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BioMed Central London

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10.1186/s12912-024-02304-1
Research
Polish infection control nurses’ burnout in the context of cooperation of different hospital professionals during COVID-19 pandemic
Jaślan Dorota 1
Rosiński Jerzy 2
Micek Agnieszka 3
Szczypta Anna 4
Nowacka Anna 5
Wójkowska-Mach Jadwiga 1
Różańska Anna a.rozanska@uj.edu.pl

1
1 https://ror.org/03bqmcz70 grid.5522.0 0000 0001 2337 4740 Department of Microbiology, Jagiellonian University Medical College, Cracow, 31-121 Poland
2 https://ror.org/03bqmcz70 grid.5522.0 0000 0001 2337 4740 Faculty of Management and Social Communication, Jagiellonian University, ul. Łojasiewicza 4, Kraków, 30-348 Poland
3 https://ror.org/03bqmcz70 grid.5522.0 0000 0001 2337 4740 Statistical Laboratory, Institute of Nursing and Midwifery, Faculty of Health Sciences, Jagiellonian University Medical College, ul. Michałowskiego 12, Cracow, 31-126 Poland
4 grid.445217.1 0000 0001 0724 0400 Faculty of Medicine and Health Science, Andrzej Frycz Modrzewski Krakow University, ul. Herlinga-Grudzińskiego 1, Kraków, 30-705 Poland
5 https://ror.org/03bqmcz70 grid.5522.0 0000 0001 2337 4740 Faculty of Health Sciences, Jagiellonian University Medical College, ul. Kopernika 25, Cracow, 31- 501 Poland
13 9 2024
13 9 2024
2024
23 65012 2 2024
29 8 2024
© The Author(s) 2024
2024
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Backgrounds

Infection control nurses’ job are crucial for patient and healthcare workers safety. However, effective infections prevention is based on the interdisciplinary team work, involving almost all hospital employees professionals. Difficulties in cooperation in such a team, especially prolonged ones, as well as crisis situations, may cause burnout. The aim of the study was to determine burnout among infection control nurses working during the COVID-19 pandemic in the context of difficulties in cooperation with different professionals working in hospitals.

Methods

The observational study was conducted between May and September 2021, using an online survey questionnaire consisting of two parts: describing difficulties in ICNs cooperation with different hospital professionals and Maslach Inventory Burnout scale, describing emotional exhaustion (EE), depersonalization (DP) and personal accomplishment rates (PA). Correctly completed online surveys were obtained from 177 participants.

Results

Most of the respondents (176 of 177) were women, working in public hospitals (81.48%). All respondents had considerable experience in work as nurses - the median was 30 years. However, the median experience in the ICNs position was 12 years. Median age of respondents was 51 years. The median level of EE was 31.0, w ith the range 23.0 to 39.0. For DP it was 5.0, with the range 3.0 and 11.5, while for PA – 24.0 (19.0–29.0). The highest values of EE were observed in the context of high level of difficulties with cooperation with management – the median was 36.0. DP was lowest among nurses declaring the lowest difficulties in cooperation with doctors. For PA the lowest level was observed in the group declaring high difficulties in the cooperation with doctors – median 22.0, with range 14.0–29.0.

Conclusions

The surveyed ICNs had higher rates of EE and PA than nurses working with patients, both before and during the pandemic. The level of burnout found in the ICN study group reached a level correlating in other studies with the intention to quit the job. The obtained results indicate the need to include effective training in the skills of working in multidisciplinary teams and the art of communication and achieving goals by ICNs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-024-02304-1.

Keywords

MBI scale
Infection control nurse
Professional burnout
COVID-19
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcBackgrouds

The COVID-19 pandemic, particularly in 2020–2021, presented significant challenges to infection control teams, especially infection control nurses (ICNs). Facing unprecedented conditions and the need to quickly respond to a dynamically changing epidemiological situation with limited resources may cause or intensify the symptoms of burnout. In the conditions of the pandemic it may be expected that the work of infection control nurse, which concerns the safety of patients and staff, should be appreciated. This would in turn be reflected in good cooperation with various groups of hospital employees. The study by Jaślan et al., however, showed that Polish infection control nurses encountered equally great difficulties in cooperation with hospital staff as before the pandemic [1]. Such conditions of everyday work, aggravated by the pandemic, may result in professional burnout. A commonly used tool for assessing burnout is the Maslach and Jackson model, which takes into account three components of burnout, i.e. the psychological syndrome of emotional exhaustion, depersonalization and a sense of reduced personal accomplishment [2].

