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Associations among infection prevention professionals' mental/physical health, lifestyle behaviors, shift length, race, and workplace wellness support during COVID-19

      Highlights

      • Infection prevention professionals (IPs) struggled during the COVID-19 pandemic.
      • Rates of depression, anxiety, and burnout were 21.5%, 29.8%, and 65%.
      • A total of ≤ 34% met guidelines for sleep, physical activity, and fruit and/or vegetable consumption.
      • IPs with organizational wellness support reported less negative COVID-19 impacts.
      • Workplaces must fix system issues and invest in workforce wellness.

      Abstract

      Background

      COVID-19 added stress to infection prevention professionals’ (IPs) work-life that may have impacted their well-being. This study aimed to describe IPs’ mental and physical health and lifestyle behaviors during the pandemic and their associations with IP role, perceived worksite wellness support, shift length, and race and/or ethnicity.

      Methods

      A random sample of Association for Professionals in Infection Control and Epidemiology members (6,000) were emailed a survey assessing mental and physical well-being, lifestyle behaviors, and perceived worksite wellness support.

      Results

      A total of 926 IPs responded (15% response rate). Few met guidelines for sleep (34.1%), physical activity (18.8%), and fruit and vegetable consumption (7.3%). Rates of depression, anxiety, and burnout were 21.5%, 29.8%, and 65%. Front line and practicing IPs and IP administrators and directors had more negative mental health impacts than IPs in other roles. IPs with organizational wellness support were less likely to report negative COVID-19 impacts. IPs working 9-11+ hours/day were more likely to report worsening physical and mental health due to COVID-19. There were no significant differences in odds of negative COVID-19 impacts on lifestyle behaviors between white and racial and ethnically diverse IPs.

      Conclusions

      IPs who worked shorter shifts and had more organizational wellness support had better well-being outcomes. Organizations must fix system issues that result in poor health and invest in workforce wellness.

      Key Words

      Infection prevention professionals (IPs) reduce and eliminate hospital associated infections (HAIs) through evidence-based infection control programming within health care systems. IPs come from diverse professional backgrounds (eg, epidemiologists, nurses, doctors, public health professionals, microbiologists), and have played a critical role in preventing the spread of SARS-CoV-2 (COVID-19) in acute and outpatient settings. During the COVID-19 pandemic, IPs have had to manage rapidly changing prevention guidance, shortages in personal protection equipment, and increases in HAIs and workload,
      • Rebmann T
      • Alvino RT
      • Mazzara RL
      • Sandcork J.
      Infection preventionists' experiences during the first nine months of the COVID-19 pandemic: Findings from focus groups conducted with Association of Professionals in Infection Control & Epidemiology (APIC) members.
      which have added substantial stress to their job.
      Chronic stress impacts health care professionals’ mental health (eg, anxiety, stress, depression, and burnout) and physical well-being.
      • Melnyk BM
      • Tan A
      • Hsieh AP
      • et al.
      Critical care nurses' physical and mental health, worksite wellness support, and medical errors.
      Engaging in healthy lifestyle behaviors, such as obtaining ≥7 hours of sleep per night, exercising ≥150 minutes per week, and eating ≥5 servings of fruits and vegetables per day are known to support improvements in mental and physical health.
      • Noordsy DL
      Lifestyle Psychiatry.
      However, health care professionals often do not meet these guidelines.
      • Melnyk BM
      • Hsieh AP
      • Tan A
      • et al.
      The state of mental health and health lifestyle behaviors in nursing, medicine, and health sciences faculty and students at Big 10 Universities with implications for action.
      Deficits in clinician well-being can proliferate employee turnover
      • Kelly LA
      • Gee PM
      • Butler RJ.
      Impact of nurse burnout on organizational and position turnover.
      and negatively influence high-value care.
      • Melnyk BM
      • Tan A
      • Hsieh AP
      • et al.
      Critical care nurses' physical and mental health, worksite wellness support, and medical errors.
      Clinicians that perceive their workplace as being supportive of well-being tend to have better mental and physical health outcomes than clinicians that do not feel the same level of support.
      • Melnyk BM
      • Tan A
      • Hsieh AP
      • et al.
      Critical care nurses' physical and mental health, worksite wellness support, and medical errors.
      ,
      • Melnyk BM
      • Hsieh AP
      • Tan A
      • et al.
      The state of mental health and health lifestyle behaviors in nursing, medicine, and health sciences faculty and students at Big 10 Universities with implications for action.
      The impact of workplace wellness support has been studied in nurses and physicians, but a paucity in the research remains for IPs. As the Association for Professionals in Infection Control and Epidemiology (APIC) advances the role for IPs in the 21st century,
      • Crist K
      • Murphy D
      • Wright MO
      • Wallace E
      • Manning ML
      The role of the infection preventionist in a transformed health care system: meeting health care needs in the 21st century.
      it is important to understand the current state of IPs’ health and well-being so that targeted interventions can be implemented to ensure safe high-value care.
      Therefore, the aims of the current study were threefold: (1) describe the health (mental & physical) and healthy lifestyle behaviors of IPs; (2) compare the healthy lifestyle behaviors and health of IPs in various roles; and (3) examine the associations among healthy lifestyle behaviors, mental and physical health, IP role, perceived support of worksite wellness, work shift length, and race and ethnicity.

      Methods

      Design, sample, and recruitment

      This study used a cross-sectional, descriptive correlational design. Exempt status was granted by the first author's Institutional Board Review (IRB). Data were collected between July and August 2021.
      The study population was IP members of APIC. The association emailed study information and the survey link to a random selection of 6,000 members (out of 16,000 members). The email stated that participation was voluntary, anonymous, and that there was no obligation to complete the survey.

      Measures

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

      Healthy Lifestyle Behaviors

      Questions were guided by the Centers for Disease Control and Prevention's (CDC) healthy behavior guidelines

      How you can prevent chronic diseases. Centers for disease control and prevention. Available at: https://www.cdc.gov/chronicdisease/about/prevent/index.htm. Published April 28, 2021. Accessed November 31, 2021.

      and inquired about hours of sleep obtained/night, minutes of physical activity obtained and/or week, number of fruits and vegetables eaten and/or day, and extent of tobacco and alcohol use.
      COVID-19 Impact on Healthy Behaviors. After each healthy lifestyle behavior question, participants were asked if COVID-19 impacted their healthy lifestyle behaviors in a positive or negative way.

      Patient Health Questionnaire-2 (PHQ-2)

      The PHQ-2 was used to measure depressive symptoms as it is valid, reliable, and widely utilized.
      • Kroenke K
      • Spitzer RL
      • Williams JB
      • Löwe B.
      The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review.
      The 2 itemed instrument inquires about the frequency of depressive symptoms experienced over the past 2 weeks. Participants respond to the items using a 4 point Likert-type scale, 0 (not at all) to 3 (nearly every day). The Cronbach's α for this sample was 0.83.

