Antecedents of Nurse Burnout During a Pandemic: Managerial Way Out

Abstract

The aim of this research is to uncover whether nurses’ fear of contracting Coronavirus Disease 2019 (COVID-19) has resulted in stress-related presenteeism and burnout, and whether perceived organisational support is effective in dealing with both nurses’ fear of contracting COVID-19 and its undesired consequences. For this purpose, a cross-sectional and descriptive research has been conducted. The data are collected from 513 nurses working in Ankara, Turkey, through a questionnaire survey. Independent samples t-test, one-way analysis of variance test and partial least squares structural equation modelling technique are employed to analyse the data. Findings indicate that nurses fear infection and experience stress-related presenteeism and burnout considerably. However, they perceive slightly inadequate level of organisational support. Fear of infection has resulted in stress-related presenteeism and burnout. Stress-related presenteeism has mediated the relationship between fear of infection and burnout. Perceived organisational support has negatively related to fear of infection and its negative consequences. In this research, to our knowledge, for the first time, the burnout, stress-related presenteeism, fear of infection and perceived organisational support levels of nurses are compared according to the pandemic-related criteria. Besides, the mediating role of nurses’ stress-related presenteeism between their fear of contracting COVID-19 and burnout is discovered.

Keywords

Nurses’ fear of COVID-19 infection stress-related presenteeism burnout perceived organisational support structural equation modelling

Introduction

At present, a case of contagious disease spreading like wildfire that humanity is facing is the Coronavirus Disease 2019 (COVID-19). The new member of the coronaviruses family, which caused the COVID-19 disease, was named severe acute respiratory syndrome coronavirus 2 (i.e., SARS-CoV-2) (Venkatapuram, 2020). The COVID-19 was first diagnosed in Wuhan, a city in Hubei province of China, on 8 December 2019 (Muralidar et al., 2020). It was declared a pandemic by the World Health Organisation (WHO, 2020) on 11 March 2020 as the virus spread across the world in a very short time and infected millions of people. The first COVID-19 case in Turkey was officially declared on 11 March 2020, and the first death from COVID-19 occurred on 17 March 2020 (Pala, 2020). As of 7 June 2021, when we completed the data collection, the total number of COVID-19 cases totalled 172,956,039 and the total number of deaths amounted to 3,726,466 globally (WHO, 2021). Of the worldwide cases (5,293,627) and of the worldwide deaths (48,255) occurred in Turkey (Ministry of Health, 2021). During the pandemic, in almost every country including Turkey, many measures were undertaken to control and prevent the spread of the disease. Meanwhile, efforts to develop a vaccine bore fruit in less than a year after the onset of the disease (i.e., the Pfizer/BioNTech vaccine). Subsequently, other vaccines were developed and the development process is still ongoing. However, due to the constant mutations of the virus, the threat has not been eliminated completely yet (Piret & Boivin, 2021). In addition to the measures and vaccine development efforts, many people actively took part in fighting the pandemic. Among them, nurses, along with other healthcare professionals, played a very crucial role in the fight against the pandemic as they were in constant contact with patients and paid close attention to them towards their road to recovery (Aksoy & Kocak, 2020).

Recent studies showed that in addition to its lethality and other negative physiological consequences, due to the obligations, restrictions and measures, as well as the stigmatisation experienced by infected people, the pandemic can also cause various mental, psychological and social problems, such as anxiety, panic, fear, stress, insomnia, desperation, increased use of drugs and/or alcohol, domestic violence against women and children, depression, hopelessness, loneliness and, finally, suicides or suicide attempts (Kumar & Nayar, 2020). Accordingly, physiological and psychological well-being of many nurses was negatively affected due to the pandemic. In the meantime, a sizeable number of nurses contracted the disease, and some of them lost their lives too (Labrague & Santos, 2020; Sun et al., 2020). Therefore, nurses fear contracting COVID-19, especially since they are in constant contact with patients, and so are exposed to the risk of being infected. Likewise, findings of Ness et al. (2021) and Sun et al. (2020) supported this view. What needs to be done at this point should be to discover the consequences of and remedies for nurses’ fear of COVID-19 infection in order to sustain effective healthcare during and immediately after the pandemic.

