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• Research article
• Open access
• Published: 14 June 2021

Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice

• Jannine van Schothorst–van Roekel 1 ,
• Anne Marie J.W.M. Weggelaar-Jansen 1 ,
• Carina C.G.J.M. Hilders 1 ,
• Antoinette A. De Bont 1 &
• Iris Wallenburg 1  

BMC Nursing volume  20 , Article number:  97 ( 2021 ) Cite this article

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Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice.

A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis.

Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses’ invisible work; (2) nurses’ roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses’ (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients’ needs to organizational capacity.

Conclusions

Conducting small-change experiments, anchored by action and appraisal rather than by design , clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a ‘two-way-window’ in nursing role development, aligning policy initiatives with daily nursing practices.

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The aging population and mounting social and healthcare needs are challenging both healthcare delivery and the financial sustainability of healthcare systems [ 1 , 2 ]. Nurses play an important role in facing these contemporary challenges [ 3 , 4 ]. However, nursing shortages increase the workload which, in turn, boosts resignation numbers of nurses [ 5 , 6 ]. Research shows that nurses resign because they feel undervalued and have insufficient control over their professional practice and organization [ 7 , 8 ]. This issue has sparked renewed interest in nursing role development [ 9 , 10 , 11 ]. A role can be defined by the activities assumed by one person, based on knowledge, modulated by professional norms, a legislative framework, the scope of practice and a social system [ 12 , 9 ].

New nursing roles usually arise through task specialization [ 13 , 14 ] and the development of advanced nursing roles [ 15 , 16 ]. Increasing attention is drawn to role distinction within nursing teams by differentiating the staff and skill mix to meet the challenges of nursing shortages, quality of care and low job satisfaction [ 17 , 18 ]. The staff and skill mix include the roles of enrolled nurses, registered nurses, and nurse assistants [ 19 , 20 ]. Studies on differentiation in staff and skill mix reveal that several countries struggle with the composition of nursing teams [ 21 , 22 , 23 ].

Role distinctions between licensed vocational-trained nurses (VNs) and Bachelor of Science-trained nurses (BNs) has been heavily debated since the introduction of the higher nurse education in the early 1970s, not only in the Netherlands [ 24 , 25 ] but also in Australia [ 26 , 27 ], Singapore [ 20 ] and the United States of America [ 28 , 29 ]. Current debates have focused on the difficulty of designing distinct nursing roles. For example, Gardner et al., revealed that registered nursing roles are not well defined and that job profiles focus on direct patient care [ 30 ]. Even when distinct nursing roles are described, there are no proper guidelines on how these roles should be differentiated and integrated into daily practice. Although the value of differentiating nursing roles has been recognized, it is still not clear how this should be done or how new nursing roles should be embedded in daily nursing practice. Furthermore, the consequences of these roles on nursing work has been insufficiently investigated [ 31 ].

This study reports on a study of nursing teams developing new roles in daily nursing hospital practice. In 2010, the Dutch Ministry of Health announced a law amendment (the Individual Health Care Professions Act) to formalize the distinction between VNs and BNs. The law amendment made a distinction in responsibilities regarding complexity of care, coordination of care, and quality improvement. Professional roles are usually developed top-down at policy level, through competency frameworks and job profiles that are subsequently implemented in nursing practice. In the Dutch case, a national expert committee made two distinct job profiles [ 32 ]. Instead of prescribing role implementation, however, healthcare organizations were granted the opportunity to develop these new nursing roles in practice, aiming for a more practice-based approach to reforming the nursing workforce. This study investigates a Dutch teaching hospital that used an experimental development process in which the nurses developed role distinctions by ‘doing and appraising’. This iterative process evolved in small changes [ 33 , 34 , 35 , 36 ], based on nurses’ thorough knowledge of professional practices [ 37 ] and leadership role [ 38 , 39 , 40 ].

According to Abbott, the constitution of a new role is a competitive action, as it always leads to negotiation of new openings for one profession and/or degradation of adjacent professions [ 41 ]. Additionally, role differentiation requires negotiation between different professionals, which always takes place in the background of historical professionalization processes and vested interests resulting in power-related issues [ 42 , 43 , 44 ]. Recent studies have described the differentiation of nursing roles to other professionals, such as nurse practitioners and nurse assistants, but have focused on evaluating shifts in nursing tasks and roles [ 31 ]. Limited research has been conducted on differentiating between the different roles of registered nurses and the involvement of nurses themselves in developing new nursing roles. An ethnographic study was conducted to shed light on the nurses’ work of seeking openings and negotiating roles and responsibilities and the consequences of role distinctions, against a background of historically shaped relationships and patterns.

The study aimed to understand the formulation of nursing role distinctions between different educational levels in a development process involving experimental action (doing) and appraisal.

We conducted an ethnographic case study. This design was commonly used in nursing studies in researching changing professional practices [ 45 , 46 ]. The researchers gained detailed insights into the nurses’ actions and into the finetuning of their new roles in daily practice, including the meanings, beliefs and values nurses give to their roles [ 47 , 48 ]. This study complied with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Setting and participants

Our study took place in a purposefully selected Dutch teaching hospital (481 beds, 2,600 employees including 800 nurses). Historically, nurses in Dutch hospitals have vocational training. The introduction of higher nursing education in 1972 prompted debates about distinguishing between vocational-trained nurses (VNs) and bachelor-trained nurses (BNs). For a long time, VNs resisted a role distinction, arguing that their work experience rendered them equally capable to take care of patients and deal with complex needs. As a result, VNs and BNs carry out the same duties and bear equal responsibility. To experiment with role distinctions in daily practice, the hospital management and project team selected a convenience but representative sample of wards. Two general (neurology and surgery) and two specific care (oncology and pneumatology) wards were selected as they represent the different compositions of nursing educational levels (VN, BN and additional specialized training). The demographic profile for the nursing teams is shown in Table  1 . The project team, comprising nursing policy staff, coaches and HR staff ( N  = 7), supported the four (nursing) teams of the wards in their experimental development process (131 nurses; 32 % BNs and 68 % VNs, including seven senior nurses with an organizational role). We also studied the interactions between nurses and team managers ( N  = 4), and the CEO ( N  = 1) in the meetings.

Data collection

Data was collected between July 2017 and January 2019. A broad selection of respondents was made based on the different roles they performed. Respondents were personally approached by the first author, after close consultation with the team managers. Four qualitative research methods were used iteratively combining collection and analysis, as is common in ethnographic studies [ 45 ] (see Table  2 ).

Shadowing nurses (i.e. observations and questioning nurses about their work) on shift (65 h in total) was conducted to observe behavior in detail in the nurses’ organizational and social setting [ 49 , 50 ], both in existing practices and in the messy fragmented process of developing distinct nursing roles. The notes taken during shadowing were worked up in thick descriptions [ 46 ].

Observation and participation in four types of meetings. The first and second authors attended: (1) kick-off meetings for the nursing teams ( n  = 2); (2) bi-monthly meetings ( n  = 10) between BNs and the project team to share experiences and reflect on the challenges, successes and failures; and (3) project group meetings at which the nursing role developmental processes was discussed ( n  = 20). Additionally, the first author observed nurses in ward meetings discussing the nursing role distinctions in daily practice ( n  = 15). Minutes and detailed notes also produced thick descriptions [ 51 ]. This fieldwork provided a clear understanding of the experimental development process and how the respondents made sense of the challenges/problems, the chosen solutions and the changes to their work routines and organizational structures. During the fieldwork, informal conversations took place with nurses, nursing managers, project group members and the CEO (app. 15 h), which enabled us to reflect on the daily experiences and thus gain in-depth insights into practices and their meanings. The notes taken during the conversations were also written up in the thick description reports, shortly after, to ensure data validity [ 52 ]. These were completed with organizational documents, such as policy documents, activity plans, communication bulletins, formal minutes and in-house presentations.

Semi-structured interviews lasting 60–90 min were held by the first author with 22 respondents: the CEO ( n  = 1), middle managers ( n  = 4), VNs ( n  = 6), BNs ( n  = 9, including four senior nurses), paramedics ( n  = 2) using a predefined topic list based on the shadowing, observations and informal conversations findings. In the interviews, questions were asked about task distinctions, different stakeholder roles (i.e., nurses, managers, project group), experimental approach, and added value of the different roles and how they influence other roles. General open questions were asked, including: “How do you distinguish between tasks in daily practice?”. As the conversation proceeded, the researcher asked more specific questions about what role differentiation meant to the respondent and their opinions and feelings. For example: “what does differentiation mean for you as a professional?”, and “what does it mean for you daily work?”, and “what does role distinction mean for collaboration in your team?” The interviews were tape-recorded (with permission), transcribed verbatim and anonymized.

The fieldwork period ended with four focus groups held by the first author on each of the four nursing wards ( N  = 19 nurses in total: nine BNs, eight VNs, and two senior nurses). The groups discussed the findings, such as (nurses’ perceptions on) the emergence of role distinctions, the consequences of these role distinctions for nursing, experimenting as a strategy, the elements of a supportive environment and leadership. Questions were discussed like: “which distinctions are made between VN and BN roles?”, and “what does it mean for VNs, BNs and senior nurses?”. During these meetings, statements were also used to provoke opinions and discussion, e.g., “The role of the manager in developing distinct nursing roles is…”. With permission, all focus groups were audio recorded and the recordings were transcribed verbatim. The focus groups also served for member-checking and enriched data collection, together with the reflection meetings, in which the researchers reflected with the leader and a member of the project group members on program, progress, roles of actors and project outcomes. Finally, the researchers shared a report of the findings with all participants to check the credibility of the analysis.

Data analysis

Data collection and inductive thematic analysis took place iteratively [ 45 , 53 ]. The first author coded the data (i.e. observation reports, interview and focus group transcripts), basing the codes on the research question and theoretical notions on nursing role development and distinctions. In the next step, the research team discussed the codes until consensus was reached. Next, the first author did the thematic coding, based on actions and interactions in the nursing teams, the organizational consequences of their experimental development process, and relevant opinions that steered the development of nurse role distinctions (see Additional file ). Iteratively, the research team developed preliminary findings, which were fed back to the respondents to validate our analysis and deepen our insights [ 54 ]. After the analysis of the additional data gained in these validating discussions, codes were organized and re-organized until we had a coherent view.

Ethnography acknowledges the influence of the researcher, whose own (expert) knowledge, beliefs and values form part of the research process [ 48 ]. The first author was involved in the teams and meetings as an observer-as-participant, to gain in-depth insight, but remained research-oriented [ 55 ]. The focus was on the study of nursing actions, routines and accounts, asking questions to obtain insights into underlying assumptions, which the whole research group discussed to prevent ‘going native’ [ 56 , 57 ]. Rigor was further ensured by triangulating the various data resources (i.e. participants and research methods), purposefully gathered over time to secure consistency of findings and until saturation on a specific topic was reached [ 54 ]. The meetings in which the researchers shared the preliminary findings enabled nurses to make explicit their understanding of what works and why, how they perceived the nursing role distinctions and their views on experimental development processes.

Ethical considerations

All participants received verbal and written information, ensuring that they understood the study goals and role of the researcher [ 48 ]. Participants were informed about their voluntary participation and their right to end their contribution to the study. All gave informed consent. The study was performed in accordance with the Declaration of Helsinki and was approved by the Erasmus Medical Ethical Assessment Committee in Rotterdam (MEC-2019-0215), which also assessed the compliance with GDPR.

Our findings reveal how nurses gradually shaped new nursing role distinctions in an experimental process of action and appraisal and how the new BN nursing roles became embedded in new nursing routines, organizational routines and structures. Three empirical appeared from the systematic coding: (1) distinction based on complexity of care; (2) organizing hospital care; and (3) evidence-based practices (EBP) in quality improvement work.

Distinction based on complexity of care

Initially, nurses distinguished the VN and BN roles based on the complexity of patient care, as stated in national job profiles [ 32 ]. BNs were supposed to take care of clinically complex patients, rather than VNs, although both VNs and BNs had been equally taking care of every patient category. To distinguish between highly and less complex patient care, nurses developed a complexity measurement tool. This tool enabled classification of the predictability of care, patient’s degree of self-reliance, care intensity, technical nursing procedures and involvement of other disciplines. However, in practice, BNs questioned the validity of assessing a patient’s care complexity, because the assessments of different nurses often led to different outcomes. Furthermore, allocating complex patient care to BNs impacted negatively on the nurses’ job satisfaction, organizational routines and ultimately the quality of care. VNs experienced the shift of complex patient care to BNs as a diminution of their professional expertise. They continuously stressed their competencies and questioned the assigned levels of complexity, aiming to prevent losses to their professional tasks:

‘Now we’re only allowed to take care of COPD patients and people with pneumonia, so no more young boys with a pneumothorax drain. Suddenly we are not allowed to do that. (…) So, your [professional] world is getting smaller. We don’t like that at all. So, we said: We used to be competent, so why aren’t we anymore?’ (Interview VN1, in-service trained nurse).

In discussing complexity of care, both VNs and BNs (re)discovered the competencies VNs possess in providing complex daily care. BNs acknowledged the contestability of the distinction between VN and BN roles related to patient care complexity, as the next quote shows:

‘Complexity, they always make such a fuss about it. (…) At a given moment you’re an expert in just one certain area; try then to stand out on your ward. (…) When I go to GE [gastroenterology] I think how complex care is in here! (…) But it’s also the other way around, when I’m the expert and know what to expect after an angioplasty, or a bypass, or a laparoscopic cholecystectomy (…) When I’ve mastered it, then I no longer think it’s complex, because I know what to expect!’ (Interview BN1, 19-07-2017).

