The association between the work environment and the fear of COVID-19 experienced by nurses

Abstract

BACKGROUND:

The conditions in the workplace have a critical influence on the mental health of nurses and their attitudes toward their job, which may impact patient care.

OBJECTIVE:

This cross-sectional study aimed to investigate the association between perceptions of the work environment and fear of COVID-19 experienced by nurses.

METHODS:

The data were collected using a demographic data form, the Work Environment Scale (WES), and the Fear of COVID-19 Scale. The study was completed with 183 nurses who provide care to COVID-19 patients.

RESULTS:

The mean scores for the WES and Fear of COVID-19 Scale were 63.59±12.35 and 21.98±8.36, respectively. There was a positive correlation between the points acquired from the “employee fears” section of the WES and the Fear of COVID-19 Scale mean ranks (r = 0.22). There was a weak negative correlation between the Fear of COVID-19 score and the WES “job satisfaction” score (r = –0.214). There was a weak negative correlation between the scores of the Fear of COVID-19 Scale and perceived support at work (r = –0.33) and between the WES scores and weekly working hours (r = –0.27). However, there was a weak to moderate positive correlation between the WES scores and number of days off per week (r = 0.45).

CONCLUSIONS:

Nurses experience a high fear of COVID-19, and a decrease in their attitudes of the work environment was associated with an increased fear of COVID-19. The fear of COVID-19 may be reduced by various interventions to provide support at work and increase nurses’ job satisfaction.

Keywords

Associated conditions environment fear nurse pandemic workplace

1 Introduction

The COVID-19 pandemic has had a huge impact on healthcare globally. During the pandemic, nurses were members of healthcare teams that were at very high occupational risk, according to the Occupational Safety and Health Administration [1].

Nurses worked under harsh conditions, such as exposure to COVID-19, isolation from family and loved ones, high numbers of cases, long working hours, inadequate staffing levels, inadequate personal protective equipment (PPE), lack of workplace safety training, and poor preparation [2 –6]. Owing to the increased number of patients seeking healthcare, there was a need for increased staffing levels in emergency units, wards, and intensive care units (ICU) that provide care to COVID-19 patients [7, 8]. However, many nurses were infected with COVID-19 and required to self-isolate, and thus were unable to work, which led to other nurses working extra days and hours without taking days off or breaks during their shifts [5]. Solutions to meet this demand, such as deploying nurses from other areas or replacing missing staff members with less experienced, less trained, or recently qualified nurses in high-risk units (e.g., ICU), caused increased stress levels for both new and existing staff members [9]. These difficulties caused nurses to worry about their own health and safety.

Workplace conditions are the most critical factor that influences the mental health of nurses and their perceptions toward their job, which may impact patient care [10 –12]. Nurses’ fear of COVID-19 interacts with many factors relating to the work environment. The work environment is a complex construct that includes a combination of physical, social, and psychological characteristics. These characteristics can be associated with factors such as the stress experienced by employees, support systems, communication, and leadership style. Therefore, the effect of the work environment on nurses’ fear of COVID-19 is an important area of research. Determining the fear level of nurses will help us to understand how effective the work environment is in meeting the emotional needs of health workers. The results of this study will guide health administrators, policymakers, and health organizations in developing strategies to reduce nurses’ fears. This would improve their working environment and contribute to improving patient care.

Thus, the aim of this study was to examine the relationship between the perceptions of the working environment of nurses who care for COVID-19 patients and their COVID-19 fear levels.

Research questions:

What is nurses’ perception of their work environment when caring for COVID-19 patients?

What is the level of fear experienced by nurses toward COVID-19?

Is there an association between nurses’ perceptions of their work environment and their level of fear toward COVID-19?

2 Methods

2.1 Design and participants

The target population of this cross-sectional study was 983 nurses working in five pandemic hospitals on the European side of Istanbul, Turkey, who provided care to COVID-19 patients during the recruitment period (August 2020–January 2021). At the time of planning the project and during the process of obtaining ethics approval, only those five hospitals on the European side of Istanbul met the criteria to serve as pandemic hospitals and their administrations agreed to take part in the study [13]. During the data collection period, all hospitals in Istanbul started serving as pandemic hospitals [14]; however, the initial five hospitals remained as the target hospitals due to time constraints and considering the longer experience of staff members working with COVID-19 patients in those hospitals. The minimum sample size was calculated as 276 nurses, using the sample size table with a 95% confidence interval and±0.05 margin of error [15].

