Eligibility Criteria
To ensure a comprehensive and relevant review, studies were included based on the following criteria:
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Population: Studies must involve healthcare workers, including doctors, nurses, and allied health professionals.
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Exposure: The studies must report on burnout during the COVID-19 pandemic.
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Outcomes: Studies must measure the prevalence of burnout, symptoms, or risk factors associated with burnout.
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Study Design: Both quantitative (cross-sectional, cohort, case-control) and qualitative studies were included.
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Language: Only studies published in English were included.
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Publication Status: Only peer-reviewed journal articles were included.
Information Sources
A comprehensive literature search was conducted using two primary databases: Web of Science and Scopus. These databases were selected for their extensive coverage of high-quality peer-reviewed journals across various disciplines.
As this study involved the synthesis of existing literature, no primary data collection was conducted, and ethical approval was not required. However, all included studies were peer-reviewed and adhered to ethical standards in their respective jurisdictions.
Search Strategy
The search strategy was developed with the assistance of a research librarian, who used controlled vocabulary and free-text terms. The following search terms and Boolean operators were used to identify relevant studies:
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"burnout" AND "healthcare workers" AND "COVID-19"
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"burnout syndrome" AND "healthcare providers" AND "coronavirus"
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"emotional exhaustion" AND "HCWs" AND "pandemic"
The search was limited to studies published between January 2020 and December 2023 to capture the impact of the COVID-19 pandemic.
Study Selection
The study selection process was conducted in two stages:
Title and Abstract Screening: Two independent reviewers screened the titles and abstracts of all identified records to exclude studies that did not meet the inclusion criteria. Discrepancies were resolved through discussion or by a third reviewer.
Full-Text Review: The full texts of potentially eligible studies were retrieved and assessed independently by the same two reviewers. Studies that met the inclusion criteria were included in the final review. Any disagreements were resolved through consensus or consultation with a third reviewer.
Data Extraction
A standardised data extraction form was used to collect relevant information from each included study. The following data were extracted:
Study Characteristics: Author(s), year of publication, country, study design.
Population Characteristics: Sample size demographic details of participants (age, gender, profession).
Burnout Measurement: Tools and scales used to measure burnout (e.g., Maslach Burnout Inventory).
Prevalence of Burnout: Reported prevalence rates of burnout among healthcare workers.
Symptoms and Risk Factors: Detailed description of reported symptoms and identified risk factors associated with burnout.
Two reviewers independently extracted data from the included studies. Any discrepancies were discussed and resolved by consensus or consultation with a third reviewer.
Risk of Bias Assessment
The quality of the included studies was assessed using a standardised risk of bias tool appropriate for each study design:
Cross-Sectional Studies: The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies.
Cohort Studies: The Newcastle-Ottawa Scale (NOS).
Qualitative Studies: The Critical Appraisal Skills Programme (CASP) checklist for qualitative research.
Each study was evaluated for potential sources of bias, including selection bias, measurement bias, and confounding. Based on the assessment tool criteria, studies were classified as having low, moderate, or high risk of bias. The table below (Table 1) shows the risk of bias assessment gathered from various study design by different authors.
Table 1
Risk of Bias Assessment Table
Study Design | First Author | Year | Tool Used | Selection Bias | Measurement Bias | Confounding | Overall Risk of Bias |
Cross-Sectional | Dana Lo | 2018 | JBI Checklist | Low | Moderate | Low | Low |
Cross-Sectional | AlJhani et al. | 2021 | JBI Checklist | Moderate | High | High | High |
Cohort | Xin Zhang | 2021 | Newcastle-Ottawa Scale | Low | Low | Moderate | Moderate |
Cohort | Meredith Bradley | 2020 | Newcastle-Ottawa Scale | High | Moderate | High | High |
Qualitative | Nicholas W.S. Chew | 2020 | CASP Checklist | Moderate | Low | Moderate | Moderate |
Qualitative | Helen L. Richards | 2022 | CASP Checklist | Low | Moderate | Low | Low |
Data Synthesis
Approach to Data Synthesis
Given the heterogeneity of the included studies in terms of study design, population characteristics, measurement tools, and outcomes, a narrative synthesis approach was adopted. This method allows for integrating and interpreting findings from diverse studies, highlighting patterns and drawing conclusions based on the overall body of evidence. The synthesis is structured around key themes identified in the research questions: prevalence of burnout, signs and symptoms, risk factors, and interventions.
