COVID19

The COVID-19 pandemic has resulted in an unprecedented healthcare crisis with a high
prevalence of psychological distress in healthcare providers. We sought to document the
prevalence of burnout syndrome amongst intensivists facing the COVID-19 outbreak. (Azoulay
et’al,2020) It has been outbreak and even spread to the global. The whole medical system in the
world is facing great challenges. As one of the main forces, nursing staff are at the highest risk.
Their negative emotions and job burnout are worthy of attention as stated by Bruyneel et’al
(2021) During the COVID-19 pandemic, most countries adopted lockdown and physical
distancing measures as containment strategies. This situation led to severe social and economic
consequences and affected mental health.1-4 Several surveys have reported pandemic-related
increases in emotional distress, depression,3,5 anxiety,3,5 posttraumatic stress disorder
(PTSD),3-6 and insomnia,6 particularly among frontline health care workers according to Iob
et’al (2020)

PHILIPPINES: COVID19

Philippines, one of the high-risk countries from the Wuhan coronavirus outbreak, recorded the
first death outside China. The government has announced lock-down of Metro Manila, followed
by the entire Luzon island and is mulling over more localised lock-downs. The Philippines
government declared a state of calamity in the country for six months on 17 March. (Duddu,
2020).

The first suspected case in the Philippines was investigated on January 22, 2020, and 633
suspected cases were reported as of March 1. We describe the clinical and epidemiological
aspects of the first two confirmed COVID-19 cases in the Philippines, both admitted to the
national infectious disease referral hospital in Manila. (Edrada etal, 2020)
The Philippine response to COVID-19 has been described as being one of the longest and
strictest lockdowns in the world. Entire provinces and cities were put into lockdown, mobility
was restricted, and the wearing of masks and social distancing were strictly enforced.
(Maru,2020)

Nearly a fifth of hospitals in the Philippines are close to full capacity as a surge in COVID-19
infections, driven by the highly contagious Delta variant of the virus, spreads across the
Southeast Asian country, the health ministry said on August 9 2021. Coronavirus cases in the
Philippines, a country of 110 million, have been growing at a rate of around 8,000 to 10,000
infections a day over recent weeks, above the daily average of 5,700 cases reported last month,
according to official data. Of the 1,291 hospitals in the Philippines, 236 have reached "critical
levels" of over 85% occupancy because of the rise in cases, she said. Hospitals in the capital
region, the epicentre of the current outbreak, were facing a similar situation with 25 of 159
facilities nearing full capacity. (Reuters, 2021)

Despite having the strictest and longest lockdown in the world, COVID-19 cases in the
Philippines continue to rise. Given the “seemingly endless number of patients trooping” to
hospitals for emergency care and admission, “the healthcare system has been overwhelmed”. As
a consequence, they say that healthcare workers have been experiencing fatigue and depression
as they “can no longer bear the burden of deciding who lives and who dies”. Besides the lack of
personal protective equipment, our frontliners are underpaid and do not get the respect they
deserve. They answer “to the call of duty while battling fear and anxiety”. Aside from this, they
also experience pressure, stress, insomnia, denial, anger, and fear. All over the world though,
frontliners may still suffer from “post-traumatic stress disorder, depression, and substance use
disorders” amid the pandemic. Even before the COVID-19 pandemic, health workers have
already been experiencing shift fatigue. The current outbreak has magnified it further.( Bianca et,
al,2020)

BURNOUT
Burnout and psychological distress seem to have been some of the immediate effects of the
pandemic on health professionals. Burnout is defined as a “state of physical, emotional and
mental exhaustion that results from long-term involvement in work situations that are
emotionally demanding” (Schaufeli et al, 2001). Kristensen et al. indicate that the core of
burnout is fatigue and exhaustion, in three contexts, i.e., person (personal/self) related, client-
related, and work/workplace. Psychological distress is “a state of emotional suffering
characterized by symptoms of depression and anxiety sometimes accompanied by somatic
symptoms, several characteristic features emerge”. (Drapeau,2012)

BURNOUT TO NURSES

In this pandemic scenario, fear of COVID-19 contagion seems to be an exacerbator of distress

and has been found to be associated with negative mental health outcomes In this line,
Wankowicz et al. reported that healthcare workers who are exposed to SARS-CoV-2-infected
patients in emergency wards, infectious wards, and intensive care units are at a much higher risk
of experiencing symptoms of anxiety and depression than HCW working in other wards.

