Problems Causing Work-Related Stress and Strategies for Coping

with Stress Suggested by Nurses During Covid-19 Pandemic

L. LINNIK, J. SEPP

Tallinn Health Care College,

Kannu 69, Tallinn, 13418,

ESTONIA

Abstract: - Nurses play a pivotal role in the battle against COVID-19. Investigation of the stressful

circumstances nurses have encountered provides an opportunity to identify potential strategies for relieving

occupational stress among nurses during a crisis. Research on nurses’ occupational stress in Estonia has been

limited, so our understanding of what causes stress is incomplete. This study uses Karasek’s JDC model to

explore the factors that can lead to occupational stress for nurses.

The purpose of this research is to investigate the stressful circumstances encountered by nurses during the

COVID-19 pandemic and to identify potential strategies for reducing occupational stress among nurses in

Estonia. Using Karasek’s JDC model, this study seeks to explore the factors that contribute to nurses’

occupational stress and develop effective strategies to address these stressors.

Content analysis was used to analyze the data and identify themes and patterns. The themes were related

to the topics of the study, such as nurses’ experiences working on a COVID-19 ward, the challenges they

faced, and the strategies they used to deal with these challenges.

The results of the study will be used to improve the quality of care provided to COVID-19 patients in

the hospital. Nurses’ main issues were linked to high work demands and low discretion regarding decisions.

The problems concerning work demands were mainly associated with a lack of management, interpersonal

relations, and a heavy workload. Insufficient management support, unclear instructions, inadequate knowledge

about how to use PPE, and nurses’ differing understandings of work organization were reported as existing

problems. Heavy workloads and insufficient rest periods resulted in physical and mental health problems

among nurses. Low discretion was caused by unexpected situations necessitating quick and ethical decision-

making.

The findings of this study indicate that nurses in hospitals are facing several issues related to high work

demands and a lack of discretion in decision-making. Strategies proposed by nurses to address these issues

include offering additional training and classes, increasing the number of nurses, improving communication,

and enhancing access to professional mental health support. These findings can be used to improve the quality

of care provided to COVID-19 patients in hospitals.

Key-Words: - COVID-19 pandemic, COVID-19 ward, Occupational stress, Nurses

Received: February 16, 2023. Revised: June 13, 2023. Accepted: June 24, 2023. Published: July 7, 2023.

1 Introduction

The coronavirus pandemic (COVID-19), whose

onset occurred in China in December 2019 and

spread globally, has led to a multitude of problems

and challenges in health care. The pandemic has

demonstrated that no country – not even the most

advanced – was ready for a pandemic of such

magnitude, [1], [2]. The exposure of gaps in

national preparedness due to the emergence of the

SARS-CoV-2 virus has revealed deficits in global

leadership. The European Centre for Disease

Prevention and Control (ECDC) and the Centers

for Disease Control and Prevention (CDC) concur

that the virus is unlikely to disappear soon. Various

scenarios have been discussed, ranging from mild

to severe, including the potential for a new

pandemic. It is prudent to be prepared for all

possible contingencies, [3]. Nurses experience

occupational stress due to the high societal

expectations and rapidly changing conditions

associated with treating COVID-19 patients, [4],

[5]. Prolonged stress can be a precipitating factor

in the development of depression, which can have

detrimental consequences for cognitive, affective,

and behavioral functioning, [5]. The presence of

heightened tension in work environments, which is

often the result of high psychological demand and

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limited discretion in decision-making, can have

deleterious effects on health outcomes, [6].

The WHO Model of a Healthy Workplace, [7],

[8], identifies the four components of a thriving

work atmosphere: physical and psychosocial

conditions; individual well-being; and the

involvement of the organizational community.

Organizations should focus on the prevention of

mental health issues by evaluating potential risks

from the beginning, rather than providing stress

management, pressure management education, or

counselling for stressed employees, [9].

Occupational stress as a hazard in the workplace

has been cited since the middle of the 1950s.

Burnout is a potential consequence of chronic

occupational stress, [10]. The World Health

Organization declared burnout an occupational

phenomenon during the COVID-19 pandemic

(WHO 2020). Despite the relevance of the topic,

few studies provide recommendations for

healthcare professionals to establish the necessary

changes in times of crisis, [11]. It is important to

examine nurses’ experiences and well-being in

times of crisis; an understanding of nurses’ well-

being is essential to ensuring a high-quality

workforce, [12].

This research is underpinned by Robert

Karasek’s Job-Demand-Control (JDC) model,

[13], which has been widely utilized to investigate

work-related stress. Substantial empirical evidence

has been amassed in support of the JDC model

from numerous studies conducted by psychosocial

and work-related stress researchers, [13], [14],

[15]. This model provides a comprehensive

understanding of the sources of stress in the

workplace by assessing both the demands of the

job and the employee’s control over their work

environment. It can be used to identify areas of

potential risk and to develop strategies for

improving job satisfaction and reducing stress.

