How Nurses Perceived Their Work-Environments and Its Related Nursing Management Perspectives during the COVID-19 Pandemic: An Investigatory Study

: Human resource management could be deﬁned as the set of policies which, if properly designed and developed, contribute to improving the performance of employers. The present study aimed to investigate how nurses directly involved in the care of COVID-19 patients perceived their working activities and environments during the pandemic and if there were any associations between their perceptions’ levels and sampling characteristics. An observational, multicenter, cross- sectional study was carried out from October 2021 to February 2022. Socio-demographic characteristics and a total of 10 items were collected in order to assess nurses’ perceptions on their working activities and environments during the pandemic. A total of 126 nurses were recruited in this study. Of these, 35 (27.8%) were males and 91 (72.2%) were females. The most part of participants (62.7%) aged between 20–30 years and were employed during their ﬁrst decade of work experience (69.8%), were employed only during the morning (46%) and attended the basic nursing course (82.5%). Most of participants considered their nursing activities as very hard, in both the age and work experience groups. Additionally, further associations were reported between nurses who were employed during the three shifts par day, as they considered their activities very hard; however, data were higher in one/shift group than in the three-shift group, too. Younger nurses reported higher emotional levels in their nursing activities than their older collogues (11–20 years and 21–30 years), while the oldest group recorded higher levels of emotional involvement than the younger groups (11–20 years and 21–30 years), respectively. Finally, all groups of work experience nurses considered the nursing activities very hard. The perceived organization work environment was not favorable, explaining potential opportunities for intervention by also improving nurses’ well-being, particularly during this very hard period of the pandemic. Therefore, nursing leaders might inﬂuence the orientation and development of collaborators by involving them with respect to the choices and challenges of the administration, rather than traditional managers who interpreted their role through complicated command procedures and control.


Introduction
The deep challenges in healthcare systems strongly influenced the changeover from a traditional and complicated procedural handling to a managerial one, distinguished on the grant of trustee-type engagements and periodic controls of the outcomes [1].
Human resource management could be defined as the set of policies which, if properly designed and developed, contributed to make the performance of employees more effective in terms of performance [1]. Careful management of human resources, in fact, ensures that customers and employees of a company see their satisfaction growth.
The concept of human resources and organizational climate took greater significance in healthcare companies that based their activities on knowledge, manual/operational skills and interpersonal skills and among the fundamental factors that influenced the achievement of the strategic objectives set by healthcare authorities; the most prevalent Psych 2022, 4 were skills and employees' professionalism, organizational well-being, perceived climate, health and quality of life in the workplace. The literature tried to provide an answer to this problem, defining the climate as the result of the interaction between individual perceptions and environments that is also formed through the perception of other subjects, defining it as a concept that was neither objective nor subjective, but intersubjective [2]. In this context, nursing management is considered as the key tool for nurses to better combine the care improvement with human resource, by optimizing and enhancing them [2][3][4]. Healthcare systems focused on their workplace security and associations with their multi-professional staffs, promoting a satisfactory management which positively effected their employers' health [5].
The literature evidenced how nurses who positively assessed the figure of their nursing managers in all their working environments registered a positive awareness in justice and work in their working systems [6][7][8]. Therefore, nurses also associated their working satisfactions with their needs and working-related conditions [9,10] by highlighting the importance of organizational and managerial implementation through standardized practical procedures. In this regard, a perceived unsafe workplace provoked high levels of stress among the nursing staff which will influence also the nursing care provided [11]. In this scenario, the organizational health became a more important topic in healthcare management studies [12,13] in order to promote sufficient physical and psychological well-being [14], which directly involved the whole healthcare system [15,16].
Reduced organizational well-being conditions induced phenomena such as: decreased efficiency, absenteeism, reduced stimulus levels and predisposition to nursing activity, stress and burn out, lack of trust, increasing in patients' claims and the perception in unease and psychological malaise of the entire involved system [9,[17][18][19].
In Italy, the issue of the organizational well-being in all work-environment contexts took hold after 2000. On the basis of this definition, researchers identified fourteen dimensions considered as fundamental in determining the quality of working life, by also determining a series of indicators of well-being and malaise and a scale to measure psychophysical disorders, such as:

