FAST TRACK ARTICLE
Personal Protective Equipment and Mental Health Symptoms
Among Nurses During the COVID-19 Pandemic
Judith E. Arnetz, PhD, MPH, Courtney M. Goetz, BA, Sukhesh Sudan, MPH, Eamonn Arble, PhD,
James Janisse, PhD, and Bengt B. Arnetz, MD, PhD
Objective: To determine the association between access to adequate per-
sonal protective equipment (PPE) and mental health outcomes among a
sample of U.S. nurses. Methods: An online questionnaire was administered
in May 2020 to Michigan nurses via three statewide nursing organizations
(n ¼ 695 respondents). Multivariable logistic regression analysis was used to
identify factors associated with mental health symptoms. Results: Nurses
lacking access to adequate PPE (24.9%, n ¼ 163) were more likely to report
symptoms of depression (OR 1.96, 95% CI 1.31, 2.94; P ¼ 0.001), anxiety
(OR 1.64, 95% CI 1.12, 2.40; P ¼ 0.01) and post-traumatic stress disorder
(OR 1.83, 95% CI 1.22, 2.74; P ¼ 0.003). Conclusions: Healthcare orga-
nizations should be aware of the magnitude of mental health problems
among nurses and vigilant in providing them with adequate PPE as the
pandemic continues.
Keywords: COVID-19, mental health, nurses, personal protective
equipment
BACKGROUND
T he coronavirus disease (COVID-19) pandemic has been
defined by the rapid spread of the severe acute respiratory
syndrome (SARS) coronavirus-2 and the healthcare system’s strug-
gle to fulfill demands for patient care.1 From the pandemic’s onset,
overwhelming numbers of critically ill patients have strained hos-
pitals and community-based care facilities. Limited knowledge of
the new disease has been compounded by a lack of emergency
preparedness, with healthcare organizations dealing with a lack of
proper medical and personal protective equipment (PPE).2 The
sheer volume of patients has necessitated the influx of nurses from
non-pulmonary disciplines to help treat patients with this respiratory
virus.1 This has resulted in unprecedented stress on an already-
overburdened nursing corps.3 Research from China4,5 and Italy6 has
identified frontline nurses as being at increased risk compared to
physicians for mental health problems associated with the care of
COVID-19 patients. To date, however, the impact of the pandemic
on the mental health of U.S. nurses, and the role played by
emergency preparedness, has not been investigated.
From the Department of Family Medicine, College of Human Medicine, Mich-
igan State University, Grand Rapids, Michigan (Dr Arnetz JE, Goetz, Sudan,
Dr Arnetz BB); Department of Psychology, Eastern Michigan University,
Ypsilanti, Michigan (Dr Arble); Department of Family Medicine and Public
Health Sciences, School of Medicine, Wayne State University, Detroit,
Michigan (Dr Janisse).
Ethical Considerations & Disclosure(s): The study was determined exempt by the
Institutional Review Board at Michigan State University.
Source of funding: This study was not supported by external funding.
The authors report no conflicts of interest.
Clinical significance: Lack of adequate personal protective equipment (PPE) was
a risk factor for depression, anxiety, and post-traumatic stress disorder
symptoms in nurses. Providing adequate PPE is a concrete measure that
healthcare organizations can take to protect both the physical and mental
health of their nurses caring for Covid-19 patients.
Address correspondence to: Judith E. Arnetz, PhD, MPH, Department of Family
Medicine, College of Human Medicine, Michigan State University, 15
Michigan Street NE, Grand Rapids, Michigan 49503 (arnetzju@msu.edu).
Copyright ß 2020 American College of Occupational and Environmental
Medicine
DOI: 10.1097/JOM.0000000000001999
892
Copyright © 2020 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited
The lack of emergency preparedness was reported in a
national U.S. survey of 32,000 nurses conducted March 20–
April 10, 2020. The survey asked about perceived needs for
COVID-related education and staffing as well as professional
concerns. Nurses’ primary concern was the lack of adequate PPE
(74%) followed by concern for the safety of family and friends
(64%). More than 85% were afraid to go to work.7 However, this
first large-scale survey of U.S. nurses related to COVID-19 did not
measure mental health and well-being. Media reports document
nurse exhaustion from long work hours compounded by fear for
oneself, one’s co-workers and one’s family members/friends of
contracting the virus, and by the frequent and daily deaths of
patients. Nurses experience trauma by risking infection themselves,
witnessing colleagues get sick and even die,8 and by seeing patients
die alone, without any loved ones, due to the risk of contagion.9
The limited robust research currently available comes from
China4,5 where the virus is presumed to have originated, and from
Italy, which was especially hard hit by the virus.6 A study among
1257 frontline healthcare workers treating COVID patients in China
found that nurses were at increased risk, and experienced greater
