Highlights
- •The more that nurses cared for patients the higher the nurses’ depression and anxiety.
- •Both home-work and work- home conflict were associated with higher levels of depression and anxiety.
- •Perceived mastery had the strongest negative correlation with depression and anxiety.
- •When asked what has helped the nurses to carry out their care of patients the most common responses were co-worker support, training in proper PPE, and support from family/friends.
- •Fewer than one quarter of the nurses reported that their profession nursing education was helpful in caring for the COVID population.
Abstract
Background
Infectious disease pandemics, such as COVID-19, have dramatically increased in the last several decades.
Purpose
To investigate the personal and contextual factors associated with the psychological functioning of nurses responding to COVID in the New York City area.
Method
Cross sectional data collected via a 95-item internet-based survey sent to an email list of the 7,219 nurses employed at four hospitals.
Findings
2,495 nurses responded (RR 35%). The more that nurses cared for COVID patients as well as experienced home-work conflict and work-home conflict the higher the nurses' depression and anxiety. When asked what has helped the nurses to carry out their care of patients the most common responses were support from and to co-workers, training in proper PPE, and support from family/friends.
Discussion
Understanding the potential triggers and vulnerability factors can inform the development of institutional resources that would help minimize their impact, reducing the risk of psychological morbidity.
Keywords
Background
Emerging and re-emerging infectious disease pandemics have dramatically increased in the last several decades (
Smith et al., 2014
). Prior to 2000, pandemics generally emerged once in every decade. In recent years, they have become significantly more frequent. For example, since 2000 six global outbreaks have occurred: Severe Acute Respiratory Syndrome (2003), Influenza A H1N5, bird flu (2007) H1N1 swine flu (2009), Middle East Respiratory Syndrome (2012), Ebola Virus Disease (2014)) (- Smith K.F.
- Goldberg M.
- Rosenthal S.
- Carlson L.
- Chen J.
- Chen C.
- Ramachandran S
Global rise in human infectious disease outbreaks.
Journal of the Royal Society, Interface. 2014; 1120140950https://doi.org/10.1098/rsif.2014.0950
Ross et al., 2015
) and SARS-CoV-2 (COVID-19) (2020).- Ross A.G.P.
- Crowe S.M.
- Tyndall M.W
Planning for the next global pandemic.
International Journal of Infectious Diseases. 2015; 38: 89-94https://doi.org/10.1016/j.ijid.2015.07.016
As the nation's largest healthcare profession, nurses play a significant role in responding to disasters, such as pandemics. Studies consistently show that many nurses feel they are under- prepared to respond effectively (
Speroni et al., 2015
; - Speroni K.G.
- Seibert D.J.
- Mallinson R.K
Nurses’ perceptions on Ebola care in the United States, part 2: A qualitative analysis.
The Journal of Nursing Administration. 2015; 45: 544-550https://doi.org/10.1097/NNA.0000000000000261
VanDevanter et al., 2017
). In a study of New York City (NYC) nurses responding to a hospital evacuation due to Superstorm Sandy, nurses reported considerable psychosocial challenges in responding to the disaster due to limited prior disaster experience, training, and education (VanDevanter et al., 2017
). A number of studies in the US have shown that nurses responding to disasters experience anxiety, depression and stress (Li et al., 2015
; VanDevanter et al., 2017
; von Strauss et al., 2017
). Global studies have shown that health care workers, in general, are at high risk for developing mental health symptoms, as a result of their exposure to disaster (- von Strauss E.
- Paillard-Borg S.
- Holmgren J.
- Saaristo P
Global nursing in an Ebola viral haemorrhagic fever outbreak: Before, during and after deployment.
Global Health Action. 2017; 101371427https://doi.org/10.1080/16549716.2017.1371427
Mamidipalli et al., 2020
). The purpose of this study was to investigate the personal and contextual factors associated with the psychological functioning of nurses responding to the COVID-19 pandemic.- Mamidipalli S.
- Pratapa S.K.
- Mahant S
Mental health problems faced by healthcare workers due to the COVID-19 pandemic—A review.
Asian Journal of Psychiatry. 2020; (Advance online publication)https://doi.org/10.1016/j.ajp.2020.102119
This study was conducted from May through July 2020, in NYC, during the first US wave of the COVID-19 pandemic. The virus, first reported in Wuhan, China in December 2019, quickly spread to other regions of China (
Schumaker, 2020
). As a result, it was assumed that the virus was most likely to enter the US through West Coast cities and some early cases did. However, due to viral spread from China to Europe, the early major port of US COVID-19 entry was largely through NYC international airports bringing travelers from Europe. The first COVID-19 case in New York State (NYS) was reported on March 1, 2020 (Schumaker, E. (2020): “Timeline: How coronavirus got started,” ABC News, 9 April viewed on 11 April 2020, https://abcnews.go.com/Health/timeline-coronavirus-started/story?id=69435165.
West, 2020
). By March 23 there were 21,000 cases statewide, with 12,305 in NYC. Throughout the spring of 2020 NYS had more cases of COVID-19 than any state in the US. The health care infrastructure of the region was unprepared for the scope and intensity of the care needs for the affected population. Registered Nurses (RNs) were the largest group of health professionals responding to the pandemic (Choi et al., 2020
).Theoretical Framework
The nature of the nursing profession increases the risk of encountering situations of personal risk and, multiple causality events, such as the COVID-19 pandemic, that generate role demands which may impede or conflict with personal lives and family responsibilities. Resiliency theory provides the conceptual framework for understanding the personal and contextual factors impacting the psychological functioning of hospital RNs caring for patients during the months-long surge in COVID-19 illness. This conceptual framework focuses attention on the promotive factors – personal characteristics (assets) and social/environmental protective factors (resources) that can positively affect RNs’ coping (short-term) and the adaptation, restoration, and recovery process (long term) (
Fergus and Zimmerman, 2005
), as well as, identifying the vulnerability and risk factors that can adversely impact current functioning or impede post-event recovery (- Fergus S.
