Skip to main content
Download PDF

Managing the work stress of inpatient nurses during the COVID-19 pandemic: a systematic review of organizational interventions

BMC Nursing volume 23, Article number: 691 (2024) Cite this article

Abstract

Background

During the coronavirus disease 2019 (COVID-19) pandemic, inpatient nurses faced various work stressors. Little is known about organizational interventions that can mitigate the negative consequences of pandemic-related stressors.

Objective

The aim was to provide a synopsis of the literature concerning the types and outcomes of organizational interventions performed during the COVID-19 pandemic that directly (re)organized the work structures of inpatient nurses to address pandemic-related work stressors or to increase nurses’ ability to cope.

Methods

Within this preregistered systematic literature review, we searched four databases (PubMed, PsycINFO, PsycARTICLES, CINAHL) and two preprint databases (MedRxiv, PsyArXiv) for interventional studies of organizational interventions published between 01/2020 and 03/2023 (k = 990 records). We included 12 primary studies after title-abstract and full-text screening. A synthesis of results without meta-analysis was conducted. Risk of bias was assessed with the Cochrane risk-of-bias tool for randomized trials – version 2 (RoB-2) and Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool.

Results

All interventions were implemented in hospitals. The reasons given for implementation included pandemic-related work stressors such as a high workload, understaffing, and a lack of medical resources. To respond to the various work stressors, half of the studies took a multilevel approach combining organizational and person-oriented interventions (k = 6). Most studies (k = 8) took a secondary prevention approach, focusing on the organization of rest breaks (k = 5). With respect to outcomes, the studies examined nurse-related stress and resilience, turnover intention, job satisfaction, and other factors. Risk-of-bias analyses revealed that conclusions about the effectiveness of the interventions are limited due to confounding factors and self-selection.

Conclusions

The identified interventions provide a basis for future research to draw conclusions on the effectiveness of organizational interventions during pandemics. The promotion of adequate work breaks could be useful if the work stressors associated with strain and negative consequences cannot be changed directly. However, the same stressors (e.g., high workload) can hinder nurses from participating in offered interventions. This emphasizes the importance of directly addressing inpatient nurses’ work stressors.

Registration

Prospero-ID CRD42023364807 (March 2023).

Peer Review reports

Background

The coronavirus disease 2019 (COVID-19) pandemic has demonstrated the incremental systemic importance of nurses and the effectiveness of the healthcare system for society. Moreover, nurses’ working conditions and the professional challenges faced by nurses in delivering high-quality patient care—often with constrained resources and frequent ethical dilemmas—are sources of high levels of work stress [1]. Working conditions that reduce work stress and allow nursing staff to remain healthy in times of crisis is particularly important to ensure high-quality health care.

The COVID-19 pandemic exacerbated the already suboptimal working conditions in inpatient care settings; among all health care workers, nurses suffered the most from pandemic-related work stressors [2]. Specifically, nurses working with COVID-19 inpatients experienced direct consequences of the pandemic: high infection risks (two times greater than that of non-essential workers in Germany [3]; and almost four times greater than that of the general community in the UK and USA; [4]), the suffering of patients and patient caregivers, and death and isolation [2]. Additionally, inpatient nurses faced changes in their working conditions, such as staff shortages, high workloads, long work shifts, a lack of breaks and personal protective equipment (PPE), and social stigma [5, 6]. However, little is known about which organizational measures can prevent such stressors or at least mitigate their negative effects.

The need for action arises when the consequences of the aforementioned work stressors for nurses, patients, and inpatient facilities (that is, hospitals or nursing homes) during the pandemic are considered. Several meta-analyses revealed that high levels of pandemic-related work stress are related to a greater risk of physical strain (e.g., skin irritation from continuously wearing PPE), mental strain (e.g., depression, anxiety, emotional exhaustion) and negative organizational outcomes (e.g., patient safety and high turnover risks) [5, 7,8,9,10].

To prevent such negative consequences, organizations (hospitals, nursing homes, etc.) adopted early interventions focusing predominantly on relieving individual stress-related symptoms [11]. Individual-level interventions, as part of the person-oriented approach, aim to influence employee behavior, coping strategies, and strain reactions (e.g., fatigue) in response to work stressors. Systematic reviews have shown that such interventions improved nurses’ resilience and ability to cope with work stressors during the COVID-19 pandemic [12, 13]. However, Muller et al. [11] noted that there is a mismatch between ‘organizational sources of psychological distress, such as workload and lack of PPE, and how healthcare systems are attempting to relieve distress at an individual level’ (p. 8). Therefore, there is a strong need for a human-centered work design that ensures nurses’ well-being. This can be achieved by interventions that take a job-oriented approach that aims to modify work stressors themselves. Interventions based on the job-oriented approach aim to permanently change working conditions to address sources of adverse effects or provide resources to reduce these effects [14, 15].

Focusing on the job-oriented approach and thus directly influencing the work design of inpatient settings has stronger sustainable effects on employee health than individual-level interventions considering the person-oriented approach [16]. Furthermore, the job-oriented approach is important for primary and secondary prevention. A review of earlier pandemics and epidemics supported the belief of Muller et al. [11]. Kisely et al. [17] who identified organizational factors such as transparent and supportive communication, rest breaks, personal health protection, and practical support as important components of primary prevention interventions. The job-oriented approach is also relevant in the context of secondary prevention interventions: by directly changing working conditions (for example, by providing work breaks), inpatient nurses can be supported in coping with stressful working conditions that cannot be changed directly (e.g., a high COVID-19 patient load). In conclusion, interventions that take a job-oriented approach could either modify adverse work stressors themselves (primary prevention) or change working conditions to provide buffering resources or reduce adverse short-term strain outcomes (secondary prevention).

To address the work stressors and strain that arose throughout the COVID-19 pandemic through interventions that take a job-oriented approach, it is important to consider the complexity of the sociotechnical work system of inpatient nurses [18]. The Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0; [19]) model considers the work system of inpatient nurses during the COVID-19 pandemic [20]. This is due to its explicit inclusion of the external environment; its ability to distinguish patient, professional, and organizational outcomes; and its recent wide use in nursing systems research.

The SEIPS 2.0 model [19] proposes that work stressors comprise six interacting components: persons, tasks, tools and technologies, organization, and the internal and external environment. In light of the objective of this review, the organization and the external environment components are briefly explained in the following paragraphs.

The organization component includes all external structures and can also refer to the physical environment, time, resources, and activities. Consequently, the organization of activities includes the task component of the work system. Similarly, resources are related to tools and technologies, and the physical environment is related to the internal environment. Additionally, social organization is seen as part of the organization component. The organization component was particularly important in this review, as it is related to the work system by means of work organization (i.e., searching for interventions that reorganize the external structures of nurses) [19].

The external environment of the work system represents macrolevel factors outside an organization, such as ecological, societal, and policy factors. During the COVID-19 pandemic, external factors included, for example, high infection rates associated with higher hospitalization rates or political regulations regarding infection control and infection prevention that influenced inpatient nurses’ work behavior [6].

By taking a job-oriented approach, in the present review, we searched for and analyzed interventions that were implemented at an organizational level and carried out during the COVID-19 pandemic. Organizational interventions were defined as prospectively planned interventions that directly shaped the work content and/or work context in a ‘top-down’ manner. This included the (re)design of work system components outside the individual person, such as work activities (e.g., quantity of work tasks), work resources (e.g., technologies, human resources), the physical work environment (e.g., lighting, unit organization), and temporal (e.g., work schedules) or social (e.g., mentorships) aspects, according to the SEIPS 2.0 categories for work organization.