Emotional exhaustion (EE) is the feeling of excessive emotional burden and a simultaneous deficit of resources at one’s disposal. It is a feeling of emptiness and loss of strength caused by excessive demands placed on the individual by their job (the case may also be that the professional in question sets too high demands on themself). The second element of burnout syndrome according to Maslach is depersonalization (DP). Depersonalization is a negative reaction to other people (clients, patients, pupils), which involves an objectification of the other person. It is a feeling of callousness, impersonality, a cynical view of others, and reduced sensitivity. The third independent dimension of burnout, associated with lack of job satisfaction, is a reduced sense of personal accomplishment (PA), which expresses a diminished perception of one’s competences and successes at work [3].

In management theory and behavioral studies, team cooperation is a multidimensional process influenced by various organizational factors as well as those resulting from the behaviors of individual team members [4]. Effective prevention of infections, consisting in the development of prevention procedures, staff training in this area, recording of infections, analysis of the obtained data and feedback for doctors and nurses, is indeed an example of work in an interdisciplinary team, involving almost all hospital employees [5]. Difficulties in cooperation in such a team, especially prolonged ones, as well as crisis situations, may cause burnout.

Over the last years, numerous studies on burnout have been conducted [6], including among Polish nurses working in various types of hospital departments. However, such a study has not yet been conducted specifically among Polish ICNs. There have also been few studies examining this phenomenon among infection control personnel abroad.

The aim of the study was to determine burnout among infection control nurses working during the COVID-19 pandemic in the context of difficulties in cooperation with medical staff and other groups of hospital employees, including hospital management.

Materials and methods

Study tools

The observational study was conducted between May and September 2021, using an online survey questionnaire consisting of:

Questions on sociodemographic characteristics of the respondents (e.g. age, gender and education), their work (e.g. occupation, workplace and work experience).

Questions regarding problems in cooperation with various groups of staff: nurses (surgical, intensive care, medical wards), infection control physician , hospital management, microbiological laboratory and with other employees. The principal components analysis (PCA, Supplementary file) has shown that three components reflect the level of problems reported by ICNs in cooperation with three groups of staff: doctors, nurses/microbiological laboratory, and administration/management (Table 1).

Table 1 Hospital professionals characterized by similar level of difficulties in cooperation with infection control groups

Subscale	Indication of the level of difficulties in cooperation with given group	
Doctors	Cooperation with doctors working in surgical wards	
Cooperation with doctors working in intensive care units	
Cooperation with doctors working in medical wards	
Nurses, microbiological laboratory	Cooperation with nurses working in surgical wards	
Cooperation with nurses working in intensive care units	
Cooperation with nurses working in medical wards	
Cooperation with microbiology laboratory workers	
Administration,

management

	Cooperation with infection control physician (head of ICT)	
Cooperation with administration departments workers	
Cooperation with other groups	
Cooperation with management	

Problems in cooperation with each professional group were rated by the respondents on a scale with values such as: very high, high, medium, low, very low and none, but for the purposes of analysis the level of difficulty in cooperation was reduced to three levels, low – tertile first (T1), medium – tertile second (T2) and high level of difficulties – tertile third (T3). This part of the questionnaire were prepared by a panel of experts working in infection control, including two nurses and two epidemiologists (authors), in two-stage process. Firstly, two authors proposed the tool frame and answers, and then – others with additional practical experience reviewed the questionnaire. The questionnaire was evaluated in terms of compliance with the rules of simple vocabulary, avoiding abstract words, not fully defined or ambiguous, negations, names of institutions, too long and/or covering more than one issues items. Additionally, Cronbach’s alpha test was conducted and the reliability proved to be satisfactory: the raw alpha value and 95% CI were 0.854 (0.814;0.888).

