SALVIATO, Lais Spinelli. VASCONCELOS FILHO, Paulo de Oliveira. Burnout Syndrome in health professionals in a Covid-19 pandemic scenario: analysis of a university hospital. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 06, Ed. 08, Vol. 06, pp. 27-44. August 2021. ISSN: 2448-0959, Access link: https://www.nucleodoconhecimento.com.br/psychology/university-hospital
Introduction: Burnout Syndrome (BS) occurs when there is physical and emotional exhaustion of the worker. Research has shown that the characteristics of the work are associated with the development of this disease. The coronavirus 2019 pandemic (COVID-19) was responsible for establishing new challenges for health professionals related to the emergence of a new disease, such as: prolonged workloads and feeling of insecurity about a possible virus infection. Guide question: What is the prevalence of BS among health professionals working on the front line in the fight against COVID-19? Objective: The aim of this research was to analyze the repercussion of the COVID-19 pandemic on the development of BS among health workers working to combat the disease. Methodology: The survey was conducted entirely through digital means. The research used the Maslach Burnout Inventory to evidence the presence of the syndrome among participants, and related the information obtained with data from a sociodemographic questionnaire to analyze its impact on the development of BS. Results: In all, 73 people participated in the study, composed mainly of nurses, nursing technicians and physicians, of whom 83.5% were women. The study showed a high prevalence of depersonalization among participants (mean of 65.51%, higher in physicians with 73.3%) and moderate prevalence of emotional exhaustion (mean of 48.27%; higher in nursing technicians, with 56.52%). On the other hand, low personal achievement was evidenced in 32.75% of the participants, which contributed to the prevalence of BS among health professionals in the studied hospital to be 14%. Conclusion: Factors such as: the feeling of personal accomplishment by acting in the pandemic, management strategies aimed at reducing the overload of professionals and the characteristics of the functioning of the institution analyzed may justify the low prevalence of the syndrome in this scenario.
Keywords: Burnout syndrome, COVID-19, health professionals.
Coronavirus disease 2019 (COVID-19) was first reported in late December 2019 in China and soon reached worldwide scale (LIU et al., 2020). Coronavirus is a betacoronavirus and has been called SARS-Cov-2 (LIU et al., 2020). The main feature of the disease is viral pneumonia with a high infection rate. Approximately 15% of patients present with a severe condition of the disease, requiring hospitalization (WHO, 2021). The pandemic forced the remodeling of health services, with specific units for the treatment of COVID-19. Research on mental health of health professionals who treat COVID-19 indicates that those on the front line experience a great psychological burden and present very unfavorable mental health outcomes, such as depression, anxiety and insomnia (LAI et al., 2020; SASANGOHAR et al., 2020).
Burnout Syndrome (BS) was identified in the early 1970s (MASLACH and JACKSON, 1981). Maslach and Jackson, through the Maslach Burnout Inventory (MBI), conducted an investigation on the three dimensions that make up the syndrome: emotional exhaustion, depersonalization (distancing from one’s own personality and attitudes) and the reduced sense of personal fulfillment (MASLACH and JACKSON, 1984; MASLACH et al., 2001). MBI is the standard tool for measuring BS in research. People who experience the three dimensions are prone to develop BS, although the central factor of the syndrome is emotional exhaustion (MASLACH et al., 2001; TAMAYO et al., 2002). High stress jobs can more easily lead to BS than those with less stress (CODO, 2003). Health professionals are often prone to BS (EMBRIACO et al., 2007). The syndrome is characterized by the physical and emotional exhaustion of the professional and occurs when the individual no longer has strategies to face situations and conflicts at work (CODO, 2003). Therefore, BS occurs when there is an inability to deal with emotional stress at work or when excessive use of mental and physical energy is made, which leads to feelings of failure and exhaustion (MASLACH et al., 2001). Several studies indicate that the characteristics of the work environment and the worker are associated with the development of BS (TRINDADE et al., 2010; EMBRIACO et al., 2007; EBLING et al., 2012). Clinical symptoms of BS are nonspecific and include tiredness, headaches, problems with eating, insomnia, irritability, emotional instability, and stiffness in relationships with others. Large variations in the prevalence of BS in health professionals have been reported in both nurses and physicians (EMBRIACO et al., 2007; GREENGLASS et al., 2001; ROTENSTEIN et al., 2018). The climate in the workplace and workload were determinants of SB (CODO, 2003).