To date, only the review by Nicolakakis et al. [21] has explicitly addressed the effectiveness of organizational interventions published up to 2021. However, they considered organizational interventions during pandemics or epidemics in general while limiting their search for studies reporting mental no studies on comparable interventions seven studies, with all studies (k = 5 [22,23,24,25,26]), referring to the COVID-19 pandemic being observational. Within these five studies, the interventions ranged from interventions involving leadership training and the provision of peer support and rest breaks to simulation-based interventions. Interventions that changed multiple work aspects, offered psychological support (from peers or nurse leaders) or integrated participatory elements to tailor the intervention to nurses’ needs were identified as helpful in reducing nurses’ work stress and improving their mental health. Owing to poor study quality, the authors expressed low confidence in their effectiveness and the need for better-designed studies with good implementation strategies. A common problem of the five identified studies was the failure to address the core issue of nurses’ stress or methodological issues [21].

In this systematic review, we updated the findings of Nicolakakis et al. [21] without restricting our search to specific outcomes and focusing on studies with an interventional design. Therefore, we expanded our knowledge of evidence-based interventions that aim to directly change workplace aspects that can cause strain or hinder (for example, high workloads) or support (for example, adequate rest breaks) inpatient nurses’ ability to cope with high job demands. Therefore, our core research question, which followed the PICOS framework, was as follows:

Which organizational interventions (I) during the COVID-19 pandemic addressed pandemic-associated work stressors among inpatient nurses (P) in interventional studies (S), and what were the outcomes of these interventions (O) compared with those of no or other interventions (C)?

Following the general research question, further questions were derived from the findings and theoretical arguments presented above. Therefore, the considerations by Nielsen and Noblet [27] regarding the question ‘what works for whom?’ and the Template for Intervention Description and Replication (TIDieR) checklist [28] were considered.

  1. (1)

    What pandemic-associated work stressors were addressed by intervention studies during the COVID-19 pandemic?

  2. (2)

    Which organizational level interventions implemented what materials/procedures in what way to address work stressors of inpatient nurses during the COVID-19 pandemic?

  3. (3)

    Did the included studies modify the adverse work stressors themselves (primary prevention) or change work aspects to buffer the negative effects (secondary prevention)?

  4. (4)

    Which types of components of the work system (activities, resources, physical environment, temporal or social aspects) were modified, and how often were they modified?

  5. (5)

    Were the organizational interventions combined with other (e.g., person-oriented) interventions?

  6. (6)

    What patient, professional and/or organizational outcomes of the organizational interventions implemented to address the COVID-19 pandemic-associated work stressors of inpatient nurses were reported by the included studies?

  7. (7)

    What hindrances or promoting factors were discussed in the included intervention studies?

Question 1 considered the circumstances and the rationale for why the intervention was implemented. Questions 2, 3, 4 and 5 aimed to describe the interventions in more detail. Questions 6 and 7 provided information on the outcome and ‘how well and why’ an intervention worked or did not work.

Methods

The review protocol was preregistered in the International Prospective Register of Systematic Reviews (PROSPERO 2023 CRD42023364807).

Eligibility criteria

Title-abstract and full-text screening was conducted according to predefined eligibility criteria, which were developed according to the PICOS framework. The PICOS criteria, together with additional considerations not included in the PICOS framework, such as further definitions of the context, included publication types (randomized controlled trials (RCTs), quasiexperimental studies with at least one pretest and one posttest) or database filters used to specify the language and the publication date, are summarized in Table 1.

Table 1 Inclusion and exclusion criteria
Full size table

Information sources and search strategy

Six databases including nursing and psychology literature were searched: PubMed, PsycINFO, PsycARTICLES, CINAHL, MedRxiv, and PsyArXiv. The latter two preprint databases were included to identify the most recent studies published during the COVID-19 pandemic. The search strategy consisted of keywords related to the population (e.g., assistants and registered nurses working in acute care hospitals or nursing homes), the pandemic context (e.g., COVID-19, SARS-CoV-2), the organizational intervention (e.g., intervention, training, work design) and the study design (e.g., RCT, quasiexperiment). Keywords related to outcomes were not specified because the review focused primarily on interventions delivered to manage a broad range of work stressors during the COVID-19 pandemic. The search was restricted to studies published in English and German, was performed on 13.03.2023 and covered all available studies published since 01.01.2020 (for the full search strategy, see Supplementary 3: Tables S1 and S2).

Study selection process

A checklist with definitions of each PICOS element was prepared in advance and completed by two reviewers following a prespecified check sequence (see Supplementary 3: Figure S1 and Table S3). One reviewer screened and selected a total of 990 studies identified on the basis of their titles and abstracts. Together with a second reviewer, an independent decision on the inclusion or exclusion of a random set of 100 of the 990 identified publications was made to pilot the checklist and calculate interrater agreement. The program Rayyan [29] was used as a collaboration tool. The reviewers categorized title and abstracts for full-text screening as follows: ‘include’, ‘maybe’ or ‘exclude’. The interrater agreement was ‘moderate’ (κ = 0.55; 30). After discussing changes to the checklist, we reran the procedure with a new set of 100 random title and abstracts (only using ‘include’ and ‘exclude’ categories), resulting in ‘fair’ agreement (κ = 0.34; 30). The reason for the lower agreement may be that the reviewers conducted their screenings at different time points and had an additional work group meeting between those time points. Following this conventional double screening, the project team agreed on studies for further selection. After title-abstract screening, 141 full texts were screened by one reviewer, supplemented by spot checks performed by a second reviewer for 20% of the abstracts or full texts. In cases of disagreement, the entire research team was consulted for a final decision. After the study selection process, 12 studies were included in the review.

Data extraction

Extraction tables were developed during the data extraction process and were spot-checked by a second reviewer. The custom-made data extraction form included an intervention description developed via the TIDieR checklist [28] and can be found in Supplementary 3: Table S4.

Study risk of bias assessment

For the risk of bias assessment, we selected different validated tools depending on the study design, as recommended by Seidler et al. [31]. As recommended in the Cochrane Handbook for systematic reviews of interventions [32], we applied the Cochrane risk-of-bias tool for randomized trials – version 2 (RoB-2) tool [33] for randomized studies and the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool [34] for nonrandomized studies. The risk of bias assessment considered confounding, randomization/selection of participants, classification of interventions, deviations from the intended intervention, missing outcome data, measurement of outcomes and selection of reported results. A risk of bias assessment was conducted for each study outcome and spot checked by a second reviewer (see Supplementary 3: Tables S5 and S6). Conflicts were discussed between the two reviewers. If no consensus could be reached, the whole project team discussed the issue.

Effect measures

We did not conduct quantitative effect size synthesis. Whether an effect measure was reported or not was noted in the data extraction form. In the presentation of the results, only the significance and direction of relationships were tabulated (see Supplementary 3: Table S4).

Evidence synthesis methods

We performed a synthesis without meta-analysis of the results and considered the risk of bias to answer the guiding questions (e.g., outcome, significance, and study quality; see Supplementary 3: Tables S8 and S9). The body of evidence for single outcomes (e.g., with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, [35]) was not rated, as there were no studies on comparable interventions with the same outcome measure.

Since the comparability among the included interventions was limited, no quantitative synthesis was performed. Therefore, no meta-analysis of effect sizes was conducted, and no reporting bias was calculated.

Results

Study selection

The search yielded 990 records after the automatic elimination of duplicates. After screening the titles and abstracts of these records with the help of a prespecified check sequence of the selection criteria (see Supplementary 3: Figure S1 and Table S3), 158 records remained for full-text screening. By means of title-abstract screening, 15 records were pending study results. To ensure that of these 15 records, no more recent publications had been neglected, we performed additional manual searches in Google and Google Scholar on the basis of the information given by the title-abstract screening. Two full texts were found and retrieved for full-text screening but ultimately did not meet the inclusion criteria. The eligibility of a total of 141 retrieved full texts was assessed, resulting in 12 intervention studies (all published in peer-reviewed journals) that met the inclusion criteria. Even though the search included records from preprint databases, none of the records identified were included in the final sample.

There were studies that did not meet all of the inclusion criteria. First, the inclusion criteria for the inpatient nurse population, i.e., assistants and registered nurses working in acute care hospitals or nursing homes, were very strict. Some studies included patients, residents, or their caregivers as the primary target group with only the goal of improving the quality of care (e.g., [36,37,38,39]). These studies changed the work of nurses, for example, by activating a task force in the event of nursing home resident deaths [36]. However, these studies were excluded because the benefits or harms of the interventions for nurses were neither measured nor discussed. Other studies regarded healthcare workers as a whole group and did not distinguish their results between nurses and other staff (e.g., [40,41,42,43,44]). These studies were excluded, as no reliable nurse-specific statements could be derived regarding the intervention effects.

