The JD-R theory has been developed to broadly involve multiple and various job demands, job resources, and worker health outcomes, applicable to any occupation. Among nurses, evidence suggests that high psychological and physical job demands are related to the intention to quit nursing, emphasizing the relevance of the JD-R theory to this population. Additional significant findings from research applications of the JD-R theory in the COVID-19 pandemic context indicate a negative association between the perception of work organization support and post traumatic stress disorder symptoms in a sample of U.S. nurses working in COVID-19 hospital units. As an extension of the JD-R theory to our study of prison nurses, the domain of job demands includes efforts, work hours, and the types of shift assignment and patient care. The job resources domain encompasses PPE supply and work-related rewards. The well being outcome measures are the psychological characteristics of anxiety, depression, and post-traumatic stress symptoms. Thus, research applying this JD-R theory to correctional nurses working during the COVID-19 pandemic will further characterize the job demands, resources,hydroponic vertical farm and outcomes unique to this population and compounded by the pandemic.
Prior to the COVID-19 pandemic, published reviews related to nurses and other health professionals working in correctional facilities identified occupational stressors including security prioritization, conflicts, fear, job demands, burnout, stress, and secondary trauma. Within North America, older U.S. studies have demonstrated moderate and high work-related mean stress levels among correctional nurses. Other North American pre-pandemic studies of correctional worker mental health in Canada have included nurses, but within healthcare worker subgroups. A recent study of U.S. correctional workers during the COVID-19 pandemic found that correctional healthcare workers reporting any degree of depression, anxiety, burnout, and post-traumatic stress symptoms ranged from 37% to 50%. However, this study was concentrated on correctional facilities located in eastern U.S. states. To the best of our knowledge, there are no available scientific reports focused solely on prison nurses and their working conditions and well being during the COVID-19 pandemic. The prevalence of COVID-19 cases in U.S. correctional facilities has been significantly higher than that of the general population. Based on the facilities’ available reports, which vary in data quality, there were 42,107 COVID-19 cases among incarcerated individuals in U.S. federal and state prisons, a rate that was five-and-a-half-fold greater than that of the U.S. population, between March and June 2020.
There were 13,781 documented or reported COVID-19 cases specifically in California correctional institutions, a rate that was on average over eight-and-a-half-fold greater than that of the aggregated Californian population between September and November 2020. Research on healthcare workers and nurses working through the COVID-19 pandemic has demonstrated elevated levels of occupational and psychological concerns. Studies conducted in Europe and Asia have identified elevated levels of occupational stress , insomnia, workload, anxiety, and depression. Additionally, effort and over-commitment have been associated with anxiety and depression. Literature reviews and meta-analyses of international healthcare workers have reinforced these individual study findings, with pooled prevalence rates ranging from 43% to 56.5% for stress, 40% to 44% for sleep issues, and 18.75% to 48% for post-traumatic stress . Qualitative and quantitative research on U.S. nurses during the COVID-19 pandemic have recognized occupational challenges regarding patient care, increased workload, and inadequate personal protective equipment , as well as psychological outcomes including post-traumatic stress, depression, and anxiety. However, these studies heavily focus on hospital settings, and are mostly concentrated in the U.S. Northeast, South, and Midwest . A December 2020 national survey that provided state-specific data reported that the majority of California nurses felt exhausted, overwhelmed, and anxious, with 52% expressing neutrality or disagreement with the statement that their workplace val-ued employee safety and health. Yet, there was minimal representation of correctional nurses in California.
In California correctional settings, the Legislative Analyst’s Office 2019 report acknowledged the California Department of Corrections and Rehabilitation’s use of mandatory overtime for nursing staff, despite previous state agreement to decrease this practice. The under representation of correctional nurses in California and the combined challenges intrinsic to the correctional work setting and to the COVID-19 pandemic warrant further investigation. To the best of our knowledge, this is the first study in the western U.S. region to exclusively target prison nurses and their working conditions and well being in the context of the COVID-19 pandemic, and compared to a non-correctional worker group. This study aims to evaluate a group of California prison nurses and compare their work characteristics and well being outcomes with those of a community nurse group. Recruitment for the community group occurred through nursing organization websites during an approximate 1.5-month survey window between late May and early July 2020. Most of the community nurse participants were in California. The prison nurse group was subsequently enrolled through collaboration with healthcare administrators at a California state prison. The survey window for the prison nurse group was about two months, from early September to late November 2020. For both groups, eligible nurses had to have current paid employment in a healthcare setting since the start of the COVID-19 pandemic. Informed consent was obtained from participants at the initiation of the online survey. Each participant received a USD 10 gift card incentive.