Stress is one of the notable outcomes of nurses’ fear of contracting COVID-19 (Said & El-Shafei, 2021; Sampaio et al., 2021; Santos & Labrague, 2021; Yildirim et al., 2020). Stress simply refers to continually fluctuating cognitive and behavioural exertions of a person to handle exterior and/or interior requirements, forces, needs and burdens, which are perceived as draining the individual energy and resources. In this sense, stress can be conceived as a negative interaction between an individual and his or her environment where several factors (i.e., stressors) are perceived by the individual as a threat to his or her well-being (Yildirim & Solmaz, 2020). Nurses could experience stress resulting from fear of contracting COVID-19 in the form of stress-related presenteeism, since it was clear from previous research that although nurses experienced stress due to the fear of contracting COVID-19, they continued to work. One of the reasons of this could be nurses’ loyalty and commitment to the values, norms and basic principles of their profession and/or their professional identification (Rainbow & Steege, 2017). Hence, we believed that what nurses experienced can best be explained with their stress-related presenteeism. Stress-related presenteeism occurs when someone goes to work, although he or she experiences high levels of chronic stress and, accordingly, cannot be mentally present and fully engaged, cannot perform well and cannot focus properly on his or her duties (Gilbreath & Karimi, 2012; Rainbow et al., 2019). Another form of presenteeism is usually called only presenteeism or sickness presenteeism. This occurs when an employee goes to work but cannot perform well due to some medical condition (i.e., a sickness), although he or she should be resting at home or be treated at a hospital (Rainbow et al., 2020). Each form of presenteeism results in a loss of resources, energy, productivity and performance (Brunner et al., 2019). In this study, our focus will be on the stress-related presenteeism of nurses.

Another notable consequence of nurses’ fear of contracting COVID-19 is burnout (Hu et al., 2020). Burnout simply refers to an individual’s psychological state of mental fatigue in which he or she depletes his or her resources and energy due to the excessive work demands, such as work overload, fear of contagion, protracted contact with patients, ambiguity, mismanagement and chronic stress (Basar, 2020; Maslach & Leiter, 2016). The most frequently observed symptoms of burnout are emotional exhaustion, cynicism (depersonalisation) and inefficacy (reduced personal accomplishment). These symptoms are also considered as basic responses of an individual to several workplace stressors. Additionally, they constitute the construct of burnout concept (Maslach et al., 2001; Schaufeli et al., 1996).

Although the rationale is very straight that nurses’ fear of contagion can result in burnout, there should be some mediating mechanisms. That is, we have already learnt that nurses’ fear of contracting COVID-19 could result in both stress and burnout. From the definition of burnout and findings of previous research, it is also clear that stress is one of the antecedents of a nurse’s burnout (Basar & Basim, 2016; Yildirim et al., 2021). Hence, we can expect nurses’ stress-related presenteeism to mediate the relationship between their fear of COVID-19 infection and burnout. This process can be explained as follows: nurses fear contracting COVID-19. Therefore, they experience stress. However, they continue to work and care for patients although they are under stress. That is, they actually experience stress-related presenteeism. Consequently, they deplete their physical and psychological resources and burn out. This approach is also compatible with the job demands–resources model, a theoretical model used to explain the burnout process (Demerouti et al., 2001). From these explanations, we can understand how nurses burn out due to the fear of contracting COVID-19. Then, what about the way outs? What can we do to help nurses cope with the fear, stress-related presenteeism and burnout?

Previous research addressed the importance of support that nurses needed (i.e., social support, organisational support, supervisor support, co-worker support and psychological support) when they were taking care of COVID-19 patients, and they were exposed to the risk of infection (Kackin et al., 2021; Labrague & Santos, 2020; Zhang et al., 2020). However, to the best of our knowledge, in neither of them, how perceived organisational support contributed to the alleviation of nurses’ fear of COVID-19 infection, and its negative outcomes, such as stress-related presenteeism and burnout, was investigated empirically in a single research model. In fact, the organisational support provided to nurses can be effective to deal with the fear of contracting COVID-19 and its negative outcomes. Perceived organisational support refers to the extent to which employees (i.e., nurses) perceive that executives in their organisation (i.e., an hospital) value their contributions, services, labour and efforts; consider their well-being; care about their satisfaction at work; take pride in their achievements; appreciate their extra effort; take their complaints into consideration; are aware that they do their job in the best way; are fair and approachable; provide tangible and/or intangible resources (i.e., protective suits, face masks, gloves, participation in decision-making, motivation and empowerment) needed by them,; encourage them; uphold their rights; communicate with them; and show interest to their personal and work-related problems. So, perceived organisational support covers the psychological, social and technical aspects of the support provided by the executives in hospitals to nurses (Labrague & Santos, 2020; Yakut, 2020).

