key: cord-0985031-s3rddhln
authors: Melnyk, Bernadette Mazurek; Hsieh, Andreanna Pavan; Tan, Alai; Teall, Alice M.; Weberg, Dan; Jun, Jin; Gawlik, Kate; Hoying, Jacqueline
title: Associations Among Nurses' Mental/Physical Health, Lifestyle Behaviors, Shift Length, and Workplace Wellness Support During COVID-19: Important Implications for Health Care Systems
date: 2021-09-20
journal: Nurs Adm Q
DOI: 10.1097/naq.0000000000000499
sha: daddcf34028edfb4d79361fbeb5e10de4a530847
doc_id: 985031
cord_uid: s3rddhln

Work cultures supportive of wellness and shorter shift length have been associated with better mental/physical health outcomes in nurses, but how the coronavirus disease-19 (COVID-19) pandemic impacted such outcomes is not known. This study's aims were to (1) describe the mental/physical health, well-being, and healthy lifestyle behaviors of nurses during the pandemic; (2) explore the pandemic's impact on their health and healthy lifestyle behaviors; and (3) determine the associations of perceived workplace wellness support and shift length with nurses' health, well-being, and healthy lifestyle behaviors. A cross-sectional descriptive design was used with 264 nurses associated with Trusted Health. Nurses completed a survey containing valid and reliable scales measuring depression, anxiety, burnout and quality of life, perceived wellness culture, and healthy lifestyle behaviors. Results indicated that more than 50% of nurses had worsening mental/physical health relating to the pandemic. Compared with nurses whose workplaces provided little/no wellness support, nurses with workplaces that supported their wellness were 3 to 9 times as likely to have better mental/physical health, no/little stress, no burnout, and high quality of life. Nurses who worked longer shifts had poorer health outcomes. These findings indicate that workplace wellness support and shorter shifts positively impacted nurse mental/physical health and professional quality of life amidst the pandemic.

NURSING ADMINISTRATION QUARTERLY/JANUARY-MARCH 2022 physical health relating to the pandemic. Compared with nurses whose workplaces provided little/no wellness support, nurses with workplaces that supported their wellness were 3 to 9 times as likely to have better mental/physical health, no/little stress, no burnout, and high quality of life. Nurses who worked longer shifts had poorer health outcomes. These findings indicate that workplace wellness support and shorter shifts positively impacted nurse mental/physical health and professional quality of life amidst the pandemic. Key words: nurses, occupational health, pandemic, well-being B EFORE THE CORONAVIRUS DISEASE-2019 (COVID- 19) pandemic, national studies indicated that nurses experience high rates of mental/physical health problems that negatively impact the quality and safety of health care. 1, 2 Currently, research indicates that rates of burnout, stress, anxiety, and posttraumatic stress disorder are on the rise in health care professionals as has been found in past viral epidemics. [3] [4] [5] System failures such as inadequate staffing, lack of training when deployed to a new clinical area, and personal protective equipment shortages, as well as being the primary support person to dying patients, have contributed to clinician distress during the pandemic. 6 Frontline health care professionals also face 3 times the risk of a positive COVID-19 test when compared with the general community. 7 Consequently, nurses and other health care professionals are facing a mental health pandemic inside of the COVID-19 pandemic that requires urgent action. 5, 8 Nurses are skilled at promoting the wellbeing of the patients they serve; however, they struggle to prioritize their own wellbeing. A study of 1790 nurses found that less than 50% of participants were in suboptimal mental/physical health. 1 Burnout has become endemic in health care professionals, with the prevalence between 35% and 60%. 9, 10 Nurses also report high rates of depression, anxiety, and stress, 1,2 placing them at a greater risk of suicidal action than the public. 11, 12 A proposed solution for solving the clinician mental health crisis is the promotion of a systems approach. 13, 14 This requires understanding system drivers in poor clinician mental health, such as heavy workloads, poor staffing, long work hours, electronic health record problems, and workplace culture. 15 Preceding the COVID-19 pandemic, positive work environments/cultures where clinicians felt supported in their wellness were identified as a key component in mitigating clinician wellness concerns. However, it is not known how nurses' perception of workplace wellness culture has impacted their mental/physical health and lifestyle behaviors during the COVID-19 pandemic.

This study's aims were to (1) describe the mental/physical health, well-being, and healthy lifestyle behaviors of nurses during the pandemic; (2) explore the pandemic's impact on their health and healthy lifestyle behaviors; and (3) determine the associations of perceived workplace wellness support and shift length with nurses' health, well-being, and healthy lifestyle behaviors.

