Identifying Psychosocial Risks and Protective Measures for Workers’ Mental Wellbeing at the Time of COVID-19: A Narrative Review

: The spread of the SARS-CoV-2 virus has caused crucial changes in the workplace. Almost two years after the start of the COVID-19 era, new and old psychosocial risks in the workplace threaten workers’ mental wellbeing and represent an occupational health challenge. The aim of this review is to identify the most relevant psychosocial factors, negative or protective, contributing to occupational stress during the current pandemic. A literature search was conducted in PubMed, EMBASE, Cochrane Library, Web of Science, Google Scholar and PsycINFO and a total of 51 articles were deemed suitable for inclusion in the review. Analysis of the retrieved articles revealed ﬁve main topics related to psychosocial wellbeing in the workplace: 1. Support from colleagues and organizations; 2. Home–work interface and balance; 3. Changes in workload and work demand; 4. Job competence and appropriate training; 5. Job insecurity and ﬁnancial stress. All ﬁve themes were associated with occupational stress and poor mental outcomes, like anxiety, depression, and burnout symptoms. Peer and organizational support seem to have a major impact on workers’ mental wellbeing. Recognizing these factors and projecting interventions that mitigate their effects or boost their efﬁcacy is a fundamental step towards dealing with COVID-19 in the workplace, or any such future emergencies.


Introduction
The world of work has been profoundly affected by the global virus pandemic. Workers have been forced to change their habits and lifestyle both at an individual and organizational level. Work arrangements and conditions have changed considerably, raising new challenges for the health and wellbeing of workers, whether in the frontline, in essential services, working from home, or having lost their businesses and jobs. The effects of COVID-19 on the mental health of workers have been widely addressed [1][2][3], especially for healthcare workers (HCWs). The shortage of personal protective equipment (PPE), and the stigmatization of those working in direct contact with the infected, contributed towards the poor mental outcomes of HCWs involved in the sanitary emergency, particularly at the beginning of the pandemic [4,5]. Anxiety, depression, burnout, post-traumatic syndrome disorder (PTSD) and overall poor mental outcomes have been identified in HCWs dealing with the emergency [1,6,7]. For instance, poor workplace infection control put HCWs, especially those on the frontline, at the risk of being infected and bringing the contagion Intervention: occupational psychosocial stress factors related to COVID crisis/pandemic; Comparison: not considered; Outcome: negative psychological outcomes (e.g., depression, anxiety, mental stress). Two independent reviewers read titles and abstracts of the reports identified by the search strategy and made a first screening; subsequently a further selection was made analyzing the full text of the articles. The judgement about the inclusion of each paper was performed separately by the investigators; disagreements were solved by discussing with a third reviewer. Data were extracted by two reviewers and inserted in a spreadsheet, including country of provenience of the study, type of job considered, scale and tools administered to the sample. Each paper was labelled with one or more main topics related to psychosocial factors at work and the main mental outcomes were identified.

Inclusion Criteria
We included in this review only articles that provide an insight into specific psychosocial occupational stress issues and described workplace characteristics that may be related to job stress and negative psychological outcomes. Moreover, the articles selected contain psychological negative outcomes such as depression or anxiety symptoms, or work-related stress outcomes such as emotional exhaustion or job satisfaction. We included in the review only original articles while previous relevant review articles are discussed in the Introduction and Discussion paragraph.

Exclusion Criteria
Reports of less academic significance, editorial articles, letters to the editors, not peer reviewed articles, individual contributions and purely descriptive studies published in scientific conferences, without any quantitative and qualitative inferences were excluded from this review. Moreover, we excluded all the articles describing workers mental issues during the COVID pandemic without any insight into the workplace characteristics and job stress dimension. Finally, we excluded articles referring exclusively to the lack of PPE or impaired safety measures at work as the only workplace dimension analyzed, since the literature has widely proved the negative impact of this dimension on workers mental health.

