BRAIN. Broad Research in Artificial Intelligence and Neuroscience ISSN: 2068-0473 | e-ISSN: 2067-3957 Covered in: Web of Science (WOS); PubMed.gov; IndexCopernicus; The Linguist List; Google Academic; Ulrichs; getCITED; Genamics JournalSeek; J-Gate; SHERPA/RoMEO; Dayang Journal System; Public Knowledge Project; BIUM; NewJour; ArticleReach Direct; Link+; CSB; CiteSeerX; Socolar; KVK; WorldCat; CrossRef; Ideas RePeC; Econpapers; Socionet. 2022, Volume 13, Issue 1Sup1, pages: 230-246 | https://doi.org/10.18662/brain/13.1Sup1/316 Submitted: February 1st, 2022 | Accepted for publication: March 4th, 2022 Burnout Syndrome in Personnel of an Infectious Diseases Hospital, One Year after the Outbreak of the COVID-19 Pandemic Elena DUMEA¹, Nela Daniela EFRIM2, Adina PETCU3, Lucretia ANGHEL4, Cristina Gabriela PUSCASU5 1 University lecturer, “Ovidius” University by Constanta, Medicine Faculty, Constanta, Romania, elenadumea@yahoo.com 2 PhD student, “Ovidius” University by Constanta, Medicine Faculty, Constanta, Romania, daniela.efrim@gmail.com 3 University lecturer, “Ovidius” University by Constanta, Pharmacy Faculty, Constanta, Romania, adinpetcu@yahoo.com 4 University lecturer, Clinical Medical Department, Faculty of Medicine and Pharmacy “Dunarea de Jos” University Galati,, Romania, anghel_lucretia@yahoo.com 5 University lecturer, “Ovidius” University by Constanta, Faculty of Dentistry, Constanta, Romania, cristinap@gmb.ro Abstract: Healthcare workers (HCWs) are important players in the COVID-19 pandemic management and are inescapably in the first line to be exposed to the SARS CoV-2 virus. They were at risk of losing their lives while caring for their duty for COVID patients. This pandemic has substantial psychological impact on HCWs. This study describes the prevalence of burnout between HCWs handle with COVID-19 pandemic. The study explored the level of burnout in this population and examined factors involved in development of this psychological consequence. This cross-sectional survey was conducted on personnel from an Infectious Diseases monospecialty Hospital, which provides care for COVID-19 patients. The study was attended at 12 months after the outbreak. A questionnaire- based survey using Maslach Burnout Inventory (MBI) was conducted for all personnel. Participation was voluntary and anonymous. Age, gender, job category and the level of burnout in each subscale was measured. 186 persons completed the questionnaire (79%from employees). 61.86% experienced medium and high levels of burnout comparable with other country studies. The mean score and SD in emotional exhaustion, depersonalization and lack of personal accomplishment were 23.26+8.45, 11.11+4.05, and 22.62+6.83, respectively. The prevalence of burnout in the hospital`s personnel was 38.179% in low rates, 46.77% had medium level and 15.05% high level. Doctors and administrative staff were more affected than others. Nevertheless, there are no significant statistical differences in the level of the three domains of burnout studied regarding the age and job profile. In conclusion, in our hospital, designated to treat moderate and severe COVID-19 patients burnout is equally present among HCWs. Keywords: COVID-19, burnout, healthcare workers, SARS- CoV-2, professional emotional exhaustion. How to cite: Dumea, E., Efrim, N.D., Petcu, A., Anghel, L., & Puscasu, C.G. (2022). Burnout Syndrome in Personnel of an Infectious Diseases Hospital, One Year after the Outbreak of the COVID-19 Pandemic. BRAIN. Broad Research in Artificial Intelligence and Neuroscience, 13(1Sup1), 230-246. https://doi.org/10.18662/brain/13.1Sup1/316 https://doi.org/10.18662/brain/13.1Sup1/316 mailto:elenadumea@yahoo.com mailto:daniela.efrim@gmail.com mailto:adinpetcu@yahoo.com mailto:anghel_lucretia@yahoo.com mailto:cristinap@gmb.ro https://doi.org/10.18662/brain/13.1Sup1/316 Burnout Syndrome in Personnel of an Infectious Diseases Hospital, One Year … Elena DUMEA, et al. 231 1. Main text 1.1. Introduction Epidemics of infectious diseases: 1918 influenza pandemic (Spanish flu) (Luca et al., 2021), Zika, Ebola and now Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has marked the history of humanity (Cambrea et al., 2014). Due to globalization, an infectious disease can be spread in hours from one continent to another. The World Health Organization (WHO) declared the COVID-19 pandemic