A convenience sampling approach was followed considering the unavailability of many nurses owing to their increased workload. Nurses who (1) were working in a pandemic hospital during the study period, (2) agreed to take part in the study, and (3) provided care to patients who had a diagnosis of COVID-19 were deemed eligible for inclusion. The potentially eligible nurses were identified by the clinical nurse tutors in the respective hospitals. The exclusion criteria of the study are as follows: nurses not volunteering to participate in the study and not providing care to a patient with a diagnosis of COVID-19. As a result of the challenges with recruiting nurses with busy work schedules during the pandemic, only 183 nurses participated.

2.2 Data collection

The study data were collected online using Google Forms (google.com/forms/about/). A demographic form titled “Nurse Information Form” along with the “Work Environment Scale” and the “Fear of COVID-19 Scale” were used for data collection.

The clinical nurse tutors of the hospitals sent the data collection tools to the nurse managers of each relevant unit as a link to the online platform, and then the nurse managers circulated the link to their teams. It took approximately 20–25 minutes for nurses to complete the survey. Further details about the data collection tools are provided below:

Nurse Information Form: The researchers developed this form based on the relevant literature, and it consisted of questions regarding the participants’ demographic information such as age, gender, marital status, and education, as well as work characteristics (i.e., department; years of working experience as a nurse; working hours per week; days off per week; chronic diseases; mental disorders; being infected with COVID-19 at any point; staying in a place that is not their usual home during the pandemic to prevent the spread of the virus; performing tasks that cause the spread of droplets or aerosolization; perceived support at work during the pandemic; and concerns about the work environment). Since this form was developed by the researchers with the purpose of collecting general information about the nurses, the form’s validity and reliability were nottested.

Work Environment Scale (WES): The WES is a multidimensional scale and it has five sub-dimensions: quality management of the organization, physical resources, professional relations, employee fears, and job satisfaction. In total, this five-item Likert-type scale consists of 26 questions. The points obtained from each sub-dimension are added together to give a total score between 26 and 130. Points from each sub-dimension have a positive correlation with overall work environment satisfaction, meaning that higher total scores indicate increased satisfaction with the work environment. The scale was developed by Blegen et al., and its Turkish validity and reliability tests were performed by Sezgin [16, 17]. The Turkish translation of the scale was performed by two language experts. Its back translation to English was performed by another independent expert. For the content validity, 15 experts with backgrounds in nursing, hospital administration, and psychology provided their opinions on the scale items, and their recommended changes were addressed; the scale’s content validity index was found to be 0.96. Sezgin found its item-total correlation (Cronbach’s alpha coefficient) to be 0.74 for the 26 items. The test-retest reliability of the scale and its sub-dimensions were determined using the Pearson moment correlation coefficient (r), which was found to be statistically significant (p < 0.001). The coefficient points of the five sections of the scale were: quality management of the organization (r = 0.68), physical resources (r = 0.70), professional relations (r = 0.56), employee fears (r = 0.73), and job satisfaction (r = 0.77). The correlation between the scores of individual items under each section and the total score of their section showed statistical significance (p < 0.001), as the r values were between 0.59 and 0.74 for quality management of the organization section; 0.72–0.79 for the physical resources section; 0.64–0.78 for the professional relations section; 0.51–0.73 for the employee fears section; and 0.47–0.75 for the job satisfaction section. For this study, the Cronbach’s alpha coefficient of the scale was found to be 0.82, indicating goodreliability.

