key: cord-0752350-nxbhem81
authors: Pourteimour, Sima; Yaghmaei, Safura; Babamohamadi, Hassan
title: The relationship between mental workload and job performance among Iranian nurses providing care to COVID‐19 patients: A cross‐sectional study
date: 2021-03-20
journal: J Nurs Manag
DOI: 10.1111/jonm.13305
sha: 054e9fd453815abec97a68ebc448f9f424fec2db
doc_id: 752350
cord_uid: nxbhem81

AIMS: To evaluate the relationship between mental workload and job performance among nurses providing care to patients with COVID‐19, and to explain the factors predicting their performance. BACKGROUND: The increased workload of health care workers in the COVID‐19 pandemic affects their job performance, causes medical errors, contributes to patients’ mortality and is a major concern for all health care organisations in the world. METHODS: This cross‐sectional study recruited 139 nurses selected from the ICUs, infectious disease wards and emergency units of two hospitals in Iran. The NASA‐Task Load Index and Paterson's job performance questionnaire were used. RESULTS: Mean scores of mental workload and job performance of the nurses were 67.14 ± 30.53 and 37.37 ± 7.36, respectively. A total of 71.95% and 96.4% of the nurses had high mental workload and job performance levels, respectively. The results indicated a weak positive correlation between mental workload and the mean score of job performance(r = .057). Unlike the mental demand (r = .175, p = .04) and temporal demand (r = .307, p < .001) that had a significant positive correlation with job performance, frustration had a significant negative correlation with job performance (r = −.183, p = .032). The following variables explained 33% of the variance of nurses’ job performance: age, gender, type of ward, working shift, experience of providing care to patients with COVID‐19 and frustration. CONCLUSION: The nurses’ mental workload increased during the COVID‐19 pandemic. Given the negative effect of mental workload on the nurses’ behaviour and performance, the rise in their job performance and its weak positive correlation with their mental workload should be further addressed. IMPLICATIONS FOR NURSING MANAGEMENT: The present study results support the need for focusing on implementing strategies such as providing social and psychological support to moderate mental workload and improve job performance of nurses who provide care to patients with COVID‐19.

The 2019 novel coronavirus disease was first reported in Iran on 18 February 2020. The latest statistics (01 February 2021) show a total of 1,424,596 infected cases in Iran, 58,038 deaths, 1,216,305 recovered cases, 150,253 active cases and 3,896 seriously critical cases (Worldometers.info/coronavirus) . In late January 2020, the WHO declared the outbreak of COVID-19 as a public health emergency and an international concern (Wilder-Smith et al., 2020). The spread of major pandemics such as COVID-19 creates an increasing demand on the health care workers (HCWs) . The constantly rising incidence and mortality rates, the lack of medications and vaccines, huge workload, inadequate personal protective equipment (PPEs) and inadequate support can implicate the health of HCWs . In such circumstances, despite severe pressures, HCWs were expected to work long hours (16-22 hr per day). Moreover, they were exposed to high risk of infection and increased workload while providing patient care (Dai et al., 2020) . Other consequences of this pandemic included job burnout, increased health costs and psychological distress (fear, anxiety, depression, stress, insomnia, denial, anger, etc.) (Hassannia et al., 2020; Vizheh et al., 2020) . High-risk situations plus constant contact with contaminated environments, inadequate PPEs, lack of contact with the family members, frustration, prejudice, loneliness and exhaustion have been blamed for increased mental health problems in HCWs. These problems not only affected the personnel's focus, perception and ability to make decisions, but also hindered their fight against the virus in some cases .

Control and management of COVID-19 was prioritized by Iran's Ministry of Health and Medical Education. Strategies to control the spread of the virus and mitigate the workload of HCWs were established on 20 March 2020. These strategies included the creation of the National Committee to Fight COVID-19, raising public awareness of viruses and protective methods through the national mass media, restriction on gatherings in crowded places, closure of educational institutions (schools and universities), reducing working hours of many offices, disinfecting crowded areas, controlling and identifying suspected cases at points of entry and exit (Abdi, 2020) , and encouraging people to isolate themselves and observe social distancing.

Unfortunately, at least 40 HCWs have died of COVID-19 in Iran.