Moreover, the JDC model can be utilized to better

understand the psychological consequences of job

stress and provide a framework for developing

effective interventions. The study, [14], examined

the efficacy of the JDC model in predicting work-

related stress among nursing professionals.

Similarly, a review by [15], found that the JDC

model had significant predictive value in

evaluating job demands and levels of stress in the

workplace. Therefore, Karasek’s JDC model is a

powerful and comprehensive tool for exploring the

relationship between job demands, control, and

employee stress, and for developing strategies to

reduce job stress and improve job satisfaction.

2 Problem Formulation

2.1 Occupational Stressors Faced by Nurses

during COVID-19

Nurses are a vital component of the healthcare

system, providing essential care to patients in

various healthcare settings. However, the nature of

their job comes with numerous psychosocial risk

factors that can negatively impact their well-being

and work performance. In literature, the heavy

workload of nurses, the emotional stress caused by

observing patients in a critical condition, and the

lack of resources and social life have been

identified as the main psychosocial risk factors,

[11], [16], [17].

In addition, the COVID-19 pandemic has

further increased the burden on nurses, with the

uncertainty surrounding treatment policies affecting

nursing quality and causing staff members to quit,

[18], [19]. The departure of staff members has

resulted in increased stress for the remaining

employees, leading to burnout among nurses, [20].

[11], the authors identified conflicts arising

between people, with a lack of emotional

intelligence, personal characteristics, unclear roles,

and poor communication seen among the main

causes. The study, [16], found that the use of

personal protective equipment (PPE) caused

physical problems for nurses, such as fatigue and

psychological stress. Communication and vision

were also affected, with fogging of protective

glasses reported, [21].

Estonian nurses working with COVID-19

patients experienced a significant increase in

workload and tension, as reported by [22]. The

provision of support in managing tensions derived

from the COVID-19 situation was found to be

adequate, but nurses relied mainly on support from

family and friends, with less perceived support from

their organization. The study, [23], analyzed

psychosocial risk factors in Estonian care homes

and found a correlation between these factors and

burnout, stress, sleep problems, and cognitive,

depressive, and somatic symptoms. Heavy

workload, quick pace, and uneven working patterns

caused difficulty focusing and memory problems

and hindered clear thinking and decision-making

among employees. In [24], the authors reported that

the meaning of the job, clear roles, social relations,

and mutual trust among employees were important

factors for Estonian nurses. Work-related

psychosocial risk factors such as workload,

emotional requirements, work pace, and role

conflicts were positively correlated with the

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occurrence of stress and burnout. Occupational

stress and burnout were found to have the highest

average scores among mental health problems. In,

[25], the authors found that work-related

psychosocial risk factors, particularly quantitative

and emotional requirements, work pace, low justice

and respect in the workplace, and role conflicts, had

a significant influence on the occurrence of

musculoskeletal pain among nurses.

In conclusion, the nursing profession is

associated with numerous psychosocial risk factors

that have implications for the well-being and work

performance of nurses. The COVID-19 pandemic

has further increased the burden on nurses, making

it crucial to address psychosocial risk factors and

support the well-being of healthcare workers in

general. It is recommended that healthcare

organizations provide adequate resources and

support systems to help nurses manage their

workload, improve communication and the

organizational culture and provide adequate

training. Overall, the literature highlights the

importance of addressing psychosocial risk factors

in the nursing profession, particularly in relation to

the COVID-19 pandemic, to promote the well-

being of nurses and ensure high-quality patient care.

As the COVID-19 pandemic continues to challenge

the nursing profession, understanding the coping

strategies used by nurses to manage stress is crucial

for promoting their well-being and ensuring high-

quality patient care.

2.2 Stress Coping Strategies used by Nurses

during the COVID-19 Pandemic

According to, [26], stress arises from the

interaction between the person and their

environment; effective stress management requires

consideration of both parties. The stress

management model proposes that individuals use

either problem-centered or emotion-based coping

strategies based on their evaluation of the situation

and their coping resources, which can be physical,

social, psychological, or material. Coping serves

two main functions: regulating emotions or

stressors derived from stressful situations; and

managing the cause of stress by changing elements

of stress directly.

In, [27], the authors observed that people tend

to use problem-based coping strategies when the

situation is assessed as changeable and emotion-

based strategies when the situation is assessed as

less changeable or unchangeable. In, [28], [29], the

authors found that nurses tend to focus on

problem-centered strategies rather than emotion-

based ones.

Studies conducted during the COVID-19

pandemic show that nurses have sufficient

resources to implement constructive management

strategies, [30]. In [31], the authors found that

nurses working with SARS-CoV-2 patients used

coping strategies focused on both problems and

emotions, whereas nurses working with patients

without COVID-19 primarily used problem-

centered coping strategies. The use of psychoactive

substances to alleviate unpleasant emotions was

rare among nurses.

