key: cord-0954262-biupfwra
authors: Galanis, Petros; Vraka, Irene; Fragkou, Despoina; Bilali, Angeliki; Kaitelidou, Daphne
title: Nurses' burnout and associated risk factors during the COVID‐19 pandemic: A systematic review and meta‐analysis
date: 2021-03-25
journal: J Adv Nurs
DOI: 10.1111/jan.14839
sha: d0887dffa47196b4fcce3dd010285a838b17cd31
doc_id: 954262
cord_uid: biupfwra

AIMS: To examine the nurses' burnout and associated risk factors during the COVID‐19 pandemic. DESIGN: We followed the Cochrane criteria and the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines for this systematic review and meta‐analysis. DATA SOURCES: PubMed, Scopus, ProQuest, Cochrane COVID‐19 registry, CINAHL and pre‐print services (medRχiv and PsyArXiv) were searched from January 1 to November 15, 2020 and we removed duplicates. REVIEW METHODS: We applied a random effect model to estimate pooled effects since the heterogeneity between results was very high. RESULTS: Sixteen studies, including 18,935 nurses met the inclusion criteria. The overall prevalence of emotional exhaustion was 34.1%, of depersonalization was 12.6% and of lack of personal accomplishment was 15.2%. The main risk factors that increased nurses' burnout were the following: younger age, decreased social support, low family and colleagues readiness to cope with COVID‐19 outbreak, increased perceived threat of Covid‐19, longer working time in quarantine areas, working in a high‐risk environment, working in hospitals with inadequate and insufficient material and human resources, increased workload and lower level of specialized training regarding COVID‐19. CONCLUSION: Nurses experience high levels of burnout during the COVID‐19 pandemic, while several sociodemographic, social and occupational factors affect this burnout. IMPACT: We found that burnout among nurses is a crucial issue during the COVID‐19 pandemic. There is an urgent need to prepare nurses to cope better with COVID‐19 pandemic. Identification of risk factors for burnout could be a significant weapon giving nurses and health care systems the ability to response in a better way against the following COVID‐19 waves in the near future.

In December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and related disease (coronavirus disease 2019, COVID-19) emerged from the Wuhan, capital of Hubei province, China . The spread of SARS-CoV-2 infection is much broader than other recent epidemic infections (SARS, MERS) resulting on 58,712,326 cases globally and 1,388,528 deaths by November 24, 2020 (WHO Coronavirus Disease (COVID-19) Dashboard, 2020).

Health care workers (HCWs) represent a high-risk group for SARS-CoV-2 infection since the seroprevalence of SARS-CoV-2 antibodies among HCWs (Galanis et al., 2020) is higher than the general population (Chen et al., 2020b) worldwide (8.7% vs. 5.3%).

A meta-analysis with data until 8 May 2020 found that 25.3% of deaths from COVID-19 among HCWs were nurses (259 of 1024), while mental health nurses were the highest risk group for deaths (Bandyopadhyay et al., 2020) . According to the International Council of Nurses, 1500 nurses have died from COVID-19 in 44 countries up to 28 October 2020 (International Council of Nurses, 2020) . In the USA, as of 16 September 2020, 31.9% (143 of 448) of the hospital HCWs who have died were nurses, while 12.4% (213 of 1718) of the HCWs who have died were nurses (National Nurses United, 2020). It is extremely likely that these numbers are probably an underestimation of the true number of deaths.

Several systematic reviews and meta-analyses have already shown that nurses present moderate to high levels of burnout syndromes (Adriaenssens et al., 2015; De la Fuente-Solana et al., 2019; Gómez-Urquiza et al., 2016; López-López et al., 2019; Owuor et al., 2020; Pradas-Hernández et al., 2018; Woo et al., 2020) . The prevalence of burnout syndromes is different between geographical regions and specialties. In particular, Central Asia and Europe had the lowest burnout symptoms prevalence, while the Sub-Saharan Africa region had the highest (Owuor et al., 2020; Woo et al., 2020) . Also, paediatric, oncology and emergency nurses had the highest burnout symptoms prevalence (Gómez-Urquiza et al., 2016 Parola et al., 2017; Pradas-Hernández et al., 2018) . Burnout among nurses is a serious and frequent health issue carrying serious negative implications not only for nurses but also for patients, colleagues and health care organizations.

