Social Support and Resilience Are Protective Factors against COVID-19 Pandemic Burnout and Job Burnout among Nurses in the Post-COVID-19 Era

1. Introduction

The COVID-19 pandemic has been a major challenge for citizens, health systems and health professionals. The effort to reduce the transmission of the virus and control the pandemic involved a series of stringent measures that restricted the social and professional life of citizens. At the same time, however, there have been massive hospital admissions of patients with COVID-19, with a significant proportion of them requiring intensive care in intensive care units, which have been a major test of the resilience both the health systems and health professionals, particularly nurses who have been on the front line.

The response of governments worldwide to the spread of pandemic COVID-19 included a series of stringent measures, including restrictions on citizens' mobility, professional activities, interruption of education, restrictions on travel and entertainment [1]. The most stringent measure of all was quarantine. Despite the effectiveness of these measures, there have been significant effects on the well-being of citizens. There was a significant incidence of loneliness, agitation, depression, anxiety, irritability and mental distress, as well as stress, psychological distress and a deterioration in quality of life [2,3,4,5,6]. Also, the fear of infection of both the individuals and those close to them was a factor that had a negative impact on their mental health [7]. Even after the end of quarantine period, people continued to experience symptoms of depression, anxiety and acute stress disorder condition, according to findings from longitudinal studies [8,9]. This constant exposure to stress can lead to burnout. According to Maslach and Leiter the burnout is a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job, and the characteristics of its three dimensions include the loss of energy, depletion, debilitation, and fatigue, irritability, loss of idealism, and withdrawal, reduced productivity or capability, low morale, and an inability to cope [10]. However, during the pandemic period the incidence of burnout was not limited to workers, but the general population also experienced symptoms of burnout [11,12,13]. The existing literature on nurses' burnout is exclusively related to burnout from work. To the best of our knowledge, the present study is the first to investigate the effect of social support and resilience of nurses on COVID-19 pandemic burnout among nursing staff.

The burnout of nurses is a long-standing problem. Before the pandemic period, the incidence of burnout among nursing staff was as high as 50% of the staff [14,15]. Research on burnout has highlighted a significant number of mainly organizational factors associated with the occurrence of burnout in nurses. In particular, the work environment characterized by lack of staff and resources, high workload, inability of leadership to support staff, poor working relationships between doctors and nurses and the lack of nurses' involvement in hospital issues, ≥ 12-h shifts, time pressure, high job and psychological demands and low autonomy constitute the factors that contribute to the occurrence of burnout [16,17,18,19,20]. The outcomes of burnout affect both patients and nursing staff. Concerning nurses, burnout has been associated with reduced job performance and intention to leave, and concerning patients, burnout can result in poor quality of care, poor patient safety, adverse events, patient negative experience, medication errors, infections and patient falls [20,21]. The organizational weaknesses became even more pronounced during the pandemic, as the mass admission of patients with COVID-19 increased the workload and work intensity. This high workload combined with nursing understaffing, lack of resources and longer working time in quarantine areas, increased the likelihood of developing burnout [22,23]. Even now in the post COVID-19 era, where the impact of the pandemic on health systems has been significantly reduced and the functioning of health organizations has been normalized, burnout continues to have a very high incidence among nurses compared to other healthcare professionals [24]. This can be explained by the fact that organizational problems remain unresolved and that the impact of the pandemic on nurses is still quite recent.

In the demanding work environment with the highly stressful nature of nurses' work, the support that they should receive to cope with their daily challenges is particularly crucial. One such form of support is social support, which, in general, refers to psychological or material resources that are provided to a focal individual by partners in some form of social relationship [25]. The source of social support can be family members, friends, work colleagues, supervisor or the organization. Social support can be provided in four forms [26]. The first is the emotional support, which involves provision of caring, empathy, love, and trust; the second one, instrumental support, concerns the provision of tangible goods, services, or concrete assistance. The third form, informational support, contains information provided to another during a time of stress, and also Informational support assists one to problem solve. The fourth form is the appraisal support, which is consisting of the communication of information that is relevant to self-evaluation rather than problem solving. Regardless of the source and type of social support, studies have shown their positive impact on healthcare workers. In particular, the benefits in the field of mental health are significant. Medical staff who receive social support experience lower levels of anxiety and stress, and also report better self-efficacy and sleep quality [27]. Low supervisor support of healthcare professionals is associated with higher levels of secondary traumatic stress [28], and low perceived support by friends predicts burnout [29]. Nurses who perceive higher organizational and social support are more likely to report lower anxiety related to COVID-19 [30]. Also, the social support that nurses receive from family and significant others outside the family protects them from developing burnout, anxiety and depression [31]. The support that nurses receive in the workplace from supervisors and coworkers was found to play a fundamental role in preventing the burnout syndrome [32].

