Predictors of nurses' work-related mental health during the COVID-19 pandemic: a paired follow-up study.

doi:10.21203/rs.3.rs-4862432/v1

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Predictors of nurses' work-related mental health during the COVID-19 pandemic: a paired follow-up study.

https://doi.org/10.21203/rs.3.rs-4862432/v1

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Nurses are among society's mainstays, as they care for and take care of sick people. Therefore, it is also important that society ensure that nurses have a good working situation, as they run an increased risk of experiencing negative psychological conditions, including depression, anxiety, stress, and emotional exhaustion, due to the demanding nature of their work. The strain on healthcare staff, especially during the COVID-19 pandemic, has highlighted these challenges. The aim was to investigate predictors of work-related mental health problems in nurses’ work situations. A questionnaire was sent to 9219 Swedish nurses in 2017, and 4962 responded. Of these, 3777 had no diagnosed work-related mental health problems and were therefore selected as the study population. The questionnaire was resent to the nurses during the pandemic in 2020, and 3107 responded. Of these previously healthy registered nurses, 143 stated that they now suffered from a work-related mental health problem. The data were analyzed by logistic regression analysis, and 6 out of the 24 investigated statements were statistically significant, i.e., there was a possible causal relationship between nurses’ work situation and their worsening of mental health problems. The statements used were “I do not feel I get enough rest/recuperation between work shifts”, “The work pace in my daily work is too high”, “I do not feel I have enough support from my coworkers”, “I do not experience joy in my daily work”, “I do not feel like my daily work is meaningful”, and “I do not get enough opportunities at work to utilize my skills and knowledge”. Conclusions: This study revealed that work pace, recovery, support from colleagues, joy, meaningfulness, and development opportunities at work are particularly important for nurses' mental health. Actions in those areas are needed for nurses to have a sustainable work situation.

Nursing

Health Economics & Outcomes Research

workplace

psychological phenomena

social support

registered nurses

During the COVID-19 pandemic, healthcare workers (HCWs), primarily nurses, were on the frontline [1]. This has caused strain on nurses and healthcare organizations [1–5]. Nurses constitute half the global health workforce [6] and are often the first providers that a patient sees in a health facility. Nurses face a greater risk of developing negative mental health conditions, such as depression, anxiety, stress [7], emotional exhaustion and burnout [8], due to the demanding nature of their work [,9]. Since nurses have a high percentage of sick leave due to mental health diagnoses, it is important to investigate whether there are areas and factors within their work situation that cause mental illness and, if so, which areas and factors.

Depression is a common mental disorder. It is characterized by persistent feelings of sadness and a loss of interest or pleasure in activities. Depression affects various aspects of life, including relationships, and can also lead to difficulties in the workplace [10]. Anxiety is a common feeling, but for people with anxiety disorders, anxiety does not go away and can worsen over time. There are several types of anxiety disorders, including generalized anxiety disorder (GAD) and panic disorder [11]. Symptoms of mental disorders can affect daily activities such as work performance and relationships. Elevated levels of professional stress are associated with reduced quality of life [12]; physical health problems such as migraines, muscle, and joint pains [13]; and negative consequences for the psychological well-being of health care workers [14–16]. Increased workloads, time pressure [17–19], lack of support [20] and nurses’ work environment [18–19] have been positively associated with negative stress, burnout symptoms [17, 19, 21] and job dissatisfaction [19]. Previous studies have shown that long working hours, lack of control over work, lack of participation in decision making, poor social support and poor support from nurse managers are associated with mental ill health [15, 17]. A previous study showed that HCWs in hospitals experience comparatively elevated levels of mental stress while caring for patients [22]. Another study showed that workload and work pressure have an impact on job outcomes and quality of care [23]. The impact of stress on nurses can have serious repercussions, such as depression, reduced job satisfaction, an elevated risk of medical errors, decreased productivity, and a greater likelihood of turnover [17]. Disregarding the symptoms of anxiety and depression may lead to heightened physical and emotional strain for the affected person. Additionally, it could contribute to subpar patient care quality and place a heavier workload on organizations [24–25]. In Sweden, as well as in several other countries, it is difficult to obtain a mental health diagnosis classified as work related [26]. The ones that have been approved relate to stress caused by a high workload, and a few cases have been related to bullying and/or harassment in the workplace [26]. Previous research has shown that the prevalence of mental health problems is high among nurses [27] and that there has been an increase in stress, anxiety, depression, and burnout symptoms in Swedish nurses [28]. Previous research has explored nurses’ stress related to health and their work environment. However, to the best of our knowledge, there has been no prior investigation into nurses’ overall work situation—examining all aspects of impact and determinants of a sustainable working life—both before and during the COVID-19 pandemic. It is therefore important to investigate the extraordinary work situation during the COVID-19 pandemic, as a trigger that results in a natural stress test of health care organizations affects all impact and determinant areas associated with nurses’ self-reported work-related mental health diagnoses.

