Background: The COVID-19 pandemic is placing unprecedented pressure on a nursing workforce that is already under considerable mental strain due to an overloaded system. Convergent evidence from the current and previous pandemics indicates that nurses experience the highest levels of psychological distress compared with other health professionals. Nurse leaders face particular challenges in mitigating risk and supporting nursing staff to negotiate moral distress and fatigue during large-scale, sustained crises. Synthesizing the burgeoning literature on COVID-19-related burnout and moral distress faced by nurses and identifying effective interventions to reduce poor mental health outcomes will enable nurse leaders to support the resilience of their teams.
Aim: This paper aims to (1) synthesize existing literature on COVID-19-related burnout and moral distress among nurses and (2) identify recommendations for nurse leaders to support the psychological needs of nursing staff.
Methods: Comprehensive searches were conducted in Medline, Embase and PsycINFO (via Ovid); CINAHL (via EBSCOHost); and ERIC (via ProQUEST). The rapid review was completed in accordance with the World Health Organization Rapid Review Guide.
Key Findings: Thematic analysis of selected studies suggests that nurses are at an increased risk for stress, burnout and depression during the ongoing COVID-19 pandemic. Younger female nurses with less clinical experience are more vulnerable to adverse mental health outcomes.
The novel coronavirus 2019 (COVID-19) pandemic has thrust an already strained nursing workforce into largely uncharted territory. Nurse leaders face particular challenges in managing morale, mitigating risk and supporting nursing staff to negotiate moral and ethical distress and fatigue during large-scale crises. Convergent evidence indicates that nurses report the highest levels of pandemic-related psychological distress compared to other health professionals (Tang et al. 2016; Tolomiczenko et al. 2005). Burgeoning research, likewise, suggests that nurses are experiencing significant levels of insomnia, anxiety and depression in the context of the ongoing COVID-19 crisis (Pappa et al. 2020). However, nurses' experiences of pandemic-related burnout and moral distress are not well understood.
According to Maslach and Leiter (2016), burnout is a psychological syndrome characterized by overwhelming exhaustion, depersonalization or cynicism and a reduced sense of personal accomplishment or efficacy that presents as a maladaptive response to chronic interpersonal stressors at work. Although the Maslach Burnout Inventory (MBI) (Maslach et al. 1996) is the most widely used instrument for measuring burnout and has good psychometric properties, there remains substantial conceptual and definitional ambiguity, with some scholars variously conceptualizing burnout as a unidimensional or two-factor phenomenon as well as a dimension of, or precipitating factor for, depression or anxiety (Maslach and Leiter 2016; Poghosyan et al. 2010). Recent systematic and meta-analytic research suggests, however, that burnout, depression and anxiety are distinct and robust constructs (Koutsimani et al. 2019).
Moral distress, similar to burnout, is operationalized in myriad ways (McCarthy and Gastmans 2015). For the purposes of this study, moral distress is defined as "the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behaviour indicated by that decision" (Wilkinson 1987: 16) due to internal or external constraints. The most commonly used instrument for assessing moral distress in nurses working in high-acuity settings is Corley's (1995) Moral Distress Scale.
Moral distress is associated with burnout among nurses (Dalmolin et al. 2014; Fumis et al. 2017), and both burnout and moral distress are independently associated with suboptimal patient care, job dissatisfaction and high staff turnover (Austin et al. 2017; Poghosyan et al. 2010). Understanding nurses' experiences of burnout and moral distress in the context of COVID-19 will enable nurse leaders to respond effectively, support the long-term health of nurses and ensure the retention of the nursing workforce.
The purpose of this rapid review is to (1) summarize the empirical research on COVID-19-related burnout and moral distress in nurses and interventions to mitigate these adverse outcomes and (2) identify recommendations for nurse leaders to support nurses' psychological needs and minimize their burnout and moral distress.
In order to provide the Canadian Nurses Association's decision makers with timely results, a rapid scoping review was conducted in accordance with the World Health Organization (WHO) Rapid Review Guide and the Joanna Briggs Institute (JBI) 2020 guide to scoping reviews (Peters et al. 2020; Tricco et al. 2018). It was reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for scoping reviews (Tricco et al. 2018).