Results
The literature search yielded a total of 3159 results: 392 from Pubmed; 42 from EMBASE; 192 from Web of Science; 11 from Cochrane Library; 82 from PsycINFO; and 2440 from Google Scholar. After a first screening by title and abstract, the subsequent reading of the full texts and the removal of duplicates, a total of 51 papers were deemed suitable for inclusion in the review, according to the inclusion and exclusion criteria. The selection process is described in Figure 1. The selected papers are reported in Appendix A Table A1. ustainability 2021, 13, x FOR PEER REVIEW Figure 1. Flow diagram of the literature search and article selection (adapted from guidelines for systematic reviews) [16].
A total of 96% of the papers selected (49/51) were cross sectional stu two studies showed a longitudinal design. Online self-administered sur most frequent tools used to test the sample. Several psychological dimensi lyzed. Anxiety was mainly tested with the General Anxiety Disorder Scale pression with the 9-item Patient Health Questionnaire (PHQ-9) or the Gol and Depression Scale (GADS), post traumatic syndrome symptoms with th pact of Event Scale-Revised (IES-R), and burnout with the Maslach Burn (MBI) scale. Often ad hoc questionnaires were developed for some studies; F ies a qualitative approach with interviews and open questions was adopted Regarding workplace aspects, ad hoc questionnaires were generally d used by the authors. Validated questionnaires used were the Perceived S Questionnaire (PSSQ) and the Perceived Organizational Support (POS) que Effort-Reward Imbalance questionnaire (ERI), the Colquitt Scale for organiz the Utrecht Work Engagement Scale (UWES) for job satisfaction. Six stud qualitative approach administering free text questionnaires.
Regarding the geographical provenance of the studies included, Europ were the most represented (21/51, 41.6%), followed by North America (9/ China (7/51, 13.7%). A total of 38 (74.5%) studies tested healthcare workers o fessions, such as physicians from various specialty backgrounds, nurses, medical assistants, and radiology technicians employed directly or not in th A total of 96% of the papers selected (49/51) were cross sectional studies, and only two studies showed a longitudinal design. Online self-administered surveys were the most frequent tools used to test the sample. Several psychological dimensions were analyzed. Anxiety was mainly tested with the General Anxiety Disorder Scale (GAD-7), depression with the 9-item Patient Health Questionnaire (PHQ-9) or the Goldberg Anxiety and Depression Scale (GADS), post traumatic syndrome symptoms with the 22-item Impact of Event Scale-Revised (IES-R), and burnout with the Maslach Burnout Inventory (MBI) scale. Often ad hoc questionnaires were developed for some studies; For other studies a qualitative approach with interviews and open questions was adopted.
Regarding workplace aspects, ad hoc questionnaires were generally developed and used by the authors. Validated questionnaires used were the Perceived Social Support Questionnaire (PSSQ) and the Perceived Organizational Support (POS) questionnaire, the Effort-Reward Imbalance questionnaire (ERI), the Colquitt Scale for organizational justice, the Utrecht Work Engagement Scale (UWES) for job satisfaction. Six studies adopted a qualitative approach administering free text questionnaires.
Regarding the geographical provenance of the studies included, European countries were the most represented (21/51, 41.6%), followed by North America (9/51, 17.6%) and China (7/51, 13.7%). A total of 38 (74.5%) studies tested healthcare workers of various professions, such as physicians from various specialty backgrounds, nurses, hospital staff, medical assistants, and radiology technicians employed directly or not in the assistance of COVID patients. A further 23 studies (25.5%) explored work-related stress in non-healthcare workers, employed in several sectors, mostly referring to the homeworking population.
The analysis of the articles retrieved evidenced five major topics related to psychosocial aspects in the workplace during the COVID-19 pandemic:
Home-work interface and balance; 3.
Changes in workload and job demand; 4.
Work competence and adequate training; 5.
Job insecurity and financial stress.
The results for each topic are reported in the following paragraphs. A summary of the content of each article is included in Table 1 and an overall summary of the findings is presented in Table 1.

Changes in workload
-In HCWs, augmented workloads causes anxiety, depression and burnout symptoms; -reduced workloads is associated with loss of economic status and subsequent poor mental outcomes; -for remote workers, it can be configured as technostress and threatens home-work balance.
-Providing adequate resting time is crucial not only for workers' health but also for patients' safety; -balancing job demands and requests with the physical and psychological resources of workers is mandatory in every working environment

Work competence and adequate training
-This is a major source of stress for HCWs; -the fear of making mistakes is enhanced by the lack of general protocols to treat COVID; -the feeling of being pushed beyond training contributes to the development of burnout symptoms especially in young HCWs.
-Healthcare organizations must provide adequate training programs, especially when a worker is redeployed from one department to another; -supervisors should understand when workers are pushed beyond training -protocols for the management of COVID patients and scientific data sharing are a relevant resource.

