key: cord-0866989-3r0vhji7
authors: Brayden, N.; Fradkin, Dina; Lee, Heeyoung; Mitchell, Ann
title: Mental Wellness Among Psychiatric-Mental Health Nurses During the COVID-19 Pandemic()()
date: 2021-05-11
journal: Arch Psychiatr Nurs
DOI: 10.1016/j.apnu.2021.05.003
sha: efc712c6220938225c47bdcf30618c317b3db176
doc_id: 866989
cord_uid: 3r0vhji7

Psychiatric nursing providers and their unique challenges in the face of the COVID-19 pandemic are not well-represented in the literature. Therefore, this study sought to describe mental wellbeing of psychiatric nurses, and sought to elucidate factors related to mental wellness during the COVID-19 pandemic. This study utilized cross-sectional survey methodology to evaluate burnout, mental wellness, COVID-related anxiety, professional fulfillment, depressive symptoms, and anxiety symptoms among psychiatric nurses. There was a total of 151 respondents. A linear regression model was employed to identify predictors of mental wellness. The final regression model included the following predictors: depressive symptoms, burnout, professional fulfillment, and educational status. These predictors together accounted for 73% of the variance for the outcome variable of mental wellbeing.

The COVID-19 pandemic has brought about unprecedented hardship across the globefrom astronomical mortality and morbidity rates (Centers for Disease Control and Prevention, 2021) to economic and financial hardship (University of Rochester, 2020), the lives of patients and families have been undoubtedly affected. Initial reports in early 2020 showed demonstrable concern regarding the subsequent impact of the pandemic on the development of stress, anxiety, mood symptoms, sleep disturbances (Shuja, Aqeel, Jaffar, & Ahmed, 2020; Torales, O'Higgins, Castaldelli-Maia, & Ventriglio, 2020) and their resulting public health and diagnostic implications (Dong & Bouey, 2020; Heitzman, 2020) .

While initial literature focused on promoting the identification of comorbid mental health symptoms among patients diagnosed with COVID-19 (Pfefferbaum & North, 2020) , health care providers and other front-line workers simultaneously faced a significant proportion of the pandemic burden. Presently, health care providers, the celebrated heroes of the global pandemic, are tasked with extraordinary challenges in their work. The study was done in China to investigate nurses' responses from February 9, 2020, to March 15, 2020, indicated that nurses who took care of patients with COVID-19 went through three stages of reactions: ambivalence toward their role (e.g., patient care vs. concern of infection), emotional exhaustion (e.g., anxiety, entrusted with providing comprehensive psychological and psychiatric care while facing their own novel challenges.

The mental health and overall well-being of front-line workers in the face of COVID-19 is undoubtedly affected, and akin to previously mentioned studies, increased levels of anxiety, depression, insomnia, and stress were detected in a recent study (Garcia-Iglesias et al., 2020) .

The effect of the COVID-19 pandemic on burnout and professional fulfilment in physicians is discussed (Amanullah & Ramesh Shankar, 2020) . Likewise, mental health nursing providers would experience burnout because patients with mental illness reported significant psychiatric symptoms such as anxiety, depression, or insomnia during the peak of the pandemic (Hao et al., 2020) . However, there is an evident gap in the literature surrounding the identification of COVID-19-related mental health and well-being concerns among certain providers. Specifically, mental health nursing providers and their unique challenges in the face of the pandemic are not well-represented in the literature. Therefore, this study sought to describe mental wellbeing of mental health nurses, and sought to elucidate factors related to mental wellness during the COVID-19 pandemic.

Health workforce stress and resulting burnout is not a novel concept-in fact, as some authors note, burnout syndrome was initially described in the literature in the 1900s (Roy, 2018) . professional efficacy (World Health Organization, 2019) . Prior to the pandemic, burnout prevalence among mental health nurses was studied, and contributory variables identified included work overload, work-related stress, professional seniority, male gender, single status, and work-place aggression (Lopez-Lopez et al., 2019) . In the context of the pandemic, risk factors for burnout among nurses include younger age, social isolation, an increased workload (Tiete et al., 2021) . Estimated burnout prevalence among 868 nurses included 25% for emotional exhaustion, 15% for depersonalization, and 22% for low personal accomplishment (Lopez-Lopez et al., 2019) . Burnout is a serious condition that can lead to feelings of failure and shame while negatively affecting patient care (Foster et al., 2019) . Additionally, compassion fatigue, defined as stress from repeated exposure (Cocker & Joss, 2016) , has been studied among many health care professions, but, notably, advanced practice providers have been underrepresented in the past (Sorenson, Bolick, Wright, & Hamilton, 2016) .

