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RESEARCH ARTICLE
The prevalence of nurse burnout and its
association with telomere length pre and
during the COVID-19 pandemic
Holly WeiID 1‡*, Julia Aucoin2‡, Gabrielle R. Kuntapay2‡, Amber Justice2‡, Abigail Jones3‡,
Chongben Zhang4‡, Hudson P. Santos, Jr.5‡, Lynne A. Hall1‡
1 University of Louisville School of Nursing, Louisville, KY, United States of America, 2 University of North
Carolina REX Healthcare, Raleigh, NC, United States of America, 3 Piedmont Athens Regional Medical
Center, Athens, GA, United States of America, 4 Biobehavioral Lab, University of North Carolina Chapel Hill,
NC, United States of America, 5 Biobehavioral Laboratory and Health Resilience & Omics Science (HEROS)
Hub, University of North Carolina Chapel Hill, NC, United States of America
‡ These authors contributed equally to this work. HW share first authorship on this work.
Abstract
Background
Burnout is a work-related stress syndrome characterized by emotional exhaustion, deper-
sonalization, and reduced personal accomplishment. Nurse burnout is related to nurses’
deteriorating mental health and poorer patient care quality and thus, is a significant concern
in healthcare. The Coronavirus Disease 2019 (COVID-19) pandemic has swept the world
and distressed the healthcare systems. Because of the body’s stress mechanism, it is vital
to examine the current prevalence of nurse burnout and understand it at a biological level,
using an epigenetic biomarker, telomere length.
Purpose
To determine the prevalence of burnout among nurses in the Peri-Operative and Labor &
Delivery settings pre and during the COVID-19 pandemic and to examine the effects of
burnout on absolute telomere length.
Methods
This is a cross-sectional study assessing the prevalence of nurses’ burnout and the relation-
ships between nurses’ burnout and telomere length. Due to the COVID-19 pandemic, we
had to stop the study during the mid of data collection. Even though the study was not
designed to capture changes before and during the pandemic, we analyzed two groups’
data before and during the pandemic. The study took place in a US hospital. Nurses in the
hospital’s Operating Room, Post-Anesthesia Care Unit, and Labor & Delivery Unit partici-
pated in the study. Maslach Burnout Inventory survey and nurses’ demographics were
administered online. Telomere length was measured via finger-prick blood.
PLOS ONE
PLOS ONE | https://doi.org/10.1371/journal.pone.0263603 March 16, 2022 1 / 14
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OPEN ACCESS
Citation: Wei H, Aucoin J, Kuntapay GR, Justice A,
Jones A, Zhang C, et al. (2022) The prevalence of
nurse burnout and its association with telomere
length pre and during the COVID-19 pandemic.
PLoS ONE 17(3): e0263603. https://doi.org/
10.1371/journal.pone.0263603
Editor: James Curtis West, Uniformed Services
University of the Health Sciences, UNITED STATES
Received: July 30, 2021
Accepted: January 22, 2022
Published: March 16, 2022
Copyright: © 2022 Wei et al. This is an open access
article distributed under the terms of the Creative
Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in
any medium, provided the original author and
source are credited.
Data Availability Statement: Data are not shared
publicly due to the IRB agreement and the HIPPA
regulation. The data are saved in an organization-
owned and password-protected computer
according to the IRB protocol. Data are available
for relevant researchers in accordance with IRB
approval from the Institutional Data Access
(contact via corresponding author holly.
[email protected] with additional author contact
Dr. Lynne A. Hall, email: [email protected]).
Although the authors cannot make their study’s
data publicly available at the time of publication, all
Results
146 nurses participated in the study, with 120 participants’ blood samples collected. The
high-level burnout rate was 70.5%. Correlation analysis did not reveal a direct correlation
between nurse burnout and telomere length. However, in a multiple regression analysis, the
final model contained the burnout subscale of emotional exhaustion, years as an RN, and
work unit’s nursing care quality. There was a low degree of departure from normality of the
mean absolute telomere length in the pre-pandemic group and a substantial degree of
departure in the during-pandemic group.
Conclusions
Nurse burnout is a prevalent phenomenon in healthcare, and this study indicates that nurses
currently experience high levels of burnout. Nurses’ cellular biomarker, telomere length, is
shorter in the group of nurses during the COVID-19 pandemic than before. Appropriate
measures should be implemented to decrease nurses’ burnout symptoms and improve
nurses’ psychological and physical health. Nurses, especially those younger than 60, report
higher burnout symptoms, particularly emotional exhaustion. This study indicates the need
for intervention to promote nurses’ health during the pandemic and beyond. If not appropri-
ately managed, nurse burnout may continue to be a significant issue facing the healthcare
system.