Job burnout and staff shortage have had serious consequences for the patients and can debilitate health care system (Shoja et al., 2020) .

At the front line of the fight against COVID-19, nurses have suffered the most adverse consequences of this pandemic (Garosi et al., 2020) .

Nurses comprise the largest group of HCWs in any country and play a vital role in the prevention of COVID-19, responding to its spread and providing care to the patients (Choi et al., 2020) . While concerned about the health and safety of hospital nurses, societies should not forget that patients with COVID-19 still need nurses to recover and continue treatment (D'Antonio et al., 2020) . Therefore, nurses' work efficiency is very important in this pandemic.

A workload is defined as a general task performed by an individual or a team over a period. Nurses' workload includes both their practical duties and their cognitive tasks, such as thinking, decisionmaking, calculating, remembering and searching (Destiani et al., 2020) .

Nurses face a high mental workload in the performance of their duties (Sarsangi et al., 2015; Abazari et al., 2020) . The US National Institute for Occupational Safety and Health (NIOSH) ranks the nursing profession among the top-40 professions with a high prevalence of diseases caused by a heavy workload (Safari et al., 2013) .

Because of the particular nature of their occupation, nurses are burdened with a great responsibility, a heavy workload, extreme work pressure and the need to work in rotating shifts (Huang et al., 2018) .

Also, about 18% of nurses are forced to leave their job due to their heavy workload (Kaewboonchoo et al., 2014) . Research findings indicate that a heavy workload leads to less-than-optimal care for the patients (Arghami et al., 2015) . Therefore, an increased workload can affect job performance as one of the major indicators of success in all organisations (Ardestani-Rostami et al., 2019) .

Job performance is defined as one's efficiency to carry out roles and responsibilities relating to direct patient care. It can also be defined as the effective performance of one's specified roles and responsibilities (Al-Makhaita et al., 2014) . Generally, job performance is a multidimensional phenomenon affected by many variables such as personal characteristics, workload, job satisfaction, personal competencies, social support and organisational atmosphere (Foy et al., 2019) .

Few studies have investigated the relationship between nurses' workload and job performance. In a descriptive correlational study by Ardestani-Rostami et al. (2019) on 371 nurses to determine the relationship between workload and clinical performance in nurses at the ICUs of hospitals affiliated to Tehran University of Medical Sciences, 75% of the nurses rated their performance as average. A negative correlation was observed between different dimensions of workload and clinical performance. According to the results of this study, workload can predict the performance of nurses with a variance of 39% (Ardestani-Rostami et al., 2019) . The results of another study also showed that the level of patient safety decreases as the workload of nurses increases (Akbari, 2017) . Nurses are also the first line of care for patients with COVID-19 in need of hospitalization. Nurses' workload increased extensively in 2020 due to the rise in the number of patients with COVID-19 (Rothan and Byrareddy, 2020) and their need for nursing care. Nurses not only provide therapeutic care to patients with COVID-19, but also give them primary health care and psychological care. The results of a study conducted in Iran showed that HCWs who had been in contact with COVID-19 patients suffered higher K E Y W O R D S COVID-19, job performance, nurse, workload workloads compared with those who had no contact with these patients (Shoja et al., 2020) . The role of nurses' performance in combating this virus is therefore of paramount importance (Jiang et al., 2020) .

Studies on the relationship between workload and job performance during the COVID-19 pandemic are still limited. The present research was thus conducted to determine (1) the relationship between the mental workload of nurses taking care of patients with COVID-19 and their job performance, and (2) explain the factors predicting their job performance.

This cross-sectional study was conducted on a target population con- The nurses' unwillingness to continue cooperation with the study and complete the questionnaires was considered the exclusion criterion.

Before distributing the questionnaires, researchers explained the study objectives to the participants and assured them of confidentiality of their personal data, and then obtained their informed consents.

The questionnaires were completed face-to-face in the hospital over ten minutes in the presence of researchers during nurses' break.

