Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s2):13464 Factors correlated with burnout syndrome among nursing staff Raja Fitrina Lastari,1,2 Mohamed Saifulaman,2 Reza Hariandi,1 Nicky Putri Fadilla,1 Adinda Nurul Aisyah1 1Hang Tuah Pekanbaru University, Pekanbaru, Indonesia; 2Lincoln University, Selangor, Malaysia Abstract Burnout syndrome is a psychological condition characterized by prolonged emotional, mental, and physical exhaustion, often resulting in decreased motivation, reduced professional efficacy, and impaired work performance. Among healthcare professionals, particularly nurses, burnout can significantly compromise the qua- lity and safety of patient care. This study aimed to find the rela- tionship between age and educational background and the preva- lence of burnout syndrome among nurses working in the inpatient ward in a hospital in Riau Province, Indonesia. A cross-sectional research design was employed, involving a total of 120 inpatient nurses selected through random sampling. Data collection was conducted using the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSS-MP), which measures three key dimensions of burnout: emotional exhaustion, deperso- nalization, and personal accomplishment. Statistical analysis was performed using the chi-square test to determine the association between demographic variables and burnout levels. The findings revealed a significant correlation between age and educational background with the occurrence of burnout syndrome. Specifically, nurses with higher educational attainment and those within certain age groups demonstrated increased vulnerability to emotional exhaustion and reduced personal accomplishment. These results underscore the importance of integrating individual demographic factors into the development of targeted strategies and institutional support systems to prevent and manage burnout. Enhancing such interventions is essential to safeguarding the well- being of nursing staff and ensuring the delivery of safe, effective, and sustainable patient care. Introduction The nursing profession involves high physical, emotional, and cognitive demands, including routine work, strict schedules, and responsibility for the health and safety of both patients and fellow staff members, often within team-based environments.1 These stressors contribute to the vulnerability of nurses to burnout syn- drome, a psychological condition characterized by emotional exhaustion, depersonalization, and a diminished sense of personal achievement.2,3 As central figures in healthcare systems, nurses are expected to maintain a high standard of patient care while sustai- ning their own physical, mental, and emotional well-being.4,5 Burnout syndrome is a growing concern in the healthcare field. Nurses, due to the intensity and continuity of their work, are particularly susceptible and must often adapt to prolonged profes- sional stress.6,7 A systematic review spanning 182 studies across 45 countries reported that the global prevalence of burnout among physicians reached 67.0%.8 In Indonesia, a 2017 study examining nurses at Cilandak Marine Hospital found that out of 138 respon- dents caring for patients under the National Health Coverage (BPJS), 59.4% experienced severe burnout, while 40.6% reported mild burnout.9 Meanwhile, a study in Sulawesi indicated that 15.7% of nurses in the region showed symptoms of burnout.10 Individuals experiencing burnout often report psychosomatic symptoms, such as fatigue and insomnia, emotional problems, including anxiety and depression, attitudinal changes, like apathy and suspicion, and behavioral issues, such as irritability and withdrawal.11,12 These symptoms underscore the critical impact of burnout on both personal health and professional functioning. The complexity of nurses’ roles continues to make the profession par- ticularly vulnerable.3 A study emphasized that burnout is now increasingly preva- lent in professional environments, with contributing factors that include not only job demands but also environmental conditions such as teamwork dynamics and shift patterns.13 Preliminary inter- views and observations with senior nurses in the inpatient unit of Correspondence: Raja Fitrina Lastari, Lincoln University, Selangor, Malaysia. E-mail: rajafitrinalestari@htp.ac.id Key words: age; burnout syndrome; education; hospital; nurses. Contributions: RFL, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; MS, methodology, visualization, writing – review & editing; RH, resources, supervision, and writing –review & editing; NPF, resources, supervision, and writing –review & editing; ANA, resources, supervi- sion, and writing –review & editing. Conflict of interest: the authors declare no potential conflict of interest. 