Quality of life and its health and occupational determinants among hospital-based nurses during the COVID-19 pandemic
Abstract
BACKGROUND:
Nurses worldwide were exposed to increased levels of occupational stress during the COVID-19 pandemic which could have hindered their level of health-related quality of life (HRQoL).
OBJECTIVES:
This project investigated HRQoL level in nurses during the COVID-19 pandemic and its health and occupational predictors.
METHODS:
A cross-sectional design was adopted and targeted full-time nurses in Jordan. Study collected data included demographics, 12-item Short Form health survey (SF-12) to measure HRQoL, Nordic Musculoskeletal Questionnaire (NMQ), nurses’ evaluation of work conditions during COVID-19, and Depression Anxiety Stress Scale (DASS21). Data was analyzed descriptively to summarize main outcome measures and using multiple linear regression model to identify factors significantly associated with HRQoL.
RESULTS:
In total 245 nurses successfully completed the survey, 39.6% were males with a mean age of 35±6 years. Participant SF-12 scores were 65.94±17.85 for physical component and 50.09±19.36 mental component. The statistical model significantly explained 53.2% of variance in HRQoL (r2 = 0.534, F = 57.849, p < 0.001). Better sleep quality self-evaluation was significantly associated with higher HRQoL levels, while increased levels of depression, musculoskeletal pain, and financial burden on family were significantly associated with worse HRQoL level.
CONCLUSION:
Jordanian nurses’ HRQoL level was relatively low during COVID-19. Sleep quality, mental health status, musculoskeletal health status, and financial status were identified as factors possibly influenced HRQoL among nurses during the COVID-19 pandemic. Nurses’ quality of life along with their mental and physical health should be considered by healthcare administrators in the remaining period of COVID-19 and in future similar emergencies.
1Introduction
With the world’s exposure to many health pandemics in recent decades; the awareness of the possibility of sudden occurrence of pandemics, added to that their devastating effects on various levels, was noted [1]. In 2003 the awareness was increased among the public due to the SARS pandemic. Healthcare professionals played a vital role in dealing with SARS [1]. However, nurses were the largest group exposed to infection because the direct contact with the affected patients. This warranted nurses to apply high standards of infection control processes; in which, they are daily spending hours applying and removing protective equipment which add more stress and job load, making their working environment and conditions even more stressful [2].
It is not an easy task to state what the occupational health determents are in a specific work environment for any profession. However, previous studies targeted nurses claimed that this is a multifactorial issue could be influenced by many factors related to occupational health. These potential influencing factors include (but do not exclude) musculoskeletal health, mental health, lifestyle, age and gender, cultural and health beliefs factors, physical activity level, sleep quality, diet, and work environment policies and factors such as work shift and safety precautions [3–8].
The mental disorder that is most related to pandemics is the posttraumatic stress disorder and was previously addressed in the literature [1, 2, 9]. Furthermore, depression, insomnia, stress, low mood, and irritability might be noticed during health pandemics [10]. Many health problems and challenges among nurses have been reported worldwide [11–13]. About more than 50% of European nurses have suffered from musculoskeletal disorders and about 19% have mental disorders [14]. Several reviews targeted nurses have related the mental health factors to work-related musculoskeletal disorders (WMSDs) with a significant linkage [15, 16].
Studies show a relationship between psychosocial factors with low back and neck pain. Psychosocial factors like: low social support, elevated levels of stress, anxiety, along with signs of depression. In addition, other stressors such as time burden, low job control, and unsuitable work shifts were statistically linked with higher levels of nurses’ WMSDs [5]. A study conducted on Hong Kong nurses using: Depression, Anxiety, Stress Scale 21 (DASS21), reports overall prevalence of depression as (35.8 %), while anxiety has a comparable percentage of (37.3%) and (41.1%) is the prevalence of stress. Their results show a higher percentage of female nurses with mental health symptoms as compared to males [17]. This increased levels of stress might be work-related as nurses usually work in high-stress settings and environments. Nurses worldwide are facing serious occupational and non-occupational stressors that might negatively impacted their HRQoL and well-being [18]. Out of pandemic situations, studies reported that hospital-based nurses have relatively low HRQoL level, which tended to statistically associate with many demographical and occupational factors [11]. Previous studies suggested that nurses are subjected to high levels of mental health challenges (such as depression, stress, and anxiety), work related musculoskeletal disorders, and sleep quality deficits that might hinder nurses’ wellbeing [12, 13, 19].
