Work related burnout syndrome, information satisfaction, and concern of safety among Greek nurses during the first wave of COVID-19 outbreak

At the end of 2019, humanity along with the scientific community faced a Coronavirus disease 2019 (COVID-19) outbreak, caused by a novel virus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The SARS-CoV-2 causes severe respiratory syndrome leading to life-threatening conditions that might even result in death. The outbreak of the virus began in Wuhan, China, and rapidly spread all around the world, a situation that was a particularly aggravating factor for health systems worldwide.¹ By November 2021, >251 million people worldwide have been detected with COVID-19, and >5,077,907 have died.² More than 15% of patients diagnosed with COVID-19 developed severe complications of the disease, with 5%–10% needing to be admitted in an intensive care unit (ICU) due to the severity of the symptoms and the high mortality risk (3%–7%).^3,4 The pressure for patients’ hospitalization in many health care settings has increased excessively. The high transmission rates, the lack of immunity in the community, the delay in the implementation of the tests, the lack of medical material and technical infrastructure, and people's feelings of uncertainty and stress have led an increased number of individuals to seek health services. The health care systems worldwide faced increased and continuous pressure to deal with the COVID-19 cases, and health professionals, particularly the frontline ones, suffered a great deal of physical and psychological burden.^5,6,7,8 In addition, the lack of adequate personal protection equipment (PPE) and staff shortages, as well as shortages of beds and mechanical ventilators, have resulted in increased stress and depersonalization, with detrimental effects on the physical and psychological state of the nurses and other health professionals.^9,10,11 Recently, several studies have reported severe impacts of the pandemic on the mental health of the health professionals, with increased depression and anxiety rates because of their inexperience in managing COVID-19 patients.^12,13 Extremely high rates of burnout and compassion fatigue have been reported among the health professionals who treat COVID-19 patients, and particularly among those who are at the frontline and work in settings with high admission rates of COVID-19 patients, whose outcome is poor.^14,15

Exploring the health care providers’ professional and emotional exhaustion in various health care settings was an area of research worldwide.¹⁶ Studies on nurses’ burnout and emotional exhaustion were also conducted in several countries.^17,18,19,20 In a systematic review and meta-analysis conducted to examine nurses’ burnout and associated risk factors during the COVID-19 pandemic, findings showed that the overall prevalence of emotional exhaustion was 34.1%, of which depersonalization was 12.6% and of lack of personal accomplishment was 15.2%. It was highlighted that the main risk factors that increased nurses’ burnout were the young age, the decreased social support, the low family and colleagues’ readiness to cope with COVID-19 outbreak, and the increased perceived threat of COVID-19, as well as the high-risk environment involving long working hours, increased workload, and inadequate or insufficient material and human resources.²¹

Studies that have been conducted in Greece during the pandemic era were mainly focused on exploring emotional exhaustion, post-traumatic stress, and associated risk factors among health care professionals.^22,23 Ilias et al.²⁴ studied the impact of the SARS-CoV-2 pandemic on the mental health of health care professionals in 2 referral hospitals in Athens, Greece. The findings showed that most of the frontline Greek health care professionals appeared to be quite resilient to this challenge, while one-third of them suffered from emotional exhaustion and post-traumatic stress disorder.²⁴ Pappa et al.²⁵ examined the levels and associated risk factors of anxiety, depression, traumatic stress, and burnout of frontline staff in Greece during COVID-19 outbreak. The authors concluded that COVID-19 pandemic adversely affects the psychological well-being of health care workers, demonstrating high prevalence rates of depression, anxiety, traumatic stress, and burnout among Greek frontline staff.²⁵ A cross-sectional study that examined the prevalence of burnout syndrome among intensivists during COVID-19 outbreak in 85 countries, including Greece, highlighted the overwhelming impact of COVID-19 pandemic on ICU specialists, with about half the ICU physicians experiencing symptoms of severe burnout and anxiety.¹⁶

Although Greek nurses are among those health professionals who experience high levels of burnout during the COVID-19 pandemic, there is limited research evidence on this area.²¹ Therefore, the need to investigate the work related burnout syndrome among Greek nurses during the COVID-19 outbreak is imperative to fill in the knowledge gap in this area.

