Burnout is defined as a psychological disorder characterized by an adverse emotional reaction to a job resulting from working in a stressful environment (1–3). Healthcare is perceived as one of the most stressful working environments as it requires intensive personal interactions with patients and other healthcare workers (HCWs) (4). Thus, among HCWs, burnout is a well-known severe problem that has received increased attention in recent years (5). Former studies have reported that HCWs can experience anxiety and depression symptoms due to stressful working conditions and high volumes of work, which consequently develops negative outcomes such as burnout (6, 7). Among studies that investigated the association between burnout and working in healthcare settings, burnout was a significant problem in excess-work settings such as emergency and critical care (5, 8).

The increased attention to HCWs burnout is driven by its negative consequences on patient safety, consistency of care, health system costs and workflow, and HCWs own safety and care (9, 10). Further, many studies confirmed that a significant relationship exists between the risk of medical errors and burnout (11–13). Shanafelt et al. (8) reported that a high number of major medical errors has been significantly associated with burnout among physicians. In addition, a significant association was reported between high burnout and therapeutic and diagnostic errors (13). Medical errors among physicians with either a few or significant burnout symptoms are higher compared with physicians who do not have burnout symptoms (14). The risk among nurses should not be underestimated, as burnout can impact their productivity and reduce the quality of care provided, especially with them being at higher risk of insomnia and sleep disturbance (15, 16). Thus, the burnout effect is not limited to losses among humans but also the whole healthcare system (17).

Not long after COVID-19 emerged in China, in late 2019, the World Health Organization (WHO) considered it a pandemic, a severe problem endangering human health (18). The first case reported in Saudi Arabia was on March 2nd, 2020. The spread of COVID-19 infection has created higher demands on the global healthcare systems and frontline HCWs have been playing an instrumental role by providing the necessary care for confirmed or suspected COVID-19 patients during the pandemic (19). Literature from previous pandemics, such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) epidemics, showed a wide range of psychological morbidities experienced by HCWs, including trauma and burnout that might last for months after the pandemic (20, 21). In addition, traumatic life events are highly related to suicidal ideation in stressful work environments (22). Perceptions of “infection stigma” from the community and social isolation also contribute to psychological distress (23). Yet, although frontline HCWs anxieties during outbreaks can lead to absence and high turnover rates, there is suggested evidence that HCWs feel a strong professional commitment and obligation to continue providing healthcare services (24). In addition, the pressure that HCWs feel to maintain high-quality healthcare during a pandemic might relate strongly to presenteeism, which is being physically present but work insufficiently because of illness (25).

There are emerging studies around the world exploring the prevalence of burnout, stress, and anxiety disorders during the COVID-19 pandemic (26, 27). A systematic review reported that the prevalence of burnout can differ between geographical regions. In Iran, over half of HCWs had high levels of burnout (28). Similarly, frontline HCWs in Italy had higher levels of emotional exhaustion than non-pandemic periods (29). On the contrary, Central Asia reported the lowest burnout symptoms (30, 31). A recent study in SA used the Maslach Burnout Inventory (MBI) to assess burnout prevalence and risk factors among HCWs. On the MBI, 38.5% of HCWs showed high emotional exhaustion, 31.2% showed high depersonalization, and 33.6% showed reduced personal achievement. The high burnout in this study was due to direct contact with infected cases and changes in the working patterns during the pandemic. Another study in SA investigated the prevalence of burnout among urologists using the Copenhagen Burnout Inventory (CBI), and found the mean personal burnout as 57.92, while the mean work-related burnout was 55.26 (32).

To fulfill high quality of care for patients and mitigate negative outcomes, there is a further a need to address healthcare workers' burnout. This study utilized the Copenhagen Burnout Inventory instead of the most common Maslach Burnout Inventory scale to assess burnout among a national sample of frontline HCWs during the COVID-19 pandemic. As the MBI considers burnout as a syndrome consisting of emotional exhaustion, depersonalization, and reduced personal accomplishment; this definition has been criticized as exhaustion alone is believed to be the core definition of burnout (33). Thus, CBI, focuses primarily on exhaustion in personal, work-related, and client-related scales (34). Furthermore, the study attempts to identify the main factors associated with the increasing burnout symptoms among frontline HCWs in Saudi Arabia.

