The COVID-19 pandemic has placed health professionals all over the world in an unprecedented situation, working under extreme pressures, both physically and psychologically (Greenberg et al., 2020; Howe et al., 2020). The new reality that the pandemic has brought has generated consequences that both organizations and individuals must face. Many people are adjusting to the new organizational demands the pandemic has caused while hoping to “return to normal” as soon as possible. However, the implications of these demands have provoked a much greater change, in which a more aptly named “new normality” has arisen. For example, the World Health Organization (WHO) has encouraged organizations to generate a work plan based on shifts and working from home, among other practices, to increase social distancing and prevent the spread of the virus (Pan American Health Organization, 2020). The changes have affected employees’ job security, financial stability, and work-family balance, especially among healthcare workers. More importantly, a less mentioned consequence has been the emotional impact that these changes have generated in employees, especially the stress they face when it comes time to go to work.

Work stress is one of the organizational responses that most impacts workers’ mental and physical health, especially in service organizations (Kim et al., 2011). González et al. (2004) found that, on comparing the stress level between health and non-health workers, the former workers suffer from more stress. In this respect, even before the COVID-19 pandemic, health care professionals were already working in high stress environments. Long hours and shift work, intensive job demands, lack of adequate resources, and fatigue are among the typical factors that make healthcare organizations environments where stress, emotional exhaustion and burnout prevail (Rice et al., 2014; Zhou and Chen, 2021). In some situations, low wages, professional invalidation, and limited career progression intensify the problem, decreasing the job satisfaction and leading workers to leave their organizations (Rice et al., 2014). Unfortunately, the COVID-19 pandemic has put these workers in an even worse situation (Greenberg et al., 2020). During the pandemic, the fear of becoming infected and dying from the virus, along with the fear of infecting family, friends, and colleagues (Monterrosa-Castro et al., 2020), has been a factor that has caused important emotional consequences in workers and increased their level of stress. The stress caused by work exhaustion and overload, often a product of long shifts and the need to cover for the absence of peers, negatively affects the quality and stability of the organization and can lead to greater dissatisfaction and intentions to leave their job (Kim et al., 2011). Stress can have significant effects on work performance, but much more importantly, on the attitudes that the workers have concerning their job stability.

Staff turnover in health care has important consequences for the organizations and the provision of quality care for patients (Gamero-Burón, 2010; Ravangard et al., 2019; Sharif et al., 2021). Hwang and Chang (2008) explain that high turnover in health care implies additional costs for human resource management and recruitment (e.g., in time and effort to employ new staff and train them for their job). Furthermore, turnover also increases the pressure on staff to work above and beyond their contracted hours, leading to errors and a decreased morale of the remaining staff (Fasbender et al., 2019). For these reasons, turnover intentions—a precursor of turnover itself (Lee and Kim, 2020)—have gained important attention throughout the years, as it could be crucial for the organizations’ productivity and the workers’ well-being.

Turnover intention refers to employees’ awareness or thoughts about leaving their job (Akgunduz and Eryilmaz, 2018). Previous research has provided evidence that a stressful working culture and increasing job demands are major contributing factors that increase employees’ intentions to leave their job (Buchbinder et al., 2001). An overburdened system, lack of support at work—especially from the supervisors, and scarce resources directly affect the emotional well-being of the employees, and certainly reduce their motivation (Flinkman et al., 2008). Therefore, the relationship between stress and turnover intentions for health care professionals needs to be revisited in the context of the current sanitary situation. By understanding this relationship, organizations can take actions to support their employees, improve their well-being, and maintain their productivity in this “new normality.”