Introduction
Nurse burnout, a significant concern in healthcare, is a work-related stress syndrome charac-
terized by emotional exhaustion, depersonalization, and reduced personal accomplishment
[1]. The phenomenon of nurse burnout was already considered a healthcare epidemic before
the Coronavirus Disease 2019 (COVID-19) pandemic, and the pandemic further worsened the
situation [2, 3]. The Medscape Nurse Career Satisfaction Report [4] obtained online replies
from 10,424 nurses and Advanced Practice Registered Nurses in the United States and sug-
gested a higher burnout rate than the pre-pandemic period. The American Nurses Association
(ANA) conducted two surveys, the Pulse on the National Nurses COVID-19 Survey Series:
Mental Health and Wellness, in 2020. The first survey was done with 10,997 nurses in the
Spring of 2020, about three to four months into the pandemic [5]. The second one included
12,881 nurses and was conducted in December 2020, a year into the pandemic [6]. The surveys
indicated that nurses had intensified feelings of being overwhelmed, exhausted, anxious, sad,
irritable, lonely, depressed, angry, numb, guilty, and feeling like a failure [6], which are similar
to burnout symptoms.
Nurse burnout is related to nurses’ deteriorating mental health, including depression, anxi-
ety, substance abuse, suicide rate, and poorer patient care quality [7]. Based on a meta-analysis
of existing studies, there is a strong association between healthcare professionals’ burnout and
patient safety actions [7]. Complicating the situation is the COVID-19 pandemic, which pre-
sented unprecedented challenges to the public and increased mental health issues among
healthcare professionals [8]. Little research has examined nurses’ physical health at a cellular
level using an epigenetic biomarker such as telomere length.
Telomeres are DNA-protein complexes at the end of chromosomes, and they cap chromo-
somal ends to promote chromosomal stability and protect the regions from degradation.
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authors commit to making the data underlying the
findings described in this study available in
compliance with the PLOS Data Availability policy.
For data sets involving personally identifiable
information or other sensitive data, data sharing is
contingent on the data being handled appropriately
by the data requester and in accordance with all
applicable local requirements.
Funding: Funded studies: HW; CCI 2019; CCI
Research Foundation; https://cc-
researchfoundation.org/; The funders had no role
in study design, data collection and analysis,
decision to publish, or preparation of the
manuscript.
Competing interests: The authors have declared
that no competing interests exist.
Telomeres shorten during cell division with aging. Accelerated telomere shortenings are asso-
ciated with chronic stress. Telomeres cannot be fully replicated when cells divide, leading to
telomere shortening and eventually cells’ senescence after numerous shortenings [9, 10].
When telomeres reach a critically short length, they lose their protective function, which leads
to chromosomal instability and ultimately adverse health outcomes [9]. Leukocyte telomere
shortening is linked to physiological and genetic mechanisms of aging, including oxidative
stress, inflammation, chronic disease, cellular senescence, mortality [9, 10], and psychological
illnesses, such as depression, posttraumatic stress disorder, and hostility [11]. Thus, telomere
length is a measure of cumulative biological weathering and accelerated aging due to chronic
stress, situating telomeres as a candidate biomarker of stress-related disorders or a stand-alone
measure of age-related declines across systems [9, 10].
Because high burnout and psychological distress can accelerate molecular aging [12], it is cru-
cial to understand whether nurses’ burnout is associated with accelerated molecular aging as mea-
sured by telomere length. The purposes of this study were to determine the prevalence of burnout
among nurses pre and during the COVID-19 pandemic and to examine the effects of burnout on
absolute telomere length. The overall hypothesis was that greater burnout symptoms pre and dur-
ing the COVID-19 pandemic would be associated with shorter telomere length.
Theoretical framework
The theoretical framework guiding this study is the Allostatic Load Theory [13, 14]. This
framework describes the wear-and-tear process of allostasis by repeated physiological
responses to psychological stress, leading to allostatic overload and eventually poor health out-
comes. Longitudinal studies linked stress with disease states such as metabolic syndrome, car-
diovascular disease, diabetes, and other diseases of aging [13]. The general and pervasive
effects of stress are related to changes proximal to the stress response, such as changes in the
regulation of the HPA axis and common cellular mechanisms. When individuals are chal-
lenged repeatedly by stressors or when the allostatic systems remain turned on when no longer
needed, the mediators of allostasis can produce wear and tear on the body and brain, leading
to allostatic overload [13, 14].
Burnout may be associated with sustained autonomic nervous system activation and sym-
pathetic adrenal medullary axis dysfunction [12]. Given that telomere length is related to vari-
ous stressor exposures, we conceptualize telomere length as a potential molecular-level
measure of allostatic load and a proxy for the HPA axis and cellular mechanisms. Allostatic
load incorporates dysregulation across multiple systems, and telomere length may index
cumulative inputs from various regulatory systems.
