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burnout, COVID-19, depersonalization, emotional exhaustion, healthcare workers, nurses
This study aimed to systematically synthesize evidence regarding burnout and post-traumatic stress disorder (PTSD) among nurses engaged in the frontline during the COVID-19 pandemic, highlighting their risk and protective factors. The specific literature on nurses’ mental health outcomes still remains not synthesized. A systematic review was performed (PROSPERO: CRD42021227939), searching literature published in 2020 on Pubmed, Scopus, CINAHL, and PsycInfo. We quantitatively pooled means of included studies measuring burnout and PTSD with the same tools. Twenty-five studies were included in this review. Seven (3766 nurses) were included in the meta-analysis for estimating means of depersonalization and emotional exhaustion assessed using the Maslach Burnout Inventory, respectively: 7,40 (95%CI=6,00-8,80) and 22,82 (95%CI=19,24-26,41). Likely, 12 studies were used to estimate two pooled means for PTSD, one for six studies adopting the Impact of Event Scale-Revised (1551 nurses), and six adopting the PTSD Scale for DSM-5 (8547 nurses). The main risk and protective factors of both outcomes were female sex and younger age, work-related variables, and physical and mental factors, such as concerns, skin lesions from wearing personal protective equipment. This systematic review portrayed the situation described in literature during 2020 on nurses’ burnout and PTSD during the COVID-19 pandemic. Although the outcomes’ levels described in the included studies are diverse, the broad situation appears alarming, and supportive multi-level strategies, considering individual and system-level, should be planned to decrease the described worsening scenario within the clinical settings avoid middle and long-term negative consequences.
2. World Health Organization (WHO). WHO Coronavirus Disease (COVID-19) [Internet]. WHO. 2021. Available from: https://covid19.who.int/
3. Task force COVID-19 del Dipartimento Malattie Infettive e Servizio di Informatica & Istituto Superiore di Sanità. Epidemia COVID-19, Aggiornamento nazionale: 13 gennaio 2021. 15 GENNAIO 2021. 2021.
4. Giusti EM, Pedroli E, D’Aniello GE, Stramba Badiale C, Pietrabissa G, Manna C, et al. The Psychological Impact of the COVID-19 Outbreak on Health Professionals: A Cross-Sectional Study. Front Psychol. 2020;11:1684.
5. Khanam A, Dar SA, Wani ZA, Shah NN, Haq I, Kousar S. Healthcare Providers on the Frontline: a Quantitative investigation of the Stress and recent Onset Psychological impact of Delivering Health Care Services During COViD-19 in Kashmir. Indian J Psychol Med. 2020;42(4):359–67.
6. Li X, Li S, Xiang M, Fang Y, Qian K, Xu J, et al. The prevalence and risk factors of PTSD symptoms among medical assistance workers during the COVID-19 pandemic. J Psychosom Res. 2020 Dec;139:110270.
7. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw open. 2020 Mar;3(3):e203976.
8. Shechter A, Diaz F, Moise N, Anstey DE, Ye S, Agarwal S, et al. Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic. Gen Hosp Psychiatry. 2020;66:1–8.
9. World Health Organization (WHO). State of the World’s Nursing 2020: Investing in Education, Jobs and Leadership [Internet]. Geneve; 2020. Available from: https://www.who.int/publications/i/item/9789240003279
10. Turale S, Meechamnan C, Kunaviktikul W. Challenging times: ethics, nursing and the COVID-19 pandemic. Int Nurs Rev. 2020 Jun;67(2):164–7.
11. Fernandez R, Lord H, Halcomb E, Moxham L, Middleton R, Alananzeh I, et al. Implications for COVID-19: A systematic review of nurses’ experiences of working in acute care hospital settings during a respiratory pandemic. Int J Nurs Stud. 2020 Nov;111:103637.
12. Lázaro-Pérez C, Martínez-López JÁ, Gómez-Galán J, López-Meneses E. Anxiety About the Risk of Death of Their Patients in Health Professionals in Spain: Analysis at the Peak of the COVID-19 Pandemic. Int J Environ Res Public Health. 2020 Aug;17(16).