This quote illustrates how complexity was shaped through clinical experience. What complex care is , is influenced by the years of doing nursing work and hence is individual and remains invisible. It is not formally valued [ 58 ] because it is not included in the BN-VN competency model. This caused dissatisfaction and feelings of demotion among VNs. The distinction in complexities of care was also problematic for BNs. Following the complexity tool, recently graduated BNs were supposed to look after highly complex patients. However, they often felt insecure and needed the support of more experienced (VN) colleagues – which the VNs perceived as a recognition of their added value and evidence of the failure of the complexity tool to guide division of tasks. Also, mundane issues like holidays, sickness or pregnancy leave further complicated the use of the complexity tool as a way of allocating patients, as it decreased flexibility in taking over and swapping shifts, causing dissatisfaction with the work schedule and leading to problems in the continuity of care during evening, night and weekend shifts. Hence, the complexity tool disturbed the flexibility in organizing the ward and held possible consequences for the quality and safety of care (e.g. inexperienced BNs providing complex care), Ultimately, the complexity tool upset traditional teamwork, in which nurses more implicitly complemented each other’s competencies and ability to ‘get the work done’ [ 59 ]. As a result, role distinction based on ‘quantifiable’ complexity of care was abolished. Attention shifted to the development of an organizational and quality-enhancing role, seeking to highlight the added value of BNs – which we will elaborate on in the next section.

Organizing hospital care

Nurses increasingly fulfill a coordinating role in healthcare, making connections across occupational, departmental and organizational boundaries, and ‘mediating’ individual patient needs, which Allen describes as organizing work [ 49 ]. Attempting to make a valuable distinction between nursing roles, BNs adopted coordinating management tasks at the ward level, taking over this task from senior nurses and team managers. BNs sought to connect the coordinating management tasks with their clinical role and expertise. An example is bed management, which involves comparing a ward’s bed capacity with nursing staff capacity [ 1 , 60 ]. At first, BNs accompanied middle managers to the hospital bed review meeting to discuss and assess patient transfers. On the wards where this coordination task used to be assigned to senior nurses, the process of transferring this task to BNs was complicated. Senior nurses were reluctant to hand over coordinating tasks as this might undermine their position in the near future. Initially, BNs were hesitant to take over this task, but found a strategy to overcome their uncertainty. This is reflected in the next excerpt from fieldnotes:

Senior nurse: ‘First we have to figure out if it will work, don’t we? I mean, all three of us [middle manager, senior nurse, BN] can’t just turn up at the bed review meeting, can we? The BN has to know what to do first, otherwise she won’t be able to coordinate properly. We can’t just do it.’ BN: ‘I think we should keep things small, just start doing it, step by step. (…) If we don’t try it out, we don’t know if it works.’ (Field notes, 24-05-2018).

This excerpt shows that nurses gradually developed new roles as a series of matching tasks. Trying out and evaluating each step of development in the process overcame the uncertainty and discomfort all parties held [ 61 ]. Moreover, carrying out the new tasks made the role distinctions become apparent. The coordinating role in bed management, for instance, became increasingly embedded in the new BN nursing role. Experimenting with coordination allowed BNs prove their added value [ 62 ] and contributed to overall hospital performance as it combined daily working routines with their ability to manage bed occupancy, patient flow, staffing issues and workload. This was not an easy task. The next quote shows the complexity of creating room for this organizing role:

The BNs decide to let the VNs help coordinate the daily care, as some VNs want to do this task. One BN explains: ‘It’s very hard to say, you’re not allowed.’ The middle manager looks surprised and says that daily coordination is a chance to draw a clear distinction and further shape the role of BNs. The project group leader replies: ‘Being a BN means that you dare to make a difference [in distinctive roles]. We’re all newbies in this field, but we can use our shared knowledge. You can derive support from this task for your new role.’ (Field notes, 09-01-2018).

This excerpt reveals the BNs’ thinking on crafting their organizational role, turning down the VNs wishes to bear equal responsibility for coordinating tasks. Taking up this role touched on nurse identity as BNs had to overcome the delicate issue of equity [ 63 ], which has long been a core element of the Dutch nursing profession. Taking over an organization role caused discomfort among BNs, but at the same time provided legitimation for a role distinction.

Legitimation for this task was also gained from external sources, as the law amendment and the expert committee’s job descriptions both mentioned coordinating tasks. However, taking over coordinating tasks and having an organizing role in hospital care was not done as an ‘implementation’; rather it required a process of actively crafting and carving out this new role. We observed BNs choosing not to disclose that they were experimenting with taking over the coordinating tasks as they anticipated a lack of support from VNs:

BN: ‘We shouldn’t tell the VNs everything. We just need this time to give shape to our new role. And we all know who [of the colleagues] won’t agree with it. In my opinion, we’d be better off hinting at it at lunchtime, for example, to figure out what colleagues think about it. And then go on as usual.’ (Field notes, 12-06-2018).

BNs stayed ‘under the radar’, not talking explicitly about their fragile new role to protect the small coordination tasks they had already gained. By deliberately keeping the evaluation of their new task to themselves, they protected the transition they had set into motion. Thus, nurses collected small changes in their daily routines, developing a new role distinction step by step. Changes to single tasks accumulated in a new role distinction between BNs, VNs and senior nurses, and gave BNs a more hybrid nursing management role.

Evidence-based practices in quality improvement work

Quality improvement appeared to be another key concern in the development of the new BN role. Quality improvement work used to be carried out by groups of senior nurses, middle managers and quality advisory staff. Not involved in daily routines, the working group focused on nursing procedures (e.g. changing infusion system and wound treatment protocols). In taking on this new role BNs tried different ways of incorporating EBP in their routines, an aspect that had long been neglected in the Netherlands. As a first step, BNs rearranged the routines of the working group. For example, a team of BNs conducted a quality improvement investigation of a patient’s formal’s complaint:

Twenty-two patients registered a pain score of seven or higher and were still discharged. The question for BNs was: how and why did this bad care happen? The BNs used electronic patient record to study data on the relations between pain, medication and treatment. Their investigation concluded: nurses do not always follow the protocols for high pain scores. Their improvement plan covered standard medication policy, clinical lessons on pain management and revisions to the patient information folder. One BN said: ‘I really loved investigating this improvement.’ (Field notes, 28-05-2018).

This fieldnote shows the joy quality improvement work can bring. During interviews, nurses said that it had given them a better grip on the outcome of nursing work. BNs felt the need to enhance their quality improvement tasks with their EBP skills, e.g. using clinical reasoning in bedside teaching, formulating and answering research questions in clinical lessons and in multi-disciplinary patient rounds to render nursing work more evidence based. The BNs blended EBP-related education into shift handovers and ward meetings, to show VNs the value of doing EBP [ 64 ]. In doing so, they integrated and fostered an EBP infrastructure of care provision, reflecting a new sense of professionalism and responsibility for quality of care.

However, learning how to blend EPB quality work in daily routines – ‘learning in practice’ –requires attention and steering. Although the BNs had a Bachelor’s degree, they had no experience of a quality-enhancing role in hospital practice [ 65 ]. In our case, the interplay between team members’ previous education and experienced shortcomings in knowledge and skills uncovered the need for further EBP training. This training established the BNs’ role as quality improvers in daily work and at the same time supported the further professionalization of both BNs and VNs. Although introducing the EBP approach was initially restricted to the BNs, it was soon realized that VNs should be involved as well, as nursing is a collaborative endeavor [ 1 ], as one team member (the trainer) put it:

‘I think that collaboration between BNs and VNs would add lots of value, because both add something different to quality work. I’d suggest that BNs could introduce the process-oriented, theoretical scope, while VNs could maybe focus on the patients’ interest.’ (Fieldnote, informal conversation, 11-06-2018).

During reflection sessions on the ward level and in the project team meetings BNs, informed by their previous experience with the complexity tool, revealed that they found it a struggle to do justice to everyone’s competencies. They wanted to use everyone’s expertise to improve the quality of patient care. They were for VNs being involved in the quality work, e.g. in preparing a clinical lesson, conducting small surveys, asking VNs to pose EBP questions and encourage VNs to write down their thoughts on flip over charts as means of engaging all team members.

These findings show that applying EPB in quality improvement is a relational practice driven by mutual recognition of one another’s competencies. This relational practice blended the BNs’ theoretical competence in EBP [ 66 ] with the VNs’ practical approach to the improvement work they did together. As a result, the blend enhanced the quality of daily nursing work and thus improved the quality of patient care and the further professionalization of the whole nursing team.

This study aimed to understand how an experimental approach enables differently educated nurses to develop new, distinct professional roles. Our findings show that roles cannot be distinguished by complexity of care; VNs and BNs are both able to provide care to patients with complex healthcare needs based on their knowledge and experience. However, role distinctions can be made on organizing care and quality improvement. BNs have an important role organizing care, for example arranging the patient flow on and across wards at bed management meetings, while VNs contribute more to organizing at the individual patient level. BNs play a key role in starting and steering quality improvement work, especially blending EBP in with daily nursing tasks, while VNs are involved but not in the lead. Working together on quality improvement boosts nursing professionalization and team development.

Our findings also show that the role development process is greatly supported by a series of small-change experiments, based on action and appraisal. This experimental approach supported role development in three ways. First, it incorporates both formal tasks and the invisible, unconscious elements of nursing work [ 49 ]. Usually, invisible work gets no formal recognition, for example in policy documents [ 55 ], whereas it is crucial in daily routines and organizational structures [ 49 , 60 ]. Second, experimenting triggers an accumulation of small changes [ 33 , 35 ] leading to the embeddedness of role distinctions in new nursing routines, allowing nurses to influence the organization of care. This finding confirms the observations of Reay et al. that nurses can create small changes in daily activities to craft a new nursing role, based on their thorough knowledge of their own practice and that of the other involved professional groups [ 37 ]. Although these changes are accompanied by tension and uncertainty, the process of developing roles generates a certain joy. Third, experimenting stimulated nursing professionalization, enabling the nurses to translate national legislation into hospital policy and supporting the nurses’ own (bottom-up) evolution of practices. Historically, nursing professionalization is strongly influenced by gender and education level [ 43 ] resulting in a subordinate position, power inequity and lack of autonomy [ 44 ]. Giving nurses the lead in developing distinct roles enables them to ‘engage in acts of power’ and obtain more control over their work. Fourth, experimenting contributes to role definition and clarification. In line with Poitras et al. [ 12 ] we showed that identifying and differentiating daily nursing tasks led to the development of two distinct and complementary roles. We have also shown that the knowledge base of roles and tasks includes both previous and additional education, as well as nursing experience.

Our study contributes to the literature on the development of distinct nursing roles [ 9 , 10 , 11 ] by showing that delineating new roles in formal job descriptions is not enough. Evidence shows that this formal distinction led particularly to the non-recognition, non-use and degradation [ 41 ] of VN competencies and discomforted recently graduated BNs. The workplace-based experimental approach in the hospital includes negotiation between professionals, the adoption process of distinct roles and the way nurses handle formal policy boundaries stipulated by legislation, national job profiles, and hospital documents, leading to clear role distinctions. In addition to Hughes [ 42 ] and Abbott [ 67 ] who showed that the delineation of formal work boundaries does not fit the blurred professional practices or individual differences in the profession, we show how the experimental approach leads to the clarification and shape of distinct professional practices.

Thus, an important implication of our study is that the professionals concerned should be given a key role in creating change [ 37 , 39 , 40 ]. Adding to Mannix et al. [ 38 ], our study showed that BNs fulfill a leadership role, which allows them to build on their professional role and identity. Through the experiments, BNs and VNs filled the gap between what they had learned in formal education, and what they do in daily practice [ 64 , 65 ]. Experimenting integrates learning, appraising and doing much like going on ‘a journey with no fixed routes’ [ 34 , 68 ] and no fixed job description, resulting in the enlargement of their roles.

Our study suggests that role development should involve professionalization at different educational levels, highlighting and valuing specific roles rather than distinguishing higher and lower level skills and competencies. Further research is needed to investigate what experimenting can yield for nurses trained at different educational levels in the context of changing healthcare practices, and which interventions (e.g., in process planning, leadership, or ownership) are needed to keep the development of nursing roles moving ahead. Furthermore, more attention should be paid to how role distinction and role differentiation influence nurse capacity, quality of care (e.g., patient-centered care and patient satisfaction), and nurses’ job satisfaction.

Limitations

Our study was conducted on four wards of one teaching hospital in the Netherlands. This might limit the potential of generalizing our findings to other contexts. However, the ethnographic nature of our study gave us unique understanding and in-depth knowledge of nurses’ role development and distinctions, both of which have broader relevance. As always in ethnographic studies, the chances of ‘going native’ were apparent, and we tried to prevent this with ongoing reflection in the research team. Also, the interpretation of research findings within the Dutch context of nurse professionalization contributed to a more in-depth understanding of how nursing roles develop, as well as the importance of involving nurses themselves in the development of these roles to foster and support professional development.

We focused on role distinctions between VNs and BNs and paid less attention to (the collaboration with) other professionals or management. Further research is needed to investigate how nursing role development takes place in a broader professional and managerial constellation and what the consequences are on role development and healthcare delivery.

This paper described how nurses crafted and shaped new roles with an experimental process. It revealed the implications of developing a distinct VN role and the possibility to enhance the BN role in coordination tasks and in steering and supporting EBP quality improvement work. Embedding the new roles in daily practice occurred through an accumulation of small changes. Anchored by action and appraisal rather than by design , the changes fostered by experiments have led to a distinction between BNs and VNs in the Netherlands. Furthermore, experimenting with nursing role development has also fostered the professionalization of nurses, encouraging nurses to translate knowledge into practice, educating the team and stimulating collaborative quality improvement activities.

