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Abstract

Objective

The study aim was to investigate the prevalence of behavioral symptoms and burnout in healthcare workers in an intensive neurological rehabilitation unit in Messina, Italy, during the first COVID-19 lockdown in Italy.

Methods

Forty-seven healthcare workers (including neurologists, physiatrists, nurses and rehabilitation therapists) were enrolled in this cross-sectional study from February 2020 to June 2020. Participants were administered the following psychometric tests to investigate burnout and related symptoms: the Maslach Burnout Inventory, which measures emotional exhaustion, depersonalization and reduced personal accomplishment; the Zung Self-Rating Depression Scale (SDS); the Pre-Sleep Arousal Scale (PSAS); the Dyadic Adjustment Scale; and the Buss–Perry Aggression Questionnaire (BPAQ).

Results

We found several correlations between test scores and burnout subdimensions. Emotional exhaustion was correlated with SDS (r = 0.67), PSAS-Cognitive (r = 0.67) and PSAS-Somatic (r = 0.70) scores, and moderately correlated with all BPAQ dimensions (r = 0.42). Depersonalization was moderately correlated with SDS (r = 0.54), PSAS-Cognitive (r = 0.53) and PSAS-Somatic (r = 0.50) scores.

Conclusion

During the first COVID-19 lockdown in Italy, healthcare workers were more exposed to physical and mental exhaustion and burnout. Research evaluating organizational and system-level interventions to promote psychological well-being at work for healthcare workers are needed.

Keywords

COVID-19 lockdown burnout healthcare worker mental health emotional exhaustion rehabilitation unit

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which caused coronavirus disease 2019 (COVID-19), has been considered by the World Health Organization a health emergency since January 2020.^1–2 Indeed, the disease spread rapidly all over the world and a pandemic state was declared on 11 March 2020. With more than six million confirmed cases worldwide and more than 350,000 deaths between February and May 2020, the COVID-19 pandemic was an unprecedented healthcare crisis.^3–5 The pandemic resulted in an overall surge in new cases of depression and anxiety and an exacerbation of existing mental health issues, with a particular emotional and physical burden on healthcare workers (HCWs).² However, the effect of these modified working conditions on psychological well-being at work remains poorly investigated and understood. Traumatic events or adverse conditions during natural disasters, conflicts and pandemics may lead to burnout. Limited resources, longer shifts, disruptions to sleep and to the work–life balance, and occupational hazards associated with exposure to COVID-19 have contributed to physical and mental fatigue, stress and anxiety, leading to severe cases of burnout.⁶ The condition of burnout, which can be considered an outcome of chronic work-related stress, is an increasingly common psychological symptom in modern society.^7–9 COVID-19 presents multiple stressors to HCWs, including risk of infection, social isolation and psychological problems such as work stress. Research during previous pandemics involving quarantine has shown that HCWs can develop symptoms of post-traumatic stress disorder, anxiety, depression, insomnia and substance abuse.⁹

Burnout is a psychological syndrome defined as a self-reported state of care- or work-related physical and mental stress^10–11 that induces emotional exhaustion, depersonalization and a sense of reduced personal accomplishment.¹² The general increased demands and limited resources of healthcare systems, as well as the COVID-19 pandemic, have increased the likelihood of burnout cases. Because the spread and burden of the pandemic varied by geographic region, with overwhelming numbers of severe cases in some places¹³ and only sporadic transmission with few cases in others, the pandemic-related psychological burden also showed regional variation.¹⁴

Preliminary reports from those countries first affected by the pandemic have highlighted the high prevalence of psychological burden in HCWs,^15–16 as well as in the general population.^17–18 Notably, in addition to depression, an important factor that is strongly related to burnout is anxiety, a psychological condition that acts as a protective factor against threatening situations. In a systematic review involving 13 studies and 33,062 participants, the pooled prevalence of anxiety and depression in HCWs was 23.2% and 22.8%, respectively.¹⁹ Moreover, it has been shown that half of the HCWs caring for patients with COVID-19 reported self-perceived burnout.²⁰

In another study of 376 HCWs in Italy, approximately 1 in 3 had a high score on emotional exhaustion, and 1 in 4 reported high levels of depersonalization, as well as low levels of personal accomplishment.²¹ Notably, the prevalence of burnout assessed using validated screening tools has never been reported in HCWs working in the rehabilitation setting during this long-lasting pandemic.

