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. 2023 Jan 29;39(2):125–132. doi: 10.1177/10598405221150879

Burnout and Mental Health and Well-Being of School Nurses After the First Wave of the COVID-19 Pandemic: A National Cross-Sectional Survey

Hsiao-Jung Chen 1, Li-Ling Liao 2, Hui-Ling Lin 1,3,4,5, Li-Chun Chang 1,3,6,✉
PMCID: PMC9902806  PMID: 36710588

Abstract

The aim of this study was to examine the associations between job stressors, COVID-19-related concerns, burnout, and mental health and well-being among school nurses, and whether any of these associations are mediated by burnout. Based on stratified proportional sampling, data collection was conducted by an online questionnaire distributed to 600 school nurses in Taiwan. A total of 256 participants aged between 27 and 62 years (mean = 47.08; standard deviation = 7.28) returned questionnaires. Results showed that burnout was the main mediating variable that fully mediated the relationship between COVID-19-related concerns and mental health and well-being. The effects of job stressors on mental health and well-being included direct negative effects (β = −.29) and indirect negative effects (β = −.67) through mediating factors. School health managers should be more aware of burnout and mental health and well-being among school nurses under the impact of COVID-19.

Keywords: school nurses, COVID-19, mental health and well-being, job stressors, burnout

The outbreak of the novel coronavirus (COVID-19) in March 2020 resulted in global uncertainty, panic, and increasing fear of contagion (World Health Organization, 2020). From April to August 2022, there was a drastic increase in the number of confirmed COVID-19 cases in Taiwan, with an average daily increase of 60,000–70,000. The number of confirmed cases among students of all grades increased by about 10,000 per month, and cumbersome pandemic control work has become a significant work burden during the pandemic for health professionals (Taiwan Centers for Disease Control, 2022).

In the fight against COVID-19, nurses worldwide are enduring enormous stressors, such as being at a high risk for contracting COVID-19 with insufficient protection from contamination, frustration at not being able to achieve job goals, prolonged working hours, uncertainty about the end of the pandemic, discrimination, and psychological exhaustion (Rogers et al., 2022). The frontline nurses experience some mental health issues such as disturbed mood, depressive symptoms, insomnia, anxiety, and feeling powerless and fearful during the COVID-19 pandemic (Kang et al., 2020; Wan et al., 2022).

During the COVID-19 pandemic, depression symptoms and burnout have been reported in 51–81% of health professionals (Alsulimani et al., 2021; Giardino et al., 2020; Morgantini et al., 2020). These symptoms not only influence their concentration, decision-making ability, and understanding but also have lasting effects on their psychological well-being (Falatah & Alhalal, 2022). Concerns regarding individual health, infecting relatives and friends, less support from supervisor, job insecurity, and mandatory lockdowns have a great impact on stress, distress mood, and depressive symptoms (Rosales Vaca et al., 2022) which have also been explored as having negative impacts on psychological health and well-being (Giorgi et al., 2020).

Burnout is a psychological syndrome characterized by emotional exhaustion, cynicism, and reduced personal accomplishment (Maslach & Leiter, 2016). The job demands-resources model was proposed by Demerouti et al. (2001) to understand the antecedents of burnout. The model proposes that employee health and well-being are influenced by the balance between positive (resources) and negative (demands) job characteristics. Importantly, previous studies show that burnout plays a significant mediating role in the relationship between job stress and mental health problems (Chen et al., 2020; Koutsimani et al., 2019). Attention to the mediating role of burnout is warranted in efforts to reduce mental health problems (Ham, Seto, Rodrigues, & Hilton, 2022).

School nurses exhibit the important role by protecting the lives of students, faculty members, and school staff (Maughan & Ellen Luehr, 2022). Since the outbreak of COVID-19, school nurses have been assigned demanding tasks such as adhering to ever-changing pandemic guidelines and performing contract tracing and vaccination checks for students and faculty (Bergren, 2021). The health workload for a single school nurse in schools is a heavy burden without sufficient time, resources, and support (Galemore et al., 2022). In Taiwan, school nurses’ daily jobs include conducting health promotion activities, health screening, referral and case management for students with abnormal health examination results, disease counseling and tracking, case management of chronic disease, and prevention and control of infectious diseases (Ministry of Education, Taiwan, 2021). Additionally, during the COVID 19 pandemic, contact tracing is a cross-departmental, human resource-intensive task in which the first round of case investigations for students and school staff is completed within 10 h by school nurses to halt the spread of the disease (Lin et al., 2020). School nurses may experience extra job stress under the heavy workload of conducting infectious disease control tasks in schools within the urgent time frame (Yim & Kim, 2022). Such perceived stressors experienced daily by school nurses can impact their mental health and well-being (Hale et al., 2022; Lee et al., 2021).

