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Compassion fatigue and burnout in Turkish pediatric emergency nurses during the COVID-19 pandemic

Published:November 21, 2022DOI:https://doi.org/10.1016/j.pedn.2022.11.004

      Highlights

      • The pandemic presents difficulties for nurses working with children.
      • PED nurses experience moderate CF and high burnout during the pandemic.
      • The needs of PED nurses should be prioritized.

      Abstract

      Purpose

      This study was conducted to determine compassion fatigue and burnout in nurses working in the pediatric emergency department (PED) during the COVID-19 pandemic in Turkey.

      Design and methods

      This descriptive and cross-sectional study was conducted with 164 nurses working in the PED and following the social media platforms of the Emergency Nurses Association between September 1, 2020, and January 1, 2021. Data were collected using the online survey method with the Descriptive Data Form, Maslach Burnout Inventory (MBI), and Compassion Fatigue-Short Scale (CF-SS).

      Results

      Pediatric emergency nurses reported that they experienced high emotional exhaustion (28.25 ± 6.05) and depersonalization (11.89 ± 2.39), low personal accomplishment (17.98 ± 3.12), and moderate compassion fatigue (4.99 ± 1.43).

      Conclusion

      Pediatric emergency nurses had high levels of burnout and moderate levels of compassion fatigue during the pandemic in Turkey. To prevent any long-term negative effects of the pandemic, addressing the physiological, psychological, and psychosocial needs of nurses should be prioritized.

      Practical implications

      Compassion fatigue and burnout can affect the quality of care provided by nurses, but also negatively affect their well-being and quality of life during the pandemic. Therefore, the development of interventions to reduce compassion fatigue and burnout can help manage these symptoms.