Figure 1 shows the study selection process according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart.

Fig. 1
figure 1

PRISMA flow-diagram [45]

Full size image

Study characteristics

The study characteristics are presented in Table 2. All the included intervention studies were carried out in hospitals, four of which were specialized COVID-19 hospitals. The studies included samples from different units: intensive care units (k = 4; [46,47,48,49]), emergency departments (k = 2; [50, 51]) or the entire hospital (k = 5; [26, 52,53,54,55]). In one study, the hospital unit was not reported [56]. The mean sample size of the nurses was approximately 138 (range: 30 to 363).

Table 2 Study information, statistically significant and nonsignificant outcomes and overall risk of bias assessment
Full size table

Organizational interventions were conducted in eight different countries: the USA (k = 4), Taiwan (k = 2), and Canada, China, Italy, the Netherlands, Pakistan, and Turkey (k = 1 for each).

The first reported interventions were carried out in February 2020 (k = 3). Some studies (k = 5) indicated that the intervention was implemented during a COVID-19 surge. The median intervention interval was three months, with the longest intervention interval lasting up to one year (i.e., a learning curriculum was evaluated that included the implementation of new or changed work tasks for nurses). The shortest intervention interval was one 15-minute break (healing touch session) during a 12-hour shift.

Seven studies implemented more than one single intervention. The highest number of interventions was implemented in a study of ‘holistic sleep improvement strategies’, with 13 interventions [55]. Half of the included studies (k = 6) included multilevel interventions that combined a person-oriented approach and a job-oriented approach.

All included studies examined nurse-related outcomes and used at least one subjective outcome assessment. Only one study [49] considered patient (e.g., discharge rate to non-intensive-care units) and hospital outcomes (e.g., patient costs) in addition to nurse-related outcomes (turnover intention).

Risk of bias assessment

We assessed the risk of bias to estimate whether an intervention effect in a study was due to an effective intervention or other (confounding) factors. The overall result of each study assessment are shown in Table 2 (for full report see Supplementary 3: Tables S5 and S6).

The most common methodological problems that increased the risk of bias were, for example, convenience sampling (k = 12), the lack of a study protocol or preregistration (k = 9), confounding due to the lack of a control group (k = 7), unclear hypotheses (k = 6), no assessment of intervention adherence or implementation success (k = 3), and a high dropout rate (k = 3). Furthermore, in many studies, confounding variables, such as a high workload during the pandemic (k = 6), could have had an unmeasured and uncontrolled influence on the use of the intervention, the completion of surveys, adherence, and dropout and thereby on the measured effect of the intervention.

In general, according to the ROBINS-I tool (k = 9), two studies were rated as critical, five studies were rated as having a serious risk of bias, and two studies were rated as having a moderate risk of bias. No study was rated as having a low risk of bias. The results of the RoB-2 tool (k = 3) revealed one study with a high risk of bias and two studies with some risk of bias (see Table 2).

Synthesis of results

In view of the seven research questions, a synthesis without meta-analysis of the results was performed. A short overview is provided in Table 2. For a detailed description according to the TIDieR checklist [28], see Supplementary 3: Tables S4, S7, S8 and S9.

Circumstances and rationale: ‘Why?’ (Research Question 1; RQ 1)

Notably, in no study were working conditions assessed before the intervention was implemented. Almost all (k = 11) of the included studies used literature reviews that supported the rationale for the intervention. Only one study mentioned unit-specific problems as the rationale for (and a hindrance to) the intervention [52].

RQ 1: The most frequently given rationale for the intervention was the high workload of nurses (k = 5; [26, 49, 51, 53, 55]). Other reported work stressors were insufficient staffing/a low nurse-to-patient ratio (k = 3; [26, 46, 52]) and limited medical resources (k = 2; [51, 53]). The work stressors addressed were allocated across the five components of the work system (activities, resources, the physical environment, and temporal or social aspects). Studies have identified the need for action with respect to all components of the work system.

For some studies (k = 3; [48, 54, 56]), the intervention rationale was not based on work stressors but rather on strain experienced by nurses or negative consequences for hospitals and patients. This reflects the secondary preventive approach to create structures to buffer pandemic-associated work strain or adverse consequences (see RQ 3).

A full description of the rationale for each study can be found in Supplementary 3: Table S7.

Intervention description: ‘What was provided by whom in what way?’ (RQs 2–5)

RQ 2: In general, the studies applied very different interventions in terms of their rationales, measures, and outcomes. The organizational interventions directly (re)designed work aspects in a ‘top down’ manner for all five components of the work system.

RQ 3: The prevention approach could be derived from the work stressors extracted for RQ 1 and whether these work stressors were modified directly (primary prevention) or other aspects of the work were changed to buffer negative effects (secondary prevention).

A frequent approach among secondary prevention interventions (k = 8) was to change the organization of nurses’ rest breaks (k = 5). For example, Goktas et al. [51] reported the excessive workload of emergency nurses as the rationale for their study. Instead of modifying the workload itself, their intervention aimed to improve motivation through smartphone messages. Emergency nurses were allowed to take short breaks to check their phones for these messages.

In general, all five studies did not discuss any theoretical rationale on why and how (re)organizing work breaks could ameliorate the negative effects of work stressors. The design of rest breaks involved changes to different work system components (time, the physical environment, resources, and activities).

An exclusively primary preventive approach was chosen by one theory-based study [49] that combined subjective and objective measurements and had one of the lowest risks of bias (moderate ratings) among the quasiexperimental studies. Piscitello et al. [49] reasoned that the moral distress of nurses likely increased during the COVID-19 pandemic. To provide sufficient care for critically ill patients, palliative medicine consultations were conducted, and family meetings were arranged.

Other studies (k = 3) combined primary and secondary intervention approaches [26, 47, 55]. These studies modified the work stressors themselves and (re)organized other aspects of the work system to buffer their effects. For example, the theory-based intervention study by Kumar and Jin [47] was one of two qualitatively well-rated quasiexperimental studies. The purpose was to decrease associated infection risks and high emotional demands due to the lack of PPE. Consequently, nurses were provided with instrumental support (for example, the provision of protective equipment) as a primary prevention approach. It was hypothesized that perceived instrumental support would mitigate the adverse effects of emotional labor on work stress in an emergency. The coaching leadership style, as a secondary prevention approach, was hypothesized to reduce the adverse effects of work stress on emotional exhaustion. However, the study revealed that perceived instrumental support itself could not fully weaken the negative effect of emotional labor on work stress. Positive feedback and clear communication with staff and social support provided via a coaching leadership style were found to be protective factors against work stress.

RQ 4: The organizational interventions modified aspects of the five components of the work system. Often, more than one work system component was changed by intervention (k = 9; [26, 47, 48, 50,51,52, 54,55,56]). Note that the studies did not further assess the actual changes in the work system.

The component most often considered was work activities (k = 10; [26, 46,47,48,49,50,51,52, 54, 55]). This very diverse category included several themes, e.g., new or changed work activities after training sessions, triggers for certain work activities, restructuring work processes, participation, or the implementation of break activities.

The second most frequently modified component was (human) resources for nurses (k = 7; [26, 47, 48, 50, 52, 55, 56]). An example is the proactive approach of Zaghini et al. [26]. In their study, an online tool was developed to provide transparent information on COVID-19-related procedures (e.g., reporting guidelines and updated information by the national authority).

The least modified component of the work system was the social aspect (k = 3; [26, 47, 55]). The studies implemented the coaching leadership style [47], positive feedback and acknowledgment [55], and opportunities for discussion regarding care adjustments, as well as participation [26].