To face workers’ stress and the constant changes associated with the sanitary crisis, organizations must place emphasis on the organizational processes that increase workplace stability for workers and their capacities to cope with the crisis (Lee, 2021; Oksanen et al., 2021). In this context, the individual perceptions of the workers with respect to safety in their workplace become more relevant. By feeling safe in the work environment and not exposed to inter-personal risks, workers can feel less stress and reduce the emotional and cognitive consequences it brings. In particular, psychological safety can be an important mechanism to reduce stress by creating a climate of trust and risk-free communication. Psychological safety refers to workers’ perception of how workmates can respond to the risky behaviors that interpersonal situations imply (Edmondson, 1999; Carmeli and Zisu, 2009; Frazier et al., 2017). In this way, psychological safety could translate into a mechanism that reduces workers’ stress, diminishing the negative attitudes toward their work position, that is, their intentions to leave the job.

Thus, to advance in understanding the relationship between stress and voluntary turnover, this work seeks to investigate the role of psychological safety as a mechanism that reduces the negative effects of stress on turnover intention. In particular, we focus on cognitive-type of stress, i.e., stress that generates cognitive deficits in information processing (Amirkhan et al., 2018), as this has important consequences in high-intensity jobs (Mauno et al., 2019). Cognitive stress can have significant effects on work performance, caused by the wear and tear of cognitive functions such as memory and concentration (Kalakoski et al., 2020). Therefore, our research questions are as follows: Does psychological safety have a mediating effect between cognitive stress and workers’ turnover intention? If it does, what factors could increase or decrease psychological safety?

Given that psychological safety could positively impact the relationship between stress and workers’ turnover intention, knowing the factors that worsen or benefit psychological safety is vital. On one hand, we evaluate the effect that worry about COVID-19 would have as a moderator between stress and psychological safety. Workers that are more worried about the consequences of COVID-19 in their lives could experience greater cognitive stress that could, in consequence, diminish their perception of psychological safety. Worry about the effects of COVID-19 has been shown to impact workers’ well-being in many aspects (Greenberg et al., 2020).

On the other hand, the organizational capacity to manage dynamics that favor a climate of psychological safety for employees could become a factor that reduces the consequence of stress in workers and allows them to feel safer when working with others (Lee, 2021). In particular, we evaluate the effect of supervisor support as a possible counter to the harmful effects of stress on perceived psychological safety. Perceiving greater support from a supervisor translates into a belief that the organization values the contributions of its employees and is concerned about their well-being (Eisenberger et al., 2002) and, therefore, could increase the perception of interpersonal safety. Previous studies on psychological safety indicate that factors such as leadership and organizational norms signal what is expected and acceptable within the organization and therefore affect how individuals perceive their work environment as safe for self-expression. In this sense, a leadership style that values the contribution of others is related to higher employee expectations that expressing oneself is acceptable in the organization (Kim, 2019). This study attempts to understand the association between cognitive-type stress and workers’ turnover intention, the possible mediating effect of perceived psychological safety and the potential moderation of worry about COVID-19 and supervisor support in the relationship between cognitive stress and psychological safety. This study aims to contribute to understanding workers’ stress in healthcare organizations, especially in the sanitary context we are facing, as well as the factors that increase/diminish those effects and their consequences in the turnover of workers. Thus, we first explain the primary relationships between the aforementioned variables to then develop hypotheses among them. Later, the hypotheses are tested on a sample of 146 workers distributed in 21 teams in different healthcare organizations. Finally, we discuss the results and implications of our findings.

The means, standard deviations, and bivariate correlations among the studied variables are shown in Table 2. At the individual level, cognitive stress is positively correlated with employees’ turnover intentions (r = 0.22, p < 0.05), while psychological safety is negatively correlated with individuals’ turnover intentions (r = −0.36, p < 0.01) and cognitive stress (r = −0.27, p < 0.01). The magnitude of the correlation coefficients suggested that these relationships were generally moderate to medium (Hemphill, 2003). These results mirrored findings from previous research that found moderate correlations between psychological safety and turnover intentions, and stress and turnover intentions (Mosadeghrad, 2013; Kruzich et al., 2014; Kirk-Brown and van Dijk, 2016). Before further analysis, we mean-centered the independent variables.