A limited number of studies have investigated nurses’ quality of life along with their associated factors through COVID-19, particularly in Jordan and its adjacent countries. However, most of these studies have either focused on a specific nursing department or have not directly focused on nurses HRQoL level and predictors [20, 21].
This study aimed to study the level of HRQoL in hospital based nurses in Jordan in COVID-19 pandemic. Additionally, the study aimed to identify significant HRQoL predictors out of the collected study variables that included occupational, health, and demographical variables. A secondary aim of this study was to characterize Jordanian nurses’ physical and mental health status along with their work-related stress during the COVID-19 pandemic. This study seems warranted and might help in better healthcare planning and management during the remaining period of COVID-19 and other similar future pandemics.
2Methods
2.1Design and sample
This study utilized a cross sectional design that was based on an online-survey. The study targeted nurses working as full-time nurses at various hospitals types (governmental and non-governmental) in Jordan. An online survey was prepared and sent as a link to all potential subjects. The online survey via Google forms provides ease in distribution, as responders can respond to it using their smart devices. The survey started with an introduction about the concept, its importance, and the study consent form.
2.2Inclusion/exclusion criteria
Inclusion criteria were being a hospital-based nurse in Jordan, aged less than 60 years (nurses’ official retirement age at targeted country is 60 years old), and working at least three shifts per week during the pandemic. Exclusion criteria included nurses who being with extended shifts, term use of analgesic medications, and a history of severe mental or physical disorders.
Sample size calculations using G*power software assuming having 15 predictors in the initial multiple linear regression model (before applying the stepwise function), indicated the need of sample of at least 139 to guarantee statistical power of 80% [22]. A total of 245 nurses completed the survey in this study.
2.3Procedures
The Institutional Review Board (IRB) at Jordan University of Science and Technology reviewed the study for ethical considerations (approval number 127/132/2020). IRB informed consent forms were signed by all participants and no participants received any form of compensation for participating.
2.4Outcome measures
The questionnaire developed for this study had a section on sociodemographic data included gender, age, smoking, health self-evaluation, diet self-evaluation, work experience, and hospital type. The second section included data on life-style and work stress during COVID-19 collected via a Likert scale specifically designed for this study. Questions in this scale were answered based on a Likert scale from 1 to 5, in which 1 means strongly disagree and 5 means strongly agree. Cronbach’s alpha in this study (0.844) indicated high internal consistency for this study. The third section consisted of the study’s health outcome measures.
The following outcome measures made up the third section of this study:
Medical Outcomes Study Short Form (SF-12): An assessment tool commonly used for evaluating HRQoL level among various healthy or unhealthy groups. The measure is consisted of a physical component score (PCS) out of 100, and a mental component score (MCS) out of 100 where higher scores suggest better quality of life status [23]. This assessment is considered valid and reliable and widely used in the literature [24].
Depression Anxiety Stress Scale (DASS21): An assessment evaluating presence and severity of mental health symptoms of depression, stress, and anxiety. The tool has 3 sub-scores where the higher the scores, the worse mental symptoms are. After multiplying by 2, scores range between 0 and 42 and the measure cut-off points of mild symptoms are 10 for depression, 8 for anxiety, and 15 for stress. DASS21 proved to be a strongly valid scale and a reliable as Cronbach’s alpha coefficients were 0.88 for depression subscale, 0.91 for anxiety subscale, and 0.87 for stress subscale [25, 26].
Nordic Musculoskeletal Questionnaire (NMQ): This is wildly used measure of musculoskeletal disorders (MSDs) and its associated functional deficits in various upper and lower body segments and trunk. The measure captures pain complaints in nine different joints during the past year and the past week along with their functional limitations. The measure can be used in the various occupational groups and has shown good validity and reliability [27].
Finally, pain intensity was assessed using Visual Analog Scale (VAS). This valid and reliable measure scores range between 0 (no-pain) and 10 (the most intense pain) [28].
Literature review and research team collaboration was used to safeguard content validity of the study survey. At the beginning, the preliminary survey version was examined by the stud expert panel and then was evaluated in a pilot study recruited a sample of 10 nurses. All of feedback related to the survey in this pilot study was positive with no difficulties in responding to the survey sections.
