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. 2023 Apr 11;69:103643. doi: 10.1016/j.nepr.2023.103643

COVID-19 pandemic increases the occurrence of nursing burnout syndrome: an interrupted time-series analysis of preliminary data from 38 countries

Meng-Wei Ge a, Fei-Hong Hu a, Yi-Jie Jia a, Wen Tang a, Wan-Qing Zhang a, Dan-Yan Zhao a, Wang-Qin Shen a, Hong-Lin Chen b,⁎
PMCID: PMC10088401  PMID: 37060733

Abstract

Aim

To evaluate the trends in nursing burnout rates before and during the coronavirus 2019 restrictions.

Method

Meta-analysis was used to extract the data on global nursing burnout from 1 Jan. 2010–15 Dec. 2022. An interrupted time-series analysis using segmented ordinary least squares (OLS) regression models was used to explore if the nursing burnout were affected by the epidemic. Newey-West standard error was used to adjust for autocorrelation and heteroskedasticity.

Results

Before the epidemic (April 2020), the nursing burnout rate rose with 0.0007497 (95% CI: 0.0000316, 0.0014677, t = 2.07, P = 0.041) per month. The trend of nursing burnout rate has increased by 0.0231042 (95 CI%:0.0086818, 0.0375266, t = 3.18, P = 0.002). The increasing trend of nursing burnout rate after the COVID-19 restrictions is 0.0007497 + 0.0231042 = 0.0238539 per month.

Conclusion

The study indicated that the Covid-19 restrictions had an impact on nursing burnout, increasing the occurrence of nursing burnout syndrome.

Keywords: Burnout, Nurse, An interrupted time series analysis, COVID-19

1. Introduction

The COVID-19 restrictions have led to a social and economic crisis and caused much disruption, with long-term impacts on healthcare systems and disrupted delivery of routine healthcare services (Frenk J et al., 2022). After the restrictions, healthcare workers feel more stressful than general population, because they must always face specific challenges and stressors (Chirico et al., 2020). A recent study has shown that nurses suffer more psychological stress from the aftermath of the COVID-19 restrictions, reporting higher depressive symptoms, exhaustion, stress and lower job satisfaction (Lai et al., 2020). Too much psychological stress like exhaustion and low job satisfaction may cause burnout syndrome (Maslach et al., 2018).

Burnout syndrome is a work-related disease defined by the WHO (WHO, 2019), which is a common psychological problem faced by nurses and would have severe negative impacts on their work. For example, Ph. D. Sullivan once summarized that burnout could cause poor overall mental health of nurses, such as chronic stress, anxiety and depression. And these traumas can cause damage to the body through inflammation and metabolic syndrome, leading to more serious diseases such as high blood pressure, cardiovascular disease, stroke and diabetes. Meanwhile, the accumulation of chronic stress may directly affect job satisfaction, patient care and nurse retention (V. Sullivan et al., 2022). Shah MK et al. once found that 31.5% nurses in America wanted to leave their jobs because of burnout (Shah et al., 2021). Before the restrictions, many studies have shown that many nurses suffered from burnout syndrome due to the particularity of hospital work, nurses easily suffer from psychological problems in the environment of high pressure, irregular working hours, shifts and overnight work (Gualano et al., 2021, Woo et al., 2020). During the restrictions, most evidence suggested that nurses were significantly more affected than other professions in the health field. Nurses were demonstrated to have a higher risk of suffering from burnout and be under considerable mental strain, especially those on the frontlines (Badahdah et al., 2021, Pappa et al., 2020). Nurses caring for patients infected with COVID-19 were found deeply troubled by burnout, showing insomnia, depression, somatization, symptoms, anxiety and Post-Traumatic Stress Disorder (Busch et al., 2021, Lavoie-Tremblay et al., 2022). Such psychological trauma even led to the suicide of some medical staff. 1500 nurses from 44 countries have died during the COVID-19 restrictions up to 28 Oct. 2020, according to the International Council of Nurses (Galanis et al., 2021).

In recent years, many articles have studied nursing burnout. Before 2019, Woo et al. found that the global nursing burnout syndrome was 11.23%, which indicated a high burnout rate (Woo et al., 2020). During the restrictions, a study found that more than 40% of nurses in Japan experienced burnout (Matsuo T et al., 2020). Women were about 50% more likely to report burnout syndrome than men (Harry et al., 2022). The European Cancer Society has conducted two online surveys and found that the burnout rate of 1520 cancer workers from 101 countries surveyed from 16 April to 3 May, 2020 was 38%, while in the follow-up survey from 16 July to 6 August 2020, it was found that the burnout rate of respondents had reached 49% (Burki, 2020). Ph. D. Sullivan reviewed the history of the restrictions and conducted a comparative study of symptoms of burnout in nurses before and during the epidemic. Nursing burnout was a severe problem, exacerbated by the COVID-19 restrictions (D. Sullivan et al., 2022). However, most studies only described the severe influence of the restrictions on nursing burnout syndrome and the changing trend of nursing burnout before and during the restrictions has not been studied.

In our study, we aimed to evaluate the trends in nursing burnout rates before and during the COVID-19 restrictions using an interrupted time-series analysis.

2. Methods

2.1. Study design

This study evaluated the impact of ‘the COVID-19 restrictions’ on the nursing burnout rates around the world using an interrupted time-series analysis before and during the restrictions. The meta-analysis was used to obtain the rates of nursing burnout syndrome around the world from 1 Jan. 2010–15 Dec. 2022.