This paper addressed the enduring challenge of developing distinct nursing roles at both the vocational and Bachelor’s educational level. It shows the importance of experimental nursing role development as it provides opportunities for the professionalization of nurses at different educational levels, valuing specific roles and tasks rather than distinguishing between higher and lower levels of skills and competencies. Besides, nurses, managers and policymakers can embrace the opportunity of a ‘two-way window’ in (nursing) role development, whereby distinct roles are outlined in general at policy levels, and finetuned in daily practice in a process of small experiments to determine the best way to collaborate in diverse contexts.

Availability of data and materials

The data generated and analyzed during the current study is not publicly available to ensure data confidentiality but is available from the corresponding author on reasonable request and with the consent of the research participants.

Abbreviations

Bachelor-trained nurse

Vocational-trained nurse

Evidence-based Practices

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The authors would like to thank all participants for their contribution to this study.

The Reinier de Graaf hospital in Delft, who was central to this study provided financial support for this research.

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A.W. and I.W. developed the study design. J.S. and A.W. were responsible for data collection, enhanced by I.W. for data analysis and drafting the manuscript. C.H. and A.B. critically revised the paper. All authors have read and approved the manuscript.

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van Schothorst–van Roekel, J., Weggelaar-Jansen, A.M.J., Hilders, C.C. et al. Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice. BMC Nurs 20 , 97 (2021). https://doi.org/10.1186/s12912-021-00613-3

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Understanding and prioritizing nurses’ mental health and well-being

Healthcare organizations continue to feel the effects of the COVID-19 pandemic, including prolonged workforce shortages, rising labor costs, and increased staff burnout. 1 The World Health Organization defines burnout as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed,” with symptoms including “feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy.” For more, see “Burn-out an ‘occupational phenomenon’: International Classification of Diseases,” World Health Organization, May 28, 2019; and “Doctors not the only ones feeling burned out,” Harvard Gazette , March 31, 2023. Although nurses routinely experience job-related stress and symptoms of burnout, the COVID-19 pandemic exacerbated the challenges of this high-intensity role.

About the research collaboration between the American Nurses Foundation and McKinsey

The American Nurses Foundation is a national research, educational, and philanthropic affiliate of the American Nurses Association committed to advancing the nursing profession by serving as a thought leader, catalyst for action, convener, and funding conduit. The American Nurses Foundation and McKinsey are partnering to assess and report on trends related to the nursing profession. A foundational part of this effort is jointly publishing novel insights related to supporting nurses throughout their careers.

In April and May 2023, the American Nurses Foundation and McKinsey surveyed 7,419 nurses in the United States to better understand their experiences, needs, preferences, and career intentions. All survey questions were based on the experiences of the individual professional. All questions were also optional for survey respondents; therefore, the number of responses may vary by question. Additionally, publicly shared examples, tools, and healthcare systems referenced in this article are representative of actions that stakeholders are taking to address workforce challenges.

As part of an ongoing, collaborative research effort, the American Nurses Foundation (the Foundation) and McKinsey surveyed more than 7,000 nurses in April and May 2023 to better understand mental health and well-being in the nursing workforce (see sidebar “About the research collaboration between the American Nurses Foundation and McKinsey”). The survey results revealed that symptoms of burnout and mental-health challenges among nurses remain high; the potential long-term workforce and health implications of these persistent pressures are not yet fully understood.

In this report, we share the highlights of our most recent survey and trends over the past few years. As healthcare organizations and other stakeholders continue to evolve their approaches to these important issues, this research provides additional insight into the challenges nurses face today and highlights opportunities to ensure adequate support to sustain the profession and ensure access to care for patients.

Current state of the nursing workforce

Although many organizations have taken steps to address the challenges facing the nursing workforce, findings from the joint American Nurses Foundation and McKinsey survey from May 2023 indicate that continued action is required. Nursing turnover is beginning to decline from its 2021 high but remains above prepandemic levels. 2 2023 NSI national health care retention & RN staffing report , NSI Nursing Solutions, 2023. Intent to leave also remains high: about 20 percent of surveyed nurses indicated they had changed positions in the past six months, and about 39 percent indicated they were likely to leave their current position in the next six months. 3 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4. Intent to leave was roughly 41 percent among nurses who provide direct care to patients, compared with 30 percent for nurses not in direct-patient-care roles. 4 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4.

Surveyed nurses who indicated they were likely to leave cited not feeling valued by their organizations, insufficient staffing, and inadequate compensation as the top three factors influencing their decisions. 5 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4. Insufficient staffing was especially important to respondents with less than ten years of experience 6 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4. —a population that will be critical to retain to ensure future workforce stability.

Key survey insights on mental health and well-being

Our joint research highlighted the magnitude of the health and well-being challenges, both physical and mental, facing the nursing workforce. More than 57 percent of surveyed nurses indicated they had been diagnosed with COVID-19, and 11 percent of those indicated they had been diagnosed with post-COVID-19 conditions (PCC or “long COVID”). Additional research may be needed to fully understand the impact of PCC on nurses, but in the meantime, employers could consider augmenting their PCC services for clinicians.

Research conducted by both the Foundation and McKinsey over the past three years has identified sustained feelings of burnout among surveyed nurses—a trend that continued this year. 7 For more, see the following articles: “Mental health and wellness survey 1,” American Nurses Foundation, August 2020; “Mental health and wellness survey 2,” American Nurses Foundation, December 2020; “Mental health and wellness survey 3,” American Nurses Foundation, September 2021; Gretchen Berlin, Meredith Lapointe, Mhoire Murphy, and Molly Viscardi, “ Nursing in 2021: Retaining the healthcare workforce when we need it most ,” McKinsey, May 11, 2021; Gretchen Berlin, Meredith Lapointe, Mhoire Murphy, and Joanna Wexler, “ Assessing the lingering impact of COVID-19 on the nursing workforce ,” McKinsey, May 11, 2022; “ Nursing in 2023: How hospitals are confronting shortages ,” McKinsey, May 5, 2023. Reported contributors to burnout include insufficient staffing, high patient loads, poor and difficult leadership, and too much time spent on administrative tasks. In our joint survey, 56 percent of nurses reported experiencing symptoms of burnout, such as emotional exhaustion (Exhibit 1). Well more than half (64 percent) indicated they feel “a great deal of stress” because of their jobs. Additionally, although there have been slight improvements year over year in respondents’ reports of stress, anxiety, and feeling overwhelmed, reports of positive emotions such as feeling empowered, grateful, and confident have declined. 8 “Pulse on the Nation’s Nurses Survey Series results,” American Nurses Foundation, accessed October 20, 2023.

Our results indicate that mental health and well-being vary by nurse experience levels (Exhibit 2). Less-tenured nurse respondents were more likely to report less satisfaction with their role, had a higher likelihood of leaving their role, and were more likely to be experiencing burnout.

Despite these sustained and high levels of burnout, approximately two-thirds of surveyed nurses indicated they were not currently receiving mental-health support (a figure that remained relatively consistent in Foundation surveys over the past two years), and 56 percent of surveyed nurses believe there is stigma attached to mental-health challenges. 9 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4; “Pulse on the Nation’s Nurses,” accessed October 20, 2023.

Reasons cited by nurse respondents for not seeking professional mental-health support have remained consistent over the past two years, 10 “Mental health and wellness survey 3,” September 2021. with 29 percent indicating a lack of time, 23 percent indicating they feel they should be able to handle their own mental health, and 10 percent citing cost or a lack of financial resources (Exhibit 3). For nurses with ten or fewer years of experience, lack of time ranked as the top reason for not seeking professional mental help.

Despite slight improvements to the most severe symptoms over the past six to 12 months, reported levels of sustained burnout and well-being challenges have remained consistently high since we began assessing this population in 2021. Moreover, research indicates that burnout has several adverse, long-term health effects; for example, it is a predictor of a wide range of illnesses. 11 Denise Albieri Jodas Salvagioni et al., “Physical, psychological and occupational consequences of job burnout: A systematic review of prospective studies,” PLoS One , October 2017, Volume 12, Number 10; D. Smith Bailey, “Burnout harms workers’ physical health through many pathways,” Monitor on Psychology , June 2006, Volume 37, Number 7. These health conditions incur not only personal costs but also societal and organizational costs because they influence productivity, employee retention, presence at work, and career longevity. 12 Prioritise people: Unlock the value of a thriving workforce , Business in the Community and the McKinsey Health Institute, April 2023.

Actions stakeholders can take to address mental health and well-being

To address these sustained levels of burnout, stakeholders will need to take steps to support nurses’ mental health and well-being. They will also need to address the underlying structural issues—for example, workload and administrative burden—that affect the nursing profession and that have been consistently acknowledged as root causes of burnout. Simultaneously reducing workload demands and increasing resources available to meet those demands will be critical.

A variety of interventions could address the drivers and effects of adverse nursing mental health and well-being, bolstering support for individuals, organizations, and the healthcare system at large. Various stakeholders are deploying a number of initiatives.

Applying process and operating-model interventions

Addressing the underlying drivers of burnout could help to prevent it in the first place. Research from the McKinsey Health Institute shows that the day-to-day work environment has a substantial impact on the mental health and well-being of employees. 13 “ Addressing employee burnout: Are you solving the right problem? ,” McKinsey Health Institute, May 27, 2022. Process and operating-model shifts—in the context of ongoing broader shifts in care models—could enable organizations and care teams to evolve working practices to better support job satisfaction and sustainability.

In our most recent collaborative research, almost a quarter of surveyed nurses believed their teams were not working efficiently; more than 40 percent reported that they had poor control over their workloads and that their day-to-day work was hectic and intense. 14 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4. Evaluating and addressing structural aspects of the job that contribute to workload—for example, by identifying opportunities to delegate activities and enable nurses to use technology—could help support these themes. 15 Gretchen Berlin, Ani Bilazarian, Joyce Chang, and Stephanie Hammer, “ Reimagining the nursing workload: Finding time to close the workforce gap ,” McKinsey, May 26, 2023. However, providing these resources without also addressing the underlying structural drivers contributing to mental-health and well-being challenges is insufficient and can unintentionally appear to place the burden for solving problems on employees themselves. Both individual-level supports and collaborative efforts to drive structural change are required.

In addition to addressing workload challenges, employers could provide flexible work options—for example, in shift length, start time, shift commitments, and virtual activities 16 Erica Carbajal, “‘Resilience isn’t a pillar by itself’: CommonSpirit’s plan to support 44,000 nurses in 2023,” Becker’s Clinical Leadership, December 9, 2022. —to better enable employees to recharge from high levels of demands and to reduce conflicts with demands outside of work.

Finally, employers could take steps to reduce the administrative burden on nurses. More than a third of nursing respondents in our joint survey felt they spent excessive time working on electronic health records on breaks or after shifts, and 45 percent reported this activity adds frustration to their day. 17 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4. Employers can look for opportunities to delegate some documentation to nursing scribes, reduce documentation requirements, or use AI to aid with documentation to help reduce this burden.

Increasing availability, awareness, and accessibility of evidence-based resources

When nurses experience symptoms of burnout or other mental-health and well-being challenges, evidence-based resources need to be available. In addition, employees need to know these resources are available, and they need to feel comfortable accessing them within the organization’s cultural context.

Investments in resources for mental health and well-being span the continuum—from mental healthcare for those experiencing clinical symptoms to well-being support tools and programs to promote healthy behaviors and mitigate sources of stress. On the higher-acuity end of the continuum, providing employees with free or subsidized access to professionally provided therapy or counseling services could help reduce the barriers employees face in getting the care they need. On the lower-acuity end, providing access to resources and training on mental-health literacy, self-monitoring, and adaptability skills could help nurses identify and mitigate sources of stress.

Investments in awareness and accessibility are important to ensure available resources are used. Roughly 19 percent of surveyed nurses who indicated they had not sought mental-health support in the past 12 months cited lack of knowledge, lack of resources, fear of losing their job, or concern about colleagues finding out as reasons for not seeking support. 18 Based on data from Pulse on the Nation’s Nurses Survey Series: Mental Health and Wellness Survey 4. To reinforce their support, employers can take steps such as establishing support networks for communities and allies, providing forums to share stories of mental health, and introducing avenues for peer-to-peer support. Additionally, resources such as a behavioral-health concierge can help all employees (including nurses) navigate, find, and access care and support.

Resources available through the Foundation

The American Nurses Foundation (the Foundation) and the American Nurses Association (ANA) provide numerous free support resources, including the following:

Well-Being Initiative. The Foundation launched the Well-Being Initiative to offer resources that focus on caring for nurses as they tirelessly care for others. 1 “Well-Being Initiative,” American Nurses Foundation, accessed October 20, 2023. These free, multimodal resources are accessible to all US nurses at any time and are completely anonymous.

Stress and Burnout Prevention Pilot Program. The Foundation launched the Stress and Burnout Prevention Pilot Program with support from the United Health Foundation to address nurse burnout and manage stress, among other goals. 2 “Stress & Burnout Prevention Program,” American Nurses Foundation, accessed October 20, 2023. The program uses the “Stress First Aid” model to facilitate discussions about stress and burnout and reduce stigma for nurses in need of support. The program goes beyond identification of burnout to intervention by helping nurses speak about stress and burnout using a common language, normalizing talking about and understanding support resources for them and their peers.

Healthy Nurse, Healthy Nation (HNHN). This ANA Enterprise program is designed to improve the nation’s health, “one nurse at a time.” 3 “Healthy Nurse, Healthy Nation,” American Nurses Foundation, accessed October 20, 2023. HNHN supports nurses in six areas: physical activity, rest, nutrition, quality of life, safety, and mental health. An online platform offers nurses inspiration, friendly competition, content and resources, and connections with other nurses, employers, and organizations.