- Zimmerman M.A
Adolescent resilience: A framework for understanding healthy development in the face of risk.
Annual Review of Public Health. 2005; 26: 399-419https://doi.org/10.1146/annurev.publhealth.26.021304.144357
Fergus and Zimmerman, 2005
; - Fergus S.
- Zimmerman M.A
Adolescent resilience: A framework for understanding healthy development in the face of risk.
Annual Review of Public Health. 2005; 26: 399-419https://doi.org/10.1146/annurev.publhealth.26.021304.144357
Garmezy et al., 1984
; Rutter, 1987
, - Rutter M
Psychosocial resilience and protective mechanisms.
The American Journal of Orthopsychiatry. 1987; 57: 316-331https://doi.org/10.1111/j.1939-0025.1987.tb03541.x
Rutter, 2006
; - Rutter M
Implications of resilience concepts for scientific understanding.
Annals of the New York Academy of Sciences. 2006; 1094https://doi.org/10.1196/annals.1376.002
Zimmerman, 2013
). The resilience framework guided our selection of variables included in this study. In this investigation we examined the short-term impact of various promotive factors (assets and resources) on the RNs’ psychological functioning. A long term follow-up is necessary to fully test the model.Methods
Design
Our approach was cross-sectional, using an internet-based survey. In addition to the quantitative survey, participants were given the opportunity to write-in further comments at the end of the survey.
Setting
The study was conducted at the NYU Langone Health System (NYULH), which includes four hospitals in the NYC area: a major medical center hospital, an urban community teaching hospital, a suburban community teaching hospital and an urban specialty hospital that was converted into a COVID-19 hospital, when all elective surgery was stopped in the early stages of the COVID-19 pandemic. Also included were a rehabilitation facility and the ambulatory care sites that are part of the system.
Sample
All RNs who were employed by NYULH on May 5, 2020 were included. Surveys were sent to 7,219 RNs; 2,495 responded, for a response rate of 35%. Ten surveys were eliminated because the respondents were LPNs and two other surveys were eliminated because respondents did not indicate that they had a professional nursing degree leaving 2,483 respondents. Of these about 1,600 completed more than half of the survey items.
Data Collection
With collaboration from NYULH, all RNs at these sites were contacted by email inviting them to participate in an online anonymous survey. Researchers were blinded to the individual email addresses. Following the Total Design Method (
Dillman et al., 2014
), we used multiple email reminders. We sent an alert email, an email with a link to the survey and two reminder emails each with a link to the survey. Respondents were anonymous; therefore, reminders were sent to all RNs whether or not they had responded to an earlier request. We collected the survey data between May 27, 2020 and July 11, 2020. Respondents entered their survey responses electronically into a RED CAP survey located on a secure NYU drive. The survey data were then downloaded to another NYU secure drive and cleaned. The study was approved by the New York University School of Medicine Institutional Review Board.Measures
Data were collected using a 95-item survey. Items and scales were from our previous work on disasters (
VanDevanter et al., 2017
), the Newly Licensed Registered Nurse survey (Kovner et al., 2007
), and a small advisory group of RNs from NYULH. The survey was pilot tested with two RNs not associated with NYULH. Based on the pilot test small changes were made. These nurses estimated that the survey would take about 15 minutes to complete.- Kovner C.T.
- Brewer C.S.
- Fairchild S.
- Poornima S.
- Kim H.
- Djukic M
Newly licensed RNs’ characteristics, work attitudes, and intentions to work.
The American Journal of Nursing. 2007; 107 (quiz 70–71): 58-70https://doi.org/10.1097/01.NAJ.0000287512.31006.66
In addition to basic demographic data we assessed psychosocial morbidity, variables that have been identified as important outcomes in prior studies of RNs and other health care workers responding to disasters, such as anxiety and depression, as well as, the stressors, strains, assets and resources that are constructs of Resiliency Theory.
Anxiety was measured using the Generalized Anxiety Disorder 2 Item scale (
Kroenke et al., 2007
). Depression was measured using the PHQ-2 Screener for depressive disorders (- Kroenke K.
- Spitzer R.L.
- Williams J.B.W.
- Monahan P.O.
- Löwe B
Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection.
Annals of Internal Medicine. 2007; 146: 317-325https://doi.org/10.7326/0003-4819-146-5-200703060-00004
Kroenke et al., 2003
). These are count measures with options ranging from 0 to 3, with zero being “not at all” and three being “nearly every day.” Variables from the resilience framework included potential personal assets (mastery, prior disaster experience, family support) and strains (personal or home life issues, home-work conflict), as well as, contextual resources, situational stressors and strains (or lack thereof) such as work–related characteristics (shift work, organizational support and constraints, work-group support, new unit support, cared for COVID-19 patients, RN-physician relations, temporary housing, work-home conflict). See Appendix A for a list of all scales, sample items and scoring instructions. Individual item such as “NYU Langone has made sufficient supportive services available to nursing staff” and forced choice lists of items such as “How has the COVID-19 pandemic impacted your person or home life (check all that apply)” were developed by the authors. For the analyses we counted the number items checked in each list.Data Analysis
Data were analyzed using SPSS. The number of items in the scales varied from 3 (Work-Life conflict) to 8 (Organizational constraints). In our sample, all scales had Cronbach Alphas of .82 or above.
