How Nurses Deliver Care Shapes Their Odds of Quitting Over Mental Health

When the COVID-19 pandemic slammed into healthcare systems in early 2020, few professions absorbed the shock as directly as nursing. Nurses stood at the bedside of critically ill patients, improvised protective equipment when supply chains buckled, and absorbed the emotional weight of separation from families who could not be at the bedsides themselves. Now, a large-scale Canadian study has added a striking new dimension to the understanding of pandemic-era nursing attrition: the way care is delivered—whether in person, online, or through a blend of both—appears to be strongly associated with whether nurses contemplate leaving their jobs because of stress, burnout, or other mental health concerns.

The research, published in PLOS Mental Health, draws on a national survey conducted by Statistics Canada between September and November 2021, a period when the pandemic’s third wave was receding in much of the country but its psychological toll on healthcare workers remained acute. The survey, known as the Survey on Health Care Workers’ Experiences During the Pandemic, or SHCWEP, was designed to capture the working conditions, health status, and career intentions of frontline medical personnel during one of the most disruptive periods in modern healthcare history. The study team, led by Shauna Clayton with colleagues Safoura Zangiabadi and Hossam Ali-Hassan, performed a secondary analysis of the survey data, focusing specifically on the nursing workforce.

The scale of the dataset lends the findings considerable weight. After exclusions, the analytical sample comprised 3,107 nurses, a figure that, through statistical weighting, was designed to represent approximately 353,980 Canadian nurses aged 18 and above. That weighting matters: it means the results are not merely a portrait of the surveyed individuals but an estimate of patterns across the entire Canadian nursing population. The central question was deceptively simple. Did nurses who delivered care primarily online, primarily in person, or through a blended model differ in their stated intention to leave their job within two years because of mental health concerns?

To answer it, the researchers employed multivariable logistic regression, a statistical technique that estimates the odds of an outcome—in this case, an intention to resign—while adjusting for other variables that could confound the relationship. The team controlled for a broad set of job-related, health-related, and sociodemographic factors, including characteristics of the nurses’ employment, their self-reported health, and their personal backgrounds. This adjustment is critical in observational research of this kind, because nurses who work in virtual settings differ from bedside nurses in many ways: their patient populations, acuity levels, work environments, and career profiles all vary. By accounting for these differences statistically, the analysis isolates the association attributable to the delivery modality itself, at least to the extent the available data allow.

The headline numbers are sobering even before modality enters the picture. Overall, 33.5 percent of nurses in the weighted sample reported a desire to quit their job, and 20.5 percent specifically cited mental health concerns—stress, burnout, or related struggles—as their reason for considering an exit. In other words, roughly one in five Canadian nurses surveyed at that moment in the pandemic was contemplating walking away from the profession not because of pay, scheduling, or career stagnation, but because the work had damaged their psychological well-being. For a health system already strained by workforce shortages, that figure represents a quiet emergency.

Against that backdrop, the modality findings stand out. Nurses who delivered care online had roughly half the odds of reporting an intention to leave due to mental health concerns compared with those delivering care exclusively in person, with an odds ratio of 0.49 and a 95 percent confidence interval of 0.45 to 0.52. Nurses in blended roles, combining virtual and in-person duties, also showed reduced odds, though the effect was more modest, at an odds ratio of 0.81 with a confidence interval of 0.78 to 0.84. Because both confidence intervals lie entirely below 1.0, the associations are statistically robust within the framework of the analysis. The pattern suggests a gradient: the more a nurse’s work was removed from the in-person bedside, the lower the reported likelihood of a mental health–driven intention to quit.

Interpreting that gradient requires care. The study is cross-sectional, capturing a single moment in time, which means it can identify associations but cannot establish that virtual work protects mental health. It is possible that nurses with existing mental health difficulties gravitated toward or away from certain roles before the pandemic, or that unmeasured differences—such as exposure to dying patients, workplace violence, or infection risk—explain part of the relationship. Reverse causation is also plausible: nurses already contemplating departure may have shifted toward virtual roles as a coping strategy. The authors are careful to frame the results as an association that provides insight into nurses’ needs, not as proof that telehealth is a mental health intervention.

Nevertheless, the findings arrive at a consequential moment. Health systems across Canada and much of the world are grappling with nursing shortages that predate the pandemic but were sharply accelerated by it, and retention has become a central policy concern. The study’s authors emphasize that nurses are a critical asset to the medical field and that their retention affects patient care directly and public health eventually. If the modality of care delivery is genuinely linked to psychological strain, then workforce planners have an additional lever to consider—one that extends beyond the usual repertoire of wage adjustments, staffing ratios, and scheduling reforms.

The practical implications cut in several directions. On one hand, expanding virtual and hybrid care roles could offer a retention pathway for experienced nurses at risk of burnout, allowing them to remain in the profession in capacities that impose a different psychological profile than acute bedside work. On the other, the findings implicitly underscore the concentrated burden borne by in-person nurses, whose working conditions the pandemic made dramatically harder. A system that solves attrition by shifting nurses to screens while leaving bedside conditions unchanged would merely redistribute the crisis. The authors suggest the results can inform future implementation strategies that enhance existing training and education protocols and support nurses’ mental well-being—a formulation that points toward integrating modality decisions into broader workforce wellness planning rather than treating them as purely operational choices.

What the study ultimately offers is a new lens on a familiar problem. The conversation about nurse retention has traditionally centered on workload, compensation, and workplace safety, and those factors remain fundamental. But this analysis of more than three thousand Canadian nurses, weighted to represent a national workforce of nearly 354,000, indicates that where and how nurses practice—the physical or virtual architecture of their daily work—is woven into their decisions about whether to stay. As health systems redesign care delivery in the pandemic’s aftermath, the mental health of the nursing workforce may depend, in part, on getting that architecture right.

Subject of Research: The association between healthcare delivery modality and mental health–related intention to leave the job among Canadian nurses during the COVID-19 pandemic

Article Title: Healthcare delivery modality and mental health–related intention to leave their job among nurses in Canada

Article References: Clayton, S., Zangiabadi, S., & Ali-Hassan, H. (2026). Healthcare delivery modality and mental health–related intention to leave their job among nurses in Canada. PLOS Mental Health, 3(9), e0000692. https://doi.org/10.1371/journal.pmen.0000692

Image Credits: AI Generated

DOI: 10.1371/journal.pmen.0000692

Keywords: nurses, mental health, burnout, healthcare delivery modality, telehealth, COVID-19, workforce retention, Canada, occupational health, logistic regression, Statistics Canada, nursing workforce