In, [32], the authors found that younger nurses

working with COVID-19 patients tended to use

instrumental social support. Only a few nurses

resorted to drug use. Nurses in leadership positions

preferred planning as a coping strategy. The

authors of the study concluded that special

attention should be paid to younger and less

experienced nurses. Monitoring the working hours

and health status of nurses is essential. Outpatient

healthcare institutions need more attention,

support, and information, with managers playing a

critical role in improving nurses’ mental health.

The study, [22], concluded that Estonian

nurses expected support measures from hospitals,

including higher salaries, more rest time, flexible

work schedules, recognition, and psychological

support. In, [23], the authors emphasized that a

healthy work environment results from good

communication, teamwork, a sufficient number of

employees, recognition, trust management, and the

decision-making skills of colleagues and managers

alike. Work organization and the provision of

support from managers are crucial to maintaining

employees’ mental health stability, ensuring

patient safety, and improving work outcomes. The

authors recommend training managers and

employees in positive conflict resolution,

supporting one another in routine work situations,

and providing constructive feedback.

3 Problem Solution

The purpose of this research is to investigate the

stressful circumstances that nurses have

encountered during the COVID-19 pandemic and to

identify potential strategies for reducing

occupational stress among nurses in Estonia. Using

Karasek’s JDC model, this study seeks to explore

the factors that contribute to nurses’ occupational

stress and develop effective strategies for

addressing these stressors. To address this purpose,

two research questions were formulated:

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(1) What occupational stressors have nurses in

Estonia faced during the COVID-19 pandemic?

(2) What strategies can be implemented to reduce

occupational stress among nurses in Estonia?

3.1 Study Design

This research is a qualitative study based on semi-

structured interviews. The authors of this study have

selected the qualitative research method because it

encompasses the personal experiences of the

subjects during COVID-19, which are needed to

achieve the aim of this study. The qualitative

content analysis described by, [33], was employed

to analyze the data. This method of analysis is

useful for revealing conflicting opinions or

unresolved issues concerning the significance and

application of concepts, strategies, and

interpretation. It offers an important perspective on

the main concepts related to qualitative content

analysis, [34].

Karasek’s model was employed as the

theoretical framework of the study. The model for

checking work demands, [13], consists of two main

terms: job decision latitude, which demonstrates to

what extent the worker has their say about what to

do at work and how; and job demands, which

involve workload, support, resources and

information from the organization, management,

and colleagues, as well as time pressure. Employees

with high demands and high discretion regarding

decisions are active, and those with high demands

and low discretion regarding decisions are strained,

[13], [35], [23], [11]. Job demands refer to the

physical, social, and organizational elements of a

job that may lead to stress or health issues, [36]. A

qualitative study was conducted in the COVID-19

wards of Central Hospital after gaining permission

from the Ethics Committee of the Estonian National

Institute for Health Development. The

phenomenological approach was used with the aim

of describing the phenomenon’s “pure experience”,

[37]. Data were collected by open semi-structured

interviews, which according to, [38], is used of

subtopics of the interview are known and the

questions may be formed before but it is the

researcher that decides when it is appropriate to

ask these. The interview included open questions,

which allowed the nurses to express their detailed

experiences as well as their understanding of the

problems causing their occupational stress, the

consequences of their occupational stress, and the

solutions they employ to alleviate their stress. The

authors used the following questions in the

interviews: “What were the most stressful situations

you encountered while working during the COVID-

19 pandemic?”, “What kind of problems arose?”,

“How were they resolved?”, “How could you avoid

this situation in the future?”, “What was the

aftermath of this situation?”, “What were the

reasons for the problem?”, “Is there anything else

you would like to add about your experience?” The

authors recorded the answers of the subjects and

later documented them manually on paper.

3.2 Sample Selection

The subjects of this research are nurses who worked

or are working on the COVID-19 ward during the

pandemic and who have described their subjective

experiences. These descriptions provide a

comprehensive picture of how stressful the

situations and problems were for nurses during the

crisis.

Nurses working in the COVID-19 ward at an

Estonian hospital formed the sample. The aim of the

research and its necessity, importance, and plan of

conduct was explained to the management board of

the COVID-19 ward after which permission to

conduct the research was granted. Since March

2020, COVID-19 patients have been treated in the

infectious disease clinic as well as in COVID-19,

COVID-2, and COVID-3 wards. The credibility of

the research was ensured by the fact that data were

collected from various COVID-19 wards. Inclusion

criteria for nurses were as follows: (1) the

participant had a nursing diploma; (2) the

participant had worked on the COVID-19 ward full-

time for at least three months; (3) the participant

agreed and was ready to take part in the study. Data

were collected from subjects who provided their

written permission. Informed consent was obtained

both in written form and orally before the beginning

of the interview. The sample size was determined by

data saturation, [39]. Interviewees participated in the

research voluntarily, and their data is anonymous.