2.2. Definition of the nursing burnout rates

Maslach Burnout Inventory (MBI) was a frequent scale to measure burnout syndrome, which consists of three dimensions: depersonalization (DP), low personal accomplishment (PA) and emotional exhaustion (EE) (Maslach et al., 2018). In the DP (5 items), a score of 12 or more is considered high DP; a score of 6–11 is considered medium and below 6 is considered low. In the PA (8 items), a score of 33 or less indicates low PA, a score of 34–39 indicates moderate PA and a score of 40 or above indicates high PA. In EE (9 items), a score of 30 or more is considered high EE; 18–29 is considered medium and under 18 is considered low. The level of burnout syndrome is high when two or three dimensions are considered severe. The resulting data were the prevalence of nursing burnout syndrome, calculated as follows:

Rates=number of burnout syndrometotal number*100%

2.3. Data on burnout rates extracted through meta-analysis

Studies published in any language using PubMed, Web of Science (WOS), bioRvix, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and medRVix were searched from1 Jan. 2010–15 Dec. 2022. Search keywords included “nurs* ”, “burnout” and “prevalence”. Specific search strategies were shown in Supplementary materials.

The type of sample in our study was nurse population, including nurses in any department and nursing assistants etc. Inclusion criteria: (a) sample inclusion time indicated in studies and the time is 2010 and later (preferably month, otherwise year); (b) When the samples mentioned in the studies were included in 2020 or April 2020 or later, the studies must mention the nursing burnout affected by the COVID-19 restrictions. Even if the sample inclusion time is mentioned, those who did not mention the COVID-19 restrictions will not be included; (d)outcome data included the rates of nursing burnout syndrome; (e) studies published in English. Exclusion criteria: (a) data error or missing in the studies; (c) duplicated literature; (e) conference abstracts without full articles and (f) reviews. The Newcastle-Ottawa Scale (NOS) scale was applied to assess the quality of the included studies, which contains three parts: selected population (4 scores), comparability of groups (2 scores) and exposure determination (3 scores). Studies with a score of 7–9 are of high quality; 4–6 are of moderate quality; 0–3 are of low quality.

The sample size and rates of nursing burnout of the included studies were imported into Stata 11.0 for calculations. The rates of the same year or month were combined using the method of literature review and meta-analysis and the forest plots were drawn. The Cochrane I-squared test was used to evaluate the heterogeneity. When I² is greater than 75%, the heterogeneity is giant; when between 50% and 90%, it is larger; when between 40%− 60%. it is moderate; when I² is less than 40%, it is low (Higgins J, 2022). The random effect model will be selected if the heterogeneity is high (I²>40%) (Page et al., 2021).

2.4. Data management

Because the meta-analysis was used to get data, not all monthly data can meet our requirements. Annual rates were combined from 1 Jan. 2010–15 Dec. 2022 to get annual nursing burnout rates and the combined annual rate averaged 12 months. They were then combined with other collected months with the same monthly data to obtain monthly nursing burnout rates. If there was no data in some months, the average value of annual data was directly selected. However, one of the drawbacks of processing data this way is that it can result in the same rate for several months.

2.5. Statistical analysis

An interrupted time series analysis using segmented ordinary least squares (OLS) regression models was used to research if the Covid019 restrictions had an impact on the rates and the trends of nursing burnout syndrome in the world. The COVID-19 restrictions were the ‘intervention’ of interest in this study. Newey-West standard errors with a lag of order one were used to adjust for autocorrelation and heteroskedasticity (A, 2015).

Yt = β0 + β1*Tt + β2*Xt + *Pt + St

The above formula was used in our study. Yt represents the nursing burnout syndrome monthly rate at time t; β0 is the baseline level; β1 represents the monthly nursing burnout rate slope before the COVID-19 restrictions; Tt refers to the time since the beginning of the study in months; β2 represents the changes in the rate in the month of the restrictions; Xt is a virtual (indicator) variable representing COVID-19 (the period before the restrictions is 0; otherwise it is 1); Pt is a continuous variable used to calculate the number of months. St represents the variable 0 that controls seasonality. Stata software 17.0 was used to analyze results.

3. Results

3.1. Study characteristics

Ninety studies with 113,438 nurses from 38 countries were included from 1 Jan. 2010–15 Dec. 2022 (Supplementary material references). The specific selection process is shown in Fig. 1. In these studies, only 28 reported sample inclusion time as the month and others reported years. Almost half of the studies stated the age of the nurses. Nearly a third of the studies did not report the gender of the nurses. Half of the studies reported whether the nurses had partners. Among different specialties, 15 were from the Intensive Care Unit (ICU); 20 studies were from Multiple specialties. 76.7% of studies used MBI to measure the nursing burnout syndrome ( Table 1).

Fig. 1.

Fig. 1

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Flow diagram of the trial selection for the meta-analysis.

Table 1.

Baseline description of included studies.

