Iran Journal of Nursing

Introduction
During the COVID-19 pandemic, healthcare workers had essential responsibilities for its control, prevention, care and treatment. In many countries, the main strategy against COVID-19 was preventive measures. The health status of health workers is important for maintaining human resources and the quality of provided care services. They are exposed to many stressors that can cause psychological pressure in them. Factors such as long working hours, high workload, lack of job security, possibility of injury at work, relationship with superiors and patients, etc can also lead to job burnout. During the pandemic, health workers were responsible for screening for suspected COVID-19 cases in households, following up the treatment process of COVID-19 patients, and compliance or non-compliance with quarantine regulations.
It is still not clear whether the existence of stressful conditions during the pandemic was effective in the job burnout of health workers. Therefore, this study aims to investigate the relationship between different levels of anxiety caused by COVID-19 and the prevalence of job burnout among health workers in Bushehr province, southern Iran.

Methods 
This descriptive-correlational study with a cross-sectional design was conducted in autumn 2022. The study population consists of health workers in the health centers affiliated to the Bushehr University of Medical Sciences. From 232 health centers, 365 health workers with at least one year of work experience and no history of mental illness were selected by a census method. Data collection was done using a questionnaire including three sections: Demographic form, the Maslach Burnout Inventory (MBI), and the corona virus anxiety scale (CDAS). The CDAS was designed by Alipour et al. (2020) to measure anxiety caused by COVID-19 in Iran. This tool has 18 items and two components (psychological symptoms and physical symptoms). The items are scored on a 4-point Likert scale: 0 (never), 1 (sometimes), 2 (most of the time), and 3 (always). The total score ranges from 0 to 54, with higher scores indicating a higher level of anxiety. The MBI has 22 items and three dimensions of exhaustion, depersonalization, and personal achievement. The items are rated on a 7-point Likert scale: 0 (never), 1 (a few times per year), 2 (once a month), 3 (a few times per month), 4 (once a week), 5 (a few times per week) and 6 (Every day). In our study, Cronbach's alpha coefficients for CDAS and MBI were 0.95 and 0.84, respectively. After obtaining permission, the link of questionnaire was sent to participants to complete. SPSS software, version 16 was used for data analysis.

Results
Of 365 health workers, 308 completed the questionnaires. The mean age of participants was 37.02±8.16 years. Most of them were female (69.5%) and married (85.7%). Among those who were married, 63.6% had two or more children. The mean work experience of participants was 13.36±9.06 years, and 71.4% had permanent employment; 61% were satisfied with personal protective equipment; 95.8% had no history of taking sedatives; 70.1% had no history of physical illness, and 97.4% had no history of leaving service or unpaid leave. The psychological dimension of COVID-19-related anxiety was mostly at a moderate level (60.7%), while its physical dimension was mostly at a mild level (57.5%). Overall, 70.8% of health workers had mild COVID-19-related anxiety (Mean CDAS=12.58±10.81). The emotional exhaustion of 68.2%, depersonalization of 82.1%, and personal achievement of 49.7% were at a low level.

Conclusion 
The COVID-19-related anxiety of most of the health workers in Bushehr is at a mild level. Also, 31.8% of health workers have moderate to severe emotional exhaustion. Most of them had low levels of depersonalization, and almost half of them had low personal achievement. The COVID-19-related anxiety in health workers has a significant positive relationship with theit job burnout. Those with high levels of anxiety had higher emotional exhaustion and depersonalization and lower personal achievement. Moreover, COVID-19-related anxiety in health workers has a significant negative relationship with their personal achievement.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1400.755). The information of participants was kept confidential and they were free to leave the study at any time.

Funding
This study was extracted from the master’s thesis of Amir Bahreinizadeh, funded by Iran University of Medical Sciences.

Authors' contributions
Conceptualization, eeview & editing: Amir Bahreini Zadeh and Marzieh Adel Mehraban; Investigation, writing, and data analysis: Amir Bahreini Zadeh and Hamid Haghani.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank the health workers and managers of selected health centers in Bushehr province for their cooperation in this study.
 