Descriptive statistics were computed. We analyzed data for normality using the Shapiro-Wilks test. Both anxiety and depression were skewed. For variables that did not satisfy the normality assumption, the non-parametric bivariate rho (Spearman) correlation test was performed. We corrected for the effects of multiple correlations on potentially related variables by performing multivariate partial correlations on variables found to be significant in the bivariate analysis. For the multivariate partial correlation analysis, variables that did not satisfy the normality assumption were transformed using the ranks of the values to achieve normality.
Findings
The sociodemographic characteristics of respondents are shown in Table 1 and are similar to those of the most recent RN National Sample Survey (NSS) (
U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis 2019
) with the exception of first professional degree and age. Baccalaureate graduates made up 77.2% of our sample and only 39.2% in the NSS sample. In the NSS, 50% of respondents were less than 50 years old, and in our sample more than 50% were less than 40 years old. However, in terms of highest degree the samples were similar; 22.7% of our and 19.3% in the NSS had a masters or higher degree (not shown). Sixty-eight percent of our respondents were white, while in the NSS sample 73.3% were white. The large majority (87.7%) of our respondents were non-Nurse Practitioner clinical RNs.Table 1Sociodemographic Characteristics of Nurses
| Percent | Number | ||
|---|---|---|---|
| Age | 20-29 | 25.1 | 364 |
| 30-39 | 29.7 | 430 | |
| 40-49 | 17.3 | 250 | |
| 50-59 | 17.3 | 251 | |
| 60-69 | 10.3 | 149 | |
| 70 or over | 0.3 | 4 | |
| Gender | Female | 91.4 | 1332 |
| Male | 6.4 | 94 | |
| Other | 0.2 | 3 | |
| Prefer not to answer | 2.0 | 29 | |
| Race | Asian | 15.4 | 221 |
| Black | 9.9 | 142 | |
| White | 68.6 | 986 | |
| Native American, American Indian, Native Hawaiian, Pacific Islander, Other | 6.2 | 89 | |
| Marital status | Married/partnered | 52.4 | 762 |
| Never married, widowed, divorced, separated | 47.6 | 712 | |
| Children | No children or none living at home | 45.5 | 652 |
| Children living at home | 54.6 | 785 | |
| Job Title | Clinical RN (excludes advanced practice nurse) | 87.7 | 1437 |
| Manager/administrator | 6.7 | 109 | |
| Advanced practice nurse | 5.7 | 93 | |
| First Professional Nursing Degree – line 5686 | Baccalaureate in Nursing (BSN) | 77.2 | 1116 |
| Associate degree/diploma | 16.4 | 236 | |
| Masters or doctoral | 6.5 | 94 |
Characteristics of the RNs’ work life are shown in Table 2. Almost 75% of the respondents worked in an inpatient setting with 25.1% working in ICUs. More than 75% did not have any prior epidemic experience or experience with the most recent natural disaster, Superstorm Sandy, which impacted the functioning of a number of hospitals in the NYC metropolitan region and required the sudden evacuation and temporary closure of the NYULH major medical center (
VanDevanter et al., 2017
). More than half of the respondents had been assigned to a new unit as part of NYULH's response to the pandemic. Of those, 75.9% thought that they had received sufficient support from staff at the new unit. Most RNs had cared for COVID-19 patients at least for a few days and the majority having cared for COVID-19 patients all or most days.Tabled
1
| Median (IQR) | Range (IQR) | ||
|---|---|---|---|
| Hours worked previous week | 37.5 (36-40) | (36-40) | 2483 |
Table 2Work-Life Characteristics of Nurses
| NYU Site | Percent | Number | |
|---|---|---|---|
| Tisch/Kimmel | 46.5 | 814 | |
| NYU Winthrop | 35.4 | 620 | |
| NYU Langone Brooklyn | 12.7 | 222 | |
| NYU Langone Orthopedic | 5.3 | 93 | |
| Unit type | |||
| Intensive Care Unit | 25.1 | 403 | |
| Inpatient-non ICU | 49.2 | 788 | |
| Other | 25.7 | 412 | |
| Participated in evacuation of hospital during Super Storm Sandy | |||
| Yes | 8.2 | 120 | |
| No | 91.8 | 1336 | |
| Prior to admission of COVID-19 patients had experience in previous epidemic/pandemic | yes | 24.4 | 356 |
| No | 75.6 | 1102 | |
| Since March 15, 2020 was assigned to a new unit | |||
| Never | 46.6 | 747 | |
| Once | 14.5 | 232 | |
| Twice | 10.8 | 173 | |
| Three or more times | 28.1 | 451 | |
| Received sufficient support from staff at new work unit | |||
| Yes | 43.7 | 694 | |
| No | 13.9 | 220 | |
| Not assigned to a new unit | 42.4 | 674 | |
| NYU Langone has made sufficient supportive services available to nursing staff | |||
| Yes | 55.8 | 842 | |
| No | 16.4 | 247 | |
| Don't know | 29.9 | 421 | |
| Typical work schedule | |||
| Days | 66.6 | 1170 | |
| Other | 33.4 | 588 | |
| How often cared for patients with COVID-19 | |||
| All/most days | 55.1 | 969 | |
| About half of days | 15.8 | 277 | |
| A few days | 17.3 | 304 | |
| Not at all | 11.8 | 208 | |
| Kind of communication received from nurse manager | |||
| Frequent, valuable | 31.5 | 554 | |
| Good | 20.7 | 364 | |
| Adequate | 26.4 | 465 | |
| Insufficient | 15.5 | 273 | |
| Poor to no | 5.9 | 104 | |
| Years worked as RN | |||
| <1 year | 5.3 | 77 | |
| ≥1 year | 94.7 | 1371 | |
| Days absent from work since March 15, 2020 | |||
| None | 55.6 | 868 | |
| 1-3 | 29.0 | 453 | |
| 4-6 | 6.1 | 96 | |
| ≥7 | 9.3 | 145 |
RNs experienced COVID-19’s impact not only at work but in their home life as well (Table 3). In addition to specific forced choice items, we included a scale that measures work-family conflict, the degree to which the respondent's job interferes with their home life (mean 3.31; SD 1.63; range 1-5) and the scale that measures family-work conflict, the degree to which home life interferes with their job (mean 1.62; SD 1.09; range 1-5). Only 16.5% of the RNs wrote that COVID-19 has no or minor impact on their personal or home life. Almost half of the RNs reported needing to self-isolate and more than 18% resided in some temporary place (NYULH provided housing, usually hotel space near the hospital for any RN who wanted or needed to isolate from their family). Fully 29% of the RNs had a family member or close friend who was critically ill or died from COVID-19 and for most of those RNs, they were unable to be with those family members or friends during their illness or when they died. When asked what has helped them to carry out their care of patients, the most common responses were co-worker support, training in proper Personal Protective Equipment (PPE), support from family/friends, providing support to others, and previous infectious disease patient care experience.