Hypotheses
The hypotheses were:
H1: Absolute telomere length is negatively related to the emotional exhaustion component of
burnout.
H2: Absolute telomere length is negatively related to the depersonalization component of
burnout.
H3: Absolute telomere length is positively associated with the personal accomplishment com-
ponent of burnout.
H4: The absolute telomere length of nurses pre-pandemic is longer than that of nurses during
the pandemic.
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H5: The nurses’ burnout scales and demographic characteristics will account for a significant
portion of the variance in absolute telomere length.
Methods
Study design
This was a cross-sectional study assessing the prevalence of nurses’ burnout and the relation-
ships between nurses’ burnout and telomere length. Due to the COVID-19 pandemic, we had
to stop the study during the mid of data collection. Even though the study was not designed to
capture changes before and during the pandemic, we had two groups’ data before and during
the pandemic. Thus, we also conducted a comparative analysis of nurses’ telomere length pre-
and during the COVID-19 pandemic.
Setting and sample
The study took place in a university-associated hospital on the east coast of the United States.
This is a tertiary care, not-for-profit hospital with 439 in-patient hospital beds and 2000 regis-
tered nurses. Nurses in the hospital’s Operating Room, Post-Anesthesia Care Unit, and Labor
& Delivery Unit were invited to participate. These units were selected because there is little
research on nurses’ burnout in peri-operative units, and there was a call for proposals on peri-
anesthesia nurses’ health. A power analysis was conducted using the software of G�Power 3.1
[15]. The analysis was performed for multiple linear regression with a fixed model, assuming
80% power, α = .05, and an effect size of R2 = .20, as recommended by Polit and Beck [16]. A
total sample size of 75 was needed for the study. Inclusion criteria were: a) hospital’s registered
nurses, b) 21 years of age or older, and c) work on the units for at least six months. Exclusion
criteria were unwilling to answer the surveys or provide a one-time blood sample from a fin-
ger-prick for telomere length determination.
Measures
Maslach burnout inventory. The Maslach Burnout Inventory-Human Services Survey
for Medical Personnel is a popular scale for measuring burnout symptoms in healthcare pro-
fessionals. It consists of 22 items that assess three aspects of burnout: Emotional Exhaustion
(EE; 9 items), Depersonalization (DP; 5 items), and low sense of Personal Accomplishment
(PA; 8 items). Each item is rated on a 7-point Likert scale of 0 = Never, 1 = A few times a year or less, 2 = Once a month or less, 3 = A few times a month, 4 = Once a week, 5 = A few times a week, or 6 = Every day. Cronbach’s alphas for the subscales were: Emotional Exhaustion (.92),
Depersonalization (.73), and Personal Accomplishment (.68).
Telomere length and quantification. Nurses’ blood spot samples were collected via finger
prick on Whatman paper cards (Catalog No 10534612) following kit instructions. There were
two findings related to the correlation between blood spot samples and whole blood samples.
In 2013, Zanet et al. [17] found that telomere length measurements were significantly higher
in dried blood spots collected directly from fingertip prick than dried blood spots prepared
with anticoagulated whole blood collected from the finger and non-blotted whole blood taken
from both finger and arm venipuncture. In 2017, Stout et al. [18] found a significant correla-
tion between blood spot samples and whole blood samples. In this study, genomic DNA was
extracted from the blood spots with QIAamp DNA kit (Catalog No 56504) per instructions.
Telomere length quantification was obtained using ScienCell Absolute Human Telomere
Length Quantification (AHTLQ) qPCR assay kit (Catalog No 8918). Specifically, the telomere
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primers recognize and amplify telomere sequences. The single-copy reference primers recog-
nize and amplify a 100bp-long region on human chromosome 17, serving as a reference for
data normalization. Reference genomic DNA with known telomere length was used as a refer-
ence for calculating the absolute telomere length of target samples. Two consecutive qPCR
reactions were set for each target DNA sample, one to amplify the telomere sequence and the
other one to amplify the SCR sequence. Both qPCR reactions were performed in triplicates
with a final reaction volume of 10μL which included 2μL of target or reference genomic DNA,
1μL of primer stock solution, 5μL of 2X qPCR GoldNStart TaqGreen master mix, and 2μL of
nuclease-free water. The PCR conditions were initial denaturation at 95˚C for 10 min, fol-
lowed by 32 cycles of 95˚C for 20 s, 52˚C for 20 s and 72˚C for 45 s. Relative telomere length
fold changes to the reference human genomic DNA were calculated using ΔΔCT method. As
the telomere length of the reference genomic DNA was known, absolute human telomere
length could be calculated accordingly. This study reports telomere length in the absolute
length per diploid cell or per chromosome end. The absolute length is the actual length and is
expressed as the kilobase (kb) value per diploid cell.