The subjects received an explanation of the aim and

process of this research.

3.3 Collection of Data

The main research method in qualitative research is

an interview, [39]. A semi-structured interview was

aimed at nurses who work in the COVID-19 ward.

The authors of this research accept the nurses’

experiences as they are. Data were collected from 2

June 2021 until saturation. Under this condition,

data were collected until 30 September 2021. A total

of 16 nurses were interviewed. Invitations were sent

to the nurses before the interview. The invitation

included the following: the title of the research; a

description of the aim and methodology; and

information on the importance of nurses’ work in

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the COVID-19 ward. All volunteers were contacted

separately, and the date of the interview was agreed

on individually.

The authors do not change the subjective

experiences of the respondents but display them as

they are, leaving aside the researchers’ original

assumptions and preconceived opinions, [39], [40].

A voice recorder was used to record the interviews.

Simultaneously, as many terms and background

details (atmosphere, body language, facial

expressions) as possible were written down. A

maximum of two interviews were held during the

day. For best results, the authors asked more

detailed questions. Detailed questions ensured that

both the interviewer and interviewee stayed focused

on the topic and aided in describing the

phenomenon expansively (Table 1).

Table 1. Problems causing occupational stress

among nurses and solutions. Categories determined

based on 16 interviews

Categories

Theme

“Teamwork must be

better. If there are

difficult situations, you

need to work

operationally.”

Better teamwork is

needed for

working in

difficult situations

Improved

teamwork for

coping

with

difficult

situations

Improving team

collaboration

Social support

from

management

Problem-

oriented

coping

“Need more personnel.

Observing takes a lot

more time, especially

when everything can

change in a patient’s

state in 30 minutes.”

The need for

more personnel to

monitor the rapidly

changing health

conditions of

patients

Need for more

staff to monitor

patients with

rapidly

changing health

conditions

Workload

regulation

“The solution would

be more nurses with

complete training on

topics, such as how to

use medical devices

and how to perform

activities on an

isolated ward.”

More nurses

with completed

training and

competence for

working in an

isolation unit

To increase

the number of

trained nurses

competent to

work in

isolation

units

Improving

Nurses’

awareness and

preparedness

“I feel more of a need

for the hospital

management to listen

to the nurses more,

not just demand that

they do this and that.

To raise nurses’

confidence in

themselves.”

The nurses feel

the hospital

management

should listen to

them more and

boost their

confidence, not

just demand

everything

Nurses need

the hospital

management

to listen to

them more

and boost

their self-

confidence

instead of

only giving

orders

Attention

from the

management

about work

pressure and

the mental

state of nurses

Source: Author’s work.

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Subtheme (5): Lack of workload regulation.

The nurses considered workload to be the most

important source of work-related stress. They had to

work in a situation where staff shortages were a

constant problem. One nurse was responsible for

several COVID-19 patients in critical condition at

the same time, requiring more time for

care/supervision than usual.

The interviews revealed a consistent decrease in

work quality due to workload: “The lack of

personnel is a very big problem; as a result, the

workload of one nurse is insane, they cannot

complete their work in a timely and physically

possible manner. The quality of work decreases.”

Subtheme (6): Physical and mental ailments from

overload.

One of the major problems discovered during the

interviews was the large workload that caused both

mental and physical health issues. Many nurses

mentioned various physical problems: “There was a

lot of turning because there were too many bed-

ridden patients. All this reactivated back issues,

constant back pain.”

4.2 Insufficient Support

Nurses described insufficient support as a lack of

feedback and recognition, poor communication

among colleagues, inadequate psychological

support, and a lack of training.

Subtheme (1): Lack of feedback and recognition.

Nurses felt that their work was not appreciated, and

they lacked feedback from colleagues and superiors.

This lack of recognition contributed to their stress

levels. One nurse stated, “We feel that we are not

appreciated by the management. Nobody asks us

how we are doing.”

Subtheme (2): Poor communication among

colleagues.

Interviews revealed poor communication among

colleagues, which hindered teamwork and increased

stress levels. Nurses felt that they were not part of a

team and that communication was limited. One

nurse mentioned, “There was no real teamwork in

the beginning. People didn’t talk to each other; we

were not working as a team.”

Subtheme (3): Lack of training.

Nurses reported a lack of training in dealing with

COVID-19 patients, which increased their stress

levels and sense of inadequacy. They felt

unprepared for the challenges that came with

working on COVID-19 wards. One nurse

mentioned, “We were not given any training before

we started working with COVID patients. It was like

throwing us into the deep end without knowing how

to swim.”