The purpose of this study was to objectively investigate the prevalence of behavioral symptoms, including emotional exhaustion and burnout, in a sample of HCWs working in an intensive neurological rehabilitation unit (INRU) during the first COVID-19 lockdown in Italy.

Materials and methods

This study conformed to the STROBE guidelines.²² Data were collected between February and June 2020 using a mail-based survey sent through the institutional email of participants, who gave consent to join this retrospective study. Participants were 47 HCWs (15 men and 32 women), including physicians, nurses, physiotherapist and speech therapists, who worked at least 36 hours per week in the INRU of the IRCCS Centro Neurolesi, Piemonte (Messina, Sicily, Italy). Participants were trained in the management and rehabilitation of acquired brain injury and were selected consecutively and enrolled in the study. Each participant was administered comprehensive online psychometric tests and several questionnaires to investigate neuropsychiatric symptomatology and burnout dimensions. We deidentified all participant details to guarantee anonymity.

Sample description

A non-probabilistic sampling method was used to ensure the participation of as many HCWs as possible. Of the 75 HCWs working in our INRU, 62.7% (45) joined the study; the remaining 37.3% (28) did not participate owing to personal reasons. Most participants were nurses, doctors and therapists; unlicensed assistive personnel comprised only 6.6% of the sample. Our sample included 47 HCWs (15 men and 32 women, i.e., 68%) with a mean age of 44.4 ± 8.4 years and a high level of education. The sample comprised a multidimensional neurorehabilitation team with a range of professional profiles, including 2 unlicensed assistive personnel, 21 nurses, 6 doctors (3 physiatrists and 3 neurologists), 11 physiotherapists, 5 speech therapists, 1 neuropsychologist and 1 psychiatric rehabilitation technician.

Outcome measures

Participants were assessed using the following measures: i) the Maslach Burnout Inventory (MBI),²³ which consists of 22 items assessing the three components of burnout: emotional exhaustion (9 items), depersonalization (5 items), and reduced personal accomplishment (8 items); ii) the Zung Self-Rating Depression Scale (SDS),²⁴ a 20-item self-report questionnaire that is widely used as a screening tool and assesses affective, psychological and somatic symptoms associated with depression; iii) the Pre-Sleep Arousal Scale (PSAS),^25–26 a 16-item self-report questionnaire that assesses insomnia and both cognitive and somatic manifestations of arousal; and iii) the Dyadic Adjustment Scale (DAS),²⁷ a 32-item measure of dyadic adjustment or the relationship quality of cohabiting (married/unmarried) couples. The DAS consists of four subscales that assess different aspects of dyadic adjustment: dyadic consensus, dyadic satisfaction, dyadic cohesion, and affectional expression. We also administered the Buss–Perry Aggression Questionnaire (BPAQ),²⁸ a self-report scale that measures four major components of aggression (physical aggression, verbal aggression, anger and hostility).

Statistical analysis

Data were analyzed using the open-source software R 4.0.5 (www.r-project.org), and p < 0.05 was considered to indicate statistical significance. Non-parametric statistics were used for analysis because the Shapiro–Wilk test showed non-normal distributions for most target variables. Pairwise comparisons were assessed using the Mann–Whitney U test, and proportions were assessed using the chi-squared test. Correlations between psychometric test scores and the burnout subdimensions were calculated using Spearman’s coefficient. In addition, for each MBI subdimension, scale cutoffs were used to classify participants as low, moderate, or high. One-way analysis of variance using the Kruskal–Wallis test was used to assess differences in psychometric test scores among classes, followed by pairwise comparisons adjusted by Bonferroni’s correction (post-hoc analysis); that is, alpha was set at 0.0167.

Ethical issues

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of IRCCS Centro Neurolesi (IRCCSME-19/2020). Informed written consent was obtained from all participants involved in the study.

Results

Details of the characteristics of the 47 participants are shown in Table 1. Except for reduced personal accomplishment (W = 340.5, p = 0.02), there were no significant sex differences in psychometric test scores, and no significant differences between participants who were in COVID-19 quarantine or still at work (Table 2). However, significant differences were found for burnout: significantly more participants had a high level of emotional exhaustion (χ² (2) = 8.34, p = 0.015) and a moderate level of reduced personal accomplishment (χ² (2) = 6.30, p = 0.043) (Table 3).