Data were collected using three questionnaires, including (1) a demographic questionnaire, (2) the NASA-Task Load Index (1988) (Hart & Staveland, 1988) and (3) Patterson's job performance questionnaire (1970) (Paterson & Husband, 1970 overall performance (OP), which is how successful and satisfied one has been in performing a given task; effort (EF), taken to indicate how hard one has had to work to accomplish a certain level of performance; and frustration (FR), which denotes how discouraged versus content one has felt while completing the task (Hart & Staveland, 1988) .

All the dimensions of NASA-TLX were presented to the nurses in this study. NASA-TLX is administered in two steps. First, participants think about the task they are asked to do (for instance, admitting patients to the emergency ward) and look at each pair of the six dimensions to decide which one better fits their personal definition of workload as related to the task. They should therefore make 15 paired comparisons. For example, they need to decide whether performance or frustration 'represents the more important contributor to the workload for the specific task you recently performed'.

In the second step, the participants should rate each dimension on scales from low to high or from good to poor. Then, the overall workload score for each task is calculated by multiplying the raw score for each item by the weight from step 1. The weight of each item from step 1 was calculated by dividing the frequency of each dimension of the 15 paired comparisons by 15 (Hart & Staveland, 1988) .

Finally, the total workload value was calculated as the mean score, ranging from 0 to 100. Based on the work conditions of the nurses and the Subjective Workload Assessment Technique (SWAT), the overall workload was divided into five levels, namely low (0 to 9), medium (10 to 29), somewhat high (30 to 49), high (50 to 79) and very high (80-100) (Madadzadeh et al., 2018) . The NASA-TLX was translated into Persian, culturally adapted and validated for the first time by Mohammadi et al. (2013) . The face and content validities of the English version of this scale had already been confirmed.

The split-half reliability of NASA-TLX was more than 0.80, and the item-total correlation coefficients were all more than 0.60 (Hart & Staveland, 1988) . The reliability coefficient of this scale, measured by the test-retest method, was reported as 0.746 . The reliability of the questionnaire was also confirmed among 30 nurses with Cronbach's alpha of 0.847 (Safari et al., 2013) .

This study confirmed the reliability of the NASA-TLX in a pilot study on ten nurses with Cronbach's alpha of 0.89.

Paterson's job performance questionnaire (JPQ) has 15 items, which are scored on a 4-point Likert scale, from 0 (rarely) to 3 (always). The range of scores for each subject is 0 to 45, and a score above 22 indicates a better job performance (Paterson & Husband, 1970) . Paterson and Husband (1970) The face and content validities of the questionnaire were also confirmed in Hosseini et al. (2017) . This study confirmed the reliability of Paterson's JPQ in a pilot study on ten nurses with a Cronbach's alpha of 0.80.

The collected data were analysed in IBM SPSS Statistics for Windows, version 23.0 (IBM Corp.), using descriptive and inferential statistics. The descriptive statistics included mean, standard deviation, percentage and frequency. Pearson's correlation coefficient was utilized for evaluating the relationship between mental workload and its dimensions with job performance. The

One-way ANOVA test and the independent t test were used to compare the differences between the mental workload and job performance based on the demographic variables. Furthermore, the stepwise multiple linear regression analysis was used to examine the prediction role of mental workload dimensions and demographic characteristics in job performance during the COVID-19 pandemic. P-values less than 0.05 were considered statistically significant.

After obtaining the approval of the Ethics Committee of Semnan from Hamadan). The mean age of the nurses was 31.92 ± 7.33 years.

Most of them were female (54%), married (60.4%), had no children (64%) and worked in the rotational shifts (75.5%). The mean total work experience and COVID-19 nursing care experience were 9.45 ± 10.34 years and 2.12 ± 1.28 months, respectively. Also, most participants worked in the emergency department (46%).

The mean scores of mental workload and job performance were 67.30 ± 14.53 and 37.37 ± 7.36, respectively. Also, 10.07%, 71.95%

and 17.98% of the nurses had somewhat high, high and very high workloads, respectively. Moreover, the classification of grades indicated that 96.4% of the nurses had a high job performance.

There was no statistically significant correlation between the mental workload and the mean score of job performance (r = .057, p = .510). In contrast to mental demand and temporal demand that had a significant positive correlation with job performance (r = .175, p = .04; r = .307, p < .001, respectively), the frustration had a significant negative correlation with job performance (r = −.183, p = .032) ( Table 2 ). working shift (night) (β = −3.80, p = .017) significantly predicted nurses' job performance as did ward of work (emergency department) (β = −5.13, p < .001) ( Table 3) .

