Introduction
Pandemics are considered an exceptional disaster with severe psychological effects, especially for health care workers (HCWs) who experience mental strain as frontline responders [
1]. This has been evidenced in previous disease outbreaks including Ebola and Severe Acute Respiratory Syndrome (SARS), whereby HCWs reported distress associated with increased chances of contracting these diseases [
2]. Such effects are known to be long-lasting with a study reporting that HCWs continued to experience negative mental health effects, including burnout, psychological distress and post-traumatic stress disorder (PTSD) one to two years after the SARS outbreak [
3].
The wellbeing of HCWs has been an ongoing challenge, with the World Health Organization (WHO) defining the state of wellbeing as one in which “an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and contribute to the community” [
4]. It is especially challenging within low and middle-income countries (LMICs) with growing evidence to suggest that HCWs are increasingly stressed and burned out. This has been attributed to reduced human resources for health as well as poor governance and management, thereby leading to reduced job satisfaction, absenteeism and high attrition among HCWs in these settings [
5,
6]. In the context of under-resourced settings such as South Africa with a vulnerable health system, characterized by critical shortages in staffing, uneven distribution of resources, and inadequate protective equipment among other shortfalls, the problem is further aggravated [
7]. It is therefore imperative that the wellbeing of HCWs be understood holistically, whereby the focus is on the complexity of various aspects that may be having an impact on them.
Coupled with increasing pressure for universal health care and the multiple disease burdens, the COVID-19 pandemic revealed major gaps in the current South African health system particularly related to the wellbeing of HCWs themselves [
7,
8]. Despite recurring evidence suggesting that nurses in particular experience a higher burden of care compared to other HCWs and suffer from stress-related outcomes at a rate of 80% more than workers from over 130 other high-stress occupations [
9], this problem has continued to persist. As the backbone of the health system and the first point of call during emergencies, South African nurses at the frontline of the COVID-19 pandemic experienced caring for infected patients while feeling exhausted, making difficult triage decisions, being isolated from their loved ones for prolonged periods, the stigma of contracting and spreading the infection, the loss of patients and colleagues, as well as fear of dying from the infection themselves [
1]. Such experiences and frustrations resulted in some nurses engaging in alcoholism with a potential mental disorder [
10]. During the last week of December 2020 when the country experienced a significant surge in infections by 105% with cases crossing the 1 million mark [
11], the Health Minister reported that nurses accounted for more than half of the infections among HCWs [
12]. The psychological impact of this may be known in other settings such as China with developed and research intense health systems, compared with the limited research in LMICs especially in the African region during the peak of the pandemic [
7].
Furthermore, nurses’ wellbeing is not often studied holistically, especially in under-resourced settings such as South Africa and the current study seeks to address this gap. Existing evidence suggests that nurses in particular have been impacted physically, mentally and psychosocially following the COVID-19 pandemic, thereby negatively affecting their quality of life [
13]. Increased stress, anxiety, burnout and hopelessness are higher among nurses than other HCW’s and contribute to the reduced quality of life [
14,
15]. This is important considering that in nursing research, wellbeing is often measured by the absence of mental health disorders, which according to Keyes 2005 [
16], encapsulates the absence of psychopathology. Arguably, wellbeing is all-encompassing and is known to help protect against the manifestation of mental health disorders, through resilience and coping mechanisms [
17,
18].
Exposure to prolonged stress is also known to compromise productivity and performance, especially when resilience is reduced [
19]. Resilience is protective of burnout through adaptation to changes [
20]. Several reviews have confirmed that the high levels of stress experienced by HCW’s during the pandemic are associated with burnout and poor wellbeing [
21]. Socio-demographic variables including gender and age have also been associated with higher stress, anxiety, depression and insomnia among HCWs during the pandemic [
22]. Additionally, supporting evidence from a meta-review of systematic reviews revealed that mental health disorders were prevalent among HCWs across all sectors globally [
23]. Unprecedented events are expected to result in a heightened risk of mental health disorders including post-traumatic stress disorder (PTSD), depression and anxiety disorders due to rapid and intensified changes in ways of functioning [
24]. More than four in every ten South African nurses were reported to be positively screened for PTSD, which is comparatively higher than nurses in other countries [
7]. Although there may be similarities in HCWs’ experiences during the pandemic, it is important to recognise that there have also been differences with HCWs responding heterogeneously about changes in their work dynamics and perceptions of psychologically safe work environments [
25].