Table 3Home Life, Well-Being and COVID-19
| Question/Variable | Response Options | % | N |
|---|---|---|---|
| Since caring for patients with COVID-19, has resided in a temporary place for at least part of the time to protect family or persons one lives with | |||
| Yes | 18.6 | 326 | |
| No | 71.2 | 1247 | |
| Have not cared for any patients with COVID-19 | 10.2 | 178 | |
| What has helped to carry out care of patients with COVID-19 (check all that apply) | |||
| Received support from co-workers | 75.0 | 1321 | |
| Support of my family/friends | 58.4 | 1029 | |
| Provided support to others | 56.3 | 992 | |
| Received training in the proper donning (putting on), doffing (taking off), and disposal of personal protective equipment (PPE) | 53.9 | 949 | |
| Usually very resourceful in difficult situations | 37.5 | 661 | |
| Have previous infectious disease/infection control patient care experiences | 34.4 | 607 | |
| Faith/spirituality/religion | 30.0 | 529 | |
| Was provided with adequate supplies of personal protective equipment (PPE) | 27.0 | 475 | |
| Received training in infectious disease/infection control | 25.9 | 456 | |
| Received support from Nursing leadership | 25.7 | 452 | |
| Professional nursing education | 23.3 | 410 | |
| Felt the hospital was well-equipped) to provide care to COVID-19 patients | 16.0 | 282 | |
| Others remained calm | 16.1 | 283 | |
| Have not cared for any patients with COVID-19 | 11.1 | 196 | |
| Other | 3.5 | 62 | |
| COVID-19 pandemic impacted personal or home life in the following ways (check all that apply) | |||
| Needed to self-isolate | 44.5 | 784 | |
| Family member/close friend needed to self-isolate | 29.4 | 518 | |
| Health professional diagnosed family member/close friend with COVID-19 | 23.5 | 414 | |
| Had no or minor impact | 16.5 | 291 | |
| Family member/close friend died from COVID-19 | 15.9 | 281 | |
| Healthcare professional diagnosed you with COVID-19 | 13.5 | 238 | |
| Family member/close friend was critically ill with COVID-19 complications | 12.7 | 223 | |
| Family member/close friend died, but not from COVID-19 | 5.4 | 96 | |
| Other | 6.7 | 118 | |
| Other ongoing issues as a result of COVID-19 (check all that apply) | |||
| Spouse/partner lost their job | 12.8 | 225 | |
| Pension or other savings negatively impacted | 26.6 | 469 | |
| Unable to pay mortgage or rent | 3.6 | 64 | |
| Had to move into a relative's or friend's home | 3.3 | 59 | |
| Relatives or friends moved into your home | 4.5 | 80 | |
| Had new caregiving responsibilities for children, other family and/or friends | 26.4 | 466 | |
| Irreparable harm to you, your family, and/or your community | 9.5 | 168 | |
| If a family member/close friend was critically ill or died from COVID-19 able to be present with them (check all that apply) | |||
| Yes | 2.8 | 38 | |
| No | 26.2 | 355 | |
| DNA, no family member/close friend was critically ill or died from COVID-19 | 71.0 | 964 |
The mean score for anxiety was 1.97 (s.d. 1.81) and median of 2.0 (Interquartile Range (0.0-3.0). About 27.4% of the RNs scored 3 or higher, which is cut off score for further evaluation for anxiety. The data were skewed (two items; range 0-3). The mean score for depression was 1.42 (s.d. 1.57) and the median was 1.0 (Interquartile Range 0.0-2.0). About 16.5% of the RNs scored 3 or higher, which is the cut off score for further evaluation for depression.
For the multivariate analyses, we first controlled for demographic variables. Table 4 shows the relationship between the control variables and both anxiety and depression. We report medians and interquartile ranges because the data are skewed. Anxiety scores were higher for younger RNs compared to older RNs, White RNs compared to Black and Asian RNs, those working in the ICU compared to other sites, clinical nurses compared to managers, and those with Baccalaureate degrees compared to other degrees. RNs without children had higher anxiety scores than those with children. Although the median anxiety score for married/partnered RNs compared to widowed, divorced, and never married was identical, the ranges varied with married RNs having a lower range.