a global public health emergency, in March 2020. A high rate of infection and mortality for SARS-CoV-2 infection has a tremendous impact on the healthcare system (Baroiu et al., 2021). The pandemic resulted in high levels of anxiety and panic worldwide (Puscasu et al., 2019). Healthcare workers (HCWs) are important players in the COVID-19 pandemic management and are inescapably in the first line to be exposed to the SARS CoV-2 virus or other infectious diseases. They were at risk of losing their lives, while caring for their duty for COVID-19 patients, in the setting of significantly decreased social support (Luca et al., 2020). In this pandemic, the staff has been subjected to huge stress through fear of illness, to train the infection of their families and to work under difficult conditions. It was an enormous emotional burden for healthcare providers who were on the first line against this disease, like our hospital. Sometimes, medical staff has become sick with COVID treating infected patients. In our hospital, more than 30% of personnel contracted the virus in one year with mild and medium forms COVID-19 and no death (Baroiu et al. 2018; Lupu et al., 2017; Padureanu et al., 2020). High mortality and uncontrollable character of this disease, with relatively raised rates of infection and mortality among staff, can provoke stress and anxiety in HCWs. Factors such as heavy workload, difficult working wearing special protective equipment, social stigmatization on the staff may aggravate this emotional change. Recent survey-noted worries of HCWs on being placed in the situation to take care of critically ill patients with comorbidities, sometimes exceeding the specialty competencies, with limited information about the diseases, at less at the beginning, limited therapeutically options, with limited access to up-to-date medical information. Many strategically workers had problems at home, where it was necessary to find a solution to take care of their children, as the schools and kindergartens have closed down. The problem increases for HCWs with single parent family or when both parents are essential staff (Shanafelt et al., BRAIN. Broad Research in April, 2022 Artificial Intelligence and Neuroscience Volume 13, Issue 1Sup1 232 2020; Valcea et al., 2016). Many healthcare providers isolate themselves within their home, due to risk of transmitting the disease to their families. Therefore, this pandemic has substantial psychological impact on HCWs. To determine the effects on sleep quality of social support, a Chinese researcher (Xiao et al., 2020), studied the structural equation model (SEM) on medical staff working with patients COVID-19. They found that respondents to the questionnaire had high levels of anxiety, stress and relatively low sleep quality. Burnout, described by Maslach & Jackson (1981), represent a state of emotional, psychological and physical stress among professionals, in response to exposure to occupational stress as long-term involvement in work situations that are emotionally requiring. It includes multidimensional factors: feelings of emotional exhaustion (depletion of emotional resources), depersonalization (developing cynical attitudes about patients) and reduced professional accomplishment (a sense of negative evaluation of oneself) (Maslach, 1998). Physician’s burnout has serious consequences, not only to the individual physician, but also to patients and to employees’ institutions (Grigoras & Ciubara, 2021). Apart from being harmful for personal, burnout can lead to suboptimal care (Shanafelt et al., 2015). 1.2. Aim The study explored the level of burnout among HCWs taking care of patients with COVID-19 pandemic and evaluated factors associated with the development of this psychological sequel. 