key: cord-0891636-at6jlpda
authors: Yang, Bey‐Jing; Yen, Ching‐Wei; Lin, Shou‐Ju; Huang, Chien‐Hua; Wu, Jhong‐Lin; Cheng, Yih‐Ru; Hsieh, Chia‐Chen; Hsiao, Fei‐Hsiu
title: Emergency nurses' burnout levels as the mediator of the relationship between stress and posttraumatic stress disorder symptoms during COVID‐19 pandemic
date: 2022-03-21
journal: J Adv Nurs
DOI: 10.1111/jan.15214
sha: 8738b8a854200400d21d33fa90c3713ccb019d7e
doc_id: 891636
cord_uid: at6jlpda

AIMS: To examine the association of the working stress with posttraumatic stress disorder symptoms (PTSD), and burnout as the mediator for this association among emergency nurses during COVID‐19 pandemic. DESIGN: Longitudinal survey study. METHODS: Online survey was used to collect data during the period from August to November 2020 with a sample of 169 emergency nurses. They were invited to complete the following questionnaires at the 6th and 9th months after COVID‐19 outbreak: Posttraumatic Symptom Scale (PTSS‐10), the emergency nurses' COVID‐19 stress questionnaire and Chinese version of 21‐item Copenhagen Burnout Inventory (CBI). RESULTS: During the 3‐month follow‐up, there were no changes in the number of suspected PTSD cases (6 and above symptoms): 41% at the 6th month and 33.3% at the 9th month. The increases of the personal burnout levels and living apart from families were the main factors associated with the PTSD symptoms. The risk for emergency nurses suffering from PTSD is through stress levels increasing their burnout levels. CONCLUSIONS: Over 30 percent of emergency nurses remained at high risk for suspected PTSD. The burnout levels mediated the relationship between the stress levels and the risks of PTSD. IMPACT: Little as know about the impact of COVID‐19 on emergency nurses' stress. This study found emergency nurses remained to be the high risk for the suspected PTSD cases. It is urged to develop a stress‐reduction program targeting at causes of stress and improving burnout for emergency nurses during COVID‐19 pandemic.

HCWs (Su et al., 2007) . The recent studies have consistently found that the HCWs, in particular, nurses were the high-risk group for suffering from posttraumatic stress disorder (PTSD) during outbreak (Chew et al., 2020; Fattori et al., 2021) . The early identification of the potential PTSD cases can not only prevent HCWs from psychological impairment but also can be easily treated at the early diagnostic stage (Greenberg et al., 2020; Moazzami et al., 2020) . It is therefore important to understand nurses' stress and its relation to their mental health in particular PTSD symptoms during pandemic. Denning et al. (2021) conducted a multinational survey and found that over 60% of HCWs, in particular, nurses and doctors presented with a significant burden of burnout. Their burnout levels were associated with their perceptions of safety in their workplace. Burnout characterized by physical and psychological exhaustion (Yes, 2008) is caused by excessive job demands and limited job recourses (Demerouti et al., 2001) . HCWs during the COVID-19 pandemic commonly experience burden from increasing job demands with limited resources such as insufficient PPE (Cabarkapa et al., 2020) might influence HCWs' perceptions of working environment safety, as a result of their occupational burnout. Chor et al. (2020) found almost 50% of HCWs in the emergency department had moderateto-severe personal burnout levels and the emergency nurses had higher burnout levels than doctors. Stress from being at the frontline in direct contact with suspected or confirmed COVID-19 patients, physical distress from care burden with prolonged wearing PPE, social isolation, poor social supports were related to emergency nurses' vulnerability to high burnout levels. The questions about the changes in burnout levels after COVID-19 outbreak and its correlations with stress levels, PTSD symptoms remain unclear.

Emergency nurses were the high-risk group for suffering from posttraumatic stress disorder (PTSD) at the postepidemic stage (Naushad et al., 2019) . The previous studies using retrospective and cross-sectional designs showed that HCWs had the greatest risk for PTSD symptoms, at 1 month of MERS outbreak (Lee et al., 2018) and 2 months after SARS outbreak (Chan & Huak, 2004) . The recent review study found that the occurrence of PTSD indicated by the posttraumatic stress scale (PTSS) during COVID-19 ranged between 2.1% and 73.4% with the highest occurrence in HCWs working in an emergency unit (d' Ettorre et al., 2021) . The recent studies with a prospective design found that there was a trend of decrease of PTSD symptoms after COVID-19 outbreak during the follow-ups among HCWs (Dufour et al., 2021; Fattori et al., 2021; Sampaio et al., 2021; Van Steenkiste et al., 2021; Zhou et al., 2021) .

