Assessing the burnout rate of health system employees related to COVID 19, related factors and strategies to reduce it

doi:10.21203/rs.3.rs-3731318/v1

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Assessing the burnout rate of health system employees related to COVID 19, related factors and strategies to reduce it

https://doi.org/10.21203/rs.3.rs-3731318/v1

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Background

Specific global conditions and the occurrence of corona pandemic and the high level of stress created due to the high risk and power of its contagion lead to double stressful conditions in medical personnel. Therefore, burnout and its related factors are very important in physicians and treatment staff related to patients with Covid-19. To determine the relationship between burnout and depression, anxiety and stress in physicians and treatment staff working in related wards of patients with Covid-19.

Methods

This cross-sectional study was performed on 108 medical staff who were in direct contact with patients with Covid-19. The Goldard questionnaire was used to assess the frequency of burnout. The DASS-21 questionnaire was also used to assess depression, stress and anxiety in the subjects. The State-Trait Anxiety Questionnaire was used to assess state and trait anxiety.

Results

84.2% of treatment staff had level 3 burnout, which as a result was not in good condition. Also, 60%, 70.4% and 64.8% of people had different degrees of depression, anxiety and stress, respectively. 84.3% and 79.6% of these people also had moderate anxiety and moderate traits, respectively. All of these factors were significantly associated with burnout. Also, stress was the most important predictor of burnout in physicians and medical staff.

Conclusions

As a result, it seems necessary to provide solutions such as the use of support packages (financial and non-financial) as well as the implementation of a systematic psychological programs - in groups or individually - to reduce stress and anxiety of these people.

burnout

Depression

Anxiety

Stress

healthcare

Covid-19

Given that healthcare workers are on the front lines of the fight against infectious diseases and Covid-19, they are among the first to be exposed to the virus (1). On the other hand, healthcare professionals have to wear heavy protective clothing and N-95 masks, which restrict mobility and make it difficult to perform medical procedures compared to normal conditions (2). All these factors, along with the risk of being infected and infecting others, increase the risk of psychological disorders among healthcare professionals (3). Also, research has shown that negative psychological experiences of Covid 19 are very evident in nurses, including negative feelings such as fatigue, discomfort, helplessness from too much work, anxiety and worry about family members (4).

Employees who suffer from burnout are those who suffer from severe emotional exhaustion, that is often accompanied by physiological symptoms. They feel confused, alienated, inadequate and unmotivated. Their behavior also changes, showing signs of depression or anger, and they may turn to drugs, alcohol, or other ineffective coping behaviors to cope with stress (5, 6). A new global pandemic like Covid-19 is a devastating event for healthcare workers, so there is little research on this disease and its relationship to burnout (7). When a respiratory syndrome like MERS and SARS spread so quickly, doctors and medical staff experienced excessive stress, to the extent that some medical staff refused to care for patients (8). In addition, factors affecting nurses' willingness to leave their jobs during SARS and measles outbreaks, increased risk of death due to the disease, occupational stress and social relations were identified (9). Since there are not enough studies on the extent and severity of burnout of healthcare professionals during this pandemic. In this study, we try to identify the factors that cause burnout in healthcare professionals and to provide solutions about how to prevent burnout.

Participants

In the present study, 120 physicians and treatment staff related to Covid 19 patients working in Mousavi and Valiasr hospitals in Zanjan were randomly selected and entered into the study and examined. Individuals who willingly participated in the study and signed the informed consent form entered the study. The person had the right not to participate in the study if he did not have an esoteric desire. Exclusion criteria also included the following: incomplete completion of questionnaires and the existence of a random pattern in the completion of questionnaires. All interventions were performed in accordance with relevant guidelines and regulations of Zanjan University of Medical Sciences. Informed contest was taken from all participants. Approval was obtained from the Zanjan University of Medical Sciences ethical committee (Approval ID: IR.ZUMS.REC.1399.374).

