Prevalence and predictors of burnout among nurses during the COVID-19 pandemic: A survey in teaching hospitals 1

Abstract

BACKGROUND:

Occupational burnout is one of the most important consequences of the coronavirus disease pandemic, associated with psychological well-being, quality of care, and intention to leave the nursing profession. This is a major health problem with serious adverse consequences not only for nurses but also for patients and healthcare systems.

OBJECTIVE:

To assess burnout and its associated factors in nurses who worked in teaching hospitals during the COVID-19 pandemic in Iran.

METHODS:

A cross-sectional study was conducted on nurses of two COVID-19 referral hospitals in Tehran, Iran. Data were collected using the sociodemographic form and Maslach burnout inventory-human service survey (MBI-HSS) questionnaire. Data were evaluated using SPSS software version 26.

RESULTS:

A total of 264 participants, 52.7% (n = 139) were males and the mean of them age was 34.41±9.71 years. Almost 50% of nurses experienced burnout, in each dimension. Emotional exhaustion was associated significantly with job retention intention (P = 0.01) and depersonalization was significantly associated with gender (P = 0.02), age (P = 0.01), educational level (P = 0.004), work shifts (P = 0.006), and job retention intention (P = 0.02). In addition, personal accomplishment score was significantly associated with age (P = 0.002), marital status (P = 0.03), educational level (P = 0.03), work shift (P = 0.04) and job retention intention (P = 0.01).

CONCLUSION:

The burnout rate in the COVID-19 era is high among nurses associated with improper care. Psychosocial support is needed to improve mental well-being among health care workers during unpredictable conditions like pandemics.

Keywords

Burnout psychological professional COVID-19 nurses prevalence

1 Introduction

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), was first found in Wuhan, China, in December 2019 and has resulted in a global pandemic since then [1, 2]. This pandemic has been associated with negative psychosocial health consequences and has been assumed as one of the critical social crises worldwide [3].

Social distancing, disease severity, unstable condition of infected individuals, and uncertainty about managing the disease have caused great mental distress, associated with adverse health outcomes in the community [4, 5]. The health care system is actively involved in the COVID-19 pandemic to overcome physical and mental damages [6, 7].

Previous statistics indicate that 1500 frontline healthcare workers (HCWS), especially nurses have succumbed to COVID-19 in 44 countries as of 28 October 2020 [8]. In a meta-analysis study, 25.3% of deaths from COVID-19 among health care workers were nurses [9]. Nurses, have an emerging role in the hospitals during the COVID-19 era, which predisposes them and their families to COVID-19 [5]. Lack of personal protective equipment, long-lasting work shifts, low numbers of staff, and being away from the family are risk factors for burnout among nurses [10].

Recent studies show that nurses at the forefront of COVID-19 pandemic experienced more psychological problems, such as fear, anxiety, and depression, due to the pandemic, which may prompt burnout [11, 12].

Burnout is known as a health hazard among HCWs, which is a syndrome resulting from chronic workplace pressure that has not been successfully managed [13] and high pressure at the workplace [14], it is characterized by physical, mental, and emotional dimensions; and also the reduced professional efficacy [15].

Maslach and Jackson described burnout in three dimensions: emotional exhaustion, depersonalization, and low personal accomplishment (inefficiency). Emotional exhaustion means that the person does not have emotional energy, and this causes a decrease in his/her level of motivation. Depersonalization is related to a person’s social relationships and causes him to treat people like objects. Personal accomplishment refers to the ability and inner feelings of achievement. Personal incompetence (inefficiency) is related to loss of self-confidence and self-belief. In other words, the person feels that he/she has not already achieved any success in his/her life [16].

Due to the nature of the job, health care employees, especially nurses, are prone to burnout. Previous studies have shown that burnout rates are higher amongst nurses than people in other professions [17 –21]. Moreover, level of burnout is likely to grow during the COVID-19 outbreak, where nurses are facing with an enormous workload in providing health services [15 –18]. In Iran, rate of stress and burnout in nurses working in COVID-19 wards has been reported to be higher than other wards [12, 22]. Burnout is important because it is not only related to negative effects on physical and mental health, and loss of interest to a job in employees [6], but can also influence employees’ job performance and reduce attention and decision-making ability of employees in the workplace [23, 24]. So, it can directly and indirectly reduce quality of care [11] and reduce patient satisfaction, increase medical errors, reduce patient safety [25] and even the influence on the mental health of their families and society [23].