illness severity, for depression, anxiety, insomnia, and psychologi-
cal distress compared to other healthcare professionals.4 In another
study among 994 physicians and nurses in Wuhan, the pandemic’s
epicenter, more exposure to COVID-infected individuals was asso-
ciated with worse mental health,5 but that study did not explicitly
examine differences between professional groups. In a sample of
1379 healthcare workers in Italy, nurses were at increased risk of
severe insomnia compared to physicians.6 All three studies identi-
fied women as being at increased risk for worse mental health
outcomes.4–6
The current study investigated mental health outcomes
among nurses in Michigan, ranked at the time among the U.S.
states with the highest number of COVID deaths.10 The overall
objective was to determine the association between exposure to
COVID-19 patients, access to adequate PPE, and mental health
outcomes. We hypothesized that exposure to COVID patients and
inadequate PPE would be associated with worse mental health
outcomes. Adequate PPE could attenuate the possible adverse
impact of COVID exposure on mental health by helping nurses
feel safer in terms of their own health, their patients and their
loved ones.
METHODS
Study Design
A cross-sectional online survey was conducted in May 2020.
The study was determined exempt by the Institutional Review Board
at Michigan State University.
Participants
Participants were recruited from the Michigan chapter of the
American Nurses Association (ANA), the Michigan Organization of
Nurse Leaders (MONL), and the Coalition of Michigan Organizations
of Nursing (COMON). All members of the three organizations
(approximately 18,300) and their colleagues were eligible to partici-
pate. The memberships of these organizations represent registered
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 JOEM  Volume 62, Number 11, November 2020
nurses who work in a wide variety of practice and education settings
across the state. By collaborating with these organizations that have
extensive networks and employing snowball recruitment, our strategy
was to maximize our chances to reach out to most categories of
relevant nurses across Michigan. ANA Michigan distributed surveys
directly to nurse members. COMON, a coalition of approximately 40
nursing organizations, and MONL, with approximately 200 mem-
bers, both used a snowball recruitment technique, asking individual
members to distribute the survey within their respective organiza-
tions. Each nursing organization sent an emailed invitation including
a link to the Qualtrics survey, which remained open from May 7 to
May 29. Nurses who agreed to participate completed a consent
statement in Qualtrics before continuing to the survey questions.
The survey was confidential and anonymous, and nurses could
terminate their participation at any time. Based on data from Chinese
nurses,4 we expected at least 40% of Michigan nurses to report
symptoms of mental health disorders. The required sample size for
our study was based on detecting a relationship between access to
adequate PPE and mental health outcomes with an odds ratio of at
least 1.6. Using a two-sided alpha of 0.05, the required sample size
with 80% power is N ¼ 580.
Study Variables
Demographic information included participants’ age, gender,
race, number of hours worked per week, years working as a nurse,
working in a management position, geographic location and work
practice setting. COVID-19 exposure was measured by a single item
asking nurses about frequency of contact with COVID-19 patients
(four-point response scale from Never to Very Often). Access to
PPE was measured by a single item asking whether adequate PPE
was provided by their workplace at the onset of the pandemic (four-
point scale from Not at all to Definitely; not applicable could also be
selected). Although single-item measures are often criticized for
lacking precision and predictive validity,11 such items are actually
preferable when measuring concrete, rather than abstract con-
structs,12,13 such as these two measures. Moreover, these two
items each utilized four-point response scales, which enabled the
examination of dose-response relationships with the mental health
outcomes.
The outcome measures were symptoms of depression, anxi-
ety, and post-traumatic stress disorder (PTSD). These were assessed
using the 9-item patient health questionnaire (PHQ-9),14 7-item
Generalized Anxiety Disorder (GAD-7),15 and 6-item PTSD Check-
list (PCL-6)16 scales, respectively. The PHQ-9 is a widely-validated
depression measure.14 Participants are asked to report how often
during the past two weeks they have been bothered by problems
such as ‘‘feeling down, depressed, or hopeless’’ or ‘‘little interest or
pleasure in doing things’’ on a four-point scale from 0 (not at all) to 3
(nearly every day).14 The responses are summed and total scores are
categorized as normal (0–4), mild (5–9), moderate (10–14), and
