Hrev_master Healthcare in Low-resource Settings 2024; volume 12:xxx Healthcare in Low-resource Settings 2024; volume 12:11815 Perception of burnout syndrome among nurses providing nursing care in the emergency room at a hospital in Riau Province Raja Fitrina Lastari, Gusvita Sari, Siska Mayang Sari, Susi Erianti, Rajunitrigo Rajunitrigo Bachelor of Nursing Program, Faculty of Health, Universitas Hang Tuah Pekanbaru, Indonesia Abstract The demands to nurses in the Emergency Room (ER) can lead to stress, potentially causing Burnout Syndrome. This may diminish the effectiveness of the nursing care provided to patients. This study aimed to explore the experience of Burnout Syndrome among nurs- es in the ER using a descriptive qualitative research design. Ten nurses from the ER participated in the study. All participants provid- ed consistent answers, leading researchers to conclude data satura- tion through purposive sampling. In-depth interviews with a semi- structured format were conducted for data collection, and the Collaizi technique was employed for analysis. Findings revealed that nurses exhibited signs of Burnout Syndrome, such as physical, emotional, and mental exhaustion, while providing patient care, attributing this to the substantial workload. Introduction A hospital serves as a comprehensive healthcare facility, offer- ing a full range of individualized health services, including inpa- tient, outpatient, and emergency care.1,2 The emergency depart- ment serves as the primary point of entry for patients seeking treatment in both urgent and non-urgent medical situations.3-5 Within a hospital, nurses play an indispensable role as they are often the first and longest point of contact with patients.6 Their responsibilities encompass the entire spectrum of nursing care, including the assessment process, nursing diagnosis, intervention, implementation, and the evaluation of care outcomes.7 It is worth noting that nursing is among the healthcare sectors with the high- est prevalence of occupational stress.8,9 Improper management of this workload can lead to workplace stress,10-12 and prolonged stress can ultimately result in feelings of ennui or the development of Burnout Syndrome.13,14 Burnout Syndrome can be defined as a condition characterized by an overwhelming sense of exhaustion, encompassing physical, mental, and emotional fatigue, leading to significant personal distress and a decline in individual achieve- ments.15,16 One of the indicators of Burnout Syndrome in nurses is reflected in their behavior, including responding negatively to patients, experiencing delays in tasks, reacting irritably to simple questions from colleagues or patients, expressing feelings of quick fatigue and dizziness, and, at its worst, displaying apathy towards their work and surroundings.17 This syndrome is typically delin- eated by three key dimensions: firstly, emotional exhaustion; sec- ondly, depersonalization; and thirdly, a decline in personal accom- plishment.18 The impact of Burnout Syndrome on nursing care can be attributed to several factors. First, there is a delay in the data collection process, resulting in extended periods for acquiring nec- essary information. Second, in the diagnosis phase, nurses often experience decreased concentration, leading to a failure in accu- rately determining the patient’s diagnosis. Nurses may mistakenly believe that the diagnosis provided by the doctor is sufficient. Third, when it comes to nursing intervention, it is uncommon to find nurses who openly acknowledge their difficulties in deter- mining appropriate interventions. Fourth, the emergence of Burnout Syndrome can lead to various adverse effects, subse- quently diminishing job performance and job satisfaction. Lastly, during the evaluation phase, nurses may encounter challenges. The nursing evaluation is a mandatory task to assess the effective- ness of the provided care for each patient.19 According to the World Health Organization (WHO), Burnout Syndrome has been included in the 11th revision of the Correspondence: Raja Fitrina Lastari, Bachelor of Nursing Program, Faculty of Health, Universitas Hang Tuah Pekanbaru, Indonesia. E-mail: rajafitrinalestari@htp.ac.id Key words: burnout syndrome, emergency room, nurse, nursing care. Contributions: RFL, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; GS, conceptualization, methodology, formal analysis, vali- dation, and writing – original draft, review & editing; SMS, methodolo- gy, visualization, writing – review and editing; SE, resources, investiga- tion, and writing –review and editing; RR, formal analysis, validation, writing – review and editing. Conflict of interest: the authors declare no potential conflict of interest. Funding: none. Ethics approval and consent to participate: the research has received eth- ical approval from the Health Research Ethics Commission, Faculty of Nursing, Universitas Hang Tuah Pekanbaru, based on ethical certificate 068/KEPK/UHTP/V/2023. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. Consent for publication: written informed consent was obtained for anonymized information to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 15 September 2023. Accepted: 1 February 2024. Early access: 7 March 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11818 doi:10.4081/hls.2024.11815 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:11815] [page 421] Non -co mmerc ial us e o nly International Classification of Diseases (ICD-11) as a manifesta- tion of work-related fatigue, without being classified as a medical condition. The prevalence of Burnout Syndrome among nurses has been extensively researched internationally. In Spain, for instance, approximately 80% of nurses exhibit a high level of Burnout Syndrome. In Iran, a study reported that 72% of nurses experi- enced Burnout Syndrome to varying degrees, while in Greece, around 44% of nurses expressed dissatisfaction with their work. The Association for Occupational Health highlights that stress and Burnout Syndrome among nurses are among the top 40 causes of stress among workers.20 In one hospital in the Tulungungung area, Emergency Room (ER) nurses were found to experience severe Burnout Syndrome, with 58% exhibiting symptoms such as easy fatigue, tiredness, physical discomfort upon completing tasks, difficulty in establish- ing a relaxed atmosphere with patients, and a lack of enthusiasm when interacting with patients. Additionally, the Ministry of Health data from 2019 indicates that a significant proportion (74%) of nurses in the Bontang ER experienced heavy workloads, which subsequently led to reduced levels of patient satisfaction.21 Based on previous research, it was found that nurses experienced a moderate workload with a percentage of 93.3% and a high catego- ry of 6.7%, characterized by nurses complaining of fatigue because a lot of work had to be done quickly and right.10 Burnout Syndrome in the workplace is a situation that cannot be avoided. Nursing work has several characteristics that can create high and stressful work demands.22 These characteristics include a tight work schedule and having to be ready to work at any time. And there are even some service settings that employ nurses with excessive workloads. Sometimes in one shift, one nurse must serve as many as 8-10 patients.22 The nurse’s role was to prioritize triage for incoming patients, which sometimes led to feeling over- whelmed. Typically, in the ER, nursing care is administered fol- lowing triage, unless there is a lower patient volume and an ade- quate nursing staff to permit direct intervention. From the various phenomena and theories that have been explained, this study aimed to analyze Burnout Syndrome in nurses in carrying out nursing care in the ER Materials and Methods Research design This study was conducted through a qualitative technique, within the framework of a descriptive research approach. Study setting and participants In this study, participants were chosen through a purposive sampling method, adhering to specific inclusion criteria: individu- als working as nurses in the ER, with a minimum of one year of experience, aged 25 years or older, and a willingness to participate. The study included a total of 10 participants, comprising 8 execu- tive nurses as the primary subjects and 2 nurse team leaders in a supporting role. Research findings In this research, the researcher explains the aims and objec- tives of the research, the letter of availability to become a partici- pant, the rights obtained when becoming a participant, and the identity of the participant is disguised in the results of the interview data obtained (credibility). Researchers can obtain consistent research results or data, namely by carrying out a structured data analysis and trying to interpret the results of the study correctly so that readers can make the same conclusions using raw data, per- spectives and analysis documents of the study being carried out and In this research, confirmability is obtained by processing the interview results and showing them to the participants with the aim that the interview results have been clarified and confirmed by the participants who have been interviewed. Data collection This descriptive qualitative study pertains to nurses working in the ER of Provincial Hospital in Riau. These variables encompass characteristics such as age, gender, marital status, highest educa- tional attainment, employment status, and years of work experi- ence. Data collection in this qualitative research focuses on the type of data and procedures that will be carried out to collect data. The type of data collected by qualitative researchers was collected by observation and interviews. The data collection process in qual- itative research was carried out simultaneously with the data analy- sis process. The data collection method will be carried out in three stages, namely: orientation stage, implementation stage, and termi- nation stage. Data analysis Data collection was accomplished by conducting comprehen- sive interviews using a semi-structured format, followed by an analysis employing the Collaizi technique. In this process, the researcher assumes the role of a data collection instrument, atten- tively listening to participants’ descriptions during interviews. Subsequently, these descriptions were meticulously examined, transcribed, and subjected to repeated review for analysis. Ethical clearance This research has obtained ethical approval from the Health Research Ethics Commission (KEPK) of Hang Tuah University Pekanbaru under the reference number 068/KEPK/UHTP/V/2023. Results This research effectively identified five primary themes, which encompass nurses’ viewpoints regarding Burnout Syndrome, their encounters