Prevalence of burnout among healthcare workers in six public referral hospitals in northeastern Brazil during the COVID-19 pandemic: a cross-sectional study

ABSTRACT BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has placed considerable psychological stress on frontline healthcare workers (HCWs). OBJECTIVE: To evaluate the prevalence of burnout syndrome among HCWs facing the COVID-19 outbreak. DESIGN AND SETTING: Cross-sectional study conducted in six public intensive care units (ICUs) in the city of Fortaleza, Brazil. METHODS: An online survey was conducted among HCWs to measure the three dimensions of burnout. RESULTS: A total of 62 physicians (23.4%), 65 nurses (24.5%), 58 nurse technologists (21.9%) and 80 physiotherapists (30.2%) completed the questionnaire. Nearly half of the participants (48.6%) had high levels of emotional exhaustion, and almost one-third of them (29.4%) had high levels of depersonalization. Low levels of professional efficacy were observed in 18.1% of the sample. The independent determinants of depersonalization burnout were age < 33 years (odds ratio, OR 2.03; 95% confidence interval, CI 1.15-3.56; P = 0.01) and female gender (OR 0.33; 95% CI 0.18-0.62; P = 0.01). Increased workload was associated with both depersonalization (OR 2.37; 95% CI 2.02-5.50; P = 0.04) and emotional exhaustion (OR 1.89; 95% CI 1.04-3.58; P = 0.030). CONCLUSION: The COVID-19 pandemic has had a great impact on the dimensions of depersonalization and emotional exhaustion. Consideration of these dimensions is important when designing future burnout prevention programs for frontline personnel.


INTRODUCTION
Burnout syndrome is defined as a set of psychological symptoms resulting from the interaction between chronic occupational stress and individual factors. These symptoms include emotional exhaustion, depersonalization and decreased professional satisfaction. Maslach and Jackson created the Maslach Burnout Inventory (MBI), which is currently the most commonly used scale for assessing the syndrome. 1 The impact of the coronavirus disease 2019 (COVID-19) pandemic on frontline healthcare workers (HCWs) has been enormous and has resulted in high prevalence of burnout. [2][3][4] This pandemic has exacerbated stressors at workplaces and increased occurrence of burnout syndrome among HCWs. 5 A study on HCWs in Italy showed that at least one out of three exhibited high levels of the domain of emotional exhaustion, and one out of four reported high levels of the domain of depersonalization. 6 The MBI is composed of three domains: emotional exhaustion, depersonalization and personal fulfillment. There is a lack of consensus regarding whether high scores are needed in one, two or all three domains to be able to state that HCWs are classified as burned out or non-burned out. 7,8 It is recommended that each of the three MBI domains should be evaluated because the symptoms differ between individuals, and exhaustion can manifest itself as cynicism or anger in some and withdrawal and silence in others. Absence of any of the domains can lead to an erroneous assessment of the problem and consequent errors in healthcare policies and actions.

Sample size
Previous studies showed that the prevalence of burnout among HCWs ranged from 6% to 47%. 11 To compare the rates of burnout between physicians and other HCWs, we assumed rates of 15% and 30%, respectively. By defining α and β as 0.05 and 0.20, respectively, at least 133 participants were required for one arm of the study, i.e. physicians versus other HCWs.  Table 5).

DISCUSSION
The results from this study were concordant with those from studies carried out in other countries. 3,4,[12][13][14] The proportions with emotional exhaustion, affecting nearly half (48.6%) of the HCWs, with depersonalization in almost one-third (29%) and with low levels of professional effectiveness in less than one-fifth (18%) were similar to the results found by Barello et al. 6 The contributions of sociodemographic variables to the three burnout domains were explored using multivariate logistic regression analysis. Our findings suggested that female gender is associated with lower levels of depersonalization burnout. This can be explained by the burnout/resilience balance. Duarte et al. 3 observed that resilience is a potentially protective factor against burnout.
There is evidence that women are more resilient and have better coping skills, which in turn reduces work stress and allows them to deal with work-related issues more effectively. 15 A recent meta-analysis on the relationship between gender and burnout showed that women are slightly more emotionally exhausted than men, while men are slightly more depersonalized than women. 16 Lower age was associated with depersonalization burnout, which is in line with previous research. 3  Increased workload is associated with depersonalization and emotional exhaustion. Our findings are consistent with previous research. 4 Work overload is one of the most important risk factors for burnout among healthcare professionals. 18,19 According to Leiter's burnout model, there is evidence to suggest that emotional exhaustion caused by work overload may lead to depersonalization and cynical attitudes. [20][21] There were no covariables associated with the HCWs' performance. This can be explained by the fact that only 18.1% of the HCWs in the sample had low levels of performance. Empirical evidence points towards exhaustion and cynicism as the core of burnout. 22 In our sample, these two domains had high prevalences.  friends, fulfillment of personal goals and ensuring organizational support from the hospital. 23 We believe that the results from this study contribute to better understanding of the factors associated with burnout among HCWs and should be considered in designing future programs and guidelines to promote protective actions and increase the psychological wellbeing of these professionals. The idea of "burnout contagion" can be useful for "emotional decontamination" in workplaces, among workers who have already been affected by this syndrome.

CONCLUSION
HCWs experience high levels of emotional exhaustion and depersonalization burnout, which warrant attention and support from policymakers.