severe (15–27) depression.17 Cronbach alpha for the PHQ-9 was
0.88 in the current study.
The GAD-7 is a self-report scale in which participants report
how often they are bothered by symptoms such as ‘‘feeling nervous,
anxious, or on edge’’ or ‘‘worrying too much about different things’’
over the past two weeks, on a four-point scale from 0 (not at all) to 3
(nearly every day).15 Responses are summed to a total score and
categorized into normal (0–4), mild (5–9), moderate (10–14), and
severe (15–21) anxiety.15 Cronbach alpha for the GAD-7 in the
current study was 0.93. The PCL-6 is a 6-item version of the full, 20-
item PTSD Checklist.16 Respondents report their experience with
symptoms of ‘‘repeated, disturbing memories, thoughts, or images
of a stressful experience from the past;’’ ‘‘feeling very upset when
something reminded you of a stressful experience from the past;’’
avoided activities or situations because they reminded you of a
stressful experience from the past; feeling distant or cut off from
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Personal Protective Equipment and Mental Health Symptoms
other people; feeling irritable or having angry outbursts; and
difficulty concentrating. All 6 items are rated on a scale from 1
(not at all) to 5 (extremely).16 Responses are then summed into a
total score. Cronbach alpha for the PCL-6 was 0.88 in the
current study.
For this study, the cutoff scores for symptoms of major
depression, anxiety and PTSD were 10, 7, and 14, respectively,
based on previously established values.17–19
Analysis
Statistical analysis was conducted using IBM SPSS
statistics, V.25, 2018 (IBM Corp, Armonk, NY). A two-sided
P value 0.05 was deemed to represent statistical significance.
Since none of the mental health outcomes were normally distributed
(skewness SE PHQ-9 0.875  0.097; GAD-7 0.968  0.097;
PTSD 1.158  0.097), scores are presented as medians with inter-
quartile ranges [IQRs]. Chi-square was used to test for differences in
mental health symptoms by demographic variables. The nonpara-
metric Kruskal–Wallis test was used to test for overall differences in
mental health symptoms by frequency of contact with COVID-19
patients and provision of adequate PPE by the workplace. These
analyses excluded the ‘‘not applicable’’ responses (n ¼ 55) to the
PPE question. The Jonckheere-Terpstra test for ordered alternatives
was then used to test for trends in mental health outcomes based on
increasing frequency of contact with COVID-19 patients and pro-
vision of PPE, respectively. Confidence intervals for the difference
in independent proportions was calculated using the Agresti and
Caffo (2000) method.20
Separate multivariable logistic regression analyses were
performed to identify factors associated with each of the three
outcomes, using the established cut off scores of 10, 7, and 14 for
depression, anxiety and PTSD, respectively to define the outcomes
in the analyses. In bivariate analyses, age and practice setting
(inpatient vs. outpatient/community) were the only demographic
variables that were significantly associated with the mental health
outcomes. Age was included as a control variable in the regression
analyses, but practice setting was not as it was highly correlated with
exposure to COVID-19 patients (chi-square (df) ¼ 73.4 (3);
P < 0.001). Nurses working in an inpatient setting were more likely
to report being exposed to COVID-19 patients (very often contact
with COVID-19 patients in inpatient vs. outpatient/community
setting: 27.5% vs. 7.0%; P < 0.001). Exposure to COVID patients
was considered a more informative independent variable than a
general categorization of inpatient vs. outpatient care since it
allowed us to determine possible dose-response associations
between COVID exposure and mental health outcomes. All non-
significant variables (management position, geographic location,
and years working as a nurse) were excluded from the regression
analyses except for hours worked per week, as it was theorized that
work hours could influence any dose–response relationship
between exposure to COVID-19 patients and mental health
outcomes.
In each regression, age and number of hours worked per week
were added in the first step. Frequency of contact with COVID-19
patients was added in the second step followed by whether adequate
PPE was provided by the workplace in the final step. Since there
were missing values in each logistic regression (ranging from 17%–
18% for the three outcomes), the analyses were rerun using multiple
imputation for the missing data and compared to the original
analyses.21 Results with imputed data were similar to the original
analyses and are not reported here.
RESULTS
A total of 695 nurses responded to the survey. An exact
response rate could not be calculated since two of the three nursing
organizations utilized a snowball recruitment technique and may
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working for more than 10 years (n ¼ 449, 67.1%). The majority

