Job demands and resources, nurses and COVID-19

Job Demands-Resources (JD-R) theory provides a means of identifying predictors for job burnout, a major problem for many healthcare workers (Reference Broetje, Jenny and BauerBroetje et al., 2020). A central assumption of JD-R theory is that each job has risk factors related to job stress that can be placed into one of two categories, job demands and job resources (Reference Hakanen, Bakker and SchaufeliHakanen et al., 2006). Job demands include physical, social, psychological and organisational demands of job roles that require employees to demonstrate sustained cognitive and emotional effort (Reference Bakker and DemeroutiBakker and Demerouti, 2017). Job demands can impose substantial physical and psychological costs on employees. The physical aspects of job demands include task duration and the intensity of labour required from employees when completing work tasks. Examples include where employees struggle to keep up with the pace of work, or when managers place excessive physical demands on them (Reference Bakker and de VriesBakker and DeVries, 2020). The social aspects of job demands include the potential for increased interpersonal conflicts within the workplace because of additional workload pressures, which can spill over into the home and give rise to conflicts with family members (Reference Xanthopoulou, Bakker and FischbachXanthopoulou et al., 2013). Women workers may experience higher levels of work-family interference compared to males because of additional societal pressure to undertake household duties and caring responsibilities in patriarchal societies such as Sri Lanka (Reference Kaufman and TaniguchiKaufman and Taniguchi, 2019). The physical consequences of sustained high job demands includes increased risks of heart attacks, heart disease, high blood pressure, type two diabetes, disturbed sleep, headaches and increased mortality (Reference Ahlin, Rajaleid and Jansson-FrojmarkAhlin et al., 2018; Reference Janssen, Van Strydonck and DecuypereJanssen et al., 2020; Reference Magnusson Hanson, Rod and VahteraMagnusson Hanson et al., 2020).

In nursing, high job demands have been identified as arising from inadequate staffing levels on hospital wards, the physical effects of shift-work and the emotional demands of dealing with sick and dying patients (Reference Broetje, Jenny and BauerBroetje et al., 2020; Reference Havaei, Ma and StaempfliHavaei et al., 2021; Reference Patience, De Braine and DhanpatPatience et al., 2020). Nurses can also experience verbal aggression and sexual harassment from patients and their relatives on hospital wards. The potential for interpersonal conflicts with other nurses and medical doctors may also increase their levels of job strain (Reference Gabriel, Erickson and DiefendorffGabriel et al., 2020; Reference Keyko, Cummings and YongeKeyko et al., 2016; Reference McVicarMcVicar, 2016; Reference LeGal, Rhéaume and MullenLeGal et al., 2019). The impact of sustained high job demands can result in nurses experiencing emotional exhaustion and job burnout (Reference Bakker and DemeroutiBakker and Demerouti, 2017). For example, approximately 80% of nurses surveyed in Canada responded that they were permanently tired at work, with psychological demands responsible for the largest proportion of their fatigue (Reference Janssen, Van Strydonck and DecuypereJanssen et al., 2020).

The COVID-19 pandemic has exacerbated the levels of exhaustion experienced by many hospital nurses caring for COVID-19 patients (Reference Lorente, Vera and PeiróLorente et al., 2021). Many nurses have received minimal training on how to assist patients who were dependent on ventilators for oxygen and they often had inadequate supplies of masks and gowns. Nurses have also experienced increased levels of fatigue and discomfort wearing PPE (personal protective equiment) (Reference Havaei, Ma and StaempfliHavaei et al., 2021; Reference Muz and YuceMuz and Yuce, 2021). Many nurses caring for COVID-19 patients experienced high levels of anxiety that they could become infected and transmit the disease to family members (Reference Lord, Loveday and MoxhamLord et al., 2021; Reference Pei, Chen and WangPei et al., 2020). Nurses caring for COVID-19 patients have also face discrimination from other nurses and the general public as potential carriers of the disease (Reference Lord, Loveday and MoxhamLord et al., 2021). In addition, nurses working on COVID-19 wards have been found to be susceptible to post-traumatic stress, anxiety and emotional exhaustion (Reference Havaei, Ma and StaempfliHavaei et al., 2021). Nurses across South Asia have also experienced increased levels of depression and reduced mental health working on COVID-19 hospital wards (Reference Saeed, Amin and TalhaSaeed et al., 2021).

