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Personal Protective Equipment and Mental Health Symptoms Among Nurses During the COVID-19 Pandemic

Arnetz, Judith E. PhD, MPH; Goetz, Courtney M. BA; Sudan, Sukhesh MPH; Arble, Eamonn PhD; Janisse, James PhD; Arnetz, Bengt B. MD, PhD

Author Information
Journal of Occupational and Environmental Medicine: November 2020 - Volume 62 - Issue 11 - p 892-897
doi: 10.1097/JOM.0000000000001999
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The 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 struggle to fulfill demands for patient care.1 From the pandemic's onset, overwhelming numbers of critically ill patients have strained hospitals 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.

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 psychological 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 associated 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 identified 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.


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 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 participate. The memberships of these organizations represent registered 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 members, both used a snowball recruitment technique, asking individual members to distribute the survey within their respective organizations. 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 = 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 constructs,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, anxiety, 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 Checklist (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 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


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 interquartile ranges [IQRs]. Chi-square was used to test for differences in mental health symptoms by demographic variables. The nonparametric 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 = 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 provision 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) = 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.


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 have reached out to nurses who were not members of these organizations. However, based on the total membership of 18,300 nurses in ANA-Michigan, MONL, and COMON, our response rate was approximately 4%. A comparison of the respondent sample with the entire population of Michigan nurses22 based on gender and ethnicity found no significant differences.

Characteristics of the respondents are summarized in Table 1. Most of the respondents were female (n = 644, 93.6%), older than 45 (n = 376, 54.7%), Caucasian (n = 611, 87.9%) and had been working for more than 10 years (n = 449, 67.1%). The majority (n = 533, 90.0%) worked in urban locations, more than half worked 20–40 hours per week (n = 368, 56.6%), while 36.6% (n = 238) worked 41–60 hours per week or more. Nearly 60% (n = 392, 59.1%) of the nurses worked in an inpatient setting and 19.7% (n = 135) held a management position. Forty percent (n = 269; 40.2%) reported being in frequent contact with COVID-19 patients while 24.9% (n = 163) reported not being provided with adequate PPE by their workplace. More than half of the nurses reported symptoms of depression (n = 381, 59.5%) and anxiety (n = 350, 54.9%) and close to one third had symptoms of PTSD (n = 184, 29.1%). Approximately 10% (n = 62; 9.7%) reported symptoms of severe depression and 8.3% (n = 53) had symptoms of severe anxiety.

TABLE 1 - Characteristics of Study Participants (n = 695)
N (%)
Age (years)
 <45 312 (45.3)
 ≥45 376 (54.7)
 Males 44 (6.4)
 Females 644 (93.6)
 White 611 (87.9)
 Black/African American 34 (4.9)
 Other 50 (7.2)
Geographic location
 Rural 59 (10)
 Urban 533 (90)
Number of years working as a nurse
 ≤10 220 (32.9)
 >10 449 (67.1)
Employed in management position
 Yes 135 (19.7)
 No 551 (80.3)
Practice setting
 Inpatient 392 (59.1)
 Outpatient/Community-based 271 (40.9)
Number of hours worked per week
 <20 44 (6.8)
 20–40 368 (56.6)
 41–60 201 (30.9)
 >60 37 (5.7)
Contact with COVID-19 patients
 Never 127 (19.0)
 Seldom 273 (40.8)
 Often 142 (21.2)
 Very Often 127 (19.0)
Adequate PPE provided by workplace
 Not at all 49 (7.5)
 Not really 114 (17.4)
 Somewhat 238 (36.3)
 Definitely 200 (30.5)
 Not applicable 55 (8.3)
Depression (0–27); Median (IQR) 6.0 (2.0–10.0)
 Normal (0–4) 260 (40.5)
 Mild (5–8) 214 (33.4)
 Moderate (9–14) 105 (16.4)
 Severe (15–27) 62 (9.7)
Anxiety (0–21); Median (IQR) 5.0 (2.0–9.0)
 Normal (0–4) 288 (45.1)
 Mild (5–8) 206 (32.3)
 Moderate (9–14) 91 (14.3)
 Severe (15–21) 53 (8.3)
PTSD (6–30); Median (IQR) 10.0 (8.0–14.0)
 Low (<14) 448 (70.9)
 High (≥14) 184 (29.1)
COVID-19, Coronavirus disease; IQR, interquartile range 25th–75th percentiles; PPE, personal protective equipment; PTSD, post-traumatic stress disorder.
Numbers do not add to group totals due to missing values.
Valid percentages are reported.