This study aimed to understand the effect of cognitive stress on turnover intentions as well as the mediating effect of perceived psychological safety in this relationship, in addition to determining whether supervisor support and COVID-19 worry have a moderating role in the effect of cognitive stress on psychological safety.

The results of the multilevel mixed models show that perceived psychological safety mediates the relationship between cognitive stress and turnover intentions. Furthermore, we found that COVID-19 worry moderates the relationship between cognitive stress and perceived psychological safety, such that higher COVID-19 worry worsened the relationship between cognitive stress and psychological safety. Although not expected, we did not find evidence of the moderation of supervisor support on the relationship between cognitive stress and perceived psychological safety. However, we did find a direct and positive effect of supervisor support on the psychological safety perceptions.

The results of the mediating analysis confirm that higher perceived psychological safety prevents the negative effects of cognitive stress on turnover intentions, thus confirming our first hypothesis. Therefore, we contribute to the literature on stress as we explore a potential mechanism that can prevent its negative effects on employees’ attitudes toward their job. These results are consistent with previous research (Edmondson, 1999; Frazier et al., 2017; Lee, 2021), which states that an individual’s perceptions of psychological safety reduce the potential risk associated with interacting with others at work and, in particular, the potential adverse effects that stress could have when working with others. Considering psychological safety as a mechanism that prevents the negative consequences of stress at work offers important opportunities to deal with cognitive stress, especially regarding the immediate effects that this has, such as loss of concentration, distraction, or confusion (Jun et al., 2021). In situations that create or reinforce cognitive stress for employees, processing information and performing tasks will be more challenging (Amirkhan et al., 2018; Kalakoski et al., 2020); hence creating an environment that allows employees to express their difficulties and challenges when performing their tasks increases the opportunities to take action and allows employees to perform their jobs accordingly. Psychological safety can become an important mechanism to manage and counteract the stressful consequences of the current sanitary crisis and the constant change the “new normality” (Oksanen et al., 2021) has brought to organizations.

The relationship between stress and turnover intention is not always straightforward because it depends on the employees’ perceptions of threats (Sindi et al., 2017). Psychological safety can explain why employees’ stress changes according to the context in which they perform their jobs, such that on many occasions being in an environment that allows them to express themselves freely and without fear of being embarrassed or punished can reduce their negative attitudes toward their job (Frazier et al., 2017).

Our results also contribute to a better understanding of how stress, particularly cognitive type stress, affects turnover intentions. Most studies on stress and its effects on turnover intentions focus on a chronic type of stress, particularly burnout (Hayes et al., 2012; Chênevert et al., 2021); and fewer have addressed the relationship with cognitive symptoms of stress (e.g., working memory difficulties, indifference to work, information overload and impaired concentration) (Rantanen et al., 2021). Cognitive stress has significant effects on the quality of attention and the performance of workers at healthcare organizations, as it increases the likelihood of errors at work and impairs the sense of self-efficacy, which has also been linked to increased intentions to quit (Buchbinder et al., 2001).

Our study also tested the potential moderating effects of COVID-19 worry and supervisor support on the relationship between cognitive stress and psychological safety. While we found that COVID-19 worry worsens the adverse effects of cognitive stress on employees’ perceptions of psychological safety, we could not prove that supervisor support had a moderating effect on this relationship.

In situations that generate high stress, as is the case of the COVID-19 pandemic, the levels of anxiety that people experience are translated into a great concern about the potential negative effects that these could for them and their surroundings. Such a situation creates a context where stress (of any type) is more likely to increase. As Jun et al. (2021) argued, stress creates an automatic sense of anxiety and concern, affecting the cognitive control required for performing tasks and functions. The fear and the insecurities that emerge in situations characterized by high distress (as it is the case of the pandemic for healthcare workers) reinforce those threats that employees perceive of being rejected or judged by their peers because they cannot perform their task as they would be in a normal situation (Ilies et al., 2010). Therefore, the employees’ perceptions of psychological safety are affected, creating an environment where workers cannot give the best. Furthermore, these negative consequences could affect the employees’ attitudes toward their job, increasing their turnover intentions in the long-term.

