes in emotional distress (stress, depression, and anxiety) as the number of patients infected with coronavirus disease 2019 (COVID-19) increased and if there were any sociodemographic, psychosocial, and work environmental influence on the change.

Methods

Using a repeated cross-sectional study design, we collected survey data among 198 South Dakota (SD) nurses. Data were collected in two waves, during the first 12 months of the COVID-19 pandemic in the United States (July and December 2020). Participants completed two online surveys: (a) The Depression, Anxiety, and Stress Scale (DASS-21); and (b) Change Fatigue Scale. Predictive factors were divided into three groups: sociodemographic, psychosocial, and work environment variables. Multiple linear regression models were run to estimate the factors associated with the change in DASS-21 subscale score.

Results

Total DASS-21 score and scores for all subscales significantly increased from Survey 1 to Survey 2. Significant positive associations were found between change fatigue and workplace barriers with change in depression, anxiety, and stress scores. A linear relationship was identified between self-worry about COVID-19 risk and depression and stress and being male and young were associated with changes in depression.

Conclusions

Increase in emotional distress of nurses as the pandemic progresses is consistent with other studies. It is vital for healthcare organizations to recognize the factors associated with the changes in emotional distress and their role in decreasing the stress levels of nurses.

1. Introduction

The novel coronavirus disease 2019 (COVID-19) pandemic has led to many unexpected changes not only in nurses' daily lives but also in the way healthcare facilities function. During the pandemic, organizations were forced into rapid and radical transformations, which led to a shift in how people value work (Amis, 2020). Healthcare is well-known for being in a state of constant change, but the pandemic has led to additional organizational changes, which has led to acute stress (Shahrout & Dardas, 2020). In addition, excessive organizational change can cause change fatigue, decrease in job satisfaction, increase in turnover rates (Bernerth et al., 2011; Brown et al., 2018; Camilleri et al., 2018), and affect the overall relations with the organization (Li et al., 2021). Lack of adequate time and preparation with organizational changes may form barriers to change and pose threats to the organization (Li et al., 2021). The current pandemic forced healthcare facilities to suddenly implement organizational changes with minimal preparation in order to meet the needs of the COVID-19 patients.

Change fatigue is the overwhelming feeling of stress, exhaustion, and burnout associated with rapid and continuous change in the workplace (McMillan & Perron, 2013). Change fatigue evolved from the discipline of management and the psychological effects of organizational change have been fundamentally under-researched in nursing. Qualitative research by McMillan and Perron (2020) revealed that the intensification of the work required of nurses and nurses' perception of repeated and ongoing self-sacrifice were core themes in nurses' experience of change fatigue. Even though organizational change and demands on nurses are at an all-time high due to the pandemic, there is currently no research focusing on nurses and change fatigue during the pandemic. It is imperative to the success of organizations to understand the effects of these changes and how nurses cope with these unexpected changes (Li et al., 2021).

Current research demonstrates the extent to which nurses are experiencing acute stress and psychological distress during the pandemic. In a recent study by Nursing Standard (2021), eight out of ten nurses reported their mental health has been affected by the pandemic. According to Shahrout and Dardas (2020), 64 % of Jordanian nurses are experiencing acute stress disorder (ASD) and 41 % are also suffering significant psychologic distress during the COVID-19 pandemic. A cross-sectional survey study carried out in February of 2020 revealed that 25.1 % of Chinese frontline nurses experienced significant psychological distress due to the COVID-19 pandemic, as evidenced by their 12-item General Health Questionnaire (GHQ-12) scores (Nie et al., 2020). These findings demonstrated a psychological distress level nearly two times as high as the general population of China. Cai et al. (2020) found similar increases in psychological distress, notably depression, anxiety, and insomnia, among nurses in the epicenter of the pandemic in Wuhan, China. Firew et al. (2020) conducted a cross-sectional survey of healthcare workers in the United States (U.S.), including nurses, with results demonstrating higher levels of psychological stress during the pandemic due to a variety of factors, including isolation and having to send cohabitants away during the height of COVID infections. In addition, Chen et al. (2020) reported a moderate degree of emotional exhaustion among nurses caring for COVID patients.