Table 1.

Demographic description of the sample.

Characteristics	All(n = 47)	Men(n = 15)	Women(n = 32)	p-value
Age (years)	44.4 ± 8.4	46.3 ± 8.8	43.5 ± 8.2	0.34
No. family members	3.2 ± 5.6	3.2 ± 1.3	3.2 ± 1.2	0.90
Education
Middle school	1 (2.1)	1 (6.7)	0 (0.0)
Vocational school	1 (2.1)	1 (6.7)	0 (0.0)	0.13
High school	3 (6.4)	0 (0.0)	3 (9.4)
University	42 (89.4)	13 (86.6)	29 (90.6)
Occupation
Medical Doctor	6 (12.8)	3 (20.0)	3 (9.4)
Nurse	21 (44.7)	7 (46.7)	14 (43.7)
Physiotherapist	11 (23.4)	2 (13.3)	9 (28.2)
Neuropsychologist	1 (2.1)	1 (6.7)	0 (0.0)	0.08
Speech therapist	5 (10.6)	0 (0.0)	5 (15.6)
Psychiatric technician	1 (2.1)	0 (0.0)	1 (3.1)
Unlicensed assistive personnel	2 (4.3)	2 (13.3)	0 (0.0)
COVID-19 quarantine
Yes	18 (32.3)	3 (20.0)	15 (46.9)	0.07
No	29 (61.7)	12 (80.0)	17 (53.1)
Pathology
None	39 (83.0)	11 (73.4)	28 (87.5)
Diabetes	2 (4.3)	2 (13.3)	0 (0.0)	0.10
Hypertension	1 (2.1)	0 (0.0)	1 (3.1)
Autoimmune disease	1 (2.1)	0 (0.0)	1 (3.1)
Other	4 (8.5)	2 (13.3)	2 (6.3)

Continuous variables are expressed as mean ± standard deviation; categorical variables as frequencies and percentages.

Table 2.

Clinical description of the sample.

	Median [first-third quartile]	Sex differences	Quarantine differences
SDS score	37.0 [32.5–43.0]	W = 273.5, p = 0.45	W = 302.5, p = 0.37
MBI score
EE	28.0 [20.0–42.0]	W = 314.5, p = 0.09	W = 302.5, p = 0.37
D	6.0 [1.0–10.5]	W = 208.0, p = 0.47	W = 276.5, p = 0.74
RPA	36.0 [31.5–37.5]	W = 340.5, p = 0.02	W = 293.0, p = 0.49
PSAS score
PSAS-Cognitive	18.0 [14.0–23.5]	W = 251.0, p = 0.81	W = 243.5, p = 0.71
PSAS-Somatic	12.0 [9.5–20.0]	W = 267.0, p = 0.54	W = 268.5, p = 0.88
BPAQ score
Physical aggression	15.0 [13.0–17.5]	W = 241.5, p = 0.98	W = 299.5, p = 0.40
Verbal aggression	15.0 [12.0–16.5]	W = 232.5, p = 0.87	W = 308.5, p = 0.30
Anger	18.0 [15.0–22.0]	W = 294.5, p = 0.22	W = 307.0, p = 0.32
Hostility	17.0 [14.5–22.5]	W = 262.5, p = 0.61	W = 323.5, p = 0.17
Total	65.0 [57.0 – 74.0]	W = 259.5, p = 0.66	W = 325.0, p = 0.16
DAS score
Dyadic consensus	43.0 [37.5–49.0]	W = 259.5, p = 0.66	W = 147.0, p = 0.52
Dyadic satisfaction	38.0 [25.0–41.5]	W = 183.0, p = 0.53	W = 178.5, p = 0.79
Dyadic cohesion	14.0 [10.5–17.0]	W = 178.0, p = 0.63	W = 159.0, p = 0.78
Dyadic affection expression	9.0 [7.0–10.0]	W = 144.5, p = 0.59	W = 143.5, p = 0.44
Total	101.0 [79.0–115.5]	W = 201.0, p = 0.24	W = 177.0, p = 0.82

Significant differences are in bold.