      Keywords

      Introduction

      Coronavirus disease (COVID-19) has spread throughout the world since its outbreak in December 2019 (). Throughout this ongoing process, there has been an increase in the number of cases in Turkey as well as throughout the world. Early in the pandemic, children were considered less likely to get infected than adults and showed fewer clinical symptoms (
      • Ludvıgsson J.F.
      Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults.
      ;
      • She J.
      • Liu L.
      • Liu W.
      COVID-19 epidemic: Disease characteristics in children.
      ). However, over time, the number of children diagnosed with COVID-19 increased and they had a mild or moderate disease course (
      • Dong Y.
      • Mo X.
      • Hu Y.
      • Qi X.
      • Jiang F.
      • Jiang Z.
      • Tong S.
      Epidemiology of COVID-19 among children in China.
      ;
      • Wu H.
      • Zhu H.
      • Yuan C.
      • Yao C.
      • Luo W.
      • Shen X.
      • Wang J.
      • Shao J.
      • Xıang Y.
      Clinical and immune features of hospitalized pediatric patients with coronavirus disease 2019 in Wuhan China.
      ).
      Patients infected with COVID-19 primarily visit the emergency department of a hospital (
      • Kocher K.E.
      • Macy M.L.
      Emergency Department Patients in the Early Months of the Coronavirus Disease 2019 (COVID-19) Pandemic—What Have We Learned?.
      ). Emergency nurses are front-line healthcare professionals directly involved in the diagnosis, care, treatment, and management of COVID-19 patients. This causes them to be susceptible to infection and to experience high levels of stress (
      • Butera S.
      • Brasseur N.
      • Filion N.
      • Bruyneel A.
      • Smith P.
      Prevalence and associated factors of burnout risk among intensive care and emergency nurses before and during the COVID-19 pandemic: A cross-sectional study in Belgium.
      ). In addition to working in a high-risk environment, the additional burdens brought by the pandemic, stress experienced while caring for special patients, long-term use of protective equipment, long shifts, increased workload, disruptions in sleep and work-life balance, and physical and mental fatigue may cause burnout (
      • An Y.
      • Yang Y.
      • Wang A.
      • Li Y.
      • Zhang Q.
      • Cheung T.
      • Ungvari G.S.
      • Qin M.Z.
      • An F.R.
      • Xiang Y.T.
      Prevalence of depression and its impact on quality of life among frontline nurses in emergency departments during the COVID-19 outbreak.
      ) and compassion fatigue in nurses (
      • Alharbi J.
      • Jackson D.
      • Usher K.
      The potential for COVID-19 to contribute to compassion fatigue in critical care nurses.
      ).
      Compassion fatigue (CF) is defined by Joinson as “a unique form of burnout that affects caregivers.” (
      • Joinson C.
      Coping with compassion fatigue.
      ). CF, or secondary traumatic stress, occurs when nurses get to know patients experiencing trauma and pain closely, identify with patients' conditions, use all their energy to care for the patients, and consequently neglect their own needs (
      • Gallagher R.
      Compassion fatigue.
      ). As a result, nurses suffer physical, emotional, social, and spiritual burnout and experience a decline in compassion, empathy, willingness to care, skills, and energy (
      • Coetzee S.K.
      • Klopper H.C.
      Compassion fatigue within nursing practice: A concept analysis.
      ).
      Burnout is defined by Maslach as “feelings of fatigue, helplessness, and hopelessness, the development of a negative self-concept, negative attitudes towards the profession, and other people, and physical, emotional, and mental exhaustion syndrome.” (
      • Maslach C.
      • Schaufeli W.B.
      • Leiter M.P.
      Job burnout.
      ). Burnout has three dimensions: emotional exhaustion (EE), depersonalization (DP), and a decrease in personal accomplishment (PA). EE is being overburdened by work and physically and emotionally exhausted. Individuals feel tired and emotionally burned-out. They lose their desire to care for their patients. Nurses who display DP exhibit attitudes and behaviors devoid of emotion toward their patients. During this period, there is a common sense of boredom. Nurses carry out work in a mechanical fashion. Inadequate PA is the inability of nurses to perform their duties properly because they feel inadequate and powerless (
      • Maslach C.
      • Schaufeli W.B.
      • Leiter M.P.
      Job burnout.
      ;
      • Rios-Risquez M.I.
      • García-Izquierdo M.
      Patient satisfaction, stress and burnout in nursing personnel in emergency departments: A cross-sectional study.
      ).
      In the literature, nurses who care for patients and display an empathetic approach during the pandemic experience burnout (
      • Arpacıoglu M.S.
      • Baltacı Z.
      • Unubol B.
      Burnout, fear of Covid, depression, occupational satisfaction levels and related factors in healthcare workers in the COVID-19 pandemic.
      ;
      • Chen R.
      • Sun C.
      • Chen J.J.
      • Jen H.J.
      • Kang X.L.
      • Kao C.C.
      • Chou K.R.
      A large-scale survey on trauma, burnout and posttraumatic growth among nurses during the COVID-19 pandemic.
      ) and CF (
      • Labrague L.J.
      • Santos J.A.
      Resilience as a mediator between compassion fatigue, nurses' work outcomes, and quality of care during the COVID-19 pandemic.
      ). These changes in the mental health of nurses can negatively affect their professional and moral values (
      • Hooper C.
      • Craig J.
      • Janvrin D.R.
      • Wetsel M.A.
      • Reimels E.
      Compassion satisfaction, burnout, and compass fatigue among emergency nurses compared with nurses in other selected inpatient specialties.
      ). Job dissatisfaction, inappropriate decision making, loss of empathy, decrease in helping capacity (
      • Hooper C.
      • Craig J.
      • Janvrin D.R.
      • Wetsel M.A.
      • Reimels E.
      Compassion satisfaction, burnout, and compass fatigue among emergency nurses compared with nurses in other selected inpatient specialties.
      ), not showing the necessary attention to the patient, and an increase in the tendency to make medical mistakes can be seen in nurses (
      • Nantsupawat A.
      • Nantsupawat R.
      • Kunaviktikul W.
      • Turale S.
      • Poghosyan L.
      Nurse burnout, nursereported quality of care, and patient outcomes in Thai hospitals.
      ).
      Nurses who work with children, one of the vulnerable and sensitive groups during the COVID-19 pandemic, also face the difficulties caused by the pandemic and experience many emotions such as fear, stress, and anxiety (
      • Góes F.G.B.
      • Silva A.C.S.S.
      • Santos A.S.T.
      • Pereira-Ávila F.M.V.
      • Silva L.J.
      • Silva L.F.
      • Goulart M.C.L.
      Challenges faced by pediatric nursing workers in the face of the COVID-19 pandemic.
      ). This situation also poses a risk for them to experience CF and burnout. Pediatric emergency department (PED) nurses, one of the pediatric nurse groups working on the front lines during the pandemic, are the health professionals who first meet, care for, and treat patients infected with a new infectious disease. Therefore, they are at risk of developing CF and burnout and may need psychological support or interventions to help them manage their condition (
      • Lai J.
      • Ma S.Y.
      • Cai Z.
      • Hu J.
      • Wei N.
      • Wu J.
      • Du H.
      • Chen T.
      • Li R.
      • Tan H.
      • Kang L.
      • Yao L.
      • Huang M.
      • Wang H.
      • Wang G.
      • Liu Z.
      • Hu S.
      Factors associated with mental health outcomes among health careworkers exposed to coronavirus disease 2019.
      ). During the COVID-19 pandemic, which continues to affect the world, it is particularly important to know the situation of PED nurses, who provide critical and emergency care services. The aim of this research was to explore CF and burnout in PED nurses during the COVID-19 health crisis in Turkey.