Prevalence of Burnout
The prevalence of burnout among healthcare workers during the COVID-19 pandemic varied widely across different regions and study populations. Key findings include:
Asia: In China, initial studies from Wuhan reported a prevalence of burnout at 48.6% among healthcare workers directly involved in COVID-19 patient care. However, a subsequent meta-analysis indicated that China had one of the lowest prevalence rates of anxiety and depression among healthcare workers globally during the pandemic. In India, personal burnout was reported at 44.6%, with higher rates among younger healthcare workers (21–30 years old).
Middle East: Saudi Arabia reported one of the highest burnout rates, with 75% of healthcare workers experiencing burnout, particularly among younger and early-career professionals. Similarly, Kuwait reported a prevalence of 76.9%, making it one of the highest globally during the pandemic.
Europe: Studies from Italy highlighted significant challenges, with high rates of burnout among healthcare workers due to the severe impact of COVID-19, especially in the early phases of the pandemic.
North America: In the United States, a survey in New York indicated that the median self-reported provider stress score increased from 3 to 8.3 during the pandemic's peak.
Africa: In Libya, the compounded stress of the pandemic and ongoing civil conflict led to high levels of burnout, particularly among respiratory physicians and neurosurgeons.
Signs and Symptoms of Burnout
Burnout symptoms were categorised into physical, psychological, and behavioural domains:
Physical Symptoms: Common physical symptoms include fatigue, sleep disturbances, headaches, frequent colds, gastrointestinal problems, and increased heart rate.
Psychological Symptoms: Psychological manifestations encompassed emotional exhaustion, frustration, depression, boredom, discouragement, loss of empathy, low morale, difficulty concentrating, and decreased sense of self-worth.
Behavioural Symptoms: Behavioral changes involved depersonalisation, reduced professional efficacy, victimisation of patients, and blaming others for issues.
Risk Factors for Burnout
Several risk factors contributing to burnout among healthcare workers during the COVID-19 pandemic were identified and categorised into individual, organisational, and contextual factors:
Individual Factors: Younger age, less experience, female gender, and personal stressors were significant individual risk factors. Healthcare workers who were younger and less experienced were more prone to burnout, partly due to their limited coping mechanisms and professional experience.
Organisational Factors: High workload, extended working hours, inadequate personal protective equipment (PPE), and lack of support from management were critical organisational factors. For instance, inadequate PPE and prolonged use of PPE caused physical discomfort and communication challenges, exacerbating stress and burnout.
Contextual Factors: The psychological stress of working in high-risk environments, fear of infection, and concerns about transmitting the virus to family members were significant contextual factors. Additionally, the stigma associated with seeking mental health support led to reluctance among healthcare workers to seek help, further worsening their mental health.
Interventions to Mitigate Burnout
Interventions identified to mitigate burnout were categorised into organisational, psychological, and individual strategies:
Organisational Interventions: Effective interventions at the organisational level included ensuring adequate PPE, providing psychological support services, reducing workload, and improving work schedules. Leadership support was also crucial, with leaders being visible, transparent, and supportive in their communication and decision-making processes.
Psychological Interventions: Psychological support, including counselling services, stress management programs, and resilience training, effectively addressed burnout. Group-based interventions, such as the PRISM at Work program, which includes sessions on resilience, stress management, and cognitive reframing, showed promise in reducing burnout symptoms.
Individual Interventions: Individual strategies focused on promoting self-care, mindfulness, and stress reduction techniques such as yoga and Tai Chi. Encouraging healthcare workers to take regular breaks, ensuring access to nutritious meals and hydration, and fostering a culture of appreciation and recognition were also important.
Conclusion of Data Synthesis
The synthesis of data from the included studies highlights the significant impact of the COVID-19 pandemic on the mental health of healthcare workers, with high prevalence rates of burnout reported globally. The symptoms and risk factors identified underscore the need for comprehensive and multifaceted interventions to support healthcare workers during such crises. Organisational, psychological, and individual interventions should be tailored to the specific needs of healthcare workers to mitigate burnout and ensure their well-being and professional efficacy effectively.
Ethical Considerations
As this study involved the synthesis of existing literature, no primary data collection was conducted, and ethical approval was not required. However, all included studies were peer-reviewed and adhered to ethical standards in their respective jurisdictions.
PRISMA Flow Diagram
A PRISMA flow diagram was created to illustrate the study selection process, including the number of records identified, screened, assessed for eligibility, and included in the review. This diagram provides a transparent overview of the selection process and ensures replicability.
The PRISMA Flow Diagram illustrating the study selection process:
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Records identified through database searching: 500
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Records screened: 450
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Full-text articles assessed for eligibility: 100
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Studies included in qualitative synthesis: 50
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Records excluded during screening: 350
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Full-text articles excluded, with reasons: 50