Table 4Relationship Between Control Variables and Anxiety and Depression
| Variable Name | Response Options | Median Anxiety (Interquartile Range) | Median Depression (Interquartile Range) |
|---|---|---|---|
| Age | 20-29 | 2.0 (1.0–4.0) a | 2.0 (0.0–2.0) b |
| 30–39 | 2.0 (1.0–3.0) | 1.0 (0.0–2.0) | |
| 40–49 | 2.0 (0.0–3.0) | 1.0 (0.0–2.0) | |
| 50–59 | 1.0 (0.0–2.0) | 1.0 (0.0–2.0) | |
| 60–69 | 1.0 (0.0–2.0) | 1.0 (0.0–2.0) | |
| 70 and over | 0.0 (0.0–0.0) | 0.0 (0.0–1.5) | |
| Gender | Male | 2.0 (0.0–3.0) | 1.5(0.0–2.0) |
| Female | 2.0 (1.0–3.0) | 1.0 (0.0–2.0) | |
| Race | White | 2.0 (1.0–3.0) c | 1.0 (0.0–2.0) |
| Asian | 1.0 (0.0–3.0) | 1.0 (0.0–2.0) | |
| Black | 1.0 (0.0–3.0) | 0.0 (0.0–2.0) | |
| Other | 2.0 (0.0–2.0) | 1.0 (0.9–2.0) | |
| Unit type | ICU | 2.0 (1.0–4.0) d | 2.0 (0.0–2.75) e |
| Inpatient non ICU | 2.0 (0.0–3.0) | 1.0 (0.0–2.0) | |
| Other | 2.0 (0.0–2.0) | 1.0 (0.0–2.0) | |
| Job Title | Clinical RN | 2.0 (1.0–3.0) f | 1.0 (0.0–2.0) |
| Advanced practice RN | 1.0 (1.0–3.0) | 1.0 (0.0–2.0) | |
| Manager/Administrator | 1.0 (0.0–2.0) | 1.0 (0.0–2.0) | |
| First professional nursing degree | BSN | 2.0 (1.0–3.0) g | 1.0 (0.0–2.0) h |
| Associate degree/Diploma | 1.0 (0.0–2.0) | 1.0 (0.0–2.0) | |
| Masters/Doctoral | 1.0 (0.0–2.0) | 0.0 (0.0–2.0) | |
| Marital status | Married/partnered | 2.0 (0.0–2.0) *** | 1.0 (0.0–2.0) |
| Widowed, divorced, separated, never married | 2.0 (1.0–3.0) | 1.0 (0.0–2.0) | |
| Children | No children or no children living at home | 2.0 (1.0–3.0) *** | 1.0 (0.0–2.0) |
| Children living at home | 1.0 (0.0–2.0) | 1.0 (0.0–2.0) |
Significance *p < .05, **p < .01, ***p < .001 Kruskal-Wallis (non-parametric equivalent to ANOVA) for categorical variables and Mann-Whiney for dichotomous variables.
*** p < .001, ** p < .01, p < .05
Anxiety
a-70+to 60-69*, 70+-50-59*, 70+-40-49, 70+to 30-39**, 70+to 20-29***, 60-69 to 40-49*, 60-69 to 30-39**, 60-69 to 20-29***, 50-59 to 30-39 **,50-59 to 20-29***, 40-49 to 20-29***, 30-39 to 20-29***
c-Black-White**, Asian-White*
d- other-ICU***, inpatient-ICU***,
f-administrator-direct care RN**
g- Masters – BSN**, associate/diploma-BSN***, *
Depression
b 60-69 to 30-39**, 60-69 to 20-29***, 60-69 to 40-49*. 50-59 to 30-39*, 50-59 to 20-29***, 40-49 to 20-29**, 30-39 to 2029 ***
e-Other-ICU**, Inpatient-ICU***
h-masters – BSN*, Diploma-BSN
There were fewer differences in depression among the RNs. Younger nurses scored higher on the depression scale than older RNs. Nurses in ICUs were more likely to be depressed than those working in other sites as were RNs with a baccalaureate degree.
Table 5 shows the Spearman Partial Nonparametric correlations between variables of interest and depression and anxiety, while controlling for the control variables described above (e.g., age, race, work location and role, and educational background). In terms of level of anxiety and Assets and Resources consistent with the resilience framework, higher scores of quality of physician-nurse work relations were associated with less anxiety. More support is associated with less anxiety, as was NYULH support services. More assets and resources were associated with less anxiety as was residing in temporary housing. More mastery was associated with less anxiety.