Nevertheless, Dufour et al. (2021) noted that about 30% of HCW presented PTSD symptoms at clinical level during the 4th-month follow-up. Steenkiste et al. identified higher PTSD symptoms were found in ICU nurses than non-ICU nurses (2021). The results suggest that nurses who were exposed to direct care for COVID-19 patients were more vulnerable to have PTSD symptoms. Emergency nurses are the frontline workers to screen and care for COVID-19 patients.

However, up to date, there is a lack of research using a prospective longitudinal design to examine the changes in stress levels and their long-term impact on the prevalence of PTSD symptoms among emergency nurses during the COVID-19 pandemic.

In addition to PTSD, the review study also showed that a significant number of emergency nurses suffered a moderate to high level of burnout after they experienced a traumatic event (Naushad et al., 2019) . The recent studies consistently found that there are a significant number of frontline HCWs experiencing at least moderate levels of burnout during the COVID-19 pandemic (Chor et al., 2020; Hu et al., 2020) . Moreover, the emergency nurses had the highest personal burnout levels than doctors during the first 3 months of the COVID-19 outbreak (Chor et al., 2020) . Their burnout levels might be associated with job strain, physical discomfort from wearing PPE (Hu et al., 2020) . Stress from fear of infecting their loved ones and being separated from family due to travel restrictions are also associated with HCWs' burnout levels . There is little known about the relationship between burnout levels and PTSD among emergency nurses in the context of COVID-19. The previous study (Kim et al., 2019) on the firefighter found the association of increased burnout with PTSD symptoms and work-stress-related burnout mediated the relationship between traumatic experience and PTSD. The results suggest that working-related burnout levels characterized by chronic physical and psychological exhaustion likely predict the increased risk of PTSD.

In summary, emergency nurses are at the highest risk of suffering from PTSD and work-related burnout. It remains not clear whether the increased burnout would result in more emergency nurses at the risk of developing PTSD. Our emergency nurses were first exposed to the COVID-19 stress event since the first patient was identified on January 21, 2020, in Taiwan. This study with the prospective design aimed to examine how nurses' working stress is related to their posttraumatic stress disorder symptoms and whether the burnout mediates this relationship.

The study aims were to explore the association of the working stress levels with posttraumatic stress disorder symptoms, and burnout as the mediator for this association among emergency nurses during the COVID-19 pandemic.

This study adopted the prospective design and used an online survey to collect emergency nurses' perceptions of stress levels, burnout levels, and PTSD symptoms at two time points: at the 6th and 9th months after the first COVID-19 patients was diagnosed in January, 21 in Taiwan.

Nurses were recruited to participate in this study if they currently worked at the department of emergency at the general hospital in the north of Taiwan which had 2600 inpatient beds and about 300 patients per day at the department of emergency. Total, 169 emergency nurses working in the hospital at time of first survey were all invited to participate in this study.

Online survey was used to collect data during the period from end of July to November 2020. After this study was approved by the hospital institution review board (No. 202006097RIND), the questionnaire was administered using Google Forms. The survey administration method is via work email communications at the end of July, 2020. In the invitation email, all nurses were explained about the purposes and the procedure of this study and they were provided with a link to the online survey website. Moreover, they were informed that their completion of the survey would be regarded as their consent to participate in this study, and their participants to the survey would get a gift voucher from 7-ELEVEN stores worth 10 US dollars. For each time of survey, they would be asked to complete the survey within 2 weeks after they received the invitation email (7/21-8/5 for the first-time survey; 10/21-11/3 for the second time survey). The total numbers of the emergency nurses in our hospital at the time of study was 169. A total of 163 nurses completed the first survey and 13 of them dropped out at the second survey as a result of dropped out rates of 8%. Online survey might be vulnerable to self-selection bias which might affect the generalizability of the results. However, for this sample, the data with a high response rate (96%) could be considered valid and representable.

Emergency nurses were invited to complete the following questionnaires at the 6th and 9th months after COVID-19 outbreak: the emergency nurses' COVID-19 stress questionnaire, Posttraumatic Symptom Scale (PTSS-10) and Chinese version of 21item Copenhagen Burnout Inventory (CBI). The online questionnaire started with demographic questions (age, gender, education, marital status, religion) and pandemic-related information (experiences of caring for suspected or confirms cases), as shown in Table 1 . Then, participants were asked to rate the perceived overall stress level before and during COVID-19 pandemic and the degree of stress caused by pandemic-related stressor (as shown in Table 2 ). Finally, we as- symptom with 'yes' or 'no'. A score of six and more 'yes' responses is considered as a potential PTSD case (high risk of PTSD). The PTSS-10 has a good internal consistency (α = 0.81) for this study.