Search Strategy and Information Sources
We completed searches in the following electronic databases: Medline (via Ovid), Embase (via Ovid), CINAHL (via EBSCOHost), PsycINFO (via Ovid) and ERIC (via ProQUEST). Search strategies were developed by an academic health sciences librarian, with input from project leads. The search was originally built in Ovid Medline and peer-reviewed using the Peer Review of Electronic Search Strategies tool (McGowan et al. 2016) before being translated into other databases using their respective command languages, if applicable. Searches were limited by date, from 2003 to the present, and by English language. Searches were limited to articles published until June 12, 2020, and by English language. The final search results were exported into Covidence, a review management software, where duplicates were identified and removed. All search strategies can be found in Open Science Framework (Sriharan et al. 2020).
Each article title was reviewed by two independent screeners using Covidence. A third reviewer reviewed conflicts and resolved disagreements through discussion. Two reviewers also independently screened the full text of potentially eligible articles to check whether the articles fulfilled the inclusion criteria.
English-language quantitative (e.g., cohort, case-control, randomized controlled trial, systematic review) or qualitative (e.g., case study, phenomenological, narrative) research articles that addressed burnout or moral distress in nurses in the context of COVID-19 and/or psychological interventions to mitigate pandemic-related burnout or moral distress in nurses were included. Due to the proliferation and accelerated mobilization of new research in the context of the COVID-19 pandemic, preliminary reports published on preprint servers (e.g., MedRxiv) that had not yet undergone peer review were also included.
Articles published in languages other than English, unstructured reviews and editorials and commentaries were excluded. Likewise, articles that did not include SARS-CoV-2-related analysis and those that did not address pandemic-related burnout or moral distress in nurses were excluded.
We used a predefined data extraction form to extract data from the papers included in the review. To ensure the integrity of the assessment, we piloted the data extraction form on three studies. We extracted the following information from the studies: research design, geographical location of study, sample characteristics (sample size, population of interest, age), mental health outcomes of interest and assessment tools, predictors/correlates (individual, organizational, systemic), interventions (individual, organizational, systemic), main results and authors' conclusions.
We did not appraise quality or risk of bias of the included articles, consistent with accepted scoping review methods (Tricco et al. 2018). Ethical approval was not required for this review.
Due to heterogeneity regarding outcome measurement and statistical analysis, data were descriptively synthesized.
The search produced a total of 3,633 titles. After data deduplication, 2,803 unique titles were included in the first level of screening. A total of 2,279 titles were deemed ineligible, yielding a total of 524 references for full text review. A total of nine studies were identified by the screening procedure for inclusion in the present rapid review (Figure 1). An overview of the selected studies is presented in Table 1 (available online here.
Five selected studies were quantitative cross-sectional surveys (Barello et al. 2020; Cai et al. 2020; Morgantini et al. 2020; Wu et al. 2020; M. Zhang et al. 2020), three were qualitative phenomenological studies (Liu et al. 2020; Sun et al. 2020; Y. Zhang et al. 2020), and one was a rapid review and meta-analysis (Kisely et al. 2020). The majority of primary studies took place in Central China (Henan, Hubei and Hunan provinces). The Barello et al. (2020) study took place in Italy, and Morgantini and colleagues (2020) conducted a global survey comprising 60 countries.
With respect to nurse-specific findings, among selected studies, Barello et al. (2020), Morgantini et al. (2020) and M. Zhang et al. (2020) reported analyses stratified by occupational role. Additionally, Sun et al. (2020) and Y. Zhang's qualitative study samples comprised only nurses. Although Kisely et al.'s (2020) meta-analysis did not compare effects by occupational role, the authors did provide some descriptive analysis of risk factors related to occupational role in their rapid review.
Outcomes of Interest
Three selected primary quantitative studies examined burnout specifically, two using the MBI (Barello et al. 2020; Wu et al. 2020) and one using a single item ("I am burned out from my work") on a 7-point Likert scale (Morgantini et al. 2020).
The MBI was also among the most commonly used standardized instruments of the studies included in Kisely et al.'s (2020) rapid review and meta-analysis of the psychological sequelae of emerging viral outbreaks on healthcare workers (the Oldenburg Burnout Inventory and a composite measure derived from the MBI were also used).