      Materials and methods

      The research is a descriptive and cross-sectional study to determine the prevalence of CF and burnout in PED nurses during the COVID-19 pandemic. The universe of the study was planned to be all PED nurses working in Turkey between 1 September and 31 December 2020. Because of the pandemic conditions, social media platforms were thought to be the most effective way to reach the universe. The Turkish Emergency Nurses Association was contacted, and their support was received for publishing the survey on social media platforms. The sample was 400 nurses who were active on social media and represented approximately 950 PED nurses working in Turkey. The sample size was calculated as 170 individuals using Cochran's sample size formula with an alpha error of 0.05 at the 95% confidence level (n0 = Z2 x p x q / e2) (
      • Singh A.S.
      • Masuku M.B.
      Sampling techniques & determination of sample size in applied statistics research: An overview.
      ). According to the known population sample formula, at least 145 nurses were needed for this study [n = n0 / [1 + {(n0−1) / N}] (
      • Singh A.S.
      • Masuku M.B.
      Sampling techniques & determination of sample size in applied statistics research: An overview.
      ). This study's participants included 164 nurses. The power of the research was 97%.

      Data collection tools

      Descriptive Information Form, Maslach Burnout Inventory (MBI), and Compassion Fatigue-Short Scale (CF-SS) were used to collect data.

      Descriptive information form

      This form was developed by the researchers according to the relevant literature (
      • An Y.
      • Yang Y.
      • Wang A.
      • Li Y.
      • Zhang Q.
      • Cheung T.
      • Ungvari G.S.
      • Qin M.Z.
      • An F.R.
      • Xiang Y.T.
      Prevalence of depression and its impact on quality of life among frontline nurses in emergency departments during the COVID-19 outbreak.
      ) and was evaluated by two experts in the field of pediatric nursing. The form contained 19 multiple choice questions (Table 1) to determine the descriptive characteristics of the nurses.
      Table 1Nurses' descriptive characteristics (N = 164).
      Descriptive Characteristicn%
      Gender
       Female10362.8
       Male6137.2
      Age
       20–30 years9658.6
       31–40 years5131.1
       ≥41 years1710.4
      Education status
       High school3118.9
       Associate degree2213.4
       Undergraduate10161.6
       Postgraduate106.1
      Working time in PED
       0–1 years5231.7
       2–10 years8753
       ≥11 years2515.2
      Work shift
       Day shift2615.9
       Night shift13884.1
      Predominant shift time
       08.00–16.002615.9
       16.00–08.004225.6
       08.00–08.009658.5
      Average number of patients given daily care (suspected or diagnosed with COVID-19)
       ≤55936
       6–157243.9
       ≥163320.1
      Contact with someone suspected and/or diagnosed with COVID-19
       No6338.4
       I don't know1710.4
       Yes8451.2
      Nurse or a loved one diagnosed with COVID-19
       No8954.3
       Yes7545.7
      Worried about getting COVID-19 in the department
       No3521.3
       Yes12978.7
      Worried about infecting someone with COVID-19
       No3320.1
       Yes13179.9
      Opinion about break times during the pandemic
       I'm insufficient8753
       I'm undecided3622
       I'm sufficient4125
      Opinion about measures in the work environment
       I find it insufficient6942.1
       I'm undecided148.5
       I find it enough8149.4
      Used PPE in the department
       Mask15493.9
       Glasses5936
       Glove15997
       Face Shield9759.1
       Overalls1911.6
       Bonnet5030.5
      Opinion about PPE to protect from COVID-19
       No5734.7
       I'm undecided1710.4
       Yes9054.8
      Fear of working during the pandemic
       No6539.6
       Yes9960.4
      Considered quitting the job during the pandemic
       No6841.5
       I'm undecided106.1
       Yes8652.4
      Most needed during the pandemic
       Healthy eating5432.9
       Quality sleep5332.3
       Accommodation place4426.8
       Cleaning/Hygiene7042.7
       Financial support11167.6
       Psychological support12073.2
       More flexible working hours5734.8
      Opinion about the gradual transition to normal life
       I find it early8250
       I think it's too late2817.1
       I don't think precautions were taken properly8149.4
       I don't think that precautions are fully followed4728.7
       If the measures are followed, I think it will be positive1710.4

      Maslach Burnout Inventory (MBI)

      The MBI is a seven-point Likert-type scale developed by
      • Maslach C.
      • Jackson S.E.
      The measurement of experienced burnout.
      . This measurement tool consists of 22 items and three subscales. Of these subscales, the emotional exhaustion (EE) section consists of 9 items, depersonalization (DP) 5 items, and personal accomplishment (PA) 8 items. Scale items are scored as “1 = never” to “7 = always.” The three subscale scores were calculated separately and categorized as low, moderate, or high levels of burnout (EE, low: ≤18, moderate: 19 to 26, high: ≥27; DP, low: ≤5, moderate: 6 to 9, high: ≥10; PA, low: ≤33, moderate: 34 to 39, high: ≥40) (
      • Maslach C.
      • Jackson S.E.
      The measurement of experienced burnout.
      ). The validity and reliability of the Turkish version of the MBI was performed by
      • Ergin C.
      Burnout in doctors and nurses and adaptation of Maslach burnout scale.
      , and the reliability coefficients were 0.83 for EE, 0.65 for DP, and 0.72 for PA. The scale, which was a 7-point Likert in its original form, has been changed to a 5-point Likert (“1 = never” to “5 = always”) in the Turkish form (
      • Ergin C.
      Burnout in doctors and nurses and adaptation of Maslach burnout scale.
      ). In the present study, Cronbach-α coefficients were 0.90 for EE, 0.76 for DP, and 0.78 for PA.