Minimal longitudinal research has been conducted on the changes of stress and anxiety of nurses as the pandemic continues. A recent survey conducted by the American Nurses Foundation (2021) reported nurses continue to be stressed (75 %), frustrated (69 %), and overwhelmed (62 %), and over 34 % rated their emotional health as unhealthy. One longitudinal study conducted by Cai et al. (2020) in China found depression, anxiety, and posttraumatic stress disorder (PTSD) was statistically higher in the outbreak period (Survey 1) compared to the stable periods (Survey 2). Researchers in Belgium evaluated the mental health impact of COVID-19 from April 1 to June 30, 2020. Data was collected at three different points of time within this period, initially following the onset of the pandemic, at 4 weeks, and at 8 weeks. The study reported that while rates of depression, anxiety and somatization did not increase, the rate of emotional distress was consistently high despite a decrease in COVID-19 patient admissions over time (Van Steenkiste et al., 2021).

The purpose of this study was twofold. The first purpose was to assess if nurses experienced changes in emotional distress (stress, depression, and anxiety) as the number of patients infected with COVID-19 increased. The seven-day moving average COVID-19 cases in South Dakota (SD) increased from 60.7 (July 1st) to 817 (December 1, 2020) (South Dakota Department of Health, n.d.). Secondly, researchers evaluated if there were any sociodemographic, psychosocial, and work environmental variables associated with the change in emotional distress during the COVID-19 pandemic.

2. Methods

Using a repeated cross-sectional study design, we collected survey data among SD nurses. Data were collected in two waves during the first 12 months of the COVID-19 pandemic in the U.S. (July and December 2020). The follow up survey was used to examine any change in stress, depression, and anxiety over time as the positivity rate of the COVID-19 pandemic increased. To recruit nurses to the first phase of the study, a link to the survey was distributed to nurses registered with the South Dakota Board of Nursing (N = 19,249). In addition, information about the study was circulated through the College of Nursing's Facebook. Detailed information regarding the methodology of the first survey referred in this study is published in a previous manuscript in Applied Nursing Research (Da Rosa et al., 2021). Nurses who consented to participate in a follow up survey were contacted via email. The study was approved by the university's Human Research Ethics Committee (IRB-2006012-EXM), and online informed consent was obtained for all participants.

2.1. Instruments

Data were collected in two waves to investigate changes in emotional distress levels. Instruments were linked using a common participant ID. The initial survey (Survey 1) included the following sections: emotional distress (anxiety, depression, and stress); socio-demographic characteristics; work environment variables; and concerns based on COVID-19 risks. The follow up survey (Survey 2) included the following sections: emotional distress; change fatigue; work environment variables and barriers at work; and concerns based on COVID-19 risks. Change fatigue was added to Survey 2 to assess the effects of multiple changes being made in facilities due to the COVID-19 pandemic.

The Depression, Anxiety, and Stress Scale (DASS-21) is a self-report scale and was used to assess emotional distress. Each of the three DASS-21 scales contains seven items. Scores for depression, anxiety, and stress are calculated by summing the scores for the relevant items (Lovibond & Lovibond, 1995a). Each of these constructs is interrelated and the combined score (sum of the three subscales) can be used to screen for general psychological distress. The DASS-21 has demonstrated excellent internal consistency in a variety of populations, with a Cronbach's ranging from 0.9 to 0.97 (Henry & Crawford, 2005; Lovibond & Lovibond, 1995b). Similarly, alpha for this study (n = 198) was 0.94. To assess change in DASS-21 subscales, absolute difference in the subscale scores between Survey 1 and 2 were calculated. Job satisfaction, number of COVID patients, and two questions on worry based on COVID-19 risk were asked in both surveys. The change in these variables was calculated as the difference of responses. Then, the new variable, representing the change in DASS-21 from Survey 1 to Survey 2, was categorized as decrease, no change, or increase.

The Change Fatigue Scale measures well-being, organizational commitment, and turnover intentions in employees experiencing multiple organizational changes. The scale is a 7-item Likert scale and has shown good reliability and internal consistency. Cronbach alpha with non-nurses is 0.85 (Bernerth et al., 2011) and with nurses 0.94 (Brown et al., 2018). In our study, the Cronbach alpha for the study population (n = 198) was 0.94. Higher total score reflects higher change fatigue.