1.3. Material and Method Maslach Burnout Inventory (MBI) is an internationally recognized, self-report, validated questionnaire for evaluating the severity of occupational burnout (Maslach & Jackson, 1981). There are three dimensions assessed: emotional exhaustion, personal accomplishment and depersonalization. There are 22 items in this questionnaire and each is answered on a Likert scale five-point. We performed a cross-sectional prospective survey, to evaluate the burnout’s prevalence on employees, in an infectious diseases hospital dealing with COVID-19 patients. It`s a teaching mono specialty hospital, with an intensive care unit department, situated in the largest city in the eastern part of the country, since the beginning of the pandemic in the battle against COVID-19 (in March 2020 was the COVID-19 first case in our hospital). The study took place after 12 months from the beginning of the outbreak. Burnout Syndrome in Personnel of an Infectious Diseases Hospital, One Year … Elena DUMEA, et al. 233 Hospital Ethics Committee granted approval for survey. Answering the survey instrument was recognized as implied consent, so written informed consent was not required. Participation was voluntary and anonymous. Researchers have analyzed only non personal data; no personal identification data was required. The study used a simple recruitment method. An invitation through professional networks to participate in the study was made. The hospital psychologists’ and head nurses invited the entire staff to complete the questionnaire explaining the purpose and principal investigator name of the study. They instructed participants to respond to items in the tool related to COVID-19 outbreak. Several questionnaires were administered to the employees. The investigators didn’t know the identity of the respondents. All questionnaires were interpreted and analyzed by the same psychologist. A questionnaire-based survey using adapted Maslach Burnout Inventory (MBI) was carried out for all personnel. We invited all hospital employees: medical staff (doctors, nurses, and healthcare assistants’, i.e) and administrative staff. The questionnaire consists of 29 questions. The questionnaire comprises general questions and specific questions in the three areas of burnout. General questions were age, gender, job profile and working department. The first domain, emotional exhaustion, based on personal burnout, had 9 items. The second domain, which evaluated depersonalization, had 6 items. The third domain evaluated the reduced sense of personnel accomplishment and consists in 10 items. Burnout is calculated by scores of each of the MBI subscales, with a high score corresponding to a high level of burnout. All specific items had five response categories each, on a five-point Likert scale (very rarely, rarely, occasionally, frequently, very frequently). Each subscale score is calculated by combining all items scores in that subscale, with the notification that some specific domain items are reversely scored (Maslach et al., 1986; Maslach & Jackson, 1984). Scores range between 9 to 46 for emotional exhaustion, 10 to 50 for personal accomplishment and range from 6 to 30 for depersonalization subscale. The sum of the points for each domain is calculated, obtaining a score, which is related to the values below. The standard threshold values were used to define levels in each dimension as low, moderate and high. The sum of those three domains provides the final burnout score: 25-50 is low level, 51-75 medium level and values > 76 high level burnout (Table 1). BRAIN. Broad Research in April, 2022 Artificial Intelligence and Neuroscience Volume 13, Issue 1Sup1 234 Table 1 The cut-off values for each domain of burnout Risk level LOW MEDIUM HIGH Domain Emotional exhaustion 9-18 19-27 28-45 Depersonalization 6-12 13-18 19-30 Personal accomplishment 10-20 21-30 31-50 BURNOUT SCALE 25-50 51-75 76-125 Source: Authors’ own conception 1.4. Statistical Analysis Data obtained from the questionnaire were analyzed using IBM SPSS Statistics 23.0. Variables measured on nominal scale were represented using proportions (%). The responses (n, %) were determined separately for each domain. Each domain mean scores were compared using ANOVA test between domain and job profile or group age. Kolmogorov-Smirnov Test was used for normality. Categorical variables were analyzed using chi-square test for association. A p value of <0.05 was taken to indicate statistical significance. 