Ohio Health Care Professionals’ Survey: Work and Home Stressors During the COVID-19 Pandemic

Background: The COVID-19 pandemic brought unparalleled strain to the United States’ already overburdened health care workforce, and research is just beginning to shed light on its effects. This study sought to document health care provider stressors during the pandemic to inform prevention and intervention strategies to better support their well-being. Methods: A one-time online survey was completed in July and August 2021 by Ohio health care professionals employed during the COVID-19 pandemic. We assessed for work and employment status changes and measured the severity of various work and home stressors among respondents who worked during the COVID-19 pandemic (N = 12 807). Results: Over a quarter of respondents had a change in work setting, and 59% had an increase in their workload; 20% of respondents were furloughed, laid off, or unemployed at some point during the COVID-19 pandemic. Over 37% reported a negative financial impact. The work stressors causing the greatest concern were spreading the virus and insufficient communication from leadership. The primary home stressors were a lack of quality time with family and friends, being too tired when home from work to cook, do chores, etc, and being a supportive, present parent. At least half of the sample scored each of these as moderate, significant, or extreme stressors. Conclusion: The COVID-19 pandemic caused unrelenting stress affecting Ohio health care professionals at work and at home. Prevention and early intervention programs and public policies are required to prevent burnout and better support health care worker well-being.


INTRODUCTION
The COVID-19 pandemic caused severe and unforeseen strain to populations and health care systems across the globe.Health care professionals have unique experiences and stressors given their varying degrees of proximity to caring for patients infected by the virus.While there have been innumerous anecdotes about the negative effects and stressors caused by COVID-19 on health care professionals, research is just beginning to determine the extent on a broader scale.
Health care professionals have reported high levels of stress related to concerns about infecting others with COVID-19 while also managing limited supplies of personal protective equipment (PPE) and inadequate staffing. 1Additional documented stressors includ-ed emotional exhaustion and fatigue, staff shortages, and the uncertainty surrounding how long it would take to get the pandemic under control. 2Further, stress and anxiety surrounding the pandemic, how to care for patients, and how to keep healthy were widespread among health care workers, whether doing direct patient care or not.Interestingly, while some research shows that frontline health care workers had more stress and negative outcomes during the pandemic, other studies found that they fared better. 3This may be explained by potentially greater preparation among frontline staff (in terms of emotional and cognitive processes as well as concrete preparation in terms of possessing needed supplies and previously established training, policies, and procedures) for other health care crises.

RESEARCH ARTICLE ojph.org
Ohio Public Health Association Recent research local to Ohio includes a study of 785 Indianabased physicians and administrators, 76% of whom reported significantly higher levels of stress during the pandemic. 4Primary stressors included fear of spreading the virus to their family members (82%), meeting productivity goals (65%), and potential salary reductions or furloughs (59%), while more than half reported having sufficient PPE.When assessing some symptoms of stress, researchers documented significant increases in participants' reports of exhaustion, sleep problems, and anxiety.
In contrast, Northeast Ohio health care workers reported moderately high levels of well-being during the pandemic-perhaps higher than expected. 5A closer look at the data showed significant gender differences whereby males reported higher overall wellbeing, more hours of exercise, and decreased emotional concerns and tobacco use compared to females; but males also reported less positive thinking, more physical concerns, less social support, and more alcohol consumption than females.
In a similar approach, we surveyed Ohio health care professionals in July and August 2021 (N = 13 532) to gain a better understanding of the impact of the COVID-19 pandemic on their employment, finances, well-being, and stressors in the workplace and the home.
Prior to this survey there had not been an examination of these factors across a broad range of health care related disciplines in Ohio.Whereas much previous research has focused on the experiences of nurses and physicians, this study expanded its reach to collect data from other licensed health care professionals as well, including but not limited to social workers, counselors, pharmacists, chiropractors, physical therapists, and chemical dependency professionals.
Three research questions guided the current study: (