TABLE 1. Characteristics of Study Participants (n ¼ 695)
(n ¼ 533, 90.0%) worked in urban locations, more than half worked
N (%)y 20–40 hours per week (n ¼ 368, 56.6%), while 36.6% (n ¼ 238)
worked 41–60 hours per week or more. Nearly 60% (n ¼ 392,
Age (years) 59.1%) of the nurses worked in an inpatient setting and 19.7%
<45 312 (45.3) (n ¼ 135) held a management position. Forty percent (n ¼ 269;
45 376 (54.7) 40.2%) reported being in frequent contact with COVID-19 patients
Gender while 24.9% (n ¼ 163) reported not being provided with adequate
Males 44 (6.4) PPE by their workplace. More than half of the nurses reported
Females 644 (93.6) symptoms of depression (n ¼ 381, 59.5%) and anxiety (n ¼ 350,
Race
54.9%) and close to one third had symptoms of PTSD (n ¼ 184,
White 611 (87.9)
Black/African American 34 (4.9) 29.1%). Approximately 10% (n ¼ 62; 9.7%) reported symptoms of
Other 50 (7.2) severe depression and 8.3% (n ¼ 53) had symptoms of severe
Geographic location anxiety.
Rural 59 (10) Table 2 summarizes the severity of mental health symptoms
Urban 533 (90) by demographic factors. Nurses younger than 45 were more likely
Number of years working as a nurse to report mental health symptoms (eg moderate depression
10 220 (32.9) among those < 45 years versus 45 years: 56 (19.6%) versus 48
>10 449 (67.1) (13.6%), P ¼.005; moderate anxiety: 58 (20.4%) versus 33 (9.4%),
Employed in management position
P < 0.001; and PTSD symptoms: 102 (36.4%) versus 81 (23.2%),
Yes 135 (19.7)
No 551 (80.3) P < 0.001). Those working in an inpatient setting were more
Practice setting likely to report mental health symptoms: severe depression
Inpatient 392 (59.1) among those working inpatient versus outpatient/community:
Outpatient/Community-based 271 (40.9) 40 (10.8%) versus 21 (8.1%), P ¼ 0.006; severe anxiety: 39
Number of hours worked per week (10.5%) versus 13 (5.0%), P < 0.001; and PTSD symptoms: 128
<20 44 (6.8) (34.9%) versus 55 (21.6), P < 0.001. Gender, race, geographic
20–40 368 (56.6) location, number of hours worked per week and working in a
41–60 201 (30.9) management position were not associated with any of the mental
>60 37 (5.7)
health symptoms.
Contact with COVID-19 patients
Never 127 (19.0) Analysis of variance (ANOVA) based on the Kruskal–Wallis
Seldom 273 (40.8) test revealed statistically significant differences in mental health
Often 142 (21.2) outcomes based on nurses’ frequency of contact with COVID-19
Very Often 127 (19.0) patients as well as access to adequate PPE (Table 3). A Jonckheere-
Adequate PPE provided by workplace Terpstra test for ordered alternatives confirmed a significant trend
Not at all 49 (7.5) for worse median mental health outcome scores as contact with
Not really 114 (17.4) COVID patients increased and as provision of PPE decreased
Somewhat 238 (36.3) (Table 3). Thus, the severity of depression, anxiety, and PTSD
Definitely 200 (30.5)
increased significantly as contact with COVID-19 patients
Not applicable 55 (8.3)
Depression (0–27); Median (IQR) 6.0 (2.0–10.0) increased. Median [IQR] scores for depression increased from
Normal (0–4) 260 (40.5) 5.0 [1.5–9.0] for nurses with no contact to 7.0 [4.0–11.0] for those
Mild (5–8) 214 (33.4) who had contact with COVID-19 patients very often (P < 0.001).
Moderate (9–14) 105 (16.4) Scores for anxiety increased from 4.0 [1.0–8.0] for nurses with no
Severe (15–27) 62 (9.7) contact to 6.0 [3.0–12.0] for nurses with frequent contact
Anxiety (0–21); Median (IQR) 5.0 (2.0–9.0) (P < 0.001), and PTSD symptom scores increased from 9.5 [7.2–
Normal (0–4) 288 (45.1) 13.0] to 13.0 [8.0–17.0], P < 0.001. (Table 3). A reverse dose–
Mild (5–8) 206 (32.3) response relationship was seen with PPE provision, where the
Moderate (9–14) 91 (14.3)
severity of all three mental health outcomes was significantly lower
Severe (15–21) 53 (8.3)
PTSD (6–30); Median (IQR) 10.0 (8.0–14.0) as PPE provision frequency increased. Median [IQR] scores for
Low (<14) 448 (70.9) depression decreased from 9.0 [5.0–13.0] to 4.0 [2.0–8.0],
High (14) 184 (29.1) P < 0.001; for anxiety scores decreased from 7.0 [2.5–11.5] to
4.0 [1.0–8.7], P < 0.001; and the PTSD scores decreased from 14.0
COVID-19, Coronavirus disease; IQR, interquartile range 25th–75th percentiles; [9.0–18.0] to 9.0 [7.0–13.0], P < 0.001 (Table 3).
PPE, personal protective equipment; PTSD, post-traumatic stress disorder. Table 4 depicts multivariable logistic regression analyses for