Despite the important role of burnout in the health professionals, little is known about its effects on the mental health and well-being of school nurses during the COVID-19 pandemic. Therefore, the aims of our study were (1) to analyze the associations between mental health and well-being and (2) to measure the mediating effect of burnout. The findings could address burnout and mental health and well-being issues in school health and provide supportive intervention strategies for school nurses.

Method

Design and Setting

The study adopted a cross-sectional design with an anonymous online questionnaire that was distributed in the fall of 2022 (August and September) in Taiwan. We distributed the survey by sending emails with a link to the Google Forms questionnaire. The power of the study was set for 80%, alpha value = 0.05, absolute risk = 10%, and response rate = 60%. The final sample size of 300 school nurses was calculated.

The stratified proportional sampling based on school levels (primary school, junior high school, senior high school, and university) in Taiwan was adopted in this study. The schools were selected according to a random number sampling method according to the proportion of schools in all 4,299 schools based on their school level. A total of 600 school contacts were invited to participate in the survey (see Table 1). If the school nurses in selected schools agreed to participate, they scanned the QR code to complete the Internet-based questionnaire. The study was approved by the Institutional Review Board of Chang Gung Memorial Hospital (reference number: 202200803B0A3). All the records were anonymous and did not contain any personal identifiers.

Table 1.

Distribution of Sampling and Participant Responses.

School level N % Sampling Returned % Response rate
University 137 3.2 19 8 3.1 42.1
Senior high school 529 12.3 74 45 17.6 60.8
Junior high school 965 22.4 135 41 16.0 30.3
Primary school 2668 62.1 372 162 63.3 43.5
Total 4299 600 256 42.7
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Measures

The sociodemographic items in the survey consisted of gender, age, marital status, education level, years of practicing as a school nurse, student caseload, positive test results for COVID-19 (school nurse), and home quarantine.

Job Stressors

Twelve potential stressors related to the pandemic were used to collect the job stressors adopted in the study by Evanoff et al. (2020). “Yes” responses were coded as 1 and “no” as 0, and their scores were summed across all items, with higher scores representing more job stressors.

COVID-19-Related Concerns

Eleven yes/no statements to collect COVID-19-related concerns in the studies of Maunder et al. (2004) and Van Wert et al. (2022) included the following three domains: fear of COVID-19 (three items), perceived social stigma/avoidance (four items), and work safety (four items). Responses are rated on a four-point Likert scale (1 = never experienced to 4 = always experienced), and the scores were summed across all statements, with higher scores representing a higher degree of concern. Cronbach's α values in the study by Van Wert et al. (2022) and in this study were 0.82 and 0.91, respectively.

Burnout

Burnout was measured using the 16-item Oldenburg Burnout Inventory (OLBI) validated in the study of Demerouti and Bakker (2008). It covers two dimensions: exhaustion and disengagement. A four-point ordinal scale (from 1 = totally disagree to 4 = totally agree) was adopted to score the degree of agreement with each item. According to the cutoff point for the burnout determination with physical symptoms by Peterson et al. (2011), we calculated the mean and standard deviation (SD) of the two domains and set a cutoff of ≥2.25 for exhaustion and ≥2.10 for disengagement.

The Chinese version of the OLBI has been presented as a useful and simple scale to assess occupational burnout and takes approximately 5 min to complete. It had acceptable internal consistency (Cronbach's alpha = 0.89) and criterion validity and could effectively evaluate the burnout level. Eight items (items 1, 5, 7, 10, 13, 14, 15, and 16) were scored in reverse order (Xu et al., 2022).