First author, year Country Time period COVID (before/ during) Age (Year) Gender (F/M) Partner (Yes/No) Specialty Burnout tool Sample size Number of burnout Nursing Burnout Rate 95% CI Quality score
Mavrovounis G, 2022 Greece 2021 during NR NR NR NR MBI-HSS 140 97 0.69 (0.61–0.77) 7
Dos Santos MA, 2022 Brazil Jun.-Aug. 2020 during 36.4 508/ 64 NR NR MBI 572 99 0.17 (0.14–0.20) 6
Noh EY, 2022 South Korea 2021 during 27.6 143/ 18 12/ 149 NR CBI 161 90 0.56 (0.48–0.64) 6
Kamali M, 2022 Iran 2020 during NR NR NR NR MBI 4409 904 0.12 (0.11–0.13) 8
Zakaria N, 2022 Malaysia Aug.-Nov. 2019 before 36.9 NR 2023/ 395 NR MBI 2418 590 0.24 (0.23–0.26) 8
Thumm EB, 2022 US 2017 before 47.6 NR NR Obstetrics MBI 2333 933 0.40 (0.38–0.42) 8
Khan Y, 2022 Belgium 2020 during 39.7 3823/ 729 NR Multiple specialties MBI 4552 3205 0.70 (0.69–0.71) 7
Feleke DG, 2022 Ethiopia 2020 during 20–49 206/ 162 157/ 211 Multiple specialties MBI-HSS 368 207 0.56 (0.51–0.61) 7
Tan KH, 2022 Singapore 2019–2020 before NR NR NR NR MBI-HSS 3032 1072 0.45 (0.43–0.47) 6
Membrive-Jimenez MJ, 2022 Spain 2021 during NR 50/ 36 71/ 15 Multiple specialties MBI 86 29 0.34 (0.24–0.44) 7
Azoulay E, 2021 France Oct. 30- Dec. 1, 2020 during NR NR NR ICU MBI 412 194 0.47 (0.42–0.52) 7
Zhou LL, 2021 China Sept.-Oct, 2020 during 20–55 1133/ 0 604/ 529 NR MBI 1133 682 0.60 (0.57–0.63) 7
Li YX, 2021 China Dec. 2020-May 2021 during NR 2831/ 137 2273/ 695 Multiple specialties MBI 2968 2095 0.71 (0.69–0.72) 8
Ferry AV, 2021 UK Jun. 2020 during NR NR NR NR CBI 286 245 0.86 (0.82–0.90) 6
Butera S, 2021 Belgium Apr. 2020 during NR NR NR ICU MBI 1149 770 0.67 (0.64–0.70) 7
Kakemam E, 2021 Iran Sept.-Nov. 2020 during NR 746/ 258 688/ 316 NR MBI 1004 316 0.31 (0.29–034) 8
Nishimura Y, 2021 Japan 2020 during NR NR NR Multiple specialties MBI 21 5 0.24 (0.09–0.39) 7
Zhang XN, 2021 China 2020 during 28 141/ 39 123/ 57 Multiple specialties MBI-GS 180 27 0.15 (0.10–0.20) 7
Alves MCEC, 2021 Brazil Mar.-Apr. 2018 before 39.0 92/ 30 79/ 43 ICU MBI 122 23 0.19 (0.12–0.27) 7
Nicholls M, 2021 New Zealand 9 Mar.− 3 Apr. 2020 before NR NR NR ED CBI 711 489 0.69 (0.65–0.72) 7
Moller G, 2021 Brazil Oct. 2018-Mar. 2019 before 37.3 53/ 9 33/ 29 ICU MBI 62 3 0.05 (0.01–0.14) 8
Aragao NSC, 2021 Brazil Jul.-Nov. 2016 before 33.9 59/ 6 36/ 27 ICU MBI 56 30 0.54 (0.40–0.67) 8
Rubin B, 2021 Canada 27 Nov. 2018–31 Jan. 2019 before NR 206/ 31 NR Multiple specialties WBI 242 188 0.78 (0.72–0.83) 8
Magalhaes AMM, 2021 Brazil Aug.-Sept. 2020 before NR NR NR Multiple specialties MBI 161 28 0.17 (0.12–0.24) 7
Slusarz R, 2021 Poland Jan.2019-Feb. 2020 before NR 196/ 10 145/ 61 Surgery Self-report questionnaire 206 66 0.32 (0.26–0.39) 8
Dyrbye LN, 2021 US Dec. 2016 before 51.6 894/ 82 713/ 263 Multiple specialties MBI 976 350 0.36 (0.33–0.39) 8
Butera S, 2021 Belgium Jan. 2020 before NR NR NR ICU MBI 283 145 0.51 (0.45–0.57) 7
Kumar A, 2021 India Dec. 2019 before NR 104/ 21 42/ 83 ICU Questionnaire 125 47 0.38 (0.29–0.47) 8
Simonetti M, 2021 Chile 2017–2018 before 31.6 1204/ 191 NR Multiple specialties MBI 1395 484 0.35 (0.33–0.38) 8
Abraham CM, 2021 UK 2018–2019 before 49.5 358/ 38 315/ 81 Multiple specialties MBI 396 100 0.25 (0.21–0.29) 8
Friganovic A, 2021 Croatia 2017 before 19–62 544/ 76 316/ 304 ICU MBI 620 72 0.12 (0.09–0.15) 8
De la Fuente-Solana EI, 2021 Spain 2019–2020 before NR 73/ 22 59/ 36 Pediatric care MBI-HSS 95 36 0.38 (0.28–0.48) 7
Paiva BSR, 2021 Brazil 2017–2018 before 26–46 297/ 26 184/ 120 Oncology MBI-HSS 305 4 0.01 (0.00–0.02) 8
Zakaria MI, 2021 Malaysia 2020 before NR NR NR ED MBI 142 31 0.22 (0.15–0.29) 6
Quijada-Martinez PJ, 2021 Venezuela 2019 before 24–70 36/ 4 17/ 23 ICU MBI 40 9 0.23 (0.10–0.36) 7
Ribeiro EKDA, 2021 Brazil 2018 before NR 73/ 10 42/ 41 ICU MBI 83 12 0.14 (0.07–0.21) 7
De la Fuente-solana EI, 2021 Spain 2019 before 22–64 118/ 32 45/ 105 Obstetrics MBI 150 42 0.28 (0.21–0.35) 7
Belay AS, 2021 Ethiopia 2018 before 21–36 144/ 138 106/ 176 NR MBI-HSS 282 96 0.34 (0.28–0.40) 7
Vitale E, 2020 Italy Jul. -Aug. 2019 before 37.0 229/ 71 NR NR MBI-HSS 300 148 0.49 (0.44–0.55) 8
Clark RRS, 2020 US 2015 before 47.8 1531/ 7 NR Obstetrics MBI 1538 381 0.25 (0.23–0.27) 8
Balinbin CBV, 2020 Philippines Aug.-Nov. 2017 before 30.57 84/ 37 42/ 79 Surgery PROQOL 121 34 0.28 (0.20–0.37) 8
Zeng LN,2020 China Oct.-Dec.2017 before 32.6 1167/ 282 908/ 541 Psychiatry Department MBI-GS 1449 867 0.60 (0.57–0.62) 8
Tsou MT, 2020 China Dec.2018-Mar. 2019 before 35.2 1685/ 73 NR Multiple specialties MBI-HSS 1758 113 0.06 (0.05–0.08) 8
Rudman A, 2020 Sweden 2017–2018 before NR 2225/ 198 NR NR NR 2423 299 0.12 (0.11–0.12) 8
Alvares MEM, 2020 Brazil 2011–2013 before 28–45 109/ 16 63/ 62 ICU MBI-HSS 125 49 0.39 (0.30–0.48) 7
