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The psychosocial impact on frontline nurses of caring for patients with COVID-19 during the first wave of the pandemic in New York City

      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 K.F.
      • Goldberg M.
      • Rosenthal S.
      • Carlson L.
      • Chen J.
      • Chen C.
      • Ramachandran S
      Global rise in human infectious disease outbreaks.
      ). 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)) (
      • Ross A.G.P.
      • Crowe S.M.
      • Tyndall M.W
      Planning for the next global pandemic.
      ) and SARS-CoV-2 (COVID-19) (2020).
      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 K.G.
      • Seibert D.J.
      • Mallinson R.K
      Nurses’ perceptions on Ebola care in the United States, part 2: A qualitative analysis.
      ;
      • VanDevanter N.
      • Raveis V.H.
      • Kovner C.T.
      • McCollum M.
      • Keller R
      Challenges and resources for nurses participating in a Hurricane Sandy hospital evacuation.
      ). 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 N.
      • Raveis V.H.
      • Kovner C.T.
      • McCollum M.
      • Keller R
      Challenges and resources for nurses participating in a Hurricane Sandy hospital evacuation.
      ). A number of studies in the US have shown that nurses responding to disasters experience anxiety, depression and stress (
      • Li Y.
      • Turale S.
      • Stone T.E.
      • Petrini M
      A grounded theory study of “turning into a strong nurse”: Earthquake experiences and perspectives on disaster nursing education.
      ;
      • VanDevanter N.
      • Raveis V.H.
      • Kovner C.T.
      • McCollum M.
      • Keller R
      Challenges and resources for nurses participating in a Hurricane Sandy hospital evacuation.
      ;
      • 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 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 (
      • Mamidipalli S.
      • Pratapa S.K.
      • Mahant S
      Mental health problems faced by healthcare workers due to the COVID-19 pandemic—A review.
      ). 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.
      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, 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.

      ). 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 (
      • West M.G
      The first case of coronavirus confirmed in New York State.
      ). 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 K.R.
      • Skrine Jeffers K.
      • Cynthia Logsdon M.
      Nursing and the novel coronavirus: Risks and responsibilities in a global outbreak.
      ).