A Chinese version of the 21-item Copenhagen Burnout Inventory (CBI) was used to measure emergency nurses' occupational burnout levels and it consists of four subscales to measure physical and psychological exhaustion from different factors of burnout: personal, work-related and client-related, personal, work, work with clients and over-commitment (Yeh et al., 2008) . The Chinese version CBI includes an additional factor of job over-involvement to the original CBT (Kristensen et al., 2005) .

The respondents were asked about how often they feel distress from never, seldom, sometimes, often to always. Their responses are scored at 0, 25, 50, 75 and 100 with high scores indicating high levels of burnout. Internal consistency in the current study was good: 5-item personal burnout = 0.92, 5-item work-related burnout = 0.92, 6-item clientrelated burnout = 0.93, 5-item over-commitment = 0.87.

After this study was approved by our hospital institution review board (No. 202006097RIND), nurses were informed about the purpose and the procedure of this study through the staff meeting and email exchange. To preserve private or confidential information, the name of the participants would be removed and replaced with case numbers. The study dataset was anonymized and uploaded to the independent researcher for management and analysis. Moreover, they were also told that nonparticipation would not influence their benefits and they would not be treated differently. To emphasize this, their managers would not access the data with their identification.

To begin with, descriptive statistics were utilized to characterize the sample and self-report measure scores. Then we used generalized estimating equations analyses with an autoregressive correlation structure using all available observations to depict change over time.

A logistic regression model was used to analyse the correlated binary responses, while a linear regression model was used to analyse the correlated continuous responses. Finally, the mediation models were analysed using the Model 4 of PROCESS macro for SPSS (Hayes, 2017) . The bootstrapping methods (with 5000 bootstrap samples) were used to estimate indirect effects. A significant indirect effect was determined if zero did not fall within the 95% biascorrected confidence intervals (CIs). 

Among the demographic information, two factors of contact history 

Longitudinal mediator models were conducted to determine causalordering assumptions among stress levels, burnout levels and risk of PTSD over time. As shown in Figure 

In this study, most emergency nurses had the experiences of caring for the suspected or confirmed COVID-19 patients in ER. Their perceptions of stress levels at the two-wave survey (at the 6th and 9th months of COVID-19) remain unchanged. In their view, the stress levels were higher than before COVID-19 outbreak and the stress at the first 3 months of COVID-pandemic was endorsed with the high- 

for the relationship between T1 current stress levels and T2 suspected PTSD. Unstandardized path coefficients and SE indicated above. *** p < .001, ** p < .01 follow-ups, the percentage of the suspected PTSD cases (6 and above symptoms) remained unchanged at the 6th month (41%) and

at the 9th month (33.33%). The review study pointed out that nurses were at a high risk for suffering from mental health problems when they worked in the frontline and were contacted with the suspected and confirmed COVID-19 patients (Cabarkapa et al., 2020) . The previous studies with a retrospective design showed that HCWs had the greatest risk for PTSD symptoms with about 20% of HCWs at 1 month later of MERS outbreak (Lee et al., 2018) and 2 months after SARS outbreak (Chan & Huak, 2004) . The recent review study found that the high PTSD rates occurred at the peak period of COVID-19

and among HCWs in the emergency unit (d' Ettorre et al., 2021) .

Similar to the recent study on HCWs (Dufour et al., 2021) , our study suggests that with 3-month prospective observations, high percent (at least 30%) of emergency nurses remained to be the potential risk of PTSD cases after they were exposed to stress from COVID-19 outbreak for 9 months. Therefore, the psychological program needs to target at this high-risk group to prevent them from suffering from PTSD.

Our study showed that while about 30% of emergency nurses remained the PTSD potential cases, there was an increased rate from 58.9% to 66.67% of emergency nurses with blow clinical cut-off levels of PTSD symptoms from the 6th to 9th month of COVID-19, although this change did not achieve a statistically significant difference. This trend of decreased numbers of PTSD symptoms is consistent with other studies on HCWs (Dufour et al., 2021; Fattori et al., 2021; Sampaio et al., 2021; Van Steenkiste et al., 2021; Zhou et al., 2021) . Dufour et al. (2021) identified over 60% of HCWs presenting the scores of the PTSD symptoms under clinical-cut, which suggested a resilient pattern after COVID-19

outbreak. Consistent with the previous prospective study on nurses' psychological adaptation during SARS, our study with the recent studies suggest that HCWs including nurses likely adapted to the crisis from COVID-19 event. In a qualitative study , there were three stages of nurses' psychological changes after the COVID-19 outbreak. These stages demonstrate that nurses' reactions from fear of being infected at the early stage, emotional distress such as anxiety, depression, somatisation, compulsiveness, fear and irritation in the middle stage and finally, the occurrence of psychological adaptation such as a sense of meaningful and valuable mission as a nurse.