One characteristic of nurses that can help them cope with their demanding work environment is resilience. Although resilience has been recognized as a trait, as a process and as an outcome, its acceptance as a dynamic process enables the individual to develop it [33]. In the context of nursing, resilience can be defined as a «…. complex and dynamic process which when present and sustained enables nurses to positively adapt to workplace stressors, avoid psychological harm and continue to provide safe, high-quality patient care» [33]. According to this definition, resilience is fundamental to maintaining the mental health of nurses in their efforts to provide high quality care. In particular, resilience is negatively associated with burnout, secondary traumatic stress and positively associated with compassion satisfaction [34,35], as well as playing a protective role in the development of depression [36]. Among the sources of resilience are environmental-systemic factors, which include social support [37]. Studies have shown the positive correlation between nurses’ social support and resilience [38,39].

To the best of our knowledge, there are no studies that investigated the relationship between social support and resilience and COVID-19 pandemic burnout and job burnout among nurses in the post-COVID-19 era. Thus, the aim of this study was to examine the impact of social support and resilience on COVID-19 pandemic burnout and job burnout in a sample of nurses.

2. Materials and Methods

2.1. Study design

The World Health Organization declared officially the end of COVID-19 pandemic as a public health emergency on 5 May 2023, but by the summer of 2022 the waves of the pandemic had receded, the number of hospital admissions had significantly decreased and health systems had returned to their pre-pandemic operation. Thus, we conducted a cross-sectional study during September 2022 to examine the impact of social support and resilience on COVID-19 pandemic burnout and job burnout in the post-COVID-19 era.

We collected data from a convenience sample of nurses in Greece. We developed an online Greek version of the study questionnaire with Google forms. We disseminated the questionnaire through Facebook, Instagram and LinkedIn. Moreover, we sent the questionnaire to our e-mail contacts. Nurses who were working in healthcare services during the COVID-19 pandemic and those who understand Greek language can participate in our study. We collected data in an anonymous and voluntary basis.

2.2. Measurements

We measured the following socio-demographic characteristics of nurses: gender (males of females), age (continuous variable), chronic disease (no or yes), self-perceived health status (very poor, poor, moderate, good, very good), SARS-CoV-2 infection (no or yes), providing care to COVID-19 patients (no or yes), and adverse effects because of COVID-19 vaccination (continuous variable).

We measured social support with the Multidimensional Scale of Perceived Social Support (MSPSS) [40]. The MSPSS includes 12 items and measures support from family, friend, and significant others. Total score ranges from 1 to 7 with higher values indicative of higher levels of social support. We used the valid Greek version of the MSPSS [41]. Cronbach’s alpha for the MSPSS in our study was 0.952.

We measured resilience with the Brief Resilience Scale (BRS) that includes six items [42]. Total score ranges from 1 to 5 with higher values indicative of higher levels of resilience. We used the valid Greek version of the BRS [43]. Cronbach’s alpha for the BRS in our study was 0.806.

We measured COVID-19 pandemic burnout with the Greek version of the COVID-19 burnout scale (COVID-19-BS) [44]. The COVID-19-BS is a specific tool to measure COVID-19-related burnout during the pandemic. The COVID-19-BS includes 13 items with a total score from 1 to 5. Higher scores on the COVID-19-BS are indicative of higher levels of burnout. The COVID-19-BS measures emotional exhaustion, physical exhaustion, and exhaustion due to measures against the COVID-19. Cronbach’s alpha for the COVID-19-BS in our study was 0.912.

We measured nurses’ burnout with one single item burnout measure [45]. The single item burnout measure has been established as a valid tool in Greek language [46]. In that case, nurses rated their job burnout in a scale from 0 (not at all burnout) to 10 (extreme levels of burnout).

2.3. Ethical considerations

We performed our study according to the guidelines of the Declaration of Helsinki [47]. We informed nurses about the aim and the study design, and they gave their informed consent to participate. We did not collect personal data of nurses. Additionally, the Ethics Committee of Faculty of Nursing, National and Kapodistrian University of Athens (reference number; 370, 02-09-2021) approved the study protocol.

2.4. Statistical analysis

We describe categorical variables with numbers and percentages. Also, we describe continuous variables with mean, standard deviation (SD), median, minimum value and maximum value. We used the Kolmogorov-Smirnov test and Q-Q plots to assess the distribution of continuous variables. We found that all continuous variables followed normal distribution. Independent variables were social support and resilience among nurses. COVID-19 pandemic burnout and job burnout were the dependent variables. We considered socio-demographic characteristics of nurses as confounders on the relationship between social support and resilience, and COVID-19 pandemic burnout and job burnout among nurses. First, we performed univariate linear regression analysis between each independent variable and COVID-19 pandemic burnout and job burnout. Then, we created two multivariable linear regression models with COVID-19 pandemic burnout and job burnout as the dependent variables to eliminate confounding causing by socio-demographic characteristics. We present unadjusted and adjusted coefficients beta, 95% confidence intervals (CI), p-values, and coefficients of determination (R²). We considered p-values <0.05 as statistically significant. Similarly, confidence intervals that included zero, were indicative of statistically significant relationships. We used the IBM SPSS 21.0 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) for the analysis.