In regard to professional fulfillment, there is little literature related to professional fulfillment in nurses, and even less within the context of the COVID-19 pandemic. A recent study by Li and colleagues (2020) evaluated the impact of the pandemic on nurses' professional identity. The study utilized cross-sectional data obtained from a survey of over 5,500 nurses residing in China. Utilizing quantitative survey data and qualitative content analysis, the authors found high levels of professional fulfillment and strong professional identity within the context of the COVID-19 pandemic. Nurses expressed a strong sense of responsibility to care for anxiety symptoms (Kannampallil et al., 2020) . Other studies of health care workers have found high rates of mental health symptoms within the context of the COVID-19 pandemic. A recent systematic review highlighted pooled rates of depression and anxiety among health care workers at 23% and 22%, respectively (Pappa et al., 2020) . In a study of over 3,200 nurses in China at the onset of the pandemic, the incidence of depression and anxiety was estimated at 34% and 18%, respectively (Zheng et al., 2021) . Another study reported that 45% of frontline nurses experienced depression or anxiety, and those with mental health symptoms were more likely to report burnout (Hu et al., 2020) . In addition to the high rates of mental health symptoms among nurses related to the pandemic, nurses qualitatively report that work challenges and working conditions during the pandemic precipitated both physical and psychological symptoms, however also reported that commitment to nursing and organizational support mitigated mental health symptoms (Goh et al., 2020) .

This study utilizes a cross-sectional design to investigate challenges faced by psychiatricmental health nurses during the COVID-19 pandemic. Psychiatric mental health nurses participated in the study. Eligibility criteria included age over eighteen years and current or former work within the mental health industry.

The University Institutional Review Board (IRB) reviewed and approved the study Participants were compensated to complete the survey via the provision of randomly selected and distributed electronic gift cards. To assure anonymity, after survey completion, participants were redirected to a separate, unlinked survey page where they input their email addresses for contact should they have been chosen to receive the electronic gift card. Electronic consent for all participants was obtained prior to survey commencement.

Demographic characteristics. Demographic data was obtained via free text response and included age, gender, highest level of education, description of current role, and description of current practice setting.

Professional fulfillment. An abbreviated, 6-item version of the Professional Fulfillment Index (PFI) with a Likert response format was utilized. Participants were asked to report the extent to which they felt happy at work, worthwhile at work, satisfied with their work, in control = -4.27, p < 0.001), or those working in outpatient settings (t = -2.33, p = 0.22) reported higher degrees of mental wellness than their counterparts (see Table 3 ).

Pearson's correlation tests were utilized to examine correlations between COVID-related anxiety, burnout, depressive symptoms, anxiety-related symptoms, and mental wellbeing. Scores in the Warwick-Edinburgh Mental Wellbeing scale were positively correlated with professional fulfilment (r = 0.696, p < 0.001), but were negatively correlated with COVID-related anxiety (r = -0.390, p < 0.001), burnout (r = -0.668, p < 0.001), depressive symptoms (r = -0.764, p < 0.001), and anxiety-related symptoms (r = -0.637, p < 0.001). Therefore, to further evaluate predictors of mental wellbeing a linear multiple regression was employed. Based on the regression, gender, work setting, work role, COVID-related anxiety, and overall anxiety were not considered to be strong predictors of mental wellbeing, and were subsequently removed from the model. The final regression model included the following predictors: depressive symptoms, burnout, professional fulfilment, and educational status. These predictors together accounted for 73% of the variance for the outcome variable of mental wellbeing. Within this model, depressive symptoms (β = -0.394), burnout (β = -0.254) and professional fulfillment (β = 0.325) were strong predictors of mental wellbeing (ps < 0.001), as was educational status (β = .101, p = 0.031).

While the adverse mental health outcomes related to the COVID-19 pandemic have been well documented amongst the general population and amongst healthcare workers, to the authors' knowledge, this is the first study that has evaluated mental health outcomes, burnout, and professional fulfillment among psychiatric-mental health nurses during the COVID-19 pandemic. Coronavirus anxiety was lower in this sample compared to previous reports, although participants experienced a moderate level of COVID-related burnout. Interestingly, our results J o u r n a l P r e -p r o o f diverge from previously reported literature on burnout among mental health workers, in which professional seniority and male gender were found to be contributing factors to burnout among mental health nurses (Lopez-Lopez et al., 2019) .

While 64% of participants reported that the demand of their job interfered with family life frequently, overall burnout scores were moderate, with an average score of about 12 out of 25. While psychiatric-mental health nurses endorsed high degrees of work demands, this finding indicates that the participants were generally able to effectively cope with the demands of work, thereby reducing overall burnout. This sample also endorsed average to above average levels of professional fulfillment, which may have also been a protective factor from the perspective of burnout. Similar studies have found that family life has been a supportive factor for nurses during the COVID-19 pandemic, and that family was an external source of supported that mitigated burnout (Goh et al., 2020) .