13. Chew NWS, Lee GKH, Tan BYQ, Jing M, Goh Y, Ngiam NJH, et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. Brain Behav Immun. 2020 Apr;
14. Luceño-Moreno L, Talavera-Velasco B, García-Albuerne Y, Martín-García J. Symptoms of Posttraumatic Stress, Anxiety, Depression, Levels of Resilience and Burnout in Spanish Health Personnel during the COVID-19 Pandemic. Int J Environ Res Public Health. 2020 Jul;17(15).
15. Woo T, Ho R, Tang A, Tam W. Global prevalence of burnout symptoms among nurses: A systematic review and meta-analysis. J Psychiatr Res. 2020;123:9–20.
16. Barello S, Falcó-Pegueroles A, Rosa D, Tolotti A, Graffigna G, Bonetti L. The psychosocial impact of flu influenza pandemics on healthcare workers and lessons learnt for the COVID-19 emergency: a rapid review. Vol. 65, International Journal of Public Health. Springer; 2020. p. 1205–16.
17. Kim JS, Choi JS. Factors Influencing Emergency Nurses’ Burnout During an Outbreak of Middle East Respiratory Syndrome Coronavirus in Korea. Asian Nurs Res (Korean Soc Nurs Sci). 2016 Dec;10(4):295–9.
18. American Psychiatric Association. Disturbo da stress post-traumatico. In: Raffaello Cortina Editore, editor. Manuale Diagnostico E Statistico dei Disturbi Mentali (DSM-5). Quinta Edi. Milano; 2014. p. 317–8.
19. Preti E, Di Mattei V, Perego G, Ferrari F, Mazzetti M, Taranto P, et al. The Psychological Impact of Epidemic and Pandemic Outbreaks on Healthcare Workers: Rapid Review of the Evidence. Curr Psychiatry Rep. 2020 Jul;22(8):43.
20. Sanghera J, Pattani N, Hashmi Y, Varley KF, Cheruvu MS, Bradley A, et al. The impact of SARS-CoV-2 on the mental health of healthcare workers in a hospital setting-A Systematic Review. J Occup Health. 2020 Jan;62(1):e12175.
21. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1-34.
22. Wells G, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. Ottawa Hospital Research Institute [Internet]. Ottawa, Canada; 2014 [cited 2021 Feb 5]. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
23. Rostami M, Younesi SJ, Mohammadi Shahboulaghi F, Malakouti SK, Foroughan M. Models of suicide in elderly: A protocol for a systematic review. Vol. 8, BMJ Open. 2018. p. e022087.
24. Nie A, Su X, Zhang S, Guan W, Li J. Psychological impact of COVID-19 outbreak on frontline nurses: A cross-sectional survey study. J Clin Nurs. 2020;29(21–22):4217–26.
25. Gorini A, Fiabane E, Sommaruga M, Barbieri S, Sottotetti F, La Rovere MT, et al. Mental health and risk perception among Italian healthcare workers during the second month of the Covid-19 pandemic. Arch Psychiatr Nurs [Internet]. 2020;34(6):537–44. Available from: https://doi.org/10.1016/j.apnu.2020.10.007
26. Zerbini Giulia, Ebigbo Alanna, Reicherts Philipp, Kunz Miriam, Messman Helmunt. Psychosocial burden of healthcare professionals in timesof COVID-19 – a survey conducted at the UniversityHospital Augsburg. GMS Ger Med Sci. 2020;18(1612–3174):1–9.
27. Barello S, Palamenghi L, Gra G. Burnout and somatic symptoms among frontline healthcare professionals at the peak of the Italian COVID-19 pandemic. Psychiatry Res. 2020;290:113129.
28. Guixia L, Hui Z. A Study on Burnout of Nurses in the Period of COVID-19. Psychol Behav Sci. 2020;9(3):31.
29. Zhang Y, Wang C, Pan W, Zheng J, Gao J, Huang X, et al. Stress, Burnout, and Coping Strategies of Frontline Nurses During the COVID-19 Epidemic in Wuhan and Shanghai, China. Front Psychiatry. 2020;11:565520.