2.5Statistical analysis
Collected data was treated statistically using SPSS software version 23.0 [29]. Mean and standard deviation or frequencies and proportion were used to describe the study main outcome measures. Bivariate correlations (Pearson Correlation) between HRQoL measured by SF12 total scores and potential factors described in the study methods were tested. Only factors with P value, constituting the correlation, of less than 0.15 with SF12 total score were included in the regression model. This study employed multiple variable linear regression analysis to spot factors that significantly predict HRQoL level measured by SF12 total score, using a stepwise technique. Before running the regression analysis, normality and collinearity of the distribution of the collected data were inspected. Normally distributed sample and lack of collinearity are the two conditions to use regression analysis modality; they can be investigated by the variance inflation factor (VIF). In the statistical analysis, p < 0.05 was considered a statistically significant point.
3Results
3.1Participants’ characteristics
Table 1 demonstrates participants’ most important demographics and health characteristics. A total of 245 nurses successfully completed the survey; they were 39.6% males with a mean age of 35±6. The distribution across Jordanian work palace types was 35.1% in ministry of health hospital, 19.9% military hospitals, 32.7%, university hospitals, 15.5% private hospitals 14.7% and 2% nongovernmental organization. Jordanian geographical region representations were 53.9% for north, 40.8% for middle, and 5.3% for south.
Table 1
Participants’ demographics and health characteristics
| Characteristic | Mean (±SD) or n (%) | |
| Age in years | 35 (±6) | |
| Gender | Male | 97 (39.6%) |
| Female | 148 (60.4%) | |
| Total members at household | 5 (±2) | |
| Social status | Single | 59 (24.1%) |
| Married | 186 (75.9%) | |
| Type of employer | Governmental | 166 (67.8%) |
| Non-governmental | 79 (32.2%) | |
| Work place (Jordanian geographical regions) | North | 132 (53.9%) |
| Middle | 105(40.8%) | |
| South | 13 (5.3%) | |
| Smoking cigarette | No | 191 (78.8%) |
| Yes | 54 (22%) | |
| Major | Nurses | 204 (85.4%) |
| Midwife | 35 (14.6%) | |
| Highest degree | Community college | 53 (21.6%) |
| BCs | 177 (72.2%) | |
| Graduate | 15 (6.1%) | |
| VAS body pain | 4.41 (±2.75) | |
| DASS21 Depression score | 12.29 (±9.29) | |
| DASS21 Anxiety score | 8.07 (±7.61) | |
| DASS21 Stress score | 15.4 (±9.82) | |
| Total SF-12 | 56.26 (±15.95) | |
| PCS | 65.94 (±17.85) | |
| MCS | 50.09 (±19.36) |
VAS: Visual Analog Pain Scale, DASS21: Depression Anxiety Stress Scale, SF-12:12-item Short-Form Health Survey, MCS: Mental Component Summary, PCS: Physical Component Summary, BCs: Bachelor of Science.
The total SF-12 score was 56.26±15.95, with a PCS score of 65.94±17.85 and an MCS score of 50.09±19.36, representing borderline physical and mental health problems. The overall depression mean score was 12.29±9.29, anxiety mean score was 8.07±7.61 and stress mean score was 15.4±9.82. According to NMQ, about 52.7% of participant suffered neck pain, 75.5% low back pain and 49% knee pain. While 86.5% complained joint pain that lasted seven days and 62.9% had activity daily living limitation that lasted twelvemonth.
3.2Nurses’ lifestyle during the COVID-19 pandemic
Table 2 shows lifestyle changes during the COVID-19 pandemic. The overall mean working hours before the pandemic was 37±12. Participants agreed that COVID-19 increased the burden of teaching their kids at home with a score of 4 on 5-point Likert scale and about 24.9% reported an increase in the time dedicated for kids’ education time. About 37.6 % of participants reported significant weight change during the pandemic. Moreover, 88.2% had irregular or tiring sleeping patterns. Participants slightly agreed (3.26 out of 5) that COVID-19 increased their work stress.