The main aim of the present study was to investigate the levels of burnout among Greek nurses during the first wave of COVID-19 pandemic. Furthermore, the researchers aimed to examine the relationship among levels of burnout, satisfaction and concern about information, PPE, and safety for COVID-19.

The present study aimed to investigate the work related burnout syndrome among Greek nurses during the COVID-19 outbreak. Furthermore, the degree of satisfaction and concern regarding information, PPE, and safety for COVID-19 was assessed.

The study results revealed that Greek nurses demonstrate a moderate level of work related burnout during the COVID-19 pandemic. Results from similar studies highlighted that in health crisis situations, the nurses’ adherence to their professional role and responsibility tends to prevail over emotional exhaustion, without, however, diminishing the possibility of future burnout incidences.^27,28,29 Livadiotis et al.,²⁹ who studied the nurses’ psychosocial burden in COVID-19 units in Cyprus, emphasized that during the first wave of the pandemic, nursing staff experienced high levels of work related stress. However, burnout symptoms were not reported, and nurses appeared to be highly attached to their professional role.

Wu et al.³⁰ compared burnout syndrome frequency among physicians and nurses working in the frontline and in usual wards during the pandemic outbreak in Wuhan. Results indicated that the frontline health professionals had a significantly lower frequency of burnout during the COVID-19 crisis than those working in usual wards. The authors further state that frontline health professionals who directly address COVID-19 may have a greater sense of control in their workplace, which is explained as a major effort of engagement as well as an important factor for avoiding burnout.

On the contrary, Hoseinabadi et al.³¹ emphasize that burnout levels appeared to be higher for frontline nurses compared to those who work in usual wards. Nevertheless, the authors state that work related stress significantly influences the burnout levels, while the sense of successfully controlling ongoing and future pandemic outbreaks may be a factor in preventing nurses’ burnout. In addition to that, Manzano and Ayala²⁰ demonstrate that organizational support, such as clear, fluid, and regular communication with the nursing staff, would help increase nurses’ confidence and sense of control and thus prevent work related burnout.

The participants in the present study showed moderate levels of satisfaction with the information received regarding the procedures that should be followed in the case of addressing a possible COVID-19 patient and a low degree of satisfaction with the PPE provided by the hospital. Livadiotis et al.²⁹ highlighted that although nurses’ satisfaction with the provided information was moderate, satisfaction with PPE was high. This discrepancy may be due to the degree of readiness of each hospital or country to provide the necessary PPE and support to health professionals. Furthermore, Mo et al.,³² who investigated the work related stress among Chinese nurses during the pandemic outbreak in Wuhan, emphasized that safe working conditions for nurses and provision of information may contribute significantly toward preserving the mental health of frontline nurses. Similar results are reported by Wu et al.,³⁰ who demonstrated the positive impact of information and training on nurses’ mental health. Finally, Said and Shafei³³ stressed that providing timely and clear information on the ideal means to manage COVID-19 patients and availability of resources help nurses attenuate their personal anxieties and fears.

Regarding the nurses’ levels of anxiety as recorded in the present study, the participants expressed a high degree of fear pertaining to possible transmission to their family and friends and less concern regarding the possibility of personal infection and self-isolation. Similar results were demonstrated in a qualitative study,³⁴ which explored nurses’ experiences of psychological distress during the care of patients with COVID-19. Results of this study revealed that nurses experienced anxiety due to the nature of the disease, death anxiety, and fear of being contaminated and of infecting their families.³⁴ Another relevant study³⁵ examined the frontline nurses’ burnout, anxiety, depression, and levels of fear in addition to their associated factors during the COVID-19 outbreak in Wuhan, China. Findings revealed that nurses experienced a moderate level of burnout and a high level of fear.³⁵ The number of colleagues who died from COVID-19 or related causes, such as fatigue and overwork, appear to have aggravated their fears. These issues are associated with nurses’ fear of infection and death as well as the fear of spreading the virus to their loved ones.