Major Findings Implications
Job insecurity and financial stress -The economic crisis linked to the sanitary emergency meant several categories of workers were uncertain of the future; -the job insecurity and the consequent financial stress causes burnout, anxiety and depression symptoms; -this also involved HCWs with a reduction in patient volume.
-Government measures aimed at sustaining certain working categories can have an important impact on mental status of workers; -when possible, companies should provide job stabilization and economic support to workers

Support from Peers and Organization
A total of 27 studies (53%) highlighting the importance of support from peers and organizations during the pandemic were included in this review. The selected articles involved different professionals (healthcare workers, employees, security workforce, remote workers, etc.). For most cases, cross-sectional studies were conducted and validated scales, and ad hoc questionnaires and interviews were administered. Depression and anxiety were found to be two psychological dimensions associated with low peer and organizational support [17][18][19][20][21][22][23]. An international, cross-sectional study conducted in 41 countries showed that workplace factors, and in particular training for redeployed staff and the provision of wellbeing and mental health support, have a significant negative association with depressive symptoms in workers [17]. Particularly for nurses, low levels of social support and organizational support predicted COVID-19 anxiety [19]. Similarly, reduced social support and difficulties in cooperation between co-workers [20], especially in hospital settings, were associated with high levels of occupational stress [22,[24][25][26][27][28][29][30]. Moreover, supervisors' support helps employees in dealing with job uncertainties [31] and for essential workers, recognition of the value of their work plays a huge role [32][33][34].
In several studies, an association between lack of support and burnout syndrome has also been reported [32,[35][36][37][38][39]. Perceived organizational support moderated the relationship between the degree of exposure to risk and stress: the relationship appeared weaker when organizational support was perceived as high and the relationship was depicted as stronger when a low level of organizational support was present [38]. Furthermore, organizational and peer support is fundamental in dealing with workplace violence [21]. The support of colleagues helps to control negative emotional reactions in home workers [40]. A supportive environment is protective towards the risk of moral injury for HCWs [41], who are also at risk of post-traumatic syndrome disorder (PTSD). Perceived organizational support, indeed, had a significant indirect effect on PTSD symptoms through the mediation of problem-focused coping strategies and self-efficacy [42].

Home-Work Interface and Balance
A total of 11 studies (22%) that treat this issue were included in the review. The studies involved healthcare workers and remote workers and explored this dimension through quantitative and qualitative surveys. During the pandemic, home-work interface has become more challenging for workers from different settings, as the effect of the pandemic on job organization threatened to negatively affect the balance between family and work. People working from home during the first lockdown periods experienced less perceived wellbeing than those who remained in their usual workplace [43]. Home workers experienced distractions in the domestic environment [44], however overall working from home had a positive impact on work life [45]. Instead, for HCWs home-work interface was found as a cause of stress and also contributed to the development of burnout symptoms [46,47]. Major concerns included childcare [22,46,48,49], household activities and the relationships with family and friends [50,51]. During this time of emergency HCWs experienced a significantly lower work-family balance due to long working hours without appropriate rest [52], which was particularly challenging for women as they tended to be more involved in family care [49]. Moreover, the fear of bringing contagion home to family members was a common issue contributing to occupational stress, anxiety and depression symptoms in HCWs [53].