Table 2
Nurses’ lifestyle during COVID-19 pandemic
| Lifestyle | Mean (SD) or n (%) | |
| Average sport activity hours per week | 1 (±2) | |
| COIVD-19 increased the financial burden on my family* | 3 (±1) | |
| COVID-19 increased the burden of teaching family kids* | 4 (±1) | |
| COVID-19 is associated with occupational shifts* | 3 (±1) | |
| COVID-19 associated weight change | No change | 153 (62.4%) |
| Increased | 56 (22.9%) | |
| Decreased | 36 (14.7%) | |
| COVID-19 associated change in family care time | No change | 62 (25.3%) |
| Increased | 109 (44.5%) | |
| Decreased | 74 (30.2%) | |
| COVID-19 sleep self-evaluation | Irregular or tiring | 216 (88.2%) |
| Comfortable | 29 (11.8%) | |
| COVID-19 diet self-evaluation | Unhealthy | 26 (10.6%) |
| Sort of healthy | 202 (82.4%) | |
| Healthy | 17 (6.9%). | |
| COVID-19 nursing work was stressful* | 3.26 (±0.86) |
*Likert scale: strongly disagree: 1, disagree: 2, neutral: 3, agree: 4, strongly agree: 5.
3.3Nurses HRQoL associated factors
Table 3 shows nurses’ HRQoL associated factors during pandemic period. The study regression model explained that 53.4% of variance in quality of life factors (r2 = 0.534, F = 57.849, p < 0.001).
Table 3
Multivariable regression analysis of health-related quality of life associated factors
| Factor | β coefficient | 95% Confidence interval | P-value | |
| DASS21 depression score | –0.98 | –1.16 | –0.81 | <0.001 |
| Body pain measured by VAS | –1.14 | –1.76 | –0.52 | <0.001 |
| Sleep self-evaluation | 6.71 | 2.07 | 11.36 | 0.005 |
| Financial burden on family | –2.06 | –3.54 | –0.58 | 0.007 |
DASS21: Depression, Anxiety, Stress Scale; VAS: Visual Analog Pain Scale.
4Discussion
This study aimed to identify level of HRQoL along with its associated factors among nurse working in Jordan during the COVID-19 pandemic. Furthermore, the study descriptively demonstrated Jordanian nurses’ occupational health determining factors (such mental and musculoskeletal health) along with lifestyle variables (such as sleep and physical activity) in addition to other stressors (financial and work-related) during COVID-19. Overall, participating nurses demonstrated a relatively low level of HRQoL measured by SF-12. Despite HRQoL was never investigated in Jordanian nurses, this study nurses’ HRQoL level COVID-19 is comparatively low considering its level among the adult population worldwide [30]. Furthermore, this current study participants have also showed high levels of adverse musculoskeletal pain, mental health symptoms, work-related and life-style stressors as well.
It is not an easy task to identify hospital based nurses’ health and occupational safety determents. However, our previous studies and similar studies in the countries have revealed similar high levels of stressors influenced mental and physical health of various occupational groups in Jordan [10, 31–33]. These physical and mental stressors appeared to have influence when investigating medical professions’ occupation groups in Jordan during the COVID-19 pandemic [9, 34].
Consistent with the literature, this study participants’ MCS and PCS HRQoL levels were statistically associated with depression, body pain measured by VAS, sleep self-evaluation, and financial burden on nurses’ families. These stressors were heavily connected with lower levels of HRQoL out of COVID-19 crisis and were not surprising to be associated with lower levels of HRQoL in our study during the COVID-19 pandemic. Identifying these associated factors may help to increase understanding of healthcare providers’ wellbeing under stressful societal situations similar to COVID-19, which might enhance future emergencies-related healthcare services planning. Up to our knowledge, this is the first in Jordan and probably worldwide investigating HRQoL level among nurses and its predictors during COVID-19.
The current health emergency related to COVID-19 imposes extreme physical and mental stress on many occupational groups [31, 32]. Current COVID-19 reports similarly demonstrated increased mental health stress impacting nurses, physicians, and many other hospital-based personnel [9, 35]. Previously published systematic reviews suggested that physical and psychological factors along with individual factors were statistically linked with increased level of stress among nurses [36]. Furthermore, cultural factors and health beliefs, like fear-avoidance beliefs are also associated with increased levels of stress among nurses [37]. This might suggest having different results across different countries.