References

1. Li Q, Chen J, Xu G, Zhao J, Yu X, Wang S, et al. The psychological health status of healthcare workers during the COVID-19 outbreak: A cross-sectional survey study in Guangdong, China. Front Public Health. 2020; 8:562885. [DOI:10.3389/fpubh.2020.562885] [PMID]
2. Labrague LJ, De Los Santos JAA. COVID-19 anxiety among front-line nurses: Predictive role of organisational support, personal resilience and social support. J Nurs Manag. 2020; 28(7):1653-61. [DOI:10.1111/jonm.13121] [PMID]
3. Ho CS, Chee CY, Ho RC. Mental health strategies to combat the psychological impact of COVID-19 beyond paranoia and panic. Ann Acad Med Singap. 2020; 49(3):155-60. [DOI:10.47102/annals-acadmedsg.202043] [PMID]
4. Yang L, Wu D, Hou Y, Wang X, Dai N, Wang G, et al. Analysis of psychological state and clinical psychological intervention model of patients with COVID-19. Medrxiv. 2020. [DOI:10.1101/2020.03.22.20040899]
5. Taylor S. The psychology of pandemics: Preparing for the next global outbreak of infectious disease. Newcastle upon Tyne: Cambridge Scholars Publishing; 2019. [Link]
6. Hollocks MJ, Lerh JW, Magiati I, Meiser-Stedman R, Brugha TS. Anxiety and depression in adults with autism spectrum disorder: A systematic review and meta-analysis. Psychol Med. 2019; 49(4):559-72. [DOI:10.1017/S0033291718002283] [PMID]
7. Bajema KL, Oster AM, McGovern OL, Lindstrom S, Stenger MR, Anderson TC, et al. Persons evaluated for 2019 novel coronavirus-United States, January 2020. MMWR Morb Mortal Wkly Rep. 2020; 69(6):166-70. [PMID]
8. Nikčević AV, Spada MM. The COVID-19 Anxiety Syndrome Scale: Development and psychometric properties. Psychiatry Res. 2020; 292:113322. [DOI:10.1016/j.psychres.2020.113322] [PMID]
9. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020; 3(3):e203976. [DOI:10.1001/jamanetworkopen.2020.3976] [PMID]
10. Meskarpour-Amiri M, Shams L, Nasiri T. [Identifying and categorizing the dimensions of Iran's health system response to the COVID-19 pandemic (Persian)]. J Mil Med. 2020; 22(2):108-14. [Link]
11. Ataei J, Kamran A, Shekarchi A, Etebar I, Haghiri E, Gorbani M. [Study of Health Promotion Life Style (HPLP) of rural primary health-care workers (Behvarzes) in Khalkhal and Kosar Counties, 1395 (Persian)]. J Health. 2018; 9(5):530-40. [DOI:10.29252/j.health.9.5.530]
12. Tahmasbi Novaee M. [Study of the effect of job stress and quality of work life dimensions on job burnout of healthcare workers (Persian)]. Tehran: Scientific Research in the Administrative and Financial Sectors of the Health System; 2016.
13. Akbari H, Eslami M, Aghamohamadi S, Parchami P, Jamshidbeigi E, Dadres M, et al. [Fundamentals and standards of executive processes of COVID-19 disease care system (Persian)]. Tehran: Ministry of Health and Medical Education; 2020. [Link]
14. Alenazi TH, BinDhim NF, Alenazi MH, Tamim H, Almagrabi RS, Aljohani SM, et al. Prevalence and predictors of anxiety among healthcare workers in Saudi Arabia during the COVID-19 pandemic. J Infect Public Health. 2020; 13(11):1645-51. [DOI:10.1016/j.jiph.2020.09.001] [PMID]
15. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. 2020. [DOI:10.2139/ssrn.3594632]
16. Raudenská J, Steinerová V, Javůrková A, Urits I, Kaye AD, Viswanath O, et al. Occupational burnout syndrome and posttraumatic stress among healthcare professionals during the novel Coronavirus Disease 2019 (COVID-19) pandemic. Best Pract Res Clin Anaesthesiol. 2020; 34(3):553-60.[DOI:10.1016/j.bpa.2020.07.008] [PMID]
17. Maslach C, Leiter MP. Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry. 2016 ; 15(2):103-11. [DOI:10.1002/wps.20311] [PMID]
18. Maslach C, Schaufeli WB. Historical and conceptual development of burnout. In: Schaufeli WB, Maslach Ch, Marek T, editors. Professional burnout: Recent developments in theory and research. London: Routledge; 2018. [Link]