In the light of these evaluations, we aimed to find answers to some research questions listed as follows.

To what extent did nurses burn out, experience stress-related presenteeism, perceive organisational support and fear contracting COVID-19?

Did fear of COVID-19 infection, burnout, stress-related presenteeism and perceived organisational support levels of nurses differ according to the demographics and COVID-19-related factors?

Did nurses’ fear of contracting COVID-19 result in stress-related presenteeism and burnout?

Did nurses’ stress-related presenteeism result in burnout?

Did nurses’ stress-related presenteeism mediate the association between their fear of infection and burnout?

Were nurses’ perceptions of organisational support effective in coping with fear of contracting COVID-19 and its undesired consequences?

Methods

Research Design and Participants

A cross-sectional research design was employed in this study. Participants of this research were 513 nurses from Ankara province of Turkey. Characteristics of participants are presented in Table 1.

Table 1.

Demographics of Participants, Descriptives and Comparison of Variables.

Criterion	Category	N	BO		SRP		FOC		POS
Criterion	Category	N	M	SD	M	SD	M	SD	M	SD
1. Tenure	1–10 years	346	4.62	1.44	3.36	0.96	3.03	1.04	2.19	1.03
	11–20 years	86	4.16	1.65	3.08	1.16	3.05	1.05	2.56	1.19
	21–30 years	66	4.48	1.34	3.27	1.06	3.25	0.84	2.44	1.09
	31–40 years	15	4.26	1.48	3.15	1.09	3.40	0.83	2.79	0.91
	F (df)		2.43 (3, 509)		1.81(3, 509)		1.43(3, 509)		4.28(3, 509)^**
2. Age	20–30	294	4.55	1.43	3.33	0.96	2.93	1.00	2.23	1.03
	31–40	118	4.51	1.63	3.23	1.05	3.27	1.07	2.35	1.15
	41–50	91	4.49	1.39	3.31	1.09	3.21	0.96	2.41	1.11
	51–60	10	3.70	1.65	2.86	1.26	3.47	0.64	3.10	0.67
	F (df)		1.09 (3, 509)		0.91(3, 509)		4.45(3, 509)^**		2.63(3, 509)^*
3. Gender	Male	77	4.09	1.46	3.12	0.95	2.56	1.05	2.34	1.03
	Female	436	4.59	1.46	3.32	1.02	3.16	0.98	2.30	1.08
	t (df)		−2.75 (511)^**		−1.60 (511)		−4.94 (511)^***		0.33 (511)
4. Marital status	Married	258	4.50	1.52	3.30	1.01	3.15	1.01	2.38	1.07
	Single	255	4.53	1.43	3.29	1.02	3.00	1.01	2.23	1.07
	t (df)		−0.20 (511)		0.17 (511)		1.70 (511)		1.58 (511)
5. Education level	High school	64	4.13	1.48	3.12	1.10	2.71	0.94	2.52	0.99
	Associate	52	4.32	1.37	3.21	1.08	2.90	1.04	2.66	0.92
	Bachelor	330	4.68	1.46	3.36	0.99	3.19	1.01	2.22	1.10
	Master	65	4.28	1.49	3.22	0.94	2.96	0.99	2.25	1.05
	Doctorate	2	2.50	1.55	2.08	1.53	2.64	0.30	2.00	0.70
	F (df)		3.69 (4, 508)^**		1.77(4, 508)		4.00(4, 508)^**		2.66(4, 508)^*
6. Infected with COVID-19?	Yes	193	4.82	1.51	3.40	1.00	3.20	1.09	2.16	1.04
	No	320	4.33	1.42	3.23	1.01	2.99	0.96	2.39	1.08
	t (df)		3.67 (511)^***		1.81 (511)		2.20 (365)^*		−2.37 (511)^*
7. Vaccinated?	Yes	358	4.63	1.43	3.31	0.99	3.15	1.01	2.25	1.06
	No	155	4.25	1.55	3.26	1.06	2.88	1.00	2.43	1.09
	t (df)		2.71 (511)^**		0.47 (511)		2.77 (511)^**		−1.80 (511)
8. Believe in cure?	Yes	215	4.12	1.44	3.18	0.99	2.96	0.89	2.52	1.08
	No	298	4.80	1.43	3.38	1.02	3.15	1.09	2.15	1.04
	t (df)		−5.29 (511)^***		−2.17 (511)^*		−2.21 (502)^*		3.91 (511)^***
9. Hospital type	Pu. Gen.	147	4.45	1.32	3.33	0.98	3.04	0.88	2.42	1.09
	Pr. Gen.	83	4.13	1.47	3.18	1.12	2.86	1.04	2.66	1.11
	Pu. Pand.	93	5.84	1.21	3.84	0.70	4.01	0.99	1.54	0.83
	Pr. Pand.	5	4.12	1.04	3.46	0.95	2.65	0.92	2.42	1.07
	Pub. Uni.	71	3.85	1.48	2.91	0.98	2.60	0.79	2.36	1.01
	Pr. Uni.	26	3.69	1.22	2.66	1.02	2.65	0.81	3.14	0.99
	Pu. Res.	88	4.37	1.18	3.25	1.02	2.86	0.83	2.29	0.89
	F (df)		21.51 (6, 506)^***		8.84(6, 506)^***		22.14(6, 506)^***		13.94(6, 506)^***
Total		513	4.51	1.47	3.29	1.01	3.07	1.01	2.30	1.07