Nurses’ demographic characteristics. Nurses’ demographic characteristics were collected
via a demographic survey designed by the researchers based on the study purpose. The infor-
mation collected included nurses’ age, work experiences, years as an RN, night shift frequency,
exercise frequency, intent to leave, job satisfaction (not satisfied to very high), life stress levels
(no to very high), and perceptions of patient care quality (very poor to very high).
Ethical considerations and procedures
The university institutional review board approved this study.
Data collection
Data collection occurred in the hospital’s Operating Room, Post-Anesthesia Care Unit, and
Labor & Delivery Unit. The research team recruited participants using several strategies,
including posting information flyers on the unit, introducing the study at the units’ staff meet-
ings, and sending emails to nurses. The information on the flyers and emails included the title,
purpose, description of the study, eligibility to participate, and contact information. Nurses
interested in knowing more about the study could contact the research team to ask questions.
REDCap, a browser-based web application for managing online surveys, was used to upload
the study surveys and build an online survey link. The survey link was distributed via units’
listservs, and nurses who were interested in participating would open the link. Upon opening
the link, participants were instructed to read the study description. If they had questions, they
could still call the phone number in the email for more questions. After reading the study
instructions and requirements, nurses could click Agree to participate or No to end. Each par-
ticipant who answered the survey received a personal number at the end of the survey, which
was placed on the blood sample to match the participants’ survey and blood sample results.
Nurses’ paper-copy informed consents were obtained at the time of blood sample collection.
Research team members collected the participants’ blood samples via finger pricks in the
hospital.
Data analysis
The IBM1 Statistical Package for the Social Sciences (SPSS)1 Statistics v. 27 was used for the
data analysis. Frequency distributions were calculated for categorical variables, including
demographic characteristics. Descriptive statistics such as means, medians, standard devia-
tions, and ranges were used to summarize the continuous variables. Pearson’s product-
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moment correlations were calculated to evaluate the strength of relationships between the vari-
ables, including each subscale of the MBI and telomere length. Independent samples t-tests
were run to determine if there were differences in mean burnout scale scores and absolute telo-
mere length between nurses pre and during COVID-19. Multiple regression with a backward
elimination stepwise variable retention procedure which maximizes the retention of valuable
contributors to the model was used to determine if the burnout scales and demographic char-
acteristics predicted absolute telomere length. Because age is a confounding factor in telomere
studies, we controlled for age when analyzing telomere-related data, specifically when compar-
ing telomere lengths before and during the pandemic (Tables 5 and 6) and conducting the
backward elimination multiple regression (Table 7). A two-way ANOVA was conducted to
examine the effect of age and the pandemic (pre and during the pandemic) on telomere
lengths. All hypotheses were tested using an alpha of .05 for statistical significance.
Results
Demographic characteristics of the sample
A total of 146 nurses participated in the study, with 120 participants’ blood samples collected.
The remaining participants could not be reached for blood collections. Thus, the effective sam-
ple size for hypothesis testing was 120.
Table 1 presents the frequency distributions for the demographic characteristics of the sam-
ple. The sample was predominantly female and Caucasian; the median age was approximately
45 years. Most of the nurses had a bachelor’s degree or higher and were at the second of the
four levels of seniority. The median number of years of experience as an RN was approximately
20. Most nurses worked in either the Operating Room or the Post-Anesthesia Care Unit.
Descriptive statistics for absolute telomere length and the independent variables are presented
in Table 2.
The prevalence of nurses’ burnout
Table 3 presents that nurses’ burnout rates. A majority of the nurses experienced high emo-
tional exhaustion and, to a lesser extent, high depersonalization. Few reported low personal
accomplishments. The total high burnout rate (the number of nurses who scored higher than
the cutoff on one or more subscales) was 70.5%.
Nurses’ burnout symptoms and telomere length
Nurses’ emotional exhaustion and telomere length. Hypothesis 1 proposed a negative
relationship between the emotional exhaustion component of burnout and telomere length.
This hypothesis was tested by correlating the scores on the Emotional Exhaustion scale of the
MBI with the telomere length measurements using the product-moment correlation. This
correlation was computed to be .133, for which the one-tailed p-value = .927. This p-value
exceeds the .05 threshold for statistical significance; thus, this hypothesis was not supported
(r = .13, p = .146).