Burnout is a major occupational problem among healthcare providers, especially during the
Covid-19 pandemic. The frontline health workforce is experiencing a high workload and
multiple psychosocial stressors which may affect their mental and emotional health, leading to
burnout symptoms. Moreover, sleep deprivation and a critical lack of psychosocial support may
aggravate such symptoms amidst Covid-19. (Sultana et al., 2020)

Sultana, A., Sharma, R., Hossain, M. M., Bhattacharya, S., & Purohit, N. (2020). Burnout among
healthcare providers during COVID-19: Challenges and evidence-based interventions. Indian
Journal of Medical Ethics, 01–04. https://doi.org/10.20529/ijme.2020.73

During the current COVID-19 pandemic, closing down of international and state borders, strict
city, and also areawise lockdown has affected HCWs and their families as well, causing
excessive negative psychological effects. Burnout, a state of “emotional exhaustion” among
professionals, was first described in the mid-1970s, by Freudenberger and Maslach. Burnout is
defined as a state of physical, emotional, and mental exhaustion that results from long-term
involvement in work situations that are emotionally demanding. It is a multidimensional
syndrome comprising emotional exhaustion, depersonalization, and reduced sense of personal
accomplishment. (Freudenberger, 1974)

Some country leaders called on retired doctors and nurses to support the fight against the
COVID-19 outbreak, and many of the retired healthcare professionals responded positively to
this call and joined the fight against the virus in their country (Iserson, 2020).

Iserson, K. (2020). Augmenting the disaster healthcare workforce. WestJEM 21.3 May Issue,
21(3), 490-496.https://doi.org/10.5811/westjem.2020.4.47553

In some countries, within the scope of combating the epidemic of COVID-19, regarding
sustainability of health services, it was given importance to the continuity of the employment of
health personnel in health facilities, and the health personnel working in health institutions by
official authorities were not allowed to leave health care institutions (Anadolu Ajansi, 2020).

Anadolu Ajansi. (2020). Turkey’s health workers not allowed toleave jobs. (n.d.).
https://www.aa.com.tr/en/latest-oncoronavirus-outbreak/turkey-s-health-workers-notallowed-to-
leave-jobs/1782673

Health professionals often feel inadequate and unprotected against COVID-19. Reasons that
reveal this sense of inadequacy and vulnerability included the insufficiency of scientific
information about COVID-19, the belief that the vaccine / drug that will cure the disease cannot
be discovered, the problems experienced in the provision of protective materials, the risk of
healthcare professionals getting infected, and the healthcare personnel’s risk of transmitting the
disease (Greenberg et al., 2020; Wu et al., 2020).

Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental
health challenges faced by healthcare workers during COVID-19 pandemic. BMJ, m1211.
https://doi.org/10.1136/bmj.m1211

Wu, Y., Wang, J., Luo, C., Hu, S., Lin, X., Anderson, A. E., Bruera, E., Yang, X., Wei, S. and
Qian, Y. (2020). A comparison of burnout frequency among oncology physicians and nurses
working on the frontline and usual wards during the COVID-19 epidemic in Wuhan, China.
Journal of Pain and Symptom Management, 60(1), e60-e65.
https://doi.org/10.1016/j.jpainsymman.2020.04.008

Although the administration of many countries created interventions such as the supply of
disposable materials, the establishment of housing facilities for health personnel, the support of
the community, and psychological assistance, it has not solved the problem of burnout
experienced by health professionals. Health professionals treating COVID-19 patients have been
reported to suffer extreme stress, which can lead to burnout and a reduced capacity to continue
work. One postulated reason for this is the ‘moral injuries’ they endure when, for example,
deciding which patient with COVID-19 should receive a lifesaving therapy that is in short
supply, at the expense of another dying patient (Greenberg et al., 2020)

The problem of burnout continues to be an important risk factor affecting the quality of life and health
of important health professionals with the rise of the pandemic

Burnout: Prevalence

According to WHO, burnout is recognized as an extended response to workplace stress, which is

not managed effectively. In a national survey conducted among nurses in the USA in April 2019,
15.6% of nurses reported a feeling of burnout, with a higher risk among nurses in the emergency
department.4 Besides workload, dealing with critically ill patients and emotionally overloaded
relatives is a highly challenging job for nurses working in the emergency department during a
pandemic. ( Ross, 2020)

Global evidence indicates the need for adopting multipronged evidence-based approaches to
address burnout during this pandemic, which may include increasing the awareness of work-
related stress and burnout, promoting mindfulness and self-care practices for promoting mental
wellbeing, ensuring optimal mental health services, using digital technologies to address
workplace stress and deliver mental health interventions, and improving organizational policies
and practices focusing on burnout among healthcare providers. (Sultana et al., 2020)
Pandemics can have a significant psychological impact on nurses, who are essential to the
healthcare response (Fernandez et al., 2020). Previous studies have shown that pandemics
exacerbate the stress felt by nurses, as they cope with intense emotional, physical, and cognitive
demands (Chen et al., 2020; Shih et al., 2007).