Given widespread consequences of job burnout and its impact on turnover intention in HCWs, and especially nurses, it is important to understand and overcome this problem [26]. Because an emerging infectious disease, such as COVID-19, can occur anywhere in the world, health managers need to be aware of occupational burnout [27].

Moreover, when a pandemic occurs, it is important to realize its psychological aspect to provide better emotional, psychological, and social support to healthcare employees and to strike a balance between employees well-being and job commitments [10]. Considering the importance of the first wave of COVID-19 in Iran, healthcare facilities with exhausted nurses are considered a dangerous situation to confront the pandemic. The COVID-19 crisis has further complicated the existing problems within the already overstrained health organizations, thus increasing the effect of burnout. To the best of our knowledge, there are limited studies that emphasized nurses and especially their occupational burnout during the COVID-19 outbreak. Therefore, it is necessary to recognize the factors associated with burnout and also identify the ways to deal with them, and will be critical in planning nurses’ occupational health. In this regard, the current study aimed to assess the level of burnout and its related factors in nurses who worked in university hospitals during the COVID-19 era.

2 Materials and methods

2.1 Study design

This prospective cross-sectional study was conducted on nurses who were occupied in two referral university hospitals in Tehran, Iran, from August to November 2020. Simple random sampling was used for sample selection, and samples were chosen based on Krejcie and Morgan’s Table [28]. Inclusion criteria assumed working experience for at least one year and working in COVID-19 care units during the study period. Nurses who had mental illness based on self-report and nurses who were unwilling to participate in the study were excluded.

2.2 Questionnaire

For collecting data, the researchers referred to COVID-19 care units in different work shifts for three months and randomly distributed tools among nurses and nursing assistants. A designed checklist, including demographics and Maslach burnout inventory-human service survey (MBI-HSS), an internationally known, validated, self-report questionnaire for measuring the frequency and severity of workplace burnout [29], was used for data collection. A valid Persian translation of MBI-HSS, which was designed by Shahhosseini et al. in 2017 [30], was applied in this study.

In this study, a valid Persian version of the MBI was used, which included emotional burnout dimension (9 items), personalization dimension (5 items), and personal achievement dimension (8 items). The Persian version of the questionnaire has been validated in Iran, and its Cronbach’s alpha was between 0.86 and 0.96 [30, 31]. MBI has frequency and intensity ratings. Intensity rating was used because of abundance of the subjects in this study. Considering the classification of burnout into three dimensions of emotional exhaustion, depersonalization, and personal accomplishment based on MBI-HSS [32], we assess the level of emotional exhaustion as high (≥30), medium (18-29), and low (≤17), the level of depersonalization as high (≥12), medium (6–11), and low (≤5), and personal accomplishment as high (≥40), medium (34–39), and low (≤33).

2.3 Statistical analysis

Data were analyzed using SPSS software version 26 (SPSS Inc., Chicago, IL, USA). Quantitative variables are reported as mean±standard deviation, and qualitative variables are reported as frequency (percentage). Independent-samples t-test and One-way analysis of variance (ANOVA) were also used for bivariate and multivariate analysis. P-value less than 0.05 was considered as significant level.

3 Results

3.1 Participant characteristics

Two-hundred and sixty-four nurses were enrolled in this study. There were 139 (52.7%) males, 173 (65.5%) married, and 167 (63.5%) people with a bachelor’s degree. The nurses’ mean (±SD) age was 34.41±9.71 years old. Most of the nurses were under 30 (41.3%) and had≤10 years of experience (56.1%).

3.2 Burnout status

The status of burnout, based on each dimension, is suggested in Fig. 1. As shown, 50.4% (n = 133) of nurses experienced moderate levels of emotional exhaustion and 34.8% (n = 92) experienced high levels of emotional exhaustion. Depersonalization was moderate in 49.6% (n = 131) of nurses and high in 34.1% (n = 90) of nurses. Furthermore, personal accomplishment was moderate in 75 nurses (28.4%) and high in 125 nurses (47.3%).

Fig. 1

The level of burnout in three dimensions in nurses working in a teaching hospital. As seen, more than 50% of nurses had moderate to high levels of burnout in emotional exhaustion, depersonalization and personal accomplishment.

In the assessment of burnout based on the demographics (Table 1), emotional exhaustion score was higher in nurses with job retention intention (P = 0.01). Depersonalization score was significantly higher in males (P = 0.02), nurses aged≤30 (P = 0.01), nurses with associate degree (P = 0.004), nurses with evening work shifts (P = 0.006), and nurses with job retention intention (P = 0.02). In addition, personal accomplishment score was significantly higher in nurses aged≥40 (P = 0.002), married (P = 0.03), those with master degree (P = 0.03), nurses with morning shifts (P = 0.04) and nurses without job retention intention (P = 0.01).