No significant differences were observed between the mean mental workload and demographic characteristics (p > .05). Furthermore, there were no significant differences between the mean job performance and variables of gender (p = .292), hospital location (p = .142), ward of work (p = .691) and the number of children (p = .145), but there were differences between this mean value and age (p < .001), clinical work experience (p < .001) and COVID-19 nursing care experience (p = .021). A significant difference was also observed in the mean score of job performance in terms of marital status (p = .002) and working shift (p = .001) ( Table 4 ).

The present study was conducted to assess the correlation between mental workload and job performance in nurses providing care to patients with COVID-19, and explain the factors predicting their job performance.

In the present study, most nurses providing care to patients with COVID-19 had high levels of mental workload. This finding was consistent with the results of most studies in critical conditions (Shoja et al., 2020; Judek et al., 2018) ; however, the score was medium to low in similar studies among different nurses in non-critical situations (Destiani et al., 2020; Mohammadi et al., 2016; Asamani et al., 2015) . Malekpour et al. (2014) Rusdi et al., 2020; Yosiana et al., 2020) . Also in contrary to the present findings, Asamani et al. (2015) in Ghana reported that moderate to high workloads among HCWs improve their job performance in hospitals significantly. In contrast, the results of another study showed that high workload reduces performance (Baethge et al., 2016) . in Iran showed that crisis management is integral for emergency nurses and requires financial, welfare, emotional and legal support, especially in critical emergencies (Vasli & Dehghan-Nayeri, 2016) . Bolghanabadi et al. (2018) in Iran also stated that mental workload and musculoskeletal disorders are higher among night shift workers than day shift workers. Extremely long work hours in bank employees correlated negatively and significantly with their performance (Siswanto et al., 2019) . Nevertheless, Malekpour et al. (2014) found that working shift and the number of patients to whom each nurse provides care have a significant positive correlation with the workload level, although there was no such correlation with the other variables. Another study also showed that an interrupted worker needs more time to restart work and to reach his proper performance (Asamani et al., 2015) . These contradictory findings demonstrate that work processes, organisational structure and differences in rules or protocols can significantly affect employees' workload and impact their performance during critical conditions such as the COVID-19 pandemic.

The present study results showed that nurses' job performance was different based on the variables of age, marital status, Kouhnavard et al., (2020) showed that job performance had a significant correlation with age, work experience and marital status. In contrast, Mosaferchi et al. (2017) reported that nurses' job performance had no significant correlation with working shift, work experience, marital status, age and gender. These conflicting results can be due to conducting the above studies in different wards and under non-critical conditions.

There were a few limitations and potential biases in this study. Although the researchers tried to avoid tiring out the participants by long questionnaires, their mental state when completing the questionnaires may have influenced their answers to the items. The sample size was small for achieving a correct inference and suitable generalizability. Furthermore, a few participants contracted COVID-19 and dropped out. This sample loss was random and out of researchers' control. However, since this study was conducted with a limited number of nurses in a small region of Iran, the results should be cautiously interpreted and applied to nurses in other countries considering the context and culture in Iran.

The researchers thus suggest a larger-scale replication of this study so as to be able to generalize the findings with greater certainty. 

Given that the COVID-19 pandemic is still an ongoing crisis and that the emergence of similar crises is possible, the current study may have several implications for policymakers and nursing managers. Unlike other studies, since nurses' mental workload had a weak positive correlation with job performance, workload management programmes can help reduce mental workload and subsequently enhance nurses' job performance. Through effective management of human resources, support, communications, training, identifying optimal job performance, and rewarding, managing workload and creating a positive working atmosphere, these programmes can empower and motivate nurses, and ultimately improve their job performance and patient care.

By considering the prediction of nurses' job performance by variables such as age, experience of providing care for patients with COVID-19 and gender, as well as their lower performance at night shifts and in emergency departments, some strategies should be considered by hospital human resource managers and planners in COVID-19 care units, including adjusting the number of night shifts and adding male nurses to the mix of workers in the units and also

improving the conditions at emergency departments.

