CHAPTER TWO

REVIEW OF RELATED LITERATURES AND

STUDIES

The research literature was explored using several databases, articles, journals and
related researches. Some databases that were used are PubMed, Philippine Journal and
Journal of Public Health. Here, the literature review of this paper will be divided into 3
parts namely; the prevalence of burnout during the COVID-19 pandemic and how it has
increased before the beginning of the outbreak, the factors and outcomes that are linked
to the increase of burnout and the interventions that have been implemented to
mitigate the issue during this pandemic.

1. The Prevalence of Burnout during Pandemic

The healthcare environment puts many of its workers at high risk for burnout. These
workers are faced with high demand of care for patients. Burnout is incredibly common
amongst all healthcare workers and has a negative impact on all aspects of health. The
COVID-19 pandemic has placed an extreme amount of stress on healthcare workers who
have been working the frontlines and they have faced high amounts of patient workload
in order to combat this disease. The Covid-19 pandemic originated from Wuhan, China
where many thousands of healthcare workers around the country were sent to assist
local healthcare teams to care for these sick patients. It was recorded that burnout was
found to be more prevalent in countries where the pandemic was surging at the time of
when the data was collected.

A cross-sectional study was conducted in two hospitals in Wuhan, China, where they
focused on frontline nurses who were caring for COVID-19 patients. A total of 2,014
frontline nurses participated in completing an online questionnaire that measured their
levels of burnout using the Chinese version of the Maslach Burnout Inventory: Human
Services Survey (MBIHSS) (Hu, et al, 2020). This survey contained 22 items that were
measured by a seven-point Likert scale which measured 3 areas such as emotional
exhaustion, depersonalization, and personal accomplishment. Results from this survey
showed that 835 (41.5%) frontline nurses reported high levels of emotional exhaustion
while 556 (27.6%) nurses marked high depersonalization while working caring for
COVID-19 patients (Hu, et al, 2020). A majority of participating nurses also disclosed
that they were experiencing moderate (28%) and high (36.2%) levels of fear when
delivering care. From conducting this study, the results demonstrate that many of the
frontline nurses in Wuhan experienced moderate levels of burnout, which indicates a
high prevalence amongst healthcare workers due to the increase of COVID-19 patients.
This increase of patient workload can significantly impact a nurse’s likelihood of
experiencing burnout. These results portray the prevalence of burnout and how it
impacted the nurses working directly with COVID-19 patients in the very beginning of
the pandemic. Healthcare workers are also faced with a significant amount of challenges
that may contribute to the increased prevalence of burnout that is occurring worldwide.
Safety is an important factor regarding healthcare workers and it is crucial for hospitals
to ensure this in order to allow their workers to provide the most adequate care for
patients.

