ABSTRACT

The outbreak of the new coronavirus pandemic has increased the workload on health professionals, who have been subjected to circumstances of great physical and psychological stress that can lead to the development of burnout. This study aimed to understand the effects and consequences of working during the Covid-19 pandemic on the mental health of healthcare workers and factors that may be associated with the development of burnout syndrome. This is an integrative review performed on the PubMed, Cinahl, Scopus, Embase and VHL databases, using the descriptors: “health personnel”, “burnout, professional”, and “Covid-19”, with the Boolean operator AND. The initial search resulted in 229 articles, and after the application of inclusion and exclusion criteria, the final sample consisted of 12 articles. Through the Descending Hierarchical Classification, performed by the IRaMuTeQ, software, a dendrogram with 6 classes was obtained, named ‘Nursing professionals and female gender’, ‘Experience in health work’, ‘Work overload and uncertainties about the future’, ‘Age of professionals’, ‘Fear of infection and transmission’, ‘Front line in the fight against the pandemic’. It was evidenced that profes- sional experience, working conditions, financial situation, relationship between work and family, fear of contamination and transmission of the disease were the main factors associated with the development of burnout in health professionals.

KEYWORDS
Burnout; psychological; Health personnel; Covid-19

Introduction

The outbreak of the new coronavirus pandemic and the increasing number of new cases and deaths from the disease have resulted in social, economic, and health consequences for the population^{11 Freitas ARR, Napimoga M, Donalisio MR. Assessing the severity of Covid-19. Epidemiol Serv Saúde. 2020; 29(2):e2020119.}. Measures such as social distancing were adopted to control the advance of the disease, affecting the population in several aspects of living and health conditions, including, significantly, mental health^{22 Barros MBA, Lima MG, Malta DC, et al. Relato de tristeza/depressão, nervosismo/ ansiedade e problemas de sono na população adulta brasileira durante a pandemia de Covid-19. Epidemiol. Serv. Saude. 2020; 29(4):e2020427.}.

Changes to one’s sleeping patterns, feeling on edge, sadness, depression, and anxiety were cited as the main consequences of the pandemic on people’s mental health, and these were shown to be aggravated in people with a history of depression^{22 Barros MBA, Lima MG, Malta DC, et al. Relato de tristeza/depressão, nervosismo/ ansiedade e problemas de sono na população adulta brasileira durante a pandemia de Covid-19. Epidemiol. Serv. Saude. 2020; 29(4):e2020427.}.

Health professionals have suffered increased work overload during the Covid-19 pandemic, and even without exact knowledge of the disease, they faced a high demand of patients, with insufficient human resources and inadequate infrastructure in the health services^{33 Barroso BIL, Souza MBCA, Bregalda MM, et al. A saúde do trabalhador em tempos de Covid-19: reflexões sobre saúde, segurança e terapia ocupacional. Cad Bras Ter Ocup. 2020; 28(3):1093-1102.}.

Besides the factors already mentioned, other challenges imposed by the pandemic, such as the high transmissibility of the virus and the lack of Personal Protective Equipment (PPE), have directly impacted on workers’ mental health, contributing to the development of burnout syndrome, since professionals are in direct contact with all the determinants of this syndrome.

The consequences of health professionals falling ill due to burnout^{44 Whittemore R. Combining in nursing research: methods and implications. Nurs Res. 2005; 54(1):56-62.} include: reduced worker performance, poor quality of care, compromised patient safety, increased adverse events, medication errors, and more infections and patient falls^{55 Dall’Ora C, Ball J, Reinius M, et al. Burnout em enfermagem: uma revisão teórica. Hum Resour Health. 2020; 18(1):1-17.}.