The approach to (re)organize rest breaks was described above (k = 5). Changes in the organization of rest breaks were also distributed across different components of the work system. The five studies reorganized rest breaks related to the time component (e.g., short breaks; k = 3; [48, 51, 54]), the physical environment (e.g., break rooms; k = 3; [48, 52, 56]), the activities during breaks (e.g., going for a walk; k = 2; [48, 54]) and the component resources (e.g., massage chairs; k = 3; [48, 52, 56]).

However, the risk of bias ratings raised concerns about confounding and participant selection (see Supplementary 3: Tables S5, S6, S8 and S9).

RQ 5: Six studies applied a multilevel intervention approach combining job-oriented and person-oriented measures. In two studies, organizational interventions served only to formalize and promote newly learned behavior at the individual level via the person-oriented approach [46, 50]. In other studies, multilevel interventions were designed directly in a holistic manner [26, 52, 55].

Outcomes and ‘how well’ did the intervention work? (RQ 6–7)

An overview of the outcomes can be found in Table 2. For a detailed presentation of the outcomes considered and an evaluation of the strengths and weaknesses, see Supplementary 3: Tables S8 and S9.

With respect to RQ 6, all studies addressed nurse outcomes. The nurse outcomes included (job) stress- and resilience-related outcomes (k = 6), turnover intention (k = 2), job satisfaction (k = 2), and other outcomes. Only one study [49] additionally assessed patient (e.g., patient discharge rates) and hospital outcomes (patient costs). The body of evidence for the mentioned outcomes was not rated and should be considered very low due to methodological limitations and heterogeneity of the interventions among studies. That is, for each outcome category, the corresponding interventions differed.

With respect to RQ 7, we found that the discussion of factors that could promote or hinder the intervention was rather limited in the studies (k = 7; [26, 46, 47, 50, 51, 53, 54]). COVID-19-related challenges, such as visitor restrictions that hindered communication with patients’ families [49], high workloads that did not allow for breaks [48], and staff turnover [52], have been reported. With respect to the studies targeting rest break organization, workload and understaffing [48] and high absence due to sickness and turnover rates [52] presented a common hindrance. Only Pagador et al. [56] discussed the factors that (in their opinion) promoted the implementation of their ‘serenity lounge’ intervention during a COVID-19 wave. First, they were able to maintain a nurse‒patient ratio of 1:4 or 1:6 (depending on shifts). Second, the authors reported on the nursing team cohesion, leadership support, and early participation and commitment of the head nurses as factors promoting the intervention. A detailed description of the characteristics and hindrances of the interventions is presented in Supplementary 3: Table S4.

Discussion

This preregistered systematic review included 12 intervention studies (published between January 2020 and March 2023) conducted during the COVID-19 pandemic with nurses from eight different countries. We updated the findings of Nicolakakis et al. [21], and our results support some of the recommendations for healthcare workers (e.g., regarding organizational support) that were derived on the basis of earlier pandemics [17].

Nicolakakis et al. [21] synthesized evidence on organizational interventions to protect the mental health of healthcare workers (mainly nursing professionals) during epidemics and pandemics. They identified five observational studies that were conducted during the COVID-19 pandemic. However, Nicolakakis et al. [21] reported low to very low confidence in intervention effectiveness. The present review also considered intervention studies with mental health outcomes, but we additionally confined our scope to prospectively planned intervention studies with at least one premeasurement and one postmeasurement.

Multilevel interventions

Most of the studies related to COVID-19 (k = 3) included in the review of Nicolakakis et al. [21] were multilevel interventions that combined job-oriented and person-oriented approaches to improve the mental health of healthcare workers, similar to the ‘resilience bundle’ [52], ‘holistic sleep improvement strategies’ [55], and ‘proactive organizational approach’ [26] included in the present review.

The combination of both approaches is a common successful concept in occupational health research [57, 58]. For example, a recent systematic review of studies of organizational interventions revealed that multilevel interventions for employees resulted in better and longer-lasting burnout prevention than did pure single-level interventions [59].

When both approaches are used, individuals (e.g., nurses) can influence their experiences and emotions by adapting and shaping their behavior to situations (e.g., changes throughout the COVID-19 pandemic; [60]). Additionally, the job-oriented approach can influence individual behavior and improve an individual’s ability to cope with work stressors. The mutual influence of organizational interventions and individual-level interventions has also been highlighted in the work design literature regarding management research and occupational health psychology [61].

In summary, performing multilevel interventions during crisis situations and pandemics could promote the health of nurses and health care management in hospitals (e.g., staff, patients) because such interventions comprehensively address multiple different and interacting work stressors in such a dynamic sociotechnical work system [19]. However, in the present review, the quality of the three mentioned studies was limited, which was also discussed by Nicolakakis et al. [21].

Organizational interventions to improve organizational support

The study by Kumar and Jin [47] examined the effect of organizational support by providing instrumental and psychological resources. Organizational support is defined as nurses’ perceptions that their organizations value their contributions and care about their well-being [62]. Healthcare organizations could support healthcare workers instrumentally and emotionally by providing access to PPE, clear communication with staff, psychological support and sufficient time and opportunities (e.g., rooms) for rest breaks [17, 63, 64], which should be beneficial, particularly in times of organizational change [65].

Kumar and Jin [47] reported that access to PPE is more common than infection control since it may influence nurses’ work stress. In particular, work stress mediated the adverse influence of emotional labor on emotional exhaustion before the provision of PPE (instrumental support) and only partially after. When PPE was provided to frontline nurses, the stress-promoting effect of emotional labor was significantly weaker. However, the scarcity of medical resources is a challenge during a global crisis [5]. For hospitals, the question is probably not whether PPE and other medical resources are effective but how to acquire these resources. In addition, nurse managers or head nurses can promote organizational support by providing emotional support, for example, through the use of a coaching leadership style [47]. In the review by Kisely et al. [17], a perceived lack of organizational support was considered a risk factor for adverse psychological outcomes in healthcare workers. Additionally, the protective factors included positive feedback, clear communication with staff, and social support. These factors were considered in the study by Kumar and Jin [47], supporting the buffering role of the coaching leadership style on the adverse effect of work stress on emotional exhaustion in nurses.

Adequate rest, short breaks, time off, and appropriate work shifts were also recommended by Kisely et al. [17] to prevent adverse psychological outcomes in the face of high job demands during epidemics. Aspects of rest breaks were reorganized in several studies of this review. High effort can lead to the depletion of an individual’s resources [66]. To regulate their effort expenditure, individuals need to recover their resources, for example, by taking temporary breaks from work [67]. Rest breaks can buffer the effect of high job demands (for example, high work intensity) on short-term strain (for example, fatigue) and therefore on long-term consequences (e.g., burnout; [68]). Different aspects of rest break organization, such as rest break activities and high-quality rest break areas, have been associated with better physical and psychological well-being among nurses outside the pandemic context [68]. However, future studies need to gather data on evidence-based recommendations to determine whether such recovery approaches also help nurses cope with high demands in a pandemic context.

In summary, the provision of PPE and other medical resources required during a pandemic addresses the lack of resources directly but also functions as organizational support. Adapting organizational support to the needs of nurses is important for creating tangible benefits and resources for their efforts [69]. Leadership strategies could increase feelings of organizational support [47]. With respect to the (re)organization of rest breaks, rest breaks could function as job resources to support nurses’ ability to cope if sources of work strain (e.g., work stressors such as high workloads) cannot be directly addressed. In addition, adequate staffing is needed to allow the use of rest breaks [56]. This was problematic even before the pandemic, when nurses already lacked opportunities for rest breaks [70].

Limited opportunities for primary interventions

We found that two-thirds of the included studies did not change work stressors themselves but rather other job-oriented aspects of work to support nurses.

However, as an example, the European Directive on measures to encourage improvements in the safety and health of workers at work (Directive 89/391/EEC) states that the source of risks must be addressed and that other interventions must be preferred over individual protective interventions [71].

This premise is even more important in the context of this review, where the antecedents of nurses’ stress also hindered them from using interventions such as rest breaks. Therefore, the question arises as to why the focus of the organizational interventions was on secondary prevention.