Numbers do not add to group totals due to missing values.
y
Valid percentages are reported. factors associated with mental health symptoms. Nurses that
reported receiving inadequate PPE from their workplace were more
likely to report symptoms of depression (OR 1.96, 95% CI 1.31,
2.94; P ¼ 0.001), anxiety (OR 1.64, 95% CI 1.12, 2.40; P ¼ 0.01)
have reached out to nurses who were not members of these orga- and PTSD (OR 1.83, 95% CI 1.22, 2.74; P ¼ 0.003). Those who
nizations. However, based on the total membership of 18,300 nurses were often in contact with COVID-19 patients were more likely to
in ANA-Michigan, MONL, and COMON, our response rate was report symptoms of anxiety (OR 1.69, 95% CI 1.18, 2.40;
approximately 4%. A comparison of the respondent sample with the P ¼ 0.003) and PTSD (OR 2.19, 95% CI 1.50, 3.19; P < 0.001).
entire population of Michigan nurses22 based on gender and eth- Nurses younger than 45 years were more likely to report anxiety
nicity found no significant differences. (OR 1.69, 95% CI 1.19, 2.41; P ¼ 0.003) and PTSD symptoms (OR
Characteristics of the respondents are summarized in Table 1. 1.67, 95% CI 1.14, 2.44; P ¼ 0.008).
Most of the respondents were female (n ¼ 644, 93.6%), older than To determine if contact with COVID-19 patients moderated
45 (n ¼ 376, 54.7%), Caucasian (n ¼ 611, 87.9%) and had been the impact of inadequate PPE on the severity of the outcomes, we