Setting
In

Design
The OhioPHP and the evaluation firm co-created the COVID-19 survey for health care professionals.The survey, shown in the Appendix, consisted of 61 questions (56 multiple choice; 5 openended) developed after completing a literature review on health care specific workplace stressors, symptoms of burnout, and related tools.Questions specific to the COVID-19 pandemic were also added (eg, stressors related to spreading the virus, availability of personal protective equipment (PPE), and concerns about homeschooling).OhioPHP's senior staff, its full board of directors, and medical director served as expert reviewers and beta tested and approved the survey before launch.The board consists of physicians, counselors, veterinarians, lawyers, and other health care professionals.Survey modifications were based on their recommendations.In addition to the focus on content, instrument length (as to not overburden respondents), ordering of items, and item clarity were also considered to increase survey validity. 7The survey was administered through an online survey platform.

Participants
The population of interest for the survey included Ohio health care professionals who belonged to the 13 OhioPHP licensing boards (Appendix, question 2), representing a wide range of license types and including chiropractors, psychologists, physical and occupational therapists, and various types of dental, veterinary, vision, medical, nursing, social work, counseling, and chemical dependency professionals.The State Board of Emergency Medical, Fire, and Transportation Services was the only board to not participate as members' contact information are not publicly available as with other licenses.Some participants were dually licensed across more than one board.These individuals were instructed to complete the survey just once, using their primary license and identifying as a member of the corresponding board.
Due to differences and limitations in record keeping across the licensing boards, the exact population size of the Ohio health care professionals licensed by OhioPHP affiliated boards is unknown.However, OhioPHP records show that 490 707 emails were delivered to licensees inviting them to participate in the survey.Using this value as a proxy for the population, the survey response rate was 2.76%.

Procedures
The OhioPHP completed a public records request to obtain health care professionals' emails from each licensing board and distributed the survey link via email.Additionally, many membership associations promoted the survey to their members.The email linked interested participants to an informed consent screen.Acknowledgment of participant rights, risks, benefits, and commencement of the survey served as confirmation of consent.The survey was conducted between July and August 2021, and 2 email reminders were sent after the initial invitation.The survey took approximately 15 minutes to complete.

Measures/Outcomes
For the purposes of this study, outcomes of interest relative to the experience of working during the COVID-19 pandemic were organized under the following categories: (1) work changes and employment and financial impact; (2) work experiences and stressors; and (3) home stressors.Employment status was established using the number of participants who reported being furloughed (temporary, unpaid time off, but still employed), laid off (temporary or permanent time off, no longer employed), and/or unemployed for any reason during the pandemic or not.Financial impact was determined by the number of participants who said they were negatively impacted financially because of furlough, forced time off, pay reduction, or other reason.Respondents were able to choose multiple responses.Work experiences included changes in work setting and workload.Participants were asked to rate all stressors on an ordinal scale: 0 (not a stressor); 1 (minimal stressor); 2 (moderate stressor); 3 (significant stressor); 4 (extreme stressor).Not applicable (NA) was also a response option.

Statistical Analysis
Data were cleaned and analyzed using IBM SPSS Statistics (Version 28). 8Duplicate surveys were identified where responses matched on every demographic variable, starting with the computer's IP address.Cases were then reviewed manually to confirm.In total, 66 cases were removed from the dataset (less than 0.4% of cases).A final sample of 12 807, inclusive of those who reported working at some point during the pandemic, was used for analysis in this study.
Missing data ranged from 0.38% to 5.63% on variables of interest.Univariate descriptive statistics (eg, frequencies, percentages, median values) and tables were used to communicate highlights and trends in the data and allow for visual comparison across var-iables.Median values were reported instead of the mean as the ordinal responses were not normally distributed, stood alone, and were not part of a scale. 9