3. Results

Our study population included 963 nurses. The majority of our nurses were females (88.4%). Mean age of nurses was 37.9 (SD=9.6). Among our sample, 25% had a chronic disease, while 71.8% have been infected by SARS-CoV-2 during the pandemic. Most of nurses (78.3%) self-assessed their health status as good/very good, while 7.3% considered their health status as moderate, and 4.4% considered it as very poor/poor. During the pandemic, 64.1% of nurses provided health care to COVID-19 patients. Table 1 shows the socio-demographic characteristics of nurses.

Descriptive statistics for the study scales are shown in Table 2. Nurses received high levels of social support (mean=6.0, SD=1.2), while their resilience was moderate (mean=3.5, SD=0.7). Median values for social support and resilience were 6.4 and 3.5, respectively. Additionally, nurses experienced moderate levels of COVID-19 burnout (mean=3.2, SD=1.0) and job burnout during the pandemic (mean=6.4, SD=2.6). Median values for COVID-19 burnout and job burnout during the pandemic were 3.2 and 7.0, respectively.

After eliminating confounders, we found that increased social support (adjusted beta = -0.075, 95% CI = -0.125 to -0.024, p-value = 0.004) and increased resilience (adjusted beta = -0.399, 95% CI = -0.491 to -0.308, p-value < 0.001) were associated with reduced COVID-19 pandemic burnout. Moreover, females (adjusted beta = 0.201, 95% CI = 0.024 to 0.378, p-value = 0.026) and nurses who provided care to COVID-19 patients (adjusted beta = 0.147, 95% CI = 0.031 to 0.263, p-value = 0.013) experienced higher levels of COVID-19 pandemic burnout. We found a positive relationship between the level of adverse effects because of COVID-19 vaccination and COVID-19 pandemic burnout (adjusted beta = 0.083, 95% CI = 0.061 to 0.105, p-value < 0.001). We present linear regression analysis with COVID-19 pandemic burnout as the dependent variable in Table 3.

Table 4 shows the results from linear regression analysis with job burnout as the dependent variable. After eliminating confounders, we found a negative relationship between social support and job burnout (adjusted beta = -0.263, 95% CI = -0.405 to -0.121, p-value < 0.001). A similar negative relationship was found between resilience and job burnout (adjusted beta = -0.529, 95% CI = -0.785 to -0.272, p-value < 0.001). Moreover, levels of job burnout were higher among nurses with a chronic disease (adjusted beta = 0.743, 95% CI = 0.367 to 1.119, p-value < 0.001), and those who provided care to COVID-19 patients (adjusted beta = 0.677, 95% CI = 0.353 to 1.002, p-value < 0.001). Additionally, we found a positive relationship between the level of adverse effects because of COVID-19 vaccination and job burnout (adjusted beta = 0.148, 95% CI = 0.086 to 0.210, p-value < 0.001).

4. Discussion

The present study highlighted the protective role of social support and resilience on the occurrence of nurses' work burnout and the one related to pandemic COVID-19. This study was the first that investigated nurses' burnout due to pandemic COVID-19 and its association with social support and resilience. Also, studies in the literature are limited to workplace burnout only and explore the relationship of social support and resilience with mental health, but not specifically with pandemic burnout.

The adoption of strict measures, such as quarantine, in response to the spread of the pandemic along with the fear of infection affected the mental health of general population together with nurses [48,49,50]. Nursing staff were not excluded from the implementation of the pandemic protection measures and in particular the quarantine, although they were allowed to move to and from work. The nurses therefore, on the one hand, experienced an extremely difficult working period with overtime work during the pandemic and on the other hand, returning home was not an option for any social activity. According to the Our World in Data database, the COVID-19 Stringency Index, is a composite measure based on nine response indicators including school closures, workplace closures, and travel bans, rescaled to a value from 0 to 100 (100 = strictest) [51]. In Greece, between March 2020 and February 2022, there were four periods when the value of this index exceeded 80, meaning that the measures in these periods were very strict. Therefore, prolonged periods of strict pandemic control measures by restricting social activities, the fear of infection, and at the same time the workload of nurses created a mixture of stressful conditions that favored the development of COVID-19 pandemic burnout. Also, among health professionals, nurses were found to have the highest rates of work-related burnout both during and after the pandemic [23,24]. These high rates of work-related burnout may have also influenced the burnout from the pandemic and may explain the findings of this study.