30. Leng M, Wei L, Shi X, Cao G, Wei Y, Xu H, et al. Mental distress and influencing factors in nurses caring for patients with COVID-19. Nurs Crit Care. 2020;1–8.
31. Şahin M, Aker S, Şahin G, Karabekiroğlu A. Prevalence of Depression, Anxiety, Distress and Insomnia and Related Factors in Healthcare Workers During COVID‑19 Pandemic in Turkey. J Community Health. 2020;45:1168–77.
32. Chen R, Sun C, Chen J, Jen H, Kang XL, Kao C, et al. A Large-Scale Survey on Trauma, Burnout, and Posttraumatic Growth among Nurses during the COVID-19 Pandemic. Int J Ment Health Nurs. 2020;
33. Wang YX, Guo HT, Du XW, Song W, Lu C, Hao WN. Factors associated with post-traumatic stress disorder of nurses exposed to corona virus disease 2019 in China. Medicine (Baltimore). 2020;99(26):e20965.
34. Cai Z, Cui Q, Liu Z, Li J, Gong X, Liu J. Nurses endured high risks of psychological problems under the epidemic of COVID-19 in a longitudinal study in Wuhan China. J Psychiatr Res J. 2020;131:132–7.
35. Jo S, Koo B, Seo W, Yun S, Kim H. The psychological impact of the coronavirus disease pandemic on hospital workers in Daegu, South Korea. Compr Psychiatry. 2020;103:152213.
36. Song X, Fu W, Liu X, Luo Z, Wang R, Zhou N. Mental health status of medical sta ff in emergency departments during the Coronavirus disease 2019 epidemic in China. Brain Behav Immun. 2020;88:60–5.
37. Crowe S, Howard AF, Vanderspank-Wright B, Gillis P, McLeod F, Penner C, et al. The effect of COVID-19 pandemic on the mental health of Canadian critical care nurses providing patient care during the early phase pandemic: A mixed method study. Intensive Crit Care Nurs [Internet]. 2020;102999. Available from: https://doi.org/10.1016/j.iccn.2020.102999
38. Haravuori H, Junttila K, Haapa T, Tuisku K, Kujala A, Rosenström T, et al. Personnel well-being in the helsinki university hospital during the COVID-19 pandemic—a prospective cohort study. Int J Environ Res Public Health. 2020;17(21):1–9.
39. Si M, Su X, Jiang Y, Wang W, Gu X, Ma L, et al. The Psychological Impact of COVID-19 on Medical Care Workers in China. SSRN Electron J. 2020;1–13.
40. Sarboozi Hoseinabad T, Kakhki S, Teimori G, Nayyeri S. Burnout and its influencing factors between frontline nurses and nurses from other wards during the outbreak of Coronavirus Disease -COVID-19- in Iran. Investig y Educ en Enferm. 2020;38(2):e03.
41. Nowicki GJ, Ślusarska B, Tucholska K, Naylor K, Chrzan-Rodak A, Niedorys B. The severity of traumatic stress associated with covid-19 pandemic, perception of support, sense of security, and sense of meaning in life among nurses: Research protocol and preliminary results from poland. Vol. 17, International Journal of Environmental Research and Public Health. 2020. p. 1–18.
42. Ruiz-Fernández MD, Ramos-Pichardo JD, Ibáñez-Masero O, Cabrera-Troya J, Carmona-Rega MI, Ortega-Galán ÁM. Compassion fatigue, burnout, compassion satisfaction and perceived stress in healthcare professionals during the COVID-19 health crisis in Spain. J Clin Nurs. 2020;29(21–22):4321–30.
43. Bassi M, Negri L, Delle Fave A, Accardi R. The relationship between post-traumatic stress and positive mental health symptoms among health workers during COVID-19 pandemic in Lombardy, Italy. J Affect Disord [Internet]. 2021;280:1–6. Available from: https://doi.org/10.1016/j.jad.2020.11.065
44. Tan BYQ, Kanneganti A, Lim LJH, Tan M, Xian Y, Mph C, et al. Burnout and Associated Factors Among Health Care Workers in Singapore During the COVID-19 Pandemic. JAMDA. 2020;21:1751–8.