      Generalized Anxiety Disorder-2 (GAD-2)

      The GAD-2 was used to measure anxiety as it is valid and reliable.
      • Kroenke K
      • Spitzer RL
      • Williams JB
      • Monahan PO
      • Löwe B.
      Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection.
      The 2 itemed instrument inquires about the frequency of anxiety symptoms experienced over the past 2 weeks. Participants respond to the items using a 4 point Likert-type scale, 0 (not at all) to 3 (nearly every day). The Cronbach's α for this sample was 0.83.
      Perceived Stress Scale-4 (PSS-4). The PSS-4 was used to measure stress perception as it is valid and reliable.
      • Andreou E
      • Alexopoulos EC
      • Lionis C
      • et al.
      Perceived stress scale: reliability and validity study in Greece.
      ,
      • Cohen S
      • Kamarck T
      • Mermelstein R.
      A global measure of perceived stress.
      The 4 item instrument assess the respondent's extent of perceived stress by inquiring about their ability to control important things in their life, confidence about handling personal problems, perception of things going their way, and inability to overcome current difficulties over the past month. Participants responded to the items using a 5 point Likert-scale, 0 (never) to 4 (very often), and higher scores indicate higher perceived stress. The Cronbach's α for this sample was 0.78.

      Professional Quality of Life (ProQOL)

      The ProQOL was used to assess IP's professional quality of life.
      • Stamm BH.
      The concise ProQOL manual.
      Four questions from the ProQOL Scale were used: “I feel worn out because of my work;” “I feel trapped by my job;” “I am not as engaged with my patients today as I used to be;” and “I believe I can make a difference through my work.” Participants responded to the questions using a 5 point Likert scale from 1 (never) to 5 (very often). The Cronbach's α for this sample was 0.79.

      Burnout.

      A non-proprietary 1 item measure that has been reported as a viable replacement for the proprietary single-item Maslach Burnout Inventory (MBI) was used to assess burnout in the current sample.
      • Dolan ED
      • Mohr D
      • Lempa M
      • et al.
      Using a single item to measure burnout in primary care staff: a psychometric evaluation.
      The non-proprietary measure asks, “Overall, based on your definition of burnout, how would you rate your level of burnout?” Participants use a 5 category ordinal scale to score responses: 1 = no symptoms; 2 = occasional stress, but don't feel burned out; 3 = definitely burning out and am experiencing physical or emotion exhaustion; 4 = symptoms of burnout won't go away; and 5 = I feel completely burned out and often wonder if I can go on.

      Self-Reported Mental and Physical Health and COVID-19

      Self-reported mental health was obtained by asking “On a scale of 0-10, how would you rate your current mental health? [0 being very unhealthy to 10 being extremely healthy]” Self-reported physical health was obtained in a similar matter with the same scale. Following the scaled mental and/or physical health questions, participants were asked “Has your mental/physical health been impacted by COVID-19?” Available responses were, “No,” “Yes, I am physically/mentally healthier as a result of COVID-19,” and “Yes, I am not as physically/mentally healthy as a result of COVID-19.”

      Shift Length

      Clinician mental health can be impacted by the number of hours worked,
      • Dyrbye LN
      • West CP
      • Johnson PO
      • et al.
      Burnout and satisfaction with work-life integration among nurses.
      thus, respondents in this study were asked to select their typical shift length. Options were less than 8 hours, 8-10 hours, 11-12 hours, and 12+ hours.

      Workplace Wellness Support

      Workplace wellness support was assessed by asking “How supportive is your work environment of personal wellness?” Participants responded to this question using a 5 point Likert scale, 0 (not at all) – 4 (very much).

      Statistical analysis

      Descriptive statistics were used to summarize sample characteristics, IPs’ healthy lifestyle behaviors, mental and physical health, and the changes impacted by COVID-19. Multiple logistic regression models were used to examine the associations between each healthy lifestyle behavior, and health measure and IPs’ primary role in infection prevention and control, perceived support of worksite wellness, work shift length, and race and ethinicity, adjusting for other sample characteristics. Each healthy lifestyle behavior and health measure was analyzed separately in the multiple logistic regression and dichotomized as better or worse categories. Better categories included sufficient sleep (7+ hours per night), adequate physical activities (150+ minutes of moderate physical activities per week), healthy eating (5+ servings of fruits/veggies per day), not current smoker, no/light alcohol use (≤3 times per week), better physical health (self-rated physical health score of 6-10), better mental health (self-rated mental health score of 6-10), no symptoms of depression (PHQ-2 score of ≤2), no symptoms of anxiety (GAD-2 score of ≤2), no and/or little stress (PSS-4 score of ≤4), high ProQOL (ProQOL-4 score of ≥12), and no burnout.
      Multiple logistic regression modeling was also used to examine the association between odds of having a negative impact from COVID-19 on each healthy lifestyle behaviors and health measure and IPs’ primary role in infection prevention and control, perceived support of worksite wellness, work shift length, and race and ethnicity, adjusting for other sample characteristics. Each negative impact indicator was analyzed separately in the multiple logistic regression model and was dichotomized as having a negative impact (yes vs no). The “yes” category included (1) negative impact on sleep by either slept more or less, (2) less physical activities, (3) eating less healthy, (4) more smoking, (5) more alcohol drinking, (7) worse physical health, and (8) worse mental health.
      In the multiple logistic regression models, IPs’ primary role was categorized as front line and practicing IP, IP administrator and director, and other; the perceived workplace wellness support was categorized as not at all or a little, somewhat, and moderately or very much. For work shift length, the comparisons were conducted across ≤8 hours, 9-10 hours, and ≥11 hours, and the comparisons for race were mainly focused on white versus non-white. Some of other covariates were also re-categorized for model fitting, including age (<35, 35-44, 45-54, 55-64, and 65+), degree (bachelor's or lower, master's or higher, and other), and primary health care setting (acute care or not). All the analyses were conducted in R 4.0.5.