Nurses’ depersonalization and telomere length. Hypothesis 2 proposed that there was a
negative relationship between the depersonalization component of burnout and telomere
length. This hypothesis was tested by correlating the scores on the Depersonalization scale of
the MBI with the telomere length measurements using the product moment correlation. This
correlation was computed to be .136, for which the one-tailed p-value = .931. This p-value
exceeds the .05 threshold for statistical significance, and accordingly, the hypothesis was not
supported (r = .14, p = .139).
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Nurses’ personal achievement perceptions and telomere length. Hypothesis 3 proposed
a positive relationship between the personal accomplishment component of burnout and telo-
mere length. This hypothesis was tested by correlating the scores on the Personal Accomplish-
ment scale of the MBI with the telomere length measurements using the product-moment
correlation. This correlation was computed to be -.028, for which the one-tailed p-value =
.617. This p-value exceeds the .05 threshold for statistical significance, and this hypothesis was
not supported (r = -.03, p = .766). The data provide no evidence of associations of the dimen-
sions of burnout with absolute telomere length.
Table 1. Frequency distributions and percentages of categorical demographic variables (n = 136).
Variable Category Frequency (n) Percent (%)
Age in years 20–29 31 21.2
30–39 28 19.2
40–49 25 17.1
50–59 34 23.3
60 or above 18 12.3
Gender Male 6 4.1
Female 129 88.4
Other 1 0.7
Race American Indian or Alaska Native 1 0.7
Asian or Asian American 7 4.8
Black or African American 9 6.2
Hispanics of any race 2 1.4
Native Hawaiian or other Pacific Islander 1 0.7
White or Caucasian 114 78.1
Two or more races 2 1.4
Education Diploma 5 4.0
Associate Degree 20 15.0
Bachelor 103 75.0
Master 7 5.0
Doctorate 1 0.7
Job title RN CN I (Clinical Nurse) 8 6.0
RN CN II (Clinical Nurse) 98 72.0
RN CN III (Clinical Nurse) 12 9.0
RN CN IV (Clinical Nurse) 7 5.0
RN Managers (Supervisory) 11 8.0
Years as an RN < 1 8 5.5
1–4 29 19.9
5–9 15 10.3
10–14 12 8.2
15–19 16 11
20–24 7 4.8
25–29 15 10.3
>30 34 23.3
Work Unit Post-Anesthesia Care Unit 41 28.1
Operating Room 56 38.4
Labor Delivery 23 15.8
Mother-Baby 1 0.7
Surgical unit 7 4.8
Other 8 5.5
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Nurses’ telomere length and the advent of the COVID-19 pandemic
Hypothesis 4 proposed that nurses’ mean absolute telomere length shortened after the advent
of the pandemic. This hypothesis was tested by comparing the means of the telomere length
measurements obtained from one group of nurses before the advent of the pandemic and a
separate group of nurses during the advent of the pandemic. An assessment of the degree of
departure from normality of the telomere length measurements in these two groups revealed a
low degree of departure from normality in the pre-pandemic group (Shapiro-Wilk W = .946)
but a substantial degree of departure in the during-pandemic group (Shapiro-Wilk W = .777).
Consequently, this hypothesis was tested by applying the parametric independent samples t- test. The means of the two groups are presented in Table 4, followed by the results of the statis-
tical tests in Table 5. The results of the tests of the differences between pre and during pan-
demic telomere lengths were significant using both the parametric and nonparametric tests
(one-tailed p< .001 in both cases). The two-way ANOVA conducted to examine the effect of
pandemic (pre and during the pandemic) on the telomere length controlling for age (Table 6)
showed that: 1) There are differences in total/average telomere lengths between different age
Table 2. Descriptive statistics for the study variables.
Variable n Minimum Maximum Mean SD
Telomere Total Length 120 46.2 999.30 355.95 251.363
MBI-Emotional Exhaustion 146 13 60 32.39 11.603
MBI-Depersonalization 146 5 31 9.88 4.862
MBI-Personal Accomplishment 146 30 56 47.68 5.463
Exercise frequency (number of days) 136 1 8 3.17 1.689
Night shift frequency (number of days) 136 1 5 1.32 0.926
Stress perceived item 136 1 5 2.75 0.841
Life stress outside of work item 136 1 5 3.11 0.932
Burnout perceived item 136 1 5 3.17 1.086
Job satisfaction item 136 1 5 2.76 0.839
Effectiveness handling work stress item 136 1 4 1.94 0.653
Stress impact on patient care item 136 1 5 3.88 0.864
Work unit’s nursing care quality item 136 1 4 1.97 0.620
https://doi.org/10.1371/journal.pone.0263603.t002
Table 3. Prevalence of burnout among nurses in the sample (N = 146).
