Anxiety and burnout in infectious disease nurses: the role of perceived stress and resilience

Burnout, a syndrome precipitated by chronic occupational stress, manifests predominantly as emotional exhaustion, engendering a cascade of adverse health outcomes including respiratory complications, cardiovascular disorders, gastrointestinal issues, cephalalgias, type 2 diabetes, and chronic fatigue [1]. Moreover, this condition exerts profound impacts on mental health, materializing as depressive episodes, anxiety disorders, sleep disruptions, and suicidal contemplations [2, 3]. The Maslach Burnout Inventory delineates three core components: persistent emotional exhaustion (EE), depersonalization (DP), and diminished personal accomplishment (PA) [4, 5]. A meta-analysis of data from 1,986 nurses elucidated prevalence rates of 31% for elevated emotional exhaustion, 18% for increased depersonalization, and 46% for decreased personal accomplishment [6]. Within the healthcare sector, particularly amongst nursing professionals, burnout is a pervasive psychosocial phenomenon. Prolonged exposure to burnout leads to a decline in work engagement, exacerbating feelings of weariness and self-doubt [7]. Nurses grappling with burnout are predisposed to committing errors, displaying reduced compassion, and delivering substandard care, thereby jeopardizing patient safety [8, 9]. Thus, addressing burnout among nursing staff is paramount, essential for sustaining superior patient care, retaining skilled personnel, safeguarding the welfare of healthcare providers, and fostering a nurturing work environment.

Conversely, anxiety is typified by feelings of trepidation, disquietude, and strain, encompassing emotional, cognitive, and behavioral facets. While a moderate degree of stress can elicit motivation and excitement, chronic anxiety can detrimentally affect mental and physical health, alongside undermining occupational efficacy. Its impact on professional performance manifests as impaired cognitive function, diminished productivity, and an escalation in errors [10]. Healthcare practitioners enduring protracted anxiety are susceptible to burnout, with potential cascading effects into chronic stress and disrupted sleep patterns [11]. Hence, the effective management of persistent anxiety is imperative for preserving professional competence and overall wellness in healthcare professionals. Simultaneously, exacerbated anxiety is correlated with maladaptive coping strategies, such as increased substance abuse, exacerbated stress, depression, and suicidal inclinations [4]. Nurses, in particular, are at an elevated risk of experiencing high-stress levels [5]. In a recent study involving 1,807 registered nurses, investigators discerned that 43.4% manifested symptoms indicative of anxiety [12]. The authors of a study examined anxiety and related factors among 1807 registered nurses, finding that 43.4% exhibited signs of anxiety. Another research conducted corroborated these findings, showing that 37.3% of nurses suffered from anxiety symptoms, which were linked to a myriad of personal and occupational determinants [13]. These determinants consisted of marital status and household income as personal factors, and specialty and duration of employment as job-related elements. Moreover, investigations have revealed that frontline nurses have encountered escalated anxiety levels during the COVID-19 pandemic. Implementing interventions aimed at alleviating anxiety could prove instrumental in shielding nurses from adverse consequences.

The COVID-19 pandemic has had a profound impact on global economies, healthcare infrastructures, and public health frameworks [14]. It is imperative to acknowledge that the COVID-19 crisis led to significant biological and psychosocial hazards among nurses [15]. Research has identified a substantial correlation between experiences of burnout and intentions to resign within one year among 3,030 nurses during this pandemic. Over 64.3% of nurses reported experiencing burnout, while 36.5% expressed intentions to depart from their hospital employment, respectively [8]. Moreover, prior investigations have demonstrated that the heightened workload during the COVID-19 pandemic contributed to substantial burnout among nursing staff, precipitating issues such as insomnia, workplace aggression, and substance misuse [9, 16, 17]. Post-pandemic, governments worldwide are recalibrating their infectious disease control strategies to better reflect contemporary epidemiological conditions. Nurses specialized in infectious diseases bore the brunt of frontline care during the outbreak, resulting in notable burnout [18]. However, there remains a paucity of data regarding their psychological health and burnout levels in the post-COVID-19 era. Although there is mounting evidence pertaining to COVID-19-induced burnout, anxiety, and perceived stress among nurses, existing research lacks a comprehensive exploration of the interplay between burnout and anxiety concerning these variables. Consequently, this study endeavors to examine the degrees of anxiety and perceived stress among nurses specializing in infectious diseases, and to elucidate how anxiety influences stress and burnout after the COVID-19 breakout.

Lately, numerous studies have concentrated on the stress and exhaustion faced by clinical nurses, especially during the outbreaks of the COVID-19 pandemic [8, 9, 34]. The happiness and burnout levels of nurses have become a topic of heightened concern [45]. Due to the high-stress environments, extended shifts, and emotional difficulties that infectious disease nurses frequently encounter, the purpose of this study was to explore the relationship between anxiety, perceived stress, and burnout, revealing anxiety affects burnout directly as well as indirectly. Furthermore, this research introduces a novel moderated mediation model to elucidate the complex relationship between anxiety, perceived stress, and burnout in infectious disease settings. Drawing from earlier research and theoretical frameworks, we developed a model that incorporated the perceived stress as a mediator and resilience as a moderator in the relationship between anxiety and burnout (see Fig. 3).

