key: cord-0742163-2ev4ma1g authors: Sullivan, Debra; Sullivan, Virginia; Weatherspoon, Deborah; Frazer, Christine title: Comparison of Nurse Burnout, before and during the COVID-19 Pandemic date: 2021-11-09 journal: Nurs Clin North Am DOI: 10.1016/j.cnur.2021.11.006 sha: 669d1e6e857b8d7a8a5ba7eb2421b96b8cc26151 doc_id: 742163 cord_uid: 2ev4ma1g Pandemics are not new, but our global community allows the spread of disease to occur much more rapidly than ever before. The recent COVID-19 pandemic has placed nurses on the frontlines caring for contagious and acutely ill patients. Nurse burnout is not new either, however these demands have put a strain on nurses and nurse burnout has been reported as being at high levels. This article looks at a history of pandemics and examines the research related to nurse burnout during previous and current pandemics. We conclude with recommendations for evidence-based interventions to decrease factors associated with nurse burnout. The recent COVID-19 (also known as the Coronavirus, SARS-CoV-2) pandemic has presented nurses with extraordinary demands in providing complex care to patients with the disease, as well as taking elaborate measures to prevent the spread of the disease to other patients, their families, and themselves. 1 These unprecedented conditions have required nurses to work longer shifts with more acute patients and limited resources, potentially leading to nurse burnout. 2 Nurse burnout has been a challenge for nurses even before the recent pandemic, but we are now seeing reports of higher levels of burnout. 3 This article looks at a history of pandemics and then examines the research of nurse burnout during previous and current pandemics. We will conclude with recommendations for evidence-based interventions to decrease factors associated with nurse burnout based on our findings. Freudenberger was first to use the term in literature "burnout" in the 1970s who defined burnout as a "state of fatigue or frustration that resulted from professional relationships that failed to produce the expected rewards." 4, 5, 6 However, nurse burnout has become a popular term and has been defined in various ways by many authors. 4 The Maslach Burnout Inventory (MBI) 7 has widespread use as an instrument used to measure burnout. 4 Maslach 8 stated that nurses have inherently stressful jobs that can result in emotional exhaustion, depersonalization, and reduced personal accomplishment. Emotional exhaustion is defined as a "depletion of one's emotional resources and the feeling that one has nothing left to give others." 8 Depersonalization is a stage where a negative attitude towards work associates develops. The third aspect is feeling that your accomplishments do not meet personal expectations. 8 It is, for this reason, the authors of the Zangaro et al 9 systematic review restricted their search of burnout to only articles that used the J o u r n a l P r e -p r o o f MBI to measure burnout in nursing. These articles in the Zangaro eta l 9 systematic review spans from 2000 thru 2019 and are used to investigate burnout before the COVID-19 pandemic. More recent literature is analyzed to report nurse burnout due to the COVID-19 pandemic. A recent study by the authors on nurse burnout during the COVID-19 pandemic is also discussed. Carl Sagan said, "You have to know the past to understand the present," so in the spirit of understanding nurse burnout in the current COVID-19 pandemic, a look to literature dated prior to 2019 related to nurse burnout and pandemics are explored. It is essential to recognize that our population may become more prone to pandemics, as we have become a global community. The risks of spreading pathogens across geographic areas have increased. 10 Other contributing factors associated with the transmission of pathogens are cross-species transmission, climate change, and drug resistance. 10 Nurses are essential in caring for the victims of infectious disease pandemics. Nurses are traditionally vulnerable to burnout, but a pandemic increases the risk of nurse burnout, and they must be protected from burnout. High levels of nurse burnout could lead to a loss in the nursing workforce that is already experiencing an occupational shortage. 1 Pandemics have affected humans throughout histories such as the plague, Cholera, influenza, and coronavirus diseases. 10 The Neolithic Revolution (aka, Agricultural Revolution) brought about a shift in human civilization and the way people lived. 11 A lifestyle change occurred that soon shifted from nomads hunting and gathering to large settlements of agricultural communities. 11 Thereby, creating prime conditions (i.e., closer contact between humans and humans and animals) fostering the growth and dispersion of pandemics. 