with this syndrome, the underlying factors contributing to burnout, the impact of Burnout Syndrome on nurses, and strate- gies for its management. The viewpoints of nurses regarding Burnout Syndrome The definition of Burnout Syndrome can be categorized into two distinct categories: physical exhaustion and psychological exhaustion. Participants in the study provided insights into the def- inition of falling under physical exhaustion, which encompasses feelings of fatigue, weariness, and a decline in work quality. On the other hand, the definition falling into the category of psychological exhaustion involves feelings of monotony, overwhelm, boredom, anxiety, and work-related stress. “It can also be categorized as physical or mental; if it’s physi- cal, it means experiencing fatigue. When we are excessively tired, our immune system weakens, especially when our physical health is compromised. This can lead to illnesses, and our work perform- ance in caring for patients may also decline” (P6) Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 422] Healthcare in Low-resource Settings 2024;12:11815] Non -co mmerc ial us e o nly “This is when we experience stress while working, like that... it means that during our work, we may not handle things smoothly, perhaps we experience anxiety, and we keep performing actions like that... maybe due to the workload or long-term service, we start to feel a sense of monotony, right?” (P2). The firsthand encounters of nurses with Burnout Syndrome The indications and manifestations of Burnout Syndrome encompass three distinct categories, specifically physical fatigue, emotional depletion, and mental exhaustion. Within the physical fatigue category, individuals who are experiencing signs and symptoms of burnout have reported sensations such as lighthead- edness, drowsiness, bodily aches, and a sense of weakness. “I often find myself unable to concentrate due to a combination of fatigue and sleepiness. There are moments when I acknowledge that my efficiency is compromised, but this typically occurs inter- mittently” (P3). Additionally, individuals grappling with Burnout Syndrome have encountered various signs and symptoms in the emotional exhaustion category, including feelings of boredom, confusion, a sense of being burdened, difficulty focusing, weariness, strained interpersonal relationships with colleagues, heightened emotional responses, a negative mood, and occasional panic. “Fatigue often intensifies our emotional reactions, and it can lead to discomfort even in our interactions with friends. For exam- ple, when we are swamped and fatigued while our friends are still engrossed in their smartphones. It’s likely because of our exhaus- tion, which affects our mood and mental state” (P2). “I’m finding it difficult to muster the energy, and I’m losing interest in my job or even coming to work. My mindset is shifting towards ‘it doesn’t matter, I’m just too exhausted.’ Essentially, I’ve become disinterested in my work, and my enthusiasm for socializ- ing has waned as well, and that seems acceptable to me” (P4). Factors contributing to the development of Burnout Syndrome The factors leading to Burnout Syndrome among participants encompass both internal and external elements. Participants dis- closed internal factors contributing to Burnout Syndrome, includ- ing aspects such as age and tenure in their roles. “Prolonged working hours could also contribute, as well as the repetitiveness of daily tasks. Age-related health issues might also play a role; the longer you work here, the more you encounter indi- viduals who have been here for two years, and their routines remain largely unchanged” (P4) “The potential causative factor, perhaps, stems from the demanding nature of the emergency room where patients keep coming in. It could be attributed to factors originating from exter- nal sources, like this continuous influx of patient complaints, which can lead to stress. It’s an unending cycle; one issue hasn’t been resolved, and another one arises, which leaves me feeling fatigued. It’s more about the sheer volume of patients from the external environment, well, the workload” (P2). The impact of Burnout Syndrome on nurses The impact of Burnout Syndrome on participants can be cate- gorized into its effects on the individual and its effects on the deliv- ery of nursing care. Participants highlighted the influence of Burnout Syndrome on individuals, including its impact on them- selves and on others, such as family members and patients. “For instance, when there is a persistent shortage of healthcare staff or an overwhelming number of patients, it can significantly affect our mood. We might end up feeling similar to the patients, or at the very least, we become so fatigued that we lose the desire to engage with our colleagues at work” (P4). “Regarding my family, well, if I’m extremely tired from work, there are times when I don’t engage in much conversation when I get home. For instance, I may prefer to rest first and request some time to recharge” (P6). Furthermore, participants also conveyed that the impact of Burnout Syndrome on the execution of nursing care could be observed in two distinct categories: its effect on the quality of nurs- ing care and its influence on the various stages involved in provid- ing nursing care. “No, we find ourselves not fully engaged, and as a result, our