1.5. Results We received responses from 186 HCWs (the overall response rate was 65.28%). Most of them, 179 (96.24%), were women, as in many hospitals in our country. Participants` demographic characteristics are shown in Table 2. Table 2. Demographic characteristics of responders Criteria Number % Age 21-30 years 19 10.22 31-40 years 39 20.97 41-50 years 76 40.86 51-60 years 50 26.88 >61years 2 1.08 Job profile Doctor 26 13.98 Nurse 88 47.31 Healthcare assistant 52 27.96 Administration staff 20 10.75 Burnout Syndrome in Personnel of an Infectious Diseases Hospital, One Year … Elena DUMEA, et al. 235 Sex Male 7 3.76 Female 179 96.24 Source: Authors’ own conception To maintain the anonymity of the participants, the age was completed as decades of age. Regarding emotional exhaustion, the responses on 9 items are represented in Table 3. The mean score for all respondents was 23.26+8.45, corresponding to a medium level. Table 3. Personal burnout and distribution of responses Questions Very rarely Rarely Occasi onally Frequ ently Very frequen tly Mean score I feel emotionally drained 50 23 62 42 9 2.66+1. 22 Toward the end of the working hours I feel like a squeezed lemon 32 17 57 57 23 3.11+1. 25 I feel tired when I wake up in the morning and have to go to work 35 22 67 53 9 2.88+1. 15 I feel full of energy and enthusiasm* 25 49 64 34 14 2.80+1. 11 I have a state of depression and apathy 68 39 59 18 2 2.17+1. 06 I feel indifferent to things I have shown interest in before 60 43 54 25 3 2.28+1. 10 I become tense and upset when I think about my current concerns 63 42 51 23 7 2.29+1. 16 I want to isolate myself from everyone and rest 57 31 59 23 16 2.51+1. 27 I feel at the limit of my powers 58 28 57 28 16 2.53+1. 29 Average score 23.26+8.45 * pointed reverse Source: Authors’ own conception BRAIN. Broad Research in April, 2022 Artificial Intelligence and Neuroscience Volume 13, Issue 1Sup1 236 Personal burnout rates for respondents were similar for all levels: low 32.22%, medium 34.40% and high 33.33%. The prevalence of emotional exhaustion among doctors (reported to mean value) is much higher than for other personnel categories, probably because they were directly involved, with many challenges, in attending COVID-19 patients, with limited information about this disease, with no internationally treatment recommendations at the beginning and many changes in national protocols. Nurses, healthcare assistant and administrative staff have had similar mean values. (Table 4) Table 4. Personal burnout and distribution by job type Emotional exhaustion level Scale Job profile LOW n, % MEDIUM n, % HIGH n, % AVERAGE RANGE Doctor 6, 23.07% 6, 23.07% 14, 56% 26.07+8.85 Nurse 29, 32.95% 31, 35.22% 28, 32.55% 22.95+8.30 Healthcare assistant 18, 34.61% 21, 40.38% 13, 25% 22.13+8.33 Administration staff 7, 35% 6, 30% 7, 35% 22.13+8.33 % 32.22 34.40 33.33 23.26+8.45 Source: Authors’ own conception There is no significant association between personal burnout scale and job profile χ 2 calc=7.453, df=6, p=0.281>α=0.05. Table 5. Personal burnout and distribution by age groups Emotional exhaustion level Scale Age group LOW MEDIUM HIGH AVERAGE RANGE 21-30 years 5 9 5 22.84+5.94 31-40 years 15 11 13 23.33+8.63 41-50 years 25 26 25 22.71+8.33 51-60 years 14 17 19 24.4+9.31 >61years 1 1 0 19+9.89 Number 60 64 62 23.26+8.45 Source: Authors’ own conception In comparison between age categories, respondents aged between 51-60 years demonstrated higher mean score for personal burnout and those over 65 (in limited number) lower score (Table 5) with no significant Burnout Syndrome in Personnel of an Infectious Diseases Hospital, One Year … Elena DUMEA, et al. 237 association between emotional exhaustion scale and age group: χ 2 calc=2.938, df =6, p=0.817>α=0.05. Regarding depersonalization, the responses on 6 items are represented in Table 6. The mean score for all respondents was 11.11+4.05, corresponding to a low level. Table 6: Domain 2: Depersonalization and distribution of responses Questions Very rarely Rarely Occasi onally Frequ ently Very frequen tly Mean score I communicate with some colleagues how I would communicate with objects 83 47 49 7 0 1.89+0. 93 Lately I have become tougher in my relationships with colleagues or subordinates 93 34 43 16 0 1.90+1. 03 The people I work with are uninteresting and boring 107 40 32 6 1 1.67+0. 90 Sometimes I don't care what happens to my colleagues or subordinates 102 42 30 10 2 1.75+0. 98 I communicate easily with people regardless of their social status and character* 58 87 34 7 0 1.94+0. 80 My subordinates and colleagues put the burden of their problems and duties on my shoulders 94 31 44 11 6 1.94+1. 