Burnout syndrome has been described in Brazilian and foreign literature as a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with other people in some way^{66 Maslach C, Jackson SE, Leiter M. The maslach Burnout inventory manual. In: Zalaquett CP, Wood RJ. Evaluating stress: a book of resources. 3. ed. Palo Alto, CA: The Scarecrow Press; 1997. p. 191-218. [acesso em 2022 fev 7]. Disponível em: https://www.researchgate.net/publication/277816643_The_Maslach_Burnout_Inventory_Manual
https://www.researchgate.net/publication...} , resulting from chronic stress in the workplace that has not been successfully managed^{77 World Health Organization. International Classification of Diseases for Mortality and Morbidity Statistics (ICD-11 MMS). Genebra: WHO; 2021.}.

This problem is recognized as one that can affect various occupations around the world, however, scholars point out that the problem is rooted in occupations that involve the provision of services and care, which applies to the work of health professionals^{88 Maslach C, Leiter M, Schaufeli WB. Measuring Burnout. In: Cooper CL, Cartwright S. The Oxford handbook of organizational well-being. 4. ed. Oxford: Oxford University Press; 2009. cap. 5. p. 86-108.}. They often deal with complex problems and work continuously under circumstances that can lead to the development of burnout^{66 Maslach C, Jackson SE, Leiter M. The maslach Burnout inventory manual. In: Zalaquett CP, Wood RJ. Evaluating stress: a book of resources. 3. ed. Palo Alto, CA: The Scarecrow Press; 1997. p. 191-218. [acesso em 2022 fev 7]. Disponível em: https://www.researchgate.net/publication/277816643_The_Maslach_Burnout_Inventory_Manual
https://www.researchgate.net/publication...} . The Agency for Healthcare Research and Quality estimated that by 2015, the syndrome could affect 10% to 70% of nurses and 30% to 50% of physicians, nurse practitioners, and physician associates. This percentage may have increased over time^{99 Bridgeman PJ, Bridgeman MB, Barone J. Burnout syndrome among healthcare professionals. Am J Health-Syst Pharm. 2018; 75(3):147-52.}.

Given the current context, we reflected on the following guiding question: what factors have been associated with the development of burnout syndrome in health care professionals during the Covid-19 pandemic, according to national and international literature?

This Integrative Review was therefore developed with the objective of understanding the effects and consequences of working during the Covid-19 pandemic on the mental health of health care workers, and factors that may be associated with the development of burnout syndrome.

Material and methods

This is an integrative review article. This type of study was chosen because it allows for results from previously developed studies, with different methodological approaches, to be synthesized, and for the provision of more extensive information about a certain matter/problem/question through scientific evidence^{44 Whittemore R. Combining in nursing research: methods and implications. Nurs Res. 2005; 54(1):56-62.}.

To achieve the proposed objective, the essential steps of an integrative review were followed: identification of the topic and selection of the research question; establishment of eligibility criteria; identification of studies in the scientific databases; evaluation of the selected studies and critical analysis; categorization of the studies; evaluation and interpretation of the results, and presentation of the data within the framework of the integrative review^{44 Whittemore R. Combining in nursing research: methods and implications. Nurs Res. 2005; 54(1):56-62.}.

The guiding question was developed using the Pico/Peco strategy (acronym for Patient, Intervention/Exposure, Comparison, Outcomes), where ‘P’ refers to healthcare professionals, ‘E’ to the Covid-19 pandemic, ‘C’ was not applicable in this review, and ‘O’ refers to burnout syndrome.

To build the corpus of articles for the research, Internet searches were performed from September 14 to 17, 2020. Five databases were used: PubMed, Cinahl, Scopus, Embase and VHL. To ensure vocabulary control and the identification of matching words, the Medical Subject Heading Terms (MeSH Terms) were used. The following descriptors were used in the search: “health personnel”, “burnout, professional”, and “Covid-19”, these were combined using the Boolean operator AND in all the databases. The article search did not cover databases of theses and dissertations as such documents were not submitted for peer review and because the subject matter is a recent one; considering the research period, no corresponding documents were found.

