INTRODUCTION:

The novel coronavirus (COVID-19) pandemic has drastically changed people’s way of living and has caused significant physical, social, psychosocial, mental, and psychological impact^1-7. At the beginning of the pandemic, the world went into lockdown. While most people had the option of staying home, frontline workers, particularly nurses, did not have that option. It was reported that about 180,000 health care workers worldwide died from the pandemic⁸.

The latest data showed that as of September 2020, about 1,518 nurses died from COVID-19 in 50 countries⁹. Nurses played a critical role in the fight against COVID-19 despite a critical shortage of protective supplies and nursing staff. For example, Filipino nurses comprise 4% of the United States (U. S.) nursing workforce, yet in 2020, they accounted for 31.5% of COVID-19 deaths¹⁰. The lingering pandemic has caused several negative effects among nurses, including fatigue and burnout¹¹. Fatigue is a common symptom experienced by nurses before the pandemic,¹² but this experience is heightened during the pandemic.

REVIEW OF THE LITERATURE:

Occupational fatigue affects more than 20% of the U. S. working population, with an estimated loss of productivity of over $136 million¹³. It is defined as "extreme tiredness and reduced functional capacity that is experienced during and at the end of the workday"¹⁴(p. 274). Work-related fatigue among nurses includes acute and chronic fatigue and intershift recovery as well¹⁴. Acute fatigue occurs after work and can progress to chronic fatigue/exhaustion. Intershift recovery refers to the person’s ability to recover between work shifts¹⁵. Occupational or work-related fatigue significantly impacts a person's and nation's socio-economic, political, and psychosocial aspects. There is ample evidence in the literature on nurses experiencing occupational or work-related fatigue^16-22. Human error is a significant consequence of fatigue that can majorly impact patient outcomes and be devastating for a nurse^23,24.

There are several work-related and non-work-related factors that contribute to fatigue among nurses. Sleep deprivation or lack of sleep is a major contributor to fatigue among nurses^25,26. Ritzy and Hendra reported that nurses from Bangoor who had poor quality of sleep had a 2.9 times likelihood of experiencing fatigue²⁷. Both fatigue and lack of sleep can significantly impact the nurse’s wellbeing. Therefore, we aimed to 1) explore the level of occupational fatigue and sleep quality among Filipino nurses working during the COVID-19; 2) determine the relationships between occupational fatigue, sleep quality, and subjective wellbeing among Filipino nurses working duringthe COVID-19 pandemic.

THEORETICAL FRAMEWORK:

Lazarus and Folkman’s (1987) Transactional Theory of Stress and Coping²⁸ was the theoretical guide for this study. The key concepts of this theory are stress, cognitive appraisal, and coping. The COVID-19 pandemic has generated significant stress and increased disparities, particularly among minority groups, including Asian Americans. Cognitive appraisal is the person’s constant evaluation of what is happening and the implication of information to the person’s well-being²⁸. There are two types of the appraisal – primary and secondary. This paper will focus on the effect of primary appraisal on coping. Primary appraisal is concerned with motivational relevance, which involves three types - harm already experienced, threat described as anticipated harm, and challenge in which a person must mobilize to cope for a positive outcome²⁸. Through primary appraisal, Filipino nurses determine whether COVID-19-related stressors threaten their wellbeing. COVID-related stressors were occupational fatigue and sleep quality.

Figure 1: Application of Lazarus & Folkman’s Stress and Coping Theory

METHODS:

Design:

A descriptive, correlational, and cross-sectional study design was conducted.

Ethical Consideration:

Institutional Review Board exempt approval was received from Eastern Michigan University.

Sample/Setting:

A convenience sample of Filipino nurses across the U. S. were recruited. Based on power analysis, 126 Filipino nurses were required to achieve a medium effect size, powered at 0.80 with a significance level of 0.05. Filipino nurses were recruited with the assistance of the Philippine Nurses Association of America (PNAA) and its regional chapters. Other recruitment avenues were through personal contacts and social media. A survey was distributed via REDCap, which was available at our university. The informed consent was included in the survey. Participants clicking the survey denoted consent to participate. The survey was anonymous, and no email addresses were collected with the survey. The study raffled $10 eGift cards to interested participants. Those interested in participating in the raffle were required to email the investigators separately to provide their names and email addresses.