Maximum efforts are needed to review nurses' work schedules, provide them with periodic consultations and physical examinations, and improve the staff's performance in future similar crises.

Since frustration can be negatively predicted job performance, nursing managers should be aware that psychological and social support for nurses can increase their performance in the current conditions.

The authors would like to express their gratitude to the research deputy of Semnan University of Medical Sciences for their approval of the project and also to all the nurses participating from Hamedan and Urmia hospitals despite their heavy workload during the current crisis, and finally, to Dr. Mohammad Heidari, for his review of the article and assistance in analysing the data.

No actual or potential conflict of interest has been declared by the authors. 

The Relationship between mental workload and job boredom proneness in female health care providers at ardabil-based health centers-Iran

Coronavirus disease 2019 (COVID-19) outbreak in Iran: Actions and problems

Relationship of nurses' mental workload with patient safety condition in emergency departments of Qom University of Medical Sciences Hospitals

Job performance among nurses working in two different health care levels, Eastern Saudi Arabia: A comparative study

Evaluation of workload and performance of nurses in ICUs of teaching hospitals of Tehran

Task performance induced work load in nursing

Direct and indirect effects of central self-assessment on job satisfaction, organizational commitment and job performance

The influence of workload levels on performance in a rural hospital

Nursing performance under high workload: A diary study on the moderating role of selection, optimization and compensation strategies

Relationship between mental workload and musculoskeletal disorders in nurses working at day and night shifts in the state hospitals

Mental health care for medical staff in China during the COVID-19 outbreak

Nursing and the novel coronavirus: Risks and responsibilities in a global outbreak

Psychological impact of the coronavirus disease 2019 (COVID-19) outbreak on healthcare workers in China

Nursing research is coronavirus research

The mental workload of nurses in the role of nursing care providers

Managing job performance, social support and work-life conflict to reduce workplace stress

Nurses and Coronavirus: Challenges and Consequences. Iran Occupational Health

Development of NASA-TLX (Task Load Index): Results of empirical and theoretical research

Anxiety and depression in health workers and general population during COVID-19 in IRAN: A crosssectional study

The relationship between job burnout and job performance of clinical nurses in Shiraz Shahid Rajaei hospital (thruma) in 2016

Risks of treated anxiety, depression, and insomnia among nurses: A nationwide longitudinal cohort study

The performance and professionalism of nurses in the fight against the new outbreak of COVID-19 epidemic is laudable

Crisis managers' workload assessment during a simulated crisis situation

Job stress and intent to stay at work among registered female nurses working in Thai hospitals

The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus

Investigating the relationship between job stress and working pressures and their effect on the job performance of personnel in educational hospitals of Larestan University of Medical Sciences

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019

The association between workload and job stress among nurses in Vasei hospital

Assessment of mental workload in nursing by using NASA-TLX

Evaluation of mental workload among ICU ward's nurses

Developing and accessing the validity and reliability of a questionnaire to assess the mental workload among ICUs Nurses in one of the Tehran University of Medical Sciences hospitals

The Role of individual effective factors on nurses' job performance. A case study: selected hospitals in Tehran. Tibbi-i-kar

Decision-making responsibility: Yardstick for job evaluation

The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak

The influence of workload on the nurses performance at Ambon general hospital. Enfermería Clínica

Evaluation mental work load in nursing critical care unit with national aeronautics and space administration task load index (NASA-TLX)

Mental workload and its affected factors among nurses in Kashan province during

Covid-19 effects on the workload and mental health of Iranian healthcare workers

Does a workload influence the performance of bank employees?

Relationship between motivation, competence, workload, and nurse performance

Emergency nurses' experience of crisis: A qualitative study

The mental health of healthcare workers in the COVID-19 pandemic: A systematic review

Can we contain the COVID-19 outbreak with the same measures as for SARS?

Effect of BMI, workload, work fatigue, and complaints of musculoskeletal disorders on nurse performance in Sawerigading Hospital Palopo. Enfermería Clínica

Nurses' stress associated with nursing activities and electronic health records: data triangulation from continuous stress monitoring, perceived workload, and a time motion study

The analysis of workload and work environment on nurse performance with job stress as mediation variable