Table 1

The mean±SD score of burnout’s dimensions based on the demographic characteristics of the study population

Variable		Value (%)	Emotional exhaustion	P value	Depersonalization	P value	Personal accomplishment	P value
Gender	Male	139(52.7)	26.07±8.77	0.7	11.00±5.27	0.02*	31.94±9.64	0.1
	Female	125(47.3)	26.48±8.181		9.57±4.75		33.78±8.50
Age (Years)	≤30	109(41.3)	26.90±9.02	0.59	11.24±5.19	0.01**	30.00±8.79	0.002**
	30-40	82(31.1)	25.93±8.63		10.34±4.88		31.10±9.68
	≥40	73(27.7)	25.67±8.61		8.94±4.87		35.94±8.36
Marital status	Married	173(65.5)	26.23±8.34	0.97	9.93±4.89	0.07	33.70±8.77	0.03
	Single	91(34.5)	26.34±9.59		11.08±5.39		31.13±9.64
Educational	Associate degree	44(16.7)	27.56±11.39	0.45	12.18±6.51	0/004**	29.93±10.13	0.03**
level	Bachelor’s degree	167(63.3)	26.21±8.13		10.33±4.75		32.97±8.72
	Master’s degree	53(20.1)	25.33±8.30		8.79±4.24		34.73±9.18
Work experience	≤10	148(56.1)	26.12±8.78	0.89	10.8±4.92	0.06	32.12±9.10	0.16
(Years)	10-20	61(23.1)	26.73±9.05		10.22±5.16		32.67±9.74
	≥20	55(2.8)	26.12±8.58		8.89±5.22		34.42±1.13
Work shift	Morning	67(25.4)	25.38±8.25	0.42	8.80±3.76	0.006**	34.40±8.80	0.04**
	Evening	15(9.7)	29.00±9.94		13.00±6.54		29.53±11.00
	Night	25(9.5)	27.68±8.58		11.72±6.21		29.16±8.16
	Rotation	157(59.5)	26.15±8.91		10.50±5.06		23.03±9.10
Job retention	Yes	36(13.6)	29.66±11.26	0.01*	12.72±6.58	0.02*	29.36±10.94	0.01*
intention	No	228(86.4)	25.72±8.22		9.95±4.70		33.36±8.73

Based on the burnout’s degree (Table 2), nurses with job retention intention had significantly more high-grade emotional exhaustion (P = 0.009). Furthermore, moderate levels of depersonalization were more prevalent in nurses aged≤30 (P = 0.003), and those who had≤10 years of experience (P = 0.000). Moreover, a low degree of personal accomplishment was significantly prevalent in those aged between 30-40 (P = 0.014) and those with evening work shift (P = 0.04).

Table 2

The prevalence of burnout’s dimensions based on the characteristics of the study population