From the set of descriptors for the article search that formed this review and through the filters of the databases themselves, the following inclusion criteria were established: articles published from December 2019 onwards, the month in which the new coronavirus emerged, available in full, without any language restriction. Each reference was imported into Rayyan QCRI software, whereby repetitions between and within databases were excluded. The exclusion criteria were: being a review article and duplication within and between the databases used, not presenting descriptors in the title or abstract of the articles selected. Also excluded were the comments, reviews, and editorials of the literature. Since there are different theories of burnout, we do not restrict this definition according to any specific theory. It should be underlined that duplicate studies were considered only once.

The first stage of the evaluation of the included references consisted of reading the titles and abstracts of the articles; the second stage consisted of reading the full text of the studies; and the third and last stage consisted of evaluating the full text of the included studies. In all steps, the reading and analysis of the articles were performed by two independent researchers to avoid selection bias. Possible disagreements were discussed and evaluated jointly with a third researcher to establish a consensus. The studies considered were those that presented in their results participants with burnout syndrome regardless of the level and aspects (emotional exhaustion, depersonalization, professional accomplishment), since the instruments used in the selected studies have different ways of being analyzed.

The selected studies were systematized in a data collection instrument, adapted from an instrument already validated by URSI in 2005^{1010 Ursi ES. Prevenção de lesões de pele no perioperatório: revisão integrativa da literatura. [dissertação]. Ribeirão Preto: Universidade de São Paulo; 2005.}, which allowed information to be obtained for: title, journal, year of publication, objectives, sample, method, and results.

The level of evidence of the studies was classified as follows: level I - meta-analysis studies of multiple randomized controlled trials; level II - individual studies with experimental design; level III - quasi-experimental studies, time series or case-control studies; level IV - descriptive studies (non-experimental or qualitative approach); level V - case or experience reports; level VI - expert committee opinions, including interpretations of information not based on research, regulatory or legal opinions^{1111 Stetler CB, Morsi D, Rucki S, et al. Utilization focused integrative reviews in a nursing service. Appl Nurs Res. 1998; 11(4):195-206.}.

A limitation of the articles selected for this review is that they are mostly cross-sectional studies, and thus it is not possible to establish a temporal relationship between the events, since it is a direct observation of a planned number of individuals at a specific time.

Since this is an integrative review study, the method does not apply to the qualification stage of the selected (primary) studies, since this is one of the stages of systematic reviews^{1212 The Joanna Briggs Institute. Joanna Briggs Institute Reviewers’ Manual: 2014 edition/supplement. Adelaide: Joanna Briggs Institute; 2014.}. By identifying themes in the area, therefore, this study can help steer other types of more robust reviews, such as systematic reviews, in which the primary articles can be qualified, which cannot be done within the methodology of the present study.

Data analysis was performed with the help of the software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRaMuTeQ, version 0.7 alpha 2). IRaMuTeQ is free software for statistical analysis of text corpora. The corpus was composed by synthesizing the articles included in the review. In this study, we performed a Descending Hierarchical Classification (DHC), which enables the construction of classes of text segments which share similar vocabulary, and have different vocabulary to the text segments of the other classes^{1313 Camargo BV, Justo AM. IRAMUTEQ: um software gratuito para análise de dados textuais. Temas Psicol. (Online). 2013; 21(2):513-18.}.

Results

The database searches resulted in a total of 229 articles; of which, 128 were excluded for not corresponding to the study. After reading the titles and abstracts, 101 remained, of which 65 were duplicates. For the reading in full, 36 articles were selected, and after reading, 24 were excluded for not being in accordance with the theme. The final sample consisted of 12 articles included in the present review (figure 1).

All the studies that comprised the sample were in the English language and published in the year 2020. As regards the type of research design of the articles evaluated, the sample was composed of: 11 cross-sectional studies and 1 descriptive study. Thus, regarding the strength of evidence obtained in the articles, they were all classified as level of evidence IV. The data show the the studies distributed among 11 journals; with Plos One standing out with two publications (table 1).