Source: The authors.

Note:^*p < 0.05, ^**p < 0.01 and ^***p < 0.001.

BO: Burnout, SRP: Stress-related presenteeism, FOC: Fear of COVID-19 infection, POS: Perceived organisational support, Pu: Public, Pr: Private, Gen: General, Pand: Pandemic, Uni: University and Res: Research.

Data Collection

A digital questionnaire survey was conducted to collect data. The questionnaire form comprised three sections (i.e., instructions, questions related to demographics of participants and items of scales). Instructions appeared on the welcome page of the digital questionnaire form, including information about the scope and purpose of the research and how to fill the questionnaire form. On this page, nurses were assured of confidentiality, and their consent to participate was requested. In the second section, questions related to demographics of the participants were listed. They included tenure, age, gender, marital status, education level, whether infected with COVID-19, whether vaccinated, whether to believe in cure for COVID-19 and hospital type. In the third section, items of each scale (i.e., perceived organisational support, stress-related presenteeism, burnout and fear of COVID-19 infection) were listed. The data were collected by sharing the link of the digital questionnaire form on the social networks of which the nurses were members between 8 May and 7 June 2021. In this way, every volunteering nurse was allowed to take part in the survey without considering any specific eligibility criteria. So, a convenience sampling technique was employed. Information about used scales is as follows.

Perceived Organisational Support Scale

To measure the perceived organisational support of the participants, a scale developed by Eisenberger et al. (1986) and adapted to Turkish by Yakut (2020) was used. The scale was unidimensional and comprised eight items. Each item was evaluated out of 5 points (i.e., 1 = strongly disagree and 5 = strongly agree). A sample item was ‘The hospital I work for values my contributions and efforts’. A Cronbach’s α = 0.96 proved to be an adequate internal consistency. Factor loadings of items varied between 0.78 and 0.94, proving construct validity.

Stress-related Presenteeism Scale

To measure the stress-related presenteeism of participants, a scale developed by Gilbreath and Karimi (2012) was used. The scale was translated into Turkish in line with the method developed by Brislin et al. (1973), following the procedures, such as translation, review, back translation, review of back translation and expert review. A special permission was obtained from the developers of the scale to translate it into Turkish. As a result, initially, the first author translated items of the original scale into Turkish. Second, the second author reviewed the translated items and made some minor revisions. Third, we requested one of the English teachers, who was working in the university of the first author, to back translate the items. Fourth, the first author and the English teacher compared the back-translated items with the original ones and noted no remarkable differences. Fifth, the third author translated the back-translated items into Turkish again. Sixth, we compared the final version with the first version of translation and made some minor revisions. Finally, we requested two professors who were experts in this field to check the availability, compatibility and accuracy of the translated items. Following the minor revisions of professors, we completed the translation process. The scale was unidimensional and comprised six items. Each item was evaluated out of 5 points (i.e., 1 = never and 5 = all the time). A sample item was ‘I’m unable to concentrate on my job because of work-related stress’. The scale proved adequate reliability (Cronbach’s α = 0.92), construct validity (i.e., factor loadings of items varied between 0.76 and 0.84) and criterion validity (i.e., β = 0.50, p < 0.001 between stress-related presenteeism and burnout).

