RRL AND RRS:

The outbreak of COVID-19 in Wuhan provoked an overwhelming public health response and
concerns with infection control during the beginning of 2020. Nurses working in the hospitals officially
designated for the patients diagnosed or suspected with COVID-19 have been and are under extreme
physical and psychological stress. There was an extremely high prevalence of somatic alteration among
frontline nurses during the outbreak compared to Chinese nurses in non-COVID times (Gu, Tan, & Zhao,
2019). Due to the requirements for isolation and disinfection, nurses need to wear several layers of
protection mask and clothing. It increases the intensity of their work and requires great physical energy,
causing hypoxia and physical symptoms such as fatigue and muscle pain. Previous studies have shown
that emotional disorders, such as depression or anxiety predict the appearance of somatic symptoms
which worsen the individual's health, and this in turn, leads to new states of anxiety and somatization
(Berghoff, Tull, DiLillo, Messman-Moore, & Gratz, 2017; Creed, Tomenson, Chew-Graham, Macfarlane,
& McBeth, 2018). The decreased psychosomatic health of nurses will also generate a negative influence
on health care performance (Gu et al., 2019; Johnson et al., 2018). 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368912/

Several studies have assessed the mental health outcomes among health care workers treating patients
exposed to COVID-19. For instance, a systematic review and meta-analysis, that aimed to synthesise and
analyse the evidence on the prevalence of anxiety, depression and insomnia among health care workers
during the COVID-19 outbreak, was conducted in April 2020. The findings pinpointed to an anxiety-
pooled prevalence of 23.2%, a depression prevalence rate of 22.8%, and an insomnia prevalence
estimated at 38.9%. Moreover, female health care workers and nurses were the ones who exhibited higher
rates of affective symptoms (Pappa et al., 2020). Another review carried out in April 2020 suggested that
health care workers presented a considerable degree of stress, anxiety, depression and insomnia due to the
COVID-19 outbreak. Furthermore, according to the same review, there is increasing evidence suggesting
that COVID-19 can even be an independent risk factor for stress in health care workers (Spoorthy et al.,
2020). In Wuhan, the epicentre of the pandemic, a study evaluated the mental health of 994 medical and
nursing staff in January/February 2020, using the 9-item Patient Health Questionnaire, and the results
showed that 36.9% presented subthreshold mental health disturbances, 34.4% mild disturbances, 22.4%
moderate disturbances, and 6.2% severe disturbance (Kang et al., 2020).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732227/

Recent literature has established the ill effects of stress on the nurses’ psychological well-being and work
outcomes (Falguera et al., 2020; Faremi et al., 2019; Vivian et al., 2019). Stress is generally sourced from
situations that a person has no control over, such as a pandemic. Currently, there is a surge of studies on
how the COVID-19 pandemic has caused much stress to the various health care systems across the globe
(Bong et al., 2020; Iyengar et al., 2020). It has compromised the workforce, particularly nurses. In fact,
among the health care workers, nurses are found to be the most anxious and stressed in caring for and
treating patients infected with the COVID-19 virus (Mo et al., 2020). For instance, it is reported that
nurses are anxious about a myriad of situations, including worrying about getting infected or
inadvertently infecting others and caring for an infectious yet dying patient (Alharbi et al., 2020;
Labrague & De los Santos, 2020a; Pappa et al., 2020). Moreover, work situations such as erratic and
exhaustive work schedules, the lack of personnel protective equipment, and forced deployment to
unfamiliar stations are additional burdens. Similarly, they are wary about the social stigma and the
uncertainty of whether their employers are genuinely concerned about their welfare (El-Hage et al., 2020;
Maben & Bridges, 2020; Zhu et al., 2020).

https://psycnet.apa.org/fulltext/2021-07858-001.pdf

COVID-19 challenged and brought turmoil to the nurses’ psychological well-being. There are reports of
increased emotional fatigue and incidence of posttraumatic stress disorder among nurses caring for
COVID-19 patients (Hu et al., 2020; Li et al., 2020). Hospital nurses, particularly women performing
diagnosis, care, treatment, and management of patients with COVID-19, have displayed psychological
disturbances such as anxiety, lack of sleep, and depression (Lai et al., 2020).To mitigate possible physical
and psychological damage to the nurses, health facilities advocated the use of mental health services such
as psychological first aid, crisis interventions, morale boosters provided by their colleagues, and access to
social media and self-help reading materials (Blake et al., 2020; Kang et al., 2020). Interestingly, one
study distinctly compared nurses’ feelings and found that those who are less exposed to infectious wards
appeared to experience more burnout than those on the actual front line (Wu et al., 2020). This implies
that attention should be provided on an organizational scale, particularly in the provision of health and
mental wellness interventions.
https://psycnet.apa.org/fulltext/2021-07858-001.pdf