Table 2 summarizes the severity of mental health symptoms by demographic factors. Nurses younger than 45 were more likely to report mental health symptoms (eg moderate depression among those < 45 years versus ≥45 years: 56 (19.6%) versus 48 (13.6%), P = .005; moderate anxiety: 58 (20.4%) versus 33 (9.4%), P < 0.001; and PTSD symptoms: 102 (36.4%) versus 81 (23.2%), P < 0.001). Those working in an inpatient setting were more likely to report mental health symptoms: severe depression among those working inpatient versus outpatient/community: 40 (10.8%) versus 21 (8.1%), P = 0.006; severe anxiety: 39 (10.5%) versus 13 (5.0%), P < 0.001; and PTSD symptoms: 128 (34.9%) versus 55 (21.6), P < 0.001. Gender, race, geographic location, number of hours worked per week and working in a management position were not associated with any of the mental health symptoms.

TABLE 2 - Severity of Mental Health Symptoms by Demographic Categories (n = 695)
Age Management Position Hours Worked per Week Practice Setting

N (%) N (%) N (%) N (%)

<45 y ≥45 y P No Yes P < = 40 h >40 h P Inpatient Outpatient 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.
Includes those working in community setting

Analysis of variance (ANOVA) based on the Kruskal–Wallis test revealed statistically significant differences in mental health outcomes based on nurses’ frequency of contact with COVID-19 patients as well as access to adequate PPE (Table 3). A Jonckheere-Terpstra test for ordered alternatives confirmed a significant trend for worse median mental health outcome scores as contact with COVID patients increased and as provision of PPE decreased (Table 3). Thus, the severity of depression, anxiety, and PTSD increased significantly as contact with COVID-19 patients increased. Median [IQR] scores for depression increased from 5.0 [1.5–9.0] for nurses with no contact to 7.0 [4.0–11.0] for those who had contact with COVID-19 patients very often (P < 0.001). Scores for anxiety increased from 4.0 [1.0–8.0] for nurses with no contact to 6.0 [3.0–12.0] for nurses with frequent contact (P < 0.001), and PTSD symptom scores increased from 9.5 [7.2–13.0] to 13.0 [8.0–17.0], P < 0.001. (Table 3). A reverse dose–response relationship was seen with PPE provision, where the severity of all three mental health outcomes was significantly lower as PPE provision frequency increased. Median [IQR] scores for depression decreased from 9.0 [5.0–13.0] to 4.0 [2.0–8.0], 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 [9.0–18.0] to 9.0 [7.0–13.0], P < 0.001 (Table 3).

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 = 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 = 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.

Table 4 depicts multivariable logistic regression analyses for 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 = 0.001), anxiety (OR 1.64, 95% CI 1.12, 2.40; P = 0.01) and PTSD (OR 1.83, 95% CI 1.22, 2.74; P = 0.003). Those who were often in contact with COVID-19 patients were more likely to report symptoms of anxiety (OR 1.69, 95% CI 1.18, 2.40; P = 0.003) and PTSD (OR 2.19, 95% CI 1.50, 3.19; P < 0.001). Nurses younger than 45 years were more likely to report anxiety (OR 1.69, 95% CI 1.19, 2.41; P = 0.003) and PTSD symptoms (OR 1.67, 95% CI 1.14, 2.44; P = 0.008).

TABLE 4 - Multivariable Logistic Regression for Factors Associated with Mental Health Symptoms
Variable OR (95% CI) P Value
Depression scores ≥ 10 (n = 574)
 ≥45 years 1 [Reference]
 <45 years 1.33 (0.90, 1.95) 0.15
Number of hours worked per week 1.12 (0.85, 1.48) 0.42
Contact with COVID-19 patients
 Never/Seldom 1 [Reference]
 Often/Very often 1.37 (0.93, 2.01) 0.11
Workplace provided adequate PPE
 Somewhat/Definitely 1 [Reference]
 No/Not really 1.96 (1.31, 2.94) 0.001
Anxiety scores ≥7 (n = 572)
 ≥45 years 1 [Reference]
 <45 years 1.69 (1.19, 2.41) 0.003
Number of hours worked per week 1.27 (0.98, 1.63) 0.07
Contact with COVID-19 patients
 Never/Seldom 1 [Reference]
 Often/Very often 1.69 (1.18, 2.40) 0.003
Workplace provided adequate PPE
 Somewhat/Definitely 1 [Reference]
 No/Not really 1.64 (1.12, 2.40) 0.01
PTSD scores ≥14 (n = 568)
 ≥45 years 1 [Reference]
 <45 years 1.67 (1.14, 2.44) 0.008
Number of hours worked per week 1.23 (0.93, 1.62) 0.14
Contact with COVID-19 patients
 Never/Seldom 1 [Reference]
 Often/Very often 2.19 (1.50, 3.19) <0.001
Workplace provided adequate PPE
 Somewhat/Definitely 1 [Reference]
 No/Not really 1.83 (1.22, 2.74) 0.003
95% CI, 95% confidence interval; COVID-19, Coronavirus disease; OR, odds ratio; PPE, personal protective equipment; PTSD, post-traumatic stress disorder.