Through the DHC performed by the IRaMuTeQ software, 192 text segments were analyzed, with 82.81% (192 text segments) of the text corpus retained for the construction of the six classes arising from the content partitions. Each class was represented by the most significant words by means of X²2 Barros MBA, Lima MG, Malta DC, et al. Relato de tristeza/depressão, nervosismo/ ansiedade e problemas de sono na população adulta brasileira durante a pandemia de Covid-19. Epidemiol. Serv. Saude. 2020; 29(4):e2020427. and p-value (<0.05), with their associations according to the classes.

Figure 2 shows the dendrogram of the classes obtained, which illustrates the partitions made in the corpus until six final classes were obtained, showing which words were most frequent in each class.

Class 1, named ‘Nursing professionals and female gender’, contributed 14.5% of the total text segments; class 2, ‘Experience in health work’, comprised 18.2% of the segments; class 3, ‘Work overload and uncertainties over the future’, corresponded to 22% of the total text segments; class 4, ‘Age of professionals’, comprised 13.2% of the total text segments; class 5, ‘Fear of infection and transmission’, represented 19.5% of the segments; and, finally, class 6, which was named ‘Front line in fighting the pandemic’, corresponded to 12.6%.

The different percentages attributed by IRaMuTeQ to the six classes resulting from the DHC refer to the quantity of words/subjects that emerged from the analysis of the articles in each class, without any weighting of classes used.

Discussion

Several factors are associated to the development of burnout syndrome in health care workers during the Covid-19 pandemic; factors related to the worker him/herself, the work environment, and the social environment.

Class 1, ‘Nursing professionals and female gender’, emphasized that the nursing category showed more symptoms of anxiety and depression, and higher levels of burnout compared to the other professional categories. The results reveal specific factors related to the work of this professional category, since these carers usually work long shifts due to the scarcity of professionals, little rest, high level of tension, and closer contact with the patient, which may result in physical fatigue and emotional exhaustion, characteristic symptoms of the development of the syndrome^{1414 Ornell F, Halpern SC, Kessler FHP, et al. The impact of the Covid-19 pandemic on the mental health of healthcare professionals. Cad. Saúde Pública. 2020; 36(4):e00063520.,1515 Silva LS, Machado EL, Oliveira HN, et al. Condições de trabalho e falta de informações sobre o impacto da Covid-19 entre trabalhadores da saúde. Rev Bras Saúde Ocup. 2020; 45:1-8.e24.}.

In addition to the factors already mentioned, the literature shows that a low degree of flexibility in their work hours, time pressures, high pressure and psychological demands, little variety in tasks, role conflict, low autonomy, poor relationships between nurses and physicians, low management support, poor leadership, conflicting relationships with staff, and job insecurity are also factors that make nurses susceptible to burnout^{55 Dall’Ora C, Ball J, Reinius M, et al. Burnout em enfermagem: uma revisão teórica. Hum Resour Health. 2020; 18(1):1-17.}.

This class also showed that females showed more symptoms of mental disorder. Women showed higher levels of burnout, post-traumatic stress, anxiety, and depression than men. They are more susceptible to developing burnout due to a series of factors that can occur individually or simultaneously: the double shift, split between professional, maternal, and domestic responsibilities; remuneration; relationship with patients and family members; contact with illness; death; lack of professional recognition; scarcity of human resources to provide an adequate service that results in work overload; as well as the lack of autonomy at work to make decisions<sup>1616 Jantsch N, Costa AEK, Pssaia LF. Síndrome de Burnout: uma revisão integrativa. Research, Society Develop. 2018; 7(1):01-18.