•
Management support: the management behavior in listening skills, valuing individuals, involvement capacity; • Collaboration between colleagues: the collaboration degree, support, fluidity of relationships; • Organizational efficiency: the efficiency degree of the organization; • Organizational fairness: the presence of conditions of fair treatment in the organization; • Conflict management: the organization's ability to manage conflict or not; • Perception of stress: the level of load and stress perceived in carrying out one's work; • Job request: some aspects in the dimension relating to the characteristics of the tasks, in relation to the physical, cognitive and emotional requests associated to work tasks; • Environmental comfort: the level of presence of specific conditions in comfort and functionality of the physical environment of the work; • Work safety: the perceived level of safety in specific conditions of the physical environment of the work; • Openness to innovation: the organization's ability to innovate and change.
In addition to these ten indicators, two others were added which referred to the satisfaction with one's organization and one's work and psychophysical disorders.
In relation to helping professions, occupational stress was indicated with the term of burnout and was mainly expressed with a feeling of emotional overload and motivational decompensation [20].
Each environmental stimulus required an adaptive response from the individual and therefore could be a source of stress (stressor); the stressful power of each stimulus was determined by the cognitive evaluation that each individual gave to the situation itself and to the skills that individual felt to deal with it. The cognitive assessment determined the strain, that was the negative impact (which is expressed with psychological distress and/or disease) that the potentially stressful situation had on the individual himself [21,22].
In the healthcare setting, the problem of occupational stress became particularly evident, partly due to the characteristics concerned helping professions, in contact with suffering and illness, partly due to the pace and organization of work. Specific stressors for the nursing staff were described, such as: lack of clarity about the role, difficulty in scheduling shifts and the work group, poor involvement in decision-making processes, low social status and poor support [23]. These factors were, in part, similar to the indicators used for the assessment of organizational well-being. This indicated that a work environment with a positive organizational climate reduced the risk of stress among its relating workers. These types of risk could be linked to more typically individual dysfunctional responses (negative feelings, depression, hypertension, cardiovascular diseases) or organizational problems (job dissatisfaction, turnover, absenteeism) [24].
In recent years there has been a decrease in "acute" reactions to occupational stress, and an increase in chronic and passive reactions [24] and the number of people seeking help due to work stress.
As healthcare systems experienced crisis during the COVID-19 pandemic, nurse health and security were implicated. Nurses experienced controlled accessibility of personal protective equipment (PPE), insufficient infection control procedures and protocols, lack or scarcity of nursing staff [25][26][27] and most of them felt to be working in unsafe environments for themselves and their patients [25][26][27]. In addition to the physical threat of exposure to COVID-19, there was the emotional worrying to transfer the SARS-CoV-2 infection to their families [28]. Therefore, remarkable levels of anxiety, depression, and burnout were reported from all studies conducted in this era from all nurses all around the world [29][30][31][32], particularly from all nurses who took care of COVID-19 patients. While deficiency in available supplies might influence mental disorders, the association between experienced job environments and mental health was more intricate. Nurses who perceived a more positive working environment could potentially temper the role of reduced resources in stress, while perceptions of a less encouraging working environment might accentuate this negative association. Several studies focused on the association of these individual factors in contributing to nurses' stress during the COVID-19 pandemic, but very few studies focused on the association between mental health disorders, the COVID-19 pandemic and work environments' perceptions [33][34][35][36][37]. The COVID-19 pandemic showed great hazards to the well-being of nurses, as they risked the contraction of the SARS-CoV-2 infection during their interminable work shifts in understaffed organizations [38][39][40][41][42][43], by contributing both to an increase in mental health disorders, such as: work-related stress, anxiety, depression, poorer quality of sleep [44][45][46][47], and to an increase in physical disorders, such as headaches caused by the PPE [48].

Aim
The present study aimed to investigate how nurses, who were at the forefront in the care of COVID-19 patients, perceived their working activities and related work environments during the COVID-19 pandemic and if there were any associations between their perceptions' levels and sampling characteristics.

Design
An observational, multicenter, cross-sectional study was carried out from October 2021 to February 2022.

Sample
Nurses from selected Italian centers directly involved in the fight against COVID-19 were invited to participate in the study. Nurses voluntarily participated in the study and also self-declared themselves to be employed in the care of COVID-19 patients by fulfilling all of the proposed questionnaire. When participants activated the link of the questionnaire, there was an exhaustive section regarding the presentation of the study and also including all the ethical characteristics of the study. The present study was approved by the Ethical Committee of General Hospital, Polyclinic in Bari, Italy, with id no. 7007/2021.