12 Average score 11.11+4.05 * pointed reverse Source: Authors’ own conception Regarding depersonalization 73.11% had low level, 24.73% had medium level and a small proportion 7.5% high level. Doctors and nurses seem to be more affected than others (mean values represented in Table 7) but there is no significant association between depersonalization scale and job profile (χ 2 calc=4.27, df=6, p=0.64>α=0.05). BRAIN. Broad Research in April, 2022 Artificial Intelligence and Neuroscience Volume 13, Issue 1Sup1 238 Table 7. Depersonalization level and distribution by job type Depersonalization Scale Job profile LOW MEDIUM HIGH AVERAGE RANGE Doctor 17 8 1 11.19+3.40 Nurse 67 21 10 11.53+4.43 Healthcare assistant 37 13 2 10.46+3.87 Administration staff 15 4 1 10.75+3.66 Average range 136 46 14 11.11+4.05 Source: Authors’ own conception In comparison between the age categories (Table 8) respondents aged 21-30 years and those over 65 had a low mean value score, but without a significant association between depersonalization scale and age: χ 2 calc=5.013, df =6, p=0.542 >α=0.05. Table 8. Depersonalization scale and distribution by the age group Depersonalization level Scale Age group LOW MEDIUM HIGH AVERAGE RANGE 21-30 years 15 4 0 10.10+2.90 31-40 years 27 7 5 11.25+4.78 41-50 years 51 20 5 11.15+4.12 51-60 years 31 15 4 11.34+3.86 >61 years 2 0 0 9.5+2.12 Number 60 64 62 11.11+4.05 Source: Authors’ own conception Regarding a reduced sense of personal accomplishment, the responses on the 10 items are represented in Table 9. The mean score for all respondents was 22.62+6.83, corresponding to a medium level. Table 9 Domain 3: reduced sense of personal accomplishment and distribution of responses Questions Very rarely Rarely Occasi onally Frequ ently Very frequen tly Mean score I have periods when I feel overwhelmed by the situation 44 37 61 36 8 2.60+1.16 Burnout Syndrome in Personnel of an Infectious Diseases Hospital, One Year … Elena DUMEA, et al. 239 Nothing happens the way I want it to 52 51 68 15 0 2.24+0.95 I can find the right solution in conflict situations* 34 74 67 9 1 2.45+0.78 I can positively influence the productivity of the work of my subordinates and colleagues*. 27 70 70 10 9 2.48+0.97 I have many plans for the future and I believe in their realization* 53 70 47 13 3 2.15+0.97 I have professional disappointments 66 42 58 17 3 2.18+1.07 I can easily create a kind and cooperative atmosphere in a group* 42 78 48 14 4 2.24+0.96 I manage to do many things* 44 77 53 8 4 2.19+0.92 I think I will be able to achieve many things in life* 48 84 42 9 3 2.11+0.90 I feel like one who went bankrupt 85 34 39 19 9 2.10+1.22 Average score 22.62+6.83 * pointed reverse Source: Authors’ own conception For the third domain, reduced sense of personal accomplishment, 37.09% of personnel had low rates, 50% had medium level and a small proportion 12.9% high level. Doctors and administrative staff had higher mean values (represented in Table 10), but no statistically significant association between reduced sense of personal scale and job profile χ 2 calc=2.555, df =6, p=0.862 > α=0.05. Table 10 Reduced sense of personal accomplishment and distribution by job type The reduced sense of personal accomplishment level Scale Job profile LOW n MEDIUM n HIGH n AVERAGE RANGE Doctor 9 12 5 23.96+6.87 Nurse 33 44 11 22.27+6.61 Healthcare assistant 20 25 7 22+7.19 Administration staff 7 12 1 23.05+5.75 Number 69 93 24 22.62+6.83 Source: Authors’ own conception BRAIN. Broad Research in April, 2022 Artificial Intelligence and Neuroscience Volume 13, Issue 1Sup1 240 In comparison between age categories, respondents between 51-60 years demonstrated higher mean values score for reduced sense of personal accomplishment (as in personal burnout) an those over 65 (in limited number) lower scores (Table 11) with no statistically significance χ 2 calc=3.664, df =6, p=0.722 >α=0.05. Table 11. Reduced sense of personal accomplishment and distribution by age group The reduced sense of personal accomplishment level Scale Age group LOW MEDIUM HIGH AVERAGE RANGE 21-30 years 8 9 2 22.26+6.49 31-40 years 15 21 3 22+6.32 41-50 years 30 36 10 22.28+7.00 51-60 years 14 27 9 23.52+6.81 > 61years 2 0 0 18.5+2.12 Number 69 93 24 22.62+6.83 Source: Authors’ own conception Summarizing the hospital personnel data, the prevalence of low level burnout is 38.17% of the participating employees, 46.77% had medium level of burnout and 15.05% high level of burnout. Doctors and administrative staff had higher mean values of burnout score (seems