key: cord-298200-rjlya399
authors: De los Santos, J. A. A.; Labrague, L. J.
title: Impact of COVID-19 on the Psychological Well-Being and Turnover Intentions of Frontline Nurses in the Community: A Cross-Sectional Study in the Philippines
date: 2020-08-06
journal: nan
DOI: 10.1101/2020.08.05.20167411
sha: 
doc_id: 298200
cord_uid: rjlya399

Purpose: This study aimed to assess fear of COVID-19 among nurses in a community setting. Methods: This study employed a cross-sectional design using self-report questionnaires. Findings: Results revealed that nurses display moderate to high fear of COVID-19 and that the female gender is correlated to fear of the virus. Moreover, the nurses fear influences their psychological distress and organizational and professional turnover intentions. Conclusion: Fear of COVID-19 is universal among nurses. There is a need to assess the factors associated with the fear to better address the nurses psychological well-being and to avoid turnover intentions.

With the increasing death toll of health workers caring for patients with COVID-19 are the psychological challenges. The uncertainty and discomfort in this new normal may pose a further threat to healthcare professionals' work outcomes and psychological wellbeing. Nurses are placed in stressful situations, fulfilling their roles on the front line while risking their lives to save others.

Recent literature has established the ill effects of stress on the nurses' psychological well-being and work outcomes (Falguera et al., 2020; Faremi et al., 2019; Vivian et al., 2019) . Stress is generally sourced from situations that a person has no control over, such as a pandemic. Currently, there is a surge of studies on how the COVID-19 pandemic has caused much stress to the various healthcare systems across the globe. It has compromised the workforce, particularly nurses. In fact, among the healthcare workers, nurses are found to be the most anxious and stressed in caring for and treating patients infected with the COVID-19 virus (Mo et al., 2020) .

For instance, it is reported that nurses are stressed about a myriad of situations, including worrying about getting infected or inadvertently infecting others and caring for an infectious yet dying patient (Alharbi et al., 2020; Pappa et al., 2020) . Moreover, work situations such as erratic and exhaustive work schedules, the lack of personnel protective equipment, and forced deployment to unfamiliar stations are additional burdens. Similarly, they are wary about the social stigma and the uncertainty of whether their employers are genuinely concerned about their welfare (Maben & Bridges, 2020; El-Hage et al., 2020; Zhu et al., 2020) .

COVID-19 challenged and brought turmoil to the nurses' psychological wellbeing. To mitigate possible physical and psychological damage to the nurses, health . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020 . . https://doi.org/10.1101 facilities advocated the use of mental health services such as psychological first aid, crisis interventions, morale boosters provided by their colleagues, and access to social media and self-help reading materials (Blake et al., 2020; Kang et al., 2020) .

Interestingly, one study distinctly compared nurses' feelings and found that those who are less exposed to fever stations appeared to experience more burnout than those on the actual front line. This implies that attention should be provided on an organizational scale, particularly to health and mental wellness interventions (Wu et al., 2020) . On the other hand, mounting studies found that nurses who provided direct patient care appeared to be more stressed, overworked, and psychologically disturbed and less fulfilled in their job compared to nurses in other areas of assignment (Zerbini et al., 2020) . Hospital nurses, particularly women performing diagnosis, care, treatment, and management of patients with COVID-19, have displayed psychological disturbances such as anxiety, lack of sleep, and depression (Lai et al., 2020) .

Researchers have thoroughly discussed the impact of the pandemic on the hospital nurses' health risks and psychological well-being. However, based on the available literature, there is an evident lack of investigation on the effect of COVID-19 on the nurses' work outcomes and turnover intention, especially among those deployed in the community. The scarcity of studies in this area prompted the need to explore the nurses' situation on the ground; hence, this study.

This study employed a descriptive cross-sectional design using self-report questionnaires.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted August 6, 2020. To reach our target participants, we computed the samples using GPower and discovered that the minimum sample required is 368 at an effect size of 0.05, 0.8 statistical power, and probability level of 0.05 (Scoper, 2015) . The researcher collaborated with nurses assigned in the field who are tasked as focal persons-incharge to conduct Psychological First Aid commissioned by the Department of Health. The core team, who was tasked to provide strategies and interventions to uplift the health workers' morale on the front line, conducted the collection of data mid-June 2020.

Four self-administered questionnaires were used to gather the data to quantify the variables of this study.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10. 1101 In measuring fear of COVID-19, we used the Fear of COVID-19 Scale (Ahorsu et al., 2020) . The scale is a valid tool to assess the construct of fear based on its Cronbach's alpha score of 0.86, suggesting high validity and internal consistency of the scale. The unidimensional 5-point Likert scale is composed of 7 items scored as 1 "strongly disagree" to 5 "strongly agree."