Consistent with the recent studies on HCWs (Chor et al., 2020; Hu et al., 2020) , our study also found emergency nurses experienced at least moderate levels of all domains of burnout (personal, clientrelated, work-related and over-commitment) (scored over 50) during the COVID-19 pandemic and no significant changes in burnout levels across the 3-months' follow-ups. The review study showed that emergency nurses suffered a moderate to high level of burnout after they experienced a traumatic event (Naushad et al., 2019) . Exposure to COVID-19 seems to be a traumatic event for emergency nurses and our study suggests that their burnout levels remained for the 9th month after the first COVID patient was identified in Taiwan.

This longitudinal study showed that increasing personal burnout levels and living apart from their families due to COVID-19

were the two main factors associated with PTSD symptoms and suspected PTSD cases over the 3-month follow-up. The review study by d 'Ettorre et al. (2021) also found the association of lack of social support and burnout with PTSD symptoms among HCWs during the current COVID-19 stage. A finding that differs from the previous study identified the lack of expertise in treating COVID-19 patients as the main factor increasing HCWs' mental health outcomes (Rossi et al., 2020; Tian et al., 2020 Consistent with the review study (Cabarkapa et al., 2020) , our study found that common causes of stress such as insufficient PPE did not change over the two-wave period. Moreover, this study also found that patient and family factors such as concealing their TOCC history, not complying with infection control rules, emotional distress remained the main causes of distress levels events for emergency nurses. As noted, when they were continually being on the front lines, stress from their own emotional distress and interpersonal conflicts remained unchanged. To reduce the impact of stress levels on emergency nurses' burnout, the causes of their stress need to be addressed in the stress-reduction intervention. Zhou et al. (2021) and Labrague and Santos (2020) both found that HCWs including nurses' perceptions of effective organizational support was negatively correlated with PTSD symptoms after COVID-19 outbreak. Zhou et al. (2021) found that perceived organizational support reduced PTSD symptoms through the sequential mediating effect of self-efficacy and problem-focused coping. They demonstrated that consistent with social cognitive theory of posttraumatic recovery (Benight & Bandura, 2004) , HCWs perceived effective organization supports including personal protective measures, clear instructions on changes in work routines and a supportive working environment could enhance their sense of in capacity and use of internal coping resources. Based on the findings of our study, to reduce PTSD symptoms, managers of emergency department need to provide the supports to manage the unchanged stress perceived by emergency nurses including insufficient PPE, insufficient rest and interpersonal conflicts.

Online survey might be vulnerable to self-selection bias which might affect the generalizability of the results. However, for this sample, the data with a high response rate (96%) could be considered valid and

representable. Another limitation is that its participants are biased towards the younger female worker. The timing of data collection during pandemic might have an impact on the results of this study. Finally, due to the lack of data about their burnout levels and PTSD symptoms before COVID-19 pandemic, our findings need to be interpreted carefully for not all symptoms being related to the impact of COVID-19.

This 3-month follow-up study found that over 30 percent of emergency nurses remained at high risk for suspected PTSD. The increase in personal burnout levels and living apart from families were the main factors associated with the risk of PTSD. Moreover, perceived stress levels were not directly associated with PTSD but workingrelated burnout mediated the relationship between perceived stress levels and PTSD symptoms/risk of PTSD cases. That is the risk for emergency nurses suffering from PTSD is through stress levels increasing their burnout levels. According to the results, the implication of this study is to develop a stress-reduction program for emergency nurses which targets the causes of COVID-19-related stress, and improves working conditions. The stress-reduction program might reduce the impact of stress levels on burnout characterized by occupationally physical and psychological exhaustion and to further prevent emergency nurses suffering from PTSD. The future intervention study can examine the effects of stress-reduction on burnout levels and PTSD symptoms.

This study was supported by a grant from the National Taiwan University Hospital (No. 109-P12). We express our appreciation to all the emergency nurses who participated in this project and to other emergency workers for their support.

None of the authors have any declared conflicts of interest.

The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15214.

The data that support the findings of this study are available on request from the first or corresponding author.

Chia-Chen Hsieh https://orcid.org/0000-0001-9529-6593

Fei-Hsiu Hsiao https://orcid.org/0000-0003-3295-5373

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