MBI Subscales Burnout Levels Frequent Percent
Emotional Exhaustion (Score: 0–54) High (� 27) 95 65.1
Moderate (19–
26)
35 24.0
Low (0–18) 16 11.0
Depersonalization (Score: 0–30) High (� 10) 56 38.4
Moderate (6–9) 68 46.6
Low (0–5) 22 15.1
Personal Accomplishment (Score: 0–48) High (0–33) 1 0.7
Moderate (34–
39)
13 8.9
Low (� 40) 132 90.4
Total Burnout (Total High Burnout refers to the number of nurses who scored higher than the cutoff on any subscales). The
cut-off values are based on each subscale’s cut-off values listed above.
Low Burnout 43 29.5
High Burnout 103 70.5
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groups (P = 0.11); 2) There are differences in total/average telomere lengths between pre- and
during-pandemic (P< 0.001); 3) There are no interactions between nurses’ age and their pre-
and during pandemic telomere lengths (P = .654). Regardless of age, nurses’ pre-COVID-19
total/average telomere lengths were longer than during the COVID-19 pandemic.
Nurses’ burnout symptoms, demographic items, and telomere length
Hypothesis 5 proposed that nurses’ burnout symptoms and the demographic items would
explain a significant proportion of variance in telomere length. This hypothesis was tested
using hierarchical multiple regression, both controlling and not controlling for age. Regardless
of age, the models’ p-values are significant (P< .001). The three independent variables left in
the model are MBI—Emotional Exhaustion, Years as RN, and Work unit’s nursing care qual-
ity. This study provided evidence that a subset of the salient potential predictors identified
may explain a significant proportion of the variance in telomere length. The predictive vari-
ables, their coefficients, and their individual p-values are presented in Table 7.
To help understand the phenomenon, we examined the descriptive statistics for telomere
length and MBI-Emotional Exhaustion scores based on nurses’ age groups (Table 8). Table 8
shows that younger nurses generally had longer telomere lengths but had higher emotional
exhaustion symptoms. Nurses> 60 had the shortest telomere lengths and the lowest emotional
exhaustion scores.
Discussion
This study explored the effects of nurses’ burnout on the cellular level using an epigenetic bio-
marker, absolute telomere length, during the COVID-19 pandemic. In addition, because this
study crossed two time periods pre and during the COVID-19 pandemic, we compared nurses’
burnout and absolute telomere length in these two independent samples.
The study findings suggested significant differences between nurses’ telomere lengths pre
and during the pandemic, with significantly shortened telomere lengths in the during-pan-
demic group of nurses compared with the pre-pandemic group. Knowing that age is a signifi-
cant confounder, we analyzed telomere-related data controlling for age. As expected, younger
nurses, age group 20–29, have the longest telomere lengths, and as ages increase, telomere
length becomes shorter. However, regardless of nurses’ age group, we saw significantly shorter
telomere length during the pandemic than before the pandemic in this group of nurses, sug-
gesting the pandemic’s influence on nurses’ telomere lengths.
Table 4. Descriptive statistics for telomere length measures by pre- and during pandemic groups.
Variable Group N Mean SD
Telomere Total Length Pre-Pandemic 52 499.454 248.351
During-Pandemic 68 246.216 192.531
Telomere Average Length Pre-Pandemic 52 5.429 2.699
During-Pandemic 68 2.677 2.093
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Table 5. Results of parametric and non-parametric tests of pre- vs. during pandemic telomere lengths.
Variable Pre & During Difference t df� p Mann-Whitney U z p Telomere Total Length 253.238 6.086 93.60 < .001 733.5 -5.479 < .001
Telomere Average Length 2.752 6.085 93.61 < .001 734.5 -5.473 < .001
� Levine test for homoscedasticity p< .001, equal variances not assumed, Satterthwaite correction to degrees of freedom applied.
https://doi.org/10.1371/journal.pone.0263603.t005
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While we expected nurses’ burnout would have significant correlations with their telomere
lengths, the relevant hypothesis was not supported. The data did not indicate significant bivari-
ate relationships between absolute telomere length and nurses’ burnout symptoms. Findings
from this study showed that telomere lengths were shorter among participants recruited dur-
ing the pandemic onset as compared to those recruited pre-pandemic although no causal link-
ages can be made with these cross-sectional data. When we conducted multiple regression
analysis, significant predictors of telomere lengths included MBI Emotional Exhaustion, years
as an RN, and nurses’ perceptions of nursing care quality on their unit; these variables
explained a significant portion of the variance in absolute telomere length. As a proxy for age,
years as an RN were negatively associated with nurses’ telomere length.