Jones GAL, 2020 UK 2018 before NR 1131/ 63 NR ICU MBI 1194 594 0.50 (0.47–0.53) 8
Vevodova S, 2020 Czech Republic 2018 before 21–51 230/ 20 NR NR MBI 250 96 0.38 (0.32–0.44) 8
Mohammad KI, 2020 Jordan 2018 before 21–50 NR 238/ 83 Obstetrics CBI 321 121 0.38 (0.33–0.43) 8
Harizanova S, 2020 Bulgaria 2014–2015 before 30–52 206/ 8 136/ 78 NR MBI 214 18 0.08 (0.04–0.12) 8
das Merces MC, 2020 Brazil 2017–2018 before 27–47 989/ 136 519/ 606 Multiple specialties MBI 1125 206 0.18 (0.16–0.20) 8
Portero de la Cruz S, 2020 Spain 2016 before 39–56 125/ 46 39/ 132 ED MBI 171 14 0.08 (0.04–0.12) 8
Kapu AN, 2019 US Jan.-Feb. 2018 before 38.0 390/ 35 NR NR MBI 433 114 0.26 (0.22–0.31) 7
Ramirez-Baena L, 2019 Spain 2017 before 22–61 214/ 87 223/ 50 NR MBI 301 109 0.36 (0.31–0.41) 7
Zhang WY, 2019 China Jul. 2016-Jul. 2017 before NR 49,898/ 1508 34,015/ 16538 NR MBI 51,406 25,703 0.50 (0.49–0.50) 8
Arimon-Pages E, 2019 Spain 2015 before 28–51 256/ 41 NR Oncology ProQOL 297 60 0.20 (0.15–0.25) 8
Berry S, 2019 UK 2014 before 26–47 NR NR Internal medicine MBI-HSS 137 12 0.09 (0.04–0.14) 7
Nobre DFR, 2019 Portugal 2015 before NR 15/ 17 NR ED CBI 32 22 0.69 (0.53–0.85) 5
Chico-Barba G, 2019 Mexico 2016–2018 before NR 168/ 0 103/ 65 NR MBI 168 33 0.20 (0.14–0.26) 8
Card EB, 2019(Card, 2019)3433323130 US 2014 before NR 2729/ 108 NR Surgery MBI 2837 1474 0.52 (0.50–0.54) 8
Selamu M, 2019 Ethiopia 2014 before NR NR NR NR MBI-HSS 75 30 0.40 (0.29–0.51) 8
Vasconcelos EM, 2018 Brazil Jul. 2014 before 30.82 81/ 10 34/ 57 ICU MBI 91 13 0.14 (0.08–0.23) 8
Daniel A, 2018 US May-Jun. 2017 before 24–80 228/ 43 NR Multiple specialties A 10-item survey 371 73 0.20 (0.16–0.24) 7
See KC, 2018 Asian multi-country 2015–2016 before NR NR NR ICU MBI-HSS 3100 1611 0.52 (0.50–0.54) 7
Sobral RC, 2018 Brazil 2013 before NR 250/ 25 NR NR MBI-HSS 281 16 0.06 (0.03–0.09) 8
Wentzel DL, 2018 South Africa 2016–2017 before 23–65 81/ 2 39/ 44 Oncology ProQOL 83 51 0.61 (0.51–0.71) 8
Sillero A, 2018 Spain 2014 before 21–65 119/ 11 75/ 55 Surgery MBI 130 53 0.41 (0.33–0.49) 6
Bhagavathula A, 2018 Ethiopia 2016 before NR NR NR NR MBI-HSS 169 23 0.14 (0.09–0.19) 7
Vermeir P, 2018 Belgium 2015 before 30–45 NR NR ICU MBI 299 9 0.03 (0.01–0.05) 7
Fumis RRL, 2017 Brazil Aug.-Sept.2015 before NR NR NR Multiple specialties MBI 191 44 0.23 (0.17–0.30) 7
Creedy DK, 2017 Australia Sept.2014 before NR NR NR Obstetrics MBI 978 72 0.07 (0.06–0.09) 7
De la Fuente-Solana EI, 2017 Spain 2015 before NR 70/ 31 74/ 27 Oncology MBI 101 30 0.30 (0.21–0.39) 7
Merces MDC, 2016 Brazil 2015–2016 before NR 183/ 6 NR Multiple specialties MBI 189 20 0.11 (0.07–0.15) 8
Henriksen L, 2016 Norway 2014 before 40–59 NR 511/ 87 Obstetrics CBI 598 119 0.20 (0.17–0.23) 7
Biksegn A, 2016 Ethiopia 2013 before NR NR NR NR MBI-HSS 237 120 0.51 (0.45–0.57) 7
Muliira RS, 2016 Uganda 2012–2014 before 27–41 178/ 46 123/ 101 Obstetrics ProQOL 224 23 0.10 (0.06–0.14) 8
Abdo SAM, 2016 Egypt 2012–2013 before 20–53 NR NR ED MBI 284 76 0.27 (0.22–0.32) 8
Jang I, 2016 Korea 2013 before NR 285/ 0 95/ 190 Oncology ProQOL 285 70 0.25 (0.20–0.30) 7
Maruyama A, 2016 Japan 2010–2011 before 24–48 NR NR NR MBI 523 117 0.22 (0.18–0.26) 8
Markwell P, 2015 US 2013 before NR 147/ 8 NR Multiple specialties ProQOL 158 40 0.25 (0.18–0.32) 7
Berger J, 2015 US 2014 before NR 231/ 5 NR Pediatric care NR 239 70 0.29 (0.23–0.35) 7
Mangoulia P, 2015 Greece 2010–2011 before 29–45 122/ 52 98/ 76 Internal medicine ProQOL 174 86 0.49 (0.42–0.56) 6
Hegney D, 2015 Australia 2013 before NR 1487/ 121 NR NR ProQOL 1608 405 0.25 (0.23–0.27) 7
das Silva JLL, 2015 Brazil 2010–2011 before 28–41 65/ 65 NR Multiple specialties MBI 130 72 0.55 (0.46–0.64) 7
Ferreira Ndo N, 2015 Brazil 2011 before 28–48 452/ 82 300/ 234 NR MBI-HSS 534 32 0.06 (0.04–0.08) 7
Dolan ED, 2015 US 2012 before NR NR NR Multiple specialties MBI 1380 549 0.40 (0.37–0.43) 8
Ariapooran S, 2014 Iran 2013 before 25–39 67/ 106 143/ 30 NR ProQOL 173 26 0.15 (0.10–0.20) 7
Ribeiro VF, 2014 Brazil 2012 before NR 16/ 3 NR Surgery MBI 188 19 0.10 (0.06–0.14) 6
Yatasa YN, 2014 Ethiopia 2013 before NR 116/ 59 58/ 117 NR MBI-HSS 175 33 0.19 (0.13–0.25) 8
Raftopoulos V, 2012 Cyprus 2010–2011 before NR 1189/ 282 1127/ 337 Multiple specialties MBI 1482 190 0.13 (0.11–0.15) 7
Mohammadpoorasl A, 2012 Iran 2010 before 27–42 613/ 99 505/ 207 NR MBI 712 156 0.22 (0.19–0.25) 6
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ProQOL: Professional Quality of Life; ICU: Intensive Care Units; ED: Emergency Department; MBI: Maslach Burnout Inventory; MBI-HSS: Maslach Burnout Inventory-Human Services Survey; WBI: MBI-GS: Maslach Burnout Inventory-General Survey; Well- Being Index; SBI: Spanish Burnout Inventory; CBI: Copenhagen Burnout Inventory; NR: Not Reported