Barello et al. (2020) reported that levels of emotional exhaustion (EE) in their sample of front-line healthcare workers during the peak of the COVID-19 crisis in Italy were higher than normative values (t(320) = 3.765, p < 0.001, difference in means = 2.53), and the percentage of respondents who met the threshold for high EE (MBI-EE ≥ 27, 37%) was higher than those found in pre-COVID-19 Italian studies as well as in studies of healthcare workers during previous pandemics. In contrast, levels of depersonalization (DP) were comparatively lower in the study sample than in the normative sample (t(320) = –2.906, p = 0.004, difference in means = –0.91). Regarding differences in levels of burnout and symptoms experienced by gender and occupational role, Barello et al. (2020) found that females showed higher levels of EE than males (M = 24.05, SD = 11.57; M = 18.74, SD = 12.65, respectively), males experienced symptoms of burnout less frequently than females (M = 2.47, SD = 0.94; M = 3.09, SD = 0.88, respectively) and physicians experienced symptoms of burnout less frequently than nurses (M = 2.47, SD = 0.83; M = 3.05, SD = 0.93).
Comparing burnout frequency among oncology nurses and physicians working on the COVID-19 front line versus in their usual wards in post-peak-pandemic Wuhan, China, Wu et al. (2020) found that the frequency of burnout (MBI-EE > 27 and/or DP > 10) was, in fact, significantly lower in the front-line group than in the usual ward group (13% vs. 39%, p < 0.0001). In addition, a larger proportion of respondents from the front-line group compared to their usual ward counterparts disagreed or strongly disagreed that they were currently experiencing more burnout than they were prior to the onset of the COVID-19 crisis (76% vs. 48%, respectively).
In their global survey of healthcare professionals, Morgantini et al. (2020) reported that 26.6% of respondents endorsed experiencing COVID-19-related burnout (agree or strongly agree). Nurses had higher odds of burnout compared to physicians (odds ratio = 1.47, 95% confidence interval [CI]: [1.12–1.92], p = 0.006) in that study.
Kisely et al. (2020) indicated that in primary studies not included (as they did not contain data that could be combined in pairwise meta-analysis) in their meta-analysis, higher burnout morbidity was reported among healthcare workers who had direct contact with pandemic-affected patients compared with lower-risk controls, and nurses and female healthcare workers were generally at a higher risk of pandemic-related psychological distress than were doctors; however, burnout-specific findings were not reported by clinical role or gender.
COVID-19 front-line workers appear to show high levels of personal accomplishment. The majority of respondents in Barello et al.'s (2020) study endorsed moderate-to-high levels of personal gratification, and the frequency of a low level of personal achievement was lower in the front-line group compared to the usual ward group (39% vs. 61%, p = 0.002) in Wu et al.'s (2020) study.
Four studies examined feelings of COVID-19-related exhaustion and fatigue, broadly, among healthcare workers. During the peak of the pandemic in Hubei province, Cai et al. (2020) conducted a survey in adjacent Hunan province. They found that older staff were more likely to experience exhaustion (p = 0.03). This finding is based on a single measure ("You feel exhausted") in a Likert-type scale. Results were not stratified by discipline.
Liu et al. (2020) phenomenologically explored the feelings of exhaustion and being overwhelmed that characterized the experience of front-line nurses and physicians working in Hubei province, the epicentre of the COVID-19 outbreak. The authors reported that COVID-19 working conditions were particularly onerous for nurses, who had the additional burden of facilitating activities of daily living for patients who were confined to their rooms, carrying out physician orders in order to minimize contact of other personnel with affected patients and supporting the emotional needs of patients whose families were not permitted to visit. In contrast, in a cross-sectional survey of healthcare workers in early-to-mid-pandemic Henan province, M. Zhang et al. (2020) found that nurses were not statistically significantly different from doctors in terms of their likelihood of experiencing fatigue (OR = 0.81, 95% CI [0.54, 1.23]). M. Zhang et al.'s (2020) study measured fatigue with a single item regarding feelings of fatigue after the onset of the outbreak. Those with five to nine years of work experience were less likely to experience fatigue compared to those with less than five years of experience (OR = 0.64, 95% CI [0.43, 0.95], p < 0.05) (M. Zhang et al. 2020).