Nurse suicide prevention. Nurses are at higher risk of suicide than the general population. 4 Christopher R. Friese and Kathryn A. Lee, “Deaths by suicide among nurses: A rapid response call,” Journal of Psychosocial Nursing and Mental Health Services , August 2021, Volume 59, Number 8. The multiple stressors they face in their profession may lead to emotional turmoil, moral distress or injury, and cognitive overload. ANA offers resources to educate nurses about suicide prevention and strategies to help them support themselves and one another. 5 “Nurse suicide prevention/resilience,” American Nurses Association, accessed October 20, 2023; “Suicide among nurses: What we don’t know might hurt us,” American Nurses Association, accessed October 20, 2023.

Accessibility of resources within the organization’s cultural context is also important, given that stigmatization of beliefs, behaviors, and policies can prevent people from feeling able to seek help when they need it. Because mental-illness stigma includes self-stigma, public stigma, and structural stigma, companies can take a holistic approach to root it out, 19 Erica Coe, Jenny Cordina, Kana Enomoto, and Nikhil Seshan, “ Overcoming stigma: Three strategies toward better mental health in the workplace ,” McKinsey Quarterly , July 23, 2021. including with education, leadership role modeling, and policies addressing discriminatory behaviors. 20 Allison Nordberg and Marla J. Weston, “Stigma: A barrier in supporting nurse well-being during the pandemic,” Nurse Leader , April 2022, Volume 20, Number 2. They can also provide information about free support resources, such as those provided by the American Nurses Foundation and the American Nurses Association (see sidebar “Resources available through the Foundation”).

Bolstering skills and capabilities

Efforts to address structural issues can be advanced by investing in training opportunities to help individuals and teams proactively support their own mental health and that of their colleagues. Training areas could include workplace mental-health intervention; critical skills for leaders and managers, such as conflict resolution and bystander intervention; and resilience and adaptability training to inculcate mindsets and behaviors across the organization that ultimately support employee mental health and well-being.

Toward a healthier future for nurses

Tackling these sustained challenges for mental health and well-being will be critical for addressing near-term workforce shortages and ensuring the health and well-being of the nursing profession in the long term. In our joint survey, many surveyed nurses indicated they chose the profession because they wanted to make a difference—by helping improve patients’ lives and care for patients in their most vulnerable moments. They value their colleagues and the care and trust of their teams. However, with less than half of surveyed nurses feeling satisfied with their jobs, they clearly need more in return to sustain them in the profession. There isn’t a one-size-fits-all approach to tackling some of the sustained well-being challenges that face nurses, but now is the time to bring additional energy and commitment to tackle the multifaceted drivers of symptoms of burnout and to support the profession in improving sustainability and fulfillment for years to come.

Gretchen Berlin, RN , is a senior partner in McKinsey’s Washington, DC, office, where Faith Burns is an associate partner; Brad Herbig is an associate partner in the Philadelphia office; and Mhoire Murphy is a partner in the Boston office. Amy Hanley is a program manager at the American Nurses Foundation, and Kate Judge is the executive director of the American Nurses Foundation.

The authors wish to thank the nurses, physicians, and staff on the front lines who are caring for patients and communities. They also wish to thank Nitzy Bustamante, Stephanie Hammer, and Brooke Tobin for their contributions to this article.

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This paper is in the following e-collection/theme issue:

Published on 5.6.2024 in Vol 26 (2024)

Investigating Health and Well-Being Challenges Faced by an Aging Workforce in the Construction and Nursing Industries: Computational Linguistic Analysis of Twitter Data

Authors of this article:

Original Paper

• Weicong Li 1 , DPhil   ; 
• Liyaning Maggie Tang 2 , DPhil   ; 
• Jed Montayre 3, 4 , DPhil   ; 
• Celia B Harris 1 , DPhil   ; 
• Sancia West 5 , DPhil   ; 
• Mark Antoniou 1 , DPhil  

1 The MARCS Institute for Brain, Behaviour and Development, Western Sydney University, Penrith, Australia

2 School of Architecture and Built Environment, The University of Newcastle, Callaghan, Australia

3 Centre of Evidence-based Practice for Health Care Policy, The Hong Kong Polytechnic University, Hung Hom, China (Hong Kong)

4 School of Nursing and Midwifery, Western Sydney University, Penrith, Australia

5 Centre for Work Health and Safety, New South Wales Government, Gosford, Australia

Corresponding Author:

Mark Antoniou, DPhil

The MARCS Institute for Brain, Behaviour and Development

Western Sydney University

Locked Bag 1797

Penrith, 2751

Phone: 61 61 2 97726673

Email: [email protected]

Background: Construction and nursing are critical industries. Although both careers involve physically and mentally demanding work, the risks to workers during the COVID-19 pandemic are not well understood. Nurses (both younger and older) are more likely to experience the ill effects of burnout and stress than construction workers, likely due to accelerated work demands and increased pressure on nurses during the COVID-19 pandemic. In this study, we analyzed a large social media data set using advanced natural language processing techniques to explore indicators of the mental status of workers across both industries before and during the COVID-19 pandemic.

Objective: This social media analysis aims to fill a knowledge gap by comparing the tweets of younger and older construction workers and nurses to obtain insights into any potential risks to their mental health due to work health and safety issues.

Methods: We analyzed 1,505,638 tweets published on Twitter (subsequently rebranded as X) by younger and older (aged <45 vs >45 years) construction workers and nurses. The study period spanned 54 months, from January 2018 to June 2022, which equates to approximately 27 months before and 27 months after the World Health Organization declared COVID-19 a global pandemic on March 11, 2020. The tweets were analyzed using big data analytics and computational linguistic analyses.

Results: Text analyses revealed that nurses made greater use of hashtags and keywords (both monograms and bigrams) associated with burnout, health issues, and mental health compared to construction workers. The COVID-19 pandemic had a pronounced effect on nurses’ tweets, and this was especially noticeable in younger nurses. Tweets about health and well-being contained more first-person singular pronouns and affect words, and health-related tweets contained more affect words. Sentiment analyses revealed that, overall, nurses had a higher proportion of positive sentiment in their tweets than construction workers. However, this changed markedly during the COVID-19 pandemic. Since early 2020, sentiment switched, and negative sentiment dominated the tweets of nurses. No such crossover was observed in the tweets of construction workers.

Conclusions: The social media analysis revealed that younger nurses had language use patterns consistent with someone experiencing the ill effects of burnout and stress. Older construction workers had more negative sentiments than younger workers, who were more focused on communicating about social and recreational activities rather than work matters. More broadly, these findings demonstrate the utility of large data sets enabled by social media to understand the well-being of target populations, especially during times of rapid societal change.

Introduction

Construction and nursing are 2 critical industries for the Australian economy and worldwide. Healthy construction workers are needed to build homes, commercial stores, and public infrastructure, affecting transport, health care services, commerce, recreation, and all aspects of daily life. A healthy and functioning nursing workforce is an essential resource for public health, as recognized by the World Health Organization (WHO). In the recent 2022 Skills Priority List [ 1 ], which identified the most in-demand professions of the coming decade, both professions were listed in the top 10; specifically, construction managers claimed the top spot, whereas registered nurses secured the fourth position. Although both industries undeniably serve critical functions, there are immediately apparent differences between the 2 industries. These include the nature of the work, size of the organizations (60% of construction businesses are sole traders and 98.6% have <20 employees), and demographics of the 2 workforces (most construction workers are male, and most nurses are female) [ 2 ]. Despite these differences, the 2 industries face common challenges. They both have aging workforces, face worldwide labor shortages, involve work that is physically demanding and stressful, and need to retain and transfer older workers’ expert knowledge. Prior work suggests that workers across these 2 industries face different work-related pressures and stress (particularly during the COVID-19 pandemic), which in turn are likely to impact their job performance, health, and career decisions [ 3 ]. The goal of this paper is to empirically examine social media use in the construction and nursing industries to provide insights into the challenges workers are facing and to use big data analytics to compare issues between industries, across age groups, and within Australia versus overseas.

Research Using Text Data From Social Media Platforms

Social media platforms provide workers with channels to express their experiences and feelings [ 4 ]. Social media networks may provide insights into the state of mind and the experiences of users. Such insights are typically obtained by conducting surveys or interviews with the samples drawn from the population or populations of interest. Although social media data analytics do not replace traditional face-to-face data collection methods such as surveys or interviews, they complement such approaches and make it possible to explore issues in ways that are not possible using more traditional approaches. First, because social media platforms are digitized, large data sets can be obtained for empirical research. Therefore, trawling social media data has become one of the best ways to analyze and predict trends within industries [ 5 ]. Second, social media makes it possible to compare large data sets both across time and large geographic distances. Third, the data can be subjected to state-of-the-art computational linguistic and natural language processing techniques to understand the pressures and risks that workers face within a given industry at a particular time and whether these challenges differ for subgroups within an industry (eg, younger vs older workers). The knowledge gained from such analyses can inform the design of interventions and policies to safeguard workers from potential harm. For these reasons, social media data are being used to explore issues related to work pressure, performance, career advancement, and work health and safety.

Traditionally, the construction industry has not been closely associated with the use of social media platforms, but construction companies are increasingly using social media to improve visibility and build brand awareness [ 6 ], share safety knowledge [ 7 ], enhance daily operations [ 8 ], measure students’ attitudes [ 9 ], and gauge public opinion of projects. Although natural language processing is a growing area within the construction industry [ 10 ], only a few studies have applied computational linguistic techniques to social media data sets [ 5 , 11 ]. A recent systematic review of the literature on big data studies within construction called for research on how social media big data analytics can be used to prevent threats such as safety issues, injury, or mental illness caused by work-related stress [ 12 ]. This study directly addresses this need.

In nursing, numerous studies have examined the use of social media by nurses for a variety of purposes [ 13 ], including delivering health care to patients [ 14 , 15 ], training nursing students [ 16 ], and dissemination of communications during conferences [ 17 ]. However, the possibility of analyzing nurses’ activity on social media platforms such as Twitter (subsequently rebranded as X) to understand their experiences of workplace stress and risks to their work health and safety has received surprisingly little attention to date.

An analysis of 53,063 tweets from January 2019 to December 2020 revealed that nurses experienced more frequent and intense negative emotions (eg, decreased joy and increased sadness, fear, and disgust) than in the year preceding the COVID-19 pandemic [ 18 ]. Notably, fear preceded the COVID-19 pandemic waves by 2 weeks, suggesting that frontline workers are finely attuned to increases in work pressure even in an already high-stress work environment. This has implications for preventing fatigue, burnout, and mental health disorders related to unhealthy or unsustainable work conditions via sensitive detection of changes to well-being at the population level.

An analysis of 4.5 million tweets posted by US and UK nurses revealed that health care providers in the 2 countries experienced common challenges concerning public health (eg, policy and COVID-19–related pressures), social values (related to aspects of health), and political issues related to the COVID-19 pandemic (more positive in the United Kingdom) [ 19 ]. However, the experiences in the 2 countries reflected local sociopolitical trends and the cultural norms regarding emotional display (more accepted in the United States and more reserved in the United Kingdom). Both countries showed sharp increases in fear and sadness during the first wave of the COVID-19 pandemic and when there was an increase in the virus reproduction rates. Fear gradually reduced with time, but sadness was maintained. Anger was experienced by both groups in response to a rise in the number of COVID-19 deaths.

This raises the possibility that nurses are particularly vulnerable to poor mental health (eg, concerns, fear, and anxiety) due to the nature of their work, characterized by long working hours, burnout, loneliness, fatigue, and occupational stigma [ 20 , 21 ]. These risks are magnified when needing to manage a long-lasting emergency situation such as the COVID-19 pandemic, often with a lack of resources and under more demanding conditions [ 22 ]. While nurses have been praised for their frontline efforts in the care and treatment of patients with COVID-19, very little is known regarding how nurses have responded to the current emergency and how this is reflected in the language of their social media posts [ 23 ]. Furthermore, nurses have not been compared to workers in other industries. This study will directly address this knowledge gap.

Comparing Age Groups and Industries

Studies comparing work health and safety issues across different subgroups of workers (eg, younger vs older workers) and industries with diverse demographical profiles (eg, nursing and construction) are scarce. To our knowledge, this is the first study to compare construction and nursing industries with the goal of developing a detailed understanding of both the common and unique challenges faced by workers in these critical industries and how these challenges and risks interact with aging.

Age may be a key differentiator between workers that impacts their mental health and response to stress. In general, among health care workers [ 24 ], older adults compared to younger adults show better mental health and emotion regulation [ 25 ], including during the COVID-19 pandemic [ 26 ]. This suggests that although older workers are frequently depicted as frail and vulnerable, broader evidence from aging research suggests they could be more resilient and better able to adapt and accommodate periods of instability than younger workers. In prior work, we conducted a scoping literature review to understand the physical and mental factors that affect older construction workers’ work ability [ 2 ]. We found that the literature was dominated by studies focusing on physical health factors (eg, hearing loss, muscle pain, respiratory issues, and conditions resulting from prolonged work in and around construction sites), and although there was evidence of mental health risks and harms [ 27 ], these were less well understood, including their interaction with physically debilitating conditions (eg, diminished mental health due to work-related stress is a precursor of physical injuries and chronic pain).