4.3 Ethical Dilemmas Regarding COVID-19

Deniers

Nurses described ethical dilemmas regarding

COVID-19 deniers as difficult situations that

required them to balance their duty of care to

patients against their safety and that of their

families. Some patients denied the existence of

COVID-19 or refused to comply with hospital

regulations.

Subtheme (1): Balancing duty of care with personal

safety.

Nurses felt conflicted between their duty of care to

patients and their safety and that of their families.

They were concerned about bringing the virus home

and potentially infecting their loved ones. One nurse

mentioned, “It’s not just a question of your own

health, but you are also responsible for your

family.”

Subtheme (2): Dealing with COVID-19 deniers.

Nurses reported dealing with patients who refused

to believe in the existence of COVID-19 or refused

to comply with hospital regulations. They felt

frustrated and unsupported in these situations. One

nurse stated, “I had a patient who refused to wear a

mask, and when I asked her to do so, she called me

a liar and said COVID was a hoax.”

Overall, the analysis of the interviews revealed

that nurses working in COVID-19 wards face

various job demands related to inadequate

management, insufficient support, and ethical

dilemmas regarding COVID-19 deniers. These

findings suggest the need for improved support,

training, and resources for nurses working on

COVID-19 wards to help mitigate these job

demands and promote their well-being.

4.4 Solutions Offered by Nurses for Solving

Work Stress-Causing Problems

In their interviews, nurses working with COVID-19

patients suggested coping strategies for reducing

work stress focused only on addressing the

problems. The coping strategy, describing the

upper-level theory of Social Support Management,

was formed by four subthemes: improving team

collaboration; regulating work processes and

mentoring new nurses; workload regulation; and

improving nurses’ awareness and preparedness.

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Subtheme (1): Improving team collaboration.

During the analysis of the nurses’ interviews, it

became apparent that the main problems were due to

the lack of social support. As a result, the solutions

offered by the nurses were primarily focused on

improving social support. Nurses mentioned that

better teamwork was needed in complex and

unpredictable situations: “Teamwork must be better.

If there are difficult situations, you need to work

operationally.”

Subtheme (2): Regulating work processes and

mentoring new nurses.

Nurses stated that there was insufficient support

from management and that new nurses starting to

work on the COVID-19 ward did not receive

sufficient instruction. As a solution, a mentor for

new employees was suggested to help them adapt to

the environment and ensure a pleasant work

environment and more effective nursing care: “A

mentor for new workers from the get-go. It is

possible to organize work in a way that reduces

sources of stress. For that, you mainly need a good

and well-working team and understanding superiors

who regulate the effectiveness of the work process

and work on behalf of their personnel’s well-being.

The nursing care service would be better because of

that.”

Subtheme (3): Workload regulation.

It became apparent in the interviews that increasing

the workforce’s resources was necessary to solve

problems related to workload. Having a sufficient

number of nurses and being better prepared for

crises would help reduce the burden: “We need more

personnel. Observing takes a lot more time,

especially when everything can change in 30

minutes in a patient’s state.”

Subtheme (4): Improving nurses’ awareness and

preparedness.

Nurses reported in interviews that a problem arose

in putting nurses from different wards together; their

preparedness was not always sufficient. Various

pieces of medical equipment were used in the

COVID-19 ward, such as ventilators (CPAP, etc.),

drip infusions, and perfusors. Not all nurses were

familiar with these in their daily jobs, and training

was needed before starting work. Nurses should

receive more training, including on the proper use of

PPE: “A solution would be if there were more

trained nurses who knew how to use medical

equipment, how to do things on an isolated ward.”

5 Discussion

The COVID-19 pandemic has revealed the

occupational stressors that nurses face in Estonia.

The purpose of this research was to investigate the

stressful circumstances that nurses have

encountered during the COVID-19 pandemic and to

identify potential strategies for reducing

occupational stress among nurses in Estonia using

Karasek’s JDC model.

5.1 Main Problems Causing Occupational

Stress Among Nurses in the COVID-19 Unit

The progress made in nursing in Estonia toward

creating a healthy and successful workplace is

commendable. By focusing on improving nurses'

well-being, they are not only benefiting the nurses

themselves but also enhancing the quality of patient

treatment. Karasek's model, [13], offers valuable

insights into the relationship between job demands,

decision-making discretion, and employee

motivation. Creating a working environment with

high demands and high discretion allows nurses to

be active and highly motivated, while environments

with high demands and low discretion can lead to

excessive strain and occupational stress.

By creating a working environment that aligns

with the principles of Karasek's model,

organizations can foster a culture of empowerment

and autonomy among nurses. High demands

coupled with high discretion provide nurses with the

opportunity to actively engage in their work, make

decisions, and take ownership of their roles. This, in

turn, can enhance their motivation, job satisfaction,

and overall well-being.