Previous research has underscored the significance of addressing burnout among nurses. Consistent with the findings of the present study, prolonged shift work schedules and excessive work-related stress emerged as primary contributors to burnout among nurses [46]. In our study, approximately four in five nurses presented burnout. This proportion was higher than reported previously [47, 48], particularly in terms of emotional burnout and diminished personal achievement, warranting greater focus. The perceived stress level in this study was notably higher than that of general nurses in China [49], highlighting the need to address perceived stress among infectious disease nurses. The average level of resilience in this study was consistent with previous study (55.88 ± 14.77, n = 845) [43]. Similarly, compared with the previously reported score for emergency department nurses (20.90 ± 11.78, n = 571) [44], the level of EE in our research had no statistical differences, which indicated that nurses working in emergency department and infectious disease department showed the similarly severe burnout.

A prior cross-sectional study conducted in China on nurse burnout and work quality revealed that approximately 64% of nurses experienced job burnout, with factors such as hospital classification, age, income, shift work assignments, and nurse-to-doctor ratio affecting quality of life and work [46]. Nevertheless, given that this prevalence significantly differs across various populations and clinical wards [50], it would be more suitable to analyze the contributing factors. This study showed that burnout is more pronounced in lower-titled and younger groups of nurses working in the infectious disease ward. The reason for this may be that nurses with lower-titled or young age are given simpler tasks and less responsibility; as a result, they may feel unfulfilled at work, leading to a lack of personal fulfillment [51]. In line with previous studies, our study showed that weekly working hours, shift work and years of experience were influencing factors in the emotional exhaustion dimension in the infectious disease ward [52, 53]. There are many work stressors for nurses in China, including heavy workloads and many non-nursing tasks. Nurses in the infectious disease unit encounter unique difficulties, such as frequent job-related exposure and heightened stress and exhaustion. However, 64.15% nurses in the infectious disease ward were involved in shift work and 46.23% nurses worked more than 40 h a week in our study. Obviously, nurses who were involved in shift work or worked longer hours per week are prone to exhaustion dimension, the nurse scheduling system should be optimized.

Furthermore, earlier studies demonstrated that 41.18% had different degrees of anxiety among healthcare professionals during the pandemic of COVID-19 [11]. The study found anxiety and perceived stress were positive predictors of Emotional Exhaustion (EE). These results align with earlier research indicating that increased stress and anxiety lead to more pronounced EE [54]. EE, considered the core component of the Maslach burnout model, is characterized by feelings of emotional depletion and fatigue [24]. Additionally, EE has been linked to other burnout symptoms such as depersonalization (DP) and cynicism [55]. The Hans Selye’s General Adaptation Syndrome (GAS) stress model has been proposed as a suggested as a basis for comprehending and forecasting the effects of EE. According to this model, stress responses progress through three stages: alarm, resistance, and exhaustion, with EE being a common outcome when stress reaches its peak. The combination of increased workplace stress and longer shifts may contribute to sleep deprivation and emotional exhaustion, which are major contributors to mental health problems and burnout [56].

The primary outcome of the analysis indicates that anxiety exerts both a direct and indirect impact on emotional exhaustion (EE), the latter mediated by perceived stress. These results were consistent with other research which found anxiety and perceived stress are closely related to job burnout [22]. Consistent with the previous hierarchical regression analysis [57], we found stress-burnout relationships were influenced by resilience. Among nurses in infectious disease ward with lower resilience, perceived stress has a more pronounced effect on EE compared to those with higher resilience levels. This study’s findings corroborate previous research on the protective effects of resilience in emotional exhaustion [46].

The ability of people to successfully handle and bounce back from difficult situations, known as resilience, has been associated with improved performance on the job and relieved emotional exhaustion (EE) [58]. Studies have repeatedly shown resilience was important to prevent mental health problems [59]. The resilience of nurses can be influenced by challenging work conditions, feelings of psychological emptiness, a disruption of inner balance, and mental conflict. Strategies for enhancing resilience encompass cognitive reframing, developing emotional fortitude, and fostering a sense of grounding connections, work-life balance, and reconciliation [60].

