Abstract

Introduction

Professional burnout is a major global health concern among physicians, nurses, and other healthcare providers (1, 2, 3). Healthcare providers often experience high workload, strict organisational regulations, and insufficient time to cope with occupational challenges, a rapidly evolving knowledge base, and a lack of interpersonal support in everyday life (3). These challenges often lead to “emotional exhaustion,” where a person feels overwhelmed and lacks the energy to accomplish a task. “Depersonalisation” may follow emotional exhaustion, where a person may cynically treat others as objects. Also, a diminished sense of self-efficacy and competence affect the emotional wellbeing of an individual. Thus, emotional exhaustion, depersonalisation, and a decreased sense of personal accomplishments characterise burnout, which is a growing concern for the healthcare community globally. A systematic review found burnout scores for emotional exhaustion ranged from 31% to 54.3%, depersonalisation 17.4% to 44.5%, and low personal accomplishment 6% to 39.6% among doctors in the UK (1). Another meta-analytic review found 11.23% of participating nurses experienced burnout globally (2). Such a high burden of burnout is likely to increase during the coronavirus disease (Covid-19) pandemic, where healthcare providers in most health systems face a high workload. Recent media reports also highlight this critical challenge (4, 5), which may affect healthcare values during this pandemic, necessitating ethical discourse on burnout. This article discusses the current scenario of burnout among healthcare providers during Covid-19, key ethical implications, and highlights potential strategies to address them.

Psychosocial stressors during Covid-19 and a high burden of burnout

A wide range of occupational stressors is associated with Covid-19. Large numbers of potential cases arriving in hospitals and constraining institutional capacities result in additional workplace-related stress, especially among emergency care providers. Moreover, working hard during emergencies or stressful conditions often comes with sleep deprivation, increasing the risks of burnout (6). A Canadian Medical Association study found emergency physicians are almost three times as likely to suffer depression compared to the national average while one in seven physicians had suicidal thoughts in normal times (7). Other studies have shown that healthcare providers working in infection control or among isolated or quarantined individuals are likely to experience multiple mental health problems (8). In addition, many of the existing providers are withdrawn or suggested self-isolation after working on Covid-19 cases (9). Such concurrent experience of high workload, the fear of being infected, and disrupted social support during isolation or quarantine are critical factors that may influence burnout and associated psychosocial health outcomes (8). Many other challenges like the lack of personal protective equipment, may crucially affect mental health and wellbeing among healthcare providers (10, 11). Additionally, they are sometimes stigmatised as possible carriers of the virus by members of the public, as reported in several news media (12, 13), increasing stress and hastening burnout. These are some glimpses of the difficulties experienced by frontline health workers, though the true psychosocial and epidemiological burden of burnout during Covid-19 is largely underreported.

Perspectives on healthcare ethics

The ongoing pandemic has created several unique ethical dilemmas for healthcare workers:

• While healthcare providers have the autonomy to decide on working in a healthcare organisation based on perceived safety or risks, they also have a shared responsibility to serve people in a humanitarian crisis. In a pandemic, ethical values, including the autonomy of providers to make decisions may be curtailed, thus affecting their psychological and emotional health (14).

• Moral distress has been identified across the scholarly community as a root cause of burnout in healthcare providers (14, 15, 16). Dzeng and Wachter argue that healthcare providers who struggle to balance institutional priorities with the best interests of patients are highly vulnerable to moral dissonance (14). Such distress would be aggravated when serving large numbers of patients within limited institutional capacities.

• Patient autonomy and welfare remain core ethical concepts in medical practice which are critically affected in case of patients on ventilator support (16). With limited therapeutic options for Covid-19, a physician may face moral uncertainly while deciding on treatment, with the patient unable to participate in decision-making due to a critical health condition. Earlier studies have established that intensive care providers often experience such dilemmas and experience more burnout in their careers (15, 16).

• News reports, several from developed nations, highlight that marginalised populations, including racial and ethnic minorities, are more likely to get infected and have adverse healthcare access as well as outcomes (17). This can be profoundly challenging for those struggling to cope with rapidly increasing new cases and fatalities every day of this pandemic. Despite their dedication, structural inequities may affect the emotional health of healthcare providers (14), and lead to helplessness in the face of challenges closely related to social justice and human rights.

• Lastly, ethical concerns can be uniquely different in diverse settings, which calls for a careful assessment of context-specific issues and their ethical implications through designated ethical committees in the respective institutions (18). Moreover, ongoing public health emergencies like Covid-19 may not provide adequate scope for analysing the most ethical approaches, as the institutions are stressed by the additional volume of Covid-19 patients alongside regular patients. Such challenges remain underexplored in the available literature, and this necessitates further ethical assessment and discourse.