The aim of the present study was to investigate predictors of work-related mental health problems in nurses’ work situations through paired follow-up with nurses who had developed work-related mental health problems between 2017 and fall/winter 2020.

2.1 Surveys

This longitudinal study is part of a greater research program, “Sustainable working life for all ages” [28–30]. A baseline survey was performed in the spring of 2017 and included a cohort consisting of all healthcare staff (n = 22 924) in the Region of Skane, the most southern county in Sweden. A link to an online questionnaire was sent through an employee’s work e-mail, and 11 902 individuals completed the survey [30]. The follow-up survey was conducted from September to December 2020 and included all the healthcare staff employed in 2017 and still employed in 2020 (n = 18 143).

2.2 Study population

The present study focused on nurses; in 2017, 9 217 nurses (including specialist nurses) were employed in the region, and 4789 completed the survey (50.9%). The study population in the present study included nurses in the cohort without work-related mental health problems at baseline who were still employed in 2020 and had developed work-related mental health problems (n = 143) (Fig. 1). The response rate of the employed registered nurses in the region in 2020 was 40.1%, i.e., those who completed the paired follow-up survey. When examining the dropouts, in both 2017 and 2020, twelve e-mails were unable to be delivered due to incorrect e-mail addresses. In spontaneous email responses to researcher K.N., employees cited several reasons for not completing the survey. These included absenteeism from work, time constraints, and apprehensions about their manager discovering their responses. Unfortunately, there is no way to accurately estimate the percentage of dropouts for these different reasons.

2.3 Questionnaires

The original questionnaire was developed by Professor K.N. [31] and included questions regarding the respondents’ sociodemographic characteristics, Karasek and Theorell’s demand-control questions [32] and questions about the nine impact and determinant areas for a healthy and sustainable working life described in the theoretical SwAge model [29] (see a short description of the SwAge model in the paragraph Analysis Model). The questionnaire that was sent out in 2017 contained 158 questions, and the questionnaire in 2020 included additional COVID-19-specific questions developed by Professor K.N., infection control researchers and virologists. The questionnaire was in Swedish. Some of the questions were yes/no questions, and some were open-ended questions where the participants could write freely. However, for most of the questions used in the present study, the respondents indicated their reply on a validated Likert scale, and the participants had four answer options: fully agree (1), agree (2), disagree (3), and fully disagree (4). The four available answer options were dichotomized into “agree” or “disagree”. The sample data were collected and managed by the researcher KN.

2.4 Analysis model

A theoretical model regarding sustainable working life at all ages (SwAge) was used to sort the data and to construct the analysis model [25, 29–31, 33]. The SwAge model consists of nine different impact and determinant areas of the possibility of being able to and willing to be part of working life, which relate to the four spheres of employability. Those four spheres and nine impact and determinant areas are as follows:

I. The health effects of work environments include the following areas of determination:

(1) The individual’s diagnosis, self-rated health, and diverse functionality

(2) The physical work environment with unilateral movements, heavy lifting, risk of accidents, climate, chemical exposure, and risk of contagion

(3) Mental work environment: stress and fatigue syndrome, threats, and violence

(4) Working hours, work pace, and possibility of recuperation during and between work shifts.

II. Financial incentives are associated with society’s control of various financial carrots and sticks, such as through the social insurance system. Financial incentives include the following determinant area:

(5) The personal financial situation affects individuals’ needs and willingness to work. Issues with employability due to ill health, lack of skills and lack of support risk cause individuals to be excluded from working life and have a poorer financial situation, e.g., through sick leave, unemployment, and early retirement, not least in tough times.

III. Relationships, social support, and participation, i.e., attitudes in the social context in which the individual finds himself/herself, whether the individual feels included or excluded in the group and receives sufficient social support from the environment when needed, include the following areas of determination:

(6) The effects of the personal social environment, family, friends, and leisure

contexts effect of and on work

(7) The social work environment with leadership, norms at the workplace, group dynamics with colleagues, patients, etc., and the significance of the employment relationship context for individuals’ work, participation and social support, bullying, victimization, and discrimination.

IV. The execution of work tasks and activities at work relates to individuals’ opportunity to perform their duties and inner satisfaction; this is also made possible by instrumental support and includes the following areas of determination:

(8) Experience of motivation, appreciation, satisfaction and stimulation of work tasks and activities at work

(9) The skills, knowledge, competence, and possibility for competence development for the individual’s work activities and duties.