A cross-sectional survey design was utilized. The study procedures were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration. The institutional review board at the first author's institution reviewed and determined the study as exempt, category 2a (protocol no. 2020E0874). Study data were collected from August 2020 through October 2020.

Nurse Wellness During COVID-19 7 interested in being contracted with Trusted Health, a travel nurse technology and staffing company. Trusted Health maintains e-mail listservs for sending organizational newsletters to nurses who signed up for such correspondence. The newsletters e-mailed during August 2020 to October 2020 contained information about the study, the survey, and how to participate anonymously via a secured link. Qualtrics, an online survey software program, hosted the survey. Participants provided their consent digitally before starting the survey.

Survey questions included gender, ethnicity/race, age, and primary role in nursing for demographic data collection. The remaining survey questions aimed to assess nurse well-being (mental/physical).

The Centers for Disease Control and Prevention (CDC) guidelines on preventing chronic disease were used for developing the healthy lifestyle behavior questions. 16 Questions inquired about hours of sleep obtained/night, minutes of physical activity obtained per week, number of fruits and vegetables eaten per day, and tobacco and alcohol use. Healthy lifestyle behaviors were measured because less than 7% of Americans engage in all the lifestyle behaviors recommended by public health authorities. 17 Healthy lifestyle behaviors are key in the prevention of chronic disease, including mental health conditions.

COVID-19 restrictions disrupted daily life for many people and resulted in unhealthy coping mechanisms (eg, unhealthy eating, increased alcohol use) or an inability to participate in regular health routines. 18 After each healthy lifestyle behavior question, participants were asked whether COVID-19 impacted their healthy lifestyle behaviors and in what way. Sleep and physical activity im-pact were assessed with 2 questions. For sleep, the first question asked, "Has your sleep been negatively impacted since the start of the COVID-19 pandemic?" If participants answered "Yes," they were asked, "If yes, how has your sleep been impacted?" The available responses were "I am sleeping more than usual" or "I am sleeping less than usual." The same format was used for exercise. Eating, tobacco use, and alcohol use during COVID- 19 were assessed with 1 question per behavior. For eating, participants were asked, "Has the pandemic affected your nutrition patterns in a negative way?" Responses were, "No," "Yes, I am tending to eat less healthy," and "Yes, I am eating more healthy." The tobacco and alcohol questions were formatted differently than the eating question did as they inquired whether tobacco or alcohol use had increased since the start of the pandemic. Available responses were "No" and "Yes I am using/consuming alcohol/these products more often."

The Patient Health Questionnaire-2 (PHQ-2) measures depressive symptoms and was used in this study as this instrument has been used in similar mental health and perceived workplace wellness support research. 1, 2 The PHQ-2 is valid, reliable, and widely utilized. 19 Two items inquired about how frequently participants experienced depressive symptoms over the previous 2 weeks: "How often have you been bothered by any of the following problems: little interest or pleasure in doing things; or feeling down, depressed, or hopeless." Participants responded to the items using a 4-point Like-type scale, 0 (not at all) to 3 (nearly every day). The Cronbach α for this sample was 0.83.

The Generalized Anxiety Disorder-2 (GAD-2) measures anxiety symptoms and was used in this study as it has been used in similar mental health and perceived 8 NURSING ADMINISTRATION QUARTERLY/JANUARY-MARCH 2022 workplace wellness support research. 1, 2 The GAD-2 is valid and reliable. 20 Two items on the scale inquire about how frequently participants experienced anxiety symptoms over the previous 2 weeks: "How often have you been bothered by any of the following: feeling nervous, anxious, or on edge; or not being able to stop or control worrying." Participants responded to the items using a 4-point Like-type scale, 0 (not at all) to 3 (nearly every day). The Cronbach α for this sample was 0.87.

Nurses tend to have lower perceived stress when they perceive their workplace as supportive of their wellness. 2 Therefore, the valid and reliable Perceived Stress Scale-4 (PSS-4) was used in the current study to measure stress perception via a 4-item Likert scale. 21, 22 The 4 item scores are produced by calculating the sum of the items, with reverse scoring on 2 of the items. Higher scores indicate higher perceived stress. Example items include the following: "In the last month, how often you felt that you were unable to control the important things in your life?" And "That you were unable to handle your personal problems?" Participants responded to the items using a 5-point Likert scale, 0 (never) to 4 (very often). The Cronbach α for this study was 0.87.