      Compassion Fatigue-Short Scale (CF-SS)

      The CF-SS was developed by
      • Adams R.E.
      • Boscarino J.A.
      • Figley C.R.
      Compassion fatigue and psychological distress among social workers:A validation study.
      . The scale is a 13-item self-reported questionnaire. Participants are asked to rate the frequency of how often each item applies to themselves on a 10-point Likert scale ranging from 1 to 10 points (“1= rarely/never, 10 = very often”). A higher mean score indicates a higher degree of CF (
      • Adams R.E.
      • Boscarino J.A.
      • Figley C.R.
      Compassion fatigue and psychological distress among social workers:A validation study.
      ). The Turkish validity and reliability study was carried out by
      • Dinc S.
      • Ekinci M.
      Adaptation, validity and reliability of the compassion fatigue short scale into Turkish.
      . In the study of Dinc and Ekinci, the Cronbach-α coefficient of the scale was 0.87 (
      • Dinc S.
      • Ekinci M.
      Adaptation, validity and reliability of the compassion fatigue short scale into Turkish.
      ). It was 0.91 in this study.

      Data collection

      Data were collected between 1 September and 31 December 2020 using the online survey method on the social media platforms of the Turkish Emergency Nurses Association. The researcher (AA) is a member of the platforms and answered the questions of those who wanted to participate in the research online. Filling out the online questionnaire took approximately 10 min.

      Analysis and evaluation of data

      Evaluation of the data was done using the SPSS 24 package program. Frequency, percentage, minimum-maximum, and mean and standard deviation were used for the presentation of the descriptive data. For the statistical analysis, the parametric test conditions were examined and the compatibility of the data with a normal distribution was investigated with the Kolmogorov-Smirnov test. In cases where parametric test conditions were met, the Student's t-test was used to compare two groups and One Way Analysis of Variance was used to compare three or more groups. The Tukey test was used for further analysis. Pearson correlation was used to evaluate the relationship between the scales. The significance level was accepted as p < 0.05 in all statistical analyses.

      Ethical and legal aspects of research

      Ankara University Ethics Committee permission was obtained to conduct the research. Permission was obtained from the Emergency Nurses Association Board of Directors to share the questionnaires online on social media platforms. Nurses who agreed to participate in the study continued the online survey by marking the “I agree to participate in the study” section on the first page. All ethical principles (Informed Consent Principle, Volunteering Principle, and Principle of Protection of Confidentiality) were fulfilled in the study.

      Results

      Descriptive characteristics

      One hundred sixty-four pediatric emergency nurses participated in this study. Nurses were predominantly female (n = 103, 62.8%) and over half were between 20 and 30 years of age (n = 96, 58.6%) and had completed an undergraduate education (n = 101, 61.6%). Most nurses had worked between 2 and 10 years in the PED (n = 87, 53%) and night shifts (n = 138, 84.1%) and 24-h shifts (n = 96, 58.5%) and cared for approximately 6–15 patients per day (n = 72, 43.9%). More than half of nurses found PPE sufficient to protect from COVID-19 (n = 90, 54.8%), but most nurses reported being worried about getting COVID-19 in the department (n = 129, 78.7%) and infecting someone with it (n = 131, 79.9%). PED nurses most needed financial (n = 111, 67.6%) and psychological support (n = 120, 73.2%) during the pandemic. The demographic characteristics of the nurses are reported in Table 1.

      Mean scores of Nurses' Maslach burnout inventory sub-dimensions

      Table 2 shows the prevalence of burnout among nurses. In general, nurses in this study reported high levels of EE (n = 84, 51.4%) and DP (n = 97, 58.9%) but low levels of PA (n = 147, 89.6%).
      Table 2Prevalence of burnout among pediatric nurses (N = 164).
      MBI

      Sub-Dimension
      MeanSDRangeLevel of Burnout
      LowModerateHigh
      n%n%n%
      EE28.256.0510–45149.16640.58451.4
      DP11.892.395–222314.44426.79758.9
      PA17.983.1214–3914789.61710.4

      Comparison of the MBI and CF-SS mean scores of the nurses in terms of their descriptive characteristics