2.5 Outcome Measures

In this study, eight out of the nine impact areas in the SwAge model were used in the analysis model. The first area, “health”, was used as the dependent outcome measure in the analysis. The respondents were asked whether they had a diagnosis of ill health or injury caused by their work (yes/no). If yes, they were given alternatives to the WHO´s International Classification of Disease-10 (ICD-10) principal diagnosis codes, where they self-reported that they could mark their diagnosis. The diagnoses of depression, anxiety, exhaustion, and stress symptoms were merged and used in the analysis as the dependent variable “mental health”, i.e., work-related mental health diagnoses.

In the analysis, twenty-four statements about the nurses' work situation, sorted into seven of the nine influence areas of the SwAge model, were used as independent variables. In the questionnaire, the statement regarding personal finances was mostly associated with age-retirement possibilities; therefore, this area was not included in the analysis in this study. The examined impact areas were as follows: (2) physical work environment (two statements); (3) mental work environment (five statements); (4) work pace, work time, and recuperation (three statements); (6) personal social environment (two statements); (7) work social environment, organization, and leadership situation (six statements); (8) motivation and satisfaction with and to work tasks (four statements); and (9) knowledge and competence (two statements).

2.6 Statistical analyses

The participants’ sociodemographic characteristics were analyzed descriptively (Table 1). In the investigation of factors associated with a sustainable working life, the independent variables were derived from a categorical diagnosis related to work-induced mental health. These variables were then analyzed in conjunction with the seven determinate areas for a healthy and sustainable work environment and employability, as outlined in the SwAge model (see above). All the responses (in percentages) of the 2030 participants, both those who had no work-related mental health diagnosis and those who had a diagnosis (n = 143), to the twenty-four statements included in the study were descriptively analyzed (Table 2).

Logistic regression analysis, univariate estimates were generated, and multivariate models (odds ratios (ORs) with 95% confidence intervals (CIs)) were constructed to investigate the associations between various factors and work-related mental health problems at baseline and in 2020. Out of the larger sample, a subgroup of 143 individuals, reported as not having a mental health diagnosis in 2017 but reported to have a mental health diagnosis in 2020, was examined to determine whether there was causality between mental health diagnoses and various variables.

In the initial step, to investigate the associations of the influence areas with nurses´ mental health, each of the twenty-four statements was univariate analyzed against the dependent variable (Table 3). Thereafter, the statements within each influence area were analyzed step by step together to construct an influence area model. The statements that were statistically significant (p value < 0.05 and CI not including 1,00) were placed in a model for each influence area. In the next step, each of the eliminated statements (p value > 0,05 and CI not including 1,00) was added one at a time to evaluate the robustness of the model for each influence area.

Finally, a multivariate model was developed to examine all of the influence areas included in this study on nurses´ mental health. The statements from each dependent area that were statistically significant in the initial step were examined in a multivariate model, with each influence area step by step. The statements that continued to be statistically significant (p value < 0,05 and CI not included 1,00) were placed in a model, and each of the eliminated statements (p value > 0,05 and CI not included 1,00) was added one at the time to test the robustness of the total multivariate model of all influence areas’ effects on the nurses´ mental health (Table 4). The material was analyzed with IBM SPSS software, version 27 [34].

2.7 Ethical considerations

The study was performed in accordance with Swedish law [35] and with the Helsinki declaration [36]. The benefits of the knowledge this study generates are considered to outweigh the potential risks the study can bring. The rules for handling and storing the data were followed in accordance with university policies as well as guidelines for handling sensitive data according to the GDPR [37]. The study was approved by the Swedish Ethical Review Agency (number 2016/867 and 2020 − 01897).

3.1. Participants’ sociodemographic characteristics

Of the 143 participants in the survey who had a mental health diagnosis in 2020, the median age was 50 (28–68). A total of 92.3% of the participants who answered the questionnaire were women. A majority (52,4%) of participants had worked as nurses for more than 16 years. (Table 1).