Organizations had to function under stressful time constraints and deal with the novelty of the pandemic, unclear or shifting goals, and ill-structured situations [72], which may have hindered the capacity of hospitals to address sources of work strain. For example, checklists for hospital disaster preparedness emphasize the importance of an immediate response to sudden high care demands to maintain system function [73]. Designing adequate human-centered work interventions [74] might be a secondary priority. However, according to Schmucker [70], high workloads and a lack of time were ongoing problems in professional nursing even before the pandemic.

These problems cannot be solved without increasing the number of personnel to meet the (growing) care demands [70]. In a global pandemic with a sudden rise in demand for care [6], the spontaneous acquisition of more personnel was even more difficult. An approach to this problem was to increase the expertise of existing personnel instead of the number of personnel [75] by retraining nurses in critical care. The only included study that examined these trainings was Goldsworthy [46], which implemented critical care training for nurses followed by the application of newly learned skills and work tasks. Furthermore, rehiring part-time working nurses could have been difficult during the COVID-19 pandemic. In a national German survey, more than one-third of the 8007 nurses who left their profession or worked part time stated that their readiness to reenter the job or switch from part-time to full-time employment decreased during the COVID-19 pandemic [76].

These arguments highlight the need to take action outside pandemics, not only to address the ongoing lack of personnel but also to prepare for future pandemics.

Implications for practice

In general, it is important to address ongoing structural problems to retain and gain personnel to meet the growing demand for care. Improving the working conditions of nurses considering a human-centered work design [77] through organizational interventions could be one way to improve the attractiveness of the nursing position and therefore lead to increased recruitment [70]. The following recommendations can be made.

First, a participatory approach should be considered in the process of developing organizational interventions. The participation of nurses is an important predictor of successful organizational interventions [56, 78]. Organizations can facilitate the participation of their employees in interventions by involving them in initial discussions in the preparation phase or allowing them to identify key issues through surveys or focus groups in the screening phase. Teams of employees and managers can develop interventions in the action planning phase, and employees take active roles in the implementation phase. In the evaluation phase, employees can be involved in feedback sessions or follow-up surveys [79]. Zaghini et al. [26] promoted employee participation through continuous clinical and organizational audits, lectures, and workshops, which provided opportunities to discuss care adjustments.

Second, the complexity of the crisis must be acknowledged, as it affects the whole work system of nurses. Therefore, the best approach, at least theoretically, might be combining individual-level interventions (e.g., providing mindfulness training) with job-based interventions (e.g., making scheduling changes or designing work breaks).

Third, the literature and findings of this review can be used to anticipate pandemic-associated challenges for nurses in the future. One way to prepare for pandemics is by completing extensive checklists addressing hospital crisis preparedness [73]. These checklists consider issues such as logistics, human resources, triage, and communication, which are essential to keep care systems functioning [73]. Another step would be for hospitals to stay up-to-date with research. New evidence regarding the COVID-19 pandemic is still being published. On another note, collaborating with external consultants and researchers with expertise in work and organizational psychology may benefit hospital practice as well as further research [78].

Implications for research

The main research question of this review was ‘What organizational interventions were provided?’ and not ‘How effective were the interventions?’. Therefore, future research should focus on the question of intervention effectiveness.

The findings of the summarized organizational interventions need to be replicated in similar contexts to determine whether these interventions are truly effective. Future studies should consider quality improvements in their study designs, for example, by controlling for confounding factors (e.g., nurse workload).

Furthermore, the present review, as well as the review by Nicolakakis et al. [21], identified problems with the reporting of interventions in the studies. To allow replication, interventions need to be described in more detail. Checklists such as the TIDieR checklist [28] are helpful in considering such details.

Furthermore, future research needs to evaluate the interventions considered herein in other contexts since the generalizability of the study findings is limited by the use of convenience sampling. The pandemic context may differ from country to country, from hospital to hospital, or even from unit to unit. There may also be cultural and legislative differences (for example, rest break culture and mandatory breaks) that must be considered when interventions are implemented.

This systematic review identified the most prominent research gap as evidence-based interventions for nurses working in nursing homes, as no study conducted in nursing homes met the strict criteria for inclusion in this review. Future research should focus on supporting scientific evidence of organizational interventions for nurses working in nursing homes to manage pandemic-related work stressors such as additional work activities (e.g., isolation protocols, pandemic-related protocols after death, establishment of contact with residents’ families) and social aspects (e.g., challenging behavior during pandemics; [80]).

Limitations

One limitation is that our review probably included a small excerpt of the studies conducted. The pandemic context could have led to the cancellation of studies due to the high absence rates due to illness. In some cases, the pandemic context may have allowed for only retrospective studies that were not included in this review.

Second, the selection process was very strict. This led to the exclusion of all existing studies conducted in nursing homes. For example, we excluded a study in which a task force was formed to implement measures such as infection control and nurse support actions in the event of nursing home resident deaths [36].

Additionally, it is debatable whether the limitation to one population group was reasonable in light of a pandemic that affected the whole health care organization. For example, organizational interventions, such as managing whole infection pathways of visitors in hospitals, could reduce nurses’ fear of infection. However, if outcomes for nurses were not analyzed, such studies were excluded.

Conclusions

The end of the COVID-19 pandemic was declared by the World Health Organization in May 2023 [81]. The pandemic had the consequences of global illness, death and exhaustion for patients, families, nurses and hospitals. There are several lessons to be learned from the COVID-19 pandemic.

In this context, the present systematic review adds to a small body of research aimed at improving the working conditions of nurses during the COVID-19 pandemic and provides a basis for future research on organizational interventions during pandemics to draw conclusions about their effectiveness. This review updated the findings of Nicolakakis et al. [21] by taking a wider view (more than just mental health outcomes) and by searching for non-peer-reviewed literature. We found that the use of human-centered work designs in organizational interventions can be pursued even during a pandemic crisis. Work stressors (such as a lack of PPE) should preferably be addressed directly, which can be difficult during a crisis. The promotion of adequate work breaks could be useful if the work stressors associated with strain and negative consequences cannot be changed directly. However, the same stressors (e.g., high workload) can hinder nurses from participating in offered intervention. This emphasizes the importance of directly addressing work stressors. Organizations can also support nurses by being sensitive to their needs (i.e., promoting the participation of nurses in different evaluation phases through surveys, active roles, and group sessions) and providing tangible benefits and resources (i.e., psychological support through leadership style and sufficient PPE).

Data availability

The datasets supporting the conclusions of this article are included within the article and its additional files.

Abbreviations

COVID-19:

Coronavirus disease 2019

k or n:

Study number or sample size

PPE:

Personal protective equipment

PRISMA:

The Preferred Reporting Items for Systematic reviews and Meta-Analyses

RoB:

Risk of Bias

ROBINS:

Risk Of Bias In Nonrandomized Studies of Interventions

RQ:

Research question

SEIPS 2.0:

Systems Engineering Initiative for Patient Safety, second version

TIDieR:

Template for intervention description and replication

References

  1. Dichter M, Kocks A, Meyer G, Stephan A. Pflege ist systemrelevant - Nicht nur in Corona-Zeiten: Gemeinsame Stellungnahme zum Internationalen Jahr der Pflegenden und Hebammen vor dem Hintergrund der Corona -Pandemie in Deutschland. [Nursing is systemically relevant - not only in corona times: Joint statement on the International Year of Nurses and Midwives against the background of the corona pandemic in Germany].

  2. Schulze S, Holmberg C. Bedeutung Und Belastung Von Pflegekräften während Der Corona-Krise. [Importance and strain on carers during the coronavirus crisis]. Public Health Forum. 2021;29:32–5. https://doi.org/10.1515/pubhef-2020-0114.