3.2. The burnout rate based on each year and each month

Fig. 2 A shows the summaries of nursing burnout rates from 2010 to May 2021. 2014 was taken as an example to describe our data acquisition process (Supplementary materials Fig. 1E& F). The burnout rate of the samples in 2014 was combined and the result was 0.26 (95%CI: 0.10, 0.42; I²= 99.2%; z = 3.24; p = 0.001). Then we averaged the burnout rate of 2014 over 12 months and combined with the rates of other months in 2014. The results showed that the nursing burnout rate was 0.20 (95%CI: 0.09, 0.32; I²=87.2%; z = 3.39; p = 0.001) in July 2014 and 0.16 (95%CI: −0.02, 0.35; I²= 98.4%; z = 1.72; p = 0.085) in September 2014. Supplementary materials Fig. 1E& F indicated the process of calculating the monthly rates. In 2014, the nursing burnout syndrome rates in other months except July and September were all 0.26. Monthly nursing burnout rates from 2010 to 2013 were not found. The nursing burnout rate was 0.31 (95%CI: 0.21, 0.42; I²= 97.8%; z = 5.67; p < 0.001) in 2010; 0.30 (95%CI: 0.19, 0.40; I²= 98.3%; z = 5.59; p < 0.001) in 2011; 0.25 (95%CI: 0.10, 0.40; I²= 98.3%; z = 3.36; p < 0.001) in 2012; 0.24 (95%CI: 0.17, 0.31; I²= 96.7%; z = 6.28; p < 0.001) in 2013. The process of obtaining nursing burnout rates in other years was also shown in Supplementary material Fig. 1.

Fig. 2.

Fig. 2

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Summary of nursing burnout rates in each month from 2010 to May 2021.

3.3. Interrupted time-series analysis

The global nursing rate is 0.52 (95%CI: 0.19, 0.85) at its highest in Mar. 2020 and 0.16 (95%CI: −0.05, 0.36) at its lowest in Oct. 2018. During the restrictions, the highest nursing burnout rate is 0.62 (95%CI: 0.47, 0.81) from January to May 2021. Fig. 3 showed the long-term trend of the global nursing burnout rates before the COVID-19 restrictions (January 2010 to March 2020) and later (April 2020 to May 2021). The black dot indicated the actual rate of nursing burnout each month and the solid line indicated the trend of nursing burnout before and after the restictions.

Fig. 3.

Fig. 3

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Trends in monthly nursing burnout syndrome rate around the world (pre-COVID-19 pandemic trend: 0.0007497, 95%CI: 0.0000316, 0.0014677, t = 2.07, P = 0.041; COVID-19 pandemic change: 0.0238539, 95%CI: 0.0087134, 0.0389943, P < 0.05).

The interrupted time series regression analyses found an increasing trend of nursing burnout rate from baseline ( Table 2). Statistically significant changes were found in the nursing burnout rates. Before the epidemic (April 2020), the nursing burnout rate rose with 0.0007497 (95% CI: 0.0000316, 0.0014677, t = 2.07, P = 0.041) every month; in the month of the restrictions (April 2020), the nursing burnout rate decreased by 0.0061033 (95%CI: −1401596, 0.1279529, t = −0.09, P = 0.928); compared with the rising trend of 0.0007497 before the COVID-19 restrictions, the rising trend of nursing burnout rate increased by 0.0231042 (95CI%:0.0086818, 0.0375266, t = 3.18, P = 0.002). The rising trend of nursing burnout rate after the COVID-19 restrictions is 0.0007497 + 0.0231042 = 0.0238539 every month (Table 2).