Nurses play an instrumental role in the health systems response to COVID-19 pandemic since they are the frontline health care workers directly involved in the treatment and care of patients (Hu et al., 2020; Liu et al., 2020; Zhan et al., 2020) . Nurses are under extreme and persistent psychological pressure since they are particularly exposed to the threat of SARS-CoV-2 infection, and they become overwhelmed by fear for the safety of their own health, their close family members, and their patients (Joo & Liu, 2021) . Under these circumstances nurses experience severe psychological and mental problems that could lead to burnout, and then to lower productivity, errors in clinical settings, and lack of concern in handling patients (Al Maqbali et al., 2021; Pappa et al., 2020; Salari et al., 2020) . Since the second wave of COVID-19 is hitting worldwide, health care facilities with exhausted nurses are the worst scenario to confront the pandemic. To our knowledge, there is no systematic review to emphasize in nurses and especially in burnout during the COVID-19 pandemic. Also, given the exponential increase of studies on this research area a comprehensive review to examine the nurses' burnout during the COVID-19 pandemic is needed.

We aimed to examine the nurses' burnout and associated risk factors during the COVID-19 pandemic.

We followed the Cochrane criteria and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for this systematic review and meta-analysis (Higgins et al., 2019; Moher et al., 2009 ).

PubMed, Scopus, ProQuest, Cochrane COVID-19 registry, CINAHL and pre-print services (medRχiv and PsyArXiv) were searched from January 1, 2020 to November 15, 2020 and we removed duplicates.

We used the following strategy: ((nurs* OR "nursing staff" OR "health personnel" OR "healthcare workers" OR "healthcare personnel" OR "health care personnel" OR "health care workers") AND (COVID-19 OR SARS-COV-2)) AND (burnout). Also, we searched the full reference lists of all selected articles.

We initially screened title and abstract of the records and then fulltext. Two independent authors performed study selection and disagreements were resolved by a third, senior author. We applied the following inclusion criteria: studies that were published in English, studies examining nurses' burnout and associated risk factors during the COVID-19 pandemic; studies that used standardized and valid instruments to measure burnout; studies that included all types of nurses working in hospitals that treat COVID-19 patients. We excluded studies reporting results in total for HCWs and not separately for nurses. Also, we excluded case reports, qualitative studies, reviews, protocols, editorials and letters to the Editor and studies that did not measure nurses' burnout.

We assessed the quality of studies included using the Joanna Briggs Institute critical appraisal tools (Santos et al., 2018) . This tool consisted of 9 items for prevalence studies, 8 items for cross-sectional studies and 11 items for cohort studies. One reviewer extracted the data and assessed the quality for all studies and a second reviewer checked this information for validity and completeness.

We used structured forms to extract data from each study, such as authors, location, gender, age, sample size, study design, sampling method, assessment tool, response rate, data collection time, publication (journal or pre-print service), number of nurses with burnout, scores on burnout scales, factors associated with burnout and the level of analysis (univariate or multivariable).

For each study, we extracted the sample size and the number of nurses that experienced burnout according to scores on burnout scales. Then, we calculated the prevalence of burnout and the 95% confidence interval (CI) for each included study. Prevalence from each study was transformed with the Freeman-Tukey Double Arcsine method before pooling (Barendregt et al., 2013) . We used the Hedges Q statistic and I 2 statistics to assess between-studies heterogeneity. A p-value <0.1 for the Hedges Q statistic indicates statistically significant heterogeneity, while I 2 values higher than 75% indicates high heterogeneity (Higgins, 2003) . We applied a random effect model to estimate pooled effects since the heterogeneity between results was very high (Higgins, 2003) . A priori, we considered sample size, publication type (journal or pre-print service), and the continent that studies were conducted as sources of heterogeneity.

