The association between fear of COVID‐19 and mental health: The mediating roles of burnout and job stress among emergency nursing staff

Abstract Aim This current study examined the mediation roles of burnout and job stress in the association between fear of COVID‐19 and mental health among emergency nurses. Design Cross‐sectional survey. Methods A total of 516 emergency nurses with a mean age of 41.18 (SD = 8.24), mostly females (76.16%) and married (78.9%) responded to measures on fear of COVID‐19, burnout, job stress and mental health between 15 September and 7 November 2020. Results There was a significantly direct effect between (a) fear of COVID‐19 and mental health, (b) fear of COVID‐19 and mediators (burnout and job stress) and (c) mediators (burnout and job stress) and mental health. Also, there was a significantly indirect effect between fear of COVID‐19 and mental health through job stress, burnout or both. Conclusions Fear of COVID‐19 directly and indirectly influenced the mental health of emergency nurses. Therefore, hospital authorities should provide sufficient resources to allay the fears of nurses during this COVID‐19 pandemic period.

With the increasing COVID-19 cases (over 234 million), severities and fatalities (over 4.8 million) worldwide as of 5th October 2021 (World Health Organisation, 2021), emergency department (especially if they oversee the treatment of COVID-19 cases) staff members may get overwhelmed by the influx of COVID-19 cases which directly increases their workload. This is especially a challenging issue among emergency nurses as they have to triage all patients including COVID-19 cases within a limited time period. This consequently increases their job stress as they have to deal with triaging and treating different cases with limited personal protective equipment (PPEs) and within a limited time period (Al Thobaity & Alshammari, 2020;Shoja et al., 2020;Wang et al., 2020).

| BACKG ROU N D
Recent studies have indicated that frontline workers which include emergency nurses have increased job stress as they have added tasks and new protocols which must be strictly adhered to due to the COVID-19 pandemic (Al Thobaity & Alshammari, 2020;Shoja et al., 2020;Wang et al., 2020). Other studies which reported reduced non-COVID-19 case visits to the emergency department indicated that the workload remained unchanged or increased due to changes and special extra tasks that needs to be performed by the emergency nurses (Shoja et al., 2020;Sung et al., 2020;Zhan et al., 2020). An increased workload/job stress may have cascading adverse effects on relationships, appropriate service delivery and overall job performance among nurses (Cui et al., 2021;Gualano et al., 2021;Zare et al., 2021). The situation may even be worse when most nurses fear COVID-19 due to the limited PPEs, and other uncertainties surrounding COVID-19, and unavailability of a cure or definite treatment (Al Thobaity & Alshammari, 2020;Çınar et al., 2021;Zare et al., 2021).
One of the most challenging aspects of COVID-19 is the indefinite transmission medium which includes but not limited to respiratory droplets during close face-to-face spread by asymptomatic, presymptomatic and symptomatic carriers (Wiersinga et al., 2020). This situation is especially challenging for the emergency staff members because they are charged with overseeing the treatment of COVID-19 cases and more specifically emergency nurses as they have to attend to trauma-related and other life-death cases that have unknown COVID-19 status. This increases their chance of contracting COVID-19 and hence increasing their fear of COVID-19. The fear of COVID-19 combined with limited PPEs and inadequate information among the nurses may hinder effective delivery of quality services to patients as the nurses may have decreased job satisfaction, increased psychological distress, performance, and increased organizational and professional turnover intentions (Al Thobaity & Alshammari, 2020;Rajabimajd et al., 2021;Shoja et al., 2020;Yayla & Eskici İlgin, 2021). Apart from the poor delivery of quality services, job stress in tandem with fear of contracting COVID-19 may cause burnout and mental health challenges among the nurses (Hu et al., 2020;Zare et al., 2021).
Burnout, syndrome of three feelings (emotional exhaustion, depersonalization and low personal accomplishment ;Maslach et al., 2018), among nurses is mostly due to factors such as excessive workload, low rewards and poor relationships with colleagues (Dall'Ora et al., 2020) which unfortunately may further lead to other mental health challenges if not properly dealt with (Hu et al., 2020;Shoja et al., 2020). That is, with the increasing COVID-19 cases in the hospital, inadequate resources and support structures to cope with the influx of cases, nurses may be prone to burnout (physical and emotional exhaustion, depersonalization, and low personal accomplishment). The continuous burnout among nurses may deteriorate their health and specifically their mental health which may affect their performance at work (Hamed et al., 2020;Zeng et al., 2020).
That is, burnout has strongly been associated with reduced job performance, poor quality of care, poor patient safety, adverse events, patient negative experience, medical errors, infections, patient falls and intention to leave (Al Sabei et al., 2020;Dall'Ora et al., 2020;Kwon et al., 2021) This leaves a huge financial burden and serious administrative challenges for the health authorities (managers and directors). For instance, the estimated financial cost for burnoutrelated turnover among US physicians and nurses was $17 and $14 billion, respectively, per annum (National Taskforce for Humanity in Healthcare, 2018). In other reports, the financial burden of burnour and/or mental health among nurses or healthcare workers are in several billions dollars per anum (Kline & Lewis, 2019;Medibank, 2011;Perry et al., 2015;Torjesen, 2018). Yet, no known study has examined the mediating roles of burnout and job stress in the association between fear of COVID-19 and mental health.