The race/ethnicity question allowed multiracial responses; the variable was recoded to White and Non-White because 96 % of the sample was White. The Work Environment Survey was developed by a team of interdisciplinary research experts from results of a review of literature of previous COVID-19 pandemic studies. Work environment variables included current nursing degree, years practicing as a nurse, primary work setting, job satisfaction, suspected cases of COVID-19 with direct contact, level of preparation to provide direct care, number of extra hours at work, and change fatigue. Workplace barriers score included personal protection equipment (PPE) availability, number of COVID-19 patients, lack of staffing, lack of emotional support, communication between leadership/team, and hours scheduled. These barriers were rated from not a barrier to extreme barrier. Psychosocial variables included concerns with COVID-19 exposure and mental health and worry about COVID-19 risk for self and others.

2.2. Data analysis

The outcome variables of interest in this study were change in the DASS-21 subscale scores (depression, anxiety, and stress) from Survey 1 to Survey 2 and the objective of the analysis was to determine significant associations with nurse characteristics; in particular, associations with sociodemographic and psychosocial factors, and work environment characteristics. Multiple linear regression was used to estimate associations of factors with the change in DASS-21 subscale score. Given the sample size relative to the number of factors to be evaluated, a hierarchical approach to regression model development was used. To adjust for regression towards the mean for the change in DASS-21 subscale scores, the baseline DASS subscale scores were included in all regression models. The factors were divided into three groups and separate models were run using block sequential backwards elimination. Group A included sociodemographic variables; group B included psychosocial variables (e.g., concerns with COVID-19 risks) and group C included work environment variables. At each hierarchical stage, backwards elimination was conducted by removing the factor with the highest (2-sided) p-value >0.2 until all remaining factors at that hierarchical stage had an association with the dependent variable with p < 0.2; these factors were retained in all models for subsequent hierarchical stage backward elimination procedures. For ordinal factors, linear trend and quadratic trend (when justified) were evaluated. For interpretation of final models, statistical significance for outcome variable – factor associations were set at p < 0.05. Questionnaire data were exported from QuestionPro and analyzed using Stata version 15.1 (StataCorp, College Station, TX).

3. Results

From 1599 participants with complete data on the first survey (Survey 1), 715 respondents agreed to participate in the following up survey (Survey 2). Among those, 220 respondents participated in both surveys and 198 provided complete data available for the regression analysis. Table 1A shows the descriptive characteristics of the study sample. The majority were female, white, married, and working as registered nurses. Over half were older than 40 years old, satisfied with their jobs, and felt prepared in providing direct care. Table 1B depicts the characteristics of the work environment (e.g., number of extra hours worked per week). One third reported working >10 extra hours during the first months of the pandemic, and over a third percent reported seeing >20 cases.

Table 1A.

Participants' characteristics.

Characteristic	Counts (%)
Total	198
Gender
Male	22 (11.1)
Female	176 (88.9)
Age in years
20–29 years	25 (12.6)
30–39 years	62 (31.3)
40–49 years	39 (19.7)
50–59 years	46 (23.2)
60+ years	26 (13.1)
Marital status
Single, never married	34 (17.2)
Married	137 (69.2)
Single, previously married	27 (13.6)
Two-level race
White	190 (96.0)
Non-White	8 (4.0)
Highest degree
Licensed Practical Nurse (LPN)	15 (7.6)
Associate degree (ADN)/diploma	39 (19.7)
Bachelor's degree (BSN)	101 (51.0)
Advanced practice degree	43 (21.7)
Household Income (Annual)
<$50,000	21 (10.6)
$50,000 to $74,999	57 (28.8)
$75,000 to $99,999	43 (21.7)
$100,000+	77 (38.9)
Any children living with you?
Yes	96 (48.5)
No	102 (51.5)
Current nursing degree
LPN	18 (9.1)
RN	152 (76.8)
CNP/CRNA/CNM/CNS	28 (14.1)
Years practicing as nurse
<6 years	36 (18.2)
6–10 years	42 (21.2)
11–20 years	47 (23.7)
>20 years	73 (36.9)
Primary work setting
Health center/hospital	93 (47.0)
Clinic	44 (22.2)
Ambulatory care	10 (5.1)
Long-term/assisted care	22 (11.1)
Other	29 (14.6)
Satisfied with job (1)
Very unsatisfied	4 (2.0)
Unsatisfied	10 (5.1)
Satisfied	80 (40.4)
Very satisfied	104 (52.5)
Suspected cases of COVID with direct contact (1)
None	68 (34.3)
1–10	87 (43.9)
11–20	17 (8.6)
>20	26 (13.1)
Level of preparation to provide direct care
Completely unprepared	9 (4.5)
Somewhat unprepared	32 (16.2)
Somewhat prepared	106 (53.5)
Very prepared	51 (25.8)
Concerned for COVID exposure and mental health
Yes	44 (22.2)
No	84 (42.4)
No mental health condition	70 (35.4)
Worry about COVID risk for self (1)
Extremely worried	22 (11.1)
Generally worried	97 (49.0)
Generally not worried	63 (31.8)
Not worried at all	16 (8.1)
Worry about COVID risk for others (1)
Extremely worried	44 (22.2)
Generally worried	96 (48.5)
Generally not worried	48 (24.2)
Not worried at all	10 (5.1)