Finally, both Sun et al. (2020) and Y. Zhang et al. (2020) qualitatively explored the psychological adaptation process of nurses providing direct care to COVID-19-affected patients – the former in early-to-mid-pandemic Henan and the latter in peak-pandemic Hubei. Both studies indicated that although negative emotions, including fatigue, ambivalence and EE, were pervasive prior to and immediately after entering the isolation wards, psychological adaptation occurred in the subsequent weeks. Sun et al. (2020) reported that 70% of nurses in their study had predominantly positive emotions after one week in the negative pressure ward. Our search procedure did not identify any intervention studies focused on burnout or closely related constructs.
Although none of the selected studies specifically examined moral distress as a distinct construct, aspects of moral distress were addressed in some papers. For example, Morgantini et al. (2020) indicated that almost 15% of the respondents in their international survey were forced to make life-prioritizing decisions due to resource shortages, and 32% felt pushed beyond their training (the authors did not report differences on these items by occupational role). Similarly, in their phenomenological study of nurses and physicians from COVID-19-designated hospitals in Hubei province, Liu et al. (2020) described the feelings of powerlessness experienced by participants in treating patients outside their areas of expertise, and with inadequate personal protective equipment (PPE) and limited staff. Our search procedure did not identify any intervention studies focused on moral distress.
Role of Nurse Leaders
The selected literature indicates that nurse leaders play a crucial role in supporting the mental health needs of nursing staff, minimizing burnout and ensuring the sustainability of the nursing workforce during the COVID-19 pandemic. Y. Zhang et al. (2020) found that the multifaceted support provided by nurse leaders promoted nurses' psychological adaptation to COVID-19 working conditions. Liu et al. (2020), likewise, described the critical role of nurse managers in orienting nursing staff seconded from disparate specialties to the infectious diseases environment. However, the authors also highlighted the inherent logistical challenges for nurse leaders in coordinating personnel.
Box 1 provides an overview of recommendations for nurse leaders based on the included studies. These recommendations pertain to the provision of psychological support, modifications to nursing shifts and pandemic preparation.
|Box 1. Recommendations for nurse leaders|
Adjustments to nursing shifts
This rapid review synthesizes empirical research on COVID-19-related burnout and moral distress in nurses from the first wave of the COVID-19 pandemic. In general, nurses appear to be at a high risk of burnout, particularly in the early stages of care provision to pandemic-affected patients (Barello et al. 2020; Kisely et al. 2020; Morgantini et al. 2020; Sun et al. 2020; Y. Zhang et al. 2020). Front-line, female, younger and less experienced nurses may be particularly vulnerable to pandemic-related adverse psychological effects, including emotional exhaustion (Kisely et al. 2020; Morgantini et al. 2020; M. Zhang et al. 2020; Y. Zhang et al. 2020). The disruption of household activities due to increased workload and fear around exposing family members to the virus were also identified in three studies as predisposing factors for burnout and other psychological effects of working conditions during a pandemic (Kisely et al. 2020; Liu et al. 2020; Morgantini et al. 2020).
While our search did not generate any papers that specifically examined pandemic-related moral distress in nurses, it does appear that front-line healthcare workers generally may be at risk of distress due to having to work without adequate resources and outside their usual scope of practice or training (Morgantini et al. 2020; Liu et al. 2020).
However, the selected literature also provides further evidence of the resilience of the nursing workforce in responding to the extraordinary challenges of pandemics. In the context of the COVID-19 crisis, nurses have shown high levels of psychological adaptation, energy renewal, growth under pressure, sense of personal accomplishment and dedication to the profession (Barello et al. 2020; Sun et al. 2020; Wu et al. 2020; Y. Zhang et al. 2020). This review also suggests that while nurse leaders must negotiate the complex and rapidly changing landscape of the COVID-19 pandemic, they play a critical role in supporting the psychological well-being of nursing staff (Y. Zhang et al. 2020). Our review points to some measures that nurse leaders can take to mitigate burnout, moral distress and other psychological effects in their nursing staffs. These include fostering a supportive work environment, facilitating access to mental health interventions and being vigilant to the psychological needs of younger and less experienced nurses (Kisely et al. 2020; Morgantini et al. 2020; Sun et al. 2020; Y. Zhang et al. 2020). In addition, to the extent that they are able, nurse leaders should make adjustments to nursing shifts to allow for adequate rest and account for the additional demands of infection control measures (Kisely et al. 2020; M. Zhang et al. 2020; Y. Zhang et al. 2020), provide training on infection prevention and control and ensure access to and proper use of PPE (Kisely et al. 2020; Liu et al. 2020; Morgantini et al. 2020; M. Zhang et al. 2020; Y. Zhang et al. 2020).
