1
Burnout among Medical Practitioners
Introduction
Burnout has become a concern for all humans and more so the practitioners. Burnout is a
reference to the prolonged response to interpersonal stressors and chronic emotional caused by
one’s work. People will then manifested as depersonalization, emotional exhaustion, and
reducing personal accomplishment. Zhang et al. (2020) believe that learning about this can be a
useful way of ensuring that the evidence-based practice creates a learning system for all involved
groups. Exploring these outcomes can generate better review of services while improving
productivity in the workplace. Encouraging learning into burnout can improve service delivery.
Reducing emotional distress requires better ways of increasing job satisfaction among nurses.
Integration of Evidence into Practice
Conceptual EBP Model:
1. Johns Hopkins Nursing Evidence-Based Practice Model is useful here
1. It addresses a clinician-focused process that allows rapid and appropriate
application of research and best practices
2. Cultivates a caring culture based on evidence
3. Provide better directive tools that address best practices and enhance clinical
inquiries.
1. Focusing on the practice question and the best evidence to answer the
question will be useful only if it meets evidence to practice.
4. Objectives
1. Offer training to nurses to improve care options through seminars and
workshops.
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2. To provide health coaching and care coordination to improve nursing
review of services offered
3. Review nursing objectives and schedules to address lean quality
improvement process through programs.
4. Provide education programs to improve their knowledge through
interdisciplinary teams.
5. Strategies
1. Zhang et al. (2020) argued that a bundled strategy would be useful in
addressing burnout given its complexity.
1. Care coordination, health coaching and motivational interviewing,
lean quality improvement, and onsite extended interdisciplinary
teams provided a combined focused on both the individual and
organization to reduce stress and increase resiliency training.
2. Seek training through seminars and workshops
3. Training offers new knowledge that edges them clear of the rest of the
group.
1. Working with continuing education programs through
comprehensive training programs can improve evidence-based
decision-making and identify any appraisals that can reduce
incidences of burnout.
4. The feedback offered after seminars and workshops will establish
variations in care processes.
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1. It provides room for better measures intent on service delivery.
Caring for practitioners ensures better care options and
streamlining their value systems as part of building a better clinical
setting.
5. Team-based interventions possible participatory programs show a need to
employ better tactics.
1. Reducing emotional exhaustion, stress, and burnout through
activities, such as psychosocial training, psychiatric interventions,
and coping interventions among others will show immense
progress in dealing with burnout.
6. Barriers & Strengths
1. The main barriers result from resistance to change
1. Time mismanagement, negative attitude, lack of
motivation, lack of resources, lack of motivation, lack of
training are barriers
2. Strengths emanate from improve knowledge
1. Individualized care of patients and reduction of cost of
patient care can enhance clinician expertise of the medical
professional providing your care.
3. Strategies for Engagement Related to the Specific Practice
Environment:
1. Seminars to keep engaging the nurses on their training
process
4
2. Assignments to ensure participation by nurses
1. Based on their experiences, encounters at work, and
knowledge
3. Workshops to engage employees and ensure better practice
environment
4. Policy discussions in groups to create better situational
overview
4. Timeline for Implementation
1. Training will be for six months
2. Training needs to follow PDSA cycle
1. Plan, do, study, act will improve a process to
carryout change
2. Three months of training will be enough to offer
enough contributions from the employees.
3. Feedback will define the change needed to explore
the expected outcomes
4. Evaluation will consider the sentiments from
quarters.
1. Assessing skills developments y program
participants
2. Compare behavior changes over time
3. Document success levels in accomplishing
objectives.
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Questions???
1.What other strategies that would be beneficial in the work environment I should have included
to promote and ensure 100% compliance from the staff to attend these burnout seminars?
2 Due to the complexity of work burnout that mainly affects healthcare workers, especially those
that work long hours, should it be monitory for employers to pay for psychological support to
improve mental health among healthcare workers?