Mental Health and Well-Being

We modified the Mental Health and Well-being Scale (Hedima et al., 2022) as a 10-item questionnaire. Respondents were asked to quantify the extent to which mental symptoms and distress problems during the COVID-19 pandemic included feeling upset, anxiety, depression, insomnia, meaningless, absent in work, feeling of physical uncomfortable, and crying at work, along with social dysfunction, among others. Each item is graded using the five-choice Likert method (from never = 4 to always = 0). The scores range from 0 to 40. Higher scores indicated better mental health and well-being. The Cronbach's α was 0.89 for the scale.

Data Analysis

We used IBM SPSS version 25.0 for Windows for data analysis. Descriptive statistics were used to analyze job stressors, COVID-19-related concerns, burnout, and mental health and well-being. Categorical variables are presented as numbers (N) and percentages (%). Continuous variables are presented as mean ± SD. Zero-order correlations were conducted to determine the associations between continuous variables. Serial mediation analysis was used to test the direct effect of mental health and well-being using Hayes’ PROCESS macro for SPSS (Model 4; Hayes, 2018). The indirect effects were analyzed by percentile confidence intervals (CIs) based on 5,000 bootstrap samples of the data (Hayes, 2018).

Results

All 256 participants (42.7% response rate) were female (mean = 47.08; SD = 7.28; range: 27–62) (see Table 2). Of them, 82.81% were married and 58.59% had completed their bachelor's degree. The student caseloads ranged from 13 to 13,900, with a median of 808; 50.39% had less than 10 years of school nurse practice.

Table 2.

Descriptive Results of Participants (N = 256).

Variables N % Mean SD
Age (range 27–62) 47.08 7.28
≤40 43 16.80
41–60 126 49.22
51–60 83 32.42
≥61 4 1.56
Marital status
Single 26 10.16
Married 212 82.81
Divorced/Widowed 18 7.03
Education level
Junior college 49 19.14
Bachelor's degree 150 58.59
Master's degree or above 57 22.27
Student caseload (median 808) 1210.66 1782.64
0–300 82 32.03
301–600 29 11.33
601–900 28 10.94
901–1200 23 8.98
>1200 94 36.72
Years as a school nurse (range 0.5–32) 12.13 8.03
≤5 54 21.09
6–10 75 29.30
11–15 49 19.14
16–20 36 14.06
≥21 42 16.41
Positive test for COVID-19
No 227 88.67
Yes 29 11.33
Home confinement
No 195 76.17
Yes 61 23.83
Concerns of COVID-19 (range 15–44) 32.71 6.06
Burnout 41.95 9.60
Disengagement ≥2.1 178 69.5 2.37 0.67
Exhaustion ≥2.25 212 82.8 2.86 0.87
Mental health (range 4–31) 16.54 5.28
Numbers of stressors 4.16 2.13
Manpower shortage 141 55.08
Work-family imbalance 143 55.86
Pressure from superior 87 33.98
Lack of support from colleague 79 30.86
Prolonged working time 164 64.06
Lack of support from superior 72 28.13
Unable to achieve work goals 105 41.02
Physical illness 58 22.66
Unbalance between work investment and reward 113 44.14
Stress of public opinion 57 22.27
Decrease in income 12 4.69
Insufficient knowledge of COVID-19 prevention 24 9.38
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A total of 88.67% reported they did not test positive for COVID-19 and 76.17% had not experienced home quarantine. The mean of job stressors was 4.16 (SD = 2.13), indicating that manpower shortage (n = 141, 55.08%), work–family imbalance (n = 143, 55.86%), and prolonged work time (n = 164, 64.06%) were the most significant stressors reported by participants. The mean scores of disengagement and exhaustion measured by OLBI were 2.37 and 2.86, respectively. Of all participants, 69.5% and 82.8% met the thresholds of burnout for the domains of disengagement and exhaustion, respectively, with 66.8% meeting the thresholds for both (see Table 2). The average score for the COVID-19-related concerns of the respondents was 32.71 (ranging from 15 to 44). The scores of mental health and well-being ranged between 4 and 31 with a mean of 16.54 (SD = 5.28).

Table 3 presented the correlations for the study variables. Mental health and well-being were significantly and negatively correlated with the students’ caseload, job stressors, COVID-19-related concerns, and burnout (p < .05). Years as school nurse and age presented positive associations with mental health and well-being.