19. Moradi A,  Moradi R, Zangene M, Gozarian M. [Burnout and related factors in Behvarzan province of Hamadan (Persian)]. Paper presented at: The 3rd National Conference on Organizational Innovation and Development with The Approach of the Islamic model of Iran. 27 February 2019; Khorasan, Iran. [Link]
20. Alipour A, Ghadami A, Alipour Z,  Abdollahzadeh H. [Preliminary validation of the Corona Disease Anxiety Scale (CDAS) in the Iranian sample (Persian)]. Health Psychol. 2020; 8(32):163-75. [Link]
21. Maslach C, Leiter M. and Reversing burnout: How to rekindle your passion for your work. Stanford Soc Innov Rev. 2005; 3(4):42-9. [Link]
22. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y.  A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen Psychiatr. 2020; 33(2):e100213.  [DOI:10.1136/gpsych-2020-100213] [PMID]
23. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet. 2020; 395(10227):912-20. [DOI:10.1016/S0140-6736(20)30460-8] [PMID]
24. Sabri V, Ghasemkhanloo A. [The comparison of stress, anxiety and depression between health staff, medical staff and normal people in the COVID-19 disease epidemic in Khoy city (Persian)]. Iran J Psychol Behav Sci. 2020; 25:43-50. [Link]
25. Shams S. [Predicting Covid disease-19 anxiety based on perceived stress and anxiety sensitivity in nurses: The mediating role of cognitive flexibility (Persian)]. J Health Promot Manage. 2022; 11(3):1-14. [DOI:10.22034/JHPM.11.3.1]
26. Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, et al. Psychological impact of the COVID-19 pandemic on health care workers in Singapore. Ann Intern Med. 2020; 173(4):317-20.  [DOI:10.7326/M20-1083] [PMID]
27. Zarei E, Danesh kohan A, Khodakarim S, Abbasi R. [Evaluation of burnout among primary health care providers in Markazi Province (Persian)]. J Health Based Res. 2018; 4(2):135-45. [Link]
28. Qari Alavijeh A, Arab M, Kheiri S, Akbari A, Askari M, Mohamadi Gh, et al. [Job burnout and some of its risk factors on the health workers (Behvarz) in Koohrang County, I.R.Iran, in 2010 (Persian)]. J Shahrekord Uuniv Med Sci. 2012; 14(3):62-71. [Link]
29. Barello S, Palamenghi L, Graffigna G. Burnout and somatic symptoms among frontline healthcare professionals at the peak of the Italian COVID-19 pandemic. Psychiatry Res. 2020; 290:113129. [DOI:10.1016/j.psychres.2020.113129] [PMID]
30. Biganeh J, Abolghasemi J, Alimohammadi I, Ebrahimi H, Torabi Z, Ashtarinezhad A. [Survey of occupational stress effects on burnout among nurses (Persian)]. Knowl Health. 2018; 13(1):10-18. [Link]
31. Jang Y, You M, Lee H, Lee M, Lee Y, Han JO, et al. Burnout and peritraumatic distress of healthcare workers in the COVID-19 pandemic. BMC Public Health. 2021; 21(1):2075.  [DOI:10.1186/s12889-021-11978-0] [PMID]
32. Flynn L, Thomas-Hawkins C, Clarke SP. Organizational traits, care processes, and burnout among chronic hemodialysis nurses. West J Nurs Res. 2009; 31(5):569-82. [DOI:10.1177/0193945909331430] [PMID]
33. Rahmani R, Sargazi V, Shirzaei Jalali M, Babamiri M. [Relationship between COVID-19-caused anxiety and job burnout among hospital staff: A cross-sectional study in the Southeast of Iran (Persian)]. J Occup Hyg Eng. 2021; 7(4):61-9. [DOI:10.52547/johe.7.4.61]
34. Amiri M, Chaman R, Arabi M, Ahmadinasab A, Hejazi A, Khosravi A. Factors influencing the intensity of burnout among rural health workers (Behvarz) in Northeastern Provinces of Iran. Razi J Med Sci. 2016; 22(141):116-25. [Link]
35. Medeiros AIC, Mesquita RB, Macêdo FS, Matos AGC, Pereira ED. Prevalence of burnout among healthcare workers in six public referral hospitals in northeastern Brazil during the COVID-19 pandemic: A cross-sectional study. Sao Paulo Med J. 2022; 140(4):553-8. [DOI:10.1590/1516-3180.2021.0287.r1.291021] [PMID]