The Questionnaire
An "ad hoc" questionnaire was created and a link was generated through the Google forms platform, as Google Moduli. Then, the questionnaire was publicized through the most common social platforms, such as: WhatsApp, Facebook and Instagram, in order to invite nurses to full fill the questionnaire.
The questionnaire included two main sections, particularly, the first part collected socio-demographic data of the participants, such as: shift work, as participants were employed only during the morning, or both during the morning and the afternoon or during also the night; • educational level in nursing, as nurses attended only 3 years in nursing training, between 4 to 5 years or more than 5 years.
The second section of the questionnaire included a total of 10 items which investigated participants' perceptions on their work activities during the COVID-19 pandemic. For each item a Linkert scale was proposed, which varied from 1, as "in no way" to 4, as "very". Good validity of the conceptualized items was registered, as α = 0.793.

Data Analysis
All data were stored in an Excel data sheet and elaborated thanks to the SPSS software, version 20. Sampling characteristics, such as: sex, age, years of work experience, shift and educational level and also all the items concerning the nurses' perceptions' on their work activities and environments were considered as categorical variables and showed as frequencies and percentages. Then, linear regressions were assessed between sampling characteristics and each item of nursing perceptions. The significant level was assessed at p < 0.05. Finally, frequencies and percentages were assessed for all significant associations registered in order to assess the various associations highlighted.

Results
A total of 126 nurses were enrolled in this study. Of these, 35 (27.8%) were males and 91 (72.2) were females. The majority of nurses (62.7%) aged between 20-30 years were employed during their first decade of work experience (69.8%), were employed only during the morning (46%), and attended the basic nursing course (82.5%) ( Table 1). By considering the nursing perceptions of their work activities and environments during the COVID-19 pandemic, Table 2 showed all ten items proposed as frequencies and percentages for each answer's range proposed.
By considering the nursing perceptions on their work activities and environments during the COVID-19 pandemic according to their sampling characteristics (Table 3), significant associations were reported between the item no. 1 and age (p = 0.001), work experience (p = 0.003) and shift work (p = 0.012). Further associations were assessed between the item no. 2 and work experience (p = 0.032); the item no. 3 and age (p = 0.001) and work experience (p < 0.001).
Finally, Table 4 shows how significant associations were distributed between the groups of participants considered. Specifically, for the item no. 1, concerning physical and mental fatigue, most of participants considered their nursing activities as very hard, in both the age and work experience groups. Additionally, nurses who were employed during the three shifts par day considered also their activities very hard; however, data were higher in one/shift group than in the three-shift group. Younger nurses reported higher emotional levels in their nursing activities than their older colleagues (11-20 years and 21-30 years), while the oldest group recorded higher levels of emotional involvement than their younger groups (11-20 years and 21-30 years), respectively. Finally, all groups pf work experience nurses considered the nursing activities to be very hard.

Discussion
The present study aimed to investigate how nurses, who were at the forefront of caring for COVID-19 patients, perceived their working activities and environments during the pandemic and if there were any associations between their perceptions' levels and sampling characteristics. Data showed significant associations between the item no. 1 and age (p = 0.001), work experience (p = 0.003) and shift work (p = 0.012), as most of participants considered their nursing activities to be very hard, in both the age and work experience groups. Additionally, further associations were reported between nurses who were employed during the three shifts per day, as they considered their activities to be very hard; however, data were higher in one/shift group than in the three-shift group. Younger nurses reported higher emotional levels in their nursing activities than their older colleagues (11-20 years and 21-30 years), while the oldest group recorded higher levels of emotional involvement than their younger groups (11-20 years and 21-30 years), respectively. Finally, all groups of work experience nurses considered their nursing activities to be very hard.
Noticeably, individuals who were employed in a system with poor supplies and low experienced managerial support reported greater levels of depression, anxiety and burnout. Additionally, nurses who troubled their families with the risk of transmitting the SARS-CoV-2 infection were more at risk to affect themselves with several negative mental health disorders [49]. Several helpful strategies to a nurse for improving their workwell-being conditions during the pandemic were concentrated on mental health issues, such as hospital-based support programs and stress management approaches [50]. Both mental health interventions and improvements in organizational factors were important to support nurses. Blanchard et al. [50] reported a strong association between a dangerous employment environment and mental health disturbances, particularly when managerial assistance was considered inadequate. They reported poor work environment conditions in all fields, such as physical work environment, poor training, inadequate supply, poor employer assistance and a reduced belief in leadership. However, the nurses' perception of an inadequate organizational system was not a novelty. Before the COVID-19 pan-demic [51][52][53], the National Academy of Medicine addressed provider wellbeing at several levels [54], such as barriers and difficulties to promote changes [55], by firstly considering the importance of addressing nurses' well-being [56]. It became fundamental to provide comfortable work environments and organizational settings in order to prevent mental health discomfort [57][58][59][60].
Whilst the COVID-19 pandemic seemed to be very difficult to control, there were several suggestions to promote wellbeing among nurses in this emergency period, such as: job replanning, healthier behavioral counseling and stress management interventions [47]. There was a strong perception that rotating-night-shift nurses compared to daily-shift ones had to negative health impacts, since nurses working during the night shift reported fatigue, irritability, impaired cognitive and concentration skills [61]. On the other hand, very heavy and prolonged working hours, such as more 40 h per week, could negatively influence the normal rest quality [62]. Therefore, nursing managers should not exceed 4 night shifts per month and, at the same time, support their nursing staffs, in order to prevent sleep disorders among nurses [63].
Additionally, older nurses required a more comfortable working environments, as an essential need for themselves, since older nurses often suffered from back pain, musculoskeletal disturbances and stress-related mental diseases [64]. Although older nurses were more susceptible in their health, they acquired more specific skills than their younger collogues in communicative competences, attachment to one's activity, taking fewer sick days [65]. Older nurses pretend to be respected and themselves recognize their expertise and their knowledge and experience acquired [66]. Therefore, the present data seemed to be in agreement to the current literature, as older nurses required to be appreciated to their expertise, however, during the COVID-19 pandemic their experience seemed to be less important as the COVID-19 represented a novelty in treatment and its management and so older nurses felt themselves to be not very appreciated.