Table 3.

Correlation Coefficient among Variables.

1 2 3 4 5 6 7
1. Years as a school nurse 1 −.069 .672*** −.032 .024 −.149* .132*
2. Student caseload −.054 .096 .041 .078 −.128*
3. Age −.131* −.041 −.205** .234**
4. Stressor .361*** .365*** −.373***
5. COVID-19-related concern .482** −.429***
6. Burnout −.735**
7. Mental health 1
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Regarding the indirect effects of job stressors and COVID-19-related concerns on mental health and well-being through burnout, after controlling for age, years as a school nurse, and the number of students, the results showed that the path from job stress to burnout was significant, as was the path between burnout and mental well-being. However, the direct relationship effect of COVID-19-related concerns on mental health and well-being did not reach a significant level. The total effect of perceived job stressors on mental health and well-being was nonsignificant in the direct model (see Figure 1). The results of bootstrapping for the indirect effect showed significance for job stressors (β = 0.67, SE = 0.12, 95% CI: −.45, −.91), indicating that higher perceived job stressors predicted higher burnout, which subsequently predicted lower mental well-being. Burnout exhibited a mediating effect on the relationship between COVID-19-related concerns and mental well-being. The explanatory power of job stressors or COVID-19-related concerns on mental health and well-being through burnout was 58% (see Tables 4 and 5).

Figure 1.

Figure 1.

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Standardized regression coefficients for the mediating relationships of burnout between job stressors, COVID-19-related concerns, and mental health and well-being; *p < .05; ***p < .001.

Table 4.

Regression Results for the Mediation Models.

Mediating variable model Outcome variable model
Burnout Mental well-being
B SE B t B SE B t
Perceived stressors 1.71 .28 26.15*** −.28 .12 −2.40*
Burnout - - - −.39 .02 −15.20***
R2 = .14 R2 = .58
F(1, 227) = 39.19 p < .001 F(2, 226) = 153.17 p < .001
COVID-19-related concern .78 .09 8.54*** −.06 .04 −1.41
Burnout - - - −.40 .02 −14.26***
R2 = .14 R2 = .57
F(1, 227) = 73.07 p < .001 F(2, 226) = 148.83 p < .001
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Table 5.

Bootstrap Test of the Mediating Effect of Burnout on Mental Well-Being.

Direct effect Indirect effect
Estimate SE LL95% CI UL95% CI Estimate SE LL95% CI UL95% CI
Stressor-Mental well-being −.29 .12 −.52 −.05 −.67 .12 −.91 −.45
Concerns-Mental well-being −.06 .04 −.15 .02 −.31 .04 −.39 −.23
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Discussion

The study highlighted the urgent importance of addressing burnout for the mental health and well-being of school nurses in Taiwan. Compared with other studies, the school nurses in this study were older, had more experience, and had a lower educational level (Morse et al., 2022). A total of 36.72% of the subjects served >1,200 children, and the student caseload was higher than that reported by Best et al. (2021) and Morse et al. (2022). Similar to previous studies, the unpredictable pandemic control stress caused by the heavy caseload of managing confirmed cases with insufficient resources (i.e., manpower) (Lowe et al., 2022), an imbalance between workload and home obligations (Giorgi et al., 2020), and prolonged working hours were the significant stressors perceived by school nurses. Lowe et al. (2022) addressed that workload, insufficient resources (i.e., manpower), and subsequent burnout may threaten the mental well-being of school nurses beyond the pandemic.

We also found that burnout levels were slightly higher than those reported in previous studies on healthcare workers (Tan et al., 2020) and clinical nurses (Xu et al., 2022), particularly in the exhaustion domain. However, they are consistent with the study of Hale et al. (2022), which reported that school nurses clearly indicated feeling overwhelmed, exhaustion, and stress during the start of the COVID-19 pandemic. Moreover, prolonged engagement in a job without sufficient support could lead to extra physical, emotional, and affective burdens, thereby resulting in exhaustion due to a long-term consequence of prolonged exposure to COVID-19-related job demands (Zhou et al., 2022).