Responses were received from 207 HCWs. All respondents were over the age of 21 years. Most HCWs were female (55%) and between 36 years and 40 years of age (35%). The majority were nurses (31%), followed by physicians (24%) and other allied workers (29%). Most respondents were working in full-time shifts (88%). Nearly 34% tested positive for COVID-19 and 83% felt at risk of being infected (Table 1).

The study findings demonstrate considerable levels of burnout among frontline healthcare workers during the COVID-19 pandemic. Our result is consistent with several international studies conducted to investigate the psychological effect of COVID-19 and other infectious disease epidemics on burnout among frontline HCWs, as they encounter tremendous pressure to provide timely care (37–42). Indeed, rapid decision-making is key to proper COVID-19 diagnoses, isolation, and successful treatment, which in turn increases the burden on HCWs to establish quality healthcare (41). In India, about half of the respondents (52%) had pandemic-related burnout (43). In Iran, 53% experienced high levels of burnout (28). In Saudi Arabia's early months of the pandemic (June-August, 2020), the prevalence of burnout among HCWs was 75% (44). This current study (October 2020) found that HCWs are scoring the highest burnout on personal and work-related burnout, while patient-related burnout is the lowest. This is similar to a recent study done in Denmark that indicated that patients may only have a minor role in burnout among healthcare workers (45).

Regarding the association between sociodemographic and burnout the study found that age was not significantly associated with burnout in all three burnout scales, while marital status, nationality, and years of work experience were significant factors associated with patient-related burnout. These findings are consistent with a study by Chemali et al. (17) that showed inconsistent relation between burnout, age, and years of experience. In addition, Barello et al. (29) suggest that some of the critical factors that might trigger burnout are the decreased social support, and the insufficient material and human resources.

Few studies reported that older age and more work experience were positively associated with burnout and psychological stress (46–50). Whereas other studies found that younger HCWs were more vulnerable to psychological disorders and older adults were less likely to develop burnout during pandemics (51, 52).

In terms of gender, females had significantly higher burnout level than males in both personal and work-related scales. Although this relationship is inconsistent in the literature, our finding was similar to studies that reported females at increased risk for burnout (38, 39, 53, 54). In contrast, other studies reported that the male gender is a predictor of depersonalization and is at higher risk of burnout (9, 55, 56). Few other studies reported no association at all between burnout and gender, such as a study in Turkey among medical students by Sevencan et al. and a study by Amiri in Iran among primary care physicians (9, 56).

Among HCWs in this study, nurses were found to be at greater risk of high burnout across work and patient-related scales. This finding is consistent with the results of previous studies in earlier pandemics (6, 7, 40). During the SARS epidemic, a study carried out among healthcare professionals in emergency departments showed that nurses were more likely to experience behavioral disengagement and develop distress than other healthcare professionals (49). Lai et al. (57) assessed mental health outcomes in frontline healthcare professionals during the COVID-19 pandemic in China. Their findings showed that frontline nurses caring for COVID-19 patients had a higher level of mental health disorders because of their frequent and close contact with patients and increased number of working hours (57). On the other hand, few studies reported that physicians were the most exposed to burnout amongst all healthcare professionals (58, 59).

Furthermore, irregular working shifting schedule was found to be positively related to burnout during the pandemic. A study among medical staff who work night shifts found them to be more vulnerable to psychological distress (17, 60, 61). Another study among nurses in a university hospital in Egypt, reported that working in a night shift and the number of shifts were predictors for high levels of burnout (53). Another study among Turkish nurses found that working in night shifts was more positively associated with burnout than working day shifts or occasional night shifts (60). The higher level of burnout among night shift nurses was attributed to the shortage of nurses working at night shifts, causing unbalanced nurse-to-patient ratios (61). Also, sleep deprivation is a well-reported causative factor for clinical burnout (62).