Researchers have thoroughly discussed the impact of the pandemic on the hospital nurses’ health risks
and psychological wellbeing. Mounting studies found that nurses who provided direct patient care
appeared to be more stressed, overworked, and psychologically disturbed and less fulfilled in their job
compared with nurses in other areas of assignment (Zerbini et al., 2020). For instance, in the studies of
Labrague and De los Santos (2020b) and Irshad et al. (2020), they found that hospital nurses who
perceive fear to COVID-19 have low job satisfaction, are mentally distressed, and are thinking of leaving
their jobs and their profession as nurses. In cases where there is an outbreak of infectious disease, it is
common to hear reports of stress among nurses and how this leads to work decisions. For instance, the
Ebola outbreak in West Africa caused fear and terror among frontline nurses, which made them arrive to
a difficult decision of choosing their own safety over their job (Kollie et al., 2017). Similarly, during the
MERS outbreak in South Korea, one study found how the nurses’ stress was strongly linked to their low
nursing intention (Oh et al., 2017). Generally, the literature tackles on the hospital nurses’ fear of the
COVID-19 virus. There is an evident lack of investigation on the effect of COVID-19 on the nurses’
work outcomes and turnover intention, especially among those deployed in the community.
https://psycnet.apa.org/fulltext/2021-07858-001.pdf

Nurses are at the forefront in institutional settings such as nursing homes and prisons, with homeless
people, and other hard to reach populations and are grappling with the effects of low health literacy,
rapidity of change and health information, and a lack of resources to ensure that all know and understand
what is required to keep them safe. It is so important that we all support these vulnerable populations and
the nurses working within them by advocating for resources including adequate safe accommodation for
all.
We know from our colleagues that despite being actively engaged in this fight against COVID‐19, in a
way that few other professions are, and despite appearing calm and professional; like everyone else, many
nurses are also experiencing fear of the unknown and concern for what lies ahead, for themselves, their
patients, colleagues and their own families and friends. In addition to being nurses, we are also parents,
siblings, friends and partners with all of the worries and concerns shared by most people—providing for
and protecting ourselves and our families, and so in addition to caring for patients, the well ‐being of our
own families weighs heavily on us as nurses at this time.
The global nature of this crisis means that while all countries are engaged in the battle against COVID ‐19,
some have been in the fight for longer and so there is the opportunity to learn from other countries.
Indeed, in watching the unfolding horror particularly in Italy, we see just what can (and will) happen in
the event that measures such as social distancing, hand hygiene and quarantine are not fully embraced by
all in our communities.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228254/

In this (unexpected) COVID-19 era, new factors can tremendously influence nursing workload.
COVID-19 patients require prophylactic measures to prevent or contain the spread of the virus to
other patients: donning protective garments, specific decontamination procedures, isolated
dedicated areas where specific supplies are stored. All these measures increase nursing workload
(Giuliani et al., 2018), not only for the time required of their implementation but also for their
organisation and management. Critical care nurses are experiencing a new challenging working
scenario inside the COVID-19 ICUs. In these setting, they are called to provide the usual high
standard care of patients with the additional problems caused by the personal protective
equipment, especially for long periods. COVID-19 ICU patients cannot receive external visitors,
they are dependent on support from healthcare workers.

The sudden lack of ICU beds and mechanical ventilators has led to an increasing number of
conversions of recovery and operating rooms into new COVID-19 areas. (Bambi et al.,
2020, Lucchini et al., 2020). New ICU beds were designated and critical care nurses were needed
to manage patients who were dependant on high tech organ and system support (including
extracoporeal membrane oxygenation) (Bambi et al., 2020, Lucchini et al., 2020). Some
preliminary reports identify the nursing workload is dramatically high in COVID-19 patients
(Lucchini et al., 2020, Reper et al., 2020). In addition to the severity of illness, the nursing
workload increased because of the need to provide humanistic care in the absence of family. The
introduction of mobile phone calls (Negro et al., 2020) also helped patients to mitigate their
sense of isolation and keep them and their relatives updated, about what is happening outside and
inside “the hospital walls”. When people affected by COVID-19 enter the hospital, they literally
disappear from their relatives' lives.