Nurses' professional quality of life (Pro-QOL) has been shown to increase with higher perceived workplace wellness support. 2 To assess ProQOL in the current sample, 4 questions from the ProQOL scale 23 were used: "I feel worn out because of my work"; "I feel trapped by my job"; "I am not as engaged with my patients today as I used to be"; and "I believe I can make a difference through my work." Responses used a Likert scale from 1 (never) to 5 (very often). A score of 12 to 16 indicated a high ProQOL. The Cronbach α for this sample was 0.79.

Workplace wellness support is believed to reduce clinician burnout. 13, 14 A single item from the proprietary Maslach Burnout Inventory Emotional Exhaustion (MBI:EE) subscale has been validated as a standalone burnout measure. 24 The current study used a nonproprietary 1-item measure that has been reported as a viable replacement for the single item MBI:EE to assess burnout. 24 When compared with the MBI:EE, the nonproprietary measure has a correlation of 0.79, sensitivity of 83.2%, specificity of 87.4%, and an area under the receiver operator curve of 0.93. The nonproprietary 1-item measure asks, "Overall, based on your definition of burnout, how would you rate your level of burnout?" A 5-category ordinal scale is used to score responses: 1 = no symptoms; 2 = occasional stress, but don't feel burned out; 3 = definitely burning out and am experiencing physical or emotion exhaustion; 4 = symptoms of burnout won't go away; and 5 = I feel completely burned out and often wonder if I can go on. 24 A positive score for burnout was 3 or more.

Nurse self-reported mental/physical health ratings increase with higher perceived workplace wellness support. 1,2 In the present study, self-reported mental health was obtained by asking, "On a scale of 0-10, how would you rate your current mental health? [0 being very unhealthy to 10 being extremely healthy]" Self-reported physical health was obtained in a similar matter with the same scale. Following the scaled mental/physical health questions, participants were asked, "Has your physical health been impacted by COVID-19?" And "Has your mental health been impacted by COVID-19?" Available responses for physical health were "No," "Yes, I am physically healthier as a result of COVID-19," and "Yes, I am not as physically healthy as a result of COVID-19." The responses for mental health were similar to the physical health responses, except instead using physicality verbiage in the "Yes" responses, "better mental health" and "not as mentally healthy" were used.

The mental health of nurses can be impacted by the number of hours worked. 15 Therefore, shift length was assessed by asking, "How long is your typical workday or shift?" Selections options were less than 8 hours, 8 to 10 hours, 11 to 12 hours, and 12+ hours.

Higher perceived workplace wellness support has been associated with improved mental and physical health in nurses. 1, 2 Workplace wellness support was assessed by asking, "How supportive is your work environment of personal wellness?" Participants answered this question using a 5-point Likert scale, 0 (not at all) to 4 (very much).

Descriptive statistics were used to summarize sample characteristics, healthy lifestyle behaviors, mental/physical health, and the changes during the COVID-19 pandemic. Multiple logistic regression modeling was used to examine the effects of perceived workplace wellness support and shift length on each healthy lifestyle behavior and health measure, adjusting for other sample characteristics. Healthy lifestyle behaviors and health measures were analyzed separately in the multiple logistic regression model and dichotomized as better or worse categories. Better categories included sufficient sleep (7+ hours per night), adequate physical activities (150+ minutes of moderate physical activities per week), healthy eating (5+ servings of fruits/vegetables per day), not current smoker, no/light alcohol use (≤3 times per week), better physical health (self-rated physical health score of 6-10), better mental health (self-rated mental health score of 6-10), no symptoms of depression (PHQ-2 score of 0), no symptoms of anxiety (GAD-2 score of 0), no/little stress (PSS-4 score of ≤4), and high ProQOL (ProQOL-4 score of ≥12).

Similarly, multiple logistic regression modeling was used to examine the effects of perceived workplace wellness support and shift length on the odds of having a negative impact from COVID-19 on healthy lifestyle behaviors and health measure, adjusting for other sample characteristics. Each negative impact indicator was analyzed separately in the multiple logistic regression model and was dichotomized as having a negative impact (yes vs no). The "yes" category included (1) negative impact on sleep by either slept more or less, (2) less physical activities, (3) eating less healthy, (4) more smoking, (5) more alcohol drinking, (7) worsen physical health, and (8) worsen mental health. Sample characteristics (age, sex, race/ethnicity, marital/relationship status, degree of education, and Trusted Health contract status) were adjusted as covariates in all the logistic regression models.