Table 2.

The statistical results of interrupted time series regression analyses of the impact of the COVID-19 pandemic on the nursing burnout rate in total region subgroups.

Coefficient, 95%CI
Pre-COVID-19 pandemic trend (β1) Rate change (β2) COVID-19 pandemic trend (β3) COVID-19 pandemic change (β1 + β3)
Total (n = 90) 0.0007497 * (0.0000316, 0.0014677) -0.0061033(−0.1401596, 0.1279529) 0.0231042 * *(0.0086818, 0.0375266) 0.0238539 * (0.0087134, 0.0389943)
Region subgroup
Occident (n = 56) 0.000603(−0.0005504, 0.0017563) 0.2362564 * *(0.187537, 0.2849757) -0.0021181(−0.0061508, 0.0019145) -0.001578(−0.0067012, 0.0036708)
Non-Occident (n = 34) 0.0017584 * (0.0003755, 0.0031413) -0.1694088 * *(−0.243112, −0.0957056) 0.0304174 * *(0.0230258, 0.037809) 0.0321758 * *(0.0234013, 0.0409503)
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“Pre-COVID-19 pandemic trend” indicates the pre-pandemic slope of nursing burnout rate and is β1.

“Rate change” indicates the changes in nursing burnout rate in the month of the pandemic outbreak and is β2.

“COVID-19 pandemic trend” indicates the difference of the slope of nursing burnout rate after the onset of the pandemic and is β3.

“COVID-19 pandemic change” indicates the slope in nursing burnout rate after the onset of the pandemic and is the sum of β1 and β3.

*P < 0.05, * *P < 0.001

3.4. Subgroup analysis by regions

In occident countries, no significant difference was found in the trend changes before and during the epidemic (Table 2). The nursing burnout rate rose with 0.000603 (95% CI: −0.0005504, 0.0017563, t = 1.04, P = 0.302) every month before the restrictions; in the month of the restrictions (April 2020), the nursing burnout rate increased by 0.2362564 (95%CI: 0.187537, 0.2849757, t = 9.64, P < 0.0001); compared with the rising trend of 0.000603 before the restrictions, the trend of nursing burnout rate decreased by 0.0021181 (95%CI: −0.0061508, 0.0019145, t = −1.04, P = 0.299). The trend of nursing burnout rate after the COVID-19 restrictions is 0.000603–0.0021181 = −0.001578 every month ( Fig. 4A).

Fig. 4.

Fig. 4

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Trends in monthly nursing burnout syndrome rate in (A) occident countries (Pre-COVID-19 pandemic trend: 0.000603, 95%CI: −0.0005504, 0.0017563, t = 1.04, P = 0.302; COVID-19 pandemic change: −0.001578, 95%CI: −0.0056004, 0.0036708, P = 0.601); (B) non-occident countries (Pre-COVID-19 pandemic trend: 0.0017584, 95%CI: 0.0003755, 0.0031413, t = 2.53, P = 0.013; COVID-19 pandemic change: 0.0321758, 95%CI: 0.0234013, 0.0409503, P < 0.001).

In non-occident countries, there was a statistically significant difference (Table 2). The nursing burnout rate rose with 0.0017584 (95% CI: 0.0003755–0.0031413, t = 2.53, P = 0.013) every month before the restrictions; in the month of the restrictions (April 2020), the nursing burnout rate decreased by 0.1694088 (95%CI: −0.243112,−0.0957056, t = −4.58, P < 0.001); compared with the rising trend of 0.0017584 before the COVID-19 restrictions, the trend of nursing burnout rate increased by 0.0.0304174 (95%CI: 0.0230258, 0.037809, t = 8.19, P < 0.001). The trend of nursing burnout rate after the COVID-19 restrictions is 0.0017584 + 0.0304174 = 0.0321758 every month (Fig. 4B).

4. Discussion

This interrupted time series analysis indicated that the global nursing burnout rate showed a slow upward trend, increasing at 0.0007497 (95% CI: 0.0000316–0.0014677, P = 0.041) per month before the restrictions. After the restrictions, the global nursing burnout rates increased significantly. It grew at a rate of 0.0238539 per month during the restrictions. The restrictions have influenced nursing burnout rates, leading to a rapid increase in nursing burnout rates.

A comparative analysis of nursing burnout before and during the epidemic showed that nurses had a high burnout rate during routine work and that the rate was higher during the COVID-19 restrictions (D. Sullivan et al., 2022), which is consistent with our findings. But the quantity in our study is more and the sample is more sufficient. In addition, another advantage of our study is that the interrupted time series calculated the growth rate of nursing burnout before and after the outbreak of the restrictions, which more intuitively showed the influence of the epidemic on nursing burnout rates.