Health institutions are among the institutions that work under the most difficult conditions in
epidemics that affect the entire world and result in high levels of mortality. The mental health of
healthcare teams with heavy social and work responsibilities is particularly affected in
pandemics that affect society both socioeconomically and psychologically. In the first study
involving healthcare workers in the city of Wuhan, where the COVID‐19 epidemic first
emerged, 71.3% of healthcare teams were found to have subthreshold and mild mental disorders,
22.4% moderate disorders, and 6.2% serious mental disorders immediately after the outbreak.
( Kang et al.,2019) In addition, a study of 1,257 health workers in China reported depression in
50%, anxiety in 45%, and insomnia in 34%, while 72% experienced stress.

Kang L, Ma S, Chen M, et al. Impact on mental health and perceptions of psychological care
among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak:
a cross‐sectional study. Brain Behav Immun. 2020;87:11–17. https://
doi.org/10.1016/j.bbi.2020.03.028

Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care
workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3(3):e203976.
https://doi.org/10. 1001/jamanetworkopen.2020.3976

Causative Factor:

It is mainly physicians and nurses who have the most contact with patients and spend time with
them among health professionals. Physicians and nurses are directly at risk when performing the
treatment and care of COVID-19 patients and therefore experience intense stress. They are
affected negatively by physical, mental, and social issues due to the problems they experience in
the working environment andface the problem of burnout (Talee et al., 2020)
Talaee, N., Varahram, M., Jamaati, H., Salimi, A., Attarchi, M., Kazempour dizaji, M., Sadr, M.,
et al. (2020). Stress and burnout in health care workers during COVID-19 pandemic: Validation
of a questionnaire. Journal of Public Health. Published online: 6 June 2020.
https://doi.org/10.1007/s10389-020-01313-z

Although physicians and nurses who experience burnout begin to realize the stressful work
environments, the intensity of their workloads, and their own health problems caused by
COVID19, they are unable to express these feelings due to the intensity of their work tempos,
and become tired of their jobs over time (Hu et al., 2020).

Hu, D., Kong, Y., Li, W., Han, Q., Zhang, X., Zhu, L. X., et al. (2020). Frontline nurses’
burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19
outbreak in Wuhan, China: A large-scale crosssectional study. EClinicalMedicine, 100424.
https://doi.org/10.1016/j.eclinm.2020.100424

Of the many causative factors described by Kisely et al., clinical factors (contact with affected
patients, forced redeployment to look after affected patients, training perceived to be
inadequate), personal factors (fear of quarantine, particularly in staff with children at home, and
infected family member), and societal factors (societal stigma against hospital workers) seem to
be particularly relevant in Indian healthcare scenario.Burnout, apart from being personally
harmful, can lead to suboptimal patient care.

Infectious diseases, pandemics, especially respiratory, are the most psychologically damaging
because they are so deadly, contagious, and long-lasting; the coronavirus pandemic is one with
such combinations. The COVID-19 outbreak has resulted in many mental health outcomes
depending on the individual's strengths and weaknesses, the major stressors added to the nurses
during the pandemic are the physical strain of personal protective equipments (PPEs)
(dehydration, heat, and exhaustion) and physical isolation (cannot touch others), constant
vigilance regarding infection control procedures, fears about infection, and inner conflicts about
competing needs and demands. (Salvagioni et’al, 2017)

Other studies have shown that healthcare providers working in infection control or among
isolated or quarantined individuals are likely to experience multiple mental health problems.
(Hossain et al., 2020) In addition, many of the existing providers are withdrawn or suggested
self-isolation after working on Covid-19 cases. (Alessi, 2020) Such concurrent experience of
high workload, the fear of being infected, and disrupted social support during isolation or
quarantine are critical factors that may influence burnout and associated psychosocial health
outcomes.(Hossain et al., 2020). Many other challenges like the lack of personal protective
equipment, may crucially affect mental health and wellbeing among healthcare providers
(Hossain et al., 2020)(Sasangohar et al., 2020). Additionally, they are sometimes stigmatized as
possible carriers of the virus by members of the public, as reported in several news media (Rios,
2020)(Semple,2020), increasing stress and hastening burnout. These are some glimpses of the
difficulties experienced by frontline health workers, though the true psychosocial and
epidemiological burden of burnout during Covid-19 is largely underreported.

Hossain MM, Sultana A, Purohit N. Mental health outcomes of quarantine and isolation for infection
prevention: A systematic umbrella review of the global evidence. SSRN Electron J. 2020 Mar 26 [cited
2020 Apr 14]. Epub. DOI: 10.2139/ssrn.3561265.