SDS, Zung Self-Rating Depression Scale; MBI, Maslach Burnout Inventory; PSAS, Pre-Sleep Arousal Scale; BPAQ, Buss–Perry Aggression Questionnaire; DAS, Dyadic Adjustment Scale; EE, Maslach Burnout Inventory Emotional exhaustion subdimension; D, Maslach Burnout Inventory Depersonalization subdimension; RPA, Maslach Burnout Inventory Reduced personal accomplishment subdimension.

Table 3.

Sample distribution by Maslach Burnout Inventory cutoffs.

MBI score	Low	Moderate	High	p-value
Emotional exhaustion	11 (23.4%)	11 (23.4%)	25 (53.2%)	0.01
Depersonalization	23 (48.9%)	10 (21.3%)	14 (29.8%)	0.06
Reduced personal accomplishment	9 (19.2%)	23 (48.9%)	15 (31.9%)	0.04

Neuropsychiatric symptomatology and burnout dimensions

We found several correlations between psychometric test scores and burnout subdimensions, as shown in Table 4.

Table 4.

Correlations between psychometric test scores and burnout subdimensions.

	Emotional exhaustion	Depersonalization	Reduced personal accomplishment
SDS	0.67***	0.54**	−0.26*
PSAS-Cognitive	0.67***	0.53**	−0.01
PSAS-Somatic	0.70***	0.50**	−0.09
BPAQ Physical aggression	0.45**	0.29*	0.02
BPAQ Verbal aggression	0.30**	0.03	0.32
BPAQ Anger	0.41**	0.31**	−0.03
BPAQ Hostility	0.33**	0.14	−0.03
BPAQ Total	0.42**	0.26*	0.02
DAS Dyadic consensus	−0.22	−0.31**	0.18
DAS Dyadic satisfaction	−0.09	−0.29*	0.17
DAS Dyadic cohesion	0.14	−0.03	−0.02
DAS Dyadic affection expression	−0.10	−0.17	0.26
DAS Total	−0.05	−0.25*	0.14

*weak correlation; **moderate correlation; ***strong correlation.

SDS, Zung Self-Rating Depression Scale; PSAS, Pre-Sleep Arousal Scale; BPAQ, Buss–Perry Aggression Questionnaire; DAS, Dyadic Adjustment Scale.

Emotional exhaustion was strongly correlated with SDS (r = 0.67), PSAS-Cognitive (r = 0.67) and PSAS-Somatic (r = 0.70) scores, and moderately correlated with all BPAQ dimensions (e.g., with BPAQ Total r = 0.42). Depersonalization was moderately correlated with SDS (r = 0.54), PSAS-Cognitive (r = 0.53), PSAS-Somatic (r = 0.50), BPAQ Anger (r = 0.31) and DAS Dyadic consensus (r = −0.31) scores, and weakly correlated with BPAQ Physical aggression (r = 0.29), BPAQ Total (r = 0.269), DAS Dyadic satisfaction (r = −0.29) and DAS Total (r = −0.25) scores. Reduced personal accomplishment was weakly correlated only with SDS scores (r = −0.26).

Table 5 reports the one-way analysis of variance results. The Kruskal–Wallis test detected significant differences in scores on some psychometric tests between participants with different levels of burnout. For emotional exhaustion, there were significant differences in SDS (Kruskal–Wallis χ² (2) = 11.68, p = 0.003), PSAS-Cognitive (Kruskal–Wallis χ² (2) = 17.39, p < 0.001), PSAS-Somatic (Kruskal–Wallis χ² (2) = 15.23, p < 0.001) and DAS Dyadic cohesion (Kruskal–Wallis χ² (2) = 6.27, p = 0.043) scores. For depersonalization, there were significant differences in SDS (Kruskal–Wallis χ² (2) = 14.41, p < 0.001), PSAS-Cognitive (Kruskal–Wallis χ² (2) = 14.723, p < 0.001) and PSAS-Somatic (Kruskal–Wallis χ²(2) = 13.722, p = 0.001) scores. The post-hoc analysis showed that these differences were statistically significant when evaluating low and high levels of burnout (p ranged from <0.01 to <0.001), except for PSAS-Somatic scores, which showed a significant difference between participants with moderate and high levels of the burnout dimension of depersonalization.

Table 5.

Neuropsychiatric symptomatology by burnout for each Maslach Burnout Inventory subdimension.