Table 1

Sociodemographic characteristics of the respondents in the 2020 survey compared to those who did not have a self-reported work-related mental health diagnosis.
Characteristic	Mental health diagnose 2020 n = 143	No mental health diagnose 2020 n = 1887
Age md (min–max)	50 (28–68)	53 (26–70)
Female gender (%)	92.3	90.1
Country of birth:
Sweden (%)	85.3	89.1
Nordic countries (%)	5.6	2.2
Europe (%)	6.3	5.2
Outside of Europe (%)	2.8	3.5
Civil status:
Married/Live-in partner (%)	75.5	77.5
Living apart together (%)	3.5	4.7
Single (%)	21.0	17.8
Children living at home:
16–19 years of age (%)	13.3	16.9
13–15 years of age (%)	19.6	12.6
7–12 years of age (%)	25.2	19.9
4–6 years of age (%)	13.3	11.2
0–3 years of age (%)	13.3	9.2
No children living at home (%)	41.3	43.6
Years in the profession:
< 5 (%)	13.3	11.6
6–10 (%)	18.9	13.2
11–15 (%)	15.4	14.6
> 16 (%)	52.4	60.6

3.2. Findings

3.2.1 The nurses’ experience of their work situation

A descriptive analysis of those who had no work-related mental health diagnosis and those who had developed a work-related mental health diagnosis in 2020 revealed differences in their experience with their work situation (Table 2). The largest differences between those who had no work-related mental health diagnoses and those who had developed a work-related mental health diagnosis in 2020 were detected in the area Physichal work environment of the statmendt “For the most part, I cannot cope with the physical work demands”; in the area Mental work environment of the statments “My work involves many psychologically heavy work tasks”, “I wish for more opportunities to determine how to perform my work”, “I wish for greater control over my work” and “Not having enough staff mean that I cannot perform my work”; in the area Work pace, work time, and recuperation of the statments “I do not feel like I get enough rest/recuperation between work shifts”, “I do not have time to perform the work duties I have planned for the day”, “The work pace in my daily work is too high” and “I do not have time to perform the work duties I have planned for the day”; and in the area Social work environment of the statement “The social community at my workplace does not make me want to stay”, “I do not feel I have enough support from my coworkers”; in the area Motivation and satisfaction of and to work

Table 2

A descriptive table of all the 2030 participants who responded (in percentages) to the 24 statements included in the study is provided.
		Mental health diagnoses 2020 n = 143		No mental health diagnoses 2020 n = 1887
Area of the SwAge-model	Statement	Agree	Disagree	Agree	Disagree
Physical work environment	My current work is too physically straining for my health	21.7	78.3	18.3	81.7
Physical work environment	For the most part I cannot cope with the physical work demands	11.9	88.1	4.9	95.1
Mental work environment	My work involves many psychologically heavy work tasks	71.7	28.3	58.9	41.1
	I wish for more opportunities to determine how to perform my work	53.8	46.2	43.6	56.4
	I wish for greater control over my work	51.4	48.6	39.1	60.9
	At my work there are not enough possibilities to be reallocated to less demanding work tasks for those who need it	58.7	41.3	60.9	39.1
	My work tasks usually clump together to that extent that I get frustrated	60.1	39.9	39.5	60.5
	Not having enough staff mean that I cannot perform my work	60.1	39.9	47.5	52.5
Work pace, work time, recuperation	I do not feel like I get enough rest/recuperation between work shifts	55.9	44.1	40.6	59.4
	I do not have time to perform the work duties I have planned for the day	41.3	58.7	27.1	72.9
	The work pace in my daily work is too high	57.3	42.7	40.4	59.6
Private social environment	I want to spend more time at leisure activities and will therefore work less in the future	79.4	20.6	77.9	22.1
Private social environment	I need to work more at home/care for relatives, and will therefore work less in the future	23.6	76.4	21.4	78.6
Social work environment	The social community at my workplace does not make me want to stay	28.8	71.2	18.7	81.3
	Big changes in my work situation causes me to want to leave	19.6	80.4	16.7	83.3
	I do not feel I have enough support from my closest manager	34.3	65.7	31.8	68.2
	I do not feel I have enough support from my coworkers	18.9	81.1	8.9	91.1
	I feel bullied or shut out from the community at my workplace	4.2	95.8	2.9	97.1
Motivation and satisfaction of and to work tasks	I do not feel like my daily work is meaningful	6.9	93.1	5.4	94.6
	I do not feel like my work is stimulating	13.7	86.3	9.9	90.1
	I do not experience joy in my daily work	30.8	69.2	13.6	86.4
	I do not experience satisfaction in my daily work	28.0	72.0	15.4	84.6
Knowledge and Competency	I do not get enough opportunities at work to utilize my skills and knowledge	24.9	75.1	11.8	88.2
Knowledge and Competency	I do not feel like my competencies are being utilized in a satisfactory way	27.3	72.7	17.1	82.9

3.2.2 Univariate estimates and multivariate model relations to work-related mental health

According to the univariate estimates, the six statements that showed the highest statistical significance were “I do not experience joy in my daily work” (OR 2.83, CI 1.94–4.14); “I do not feel that I have enough support from my coworkers” (OR 2.55, CI 1.62–4.03); “I do not have enough opportunities at work to utilize my skills and knowledge” (OR 2.49, CI 1.66–3.75); “My work tasks usually clump together to that extent that I get frustrated” (OR 2.23, CI 1.56–3.23); “I do not experience satisfaction in my daily work” (OR 2.13, CI 1.45–3.13); and “For the most part, I cannot cope with the physical work demands” (OR 2.12, CI 1.18–3.83).