The current scenario provides an adequate basis to acknowledge critical gaps in the context of Covid-19 that may increase burnout among healthcare providers, with the ethical implications stated above. Therefore, drawing insights from evidence-based approaches may help in mitigating burnout, and help healthcare providers to overcome the ethical challenges, manage their stress, and fulfil their professional responsibilities satisfactorily.

Potential strategies for addressing burnout in healthcare providers during Covid-19

Some steps based on multipronged evidence-based approaches which could address stress and prevent burnout during this pandemic are:

Burnout can be prevented if the providers are made aware of the risks and prepared for potential occupational stress. Such awareness can reduce the stigma linked to mental health conditions like burnout and help in developing resilience. For example, a study on Ebola response found that situational awareness alongside other preventive measures improved psychological resilience among healthcare providers (19). A meta-analysis found the correlation between resilience and burnout among Iranian nurses was -0.57 (95% confidence interval [CI]: -0.354-0.726) (20). This evidence highlights the role of increasing awareness and adopting strategies to empower healthcare providers during Covid-19.

Positive mental health can prevent work-related stress and burnout, which should be promoted among healthcare providers during the pandemic. Several strategies include decreasing the workload, improving work schedules, promoting self-management, initiating mindfulness-based stress reduction and mental health promotion activities for reducing the risks of burnout (21). A meta-analysis of 17 studies among 632 nurses had found lower standardised mean difference for emotional exhaustion (1.32; 95% CI: -9.41-6.78) and depersonalisation (1.91; 95% CI: -4.50-0.68), and a higher mean difference for personal accomplishment (2.12; 95% CI: -9.91-14.14) (22). During Covid-19, healthcare organisations and professional entities may facilitate mindfulness-based interventions and self-management exercises promoting mental health and preventing potential burnout.

Providing mental health services can be challenging during Covid-19, but such opportunities should be explored. Potential strategies to improve access to mental health services may include involving mental health experts in multidisciplinary Covid-19 teams, who may provide services or refer healthcare workers showing symptoms of burnout to appropriate resources (3). In addition, group-based counseling or peer-support sessions may effectively address burnout and improve mental health during Covid-19.

In recent years, digital interventions are increasingly being used to improve health services and outcomes. One approach can be the balanced use of electronic health records to coordinate work schedules, monitor healthy work patterns, and address the risks of overburdening frontline healthcare providers during Covid-19. Counselling and interventions using digital platforms like mobile phones, apps, or internet-enabled devices can be an alternative option (9).

It is essential to improve organisational measures to create a lasting impact on the work culture alongside interpersonal interventions, and address workplace stress. A meta-analysis found that organisation-directed interventions were associated with a medium reduction in burnout score (SMD = – 0.446; 95% CI:- 0.619 – 0.274), while physician-directed interventions were associated with a moderate reduction in burnout score (SMD = – 0.178; 95% CI: – 0.322 – 0.035) (3). Potential strategies include improving workflow management, organising services focusing on reducing workload, enhancing interoperability, arranging discussion and exchanging opinions, improving communication skills, provision for adequate rest and exercise, organising workshops on coping skills, and devising policies and practices for reducing burnout among health workforce during this pandemic (3, 9). These approaches may foster a supportive and enabling environment for healthcare providers. However, it is essential to include the healthcare provider in devising strategies for creating an enabling environment. A shared decision-making may assist in understanding potential challenges experienced by the providers, including the impacts of their participation or non-participation in Covid-19 responses on payroll or performance appraisal, operational challenges within and between hospital departments, individual and group psychosocial challenges that may affect the health workforce as well as health service delivery during this pandemic.

Conclusion

Healthcare providers often experience occupational stress leading to burnout, which may be aggravated during Covid-19. While they work to fulfil their professional responsibilities, it is essential to recognise how workplace-related stress may affect their mental and emotional wellbeing. Such stressors may further impact resource-constrained contexts resulting in a severe paucity of healthcare providers. Furthermore, those stressors have profound ethical implications including moral distress, autonomy and welfare of the patient, and social justice, affecting health service delivery and maintenance of a healthy workforce in healthcare organizations during this pandemic. Evidence-based approaches for preventing burnout that have shown effectiveness in various contexts may help in identifying appropriate measures based on unique situations and available resources. Health policy makers and practitioners should adopt such interventions and develop context-specific approaches promoting a healthy workplace, addressing ethical issues, and preventing burnout among healthcare providers during the Covid-19 pandemic.