to be more affected than the others), but no significantly statistical association between total burnout scale and job profile χ 2 calc=5.926, df=6, p=432> α=0.05 (Table 12). Table 12. Burnout level and distribution by job type Burnout scale Scale Job profile LOW n MEDIUM n HIGH n AVERAGE RANGE Doctor 8 14 4 61.23+17.14 Nurse 36 36 16 56.98+18.12 Healthcare assistant 22 24 6 54.65+17.78 Administration staff 5 13 2 58.57+15.67 Number 71 87 28 57.01+17.62 Source: Authors’ own conception Burnout Syndrome in Personnel of an Infectious Diseases Hospital, One Year … Elena DUMEA, et al. 241 For each category, the scores from each domain are normally distributed (p>α=0.05 Kolmogorov–Smirnov Test for Normality) as in Table 13. There are no significant differences between mean score values for each domain corresponding to job category (p=0.374>α=0.05) Table 13 ANOVA test for scores of each domain depending on job profile. Source: Authors’ own conception Table 14. Burnout level and distribution by age groups The reduced sense of personal accomplishment level Scale Age group LOW MEDIUM HIGH AVERAGE RANGE 21-30 years 7 11 1 55.21+13.41 31-40 years 16 16 7 56.58+18.23 41-50 years 31 34 11 56.28+18.08 51-60 years 16 25 9 59.52+18.23 >61years 1 1 0 47+14.14 Number 71 87 28 57.01+17.62 Source: Authors’ own conception Even though the age 51-60 years group had higher mean values for total score burnout (Table 14) there is no significant association between burnout level scale and age group χ 2 calc=3.397, df=6, p=0.758 > α=0.05. In the case of age group for each burnout domain, the scores are normally distributed (p>α=0.05 Kolmogorov–Smirnov Test for Normality). There are no significant differences between mean score values for each domain corresponding to age group (p=0.721>α=0.05 Table 15). BRAIN. Broad Research in April, 2022 Artificial Intelligence and Neuroscience Volume 13, Issue 1Sup1 242 Table 15 ANOVA test for scores of each domain depending the on the age group. ANOVA F Sig. Score Emotional Exhaustion .419 .739 Score Depersonalization .452 .716 Score Personal Accomplishment .478 .698 Total Score .445 .721 Source: Authors’ own conception 2. Discussions This study reveals that 15.38% of doctors, 18.18% of nurses, 11.53% healthcare assistant and 10% of administrative staff have met the criteria for high level of burnout. A percentage of 61.82% of personnel have medium and high level, being a warning signal for psychological reaction of HCWs in this pandemic (Kowalska et al., 2021; Man et al., 2020, Silistraru et al., 2021). Older people, with age between 51 and 60 have higher scores of burnout, probably linked to higher risk of being ill with severe forms of COVID-19, less adaptation to working conditions with special equipment (Anghel et al., 2011; Stanculescu, 2021;). However, those with age over 65 demonstrated lower prevalence of personal and work related burnout, maybe because they were trained in combat other infectious diseases like HIV/AIDS (Cambrea et al., 2019), viral hepatitis (Halichidis et al. 2013), flu, West Nile, Clostridium difficile (Halichidis et al., 2015), i.e. This study has some limits. It was held in a single monospecialty hospital with departments providing care or services to patients with medium and severe forms COVID-19. This can explain high percentage of burnout and no statistically significant differences between personal categories, all of them are tired and stressed. The results of this study, by the particular nature of the hospital and the disease COVID-19, cannot be generalized for other regions or countries. We didn't determine the level of burnout before the pandemic, so we cannot match the changes in prevalence. Further studies to identify the burnout and findings solutions for first line HCWs are needed to prevent burnout and reduce it. 3. Conclusions In this study, there are no significant differences between age and job category in personal dealing with COVID 19 patients. The explanation is that all of them were exposed at the same conditions. Leadership, clear Burnout Syndrome in Personnel of an Infectious Diseases Hospital, One Year … Elena DUMEA, et al. 243 communication regarding health care directives, management of diseases and guidelines, will reduce HCWs burnout. Health care professionals must be safe and healthy. 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