There is a dearth of literature focusing on the impact of COVID-19 on the wellbeing of HCWs in the Global South [
7]. Particularly, little consideration has been given to the impact of the pandemic on South African HCWs who according to a report published by the World Health Organization (2020), showed higher rates of infections than other countries in the Southern Africa Development Community (SADC) region. Lack of resources, increased inequality, higher health risks for patients with tuberculosis (TB) and HIV as well as disparities between the public and private health care sectors resulted in unique challenges faced by HCWs in South Africa [
21]. A survey indicated that psychological stress among South African nurses was significantly higher than other HCWs, with almost 20% of nurses reporting severe distress [
26]. Two similar studies also showed that psychological support was lacking and contributed to poorer mental health outcomes among South African nurses [
27,
28]. Another South African study reported that COVID-19 infections were higher among nursing administrators and nursing staff compared to medical doctors [
29], possibly because nurses are the first point of contact. This may leave a disproportionate consequence of anxiety, depression, stress and burnout among nurses, with a need for identifying the most affected for psychosocial support and holistically improving their wellbeing.
To develop appropriate and contextually suitable strategies for supporting nurses during future health threats, it is essential to holistically understand the impact of the pandemic on South African nurses’ wellbeing. Supporting studies have emphasised the importance of viewing wellbeing to benefit employees and their institutions [
30,
31]. As such, investigating the association between burnout, coping, resilience, physical and mental health as well as anxiety and depression among South African nurses who worked in the frontline during the peak of the pandemic, will provide evidence-based insights into what is required for better preserving and protecting holistic wellbeing in the event of future disasters. In the context of South Africa, HCWs including nurses are twice as likely to leave their jobs compared to HCWs from other SADC countries due to difficult working conditions [
32]. This has serious implications for patient care and response to future health emergencies in the country [
7]. Therefore, the current study aimed to investigate the holistic wellbeing of South African nurses and their coping mechanisms during the peak of the COVID-19 pandemic.
Discussion
This study sought to investigate the association between burnout, coping, resilience, physical and mental health as well as anxiety and depression among South African nurses working in the frontline during the peak of the pandemic. Nurses in this study were found to be significantly younger than nurse managers, with previous studies suggesting that generational differences in nursing influence work attitudes and values [
49]. This is thought to affect younger nurses’ working experiences, impacting their wellbeing and subsequently retention [
50]. Although age was not a significant factor in predicting burnout among nurses or nurse managers in this study, acknowledging generational differences in nursing could assist in suitable strategies for improving nurses’ work experiences by enhancing intergenerational harmony and collegiality. This is especially critical during future health threats and can be achieved by engaging generation Y in mediating communication between generation X and generation Z [
51].
Similarly, Ramdan and colleagues reported in their systematic review and meta-analysis that findings from various multi-country studies suggest that the likelihood of experiencing burnout increased with years of practice, especially among nurses during the pandemic [
52]. However, in this study years in practice were not significantly associated with burnout, indicating that years of working experience may not influence South African nurses and nurse managers’ wellbeing in the workplace. Noteworthy, is that no studies from the African region were included in the systematic review and meta-analysis, which may mean that there is a need for further research aimed at understanding relevant factors associated with burnout within the African context. This is supported by research conducted among South African emergency nurses, which uses the capability approach to explain the importance of context and considering nurses’ capabilities as well as how these are enabled for reducing burnout risk [
53]. The unique socio-economic and health system challenges in South Africa warrants region specific research, which may support the development of tailored strategies for promoting wellbeing and strengthening the nursing workforce [
7,
21].
Occupation was a significant predictor of burnout with reports revealing that nurses rank higher than one hundred and thirty other high-stress occupations for suffering from poor mental health-related outcomes [
9]. A study comparing burnout levels between Brazilian nurses in management and nurses in care found that there was a significant difference in burnout between the two groups [
54]. Aligned with the findings of this study, nurses reported significantly higher burnout levels in the univariable analysis compared to nurse managers, which may be attributable to the variation in job demands and available resources [
55]. Nurses are known to be involved in direct patient care and this coupled with fear of infection and lack of protective equipment as well as higher rates of infection during the pandemic [
29,
56], could explain the difference in burnout levels in the current study.
Coping and burnout have been shown across several studies to be associated [
57], with a meta-analysis confirming sustained effects on alleviating all dimensions of burnout for up to a year [
58]. This study’s univariable analysis showed that coping is associated with burnout, but the association was not significant in the multivariable analysis. This could indicate that coping alone is adequate for addressing burnout although, during the pandemic burnout was affected by a range of unprecedented factors such as fear of contracting infection, separation from loved ones, harassment from patients and their family members, extended working hours and decreased sleep as well as reallocation to different wards [
59], which may have influenced coping mechanisms and would require a more holistic response. Unexpected challenges such as these can threaten the psychological needs necessary for regulatory action, whereby the perception of being able to control negative events and experiences towards coping becomes dysfunctional [
60]. Studies have previously confirmed the effect of new stressors including changing patient needs on HCW’s perceptions as subsequently reducing the effect of coping on burnout [
58]. This has important implications for preparedness during future health emergencies, whereby a need for an enquiry into the factors promoting coping for mitigating burnout among health workers, especially nurses, is required in under-resourced settings. In this light, a recent Gauteng-South African study indicates that positive mindsets and reappraisal were emotion-focused coping strategies commonly employed by HCWs, specifically psychiatrists, to redress the mental health effects of COVID-19 and improve their wellbeing [
61].