Measures:

a) Occupational Fatigue:

The 15-item Occupational Fatigue Exhaustion Recovery Scale (OFERS)assesses occupational fatigue¹⁵. Of the 15 statements in the OFER scale, the first five items (1-5) assess chronic fatigue (OFER-CF), the next five items (6-10) determine acute fatigue (OFER-AF), and the final five items (11-15) evaluates intershift recovery (OFER-IR). The scores on each subscale ranged from 0-100. The instrument reported excellent psychometric properties of face, construct, convergent, and discriminant validity; reliability; internal consistency; and strong predictive power. This instrument has established validity with registered nurses, with test-retest reliabilities ranging from .62 to .84 for the subscales²⁹. The OFER scale has also been translated and validated in multiple languages. The OFER scale uses subscale scores of 0-25 (low level of fatigue); 26-50 (low/moderate level of fatigue); 51-75 (moderate/high), and 76-100 (high level of fatigue). For the OFER-AF and OFER CF, the higher scores indicated a higher level of occupational fatigue, whereas, in OFER-IR, the higher score indicated a higher degree of recovery. Permission to use the survey was obtained and purchased from Dr. Peter Winwood.

b) Sleep Quality Scale:

A single-item Sleep Quality Scale³⁰ that assessed the global quality of sleep throughout 7-days will be used to assess nurses' sleep quality. The scale uses a visual analog scale from 0 (terrible sleep) to 10 (excellent sleep). This instrument's psychometric properties included concurrent criterion validity between SQS and MQI (week 1 Pearson correlation −.76) and PSQI (week 8 Goodman-Kruskal correlation −.92). Test-retest reliability (intraclass correlation coefficient) was .62 during four weeks of sleep stability in patients with insomnia and .74 in stable patients with depression (1 week)³⁰. Therefore, permission to use the scale was obtained.

c) Well-Being:

The Satisfaction with Life (SWL) scale³¹ was used to assess the wellbeing of Filipino nurses. The 5-item SWL on a 7-point Likert scale measures the global cognitive judgments of satisfaction with one’s life. The possible range of scores is 5 to 35. A score of 20 represents the neutral point on the scale; scores between 5 and 9 indicate that the respondent is extremely dissatisfied with life, and those between 31 and 35 indicate that the respondent was extremely satisfied with life. Scores between 21 and 25 represent slightly satisfied, and scores from 15 to 19 are interpreted as falling in the slightly dissatisfied range. The scale has a high internal consistency of coefficient alpha ranging from .79 to .89. The scale also has good test-retest correlations (.84, .80 over a month interval)³¹. Permission to use the scale is available electronically at https://eddiener.com/scales

Data Analysis:

The newest version of SPSS, version 26, was used for data analysis. Descriptive statistics will be used to report demographic indicators and calculate means scores in the independent and dependent variables. In addition, correlation analysis was used to determine the relationship.

RESULT:

Socio-demographic Characteristics:

One hundred ninety-nine (224) participants responded to the survey; however, after removing duplicates and incomplete survey data, only 166 surveys were included. Of the 166 responses, data from 126 Filipino nurses who were currently working during the time survey were included in the data analysis. The cohort consisted of 77% females with a mean age of 49.8 (SD = 12.1 years), 68% married, 53% had children living with them, and 91% practiced religion. The majority (56%) of the participants were from the northeast region of the U. S. Most of the nurses completed their baccalaureate degree, 81% were working full-time, hospital-based (65%), working either 8- or 10-hour shifts (43% and 42%, respectively). Table 1 presents the socio-demographic characteristics of the participants.