This study was reviewed and approved by the University of California, Los Angeles Institutional Review Board , and followed the Declaration of Helsinki guidelines, as well as the Strengthening the Reporting of Observational Studies in Epidemiology reporting guideline. The “Survey of Nurses Work and Well being during the COVID-19 Outbreak” was administered online to both groups of participants. The survey included validated instruments, Likert-type scales, visual analog scales, and numeric and free text responses to measure the working conditions and well being of nurses before and during the pandemic . Specifically, the survey focused on 3 domains of assessments on working conditions: psychosocial characteristics, organizational work characteristics, and the COVID-19 working characteristics. The survey also focused on 3 domains of assessments on psychological well being, including sleep characteristics,vertical farm psychological characteristics, and post-traumatic stress disorder. Pre-pandemic recall and current reports were requested for the variables of weekly work and sleep hours and night shift assignment. All other variables were one-time measurements.The Effort–Reward Imbalance scale was used to measure psychosocial factors at work, consisting of 10 items, 3 for effort, and 7 for reward. The effort score ranges from 3 to 12 and the reward score ranges from 7 to 28, with high scores corresponding with high magnitudes of effort and reward . The E–R ratio score ranges between 0.25 and 4.00, with scores above one suggesting high work stress. The Cronbach’s alpha coefficients were 0.80 for the effort sub-scale, and 0.78 for the reward sub-scale. The ERI measure has been widely used among nurses in Europe, as well as healthcare workers, including nurses in the United States. During the COVID-19 pandemic, several studies used the ERI for measuring work stress in front line healthcare workers . The organizational work characteristics included work years, as well as pre-pandemic and current .The Patient Health Questionnaire-4 measured depression and anxiety. The PHQ-4 features two two-item sub-scales to measure depression and anxiety symptoms over the past month. Each sub-scale’s score ranges from 0 to 6, with higher numbers relating to higher levels of depression and anxiety. For both conditions, scores of 3 and above represent positive cases of depression and anxiety. Both sub-scales were reliable, with a Cronbach’s alpha of 0.82 for depression and 0.9 for anxiety. Previous studies utilized this brief instrument during the COVID-19 pandemic among a hospital nurse sample in Romania, and a hospital nurse and nurse assistant sample in the United States. Post-Traumatic Stress Disorder symptoms over the past month were measured with a six-item screening instrument. Scores range from 6 to 30, with elevated scores reflecting elevated PTSD symptoms. A score of 14 or above indicates PTSD. The Cronbach’s alpha for this scale was 0.88. This instrument has been used in a United Kingdom healthcare worker sample during the COVID-19 pandemic. Participants with partial responses were included using pairwise deletion, with the omission of non-responses per variable rather than the implementation of missing value replacements.
Data were analyzed with Mann–Whitney U and t-tests for continuous data, and Fisher’s exact and Chi-Square tests for categorical data. The Shapiro–Wilk test checked for normal distributions. Wilcoxon signed-rank and McNemar’s tests compared pre-pandemic and current data. Means, standard deviations, and ranges were calculated. Calculations and analyses were conducted using SAS 9.4 .Among the 114 participants that originally submitted the survey, 5 participant entries were removed due to lack of consent or non-response on all items, resulting in a total sample of 109 with at least partial responses. Of this total sample, 79.82% completed the entire survey, with similar completion rates between the prison and community groups. The analysis incorporated the remaining participants’ partial responses. Table 1 shows the demographic characteristics of the study participants, with no significant differences between the two groups for gender, race, marital status, and age. The majority of participants in both groups were female, married or partnered, with a mean age within the 40-year age range. The largest racial subgroup was non-Hispanic White for both groups.Table 2 indicates the organizational characteristics before and during the pandemic. Both prison and community nurses had mean work years of about 15 years, with a minimum of 2 years, without significant differences. The pre-pandemic and current weekly mean hours of work were significantly higher for prison nurses compared to community nurses. For prison nurses, work hours significantly increased during the pandemic. Although there were no significant differences in night shift assignment between the groups before the pandemic and currently, the amount of prison nurses working any night shifts significantly increased after the start of the pandemic. There were no significant differences in psychosocial work stress experiences in terms of effort-reward imbalance between the groups, but stress levels in both groups were relatively high . Table 3 reports working conditions during COVID-19. Prison nurses reported significantly more direct COVID-19 patient contact, and had more requests to work, or had worked, in other departments. However, significantly more prison nurses perceived adequate PPE supply and had COVID-19 testing compared to community nurses. Significantly more community nurses expressed fear of contracting COVID-19 at work, and had a higher level of general fear towards the COVID-19 outbreak. Table 4 focuses on the psychological well being of the study participants. The prison nurses’ mean daily sleep hours were significantly lower than those of community nurses before the pandemic and currently. Mean scores for total insomnia and the sleep-related items indicating “trouble falling asleep” and “waking up at night” were elevated in the prison group compared to the community group, but these differences were not statistically significant. Both groups did not significantly differ in their mean PTSD scores, but both mean scores were above the cutoff score of 14. The percentage of nurses with a PTSD score equal to or above 14 was 49.02% in the prison group and 69.05% in the community group. Although depression and anxiety mean scores were more elevated in the community group, they did not significantly differ from those of the prison group. For both groups, the depression and anxiety mean scores were below the cutoff, and the prevalence of depression and anxiety cases was low.Significant findings from this study provide insight into prison nurses’ intensified challenges, including longer work hours, less sleep hours, more COVID-19 patient care demand, higher perceived PPE supply, and lower pandemic-related fear levels compared to community nurses. Although not statistically different, the occupational stress and mental distress results of prison nurses and community nurses are concerning, and reflect the pandemic context. The weekly work hours of the prison nurse study participants contrasted with those of the U.S. nurse population. Among the estimated U.S. population, 58.7% of nurses worked 32 to 40 h weekly between February and June 2020. While the community group’s mean pre-pandemic and current weekly hours were within this range, those of the prison group exceeded the national population estimate. Additionally, this finding of long working hours among the prison nurse study participants may be related to the previously mentioned issue of mandated overtime among some California state institutions.