The results of the present study were associated with the marital status of married/living with a partner and also with the higher status of professional position (from Auxiliary Nurse to Nurse Director). More specifically, nurses who were married or living with a partner demonstrated higher levels of concern compared to those who were single or divorced (P = 0.010). Additionally, both the degree of satisfaction and concern appeared to be higher for nurses who were university graduates and/or nurse managers. This is probably due to the fact that the professional positions of high responsibility (managers, supervisors, directors), create a stressful environment of applying highly demanding management interventions, as well as immediate and high-risk decision-making processes. Similar results were presented in the study of Hu et al.,³⁵ in which the levels of burnout, anxiety, depression, and fear were positively correlated with nurses’ professional position. On the contrary, Livadiotis et al.²⁹ assert that frontline nurses experience higher levels of burnout compared to nurse managers, while in the study of Labrague and de los Santos,³⁶ nurses who had part-time job roles experienced higher levels of fear of COVID-19 infection.

Furthermore, the results of the present study indicate that the degree of satisfaction and concern with regard to information is closely associated with burnout syndrome. Increased satisfaction with the information received for COVID-19 was significantly associated with reduced mental exhaustion and burnout, while increased concern about COVID-19 appeared to be significantly associated with increased levels of burnout. The importance of adequate information and training during the COVID-19 outbreak was mentioned in previous studies, which demonstrated that safe working conditions for nurses and provision of information and training may mobilize nurses’ conscientiousness and support their mental health.^30,32 Similar results were reported by Arnetz et al.,³⁷ who demonstrated that organizational interventions such as education and training are important for reducing levels of concern and anxiety and maintaining nurses’ health, safety, and well-being. Specifically, the failure of the Health Care Organization to fulfil the nurses’ educational needs regarding caring for COVID-19 patients was reported as a factor that increased nurses’ stress and anxiety. Further research showed that the type of information provided during the pandemic may affect nurses’ psychology. For instance, receiving negative or neutral information about the pandemic was referred to as a major factor for a higher risk of developing anxiety, insomnia, and related psychological problems.³⁸ Finally, Heath et al.³⁹ summarized that competency training, education, and training focused on resilience, as well as staff feedback sessions, are key interventions for minimizing the risk of psychological distress and burnout for health care professionals working with COVID-19 patients.

Specific limitations can be mentioned in relation to this study. The convenience sample and the underrepresentation of certain subgroups (e.g., males) limit the generalizability of the findings. The web-based survey may have contributed to selection bias. Social desirability bias could have been another limitation. The results should be considered in light of the fact that study participants were comprised of both registered and auxiliary nurses, 2 groups with diverse responsibilities concerning the provision of patient care. Comparisons between frontline and non-frontline nurses could have clarified further the factors contributing to increased risk of burnout. Despite the limitations, the study demonstrated useful insights about the psychological impact of the COVID-19 outbreak on Greek nurses’ mental health and burnout. assessed and tackled in similar situations.

During the first wave of COVID-19 outbreak, Greek nurses experienced a moderate level of burnout, low satisfaction concerning information, PPE, and safety and high levels of concern of possible COVID-19 transmission. Additionally, nurse managers and health professionals in higher professional posts experienced increased levels of stress and anxiety. Targeted organizational interventions such as adequate staffing, provision of appropriate PPE, safety, information, and training are important for supporting health care professionals who work with COVID-19 patients. Early detection of health professionals’ psychological distress and supportive interventions are essential to successfully address the growing health care needs and to prevent adverse psychological effects on frontline nurses during COVID-19 pandemic.