The common belief is that psychological issues negatively correlate with telomere length,
where significantly shorter telomere was identified in individuals with psychological disorders
[19]. The findings, however, suggested that emotional exhaustion had a positive relationship
with telomere length. The greater the emotional exhaustion reported, the longer the telomere
length. In addition, nurses’ perception of the work unit’s nursing care had a negative relation-
ship with telomere length. Thus, the lower/poorer the perception of quality nursing care, the
longer the telomere length. These results are contradictory with current literature and the the-
oretical framework proposed. One possible explanation for this finding is that higher emo-
tional exhaustion was reported by younger nurses in the present sample, and thus it would be
expected that they would have longer telomeres.
Even though past research has recognized the potential direct relationships between nurses’
age and burnout, the research results are inconclusive [20]. Our data show that nurses in the
younger age groups have higher emotional exhaustion scores (� 27 = cut-off values for high-
level burnout) than the nurses over the age of 60 (< 27). The literature on the relationships
Table 6. Between-subjects effects pre- and during pandemic on telomere length controlling for age.
Source Type III Sum of Squares df Mean Square F Sig.
Corrected Model 2614960.785a 9 290551.198 6.521 .000
Intercept 14440561.630 1 14440561.630 324.098 .000
Age 612236.706 4 153059.177 3.435 .011
Pre-, During-COVID 2026127.050 1 2026127.050 45.474 .000
Age � Pre-, During COVID 109413.604 4 27353.401 .614 .654
Error 4856620.158 109 44556.148
Total 22703627.960 119
Corrected Total 7471580.943 118
Note: Levine test for homoscedasticity p< .02, equal variances not assumed.
https://doi.org/10.1371/journal.pone.0263603.t006
Table 7. Results of backward elimination multiple regression of potential predictors of total telomere length
(n = 120).
Model Term Unstandardized Coefficients t p B Std. Error
(Constant) 485.037 111.071 4.367 < .001
Age 23.685 33.155 .714 .476
MBI–Emotional Exhaustion 3.911 1.996 1.959 .053
Years as RN -37.806 18.292 -2.067 .041
Work unit’s nursing care quality -83.272 37.209 -2.238 .027
https://doi.org/10.1371/journal.pone.0263603.t007
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between age and burnout indicated that older nurses or workers reported lower levels of burn-
out [21–24]. These research findings suggest that older nurses may have more cognitive, psy-
chological, and professional strengths that advance with age compared to younger nurses.
These reports were consistent with the current study’s finding, offering evidence that hospitals
may pay attention to young and mid-age nurses concerning nurse burnout symptoms.
The allostatic load theoretical framework indicates that prolonged stress can result in allo-
static load (wear-and-tear on the body), leading to impaired immunity and other diseases such
as atherosclerosis, bone demineralization, and brain nerve cell atrophy [25]. These findings
help us understand nurses’ burnout at the cellular level and may contribute to designing inter-
ventions to improve nurses’ psychological and physical health and prevent the earlier onset of
age-related diseases. The COVID-19 pandemic induced high-stress levels in individuals at the
frontline [11, 26], and stress reactivity can trigger the shortening of telomeres [27]. This study
shows the necessity of a follow-up study to observe this population for potential long-term
burnout and telomere effects.
Physically and emotionally exhausted nurses have increased absenteeism, turnover, and
presenteeism, defined as productivity loss due to health problems or adverse events [28].
Nurses’ burnout may compromise decision-making, job performance, and patient safety [7].
Nurses who feel overwhelmed tend to be more fatigued and have more difficulties facing job
demands or engaging with others [1]. They become cynical, detach from work, and view peo-
ple—especially patients—like objects [1]. Nurse burnout and less optimal work environment
are related to increased staff truancy, decreased job satisfaction, low productivity, and inade-
quate patient care quality, such as increased pressure injuries, more hospitalizations per 100
residents per year, and lower antipsychotic use [29]. Because this study was conducted in an
out-of-normalcy pandemic situation, we highly recommend more research to evaluate the
relationships between nurses’ perceptions of nursing care quality, burnout, and telomere
length.
Implications and future research
Nurses are at the forefront of caring for patients with COVID-19 and promoting public health.
At the initial wave of the pandemic, nurses had limited time to prepare. They faced severe chal-
lenges such as a shortage of personal protective equipment, an influx of high-acuity COVID-
19 patients, and piloting new work routines. These factors were significant stressors for nurses.
With the high rate of nurse burnout, this study suggests a critical need to promote nurses’
mental and physical health and well-being. The current literature indicates that it takes strate-
gies at various levels to support nurses’ health, including organizational, unit, and individual
support and efforts [30]. Organizational culture and leadership play a significant role in
Table 8. Nurses’ age groups, telomere lengths, and emotional exhaustion.