      There was no significant difference in the scores of the MBI sub-dimensions of DP and PA according to the descriptive characteristics of PED nurses (p > 0.05). However, the mean EE scores were significantly influenced by gender, age, time working in the PED, shift worked, shift time, fear of working during the pandemic, worry about getting COVID-19 in the department, and worry about infecting someone with COVID-19 (p < 0.05) (Table 3).
      Table 3Comparison of the MBI and CF-SS Mean Scores of the Nurses in terms of Their Descriptive Characteristics (N = 164).
      Descriptive CharacteristicsMaslach Burnout Inventory (MBI) Sub-DimensionsCompassion Fatigue Short Scale
      Emotional exhaustionDepersonalizationPersonal accomplishment(CF-SS)
      MeanSDtestpMeanSDtestpMeanSDtestpMeanSDtestp
      Gender
       Female29.146.11t = 0.3030.04811.912.44t = 0.1570.87718.023.19t = 0.2000.8425.211.44t = 2.5750.011
       Male28.44611.852.3217.913.024.621.35
      Age
       20–-30 years30.70 a5.53F = 8.3640.001*11.982.54F = 1.2300.29518.123.25F = 0.8450.4326.20 a1.12F = 9.8730.001*
       31–-40 years29.58 b6.58a > b > c11.52.2718.012.815.19 b1.15a > c, 0.024* a > b
       ≥41 years26.71 c5.7912.471.6917.053.244.67 c1.49
      Education status
       High school30.517.1F = 2.3080.07911.833.07F = 1.2320.87418.93.2F = 3.7370.5325.181.48F = 4.1380.057
       Associate degree28.457.1412.271.5718.863.355.151.57
       Undergraduate27.775.4511.812.36183.235.081.36
       Postgraduate25.74.3212217.82.854.890.81
      Working time in PED
       0–-1 years31.60 a5F = 6.3990.001* a > c,12.152.67F = 0.5240.59318.133.2F = 0.3400.7126.00 a1.02F = 7.9420.001* a > b > c
       2–-10 years28.34 b5.890.041* b > c11.722.2918.023.115.08 b1.35
       ≥11 years26.50 c6.1811.922.1317.523.054.81 c1.54
      Work shift
       Day shift25.85.3t = −-2.2750.02411.882.3t = −-0.1130.90918.072.86t = −-1.1430.884.31.24t = 0.7260.02
       Night shift28.716.0911.892.4117.963.175.031.46
      Predominant shift time
       08.00–-16.0025.80 a5.3F = 3.2910.035*11.882.3F = 0.7540.99418.072.86F = 0.6760.514.70 a1.24F = 2.8580.045* c > a
       16.00–-08.0027.80 b4.82c > a11.852.3817.83.314.88 b1.27
       08.00–-08.0029.11 c6.5511.92.4418.163.115.29 c1.54
      Worried about getting COVID-19 in the department
       No26.175.73t = −-2.3260.02111.912.66t = 0.1050.94717.852.85t = 0.2670.7915.06
       Yes28.826.0411.882.3218.013.25.11.42t = 0.8700.096
      Worried about infecting someone with COVID-19
       No26.426.47t = −-1.9600.04212.272.73t = 1.0270.30618.182.83t = 0.4110.6824.941.41t = 0.3870.073
       Yes28.715.8811.792.317.933.25.021.53
      Fear of working during the pandemic
       No26.984.93t = −-2.2030.02911.612.23t = −-1.1930.23417.633.14t = 1.1670.2454.931.14t = 0.8210.013
       Yes29.096.5812.072.4817.213.15.161.6
      SD: Standard deviation, t: t-test, F: ANOVA, * Tukey-Posthoc, the group from which the significance originates.
      The mean CF-SS score of the nurses was 4.99 ± 1.43. No significant differences were found for CF-SS scores based on education status, worry about getting COVID-19 at work, and worry about infecting someone with COVID-19 (p > 0.05). However, the effects of gender, age, time working in the PED, shift worked, shift time, and fear of working during the pandemic did significantly influence the mean CF-SS scores (p < 0.05) (Table 3).

      Relationship between compassion fatigue-short scale and maslach burnout inventory mean scores

      The EE and DP sub-dimensions of burnout had a positive and significant relationship with CF (p < 0.05). Although there was a negative relationship between PA and CF, it was not significant (p > 0.05) (Table 4).
      Table 4Relationship Between Compassion Fatigue-Short Scale and Maslach Burnout Inventory Mean Scores.
      ScaleMaslach Burnout Inventory
      Emotional ExhaustionDepersonalizationPersonal Accomplishment
      Compassion Fatigue
      r0.5570.341−0.112
      p0.0010.0010.154
      r: Pearson correlation, p < 0.05.