Changes in Workload and Job Demand
A total of 22 studies (43%) included in the review considered changes in workload and job demand as a risk factor for workers to develop stress, depression, anxiety and burnout symptoms. The papers selected were cross sectional, original research and descriptive studies using validated and not validated questionnaires, with quantitative and qualitative approach. In particular the articles explored this issue mostly in healthcare workers (nurses, surgeons, medical assistants, etc.) but poor mental outcomes were also attested in nonhealthcare workers. A change in workload during the COVID-19 outbreak (increased, unchanged, decreased or temporary off) is a recurring theme in the studies. For HCWs this is mostly a heavier workload, while for other professionals the negative mental outcomes are often associated with a decrease in their workload [45]. Anxiety, depression and stress were all psychological dimensions positively related to augmented workload and job demand in terms of longer working hours, intensity and efforts [18,20,25,51,[54][55][56][57][58][59]. Workload increased dramatically for workers who reported, suspected, or confirmed SARS-CoV-2 cases among their colleagues [60,61] and this plays a crucial role in the dimension of work-life balance [53,62]. Workers with too few rest breaks had more anxiety as they were exhausted, had difficulty meeting their basic needs and were constantly exposed to workplace stressors [48,63,64]. Burnout symptoms were also associated with the increase in workload for healthcare and non-healthcare workers [36,39,65]. Also, the perception of workload is connected with the overall work environment and to mental workload [39,52]. For physicians, the change in workload also affected the perception of job role, determining high levels of stress [50]. Another relevant aspect was the sudden and massive adoption of remote work, which contributed to the higher workload experienced by some workers. For remote workers, behavioral stress was positively associated with workload, in terms of heavy remote working and use of technologies [57]. For HCWs, telehealth, tele-conferences and working remotely were mostly positive experiences, however the demarcation line between work and home was often less defined [22]. Conversely, it was found that frontline doctors experienced high levels of work-related stress in managing computer work/electronic medical records [48].

Work Competence and Adequate Training
A total of 11 studies among the 51 selected (22%) underlined the relevance of the dimensions "adequate training/appropriate work competences" for the occurrence of stress and poor mental health in the workplace during the COVID-19 pandemic. All the articles regarding this theme tested healthcare workers belonging to several professions (nurses, physicians, medical assistants, etc.). The studies selected were cross sectional and used validated and not validated questionnaires or qualitative approaches through interviews to assess the dimensions considered in the sample. Anxiety, depression and stress were all psychological dimensions associated with the feeling of inappropriate work competence and the lack of adequate training [58]. At the same time, work impairment was negatively influenced by anxiety and depression [66]. Factors related to poor training correlated to more frequent depressive and anxiety symptoms, including having been redeployed without training or with unsatisfactory training [17,22,53,55]. Workplace preparation and communication were identified as controllable and modifiable factors in the workplace, which can be related to psychiatric symptoms [55]. Performance at work, fear of making mistakes and uncertainty about how to act properly were factors associated with psychological distress [25,60] as well as disinformation about COVID-19 [48]. Finally, the feeling of being pushed beyond training was found to be a factor in the development of burnout symptoms [47].

Job Insecurity and Financial Stress
Six studies (12%) identified job insecurity as well as financial issues as being major stressors during the pandemic for workers. These two dimensions related to the pandemic seem to play a role in the development of stress and can determine poor mental health outcomes. Three studies, two from USA and one from Germany, found this aspect in healthcare workers, nurses and physicians, while three studies, two from Spain and one from Canada, provide insights into the psychological conditions of hotel employees, fashion retailing workers and workers in general, respectively. Two studies about HCWs used a qualitative approach to test their sample. Despite the sanitary emergency requiring extraordinary efforts from healthcare workers, even this category experienced forms of stress related to the uncertainty about the future [65] and concerns about the financial situation related to reduced patient volumes [48,49]. Physicians reported furloughs and pay cuts and expressed frustration at assumptions that physicians would be immune to financial instability, citing both the low salaries for those still in training and extensive student loan debt [49]. Environmental changes, reduced workload, uncertainty, and negative job expectations also constituted predictors for mental workload and the subsequent occurrence of poor mental health outcomes, like burnout, anxiety and depression symptoms, especially for some categories of workers, deeply damaged by the pandemic social and economic crisis [39,67]. Moreover, job insecurity, even at the beginning of the pandemic, was already being associated with higher levels of stress and lower wellbeing [29].