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 JOEM  Volume 62, Number 11, November 2020 Personal Protective Equipment and Mental Health Symptoms

TABLE 2. Severity of Mental Health Symptoms by Demographic Categories (n ¼ 695)

Age Management Position Hours Worked per Week Practice Setting
  
N (%) N (%) N (%) N (%)

<45 y 45 y P No Yes P < ¼ 40 h >40 h P Inpatient Outpatienty P

Depression 0.005 0.63 0.48 0.006

Normal 94 (32.9) 164 (46.6) 211 (40.8) 49 (39.5) 162 (42.0) 84 (37.0) 128 (34.5) 125 (48.1)
Mild 106 (37.1) 108 (30.7) 167 (32.3) 47 (37.9) 122 (31.6) 85 (37.4) 132 (35.6) 80 (30.8)
Moderate 56 (19.6) 48 (13.6) 87 (16.8) 18 (14.5) 66 (17.1) 36 (15.9) 71 (19.1) 34 (13.1)
Severe 30 (10.5) 32 (9.1) 52 (10.1) 10 (8.1) 36 (9.3) 22 (9.7) 40 (10.8) 21 (8.1)
Anxiety <0.001 0.41 0.14 <0.001
Normal 100 (35.1) 187 (53.4) 230 (44.7) 58 (46.8) 182 (47.3) 94 (41.8) 143 (38.6) 137 (53.1)
Mild 101 (35.4) 104 (29.7) 162 (31.5) 44 (35.5) 113 (29.4) 84 (37.3) 123 (33.2) 82 (31.8)
Moderate 58 (20.4) 33 (9.4) 79 (15.4) 12 (9.7) 61 (15.8) 27 (12.0) 65 (17.6) 26 (10.1)
Severe 26 (9.1) 26 (7.4) 43 (8.4) 10 (8.1) 29 (7.5) 20 (8.9) 39 (10.5) 13 (5.0)
PTSD <0.001 0.13 0.77 <0.001
Low 178 (63.6) 268 (76.8) 354 (69.5) 94 (76.4) 271 (70.9) 155 (69.8) 239 (65.1) 200 (78.4)
High 102 (36.4) 81 (23.2) 155 (30.5) 29 (23.6) 111 (29.1) 67 (30.2) 128 (34.9) 55 (21.6)

P, P value; PTSD, post-traumatic stress disorder.


Numbers do not add to group totals due to missing values.
y
Includes those working in community setting

also tested the interaction between these two variables. The inter-
action term (contact with COVID-19 patients x inadequate PPE)
was not significantly associated with any of the mental health
outcomes (data not shown).
DISCUSSION
To the best of our knowledge, this is the first study of mental
health outcomes in a sample of nurses during the COVID-19
pandemic in the U.S., and the first to address the possible mental
health implications of working in a potentially lethal work envi-
ronment despite lacking necessary personal protective equipment.
Substantial proportions of survey respondents reported symptoms of
depression, anxiety and PTSD. Compared to early data from
Chinese nurses,4 a larger proportion of Michigan nurses experi-
enced depression (59.4%) than Chinese nurses (53.5%,
Diff ¼ 0.059, 95% CI 0.11, 0.007) as well as anxiety (54.9% vs.
47.1%, Diff ¼ 0.077, 95% CI 0.13, 0.02). The proportion of Mich-
igan nurses reporting severe mental health symptoms also exceeded
the proportion of Chinese nurses for both depression (9.7% vs.
7.1%, Diff ¼ 0.026, 95% CI 0.06, 0.003) and anxiety (8.3% vs.
5.6%, Diff ¼ 0.027, 95% CI 0.05, 0.0002). Comparisons of our
PTSD data are not possible as reports from China did not measure
PTSD4,5 and the study from Italy6 did not report scores by profes-
sional group. However, nurses in the Italian study were not at
increased risk for PTSD compared to other healthcare providers.6
As hypothesized, more frequent exposure to COVID-19
patients and poor availability of adequate PPE were both associated
with worse mental health outcomes. Importantly, analyses revealed
distinct dose-response relationships for both these variables for each
of the three mental health outcomes. The studies from both China4,5
and Italy6 found that frontline work with COVID patients was
associated with mental health disorders. However, none of these
prior studies examined possible dose-response relationships or the
role of PPE in mental health outcomes. Of note, a single-site study
from Belgium found that exposure to COVID patients was not
associated with the presence of SARS-CoV-2 antibodies in hospital

TABLE 3. COVID-19 Exposure, Personal Protective Equipment and Mental Health Symptom Scores
Depression Anxiety PTSD
Median (IQR) Median (IQR) Median (IQR)

COVID-19 exposure (n U 641)