      Results

      Sample characteristics

      The survey received 926 completed responses (15% response rate). Most respondents were female (93.5%), non-Hispanic white (86.8%), married or in a relationship (82.5%), and had a bachelor's (41.2%) or master's (42.3%) degree. A majority (77.1%) of the IPs were between 35 and 64 years old, and most (58.2%) worked 9-10 hours per day. About two thirds (68.1%) of the IPs worked in acute care settings (Table 1).
      Table 1Infection prevention professionals’ demographics, healthy lifestyle behaviors, and self-reported mental/physical health (N = 926)
      CharacteristicsN (%)
      The percentages are based on non-missing values.
      Demographics
      Age
       <251 (0.1)
       25-34124 (13.6)
       35-44201 (22.0)
       45-54212 (23.2)
       55-64292 (31.9)
       65+84 (9.2)
      Gender
       Male60 (6.5)
       Female860 (93.5)
      Race/Ethnicity
       Non-Hispanic White797 (86.8)
       Non-Hispanic Black28 (3.1)
       American Indian/Alaskan Native11 (1.2)
       Asian/Pacific Islander26 (2.8)
       Hispanic28 (3.1)
       Multiracial/Other28 (3.1)
      Marital/Relationship Status
       Never married, divorced, or widowed161 (17.5)
       Married or in a relationship760 (82.5)
      Degree
       Associate's110 (11.9)
       Bachelor's381 (41.2)
       Master's391 (42.3)
       Doctorate18 (1.9)
       Other24 (2.6)
      Hours of workday/Shift
       <815 (1.6)
       8223 (24.1)
       9-10538 (58.2)
       11-12115 (12.4)
       12+33 (3.6)
      Primary Health Care Setting
       Acute care627 (68.1)
       Ambulatory surgical centers49 (5.3)
       Outpatient clinics37 (4.0)
       Long term (acute) care107 (11.6)
       Other101 (11.0)
      Healthy Behaviors
      Hours of sleep per night
       <7610 (65.9)
       7+315 (34.1)
      Minutes of moderate physical activity per week
       <150751 (81.2)
       150+174 (18.8)
      Servings of fruits/vegies per day
       <5857 (92.7)
       5+67 (7.3)
      Current Smoker
       Yes73 (7.9)
       No852 (92.1)
      Alcohol Use
       Never128 (13.9)
       ≤3 times/week640 (69.3)
       4+ times/week156 (16.9)
      COVID Impact on Healthy Behaviors
      Sleep
       Not negatively impacted213 (23.0)
       Negatively impacted712 (77.0)
        Less than usual661 (71.5)
        More than usual51 (5.5)
      Physical activity
       No change308 (33.3)
       Less than usual597 (64.5)
       More than usual20 (2.2)
      Eating
       No change276 (29.8)
       Less healthy565 (61.1)
       More healthy84 (9.1)
      Increased smoking since COVID
       No855 (93.6)
       Yes58 (6.4)
      Increased alcohol use during COVID
       No577 (62.6)
       Yes345 (37.4)
      Physical/Mental health
      Physical health
       0-5286 (31.1)
       6-10635 (68.9)
      Mental health
       0-5313 (34.0)
       6-10608 (66.0)
      PHQ-2
       ≤2723 (78.5)
       ≥3198 (21.5)
      GAD-2
       ≤2647 (70.2)
       ≥3274 (29.8)
      PSS-4
       0-4279 (30.4)
       5-16640 (69.6)
      ProQOL-4
       0-11760 (83.1)
       12-16155 (16.9)
      Burnout
       No320 (34.8)
       Yes600 (65.2)
      COVID impact on physical health
       No change326 (35.2)
       Better44 (4.8)
       Worse555 (60.0)
      COVID impact on mental health
       No change219 (23.7)
       Better21 (2.3)
       Worse683 (74.0)
      low asterisk The percentages are based on non-missing values.

      Healthy lifestyle behaviors and related changes during COVID-19 pandemic

      A small proportion of the IPs met the CDC recommended guidelines for sleep, physical activity, and fruit and vegetable consumption. About one third (34.1%) slept ≥7 hour per night. Only 18.8% participated in ≥150 minutes of moderate physical activities per week and 7.3% consumed ≥5 servings of fruits and vegetables per day. Most IPs were not current smokers (92.1%); 128 (13.9%) never drank; 640 (69.3%) were light drinkers (≤3 times/week); and 156 (16.9%) drank ≥4 times and/or week (Table 1).
      Table 1 also shows the impact of the COVID-19 pandemic on IPs’ healthy lifestyle behaviors. Most (77.0%) reported that the pandemic negatively affected their sleep, either through sleeping less (71.5%) or through sleeping more (5.5%). More than half reported less physical activity (64.5%) and less healthy eating (61.1%) during the pandemic. The pandemic had some impact on smoking with 58 (6.4%) reporting increased smoking. Additionally, 37.4% reported increased alcohol intake due to the pandemic.

      Mental/Physical health and the related changes during the COVID-19 pandemic

      About two thirds of the IPs self-scored themselves as having good physical (68.9%) and mental (66.0%) health. Twenty-one percent of IPs screened positive for depression (PHQ-2 ≥ 3) and 29.8% screened positive for anxiety (GAD-2 ≥ 3). Only a small proportion of IPs (16.9%) reported high ProQOL. The majority of IPs indicated that COVID-19 had adversely impacted their mental and physical health, with 74.0% reporting worse mental health and 60.0% reporting worse physical health (Table 1).

      Associations of IPs’ primary role in infection prevention and control with healthy lifestyle behaviors and the related changes during COVID-19 pandemic

      The proportions were similar between front line and practicing IPs and IP administrators/directors in ≥7 hours of sleep per night, 150+ minutes moderate physical activity per week, 5 or more servings of fruits and vegies per day, no smoking, and no or light alcohol use; while IPs working in other roles had larger proportions in ≥7 of sleep per night, 150+ minutes moderate physical activity per week, and no smoking, but smaller proportions in 5 or more servings of fruits and vegies per day, and no or light alcohol use. Larger proportions of IP administrators and directors and smaller proportions of IPs in other roles were negatively impacted by COVID-19 pandemic compared to front line and practicing IPs. IP administrators and directors had similar odds with front line and practicing IPs in all health lifestyle behaviors and related changes, while other IPs had a higher odds (OR = 2.68, 95% CI: 1.24 – 5.66; Table 2) in 150+ minutes moderate physical activity per week compared to front line and practicing IPs after adjusting for age, gender, race and ethnicity, marital status, education, hours of workday or shift, health care settings, and perceived support of wellness in the multiple logistic regression models.
      Table 2The relationship of infection prevention professionals’ primary role with their healthy lifestyle behaviors, mental/physical health and the changes during COVID-19 pandemic
      Professionals’ primary role in infection prevention and control
      N (%)Adjusted odds ratio (95% CI)
      Odds ratios (OR) and 95% confidence intervals (CI) were derived from logistic regression models.
      Front line/