2. Factors and Outcomes due to Burnout

When the Covid-19 pandemic started, , many hospitals did not have established
guidelines or treatment plans in relation to how to care for COVID patients, which also
resulted in having a limited availability of personal protective equipment. Many HCWs
were faced with feelings of uncertainty and unpreparedness when having to treat these
patients. A cross sectional study was conducted in order to specifically measure the
outcomes from healthcare worker burnout. The researchers used the Maslach Burnout
Inventory (MBI) is a 22-item questionnaire which uses a 5-point Likert scale in order to
assess 3 components of burnout syndrome (Maslach et al, 1997). These components are
emotional exhaustion, depersonalization, and personal accomplishment. Higher scores
within the emotional exhaustion and depersonalization categories may indicate a higher
likelihood of experiencing burnout, while higher scores in personal accomplishment
indicates less burnout. Here, an online questionnaire was sent out to healthcare workers
working in the hospitals of Istituto Auxologico Italiano in order to investigate burnout
and psychological factors. The results reported that 107 (35.7%) had moderate and 105
(31.9%) had severe levels of emotional exhaustion, moderate (31.9%) and 40 (12.1%)
severe levels of depersonalization, and 132 (40.1%) had moderate and 113 (34.3%) had
severe levels of reduced personal accomplishment (Giusti, et al, 2020). There was a high
prevalence of severe levels of burnout in this sample. The high prevalence has a negative
impact on healthcare workers, and this may affect how they cope with this increased
demand of care. The increased workload and constant contact with COVID-19 patients
may consume an individual’s time and energy, leading to moderate and severe levels of
depersonalization. They may become absorbed into their work, and constantly being
placed in this high stress environment may affect how they perceive themselves. With
this high patient load, many employees feel powerless when faced with an excessive
amount of negative health outcomes. Being dealt with numerous amounts of deaths,
healthcare workers around the world may feel as if they are not doing enough because
they are faced with more patient losses than successes.
Again, the factors contributing to the increased likelihood of experiencing burnout
affects the mental health outcomes in healthcare workers. A meta-analysis was done in
order to measure the most frequently reported psychological symptoms. Fear (43.7%)
was one of the most common mental health concerns amongst this population. This
feeling of fear was associated with a frequency of psychological distress (37.8%) as well
(Salazar de Pablo, et al, 2020). This may be due numerous contributing factors of the
pandemic such as the increase in demand of longer shifts and hours. The report also
stated a higher frequency of anxiety (29%) and depressive (26.3%) features within
healthcare workers (Salazar de Pablo, et al, 2020). This was compared to the previous
population who experienced the SARS/MERs infection. Anxiety and depressive features
had an increase of about 10% from COVID-19 pandemic compared to the previous
epidemics. Healthcare workers also reported having stigmatization feelings (39.5%)
compared to the general population (Salazar de Pablo, et al, 2020). Due to the fact that
these healthcare workers are in contact with COVID-19 patients, some expressed that
their family members and friends have avoided them in fear of contracting the virus.
This may contribute to healthcare workers feeling isolated from their support system
which ultimately takes a toll on their mental health.

3. The Interventions Implemented to Mitigate or Decrease Burnout

In the midst of the COVID-19 pandemic, it is important to protect the mental health of
the HCWs in order to upkeep the working capacity that is required to treat patients.
Fear and anxiety are very prevalent amongst this particular population due to the
uncertainty of COVID-19 and the increased workload that comes with the sick patients.
There must be a greater promotion of self-care in favor of the healthcare workers in
order to support them in creating healthy coping skills while fighting this disease. There
is a huge need for psychosocial support in order to create a safe environment with clear
organizational strategies to ensure communication and support among all healthcare
team members. Making accessible resources and providing them with support will help
create resiliency among all healthcare teams.

Firstly, the United Kingdom came up with an intervention which consisted of a digital
care package in order to help support the psychological wellbeing of healthcare workers
during and possibly after the COVID-19 pandemic. The digital package was named,
“Psychological Wellbeing in Healthcare Workers: Mitigating the Impacts of COVID-19”
where the package was accessed over 17,000 times through social media within a week
of release (Blake, et al, 2020). This package includes tools to help provide healthcare
workers with resources about topics such as communication, social support, self-care,
managing emotions, etc. Upon testing this digital care package, creators decided that the
material must be interactive and engaging, such as including phone applications and
video materials. In order to test this package, 97 healthcare workers were divided into
three consultation groups. The discussions were held for 3 months and participants
discussed their perceptions about the digital platforms and the need for psychological
support. Many of them were extremely positive about using this new form of technology
in order to help promote psychological health. They felt like using this care package
would also address the issues that are occurring in the workplace environment. This
intervention has provided strong evidence that there is a high demand for delivering
support to healthcare workers who are experiencing burnout and are in need of
resources to promote healthier coping mechanisms.

Secondly, another intervention that may be implemented is the Mindfulness-Based

Stress Reduction (MSBR) program which works to manage work stress and improve
patient outcomes (Conversano, et. al, 2020). This program may be very effective for
healthcare workers who are struggling to cope with the stress of COVID and this may
help teach how to better deliver patient care when faced with challenges. In order to test
the results, researchers may use the Mindfulness Attention Awareness Scale (MAAS) in
order to evaluate mindfulness levels for burnout (Conversano, et. al, 2020). For
example, one program is called, “Mindful Nursing Pilot Study” where 46 nurses
participated in a 10-week mindfulness training program. This classe was held once a
week for about thirty minutes. After participating in these classes, the nurses reported
an improvement in levels of mindfulness, burnout, stress, and patient satisfaction
(Conversano, et. al, 2020). MSBR may help address the psychological challenges that
the healthcare workers face and help improve the levels of burnout that has been caused
by the pandemic.