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 461/KEPK/UHTP/VIII/2024. During the research, the researcher paid attention to the ethical principles of informed 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: 8 December 2024. Accepted: 23 July 2025. Early view: 4 September 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 12(s2):13464 doi:10.4081/hls.2025.13464 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 prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 110] [Healthcare in Low-resource Settings 2025;13(s2):13464] one hospital in Riau Province revealed frequent signs of burnout, including a lack of motivation, emotional fatigue, and persistent tiredness even after rest. These issues were frequently attributed to monotonous routines, complaints from patients and their families, interpersonal conflicts, and inadequate incentives. While environmental and occupational stressors have been widely studied, individual characteristics such as age and educatio- nal background have received less empirical attention in relation to burnout. Understanding the potential correlation between these factors and burnout is essential to developing targeted interven- tions for prevention and early management. Therefore, this study aims to find the relationship between age and educational back- ground with burnout syndrome among nursing staff. Materials and Methods Design, sample, and variables A cross-sectional observational study design was used. The data collected from December 9th, 2024, to January 10, 2025, in one of the Riau Province hospitals, specifically in the inpatient rooms, including Surgical, Medical, and Intensive Care Units. Respondents in this study were 120 nurses, selected using a total sampling. The variables included age, gender, marital status, edu- cation, length of service, and employment status, while the depen- dent variable was burnout syndrome. Instrument This study employed the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSS-MP) because of its strong validity and reliability. This questionnaire shows high internal consistency with Cronbach’s alpha values between 0.70 and 0.90. The MBI-HSS-MP has been translated into Indonesian and has been tested for validity and reliability. Based on the cor- rected item-total correlation results, 22 items were deemed valid because the calculated r value exceeded 0.444, and reliable since Cronbach’s alpha was 0.969 (>0.60). The questionnaire consists of three dimensions, namely physical and emotional exhaustion, depersonalization, and decreased personal accomplishment. The emotional exhaustion dimension describes feelings of fatigue, depleted energy, and prolonged feelings of emptiness. The deper- sonalization dimension relates to a cynical and withdrawn attitude towards others at work. Meanwhile, the decreased personal accom- plishment dimension describes feelings of helplessness and incom- petence at work. The MBI-HSS-MP comprises 22 statement items, and each item contains seven answer options, namely 0 (never), 1 (a few times a year), 2 (once a month or less), 3 (several times a month), 4 (once a week), 5 (several times a week), 6 (every day). The questionnaire includes positive and negative statement items. Data analysis Data analysis conducted in this study includes univariate and bivariate analysis. Univariate analysis was used to examine nurse burnout, which can be presented in the form of frequency distribu- tion tables and percentages of each variable, such as age, gender, marital status, level of education, length of work, and employment status. Bivariate analysis was conducted to test differences betwe- en variables using the chi-square test, with α=0.05. Ethical clearance This research has obtained ethical approval from the Health Research Ethics Commission (KEPK) of Hang Tuah University, Pekanbaru, under the reference number 461/KEPK/UHTP/ VIII/2024. Results Among the 120 respondents, the majority were aged 31-40 years, totaling 52 respondents (43.3%), followed by 41-50 years with 39 respondents (31.7%) and 21-30 years with 30 respondents (25%). Regarding gender, the majority of the respondents were female, totaling 105 respondents (87.5%). For marital status, 105 respondents (87.5%) were married. The majority of respondents (64.2%) held a bachelor’s degree in nursing. Most respondents had a work duration of over 10 years, totaling 68 respondents (56.7%). Regarding employment status, 49.2% were contract workers, fol- lowed by civil servants at 40.8%, and government contract emplo- yees at 10.0% (Table 1). The analysis of burnout syndrome among nursing staff was conducted across three core dimensions: emotional exhaustion, depersonalization, and personal accomplishment, based on several demographic characteristics (Table 2). In terms of age, the 31-40-year age group exhibited the highest frequency of low-level emotional exhaustion (35.0%), followed by the 41-50 group (28.3%) and the 21-30 group (20.8%). Notably, high levels of emotional exhaustion and depersonalization were minimal across all age categories, though a few respondents aged 21-30 reported high burnout in these dimensions. Across all age groups, however, there was a consistent and striking pattern of high burnout in the personal accomplishment dimension, with 25.0%, 43.3%, and 31.6% of respondents in the respective age groups reporting diminished personal efficacy. In terms of gender, female nurses experienced a markedly higher prevalence of burnout across all dimensions. Specifically, 74.2% of female respondents reported low emotional exhaustion, compared to 10.0% of males; however, females also accounted for Pathways of Change, Part II Table 1. Frequency distribution of respondent characteristics (n=120). Respondent characteristics n % Age 21-30 years old 30 25.0 31-40 years old 52 43.3 41-50 years old 38 31.7 Gender Male 15 12.5 Female 105 87.5 Marital status Married 105 87.5 Single 15 12.5 Education Diploma 43 35.8 Bachelor 77 64.2 Length of work 1-5 years 36 30.0 6-10 years 16 13.3 > 10 years 68 56.7 Employment status Civil servant 49 40.8 Government contract employee 12 10.0 Contract worker 59 49.2 [Healthcare in Low-resource Settings 2025;13(s2):13464] [page 111] nearly all medium and high levels of burnout in emotional exhau- stion and depersonalization. Additionally, 87.5% of females repor- ted high burnout in the personal accomplishment domain, highli- ghting a significant trend of emotional strain and reduced self-per- ception of effectiveness among female staff. Regarding marital status, married nurses showed higher levels of burnout compared to their unmarried counterparts. A total of 73.3% of married respondents experienced low emotional exhau- stion, with 14.2% reporting moderate levels. Both groups, regar- dless of marital status, exhibited high levels of burnout in the per- sonal accomplishment domain, further confirming the pervasive nature of this dimension. Educational background also appeared to influence burnout levels. Nurses with a bachelor’s degree were more likely to report medium or high emotional exhaustion and depersonalization compared to those with a diploma. While 50.8% of bachelor’s degree holders showed low emotional exhaustion, 12.5% reported moderate levels, and 0.8% reported high levels. Furthermore, 64.2% of respondents with a bachelor’s degree repor- ted high burnout in personal accomplishment, compared to 35.8% of diploma holders. This suggests that higher education may be associated with elevated work expectations or stressors, contribu- ting to increased burnout. The length of work experience revealed that nurses with more than 10 years of service had the highest levels of low emotional exhaustion (49.2%) and depersonalization (47.5%). However, moderate and high levels were more common among those with shorter tenures (1-5 years), possibly indicating greater vulnerability to burnout in the early years of practice. Regardless of tenure, a high percentage of all groups experienced Pathways of Change, Part II [page 112] [Healthcare in Low-resource Settings 2025;13(s2):13464] Table 2. Frequency distribution of burnout syndrome identification in the emotional exhaustion, depersonalization, and personal accom- plishment dimensions, based on respondents’ demographics. Respondent characteristic Category Burnout dimension Low n (%) Medium n (%) High n (%) Age 21-30 Emotional exhaustion 25 (20.8) 4 (3.3) 1 (0.8) Depersonalization 25 (20.8) 3 (2.5) 2 (1.7) Personal accomplishment 0 (0) 0 (0) 30 (25.0) 31-40 Emotional