      Practicing IP

      (N = 649)
      IP administrator/

      Director

      (N = 228)
      Other

      (N = 45)
      IP administrator/director vs Front line/Practicing IPOther vs Front line/Practicing IP
      Good Healthy Lifestyle Behavior
       7+ hours sleep per night218 (33.6)75 (32.9)21 (46.7)1.20 (0.85-1.70)1.70 (0.82-3.53)
       150+ mins moderate physical activity per week111 (17.1)46 (20.2)17 (37.8)1.30 (0.86-1.93)2.68 (1.24-5.66)
       5+ servings of fruits/vegies per day48 (7.4)18 (7.9)1 (2.2)1.02 (0.55-1.82)0.19 (0.01-1.00)
       No smoking601 (92.6)206 (90.4)43 (95.6)0.76 (0.44-1.36)1.48 (0.39-9.67)
       No/light alcohol use547 (84.4)184 (80.7)34 (75.6)0.81 (0.54-1.24)0.75 (0.34-1.83)
      Negative Impact of COVID on Healthy Lifestyle Behavior
       Less/more sleep499 (76.9)183 (80.3)27 (60.0)0.97 (0.65-1.46)0.59 (0.28-1.26)
       Less physical activities411 (63.3)160 (70.2)24 (53.3)1.08 (0.76-1.54)0.62 (0.30-1.28)
       Less healthy eating390 (60.1)148 (64.9)24 (53.3)1.14 (0.81-1.60)1.05 (0.52-2.16)
       Increased smoking38 (5.9)18 (8.0)2 (4.7)1.34 (0.71-2.45)0.91 (0.14-3.52)
       Increased alcohol use234 (36.1)97 (42.9)14 (31.1)1.28 (0.92-1.77)0.75 (0.33-1.60)
      Good Health
       Good physical health434 (67.2)165 (72.7)34 (75.6)1.45 (1.02-2.09)1.39 (0.63-3.31)
       Good mental health423 (65.4)146 (64.6)36 (80.0)0.97 (0.69-1.38)1.80 (0.78-4.55)
       No depression508 (78.5)174 (76.7)39 (88.6)0.96 (0.66-1.42)2.42 (0.89-8.54)
       No anxiety447 (69.2)162 (71.4)36 (80.0)1.10 (0.77-1.59)1.34 (0.59-3.38)
       No/little stress196 (30.3)63 (27.8)19 (43.2)0.97 (0.67-1.39)1.49 (0.70-3.10)
       High professional QOL105 (16.3)35 (15.8)14 (31.8)1.26 (0.77-2.02)2.70 (1.11-6.35)
       No burnout230 (35.5)66 (29.2)24 (53.3)0.85 (0.59-1.23)1.87 (0.88-3.99)
      Negative Impact of COVID on Health
       Worsen physical health390 (60.1)136 (59.6)27 (60.0)0.80 (0.58-1.12)0.98 (0.48-2.02)
       Worsen mental health480 (74.1)174 (76.3)27 (61.4)0.98 (0.67-1.45)0.59 (0.28-1.29)
      NOTE. Dependent variable – each behavior/health measure; Primary independent variable of interest – professionals’ primary role in infection prevention and control; Covariates – age, gender, race/ethnicity, marital status, degree, hours of work day/shift, primary health care setting, and perceived support of wellness.
      low asterisk Odds ratios (OR) and 95% confidence intervals (CI) were derived from logistic regression models.

      Associations of IPs’ primary role in infection prevention and control with health and the related changes during COVID-19 pandemic

      IPs working in other roles had larger proportions of good health regarding all health measures compared to front line and practicing IPs and IP administrators and directors, while front line and practicing IPs and IP administrators and directors had similar proportions. About 60% of the IPs across different roles reported worsening physical health due to COVID-19, but larger proportions of front line and practicing IPs (74.1%) and IP administrators and directors (76.3%) were negatively impacted in mental health than other roles (61.4%). IP administrators and directors were more likely to have good physical health (OR = 1.45, 95% CI: 1.02-2.09) and IPs in other roles were more likely to have high professional QOL (OR = 2.70, 95% CI: 1.11-6.35) compared to front line and practicing IPs after adjusting for age, gender, race and ethnicity, marital status, education, hours of workday or shift, health care settings, and perceived support of wellness in the multiple logistic regression models. There were no significant differences in the odds of IP administrators and directors and other IPs to have negative changes during the pandemic compared to front line and practicing IPs.

      Associations of workplace wellness support with healthy lifestyle behaviors and the related changes during COVID-19 pandemic

      The proportion of IPs who had ≥7 hours of sleep per night increased with higher perceived workplace wellness support (28.3%, 30.4%, and 40.2%, respectively, for not at all and/or a little, somewhat, and very much and/or moderately; Table 3). Similar trends for other healthy lifestyle behaviors also were observed, including weekly physical activities and no smoking. Compared to those whose workplaces provided a little or no support, IPs whose workplaces supported wellness very much or moderately had 67% higher odds for obtaining 7 hours of sleep per night (OR = 1.67, 95% CI: 1.17-2.40) after adjusting for age, gender, race and ethnicity, marital status, education, hours of workday or shift, health care settings, and primary roles in infection prevention and control in the multiple logistic regression models. IPs with very much or moderate support were less likely to report a negative impact of COVID-19 pandemic on their healthy lifestyle behaviors compared to those with a little or no support. Those with very much or moderate support had a 35% lower odds (OR = 0.65, 95% CI: 0.43 – 0.97) of being impacted in sleep and a 43% lower odds (OR = 0.57, 95% CI: 0.40-0.81) of being impacted in physical activities compared to those with no or a little support.
      Table 3The relationship of perceived support of worksite wellness with infection prevention professionals’ healthy lifestyle behaviors, mental/physical health and the changes during COVID-19 pandemic
      Perceived support of wellness at the place of employment
      N (%)Adjusted odds ratio (95% CI)
      Odds ratios (OR) and 95% confidence intervals (CI) were derived from logistic regression models.
      Not at all/A little