Strengths and Limitations
The present study proposed an interesting reflection on the nurses' perceptions related to their work environments and activities during the COVID-19 pandemic. However, the present study was limited by a small sample size (n = 126), which was not representative for the entire Italian nursing population and also the potential heterogeneity in the estimated effects, too. The work specifically concerned only young workers (most of them very young) working for a short period of time, with a low level of education, these facts could indicate a difficult organization at work and could be perceived as bad, thus not only the pandemic will have an impact on it. Additionally, the strategy used to publicize and administered the questionnaire could be considered another limitation, since the online method could influence the answers given and individual involvement: nurses who perceived the worst work conditions and being least satisfied with their work might be least likely to respond to the present survey. Finally, employers were not randomly assigned into workplaces: failure to account for sorting of employees will bias any estimated effects in the work-related well-being assessment.

Conclusions
In conclusion, the COVID-19 pandemic presented exceptional, hostile conditions which negatively influenced mental health and well-being in nurses. The present data showed how nurses, who were employed during the daily shift, felt themselves to be more tired than their colleagues and also how younger nurses reported higher emotional levels in their nursing activities than their older colleagues (11-20 years and 21-30 years), while the oldest group recorded higher levels of emotional involvement than their younger groups (11-20 years and 21-30 years). Additionally, all groups of work experience considered their own nursing activities to be very hard.
From the current literature, this was particularly present when the perceived organization work environment was not favorable, explaining potential opportunities for intervention by also improving nurses' well-being, particularly during this very hard period of the pandemic. There was no company that did not have the centrality of people among its values or that did not claim that they represented one of the main strategic assets. However, the reality was that, in everyday life, opposing logics prevailed all too often, which placed the interests of the company or business before those of individuals.
For those dealing with people and organizations, a "frontier" was represented by the possibility of demonstrating a positive link between the activities aimed at enhancing human resources and the performance of the company. Speaking of investments and human resources, two pillars must be considered: on the one hand, the systems, policies and tools aimed at people management; on the other hand, the set of conditions and activities aimed at improving the quality of life of people in work and therefore the organizational climate. Developing and managing human resources in modern organizations essentially might include motivating them. However, motivation could be built with time, constancy and with attention to highly complex processes. Only for a few decades there has been a tendency to involve the individual in the healthcare system, as a collaborator involved in making their own contribution developed a sense of belonging to the own organization. In this way, the organizational climate will improve and consequently increase the moments of comfort and exchange of skills involved, by influencing the behaviors, values and visions of the people who work in organizations. The need that emerged was to be able to count on the ability of leaders to influence the orientation and development of collaborators by involving them with respect to the choices and challenges of the administration, rather than traditional managers who interpreted their role through complicated command procedures and control. There was a need to rethink the role of leaders in a new perspective, which involves more workers in the organization and at the same time makes them more responsible and involved in achieving the objectives. Institutional Review Board Statement: Ethical review and approval were waived for this study due to the nature of the study, as dealing with an online, observational study. Both all Italian nurses and nursing students, who voluntarily agreed to participate in the study, were enrolled. All the ethical concerns of the study were stated in the first part of the questionnaire in agreement with the principles of the Italian data protection authority (DPA).

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study. Written informed consent for publication was obtained from participating nurses. Data Availability Statement: Data is contained within the article.

Conflicts of Interest:
The author declares no conflict of interest.