Contact with COVID-19 patients (No., %)
Never (117, 18.3) 5.0 (1.5–9.0) 4.0 (1.0–8.0) 9.5 (7.2–13.0)
Seldom (263, 41.0) 5.0 (2.0–9.0) 5.0 (2.0–7.0) 10.0 (7.0–13.0)
Often (136, 21.2) 6.0 (3.0–10.0) 5.0 (3.0–10.0) 10.0 (8.0–15.0)
Very often (125, 19.5) 7.0 (4.0–11.0) 6.0 (3.0–12.0) 13.0 (8.0–17.0)
Kruskal-Wallis H (P value) 12.980 (0.005) 17.339 (0.001) 17.858 (0.001)
Jonckheere-Terpstra z (P value) 3.485 (<0.001) 4.170 (<0.001) 3.672 (<0.001)
Personal protective equipment (n U 587)
Workplace provided adequate PPE (No., %)
No, not at all (49, 8.3) 9.0 (5.0–13.0) 7.0 (2.5–11.5) 14.0 (9.0–18.0)
Not really (112, 19.1) 7.0 (3.0–11.7) 6.0 (3.0–10.7) 11.0 (8.0–15.0)
Somewhat (233, 39.6) 6.0 (3.0–9.0) 5.0 (3.0–8.0) 10.0 (8.0–14.0)
Definitely (193, 33.0) 4.0 (2.0–8.0) 4.0 (1.0–8.7) 9.0 (7.0–13.0)
Kruskal-Wallis H (P value) 28.886 (<0.001) 13.880 (0.003) 29.300 (<0.001)
Jonckheere-Terpstra z (P value) –5.213 (<0.001) –3.706 (<0.001) –5.385 (<0.001)

COVID-19, Coronavirus disease; IQR, interquartile range 25th–75th percentiles; PPE, personal protective equipment; PTSD, post-traumatic stress disorder.

ß 2020 American College of Occupational and Environmental Medicine 895

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 Arnetz et al JOEM  Volume 62, Number 11, November 2020