      (N = 247)
      Somewhat

      (N = 273)
      Very much/

      Moderately

      (N = 403)
      Somewhat vs Not at all/A littleVery much/Moderately vs Not at all/A little
      Good Healthy Lifestyle Behavior
       7+ hours sleep per night70 (28.3)83 (30.4)162 (40.2)1.02 (0.68-1.52)1.67 (1.17-2.40)
       150+ mins moderate physical activity per week42 (17.0)49 (17.9)83 (20.6)1.07 (0.66-1.72)1.27 (0.83-1.97)
       5+ servings of fruits/vegies per day21 (8.5)12 (4.4)34 (8.4)0.56 (0.26-1.18)1.02 (0.57-1.88)
       No smoking219 (88.7)254 (93.0)377 (93.5)1.79 (0.94-3.48)1.63 (0.91-2.93)
       No/light alcohol use198 (80.2)230 (84.2)338 (84.1)1.32 (0.83-2.11)1.40 (0.91-2.15)
      Negative Impact of COVID on Healthy Lifestyle Behavior
       Less/more sleep197 (79.8)221 (81.0)292 (72.5)1.01 (0.63-1.60)0.65 (0.43-0.97)
       Less physical activities174 (70.4)192 (70.3)229 (56.8)1.00 (0.67-1.49)0.57 (0.40-0.81)
       Less healthy eating160 (64.8)170 (62.3)233 (57.8)0.85 (0.58-1.23)0.76 (0.54-1.07)
       Increased smoking23 (9.4)16 (5.9)19 (4.8)0.60 (0.29-1.19)0.53 (0.27-1.03)
       Increased alcohol use100 (40.5)100 (36.6)145 (36.2)0.85 (0.59-1.24)0.85 (0.60-1.19)
      Good Health
       Good physical health151 (61.1)180 (65.9)303 (75.9)1.16 (0.80-1.70)1.94 (1.35-2.79)
       Good mental health133 (53.8)182 (66.9)291 (72.8)1.81 (1.24-2.65)2.36 (1.65-3.37)
       No depression172 (69.9)212 (77.9)338 (84.3)1.51 (1.00-2.28)2.20 (1.48-3.28)
       No anxiety137 (55.5)188 (69.4)321 (80.0)1.86 (1.28-2.72)3.20 (2.22-4.63)
       No/little stress44 (18.0)66 (24.4)168 (41.8)1.44 (0.93-2.25)3.21 (2.18-4.81)
       High professional QOL13 (5.3)22 (8.1)119 (30.0)1.77 (0.84-3.86)9.00 (4.91-18.02)
       No burnout50 (20.3)76 (28.1)194 (48.1)1.77 (1.14-2.77)4.09 (2.76-6.16)
      Negative Impact of COVID on Health
       Worsen physical health166 (67.2)173 (63.4)214 (53.1)0.86 (0.59-1.26)0.57 (0.40-0.80)
       Worsen mental health194 (78.9)221 (81.2)267 (66.3)1.10 (0.70-1.75)0.51 (0.34-0.75)
      NOTE. Dependent variable – each behavior/health measure; Primary independent variable of interest – perceived support of wellness at the place of employment; Covariates – age, gender, race/ethnicity, marital status, degree, hours of work day/shift, primary health care setting, and primary role in infection prevention and control.
      low asterisk Odds ratios (OR) and 95% confidence intervals (CI) were derived from logistic regression models.

      Associations of workplace wellness support with health and the related changes during COVID-19 pandemic

      The proportions of IPs reporting good health in all health measures increased as the wellness support level increased. The significant relationship between greater perceived support of wellness and better health held after adjusting for IPs’ age, gender, race and ethnicity, marital status, education, hours of workday or shift, health care settings, and primary roles in infection prevention and control. IPs whose workplaces provided somewhat support were more likely to have good mental health (OR = 1.81, 95% CI: 1.24-2.65), no depression (OR = 1.51, 95% CI: 1.00-2.28), no anxiety (OR = 1.86, 95% CI: 1.28-2.72), and no burnout (OR = 1.77, 95% CI: 1.14-2.77) compared to those with no or a little support. IPs whose workplaces supported wellness very much or moderately had significantly higher odds in all health indicators compared to those with no or a little support, and the odds ratios ranged from 1.94 for physical health to 9.00 for high professional QOL. IPs with very much or moderate wellness support were less likely to report negative impacts of COVID-19, and they had 43% lower odds (OR = 0.57, 95% CI: 0.40-0.80) of having worse physical health and 49% lower odds (OR = 0.51, 95% CI: 0.34-0.75) of having worse mental health when compared to those with no or a little support.

      Associations of shift length with healthy lifestyle behaviors and the related changes during COVID-19 pandemic

      The proportion of IPs who had seven or more hours of sleep per night decreased with longer workday or shift (49.2%, 31.0% 20.9%, respectively, for ≤8, 9-10, 11+ hours per day; Table 4). Similar trends for other good healthy lifestyle behaviors also were observed, including 150+ minutes moderate physical activity per week and no smoking. The significant relationship between longer shift length and lower likelihood of having ≥7 hours sleep per day held after adjusting for IPs’ age, gender, race and ethnicity, marital status, education, primary health care setting, primary role in infection prevention and control, and perceived support of wellness in the multiple logistic regression models. Compared to IPs with workday or shift of ≤8 hours per day, those who worked 9-10 hours or 11+hours per day were less likely to sleep 7 or more hours per night (OR = 0.45, 95% CI: 0.32-0.62; OR = 0.25, 95% CI: 0.15-0.43). Table 4 also shows that higher percentages of IPs who worked longer hours per day reported a negative impact of COVID-19 pandemic on their healthy lifestyle behaviors than those who worked ≤8 hours per day. The significant relationships between longer shift length and higher likelihood of negative impact of COVID-19 pandemic on sleep (OR: 2.66-4.23), physical activities (OR: 2.12-4.30), and eating (OR: 2.10-2.76) held after adjusting for nurses’ age, gender, race and ethnicity, marital status, education, primary health care setting, primary role in infection prevention and control, and perceived support of wellness in the multiple logistic regression models.
      Table 4The relationship of infection prevention professionals’ work shifts with their healthy lifestyle behaviors, mental/physical health and the changes during COVID-19 pandemic
      Hours of work day/shift
      N (%)Adjusted odds ratio (95% CI)
      Odds ratios (OR) and 95% confidence intervals (CI) were derived from logistic regression models.
      ≤8 hours

      (N = 238)
      9-10 hours

      (N = 538)
      ≥11 hours

      (N = 148)
      9-10 hours vs ≤8 hours≥11 hours vs ≤8 hours
      Good Healthy Lifestyle Behavior
       7+ hours sleep per night117 (49.2)167 (31.0)31 (20.9)0.45 (0.32-0.62)0.26 (0.15-0.43)
       150+ mins moderate physical activity per week53 (22.3)96 (17.8)25 (16.9)0.81 (0.55-1.22)0.82 (0.46-1.43)
       5+ servings of fruits/vegies per day19 (8.0)36 (6.7)12 (8.1)0.70 (0.38-1.32)0.89 (0.39-1.98)
       No smoking222 (93.3)494 (91.8)135 (91.2)0.88 (0.46-1.61)0.88 (0.39-2.00)
       No/light alcohol use198 (83.2)440 (81.9)129 (87.2)0.85 (0.55-1.29)1.32 (0.71-2.50)
      Negative Impact of COVID on Healthy Lifestyle Behavior
       Less/more sleep146 (61.3)435 (80.9)130 (87.8)2.66 (1.85-3.81)4.23 (2.39-7.82)
       Less physical activities114 (47.9)360 (66.9)122 (82.4)2.12 (1.52-2.95)4.30 (2.59-7.34)
       Less healthy eating111 (46.6)348 (64.7)105 (70.9)2.10 (1.52-2.92)2.76 (1.73-4.44)
       Increased smoking12 (5.1)36 (6.7)10 (7.0)1.29 (0.66-2.70)1.21 (0.47-3.01)
       Increased alcohol use86 (36.1)201 (37.5)58 (39.5)1.09 (0.78-1.52)1.25 (0.79-1.97)
      Good Health
       Good physical health178 (75.1)365 (68.2)92 (62.2)0.66 (0.46-0.96)0.47 (0.29-0.76)
       Good mental health168 (70.9)349 (65.2)90 (60.8)0.74 (0.52-1.06)0.58 (0.36-0.94)
       No depression192 (81.4)422 (78.7)108 (73.0)0.89 (0.59-1.34)0.65 (0.38-1.10)
       No anxiety173 (73.6)381 (70.9)92 (62.2)0.83 (0.57-1.20)0.60 (0.36-0.97)
       No/little stress81 (34.3)167 (31.2)30 (20.4)0.87 (0.61-1.23)0.56 (0.33-0.93)
       High professional QOL60 (25.4)81 (15.3)13 (8.8)0.49 (0.32-0.75)0.31 (0.15-0.62)
       No burnout117 (49.4)171 (32.0)32 (21.6)0.45 (0.32-0.64)0.31 (0.18-0.51)
      Negative Impact of COVID on Health
       Worsen physical health111 (46.6)334 (62.1)109 (73.6)2.02 (1.46-2.80)3.34 (2.08-5.44)
       Worsen mental health156 (65.8)407 (75.8)120 (81.1)1.67 (1.16-2.40)2.21 (1.30-3.83)
      NOTE. Dependent variable – each behavior/health measure; Primary independent variable of interest – hours of work day/shift; Covariates – age, gender, race/ethnicity, marital status, degree, primary health care setting, primary role in infection prevention and control, and perceived support of wellness.
      low asterisk Odds ratios (OR) and 95% confidence intervals (CI) were derived from logistic regression models.