The Fear of COVID-19 Scale: This five-item Likert-type unidimensional scale does not have any sub-scales, and it consists of seven items. The items are: “I am most afraid of coronavirus-19. It makes me uncomfortable to think about coronavirus-19. My hands become clammy when I think about coronavirus-19. I am afraid of losing my life because of coronavirus-19. When watching news and stories about coronavirus-19 on social media, I become nervous or anxious. I cannot sleep because I worry about getting coronavirus-19. My heart races or palpitates when I think about getting coronavirus-19.” [18]. The total points obtained from the scale can range between 7 and 35. The highest score achieved from the scale indicates a very high level of fear of COVID-19. The scale was developed by Ahorsu et al. in the early stages of the pandemic as a rapid response. Shortly after that, its Turkish validity and reliability tests were performed by Bakioglu, Korkmaz, and Ercan [19]. Translation, back translation, and final evaluation of the scale was performed by experts in the area. To determine the construct validity of the scale, a confirmatory factor analysis was performed, and its goodness of fit index (adjusted and not adjusted) indicated good validity (χ²: 22.08, sd: 9, p <0.001; χ² / sd: 2.45; RMSEA: 0.03; CFI: 0.99; GFI: 0.99; AGFI: 0.99; TLI: 0.99). The item analysis results (factor load values) varied between 0.73 and 0.82. For the reliability analyses, Bakioglu, Korkmaz, and Ercan found the scale’s Cronbach’s alpha internal consistency coefficient to be 0.88. The corrected item–total correlations of the individual scale items ranged between 0.62 and 0.72. For the present study, Cronbach’s alpha coefficient of the scale was found to be 0.95, indicating excellent reliability.

2.3 Ethical considerations

Permission for collecting data from the pandemic hospitals was obtained from the Turkish Ministry of Health. Ethics approval was granted by the Istanbul Medipol University Ethics Committee (10840098-772.02-E.34480). The nurses read a participant information sheet and gave their informed consent prior to viewing the questionnaires on the online platform (Google Forms).

2.4 Data analysis

The statistical analyses were performed using IBM SPSS for Windows Version 22.0. Descriptive tests of frequency, percentage, mean, and standard deviation were employed. The distribution of numeric variables was assessed using the Kolmogorov–Smirnov test, and it was identified that the data did not have a normal distribution (p = 0.00). For this reason, the differences between individual characteristic variables and the questionnaire scores were analyzed using the Mann–Whitney U and Kruskal–Wallis tests. In order to determine the association between the scores of the Fear of COVID-19 Scale and the WES, Spearman’s rank correlation coefficient analysis was performed. The statistical significance was considered as p < 0.05.

3 Results

A total of 183 nurses participated in this study (response rate: 18.61%) with a mean age of 25.67±4.10 years (range 21–50 years). Their average weekly working hours were 58.10±10.29 hours (range 40–101 hours), and they had 3.07±2.36 (range 2–4) days off per week. Other individual characteristics of the nurses are presented in Table 1.

Table 1
Individual characteristics of nurses and their association with the scores obtained from the Work Environment Scale and Fear of COVID-19 Scale (n = 183)