Note: Household income is in U.S. dollar. Based on the study population with complete data for all variables from both Survey 1 (1) and Survey 2 that are used in the regression models.

Table 1B.

Psychosocial variables and work environment characteristics (Survey 2).

Characteristic	Counts (%)
Total	198
Extra hours worked per week since July 2020
0 h	57 (28.8)
1–10 h	70 (35.4)
>10 h	71 (35.9)
Suspected direct contact with COVID patients (2)
Zero	15 (7.6)
1–10	75 (37.9)
11–20	38 (19.2)
>20	70 (35.4)
Worry about COVID risk for self (2)
Extremely worried	14 (7.1)
Generally worried	70 (35.4)
Generally not worried	96 (48.5)
Not worried at all	18 (9.1)
Worry about COVID risk for others (2)
Extremely worried	40 (20.2)
Generally worried	86 (43.4)
Generally not worried	60 (30.3)
Not worried at all	12 (6.1)
Satisfied with job (2)
Completely dissatisfied	12 (6.1)
Somewhat dissatisfied	31 (15.7)
Somewhat satisfied	86 (43.4)
Very satisfied	69 (34.8)
Changed facilities since July 2020
No	180 (90.9)
Yes	18 (9.1)
Changed nursing units since July 2020
No	178 (89.9)
Yes	20 (10.1)

Based on the study population with complete data for all variables from both Survey 1 and Survey 2 that are used in the regression models.

As shown on Table 2 , the total DASS-21 score and the scores for all subscales significantly increased from Survey 1 to Survey 2. The total average score (DASS-21) changed from 16.5 (SD = 17.4) to 24.31 (SD = 17.8), an increase of 7.8 units (p-value <0.001). A similar trend was observed for all subscales.

Table 2.

Descriptive statistics (mean, standard deviation) for numerical variables on Surveys 1 and 2.

Variable	Survey 1	Survey 2	Change	P-value
Mean ± SD
DASS score total	16.51 ± 17.40	24.31 ± 17.83	7.81 ± 17.38	0.001
DASS anxiety subscale	3.67 ± 5.67	6.03 ± 6.42	2.36 ± 5.80	0.001
DASS depression subscale	4.77 ± 5.89	6.82 ± 6.77	2.05 ± 6.63	0.001
DASS stress subscale	8.07 ± 7.87	11.46 ± 7.30	3.39 ± 7.79
Change fatigue total score		25.27 ± 8.59
Workplace barriers total score		12.12 ± 4.15

N = 198; based on the study population with complete data for all variables from both Survey 1 and Survey 2 that are used in the regression models. The first number in parentheses is the p-value for the 2-sided t-test that the mean difference is zero, and the second number is the 2-sided p-value for the non-parametric Wilcoxon signed-rank test.

For the linear regression, results for change in DASS-21 total score, anxiety, depression, and stress score are shown in Table 3 . Significant positive associations were found between change fatigue and workplace barriers with change in depression, anxiety, and stress scores. For instance, a one unit increase in the change fatigue score was associated with a 0.18 unit increase in the mean change in stress score, and 0.11 increase in the mean change in depression score. For workplace barriers, an increase in the workplace barrier score was associated with increased mean change in stress (Beta = 0.394, p-value = 0.001), depression (Beta = 0.306, p-value = 0.012), and anxiety (Beta = 0.259, p-value = 0.010) scores. Another significant factor was concern for COVID-19 and worsening of a previous mental health condition. The mean change for anxiety concern was 2.77 higher (p-value = 0.034) than the mean change for nurses that reported No concern for anxiety. A similar result was found for the mean change in depression score (Beta = 0.880, p-value = 0.031). In addition, a significant linear trend association was found with mean change in depression and stress with self-worry about COVID-19 risk, meaning that as self-worry increases the mean change in depression and stress score increases. Gender and age were also associated with mean change in depression. The mean change in depression score for males was 2.63 higher than the mean change in depression score for females. Conversely, older nurses (50–59 years) reported a decrease in the mean change (Beta = −4.94, p-value = 0.018) in depression compared to nurses ages 20–29. Race, income, years practicing, preparedness, job satisfaction and primary setting were not associated with change in anxiety, depression, and stress scores.