In contrast to the paucity of research on the mental health of construction workers, many reviews have been published on the work health and safety of nurses, including reviews focusing specifically on older nurses [ 28 , 29 ]. However, most of these reviews focused on macrolevel issues that affect workers at the organizational level. Consequently, in a systematic review of evaluated programs and interventions intended to support the health, well-being, and retention of aging nurses, we discovered that the interventions were often mismatched to the needs of the nurses the program was trying to address [ 30 ]. For example, wellness interventions that focus on healthy eating or yoga are unlikely to address the underlying systemic workplace challenges that nurses encounter as they age at work. Furthermore, support programs and interventions for nurses need to be both sustainable at the organizational level as well as adaptable to the workers’ changing circumstances, as determined by their health and aging.

In addition, a recent survey of construction workers and nurses within New South Wales revealed that nurses were far more likely to experience the effects of stress, burnout, and workload pressures (LM Tang et al, unpublished data, September 2021). These effects were exacerbated by the COVID-19 pandemic in nurses, whereas construction workers reported being far less affected by the pandemic. Age differences were also observed.

Taken together, the findings from the abovementioned studies provide converging evidence from which a picture is beginning to emerge concerning the pressures under which workers in each industry are having to operate.

In this study, we conducted a detailed linguistic analysis of a large data set of social media posts from younger and older individuals working in the construction and nursing industries. Industry membership was determined by sourcing data from industry-based groups and Twitter hashtags and then filtering the data. Big data analytics and computational linguistics were used to examine patterns of word use relating to industry, age, location, and mental and physical health. Content and sentiment analyses allowed us to determine common issues discussed on social media across individuals working in nursing and construction industries and how they are associated with age. On the basis of the emerging picture of the work pressures within the nursing and construction industries reviewed in the earlier sections, we hypothesized that our analysis of tweets would detect greater effects of stress, burnout, and workload pressures in nurses, and these mental health effects would be exacerbated by the COVID-19 pandemic. An additional consideration was whether any observed barriers to well-being would vary across ages (ie, younger vs older workers) and locations (ie, Australia vs overseas).

Ethical Considerations

This study was conducted in full compliance with the National Statement on Ethical Conduct in Human Research and approved by the Western Sydney University Human Ethics Committee (approval number: H14518).

Twitter is a social media platform that allows users to publish short posts, called tweets, consisting of up to 280 characters about any topic, including their thoughts, daily activities, political opinions, and news. Twitter enables users to follow others without requiring confirmation, making tweets public. In total, >240 million active users access the Twitter service. Approximately 6000 tweets are posted every second, which equates to 350,000 tweets per minute, 500 million tweets per day, and a staggering 200 billion tweets per year [ 31 ]. It has become one of the most important social media platforms in the world. At the time, Twitter had a publicly available application programming interface that developers and researchers could access to download Twitter data that fit a specific combination of criteria. For this study, data collection and processing were performed as illustrated in Figure 1 . Notably, there were 2 steps: first, the data were harvested and filtered, and second, we performed data analytics, processing, and mining knowledge from the data.

To identify workers within construction and nursing professions, we first collected tweets together with their metadata using keywords such as registered nurse and construction worker . From these tweets and metadata, we identified a list of Twitter accounts of the relevant unions, companies, and organizations for each industry. Then, we collected the large lists of followers of these accounts. Next, we identified which of these followers were construction workers and nurses and used a combination of their publicly available metadata to determine their location (in or outside Australia) and their age category (eg, using their name and short biographical profile). This process was partially automated but also involved a manual component, particularly for determining the age category (>45 years or <45 years). We adopted the definition provided by the Australian Department of Employment and Workplace Relations [ 32 ], which categorizes mature-age workers as those aged >45 years. Determining the age of users involved some combination of looking at the user’s profile picture, name or handle, cross-referencing with other social media accounts (eg, LinkedIn [Microsoft Corp] or Facebook [Meta Platforms, Inc]) or professional profile pages (eg, company, hospital, and university websites) that provide age data, or some proxy for estimating age (eg, the year a professional qualification was awarded). Users for whom we could not confidently determine their age category were excluded.

Data Collection

Data were collected from the Twitter platform using the Twitter application programming interface and were subject to the privacy policy regarding the release of the data held by the social media platforms to the public. Furthermore, keywords such as construction worker and registered nurse were used to retrieve potential nurses and construction workers and their tweets as an initial step. Metadata including username; name; user ID; language; hashtags; tweet time; and number of likes, replies, and retweets were collected simultaneously using Twint and Tweepy , Twitter scraping packages written in Python (Python Software Foundation) that allow for data collection from Twitter profiles.

Data Filtering and Preparation

Only tweets written in English were included in the analyses. URLs, punctuation marks, symbols, and emojis were removed. Stanza developed by Stanford Natural Language Processing Group and Python Natural Language Toolkit package were used for tokenization (ie, breaking a sentence into small units for subsequent analysis), removing stop words (eg, are, is, an, this, and that; the complete list is available on GitHub [ 33 ]), sentiment analysis, and monogram and bigram keyword analysis (ie, 1 word vs 2 words that co-occur, eg, bigrams involving mask included “wear mask” vs “anti mask”).

Hashtag Topics

A hashtag is a word or combination of words preceded by a # symbol, which is used to index topics on Twitter (eg, #construction, #nursing, and #COVID). This function was created on Twitter and allows people to easily follow topics they are interested in. We took advantage of this functionality to conduct a series of data visualizations and quantitative analyses to explore trending topics within and across industries and age categories.

In addition to the abovementioned hashtag analysis, we analyzed the keywords contained in tweets (ie, the content words that remained after stop words, punctuation marks, and so on were removed). This analysis provided a more detailed exploration of the themes raised by the hashtag topic analyses.

Word Counts Analysis

The Linguistic Inquiry and Word Count (LIWC) application [ 34 ] is the most widely used corpus of dictionaries for computational linguistic analyses of text data. Numerous studies on mental health topics using LIWC have shown strong evidence of particular patterns of language use that are highly relevant to certain mental health issues. Notably, LIWC compares words appearing in an input text file with the words listed in its customizable dictionary. Then, LIWC uses its algorithms to sort words into predefined and psychologically meaningful categories and performs a series of calculations. The end result is a summary of the statistical distribution of words within a given text into those that fall into LIWC categories, which include function words, pronouns, impersonal pronouns, verbs, auxiliary verbs, and past-tense words.

For this study, we used the latest version of LIWC (LIWC-22; Pennebaker Conglomerates, Inc) and the built-in English dictionary. Tweets containing <10 words were not included in the LIWC analysis, as they are unlikely to satisfy the requirements of LIWC and will not produce meaningful results.

Sentiment Analysis

Sentiment analysis was conducted using Stanza , the Python package of Stanford Core Natural Language Processing Group [ 35 , 36 ], which is based on deep learning and has been shown to have state-of-the-art performance [ 37 ]. Sentiment analysis is a powerful technique used to understand the public opinion of social media users and is suitable for use with short text posts such as tweets [ 38 ]. Using this approach, text can be classified as either positive, negative, or neutral sentiments. Examples of positive, negative, and neutral sentiments are as follows:

Great choice and important area that needs exploring. I would be confident even if you found someone exploring similar, you would be able to provide unique new knowledge. The anxiety element is real and recognised though! Good luck and feel free to DM. [Positive sentiment]

Nope, so much bad energy used to devalue and treat ordinary Australians like cattle. Fascism, led by the religious right, will destroy this country. There hasn’t been a time, in my life, when AU wellbeing is so low. [Negative sentiment]

I was watching a show on tv last night re improving mental health which was timely given the day I had yesterday. It mentioned effects of social media on mental health. [Neutral sentiment]

Data Summary

The data set consisted of 1,505,638 tweets from 395 Twitter users, as presented in Multimedia Appendix 1 . The data were collected across a period spanning 54 months, from January 2018 to June 2022, which equates to approximately 27 months before and 27 months after the WHO declared COVID-19 a global pandemic on March 11, 2020. Data were separated into those that originated in Australia versus those that originated in other parts of the world because tweets are known to reflect local sociopolitical trends and cultural norms (eg, regarding the display of emotions [ 19 ]). Furthermore, we divided users into younger and older workers to explore whether the challenges that workers face interact with age.

The large data set contained a wide variety of hashtag topics. Overall, younger workers tended to use a wider variety of hashtag topics than older workers, and this pattern held for both industries. Comparing industries, nurses tended to use more hashtag topics than construction workers ( Multimedia Appendix 2 ). Our large data set contained thousands of hashtag topics, with a very long tail in their distribution (ie, some obscure hashtags had only 1 or 2 times). To reduce the data for analysis, we grouped the top 200 hashtag topics into groups based on themes, and 10 unique thematic categories emerged ( Multimedia Appendix 3 ).

Political hashtags were popular in both industries. In particular, older workers made greater use of political hashtags than younger workers, and this difference was especially pronounced in construction workers. Younger construction workers were by far the most likely to tweet about “life,” including various entertainment activities, such as sports, eating out, camping, television shows, shopping, hobbies, and pets. This suggests the presence of a work-life balance disparity across the 2 industries. Delving deeper, we found that construction workers had a work-life topics ratio >1, whereas the ratio for nurses was <1, indicating that work was taking a disproportionate amount of nurses’ time and attention, and this could be interpreted as an indicator of nurses being overworked. This pattern was exacerbated in the younger groups of workers: the work and life topics ratio of younger construction workers was 5 times higher than that of younger nurses.

Consistent with the expectations, nurses used COVID-19–related hashtags (eg, #COVID-19, #coronavirus, #mask, #vaccination, #lockdown, and #ppe) to a far greater extent than construction workers. This likely reflects their practice scope, expertise, and daily experiences in the course of performing their professional duties. Furthermore, nurses were more likely to include hashtags in their tweets falling within the “campaign” and “organization” categories, which included social media calls for action to improve working conditions (not relating to political purposes) and to voice support. Nurses, and especially older nurses, were more likely to use “positive words” in their hashtags, which consisted of SMS text messages voicing support for colleagues and others facing challenging circumstances in their industry (eg, #kind, #kindnessmatters, #respect, #grateful, #empathy, and #teamwork).

As shown in Table 1 , nurses were far more likely to tweet hashtags about their well-being; mental health issues; and the deleterious effects of burnout, fatigue, and tiredness. Younger nurses tended to focus on mental health issues and burnout or fatigue, whereas older nurses were more likely to tweet about well-being. Older construction workers were more likely to tweet about pains, aches, and physical health issues.

Tweets with hashtag topics had a higher average number of likes, replies, and retweets than topics without hashtags ( Multimedia Appendix 4 ). Furthermore, tweets containing hashtag topics related to health and well-being had a higher average number of likes and retweets than those with hashtag topics other than health and well-being. Overall, tweets with hashtag topics received more attention and engagement, especially those about health and well-being topics.

Monogram Keywords

Monogram keywords refer to individual content words within tweets that convey meaning. Compared to hashtags, keywords are more indicative of the content of the tweet, in that they better reflect the author’s intended meaning. A summary of the monogram keyword data is provided in Multimedia Appendix 5 .

Consistent with what was observed for hashtags, monogram keyword counts revealed that nurses made greater use of keywords associated with burnout, health issues, and mental health compared to construction workers ( Table 2 ). Compounding the above, COVID-19 also had a huge effect on nurses, and this was especially pronounced for younger nurses.

An analysis of likes, replies, and retweets revealed that tweets containing health and well-being keywords were more likely to gain the attention of other Twitter users, resulting in more engagement ( Multimedia Appendix 6 ).

Monogram keywords directly related to physical and mental health and well-being were visualized as word clouds to illustrate the differences between industries and the age subgroups ( Multimedia Appendix 7 ). Within each word cloud, the size of each word represents its frequency of occurrence, and the density of the cloud depicts the number of different keywords used. Differing patterns were observed for the 4 subgroups. Younger workers in both industries had word clouds that were denser, indicating that they posted about a wider variety of topics and problems. Younger nurses tweeted most frequently about “mental” and “sleep,” whereas older nurses mentioned “pain” and “well-being” to a far greater extent and placed much less focus on “sleep.” Among construction workers, both younger and older workers mentioned “sleep,” “pain,” and “tired.” The older construction workers had the sparsest word cloud.

Bigram Keywords

Bigram keywords refer to pairs of content words that co-occur within tweets and convey additional context and the author’s intended meaning (eg, the monogram “mask” has different connotations in the bigrams “wear mask” vs “anti mask”). A summary of bigrams is presented in Multimedia Appendix 8 . Nurses consistently used more bigrams than construction workers.

Consistent with what was observed for hashtag topics and monograms, nurses made greater use of bigram keywords associated with burnout and physical and mental health issues ( Table 3 ). Furthermore, the COVID-19 pandemic disproportionately affected nurses, and this effect was magnified for younger nurses.

Bigram word clouds related to physical and mental health issues and well-being are presented in Multimedia Appendix 9 . The bigrams reveal additional details that were obscured in the monogram clouds. “Mental health” was the most frequently occurring bigram for all groups. “Mental illness” featured prominently for younger nurses and both groups of construction workers, but “mental well-being ” occurred more frequently for older nurses. Furthermore, older nurses posted about physical well-being more than the other groups. Notably, density increased for the older groups relative to their monogram clouds. Younger nurses still had the densest cloud, and the bigrams within indicated that they were experiencing the most distress of all the groups (eg, “fall asleep,” “I am tired,” “not sleep,” “sleep tonight,” and “pain relief”). Older construction workers made frequent reference to specific medical conditions such as cardiovascular disease. Younger construction workers posted about nerve pain and neuropathic pain, likely related to the physical nature of construction work.