The perceived workplace wellness support (the primary independent variable for the logistic regression models) was distributed as n = 121, 122, 19 for "not at all," "somewhat," and "very much" categories, respectively. Our sample size (n = 264) was not powered to detect an odds ratio (OR) of less than 2.2 for the somewhat versus not at all comparisons and an OR of less than 5.1 for the very much versus not at all comparisons. Similarly, the sample size was not powered to detect an OR of less than 2.1 for the shift length comparisons (<12 vs 12+ hours per day). The power analyses were conducted using logistic regression modeling with a 2-sided significance level of .05, assuming an outcome (eg, sleeping 7+ hours per week) had a prevalence of 10% to 50%. Therefore, result interpretations were guided by both effect sizes (ie, ORs for logistic regression analysis) and inferential statistics. Cutoffs of OR for small, medium, and large effect sizes were 1 

Of the 264 nurses who completed the survey, most were female (n = 235; 89.0%), non-Hispanic White (n = 187; 70.8%), and married or in a relationship (n = 153; 58.0%). The average age was 39.9 years (SD = 12.8).

More than half of the nurses were between 25 and 44 years of age (n = 175; 66.2%) and worked in a point-of-care/bedside setting (n = 138; 52.3%). Fifty (18.9%) of the nurses had an associate degree or diploma, 160 (60.6%) had a Bachelor of Science degree, 42 (15.9%) had a master's or doctorate degree. A majority (n = 174; 65.9%) of the nurses worked 12 hours or longer per day. Only 25 (9.5%) of nurses were currently contracted with Trusted Health, and the remaining were previously or interested in being contracted nurses (see Supplemental Digital Content Table 1 , available at: http://links.lww.com/ NAQ/A9).

A small proportion of nurses met the CDCrecommended guidelines for sleep, physical activity, and fruit/vegetable consumption. About a third (n = 93; 34.8%) of the nurses slept 7 or more hours per night. Fiftynine (22.3%) reported 150 minutes or more of moderate physical activities per week. Only twenty-one (8.0%) nurses consumed 5 or more servings of fruits/vegetables per day. Most nurses were not current smokers (n = 233; 88.3%). Thirty-nine nurses (14.8%) never drank alcohol, 195 (73.9%) were light drinkers, and 30 (11.4%) reported moderate/heavy drinking (Table 1) .

Results listed in Table 1 demonstrate the impact of the COVID-19 pandemic on healthy lifestyle behaviors. Most of the nurses (n = 171; 64.8%) reported that the pandemic neg- 

The nurses reported suboptimal health, with 197 (74.6%) reporting a physical health score of 5 or less and 213 (80.7%) reporting a mental health score of 5 or less. A substantial proportion of nurses reported some degree of depressive symptoms (n = 78; 29.5%), anxiety symptoms (n = 99; 37.5%), stress (n = 200; 78.5%), and burnout (n = 173; 65.5%). Only a small proportion of the nurses (n = 39; 14.8%) reported high ProQOL. More than half of the nurses reported worse physical health (n = 142; 53.8%) and worse mental health (n = 209; 79.2%) due to the pandemic ( Table 2) .

The proportion of nurses who had 7 or more hours of sleep per night increased with higher perceived workplace wellness support (28.9%, 38.5%, and 52.6% for "not at all/a little," "somewhat," and "very much support," respectively; Table 3 ). Similar trends for other healthy lifestyle behaviors were observed, including fruit/vegetable consumption, smoking, and alcohol use. The significant relationships between greater perceived support of wellness and better healthy lifestyle behaviors held after adjusting for nurses' age, gender, race/ethnicity, marital status, education, hours of workday/shift, and Trusted Health contract status in the multiple logistic regression models. Compared with nurses whose workplaces provided little or no support, those whose workplaces supported higher wellness were 5 times as likely to have 7 hours of sleep per night (OR = 4.89; 95% CI, 1.34-17.84) and 16 times as likely to Table 3 ). Information listed in Table 3 reveals that compared with nurses whose workplaces provided little/no support, those whose workplaces supported higher wellness were less likely to report a negative impact of the COVID-19 pandemic on their healthy lifestyle 12 NURSING ADMINISTRATION QUARTERLY/JANUARY-MARCH 2022 Nurse Wellness During COVID- 19 13 behaviors. Although the differences were not statistically significant due to a small number (n = 9) of nurses who reported very much wellness support in workplace, the ORs (0.21-0.53) were of small to medium effect sizes.