| Research question
Hence, and considering current COVID-19 situation, this current study aimed to examine the mediation roles of burnout and job stress in the association between fear of COVID-19 and mental health (see Figure 1). The findings will be beneficial to hospital authorities and health professionals themselves by providing information on how to handle their workplace challenges and their mental health appropriately. It will also serve as a background for future clinical studies among health professionals during this COVID-19 pandemic period.

| Design
This study used the cross-sectional design and with the help of a survey to gather the needed data from emergency nursing staff.

| Participants and procedure
This study recruited 516 emergency nursing staff between 15 September and 7 November 2020 from 18 hospitals in Qazvin (Iran) using a list of nursing staffs who were working at emergency departments as prepared by Treatment Affairs (Qazvin, Iran). An online questionnaire was sent by SMS to 800 staff members and 516 (response rate of 64.5%) of them agreed to participate in the study.
Inclusion criteria were as follows: educated in nursing, working at emergency department and provided online consent form for participation.

Fear of COVID-19
The emergency nurses' fear of COIVD-19 was assessed using the fear of COVID-19 scale. This scale was developed by . It is made up of seven items which are rated on a five-point Likert-type scale response format (strongly agree = 5 to strongly disagree = 1). The total score which was generated by adding all the responses ranged from 7 to 35. Hence, higher scores indicated greater fear of COVID-19. The Persian version was used for this study with an acceptable internal consistency (α = 0.82; .

Job stress
The emergency nurses' occupational stress was assessed using the occupational stress inventory (revised) which was developed by Osipow (1998). It is made up of six subscales (role overload, role insufficiency, role ambiguity, role boundary, responsibility and physical environment) with 10 items per each subscale. It is rated on a five-point Likert-type scale response format (1 = never, 2 = occasionally, 3 = sometimes, 4 = usually and 5 = most of the time) with a higher subscale score depicting a greater level of role stressor. The Persian version was used for this study with an acceptable internal consistency (α = 0.83; Sharifian et al., 2006).

Burnout
The nurses' burnout was assessed using the Maslach Burnout Inventory Human Services Survey for Medical Professionals, fourth edition (MBI-HSS MP, 4th Ed.) developed by Maslach et al. (2018). It is made up of 22 items with frequency rating choices of Never (0), A few times a year or less (1), Once a month or less (2), A few times a month (3), Once a week (4), A few times a week (5) or Every day (6) that covers 3 areas (Emotional Exhaustion, EE; Depersonalization, DP; and low sense of Personal Accomplishment, PA). Hence, three MBI scale scores were calculated and interpreted separately for each nurse. The Persian version of MBI showed acceptable Cronbach's alpha coefficients (0.71-0.85) from a previous study Moalemi et al. (2018). Moreover, the Cronbach's alpha coefficients of MBI calculated using the present study's data were acceptable with the range between 0.73 and 0.83.