RESULTS
Participants' demographic data are provided in Table 3 provides the median values for the top work and home stressors and the percentage of the sample who identified the stressor as significant or extreme.Among work stressors, concerns of spreading COVID-19 caused the highest levels of stress followed by insufficient communication from leadership (both had a median score of 2 (moderate stressor).Concerns about spreading the virus were a significant or extreme stressor for 41.23% of the sample and insufficient communication was a significant or extreme stressor for 28.64%.Insufficient PPE and working too many hours were the next highest reported work stressors.Over 25% of individuals also reported that insufficient PPE and working too many hours were significant or extreme stressors.The 2 work stressors causing the lowest levels of stress were inappropriate role designation and working at a new location.Lack of quality time with family and friends (38.71%), being too tired when home from work to cook, do chores, etc (33.71%), and family and friends not understanding the stress individuals were experiencing represented the most frequently reported significant and extreme home stressors; they all had a median of 2. The 2 top stressors among respondents with children were being able to support children/being a present parent (32.36%) and lack of quality time with children (30.98%).Other significant and extreme home and child-related stressors accounting for more than 25% of the sample included worry and/or guilt about infecting household members, taking stress out on family and friends, and homeschooling.The 2 home stressors causing the lowest levels of stress were needing other family members to take over one's responsibilities and financial stress.When summarizing work and home stressors together, over 50% of the sample ranked spreading the virus; insufficient communication from leadership; a lack of quality time with family and friends; being too tired when home from work to cook, do chores, etc; and being a supportive, present parent as a moderate, significant, or extreme stressor.

DISCUSSION
In this study, we examined Ohio health care professionals' employment and financial status, and work and home-related stressors during the COVID-19 pandemic.More than half of Ohio's health care professionals maintained employment and reported no negative financial impact.However, experiencing numerous work and home stressors simultaneously were very common.This is especially noteworthy as half the sample reported not providing direct COVID-19 patient care.
Study results point to a contrast between a smaller group of health care professionals who reported job loss or insecurity (ie, decreased hours, furlough) and a larger group who reported substantial increases in their workloads.Generally speaking, health care layoffs were common during the pandemic as revenue was dramatically reduced when nonemergency health care was placed on hold and patients were hesitant to seek care even when it was available. 10Additionally, a recent scoping review documented financial insecurity related to pandemic salary reductions, furloughs, and unemployment among health care providers as a major stressor. 11Contradicting much of the literature, furloughs, pay reductions, and financial insecurity were not commonly experienced by our sample.On the other hand, heavy workloads during the pandemic have been identified as a common cause of stress, burnout symptoms, and feeling generally overwhelmed for many providers worldwide. 12This finding was validated by our sample as workload increases were widespread and working too many hours was identified a top stressor.In preparing for future public health emergencies, strategies for offering unemployed or furloughed health care workers reassignment from nonessential services to areas in increased demand for providers should be considered.
In this study, the top work-related stressors were related to issues of basic safety.Concern about spreading the virus, insufficient PPE, and insufficient communication from leadership relate to protecting oneself and others and feeling supported by those in positions of power.Similar safety concerns (eg, resource adequacy and getting/spreading COVID-19) have been documented in the literature and may be particularly important to women in health care. 13Other research has shown that steady communication from leadership, in terms of providing acknowledgement of challenges, gratitude, support, and/or sharing good quality organizational information and updates on safety protocols, is fundamental to reduce workers' stress and anxiety. 14,15Basic safety and clear communication are, first and foremost, required for health care provider well-being and, secondarily, are needed to ensure good patient care.
Home stressors were also present for most respondents during the pandemic, and some were considered more severe than those specific to work.There was an inherent conflict between the desire to keep family and friends safe (ie, by not spreading the virus) and wanting to spend quality time with loved ones.Similarly, other researchers have also documented health care providers' struggles related to work-life balance, the fear of exposing family, feeling emotionally exhausted, and neglecting personal and family needs. 2,16,17In our study, health care workers wanted more quality time with family and friends, yet were tired and also felt that family and friends misunderstood the stress they were under at work.In an extension of these findings, a scoping review of health care workers' pandemic experiences summarized that for some, social and emotional connectedness to others served as a support, reduced anxiety, and provided encouragement for their work; for others; it was potentially harmful when family and friends rejected or stigmatized them out of fear that they would transmit the virus due to their increased exposure. 18It is important not to overlook the effect of home stressors on health care providers at work and how home and work stressors can exacerbate one another, particularly during an unrelenting pandemic.
Furthermore, study results show that health care professionals who were also parents carried additional psychological and logistical burdens.Respondents were concerned about not spending enough quality time with their children and challenged by navigating their learning needs.In a study of health care workers in Turkey who were also parents, parenting stress during COVID-19 was highest for those who had a school-aged child and for those with multiple children. 19Similarly, Canadian health care workers were strained by trying to work while having school-aged children whose education moved back and forth between in-person and virtual learning, and/or when children had to unexpectedly stay home because of exposure or required testing to rule out infection. 20