Assessments

In this study, Goldard burnout questionnaires, DASS21 and State-trait anxiety questionnaires and a questionnaire called items that help reduce stress and job fatigue in conditions of severe job stress were used to collect information. The reliability and validity of these questionnaires have been proven in previous studies (10). These questionnaires are attached at the end of the final report. Information about employee burnout was collected using the Goldard burnout questionnaire (11), which shows a person's feelings about work in the form of 40 phrases. The scoring method is based on the Likert scale. The validity of this questionnaire has been proven by various methods including test-retest method (11). The Stress-Anxiety-Depression Inventory was developed by Lovibond & Lovibond in 1995 to measure stress-anxiety-depression and has 21 questions. The DASS-21 questionnaire consists of 3 components, each of which is a subset of 7 questions, and the final score of each is obtained through the sum of the scores of the related questions. State-trait anxiety questionnaire was used to measure anxiety and its differentiation from depression syndrome. The most common version of this "Anxious Form Y" questionnaire has 20 items for assessing anxiety traits and 20 items for anxiety states (10). The questionnaire "Assessment of items that help reduce stress and job fatigue of staff in conditions of severe job stress" was used to assess items and items that help to reduce job fatigue. The questionnaire had 10 questions that were ranked on a 5-point scale, each of which can indicate a dimension of the solutions to reduce stress and job fatigue of staff in conditions of severe job stress. The content validity of this questionnaire was determined through a survey of 5 experts in the field of effective factors in job stress and burnout and the calculation of statistics related to content validity. Also, the formal validity of the items was performed using a sample of 20 participants and the ambiguous items were rewritten, which were formally inappropriate and rewritten based on the characteristics of partiality, brevity, clarity and comprehensibility. After execution, the internal consistency coefficient of the questionnaire was reported using Cronbach's alpha coefficient and halving. To determine the simultaneous validity, its correlation with the overall score and dimensions of Goldard burnout questionnaire, state trait anxiety questionnaire and depression, anxiety and stress questionnaire were calculated.

Statistical analysis

Descriptive statistics of mean, standard deviation, variance, minimum and maximum, and single and compression percentages were used to assess depression. Pearson correlation was used to evaluate anxiety in the form of correlation matrix and significance coefficients. Stress was tested using multivariate intergroup analysis of variance. Finally, linear and multiple regression analysis tests were used to assess stress.

Of the 120 health care professionals invited to participate in the study, 108 agreed. Most of the participants were female (56.5%), married (43.5%), and had a bachelor’s degree (57.4%). Among the forty-four participants who responded to the question regarding work experience and the average hours of the Corona shift per week; the mean was 12.36 ± 32/7 years, and 45.66 ± 17.26 years respectively. More details of demographic characteristics of the study population are illustrated in Table 1.

Table 1

Frequency distributions and percentages of categorical demographic variables (N = 108)
Variables	N (%)
Sex
Male	30 (27.8)
Female	61 (56.5)
Missing	17 (15.7)
Marital status
Single	42 (38.9)
Married	47 (43.5)
Missing	19 (17.6)
Education
Diploma	8 (7.4)
Bachelor	62 (57.4)
Above bachelor	7 (6.5)
Missing	31 (28.7)

The result of our study showed that the mean score was 151.47 for burnout. Most health care professionals (84.2%) had Level 3 burnout which meant they were not in a good condition and should be more careful. An analysis of DASS questionnaire revealed the mean score of 14.26 for depression, 19.61 for anxiety, and 19.15 for stress. Half of the health care professionals (48 to 53%) indicated a normal to mild range on depression and stress, however 61% of them indicated a moderate to very severe range on anxiety. Also, according to the state-trait anxiety questionnaire, the mean of state and trait anxiety was 49.8, and 49.5 respectively (Table 2).