11 Inadequate sanitation, unsafe water, and infected food supplies intensify the expansion and spread of infectious J o u r n a l P r e -p r o o f Scientific discoveries such as the bacillus responsible for the plague and the culprit (fleas) in transmission by Alexandre Yersin in 1894. 13, 16 Cholera For well over a millennium, Cholera has made its name known. This acute, and at times fatal disease 16 began with the first wave, originating in India in 1817. After that, spread to other parts of the world via feces, contaminated water, or food (i.e., seafood) 13 and continues to present itself, with the seventh wave occurring even until this day .15,16 Caused by Vibrio cholerae, this has caused deaths in over a million people. 16 In 2019, the WHO 19 estimated that 1.3 to 4 million people contact Cholera annually, and up to 143,000 deaths, caused by Cholera, occur worldwide. In the 19 th , 20 th , and early21 st century, the WHO declared several flu pandemics. Beginning with the Russian Flu in 1889 and by most accounts ended in 1890, 13, 15 this influenza virus emerged in St. Petersburg, Russia 13 and spread to large portions around the globe secondary to an increase in world population and transportation networks (i.e., railways, canals, roads). 13, 15, 16 The worldwide fatality rate resulting from the Russian Flu is estimated at 1 million people. 15, 16 During the start of the 20 th century, The Spanish Flu emerged in 1918, and while lasting only a year, it went down in the record books as one of the most severe pandemics in history. [11] [12] [13] Infecting an estimated 500 million people around the globe, mainly between the ages of 1 and 60, it had the highest impact of morbidity (50 million) occurring in the healthy young adult population (age 20-40). 13, 15, 16 The next pandemics, both the Asian Flu (1957) (1958) , which originated in Singapore, 13 and the Hong Kong Flu (1968) (1969) (1970) ) that originated in Hong Kong and involved a new strain of J o u r n a l P r e -p r o o f the influenza type A virus (H2N2 and H3N2, respectively). 13, 15, 16 Finally, the last influenza pandemic now known as the H1N1pdmo9, the Swine Flu (zoonotic, pigs to human, then through humans) likely originated in Mexico. The National Foundation of Infectious Diseases 20 and the Centers for Disease Control (CDC) 21 report Coronaviruses, named for crown-like spikes on their surface, are often circulating among animals (e.g., camels, cats, and bats) and are viruses that can evolve and infect people. Coronaviruses can cause various signs and symptoms in animals and humans. For example, in cows and pigs, the virus can cause diarrhea, however in humans, mild respiratory infections such as a sore throat, cough, or nasal congestion. 20, 21 In the 1960s, human coronaviruses were identified. 20, 21 Although there are hundreds of coronaviruses, currently only seven human coronaviruses (HCoVs) can affect people and can be categorized into two groups. The first group, common human coronaviruses, includes 229E alpha CoV, NL63 alpha CoV, OC43 beta CoV, and HKU1 beta CoV. 21 Namely, these pathogens typically cause mild upper respiratory tract infections, like the common cold or pharyngitis. 22 The second group, known as other human coronaviruses, originated as animal infections that evolved over time and transmitted to humans. 21 These coronavirus pathogens include Middle East Respiratory Syndrome (MERS-CoV), Severe Acute Respiratory Syndrome (SARS-CoV), and lastly, the novel coronavirus, an infectious disease representing a newly identified strain (2019-nCoV, a.k.a. SARS-CoV-2). 21,22 These pathogens also impact people and cause more severe lower respiratory tract infections/illnesses (e.g., pneumonia, acute bronchitis). 22 Lastly, primary symptoms of SARS-CoV-2C are fever, shortness of breath, cough, loss of taste or smell. 23 J o u r n a l P r e -p r o o f To this end, history taught us that plagues, Cholera, influenza, and coronavirus pandemics know no borders, and every continent, country, state, city, and community around the world are susceptible. Moreover, not out of danger. Sadly, history has shown that in time, pandemics repeat themselves. Looking at the lessons learned from past pandemics and taking them forward to positively impact the potential course one of them might have on the world as we know it, is essential to the future of the whole human race. Respiratory infections are especially virulent since the spread of the infectious agents are by droplets and interpersonal contact. 1 Nurses are in close contact with patients afflicted with pandemic diseases and are on the frontlines of the healthcare response, making them vulnerable to stressful environments. 