Burnout syndrome in health care workers of the Hospital Arequipa (Peru) during the pandemic.

ABSTRACT

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Introduction: At the end of 2019, the global community was surprised by the new outbreak of coronavirus in China. We argued that the chronic exposure to psychosocial risk factors during four months, could precipitate the burnout syndrome among the healthcare workers who attend patients with COVID-19. Objective: To determine the frequency and severity of burnout syndrome in healthcare personnel who working Goyeneche Hospital from Ministry of Health Hospital from Arequipa City along the COVID-19 pandemic. Material and Methods: Descriptive transectional study, in which there were registered the sociodemographic characteristics of 147 healthcare workers in Goyeneche Hospital and there was applied the Burnout Maslach Inventory. Results: The
70.7% of the Goyeneche Hospital health care personnel presents burnout syndrome, and major part of the percentage have concerns about the attention of patients with COVID-19, also they don’t feel trained enough for this, they also are concern because don´t have the Personal protective equipment and they don’t know the safety attention protocols. Conclusion: There is a significant association among the burnout syndrome punctuation and the attention of patients with COVID-19.

Key words: Burnout syndrome, COVID-19, healthcare workers, pandemic.

INTRODUCTION

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p>COVID-19   (Coronavirus   Disease   2019)   is a   respiratory   viral   disease,   denoted   by   dry cough, sore throat, and fever; but it can present complications such as pneumonia, pulmonary edema and septic shock(1). COVID-19 is caused by SARS-CoV2 (Severe Accute Respiratory Syndrome – Coronavirus 2). Its’ outbreak began on  December  12,  2019  in  Wuhan  (China),  in a  wholesale  market  where  live  animals  were sold, from where it is thought to have mutated from bats to humans(2). Due to the exponential increase of infected people, the disease caused by this variety of coronavirus was declared a pandemic. Until today, it has spread to more than
200 countries around the world and has infected around 10 million people.(3)

However, the isolation to which the population was   subjected   has   been   related   to   feelings of  loneliness  and  mourning  over  the  loss  of loved ones, especially  of elderly  people(4),  but it has been reported that the pandemic has had a negative impact on the mental health of the general population, mediated by demographic factors   such   as   gender,   age   and   place   of residence. Women, elderly people, those who live in areas with a higher risk of infection, as well as people who have less access to public health systems  or  medication  and  specific treatments for COVID-19(6), have presented signs such as anxiety and depression(5). Due to these factors and the conspiracy theories that are emerging around the pandemic, even more cases of psychosis are being registered among the population.(7)

COVID-19 is known to be more lethal in older adults and in people with cardiovascular diseases or diabetes, making them a high-risk population(8). This also involves health personnel, since they are at the front line, fighting COVID-19, and therefore considered among the population at risk. In fact, the first reports in China stated that of 3,387 health workers, 23 died; while in Italy 168 have died, in Brazil 113, and in Peru 25 of the 1867 who were infected, passed away.(9)

Due to these reasons, recent studies have shown that health personnel are registering high rates of anxiety, especially female personnel, and nurses(10). This has motivated extreme biosafety measures, training personnel, enabling mental health care through telemedicine, and researching more about this new reality that threatens the physical and mental state of health personnel.(11)

Also, health care staff has reported to have experienced a wide variety of negative emotions (stress, anger, confusion, frustration, loneliness, anxiety, hopelessness, guilt, suicidal ideas) due to the care demands during COVID-19, and this is resulting in a severe psychological impact. In China, for example, 53% of nurses have anxiety and 17% have depression, while up to 75% are afraid that a family member will be infected(10). Fear of becoming infected or of infecting colleagues,  family,  and  friends,  is  triggering high stress levels, anxiety and depression. Working in areas with higher infection rates or prevalence of COVID-19(12)  also contributes to this. We must add certain working conditions that increase stress levels and their physical manifestations (headaches, chest discomfort, sweating,  nausea  and  fatigue),  such  as working in the ICU or caring for patients with higher risk or  with a more severe state of the disease.(13)

Given these demanding conditions, work overload and interpersonal relationships in health emergency contexts can relate burnout syndrome and health personnel(14). This occupational   disease   currently   has   a   high record.  For example, in Italy, a country that has been severely affected by the pandemic, up to
45% of health care staff have severe levels of this syndrome(15). And in China, doctors who care for patients affected by COVID-19 show the highest burnout levels.(16)

Although some explanatory mechanisms of the syndrome have to do with job satisfaction, quality and safety perceived during work(17), the overflow of  health  systems  and  their  precariousness  are determinant factors in the incidence of burnout in health personnel. In addition, it has been reported that in some places health personnel have been “stigmatized”  in  their  areas  of  residence,  and have turned into victims of segregation and social harassment.(18)

In  Peru,  this  reality  is  worse.  This  is  due to high demand, and to the inexistence of adequate     personal     protection     equipment, nor sufficient equipment such as, (molecular tests, ventilators, hospital beds in the ICU) to adequately treat patients; or because health emergency plans were not implemented on time. Therefore, despite preventive measures (poorly implemented according to public opinion), to date,  20,424  deaths  due  to  coronavirus  have been  registered:  842  of  them  in  Arequipa. This is the second most important city in the country, but it is the one that registers one of the highest rates of morbidity and mortality due to COVID-19.