Before the outbreak of COVID-19 restrictions, nurses were reported high burnout due to the environment of high pressure, irregular working hours, shifts and overnight work (Galanis et al., 2021). After the restrictions, nurses faced even greater challenges. It is well known that nurses play an extraordinary role in combating the COVID-19 restrictions among all healthcare professionals. They put their lives at a risk on the front lines, such as infection control units, emergency departments and intensive care units, etc. (Catton, 2020) COVID-19 has placed enormous stress on nurses and exacerbated pre-existing burnout mechanisms (Pappa et al., 2020). The most direct reason is that they felt anxious, such as lack of knowledge about the infection of COVID-19 (Sun et al., 2020), fear that they may be infected with the virus and exhaustion caused by overwork (Tan et al., 2020). At the same time, concerns about the health of their family are also a factor (Sun et al., 2020). Too many psychological problems easily lead to emotional exhaustion. To prevent infecting their relatives or family members, nurses were isolated in different places most of the time during the restrictions, resulting in a lack of social and emotional support for these nurses, which negatively affected their psychosocial status (Mo et al., 2020). In addition, many nurses perceived little support or management response to increased risk and stress (Foli et al., 2021). An online survey of factors related to nursing burnout during the restrictions found that staffing was negatively associated with the occurrence of burnout, with nurses who were adequately paid during the restrictions experiencing less burnout (D. Sullivan et al., 2022). Due to the high acuity and mortality of COVID-19 patients, nurses working in intensive care may experience feelings of powerlessness, low control, insufficient support, or resources (personal protective equipment, rescue equipment, etc.), high job demands. All these factors increased the risk of moral distress and burnout among nurses (Guttormson et al., 2022).

During the restrictions, nursing staff experienced chronic staffing shortages, high turnover and burnout in long-term care environment (Hung, 2021), with significant implications for the nurses themselves and for nursing work as a whole. Nursing burnout should be paid more attention to. Nurses play an essential role in achieving national and global goals related to health priorities and nursing is an indispensable profession in the world (WHO, 2020). According to our study, the nursing burnout rate was higher and the restrictions increased the nursing burnout rates. At present, the global epidemic has come to an end. To prevent the negative impact of similar public health events on nursing burnout once again, relevant management departments should take corresponding measures to reduce nursing burnout and reduce nurse turnover rates and ensure the high quality of nursing work. Studies have shown that a variety of ways to support nurses and reduce burnout, such as mindfulness training (Luberto et al., 2020), access to psychological and psychosocial support (Kakemam et al., 2021), prioritizing rest and breaks (Sarboozi Hoseinabadi et al., 2020), meditation apps (Janeway, 2020) and self-care techniques (Kakemam et al., 2021). However, theses methods still need to be monitored for their effectives and more policies and measures to protect nurses’ health need to be developed and implemented, such as considering fostering a culture of respect, appreciation, adequate allocation of resources and appropriate financial compensation for nurses during the restrictions. Adjusting nurses’ working hours and providing better psychological support might also good ideas. At the same time, preventive strategies need to be developed to prevent the impact of similar public health events on nursing burnout in the future.

There were some limitations in our study. Firstly, because the data were obtained through the method of meta-analysis, it was inevitable that some data would be missing. According to the data management method in our paper, there were the same data for several months, which was an avoidable limitation. Secondly, due to the limited data, the trend change of nursing burnout rates in various countries or departments cannot be calculated. Thirdly, only papers published in English were included in the study. Therefore, more high-quality research on nursing burnout should be conducted.

In conclusion, the results indicated a slowly rising trend in the nursing burnout rates before the COVID-19 restrictions and the rising trend significantly increased after the restrictions. The COVID-19 restrictions influenced nursing burnout. The study may draw the nursing management departments more attention and provide some basis for changing the phenomenon of nursing burnout.

Funding

None.

CRediT authorship contribution statement

Meng-Wei Ge: Writing – original draft, Data curation, Formal analysis, Writing – review & editing. Fei-Hong Hu: Writing – original draft, Formal analysis. Yi-Jie Jia: Data curation, Software. Wen Tang: Data curation, Software. Wan-Qing Zhang: Investigation. Dan-Yan Zhao: Formal analysis. Wang-Qin Shen: Formal analysis. Hong-Lin Chen: Writing – review & editing, Supervision, Data curation.

Conflict of Interest

There was no conflict of interest in our paper.

Acknowledgments

None.

Supplementary material

Supplementary material associated with this article can be found, in the online version at doi:

Footnotes

Appendix A

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.nepr.2023.103643.

Appendix A. Supplementary material

Supplementary material

mmc1.docx (391.2KB, docx)

.