Conversely, when nurses face high demands but

have limited discretion in decision-making, it can

lead to a sense of powerlessness and increased stress

levels. Such situations may result in feelings of

being overwhelmed, inadequate, and unable to cope

effectively. This can negatively impact not only the

nurses' mental and physical health but also their

performance and the quality of patient care.

The findings of the study discussed in the text

shed light on the challenges faced by nurses

working on COVID-19 wards in Estonia.

Inadequate management, lack of support, and ethical

dilemmas related to COVID-19 deniers were

significant job demands that affected nurses' work

and well-being. Inadequate management manifested

in poor work organization, insufficient preparation,

authoritarian attitudes, and a lack of necessary

equipment and tools. Insufficient support was

characterized by a lack of feedback, recognition,

and poor communication among colleagues.

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Therefore, it is essential for healthcare organizations

to recognize the significance of Karasek's model and

strive to create work environments that promote

high discretion alongside appropriate levels of job

demands. This can be achieved through measures

such as providing opportunities for nurses to

participate in decision-making processes, offering

support and resources to enhance their skills and

competencies, and fostering a culture of open

communication and collaboration.

The results of this study shed light on the potential

benefits of incorporating the principles of Karasek's

model into the design and management of nursing

workplaces. By doing so, organizations have the

opportunity to reduce occupational stress and create

a work environment that promotes the well-being of

nurses. This is crucial because nurses play a vital

role in delivering high-quality patient care. The

results of this study are in line with previous results

and showed that when nurses experience high levels

of occupational stress, it can have detrimental

effects on their physical and mental health, job

satisfaction, and overall performance. It can lead to

burnout, decreased motivation, and increased

turnover rates, which can negatively impact the

continuity and quality of patient care.

Other Estonian researchers have found similar

results. Role conflicts, workload, the rapid pace at

work, and uneven work patterns have been

described as the main factors causing occupational

stress, resulting in difficulties in focusing and

decision-making as well as memory problems, [22],

[23], [25]. Studies conducted elsewhere have

highlighted the main factors causing occupational

stress as heavy workload, insecure treatment

policies, and lack of resources and social life, [16],

[11], [17]. By aligning with Karasek's model,

organizations can foster a work environment that

empowers nurses, provides them with decision-

making discretion, and supports their autonomy.

This can contribute to a sense of control and

ownership over their work, enhancing their

motivation and job satisfaction. As a result, nurses

are more likely to be engaged, resilient, and

committed to providing the best possible care to

their patients.

Furthermore, when nurses are working in a

healthy and thriving environment, the quality of

patient care naturally improves. Nurses are better

equipped to handle the demands of their roles, make

informed decisions, and effectively communicate

with patients and other healthcare professionals.

This ultimately leads to better patient outcomes,

increased patient satisfaction, and a more effective

healthcare system as a whole.

Therefore, healthcare organizations must

recognize the significance of incorporating

Karasek's model into their approach to designing

and managing nursing workplaces. By prioritizing

the well-being of nurses and creating a supportive

work environment, organizations can

simultaneously reduce occupational stress and

enhance the quality of patient care. This holistic

approach benefits not only the nurses but also the

patients and the overall effectiveness of the

healthcare system.

Conflicts between Estonian nurses, lack of team

spirit, and insufficient support from management

were also identified as existing problems.

Insufficient support from the management for

Estonian nurses has been described by [22], who

claims that the main support came from family and

friends. The establishment of COVID-19 wards with

nurses selected from different hospitals and wards

resulted in strain due to differences in work habits

and experience. The lack of preparation for working

with patients with COVID-19, including the use of

CPAP ventilators, also caused problems.

Interpersonal conflicts mainly caused by a lack of

emotional intelligence, personal characteristics,

workplace-related aspects, unclear roles at work,

and poor communication were reported [11].

Overall, these findings highlight the importance

of addressing job demands and providing

appropriate support and resources for nurses

working on COVID-19 wards to ensure their well-

being and the quality of patient care.

According to the authors of this research,

insufficient rest periods and a heavy workload were

major causes of physical problems among nurses in

Estonia during the COVID-19 pandemic. These

physical problems included backaches and

headaches due to turning patients as well as rash and

worsening of allergic dermatitis caused by PPE.

Nurses also faced limited options for consuming

fluids and food regularly. The literature mentions

several other physical problems caused by PPE,

including the onset of headaches, discomfort,

anxiety, nausea, dizziness, physical exhaustion,

reduction of speed in completing assignments, and

excessive sweating, which itself caused skin

irritation and skin issues, [21], [44], [16].

It can be concluded that physical, psychological,

social, and organizational factors result in negative

consequences and the development of occupational

stress during the COVID-19 pandemic at nurses’

workplaces.

