Addressing Workplace Stressors Emerging from the Pandemic.

Introduction

Faced with new and exacerbated stressors on workers due to COVID-19, employers are asking what they can do to support employees’ mental health and wellbeing and rebuild a resilient workforce. To serve as a guide, this paper reviews workplace interventions aimed at improving workers’ mental health and wellbeing. The review was developed with support from the National Institute for Occupational Safety and Health (NIOSH) Total Worker Health® Centers of Excellence as part of a broader program to design, implement, and evaluate large-scale initiatives focused on mental health in the workplace.[1]

Background

In March 2020, the World Health Organization[2] (WHO) declared COVID-19 a pandemic, the effects of which would create immense and long-lasting damage to societies and their economies. COVID-19 negatively affected employee mental and physical health, and consequently workforce productivity.[3] Specifically, since the COVID-19 pandemic emerged, employees have reported increased stress and anxiety levels precipitated by new circumstances affecting work-life balance, employment status, and financial insecurity.[4] Organizations have endured forced shutdowns, revenue instability, absenteeism, vacancies, and low productivity, all of which have exerted a profound impact on business climate and the global economy.[5-7]

Factors affecting workplace mental health and wellbeing during the pandemic were organized into 3 stressor categories: Psychosocial, Organizational, and Environmental (POE factors).

Psychosocial Stressors

A worker’s personal characteristics and psychological state influence their workplace behaviors and interface with psychosocial stress at work, eg, job demand-support and effort-reward imbalance. One of the most prominent psychosocial stressors is work-life conflict, which the pandemic aggravated through increased workload and irregular work schedules.[8,9] Additionally, school and daycare closures blurred home-life boundaries, especially for women who are often expected to take on a larger share of family and childcare responsibilities in addition to their paying jobs.[10,11]

Fear of COVID-19 exposure and infection was another psychosocial stressor. For months, the novel nature of the virus and limited treatment options fostered intense anxiety among workers who were unable to limit contact to infected individuals. Some workers were faced with the dilemma of protecting the health of members of their household or keeping a job that provided needed income. For workers who were able to limit physical contact with others, social isolation took a heavy toll on their sense of connectedness and social engagement.[12,13]

Organizational Stressors

Organizational conditions include the set of programs, policies and environmental supports that foster a healthy and safe workplace. During the pandemic, organizations had to modify processes and policies to address emergent supply chain shortages, requirements for technological adaptation, staffing limitations, and uneven demand for products and services. Unprepared human resource management led to increased anxiety and uncertainty among staff, which intensified workplace conflicts.[14,15]

Wages and salaries did not increase in proportion to workload and work demands, causing increased financial stress on employees. For workers in industries whose earnings included tips from in-person interactions, the pandemic reduced take-home pay. Over half of restaurant workers reported they would not come back to their jobs unless higher steady wages and consistent schedules were offered.[16] Further, the pandemic intensified known structural issues such as inadequate employer and government-sponsored benefits (eg, health insurance, childcare benefits, and paid sick leave).

Environmental Stressors

Biological (including viral), chemical, mechanical/ergonomic, and physical exposures impact worker illness, injury and mental health outcomes. Front line workers reported feeling unsafe during the early stages of the pandemic because social distancing to reduce viral exposures was not always possible or enforced. Further, access to personal protective equipment (PPE) was limited even for health care workers, and communications regarding safe working conditions were inconsistent.[14,17-21]

Employee Outcomes

As a result of these stressors, employees have reported increased psychological distress, depression, anxiety, burnout, feelings of isolation, insomnia, anger, and cynicism.[17,20-22] Working in unsafe environments heightened the risk of contracting COVID-19 and sustaining injuries.[22,23] Workers also experienced increased drug and alcohol use as mechanisms to cope with stress.[13,23,24] Workers' deteriorated health has been linked to decreased employee performance, increased job vacancies, and high turnover.[14,16,22,25-28]

Interventions

We conducted a literature review to identify interventions to address the immediate crisis of COVID-19 along with strategies applicable to non-crisis situations (Table 1 and Table 2). In the narrative that follow the tables, we elaborate on the interventions and their value in addressing mental health and wellbeing challenges at work.

Table 1.

Psychosocial, organizational, and environmental (POE) stressors, interventions, and expected outcomes.