This rapid review has several limitations that may impede the translation of the findings. Rapid reviews are inherently less rigorous than systematic reviews. Although we performed a robust search, we omitted certain steps in order to expeditiously synthesize the current research for the field. For instance, we did not perform data extraction in duplicate, as is best practice (Higgins and Green 2011). Furthermore, we included a preprint article (i.e., Morgantini et al. 2020) that had not yet undergone peer review. Although preprints should not be relied on to guide clinical practice or health-related behaviour, we felt that due to the urgency in deploying available knowledge related to the pandemic, and as this particular paper offered a unique global comparative perspective, it was prudent to include it. As Morgantini and colleagues (2020) suggested based on their analysis, strategies to address pandemic-related psychological effects among healthcare workers must take socio-cultural contexts into consideration.
The majority of the selected studies in the current review were conducted in Central China in the early days of the pandemic; thus, the findings may not be generalizable to the Canadian context or reflective of the current state of the pandemic. Features of the Chinese society and governance, including centralized political control, mobilization capacity (e.g., the ability to swiftly marshal healthcare personnel, medical equipment and infrastructure, and intensive surveillance technology) and high behavioural compliance, create a vastly different ecology in terms of pandemic response compared to the North American landscape (He et al. 2020; Liang 2020; Nkengasong 2020). In addition, China's institutional and social memory of the severe acute respiratory syndrome (SARS) pandemic may have better prepared both healthcare workers and the general public to address the practical and psychological challenges of the pandemic (Chen et al. 2020; He et al. 2020). Nevertheless, there are important lessons to be learned from the common experiences of nurses and other front-line healthcare workers globally. From the literature, there appear to be some fairly consistent risk factors for psychological sequelae among nurses across countries, and in the absence of research or guidelines from the North American context, mitigation strategies from other countries that are further along the curve fill an important void.
Finally, we took a broad view of burnout and moral distress due to the definitional and conceptual ambiguity described earlier. This, combined with the methodological heterogeneity among the selected studies, including in the operationalization of the burnout and moral distress constructs, makes interpretation difficult.
The COVID-19 pandemic is placing unparalleled pressure on a nursing workforce already under considerable mental strain due to an overloaded system. Nurses appear to be at high risk for burnout as a result of the working conditions during the ongoing COVID-19 crisis. Nurse leaders play an important role in supporting nurses' psychological adaptation to the pandemic environment and ensuring the sustainability of the nursing workforce. Further research is needed to understand the long-term impacts of pandemic-related burnout and moral distress in nurses, particularly in the Canadian context, as well as the experiences of nurse leaders in supporting the mental health needs of their teams. Prospective studies investigating interventions to mitigate the psychological sequelae of emerging viral outbreaks in nurses will strengthen the public health response to future pandemics.
This research was supported by a Canadian Institute for Health Research Operating Grant named Knowledge Synthesis: COVID-19 in Mental Health & Substance Use.
About the Author(s)
Abi Sriharan, MSc, DPhil, Assistant Professor and Program Director Systems Leadership and Innovation, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
Keri J. West, MSW, PhD Candidate, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON
Joan Almost, RN, PhD, Associate Professor, School of Nursing, Queen's University, Kingston, ON
Aden Hamza, RN, MScN, Policy Advisor, Policy and Government Relations, Canadian Nurses Association, Ottawa, ON
Correspondence may be directed to: Abi Sriharan, MSc (Oxon), D. Phil, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Rm 462, Toronto, ON M5T 3M6. She can be reached by phone at 416-946-0911 and by e-mail at firstname.lastname@example.org
The authors acknowledge the contribution by Ana Patricia Ayala and Sabine Caleja, who helped with article retrieval and screening. Hilary Pang and Dongjoo Daniel Lee helped with full-text data extraction.
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