Due to the limited variability of these variables and the limited number of studies, we decided to perform meta-regression analysis only with sample size as the independent variable. We performed a leaveone-out sensitivity analysis to determine the influence of each study on the overall effect. We used a funnel plot and the Egger's test to assess the publication bias with a p-value <0.05 indicating publication bias (Egger et al., 1997) . We did not a perform meta-analysis for the risk factors associated with nurses' burnout since the data were very limited and highly heterogeneous. Statistical analysis was performed with OpenMeta[Analyst] (Wallace et al., 2009 ).

Flowchart of the literature search is presented in Figure 1 according to PRISMA guidelines. Initially, we identified 439 potential records through electronic databases and 270 were left after removing duplicates. After the screening of the titles and abstracts, we removed 212 records and we added four more records found by the reference lists scanning. Finally, we included 16 studies (Aydin Sayilan et al., 2020; Buselli et al., 2020; Chen et al., 2020a; Chor et al., 2020; Cortina-Rodríguez & Afanador, 2020; Ferry et al., 2020; Hoseinabadi et al., 2020; Hu et al., 2020; Jalili et al., 2020; Khasne et al., 2020; Manzano García & Ayala Calvo, 2020; Matsuo et al., 2020; Prasad et al., 2020; Ruiz-Fernández et al., 2020; Tan et al., 2020; Zhang et al., 2020) in this systematic review that met our inclusion criteria and among them six studies in the meta-analysis included the appropriate data.

Main characteristics of the 16 studies included in our systematic review are shown in Table 1 . Study population included only nurses in six studies (Aydin Sayilan et al., 2020; Chen et al., 2020a; Hoseinabadi et al., 2020; Hu et al., 2020; Manzano García & Ayala Calvo, 2020; Zhang et al., 2020) , while ten studies (Buselli et al., 2020; Chor et al., 2020; Cortina-Rodríguez & Afanador, 2020; Ferry et al., 2020; Jalili et al., 2020; Khasne et al., 2020; Matsuo et al., 2020; Prasad et al., 2020; Ruiz-Fernández et al., 2020; Tan et al., 2020) included HCWs in general. A total of 18,935 nurses were included in this systematic review, while two studies (Matsuo et al., 2020; Prasad et al., 2020) did not report the number of nurses. All studies were crosssectional, while 13 studies (Buselli et al., 2020; Chen et al., 2020a; Chor et al., 2020; Hoseinabadi et al., 2020; Hoseinabadi et al., 2020; Hu et al., 2020; Jalili et al., 2020; Khasne et al., 2020; Manzano García & Ayala Calvo, 2020; Matsuo et al., 2020; Prasad et al., 2020; Ruiz-Fernández et al., 2020; Tan et al., 2020; Zhang et al., 2020 ) used a convenience sampling method, two studies (Cortina-Rodríguez & Afanador, 2020; Ferry et al., 2020) used a snowball sampling method, and one study used a random sampling method (Aydin Sayilan et al., 2020) . Ten studies (Aydin Sayilan et al., 2020; Chen et al., 2020a; Chor et al., 2020; Hoseinabadi et al., 2020; Hu et al., 2020; Jalili et al., 2020; Khasne et al., 2020; Matsuo et al., 2020; Tan et al., 2020; Zhang et al., 2020) were conducted in Asia (China, India, Japan, Turkey, Singapore, Taiwan and Iran), four studies (Buselli et al., 2020; Ferry et al., 2020; García & Calvo, 2020; Ruiz-Fernández et al., 2020) in Europe (United Kingdom, Spain and Italy) and two studies (Cortina-Rodríguez & Afanador, 2020; Prasad et al., 2020) in North America (USA and Puerto Rico). Thirteen studies (Aydin Sayilan et al., 2020; Buselli et al., 2020; Chen et al., 2020a; Chor et al., 2020; Hoseinabadi et al., 2020; Hu et al., 2020; Khasne et al., 2020; Manzano García & Ayala Calvo, 2020; Matsuo et al., 2020; Prasad et al., 2020; Ruiz-Fernández et al., 2020; Tan et al., 2020; Zhang et al., 2020) were published in journals and three studies (Cortina-Rodríguez & Afanador, 2020; Ferry et al., 2020; Jalili et al., 2020) in pre-print services. Limited data were available regarding response rate, gender and age. (Hoseinabadi et al., 2020; Tan et al., 2020) used the Oldenburg Burnout Inventory (OLBI), one study (Prasad et al., 2020) used the Mini-Z and one study (García & Calvo, 2020) used the Spanish Burnout Inventory.