	Emotional Exhaustion				Depersonalization				Personal Accomplishment
	Low	Moderate	High	P value	Low	Moderate	High	P value	Low	Moderate	High	P value
Gender
Male	42(15.8)	69(49.6)	48(24.5)	0.87	18(12.9)	65(46.8)	56(40.3)	0.05	72(51.8)	34(24.5)	33(23.7)	0.23
Female	17(13.6)	64(51.2)	44(35.2)		25(23)	66(5.8)	34(27.2)		53(42.4)	41(32.8)	31(24.8)
Age
≤30 years	13(11.9)	57(52.3)	39(35.8)	0.69	10(9.2)	54(49.5)	45(41.3)	0.003	55(50.5)	32(29.4)	22(20.2)	0.014
30-40 Years	13(15.9)	38(46.3)	31(37.8)		13(15.9)	38(46.3)	31(37.8)		47(57.3)	19(23.2)	16(19.5)
≥40 Years	13(17.8)	38(52.1)	52(30.1)		20(27.4)	39(53.4)	14(19.2)		23(31.5)	24(32.9)	26(35.6)
Marital status
Married	25(14.5)	87(50.3)	61(35.3)	0.97	30(17.3)	87(50.3)	56(32.4)	0.66	76(43.9)	51(29.5)	46(26.6)	0.27
Single	14(15.4)	46(50.5)	31(34.1)		13(14.3)	44(48.4)	34(37.4)		49(53.8)	24(26.4)	18(19.8)
Educational level
Associate	10(22.7)	16(36.4)	18(40.9)	0.18	7(15.9)	17(38.6)	20(45.5)	0.27	27(61.4)	9(20.5)	8(18.2)	0.17
Bachelor’s	20(12)	88(52.7)	59(35.3)		26(15.6)	85(50.9)	56(33.5)		79(27.3)	48(28.7)	40(24)
Master’s	9(17)	29(54.7)	15(28.3)		10(18.9)	29(54.7)	14(26.4)		19(35.8)	18(23)	16(30.2)
Work experience
≤10 Years	21(14.2)	80(54.8)	47(31.8)	0.39	12(8.1)	80(54.1)	56(37.8)	0.000	74(50)	41(27.7)	33(22.3)	0.58
10-20 Years	10(16.4)	24(39.3)	27(44)		14(23)	24(39.3)	23(37.3)		30(49.2)	15(24.6)	16(26.2)
≥20 Years	8(14.5)	29(52.7)	18(32.7)		17(30.9)	27(49.1)	11(23)		21(38.2)	19(34.5)	15(27.3)
Work shift
Morning	8(11.9)	40(59.7)	19(28.4)	0.54	15(22.4)	36(53.7)	16(23.9)	0.05	27(40.3)	20(29.9)	20(29.9)	0.04
Evening	1(6.6)	7(46.7)	7(46.7)		1(6.7)	5(33.3)	9(60)		10(66.7)	3(23)	2(13.3)
Night	3(12)	13(52)	19(36)		5(25)	8(32)	12(23)		19(76)	3(12)	3(12)
Rotation	27(17.2)	73(46.5)	57(36.3)		22(14.1)	82(52.2)	53(38.8)		69(43.9)	49(31.2)	39(24.8)
Job retention intention
Yes	6(16.7)	10(27.8)	20(55.6)	0.009	6(16.7)	13(36.1)	17(47.2)	0.16	23(63.9)	6(16.7)	7(19.4)	0.58
No	33(14.5)	123(53.9)	72(31.6)		37(16.2)	118(51,8)	73(32)		102(44.7)	69(30.3)	57(25)

4 Discussion

This study was performed to assess burnout among nurses and the associated factors during the COVID-19 pandemic in Iran. In the current paper, we have assessed the burnout in nurses who worked in teaching hospitals, places with a massive load of COVID-19 patients. We selected a group of nurses by simple random sampling method, and we used Maslach burnout inventory-human service survey (MBI-HSS) as the assessment tool (one of the best assessment tools for evaluating burnout). We showed that more than half of nurses had a high (moderate to severe) level of burnout. Previous studies on burnout have already demonstrated that the highest prevalence rate of burnout occurs among HCWs, especially nurses in hospital emergencies, which was in line with the results of other studies [33]. Without comparing this situation with the pandemic, it is also believed that health providers deal with hazardous conditions [34]. So, exacerbation of this status would be evident in a pandemic. Indeed, during the COVID-19 crisis, nurses responsible for caring for patients with COVID-19 infection, had long work shifts, more stress, and anxiety [35]. They will experience several degrees of psychological disorders such as mental fatigue, sleep disorder, and burnout [26].

Our study showed that the burnout was moderate in dimensions of emotional exhaustion and depersonalization and was at a high level in personal accomplishment dimension, respectively. In a study conducted in Iran, the level of burnout in HCWs during the COVID-19 pandemic was also reported in dimensions of emotional exhaustion and personal accomplishment at a high level and dimension of depersonalization at a medium level [13]. Also, according to a study among nurses in the United States, the prevalence of burnout in dimension of emotional exhaustion and depersonalization was moderate and personal accomplishment was at a higher level [36].

This study suggested higher levels of personal accomplishment in nurses during COVID-19. This burnout’s dimension is related to loss of efficacy and is described as the reduced production capacity and individual ability, low morale and inability to cope with problems [37]. On the other hand, it was observed that a sense of personal success would be created among nurses when nurses observe the improvement of patients’ conditions [38]. As a result, they are more motivated to seek medical care and are less likely to be influenced by workplace stressors. One reason for the increase in nurses’ sense of efficiency and personal accomplishment, despite challenging conditions in the COVID-19 pandemic, can be attributed to life-giving care [39]. Other reasons include lack of exposure and previous experience in caring for patients with COVID-19, and similar diseases, such as severe acute respiratory syndrome (SARS) or the Middle East respiratory syndrome (MERS). In fact, at the onset of the COVID-19 pandemic, lack of knowledge, instability in treatment, and care of patients would probably have caused the reduced personal accomplishment in the nurses.