Although we could not confirm that supervisor support moderated the relationship between cognitive stress and perceived psychological safety, we found that supervisor support has an important contribution in creating a psychologically safe environment. That is, our results show a direct and positive effect of supervisor support on perceived psychological safety. The literature on supervisor support for stress management is nascent (Horan et al., 2018). Most of the studies have attempted to show that low levels of supervisor support contribute to increased stress and even turnover, paying less attention to the moderating effects on these variables and other organizational processes (Bélanger et al., 2015; Meral et al., 2018). In this respect, the lack of the moderation effect can be explained in two ways. First, for supervisor support to be effective in reducing employees’ stress, supervisors should be concerned about their workers’ stress levels specifically and make stress management a priority (Kath et al., 2012). Effective stress management will only be possible when direct actions are taken in order to alleviate the factors that cause stress in the employees and the work environment. Precisely, Lee (2021) states that supervisor support becomes an organizational resource only once it means that employees feel listened to and considered. Alternatively, for cognitive type stress, a more task-focused supervisor support could diminish the employees’ concerns regarding their job. Higher orientation, attention, and feedback from the supervisor to workers in relation to their work tasks can be more effective rather than a general support (Eisenberger et al., 2002).

Previous studies have also confirmed the association between supervisor support and psychological safety (Edmondson and Lei, 2014). Supervisors can enhance open communication and facilitate employees to express their concerns (Singh et al., 2018). Systematic support from supervisors to employees enhances the knowledge of the current conditions that the employees are undergoing at work, whilst at the same time reducing the uncertainty that a crisis or constant change could create (Singh et al., 2018). Although we could not prove that supervisor support can be necessary for reducing the negative effects of cognitive stress on psychological safety, increasing the support that supervisors give to employees in the context of the COVID-19 pandemic can certainly make them feel safe to express their concerns and difficulties.

Overall, our findings provide evidence of cognitive stress’s consequences for employees working at healthcare organizations in situations of high distress, as it is the case of the current pandemic. Although not as evident as other types of stress, cognitive difficulties that arise from the anxiety that employees experience at work can seriously undermine their relationships with colleagues and, most importantly, their attitude toward their job. Therefore, we contribute to the stress literature by showing concrete evidence of how cognitive stress affects turnover intentions in healthcare organizations. Furthermore, our findings also contribute to the psychological safety literature by providing direct evidence of how cognitive stress affects employees’ perceptions of psychological safety and, at the same time, how psychological safety can counteract the negative effects of stress on turnover intentions. Psychological safety is a crucial variable for increasing learning, engagement, and performance among workers (Frazier et al., 2017), especially in the constant change that organizations experience. We also tested two variables that have a contingent effect on the relationship between stress and psychological safety, showing how COVID-19 worry combines with stress to undermine psychological safety perceptions. Finally, we tested our hypotheses in a sample collected during the crisis that COVID-19 has brought to the healthcare organizations. Therefore, we capture real-time perceptions and emotions of the employees in these organizations.

The study results point out that the employees’ cognitive stress has a significant impact on their intentions to leave the organization. Health care workers are consistently exposed to factors that produce stress (e.g., overload, lack of adequate resources, exhaustion, etc.), and it is undeniable that the COVID-19 pandemic has increased the sources of stress. The constant threat of the consequences of the virus and the emotional exhaustion that carries have direct effects on the employees’ capacity to use their knowledge, perform their tasks according to expectations and collaborate with others. Therefore, in these times of change, healthcare organizations should look deeper at the consequences of stress and the mental health of their employees and the processes that reduce their impact on the employees’ work and well-being, e.g., psychological safety.