Table 1: Demographic Characteristics

Socio-Demographic Characteristics

Frequency (n)

Age (mean)

49.8 (SD=12.1) years (n=125)

Gender (%)

Male

Female

% (n)

23% (29)

77% (95)

Marital status

% (n)

Single

In a relationship

Married

Separated/Divorced

Widow/er

16% (20)

8% (10)

68% (85)

6% (7)

2% (3)

Practice religion

Yes

% (n)

91% (113)

9% (11)

Highest Educational Attainment

Associate Degree

Baccalaureate Degree

Master’s Degree

Doctoral Degree

% (n)

3% (n=4)

51% (n=64)

41% (n=52)

5% (n=6)

Number of Years as a Nurse (mean)

25 years (SD=13) (n=126)

Working Status

Full time

Part-time

Areas where RN is working

Hospital

Ambulatory/Clinic

Home care

School

Academic

Others

Work Shift

8-hour

10-hour

12-hour

Others

% (n)

87% (n=110)

13% (n=15)

% (n)

65% (n=82)

10% (n=12)

7% (n=9)

1% (1)

6% (n=7)

11% (14)

% (n)

43% (n=54)

42% (n=52)

11% (n=14)

4% (n=50

Shift Time

Days

Afternoon

Nights

% (n)

81% (n=102)

5% (n=6)

14% (17)

Sleep quality score (mean)

Terrible/Poor

Fair

Good

Excellent

6.4 (SD=1.96), (n=126)

10% (n=13)

40% (n=28)

46% (n=58)

4% (n=5)

OFER

OFER-AF

OFER – CF

OFER-IR

Mean (SD), (n=126)

59.4 (SD=22.2)

54.8 (SD=27.6)

49.7 (SD=18.9)

Overall SWL

Extremely dissatisfied with life (5-9)

Dissatisfied with life (10-14)

Somewhat dissatisfied with life (15-19)

Neutral (score: 20)

Somewhat satisfied with life (21-25)

Satisfied with life (26-30)

Extremely satisfied with life (31-35)

23.9 (SD=7.1) (n=126)

3% (n=4)

8% (n=10)

16% (n-20)

4% (n= 5)

20% (n=25)

32% (n=41)

17% (n=21)

Descriptive Analyses of Variables:

The mean OFER -AF score of Filipino nurses working during COVID-19 was 59.4(SD=22.2), whereas the mean score on OFER -CF was 54.8(SD=27.6), indicating a moderate/high level of fatigue. Filipino nurses’ score in intershift OFER was 49.7(SD= 18.6). Sixty-two nurses experienced moderate/high to high acute occupational fatigue; 56% moderate/high to high OFER-CF, and 58% reported moderate/high to high intershift OFER. (Table 3).

Table 3: Overall OFER score and subscales

Ofer Categories	Ofer-AF (%)	Ofer-CF	OFER-I
Low	18% (n=23)	21% (n=27)	22% (n=28)
Low/Moderate	20% (n=25)	23% (n=29)	18% (n=23)
Moderate/High	31% (n=39)	23% (n=29)	31% (n=39)
High	31% (n=39)	33% (n=41)	27% (n=36)

The overall mean sleep quality was 6.4 (SD=1.96). Ten percent of the Filipino nurses reported poor quality of sleep. On the other hand, most nurses reported fair and good sleep quality (40% vs. 46%, respectively). The overall mean SWL score was 23.9 (SD= 7.1), indicating somewhat satisfaction with life. Twenty-seven percent of Filipino nurses reported being somewhat dissatisfied with life’s current situation, whereas 69% were somewhat satisfied to extremely satisfied with life.

CORRELATIONAL ANALYSES:

A significant negative correlation was noted between SWL, OFER-AF, and OFER-CF (p=0.003 and p=0.006, respectively) among nurses working during COVID-19. There was, however, a significant positive correlation between OFER-IR and SWL. No significant relationship between sleep quality and SWL. Sleep quality had significant negative correlations with OFER-AF and OFER CF but a significant positive correlation with OFER-I. A significant (See Table 4).

Table 4: Variable Correlations [Pearson’s r (N)]

Sleep Quality

OFER CF

OFER AF

OFER IR

Wellbeing (SWL)

Sleep Quality

-0.257**

(126)

-195*

(n=126)

229**

(n=126)

0.109

(126)

OFER CF

-0.257**

(126)

0.654**

(n=126)

-0.257**

(126)

-0.243**

(n=126)

OFER AF

-195*

(n=126)

0.654**

(n=126)

-.648**

(126)

-0.263**

(n=126)

OFER IR

0.229**

(n=126)

-0.634**

(126)

-0.648**

(126)

0.212*

(n=126)

Wellbeing (SWL)

0.109

(n=126)

-0.243**

(126)

-0.263**

(n=126)

0.212*

(n=126)

* = p < .05, ** p = <.001

DISCUSSION:

This study found that Filipino nurses working during COVID-19 experienced moderate to high acute and chronic occupational fatigue levels, lower intershift recovery levels, and good fair sleep quality. In addition, a significantly negative correlation between OFER-AF and OFER-CF and wellbeing, and a significant positive correlation between OFER-IR and wellbeing among Filipino nurses working during COVID-19. However, there is no significant relationship between sleep quality and wellbeing among working Filipino nurses, but sleep quality has a significant relationship with occupational fatigue scores.