    Article  Google Scholar 

  3. Reuter M, Rigó M, Formazin M, Liebers F, Latza U, Castell S, et al. Occupation and SARS-CoV-2 infection risk among 108 960 workers during the first pandemic wave in Germany. Scand J Work Environ Health. 2022;48:446–56. https://doi.org/10.5271/sjweh.4037.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo C-G, Ma W, et al. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Public Health. 2020;5:e475–83. https://doi.org/10.1016/S2468-2667(20)30164-X.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Danesh MK, Garosi E, Golmohamadpour H. The COVID-19 pandemic and nursing challenges: a review of the early literature. WOR. 2021;69:23–36. https://doi.org/10.3233/WOR-213458.

    Article  Google Scholar 

  6. Xu H, Stjernswärd S, Glasdam S. Psychosocial experiences of frontline nurses working in hospital-based settings during the COVID-19 pandemic - A qualitative systematic review. Int J Nurs Stud Adv. 2021;3:100037. https://doi.org/10.1016/j.ijnsa.2021.100037.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Falatah R. The impact of the Coronavirus Disease (COVID-19) pandemic on nurses’ turnover intention: an integrative review. Nurs Rep. 2021;11:787–810. https://doi.org/10.3390/nursrep11040075.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Garcia C, Abreu L, Ramos J, Castro C, Smiderle F, Santos J, Bezerra I. Influence of Burnout on Patient Safety: systematic review and Meta-analysis. Medicina. 2019;55:553. https://doi.org/10.3390/medicina55090553.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Ślusarska B, Nowicki GJ, Niedorys-Karczmarczyk B, Chrzan-Rodak A. Prevalence of depression and anxiety in nurses during the First Eleven months of the COVID-19 pandemic: a systematic review and Meta-analysis. IJERPH. 2022;19:1154. https://doi.org/10.3390/ijerph19031154.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Varghese A, George G, Kondaguli SV, Naser AY, Khakha DC, Chatterji R. Decline in the mental health of nurses across the globe during COVID-19: a systematic review and meta-analysis. J Glob Health. 2021;11:5009. https://doi.org/10.7189/jogh.11.05009.

    Article  Google Scholar 

  11. Muller AE, Hafstad EV, Himmels JPW, Smedslund G, Flottorp S, Stensland SØ, et al. The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: a rapid systematic review. Psychiatry Res. 2020;293:113441. https://doi.org/10.1016/j.psychres.2020.113441.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Park J-H, Jung S-E, Ha D-J, Lee B, Kim M-S, Sim K-L, et al. The effectiveness of e-healthcare interventions for mental health of nurses. Medicine. 2022;101:e29125. https://doi.org/10.1097/MD.0000000000029125.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Velana M, Rinkenauer G. Individual-level interventions for decreasing job-related stress and enhancing coping strategies among nurses: a systematic review. Front Psychol. 2021. https://doi.org/10.3389/fpsyg.2021.708696.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Lamontagne AD, Keegel T, Louie AM, Ostry A, Landsbergis PA. A systematic review of the job-stress intervention evaluation literature, 1990–2005. Int J Occup Environ Health. 2007;13:268–80. https://doi.org/10.1179/oeh.2007.13.3.268.

    Article  PubMed  Google Scholar 

  15. International Labour Organization. Report of the Joint ILO/WHO Committee on Occupational Health (twelfth session, Geneva, 5–7 April 1995); 1995.

  16. Montano D, Hoven H, Siegrist J. Effects of organisational-level interventions at work on employees’ health: a systematic review. BMC Public Health. 2014. https://doi.org/10.1186/1471-2458-14-135.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Kisely S, Warren N, McMahon L, Dalais C, Henry I, Siskind D. Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. BMJ. 2020;369:m1642. https://doi.org/10.1136/bmj.m1642.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Carayon P, Bass EJ, Bellandi T, Gurses AP, Hallbeck MS, Mollo V. Sociotechnical systems analysis in health care: a research agenda. IIE Trans Healthc Syst Eng. 2011;1:145–60. https://doi.org/10.1080/19488300.2011.619158.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Holden RJ, Carayon P, Gurses AP, Hoonakker P, Hundt AS, Ozok AA, Rivera-Rodriguez AJ. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics. 2013;56:1669–86. https://doi.org/10.1080/00140139.2013.838643.

    Article  PubMed  Google Scholar 

  20. Bethel C, Reed PG, Brewer BB, Rainbow JG. Selecting a theoretical framework to guide research on the COVID-19 pandemic impacts on nursing care delivery and the critical care work system (using Reed’s Intermodern approach to theory critique). Appl Nurs Res. 2022;63:151513. https://doi.org/10.1016/j.apnr.2021.151513.

    Article  PubMed  Google Scholar 

  21. Nicolakakis N, Lafantaisie M, Letellier M-C, Biron C, Vézina M, Jauvin N et al. Are Organizational Interventions Effective in Protecting Healthcare Worker Mental Health during Epidemics/Pandemics? A Systematic Literature Review. IJERPH. 2022. https://doi.org/10.3390/ijerph19159653

  22. Beneria A, Arnedo M, Contreras S, Pérez-Carrasco M, Garcia-Ruiz I, Rodríguez-Carballeira M, et al. Impact of simulation-based teamwork training on COVID-19 distress in healthcare professionals. BMC Med Educ. 2020;20:515. https://doi.org/10.1186/s12909-020-02427-4.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Blake H, Yildirim M, Wood B, Knowles S, Mancini H, Coyne E, Cooper J. COVID-Well: evaluation of the implementation of supported Wellbeing centres for Hospital employees during the COVID-19 pandemic. Int J Environ Res Public Health. 2020. https://doi.org/10.3390/ijerph17249401.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Giordano F, Cipolla A, Ungar M. Building resilience for healthcare professionals working in an Italian red zone during the COVID-19 outbreak: a pilot study. Stress Health. 2022;38:234–48. https://doi.org/10.1002/smi.3085.

    Article  PubMed  Google Scholar 

  25. Zhu Z, Xu S, Wang H, Liu Z, Wu J, Li G, et al. COVID-19 in Wuhan: sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on healthcare workers. eClinicalMedicine. 2020;24:100443. https://doi.org/10.1016/j.eclinm.2020.100443.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Zaghini F, Fiorini J, Livigni L, Carrabs G, Sili A. A mixed methods study of an organization’s approach to the COVID-19 health care crisis. Nurs Outlook. 2021;69:793–804. https://doi.org/10.1016/j.outlook.2021.05.008.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Nielsen KM, Noblet A. Organizational interventions: where we are, where we go from here? In: Nielsen KM, Noblet A, editors. Organizational Interventions for Health and Well-being: A Handbook for Evidence-Based Practice. pp. 1–22.

  28. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:1–12. https://doi.org/10.1136/bmj.g1687.

    Article  Google Scholar 

  29. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016. https://doi.org/10.1186/s13643-016-0384-4.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Landis JR, Koch GG. The measurement of Observer Agreement for Categorical Data. Biometrics. 1977;33:159. https://doi.org/10.2307/2529310.

    Article  CAS  PubMed  Google Scholar 

  31. Seidler A, Nußbaumer-Streit B, Apfelbacher C, Zeeb H. Rapid Reviews in Zeiten Von COVID-19 – Erfahrungen Im Zuge Des Kompetenznetzes Public Health zu COVID-19 und Vorschlag eines standardisierten vorgehens. [Rapid Reviews in the Time of COVID-19 - experiences of the Competence Network Public Health COVID-19 and proposal for a standardized Procedure]. Gesundheitswesen. 2021;83:173–9. https://doi.org/10.1055/a-1380-0926.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Boutron I, Page MJ, Higgins JPT, Altman DG, Lundh A, Hróbjartsson A. Considering bias and conflicts of interest among the included studies. In: Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editors. Cochrane handbook for systematic reviews of interventions. Hoboken, NJ, Chichester: Wiley Blackwell; 2019. pp. 177–204. https://doi.org/10.1002/9781119536604.ch7.

    Chapter  Google Scholar 

  33. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;l4898. https://doi.org/10.1136/bmj.l4898.

  34. Sterne JAC, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;i4919. https://doi.org/10.1136/bmj.i4919.

  35. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al. GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64:383–94. https://doi.org/10.1016/j.jclinepi.2010.04.026.