Fear of Coronavirus Disease 2019 Infection Scale

To measure the fear of COVID-19 infection of the participants, a scale developed by Ahorsu et al. (2020) and adapted to Turkish by Satici et al. (2020) was used. The scale was unidimensional and comprised seven items. Each item was evaluated out of 5 points (i.e., 1 = strongly disagree and 5 = strongly agree). A sample item was ‘It makes me uncomfortable to think about COVID-19’. A Cronbach’s α = 0.91 proved adequate internal consistency. Factor loadings of items varied between 0.62 and 0.90, proving construct validity.

Burnout Scale

To measure the burnout of the participants, a scale developed by Malach-Pines (2005) and adapted to Turkish by Tumkaya et al. (2009) was used. The scale was unidimensional and comprised 10 items. Each item was evaluated out of 7 points (i.e., 1 = never and 5 = always). A sample item was ‘I feel depressed’. A Cronbach’s α = 0.95 proved adequate internal consistency. Factor loadings of items varied between 0.66 and 0.88, proving construct validity.

Ethical Considerations

An ethical approval numbered E-65836846-044-209579 was obtained from the ethical committee of the university where the first author works. Information about the purpose and scope of the research was given on the welcome page of the digital questionnaire form, and a commitment was made that the information of the participants would be kept confidential and not shared with third parties. Those who accepted this condition were asked to click the continue button. In this way, individual consent was obtained from the participants, and only those who clicked the continue button and volunteered to participate were allowed to fill out the questionnaire form. All statements/questions were required to be answered in the digital questionnaire form. Otherwise, submission was not allowed. In addition, the scales used in the questionnaire form (i.e., scales of burnout, fear of COVID-19 infection, stress-related presenteeism and perceived organisational support) were open access and in public domain. Therefore, no special permission was required for the use of the scales.

Data Analysis Procedure

Demographics of the participants, mean scores and standard deviations of the variables, and the correlation coefficients between variables were calculated using IBM SPSS Version 24. Independent samples t-test was used to compare mean scores of variables where there were two groups in demographics and COVID-19-related criteria, like gender and whether to be vaccinated. One-way analysis of variance test was used to compare mean scores of variables where there were more than two groups in demographics and COVID-19-related criteria, like hospital type and education level. Relationships between variables were investigated in line with the partial least squares structural equation modelling technique using SmartPLS (v. 3.3.3). By employing this technique, we tried to minimise any potential sources of bias (Ringle et al., 2015).

Results

Demographics, Descriptive Statistics and Comparison of Mean Scores

Demographics of participants, descriptive statistics of variables and comparison of mean scores of variables according to demographics and COVID-19-related criteria are presented in Table 1.

Findings indicated that only the mean score of perceived organisational support differed significantly according to the categories of the first criterion (i.e., tenure). Considering the second criterion (i.e., age), mean scores of fear of COVID-19 infection and perceived organisational support differed significantly according to the categories. In terms of the third criterion (i.e., gender), mean scores of burnout and fear of COVID-19 infection differed significantly according to the categories. The fourth criterion (i.e., marital status) did not result in any significant differentiation in the mean scores of variables. In terms of the fifth and sixth criteria (i.e., education level and whether infected with COVID-19), except from the stress-related presenteeism, mean scores of other variables differed significantly according to the categories. Considering the seventh criterion (i.e., whether vaccinated), mean scores of burnout and fear of COVID-19 infection differed significantly according to the categories. Finally, when the eighth and ninth criteria (i.e., whether to believe in cure and hospital type) were considered, the mean scores of all variables differed significantly according to the categories. Additionally, findings showed that participating nurses feared contracting COVID-19 considerably (M = 3.07, SD = 1.01). They also reported notable levels of burnout (M = 4.51, SD = 1.47) and stress-related presenteeism (M = 3.29, SD = 1.01), as well as slightly inadequate levels of perceived organisational support (M = 2.30, SD = 1.07).

Relationships Between Variables

Correlation coefficients between variables are presented in Table 2.

Table 2.

Correlation Coefficients.

	1. Burnout	2. Stress-related Presenteeism	3. Fear of COVID-19 Infection	4. Perceived Organisational Support
1.	1
2.	0.68^**	1
3.	0.57^**	0.41^**	1
4.	−0.40^**	−0.34^**	−0.19^**	1

Source: The authors.

Note: ^*p < 0.05, ^**p < 0.01, and ^***p < 0.001.