Table 5Spearman Partial Nonparametric Correlation: Depression and Anxiety Levels When Controlling for Age, Gender, Race, Unit Type, Title, First Professional Nursing Degree, Marital Status, Children
| Variable | Correlation with Anxiety (sig) | Correlation with Depression (sig) |
|---|---|---|
| ASSETS AND RESOURCES | ||
| Quality of communication with nurse managers (Lower score, higher quality) | 0.044 | 0.043 |
| Quality of physician-nurse work relations (Higher score, higher quality) | -0.095* | -0.107** |
| Sufficient support from staff at new unit (Lower score, higher support) | 0.117 ** | 0.040 |
| NYU Langone made sufficient supportive services available to nursing staff (Lower score, higher support) | 0.109** | 0.143*** |
| Number of assets and resources helpful in carrying out care of COVID-19 patients | -0.049 | -0.074* |
| Resided in temporary housing to protect others in household | -0.083* | -0.082* |
| Prior epidemic experience | 0.006 | -0.011 |
| Mastery (Lower score, higher mastery) | 0.402*** | 0.405*** |
| STRESSORS AND STRAINS | ||
| Stressful knowing that COVID-19 patients were being cared for in your hospital (Lower score, higher stress) | -0.250*** | -0.156 *** |
| Frequency of caring for Covid-19 patients (Lower score higher frequency) | -0.152*** | -0.129 ** |
| Frequency of organizational constraints that impeded ability to do job (Higher score, higher frequency) | 0.252*** | 0.202*** |
| Number of ways in which COVID-19 pandemic impacted your personal or home life | 0.179*** | 0.134*** |
| Days absent from work | 0.056 | 0.056 |
| Hours worked previous week | 0.036 | 0.024 |
| Work schedule shifts | -0.006 | -0.049 |
| Work-home life conflict (Higher score, higher conflict) | 0.265*** | 0.254 *** |
| Home-work life conflict (Higher score, higher conflict) | 0.244*** | 0.244*** |
| Family member or close friend died | 0.146*** | 0.083* |
| Number of other ongoing issues due to COVID-19 pandemic | 0.208*** | 0.171*** |
*** p < = .001, **p < = .01,*p < .05
In terms of stressors and strains consistent with the resilience framework, more stress was associated with more anxiety as was higher frequency of caring for COVID-19 patients. More organizational constraints, as well as, higher number of ways in which COVID impacted one's home life was associated with more anxiety. More work-home and home-work conflict was associated with more anxiety, as well as, having a family member die and higher number of ongoing issues due to COVID-19.
Relationships with depression followed a similar pattern. In terms of assets and resources, consistent with the resilience framework, the higher the perceived quality of physician-nurse relations the lower the depression level. Higher perceived NYULH support services was also associated with a lower depression level, as was residing in temporary housing. The strongest relationship was between higher mastery scores and lower depression scores.
In terms of stressors and strains, knowing that COVID-19 patients were being cared for in the RNs hospital, as well as, the higher the frequency of caring for COVID-19 patients were associated with higher levels of depression. Higher frequency of organizational constraints and personal impacts were associated with higher levels of depression. Greater work-home and home-work conflict were associated with high levels of depression. Having a. family member or friend die from COVID-19 and other ongoing personal issues were also associated with higher levels of depression.
Discussion
The COVID-19 pandemic is a public health crisis. Since the World Health Organization (WHO) designated “the novel coronavirus outbreak a public health emergency of international concern (PHEIC)” on January 30, 2020, (
World Health Organization 2020
), the pandemic has continued unabated with the number of COVID-19 related mortality and morbidity in the US and world-wide at high levels. The virus's impact on the public health infrastructure continues to mount. RNs, primary front-line workers in the COVID-19 pandemic, encounter not only the stresses and risk of a serious and potentially fatal health condition, but also the increased risk of a mental health impact. The pandemic has subjected RNs, and other front-line healthcare workers, to situations of unparalleled stress, as routine roles and responsibilities are disrupted and there is a necessity to work outside of their normal routine.World Health Organization (2020). Timeline: WHO's COVID-19 response. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timelineAccessedOctober242020.
Coping with this changed work environment, one that is now a site for exposure to life threatening infection, presents a challenge the health care work force may be ill-prepared to address. This daunting task is complicated further by concerns not only about personal risk but also worry about infecting family members and others in their social network. These situational factors increase the risk for psychological morbidity and burnout. Indeed, there is growing recognition that a critical part of the public health response to the COVID-19 pandemic should be supporting the mental health of the healthcare workers (
Chew et al., 2020
; - Chew N.W.S.
- Lee G.K.H.
- Tan B.Y.Q.
- Jing M.
- Goh Y.
- Ngiam N.J.H.
- Yeo L.L.L.
- Ahmad A.
- Khan Ahmed
- F. Napolean Shanmugam
- G. Sharma
- K. A.
- Komalkumar R.N.
- Meenakshi P.V.
- Shah K.
- Patel B.
- Chan B.P.L.
- Sunny S.
- Chandra B.
- Ong J.J.Y.
- Sharma V.K.
A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak.
Walton et al., 2020
).Although it not possible to fully eliminate the risk of psychosocial morbidity, an achievable goal is to promote the factors that can build and sustain resiliency in the health care workforce. Understanding the potential triggers and vulnerability factors (e.g. stresses and strains) that contribute to psychological morbidity, such as depression and anxiety in the nursing workforce, can inform the development of institutional resources and services that would help reduce or minimize their impact, thereby, reducing the risk of psychological morbidity.
A review of the limited early studies that explored the COVID-related psychological morbidity experienced by healthcare workers, primarily nursing and medical personnel, noted that in addition to depression and anxiety symptoms, extensive stress-related strain was reported as well (
Bohlken et al., 2020
); as we have observed in the present investigation. Consistent with the strategies to decrease morbidity are both peer and institutional support including temporary housing. Similarly decreasing organizational constraints such as insufficient protective gear and incorrect directions is likely to decrease morbidity.In a rapid review and meta-analysis of the occurrence, prevention and management of the adverse psychological impact of emerging virus outbreaks (e.g. SARS, MERS, Ebola, H1N1, H7N9, as well as, COVID-19) on healthcare workers, consistent with the resilience framework, the factors associated with reduced psychological morbidity included situational and psychosocial resources, such as access to adequate PPE, clear communication, adequate rest and practical as well as emotional support (
Kisely et al., 2020
). The importance of social support in promoting resilience was noted in a review of COVID-19-related research (Bohlken et al., 2020
). These finding echo the relationships we have observed in the present study.We observed that institutional resources and support (i.e., adequacy of PPE, sufficient communication, supportive staff relationships and sufficient supportive services) were associated with lower levels of anxiety and depression in the nursing workforce. It also merits noting that institutional resources devoted to professional development were particularly important. We found that training in the proper donning, doffing, and disposal of PPE was one of the top factors the majority of RNs identified as having helped them in caring for patients with COVID-19. Of concern, less than one quarter of the RNs in this study reported that their professional nursing education, the foundational resource for the nursing workforce, was helpful in caring for this patient population. Given the health care challenges posed by the emergence of this highly, infectious agent, this nursing education issue merits further attention.