Quality assessment of cross-sectional studies in this review is shown in Table S1 . The most frequent biases were that the studies did not F I G U R E 1 Flowchart of the literature search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. take into account confounding factors and did not apply multivariable methods to eliminate them. Other frequent biases were that the study subjects and the settings were not described in detail and the criteria for inclusion in the sample were not clearly defined.

Data regarding burnout scales were highly heterogeneous. Regarding the most frequent tool to measure burnout (MBI), the prevalence of nurses' burnout in three subscales (emotional exhaustion, depersonalization and personal accomplishment) was measured in six studies Table 2 .

The overall prevalence of emotional exhaustion among nurses according to the MBI was 34.1% (95% CI: 22.5-46.6%) ( Figure 2 ). The prevalence of emotional exhaustion ranged from 5.6% to 69.6% with a very high heterogeneity between results (I 2 =98.9%, p-value for the Hedges Q statistic <0.001). According to meta-regression analysis, the prevalence was independent of the sample size (p = 0.39).

A leave-one-out sensitivity analysis showed that removal of studies had an influential effect on the pooled prevalence, which varied between 29.3% (95% CI: 17.9-42.2%), with Cortina-Rodríguez and

Afanador (2020) Figure S1 ). The asymmetrical shape of the funnel plot ( Figure S2 ) and p-value <0.05 for Egger's test implied potential publication bias.

Regarding nurses' depersonalization according to the MBI, the pooled prevalence was 12.6% (95% CI: 6.9-19.7%) (Figure 3 ), while the sample size did not affect it (p = 0.57 (2020) excluded ( Figure S3 ). The funnel plot ( Figure S4 ) and Egger's test (p-value <0.05) indicated potential publication bias. Figure S5 ). The asymmetrical shape of the funnel plot ( Figure S6 ) and p-value<0.05 for Egger's test implied potential publication bias. increased nurses' burnout.

Several social factors increased nurses' burnout such as decreased social support (García & Calvo, 2020) , having a relative/ friend diagnosed with COVID-19 (Aydin Sayilan et al., 2020), low family and colleagues readiness to cope with the COVID-19 outbreak (Hu et al., 2020) , increased perceived threat of Covid-19 (García & Calvo, 2020) , and longer working time in quarantine areas .

Occupational factors affected nurses' burnout during the COVID-19 pandemic to a large extent. Nurses that work in a high-risk environment e.g. a COVID-19 designated hospital, a COVID-19 unit or a critical care unit (Aydin Sayilan et al., 2020; Chen et al., 2020a) had higher level of burnout as well as nurses that work in hospitals with inadequate and insufficient material and human resources (García & Calvo, 2020) . Also, nurses with lower levels of specialized training regarding COVID-19, job experience and self-confidence in caring for COVID-19 patients experienced burnout more frequently (Hu et al., 2020; Zhang et al., 2020) 

We conducted a comprehensive systematic review to investigate the prevalence of nurses' burnout during the COVID-19 pandemic and to identify associated risk factors. Also, we performed a metaanalysis examining the prevalence of three aspects of nurses' burnout according to the MBI; emotional exhaustion, depersonalization and lack of personal accomplishment.

