Frontline Nurses’ Burnout, Anxiety, Depression, and Fear Statuses

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The study conducted by Hu et al. (2020) aimed to investigate the influence of the exposure of frontline nurses to the COVID-19 outbreak challenges on their mental health indicators. The researchers sought to fill the identified gap in scholarly literature. The sources of data for the systematic review included reputable electronic databases, and the survey results were used as sources of data for the following cross-sectional study. For the systematic review, 31 articles published between 2003 and 2020 in English and Chinese, including non-intervention studies focusing on physical and psychological health, were selected. The results showed that all studies found health impairments in pandemic first responders, and none of the studies investigated the mental health statuses of nurses working during COVID-19.

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The analyzed study’s rationale is based on the omnipresence of frontline healthcare workers’ participation in response to the COVID-19 outbreak and their experience of adverse mental health symptoms. In particular, the study focuses on the nurses working in the hospitals of Wuhan, China, which was an epicenter of the pandemic in 2019 and 2020. The overview of the research conducted before the current study demonstrated that more effective means of nurse management and mental health relief policies and practices are required.


The study’s objective is to investigate the prevalence of fear, anxiety, depression, and burnout in frontline nurses in China during their work as health care providers to patients with COVID-19. The researches examine how mental health experiences of Chinese hospital nurses (P) providing care during the COVID-19 pandemic (I) differ from the mental health of other sociographic groups of nurses (C) to identify the statistical correlation between variables (O) using a large-scale cross-sectional, descriptive, correlational study design (S).

Protocol and Registration

The registration number of the study is unavailable and not indicated in the article. It is stated that the study protocol “has been published on the last author’s institutional website” (Hu et al., 2020, p. 3). Thus, the review protocol exists and might be accessed through the indicated website.

Eligibility Criteria

The systematic review was used to collect evidence before the study and to identify the gap in available research on the examined topic. Nurses’ (P) mental health experiences during pandemics (I) were compared across the studies (C) to identify decisive factors of triggering adverse outcomes (O) as examined in non-interventional studies. The lengths of follow up were not considered within the scope of eligibility criteria. The eligibility criteria for inclusion of studies included non-interventional studies on various outbreaks of pandemics and research articles that investigated the influence of pandemics on medical workers’ health in general.

In addition, “studies that identified various contributing factors of the experiences described by healthcare workers during any pandemic outbreaks” were included in the systematic review (Hu et al., 2020, p. 2). Only the studies published in English and Chinese from 1 January 2003 to 12 February 2020 were included in the review. The exclusion criteria were related to studies focusing on the surveillance system and transmission improvement, change in nursing practice under the influence of pandemics, and studies with participants working as humanitarian aid providers.

Information Sources

The researchers used several reliable online academic databases as sources for the articles for the systematic review. In particular, Hu et al. (2020) searched such electronic databases as “CINAHL, PubMed, Google Scholar, and the China National Knowledge Infrastructure” (p. 2). The publication dates ranged from 1 January 2003 to 12 February 2020; the date last searched was 12 February 2020.

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Search and Study Selection

To search for articles using Google Scholar and other electronic databases, the researchers indicated the limits of dates of publication. They included from 1 January 2003 to 12 February 2020. The language of publications was selected to be either English or Chinese. Also, the researchers used such keywords as “disease outbreak, pandemic, medical crises, quality of life, self-efficacy, resilience, social support, fatigue, anxiety, depression, fear, nurses, healthcare workers, and healthcare professionals” (He et al., 2020, p. 2). The search results were then scanned to exclude articles according to the exclusion criteria discussed above and the studies correlated with the inclusion criteria. The exclusion and inclusion criteria were applied while reading titles and abstracts of the search results.

Data Selection Process

The analyzed study does not explain the data selection and extraction methods.

Data Items

At the stage of the systematic review, the researchers selected the information from the studies to compile evidence on the psychological and physical health and wellbeing of the workers in the health care provision sector. Overall, the study variables included such mental health issues in nurses working during the pandemics as “burnout, fear, anxiety, depression, fear, skin lesion, self-efficacy, resilience, and social support” (Hu et al., 2020, p. 2). The assumptions about the omnipresence of negative psychological impacts on nurses’ health due to their exposure to pandemic manifestations as first responders were made.

Risk of Bias in Individual Studies

In the analyzed article, no risk of bias assessment methods was mentioned. However, the researchers excluded articles that investigated the work of humanitarian aid workers. Such an approach might imply that the authors of the systematic review eliminated the risk of investigating the biased implications of healthcare workers’ efforts that work under conditions different from conventional nurses in frontline hospitals providing care to the pandemic patients.

Summary Measures

The description of the systematic review process does not explain or discuss the methods of principal summary measures.

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Synthesis of Results

No methods of handling data and combining results of studies are available from the analyzed article.

Risk of Bias Across Studies

The article’s authors did not explicitly address any risk of bias across the reviewed studies.

Additional Analyses

No additional analysis of studies was used or addressed in the analyzed systematic review.