Table 3.

Associations with change in DASS-21 subscale scores.

Characteristic	Depression		Anxiety		Stress
	Beta	P-value	Beta	P-value	Beta	P-value
DASS depression subscale, initial	−0.510	<0.001	−0.321	0.001	−0.105	0.345
DASS anxiety subscale, initial	−0.097	0.372	−0.552	<0.001	−0.087	0.433
DASS stress subscale, initial	−0.006	0.950	0.182	0.029	−0.668	<0.001
Change fatigue total score	0.109	0.046	0.096	0.045	0.180	0.001
Workplace barriers total score	0.306	0.012	0.259	0.010	0.394	0.001
Changed nursing units since July 2020	n/m				n/m
No			R	0.187(e)
Yes			−1.623
Concerned for COVID and mental health
Yes	0.880	0.031(e)	2.773	0.034(e)	2.042	0.094(e)
No	R		R		R
No mental health condition	−1.898		0.257		−0.704
Worry about COVID risk for self (Survey 1)
Extremely worried	R	0.026(e)	R	0.225(e)	R	0.181(e)
Generally worried	−0.300	0.035(l)	−0.464	0.069(l)	−2.093	0.040(l)
Generally not worried	−3.092	0.760(q)	−0.824	0.218(q)	−2.124	0.762(q)
Not worried at all	−4.032		−3.624		−4.904
Change in self worry
Decrease	−0.375	0.021(e)	−1.059	0.020(e)	−0.068	0.232(e)
No change	R	0.011(l)	R	0.005(l)	R	0.138(l)
Increase	3.408	0.073(q)	2.599	0.312(q)	2.231	0.218(q)
Gender			n/m		n/m
Male	2.634	0.048(e)
Female	R
Age in years
20–29 years	R	0.018(e)	R	0.669(e)	R	0.338(e)
30–39 years	−4.316	0.036(l)	−1.590	0.965(l)	0.246	0.525(l)
40–49 years	−3.009	0.039(q)	−0.589	0.407(q)	2.550	0.672(q)
50–59 years	−4.935		−0.919		0.350
60+ years	−3.529		−0.409		1.896
Highest degree	n/m				n/m
Licensed Practical Nurse (LPN)			1.447	0.192(e)
Associate degree (ADN)/diploma			R	0.045(l)
Bachelors (BS)			−0.206	0.970(q)
Advanced degree			−1.586

Regression models used change in subscales scores as dependent variables and block sequential backwards elimination to determine factors (characteristics) to retain in models. Characteristics listed include only those retained in at least one of the subscale models; n/m indicates the variable was not retained in the model; R indicates the reference category. Variable also entered in the model: race, household income, years practicing, primary setting, preparedness, and job satisfaction.

For categorical variable p-values, (e) is for the overall effect; (l) is for a linear trend; (q) is for a quadratic trend.

4. Discussion

The purpose of this study was to determine if nurses experienced changes in emotional distress (stress, depression, and anxiety) as the COVID-19 pandemic progressed and the number of infections increased. The impact of sociodemographic, psychosocial, and work environment factors on changes in emotional distress was also evaluated. Nurses have experienced significant psychological distress throughout the COVID-19 pandemic. Our findings demonstrate a statistical increase in depression, anxiety, and stress in nurses caring for patients as COVID-19 cases increased. Early recognition of the impact of COVID-19 on the mental health of nurses may be a key factor in preventing nurse burnout and lessening the nursing shortage.