Table 2

Mean and prevalence for burnout, depression, anxiety, stress, state anxiety, trait anxiety, and items that help to reduce the level of stress and job fatigue of health care professionals
Variable	Mean ± SD	Min-Max	Prevalence cut-off	N (%)
Burnout (N = 108)	151.47 ± 24.96	83–215	Level 1 (Without burnout) (40–80)	0 (0)
			Level 2 (does its job well) (81–120)	14 (13)
			Level 3 (not in good condition and should be more careful) (121–200)	91(84.2)
			Level 4 (at risk and require immediate action) (201–280)	3 (2.8)
Depression (N = 108)	14.26 ± 11.39	0–42	Normal (0–9)	44 (40.7)
			Mild (10–13)	14 (13)
			Moderate (14–20)	19 (17.6)
			Severe (21–27)	14 (13)
			Very severe (> 27)	17 (15.7)
Anxiety (N = 108)	12.61 ± 9.39	0–36	Normal (0–7)	32 (29.6)
			Mild (8–9)	10 (9.3)
			Moderate (10–14)	29 (26.8)
			Severe (15–19)	10 (9.3)
			Very severe (> 19)	27 (25)
Stress (N = 108)	19.15 ± 10.11	0–40	Normal (0–14)	38 (35.2)
			Mild (15–18)	13 (12)
			Moderate (19–25)	27 (25)
			Severe (26–33)	20 (18.5)
			Very severe (> 33)	10 (9.3)
State anxiety (N = 108)	49.8 ± 7.64	33–79	Low (20–40)	10 (9.3)
			Moderate (41–60)	91 (84.3)
			High (61–80)	7 (6.4)
Trait anxiety (N = 108)	49.5 ± 7.51	33–70	Low (20–40)	13 (12)
			Moderate (41–60)	86 (79.7)
			High (61–80)	9 (8.3)
Factors that help to reduce the level of stress and job fatigue (N = 108)	33.64 ± 12.34	10–50	Low (10–23)	29 (26.9)
			Moderate (24–37)	23 (21.2)
			High (38–50)	56 (51.9)

Also, the mean score of our questionnaire for the evaluation of factors that help to reduce the level of stress and job fatigue of health care professionals in conditions of severe occupational stress (108 samples, α = 0.95) was 33.64. 51.9% of the total score was in the high range (38–50). The "implementation of continuous and regular psychological support programs through the establishment of individual meetings with mental health experts" and the "implementation of support and incentive packages (based on goods through the administrative system)" were the two factors that received "very high" score (25%) more than the other items.

The results of Pearson's correlation coefficient showed that there was a direct and significant relationship between burnout and the level of depression (R = 0.540, P_value > 0.001), anxiety (R = 0.428, P_value> 0.001), and stress (R = 0.569, P_value> 0.001). It means that as the level of depression, anxiety and stress in health professionals increased, the level of burnout also increased and vice versa.

As shown in Table 3, the regression analysis results of predicting burnout based on depression, anxiety and stress indicated that depression (β = 0.33), and stress (β = 0.47) can significantly predict burnout (P_value > 0.05), but anxiety cannot (β=-0.2, P_value= 0.156).

Table 3

Results of multiple linear regression analysis of predicting burnout based on anxiety, depression and stress
Predictive variables	R	R²	Adjusted R square	F	P value of F	Beta	t	P-value
	0.60	0.36	0.34	19.53	001/0>
Constant							29.54	001/0>
Depression						0.33	2.40	0.018
Anxiety						0.47	3.33	0.001
Stress						-0.20	-1.43	0.156

Furthermore, the results of Pearson's correlation coefficient showed that there was a direct and significant relationship between burnout and state anxiety (R = 0.55, P_value =0.008), while no significant relationship was found between burnout and trait anxiety (R = 0.088, P_value =0.363).

The results of the regression analysis of predicting job burnout based on state anxiety and trait anxiety indicated that state anxiety can significantly predict burnout (β = 0.38, P_value =0.004), while trait anxiety cannot significantly predict it (β=-0.18, P_value =0.177) (Table 4).

Table 4

Results of multiple linear regression analysis of predicting burnout based on state and trait anxiety
Predictive variables	R	R²	Adjusted R square	F	P value of F	Beta	t	P-value
	0.29	0.084	0.066	4.72	0.011
Constant							6.03	001/0>
State anxiety						0.38	2.94	0.004
Trait anxiety						-0.18	1.36	0.177

The results of stepwise regression analysis revealed that the best variable predicting the total burnout score was stress, which alone explained 32% of the variances of burnout (R = 0.57, F = 50.73, β = 0.57, P_value> 0.001).

As the Pearson correlation coefficient results in Table 5 show, there was an inverse relationship between the factors that help to reduce the level of stress and fatigue of the health care professionals with the variables of burnout, anxiety, depression, stress, state and trait anxiety, but none of these relationships were statistically significant (P_value > 0.05).