      Associations of shift length with health and the related changes during COVID-19 pandemic

      The proportion of IPs with good health regarding all health indicators decreased with longer workdays or shifts. The significant relationship between longer workday or shift length and worse health held after adjusting for IPs’ age, gender, race and ethnicity, marital status, education, primary health care setting, primary role in infection prevention and control, and perceived support of wellness in the multiple logistic regression models. Compared to IPs that worked ≤8 hours per day, those who worked 9-10 hours per day were less likely to have good physical health (OR = 0.66, 95% CI: 0.46-0.96), high ProQOL (OR = 0.49, 95% CI: 0.32-0.75), and no burnout (OR = 0.45, 95% CI: 0.32-0.64); and those who worked 11+ hours per day were less likely to have good physical health (OR = 0.47, 95% CI: 0.29-0.76), good mental health (OR = 0.58, 95% CI: 0.36-0.94), no anxiety (OR = 0.60, 95% CI: 0.36-0.97), no and/or little stress (OR = 0.56, 95% CI: 0.33-0.93), higher ProQOL (OR = 0.31, 95% CI: 0.15-0.62), and no burnout (OR = 0.31, 95% CI: 0.18-0.51). IPs who worked 9-10 hours or 11+ hours per day were more likely to report worsening physical health (OR = 2.02, 95% CI: 1.46-2.80; OR = 3.34, 95% CI: 2.08-5.44) and worsening mental health (OR = 1.67, 95% CI: 1.16-2.40; OR = 2.21, 95% CI: 1.30-3.83) due to the pandemic.

      Associations of Race/Ethnicity with healthy lifestyle behaviors and the related changes during COVID-19 pandemic

      In terms of healthy lifestyle behaviors, white IPs reported obtaining ≥7 hour of sleep per night, 150+ minutes of moderate physical activity per week, and ≥5 servings of fruits and vegetables per day more frequently than racial and ethnic diversity IPs. However, racial and ethnic diversity IPs reported no smoking and no or light alcohol use more frequently than white IPs. After adjusting for IPs’ age, gender, marital status, education, hours of workday or shift, primary health care setting, primary role in infection prevention and control, and perceived support of wellness in the multiple logistic regression models, racial and ethnic diversity IPs had 85% higher odds (OR = 1.85, 95% CI: 1.05-3.51; Table 5) of no or light alcohol use compared to white IPs. There were no significant differences in the odds of negative impact of COVID-19 on healthy lifestyle behaviors between white IPs and IPs from racially and ethnically diverse backgrounds.
      Table 5The relationship of infection prevention professionals’ race/ethnicity with their healthy lifestyle behaviors, mental/physical health and the changes during COVID-19 pandemic
      Race
      N (%)Adjusted odds ratio (95% CI)
      Odds ratios (OR) and 95% confidence intervals (CI) were derived from logistic regression models.
      White

      (N = 797)
      Minorities

      (N = 121)
      Minorities vs White
      Good Healthy Lifestyle Behavior
       7+ hours sleep per night281 (35.3)32 (26.4)0.60 (0.37-0.93)
       150+ mins moderate physical activity per week157 (19.7)16 (13.2)0.61 (0.34-1.06)
       5+ servings of fruits/vegies per day64 (8.0)3 (2.5)0.26 (0.06-0.73)
       No smoking731 (91.7)114 (94.2)1.59 (0.73-3.98)
       No/light alcohol use655 (82.3)107 (88.4)1.85 (1.05-3.51)
      Negative Impact of COVID on Healthy Lifestyle Behavior
       Less/more sleep616 (77.3)90 (74.4)0.88 (0.55-1.43)
       Less physical activities509 (63.9)82 (67.8)1.27 (0.83-1.99)
       Less healthy eating493 (61.9)68 (56.2)0.87 (0.58-1.31)
       Increased smoking53 (6.7)5 (4.1)0.50 (0.17-1.21)
       Increased alcohol use305 (38.4)39 (32.2)0.67 (0.43-1.02)
      Good Health
       Good physical health542 (68.2)88 (73.3)1.28 (0.82-2.04)
       Good mental health517 (65.1)88 (72.7)1.58 (1.01-2.52)
       No depression617 (77.7)100 (82.6)1.44 (0.87-2.48)
       No anxiety555 (69.9)90 (74.4)1.40 (0.89-2.25)
       No/little stress238 (30.1)40 (33.1)1.23 (0.79-1.89)
       High professional QOL131 (16.6)23 (19.2)1.23 (0.69-2.12)
       No burnout279 (35.2)40 (33.1)0.87 (0.55-1.36)
      Negative Impact of COVID on Health
       Worsen physical health490 (61.5)60 (49.6)0.59 (0.39-0.88)
       Worsen mental health596 (75.0)83 (68.6)0.63 (0.41-1.00)
      NOTE. Dependent variable – each behavior/health measure; Primary independent variable of interest – race; Covariates – age, gender, marital status, degree, hours of work day/shift, primary health care setting, primary role in infection prevention and control, and perceived support of wellness.
      low asterisk Odds ratios (OR) and 95% confidence intervals (CI) were derived from logistic regression models.