Such high job demands may be offset where senior managers and supervisors provide organisational job resources and social support to nurses to enhance their levels of job satisfaction, work motivation and resilience (Reference Bakker and DemeroutiBakker and Demerouti, 2007; Reference Cooper, Brown and ReesCooper et al., 2020; Reference Labrague and De Los SantosLabrague and De Los Santos, 2020). Job resources include positive relationships between co-workers, team cohesion and positive interactions with supervisors (Reference Bakker and DemeroutiBakker and Demerouti, 2007). Social job resources experienced by nurses include positive interpersonal relationships with other nurses and regular communications and feedback from hospital supervisors and managers (Reference Broetje, Jenny and BauerBroetje et al., 2020). The provision of social resources are important to workers in Sri Lanka’s collectivist national culture, where close-knit in-groups extend beyond employees’ immediate families and across extended social networks (Reference Ibrahim and IrfanIbrahim and Irfan, 2016).

Organisational resources include learning and development opportunities that can enhance employees’ opportunities for personal and professional growth, increase work engagement and reduce turnover intentions (Reference Bakker and DemeroutiBakker and Demerouti, 2017; Reference Schaufeli, Bakker and Van der HeijdenSchaufeli et al., 2009). Organisational job resources also extend to the provision of job security, role clarity, opportunities to participate in decision-making and trust in managers. They further include employees’ perceptions of organisational justice and access to fair remuneration (Reference Bakker and DemeroutiBakker and Demerouti, 2017; Reference McVicarMcVicar, 2016). Additionally, organisational job resources for nurses include participation in decision-making regarding patient care, their ability to have control over their work schedules and opportunities for career advancement (Reference Patience, De Braine and DhanpatPatience et al., 2020).

Nurses who received valued job resources from hospital managers have been found to be more successful in coping with the additional job demands caused by COVID-19. Nurses in South Africa who received high quality support from hospital supervisors when caring for COVID-19 patients experienced enhanced levels of work engagement and reciprocated by demonstrating increased organisational commitment (Reference Patience, De Braine and DhanpatPatience et al., 2020). Nurses who received high levels of support from other nurses, their families and from the public in South Africa during the pandemic also experienced reduced levels of anxiety and depression and increased levels of professional pride (Reference Patience, De Braine and DhanpatPatience et al., 2020).

Job resources includes individual employee’s personal resources, or self-assessment of their levels of resilience, self-efficacy and sense of optimism when exposed to situations that cause increased job stress (Reference Xanthopoulou, Bakker and DemeroutiXanthopoulou et al., 2007). Nevertheless, reliance on personal resources can give rise to emotional coping involving venting at other employees and family members that can exacerbate employees’ levels of emotional exhaustion (Reference Bakker and de VriesBakker and DeVries, 2020).

Applying JD-R theory, this study explores the types of job demands and job resources experienced by nurses in public and private hospitals in Sri Lanka prior to and during the COVID-19 pandemic. The following section examines Sri Lanka’s public and private healthcare systems and considers their ability to cope with COVID-19 hospitalisations.

Sri Lanka’s public and private healthcare system

Sri Lanka represents a lower middle income developing country with a history of providing ‘good healthcare at low cost’ (Reference ThresiaThresia, 2013). Sri Lanka’s public healthcare system has historically focused on treating communicable diseases through an extensive network of community clinics, public hospitals and pharmacies (Reference Pallegedara and GrimmPallegedara and Grimm, 2017). From the 1930s onwards, healthcare was provided at minimal cost in public hospitals and clinics to the population regardless of income level (Reference Chapman and DharmaratneChapman and Dharmaratne, 2019). This public healthcare network focused on training public health workers, improving maternal and child welfare and providing immunisations to the population. Sri Lanka’s public healthcare network has delivered positive public health outcomes and facilitated improvements in life expectancy, which had increased to 78 years for women and 72 years for men by 2019 (Central Bank of Sri Lanka, 2020).

Expenditure by the government of Sri Lanka on healthcare, however, has declined over recent decades and represented merely 1.6% of GDP in 2019 (Central Bank of Sri Lanka, 2020). The decline in public healthcare funding has resulted in chronic overcrowding on public hospital wards, limited access to specialist medical treatments and declining levels of service quality (Reference ThresiaThresia, 2013). In addition, public hospitals in Sri Lanka have experienced a shortage of nurses over several decades. In 2019, there were 38,276 nurses employed across 603 public hospitals with a total bed capacity of 77,964, representing a shortage of approximately 30,000 nurses (Central Bank of Sri Lanka, 2020). Such shortages were exacerbated by limited government funding of student places in nurse training colleges. As a result, Sri Lanka had a relatively low density of 22 nurses per 10,000 population (Reference Aluwihare-Samaranayake, Ogilvie and CummingsAluwihare-Samaranayake et al., 2017). The overwhelming majority of nurses were women, with the recruitment of male nurses restricted to 5% of the public nursing workforce (Reference Jayasekara and AmarasekaraJayasekara and Amarasekara, 2015).