17 Modesto JG, Souza LM, Rodrigues TSL. Esgotamento profissional em tempos de pandemia e suas repercussões para o trabalhador. Rev Pegada. 2020; 21(2):376-91.-1818 Moreira DS, Magnago RF, Sakae TM, et al. Prevalência da síndrome de burnout em trabalhadores de enfermagem de um hospital de grande porte da Região Sul do Brasil. Cad. Saúde Pública. 2009; 25(7):1559-1568.</sup>.

However, Jarruche and Mucci^{1919 Jarruche LT, Mucci S. Burnout syndrome in healthcare professionals: an integrative review. Rev. bioét. 2021; 29(1):162-173.} point out the need to develop more research on burnout syndrome in order to study its prevalence in the female gender and its impact, as well as studies involving other professions besides nursing and medicine, since it is necessary to clarify whether, indeed, these areas are the most affected by the syndrome or if their rates seem higher because they are the subject of most research.

In class 2, ‘Health work experience’, it was shown that health workers were subjected to higher levels of stress during the pandemic. Furthermore, in this class, it could be observed that burnout was more prevalent among participants with fewer years of work experience. Professional experience is seen as a factor that can contribute to greater control in dealing with situations of stress and anxiety, as well as being related to greater confidence and problem-solving ability in the work environment^{2020 Duarte I, Teixeira A, Castro L, et al. Burnout among Portuguese healthcare workers during the Covid-19 pandemic. BMC Public Health. 2020; 20(1):1-10.}. The less experienced professionals showed high anxiety due to lack of familiarity with PPE and reduced hours of sleep compared to the pre-pandemic period.

In class 3, ‘Work overload and uncertainty about the future’, it was highlighted that increased exposure of health care workers to patients with Covid-19 symptoms, with a consequent increase in the workload, has caused increased levels of burnout. The work overload of health care professionals during the pandemic, due to the increased demand of infected people, predisposes to the development of burnout syndrome, reflected in the quality of life of these professionals<sup>2121 El-Hage W, Hingray C, Lemogne C, et al. Les professionnels de santé face à la pandémie de la maladie à coronavirus (Covid-19): quels risques pour leur santé mentale? Encéphale. 2020; 46(3):73-80.

22 Babamiri M, Alipour N, Heidarimoghadam R. Research on reducing burnout in health careworkers in critical situations such as the Covid-19 outbreak. Work. 2020; 66:379-380.-2323 Ribeiro YSFS, Lopes RN, Brito FLT, et al. Implicações da Síndrome de Burnout em profissionais da saúde durante a pandemia de Covid-19: uma revisão integrativa. Rev Cient Multidisci Núcl Conhecimento. 2020; 1-23.</sup>.

Furthermore, healthcare workers who care for Covid-19 patients have higher levels of stress in the relationship between work and the family and childcare. The results corroborate a study that showed that the main sources of anxiety and fear during the pandemic include the concern of health professionals about access to day care centers and school closures, as well as support for personal and family demands in the face of increased work hours^{2424 Shanafelt T, Ripp J, Trockel M. Understanding and address sources of anxiety among health care professionals during the Covid-19 pandemia. JAMA. 2020; 323(21):2133-2134.}.

This class also concentrates words that emphasized that uncertainty in relation to the future caused by the pandemic is also a factor associated with burnout in health workers - misgivings about the duration of the pandemic and its short- and long-term impacts, including in the financial realm (economic crisis/fall in household incomes). Similar results were found in a study developed in Portugal, which concluded that wage cuts were considered a significant factor for the development of burnout among health professionals during the pandemic^{2020 Duarte I, Teixeira A, Castro L, et al. Burnout among Portuguese healthcare workers during the Covid-19 pandemic. BMC Public Health. 2020; 20(1):1-10.}.