Discussion
This review tries to identify job dimensions that played a role in the psychological wellbeing of workers during the outgoing COVID pandemic. Despite the vaccination campaigns, the virus seems to remain endemic and long coexistence with the contagion is expected. Recognizing the main aspects to address in the management of the pandemic in the workplace, especially in this precise historic moment, is fundamental for the planning of interventions at various levels and for preparedness for possible future emergencies. The COVID-19 pandemic has shown us the importance of being deeply prepared for the unexpected events that can lead to change in people's daily life work habits. We identified five major topics in the work environment, which have affected the psychological wellbeing of workers during the pandemic, and which can be a target for specific interventions. First of all, in workplaces the need for support from peers and organizations seems to involve all work categories, from the HCW working in direct contact with the virus to remote workers. Low levels of support from peers and supervisors are associated with poor mental outcomes [68]. A supportive workplace environment, where workers can rely on their colleagues and supervisors is known to be one of the major issues when dealing with difficulties at work [69,70]. Peer support can be defined as "a system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful" [71]. The main support for workers within their organizations often comes from colleagues and managers [72]. Peer support at work strengthens psychological resilience by enhancing coping skills and the development of post-traumatic growth, factors which can protect workers involved in stressful situations [73,74]. In our review peer and organizational support during the COVID-19 pandemic was associated with post-traumatic disorder symptoms, anxiety and depression, occupational stress, job satisfaction, burnout, uncertainty at work, emotional exhaustion, moral injury, and sleep disturbances. We found that during the COVID pandemic, when occupational stress was at very high levels, peer support was a key factor for managing stress at work and it contributed to mitigating the job insecurity faced by several work categories [30,75]. It can be hypothesized that especially in the lockdown phases or in work overload periods, the support of colleagues could partially replace the support of families and friends, thus explaining the relevance of this issue in preventing and mitigating work stress. In this optic, investing in peer support programs may increase social support and develop resilience, which is a key factor in managing significant sources for stress or trauma [76]. Communication and team building training programs could help boost social support, especially in healthcare settings. Organizational support is another aspect linked to the maintenance of workers' mental wellbeing: the perception of organizational support refers to employees' global beliefs regarding the extent to which the organization values their contributions and cares about their wellbeing [77]. This organizational support not only motivates employees to work harder and fosters a bond to the company, but also protects workers from poor mental outcomes during this emergency phase [78]. Organizational changes can mitigate the impact of the emergency on workers, and clear and effective communication between colleagues and supervisors is a key factor that is needed to prevent poor mental outcomes. Organizational support can also be related to the provision of adequate training for workers. Training is defined as the process by which employees are provided with the knowledge and skills needed to function in their work environment [79]. Several studies highlighted the strain experienced by HCWs in their job as they did not feel prepared and did not have protocols to follow in order to treat COVID patients. Throughout our research, a lack of adequate training is associated to depression, anxiety, PTSD and burnout symptoms, as well as to general psychological distress, work-related stress and the loss of motivation. During the most acute phases of the pandemic in particular, HCWs have been deployed from one department to another, without receiving suitable training. These findings suggest the need for regular training programs, not only regarding professional topics, but also on emotional regulations and team-work training with a view to making employees feel supported and to decrease their feelings of perceived occupational stress and workload [80,81]. Healthcare organizations should provide adequate training programs; shared protocols and guidelines on managing the COVID-19 emergency are crucial to guiding HCWs in their job. Another occupational issue to have emerged during the pandemic is the change in workload. Workload is a traditional job demand item characterized by the need to work faster, to offer quicker responses, to reach several objectives at the same time and perform multiple tasks. According to the job-demand resource model [82], the work environment possesses job demands (e.g., workload, physical working conditions and physical demands) that exhaust employees' cognitive and physical resources, which result in health problems and a loss of energy. Occupational strain, which was even a worldwide problem among health professionals before the COVID-19 pandemic, became a major topic and an actual risk for healthcare personnel and we found that it was associated with emotional exhaustion, anxiety, depression, PTSD and burnout symptoms. This aspect is particularly relevant as it affects not only the single worker, but is known to have an impact on patients' safety, in particular in terms of medical errors reported [83]. Thus, it is essential that healthcare organizations provide enough time to recover from fatigue as rest is a priority for the wellbeing of both workers and patients. In this sense, the organization of work shifts can be a crucial factor for management to consider. Strictly connected to the increasing workload, we found that home-work imbalance was another relevant issue associated with mental health impairment during the pandemic. Work-life balance can be described as the balance that individuals need between the time allocated for work and other aspects of life, including family, social and leisure pursuits, and other domains of health and well-being [84]. The imbalance between home life and work life is associated in our review to perceived job productivity and satisfaction, occupational stress, and burnout symptoms. The connections between work and home life are crucial, especially in a society where double-paying couples are common. Even before the COVID-19 pandemic, doctors experienced the stress derived from a poor balance between life at work and at home, often causing emotional exhaustion [85,86]. Childcare was one of the major concerns, for training doctors for example, as they were exposed to higher levels of workload. This specific psychosocial factor may affect female workers more than their male counterparts, configuring the need for an appropriate gender specific approach to the issue [87]. In this scenario, practical organizational support measures, such as flexible schedules, are relevant interventions that can address workers' issues and boost their mental wellbeing. Government and organizational measures in order to support family care can also support workers and protect their mental health. On the other hand, remote workers experienced a different kind of imbalance between work and home. If there was an overall appreciation of the possibility of working from home, remote working, which was widely adopted by companies since the very beginning of the pandemic, can often blur the line between work and free time, not allowing employees to take a substantial break from work [88]. Remote workers may experience the constant willingness to be connected to their work using information and communication technologies (ICT) and may tend to work longer than usual as ICTs create expectations for a faster response. In this sense, work-related technostress can emerge as a relevant risk factor. Technostress is "an IT user's experience of stress when using technologies" [89]. In workplaces, the ICT demands were associated with increased strain, stress, and burnout [90]: the massive adoption of remote working, which is probably set to last after the pandemic, needs further research involving the issue of technostress. Educating employees and supervisors to make a clear distinction between free time and work time can be a suitable intervention in mitigating the uneasiness derived from this issue. In our review we also found that the reduction in workload may cause poor mental outcomes, mainly linked to insecurity about the future and the loss of economic status. The mental outcomes associated with this dimension are anxiety, depression, PTSD and burnout symptoms, as well as work-related stress. Even the perception of job insecurity, which characterizes the job market during COVID-19, may have an impact on employees' financial anxiety. The job insecurity related to COVID was found to be associated with psychological wellbeing through financial stress [91] and is also linked to lower vitality. Interestingly, job insecurity also involved healthcare professionals, who found themselves in a sort of paradox, caught between high workload and financial instability. Government measures aimed at sustaining certain working categories can have an important impact on the mental status of workers and when possible, companies should provide job stabilization and economic support to workers.
A summary of main findings of the review and other implications are reported in Table 1.