According to the findings, there were significant relationships between each variable. However, although the correlation coefficients contribute to having an idea about the direction and existence of the significant relations between variables, they do not prove whether these relationships are or are not coincidental (Saunders et al., 2009). Therefore, in the following stage, the partial least squares structural equation modelling technique was employed to find out whether the relationships between variables were incidental or dependent (Ringle et al., 2015). The structural equation model is presented in Figure 1.

Figure 1.

Source: The authors.

In Figure 1, each variable is represented with a circle. The values on the arrows between variables (i.e., circles) indicate the standardised β coefficients. The values in parentheses next to the standardised β coefficients indicate the significance level. The values in the circles indicate the variance (adjusted R²) explained by independent variables. The values on the arrows between a variable and its items represent the factor loadings. The values in parentheses next to the factor loadings indicate the significance level.

Findings indicated that fear of COVID-19 infection resulted in burnout (β = 0.35, p < 0.001) and stress-related presenteeism (β = 0.39, p < 0.001). Stress-related presenteeism also resulted in burnout (β = 0.50, p < 0.001), mediating the relationship between fear of contracting COVID-19 and burnout. Additionally, perceived organisational support negatively related to fear of COVID-19 infection (β = −0.21, p < 0.001), burnout (β = −0.15, p < 0.001) and stress-related presenteeism (β = −0.28, p < 0.001). Findings also indicated that the relationships between variables were not coincidental. That is, a significant change in an independent variable resulted in a significant variation in a dependent variable. Likewise, perceived organisational support explained 4% of variance in the fear of COVID-19 infection. Fear of COVID-19 infection and perceived organisational support explained 28% of variance in stress-related presenteeism. Perceived organisational support, fear of COVID-19 infection and stress-related presenteeism explained 65% of variance in burnout, proving that relationships were not coincidental.

Discussion

Findings showed that nurses fairly feared contracting COVID-19. Accordingly, they reported burnout and stress-related presenteeism to a considerable extent but perceived organisational support to a lesser extent. Additionally, the burnout levels of female nurses were higher than that of male nurses; those who had previously contracted COVID-19 had higher burnout levels than those who did not; those who were vaccinated had higher burnout levels than those who were not; those who did not believe in treatment had higher burnout levels than those who believed; those with a bachelor’s degree had the highest level of burnout, while those with a doctorate degree had the lowest; and those working in public pandemic hospitals had the highest levels of burnout, while those working in private university hospitals had the lowest. The stress-related presenteeism levels of nurses who did not believe in treatment were higher than that of those who believed, and those working in public pandemic hospitals had the highest level of stress-related presenteeism, while those working in private university hospitals had the lowest. Fear of COVID-19 infection levels of female nurses was higher than that of male nurses; those who had previously contracted COVID-19 had higher fear levels than those who did not; those who were vaccinated had higher fear levels than those who were not; those who did not believe in treatment had higher fear levels than those who believed; those with a bachelor’s degree had the highest level of fear, while those with a doctorate degree had the lowest; those working in public pandemic hospitals had the highest level of fear, while those working in public university hospitals had the lowest; and those between the ages of 51 and 60 had the highest levels of fear, while those between the ages of 20 and 30 had the lowest levels. The perceived organisational support levels of nurses who were previously infected with COVID-19 were lower than those who did not; those who did not believe in treatment had a lower level of perceived organisational support than those who believed; and those working in public pandemic hospitals had the lowest levels of perceived organisational support, while those working in private university hospitals had the highest levels. As far as we know, for the first time, we compared the burnout, stress-related presenteeism, fear of contracting COVID-19 and perceived organisational support levels of nurses according to whether they had the disease, whether they were vaccinated, whether they believed in the treatment and the type of hospital. This is important because we made inferences from the results of these comparisons regarding nursing practices. Besides, drawing on the results of comparisons, relationships can be established between age of nurses and their fear of catching COVID-19; between gender of nurses and their burnout and fear; between the education level of nurses and their burnout and fear; between whether nurses have been diagnosed with COVID-19 before and their burnout, fear and perceived organisational support; between nurses’ previous vaccination status and their burnout and fear; between nurses’ belief in treatment and their burnout, stress-related presenteeism, fear and perceived support; and between hospital type and nurses’ burnout, stress-related presenteeism, fear and perceived organisational support.