	One-way analysis			Post-hoc analysis
	EE	D	RPA	EE		D		RPA
	KWp-value	KWp-value	KWp-value	Pairwise comparisons	p-value	Pairwise comparisons	p-value	Pairwise comparisons	p-value
SDS	<0.01	<0.001	0.214	Low-moderateLow-highModerate-high	0.126<0.010.083	Low-moderateLow-highModerate-high	0.023<0.0010.083	–	–
PSAS-Cognitive	<0.001	<0.01	0.767	Low-moderateLow-highModerate-high	0.073<0.0010.012	Low-moderateLow-highModerate-high	0.162<0.0010.015	–	–
PSAS-Somatic	<0.001	<0.001	0.236	Low-moderateLow-highModerate-high	0.048<0.0010.018	Low-moderateLow-highModerate-high	0.525<0.001<0.01	–	–
BPAQ Physical aggression	0.071	0.055	0.405	–	–	–	–	–	–
BPAQ Verbal aggression	0.490	0.467	0.610	–	–	–	–	–	–
BPAQ Anger	0.080	0.077	0.577	–	–	–	–	–	–
BPAQ Hostility	0.241	0.264	0.402	–	–	–	–	–	–
DAS Dyadic consensus	0.795	0.190	0.071	–	–	–	–	–	–
DAS Dyadic satisfaction	0.213	0.111	0.769	–	–	–	–	–	–
DAS Dyadic cohesion	0.043	0.932	0.458	Low-moderateLow-highModerate-high	0.0250.0280.612	–	–	–	–
DAS Dyadic affection expression	0.728	0.539	0.054	–	–	–	–	–	–

Significant differences are in bold.

SDS, Zung Self-Rating Depression Scale; PSAS, Pre-Sleep Arousal Scale; BPAQ, Buss–Perry Aggression Questionnaire; DAS, Dyadic Adjustment Scale; EE, Maslach Burnout Inventory Emotional exhaustion subdimension; D, Maslach Burnout Inventory Depersonalization subdimension; RPA, Maslach Burnout Inventory Reduced personal accomplishment subdimension; KW, Kruskal–Wallis test.

Discussion

This study confirmed that pandemics may cause or exacerbate neuropsychiatric symptoms, including burnout, in HCWs. This effect is caused both by increased workload and fear of contamination. In fact, the working hours of our hospital staff gradually increased during lockdown (compared with the pre-pandemic period) to considerably over the conventional 36 hours a week (and in some cases also with double consecutive shifts), because many HCWs tested positive for COVID-19 and had to isolate at home until they tested negative. This led to a growing and unsustainable workload for those HCWs who remained at work. There is evidence for negative psychological adjustment outcomes in HCWs during the pandemic, although studies on the effect of the COVID-19 pandemic on HCWs working in rehabilitation units are limited.²⁹ Regarding the negative psychological effect of the COVID-19 pandemic in our Sicilian INRU, we observed a high prevalence of moderate-to-severe anxiety, distress and burnout, which strongly correlated with the family- and work-related conditions induced by the pandemic. Our data support previous work showing that clinicians report high levels of anxiety and low self-efficacy levels.^5,30–32 A study performed in Wuhan, China (the location of the first COVID-19 outbreak), found substantial vulnerability to stress, anxiety and depression in HCWs, suggesting that frontline HCWs should be closely monitored as a high-risk group for maladjustment.³⁰ The same results have been reported in European countries, including Italy,^33–39 although researchers need to pay greater attention to this important topic.