An important concept in resiliency theory is stress-related growth and psychological thriving – the triumphs and opportunity for personal growth one may achieve by living through and coping with an adverse experience, facing a profound challenge or adapting to a changed reality (
Calhoun and Tedeschi, 2010
; O'Leary and Ickovics, 1995
; Park, 1998
). Those who have successfully endured this type of strengths-building experience, emerge better enabled to psychologically recover from future events, continuing to grow and function, e.g. thrive, even when faced with additional hardships (Ledesma, 2014
; - Ledesma J
Conceptual frameworks and research models on resilience in leadership.
SAGE Open. 2014; 4215824401454546https://doi.org/10.1177/2158244014545464
O'Leary, 1998
). These benefits or gains include acquisition of newly developed skills and knowledge, a sense of mastery or increased confidence, a strengthening of personal relationships and a changed philosophy of life (Carver, 2010
; Tedeschi and Calhoun, 1996
). Long-term follow-up is required to determine the extent to which frontline RNs will experience stress-related growth and psychological thriving in the post COVID-19 pandemic era,. However, the potential for such a positive outcome in the future, supports the value of maintaining adequate, evidence-based, institutional resources to facilitate and maintain resilience in the healthcare workforce, ensuring their readiness to respond to future public health emergencies.Author Contribution
Christine Kovner: 1) substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published
Victoria Raveis: 1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; 2) revising it critically for important intellectual content; and 3) final approval of the version to be published
Nancy Van Devanter: 1) substantial contributions to conception and design, and interpretation of data; 2) revising it critically for important intellectual content; and 3) final approval of the version to be published
Gary Yu: 1) substantial contributions to acquisition of data, analysis and interpretation of data; 2) final approval of the version to be published
Kimberly Glassman: 1) substantial contributions to conception and design, acquisition of data, and interpretation of data; 2) revising it critically for important intellectual content, 3) final approval of the version to be published
Laura Ridge: 1) substantial contributions to conception and interpretation of data; and 2) final approval of the version to be published
Acknowledgment
This work was supported by NYU Langone Hospitals. We would like to thank Debra Albert, DNP, MBA, RN, NEA-BC, Senior Vice President for Patient Care Services & Chief Nursing Officer NYU Langone Health System for the help that she provided.
Appendix A
Scales
Tabled
1
| Scale | Sample Question or Statement (number of items) | Response Range | Mean (sd) | Cronbach's Alpha |
|---|---|---|---|---|
| Organizational Constraints (degree to which employees cannot turn knowledge and effort into strong job performance) | How often do you find it difficult or impossible to do your job because of conflicting job demands? (7) | 1 = Never, 2 = less than once a month, 3 = 1-3 days per month, 4 = 1-2 days per week, 5 = 3-4 days per week, 6 = 5 or more days per week | 2.55 (1.11) | .908 |
| Collegial RN-MD Relations (degree to which there is a positive working relationship between nurses and physicians) | Physicians and nurses have good working relationships (3) | 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree | 3.25 (1.05) | .969 |
| Pearlin Mastery Scale | I can do just about anything I set my mind to (7) | 1=strongly disagree, 2=disagree, 3=neither agree nor disagree, 4=agree, 5=strongly agree | 2.79 (0.56) | 0.84 |
| PHQ-4: Depression | Over the last two weeks, how often have you been bothered by feeling down, depressed, or hopeless (2) | 1 = not at all, 2 = several days, 3 = more than half the days, 4 = nearly every day | 3.44 (1.57) | 0.87 |
| PHQ4: Anxiety | Over the last two weeks, how often have you been bothered by feeling nervous, anxious or on edge (2) | 1 = not at all, 2 = several days, 3 = more than half the days, 4 = nearly every day | 3.98 (1.81) | 0.88 |
| Work-family conflict (degree to which the respondent's job interferes with their homelife) | How often did you experience your job keep you from spending the amount of time you would like to spend with your family? (3) | 1 = Never, 2 = less than once a month, 3 = 1-3 days per week, 4 = 1-2 days per week, 5 = 3-4 days per week, 6 = 5 or more days per week | 3.31 (1.63) | 0.88 |
| Family-Work conflict (degree to which the respondent's job interferes with their homelife) | How often did you experience your home-life interfered with your job or career (3) | 1 = Never, 2 = less than once a month, 3 = 1-3 days per week, 4 = 1-2 days per week, 5 = 3-4 days per week, 6 = 5 or more days per week | 1.62 (1.09) | 0.89 |
| Commitment to Nursing | Do you stand by your choice of the nursing profession? (3) | 1-6, 1-not at all to 6-very much | 1.55 (0.83) | 0.82 |
References
- COVID-19 pandemic: Stress experience of healthcare workers - A short current review.Psychiatrische Praxis. 2020; 47: 190-197https://doi.org/10.1055/a-1159-5551