Variables n % Work Environment Scale (WES) Fear of COVID-19 Scale

Mean rank Test value Mean rank Test value

Gender

Female 145 79.2 92.99 Z= –0.687 92.83 Z^† = –0.414

Male 38 20.8 61.54 p = 0. 492 88.84 p = 0.679

Marital status

Single 129 70.5 84.24 Z= –0.687 92.03 Z= –0.011

Married 54 29.5 89.82 p = 0.492 91.94 p = 0.991

Education

Vocational school 38 20.9 96.5 X²=7.595 90.25 X^2 ‡ = 8.149

Associate degree 8 4.4 91.98 p = 0.124 95.67 p = 0.132

Bachelor’s degree 127 69.2 98.26 97.41

Master’s degree 10 5.5 97.5 94.37

Working experience as a nurse

Less than 1 year 78 42.6 90.56 X² = 8.309 91.26 X² = 8.138

2–5 years 81 44.3 90.51 p = 0.112 94.66 p = 0.143

6–9 years 16 8.7 88.38 94.47

10 years and above 8 4.4 97.44 97.31

Staying in a place different than home during the pandemic

Yes 70 38.3 69.15 Z= –3.417 92.82 Z= –0.372

No 113 61.7 95.41 p = 0.001^ 89.85 p = 0.710

Chronic diseases

Yes 28 15.3 76.75 Z= –1.082 95.21 Z= –0.350

No 155 84.7 87.81 p = 0.279 91.42 p = 0.727

Mental disorder

Yes 23 12.6 50.09 Z= –3.743 94.4 Z= –1.619

No 160 87.4 91.58 p = 0.000^* 75.33 p = 0.106

Department

Intensive care unit 68 37.2 89.64 Z= –0.717 101.58 Z= –3.190

Ward 115 62.8 83.98 p = 0.474 75.79 p = 0.001^**

Performing tasks that cause spread of droplets or aerosolization

Yes 112 61.2 85.97 Z= –0.011 99.51 Z= –2.416

No 71 38.8 86.05 p = 0.991 80.15 p = 0.016^*

Being infected with COVID-19 at any point

Yes 44 24 78.53 Z= –1.162 88.08 Z= –0.565

No 139 76 88.59 p = 0.245 93.24 p = 0.572

Variables	n	%	Work Environment Scale (WES)	Fear of COVID-19 Scale
Gender
Female	145	79.2	92.99	Z= –0.687	92.83	Z^† = –0.414
Male	38	20.8	61.54	p = 0. 492	88.84	p = 0.679
Marital status
Single	129	70.5	84.24	Z= –0.687	92.03	Z= –0.011
Married	54	29.5	89.82	p = 0.492	91.94	p = 0.991
Education
Vocational school	38	20.9	96.5	X²=7.595	90.25	X^2 ‡ = 8.149
Associate degree	8	4.4	91.98	p = 0.124	95.67	p = 0.132
Bachelor’s degree	127	69.2	98.26		97.41
Master’s degree	10	5.5	97.5		94.37
Working experience as a nurse
Less than 1 year	78	42.6	90.56	X² = 8.309	91.26	X² = 8.138
2–5 years	81	44.3	90.51	p = 0.112	94.66	p = 0.143
6–9 years	16	8.7	88.38		94.47
10 years and above	8	4.4	97.44		97.31
Staying in a place different than home during the pandemic
Yes	70	38.3	69.15	Z= –3.417	92.82	Z= –0.372
No	113	61.7	95.41	p = 0.001^**	89.85	p = 0.710
Chronic diseases
Yes	28	15.3	76.75	Z= –1.082	95.21	Z= –0.350
No	155	84.7	87.81	p = 0.279	91.42	p = 0.727
Mental disorder
Yes	23	12.6	50.09	Z= –3.743	94.4	Z= –1.619
No	160	87.4	91.58	p = 0.000^***	75.33	p = 0.106
Department
Intensive care unit	68	37.2	89.64	Z= –0.717	101.58	Z= –3.190
Ward	115	62.8	83.98	p = 0.474	75.79	p = 0.001^**
Performing tasks that cause spread of droplets or aerosolization
Yes	112	61.2	85.97	Z= –0.011	99.51	Z= –2.416
No	71	38.8	86.05	p = 0.991	80.15	p = 0.016^*
Being infected with COVID-19 at any point
Yes	44	24	78.53	Z= –1.162	88.08	Z= –0.565
No	139	76	88.59	p = 0.245	93.24	p = 0.572

^†Z = Mann–Whitney U test. ^‡X² = Kruskal–Wallis test. ^*p < 0.05, ^**p < 0.01, ^***p < 0.001.

3.1 Rating of the perceived support at work and overall concerns

The nurses rated the support that they perceived at work during the pandemic as 4.52±2.21 out of 10 (range 0–10). More than half of the nurses reported concerns about the work environment, such as the risk of transmitting he infection to the people they live with, not being able to meet the needs of their family in case of becoming sick, having patient numbers that exceed the capacity of the hospital, and poor quality of nutrition and eating standards at work (Table 2).