A study conducted with health professionals in intensive care during the pandemic showed that, in almost 9,500 providers, the mean self-reported stress, which was measured by a specific study instrument, showed an increase in the score evaluated from 3 to 8 after COVID-19 (SCCM, 2020). They were reported as reasons for stress: lack of personal protective equipment, fear of contracting the disease and fear of spreading the infection to family members (SHANAFELT et al., 2020). In addition to these concerns, conflicts also occur when there is a request to care for patients in a more severe condition without having the proper knowledge or training to do so (CHUNG et al., 2020). These work-related stressors have been associated with anxiety and depression and reflect real physical and emotional risks faced by frontline professionals (EBLING et al., 2012).
Due to the speed of spread of the COVID-19 pandemic, some health professionals were exposed to contamination and many eventually developed the severe form of the disease. This fact also leads to a feeling of insecurity that may have increased the tension and work stress of professionals directly involved in care. The purpose of this study was to identify the prevalence of BS in health professionals of a university hospital working in the fight against COVID-19, and how the pandemic impacted the prevalence of the syndrome among professionals working on the front line.
The project was reviewed and approved by the Research Ethics Committee (CEP) of the Federal University of São Carlos (UFSCar) under the number CAAE 4,053,302.
This is a descriptive study with a cross-sectional design and quantitative approach carried out with health professionals working at the University Hospital of the Federal University of São Carlos, where, during the pandemic, an adequacy was made for the care of patients with COVID-19.
In addition to the Maslach Burnout Inventory suitable for health care/caregivers or human/social services (MBI-HSS), a questionnaire was elaborated for the collection of sociodemographic data. Both the questionnaire and the MBI-HSS and the Informed Consent Form (TCLE) were transformed into an online form and made available in the e-mail of a total of 293 professionals and ten students.Thus, data collection was performed through a self-completed form that could only be accessed with the consent of the TCLE. The first part collected demographic data. The final sample consisted of 71 professionals and 2 students. Data were collected between June and September 2020. The heads and participants of the institution were informed of the voluntary, anonymous and confidential nature of the study, and it was ensured that the collected data would not be used for individual or institutional evaluation purposes.
The MBI-HSS is a universal reference for evaluating institutional BS and has been translated into Portuguese, adapted and validated by Lautert (1997), Tamayo (1997) and others. The MBI evaluates the three dimensions of BS. It is a seven-point Likert scale with 22 questions: nine questions of emotional exhaustion (EE), five for depersonalization (DE) and eight for reduced personal achievement (PA), the latter with reverse score. The MBI questionnaire can indicate whether a person tends to have BS or if they already have BS. For the manifested BS, the three dimensions must be present, that is, individuals who manifest BS have high classifications for EE and DE and low classification for PA. The dimensions should be scored separately, because the contribution of each dimension of the syndrome is unknown. When all dimensions are negative, the risk of SB is reduced. The risk increases as the domains become positive (MASLACH et al., 2001).
For data analysis, the Statistical Package of Social Sciences (SPSS), version 25 (IBM SPSS STATISTICS, 2017), was used. In addition to the basic exploratory analysis techniques such as mean, standard deviation and frequency, the differences in proportions were tested by pearson’s test (chi-square). To study the factors related to the three aspects of MBI-HSS (EE, DE and PA), calculations were made separately for each category. Odds ratios (OR) were calculated with respective intervals of 95% confidence (CI – 95%). The Wald test was applied to obtain estimates of the association of sociodemographic variables with BS dimensions. The significance level (α) was set at 5%, being considered significant values of p <0,05 e intervalo de confiança.
A total of 71 questionnaires were completed by hospital professionals and 2 by medical interns. Among the professionals, 69 worked in patient care, and this was the composition: 25 nurses, 23 nursing technicians, 15 physicians, 6 physiotherapists and 2 managers. The demographic data collected in the questionnaires are presented in Table 1 and can be summarized as follows: 90.4% were directly working in the specific area for patients infected with COVID-19; the highest percentage of respondents were between 35 and 44 years old (53.4%); the highest prevalence was of women, with 83.5% of the answers. There was also a predominance of white people (65.7%); only 19.18% of the total lived alone; most had at least one child (64.3%); the most reported marital status was stable/married union (50.6%); 61.6% were residents of the city and did not need to travel to work. All participants had completed at least technical education and, among the graduates, the majority had at least one graduate degree (28.7%). Working in more than one location was a factor reported by 72.6% and, regarding the number of hours worked per week, the response from 21h to 40h showed a percentage of 65.75% (Table 1).
Table 1: Answers to the sociodemographic questionnaire – São Carlos, Brazil, 2020.
The distribution of dimensions and their respective percentages are described in Table 2. A common characteristic among nursing technicians (NT), nurses (N) and physicians (P) was high professional achievement in the three professions (69%, 76% and 60%, respectively), and depersonalization was also high (65%, 48% and 73%, respectively). In the case of physical therapists (T), the three dimensions appeared in half of the respondents. For two managers (MA) and two students (IM) participating, depersonalization was the dimension that was present.