We also used Schriesheim and Tsui's (1980) Job Satisfaction Index to measure the participants' satisfaction with their current work assignments. Based on a previous study, the scale demonstrated high reliability and validity coefficients with Cronbach's alpha of 0.87, implying that the scale is a dependable tool to measure job satisfaction (Labrague et al., 2020) . The scale is answerable using a 5-point Likert Scale ranging from 1 "strongly disagree" to 5 "strongly agree." The job satisfaction scale is composed of 5 items measuring characteristics of work, organizational support, colleagues, salary, and career development, all of which are crucial elements involved in a job.

We then used House and Rizzo's (1970) Job Stress Scale to measure the psychological distress variable. The scale is a valid and reliable instrument based on its high internal consistency of Cronbach's alpha coefficient score of 0.83. The participant nurses answered this section using a 5-point Likert scale of 1-5 (strongly disagree -strongly agree).

Finally, we used two single-item measures to assess each of the turnover intention variables using a 5-point Likert scale ranging from 1 to 5 using the same description as above. Specifically, the organizational turnover intention was assessed with the question, "Given the current situation, I am thinking about leaving this healthcare facility." Likewise, to assess the participants professional turnover . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20167411 doi: medRxiv preprint intention, we asked them to rate the statement, "Given the current situation, I am thinking of leaving nursing as a profession."

The authors assured that the study adhered to the basic ethical protocols and was given ethical clearance in one state university with protocol code IRERC EA-0012-I. The researchers secured the approval of the institution and appropriate authorities for the intention to conduct the study. The data gathering was done after the PFA session of the nurses. The participants were informed of the purpose of the study and provided informed consent. It was made clear to the nurses that their participation is voluntary and that they can choose not to complete the questionnaire without any consequence. Further, the participants were informed of their option to remain anonymous and that the data provided was kept confidential.

The gathered data were entered into a spreadsheet to facilitate the analysis.

The Statistical Package for Social Sciences ver. 23 software program was used in the analysis. Descriptive and inferential statistics were used to analyze the data. To quantify the data, we used frequency counts, percentages, and arithmetic mean.

Bivariate analysis and Spearman Rho coefficients were used to assess relationships between fear of COVID-19, nurses' characteristics, and other key study variables (job satisfaction, psychological distress, and turnover intentions). The predictive analysis between the variables was done using multivariate regression analysis accepted at p < 0.05 level of significance.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20167411 doi: medRxiv preprint Presented in Table 1 is the profile of the participants in this study. There was a total of 385 nurse participants with a mean age of 32.65 years old (SD=7.73). Most of the nurses are females (84.2%), married (51.4%), and have completed BS Nursing degrees (96.1%). The nurses have been in active service within the past 7.94 years (SD=7.73) and in full-time service (73.2%) in their present employment. Bivariate analysis was used to examine the correlations between the nurses' profiles, Fear of COVID-19, and psychological well-being and the nurses' turnover intentions ( Table 3) . Results revealed that gender is significantly correlated with fear of COVID-19 (t=-2.110, p=0.036), depicting females to be generally more affected by it as compared to males. Moreover, factors such as psychological distress (r=0.354, p=0.001), organizational turnover intentions (r=0.249, p=0.001), and professional turnover intentions (r=0.234, p=0.001) are correlated to the nurses' fear of COVID-19. Table 4 presents the multivariate analysis of the key variables of this study.

Results showed that fear of COVID-19 influenced the nurses' psychological distress and turnover intentions (organizational and professional). After controlling the nurses' profile variables (age, marital status, education, year in nursing, year in the . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20167411 doi: medRxiv preprint organization, job role, and hospital characteristics including facility size and type of hospital), an increased level of fear of COVID-19 is associated with increased psychological distress (β =0.357; p=0.001), as well as increased organizational (β =0.241, p=0.001) and professional (β =0.221, p=0.001) turnover intentions.

The authors believe that this is the first study to investigate the welfare of nurses deployed in a community setting. This study's primary goal was to assess the fear of COVID-19 and its influence on the psychological well-being and turnover intentions among nurses assigned to care and manage COVID-19 patients outside the hospital setting. Our results revealed that community nurses are relatively young and have been in government service since the onset of their professional careers. The CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. (Shen et al., 2020) . Also, there is a higher perception of perceived stress and depression . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) conditions. This is similar to the study of Zhang et al. (2020) in Iran, who found that better physical health conditions influence job satisfaction in healthcare personnel despite the odds of a risky work environment.

Additionally, there is job satisfaction among nurses in the community because they can function in their nursing roles, especially in these unconventional times.

Nurses choose to face the adversities of COVID-19 because they can personify the value of altruism and teamwork attached to their jobs as care providers . The literature revealed that nurses tend to be work-excited and highly committed to their work, especially when they are professionally challenged (Chang et al., 2020). Nurses display more dedication to their professional duties at their . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20167411 doi: medRxiv preprint expense in times of pandemic (Fernandez et al., 2020) , as projected by these nurses in the community.