As the results of this study show, psychological safety can play an important role in preventing the negative consequences of cognitive stress on turnover intentions. Prior to the pandemic, Nembhard and Edmondson (2006) found that within health care teams, psychological safety is a key factor to promote workers speaking up and learning behaviors. Practitioners in the field of people management in healthcare organizations should bear in mind that psychological safety could be an important factor in creating a safe and protected environment for the employees to express their concerns. More importantly, in this “new normality,” psychological safety can be a catalyst of important organizational processes, by contributing to reducing employees’ dissatisfaction with their job (as reflected in less intentions to leave their organization).

Managers should place emphasis on the practices that increase psychological safety. First, reducing the threat that COVID-19 presents for employees can have important effects in reducing the negative effects of cognitive stress on psychological safety as our study shows. For instance, Khan (2021) shows that social media disinformation has a positive relationship with the threat of COVID-19 in healthcare workers. By introducing reliable sources and clear communication, managers can help to reduce employees worries about the pandemic. Further, promoting social distance, and utilizing alternative channels for work and communication (e.g., webinars, social media platforms, and video calls) can also contribute to the feelings of safety for the employees. The threat that COVID-19 presents for health care workers should continue to be studied as its effects on different spheres are still uncertain. Future research can include other individual differences as moderators of the worry for the COVID-19, such as personality and locus of control.

Second, supervisor support can directly increase psychological safety. By training supervisors to give better support to employees and creating a climate with open communication and receptiveness of employees’ concerns, health care organizations can promote a climate of psychological safety. It is also essential that the supervisor support is persistent and inclusive (Nembhard and Edmondson, 2006). Supervisors should accompany the workers throughout their difficulties, encourage open communication and reduce the barriers that make employees feel excluded. Future research could look more in detail at the role of specific types of supervision in the relationship between stress and psychological safety, especially in emotionally challenging situations. When interpreting and generalizing the study’s results, caution should be kept in mind in light of the following limitations. First, we applied a single questionnaire to collect the employees’ perceptions of the main variables. This can give way to certain biases of desirability and self-report. Future studies should consider longitudinal samples, where the temporal aspects of the variables under study are considered. Second, this study was conducted in only two healthcare organizations in Chile which we accessed by convenience; this may affect the generalizability of the findings to other countries and the general population. However, our results still pose significant contributions for healthcare organizations’ managers and how they can deal with employees’ stress in the current sanitary situation and the “new normality.” Third, for this study we measured supervisor support in a general way and given our findings, future studies should consider the specific type of support given by the supervisor. Other variables related to the supervisor’s well-being and leader characteristics can also help to understand how they can contribute to reducing employees’ stress and promote psychological safety at work. Finally, although this study was implemented during the COVID-19 sanitary crisis, our results can also offer important guidelines for the management of public health organizations outside the context of the pandemic. Healthcare organizations are emotionally charged environments, where stress is inherent to the work that employees perform on a day-to-day basis.

To sum up, in this study, we aimed to understand the effects of cognitive stress on turnover intentions, showing that psychological safety can indeed prevent the adverse effects of stress on turnover intentions. We further found that COVID-19 worry increases the harmful effects of cognitive stress on psychological safety. Therefore, we found that psychological safety needs to be considered within healthcare organizations, especially during the pandemic, as this can help to reduce part of the stress that employees at these organizations experience. We trust that the knowledge elaborated here will be informative for practitioners in these organizations to look after the well-being of the employees during these times of change.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

The studies involving human participants were reviewed and approved by the Comité de ética de la Universidad Católica de la Santísima Concepción (Número 19-2020). The patients/participants provided their written informed consent to participate in this study.

MH and FT-M contributed equally to the conception, design of the study, data collection, analysis, and writing of the manuscript. KO collected part of the data and contributed to the writing of the manuscript. All authors reviewed, read, and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.