3. The third part of the survey consisted of the questions included in the burnout questionnaire - MBI-HSS [7]. The MBI-HSS contains 22 items (each scored on a 7-point scale: from 0 = never to 6 = every day) on three dimensions: emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). For the emotional exhaustion subscale, a score of 27 or more represented a high level, average level scores ranged between 17 and 26, and low level ranged between 0 and 16. In the case of the depersonalization scale, a score of 13 or more meant a high level, 7–12 average level, and 0–6 low level. For the subscale of sense of personal accomplishment, a score of 39 or more was considered a high level, 32–38 average level, and 0–31 low level [7].

Information about the study, along with an invitation explaining its purpose, the information about anonymity and the survey questionnaires, were all sent by e-mail to infection control nurses by voivodeship consultants in this specialty. Correctly completed online surveys in the scope covered by the analysis were obtained from 177 participants.

Statistical analysis

The main exposures were obtained based on subscales extracted from PCA. Details regarding PCA analysis are presented in the supplementary materials. The scores of components addressing to patterns reflecting level of problems in cooperation with three groups of staff: doctors, nurses/microbiological laboratory, administration/management were calculated. The Cronbach’s alpha statistic for the overall scale was amounted to 0.85, and for individual subscales 0.881 (nurses), 0.658 (doctors) and 0.800 (management), respectively. The association between tertile groups defined for each pattern Maslash scores were examined. Next, such scores were divided to tertile groups and tested whether they are associated with Maslash. Baseline characteristic of the sample for sex, education and hospital status was presented as counts and percentages while length of working as a nurse (in total), length of working as an infection control nurse, hospital size, number of nurses and age were characterised by medians with quartiles. Scores of Maslash scales and subscales were compared between tertile groups of defined patterns using Kruskal-Wallis test followed by Dunn Post hoc test with Benjamini & Hochberg correction for multiple comparisons. Multivariable linear regression analysis was performed separately for each “problematic pattern” with effect size expressed by unstandardised beta coefficients and 95% confidence intervals (CIs). The main explanatory variables were introduced to the models by setting the lowest tertile as a reference category. The most fully adjusted models were adjusted to sex, length of working as nurse (in total), education, hospital size, hospital status, number of nurses. Additionally, trend analysis was performed by model consecutive tertile categories numerically (by assigning 1,2,3 scores).

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement guidelines for reporting observational studies were used for manuscript preparation.

Ethics

This study was done on the basis of completely anonymous on-line survey in which the questions were preceded by information on the purpose of the study and the fact that completing it meant consent for participation and publication of the results. The study received approval of the Bioethics Commission of the Jagiellonian University in Krakow (no KBET 1072.6120.57.2021 from 17.03.2021). The survey was carried out in accordance with the principles contained in the Helsinki Declaration as revised in 2013.

Results

Characteristics of study sample

Most of the respondents (176 of 177) were women, who held a master diploma (78.52%) and worked in public hospitals (81.48%) (Table 2).

Table 2 Characteristics of the study group

Variable	Category	Number (%)	
Sex			
	Female	134 (99.26)	
	Male	1 (0.74)	
Education			
	Other	29 (21.48)	
	Higher	106 (78.52)	
Hospital status			
	Non public/private	25 (18.52)	
	Public	110 (81.48)	

All respondents had considerable experience in work as nurses - the median was 30 years. However, the experience was much shorter in the infection control nurse position – the median was 12 years, with a range from 5 to 17 years. Median age of respondents was 51 years. Most respondents worked in medium size hospitals (Table 3).

Table 3 Respondents job experience and characteristic of hospitals

Variable	Q2 (Q1; Q3)	
Length of working as nurse (in total),	30.0 (25.5;34.0)	
Length of working as epidemiologic nurse	12.0 (5.0;17.0)	
Hospital size (number of beds)	309.0 (200.0;427.5)	
Number of nurses	2.0 (1.0;2.0)	
Age	51.0 (47.0;55.0)	
Q2 – median, Q1 – first quartile, Q3 – third quartile

The highest level of difficulties was indicated by ICN in the context of cooperation with physicians and management. The difficulties were perceived as less difficult in cooperation with nursing staff and other professional groups. Detailed analysis of difficulties in cooperation with different groups were previously described in a separate paper [1].