    Article  PubMed  Google Scholar 

  36. Dolveck F, Strazzulla A, Noel C, Aufaure S, Tarteret P, de Pontfarcy A, et al. COVID-19 among nursing home residents: results of an urgent pre-hospital intervention by a multidisciplinary task force. Brazilian J Infect Dis. 2021;25:101039. https://doi.org/10.1016/j.bjid.2020.11.004.

    Article  CAS  Google Scholar 

  37. Li B, Yang Q. The effect of an ICU liaison nurse-led family‐centred transition intervention program in an adult ICU. Nurs Crit Care. 2023;28:435–45. https://doi.org/10.1111/nicc.12764.

    Article  PubMed  Google Scholar 

  38. Mottaghi K, Hasanvand S, Goudarzi F, Heidarizadeh K, Ebrahimzadeh F. The role of the ICU liaison nurse services on anxiety in family caregivers of patients after ICU discharge during COVID-19 pandemic: a randomized controlled trial. BMC Nurs. 2022. https://doi.org/10.1186/s12912-022-01034-6.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Zhang X, Wang W, Zhao X, Cheng H, Song Y, Song X. Implementing caregiver management measures in general hospitals to prevent the COVID -19 pandemic. Nurs Open. 2023;10:2983–90. https://doi.org/10.1002/nop2.1542.

    Article  PubMed  Google Scholar 

  40. Calamassi D, Li Vigni ML, Fumagalli C, Gheri F, Pomponi GP, Bambi S. The listening to music tuned to 440 hz versus 432 hz to reduce anxiety and stress in emergency nurses during the COVID-19 pandemic: a double-blind, randomized controlled pilot study. Acta Biomed. 2022;93:e2022149. https://doi.org/10.23750/abm.v93is2.12915.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Mohanty S, Lakkireddy D, Trivedi C, MacDonald B, Mayedo A, Della Rocca DG, et al. Creating a safe workplace by universal testing of SARS-CoV-2 infection in patients and healthcare workers in the electrophysiology unit having no symptoms of COVID-19: a multi-center experience. J Interventional Cardiac Electrophysiol. 2021;62:171–6. https://doi.org/10.1101/2020.07.14.20153494.

    Article  Google Scholar 

  42. Ohta R, Ryu Y, Sano C. Effects of implementation of infection control measures against COVID-19 on the Condition of Japanese rural nursing homes. IJERPH. 2021;18:5805. https://doi.org/10.3390/ijerph18115805.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Stemler J, Kramer T, Dimitriou V, Wieland U, Schumacher S, Sprute R, et al. Mobile PCR-based surveillance for SARS-CoV-2 to reduce visiting restrictions in nursing homes during the COVID-19 pandemic: a pilot study. Infection. 2022;50:607–16. https://doi.org/10.1007/s15010-021-01716-4.

    Article  CAS  PubMed  Google Scholar 

  44. Teixeira Mendes E, Neto DGPV, Ferreira GM, Valença IN, Lima MPJS, de Freitas MFMB, et al. Impact of COVID-19 RT-PCR testing of asymptomatic health care workers on absenteeism and hospital transmission during the pandemic. Am J Infect Control. 2023;51:248–54. https://doi.org/10.1016/j.ajic.2022.10.014.

    Article  CAS  PubMed  Google Scholar 

  45. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;n71. https://doi.org/10.1136/bmj.n71.

  46. Goldsworthy S. The influence of simulation in predicting intent to stay, among critical care nurses. CJCCN. 2021;32:5–13. https://doi.org/10.5737/23688653-322513.

    Article  Google Scholar 

  47. Kumar N, Jin Y. Impact of nurses’ emotional labour on job stress and emotional exhaustion amid COVID-19: the role of instrumental support and coaching leadership as moderators. J Nurs Manage. 2022;30:2620–32. https://doi.org/10.1111/jonm.13818.

    Article  Google Scholar 

  48. Nijland JWHM, Veling W, Lestestuiver BP, van Driel CMG. Virtual reality relaxation for reducing perceived stress of Intensive Care nurses during the COVID-19 pandemic. Front Psychol. 2021. https://doi.org/10.3389/fpsyg.2021.706527.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Piscitello GM, Lamadrid VJ, Post Z, Kaur R, Gulczynski B, Baldeo R, et al. The Effect of Triggered Palliative Medicine consults on Nurse Moral Distress in the Medical Intensive Care Unit. Am J Hosp Palliat Care. 2022;39:1039–45. https://doi.org/10.1177/10499091211049398.

    Article  PubMed  Google Scholar 

  50. Chang Y-C, Hsu M-C, Ouyang W-C. Effects of Integrated Workplace Violence Management Intervention on Occupational coping Self-Efficacy, goal commitment, attitudes, and confidence in Emergency Department nurses: a cluster-randomized controlled trial. IJERPH. 2022;19:2835. https://doi.org/10.3390/ijerph19052835.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Goktas S, Gezginci E, Kartal H. The effects of motivational messages sent to emergency nurses during the COVID-19 pandemic on job satisfaction, Compassion fatigue, and communication skills: a Randomized Controlled Trial. J Emerg Nurs. 2022;48:547–58. https://doi.org/10.1016/j.jen.2022.06.001.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Haugland WA, Crenshaw JT, Gilder RE. Implementing a Resilience Bundle for Emergency nurses: an evidence-based Practice Project. J Emerg Nurs. 2023;49:40–9. https://doi.org/10.1016/j.jen.2022.08.009.

    Article  PubMed  Google Scholar 

  53. Hung C-L, Lin Y-L, Chou C-M, Wang C-J. Efficacy of aromatherapy at relieving the Work-Related Stress of Nursing Staff from various hospital departments during COVID-19. Healthcare. 2023;11:157. https://doi.org/10.3390/healthcare11020157.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Rosamond RL, Giarratano G, Orlando S, Sumner J, Devier D, McDaniel LS, Wardell DW. Healing touch: a strategy for Acute Care nurses’ stress reduction. J Holist Nurs. 2023;41:347–59. https://doi.org/10.1177/08980101221142193.

    Article  PubMed  Google Scholar 

  55. Zhang Y, Tang M, Zhou Y. Holistic sleep improvement strategies for frontline nurses served during a public health emergency (COVID -19) in Wuhan, China: a quasi‐experimental study. Nurs Open. 2023;10:1471–81. https://doi.org/10.1002/nop2.1397.

    Article  PubMed  Google Scholar 

  56. Pagador F, Barone M, Manoukian M, Xu W, Kim L. Effective holistic approaches to reducing nurse stress and burnout during COVID-19. AJN. Am J Nurs. 2022;122:40–7. https://doi.org/10.1097/01.NAJ.0000830744.96819.dc.

    Article  PubMed  Google Scholar 

  57. Ilmarinen J, Rantanen J. Promotion of work ability during ageing. Am J Ind Med. 1999;Suppl 1:21–3. https://doi.org/10.1002/(sici)1097-0274(199909)36.

    Article  CAS  PubMed  Google Scholar 

  58. Lippke S, Hessel A. Verhaltens- Und Verhältnisinterventionen in Der Prävention: Metaanalytische Befunde Und Implikationen. [Behavioural and relationship interventions in prevention: meta-analytical findings and implications]. PR. 2018;30:121–32. https://doi.org/10.5414/PRX0533.

    Article  Google Scholar 

  59. Aust B, Møller JL, Nordentoft M, Frydendall KB, Bengtsen E, Jensen AB, et al. How effective are organizational-level interventions in improving the psychosocial work environment, health, and retention of workers? A systematic overview of systematic reviews. Scand J Work Environ Health. 2023;49:315–29. https://doi.org/10.5271/sjweh.4097.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Demerouti E, Bakker AB. Job demands-resources theory in times of crises: New propositions. Organizational Psychol Rev. 2023;13:209–36. https://doi.org/10.1177/20413866221135022.

    Article  Google Scholar 

  61. Parker SK, Jorritsma K. Good work design for all: multiple pathways to making a difference. Eur J Work Organizational Psychol. 2021;30:456–68. https://doi.org/10.1080/1359432X.2020.1860121.