Table 2
Concerns about the pandemic (n = 183)

Expressions Never Somewhat Moderate High Very high

Concerned about transmitting the infection to the people they live with 1.6% 2.7% 4.4% 35.5% 55.7%

Concerned about not being able to access personal protective equipment 32.6% 18.6% 20.8% 22.4% 16.2%

Concerned about not being able to meet the needs of their family in case of becoming sick 8.2% 18.6% 9.3% 29.5% 34.4%

Concerned about not being able to provide care for children during working hours 31.1% 13.1% 7.7% 20.8% 20.2%

Thinking that his/her knowledge about COVID-19 is insufficient 9.8% 11.5% 37.2% 19.7% 20.8%

Concerned about the patient numbers exceeding the capacity of the hospital 0% 16.9% 26.2% 24.6% 32.2%

Concerned about poor quality of nutrition and eating standards 3.3% 10.4% 19.1% 30.6% 36.6%

Expressions	Never	Somewhat	Moderate	High	Very high
Concerned about transmitting the infection to the people they live with	1.6%	2.7%	4.4%	35.5%	55.7%
Concerned about not being able to access personal protective equipment	32.6%	18.6%	20.8%	22.4%	16.2%
Concerned about not being able to meet the needs of their family in case of becoming sick	8.2%	18.6%	9.3%	29.5%	34.4%
Concerned about not being able to provide care for children during working hours	31.1%	13.1%	7.7%	20.8%	20.2%
Thinking that his/her knowledge about COVID-19 is insufficient	9.8%	11.5%	37.2%	19.7%	20.8%
Concerned about the patient numbers exceeding the capacity of the hospital	0%	16.9%	26.2%	24.6%	32.2%
Concerned about poor quality of nutrition and eating standards	3.3%	10.4%	19.1%	30.6%	36.6%

3.2 Work Environment Scale scores

The scores obtained from the WES and its individual sections are presented in Table 3. When the WES scores and individual characteristics of nurses were compared, there was found to be a statistically significant difference between the score for “having to stay in an accommodation different than their home during the pandemic” and the mean ranks obtained from the WES (p < 0.05) (Table 1). Nurses who lived in their homes had higher and statistically significant WES mean ranks than those who lived in an alternative accommodation due to safety concerns (Table 1).

Table 3
Scores obtained from the Work Environment Scale (total and individual sections) and the Fear of COVID-19 Scale (n = 183)

Scales and sub-dimensions Minimum Maximum Mean Standard deviation

WES Total 63.06 116.00 63.59 12.35

Employee fears 14.00 35.00 18.02 5.04

Quality management of the organization 10.00 30.00 12.40 5.26

Professional relations 6.00 20.00 9.87 2.93

Physical resources 3.00 15.00 9.57 2.32

Job satisfaction 11.00 23.00 13.83 2.52

Fear of COVID-19 Scale total 7.00 35.00 21.98 8.36

Scales and sub-dimensions	Minimum	Maximum	Mean	Standard deviation
WES Total	63.06	116.00	63.59	12.35
Employee fears	14.00	35.00	18.02	5.04
Quality management of the organization	10.00	30.00	12.40	5.26
Professional relations	6.00	20.00	9.87	2.93
Physical resources	3.00	15.00	9.57	2.32
Job satisfaction	11.00	23.00	13.83	2.52
Fear of COVID-19 Scale total	7.00	35.00	21.98	8.36

3.3 Fear of COVID-19 Scale scores

The mean score of the Fear of COVID-19 Scale was 21.98±8.36 (Table 3). The Fear of COVID-19 scores were significantly higher in ICU nurses than in nurses who work in wards (p < 0.05). Similarly, nurses performing tasks that cause the spread of droplets or aerosolization scored higher on the Fear of COVID-19 Scale compared to others who are not involved in those tasks (p < 0.05). (Table 1).

3.4 Associations between WES scores, Fear of COVID-19 scores, working conditions, and perceived support

The mean rank scores obtained from the Fear of COVID-19 Scale were compared with the WES total and individual section scores. There was a weak positive correlation between the Fear of COVID-19 score and the WES “employee fears” section (r = 0.223), and a weak negative correlation between the Fear of COVID-19 score and the WES “job satisfaction” score (r = –0.214). There was no correlation between the Fear of COVID-19 Scale and other scores of the WES (r < 0.20) (Table 4).