LIWC Results

For the LIWC analyses, tweets were grouped into those that did or did not contain health and well-being keywords. In Multimedia Appendix 10 , we present the basic LIWC summary variables. Authenticity scores suggest that tweets were equally truthful regardless of whether the tweet was about a health-related topic or other topics. Analytical thinking, clout, and positive emotional tone were greater in tweets about non–health-related topics.

As presented in Multimedia Appendix 11 , overall, tweet authors used more first-person singular pronouns and affect words when posting about health and well-being. Increased use of first-person singular pronouns is a reliable predictor of elevated levels of stress, depression, and suicidal ideation [ 39 , 40 ]. Furthermore, we found more affect words in health-related tweets. As expected, non–health-related tweets contained more words associated with the social category.

LIWC analyses of positive versus negative emotions and tone revealed that tweets about health and well-being were far more likely to convey negative emotions, perhaps reflecting fear, despair, sadness, or anger ( Multimedia Appendix 12 ). Central to our research question and aims, we observed that words falling within the LIWC categories of health , fatigue , illness , wellness , and mental were far more likely to occur in tweets about health and well-being.

Then, we further examined the LIWC indicators for the tweets with health and well-being keywords. Comparing younger and older workers across industries, we observed that younger nurses showed language use patterns, suggesting that they were experiencing the deleterious effects of suboptimal work conditions ( Multimedia Appendix 13 ). Younger nurses used words within the fatigue , illness , and mental categories more often than their older colleagues. Older nurses made greater use of words in the wellness category. These differences all reached statistical significance ( Table 4 ). In contrast, no differences were found between the younger and older construction workers. In general, construction workers spent less time posting about health and well-being topics, and no differences were observed between younger and older construction workers.

Sentiment analysis revealed that, overall, older construction workers made more tweets with negative sentiment ( Figure 2 ). Younger construction workers were the most neutral. Older nurses tended to be more positive. Other than that, the differences between the younger and older nurses were relatively minor.

Next, we conducted a sentiment analysis of the tweets that did or did not contain keywords related to health and well-being. The right panel of Multimedia Appendix 14 presents the tweets without health and well-being keywords and serves as a baseline. The left panel of Multimedia Appendix 14 shows an increase in negative sentiment when tweeting about health or well-being topics. Younger nurses and older construction workers were the most negative, whereas older nurses were the most positive.

Australian Workers Versus Non-Australian Workers (LIWC Analysis)

To explore whether our observations were specific to the Australian context or reflected trends observable in other nations, we compared LIWC categories in Australian and non-Australian workers ( Multimedia Appendix 15 ). In total, 51.5% (53/103) of the non-Australian construction workers come from Europe and North America, whereas 48.5% (50/103) come from Africa, Asia, and Latin America. Regarding nurses, 75% (78/104) of the non-Australian workers come from Europe and North America, and 25% (26/104) come from Africa, Asia, and Latin America. We observed that Australian workers in both industries used more words falling within the mental category, which was significant as confirmed by ANOVA tests ( Table 5 ).

This could be a sign of greater stress in Australian workers, potentially leading to future mental health concerns. Furthermore, Australians made more frequent reference to health and illness (with the exception of younger construction workers), suggesting that their health had been adversely affected, or at least that it was on their mind. Use of health- , fatigue- , illness-, and wellness -related words by younger nurses within and outside Australia were similar, whereas older Australian nurses made significantly more use of health- and illness-related words and less use of wellness-related words than their peers outside Australia. Similar results were found for older Australian construction workers compared to those outside Australia (except for more use of wellness-related words). On the other hand, younger Australian construction workers had less use of fatigue- and illness-related words, which might suggest that they are in a better condition compared to their colleagues worldwide.

The COVID-19 Pandemic Influence

The average number of tweets per user over the 54-month period between January 2018 and June 2022 increased more for both younger and older nurses than construction workers, especially since the COVID-19 pandemic. Furthermore, we observed marked differences in the 4 subgroups regarding sentiment at baseline and changes that occurred during the COVID-19 pandemic ( Figure 3 ). Overall, nurses had a higher proportion of positive sentiment in their tweets than construction workers. However, this changed markedly in early 2020 as the positive and negative sentiments crossed over in the months leading up to the WHO’s declaration of COVID-19 as a global pandemic. Since that time, negative sentiment dominated the tweets of nurses. No such crossover was observed among construction workers, in part because both younger and older construction workers consistently had more negative sentiments dating back to January 2018.

For all groups, LIWC for illness , mental, and fatigue categories were the most prominent, whereas the LIWC for the wellness category either declined or remained low across the 54-month period ( Figure 4 ). For the older nurses, LIWC for the wellness category decreased but showed a bump that peaked in mid-2021, although the peak was considerably lower than the pre–COVID-19 pandemic levels. Younger nurses showed a substantial increase in mental words leading up to the WHO’s COVID-19 pandemic declaration in March 2020. Younger construction workers were the only group for whom the fatigue category had a higher percentage than the mental category, indicating that their focus was on their physical health rather than mental health during the sampling period.

Principal Findings

This is the first social media analysis to compare the tweets of younger and older workers in the construction and nursing industries with a view to understanding the common and unique work health and safety challenges they face and subsequent risks to their mental health. A robust observation across each type of analysis was that younger nurses were facing very challenging working conditions (eg, understaffing, high workload, and poor management and communication) that presented barriers to their mental health and well-being. Older nurses faced similar challenges but tended to place greater focus on promoting well-being in their tweets than their younger counterparts. Overall, nurses were unquestionably negatively impacted by the COVID-19 pandemic. In contrast, construction workers showed minimal impacts due to the COVID-19 pandemic. Older construction workers tended to post more negative tweets; however, construction workers in general tended to post less about work-related topics and more about life-related topics, indicating a better work-life balance than was observed in nurses. Younger construction workers posted mostly about life events, suggesting that they faced fewer mental health risks than the other groups.

Comparison With Prior Work

The most concerning observation that was borne out in each of our different social media analyses was that nurses (and especially younger nurses) were under more work pressure and stress and experienced greater and more intense negative emotions. Moreover, all these emotions were exacerbated by the COVID-19 pandemic. This puts younger nurses at increased risk of burnout and mental harm that may lead to attrition. This pattern of findings is consistent with a recent report that found a 131.5% increase in job vacancies under “health care and social assistance” industries between February 2020 and May 2022 [ 41 ]. Although there is a high attrition rate among our older nursing population through retirement, there may be higher attrition among the next generation of nurses through burnout. Previous research has shown that nurses’ mental state plays a critical role in how they respond to situations, patients, and colleagues, as well as their clinical judgment and communication, potentially affecting patient safety [ 42 ].

Furthermore, we observed more negative sentiment in tweets about health and well-being topics. This does not align with prior reports that tweets with health care hashtags expressed more positivity and more action-oriented language than non–health care–initiated hashtags [ 19 , 43 ]. It has been suggested that nurses may be reluctant to share negative events on social media due to societal expectations of professionalism from medical experts [ 13 ]. It is possible that the discrepancy between prior findings and our results may reflect Australian cultural norms and the extreme pressure that Australian health care workers were experiencing during the study period [ 13 ]. Notably, an analysis of tweets comparing UK and US health care workers revealed that while they experienced common challenges during the COVID-19 pandemic, nurses’ experiences in the 2 countries reflected local sociopolitical trends and cultural norms regarding emotional display [ 19 ]. Future work should systematically investigate such processes in the Australian context.

Similar to their younger colleagues, older nurses faced challenging work conditions. Furthermore, although they showed signs of elevated distress and negative effects, we found evidence that older nurses possess more effective tools and strategies for dealing with periods of increased uncertainty, stress, and accelerated work demands (eg, emotional regulation and big picture thinking). A common assumption is that older workers are frail and vulnerable; however, evidence suggests that this is an inaccurate stereotype. A lifetime of experience seems to have equipped older workers with resilience and the ability to take a long-term view that permits them to better accommodate periods of instability. These suggestions in our data are consistent with broader research on cognitive aging, which suggests that older adults are skilled at emotion regulation [ 25 ]. Moreover, the findings are consistent with prior work on the effects of the COVID-19 pandemic on health care workers, which suggested that younger workers were most at risk of mental illness [ 26 ].

Overall, construction workers were less affected by the COVID-19 pandemic. Younger construction workers were mostly focused on posting about life events, including socializing, participating in hobbies, and engaging in recreational activities. Their tweets suggested that they had the best work-life balance, were not preoccupied with work, and showed minimal signs of mental distress. We did find evidence of concern with physical pains and injuries, which is notable given their young age. Older construction workers were more likely to post with more negative sentiment. However, these tweets tended to be regarding issues and events outside of their work, such as politics and current events, rather than about issues concerning their job role or working conditions (in contrast to what was observed for the nurses).

Unlike prior reports [ 44 - 46 ], we did not find evidence of widespread ageism (or reverse ageism) in either industry, although aspects of workplace culture could be improved. Instances of bullying were observed in both industries, originating from various sources, but they did not seem to be widespread. Differences in well-being were primarily related to age, job role, and job type. The findings of this study are compatible with the abovementioned observations and complement the data to provide a detailed insight into the mental health challenges faced by workers in each industry.

This work introduced several innovations. Our team applied social media–based big data analysis to inform our understanding of work health and safety issues. Furthermore, this was the first study to pay particular attention to issues concerning older workers’ mental health by comparing findings and trends across 2 industries as well as comparing patterns in Australia versus overseas.

Implications

Computational linguistic tools and algorithms are able to reliably predict risks of future mental illness [ 47 , 48 ]. The patterns observed in this study strongly suggested that nurses were experiencing stress and negative emotions, and this was more extreme in younger nurses. A well-developed literature has established which linguistic indicators are reliable predictors of mental ill health (eg, first-person pronouns and negative emotion words) [ 39 ]. Language analysis technologies represent an important advancement in mental health care for the prevention and early diagnosis of mental health problems. These tools may aid professionals in identifying at-risk individuals and the follow-up and prognosis of patients [ 49 ].

Limitations

There were several limitations inherent to social media analysis when attempting to extrapolate to real-world work settings. First, not everyone (especially older workers) uses social media; therefore, we cannot assume that the comments, word use patterns, or sentiments of social media users accurately capture those of all construction workers or nurses. To address this limitation, we advocate not relying on any individual tool or method when attempting to develop a deep and holistic understanding of the issues facing an industry or workforce. It is for this reason that, in the present line of research, our team has conducted multiple literature reviews, a survey study, and now a social media analysis before attempting to design an intervention to improve the mental well-being of workers in these 2 industries.

A second limitation is that people whose data were included in this study tend to be those either who have sufficient free time or those who have strong opinions on the subject being studied. This limitation is somewhat circumvented by conducting a big data analysis on tweets that were already publicly available and freely expressed in different contexts. Furthermore, the fact that our observations converge with what we observed in our prior work gives us a high level of confidence that the conclusions drawn from these data are valid.

Conclusions

This study has advanced our understanding of the well-being of younger and older construction workers and nurses in Australia. The analyses have revealed that nurses (both younger and older) more often communicated about burnout, stress, and ill effects due to poor working conditions during the COVID-19 pandemic than construction workers. However, older nurses tended to promote well-being in their tweets more than their younger counterparts, suggesting that they could be more resilient and better able to adapt and accommodate periods of instability. Older construction workers had more negative sentiments than younger workers, who were more focused on communicating about social and recreational activities rather than work matters. These findings will inform the development of interventions that will protect the mental health of workers in highly demanding work environments such as nursing and construction. In a recent strategic report, the WHO [ 50 ] advised that social media accounts (eg, Twitter) could be used for monitoring and provisioning training and educational materials for health care professionals and the evaluation of action plans. Our findings support the value of analyzing social media posts to gain insights into the well-being of workers in target industries and during key social challenges. These tools, and the evidence they generate, should be used to improve the lives of workers, especially those in critical industries.

Acknowledgments

This study was supported by funding from the New South Wales Government Centre for Work Health and Safety (tender SAFE/1848—CWHS_RP_091).

Data Availability

The data sets generated and analyzed during this study are available in the Western Sydney University Research Direct repository [ 51 ].

Conflicts of Interest

None declared.

Summary of users and tweets collected during the study period (January 2018 to June 2022).

Summary of the hashtag topics used by younger and older workers in the nursing and construction industries.

Distribution of the top 200 hashtag topics used by nurses (top panel) and construction workers (bottom panel) expressed as a percentage of the 10 most popular categories.

Average (SE) number of likes, replies, and retweets for tweets with hashtag topics related to health and well-being, with other hashtag topics and topics without hashtags.

Summary of the monogram keywords used in tweets by younger and older nurses and construction workers.

Average (SE) number of likes, replies, and retweets for tweets with and without health and well-being keywords.

Word clouds summarizing the monogram keywords related to physical and mental health issues and well-being for younger nurses (top left), older nurses (top right), younger construction workers (bottom left), and older construction workers (bottom right).

Summary of the bigram keywords used by younger and older nurses and construction workers.

Word clouds summarizing the bigram keywords related to physical and mental health issues and well-being for younger nurses (top left), older nurses (top right), younger construction workers (bottom left), and older construction workers (bottom right).

Descriptive statistics of the Linguistic Inquiry and Word Count scores for the basic summary variables: analytical thinking, clout, authenticity, and emotional tone. Average scores and SE are calculated based on the text from each tweet.

Percentage of words falling within the Linguistic Inquiry and Word Count categories: first-person singular pronouns, drives, cognition, affect, and social. Average percentage and SE are calculated based on the text from each tweet.

Percentage of words falling within the Linguistic Inquiry and Word Count categories: positive emotional tone, negative emotional tone, positive emotion, negative emotion, health, fatigue, illness, wellness, and mental. Average percentage and SE are calculated based on the text from each tweet.