Alessi C. Clinician burnout during the times of COVID-19. Healthcare IT News, 2020 Apr 3[cited 2020 Apr
14]. Available from: https://www. healthcareitnews.com/blog/europe/clinician-burnout-during-
timescovid-19

Hossain MM, Tasnim S, Sultana A, Faizah F, Mazumder H, Zou L. Epidemiology of mental health
problems in COVID-19: A review. PsyArXiv. 2020 May 28. Epub ahead of print. DOI:
10.31234/osf.io/q8e5u. 11. Sasangohar F, Jones SL, Masud FN, et al. Provider burnout and fatigue during
the COVID-19 pandemic: Lessons learned from a high-volume intensive care unit. Anesth Analg. Epub
ahead of print. 2020 Apr 9. DOI: 10.1213/ANE.0000000000004866

Rios L. Mexican doctors attacked with bleach over coronavirus fears. Time. 2020 Apr 25[cited 2020 Jun
3]. Available from:https://time. com/5827496/mexico-doctors-coronavirus-attacks/

Semple K. ‘Afraid to be a nurse’: Health workers under attack during coronavirus pandemic. New York
Times. 2020 Apr 27[cited 2020 Jun 3]. Available from:
https://www.nytimes.com/2020/04/27/world/americas/ coronavirus-health-workers-attacked.html
Effects: Burnout:

According to Sing et al., in a pandemic outbreak of infectious disease, the mental and physical
burdens of health care providers increase with time. Their burnout can lead to treatment errors,
medical malpractice suits, patient mortality, and elevated suicidal ideation and substance abuse
in medical staffs.

Sung, C.-W., Chen, C.-H., Fan, C.-Y., Su, F.-Y., Chang, J.-H., Hung, C.-C., Fu, C.-M., Wong,
L., Pei-Chuan Huang, E., & Lee, T. S.-H. (2020). Burnout in Medical Staffs During a
Coronavirus Disease (COVID-19) Pandemic. SSRN Electronic Journal.
https://doi.org/10.2139/ssrn.3594567

Potential strategies for addressing burnout in healthcare providers during

COVID-19
Making healthcare providers aware of potential burnout. . For example, a study on Ebola
response found that situational awareness alongside other preventive measures improved
psychological resilience among healthcare providers (Schreiber et al, 2019). A meta-analysis
found the correlation between resilience and burnout among Iranian nurses was -0.57 (95%
confidence interval [CI]: -0.354-0.726) (Deldar,2018). This evidence highlights the role of
increasing awareness and adopting strategies to empower healthcare providers during Covid-19.
Secondly, Promoting positive mental health: Mindfulness and self-care practices Several
strategies include decreasing the workload, improving work schedules, promoting self-
management, initiating mindfulness-based stress reduction and mental health promotion
activities for reducing the risks of burnout (Fessel et al,2020). A meta-analysis of 17 studies
among 632 nurses had found lower standardized mean difference for emotional exhaustion (1.32;
95% CI: -9.41-6.78) and depersonalization (1.91; 95% CI: -4.50-0.68), and a higher mean
difference for personal accomplishment (2.12; 95% CI: -9.91-14.14) (Suleiman-Martos,2020).
Ensuring the availability of mental health services. . Potential strategies to improve access to
mental health services may include involving mental health experts in multidisciplinary Covid-
19 teams, who may provide services or refer healthcare workers showing symptoms of burnout
to appropriate resources (De Simone,2019). In addition, group-based counseling or peer support
sessions may effectively address burnout and improve mental health during Covid-19. The next
one is Leveraging digital technologies to prevent burnout One approach can be the balanced use
of electronic health records to coordinate work schedules, monitor healthy work patterns, and
address the risks of overburdening frontline healthcare providers during Covid-19. Counselling
and interventions using digital platforms like mobile phones, apps, or internet-enabled devices
can be an alternative option (Alessi,2020). And lastly is Creating an enabling environment
through organizational

Approaches. It is essential to improve organizational measures to create a lasting impact on the

work culture alongside interpersonal interventions, and address workplace stress. Potential
strategies include improving workflow management, organizing services focusing on reducing
workload, enhancing interoperability, arranging discussion and exchanging opinions, improving
communication skills, provision for adequate rest and exercise, organizing workshops on coping
skills, and devising policies and practices for reducing burnout among health workforce during
this pandemic(Alessi,2020) (De Simone et al., 2019). Healthcare providers often experience
occupational stress leading to burnout, which may be aggravated during Covid-19. While they
work to fulfil their professional responsibilities, it is essential to recognise how workplace-
related stress may affect their mental and emotional wellbeing. (Sultana et al., 2020)

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Sultana, A., Sharma, R., Hossain, M. M., Bhattacharya, S., & Purohit, N. (2020). Burnout among
healthcare providers during COVID-19: Challenges and evidence-based interventions. Indian
Journal of Medical Ethics, 01–04. https://doi.org/10.20529/ijme.2020.73