We found a significant prevalence of nurses' burnout during the COVID-19 pandemic according to the MBI. In particular, 34.1%, 15.2% and 12.6% of nurses experienced high levels of emotional exhaustion, low personal accomplishment and depersonalization respectively. These levels of burnout are higher by far even among nurses working in a highly stressful environment such as palliative care; the prevalence of emotional exhaustion, low personal accomplishment and depersonalization is 19.5%, 9.3%, 8.2% respectively (Parola et al., 2017) . Another meta-analysis (Woo et al., 2020) (Joshi & Sharma, 2020) .

Also, higher job demands, workload, job complexity, job pressure and working time during the COVID-19 pandemic increases workrelated stress among nurses leading to emotional exhaustion. On the other hand, nurses during the COVID-19 pandemic experienced depersonalization and low personal accomplishment but not in higher levels than nurses working in a stressful environment such as mental health nurses, nurses in primary health care services, nurses in gynecology and obstetrics services, paediatric nurses and emergency nurses. This may be explained because of empathy and feelings that nurses have developed toward COVID-19 patients during a frightening situation that impacts all individuals' lives such as a pandemic.

A pandemic may trigger compassionate behaviours among nurses connecting them with patients in a deeper level. Also, the effective treatment and care of COVID-19 patients improve nurses' moral feeling competent and successful in their duty.

Apart from burnout, HCWs experience several other negative psychological outcomes during the COVID-19 pandemic like depression, anxiety, post-traumatic stress disorder, psychological distress, sleep disturbances, insomnia and fear Galli et al., 2020; Kisely et al., 2020; Luo et al., 2020; Pan et al., 2020; Pappa et al., 2020; Raudenská et al., 2020; Salari et al., 2020; Salazar de Pablo et al., 2020; Sanghera et al., 2020; Serrano-Ripoll et al., 2020; Shaukat et al., 2020; Stuijfzand et al., 2020) . The situation is even worse for nurses since it is well-known that they struggle with burnout symptoms and other psychological issues more often than other HCWs resulting in negative consequences for themselves, their patients, their family members, their colleagues and the health care organizations (Pappa et al., 2020; Parola et al., 2017) .

Nurses who are exposed and in contact with verified or suspected COVID-19 patients are more often distressed, nervous and frightened (Rana et al., 2020) . Moreover, nurses have extra concerns in the COVID-19 pandemic like the shortage of personal protective equipment, and the fear of being exposed at work, spreading the SARS-CoV-2, and taking the virus home to their close family members (Kisely et al., 2020) . Thus, nurses are facing a continuous stress that may trigger post-traumatic stress, suicide ideation and suicide (Okechukwu et al., 2020) . Also, this stress leads to burnout which will negatively affect the quality of health care that nurses provide to patients (Rupert & Morgan, 2005) .

We found that several sociodemographic, social and occupational factors increase nurses' burnout during COVID-19 burnout.

Gender is a controversial issue since our review showed that females have higher levels of emotional exhaustion, but males have higher level of depersonalization and lack of personal accomplishment.

Also, three studies (Aydin Sayilan et al., 2020; García & Calvo, 2020; Zhang et al., 2020) did not find relation between gender and nurses'

burnout increasing the uncertainty about this relation. After exposure to stressful events, females were more likely to be traumatized than males (De Stefano et al., 2018; Jones et al., 2020; Olff et al., 2007) . In contrast, a meta-analysis (Cañadas-De la Fuente et al.,

2018) with 57 studies found that being male is related to a higher level of burnout among nurses. Moderator variables (age, job satisfaction, position, clinical experience, etc.) should be taken into consideration to infer more valid results regarding the role of gender on nurses' burnout. Younger nurses are more likely to exhibit burnout during the COVID-19 pandemic than older nurses and this might be related to the fact that younger are less familiar with infection control and protective measures and less experienced in handling extreme events such as a pandemic (Tam et al., 2004) . Probably, younger nurses are more vulnerable when facing difficult situations such as patients suffer and die from COVID-19 especially in cases

where HCWs cannot offer the standard health care due to sources limitations.

According to our review, decreased social support is related to increased nurses' burnout during the COVID-19 pandemic.

Psychological support that HCWs received during and after a pandemic can significantly influence their feelings and emotions handling in a better way during the negative effects of such a devastating event (Balicer et al., 2006; Kahn et al., 2016) . Also, we found that longer working time in quarantine increases nurses' burnout.