Thirdly, an additional method that is used to help combat burnout from the pandemic is
based off of the Acceptance and Commitment Therapy (ACT) model. This type of
educational model helps create psychological flexibility through acceptance and
mindfulness (Cartwright, 2020). Dr. Russ Harris, a psychotherapist, has created a
resource to help HCWs manage and cope with the stress from the work environment. He
has created an acronym called, “FACE COVID” in order to create awareness about how
the current pandemic may impact individuals. This tool may help normalize responses
of fear and anxiety by allowing HCWs to take a step back and acknowledge what they
may be feeling at the moment (Cartwright, 2020). This acronym is easily accessible, and
many workers may be able to use this tool at any moment when working in the hospital.
The acronym is: F- Focus on what is in your control, A- Acknowledge your thoughts and
feelings, C- Come back into your body, E- Engage in what you’re doing, C- Committed
action, O- Opening up, V- Values, I- Identify resources, D- Disinfect and distance. This
acronym will take an individual through a series of steps in order to help focus on what
feelings they may control in order to help manage their psychological response in times
of crisis. This pandemic has created an environment that consists of stress and high
demanding work, which makes it extremely difficult for an individual to manage their
emotions and open up about how they feel about their experiences.
CHAPTER THREE

METHODOLOGIES

The purpose of this research is to identify long-term effects of the COVID-19 pandemic
on healthcare workers who experience burnout as well as the success of interventions
designed to mitigate the impact.

Majority of the studies that were analyzed in this paper had a cross-sectional design
study, and the major weakness associated with this design is the lack of follow-up with
the participants. The timing of the surveys within these studies were completed during
the peak of the pandemic and may limit the generalization of the participants when
answering their perceptions of burnout.

The population sample will be representing are hospital employees who are working in
hospitals in the Philippines. The surge of COVID-19 cases began to overwhelm various
parts of in the Philippines, where many hospitals began to struggle finding spaces to
treat and house these COVID-19 patients. Hospitals began treating these patients during
the first few weeks of shelter in place and this population would be valuable to follow
since they have been working the frontlines for many months now. The sample size that
would be used for this study is 300 hospital employees, one half being male while the
other is female. One shared limitation that was prevalent was that females were
predominantly part of the sample sizes used in the studies. It would be beneficial to have
an equal representation of men and women in order to evaluate how both genders
handle stress. Therefore, an effort will be made to recruit male healthcare workers as
well as female

Here, creating a longitudinal quantitative study that will be conducted within a five-year
timeline. Data was collected using surveys, online researches, cross-section studies and
analysis. To collect the data, this study used the Digital Learning Package Scale that was
used for the UK sample group for the new survey results. This is a Likert scale which
rates the participant’s responses from 1-10, and also includes 2 yes or no questions.
Some of the questions that were used for collecting data were if there were financial
challenges, were there a lack of required technical skills, time challenges, their perceived
usefulness of the package, etc. (Blake, et al, 2020). The survey will be distributed
monthly to the participant’s email where they can complete the questions on their own
personal device. The survey results will then be compiled after five years and this will
allow researchers to compare answers to the UK sample group as well as to evaluate if
there are trends among the answers.
Inferential statistics will be used to analyze the data and researchers will use a
dependent T test. This will allow for comparison of the survey results from the original
UK sample who had first access with the digital care package. The UK answers will be
compared with Philippines healthcare workers once all the data has been collected. This
will allow for more insight on the long-term effects of the digital care package.
Researchers will be able to determine what components and resources were successful
to HCWs and what has not been favored by the participants.

Here, being able to determine what components were successful, this will help modify
any needed changes for the digital care package. Having these survey results may also
help future HCWs when trying to determine what stress-relieving interventions may be
useful to alleviate the high burnout levels.