Dimension	Stressors	Interventions	Expected Outcomes
Psychosocial	• Work-life conflict	• Self-care	Decrease in
	• Fear of COVID-19 exposure and infection	• Employee empowerment	• Psychological stress, distress, and anxiety
	• Social isolation	• Social connectedness	• Burnout
		• Mental health services	• Stigma and feelings of isolation
			• Post-traumatic and other stress disorders
			• Insomnia
			• Anger and cynicism
			• Behavioral deviance
Organizational	• Increased workload	• Assistance programs providing concrete support	Decrease in
	• Poor human resource management	• Improved communication	• Employee turnover rates and voluntary resignations
	• Economic/job insecurity		• Inability to fill job vacancies
	• Lack of employer-sponsored benefits		• Poor employee performance
Environmental	• Physical environment conducive to virus transmission	• Reinforcing infection control measures	Decrease in
	• Frequent face-to-face interactions	• Providing PPE and clear instructions on use	• Risk of contracting COVID-19
	• Loosely enforced safety protocols	• Adding safety trainings and workshops	• Risk of sustaining an injury
	• Limited access to personal protective equipment (PPE)	• Reaching out directly to employees regarding environmental interventions	• Substance and alcohol use
	• Unclear regulatory guidance and communication	• Ensuring workspaces are well-ventilated, accommodate social distancing, and installing appropriate physical barriers	• All-cause mortality

Table 2.

Sample Programs Addressing the POE Factors.

Dimension	Sample Program	Program Elements	Satisfaction	Program Impact
Psychosocial	A “help point” program[29]	After psychological support requests are made by healthcare workers, a multidisciplinary team follow 6 steps:	High	• Improved healthcare workers’ productivity
		1. Conduct a demand analysis of the support request
		2. Conduct a case assessment		• Sickness absence days reduced by 60%
		3. Provide psychological support to healthcare workers when needed
		4. Collect feedback		• Net profit related to reduced absenteeism in a year was estimated to be EUR 58919.13, yielding a return on investment (ROI) of EUR 2.73 for each euro spent
		5. Compare pre- and post-intervention health status
		6. Monitor healthcare workers’ health status to ensure improvement sustainability
	A digital psychological wellbeing support package for healthcare workers[30]	Healthcare workers use an interactive e-learning package to locate information and resources on COVID-19-related psychological impacts, psychologically supportive teams, communication, social support, self-care, managing emotionsetc.	High	• High participation. Accessed 17 633 times within 7 days of release, High satisfaction. Recruited healthcare workers and students (n = 55) assessed the package and reported high content quality, intervention practicality, and package usability • Outcomes not yet assessed
	Improving employees’ physical and mental behavioral health with the assistance of wearable devices[31]	Employees wear a device that keeps track of behaviors such as physical activity, healthy food choices, and sleep	Not directly measured	• Increased likelihood of engaging in physical activity, healthy eating • Positive changes in employee engagement, job satisfaction, and organizational commitment
	Prioritizing a diversity climate and perceived supervisor support[32]	Supervisors provide informational and emotional support to employees and address cynicism that can foster distrust and harassment in the workplace	Not directly measured	• Increased sense of fairness  • Decreased sense of discrimination and social exclusion
Organizational	Inclusive leadership[8]	Managers exhibit “words and deeds that invite and appreciate others' contributions”	High	• Assessment results showed that inclusive leadership negatively correlated to psychological distress and positively correlated to work engagement  • Created an open and engaging environment for healthcare workers, Reduced psychological distress significantly and sustainably
	Managers’ supportive behaviors[15]	Managers create a positive psychosocial safety climate in which organizational policies and practices are perceived as protective to employees’ physical and psychological health. Showing genuine concerns about employees’ welfare and acting quickly to address employee health issues are 2 examples of manager support Managers demonstrate supportive behaviors such as paying attention to employees’ health and wellbeing, showing appreciation, and providing guidance	Not directly measured	• A positive psychosocial safety climate accounts for a 13% increase in employees’ wellbeing score and a 13% decrease in employees’ symptoms of common mental disorders  • Managers’ supportive behaviors account for a 10% increase in employees’ wellbeing score and a 7% decrease in employees’ symptoms of common mental disorders
	Paid sick leave[33]	Provide employees in all states with 1 hour of paid sick leave for every 30 hours worked. The formula is retroactively applied to the prior 26 weeks	High	• A 49% expansion of paid sick leave access (employees who were qualified for paid sick leave were expanded from those from 11 states and DC to all employees) reduced presenteeism by approximately 15%  • Workers who had 2 or more years of tenure with the company had the largest decrease in presenteeism
	A fun workplace[28]	Plan fun activities, social opportunities, and set expectation that manager encourages employee socializing, and provides clear and meaningful job description at training	Moderate	• Turnover was significantly reduced by coworker socializing and managerial support for fun at workplace
Environmental	Universal masking[34]	Require mask-wearing for all healthcare workers at workplace	Not measured	• PPE can effectively prevent healthcare workers from being infected

Psychosocial Interventions

Employers can implement psychosocial interventions that focus on self-care, employee empowerment, social connectedness, and access to mental health services. We describe examples of each in this section.