exhaustion 42 (35.0) 10 (8.3) 0 (0) Depersonalization 39 (32.5) 8 (6.7) 5 (4.2) Personal accomplishment 0 (0) 0 (0) 52 (43.3) 41-50 Emotional exhaustion 34 (28.3) 4 (3.3) 0 (0) Depersonalization 32 (26.6) 6 (5.0) 0 (0) Personal accomplishment 0 (0) 0 (0) 38 (31.6) Gender Male Emotional exhaustion 12 (10) 3 (2.5) 0 (0) Depersonalization 11 (9.2) 2 (1.7) 2 (1.7) Personal accomplishment 0 (0) 0 (0) 15 (12.5) Female Emotional exhaustion 89 (74.2) 15 (12.5) 1 (0.8) Depersonalization 85 (70.8) 15 (12.5) 5 (4.2) Personal accomplishment 0 (0) 0 (0) 105 (87.5) Marital status Married Emotional exhaustion 88 (73.3) 17 (14.2) 0 (0) Depersonalization 84 (70) 14 (11.7) 7 (5.8) Personal accomplishment 0 (0) 0 (0) 105 (87.5) Not married Emotional exhaustion 13 (10.8) 1 (0.8) 1 (0.8) Depersonalization 12 (10) 3 (2.5) 0 (0) Personal accomplishment 0 (0) 0 (0) 15 (12.5) Education Diploma Emotional exhaustion 40 (33.3) 3 (2.5) 0 (0) Depersonalization 38 (31.7) 5 (4.2) 0 (0) Personal accomplishment 0 (0) 0 (0) 43 (35.8) Bachelor Emotional exhaustion 61 (50.8) 15 (12.5) 1 (0.8) Deprsonalization 58 (48.3) 12 (10) 7 (5.8) Personal accomplishment 0 (0) 0 (0) 77 (64.2) Length of work 1-5 years Emotional exhaustion 28 (23.3) 7 (5.8) 1 (0.8) Depersonalization 25 (20.8) 7 (5.8) 4 (3.3) Personal accomplishment 0 (0) 0 (0) 36 (30) 6-10 years Emotional exhaustion 14 (11.7) 2 (1.7) 0 (0) Depersonalization 14 (11.7) 2 (1.7) 0 (0) Personal accomplishment 0 (0) 0 (0) 16 (13.3) >10 years Emotional exhaustion 59 (49.2) 9 (7.5) 0 (0) Depersonalization 57 (47.5) 8 (6.7) 3 (2.5) Personal accomplishment 0 (0) 0 (0) 68 (56.7) Employment status Civil servant Emotional exhaustion 45 (37.5) 4 (3.3) 0 (0) Depersonalization 40 (33.3) 8 (6.7) 1 (0.8) Personal accomplishment 0 (0) 0 (0) 49 (40.8) Government contract Emotional exhaustion 7 (5.8) 4 (3.3) 1 (0.8) Depersonalization 10 (8.3) 1 (0.8) 1 (0.8) Personal accomplishment 0 (0) 0 (0) 12 (10) Contract workers Emotional exhaustion 49 (40.8) 10 (8.3) 0 (0) Depersonalization 46 (38.3) 8 (6.7) 5 (4.2) Personal accomplishment 0 (0) 0 (0) 59 (49.2) burnout in personal accomplishment, with the highest rate (56.7%) observed among those with more than ten years of service. Employment status revealed differences in burnout exposure. Non-civil servant nurses reported the highest levels of low emotio- nal exhaustion (40.8%) and depersonalization (38.3%), as well as notable percentages in the medium and high categories. By con- trast, civil servants showed relatively lower burnout across emotio- nal and depersonalization dimensions. Despite this, high burnout in personal accomplishment remained consistent across all employment types, with contract workers reporting the highest rate (49.2%). Table 3 presents the results of a bivariate analysis using the chi-square test to examine the relationship between various respondent characteristics and the incidence of burnout syndrome among nurses. The significance level was set at p≤0.05. The ana- lysis revealed that age and educational background had a statisti- cally significant relationship with burnout syndrome. Nurses aged 31-40 years had the highest percentage experiencing burnout (15.4%), followed by those aged 21-30 years (13.3%). Notably, none of the respondents aged 41-50 years experienced burnout. The p-value for age was 0.044, indicating a significant association. Regarding education, burnout was experienced by 15.6% of respondents with a bachelor’s degree, while none of the diploma holders reported experiencing burnout. This yielded a p-value of 0.004, suggesting a strong correlation between higher educational attainment and increased risk of burnout. On the other hand, the variables gender, marital status, length of work, and employment status did not show statistically significant associations with bur- nout syndrome. Burnout was slightly more prevalent among male nurses (13.3%) than females (9.5%), but the difference was not significant (p=0.646). Similarly, marital status showed no meanin- gful difference, with 13.3% of unmarried and 9.5% of married nur- ses experiencing burnout (p=0.646). Burnout appeared more fre- quently among nurses with shorter work experience (16.7%) for those with 1-5 years of experience, compared to 12.5% for 6-10 years, and 5.9% for more than 10 years. However, this trend was not statistically significant (p=0.205). Although employment status did not reach statistical significance (p=0.0777), the data showed that government contract employees had the highest burnout rate at 25%, followed by contract workers (11.9%), and civil servants (4.1%). Discussion Relationship between age and burnout syndrome The results of this study indicate a significant relationship between age and the incidence of burnout syndrome. Nurses in the 31-40 years age group exhibited the highest prevalence of burnout compared to other age categories. This finding aligns with the per- spective of Maslach and Leiter, who suggest that younger profes- sionals often possess high idealism and motivation but lack the coping mechanisms and emotional resilience needed to manage occupational stress effectively.14 Nurses in their 30s typically represent the productive middle phase of life, often experiencing increased responsibilities both at work and at home. Professionally, they may be expected to take on leadership roles or manage complex patient cases, while personal- ly, they may be balancing family demands such as raising young children or supporting aging parents.15 These converging pressures can contribute to a heightened risk of emotional exhaustion, deper- sonalization, and reduced personal accomplishment, core elements of burnout. This finding is consistent with previous research that has demonstrated a statistically significant relationship between age and burnout levels among nurses.16 Although burnout is not exclusive to a particular age group, younger and mid-career nurses may be more vulnerable due to limited experience in stress man- Pathways of Change, Part II Table 3. Analysis results of demographic data and burnout syndrome among nurses. Respondent characteristics Burnout syndromep-value* Experiencing Not experiencing Total Value n % n % n % Age 0.044** 21-30 years old 4 13.3 26 86.7 30 100 31-40 years old 8 15.4 44 86.4 52 100 41-50 years old 0 0.0 38 100 38 100 Gender 0.646 Male 2 13.3 13 86.7 15 100 Female 10 9.5 95 90.5 105 100 Marital status 0.646 Married 10 9.5 95 90.5 105 100 Not Married 2 13.3 13 86.7 15 100 Education 0.004** Diploma 0 0.0 43 100 43 100 Bachelor 12 15.6 65 84.4 77 100 Length of work 0.205 1-5 years 6 16.7 30 83.3 36 100 6-10 years 2 12.5 14 87.5 16 100 > 10 years 4 5.9 64 94.1 68 100 Employment status 0.077 Civil servant 2 4.1 47 95.9 49 100 Government contract employee 3 25 9 75 12 100 Contract worker 7 11.9 52 88.1 59 100 *p=0.05; **p<0.05. [Healthcare in Low-resource Settings 2025;13(s2):13464] [page 113] agement, fewer coping strategies, and higher expectations placed upon them. The results from this study reinforce the need for age- sensitive interventions, including mentorship, professional devel- opment, and stress reduction programs, especially targeted at nurs- es in the 30-40 age group. Relationship between educational background and burnout syndrome This study also found a significant association between educa- tional background and burnout syndrome. Nurses holding a bache- lor’s degree in nursing reported higher levels of burnout (15.6%) compared to those with a diploma, none of whom experienced bur- nout. This difference may stem from the greater responsibilities typically assigned to nurses with a bachelor’s degree, including administrative duties, clinical decision-making, mentoring junior staff, and engaging in evidence-based practice. Previous studies have highlighted that nurses with higher edu- cational attainment tend to have stronger clinical competencies, deeper theoretical understanding, and more developed critical thin- king skills, making them valuable assets to healthcare teams.17,18 However, these advanced capabilities often translate into higher professional expectations and workloads, which can contribute to emotional strain and occupational stress if not managed proper- ly.19,20 The present findings support this notion, suggesting that higher educational attainment may increase perceived job pressu- re, especially in settings where organizational support systems are lacking or insufficient. When increased responsibility is not mat- ched with adequate resources, recognition, and stress management strategies, even highly capable nurses can experience burnout. This highlights the importance of ensuring role clarity, workload balance, and support structures, particularly for nurses in advanced roles. Conclusions This study reveals that burnout syndrome among nursing staff is prevalent across all demographic categories, with