In the aftermath of COVID-19, nurses’ resilience is crucial due to various reasons. To begin with, nurses frequently encounter numerous pressures and obstacles in both their work and personal lives, which restrict their chances for relaxation and maintaining healthy social interactions. Developing high levels of psychological resilience can enhance their ability to communicate effectively and foster positive psychosocial relationships. Secondly, the prolonged shift work and high levels of work-related stress experienced by clinical nurses can adversely affect their quality of sleep. Neurobiological aspects of sleep quality and psychological resilience suggests that individuals with higher levels of resilience are less affected by perceived stress compared to those with lower resilience [61, 62]. Furthermore, people with strong resilience demonstrate qualities like effective coping skills, positive outlooks, realistic optimism, and mental adaptability, which can aid in working well with parents and teams in stressful scenarios [27]. The influence of resilience on anxiety and burnout revealed that nurses experiencing higher anxiety and lower resilience consequently faced intense burnout.

The implications of this study are both theoretical and practical. The findings may provide insight into the mechanisms underlying the relationships between anxiety, perceived stress, resilience, and burnout. Additionally, by highlighting the mediating role of resilience, this study may inform interventions aimed at implementing resilience training to alleviate burnout among nurses. Specifically, resilience training, drawing from positive psychology, cognitive behavioral therapy, and mindfulness, is anticipated to mitigate or eradicate burnout and anxiety in individuals experiencing high levels of occupational stress [63]. Resilience training is anticipated to mitigate burnout and anxiety in individuals experiencing high levels of occupational stress, particularly clinical nurses. Previous studies have shown that mindfulness-based resilience training (MBRT) effectively reduces stress and emotional burnout among healthcare professionals [64]. Therefore, further research is necessary to assess how resilience training can reduce anxiety-related burnout and improve job satisfaction among clinical nurses working in infectious disease ward. Thus, upcoming research could consider utilizing a longitudinal or an experimental research design.

Alongside its merits, it is imperative to recognize certain limitations inherent to this study. This investigation utilizes a cross-sectional methodology, which inherently lacks the capacity to delineate temporal sequences, thereby complicating the establishment of causality. Absent knowledge regarding the chronological precedence of variables, we are precluded from confidently inferring causal relationships. Given that the cross-sectional framework provides solely a snapshot of the interrelations among burnout, anxiety, and perceived stress, it is incapable of depicting the evolution or transformation of these associations over time. Previous research on mediation analysis often overlooked temporal considerations, highlighting the potential for bias when employing a cross-sectional approach to investigate mediational dynamics. Drs. Judd and Kenny underscored the importance of incorporating prior assessments of both the mediator and the outcome within longitudinal mediation studies to minimize bias. Longitudinal investigations are indispensable for determining the causal influence of anxiety on burnout within nursing populations [65]. Moreover, this study’s reliance on self-reported measures may engender various biases. When addressing sensitive subjects, respondents may opt for answers deemed socially desirable instead of providing truthful responses. There is a likelihood that participants may exhibit systematic responding (such as selecting median options) or be swayed by question phrasing. Additionally, self-report data hinge on individuals’ subjective perceptions and interpretations, which might diverge from objective realities. Subsequent investigations should embrace a diversity of methodological approaches for evaluating stress and burnout.

Our findings revealed that age, professional designation, weekly working hours, shift work, and years of working were statistically significant predictors of emotional exhaustion among nurses in infectious disease wards. Although causality remains unestablished, our results suggest that policymakers and nursing leaders should prioritize improvements in the nurse scheduling system, maintain equitable patient-to-nurse ratios, and foster professional development to alleviate or prevent job burnout in infectious disease nurses. Moreover, it is imperative for supervisors to encourage infectious disease nurses to incorporate established stress-reduction practices, such as mindfulness exercises, relaxation strategies, and efficient time management techniques. Promote the sharing of experiences, challenges, and coping mechanisms among nurses through peer support networks. To enhance resilience among infectious disease nurses, managers ought to periodically evaluate current resilience levels utilizing validated instruments such as the Resilience Scale, and design a customized resilience program comprising modules on stress management, emotional control, and positive mindset cultivation.

Nurses specializing in infectious diseases report elevated levels of anxiety, perceived stress, and burnout. Anxiety not only has a direct impact on burnout but also indirectly influences it through its effect on perceived stress, which is acknowledged as mediating the relationship between anxiety and burnout. This research highlights that resilience significantly contributes to stress management and the prevention of burnout. Further studies are warranted to elucidate the determinants that foster resilience, mitigate burnout, and enhance well-being. Additional research is imperative to uncover the causal mechanisms elucidating factors that enhance resilience, diminish burnout, and augment well-being. Employing longitudinal methodologies, researchers could examine temporal variations in burnout among nurses in infectious disease specialties, track fluctuations in anxiety and stress, and ascertain the impact of resilience training and stress management techniques on occupational satisfaction. The findings herein recommend that administrative bodies implement resilience training programs focusing on stress management, emotional regulation, and coping strategies. Supervisors are advised to devise targeted strategies promoting work-life equilibrium via policies enabling flexible scheduling and adequate leave, alongside establishing robust support systems encompassing mentorship initiatives, peer assistance groups, and access to counseling resources.