In regard to mental wellbeing, advanced practice nurses, those with post-graduate education, and those working in outpatient settings generally reported higher degrees of mental wellness than their counterparts. It is possible that multiple factors contribute to mental wellbeing, in that those with post-graduate education are more likely to be advanced practice nurses, and thereby more likely to work in outpatient settings. Those working in outpatient settings are more likely to utilize telepsychiatry services, and therefore may be less likely to be exposed to COVID, which may have also been a protective factor from a mental wellness However, these authors did not find statistically significant differences in levels of burnout among inpatient versus outpatient mental health workers (Rapisardi et al., 2020) .

When variables were combined into a regression model, work setting and role were not found to be strong predictors of mental wellbeing, despite their association, although educational status was found to be a strong predictor. Depressive symptoms, burnout, and professional fulfillment significantly predicted outcomes related to mental wellness. Similarly, Rapisardi and colleagues found that burnout, GAD-7, and PHQ-9 predicted burnout in a sample of Italian mental health workers during the early COVID-19 pandemic. It is possible that educational status is related to professional fulfillment, and thereby influences both depressive symptoms and burnout, ultimately improving degrees of mental wellness. These four variables should be considered when identifying psychiatric-mental health nurses at-risk for adverse mental wellness, and are important considerations when developing interventions.

Interestingly, similar phenomena have been reported in both epidemics and pandemics that preceded the COVID-19 pandemic. A recent review examined mental health impacts among health care workers in the context of not only the COVID-19 pandemic, but also the sudden acute respiratory syndrome (SARS) pandemic, the Middle Eastern respiratory syndrome (MERS) pandemic, Ebola outbreaks, and influenza A epidemics. About 27-50% of health care workers endorsed depressive symptoms and 45% of health care workers endorsed anxiety symptoms (Preti et al., 2020) . While our study is a cross-sectional survey, the authors of this review concluded that symptoms persisted between one and three years in up to 40% of health care workers, highlighting the importance of identifying mental health symptoms in health care workers related to COVID-19 and expediently addressing them.

Three are a few caveats to keep in mind when interpreting the findings. Because of the cross-sectional nature of the study, the authors are unable to infer causal relationships based on the aforementioned variables. The convenience sample precludes generalizing the results to the wide population. Self-reported data collection introduces the possibility for recall bias or social desirability bias. Additionally, due to the breadth of information sought, respondents may have experienced survey fatigue, which could have resulted in survey discontinuation or inaccurate responses.

Additional studies with larger sample sizes should continue to explore the aforementioned variables in the context of the COVID-19 pandemic. Furthermore, additional research is needed to better understand resiliency among psychiatric-mental health nurses in the context of the COVID-19 pandemic or other crises or disasters. This work, in addition to future work, will inform best practices related to policies or workforce interventions that support the mental wellbeing of psychiatric-mental health nurses providing care in high-stress situations. The efficacy of such policies and interventions should be evaluated via high-quality research studies to promote optimum outcomes amongst the psychiatric-mental health nursing workforce.

In regard to clinical practice, these findings have implications for nursing administrators and health care executives. It is critical that the mental health of frontline nurses is well supported, not only during times of crisis such as the COVID-19 pandemic, but also as a general practice. Nurses should be provided with access to timely mental health resources including peer support, employee assistance programs, and formalized mental health symptoms. Administrators and health care executives should be mindful of risk factors for burnout, and should actively seek J o u r n a l P r e -p r o o f to promote work environments that provide nurse support, equitable workload, and appropriate amount of time off of work for mental and physical recuperation.

Our findings highlight that psychiatric-mental health nurses are generally resilient. In this sample, participants reported only mild levels of depressive and anxiety-related symptoms, and average levels of professional fulfillment and mental wellness. Furthermore, COVID-specific anxiety was lower in this sample compared to previously reported literature. Predictors that influenced mental wellness included depressive symptoms, burnout, professional fulfillment, and educational status. When considering interventions to promote mental wellness among psychiatric-mental health nurses in the context of the COVID-19 pandemic, these predictors should be considered. Psychiatric-mental health nurses struggling with depression, high levels of burnout, and low levels of professional fulfillment should be targeted, and additional support and resources should be offered. These results can inform nursing administrators and general policy makers to best improve resources and subsequent mental health outcomes among frontline psychiatric-mental health nurses, not only during the COVID-19 pandemic, but also for future crises or disasters.

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