The median level of emotional exhaustion was 31.0, with first and third quartiles at 23.0 and 39.0, respectively. For depersonalization it was 5.0, with Q1 at 3.0 and Q3 at 11.5, while for personal accomplishment – 24.0 (19.0–29.0).

The highest values of EE were observed in the context of acute problems with cooperation with management – the median was 36.0 with the range between 27.0 and 47.0. The difference was significant compared to the groups declaring low and medium problems in cooperation (Table 4). Median values of EE did not differ between groups declaring low and medium problems in cooperation both with doctors and nurses.

Depersonalization was lowest (median 4.0 with the range from 2.0 to 7.0) among nurses who had the lowest level of problems in cooperation with doctors (first tertile). The depersonalization levels differed significantly between groups declaring low and medium problems (Table 4). Regarding personal accomplishment, the lowest level was observed in the group declaring high problems in the cooperation with doctors – median 22.0, ranging from 14.0 to 29.0, with significant positive correlation with the level of difficulties.

Table 4 Maslach scale dimensions according to the level of difficulties in cooperation with selected professionals

Score category	Tertile 1	Tertile 2	Tertile 3	p	
Doctors	
Emotional exhaustion	27.00 (21.00; 33.00)	31.00 (23.00; 40.00)	33.00 (27.00; 42.00)	0.073	
Depersonalisation	4.00 (2.00; 7.00)a	7.00 (4.00; 15.00)a	6.00 (3.00; 14.00)	0.034	
Personal accomplishment	27.00 (22.00; 30.00)ab	23.00 (19.00; 26.00)a	22.00 (14.00; 29.00)b	0.035	
Nurses/microbiological laboratory	
Emotional exhaustion	30.00 (23.00; 42.00)	31.00 (23.00; 41.00)	31.00 (23.00; 36.00)	0.756	
Depersonalisation	5.00 (2.00; 11.00)	8.00 (3.00; 14.00)	5.00 (3.00; 9.00)	0.494	
Personal accomplishment	24.00 (20.00; 27.00)	24.00 (17.00; 28.00)	25.00 (21.00; 31.00)	0.390	
Administration, management	
Emotional exhaustion	30.00 (22.00; 35.00)a	28.00 (23.00; 37.00)b	36.00 (27.00; 47.00)ab	0.030	
Depersonalisation	4.00 (2.00; 11.00)	6.00 (4.00; 10.00)	6.00 (2.00; 15.00)	0.255	
Personal accomplishment	24.00 (21.00; 29.00)	24.00 (17.00; 30.00)	24.00 (18.00; 28.00)	0.491	

Results are presented as medians and quartiles: Q2 (Q1; Q3), the same letters denote pairs of groups with statistically significant (P < 0.05) differences based on Dunn test for multiple comparisons with Benjamini & Hochberg correction.

Multiple linear regression (Table 5.) after controlling for sex, work experience as a nurse (in total), education, hospital size, hospital status, and number of nurses in hospital confirmed the positive correlation between EE, DP and difficulties in cooperation with doctors and management. Nurses with moderate problems in cooperation with doctors had significantly higher levels of depersonalization compared to the lowest tertile – but in the third tertile the difference lost its statistical significance. However in the third tertile the level of personal accomplishment was significantly lower than in the first.

Regarding the cooperation with administration/management, for both EE and PA a trend of, respectively, increasing and decreasing level of scores was noted with both second and third tertile, with statistically significant differences compared to the first tertile.

In the case of ward nurses no statistically significant trend was observed in any dimensions of burnout in correlation to the level of difficulties in cooperation.