For the multivariate variables, we found that the statements that showed the highest statistical significance were “I do not experience joy in my daily work” (OR 3.28, CI 1.78–6.04), “I do not feel I have enough support from my coworkers” (OR 2.39, CI 1.44–3.99), “For the most part, I cannot cope with physical work demands” (OR 2.14, CI 1.18–3.91) and “My work tasks usually clump together to that extent that I get frustrated” (OR 2.12, CI 1.46–3.09). (Table 3).

Table 3

Univariate estimates and multivariate model inside earch areas of the SwAge model, i.e., the statements in the different areas in association with work-related mental health diagnoses among nurses who developed a mental health diagnosis between 2017 and 2020. OR = odds ratio; CI = confidence interval.
		Univariate		Multivariate
Area of the SwAge-model	Statement	OR	95% CI for OR	OR	95% CI for OR
Physical work environment	My current work is too physically straining for my health	1.27	1.00-1.92	1.22	.80-1.86
Physical work environment	For the most part I cannot cope with the physical work demands	2.12	1.18–3.83	2.14	1.18–3.91
Mental work environment	My work involves many mentally heavy work tasks	1.81	1.24–2.64	1.33	.89-1.99
	I wish for more opportunities to determine how to perform my work	1.53	1.09–2.16	1.02	.66-1.58
	I wish for greater control over my work	1.65	1.17–2.52	1.19	.77-1.85
	At my work there are not enough possibilities to be reallocated to less demanding work tasks for those who need it	1.12	.79-1.59	1.18	.82 − 1.70
	My work tasks usually clump together to that extent that I get frustrated	2.23	1.56–3.23	2.14	1.46–3.07
	Not having enough staff mean that I cannot perform my work	1.73	1.22–2.45	1.23	.82-1.85
Work pace, work time, recuperation	I do not feel like I get enough rest/recuperation between work shifts	1.87	1.32–2.63	1.72	1.19–2.49
	I do not have time to perform the work duties I have planned for the day	1.88	1.32–2.68	1.45	.91-2.11
	The work pace in my daily work is too high	1.96	1.39–2.76	1.51	.89 − 2.20
Private social environment	I want to spend more time at leisure activities and will therefore work less in the future	1.12	.73-1.71	1.08	.70-1.67
Private social environment	I need to work more at home/care for relatives, and will therefore work less in the future	1.14	.76 − 1.70	1.15	.77-1.74
Social work environment	The social community at my workplace does not make me want to stay	1.82	1.24–2.67	1.50	.99-2.28
	Big changes in my work situation causes me to want to leave	1.19	.77-1.82	1.09	.69-1.72
	I do not feel I have enough support from my closest manager	1.11	.77-1.58	1.18	.79-1.74
	I do not feel I have enough support from my coworkers	2.55	1.62–4.03	2.43	1.46–4.05
	I feel bullied or shut out from the community at my workplace	1.46	.82-4.69	1.16	.42-3.19
Motivation and satisfaction of and to work tasks	I do not feel like my daily work is meaningful	1.20	.59-2.42	1.74	.77-3.95
	I do not feel like my work is stimulating	1.30	.84-2.31	1.30	.69-2.43
	I do not experience joy in my daily work	2.83	1.94–4.14	3.28	1.78–6.04
	I do not experience satisfaction in my daily work	2.13	1.45–3.13	1.13	.61 − 2.10
Knowledge and Competency	I do not get enough opportunities at work to utilize my skills and knowledge	2.49	1.66–3.75	1.71	1.05–2.89
Knowledge and Competency	I do not feel like my competencies are being utilized in a satisfactory way	1.87	1.23–2.76	1.18	.66-2.09

3.2.2 Final multivariate model

In the last step of the analysis, a final joint multivariate model was modeled. The multivariate variables that remained statistically significant were placed in a joint model including all examined areas of the SwAge model that was assessed for robustness and stability by adding one excluded variable at a time until the final multivariate model was established. The final multivariate model revealed that “I do not feel like my daily work is meaningful” (OR 2.49, CI 1.12–5.54), “I do not experience joy in my daily work” (OR 2.34, CI 1.45–3.78) and “I do not have enough opportunities at work to utilize my skills and knowledge” (OR 2.33, CI 1.44–3.76) were the strongest predictors connected to nurses’ work-related mental health diagnoses (Table 4).