Table 4
Association between mean rank scores of the Fear of COVID-19 Scale and Work Environment Scale and its individual sections (n = 183)

Scales and sub-dimensions Fear of COVID-19 Scale Total

Employee fears 0.223^*

Quality management –0.003

Professional relations –0.095

Physical resources 0.016

Job satisfaction –0.214^*

Work Environment Scale total 0.096

Scales and sub-dimensions	Fear of COVID-19 Scale Total
Employee fears	0.223^*
Quality management	–0.003
Professional relations	–0.095
Physical resources	0.016
Job satisfaction	–0.214^*
Work Environment Scale total	0.096

^*p < 0.01.

Given that working conditions and perceived support may affect nurses’ perceptions of their work environment and fear of COVID-19, further correlation tests were considered. The correlations between weekly working hours, number of days off (per week), perceived support at work during the pandemic, and mean rank scores for the Fear of COVID-19 Scale and WES were tested. There was a weak negative correlation between the scores of the Fear of COVID-19 Scale and perceived support at work (r = –0.33) and between the WES scores and weekly working hours (r = –0.27). However, there was a weak to moderate positive correlation between the WES scores and number of days off (per week) (r = 0.45) (Table 5).

Table 5

Association between the Work Environment Scale and the Fear of COVID-19 Scale scores and nurses’ working hours (per week), number of days off (per week), and perceived support at work during the pandemic

Variables	Working hours (per week)	Number of days off (per week)	Perceived support at work during the pandemic (0–10 scale)
WES	–0.268^**	0.446^**	–0.016
Fear of COVID-19 Scale	0.016	0.001	–0.325^*

^*p < 0.01.

4 Discussion

The COVID-19 pandemic had a shocking effect on the world. It was found that 24% of the nurses participating in this study had COVID-19 at any time in their lives. The Turkish Nurses Association reported that many nurses were infected with COVID-19 as a result of limited or inappropriate supplies of PPE and the use of surgical masks (rather than higher-grade masks), even during high-risk tasks such as suctioning [20]. According to the International Council of Nurses, in early June 2020, more than 600 nurses around the world lost their lives due to inadequate PPE [21]. Similarly, despite having received relevant training about the use of PPE, nurses in Brazil reported problems with limited supply or poor quality of PPE in their clinical area [22]. Another study conducted with 103 healthcare professionals working in Wuhan, China and had been infected with COVID-19 reported that 87 of those healthcare workers believed that they were infected by the virus while working, and 43 of them complained about the low quality of the PPE they used [23]. Other studies conducted in Europe [24] and the United States [25] also found that nurses had a limited supply of PPE when working during the pandemic.

4.1 Overall concerns of nurses

In this study, the nurses mainly reported concerns about the risk of transmitting the infection to the people they live with or not being able to meet the needs of their family in case of becoming sick. Other studies have reported similar findings. A qualitative study conducted in China by Liu et al. reported nurses’ and other healthcare professionals’ concerns about infecting family members and people around them with COVID-19 [26]. Similarly, another qualitative study by Sun et al. investigating the psychological experiences of nurses providing care to COVID-19 patients found that nurses were experiencing intense fear owing to concerns about their patients and their own family members [27]. Aksoy and Kocak and Saricam found that nurses expressed concerns about infecting other family members and experienced challenges as a result of staying away from their spouses, children, and other family members [28, 29]. During the COVID-19 pandemic, nurses who were in close contact with the virus in their workplace had anxiety due to stress and conflict between their ethical responsibilities to provide continuous care for their patients and risks to their own and their family’s health [30, 31]. Nurses in Italy reported high levels of stress due to the unprecedented nature of the events, as they could not be sure about whether they or their loved ones would be infected, how long the pandemic would last, and the duration of further interruptions to their lives [32]. Previous studies discussed the potential spectrum of profound and broad psychological impacts that epidemics could have on people [6, 33].