1 Since influenza and coronavirus diseases are the most virulent, putting nurses at the highest risk; the authors will discuss these pandemics and how they affect nurse burnout as reported in the literature. The Zangaro et al . 9 systematic review articles that screened articles from 2000-2019 for nurse burnout as measured by the entire MBI-HSS were further screened for articles related to influenza pandemics. Keywords used were "pandemic," "influenza,"" Spanish Flu,"" Avian Flu,"" Bird Flu," "Hong Kong Flu," and" Swine Flu." This search produced no articles that met this criterion. In an attempt to find related literature, a search was then done on Google Scholar using the exact keywords, and only one peer-reviewed article was found related to nurse burnout. Usher et al. 24 addressed the H1N1 Swine flu, but did not address nurse burnout, only discussing the potential to place greater demands on health services in tropical and rural regions of Australia. 24 J o u r n a l P r e -p r o o f Coronaviruses are positive-sense, single-stranded RNA viruses and can affect humans and many species of animals. 25 Alpha-coronavirus genes are responsible for the common cold, and the beta-coronavirus causes more severe respiratory infections. 25 The beta-coronavirus includes highly pathogenic viruses that cause severe acute respiratory syndrome coronavirus (SAR-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV), and SARS-CoV-2 (also known as COVID-19). 26 The SARS-CoV was considered an epidemic and originated in Guangdong province (China) in 2003, where bats were likely responsible for passing it to humans. 27 It spread to 29 countries with 813 related fatalities. 28 MERS-CoV was reported ten years after SARS-CoV in Saudi Arabia. It is believed that bats and camels spread the virus to humans. 29 MERS-CoV has resulted in 866 deaths in 27 countries. 28 The SARS-CoV-2 pandemic was first reported in December 2019 in Wuhan, China. 30 As of June 2021there have been 3,899,172 deaths reported to WHO. 31 The articles in the Zangaro et al. 9 systematic review, was additionally filtered for coronavirus pandemics SARS-CoV, MERS-CoV, and SARS-CoV-2. Keywords used were "pandemic," "influenza," SARS-CoV," MERS-CoV," "SARS-CoV-19," COVID-19," and "Coronavirus." The authors found no studies that met these criteria. A search was done on Google Scholar using the exact keywords but searched in years 1960-2021. The authors only found one article that was related to nurse burnout during SARS-CoV. Marjanovic et al. 32 was the only article found that related nurse burnout to a coronavirus pandemic prior to 2020. However, only the emotional exhaustion portion of the MBI was used to J o u r n a l P r e -p r o o f test for burnout as it correlates with psychosocial variables. There were 333 nurses who were surveyed during the 2003 SAR-CoV crisis in Canada. The authors found significant positive correlations between emotional exhaustion and measures of anger, avoidance behavior, contact with SARS patients, and time spent in quarantine. Negative correlations were found between emotional exhaustion as compared to vigor, organizational support, and trust in infection control initiatives . 32 The authors conclude that preparedness and efficacy to manage a pandemic crisis should be a priority. Teaching nurses new working strategies to prevent burnout and helping nurses reduce feelings of uncertainty and fear can benefit crisis management. 32 The authors then searched Google Scholar using keywords "nurses," pandemic," burnout," MBI," OBI," COVID-19," and" SARS-CoV-2." Combinations of keywords resulted in many narrative reviews, qualitative studies, commentaries, and study protocols, which were not considered in this report. Studies that reported statistics on burnout in nurses were included in this report. There were 14 studies found that used the MBI or portions of the MBI to report nurse burnout, [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] one used the Spanish Burnout Inventory, 47 one used the Copenhagen Burnout Inventory,50 and 3 utilized the Oldenburg Burnout Inventory (OBI). [49] [50] [51] J o u r n a l P r e -p r o o f In this section, the authors report on their own cross-sectional, online survey study preliminary findings. This study was carried out from April 7, 2020, to January 15, 2021, when COVID-19 first hit the US. Included is data from nurses in 48 states (no data were obtained from nurses in Utah and Alaska) and two other countries. The purpose of this study was to examine the mental health of nurses during the COVID-19 pandemic. It was hypothesized that there would be higher rates of adverse mental health outcomes due to staffing shortages, increased