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The COVID-19 pandemic created increased strain in healthcare settings, and psychological distress has been documented among healthcare workers such as depression, posttraumatic stress disorder, and anxiety (Marvaldi et al., 2021).
Further, workplace-related stressors have received interest during the pandemic, such as exposure to COVID via patient care, personal protective equipment shortages, fear of contracting and spreading COVID to loved ones, and witnessing increased deaths (American Nurses Association, 2020). These workplace-specific factors have been documented in the wider literature as having negative impacts on psychological well-being. Specifically, contact with COVID-positive patients and lack of personal protective equipment was associated with increased symptoms of posttraumatic stress, depression, and generalized anxiety (Arnetz et al., 2020). Similarly, witnessing patient deaths was associated with increased risk for posttraumatic symptoms, and fear of infecting family members was associated with symptoms of posttraumatic stress, depression, and generalized anxiety (Mosheva et al., 2020). 
In this context, these workplace-related stressors can be conceptualized as institutional betrayal. Institutional betrayal occurs when an institution (i.e., hospital, government, university) does not protect or fulfill its obligation to those who depend upon it (i.e., nurses, constituents, students; e.g., Smith & Freyd, 2014). Institutional betrayal extends betrayal trauma theory by exploring systemic level betrayal, rather than individual-level betrayal. Institutional betrayal has received interest during the COVID-19 pandemic and has been noted to increase psychological distress (Adams-Clark & Freyd, 2021).
COVID-19 pandemic created a context that has facilitated opportunities for perceived institutional betrayal (i.e., lack of PPE). Given that different risk and protective factors impact mental health following stressful events, it is important to explore these possible moderating factors to better understand mental health outcomes and how best to support nurses. 
We explored whether workplace institutional betrayal moderated (or influenced) the relationship between workplace-related stressors (i.e., percentage of work with involving COVID-positive patients, number of witnessed COVID-related patient deaths, and living separately from family due to safety concerns) and mental health outcomes (symptoms of posttraumatic stress, depression, and generalized anxiety). It was expected that perceptions of institutional betrayal would exacerbate the impacts of each workplace stressor on each mental health outcome. 
Participants included 391 nurses working in healthcare settings in Massachusetts. Three separate models were examined with each predictor, and one model including all predictors were examined. Results indicated that perceived institutional betrayal was associated with increased symptoms of posttraumatic stress, depression, and generalized anxiety in every model. Percentage of work with COVID-positive patients was associated with increased symptoms of posttraumatic stress, depression, and generalized anxiety in the individual models, and associated with symptoms of posttraumatic stress only in the combined model. Living away from family was associated with symptoms of posttraumatic stress and depression in both models. Lastly, number of witnessed patient deaths was associated with symptoms of posttraumatic stress in the individual model and was not associated with any mental health outcomes in the combined model. 
Perceptions of institutional betrayal did not impact the relationship between workplace stressors and any of the mental health outcomes, contrary to our hypothesis. However, institutional betrayal consistently and significantly predicted increases in symptoms related to each condition. These results underscore the deleterious impact that institutional betrayal has on nurses. Further, this finding distinguishes institutional betrayal as a unique predictor of distress, rather than a moderating factor, which is consistent with prior conceptualizations of this phenomenon (Lind et al., 2020). Additionally, results suggest that not all workplace stressors have the same association with mental health outcomes. In particular, working closely with COVID-positive patients may be associated with more distress due to lack of PPE and fear of infection relative to witnessing patient deaths, as some nurses may have more experience with patient deaths depending on their experience and background. 
The current study highlights the importance of prioritizing nursing staff’s mental health, given increased rates of psychological distress that began during the onset of the pandemic. Further, given that healthcare settings have experienced high personnel turnover rates (e.g., Yong, 2021), nurses' perceptions of their workplace, centered on betrayal, should be considered as a potentially relevant contributor.
Future research should employ longitudinal study designs to examine nurses’ trajectories of psychological distress and coping over time, given the pervasive nature of COVID. Future research could also benefit from exploring other workplace-related stressors and supports, such as staffing ratios. Lastly, future research should include a diverse sample from varying geographical locations.