These results support recent research findings demonstrating increased emotional distress in nurses during the pandemic (Chen et al., 2020; Nie et al., 2020; Shahrout & Dardas, 2020). In contrast, Cai et al. (2020) found in a longitudinal study that nurses in Wuhan, China had significantly higher depression, anxiety, and posttraumatic stress disorder (PTSD) at the outbreak period (Survey 1) compared to the stable period (Survey 2). The variation in the timing of the most significant mental health impact of COVID suggests that nurses are at risk for emotional distress throughout all phases of the pandemic. This highlights the importance of continual administrative and facility support of nurses, regardless of the current pandemic phase. In our study, gender and age were associated with change in depression, with males having higher change in depression, compared to females. In contrast, with a longitudinal study by Cai et al. (2020), age and gender were not significant factors for depression, anxiety, and PTSD with nurses in Wuhan, China. Chen et al. (2020) found female nurses had significantly higher emotional exhaustion during the pandemic. The COVID-19 pandemic has led to increased emotional stress for nurses, but there are conflicting results related to individual characteristics. The reason for this is unclear but demonstrates the importance of implementing supportive measures for both male and female nurses as both may have other significant outside life stresses that compound the impact of COVID-19. More research is needed to study individual characteristics and the relationship to emotional distress.

Workplace barriers total score, including PPE availability, number of COVID patients, lack of staffing, lack of emotional support, communication between leadership/team, and hours scheduled, were found to have a significant impact on the stress scores of nurses. Nie et al. (2020) found similar results with the lack of PPE affecting the mental health of nurses in China. Understanding the workplace barriers that have the potential to increase nurses' emotional distress is essential when designing strategies and solutions to mitigate the burden of mental health problems during the pandemic. Knowledge of these workplace barriers may also inform future surge planning efforts in the event of another pandemic.

Change fatigue was also found to be a significant factor of changes in stress and depression scores of nurses. Healthcare facilities have been in a constant state of change since the onset of the pandemic and the impact of these continual and rapid changes has undoubtedly been experienced by nurses as vital frontline employees. To our knowledge, there is no current research with change fatigue and the pandemic. One study prior to the pandemic reported nurses' job satisfaction had a statistically significant negative association with change fatigue (Brown et al., 2018). Change fatigue caused changes in stress and depression, but there is minimal research on this important topic. More research is needed to assess the effects of change fatigue during the pandemic and whether it contributes to nurses leaving the profession, especially now given an increased focus on the nursing shortage and the development of solutions to combat its rising prevalence.

In this study, a concern for COVID-19 and worsening of a previous mental health condition was a strong factor. In addition, a linear trend was found with change in depression and stress and self-worry about COVID-19 risk. As self-worry increased, depression and stress increased. Given the negative impact high levels of stress can have on mental health and well-being, it is vital for healthcare organizations to recognize these workplace barriers and their role in increasing stress levels of nurses. Ensuring the availability of adequate PPE, establishing safe and acceptable nurse to patient care ratios, and fostering effective communication between leadership and the healthcare team may support the emotional health of nurses. These efforts to reduce the impact of workplace barriers and subsequently decrease nurses' stress levels may in turn result in decreased nurse burnout and turnover (Mosadeghrad, 2013). In addition, implementing interventions to lessen the psychological impact of COVID-19 on nurses and removing barriers to access to mental health support resources during and following the pandemic are essential. Cai et al. (2020) found nurses in China benefited from online psychological consultation. Increasing the availability of telehealth mental health services for nurses may be beneficial in both urban and rural settings.

4.1. Limitations

There are important methodological limitations to this study. First, this study was carried out among a convenience sample that comprised mostly white females, more aware of their mental health condition, and from a rural state in which a small percent consented to the second survey. Thus, the study population may not be representative of nurses in general. Third, emotional distress was measured using a self-reported questionnaire and not an objective assessment of a health professional. However, the scales used in this study demonstrated good reliability and have been successfully used in several other studies (Bernerth et al., 2011; Brown et al., 2018; Henry & Crawford, 2005). An additional follow-up survey of this study would allow us to assess whether the levels of emotional distress differ over time and investigate whether the associated factors remained the same. Finally, similar studies carried out among a more representative sample would be warranted.

5. Conclusion

In conclusion, this repeated cross-sectional study among nurses found that workplace environmental factors, including change fatigue, concerns for COVID-19, worsening of a previous mental health condition, and self-worry about COVID-19 exposure were risk factors for changes in emotional distress. This study further indicated that being male and young were also associated with changes in depression. Strategies to reduce workplace stressors and provide mental wellbeing among nurses are crucial to ensure quality of care and nurses' ability to provide healthcare services during the COVID-19 pandemic. Given the uncertain trajectory of the pandemic, developing, and implementing interventions to lessen the psychological impact of COVID on nurses in a timely manner is essential.

Declaration of competing interest

None.