stress due to the fear of contracting COVID-19, and low amounts of support and protection, among other reasons. Participants in this study were administered several standardized measures of 4 aspects of mental health (depression, anxiety, trauma, and burnout) via an online survey. The finding from the burnout measure will be reported on in the following discussion. In the authors study the Oldenburg Burnout Inventory (OBI) 52 was administered to measure nurse burnout, as it is a free public domain instrument. It has been validated as a reliable instrument. [53] [54] In the author's study, the OBI was administered to 1,364 nurses working during the COVID-19 pandemic as part of this online survey. The OBI is a 16-item measure of two dimensions of burnout scored by a 4-point scale ranging from 1 (strongly agree) to 4 (strongly disagree). All scores were reversed (except for reverse scoring items) so that higher scores indicated more burnout. The OBI measures two dimensions of burnout, exhaustion, and disengagement from work. These two dimensions have been found to have a moderate to high correlation with the emotional exhaustion and depersonalization scales of the Maslach Burnout Inventory (r = .716 and r = .550, respectively) (Bellanti) . For this analysis, a cutoff score of greater than, or equal to, 2.25 was used to determine exhaustion on the OBI, and a cutoff score of greater than or equal to 2.1 was used to determine disengagement on the OBI, as recommended by Peterson et al 55 Results from the demographic variables and the full-scale OBI are presented in Table 1 . Significant, negative correlations were found for age, education, and level of contact with COVID-19 patients (frontline workers). A significant, positive correlation was identified between burnout and whether or not the nurse is a current degree-seeking student. Based on Cohen's recommendations for the strength of a correlation, the demographic variable "age" showed a weak, negative correlation (r = -.298). 56 However, while other variables were significant, they were not strong relationships, according to these recommendations. 56 Near the end of the online survey, we asked a series of questions related to possible contributing factors to mental health and burnout, specific to the pandemic. For the full-scale OBI, we found positive, significant correlations for the first question, "Estimate what capacity your hospital is at right now" (capacity), the second question, "Do you feel that there is a shortage of personal protective equipment (PPE) at your hospital?"(PPE), and the fifth question "Are you working overtime due to the COVID-19 pandemic?" (overtime). We found negative, significant correlations for the third question "How staffed do you feel your institution is?" (staffed feel), the fourth question "Do you feel that your institution is adequately staffed?" (staffed adequate), and the eighth question "Do you feel that you are being adequately paid for your work?"(adequate pay). Based on Cohen's recommendations for the strength of a J o u r n a l P r e -p r o o f correlation, questions three (staffed feel), four (staffed adequate), and eight (adequate pay) showed weak, negative correlations (r =-.304, r = -.266, and r = -.280, respectively). 56 We also examined the association between these questions and the exhaustion and disengagement subscales of the OBI (Table 2) . We found significant, positive correlations between questions one (capacity), two (PPE), and five (overtime work) and the exhaustion subscale. Significant, negative correlations between the exhaustion subscale and questions three (staffed feel), four (staffed adequate), and eight (adequate pay) were identified. We found significant, positive correlations between questions two (PPE) and five (overtime work) and the disengagement subscale. Significant, negative correlations between the disengagement subscale and questions three (staffed feel), four (staffed adequate), and eight (adequate pay) were identified. Based on Cohen's recommendations, questions three (staffed feel), four (staffed adequate), and eight (adequate pay) showed weak, negative correlations with the exhaustion subscale (r =-.293, r = -.254, and r = -.251, respectively), and questions three (staffed feel) and eight (adequate pay) showed weak, negative correlations with the disengagement subscale (r =-.265 and r = -.259, respectively). 