models. In the general population, older adults have better mental

TABLE 4. Multivariable Logistic Regression for Factors Asso-
health than younger adults26,27 and this seems to hold true
ciated with Mental Health Symptoms
during the current pandemic.28,29 It is possible that older nurses
Variable OR (95% CI) P Value were more experienced and better equipped both professionally
and psychologically to deal with the stress of the pandemic. An
Depression scores  10 (n U 574) Italian report pointed to the organizational changes and manage-
Age ment challenges presented by the pandemic, suggesting that the
45 years 1 [Reference] difficulties in patient care were likely greatest for the newer,
<45 years 1.33 (0.90, 1.95) 0.15 lesser-skilled nurses.1 Results suggest that nurse managers
Number of hours worked per week 1.12 (0.85, 1.48) 0.42 should increase training and support related to COVID care for
Contact with COVID-19 patients younger, less experienced nurses in order to mitigate mental
Never/Seldom 1 [Reference]
health problems.
Often/Very often 1.37 (0.93, 2.01) 0.11
Workplace provided adequate PPE The lack of PPE was identified as a top concern for U.S.
Somewhat/Definitely 1 [Reference] nurses in a survey conducted by the American Nurses’ Association7
No/Not really 1.96 (1.31, 2.94) 0.001 and results of the current study indicate that this was a significant
Anxiety scores 7 (n U 572) factor in nurses’ mental health. In 2007, the Occupational Safety
Age and Health Administration (OSHA) published guidelines to assist
45 years 1 [Reference] workplaces in preparing for a possible influenza pandemic.30
<45 years 1.69 (1.19, 2.41) 0.003 Personal protective equipment is stressed throughout the document
Number of hours worked per week 1.27 (0.98, 1.63) 0.07 as a key factor in keeping workers safe, especially those in high-risk
Contact with COVID-19 patients
environments, such as healthcare workers. Guidelines for these
Never/Seldom 1 [Reference]
Often/Very often 1.69 (1.18, 2.40) 0.003 environments include respiratory protection (masks, respirators,
Workplace provided adequate PPE face shields), medical/surgical gowns, gloves, and eye protection.
Somewhat/Definitely 1 [Reference] Despite the fact that the guidance was written 12 years before the
No/Not really 1.64 (1.12, 2.40) 0.01 current pandemic, it warned employers of the increased stress likely
PTSD scores 14 (n U 568) to be experienced by workers in high-risk occupations, citing fear
Age for workers’ own safety as well as the safety of their family
45 years 1 [Reference] members.30 Conducted only weeks after the pandemic’s onset in
<45 years 1.67 (1.14, 2.44) 0.008 March of 2020, our study identified mental health problems in a
Number of hours worked per week 1.23 (0.93, 1.62) 0.14
substantial proportion of nurses; those problems were significantly
Contact with COVID-19 patients
Never/Seldom 1 [Reference] higher among nurses with greater exposure to COVID patients and
Often/Very often 2.19 (1.50, 3.19) <0.001 poor access to adequate PPE.
Workplace provided adequate PPE
Somewhat/Definitely 1 [Reference] Limitations
No/Not really 1.83 (1.22, 2.74) 0.003 This study has several limitations. It utilized a convenience
sample of nurses in a single state and results may not be generaliz-
95% CI, 95% confidence interval; COVID-19, Coronavirus disease; OR, odds able to U.S. nurses nationwide. Nevertheless, our sample was
ratio; PPE, personal protective equipment; PTSD, post-traumatic stress disorder.
similar to the total population of Michigan nurses based on gender
and ethnicity.22 An exact response rate could not be calculated due
to the use of snowball sampling. Self-selection bias may have
influenced results since it is possible that nurses with higher levels
workers. The authors attributed that finding to the adequate avail- of depression, anxiety, and PTSD symptoms were more likely to
ability of PPE.23 Although we cannot establish causal relationships respond. We used a cross-sectional design and causal relationships
between the frequency of exposure to Covid-19 patients, PPE, and between exposures and mental health outcomes cannot be assumed.
mental health disorders, the dose–response relationships for these While we did find consistent dose-response associations between
variables are suggestive of a causal mechanism. With higher exposure to COVID patients as well as access to PPE and mental
frequency of exposure, nurses are at higher risk of contracting health outcomes, we cannot confirm causality, nor can we be sure of
the disease. This supports the relationship to both anxiety and the direction of any possible causal association. Nurses with higher
PTSD—both reflective of experiencing traumatic events, in this levels of depression, anxiety, and PTSD symptoms may have
case a potentially lethal exposure. Lack of adequate PPE, but not responded to the questions on COVID-patient contact and PPE
exposure to COVID patients, was significantly association with provision differently, suggesting an opposite causal direction.
depression. This may reflect feelings of hopelessness and helpless- Finally, this study only considered a limited number of variables.
ness, both of which have been linked to depression,24,25 in a high- It is therefore possible that potential third variables, including
risk occupational environment. confounders, may also influence the associations with nurses’
The multivariable regression analyses confirmed that fre- mental health reported here.
quent exposure to COVID patients was a risk factor for symptoms of
anxiety and PTSD, while lack of adequate PPE was a risk factor for CONCLUSION
all three outcomes and was the only significant factor associated Substantial proportions of nurses in this sample from Mich-
with depression. This is an important finding for healthcare insti- igan reported symptoms of depression, anxiety, and PTSD. Fre-
tutions in that providing nurses with PPE is a concrete, malleable quency of exposure to COVID patients and inadequate PPE were
measure that can be taken to protect their mental health. Of note, we significant risk factors. These findings point to a need for an
found no interaction effect between frequency of exposure to organized strategy to survey mental health among nurses and
COVID patients and inadequate PPE, underscoring the independent proactively identify those in high-risk groups and in need of support.
effect of each of these variables on the mental health outcomes. Providing them with appropriate and adequate PPE is a concrete
Younger age was a risk factor for anxiety and PTSD, even measure that can enable them to work safely and prevent and/or
after COVID exposure and PPE availability were added to the mitigate mental health disorders.

896 ß 2020 American College of Occupational and Environmental Medicine

Copyright © 2020 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited
 JOEM  Volume 62, Number 11, November 2020
ACKNOWLEDGMENTS
The authors extend sincere thanks to Kathleen Kessler, MSN
MSA RN, Carole A. Stacy, MSN, MA, RN, and Tobi L. Moore, MBA
for their assistance in administering the online survey. Many thanks
to the nurses who responded to the survey.
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