      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 S.
      • Zimmerman M.A
      Adolescent resilience: A framework for understanding healthy development in the face of risk.
      ), 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.
      ;
      • Garmezy N.
      • Masten A.S.
      • Tellegen A
      The study of stress and competence in children: A building block for developmental psychopathology.
      ;
      • Rutter M
      Psychosocial resilience and protective mechanisms.
      ,
      • Rutter M
      Implications of resilience concepts for scientific understanding.
      ;
      • Zimmerman M.A
      Resiliency theory: A strengths-based approach to research and practice for adolescent health.
      ). 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 D.A.
      • Smyth J.D.
      • Christian L.M
      Internet, phone, mail, and mixed-mode surveys: The tailored design method.
      ), 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 N.
      • Raveis V.H.
      • Kovner C.T.
      • McCollum M.
      • Keller R
      Challenges and resources for nurses participating in a Hurricane Sandy hospital evacuation.
      ), the Newly Licensed Registered Nurse survey (
      • Kovner C.T.
      • Brewer C.S.
      • Fairchild S.
      • Poornima S.
      • Kim H.
      • Djukic M
      Newly licensed RNs’ characteristics, work attitudes, and intentions to work.
      ), 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.
      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 K.
      • Spitzer R.L.
      • Williams J.B.W.
      • Monahan P.O.
      • Löwe B
      Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection.
      ). Depression was measured using the PHQ-2 Screener for depressive disorders (
      • Kroenke K.
      • Spitzer R.L.
      • Williams J.B.W
      The patient health questionnaire-2: Validity of a two-item depression screener.
      ). 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
      Brief summary results from the 2018 National Sample Survey of Registered Nurses.
      ) 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
      PercentNumber
      Age20-2925.1364
      30-3929.7430
      40-4917.3250
      50-5917.3251
      60-6910.3149
      70 or over0.34
      GenderFemale91.41332
      Male6.494
      Other0.23
      Prefer not to answer2.029
      RaceAsian15.4221
      Black9.9142
      White68.6986
      Native American, American Indian, Native Hawaiian, Pacific Islander, Other6.289
      Marital statusMarried/partnered52.4762
      Never married, widowed, divorced, separated47.6712
      ChildrenNo children or none living at home45.5652
      Children living at home54.6785
      Job TitleClinical RN (excludes advanced practice nurse)87.71437
      Manager/administrator6.7109
      Advanced practice nurse5.793
      First Professional Nursing Degree – line 5686Baccalaureate in Nursing (BSN)77.21116
      Associate degree/diploma16.4236
      Masters or doctoral6.594
      Tabled 1
      Median (IQR)Range (IQR)
      Hours worked previous week37.5 (36-40)(36-40)2483
      Table 2Work-Life Characteristics of Nurses
      NYU SitePercentNumber
      Tisch/Kimmel46.5814
      NYU Winthrop35.4620
      NYU Langone Brooklyn12.7222
      NYU Langone Orthopedic5.393
      Unit type
      Intensive Care Unit25.1403
      Inpatient-non ICU49.2788
      Other25.7412
      Participated in evacuation of hospital during Super Storm Sandy
      Yes8.2120
      No91.81336
      Prior to admission of COVID-19 patients had experience in previous epidemic/pandemicyes24.4356
      No75.61102
      Since March 15, 2020 was assigned to a new unit
      Never46.6747
      Once14.5232
      Twice10.8173
      Three or more times28.1451
      Received sufficient support from staff at new work unit
      Yes43.7694
      No13.9220
      Not assigned to a new unit42.4674
      NYU Langone has made sufficient supportive services available to nursing staff
      Yes55.8842
      No16.4247
      Don't know29.9421
      Typical work schedule
      Days66.61170
      Other33.4588
      How often cared for patients with COVID-19
      All/most days55.1969
      About half of days15.8277
      A few days17.3304
      Not at all11.8208
      Kind of communication received from nurse manager
      Frequent, valuable31.5554
      Good20.7364
      Adequate26.4465
      Insufficient15.5273
      Poor to no5.9104
      Years worked as RN
      <1 year5.377
      ≥1 year94.71371
      Days absent from work since March 15, 2020
      None55.6868
      1-329.0453
      4-66.196
      ≥79.3145
      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/VariableResponse 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
      Yes18.6326
      No71.21247
      Have not cared for any patients with COVID-1910.2178
      What has helped to carry out care of patients with COVID-19 (check all that apply)
      Received support from co-workers75.01321
      Support of my family/friends58.41029
      Provided support to others56.3992
      Received training in the proper donning (putting on), doffing (taking off), and disposal of personal protective equipment (PPE)53.9949
      Usually very resourceful in difficult situations37.5661
      Have previous infectious disease/infection control patient care experiences34.4607
      Faith/spirituality/religion30.0529
      Was provided with adequate supplies of personal protective equipment (PPE)27.0475
      Received training in infectious disease/infection control25.9456
      Received support from Nursing leadership25.7452
      Professional nursing education23.3410
      Felt the hospital was well-equipped) to provide care to COVID-19 patients16.0282
      Others remained calm16.1283
      Have not cared for any patients with COVID-1911.1196
      Other3.562
      COVID-19 pandemic impacted personal or home life in the following ways (check all that apply)
      Needed to self-isolate44.5784
      Family member/close friend needed to self-isolate29.4518
      Health professional diagnosed family member/close friend with COVID-1923.5414