Therefore, the COVID-19 era is driving the need to enhance nursing workload scores with new
issues, including the time for donning and doffing personal protective equipment (PPE), the
additional time taken to provide care wearing PPE, the need for distanced communication
between patient and relatives, and the need to manage the increasing incidence and severity of
agitation and delirium due to the isolated environment (Kotfis et al., 2020).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418697/

A workload is defined as a general task performed by an individual or a team over a period. Nurses’
workload includes both their practical duties and their cognitive tasks, such as thinking, decision making,
calculating, remembering and searching (Destiani et al., 2020). Nurses face a high mental workload in the
performance of their duties (Sarsangi et al., 2015; Abazari et al., 2020). Nurses are burdened with a great
responsibility, a heavy workload, extreme work pressure and the need to work in rotating shifts because
of the particular nature of their occupation. Huang et al., 2018). An increased workload can affect job
performance as one of the major indicators of success in all organisations (Ardestani-Rostami et al.,
2019). Heavy workload leads to less-than-optimal care for the patients (Arghami et al., 2015).

Few studies have investigated the relationship between nurses’ workload and job performance. In a
descriptive correlational study by Ardestani-Rostami et al. (2019) on 371 nurses to determine the
relationship between workload and clinical performance in nurses at the ICUs of hospitals affiliated to
Tehran University of Medical Sciences, 75% of the nurses rated their performance as average. A negative
correlation was observed between different dimensions of workload and clinical performance. According
to the results of this study, workload can predict the performance of nurses with a variance of 39%
(Ardestani-Rostami et al., 2019). The results of another study also showed that the level of patient safety
decreases as the workload of nurses increases (Akbari, 2017). Nurses are also the first line of care for
patients with COVID-19 in need of hospitalization. Nurses' workload increased extensively in 2020 due
to the rise in the number of patients with COVID-19 (Rothan and Byrareddy, 2020) and their need for
nursing care. Nurses not only provide therapeutic care to patients with COVID-19, but also give them
primary health care and psychological care. The results of a study conducted in Iran showed that HCWs
who had been in contact with COVID-19 patients suffered higher workload workloads compared with
those who had no contact with these patients (Shoja et al., 2020). The role of nurses' performance in
combating this virus is therefore of paramount importance (Jiang et al., 2020).

Studies on the relationship between workload and job performance during the COVID-19 pandemic are
still limited. The present research was thus conducted to determine (1) the relationship between the
mental workload of nurses taking care of patients with COVID-19 and their job performance, and (2)
explain the factors predicting their job performance.
https://onlinelibrary.wiley.com/doi/full/10.1111/jonm.13305

In the present study, the workload and mental health levels affected by the COVID-19 outbreak were
assessed among Iranian health care staff. More than 80% of the participants encountered COVID-19
patients in the workplace. Several variables such as age, marital status, experience, educational level, type
of employment, ward of work interest in the job, and having contact with COVID-19 patients in the
workplace had influences on the score of GHQ. Moreover, jobs, the shift of work, educational level, and
facing COVID-19 affected the score of NASA-TLX. Generally, NASA-TLX scores were higher in
nursing compared to other health staff groups. The results of this study indicated that the total workload
and mental health levels of staff who treated COVID-19 patients were significantly worse than those who
had no contact with COVID-19 patients. In a study by Lucchini et al., a 33% increase was indicated in the
nursing workload among those who worked with COVID-19 patients in ICU. The authors suggested their
colleagues worldwide to make an effort to increase the ICU nursing staff, to start training registered
nurses from general wards to perform basic ICU procedures, and to dedicate intensive care nurses to
manage more complex procedures, in order to be prepared to face the epidemic. During the COVID-19
pandemic, it was shown that healthcare workers are at a higher risk of exposure, so the application of
personal protective equipment (PPE) is necessary. Accordingly, the mandatory use of PPE dramatically
elevates both nursing workload and fatigue. Achieving a sufficient health care workforce during this
infection epidemic not only needs a sufficient number of health care providers, but also maximizes the
ability of each clinician in caring for a high volume of patients. Cao et al. in their study concluded that the
hospital emergency management plan of West China Hospital could reduce the emergency department
(ED) workload, protect healthcare staff, and control the cross-infection during the COVID-19 epidemic.
Additionally, they approved that each hospital should establish a specific contingency plan according to
its condition.
Few studies have been conducted on the physical and psychological effects of outbreaks of serious
infectious diseases among the medical staff, particularly when they have increased workload and the
stress associated with the risk of infection. Liu et al. conducted a qualitative study on nurses and
physicians who were selected from five COVID-19-designated hospitals in Hubei province. In line with
our findings the authors indicated that intensive work drains healthcare providers both physically and
emotionally. Healthcare providers showed their resilience as well as a great strength of professional
dedication to overcome problems. The authors suggested that a comprehensive support should be
supplied to protect the well-being of healthcare providers. Also, a regular and intensive training plan for
all healthcare providers is necessary to promote their preparedness and efficacy to deal with crises.
https://link.springer.com/article/10.1186/s12889-020-09743-w