Nursing shortages in public hospitals resulted in hospital managers requiring nurses to accept compulsory overtime. Before the COVID-19 pandemic, approximately two-thirds of nurses in Sri Lankan public hospitals were required to work regular overtime hours to ensure public hospital wards maintained minimum workforce levels. Public hospital nurses were expected to accept high workloads and it was not unusual for one public hospital nurse to care for 25–30 patients during a day shift and over 50 patients during a night shift. Public sector nurses also experienced low pay – in 2018, public nurses’ salaries ranged from USD181 to USD279 per month (Central Bank of Sri Lanka, 2019). In addition, public hospital nurses in Sri Lanka experienced limited opportunities for career progression and a lack of decision-making authority over patient care on hospital wards (Reference Aluwihare-Samaranayake, Ogilvie and CummingsAluwihare-Samaranayake et al., 2017; Reference Hellerawa and AdambarageHellerawa and Adambarage, 2015).

Sri Lanka’s extensive public healthcare network enabled it to respond successfully to the initial impact of the COVID-19 pandemic. The national government responded rapidly and decisively to the initial outbreak of COVID-19 cases from March 2020. Those infected with COVID-19 were isolated in selected public tertiary hospitals across the country. A series of quarantine centres overseen by the military were also established and international arrivals and those suspected of being close contacts of persons infected with COVID-19 were required to remain in these centres for 14 days (Reference Arambepola, Wickramasinghe and JayakodyArambepola et al., 2021). A nation-wide lockdown and curfew were also implemented from March 2020 to restrict population movement and to ensure that people remained at home to minimise spread of the disease (Reference Hettiarachchi, Noordeen and GamakaranageHettiarachchi et al., 2021).

Sri Lanka has experienced a series of COVID-19 outbreaks over 2020–2021. The first wave occurred among Navy sailors in April 2020 and a second outbreak began among garment workers from October 2020. As a result of its decisive actions from the beginning of the pandemic, Sri Lanka managed to limit the spread of COVID-19 to mainly younger populations who experienced milder forms of the disease (Reference Hettiarachchi, Noordeen and GamakaranageHettiarachchi et al., 2021). The Delta variant of COVID-19 spread rapidly across Sri Lanka over 2021 and resulted in a third nation-wide lockdown in August that lasted until October 2021. The Delta and Omicron variants significantly increased the number of people infected by COVID-19 and by 3 January 2022 Sri Lanka had experienced 587,435 infections and 15,019 deaths from COVID-19 among its population of 21.8 million people (Johns Hopkins University, 2021).

In this resource context, we identify the job demand impacts of COVID-19 through case studies of the experiences of nurses in one public tertiary hospital that was responsible for caring for COVID-19 patients and one private hospital. The following section outlines the research methodology utilised to gather the views of hospital nurses.

Research method

The research involved interviews with nurses in one large public hospital and one private hospital located in Colombo in 2016, 2018 and 2020. The public hospital was a large teaching and general hospital that employed over 1700 public nurses and delivered cardiology, general medicine and surgical procedures free-of-charge to public patients. The private hospital was a multi-specialty hospital that employed 130 nurses and delivered paediatrics, obstetrics, gynaecology, dialysis, intensive care and neonatal medical services to private patients. The study was underpinned by a subjectivist epistemology where ‘… what constitutes knowledge depends on how people perceive and understand reality’ (Reference Moon and BlackmanMoon and Blackman, 2014: 1172). This highlights that reality may emerge through the perceptions of multiple individuals (Reference CreswellCreswell, 2018) captured through a qualitative research methodology involving the collection of multiple sources of evidence (Reference YinYin, 2014).