In class 4, ‘Age of professionals’, one can point to words that, regardless of professional experience, related the age of the health professionals to mental health problems during the pandemic, as younger professionals showed higher levels of anxiety and distress. These results are consistent with a study that showed that professionals under the age of 40 suffered from higher levels of stress, anxiety, depression, work exhaustion, and impaired general well-being^{2525 Evanoff BA, Strickland JR, Dale AM, et al. Work-related and personal factors associated with mental well-being during the Covid-19 response: survey of health care and other workers. J Med Internet Res. 2020; 22(8):e21366.}.

Class 5, ‘Fear of infection and transmission’, highlighted words that show that the fear felt by health workers of being infected by Covid-19 and transmitting the disease to their family would harm their mental health, especially when the health workers lived with people in a risk group. A similar result was found in the study by Juan et al.^{2626 Juan Y, Yuanyuan C, Qiuxiang Y, et al. Psychological distress surveillance and related impact analysis of hospital staff during the Covid-19 epidemic in Chongqing, China. Compr Psychiatry. 2020; 103:152198.}, in which the fear of going home and infecting the family was one of the main factors related to mental suffering among health professionals.

Furthermore, resilience stood out as a protective factor against burnout syndrome. An individual becomes resilient when facing adverse situations, from which he/she becomes stronger and acquires skills. Amid the adversities faced during the Covid-19 pandemic, resilience is considered a key characteristic for maintaining the mental health of health care workers^{2727 Schultz CC, Corrêa KID, Vaz SMC, et al. Resiliência da equipe de enfermagem no âmbito hospitalar com ênfase na pandemia Covid-19. Res Soc Dev. 2020; 9(11):e539119466.}.

Class 6, called ‘Front line in fighting the pandemic’, showed that front line professionals suffered from fear of infection and death. Healthcare professionals involved in the care of Covid-19 patients, such as nurses, also showed high levels of stress and burnout when compared to nurses assisting other patients not stricken by the disease^{2828 Hoseinabadi TS, Kakhki S, Teimori G, et al. 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):1-12.e03.}. However, the higher the self-efficacy and willingness to work on the front line, the lower the burnout levels found.

In this class, there were also words that demonstrate the relationship of burnout with skin lesions caused by the prolonged use of masks in nurses, insofar as the worse the lesion, the higher the levels of this grievance. Lan et al.^{2929 Lan J, Song Z, Miao X, et al. Skin damage among health care workers managing coronavirus disease-2019. J Am Acad Dermatol. 2020; 82(5):1215-1216.} found a 97% prevalence rate of skin lesions among front line health care workers in China during the Covid-19 epidemic period, potentially generating reduced enthusiasm for work and making them anxious.

Psychosocial support from friends and family members stood out as critical to the mental health of front-line health care workers. Moreira and Lucca^{3030 Moreira AS, Lucca SR. Apoio psicossocial e saúde mental dos profissionais de enfermagem no combate ao covid-19. Enferm Foco. 2020; 11(1):155-161.} state that, in addition to adequate working conditions, psychosocial support is very important for the preservation of the mental health of the professionals involved in the fight against Covid-19 and for the quality of the care provided.

Conclusions

Extreme work demands have been placed on health care workers due to the Covid-19 pandemic, contributing to the deterioration of their mental health. This article reports a set of findings about the factors associated with burnout syndrome in health care workers in the context of the Covid-19 pandemic. It demonstrated that the main factors associated with the development of burnout are belonging to the nursing category, being female, the worker’s professional experience, working conditions, financial situation, relationship between work and family, and fear of becoming infected and transmitting the disease to others.

The impact on health systems around the world and the changes in work dynamics generated by the pandemic may last for a long time, and the health worker’s exposure to this new work context may generate health consequences. It is known that burnout is not an acute condition, but rather a response to the persistent and unsolvable stress of work. Thus, the study concludes that it is of utmost importance to understand the factors that are associated with the development of burnout syndrome in health professionals in the scenario that now includes Covid-19, as this will allow for the planning and development of adequate and targeted coping strategies for health professionals in order to mitigate the risk indicators that can lead to the experience of burnout syndrome.

References

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