The proportion of nurses with good physical health increased with higher perceived workplace wellness support (19.0%, 30.3%, and 36.8% for "not at all/a little," "somewhat," and "very much support," respectively; Table 3 ). The same trend was observed for other health indicators, including mental health, depression, stress, ProQOL, and burnout. The significant relationship between greater perceived support of wellness and better health held after adjusting for nurses' age, gender, race/ethnicity, marital status, education, hours of workday/shift, and Trusted Health contract status in the multiple logistic regression models. Compared with nurses whose workplaces provided little or no support, those whose workplaces supported wellness very much were 3 to 9 times as likely to have good physical health (OR = 2.99; 95% CI, 0.84-10.59), good mental health (OR = 4.96; 95% CI, 1.12-21.89), no/little stress (OR = 4.96; 95% CI, 1. 25-19.64) , no burnout (OR = 6.34; 95% CI, 1.84-21.88), and higher ProQOL (OR = 9.19; 95% CI, 1.88-44.96; Table 3 ). Table 3 also shows that compared with nurses whose workplaces provided little or no support, those whose workplaces supported higher wellness were significantly less likely to report worsening physical and mental health due to the pandemic, with ORs ranging from 0.32 to 0.45.

The proportion of nurses who had 7 or more hours of sleep per night decreased with longer workday/shift (40.0% vs 32.2% for <12 vs 12+ hours per day; Table 4 ). Similar trends for other good healthy lifestyle behaviors were observed, including 150+ minutes of moderate physical activity per week, 5+ servings of fruit/vegetable consumption per day, and no smoking. The significant relationships between longer shift length and a higher likelihood of smoking held after adjusting for nurses' age, gender, race/ethnicity, marital status, education, perceived workplace wellness support, and Trusted Health contract status in the multiple logistic regression models. Compared with nurses with workday/ shift of less than 12 hours per day, those who worked 12+ hours per day were much less likely to be nonsmoker (OR = 0.09; 95% CI, 0.02-0.51; Table 4 ). Table 4 also shows that a higher percentage of nurses who worked 12+ hours per day reported a negative impact of the COVID-19 pandemic on their healthy lifestyle behaviors than nurses who worked less than 12 hours per day. The significant relationships between longer shift length and a higher likelihood of negative impact of the COVID-19 pandemic on sleep (OR = 4.55; 95% CI, 2.21-9.36) and smoking (OR = 12.50; 95% CI, 1.57-99.16) held after adjusting for nurses' age, gender, race/ethnicity, marital status, education, perceived workplace wellness support, and Trusted Health contract status in the multiple logistic regression models.

The proportion of nurses with good mental health decreased with longer workday/shift (23.3% vs 17.2% for <12 vs 12+ hours per day; Table 4 ). The same trend was observed for other health indicators, including depression, stress, ProQOL, and burnout. The significant relationship between longer shift length and worse health held after adjusting for nurses' age, gender, race/ethnicity, marital status, education, perceived workplace wellness support, and Trusted Health contract Table 4 ). Table 4 also shows that compared with nurses who worked less than 12 hours per day, those who worked 12+ hours per day were more likely to report worsening physical (OR = 2.29; 95% CI, 1.18-4.46) and mental health (OR = 1.68; 95% CI, 0.76-3.71) due to the pandemic.

This study's results indicate that the aspects of health and well-being that nurses struggled with before the pandemic were amplified during the pandemic. More than half of the nurses reported worsening physical/ mental health in relation to the pandemic. A large proportion of the sample reported depressive symptoms, anxiety, stress, and burnout. Furthermore, the majority did not meet evidence-based recommendations for healthy lifestyle behaviors that can prevent chronic disease, such as physical activity, healthy eating, and adequate sleep.

The extent to which COVID-19 has impacted nurse wellness became more evident when comparing this study's results with similar research published before the pandemic. A 2018 study of health and well-being in nurses reported that 46% were in good physical health, 39% had a high level of perceived stress, and 46% had a high ProQOL. 1 A 2019 cross-sectional study estimated a burnout prevalence of 35.3% in nurses. 15 In comparison, only 25% of nurses in the current study were in good physical health, 75.8% had a high level of perceived stress, 14.8% reported a high ProQOL, and 65.5% experienced burnout. Thus, this study's findings highlight the substantial negative impact of the COVID-19 pandemic on nurses' health and well-being.