      Discussion

      This is the first study to determine CF and burnout in nurses working in the PED during the COVID-19 pandemic. The data of the study were collected during the high incidence of COVID-19 cases in Turkey (). There is no study evaluating CF and burnout in PED nurses before the pandemic in Turkey. Therefore, the literature on nurses working in adult and pediatric services was used for discussion. Approximately 50% of nurses had moderate CF and burnout before the pandemic(
      • Berger J.
      • Polivka B.
      • Ann E.
      • Owens H.
      Compass fatigue in pediatric nurses.
      ,
      • Hunsaker S.
      • Chen H.C.
      • Maughan D.
      • Heaston S.
      Factors that influence the development of compassion fatigue, burnout, and compassion satisfaction in emergency department nurses.
      ,
      • O'Callaghan E.L.
      • Lama L.
      • Canta R.
      • Mossa C.
      Compass satisfaction and compassion fatigue in Australian emergency nurses: A descriptive cross-sectional study.
      ). For the pandemic comparison, studies evaluating CF and burnout in adult nurses were used. These nurses have moderate to high levels of CF and burnout (
      • Butera S.
      • Brasseur N.
      • Filion N.
      • Bruyneel A.
      • Smith P.
      Prevalence and associated factors of burnout risk among intensive care and emergency nurses before and during the COVID-19 pandemic: A cross-sectional study in Belgium.
      ;
      • Erkin O.
      • Konakcı G.
      • Duran S.
      Secondary traumatic stress in nurses working with patients with suspicion/confirmed COVID-19 in Turkey.
      ;
      • Labrague L.J.
      • Santos J.A.
      Resilience as a mediator between compassion fatigue, nurses' work outcomes, and quality of care during the COVID-19 pandemic.
      ;
      • Ruız-Fernández M.
      • Ramos-Pıchardo J.D.
      • Ibáñez-Masero O.
      • Cabrera-Troya J.
      • Carmona-Rega M.I.
      • Ortega-Galán A.M.
      Compassion fatigue, burnout, compassion satisfaction and perception stress in healthcare professionals during the COVID-19 health crisis in Spain.
      ) This finding is similar to that of this study. The unpredictable and rapidly spreading nature of COVID-19 has created a great burden on all healthcare professionals, as it causes high morbidity and mortality (
      • Hores D.
      • Brown A.D.
      Traumatic stress in the age of COVID-19: A call to close critical gaps and adapt to new realities.
      ). This situation led to an increase in the already existing levels of CF and burnout in nurses.
      In fact, PED nurses are trying to adapt to new ways of working and protocols due to a crowded and stressful environment, high workload, increased patient circulation (
      • Galehdar N.
      • Kamran A.
      • Toulabi T.
      • Heydari H.
      Exploring nurses' experiences of psychological distress during care of patients with COVID-19: A qualitative study.
      ), and more exposure to infected patients and families with COVID-19 in the PED (
      • Cinar D.
      • Kilic Akca N.
      • Zorba Bahceli P.
      • Bag Y.
      Perceived stress and affecting factors related to COVID-19 pandemic of emergency nurses in Turkey.
      ). Therefore, they might have more CF and burnout than adult nurses. In addition to working in an emotional, stressful, and intense environment during the pandemic, caring for children who cannot express themselves and report their contact history, who need someone else to meet their personal care needs (
      • Góes F.G.B.
      • Silva A.C.S.S.
      • Santos A.S.T.
      • Pereira-Ávila F.M.V.
      • Silva L.J.
      • Silva L.F.
      • Goulart M.C.L.
      Challenges faced by pediatric nursing workers in the face of the COVID-19 pandemic.
      ), and witnessing the suffering of parents can negatively affect (
      • Kellogg M.B.
      • Mccune N.
      • Barker M.
      The lived experience of pediatric burn nurses following patient death.
      ) emergency nurses both physically and mentally and contribute to their CF and burnout.
      The findings of this study revealed that there are some factors affecting the status of CF and burnout in PED nurses working during the pandemic. One of these factors was gender. Female nurses had higher mean EE and CF scores. Similar to this study, there are studies stating that female nurses who worked during the COVID-19 pandemic had higher EE (
      • Arpacıoglu M.S.
      • Baltacı Z.
      • Unubol B.
      Burnout, fear of Covid, depression, occupational satisfaction levels and related factors in healthcare workers in the COVID-19 pandemic.
      ;
      • Barello S.
      • Palamenghi L.
      • Graffigna G.
      Burnout and somatic symptoms among frontline healthcare professionals at the peak of the Italian COVID-19 pandemic.
      ;
      • Brera A.S.
      • Arrigoni C.
      • Dellafiore F.
      • Odone A.
      • Magon A.
      • Nania T.
      • Pittella F.
      • Palamenghi L.
      • Barello S.
      • Caruso R.
      Burnout syndrome and its determinants among healthcare workers during the first wave of the Covid-19 outbreak in Italy: A cross-sectional study to identify sex-related differences.
      ;
      • Chen R.
      • Sun C.
      • Chen J.J.
      • Jen H.J.
      • Kang X.L.
      • Kao C.C.
      • Chou K.R.
      A large-scale survey on trauma, burnout and posttraumatic growth among nurses during the COVID-19 pandemic.
      ) and CF scores (
      • Orrù G.
      • Marzetti F.
      • Conversano C.
      • Vagheggını G.
      • Miccoli M.
      • Ciacchini R.
      • Panait E.
      • Gemignani A.
      Secondary traumatic stress and burnout in healthcare workers during COVID-19 outbreak.
      ) than male nurses did. Because women might experience feelings of loss of control (
      • Lai J.
      • Ma S.Y.
      • Cai Z.
      • Hu J.
      • Wei N.
      • Wu J.
      • Du H.
      • Chen T.
      • Li R.
      • Tan H.
      • Kang L.
      • Yao L.
      • Huang M.
      • Wang H.
      • Wang G.
      • Liu Z.
      • Hu S.
      Factors associated with mental health outcomes among health careworkers exposed to coronavirus disease 2019.
      ), fear, and anxiety more intensely than men (
      • Arpacıoglu M.S.
      • Baltacı Z.
      • Unubol B.
      Burnout, fear of Covid, depression, occupational satisfaction levels and related factors in healthcare workers in the COVID-19 pandemic.