the personal accomplishment dimension consistently showing high levels of burnout. This indicates a widespread sense of reduced professional efficacy and fulfillment among nurses, regardless of age, gender, marital status, education, work experience, or employment status. These results highlight the importance of considering individual factors such as age and educational background when assessing burnout risk. Targeted interventions should be developed to address emotional fatigue and to restore a sense of accompli- shment, particularly among at-risk groups, in order to maintain the mental health and professional performance of nursing staff. References 1. Sani DI, Paskarini I. Hubungan Antara Kualitas Kehidupan Kerja dengan Kepuasan Kerja Perawat Rawat Inap Rumah Sakit X Gresik [The relationship between quality of work life wih job satisfaction of inpatient nurses at X Hospital X Gresik]. Media Publ Promosi Kesehat Indones 2022;5:1234- 40. 2. Moya-Salazar J, Buitrón LA, Goicochea EA, et al. The age of young nurses is a predictor of burnout syndrome during the care of patients with COVID-19. Nurs Rep 2023;13:721-30. 3. Lailani F. Burnout Pada Perawat Ditinjau Dari Efikasi Diri Dan Dukungan Sosial Di Rumah Sakit Di Surakarta [Nurses Burnout in terms of Self Efficacy and Social Support at Hospital of Surakarta]. J Talent 2014;3. 4. Aqsa A, Paskarini I. Hubungan Faktor Gaya Hidup dengan Burnout pada Perawat Rawat Inap di Rumah Sakit Jiwa [The Relationship Between Lifestyle with Burnout in In-patient Nurse of Mental Health Hospital]. Media Publ Promosi Kesehat Indones 2022;5:1114-21. 5. Herachwati N, Haqq ZN, Choirunnisa Z, et al. Revealing Indonesian healthcare workers’ burnout, work engagement, and job satisfaction during the covid-19 pandemic: the lens of the job demands-resources model. Cogent Bus Manag 2024;11:2371328. 6. Riu SDM, Nursalam N, Ruku DM. Burnout intervention stra- tegies on healthcare provider burnout (cultural differences): a systematic review and meta-analysis. J Liaquat Univ Med Heal Sci 2025;2025:28-35. 7. Raudenská J, Steinerová V, Javůrková A, et al. Occupational burnout syndrome and post-traumatic stress among healthcare professionals during the novel coronavirus disease 2019 (COVID-19) pandemic. Best Pract Res Clin Anaesthesiol 2020;34:553-60. 8. World Health Organisation U. Burn-out an ‘occupational phe- nomenon’: international classification of diseases. WHO Dep News; 2019. 9. O’Mahony N. Nurse burnout and the working environment. Emerg Nurse 2011;19. 10. Renzi C, Di Pietro C, Tabolli S. Psychiatric morbidity and emotional exhaustion among hospital physicians and nurses: association with perceived job-related factors. Arch Environ Occup Health 2012;67:117-23. 11. Lee HF, Hsu HC, Efendi F, et al. Burnout, resilience, and empowerment among COVID-19 survivor nurses in Indonesia. PLoS One 2023;18:e0291073. 12. Paskarini I, Dwiyanti E, Syaiful DA, Syanindita D. Burnout among nurses: Examining psychosocial work environment causes. J Public health Res 2023;12:22799036221147812. 13. Moustaka E, Malliarou M, Konstantinidis T, et al. Burnout in nursing personnel in a regional university hospital. Balk Mil Med Rev 2009;12:1-7. 14. Maslach C, Leiter MP, Jackson SE. Making a significant diffe- rence with burnout interventions: Researcher and practitioner collaboration. J Organ Behav 2012;33:296-300. 15. Chin Rekaya V, Wider W, Tanucan JCM, et al. Leadership competencies and managerial competencies of nurse managers in Kuala Lumpur Hospital, Malaysia. J Ners 2024;19:292-301. 16. Hatch DJ, Freude G, Martus P, et al. Age, burnout and physical and psychological work ability among nurses. Occup Med (Chic Ill) 2018;68:246-54. 17. Ahmady S, Shahbazi S. Impact of social problem-solving trai- ning on critical thinking and decision making of nursing stu- dents. BMC Nurs 2020;19:94. 18. Cummings GG, Lee S, Tate K, et al. The essentials of nursing leadership: A systematic review of factors and educational interventions influencing nursing leadership. Int J Nurs Stud 2021;115:103842. 19. Indiawati OC, Syaâ H, Rachmawati DS, Suhardiningsih AVS. Analisis faktor yang mempengaruhi kejadian burnout syndro- me perawat di RS Darmo Surabaya. J Keperawatan Dan Kesehat Masy Cendekia Utama 2022;11:25-41. 20. Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry 2016;15:103-11. Pathways of Change, Part II [page 114] [Healthcare in Low-resource Settings 2025;13(s2):13464]