actions may not be as effective or efficient. This happens because we become disinterested, and it affects our ability to fully attend to the needs of the patients. Serving patients becomes somewhat compromised” (P2) “When we are under stress, our focus can waver. For instance, when we are entering patient data into the computer’s electronic health records (IMR), we may inadvertently mix up details. For example, if a patient initially complained of stomach pain during the initial assessment, we might accidentally record it as lower back pain. So, it becomes a state of confusion, necessitating fol- low-up questions to the patient for clarification. This primarily impacts the assessment and evaluation process within the SOAP” (P2) Management of Burnout Syndrome The management of Burnout Syndrome among participants involves three main components: individual efforts, organizational initiatives, and hospital policies. Participants highlighted that indi- vidual effort management, which includes practicing self-care, can effectively mitigate the occurrence of Burnout Syndrome. “How to address it, well, it’s like taking a breather first, finding alternative activities, you know, not just constantly scrolling through your phone or looking at your phone” (P2) “Yes, when we return home, prioritizing sleep, relaxation, and ensuring we eat and hydrate. Regardless of the challenges we face with our patients, taking care of ourselves by maintaining our nourishment and well-being is essential” (P4) Discussion Participants provided various definitions of Burnout Syndrome, including feeling exhausted, fatigued, reduced work quality, boredom, a sense of being burdened, disinterest, panic, and workplace stress. Among these descriptions, sensations of exhaus- tion, fatigue, and boredom were the most prominent in partici- pants’ responses. The statements offered by the participants align with the definition of Burnout Syndrome. According to her, Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions Healthcare in Low-resource Settings 2024;12:11815] [page 423] Non -co mmerc ial us e o nly Burnout Syndrome encompasses both physical and mental fatigue, leading to the development of a negative self-concept, diminished concentration, and negative work-related behaviors. Additionally, Burnout Syndrome can be characterized as a form of work-related fatigue or a psychological condition resulting from extreme fatigue, whether it is physical, mental, or emotional, leading to per- sonal disturbance and reduced personal achievement.15 Nurses’ encounters with Burnout Syndrome are identifiable through the signs and symptoms they manifest. Burnout Syndrome exhibits itself through physical, emotional, and mental exhaustion. In the research findings, many participants shared their experi- ences regarding the signs and symptoms of Burnout Syndrome encountered while working in the ER. Interestingly, during inter- views, one participant initially claimed to have never experienced Burnout Syndrome. However, as they were probed with questions about the signs and symptoms of Burnout Syndrome, participants came to recognize these indicators accurately. This suggests that nurses often go through Burnout Syndrome without realizing that these are indeed signs and symptoms of the condition. Burnout Syndrome entails physical, emotional, and mental exhaustion stemming from enduring emotionally taxing situations.19 Physical fatigue can manifest as headaches, insomnia, bodily pain, aches, gastrointestinal disturbances, and persistent weariness. Emotional exhaustion leads to negative emotions such as emptiness, ennui, fatigue, feelings of inadequacy, helplessness, diminished self- esteem, anxiety, disorientation, loss of values and hope, alterations in self-perception, difficulties in concentration, lowered tolerance, and heightened irritability. On the other hand, mental fatigue can be identified by avoidance behaviors, an inability to enjoy a relaxed life, engagement in high-risk activities, reduced personal performance, and a lack of organization.23 The factors contributing to the development of Burnout Syndrome can be categorized into internal factors, such as age and length of service, and external factors, including role ambiguity, workload, social support, organizational culture, recognition sup- port, and human resources-related aspects. The research findings indicate that a significant portion of Burnout Syndrome factors can be attributed to workload. Nurses working in the ER experience substantial workload due to the demanding nature of their work environment. This includes the need for heightened vigilance in providing comprehensive care to patients with various levels of emergency and diverse medical conditions. Additionally, nurses often encounter anxious patient families who frequently seek updates on their loved ones’ conditions. Furthermore, there is a constant demand for swift decision-making in emergency and crit- ical situations to prevent more severe complications. The workload encompasses a large patient volume, pressures from patients and their families, ongoing work tasks, and limited break opportunities, all of which contribute to workplace fatigue and stress.24,25 Previous research highlighted the relationship between nurses’ high workload and the development of Burnout Syndrome. To mit- igate this, hospitals should adjust their nurse staffing