The association between workload and quality of work life of nurses taking care of patients with COVID-19

The current study’s findings, which sought to ascertain the relationship between nurses’ workload and the quality of their working lives while caring for COVID-19 patients, showed that the average workload for the nurses was 71.43 ± 14.15. Consistent with the results of the present study, Pourteimour et al. (2021) reported the mean workload of nurses who took care of patients with COVID-19 in Urmia and Hamedan hospitals (67.30 ± 14.53) [35]. The results of studies by Shoja et al. (2020) and Judek et al. (2018) also confirmed this finding [36, 37]. Based on findings of research by Bakhshi et al. in Kermanshah hospitals (2017), the mean ± standard deviation of workload score was 69.73 ± 15.26 [5], and it was 59.95 ± 16.41in a study by Jarahian et al. [6], and it was partially less than the present study. In similar studies, nurses’ mean workload was moderate to low in non-critical situations [38‐40]. Malekpour et al. (2014) reported that nurses were responsible for 80% of tasks in health and medical centers and generally had a heavy workload [3]. The COVID-19 epidemic has significantly increased the workload for nurses, as indicated by the results. According to the findings, mental demand was identified as the dimension with the highest perceived workload, while overall performance had the lowest workload, aligning with a study by Gharagozlou et al. (2020) [41]. Shoja et al. (2020) examined the subscales of the workload questionnaire and observed increased scores for mental demand, physical demand, temporal demand, and frustration, leading them to conclude that the COVID-19 pandemic negatively affected staff workload and mental health [36]. A study conducted by Bakhshi et al. (2017) found that mental workload made the highest contribution, while the feeling of frustration had the lowest contribution [5]. Rafiee et al. (2015) conducted a study to measure the mental workload of nurses in the emergency department of a hospital and reported that the dimension of overall performance had the lowest score, while frustration had the highest score [42].

Furthermore, the nurses caring for COVID-19 patients endure high physical and mental demands. Based on the results of some studies conducted before the prevalence of COVID-19, nurses who took care of COVID-19 patients felt more frustrated and discouraged but considered their activities more effective. High and frequent workloads are two key factors leading to exhaustion and burnout [12], resulting in lower overall performance, memory, and thinking process, irritability, annoyance, and reduced learning [43]. The findings of Mohamadzadeh Tabrizis’ study show the negative impact of caring for COVID-19 patients on nurses’ quality of life [44].

This study showed that other than age, there was no link between workload and demographic factors like sex, marital status, number of children, working shifts, and years of work experience. There was a relationship between marital status, mental demand, the number of children, and temporal demand. There was no correlation between workload and work experience in the COVID-19 unit and shift work. Jarahian et al. (2018) found a correlation between workload, work experience, and the number of children. The study indicated that individuals with lower work experience and no children had lower mental workloads [6].

The findings of a study on determinants of workload indicated a significant relationship between physical workload with work experience, age, work pattern, number of shifts, and type of employment, and between temporal demand with body mass index (BMI), work experience, and type of employment [5]. Based on research by Shoja et al., the type of job, work shift, education level, and exposure to COVID-19 affected the workload score [36]. Older nurses, married individuals, and those with children might experience a higher workload due to increased work shifts and forced overtime. The higher workload, particularly regarding temporal demand, is especially evident. Establishing a balance between work life and personal/family demands is vital since research indicates that personal and professional lives often intertwine [4]. Nurses, regardless of gender or age, must work various shifts and wear protective masks in hospitals during the COVID-19 outbreak. Huang et al. (2018) confirm that nurses face high responsibility, heavy workload, intense work pressure, and the need to work in rotational shifts due to the unique nature of their profession [45].

Based on the results, the mean QWL of the nurses was 88.26 ± 19.50. In line with the findings of the present study, Nikeghbal et al. reported that the QWL of nurses who took care of patients with COVID-19 was 92.57 with a standard deviation of 13.2, which was better than the non-COVID-19 caregivers (79.43). A significant association between the two groups was revealed by the comparison (p = 0.001) [46]. The results of Mohammadi’s study in Iran [29], and most studies in the world, show that nursing QWL is mainly at a moderate level and requires improvement interventions [40, 42, 47]. Some studies show an increase in depression, anxiety [48], stress, and burnout [49, 50] among nurses during the pandemic of Coronavirus Disease.

Based on the results, the highest score of subscales belonged to safety and health in working conditions, while the lowest score belonged to work and total living space. Like Aminizadeh’s finding in pre-hospital staffs, Opportunity to use and develop human capabilities had a significant role in nurses’ QWL [26]. According to research on the relationship between job burnout, performance, and QWL, the constitutionalism in how work is organized contributed the most to the QWL score, while the social significance of work life contributed the least [51].

In a study on the relationship between the components of the QWL and job satisfaction of midwives, the results indicated that providing career opportunities and job security had the most significant contribution, and social relevance of work life in the organization had the minor contribution to the QWL in the midwives [52].

Falahi Khoshknab’s study before the COVID-19 pandemic indicated that 21% of nurses described their quality of work life (QWL) as moderate, while 67% described it as good, and 11% of nurses were delighted with their QWL [53]. In a study by Faraji et al. conducted prior to the prevalence of COVID-19, 61% of nurses had a low QWL, and even 39.7% of them wanted to leave their jobs [54]. In line with these studies, the current study, as well as Jafari’s study [48], suggests that nurses must receive adequate support to overcome workplace stressors. The findings of Shirali’s study showed job stress and low resilience as threatening factors in nurses during the care of COVID-19 patients [55]. Therefore, support for nurses should focus on both individual and organizational aspects.