Nurses who participated in this study expressed increased concerns about patient numbers exceeding the hospital’s capacity. An increased number of patients being admitted to hospital during the pandemic may lead to different feelings in healthcare professionals, such as fear, grief, disappointment, guilt, and exhaustion, as well as concerns relating to the inability to protect themselves or save their patients [9]. Compared to other professions, nurses suffer from higher fatigue, depression, and anxiety due to occupational stress [34, 35]. The prevalence of depressive symptoms in nurses has a wide range of 10–80%, while the incidence of anxiety has been reported to be as high as 66% [29]. In the present study, 12.6% of nurses reported a mental health issues. Increasing patient numbers and workload as well as concerns related to the lack of COVID-19 control measures in the workplace may increase fears among nurses and affect their mental and emotional health [36]. The mental health of nurses has been adversely affected in intense situations in the past, such as disasters and pandemics, since they stand as close witnesses of those events [37, 38].

4.2 Working environment and work conditions of nurses

In this study, the nurses expressed concerns about the poor quality of nutrition and eating standards while they were at work. A situation analysis report published by the Turkish Nurses Association highlighted that more than 50% of nurses had insufficient or poor-quality food facilities in their hospitals or units [20]. Hospital nursing staff in the United States reported that they received adequate support from their hospital for their basic needs, including on-site food and groceries; however, some complained about the hospital cafeteria having very limited operational hours or bans on food deliveries from outside [25]. Supporting the basic needs of nurses during a crisis could have benefits in terms of improving both the physical and emotional well-being of nurses [39].

The mean WES total score of the nurses indicated a medium level of dissatisfaction with their work environment. This dissatisfaction with the work environment during the pandemic might have been caused by the increasing number of patients due to the pandemic, the shortage of staff due to the high number of nurses on sick leave, long working hours, short rest periods, difficulties with equipment, and the increased risk of becoming sick or infecting family, friends or other employees. Santos et al. from Brazil also concluded that nurses who worked during the COVID-19 pandemic had a fear of being infected due to their work environment. They recommended urgent improvements to nurses’ working conditions [22]. Nurses are not adequately protected in their work environments due to unsafe staffing levels, low-quality PPE, increased workload, change of routines, and lack of clarity with their roles; this brings ethical challenges and decreases quality of care [8 , 40].

In this study, 38.3% of the nurses reported that they had to live away from their homes during the pandemic. Those living in their homes perceived the working environment more positively than those who were staying away from home. Nurses working in the COVID-19 wards or hospitals may be exposed to trauma due to changes in their lifestyle and staying away from their families and children as part of physical distancing and isolation requirements. This situation may create negative emotions and thoughts by causing primary traumatic stress reactions in nurses, and they may perceive the work environment negatively [29, 41].

4.3 Fear of COVID-19

Nurses in this study scored above the midpoint of the Fear of COVID-19 Scale, indicating a high level of fear. Since nurses work on the frontline during the pandemic and are directly involved in patient care, their risk of contracting COVID-19 is higher than that of the general population. Similar to the findings of this study, researchers from other countries observed that nurses scored above the midpoint in the Fear of COVID-19 Scale [42 –44]. Another study on the fear of COVID-19 found that nurses scored higher on the COVID-19 fear scale than other health professionals [45]. We found that nurses working in ICUs had higher fear of COVID-19 than nurses working in wards. Liang et al. and Saricam reported that nurses working in ICUs during the pandemic had higher levels of anxiety and depressive symptoms than those working in otherunits [29, 46].

4.4 Association between nurses’ work environment and fear of COVID-19

There was a weak positive correlation between the scores obtained from the Fear of COVID-19 Scale and the WES “fears of staff” section. Labrogue and Los Santos reported in their study that higher scores on the Fear of COVID-19 Scale were associated with higher scores on the psychological distress scale in frontline nurses [42]. Similarly, another study conducted by Havaei et al. during the pandemic found that nurses who responded negatively to a workplace evaluation survey had increased levels of anxiety and depression [10].