levels to match the workload they face. The multitude of responsibilities and job demands can potentially lead to stress for nurses. When this stress becomes chronic and the individual is unable to adapt, it can result in a collection of symptoms known as Burnout Syndrome.26 The repercussions of Burnout Syndrome on nurses can mani- fest in two forms: affecting the individual and influencing the exe- cution of nursing care. Burnout Syndrome can exert adverse effects on various levels, including the individual, organizational, and service levels. On an individual level, Burnout Syndrome can lead to a range of negative physical and mental health issues. At the organizational level, it can result in reduced organizational commitment and job satisfaction. Additionally, at the service level, research indicates that Burnout Syndrome can lead to a decline in the quality of care and services provided to patients.19 The impact of Burnout Syndrome on individuals includes symptoms such as confusion, sleep disturbances, mood swings, and a lack of focus while at work. This is consistent with previous findings, which involved interviews with several non-PNS (civil servants) employees. The study revealed that during their work duties, these employees frequently experienced headaches, drowsi- ness, dizziness, and reduced concentration, especially after serving in the emergency department. They also reported feelings of irri- tability, a negative mood, boredom, and a decline in self-confi- dence.27 The impact of Burnout Syndrome on other individuals includes emotional changes and reduced communication with col- leagues and family members. The influence of Burnout Syndrome experienced by individuals on others is primarily perceived by the recipients of the service and their families.19 Additionally, Burnout Syndrome can disrupt the various stages of nursing care imple- mentation, leading to errors in the assessment, implementation, and evaluation processes. Several nurses frequently expressed con- cerns about this issue, acknowledging that comprehensive assess- ments were infrequently conducted due to physical exhaustion, causing them to focus solely on data related to the patient’s com- plaints. The management of Burnout Syndrome can be approached through individual efforts, organizational initiatives, and hospital policies. Burnout Syndrome should not be regarded as normal because if left untreated, it can have severe consequences on indi- viduals, both physically and mentally. Consequently, there are sev- eral methods and expectations from participants for addressing the issue of Burnout Syndrome, encompassing self-management strategies and anticipations related to hospital policies. Self-care constitutes a means for individuals to attend to their physical, emo- tional, social, and spiritual needs. Dedication of time to fulfilling these basic requirements empowers nurses to reduce stress levels, relax their bodies and minds, and sustain a positive mood.28 Research indicates that support from supervisors plays a pivotal role in helping employees combat work-related dysfunction and the effects of stress on their performance and overall well-being. Such support involves displaying genuine concern for employ- ees.29 This aligns with findings which underscored the crucial role of managers employing a caring approach toward nurses in miti- gating Burnout Syndrome. Furthermore, managerial care for nurs- es constitutes a strategy that can cultivate a healthy work environ- ment, enhancing nurses’ self-efficacy and reducing emotional exhaustion and depersonalization among them.30 Conclusions In the context of nursing care within the ER, nurses exhibit vulnerability to experiencing Burnout Syndrome. They display signs and symptoms associated with Burnout Syndrome, yet often remain unaware of their condition. The presence of Burnout Syndrome among nurses significantly impacts the execution of nursing care, leading to errors in actions that, in turn, affect the quality of care delivered to patients. Nurses hold expectations for hospital policies designed to address Burnout Syndrome, with a focus on managerial support. This support encompasses measures such as increasing staffing levels, providing training opportunities, facilitating educational counseling activities that involve interac- tions with room heads and team leaders, conducting employee fol- Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 424] Healthcare in Low-resource Settings 2024;12:11815] Non -co mmerc ial us e o nly low-ups, and offering rewards such as performance incentives, rejuvenation programs, additional time off, and family gatherings. References 1. Kepmenkes RI. Standar Instalasi Gawat Darurat (IGD) Rumah Sakit. 2009. Available from: https://sardjito.co.id/wp- content/uploads/2015/12/kepmenkes-856-thn-2009-standar- IGD.pdf 2. Dewi YS, Wahyuni ED, Arifin H, et al. Health literacy of ICU patients’ family: a review. Malaysian J Med Heal Sci 2022;18:302-6. 3. Kepmenkes RI. Riset kesehatan dasar - Riskesdas 2013. 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Putra KR, Sutadi H, Setyowati S, Hariyati RTS. The impact of nurse manager caring behaviors and work environment on burnout syndrome among nurses. KONTAKT-Journal Nurs Soc Sci Relat to Heal Illn 2021;23. Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:11815] [page 425] Non -co mmerc ial us e o nly