Reference
Zhang, Y., Wang, C., Pan, W., Zheng, J., Gao, J., Huang, X., … Zhu, C. (2020). Stress, burnout,
and coping strategies of frontline nurses during the COVID-19 epidemic in Wuhan and
Shanghai, China. Frontiers in Psychiatry, 11. doi:10.3389/fpsyt.2020.565520
ORIGINAL RESEARCH
published: 26 October 2020
doi: 10.3389/fpsyt.2020.565520
Stress, Burnout, and Coping
Strategies of Frontline Nurses During
the COVID-19 Epidemic in Wuhan
and Shanghai, China
Yuxia Zhang 1 , Chunling Wang 1 , Wenyan Pan 1 , Jili Zheng 1 , Jian Gao 2 , Xiao Huang 3 ,
Shining Cai 1 , Yue Zhai 4 , Jos M. Latour 5* and Chouwen Zhu 6,7*
1
Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China, 2 Department of Biostatistics, Zhongshan
Hospital, Fudan University, Shanghai, China, 3 Department of Psychology, Zhongshan Hospital, Fudan University, Shanghai,
China, 4 School of Nursing, Fudan University, Shanghai, China, 5 School of Nursing and Midwifery, Faculty of Health:
Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom, 6 Department of Hospital
Administration, Zhongshan Hospital, Fudan University, Shanghai, China, 7 Department of Gastroenterology, Zhongshan
Hospital, Fudan University, Shanghai, China
Background: Nurses at the frontline of caring for COVID-19 patients might experience
mental health challenges and supportive coping strategies are needed to reduce their
stress and burnout. The aim of this study was to identify stressors and burnout among
frontline nurses caring for COVID-19 patients in Wuhan and Shanghai and to explore
perceived effective morale support strategies.
Edited by:
Antonio Ventriglio,
University of Foggia, Italy
Reviewed by:
Bárbara Oliván Blázquez,
University of Zaragoza, Spain
Yesim Erim,
University of Erlangen
Nuremberg, Germany
*Correspondence:
Chouwen Zhu
[email protected]
Jos M. Latour
[email protected]
Specialty section:
This article was submitted to
Psychosomatic Medicine,
a section of the journal
Frontiers in Psychiatry
Received: 25 May 2020
Accepted: 02 October 2020
Published: 26 October 2020
Citation:
Zhang Y, Wang C, Pan W, Zheng J,
Gao J, Huang X, Cai S, Zhai Y,
Latour JM and Zhu C (2020) Stress,
Burnout, and Coping Strategies of
Frontline Nurses During the COVID-19
Epidemic in Wuhan and Shanghai,
China. Front. Psychiatry 11:565520.
doi: 10.3389/fpsyt.2020.565520
Frontiers in Psychiatry | www.frontiersin.org
Method: A cross-sectional survey was conducted in March 2020 among 110 nurses
from Zhongshan Hospital, Shanghai, who were deployed at COVID-19 units in Wuhan
and Shanghai. A COVID-19 questionnaire was adapted from the previous developed
“psychological impacts of SARS” questionnaire and included stressors (31 items), coping
strategies (17 items), and effective support measures (16 items). Burnout was measured
with the Maslach Burnout Inventory.
Results: Totally, 107 (97%) nurses responded. Participants mean age was 30.28 years
and 90.7% were females. Homesickness was most frequently reported as a stressor
(96.3%). Seven of the 17 items related to coping strategies were undertaken by all
participants. Burnout was observed in the emotional exhaustion and depersonalization
subscales, with 78.5 and 92.5% of participants presenting mild levels of burnout,
respectively. However, 52 (48.6%) participants experienced a severe lack of personal
accomplishment. Participants with longer working hours in COVID-19 quarantine units
presented higher emotional exhaustion (OR = 2.72, 95% CI 0.02–5.42; p = 0.049) and
depersonalization (OR = 1.14, 95% CI 0.10–2.19; p = 0.033). Participants with younger
age experienced higher emotional exhaustion (OR = 2.96, 95% CI 0.11–5.82; p = 0.042)
and less personal accomplishment (OR = 3.80, 95% CI 0.47–7.13; p = 0.033).
Conclusions: Nurses in this study experienced considerable stress and the most
frequently reported stressors were related to families. Nurses who were younger and
those working longer shift-time tended to present higher burnout levels. Psychological
support strategies need to be organized and implemented to improve mental health
among nurses during the COVID-19 pandemic.
Keywords: COVID-19, stress, burnout, coping strategy, nurses, mental health, psychology, psychiatry
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October 2020 | Volume 11 | Article 565520
Zhang et al.
Coping of Nurses During COVID-19
INTRODUCTION
intensive care units with 34-beds, respectively. They left their
families and lived in the designated hotels. Additionally, they
cared for COVID-19 infected patients with new colleagues in
a new working environment. All of these were exposed to an
extremely stressful environment.
The unknown and uncertain hospital environment with
COVID-19 patients may aggravate burden and increase stress
among nurses while fighting the epidemic. To address these
mental health challenges and well-being of nurses who work in
the frontline of the COVID-19 pandemic, psychological support
should be provided by hospital management and organizations
that meet the needs of these vulnerable group of nurses.
Therefore, the aim of this study was to identify stressors and
burnout among nurses who cared for COVID-19 patients during
their stay in the frontline and to explore coping strategies and
perceived effective support factors to address stressors.