56 These results are similar to the findings for the full-scale OBI, and we will discuss these findings in terms of overall burnout. Due to the nature of the scoring of this scale, we felt it was beneficial to observe these relationships in terms of these subscales as well. Weak, negative associations were found between the questions three (staffed feel) and four (staffed adequate), and eight (adequate pay). Nurses working during the COVID-19 pandemic who felt that their institution was more staffed experienced less burnout than those J o u r n a l P r e -p r o o f who reported that their institution was understaffed. Likewise, nurses who felt that their institution was adequately staffed were less burned out than those who felt that their institution was not adequately staffed. Lastly, nurses who felt that they were adequately paid for their work during the COVID-19 pandemic were experiencing less burnout, and those who did not feel that they were adequately paid were more burned out. Adequate hospital staffing is an environmental stressor that has been shown to impact burnout in nurses in several other studies. 57 It was expected that a more robust correlation during the COVID-19 pandemic, but these results show that adequate staffing is a problem for nurse burnout during the COVID-19 pandemic. Another study that investigated pay and burnout found that wage was associated with job dissatisfaction and intent to leave, but only had a small effect on burnout. 58 The relationship between pay and burnout in this study is weak, but it suggests that nurses who do not feel they are being adequately paid for the increase in work due to the pandemic are experiencing more burnout. Global pandemics present a unique challenge to nurses who already show high rates of burnout. 59 This topic is of considerable interest at the present time because of the incredible demand that has been placed on nurses during the COVID-19 pandemic. In our literature review, we found that nurses experience high rates of burnout when working under normal circumstances, but even higher rates of burnout are being reported during the COVID-19 pandemic. 2 In a study conducted by the authors of this article, nurses are experiencing high rates of burnout during the COVID-19 pandemic. The two dimensions measured by the OBI, have moderate to high correlations with the emotional exhaustion and depersonalization scales of the MBI (r = 0.716 and r = 0.550, respectively). 52 The MBI is considered the "gold standard" tool for measuring burnout and was used in several studies mentioned in this article, where high rates J o u r n a l P r e -p r o o f of burnout are also reported. [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] In the authors study, it was found that 68.0% of nurses met criteria for the exhaustion dimension, and 88.3% of nurses met criteria for the depersonalization dimension. In the study conducted by the authors of this article, there were some contributing factors to burnout which other studies have supported, such as job stress, 46, 49, 51 inadequate staffing, 36 and inadequate pay for the work performed. 58 However, the findings from the author's study are even higher than has been reported in other studies. When combined with findings from other studies, these results provide evidence that nurses need additional support during global pandemics to decrease burnout and combat its adverse consequences, such as poor quality of patient care, nurse turnover, and negative consequences for the nurse's health. Literature has suggested that healthcare organizations can support their nurses and lower burnout by addressing these factors and creating policies to protect nurses. 36, 38 Healthcare organizations should monitor nurses for risk of burnout. 37, [60] [61] [62] Studies performed during the COVID-19 pandemic and other pandemics have found various ways to support nurses and decrease burnout such as teaching nurses new strategies to protect their well-being. 1,62,63 These strategies include mindfulness training, 62,64,65 self-care techniques, 42 access to psychosocial and psychological support, 42, 44, 50, 51 prioritize rest and breaks, 50 and meditation apps. 64 Preventing burnout and supporting nurses to reduce feelings of uncertainty and fear 34 can benefit crisis management during pandemics. 32, 66 In conclusion, this literature review and the author's research confirmed that nurses are experiencing high levels of burnout during the COVID-19 pandemic and suggest that healthcare organizations need to support nurses by creating policies to protect nurses, monitoring nurses for J o u r n a l P r e -p r o o f signs and symptoms of burnout, and help nurses to implement strategies to protect their wellbeing.  Healthcare organizations should support nurses by implementing interventions to protect their well-being.  Nurses should be monitored for risk of burnout.  Policies should be written to protect nurses from inadequate staffing and prioritizing rest and breaks. 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