Table 4

The final joint multivariate model. Factors significantly related to work-related mental health diagnoses. OR = odds ratio; CI = confidence interval; Nagelkerke R² = 0.066. Tolerance = > 0.8. Hosmer-Lemeshov 0.981
			95% CI for OR
Area of the SwAge-model	Statement	OR	Lower	Upper
Work time, work pace, recuperation.	I do not feel I get enough rest/recuperation between work shifts	1.40	1.04	2.05
Work time, work pace, recuperation.	The work pace in my daily work is too high	1.62	1.11	2.37
Social work environment	I do not feel I have enough support from my coworkers	1.57	1.05	2.90
Motivation and satisfaction of and to work tasks	I do not experience joy in my daily work	2.34	1.45	3.78
Motivation and satisfaction of and to work tasks	I do not feel like my daily work is meaningful	2.49	1.12	5.54
Knowledge and Competency	I do not get enough opportunities at work to utilize my skills and knowledge	2.33	1.44	3.76

The Nagelkerke R² value showed that the final joint multivariate model could predict a risk of 6.6% of patients being in the state of the dependent variable; in this case, they had a mental health diagnosis caused by work-related factors. The final joint multivariate model can be considered meaningful since the Hosmer–Lemeshov score is greater than 0.05, implying that the model's estimates fit the data at an acceptable level. A tolerance > 0.40 indicates that there is a decreased risk of multicollinearity.

Nurses are considered one of society's mainstays; however, many nurses in the profession suffer from work-related mental illness. Therefore, the purpose of this study was to investigate which areas and which factors are of greatest importance for nurses developing work-related mental illness over time based on the SwAge model's comprehensive approach to areas of importance for a sustainable working life [25, 29, 31, 33]. In this study, we used a cohort of nurses who were without mental illness in 2017; however, under the impact of the COVID-19 pandemic's extreme strain on nurses' work situation, some nurses developed work-related mental diagnoses until 2020. The results from the present study showed that nurses who did not experience their daily work as meaningful and joyful, who did not have enough rest and recuperation between work shifts or opportunities at work to utilize their skills and knowledge, who felt that the work pace in their daily work was too high and who additionally did not feel enough support from their coworkers, had an increased risk of developing work-related mental health issues. Therefore, it is particularly important to take action in these areas to offer nurses a more sustainable working life.

The final joint multivariate model revealed the following areas to be the most important for nurses’ development of work-related mental illness: motivation and satisfaction with and with work tasks; knowledge and competence; work time, work pace, recuperation; and the social work environment. Earlier studies of nurses reported that younger nurses were significantly more likely to report higher levels of stress and that those living alone had significantly greater levels of depressive and anxiety symptoms [15]. The results of this study revealed no major discrepancies in the private social environment or in terms of age or marital status between the two groups, i.e., those who developed a work-related mental health diagnosis and those who did not. However, the median age of the respondents who had received a mental health diagnosis was slightly lower than that of the other respondents, and there were a few more single participants in this group.

Motivation and satisfaction with and with work tasks

Not experiencing the work task as meaningful had the strongest association with work-related mental health in the present study, followed by not experiencing joy in daily work. Earlier studies stated that it is important to carry out the tasks that are the core of the employee profession, as well as to both their own satisfaction from having done a good job and getting recognition from others for a well-done task, to experience the work as meaningful [25, 29, 31, 33, 38]. If employees are assigned far too many tasks, tasks that are not considered to be part of their professional role, they experience the work as too fragmented into too many different tasks, or they receive no internal or external reward for their efforts; then, the work is perceived as unsatisfying, less stimulating or pointless [38]. A previous study showed a positive relationship between meaningful work and job embeddedness and that the effect of meaningful work on turnover intention is mediated by job embeddedness [39]. Although there is a high turnover rate among nurses worldwide, feeling that the work they do is meaningful may be the very reason why many nurses choose to stay in health care [40]. Additionally, experiencing joy at work is important for coping with the stressors that the nursing profession entails; i.e., joy could be a coping strategy when the mental work environment is hard and demanding, as it was during the COVID-19 pandemic. Previous research has shown that it is important to meet healthcare workers’ needs to experience joy at work [41]. Appreciation from others for work is one element that promotes joy at work and contributes to a decent work climate with camaraderie and teamwork [42]. Prior research has shown that health care leaders need to understand what factors diminish joy at work to improve working conditions for healthcare professionals [43].