Study Selection

The study selection stage was characterized by applying the inclusion and exclusion criteria to select only the studies that complied with the requirements of the systematic review. Upon searching the eligible electronic databases, the researchers selected 31 articles for their review. The analyzed study does not provide specific information on the number of studies screened and excluded at various stages. However, the 31 selected articles were full-text articles published in reputable academic journals. The researchers did not provide a flow diagram to track the study selection process.

Study Characteristics

When referring to the conducted systematic review, the researchers did not present specific citations of the selected articles. The characteristics of the data extracted from the reviewed articles were based on their alignment with the considerations of the influence of work conditions during the times of pandemics on the physical and psychological wellbeing of frontline nursing practitioners. The factors considered by the reviewed articles’ authors as influential for the health outcomes of nurses were specifically evaluated and reviewed.

Risk of Bias

To avoid the risk of bias, the reviewers omitted articles and studies that were outside the inclusion criteria, were published in languages other than English or Chinese or were published earlier than 2003. Moreover, the studies selected for the review included those addressing the issues selected for the examination in the cross-sectional design. In such a manner, only appropriate publications with evidence contributing to the context of the study were used.

Results of Individual Studies

Given the brief addressing of the process of conducting the systematic review, Hu et al. (2020) did not specify the results of the individual studies as laid out in the 31 articles included in the review. Therefore, no accurate and detailed information on data and interventions from the individual research studies is available.

Synthesis of Results

Upon synthesising the systematic review results, the authors of the study managed to identify an overall tendency to concentrate on psychological issues in nurses’ work during pandemics. The synthesized data of all the selected and reviewed articles demonstrated that all the studies found deterioration in first responding health care workers’ physical and psychological health due to their work during pandemics. Many studies omitted factors influencing nurses’ wellbeing outside the scope of psychological factors. Moreover, the reviewed studies mentioned physical and psychological wellbeing impairments during the pandemic outbreaks but none of the reviewed articles mentioned “mental health statuses of frontline nurses” (Hu et al., 2020, p. 2). Specifically, the reviewed research studies did not address the mental health outcomes of nurses working, particularly during the COVID-19 pandemic outbreak in China.

Risk of Bias Across Studies

The risk of bias across studies was not specifically and explicitly addressed. However, it is implied that the same considerations as those used during the study selection stage were applied to eliminate the risk of bias in the synthesized data across studies. Only objective and credible data were included to make conclusions and draw implications of the systematic review findings.

Additional Analysis

The researchers did not conduct any additional analysis of the data provided by the systematic review results. The implications of the systematic review were further used to identify the literature gap for the following conducting of the cross-sectional study with participants.

Summary of Evidence

When summarizing the evidence, the scholars were able to identify that the majority of the reviewed studies did not address the particularities of COVID-19-working nurses. However, the strength of the evidence collected upon the systematic review is based on the finding that all nurses experience physical and psychological well-being deterioration due to working as first responders to pandemic outbreaks, and COVID-19 is not an exclusion.


The limitations of the conducted systematic review include the lack of a detailed description of the study selection and data extraction. Moreover, the systematic review is likely to contain biased data due to the lack of methods to assess the risk of bias in the individual studies. The systematic review does not comprehensively deliver the data extraction methods and principles of findings’ synthesis.


The results of the conducted systematic review contributed to the planning and carrying out of the actual cross-sectional study with nurses participating in the survey later in Hu et al.’s (2020) study. The implications of the findings hold that the lack of data on nurses’ experiences working during COVID-19 and their mental health outcomes might be used as a valuable rationale for further research. Effective measures for preventing and minimizing mental health burden on frontline nurses working with COVID-19 patients should be researched, developed, and implemented.


The study by Hu et al. (2020) was funded by the 2020 COVID-19 Emergency Response Special Fund from Xiamen University (20720200025) and Huazhong University of Science and Technology (2020kfyXGYJ001) in China” (p. 9). The funding body did not influence the process and results of the conducted study.


Hu, D., Kong, Y., Li, W., Han, Q., Zhang, X., Zhu, L. X., Wen, S. W., Liu, Z., Shen, Q., Yang, J., He, H.-G., & Zhu, J. (2020). Frontline nurses’ burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19 outbreak in Wuhan, China: A large-scale cross-sectional study. EClinical Medicine, 24, 1-10. Web.

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"Frontline Nurses’ Burnout, Anxiety, Depression, and Fear Statuses." NursingBird, 28 Oct. 2022,


NursingBird. (2022) 'Frontline Nurses’ Burnout, Anxiety, Depression, and Fear Statuses'. 28 October.


NursingBird. 2022. "Frontline Nurses’ Burnout, Anxiety, Depression, and Fear Statuses." October 28, 2022.

1. NursingBird. "Frontline Nurses’ Burnout, Anxiety, Depression, and Fear Statuses." October 28, 2022.


NursingBird. "Frontline Nurses’ Burnout, Anxiety, Depression, and Fear Statuses." October 28, 2022.