In addition to these findings, to the best of our knowledge, we were the first to discover that nurses’ fear of contracting COVID-19 resulted in stress-related presenteeism, although it was previously uncovered that nurses’ fear of catching COVID-19 resulted in stress (Said & El-Shafei, 2021; Sampaio et al., 2021; Santos & Labrague, 2021; Yildirim et al., 2020). This finding has important implications because stress-related presenteeism is one of the harmful facts and, as previously explained, a distinct concept from stress, causing poor performance, productivity and efficiency in organisations (Brunner et al., 2019). Likewise, for the first time, we discovered that nurses’ stress-related presenteeism resulted in burnout, proving the negative aspect of presenteeism. We believed that by focusing on a novel aspect of stress among nurses, this discovery improved the findings of previous studies that revealed that stress leads to burnout (Yildirim & Solmaz, 2020; Yildirim et al., 2021). We also found that nurses’ fear of COVID-19 infection resulted in burnout. This finding proved the propositions of previous studies, which addressed the fact that nurses’ fear of catching a contagious disease leads to burnout (Hu et al., 2020). Moreover, to the best of our knowledge, we were the first to discover the mediating role of nurses’ stress-related presenteeism between their fear of contracting COVID-19 and burnout. In this way, we contributed to the understanding of how nurses burnt out due to the fear of catching COVID-19. According to this finding, nurses were afraid and stressed because of catching COVID-19, and they continued to go to work despite the chronic and severe stress they experienced. Consequently, their resources were gradually depleted and they burnt out. As a managerial way out, we uncovered that nurses’ perceptions of organisational support (i.e., psychological, social and technical support) were effective in alleviating their fear of COVID-19 infection and its harmful consequences, like stress-related presenteeism, and burnout. By this means, we believed that we contributed to the results of previous studies, such as Labrague and Santos (2020), Zhang et al. (2020) and Kackin et al. (2021) that addressed the importance of support needed by nurses to cope effectively with Covid-19-related issues. Therefore, we think and hope that findings matter and make sense in terms of both practice and theory.

Despite its notable contributions, this research had some limitations as well. The most important limitation of this study was its cross-sectional design, leading to impotency in interpretation of cause and effect relationships. Another limitation could be the use of only the self-reported questionnaire survey technique in the data collection process as it could cause biases among participants. The last limitation could be that the research was conducted only in a certain region (i.e., Ankara, Turkey), weakening the generalisability of the findings. Therefore, we recommend researchers to test the accuracy and generalisability of the findings in the future through longitudinal studies that will be conducted in different cultures and of which data will be collected through semi-structured and/or unstructured interviews in addition to questionnaires. Despite these limitations, the large sample size, the use of valid and reliable measurement tools and the use of the structural equation modelling technique in which all variables were included in the analysis at the same time were the factors that increased the accuracy and value of the findings.

Drawing on the findings, we recommend hospital managers, nursing managers (i.e., head nurses) and all nurses to be aware of the benefits of the support provided through managerial policies and practices in hospitals in terms of coping with COVID-19-related troubles, such as fear of infection, stress-related presenteeism and burnout. Findings proved that organisational support was effective in alleviating nurses’ fear of catching COVID-19 and its negative consequences. Therefore, to help nurses cope efficiently with COVID-19-related negative situations, efforts and contributions of nurses should be valued; nurses should be honoured, appreciated and encouraged through rewards and/or some special privileges; their well-being and satisfaction should be ensured; they should be given a say in every opportunity; they should be treated fairly, sincerely, kindly and professionally; every material, equipment and training should be provided; and finally, a culture of cooperation and solidarity should be established in the hospitals and among colleagues. The efforts directed to provide support should be focused on alleviating nurses’ fear of catching the disease, since it resulted in undesired and costly consequences like stress-related presenteeism and burnout. Meanwhile, findings suggested that in this process, primary psychological, social and technical support should be provided to those aged between 51 and 60 or older; to female nurses; to those with a bachelor’s degree; to those who have previously had the disease; to those at high risk of re- or first-time infection; to those who have been vaccinated; to those who do not believe in treatment; and to those working in pandemic hospitals.

Footnotes

Acknowledgements

We cordially thank every participant for their valuable contributions to this research.

Author Contributions

Study conception and design: Ufuk BASAR, Aysun DOGAN, Bekir ERTUGRUL

Data collection: Aysun DOGAN, Bekir ERTUGRUL

Data analysis and interpretation: Ufuk BASAR

Drafting of the article: Aysun DOGAN

Critical revision of the article: Ufuk BASAR

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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