Percentage of words falling within the Linguistic Inquiry and Word Count categories: health, fatigue, illness, wellness, and mental. Average percentage and SE are calculated based on the text from each tweet containing health and well-being keywords. Error bars show SE values.

Percentage of tweets with negative, neutral, and positive sentiments for younger and older nurses and construction workers, grouped by with and without keywords related to health and well-being in the tweets.

Percentage of words falling within the Linguistic Inquiry and Word Count categories: health, fatigue, illness, wellness, and mental. Average percentage and SE are calculated based on the text from each tweet containing health and well-being keywords.

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Abbreviations

Edited by A Mavragani; submitted 29.05.23; peer-reviewed by R Fang, Y Chen; comments to author 18.10.23; revised version received 07.11.23; accepted 09.02.24; published 05.06.24.

©Weicong Li, Liyaning Maggie Tang, Jed Montayre, Celia B Harris, Sancia West, Mark Antoniou. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 05.06.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

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Quantitative research on the impact of COVID ‐19 on frontline nursing staff at a military hospital in Saudi Arabia

Loujain sharif.

1 Faculty of Nursing, King Abdulaziz University, Jeddah Saudi Arabia

Khalid Almutairi

2 King Fahad Armed Forces Hospital (KFAFH), Jeddah Saudi Arabia

Khalid Sharif

Alaa mahsoon, maram banakhar, salwa albeladi, yaser alqahtani, zalikha attar, farida abdali, rebecca wright.

3 Johns Hopkins School of Nursing, Baltimore Maryland, USA

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

The aim of the study was to examine the relationship between stress, psychological symptoms and job satisfaction among frontline nursing staff at a military hospital in Saudi Arabia during the COVID‐19 pandemic.

Descriptive cross‐sectional study.

Data were collected using an online survey. All Registered Nurses ( N  = 1,225) working at a military hospital between February to April 2021 were contacted, 625 responded (51%). Data were analysed using descriptive and multivariate analysis, Student's t‐test for independent samples and one‐way analysis of variance followed by Tukey's multiple comparison tests.

Stress was experienced more significantly than depression or anxiety. Approximately 29% of the change in scores for psychological symptoms was explained by age group, being a Saudi national and working in emergency departments ( F [3,620]  = 19.063, p  < 0.0001). A 37% change in nursing stress scores was explained by nationality and work department. ( F [5,618]  = 19.754, p  < 0.0001). A 29% change in job satisfaction scores was explained by nationality and work department ( F [3,620]  = 19.063, p  < 0.0001).

1. INTRODUCTION

Saudi Arabia reported its first case of coronavirus disease 2019 (COVID‐19) on March 2, 2020 (Reuters Staff,  2020 ; Zu et al.,  2020 ). The World Health Organization has identified the COVID‐19 outbreak as a public health emergency and global pandemic (World Health Organization,  2020 ). The impact of COVID‐19 on those who have contracted it received rapid investigation and documentation (Harper et al.,  2020 ). However, healthcare workers were quickly recognized to be experiencing a secondary impact of COVID‐19, owing to vulnerability to stressors such as inadequate resources, long shifts, sleep problems, work−life imbalances and new occupational hazards (Sasangohar et al.,  2020 ). Notably, previous research on the impact of other coronavirus syndromes (severe acute respiratory syndrome, Middle East respiratory syndrome) found that approximately 62% of healthcare workers reported general health concerns, fear, insomnia, psychological distress, burnout, anxiety, depressive symptoms, posttraumatic stress disorder, psychosomatic symptoms and perceived stigma (Sasangohar et al.,  2020 ).

Compared with other healthcare professionals, nursing staff are particularly susceptible to the negative impact of a pandemic, with a higher vulnerability to negative outcomes associated with working in high‐risk departments (Shaukat et al.,  2020 ). Moreover, the impact is not limited to psychological effects. One systematic review on estimated COVID‐19 infections and deaths among healthcare workers reported 37.2 deaths per 100 infections in nursing staff aged at least 70 years (Bandyopadhyay et al.,  2020 ). Another study conducted in the UK found that out of 157 COVID‐19‐related deaths among medical health workers, 48 (30.6%) were nurses (Kursumovic et al.,  2020 ). This combination of physical (e.g. infection transmission and the underlying manifestations) and psychological effects (e.g. burnout, stress, anxiety and depression) caused by the pandemic (Hu et al.,  2020 ) has led to substantial concerns for nursing staff, with statistically significant bearing on job satisfaction (Del Carmen Giménez‐Espert et al.,  2020 ).

2. BACKGROUND

There has been a concerted effort in Saudi Arabia to understand and mitigate the impact of COVID‐19 on nursing staff, with studies investigating stress, fear of infection and resilience in relation to COVID‐19 (Tayyib & Alsolami,  2020 ); stress and coping strategies in dealing with COVID‐19 (Muharraq, 2021); and nursing knowledge and anxiety related to COVID‐19 (Alsharif,  2021 ). However, these studies give descriptive statistics with relatively small samples of less than 300 nurses, and, to the best of our knowledge, no study has yet focused on assessing multiple psychological symptoms (depression, anxiety, and stress) collectively in relation to job satisfaction. Furthermore, the effects of COVID‐19 among nursing staff in military hospitals have not yet been explored.

This is a key setting for investigation, as military hospitals in Saudi Arabia are considered highly specialized healthcare organizations, providing all forms of health care to an exclusive population of military personnel and their family members (Walston et al.,  2008 ). Healthcare providers recruited for military hospitals must meet high standards and requirements that differ from those in non‐military care settings (Olenick et al.,  2015 ). Because of higher standards and higher pay levels compared with other healthcare organizations in Saudi Arabia, military hospitals often employ healthcare providers, and nurses in particular, from different countries worldwide (Almalki et al.,  2011 ). Despite the higher salaries and expectations of care associated with urgent needs, military hospitals have had to adapt their policies and protocols in response to greater and new patient needs as a result of COVID‐19. Therefore, these hospitals have also been impacted by the brutal reality, thereby leading to an increase in resignations among nursing staff. Probable reasons for this increase include greater workloads, mandatory overtime, withholding of annual leave and switching of nurses from less demanding areas (e.g. outpatient clinics) to more demanding care areas (e.g. inpatient units), along with the risk of contracting COVID‐19 (King Fahad Armed Forces Hospital,  2020 ). These changes suggest that nursing staff at military hospitals have experienced many of the same mental and physical side effects as nurses in non‐military hospitals, with the same consequential burnout and resignations. However, it is also commonly reported that nurses avoid seeking psychological support and services (Knaak et al.,  2017 ). This may be due to a fear of stigma and discrimination in the workplace, where needing mental health help can be perceived as weakness (Jones et al.,  2020 ), which is a phenomenon that is particularly common among military personnel (Hernandez et al.,  2014 ).

Despite investigations into the types of symptoms experienced by nursing staff as outlined above, few studies have explored the relationship between psychological impact and nurses' job satisfaction within the context of military hospitals in the Middle East. Therefore, the present study aimed to examine the relationships within and between stress, psychological symptoms (including depression and anxiety) and job satisfaction among frontline nursing staff at a military hospital in Saudi Arabia during the COVID‐19 pandemic. The purpose of this study was to identify key components that may benefit not only the study site in improving nursing staff retention but also the wider healthcare field, as nursing retention is an increasingly documented challenge. We hypothesized that the abovementioned challenges encountered by nurses, as a secondary impact of COVID‐19, are likely to be linked to low job satisfaction among frontline nurses.

3.1. Design

We used a descriptive cross‐sectional design with a quantitative questionnaire. Convenience sampling was used to recruit Registered Nurses (RNs) working in all hospital units. Overall, 1,125 RNs worked at the study site. The hospital only has full‐time RNs and does not employ part‐time or agency RNs. As such there was no criteria excluding any RN employed at the hospital from participation in this study. Five hundred seventy‐six participants were required for a 50% response rate (Sataloff & Vontela,  2021 ). Data were collected from one military healthcare organization in the western region of Saudi Arabia. The hospital provides all medical services with a 420‐bed capacity, serving members of the Saudi Arabian Armed Forces and their families. The hospital is accredited by the Central Board for Accreditation of Healthcare Institutions, Joint Commission International and International Organization for Standardization, and it is the only adult cardiac surgical facility in the western region.

3.2. Method

The questionnaire comprised four sections and was in English language, with 122 items, in total and took approximately 35 minutes to complete.

Section 1 – Demographic information : We collected data on eight items: age, gender, marital status, nationality, education level, experience and department.

Section 2 – Expanded Nursing Stress Scale (ENSS; French et al.,  2000 ): The ENSS (Cronbach's alpha = 0.96) identifies the sources and frequency of stress among hospital nurses. The scale comprises a total of 57 items on the following stressful situations: death and dying patients (7 items), conflict with physicians (5 items), inadequate emotional preparation (3 items), problems related to peers (6 items), problems related to supervisors (7 items), workload (9 items), uncertainty concerning treatment (9 items), patients and their families (8 items) and discrimination (3 items). The ENSS was also used in the present study to assess the frequency in which nurses experienced work stressors, rated within a range between 0–4, on a scale modified from the original as follows: I have not encountered it (0), never stressful (1), occasionally stressful (2), frequently stressful (3) and always stressful (4). In a pilot test of the modified ENSS, conducted by the authors of this study, the Cronbach's alpha was 0.98.

Section 3 – Depression , Anxiety and Stress Scales (DASS; Lovibond & Lovibond,  1995 ): The DASS (Cronbach's alpha = 0.89) focuses on assessing depression, anxiety and stress among hospital nurses. Each of the three scales contains seven items. The depression scale assesses dysphoria, hopelessness, devaluation of life, self‐deprecation, lack of interest/involvement, anhedonia and inertia. The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety and subjective experience of anxious affect. The stress scale assesses difficulty relaxing, nervous arousal and being easily upset/agitated, irritable/over‐reactive and impatient. The DASS is rated on a scale ranging between 0–3: (0) does apply to me at all , (1) applies to me to some degree or some of the time , (2) applies to me to a considerable degree or a good part of time and (3) applies to me very much or most of the time . Cronbach's alpha for the DASS in the current study was calculated as 0.969, indicating excellent reliability.

Section 4 – Job Satisfaction Survey (JSS; Spector,  1985 ): The JSS (Cronbach's alpha 0.91) assesses job satisfaction among hospital nurses. It includes 36 items with nine facets as follows: pay (4 items), promotion, supervision (4 items), fringe benefits (4 items), contingent rewards (4 items), operating procedures (4 items), co‐workers (4 items), nature of work (4 items) and communication (4 items). Items are rated on a six‐point Likert scale with responses ranging from 1 ( disagree very much ) to 6 ( agree very much ). The JSS demonstrated acceptable reliability in the current study, with a Cronbach's alpha of 0.798. Regarding the scoring system, scores for each four‐item subscale ranged from 4 to 24 and were scored as follows: dissatisfied (4–12 points), ambivalent (12–16) and satisfied (16–24). For the total 36‐item JSS, scores ranged from 36 to 216 and were scored as follows: dissatisfied (36–108 points), ambivalent (108–144) and satisfied (144–216; Spector,  1994 ).

3.3. Data collection process

After obtaining ethical approval, potential study participants who were recruited to participate through unit meetings by the head nurses of the units, who acted as gatekeepers. All relevant information on the study, including its research topic, aim, sample and significance were explained to all RNs in each unit. Within Saudi culture, in addition to communication modalities such as email, social media platforms are a common and effective method of communicating with groups within different organizations. Therefore, the head nurse in each unit sent the survey using google form as an electronic link via the social media application “WhatsApp” to all RNs who agreed to participate in the study. The survey was sent out in February 2021 and remained available until April 2021.

3.4. Analysis

Data were analysed using SPSS 26.0 Windows version statistical software (IBM, Armonk, NY, USA). Descriptive statistics (means, standard deviations, frequencies and percentages) were used to describe the quantitative and categorical variables. Student's t‐test for independent samples was used to compare the mean values of quantitative outcome variables in relation to the categorical study variable with two categories. One‐way analysis of variance, followed by Tukey's multiple comparison tests (Tukey,  1953 ), was used to compare the mean values of quantitative outcome variables in relation to the categorical study variables with more than two categories. A p ‐value of ≤0.05 was used to report the statistical significance of the results.

For the multivariate analysis, a stepwise Multiple linear regression was carried out to observe the independent relationship of variables of categorical study variables with the three quantitative variables (DASS, ENSS and JSS scores). As the study variables were categorical, dummy variables were created to include them in the model. The proportion of variability R 2 was used to observe the change in the outcome variable explained by the significant independent variables in the model. Regression coefficients were used to observe changes in the outcome variables. A p ‐value ≤0.05, was used to report the statistical significance of the estimates.

3.5. Ethics

Ethical approval was obtained from the King Fahd Armed Forces Hospital‐ Jeddah, Research and Ethics Committee (Ref. number: REC 398), confirming no risk to study participants via the application of an anonymous online survey. The cover page of the survey provided key information, including the importance and purpose, expected time necessary to complete the survey, and why survey recipients were asked to participate. A statement regarding confidentiality and anonymity was included within the online link to the survey. No financial incentives were offered.

Of the 624 nurses who completed the survey (response rate: 51%), 91.3% were women, approximately two‐thirds (66.8%) were aged between 25–35 years, and more than 50% were unmarried. The majority were Filipino (75.8%), and only 5.6% were Saudi. Approximately 90% of the sample had a bachelor's degree, and 48.4% had 1–5 years of experience; 6.3% had more than 15 years of experience. The sample was distributed among the following departments and units: emergency departments (14.6%), intensive care units (22.6%), inpatient units (39.1%) and outpatient units (9.6%); the remaining 14.1% were from other departments. A quarter of the sample (n = 156) had tested positive for COVID‐19 (Table  1 ).