      ), they might be more prone to experiencing the EE caused by COVID-19 stressors. In addition, female nurses can experience CF as a result of placing a high value on nurse-patient relationships and experiencing high levels of empathy with patients (
      • Brera A.S.
      • Arrigoni C.
      • Dellafiore F.
      • Odone A.
      • Magon A.
      • Nania T.
      • Pittella F.
      • Palamenghi L.
      • Barello S.
      • Caruso R.
      Burnout syndrome and its determinants among healthcare workers during the first wave of the Covid-19 outbreak in Italy: A cross-sectional study to identify sex-related differences.
      ). This may negatively affect the attitudes of female nurses toward pediatric patients and their clinical performance may decrease.
      Nurses between the ages of 20 and 30 who worked in the PED for <1 year had higher mean EE and CF scores. Similar to this study, the mean EE (
      • Zhang Y.
      • Wang C.
      • Pan W.
      • Zhen J.
      • Gao J.
      • Huang X.
      • Cai S.
      • Zhai Y.
      • Latour J.M.
      • Zhu C.
      Stress, burnout, and coping strategies of frontline nurses during the COVID-19 epidemic in Wuhan and Shanghai, China.
      ) and CF scores of (
      • Labrague L.J.
      • Santos J.A.
      Resilience as a mediator between compassion fatigue, nurses' work outcomes, and quality of care during the COVID-19 pandemic.
      ) young nurses with less work experience were higher during the COVID-19 pandemic. In this study, young nurses who worked in an intense and stressful environment such as a PED and who were new to the profession may experience EE due to the additional workload brought about by the pandemic. They might also have less experience coping with different stressors (
      • Garcia-Martin M.
      • Roman P.
      • Dean V.
      • Rodriguez-Arrastia M.
      • Diaz-Cortes M.
      • Soriano-Martin P.J.
      • Ropero-Padilla C.
      Novice nurse's transitioning to emergency nurse during COVID-19 pandemic: A qualitative study.
      ). It is thought that CF develops in PED nurses because the pandemic affected the communication methods with patients and the way of providing care (
      • Brown A.
      Will Covid-19 affect the delivery of compassionate nursing care?.
      ). Thus, the ability to make clinical decisions to meet the care needs of infected patients is limited (
      • Garcia-Martin M.
      • Roman P.
      • Dean V.
      • Rodriguez-Arrastia M.
      • Diaz-Cortes M.
      • Soriano-Martin P.J.
      • Ropero-Padilla C.
      Novice nurse's transitioning to emergency nurse during COVID-19 pandemic: A qualitative study.
      ). This may result in nurses' inability to adapt to the tempo of the emergency service and inability to maintain their professional care for children with complex nursing needs such as COVID-19 during the ongoing pandemic.
      PED nurses working shifts and mostly 24-h shifts had high EE and CF. Similar to this study, nurses working long hours during the COVID-19 pandemic have higher mean EE (
      • Zhang Y.
      • Wang C.
      • Pan W.
      • Zhen J.
      • Gao J.
      • Huang X.
      • Cai S.
      • Zhai Y.
      • Latour J.M.
      • Zhu C.
      Stress, burnout, and coping strategies of frontline nurses during the COVID-19 epidemic in Wuhan and Shanghai, China.
      ) and CF scores (
      • Orrù G.
      • Marzetti F.
      • Conversano C.
      • Vagheggını G.
      • Miccoli M.
      • Ciacchini R.
      • Panait E.
      • Gemignani A.
      Secondary traumatic stress and burnout in healthcare workers during COVID-19 outbreak.
      ). The pandemic has caused nurses to work long hours with protective equipment that makes it difficult to work but still has a high risk of infection due to long-term contact with patients (
      • Galanis P.
      • Vraka I.
      • Fragkou D.
      • Bilali A.
      • Kaitelidou D.
      Nurses' burnout and associated risk factors during the COVID-19 pandemic: A systematic review and meta- analysis.
      ). Furthermore, there has been a change of care practices such as the inability to use therapeutic touches, gestures, and facial expressions and subsequent worry about not being able to provide adequate care (
      • Brown A.
      Will Covid-19 affect the delivery of compassionate nursing care?.
      ). While the long shifts of nurses are a risk factor for exhaustion (
      • Witkoski Stimpfel A.
      • Sloane D.M.
      • Aiken L.H.
      The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction.
      ), the pandemic also brought additional workloads to PED nurses and increased their working hours. This can increase their physical and mental fatigue (
      • Wendekier C.
      • Kegerreis K.
      Nurse compassion fatigue An unintended consequence of the COVID-19 pandemic.
      ), which is associated with CF and EE. It can also affect their overall health, leading to a lack of motivation, distractions, job dissatisfaction, and alienation from the profession (
      • Labrague L.J.
      Pandemic fatigue and clinical nurses’ mental health, sleep quality and job contentment during the covid-19 pandemic: The mediating role of resilience.
      ).
      Although most nurses used PPE for protection from infection and found the precautions in the working environment sufficient, they were worried that they would be infected with COVID-19 and subsequently infect their relatives. Nurses who experienced this anxiety and were afraid of working during the pandemic had high average EE scores. The high patient density and circulation in the emergency department caused the nurses to experience anxiety and stress about being infected and transmitting the disease because of the high viral load in this environment and the rapidly spreading nature of the COVID-19 virus even though full PPE was provided (
      • Cinar D.
      • Kilic Akca N.
      • Zorba Bahceli P.
      • Bag Y.
      Perceived stress and affecting factors related to COVID-19 pandemic of emergency nurses in Turkey.
      ). This anxiety and stress may contribute to the development of EE. Furthermore, nurses during the pandemic were negatively affected by the loss of infected colleagues (
      • Atac M.
      • Kaplan A.
      Psychological effect and protection of mental health of nurses in the COVID-19 pandemic.
      ). Having this same risk for themselves and their families as well as fear of death and loss may cause them to experience EE. As a result, nurses may experience difficulties in achieving and maintaining work-life balance.