36. Sohrabi H, Majzobi S, Shahoei R. [Burnout rate and related factors among midwives (Persian)]. J Nurs Midwifery Param. 2018; 3(4):67-76. [DOI:10.29252/sjnmp.3.4.67]
37. Hamidi Y, Bashirian S, Babamiri M, Norouzi B, Roshanaei G. [Stress and its relationship with burnout of health workers (Persian)]. J Occup Hyg Eng. 2018; 5(1):35-43. [DOI:10.21859/johe-5.1.35]
38. Kamali M, Azizi M, Moosazadeh M, Mehravaran H, Ghasemian R, Reskati MH, et al. Occupational burnout in Iranian health care workers during the COVID-19 pandemic. BMC Psychiatry. 2022; 22(1):365.  [DOI:10.1186/s12888-022-04014-x] [PMID]
39. Akova İ, Kiliç E, Özdemir ME. Prevalence of burnout, depression, anxiety, stress, and hopelessness among healthcare workers in COVID-19 pandemic in Turkey. Inquiry. 2022; 59:469580221079684. [DOI:10.1177/00469580221079684] [PMID]
40. Khajehnoriranjbar M, Banisi P. The relationship between COVID-19 anxiety on depression and burnout and mental health of nurses. Paper presented at: The 7th International Conference on Psychology, Counseling and Educational Sciences. 2 January 2019; Tbilisi, Georgia. [Link]
41. Arenliu Qosaj F, Weine SM, Sejdiu P, Hasani F, Statovci S, Behluli V, et al. Prevalence of perceived stress, anxiety, and depression in HCW in Kosovo during the COVID-19 Pandemic: A cross-sectional survey. Int J Environ Res Public Health. 2022; 19(24):16667. [DOI:10.3390/ijerph192416667] [PMID]
42. Koutsimani P, Montgomery A, Georganta K. The relationship between burnout, depression, and anxiety: A systematic review and meta-analysis. Front Psychol. 2019; 10:284. [DOI:10.3389/fpsyg.2019.00284] [PMID]
43. Treluyer L, Tourneux P.  Burnout among paediatric residents during the COVID-19 outbreak in France. Eur J Pediatr. 2021; 180(2):627-33. [DOI:10.1007/s00431-020-03907-x] [PMID]
44. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020; 395(10229):1054-62. [DOI:10.1016/S0140-6736(20)30566-3] [PMID]
45. Ajab S, Ádam B, Al Hammadi M, Al Bastaki N, Al Junaibi M, Al Zubaidi A,  et al. Occupational health of frontline healthcare workers in the United Arab Emirates during the COVID-19 pandemic: A snapshot of summer 2020. Int J Environ Res Public Health. 2021; 18(21):11410.  [DOI:10.3390/ijerph182111410] [PMID]
46. Alanazi KH, bin Saleh GM, AlEidi SM, AlHarbi MA, Hathout HM. Prevalence and risk factors of burnout among healthcare professionals during COVID-19 Pandemic-Saudi Arabia. Am J Public Health. 2021; 9(1):18-27. [DOI:10.12691/ajphr-9-1-3]
47. Abdelrazek EM, Higazy OA. Burnout among nurses in Jazan General Hospital, Saudi Arabia: Its prevalence and associated factors. Af J Reprod Health. 2023; 27(4):43-53. [Link]
48. Fateminia A, Hasanvand S, Goudarzi F, Mohammadi R.  Post-traumatic stress disorder among frontline nurses during the COVID-19 pandemic and its relationship with occupational burnout. Iran J Psychiatry. 2022; 17(4):436-45. [DOI:10.18502/ijps.v17i4.10693] [PMID]
49. Ismail AA, Sulaiman T, Roslan S. Models of relationship between emotional, spiritual, physical and social intelligence, resilience and burnout among high school teachers. Univ J Educ Res. 2020; 8(1):1-7. [DOI:10.13189/ujer.2020.081301]
50. Rahimi S, Farhadi M, Sadeqi J. [A survey on relationship between resilience and burnout amongst the academic librarians: (A case study of Academic Libraries in Kermanshah) (Persian)]. Acad Librar Inf Res. 2018; 51(4):137-53. [Link]
51. Shareinia H, Khalilian R, Bloochi Beydokhti T, Javadi H, Hosseini M. [Relationship between job satisfaction and burnout among prehospital emergency staff (Persian)]. Q J Ners Manage. 2017; 6(2):9-19. [DOI:10.29252/ijnv.6.2.9]
52. Bruyneel A, Smith P, Tack J, Pirson M. Prevalence of burnout risk and factors associated with burnout risk among ICU nurses during the COVID-19 outbreak in French speaking Belgium.  Intensive Crit Care Nurs. 2021; 65:103059. [DOI:10.1016/j.iccn.2021.103059] [PMID]