In the case of health personnel, out of the 5,220 active doctors in Arequipa, 60 have been infected and 10 have died(3). Previous reports on burnout syndrome in health personnel showed that only
5.6%  had  severe  levels(19)     of  this  syndrome, while 21.3% of nurses had severe levels of emotional exhaustion and 29.8% severe levels of depersonalization(20). Currently, in a COVID-19 context,   84.5%   of   doctors   reported   having been  victims  of  violence  at  their  workplace(21) and 6.9% presented severe levels of burnout, being higher in those who work in health clinics.(22)

Therefore,    we    have    analyzed    the    levels of burnout syndrome and its dimensions (emotional exhaustion, depersonalization and low  personal  fulfillment), in  health  personnel of   Hospital   II   Goyeneche   of   the   Ministry of  Health  (MINSA),  which  is  known  in  the city as the “hospital of the poor”, because it serves the most vulnerable population and is poorly equipped. All these aspects, lead us to hypothesize  about  the  high  incidence  of  this

syndrome and its manifestations in the context of  the  pandemic.  Work  stressors,  in  addition to to being chronic, acquire greater relevance due to the demands generated by COVID-19 patient care in unfavorable conditions for health personnel.

MATERIAL AND METHODS

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Type of Study
This is a descriptive cross-sectional study, based on the application of measurement instruments through the self-report technique.

Sample

The sample considers members of the health personnel belonging to both sexes, who work in the ICU, emergency, hospitalization and triage departments of Hospital II Goyeneche, in the city of Arequipa of the Ministry of Health (MINSA), in southern Peru. An intentional non-probabilistic sampling was applied.

Instruments

Health  personnel  data,  such  as  age,  gender, work   hours   and   department,   contact   or   no contact with COVID-19 patients, have received training  to  care  for  patients  or  not,  access to personal protective equipment, etc, was documented  through  a  sociodemographic record.

As an assessment instrument, the Maslach Burnout Inventory was applied, it is a scale in self-report format, which was created by Maslach and Jackson in 1981(23). This scale has 22 items with five Likert-type  response  alternatives,  ranging  from
0 to 6, and includes three subscales: Emotional exhaustion (items 1, 2, 3, 6, 8, 13, 14, 16 and 20), Depersonalization (items 5, 10, 11, 15 and 22) and low personal fulfillment (items 4, 7, 9, 12, 17, 18,
19 and 21).

In order to qualify and interpret the results, high levels of emotional exhaustion are considered greater than or equal to a score of 27. High levels of depersonalization is greater than or equal to a score of 10, and low levels of personal accomplishment are below 33 points. To diagnose burnout, MBI scores are considered low if they are between 1 and 33, moderate between 34 and 66, and severe if they are between 67 and 99. The test has been validated in Arequipa through previous studies, which reported adequate validity and reliability indexes.(19,24)

Procedure

Health personnel was evaluated during their work hours within the hospital facilities, during their breaks. All participants gave their consent to participate as part of the sample and was informed about the purpose of the study.

Statistical analysis

The  data  was  collected  between  the  months of May and July 2020, and once this stage concluded,    the    information    was   processed

through descriptive statistics and inferential tests according to the level of measurement of the variables. The Chi square test was used to assess the relationship between burnout levels and certain sociodemographic data.

Ethical Aspects

To implement the research, the ethics committee of the Universidad Católica de Santa María approved the research project, it was authorized by the directors of Hospital II Goyeneche and informed consent was obtained from each participant.

RESULTS

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Table 1 shows that 61.2% of the health personnel evaluated is female and 38.8% is male. In addition,
85.7% of the staff is over 30 years old, 12.9% is between 25 and 30 years old, and 1.4% is under
25 years old. Regarding marital status, 45.6% is married, 40.1% is single, 10.2% are partners, and
4.1% have a different marital status (widowed or divorced).

Table 2 shows that 60.5% of the evaluated health personnel lives in a family home, 37.4% live in their own home and 2% in a boarding house. 54.4% do not have children, while 14.3% have one child, 21.8% two children and 9.5% more than two. Regarding the people they live with, 32.7% live with their partner,
17% live with their parents, 2.7% only with their father, 9.5% only with their mother, 26.5% with 1st degree relatives and 11.6% with other relatives.

 

Table   3   shows   that   47.6%   of   the   health personnel  evaluated  are  attending  physicians,
19.7%  are  residents,  23.8%  are  nurses,  0.7% are obstetricians, 1.4% work in the laboratory, and  6.8%  are  nursing  technicians.  Regarding the area they work in, 31.3% work in the emergency service, 9.5% in the ICU, 18.4% in hospitalization, and the remaining 40.1% in other areas.