      Practical implications

      The COVID-19 pandemic is an unprecedented global public health problem, and its impact continues. PED nurses experienced CF and burnout like nurses working in adult clinics. However, no study was found in which CF and burnout levels were discussed in PED nurses during the pandemic. This may be due to the more severe course of COVID-19 in adult patients and the almost complete focus on adult care in the delivery of health services. This study provides an important contribution by raising awareness about the problems faced by PED nurses during the pandemic and illuminating future studies on this issue. CF and burnout affected the quality of care provided by nurses, but also negatively affected their well-being and quality of life during the pandemic. Therefore, the development of interventions to reduce CF and burnout can help reduce and manage these symptoms during the pandemic.

      Limitations

      This study has several limitations. First, it was carried out during the most intense period of the pandemic in Turkey. The timing of data collection during the pandemic might have an impact on the results of this study. Finally, the impact of COVID-19 on the findings needs to be interpreted with caution, as there were no data on PED nurses' CF and burnout status before the COVID-19 pandemic in Turkey. A future follow-up study is needed to fully understand the impact of the pandemic on PED nurses.

      Conclusion

      COVID-19, which has lasted for a long time and affected the world, negatively affected nurses working in all services including PED nurses. The pandemic has demonstrated how necessary and important it is to invest in health systems. PED nurses provide clinical care to pediatric patients in a busy environment at an intense pace. The role of PED nurses, who first encounter pediatric patients and provide their nursing care, is very important and they need support. If the health of children is to be secured, the health of nurses must be protected first. Therefore, within the scope of the findings of this study, it is necessary to protect and maintain the mental health of all nurses, especially female, young, and less experienced PED nurses. Also, to prevent long-term effects of the pandemic, the physiological and psychosocial needs of nurses should be prioritized. To create a high-quality nursing workforce, safe working environments should be created in health institutions, nurses' working hours should be organized considering their roles and responsibilities in their daily lives, and employee rights should be improved (salary, leave, rest and break times, etc.). Nurses should be supported to develop strategies to cope with the psychosocial problems they experience during the pandemic.

      Funding information

      The authors received no financial support for the study.

      CRediT authorship contribution statement

      Aylin Arikan: Conceptualization, Methodology, Investigation, Resources, Data curation, Formal analysis, Writing – original draft, Writing – review & editing, Project administration. Figen Işık Esenay: Conceptualization, Methodology, Data curation, Formal analysis, Writing – review & editing, Supervision, Project administration.

      Data availability

      The data that support the findings of this study are available from the corresponding author upon reasonable request.

      Declaration of Competing Interest

      The authors declared no potential conflicts of interest.

      Acknowledgments

      We would like to express our gratitude to all the nurses who took part in the study, as well as the Turkish Emergency Nurses Association, for their contributions.

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