Self-care is the first step in resilience building. Employers can communicate the importance of self-care during crises by addressing the health benefits of self-care routines such as: taking breaks, getting enough sleep, and healthy eating and meal preparation; and offer resources such as: mindfulness and relaxation trainings, access to meditation apps, and physical exercise incentives.[3,30,35-38] Employers can also give employees permission to flexibly schedule self-care into their daily routine.[30,37] Finally, employers can train managers to model self-care to build healthy cultural norms.[13,19,38-40]

Employers can also acknowledge that it is common to feel powerless during a crisis that has a long-lasting, worldwide impact. Employers can empower their employees by encouraging employees to take breaks when needed; encouraging employees to speak up when struggling[9,40-43]; offer employees accommodative work arrangements[44,45]; and grant employees the opportunity and authority to participate in decision-making.[23,40,44,46,47]

For workers who report feeling isolated and disconnected, employers can help build interpersonal support and social connectedness to instill a sense of belonging, support, and social fulfillment in the workplace[46]; be attentive to workers’ feelings, feedback, and non-workplace needs[48]; highlight shared goals and promote a team growth mindset[41]; provide platforms to bond employees over shared experiences and mutual concerns[12,40]; implement a buddy system in which employees are paired to provide mutual support[38,41,49]; and use digital communication platforms when in-person check-ins are not feasible.[35]

Supporting access to mental health care is critical and can address employees’ stress and anxiety,[50,51] foster healthy relationships in the workplace, and improve productivity.[52] Employers can remove barriers to treatment by having counselors available on site or near workplaces[12,53]; offering virtual mental health resources as an alternative when in-person care is not available[54]; expanding Employee Assistance Programs (EAPs) using online mental health resources[44]; and providing free subscriptions to credible mental health applications and platforms.[44]

For employees experiencing acute psychological symptoms of stress, psychological first aid should be added in the toolkit. A mental health analogue to physical first aid, psychological first aid (PFA) is a form of psychological crisis intervention that has been shown to be effective in reducing acute stress.[55] For example, the Johns Hopkins RAPID psychological first aid model is an evidence-based intervention involving Reflective listening, Assessment, Prioritization, Intervention and Disposition.[56]

Example interventions providing psychosocial support (see Table 2)

A “Help Point” program, offered by Bambino Gesù Children’s Hospital in Rome, Italy, was led by a multidisciplinary team and followed a six-step process to provide psychological support to healthcare workers.[29] A “demand analysis” was first completed to assess healthcare workers’ contextual needs for psychological assistance. Then, psychologists and occupational health physicians examined reported problems and complaints. A series of therapeutic interviews conducted by the psychologist followed. The monitoring phase assessed the sustainability of the program. Evaluation of the program found that 8 meetings were adequate for significant mental health improvement. Participants reported reduced work discomfort, improved mental health, and decreased absenteeism. The intervention also benefited the organization, in that sickness absence days were reduced by 60% and over EUR 58,000 of net profit related to reduced absenteeism in a year was generated for the hospital as workers’ productivity improved, yielding a return on investment (ROI) of 2.73 for the program.

A digital psychological wellbeing support package for healthcare workers[30] was developed at the University of Nottingham during the first 3 weeks of the COVID-19 outbreak. The intervention included an interactive e-learning toolkit with links to psychological resources, supportive teams, self-care guides, and other sources relevant for the early stages of the pandemic. The platform was accessed 17 633 times within the first 7 days of release. Users reported high satisfaction with the content quality, intervention practicality, and package usability.