The major focus during this pandemic has been on addressing the acuity of patient presentation,
containment, preventing spread or at least limiting the spread of the virus. While this is certainly
important from the point of view of pandemic management, the needs of healthcare workers are
something that needs to be addressed. One only needs to consider that most places are in the first wave
with the possibility of second and third waves, therefore, the likelihood of added stress on physicians
needs to be kept in mind. Although there are very few papers to substantiate current levels of burnout, the
emerging impact of COVID-19 and prevalence of burnout should raise urgency with which we should
address burnout amongst physicians Burnout may appear to be less frequent among frontline workers
compared to usual ward workers, however, there is still a staggering prevalence of burnout in general
amongst physicians compared to non-COVID times. A recurring theme of a sense of control amongst
frontline workers in dealing with the pandemic was evident. Hence, it may be important for upcoming
physicians to have early training on pandemic planning and incorporate burnout management techniques.

Burnout caused by occupational factors such as the department an individual works in may be inevitable,
hence, management of burnout must be considered. A study by Amanullah et al. showed that a hospital-
based programme using mindfulness helped reduce the impact of organizational change on physicians.
The authors saw the role of a mindfulness-based programme as being positive. Physicians who took part
reported that they handled burnout better. While the costs were minimal, the outcome clearly showed that
we are not helpless in challenging situations. This was further supported by Krasner et al., who also found
that self-awareness and mindfulness have been shown to effectively reduce burnout. This study showed
that while some took the time to learn how to be mindful, the results were evident to those who stayed the
course. Being busy was often cited as a reason for not being able to be part of the study. In addition to the
department that an individual works in and the lack of support from peers, Sansongahar et al. reported
other occupational hazards with exposure to COVID-19 including “limited resources, longer shifts, and
disruptions to work-life balance/sleep”, which have been reported to increase physicians’ burnout levels.
The lack of PPE has been correlated with an increase in burnout, hence, Santarone et al. recommends that
providing adequate PPE should be top priority.

In addition, these authors referenced one study that showed “limiting shifts to less than 16 h” resulted in
an “18% reduction of attention failures”. Hence, manageable shifts should be timetabled for physicians. It
is imperative that periods of rest and relaxation are given to physicians to prevent burnout. With
manageable shifts put into place, sufficient sleep takes priority since sleep deprivation has been linked
with burnout. Stewart et al. recommend early detection and intervention to improve both sleep
deprivation and burnout.

Another important aspect of burnout, as reported by McMurray et al., is that when physicians feel they
are supported by each other and at home, the incidence of burnout is less. In this study, they found that
support by a spouse decreased burnout by 40% and support from colleagues decreased burnout by 45%.
Shanafelt et al. agree that having a partner or being married was associated with a decreased risk of
burnout. It is clear that physicians who are supported or feel supported by their peers or loved ones
experience less burnout when compared to those who do not. We can infer that colleagues’ ability to offer
help in a stressful work environment helps to reduce the burden more than just the support at home. It is
clear that we need more studies to prove such a hypothesis and findings. Adapting programmes may be
the way forward; this however will require the creating of hospital-based committees or physician
organizations working to address acute, subacute and longer-term needs post COVID-19.

This review also found that, overall, female physicians reported increased burnout in comparison with
their male counterparts. As women account for a huge proportion of the healthcare workforce worldwide,
one could speculate the impact that this pandemic has had on the mental health/burnout of working
female healthcare workers to be considerable. The loss of earnings is one aspect. Paying off debt, the
uncertainty of single parents about their ability to provide, added to emotional stressors if they are going
through a separation, divorce, substance abuse only adds to the enormous stress being faced by female
physicians. Hence, targeted support for the mental wellbeing of female physicians is a must, although
there is little research-based evidence on successful support methods. However, from our review, it
became evident that women may have felt a greater sense of burnout due to lack of control in their
workplace. In fact, from a review of data, it is apparent that systems have a duty to recognize that there
should be autonomy for physicians in practice.
https://onlinelibrary.wiley.com/doi/full/10.1111/inm.12826