Moreover, our results suggest that despite their job satisfaction, community nurses are not married to their jobs during this pandemic. Our findings indicate that these nurses would still prefer to leave their jobs and shift to another career. This contrasts with other studies that discussed how job satisfaction negatively influences 2020), who found high turnover intentions among nurses caring for patients in infectious disease outbreaks. COVID-19, as a highly contagious and pathogenic disease, has taken the lives of thousands, and healthcare providers could be discouraged by the risk to their lives. While it is true that the need for nurses at these times has never been higher, the novelty and the enormous ramifications of COVID-19 force these nurses to consider leaving their jobs and shifting to another means of living.

Finally, the regression analyses in this study revealed that the nurses' fear of COVID-19 is related to their psychologically distressed disposition and turnover intentions. This finding is similar to the mounting studies associating COVID-19 to nurses' psychological distress (Chew et al., 2020; Schecter et al., 2020; Fernandez et al., 2020) . However, as of this writing, there is no literature discussing the influence of fear of COVID-19 on nurses' organizational and professional turnover intentions.

Nonetheless, fear of COVID-19 has brought enormous stress and psychological distress to the nurses, influencing their high turnover intentions. The findings of this study relate to previous studies discussing how burnout, moral distress (Hatamizadeh et al., 2020) , job demands (Boudrias et al., 2020) , and work pressure influence . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20167411 doi: medRxiv preprint turnover intention and work engagement among nurses in the community (Li et al.,

The pandemic has undeniably challenged the roles of nurses. The real scenario at present is that nurses, including those in community settings, are placed in a dilemma of whether to protect and save patients or preserve themselves for their families and loved ones who are also depending on them. The vulnerability of life outweighs the call of duty in these desperate times, considering that nurses, too, have families and loved ones waiting for their safe return from the battlefield with this unseen yet deadly virus. Despite this threat and the psychological distress, nurses continue to function and fulfill their professional tasks in caring deserved by their patients and communities.

Community nurses facing persons who may be COVID-19 positive when doing contact tracing and specimen collection are facing a risk on their end, which may be attributed to their anxiety or fear of viral transmission. Consequently, these nurses need attention and aid from nurse administrators and other executives in the health sector. To provide nurses with assurance, comfort, and mental health, there is a need to increase capacity building to boost issues on caring and patient management incapacity, institute psychological support services, and stress reduction. For instance, the provision of enough PPE and testing for COVID-19 exposure is one strategy that can be followed to mitigate feelings of fear and anxiety among these nurses . Studies also suggest physical exercise can help (Schecter et al., 2020) .

However, these strategies should be initiated by colleagues outside the COVID-19 areas to drive more energy and enthusiasm to these already psychologically disturbed . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20167411 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20167411 doi: medRxiv preprint 1 9

International Council of Nurses (2020). More than 600 nurses die from worldwide. https://www.icn.ch/news/more-600-nurses-die-covid-19-worldwide.

Accessed is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20167411 doi: medRxiv preprint Dashboard. https://covid19.who.int/. Accessed July 19, 2020

Wu, Y., Wang, J., Luo, C., Hu, S., Lin, X., Anderson, A. E., Bruera, E., Yang, X., Wei, S., & Qian, Y. (2020) . A Comparison of burnout frequency among . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20167411 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted August 6, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20167411 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20167411 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted August 6, 2020. . https://doi.org/10.1101/2020.08.05.20167411 doi: medRxiv preprint

Implications for COVID-19: a systematic review of nurses' experiences of working in acute care hospital settings during a respiratory pandemic

Health care reform in Iran: Implications for nurses' moral distress, patient rights, satisfaction and turnover intention

Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic

Psychological stress of ICU nurses in the time of COVID-19

Mental health status of medical staff in emergency departments during the Coronavirus disease 2019 epidemic in China. Brain, behavior, and immunity

A qualitative study on the psychological experience of caregivers of COVID-19 patients

A cross-sectional study of perceived stress, mindfulness, emotional selfregulation, and self-care habits in registered nurses at a tertiary care medical center

WHO Coronavirus Disease (COVID-19) oncology physicians and nurses working on the frontline and usual wards during the COVID-19 epidemic in Wuhan

COVID-19 pandemic as a watershed moment: A call for systematic psychological health care for frontline medical staff

Psychosocial burden of healthcare professionals in times of COVID-19 -a survey conducted at the University Hospital Augsburg. German medical science

At the height of the storm: Healthcare staff's health conditions and job satisfaction and their associated predictors during the epidemic peak of COVID-19

The role of telehealth in reducing the mental health burden from COVID-19

Prevalence and influencing factors of anxiety and depression symptoms in the