Compared to previous studies involving healthcare workers and pharmacists, our participants had a lower level of COVID-19-related concerns (Van Wert et al., 2022) and higher scores for mental health and well-being (Hedima et al., 2022). The school setting was an environment with a relatively low risk of contracting COVID-19. Nurses who were not at risk of coronavirus infection were significantly associated with no psychological disorders (Zakeri et al., 2021). This supported our finding that the stress or burden of caring for confirmed cases was not the main stressor to influence their professional role (Lee et al., 2021).

The high correlation (>0.7) between the burnout scale and mental health scale in our study was indeed slightly higher than that reported in other studies (Godfrey et al., 2021), which may reflect the same variable or strong correlation between burnout and mental well-being during the pandemic. Similar to many studies, our study found that burnout significantly affected mental health (Koutsimani et al., 2019) and played a mediating role in the relationship between job stressors (Huang et al., 2022; Zhou et al., 2022) and COVID-19-related concerns and mental health and well-being (Ahorsu et al., 2022; Babamiri et al., 2022; Chen et al., 2020). Furthermore, school nurses experienced new occupational risks, burdens, and stressors during and after the peak of the pandemic that led to negative effects on mental health (Lowe et al., 2022). This study identified that job stressors from burnout affect mental health and well-being both directly and indirectly, of which the indirect effects are greater. This was similar to the study of Chen et al. (2020), which showed that school nurses can still positively cope with stress and maintain professionalism in the face of stress during the pandemic until they experience burnout, which affects their mental health. The effects of COVID-19-related concerns on mental health and well-being through the effects of burnout mean that even though school nurses have concerns about COVID-19, it only affects their mental well-being when burnout is present.

Limitations

For gathering representative national samples, we adopted stratified proportional sampling for 600 school nurses; only 256 questionnaires were returned, with the response rate ranging from 30.3% to 60.8% in four grade levels of school. According to the power analysis, we plan to collect 300 SHNs without any incentives, reminders, and promotion in a very short period after the peak period of the pandemic. Considering the confounding factors for the stressors of starting school after summer vacation, we ended the online survey by collecting 256 questionnaires on September 30, 2022. This method may be a limitation of this study as it decreased the probability of delivering the survey to all possible participants. We only included job stressors and COVID-19-related concerns to analyze the effects on burnout and mental health and well-being. Future studies should examine organizational and interpersonal factors related to burnout, such as social support, resilience, and coping methods, as they may provide additional insights for school health managers.

School Nursing Implications

The COVID-19 pandemic had a significant impact and changed the work of school nurses. Insufficient manpower as well as prolonged working hours are major job stressors that cause burnout among school nurses, thereby affecting their mental health and well-being. COVID-19 pandemic control work was urgent, and insufficient staffing of school health professionals was important job stressor for school nurses. As the pandemic continues, school health management should redesign school healthcare manpower and arrange for extra staff who can be available during emergencies to help schools cope with the stress of the COVID-19 pandemic. Considering the mediating role of burnout in mental health, school nurse associations and managers could design mental health programs to include mindfulness activities. Furthermore, school managers need to regulate reasonable work schedules, decrease long working hours, and implement incentive mechanisms for school nurses.

Conclusion

In this study, burnout and the mental well-being of school nurses were investigated through national sampling. The study shows that school nurses in Taiwan have high burnout, which significantly affects mental health and well-being despite the country's effective COVID-19 pandemic control measures. Moreover, school nurses endured serious job stressors that negatively affected their mental health. Job stressors have minor direct effects on mental health and well-being and can only significantly affect mental health and well-being when burnout occurs. In the face of the mental health impact of emerging infectious diseases, school health managers need to be more aware of burnout and mental health and well-being among school nurses impacted by COVID-19 and design strategies to provide external support to reduce burnout in school settings.

Acknowledgments

The authors thank all the participants who engaged in this online survey.

Author Biographies

Hsiao-Jung, Chen, RN, MS, Instructor, School of Nursing, Chang Gung University of Science and Technology.

Li-Ling Liao, RN, Ph.D, Professor, Department of Health Management, I-Shou University.

Hui-Ling, Lin, RN, MS, Supervisor, Department of Nursing, Linkou Chang Gung Memorial Hospital.

Li-Chun Chang, RN, Ph.D, Professor, School of Nursing, Chang Gung University of Science and Technology and Chang Gung University. Researcher, Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

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