Table 5 Linear regression analysis by tertiles of ‘patterns problems’

Score category	Tertile 1	Tertile 2	Tertile 3	Per tertile	
Doctors	
Emotional exhaustion	0 (ref.)	3.91 (-0.93; 8.76)	4.70 (-0.08; 9.47)	2.34 (-0.04; 4.73)	
Depersonalisation	0 (ref.)	4.25 (1.34; 7.15)**	2.46 (-0.41; 5.32)	1.22 (-0.24; 2.68)	
Personal accomplishment	0 (ref.)	-3.10 (-6.36; 0.15)	-3.99 (-7.20; -0.78)*	-1.99 (-3.59; -0.39)*	
Nurses/microbiological laboratory	
Emotional exhaustion	0 (ref.)	1.11 (-3.74; 5.97)	-1.92 (-6.79; 2.94)	-0.97 (-3.40; 1.46)	
Depersonalisation	0 (ref.)	1.60 (-1.34; 4.55)	-0.61 (-3.56; 2.34)	-0.32 (-1.80; 1.17)	
Personal accomplishment	0 (ref.)	-1.57 (-4.85; 1.71)	1.22 (-2.06; 4.50)	0.62 (-1.03; 2.27)	
Administration, management	
Emotional exhaustion	0 (ref.)	0.78 (-4.07; 5.62)	5.93 (1.16; 10.71)*	3.01 (0.62; 5.39)*	
Depersonalisation	0 (ref.)	1.70 (-1.30; 4.70)	2.51 (-0.44; 5.47)	1.25 (-0.22; 2.72)	
Personal accomplishment	0 (ref.)	-2.32 (-5.64; 1.01)	-3.31 (-6.59; -0.04)*	-1.64 (-3.28; -0.01)*	
Results are presented as unstandardised regression coefficients with confidence intervals β (95%CI), **P < 0.01, *P < 0.05, all models were additionally adjusted for sex, work experience as a nurse (in total), education, hospital size, hospital status, and the number of nurses

Discussion

Polish ICNs participating in this study just after the wave of infections related to the COVID pandemic, declared an average high level of burnout in the area of EE − 31, a low level in the area of DP – 5, and a low sense of PA − 24. In the study by Nowacka et al., the average EE score was 22.9, and the average PA score was 27.63. A value closer to the one found in our study was recorded in the area of DP: 6 points [ 7 ]. In the study by Szczerbińska et al. [8], the average values in the EE and PA areas were slightly lower than in the study by Nowacka et al., i.e. 18.82 and 26.68, respectively. This means that, according to the results of our study, ICNs presented a higher level of burnout compared to the cited research on a group of Polish nurses working in various types of departments [7 ], as well as compared to other groups of employees during the COVID-19 pandemic [ 8]. Lower EE scores than in our group of ICNs were also recorded by other authors: during the COVID-19 pandemic among ICU specialists – 18 [9], and before pandemic among trauma nurses − 23.8 [10] and among Chinese nurses − 23.95 [11]. At the same time, all cited authors also found higher indicators in the PA area, equaling 35, 35.31 and 32.46, respectively, while the DP indicators were closer to our results, i.e. 8, 6.72 and 6.63 [9–11].

Lee et al. in a survey among 203 Korean ICNs indicate that work in the conditions of the COVID-19 pandemic, which involves greater effort and stress, significantly correlates with a higher level of burnout in this professional group and with higher turnover [12]. However, in Polish conditions, it turned out that the level of burnout during the COVID-19 pandemic was lower among doctors and nurses working directly with patients infected with the SARS-CoV-2 virus [8, 13] than among ICNs in our study. Therefore, it seems that the professional burnout of Polish ICNs is related to the work environment and difficulties in cooperation with various groups of hospital employees, including nurses and ward doctors. These difficulties were declared by ICNs both during and before the COVID-19 pandemic [1]. In a pre-pandemic questionnaire, only 31.6% of 253 nursing students concluded that ICNs enjoy due respect among the hospital staff. In fact, most of the staff perceive their work as a nuisance [14]. Our study showed a significant positive correlation between the level of difficulty in cooperation with doctors and the level of EE and decreased sense of PA. Zielińska- Więczkowska and Buśka showed that, according to 60% of the surveyed nurses, the factor disturbing proper cooperation at work is the stress felt by the nurse, the “main source of which (.) are doctors” [15]. Similar observations were also made by Puto et al. in a survey among nurses working in hospitals during the COVID-19 pandemic [13]. These authors noted lower EE values (on average 21.32 among nurses working with patients with COVID-19 and 21.81 working with patients without infection), higher DP (12.18 and 12.90, respectively) and lower PA values (18.99 and 18.88), but confirmed the correlation of these parameters with the characteristics of the work environment, i.e. lack of ability to make independent decisions and problems in relationships with colleagues. This problem is not restricted to Polish nurses and hospitals. Quesada-Paga et al. in a systemic review with meta-analysis found several studies with similar conclusions [16].