There was a weak negative correlation between the Fear of COVID-19 and the WES “job satisfaction” scores. Similarly, a study by Labrogue and Los Santos observed that the job satisfaction of nurses decreased as the fear of COVID-19 increased [42]. Nurses’ job performance may decrease as a psychological reaction to a threatening situation or stimuli, leading to job dissatisfaction and a tendency to leave the profession [47]. In the present study, the nurses’ perceived support level at work during the pandemic was 4.5 out of 10, and the Fear of COVID-19 Scale increased as this rating decreased. This result can be attributed to the beneficial effects of support from the organization or the healthcare team on fear and stress, consistent with other COVID-19 studies in the literature [10, 42].

4.5 Association between nurses’ other working conditions and fear of COVID-19

Nurses participating in this study reported that they worked an average of 58 hours per week. The researchers observed a decrease in the perception of a positive working environment as the weekly working hours increased. Additionally, increased satisfaction with the work environment was noted in those who reported a higher number of days off. The pandemic had to psychosocial effects on nurses and negative perceptions toward their work environment due to reasons such as long working hours, being away from family and social support sources, risk of transmission, and witnessing the death of caregivers and colleagues [36, 48]. Weigl et al. reported the association between demanding work environments and burnout, and suggested that nurses’ excessive workload should be reduced to improve their wellbeing [49]. It is also beneficial to increase the number of days off for nurses during the pandemic to reduce their viral load.

Effective infection control measures in the work environment are essential to provide safety and control the fear of COVID-19. A large proportion of the nurses who participated in this study (62%) reported performing tasks that causeed aerosolization. Nurses involved in aerosolization-related tasks reported a higher level of fear than those not involved in these tasks. This result could be related to it being well-known that COVID-19 is transmitted via aerosolized droplets [50]. It must be ensured that evidence-based preventive measures are followed to control the spread of COVID-19. For example, tasks that cause aerosolization (such as aspiration, bronchoscopy and bronchoscopic procedures, intubation, endoscopy, taking swabs from the respiratory tract, and other tasks that require significant exposure to secretions) should be performed in rooms that are sufficiently ventilated with natural airflow or, if possible, in rooms with negative pressure [51, 52]. Unfortunately, there are issues with some hospitals’ physical structure and design [53], as some of them do not have rooms with negative pressure, and the doors of patient rooms are not designed to enable observations from the outside. In order to ensure workplace safety for nurses during pandemics, it is necessary to appropriately design hospital units, eliminate the limitations with PPE provision, adjust the nurse-patient ratios, and enforce regulations to prevent excessive working hours.

4.6 Limitations

The convenience sampling approach was followed because many nurses could not participate in the study due to irregular shifts, increased workload, and intense working hours during the pandemic period. Another reason for the low number of participants was that researchers’ access to hospital areas was limited due to COVID-19 restrictions, so we were unable to encourage nurses to participate in the study. Despite limitations in data collection, the sample included nurses from a wide variety of backgrounds. Another potential disadvantage of this study is that it is based on a cross-sectional design. Cross-sectional studies only provide a snapshot of data collected at a specific point in time, making it difficult to establish causal relationships or determine the direction of associations. In future studies, it is recommended to conduct longitudinal and experimental studies, as they provide solid evidence in establishing causality.

5 Conclusions

There is a high level of fear toward COVID-19 among nurses, and a more negative perception of the work environment is associated with a higher level of fear. Since there is an association between perceptions of the workplace environment and the fear of COVID-19, there may be a potential to improve nurses’ mental health by improving their work environment and working conditions. Nursing care is significant investment in healthcare and therefore has the greatest impact on patient outcomes. Regulations to improve nurses’ working conditions could reduce health risks and help strengthen the healthcare response during pandemics. Increased staffing levels, provision of adequate and appropriate PPE, and reduced working hours are likely to improve nurses’ perceptions of their work environment as well as reduce their fears of COVID-19. We are conscious that the allocation of adequate resources is essential to make these targeted changes achievable. Simple actions such as supporting nurses’ basic needs would help improve their well-being. Further studies evaluating the effectiveness of these proposed interventions are recommended.

Ethical approval

Prior to the study, ethics approval was granted by the Istanbul Medipol University Ethics Committee (10840098-772.02-E.34480).

Conflict of interest

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Footnotes

Acknowledgments

We would like to thank all nurses who participated in this study.

Funding

The authors received no financial support for the research and/or authorship of this article.

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