To determine if contact with COVID-19 patients moderated the impact of inadequate PPE on the severity of the outcomes, we also tested the interaction between these two variables. The interaction term (contact with COVID-19 patients x inadequate PPE) was not significantly associated with any of the mental health outcomes (data not shown).


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 environment 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 experienced depression (59.4%) than Chinese nurses (53.5%, Diff = 0.059, 95% CI 0.11, 0.007) as well as anxiety (54.9% vs. 47.1%, Diff = 0.077, 95% CI 0.13, 0.02). The proportion of Michigan nurses reporting severe mental health symptoms also exceeded the proportion of Chinese nurses for both depression (9.7% vs. 7.1%, Diff = 0.026, 95% CI 0.06, −0.003) and anxiety (8.3% vs. 5.6%, Diff = 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 professional 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 workers. The authors attributed that finding to the adequate availability of PPE.23 Although we cannot establish causal relationships between the frequency of exposure to Covid-19 patients, PPE, and mental health disorders, the dose–response relationships for these variables are suggestive of a causal mechanism. With higher frequency of exposure, nurses are at higher risk of contracting the disease. This supports the relationship to both anxiety and PTSD—both reflective of experiencing traumatic events, in this case a potentially lethal exposure. Lack of adequate PPE, but not exposure to COVID patients, was significantly association with depression. This may reflect feelings of hopelessness and helplessness, both of which have been linked to depression,24,25 in a high-risk occupational environment.

The multivariable regression analyses confirmed that frequent exposure to COVID patients was a risk factor for symptoms of anxiety and PTSD, while lack of adequate PPE was a risk factor for all three outcomes and was the only significant factor associated with depression. This is an important finding for healthcare institutions in that providing nurses with PPE is a concrete, malleable measure that can be taken to protect their mental health. Of note, we found no interaction effect between frequency of exposure to COVID patients and inadequate PPE, underscoring the independent effect of each of these variables on the mental health outcomes.

Younger age was a risk factor for anxiety and PTSD, even after COVID exposure and PPE availability were added to the models. In the general population, older adults have better mental health than younger adults26,27 and this seems to hold true during the current pandemic.28,29 It is possible that older nurses were more experienced and better equipped both professionally and psychologically to deal with the stress of the pandemic. An Italian report pointed to the organizational changes and management challenges presented by the pandemic, suggesting that the difficulties in patient care were likely greatest for the newer, lesser-skilled nurses.1 Results suggest that nurse managers should increase training and support related to COVID care for younger, less experienced nurses in order to mitigate mental health problems.

The lack of PPE was identified as a top concern for U.S. nurses in a survey conducted by the American Nurses’ Association7 and results of the current study indicate that this was a significant factor in nurses’ mental health. In 2007, the Occupational Safety and Health Administration (OSHA) published guidelines to assist workplaces in preparing for a possible influenza pandemic.30 Personal protective equipment is stressed throughout the document as a key factor in keeping workers safe, especially those in high-risk environments, such as healthcare workers. Guidelines for these environments include respiratory protection (masks, respirators, face shields), medical/surgical gowns, gloves, and eye protection. Despite the fact that the guidance was written 12 years before the current pandemic, it warned employers of the increased stress likely to be experienced by workers in high-risk occupations, citing fear for workers’ own safety as well as the safety of their family members.30 Conducted only weeks after the pandemic's onset in March of 2020, our study identified mental health problems in a substantial proportion of nurses; those problems were significantly higher among nurses with greater exposure to COVID patients and poor access to adequate PPE.


This study has several limitations. It utilized a convenience sample of nurses in a single state and results may not be generalizable to U.S. nurses nationwide. Nevertheless, our sample was 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 of depression, anxiety, and PTSD symptoms were more likely to respond. We used a cross-sectional design and causal relationships between exposures and mental health outcomes cannot be assumed. While we did find consistent dose-response associations between exposure to COVID patients as well as access to PPE and mental health outcomes, we cannot confirm causality, nor can we be sure of the direction of any possible causal association. Nurses with higher levels of depression, anxiety, and PTSD symptoms may have responded to the questions on COVID-patient contact and PPE provision differently, suggesting an opposite causal direction. Finally, this study only considered a limited number of variables. It is therefore possible that potential third variables, including confounders, may also influence the associations with nurses’ mental health reported here.


Substantial proportions of nurses in this sample from Michigan reported symptoms of depression, anxiety, and PTSD. Frequency of exposure to COVID patients and inadequate PPE were significant risk factors. These findings point to a need for an organized strategy to survey mental health among nurses and proactively identify those in high-risk groups and in need of support. Providing them with appropriate and adequate PPE is a concrete measure that can enable them to work safely and prevent and/or mitigate mental health disorders.


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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2. Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. JAMA 2020; 323:1439.
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