Table 2: BS dimensions and their percentages – São Carlos, Brazil, 2020.
The association between the dimensions of BS is presented in Table 3. According to the MBI-HSS criteria, in five nursing technicians, three nurses, one physician and one physiotherapist, the three positive dimensions were found in the answers, which represents the presence of BS.
Table 3 – Distribution of the three dimensions of the MBI-HSS and the respective percentages for each professional category – São Carlos, Brazil, 2020.
Table 4 shows the correlation between sociodemographic variables and MBI-HSS dimensions for each professional category. In the case of nursing technicians, a positive association was observed between married/stable union and professional achievement (OR = 2.25; CI 95% [0,2; 17,7] ; p = 0.04). For nurses, there was a positive association between having a child and depersonalization (OR = 2.48; CI 95% [1,11; 5,57] ; p = 0.01). As for physicians, each dimension had a positive association: the fact of having more than one job impacted emotional exhaustion (OR = 0.5; CI 95% [0,04; ,7,7] ; p = 0.02); the fact of being married contributed to a greater depersonalization (OR = 2.5; CI 95% [0,19; 32,1] ; p = 0.01). And, in females, there was a higher professional achievement (OR = 2.5; CI 95% [0,19; 32,1] ; p = 0.01). The statistical validation of physical therapists, managers and students was not significant.
Table 4 – Correlation between sociodemographic variables and MBI-HSS dimensions for each professional category. – São Carlos, Brasil, 2020.
According to the criteria adopted for the analysis of the three dimensions of the MBI-HSS and considering only the professionals working in the fight against COVID-19 of the categories statistically relevant to the study (nurses, nursing technicians and physicians), the answers obtained in this survey showed a moderate prevalence of emotional exhaustion (mean of 48.27%, being the highest in nursing technicians, with 56.52%) and a high prevalence of depersonalization (mean of 65.51%, being the highest in physicians, with 73.3%). However, as the results for low personal achievement stood, on average, at 32.75%, the prevalence of BS among health professionals in the studied hospital was about 14%. The world literature presents higher levels of BS in health units (33.8%) even without the presence of COVID-19 (CAÑADES et al., 2015; SUÑER-SOLER et al., 2014). Initial Chinese studies on mental health of frontline health care professionals from coping with COVID-19 showed that prevalence increases as patient demand for health services grows (LAI et al., 2020; CHEN et al., 2020). Then, with the progress of the pandemic, studies in other countries also indicated a higher frequency of signs of exhaustion and BS in frontline professionals (SASAGOHAR et al., 2020; MATSUO et al., 2020; BARELLO et al., 2020; KOH, 2020; HORTA et al., 2021; FREITAS et al., 2021).
In this study, there were some limitations. The statistical power of the analysis was limited by the reduced sample size. The sample, however, corresponds to 25% of the hospital’s health professionals. The vast majority of respondents performed the work in the area reserved for the care of patients with COVID-19. Since there is no previous study in the institution on the prevalence of BS, it is not possible to make a comparative analysis of the prevalence before COVID-19. Thus, the sample is only representative of the presence of BS in professionals during the pandemic period. Another limitation is the local character, which was one of the focuses of the study, but which cannot be generalized to other regions of the country.
Although the study extended to other professionals, such as physiotherapists, managers and even medical students, there were few participants, so the results for these categories were not statistically significant. In relation to nursing technicians, nurses and physicians, there is the possibility that the result is influenced by the environment of exposure to the pandemic, which may result in an overvaluation of feelings.As the study was conducted through a questionnaire, the initiative to respond to it may have been influenced by the affinity that participants have with the profession. However, the results obtained show a parity with other Brazilian studies (HORTA et al., 2021; FREITAS et al., 2021).
In the results of each professional category, it was verified that the presence of BS in technicians was 21.7%. Slightly smaller than that found by Freitas et al. in 2020 (FREITAS et al., 2021): in a study with intensive care nursing technicians who are working on the front line of the COVID-19 pandemic, the prevalence of BS was 25.5%. Sociodemographic, occupational and behavioral factors were shown to be predictors of the syndrome. According to the results of this study, it was not possible to make this type of association, although the levels of depersonalization were high. In addition, the nursing technicians were the collaborators who presented the highest percentage of emotional exhaustion (EE) and low personal achievement (PA). The daily routine involved in the work of nursing technicians is exhausting, leads to fatigue and may be responsible for the high rate of depersonalization (VASCONCELOS, 2016).