For emotional exhaustion, the reason for its high prevalence during the COVID-19 pandemic can be related to frequent and close contact with patients who are frightened due to COVID-19 and its adverse outcome. In fact, negative emotions and feelings of patients and colleagues, can intensify similar emotions in nurses and make them more vulnerable to emotional exhaustion [40]. Also, due to higher occupational demand, heavy workload, job complexity, job stress, and long working hours, occupational stress in healthcare workers has increased, leading to the occurrence or exacerbation of emotional exhaustion.

In the assessment of depersonalization, we found a moderate level of depersonalization, which was consistent with results of other studies [19]. Depersonalization is defined as a misunderstood and distorted perception of oneself, colleagues, and the workplace [41]; thus, it can occur in the nursing profession in response to stressful and challenging daily situations. It was suggested that mental workload and lack of support cause a feeling of apathy and isolation, ultimately leading to depersonalization [42]. In the present study, depersonalization may relate to empathy and adverse feelings resulting from contracting with the COVID-19 pandemic.

In this study, the level of burnout was significantly higher in males, which was in line with findings of the study by Galanis et al. [19]. However, in some studies, there was no difference in dimensions of burnout between men and women [43], in other studies, women were exposed to higher levels of burnout due to greater vulnerability compared to men [44].

In the context of marital status, our study showed that single nurses expressed lower levels of personal accomplishment and higher depersonalization than married nurses. It was observed that marital status is a risk factor for burnout [45]. In a systematic review in 2018, the marital status was significantly correlated with depersonalization, attributed to the positive role of a partner in supporting individuals [46]. In assessing age and working experience, young nurses and those with less than ten years of experience had higher emotional exhaustion. This was consistent with the study of Marchand et al., which demonstrated the highest emotional exhaustion and burnout in individuals aged between 20–35 [47]. It might be due to lack of sufficient experience and fear of error, stressful situations, and feeling of less personal efficiency, less familiarity with how to control infection and protective measures, and less experienced in managing severe events, such as pandemics. Furthermore, our findings demonstrated a significant association between work shifts during the COVID-19 pandemic and a sense of depersonalization and inefficiency. This is in association with the study of Bakhtom et al. which demonstrated high levels of emotional exhaustion in ICU nurses who work in rotational shifts [48]. This issue can justify by not having a consistent work schedule, disrupted sleep cycle, more job stress, and being away from family. Moreover, our findings showed that burnout was more common among nurses who tended to leave service. According to the previous studies, burnout is one of the most important factors influencing tendency to leave job [49]. Work-related burnout is associated with the increased absenteeism, the reduced quality of health care, the increased errors, and the decreased patient safety [50].

The results of this study on health of employees in the current crisis and other various health crises in the future can be useful for planning by managers and policymakers of the health system. Our research had two positive point: first, we assessed burnout in nurses, and not all HCWs, because nurses are majorly in contact with COVID-19 patients, which can impress the burnout level. Second, we assessed the burnout in teaching hospitals, which have more cases of COVID-19, compared to private hospital, or other governmental hospital, and this issue can also affect the burnout level.

There were some limitations in the present study. First, sample size was small, so similar studies with larger sample sizes may provide additional results. Second, the subjects in this study were all from a city, Tehran and conducted in a teaching hospital. For increasing generalization of the results, future research may include nurses as well as other HCWs from other cities in Iran and other public and private hospitals for review and comparison, as well as assessing possible differences between nurses’ burnout due to different hospital structures, such as their culture and organizational climate.

5 Conclusion

Nurses experienced high levels of burnout during the COVID-19 pandemic. Some individual, social, and occupational factors influenced this burnout, including age, work experience, marital status, and work shift. Preventive measures such as social support are necessary to provide security and mental well-being for HCWs during unpredictable conditions like pandemics.

Ethical approval

This study is part of the results of a large research project. The ethics committee of Baqiyatallah University of Medical Sciences has approved the present study (No. IR.BMSU.REC.1399.072).

Informed consent

The contributors were informed that participation in this study is voluntary and they could withdraw at any time. The aims of the study were explained to the participants and they were reassured that the researchers would secure their information.

Conflict of interest

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.

Footnotes

Acknowledgments

The authors are grateful to all nurses who contributed in any way to the completion of this study. They are furthermore thankful for the guidance and advice from the Clinical Research Development Unit of Baqiyatallah Hospital of Medical Sciences, Tehran, Iran.

Funding

This project was fully supported and funded by Baqiyatallah University of Medical Sciences, Tehran, Iran.

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