Findings with acute and chronic occupational fatigue are not surprising as COVID-19 cases and death tolls continue, and new variants keep evolving³². This result applies to nurses in the U.S. but worldwide as well^16,33-35. Some factors contributing to acute fatigue among nurses working during COVID-19 included level of risk³⁶, staff shortages, insufficient PPEs, emotional demands and lack of sleep³⁷.

The present study also noted that Filipino nurses working during the pandemic had a low recovery threshold, as evident in their OFER-IR score. This means that nurses working during the pandemic did not have enough time between shifts to recover from the fatigue of previous shifts. Intershift recovery of nurses working rotating shifts is vital as this can disrupt their circadian rhythm leading to inadequate sleep³³. The low intershift recovery can be explained by nurses being required to work longer hours and overtime due to staffing shortages and patient acuity during the pandemic. Nurses' recovery in-between shifts are important as there is evidence that inadequate intershift recovery is related to poor patient outcomes, such as increased medication errors, patient falls, and patient mortality^16,38. A recent study by Haluza et al. reported that after two consecutive 12-hour night shifts, nurses need at least three days off work to have full recovery³⁹. This further demonstrates the magnitude of fatigue experienced by nurses who work continuously during the COVID-19 pandemic. Lack of rest breaks and burnout were identified in Alshammari et al.’s study³⁵.

Further, a significantly negative correlation between OFER-AF and OFER-CF and wellbeing, and a significant positive correlation between OFER-IR and wellbeing among Filipino nurses working during COVID-19. These findings supported previous studies on fatigue and wellbeing among nurses^,40,41. This was not surprising as Filipino nurses, like other nurses working during the pandemic, remain resilient and hopeful despite the toll of the pandemic⁴².

Filipino nurses in this present study reported having good and fair sleep quality. This was in contrast to most of the studies that examined the sleep quality of nurses during the pandemic^43,44. Interestingly, sleep quality had no significant relationship with wellbeing among Filipino nurses; however, a relationship was noted between sleep quality and occupational fatigue. Culture may play a role in the lack of relationship between sleep and wellbeing. Spirituality and social support may directly influence Filipino wellbeing more than sleep quality^45-47. However, it is imperative to note that there is evidence that poor sleep quality is an important cause of fatigue among frontline workers^38,48; hence, strategies to improve sleep among healthcare workers remain an important goal_.

We acknowledge several limitations of the study. First, this study was among Filipino nurses only; hence generalization is limited to this group of nurses. Second, most respondents were from the country's northeast region and therefore may not be a good representation of all nurses. Third, we did not examine relationships between demographic characteristics and studied variables. Finally, future research is needed for intervention studies to decrease nurses' occupational fatigue.

CONCLUSION:

This study presented the significant effect of the COVID-19 pandemic concerning occupational fatigue, sleep quality, and wellbeing among Filipino nurses working during the pandemic. Filipinos have the occupational calling for nursing, and the pandemic did not deter them from this calling by continuing to work without complaint during this critical period. Therefore, there is sufficient evidence and opportunities for health care administrations to create strategies to enhance the wellbeing of their largest and most valuable workforce.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGMENTS:

The authors would like to thank the Philippine Nurses Association of American (PNAA) for awarding the research scholarship award to Dr. Meriam Caboral-Stevens to conduct this study and to all the regional chapters of PNAA for assisting in data collection.

We also would like to thank Dr. Maria Rosario-Sim, Dr. Brigitte Cypress, and Ms. Laarni Florencio for recruiting participants for this project.

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Received on 18.08.2022 Modified on 03.10.2022

Asian J. Nursing Education and Research. 2023; 13(1):67-72.

DOI: 10.52711/2349-2996.2023.00016