In Brazil, BS studies in nurses are more frequent than in other categories of health professionals. For nurses, studies on BS show a prevalence of around 25-50% (MATSUO et al., 2020; AZEVEDO et al., 2019). Although the results showed moderate rates of emotional exhaustion and depersonalization, the prevalence of BS among nurses was 12% in the hospital analyzed. One data that was observed and is not present in the literature was the positive association between depersonalization and professionals with children. Here can be considered an overload factor.
In relation to physicians, the incidence of BS was 6%, which is low compared to the literature (CHEN et al., 2020; WU et al., 2020). Nevertheless, a high depersonalization and a high professional achievement were verified. The fact that the professional had more than one job had an impact on emotional exhaustion (OR = 0.5; CI 95% [0,04; ,7,7] ; p = 0.02). Higher rates of emotional exhaustion are found with a higher workload. The fact that the professional was married contributed to a greater depersonalization (OR = 2.5; CI 95% [0,19; 32,1] ; p = 0.01). Studies of BS with physicians are very heterogeneous, and several causes are sources of deviation, such as number of jobs, specialty and workload. Higher rates of emotional exhaustion are found to have a higher workload (FREITAS et al., 2021). Depersonalization may be linked to a lower bond between the professional and the institution, since the profile of the institution’s physicians is that they do not work daily in the same place.
In relation to the specific care of patients with COVID-19, there is a recent study by Dinibutun (DINIBUTUN, 2020) in which physicians presented low prevalence of BS. The result suggested that physicians actively involved in coping with COVID-19 had a strong sense of personal fulfillment and satisfaction with work, as they perceived the immediate results of care for infected people and, consequently, suffered less from BS. In addition, the recent study by Yıldırım and Solmaz demonstrated the importance of the role of resilience in mediating the development of BS related to COVID-19, and resilience acts contrary to stress in the development of the syndrome in the context of pandemic (SOLMAZ et al., 2020)
Another aspect that possibly impacts the outcome of the study is the fact that the hospital analyzed receives patients whose origin is necessarily from another health service in the city (“closed door”), not being subject to the spontaneous demand of the population. Thus, the hospital is less subject to sudden fluctuations in demand for care and overcrowding, which may result in professionals less burdened due to work.
BS is a process that results from the interaction between the work environment and personal characteristics. The most used definition was proposed by Maslach and Jackson in 1981 (MASLACH et al., 2001). Emotional exhaustion is considered a central factor in BS. It is characterized by the emotional and the sense of lack of energy, showing an inverse association with the performance of the work. EE is often related to excessive demands and personal conflicts, predominantly in people with a higher degree (TAMAYO et al., 2002). Depersonalization refers to loss of motivation, anxiety, irritability and reduced idealism. The health area is considered an activity that requires emotional stability and ability to express emotions (EMBRIACO et al., 2007). Low professional achievement is related to a feeling of incompetence and inadequacy, negative self-assessment and the drop in productivity. Another factor that can influence the feeling of reduction of professional achievement is the lack of recognition at work (MASLACH et al., 2001; ALMEIDA et al., 2009). SB is a process that results from the interaction between the work environment and personal fulfillment. The findings of this study can be explained by the profile of the institution investigated. Health care activities can generate high emotional demands in the professional. Work overload in technicians, nurses and physicians increases the turnover of professionals, which impacts the quality of care (SILVA et al., 2008). Although the purpose of helping others is recognized as a noble goal, the relationship between a professional and patients and the fine distinction between professional and personal involvement are permeated by ambiguity (ALMEIDA et al., 2009).
The COVID-19 pandemic posed challenges to health services and forced changes in routines and the performance of professionals. The adaptations of routines and physical spaces were necessary, besides having also had to offer emotional support to the teams. MBI-HSS does not have diagnostic power for BS, which should be diagnosed by an experienced psychiatrist (VASCONCELOS, 2016). However, the tool, besides being a complement to the clinical diagnosis, shows the impact that the environment has on emotional exhaustion. Thus, it becomes an important evaluation method for services during the pandemic period.
The research aimed to evaluate the prevalence of BS presented by health professionals in the COVID-19 pandemic period and whether some sociodemographic factors could contribute to the development of the syndrome. In the three professional categories in which it was possible to survey, eight workers with the three dimensions of BS (prevalence of 14% in the sample) were found. Although emotional exhaustion and depersonalization were high, there was also high personal achievement, regardless of the category. It is possible that the affinity of professionals with the service, as well as the feeling of personal accomplishment for the performance in the pandemic, contributed to the result. It is also possible that management strategies can decrease levels of emotional exhaustion and depersonalization, such as mitigation of prolonged workloads and adequate resting conditions (CHUNG et al., 2020; CHEN et al., 2020). Moreover, characteristics specific to the functioning of the institution may play a significant role in the development of BS among the professionals in this study.
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 A graduate of higher education.
Submitted: May, 2021.
Approved: August, 2021.