About the the systematic literature review
The systematic literature review summarises the impact of the Covid-19 pandemic on healthcare workers over time and the effects of interventions for improving their work environment and health.
Summary
The origin of this compilation of knowledge is that the Swedish Agency for Work Environment Expertise was allocated additional financial resources in the appropriation directions for 2022 for the identification and analysis of the short-term and long-term consequences of the corona pandemic for the work environment in Sweden.
Aim and research questions
The overall aim of this systematic review is to map and summarise research about how the Covid-19 pandemic has affected the work environment and health in healthcare workers and to map and summarise research about effects of interventions aimed at improving the work environment and health. The time span is the start of the pandemic in November 2019 until spring 2022.
The specific research questions were:
1. What changes in the work environment were observed over time in the healthcare sector during the Covid-19 pandemic?
2. What associations over time between the work environment and employee health were identified in the healthcare sector during the Covid-19 pandemic?
3. What effect did interventions have to improve the work environment or employee health in the health care sector during the Covid-19 pandemic?
For each of the three research questions, are there any differences between subgroups of employees, for example based on profession and sex?
Inclusion and exclusion criteria
The systematic literature review includes studies of all occupational categories within healthcare. Studies of care homes, such as elderly care, were excluded. All kinds of work environment (physical, ergonomic and psychosocial) and all types of health outcomes were included. No restriction regarding health was used in the search strategy. Only empirical peer-reviewed studies published in English, Swedish and other Nordic languages were selected, and only observational studies with repeated measurements or intervention studies. Studies based on qualitative or cross-sectional quantitative data were excluded because research based on such study designs was thoroughly examined in a previous review performed on commission by the Swedish Agency for Work Environment Expertise (1).
Methods
The development of the research review followed the method used by the Swedish Agency for Work Environment Expertise as well as Prismas guidelines for systematic literature reviews. The search strategy was based on restrictions in Population (healthcare personnel), Exposure (Covid-19) and Outcome (work environment). The databases PsycINFO (EBSCO), PubMed (NCBI) and Web of Science were searched at the beginning of May 2022 and articles published from November 2019 to 3rd May 2022 were included. The search yielded 4601 titles. The articles were imported to the software programme Covidence. Titles and abstracts were screened for inclusion and exclusion criteria independently by two researchers. In the next step the full texts of the selected articles were reviewed by two researchers and, if excluded, the reason was registered. Of the 4601 titles, 64 articles met the inclusion criteria and were included in quality assessment. The quality was assessed using an extended version of the Mixed Methods Appraisal Tool (MMAT). Observational studies were assessed using one set of criteria and randomised controlled trials using another set. Of the studies that were assessed, 23 were excluded due to low quality. The results of the systematic research review are based on 41 studies published during 2020-2022. An external reviewer suggested the term ’occupational risk’ complement the original search terms.
This additional search term generated 74 titles, of which 20 full texts were reviewed. All 20 were excluded due to either wrong study design (n=14), wrong exposure (n=3), wrong population (n=2) or wrong outcome (n=1).
Results
1. What changes in the work environment were observed over time in the healthcare sector during the Covid-19 pandemic?
- Several studies showed consistently that the workload increased during the Covid-19 pandemic.
- The results were inconsistent regarding the availability of emotional support to employees by managers and external consultants.
- The results were also inconsistent regarding how access to personal protective equipment varied over time.
2. What associations over time between the work environment and employee health were identified in the healthcare sector during the Covid-19 pandemic?
Increased risk for mental ill-health over time was associated with:
– Working in direct contact with Covid-19 patients
– Heavy workload
– Moral distress at work
3. What effect did interventions have to improve the work environment or employee health in the health care sector during the Covid-19 pandemic?
- Interventions at the individual level (for example, meditation and breathing/ relaxation exercises) had immediate, positive effects on mental health, but the studies are few in number and are based on study designs that do not allow for conclusions regarding neither causal relationships nor long-term effects.
- Interventions at the organisational level (for example, changes in work routines, staffing and professional supervision) resulted in immediate, moderately strong positive changes in mental health in employees. Noconclusions about causal associations can be made, however, due to limitations in study designs.
For each of the three research questions, are there any differences between subgroups of employees, for example based on profession and sex?
- A few studies compared subgroups based on profession, sex and age, but the results were inconsistent and it is not possible to draw any strong conclusions.
Methodological limitations in the original studies
- Self-reported data have been used for most exposure and outcome measures.
- The exposure measurements were often based on non-validated questions.
- Some studies of associations between the work environment and health did not adjust for the health level at baseline, limiting support for causal associations.
- Intervention studies lacked long-term follow-ups.
Research gaps and future research
- Longitudinal studies from Sweden and other Nordic countries are few in number and studies that compare the work environment and health in the healthcare sector between Nordic countries during Covid-19 are lacking. Such studies could contribute with increased knowledge about the consequences of different strategies to handle pandemics.
- Studies of organisational factors, such as allocation of resources, staffing, work schedules and so on are few in number regarding both development over time during the Covid-19 pandemic and the effects on employee health.
- More studies on how protective workplace resources, such as support from managers and colleagues, developed during the Covid-19 pandemic and the possibility of workplace resources to buffer negative health outcomes are needed.
- Intervention studies focused primarily on coping strategies among personnel with short-term effects on mental health. More studies of interventions at an organisational level and with longer follow-ups are
needed. - More studies with longer follow-up times are needed generally.
- To strengthen the quality of the research, more studies with representative samples, in which exposure measures were validated, and in which internal attrition and relevant confounders were taken into account are needed.
The authors of the systematic literature review
- Anna Nyberg, Docent
Health Equity and Working Life (HEAL), Uppsala University - Ingrid Demmelmaier, Docent
Uppsala University - Kristiina Rajaleid, PhD
The Stress Research Institute, Stockholm University - Magnus Helgesson, PhD
Karolinska Institutet - Åsa Andersén, PhD
Uppsala University - Ingrid Anderzén, Docent
Uppsala University - Beatrice Carpentsier, Research Assistant
Uppsala University