    Article  Google Scholar 

  62. Eisenberger R, Rhoades Shanock L, Wen X. Perceived organizational support: why Caring about employees counts. Annu Rev Organ Psychol Organ Behav. 2020;7:101–24. https://doi.org/10.1146/annurev-orgpsych-012119-044917.

    Article  Google Scholar 

  63. Beehr TA, Jex SM, Stacy BA, Murray MA. Work stressors and coworker support as predictors of individual strain and job performance. J Organiz Behav. 2000;21:391–405. https://doi.org/10.1002/(SICI)1099-1379(200006)21:4<391::AID-JOB15>3.0.CO;2-9.

    Article  Google Scholar 

  64. Amason P, Allen MW, Holmes SA. Social support and acculturative stress in the multicultural workplace. J Appl Communication Res. 1999;27:310–34. https://doi.org/10.1080/00909889909365543.

    Article  Google Scholar 

  65. Daniels RA, Miller LA, Mian MZ, Black S. One size does NOT fit all: understanding differences in perceived organizational support during the COVID-19 pandemic. Bus Soc Rev. 2022;127:193–222. https://doi.org/10.1111/basr.12256.

    Article  Google Scholar 

  66. Zijlstra FRH. Effort as energy regulation. In: Battmann W, Dutke S, editors. Processes of the molar regulation of behavior. Berlin, Düsseldorf: Pabst Science Publ;: Lengerich; 1996. pp. 219–35.

    Google Scholar 

  67. Meijman TF, Mulder G. Psychological aspects of workload. In: Drenth PJD, Thierry H, editors. A handbook of work and organizational psychology: volume 2: work psychology. 2nd ed. Hoboken: Psychology; 1998. pp. 5–33.

    Google Scholar 

  68. Wendsche J, Ghadiri A, van Bengsch A, Wegge J. Antecedents and outcomes of nurses’ rest break organization: a scoping review. Int J Nurs Stud. 2017;75:65–80. https://doi.org/10.1016/j.ijnurstu.2017.07.005.

    Article  PubMed  Google Scholar 

  69. Cropanzano R, Mitchell MS. Social Exchange Theory: an Interdisciplinary Review. J Manag. 2005;31:874–900. https://doi.org/10.1177/0149206305279602.

    Article  Google Scholar 

  70. Schmucker R. Arbeitsbedingungen in Pflegeberufen. [Working conditions in nursing professions]. In: Jacobs K, Kuhlmey A, editors. Pflege-Report 2019; 2020. pp. 49–60. https://doi.org/10.1007/978-3-662-58935-9_3

  71. Federal Ministry of Labour and Social Affairs. editor. Act on the implementation of measures of occupational safety and health to encourage improvements in the safety and health protection of workers at work: Arbeitsschutzgesetz, ArbSchG.

  72. Dirani KM, Abadi M, Alizadeh A, Barhate B, Garza RC, Gunasekara N, et al. Leadership competencies and the essential role of human resource development in times of crisis: a response to Covid-19 pandemic. Hum Resource Dev Int. 2020;23:380–94. https://doi.org/10.1080/13678868.2020.1780078.

    Article  Google Scholar 

  73. Nekoie-Moghadam M, Kurland L, Moosazadeh M, Ingrassia PL, Della Corte F, Djalali A. Tools and checklists used for the evaluation of Hospital Disaster preparedness: a systematic review. Disaster med Public Health prep. 2016;10:781–8. https://doi.org/10.1017/dmp.2016.30.

    Article  PubMed  Google Scholar 

  74. Richter P, Hacker W. Belastung und Beanspruchung: Stress, Ermüdung und Burnout im Arbeitsleben. [Stress and strain: stress, fatigue and burnout at work]. 1998.

  75. Andel SA, Tedone AM, Shen W, Arvan ML. Safety implications of different forms of understaffing among nurses during the COVID-19 pandemic. J Adv Nurs. 2022;78:121–30. https://doi.org/10.1111/jan.14952.

    Article  PubMed  Google Scholar 

  76. Auffenberg J, Becka D, Evans M, Kokott N, Schleicher S, Braun E. „Ich pflege wieder, wenn …“: Potenzialanalyse zur Berufsrückkehr und Arbeitszeitaufstockung von Pflegefachkräften. [‘I'll nurse again if …’: Potential analysis for returning to work and increasing the working hours of nursing staff]. Bremen

  77. Stab N, Hacker W. Stationsorganisation Im Krankenhaus: Entwicklung Und Erprobung eines kriteriengeleiteten Bewertungs- Und Gestaltungsverfahrens: Forschung Projekt F 2253. BAUA-Bericht. [Ward organisation in hospitals: development and testing of a criteria-based evaluation and design procedure. Research Project F 2253]; 2016.

  78. Roodbari H, Nielsen K, Axtell C, Peters SE, Sorensen G. Testing middle range theories in realist evaluation: a case of a participatory organisational intervention. IJWHM. 2022;15:694–710. https://doi.org/10.1108/IJWHM-12-2021-0219.

    Article  Google Scholar 

  79. Nielsen K, Christensen M. Positive participatory organizational interventions: a Multilevel Approach for creating healthy workplaces. Front Psychol. 2021;12:696245. https://doi.org/10.3389/fpsyg.2021.696245.

    Article  PubMed  PubMed Central  Google Scholar 

  80. Palacios-Ceña D, Fernández-Peña R, Ortega-López A, Fernández-Feito A, Bautista-Villaécija O, Rodrigo-Pedrosa O, et al. Long-term care facilities and nursing homes during the First Wave of the COVID-19 pandemic: a scoping review of the perspectives of professionals, families and residents. IJERPH. 2021;18:10099. https://doi.org/10.3390/ijerph181910099.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  81. UN news. WHO chief declares end to COVID-19 as a global health emergency; 05,05.2023.

Download references

Acknowledgements

We would like to thank Prof. Dr. Petra Kemter-Hofmann (TU Dresden, Germany), Prof. Dr. Martin Schütte, and Dr. Ulrike Rösler (German Federal Institute for Occupational Safety and Health) for helpful comments on an earlier draft of this paper. We also thank Helene Müller and Annett Gutschick (German Federal Institute for Occupational Safety and Health) for their support during the collection of the literature.

Funding

This work was supported by the Federal Institute for Occupational Safety and Health, Germany (project number F 2541 ‘Interventions focusing on work organisation as part of pandemic management in inpatient care’).

Open Access funding enabled and organized by Projekt DEAL.

Author information

Author notes

  1. Maria Zink and Frederike Pischke share first authorship of this paper.

Authors and Affiliations

  1. Federal Institute for Occupational Safety and Health (BAuA), Dresden, Germany

    Maria Zink, Johannes Wendsche & Marlen Melzer

  2. Technische Universität Dresden (TUD), Dresden, Germany

    Frederike Pischke

Authors
  1. Maria Zink
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Frederike Pischke
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Johannes Wendsche
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Marlen Melzer
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Authors of this publication made substantial contributions to different parts in the publication process. These are as follows: Maria Zink: Conceptualization, Visualization, Investigation, Formal analysis, Methodology; Roles/Writing: Original Draft; review & editingFrederike Pischke: Data curation, Formal analysis, Visualization, Investigation, Methodology; Roles/Writing: Original Draft; review & editingDr. Johannes Wendsche: Conceptualization, Supervision, Funding acquisition, Methodology; Roles/Writing: Review & EditingDr. Marlen Melzer: Project administration, Conceptualization, Supervision, Funding acquisition, Methodology; Roles/Writing: Review & Editing.

Corresponding author

Correspondence to Maria Zink.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Conflict of interest

The authors declare that they have no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zink, M., Pischke, F., Wendsche, J. et al. Managing the work stress of inpatient nurses during the COVID-19 pandemic: a systematic review of organizational interventions. BMC Nurs 23, 691 (2024). https://doi.org/10.1186/s12912-024-02358-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12912-024-02358-1

Keywords

BMC Nursing

ISSN: 1472-6955

Contact us