The association between resilience and burnout has been previously established whereby resilience has been thought to be protective of burnout owing to one’s ability to restore baseline functioning through positive adaptation [
62,
63]. Several studies have confirmed that higher levels of resilience are associated with lower burnout among nurses before as well as during the pandemic [
62,
64]. However, the findings of this study show that resilience and burnout are positively associated, which may indicate that there is a more complex dynamic between these factors. A study conducted among physicians revealed that despite high levels of resilience, they remained susceptible to burnout [
65]. Resilience is achieved through emotional recovery and emotional thriving, whereby positive emotions are critical for overcoming negative experiences [
66]. This is especially critical for nurses, who according to a recent survey showed lower levels of resilience during the pandemic [
67]. Perhaps future research ought to focus on understanding the role of emotions in promoting resilience and preventing burnout among nurses working in emergency situations. An example from a study among emergency response workers in Italy showed that problem-focused strategies enabled workers to overcome negative emotions, which offered protection against burnout [
67]. Contextual factors such as lack of protective equipment and higher risk for those with comorbidities such as TB and HIV [
21], may have also influenced burnout rates despite resilience.
General physical health and mental health as well as depression, anxiety and resilience were significantly associated with burnout in this study. Several studies have confirmed that burnout can compromise the general health outcomes of HCWs, due to stressful conditions that are not managed [
68]. However, fewer studies have shown that poor physical and mental health increases the risk of burnout among nurses, with the pandemic worsening these outcomes. A Namibian study revealed that poor physical and mental health depletes the positive resources necessary for dealing with stressors that contribute to burnout among nurses, especially considering the difficult working conditions they were exposed to during the pandemic [
69]. Implications for nurse wellbeing during future outbreaks are critical in ensuring preparedness, which ought to include holistic strategies aimed at preserving and promoting the physical and mental health of nurses in efforts to prevent burnout.
Depression and anxiety have been known to be associated with burnout among nurses, and more recently due to challenges experienced during the pandemic, including high risk of infection and separation from family without social support for extended periods of time [
70,
71]. These findings were confirmed in this study, showing that both depression and anxiety in hospital settings are associated with burnout among nurses at the frontline of the COVID-19 pandemic. Although this is supported by previous research [
72], the findings in this study reveal that depression and anxiety contribute to burnout among nurses, thus contradicting the suggestion that depression overlaps with burnout, which may be a symptom of it [
73]. A possible explanation involves nurses experiencing compassion fatigue owing to contact with excessive suffering of others [
74], with a recent study using network analysis, showing that fatigue is the connection between depression and burnout [
75]. Further research aimed at understanding how depression, anxiety and burnout are related to one another within under-resourced settings is necessary for appropriate intervention during future health emergencies.
These findings contribute an interesting perspective to the existing knowledge base, whereby the association between burnout, coping and resilience appears to be more complex in the context of a health emergency. However, the association between the general health of nurses, and especially with respect to their mental health, seems to be beneficial for future interventions in reducing burnout. In lieu of adopting a more holistic approach to understanding wellbeing among nurses during the pandemic, the findings in this study support a fundamental principle in holistic wellbeing models suggesting that wellbeing cannot be understood, without integrating the wide range of elements of which it comprises [
30]. In examining multiple aspects of wellbeing in this study, it is possible that coping and resilience may not be key factors in promoting the wellbeing of South African nurses and in fact, their mental health may be critical for mitigating burnout during future health emergencies. Future studies examining the associations between general health, coping and resilience may help generate further evidence towards holistic interventions aimed at promoting nurses’ wellbeing. It is recommended that lifestyle health promotion interventions such as mindfulness be prioritised, especially considering its higher levels of effectiveness in promoting wellbeing among nurses compared to educational interventions [
76]. A way forward would be to explore longitudinal designs for capturing the evolution of burnout and related factors as well as its impact on wellbeing over time, particularly in resource-constrained settings.
Limitations and strengths
The sample size of 139 participants and the inclusion of nurses drawn only from purposively selected hospitals due to accessibility during the pandemic, impact the generalisability of the findings. Only analysing burnout as an outcome limits the scope of the study and it is recommended that future studies consider multiple outcomes. Although this study considered various aspects of wellbeing, additional aspects including socioeconomic, spiritual, and emotional wellbeing should be studied in future for a more holistic understanding. A major strength of this study is the sampling of nurses from Gauteng, KwaZulu-Natal and Western Cape provinces, which contributed to the bulk of COVID-19 infections and mortality in South Africa and may have far-reaching implications within this context.
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