To address the challenges identified and

alleviate the occupational stress experienced by

nurses, it is crucial to explore the solutions

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suggested by nurses themselves. The next sub-

chapter delves into the valuable insights provided by

nurses, offering potential strategies to mitigate the

physical, psychological, social, and organizational

factors contributing to their stress levels. By

incorporating the perspectives of those directly

affected, a more comprehensive and effective

approach to enhancing nurses' well-being and the

quality of patient care can be developed.

5.2 Solutions Suggested by Nurses to Solve

Problems Causing Occupational Stress

The research conducted in Estonia during the

COVID-19 pandemic identified several potential

strategies that could help reduce the burden of

occupational stress among nurses. One key

recommendation is to provide nurses with adequate

rest periods and reduce their workload. By ensuring

sufficient time for rest and recovery, nurses can

better cope with the physical demands of their work

and minimize the risk of physical problems such as

backaches and headaches. Additionally, improving

management practices, communication, and

teamwork can contribute to a more supportive work

environment and reduce stress levels. Proper

preparation and training for nurses working with

COVID-19 patients, including education on the use

of CPAP ventilators, can enhance their confidence

and competence, thereby reducing stress.

Additionally, implementing emotional

intelligence training and improving workplace-

related aspects, such as role clarity, could help

reduce interpersonal conflicts among nurses. The

literature also suggests providing psychological

support for nurses to help reduce mental stress and

burnout, [16], [21], [44]. Overall, addressing these

stressors and implementing these strategies could

help reduce occupational stress among nurses in

Estonia during the COVID-19 pandemic.

The COVID-19 pandemic has highlighted the

need for effective stress management strategies

among nurses. Estonian nurses reported difficulties

in making decisions due to a lack of information and

clear instruction, especially in rapidly changing

situations. They also faced ethical dilemmas

regarding patients who refused to wear protective

masks or receive the COVID-19 vaccine. In

interviews, nurses suggested various solutions to

improve their discretion, such as improved

teamwork, efficient communication, mentorship,

and training. In [45], [17], have suggested individual

and/or group-based psychological interventions to

improve nurses’ mental health and well-being, while

[46], suggested rotation among nurses to increase

their skills and experience in working in a

multidisciplinary team. Overall, effective

communication, adequate workload management,

mentorship, training, and psychological support are

crucial for managing occupational stress among

nurses. Healthcare organizations need to invest in

the mental health and well-being of their nurses to

ensure a safe and productive working environment.

The findings of this study are consistent with

previous research, which has highlighted the

importance of addressing job demands and

providing appropriate support and resources for

nurses to ensure their well-being and the quality of

patient care. Karasek’s JDC model suggests that

working regarding decision-making allows

employees to be active and highly motivated,

whereas high demands and low discretion result in

excessive strain and occupational stress. Therefore,

providing nurses with the necessary information and

resources to make informed decisions can help

reduce occupational stress.

5.3 Ensuring the Credibility of this Research

The description of the studied phenomenon, the

analysis, and trustworthy results were the focus of

this research to ensure its credibility. Robert

Karasek’s Job-Demand-Control (JDC), [13], [26],

stress management models were used as a

background against which to determine the

characteristics of the researched phenomenon, as

well as for the analysis of said characteristics. The

credibility of these models has been confirmed in

several studies, [13], [14], [15]. The models have

not been used previously to describe occupational

stress among Estonian nurses during the COVID-19

pandemic. Thus, this research has theoretical and

practical value. The framework for the content

analysis of the interviews consists of Graneheim and

Lundman’s qualitative content analysis principles,

[33]. Since the credibility of the results is ensured

by an appropriate sample size, data collection, and

analysis were conducted as a parallel process during

the research. It was confirmed during the sixteenth

interview that no new data were being obtained.

This was the basis for deciding against further data

collection.

This research paper has some limitations. The

group of participants works in the same central

hospital; therefore, the results cannot be generalized

to all Estonian nurses working in COVID-19 units.

While limitations exist, the findings of this study

provide valuable insights that can serve as a

springboard for further exploration of occupational

stress among Estonian nurses during the COVID-19

pandemic.

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In conclusion, this research has taken careful

steps to ensure its credibility by drawing on well-

established theoretical frameworks, adhering to

rigorous analysis principles, and reaching data

saturation. While limitations exist, the findings of

this study provide valuable insights that can serve as

a springboard for further exploration of occupational

stress among Estonian nurses during the COVID-19

pandemic.

6 Conclusion

In conclusion, this study provides significant insight

into the occupational stressors experienced by

nurses in Estonia during the COVID-19 pandemic.

The findings highlight the detrimental impact of

heavy workloads, insufficient rest periods, and

inadequate management on nurses' physical and

psychological well-being. These challenges, such as

backaches, headaches, and burnout, necessitate

immediate attention and the implementation of

strategies to alleviate occupational stress among

nurses.