      Had no or minor impact16.5291
      Family member/close friend died from COVID-1915.9281
      Healthcare professional diagnosed you with COVID-1913.5238
      Family member/close friend was critically ill with COVID-19 complications12.7223
      Family member/close friend died, but not from COVID-195.496
      Other6.7118
      Other ongoing issues as a result of COVID-19 (check all that apply)
      Spouse/partner lost their job12.8225
      Pension or other savings negatively impacted26.6469
      Unable to pay mortgage or rent3.664
      Had to move into a relative's or friend's home3.359
      Relatives or friends moved into your home4.580
      Had new caregiving responsibilities for children, other family and/or friends26.4466
      Irreparable harm to you, your family, and/or your community9.5168
      If a family member/close friend was critically ill or died from COVID-19 able to be present with them (check all that apply)
      Yes2.838
      No26.2355
      DNA, no family member/close friend was critically ill or died from COVID-1971.0964
      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 NameResponse OptionsMedian Anxiety (Interquartile Range)Median Depression (Interquartile Range)
      Age20-292.0 (1.0–4.0) a2.0 (0.0–2.0) b
      30–392.0 (1.0–3.0)1.0 (0.0–2.0)
      40–492.0 (0.0–3.0)1.0 (0.0–2.0)
      50–591.0 (0.0–2.0)1.0 (0.0–2.0)
      60–691.0 (0.0–2.0)1.0 (0.0–2.0)
      70 and over0.0 (0.0–0.0)0.0 (0.0–1.5)
      GenderMale2.0 (0.0–3.0)1.5(0.0–2.0)
      Female2.0 (1.0–3.0)1.0 (0.0–2.0)
      RaceWhite2.0 (1.0–3.0) c1.0 (0.0–2.0)
      Asian1.0 (0.0–3.0)1.0 (0.0–2.0)
      Black1.0 (0.0–3.0)0.0 (0.0–2.0)
      Other2.0 (0.0–2.0)1.0 (0.9–2.0)
      Unit typeICU2.0 (1.0–4.0) d2.0 (0.0–2.75) e
      Inpatient non ICU2.0 (0.0–3.0)1.0 (0.0–2.0)
      Other2.0 (0.0–2.0)1.0 (0.0–2.0)
      Job TitleClinical RN2.0 (1.0–3.0) f1.0 (0.0–2.0)
      Advanced practice RN1.0 (1.0–3.0)1.0 (0.0–2.0)
      Manager/Administrator1.0 (0.0–2.0)1.0 (0.0–2.0)
      First professional nursing degreeBSN2.0 (1.0–3.0) g1.0 (0.0–2.0) h
      Associate degree/Diploma1.0 (0.0–2.0)1.0 (0.0–2.0)
      Masters/Doctoral1.0 (0.0–2.0)0.0 (0.0–2.0)
      Marital statusMarried/partnered2.0 (0.0–2.0) ***1.0 (0.0–2.0)
      Widowed, divorced, separated, never married2.0 (1.0–3.0)1.0 (0.0–2.0)
      ChildrenNo children or no children living at home2.0 (1.0–3.0) ***1.0 (0.0–2.0)
      Children living at home1.0 (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
      VariableCorrelation with Anxiety (sig)Correlation with Depression (sig)
      ASSETS AND RESOURCES
      Quality of communication with nurse managers (Lower score, higher quality)0.0440.043
      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 experience0.006-0.011
      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 life0.179***0.134***
      Days absent from work0.0560.056
      Hours worked previous week0.0360.024
      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 died0.146***0.083*
      Number of other ongoing issues due to COVID-19 pandemic0.208***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, (), 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.
      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 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 M.
      • Murray E.
      • Christian M.D
      Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic.
      ).
      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 J.
      • Schömig F.
      • Lemke M.R.
      • Pumberger M.
      • Riedel-Heller S.G
      COVID-19 pandemic: Stress experience of healthcare workers - A short current review.
      ); 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 S.
      • Warren N.
      • McMahon L.
      • Dalais C.
      • Henry I.
      • Siskind D
      Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: Rapid review and meta-analysis.
      ). The importance of social support in promoting resilience was noted in a review of COVID-19-related research (
      • Bohlken J.
      • Schömig F.
      • Lemke M.R.
      • Pumberger M.
      • Riedel-Heller S.G
      COVID-19 pandemic: Stress experience of healthcare workers - A short current review.
      ). 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 L.G.
      • Tedeschi R.G
      Beyond recovery from trauma: Implications for clinical practice and research.
      ;
      • O'Leary V.E.
      • Ickovics J.R
      Resilience and thriving in response to challenge: An opportunity for a paradigm shift in women's health.
      ;
      • Park C.L
      Stress-related growth and thriving through coping: The roles of personality and cognitive processes.
      ). 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 J
      Conceptual frameworks and research models on resilience in leadership.
      ;
      • O'Leary V.E
      Strength in the face of adversity: Individual and social thriving.
      ). 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 C.S
      Resilience and thriving: Issues, models, and linkages.
      ;
      • Tedeschi R.G.
      • Calhoun L.G
      The posttraumatic growth inventory: Measuring the positive legacy of trauma.
      ). 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

      Tabled 1
      ScaleSample Question or Statement (number of items)Response RangeMean (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 week2.55 (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 agree3.25 (1.05).969
      Pearlin Mastery ScaleI 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 agree2.79 (0.56)0.84
      PHQ-4: DepressionOver 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 day3.44 (1.57)0.87
      PHQ4: AnxietyOver 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 day3.98 (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 week3.31 (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 week1.62 (1.09)0.89
      Commitment to NursingDo you stand by your choice of the nursing profession? (3)1-6, 1-not at all to 6-very much1.55 (0.83)0.82

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