Nurses in the public and private hospitals were asked to volunteer for this study in 2016 and 2018 and additional interviews were held with nurses working on COVID-19 hospital wards in 2020. The first researcher interviewed 26 nurses in the large public hospital prior to the pandemic, with 14 interviews conducted in 2016 and 12 in 2018. Some 30 interviews were conducted with nurses in the private hospital prior to the pandemic, 17 in 2016 and 13 in 2018. In addition, eight interviews were conducted with female nurses working on COVID-19 wards in the large public hospital in November 2020. The interviews lasted between 30 and 90 min and were conducted mainly in Sinhala. All interviews were digitally recorded, transcribed from Sinhala into English and loaded into the qualitative research software Nvivo11 software to assist with coding and analysis. To analyse interview data, the researchers collated a list of open codes that emerged from the interview transcripts into broader themes to facilitate thematic analysis. The open coding involved comparing the interview data for similarities and differences and grouping the data into categories based on this comparison (Reference Corbin and StraussCorbin and Strauss, 2008).

The trustworthiness of the interview data was enhanced by a focus on credibility and confirmability (Reference Lincoln and GubaLincoln and Guba, 1986). Confirmability involved ensuring that the findings of the study emerged from the experiences and suggestions of participants. The first researcher shared drafts of case study findings with interview participants to confirm the accuracy of the data and maintained contact with public and private sector nurses throughout the period of data gathering from 2016 to 2020. During the second round of interviews in 2018, the first researcher discussed the findings of earlier interviews with participants to ensure that the interpretation of job demands and job resources accurately represented their views. The following section examines nurses’ perspectives of their job demands and resources prior to the COVID-19 pandemic.

Nurses’ experiences of job demands

Prior to the COVID-19 pandemic, nurses in the public hospital experienced overcrowded hospital wards that they had to manage with limited nursing staff. It was not unusual for two nurses to manage up to 50 patients at a time during day shifts. Understaffing also resulted in nurses working additional shifts back-to-back. One public hospital nurse noted:

Many nurses believed they had little option but to remain on the hospital ward to ensure that patients received a minimal level of care. One nurse stated,

A significant job demand experienced by nurses involved the emotional demands of dealing with dying patients and their relatives (Reference McVicarMcVicar, 2016). One public hospital nurse noted:

Women nurses in the Sri Lankan public healthcare sector also experienced verbal aggression from male patients. One public hospital nurse noted that ‘… We have not been harassed physically. But we have faced verbal harassment. They shout at us …’ (woman nurse, 2016). Patients vented their frustration at nurses over inadequate facilities on public hospital wards, such as the limited numbers of beds, the lack of bed sheets, the lack of bathroom facilities and the poor quality of the food. One public nurse stated:

Some male patients removed their clothes and made sexualised comments, for example:

Another nurse stated,

Nurses also experienced verbal aggression from patients’ family members and visitors dissatisfied with the attention patients received on hospital wards. Some 23 out of 26 public hospital nurses interviewed experienced verbal aggression from patients’ relatives and visitors. Relatives of patients often became aggressive when they were expected to purchase medicines for patients when the hospital’s medical stocks were depleted. One nurse noted:

Another public nurse noted that ‘(e)ven though we want to do a service it is not possible because of a lack of facilities … (woman nurse, 2016). In addition, public hospital nurses experienced verbal aggression from bystanders on hospital wards. Bystanders comprised former hospital workers hired by patients’ relatives to look after the patient. One public hospital nurse highlighted that:

Another public hospital nurse stated,

The combination of high workloads, understaffing and verbal aggression from patients, visitors and bystanders created an environment of low job control and high job demands for many nurses on public hospital wards in Sri Lanka.

Job demands and private hospital nurses

Over the past four decades, private healthcare providers have played a more significant role in the delivery of healthcare in an environment of declining public investment (Reference Chapman and DharmaratneChapman and Dharmaratne, 2019). Rising income levels among Sri Lanka’s urban middle class led to increased demand for less crowded, cleaner hospital wards and specialist medical services and procedures. Private hospital patients, however, faced relatively high out-of-pocket expenses and few private patients possessed medical insurance resulting in demands for discounts on hospital bills (Reference Pallegedara and GrimmPallegedara and Grimm, 2017). By 2021, the private healthcare sector comprised 207 registered private hospitals and a total bed capacity of 5147 (Central Bank of Sri lanka, 2019; Private Health Services Regulatory Council, 2021).

Private hospital nurses faced different work pressures from public hospital nurses as they undertook both healthcare and customer service roles, which included managing patients’ billing queries. One private hospital nurse stated:

When the bill was presented to the patient, or their family, they often complained that the hospital’s charges were too high. One private sector nurse noted that ‘… when they get the bill, most of them become aggressive …’ (male nurse, 2018).