Early in the pandemic (i.e., in April/May 2020 in Italy and Belgium), studies reported severe levels of emotional exhaustion (MBI-EE scores >26) in 32% to 41% of hospital workers;^27,40–41 these levels are similar to the pre-pandemic benchmark. A weekly survey of 231 Canadian emergency physicians conducted over 10 weeks (from March to May 2020) found that emotional exhaustion and depersonalization did not change, consistent with the assumption that COVID-19-related burnout increases slowly.⁴² Finally, two interesting systematic reviews and meta-analyses that investigated the mental health of HCWs identified a relatively high prevalence of anxiety (24.94%), depression (24.83%) and sleep disorders (44.03%).⁴³ As burnout results from cumulative occupational stress,³⁹ its effect is likely to increase over time during pandemics, an effect that has unfortunately been confirmed. Our data analysis identified a significant correlation between psychometric test scores and burnout subdimensions (see Table 4). In particular, scores on the MBI dimension of emotional exhaustion were strongly correlated with the presence of depressive symptoms, insomnia, and cognitive and somatic manifestations of arousal. A further interesting consideration is the moderate correlation between the MBI dimension of depersonalization and depressive symptoms, insomnia and aggression (anger), and between depersonalization and dyadic consensus in the individual’s perceptions of his/her relationship with an intimate (see Table 4), which may have consequences for the quality of relationships. This retrospective study showed that frontline HCWs experienced a high workload and multiple psychosocial stressors that affected their mental and emotional health, leading to burnout symptoms. Global evidence points to the need for evidence-based multipronged approaches to addressing pandemic-related burnout, which may include raising awareness of work-related burnout and stress, promoting awareness and self-care practices to promote mental well-being, ensuring optimal mental health services, using digital technologies to address workplace stress and deliver mental health interventions, and improving organizational policies and practices focused on burnout among HCWs.^44–49 Despite the considerable literature on interventions that alleviate social isolation or loneliness, many interventions may not be compatible with shielding or social distancing. Potential strategies to improve access to mental health services include involving mental health experts in multidisciplinary COVID-19 teams, who can provide support services or refer HCWs with burnout symptoms to appropriate resources. In addition, group-based counselling or peer support sessions could effectively address burnout and improve mental health during the COVID-19 pandemic.⁵⁰ Counselling and interventions that use digital platforms like mobile phones, apps or internet-enabled devices are an alternative option.⁵¹ These potential strategies include improving workflow management, organizing services that focus on reducing workload, enhancing interoperability, arranging discussions and exchanges of opinions, improving communication skills, providing adequate rest and exercise facilities, organizing workshops on coping skills, and devising policies and practices for reducing burnout among HCWs during the pandemic.^51–52

These approaches could foster a supportive and enabling environment for HCWs, so it is essential to include them in the development of strategies for creating such an environment. Moreover, it is possible to learn to recognize and manage burnout and anxiety using specialized therapeutic pathways, which can be personalized in relation to individuals’ specific needs. It is noteworthy that social distancing and spending more time alone can worsen some severe mental health symptoms. In line with the findings of one systematic review,⁵³ we believe that it may be useful to consider several simple but effective ways to deal with isolation and loneliness, such as calling a neighbor or friend to check how they are. Sending texts or notes to friends and loved ones may also be helpful, as written communication has been shown to help people feel less sad or upset.⁵⁴ Another useful strategy is to schedule a virtual “hangout”: spending time in a virtual setting with friends or loved ones using an online video system such as FaceTime or Google Hangout. Focusing on positive thoughts and practicing meditation, deep breathing or yoga can also help to manage anxiety in a healthy way.

Work in a range of different healthcare settings during the pandemic can contribute to burnout, as such work presents a health risk to individuals and their families and involves uncertainty about infectious risks and precautions. Public health measures such as school and business closures may have affected HCW well-being and caused tension between work and personal or family obligations. Indeed, the management of children during the pandemic is still a debated topic. It is important to recognize that child protection services can save lives and should therefore continue to be provided and accessible to all children, even during the implementation of movement restrictions, quarantines and other types of restrictions. Parents and caregivers play an important role in informing, supporting and protecting children of all ages. Therefore, it is important to provide parents and caregivers with tools to help them help children. Communication with parents and thus indirectly with their children is a key part of the COVID-19 risk communication strategy. HCWs infected with COVID-19 must remain at home in isolation to avoid cross-infection and should return to work only after obtaining a negative test result. Childcare measures adopted in some places during the pandemic included child leave that allowed at least one parent to stay at home and take care of children.^52–53 However, legal experts have suggested that it is essential that all parents, regardless of whether they are at high risk of infection or not, partnered or single, promptly devise a backup plan, even if they are not currently sick.

Another interesting point is that contrary to our expectations, we found no significant interaction between reduced personal accomplishment and depressive symptoms as measured by the SDS, and no differences between participants in depersonalization. We suggest that other variables (such as the relationships that develop between medical staff or perceived social support) may better explain differences in depersonalization levels in HCWs working in the most critical situations. However, as we did not assess these variables, no conclusions can be drawn regarding this issue.