Telomere Length MBI–Emotional Exhaustion
Telomere Total Length Telomere Average Length
Age Group (years) N Mean (Std. Deviation) Min. Max. Mean (Std. Deviation) Min. Max. N Mean (Std. Deviation) Min. Max.
20–29 31 461.43 (262.57) 106.10 920.20 5.02 (2.85) 1.15 10.00 31 32.81 (11.56) 16 56
30–39 24 330.00 (262.45) 68.20 999.30 3.59 (2.85) .74 10.86 28 33.93 (11.73) 16 59
40–49 22 337.08 (242.93) 51.50 791.20 3.67 (2.64) .56 8.60 25 30.72 (10.70) 14 54
50–59 28 334.52 (239.55) 103.10 957.10 3.64 (2.60) 1.12 10.40 34 34.06 (12.99) 13 60
> 60 15 268.65 (209.53) 46.20 794.90 2.92 (2.28) .50 8.64 18 26.33 (8.17) 13 45
Total 120 357.77 (251.63) 46.20 999.30 3.87 (2.74) .50 10.86 136 32.11 (11.56) 13 60
https://doi.org/10.1371/journal.pone.0263603.t008
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promoting nurses’ work environment and psychological health [31–34]. In addition, nurses’
self-care is crucial [35–37]. However, further studies are necessary to quantify the stressors
associated with the COVID-19 pandemic and the long-term effects on stress physiology and
molecular age acceleration. This can inform the need for interventions that can help promote
health and well-being.
Limitations
This is a cross-sectional study in which we measured the outcome and exposures in the partici-
pants at the same time. Thus, it is challenging to derive causal relationships from this one-time
measurement of exposure and outcome. In addition, data collection was interrupted because
of the COVID-19 pandemic. This study was initiated before the pandemic, interrupted by the
adverse event, and restarted after half a year. This process may have affected nurses’ participa-
tion in blood collection, as some did not complete the study. Another limitation is whether
nurses’ telomere lengths are shorter than expected for their age, which is beyond the scope of
this study.
Furthermore, this study took place in one hospital’s peri-operative units, limiting the find-
ings’ generalization. Lastly, this study included largely perioperative nurses. This population
may not have been significantly impacted by COVID demands, and thus any inference about
the impact of the pandemic on the nurses is hard to connect. During the COVID-19 pandemic,
some elective surgeries had to be placed on hold due to a shortage of resources. Some nurses
might be reassigned to work outside of their normal duties or be placed on leave. These out of
normalcy situations may have affected the findings of the study. Thus, more research needs to
be conducted in this area.
Conclusions
Nurse burnout is a prevalent phenomenon in healthcare, and this study indicates that nurses
currently experience high levels of burnout. Nurses’ cellular biomarker, telomere length, is
shorter in the group of nurses during the COVID-19 pandemic than before. Appropriate mea-
sures should be implemented to decrease nurses’ burnout symptoms and improve nurses’ psy-
chological and physical health. Nurses, especially those younger than 60, report higher
burnout symptoms, particularly emotional exhaustion. This study indicates the need for inter-
vention to promote nurses’ health during the pandemic and beyond. If not appropriately man-
aged, nurse burnout may continue to be a significant issue facing the healthcare system.
Author Contributions
Conceptualization: Holly Wei.
Data curation: Holly Wei, Chongben Zhang, Lynne A. Hall.
Formal analysis: Holly Wei, Lynne A. Hall.
Funding acquisition: Holly Wei.
Investigation: Holly Wei, Julia Aucoin, Gabrielle R. Kuntapay, Amber Justice, Abigail Jones,
Chongben Zhang, Hudson P. Santos, Jr.
Methodology: Holly Wei, Julia Aucoin, Gabrielle R. Kuntapay, Amber Justice, Abigail Jones,
Chongben Zhang, Hudson P. Santos, Jr., Lynne A. Hall.
Project administration: Holly Wei, Julia Aucoin, Gabrielle R. Kuntapay, Amber Justice, Abi-
gail Jones.
PLOS ONE The prevalence of nurse burnout and its association with telomere length
PLOS ONE | https://doi.org/10.1371/journal.pone.0263603 March 16, 2022 12 / 14
Resources: Holly Wei, Julia Aucoin.
Supervision: Holly Wei, Julia Aucoin, Lynne A. Hall.
Writing – original draft: Holly Wei.
Writing – review & editing: Holly Wei, Julia Aucoin, Gabrielle R. Kuntapay, Amber Justice,
Abigail Jones, Chongben Zhang, Hudson P. Santos, Jr., Lynne A. Hall.
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