      Associations of Race/Ethnicity with health and the related changes during COVID-19 pandemic

      Racial and ethnic diversity IPs had larger proportions in having good physical health, good mental health, no depression, no anxiety, no/little stress, and high professional QOL than white IPs. The significant relationship between race and ethnicity and good mental health held after adjusting for other demographical variables. Racial and ethnic diversity IPs were more likely to have good mental health (OR = 1.58, 95% CI: 1.01–2.52) and less likely to be impacted by COVID-19 on physical health (OR = 0.59, 95% CI: 0.39-0.88) than white IPs.

      Discussion

      This study's findings indicate that IPs in other roles and with increased workplace wellness support and shorter workday or shift lengths had better well-being outcomes during the pandemic than front line and practicing IPs, IP administrators and directors, and those with less workplace wellness support and longer shift lengths. Overall, only a small proportion of IPs (16.8%) reported high professional QOL and 65.2% had symptoms of burnout. Three fourths reported worsening mental health and three fifths reported worsening physical health due to stressors related to the COVID-19 pandemic. Such trends have been observed across the general population as well. According to an American Psychological Association survey, psychologists have reported substantial treatment demand increases for anxiety, depression, trauma disorders, and sleep disturbances in 2021 when compared to 2020.

      Worsening mental health crisis pressures psychologist workforce. American Psychological Association. Available at: https://www.apa.org/pubs/reports/practitioner/covid-19-2021. Published October 19, 2021. Accessed March 31, 2022.

      Only 34.1% of IPs in the current study slept ≥7 hours per night, 18.8% participated in ≥150 minutes of moderate physical activities per week, and 7.3% consumed ≥5 servings of fruits and vegetables per day. These findings signal that IPs are facing a well-being crisis similar to their practicing clinician counterparts.

      Kirzinger A, Kearney A, Hamel L, Brodie M. KFF/The Washington Post frontline health care workers: The Washing Post/KFF survey project. Available at: https://www.kff.org/report-section/kff-the-washington-post-frontline-health-care-workers-survey-toll-of-the-pandemic/. Published 2021. Accessed January 7, 2022.

      ,
      • Melnyk BM
      • Hsieh AP
      • Tan A
      • et al.
      Associations among nurses' Mental/Physical health, lifestyle behaviors, shift length, and workplace wellness support during COVID-19: Important Implications for Health Care Systems.
      A prior qualitative study with IPs identified workplace culture, organizational leadership, and management as contributors to staff burnout and low morale during COVID-19.
      • Yau B
      • Vijh R
      • Prairie J
      • McKee G
      • Schwandt M.
      Lived experiences of frontline workers and leaders during COVID-19 outbreaks in long-term care: a qualitative study.
      The current study found that as workplace culture in the form of workplace wellness support increased, IPs reporting good health also increased, thus substantiating the importance of workplace wellness culture on mitigating the negative impacts of COVID-19 stressors on the well-being of IPs.
      Nationally, there is a 25% vacancy rate for IPs and 40% of the current IP workforce is expected to retire over the next 10 years.
      • Gilmartin H
      • Reese SM
      • Smathers S.
      Recruitment and hiring practices in United States infection prevention and control departments: Results of a national survey.
      ,
      • Landers T
      • Davis J
      • Crist K
      • Malik C
      APIC MegaSurvey: methodology and overview.
      Retainment and recruitment of highly skilled IPs is therefore of utmost importance to infection prevention leadership. Considering that poor clinician well-being increases turnover,
      • Kelly LA
      • Gee PM
      • Butler RJ.
      Impact of nurse burnout on organizational and position turnover.
      APIC must continue to endorse the importance of investing in worksite wellness cultures that promote well-being through “empowerment, risk-taking, engagement, resilience, transparency, and respect”.
      • Crist K
      • Murphy D
      • Wright MO
      • Wallace E
      • Manning ML
      The role of the infection preventionist in a transformed health care system: meeting health care needs in the 21st century.
      (pp 354) Doing so requires a strategic approach with organizational and individual level interventions. These include fixing system issues that are known to cause burnout and poor health (eg, short staffing, problems with the electronic medical record), hiring Chief Wellness Officers to focus on improving their organization's culture and work environment, implementing targeted interventions to promote resilience and self-care, performing anonymous mental health screening and referrals to treatment, and instituting shorter shift lengths.
      • Melnyk BM
      • Hsieh AP
      • Tan A
      • et al.
      Associations among nurses' Mental/Physical health, lifestyle behaviors, shift length, and workplace wellness support during COVID-19: Important Implications for Health Care Systems.
      ,
      National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine
      Committee on systems approaches to improve patient care by supporting clinician well-being.
      ,

      The Ohio State University College of Nursing, Helen fuld health trust national institute for evidence-based practice in nursing and health care, Health Policy Institute of Ohio. A call to action: Improving clinician wellbeing and patient care and safety. Published February 2020. Available at: https://www.healthpolicyohio.org/a-call-to-action

      Providing manualized cognitive-behavioral skills building programs to clinicians, like MINDBODYSTRONG, have been shown to decrease depression, anxiety, and stress and improve job satisfaction.
      • Sampson M
      • Melnyk BM
      • Hoying J.
      The MINDBODYSTRONG intervention for new nurse residents: 6-month effects on mental health outcomes, healthy lifestyle behaviors, and job satisfaction.
      ,
      • Sampson M
      • Melnyk BM
      • Hoying J.
      Intervention effects of the MINDBODYSTRONG cognitive behavioral skills building program on newly licensed registered nurses' mental health, healthy lifestyle behaviors, and job satisfaction.
      Anonymous mental health screening programs, like HEAR (Healer Education Assessment and Referral), have also been successful in identify clinicians with depression, anxiety, and suicidal ideation and connecting them with treatment options.
      • Davidson JE
      • Proudfoot J
      • Lee K
      • Terterian G
      • Zisook S.
      A Longitudinal analysis of nurse suicide in the United States (2005-2016) with recommendations for action.
      ,
      • Davidson JE
      • Accardi R
      • Sanchez C
      • Zisook S
      • Hoffman LA.
      Sustainability and outcomes of a suicide prevention program for nurses.
      This study did have some limitations. For example, while the correlation between workplace wellness support, shift length, and improved IP health outcomes is critical, the relationships were correlative and not causative. Because this study was cross sectional in nature, it is unclear whether the negative impact that COVID-19 had on mental and physical health will stable out over time. However, the relationship between protective factors (like workplace wellness support) and positive outcomes appears to remain consistent; highlighting the importance of providing protective factor interventions on a large scale.
      • Melnyk BM
      • Tan A
      • Hsieh AP
      • et al.
      Critical care nurses' physical and mental health, worksite wellness support, and medical errors.
      ,
      • Melnyk BM
      • Hsieh AP
      • Tan A
      • et al.
      The state of mental health and health lifestyle behaviors in nursing, medicine, and health sciences faculty and students at Big 10 Universities with implications for action.
      ,
      • Menculini G
      • Albert U
      • Bianchini V
      • et al.
      Did we learn something positive out of the COVID-19 pandemic? Post-traumatic growth and mental health in the general population.
      Lastly, some of the survey questions utilized self-scoring, which lacks objectivity.