Strengths and Limitations
This review has some strengths that need to be highlighted. First, it searched the literature after 18 months of COVID-19 pandemic, thus giving an updated overview of the mental outcomes in the workplace in the era of COVID-19. Moreover, the selection of articles focused on papers that gave insights into the working conditions during the pandemic and made some associations between mental outcomes and specific psychosocial factors in the workplace. Some specific interventional possibilities have been recognized that could protect and boost workers' mental health. Although this review adopted a qualitative approach, this is compliant with the PRISMA statement, which gives more strength to the evidence retrieved. Finally, unlike previous research, this review also focused on non HCWs workers, recognizing characteristics of work which had an impact on mental health during the pandemic and during emergencies in general. Nevertheless, some limitations should be addressed. Most of the studies selected have a cross-sectional design, thus limiting the strength of the conclusions and the possibility of making causal inferences. Moreover, data have been collected in different stages of the pandemic and in different countries, which may have affected the results, especially considering the heterogeneity in the management of pandemic in workplaces in the world. Another concern is related to the scales and tools used to test the participant and to adequacy in the selection of samples.

Conclusions
Support from peers and organization, home-work balance, changes in workload, training and job insecurity are relevant topics for the mental wellbeing of workers during the pandemic. Recognizing these factors and projecting interventions in order to mitigate their effects, or to boost their efficacy, is a fundamental step in dealing with COVID-19 in the workplace and with future emergencies. The five dimensions retrieved play a fundamental role in the wellbeing of workers, HCWs and non HCWs, during the pandemic: they are associated to anxiety; depression; burnout; PTSD symptoms; and work-related stress. Intervening in these psychosocial risks, with specific programs from companies and policy makers, can prevent poor mental outcomes in workers during the ongoing COVID-19 pandemic.

Conflicts of Interest:
The authors declare no conflict of interest.            The lack of human resources predicted emotional exhaustion through the workload and secondary traumatic stress through fear of contagion, contact with death/suffering, and workload.