- Beyond recovery from trauma: Implications for clinical practice and research.Journal of Social Issues. 2010; 54: 357-371https://doi.org/10.1111/j.1540-4560.1998.tb01223.x
- Resilience and thriving: Issues, models, and linkages.Journal of Social Issues. 2010; 54: 245-266https://doi.org/10.1111/j.1540-4560.1998.tb01217.x
- A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak.Brain, Behavior, and Immunity. 2020; 88: 559-565https://doi.org/10.1016/j.bbi.2020.04.049
- Nursing and the novel coronavirus: Risks and responsibilities in a global outbreak.Journal of Advanced Nursing. 2020; 76: 1486-1487https://doi.org/10.1111/jan.14369
- Internet, phone, mail, and mixed-mode surveys: The tailored design method.4th ed. Wiley, 2014
- Adolescent resilience: A framework for understanding healthy development in the face of risk.Annual Review of Public Health. 2005; 26: 399-419https://doi.org/10.1146/annurev.publhealth.26.021304.144357
- The study of stress and competence in children: A building block for developmental psychopathology.Child Development. 1984; 55: 97-111
- Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: Rapid review and meta-analysis.BMJ (Clinical Research Ed.). 2020; 369: m1642https://doi.org/10.1136/bmj.m1642
- Newly licensed RNs’ characteristics, work attitudes, and intentions to work.The American Journal of Nursing. 2007; 107 (quiz 70–71): 58-70https://doi.org/10.1097/01.NAJ.0000287512.31006.66
- The patient health questionnaire-2: Validity of a two-item depression screener.Medical Care. 2003; 41: 1284-1292https://doi.org/10.1097/01.MLR.0000093487.78664.3C
- Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection.Annals of Internal Medicine. 2007; 146: 317-325https://doi.org/10.7326/0003-4819-146-5-200703060-00004
- Conceptual frameworks and research models on resilience in leadership.SAGE Open. 2014; 4215824401454546https://doi.org/10.1177/2158244014545464
- A grounded theory study of “turning into a strong nurse”: Earthquake experiences and perspectives on disaster nursing education.Nurse Education Today. 2015; 35: e43-e49https://doi.org/10.1016/j.nedt.2015.05.020
- Mental health problems faced by healthcare workers due to the COVID-19 pandemic—A review.Asian Journal of Psychiatry. 2020; (Advance online publication)https://doi.org/10.1016/j.ajp.2020.102119
- Resilience and thriving in response to challenge: An opportunity for a paradigm shift in women's health.Women's Health (Hillsdale, N.J.). 1995; 1: 121-142
- Strength in the face of adversity: Individual and social thriving.Journal of Social Issues. 1998; 54: 425-446https://doi.org/10.1111/j.1540-4560.1998.tb01228.x
- Stress-related growth and thriving through coping: The roles of personality and cognitive processes.Journal of Social Issues. 1998; 54: 267-277https://doi.org/10.1111/j.1540-4560.1998.tb01218.x
- Planning for the next global pandemic.International Journal of Infectious Diseases. 2015; 38: 89-94https://doi.org/10.1016/j.ijid.2015.07.016
- Psychosocial resilience and protective mechanisms.The American Journal of Orthopsychiatry. 1987; 57: 316-331https://doi.org/10.1111/j.1939-0025.1987.tb03541.x
- Implications of resilience concepts for scientific understanding.Annals of the New York Academy of Sciences. 2006; 1094https://doi.org/10.1196/annals.1376.002
Schumaker, E. (2020): “Timeline: How coronavirus got started,” ABC News, 9 April viewed on 11 April 2020, https://abcnews.go.com/Health/timeline-coronavirus-started/story?id=69435165.
- Global rise in human infectious disease outbreaks.Journal of the Royal Society, Interface. 2014; 1120140950https://doi.org/10.1098/rsif.2014.0950
- Nurses’ perceptions on Ebola care in the United States, part 2: A qualitative analysis.The Journal of Nursing Administration. 2015; 45: 544-550https://doi.org/10.1097/NNA.0000000000000261
- The posttraumatic growth inventory: Measuring the positive legacy of trauma.Journal of Traumatic Stress. 1996; 9: 455-471https://doi.org/10.1007/BF02103658
- Brief summary results from the 2018 National Sample Survey of Registered Nurses.2019 (Rockville, Maryland)
- Challenges and resources for nurses participating in a Hurricane Sandy hospital evacuation.Journal of Nursing Scholarship. 2017; 49: 635-643https://doi.org/10.1111/jnu.12329
- Global nursing in an Ebola viral haemorrhagic fever outbreak: Before, during and after deployment.Global Health Action. 2017; 101371427https://doi.org/10.1080/16549716.2017.1371427
- Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic.European Heart Journal. 2020; 9: 241-247https://doi.org/10.1177/2048872620922795
- The first case of coronavirus confirmed in New York State.The Wall Street Journal. 2020; (https://www.wsj.com/articles/first-case-of-coronavirus-confirmed-in-new-york-state-11583111692). Retrieved November 1,2020
World Health Organization (2020). Timeline: WHO's COVID-19 response. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timelineAccessedOctober242020.
- Resiliency theory: A strengths-based approach to research and practice for adolescent health.Health Education & Behavior. 2013; 40: 381-383https://doi.org/10.1177/1090198113493782
Article info
Publication history
Published online: April 05, 2021
Accepted:
March 27,
2021
Received in revised form:
March 11,
2021
Received:
January 6,
2021
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