Private hospital management were keen to minimise negative feedback from patients and their relatives in an effort to generate repeat business. One private hospital nurse stated:

Private hospital nurses were also expected to provide medical assistance to support specialist doctors, such as surgeons, who often performed two to three surgeries in a short timeframe. One nurse noted:

Job resources, personal resources and resilience

The provision of job resources by hospital managers and nursing supervisors had the potential to mitigate nurses’ high job demands (Reference Patience, De Braine and DhanpatPatience et al., 2020). Many nurses, however, experienced limited organisational support from hospital managers prior to the COVID-19 pandemic. The public hospital did not offer professional counselling services, or organised employee assistance programmes to assist hospital staff to cope with job stress. Some 20 out of 26 public hospital nurses interviewed highlighted that they had to develop their own coping strategies to mitigate job stress. One nurse noted that:

In place of organisational resources, many nurses relied on social support from other nurses and nursing supervisors. One public hospital nurse stated: ‘I talk with other nurses in the ward … Then I feel that I am not the only victim (woman nurse, 2016). Another public hospital nurse noted:

Many Sinhalese nurses in Sri Lanka were Buddhist and they visited religious places, or listened to Buddhist sermons, following stressful incidents on hospital wards. These nurses believed in Buddhist teachings that included Karma (the belief that one’s fate is determined by good and bad deeds committed in past lives) and believed that by caring for the sick they accumulated good deeds. They also believed in Samsara, the cycle of birth, mundane existence, death and rebirth. One public hospital nurse highlighted:

Nurses’ reliance on their own personal resources though could also result in emotional venting towards other nurses and family members. One public hospital nurse noted:

Emotional venting was also relied on by private hospital nurses to cope with job stress. Some 16 out of 30 private sector nurses interviewed admitted that they vented their frustrations at family members and junior colleagues. One private hospital nurse noted that “… my husband has to absorb everything …” (woman nurse, 2016).

The limited job resources provided to nurses in Sri Lanka meant that they had limited buffers available to them to mitigate the high job demands they experienced on hospital wards. The persistence of high job demands resulted in nurses in both public and private hospitals in Sri Lanka suffering from ongoing health issues that included insomnia, hypertension, depression and heart palpitations (interviews with public and private hospital nurses, 2016, 2018, 2020). The following section explore nurses’ experiences of job demands and job resources during the COVID-19 pandemic.

COVID-19 and nurses’ job demands and job resources

COVID-19 created a range of specific job demands for nurses in Sri Lanka that included being allocated to COVID-19 wards without their consent and the physical discomfort of wearing PPE for lengthy periods. For example, nurses who were not married, or who were still on probation, were often the first to be allocated to COVID-19 centres and hospital wards. One nurse stated,

Nurses working on COVID-19 hospital wards were also expected to wear PPE for lengthy periods and experienced considerable physical discomfort wearing PPE in Sri Lanka’s humid tropical climate. Wearing PPE for long periods of time resulted in nurses experiencing headaches and vomiting. One nurse highlighted that:

Many nurses who worked in COVID-19 centres also experienced discrimination and social isolation from other nursing colleagues who feared they might be infected with the virus. One nurse stated:

Hospital management were often reluctant to conduct COVID-19 PCR (polymerase chain reaction) tests for nurses but relented following pressure from medical doctors that all healthcare workers be tested for COVID-19 regularly. One nurse interviewed noted that:

… nurses were later really scared of contracting the disease. However, the authorities conducted PCR on us. That was because the doctors refused to return to their families without being tested. Then we [nurses] also protested that we want PCR tests to be done on us. Then the authorities did. We did not return home until we received the test results … (woman nurse, COVID-19 Centre, 2020).

In addition, nurses working on specialist COVID-19 wards received limited organisational support from public hospital managers. This included being provided with a limited supply of masks and other PPE along with limited training in the provision of healthcare to COVID-19 patients. One nurse highlighted that:

Public hospital nurses highlighted that they received limited formal training before they were sent to COVID treatment centres and had to learn on the job how to care for COVID-19 patients. One nurse stated:

Only a small number of nurses were trained by the infection control units of the hospital and they were expected to share their knowledge with their colleagues. One nurse noted that:

The lack of organisational job resources provided to nurses by the public hospital’s management during COVID-19 meant that they drew more heavily on their own levels of resilience amid fears of contracting the virus and transmitting it to family members. One participant stated: