The demands of the healthcare system, including high expectations, time constraints, a lack of social support, and a sense of inadequate skills to address patient suffering, can lead to severe stress in healthcare providers, which affects their health and performance and impacts job satisfaction, workforce

stability, retention, workplace wellness, and patient outcomes [1]. However, nurses play a critical role during emergency and disaster situations [2], and even though nurses remain committed to this role, the unprecedented pressure exerted by the COVID-19 pandemic on every country’s healthcare system has presented various challenges that could affect nurses’ well-being and work well-being [3].

A professional quality of life (ProQOL) has emerged as a growing interest in the healthcare literature, centered on concerns about professionals’ compassion within a context of work characterized by pain and death [4]. From the beginning of stress research, working in social and health services has been pointed out as particularly stressful [5].

Compassion fatigue (CF) describes a work-related stress response in healthcare providers, which is considered the cost of caring and a key contributor to the loss of compassion in healthcare [1]. The most commonly used definition of CF is Figley’s “secondary traumatic stress reaction resulting from helping, or desiring to help, a person suffering from traumatic events” (p. 271) [6]. Studies have revealed that burnout (BO) and secondary traumatic stress (STS) are associated with CF [7]. Burnout consists of three components: fatigue, pessimism, and loss of efficacy [8]. Additionally, it is also associated with symptoms, such as emotional exhaustion, irritability, disappointment, and indifference, which decrease both the quality of care and patient satisfaction [7, 8]. Secondary traumatic stress is the consequence of constant exposure to the suffering of others and not the result of a person’s direct exposure to an accident [7]. Over the past few decades, there has been increasing concern about trauma due to higher rates of traumatic events caused by natural and man-made disasters [9]. Traumatic stress is an emerging concept introduced in the nursing literature to better understand the experiences of nurses who provide care for traumatized patients [10]. The primary symptoms of stress include disturbing thoughts, irritability, sleep problems, and fear that affect the quality of care provided to patients [11]. Unfortunately, the risk of stress and other related variables, such as CF, is high in this cohort [12], prompting nurses to leave their jobs owing to a sense of dread and helplessness [13].

Compassion satisfaction (CS) is a positive aspect of caring for others and is contrary to CF [7]. It is defined as a positive feeling of being able to relieve the confusion of others and satisfaction with the ability to perform one’s job correctly [14]. Compassion satisfaction enables nurses to enjoy their work by helping others [7], whereby nurses experience an intrinsic sense of fulfillment derived from their work in caring for other people [15]. Therefore, positive emotional aspects, such as CS, must be encouraged while CF is recognized and addressed [16].

Excessive fear, alongside the social, economic consequences, can impair individuals’ rational thinking behavior and may lead to mental-health suffering and challenges [17-20]. Evidence has shown a significant association between the COVID-19 outbreak and adverse health issues, such as stress or BO, depression, and anxiety [21-24]. The severity and fatality of and susceptibility to disease can create or intensify anxiety and fear among nurses, potentially affecting their health and well-being while working effectively during times of an infectious epidemic crisis [17].

The results of the study are based on two research questions:

RQ1: Do burnout, secondary traumatic stress, compassion satisfaction, and fear of COVID-19 predict registered nurses’ turnover intention in South Florida during the COVID-19 pandemic?

After complete analysis, a total of 202 surveys collected from March 1^st to August 6^th, 2021, were deemed acceptable for the study. Multiple linear regression analysis for model one (Table 3; Coefficients) indicates that the independent variable BO has a significant positive relationship with the dependent variable TIS (p < 0.001). Whereas the remaining independent variables of STS (p > 0.789), CS (p > 0.756), and FCV-19 (p > 0.316) are not statistically significant. The beta coefficient for BO is 0.407 (p < 0.407), meaning that for every 1 increase of BO, TIS increased by 0.407.

A hierarchical regression analysis of research question one (Table 4; Model Summary) shows that BO is significantly more predictive of TIS than other models as it accounts for more variance at 0.154 (15.4%) at p < 0.001. Model two (block 2 in SPSS) accounts for 0.162 (16.2%) of the variance when the other independent variables (STS, CS, FCV-19) are added with BO with an incremental R2 square change of 0.008. However, this is not statistically significant at p > 0.589.

Therefore, for research question one, the alternative hypothesis H1a is supported. The alternative hypotheses for H2a, H3a, and H4a are not supported (Table 5).

RQ:2 Do perceived job market outlook moderate burnout, secondary traumatic stress, compassion satisfaction, fear of COVID-19, and registered nurses’ turnover intention in South Florida during the COVID-19 pandemic?

Table 6 (Coefficients) shows the moderating variables entered where the BO, STS, CS, and FCV-19 (independent variables) are multiplied with perceived job market outlook 2 to uncover the statistical interaction of the independent variables and the dependent variable (TIS). The results showed that the moderating variable perceived job market outlook 2 (burnout, secondary traumatic stress, compassion satisfaction, fear of COVID-19) is not statistically significant

p > 0.144. Research question 2 showed no statistical interaction between perceived job market outlook 2 (moderating variable) and turnover intention (dependent variable).

Therefore, for research question two, the alternative hypothesis for H1a is not supported (Table 7).

All healthcare professionals, especially nurses, are affected psychosocially due to the uncertainty and work intensity experienced during the COVID-19 pandemic [33]. This research has uncovered the impact of BO on RNs in South Florida during the COVID-19 pandemic. Research question one showed a statistically significant relationship (p < .001) of BO with RNs TIS. Hierarchical regression analysis further confirmed that when compared to other models, BO is more predictive of TIS and accounts for a variance of 15.4% (p < .001). The presence of BO is the negative half of CF, while STS is the other half of the ProQOL model [7].

It has been stated that at least 50% of caretakers across medical fields reported serious symptoms of BO, including emotional exhaustion, cynicism, and a low sense of professional accomplishment [34]. Recent studies have uncovered that the prevalence of BO among nurses in the United States ranged from 35-45% [35] and that nurses have twice the rate of depression compared to other healthcare professionals [35-38]. Nurses experiencing BO may also have problems with concentration and memory, which are very important in clinical units [39].

During the COVID-19 pandemic, it was seen that working for long periods in an environment with a high level of stress and uncertainty, relocating nurses’ units or wards and increasing workload caused nurses to experience BO more rapidly [33]. Nurses are considered the frontline interface with patients, and they suffer more COVID-19-related fatalities than any other classification of healthcare worker [40]. Unfortunately, the incompatibility between the ideal expectations of the nursing profession and the situations encountered in real life also brings about BO [41]. With increasing demands placed on frontline nurses during the COVID-19 pandemic, there is an urgent need to address BO among nurses [42] whereby complicating the fact that turnover leads to staff shortage, affecting patients’ safety and nurses’ ability to meet patients’ needs by providing quality care [43].

Research question two uncovered that even though respondents appeared to be optimistic about the perceived job market opportunities in South Florida, PJMO2 did not moderate between the independent variables BO, STS, CS, and FCV-19 (p > 0.144) and the dependent variable TIS. This is not a surprising result since there is a need for RNs in a market that is already understaffed.

Statistics prove that RN jobs are on the rise, with more than 438,000 RN jobs needed by 2026, equating to a 15% jump in employment opportunities, doubling the total of all occupations which is at 7% [44]. The average wage for RNs is $75,330, and RNs living in Florida have the third-highest employment at 183,130, with an hourly mean wage of $33.42 and an annual mean wage of $69,510 [44]. Specifically, Miami, Fort Lauderdale, and West Palm Beach are all in the top ten metropolitan areas in the United States, employing 53,900 RNs with an annual mean wage of $72,300 [44].

This study provides a better understanding of which independent variables of BO, STS, CS, and FCV-19 predicted TIS in RNs in South Florida during the COVID-19 pandemic. A multiple linear regression analysis proved that BO significantly predicted RNs’ TIS (p < 0.001). A hierarchical regression analysis confirmed that BO was statistically significant when predicting RNs’ TIS (15.4% variance; p < 0.001) in South Florida during the COVID-19 pandemic. Furthermore, STS (p > 0.789), CS (p > 0.756), and FCV-19 (p > 0.316) were not statistically significant when predicting RNs' turnover intention.

This study also provides a better understanding of whether the perceived job market outlook moderates the independent variables (BO, STS, CS, and FCV-19) and the dependent variable TIS. A multiple linear regression analysis confirmed that PJMO2 was not statistically significant (p > 0.144) and did not moderate the independent and dependent variables when predicting RNs’ TIS in South Florida during the COVID-19 pandemic.

This research confirmed that BO was a significant predictor of RNs’ TIS in South Florida during the COVID-19 pandemic, warranting further research and proposals to eliminate BO in the healthcare community.

This is the first known research study designed specifically to examine the professional quality of life (ProQOL), fear of COVID-19 (FCV-19), perceived job market outlook (PJMO), and registered nurses’ (RN) turnover intentions (TIS) in South Florida during the COVID-19 pandemic. It has been observed that the COVID-19 pandemic accelerated many negative repercussions of uncertainty and inadequate support [51].

The objective is to further prepare the medical community, in this case, RNs, for future calamities, such as a pandemic, and reduce CF (BO and STS), particularly BO, and turnover intentions in the nursing community, which continues to be an area of concern, whereby COVID-19 seems to exacerbate the problem further, as evident from the continued pandemic outbreak in South Florida in 2021.

Data analysis illustrates that creative solutions and collaborative healthcare efforts are necessary for optimizing patient care [52]. Interprofessional teams need to lean on one another emotionally and professionally in dealing with deep stress and uncertainty in practice, while intraprofessional collaboration is fundamental when implementing new ideas to reduce nurses’ fatigue and BO in the clinical setting [52]. For example, during COVID-19, nurses reached out through social media to political and nursing leaders to advocate for change, thus using more technology to identify and manage COVID-19 [53]. Nurses critiqued the quality of information available during the global pandemic, reflecting the scientific uncertainty that characterized its early stages. Nurses emphasized the need to distinguish between misleading information versus emerging scientific evidence to inform the public health response. Furthermore, nurses used Twitter and other social media platforms to voice their pride in their profession and advocate for greater recognition of their role in responding to public health emergencies [54].

This research focused on the registered nurses in all disciplines in and outside the hospital of the seven counties in South Florida. However, the research did not elaborate on the differences or similarities between these disciplines. For example, in an intensive care unit, a nurse’s professional quality of life may have been different from the professional quality of life of a registered nurse in an acute care office.

This research only focused on registered nurses and not on other healthcare workers. This narrow approach answered the registered nurses' question in South Florida, but it cannot be generalized to other healthcare workers, including physicians.

There is a “geographical bias” in this research. The professional quality of life for registered nurses in South Florida cannot be generalized to registered nurses in other parts of the state or the United States.

Finally, this research was conducted from March to August 2021, in the “post-vaccination” period of the COVID-19 pandemic. It is certainly possible that if this research had been conducted a year earlier, in 2020, during the “pre-vaccination period,” results could have been different and altered the outcome of the study when considering personal protective equipment and other protective resources, communication, disease knowledge, and protocols, etc. The timing of this research may have impacted the other independent variables (secondary traumatic stress, compassion fatigue, and fear of COVID-19) in predicting the dependent variable (turnover intention).

The authors would like to dedicate this research to registered nurses and all other healthcare workers for their commitment, dedication, and loyalty toward their patients, particularly during the COVID-19 pandemic. The authors are hopeful that this research will benefit nurses’ practice and the healthcare community not only today but also in the future.