Organizational Interventions

Organizations can support the wellbeing of employees by offering living wages, competitive benefits, incentives for risky assignments, and flexible work arrangements (eg, condensed work weeks, lower exposure positions for high-risk workers, and cross-training).[16,23,44,45] Examples of organizational interventions include: non-punitive absence policies[45]; paid time off and sick leave[29,57]; provision of explicit career path growth opportunities[58]; expanded benefits (including mental health care, childcare, eldercare)[44,45,50]; free access to EAPs with allowances for additional therapy sessions[44,50]; enhanced job security by offering furloughs (instead of layoffs or terminations) to employees not able to work due to temporary organizational insolvency or personal health reasons[24,44]; provision of perks, such as food delivery, alternative housing/lodging, and childcare[14,41,44]; and use of practical reintegration protocols for returning employees including reassimilation training, career advancement, and widely publicized resources for emotional and physical support.[59-69]

A healthy work environment is beneficial to workers’ mental health and wellbeing during crises.[70,71] Building a healthy company culture includes recognizing employees for their hard work; giving positive feedback routinely (not just during performance reviews); communicating opportunities for promotions and raises; and demonstrating social intelligence by listening closely in times of grief or high stress.[8,23,72,73] Other ways to build healthy company cultures include organizing informal fun social events such as light-hearted team challenges.[28] Also shown to be effective in maintaining a healthy company culture is building an inclusive workforce that emphasizes diversity of opinion, race, ethnicity, gender, sexual orientation, and cultural background.[8,32,50,74]

Organizations can heighten stressors if workplace communication lacks consistency, clarity, or empathy.[39] Strengthened communication can reduce unnecessary stress and improve team morale. Examples of activities that improve communications to employees include routine messaging to address fear or uncertainty[18] provided in clear language,[41] eg, updated policies, health behavior recommendations, and required safety protocols[59]; increasing managers’ availability to employees, welcoming constructive input, transparency in providing alternative actions, resources, and career growth opportunities[9,57,60]; and communicating positive and hopeful sentiments and stories.[44,61]

Example interventions involving organizational support (see Table 2)

Paid sick leave has been shown to be effective in reducing presenteeism and retaining tenured employees.[33] An example is Olive Garden’s approach that credits employees with 1 hour of paid sick leave for every 30 hours worked, and this formula is also retro-actively applied to the prior 26 weeks.[63] A study found that a 49% expansion of Olive Garden’s paid sick leave access reduced presenteeism by approximately 15%, and workers who had 2 or more years of tenure with the company had the most substantial reduction in presenteeism.[33]

Environmental Interventions

The pandemic has required that workplaces consider both infrastructure and administrative controls to guard against exposure to infectious agents. A healthy work environment, along with training in problem-focused coping strategies, has been shown to reduce post-traumatic stress disorders (PTSD).[64] Organizations can lessen environmental hazards by reinforcing infection control measures through frequent updates of safety protocols, ongoing monitoring of hazards, and investing in environmental air purification systems[14,16,17,45,57,65-68]; providing PPE and clear instructions on its use as part of a normal work routine[34,69]; providing safety trainings and workshops[17,41,42,45,57,65]; ensuring workspaces are well-ventilated, accommodate social distancing, and contain appropriate physical barriers[45,69]; and employee engagement to inform environmental interventions to make them feel safe returning to work.[50]

A healthy work environment can provide comfort, foster a sense of security, encourage social bonding and community support, and help employees cope with stress during crises.[70,71] Investment in workplace built environment (eg, ventilation and air purification systems, physical barriers) and administrative controls (e,g, social distancing, one-way traffic) can reduce exposures to the virus that causes COVID-19 and can improve worker perceptions of safety culture.

Example intervention involving environmental support (see Table 2)

Because the virus that causes COVID-19 is so infectious through airborne routes,[2] universal masking – requiring employees to wear masks at workplace – has proven to be an effective environmental intervention. A Massachusetts community healthcare system secured N95 masks for all healthcare workers who directly worked with patients either confirmed or suspected of COVID-19 infection and other approved masks for all clinical and non-clinical staff. As a result, the 7-day average incidence rate between March 17th, 2020 to May 6th, 2020 decreased among the healthcare workers, whereas it increased among Massachusetts residents where universal masking was not mandated. The results showed that mask mandates among healthcare workers can significantly decrease SARS-CoV-2 positivity rate and slow the spread of the virus.[34]

Conclusion

The impact of the COVID-19 pandemic has been significant and reverberating. When employers take initiative to identify psychosocial, organizational, and environmental stressors and intervene strategically in these areas, it will likely mitigate employee stress and further support a healthy, productive, resilient, and thriving workforce.