Limitations
Limitations of the study include the use of a convenience sample and a very low response rate which precluded the generalization of the findings to the larger population of health care providers in Ohio.However, respondents were fairly representative of what we a Scored on a 0 (not a stressor) to 4 (extreme stressor) scale.
know about the health care professional demographic in Ohio, which is heavily White and female. 21,22Additionally, the survey was cross-sectional and represents just one snapshot of experiences in time.It is likely that health care professionals may have rated the severity of stressors differently at other points during the pandemic.While the work and home stressors of interest in the study were compiled based on a literature search, it is possible that other stressors that were not included in our survey impacted individuals.

PUBLIC HEALTH IMPLICATIONS
This research study adds to the growing knowledge base about the impact of the COVID-19 pandemic on health care professionals and provides a glimpse into stressors affecting those in Ohio.Numerous preexisting stressors worsened, and others were brought to light.An application of the findings about work and home experiences and stressors has implications for individual health care workers, workplaces, professional organizations, and public policy.By preventing and ameliorating stressors and bolstering the mental health and well-being of health care workers, we can prevent burnout and improve patient safety and quality of care.
The literature is rich with individual-focused, self-care practices for health care workers to reduce stress and improve overall wellbeing.4][25] The problem, however, is that many health care professionals do not utilize self-care activities because of lack of time and fatigue (both identified as prominent workplace stressors through our survey) and a lack of institutional support during work hours for these practices. 26,27Health care leadership and professional organizations need to model these behaviors, facilitate cultures that encourage self-care, and integrate regular opportunities for self-care during the workday. 28 situations where burnout and mental health symptoms are severe, intervention beyond self-care may be required.In Ohio, a new tool has been introduced by the Ohio State Medical Association in partnership with OhioPHP to provide licensed health care professionals and students in the state with a free, fast, and confidential way to be screened and referred for emotional support.Through the Well-Being CARE (WellBeingCARE.org)service, health care professionals can anonymously complete a brief online screening and receive personalized recommendations from licensed mental health providers for local resources, including online and telehealth options. 29ile individual-level interventions are crucial, they remain inadequate to address the widespread stress affecting health care workers in general and, particularly, during a pandemic.Various intraorganizational changes are also needed.As insufficient communication at the workplace was a noteworthy stressor in our study, facilitating effective internal communication is important to decrease stress among workers, in addition to improving efficiency and effectiveness. 15,30Additionally, an easy to implement activity such as having hospital leaders provide daily COVID-19 updates can reduce workers' stress. 2Health care workers desire rationales for protocol changes and inclusion in decision-making processes, and a lack of clear communication and collaboration between clinical and administrative staff can contribute to stress and burnout. 18her research-based recommendations for improving intraorganizational support and reducing stress for health care workers includes making time for camaraderie, developing a culture of teamwork, and providing recognition in terms of personal acknowledgement and financial remuneration. 2,16Building social support resources in the workplace via interprofessional health care teams, the creation of shared spaces and opportunities to discuss stressful issues, and the development of an inclusive, organizational culture can combat feelings of isolation and symptoms of stress and burnout. 31Such activities may have also provided validation to the many study respondents who reported that their stress was misunderstood by family and friends.Furthermore, research suggests that social integration and support are stress buffering and bolster the immune system, reducing the susceptivity to viruses like COVID-19. 32,33veloping peer-driven support networks within organizations may also be helpful in reducing stress and supporting health care worker well-being. 34One program originating from Johns Hopkins University, Resilience in Stressful Events (RISE), emerged from staff requests and trains employees to give confidential support to each other surrounding stressful events to decrease the risk of burnout, self-doubt, and negative thoughts affecting health care workers. 35The RISE program, which has been replicated by over 30 hospitals in the United States, has shown promising effects.Nurses who used RISE reported being more resilient than those who had not used the program, 65% felt better after utilizing it, and 80% of nurse leaders found that it created a safe and nonjudgmental space to discuss job concerns. 36A similar program called YOU Matter has been employed at Nationwide Children's Hospital (NCH) in Columbus, Ohio.Since 2013, NCH has been training staff peers and offering individual and group support which is now available 24 hours a day. 37Moreover, NCH has provided guidance to over 35 hospitals to initiate their own programs. 38These strategies and others may be further supported by the appointment of leadership whose sole purpose is to promote a healthy workplace culture and ensure staff well-being.In 2011, The Ohio State University was the first university in the United States to hire a chief wellness officer and has since shown positive returns on the investment in terms of health care spending, morale, and job and patient satisfaction. 39stly, there is a weighty role for public policy in increasing support for health care worker well-being.This would require a shift from chiefly focusing on treatment and intervention postexposure to an emphasis on public health and prevention.Policies should incorporate flexible schedules to support workers' personal needs and ensure that individuals who must stay home when they are sick do not have to fear job loss or loss of income. 40Since the COVID-19 pandemic, health care workers have been advocating for clear and strengthened policies regarding evidence-based guidelines for staff testing, infection prevention, illness and return to work protocols, and protected time for breaks at work and time away from work. 41Pandemic-related policy changes should also consider placing limitations on hours worked, allowing for additional paid time off, hazard pay, safeguarding adequate staffing and patient-clinician ratios, and funding best practices and clearinghouses focused on health care worker well-being. 42Such policies may help reduce or remove the primary stressors of spreading illness, inadequate PPE, insufficient communication from leadership, and working too many hours as identified by workers in the current study.