This study proposes several practical strategies

for addressing these challenges, including providing

adequate rest periods, reducing workload,

improving management, communication, and

teamwork, and providing better preparation training

for nurses working with COVID-19 patients. This

study also highlights the importance of effective

stress management strategies, such as individual

and/or group-based psychological interventions,

mentorship, training, and psychological support in

managing occupational stress among nurses.

Overall, the study emphasizes the need for

healthcare organizations to invest in the mental

health and well-being of their nurses to ensure a safe

and productive working environment. This requires

a multifaceted approach that addresses the root

causes of occupational stress, such as inadequate

staffing and management practices, while also

providing resources and support for nurses to

manage the stressors they face.

In conclusion, this study offers valuable insights

into the occupational stressors faced by nurses in

Estonia during the COVID-19 pandemic and

proposes practical strategies to alleviate this stress.

Implementing these strategies is crucial to

safeguarding the well-being of nurses and upholding

the quality of patient care. However, further

research is warranted to evaluate the effectiveness

of these strategies and explore additional measures

for addressing occupational stress among nurses in

Estonia and beyond.

7 Recommendations

Based on the findings of this study, several

recommendations can be made to address

occupational stress and promote the well-being of

nurses in Estonia.

Development of Estimating Frameworks:

Organizations should invest in the development and

implementation of estimating frameworks that allow

for the prediction of potential problems and evaluate

the impact of improvement activities. These

frameworks can provide valuable insights into the

factors contributing to occupational stress and help

inform proactive strategies to mitigate its effects. By

adopting a systematic approach, organizations can

identify stressors in advance and take appropriate

measures to prevent occupational stress among

nurses.

Expanded Research Scope: While this study

focused on nurses, it is important to acknowledge

that occupational stress affects individuals across

various levels of the healthcare system. Future

research should explore the experiences of middle

and top managers in nursing, members of

management boards of clinics, and care assistants.

By examining the perspectives of individuals in

different roles, a more comprehensive understanding

of occupational stress can be achieved, leading to

tailored interventions and support systems for all

healthcare professionals.

Implement Preventive Measures: Organizations

should prioritize the implementation of preventive

measures to address occupational stress. This

includes providing training and resources to enhance

stress management skills, promoting work-life

balance through effective scheduling and workload

distribution, and fostering a supportive and inclusive

work environment. By proactively addressing the

underlying causes of occupational stress,

organizations can create a culture that prioritizes

employee well-being and reduces the negative

impact of stress on nurses.

Collaboration and Knowledge Exchange:

Collaboration between healthcare organizations,

professional associations, and research institutions is

essential for sharing best practices, innovative

approaches, and research findings related to

occupational stress. Establishing platforms for

knowledge exchange and collaboration can facilitate

the implementation of effective strategies to manage

and prevent occupational stress. This collective

effort can contribute to the overall well-being of

nurses and the improvement of patient care.

Long-term Monitoring and Evaluation: It is

crucial to establish long-term monitoring and

evaluation mechanisms to assess the effectiveness of

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implemented interventions and measure the impact

on nurses' well-being. Regular feedback loops and

continuous improvement processes should be

integrated to ensure that strategies are continuously

refined based on emerging needs and feedback from

nurses. This iterative approach will enable

organizations to adapt and optimize their efforts in

reducing occupational stress over time.

These recommendations aim to address the

occupational stress faced by nurses in Estonia and

promote their well-being. By implementing these

measures, healthcare organizations can create a

healthier and more supportive work environment for

nurses, ultimately improving patient care.

Acknowledgment:

Ljudmila Linnik and Jaana Sepp’s research is

carried out within the framework of the research

project “The aim of applied research: to describe the

influence of blended learning on the skills of the

nurses and their self-efficacy and development of

their creative thinking in the case of COVID-19

patients.” (01.06.2021−31.12.2024). Financing:

EUR 23,204, Chair of Nursing, Tallinn Health Care

College.

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Contribution of Individual Authors to the

Creation of a Scientific Article (Ghostwriting

Policy)

L. Linnik, designed the idea and wrote the

manuscript and J. Sepp supervised the research.

Sources of Funding for Research Presented in a

Scientific Article or Scientific Article Itself

This research is supported by Tallinn Health Care

College, Estonia.

Ljudmila Linnik and Jaana Sepp’s research is

carried out within the framework of the research

project “The aim of applied research: to describe the

influence of blended learning on the skills of the

nurses and their self-efficacy and development of

their creative thinking in the case of COVID-19

patients.” (01.06.2021−31.12.2024). Financing:

EUR 23,204, Chair of Nursing, Tallinn Health Care

College.

Conflict of Interest

The authors have no conflict of interest to declare.

Creative Commons Attribution License 4.0

(Attribution 4.0 International, CC BY 4.0)

This article is published under the terms of the

Creative Commons Attribution License 4.0

https://creativecommons.org/licenses/by/4.0/deed.en

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