In contrary to studies suggesting that inadequate PPE can be a considered a principal stressor increasing the burnout (19, 63), our findings showed that those wearing adequate PPE while interacting with COVID-19 patients had higher personal burnout. As frontline HCWs are the first responders for COVID-19 patients, they can be physically and mentally exhausted during their prolonged wear of PPE given its limitations of comfort and reduced ability to communicate. Particular features of PPE can impose physiological and personal burden especially if accompanied with long work hours with few breaks for self-care, nutrition, and hydration (64). In addition, other factors such as obesity and respiratory conditions can exacerbate the PPE burden, and could cause heat stress, skin irritation, headache and dizziness which compromise HCWs wellbeing and patient safety (64, 65).

Further studies found elevated levels of burnout among HCWs working in a COVID-19 unit, those with low self-confidence in self-protection, those who reported uncertainty about future availability of PPE, and those who were unsure whether the type of PPE provided was appropriate for their role (66–68). In addition, the possibility of developing burnout symptoms increased two folds among physicians in Egypt who needed to buy their own PPE (69). Yet, the current study found that perceived threat for exposure to COVID-19 was not significantly related to any of the burnout scales, which is inconsistent with other studies (29).

As the work nature of HCWs is challenging, they are also a vulnerable group of which their mental health and wellbeing must be safeguarded. Earlier studies have indicated that nurses with high sources of social support reported less burnout (70, 71). However, although social and family support is important in coping, HCWs are cautious when spending time with their close family members due to the fear of spreading infection. In addition, many HCWs are reluctant to reveal their challenges and difficulties even when encountering significant psychological distress (72). Reducing the stigma of impaired mental health and promoting support and sharing among colleagues in the work environment can foster help-seeking attitudes and behaviors (73). For example, regular check-ins by frontline supervisors to support staff and assess their symptoms or concerns is a potential method to identify early signs of burnout. In addition, administrative control should be more effective by instituting policies and procedures for workload, workhours, and breaks especially among HCWs working in the ICU. Furthermore, a mechanism for timely reporting of burnout symptoms without fear of judgement or penalty can reinforce care for HCWs.

This study provides a significant addition to the literature on frontline HCWs burnout during the COVID-19 pandemic in the personal, work, and patient-related scales using a validated assessment tool. However, some of the encountered limitations include the limitation of the questionnaire to identify the cause of the burnout, and what could be ways to mitigate personal, work, or patient-related burnout among HCW. In addition, the nature of the study's cross-sectional design is a limitation, as causality between variables cannot be concluded. Also, there might be a risk of selection bias as the questionnaire was distributed online, and thus, did not reach HCWs who were busy or offline during the e-distribution period. Moreover, frontline HCWs experiencing a high level of burnout may be more interested in filling out the survey, making the results overestimate. However, the study builds on current literature to add an extensive assessment about HCW's factors that are associated with each burnout sub-scale, providing a holistic understanding of factors associated with frontline HCWs psychological health.

There is an urgent need to inform policymakers about this critical situation and recommend applicable and appropriate burnout prevention for the healthcare force. Although HCWs heavily rely on the training and equipment provided by their organizations, managerial support and effective leadership must be contributed to avoid and mitigate HCWs adverse psychological outcomes (73). Policy-makers need to adopt interventions to promote a healthy work environment and prevent burnout among HCWs during pandemics and emergencies.

Frontline HCWs in Saudi Arabia face considerable burnout during the COVID-19 pandemic. Several sociodemographic and occupational factors have contributed to increasing HCWs burnout levels during the pandemic. Findings emphasize the need for urgent strategies on the individual and organizational level to discuss burnout factors and invest in psychological interventions that reduce the risk of burnout and promote HCWs wellness in facing prolonged pandemics.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Institutional Research Board of Imam Abdulrahman Bin Faisal University: IRB# PGS-2021-03-167. The patients/participants provided their written informed consent to participate in this study.

All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potentialconflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.