Socio‐demographic and professional characteristics of participants ( N  = 624)

Table  2 shows the mean values of the three DASS subscales (depression, anxiety and stress). The mean stress score was higher than the mean scores for either depression or anxiety. Table  3 shows the ENSS scores and mean values of its nine domains, in which the mean score of the “workload” domain was highest (2.39), followed by mean scores of “patients and their families” (2.30) and “problems relating to supervisors” (2.14); the mean scores of the remaining six domains were less than 2.0 The mean value for the nine domains of the JSS was 121.07 (22.1), which indicated ambivalence (Table  4 ). The only mean score that indicted satisfaction was in the “nature of work” domain (17.04), followed by “co‐workers” (15.88) and “supervision” (15.16). The mean scores of the remaining six domains were less than 15.0, ranging from ambivalent to dissatisfied.

Comparison of mean scores of DASS sub scales and total score in relation to socio‐demographic and professional characteristics of study subjects ( n  = 624)

Note : Bolded text denotes p value of <0.05.

Comparison of mean values of nine domains and total score of ENSS scale in relation to socio‐demographic and professional characteristics of study subjects ( n  = 624)

Comparison of mean values of nine domains and total score of job satisfaction scale in relation to socio‐demographic and professional characteristics of study subjects ( n  = 624)

4.1. Bivariate and multivariate analyses

For mean DASS scores, bivariate analysis showed statistically significant differences in relation to age group, nationality and work department with further statistically significant differences found in mean anxiety scores among nurses who had tested positive for COVID‐19 ( p  = 0.030; Table  2 ). Multivariate analysis revealed that the overall regression model was statistically significant ( F [3,620]  = 19.063, p  < 0.0001), with an R 2 of 29.1 (Table  S1 ). The R 2 is the proportion of variability, which means approximately 29% of the change in DASS scores was explained by age group (25–30 years), being a Saudi national and working in emergency or “other” departments. The corresponding regression coefficients of these variables indicated that the DASS scores increased on average (i) by 6.334 units in nurses aged 20–30 years when compared to those aged 46–50 years, (ii) by 17.725 units in Saudi nationals when compared to South African nationals and (iii) by 11.699 units in nurses who worked in emergency departments when compared to those who worked in outpatient departments (Table  S1 ).

For ENSS scores, bivariate analysis showed statistically significant differences related to nationality, place of work and experience (Table  3 ). Multivariate analysis showed that the overall regression model was statistically significant ( F [5,618]  = 19.754, p  < 0.0001) with an R 2 of 37.1 (Table  S2 ). A 37% change in ENSS score was explained by nationality and place of work. The corresponding regression coefficients of these variables indicated that ENSS scores increased, on average, (i) by 5.619 units in Filipino nationals when compared to Indian nationals, (ii) by 7.987 units in Malaysian nationals when compared to Indian nationals, (iii) by 4.976 units in Saudi nationals when compared to Indian nationals and (iv) by 4.996 units in nurses who worked in emergency departments when compared to those who worked in inpatient departments (Table  S2 ).

For JSS scores, bivariate analysis showed that the mean values had statistically significant differences in relation to nationality, place of work and education level (Table  4 ). Multivariate analysis showed that the overall regression model was statistically significant ( F [3,620]  = 19.063, p  < 0.0001), with an R 2 of 29 (Table  S3 ). A 29% change in JSS score was explained by nationality and place of work. The corresponding regression coefficients of these variables indicated that JSS scores increased, on average, (i) by 13.022 units in Indian nationals when compared with Filipino nationals, (ii) by 10.017 units in Saudi nationals when compared to Filipino nationals and (iii) by 9.992 units in nurses who worked in inpatient departments when compared to those who worked in outpatient departments (Table  S3 ).

5. DISCUSSION

The present study explored the impact of COVID‐19 on nurses working in a military hospital in Saudi Arabia and identified correlations between psychological symptoms and job satisfaction. The data give a detailed understanding of specific challenges to enable the study site to give additional support where needed, as well as give the wider field with new insights that can be built upon in future research. We found that the COVID‐19 pandemic is driving frontline nursing staff in the Jeddah region of Saudi Arabia to experience severe psychological strain.

Based on mean DASS scores, stress was the highest, when compared to depression and anxiety. This result is consistent with a meta‐analysis of 93 studies in which stress was found to be the most severe psychological symptom among nurses working during the COVID‐19 pandemic (Al Maqbali et al.,  2021 ). This result itself is unsurprising, as stress is considered a normal reaction to circumstances related to the pandemic, whereas depression and anxiety are considered psychiatric disorders that should meet certain symptom criteria for a specific duration (Regier et al.,  2013 ). However, nurses in the present study, who tested positive for COVID‐19 showed symptoms of anxiety. A previous qualitative exploration with nurses who had contracted COVID‐19 revealed similar results, while also providing further context regarding the depth of anxiety, fear and psychological shock they experienced (He et al.,  2021 ). However, as that was the only qualitative study, we were able to identify on this topic to date, we highlight this as an area that would benefit from further qualitative research not only to determine lived experiences but also to identify mitigating and supporting factors.

Data collected using the ENSS and JSS indicated that the most significant sources of stress for nursing staff in the present study were those associated with their work environment, such as workload, working under pressure, short time allotted to complete tasks, unsuitable rest/work regimens, frequent night shifts and overtime work. Pre‐pandemic, unusually high workloads were countered by reductions in outpatient appointments and treatments. However, the uniquely intense and demanding nature of COVID‐19 has made that an impossibility for isolation and triage hospitals. Similar findings have been reported elsewhere, as continuous emergency COVID‐19 cases, along with sustained increases in the number of suspected and confirmed cases, are placing frontline nursing staff under intense pressure (Brahmi et al.,  2020 ; Kakar et al.,  2021 ). Moreover, the extreme nature of COVID‐19 cases and high mortality rates have also changed the challenges nurses face in their work environment. New infection control safety policies have physically separated patients and families to reduce the risk of cross‐infection (Hsu et al.,  2020 ; Jaswaney et al.,  2022 ). Nurses implementing these policies have at times faced unreasonable demands and even abuse from distressed families, which exacerbates stressors and increases the pressure on them (Abu‐Snieneh,  2021 ). We found this to be the case among our nursing participants, who reported distress at the manner and frequency of patients deteriorating and dying, regardless of all medical and nursing efforts and care. These encounters led to a sense that the pandemic cannot be overcome, causing some nurses to experience guilt and self‐blame. This phenomenon has been noted elsewhere, as nurses have responded to blaming themselves, distressed, or angry relatives and patients and cited as one of the main stressors among frontline nurses (Byrne et al.,  2021 ; Liu et al.,  2020 ). We suggest that training in end‐of‐life care processes and approaches may be beneficial to give nurses with the skills to care for patients and families and to equip them with resiliency skills for this type of care (Peters et al.,  2013 ).

Frontline nurses were further impacted by the department in which they worked. We found nurses who worked in emergency departments scored the highest on the DASS, and ENSS, which is consistent with another study showing that nurses working in high‐exposure units with suspected COVID‐19 patients had higher levels of depression than nurses working in other units (Doo et al.,  2021 ). There could be several reasons for this finding, such as an unsafe work environment, insufficient personal protective equipment and unknown patient conditions. In addition, emergency departments are known to be unpredictable work environments, which not only means nurses must be ready to respond to any potential patient need but also increases their vulnerability to unexpected events, such as workplace violence and crises (Cui et al.,  2021 ).

There were other multiple domains on the ENSS and JSS that contributed to frontline nurses experiencing occupational stress and lacking job satisfaction, respectively. Interestingly, one correlation that was found was between the level of satisfaction and the level of education. Other researchers have found that the higher the level of education, the higher the level of satisfaction (Coomber & Barriball,  2007 ). Conversely in the present study, we found that the higher the level of education, the lower the level of satisfaction. One possible explanation for this could be that during the COVID‐19 pandemic, nurses with higher levels of education are more prepared and equipped to understand evidence‐based practice and policies and guidelines, and the absence of such may have contributed towards feelings of distress and lower satisfaction than nurses who are less highly trained and may not be as aware of the lack of research underpinning rapidly developed new policies and guidelines. This finding is at odds with other studies exploring this relationship (Lorber & Skela Savič,  2012 ). Another possible reason is that “job satisfaction” has not been consistently defined across studies (Coomber & Barriball,  2007 ), and those previous studies were performed in other counties where the term's meaning may have different cultural nuances.

Another area of note was as a perceived lack of support from supervisors. Although they are generally more experienced than their subordinates, nursing supervisors have been asked to serve in their roles with greater demands on them to manage an unfamiliar scenario (Alnazly et al.,  2021 ). As such, previously developed regulations, protocols and processes have not been effective or appropriate for responding to changing patient needs or care practices for infection control management; thus, supervisors have simply not had the information needed to guide practice and support junior staff, patients and families (Buheji & Buhaid,  2020 ). We found the nature of relationships to be a consistent source of stress for nurses, with conflicts between co‐workers (nurse to nurse) and with physicians, and a sense of continuous blame directed at nurses being particularly challenging. This is not an unsubstantiated perception, as Wang et al. ( 2020 ) found that other medical professionals often treat nurses as scapegoats.

Age was of particular significance in the present study, as depression, anxiety and stress were significantly higher in nurses aged 25–30 years. This is in line with the results of other studies with nurses in Saudi Arabia (Abu‐Snieneh,  2021 ; Ghawadra et al.,  2019 ) and internationally. For example, in China, Portugal and Turkey, younger frontline nurses were found to be more likely to experience depression and worry about personal or family health during the COVID‐19 pandemic (Murat et al.,  2021 ; Sampaio et al.,  2021 ; Zheng et al.,  2021 ). Potential explanations include a lack of preparedness for the occupational role in a pandemic and less experience responding to crisis situations among younger nurses, compared with older nurses (Shahrour & Dardas,  2020 ). Within our setting, another possible explanation connects to a prevailing cultural expectation. In Arab cultures it is expected that by age 25, most people will have settled down and established a family. Thus, attempts to meet expectations, such as finding the right partner, during the pandemic while experiencing mental and physical distress is likely to increase the negative psychological impact on individuals in this age group.

Nationality was of particular interest, as although the five nationalities of nurses captured in the questionnaire (Filipino, Indian, Malaysian, Saudi and South African) were not normally distributed, Saudi nurses showed higher levels of depression, anxiety and stress than nurses of other nationalities. Similar findings were reported by Al‐Dossary et al. ( 2020 ), whose study on the effect of COVID‐19 in 500 nurses found that non‐Saudi nurses had higher self‐reported awareness, positive attitudes, optimal prevention and positive perceptions compared with Saudi nurses. A possible explanation is that many non‐Saudi nurses working in the region are away from their families, while Saudi nurses are in their usual living arrangements. Therefore, during the pandemic, Saudi nurses have an additional concern of transmitting the virus to their families, while non‐Saudi nationals may be concerned about their loved ones, but do not experience the distress of their job leading to direct risk or harm to them (Abu‐Snieneh,  2021 ). Other studies have also shown family safety to be a significant concern among frontline nursing staff during the COVID‐19 pandemic (Labrague,  2021 ).

5.1. Limitations

The present study has some limitations that should be noted. Although this study provides insights into the main psychological stressors that are impacting the nursing workforce and to what degree, it would have been strengthened by including a qualitative arm to provide context and depth to our findings. This research is planned as our next phase. Survey tools were delivered in their original English language as our hospital nursing staff includes a wide range of nationalities and English is the official language of Saudi healthcare organizations. However, it may be beneficial in future research to develop alternative translations and variables that would more directly capture cultural context.

6. CONCLUSION

The present findings demonstrated a relationship between stress, psychological symptoms and job satisfaction. The main concerns were workload, work department, supervision, collegial relationships and high mortality rates in patients. More research is needed to identify what types of support are required, along with mechanisms to tailor such support to the different variables identified by the nursing participants. Based on the findings of this study, we recommend focusing efforts on raising awareness among hospital managers regarding nurses' psychological symptoms and possible support measures, which may include flexible working hours, clear communication and training in palliative and end‐of‐life care. Finally, qualitative investigation is highly recommended to explore in‐depth further context for the identified sources of stress, and psychological and emotional experiences among nurses as frontline workers facing COVID‐19. A co‐design approach may be particularly beneficial, as this will not only lead to strategies that draw from the knowledge and experience of the nursing staff but also potentially offer these nurses the opportunity to take back some control in a time of immense instability.

AUTHOR CONTRIBUTIONS

All authors listed have met all four of the following criteria: Have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; Been involved in drafting the manuscript or revising it critically for important intellectual content; Given final approval of the version to be published. Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

FUNDING INFORMATION

This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.

CONFLICT OF INTEREST

The authors have no conflict of interest to declare.

ETHICS STATEMENT

Ethical approval was obtained from the King Fahd Armed Forces Hospital—Jeddah Research and Ethics Committee (Ref. number: REC 398), confirming no risk to study participants via the application of an anonymous online survey. This study conforms to the recognized standards listed by the Declaration of Helsinki.

Supporting information

Sharif, L. , Almutairi, K. , Sharif, K. , Mahsoon, A. , Banakhar, M. , Albeladi, S. , Alqahtani, Y. , Attar, Z. , Abdali, F. , & Wright, R. (2023). Quantitative research on the impact of COVID‐19 on frontline nursing staff at a military hospital in Saudi Arabia . Nursing Open , 10 , 217–229. 10.1002/nop2.1297 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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