As mentioned above, in our study the median values of EE and PA were higher than in the cited studies among nurses working in wards and among doctors, both before and during the pandemic. Malinowska-Lipień et al. in a study among 1,509 nurses working in surgical and non-surgical departments of Polish hospitals, assessed the intention to stop working in the hospital depending on a number of factors and conditions, including the level of burnout [17]. The results of this study have indicated that occupational burnout is significantly higher among nurses expressing an intention to leave their jobs compared to those who did not declare such intentions, and the average burnout score in the three areas examined is:: EE, DP and PA: 32.01, 12.55 i 25.02 [17]. The median values for EE and PA in our study were close to the values correlating with nurses’ willingness to change jobs in the Malinowska-Lipień study.

These values were doubtlessly influenced during the pandemic by the higher workload and the additional challenges, as indicated by other authors examining this issue among ICPs, who should necessitate participation in ongoing training and readiness [18].

Of utmost importance in this case is the position in the hierarchy and the perception of the work of infection control nurses in Polish hospitals, related to the organizational culture. Polish hospitals are characterized by high power distance, masculine culture and a tendency towards centralized decision-making [19, 20]. In modern organizations, including hospitals, matching mutual requirements and expectations (including doctor-nurse relations) takes place on the basis of negotiation and agreement on individual counseling [21], and not by way of orders or decisions resulting from the organizational hierarchy. Inadequate organization’s culture may lead to burnout.

Our study did not find high rates of the depersonalization parameter, which reflects callous, impersonal treatment of others and decreased sensitivity. This parameter would be a more sensitive indicator of burnout in working with patients, which in the case of ICNs has a very limited significance. However, Tarcan et al. claimed EE to be the best indicator of burnout, comparing to DP [22].

The limitation of our study may be the lack of including any personal features of respondents, such as marital status, having children, religion, lifestyle, which may interfere with burnout. We included only some basic characteristic of respondents connected with workplace.

Conclusions

The surveyed ICNs had higher rates of EE and PA than nurses working with patients, both before and during the pandemic. The level of burnout found in the ICN study group reached a level correlating in other studies with the intention to quit the job.

A significant decrease in the sense of PA correlated with difficulties in cooperation with doctors and management. High difficulties in cooperation with management also correlated significantly with the level of emotional exhaustion.

The obtained results indicate the need to include effective training in the skills of working in multidisciplinary teams as well as the art of communication and achieving goals in the groups of infection control nurse or those still training in this specialization path.

Moreover, the implementation of effective infection surveillance programs requires systemic changes in the functioning of hospitals towards modern organization standards based on the cooperation of experts from various disciplines and specialties.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Acknowledgements

This research was done as a part of the CRACoV-HHS project supported by the National Center for Research and Development (Model of multi-specialist hospital and non-hospital care for patients with SARS-CoV-2 infection) through the initiative “Support for specialist hospitals in fighting the spread of SARS-CoV-2 infection and in treating COVID-19” (contract number: SZPITALE-JEDNOIMIENNE/18/2020). The described research was implemented by the consortium of University Hospital in Krakow and the Jagiellonian University Medical College.

MBI-Human Services Survey (MBI-HSS) was used based on Remote Online Survey License issued by Mind Garden no. 43181 and 65895.

Author contributions

Conceptualization A.R., J.R.; Methodology, D.J., A.N.; Formal Analysis, D.J., A.M. .; Investigation A.S., A.R.; Writing—Original Draft Preparation, D.J. Writing—Review and Editing J. R., J. W.-M.

Funding

No external funding.

Data availability

Data are available from corresponding author upon reasonable request.

Declarations

Ethics approval

The study received approval of the Bioethics Commission of the Jagiellonian University in Krakow (no KBET 1072.6120.57.2021 from 17.03.2021).

Consent for publication

This study was done on the basis of completely anonymous on-line survey in which the questions were preceded by information on the purpose of the study and the fact that completing it meant consent for participation and publication of the results. In such case informed consent is not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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