      Conclusions

      IPs have played a critical role in preventing the spread of COVID-19 in acute and outpatient settings, but the resulting increases in stress have negatively impacted their mental and physical well-being. However, IPs with shorter shift lengths and more workplace wellness support had better well-being outcomes during the pandemic than those working longer shift lengths and having no workplace wellness support. APIC must continue to promote and provide guidance on instituting and sustaining work cultures that promote IPs well-being and fixing system issues known to cause burnout and other mental health problems as there is a growing body of evidence that poor mental and physical health in clinicians adversely impacts the quality and safety of health care.

      References

        • Rebmann T
        • Alvino RT
        • Mazzara RL
        • Sandcork J.
        Infection preventionists' experiences during the first nine months of the COVID-19 pandemic: Findings from focus groups conducted with Association of Professionals in Infection Control & Epidemiology (APIC) members.
        Am J Infect Control. 2021; 49: 1093-1098
        • Melnyk BM
        • Tan A
        • Hsieh AP
        • et al.
        Critical care nurses' physical and mental health, worksite wellness support, and medical errors.
        Am J Crit Care. 2021; 30: 176-184
        • Noordsy DL
        Lifestyle Psychiatry.
        American Psychiatric Publishing, Washington, DC2019
        • Melnyk BM
        • Hsieh AP
        • Tan A
        • et al.
        The state of mental health and health lifestyle behaviors in nursing, medicine, and health sciences faculty and students at Big 10 Universities with implications for action.
        J Pro Nursing. 2021; 37: 1167-1174
        • Kelly LA
        • Gee PM
        • Butler RJ.
        Impact of nurse burnout on organizational and position turnover.
        Nurs Outlook. 2021; 69: 96-102
        • Crist K
        • Murphy D
        • Wright MO
        • Wallace E
        • Manning ML
        The role of the infection preventionist in a transformed health care system: meeting health care needs in the 21st century.
        Am J Infect Control. 2019; 47: 352-357
      1. How you can prevent chronic diseases. Centers for disease control and prevention. Available at: https://www.cdc.gov/chronicdisease/about/prevent/index.htm. Published April 28, 2021. Accessed November 31, 2021.

        • Kroenke K
        • Spitzer RL
        • Williams JB
        • Löwe B.
        The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review.
        Gen Hosp Psychiatry. 2010; 32: 345-359
        • Kroenke K
        • Spitzer RL
        • Williams JB
        • Monahan PO
        • Löwe B.
        Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection.
        Ann Intern Med. 2007; 146: 317-325
        • Andreou E
        • Alexopoulos EC
        • Lionis C
        • et al.
        Perceived stress scale: reliability and validity study in Greece.
        Int J Environ Res Public Health. 2011; 8: 3287-3298
        • Cohen S
        • Kamarck T
        • Mermelstein R.
        A global measure of perceived stress.
        J Health Soc Behav. 1983; 24: 385-396
        • Stamm BH.
        The concise ProQOL manual.
        2nd Edition. Professional Quality of Life Measure, Published 2010 (Available at:)
        • Dolan ED
        • Mohr D
        • Lempa M
        • et al.
        Using a single item to measure burnout in primary care staff: a psychometric evaluation.
        J Gen Intern Med. 2015; 30: 582-587
        • Dyrbye LN
        • West CP
        • Johnson PO
        • et al.
        Burnout and satisfaction with work-life integration among nurses.
        J Occup Environ Med. 2019; 61: 689-698
      2. Worsening mental health crisis pressures psychologist workforce. American Psychological Association. Available at: https://www.apa.org/pubs/reports/practitioner/covid-19-2021. Published October 19, 2021. Accessed March 31, 2022.

      3. Kirzinger A, Kearney A, Hamel L, Brodie M. KFF/The Washington Post frontline health care workers: The Washing Post/KFF survey project. Available at: https://www.kff.org/report-section/kff-the-washington-post-frontline-health-care-workers-survey-toll-of-the-pandemic/. Published 2021. Accessed January 7, 2022.

        • Melnyk BM
        • Hsieh AP
        • Tan A
        • et al.
        Associations among nurses' Mental/Physical health, lifestyle behaviors, shift length, and workplace wellness support during COVID-19: Important Implications for Health Care Systems.
        Nurs Adm Q. 2022; 46: 5-18
        • Yau B
        • Vijh R
        • Prairie J
        • McKee G
        • Schwandt M.
        Lived experiences of frontline workers and leaders during COVID-19 outbreaks in long-term care: a qualitative study.
        Am J Infect Control. 2021; 49: 978-984
        • Gilmartin H
        • Reese SM
        • Smathers S.
        Recruitment and hiring practices in United States infection prevention and control departments: Results of a national survey.
        Am J Infect Control. 2021; 49: 70-74
        • Landers T
        • Davis J
        • Crist K
        • Malik C
        APIC MegaSurvey: methodology and overview.
        Am J Infect Control. 2017; 45: 584-588
        • National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine
        Committee on systems approaches to improve patient care by supporting clinician well-being.
        Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington (DC). National Academies Press (US), October 23, 2019
      4. The Ohio State University College of Nursing, Helen fuld health trust national institute for evidence-based practice in nursing and health care, Health Policy Institute of Ohio. A call to action: Improving clinician wellbeing and patient care and safety. Published February 2020. Available at: https://www.healthpolicyohio.org/a-call-to-action

        • Sampson M
        • Melnyk BM
        • Hoying J.
        The MINDBODYSTRONG intervention for new nurse residents: 6-month effects on mental health outcomes, healthy lifestyle behaviors, and job satisfaction.
        Worldviews Evid Based Nurs. 2020; 17: 16-23
        • Sampson M
        • Melnyk BM
        • Hoying J.
        Intervention effects of the MINDBODYSTRONG cognitive behavioral skills building program on newly licensed registered nurses' mental health, healthy lifestyle behaviors, and job satisfaction.
        J Nurs Adm. 2019; 49: 487-495
        • Davidson JE
        • Proudfoot J
        • Lee K
        • Terterian G
        • Zisook S.
        A Longitudinal analysis of nurse suicide in the United States (2005-2016) with recommendations for action.
        Worldviews Evid Based Nurs. 2020; 17: 6-15
        • Davidson JE
        • Accardi R
        • Sanchez C
        • Zisook S
        • Hoffman LA.
        Sustainability and outcomes of a suicide prevention program for nurses.
        Worldviews Evid Based Nurs. 2020; 17: 24-31
        • Menculini G
        • Albert U
        • Bianchini V
        • et al.
        Did we learn something positive out of the COVID-19 pandemic? Post-traumatic growth and mental health in the general population.
        Eur Psychiatry. 2022; 64 (Published 2022 Jan 10): e79