Conclusion
As the peak period of the COVID-19 pandemic appears to be behind us, time has come to examine its longer-term sequela which include the psychological burden of Ohio's health care professionals.As expected, Ohio health care workers' stress was magnified at work and at home during the pandemic.These stressors are important to monitor as they can lead to burnout and physical and mental health problems.Furthermore, if left unaddressed they can negatively impact patient care and result in resignation from the health care workforce.Supporting health care professionals' well-being through interventions at all levels (eg, individual, interpersonal, community, organizational) is vital for individual and population health now as well as for preparing for the next pandemic.

2
2021, the Ohio Physicians Health Program, Inc. (OhioPHP), a nonprofit organization focused on advancing the health and wellbeing of health care professionals to improve patient care and safety, 6 received a grant from the Federation of State Medical Boards Foundation to facilitate increased understanding of the influence of the pandemic on Ohio health care workers' stress to improve health care providers' well-being and patient outcomes.The OhioPHP commissioned a Central Ohio-based professional services firm with research and evaluation expertise in the areas of public health and human services to conduct an online survey and analyze the results.

Table 1 .
Most identified as female (76.69%) and White (89.99%).Over twothirds (69.71%) were between the ages of 35 and 64 years.Nearly half (47.72%) reported having children who lived with them at home.The largest number of participants were from the Ohio Board of Nursing, followed by the State Medical Board of Ohio.Respondents averaged 18.67 years of work experience (SD = 12.49) and just less than half (46.90%) reported being directly involved in COVID-19 patient care.Changes in work, employment status, and financial status are detailed in Table2.Over a quarter reported a change in work setting (eg, from in-person to remote work, partially remote, or relocation from department).Over three-quarters had a change in workload.
While 17.56% reported a decrease in workload, 58.98% had an increase or significant increase in workload.Nearly one-fifth of the sample (19.97%) lost a job and over one-third (37.24%) were negatively impacted financially during the pandemic.In addition to those who reported financial strain via furlough, forced time off, and/or a reduction in pay, another 7.06% submitted "other" reasons including partners' loss of income, having to care for family members who were unable to work, and leaving employment due to stress or fear of becoming ill.

Table 2 . Work Changes, Employment Status, Financial Status (N = 12 807) Work a changes n (%)
a Participants could choose multiple responses.