Social support and resilience are two important predictors of prosocial behaviors, as these behaviors refers to a wide range of actions such as helping, sharing, comforting, and cooperating, and are key elements for the proper functioning of society, especially in the face of a crisis such as COVID-19 [52]. During pandemic period, social support and resilience were identified as protective factors of the mental health of general population of different age groups and professional activities [53,54,55]. The populations’ benefits of social support and resilience remain significant even after the impact of the pandemic [56].

The positive effect of social support and resilience on nurses, who were the professional group with a very high incidence of burnout, was significant. In particular, when nurses do not receive adequate support from their supervisor, they are more likely to develop burnout [57]. Moral resilience can be an essential protective factor against high levels of job burnout, quiet quitting, and turnover intention among nurses [58]. Organizational support is also an important form of support for nurses, which is associated with burnout. When nurses receive recognition and their organization values their contribution and cares about their well-being, what is called perceived organizational support [59], and at the same time have high resilience, then the likelihood of burnout is reduced [60,61]. The most important forms of organizational support, that healthcare organizations should ensure for nurses, include organizational rewards, favorable job conditions, assistance to a nurse to perform tasks efficiently and manage stressful situations, and support from the supervisor [62].

Social support, also, have an impact on resilience. In particular, the more social support nurses receive, the better their resilience [63,64]. The resilience of nurses can also be fostered by the supervising nurse. The actions through which nurses' resilience is cultivated by supervisors include facilitating social connections, promoting positivity, capitalizing on nurses’ strengths, nurturing nurses’ growth, encouraging nurses’ self-care, fostering mindfulness practice and conveying altruism [65].

The present study highlighted nurses' care of patients with COVID-19 as a contributing factor to their pandemic and job burnout, as well as the existence of nurses' chronic disease as a predictor factor of job burnout. Nurses working in the nursing departments of patients with COVID-19 experienced extremely difficult conditions in and outside of their workplace. Outside the hospital in the community, they experienced the harsh quarantine measures with restriction on movement, were isolated in a different room of the house from the rest of the family or moved to another house on their own to avoid transmission of COVID to their family. They experienced stigma as their community members avoided socializing with them [66]. However, the support the nurses received, mainly from family and friends, helped them to have better mental health, and in particular less likelihood of fear, depression, anxiety, and stress [67]. The working conditions in the COVID-19 wards and ICUs were extremely stressful and burdensome for the nurses. High workload, overtime, negative ratings of workplace relations, organizational support, organizational preparedness, psychological support, workplace safety, and access to supplies and resources were characterized their working environment. These conditions led to the development of mental health issues such as burnout, depression, anxiety and post-traumatic stress disorder [23,68,69,70]. The existence of chronic disease by nurses increased their stress and fear of possible severe disease from COVID-19. During the pandemic, patients with chronic disease were identified as vulnerable groups, as they were more likely to experience severe disease, hospital admission and/or mortality from COVID-19, than those without chronic disease [71,72]. Studies have shown that the greater the nurses' fear of COVID-19 infection, the higher their degree of burnout, which is consistent with the findings of our study [73,74]. Support and attention from the organization, alongside building resilience, can help nurses manage the abundant physical and emotional stress while treating COVID-19 patients, who arose from risk of infection [75].

Our study had several limitations. First, we conducted a cross-sectional study to explore the impact of social support and resilience on COVID-19 pandemic burnout and job burnout in a sample of nurses in Greece. Although, we eliminated several confounders, the cross-sectional nature of our study did not allow inferring causal relationships between social support and resilience, and COVID-19 pandemic burnout and job burnout. Second, future studies should eliminate more confounders to establish a more valid relationship between social support and resilience, and COVID-19 pandemic burnout and job burnout among nurses. Additionally, we used self-reported questionnaires to measure social support, resilience, COVID-19 pandemic burnout and job burnout. Although, these scales are valid, information bias was probable in our study. Additionally, we used a convenience sample with unknown response rate. Thus, selection bias can arise in our study and we should generalize our results with caution. Further research with random and more representative samples of nurses can add valuable information. Studies in different countries and clinical settings are necessary to improve our knowledge. Moreover, longitudinal studies will offer substantial knowledge on the issue by monitoring changes in levels of social support, resilience and burnout among nurses.

5. Conclusions

The COVID-19 pandemic, containment measures and fear of infection have taken a toll on the mental health of the general population. Nurses were not excluded from this burden. According to our study, nurses experienced moderate levels of COVID-19 burnout and job burnout during the pandemic. Important protective factors of burnout, both pandemic and job burnout, were social support and resilience. Apart from the support that nurses can receive from family and friends, organizational support is also essential. Recognition of nurses' work, rewarding them and daily support from supervisors reduces burnout and fosters resilience. Nurses’ managers, stakeholders and organizations should adopt appropriate interventions to improve resilience and social support of nurses. In this context, negative consequences such as burnout may be reduced.