Nurses’ workload has significantly increased, yet their work-life quality remains moderate. Various factors contribute to this category, and we will address some below. The present study identified a significant relationship among age, number of children, work experience, and specific aspects of QWL. Previous studies, such as those conducted by Gharagozlou et al. and Shafipour et al., found no significant relationship between QWL and demographic variables like age, gender, and marital status [41, 56]. Dehghannayieri et al. [57] and Dargahi et al. [58] also found no significant relationship between marital status and QWL, but Khaghanizadeh [59] and Falahi Khoshknab [53] reported a significant relationship. Mohammadi et al. (2017) reported a significant correlation between the QWL and employment status, shift work, hospital, and satisfaction with the field of study (p < 0.001) [29]. According to Gharagozlou’s study, there was no significant relationship between nurses’ QWL with the number of shifts and the number of patients in each shift, but there was a significant relationship between the QWL and overtime hours among the nurses [41]. In a study by Shafipour et al., there were significant relationships between the QWL, overtime hours, number of night shifts per month, and income level, but there was no significant relationship with the job unit [56]. A study indicated that working on the night shift negatively influences nurses’ QWL [60]. Researchers considered possible reasons for contradictions and differences in the types of sectors based on the characteristics of the participants and the study time (before and during the pandemic) in the study. The present study reported no difference among different shifts regarding QWL, but the night shift was associated with a better QWL. Researchers believe this was because most diagnostic and therapeutic procedures were carried out during the morning shift, and systemic supervision and nurses’ freedom of action were reduced during the night shift. However, the difference was not statistically significant.

Furthermore, there was a relationship between work experience and adequate and fair compensation, indicating the financial concerns of married nurses with higher experience and more children. In the present study, the Opportunity to use and develop human capabilities and safety and health in working conditions had the most significant contribution, adequate and fair compensations, and work and total living space had the minor contribution. Consistent with this finding, Jafari et al. reported that the highest contribution to the QWL was the development of human capabilities, career opportunities, and job security, but the lowest was fair compensations [34]. In a study by Dargahi et al. [58] and research in Ethiopia [4], there was a significant relationship between the monthly income level and the QWL. The QWL increased with higher total compensation. A study in Canada indicated that a higher level of income increased the QWL [61], but in a study by Nikeghbal et al., there was a significant relationship between the QWL index (adequate and fair compensations) and monthly income only in nurses who took care of COVID-19 patients [46].

The results of this study indicate a significant inverse relationship between nurses’ workload and quality of work life (QWL). In other words, a higher workload leads to a decrease in QWL. The COVID-19 pandemic has imposed difficult circumstances, and due to the intensity of the workload, nurses have had to put their own lives and the lives of their loved ones at risk while treating COVID-19 patients. The risk of infection and death from COVID-19 has caused significant psychosocial stress for nurses and other healthcare professionals [62]. In similar studies, Lai et al. [63] and Gharagozlou et al. [41] investigated the QWL and workload status using the same tools as in the present study and reported significant relationships between different dimensions of workload and QWL.

Numerous studies have indicated that a high workload endangers the quality and safety of patient care, increases errors, and ultimately prolongs hospitalization time. This situation affects the relationship between nurses, physicians, and patients [64]. In a study by Ardesatni Rostami et al. (2019) focusing on nurses in ICUs, a negative correlation was found between workload and job performance. According to the study, 75% of nurses rated their performance moderate [65]. These studies were conducted primarily before the COVID-19 pandemic, but nurses have always had to work long hours to manage their workload. Although the pandemic has further increased their workload, it has not significantly impacted the quality of their work life. Similar to the pre-COVID-19 era, the quality of work life remains predominantly dependent on organizational factors such as support and financial assistance.

The present findings indicate that an increase in the number of children and effort contributes to a high level of QWL, while work experience and total workload decrease the QWL of nurses during the COVID-19 pandemic. Consistent with these findings, Navales et al. (2021) reported a relationship between individual factors, such as older nurses, females, bachelor graduates with more dependents, more children, and job positions with more extended work experience, and nurses’ QWL in Indonesia [66]. Woon et al. (2021) found that social support from friends and significant others (such as children and spouse) predicted higher QWL. Despite the COVID-19 restrictions, encouragement regarding family and children appears to have positively influenced the quality of nurses’ work life [67].

Contrary to the findings of Gharagozlou’s study, nurses who encounter COVID-19 patients require additional effort, potentially resulting in an enhanced QWL [41]. Hence, despite the numerous adverse effects of the COVID-19 pandemic on nurses, it has also presented opportunities for provisional, organizational, and individual improvements in their quality of life.

The mental burden experienced by nurses in these job groups is significant. Several factors contribute to the creation and escalation of this burden, including consistent and uninterrupted work, work duration, job requirements (such as concentration, accuracy, and effort), physical stress-induced fatigue, age, work experience, environmental factors (such as sound and vibration), equipment usage, individual feedback on work and interpersonal interactions, overtime, and ergonomic working conditions [46]. Thus, these factors are among those that contribute to the increased workload of nurses. Furthermore, as these employees operate within a consistent and stable work environment characterized by the nature of the job and working conditions, they often have longer working hours. Consequently, this leads to physical and mental fatigue, exhaustion, burnout and ultimately diminishing their QWL. In line with the negative effect of workload on QWL, Nikeghbal et al.‘s study supported that an increased workload was associated with a decreased QWL [46].