References

  1. A L. Conducting interrupted time-series analysis for singleand multiple-group comparisons. Stata J. 2015;15(2):480–500. [Google Scholar]
  2. Badahdah A., Khamis F., Al Mahyijari N., Al Balushi M., Al Hatmi H., Al Salmi I., Al Noomani J. The mental health of health care workers in Oman during the COVID-19 pandemic. Int J. Soc. Psychiatry. 2021;67(1):90–95. doi: 10.1177/0020764020939596. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Burki T. Burnout among cancer professionals during COVID-19. Lancet Oncol. 2020;21(11):1402. doi: 10.1016/s1470-2045. (20)30584-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Busch I., Moretti F., Mazzi M., Wu A., Rimondini M. What we have learned from two decades of epidemics and pandemics: a systematic review and meta-analysis of the psychological burden of frontline healthcare workers. Psychother. Psychosom. 2021;90(3):178–190. doi: 10.1159/000513733. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Catton H. Global challenges in health and health care for nurses and midwives everywhere. Int Nurs. Rev. 2020;67(1):4–6. doi: 10.1111/inr.12578. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Chirico F., Nucera G., Magnavita N. Protecting the mental health of healthcare workers during the COVID-19 emergency. BJPsych Int. 2020:1–2. [Google Scholar]
  7. Foli K.J., Forster A., Cheng C., Zhang L., Chiu Y.C. Voices from the COVID-19 frontline: nurses' trauma and coping. J. Adv. Nurs. 2021;77(9):3853–3866. doi: 10.1111/jan.14988. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Frenk J C.L., Chandran L., Groff E.O.H., King R., Meleis A., Fineberg H.V. Challenges and opportunities for educating health professionals after the COVID-19 pandemic. Lancet. 2022;400(10362):1539–1556. doi: 10.1016/S0140-6736(22)02092-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Galanis P., Vraka I., Fragkou D., Bilali A., Kaitelidou D. Nurses' burnout and associated risk factors during the COVID-19 pandemic: a systematic review and meta-analysis. J. Adv. Nurs. 2021;77(8):3286–3302. doi: 10.1111/jan.14839. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Gualano M., Sinigaglia T., Lo Moro G., Rousset S., Cremona A., Bert F., Siliquini R. The burden of burnout among healthcare professionals of intensive care units and emergency departments during the COVID-19 pandemic: a systematic review. Int. J. Environ. Res. Public Health. 2021;18(15) doi: 10.3390/ijerph18158172. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Guttormson J.L., Calkins K., McAndrew N., Fitzgerald J., Losurdo H., Loonsfoot D. Critical care nurse burnout, moral distress and mental health during the COVID-19 pandemic: a United States survey. Heart Lung. 2022;55:127–133. doi: 10.1016/j.hrtlng.2022.04.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Harry E., Carlasare L., Sinsky C., Brown R., Goelz E., Nankivil N., Linzer M. Childcare stress, burnout and intent to reduce hours or leave the job during the COVID-19 pandemic among US health care workers. JAMA Netw. Open. 2022;5(7) doi: 10.1001/jamanetworkopen.2022.21776. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Higgins J, G.S. ( 2022). Cochrane Handbook for Systematic Reviews for Interventions, Version 5.1.0. 2011. http://handbook-5–1.cochrane.org/.
  14. Hung L. Caring for residents with dementia during a COVID-19 outbreak in a long-term care home. Alzheimer's Dement.: J. Alzheimer'S. Assoc. 2021 doi: 10.1002/alz.057324. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Janeway D. The role of psychiatry in treating burnout among nurses during the Covid-19 pandemic. J. Radio. Nurs. 2020;39(3):176–178. doi: 10.1016/j.jradnu.2020.06.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Kakemam E., Chegini Z., Rouhi A., Ahmadi F., Majidi S. Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: a cross-sectional online survey among nurses. J. Nurs. Manag. 2021;29(7):1974–1982. doi: 10.1111/jonm.13359. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Lai J., Ma S., Wang Y., Cai Z., Hu J., Wei N., Hu S. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw. Open. 2020;3(3) doi: 10.1001/jamanetworkopen.2020.3976. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Lavoie-Tremblay M., Gélinas C., Aubé T., Tchouaket E., Tremblay D., Gagnon M.P., Côté J. Influence of caring for COVID-19 patients on nurse's turnover, work satisfaction and quality of care. J. Nurs. Manag. 2022;30(1):33–43. doi: 10.1111/jonm.13462. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Luberto C.M., Goodman J.H., Halvorson B., Wang A., Haramati A. Stress and coping among health professions students during COVID-19: a perspective on the benefits of mindfulness. Glob. Adv. Health Med. 2020;9 doi: 10.1177/2164956120977827. 2164956120977827. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Maslach, C., Jackson S., Leiter M. (2018). Maslach Burnout Inventory, 4th ed. Mind Garden: Menlo Park, CA, USA.
  21. Matsuo T K.D., Taki F., Sakamoto F., Uehara Y., Mori N., Fukui T. Prevalence of health care worker burnout during the coronavirus disease 2019 (COVID-19) pandemic in Japan. JAMA Netw. Open. 2020;3(8) doi: 10.1001/jamanetworkopen.2020.17271. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Mo Y., Deng L., Zhang L., Lang Q., Liao C., Wang N., Huang H. Work stress among Chinese nurses to support Wuhan in fighting against COVID-19 epidemic. J. Nurs. Manag. 2020;28(5):1002–1009. doi: 10.1111/jonm.13014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Page M.J., Moher D., Bossuyt P.M., Boutron I., Hoffmann T.C., Mulrow C.D., McKenzie J.E. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021;372:n160. doi: 10.1136/bmj.n160. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Pappa S., Ntella V., Giannakas T., Giannakoulis V.G., Papoutsi E., Katsaounou P. Prevalence of depression, anxiety and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav. Immun. 2020;88:901–907. doi: 10.1016/j.bbi.2020.05.026. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Sarboozi Hoseinabadi 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. Invest Educ. Enferm. 2020;38(2) doi: 10.17533/udea.iee.v38n2e03. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Shah M.K., Gandrakota N., Cimiotti J.P., Ghose N., Moore M., Ali M.K. Prevalence of and factors associated with nurse burnout in the US. JAMA Netw. Open. 2021;4(2) doi: 10.1001/jamanetworkopen.2020.36469. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Sullivan D., Sullivan V., Weatherspoon D., Frazer C. Comparison of nurse burnout, before and during the COVID-19 pandemic. Nurs. Clin. North Am. 2022;57(1):79–99. doi: 10.1016/j.cnur.2021.11.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Sullivan V., Hughes V., Wilson D.R. Nursing burnout and its impact on health. Nurs. Clin. North Am. 2022;57(1):153–169. doi: 10.1016/j.cnur.2021.11.011. [DOI] [PubMed] [Google Scholar]
  29. Sun N., Wei L., Shi S., Jiao D., Song R., Ma L., Wang H. A qualitative study on the psychological experience of caregivers of COVID-19 patients. Am. J. Infect. Control, 48 (6), 592-598. 2020 doi: 10.1016/j.ajic.2020.03.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Tan R., Yu T., Luo K., Teng F., Liu Y., Luo J., Hu D. Experiences of clinical first-line nurses treating patients with COVID-19: A qualitative study. J. Nurs. Manag. 2020;28(6):1381–1390. doi: 10.1111/jonm.13095. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. WHO . World Health Organization; Geneva: 2019. Burn-out an “Occupational phenomenon”: International Classification of Diseases. [Google Scholar]
  32. WHO. (2020). STATE OF THE WORLD’S NURSING. World Health Organization.
  33. 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. doi: 10.1016/j.jpsychires.2019.12.015. [DOI] [PubMed] [Google Scholar]

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