45. Sagherian K, Steege LM, Cobb SJ, Cho H. Insomnia, fatigue and psychosocial well-being during COVID-19 pandemic: A cross-sectional survey of hospital nursing staff in the United States. J Clin Nurs. 2020;1–14.
46. Wang Y, Ma S, Yang C, Cai Z, Hu S, Zhang B, et al. Acute psychological effects of Coronavirus Disease 2019 outbreak among healthcare workers in China: a cross-sectional study. Transl Psychiatry [Internet]. 2020;10:348. Available from: http://dx.doi.org/10.1038/s41398-020-01031-w
47. Li X, Zhou Y, Xu X. Factors associated with the psychological well-being among front-line nurses exposed to COVID-2019 in China: A predictive study. J Nurs Manag. 2020;(August):1–10.
48. Hu D, Kong Y, Li W, Han Q, Zhang X, Zhu LX, et al. Frontline nurses’ burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19 outbreak in Wuhan, China: A large-scale cross-sectional study. EClinicalMedicine. 2020;24:100424.
49. Arrigoni C, Caruso R, Campanella F, Berzolari FG, Miazza D, Pelissero G. Investigating burnout situations, nurses’ stress perception and effect of a post-graduate education program in health care organizations of northern Italy: a multicenter study. G Ital Med Lav Ergon. 2015;37(1):39–45.
50. De Hert S. Burnout in healthcare workers: Prevalence, impact and preventative strategies [Internet]. Vol. 13, Local and Regional Anesthesia. Dove Medical Press Ltd; 2020 [cited 2021 Feb 6]. p. 171–83. Available from: /pmc/articles/PMC7604257/?report=abstract
51. Schaufeli WB, Van Dierendonck D. A cautionary note about the cross-national and clinical validity of cut-off points for the Maslach Burnout Inventory. Psychol Rep [Internet]. 1995 Jun 1 [cited 2021 Feb 6];76(3 Pt 2):1083–90. Available from: http://journals.sagepub.com/doi/10.2466/pr0.1995.76.3c.1083
52. Badolamenti S, Sili A, Caruso R, Fida R. What do we know about emotional labour in nursing? A narrative review. Br J Nurs [Internet]. 2017 [cited 2021 Feb 6];26(1):48–55. Available from: https://pubmed.ncbi.nlm.nih.gov/28079419/
53. Zaghini F, Biagioli V, Caruso R, Badolamenti S, Fida R, Sili A. Violating organizational and social norms in the workplace: a correlational study in the nursing context. Med Lav [Internet]. 2017 [cited 2021 Feb 6];108(2):98–110. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28446736
54. Nania T, Dellafiore F, Caruso R, Barello S. Risk and protective factors for psychological distress among Italian university students during the COVID-19 pandemic: The beneficial role of health engagement. Int J Soc Psychiatry. 2020 Jul 28;002076402094572.
55. Siragatti S, Stefanile C. The Maslach Burnout Inventory: adattamento e taratura per l’Italia. In: Maslach C, Jackson S, editors. MBI Maslach Burnout Inventory Manuale . Florence (Italy): Organizzazioni Speciali ; 1993. p. 33–42.
56. Purvanova RK, Muros JP. Gender differences in burnout: A meta-analysis. Artic J Vocat Behav. 2010;77:168–85.
57. Caruso R, Miazza D, Berzolari FG, Grugnetti AM, Lichosik D, Arrigoni C. Gender differences among cancer nurses’ stress perception and coping: An Italian single centre observational study. G Ital Med Lav Ergon. 2017;39(2):93–9.
58. Yehuda R. Post-Traumatic Stress Disorder. N Engl J Med. 2002 Jan 10;346(2):108–14.
59. Singh A, Agrawal S, Gargya S, Saluja S, Kumar A, Kumar A, et al. Posttraumatic stress disorder after myocardial infarction and coronary artery bypass grafting. Int J Crit Illn Inj Sci [Internet]. 2017 Apr 1 [cited 2021 Feb 6];7(2):84–90. Available from: /pmc/articles/PMC5479081/?report=abstract