This result is confirmed by studies with nurses that work in quarantine areas during epidemics where loneliness has been recognized as a significant stressor (Hall et al., 2003; Kim, 2018) . Loneliness is magnified in cases that nurses have to separate from their families and stay at designated hospitals as has happened in Wuhan, China . Especially family and social support is an essential weapon for nurses to confront the psychological distress that have during epidemic outbreaks . A systematic review found that lack of social support is a crucial risk factor for the development of psychological problems in HCWs during disasters (Naushad et al., 2019) . Support from families, friends, colleagues and health care organizations gives nurses the opportunity to control effectively and avoid negative feelings and emotions decreasing the danger of burnout syndrome. In particular, several studies show that a strong social support network during the COVID-19 pandemic can decrease feelings of isolation and strength resilience among HCWs (Hou et al., 2020; Southwick & Southwick, 2020; Wu et al., 2020) .

Moreover, we found that nurses having a relative/friend diagnosed with COVID-19 experience a higher level of burnout. The COVID-19 pandemic and public health response to it ultimately had changed work and life conditions such as other epidemic outbreaks e.g. SARS. In that case, nurses worry more about the health of their close family members/friends/colleagues than their own (Maunder et al., 2003; Tam et al., 2004) . Nurses try to avoid close contact in purpose, to reduce the spread of SARS-CoV-2 to their family members/friends/colleagues. Thus, nurses' home and social life are significantly disrupted resulting in fear, anxiety and psychological distress. Also, caring for relatives/friends/colleagues as patients is emotionally difficult and exhausted. Especially in the case that nurses take care of their colleagues suffer from the fear of their own personal vulnerability (Maunder et al., 2003; Tam et al., 2004) .

We found that nurses working in a high-risk clinical environment (a COVID-19 designated hospital, a COVID-19 unit, hospitals with inadequate and insufficient material and human resources, low working safety while caring for COVID-19 patients, etc.) have a higher level of burnout. This finding is confirmed by previous research during the SARS outbreak (Lee et al., 2007) . SARS epidemic (Liu et al., 2012) underline nurses' concern about inadequate training and expertise in handling challenging health care

issues. There is a need for nurses to obtain new knowledge and skills about COVID-19 to built their confidence in providing health care under this extreme situation. Well-trained nurses could improve their self-efficacy that is necessary to confront disasters such a pandemic (Kılıç & Şimşek, 2019) .

It is worth noting that protective factors regarding nurses' burnout were found in some studies such as belief in readiness to cope with COVID-19 outbreak, willingness to participate in frontline work, prior training and experience in COVID-19 patients' management, protection safety during the clinical work, and increased social support (García & Calvo, 2020; Hu et al., 2020) . Since burnout is a multifactorial issue researchers should emphasize the importance of protective factors revealing at least the most important of them.

Another issue that should be addressed is that some variables found not be significantly associated with burnout in multivariable 

There were some limitations in this systematic review and metaanalysis. There were different sources of bias. First, only three studies of 16 eliminated confounding through multivariable methods.

Usually, control of confounding decreases the value of measures of effect (e.g. odds ratio) and the number of independent variables that are related to the dependent variable (e.g. nurses' burnout). Probably this is the case in our review also but the real effect of confounding on nurses' burnout is impossible to determine. Since nine studies included health care professionals in general and not only nurses, the study subjects and the settings were not described in detail in many studies included in our review. Thus, due to the limited data and the limited number of studies, subgroup analysis and meta-regression analysis using nurses' characteristics (e.g. gender, age, response rate, etc.) as the independent variables cannot be performed. Another frequent bias was that the criteria for inclusion in the study sample were not clearly defined. In that case, we cannot be certain about the direction of effects on nurses' burnout since we cannot understand the study participants in a clear way. Finally, in some cases, the exposure was not measured in a valid and reliable way and a misclassification bias is possible.