COVID-19, a novel coronavirus featuring human-to-human
transmission (1) and has spread throughout the world since
its outbreak in December 2019 with thousands of new cases
emerging daily during its peaks (2). The world has experienced
several pandemics of contagious diseases in the past two decades
such as SARS in 2003, H1N1 in 2009, Ebola, Zika, and MERS
in 2014∼2016 (3). High levels of psychological stress have been
documented among nurses who cared for infected patients
during these disease outbreaks (4–6).
Frontline nursing and medical staff, especially in the early
stages of epidemics, have suffered from anxiety and depression
due to high workload, insufficient personal protective equipment,
lack of knowledge of the pathogen and direct contact with
patients (7–10). Consequently, nurses have commonly reported
to experience a greater decline of morale and decreased job
satisfaction due to the nature of the profession (11). Therefore,
mental health initiatives are important to support nurses and
doctors during an unprecedented health crisis of a pandemic
(12, 13).
Burnout syndrome, a state of emotional exhaustion, is
prevalent among nurses working in critical care areas across the
world. A review and meta-analysis of 13 included studies using
the Maslach Burnout Inventory (MBI) with a total sample of
1,566 emergency nurses revealed that burnout prevalence is high
(14). Around 30% of the included nurses showed burnout in each
of the three subscales of the MBI with the highest affected levels
in the Depersonalization subscale followed by the Emotional
Exhaustion and Personal Accomplishment subscales (14). A
study among 3,100 nurses and 992 physicians working in 159
Asian intensive care units documented that nurses and physicians
had high levels of burnout, 52 and 50.3%, respectively (15).
Studies revealed that the factors related to working
environment, shift work, and workloads can lead to the burnout
among clinical nurses (16). Consequently, this can negatively
impact the quality and safety of patient care. The emergent
infection disease outbreaks expose nurses to risks of infection
and may trigger or aggravate burnout levels among frontline
nurses. A study investigating factors of burnout among nurses
working at the frontline during the SARS outbreak identified
that nurses who were single and having been quarantined during
the outbreak had higher level of depressive symptoms (17).
Subsequently, 3 years later, this group of nurses who also had
been exposed other traumatic events experienced ongoing high
level of depression symptoms (17).
During the outbreak of COVID-19 in China, medical teams
nationwide have been assigned to support local health workers
in Wuhan, Hubei Province, the area that has been worst affected
by the pandemic. Zhongshan Hospital of Fudan University,
a tertiary teaching hospital in Shanghai, organized a medical
team consisting of 30 physicians and 104 nurses to support
hospitals in Wuhan (18). Additionally, another six nurses were
deployed to the Shanghai Public Health Medical Center, a
COVID-19-designated hospital (19). Theses nurses had at least
3 year work experience in emergency, critical care, respiratory
and infection departments. The frontline nurses took over two
Frontiers in Psychiatry | www.frontiersin.org
MATERIALS AND METHODS
Design and Procedure
A prospective observational survey design was adopted for
this study. The guideline “The Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) Statement:
guidelines for reporting observational studies” was used to report
the study (20). A total of 110 nurses were eligible to participate,
including 104 nurses in Wuhan Renmin hospital and six nurses
in Shanghai Public Health Medical Center. The two designated
hospitals both admitted COVID-19 patients only. The study
and questionnaires were designed in 25–29 February and was
conducted using an online survey platform between 10 and
14 March 2020. At that time, participants had worked on the
frontline for more than 1 month, and all participants cared for
severe and critically ill COVID-19 patients.
Measures
Sociodemographic variables were collected. These included
age (≤30 years or >30 years), gender, marital status, family
composition (number of children), education degree, nursing
degree, work experience (≤8 years or >8 years), work
environments (quarantine, semi-quarantine or COVID-19 free
units), and working hours per week of those working in
quarantine areas.
A self-administered COVID-19 questionnaire was adapted
from a survey designed and used during the SARS epidemic
measuring the psychological impacts of SARS of frontline nurses
(21). Several items were modified and added through an online
panel discussion and consultation with five frontline nurses. The
content validity index (CVI) of the revised questionnaires was
9.4. A pilot study with 23 nurses confirmed the acceptability
of the final version of the COVID-19 questionnaire. The final
COVID-19 questionnaire included three subscales: (1) Stressor
subscale including 31 items with a 4-point answer option scale
(0 = not at all; 1 = slightly; 2 = moderately; 3 = very much);
(2) Coping strategies subscale including 17 items with a 4-point
answer option scale (0 = almost never; 1 = sometimes; 2 = often;
3 = almost always); and (3) Effective support subscale including
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October 2020 | Volume 11 | Article 565520
Zhang et al.
Coping of Nurses During COVID-19
16 items with a 4-point answer option scale (0 = not effective; 1
= mildly effective; 2 = moderately effective; 3 = very effective).