The finding that nurses who perceived their workplaces as supportive of their wellness had better physical/mental health and engaged more in healthy lifestyle behaviors than those who did not have the same level of support was critical. When compared with nurses whose workplaces provided little or no support, nurses who reported having workplaces that very much supported wellness were 3 to 9 times as likely to have good physical health, good mental health, no/little stress, no burnout, and high Pro-QOL. Nurses whose workplaces supported higher wellness were 5 times as likely to have 7 or more hours of sleep/night and 16 times as likely to have 5+ servings of fruits/vegetables per day when compared with nurses whose workplaces provided little/no support. Previous research has found a significant relationship between workplaces that are supportive of wellness and better health, 1,2 thus strengthening the importance of building and sustaining workplace wellness cultures to support clinicians' health and well-being.

There are several evidence-based programs and tactics that enhance nursesʼ and other cliniciansʼ health and well-being that should be adopted by health care systems. A recent systematic review by Melnyk and colleagues 25 indicated that effective interventions to improve mental/physical health, well-being, and healthy lifestyle behaviors in physicians and nurses include mindfulness, health coaching, deep abdominal breathing, gratitude, cognitive-behavioral therapy/skills building, and visual triggers. Specifically, evidence-based programs, titled Mindfulness in Motion 26 and MINDBODYSTRONG for clinicians, 27, 28 which is manualized and based on cognitive-behavioral therapy, are efficacious in decreasing depression, anxiety, stress, and burnout and improving job satisfaction and are being scaled throughout the nation to improve the health and wellbeing of clinicians. In addition, anonymous mental health screening programs should be implemented by health systems, such as the Healer Education and Referral (HEAR) program, which provides referral and access to mental health treatment of clinicians suffering from depression. 29, 30 Beyond evidence-based programming and wellness cultures and tactics, intense effort must be placed in fixing system drivers such as long working hours that lead to burnout and unhealthy behaviors. Nurses tend to prefer 12-hour shift lengths as they perceive that it improves work-life balance. 31, 32 However, the current study found that the proportion of nurses who met good healthy lifestyle behaviors (sleep, exercise, and fruit and vegetable consumption) was higher in the nurses who worked shifts of less than 12 hours than nurses who worked shifts of 12 hours or more. Furthermore, when compared with nurses who worked shifts of less than 12 hours, those who worked 12+ hours were more likely to report worsening 16 NURSING ADMINISTRATION QUARTERLY/JANUARY-MARCH 2022 physical/mental health due to the pandemic. Previous research supports these findings as nurses who work 12-hour shifts reported more sick absences, 33 work-induced fatigue, 34 and burnout 35 Nurses with 12+hour shifts tend to work in acute and critical care, which can be a more stressful and complex work environment than an 8-hour ambulatory care work environment. 2 Discussing changes to shift length can be challenging as shift length preference is not homogeneous among nurses and can vary depending on their individual experiences. 35 Acute and intensive care unit nurses may be especially concerned with reductions in shift length due to complexity compression (ie, when nurses must conduct their daily tasks in addition to unplanned responsibilities within a condensed time frame). 36 However, a recent qualitative study demonstrated that nurses actually had a greater physical and mental workload during a 12-hour shift than an 8-hour shift. 37 Grassroots efforts are needed to inform nurses about the potential negative impact that longer shifts can have on their physical and mental well-being. Obtaining nurse buy-in will assist in overcoming C-suite concerns about eliminating 12-hour shifts and having experienced, valued nurses leave for another health system that continue to have the option.

While the correlation between workplace wellness support, shift length, and improved nurse wellness outcomes is critical, the relationships were correlative and not causative. Sampling for this study was not random, so findings cannot be generalized. Despite these limitations, the increase in poor mental/physical health, stress, and burnout in addition to the decrease in ProQOL is concerning. Wellness culture is one important driver in clinician health and well-being. Health care systems must invest in building and sustaining wellness cultures. Evidencebased programs and resources to support clinician mental/physical health and healthy lifestyle behaviors should be provided as a first line of defense for improving clinician well-being and for improving other health care quality indicators. Findings from prior studies indicate that the health and well-being of clinicians negatively impact health care quality, safety, and costs. 1, 2, 38, 39 CONCLUSION Nurses continue to report poor mental/ physical health and well-being, which the COVID-19 pandemic has exacerbated. Health care systems need to invest in creating supportive wellness cultures through evidence-based programs and access to mental health counseling and resources. Fixing system problems, such as long work hours and poor staffing, that contribute to poor clinician well-being should also be a priority as poor clinician well-being adversely impacts health care quality, safety, and costs. Nurses can be resilient and healthy but still suffer when appropriate staffing levels are not met and realistic shift lengths are not provided. Workplace wellness support is of immense value as it can lead to nurses with better mental/physical health and ProQOL.

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