Knowledge and Competency

The results of this study showed that knowledge and competence are important for nurses' work-related mental well-being. Previous research has shown that having the right knowledge to perform one's tasks is important for performing godwork to feel calm and safe in one's work and for handling work under stress [25, 29, 31, 33], not least during the pressured situation during the COVID-19 pandemic and before the virus's transmission routes were identified [15]. There was a slightly increased risk for younger nurses with less experience in the profession for work-related mental illness in this study, but this difference has previously been more evident in other studies [15]. In contact professions and human care professions, such as nurses, knowledge of experience, i.e., the knowledge gathered over a lifetime and through work experience, is highly important for the treatment and handling of contact with patients [25, 29, 31, 33, 38]. Additionally, not having enough opportunities at work to utilize one’s skills and knowledge was significantly correlated with work-related mental health diagnoses in the present study. If nurses feel that their knowledge and skills are not utilized, this can lead to a decrease in work motivation, prompting them to look for other workplaces and/or work-related mental health issues. Continuing staff development is also seen as beneficial for adapting to rapid changes in healthcare [44].

Social work environment

A previous study revealed that the social work environment with coworkers and leadership are highly important for nurses’ work-related mental health issues. Not feel that they have enough support from their coworkers, affecting their wellbeing. In stressful and stressful situations such as during the initial stage of the COVID-19 pandemic, there is often concern in organizations and leaders about how work should be organized, which affects work groups and increases the risk of scapegoating and lack of social support [15]. In work groups that manage uncertainty and where employees find support and trust each other at work, both the work situation and the performance of work tasks cope better than do work groups where cohesion and social support are lacking. Social support is multidimensional and influenced by numerous factors [25, 29, 31, 33, 38, 45]. Support from coworkers has been found to increase job satisfaction [25, 29, 31, 33, 46], increase the quality of care and help nurses deal with stressful work situations [38, 42], and allow nurses to care effectively and holistically for patients [47]. The British Psychological Society (BPS) released guidelines for supporting the mental well-being of healthcare workers during the pandemic. Continued peer support was a vital component of their guidelines, as was the importance of normalizing feelings of anxiety [48].

Work time, work pace, and recuperation

The final multivariate model in this study showed that not receiving enough rest between work shifts and experiencing that the work pace is too high were predictors of the development of work-related mental health issues. A high work pace was found to be correlated with mental health diagnoses in the present study. The possibility of recovery both during and between work shifts is important for coping with one's work and for the health of individuals [25, 29, 31, 33]. Not enough rest was also found in our previous research [28] to contribute to poor mental health. Previous studies have shown that staff shortages result in higher workloads, which in turn affect job satisfaction [49]. A study from Lebanon showed that nurses who had a greater workload and poorer teamwork climate had greater odds of developing mental health conditions, which could affect several other aspects of nurses’ health and function and the risk of comorbidities [50]. It is also difficult to achieve a good balance between work and leisure as well as sufficient recovery if one does not have a manageable workload.

The present study showed an association between a lack of recuperation during work shifts and the development of a work-related mental health diagnosis. A study by Finish showed that nurses who worked at a higher physical intensity, had increased time pressure, and experienced mental strain had reduced recovery from work [51]. Sleep is a basic need of every human being. Without sleep, it is impossible to function properly [52]. Several participants in a previous study described having trouble falling asleep and attributed this to lack of time to decompress mentally despite being physically exhausted [53]. A lack of rest or recuperation can lead to decreased concentration and other somatic problems [54]. One factor that can affect the lack of recuperation between work shifts is demanding work schedules. Not enough rest between work shifts can contribute to fatigue, increased risk of work-related injury and burnout [55]. Getting an injury or illness judged as being caused by or related to work is a lengthy process and is seldom approved since it is difficult to determine whether it is solely caused by work [26]. Therefore, many individuals abstain from reporting their injuries/illnesses. There are, however, many who believe that the injuries/illnessings they have obtained would not have been so if they had not been for their work situation. One thing that has become clear during the pandemic is that nurses need to be in good physical and mental health to provide quality care to patients [56].