Targret Article

Beck, J. G., Majeed, R., Brown, T.A., Free, B. L., Bowen, M. E., Farchione, T. J., & Brown, B. S. (2023). Understanding the role of COVID-related workplace stress and institutional betrayal on mental health in nurses: Some heroes wear scrubs. Journal of Traumatic Stress, 1-12. https://doi.org/10.1002/jts.22920

Discussion Questions

1. What policy adaptations could be made in healthcare settings at the systemic level to better support nursing staff, especially how it relates to nurses’ perceptions of institutional betrayal ? 
2. What other factors may play a role in nurses’ mental health related to workplace environment? And, how can we bolster or reduce these factors?
3. When considering burnout and turnover among nurses generally, what should be considered when safeguarding mental and physical health?       

About the Authors

J. Gayle Beck, Ph.D. is the Chair of Excellence Emerita in the Department of Psychology at the University of Memphis. Her interests focus on the emotional aftereffects of trauma, including the role of cognitive processes in co-occurring mental health conditions. She has worked with survivors of intimate partner violence, as well as individuals who experienced serious motor vehicle accidents, sexual assault survivors, and adolescents who experienced childhood sexual abuse.
Rimsha Majeed, M.S. – is in her second year of the clinical psychology Ph.D. program at the University of Memphis. Her research interests focus on cognitive processes that undergird mental health problems following trauma.
Dr. Timothy Brown is a professor  of psychology with expertise in quantitative methodology who provided oversight and guidance in the statistical analyses conducted for this report.
Bre'Anna Free is a third year clinical psychology phd student whose research has been primarily focused on mental health outcomes (including PTSD, depression, and anxiety) following traumatic events.
Mya Bowen is in her fourth year of a clinical psychology Ph.D. program. Her program of research includes the etiology of posttraumatic stress disorder (PTSD), related coping factors, and subsequent behavioral health patterns following trauma exposure (e.g., substance use, sleep).
Dr. Todd Farchione is a Research Associate Professor in the Department of Psychological and Brain Sciences at Boston University (BU). He currently directs a research group at the Center for Anxiety and Related Disorders that focuses on understanding emotion and emotion regulation processes, identifying higher-order, functional, psychopathological mechanisms, and dissemination of improved treatments for anxiety, mood, and commonly co-occurring disorders.
Bonnie Brown is a nurse who has been involved over many years on numerous research studies, has worked on medical/surgical units in New York and Massachusetts, has a degree in communications which was used in outreach to the Massachusetts Nurses Association to capture the data used for this study.

References Cited

Adams-Clark, A. A. & Freyd, J. J. (2021). COVID-19-related institutional betrayal associated 
with trauma symptoms among undergraduate students. PLOS ONE, 16(10), Article e0258294. https://doi.org/10.1371/journal.pone.0258294
American Nurses Association (2020). Initial COVID-19 survey. Retrieved December 10, 2021, from https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/what-you-need-to-know/covid-19-survey-results/
Arnetz, J. E., Goetz, C. M., Sudan, S., Arble, E., Janisse, J., & Arnetz, B. B. (2020). Personal 
protective equipment and mental health symptoms among nurses during the COVID-19 pandemic. Journal of Occupational and Environmental Medicine, 62(11), 892-897. https://doi.org/10.1097/jom.0000000000001999
Lind, M. N., Adams-Clark, A. A., & Freyd, J. J. (2020). Isn’t high school bad enough? Rates of 
gender harassment and institutional betrayal in high school and their association with trauma-related symptoms. PLOS ONE, 15(8), Article e0237713. https://doi.org/10.1371/journal.pone.0237713
Marvaldi, M., Mallet, J., Dubertret, C., Moro, M. R., & Guessoum, S. B. (2021). Anxiety, depression, trauma-related, and sleep disorders among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Neuroscience and Biobehavioral Reviews, 126, 252–264. https://doi.org/10.1016/j.neubiorev.2021.03.024 
Mosheva, M., Gross, R., Hertz-Palmor, N., Hasson-Ohayon, I., Kaplan, R., Cleper, R., Kreiss,
Y., Gothelf, D., & Pessach, I.M. (2020). The association between witnessing patient death and mental health outcomes in frontline COVID-19 healthcare workers. Depression and Anxiety, 38(4), 468-479. https://doi.org/10.1002/da.23140
Smith, C. P. & Freyd, J. J. (2014). Institutional betrayal. American Psychologist, 69(6), 575-587. 
Yong, E. (2021, November 16). Why health-care workers are quitting in droves. The Atlantic. https://www.theatlantic.com/health/archive/2021/11/the-mass-exodus-of-americas-health-care-workers/620713/