 

Table 4 shows that 55.1% of the health personnel evaluated have direct contact with COVID-19 patients, while 15% do not and 29.9% ignore it. As for what overwhelms them the most, 44.9% say it is PPE shortage, 32.7% to have contact with patients with COVID-19, 15.6% medical equipment shortage, 4.8% staff shortage, 1.4% duty shifts and 0.7% personal problems. In addition,  73.5%  affirm  that  the  health  team is not properly trained to care for COVID-19 patients. 84.4% of the staff are concerned about getting  infected  while  caring  for  COVID-19 patients, while 61.9% stated that they have not received training on how to work safely, 78.9% are unaware of the protocols to care for patients suspected of having COVID-19 and 51.7% do not observe an ethical dilemma in COVID-19 patient care, while 48.3% do.

 

Regarding burnout syndrome, 95.2% of the health personnel of Hospital II Goyeneche show high levels of emotional exhaustion, 96.6% have high levels of depersonalization, and 71.4% of the health personnel present a low level of personalfulfillment (see Table 5). Based on the previous information, we can say that 70.7% of the health personnel of Hospital II Goyeneche is affected by burnout syndrome, while only 29.3% of the personnel is not.

 

According to the chi square test, burnout syndrome is related to several aspects involved in COVID-19 patient care, in a statistically significant way (p < 0.05).46.3%  of  the  evaluated  health  personnel who work at Hospital II Goyeneche who present burnout syndrome are in direct contact with COVID-19 patients, 34% of those with burnout syndrome are overwhelmed by the lack of and personal  protective  equipment,  while  66%  of staff with burnout do not feel trained to care for COVID-19 patients. In addition, 70.1% of staff experiencing burnout syndrome is concerned about getting infected when caring for infected patients, 60.5% of staff with burnout does not feel trained to work safely and 70.7% of staff with burnout does not know the protocol for caring for suspected COVID-19 patients (see Table 6).

 

DISCUSSION

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Health personnel is exposed to several occupational stressors that, when chronic, become manifestations of burnout syndrome (emotional exhaustion, depersonalization and low personal fulfillment). This has been studied in many countries, obtaining similar results. As well as in Peru, although most workers have moderate level of burnout, only a small percentage has severe symptoms(19,20,22,25,26).  However, in the context of the pandemic caused by COVID-19, the increase of infected patients as well as the lack of necessary implements, and the consequent work overload

that derives from it; suggest that burnout rates have increased. The added the fear of becoming infected and infecting loved ones(27), as well as the stigmatization suffered by health personnel(18), are related to current rates of depression, stress, and anxiety in healthcare staff.(28)

This study assessed 147 health workers of Hospital II Goyeneche in Arequipa, and found that 70.7% of them present severe levels of burnout, which compared to the 6.9% out of 87 doctors from different health hospitals, who were assessed in a previous investigation(22), suggests an alarming increase in the symptoms of this syndrome; since in addition, 95.2% presented high levels of emotional exhaustion, 96.6% high levels of depersonalization and 71.4% high levels of low personal fulfillment.

It was also possible to relate in a statistically significant way, the severity of the syndrome to several aspects involved in COVID-19 patient care. Therefore 46.3% of the health personnel evaluated have had direct contact with COVID-19 patients, 34% perceive that personal protective equipment is insufficient, 66% do not feel trained to care for COVID-19 patients, 70.1% are afraid of catching COVID-19, and 70.7% do not know the protocol for caring for COVID-19 patients or those who ere suspected of being infected.

This implies that regardless of whether they deal directly with COVID-19 patients or not, the fear of infection and the lack of training and adequate personal protective equipment; are precipitating factors of burnout syndrome in health personnel who work at Hospital II Goyeneche (MINSA). Therefore, it is recommended to adopt measures that have been implemented in several countries in  order  to  reduce  the  impact  of  these  factors, such as enabling communication, helping to better perceive risk situations, promoting self-care, providing complete and adequate PPE, providing mental health support, maintaining healthy habits, taking short breaks, exercising and enjoying time at home as much as possible.(29)

It is also important to strengthen family relationships(30), provide training in stress coping techniques and reduce stigmatization of health personnel18, provide psychosocial support and prevent chronic stress through efficiently designed training programs(31), rotate staff, and have flexible working hours.(32)

It is important to promote resilience within the staff, since many studies show that it constitutes a protective factor against burnout syndrome(33). Defusing and debriefing techniques, used in emergency   and   disasters      psychology,   could be implemented(34). These measures include generating spaces to share as a group the most stressful   and   traumatic   moments  experienced during the working day, favoring emotional relief and providing social support to workers.

Finally, cognitive behavioral therapies are also necessary,  as  non-pharmacological  alternatives, to cognitively restructure the emotional defenses of health workers affected by this syndrome and modify possible distorted behaviors.

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