Getting exposed to multiple stress related risk factors might increase the risk of developing mental or physical stress among nurses. The profession of nursing is identified in the literature as one of the top stressful jobs [38]. Also, it is possibly one of most professions with highest levels of mental health and emotional stress. This might be explained by working a stressful environment [39]. One study reported that about 35.9% of their nurses participants were found under high-stress level [40]. Another study cited a high prevalence of depression, anxiety, and stress among nurses which were 35.8 % for depression, 37.3% for anxiety, and 41.1% for stress, with prevalence among female higher than male [17]. Whereas, the percentages are lower in the study by Hegney et al. as they reported a percentage of (11.4%) Australian nurses suffered stress, (15.2%) of them suffered from anxiety and (13.6 %) were depressed [38]. A study conducted in Malaysia reports a prevalence of 80% for anxiety with score 16.2, 40.5% for depression with score of 22, and 37.8% for stress with score of 21 [41].
Sleep quality deficits were statistically linked in the literature with many factors related to the environment and several pathological conditions [19, 42]. Factors might be related to sleep disruption included demographics, job demands, and health status [43]. High rate of mental health problem such as affective disturbance or sleep problem have been frequently described [44]. Previous studies have also suggested that sleep quality deficits in nurses might also adversely impact nurses’ work performance [45]. Finally, consistent with this study, previous studies showed that fear of infection at healthcare workplace was significantly related to levels of insomnia, stress, and depression [46]. The job stress has the strongest negative effect on nurses HRQoL [14].
Many factors are thought to impact nurses’ health and well status; of these are: the personal factors, the factors specific to the job requirements, the factors dictated by the work place and system regulations [47]. Healthcare facilities’ administrators, particularly managing nursing workforce, should carefully mentor their nursing staff psychological and physical well-being and attempt reducing burnout related to nursing occupational stress. COVID-19 is an ongoing crises and its potential adverse effects on nurses’ well-being might last for long period. Healthcare administrations need to increase adoption of therapeutic interventions aiming at improving nurses’ physical and mental health status.
Healthy life-style strategies including improving quality of sleep, level of physical activity, diet quality may enhance nurses physical and mental wellbeing and contribute in a better HRQoL level [48].
The results of this study might be informative to reduce work-related stress challenging hospital-based nurses during similar pandemics and regular circumstances [9, 12, 13, 19]. Musculoskeletal pain challenging nurses might be managed using proper manual handling and ergonomic training and by consulting rehabilitation professionals [49, 50]. A study targeted group of surgeons found that quality of life level was moderate and significantly associated with musculoskeletal pain complaints in health care workers [51]. Mental health symptoms might be managed through providing psychological support interventions [52].
4.1Limitations and future directions
A larger sample size and a better representation of targeted country nurses could have improved the study. Furthermore, a longitudinal design could have revealed the progressive nature of COVID-19 pandemic related stress imposed on nurses. Adopting an online survey might have impacted the generalizability of this current study results. Furthermore, most of this study data was self-reported. However, the questionnaire was filled out anonymously without imposing any positive or negative consequences on participants. Additionally, the outcome measurements tools were self-reporting. Future studies are advised to suggest and inspect the efficacy of therapeutic interventions aiming at to improving HRQoL among Jordanian hospitals nurses.
5Conclusion
A relatively low level of HRQoL was identified in full-time Jordanian nurses demonstrated by both physical and mental components scores of SF-12. Furthermore, participating nurses were experiencing high prevalence mental health (depression, anxiety, and stress measured by DASS21) and musculoskeletal pain symptoms measured by NMQ and VAS in COVID-19 pandemic. Furthermore, participating nurses reported high levels of work-related stress during the COVID-19 pandemic. These complaints percentages were high, but not all were significantly associated with participants HRQoL. The study demonstrated that levels depression, body pain measured by VAS, sleep self-evaluation, and financial burden on nurses’ families were significantly associated with HRQoL levels among Jordanian nurses during the pandemic. COVID-19 pandemic crisis is the current global health of most concern and studies related to alleviating its negative effects are encouraged. Nursing departments administrators should take the results of this study in their concern to optimize their working environment reducing revealed work-related stressors during future similar pandemics. Experimental studies establishing the efficacy of potential interventions targeting nurses well-being are encouraged in the future.
Ethics statement
All procedures performed in this study were in accordance with the Declaration of Helsinki. The study was approved by the institutional review board of Jordan University of Science and Technology (Approval number 127/132/2020). Written informed consent was obtained from all participants prior to participation.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgments
The authors would like to express their deep appreciation to participating nurses for sharing their valuable time responding to the study survey.
Funding
The study project was funded by the Jordan University of Science and Technology (Grant number 20200380).
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