Limitations and strengths

One limitation of the study is that we had a substantial percentage of nonresponders; the response rates were 50.9% and 40.1% in 2017 and 2020, respectively. However, considering that this was a survey, a low response rate was expected. Regarding selection, there is a risk of a healthy worker effect, as those who may, for example, have more pronounced depression may be on sick leave or simply not able to answer the questionnaire; we have tried to prevent this by having a broad exposure group. There is always a chance to lose individuals during research since they may be too ill to continue working. All nurses who were employed in 2017 and did not have a previous diagnosis of stress, burnout, depression, or anxiety were considered viable participants. The nurses who completed the survey but had a previous diagnosis of mental health were also sorted, as were those who completed only one of the surveys. Regarding the dropout analysis, we can only see who is currently employed in the participating health care organizations, i.e., in the southern region of Sweden. We can speculate only whether the nurses who have left their employment in the region have done so due to leaving the workplace, leaving the profession, having retired, or being deceased. We do not know whether those who did not answer the survey were due to parental leave, sick leave, unwillingness to participate or simply lack of time. Another limitation is that there are only 24 statements included in the analysis and not an equal number of statements in the seven examined areas of the SwAge model in this study, which could influence the results. However, seven areas are many more areas within nurses' complex working situation than other studies generally address, based on what we identified through a systematic review of published studies in international peer-reviewed scientific journals [15].

We chose to use logistic regression analysis in the present study and view this as a satisfactory method. However, there are alternative methods, such as factor analysis, where we can compute indices for the dependent areas. As suggested by Sloan et al. [57], single-item measurements are less reliable than indices. On the other hand, a recent study by Matthews et al. [58] states that using single-item measures is not indicative of a weak research design and that it is possible to develop measures that accurately and reliably represent a given construct.

A strength of this study is that the respondents were nurses with diverse types of work areas, work tasks and specialties. In general, they provided a broad representation of nurses from all parts of the health care organization and included different types of nurses (with basic training and with specialist training); i.e., the study population was not limited to a certain type of specialty for nurses or to a certain type of care. Therefore, these findings could contribute to the greater generalizability of the findings to nurses in general. Another possible strength is that the participants had four reply options regarding the statements, which meant that all the data were used; when you use dichotomization with more than four answer options, there is always a risk of losing valuable information. An experienced researcher dichotomized the data.

The results of this study showed that there is potential causality between nurses’ work-related mental health diagnoses and experience of lack of joy and not feeling that the work is meaningful, lack of skills and knowledge, lack of support from coworkers, lack of recuperation between work shifts, and experiencing that the work pace is too high. To offer nurses a more sustainable mental working life, it is particularly important to take action in these areas. In recent years, nurses have worked under high pressure, which has escalated with the COVID-19 pandemic; unfortunately, the future does not look so bright because, for the foreseeable future, nurses will continue to work in challenging conditions with a rising deficit of healthcare professionals. The results from this study can be used by hospitals and ministries of health, etc., as directions for nurses to take action and improve their working conditions and quality of life at work and for interventions that best address their current mental health needs.

Author Contributions: Conceptualization, C.N. and K.N.; methodology, C.N. and K.N.; software, C.N.; formal analysis, C.N.; writing—original draft preparation, C.N.; writing—review and editing, C. N and K.N.; supervision, K.N.; project administration, K.N.; funding acquisition, K.N.

Consent for publication: Not applicable.

Funding: This research was funded by Interreg (European Regional Development Fund, EU), grant number NYPS20303383; FORTE FORMAS, grant number 2020-02746; and the Research Platform for Collaboration for Health, Kristianstad University, Sweden. Funding number 9/2021.

Ethics approval and consent to participate: The study was conducted in accordance with the Declaration of Helsinki and approved by the Swedish Ethical Review Agency (2016/867 and 2020-01897). Informed consent was obtained from all the subjects involved in the study.

Availability of data and materials: Not applicable.

Acknowledgments: A special thank you to the nurses who took time out of their life to partake in this study in 2017, especially in 2020. The authors wish to acknowledge the valuable input given to us by Jens Peter Ellekilde Bonde, Sandra Sögaard Töttenborg, Esben Meulengracht Flachs, Kajsa Kirstine Ugelvig Petersen and Christel Nielsen on early versions of the manuscript. We wish to acknowledge the valuable input given to us regarding the statistical analysis by Lars Rylander at Lunds University.

Competing interest: The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of the data; in the writing of the manuscript; or in the decision to publish the results.

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The authors declare no competing interests.

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Predictors of nurses' work-related mental health during the COVID-19 pandemic: a paired follow-up study.

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Abstract

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1. Introduction

2. Materials and Methods

2.1 Surveys

2.2 Study population

2.3 Questionnaires

2.4 Analysis model

2.5 Outcome Measures

2.6 Statistical analyses

2.7 Ethical considerations

3. Results

3.1. Participants’ sociodemographic characteristics

3.2. Findings

3.2.1 The nurses’ experience of their work situation

3.2.2 Univariate estimates and multivariate model relations to work-related mental health

3.2.2 Final multivariate model

4. Discussion

5. Conclusions

Declarations

References

Additional Declarations

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