Mental health
The nurses' mental health was assessed using the 12-Item Short Form Health Survey (SF-12) developed by Ware Jr et al. (1996).
Specifically, this study used the Mental Component Summary (MCS) of the scale. The Persian version was used for this study with acceptable Cronbach's alpha coefficient of above 0.82 (Montazeri et al., 2011;Pakpour et al., 2011).

| Data analysis
The demographic information of the participants was presented using descriptive statistics, including mean (SD) and frequency (percentage). Then, Pearson's correlation was applied to examine the bivariate correlations among the studied variables. After the con- of COVID-19 was the independent variable, job stress and burnout were the mediators, and mental health was the outcome variable.
Age, sex, years of clinical experience and marital status were adjusted for the mediation model. Moreover, bootstrapping method with a total of 5,000 resamples was used to examine the mediation effect.
Values of CFI and TLI > 0.9 together with SRMR and RMSEA < 0.08 indicate a supported mediation model (Hyland et al., 2014). The sample size was also calculated using the proposed mediation model.
The mediation model contains 23 degrees of freedom, with the set-up of type I error at 0.05, power at 0.9, null RMSEA at 0 and alternative RMSEA at 0.05, the desired sample size for the mediation model is around 480 (Preacher & Coffman, 2006). All statistical analyses were conducted using SPSS version 25 and Amos version 24.

| RE SULTS
A total of 516 emergency nurses with a mean age of 41.18 (SD = 8.24) years were used for this study. They were mostly females  Table 1. Table 2 shows the Pearson r correlation matrix between fear of COVID-19, job stress, medical professionals' burnout (emotional exhaustion, depersonalization and low sense of personal accomplishment) and mental health. All the correlation coefficients (r = 0.12-0.68) were significant (p < .05). Table 3 shows that there was a significant direct effect of fear of COVID-19 on burnout (β = 0.311, 95% CI = 0.031-0.07), job stress

| DISCUSS ION
This cross-sectional survey study examined the mediation roles of burnout and job stress in the association between fear of COVID-19 and mental health. The correlation results revealed that fear of COVID-19 related positively to job stress, emotional exhaustion and depersonalization but related negatively to personal accomplishment and mental health with small effect size for all these relationships (Cohen, 1988(Cohen, , 1992 which is similar to previous studies Hu et al., 2020). This indi- mental health, burnout and stress Hu et al., 2020).
These interrelationships ( Age ( findings strengthen the earlier relationships observed between the variables. That is, fear of an infectious disease such as COVID-19 may significantly influence nurses' burnout, job stress or both which may influence their mental health as reported in previous studies Hu et al., 2020;Shoja et al., 2020). Additionally, the mediating effects  hence, there may be biases such as social desirability. However, the use of appropriate administering procedures and the robustness of the psychometric properties for these measures suggest that the data are valid and trustworthy to an appreciable degree.

| Conclusion
This cross-sectional survey study revealed that fear of COVID-19 may, directly and indirectly (through burnout, job stress or both), influence the mental health of emergency nurses negatively. This is a very important finding not only because of COVID-19 but that it also pertains to the mental health of nurses and the life of patients they are treating. This finding suggests that fear of COVID-19 and other fatal infectious condition for that matter influences the mental health of nurses. Hence, hospital authorities such as administrators and medical directors should provide enough resources to allay the fears of nurses in their line of duty during this COVID-19 pandemic period. Replication of this study may be needed to ascertain how the variables used in this study differed from other countries.

ACK N OWLED G EM ENTS
The authors wish to thank all the participants who took part in this study.

CO N FLI C T O F I NTE R E S T S
None.

E TH I C A L S TATEM ENT
All participants provided written informed consent before study participation. The study protocol was approved by the Ethics Committee of Qazvin University of Medical Sciences (n. IR.QUMS. REC.1399.351) and conformed to the requirements of the Declaration of Helsinki. Approval from the participating institutions was also obtained. The data of the participants were kept confidential and used for academic research only.

DATA AVA I L A B I L I T Y S TAT E M E N T
The authors elect not to share data. Research data are not shared for ethical and confidentiality reasons.