There were several study limitations: i) the sample size was unbalanced for sex; most participants were women, although this distribution is representative of the sex differences among Italian HCWs; ii) the number of participants at the intersection of the two between-subject factors we considered was not balanced; iii) our measurements were exclusively based on self-report questionnaires; iv) and the cross-sectional design does not permit the identification of cause–effect relationships. Finally, because a non-probability sampling method was used, we cannot assume that the sample was representative of the population.

All of these factors limit the generalizability of the current findings to other professional groups and situations different from the current COVID-19 pandemic. Further research is needed to explore these issues with larger and numerically homogeneous groups.

Conclusions

To the best of our knowledge, we were among the first to examine the psychological adjustment of Sicilian HCWs working in a rehabilitation setting during the COVID-19 lockdown in Italy, and we assessed several variables associated with personal and professional adjustment. Although other HCWs, such as those working in emergency rooms, COVID-19 hospitals and general practitioners, were (and are) more directly involved in managing the very rapid spread of the pandemic in Italy (which resulted in a high number of deaths and infected individuals who developed serious medical conditions: on 15 April 2020, 27,643 individuals in Italy were hospitalized with symptoms and 3079 hospitalized in intensive care units), HCWs in INRUs also deserve attention regarding their experiences of work stress and burnout. In fact, our findings indicate that professionals working in INRUs are at higher risk of stress,^42,44–45 burnout and other behavioral symptoms, which may be exacerbated during pandemics.⁴⁶ Burnout was a major concern for HCWs since before the COVID-19 pandemic,⁴⁷ and this issue should be addressed to reduce mental health problems in this population. Health policymakers and practitioners should implement interventions and develop context-specific approaches to promote healthy workplaces, address ethical issues and prevent burnout among HCWs during the COVID-19 pandemic. It is essential to improve organizational measures to create a lasting impact on work culture, alongside interpersonal interventions, and to address workplace stress. Most effective interventions for loneliness have either included cognitive or educational components, or have facilitated communication and networking between peers; we found few effective interventions for social isolation. Delivery of available interventions may require modifications to align with COVID-19 shielding/social distancing measures: many interventions involved physical contact in their original protocol but were deemed feasible to implement using telephone or video call technology. This has implications for the accessibility of interventions by the wider public.^52–53

The current emergency context has added new social- and job-related factors that increase the risk of burnout, with its associated effects on quality of care and efficiency of the healthcare system. If, as it seems, we must adapt to living with the risk of future pandemics, it is important to be prepared, particularly by adequately supporting not only the professionals who work on the front line but also those working in rehabilitation units. It is important to consider the potential long-term effects of this type of work, such as exhaustion, and to remember to help those individuals who help others.

Supplemental Material

sj-pdf-1-imr-10.1177_03000605231182664 - Supplemental material for Healthcare worker burnout during the first COVID-19 lockdown in Italy: experiences from an intensive neurological rehabilitation unit

Supplemental material, sj-pdf-1-imr-10.1177_03000605231182664 for Healthcare worker burnout during the first COVID-19 lockdown in Italy: experiences from an intensive neurological rehabilitation unit by Rosaria De Luca, Carmela Rifici, Aurelio Terranova, Luigia Orecchio, Milva Veronica Castorina, Michele Torrisi, Antonino Cannavò, Alessia Bramanti, Mirjam Bonanno, Rocco Salvatore Calabrò and Maria Cristina De Cola in Journal of International Medical Research

Footnotes

Author contributions

Conceptualization, R.D.L. and A.C.; Methodology, R.D.L., A.C., M.C.D., and A.B.; software A.C. and M.B.; validation, C.R., A.T., and M.B.; formal analysis, M.C.D.; investigation, R.D.L. and M.T.; resources, L.O. and M.V.C.; data curation, M.T.; writing—original draft preparation, R.D.L.; writing—review and editing, R.S.C.; visualization, A.T.; A.B., and L.O.; supervision, R.D.L. and R.S.C.; project administration. C.R. All authors have read and agreed to the published version of the manuscript.

Declaration of conflicting interests

The authors declare no conflict of interest in preparing this article.

Funding

This research was funded by the Italian Ministry of Health – Current Research 2022 (the funding does not have an alphanumeric identification code).

ORCID iDs

Rosaria De Luca

Michele Torrisi

Maria Cristina De Cola

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