Also, only one study used a random sample, nine studies had a small sample size (≤300 nurses), and three studies collected data from China. Thus representativeness may be a potential limitation and studies with large random samples worldwide should be conducted.

Data regarding risk factors for nurses' burnout during the COVID-19 pandemic were available only in five studies and among them, three used multivariable methods to eliminate confounders.

Also, several risk factors (social support, relatives diagnosed with COVID-19, insufficient resources and longer working time in quarantine areas) were examined only in one study and further research is needed to infer valid results.

Moreover, we searched five major databases and pre-print services as well as the full reference lists of all selected articles but there is still the probability to not identify some studies e.g. in grey literature. Also, we did not use MeSH terms in our search strategy and papers may be omitted. The heterogeneity between results was very high and we applied random effects model to handle this issue. Additionally, we included studies that used standardized and valid instruments to measure burnout but these data are still selfreported and inherently subjective. Moreover, only cross-sectional studies with convenience or snowball sampling method were identified making definite causal relationships impossible.

Nurses experience high levels of burnout during the COVID-19 pandemic, while several sociodemographic, social and occupational factors affect this burnout. The COVID-19 pandemic is a significant challenge for nurses worldwide and learning lessons from the first wave is imperative to prepare better strategies for the subsequent waves. Several measures could be introduced to mitigate the mental health impact of the COVID-19 pandemic on nurses, e.g. screening for mental health illness and early supportive interventions for high-risk nurses, immediate access to mental health care services, designated rest periods, social support through hospital support groups to reduce feelings of isolation, sufficient personal protective equipment for all nurses to provide security etc. As the second wave of the COVID-19 pandemic is hitting worldwide and there are predictions for the following waves in the near future, there is a need to decrease nurses' burnout and improve their mental health. Governments, health care organizations, and policymakers should act in this direction to prepare health care systems, individuals and nurses for a better response against the COVID-19 pandemic.

None.

P.G., I.V. and D.K. were responsible for the conception and design of the study. P.G., I.V., D.F. and A.B. were responsible for the acquisition, analysis and interpretation of the data. All the authors drafted the article or revised it critically for important intellectual content, and provided final approval of the version to be submitted.

The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.14839.

https://orcid.org/0000-0002-1308-5782

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Mental health of medical workers in Pakistan during the pandemic COVID-19 outbreak

Occupational burnout syndrome and post-traumatic stress among healthcare professionals during the novel coronavirus disease 2019 (COVID-19) pandemic. Best Practice & Research

Compassion fatigue, burnout, compassion satisfaction and perceived stress in healthcare professionals during the COVID-19 health crisis in Spain

Work setting and burnout among professional psychologists

The prevalence of sleep disturbances among physicians and nurses facing the COVID-19 patients: A systematic review and meta-analysis

Impact of coronavirus syndromes on physical and mental health of health care workers: Systematic review and meta-analysis

The impact of SARS-CoV-2 on the mental health of healthcare workers in a hospital setting: A systematic review

Impact of viral epidemic outbreaks on mental health of healthcare workers: A rapid systematic review and metaanalysis

Physical and mental health impacts of COVID-19 on healthcare workers: A scoping review

The loss of social connectedness as a major contributor to physician burnout: Applying organizational and teamwork principles for prevention and recovery

Psychological impact of an epidemic/pandemic on the mental health of healthcare professionals: A rapid review

Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: Stress and psychological impact among frontline healthcare workers

Burnout and associated factors among health care workers in Singapore during the COVID-19 pandemic

Systematic review on the relationship between the nursing shortage and job satisfaction, stress and burnout levels among nurses in oncology/haematology settings

Meta-Analyst: Software for meta-analysis of binary, continuous and diagnostic data

The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope

Global prevalence of burnout symptoms among nurses: A systematic review and meta-analysis

Mitigating the psychological effects of COVID-19 on health care workers

The current situation and influencing factors of job stress among frontline nurses assisting in Wuhan in fighting COVID-19

Stress, burnout, and coping strategies of frontline nurses during the COVID-19 epidemic in Wuhan and

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