Burnout was measured using the 22-item Maslach Burnout
Inventory (MBI), developed and validated by Maslach and
Jackson, and is divided into three subscales: Emotional
Exhaustion (EE, 9 items), Depersonalization (DP, 5 items) and
Lack of Personal Accomplishment (PA, 8 items) (22, 23). The
EE subscale measures feelings of being emotionally strained and
exhaustion by own work. The DP subscale measures an unfeeling
and impersonal response toward the recipients of care. Higher
mean scores relate to a higher degree of experiencing burnout.
The items in the PA subscale measure feelings of competence
and successful achievements. Scores of this subscale are revered
and lower mean scores indicate a higher degree of experienced
burnout. Each item of the MBI is scores on a 7-point scale ranging
from 0 (never) to 6 (every day). The range of the subscales scores
are; EE = 0–54, DP = 0–30, and PA = 0–48 (reversed).
TABLE 1 | Characteristics of participants (n = 107).
Characteristics
≤30 years
71 (66.36)
>30 years
36 (33.64)
Female
97 (90.65)
Married
45 (42.06)
Have Children
33 (30.84)
EDUCATION DEGREE
College
32 (29.91)
Bachelor and above
75 (70.09)
NURSING DEGREE
RN
86 (80.37)
APN or head nurse
21 (19.63)
WORK EXPERIENCE
≤8 years
72 (67.29)
>8 years
35 (32.71)
WORKING ENVIRONMENTS AND WORK HOURS
Data Analysis
Quarantine areas
The analyses were performed using IBM-SPSS version 22.0 (IBM,
New York, NY, USA) and R statistical software (R, version
3.5.1; R Project). Normally distributed measurement data are
presented as mean and standard deviation, and categorical data
are presented as frequency (percentage). Normally distributed
continuous variables were compared using one-way analysis of
variance. The Pearson χ2 test was applied to all categorical
variables. A restricted cubic spline was employed to estimate
the relation between age and working time in quarantine
areas and burnout level. The internal consistency of the two
questionnaires on subscale level was calculated by Cronbach’s
alpha. All significance tests were two-sided, and P < 0.05 was
considered statistically significant.
98 (91.59)
≤10 h per week
31 (31.63)
10–20 h per week
58 (59.18)
>20 h per week
9 (9.19)
Semi-quarantine areas
44 (41.12)
COVID-19 free areas
27 (25.23)
RN, registered nurse; APN, advanced practice nursing.
COVID-19 Questionnaire
The COVID-19 questionnaire with the three subscales revealed
adequate internal consistency measures. The Cronbach’s α of
three subscales were: Stressors, α 0.90; Coping Strategies, α 0.77;
Effective Support, α 0.84.
Among the 31 items of the subscale Stressors in the COVID19 questionnaire, the stressors that ranked and scored highest
were homesickness (96.3%, mean 1.97), followed by uncertainty
how long the current working status will last (85.0%, mean
1.19), worrying I might get infected myself (84.1%, mean 1.05),
prolonged wearing of protective equipment will damage my
skin (75.7%, mean 1.11), and discomfort caused by protective
equipment (75.7%, mean 1.07) (Table 2).
In the subscale Coping Strategies, the top 5 common
strategies indicated by participants to cope with stress were:
Taking preventive measures; Actively learning about COVID19; Actively learning professional knowledge; Adjusting attitude
and facing the COVID-19 epidemic positively; and Chatting with
family and friends (Table 3). Seven of the 17 coping items were
performed by all study participants (Table 3).
All 16 items listed in the subscale Effective Support were
regarded as effective measures by most frontline nurses. Seven
items were rated as an effective support measure by all
participants. The top five ranked most effective support measures
to reduce stress as perceived by the study participants were:
Support from supervisors; Sufficient material supply; Allowance
provided by government; Clear instruction on treatment
procedures; and Adequate knowledge of COVID-19 (Table 4).
Ethics
The study was approved by the Research Ethics Committee of
Zhongshan Hospital, Fudan University (B2020-075). The study
was conducted in accordance with the International Council
for Harmonization and Good Clinical Practice principles. The
study adhered to the ethical principles stated in the Declaration
of Helsinki (24). Informed consent was obtained from each
participant before data collection. Participants could withdraw
from the study at any time without providing a reason. The
survey was anonymous, and confidentiality of information
was assured.
RESULTS
Demographic Characteristic
A total of 107 (97%) participants responded to the questionnaires.
Participants had a mean age of 30.28 (SD 5.49) years, and 66.36%
of the nurses were under 30 years old. Most frontline nurses were
female (90.65%), 42.06% were married, and 30.84% had children.
The mean work experience was 8.63 (SD 6.45) years, and 67.29%
had worked for
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