Table 5

Correlation matrix to determine the relationship between the factors that help to reduce the level of stress and fatigue of the health care professionals with the variables of burnout, anxiety, depression, stress, state, and trait anxiety
Variables	Factors that help to reduce stress and job fatigue
Variables	R P-value
Burnout		-0.067	0.492
Depression		-0.101	0.298
Anxiety		-0.150	0.122
Stress		-0.058	0.552
State anxiety		-0.092	0.345
Trait anxiety		-0.022	0.822

The results of the presented study showed that 84.2% of healthcare professionals had level 3 burnout, which is not in good condition, and they should take more care of themselves. Also, 60%, 70% and 65% of them had different degrees of depression, anxiety, and stress, respectively. 85 and 80% of these people had moderate anxiety and moderate traits, respectively. All these factors were significantly related to burnout. Also, stress was the most important predictor of burnout in physicians and medical staff.

In our study, in addition to the implementation of psychological programs, the medical staff mentioned the implementation of support packages - financial and non-financial - as factors that can help reduce stress and burnout. As a result, financial problems of healthcare professionals, especially nurses, can be another factor that contributes to their psychological problems.

Several factors contribute to the burnout of medical staff. Studies have shown that younger age is associated with higher burnout rates because these people have less experience. The number of night shifts and the increase in the number of hours of work shifts and the type of job (nurse, doctor, etc.) also affect the rate of burnout (12, 13).

There is no doubt that burnout in healthcare professionals reduces their efficiency and job performance, and this is the starting point of their lack of motivation due to respect for clients and their duties. Due to the reduction of stress and heavy workload, psychological stress and burnout are also reduced (14).

Therefore, it is necessary to take appropriate measures and solutions, including the use of support packages (financial and non-financial) as well as the implementation of psychological programs to reduce job burnout. This should be done to be sensitive to individual emotional reactions and their impact on the work system and patient care services. It's important to respond appropriately and in a timely manner. To promote mental well-being, a mental health monitoring system will be established. This will involve periodic individual assessments and regular participation of employees in group meetings for active feedback. Additionally, professional conditions will be created to support emotional discharge in a safe environment, leading to better understanding of employees' emotional state.

One of the advantages of the present study was that in addition to examining burnout, the predictors of burnout such as stress, anxiety and depression were also evaluated. Also, in a researcher-made questionnaire, the items that help to reduce stress and burnout were examined. On the other hand, this study, like other studies, has some limitations. This study is a cross-sectional study and lacks a control group, which means that the effect of Covid-19 disease on burnout can not be well determined in comparison with the control group; Because previous studies conducted before the outbreak of Covid-19 disease also show high burnout in the medical staff, especially in Iran (15–17). Other limitations of the study include the inherent limitations of the questionnaire studies, including the lack of cooperation of some members of the medical staff, the distrust of some of them towards the questionnaire and research.

What the results of the present study show is that the Covid-19 disease epidemic has largely caused burnout in healthcare professionals. This pandemic causes the rate of healthcare professionals burnout by increasing stress, anxiety and depression. Meanwhile, stress was the most important predictor of burnout. Therefore, providing solutions such as the use of support packages (financial and non-financial) as well as the implementation of psychological programs - on a group or individual basis - seems necessary to reduce stress and anxiety.

DATA AVAILABILITY STATEMENT

All data has been presented in the manuscript.

Acknowledgment

Not applicable.

Ethical statement

All interventions were performed in accordance with relevant guidelines and regulations of Zanjan University of Medical Sciences. Informed contest was taken from all participants. Approval was obtained from the Zanjan University of Medical Sciences ethical committee (Approval ID: IR.ZUMS.REC.1399.374).

Consent for publication

Not applicable.

Credit Author Statement:

A.G, O.S, R.J, F.J: Project Administration, Data curation, Writing- Original Draft, Writing – Review & Editing, Visualization

A.S, S.K: Validation, Resources, Methodology, Software, Formal analysis, Writing – Original Draft

Funding

This study did not receive funding, grant, or sponsorship from any individuals or organizations.

Conflicts of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript.

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No competing interests reported.

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You are reading this latest preprint version

Assessing the burnout rate of health system employees related to COVID 19, related factors and strategies to reduce it

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Abstract

Background

Methods

Results

Conclusions

Introduction

Materials and methods

Participants

Assessments

Statistical analysis

Results

Discussion

Declarations

References

Additional Declarations

Supplementary Files

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